Pitting oedema in a patient with lumbar disc herniation: case report of an unusual association

Oedema refers to the excessive accumulation of fluid within intercellular tissues as a result of disequilibrium between the capillary hydrostatic and oncotic pressure gradients. Lumbar disc herniation [LDH] commonly causes lower back pain and radicular leg pain. We report a 57-year-old female who presented to the neurosurgery clinic of the Bam University of Medical Sciences, Bam, Iran, in 2015 with pain and pitting oedema in the bilateral lower extremities. Magnetic resonance imaging confirmed a diagnosis of LDH of the L3-L4 and L4-L5 vertebrae. The patient subsequently underwent a bilateral laminotomy and foraminotomy of the involved vertebrae to relieve her pain. Following the surgery, there was a complete resolution of the LDH-related symptoms as well as the oedema. Although LDH has never before been associated with oedema, it may nevertheless cause lower limb oedema in exceptional and rare cases, as highlighted in this patient

Traumatic Spinal Cord Injury: Long-Term Motor, Sensory, and Urinary Outcomes

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate how motor, sensory, and urinary outcomes of spinal cord injury (SCI) patients were influenced in the long term. OVERVIEW OF LITERATURE: SCI is a potentially disabling and devastating neurological outcome that can occur because of spinal column fractures. Most studies have not evaluated or have failed to show the influence of different surgical approaches and other parameters on neurological recovery. METHODS: A thorough history regarding sensory, motor, and urinary complaints was taken from 103 patients with SCI due to vertebral fracture; patients were followed by a thorough neurological examination. Subsequently, all medical records of patients, including neurological state after trauma, trauma mechanism, treatment protocol, surgical protocol, and imaging findings, were evaluated. RESULTS: Of the 103 patients, 73.8% were survivors of a major earthquake and 26.2% were victims of vehicle accidents; 92.2% patients were surgically treated, while 7.8% underwent conservative management. The mean follow-up duration was 10.3 years. In follow-up visits, 67.0%, 12.6%, 13.6%, and 6.8% patients showed no, partial, substantial, and complete motor improvement, respectively; 68.0%, 26.2%, and 5.8% showed no, mild, and substantial sensory improvement, respectively; and 73.8%, 17.5%, and 8.7% showed no, substantial, and complete urinary improvement, respectively. Logistic regression analysis showed that sex, age at injury time, follow-up duration, trauma mechanism, and stem cell therapy had no effect on motor, sensory, and urinary improvement. Higher initial scores on the American Spinal Injury Association (ASIA) classification, lumbar fracture level, and performance of laminectomy improved motor outcome; higher initial ASIA scores improved urinary and sensory outcomes. CONCLUSIONS: The initial ASIA score is the most important factor for prognosticating motor, sensory, and urinary improvement in SCI patients. Lumbar (L3–L5) and thoracic (T1–T10) fractures have the best and worst prognosis, respectively, in terms of motor recovery. Laminectomy during surgery improves motor function.

C2 Body Fracture: Report of Cases Managed Conservatively by Philadelphia Collar

STUDY DESIGN: Case series. PURPOSE: To present results of conservative management in patients with pure C2 body fractures. OVERVIEW OF LITERATURE: Axis body fractures, a less common subgroup of C2 fractures, are commonly classified as vertical coronal, vertical sagittal, and transverse subtypes. While the treatment paradigm for other C2 fractures is clear, there is insufficient evidence to support treatment guidelines for C2 body fractures. METHODS: Eleven patients with pure C2 body fractures were managed with external immobilization and followed thereafter. RESULTS: All neurologic examinations were normal. In computed tomography (CT) scans, four, two, three, and two patients had a coronal, sagittal, horizontal, and burst fracture, respectively. Magnetic resonance imaging showed hematoma and partial rupture in the anterior longitudinal ligament in four patients, posterior ligamentous complex injury in one, and normal ligamentous structure in six. All fractures were managed conservatively using the Philadelphia collar, which was continued until complete disappearance of symptoms (within 1–3 months in all patients). The decision to discontinue the neck collar was made by a dynamic neck X-ray and CT scan that showed complete bony fusion. All patients were then followed for an additional 1.5 years (mean follow-up of 21 months for all patients). No patient showed any neurologic symptoms or deficits during the follow-up period. CONCLUSIONS: In patients with pure C2 body fracture, non-operative management with Philadelphia neck collar is a safe and efficacious option, even in the presence of some sort of ligamentous injury.

Clinical and Magnetic Resonance Imaging Factors Which May Predict the Need for Surgery in Lumbar Disc Herniation

STUDY DESIGN: Case-control. PURPOSE: Evaluate clinical and imaging factors which may predict the risk of failure of medical therapy in patients with lumbar disc herniation (LDH). OVERVIEW OF LITERATURE: LDH is a common cause of low back pain and radicular leg pain, with a generally favorable natural course. At present, however, it is not possible to identify patients who may be candidates for surgery in an early stage of their disease by means of clinical signs or diagnostic imaging criteria. METHODS: We designed a study investigating patients with untreated low back pain to assess the predictive value of demographic, clinical or imaging findings in identifying patients who finally would meet the classic current criteria for surgery. RESULTS: Among 134 patients, 80.6% were successfully treated with conservative therapy and 19.4% finally underwent surgery. Sex, occupation, involved root level, presence of Modic changes, osteophytes or annular tears were not significantly different between the 2 groups, while cerebrospinal fluid block, Pfirrmann's grade, location of herniation with regard to the midline, and type of herniation were significantly different. Anteroposterior fragment size was significantly higher and intervertebral foramen height and thecal sac diameters were significantly lower in the surgical group. CONCLUSIONS: Although it is strongly recommended to practice conservative management at first for patients with LDH symptoms, the results of this study shows that higher Pfirrmann's grade, more laterally located discs, extrusion and protrusion herniation types, and larger fragments could predict the risk of conservative treatment failure. This way, unnecessarily prolonged conservative management (beyond 4-8 weeks) may be precluded.