Delayed Sub-axial Fracture Dislocation Surgical Management: Technical Notes and Review of the Literature.

The surgical treatment of delayed, unstable sub-axial cervical spine injuries is challenging. Multiple treatment regimens have been described in the literature, although there is no consensus regarding the best treatment approach. This report presents a 35-year-old obese woman who experienced a delayed sub-axial fracture-dislocation following a motor vehicle accident (MVA) and was successfully managed after three weeks via pre-operative traction followed by a novel single-surgery, single-approach technique with pedicle screws and tension-band wiring as a reduction method. A 35-year-old obese woman with a body mass index (BMI) of 30.1 sustained a frontal impact MVA and suffered from complete quadriplegia below C5 (American Spinal Cord Association Injury A) three weeks prior to presentation. She was intubated and presented with a Glasgow Coma Scale score of 11/15. Trauma computed tomography (CT) showed an isolated spine injury. Moreover, whole-spine CT showed an isolated cervical spine injury involving a basin tip fracture, a comminuted C1 arch fracture, a C2 fracture, and a C6-C7 fracture-dislocation. In addition, magnetic resonance imaging revealed cord contusion at the same level, with C1-C2 left atlantoaxial joint instability. Neck magnetic resonance angiograms and carotid CT angiograms showed left vertebral artery attenuation. She was admitted to the intensive care unit and taken for C6-C7 reduction and instrumentation using only a posterior approach after medical optimization and the application of sufficient traction. Delayed cervical spine fracture-dislocation imposes a challenge for surgical reduction. However, a proper reduction can be achieved through a sufficient duration of pre-operative traction and an isolated anterior or posterior approach.

Clinical and Radiological Outcomes Following Medial Pivot Total Knee Arthroplasty: A Retrospective Chart Review Study.

Medial pivot total knee arthroplasty (MP-TKA) is a relatively new design that simulates normal knee mechanics with the aim of enhancing postoperative recovery. Furthermore, it reduces postoperative complications in patients with end-stage osteoarthritis of the knee. No study has been done regarding this topic in Saudi Arabia yet, so we aimed to study the post-operative clinical and radiological outcomes of MP-TKA, as well as the postoperative complications. A retrospective cohort chart review study was conducted on 46 patients and 70 knees after applying our inclusion/exclusion criteria. The patients were followed up for an average period of two years. Clinical outcomes were assessed pre- and postoperatively by the validated Saudi Arabian version of the Knee Injury and Osteoarthritis Outcome Score (KOOS), as well as radiological outcomes and postoperative complications gathered from patients' charts. The postoperative KOOS score showed a statistically significant improvement in pain, symptoms, and activities of daily living in comparison with the preoperative score (P-value < 0.0001). The mean time until ambulation and length of hospital stay were five and 14 days, respectively. Four patients (8.7%) showed radiological complications. Deep vein thrombosis was observed in only two knees (4.3%), and there were no revision cases. Thus, MP-TKA has been shown to improve pain, symptoms, and activities of daily living with a relatively short time until ambulation and length of hospital stay, in addition to a low incidence of postoperative and radiological complications.

Progressive Multifocal Leukoencephalopathy in the Absence of Typical Radiological Changes: Can We Make a Diagnosis?

BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a serious opportunistic infectious disease with high morbidity and mortality. Its incidence in multiple sclerosis (MS) patients has risen since the introduction of disease modifying drugs. In the absence of a specific treatment, the outcome depends heavily on early diagnosis, which illustrates the importance of the role of characteristic brain magnetic resonance imaging (MRI). However, when relying mainly on MRI, the diagnosis of cases with atypical radiological changes may be missed or delayed. CASE REPORT A 32-year-old female diagnosed with elapsing remitting MS in 2009 was started on interferon-beta-1b that was escalated to natalizumab due to progression of the disease. Later, she was shifted to fingolimod as testing for John Cunningham polyoma virus (JCV) antibodies was positive. Three years later, she presented with a 3-week history of progressive walking impairment associated with twitching of her facial muscles and abnormal sensation all over her body that was associated with left hemi-paresis and sensory changes, in addition to truncal ataxia, which was treated with steroids as a relapse of MS. However, the patient continued to deteriorate and developed significant cognitive and behavioral changes. In view of this clinical picture, the diagnosis of PML was raised in spite of her atypical brain MRI features. Treatment with fingolimod was stopped and a sample of her cerebrospinal fluid was sent for JCV DNA analysis, which came back positive at 11 copies/mL. Treatment with mirtazepine and mefloquine was started, but the patient deteriorated further, and MRI showed severe changes consistent with immune reconstitution inflammatory syndrome. Intravenous steroids and intravenous immunoglobulin were given, and within a few weeks, the patient was stabilized and started to gradually improve. CONCLUSIONS In patients at risk for developing PML who present with typical clinical features, testing for JCV DNA is recommended even in the absence of typical radiological findings in order to prevent any delay in the diagnosis.

An Unusual Cause of Cauda Equina Syndrome: Lumbar Epidural Venous Engorgement.

BACKGROUND Epidural venous plexus (EVP) engorgement occurs due to many conditions, so it can be easily misdiagnosed. This becomes problematic when the diagnosis requires prompt treatment for a good outcome, especially when it results in cauda equina syndrome (CES). We report a case of extensive iliocaval thrombosis leading to epidural venous plexus and ascending lumbar vein engorgement as an outcome of deep venous thrombosis (DVT) due to probable adverse effects of oral combined contraceptive pills (OCCP). CASE REPORT A 42-year-old woman presented to a rural medical facility with bilateral lower-limb swelling and skin darkening for 2 days. She was transferred to a tertiary medical facility where her condition deteriorated to severe CES. A lower-limbs ultrasonography confirmed the presence of extensive DVT extending to the lower segment of the inferior vena cava. Spine magnetic resonance imaging showed abnormal enhancement of the conus medullaris with thick enhanced cauda equina nerve roots, consistent with a possible case of Guillain-Barré syndrome. However, there was engorgement of the EVP extending to the ascending lumbar, azygos, and hemiazygos veins, which was misdiagnosed. The patient was managed immediately with low-molecular-weight heparin and steroids. She died 4 weeks after admission due to hospital-acquired pneumonia and acute respiratory distress syndrome, probably due to the high dose of steroids. CONCLUSIONS Acute CES has a wide differential diagnosis. This report describes an unusual cause of CES and emphasizes the importance of early recognition to avoid misdiagnosis and management delay. Early identification of this clinical entity markedly decreases morbidity and mortality and thus improves the prognosis. Likewise, underlying causing factors such as venous congestion due to OCCP-related DVT should be considered in the diagnosis.