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How to perform revision lumbar decompression
Published in Gregory D. Schroeder, Ali A. Baaj, Alexander R. Vaccaro, Revision Spine Surgery, 2019
Jacob Hoffman, Ryan Murphy, Mark L. Prasarn, Shah-Nawaz M. Dodwad
After appropriate patient positioning, the patient's skin over the planned surgical site is cleansed with isopropyl alcohol and allowed to dry prior to squaring off the surgical field with 1010 drapes (3M, Maplewood, Minnesota). The drapes should be placed wide. For lumbar spine surgery, draping includes the cranial aspect of the intergluteal cleft, which may be used as a midline landmark. An alcohol-based prep is then used for sterilization of the surgical field. After sterile prep, a spinal needle is placed at the desired surgical level with the use of lateral intraoperative fluoroscopy. The level is then marked out and the spinal needle removed. A second alcohol-based prep is used for final skin sterilization.
Pilonidal cysts
Published in Alisa McQueen, S. Margaret Paik, Pediatric Emergency Medicine: Illustrated Clinical Cases, 2018
Surgery. Pilonidal cysts are caused by an inflammatory process in the gluteal region. They are most common in 15- to 20-year-old males with a deep natal or intergluteal cleft. Other risk factors include obesity, sedentary occupation (>6 hours a day sitting down), poor hygiene with <3 baths per week, and extensive body hair. These clefts can get infected due to trapping of perspiration and moisture in the deep pockets. An infected pilonidal cyst needs to be treated. They can cause systemic symptoms such as fever, chills, and pain. A sinus tract can also develop, and when present there can be intermittent discharge of pus or blood. Chronic pilonidal cysts can have multiple sinus tracts. During workup, physicians need to consider possible anal fistula development and perianal Crohn’s disease. Management of these cysts involves antibiotics, pain control, surgery, and wound care. Antimicrobials should cover gram positive, gram negative, and anaerobic bacteria due to skin flora and close proximity to the anus. Hygiene is also very important in the treatment of these cysts. Baths need to be avoided while the wound heals and the use of handheld showerheads is recommended to be able to direct water to the site. Wounds must be cleaned after stooling and hair needs to be removed from wounds. Patients also need to be careful to avoid activities with excessive friction to the buttock such as cycling and driving/sitting for long periods.
Differential diagnoses of psoriasis
Published in M. Alan Menter, Caitriona Ryan, Psoriasis, 2017
Flexural (inverse) psoriasis is a rare variant that occurs in the flexural skin folds.55 It affects between 3% and 7% of all patients with psoriasis and is characterized by well-defined plaques confined to the flexural areas. Flexural psoriasis can be localized to the axillae (Figure 12.75), groin, genital area, umbilicus, postauricular area, intergluteal cleft (Figure 12.76), inframammary creases (Figure 12.77), antecubital fossae, and popliteal fossae.55 The sites most commonly affected include the groin.55 Plaques are thin, and have minimal scale and a shiny nonscaly surface (Figure 12.78) commonly accompanied by secondary fissuring and/or maceration.3,55 Clinical diagnosis of flexural psoriasis can be difficult.3 A full body examination, in particular, the anogenital, peri-umbilical, and retroauricular areas, scalp, and nails should be included to look for psoriasis.3,56 Flexural psoriasis is slightly more common in patients with nail involvement.56 Characteristic features on histopathology include reduced epidermal hyperplasia and more pronounced spongiosis than chronic plaque psoriasis.56
Zoster sine herpete causing voiding disorders in females
Published in Scandinavian Journal of Urology, 2022
Varicella-zoster virus causes chickenpox in childhood and remains dormant in dorsal root, enteric, and cranial ganglia for the rest of life. Different risk factors may contribute to the VZV reactivation, such as stress, fatigue, immunodeficient state, diabetes mellitus, and systemic diseases [3]. It is difficult to diagnose ZSH as it has no visible signs. Clinical features include unilateral dermatomal pain with different manifestations of nerve injury [3]. Voiding disorders are one of those manifestations. They can be clinically classified as cystitis-associated, neuritis-associated, and myelitis-associated [4]. Our patient suffered from cystitis-associated voiding disorders caused by VZV direct invasion into the bladder wall. Pain in the intergluteal cleft in our patient indicates S2–S3 dermatomes involvement.
Bilateral Drug-Induced Uveitis and Epiretinal Membrane during the Treatment of a Metastatic Cutaneous Melanoma
Published in Ocular Immunology and Inflammation, 2021
Marcos Mozo Cuadrado, Laura Tabuenca Del Barrio, Esther Compains Silva
A 75-year-old female treated with Dabrafenib 150 mg/twice a day and Trametinib 2 mg/once a day due to a cutaneous melanoma stage IV in the intergluteal cleft spread to the liver and paratracheal lymph nodes with the mutation V600K/R/M of the BRAF gene presented with blurriness in both eyes. Visual Acuity (VA) was 0.5 logMAR in the right eye (RE) and 0.2 logMAR in the left eye (LE) and slit-lamp examination revealed bilateral intraocular signs of inflammation (Tyndall +1 according to SUN working group grading.3) Fundoscopy showed bilateral chorioretinal folds, retinal vascular tortuosity and Neurosensory Retinal Detachment (NRD) (Figure 1a,b). Enhanced Depth Imaging Optical Coherence Tomography (EDI-OCT) was performed confirming the bilateral NRD (Figure 1c,d) and Fluorescein Angiography (FA) showed blockage of the normal fluorescence in the macular area of both eyes. Due to a worsening of VA in the RE from 0.5 to 1 logMAR and the persistence of intraocular inflammation in spite of topical prednisolone acetate treatment, the therapy with Dabrafenib + Trametinib was interrupted, after having been administered for 4 months, and replaced by Nivolumab 3 mg/kg twice a week. The fundus abnormalities and the intraocular inflammation improved so the topical therapy was stopped, but VA in the RE remained low due to the presence of the epiretinal membrane (Figure 2a,b)
Prediction of pelvic tumour coverage by magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) from referral imaging
Published in International Journal of Hyperthermia, 2020
Ngo Fung Daniel Lam, Ian Rivens, Sharon L. Giles, Emma Harris, Nandita M. deSouza, Gail ter Haar
Air gaps between the patient and the gel-pad act as acoustic obstructions. Extracorporeal air in volunteer treatment imaging datasets was not segmented, because the trousers worn by volunteers during image acquisition prevented skin-to-gel-pad acoustic coupling. Instead, volunteer acoustic coupling limits in the left-right direction were manually identified, as shown in Figure 4. For volunteers, it was assumed that the intergluteal cleft would be filled with acoustic-coupling gel as part of clinical preparations, and hence, they were not treated as acoustic obstructions. Extracorporeal air in the patient treatment imaging datasets was segmented to define the limits of acoustic coupling, using an automatic segmentation algorithm inspired by Kullberg et al. [14]. In some cases, the intergluteal cleft was seen to contain air, and was therefore manually contoured and included as part of the extracorporeal air segment.