Dorsal Epidural Intervertebral Disk Herniation With Atypical Radiographic Findings: Case Report and Literature Review

Background/Objective:

Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.

Design:

Case report.

Findings:

A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.

Conclusions:

Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.     

Cervical cord compressive myelopathy in a man with a primary complaint of knee pain

Background:

Diagnosing patients with cervical cord compressive myelopathy in a timely manner can be challenging due to varying clinical presentations, the absence of pathognomonic findings, and symptoms that are usually insidious in nature.

Objective:

To describe the clinical course of a patient with primary complaint of left medial knee pain that was nonresponsive to surgical and conservative measures; the patient was subsequently diagnosed with cervical cord compressive myelopathy.

Design:

Case report.

Subject:

A 63-year-old man with a primary complaint of left medial knee pain.

Findings:

Physical examination of the left knee was normal except for slight palpable tenderness over the medial joint line. During treatment, he noted loss of balance during activities of daily living. Reassessment revealed bilateral upper extremity hyperreflexia, bilateral Babinski reflex, and positive bilateral Hoffman reflex. Magnetic resonance imaging of the cervical spine demonstrated moderately severe spinal stenosis at the C3-C4, C5-C6, and C6-C7 levels. After C3-C7 laminoplasty for cervical cord compressive myelopathy, he reported substantial improvement of his left medial knee. Three years later, he had no complaint of knee pain.

Conclusion:

Appropriate diagnosis and treatment of cervical cord compressive myelopathy may avoid unnecessary diagnostic imaging, medical evaluations, invasive procedures, and potential neurologic complications.     

Gastric Bypass and Abdominal Pain: Think of Petersen Hernia

Background:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most commonly performed bariatric surgical procedures. A laparoscopic gastric bypass is associated with specific complications: internal herniation is one of these.

Case Report:

A 47-year-old woman had undergone a laparoscopic Roux-en-Y gastric bypass (LRYGB) 18 months before presentation at our emergency department with mild abdominal complaints. Physical examination showed signs of an ileus in the absence of an acute abdomen. Laboratory investigations revealed no abnormalities (CRP 2.0 mg/L, white blood count 6.3 × 109/L). During admission, there was clinical deterioration on the third day. Emergency laparotomy was performed. An internal herniation through Petersen''s space was found that strangulated and perforated the small bowel. A resection with primary anastomosis and closure of the defects was performed.

Conclusion:

Diagnosing an internal herniation through Petersen''s space is difficult due to the nonspecific clinical presentation. The interpretation of the CT scan poses another diagnostic challenge. This sign is present in 74% of the cases with this herniation. A missed diagnosis of internal herniation may cause potentially serious complications. A patient with a gastric bypass who experiences intermittent abdominal complaints should undergo laparoscopy to rule out internal herniation.     

Nontraumatic Acute Paraplegia Associated With Cervical Disk Herniation

Abstract

Background: Acute paraplegia is a true emergency. It is often the result of trauma but is rarely reported in association with cervical disk herniation in patients without antecedent injury.

Methods: Case report.

Findings: This 75-year-old man presented with acute paraplegia due to severe compression of the spinal cord by herniation of the C4-C5 cervical disk. He underwent emergency diskectomy and anterior fusion. Postoperatively, his neurologic functions improved gradually.

Conclusions: Cervical disk herniation should be considered in the differential diagnosis of nontraumatic acute paraplegia. Pre-existing narrowed canal is an important predisposing factor and excessive neck movements are believed to be triggering factors. Immediate early decompressive surgery is recommended to avoid irreversible progression of neurologic deficit.

J Spinal Cord Med. October 2010; 33(4):420-424     

Right sided transmesentric hernia: A rare cause of acute abdomen in adults

INTRODUCTION

Transmesenteric mesocolic hernias are a rare cause of acute abdomen in adults with few reported cases in published literature.

PRESENTATION OF CASE

We report a rare case of a 30-year-old male with right-sided transmesenteric hernia of ileum due to a congenital mesocolic defect resulting in acute abdomen, presenting as acute abdomen. The hernia was reduced, small bowel inspected for gangrene and mesenteric hernia repaired, following which the patient made a good recovery and was discharged 5 days later.

DISCUSSION

The insidious onset of transmesenteric herniae and lack of specific radiological or laboratory investigations reaffirms the importance of surgeons maintaining a high index of suspicion for this surgical emergency.

CONCLUSION

Transmesentric hernia though rare can present as a case of acute abdomen in an emergency. The diagnosis is purely by a CT scan and close monitoring of the patient''s general condition in cases of non-specific abdominal pain is essential to identify the rare deteriorating patient for early surgical intervention and optimal outcome.     

Steroid-Responsive Myeloneuropathy Associated With Antithyroid Antibodies

Background/Objective:

To present information about 2 steroid-responsive, antithyroid antibody–positive patients with myeloneuropathy and myelopathy.

Methods:

Case reports.

Results:

A 48-year-old woman and a 42-year-old man presented with acute onset tetraparesis and magnetic resonance imaging studies showing cervical spinal lesions. Nerve conduction and biopsy studies of the woman were suggestive of a demyelinating polyradiculoneuropathy. Detailed diagnostic workup turned out to be negative for both patients, except for highly elevated antithyroid antibodies with normal thyroid functions and imaging. Both patients responded remarkably well to high-dose steroid treatment, and their symptoms disappeared in a few months. Both patients'' antithyroid antibody levels were reduced shortly after steroid treatment and in parallel with the amelioration of symptoms.

Conclusions:

Antithyroid antibodies might be associated with acute demyelinating myeloneuropathy or myelopathy pathogenesis and might indicate a good response to steroid treatment in these syndromes.     

Hemorrhagic intramedullary hemangioblastoma of the cervical spinal cord presenting with acute-onset quadriparesis: Case report and review of the literature

Context

Hemangioblastomas of the spinal cord are uncommon vascular tumors. Patients commonly present with subtle neurologic findings that are thought to represent growth of the lesion over time. Hemorrhage of an intramedullary hemangioblastoma presenting as acute neurologic deficit is an extremely rare occurrence. Although the cervical spine is the most common location for hemangioblastoma of the spinal cord, there have been no previously published cases in the literature of intramedullary hemorrhage from such a lesion.

Findings

A 22-year-old woman with a previously undiagnosed spinal cord hemangioblastoma presented with sudden-onset dense quadriparesis due to intramedullary hemorrhage in the cervical spinal cord. The patient did not have any clinical findings of von-Hippel Lindau disease. Laminoplasty from C5 to T2 and posterior midline myelotomy for resection of the intramedullary tumor with hematoma evacuation were completed without complication.

Conclusion

Intramedullary hemangioblastoma of the spinal cord is uncommon, and hemorrhage from a cervical spinal cord lesion has not previously been reported. Symptoms from these usually indolent lesions are commonly associated with tumor growth, edema, or associated syrinx, whereas devastating acute neurologic deficit from hemorrhage is exceedingly rare. Microsurgical resection should be done in cases of symptomatic lesions and considered in isolated symptomatic lesions without the known diagnosis of von Hippel-Lindau disease.     

Torsion of a huge accessory spleen in a 20-year-old patient

INTRODUCTION

Accessory spleen is a rare condition. Torsion of accessory spleen can lead to acute abdomen.

PRESENTATION OF CASE

We describe a young woman with an acute abdomen caused by torsion of accessory spleen. Abdominal computed tomography angiography (CTA) demonstrated an ischemic giant accessory spleen with a twisted vascular pedicle. An emergency laparotomy was performed with resection of the infarcted accessory spleen.

DISCUSSION

Accessory spleen is a rare and asymptomatic condition. Torsion of accessory spleen is also uncommon. Abdominal pain is the main symptom. CTA is effective in reaching a diagnosis. Definitive treatment of an acute abdomen due to accessory splenic torsion is emergency accessory splenectomy.

CONCLUSION

Elective accessory splenectomy should be recommended for known giant accessory spleen to prevent complications in future.     

A delayed diagnosis of bilateral facet dislocation of the cervical spine: a case report

Objective:

To review the case of a patient suffering from bilateral facet dislocation of the cervical spine.

Clinical features:

A 53-year-old male was involved in a car accident and was transported to the hospital. Cervical radiographs were taken at the emergency department and interpreted as normal. Four days later, he consulted a chiropractor where radiographs of the cervical spine were repeated. The examination revealed bilateral cervical facet joint dislocation at C5–C6 as well as a fracture involving the spinous process and laminae of C6.

Intervention and outcome:

The patient was referred to the hospital and underwent surgery.

Conclusion:

Patients involved in motor vehicle accidents often consult chiropractors for neck pain treatment. A high index of suspicion due to significant history and physical examination findings should guide the clinician in determining the need for reviewing the initial radiographs (if taken and available) or request repeat studies, regardless of the initial imaging status.     

Heavy reliance on carbohydrate across a wide range of exercise intensities during voluntary arm ergometry in persons with paraplegia

Context/objective

To describe and compare substrate oxidation and partitioning during voluntary arm ergometry in individuals with paraplegia and non-disabled individuals over a wide range of exercise intensities.

Design

Cross-sectional study.

Setting

Clinical research facility.

Participants

Ten apparently healthy, sedentary men with paraplegia and seven healthy, non-disabled subjects.

Interventions

Rest and continuous progressive voluntary arm ergometry between 30 and 80% of peak aerobic capacity (VO_2peak).

Outcome measures

Total energy expenditure and whole body rates of fat and carbohydrate oxidation.

Results

A maximal whole body fat oxidation (WBFO) rate of 0.13 ± 0.07 g/minute was reached at 41 ± 9% VO_2peak for subjects with paraplegia, although carbohydrate became the predominant fuel source during exercise exceeding an intensity of 30–40% VO_2peak. Both the maximal WBFO rate (0.06 ± 0.04 g/minute) and the intensity at which it occurred (13 ± 3% VO_2peak) were significantly lower for the non-disabled subjects than those with paraplegia.

Conclusion

Sedentary individuals with paraplegia are more capable of oxidizing fat during voluntary arm ergometry than non-disabled individuals perhaps due to local adaptations of upper body skeletal muscle used for daily locomotion. However, carbohydrate is the predominant fuel source oxidized across a wide range of intensities during voluntary arm ergometry in those with paraplegia, while WBFO is limited and maximally achieved at low exercise intensities compared to that achieved by able-bodied individuals during leg ergometry. These findings may partially explain the diminished rates of fat loss imposed by acute bouts of physical activity in those with paraplegia.     

Effects of compression stockings on sympathetic activity and heart rate variability in individuals with spinal cord injury

Objective

To investigate whether wearing graduated compression stockings (GCS) could affect the sympatho-adrenergic and heart rate variability (HRV) responses at rest and after a strenuous wheelchair exercise in individuals with spinal cord injury (SCI).

Design

Crossover trial.

Setting

Department of Physical Medicine and Rehabilitation, Saint Etienne, France.

Participants

Nine men with SCI (five with low paraplegia: LP, four with high paraplegia: HP).

Interventions

Two maximal wheelchair exercise tests: with and without GCS (21 mmHg).

Main outcome measures

HRV measurements: high frequency (HF), low frequency (LF), and LF/HF ratio. Norepinephrine (NOR) and epinephrine (EPI), at rest and post-exercise. Secondary measures were: blood pressure, heart rate, maximal power output, oxygen uptake, stroke volume, cardiac output, at rest, during and after exercise.

Results

When wearing GCS: LFnu_wavelet-post significantly increased and HFnu_wavelet-post significantly decreased (P < 0.05) in SCI subjects, leading to an enhance ratio of LF_wavelet/HF_wavelet and a significantly increased in NOR_rest (P < 0.05).

Conclusions

GCS induces an enhanced sympathetic activity in individuals with paraplegia, regardless of the level of the injury. Enhanced post-exercise sympathetic activity with GCS may help prevent orthostatic hypotension or post-exercise hypotension.     

Unilateral right occipital condyle to C2 level spinal cord infarction associated with ipsilateral vertebral artery stenosis and contralateral vertebral artery dissection: a case report

Objectives

To illustrate the clinical presentation, diagnosis, management, and outcome of unilateral right occipital condyle to C2 level spinal cord infarction.

Setting

A teaching hospital in Taiwan.

Findings

A 37-year-old man presented with acute-onset severe right neck pain before weakness developed in both right limbs. Early diagnosis was delayed due to mild intervertebral herniation of the C4–C5 disk. Magnetic resonance imaging revealed unilateral right occipital condyle to C2 level infarction. Angiography showed stenosis of the right vertebral artery (foraminal and intradural segments), and dissection of the left vertebral artery at the C1–C2 level. At discharge, he walked with assistance; 2 weeks later, he walked independently.

Conclusions

An early diagnosis is difficult but important, as it facilitates appropriate treatment for better functional and survival outcomes. Accurate early diagnosis can be made with adequate knowledge of spinal cord infarction and high index of suspicion for this condition.     

The influence of shoulder pain on functional limitation,perceived health,and depressive mood in patients with traumatic paraplegia

Objective

To assess whether functional activity, perceived health, and depressive symptoms differ between individuals with traumatic paraplegia with and without shoulder pain.

Design

Cross sectional and comparative investigation using the unified questionnaire.

Setting

Neural Regeneration and Repair Division unit of Taipei Veterans General Hospital in Taiwan.

Participants

Seventy-six patients with paraplegia (23 with and 53 without shoulder pain) who had experienced spinal cord injury at American Spinal Injury Association Impairment Scale T2 to T12 neurologic level (at least 6 months previously).

Outcome measures

Spinal Cord Independence Measure (SCIM), a single item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Patient Health Questionnaire-9 (PHQ-9) depression scale.

Results

Shoulder pain was prevalent in 30% patients. Patients with shoulder pain had significantly worse perceived health and greater depressive symptoms than those without. No significant difference was found in functional ability between groups. Greater shoulder pain intensity was related to higher depressive scores (r = 0.278, P = 0.017) and lower self-perceived health scores (r = −0.433, P < 0.001) but not SCIM scores (P = 0.342).

Conclusion

Although shoulder pain was unrelated to functional limitation, it was associated with lower perceived health and higher depressive mood levels.     

Dysphagia and Associated Respiratory Considerations in Cervical Spinal Cord Injury

Background:

Dysphagia is a relatively common secondary complication that occurs after acute cervical spinal cord injury (SCI). The detrimental consequences of dysphagia in SCI include transient hypoxemia, chemical pneumonitis, atelectasis, bronchospasm, and pneumonia. The expedient diagnosis of dysphagia is imperative to reduce the risk of the development of life-threatening complications.

Objective:

The objective of this study was to identify risk factors for dysphagia after SCI and associated respiratory considerations in acute cervical SCI.

Methods:

Bedside swallow evaluation (BSE) was conducted in 68 individuals with acute cervical SCI who were admitted to an SCI specialty unit. Videofluroscopy swallow study was conducted within 72 hours of BSE when possible.

Results:

This prospective study found dysphagia in 30.9% (21 out of 68) of individuals with acute cervical SCI. Tracheostomy (P = .028), ventilator use (P = .012), and nasogastric tube (P = .049) were found to be significant associated factors for dysphagia. Furthermore, individuals with dysphagia had statistically higher occurrences of pneumonia when compared with persons without dysphagia (P < .001). There was also a trend for individuals with dysphagia to have longer length of stay (P = .087).

Conclusion:

The role of respiratory care practitioners in the care of individuals with SCI who have dysphagia needs to be recognized. Aggressive respiratory care enables individuals with potential dysphagia to be evaluated by a speech pathologist in a timely manner. Early evaluation and intervention for dysphagia could decrease morbidity and improve overall clinical outcomes.     

Role of Conventional and Diffusion-Weighted Magnetic Resonance Imaging of Spinal Treatment Protocol for Hydatid Disease

Objective:

To demonstrate the role of magnetic resonance imaging (MRI) in determining the treatment protocol for hydatid disease of the spine.

Design:

Case report; literature review.

Findings:

Diffusion-weighted MRI can help differentiate complicated infected hydatidosis from abscesses, epidermoid cysts from arachnoid cysts, and benign from malignant vertebral compression fractures. It is also helpful in differentiating between abscesses and necrotic tumors.

Conclusion:

Diffusion-weighted MRI can help differentiate between infections requiring immediate surgery and those that can be treated medically with antihelmintic treatment.     

Simultaneously diagnosed pulmonary thromboembolism and hemopericardium in a man with thoracic spinal cord injury

Background

Simultaneous pulmonary thromboembolism (PTE) and hemopericardium is a rare but life-threatening condition. As hemopericardium is a contraindication to anticoagulation treatment, it is challenging to handle both conditions together.

Objective

The objective of the study was to report a rare case of a man with thoracic spinal cord injury presenting with simultaneous PTE and hemopericardium.

Design

Case report.

Subject

A 43-year-old man with incomplete T9 paraplegia (American Spinal Injury Association Impairment Scale D) complained of fever one and a half months after spinal cord injury sustained in a fall.

Findings

During evaluation of fever origin, chest computed tomography and transthoracic echocardiogram revealed simultaneous PTE and hemopericardium. After serial echocardiograms over 2 days demonstrated stability, intravenous heparin, and oral warfarin were administered and his medical status was observed closely. Ultimately, both conditions improved without significant complications.

Conclusion

We report successful treatment of man with acute spinal cord injury who presented with simultaneously diagnosed PTE and hemopericardium, a rare complication involving two distinct and opposing pathological mechanisms and conflicting treatments.     

Spinal epidural abscess with myelitis and meningitis caused by Streptococcus pneumoniae in a young child

Background

Spinal epidural abscess (SEA) in children is a rare infectious emergency warranting prompt intervention. Predisposing factors include immunosuppression, spinal procedures, and local site infections such as vertebral osteomyelitis and paraspinal abscess. Staphylococcus aureus is the most common isolate.

Design

Case report and literature review.

Findings

A 2.5-year-old boy with tetraparesis was found to have an SEA in the posterior lumbar epidural space with evidence of meningitis and myelitis on MRI spine in the absence of any local or systemic predisposing factors or spinal procedures. Streptococcus pneumoniae was isolated from the evacuated pus.

Conclusions

Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit.     

Thoracic Myelopathy Secondary to Intradural Extramedullary Bronchogenic Cyst

Background/Objective:

To report a case of thoracic myelopathy secondary to intradural extramedullary bronchogenic cyst.

Study Design:

Case report.

Methods/Findings:

A 20-year-old man presented to the emergency department with increasing back pain and lower-extremity weakness. Magnetic resonance imaging demonstrated a cystic lesion at the T4 level with mass effect on the spinal cord.

Results:

The lesion was resected, and histopathologic evaluation showed a cyst lined by respiratory-type epithelium consistent with a bronchogenic cyst.

Conclusions:

Intradural extramedullary bronchogenic cysts of the thoracic spine have been reported previously but are extremely rare. The treatment of choice is surgical resection.