Lumbar disc herniation associated with scoliosis in a 15-year-old girl: case report

Intervertebral disc herniation is a rare condition in childhood and adolescence, although some cases have already been reported in the literature. We present the case of a 15 year-old-girl with low back pain and scoliosis. She had no previous history of trauma or collagen diseases. MRI showed L4-L5 and L5-S1 disc herniations and no further bone and structural changes. After two level discectomy, pain ceased and scoliosis improved, without further treatment. Based on her evolution and on what has already been reported in literature, we consider that scoliosis associated with disc herniation in young patients is most likely to be only an anthalgic position, not indicative of further structural changes.     

One-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of cervicothoracic spinal tuberculosis with kyphosis in children: a preliminary report

Purpose  

To determine the efficacy and feasibility of surgical management of cervicothoracic tuberculosis accompanied by kyphosis in children by using one-stage posterior focus debridement, bone graft fusion, and instrumentation at a single institution.     

Case report: electroconvulsive therapy in a 33-year-old man with hysterical quadriplegia

Conversion disorder refers to the occurrence of neurological-like symptoms or deficits that are neither intentionally produced nor simulated. While it cannot be explained by an organic disease, it is often related to psychological events. CASE REPORT: We report the case of a 33-year-old patient with a fluctuating hysterical tetraplegia, which had started three years earlier. After the failure or the exhaustion of several biological (psychotropic medication, transcranial magnetic stimulation) and psychotherapeutic strategies, treatment with electroconvulsive therapy (ECT) was conducted. A total of thirty-five ECT sessions were performed. Whereas the patient's clinical state was initially characterized by a complete quadriplegia and an uncontrollable muscular hypertonia, we noted that the ECT sessions were associated with a slow, though remarkable, progress. At first, the sessions were followed by moments of altered consciousness during which the patient would be relaxed and could make simple movements. Secondarily, not only was our patient able to consciously move his four limbs, but he was also able to walk. However, those improvements remained partial and fluctuating, sometimes allowing the symptom to return temporarily secondary to frustrations or annoyances. Finally, our patient relapsed. Nevertheless, his clinical state presently remains better than that in which we first knew him. DISCUSSION: The treatment of conversion disorders has been the subject of few studies and predominantly remains symptomatic. Its main goals are: to lessen secondary gains impact by adopting a neutral behaviour towards the symptom and by encouraging physical rehabilitation; to lower the symptom by allowing the patient to understand the normal functioning of the diseased organ, and; to help the patient to deal with stressful situations. There is no evidence that hypnosis is superior to medical and other psychotherapeutic approaches. Pharmacological treatments may be helpful in the case of anxiety, impulsivity or depression, albeit delivered with caution. According to some case reports, transcranial magnetic stimulation has also been associated with clinical remission. Although the use of ECT in motor conversion disorders constitutes an uncommon procedure, and even if no clinical trial has evaluated its impact on such a pathological condition, several case reports suggest that electroconvulsive therapy can be efficient in the treatment of motor conversion disorders. This efficacy may rely on several hypotheses. ECT could induce neural modifications, and participate in the suppression of an active inhibition, which is responsible for hysterical symptoms. Indeed, conversion cerebral disorder correlates can be explored with the help of functional neuro-imaging techniques, which could therefore also identify ECT neural effects. ECT adverse effects on memory could lead to a new relationship with the symptom, and modulate the psychological conflict which has participated in its emergence. Narcoanalysis, ECT sessions could have an impact on consciousness by means of some dissolution and reorganization phenomenon. It could therefore participate in the ending of an emotional block, the psychic integration of traumatic events and the recovery of a voluntary motor control. Finally, ECT could be efficient thanks to its antidepressant properties, especially its ability to stimulate triaminergic, and particularly dopaminergic transmission. This case report reminds us how difficult it can be to deal with severe conversion disorders, and to navigate between two reefs, which are abstention, and therapeutic escalation.     

One-stage posterior focus debridement,fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children

Objective

The purpose of this study is to investigate the clinical efficacy and feasibility of one-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children.

Methods

From December 2007 to May 2012, 13 patients (six males and seven females) suffering from lumbar spinal tuberculosis with kyphosis were admitted. All patients were treated with one-stage posterior focus debridement, fusion, and instrumentation. Then, the clinical efficacy was estimated by statistical analysis based on the data about Frankel grade, the Cobb angle of kyphosis, and erythrocyte sedimentation rate (ESR), which were collected at certain time.

Results

The age of all patients ranged from 5 to 13 years (average, 8.8 years). Operation time ranged from 120 to 190 min (average, 165 min). Intraoperative blood loss ranged from 200 to 800 ml (average, 460 ml). All patients were followed up for 24 to 57 months postoperatively (average, 33.5 months). The Cobb angle was changed significantly between preoperation and postoperation (P?<?0.05), and there was no significant loss at the last follow-up. The preoperation ESR (62.5?±?15.7) returned to normal (16.6?±?8.1) within 3 months postoperatively in all patients (P?<?0.05). Bone fusion was achieved within 3–5 months (average, 3.5 months). In the 13 cases, no postoperative severe complications occurred and neurologic function improved in various degrees.

Conclusion

The outcomes of follow-up showed that one-stage posterior focus debridement, fusion, and instrumentation can be an effective treatment method for the lumbar spinal tuberculosis with kyphosis in children.

     

Chronic meningoencephalomyelitis with spastic spinal paralysis: a case report.

A case of chronic meningoencephalomyelitis in a 48-year-old housewife is presented. The onset was characterized by spastic paralysis of the lower extremities. The course was progressive with repeated remissions and exacerbations, and the patient died approximately seven years after the onset of disease. Laboratory tests showed slightly increased cell count in the spinal fluid, accelerated sedimentation rate, positive CRP and RA, and increased ASLO and gamma globulin levels. Neuropathologic examination revealed such changes as perivascular cellular infiltration, glial nodules, poorly demarcated demyelination and recent necrosis in the spinal cord and basal ganglia. Only mild inflammatory findings were noted in the telencephalon and brain stem. The clinico-pathologic findings in this case supported a diagnosis of chronic meningoencephalomyelitis which could not be classified as any known type of encephalomyelitis.     

Life expectancy in pediatric patients with cerebral palsy and neuromuscular scoliosis who underwent spinal fusion

The aim of this study was to document the rate of survival among 288 severely affected pediatric patients (154 females, 134 males) with spasticity and neuromuscular scoliosis who underwent spinal fusion (mean age at surgery 13 years 11 months, SD 3 years 4 months), and to identify exposure variables that could significantly predict survival times. Kaplan-Meier survival analysis was performed demonstrating a mean predicted survival of 11 years 2 months after spinal surgery for this group of globally involved children with cerebral palsy (CP). Cox's proportional hazards model was used to evaluate predictive efficacy of exposure variables, such as sex, age at surgery, level of ambulation, cognitive ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in hospital, and days in the intensive care unit. Number of days in intensive care unit after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. This demonstrated statistically significant predictability for decreased life expectancy after spinal fusion in children with CP.     

Combined use of melatonin and low-dose flunitrazepam for treatment of sleep disturbance in a child with spastic quadriplegia: evaluation using polysomnography

A 14-year-old boy born at 39 gestational weeks with the birth weight of 3,250 g, had severe mental retardation and spastic quadriplegia of unknown etiology from early childhood. At 7 years of age, disturbance of night sleep appeared with several awakenings. Combined treatment with melatonin (MLT; 0.04 mg/kg) and flunitrazepam (FNZ; 0.025 mg/kg) was more effective than monotherapy with FNZ for the sleep disturbance. Difference of the effects of the combined therapy and the monotherapy for the sleep disturbance were assessed by polysomnographies (PSGs), consisted of EEG (C3, C4), bipolar EOG and surface EMG on the mentalis muscle. The PSGs were performed twice at 13 years 6 months old, and at 14 years 1 month old. In both trials, the number of awakening was fewer, total sleep time was longer, percent (%) stage I and II were lower and %REM sleep was larger in combined MLT and FNZ therapy than in FNZ monotherapy. The present study suggests that the combined MLT and FNZ therapy not only reduces awakening during sleep but also normalizes sleep architecture. This therapy is valuable because normalization of sleep is important for the developing brain as it reflects the normal functioning of the aminergic neurons of the midbrain and the brainstem which have important roles for morphological and functional development of the brain in immature brain.     

A retrospective review to assess whether spinal fusion and scoliosis correction improved activity and participation for children with Angelman syndrome

Objective: This study investigates outcome of scoliosis treatment for 11 children with Angelman syndrome (AS), with particular focus on activity, participation and the musculoskeletal factors that may affect these outcomes. Methods: Retrospective review of medical records, radiographs and questionnaires administered to caregivers of 11 children (8M:3F) with AS and scoliosis. Six underwent observational treatment during childhood and five underwent spinal fusion. The Activities Scale for Kids (ASKp) questionnaire was used to measure activity and participation. Questionnaire and radiographic data were recorded over a 2 year period. Results: In the observational group, scoliosis increased from 31° to 46°. Mean ASKp decreased from 13.8 to 11.9 (p?=?0.06). In the operative group, scoliosis decreased from 68° to 29°. Mean ASKp increased from 11.4 to 15.9 (p?<?0.01). There was also a reduction in spinal-related pain and mean number of hospital admissions for chest infection. However, there was a 60% major complication rate. There was no difference in mobility, GMFCS level, feeding or communication in either group before or after treatment. Conclusion: In children with significant scoliosis and AS, spinal fusion was associated with a small improvement in activity and participation, reduction in pain and a decrease in frequency of severe chest infections. Non-operative treatment resulted in progression of scoliosis during childhood and decrease in activity.     

Severe resting clonus caused by thyrotoxicosis in a 16-year-old girl with hereditary spastic paraparesis: a case report.

A 16-year-old girl with a history of hereditary spastic paraparesis developed the subacute onset of severe clonus and new upper-extremity spasticity due to thyrotoxicosis. This case demonstrates the ability of hyperthyroid states to worsen symptoms of spasticity in a child with an underlying spastic disorder. It also demonstrates the importance of investigating for common systemic diseases as a cause of movement disorders even in children with underlying known genetic disorders.     

Minimally invasive multi-level posterior lumbar interbody fusion using a percutaneously inserted spinal fixation system : technical tips, surgical outcomes

Objective

There are technical limitations of multi-level posterior pedicle screw fixation performed by the percutaneous technique. The purpose of this study was to describe the surgical technique and outcome of minimally invasive multi-level posterior lumbar interbody fusion (PLIF) and to determine its efficacy.

Methods

Forty-two patients who underwent mini-open PLIF using the percutaneous screw fixation system were studied. The mean age of the patients was 59.1 (range, 23 to 78 years). Two levels were involved in 32 cases and three levels in 10 cases. The clinical outcome was assessed using the visual analog scale (VAS) and Low Back Outcome Score (LBOS). Achievement of radiological fusion, intra-operative blood loss, the midline surgical scar and procedure related complications were also analyzed.

Results

The mean follow-up period was 25.3 months. The mean LBOS prior to surgery was 34.5, which was improved to 49.1 at the final follow up. The mean pain score (VAS) prior to surgery was 7.5 and it was decreased to 2.9 at the last follow up. The mean estimated blood loss was 238 mL (140-350) for the two level procedures and 387 mL (278-458) for three levels. The midline surgical scar was 6.27 cm for two levels and 8.25 cm for three level procedures. Complications included two cases of asymptomatic medial penetration of the pedicle border. However, there were no signs of neurological deterioration or fusion failure.

Conclusion

Multi-level, minimally invasive PLIF can be performed effectively using the percutaneous transpedicular screw fixation system. It can be an alternative to the traditional open procedures.     

Infarct presenting with a combination of Wallenberg and posterior spinal artery syndromes

This is the first report of a patient presenting with a combination of Wallenberg and posterior spinal artery syndromes. The patient developed right hemiplegia and sensory disturbances on the right side of the face and over the whole body. MRI showed infarcts of the cerebellum, medulla oblongata, and upper cervical cord. These lesions were in the territory of the right posterior inferior cerebellar artery (PICA) and the right posterior spinal artery (PSA). The combination was due to severe stenosis of the right vertebral artery.     

Cement augmented anterior reconstruction with short posterior instrumentation: A less invasive surgical option for Kummell’s disease with cord compression

We report the surgical procedure and clinical outcomes of a cement augmented anterior reconstruction with pedicle screw fixation for osteoporotic vertebral collapse with an intravertebral cleft (Kummell’s disease). Ten consecutive patients with cord compression were enrolled in this study. The mean number of fused segments was 3.2. Instrumentation and posterolateral bone grafts were performed for one level above and below the collapsed vertebra with the exception of one patient. Polymethylmethacrylate (PMMA) cement was then injected into the intravertebral cleft and posterior decompression was performed when needed. The visual analog scale (VAS) pain score and Frankel grade were used to evaluate the clinical results and radiological parameters were also assessed. The mean VAS score before vertebroplasty was 7.5, which was reduced to 3.2 postoperatively, and was 3.7 at the most recent follow-up. The mean follow-up duration was 12.1 months. Seven (83%) of the eight patients with motor deficits showed an improvement in neurological function by at least 1 Frankel grade. The mean decrease in the kyphosis (Cobb) angle was 12.6° and the wedge angle was 12.1° (p < 0.05). However, the angle improvement regressed slightly during follow-up. None of the patients showed vertebral collapse, or loss or leakage of PMMA into the canal. One patient developed wound dehiscence. There was no need for revision or evidence of instrument failure. Based on the preliminary results, we advocate the use of short instrumentation in combination with vertebroplasty with PMMA and posterolateral fusion for Kummell’s disease in patients who are elderly or medically compromised.     

Therapeutic electrical stimulation folio wing selective posterior rhizotomy in children with spastic diplegia cerebral palsy: a randomized clinical trial

A randomized controlled trial was carried out to determine the effectiveness of therapeutic electrical stimulation (TES) in improving the function of children with spastic cerebral palsy (CP), who had undergone selective posterior lumbosacral rhizotomy more than a year previously. Children were randomly assigned to groups to receive TES for 1 year, or to have no TES. The primary outcome was the change in the Gross Motor Function Measure (GMFM), a quantitative and validated measure for use in children with spastic CP. There was a statistically significant and clinically important improvement in outcome for the treated children, with the mean change in the GMFM score at one year being 5.5% compared with 1.9% in the untreated group (P=0.001). TES was simple to use, had no significant complications, and was well accepted by the children and their caregivers, as indicated by an average compliance of 93% for the application of TES on a nightly basis over the course of the study. It was concluded that TES may be beneficial in children with spastic CP who have undergone a selective posterior rhizotomy procedure more than 1 year previously.     

Combined anterior and posterior instrumentation in severe fracture-dislocation of the lower cervical spine with help of navigation: a case report.

The authors report a case of severe fracture-dislocation of C6-C7 with dural and spinal cord damage causing quadriplegia. The patient was treated surgically with circumferential stabilisation. Intense spinal instrumentation with pedicle screw fixation in addition to anterior decompression and plate fixation was essential for restoring the original vertebral column. This technique of internal fixation provided a more rigid anchor, however the risk to the neurovascular structures could not be completely eliminated. Therefore, the combined anterior and posterior stabilisation assisted with a navigation system was a safer and reasonable surgical treatment for this patient with severe cervical injuries.