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All abdominal operations for rectal prolapse testing may be performed to provide postoperative prognos- have been performed laparoscopically with equivalent tic information for patient counseling discount isoniazid 300 mg symptoms nausea headache. For patients with sig- recurrence rates (4–8 %) compared with open approaches; niﬁcant chronic constipation buy discount isoniazid 300 mg online symptoms of strep throat, a preoperative colon transit however 300mg isoniazid for sale treatment vertigo, improvements in pain control purchase isoniazid 300 mg with mastercard medicine shoppe, length of stay, and study should be performed to assess whether a concomitant return of bowel function have been observed with laparos- total abdominal colectomy should be considered (Varma copy (Varma et al. Two general surgical approaches are of the anus and excisional rectosigmoidectomy. The surgical approach encirclement, the Thiersch procedure, has evolved over is chosen based on the patients’ comorbidities and bowel time but has been relegated to historical curiosity due to function as well as the surgeon’s preference and experi- high rates of recurrence and septic complications. The abdominal approaches generally have the lowest rectosigmoidectomy involves a full-thickness resection recurrence rates and are the preferred treatment for health- of the rectum and sigmoid colon through the anus with ier patients. However, although morbidity and mortality a coloanal hand-sewn or stapled anastomosis (Altemeier rates are low after an abdominal approach, they are slightly et al. Compared with an abdominal approach, this higher than rates associated with perineal repairs (Varma operation involves a shorter hospital stay and has lower et al. The perineal approaches result in reduced mor- complication rates (10 %), which include anastomotic bidity, pain, and hospital stay; however, recurrence rates are bleeding, pelvic abscess, and, rarely, an anastomotic leak; higher than those for abdominal operations. Furthermore, however, recurrence rates have been reported to be as high as the rectum is removed, suboptimal functional outcomes as 16–30 %. A Delorme procedure, circum- Abdominal approaches include rectopexy, with or with- ferential mucosal sleeve resection and imbrication of the out a segmental resection. Fixation of the rectum in the pel- muscularis layer with serial vertical sutures, can be per- vis with suture, ﬁrst described by Cutait in 1959, aims to formed for short full-thickness rectal prolapse or mucosal correct the telescoping of the redundant bowel and causes prolapse. Recurrence rates are higher for this procedure ﬁxation of the rectum from the resultant scarring and ﬁbro- than for perineal rectosigmoidectomy, and the recurrence sis (Cutait 1959; Madoff and Mellgren 1999). The recur- rates for all perineal procedures are higher than for all rence rates for suture rectopexy are generally reported to be abdominal procedures. The second stage is gen- erally a restorative completion proctocolectomy with ileal Mucosal Ulcerative Colitis J-pouch-anal anastomosis and a diverting loop ileostomy. It is conﬁned to the colonic the “J”-pouch conﬁguration is the most widely used because mucosa and characteristically starts in the rectum and of its simplicity, suitability for ﬁtting into the pelvis, and extends proximally without skip lesions. A stapled pouch- 50 % of cases have disease conﬁned to the rectum, 30 % anal anastomosis is then performed 1–2 cm from the dentate have disease extending to the left colon, and 20 % have line. Backwash However, if the patient has a history of low rectal cancer or ileitis (inﬂammation of the most distal terminal ileum sec- dysplasia, a mucosectomy and hand-sewn ileoanal anasto- ondary to reﬂux of stool from the cecum (Gordon and mosis may be performed (Lovegrove et al. Prior to Nivatvongs 2007)) may occur in up to 10 % of patients and the third operation, closure of the diverting loop ileostomy, resolves after surgery. The progression of the disease may the integrity of the anastomosis is assessed with a pouchos- be insidious, acute, or fulminant. Typically, patients include chronic disease refractory to medical management, have excellent outcomes following this procedure, averag- complications of medical management, dysplasia or can- ing approximately six to ten bowel movements per day with cer, fulminant colitis, growth retardation (in children), or good control and no urgency. The goal of surgery is to cure the patient Patients with all other surgical indications may be candi- from disease and, whenever possible and desirable, to dates for a two-stage procedure: restorative proctocolec- restore intestinal continuity. This procedure may be per- tomy and ileoanal pouch anastomosis with diverting loop formed in one to three stages. Prior to largely depends on the patient’s current nutritional status, offering a restorative proctocolectomy with ileoanal pouch medical ﬁtness, recent use of immunosuppressant medica- anastomosis, the surgeon must have diligently excluded any tions, and sphincter function. This conﬁrmation can be achieved by of Truelove and Witts and is deﬁned as colitis with more a detailed history and examination to exclude any perianal than six bloody stools per day, fever (temperature >37. In approximately 40 % of patients, there is a are malnourished, receiving high-dose steroids (>40 mg/ disparity in diagnosis between general and specialist pathol- day) or tumor necrosis factor inhibitors, or who have inde- ogists; thus a preoperative review of previous colonoscopic terminate colitis (The Standards Practice Task Force of The biopsies by a gastrointestinal expert pathologist is important American Society of Colon and Rectal Surgeons 2005 ). It is important at this ﬁrst operation that the presacral alternate procedure is a total proctocolectomy and continent space be preserved and the integrity of the stapled rectosig- ileostomy (“Kock pouch”) which is constructed from 45 cm moid stump be assured. If there is any question about this of distal terminal ileum with intussusception of the ileum seal, the staple line may be oversewn, or a mucous ﬁstula just back into the pouch to create a nipple valve. This procedure is often has not gained widespread acceptance because of its intricate well suited for a laparoscopic approach. In addition to mini- construction and its high rate of complications, namely, val- mizing scars, pain, and disability, the laparoscopic method vular dysfunction requiring revisions. In this setting, the authors recommend delay of the pouch anastomosis have been demonstrated in the elderly, completion proctectomy and ileoanal pouch reconstruction with physiologic age, rather than chronological age being a to allow a period of observation for the clinical evolution of determining factor (Takao et al. If after 6–12 months, there is no evidence of Crohn’s disease, an ileoanal pouch reconstruction can be offered to Obesity the patient after an informed discussion. Pouch failure rates Ileoanal pouch reconstruction is feasible in patients with a for indeterminate colitis may be as low as those for ulcer- body mass index >30 kg/m2; however, it is associated with ative colitis or slightly higher (2–10 %) (Delaney et al. Furthermore, it is the authors’ experience that obesity decreases the ease and likelihood of pouch reach. Accordingly, treatment focuses on safely alleviating Laparoscopy has been shown to be safe and effective, disease symptoms and restoring quality of life while attempt- and in most cases superior for two- and three-stage restor- ing to maintain continuity of the intestinal tract. Surgery is indicated for complications of disease (nondrainable abscesses, per- Pouch That Does Not Reach foration, chronic bleeding and anemia, stricture formation, There are several maneuvers that can be performed if there fulminant colitis, and the development of dysplasia or adeno- is inadequate pouch length to perform a tension-free pouch- carcinoma) and failure of medical management (including anal anastomosis. First, it is important to ensure complete dependence on high doses of immunosuppressive agents and mobilization of the small bowel mesentery up to and ante- steroids) (Standards Practice Task Force of The American rior to the duodenum. Second, a slightly more proximal por- Society of Colon and Rectal Surgeons 2007 ). Third, superﬁcial inci- colitis should undergo a total abdominal colectomy with end sions on the anterior and posterior aspects of the small ileostomy (Standards Practice Task Force of The American bowel mesentery along the course of the superior mesen- Society of Colon and Rectal Surgeons 2007 ). Fourth, selective division of anemia, malnutrition, and sepsis rapidly resolve following mesenteric vessels to the apex of the proposed J-pouch can colectomy. Last, division of the ileocolic vessels can be mended in select patients who demonstrate minimal mucosal performed. Finally, when the ileum will not reach the pelvic inﬂammation, adequate rectal compliance, absence of ano- ﬂoor despite these maneuvers, it may be necessary to staple rectal disease, and good sphincter function. Otherwise, the the distal rectum and perform an abdominal colectomy and diseased rectum may be removed or left in place with appro- end ileostomy with Hartmann’s pouch. Isolated sigmoid or left-sided tis, the diagnosis of Crohn’s or ulcerative colitis is equivocal colon disease can be treated with a segmental colectomy, even after a thorough endoscopic and histopathologic evalu- whereas disease limited to the rectum can be treated with ation. The preferred approach for these patients is a total abdominoperineal proctectomy with end colostomy. If a diagnosis of ulcerative colitis rence rate compared to proctocolectomy with ileostomy. Wexner In the presence of pancolitis, a proctocolectomy with end are the most common presenting symptoms (Beck et al. Thorough physical examination and standard ing a proctectomy and permanent stoma, an intersphincteric preoperative laboratory tests should be performed. Because resection has been found to improve perineal wound healing, anemia is common in colon cancer patients, it is important to a difﬁcult and morbid complication of this procedure check hemoglobin level prior to surgery. Whenever possible, all patients should undergo a full colonic evaluation prior to surgery. The majority of patients will have undergone a colonos- Premalignant and Malignant Conditions copy; however, conﬁrmation of a complete examination is important as the risk of synchronous carcinomas or adeno- Polyps mas within the colon may be as high as 10 % in the general population (Standards Practice Task Force of the American Adenomas are the most common colorectal polyps and are Society of Colon and Rectal Surgeons 2012). The risk of invasive cancer increases with polyp size planned and endoscopic localization is unreliable (all loca- and histology (degree of villous component) (Stein and Coller tions except for the cecum and distal rectum).

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Sometimes there is an iliac part of the abscess which is determined by cross-fluctuation buy 300 mg isoniazid with amex symptoms 9dpo. Examinations of the back and corresponding iliac fossa including X-rays clarify the diagnosis buy isoniazid 300mg fast delivery treatment zone lasik. Presence of osteoarthritis in the hip joint buy 300mg isoniazid otc symptoms 0f gallbladder problems, a cystic swelling generic 300 mg isoniazid visa symptoms diverticulitis, absence of impulse on coughing and that the swelling diminishes in size during flexion of the hip joint are the diagnostic points in favour of this condition. The neck of the hernia is generally wide and hardly gives rise to intestinal obstruction or strangulation. The main diagnostic features are — (i) Bulge through the centre of the umbilical scar everting the whole umbilicus; (ii) Age of the patient; (iii) The swelling is easily reducible (spontaneously reduced when the child lies down) and there is definite impulse on crying; (iv) The size of the hernia varies — it may be a small defect admitting the tip of the little finger alone to quite a large opening admitting two or three fingers; (v) The content is usually small intestine, so resonant to percussion; (vi) About 90% of these herniae disappear spontaneously during the first 5 years of life as the umbilical scar thickens and contracts. It is very rare in comparison to the para-umbilical hernia which is described below. Almost invariably it is due to raised intra-abdominal pressure which has forced the hernia through the umbilical scar. One must try to find out the cause of raised intra-abdominal pressure in these cases. Common causes are — pregnancy, ascites, bowel distension, ovarian cyst and fibroid. The usual site is just above the umbilicus between the two recti, in fact lower half of the fundus of the sac is covered by the umbilicus. The diagnostic features are as follows : (i) Para-umbilical hernia develops in the middle and old age; (ii) Obese women are more commonly affected; (iii) Usual symptoms are pain and swelling. If the swelling is very small, it may not be noticed by the patient and the pain and discomfort become the main symptoms; (iv) The surface is smooth and the edge is distinct except when the patient is very fat; (v) It contains omentum or bowel. The lump is soft and resonant to percussion when the content is bowel; (vi) Many paraumbilical herniae are irreducible when the contents become adherent to the sac or the neck of the sac becomes narrow. If the hernia can be reduced, the firm fibrous edge of the defect in the linea alba can be felt; (vii) As the defect in the linea alba is firm and does not enlarge proportionately these herniae do give rise to intermittent abdominal pain, though strangulation is not common. This defect is usually placed somewhere between the xiphisternum and the umbilicus. So whenever a patient will complain of epigastric discomfort or pain palpate the abdominal wall first to detect a small lump of epigastric hernia. It must be remembered that usually these herniae do not have impulse on coughing and cannot be reduced. That the swelling cannot be moved over the underlying structures favours the diagnosis of epigastric hernia. By repeated contractions of the flat muscles of the abdomen the two recti show tendency to diverge particularly when the linea alba is weak. In this condition the hernial sac passes between the layers of the anterior abdominal wall. There is another superior lumbar triangle being bounded by the 12th rib above, by the sacrospinalis medially and the posterior border of the internal oblique laterally. Incisional lumbar hernia may follow an operation on kidney, the incisional wound being infected. Pain often radiates along the obturator nerve and may even be referred to the knee via its geniculate branch. The leg is usually kept in the semiflexed position and movement of the limb gives rise to pain. If the limb is flexed, abducted and rotated outwards the hernia becomes prominent. Patients are mostly over 60 years of age and women are more frequently affected than men. Tuberculous thickening of the cord, as an extension upwards from the epididymis, is also associated with pain. Sudden agonising pain over inguinoscrotal region and in the lower abdomen is complained of in torsion of the testis. A varicocele appears spontaneously whereas a funiculitis starts with fever, ushered in with chill and rigor. An inguinal hernia appears from above whereas an infantile hydrocele, testicular growth and varicocele appear from below. An encysted hydrocele of the cord and diffuse lipoma of the cord appear first in the cord and then gradually enlarge. Undescended testis may give rise to the swelling in the inguinal region from the beginning. A varicocele disappears spontaneously when the patient lies down with the scrotum elevated. A lymph varix also reduces spontaneously on lying down although slower than a varicocele. Rapid onset of varicocele on the left side with haematuria indicates carcinoma of the kidney on that side. Sterility may be complained of in case of bilateral undescended testes (cryptorchism). A localised swelling in the spermatic cord is encysted hydrocele of the cord whereas a diffuse swelling of the cord may be a lipoma. A swelling in the superficial inguinal pouch (just above and slight lateral to the superficial inguinal ring) with absence of testis in the scrotum is probably an ectopic testis. Similarly a swelling in the inguinal region with absence of testis in the scrotum is an undescended testis. This must be differentiated from strangulated hernia which also shows signs of inflammation. It must be remembered that lymph varix (lymphangiectasis) also gives an impulse (thrill-like) on coughing. A diffuse swelling of the cord may be a lipoma when it is non-inflammatory and a funiculitis when it is inflammatory. The commonest position of an ectopic testis is at the superficial inguinal pouch whereas an undescended testis may be felt in the inguinal canal. But a lymph varix and a varicocele become spontaneously reduced when the patient lies down. After reduction the external abdominal ring is pressed with a finger and the patient is asked to stand up. A varicocele and a lymph varix also give impulse on coughing, but the impulse is felt like a thrill and is not the typical expansile impulse as felt in the case of a hernia. Percussion is helpful in differentiating a strangulated hernia from acute funiculitis, the former being resonant as it contains the intestine. It is always advisable to examine the testis, epididymis and the spermatic cord in these cases.

The gauze ﬂuffs are then taped into musculature with interrupted 3-0 silk: About six such sutures place over the graft discount 300 mg isoniazid amex treatment 1st degree burns. Then insert a con- tinuous over-and-over suture of atraumatic 5-0 nylon to attach the skin graft to the edges of the skin defect using Split-Thickness Skin Graft small bites isoniazid 300mg mastercard medicine and technology. When there is no surplus of skin on the chest wall to be har- Make multiple puncture wounds in the skin graft with a vested for a skin graft cheap isoniazid 300 mg without a prescription symptoms pulmonary embolism, use a dermatome to obtain a split- No order 300mg isoniazid mastercard 5 asa medications. Chassin iodophor solution has been applied, dry the area and apply a sterile lubricating solution of mineral oil. Have the assistants then stretch the skin by applying traction in opposite direc- tions with wooden tongue depressors. Apply the dermatome to the sur- face of the skin with ﬁrm pressure and activate it. It may be helpful for the scrub nurse to pick up the cut edge of the graft with two forceps while the surgeon continues to operate the dermatome until an adequate patch of skin has been obtained. Dress the donor site with a semipermeable plastic adhe- sive skin covering followed by a dry sterile dressing. Postoperative Care Unless there are signs of infection, leave the gauze stent from the skin graft in place for 5–7 days. Remove the gauze dressing from the donor site the day after surgery, but leave the plastic dressing intact until the site is healed (1–2 weeks). If blood or serum accumulates under the plastic dressing, aspirate it with a small sterile needle. With reference to the skin graft, complications include infection of the grafted area and occasionally of the donor site. Failure of a complete “take” is generally due to hema- toma or serum collecting underneath the graft and separating it from its bed. It can be prevented by careful hemostasis at the time of surgery and by making several perforations with a scalpel blade to permit seepage of serum. Low risk of locoregional recurrence of primary breast carcinoma after treatment with a modi- ﬁcation of the Halsted radical mastectomy and selective use of radiotherapy. Chassin† Indications Preoperative Preparation Wide Local Excision Wide local excision requires no speciﬁc preoperative preparation. Patients receive an injection of technetium 99m in The diagnosis of melanoma is usually made by punch or nuclear medicine several hours before surgery. Occasionally a shave biopsy will have Lymphoscintigraphy is performed to determine the drain- been performed. Wide local excision is indicated for local age pattern and help guide incision placement. The width of the margin required is determined by Blue dye, if used, is injected on the operating table after the thickness of the lesion. Pitfalls and Danger Points Sentinel Lymph Node Biopsy Inadequate excision Failure to identify a positive sentinel lymph node due to Sentinel lymph biopsy is used to stage clinically node- technical problems or poor localization negative patients whose melanomas exhibit any of the fol- lowing characteristics: • Thickness ≥1. Often the diagnosis of melanoma will ered an indication for completion node dissection (see Chaps. Biopsy Contraindications The manner in which that diagnostic biopsy was done can Widespread metastatic disease may be a contraindication. Therefore, a Sentinel node biopsy is rarely indicated in known node- few words are in order about the unique considerations positive patients. For the extremities, this requires placing the long axis parallel to the long axis of the limb (rather than in a natural skin crease). For the torso, incisions parallel to the likely lymphatic drain- age pattern are often preferred; however, the skin is usually loose enough that a skin crease incision can be made. If the lesion is large, take a representative biopsy from the thickest (non-ulcerated) part of the lesion either by making a small incision or performing a punch biopsy. Wide Local Excision The margin is deﬁned from the edge of the lesion or edge of the biopsy site if the lesion has been “biopsied away. Then plan the long axis of your excision site and draw Thus, even for extremity melanoma, lymphoscintigraphy may triangles at both ends to convert your circle into a lens- be helpful. The trunk can be divided into four quadrants by a advocated to allow closure without “dog ears” at the ends, vertical line down the middle and a transverse line at the level of but fatter excisions can be used if necessary. Generally the lymphatics drain to the regional following general guidelines into consideration. For the lymph node basin in their respective quadrant; thus, the skin of extremities, use an incision parallel to the long axis of the the left upper quadrant of the trunk will usually drain to the left extremity. Plan your excision ﬁrst and ies from person to person, so lymphatic drainage in this region is worry about closure later. It is no longer con- and lymphoscintigraphy to localize the node is of crucial impor- sidered necessary to take the fascia with the excision. Sometimes a local rotation or tis- would not have been predicted based upon anatomic location. It also makes it easy to see and clip or ligate lym- primary or transposed local tissue closure is not feasible. Because blue dye travels through the lymphatic system rapidly, it is injected just before surgery. Sentinel Lymph Node Biopsy Use the gamma probe to identify the region of greatest radioactivity and make an incision over this spot (see Chap. Always make this incision in such a way that you can tinel lymph node biopsy are discussed in detail in Chap. The • Complex layered closure (if used) radius of the circle depends upon the thickness of the mela- • Flap closure (if used) noma, with 1 cm being adequate for thin melanomas • If split-thickness skin graft, document area grafted in (<1. As noted previously (see Operative Strategy ), intermediate-thickness melanomas generally are excised with 1–2 cm margins. Operative Technique Convert the circle to an elliptical or lens-shaped incision by outlining two triangles at apposing ends (Fig. Frequently, wide excision and sentinel node biopsy are done Align the long access of the resulting incision with the under the same anesthesia. It may be possible to position the regional lymphatics or the long axis of the limb (if arm or patient to allow both procedures to be done under the same leg). Melanomas of the head and neck present particular prep, for example, a melanoma of the anterior trunk which challenges (see references at the end). However, in many cases, it will be Incise the skin sharply and deepen the incision straight necessary to reposition the patient and re-prep and redrape to down to the deep fascia. Grasp one end of the specimen with provide optimum exposure for both portions of the operation. If this step is performed immediately rior) and submit it for pathological examination. We rarely use a subcuticular closure for this purpose, as the incision is gener- ally under some tension. This decision is best made at the initial part of the procedure and the incision outlined accordingly. Sentinel Lymph Node Biopsy Reposition and drape the patient, if necessary, to provide optimal exposure of the appropriate nodal basin as deter- mined by the lymphoscintigram.

Diseases

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Sacral defect anterior sacral meningocele
Uniparental disomy of 13
3-M syndrome, rare (NIH)
Luteinizing hormone releasing hormone, deficiency of with ataxia
Cerebral ventricle neoplasms
Adducted thumb club foot syndrome
Hyperimmunoglobulinemia D with periodic fever
Gastrointestinal autonomic nerve tumor

Fibrous dysplasia Proliferation of fibrous tissue in the medullary cavity may infrequently involve the spine and cause one or more vertebral bodies to expand order 300 mg isoniazid treatment definition math. Essentially complete fusion of the cervical spine into a solid mass in a patient with Klippel-Feil deformity buy isoniazid 300 mg fast delivery symptoms heart attack women. Primarily the bone density of the vertebral body decreases the involves the lumbar and lower thoracic spine cortex appears as a thin line that is relatively dense (where weight-bearing stress is directed toward and prominent cheap isoniazid 300mg with mastercard symptoms for bronchitis, producing a picture-frame pattern purchase 300mg isoniazid with mastercard administering medications 7th edition. In addition to the typical “fish vertebrae” appear- ance, osteoporotic vertebral bodies may demon- strate anterior wedging and compression fractures. The characteristic concave contours of the superior and inferior disk surfaces result from expansion of the nucleus pulposus into the weakened vertebral bodies. Hyperparathyroidism Generalized demineralization of the vertebral Subchondral resorption at the diskovertebral bodies produces arch-like contour defects of junctions produces areas of structural weakening the superior and inferior vertebral surfaces, that allow herniation of disk material into the simulating osteoporosis. In patients with hyperparathyroidism secondary to renal failure, thick bands of increased density adjacent to the superior and inferior margins of vertebral bodies produce the characteristic “rugger jersey” spine. This results in a striking thickening of the cortices and increased trabeculation of spongy bone. Nevertheless, the bony architecture is abnormal and is prone to fracture with relatively minimal trauma. Severe loss of bone substance in the the pedicles (lacking red marrow) that are fre- spine often results in multiple vertebral com- quently destroyed by metastatic disease. Metastases Destructive process involving not only the Destruction of one or more pedicles may be the vertebral bodies but also the pedicles and neural earliest sign of metastatic disease and aids in arches. Pathologic collapse of vertebral bodies differentiating this process from multiple myeloma frequently occurs in advanced disease. Because cartilage is resistant to invasion by metastases, preservation of the intervertebral disk space may help to distinguish metastases from an inflamma- tory process. Osteomyelitis Pyogenic Various radiographic patterns, including disk Rapid involvement of the intervertebral disks space narrowing, loss of the normally sharp (loss of disk spaces and destruction of adjacent adjacent subchondral plates, areas of cortical end plates), in contrast to the vertebral body demineralization, vertebral body destruction involvement and preservation of disk spaces in and even collapse, and sclerotic new bone metastatic disease. The diffuse myelomatous infiltration causes generalized demineralization of the vertebral bodies and a compression fracture of L2. Unlike pyo- genic infection, tuberculous osteomyelitis is rarely associated with periosteal reaction or bone sclero- sis. In the untreated patient, progressive vertebral collapse and anterior wedging lead to the develop- ment of a characteristic sharp kyphotic angulation and gibbous deformity. Healed lesions may demon- strate mottled calcific deposits in a paravertebral abscess and moderate recalcification and sclerosis of the affected bones. Fungal infections Generally produce spinal involvement mimick- Infrequent manifestation of actinomycosis, blasto- ing tuberculosis. Severe compressive patients, it may be difficult to distinguish an acute forces may drive the nucleus pulposus into the spinal fracture from the vertebral compression that vertebral body, resulting in a burst fracture with is frequently associated with osteoporosis. In the posterosuperior fragment often driven into acute trauma, there is often evidence of cortical the spinal canal. In patients who have jumped disruption, a paraspinal soft-tissue mass, or an ill- from great heights, compression fractures of defined increase in density beneath the end plate the thoracolumbar junction are frequently of an involved vertebra, indicating bone impaction. In osteoporosis, vertebral compression is often associated with osteophytic spurs arising from the apposing margins of the involved and adjacent vertebral bodies. An acute spinal fracture may be difficult to distinguish from a pathologic fracture caused by metastases or multiple myeloma. The affected vertebrae tend to become produces a dorsal kyphosis, which persists even wedge shaped (they decrease in height ante- after the disease has healed. The overall radiographic appearance is indistinguishable from that of tuberculous spondylitis. Paget’s disease Arch-like contour defects of the superior and Although there is typically enlargement of the inferior vertebral surfaces or a pathologic frac- vertebral body with increased trabeculation that is ture. There may also be which retard growth in the central portion of the biconcave indentations on the superior and vertebral cartilaginous growth plate while the inferior margins of the softened vertebral bodies periphery of the growth plate (with a different blood due to expansile pressure of the adjacent supply) continues to grow at a more normal rate. Gaucher’s disease Localized step-like central depression of mul- Probably caused by circulatory stasis and ischemia, tiple vertebral end plates. This inborn error of metabolism is characterized by the accumulation of abnormal quantities of complex lipids in the reticuloendothelial cells of the spleen, liver, and bone marrow. Severe kyphoscoliosis results from a combination of ligamentous laxity, osteoporosis, and post-traumatic deformities. Although the degree of compres- sion may be substantial, the fractures infrequently cause pain and usually do not lead to neurologic sequelae. Amyloidosis Loss of bone density and collapse of one or more Rare manifestation caused by diffuse infiltration of vertebral bodies. Gene- ralized demineralization with collapse of vertebral bodies is usually a manifestation of underlying multiple myeloma. Hydatid (echinococcal) cyst Expanding lytic lesion causing a pathologic Bone involvement occurs in approximately 1% of fracture. Thanatophoric dwarfism Extreme flattening of hypoplastic vertebral An H or U configuration of the vertebral bodies can bodies. Generalized flattening of verte- bral bodies associated with fractures of multiple ribs and long bones in an infant. Reactive sclerosis is common with sion of vertebral osteomyelitis may cause retro- pyogenic inflammation but infrequent with pharyngeal abscess, mediastinitis, pericarditis, tuberculosis. Posterior extension of inflammatory tissue can compress the spinal cord or produce meningitis if the infection penetrates the dura to enter the subarachnoid space. Trauma Well-defined sclerotic vertebral margins, soft- Disk injury and degeneration is the underlying tissue mass, and evidence of fracture. Note the linear lucent collections (vacuum phe- nomenon) overlying several of the intervertebral disks. Note the reactive sclero- sis of the apposing end plates and the subluxation of the vertebral bodies seen on the frontal view. The most common cause is an ependymoma of the cord, especially of the conus or filum terminale. Also may occur with astrocytoma, oligodendroglioma, glioblastoma multiforme, and medulloblastoma. Meningocele/ Large posterior spinal defect through which there is herniation of the meninges (meningocele) or of myelomeningocele the meninges and a portion of the spinal cord or nerve roots (myelomeningocele). If the septum dividing the cord is ossified, it may appear on frontal views as a pathognomonic thin vertical bony plate lying in the middle of the neural canal. The condition most commonly occurs in the lower thoracic and upper lumbar regions and is often associated with a variety of skeletal and central nervous system anomalies. Other skeletal abnormalities include para- vertebral soft-tissue masses, dense vertebral sclerosis (ivory vertebrae), and a mottled pattern of destruction and sclerosis with hematogenous spread that may simulate metastatic disease. Other causes of Metastases or inflammatory processes (especially lymphadenopathy tuberculosis). Aortic aneurysm Continuous pulsatile pressure can rarely cause erosions of the anterior aspect of one or more vertebral bodies.

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