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1.  Giant Chordoma of the Upper Thoracic Spine with Mediastinal Involvement: A Surgical Challenge 
Asian Spine Journal  2014;8(3):353-356.
Thoracic chordomas are very rare malignant tumours originating from notochordal remnants. These tumours develop within a vertebral body and enlarge involving the mediastinal compartment. Because of their slow-growing attitude, they become symptomatic only when they invade or compress the spinal cord and/or mediastinal organs. We present a rare case of a thoracic spine chordoma presenting with increasing paraparesis with a huge mediastinal component which was surgically debulked to decompress the spinal cord and medistinal organs.
PMCID: PMC4068856  PMID: 24967050
Chordoma; Spine; Bone neoplasms; Mediastinum; Surgery
2.  Sciatica in a Five-Year-Old Boy 
Asian Spine Journal  2014;8(3):357-360.
The prevalence of back pain during childhood is 50%; in 22% of these cases, a specific diagnosis can be found. Osteoid osteoma is a rare benign tumor that occursonly in 20% of cases and involves the spine. The aim of this report is to explain an atypical case of lumbar osteoid osteoma with significant neurologic deficit at a very young age. A five-year-old boy was presented with refractory pain in the low back and left extremity for approximately one year. Positive clinical findings were antalgic gait, stiff lumbar spine, weak left big toe extension force and a positive straight leg rising test on the left side. Paraclinical studies revealed osteoid osteoma in the left-sided pedicle of the fifth lumbar vertebra. With surgical excision, he recovered immediately. Lumbar osteoid osteoma should be suspected as the cause of low back pain or sciatalgia in any young patient.
PMCID: PMC4068857  PMID: 24967051
Osteoid osteoma; Children; Lumbar spine; Surgery
3.  Whole Spontaneous Spinal Epidural Hematoma 
Asian Spine Journal  2014;8(3):361-364.
A 26-year-old male who had no underlying disease, including coagulopathy, underwent thoracotomy and bleeding control due to hemothorax. On the fifth postoperative day, paralysis of both lower limbs occurred. Urgent spine magnetic resonance imaging showed a massive anterior spinal epidural hematoma from C2 to L1 level with different signal intensities, which was suspected to be staged hemorrhage. Hematoma evacuation with decompressive laminectomy was performed. The patient's neurologic deterioration was recovered immediately, and he was discharged without neurological deficits. A drug history of naftazone, which could induce a drug-induced platelet dysfunction, was revealed retrospectively. To our knowledge, this is the first report of whole spontaneous spinal epidural hematoma in a young patient, with a history of hemorrhoid medication.
PMCID: PMC4068858  PMID: 24967052
Epidural hematoma; Naftazone; Spinal hematoma
4.  Arteriovenous Fistula of the Filum Terminale Misdiagnosed and Previously Operated as Lower Lumbar Degenerative Disease 
Asian Spine Journal  2014;8(3):365-370.
Filum terminale arteriovenous fistula (FTAVF) presenting as a cause of failed back surgery syndrome is a rare entity. We report a 48-year-old male patient who presented with clinical features of a conus medullaris/cauda equina lesion. He had upper and lower motor neuron signs in both the lower limbs with autonomic dysfunction. The patient was misdiagnosed and was operated twice earlier for lumbar canal stenosis and disc prolapse. After reviewing his clinical and radiological findings a diagnosis of FTAVF was made. He underwent surgery and there was a significant improvement in his neurological functions. We discuss the case and review the literature on FTAVF's.
PMCID: PMC4068859  PMID: 24967053
Failed back surgery syndrome; Filum terminale arteriovenous fistula
5.  Intraoperative Life Threatening Acute Lung Injury Due to Multiple Septic Pulmonary Emboli during Transpedicular Biopsy and Kyphoplasty 
Asian Spine Journal  2014;8(2):197-201.
A 55-year-old gentleman was presented to our clinic two months after a trivial fall with persistent pain, gibbus at the thoraco-lumbar junction and intact neurology. Radiological and laboratory investigations suggested osteoporotic fracture or metastasis. Due to unremitting pain, a plan was made to do transpedicular biopsy and kyphoplasty. Biopsy needles were inserted into both pedicles and an attempt at aspiration was made. Since the aspirate was dry, 5 to 6 mL of saline was injected through one needle and an attempt at aspiration was made through the other. Three-millilitres of sero-sanguineous material mixed with pus came out and kyphoplasty was deferred. After extubation, the patient developed severe bronchospasm and was transferred to the intensive care unit. Investigations confirmed multiple septic pulmonary emboli and the patient recovered completely after treatment. This report highlights that confirmation of the diagnosis is essential before performing any procedure that increases the intravertebral pressure and the place should have appropriate facilities to manage complications.
PMCID: PMC3996345  PMID: 24761203
Transpedicular biopsy; Kyphoplasty; Septic pulmonary emboli; Acute lung injury; Infective spondylitis
6.  Cervical Perineural Cyst Masquerading as a Cervical Spinal Tumor 
Asian Spine Journal  2014;8(2):202-205.
Tarlov (perineural) cysts of the nerve roots are common and usually incidental findings during magnetic resonance imaging of the lumbosacral spine. There are only a few case reports where cervical symptomatic perineural cysts have been described in the literature. We report such a case where a high cervical perineural cyst was masquerading as a cervical spinal tumor.
PMCID: PMC3996346  PMID: 24761204
Tarlov's cysts; Perineural cyst; Spinal cyst; spine; Cervical spine
7.  Literature Review and Clinical Presentation of Cervical Spondylitis Due to Salmonella Enteritidis in Immunocompetent 
Asian Spine Journal  2014;8(2):206-210.
A 48-year-old woman was presented to our clinic with some fever and neck pains for about one month. Based on the symptoms and results of image, an empirical diagnosis of tuberculous cervical spondylitis was made. The pain was not significantly decreased after anti-tuberculosis therapy. And, 3 weeks later, she was re-admitted to our hospital for the unbearable pain. An exploration of the C4/5 by the anterior medial approach was recommended to evaluate the germ and debridement. Bacteriological tests showed that the pathogen was Salmonella Enteritidis. The pain was relieved significantly after operation and sensitive antibiotic treatments. Infections with Salmonella Typhi or Salmonella Paratyphi have been well-documented, while there are few reports of cervical spondylitis caused by Salmonella Enteritidis. We reported a case of a healthy woman with whom pyogenic cervical spondylitis of Salmonella Enteritidis was corroborated and treated and reviewed according to previous reports about spondylitis caused by Salmonella Enteritidis in the literature.
PMCID: PMC3996347  PMID: 24761205
Salmonella Enteritidis; Cervical vertebrae; Spondylitis; Immunocompetent
8.  Symptomatic Solitary Osteochondroma of the Subaxial Cervical Spine in a 52-Year-Old Patient 
Asian Spine Journal  2014;8(1):84-88.
Osteochondromas are the most common benign tumors of the bone. They mostly arise from the appendicular skeleton and present clinically in the second or third decade of life. Ostechondromas arising from the subaxial cervical spine and presenting after the 5th decade of life are extremely rare. We report a 52-year-old male patient who presented with numbness and subjective weakness of left upper and lower limbs and neck pain, and had lobulated bony hard fixed swelling in the right lower cervical paraspinal region. Radiological images revealed a bony swelling arising from C4 and C5 lamina with a cartilaginous cap and intraspinal extension. Excision biopsy with stabilisation of the spine was performed. Histopathalogical examination of the specimen confirmed the diagnosis of osteochondroma. We conclude surgical excision of such rare tumors, including the cartilaginous cap as well as the intraspinal component can reliably produce a good clinical outcome.
PMCID: PMC3939376  PMID: 24596611
Osteochondroma; Cervical spine; Elderly
9.  Robotic-Assisted Device in Posterior Spinal Fusion for a High Risk Thoraculombar Fracture in Ankylosing Spondylitis 
Asian Spine Journal  2014;8(1):64-68.
Fractures in ankylosing spondylitis (AS) are often difficult to treat and surgical treatment may be fraught with complications. We describe the use of a robotic-assisted device in the surgical treatment of an unstable L1 fracture in an elderly patient with chronic lymphocytic leukemia and AS. The postoperative course was uneventful and the patient was discharged after 3 days. The use of a robotic-assisted device in spine surgery is particularly indicated in difficult high risk cases.
PMCID: PMC3939371  PMID: 24596607
Ankylosing spondylitis; Posterior spine fusion; Robotic assisted
10.  Ordinary Disc Herniation Changing into Posterior Epidural Migration of Lumbar Disc Fragments Confirmed by Magnetic Resonance Imaging: A Case Report of a Successful Endoscopic Treatment 
Asian Spine Journal  2014;8(1):69-73.
The posterior epidural migration of lumbar disc fragments is an extremely rare event with an unknown pathogenesis. To the best of our knowledge, there are no previously reported cases of a change of ordinary disc herniation into the posterior epidural migration of lumbar disc fragments as confirmed by magnetic resonance imaging (MRI). A 26-year-old male presented to our department complaining of left buttock and lateral leg pain. An ordinary herniation was shown in the first MRI. The patient's unilateral symptoms changed into bilateral symptoms while awaiting admission to the hospital. Posterior migrated lumbar disc fragments were shown in the second MRI taken at the time of admission. Microendoscopic surgery providing a detailed observation of the region was performed. Our case indicates that an ordinary lumbar disc herniation may lead to the posterior migration of lumbar disc fragments, and that microendoscopic surgery may provide a treatment.
PMCID: PMC3939372  PMID: 24596608
Lumbar; Hernia; Endoscopy
11.  Cervical Symmetric Dumbbell Ganglioneuromas Causing Severe Paresis 
Asian Spine Journal  2014;8(1):74-78.
We report an extremely rare case with bilateral and symmetric dumbbell ganglioneuromas of the cervical spine in an elderly patient. A 72-year-old man came by ambulance to our hospital due to progressive incomplete paraplegia. Magnetic resonance imaging demonstrated bilateral symmetric dumbbell tumors at the C1/2 level. We performed total resection of the intracanalar tumor, aiming at complete decompression of the spinal cord, and partial and subtotal resection of foraminal outside portions. Histopathological examination of the surgical specimen indicated the tumor cells to be spindle cells with the presence of ganglion cells and no cellular pleomorphism, suggesting a diagnosis of ganglioneuroma. Although the surgery was not curative, the postoperative course was uneventful and provided a satisfactory outcome. This is the fourth known case of cervical ganglioneuromas of the bilateral symmetric dumbbell type.
PMCID: PMC3939373  PMID: 24596609
Ganglioneuroma; Symmetric; Dumbbell tumor; Cervical spine
12.  Ewing's Sarcoma of the Sacroiliac Joint Presenting as Tubercular Sacroiliitis: A Diagnostic Dilemma 
Asian Spine Journal  2014;8(1):79-83.
We report a case of Ewing's sarcoma of the sacroiliac joint in a 21-year-old male mimicking tubercular sacroiliitis, a rare entity not reported in literature. He presented with pain in the lower back radiating to the right lower limb along with constitutional symptoms of 3 months duration. On examination, the right sacroiliac joint was tender. The laboratory investigations showed anaemia, leukocytosis and raised erythrocyte sedimentation rate. On X-ray, features of right sacroiliitis were seen. This was further investigated with magnetic resonance imaging (MRI), which showed features consistent with tubercular sacroiliitis. Patient was then started on antitubercular treatment, but the improvement was not consistent. So, a contrast MRI was done, which indicated features of primary sarcoma. It was then further confirmed by a computed tomography-guided biopsy, which showed features consistent with Ewing's sarcoma of the sacroiliac joint.
PMCID: PMC3939374  PMID: 24596610
Sacroiliac joint; Sacroiliitis; Ewing sarcoma; Magnetic resonance imaging
13.  Vertebral Artery Dissection as a Cause of Cervical Radiculopathy 
Asian Spine Journal  2013;7(4):335-338.
The acute onset of neck pain and arm weakness is most commonly due to cervical radiculopathy or inflammatory brachial plexopathy. Rarely, extracranial vertebral artery dissection may cause radiculopathy in the absence of brainstem ischemia. We describe a case of vertebral artery dissection presenting as cervical radiculopathy in a previously healthy 43-year-old woman who presented with proximal left arm weakness and neck pain aggravated by movement. Cervical magnetic resonance imaging (MRI) and angiography revealed dissection of the left vertebral artery with an intramural hematoma compressing the left C5 and C6 nerve roots. Antiplatelet treatment was commenced, and full power returned after 2 months. Recognition of vertebral artery dissection on cervical MRI as a possible cause of cervical radiculopathy is important to avoid interventions within the intervertebral foramen such as surgery or nerve root sleeve injection. Treatment with antithrombotic agents is important to prevent secondary ischemic events.
PMCID: PMC3863660  PMID: 24353851
Vertebral artery dissection; Neck pain; Radiculopathy; Cervical spine
14.  Ventral Schwannoma of the Thoracolumbar Spine 
Asian Spine Journal  2013;7(4):339-344.
We report two patients with ventral schwannoma in the thoracolumbar region manifesting as low back pain with or without paraparesis. In both patients magnetic resonance imaging (MRI) revealed a heterogeneously-enhanced intradural extramedullary mass in the thoracolumbar region. The tumors were successfully removed via the posterior approach. Their histology was consistent with schwannoma. Postoperative MRI showed no evidence of a tumor in either patient. Spinal schwannomas are common benign intradural extramedullary spinal neoplasms; most arise from the dorsal- and very few from the anterior roots. A literature review revealed that ventral schwannomas, including giant tumors as in the one from case 2 in our study, affect mainly the cervical region, and most are surgically addressed via the posterior approach. Careful handling of the spinal cord is mandatory for satisfactory surgical results.
PMCID: PMC3863661  PMID: 24353852
Spinal schwannoma; Intradural lesion; Ventral schwannoma; Giant
15.  Delayed Infrarenal Aortic Pseudoaneurysm Treated by Endovascular Stent Graft in Pyogenic Spondylitis 
Asian Spine Journal  2013;7(4):345-350.
A 61-year-old male patient with pyogenic spondylodiscitis and epidural and psoas abscesses underwent posterior decompression, debridement, and instrumented fusion, followed by anterior debridement and reconstruction. Sudden onset flank pain was diagnosed 7 weeks postoperatively and was determined to be a pseudoaneurysm located at the aorta inferior to the renal artery and superior to the aortic bifurcation area. An endovascular stent graft was applied to successfully treat the pseudoaneurysm. Postoperative recovery was uneventful and infection status was stabilized.
PMCID: PMC3863662  PMID: 24353853
False aneurysm; Endovascular procedure; Stents; Spondylitis
16.  Isolated Tuberculosis of Sacrum with Monoparesis: An Atypical Presentation 
Asian Spine Journal  2013;7(4):351-354.
Tuberculosis is a major health problem in developing nations. Spine is the most commonly affected site for skeletal tuberculosis but involvement of sacrum is rare. Isolated involvement of sacrum has been reported in literature but none of the reports has mentioned its clinical presentation as monoparesis. Our case presented with symptoms of sensory and motor deficit in right lower limb. The magnetic resonance imaging spine and non contrast computerized tomogram revealed a sacral lesion but were inconclusive of diagnosis. Histological examination after computed tomography guided biopsy revealed the condition as tuberculosis. Anti tubercular treatment was started after confirmation of diagnosis and continued for 18 months. Erythrocyte sedimentation rate and C-reactive protein drooped to normal range and patient was symptom free at two-year follow up. This case report intends to emphasize that sacral tuberculosis, being itself a rare condition, may present atypically as monoparesis.
PMCID: PMC3863663  PMID: 24353854
Tuberculosis; Sacroiliac joint; Antibiotics; Monoparesis
17.  Arachnoiditis Following Caudal Epidural Injections for the Lumbo-Sacral Radicular Pain 
Asian Spine Journal  2013;7(4):355-358.
Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately.
PMCID: PMC3863664  PMID: 24353855
Caudal; Epidural; Low back pain; Sciatica; Arachnoiditis
18.  Tuberculosis Affecting Multiple Vertebral Bodies 
Asian Spine Journal  2013;7(3):222-226.
Spinal tuberculosis usually occurs in a single vertebral body or two to three adjacent vertebrae; it rarely occurs in multiple vertebral bodies. Surgery is indicated in cases that do not improve with conservative therapy, or when paralysis is evident. Two cases regarding patients with spinal tuberculosis in multiple vertebral bodies on whom surgery was performed are reported. Case 1, the patient was a 77-year-old woman with spinal tuberculosis in four vertebral bodies from the lower thoracic to the lumbar spine. As she had pronounced lower back pain, posterolateral fusion with a pedicle screw was performed. Case 2, the patient was a 29-year-old Indonesian man with spinal tuberculosis in 17 vertebral bodies of the spine who was unable to stand due to paralysis of both legs, thus posterolateral fusion with a pedicle screw was performed. Good results were obtained from tuberculostatic drug therapy and surgical instrumentation.
PMCID: PMC3779775  PMID: 24066219
Spinal tuberculosis; Instrumentation; Antitubercular agents
19.  Is Kyphoplasty Necessary? 
Asian Spine Journal  2013;7(3):218-221.
We describe four cases of delayed union in female patients with severe osteoporotic vertebral fractures, which were treated in a similar but less costly method to kyphoplasty. Due to domestic regulations, inflatable tamps for kyphoplasty are not available to every clinical orthopedists in Japan. In our clinical experience of four cases of delayed lumbar spine union between 2009 and 2010, we performed vertebroplasty using a reduction and spreading prod (Oyamada prod) for fracture reduction and a pediatric uromatic balloon (Medicon Co. Ltd.) to enlarge the pre-existing cavity. Our clinical results were comparable to those of kyphoplasty procedures performed in the USA. Our procedure could be used to overcome the shortage of medical supplies in developing countries or in countries such as Japan, which often prioritize financial concerns over providing optimal health care. Our method could serve as a useful compromise for moribund patients considering its cost efficiency.
PMCID: PMC3779774  PMID: 24066218
Osteoporotic vertebral fracture; Kyphoplasty; Pediatric uromatic balloon; Cost-efficiency
20.  Giant Invasive Sacral Schwannoma Showing Chromosomal Numerical Aberrations [-14,+18,+22] 
Asian Spine Journal  2013;7(3):227-231.
Here, we report on a rare case of a giant invasive sacral schwannoma. The patient was a 58-year-old woman who had a 6-year history of non-specific buttock pain. Histological investigation confirmed the diagnosis of cellular schwannoma. The following numerical aberration was detected using the GTG-banding method for karyotypes: 47,XX,-14,+18,+22. Cytogenetic studies of schwannomas have indicated a complete or partial loss of chromosome 22 as the most common abnormality, but this case is cytogenetically rare because of the recurrence of trisomy 22.
PMCID: PMC3779776  PMID: 24066220
Sacrum; Neurilemmoma; Cytogenetics
21.  Delayed Diagnosis of Cauda Eqina Syndrome with Perineural Cyst after Combined Spinal-Epidural Anesthesia in Hemodialysis Patient 
Asian Spine Journal  2013;7(3):232-235.
Symptomatic Tarlov (perineural cysts) are uncommon. In the following hemodialysis case, cauda equina syndrome was not detected after combined spinal-epidural anesthesia untilthe patient reported a lack of sensation in the perianal area 14 days postoperatively. She had normal motor function of her extremities. A laminectomy and cyst irrigation was performed. After the operation, her sphincter disturbance subsided gradually and her symptoms had disappeared.
PMCID: PMC3779777  PMID: 24066221
Cauda eqina syndrome; Perineural cyst; Hemodialysis
22.  Lumbar Spinal Stenosis Due to a Large Calcified Mass in the Ligamentum Flavum 
Asian Spine Journal  2013;7(3):236-241.
We describe a rare case of lumbar spinal stenosis due to a large calcified mass in the ligamentum flavum. This patient presented with a 12-month history of severe right leg pain and intermittent claudication. A computed tomography scan was performed, revealing a large calcified mass on the ligamentum flavum at the right-hand side of the lumbar spinal canal. We performed a laminotomy at the L4/5 level with resection of the calcified mass from the ligamentum flavum. The findings of various analyses suggested that the calcified mass consisted mostly of Ca3(PO4)2 and calcium phosphate intermixed with protein and water. The calcified mass in the ligamentum flavum was causing lumbar spinal stenosis. Surgical decompression by resection of the mass was effective in this patient. The calcified material was composed mainly of elements derived from calcium phosphate. Degenerative changes in the ligamentum flavum of the lumbar spine may have been involved in the production of this calcified mass.
PMCID: PMC3779778  PMID: 24066222
Spinal stenosis; Calcification; Ligamentum flavum; Calcium phosphate
23.  Gorham's Disease of Spine 
Asian Spine Journal  2013;7(3):242-247.
Gorham's disease is a rare disorder characterized by clinical and radiological disappearance of bone by proliferation of non-neoplastic vascular tissue. The disease was first reported by Jackson in 1838 in a boneless arm. The disease was then described in detail in 1955 by Gorham and Stout. Since then, about 200 cases have been reported in the literature, with only about 28 cases involving the spine. We report 2 cases of Gorham's disease involving the spine and review related literature to gain more understanding about this rare disease.
PMCID: PMC3779779  PMID: 24066223
Gorham's disease; Spine
24.  Treatment of Irreducible Bilateral Cervical Facet Fracture-Dislocation with a Prolapsed Disc Using a Prefixed Polyetheretherketone Cage and Plate System 
Asian Spine Journal  2013;7(2):111-114.
When anterior reduction fail in the surgical treatment of cervical bilateral facet fracture-dislocation with concomitant disc extrusion, it is necessary to perform a reduction using a posterior approach and then a third anterior procedure is often necessary to accomplish the anterior reconstruction. This presents difficulties for both patients and surgeons because of the need for frequent position changes (supine-prone-supine). The purpose of this study is to illustrate a modified surgical technique, which is anterior reduction and fixation with a prefixed polyetheretherketone (PEEK) cage to a buttress plate for the treatment of irreducible bilateral cervical facet fracture-dislocation with a prolapsed disc is an enhancing technique for the stability of the interbody graft than a buttress plate alone because the PEEK cage has more fixation power and reduces both the number of position changes and the length of the operation.
PMCID: PMC3669695  PMID: 23741548
Fracture dislocation; Cage; Anterior reduction
25.  V-Rod Technique for Direct Repair Surgery of Pediatric Lumbar Spondylolysis Combined with Posterior Apophyseal Ring Fracture 
Asian Spine Journal  2013;7(2):115-118.
We report a pediatric baseball player having both a fracture of the posterior ring apophysis and spondylolysis. He was presented to a primary care physician complaining of back pain and leg pain. Despite conservative treatment for 3 months, the pain did not subside. He was referred to our clinic, and surgical intervention was carried out. First, a bony fragment of the caudal L5 apophyseal ring was removed following fenestration at the L5-S interlaminal space, bilaterally: and decompression of the bilateral S1 nerve roots was confirmed. Next, pseudoarthrosis of the L5 pars was refreshed and pedicle screws were inserted bilaterally. A v-shaped rod was inserted beneath the L5 spinous process, which stabilized the pars defects. After the surgery, back pain and leg pain completely disappeared. In conclusion, the v-rod technique is appropriate for the spondylolysis direct repair surgery, especially, in case the loose lamina would have a partial laminotomy.
PMCID: PMC3669696  PMID: 23741549
Spondylolysis; V-rod technique; Apophyseal ring fracture

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