Morphometric parameters of the odontoid process of C2 vertebrae, in Indian population, a CT evaluation.

BACKGROUND: Osteosynthesis of odontoid fractures, especially for type II odontoid fractures, is often achieved by the placement of screws. Here, utilizing CT, we evaluated the normal anatomy of the odontoid process in an Indian population to determine whether one or two screws could be anatomically accommodated to achieve fixation. METHODS: CT-based morphometric parameters of the odontoid process were assessed in 200 normal Indian patients (2018-2020). RESULTS: Of 200 patients, 127 were male, and 73 were female. The mean minimum external transverse diameter (METD) was 8.80 mm (range 6.1-11.9 mm). Six (3%) patients had a minimum internal transverse diameter (TD) of >8.0 mm that would allow for the insertion of two 3.5-mm cortical screws without tapping, while 10 (5%) patients had TDs of <7.4 mm; none had diameters of <5.5 mm. The mean length of the implant was 36.45 mm in females and 36.89 mm in males, and the mean angle of screw insertion was 60.34° in females and 60.53° in males. CONCLUSION: About two-thirds (59%) of the 200 subjects in our study had a METD of <9 mm, indicating the impracticality for introducing second screws for odontoid fixation.

Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature.

BACKGROUND: Intraoperative anteropulsion of a transforaminal lumbar interbody fusion (TLIF) cage is infrequent but may have disastrous complications. Here, we present an 80-year-old female whose L5-S1 TLIF cage extruded anteriorly and later migrated into the pouch of Douglas (i.e. an anterior peritoneal reflection between the uterus and the rectum) posing potential significant risks/complications, particularly of a major vessel injury. Notably, this 80-year-old patient with degenerative lumbosacral scoliosis should have only undergone a lumbar decompression alone. CASE DESCRIPTION: An 80-year-old female underwent a two-level L4-L5 and L5-S1 TLIF to address lumbosacral canal stenosis with degenerative scoliosis. During the L5-S1 TLIF, intraoperative fluoroscopy showed the anterior displacement of the cage ventral to the sacrum. As she remained hemodynamically stable, the cage was left in place. The postoperative CT scan confirmed that the cage was located in the retroperitoneum but did not jeopardize the major vascular structures. Three months later, however, the cage migrated inferiorly into the pouch of Douglas. Although asymptomatic, general surgery and gynecology advised laparoscopic removal of the cage to avoid the potential for a major vessel/bowel perforation. However, the patient refused further surgery, and 3 years later remained asymptomatic. CONCLUSION: Anterior cage migration following TLIF has been rarely reported. In this case, an L5-S1 TLIF cage extruded anteriorly in an 80-year-old severely osteoporotic female and migrated 3 months later into the pouch of Douglas, posing the risk of a major vessel/bowel injury. Although surgical removal was recommended, the patient refused further surgery but remained asymptomatic 3 years later. Notably, the authors, in retrospect, recognized that choosing to perform a 2-level TLIF in an 80-year-old female reflected poor judgment.

Misdiagnosis of "White Cord Syndrome" following posterior cervical surgery for ossification of the posterior longitudinal ligament: A case report.

BACKGROUND: Following decompressive cervical surgery for significant spinal cord compression/myelopathy, patients may rarely develop the "White Cord Syndrome (WCS)." This acute postoperative reperfusion injury is characterized on T2W MRI images by an increased intramedullary cord signal. However, it is a diagnosis of exclusion, and WCS can only be invoked once all other etiologies for cord injury have been ruled out. CASE DESCRIPTION: A 49-year-old male, 3 days following a C3-C7 cervical laminectomy and C2-T1 fusion for extensive cord compression due to ossification of the posterior longitudinal ligament (OPLL), developed acute quadriparesis. This new deficit should have been attributed to an intraoperative iatrogenic cord injury, not the WCS. CONCLUSION: Very rarely patients sustain postoperative significant/severe new neurological deficits attributable to the WCS. Notably, the WCS is a diagnosis of exclusion, and all other etiologies (i.e. intraoperative iatrogenic surgeon-based mechanical cord injury, graft/instrumentation extrusion, failure to adequately remove/resect OPLL thus stretching cord over residual disease, other reasons for continued cord compression, including the need for secondary surgery, etc.) of cord injury must first be ruled out.

Incidental unintentional breakage of epidural catheter in supralaminar area: A case report.

BACKGROUND: Among some of the known complications, breakage of epidural catheter, though is extremely rare, is a well-established entity. Visualization of retained catheter is difficult even with current radiological imaging techniques, and active surgical intervention might be necessary for removal of catheter fragment. We report such a case of breakage of an epidural catheter during its insertion which led to surgical intervention. CASE DESCRIPTION: A 52-year-old, an 18G radiopaque epidural catheter was inserted through an 18G Tuohy needle into the epidural space at T8-T9 interspace in left lateral position. Resistance was encountered. While the catheter was being removed with gentle traction along with Tuohy needle, it sheared off at 12 cm mark. After informing the operating surgeon and the patient, immediately an magnetic resonance imaging and computed tomography (CT) scan were done. CT scan with sagittal and coronal reconstruction was done. Epidural catheter was visualized at D9 lamina-spinous process junction who was removed by surgical intervention. CONCLUSION: Leaving of epidural catheter puts the anesthetist in a dilemma. To evade such an event, it is important to stick to the traditional guiding principle for epidural insertion and removal. In spite of safety measures, if event occurs, the patient should be informed about it. Surgery is reserved for symptomatic patients or asymptomatic patients to avoid future complications.

A Case Series of Acute Painless Bilateral Foot Drop Without Cauda Equina Syndrome.

Introduction: Acute painless bilateral foot drop without bowel/bladder involvement is a very rare presentation of lumbar degenerative disorders. Only a few cases have been published on it in the literature. An early intervention could prove to be very helpful for the neurological recovery. Case Report: We present three cases where patients developed acute onset bilateral foot drop without radiculopathy and without bowel/bladder involvement. The first case was due to acute lumbar disc herniation, the second was caused by acute disc prolapse in a pre-existing asymptomatic lumbar canal stenosis, and the third one precipitated in a progressive degenerative severe lumbar spinal stenosis. Two cases (case reports 1 and 3) underwent minimal invasive decompression while the other case (case report 2) underwent instrumentation+ decompression + fusion. Case 1 and 2 with a short duration of symptoms showed good neurological recovery, whileereas Case 3 with longer duration of complaints did not improve. Conclusion: Patients presenting with painless bilateral foot drop without cauda equine syndrome should be evaluated for spinal causes besides central nervous systemCNS, peripheral nerve, metabolic and autoimmune causes. Any finding in support of lumbar degenerative disease as the cause after excluding other causes should prompt for surgical decompression of the spine as an early intervention might help patient recover back to a normal and active lifestyle.

Tophaceous gout in thoracic spine mimicking meningioma: A case report and literature review.

BACKGROUND: Gout is a common metabolic disorder of purine metabolism, causing arthritis in the distal joints of the appendicular skeleton. Spine involvement is rare, and very few cases of spinal gout have been reported. The authors present a rare case of axial gout with tophaceous deposits in the thoracic spinal canal resulting in cord compression and mimicking a meningioma. CASE DESCRIPTION: A 33-year-old male presented with chronic mid back pain and a progressive paraparesis. The presumed diagnosis was meningioma based on MR imaging with/without contrast that showed a posterolateral, right-sided, and T10-T11 intradural extramedullary lesion. Notable, was hyperuricemia found on hematological studies. The patient underwent a decompressive laminectomy (T9-T11) for excision of the lesion, intraoperatively, an intraspinal, chalky, white mass firmly adherent to and compressing the dural sac was removed. The histopathology confirmed the diagnosis of a gouty tophus. Postoperatively, the patient's pain resolved, and he regained the ability to walk. CONCLUSION: A gouty tophus should be included among the differential diagnostic considerations when patients with known hyperuricemia present with back pain, and paraparesis attributed to an MR documented compressive spinal lesion.

Traumatic posterior dislocation of sacrococcygeal joint: A case report and review of the literature.

BACKGROUND: Sacrococcygeal joint dislocation is very rare. There are seven cases of sacrococcygeal joint dislocation found in the literature; most are anterior, and only one prior case of posterior dislocation was reported involving the mid-coccygeal joint. Here, we report another case of posterior dislocation of the sacrococcygeal joint. CASE DESCRIPTION: A 19 year-old female developed acute low-back and groin pain following a fall from the first floor. She was diagnosed with an unstable pelvic fracture along with posterior dislocation of the sacrococcygeal joint. The next day, after being hemodynamically stabilized, she underwent percutaneous fixation of the sacral fracture, while the sacrococcygeal joint dislocation was managed conservatively. Her pain decreased, and she was discharged on the third postoperative day and followed up to 6 weeks. CONCLUSION: Most sacrococcygeal joint dislocations can be managed conservatively.

Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature.

BACKGROUND: The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4-L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management). CASE DESCRIPTION: A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4-L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4-L5 level. This was treated with a L4-L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection. CONCLUSION: Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions.

Progressive dysphagia and dysphonia secondary to DISH-related anterior cervical osteophytes: A case report.

BACKGROUND: Dysphagia due to diffuse idiopathic skeletal hyperostosis (DISH)-related anterior cervical osteophytes is not uncommon. However, this rarely leads to dysphonia and/or dysphagia along with life- threatening airway obstruction requiring emergency tracheotomy. CASE DESCRIPTION: A 56-year-old male presented with progressive dysphagia and dysphonia secondary to DISH-related anterior osteophytes at the C3-C4 and C4-C5 levels. The barium swallow, X-ray, magnetic resonance imaging, and computed tomography scans confirmed the presence of DISH. Utilizing an anterior cervical approach, a large beak-like osteophyte was successfully removed, while preserving the anterior annulus. After clinic-radiological improvement, the patient was discharged with a soft cervical collar and nonsteroidal anti-inflammatory drug (NSAID). CONCLUSION: Large anterior osteophytes in Forestier disease/DISH may cause dysphagia and dysphonia. Direct anterior resection of these lesions yields excellent results as long as other etiologies for such symptoms have been ruled out.

Stenotrophomonas maltophilia spondylodiscitis following lumbar microdiscectomy mimicking a cotton granuloma: A case report and literature review.

BACKGROUND: Vertebral osteomyelitis caused by Stenotrophomonas maltophilia is very rare. There are only two cases reported in literature. Here, we present a 48-year-old immunocompetent male who, following a lumbar microdiscectomy, developed postoperative spondylodiscitis due to S. maltophilia that mimicked a cotton granuloma. CASE REPORT: Two months ago, a 48-year-old male underwent a lumbar L4-L5 microdiscectomy, he newly presented with the left thigh and leg pain of 4 weeks duration. Laboratory studies revealed a CRP of 26 mg/l, an ESR of 6 mm (1st h), and total leukocyte count of 7.85 thousand/ul. The MRI T2 images showed a focal hyperintense lesion in the left lateral recesses at the L4-L5 level; the accompanying hypointense-smooth margin resembled a cotton granuloma. At surgery, we found a localized epidural collection of pus; S. maltophilia was isolated from the culture. His symptoms gradually improved, and symptoms fully resolved with 3 months of subsequent antibiotic therapy. CONCLUSION: S. maltophilia causing vertebral osteomyelitis is extremely rare and can sometimes mimic a cotton granuloma. MR diagnosis, surgical decompression, and obtaining cultures are requisite to direct appropriate antibiotic therapy.

Congenital absence of a lumbosacral facet joint: A case report.

BACKGROUND: Congenital absence of the lumbosacral facet joint is extremely rare, with only 26 cases reported in the literature. Here, we present a patient with the unilateral absence of the left fifth lumbar inferior articular process and reviewed the relevant literature. CASE DESCRIPTION: A 32-year-old gentleman, who had undergone right L4-5 lumbar microdiscectomy 3 months ago now presented with acute low back and left leg pain following a fall. He is now presented with acute low back and left leg pain following a fall. Plain radiographs of the L-S spine revealed an absent left L5-S1 zygapophyseal joint. The magnetic resonance imaging and computed tomography studies additionally confirmed an absent unilateral left L5 lumbar inferior articular process. CONCLUSION: Patients presenting for lumbar surgery may have unilaterally absent lumbosacral zygapophyseal joints, which may impact the outcome of surgical treatment.

Thoracic cryptococcal osteomyelitis mimicking tuberculosis: A case report.

BACKGROUND: Isolated cryptococcal osteomyelitis of the spine is extremely uncommon; there have been only seven cases identified in literature. The majority were originally misdiagnosed as tuberculosis. Here, we present a patient with cryptococcal osteomyelitis of the thoracic spine with associated fungal retinal deposits. CASE DESCRIPTION: A 45-year-old, type II diabetic female presented with a 5-month history of severe back pain. Her magnetic resonance imaging (MRI) revealed osteomyelitis involving the T4 vertebral body with epidural and prevertebral extension; notably, the intervertebral disc spaces were not involved. Although the fine-needle aspiration cytologic examination was inconclusive, the patient was empirically placed on antitubercular drug therapy. One month later, she became fully paraplegic. The MRI now demonstrated osteolytic lesions involving the T4 vertebral body with cord compression. She underwent biopsy of the T4 vertebral body and a transfacet T4 decompression with T2-T6 pedicle screw fixation. Culture and histopathological examinations both documented a cryptococcal infection, and she was placed on appropriate antifungal therapy. Notably, 3 weeks after surgery, she developed a sudden loss of vision loss due to retinal fungal endophthalmitis. She recovered vision in one eye after the administration of intravitreal voriconazole but lost vision in the other eye despite a vitrectomy. Over the next 8 months, she gradually recovered with motor function of 4/5 in both lower extremities without evidence of recurrent disease. CONCLUSION: Cryptococcal infection should be among the differential diagnostic considerations for patients with vertebral osteomyelitis. Notably, diagnostic delay can lead to devastating neurological deficits and involvement of other organ systems.

The iron-hydrogen peroxide-iodide system is fungicidal: activity against the yeast phase of Blastomyces dermatitidis.

A series of experiments show the potency of a newly described microbicidal system, involving iron, H2O2, and halide, in killing a fungus (Blastomyces dermatitidis). B dermatitidis has previously been shown susceptible to the myeloperoxidase-H2O2-halide system. The present studies show killing of either of two strains in 1 hour if Fe++ at 5 X 10(-5)M, H2O2 at 5 X 10(-5)M and Kl at 5 X 10(-4)M are all present (P less than 0.001). EDTA, a Fe++ chelator, abrogates killing. The mechanism presumably utilizes hydroxyl radical, since an inhibitor, ethanol, also neutralizes the system. The bactericidal and fungicidal system is of great potential importance in vivo.

A cephalosporin active in vivo against Nocardia: efficacy of cefotaxime in murine model of acute pulmonary nocardiosis.

Cefotaxime, a cephalosporin drug, has been shown to be active in vitro against nocardiae, a finding confirmed in this study. Pharmacokinetic studies were performed in mice to define regimens which provided peak serum levels comparable to that achieved in man with currently used doses. These regimens were shown to be effective with only short courses of therapy of rapidly progressive and highly lethal N. asteroides infection, produced by pulmonary challenge of mice. This suggests the possible utility of this drug in human nocardiosis.

Susceptibility of Blastomyces dermatitidis strains to products of oxidative metabolism.

Three strains of Blastomyces dermatitidis which differ in their virulence for mice were exposed in their yeast form to various components of the peroxidase-hydrogen peroxide-halide system. Susceptibility to H2O2 alone correlated with virulence, with the most virulent strain (ATCC 26199) least susceptible (50% lethal dose, greater than 50 mM) and an avirulent strain (ATCC 26197) most susceptible (50% lethal dose less than 3.3 mM). A strain of intermediate virulence (ATCC 26198) was of intermediate susceptibility (50% lethal dose, 11.5 mM). The addition of a nontoxic concentration of KI (5 X 10(-4) M) did not increase H2O2 toxicity. However, the addition of either myeloperoxidase or horseradish peroxidase and KI markedly decreased the amount of H2O2 required to kill the organisms, with 100 +/- 0% of all strains killed at 5 X 10(-5) M H2O2 and 97 +/- 4, 100 +/- 0, and 94 +/- 8% of ATCC 26199, ATCC 26198, and ATCC 26197 killed, respectively, at 5 X 10(-6) M H2O2. Kinetic studies with H2O2 alone revealed a delayed onset of killing, but virtually 100% of organisms were killed by 120 min of exposure in all strains. By comparison, the peroxidase-hydrogen peroxide-halide system was 100% lethal for all strains at 1 min. The relatively high concentrations of H2O2 required to kill the yeast phase of B. dermatitidis suggest that H2O2 alone does not account for host resistance to the organism. However, the rapidly lethal effect of the peroxidase-hydrogen peroxide-halide system at physiologically relevant concentrations suggests that this may be one mechanism of host defense to B. dermatitidis.