Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: Case report and review of literature

Abstract

Context

Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture.

Findings

We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful.

Conclusion

In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.     

Management of fracture-dislocation of the lower cervical spine with the cervical pedicle screw system

INTRODUCTION

Usually, cervical pedicle screw fixation has been considered too risky for neurovascular structures. The purpose of this study was to investigate the method and efficacy of the cervical pedicle screw system for fracture-dislocation of the cervical spine because of its rigid fixation.

PATIENTS AND METHODS

A prospective study was conducted involving 48 patients with cervical spine fracture-dislocation who underwent cervical pedicle screw fixation surgery between January 2003 and January 2007. All patients had various degrees of cord injury, and they were classified according to the American Spinal Cord Injury Association (ASIA) Impairment Scale: 18 cases were grade A, 15 grade B, 10 grade C, and 5 grade D.

RESULTS

Six months after the operation, all patients had achieved solid bony fusion and stable fixation of the related segments. Thirty patients with incomplete spinal cord injury improved their ASIA Impairment Scale classification by 1 to 2 grades after the operation. Eighteen patients with complete spinal cord injury had no improvement in neural function. However, nerve root symptoms such as pain and numbness were alleviated to some extent.

CONCLUSIONS

The cervical pedicle screw system is an effective and reliable method for the restoration of cervical stability. Sufficient pre-operative imaging studies of the pedicles and strict screw insertion technique should be emphasised.     

Spinal deformity progression after posterior segmental instrumentation and fusion for idiopathic scoliosis

Study design

Retrospective chart and radiographic review.

Purpose

To assess the incidence of and variables associated with spinal deformity progression after posterior segmental instrumentation and fusion at a single institution. Progression of the scoliotic deformity after posterior instrumented spinal fusion has been described. Recent studies have concluded that segmental pedicle screw constructs are better able to control deformity progression.

Methods

Retrospective review of a consecutive series of idiopathic scoliosis patients (n = 89) with major thoracic curves (Lenke types 1–4) treated with posterior segmental instrumentation and fusion. Deformity progression was defined as a 10° increase in Cobb angle between the first-erect and 2-year post-operative radiographs. Clinical and radiographic data between the two cohorts (deformity progression versus stable) were analyzed to determine the variables associated with deformity progression.

Results

Patients in the deformity progression group (n = 13) tended to be younger (median 13.7 vs. 14.7 years) and experienced a significant change in height (p = 0.01) during the post-operative period compared to the stable group (n = 76). At 2-years post-op, the patients in the deformity progression group had experienced a significantly greater change in upper instrumented vertebra (UIV) angulation, lower instrumented vertebra (LIV) angulation, and apical vertebral translation (AVT). Two-year post-op Scoliosis Research Society questionnaire (SRS-22) scores in the appearance domain were also significantly worse in the deformity progression group. Patients in the deformity progression group had a significantly greater difference between the lowest instrumented vertebra and stable vertebra compared to patients in the stable group (p = 0.001).

Conclusions

Deformity progression after posterior spinal fusion does occur after modern segmental instrumentation. Segmental pedicle screw constructs do not prevent deformity progression. Skeletally immature patients with a significant growth potential are at the highest risk for deformity progression. In immature patients, extending the fusion distally to the stable vertebra may minimize deformity progression.

Level of evidence

Level III.     

Intractable Pruritus After Traumatic Spinal Cord Injury

Background:

This report describes a young woman with incomplete traumatic cervical spinal cord injury and intractable pruritus involving her dorsal forearm.

Method:

Case report.

Findings:

Anatomic distribution of the pruritus corresponded to the dermatomal distribution of her level of spinal cord injury and vertebral fusion. Symptoms were attributed to the spinal cord injury and possible cervical root injury. Pruritus was refractory to all treatments, including topical lidocaine, gabapentin, transcutaneous electrical nerve stimulation, intravenous Bier block, stellate ganglion block, and acupuncture.

Conclusions:

Further understanding of neuropathic pruritus is needed. Diagnostic workup of intractable pruritus should include advanced imaging to detect ongoing nerve root compression. If diagnostic studies suggest radiculopathy, epidural steroid injection should be considered. Because the autonomic nervous system may be involved in complex chronic pain or pruritic syndromes, sympatholysis via such techniques as stellate ganglion block might be effective.     

Cervical instability presenting as thoracic pain: case report and literature review

Study design

Case report.

Objective

To report a case of cervical instability from an os odontoideum that presented as posterior thoracic pain and to present a review of the literature.

Background

Thoracic posterior paraspinal spasms and pain are common chief complaints in individuals with spinal abnormalities.

Methods

A 19-year-old man presented with posterior thoracic pain for nearly 1 year following a college sports-related injury (lacrosse). Computed tomography and magnetic resonance imaging did not reveal any significant thoracic or lumbar spinal cord or nerve root pathology, but did reveal an incidental finding of an os odontoideum.

Results

Surgical stabilization of the atlantoaxial instability resulting from the os odontoideum resulted in complete resolution of the patient''s thoracic pain.

Conclusions

Thoracic back pain without a clear thoracic spine etiology warrants further workup to rule out the possibility of spinal instability.     

Spinal epidural abscess with myelitis and meningitis caused by Streptococcus pneumoniae in a young child

Background

Spinal epidural abscess (SEA) in children is a rare infectious emergency warranting prompt intervention. Predisposing factors include immunosuppression, spinal procedures, and local site infections such as vertebral osteomyelitis and paraspinal abscess. Staphylococcus aureus is the most common isolate.

Design

Case report and literature review.

Findings

A 2.5-year-old boy with tetraparesis was found to have an SEA in the posterior lumbar epidural space with evidence of meningitis and myelitis on MRI spine in the absence of any local or systemic predisposing factors or spinal procedures. Streptococcus pneumoniae was isolated from the evacuated pus.

Conclusions

Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit.     

Treatment of acute thoracolumbar burst fractures with kyphoplasty and short pedicle screw fixation: Transpedicular intracorporeal grafting with calcium phosphate: A prospective study

Background:

In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to loss of correction and instrumentation failure with associated complaints. We conducted this prospective study to evaluate the outcome of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty, grafting with calcium phosphate cement and short pedicle screw fixation plus fusion.

Materials and Methods:

Twenty-three consecutive patients of thoracolumbar (T₉ to L₄) burst fracture with or without neurologic deficit with an average age of 43 years, were included in this prospective study. Twenty-one from the 23 patients had single burst fracture while the remaining two patients had a burst fracture and additionally an adjacent A1-type fracture. On admission six (26%) out of 23 patients had neurological deficit (five incomplete, one complete). Bilateral transpedicular balloon kyphoplasty with liquid calcium phosphate to reduce segmental kyphosis and restore vertebral body height and short (three vertebrae) pedicle screw instrumentation with posterolateral fusion was performed. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre- to postoperatively.

Results:

All 23 patients were operated within two days after admission and were followed for at least 12 months after index surgery. Operating time and blood loss averaged 45 min and 60 cc respectively. The five patients with incomplete neurological lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. The VAS and SF-36 (Role physical and Bodily pain domains) were significantly improved postoperatively. Overall sagittal alignment was improved from an average preoperative 16° to one degree kyphosis at final followup observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P<0.001) postoperatively, while posterior vertebral body height improved from 0.95 to 1 (P<0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. Cement leakage was observed in four cases (three anterior to vertebral body and one into the disc without sequalae). In the last CT evaluation, there was a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within six months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients.

Conclusions:

Balloon kyphoplasty with calcium phosphate cement secured with posterior short fixation in the thoracolumbar spine provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level.     

Spinal infection: a case report

Objective:

To present a case of a patient with spinal infection (SI) and highlight the chiropractor’s role in the prevention or minimization of devastating complications of SI.

Background:

Recent literature trends suggest an increasing prevalence of SI. Patients with SI most commonly present with unremitting progressive back pain and may or may not have fever or neurological signs. To avoid negative post-infection sequelae, establishing an early diagnosis and treatment is crucial.

Clinical Features:

A 29-year-old female diagnosed with L5-S1 disc herniation with impingement of the right S1 nerve root opted for surgical management. Iatrogenic bowel perforation during her spinal surgery resulted in contamination of the spinal surgical site, and findings in keeping with disco-osteomyelitis with epidural and paraspinal phlegmon formation were visualized on contrast enhanced MRI.

Conclusion:

Recent trends of increased spinal infection urge a heightened awareness by the chiropractor. The chiropractor can provide early diagnosis and supportive multidisciplinary care for such patients.     

Balloon osteoplasty-a new technique for reduction and stabilisation of impression fractures in the tibial plateau: A cadaver study and first clinical application

Purpose

Fractures of the tibial plateau are among the most severe injuries of the knee joint and lead to advanced gonarthrosis if the reduction does not restore perfect joint congruency. Many different reduction techniques focusing on open surgical procedures have been described in the past. In this context we would like to introduce a novel technique which was first tested in a cadaver setup and has undergone its successful first clinical application.

Methods

Since kyphoplasty demonstrated effective ways of anatomical correction in spine fractures, we adapted the inflatable instruments and used the balloon technique to reduce depressed fragments of the tibial plateau.

Results

The technique enabled us to restore a congruent cartilage surface and bone reduction.

Conclusions

In this technique we see a useful new method to reduce depressed fractures of the tibial plateau with the advantages of low collateral damage as it is known from minimally invasive procedures.     

Balloon osteoplasty—a new technique for minimally invasive reduction and stabilisation of Hill–Sachs lesions of the humeral head: a cadaver study

Purpose

Traumatic shoulder dislocation may be complicated by concomitant bony injury of the glenoid rim or the humeral head. In Hill–Sachs lesions, reconstruction techniques vary widely and range from open reduction to tendon transposition or humeral head derotation. These operations are extensive and have questionable outcomes. With the expertise from vertebral compression fracture reduction by kyphoplasty, we examined in a cadaver feasibility study whether reduction of the Hill–Sachs lesion via hydraulic lift might be an anatomical and minimally invasive treatment option. We postulated that the use a of a balloon- assisted kyphoplasty reduction could achieve almost anatomical correction of the defect.

Methods

We created Hill–Sachs lesions in six humeral specimens and performed a computed tomography (CT) scan before and after reduction with the kyphoplasty system. The entry point at the greater tuberosity and balloon positioning was visualised by fluoroscopy. The size of the Hill–Sachs lesion before and after reduction was measured using CT scans in the axial orientation.

Results

Using the balloon kyphoplasty system, we achieved a statistically significant reduction (80 % ) of the Hill–Sachs lesion.

Conclusion

In a preliminary cadaver study we show that using a balloon kyphoplasty system might be an alternative treatment option for Hill–Sachs lesions, with reduced collateral damage that can occur with other minimally invasive techniques. Future work is needed to evaluate the technique under arthroscopic conditions.     

Acute sciatica and progressive neurological deficit secondary to facet synovial cysts: A report of two cases.

Objective:

To describe two patients with lumbar facet synovial cysts causing sciatica and progressive neurological deficit.

Clinical Features:

A 52-year-old female with bilateral sciatica and a neurological deficit that progressed to a foot drop; and a 54-year-old female with worsening sciatica and progressive calf weakness were seen at a major tertiary care centre. Diagnostic imaging studies revealed the presence of spinal nerve root impingement by large facet synovial cysts.

Interventions and Outcomes:

Activity modification, gabapentinoid and non-steroidal anti-inflammatory medications were unsuccessful in ameliorating either patient’s symptoms. One patient had been receiving ongoing lumbar chiropractic spinal manipulative therapy despite the onset of a progressive neurological deficit. Both patients eventually required surgery to remove the cyst and decompress the affected spinal nerve roots.

Conclusion:

Patients with acute sciatica who develop a progressive neurological deficit while under care, require prompt referral for axial imaging and surgical consultation. Primary care spine clinicians need to be aware of lumbar facet synovial cysts as a possible cause of acute sciatica and the associated increased risk of the patient developing a progressive neurological deficit.     

Upper cervical spinal cord gunshot injury without bone destruction

INTRODUCTION

This report describes a rare case of the gunshot injury of the spine and spinal cord.

PRESENTATION OF CASE

A rare case of the bullet lodged intra-durally in the upper cervical region without damaging the vertebrae or the spinal cord. The bullet was removed as microneurosurgical and duraplasty was performed.

DISCUSSION

Surgical management of the gunshot wounds of the spine and spinal cord is not widely advocated and controversial.

CONCLUSION

Advances in microneurosurgical instrumentation and microscopic techniques may open up a new era of surgical treatment of spinal cord gunshot wounds.     

Multilevel oblique corpectomy for cervical spondylotic myelopathy preserves segmental motion

Purpose

To document the neurological outcome, spinal alignment and segmental range of movement after oblique cervical corpectomy (OCC) for cervical compressive myelopathy.

Methods

This retrospective study included 109 patients—93 with cervical spondylotic myelopathy and 16 with ossified posterior longitudinal ligament in whom spinal curvature and range of segmental movements were assessed on neutral and dynamic cervical radiographs. Neurological function was measured by Nurick’s grade and modified Japanese Orthopedic Association (JOA) scores. Eighty-eight patients (81%) underwent either a single- or two-level corpectomy; the remaining (19%) undergoing three- or four-level corpectomies. The average duration of follow-up was 30.52 months.

Results

The Nurick’s grade and the JOA scores showed statistically significant improvements after surgery (p < 0.001). The mean postoperative segmental angle in the neutral position straightened by 4.7 ± 6.5°. The residual segmental range of movement for a single-level corpectomy was 16.7° (59.7% of the preoperative value), for two-level corpectomy it was 20.0° (67.2%) and for three-level corpectomies it was 22.9° (74.3%). 63% of patients with lordotic spines continued to have lordosis postoperatively while only one became kyphotic without clinical worsening. Four patients with preoperative kyphotic spines showed no change in spine curvature. None developed spinal instability.

Conclusions

The OCC preserves segmental motion in the short-term, however, the tendency towards straightening of the spine, albeit without clinical worsening, warrants serial follow-up imaging to determine whether this motion preservation is long lasting.     

The incidence of epidural abscess following epidural analgesia in open abdominal aortic aneurysm repair

INTRODUCTION

Complications of epidural catheterisation can cause significant morbidity. Epidural abscess following epidural catheterisation is rare and the reported incidence is variable. The purpose of this study was to review the incidence of epidural abscess in patients undergoing open abdominal aortic aneurysm (AAA) repair.

PATIENTS AND METHODS

A retrospective case note review of all patients having open AAA repair over a 5-year period.

RESULTS

A total of 415 patients underwent open AAA repair between January 2003 and March 2008. Of these, 290 were elective procedures and 125 were for ruptured aneurysms. Six patients underwent postoperative magnetic resonance imaging of the spine for clinical suspicion of an epidural abscess. Two of these (0.48%) had confirmed epidural abscess and two superficial infection at the epidural site.

CONCLUSIONS

The incidence of epidural abscess following epidural analgesia in patients undergoing open AAA repair within our department was 0.48%. Although a rare complication, epidural abscess can cause significant morbidity. Epidural abscesses rarely develop before the third postoperative day.     

The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area

Background

This study examined the relationship between four radiological parameters (Pavlov''s ratio, sagittal diameter, spinal cord area, and spinal canal area) in patients with a traumatic cervical spine injury, as well as the correlation between these parameters and the neurological outcome.

Methods

A total of 212 cervical spinal levels in 53 patients with a distractive-extension injury were examined. The following four parameters were measured: Pavlov''s ratio on the plain lateral radiographs, the sagittal diameter, the spinal cord area, and the spinal canal area on the MRI scans. The Pearson correlation coefficients between the parameters at each level and between the levels of each parameter were evaluated. The correlation between the radiological parameters and the spinal cord injury status classified into four categories, A (complete), B (incomplete), C (radiculopathy), and D (normal) was assessed.

Results

The mean Pavlov''s ratio, sagittal diameter, spinal cord area and spinal canal area was 0.84, 12.9 mm, 82.8 mm² and 236.8 mm², respectively. An examination of the correlation between the radiological spinal stenosis and clinical spinal cord injury revealed an increase in the values of the four radiological parameters from cohorts A to D. Pavlov''s ratio was the only parameter showing statistically significant correlation with the clinical status (p = 0.006).

Conclusions

There was a correlation between the underlying spinal stenosis and the development of neurological impairment after a traumatic cervical spine injury. In addition, it is believed that Pavlov''s ratio can be used to help determine and predict the neurological outcome.     

Minimally invasive fixation techniques for thoracolumbar fractures: comparison between percutaneous pedicle screw with intermediate screw (PPSIS) and percutaneous pedicle screw with kyphoplasty (PPSK)

Purpose

To assess and compare the efficacy of two minimally invasive techniques (percutaneous pedicle screw with intermediate screw vs. percutaneous pedicle screw with kyphoplasty) for spinal fracture fixation by comparing the segmental kyphosis and vertebral kyphosis angles after trauma before surgery, after surgery, and at 4-month and 12-month follow-up.

Methods

Data from 49 patients without neurological deficit treated by either percutaneous pedicle screw with intermediate screw or percutaneous pedicle screw with kyphoplasty were retrospectively analysed. The segmental kyphosis and vertebral kyphosis angles over time were calculated and correlated with the type of procedure, AO classification, lumbar or thoracic site and the age and sex of the patients.

Results

After surgery, both techniques were found to be efficacious means of bringing about a significant correction of the segmental kyphosis angle (p = 0.002) and a just significant correction of the vertebral kyphosis angle (p = 0.06), although less effectively in thoracic fractures (p = 0.004). At follow-up, the vertebral kyphosis angle was stable in both groups, while there was a significant loss of segmental kyphosis angle stability in the percutaneous pedicle screw with kyphoplasty group at 1 year (p = 0.004); fractured thoracic vertebrae maintained a greater vertebral kyphosis angle (p = 0.06) and segmental kyphosis angle (p < 0.001), than the lumbar.

Conclusion

At 1 year after surgery, the use of intermediate screws in fractured vertebrae seemed to maintain a more efficacious correction with respect to kyphoplasty, although thoracic fracture sites appear to be associated with greater post-traumatic segmental kyphosis and lesser stability in the long term after both percutaneous surgical techniques.

     

Feasibility of Nerve Stimulator as a Supplemental Aid for Lumbar Transforaminal Epidural Block

Background

The purpose of this study was to evaluate the clinical feasibility of an electric nerve stimulator in a lumbar transforaminal epidural block.

Methods

Using an electric nerve stimulator, transforaminal epidural blocks were performed in 105 segments of 49 patients who presented with lower back pain with radiating pain to lower extremities. The contrast medium was injected to delineate the nerve root after positioning an insulated needle at the intervertebral foramen under fluoroscopic guidance. Then, the nerve root was electrically stimulated with the insulated needle to confirm whether or not the same radiating pain was evoked.

Results

Of the 105 foraminal segments, the same radiating pain was evoked at 0.5 mAh in 47 segments (44.8%), at 1.0 mAh in 22 (21.0%), at 1.5 mAh in 3 (2.9%), at 2.0 mAh in 15 (14.3%), at 2.5 mAh in 4 (3.8%), and at 3.0 mAh in 5 (4.8%). No response was observed in 9 segments (8.6%). The fluoroscopy revealed successful positioning of the needle in the patients with an evoked radiating pain over 2.0 mAh. The visual analogue scale (VAS) obtained for pain improved from a mean of 7.5 to 2.7 after the block (p = 0.001). In the 9 cases without response to electrical stimulation, the patients showed an improvement on VAS from 7.8 to 3.4 (p= 0.008) also.

Conclusions

A nerve stimulator can help to predict the accuracy of needle positioning as a supplemental aid for a successful lumbar transforaminal epidural block. It is sufficient to initiate a proper stimulation amplitude of the nerve at 2 mAh.     

Comparison of lifetime incremental cost:utility ratios of surgery relative to failed medical management for the treatment of hip, knee and spine osteoarthritis modelled using 2-year postsurgical values

Background

Demand for surgery to treat osteoarthritis (OA) of the hip, knee and spine has risen dramatically. Whereas total hip (THA) and total knee arthroplasty (TKA) have been widely accepted as cost-effective, spine surgeries (decompression, decompression with fusion) to treat degenerative conditions remain underfunded compared with other surgeries.

Methods

An incremental cost–utility analysis comparing decompression and decompression with fusion to THA and TKA, from the perspective of the provincial health insurance system, was based on an observational matched-cohort study of prospectively collected outcomes and retrospectively collected costs. Patient outcomes were measured using short-form (SF)-36 surveys over a 2-year follow-up period. Utility was modelled over the lifetime, and quality-adjusted life years (QALYs) were determined. We calculated the incremental cost per QALY gained by estimating mean incremental lifetime costs and QALYs of surgery compared with medical management of each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses were also conducted.

Results

The lifetime incremental cost:utility ratios (ICURs) discounted at 3% were $5321 per QALY for THA, $11 275 per QALY for TKA, $2307 per QALY for spinal decompression and $7153 per QALY for spinal decompression with fusion. The sensitivity analyses did not alter the ranking of the lifetime ICURs.

Conclusion

In appropriately selected patients with leg-dominant symptoms secondary to focal lumbar spinal stenosis who have failed medical management, the lifetime ICUR for surgical treatment of lumbar spinal stenosis is similar to those of THA and TKA for the treatment of OA.     

Tophaceous gout causing thoracic spinal cord compression: Case report and review of the literature

Objective

To improve neurologists’ awareness of spine gout by showing a rare case of tophaceous gout in thoracic spine and a summary of vertebral gout in order.

Dorsal Epidural Intervertebral Disk Herniation With Atypical Radiographic Findings: Case Report and Literature Review

Background/Objective:

Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.

Design:

Case report.

Findings:

A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.

Conclusions:

Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.