Anterior Approach Following Intraoperative Reduction for Cervical Facet Fracture and Dislocation

Objective@#: The purpose of this study was to evaluate the efficacy of the anterior approach following intraoperative reduction under general anesthesia in patients with cervical facet fracture and dislocation. @*Methods@#: Twenty-three patients with single level cervical facet fracture and dislocation who were subjected to the anterior approach alone following immediate intraoperative reduction under general anesthesia from March 2013 to December 2017 were enrolled in this study. Neurological status, clinical outcome, and radiological studies were evaluated preoperatively, postoperatively, and during the follow-up period. @*Results@#: The cohort comprised 15 men and eight women with a mean age of 57 years (from 24 to 81). All patients were operated on within the first 8 hours following the injury. After gentle manual reduction or closed reduction with Gardner-Wells traction, under general anesthesia monitored by somatosensory-evoked potentials, all operations were successfully completed using the anterior approach alone except in two patients, who had a risk of over-distraction. In them, a satisfactory gentle manual reduction or closed reduction was not possible, and required open posterior reduction of the locked facets followed by anterior cervical discectomy and fusion. In one patient, screw retropulsion was observed in 1 month after surgery. There were no reduction-related complications or neurological aggravations after surgery. All patients showed evidence of stability at the instrumented level at the final follow-up (mean follow-up, 12 months). @*Conclusion@#: Anterior approach following intraoperative reduction monitored by somatosensory-evoked potentials under general anesthesia for cervical dislocation and locked facets is a relatively safe and effective alternative when cervical alignment is achieved by intraoperative reduction.

Spontaneous Intracranial and Spinal Subdural Hematoma: A Case Report / 대한신경손상학회지

Spinal subdural hematoma (SDH) is rarely reported, and their simultaneous occurrence with intracranial SDH is even more rare. A 67-year-old male patient with a history of posterolateral fusion to treat an L2 burst fracture came to our outpatient clinic due to an inability to walk by himself over the previous 3 weeks. A neurological examination revealed that the patient was alert with occasional confusion and slight motor weakness in the lower extremities. Brain and lumbar spine magnetic resonance imaging (MRI) was then performed. A brain MRI revealed a large subacute SDH along the right cerebral convexity and falx cerebri with midline shifting, and a spine MRI revealed a right side-predominant subacute SDH extending from L4 to S1. For treatment, burr hole trephination of the intracranial SDH and fluoroscopy-guided lumbar puncture of the spinal SDH were performed and resulted in a favorable outcome. This is a report of a rare case of spontaneous intracranial and lumbar spine SDH. We include a review of the current literature and a discussion of the pathogenesis of this condition in this report.

Malignant Metastasis Misdiagnosed as Osteoporotic Compression Fracture: A Case Report / 대한신경손상학회지

In cases of vertebral collapse after a trivial injury in elderly patients with severe osteoporosis, it can be a diagnostic challenge to determine whether the cause is a benign compression fracture or malignant metastasis. A 78-year-old male patient was referred to the emergency department for the evaluation of weakness of the left lower limb. He had undergone percutaneous vertebroplasty four months earlier after being diagnosed with L3 osteoporotic compression fracture. He was treated with foraminotomy at the L3–4 level after being diagnosed with foraminal stenosis two months earlier at a spine clinic. Magnetic resonance (MR) images showed significant signal change from the vertebral body to the posterior element, and widely spreading extraspinal extension of soft tissue at L3. Computed tomography scan revealed osteolytic changes in regions including the ventral body and pedicle. Emergent decompressive laminectomy and bone biopsy were performed, and the histologic evaluation showed metastatic squamous cell carcinoma. A retrospective review of previous MR images showed obvious pedicle and facet involvement, and paraspinal extension of soft tissue, which are highly suggestive of malignant metastasis.

Severe Retrolisthesis at the Adjacent Segment after Lumbar Fusion Combined with Dynamic Stabilization / 대한신경손상학회지

Lumbar fusion using the pedicle screw system is a popular operative procedure, with favorable clinical results and high fusion rates. However, the risk of adjacent segment disease after lumbar fusion is problematic. We report a complicated case of severe retrolisthesis at L3-4 level following dynamic interspinous process stabilization at L2-3 level and a fusion at L4-5 level. The radiological and clinical findings of this complication are discussed, and a review of the literature is presented.

Cerebellar Infarction Following Epidural Abscess after Epidural Neuroplasty

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.

Implant Removal after Percutaneous Short Segment Fixation for Thoracolumbar Burst Fracture : Does It Preserve Motion?

OBJECTIVE: 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. METHODS: 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. RESULTS: 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 10.5degrees (19.5/9.0degrees) at last follow-up, and in Group B was 10.2degrees (18.8/8.6degrees) at last follow-up. Both groups showed marked improvement in ROM as compared with the screw fixation state, which was considered motionless. CONCLUSION: Removal of percutaneous implants after vertebral fracture consolidation can be an effective treatment to preserve motion regardless of osteoporosis for thoracolumbar burst fractures.

Short Segment Screw Fixation without Fusion for Low Lumbar Burst Fracture: Severe Canal Compromise but Neurologically Intact Cases / 대한신경손상학회지

OBJECTIVE: The purpose of this study was to determine whether screw fixation without bone fusion in patients with a low lumbar burst fracture has satisfactory outcomes. METHODS: Twelve patients that underwent screw fixation without bone fusion for a low lumbar burst fracture (L3-5) between 2006 and 2009, were included in this study. Motor power was intact despite severe canal compromise in all. Surgical procedures included postural reduction for 2 days and screw fixation without bone fusion. Imaging and clinical findings, including level of the involved vertebra, vertebral height, canal compromise, clinical outcomes, and related complications were analyzed. RESULTS: Mean follow-up was 23.1+/-11.0 months. Mean pain score (visual analogue scale) prior to surgery was 7.8+/-2.0 and this decreased to 1.8+/-1.0 at final follow-up. In 5 patients, open screw fixation by midline skin incision was performed and 7 patients underwent percutaneous screw fixation at one level above, one level below the fractured vertebra and fractured level itself. The proportion of canal compromise at the fractured level improved significantly from 60% to 30% at final follow-up (p<0.001). Mean preoperative vertebral height loss was 31.0%, and improved to 20.5% at final follow-up, though this improvement was not statistically significant (p<0.001). No neurological aggravation related to neural injury was observed. CONCLUSION: Short segment pedicle screw fixation without bone fusion can be an effective and safe operative technique for the management of selected low lumbar burst fractures.

Spontaneous Chronic Subdural Hematoma in an Adolescent Girl

In most cases, subdural hematoma (SDH) is regarded as a complication of head injury and nontraumatic causes are rare. Moreover, spontaneous chronic SDH in child or adolescent is very unusual. Here, we present the case of a healthy 14-year-old girl who was diagnosed as a spontaneous chronic SDH. The patient presented with severe headache following blurring of vision two weeks ago without any history of trivial head injury. Computed tomography and magnetic resonance imaging depicted a chronic SDH. The cause of the hematoma was not established. After performing burr hole drainage of the hematoma, the patient made an uneventful recovery. We explore the potential risk factors and pathophysiology implicated in this condition. Possible pathogenic mechanisms of this unique case are discussed and a review of the pertinent literature is included.

Spontaneous Resolution of Non-traumatic Cervical Spinal Subdural Hematoma Presenting Acute Hemiparesis: A Case Report

Spontaneous cervical SDH with no underlying pathology is a very unusual condition. To the best of the authors' knowledge, only two cases have been previously reported. A 48-year-old female patient was admitted to our emergency room due to severe neck pain following standing up position with rapid onset of hemiparesis. MRI revealed a dorsolateral subdural hematoma from C3-C5 with cord compression. An emergency laminectomy was planned, but motor weakness gradually improved during surgical preparation. The patient showed substantial clinical improvement and complete recovery was confirmed after 7 days of conservative management without surgical treatment. To determine a differential diagnosis distinct from other conditions such as cervical epidural hematoma, a lumbar spinal puncture was performed. Follow-up MRI performed 10 days after admission revealed complete resolution of the hematoma. We report an extremely rare case of spontaneous cervical spinal subdural hematoma (SDH), present a review of relevant literature, and discuss the etiology, pathogenesis, and prognosis of this case.

Advantages of the Plating for Anterior Cervical Discectomy and fusion: Comparison with Wearing Cervical Collar Without Plate

OBJECTIVE: Most patients wear cervical braces regardless of any anterior cervical discectomy and fusion (ACDF) technique for cervical disc herniation, even in the plating. We compared clinical and radiological results in patients with cervical disc herniations. The purpose of this study was to evaluate the efficacy of plate insertion during ACDF and determine if this could eliminate the need for external cervical braces after ACDF. METHODS: In this study, we evaluated 67 patients treated for single level cervical disc herniation with radiculopathy. The patients were divided into two groups: 30 patients treated with ACDF using a Solis(R) cage with plating who did not wear a cervical brace after the operation (Group I: Plated group), and 37 patients treated with ACDF using a Solis(R) cage without plating who wore a cervical brace for 3 months (Group II: Non-plated group). Clinical outcomes were assessed using the neck disability index (NDI), and visual analogue scale (VAS) for neck and arm pain at different times after the surgery. In addition, modified MacNab's grading criteria were used to assess the subjective patients' outcome at the last follow-up. Fusion was assessed at 6, 12, and 18 months after the surgery using upright AP, lateral, and flexion-extension views. RESULTS: Excellent or good results were achieved in the most patients from both groups. Patients in both groups showed marked pain relief in terms of neck and arm pain scores over all time intervals. The NDI scores in both groups significantly improved when compared to preoperative scores; however, at 1 and 2 months after the surgery, patients in Group I (Plated group) had significantly better NDI scores compared to Group II (Non-plated group). Higher rates of fusion were reported in Group I over all time intervals although none of these were statistically significant. There were two patients who required second surgery for cage subsidence in Group II. CONCLUSION: Our study demonstrates that anterior cervical fusion with plating for cervical radiculopathy is a safe and effective treatment which can eliminate unnecessary need for an external cervical brace.

Bone Cement Augmented Screw Fixation for Severe Osteoporotic Spine: Large Series of Clinical Application

OBJECTIVE: The purpose of this study was to evaluate the clinical efficacy of bone cement augmented screw fixation for the patients accompanying severe osteoporosis. METHODS: Between February 2004 and August 2007, 157 patients with various spinal diseases including fractures accompanying severe osteoporosis underwent a bone cement augmented screw fixation (947 levels). About 4.8cc of polymethylmethacrylate was injected into the each vertebral body through transpedicular route. We divided the patients into two groups (Group I: Posterior fusion for compression/burst fractures or idiopathic scoliosis, Group II: Interbody fusion for various spinal diseases). Imaging and clinical features were analyzed, including bone cement augmented levels, fusion rate, clinical outcome and complications. The visual analog scale (VAS), Oswestry disability questionnaire and modified MacNab's criteria were used for the assessment of pain and functional capacity. RESULTS: In both groups, a significant improvement in VAS and Oswestry disability questionnaire was achieved. 146 out of 157 patients (93%) were graded as excellent or good result according to the modified MacNab's criteria. None of the patients experienced operative death, screw pullout or cut-up. However, there were two cases of neurologic deterioration as a result of bone cement extravasation. CONCLUSION: Bone cement augmented transpedicular screwing can reduce the possibility of screw loosening and pullout in patients with severe osteoporosis.