Spontaneous epidural hematoma of thoracic spine presenting as Brown-Séquard syndrome: report of a case with review of the literature

Background

Spontaneous spinal epidural hematoma (SSEH) is an uncommon clinical entity. It produces a severe neurological deficit and prompt decompression is usually the first choice of treatment. Brown-Séquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely caused by SSEH.

Methods

Case report and literature review.

Findings

A previously healthy man presented with Brown-Séquard syndrome below T5–T6 cord segment secondary to spontaneous epidural hematoma. He opted for conservative treatment, which was followed by rapid resolution.

Conclusions

Although Brown-Séquard syndrome as a presenting feature of SSEH is rare, it does exist in exceptional case, which should be taken into consideration for differential diagnosis. Prompt surgical decompression is an absolute surgical indication widely accepted for patient with progressive neurological deficit. However, SSEH presenting with incomplete neurological insult such as Brown-Séquard syndrome might have a benign course. Successful non-operative management of this problem does not make it a standard of care, and surgical decompression remains the standard treatment for SSEH.     

Thoracic outlet syndrome in a patient with SAPHO syndrome – A case report

Introduction and ImportanceThoracic outlet syndrome (TOS) includes disorders caused by compression of the neurovascular structures in the upper thoracic outlet (Roos and Owens, 1996 [1]; Bürger, 2014; Curuk, 2020 [3]). Depending on the compressed structure, it is categorized into neurological, arterial and venous TOS.SAPHO syndrome (synovitis–acne–pustulosis–hyperostosis–osteitis syndrome) is a rare chronic inflammatory disease of unknown etiology. With its typical involvement of sternoclavicular joint and clavicle, complication due to hyperostosis in this region, leading to thrombosis of the subclavian vein have been reported in some cases of SAPHO syndrome.Between 2015 and 2019 488 patients, suffering from neurological, vascular or combined TOS presented at our department. Depending on clinical and diagnostic results surgical therapy was performed in 175 cases via the transaxillary approach, including complete first rib and/or cervical rib resection, neurolysis of plexus brachialis, thoracic sympathectomy and vascular reconstruction if indicated (Curuk, 2020). During this period, only one single patient presented with SAPHO syndrome with thrombosis of the subclavian vein and neurovascular TOS.Case presentationWe present a 50-year-old female patient, in line with the SCARE 2020 criteria (Agha et al., 2020 [12]) suffering from extremely rare combination of neurovascular TOS and SAPHO syndrome with thrombosis of the left subclavian vein due to hyperostosis of the left clavicle.ConclusionProgressive bone changes associated with SAPHO syndrome can lead to narrowing of the thoracic outlet. Pharmacological therapies to avoid the progression of the hyperostosis of the costoclavicular joint and the clavicle do currently not exist. First rib resection is a therapeutic option to widen the space in the upper thoracic region. Surely, it is a rare condition and more long-term follow-up data are required.     

Schwannoma of the upper cervical spine–a case report

Upper cervical schwannoma is rare, and belongs to benign tumors that is usually asymptomatic. It accounted for only ten percent of schwannomas cases and mostly occurs in 40e50 years old patients. Aggressive and total resection is the treatment of choice for this tumor. Preoperative diagnosis is difficult, relying on clinical suspicion, and confirmed by surgical pathology. We report a 54-year-old male patient with chief complain of progressive weakness and numbness of his right arm for four months. He had a history of lymph node tumor in 2007 and excised in 2011. Neurological decrease was found on the right arm. The radiographic examination showed lytic lesion on the second, third, and fourth cervical spine. Computed tomography scan showed destruction extending to the first cervical vertebra. Capsulated extradural and extramedullary mass and compression to the spinal cord was found from the magnetic resonance imaging. Two-stage operation was performed. The first stage was posterior decompression with occipitocervical fusion and instrumentation, while the second was anterior decompression and iliac strut graft. Both operations performed using the surgical ultrasonic dissector. During three months'' follow-up, it showed neurological improving. Neurological deficit appears when there is compression on the spinal cord. Total resection is the treatment of choice for these tumors. Preoperative imaging should be performed to exclude malignant tumor and found tumor extension.     

Isolated metastatic melanoma to the gallbladder: is laparoscopic cholecystectomy indicated?: a case report and review of the literature

Metastatic involvement of the gallbladder in melanoma is rare, but constitutes the most common metastatic lesion involving this organ. The surgical management seems to be indicated for patients with isolated and resectable gallbladder metastases to avoid symptoms or tumor complications. We report on a case of a young woman with an isolated metastatic gallbladder melanoma who presented with symptoms of acute cholecystitis. The patient underwent laparoscopic cholecystectomy (LC) and lymphadenectomy of the hepatoduodenal ligament. Histology was characteristic for metastatic malignant melanoma. Nodes were negative for metastases. We emphasize the appropriateness of a laparoscopic approach, once ruled out a widespread metastatic disease. It can be done with a remarkably low rate of complications. Gentle manipulation, avoidance of perforation, and use of a retrieval bag for the removal of the gallbladder should be practiced to help minimize the chance of mechanical exfoliation or implantation of malignant cells during LC. In isolated metastatic localization, LC may be curative and provide adequate palliation of symptoms with a short convalescence and a fast recovery.     

Domino liver transplantation with double piggyback: is this the best technique? A case report

Sequential or domino liver transplantation is a well-established procedure for patients with familial amyloidotic polyneuropathy (FAP). Donation for domino liver transplantation imposed the resection of the inferior vena cava along with the liver, requiring complete suprarenal vena cava clamping and usually the use of venovenous bypass. We describe a successful case in which it was possible to perform the FAP hepatectomy by the piggyback technique.     

Laparoscopic management of a complicated case of Wilkie’s syndrome: A case report

IntroductionSuperior mesenteric artery (SMA) syndrome also known as Wilkie’s syndrome is a rare condition caused by the entrapment of the third part of the duodenum between the aorta and the SMA. The incidence of Wilkie’s syndrome range between 0.013% and 0.3%. The normal angle between the aorta and SMA has been described to range between 38° and 65°, whereas in Wilkie’s syndrome this angle is reduced to less than 20° causing gastric outlet obstruction.Case presentationWe report a case of a previously diagnosed 43 year-old male with SMA syndrome, whom had been conservatively managed for 5-years for recurrent admissions with symptoms of gastric outlet obstruction. During his last admission, CT abdomen demonstrated gastric pneumatosis and portal venous gas requiring urgent surgical intervention. Duodenojejunostomy was successfully performed using laparoscopic technique.DiscussionSMA syndrome is thought to occur secondary to the rapid and excessive weight loss leading to the reduction of the mesenteric fat around the aorta and SMA, thereby reducing the normal angle between the two arteries. Conservative medical management is usually the first line of treatment in uncomplicated cases. Surgical management is usually reserved only after failed conservative management or complicated cases, at which time either an open or laparoscopic surgical approach is undertaking.ConclusionSurgical intervention is the mainstay in complicated cases of SMA syndrome and in refractory cases to conservative management. Advantages of laparoscopic approach over open surgery include rapid recovery time, reduced post-operative pain and shorter hospital stay.     

Brown-Séquard syndrome after a gun shot wound to the cervical spine: a case report

Background contextBrown-Séquard syndrome is characterized by a hemisection of the spinal cord most commonly after spinal trauma or neoplastic disease. The injury causes ipsilateral hemiplegia and proprioceptive sensory disturbances with contralateral loss of pain and temperature sensation. Patients with Brown-Séquard syndrome have the best prognosis of all spinal cord injury patterns. At this time, the ideal management for Brown-Séquard syndrome after penetrating trauma has yet to be defined.PurposeTo report a case of a gun shot wound to the upper cervical spine that resulted in Brown-Séquard syndrome and was treated effectively with early cervical spine decompression and fusion.Study designObservational case report.MethodsA 28-year-old woman presented after sustaining a low-velocity gun shot wound in to the upper cervical spine in a civilian assault. On initial presentation, she had 0/5 motor scores in the left upper and lower extremities and normal motor scores on the right. Sensory examination was limited as she was intubated and sedated on admission due to airway compromise. A computed tomography scan revealed a bullet lodged in the vertebral body of C3 with boney fragments and soft tissue encroaching on the spinal cord. Subsequently, she underwent C3 corpectomy, bulletectomy, and anterior cervical decompression with fusion.ResultsIntraoperatively, no dural disruption or cerebral spinal fluid leak was noted, and her posterior longitudinal ligament was intact. One month postoperatively, her left lower extremity motor score was 5/5 with movement of her left thumb and all fingers. Strength in her biceps, triceps, and wrist extensors and flexors was 3/5. Her functional capacity and strength gradually improved.ConclusionsReinke et al. support surgical intervention for patients with incomplete paraplegia after the patient is medically stabilized, although their case report discussed lower thoracic injury, which carries a more favorable prognosis. All other prior case reports and prospective studies that reported favorable outcomes after Brown-Séquard syndrome involved the midthoracic, low thoracic, or lumbar spinal levels. This report is the first case of Brown-Séquard syndrome after a high cervical gun shot wound, which was managed with immediate decompression and fusion, where near complete recovery was obtained.     

Isolated congenital absence of posterior cruciate ligament? A case report

A rare case of a 28-year-old Asiatic male with the isolated absence of a posterior cruciate ligament is reported. Clinical features, diagnostic steps, therapeutic strategies and follow-up are described. A review of the literature is also presented.     

Venous malformation as source of a tarsal tunnel syndrome: treat the source or the cause of the complaints? A case report

Painful tarsal tunnel syndrome is a compression neuropathy with a variety of possible sources. As it presents a challenging differential diagnostic problem, it is often under-diagnosed. Among the intrinsic and extrinsic factors, varicose veins are the main source in case of a venous etiology.

We report a case of a 39-year old male patient who presented with complaints of paresthesia and excessive pain of the right foot, especially the medial side. Further work up by ultrasonography, magnetic resonance imaging and electromyography revealed an extensive congenital venous malformation of the right lower limb with subsequent compression of the tibial nerve in the tarsal tunnel. We did not treat the source, but the cause by open tarsal tunnel release. Excellent result with immediate full relieve of the patients complaints was achieved.     

Breast mass as the primary presentation of Wegener’s granulomatosis: a case report

A case report of a 27-year-old African-American female with a history of bilateral breast masses is presented. Primary breast cancer or metastatic disease was the presumed etiology. On work-up, however, fine-needle aspiration biopsy followed by open excisional biopsy revealed the diagnosis of Wegeners granulomatosis. Initial presentation of this necrotizing granulomatous vasculitis in the breast is exceedingly rare, and this case highlights the importance of maintaining a degree of suspicion for this clinical entity in the evaluation of a breast mass.     

Laparoscopic resection of a large GIST of the stomach: is it preferable in elderly patients? A case report

Gastrointestinal stromal tumour (GIST) of the stomach is extremely rare in the elderly. Surgical resection of the stomach by partial gastrectomy or wedge resection is the standard treatment. Today the resection can also be performed laparoscopically, especially in the case of small tumours as well as for larger GIST though there are unclearly defined oncological limits. The authors report the successful treatment of a large 7.5 cm GIST of the stomach by laparoscopic wedge resection in a 78-year-old patient. The GIST was almost entirely located intraperitoneally between the stomach and the spleen and could be radically resected with a minimal touch technique. The patient recovered promptly and manifested no recurrence at a 2-year follow-up. The authors focus on the main factors supporting the indication for laparoscopic resection of large gastric GIST, especially in the elderly. The surgical risk/benefit ratios of the different approaches, the surgeon's skills in laparoscopically respecting the rules of oncological surgery, and informed consent of the patient in relation to the limited scientific evidence concerning the main risk factors of recurrence are all important considerations.     

Stewart–Treves syndrome: a case report

We present a case of chronic lymphoedema that progressed to Stewart–Treves syndrome in a 63-year-old woman with a previous modified radical mastectomy, associated lymph node dissection, chemotherapy and radiotherapy. While producing stabilisation of most cutaneous lesions initially, chemotherapeutic treatment of the angiosarcoma did not prevent subsequent metastasis and patient death. We urge vigilance and regular follow-up appointments for patients following a mastectomy with chronic lymphoedema to facilitate prevention or early treatment of this devastating syndrome.     

Can Denosumab cure giant cell tumors of the spine? A case report and literature review

European Journal of Orthopaedic Surgery & Traumatology - Bone giant cell tumors, although benign, may be locally aggressive and cause severe morbidity; in some cases, they can also disseminate...     

Compartment syndrome or gas gangrene? A case report

A case of forearm compartment syndrome due to a minor trauma is reported. The severe clinical conditions due to a shock state lead to an initial misdiagnosis of clostridial myonecrosis. The patient, 68 y-old woman, was admitted to the intensive care unit of Authors' hospital for a traumatic injury of the right forearm. A diagnosis of gas gangrene due to clostridial myonecrosis was done and forearm amputation suggested. In spite of this indication a decompression fasciotomy of the forearm compartments was performed as well as a hyperbaric oxygene therapy. Since culture of necrotic tissue samples did not demonstrate any bacterial growth, the Authors decided to avoid amputation and perform a radial arteriovenous fistula to improve venous return and reduce distal edema and continuous bleeding, with a complete recovery within 40 days. Good evaluation of patient with suspected compartment syndrome means correct and not delayed treatment, avoiding invalidating outcome.     

A case report of Gorham–Stout syndrome remission

Gorham–Stout syndrome (GSS) is a rare disorder characterized by spontaneous bone resorption with rapid progression, occasionally after minor trauma. It is also known as massive osteolysis or vanishing bone disease [1–3]. Some patients present with relatively abrupt pain and have swelling in the affected extremity, whereas others present with a history of insidious onset of pain, limitation of motion, and progressive weakness in the involved limb. The affected bone disappears completely [4]. The degree of osseous deformity in patients with GSS becomes severe. Paraplegia occurs in patients with spinal cord compression caused by vertebral involvement. Spinal involvement increases mortality to over 30%, because of complications such as spinal cord compression [5]. Thoracic cage, pulmonary, or pleural involvement leads to compromise of respiratory function and consequent death [3, 6]. Visceral complication can occur when the disease invades the surrounding tissues [7]. Recently, interferon and bisphosphonates have been reported to have remissive effects, although the mechanisms are unclear [8, 9]. Understanding the mechanisms that contribute to spontaneous or drug-induced remission is important in the control of this severe condition.     

Boerhaave’s syndrome in a tracheoesophageal speaker: report of a case

Boerhaave’s syndrome is still associated with a high mortality rate and remains a therapeutic challenge. Pharyngo-laryngo-esophagectomy is performed as the standard treatment for advanced hypopharyngeal cancer and tracheoesophageal speech is an option for esophageal speech rehabilitation. We report what, to our knowledge, is the first case of Boerhaave’s syndrome developing in a tracheoesophageal speaker.