Spinal cord compression due to vertebral osteochondroma: report of two cases

Osteochondroma, or exostosis, is the most common of all benign bone tumors. Spinal osteochondromas are uncommon but may cause neurological compromise. We report two cases of spinal cord compression by osteochondromas. One patient was a 17-year-old man with hereditary multiple exostoses who was presented with spastic paraparesis, a sensory level at T3-T4, and a pyramidal syndrome. Vertebral exostosis was suspected by magnetic resonance imaging and confirmed by histological examination. Surgical decompression was followed by complete resolution of the neurological impairments. The other patient was a 19-year-old man with spastic paralysis of the right lower limb and a pyramidal syndrome. Whereas magnetic resonance imaging suggested a neurofibroma, histological features were those of osteochondroma. Nine months elapsed from symptom onset to surgery. This delay led to residual neurological impairments, which resolved almost completely after rehabilitation therapy. Vertebral osteochondromas contribute only 1.3-4.1% of all osteochondromas. The lesion may be solitary or a manifestation of hereditary multiple exostosis. Magnetic resonance imaging shows the exact location of the lesion, most notably with relation to neighboring neurological structures. Spinal cord compression is uncommon and usually has a favorable outcome provided surgical decompression is performed before major neurological damage develops.     

Management of cervical spinal cord trauma in Southern California.

Acute cervical spinal cord injuries were reviewed in 356 patients treated by the neurosurgical community in Southern California. Neurological recovery was compared in operated and nonoperated patients with complete and incomplete cervical myelopathies. The complications of nonsurgical and surgical therapy are identified. No neurological improvement was noted in any patient with a complete lesion who underwent early surgical decompression. In those with incomplete sensorimotor paralysis, it was difficult to document any effect of surgical decompression on neurological recovery. Patients with some degree of sensory preservation had a similar incidence of motor recovery in both surgical and nonsurgical groups. With complete sensorimotor paralysis, anterior cervical fusion within the first week of injury was associated with increased pulmonary morbidity.     

Endovascular management of spinal vascular malformations

Spinal vascular malformations are rare diseases with a wide variety of neurological presentations. In this article, arteriovenous malformations (both from the fistulous and glomerular type) and spinal dural arteriovenous fistulae are described and an overview about their imaging features on magnetic resonance imaging (MRI) and digital subtraction angiography is given. Clinical differential diagnoses, the neurological symptomatology and the potential therapeutic approaches of these diseases which vary depending on the underlying pathology are given. Although MRI constitutes the diagnostic modality of first choice in suspected spinal vascular malformation, a definite diagnosis of the disease and therefore the choice of suited therapeutic approach rests on selective spinal angiography. Treatment in symptomatic patients offers an improvement in the prognosis. In most spinal vascular malformations, the endovascular approach is the method of first choice; in selected cases, a combined or surgical therapy may be considered.     

Facial nerve paralysis secondary to occult malignant neoplasms.

OBJECTIVE: This study reviewed patients with unilateral facial paralysis and normal clinical and imaging findings who underwent diagnostic facial nerve exploration.Study design and setting Fifteen patients with facial paralysis and normal findings were seen in the Mayo Clinic Department of Otorhinolaryngology. RESULTS: Eleven patients were misdiagnosed as having Bell palsy or idiopathic paralysis. Progressive facial paralysis with sequential involvement of adjacent facial nerve branches occurred in all 15 patients. Seven patients had a history of regional skin squamous cell carcinoma, 13 patients had surgical exploration to rule out a neoplastic process, and 2 patients had negative exploration. At last follow-up, 5 patients were alive. CONCLUSIONS: Patients with facial paralysis and normal clinical and imaging findings should be considered for facial nerve exploration when the patient has a history of pain or regional skin cancer, involvement of other cranial nerves, and prolonged facial paralysis. SIGNIFICANCE: Occult malignancy of the facial nerve may cause unilateral facial paralysis in patients with normal clinical and imaging findings.     

Pyogenic liver abscess. Modern treatment

Historically, open surgical drainage has been the treatment of choice for pyogenic liver abscess. The records of 54 patients with pyogenic liver abscess were reviewed to determine whether earlier diagnosis with current imaging tests and definitive treatment with antibiotics, aspiration, or catheter drainage was an effective alternative to open drainage. Twenty-nine patients were treated with broad-spectrum antibiotics and diagnostic aspiration. Twenty-three (79%) recovered uneventfully, and six required catheter or operative drainage. Twenty-three patients (including five who failed aspiration) underwent drainage with percutaneously placed catheters. Nineteen (83%) recovered; four required open surgical drainage. Of seven patients who required open surgical drainage, six recovered. One (2%) of the 54 patients died following failed aspiration and catheter and surgical drainage. Four patients were successfully treated with antibiotics alone without aspiration. These results confirm that pyogenic liver abscess can be successfully treated with broad-spectrum antibiotics and aspiration or percutaneous catheter drainage. Open surgical drainage is reserved for patients in whom treatment fails or who require celiotomy for concurrent disease.     

Cruciate paralysis and hemiplegia cruciata: report of three cases

STUDY DESIGN: Report of three cases of cruciate paralysis and hemiplegia cruciata. OBJECTIVE: To stress the importance of upper cervical spine lesions causing neurological symptoms and signs. SETTING: Neuro-orthopedic service, Fukui University Hospital, Japan. RESULTS: Three patients (all females; one with congenital anomaly at the occiput-atlas level, one with assimilation of the atlas, and one with rheumatoid arthritis-related proliferative synovium) had clinical features of cruciate paralysis and hemiplegia cruciata. All three cases underwent decompressive surgeries. CONCLUSION: Neurological symptoms and signs of cruciate paralysis and hemiplegia cruciata should be carefully assessed, and surgical therapy should be based on the pathological condition.     

A retrospective study of surgical and conservative treatment for spinal extradural abscess

The management of spinal extradural abscess (SEA), particularly the choice between surgical and conservative treatment, is controversial. We therefore undertook a retrospective study of patients admitted with this diagnosis: Details of presentation, treatment and outcome were obtained by review of inpatient notes and radiology. Twenty-five ¶individuals with SEA aged 10–¶79 years were admitted between 1989 and 1995. Nine were treated non-operatively with antibiotics, of which three also underwent diagnostic CT-guided biopsy, and 16 underwent surgical drainage. There was no significant difference in the neurological features at presentation between the two groups. Two patients (8%) died; 11 (44%) patients remained the same and 12 (48%) improved following treatment. Four patients treated conservatively (44%) and seven treated surgically (43%) were capable of return to work or school, whilst a further seven patients (three treated conservatively and four treated surgically) were able to lead independent lives. No significant difference in outcome was demonstrated between patients treated non-operatively and those treated surgically. We conclude that certain carefully selected patients can be treated conservatively, but that surgery should remain the mainstay of management.     

Incidence and prognostic factors of Japanese breast cancer patients with bone metastasis

Background Few previous studies have analyzed the incidence of bone metastases in a defined population of Japanese breast cancer patients and their prognosis after chemotherapy. Methods This is a retrospective cohort study. We investigated 695 patients who underwent surgery for breast cancer. The strategy of adjuvant therapy was as follows. Patients with both estrogen receptors (ERs) and progesterone receptors (PgRs) had endocrine therapy as initial adjuvant therapy (n = 239). Patients with neither ERs nor PgRs had chemotherapy. When metastasis to other organs, including bone, was identified, patients received chemotherapy. The survival rates after surgery and after the onset of bone metastasis, as well as the incidence of bone metastasis, were calculated. We also evaluated the prognostic and predictive factors. Results Bone metastases developed in 148 of 695 patients. All 148 received chemotherapy, and 121 of them developed spinal metastases. The 5-year survival rate after bone metastases was 26.1%. Prognostic factors for bone metastases were visceral metastases and PgR status. Cord compression was observed in 17 of the 148 patients, with the thoracic spine being the most common. The 1-year survival rate for patients with bone metastases who received chemotherapy was 66.3%, whereas that of patients with paralysis after spinal metastases was 17.6%. Within 6 months of the development of spinal cord compression, 70.6% of the patients died. Conclusions We reported the incidence and prognostic factors for a defined population of Japanese breast cancer patients with bone and spinal metastases. Our results suggest that the expected survival time for patients with paralysis who received adequate endocrine therapy or chemotherapy is generally poor. However, to detect a predictive factor of long survival after paralysis and establish the indications for surgery, a comparative study among large groups of patients with paralysis and with different backgrounds is necessary.     

Chondrosarcoma of the spine

Twenty patients were diagnosed as having chondrosarcoma of bone that originated in the spine and, except for one, were treated surgically at the Mayo Clinic. The patients' ages ranged from eighteen to seventy years. Pain in the area of involvement was the first symptom in nearly all patients. Nearly one-half of the patients had detected a mass before being diagnosed. In addition, nine patients had neurological symptoms and signs when they were first seen. All patients had a surgical biopsy of the lesion, often combined with decompressive laminectomy. Five patients received postoperative radiation therapy in various dosages. No patient received adjunctive chemotherapy. All but five patients died of local progression of the disease. The five-year survival rate was 55 per cent. The median length of survival was six years. Although it is rare, chondrosarcoma of the spine can usually be identified on radiographs. Preoperative assessment must include computed tomography, magnetic resonance imaging, and, possibly, arteriography to assess the precise extent of the disease. Although surgical ablation often is technically difficult, a wide excision should be attempted. If this is not obtainable, postoperative radiation therapy should be considered.     

Predictors of outcomes in managing breast abscesses—A large retrospective single‐center analysis

We have retrospectively examined a wide range of clinical characteristics, sonographic features, microbiology, and antibiotic regimens in patients with breast abscesses to seek predictive features related to outcome. Because consensus for optimal treatment of breast abscesses has moved toward minimally invasive management using single or repeated needle aspiration (ASP) coupled with adjuvant antibiotics, we assessed whether any factors correlate with the need for repeat procedures by analyzing the number of ASPs and/or surgical incision and drainage (I&D) per abscess. We examined 127 abscesses in 114 patients from a single urban public hospital, and among clinical characteristics, we found that only smoking history (P = .021) and the presence of nipple rings (P = .005) were associated with greater likelihood of necessitating repeat for abscess resolution procedures. Neither diabetes, lactational status, and HIV nor ultrasound features imaging of an abscess including size >3 cm, multiloculation, rind thickness, or central vs peripheral location were correlated with the need for a repeat procedure. Likewise, no specific micro‐organisms predicted a greater likelihood of requiring repeat procedures, and no specific initial antibiotic regimen (gram‐positive and/or gram‐negative or multiresistance coverage) impacted clinical outcomes. Our data indicate that no specific imaging abscess characteristics, type of micro‐organism, or initial choice of antibiotics affect outcomes, and therefore, these features should not preclude attempts at conventional therapy by repeated aspiration and antibiotic treatment. While a smoking history and presence of a nipple ring may increase the risk of a prolonged course, the decision to change antibiotics or repeat aspiration should rely instead on clinical evaluation and judgment by experienced physicians.     

Cervical epidural anaesthesia for carotid artery surgery

A series of 394 patients (251 men, 143 women; mean age 70.0 +/- 8.4 yr) selected for carotid artery surgery (CAS) performed under cervical epidural anaesthesia (CEA) was analysed retrospectively. Carotid endarterectomy was performed in 326 patients and saphenous vein bypass in 68. The cervical epidural administration of 15 ml 0.5 per cent bupivacaine or 0.37-0.40 per cent bupivacaine plus fentanyl (50-100 micrograms) resulted in an effective sensory blockade from C2 to T4-T8. Patients were maintained awake during the surgical procedure in comfortable condition. Serious complications included dural puncture in two patients, epidural venipuncture in six patients and respiratory muscle paralysis in three patients. Hypotension (10.9 per cent) and bradycardia (2.8 per cent) were the most frequent side-effects of CEA. Transient neurological events were noticed in 84 patients during the surgical procedure. A definite neurological deficit occurred postoperatively in 12 patients. Three patients suffered postoperative myocardial infarction. The mortality rate was 2.3 per cent (nine patients). Carotid artery surgery may be performed under CEA but haemodynamic variables should be monitored closely and managed closely during the procedure.     

Trends in the management of bacterial brain abscesses: a review of 102 cases over 17 years

The records of 102 patients with brain abscesses treated over 17 years were analyzed. In recent years, cardiac and pulmonary causes were less frequent, the abscesses were smaller, and fewer patients were in poor neurological condition. There has been no significant change in the type or number of infective organisms or in the number of abscesses during the study period. Computed tomographic brain scanning was the most important factor in reducing the mortality rate from 41% to 4%. The patients were grouped according to the treatment received: excision (n = 46), aspiration (n = 33), or nonsurgical therapy (n = 17). Patients treated nonsurgically were more likely to have smaller abscesses and multiple lesions than were patients in the other two groups. There were no significant differences in the morbidity or mortality rates between treatment groups. Patients whose abscesses were excised had a significantly shorter course of antibiotics than the other patients. Organisms were identified in 85% of the cultures from surgical specimens. The use of preoperative antibiotics was significantly associated with sterile cultures; 30% of patients who received antibiotics preoperatively had sterile cultures, compared with only 4% of patients who did not receive such treatment. The mortality rate among all treated patients (the diagnosis of brain abscess was missed in 6 patients before computed tomographic scanning became routine) was significantly related to the initial neurological grade and the size of the lesion but not to age, sex, or the number of abscesses. Four of the 8 treated patients who died had congenital cyanotic heart disease; an aggressive surgical approach is recommended for such patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Solid haemangioblastomas of the CNS: a review of 17 consecutive cases

A retrospective study on solid central nervous system haemangioblastomas was performed to characterize clinical features, treatment strategies and outcome in these rare lesions. Between 1993 and 2006 23, solid haemangioblastomas were surgically removed in 17 patients. Eight lesions were located within pons Varolii and medulla oblongata, six within the cerebellar hemispheres and three in the cerebellopontine angle. Three haemangioblastomas were located supratentorially and three within the spinal cord. All patients except two underwent pre-operative magnetic resonance imaging (MRI). Post-operative digital subtraction angiography and/or MRI was performed in all surviving patients. Except for spinal cord lesions, rather unsystematic clinical symptoms were observed. Twenty-two tumours could be resected completely. Two patients with brainstem lesions died within 10 weeks after surgery from infectious complications. Persistent new neurological deficits occurred in two patients. Three patients underwent radiosurgery prior to or following the surgical procedure. Solid haemangioblastomas represent a surgical challenge due to their arteriovenous malformation-like vascularisation and their frequent location in eloquent areas. Surgery is the therapy of choice. Circumferential dissection with devascularization and en bloc removal yields good functional results. A location within the brainstem carries the most unfavourable prognosis.     

Clostridium difficile infection in the pediatric surgery population

PurposeThe incidence of Clostridium difficile–associated disease (CDAD) in the adult population doubled in the past decade, with increasing morbidity and mortality; however, little research has been performed in the pediatric population. We characterized C difficile infection in the pediatric population, with emphasis on the surgical population.MethodsAt a university-based children's hospital, we reviewed 231 patient (birth to 18 years of age) records containing a diagnosis of CDAD between January 1, 2002, and December 31, 2008.ResultsClostridium difficile–associated disease incidence increased from 250 per 100,000 hospitalizations in 2002 to 580 per 100,000 hospitalizations in 2008. No fatalities or surgical interventions were attributable to CDAD. Eighty-seven percent of patients received antibiotics within 2 months of diagnosis. Fifty-two percent of patients underwent operative intervention within 2 months of diagnosis; of these, 89% percent received previous antibiotic therapy and 57% were immunosuppressed. The most common antecedent procedures were bone marrow biopsy and line placement for myelodysplastic diseases (40%), followed by renal transplant (11%).ConclusionsPediatric CDAD incidence doubled during the study period but was not associated with death or operative intervention. A substantial number of CDAD cases were associated with previous operative procedures, particularly in immunosuppressed patients and those who received prior antibiotics.     

Frakturen der Halswirbelsäule

Due to the high incidence of concomitant neurological lesions, standardized clinical and radiologic diagnostic procedures in cervical spine injuries are mandatory. Magnetic resonance imaging or a stress X-ray should be performed when discoligamentous injuries are suspected. The three most important pillars in the treatment of cervical spine injuries are the surgical indication, the surgical approach and the choice of implant. However, despite prompt and appropriate therapy many of these injuries lead to permanent functional impairment depending on the type of fracture. This article summarizes the most frequent fracture types of the cervical spine, as well as the corresponding therapeutic options and outcome.     

Comparison of ulcer surgery at a Veterans Administration and University Hospital

We compared the patient populations and outcome of surgery for peptic ulcer disease in 81 patients at a Veterans Administration Hospital (OVAH) and 97 patients at an affiliated University Hospital (UNH). The surgeons and choice of operation were comparable at both facilities. Patients were similar with respect to severity of ulcer disease, percentage of elderly patients and distribution of comorbid conditions. There were significantly more female patients (45% vs 2%, P less than 0.05), patients less than 40 years old (22% vs 6%, P less than 0.05), and patients with gastric ulcers (27% vs 12%, P less than 0.05) at UNH. Alcoholism was more prevalent at OVAH (57% vs 22%, P less than 0.05). Postoperative morbidity and mortality rates were 27 per cent and 14 per cent at OVAH and 25 per cent and 16 per cent at UNH. These data suggest that quality of care for surgical therapy of ulcer disease at a VA Hospital is comparable to its tertiary care affiliate with a similar patient population.     

Correlation between neurological recovery and magnetic resonance imaging in Pott's paraplegia

Background:

Spinal cord/nerve root compression secondary to a tubercular epidural abscess leads to neurological deficit. Depending on the extent and duration of compression, the end result after treatment may vary from complete recovery to permanent deficit. ASIA has been used extensively to correlate between MRI and neurological status due to traumatic spine injuries. MRI has stood as an invaluable diagnostic tool out of the entire range of current imaging modalities. However, inspite of considerable literature on the applications of MRI in spinal tuberculosis, there have been few studies to assess the relationship between the MRI findings and the neurological deficit as assessed by clinical examination.

Aims:

The objective of this study was to ascertain whether the findings of magnetic resonance imaging (MRI) correlate well with the actual neurological recovery status using the American Spinal Injury Association impairment scale (ASIA) in patients with spinal compression secondary to tuberculous spondylitis.

Materials and Methods:

60 patients (mean age 43.6 years) diagnosed as spinal tuberculosis by MRI/cytology/histopathology were examined and classified into ASIA impairment scale A-E based on the ASIA and again reclassified after 6 months of therapy to assess functional recovery. Similarly, they underwent MR imaging at the start and at the completion of 6 months of therapy to assess the structural recovery. The MRI features of recovery were correlated with the actual neurological recovery as ascertained by the ASIA.

Results:

Before starting treatment 1 patient (2.08%) was in ASIA A, 2 (4.16%) were in ASIA B, 9 (18.75%) were in ASIA C, 36 (75%) were in ASIA D and 12 (20%) were in ASIA E. There was a significant difference in the epidural abscess thickness, thecal compression and cord compression between ambulatory (ASIA D and ASIA E) and non ambulatory patients (ASIA A, ASIA B and ASIA C). After 6 months of therapy 30 (90%) patients in ASIA D and 5 (55.5%) in ASIA C had complete neurological recovery. Both patients from ASIA B improved to ASIA D. Single patient who was in ASIA A before treatment remained non ambulatory (ASIA C) after treatment. Overall 33 (78.5%) patients showed complete recovery at final followup. Out of all the MRI features, only size of epidural abscess was found to be a poor prognostic factor for recovery of neurological deficit.

Conclusions:

There are several parameters on MRI which correlate with the severity of neurological impairment according to ASIA score and resolution of those features on treatment is also correlated well with neurological recovery.     

Spinal epidural abscesses: clinical manifestations,prognostic factors,and outcomes

OBJECTIVE: This study was performed to evaluate the clinical manifestations and prognostic factors for outcomes among patients with nontuberculous spinal epidural abscesses. METHODS: The records and magnetic resonance imaging/computed tomographic results for patients treated between 1994 and 2000 were retrospectively evaluated. Outcomes were assessed after 11 months, using scores ranging from 0 (dead) to 4 (no neurological deficits). RESULTS: All 25 patients (mean age, 62 yr) underwent surgery and subsequently received antibiotics. Back/neck pain (72% of patients), leukocytosis (64%), fever (60%), and motor deficits (56%) were the most common symptoms at admission. Outcomes were assessed as poor for 40% of the patients and as good (no deficit or independently ambulatory) for 60%. Low leg muscle strength grades (r = 0.68, P < 0.001) and high white blood cell (WBC) counts (r = -0.56, P = 0.006) at admission were significantly correlated with low outcome scores. From the time of admission until 14 days after surgery, the poor-outcome group exhibited significantly (P < 0.005) higher WBC counts, compared with the good-outcome group. The same was true for C-reactive protein levels, with the exception that no differences between groups were observed until 8 days after surgery. Factors such as cervicothoracic abscess locations (P = 0.041), lower limb motor deficits (P = 0.005), complete paralysis (P = 0.005), and WBC counts of more than 14,000 cells/microl (P = 0.049) at admission were observed to be prognostic for poor outcomes. CONCLUSION: Surgical decompression combined with antimicrobial therapy remains the recommended treatment. In addition to abscess locations and motor deficits, inflammatory markers such as WBC counts and C-reactive protein levels are prognostic for outcomes.     

Cerebral salvage in near-drowning following neurological classification by triage

This paper describes a simple neurological classification for near-drowning victims into three main categories consisting of: Category A (Awake) Category B (Blunted Consciousness) Category C (Comatose). Category C is sub-classified into: C.1 (Decorticate) C.2 (Decerebrate) C.3 (Flaccid). This triage classification is based on the level of consciousness at a post-rescue time interval of approximately one to two hours, and functions as a guide to therapeutic management. Cerebral salvage results using this classification and comparing routine and aggressive therapy are reported in a retrospective review of 96 patients seen at The Hospital for Sick Children, Toronto, during a 10-year period (1970-1979 inclusive). Aggressive therapy for neurological purposes included continuous dehydration, controlled hyperventilation, moderate hypothermia, barbiturate coma, and continuous muscular paralysis for four days. All patients in categories A (51 cases) and B (6 cases) recovered completely using routine medical management. In category C (39 comatose patients) there was an overall mortality of 33.3 per cent with a cerebral morbidity of 23.9 per cent and normal recovery in 43.6 per cent. When reviewing the results of treatment, two subcategories, (C.l and C.2) were combined for comparative purposes. Results in 14 cases using routine therapy revealed a mortality of 21.4 per cent, a morbidity of 42.8 per cent and an intact survival rate of 35.7 per cent. In comparison, 11 patients who received aggressive (H.Y.P.E.R.) therapy had no mortality, a morbidity of 9.0 per cent and a significant 90.9 per cent incidence of intact survival. In subcategory C.3 (14 patients) there were only four survivors, with one patient in each treatment group surviving intact (14.2 per cent). Intact cerebral survival is of paramount importance. Our findings justify immediate resuscitation in all near-drowning cases regardless of the patient’s initial condition or possible prognosis. The use of an early neurological triage classification seems most appropriate to facilitate therapeutic management. Aggressive treatment (H.Y.P.E.R. therapy) in decorticate cases (subcategory C.l) and decerebrate cases (subcategory C.2) has led to a significant reduction in morbidity and mortality in near-drowned patients.