Medicolegal corner (spine): Contraindicated use of DuraSeal in anterior cervical spine led to quadriplegia

Background: The package insert for DuraSeal (Integra LifeSciences, Princeton NJ) states it is Contraindicated for use in the anterior cervical spine (confined space): “Do not apply DuraSeal® hydrogel to confined bony structures where nerves are present since neural compression may result due to hydrogel swelling (…up to 12% of its size in any direction).” Further, it should not be used to treat massive unrepaired cerebrospinal fluid (CSF) leaks in any location; “…(it) is indicated as an adjunct to sutured dural repair during spine surgery to provide watertight closure,” but it is not to be used “...for a gap greater than 2 mm….” Methods: A spinal surgeon interpreted a geriatric patient’s MR as showing severe C3-C4 to C5-C6 anterior cord compression due to disc disease/spondylosis. However, he never reviewed the CT report/images that documented marked ossification of the posterior longitudinal ligament (OPLL) with multiple signs of dural penetrance. Results: The anterior C4, C5 corpectomy, and C3-C6 strut fusion/plating resulted in a massive, irreparable cerebrospinal fluid (CSF) leak. Despite the contraindications, the surgeon mistakenly applied DuraSeal which caused the patient’s postoperative quadriplegia (i.e., as documented on the delayed postoperative MR scan). Following a secondary surgery consisting of a laminectomy/posterior fusion, the patient was still quadriplegic. Further, as he requested no postoperative MR scan and performed no subsequent corrective surgery (i.e., anterior removal of DuraSeal), the patient remained permanently quadriplegic. Conclusion: DuraSeal is directly contraindicated for use in the anterior cervical spine, with/without a CSF leak. Here, utilizing DuraSeal for anterior cervical OPLL surgery resulted in permanent quadriplegia, and was below the standard of care.

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Cervical spinal disease

Oxford Textbook of Neurological Surgery ◽

10.1093/med/9780198746706.003.0060 ◽

2019 ◽

pp. 697-710

Author(s):

Navin Furtado ◽

Georgios Tsermoulas ◽

Adikarige Haritha Dulanka Silva

Keyword(s):

Cervical Spine ◽

Natural History ◽

Neck Pain ◽

Diffuse Idiopathic Skeletal Hyperostosis ◽

Posterior Longitudinal Ligament ◽

Surgical Approaches ◽

Systemic Diseases ◽

Spinal Disease ◽

Disc Disease ◽

Degenerative Cervical Myelopathy

Degenerative cervical spinal disease refers to neck pain, myelopathy, and/or radiculopathy. It is a common problem with increased prevalence above the age of 55 years. Understanding the natural history and pathophysiology is crucial in selecting patients for surgery. The degenerative pathological processes that can occur in the cervical spine include degenerative disc disease, degenerative cervical myelopathy, ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF). There are also systemic diseases affecting the cervical spine and these include rheumatoid disease, sero-negative spondyloarthropathies and diffuse idiopathic skeletal hyperostosis (DISH). This section describes the pathology of cervical spinal disease, the clinical management, surgical approaches, and controversies in the field.

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Case report of ervical myelopathy due to ossification of the posterior longitudinal ligament in association with flavum ligament ossification: MRI and CT appearance

Acta medica Lituanica ◽

10.6001/actamedica.v20i2.2696 ◽

2013 ◽

Vol 20 (2) ◽

pp. 79-83

Author(s):

Monique Boukobza ◽

Jurgita Ušinskienė ◽

Simona Letautienė

Keyword(s):

Spinal Cord ◽

Cervical Spine ◽

Double Layer ◽

Spinal Canal ◽

Mixed Type ◽

Cervical Spinal Cord ◽

Asian Population ◽

Posterior Longitudinal Ligament ◽

Cord Compression ◽

Cord Injury

Background. Our objective is to analyze the cervical spinal cord damage and spinal canal stenosis due to OPLL which usually affects the cervical spine and leads to progressive myelopathy in 50–60s in Asian population; to demonstrate the mixed type OPLL and to show OPLL specific dural penetration signs: “double- layer” and “C-sign” on imaging. Materials and methods. Subacute cord compression developed over a 3-month period in a 43-year-old Japanese patient. Severe spinal canal narrowing was related to the mixed type OPLL at C3–C4 through C6–C7 associated to flavum ligament ossification at T3–T4. Lateral radiograph of the cervical spine showed intraspinal ossification, CT demonstrated specific dural penetration signs, and MRI disclosed spinal cord compression. Laminectomy at C3–C7 was performed and decompression of the spinal cord was confirmed by postoperative MRI. Conclusions. Absolute cervical stenosis and association with other diseases (like calcification of flavum ligament) predispose the patient to develop more severe deficit earlier in the clinical course. Specific CT signs, “double-layer” and “C-sign”, show dural involvement. MRI is a very useful modality to identify the precise level and extent of the spinal cord injury. OPLL must be included in the differential diagnosis of subacute cervical myelopathy.

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Clinical Correlations of Cervical Myelopathy and the Hoffmann Sign

Journal of Neurosurgery Spine ◽

10.3171/spi/2008/9/9/237 ◽

2008 ◽

Vol 9 (3) ◽

pp. 237-242 ◽

Cited By ~ 35

Author(s):

John K. Houten ◽

Louis A. Noce

Keyword(s):

Cervical Spine ◽

Cervical Myelopathy ◽

Imaging Study ◽

Posterior Longitudinal Ligament ◽

Cord Compression ◽

Neurological Deficits ◽

Positive Sign ◽

Cervical Cord ◽

Babinski Sign ◽

Tertiary Center

Object The Hoffmann sign is commonly used in clinical practice to assess cervical spine disease. It is whether the sign correlates with the severity of myelopathy, and no consensus exists regarding the significance a positive sign in asymptomatic individuals. Methods In a retrospective review of cervical spine surgeries for myelopathy due to cervical spondylosis, fication of the posterior longitudinal ligament, or disc herniation performed at a tertiary center, the authors data on the presence of hyperreflexia, the Hoffmann and Babinski signs, and modified Japanese Orthopaedic ciation (mJOA) scale scores. Then, in a prospective evaluation, new patients with lumbar spine complaints examined for the presence of a Hoffmann sign, and, if present, a cervical MR imaging study was assessed for compression. Results Of the 225 surgically treated patients, a Hoffmann sign occurred in 68%, hyperreflexia in 60%, and Babinski sign in 33%. In patients with milder disability (mJOA Scores 14–16), the Hoffmann sign was present 46%, whereas a Babinski sign occurred in 10%; in those with severe myelopathy and mJOA scores of ≤ 10, Hoffmann sign was present in 81% and the Babinski sign in 83%. Of 290 patients presenting exclusively with bar spine–related complaints, 36 (12%) had a positive Hoffmann sign. Magnetic resonance imaging demonstrated spinal cord compression in 91% when the sign was present bilaterally and 50% when positive unilaterally. Conclusions In patients surgically treated for cervical myelopathy, the Hoffmann sign is more prevalent more likely to be seen in individuals with less severe neurological deficits than the Babinski sign. In patients lumbar symptoms, a bilateral Hoffmann sign was a highly sensitive marker for occult cervical cord compression, whereas a unilateral Hoffmann sign correlated with similar disease in about one-half of patients.

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Intracranial Hypotension Headache Caused by a Massive Cerebrospinal Fluid Leak Successfully Treated with a Targeted C2 Epidural Blood Patch: A Case Report

January 2018 - Pain Physician ◽

10.36076/ppj.2013/16/399 ◽

2013 ◽

Vol 4;16 (4;7) ◽

pp. 399-404

Author(s):

Xiaobin Yi

Keyword(s):

Cerebrospinal Fluid ◽

Cervical Spine ◽

Intracranial Hypotension ◽

Epidural Blood Patch ◽

Steroid Injection ◽

Epidural Steroid Injection ◽

Csf Leak ◽

Blood Patch ◽

High Cervical ◽

Epidural Steroid

Cervical epidural steroid injections, administered either intralaminarly or transforaminally, are common injection therapies used in many interventional pain management practices to treat cervicalgia or cervicobrachial pain secondary to spondylosis or intervertebral disc displacement of the cervical spine. Among the risks associated with these procedures are the risk for inadvertent dural puncture and the development of positional headache from intracranial hypotension. We report the case of a 31-year-old woman with a history of migraine and cervicalgia from cervical spine spondylosis and cervical disc degenerative disease that developed an intractable orthostatic headache accompanied by nausea and vomiting after a therapeutic high cervical intralaminar epidural steroid injection was administered directly to the C1-C2 spinal level. Although the initial magnetic resonance imaging of the brain was unremarkable, a computed tomography myelogram study revealed a massive cerebrospinal fluid (CSF) leak from the cervical spine. Repeated cervical epidural blood patches using a catheter targeted to the high cervical spine (C2) to inject 15 mL of autologous blood was required to totally alleviate her symptoms after she failed conservative therapy. Determining the optimal location or approach to administer an epidural blood patch can be a challenge depending on the location of the CSF leak. Our case demonstrates that targeted cervical epidural blood patch placement using an easily manipulated catheter under fluoroscopic guidance is a safe and effective approach to treat a massive CSF leak in the high cervical spine region caused by prior therapeutic cervical spine epidural steroid injection. Key words: Cervical epidural blood patch, intracranial hypotension, intracranial hypotension headache, spinal headache, orthostatic headache, epidural steroid injection, cerebrospinal fluid leak, post dural headache

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Analysis of Hypertrophy of the Posterior Longitudinal Ligament of the Cervical Spine, on the Basis of Clinical and Experimental Studies

Neurosurgery ◽

10.1097/00006123-200111000-00013 ◽

2001 ◽

Vol 49 (5) ◽

pp. 1091-1098 ◽

Cited By ~ 1

Author(s):

Junichi Mizuno ◽

Hiroshi Nakagawa ◽

Yoshio Hashizume

Keyword(s):

Magnetic Resonance Imaging ◽

Cervical Spine ◽

Magnetic Resonance ◽

Anterior Approach ◽

Japanese Orthopaedic Association ◽

Posterior Longitudinal Ligament ◽

Cord Compression ◽

Intervertebral Discs ◽

Decompression Surgery ◽

Resonance Imaging

ABSTRACT OBJECTIVE The goal of this study was to elucidate the pathophysiological features and treatment of hypertrophy of the posterior longitudinal ligament (HPLL) of the cervical spine. HPLL is defined as a pathological thickening of the posterior longitudinal ligament (PLL), causing spinal cord compression. Incomplete decompression via removal of only coexisting herniated intervertebral discs or spondylotic spurs might be performed, resulting in unsatisfactory surgical outcomes, when the PLL becomes abnormally thickened and contributes to myelopathy. METHODS Patients with HPLL who underwent cervical decompression surgery were selected. Medical records and radiographs were retrospectively reviewed, to obtain data on the pre- and postoperative clinical conditions of the patients. Autopsy cases with HPLL proven by low-energy x-ray examinations were chosen for assessment of the pathological characteristics. RESULTS Seventeen men and three women with HPLL underwent treatment via an anterior approach, with direct removal of HPLL. Nineteen patients developed myelopathy, whereas one patient developed radiculopathy. Radiologically, all HPLL cases exhibited coexisting herniated intervertebral discs and 10 exhibited small segmental ossifications of the PLL. Magnetic resonance imaging or computed tomographic myelography revealed extensive cord compression across the vertebral endplate level. The average preoperative Benzel modified Japanese Orthopaedic Association score was 10.8, and the average postoperative score was 13.2. Histological examinations revealed thickening of the PLL with proliferation of chondrocytes, together with various degenerative changes. CONCLUSION Patients with HPLL can benefit from an anterior approach with direct removal of the HPLL and associated herniated intervertebral discs or ossification of the PLL. Cervical polytomography, computed tomography, and magnetic resonance imaging are useful in establishing a diagnosis of HPLL.

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Biomechanical Effects on Cervical Spinal Cord and Nerve Root Following Laminoplasty for Ossification of the Posterior Longitudinal Ligament in the Cervical Spine: A Comparison Between Open-Door and Double-Door Laminoplasty Using Finite Element Analysis

Journal of Biomechanical Engineering ◽

10.1115/1.4039826 ◽

2018 ◽

Vol 140 (7) ◽

Cited By ~ 2

Author(s):

Batbayar Khuyagbaatar ◽

Kyungsoo Kim ◽

Tserenchimed Purevsuren ◽

Sang-Hun Lee ◽

Yoon Hyuk Kim

Keyword(s):

Spinal Cord ◽

Finite Element ◽

Cervical Spine ◽

Nerve Root ◽

Cervical Spinal Cord ◽

Posterior Longitudinal Ligament ◽

Cord Compression ◽

Open Door ◽

Nerve Roots ◽

Posterior Shift

Many clinical case series have reported the predisposing factors for C5 palsy and have presented comparisons of the two types of laminoplasty. However, there have been no biomechanical studies focusing on cervical spinal cord and nerve root following laminoplasty. The purpose of this study is to investigate biomechanical changes in the spinal cord and nerve roots following the two most common types of laminoplasty, open-door and double-door laminoplasty, for cervical ossification of the posterior longitudinal ligament (OPLL). A finite element (FE) model of the cervical spine and spinal cord with nerve root complex structures was developed. Stress changes in the spinal cord and nerve roots, posterior shift of the spinal cord, and displacement of the cervical nerve roots were analyzed with two types of cervical laminoplasty models for variations in the degree of canal occupying ratio and shape of the OPLL. The shape and degree of spinal cord compression caused by the OPLL had more influence on the changes in stress, posterior shift of the spinal cord, and displacement of the nerve root than the type of laminoplasty. The lateral-type OPLL resulted in imbalanced stress on the nerve roots and the highest nerve root displacement. Type of laminoplasty and shape and degree of spinal cord compression caused by OPLL were found to influence the changes in stress and posterior displacement of the cervical spinal cord and nerve roots. Lateral-type OPLL might contribute to the development of C5 palsy due to the imbalanced stress and tension on the nerve roots after laminoplasty.

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Abnormal [18F]FDG PET/MRI findings in paraspinal structures of patients with suspected cerebrospinal fluid leak

Scientific Reports ◽

10.1038/s41598-021-95056-w ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Daehyun Yoon ◽

Peter William Cipriano ◽

Ryan Penticuff ◽

Jessa Ballesteros Castillo ◽

Yingding Xu ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Fdg Pet ◽

Cerebrospinal Fluid Leak ◽

Standard Of Care ◽

Whole Body ◽

Csf Leak ◽

Healthy Controls ◽

Mri Findings ◽

Standardized Uptake Values ◽

18F Fdg

AbstractA combination of magnetic resonance imaging (MRI), computed tomography (CT), and radionuclide cisternography are typically used to locate a cerebrospinal fluid (CSF) leak. However, the site of leakage cannot be determined, making treatment more difficult. Therefore, more sensitive imaging tools are needed. A whole-body [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/MRI was conducted on six patients with suspected CSF leak and the resulting images were reviewed in comparison with those from six healthy controls. Paraspinal regions of focally increased uptake of [18F]FDG were quantified using maximum standardized uptake values (SUVmax) and compared to the SUVmax of corresponding regions in the healthy controls. All six patients with suspected CSF leak showed paraspinal regions of significantly greater [18F]FDG uptake compared to the corresponding areas in controls (P < 0.05). Two patients treated with local injections (epidural blood patches and/or epidural fibrin patches) on the site of abnormal PET/MRI findings reported temporary but significant improvement in symptoms. Our results suggest [18F]FDG PET/MRI is sensitive to abnormalities potentially due to suspected CSF leak, which are not necessarily visible on conventional MRI alone or by the standard-of-care imaging methods.

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