Thoracolumbar intradural extramedullary bronchiogenic cyst

Summary Intradural extramedullary bronchiogenic cysts are rare findings. All five reported cases were located cervically or upper thoracically. To our knowledge, we describe the first case of an intraspinal bronchiogenic cyst in a thoracolumbar location.We present the case of a 41-year-old patient with a known spina bifida occulta who suffered from a continuous, sharp, and therapy-refractory pain in the left leg. Magnetic resonance imaging of the thoracic and lumbar vertebra revealed an intradural extramedullar mass at T12 to L1 level. After laminectomy T-12 through L-1/L-2 and longitudinal opening of the dura mater, the cystic mass was shown to be attached to the conus medullaris and the cauda equina, and therefore could be removed only partially. Histopathological examination revealed the diagnosis of bronchiogenic cyst. We therefore conclude that intradural extramedullary bronchiogenic cysts may appear also at thoracolumbar levels. Surgical resection can be achieved with good outcome.     

Predictors of kyphotic deformity in osteoporotic vertebral compression fractures: a radiological study

Purpose

To report the radiological predictors of kyphotic deformity in osteoporotic vertebral compression fractures (OVCF).

Methods

This is a retrospective study of 64 consecutive patients with OVCF. We studied the radiographic features in the immediate post-injury image of patients, who developed significant (more than 30°) segmental kyphotic deformity at final follow-up and compared them with those patients who did not.

Results

Thirty-three (82.5 %) out of 40 patients with fracture at thoracolumbar (TL) junction, 5 (33.3 %) patients out of 15 with fracture at lumbar (L) spine and 7 (77.7 %) patients out of 9 with fracture at thoracic (T) spine developed significant segmental kyphotic deformity. Forty-one (75.9 %) [TL-33 (80.5 %), L-4 (33.33 %) and T-4 (80 %)] out of 54 [TL-37 (68.51 %), L-12 (22.23 %) and T-5 (9.26 %)] patients with superior endplate fracture developed significant segmental kyphotic deformity. Forty patients (86.9 %) [TL-28 (70 %), L-6 (15 %) and T-6 (15 %)] out of 46 [TL-32 (69.56 %), L-8 (17.4 %) and T-6 (13.04 %)] with anterior cortical wall fracture developed significant segmental kyphotic deformity. Five patients (71.42 %) [TL-2 (40 %) and T-3 (60 %)] out of 7 [TL-02 (28.58 %), L-01 (14.28 %), T-04 (57.14 %)] with adjacent level fracture developed significant segmental kyphotic deformity. The average immediate post-injury kyphosis of 11° (5°–25°) increased to 29° (15°–50°) at final follow-up.

Conclusion

Progressive segmental kyphotic collapse following an OVCF seems unavoidable. Patients with TL junction and superior endplate fracture are probably at the highest risk for significant segmental kyphotic deformity.     

A dumbbell (hourglass) neurofibroma of the spine in a patient with von Recklinghausen's disease. A case report with twelve-year follow-up

A five-and-one-half-year-old boy, referred for orthopaedic evaluation of spinal curvature, was diagnosed as having neurofibromatosis (von Recklinghausen's disease) with a 44-degree right thoracolumbar curve from T-10 to L-3. A soft-tissue mass was identified in the area of T-7 to T-12 and, when neurological signs developed, the mass was removed by extraperitoneal laparothoracotomy. Tumor root was noted to extend into the spinal canal, and subsequent surgery was undertaken to remove this tissue. There was no postoperative increase in the neurologic deficit, although the scoliosis progressed to the point where spinal fusion was required. This was followed by brace treatment to maintain correction during the growth years. Long-term follow-up (12 years) revealed that the patient's spine was balanced, the fusion mass appeared to be solid radiographically, and the neurological examination was normal.     

Spontaneous migration of a bullet in the spinal subarachnoid space causing delayed radicular symptoms

The authors report a case of a gunshot wound to the left lower quadrant of the abdomen in a patient who initially was neurologically intact. The bullet had lodged at the T-11, T-12 level in the spinal canal. After an exploratory laparotomy, the patient developed severe low back pain radiating to his left lower extremity and an incomplete footdrop. Repeat x-ray films and a myelogram showed that the bullet had migrated to the L-4, L-5 level on the left. Bullet emboli and delayed sequelae of gunshot wounds to the spine are discussed.     

Bilateral symptomatic intraspinal T12-L1 synovial cysts

A 72-year-old man presented with several months of increasing lumbar pain, sciatica, lower extremity weakness, numbness in his buttocks and posterior thighs, burning sensations in his scrotum, and urinary incontinence. Myelogram-computed tomography scan demonstrated a high grade incomplete block at the T12-L1 level due to bilateral synovial cysts and simultaneously a high grade partial block at L4-L5 due to spinal stenosis. Laminectomy of the T-12 vertebra and partial laminectomy of the L-1 vertebra with excision of both synovial cysts and laminectomies of the L-4 and L-5 vertebrae with foraminotomies resulted in a reversal of the patient's symptomatology.     

Spine-shortening vertebral osteotomy in a patient with tethered cord syndrome and a vertebral fracture. Case report

The authors report a rare case of tethered cord syndrome with low-placed conus medullaris complicated by a vertebral fracture that was successfully treated by a spine-shortening vertebral osteotomy. The patient was a 57-year-old woman whose neurological condition worsened after a T-12 vertebral fracture because a fracture fragment and the associated local kyphotic deformity directly compressed the tethered spinal cord. An osteotomy of the T-12 vertebra was performed in order to correct the kyphosis, remove the fracture fragment, and reduce the tension on the spinal cord. Postoperative radiographs showed the spine to be shortened by 22 mm, and the kyphosis between T-11 and L-1 improved from 23 degrees to 0 degrees . Two years after the surgery, the patient's neurological symptoms were resolved. The bone union was complete with no loss of correction.     

Multiple spinal extradural meningeal cysts presenting as acute paraplegia. Case report and review of the literature

Multiple spinal extradural meningeal cysts are rare. To the authors' knowledge, there have been only four reported cases in the world literature. The authors report a case of multiple spinal extradural meningeal cysts in a 31-year-old woman presenting with acute paraplegia. Magnetic resonance imaging of the thoracolumbar spine revealed multiple extradural cystic lesions extending from T-7 to T-8 and from T-12 to L-3. Intraoperative findings demonstrated a white, fibrous, and tense cyst filled with cerebrospinal fluid-like colorless fluid. Excision of the posterior wall of the symptomatic cyst was followed by immediate neurological improvement. The examination of the pathological specimen showed a thick duralike layer of collagen and an inner membrane of arachnoid that is often not found in these lesions. The final diagnosis was based on combined imaging, intraoperative, and histopathological findings. The authors review the literature and discuss the etiological, diagnostic, and therapeutic aspects of this lesion.     

Spinal extradural arachnoid cyst--case report.

A 48-year-old male presented with progressive leg weakness. Magnetic resonance imaging and computed tomography myelography showed an extradural arachnoid cyst extending from the T-12 to L-2 levels in the thoracolumbar region. The cyst was confirmed at surgery and completely removed. This surgical intervention achieved improvement in the neurological symptoms.     

Correlation of anomalous vascular and osseous anatomy in congenital kyphosis type I. Case report

Congenital kyphosis Type I results from failure of formation of the vertebral body (VB). The clinical course is characterized by progressive deformity and neurological dysfunction unless the patient undergoes fusion. It has been postulated that failure of VB formation may be secondary to anomalies of the segmental arteries arising from the aorta. There is limited clinical evidence in the literature, however, to support this hypothesis. The authors report on the case of an adult patient with congenital kyphosis Type I in whom spinal angiography correlated vascular with vertebral anomalies. This 32-year-old man presented with back pain, lower-extremity paresthesias, and incomplete voiding, which had progressed over several years. Imaging revealed that the L-1 and L-2 vertebrae had not fully formed, causing kyphotic deformity such that the anterior portion of T-12 nearly articulated with that of L-3; this anomaly produced significant mobility in flexion and extension. Magnetic resonance imaging revealed distal spinal cord atrophy and signal change on T2-weighted images. Spinal angiography showed that the right and left segmental arteries at both L-1 and L-2 arose from a common trunk from the aorta. This was confirmed during subsequent T12-L3 anterior-posterior fusion. Postoperatively the patient experienced relief of pain and remained neurologically stable throughout a 3-year follow-up period. The presence of corresponding anomalies of the segmental arteries and vertebrae in this case of congenital kyphosis Type I indicates that a relationship may exist in the genesis of aberrant spinal vertebral and vascular structures.     

Balloon kyphoplasty for vertebral compression fractures secondary to polyostotic fibrous dysplasia. Case report

This 25-year-old woman with polyostotic fibrous dysplasia (McCune-Albright syndrome) suffered low-back pain after a minor traumatic injury. Neurological examination demonstrated normal status. Magnetic resonance imaging revealed cystic lesions in multiple thoracic and lumbar vertebral bodies, consistent with polyostotic fibrous dysplasia. Severe vertebral compression fractures (VCFs) were seen at T-8 and L-2. Balloon kyphoplasty was performed to treat the T-8 and L-2 VCFs and also prophylactically at T-9 and T-10 to forestall impending fractures at those levels. The patient tolerated the procedures very well and reported complete resolution of back pain. Balloon kyphoplasty may be an option in patients with painful VCFs caused by fibrous dysplasia.     

Cemented revision total hip arthroplasty with impaction bone grafting in Gaucher's disease

Total hip arthroplasty in Gaucher's disease has been associated with high rates of loosening after all types of arthroplasty. We present a patient with type 1 Gaucher's disease who underwent revision cemented total hip arthroplasty for aseptic loosening after 12 months of enzyme replacement therapy. Major osteolysis was managed by impaction morcellized bone grafting. An excellent clinical and radiographic result was obtained at 5-year follow-up. Enzyme replacement therapy combined with modern revision techniques may offer improved outcomes for patients with Gaucher's disease.     

Nasopharyngeal carcinoma metastatic to the cauda equina

A case of nasopharyngeal carcinoma metastatic to the cauda equina is reported. The patient, treated 3 years earlier for his primary disease, presented with bilateral weakness of his legs. Myelographic studies showed only patchy thickening of certain lumbosacral nerve roots. A biopsy from a root in the cauda equina was made through a T-12 to L-2 laminectomy revealing carcinomatous involvement. Careful examination of the specimen was necessary to distinguish the tumor from a lymphoma. Review of the literature has revealed no other cases of this type of neoplastic metastasis.     

Diastematomyelia and intramedullary epidermoid spinal cord tumor combined with extradural teratoma in an adult. Case report

Diastematomyelia is rarely diagnosed in the adult. Only a few such cases have been reported in the literature. A 26-year-old Mexican man with lumbar diastematomyelia is reported who also harbored a T-12 intramedullary epidermoid tumor and an extradural teratoma located in the dorsal aspect of the dural sac opposite L-4. These three rare coincidental lesions were removed at surgery. The patient's condition improved.     

Quantitative anatomy of the thoracolumbar epidural space

Quantitative measurements of the epidural space between T-7 and L-4 were made in the sagittal and coronal planes utilizing x-ray films made after the injection of iodized oil into the epidural space in the low thoracic and upper lumbar areas. These data reveal a 1-mm ventral epidural space and a 2-mm lateral epidural space, with a sawtooth shape to the dorsal epidural space measuring between 1.1 and 2.9 mm at the rostral lamina and between 3.8 and 6.5 mm at the caudal lamina. Additionally, five patients with chronic pain were studied by computed tomography of T-8 to T-12, with confirmation of the sawtooth shape of the dorsal epidural space. Computed tomography showed the measurements of the epidural space at the rostral lamina to vary between 1.3 and 1.6 mm and those at the caudal lamina/interlaminar space to range from 6.9 to 9.1 mm.     

The Length and Proportions of the Thoracolumbar Spine in Children with Idiopathic Scoliosis

The length of the thoracolumbar spine was measured on standardized X-ray films from 274 children (61/2-181/2 years) with idiopathic scoliosis and 212 controls. Where possible, the height and width (transverse diameter) of two vertebral bodies (T-6 and L-4) were also measured.

Although a tendency towards longer spines in the scoliotics could be found, there was no significant difference between children with idiopathic scoliosis and controls in this respect. In girls the pubertal growth-spurt of the spine was found to start about 1 year earlier than in the controls and the growth of the spine seemed to cease later in the scoliotics.

The height and width of T-6 was significantly greater in the scoliotics than in the controls for girls under 13 years of age. In the older girls and in the boys no significant difference could be demonstrated. The height of L-4 tended to be greater in the scoliotic boys and younger girls, though the differences were not statistically significant. The index height/width was calculated for T-6 and L-4 in all groups of patients and higher values could be demonstrated in the scoliotics for all test groups.

The greater height of T-6 in scoliotics might indicate a longer thoracic spine in these children. The higher values of the height/width indices suggest that the thoracolumbar spine in children with idiopathic scoliosis has an increased slenderness compared with the spine in non-scoliotic children.     

Dural repair for intraspinal extradural meningeal cyst

A 52-year-old woman presented with an intraspinal extradural meningeal cyst in the thoracolumbar region manifesting as progressive sensory disturbance of the bilateral lower extremities. Magnetic resonance imaging and computed tomography myelography showed an extradural meningeal cyst extending from the T-12 to L-4 levels in the thoracolumbar region with a dural defect and a valve-like mechanism developed in the enlarging cyst. Operative findings revealed a dural defect that allowed communication between the extradural cyst cavity and the subarachnoid space. Surgical resection of the cyst wall and repair of the dural defect resolved the symptoms.     

Effect of thoracic epidural bupivacaine on somatosensory evoked potentials after dermatomal stimulation

The effect of epidural bupivacaine (9 ml 0.5%) analgesia on early (less than 500 msec) somatosensory evoked potentials (SEPs) with electrical stimulation of the T-10 and L-1 dermatomes was examined in eight patients. Cortical amplitudes decreased only insignificantly after stimulation of both dermatomes, despite the presence of sensory analgesia (pin prick) from T-3.5 +/- 0.4 to L-2.9 +/- 0.4 (mean +/- SEM). Latency of the SEP components remained unchanged and sensory threshold increased only insignificantly during blockade. We conclude that thoracic epidural analgesia with conventional doses of bupivacaine provides only a limited blockade of fast conducting afferent nerve fibers.     

Direct noninvasive monitoring of spinal cord motor function during thoracic aortic occlusion: use of motor evoked potentials

Spinal cord monitoring during thoracic aneurysmectomy by somatosensory evoked potentials has been criticized for its failure to measure anterior (motor) spinal cord function. We have developed a clinically applicable, noninvasive technique for intraoperative monitoring of motor evoked potentials (MEP), which allows direct functional assessment of spinal cord motor tracts during thoracic aortic occlusion. Twelve dogs underwent continuous intraoperative monitoring of MEP before, during, and after thoracic aortic cross-clamping. Motor tract response to noninvasive cord stimulation (5 to 10 mA, 0.02 msec, 4.3 H2) was recorded by subcutaneous electrodes placed along the length of the spine (T-10, L-1, and L-4). Six animals (group I) subjected to aortic cross-clamping alone demonstrated a characteristic time- and level-dependent deterioration and loss of MEP. Ischemic cord dysfunction (as determined by time from clamping to loss of MEP) progressed from the distal to the proximal cord (L-4 = 11.3 +/- 1.5 minutes; L-1 = 14.9 +/- 2.3 minutes; T-10 = 16.9 +/- 2.3 minutes; p less than 0.05 between all levels). Reperfusion of the distal aorta 20 minutes after clamping resulted in MEP return that progressed from the proximal (T-10) to distal (L-1 and L-4) cord. In another six animals (group II), distal perfusion (mean blood pressure = 95 mm Hg) was maintained for 1 hour after cross-clamping by left atrial-femoral artery bypass. Normal configuration and amplitude of MEP was maintained throughout the cross-clamping period. These data suggest that distinctive changes in MEP indicative of reversible ischemia of spinal cord motor tracts occur after aortic cross-clamping. Such ischemia begins in the most distal cord, exhibits upward progression with time, and can be prevented by maintenance of adequate distal aortic perfusion. Clinical use of MEP monitoring during thoracic aneurysmectomy may provide a method for intraoperative assessment of the adequacy of motor tract perfusion.     

Intravenous bisphosphonate treatment and pregnancy: its effects on mother and infant bone health

Introduction  

Type 1 Gaucher's disease (GD1) is a lysosomal storage disorder associated with disabling bone involvement. The choice treatment for Gaucher's disease is enzyme replacement therapy (ERT). The use of bisphosphonate treatment for osteopenia and osteoporosis has been suggested.     

N-type calcium channel and renal injury

International Urology and Nephrology - Accumulating evidences indicated that voltage-gated calcium channels (VDCC), including L-, T-, N-, and P/Q-type, are present in kidney and contribute to renal...