Does an intraoperative finding of an intact dural sac help to prognosticate neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures? An analysis of 31 patients

Objective

To evaluate the effect of integrity of dural sac in determining motor neurological recovery in patients with cauda equinal and epiconal injuries in vertebral fractures at thoracolumbar junction.

Methods

Thirty-one patients with single-level vertebra fracture over T12–L2 with cauda equinal or epiconal injuries that underwent posterior spinal decompression and stabilization were evaluated in the period between 2006 and 2012. All patients included had motor incomplete ASIA C in neurology and were either Type B or C (AO/Magerl classification) of fracture morphology. Radiologist opinion to confirm the level of conus in MRI was done preoperatively. Intraoperative findings with respect to intactness of dura was noted. All MRI images were postoperatively evaluated by an independent, blinded radiologist for evidence of dural breach caused by the trauma. All participants provided basic demographic data, ambulatory status, and current neurology and received neurologic examination at intervals. The differences in neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cut-off value of lower extremities motor score (LEMS) in functional walkers and non-walkers. All patients were seen at a postoperative follow-up of minimum 18 months.

Results

Data of the 31 patients were analyzed. Seventeen patients (55 %) had epiconus and lumbar roots lesions and 14 (45 %) had cauda equina lesions. The injury was at the T12 vertebra in 9 patients (29 %), L1 in 12 (39 %) and in L2 in 10 patients (32 %). Mean LEMS for patients with T12, L1, and L2 fractures were calculated. Fourteen patients had intraoperative findings of intact dura as against 17 patients with dural breach. MRI images when revisited by an independent radiologist by keeping him blind about the intraoperative surgeons findings showed statistically very good interobserver agreement (κ = 0.618) with regard to integrity of the dural sac. Postoperative neurological assessment at minimum 18 months follow-up showed that four out of the 14 patients with intact dura were walkers (28 %) whereas of the 17 patients with dural breach, 13 were walkers (82 %).

Conclusion

Neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures is significantly less likely in an intact dural sac, probably because the dural breach prevents the roots to take as much impact as compared to an intact dural sac.

     

Spinal instability in ankylosing spondylitis

Background:

Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome.

Materials and Methods:

In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy (no obvious/trivial) trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (± 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery.

Results:

Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients (Cases 6, 7 and 8) which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status.

Conclusion:

In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal.     

Solid tumors complicating Hodgkin's disease. A report on two patients with immunoglobulin deficiency.

Multiple epithelial malignant neoplasms developed in two patients with Hodgkin's disease subsequent to radiotherapy and intensive chemotherapy. At the time of diagnosis, each patient also demonstrated a serum immunoglobulin deficiency. The significance of the occurrence of solid tumors in patients following therapy for Hodgkin's disease and the significance of cellular and humoral immunodeficiency in Hodgkin's disease in relation to second cancer development were studied. We suggest the establishment of a registry of leukemias and solid tumors developing in patients treated for Hodgkin's disease and other malignant neoplasms, possibly with detailed recording of immunocompetence data.     

Giant cell tumor of the spine: A review of 9 surgical interventions in 6 cases

Background:

Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. We present our observation on six cases of GCT of the spine. We treated six patients with giant cell tumors (GCT) of the spine between 1993 and 2006. A total of nine surgical interventions were carried out. Four interventions were carried out in patients presented as ‘new’ cases, while five on recurrences from past GCT resections. All presented with cord compression and neurological deficits of varying grades. All patients also presented with clinical as well as radiological instability. Preoperative tissue diagnosis was available only in the five recurrences (tissue from the old resection). Posterior only (n=2), anterior only (n=4) and single-stage back and front (n=3) surgeries were carried out depending on the nature of the tumor.

Results:

Overall results were satisfactory, as all patients were symptom-free postoperatively. Two out of our four new patients had tumor recurrence and both needed repeat resection. Both have been disease-free at last follow-up.

Conclusion:

Surgical intervention is mandatory. Close follow up is needed for early diagnosis of recurrences.     

Quillaja bark (soapbark)-induced asthma

A 24-yr-old man developed sensitization to Quillaja bark (soapbark) dust at his work place. Within 3 mo of being employed in a factory processing Quillaja bark to produce saponin, he experienced asthma symptoms while handling the bark but only nasal symptoms on being exposed to the purified saponin. Bronchial provocation using Quillaja bark dust resulted in immediate bronchoconstriction as well as faintness, diffuse erythema, and hypotension. Radioallergosorbent test (RAST) using the pulverized crude Quillaja bark was markedly positive, and cross-reactivity between gum acacia and gum tragacanth was demonstrated using this technique.     

Familial eosinophilia: Clinical and laboratory results on a U.S. Kindred

We describe a five-generation kindred with familial eosinophilia (FE; MIM131400), characterized by the occurrence of sustained eosinophilia of unidentifiable cause in multiple relatives. The inheritance pattern is consistent with an autosomal dominant pattern. Among 52 related subjects studied, 19 were affected and 33 were unaffected. Ten unaffected spouses were also evaluated. Four subjects with sustained eosinophilia were diagnosed with cardiac abnormalities and two of them also had neurologic symptoms. In comparison with the unaffected or spouses, evaluation of complete blood counts showed that the affected relatives had, as expected, significantly higher white cell (P < 0.005) and absolute eosinophil counts (P < 0.001) and lower red cell counts (P < 0.05). Evaluation of serum cytokine levels (IL-5, IL-3, and granulocyte-macrophage colony-stimulating factor (GMCSF) and serology for parasitic helminth infection demonstrated no differences between the affected and unaffected individuals; no individuals studied had serologic evidence for parasitic infection. There were also no differences in anti-nuclear antibody, serum cobalamin (vitamin B₁₂) level, immunoglobulin level, leukocyte alkaline phosphatase, rheumatoid factor, HLA analysis, and stool findings for ova and parasites. Among eight affected persons who had peripheral blood or bone marrow karyotype analysis, two carried the same chromosome abnormality, a pericentric inversion of chromosome 10, inv (10) (p11.2q21.2). A gene mapping study is currently underway to study the underlying genetic mechanism(s) of this syndrome. Am. J. Med. Genet. 76:229–237, 1998. © 1998 Wiley-Liss, Inc.     

Synthesis,anti-inflammatory evaluation,and docking studies of some new thiazole derivatives

A series of new 2-substituted-N-(1,3-thiazole-2-yl)acetamide 3–7 and N-(benzo[d]thiazol-2-yl)-2-(substituted)acetamide 10–13 derivatives have been synthesized and evaluated in vivo (rat paw edema) for their anti-inflammatory activities and in silico(docking studies) to recognize the hypothetical binding motif of the title compounds with the cyclooxygenase isoenzyme (COX-2) employing GLIDE software (Schrodinger Inc.). The compounds, 10–13 were found to have good anti-inflammatory activities [around 84–93 % of the standard: indomethacin]. The binding mode of the title compounds has been proposed based on the docking studies. Further, the predicted ADME properties of all the tested compounds were found to be in the ranges as predicted by QikProp for 95 % of known oral drugs and also satisfy the Lipinski’s rule of five.     

Spinal loop rectangle and sub laminar wiring as a technique for scoliosis correction

Background:

Most literature popularizes the efficacy of third generation instrumentation in the surgical correction of spinal deformities. A cheap and effective scoliotic deformity correction method is reviewed in this article. The aim of this study is to evaluate the efficacy of spinal loop rectangle and sub laminar wires as a modality for spinal deformity correction and its co-relation with patients'' satisfaction and clinical outcome.

Material and Methods:

Thirty six patients of scoliotic spinal deformities with various etiologies (congenital-4, idiopathic- 25, neurofibromatosis-3, neuromuscular-2 and ‘syndromic’-3) with ages ranging from 8 to 23 years underwent corrective posterior spinal arthrodesis with stainless steel Hartshill loop rectangle and sublaminar wires. Clinicoradiological evaluation was done at an average follow-up of 6 ½ years (min-2 ½, years). Along with clinicoradiological outcome, patient satisfaction (as per the SRS 24), was accounted.

Results:

Average preoperative Cobb''s angle were 73.25° in the entire group and 66.48° in the idiopathic group. Average percentage correction was 64.34% in the entire group and the (average degree of correction was 47.13). In the idiopathic group, the respective values were 69.19% and 46°. Loss of correction in the whole group was 2.2° at two year follow up. Sagittal profiles, truncal balance were well corrected too; minimal complications were seen. Patient satisfaction results were encouraging in 36 patients as per – SRS24). About 80.2% patients were ready to undergo the same surgery if required. (SRS24).

Conclusion:

Segmental spinal fixation with locally made spinal loop rectangle and sublaminar wires is comparable as a modality to correct scoliotic spinal deformities.