Leriche综合征漏诊一例报告

Leriche综合征是腹主动脉末段至髂动脉段,因动脉炎或动脉粥样硬化后发生钙化、溃疡、血栓形成引起纤维斑块病变,使管腔狭窄或闭锁导致远端血运不足而引起的一种罕见疾病。本文报告一例69岁男性患者曾误诊为腰椎管狭窄症,行保守治疗5年无效。再次就诊MRI显示腰椎未见明显异常,转血管外科排除血管病变。双下肢血管超声检查显示未见异常,认为症状与血管病变相关性较小,建议再次骨科就诊,以排除腰椎病变。经仔细查阅腰椎MRI后发现L2椎体水平以下腹主动脉腔内信号强度不均匀性增加,行腹主动脉CTA检查示腹主动脉及髂总动脉硬化,并肾动脉开口水平以下腹主动脉及髂总动脉管腔狭窄及闭塞,诊断为Leriche综合征。     

Retroperitoneal approach for lumbar interbody fusion with anterolateral instrumentation for treatment of spondylolisthesis and degenerative foraminal stenosis

BACKGROUND: An alternative approach for the treatment of the degenerative or unstable lumbar spine using retroperitoneal lateral LIF with anterolateral screw-plate or screw-rod fixation is introduced. Special attention is given to application of this procedure in patients who have undergone prior lumbar surgery. METHODS: Between 1998 and 2001, 14 patients underwent lateral LIF with anterolateral instrumentation to treat degenerative foraminal stenosis or spondylolisthesis. Eleven patients (79%) had undergone prior posterior lumbar surgery, 7 of whom were also fused at that time. All patients first presented with mechanical back pain, radicular pain, or both. The mean follow-up was 21 months (range, 8 to 36 months). RESULTS: Radicular pain and mechanical back pain significantly improved in 71% and 54% of patients, respectively. Of the 9 patients with preoperative neurological deficits, 7 were intact or had improved at their follow-up examination. One patient developed postoperative radiculopathy contralateral to his original symptoms. Radiography confirmed good positioning of the hardware and evidence of fusion in all 14 patients. No major complications occurred. CONCLUSIONS: Retroperitoneal lateral LIF with anterolateral instrumentation is an attractive alternative for the treatment of the degenerative or unstable lumbar spine in the absence of significant spinal stenosis. This approach is particularly useful for treating spondylolisthesis or degenerative foraminal stenosis in the postoperative lumbar spine.     

Lumbar disc herniation mimicking meralgia paresthetica: case report

BACKGROUND: Meralgia paresthetica, a syndrome of pain and/or dysesthesia in the anterolateral thigh, is normally caused by an entrapment of the lateral femoral cutaneous nerve (LFCN) at the anterior superior iliac spine. In a few cases compression of the nerve in the retroperitoneum has been reported to mimic meralgia paresthetica. CASE DESCRIPTION: A 67-year-old woman presented with a 5-year history of permanent paresthesia in the anterolateral thigh. Motor weakness was not detected. Electromyography showed a neurogenic lesion at the level of L3. Lumbar spine MRI detected a foraminal-extraforaminal disc herniation at L2/L3, which was extirpated via a lateral transmuscular approach. The patient was free of symptoms on the first postoperative day. CONCLUSION: In patients with meralgia paresthetica we emphasize a complete radiological investigation of the lumbar spine, including MRI, to exclude radicular compression by a disc herniation or a tumour at the level of L2 or L3.     

Bilateral occlusion of common iliac artery following anterior retroperitoneal approach for lumbar fracture instrumentation

There are only four reports on unilateral occlusion of the common iliac artery following ipsilateral anterior retroperitoneal approach to the lumbar spine. To the authors' knowledge, there are no previous reports on delayed bilateral iliac artery occlusion following retroperitoneal approach. We report on a rare case of a 37-year-old paraplegic man who sought this department with bilateral iliac artery occlusion and simultaneous unilateral thromboembolism to the left popliteal artery. The problem occurred following retroperitoneal approach for instrumentation of an L2 fracture performed 2 years ago. The left leg was amputated above the knee because of gangrene, while a left-sided abdominal-to-femoral artery bypass was performed to salvage the right leg. Six months later, the right leg was amputated below the knee because the patient was admitted again with gangrene of his right foot. Following that, the loosened anterior hardware was removed via a right retroperitoneal approach. Revision surgery revealed an apposition of the common iliac vessels from the loosened hardware, while the vertebral bodies at the affected area were severely osteoporotic. Spine surgeons should be aware for the appearance of this disastrous complication following anterior retroperitoneal surgery in patients with loss of sensation in the lower extremities who do not present subjective symptoms of ischemia. The presence of hardware loosening and migration, loss of correction and pseudarthrosis are the warning signs for diagnosis of such a complication.

     

Meralgia paresthetica occurring 40 years after iliac bone graft harvesting: case report

OBJECTIVE AND IMPORTANCE: Meralgia paresthetica is an entrapment neuropathy involving the lateral femoral cutaneous nerve. We describe an unusual case in which meralgia paresthetica occurred many years after iliac bone graft harvesting. CLINICAL PRESENTATION: An 81-year-old man presented with a 1-year history of pain, dysesthesia, and hypesthesia in the anterolateral aspect of the right thigh. This patient had undergone iliac bone grafting when he sustained a calcaneal fracture 40 years previously. Radiographs and computed tomographic scans of the pelvis revealed a bony excrescence in the anterosuperior iliac spine. INTERVENTION: The patient underwent neurolysis of the lateral femoral cutaneous nerve and excision of the bony excrescence. At surgery, the nerve was densely adherent to the bony excrescence. CONCLUSION: The etiology of meralgia paresthetica in this patient is considered to be heterotopic ossification on the anterosuperior iliac spine and pubic symphysis degeneration. A significant relationship between pubic symphysis degeneration with increasing age and meralgia paresthetica has been reported. One should be aware of meralgia paresthetica as a late complication of iliac bone graft harvesting.     

Aortic dissection with vascular abnormalities

A limited number of cases have been reported in the medical literature in which aortic dissection occurs with an aberrant right subclavian artery and a common carotid trunk. The authors report the case of a 59-year-old man who presented to the emergency department with sudden onset pain of 30 minutes duration on the right side of the buttocks. After presentation, the patient developed chest pain, which radiated to the back. Computed tomography angiogram revealed a Stanford type A aortic dissection that extended down to the bifurcation of the iliac arteries. He was also found to have an aberrant right subclavian artery with a retroesophageal tract and a common trunk of the common carotid arteries. The patient was transferred to a tertiary care center and underwent surgery for aortic arch replacement. The authors also discuss the embryologic development of these vascular abnormalities.     

Arterio-venous fistula following a lumbar disc surgery

Vascular complications during posterior lumbar disc surgery are rare and its presentation with varicose veins is even rarer. A 23 year-old male patient presented with large varicose veins in right lower limb. He underwent a posterior lumbar spine discectomy surgery. He noticed mild swelling of the distal third right lower limb 3 months after index surgery and reported 6 months later when he developed varicose veins. Duplex Doppler confirmed varicose veins of the long saphenous vein and its tributaries with a patent deep venous system. A digital subtraction angiogram demonstrated a large right common iliac artery (CIA) false aneurysm with an arteriovenous fistula between right common iliac vessels. He had a right CIA covered stent insertion with good results. Varicose veins were later managed with sapheno-femoral junction ligation and a below knee long saphenous vein stripping. At six month follow-up the lower limb swelling had completely recovered and duplex ultrasound did not show any recurrence of varicose veins.     

Sacroiliac joint dysfunction with groin pain after an operation for lumbar spinal disorder. A case report

A 75-year-old male presented with groin pain after an operation to treat lumbar spondylolisthesis (L5). Groin tenderness was localized to the medial border of the anterior superior iliac spine (ASIS). Radiographical and physical examination raised the suspicion of sacroiliac joint (SIJ) dysfunction. Injection of a painkiller into the SIJ relieved symptoms, including groin tenderness. Symptoms improved gradually, and finally disappeared after five SIJ injections. Groin pain has been reported as a referred symptom of SIJ dysfunction in 9.3-23% of patients. Prior to the patient undergoing surgery to treat lumbar spondylolisthesis, SIJ dysfunction had not been noted on physical examination. Long periods spent in the abnormal posture due to lumbar spondylolisthesis induced SIJ stress. After the operation, an improvement in daily activity actually increased stress on the SIJ, resulting in SIJ dysfunction. Certain pathologies, including SIJ dysfunction, should be considered as residual symptoms after operations for lumbar spinal diseases.     

Operative treatment of hip impingement caused by hypertrophy of the anterior inferior iliac spine

A 30-year-old man presented with pain and limitation of movement of the right hip. The symptoms had failed to respond to conservative treatment. Radiographs and CT scans revealed evidence of impingement between the femoral head-neck junction and an abnormally large anterior inferior iliac spine. Resection of the hypertrophic anterior inferior iliac spine was performed which produced full painless restoration of function of the hip. Hypertrophy of the anterior inferior iliac spine as a cause of femoro-acetabular impingement has not previously been described.     

Occlusion of the left common iliac artery and consecutive thromboembolism of the left popliteal artery following anterior lumbar interbody fusion

We report on a case of occlusion of the left common iliac artery due to arteriosclerosis and consecutive thrombotic occlusion of the left popliteal artery in a 52-year-old man following anterior retroperitoneal interbody fusion of L4--S1. Initial symptoms included leg pain and numbness of the lateral shank, which were thought to be a result of lumbar nerve root irritation from surgery. Diagnosis was not made until 13 days after surgery, when motor deficits were observed. Angiography showed occlusion of the left common iliac artery and thromboembolism of the left popliteal artery. After thromboendarterectomy of the common iliac artery and thrombectomy of the popliteal artery, motor deficits of the left foot were resolved whereas symptoms of pain and sensory deficits continued. Spine surgeons should be aware of this rare complication in cases of postoperative leg pain or of neurologic deficits in the lower extremity after anterior lumbar interbody fusions.     

Dysphagia Lusoria: A Complication Following Gastric Bypass Surgery?

A 23-year-old Caucasian female presented with progressive dysphagia beginning 5 months following laparoscopic gastric bypass for morbid obesity. She was diagnosed with an aberrant right subclavian artery and underwent a combined right supraclavicular approach and left thoracotomy for resection, with reimplantation of the vessel to the ipsilateral carotid artery. The patient had complete resolution of symptoms.     

Surgical experience in arteriovenous fistula following disk surgery

A 21 year-old woman was admitted to our hospital due to congestive heart failure with severe leg edema. A continuous murmur was heard around the lumbar spine close to a surgical scar after laminectomy of the L4-L5 and L5-S1 disc that the patient had undergone six months before. Aortography demonstrated an arteriovenous fistula between the right common iliac artery and the inferior vena cava. At operation, we found the moderate sized venous defect and it corresponded with the angiographic finding. It was repaired by direct suture from inner side of the right common iliac artery. Arterial reconstruction was made with a 8mm woven dacron graft. Postoperative course was uneventful. The cardiac silhouette diminished in size and cardiac output improved from 12.5l/min. to 8l/min. after surgery. This report is the fourth case of successful repair for the arteriovenous fistula after disc surgery in Japan.     

Abdominal aortic and iliac aneurysm presented as lower limb deep vein thrombosis: case report

Abstract

Introduction: We report a rare case of a symptomatic abdominal aneurysm presented as a lower limb deep vein thrombosis (DVT).

Case presentation: A 63-year old male presented to our hospital with a recent progressive onset of the right lower limb swelling and pain. The patient had a history of a previous cardiovascular disease. A Duplex ultrasound was performed, which confirmed a right lower limb DVT extending to the right iliac vein. The patient had a pulsatile abdominal mass. Computed tomography scan of the abdomen showed an abdominal aortic and a right iliac artery aneurysm compressing the thrombosed inferior caval and the right iliac vein. The patient was treated with low molecular weight heparin. After resolution of the DVT on day 3 of hospitalization, a surgery on the abdominal and iliac artery aneurysm was performed. The aneurysm was resected and an aortobifemoral bypass was placed using a Dacron prosthesis. The patient remained to be asymptomatic for 6 months after the surgery. Follow up computed tomography demonstrated a fully patent inferior caval and iliac vein and the absence of the aneurysmal disease.

Conclusion: Although rare, our case confirms that the DVT should be considered as a possible symptom of an abdominal aneurysm in selected patients.     

Incisional hernia after extreme lateral interbody fusion on the lumbar spine: A case report

IntroductionExtreme lateral interbody fusion is a minimally invasive lateral transpsoas approach for spine surgery. We herein report a case of an incisional hernia after an extreme lateral interbody fusion on the lumbar spine that was successfully treated by laparoscopic surgery with intraperitoneal onlay mesh repair.Presentation of caseA 78-year-old woman was referred to our hospital with a complaint of left abdominal bulge and pain. She had undergone an extreme lateral interbody fusion for a lumbar spinal canal stenosis from L1 to L4 a year prior. Abdominal computerized tomography showed a left lumbar incisional hernia, and laparoscopic surgery was performed. The hernia orifice was sutured closed and covered with mesh. The patient was discharged five days after the operation with no complications.DiscussionWhen performing XLIF for a spinal disorder, the muscles should be separated bluntly along their fibers to prevent muscle atrophy, and the incised fascia should be securely sutured closed. Abdominal wall incisional hernias can occur after spinal surgeries such as extreme lateral interbody fusion.ConclusionLaparoscopic repair for abdominal wall incisional hernia after spine surgery is safe and feasible.     

Complex multilevel lumbar spine fractures with transverse sacral fracture

We report an unusual and complex case of spinal trauma in a 17-year-old boy who presented with a transverse sacral fracture associated with multiple-level lumbar fractures, paraparesis, and bladder involvement. A two-stage surgery was performed. The lumbar spine fractures were treated with posterior instrumented correction of displacements, followed by anterior instrumentation and fusion. The sacral fracture was left untreated. At 5-year followup, the patient had complete neurological recovery except for the right L5 root function. The long-segment lumbar fusion and the untreated displaced sacral fracture contributed to spinal imbalance, due to which the patient is now able to stand only in a crouched posture. Determining the optimal treatment for the case is presented due to the relative rarity of transverse sacral fracture and paucity of evidence-based treatment approaches. In patients with associated lumbar spine fractures that require extension of instrumentation to the upper lumbar spine, it is critical to restore sacropelvic alignment to achieve spinal balance. Adequate reduction of sacropelvic anatomy can be achieved with iliac screw fixation.     

An isolated aneurysm of the internal iliac artery simulating lumbar disc herniation. Case report

A case is presented of an isolated aneurysm of the internal iliac artery in a patient with signs of lumbar disc herniation. Isolated aneurysms of the internal iliac artery are rare and they may present with symptoms of compression of adjacent structures or hemorrhage.     

Aneurysm of the arteria lusoria. Case report and review of the literature

Aneurysms arising from an aberrant subclavian artery represent a seldom but dangerous condition, which can be treated successfully when appropriately diagnosed. From 37 patients described in the literature most presented a mediastinal mass and had symptoms like dysphagia, dyspnoe or chest pain. Diagnosis is today possible by contrast-enhanced computed tomography. The aneurysm should be resected to prevent lethal rupture. Left thoracotomy seems to be the appropriate approach in most cases. Reestablishment of blood flow to the right subclavian artery seems not necessary and may be done if ischemia develops in a second procedure by subclavian transposition to the common carotid artery. The case of a 74-year-old women who had resection of an aneurysm in an aberrant subclavian artery is described together with a review of the literature and discussion of the surgical management.     

Aneurysm of the common iliac artery presenting as a lumbosacral plexopathy

We describe a case of lumbosacral plexopathy caused by an isolated aneurysm of the common iliac artery. The patient presented with worsening low back pain, progressive numbness and weakness of the right leg in the L2-L4 distribution. This had previously been diagnosed as sciatica. A CT scan showed an aneurysm of the right common iliac artery which measured 8 cm in diameter. Despite being listed for emergency endovascular stenting, the aneurysm ruptured and the patient died. It is important to distinguish a lumbosacral plexopathy from sciatica and to bear in mind its treatable causes which include aneurysms of the common and internal iliac arteries.     

A case of acute A type aortic dissection with lower extremity ischemia--percutaneous fenestration of the aortic septum followed by ascending aortic graft replacement by open distal anastomosis and retrograde cerebral perfusion]

A 56-year-old woman with severe back pain and a cold, pulseless right extremity was admitted to our hospital. Angiogram revealed a type A aortic dissection extending from ascending aorta to the aortic bifurcation with no definite re-entry point. The false lumen gave origin to the right renal artery and the right external iliac artery was occluded. Therefore, a catheter was manipulated into the true lumen through a percutaneous right femoral artery approach, and was advanced into the false lumen through the right posterolateral wall of the dissecting aortic septum. Fenestration was then performed with fully dilated angioplasty balloon across the septum. Immediately after the procedure, the patient's symptoms improved. The day after the fenestration, replacement of the ascending aorta with 24 mm woven Dacron graft was followed under the deep hypothermia and the retrograde cerebral perfusion. The patient followed a satisfactory postoperative course and postoperative angiogram showed a complete closure of the entry at the ascending aorta and adequate revascularization of the right renal and external iliac arteries.     

Low back pain: diagnosis by six newly discovered sacral tender points and treatment with counterstrain

Although counterstrain and exercises reestablished relative lumbar stability in a patient with chronic low back pain and lumbar hypermobility on gross and segmental motion testing, the patient still had tender points in the middle of the sacrum. After initially ignoring these tender points, we tested various release positions in an attempt to relieve the patient's discomfort. Next, we discovered that 14 patients with low back pain had tenderness at one or more of the tender points. Eventually, we discovered what we believe to be six previously undocumented medial sacral tender points. Two are located 1.5 cm directly medial to the inferior aspect of the posterior iliac spine bilaterally; two are located 1 cm medial and 1 cm superior to the inferior lateral angles bilaterally; one lies on the midline between the first and second spinous tubercles of the sacrum; and one lies on the midline on the cephalad-most border of the sacral hiatus. We describe the use of these tender points in diagnosis and their release by counterstrain technique.