Reactivation of dormant lumbar methicillin-resistant Staphylococcus aureus osteomyelitis after 12 years.

The adequate treatment of methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis has intrigued clinicians for some time. As the resistance of these pathogens, coupled with the increase in community-acquired cases, continues steadily to rise, clinicians are finding it useful to employ multi-modal approaches for efficacious treatment. The authors present a single case report of a patient with recurrent MRSA osteomyelitis, lumbar paraspinal and epidural abscess. He was found to have decreased muscle strength and was hyporeflexic in the involved extremity. Serum testing demonstrated MRSA bacteremia. Neuroimaging studies revealed evidence of paraspinal abscess and a presumed herniated nucleus pulposus at the L5/S1 interspace with significant nerve root compromise. Despite antimicrobials, his symptoms persisted, necessitating surgical exploration. At surgery, paraspinal and epidural abscesses were encountered and debrided; however, no herniated disc was visualized. This case demonstrates the diagnostic and therapeutic dilemmas with which these lesions present. We postulate that the MRSA osteomyelitis/discitis pathogens were walled off in the disc space and subsequently inoculated the soft tissues with ensuing bacteremia. We concur that antimicrobial treatment should be the first line of therapy for these patients; however, surgical debridements and cautious spinal instrumentation should be employed where appropriate.

Intradural extramedullary mature cystic teratoma: not only a childhood disease.

OBJECTIVE: The authors report on the first case of a spinal intradural extramedullary cystic teratoma in an aged patient. These lesions have been reported in adolescents and young adults often with a history of spinal dysraphism. They are believed to be congenital lesions; however, they have also been reported in patients with a history of posterior spinal surgery or lumbar puncture. METHOD: An 85-year-old man was evaluated for persistent and progressive lower extremity paresis. His symptoms began after relatively minor trauma. He had no prior lumbar surgeries. Neuroimaging studies revealed an L1-L2 intradural mass. A putative diagnosis of a cystic intradural extramedullary mass was made. A lumbar laminectomy and durotomy were performed. RESULTS: A cystic lesion containing hair follicles, cartilage, adipose, and neural tissue was encountered. Pathologic review corroborated the diagnosis of cystic teratoma. CONCLUSIONS: The occurrence of cystic teratomas in the absence of previous surgery or lumbar puncture is uncommon. Even rarer are reports of these lesions in aged patients. Of particular interest in this case is the fact that this patient had not undergone any previous lumbar procedures nor did he have a history of spinal dysraphism. Though rare, this entity should be included in the differential of cystic intradural spinal cord lesions.

Umbilical and bilateral inguinal hernias in a veteran powerlifter: is it a pressure-overload syndrome?

Umbilical, inguinal and hiatal hernias are all thought to occur from basically the same etiology, a malformation in the tissue leading to herniation. The mechanisms for these malformations range from congenital to degenerative. Earlier studies proposed that hiatal hernias result from age-related degenerative changes in the phrenoesophageal ligament leading to subsequent herniation. We found that hiatal hernias occur in young power athletes secondary to intra-abdominal pressure overload of the phrenoesophageal ligament. We present a case of umbilical and bilateral inguinal hernias occurring in a veteran powerlifter. The pathogenesis of multiple hernias and the physiological pressure systems involved in the development of multiple hernias in a power athlete are discussed.

Radial tunnel syndrome in an elite power athlete: a case of direct compressive neuropathy.

Radial tunnel syndrome (RTS) is thought to result from intermittent and dynamic compression of the posterior interosseous nerve (PIN) in the proximal part of the forearm associated with repeated supination and pronation. The diagnostic criteria encompassing RTS are purely clinical and the term "radial tunnel syndrome" has become controversial because of the lack of focal motor weakness in the majority of patients diagnosed with RTS. Retrospective cadaveric and surgical studies have revealed several areas within the forearm in which the PIN may become entrapped. Recent studies have suggested that the PIN is "fixed" in the supinator muscle and that wrist pronation is the actual movement that places the most stress on the PIN. The patients most often afflicted with RTS appear to be those who perform repetitive manual tasks involving rotation of the forearm and athletes involved in racket sports. Surgical exploration with decompression of the PIN is often required in patients with RTS. We present the first case of RTS occurring in an elite power athlete and believe this case represents a direct compressive sensory neuropathy. The optimum nonsurgical treatment plan for the elite athlete in training for competition and the cause of this compressive neuropathy in power athletes will be discussed.