The purpose of this study was to analyze the relationship between fracture pattern and the development of acute radiculopathy after osteoporotic lumbar compression fracture.
This study included 59 patients who underwent bone cement augmentation for osteoporotic compression fracture below the L2 level, which can lead to radiculopathic radiating pain. The patients were divided into two groups according to the presence of radiculopathy (group A : back pain only; group B : back pain with newly developed radiating pain). We categorized compression fractures into three types by the position of the fracture line. The incidence of newly developed radiculopathy was examined retrospectively for each compression fracture type.
The overall incidence of newly developed leg pain (group B) was 25%, and the frequency increased with descending spinal levels (L2 : 0%, L3 : 22%, L4 : 43%, and L5 : 63%). The back pain-only group (group A) had mostly superior-type fractures. On the other hand, the back pain with radiculopathy group (group B) had mostly inferior-type fractures. Most patients in group B showed significant relief of leg pain as well as back pain after bone cement augmentation.
The incidence of a newly developed, radiating pain after osteoporotic compression fractures increased gradually from the L3 to L5 levels. Most of these fractures were of the inferior type, and the bone cement augmentation procedures seemed to be sufficient for relief of both back and radiating pain.
Fracture; Osteoporosis; Radiculopathy
Orientia tsutsugamushi induces vasculitis leading to symptoms of systemic organ invasion including meningitis and meningoencephalitis. We conducted a retrospective case-control study of scrub typhus patients to investigate the clinical and laboratory features of patients with scrub typhus meningitis or meningoencephalitis, and the therapeutic outcomes, and to determine the predictor factors. Cases were 22 patients with scrub typhus meningitis or meningoencephalitis, and controls were 303 patients without meningitis or meningoencephalitis. Multivariate analysis showed that the presence of pneumonitis was associated with the occurrence of scrub typhus meningitis and meningoencephalitis (odds ratio [OR] 8.9; P < 0.001; confidence interval [CI] 2.9–27.2). Although appropriate antimicrobials such as doxycycline agents were administered at an early stage, meningitis or meningoencephalitis still occurred in some cases. Physicians should be aware that meningitis or meningoencephalitis may develop during appropriate drug therapy such as doxycycline. Close observation and great care are essential for patients with risk factors, particularly pneumonitis.
We generally believe that obese patients are faced on higher risk of developing perioperative complications. Rhabdomyolysis is a rare but potentially life-threatening condition caused by the release of injured skeletal muscle components into the circulation. It usually results from mechanical damage to the muscle, intoxication, or a postictal state after a seizure. In the present study, we have reported a rare case of rhabdomyolysis developing in a morbidly obese patient after upper thoracic spinal fusion surgery. We have found acute renal failure that evolved during the course of treatment resulted in a fatal outcome even though the patient received intensive supportive care. Our experience suggests that this rare complication should be considered in morbidly obese patients and those efforts should be made to avoid rhabdomyolysis.
Spine; Rhabdomyolysis; Obesity
The purpose of this study was to investigate the prenatal hypoxic effect on the fetal brain development.
We used the guinea pig chronic placental insufficiency model to investigate the effect of hypoxia on fetal brain development. We ligated unilateral uterine artery at 30-32 days of gestation (dg : with term defined as -67 dg). At 50 dg, 60 dg, fetuses were sacrificed and assigned to either the growth-restricted (GR) or control (no ligation) group. After fixation, dissection, and sectioning of cerebral tissue from these animals, immunohistochemistry was performed with NeuN antibody, which is a mature neuronal marker in the cerebral cortex.
The number of NeuN-immunoreactive (IR) cells in the cerebral cortex did not differ between the GR and control groups at 50 dg. However, the number of NeuN-IR cells was lesser in GR fetuses than in controls at 60 dg (p<0.05).
These findings show that chronic prenatal hypoxia affect the number of neuron in the cerebral cortex of guinea pig fetus at 60 dg. The approach used in this study is helpful for extending our understanding of neurogenesis in the cerebral cortex, and the findings may be useful for elucidating the brain injury caused by prenatal hypoxia.
Hypoxia; Cerebral cortex; Neuron
Penetrating cerebral injuries caused by foreign bodies occur rarely due to the substantial mechanical protection offered by the skull. Throughout most of history, the brain, residing in a "closed box" of bone, has not been vulnerable to external aggression. Recently, we encountered a serious penetrating craniocerebral injury caused by a nail gun. Total excision of the offending nail via emergency craniotomy was performed, but the patient's neurologic status was not improved in spite of aggressive rehabilitative treatment. Here, we report on this troublesome case in light of a review of the relevant literature.
Head; Injury; Penetrating
Hydrocephalus is a well-known complication of head injury, but an uncommon complication of a spinal lesion. Here, we present a rare case of acute obstructive hydrocephalus secondary to a cervical fracture and dislocation. A 60-year-old female patient was transferred to the emergency department with quadriplegia and respiratory difficulty. Imaging studies showed a cervical fracture and dislocation at the C3-4 level. She required intubation and mechanical ventilation. Twenty-four hours after admission, her mental status had deteriorated and both pupils were dilated. Computed tomography of the brain showed acute hydrocephalus; therefore, extraventricular drainage (EVD) was performed. After the EVD, her mental status recovered and she became alert, but she remained quadriplegic and dependent on the ventilator. Two months after injury, she died because of respiratory failure caused by pneumonia.
Hydrocephalus; Cervical; Fracture
Synovial cysts are recognized as an uncommon cause of radicular and myelopathic symptoms. They are most frequently found in the lumbar region. The cervical spine or cervicothoracic junction is a rare location for a degenerative intraspinal synovial cyst as compared with the lumbar spine. At given cervical spinal levels, synovial cysts probably share clinical features with disc herniation and stenosis. However, the pathogenesis of synovial cysts remains still controversial. Here, we report a rare case of a synovial cyst in the lower cervical spine presented as Brown-Séquard syndrome and include a brief review of the literature. To the best of our knowledge, no previous report has been issued in the English literature on a synovial cyst presenting with Brown-Séquard syndrome. Neurologic function recovered completely after complete removal of the cyst and expansive laminoplasty.
Brown-Séquard syndrome; Synovial cyst; Cervical
Giant cell tumor (GCT) of the spine is a rare benign tumor, but can be aggressive and can exhibit a high local recurrence rate. Furthermore, GCT of the upper thoracic spine may pose diagnostic and management difficulties. Here, we report a rare case of GCT of the upper thoracic spine with soft tissue extension to the spinal canal. The patient was managed by decompressive laminectomy and posterolateral fusion followed by an injection of polymethylmethacrylate into the vertebral lesion. The patient recovered clinically and showed radiological improvement after surgical treatment without tumor recurrence at his last follow-up of postoperative 7 years. We present this unusual case of GCT and include a review of the literature.
Giant cell tumor; Thoracic; Polymethylmethacrylate
The purpose of this study was to evaluate the efficacy of implant removal of percutaneous short segment fixation after vertebral fracture consolidation in terms of motion preservation.
Between May 2007 and January 2011, 44 patients underwent percutaneous short segment screw fixation due to a thoracolumbar burst fracture. Sixteen of these patients, who underwent implant removal 12 months after screw fixation, were enrolled in this study. Motor power was intact in all patients, despite significant vertebral height loss and canal compromise. The patients were divided into two groups by degree of osteoporosis : Group A (n=8), the non-osteoporotic group, and Group B (n=8), the osteoporotic group. Imaging and clinical findings including vertebral height loss, kyphotic angle, range of motion (ROM), and complications were analyzed.
Significant pain relief was achieved in both groups at final follow-up versus preoperative values. In terms of vertebral height loss, both groups showed significant improvement at 12 months after screw fixation and restored vertebral height was maintained to final follow-up in spite of some correction loss. ROM (measured using Cobb's method) in flexion and extension in Group A was 10.5° (19.5/9.0°) at last follow-up, and in Group B was 10.2° (18.8/8.6°) at last follow-up. Both groups showed marked improvement in ROM as compared with the screw fixation state, which was considered motionless.
Removal of percutaneous implants after vertebral fracture consolidation can be an effective treatment to preserve motion regardless of osteoporosis for thoracolumbar burst fractures.
Fusion; Percutaneous; Removal
Tapia syndrome is a rare entity characterized by unilateral paralysis of the tongue and vocal cord caused by Xth and XIIth cranial nerve lesions. However, there has been no report of Tapia syndrome immediately following spine surgery. A 47-year-old man underwent posterior decompressive laminectomy for cervical stenosis. The surgery took about 117 minutes and it was uneventful. Postoperatively he developed hoarseness of voice during speech, with deviation of tongue protrusion. On laryngoscopic examination, paralysis of the left side of the tongue and the soft palate was found and complete palsy of the left vocal cord was noted. After excluding surgical cause and craniocervical lesion, a clinical diagnosis of Tapia syndrome was made. Here we report a rare case of Tapia syndrome developed after posterior approach for cervical spine surgery and discuss the possible mechanisms of this uncommon syndrome.
Cranial nerve palsy; Tapia syndrome; Spine surgery
Although anterior approaches to the cervical spine are popular and safe, they cause some of complications. Esophageal perforation after anterior spinal fusion is a rare but potentially life-threatening complication. We present a rare case of delayed esophageal perforation caused by a cervical screw placed via the anterior approach. A 43-year-old man, who had undergone surgery for complete cord injury at another orthopedic department 8 years previously, was admitted to our institute due to painful neck swelling and dysphagia. Radiological studies revealed a protruding screw and esophageal perforation. The perforation was found during surgery and was successfully repaired. This case emphasizes the need for careful long-term follow-up to check for delayed esophageal perforation in patients that have undergone anterior cervical spine plating.
Anterior cervical surgery; Esophageal perforation
Intracranial calcifications are relatively common computed tomographic findings in the field of neurosurgery, and cysticercosis, tuberculosis, HIV, and cryptococcus are acquired intracranial infections typically associated with calcifications. However, intracranial calcification caused by a bacterial brain abscess is rare. Here, we present a rare case of intracranial calcification caused by a bacterial brain abscess, from which staphylococcus hominis was isolated. To the best of our knowledge, no previous report has been published on intracranial calcification caused by bacterial brain abscess after decompressive craniectomy for traumatic brain injury. In this article, the pathophysiological mechanism of this uncommon entity is discussed and relevant literature reviewed.
Brain abscess; Calcification
Pneumorrhachis, which involves the entrapment of air or gas within the spinal canal, is a rare clinical entity, and the pathogenesis and etiologies of this uncommon entity are various and can present a diagnostic challenge. Usually, pneumorrhachis represents an asymptomatic epiphenomenon but it can produce symptoms associated with its underlying pathology. Here, we report a rare case of symptomatic epidural pneumorrhachis accompanying pneumothorax. Possible pathogenic mechanisms are discussed and a review of the literature is included.
Perforation of the hypopharynx, which can occur after anterior cervical approach, is a very rare type of complication. If diagnosed late, it can lead to very fatal course, such as mediastinitis and hematosepsis. Therefore, a precise and prompt diagnosis is crucial. When conservative treatment alone is not expected to heal the perforated site or is likely to lead to serious complications, surgical treatment becomes necessary. This report demonstrates that surgical intervention performed immediately after an early diagnosis can lead to the successful treatment of a large perforation in the hypopharynx on a 58-year-old male patient.
Hypopharynx; Perforation; Cervical
The purpose of this study was to evaluate the clinical presentation and surgical outcome in patients with symptomatic discal cyst.
The authors reviewed consequent 9 patients in whom microscopic excision of the discal cyst with or without additional discectomy for discal cyst from 2005 to 2012. Diagnostic imagings including simple radiographs, computed tomography with discogram and magnetic resonance images were performed in each case. The patients were reviewed to evaluate the clinical presentation, surgical outcome and related complications.
In all patients, discal cyst was located in the lumbar region and they presented with back pain and unilateral radiating pain. The preoperative magnetic resonance images (MRI) and computed tomography (CT) scan with discogram showed a connection between the cyst and the involved intervertebral disc. All patients obtained immediate relief of symptoms after microscopic excision of discal cyst. There were no recurrent lesions during follow-up period. The mean preoperative visual analogue scale (VAS) was 7.8 when compared with 2.6 in preoperative assessment. All patients obtained excellent or good outcome according to modified MacNab's criteria.
Discal cysts are rare lesions that can lead to back pain and refractory sciatica. Microscopic excision of the cyst can achieve remarkable improvement of symptoms.
Discal cyst; Excision; Microscope
So far, there have been few previous reports of tuberculous spondylitis occurring after percutaneous vertebroplasty. We report an unusual case of tuberculous spondylitis diagnosed after percutaneous vertebroplasty in a patient who had a history of pulmonary tuberculosis for the first time. A 58-year-old woman, who had a history of complete recovery from pulmonary tuberculosis six years previously, was hospitalized due to severe back pain after a fall. Radiological studies revealed a fresh compression fracture at the T12 thoracic vertebra. The back pain improved dramatically, and the patient was discharged two days after the vertebroplasty. However, cold sweats and a low grade fever with severe back pain developed four weeks after the procedure. Magnetic resonance imaging revealed a severe kyphosis and the T11-T12 disc space had collapsed with heterogeneous signal intensity. The results of the culture of the biopsy specimens were negative, and did not lead to identification of the causative micro-organism. However, the polymerase chain reaction for Mycobacterium tuberculosis was positive. Treatment for tuberculous spondylitis was started and she underwent posterior fusion and instrumentation from T9-L2 after the markers for infection returned to normal. After surgical intervention, the pain improved and the kyphotic deformity was corrected.
Tuberculous spondylitis; Percutaneous vertebroplasty
The use of titanium cages for posterior lumbar interbody fusion (PLIF) has gained popularity because it offers the advantages of anterior column support and stabilization. However, cage migration into the spinal canal may have severe or disastrous consequences. Here, the authors report an unexpected case of posterior migration of fusion cages after screw removal in a patient that underwent PLIF 12 months previously. Removal of the offending cages through revision extraforaminal lumbar interbody fusion (ELIF) with percutaneous screw fixation successfully managed this complication. As far as the authors' knowledge, this is the first case report to describe this sort of complication, and cautions that care must be taken to prevent cage migration.
AIM: To evaluate the efficacy and safety of sodium hyaluronate solution (SH) in endoscopic submucosal dissection (ESD) of gastric neoplasms.
METHODS: A prospective multicenter randomized, double blind, controlled trial was designed and utilized in this study. A total of 76 patients with 5-20 mm sized gastric neoplasms were enrolled at three academic hospitals in South Korea from June 2011 to October 2011. Patients were randomly assigned to the 0.4% sodium hyaluronate or control groups. All lesions underwent endoscopic ESD. ESD was performed with 0.4%SH and normal saline (NS) solution for submucosal injection. Efficacy was assessed using en bloc resection and the number of additional injections. Secondary evaluation variables were the volume of injection material, steepness of mucosal elevation, bleeding rate, procedural time and operator satisfaction. Finally, the safety was assessed by analyzing adverse events during the study.
RESULTS: The usefulness rate in the 0.4%SH group and the controlled group had statistically significant difference under intention to treat (ITT) analysis (90.91% vs 61.11% P = 0.0041). Under per protocol (PP), the usefulness rate is statistically significant different (93.10% vs 61.76%, P = 0.0036). The difference in volume of the solution injected between 0.4%SH group and the controlled group and NS group was also statistically significant under intention to treat and per protocol analysis (ITT: 0.03 ± 0.02 mL vs 0.06 ± 0.03 mL, P = 0.0003, PP: 0.03 ± 0.02 mL vs 0.06 ± 0.03 mL, P = 0.0004). Satisfaction above the grade good was significantly higher in the SH group under intention to treat and per protocol analysis (ITT: 90.91% vs 61.11%, P = 0.0041, PP = 93.11% vs 61.77%, P = 0.0022). Adverse events above grade 3 were not noticed in either group. All adverse events were treated and were judged as not associated with the submucosal injection solutions.
CONCLUSION: 0.4%SH solution is a safe and effective agent that doesn’t cause any significant adverse events and is useful for submucosal injection during ESD.
Sodium hyaluronate; Endoscopic submucosal dissection; Gastric neoplasm; Endoscopic mucosal resection
Rhabdomyolysis is a rare but potentially life-threatening disorder caused by the release of injured skeletal muscle components into the circulation. The authors report a case of severe head injury, in which a hyperosmolar state and continuous seizure complicated by severe rhabdomyolysis and acute renal failure evolved during the course of treatment resulted in a fatal outcome despite intensive supportive treatment. Our bitter experience suggests that rhabdomyolysis should be born in mind in patients with severe head injury who may develop hyperosmolar state and continuous seizure.
Rhabdomyolysis; Head injury
Pneumocephalus is a condition characterized by the presence of air in the cranium, and it is mainly caused by trauma or a neurosurgical procedure. In the absence of head trauma or a neurosurgical procedure, meningitis is an extremely rare cause of pneumocephalus. Here, the authors present a rare case of spontaneous pneumocephalus caused by pneumococcal meningitis, in which simple lateral radiography and computed tomography (CT) findings of the skull suggested the diagnosis. Cerebrospinal fluid analysis showed bacterial meningitis which later revealed streptococcus pneumonia. The patient was treated with antibiotics and responded remarkably well. Repeat CT performed after 2 weeks of treatment showed complete resolution of the intracranial gas. Here, the authors report an unusual case of a pneumocephalus caused by meningitis in the absence of head trauma or a neurosurgical procedure.
Although posterior lumbar interbody fusion (PLIF) is a widely accepted procedure, perioperative and postoperative complications are still encountered. In particular, cage migration can result in severe sequelae, and revision surgery is technically demanded. Here, we report a rare case of repeated migration of a fusion cage after PLIF. To the best of our knowledge, no report has been previously issued on repeated migration of a fusion cage after PLIF. The authors discuss the radiological and clinical findings of this unusual complication with a review of the literature.
Cage; Migration; Complication
Burr hole drainage has been widely used to treat chronic subdural hematomas (SDH), and most of them are easily treated by simple trephination and drainage. However, various complications, such as, hematoma recurrence, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand due to cerebro-cranial disproportion may develop after chronic SDH drainage. Among them, intracerebral hemorrhage after evacuation of a recurrent chronic SDH is very rare. Here, we report a fatal case of delayed intracerebral hemorrhage caused by coagulopathy following evacuation of a chronic SDH. Possible pathogenic mechanisms of this unfavorable complication are discussed and a review of pertinent literature is included.
Chronic subdural hematoma; Complication; Intracerebral hemorrhage
The purpose of this study was to compare the results of three types of short segment screw fixation for thoracolumbar burst fracture accompanying osteopenia.
The records of 70 patients who underwent short segment screw fixation for a thoracolumbar burst fracture accompanying osteopenia (-2.5< mean T score by bone mineral densitometry <-1.0) from January 2005 to January 2008 were reviewed. Patients were divided into three groups based on whether or not bone fusion and bone cement augmentation procedure 1) Group I (n=26) : short segment fixation with posterolateral bone fusion; 2) Group II (n=23) : bone cement augmented short segment fixation with posterolateral bone fusion; 3) Group III (n=21) : bone cement augmented, short segment percutaneous screw fixation without bone fusion. Clinical outcomes were assessed using a visual analogue scale and modified MacNab's criteria. Radiological findings, including kyphotic angle and vertebral height, and procedure-related complications, such as screw loosening or pull-out, were analyzed.
No significant difference in radiographic or clinical outcomes was noted between patients managed using the three different techniques at last follow up. However, Group I showed more correction loss of kyphotic deformities and vertebral height loss at final follow-up, and Group I had higher screw loosening and implant failure rates than Group II or III.
Bone cement augmented procedure can be an efficient and safe surgical techniques in terms of achieving better outcomes with minimal complications for thoracolumbar burst fracture accompanying osteopenia.
Burst fracture; Osteopenia; Fusion
Non-Hodgkin's lymphoma rarely originates from bone, and even more infrequently from a vertebral body. Lymphoblastic lymphoma is a rare type of non-Hodgkin's lymphoma, and results from an abnormality in adaptive immune cells. A 27-year-old man presented with a two-month history of night sweats, weight loss, and severe back pain. Radiological studies demonstrated an osteolytic lesion compressing the subarachnoid space at the T11 level. Posterolateral fusion with decompression was performed and a pathologic examination confirmed lymphoblastic lymphoma of the B-cell precursor type. To our knowledge, this is the first report of solitary lymphoblastic lymphoma from B-cell precursors in of the thoracic spine. Herein, we discuss the presenting symptoms and the management of this rare case of lymphoblastic lymphoma.
Lymphoblastic lymphoma; Spine
Isolated tuberculosis of the coccyx is extremely rare. A 35-year-old man presented with a 3-month history of coccygeal and gluteal pain. Computed tomography and magnetic resonance imaging revealed osseous destruction and a large enhancing mass involving the coccyx with anterior and posterior extension. Pathologic examination of the surgical specimen revealed necrosis, chronic granulomatous inflammation, and multinucleated giant cells consistent with tuberculosis. This case highlights the importance of considering tuberculosis as a diagnosis even though unusual sites are involved.