Search results for: spinal ligaments

Authors: P. W. G. D. P. Samarasekara, S. M. K. S. Seneviratne, D. Munidasa, S. S. Williams

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Sustaining a spinal cord injury (SCI) causes severe disruption of all aspects of a person’s life, resulting in the difficult process of coping with the distressing effects of paralysis affecting their ability to lead a meaningful life. These persons are hospitalized in the acute stage of injury and subsequently for rehabilitation and the treatment of complications. The purpose of this study was to explore coping strategies used by persons with SCI during their rehabilitation period. A qualitative study was conducted among persons with SCI, undergoing rehabilitation at the Rheumatology and Rehabilitation Hospitals, Ragama and Digana Sri Lanka. Twelve participants were selected purposively to represent both males and females, with cervical, thoracic or lumbar levels of injuries due to traumatic and non-traumatic causes as well as from different socioeconomic backgrounds. Informed consent was taken from the participants. In-depth interviews were conducted using an interview guide to collect data. Probes were used to get more information and to encourage participants. Interviews were audio taped and transcribed verbatim. Qualitative content analysis was conducted. Ethical approval for this study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya. Five themes were identified in the content analysis: social support, religious beliefs, determination, acceptance and making comparisons. Participants indicated that the support from their family members had been an essential factor in coping, after sustaining an SCI and they expressed the importance of emotional support from family members during their rehabilitation. Many participants had a strong belief towards the God, who had a personal interest in their lives, played an important role in their ability to cope with the injury. They believed that what happens to them in this life results from their actions in previous lives. They expressed that determination was essential as a factor that helps them cope with their injury. They indicated their focus on the positive aspects of the life and accepted the disability. They made comparisons to other persons who were worse off than them to help lift them out of unpleasant experience. Even some of the most severely injured and disabled participants presented evidence of using this coping strategy. Identification of coping strategies used by persons with SCI will help nurses and other health-care professionals in reinforcing the most effective coping strategies among persons with SCI. The findings recommend that engagement coping positively influences psychosocial adaptation.

Keywords: content analysis, coping strategies, rehabilitation, spinal cord injury

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Authors: V. K. Tewari, M. Hussain, H. K. D.Gupta

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Aims/Background: The existing Intraoperative-MRI(IMRI) of developed countries is too costly to be utilized in any developing country. We have used the preexisting 3-side open 0.2-tesla MRI for IMRI in India so that the maximum benefit of the goal of IMRI is attained with cost effective state of the art surgeries. Material/Methods: We have operated 36-cases since 13thNov2005 via IMRI to till date. The table of MRI is used as an operating table which can be taken to the P3 level and as and when we require MRI to be done then the table can slide to P1 level so that the intraoperative monitoring can be done. The oxygen/nitrous tubes were taken out from vent made in the wall of the MRI room to outside. The small handy Boyel’s trolley was taken inside the MRI room with a small monitor. Anesthesia is been given in the MRI room itself. Usual skin markings were given with the help of scout MRI fields so the preciseness is increased. Craniotomy flap raised or the laminectomy and the dura opened in the similar fashion by same instruments as for the non IMRI case. Now corticectomy is planned after the T1 contrast image to localize and minimize the cortical resection. Staged and multiple P3 to P1 position and vice versa is planned respectively so that the resection is optimized to around 0.5 mm for radiotherapy. Immediate preclosure hematoma and edemas can be differentiated and cared for it. Results: Same MRI images as compared to highly expensive MRI of western world are achieved. Conclusion: 0.2 tesla Intraoperative MRI can be used for operative work for cranial and spinal cases easily with highly cost effectiveness.

Keywords: intraoperative MRI, 0.2 tesla intraoperative MRI, cost effective intraoperative MRI, medical and health sciences

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Authors: Lalita Khuna, Sugalya Amatachaya, Pipatana Amatachaya, Thiwabhorn Thaweewannakij, Pattra Wattanapan

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The five times sit-to-stand test (FTSST) has been widely used to quantify lower extremity motor strength (LEMS), dynamic balance ability, and risk of falls in many individuals. Recently, it has been used in ambulatory patients with spinal cord injury (SCI) but variously using with or without hands according to patients’ ability. This difference might affect the validity of the test in these individuals. Thus, this study assessed the concurrent validity of the FTSST in ambulatory individuals with SCI, separately for those who could complete the test with or without hands using LEMS and standard functional measures as gold standards. Moreover, the data of the tests from those who completed the FTSST with and without hands were compared. A total of 56 ambulatory participants with SCI who could complete sit-to-stand with or without hands were assessed for the time to complete the FTSST according to their ability. Then they were assessed for their LEMS scores and functional abilities, including the 10-meter walk test (10MWT), the walking index for spinal cord injury II (WISCI II), the timed up and go test (TUGT), and the 6-minute walk test (6MWT). The Mann-Whitney U test was used to compare the different findings between the participants who performed the FTSST with and without hands. The Spearman rank correlation coefficient (ρ) was applied to analyze the levels of correlation between the FTSST and standard tests (LEMS scores and functional measures). There were significant differences in the data between the participants who performed the test with and without hands (p < 0.01). The time to complete the FTSST of the participants who performed the test without hands showed moderate to strong correlation with total LEMS scores and all functional measures (ρ = -0.71 to 0.69, p < 0.001). On the contrary, the FTSST data of those who performed the test with hands were significantly correlated only with the 10MWT, TUGT, and 6MWT (ρ = -0.47 to 0.57, p < 0.01). The present findings confirm the concurrent validity of the FTSST when performed without hands for LEMS and functional mobility necessary for the ability of independence and safety of ambulatory individuals with SCI. However, the test using hands distort the ability of the outcomes to reflect LEMS and WISCI II that reflect lower limb functions. By contrast, the 10MWT, TUGT, and 6MWT allowed upper limb contribution in the tests. Therefore, outcomes of these tests showed a significant correlation to the outcomes of FTSST when assessed using hands. Consequently, the use of FTSST with or without hands needs to consider the clinical application of the outcomes, i.e., to reflect lower limb functions or mobility of the patients.

Keywords: mobility, lower limb muscle strength, clinical test, rehabilitation

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Authors: Steven Robinson, Adriana Dager, Param Patel

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Wandering spleen is a rare variant where there is abnormal development of the ligamentous peritoneal attachments of the spleen which normally anchor it in the left upper quadrant of the abdomen. Ligamentous abnormalities can be congenital, or acquired through pregnancy, injury, or iatrogenic causes. Absence or laxity of these ligaments allows migration of the spleen into ectopic portions of the abdomen, which is also associated with an elongated vascular pedicle. Incidence of wandering spleen is reported at less than 0.25% with a female to male ratio of approximately 6:1. The most common complication of a wandering spleen is torsion around its vascular pedicle which can lead to thrombosis and infarction. Torsion of a wandering spleen is a rare but important cause of an acute abdomen. Imaging, and specifically CT or ultrasound, is crucial in the diagnosis. We present a case of a torsed wandering spleen which was treated with splenectomy.

Keywords: Wandering Spleen, Torsion, Splenic Torsion, Spleen

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Authors: Buchh Aqsa, Inayat Umar

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Background- Clonidine, α 2 agonist, possesses several properties to make it valuable adjuvant for spinal anesthesia. The study was aimed to evaluate the clinical effects of oral clonidine premedication for laparoscopic gynecological procedures under subarachnoid block. Patients and method- Sixtyfour adult female patients of ASA physical status I and II, aged 25 to 45 years and scheduled for laparoscopic gynecological procedures under the subarachnoid block, were randomized into two comparable equal groups of 32 patients each to received either oral clonidine, 100 µg (Group I) or placebo (Group II), 90 minutes before the procedure. Subarachnoid block was established with of 3.5 ml of 0.5% hyperbaric bupivacaine in all patients. Onset and duration of sensory and motor block, maximum cephalad level, and the regression time to reach S1 sensory level were assessed as primary end points. Sedation, hemodynamic variability, and respiratory depression or any other side effects were evaluated as secondary outcomes. Results- The demographic profile was comparable. The intraoperative hemodynamic parameters showed significant differences between groups. Oral clonidine was accelerated the onset time of sensory and motor blockade and extended the duration of sensory block (216.4 ± 23.3 min versus 165 ± 37.2 min, P <0.05). The duration of motor block showed no significant difference. The sedation score was more than 2 in the clonidine group as compared to the control group. Conclusion- Oral clonidine premedication has extended the duration of sensory analgesia with arousable sedation. It also prevented the post spinal shivering of the subarachnoid block.

Keywords: oral clonidine, subarachnoid block, sensory analgesia, laparoscopic gynaecological

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Authors: Thuraya Ahmed Hamood Al Shidhani

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Sports Medicine injuries are very common in primary health care. It is not necessary related to direct trauma, but it could be because of repetitive stress and overuse injuries. Knowledge of Primary Health care providers about the common sports medicine injuries and when to refer to a specialist is essential. Common sports injuries are muscle strain, joint sprain, bone bruise, Patellofemoral pain syndrome, Anterior cruciate ligament injuries, meniscal injuries, ankle ligaments injuries, concussion, Rotator cuff tendinosis/impingement syndrome, lateral and medial epicondylitis and fractures. Systematic approach is very useful in evaluation of sports injuries. RICE is important in initial management. Physiotherapy is essential for rehabilitation. Definitive Management is dependent on patient’s condition and function.

Keywords: common, sports medicine injuries, primary health care, injuries

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Authors: Hasmik V. Zanginyan, Gayane S. Ghazaryan, Laura M. Hovsepyan

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Experimental autoimmune encephalomyelitis (EAE) is an inflammatory demyelinating disease of the central nervous system that is induced in laboratory animals by developing an immune response against myelin epitopes. The typical clinical course is ascending palsy, which correlates with inflammation and tissue damage in the thoracolumbar spinal cord, although the optic nerves and brain (especially the subpial white matter and brainstem) are also often affected. With multiple sclerosis, there is a violation of lipid metabolism in myelin. When membrane lipids (glycosphingolipids, phospholipids) are disturbed, metabolites not only play a structural role in membranes but are also sources of secondary mediators that transmit multiple cellular signals. The purpose of this study was to investigate the effect of ganglioside as a therapeutic agent in experimental multiple sclerosis. The biological activity of a ganglioside-containing medicinal preparation (Cronassial) was evaluated in an experimental model of multiple sclerosis in laboratory animals. An experimental model of multiple sclerosis in rats was obtained by immunization with myelin basic protein (MBP), as well as homogenization of the spinal cord or brain. EAE was induced by administering a mixture of an encephalitogenic mixture (EGM) with Complete Freund’s Adjuvant. Mitochondrial fraction was isolated in a medium containing 0,25 M saccharose and 0, 01 M tris buffer, pH - 7,4, by a method of differential centrifugation on a K-24 centrifuge. Glutathione peroxidase activity was assessed by reduction reactions of hydrogen peroxide (H₂O₂) and lipid hydroperoxides (ROOH) in the presence of GSH. LPO activity was assessed by the amount of malondialdehyde (MDA) in the total homogenate and mitochondrial fraction of the spinal cord and brain of control and experimental autoimmune encephalomyelitis rats. MDA was assessed by a reaction with Thiobarbituric acid. For statistical data analysis on PNP, SPSS (Statistical Package for Social Science) package was used. The nature of the distribution of the obtained data was determined by the Kolmogorov-Smirnov criterion. The comparative analysis was performed using a nonparametric Mann-Whitney test. The differences were statistically significant when р ≤ 0,05 or р ≤ 0,01. Correlational analysis was conducted using a nonparametric Spearman test. In the work, refrigeratory centrifuge, spectrophotometer LKB Biochrom ULTROSPECII (Sweden), pH-meter PL-600 mrc (Israel), guanosine, and ATP (Sigma). The study of the process of lipid peroxidation in the total homogenate of the brain and spinal cord in experimental animals revealed an increase in the content of malonic dialdehyde. When applied, Cronassial observed normalization of lipid peroxidation processes. Reactive oxygen species, causing lipid peroxidation processes, can be toxic both for neurons and for oligodendrocytes that form myelin, causing a violation of their lipid composition. The high content of lipids in the brain and the uniqueness of their structure determines the nature of the development of LPO processes. The lipid layer of cellular and intracellular membranes performs two main functions -barrier and matrix (structural). Damage to the barrier leads to dysregulation of intracellular processes and severe disorders of cellular functions.

Keywords: experimental autoimmune encephalomyelitis, multiple sclerosis, neuroinflammation, therapy

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Authors: Nermeen Elbeltagy, Sara Hassan, Tamer Hosny, Mostafa Abdelaziz

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Introduction: Adequate postoperative analgesia after caesarean section (CS) is crucial as it impacts the distinct surgical recovery needs of the parturient. Over recent years, there has been increased interest in regional nerve block techniques with promising results on efficacy. These techniques reduce the need for additional analgesia, thereby lowering the incidence of drug-related side effects. As postoperative pain after cesarean is mainly due to abdominal incision, the transverses abdomenis plane ( TAP ) block is a relatively new abdominal nerve block with excellent efficacy after different abdominal surgeries, including cesarean section. Objective: The main objective is to compare ultrasound-guided TAP block provided by the anesthesiologist with TAP provided by the surgeon through a caesarean incision regarding the duration of postoperative analgesia, intensity of analgesia, timing of mobilization, and easiness of the procedure. Method: Ninety pregnant females at term who were scheduled for delivery by elective cesarean section were randomly distributed into two groups. The first group (45) received spinal anesthesia and postoperative ultrasound guided TAP block using 20ml on each side of 0.25% bupivacaine which was provided by the anesthesiologist. The second group (45) received spinal anesthesia plus a TAP block using 20ml on each side of 0.25% bupivacaine, which was provided by the surgeon through the cesarean incision. Visual Analogue Scale (VAS) was used for the comparison between the two groups. Results: VAS score after four hours was higher among the TAP block group provided by the surgeon through the surgical incision than the postoperative analgesic profile using ultrasound-guided TAP block provided by the anesthesiologist (P=0.011). On the contrary, there was no statistical difference in the patient’s dose of analgesia after four hours of the TAP block (P=0.228). Conclusion: TAP block provided through the surgical incision is safe and enhances early patient’s mobilization.

Keywords: TAP block, CS, VAS, analgesia

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Authors: Po-Ching Chou, Wen-Chen Liang, I. Chen Chen, Jong-Hau Hsu, Yuh-Jyh Jong

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Background：Cardiopulmonary complications seem to cause high morbidity and mortality in patients with neuromuscular diseases (NMD) but so far there is no domestic data reported in Taiwan. We, therefore attempted to analyze the factors to cause the death in NMD patients from our cohort. Methods：From 1998 to 2013, we retrospectively collected the information of the NMD patients treated and followed up in Kaohsiung Medical University Hospital. Forty-two patients with NMD who expired during these fifteen years were enrolled. The medical records of these patients were reviewed and the causes of death and the associated affecting factors were analyzed. Results：Eighteen patients with NMD (mean age=13.3, SD=12.4) with complete medical record and detailed information were finally included in this study, including spinal muscular atrophy (SMA) (n=9, 7/9: type 1), Duchenne muscular dystrophy (n=6), congenital muscular dystrophy (n=1), carnitine acyl-carnitine translocase (CACT) deficiency (n=1) and spinal muscular atrophy with respiratory distress (SMARD)(n=1). The place of death was in ICU (n=11, 61%), emergency room (n=3, 16.6%) or home (n=4, 22.2%). For SMA type 1 patients, most of them (71.4%, 5/7) died in emergency room or home and the other two expired during an ICU admission. The causes of death included acute respiratory failure due to pneumonia (n=13, 72.2 %), ventilator failure or dislocation (n=2, 11.1%), suffocation/choking (n=2, 11.1%), and heart failure with hypertrophic cardiomyopathy (n=1, 5.55%). Among the 15 patients died of respiratory failure or choking, 73.3% of the patients (n=11) received no ventilator care at home. 80% of the patients (n=12) received no cough assist at home. The patient died of cardiomyopathy received no medications for heart failure until the last admission. Conclusion: Respiratory failure and choking are the leading causes of death in NMD patients. Appropriate respiratory support and airway clearance play the critical role to reduce the mortality.

Keywords: neuromuscular disease, cause of death, tertiary care hospital, medical sciences

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Authors: Anshu Bahl, Saroj Kaler, Shivani Gupta, S B Ray

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Background: Somatostatin is an endogenous regulatory neuropeptide. Somatostatin and its analogues play an important role in neuropathic and inflammatory pain. Neuropeptide Y is extensively distributed in the mammalian nervous system. NPY has an important role in blood pressure, circadian rhythm, obesity, appetite and memory. The purpose was to investigate somatostatin and NPY expression in dorsal root ganglia during pain. The plantar incision model in rats is similar to postoperative pain in humans. Methods: 24 adult male Sprague dawley rats were distributed randomly into two groups – Control (n=6) and incision (n=18) groups. Using Hargreaves apparatus, thermal hyperalgesia behavioural test for nociception was done under basal condition and after surgical incision in right hind paw at different time periods (day 1, 3 and 5). The plantar incision was performed as per standard protocol. Perfusion was done using 4% paraformaldehyde followed by extraction of dorsal root ganglia at L4 level. The tissue was processed for immunohistochemical localisation for somatostatin and neuropeptide Y. Results: Post incisional groups (day 1, 3 and 5) exhibited significant decrease of paw withdrawal latency as compared to control groups. Somatostatin expression was noted under basal conditions. It decreased on day 1, but again gradually increased on day 3 and further on day five post incision. The expression of Neuropeptide Y was noted in the cytoplasm of dorsal root ganglia under basal conditions. Compared to control group, expression of neuropeptide Y decreased on day one after incision, but again gradually increased on day 3. Maximum expression was noted on day five post incision. Conclusion: Decrease in paw withdrawal latency indicated nociception, particularly on day 1. In comparison to control, somatostatin and NPY expression was decreased on day one post incision. This could be correlated with increased axoplasmic flow towards the spinal cord. Somatostatin and NPY expression was maximum on day five post incision. This could be due to decreased migration from the site of synthesis towards the spinal cord.

Keywords: dorsal root ganglia, neuropeptide y, postoperative pain, somatostatin

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Authors: Y. C. Khoo, W. T. Lai

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The single orifice hydraulic flat spray nozzle was evaluated with two global imaging techniques to characterize various aspects of the resulting spray. The two techniques were high resolution flow visualization and Particle Image Velocimetry (PIV). A CCD camera with 29 million pixels was used to capture shadowgraph images to realize ligament formation and collapse as well as droplet interaction. Quantitative analysis was performed to give the sizing information of the droplets and ligaments. This camera was then applied with a PIV system to evaluate the overall velocity field of the spray, from nozzle exit to droplet discharge. PIV images were further post-processed to determine the inclusion angle of the spray. The results from those investigations provided significant quantitative understanding of the spray structure. Based on the quantitative results, detailed understanding of the spray behavior was achieved.

Keywords: spray, flow visualization, PIV, shadowgraph, quantitative sizing, velocity field

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Authors: David Dolbow, Daniel Credeur, Mujtaba Rahimi, Dobrivoje Stokic, Jennifer Lemacks, Andrew Courtner

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Introduction: Obesity is at epidemic proportions in the spinal cord injury (SCI) population (66-75%), as individuals who suffer from paralysis undergo a dramatic decrease in muscle mass and a dramatic increase in adipose deposition. Obesity is a major public health concern which includes a doubling of the risk of heart disease, stroke and type II diabetes mellitus. It has been demonstrated that physical activity, and especially HIIT, can promote a healthy body composition and decrease the risk cardiometabolic disease in the able-bodied population. However, SCI typically limits voluntary exercise to the arms, but a high prevalence of shoulder pain in persons with chronic SCI (60-90%) can cause increased arm exercise to be problematic. Functional electrical stimulation (FES) cycling has proven to be a safe and effective way to exercise paralyzed leg muscles in clinical and home settings, saving the often overworked arms. Yet, HIIT-FES cycling had not been investigated prior to the current study. The purpose of this study was to investigate the body composition changes with combined HIIT-FES cycling and nutritional counseling on individuals with SCI. Design: A matched (level of injury, time since injury, body mass index) and controlled trail. Setting: University exercise performance laboratory. Subjects: Ten individuals with chronic SCI (C5-T9) ASIA impairment classification (A & B) were divided into the treatment group (n=5) for 30 minutes of HIIT-FES cycling 3 times per week for 8 weeks and nutritional counseling over the phone for 30 minutes once per week for 8 weeks and the control group (n=5) who received nutritional counseling only. Results: There was a statistically significant difference between the HIIT-FES group and the control group in mean body fat percentage change (-1.14 to +0.24) respectively, p = .030). There was also a statistically significant difference between the HIIT-FES and control groups in mean change in legs lean mass (+0.78 kg to -1.5 kg) respectively, p = 0.004. There was a nominal decrease in weight, BMI, total fat mass and a nominal increase in total lean mass for the HIIT-FES group over the control group. However, these changes were not found to be statistically significant. Additionally, there was a nominal decrease in the mean blood glucose levels for both groups 101.8 to 97.8 mg/dl for the HIIT-FES group and 94.6 to 93 mg/dl for the Nutrition only group, however, neither were found to be statistically significant. Conclusion: HIIT-FES cycling combined with nutritional counseling can provide healthful body composition changes including decreased body fat percentage in just 8 weeks. Future study recommendations include a greater number of participants, a primer electrical stimulation exercise program to better ready participants for HIIT-FES cycling and a greater volume of training above 30 minutes, 3 times per week for 8 weeks.

Keywords: body composition, functional electrical stimulation cycling, high-intensity interval training, spinal cord injury

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Authors: Avik Banerjee, Kavita Saggar

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Infections of the nervous system and adjacent structures are often life-threatening conditions. Despite the recent advances in neuroimaging evaluation, the diagnosis of unclear infectious CNS disease remains a challenge. Our aim is to evaluate the typical and atypical neuro-imaging features of the various routinely encountered CNS infected patients so as to form guidelines for their imaging recognition and differentiation from tumoral, vascular and other entities that warrant a different line of therapy.

Keywords: central nervous system (CNS), Cerebro Spinal Fluid (Csf), Creutzfeldt Jakob Disease (CJD), progressive multifocal leukoencephalopathy (PML)

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Authors: Sarita Magu, Deepak Singh

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Study Design: This prospective study was conducted at the department of Radio Diagnosis, at Pt B.D. Sharma PGIMS, Rohtak in 57 patients of spine injury on radiographs or radiographically normal patients with neurological deficits presenting within 72 hours of injury. Aims: Evaluation of the role of Magnetic Resonance Imaging (MRI) in Spinal Trauma Patients and to compare MRI findings with clinical profile and neurological status of the patient and to correlate the MRI findings with neurological recovery of the patient and predict the outcome. Material and Methods: Neurological status of patients was assessed at the time of admission and discharge in all the patients and at long term interval of six months to one year in 27 patients as per American spine injury association classification (ASIA). On MRI cord injury was categorized into cord hemorrhage, cord contusion, cord edema only, and normal cord. Quantitative assessment of injury on MRI was done using mean canal compromise (MCC), mean spinal cord compression (MSCC) and lesion length. Neurological status at admission and neurological recovery at discharge and long term follow up was compared with various qualitative cord findings and quantitative parameters on MRI. Results: Cord edema and normal cord was associated with favorable neurological outcome. Cord contusion show lesser neurological recovery as compared to cord edema. Cord hemorrhage was associated with worst neurological status at admission and poor neurological recovery. Mean MCC, MSCC, and lesion length values were higher in patients presenting with ASIA A grade injury and showed decreasing trends towards ASIA E grade injury. Patients showing neurological recovery over the period of hospital stay and long term follow up had lower mean MCC, MSCC, and lesion length as compared to patients showing no neurological recovery. The data was statistically significant with p value <.05. Conclusion: Cord hemorrhage and higher MCC, MSCC and lesion length has poor prognostic value in spine injury patients.

Keywords: spine injury, cord hemorrhage, cord contusion, MCC, MSCC, lesion length, ASIA grading

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Authors: Amirul Adlan, Motaz AlAqeel, Scott Evans, Vaiyapuri sumathi, Mark Davies, Rajesh Botchu

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Background & Objectives: Osteoid osteoma (OO) is a benign tumor of the bone commonly found in childhood and adolescence, causing bone pain, especially during the night. CT-guided radiofrequency ablation (RFA) is currently the mainstay treatment for OO. There is currently no literature reporting the outcomes of OO following RFA based on the histological presence of a nidus seen on a biopsy taken at the time of RFA. The primary aim of this study was to compare the clinical outcomes of OO between the group of patients with the presence of nidus on biopsy samples from RFA with those without nidus. Secondly, we aimed to examine other factors that may affect the outcomes of OO, reflecting our experience as a tertiary orthopedic oncology center. Methods: We retrospectively reviewed 88 consecutive patients diagnosed with osteoid osteoma treated with RFA between November 2005 and March 2015, consisting of 63 males (72%) and 25 females (28%). Sixty-six patients (75%) had nidus present in their biopsy samples. Patients’ mean age was 17.6 years (4-53). The median duration of follow-up was 12.5 months (6-20.8). Lesions were located in the appendicular skeleton in seventy-nine patients (90%), while nine patients (10%) had an OO in the axial skeleton. Outcomes assessed were based on patients’ pain alleviation (partial, complete, or no pain improvement) and the need for further interventions. Results: Pain improvement in the patient group with nidus in the histology sample was significantly better than in the group without nidus (OR 7.4, CI 1.35-41.4, p=0.021). The patient group with nidus on biopsy demonstrated less likelihood of having a repeat procedure compared to the group without nidus(OR 0.092, CI 0.016-0.542, p=0.008). Our study showed significantly better outcomes in pain improvement in appendicular lesions compared to the axially located lesions (p = 0.005). Patients with spinal lesions tend to have relatively poor pain relief than those with appendicular or pelvic lesions (p=0.007). Conclusions: Patients with nidus on histology had better pain alleviation compared to patients without nidus. The histological presence of nidus significantly reduces the chance of repeat interventions. The pain alleviation of osteoid osteoma following RFA is better in patients with appendicular lesions than spinal or axially located lesions.

Keywords: osteoid osteoma, benign tumour, radiofrequency ablation, oncology

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Authors: Makamas Kumprou, Pipatana Amatachaya, Sugalya Amatachaya, Thiwabhorn Thaweewannakij, Preeda Arayawichanon

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Many individuals with spinal cord injury (SCI) need an ambulatory assistive device (AAD) to promote their independence and experience of task-specific walking practice. Without a periodic follow-up for their walking progression, however, many individuals may use the same AAD even though up to 66% of them had the potential to progress walking ability. This may distort their optimal ability and increase the possibility of having negative impacts due to the long-lasting used of an AAD. However, these findings were cross-sectionally collected without data confirmation for the benefit or negative impacts of those who changed the types of AAD used. Therefore, this study prospectively assessed the proportion of ambulatory individuals with SCI who were able to progress their walking ability as determined using a type of AAD, and the changes of their functional ability as well as the incidence of falls over 6 months. Twenty-four subjects with SCI who daily walked with an AAD were involved in the study for 2 visits over 6 months. At the first visit (baseline assessments), the subjects were assessed for their spatiotemporal variables (i.e., cadence, step length, stride length, and step symmetry) and walking ability using the 10-meter walk test (10MWT). Then, they were assessed for the possibility of their walking progression as determined using the ability of walking with the least support AAD with no more than contact guarding assist. Those who were capable of changing an AAD were trained for the ability to walk with a new AAD. Thereafter, all subjects were monthly monitored for incidence of fall over 6 months. At the second visit (after 6 months followed-up), subjects were reassessed for their spatiotemporal variables and 10MWT. The findings indicated that, of all 24 subjects, 8 subjects (33.3%) were able to walk with less support AAD than their usual one. The walking cadence, step length symmetry, and walking ability of these subjects improved significantly greater than those who walked with the same AAD (p < 0.05). Among these subjects, one subject (12.5%) reported fell (3 times) during the follow-up period, whereas 5 subjects (31.3%) who walked with the same AAD experienced at least one fall (range 1 – 16 times). The findings indicated that a large proportion of ambulatory individuals with SCI who daily walked with an AAD could progress their walking ability, whereby their walking ability and safety also significantly improved after they walked with an optimal AAD. The findings suggest the need for a periodic follow-up for an appropriate AAD used for these individuals.

Keywords: walking device, walker, crutches, cane, rehabilitation

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Authors: Diane Ghanem, Arjun Gupta, Rohan Vijayan, Ali Uneri, Babar Shafiq

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Introduction: Ankle sprains and fractures often result in syndesmosis injuries. Unstable syndesmotic injuries result from relative motion between the distal ends of the tibia and fibula, anatomic juncture which should otherwise be rigid, and warrant operative management. Clinical and radiological evaluations of intraoperative syndesmosis stability remain a challenging task as traditional 2D fluoroscopy is limited to a uniplanar translational displacement. The purpose of this pilot cadaveric study is to compare the 2D fluoroscopy and 3D cone beam computed tomography (CBCT) stress-induced syndesmosis displacements. Methods: Three fresh-frozen lower legs underwent 2D fluoroscopy and 3D CIOS CBCT to measure syndesmosis position before dissection. Syndesmotic injury was simulated by resecting the (1) anterior inferior tibiofibular ligament (AITFL), the (2) posterior inferior tibiofibular ligament (PITFL) and the inferior transverse ligament (ITL) simultaneously, followed by the (3) interosseous membrane (IOM). Manual external rotation and Cotton stress test were performed after each of the three resections and 2D and 3D images were acquired. Relevant 2D and 3D parameters included the tibiofibular overlap (TFO), tibiofibular clear space (TCS), relative rotation of the fibula, and anterior-posterior (AP) and medial-lateral (ML) translations of the fibula relative to the tibia. Parameters were measured by two independent observers. Inter-rater reliability was assessed by intraclass correlation coefficient (ICC) to determine measurement precision. Results: Significant mismatches were found in the trends between the 2D and 3D measurements when assessing for TFO, TCS and AP translation across the different resection states. Using 3D CBCT, TFO was inversely proportional to the number of resected ligaments while TCS was directly proportional to the latter across all cadavers and ‘resection + stress’ states. Using 2D fluoroscopy, this trend was not respected under the Cotton stress test. 3D AP translation did not show a reliable trend whereas 2D AP translation of the fibula was positive under the Cotton stress test and negative under the external rotation. 3D relative rotation of the fibula, assessed using the Tang et al. ratio method and Beisemann et al. angular method, suggested slight overall internal rotation with complete resection of the ligaments, with a change < 2mm - threshold which corresponds to the commonly used buffer to account for physiologic laxity as per clinical judgment of the surgeon. Excellent agreement (>0.90) was found between the two independent observers for each of the parameters in both 2D and 3D (overall ICC 0.9968, 95% CI 0.995 - 0.999). Conclusions: The 3D CIOS CBCT appears to reliably depict the trend in TFO and TCS. This might be due to the additional detection of relevant rotational malpositions of the fibula in comparison to the standard 2D fluoroscopy which is limited to a single plane translation. A better understanding of 3D imaging may help surgeons identify the precise measurements planes needed to achieve better syndesmosis repair.

Keywords: 2D fluoroscopy, 3D computed tomography, image processing, syndesmosis injury

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Authors: Agata Migdalska, Joanna Berczynska, Ewa Bieniek, Jacek Sterna

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Muscle relaxation is considered important during general anesthesia for spine stabilization. In a presented case peripherally acting muscle relaxant was applied during general anesthesia for spine stabilization surgery. The patient was a dog, 11-years old, 26 kg, male, mix breed. Spine fracture was situated between Th13-L1-L2, probably due to the car accident. Preanesthetic physical examination revealed no sign underlying health issues. The dog was premedicated with midazolam 0.2 mg IM and butorphanol 2.4 mg IM. General anesthesia was induced with propofol IV. After the induction, the dog was intubated with an endotracheal tube and connected to an open-ended rebreathing system and maintained with the use of inhalation anesthesia with isoflurane in oxygen. 0,5 mg/ kg of rocuronium was given IV. Use of muscle relaxant was accompanied by an assessment of the degree of neuromuscular blockade by peripheral nerve stimulator. Electrodes were attached to the skin overlying at the peroneal nerve at the lateral cranial tibia. Four electrical pulses were applied to the nerve over a 2 second period. When satisfying nerve block was detected dog was prepared for the surgery. No further monitoring of the effectiveness of blockade was performed during surgery. Mechanical ventilation was kept during anesthesia. During surgery dog maintain stable, and no anesthesiological complication occur. Intraoperatively surgeon claimed that neuromuscular blockade results in a better approach to the spine and easier muscle manipulation which was helpful in order to see the fracture and replace bone fragments. Finally, euthanasia was performed intraoperatively as a result of vast myelomalacia process of the spinal cord. This prevented examination of the recovering process. Neuromuscular blocking agents act at the neuromuscular junction to provide profound muscle relaxation throughout the body. Muscle blocking agents are neither anesthetic nor analgesic; therefore inappropriately used may cause paralysis in fully conscious and feeling pain patient. They cause paralysis of all skeletal muscles, also diaphragm and intercostal muscles when given in higher doses. Intraoperative management includes maintaining stable physiological conditions, which involves adjusting hemodynamic parameters, ensuring proper ventilation, avoiding variations in temperature, maintain normal blood flow to promote proper oxygen exchange. Neuromuscular blocking agent can cause many side effects like residual paralysis, anaphylactic or anaphylactoid reactions, delayed recovery from anesthesia, histamine release, recurarization. Therefore reverse drug like neostigmine (with glikopyrolat) or edrofonium (with atropine) should be used in case of a life-threatening situation. Another useful drug is sugammadex, although the cost of this drug strongly limits its use. Muscle relaxant improves surgical conditions during spinal surgery, especially in heavily muscled individuals. They are also used to facilitate the replacement of dislocated joints as they improve conditions during fracture reduction. It is important to emphasize that in a patient with muscle weakness neuromuscular blocking agents may result in intraoperative and early postoperative cardiovascular and respiratory complications, as well as prolonged recovery from anesthesia. This should not appear in patients with recent spine fracture or luxation. Therefore it is believed that neuromuscular blockers could be useful during spine stabilization procedures.

Keywords: anesthesia, dog, neuromuscular block, spine surgery

Procedia PDF Downloads 155

Authors: Suehyun Cho, Darrell Harrington, Florent Cros, Olin Palmer, John Caputo, Michael Kardosh, Eran Oren, William Loudon, Alex Kiselyov, Michael Shpigelmacher

Abstract:

The Dandy-Walker malformation (DWM) represents a clinical syndrome manifesting as a combination of posterior fossa cyst, hypoplasia of the cerebellar vermis, and obstructive hydrocephalus. Anatomic hallmarks include hypoplasia of the cerebellar vermis, enlargement of the posterior fossa, and cystic dilatation of the fourth ventricle. Current treatments of DWM, including shunting of the cerebral spinal fluid ventricular system and endoscopic third ventriculostomy (ETV), are frequently clinically insufficient, require additional surgical interventions, and carry risks of infections and neurological deficits. Bionaut Labs develops an alternative way to treat Dandy-Walker Malformation (DWM) associated with non-communicating hydrocephalus. We utilize our discreet microsurgical Bionaut™ particles that are controlled externally and remotely to perform safe, accurate, effective fenestration of the Dandy-Walker cyst, specifically in the posterior fossa of the brain, to directly normalize intracranial pressure. Bionaut™ allows for complex non-linear trajectories not feasible by any conventional surgical techniques. The microsurgical particle safely reaches targets in the lower occipital section of the brain. Bionaut™ offers a minimally invasive surgical alternative to highly involved posterior craniotomy or shunts via direct fenestration of the fourth ventricular cyst at the locus defined by the individual anatomy. Our approach offers significant advantages over the current standards of care in patients exhibiting anatomical challenge(s) as a manifestation of DWM, and therefore, is intended to replace conventional therapeutic strategies. Current progress, including platform optimization, Bionaut™ control, and real-time imaging and in vivo safety studies of the Bionauts™ in large animals, specifically the spine and the brain of ovine models, will be discussed.

Keywords: Bionaut™, cerebral spinal fluid, CSF, cyst, Dandy-Walker, fenestration, hydrocephalus, micro-robot

Procedia PDF Downloads 190

Authors: Sasibhushan Yengala, Nelson Muthu, Subramani Kanagaraj

Abstract:

The abstract reports on the design related to a modular and affordable standing cum sitting device to meet the requirements of paraplegic patients of the different physiques. Paraplegic patients need the assistance of an external arrangement to the lower limbs and trunk to help patients adopt the correct posture while standing abreast gravity. This support can be from a tilt table or a standing frame which the patient can use to stay in a vertical posture. Standing frames are devices fitting to support a person in a weight-bearing posture. Commonly, these devices support and lift the end-user in shifting from a sitting position to a standing position. The merits of standing for a paraplegic patient with a spinal injury are numerous. Even when there is limited control on muscles that ordinarily support the user using the standing frame in a vertical position, the standing stance improves the blood pressure, increases bone density, improves resilience and scope of motion, and improves the user's feelings of well-being by letting the patient stand. One limitation with standing frames is that these devices are typically function definitely; cannot be used for different purposes. Therefore, users are often compelled to purchase more than one of these devices, each being purposefully built for definite activities. Another concern frequent in standing frames is manoeuvrability; it is crucial to provide a convenient adjustment scope for all users. Thus, there is a need to provide a standing frame with multiple uses that can be economical for a larger population. There is also a need to equip added readjustment means in a standing frame to lessen the shear and to accommodate a broad range of users. The proposed Versatile Standing cum Sitting Device (VSD) is designed to change from standing to a comfortable sitting position using a series of mechanisms. First, a locking mechanism is provided to lock the VSD in a standing stance. Second, a dampening mechanism is provided to make sure that the VSD shifts from a standing to a sitting position gradually when the lock mechanism gets disengaged. An adjustment option is offered for the height of the headrest via the use of lock knobs. This device can be used in clinics for rehabilitation purposes irrespective of patient's anthropometric data due to its modular adjustments. It can facilitate the patient's daily life routine while in therapy and giving the patient the comfort to sit when tired. The device also provides the availability of rehabilitation to a common person.

Keywords: paraplegic, rehabilitation, spinal cord injury, standing frame

Procedia PDF Downloads 177

Authors: Yuko Ishiwaka, Tomohiro Yoshida, Tadateru Itoh

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Human makes preparation called readiness potential unconsciously (RP) before awareness of their own decision. For example, when recognizing a button and pressing the button, the RP peaks are observed 200 ms before the initiation of the movement. It has been known that the preparatory movements are acquired before actual movements, but it has not been still well understood how humans can obtain the RP during their growth. On the proposition of why the brain must respond earlier, we assume that humans have to adopt the dangerous environment to survive and then obtain the behavior to cover the various time lags distributed in the body. Without RP, humans cannot take action quickly to avoid dangerous situations. In taking action, the brain makes decisions, and signals are transmitted through the Spinal Cord to the muscles to the body moves according to the laws of physics. Our research focuses on the time lag of the neuron signal transmitting from a brain to muscle via a spinal cord. This time lag is one of the essential factors for readiness potential. We propose a firing pattern controller model of a motor nerve system considered innervation and jitter, which produces time lag. In our simulation, we adopt innervation and jitter in our proposed muscle-skeleton model, because these two factors can create infinitesimal time lag. Q10 Hodgkin Huxley model to calculate action potentials is also adopted because the refractory period produces a more significant time lag for continuous firing. Keeping constant power of muscle requires cooperation firing of motor neurons because a refractory period stifles the continuous firing of a neuron. One more factor in producing time lag is slow or fast-twitch. The Expanded Hill Type model is adopted to calculate power and time lag. We will simulate our model of muscle skeleton model by controlling the firing pattern and discuss the relationship between the time lag of physics and neurons. For our discussion, we analyze the time lag with our simulation for knee bending. The law of inertia caused the most influential time lag. The next most crucial time lag was the time to generate the action potential induced by innervation and jitter. In our simulation, the time lag at the beginning of the knee movement is 202ms to 203.5ms. It means that readiness potential should be prepared more than 200ms before decision making.

Keywords: firing patterns, innervation, jitter, motor nerve system, readiness potential

Procedia PDF Downloads 802

Authors: Atitallah Sofien, Bouyahia Olfa, Romdhani Meriam, Missaoui Nada, Ben Rabeh Rania, Yahyaoui Salem, Mazigh Sonia, Boukthir Samir

Abstract:

Introduction: Spondylothoracic dysostosis, also known as Jarcho-Levin syndrome, is defined by a shortened neck and thorax, a protruding abdomen, inguinal and umbilical hernias, atypical spinal structure and rib fusion, leading to restricted chest movement or difficulty in breathing, along with urinary tract abnormalities and, potentially severe scoliosis. Aim: This is the case of a patient diagnosed with Jarcho-Levin syndrome, aiming to detail the range of abnormalities observed in this syndrome, the observed complications, and the therapeutic approaches employed. Results: A three-month-old male infant, born of a consanguineous marriage, delivered at full term by cesarean section, was admitted to the pediatric department for severe acute bronchiolitis. In his prenatal history, morphological ultrasound revealed macrosomia, a shortened spine, irregular vertebrae with thickened skin, normal fetal cardiac ultrasound, and the absence of the right kidney. His perinatal history included respiratory distress, requiring ventilatory support for five days. Upon physical examination, he had stunted growth, scoliosis, a short neck and trunk, longer upper limbs compared to lower limbs, varus equinus in the right foot, a neural tube defect, a low hairline, and low-set ears. Spondylothoracic dysostosis was suspected, leading to further investigations, including a normal transfontaneous ultrasound, a spinal cord ultrasound revealing a lipomyelocele-type closed dysraphism with a low-attached cord, an abdominal ultrasound indicating a single left kidney, and a cardiac ultrasound identifying Kommerell syndrome. Due to a lack of resources, genetic testing could not be performed, and the diagnosis was based on clinical criteria. Conclusion: Jarcho-Levin syndrome can result in a mortality rate of about 50%, primarily due to respiratory complications associated with thoracic insufficiency syndrome. Other complications, like heart and neural tube defects, can also lead to premature mortality. Therefore, early diagnosis and comprehensive treatment involving various specialists are essential.

Keywords: Jarcho-Levin syndrome, congenital disorder, scoliosis, spondylothoracic dysostosis, neural tube defect

Procedia PDF Downloads 34

Authors: Hemabushan K., Manikandan

Abstract:

In a swirl atomizer, fluid undergoes a swirling motion as a result of centrifugal force created by opposed tangential inlets in the swirl chamber. The angular momentum of fluid continually increases as it reaches the exit orifice and forms a hollow sheet. Which disintegrates to form ligaments and droplets respectively as it flows downstream. This type of atomizers used in rocket injectors and oil burner furnaces. In this present investigation a swirl atomizer with two opposed tangential inlets has been designed. Water as working fluid, experiments had been conducted for the fluid injection pressures in regime of 0.033 bar to 0.519 bar. The fluid has been pressured by a 0.5hp pump and regulated by a pressure regulator valve. Injection pressure of fluid has been measured by a U-tube mercury manometer. The spray pattern and the droplets has been captured with a high resolution camera in black background with a high intensity flash highlighting the fluid. The unprocessed images were processed in ImageJ processing software for measuring the droplet diameters and its shape characteristics along the downstream. The parameters such as mean droplet diameter and distribution, wave pattern, rupture distance and spray angle were studied for this atomizer. The above results were compared with theoretical results and also analysed for deviation with design parameters.

Keywords: swirl atomizer, injector, spray, SWIRL

Procedia PDF Downloads 466

Authors: Jheanel E. Estrada, Larry A. Vea

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This study developed model to detect proper/improper sitting posture using the built in web camera which detects the upper body points’ location and distances (chin, manubrium and acromion process). It also established relationships of human body frames and proper sitting posture. The models were developed by training some well-known classifiers such as KNN, SVM, MLP, and Decision Tree using the data collected from 60 students of different body frames. Decision Tree classifier demonstrated the most promising model performance with an accuracy of 95.35% and a kappa of 0.907 for head and shoulder posture. Results also showed that there were relationships between body frame and posture through Body Mass Index.

Keywords: posture, spinal points, gyroscope, image processing, ergonomics

Procedia PDF Downloads 305

Authors: Majid A. AlSayari

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The study reported here investigated social cognitive theory (SCT) in the context of Vocational Rehab (VR) for people with disabilities. The prime purpose was to increase knowledge of VR phenomena and make recommendations for improving VR services. The sample consisted of 242 persons with Spinal Cord Injuries (SCI) who completed questionnaires. A further 32 participants were Trainers. Analysis of questionnaire data was carried out using factor analysis, multiple regression analysis, and thematic analysis. The analysis suggested that, in motivational terms, and consistent with research carried out in other academic contexts, self-efficacy was the best predictor of VR performance. The author concludes that that VR self-efficacy predicted VR training performance.

Keywords: people with physical disabilities, social cognitive theory, self-efficacy, vocational training

Procedia PDF Downloads 275

Authors: Kyeong-Ri Ko, Seong Bong Bae, Jang Sik Choi, Sung Bum Pan

Abstract:

A simple method for testing the posture imbalance of the human body is to check for differences in the bilateral shoulder and pelvic height of the target. In this paper, to check for spinal disorders the authors have studied ways to establish a motion capture system to obtain and express motions of 4-joints, and to acquire data based on this system. The 4 sensors are attached to the both shoulders and pelvis. To verify the established system, the normal and abnormal postures of the targets listening to a lecture were obtained using the established 4-joint based motion capture system. From the results, it was confirmed that the motions taken by the target was identical to the 3-dimensional simulation.

Keywords: inertial sensor, motion capture, motion data acquisition, posture imbalance

Procedia PDF Downloads 489

Authors: Sangram A. Sathe, Neha A. Madgulkar, Shruti S. Raut, S. P. Wadkar

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Transforaminal lumbar interbody fusion (TLIF) surgeries have nowadays became popular for treatment of degenerated spinal disorders. The interbody fusion technique like TLIF maintains load bearing capacity of the spine and a suitable disc height. Currently many techniques have been introduced to cure Spondylolisthesis. This surgery provides greater rehabilitation of degenerative spines. While performing this TLIF surgery existing methods use guideway, which is a troublesome surgery technique as the use of two separate instruments is required to perform this surgery. This paper presents a concept which eliminates the use of guideway. This concept also eliminates problems that occur like reverting the cage. The concept discussed in this paper also gives high accuracy while performing surgery.

Keywords: TLIF, spondylolisthesis, spine, instruments

Procedia PDF Downloads 309

Authors: Sukhwinder K. Bhullar, M. B. G. Jun

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The developments in biomedical industry have demanded the development of biocompatible, high performance materials to meet higher engineering specifications. The general requirements of such materials are to provide a combination of high stiffness and strength with significant weight savings, resistance to corrosion, chemical resistance, low maintenance, and reduced costs. Auxetic materials which come under the category of smart materials offer huge potential through measured enhancements in mechanical properties. Unique deformation mechanism, providing cushioning on indentation, automatically adjustable with its strength and thickness in response to forces and having memory returns to its neutral state on dissipation of stresses make them good candidate in biomedical industry. As simple extension and compression of tissues is of fundamental importance in biomechanics, therefore, to study the elastic behaviour of auxetic soft tissues implant is targeted in this paper. Therefore development and characterization of auxetic soft tissue implant is studied in this paper. This represents a real life configuration where soft tissue such as meniscus in knee replacement, ligaments and tendons often are taken as transversely isotropic. Further, as composition of alternating polydisperse blocks of soft and stiff segments combined with excellent biocompatibility make polyurethanes one of the most promising synthetic biomaterials. Hence selecting auxetic polyurathylene foam functional characterization is performed and compared with conventional polyurathylene foam.

Keywords: auxetic materials, deformation mechanism, enhanced mechanical properties, soft tissues

Procedia PDF Downloads 443

Authors: S. AliReza Mirghasemi, Amin Mohamadi, Zameer Hussain, Narges Rahimi Gabaran, Mir Mostafa Sadat, Shervin Rashidinia

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In progressive cases of Ankylosing Spondylitis, patients will have high degrees of kyphosis leading to severe disabilities. Several operative techniques have been used in this stage, but little knowledge exists on the indications for and outcome of these methods. In this study, we examined the efficacy of monosegmental transverse open wedge osteotomy of L3 in 11 patients with progressive spinal kyphosis. The average correction was 36̊ (20 to 42) with no loss of correction after operation. The average operating time was 120 minutes (100 to 130) and the mean blood loss was 1500 ml (1100 to 2000). Osteotomy corrected all patients sufficiently to allow them to see ahead and their posture was improved. There were no fatal complications but one patient had paraplegia after the operation.

Keywords: ankylosing spondylitis, thoracolumbar kyphosis, open wedge osteotomy, L3 transverse open wedge osteotomy

Procedia PDF Downloads 358

Authors: Rim Frikha, Nouha Bouayed Abdelmoula, Afifa Sellami, Salima Daoud, Tarek Rebai

Abstract:

Klippel-Feil Syndrome (KFS) is characterized by congenital vertebral fusion of the cervical spine resulting from faulty segmentation along the embryo's developing axis. A wide spectrum of associated anomalies may be present. This heterogeneity has complicated elucidation of the genetic etiology and management of the syndrome. We report a case of an isolated Klippel-Feil Syndrome with C5-C6 fusion on the cervical spine. It‘s the rarest form of congenital fused cervical vertebrae which is predisposed to the risk of spinal cord injury and neurologic problems. The aim of this paper was to review clinical heterogeneity; radiographic abnormalities and genetic etiology in Klippel-Feil Syndrome. We insist in comprehensive evaluation and delineation of diagnostic and prognostic classes.

Keywords: Klippel–Feil anomaly, genetic, clinical heterogeneity, radiographic abnormalities

Procedia PDF Downloads 459