Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report

Acute spinal subdural haematoma complicating a posterior spinal instrumented fusion for congenital scoliosis: A case report

BACKGROUND

Acute spinal subdural haematoma (ASSH) is a rare and potentially devastating condition with a variable prognosis. Previously described subdural haematomas were thought to have occurred spontaneously or be related to major or minor iatrogenic or traumatic injuries caused by surgery, spinal puncture or epidural anaesthesia. Other contributing pathologies have been described, such as intradural tumours or spinal arteriovenous malformations. ASSH has also been associated with anticoagulation therapy, haemostatic abnormalities and risk factors such as pregnancy. To the best of our knowledge, this case study described the first reported occurrence of an ASSH during spinal surgery in a paediatric patient. The patient was not known to have any coagulopathies, and no obvious vascular lesions were documented. The surgical procedure did not directly involve the dura mater, and no evident intraoperative dural tears were found.

CASE SUMMARY

We reported and discussed a case of ASSH complicating a posterior spinal instrumented fusion during surgery for paediatric congenital scoliosis. This condition has not been previously described. We made recommendations for facing such an occurrence, explored its aetiology in the context of malformation and discussed the benefits of neuromonitoring during scoliosis correction and the management protocol. We conducted a PubMed literature review for cases of paediatric ASSH and other closely related disorders. We reviewed recommendations regarding neuromonitoring and treatment management in such cases.

CONCLUSION

ASSH is a rare complication of posterior spinal instrumented fusion. Published cases are more often associated with anticoagulation therapy or coagulopathy. Neuromonitoring is strongly recommended to detect and assess neurological status, thus enabling rapid diagnosis and treatment and facilitating early spinal decompression and a return to a normal neurological status.

Acute spinal subdural haematoma complicating a posterior spinal instrumented fusion for congenital scoliosis: A case report

BACKGROUND

Acute spinal subdural haematoma (ASSH) is a rare and potentially devastating condition with a variable prognosis. Previously described subdural haematomas were thought to have occurred spontaneously or be related to major or minor iatrogenic or traumatic injuries caused by surgery, spinal puncture or epidural anaesthesia. Other contributing pathologies have been described, such as intradural tumours or spinal arteriovenous malformations. ASSH has also been associated with anticoagulation therapy, haemostatic abnormalities and risk factors such as pregnancy. To the best of our knowledge, this case study described the first reported occurrence of an ASSH during spinal surgery in a paediatric patient. The patient was not known to have any coagulopathies, and no obvious vascular lesions were documented. The surgical procedure did not directly involve the dura mater, and no evident intraoperative dural tears were found.

CASE SUMMARY

We reported and discussed a case of ASSH complicating a posterior spinal instrumented fusion during surgery for paediatric congenital scoliosis. This condition has not been previously described. We made recommendations for facing such an occurrence, explored its aetiology in the context of malformation and discussed the benefits of neuromonitoring during scoliosis correction and the management protocol. We conducted a PubMed literature review for cases of paediatric ASSH and other closely related disorders. We reviewed recommendations regarding neuromonitoring and treatment management in such cases.

CONCLUSION

ASSH is a rare complication of posterior spinal instrumented fusion. Published cases are more often associated with anticoagulation therapy or coagulopathy. Neuromonitoring is strongly recommended to detect and assess neurological status, thus enabling rapid diagnosis and treatment and facilitating early spinal decompression and a return to a normal neurological status.

Spinal subarachnoid hemorrhage after percutaneous kyphoplasty: a case report and literature review

Background

Spinal intradural (subdural and subarachnoid) hematoma following percutaneous kyphoplasty is an extremely rare complication. In this report, we describe a case of subarachnoid hemorrhage with delayed paralysis after kyphoplasty and review the literature on similar cases to describe the complications of kyphoplasty and vertebroplasty (VP).

Case Description

An 80-year-old man underwent percutaneous kyphoplasty at a local hospital an osteoporotic vertebral fracture (OVF) at the T12 and L1 level. On the second day after kyphoplasty for T12 OVF, he developed paralysis of the lower limbs. At his initial visit to our clinic, he had a complete loss of sensation below T11 and complete paralysis of both lower extremities. Thoracolumbar magnetic resonance imaging revealed an intradural hematoma on the ventral side of the spinal cord, in the spinal canal from T5 to T12, compressing the spinal cord. Thoracolumbar computed tomography showed a fracture line in the medial cortex of the right pedicle at T12 and a tract from the spinal canal to the vertebral body. An emergency posterior decompression from T11 to L1 was performed. A small hole was found on the right side of the pedicle at T12, and tear of the nerve and subarachnoid hematoma were observed in the vicinity of the T11 nerve root. The subarachnoid hematomas were removed. Postoperatively, the neurological symptoms improved rapidly. Eventually, he was able to walk and was transferred for rehabilitation.

Conclusions

Percutaneous surgery through the pedicle might cause hematoma and bone cement leakage into the spinal canal. This can be a serious complication: hence prevention is important.

Artery of Adamkiewicz

This article reviews the case of a 65-year-old patient with unstable L1 fracture after trauma. The fracture was treated via balloon kyphoplasty, shortly after which the patient developed shortness of breath and severe headache. Subsequent computed tomography (CT) of the head revealed subarachnoid hemorrhage. CT angiography did not reveal any intracranial aneurysms or arteriovenous malformations. A massive spinal subdural hematoma, which caused the patient to develop right leg paresis and hip joint weakness with grade 2-3, was found during magnetic resonance imaging (MRI). The hematoma was removed using multi-stage laminectomy Th5-L3. A follow-up MRI showed no pathological findings. Due to the unusual findings, spinal angiography was performed, revealing the artery of Adamkiewicz (A. radicularis magna, AKA) on the L1 level on the right side. Control CT showed a suboptimal insertion of the needle into the right pedicle, which caused the injury of the artery. AKA is present in the majority of the population, and surgical attention should be paid to avoid injury. Surgeons operating on the thoracolumbar spinal cord should have a thorough understanding of the anatomical features and surgical implications of this artery.

The usefulness of vertebral needle targeting simulation training system using ray-summation imaging: experimental study

PURPOSE

Using the multi-detector computed tomography and related three-dimensional imaging technology, we developed a vertebral needle targeting simulation training system named spinal needling intervention practice using ray-summation imaging (SNIPURS). Herein, we assessed the utility of SNIPURS by evaluating changes in the learning curves of SNIPURS trainees.

METHODS

Twenty-one examinees were enrolled: seven experienced operators (expert group), seven trainees with coaching (coaching group), and seven trainees without coaching (non-coaching group). They performed six tests of vertebral needle targeting simulation on the workstation-generated spinal ray-summation images of six patients with vertebral fractures. In each test, they determined the bilateral trans-pedicular puncture points and angles on two thoracic and two lumbar vertebrae on ray-summation imaging (i.e., 8 simulations per test). The coaching group received coaching by a trainer after Tests 1 and 4, while the others did not. Scores were given based on the trans-pedicular pathway (1 point) or not (0 point). Eight virtual needles were evaluated in each of Tests 1-6.

RESULTS

Among the three groups, the expert group had the highest average scores on Tests 1-4 (expert: 3.86, 6.57, 7.43, and 7.57; coaching: 1.86, 6.14, 6, and 6.29; and non-coaching: 1.14, 4.14, 4.71, and 4.86). The coaching group's scores caught up with the expert groups' average scores on Tests 5 and 6, whereas those of the non-coaching group did not (expert and coaching: 7.86 and 8.00, non-coaching: 5.86 and 7.14). All examinees in the expert and coaching groups achieved a perfect score on the final Test 6, whereas three of the seven non-coaching trainees did not.

CONCLUSION

SNIPURS might be suitable for vertebral needle targeting training. The coaching provided during SNIPURS training helped the trainees to acquire the spinal puncture techniques in PVP.

Spinal subdural hematoma from a ventral dural puncture after percutaneous vertebroplasty: illustrative case

BACKGROUND

Percutaneous vertebroplasty (PVP) is a common procedure, but cement leaks are not uncommon. Leakages do not always have consequences, but rarely complications do occur. Spinal subdural hematomas (sSDHs) are rare and even rarer presented as a complication after PVP. The best management for sSDH is, therefore, difficult to decide.

OBSERVATIONS

The patient first received PVP for acute low back pain after falling. Cement leakages were noted after the procedure, but a sudden new-onset leg weakness only developed later. An emergency lumbar computed tomography scan showed cement leakages anterior to the dural sac; lumbar magnetic resonance imaging revealed a subdural spinal hematoma, and a decompressive laminectomy was performed. During the operation, a small cement mass in the shape of a horn was seen and was believed to have caused the sSDH. Postoperatively, the patient recovered to leg strength 5/5.

LESSONS

PVP is considered a low-risk procedure, and cement leaks rarely give rise to complications. However, when leakages present anterior to the dural sac, they may cause dural tear and possible sSDH, regardless of size. This possibility draws attention to keeping awareness of such rare but possible complications after routine PVP procedures. Timely intervention for sSDH is necessary to ensure meaningful recovery.

Accuracy of vertebral puncture in percutaneous vertebroplasty

Purpose

To clarify the accuracy of vertebral puncture of the vertebral tertile area needling (VETERAN) method puncturing the pedicle superimposed on one-third of the width between the lateral vertebral line to the contralateral medial lamina line compared with Cathelin-needle-assisted puncture (CAP) method puncturing using the Cathelin needle as a guide in percutaneous vertebroplasty.

Materials and methods

449 punctures by CAP method and 125 punctures by VETERAN method were enrolled. We compared the puncture accuracy of both methods. We estimated a vertebral estimated tilting ratio (VET-ratio) defined as ratio of the distance between the lateral vertebral line and the contralateral medial laminal line to the distance between the vertebral lateral line and the puncture point measured by computed tomography. We also estimated the procedural items and clinical outcomes.

Results

VETERAN method with 100% of punctures within safe zone (cortical breaches within 2 mm) had significantly higher accuracy than CAP method with 97.8% (p < 0.01) for the 2 mm incremental evaluation. No cases with a VET-ratio of 36% or less had cortical breaches. VETERAN method had shorter operative time per puncture (p < 0.01) and exposure time per puncture (p < 0.05).

Conclusion

VETERAN method reduced the occurrence of the inaccurate puncture, operative times, and exposure times. A VET-ratio with 36% or less is associated with a safe puncture using VETERAN method.

Spinal Epidural Hematoma After Percutaneous Kyphoplasty: Case Report and Literature Review

Objective

To present the case of a patient on long-term anticoagulants who developed acute spinal epidural hematoma (SEH) after percutaneous kyphoplasty (PKP) without signs of major cement extravasation to the spinal canal.

Methods

A 64-year-old woman with long-term oral antiplatelet drugs underwent the L1 PKP. Immediately after the operation, the back pain improved significantly without neurological deficit. However, 12 hours later, she developed progressive weakness of the bilateral lower limbs. No intraspinal cement leakage was obvious on the postoperative lumbar radiograph and computed tomography.

Results

An emergency MRI examination revealed a high signal aggregation in front of the spinal cord from T12 to L1, indicating spinal cord compression. The SEH was verified and removed during the laminectomy from T12-L1. Following the decompression surgery, the neurological deficit of the lower limbs improved. On follow-up after 6 months, the muscle strength of the bilateral lower limbs had returned to normal.

Conclusion

For the patient with long-term oral antiplatelet drugs or coagulation malfunction, the transpedicle approach or that via the costovertebral joint with a smaller abduction angle is recommended to reduce the risk of injury to the inner wall of the pedicle. For progressive aggravation of neurological dysfunction after surgery, SEH formation should be suspected despite the absence of intraspinal bone cement leakage. Secondary emergency decompression should be considered to avoid permanent damage to spinal cord nerve function caused by continuous compression.

Spinal subdural and epidural hematomas after vertebroplasty for compression fracture: a case report

Introduction

Vertebroplasty (VP) is a well-known and effective therapeutic method for relieving the pain and improving the quality of life of patients with vertebral compression fractures. Major complications of VP are infrequent, occurring in no more than 1% of such procedures, whereas spinal subdural and epidural hematomas are extremely rare complications.

Case Presentation

We present a unique case of a spinal subdural hematoma (sSDH) (from T4 to T12) occurring immediately after VP to treat a traumatic vertebral compression fracture, followed by a spinal epidural hematoma (SEH) (from T3 to T12) after the decompressive laminectomy, occurring in a 64-year-old patient. After removing of the big spinal epidural hematoma, the patient's symptoms improved progressively and she recovered after 2 months.

Discussion

This is a rare case of sSDH and SEH occurring continuously after VP. The pathogenesis may be that the puncture damaged the abnormal blood vessel of spinal dura mater. A small-probability event is not an impossible event. We hope to bring more attention to the rare complications of VP by sharing this unusual case.