A rare complication of lumbar disk surgery: Ureteral avulsion

A 49-year-old woman was admitted to our clinic with high fever, left lumbar pain and a mass at the flank following spinal surgery for disk disease. Complete left ureteral avulsion with urinoma formation was detected and she was treated with ureteroureterostomy. As in this case shows that the possibility of ureteral injury to the ureter during surgery for a disk hernia should be familiar to all neurosurgeons, orthopedic surgeons and urologists. When the diagnosis is made during early postoperative period, good results with preservation of the kidney can be achieved.     

Lymphocoele: a rare and little known complication of anterior lumbar surgery

Lymphocoele is a rare and little known complication with only a handful of reports available. We report two cases of lymphocoele after anterior lumbar surgery that have occurred in two different centres and discuss diagnosis and management options. The first case is that of a 53-year-old male patient undergoing two level anterior lumbar interbody fusion (ALIF) for disabling back pain due to disc degeneration in the context of an old spondylodiscitis. He developed a large fluid mass postoperatively. Fluid levels of creatinin were low and intravenous urography ruled out a urinoma suggesting the diagnosis of a lymphocoele. Following two unsuccessful drainage attempts he underwent a laparoscopic marsupialization. The second case was that of a 32-year-old female patient developing a large fluid mass following a L5 corpectomy for a burst fracture. She was treated successfully with insertion of a vacuum drain during 7 days. Lymphocoele is a rare complication but should be suspected if fluid collects postoperatively following anterior lumbar spine procedures. Chemical analysis of the fluid can help in diagnosis. Modern treatment consists of laparoscopic marsupialization. Lymph vessel anatomy should be borne in mind while exposing the anterior lumbar spine.     

Permanent postoperative anosmia: A hitherto undescribed complication following surgery of the posterior cranial fossa in the sitting position

Summary Although the sitting position offers advantages for posterior fossa surgery, it is accompanied by complications such as air embolism and pneumatocephalus. Subdural and epidural haematomas are less common postoperative complications of posterior fossa surgery. To the best of our knowledge, however, anosmia is not a known sequela of surgery in the sitting position. It has been described following aneurysm surgery in the rostral part of the circle of Willis and is, of course, well known in traumatic brain injury.     

Seizures following posterior fossa surgery

A retrospective analysis of seizure incidence in 511 patients who underwent posterior possa operations via a suboccipital craniectomy with prophylactic anticonvulsant agents, was performed. Thirty patients (5.9%) experienced seizures within 2 weeks postoperatively. Their mean age was 15 years. Twenty patients had seizures within 3 h of operation; 24 patients had generalized tonic clonic seizures. Focal motor seizures with secondary generalization and simple focal motor seizures were recorded in three patients each. The incidence of postoperative seizures was highest in patients with acoustic schwanommas (9.09%) followed by those with medulloblastomas (8.54%) and astrocytomas (8.33%). The sitting position, associated with venous air embolism (VAE) and or pneumocephalus, was related to the occurrence (p = 0.001) of postoperative seizures. Seizures occurred in 24 patients out of 250 cases operated on in the sitting position compared with 3/170 and 3/91 in the prone and lateral positions, respectively. Intraoperatively significant VAE occurred in 10 out of 30 patients and postoperative computed tomography revealed pneunocephalus in 20 out of 30 patients. A higher percentage was found in patients with a preoperative ventriculoperitoneal shunt or intraoperative ventriculostomy (6.5%) than in those without (5.1%), but the difference was not statistically significant. In conclusion, seizures after posterior fossa surgery are a significant problem which is not reflected in the published literature. Our study highlights the significance of the sitting position in the causation of seizures after posterior fossa surgery.     

Anaesthesia for posterior fossa surgery

Surgery on the posterior fossa is technically challenging and requires surgical skill and judgement. The anaesthetist through an understanding of the surgeon's problems, the provision of ideal operating conditions, the meticulous monitoring for changes in vital signs and good communication with the surgeon can make a crucial contribution to successful outcome for the patient. The positioning of patients poses particular problems. The prone and lateral positions, together with the supine for transoral surgery, can provide for appropriate access to all parts of the posterior fossa. Traditionally it has been argued that the sitting position offers specific advantages although it creates additional problems for the anaesthetist. In recent years the potential risks of sitting patients up have been extensively investigated and concern has focused in particular on the danger of paradoxical air embolism. Although its safety in recognized centres has been demonstrated, it is clear that this position is now falling out of favour.     

Sponge-induced granuloma ("gauzoma") as a complication of posterior lumbar surgery

A 45-year-old woman presented with complaints of low back pain and sciatica on the left persisting for 2 years. She had undergone left hemilaminectomy and discectomy for L4-5 intervertebral disc herniation at another medical center. Spinal computed tomography and magnetic resonance (MR) imaging revealed a mass lesion in the posterior paravertebral region. The mass was hypointense with ring enhancement on the T(1)-weighted images and hyperintense on the T(2)-weighted images. Surgery found a retained sponge within the paraspinal mass cavity which was removed totally. Foreign-body granuloma ("gauzoma") induced by forgotten sponge material is not an unusual complication of posterior lumbar surgery and should be considered as a potential cause in cases of surgical wound infections. MR imaging is essential to achieve the correct differential diagnosis.     

A rare vascular complication of transsphenoidal surgery

We report a rare case of anterior cerebral artery (ACA) thrombosis following transsphenoidal surgery in a case of growth hormone secreting pituitary macroadenoma. During the surgery, there was arachnoid breach with cerebrospinal fluid (CSF) leak. Post operatively, she became blind in both eyes for which re-exploration was done. A computed tomographic (CT) scan 16 hours after surgery showed a large tumor bed haematoma which was explored transcranially. During surgery, the right A1 was thrombosed while the ICA and middle cerebral artery (MCA) were patent as confirmed by post-operative magnetic resonance imaging (MRI). However, she died on the second post-operative day. ACA thrombosis following transsphenoidal surgery has not been reported before. A review of literature and possible mechanism of this complication has been discussed.     

腰椎后路减压术后预后及稳定性的相关因素分析

[目的]探讨腰椎后路手术不同程度地切除后部结构与术后脊柱稳定性的关系,以及在腰椎后部结构切除后的机体反应和机械稳定性改变,分析机体对自身稳定性损伤修复的能力及机制.[方法]对腰椎术后稳定性表现进行临床回顾分析.[结果]对临床病例的总结显示腰椎板切除减压手术对退行性腰椎管狭窄症效果满意,通过对手术改善率低者的影像学检查,未见手术节段椎间不稳定发生;腰椎板切除减压手术临床结果与术前JOA评分、年龄、手术涉及的小关节数、椎板减压节段数没有相关性;术后功能恢复率与术后时间长短及病史长短有统计学负相关性.[结论]在术前无失稳存在时不同范围和程度的腰椎后部结构切除均可获得满意的临床效果,并未造成随访时限内的腰椎不稳定的发生,提示机体对损伤具有修复代偿的能力.     

Appendiceal tie syndrome:A very rare complication of a common disease

Acute appendicitis is the most common surgical emergency that we encounter. Adynamic Intestinal obstruction due to appendicitis or its complication may be seen time and often. Mechanical obstruction because of appendicitis is uncommon and even rarer for a closed loop obstruction to occur. Although it was described as early as 1901, very few cases have been reported. We report the case of a 20 years male who presented with generalized colicky pain abdomen, abdominal distension, vomiting and obstipation for three to four days. Vital signs were stable. His abdomen was distended and peritonitic, especially in the right iliac fossa. Rest of the physical examination was unremarkable. Blood tests were normal except for leucocytosis with neutrophilia. An abdominal X-ray finding was indicating a small bowel obstruction. A midline laparotomy was performed. On intraoperative examination, distended loops of small bowel from the jejunum to the distal ileum was observed, and a constricting ring around the terminal ileum created by a phlegmonous appendicitis with its tip adherent to the root of mesentery was found, obstructing an edematous loop of small bowel without signs of ischemia. As the bowel was viable simple appendectomy was done. Postoperatively, he had an uneventful recovery and was discharged after 3 d.     

Life-threatening posterior reversible encephalopathy syndrome in the cerebellum treated by posterior fossa decompression

Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological syndrome associated with various clinical conditions, such as headache, encephalopathy, and seizures. It is reversible if a prompt diagnosis is made and treatment undertaken. We report a 52-year-old male with hypertensive crisis. Progressing somnolence and an unresponsive left pupil occurred. MRI revealed an intra-axial hyperintensity of the cerebellum and brainstem and occlusive hydrocephalus suggestive of encephalitis or a tumor. Because of the life-threatening clinical picture, posterior fossa decompression was performed. Histopathology failed to identify any pathology. After decompression, the edema improved immediately. Under life-threatening conditions, a decompressive craniectomy in PRES seems to achieve the same results as supportive treatment.

     

Clip-grafts in microvascular decompression of the posterior fossa. Technical note

A method is described for the protection of the trigeminal root from recurrent vascular irritation or compression after posterior fossa microvascular decompression. A vascular clip-graft, using a Sundt clip of suitable size, is applied to the sensory root of the trigeminal nerve. The technique has proven safe and effective in a series of nine patients followed for up to 28 months.     

体重对腰椎后路开窗减压手术疗效的影响

目的对不同体重老年腰椎管狭窄患者行单纯腰椎后路开窗减压手术,并评价其治疗效果。方法回顾性分析1996年12月～2002年12月间145例因老年腰椎管狭窄而采用单纯腰椎后路开窗减压手术治疗患者的病例资料,结合问卷调查患者对手术的满意程度,比较不同体重患者住院期间及术后症状改善情况,评估手术疗效。结果不同体重患者术后腰腿疼痛明显缓解、日常生活质量改善,患者对手术的满意率达67.59%。而且患者的各种统计数据表明,不同体重组之间差异无显著性意义(P>0.05)。结论体重在一定程度上影响老年腰椎管狭窄患者的手术治疗结果。单纯腰椎后路开窗减压手术,可以达到较为理想的治疗效果。     

Symptomatic pneumocephalus: A rare complication of discal herniation's surgery

Context: We report the case of a 40-year-old woman with no pathological history, operated from an L4-L5 disc herniation by a left unilateral approach. The dura mater enveloping the left L5 root was accidentally injured at its lateral face causing a breach with CSF leakage. This breach could not be sutured. A few hours after waking, the patient presented an agitation followed by three generalized tonico-clonic seizures. Cerebral imaging revealed pneumocephalus. The patient was hospitalized in an intensive care unit. The symptoms gradually faded and the patient was discharged 3 days after surgery.

Findings: Pneumocephalus is defined by the presence of air inside the skull. The symptoms of pneumocephalus are generally non-specific and varied, and this complication should also be kept in mind to prevent potentially severe course. The prevention of postoperative pneumocephalus depends on a well-defined strategy in the case of iatrogenic dural tear.

Conclusions: Symptomatic pneumocephalus is a very rare complication in the course of lumbar surgery. Conservative therapy may be appropriate even in severe symptomatic manifestations.     

Lymphatic fluid fistula: an extremely rare complication of posterior lumbar transpedicular screw fixation. Case report

The authors describe the unique case of a patient who had undergone posterior stabilization of the lumbar spine complicating the course of a lymphatic fistula. A lymphatic fistula is a rare complication of posterior lumbar surgery. Predisposing factors include individual anatomy, scarring adherences due to previous abdominal operations or surgical maneuvers deep in the plane of the transverse processes. Because the onset of lymphatic fistulas is subtle, and because they are associated with a high mortality rate and require multidisciplinary treatment, care is needed to avoid misdiagnosing these lesions as the more common cerebrospinal fluid fistula.