Herniation of the cauda equina into the facet joint through a pseudomeningocele: A case report and literature review

Background: Incidental durotomy is a well-known complication of spinal surgery. It can lead to persistent cerebrospinal fluid leakage resulting in significant secondary complications. Here, we present a case in which the cauda equina herniated into a pseudomeningocele that penetrated a facet joint, leading to lower extremity radiculopathy warranting surgical correction. Case Description: One year ago, a 67-year-old male underwent a partial left L4-L5 laminectomy. At surgery, a durotomy was repaired with a nylon suture and reinforced with a fat patch. He subsequently presented with severe left lower extremity radiculopathy and a partial cauda equina syndrome. On MR, the cauda equina had herniated into a pseudomeningocele that penetrated the left facet joint. Once the defect was repaired at surgery, the patient’s symptoms improved. Conclusion: It is critical to correctly repair an intraoperative durotomy to avoid further neurological deficits that may include cauda equina herniation into pseudomeningoceles penetrating facet joints.

Download Full-text

Hypertrophic Synovitis of the Facet Joint Causing Root Pain

Clinical medicine Arthritis and musculoskeletal disorders ◽

10.4137/cmamd.s411 ◽

2008 ◽

Vol 1 ◽

pp. CMAMD.S411

Author(s):

Koichi Iwatsuki ◽

Toshiki Yoshimine ◽

Masanori Aoki ◽

Kazuhiro Yoshimura

Keyword(s):

Facet Joint ◽

Cauda Equina ◽

Radicular Pain ◽

Leg Pain ◽

Facet Joints ◽

Resonance Imaging ◽

Disc Disease ◽

Articular Surfaces ◽

Synovial Cysts ◽

Magnetic Resonance Imaging Mri

Osteoarthritic changes in the facet joints are common in the presence of degenerative disc disease. Changes in the joint capsule accompany changes in the articular surfaces. Intraspinal synovial cysts that cause radicular pain, cauda equina syndrome, and myelopathy have been reported; however, there have been few reports in orthopedic or neurosurgical literature regarding hypertrophic synovitis of the facet joint presenting as an incidental para-articular mass. Here, we report a case of hypertrophic synovitis causing root pain. We describe the case of a 65-year-old man suffering from right sciatica and right leg pain in the L5 nerve-root dermatome for 1 year; magnetic resonance imaging (MRI) revealed an enhanced mass around the L4–5 facet joint. We investigated this mass pathologically. After right medial facetectomy, the symptoms resolved. Pathological investigation revealed this mass was hypertrophic synovitis. Hypertrophic synovitis of the facet joint might cause root pain.

Download Full-text

Spinal Intramedullary Metastasis of Breast Cancer

Case Reports in Medicine ◽

10.1155/2014/583282 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Recep Basaran ◽

Mehmet Tiryaki ◽

Dilek Yavuzer ◽

Mustafa Efendioglu ◽

Ece Balkuv ◽

...

Keyword(s):

Breast Cancer ◽

Lower Extremity ◽

Cancer Metastasis ◽

Breast Cancer Metastasis ◽

Neurological Deficits ◽

Histological Evaluation ◽

High Morbidity ◽

Intramedullary Metastasis ◽

Left Lower Extremity ◽

Thoracic Spinal

Objective.Breast cancer accounts for approximately one-third of all cancers in females. Approximately 8.5 % of all central nervous system metastases are located in the spinal cord. These patients have rapidly progressing neurological deficits and require immediate examination. The aim of surgery is decompression of neural tissue and histological evaluation of the tumor. In this paper, we present a case of breast cancer metastasis in thoracic spinal intramedullary area which had been partially excised and then given adjuvant radiotherapy.Case.A 43-year-old female patient with breast cancer for 8 years was admitted to our hospital with complaints of weakness in both legs. Eight years ago, she received chemotherapy and radiotherapy. On her neurological examination, she had paraparesis (left lower extremity: 2/5, right lower extremity: 3/5) and urinary incontinence. Spinal MRI revealed a gadolinium enhancing intramedullary lesion. Pathologic examination of the lesion was consistent with breast carcinoma metastasis. The patient has been taken into radiotherapy.Conclusion.Spinal intramedullary metastasis of breast cancer is an extremely rare situation, but it has a high morbidity and mortality rate. Microsurgical resection is necessary for preservation or amelioration of neurological state and also for increased life expectancy and quality.

Download Full-text

Cauda equina syndrome caused by lumbar leptomeningeal metastases from lung adenocarcinoma mimicking a schwannoma

Surgical Neurology International ◽

10.25259/sni_365_2020 ◽

2020 ◽

Vol 11 ◽

pp. 225 ◽

Cited By ~ 1

Author(s):

Giovanni Federico Nicoletti ◽

Giuseppe Emmanuele Umana ◽

Francesca Graziano ◽

Alessandro Calì ◽

Marco Fricia ◽

...

Keyword(s):

Lower Extremity ◽

Lung Adenocarcinoma ◽

Lung Carcinoma ◽

Cauda Equina ◽

Leptomeningeal Metastases ◽

Subtotal Resection ◽

Left Lower Extremity ◽

Metastatic Lung ◽

History Of ◽

Gamma Knife Stereotactic Radiosurgery

Background: Cauda equina syndromes (CESs) due to leptomeningeal metastases from primitive lung tumors are rare. Despite recent advancements in neuro-oncology and molecular biology, the prognosis for these patients remains poor. Here, we present a case in which a patient developed lumbar leptomeningeal metastases from lung carcinoma that contributed to a CES and reviewed the appropriate literature. Case Description: A 55-year-old female presented with the left lower extremity sciatica/weakness. Two years ago, a then 53-year-old female had received Gamma Knife stereotactic radiosurgery (SRS) for a cerebellopontine angle schwannoma. Recently, she underwent resection of lung carcinoma and SRS for a right hemispheric cerebellar metastasis. Now at age 55, she presented with the left lower extremity sciatica/weakness. When her new lumbar MR was interpreted as showing a L5 schwannoma, a L4-L5 laminectomy was performed at surgery, the authors encountered multifocal leptomeningeal metastases densely infiltrating the cauda equina. Although only subtotal resection/decompression of tumor was feasible, she did well for the ensuing year. The histological diagnosis confirmed the lesion to be a poorly differentiated lung adenocarcinoma. Conclusion: Patients with a history of prior metastatic lung cancer may present with spinal leptomeningeal metastases resulting in a CES.

Download Full-text

Combined Type 1 and 2 split cord malformations, kyphoscoliosis, tethered cord, and a lipoma

Surgical Neurology International ◽

10.25259/sni_331_2020 ◽

2020 ◽

Vol 11 ◽

pp. 172

Author(s):

Turki Elarjani ◽

Sami Khairy ◽

Wael Alshaya

Keyword(s):

Lower Extremity ◽

Tethered Cord ◽

Congenital Scoliosis ◽

Neurological Deficits ◽

Split Cord Malformation ◽

Older Children ◽

Left Lower Extremity ◽

Intradural Lipoma ◽

Membranous Septum

Background: Split cord malformations (SCMs) are uncommon congenital anomalies. They can be divided into Type 1 (bony septum and two separate dural sheaths) and Type 2 (fibrous septum and a single dural sheath).[1,2,4] Rarely,SCM can be associated with orthopedic anomalies (mostly seen in older children), such as scoliosis, followed by kyphosis, and/or both.[1-3] Conversely, patients with congenital scoliosis have 40% risk of congenital underlying neural deformities, with 16.3% attributed to SCM.[1,4] Those with thoracic or lumbosacral SCM may have congenital tethering lesions, predominantly consisting of intradural lipomas.[3,4] Surgery is optimally performed in two stages: first, removal of the spinal septum and untethering of the cord, and second, correction of the kyphosis, scoliosis, and/or both.[1-5] Case Description: In this video, a 44-year-old female initially presented after having progressively developed kyphoscoliosis since childhood. Three months before presentation, she had developed increased left lower extremity pain with hypoesthesia followed 1 month later by the onset of the left lower extremity monoplegia (0/5). The computed tomography and magnetic resonance imaging studies revealed a SCM at the L3 level with bony and membranous septum, accompanied by an intradural lipoma, and tethered cord. She underwent a two- stage procedure; first, removal of the bony and membranous septum, resection of the intradural lipoma, and untethering of the cord; second, she had correction of the kyphoscoliosis. Postoperatively, although the pain and sensory deficits improved, the left lower extremity monoplegia remained. Conclusion: SCM is a rare cause of spinal deformity. If left untreated, the associated neurological deficits may progress. Treatment should include a two-staged approach; first, the bony and membranous septum should be removed followed by lipoma resection and untethering the cord with adequate cord decompression, while second, a fusion may be performed to address attendant kyphoscoliosis. Keywords: Intradural lipoma, Kyphoscoliosis, Split cord malformation, Tethered cord

Download Full-text

Effect of CT-based attenuation correction on uptake ratios in skeletal SPECT

Nuklearmedizin ◽

10.1055/s-0037-1616624 ◽

2007 ◽

Vol 46 (01) ◽

pp. 38-42 ◽

Cited By ~ 12

Author(s):

V. Schulz ◽

I. Nickel ◽

A. Nömayr ◽

A. H. Vija ◽

C. Hocke ◽

...

Keyword(s):

Vertebral Body ◽

Facet Joint ◽

One Dimension ◽

Patient Specific ◽

Data Sets ◽

Facet Joints ◽

Lumbar Vertebral Body ◽

Ct System ◽

Ct Data ◽

Attenuation Corrected

SummaryThe aim of this study was to determine the clinical relevance of compensating SPECT data for patient specific attenuation by the use of CT data simultaneously acquired with SPECT/CT when analyzing the skeletal uptake of polyphosphonates (DPD). Furthermore, the influence of misregistration between SPECT and CT data on uptake ratios was investigated. Methods: Thirty-six data sets from bone SPECTs performed on a hybrid SPECT/CT system were retrospectively analyzed. Using regions of interest (ROIs), raw counts were determined in the fifth lumbar vertebral body, its facet joints, both anterior iliacal spinae, and of the whole transversal slice. ROI measurements were performed in uncorrected (NAC) and attenuation-corrected (AC) images. Furthermore, the ROI measurements were also performed in AC scans in which SPECT and CT images had been misaligned by 1 cm in one dimension beforehand (ACX, ACY, ACZ). Results: After AC, DPD uptake ratios differed significantly from the NAC values in all regions studied ranging from 32% for the left facet joint to 39% for the vertebral body. AC using misaligned pairs of patient data sets led to a significant change of whole-slice uptake ratios whose differences ranged from 3,5 to 25%. For ACX, the average left-to-right ratio of the facet joints was by 8% and for the superior iliacal spines by 31% lower than the values determined for the matched images (p <0.05). Conclusions: AC significantly affects DPD uptake ratios. Furthermore, misalignment between SPECT and CT may introduce significant errors in quantification, potentially also affecting leftto- right ratios. Therefore, at clinical evaluation of attenuation- corrected scans special attention should be given to possible misalignments between SPECT and CT.

Download Full-text

1497-P: Secular Trends in Incidence and One-Year Mortality Rates of Lower Extremity Amputation in People with Diabetes in Hong Kong between 2001 and 2016

Diabetes ◽

10.2337/db20-1497-p ◽

2020 ◽

Vol 69 (Supplement 1) ◽

pp. 1497-P

Author(s):

HONGJIANG WU ◽

AIMIN YANG ◽

ERIC S. LAU ◽

RONALD C. MA ◽

ALICE P. KONG ◽

...

Keyword(s):

Hong Kong ◽

Lower Extremity ◽

Mortality Rates ◽

Secular Trends ◽

Lower Extremity Amputation ◽

One Year ◽

Extremity Amputation

Download Full-text

Neurosurgical intervention in penetrating spinal trauma with associated visceral injury

Journal of Neurosurgery ◽

10.3171/jns.1989.70.4.0514 ◽

1989 ◽

Vol 70 (4) ◽

pp. 514-518 ◽

Cited By ~ 30

Author(s):

Benjamin H. Venger ◽

Richard K. Simpson ◽

Raj K. Narayan

Keyword(s):

Neurological Outcome ◽

Cauda Equina ◽

Neurological Deficits ◽

Neurological Injury ◽

Infection Prophylaxis ◽

Associated Injuries ◽

Visceral Injury ◽

Surgical Exploration ◽

Significant Difference ◽

Neurosurgical Intervention

✓ Associated injuries to the neck, chest, or abdomen are found in approximately one-quarter of all civilians with penetrating spinal cord or cauda equina injuries. While the value of and indications for general surgical exploration and repair of these injuries are fairly self-evident, the value of neurosurgical intervention in terms of neurological outcome and infection prophylaxis remains the subject of debate. To study this issue, 160 civilian patients with penetrating spinal injuries and neurological deficits were retrospectively reviewed. Associated injuries of the esophagus, trachea, bronchi, or bowel were seen in 107 individuals (67%); 33 (31%) of these patients had abdominal injuries, 25 (23%) had neck injuries, 23 (21%) had thoracic injuries, and 26 (24%) had injuries occurring at multiple sites. Of these 107 patients, 67 (63%) had complete neurological injuries and the remaining 40 (37%) demonstrated incomplete deficits. All 107 patients underwent surgical exploration and repair of their visceral injuries; in 19 of them a neurosurgical procedure was also performed for decompression of the neural elements and/or debridement of the wound. Regardless of the presence of associated visceral injuries, the mechanism of injury, and the extent of the neurological deficit, no statistically significant difference in neurological outcome was found in patients with or without neurosurgical intervention. Complications associated with neurological injury were reported in 17 (11%) of the total group of 160 patients. Four (21%) of the 19 patients who had neurosurgical intervention suffered a related complication, compared to only six (7%) of the 88 patients who were managed conservatively (p < 0.05). Within the limitations of a retrospective review, the results of this study do not clearly support the value of routine neurosurgical intervention as an adjunct to general surgical repair in cases of spinal injury associated with penetrating visceral trauma.

Download Full-text

Full circumference lower extremity degloving injury treated with hydrosurgical debridement and negative-pressure wound therapy with gauze wound filler for fixation of avulsed flap skin grafts

Journal of Surgical Case Reports ◽

10.1093/jscr/rjaa498 ◽

2020 ◽

Vol 2020 (12) ◽

Author(s):

Tae Nagama ◽

Natsuko Kakudo ◽

Atsuyuki Kuro ◽

Yujiro Ozaki ◽

Yasuko Shirasawa ◽

...

Keyword(s):

Lower Extremity ◽

Negative Pressure ◽

Negative Pressure Wound Therapy ◽

Traumatic Injury ◽

Skin Grafts ◽

Wound Therapy ◽

Left Lower Extremity ◽

Degloving Injury ◽

Severe Traumatic Injury ◽

Degloving Injuries

Abstract Degloving, a skin and subcutis avulsion, is a severe traumatic injury sometimes caused by rolling wheels or machines. Although avulsed flaps are often readapted to its original site, most of these tissues become necrotic. Due to the extensive skin and soft tissue deficiency caused by necrosis, treatment becomes difficult. Skin grafts harvested from avulsed flaps may be used to treat degloving injuries, while negative pressure wound therapy (NPWT) is used to secure the grafts. Commonly used porous polyurethane foam wound fillers are difficult to set in circumferential extremity degloving injuries; gauze-based wound fillers are easier to use and cause less pain during dressing changes. We present a case of an extensive, full-circumference left lower-extremity degloving injury, treated using NPWT with gauze-based wound fillers for fixation of skin grafts harvested from avulsed flaps after hydrosurgical debridement. For complex wound geometries, gauze-based wound fillers can be easily applied for skin graft immobilization.

Download Full-text

CyberKnife rhizotomy for facetogenic back pain: a pilot study

Neurosurgical FOCUS ◽

10.3171/foc-07/12/e2 ◽

2007 ◽

Vol 23 (6) ◽

pp. E1 ◽

Cited By ~ 3

Author(s):

Gordon Li ◽

Chirag Patil ◽

John R. Adler ◽

Shivanand P. Lad ◽

Scott G. Soltys ◽

...

Keyword(s):

Back Pain ◽

Radiofrequency Ablation ◽

Facet Joint ◽

Late Onset ◽

Target Volume ◽

Facet Joints ◽

Positron Emission ◽

Cyberknife Radiosurgery ◽

Joint Injections

Object By targeting the medial branches of the dorsal rami, radiofrequency ablation and facet joint injections can provide temporary amelioration of facet joint–producing (or facetogenic) back pain. The authors used CyberKnife radiosurgery to denervate affected facet joints with the goal of obtaining a less invasive yet more thorough and durable antinociceptive rhizotomy. Methods Patients with refractory low-back pain, in whom symptoms are temporarily resolved by facet joint injections, were eligible. The patients were required to exhibit positron emission tomography–positive findings at the affected levels. Radiosurgical rhizotomy, targeting the facet joint, was performed in a single session with a marginal prescription dose of 40 Gy and a maximal dose of 60 Gy. Results Seven facet joints in 5 patients with presumptive facetogenic back pain underwent CyberKnife lesioning. The median follow-up was 9.8 months (range 3–16 months). The mean planning target volume was 1.7 cm3 (range 0.9–2.7 cm3). A dose of 40 Gy was prescribed to a mean isodose line of 79% (range 75–80%). Within 1 month of radiosurgery, improvement in pain was observed in 3 of the 5 patients with durable responses at 16, 12, and 6 months, respectively, of follow-up. Two patients, after 12 and 3 months of follow-up, have neither improved nor worsened. No patient has experienced acute or late-onset toxicity. Conclusions These preliminary results suggest that CyberKnife radiosurgery could be a safe, effective, and non-invasive alternative to radiofrequency ablation for managing facetogenic back pain. No patient suffered recurrent symptoms after radiosurgery. It is not yet known whether pain relief due to such lesions will be more durable than that produced by alternative procedures. A larger series of patients with long-term follow-up is ongoing.

Download Full-text

Acute Generalized Exanthematous Pustulosis With Multiple Organ Dysfunction Syndrome

American Journal of Critical Care ◽

10.4037/ajcc2013987 ◽

2013 ◽

Vol 22 (3) ◽

pp. 270-273 ◽

Cited By ~ 10

Author(s):

Ghulam Rehman Mohyuddin ◽

Manar Al Asad ◽

Lindsay Scratchko ◽

Ghulam Khaleeq

Keyword(s):

Lower Extremity ◽

Rare Condition ◽

Skin Condition ◽

Multiple Organ ◽

Drug Induced ◽

Acute Generalized Exanthematous Pustulosis ◽

Left Lower Extremity ◽

Causative Drug ◽

Diffuse Erythema ◽

Exanthematous Pustulosis

Acute generalized exanthematous pustulosis is a rare condition characterized by sterile pustules on erythematous and edematous tissue. Mostly drug induced, this condition can also be caused by other factors. Cases due to vancomycin are rare. A 67-year-old woman with cellulitis of the left lower extremity was admitted with marked bilateral lymphedema of the lower extremities and diffuse erythema of the left lower extremity from foot to knee. She was given clindamycin and then vancomycin. On day 5, her condition worsened, with erythema involving the entire back. Although treatment with clindamycin and vancomycin was discontinued, acute generalized exanthematous pustulosis developed. After successful treatment of other complications, the skin condition improved. Because vancomycin is frequently used, clinicians should be aware of the possibility of acute generalized exanthematous pustulosis. Because the pustulosis decreases after withdrawal of the causative drug, being able to diagnose and differentiate the abnormality from other conditions is prudent.

Download Full-text