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Background Context: The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016., Purpose: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition., Study Design: This is a guideline summary review., Methods: This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors., Results: Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature., Conclusions: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx., (Copyright © 2020. Published by Elsevier Inc.)

Background Context: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adult Isthmic Spondylolisthesis features evidence-based recommendations for diagnosing and treating adult patients with isthmic spondylolisthesis. The guideline is intended to reflect contemporary treatment concepts for symptomatic isthmic spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of June 2013. NASS' guideline on this topic is the only guideline on adult isthmic spondylolisthesis accepted in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse., Purpose: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with isthmic spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition., Study Design: This is a guideline summary review., Methods: This guideline is the product of the Adult Isthmic Spondylolisthesis Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questionsto address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Adult Isthmic Spondylolisthesis guideline was accepted into the National Guideline Clearinghouse and will be updated approximately every 5 years., Results: Thirty-one clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature., Conclusions: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with isthmic spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background Context: Knowing the side of the dominant vertebral artery (VA) may be of utmost importance if the VAs are at risk during spine surgery. Determination of the size of VAs is obtained by using Doppler ultrasonography or angiography. Because VA is the main anatomic structure occupying the transverse foramina (TF), it may be assumed that size of TF and blood flow of VAs should be proportional., Purpose: To investigate if there is a correlation between the sizes of TF and the flow of VAs and determine the diagnostic accuracy of measuring TF to predict dominant side of VA. The specific hypothesis was that the larger side of TF corresponds to the side of the dominant VA., Study Design: This is a morphologically based, prospectively designed, single-center study. Thirty patients (14 male, 16 female) who were treated for degenerative spinal pathologies were included. Patients with cervical fractures, occluded VA, prominent degenerative changes affecting TF, deformity, or previous cervical instrumentation were excluded from the study., Outcome Measures: In all patients, computed tomography of the cervical spine and Doppler ultrasonography of VAs were obtained for morphometric analysis., Methods: Axial computed tomography cuts at the C6 vertebral level were taken. Two measurements were performed for each foramen: its right to left width and its anteroposterior depth. Blood flow volumes of bilateral VAs were measured using color Doppler., Results: Diameters of TF ranged between 2.2 and 7 mm, and its width was generally slightly larger than the depth. Transverse foramina were always asymmetric, with no right or left side preference. There was a strong correlation between TF diameters and blood flow of VAs. Between TF width and VA blood flow, the Pearson correlation coefficient was 0.59 (p=.001) for right side and 0.72 for left side (p<.0001). The side of the larger TF matched with the side of dominant VA in 28 of 30 cases (93.3%) (p<.0001). The agreement between the dominant VA and the larger side of TF was almost perfect (Kappa=0.087, p<.0001)., Conclusions: There was strong correlation between TF diameters and VA blood volume. Our results suggest that TF diameter of C6 level can be used to predict the side of the dominant VA reliably., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aim: Assessment of previous vertebral fractures provides useful information to predict future fracture risk. This study aimed to determine the frequency, distribution and severity of prevalent osteoporotic vertebral fractures in postmenopausal women., Material and Methods: Data on patient characteristics, bone densitometry values, and spine radiographs (T2-L5) were reviewed in 232 postmenopausal women admitted to our osteoporosis clinic., Results: Prevalent vertebral fractures were detected in 28 (12.1%) women (95%CI: 7.8 16.3). Fifteen women (6.5%) had mild fractures and 13 (5.6%) had moderate or severe fractures according to Genant's semi-quantitative technique. The T-score was associated with the presence of prevalent vertebral fractures (OR= 0.61; 95%CI: 0.38-0.96, P= 0.034). The most frequently fractured vertebrae were T11 and T12, followed by T7 and T9. Sixty percent of fractures were wedge-type while 40% were biconcave. The frequency of wedge-type fractures at the T11-T12 levels (93.8%) was higher compared to that at all other levels (44.1%) (P= 0.001)., Conclusion: We determined the frequency, distribution, and severity of prevalent fractures and identified certain distribution patterns of fracture locations and types. To verify our results and detect possible predictive factors for fracture risk, population-based larger trials are needed.

Two cases of brucellar spondylodiscitis of the lumbar area were presented. Although both cases showed typical radiological changes, serological tests could not detect Brucella agglutinating antibodies. One of the patients was bacteremic and Brucella spp. was identified from blood culture. In the second patient needle biopsy was required for definite diagnosis. Although small, serologic tests have a certain rate of false negative results in brucellosis. Thus, a negative serology should not exclude the diagnosis of brucellosis, as it is demonstrated in the current cases.

The anterior iliac crest is the harvest site preferred by many surgeons because of the quantity and quality of bone obtainable and the simplicity of harvesting techniques. Avulsion fracture of the iliac crest following bone grafting is an extremely rare occurrence. We present a case report of avulsion fracture of the anterior iliac crest following bone graft harvesting for anterior cervical fusion in a 63-year-old man. Non-operative treatment was the method of our treatment in the patient. By means of the presented case, iliac crest bone grafting techniques, risk factors of avulsion fracture, and treatment options were reviewed.

Three patients presented with rare intrasacral extradural arachnoid cysts manifesting as sensory deficiencies and pain in the lower extremities. Magnetic resonance imaging with various sequences identified the cysts. Two patients underwent surgery via laminectomy of the sacrum for cyst exploration and disconnection of the cyst with the dural theca. Postoperative outcome was favorable in these two patients. Intrasacral extradural arachnoid cyst should be considered in the differential diagnosis of low back pain.

Growing skull fracture (GSF) is a rare complication of head trauma. A posttraumatic intraventricular arachnoid cyst (AC), neither isolated nor accompanied by a GSF has not been reported previously. A seven-year-old girl was admitted after a severe head injury with a separated right parieto-occipital fracture and contusion. She responded well to conservative therapy. Seven weeks after discharge, she was re-admitted with a large parieto-occipital pseudomeningoencephalocele due to herniation of cerebrospinal fluid and neural tissue to the subgaleal space through the widened fracture defect, an extra-axial cyst at the posterior interhemispheric space and an intraventricular cystic mass. She underwent open surgery, and the intraventricular cystic mass was totally removed. The histological findings were consistent with an AC. One week after dural repair, hydrocephalus developed, and a ventriculo-peritoneal shunt was inserted. She did well during two-year follow-up. The present case is unique as an intraventricular AC following head trauma. When an intraventricular cystic lesion is encountered after severe head trauma, the possibility of an AC should be considered; especially with neighboring contused neural tissue and leptomeningeal cyst formation.

An unusual case of a giant (8 x 6 x 6 cm) frontoparietal SDE of Streptococcus pneumoniae in a 17-month-old child is reported. The initial diagnosis was made with emergency CT. The purulent material was removed via a frontoparietal craniotomy. A series of postoperative MR imaging showed the gradual reduction in size of the lesion, although collapsed capsule, fibrous thickening of meningeal structures and associated displacement of the underlying brain persisted. The child was symptom-free in a follow-up period of 15 months. This case showed that SDE may reach a giant size and thus may mimic an intra-axial lesion; the coronal MR imaging is a more reliable diagnostic tool than the emergency axial CT in giant SDE of upper convexity localization, and the clinical improvement may be more impressive than the radiological changes.

The pathogenesis, etiology, and treatment of the spinal arachnoid cyst have not been well established because of its rarity. A 57-year-old male was presented with spastic quadriparesis predominantly on the left side. His radiological examination showed widening of the cervical spinal canal and left neural foramina due to a cerebrospinal fluid-filled extradural cyst that extended from C2 to T2 level. The cyst was located left anterolaterally, compressing the spinal cord. Through a C4-T2 laminotomy, the cyst was excised totally and the dural defect was repaired. Several features of the reported case, such as cyst size, location, and clinical features make it extremely unusual. The case is discussed in light of the relevant literature.

Although blood contamination of cerebrospinal fluid (CSF) after an intracranial operation is possible, development of a symptomatic spinal hematoma after a posterior fossa surgery has never been reported. A 43-year-old woman underwent a posterior fossa tumor removal in the prone position with no intraoperative difficulty. On the second postoperative day, she complained of severe epigastric pain and developed a rapid onset of paraplegia with anesthesia below the thoracic 5 spinal level. The emergency cranial and spinal MRIs revealed a spinal extramedullary hemorrhage spreading to the whole spinal regions, just sparing the cauda equina area. There was a prominent localized hematoma formation surrounding and compressing the spinal cord at the upper thoracic levels, which was evacuated via an urgent laminectomy. The patient showed partial neurological recovery after the decompression. Development of the spinal hematoma was explained by the movement of blood from the tumor bed into the spinal canal under the effect of gravity, during or after the operation. A 30 degrees head elevation might facilitate the accumulation of blood. Localization of the hematoma formation may be caused by the fact that the upper thoracic levels constitute the apex of the kyphosis. We conclusively suggest that a spinal hematoma should be taken into consideration as a rare but potentially severe complication of a posterior fossa surgery. Meticulous hemostasis and isolation of the surgical area from the spinal spaces are essential. Overdrainage of CSF should be abandoned. Postoperatively, patients should be monitored for spinal findings as well as cranial signs.

Nocardiosis has become a significant opportunistic infection over the last two decades as the number of immunocompromised individuals has grown worldwide. We present two patients with nocardial brain abscess. The first patient was a 39-year-old woman with systemic lupus erythematosus. A left temporoparietal abscess was detected and aspirated through a burr-hole. Nocardia farcinica infection was diagnosed. The patient had an accompanying pulmonary infection and was thus treated with imipenem and amikacine for 3 weeks. She received oral minocycline for 1 year. The second patient was a 43-year-old man who was being treated with corticosteroids for glomerulonephritis. He was diagnosed with a ring-enhancing multiloculated abscess in the left cerebellar hemisphere, with an additional two small supratentorial lesions and triventricular hydrocephalus. Gross total excision of the cerebellar abscess was performed via a left suboccipital craniectomy. Culture revealed Nocardia asteroides, and the patient was successfully treated with intravenous ceftriaxone, then oral trimethoprime-sulfamethoxazole for 1 year. The clinical course, radiological findings, and management of nocardial brain abscess are discussed in light of the relevant literature, and current clinical management is reviewed through examination of the cases presented here.

Growing skull fractures (GSFs) are rare complications of head injury and mostly occur in infancy and early childhood. Location in the posterior fossa and intradiploic development of a GSF is very uncommon. We report a 7-year-old boy with a large, 9 x 7 x 4-cm, occipital intradiploic GSF. The lesion developed progressively over a period of 5 years following a documented occipital linear fracture. This case of a GSF developing from a known occipital linear fracture demonstrates that a GSF may reach a considerable size and, although uncommon, intradiploic development and occipital localization of a GSF is possible.

We report a complication of decompressive craniectomy in the treatment of aneurismal subarachnoid hemorrhage (SAH) and accompanying middle cerebral artery (MCA) infarction. A 56-year-old man presented with subarachnoid hemorrhage and right sylvian hematoma. He was diagnosed with high-grade SAH and medical therapy was employed. He showed rapid clinical deterioration on day 9 of his admission. Computed tomographic scans showed right MCA infarction and prominent midline shift. Because of the patient's rapidly worsening condition, further evaluation to find origin of SAH could not be obtained, and decompressive right hemicraniectomy was performed. During sylvian dissection, right middle cerebral and posterior communicant artery aneurysms were detected and clipped. One week after operation, a contralateral frontoparietal subdural effusion and left to right midline shift was detected and drained through a burr-hole. Through successive percutaneous aspirations, effusion recurred and complete resolution was achieved after cranioplasty and subduroperitoneal shunt procedures. Decompressive craniectomy is generally accepted as a technically simple operation with a low incidence of complications. In the light of this current case, we hypothesize that a large craniectomy may facilitate the accumulation of recurrent effusion on contralateral side creating a resistance gradient between two hemispheres. This point may be especially true for subarachnoid hemorrhage cases requiring aneurysm surgery. We conclusively suggest that subdural effusions may be resistant to simple drainage techniques if a large contralateral craniectomy does exist, and early cranioplasty may be required for treatment in addition to drainage procedures.

The initial fixation strength of pedicle screws is commonly tested using a standard pull-out test with load applied at a constant rate. This method overlooks the cyclic nature of in situ loading responsible for clinical failure. This study was undertaken to determine the effects of stress relaxation properties at the bone-screw interface on screw fixation strength. Pedicle screws were inserted into calf lumbar vertebrae using a paired testing array. After embedding and mounting in a custom fixture, axial pull-out tests were performed at the rates of 1, 5, and 25 mm/min. For each vertebra, one screw was pulled at a continuous rate. The other screw was pulled at increments of 0.5 mm, at the same rate, with 1000 s pause between increments. Peak load, energy-to-failure, displacement-to-failure, and stiffness were calculated for each screw pull-out test. Two-way ANOVA showed that the standard pull-out method yielded significantly higher peak loads (p < 0.05) at faster pull-out rates and higher stiffnesses (p < 0.05) at all rates compared to the stress relaxation pull-out protocol. These results suggest that the stress relaxation properties of bone significantly affect the pull-out behavior of pedicle screws, reducing the peak load and stiffness values observed during testing. This mode of testing may provide a better biomechanical model of screw pull-out failure and a more accurate estimate of initial fixation strength.

A 32-year-old man presented with a combined penetrating stab injury of the spinal cord and the aorta caused by a knife wound in his back at the low thoracic level. The knife had broken, and part of the blade had been retained in the wound, passing through the spinal canal and into the aortic lumen. The patient was treated in two steps: the aorta was repaired by a thoracotomy, then spinal exploration was carried out through a laminectomy. Because of the tamponade effect of the foreign body, it was necessary to delay removal of the blade until vascular control had been achieved. Any sign of a penetrating body passing through the spine should suggest careful evaluation to detect any visceral injury, and multidisciplinary treatment should be planned.

Metastatic tumors of the pituitary gland are not commonly diagnosed during life in cancer patients. The occurrence of symptomatic lesions is also very unusual and difficult to differentiate clinically and radiologically from pituitary adenomas. Furthermore, a single intrasellar metastasis from laryngeal carcinoma mimicking a pituitary adenoma is an extremely rare pathological finding. We report on the clinical, radiological, and pathological findings in a patient with laryngeal carcinoma who had a symptomatic solitary pituitary gland metastasis that was recognized antemortem.