Recurrent solitary bone plasmacytoma: A case report.

BACKGROUND: Plasmacytoma is an hematological malignancy that originates in bone. It may involve a single skeletal location. Notably, these lesions can progress to involve multiple segments in 50% of cases, at which point they are classified as having multiple myeloma (MM). CASE DESCRIPTION: One year ago, this patient had undergone a D6 laminectomy and biopsy for plasmacytoma. Now at age 73, she newly presented with the onset of a progressive paraparesis of 4 weeks' duration. On examination, she had 3/5 strength in both lower extremities accompanied by diffuse hyperreflexia, and bilateral Babinski signs. She underwent a D5-D7 decompression, D6 corpectomy with anterior mesh cage reconstruction, and a D3-D9 posterior fusion. CONCLUSION: Patients originally treated for plasmacytoma present 50% of the time with the new onset of neurological symptoms and signs due to the subsequent evolution of MM. As these lesions may be refractory to radiation and/or chemotherapy, surgery is often warranted.

A Stepwise Posterolateral Approach for Computed Tomography Guided C2 (Axis) Transpedicular Biopsy: A Technical Note.

Introduction: Minimally invasive percutaneous CT-guided biopsies of the spine are well established. Although, technical difficulties with CT-guided percutaneous intervention of the C2 body present due to the smaller size of the vertebral elements and potential injury of the critical adjacent structures such as Carotid arteries laterally, vertebral artery, and cervical nerve posterolaterally, pharynx and larynx anteriorly, and spinal cord in the cervical spinal canal. Routinely transoral approach is used for the percutaneous intervention of the C2 body. Literature on the posterolateral approach for biopsies of the C2 vertebral body is sparse as compared to other approaches. This case report presents a case of adenocarcinoma diagnosed with CT-guided percutaneous biopsy of the C2 body using a posterolateral approach under local anesthesia. Case Report: A 70-year-old female presented to our outpatient clinic with complaints of progressively increasing neck pain with a visual analog score (VAS) 7/10. Neck pain was radiating to the base of the occiput and aggravated by neck movements. On clinical examination, there was axial tenderness at the base of the skull and the upper part of the cervical spine. Neurological examinations of sensory and power in all the limbs were normal. Systemic examination and laboratory parameters did not reveal any abnormality. X-rays and MRI revealed a fracture of the odontoid process with marrow edema with differentials of metastasis. PET scan revealed left lung lesion likely to be primary lesion and lesion in C2 vertebral body as likely metastasis. A minimally invasive percutaneous CT-guided posterolateral approach for biopsy proved moderately differentiated adenocarcinoma from the lung with metastasis to C2 vertebrae. The patient was started on an appropriate Chemotherapy regimen as per the Immunohistochemistry (IHC) and Genomic studies with adjuvant radiotherapy. Conclusion: Understanding the detailed anatomy prior to CT guided minimally invasive percutaneous C2 biopsy procedure helps in increasing its safety, precision, and high yield. Stepwise approach to the procedure aids in getting repeatable and high-yielding results especially in a technically challenging area such as C2 vertebrae.

Cauda Equina Syndrome in a Lactating Mother - A Safe Treatment Approach.

Cauda equina syndrome is widely considered as a surgical emergency. The cause of cauda equina syndrome usually is a large central lumbar disc herniation, prolapse or sequestration. Decompression at the earliest has been suggested by many authors but the planning of surgical management becomes challenging when the patient is a breastfeeding mother. Fear of harmful effects of the drugs (administered in the mother) on the infant, always confuses clinicians regarding the treatment approach. So the multidisciplinary approach is necessary with involvement of anaesthetist, paediatrician and also a gynaecologist if necessary. Thorough knowledge of the safety of drugs to be used in operative and post operative period becomes a necessity keeping the baby into consideration. We present a case of one month postpartum female with cauda equina syndrome and present a stepwise multidisciplinary approach, which involves active contributions from surgeon, for safety of the mother and the infant.

A Levering Technique Using Small Parallel Rods for Open Reduction of High-Grade Thoracolumbar Dislocation.

STUDY DESIGN: Technical report. OBJECTIVE: Dorsolumbar vertebral dislocations, with or without associated fractures, occur secondary to very high velocity trauma. The reduction procedures and techniques, which may be adopted in these situations, have been multifariously discussed in the literature. Our objective was to assess the outcome of a novel reduction maneuver, using parallel rods which we have employed in reduction of high-grade thoracolumbar fractures to achieve precise sagittal balance as well as accurate vertebral alignment with minimal soft tissue damage. METHODS: The study included a total of 11 cases of thoracolumbar dislocations, who had presented to our emergency spine services following high-velocity trauma. After appropriate systemic stabilization and necessary investigations, all patients were surgically treated using the described technique. RESULTS: There were no surgical complications at 2-year follow-up. Radiographs showed good reduction and maintained sagittal balance. CONCLUSION: We believe that this technique is an excellent means of achieving safer, easier, and accurate reduction for restoration of sagittal/coronal balance and alignment in high-grade thoracolumbar dislocations. It is easily reproducible and predictable.

Correlation between Preoperative Magnetic Resonance Imaging Signal Intensity Changes and Clinical Outcomes in Patients Surgically Treated for Cervical Myeloradiculopathy.

STUDY DESIGN: This was a single surgeon, single center-based retrospective study with prospective data collection. PURPOSE: To assess the correlation between T2-weighted magnetic resonance imaging (MRI) signal intensity (SI) changes and factors such as age, duration of symptoms, baseline modified Japanese Orthopedic Association (mJOA) score and to determine its prognostic value in predicting recovery after surgery. OVERVIEW OF LITERATURE: Whether intramedullary cord T2-weighted MRI SI changes can predict operative outcomes of cervical myeloradiculopathy remains debatable, with only a few prospective studies analyzing the same. METHODS: Forty-six consecutive patients who underwent cervical myeloradiculopathy were included and were followed up for an average of 1 year. Preoperative T2-weighted MRI SI grading was performed for all patients. The correlation between MRI SI changes and age, duration of symptoms, preoperative mJOA score, and mJOA score at 1-year follow-up were analyzed. RESULTS: Fifteen patients had single-level (21.73%) or double-level (10.86%) prolapsed discs; 54.34% had degenerative cervical spondylosis with canal stenosis or multilevel disc prolapse and 13.07% had ossified posterior longitudinal ligaments. The mean age was 56.17±9.53 years (range, 35-81 years). The mean baseline mJOA score was 10.83±2.58 (range, 6-16), which postoperatively improved to 13.59±2.28 (range, 8-17; p<0.001). There was a statistically significant correlation between mJOA score at 1 year and MRI T2 SI grading (p=0.017). CONCLUSIONS: Patients with longer symptom durations had high grades of intramedullary cord T2-weighted MRI SI changes. Age and preoperative neurological status were not significantly correlated with the existence of intramedullary cord SI changes. However, patients without or with mild and diffuse intramedullary cord T2-weighted MRI SI changes had better postoperative neurological recovery than those with sharp and focal SI changes.

Demographics of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma Centre.

STUDY DESIGN: Prospective, cross-sectional, observational study. PURPOSE: Spine traumata are devastating injuries, which may result in serious disabilities and dire consequences. The current study involves a detailed analysis and description of patients, who were operated at a tertiary care, urban level 1 Spine Centre in India. OVERVIEW OF LITERATURE: Various studies in literature have discussed the epidemiology and patterns of these injuries in trauma patients. However, literature describing the demographic profile and distribution of these traumata in the Indian population is scarce. METHODS: The current study was conducted as a prospective trial involving patients, who were treated at our Spine Centre in India between July 2009 to December 2012. We studied 92 patients with thoraco-lumbar spine fracture, who were operated with short or long segment posterior stabilization. Epidemiological details, pre- and post-hospitalisation care received and other injury pattern factors were studied. RESULTS: Fall from height (46 patients, 50%) was the most common mechanism observed in the patients. Sixty-three percent injuries belonged to AO type A fractures, while 16.2% and 19.4% of the patients had suffered from AO types B and C injuries, respectively. CONCLUSIONS: We identified interesting epidemiological data and prevailing inadequacies in Emergency Spine care management in the study patients. These observations could facilitate implementation of the changes required to improve current standards of patient care.

Extraosseous thoracic foraminal osteoblastoma: diagnostic dilemma and management with 3 year follow-up.

Osteoblastomas are bone forming lesions arising mainly from posterior elements of the vertebra. They are commonly encountered in the cervical and lumbar regions. We present a case of a thoracic osteoblastoma which is extra osseous and is not communicating with any part of the vertebra present intraforaminally. This is a rare presentation of an osteoblastoma. Imaging studies do not accurately diagnose the osteiod lesion. The size of the lesion and cortical erosion seen on the computed tomography scan help in differentiating the osteoid osteoma and osteoblastoma, but they are less sensitive and specific. Thus a histopathology is the investigation of choice to diagnose the osteoblastoma. Early and adequate removal of mass prevents malignant transformation, metastasis, and recurrence. In our case we excised the pars interarticularis unilaterally, removed the osteoid mass intact, and performed unilateral instrumented fusion. There was no recurrence and solid fusion was seen at 3 years follow up.

Correlation of kyphosis and wedge angles with outcome after percutaneous vertebroplasty: a prospective cohort study.

PURPOSE: To evaluate the correlation of kyphosis and wedge angles with pain relief and functional outcome after percutaneous vertebroplasty (PV). METHODS: 15 men and 19 women aged 41 to 85 (mean, 62) years who presented with osteoporotic wedge compression fractures of the dorsolumbar spine below T5 and had failed conservative treatment were included. Patients were assessed before and one year after PV. Kyphosis and wedge angles were measured on standardised radiographs. Pain and function were assessed using the visual analogue scale (VAS) score and the Ronald Morris Disability Questionnaire (RMDQ) score, respectively. Patients were dichotomised based on their preoperative kyphosis (≤ 10 vs. >10 degrees) and wedge angles (≤ 7 vs. >7 degrees). Outcomes were classified as excellent, fair, and poor in terms of VAS scores (<3, 3-6, >6) and RMDQ scores (<8, 8-16, >16). Correlations between the kyphosis and wedge angles and VAS and RMDQ scores were assessed. RESULTS: VAS and RMDQ scores correlated positively with the kyphosis and wedge angles; the highest correlation was between the VAS score and kyphosis angle (r=0.93). A significantly greater proportion of excellent outcomes (in terms of RMDQ and VAS scores) were noted in patients with preoperative kyphosis and wedge angles of ≤ 10 and ≤ 7 degrees, respectively. CONCLUSION: PV is a viable treatment for vertebral compression fractures with regard to pain relief and improvement of function. Preoperative kyphosis and wedge angles were predictive of post-PV outcomes in terms of VAS and RMDQ scores.

Correlation of low back pain to a high-intensity zone of the lumbar disc in Indian patients.

PURPOSE: To assess the correlation between low back pain and a high-intensity zone (HIZ) of the lumbar disc in Indian patients. METHODS: 200 patients with low back and/or leg pain underwent magnetic resonance imaging of the lumbosacral spine. The location and severity of pain and disability were assessed using the pain drawing, visual analogue scale, and Oswestry Disability Index, respectively. The inter-observer reliability was assessed using the kappa statistic. RESULTS. The prevalence of an HIZ was 13% and 17% according to observers A and B, respectively. The inter-observer reliability was fair (kappa=0.64, p<0.005). The presence of an HIZ did not correlate with low back pain according to the pain drawing, visual analogue scale, and Oswestry Disability Index. According to the pain drawing data, the sensitivity, specificity, and positive predictive values of an HIZ to low back pain were 11%, 82%, and 62%, respectively. CONCLUSION: The presence of an HIZ is not diagnostic of a disrupted and painful disc, and should be interpreted together with other prevailing symptoms and clinical findings.