Occlusion of the artery of Adamkiewicz after hip and knee arthroplasty

Vascular Myelopathy Secondary to Compression of the Artery of Adamkiewicz From an Intrathecal Catheter: A Technical Case Report

BACKGROUND AND IMPORTANCE

Although catheter-related complications in intrathecal drug delivery systems are relatively common, vascular myelopathy secondary to occlusion of the artery of Adamkiewicz (AoA) from an abutting intrathecal catheter has not yet been reported. In this study, we present a case of this extremely rare presentation, which resolved after decompression of the artery.

CLINICAL PRESENTATION

A 39-year-old woman presented with lower extremity weakness and paresthesia. She had a 20-year history of severe chronic back pain and stable sensory disturbances below T8 as sequelae of multiple injuries after a motor vehicle accident. Three years before presentation in our clinic, she underwent baclofen pump placement because of neuropathic pain refractory to oral medication. After pump placement, she gradually developed myelopathic symptoms and dysautonomia. All medications through the pump were discontinued, but her symptoms continued to progress. Workup included a spinal angiogram that showed that her intrathecal catheter was abutting the left side of the AoA at the T12 level. After interdisciplinary evaluation, it was believed that her clinical presentation was attributable to vascular compression, and she underwent surgical removal of the catheter. Three years later, her symptoms have improved and her neurological examination returned to baseline before the catheter placement.

CONCLUSION

Meticulous, multidisciplinary neurological and radiological evaluations were essential to diagnose the compression of the AoA as the cause of this patient's myelopathy. Although exceedingly rare, direct compression of the AoA by an intrathecal catheter should be on the differential diagnosis when evaluating for causes of vascular myelopathy.

Spinal Cord Injury After Extremity Surgery in Children With Thoracic Kyphosis

BACKGROUND

Spinal cord injury is a rare complication after lower extremity surgery in children with skeletal dysplasia and thoracic kyphosis. We encountered two patients who had this complication, from among 51 (39 from Nemours/Alfred I. duPont Hospital for Children and 12 from Seattle Children's Hospital) who underwent lower extremity surgery during an 8.5-year period (June 2004 to December 2012). Because spinal cord injury is a devastating complication likely not known to most physicians treating patients with skeletal dysplasias, we sought to examine factors that may contribute to this rare complication.

CASE DESCRIPTION

We performed a retrospective review of two patients with skeletal dysplasia who had paraplegia develop after extremity surgery. Outcome measures included operative time, vital signs, and postsurgery recovery of neurologic deficit. MR images were reviewed. Two patients were found-an 8.5-year-old boy with spondyloepiphyseal dysplasia congenita with a 76°-thoracic kyphosis apex at T4 and a 6.5-year-old boy with mucopolysaccharidosis type 1-H with an 80°-thoracic kyphosis apex at T2. Bilateral proximal femoral osteotomies or bilateral innominate and proximal femoral osteotomies had been performed. The spinal cord injuries occurred at the apex of the kyphosis as determined by clinical examination and MRI assessment. In both patients, the mean arterial blood pressure decreased below 50 mm Hg and might be a factor in the etiology of the paralysis. The first patient recovered motor function in 5 months; the second had no recovery.

LITERATURE REVIEW

Paraplegia is extremely rare after nonspine operations. Many factors contribute to the risk for a spinal cord event: low mean arterial pressure, duration of the surgery, position on the operating table, the kyphotic spine deformity, or unappreciated vascular disease. Motor-evoked potentials and somatosensory-evoked potentials together potentially provide high sensitivity and specificity for predicting a postoperative neurologic deficit.

CLINICAL RELEVANCE

Based on our two patients with skeletal dysplasia and a literature review of patients with hyperkyphosis undergoing extremity surgery, the surgeon must be aware of the risk of spinal cord injury. Careful preoperative assessment possibly including MRI of the spine is recommended. Mean arterial pressure should be maintained at a safe level; neuromonitoring should be considered.

Acute lumbar radiculopathy with weak legs

BACKGROUND

Inferior vena cava thrombosis is a rare but important cause of acute low back pain and lumbar radiculopathy. Failure to diagnose and treat this condition could result in propagation of the thrombosis, resulting in fatal pulmonary embolism.

CASE REPORT

We report the first known case of inferior vena cava thrombosis in a postpartum woman presenting with acute lumbar radiculopathy and weak legs. She was successfully treated with i.v. heparin and oral anticoagulation.

CONCLUSIONS

Inferior vena cava thrombosis is a rare cause of acute lumbar radiculopathy, but is in the differential diagnosis to consider, especially in those patients at increased risk of thrombosis.