Single-door cervical laminoplasty using titanium miniplates alone.

PURPOSE: To review outcome of 29 patients who underwent single-door cervical laminoplasty for myelopathy using titanium miniplates alone. METHODS: Records of 20 men and 9 women aged 35 to 79 (mean, 64.3) years who underwent single-door cervical laminoplasty for myelopathy using titanium miniplates alone were reviewed. A total of 125 laminae were opened; 97 of them were fixed with a titanium miniplate. In 19 patients, a 20-hole titanium miniplate bent to the contour of a lamina was used and fixed into 3 laminae at alternate levels. In the remaining 10 patients, the pre-contoured ARCH Laminoplasty System was used and fixed into all laminae. In most patients, screw fixation was unicortical, and no spacer or bone graft was used. RESULTS: The mean follow-up duration was 4 (range, 2-9) years. At one-year follow-up, the mean Japanese Orthopaedic Association (JOA) score improved from 9.2 to 13.2 (p<0.001). The mean JOA recovery rate was 64%. No patient had neurological deterioration. The mean anteroposterior diameter increased from 14.3 mm to 19.7 mm; the mean increase was 6.1 mm in the plated laminae and 5.3 mm in the unplated laminae (p=0.11). Out of the 125 laminae, there were 2 hinge non-unions in the unplated laminae, and 2 screw pullouts (not associated with plate loosening). No patient had penetration into the vertebral foramen or neuroforamen. Spring-back closure occurred in 5 (18%) of the 28 unplated laminae, with a mean of <3 mm loss of the initial expansion. Two patients developed transient C5 palsy presenting as shoulder abduction weakness. One patient had a delayed dural tear due to a sharp spike at the edge of the opened C6 lamina. CONCLUSION: Single-door cervical laminoplasty using miniplates alone is a safe technique and achieves a high hinge union rate, good canal expansion, and neurological recovery.

Nightmare of lumbar diskectomy: aorta laceration.

STUDY DESIGN: Case report. OBJECTIVE: To present a rare case of a patient who during posterior lumbar spinal decompression and diskectomy underwent a laceration of the aorta. The patient survived with prompt treatment. SUMMARY OF BACKGROUND DATA: Intraoperative injuries of the prevertebral and pelvic vessels are infrequent but serious complications of posterior lumbar disc surgery. Injury may cause laceration of the vessel with acute life-threatening retroperitoneal hemorrhage, which is usually massive. The aortic bifurcation is closely approximated to the anterior surface of the L4-L5 disc. METHODS: A 70-year-old gentleman with prolapsed intervertebral disc between fourth and fifth lumbar vertebrae and left-sided radiculopathy of L5 root was operated with L4-L5 laminectomy and L4-L5 diskectomy. During diskectomy, it was noticed by the surgeon that there was one episode of giving way of the pituitary rongeur anteriorly. However, no major bleeding was encountered from the disc space immediately after the event; vital signs were stable hemodynamically and we completed the diskectomy. Five minutes later, we noted the dural sac to have a collapsing pulsation. Prevertebral vessel injury was suspected. Patient became pulseless. RESULTS: We turned the patient supine for cardiopulmonary resuscitation without extubation. Vascular surgeons proceeded with laparotomy. Huge retroperitoneal hematoma and a 1.5 × 1.5 cm laceration at the bifurcation of aorta were noted anterior to the L4-L5 intervertebral disc. The vascular surgeon repaired the aorta by primary repair. The patient was extubated on day 5 and was allowed to ambulate. He was discharged subsequently with a normal neurological and vascular examination. No pseudoaneurysm or arteriovenous fistula formation was detected on magnetic resonance imaging and magnetic resonance angiography at 2 years follow-up. CONCLUSION: Iatrogenic vascular injury during posterior lumbar disc surgery, although rare, should be suspected if signs of circulatory instability or abnormal pulsation of the dural sac are noted, especially if any lapse in the ordinary technique has been observed. In preoperative imaging, note the position of the aorta and prevertebral veins and the depth and integrity of the anterior wall of the disc.

Calcinosis cutis of the hand in a renal failure patient: a case report.

A 25-year-old woman with end-stage renal failure presented with subcutaneous calcinosis cutis that grew rapidly in both hands. Radiographs showed subcutaneous lobulated calcific deposits. Magnetic resonance imaging revealed a heterogeneous mass encasing segments of the abductor pollicis longus and extensor pollicis brevis tendons. Excision of the masses was performed. Histopathology revealed amorphous calcified deposits in fibrous tissue and a foreign body reaction. There was no evidence of a tubercular lesion. Further investigation revealed the presence of hyperphosphataemia and secondary hyperparathyroidism, despite a normal serum calcium level. Oral phosphate-lowering agents failed to control the condition, and recurrence was noted 6 months later. The patient finally underwent parathyroidectomy and has had no further recurrence.

Chronic pain and psychiatric morbidity: a comparison between patients attending specialist orthopedics clinic and multidisciplinary pain clinic.

OBJECTIVE: The objective of this study was to examine the associations between chronic pain and psychiatric morbidity using interview-based assessments of psychiatric symptomatology. We compared the prevalence of common mental disorder (CMD; consistent with neurotic and somatic symptoms, fatigue, and negative affect), depression, and anxiety disorder(s), and associated factors with these psychiatric illnesses among Chinese patients with chronic pain attending specialist orthopedics clinic and multidisciplinary pain clinic. METHODS: A total of 370 patients with chronic pain were recruited from an Orthopedics Clinic (N=185) and a Pain Clinic (N=185) in Hong Kong. Psychiatric morbidity was assessed using the Revised Clinical Interview Schedule. Individual scores for neurotic symptoms and neurotic disorders (including depression and four types of anxiety disorders) were also calculated. RESULTS: The reported lifetime prevalence rates of CMD were 35.3% and 75.3% for the Orthopedics and Pain Clinic samples, respectively. Rates of depression and anxiety disorders in the Pain Clinic (57.1% and 23.2%, respectively) were significantly higher than those in the Orthopedics sample (20.2% and 5.9%, respectively) (all P<0.001). Pain characteristics including number of pain sites, pain duration, pain intensity, and pain interference were all significantly associated with psychiatric morbidity after controlling for sociodemographic factors. Pain duration and litigation/compensation status consistently predicted concurrent pain intensity and disability. CONCLUSIONS: Chronic pain is associated with psychiatric morbidity. The higher rate of depression than anxiety disorder(s) among patients with chronic pain is consistent with previous studies that have found depression to be highly prevalent in chronic pain.

Pick-up test: an indication for opponensplasty in patients with severe carpal tunnel syndrome.

PURPOSE: To use a pick-up test to assess thenar motor deficit and results of opponensplasty. METHODS: Eight consecutive patients with idiopathic severe carpal tunnel syndrome and severe thenar motor deficit were identified. All were females aged 39 to 60 (mean, 53) years and right-hand dominant. The severity of thenar motor deficit was assessed using the pick-up test. Failure to pick up a coin with the thumb and index finger only in a normal pulp-to-pulp pincer grip was an indication for an opponensplasty (in addition to open carpal tunnel release) to hasten recovery of thumb abduction. Treatment outcome was assessed using the pick-up test at 6, 8, and 12 weeks. RESULTS: Preoperatively, all patients were unable to perform the pick-up test. At postoperative 6 weeks, all patients could pick up the coin with no difficulty and were satisfied with the result of opponensplasty. There was no relapse at subsequent follow-ups and no donor-site morbidity in terms of cosmesis, scar pain or infection. Grip strength and the range of wrist motion were 63% and 92% of the normal side, respectively. CONCLUSION: The pick-up test is a simple and reliable means of identifying those in need of an opponensplasty.

Anterior spinal fusion versus laminoplasty for cervical spondylotic myelopathy: a retrospective review.

PURPOSE: To compare outcomes of anterior spinal fusion (ASF) versus laminoplasty for cervical spondylotic myelopathy (CSM). METHODS: Records of 26 women and 37 men aged 34 to 83 (mean, 67) years who underwent ASF or laminoplasty for CSM were reviewed. Patient demographics, duration of symptoms, pre- and post-operative Japanese Orthopaedic Association (JOA) scores, Hirabayashi recovery rate, and radiographic features (including anteroposterior canal diameter, Pavlov ratio, and number of levels compressed) were compared. RESULTS: The mean duration of symptoms was 9 months. The mean follow-up period was 40 months. Patients who underwent laminoplasty were older (p=0.015) and had more levels compressed (p<0.001) than those who underwent ASF. Patients with C3/4 compression were older than those without it (p=0.044). Younger patients had higher Hirabayashi recovery rate (p=0.043). CONCLUSION: The surgical decision for ASF or laminoplasty mainly depends on the number of levels compressed and patient age. Laminoplasty is usually reserved for older patients with multiple level involvement. Age is the main predictive factor for surgical outcome.

Rotary subluxation of the metacarpophalangeal thumb joint: a case report.

Irreducible rotary subluxation of the metacarpophalangeal joint (MCPJ) of the thumb is a rare entity. Open reduction is indicated when signs of irreducibility are seen on the radiographs. We present one such case caused by displacement of the sesamoid bone into the intercondylar notch of the first metacarpal bone. A 35-year-old woman sustained a twisting injury to her right thumb by pronating and hyperextending it while attempting to retrieve things that she had dropped into a basin conduit. True lateral radiographs showed rotary subluxation of the thumb MCPJ, a sesamoid bone overlapping with the metacarpal head, and loss of the subsesamoid joint space and an incongruent MCPJ on full flexion. A high level of clinical suspicion is needed to diagnose this rare entity.

Ossification of the ligamentum flavum in the cervicothoracic junction: case report on ossification found on both sides of the lamina.

STUDY DESIGN: A case of ossification on both sides of the ligamentum flavum in the cervicothoracic junction is described. OBJECTIVES: To review the pathology associated with ossification of the ligamentum flavum in the spine and its incidence at the cervicothoracic junction. SUMMARY OF BACKGROUND DATA: The literature on the common sites for ossification of the ligamentum flavum is reviewed. No report described ossification on the outer surface of the ligament presenting as ossification nodules on the medial side of the apophyseal joint. METHODS: The clinical, radiographic, and pathologic features associated with ossification of the ligamentum flavum are presented. The ossified ligament grew into nodular masses on both surfaces: posterolaterally on the medial surface of the apophyseal joint and anteromedially on the undersurface of the lamina. The masses were connected by a film of elastic fibers from the remnant ligamentum flavum. RESULTS: The symptoms and physical signs of cervical myelopathy improved after laminectomy and removal of the ossified ligament. There was no recurrence. CONCLUSION: The reported case adds to the literature on the pathology associated with ossification of the spinal ligaments.

Intradural spinal metastasis from renal cell carcinoma: A case report.

Intradural spinal metastasis is rare. This is the third case ever reported on the finding of intradural spinal metastasis from a renal cell carcinoma that had been removed surgically. The patient had a history of epidural metastasis for which excision and anterior stabilization were done 3 years before the new presentation with cauda equina lesion. Seeding from the involved osseous structure to the cerebrospinal fluid through the dura was believed to be the course that tumour had taken to reach the intradural space.