A Schmorl's node is defined as a simple endplate intravertebral herniation resulting from trauma or idiopathic causes. Although Schmorl's nodes have been considered clinically insignificant, they might indicate an active symptomatic process or cause serious complications. In this study, we report an interesting case of complete separation of a vertebral body caused by an untreated Schmorl's node accompanying severe osteoporosis. To our knowledge, this is the first clinical report in the published literature to evaluate the complete separation of a vertebral body associated with a Schmorl's node.
Schmorl's node; Osteoporosis; Fracture
The aim of this prospective study was to evaluate the efficacy of bone cement-augmented percutaneous short segment fixation for treating Kummell's disease accompanied by severe osteoporosis.
From 2009 to 2013, ten patients with single-level Kummell's disease accompanied by severe osteoporosis were enrolled in this study. After postural reduction for 1-2 days, bone cement-augmented percutaneous short segment fixation was performed at one level above, one level below, and at the collapsed vertebra. Clinical results, radiological parameters, and related complications were assessed preoperatively and at 1 month and 12 months after surgery.
Prior to surgery, the mean pain score on the visual analogue scale was 8.5±1.5. One month after the procedure, this score improved to 2.2±2.0 and the improvement was maintained at 12 months after surgery. The mean preoperative vertebral height loss was 48.2±10.5%, and the surgical procedure reduced this loss to 22.5±12.4%. In spite of some recurrent height loss, significant improvement was achieved at 12 months after surgery compared to preoperative values. The kyphotic angle improved significantly from 22.4±4.9° before the procedure to 10.1±3.8° after surgery and the improved angle was maintained at 12 months after surgery despite a slight correction loss. No patient sustained adjacent fractures after bone cement-augmented percutaneous short segment fixation during the follow-up period. Asymptomatic cement leakage into the paravertebral area was observed in one patient, but no major complications were seen.
Bone cement-augmented percutaneous short segment fixation can be an effective and safe procedure for Kummell's disease.
Osteonecrosis; Screw; Cement
Unilateral pedicle stress fracture accompanying spondylolytic spondylolisthesis is rare even in the elderly. Most are associated with major trauma, previous spine surgery, or stress-related activity. Here, the authors describe an unique case of unilateral pedicle fracture associated with spondylolytic spondylolisthesis at the L5 level, which was successfully treated by posterior lumbar interbody fusion with screw fixation at the L5-S1 level. As far as the authors' knowledge, no such case has been previously reported in the literature. The pathophysiological mechanism of this uncommon entity is discussed and a review of relevant literature is included.
Pedicle; Fracture; Spondylolysis
Intraosseous pneumatocyst is a benign, gas-filled, cystic lesion, and is commonly encountered in iliac bone or sacrum. Other locations of this lesion following trauma are rare, and only a handful of isolated cases have been reported. The pathogenesis and etiologies of this uncommon entity are various and it can present a diagnostic challenge. Only four previous cases have described the natural course of intravertebral pneumatocysts. Here, the authors report a rare case of traumatic pneumatocyst, which resolved rapidly without further complication. Possible pathogenic mechanisms are discussed and reviews of literatures are included.
Pneumatocyst; Cervical; Trauma
Dorsal extradural migration of extruded disc material is clinically uncommon. We report a rare case of posterior epidural migration of an extruded lumbar disc mimicking a facet cyst. A 32-year-old man was admitted to our institute with a 2-week history of severe low back pain and radiating pain in the left leg. The magnetic resonance (MR) images revealed a dorsally located, left-sided extradural cystic mass at the L2-3 level. The initial diagnosis was an epidural facet cyst because of the high signal intensity on MR images and its location adjacent to the facet joint. Intraoperatively, an encapsulated mass of soft tissue adherent to the dural sac was observed and excised. The pathological diagnosis was degenerated disc material. After surgery, the patient experienced complete relief from leg pain.
Disc; Cyst; Facet
Epidural neuroplasty is found to be effective in removing fibrous tissue occurring in the epidural space for various reasons. We report a case of cerebellar infarction caused by epidural abscess after epidural neuroplasty. To the best of our knowledge, this is the first report of cerebellar infarction developed as a result of epidural abscess accompanying bacterial meningitis after epidural neuroplasty. We also discuss the etiology, pathogenesis, and prognosis of this rare pathologic entity.
Neuroplasty; Epidural abscess; Infarction
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