Surgical management of idiopathic acute cervical kyphosis; A case-based review of an extremely rare entity

INTRODUCTION AND IMPORTANCE

Acute idiopathic cervical kyphosis (AICK) represents a rare entity, and its management remains controversial. Preoperative surgical planning and individual decision-making seem necessary. To date, there is a lack of sufficient evidence and clear guidelines.

CASE PRESENTATION

A 21-year-old male was referred with a progressive cervical deformity detected 3 months earlier. The patient suffered from severe progressive myelopathy and represented neither neck trauma nor a familial history of similar expected conditions. His cervical imaging revealed 95 degrees of cervical kyphosis. After 3 separate surgical sessions for 360-degree fixation, the cervical kyphosis was reduced by 90 degrees. No facet dislocation was observed, and laminectomy was unnecessary. Post-operative neurological examination detected significant improvement. Six months and 2-year follow-ups were favorable. To the authors' knowledge, the current case had the most extensive degree of cervical kyphosis reported in the literature.

CLINICAL DISCUSSION

Multistage correction of AICK would result in a favorable outcome and reduce the risk of complications. Particular attention should be paid to the wide inter-spinous spaces in high grades of kyphosis during sub-periosteal dissection to prevent iatrogenic spinal cord injuries.

CONCLUSION

The present work may provide the first report on the role of cervical postural habits in patients with opiate substance abuse disorder, which could have triggered cervical kyphosis in this particular patient. Multistage correction of AICK would result in a favorable outcome and reduce the risk of complications.

Neglected cervical meningocele in an adult: illustrative case

BACKGROUND

Posterior cervical meningoceles are rare in adults because most are surgically excised early in life. Such meningoceles in adults are mostly presented as a cystic mass and their presentation as a solid mass is very rare.

OBSERVATIONS

An asymptomatic adult with cervical meningocele presented as a congenital midline skin covered solid mass in the posterior aspect of the neck is presented. Neuroradiological surveys showed attachment of the mass to intradural spinal cord. With diagnosis of a cervical meningocele, after excision of the solid sac, the stalk extending from the core of the mass to the dura was isolated. This was followed by intradural spinal cord detethering. The mass was compatible with rudimentary meningocele in pathology.

LESSONS

Neglected cervical meningocele is quite rare in adults. Surgical removal of the mass in adults is usually for cosmetic reasons rather than neurological impairment. However, surgical removal of the mass without intradural cord detethering is not sufficient. In such cases, late onset quadriparesis may be appear due to the spinal cord tethering scenario.

Our experiences in patients with atlanto-occipital dislocation: A case series with literature review

Atlanto-occipital dislocation (AOD) is an injury to the upper cervical spine that occurs after trauma. This injury is associated with a high mortality rate. According to studies, 8%-31% of deaths caused by accidents are due to AOD. Due to the improvement in medical care and diagnosis, the rate of related mortality has decreased. Five patients with AOD were evaluated. Two cases had type 1, one case had type 2, and two other patients had type 3 AOD. All patients had weakness in the upper and lower limbs and underwent surgery to fix the occipitocervical junction. Other complications in patients were hydrocephalus, 6 nerve palsy, and cerebellar infarction. All patients improved in follow-up examinations. AOD damage is divided into four groups: anterior, vertical, posterior, and lateral. The most common type of AOD is type 1 and the most instability is type 2. There are neurological and vascular injuries due to pressure on regional components; vascular injuries are associated with high mortality rate. In most patients, their symptoms improved after surgery. AOD requires early diagnosis and immobilization of the cervical spine along with maintaining the airway to save the patient's life. It is necessary to consider AOD in cases with neurological deficits or loss of consciousness in the emergency unit because earlier diagnosis could cause a wonderful improvement of the patient's prognosis.

A Rare Scenario of Acute Traumatic Thoracic Disc Herniation and Review of the Literature

Background and Importance: Sequestrated thoracic disc herniation after a traumatic event without an apparent spinal fracture or dislocation is an extremely rare scenario. Case Presentation: Evaluation of an elderly female with acute paraparesis secondary to a fall down to the ground revealed a right-sided extruded disc at the level of T10-T11. At 6-month follow-up, she made a dramatic recovery following an appropriate surgical intervention. Conclusion: With occurrence of acute paraparesis following a traumatic event, MRI of the vertebral column is necessary, even in the absence of tomographic evidence of fracture-dislocation.

Syrinx associated with cervical spondylosis: A report of 13 cases

Background:

Sustained compression of the spinal cord by cervical spondylosis may induce arachnoid fibrotic changes and trigger local syrinx formation.

Cases Description:

Here, we describe 13 cases of syrinx formation in association with cervical spondylosis. In 12 out of 13 patients, the syrinx was incidental finding while screening for simple neck pain. In one case, it was discovered during an evaluation of upper extremity radiculopathy. Over the 3–8-year follow-up period, the syrinx size did not change in 11 cases (i.e., 10 asymptomatic and one with radiculopathy) even after surgical decompression. In the other two cases, the syrinx spontaneously resolved.

Conclusion:

With the increased utilization of cervical MR imaging, more cases of incidental asymptomatic syrinx formation versus symptomatic lesions contributing to radiculopathy have been discovered.

Biomimetic bi-material designs for additive manufacturing

Superior material properties have been recently exhibited under the concept of biomimetic designs, where the material architectures are inspired by nature. In this study, a computational framework is developed to present novel architectured bi-material structures with tunable stiffness, strength, and toughness to be used for additive manufacturing (AM). The structure of natural nacre is mimicked to design robust multilayered structures constructed from hexagonal brittle and hard building blocks bonded with soft materials and supports. A set of computational models consisting of fully bonded zones, while allowing for interlayer interactions are created to accurately mimic the interplay between the hard and soft organic phases. As required for such complex designs, the numerical constraints are properly set to run quasi-static non-linear explicit analysis, which allow for a 3× faster analysis with higher efficiency and 2× lower computational cost, when compared to static analysis. The models are used to assess the stiffness, strength and toughness of bi-material beams when subjected to a flexural three-point bending load. The influence of structural features like the soft-to-hard volume ratio (i.e. the distance between each building block, its aspect ratio, and overlap length), material features (e.g. the stiffness ratio of the hard-to-soft phases), the plastic strain failure of soft phase, and AM features (e.g. different types of within-layer/sandwiched supports) are systematically investigated. The results revealed that the toughness of the architectured beams was enhanced by up to 25% when compared to a monolithic structure. This improvement is due to the frictional tile sliding in the brittle phase and the extensive shear plastic deformation of the soft interfaces. This work provides compatible designs to facilitate the AM of nacre-based bi-martial structures with balanced/tailored mechanical performance and to understand the influence of the architectural parameters.

Six cases of occult sacral meningocele

Background:

Intrasacral occult sacral meningoceles (OSM) are uncommon congenital lesions that rarely become symptomatic, even over a patient’s life time.

Methods:

We operated on six patients with symptomatic OSM diagnosed on MR studies (all six) and/or CT examinations (four cases).

Results:

All six patients had uneventful postoperative recoveries. Nevertheless, despite the resolution of low back pain and radiculopathy, preoperative bladder dysfunction improved postoperatively in only one patient.

Conclusion:

Few cases of patients undergoing surgery for symptomatic OSM are reported in the literature. Here, we recount our experience with six patients with symptomatic OSM who demonstrated significant postoperative neurological recoveries except for rare improvement in bladder function.

Symptomatic thoracic ossified ligamentum flavum in achondroplasia: A case report and literature review

Background:

In a patient with achondroplasia, it is rare to encounter thoracic cord compression due to both spinal stenosis and ossification of the yellow ligament (OYL).

Case Description:

A 33-year-old achondroplastic female presented with a progressive spastic paraparesis attributed to thoracic stenosis combined with T10-T11 OYL. Following a laminectomy, the patient demonstrated a marked recovery of neurological function.

Conclusion:

This case and 12 others from the literature demonstrated that achondroplastic patients who present with myelopathy secondary to thoracic stenosis and OYL can be readily diagnosed with MR/CT and successfully treated utilizing decompressive laminectomies with/without fusions (i.e., for those crossing the thoracolumbar junction).

Symptomatic thoracic ossification of the ligamentum flavum in a patient with ankylosing spondylitis: Report of a case and review

Background:

Thoracic spinal cord compression due to both ankylosing spondylitis (AS) and ossification of the ligamentum flavum (OLF) is rare.

Case Description:

A 33-year-old male with AS presented with a paraparesis attributed to MR documented T9-T10 OLF/stenosis. He was successfully managed with a decompressive laminectomy; this resulted in marked improvement of his deficit.

Conclusion:

Thoracic OLF and AS rarely contribute T9-T10 spinal cord compression that may be readily relieved with a decompressive laminectomy.

Peroneal/posterior tibial nerves delayed dysfunction due to traumatic popliteal artery pseudoaneurysm resulting from trivial stab wound: A case report

Background:

Popliteal artery pseudoaneurysms due to stab wounds are extremely rate. Even more infrequently, they can contribute to the compression of multiple peripheral nerves.

Case Description:

A 23-year-old male, following a trivial stab wound, developed the delayed occurrence of a pseudoaneurysm of the popliteal artery. This resulted in the delayed onset of a compressive popliteal/posterior tibial neuropathy. Following restoration of blood flow through the popliteal artery utilizing saphenous vein grafting, additional neurolysis resulted in resolution of the compressive neuropathy.

Conclusion:

A 23-year-old male developed a pseudoaneurysm following minor trauma that resulted in peripheral nerve dysfunction.

Anaplastic myxopapillary ependymoma of the sacrum: A case report

Background

Myxopapillary ependymoma (MPE) with anaplastic features is extremely rare. There are very few such case reports in the medical literature.

Case Description

A 23-year-old female presented with lower back pain, and both urinary and fecal dysfunction. The patient underwent gross total surgical excision of the MR documented expansile intrasacral tumor. The histology was compatible with a MPE containing anaplastic features.

Conclusion

The medical literature contains a few comparable cases of subcutaneous sacrococcygeal MPE with anaplastic components. Here, however, we have a young female with an anaplastic intrasacral MPE treated with gross total surgical excision.

Acute traumatic sequestrated thoracic disc herniation: A case report and review

Background:

Pure sequestrated thoracic disc herniations secondary to a traumatic event are rare.

Case Description:

Elderly male presented with the sudden onset of severe paraparesis following a fall. The MR showed a left-sided extruded disc at the T10-T11. The patient underwent a thoracic interlaminar laminectomy, removal of one large, and several smaller sequestrated disc fragments utilizing a transfacet corridor requiring placement of an interbody Peek cage, and bilateral T10 and T11 pedicle screw instrumentation. At 6 postoperative months, he sustained a good recovery.

Conclusion:

Acute thoracic disc herniations without attendant fracture/dislocation are rare. When they result in major neurological deficits, timely surgical excision is warranted.

Painful torticollis due to tubercular atlantoaxial rotatory fixation: A case report

Background:

Tubercular atlantoaxial, rotary dislocation warranting fixation (AARF) is an extremely rare event.

Case Description:

AARF was suspected in a 23-year-old female with painful torticollis. When diagnostic studies documented unilateral destruction of the left lateral mass of the atlas, she underwent removal of the lateral mass, reduction of the deformity, and C1-C2 fusion/reconstruction utilizing an iliac bone graft. Laboratory tests and the pathologic surveys were all consistent with the diagnosis of underlying tuberculosis.

Conclusion:

We present a case of tubercular atlantoaxial, rotary dislocation (AARF) in a patient who warranted C1-C2 decompression, reduction, and fusion.

Paraganglioma of the filum terminal: Case report and review of the literature

Paraganglioma of the filum terminal/cauda equina is a rare slow growing tumor which originates from the ectopic sympathetic neurons. Surgically, total excision may be difficult for this well demarcated tumor surrounded by couple of rootlets but is usually possible in nearly all cases. Actually, final diagnosis cannot be determined intraoperatively, but is possible only after an immunohistochemical staining. Herein, the authors present a middle age woman whose initial symptoms were lower back pain and radiculopathy. Her MRI was found to be compatible with a cauda equina tumor. During her excisional surgery a hard and relatively vascular tumor was fully removed. The Immunohistochemical results were compatible with paraganglioma of the filum terminale. In addition to case presentation, thorough review of the literature is also done.

Septic cavernous sinus thrombosis secondary to halo vest pin site infection

•

Cavernous sinus thrombosis is a potentially fatal scenario that should be added to the sequels of neglected halo pin site infection.

•

Diagnosis of septic CST requires a high degree of clinical suspicion. Painful proptosis after an infection at the territory of the face is Septic CST unless proven otherwise.

•

Institution of timely and aggressive treatments is required to prevent permanent neurological disability.

•

Recently, for those resistant to medical treatment, endovascular thrombolysis and recanalization have been proposed.

Background

Pin site infection is one of the frequent complications of the halo crown application which can be easily handled if addressed early. However, if this issue is neglected then serious infectious events may quickly transpire. Among all of the medical literature that the previously described scenarios have illuminated; we did not encounter a case involving infectious cavernous sinus thrombosis.

Case description

The authors present a middle age man who arrived at our clinic with an acute left peri-orbital swelling, proptosis, and ophthalmoplegia which had occurred subsequent to an untreated halo pine site infection. With a diagnosis of septic cavernous sinus thrombosis (CST), appropriate antibiotics and anticoagulant therapies were administered.

Outcome

With the continuation of this conservative treatment regimen, he was successfully managed with no residual neurological consequences.

Conclusion

Halo vest orthosis is an appropriately tolerated upper cervical spinal stabilizing device that is a commonly used worldwide. Septic CST that is secondary to a halo vest pin site infection has not been previously described within medical literature. In the case of a neglected pin site infection, with demonstration of ipsilateral eyelid edema and proptosis, septic CST should be immediately considered and treated vigorously with antibiotics and anticoagulant therapies.

Symptomatic intraspinal lumbosacral pseudomeningocele, a late consequence of root avulsion injury secondary to a gunshot wound

Background

Traumatic pseudomeningocele are usually a late consequence of cervical root avulsion injury and its occurrence in lumbosacral region is rare. This pathology is mostly due to violent blunt traumatic events and usually develops outside of the spinal canal. Occasionally, a pseudomeningocele may grow inside of the spinal canal causing delayed neurological deficit due to compromise of the adjacent neural structures.

Case description

Evaluation of a delayed left lower extremity weakness in a young man with a history of a gunshot wound injury revealed an extradural pseudomeningocele arising from an S1 root avulsion injury with compressive effect on the adjacent L5 root

Outcome

Excision of the cyst wall and reinstitution of the nerve root sheath resulted in an uneventful recovery

Conclusion

To the best of our knowledge, the presented case with traumatic pseudomeningocele is the first example secondary to high velocity bullet injury. Furthermore, management of traumatic intraspinal pseudomeningocele subsequent to root avulsion injury has not been paid sufficient attention. In this paper, the surgical strategy will be discussed in detail.

Intramedullary mature teratoma with an exophytic component in an adult: Report of a case and literature review

Background:

Intramedullary mature teratomas (IMMTs) are rare. This is particularly true in the adult population.

Case Description:

A 49-year-old female developed progressive paraparesis due to a T6 intramedullary mature teratoma with an exophytic component. She was successfully managed, utilizing a laminectomy with microsurgical tumor removal. The literature review documented 57 similar cases.

Conclusion:

Here, we presented a 49-year-old female with a T6 intramedullary mature teratoma accompanied by an exophytic component who underwent total tumor resection with an incomplete recovery.

Double-level myelopathy due to atlantoaxial dislocation (os odontoideum) and subaxial cervical spondylosis with angular kyphosis

Background:

The surgical management of cervical spondylotic myelopathy (CSM) attributed to os odontoideum (OO with atlantoaxial instability atlantoaxial instability) and subaxial kyphosis together pose significant surgical challenges.

Case Description:

An elderly male presented with CSM/myelopathy and severe quadriparesis attributed to an unstable OO and 87° fixed, subaxial cervical kyphosis. After performing a 540° spinal cord decompression with atlantoaxial fixation, the patient did well.

Conclusion:

Double-level CSM due to an unstable OO and subaxial kyphosis is rare and typically requires combined 540° decompression and stabilization.

Anterior sacral meningocele complicated by rectothecal fistula and rectorrhea: A Case report and review of the literature

Background:

Anterior sacral meningocele (ASM) is a rare congenital anomaly. It is characterized by herniation of the dura through a defect in the anterior sacrum. Rarely, however, it may extend to the rectal area through a rectothecal fistula with or without rectorrhea.

Case Description:

Here, we present a case of ASM associated with a rectothecal fistula and rectorrhea. Surgical closure of the ostium of the cyst through a posterior approach resulted in long-term improvement

Conclusion:

An ASM with both rectothecal fistula and rectorrhea is extremely rare.

Spinal intramedullary epidermoid cysts: Three case presentations and literature review

Background:

True intramedullary epidermoid cysts (IECs) not associated with congenital anomalies or previous spinal procedures are extremely rare. In a review of the literature since 1992, only 29 such cases have been reported. Here, we add three new cases in this category.

Case Description:

Three adults presented with spastic paraparesis attributed to thoracic IECs. Gross total microsurgical removal was achieved in two cases, while one case was a partial resection due to capsular adherence to the cord. In all three cases, patients sustained complete recoveries of neurological function and remained symptom free for an average of 5 years follow-up.

Conclusion:

IECs are rare lesions; here, the three located in the thoracic spine, contributed to slow, progressive spastic paraparesis with/without incontinence, and resolved following total (2 patients) and partial (1 patient) resection.

Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review

Background:

In osteoporotic patients, a useful technique for significantly enhancing the strength of a pedicle screw is augmentation with polymethylmethacrylate cement. However, a rare complication of this procedure is a symptomatic pulmonary cement embolism.

Case Description:

A pedicle screw cement augmentation was performed in a middle-aged female for the failed back syndrome. When she developed symptomatic pulmonary cement emboli, she was successfully managed with conservative measures, including anticoagulation.

Conclusion:

Despite the increased use of cement augmentation for pedicle screw placement and the relatively high incidence of cement leakage into the prevertebral venous system, symptomatic cement pulmonary embolism remains rare. The management of such symptomatic CPE should be evaluated and treated based on both the size and location of the embolism. Here, we presented this case while reviewing three symptomatic and four asymptomatic cases from the literature.

Iatrogenic lumbar giant pseudomeningocele: A report of two cases

Background:

Iatrogenic lumbar pseudomeningoceles are an uncommon complication of lumbar spinal surgeries. This pathology is an extradural, encapsulated, and cerebrospinal fluid collection which develops as a consequence of an inadvertent, unrepaired dural tear. If a pseudomeningocele grows beyond 8 cm in length, it may be classified as “giant.”

Case Description:

Two adult females with giant pseudomeningoceles due to remote lumbar laminectomy were presented. Both patients were surgically managed.

Conclusion:

Iatrogenic lumbar giant pseudomeningocele is rare. Notably, their surgical management is similar to that utilized to treat routine pseudomeningoceles.

Intermittent penile erection in lumbar spinal stenosis: Report of four new cases and review

Background:

Lumbar spinal stenosis (LSS) classically presents with intermittent neurogenic claudication. Rarely, however, it may cause unanticipated, unpleasant, involuntary, and transient penile erections without sexual stimulation along with urinary urgency and claudication.

Case Description:

The authors present four males with LSS whose principal symptoms were intermittent neurogenic claudication and unanticipated erections while walking, accompanied by urinary urgency.

Conclusion:

There is scant literature on the topic of LSS presenting with unanticipated penile erections, urinary urgency, and neurogenic claudication.

Kyphosis and canal compromise due to refracturing of an L1 cemented vertebra managed with posterior surgery alone

Background:

An already cemented vertebral body rarely refractures and its occurrence may be signaled by the reappearance of pain and/or significant vertebral collapse/kyphosis resulting in canal compromise and neurological deterioration.

Case Description:

An 81-year-old male originally underwent an L1 kyphoplasty for an osteoporotic compression fracture. Nine months later, he presented with the late onset of recurrent collapse of the cemented vertebral body, leading to pain, kyphosis, and canal compromise. Surgery warranted total L1 corpectomy, reconstruction of the anterior column, and a posterior fixation through a purely posterior approach (posterior vertebral column resection [pVCR]).

Conclusion:

Here, we presented the safety/efficacy of utilizing a purely posterior approach (e.g., including L1 corpectomy, reconstruction of the anterior column, and posterior fusion: pVCR) in the management of a repeated fracture of a cemented L1 vertebra resulting in kyphosis and canal compromise.

Rivaroxaban-induced acute cervical spine epidural hematoma: Report of a case and review

Background:

Spontaneous spinal epidural hematomas (SEHs) due to the utilization of factor Xa inhibitors are rare.

Case Description:

A 66-year-old female presented with a Brown-Sequard syndrome attributed to a cervical epidural hematoma secondary to the utilization of rivaroxaban, one of the factor Xa inhibitors. Following a cervical laminectomy for the evacuation of the hematoma, the patient completely recovered.

Conclusion:

A spinal hemorrhagic event should be suspected in patients receiving factor Xa inhibitor drugs. Here, we had an elderly female on rivaroxaban experienced the acute onset of neck/back pain associated with a Brown-Sequard syndrome. A literature review showed that this is the seventh example of SEH occurring as a result of the use of anticoagulation drugs (OACDs; e.g., including Xa inhibitors).

Unstable os odontoideum contributing to cervical myelopathy and obstructive sleep apnea

Background:

Sleep apnea is characterized by repetitive cessation of breathing during sleep. It may be attributed to obstructive, central, or mixed pathologies close to the upper airway resulting in a decreased diameter of the oropharyngeal tract.

Case Description:

A 36-year-old male with progressive cervicomedullary myelopathy/quadriparesis exhibited obstructive sleep apnea (OSA) attributed to an anteriorly displaced os odontoideum (OO). Atlantoaxial screw-rod stabilization resulted in improvement of both neurological function and OSA.

Conclusion:

A symptomatic unstable OO may contribute to suboccipital pain, progressive quadriparesis, vertebrobasilar insufficiency, and OSA. Appropriate operative intervention utilizing atlantoaxial screw-rod stabilization may help to resolve these deficits.

T1-T2 disc herniation: Report of four cases and review of the literature

Background:

Symptomatic T1–T2 disc herniations are rare and, in most cases, are located posterolaterally. Posterior approaches may utilize transfacet pedicle-sparing techniques, while the less frequent central/anterolateral discs may warrant anterior surgery.

Case Description:

Here, we reviewed four cases of symptomatic T1–T2 disc herniations; two patients were paraparetic due to central discs and underwent anterior surgery utilizing a cage construct. The latter two cases had posterolateral discs contributing to a Brown-Sequard syndrome and radiculopathy, respectively; one patient required a transfacet pedicle-sparing procedure, while the second case was managed conservatively. All surgically treated patients recovered fully.

Conclusions:

We reviewed 4 cervical T1–T2 disc herniations; two central/anterolateral lesions warranting anterior surgical approaches/cages, and 2 lateral discs treated with a posterolateral transfacet, pedicle-sparing procedure and no surgery respectively. Follow-up magnetic resonance studies documented full resolution for the patient with radiculopathy and a posterolateral disc.

Intraoperative tension pneumothorax during posterior vertebral column resection in a child with congenital scoliosis

Background:

Intraoperative tension pneumothorax (TPT) is extremely rare in spinal surgery overall and particularly in extensive deformity procedures. Here, we report a TPT occurring in conjunction with posterior vertebral column resection (pVCR) for the treatment of congenital scoliosis.

Case Description:

A 12-year-old female undergoing congenital thoracic scoliosis surgery (e.g., pVCR) developed abrupt intraoperative increases in airway pressure and compromised hemodynamics that led to a TPT. This was directly attributed to an inadvertent pleural tear. Temporary drainage of the accumulated air was accomplished with a urethral catheter inserted directly into the pleural cavity. This was later supplemented with a standard chest tube. The child quickly improved and was routinely discharged a few days later.

Conclusion:

In patients undergoing pVCR, if the surgical team is faced with unexplained hemodynamic instability and increased airway resistance, a TPT should be strongly suspected and appropriately managed.

Congenital cervical isthmic spondylolisthesis: A case report

Background:

There are only 20 reported cases of cervical isthmic spondylolisthesis in literature that have been surgically managed either anteriorly or posteriorly. Herein, we report such a case managed with circumferential fusion.

Case Description:

A 27-year-old male became progressively quadriparetic due to cervical isthmic spondylolisthesis at the C6–C7 level. Removal of the posterior arch of C6 with subsequent C5–C7 pedicle screw/rod fixation and anterior interbody fusion resulted in marked recovery and adequate cervical realignment.

Conclusion:

For patients with cervical isthmic spondylolisthesis, circumferential fusion provides the best surgical option to achieve stability and sagittal balance.

Traumatic Chronic Irreducible Atlantoaxial Rotatory Fixation in Adults: Review of the Literature, With Two New Examples

Atlantoaxial rotatory fixation (AARF) is a rare condition in adults and is almost always due to an accompanying trauma. The first example of traumatic AARF in adults was reported by Corner in 1907 and since then only 55 adult cases with this rare traumatic scenario have been published so far. Approximately 80% of adults with traumatic AARF are diagnosed soon after the traumatic events. However, in the remaining casualties, the condition might be missed with some delay from the diagnosis to treatment. If this pathology is diagnosed early enough, the conservative attempts for a closed reduction are usually effective. After closed reduction, external immobilization is required to prevent recurrence of the dislocation. However, with delayed diagnosis, the condition may remain refractory to traction on manipulation and require an open reduction instead. In the literature, such irreducible chronic AARFs are rarely reported, being confined to only 14 adult examples, in whom surgical intervention for correction of the deformity will be required. In such cases, release of the atlantoaxial facet joints is the first surgical step. In the subsequent step, reduction of the dislocated facet joints can be done via one of the already described maneuvers. As the final step, C1-C2 fixation will be necessary for prevention of re-dislocation. Herein, 2 adult patients with chronic rotatory atlantoaxial dislocation of traumatic origin are presented. In both cases, cranial traction and manipulations were ineffective and therefore an open reduction procedure was proposed and accomplished via the posterior midline corridor. The transverse rod technique was implemented subsequent to the atlantoaxial facet release. After correction of the deformity, a C1-C2 fixation was accomplished followed by arthrodesis. In addition to the outlined procedure, an historical review of the literature on this subject from the beginning of 20th century is demonstrated.

Ossification of the cervical ligamentum flavum and case report with myelopathy

Background:

Ossification of the ligamentum flavum (OLF) occurs mostly in adult males, typically in the thoracolumbar spine where it may contribute to neurological deficits. Here we reviewed 68 cases of cervical OLF resulting in progressive quadriparesis.

Methods:

The literature on cervical OLF was reviewed between 1962 and 2018 along with the case of an 81-year-old male with progressive quadriparesis attributed to cervical OLF.

Results:

Most patients with cervical OLF are Asian, with Caucasians constituting the second most frequently impacted population.

Conclusions:

Cervical OLF is typically reported in the Asian, followed by the Caucasian population, and is most often found in the thoracolumbar spine. Here we presented an 81-year-old male with cervical OLF contributing to quadriparesis.

Intracranial Migration of a Broken Rod After Orbitocranial Injury in an Adult

BACKGROUND

Craniocerebral injuries due to the induction of sharp objects are relatively rare and are nearly always observed in the pediatric rather than the adult population. Orbitocranial injuries involving a piece of smooth steel rod are extremely rare and to our knowledge have yet to be reported in previous publications. When this particular category of injury does occur, the invading intracranial foreign body usually remains lodged within its entry position. This is most often near the entry point and within the frontal lobe after penetrating the orbit. Migration of the penetrating object far from the initial entry point is quite rare and has been historically confined to low-velocity bullet wounds.

CASE DESCRIPTION

An adult man was injured on the right eyelid by a section of steel rod. The rod had entered the cranium through the right orbital roof and was lodged within the corresponding right frontal lobe. An initial plain radiograph showed that the rod was within the right frontal lobe. However, computed tomographic angiography of the brain performed during the second day of admission demonstrated displacement of the rod to the left hemisphere. This finding was clearly demonstrated through subsequent imaging. As a result of the migration, the rod could be distracted fairly easily through a left parasagittal and interhemispheric approach. Postoperatively, the patient made a full recovery.

CONCLUSIONS

Migration of traumatically introduced intracranial foreign bodies far from their initial entry places should be suspected in objects possessing sufficient weight and a smooth surface. This means that a correct assessment of the final position of such objects is necessary before surgery, even while the patient is on the operating table.

Atlantoaxial Subluxation Secondary to Unstable Os Odontoideum in a Patient With Arrested Hydrocephalus Due to Congenital Aqueductal Stenosis: A Case Report

BACKGROUND

In a small percentage of children born with congenital hydrocephalus, enlargement of the head and the presence of ventriculomegaly may halt and ultimately stabilize the condition designated as arrested hydrocephalus. Arrested hydrocephalus in children is typically due to congenital aqueduct stenosis, which can be described appropriately as a stasis existing within the channel between the third and fourth ventricles. Os odontoideum (OO) is an uncommonly occurring pathology at the craniovertebral junction. Although the clinical and radiologic features of its existence and the therapeutic options for its pathology have been widely discussed within the medical literature, its true etiology has been a source of divisive debate, proposing both a traumatic as well as a congenital mechanism. The etiology of OO has been heartily debated in the literature for several years as well. Most authors have come to support a posttraumatic causality. However, strong evidence exists to support a congenital origin to this rarely observed malformation.

METHODS

Within this case study we present a 24-year-old woman with atlantoaxial subluxation that exists secondary to an orthotropic OO. The patient had a history of arrested hydrocephalus due to congenital aqueductal stenosis beginning in early childhood. She presented with normal intelligence and was neurologically without deficits before the occurrence of an atlantoaxial dislocation. Unfortunately, the pathology was initially misdiagnosed as a decompensation state of the arrested hydrocephalus, and after 8 months the patient became wheelchair bound. Following this unfortunate event the correct diagnosis was ultimately uncovered. Subsequently a C2-1 instrumentation procedure resulted in excellent alignment and fusion.

CONCLUSIONS

To the best of our knowledge, this is the first example of an aqueduct stenosis in the setting of an existing OO, a combination that might be another clue in favor of a congenital etiology.

Posterior Tibial Neuropathy Secondary to Pseudoaneurysm of the Proximal Segment of the Anterior Tibial Artery with Delayed Onset

Anterior tibial artery is a nonvital artery which is one of the three arteries of the leg. This artery has a short proximal l segment in the popliteal region and a long segment in the anterior compartment of the leg designated as distal segment. With consideration of the deep location of the proximal segment in the popliteal fossa, it is less susceptible to trauma and subsequent formation of an aneurysm. On the contrary, the superficial long distal segment is more susceptible to trauma with high chance of pseudoaneurysm formation at the site of unrecognized injury. In this article, a 38-year-old military man being manifested about a decade after a trivial missile fragment injury with progressive posterior tibial neuropathy is presented. A giant pseudoaneurysm arising from the proximal segment of the anterior tibial artery was confirmed with angiography and the exact size of this pathology was documented with contrasted computed tomographic scan. The aneurysmal sac removal was accomplished after ligation of the corresponding artery proximal and distal to the sac followed by tibial nerve neurolysis which result in full recovery. In careful review we found that neither pseudoaneurysm arising from the proximal tibial artery nor posterior tibial neuropathy due to the compressive effect of the aneurysmal sac of this segment has been reported previously. Our primary purpose for reporting this case is not to describe the rarity of pseudoaneurysm formation at proximal segment of this artery but rather to describe delayed-onset posterior tibial vascular compressive neuropathy due to such an aneurysm. Eventually due to the potential sequel of a pseudoaneurysm, it is important for the surgeons to have high index of suspicion to prevent a missed or delayed diagnosis.

Comparative Study of the Effect of Warming at Various Temperatures on Biochemical, Hematologic, and Hemodynamic Parameters During Spinal Fusion Surgery Under Intravenous Anesthesia

BACKGROUND

Perioperative inadvertent hypothermia (PIH) commonly occurs after major surgical procedures under local or general anesthesia and increases the risk of complications such as organ failure, hypoperfusion, and peripheral vasoconstriction, as well as adverse postoperative outcomes, such as wound infection and increased surgical bleeding.

OBJECTIVES

We hypothesized that the intra-operative warming may affect these complications and thus, we aimed to compare the most appropriate temperature of the warmer to decrease patients' complications.

METHODS

The present randomized clinical trial investigated 90 patients undergoing total intravenous anesthesia in posterior spinal fusion surgery, randomly divided into two groups of 45. The warmer was set at 38°C for group "A" during surgery and at 40°C for group "B." Patient's demographic characteristics, the serum level of hemoglobin, hematocrit, and platelet counts, mean core temperature, systolic blood pressure (BP), heart rate, and respiratory rate were recorded before and after the surgery. Variables were compared between the two groups at three time intervals (during induction, during operation, and during recovery).

RESULTS

The mean temperature was not different between the two groups at the three time intervals. Other laboratory serum tests, vital signs, and oxygen consumption were maintained within the normal range although they did not improve significantly in two groups at the three time intervals.

CONCLUSIONS

There was no significant difference in warming of the patients during operation at 38 or 40°C to prevent hypothermia-induced complications during induction, operation, and recovery.

Complete thoracolumbar fracture-dislocation with intact neurologic function: Explanation of a novel cord saving mechanism

BACKGROUND

The thoracolumbar junction from T11 to L2 is a common site of injury in which fracture and dislocations are the most prevalent ones occurring at this location. Fracture dislocation is defined as failure of all three columns of the spine with gross displacement. Considering the significant violence necessary to produce fracture dislocations, these injuries are often associated with major neural deficit, with the majority of casualties becoming paraplegic immediately. Preservation of neurological function following complete fracture dislocation is quite rare entity.

OBJECTIVE

To represent the possibility of existence of a preservation mechanism for functional integrity of cord despite spinal gross fracture dislocation by reproducing the injury on a plastic model and simulating a corresponding model using 3DSlicer software, detailed description the pathomechanism of neurologic sparing.

CASE REPORT

A 19-year-old female who sustained severe thoracolumbar fracture dislocation but with normal neurology is presented. Despite the severity of the condition, the diagnosis was initially missed due to associated vital injuries.

RESULTS

Combined posterior and anterior surgery resulted in optimal coronal and sagittal alignment, as well as proper stabilization without any complication. At 9-year follow-up, the patient was found to be doing well.

CONCLUSION

The prognosis for complete recovery with preplanned surgical intervention in thoracolumbar injuries affecting all three columns but with normal neurologic function is promising based on images, plastic models and 3D simulated model based on digital images.

Remote Cervical Pseudomeningocele Following Anterior Cervical Corpectomy and Fusion: Report of a Case and Review of the Literature

Iatrogenic cervical pseudomeningocele is a rare event and majority are located posteriorly as a delayed complication of inadvertent dural tear after decompressive laminectomy. However, iatrogenic anterior cervical pseudomeningocele subsequent to discectomy or corpectomy is a rare pathology. The time necessary for formation of pseudomeningocele varies and depend on the width of the dural tear and the flow of cerebrospinal fluid leakage. Large tears with high CSF flow usually result in early collection of the cerebrospinal fluid in anterior compartment of the neck designated acute pseudomeningoceles. Micro-tears of dura mater, with low flow of cerebrospinal fluid may lead to late formation of a pseudomeningocele known as chronic ones. Herein a 49- year-old woman in whom cervical pseudomeningocele appeared clinically as a mass on the anterior aspect of the neck, six months after anterior cervical corpectomy for cervical spondylotic myelopathy is presented. Otherwise, she was neurologically stable. Cystoperitoneal shunt was proposed which she refused. Surprisingly, at 2-year follow-up, the cyst had remained of the same size. To the best of our knowledge, this is the first example of post-operative chronic cervical pseudomeningocele in the literature, the event that might propose the self-limited natural course of this rare pathology in chronic cases.

Symptomatic pseudarthrosis in ochronotic spine: case report

In this study the authors report the first example of spinal pseudarthrosis in a patient with ochronosis, and they describe the application of posterior-only 360° surgery as an alternative approach to combined anterior-posterior surgery in the management of pseudarthrosis of an ankylosed spine, regardless of its etiology. Spinal involvement in ochronosis produces loss of flexibility and ankylosis of thoracic and lumbar segments. Pseudarthrosis is a serious complication of the diseases that present with ankylosis of the spine. However, its occurrence in ochronotic spine has not been reported previously. Evaluation of progressive paraparesis in a 68-year-old man with ochronosis revealed pseudarthrosis at the T11-12 level. Circumferential dural sac decompression, debridement of the disc space, interbody fusion, and screw-rod fixation were all done via a posterior-only approach. Postoperatively the patient exhibited a marked recovery in terms of pain and neurological status. At the 3-month follow-up, he was able to walk independently. Ochronosis should be included in the etiology of pseudarthrosis. With aggravation of back pain and the appearance of neurological deficits in an already stable patient with any ankylosing disease, pseudarthrosis should be suspected. Furthermore, single-stage, 360°, posterior-only surgery may obviate the need for single-stage or staged anterior-posterior surgical intervention in patients with pseudarthrosis of the thoracic and lumbar spine.

Management of traumatic double-level spondyloptosis of the thoracic spine with posterior spondylectomy: case report

Traumatic spondyloptosis of the thoracic spine is an uncommon injury. In most cases, spondyloptosis is confined to one vertebral body, whereas double-level spondyloptosis is extremely rare. Most patients who sustain traumatic spondyloptosis immediately become paraplegic, but in some cases neurological function is preserved. If this occurs, it is due to detachment of the pedicles from the corresponding vertebral body, resulting in spontaneous decompression of neural elements. Herein, the authors describe a case of undetected traumatic double-level spondyloptosis in the upper thoracic region in an adult male patient who was neurologically intact for 2 days but later became paraplegic. Initially, management of this pathology seemed a very challenging scenario. However, with review of the reconstructed CT images and reproduction of the injury on a plastic model, a posterior-only approach was chosen as an alternative operative solution for this catastrophic injury. Via this single-stage posterior approach, long-segment pedicle screw/rod instrumentation resulted in successful reduction, restoration of alignment, and stabilization after 1-level posterior spondylectomy. To the best of the authors' knowledge, this is the first example reported in the literature of double-level spondyloptosis of the thoracic and the lumbar spine. This report describes the rationale, mechanism, and technical details afforded for reduction and stabilization of this rare injury.

Remote Paraparesis due to a Traumatic Extradural Arachnoid Cyst Developing 2 Years after Brachial Plexus Root Avulsion Injury: Case Report and Review of the Literature

Traumatic extradural arachnoid cyst is a rare entity. However, late appearance of paraparesis due to formation of an extradural arachnoid cyst as a sequel of brachial plexus injury is extremely rare and the literature regarding this issue is scarce revealing only 11 cases. Herein, we report a patient with delayed progressive spastic paraparesis appearing after a multilevel brachial plexus root avulsion injury where imaging revealed formation of a large traumatic extradural arachnoid cyst at the cervicothoracic region. Furthermore, to propose that a high-energy trauma might simultaneously result in delayed formation of an extradural arachnoid cyst. However, preganglionic root avulsion injury with pseudomeningocele formation in association with extradural arachnoid cyst is not reported previously. A case of a 36-year-old man with spastic paraparesis developing 2 years after a multilevel brachial plexus root avulsion injury is presented. Root avulsion had immediately resulted in complete paralysis of the left upper limb that had not ameliorated. Imaging studies of the cervicothoracic region disclosed left-sided multilevel pseudomeningoceles and a large extradural arachnoid cyst extending from C5 to T2. After appropriate en bloc laminotomy, the cyst was excised and the causative dural tear was closed. Subsequently, three large defects of pseudomeningoceles were obliterated with artificial dural patch for the prevention of cord herniation. This was followed with laminoplasty of the corresponding levels after dural closure. The postoperative course was uneventful and paraparesis recovered steadily within 2 months. Paraparesis even years after brachial plexus injury should be regarded as a serious event that deserves extensive imaging survey for the possibility of the formation of an extradural arachnoid cyst. Careful review of the literature disclosed that the current case is the 12th case that an extradural arachnoid cyst has developed after brachial plexus injury and the first example that the pathogenic factor that might be implicated in occurrence of this rare association could be clarified with review of the MRI features. Actually, the presence of posttraumatic pseudomeningoceles in association with an arachnoid cyst in the current case is in favor of the belief that only preganglionic root injuries that are in close proximity to the spinal canal had been the cause dural tear with remote formation of extradural arachnoid cyst.

Human erythropoietin effect in postoperative visual loss following spine surgery: a case report

Introduction:

Postoperative visual loss (POVL) has become the focus of attention for anesthesiologists as a hallmark of perioperative management in spine surgery. A number of Intraoperative and postoperative factors has been documented but the exact etiology is still unclear. Nowadays, perioperative management and also complete curing of POLV is a big question of ophthalmologists and anesthesiologists. The purpose of this case report is to present a unique experience of complete curing the POLV.

Case Presentation:

Our patient was a 61-year-old man, with 75 kg weight and 180 cm height. The patient had no history of visual impairment except mild cataract in his right eye. The patient had a history of diffuse idiopathic skeletal hyperostosis (DISH). The patient had undergone lumbar surgery in prone position. The operation time was about 6 hours. About 30 minutes after transferring to postanesthesia care unit (PACU), patient was awake and complained of losing his eyesight. There was no vision and light perception in his right eye on primary examination. Urgent ophthalmologist consultation was requested. In ophthalmology examinations, the pupil reflex to light was absent in the right eye. After obtaining patients and his family informed consent, four hours after the operation, 40000 I.U. of recombinant human erythropoietin (rhEPO) was administered for patient in PACU (IV infusion, in 30 min). An ophthalmologist visited him every 6 hours after administration of rhEPO. The patient was transferred to intensive care unit (ICU) one hour later with total visual loss in the right eye. Ophthalmologic examination after the second dose of rhEPO, 30 hours after the operation, reported pupil reflex enhancement and light perception in his right eye. Finally the third dose of rhEPO (40000 I.U., IV infusion) was administered on the third day. Ophthalmologic examination after the third dose of rhEPO, 60 hours after the operation, reported normal pupillary light reflex of the right eye and visual acuity improvement to 20/20. The patient was discharged from hospital after six days, with normal visual acuity and without any new complications except surgical site pain.

Conclusions:

Our case report showed the therapeutic effect of rhEPO in complete curing of POVL. Regarding the side effects of EPO such as thrombogenic effects or mild hemodynamic changes like transient sinus tachycardia during infusion, it seems that beneficial effects of EPO is more than its disadvantages and expenses, for patients with POVL.

Intramedullary arachnoid cyst in association with cervical spondylosis: case report

BACKGROUND CONTEXT

Intramedullary spinal arachnoid cysts are considered to be very rare, and only 11 cases have been reported previously. Development of such a cyst in association with marked cervical spondylosis has not been reported until recently.

PURPOSE

Brief review of reported cases and debate on likely treatment strategy when such a cyst is associated with symptomatic spondylosis.

STUDY DESIGN

To report the first example of a cervicothoracic intramedullary arachnoid cyst along with a symptomatic cervical spondylosis.

METHODS

Evaluation of quadriparesis in a 58-year-old female resulted in detection of a cervical spondylotic stenosis that was accompanied with an intramedullary cystic lesion. Parallel management of both pathologies was through a wide laminectomy extending from the lower edge of C3 to T2 with subsequent fenestration and partial resection of the cyst wall via an appropriate dorsal entry root zone myelotomy. Cervicothoracic instrumentation from C3 down to T2 was done to prevent postlaminectomy deformity.

RESULT

Histopathological findings were consistent with the diagnosis of arachnoid cyst. Postoperatively, the patient exhibited marked improvement in neurologic status.

CONCLUSION

Through the review of the current case, first example from the literature, we concluded that surgery should target toward the proper management of both pathologies in a single-stage operation.

Posterior epidural migration of sequestered lumbar disc fragment causing cauda equina syndrome

Posterior epidural migration (PEM) of a sequestered free lumbar disc fragment is rare. The rarity is due to presence of several anatomical restraints which restrict a free fragment to move to the posterior compartment. This unusual presentation of disc herniation appeared in the literature either as a single case report or in small series from two to six cases. Herein two new demonstrative cases will be presented with a brief review of the literature.

Spinal extradural arachnoid cysts

OBJECTIVE: Extradural arachnoid cysts (EACs) are rare causes of spinal cord compression and cauda equina. These benign lesions appear in the literature mainly as single case reports. In this article, we present the largest series found in literature, with four new cases of spinal extradural arachnoid cysts. The characteristic imaging features, details of surgical steps and strategies to prevent postoperative kyphosis in this cystic pathology will be discussed.

Bilateral three-level lumbar spondylolysis repaired by hook-screw technique

We report a case of bilateral three-level lumbar spondylolysis that was directly repaired by use of hook-screw technique. The patient complained of low back pain for 2 years that progressively worsened and was exacerbated with standing and walking. He also mentioned bilateral sciatalgia. The neurological examination was normal. Interestingly, we found bilateral lumbar spondylolysis in L3, L4, and L5 levels in imaging studies. After proving that spondylolysis was the source of the low back pain by local anesthetic agent injection, we used a direct technique for correction of spondylolysis by use of a hook-screw device plus decortications of lysis area and iliac crest autograft. We assessed the patient after surgery to evaluate pain recovery and fusion rate. The results were favorable and proved the efficacy of the hook-screw technique for treatment of symptomatic multilevel lumbar spondylolysis.

Genital lentigines in a 6-year-old boy with a family history of Cowden's disease: clinical and genetic evidence of the linkage between Bannayan-Riley-Ruvacalba syndrome and Cowden's disease

BACKGROUND

In 1997, it was reported that a PTEN gene deletion, a common genetic mutation in Cowden's disease (CD), was identified in a patient with Bannayan-Riley-Ruvacalba (BRR), suggesting that the two diseases were allelic. However, the clinical overlap between the two diseases has largely remained unclear.

OBJECTIVE

To confirm the genetic and clinical association in a family segregating both CD and BRR.

METHODS

Clinical evaluation and genetic analysis using a denaturing gradient gel electrophoresis (DGGE), temporal temperature gradient electrophoresis (TTGE), and DNA sequencing techniques.

RESULTS

Our patient presents with typical BRR clinical manifestations, including multiple lentigines on his penis, while his mother presents with typical manifestations of CD, including multiple malignancies. Genetic analyses of leukocytes from the patient and his mother showed mutations in exon 8 that was identified as the presumably truncating mutation R335X.

CONCLUSION

This report provides clinical evidence that both BRR and CD are closely related and confirms the PTEN gene mutation in BRR and CD patients segregating in the same family, thus confirming the genetic linkage between the two genodermatoses.

The development of a Marjolin's cancer in a human immunodeficiency virus-positive hemophilic man and review of the literature

BACKGROUND

The malignant potential of chronic ulcers and scars secondary to a variety of injuries is well characterized in the medical literature. Furthermore, it has been reported that human immunodeficiency virus (HIV)-positive patients have a higher incidence of basal cell carcinoma (BCC) than the general population.

OBJECTIVE

To describe a case of an unusually aggressive morpheaform BCC that developed in a 28-year-old HIV-positive patient. The tumor developed in a scar 25 years after the initial trauma (Marjolin's ulcer).

METHODS

Description of a case and review of the literature of Marjolins ulcer.

RESULTS

The tumor was removed in a seven-stage, 21-section, micrographically controlled excision. Intraoperatively, perineural invasion of the infraorbital nerve was observed. The postoperative defect was repaired using a full-thickness skin graft.

CONCLUSION

Although most malignancies arising within chronic scars are SCCs, BCCs and a number of other tumors have been described. Mohs micrographic surgery was effective in treating this aggressive morpheaform BCC. A high degree of suspicion in any changing healed scar is recommended.

Unusual delayed radial nerve palsy caused by a traumatic aneurysm of a collateral radial artery: report of two cases

Two patients with delayed radial nerve palsy occurring a month after penetrating missile wounds are presented. The history and presence of a pulsatile mass over the posterolateral aspect of the arm were highly suggestive of a traumatic aneurysm of a collateral radial artery, confirmed by angiography in one patient and at surgery in the other. After removal of the aneurysm and radial nerve neurolysis, the patients' symptoms were relieved. In a thorough review of the literature, we found these to be the first examples of traumatic aneurysms of collateral radial arteries causing unusual delayed neural palsies.