Postoperative recovery of complete sudden paraplegia due to lumbar schwannoma. Case report

The authors present a rare case of acute complete paraplegia due to a lumbar schwannoma. The clinical presentation, magnetic resonance imaging features, and management strategy are discussed. A 29 year-old man presented with acute complete paraplegia and bladder and bowel incontinence. He had a history of stable back pain and a 4-year history of lower-extremity numbness bilaterally. Magnetic resonance imaging revealed an enhancing extraaxial mass filling the spinal canal over two segments below the conus medullaris. An L1-3 laminectomy was performed and the tumor was completely removed. Pathological evaluation showed features characteristic of a schwannoma. The patient regained almost complete motor function after 6 months. To the authors' knowledge, this is the first reported case of acute complete paraplegia secondary to lumbar schwannoma. Possible mechanisms of this occurrence are discussed.     

Paraplegia after intracord injection during attempted epidural steroid injection in an awake-patient

Epidural steroid injection is recommended in patients with back ache from spinal and radicular pain or pain suggestive of radiculopathy. During needle placement and injections, clinicians often rely on the patient's complaint of paresthesia or shooting pain along the nerve root, dura, or cord in case a needle pierces these areas. We report the accidental intracord injection of steroid solution during epidural block using fluoroscopy in a conscious patient, which caused paraplegia. This case suggests failure of undue reliance on a patient reporting pain in the vicinity of needle puncturing the spinal cord structures. IMPLICATIONS: Intracord injection of triamcinolone acetate and local anesthetic, resulting in permanent paraplegia, may occur in conscious patients.     

Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.     

Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor

This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.     

胸腰段椎体爆裂骨折并完全性瘫痪的治疗

[目的] 探讨胸腰段椎体爆裂骨折并完全性瘫痪是否有必要行前路手术。[方法] 14例胸腰段椎体爆裂骨折并完全性瘫痪病人均行前路手术，采用左侧经胸膜后，腹膜后入路椎管前方减压去除压迫物，内植物植人加钢板内固定。术后定期严密随访每4个月1次，包括详细的症状体征记录，X线片俭查，部分病人行CT俭查。与既往胸腰段骨折并完全性瘫痪行后路减压椎弓根钉内固定7例（资料完整）行历史对照：[结果]　14例获得随访时间6个月～3年8个月（平均16个月），术前肋缘下至腹股沟束榨感及腰背痛全部消失，感觉平面下降8～18cm 3例，而且分别在术后4、8、12个月恢复部分排尿功能。全组病人双下肢肌力无恢复，8例于3个月之后出现不同程度肌张力升高。对照组7例术后腰间榨感及腰背痛完全消失仅1例，感觉平面全部无下降，1例于术后8个月恢复部分排尿功能。双下肢肌力均无恢复，肌张力均明显升高。[结论]　胸腰段椎体爆裂骨折并完全性瘫痪行前路手术对缓解术前腰背痛及腰间束榨，减轻肌张力增高及稳定脊柱有一定效果，但感觉平面的下降及下肢肌力的改善效果不明显。     

A case of spinal extradural hematoma during the insertion of an epidural catheter

An epidural haematoma was observed after epidural lumbar puncture in a 75-year old patient receiving 5,000 units calcium heparinate every 12 h as antithrombotic therapy. The diagnosis was suspected by the occurrence of sudden pain and bleeding through the epidural catheter, followed by a complete paraplegia. The diagnosis was confirmed by contrast myelography. Early surgery did not improve the neurological deficit. This case report emphasized that anticoagulant therapy must be discontinued before epidural anaesthesia.     

A case of nontraumatic spinal epidural hematoma caused by extradural varix: consideration of etiology

BACKGROUND CONTEXT: Many cases of nontraumatic spinal epidural hematoma (SEH) have been reported, although the etiology of SEH remains unclear. PURPOSE: Our purpose was to report a rare case of nontraumatic acute SEH caused by extradural varices and to discuss the etiology of this entity. STUDY DESIGN/SETTING: Case report. PATIENT SAMPLE: A 27-year-old man. OUTCOME MEASURES: Resolution of the patient's paraplegia, and pathological examination of the epidural vein of the patient and three other patients with cervical spondylosis. METHODS: Not applicable. RESULTS: The patient recovered from paresis of both hands, although paraplegia remains complete. Pathological examination of the patient revealed abnormal veins that had thickened walls, varying caliber, and internal elastic lamina. In two of the three patients with cervical spondylosis, abnormally dilated veins resembling those in the SEH patient were observed. CONCLUSIONS: We describe a rare case of SEH caused by extradural varices. It is speculated that spinal epidural veins can possibly develop an abnormal structure and fragility as seen in the present case and in spondylotic cases.     

Paraparesis after posterior spinal fusion in neurofibromatosis secondary to rib displacement: case report and literature review

In patients with neurofibromatosis, rib displacement into the spinal canal is a rare cause of paraplegia. We report a patient with paraplegia caused by rib displacement whose signs and symptoms began after posterior in situ fusion for dysplastic scoliosis. There was complete recovery after anterior decompression and resection of the rib.     

Oncocytoma of the spinal cord causing paraplegia - a case report

STUDY DESIGN: Case report. OBJECTIVES: To describe a rare case of oncocytoma arising from the spinal cord in a 40-year old woman. SETTING: Republic of Korea. METHODS: The patient's history, physical examination, radiological and pathological findings were reviewed. RESULTS: A 40-year-old woman presented with 3-month history of low back pain. Magnetic resonance imaging revealed an intradural extramedullary mass located between L1 and L4. She refused any surgical treatment and so was discharged. At 10 days after discharge, an emergency operation was performed because of sudden paralysis in both lower extremities. The confirmed diagnosis is oncocytoma. At 4 months after surgery, the patient failed to obtain neurological recovery from complete paraplegia. CONCLUSIONS: Since the progression of an intradural extramedullary mass that shows minor neurological symptoms can lead to complete paraplegia in a short time, close observation and early surgical decompression are necessary.     

Cowherd's injury: Traumatic retrospondyloptosis of L1 over L2 in a 7-year-old child

Traumatic retrolisthesis of the first lumbar vertebra is a rare injury and only one case has been documented in the literature. We report a case of traumatic retrolisthesis of the first lumbar vertebra in a 7-year old child. He was injured after being dragged by a cow and presented with Frenkel grade A paraplegia. His plain radiographs revealed complete retrolisthesis of the first lumbar vertebra over the second. The patient was treated surgically with open reduction and sublaminar wire loop rectangle fixation. The patient showed Frankle grade D (Frankle grade) neurological recovery in the postoperative period over a period of 15 months. This case is reported in view of rarity and mechanism of injury is described.     

Spontanes spinales Epiduralhämatom als Ursache eines inkompletten Transversalsyndroms

Spontaneous spinal epidural hematomas are rare but are of differential diagnostic importance due to the potentially dramatic progression through to irreversible neurological deficits. At the beginning the clinical symptoms are non-specific and the development of neurological deficits leads to the diagnosis. We present the case of a 73-year-old female patient who initially reported uncharacteristic neck pain and developed incomplete quadriplegia during the next day as well as the case of a 78-year-old male patient, who complained of acute back pain and developed paraplegia a short time afterwards. Early microsurgery and spinal canal evacuation led to complete remission of the neurological deficits in both cases.     

Vertebrectomy in treating fracture-dislocation of the spine with paraplegia

From April 1980 to August 1984, 11 cases of fracture--dislocation of spine at the level of T-11 to L-2 with obvious kyphosis at the site of displacement, with paraplegia, were treated by vertebrectomy through posterior median approach. The operations were performed 2 to 28 weeks, averaging 8 weeks, after injury. 5 of the 9 patients who had complete paraplegia suffered also causalgia in both legs. The other 2 had incomplete paraplegia only. Follow-up study, 4 years and 5 months post-operation on average, revealed complete reduction of the fracture-dislocation in 10 patients and incomplete in one, getting solid bony union in all. Concerning the neurological findings of the 9 complete paraplegic patients, 5, who had suffered from causalgia got varying degree of relief, 5 regained sensation of pain in region 2 segments lower, of the 2 incomplete paraplegic patients, 1 regained sensation of pain in both legs and muscular power of degree 4 in both thighs, so that walking became possible, while the another one fell into complete paraplegia, because of compression of the cord at T-10 happened during operation and showed no signs of recovery afterward.     

Acute postoperative paraplegia complicating with emergency graft replacement of the ascending aorta for the type a dissection.

Postoperative paraplegia complicating with type A dissection is extremely rare. We describe a case of acute paraplegia after emergency graft replacement of the ascending aorta for type A dissection. A 63 year-old hypertensive man presented to hospital with chest pain. A chest computed tomography demonstrated an aortic dissection of the ascending aorta with mild pericardial effusion. Under deep hypothermic circulatory arrest with concomitant antegrade selective cerebral perfusion, the ascending aorta was replaced. The patient regained consciousness six hours after operation, however, he was complicated with paraplegia. All sensation was lost below the level of Th12. The cause of the paraplegia was assumed to be a thrombotic occlusion of costal arteries, which originated from the false lumen. Spinal fluid was drained for three days. Hyperbaric oxygenation therapy was started four days after onset of paraplegia. Fortunately, our patient recovered gradually, and he was doing well and was walking independently at one-year follow-up. (Ann Thorac Cardiovasc Surg 2003; 9: 330-3)     

Paraplegia caused by painless acute aortic dissection

OBJECTIVES: Painless acute aortic dissection in which paraplegia is the only presenting sign is rare, with limited reported cases. CASE REPORT: The authors report a patient with painless acute aortic dissection who presented with sudden onset paraplegia. Ischemic diseases of the spinal cord were suspected as the cause. MRI revealed extensive acute aortic dissection with an intramural hematoma. The patient was treated conservatively by strictly controlling his blood pressure. The treatment was successful, although the motor function of the lower extremities could not be rescued. Although 3% to 5% of patients with acute aortic dissection present with paraplegia as a result of spinal cord infarction, most of these patients experience severe pain prior to presentation. CONCLUSION: Painless acute aortic dissection in which paraplegia is the only presenting sign is very rare. However, aortic diseases, including acute aortic dissection, should always be considered as a differential diagnosis of patients with sudden onset, painless paraplegia.     

Posterior stabilisation of a malignant cervico-thoracic vertebral bone defect

Oesophageal cancer is frequently complicated by malignant fistulae. Necrosis of the tumour following radiotherapy or chemotherapy may lead to the development of fistulae between the oesophagus and adjacent tissues and organs. We report the expansion of an extra-luminal oesophageal cancer after resection, invading the cervico-thoracic spine, fortunately without neurological deficit, and leading to instability and formation of a malignant fistula linking the tracheo-bronchial tree to the subarachnoidal space. To prevent imminent paraplegia and to alleviate severe pain, we rigidly stabilised the spine at the cervico-thoracic junction using an angle-stable system through a single posterior approach. Further postoperative follow-up revealed no signs of neurological deterioration. Cervico-thoracic stability was preserved until the patient died nearly five months postoperatively. This case shows that posterior stabilisation and decompression may be a palliative option for patients with imminent paraplegia and severe pain due to advanced tumour infiltration of the cervico-thoracic spine.     

Posterior osteosynthesis in the treatment of spinal cord tumors]

Prognosis of cancerous tumors of the spine depends above all on their neurological consequences. The authors have wondered whether osteosynthesis of the spine -- in addition to decompressive surgery -- can improve patient's survival and fonctional results. 23 patients, 20 with a metastatic tumor and 3 with a plasmocytoma were treated in this way. All of them had neurological deficits, 4 had isolated radicular symptoms, 1 a cauda equina syndrome and 18 a spinal cord compression (7 of which were complete). 20 of these patients suffered intractable pain of the spine. All the patients underwent decompressive surgical removal of tumor through laminectomy, associated with a bilateral posterior metallic osteosynthesis. The type of osteosynthesis consisted of two metallic plates placed along each articular column and screwed into the articular processes and the vertebral body through the pedicles of the adjacent normal vertebrae. Cobaltotherapy was added in 14 cases, hormonotherapy in one case and radioactive 131 1 in one another patient. Selective spinal angiography, performed in one case of thoracolumbar tumor was found useful in the location and avoidance of Adamkiedwicz's artery. With regard to the complication, there were two operative wound infections requiring reoperation. Our series -- in comparaison with others -- prove the effectiveness of the combined procedure. Patients without complete spinal deficit had a 20 months survival average. Patients with complete deficit had the same survival as in comparative group. But all the 20 patients suffering pain in the spine were substantially relieved. Such a combined procedure is indicated in cases of tumors involving the vertebrae, whether or not the epidural space is invaded especially when there are riskes of unstable fracture and only partial neurological deficits. The technique may be extended even to complete paraplegia because of its worth while antalgic effects. Thus this method -- by consolidating the spine -- relieving pain and consequently allowing kinesitherapy to be resumed earlier is able to improve the functionnal status and increase survival of the patients.     

Surgery for malignant extradural tumours of the spine

We have reviewed 41 patients with malignant extradural tumours of the spine treated by anterior decompression for cord compression, or uncontrolled back pain or both. An anterior operation alone was performed in 37 cases, four had combined or staged anterior and posterior decompression. An anterior operation on its own achieved major neurological recovery in 18 of the 33 cases with neurological loss (56%); only four remained unchanged. Eleven had minor improvement but not enough to allow them to walk or to regain bladder function. No patient with complete paraplegia gained a useful neurological recovery. Back pain was improved in 30 of the 41 patients (73%), sound internal fixation being important in this respect. There were four early deaths and another 23 died from disseminated disease after a mean survival of 4.1 months. Fourteen patients are still alive with a mean survival of 14 months.     

Transient paraplegia caused by acute aortic dissection--case report.

A case of acute aortic dissection (AAD) presenting as sudden, transient paraplegia and severe back pain is reported. The patient was a 66-year-old male with a 10-year-history of hypertension. The pain characteristically migrated from the back to the neck and then returned to the back. He showed complete transverse myelopathy at the level of the 9th thoracic cord. Computed tomography disclosed internal displacement of aortic intimal calcifications, without abnormalities in the spinal canal, and myelography showed no spinal canal block or stenosis. Electrocardiography and chest x-ray indicated nonspecific changes of high amplitudes and mild cardiomegaly, respectively. Together, these findings suggested acute aortic dissection with spinal cord ischemia. The initial systolic blood pressure of 220 mmHg was lowered with medication, and the pain was controlled with morphine. He recovered fully and was discharged 80 days after the onset of symptoms, with no neurological deficits. AAD carries a very poor prognosis unless treated immediately. Therefore, it is very important to promptly differentiate this disorder from spinal vascular conditions that also produce back pain and paraparesis.     

Primary osteosarcoma of the L2 lamina presenting as “silent” paraplegia: case report and review of the literature

Summary Primary osteosarcomas of the vertebral column are not common, and to our knowledge a total of 78 cases, mostly located in the vertebral body, have been previously reported. We report a primary osteosarcoma of the spine with an extremely rare location — the lamina of the second lumbar vertebra. The patient, a 38-year-old woman, was admitted with paraplegia of a short duration without pain. Preoperatively, the patient underwent CT scanning for staging (Enneking IIB) followed by a needle biopsy and local preoperative arterial embolization. An emergency decompressive laminectomy was performed, and stabilization was carried out using methylacrylate. The patient showed a complete neurologic recovery. Combined chemotherapy and local irradiation did not prevent tumor recurrences, which occurred 12 and 19 months after the initial intervention and were associated with recurrent neurologic impairment. The patient died 19 months after the initial presentation, while in paraplegia, from lung metastases. Based on our unique observation, it seems that in primary osteosarcomas located in the posterior elements of the spine, the symptoms are not specific, and the disease may only become manifest when the tumor is no longer resectable. When the tumor is associated with neurologic impairment, spinal canal decompression should be performed even though it does not radically resect the tumor because it significantly improves the quality of the patient's life.     

经皮椎体成形术治疗脊柱转移癌

目的探讨经皮椎体成形术(PVP)在脊柱转移癌中的治疗效果和适应证的选择。方法对21例脊柱转移癌病人的30个椎体，在CT引导下经皮椎弓根向椎体内穿刺并注入聚甲基丙烯酸甲酯(PMMA)。结果20例术后2～72h内疼痛缓解，18例活动状况改善，术前有神经根损伤和截瘫者术后神经功能均无明显变化；1例多发脊柱严重破坏者术后疼痛无缓解，3例活动状况无明显改善。术后CT显示1例骨水泥硬膜外少量渗漏。21例术后随访4～20个月，平均7．5个月。18例疼痛缓解，其中15例疗效稳定。结论PVP治疗脊柱转移癌安全可行，方法容易掌握，术后多数能即刻缓解疼痛，增加脊柱稳定性，改善活动状况，并可与放疗、化疗等联合应用。