Rheumatoid pannus presenting as a large epidural mass in the subaxial cervical spine: A case report.

Rheumatoid arthritis (RA) is a debilitating inflammatory condition characterised by joint damage that affects the cervical spine most commonly at the atlantoaxial joint resulting in neck pain and myelopathy. The pathogenesis of RA involves the formation of a hyperplastic synovial tissue, termed pannus, which invades the local bone and causes osseous erosion. Here, we describe a case of rapid onset quadriparesis due to spinal cord compression at C5-C6 secondary to vertebral subluxation and mass effect from a large inflammatory pannus in the subaxial spine. Surgical decompression and resection of the subaxial pannus were performed, and the patient regained strength in all extremities. Histopathologic evaluation of the resected tissue confirmed the diagnosis of pannus over other more common epidural masses. Pannus formation commonly occurs in the peri-odontoid region; however, its presentation as a large soft tissue mass in the subaxial spine is not described in the current literature. Therefore, pannus should be considered in the differential diagnosis of epidural masses in the spine of RA patients. We use this case to discuss the pathology and radiological findings relevant to rheumatoid pannus formation in the subaxial cervical spine, as well as emphasise the importance of treatment in the context to severe degenerative disease.

Onyiuke Grading Scale: A clinical classification system for the diagnosis and management of Bertolotti syndrome.

BACKGROUND: Lumbosacral transitional vertebrae (LSTV) is a common anatomic variant of the spine, characterized by the formation of a pseudoarticulation between the transverse process of the lumbar vertebrae and sacrum or ilium. LSTVs have been implicated as a potential source of low back pain - dubbed Bertolotti syndrome. Traditionally, LSTVs have only been subdivided into types I-IV based on the Castellvi radiographic classification system. OBJECTIVE: Solely identifying the type of LSTV radiographically provides no clinical relevance to the treatment of Bertolotti syndrome. Here, we seek to analyze such patients and identify a clinical grading scale and diagnostic-therapeutic algorithm to optimize care for patients with this congenital anomaly. METHODS: Patients presenting with back pain between 2011 and 2018 attributable to a lumbosacral transitional vertebra were identified retrospectively. Data was collected from these patients' charts regarding demographic information, clinical presentation, diagnostic imaging, treatment and outcomes. Based on evaluation of these cases and review of the literature, a diagnostic-therapeutic algorithm is proposed. RESULTS: Based on our experiences evaluating and treating these patients and review of the existing literature, we propose a clinical classification system for Bertolotti syndrome: we proposed a 4-grade scale for patients with Bertolotti syndrome based upon location, severity, and characteristics of pain experienced due to LSTVs. CONCLUSION: Based on our experience with the cases illustrated here, we recommend managing patients with LSTV based on our diagnostic-therapeutic algorithm. Moving forward, a larger prospective study with a larger patient cohort is needed to further validate the treatment paradigm.

The affinity of lipid-coated microbubbles to maturing spinal cord injury sites.

OBJECTIVE: This laboratory has demonstrated that lipid-coated microbubbles (LCMs) effectively aggregate and deliver chemotherapeutic drugs into rat brain tumor cells and antigliosis agents into maturing rat brain injury sites. In this study, we report the affinity of tail vein-injected LCMs to the injured rat spinal cord by a compressive lesion to the upper thoracic region. METHODS: The accumulation of LCMs in the injured spinal cord was analyzed by labeling it with a lipid-soluble fluorescent dye, 3,3'-dioctadecyloxacarbocyanine perchlorate. Indices of glial fibrillary acidic protein were measured concomitantly with 3,3'-dioctadecyloxacarbocyanine perchlorate-labeled LCMs using confocal microscopy. RESULTS: There was no aggregation of LCMs accumulated 1 and 6 hours after injury; however, when given 2, 4, and 7 days after injury, LCMs showed a clear affinity for the injured region. LCM aggregation shifted from the central necrotic area of the injury on postinjury Day 2 and postinjury Day 4 to the white matter among glial fibrillary acidic protein-positive astrocytes by postinjury Day 7. CONCLUSION: Affinity of LCMs for spinal cord injury sites may be mediated in the early stages after injury by proliferating macrophages in the necrotic center, and then in later stages by glial fibrillary acidic protein-positive astrocytes in adjacent white matter. These findings suggest a potential for using LCMs as a delivery vehicle to concentrate lipid-soluble agents in spinal cord injury sites.

Comparison of percutaneous ventriculostomies and intraparenchymal monitor: a retrospective evaluation of 156 patients.

Intraventricular catheters (IVC) and Intraparenchymal fiberoptic catheters (IPC) are the prevalent methods of intracranial pressure (ICP) monitoring. This study assesses the complications caused by either method. Previous studies have shown a higher complication rate with IVC. In 156 consecutive patients, with IVC (n = 104) or IPC (n = 52) insertion, the demographics, Glasgow coma score (GCS), ICP, duration of monitoring, changes in monitoring device, complications and computerized tomography findings, were recorded. The patients were categorized into severe (GCS 3-8), moderate (GCS 9-12) and mild (GCS 13-15) groups. A retrospective, comparative analysis of both techniques was conducted, using Kruskal-Wallis one way analysis of variance with chi square approximation and Mann-Whitney U tests. The use of IPC at 86.5% predominated in patients with GCS 3-8, while IVC at 81.4% and 92% prevailed in GCS groups 9-12 and 13-15, respectively (p = 0.000). 43.2% IVC were used for 10+ days and 25.9% for 1-3 days, while 80% of IPC were used for less than 6 days (p = 0.000). The complication rate for IVC and IPC was 25% vs 4.4% (p = 0.000). The infection rate was 4.4% and 0.6% (p = 0.1) while, inadvertent removal 4.4% vs 1.2% (p = 0.4), respectively. Malpositions occurred only with IVC (20.1%). All documented complications were without untoward clinical sequelae. We conclude that, IVC remains comparable to IPCs in complications.

Hemorrhagic necrotic schwannoma presenting as purulent meningitis.

BACKGROUND: Intracranial schwannoma involving the XIIth cranial nerve is rare. We report an unusual clinical presentation and pathological verification of a schwannoma, which had become haemorrhagic and necrotic, simulating acute purulent meningitis. METHODS: A literature review of intracranial tumors presenting as acute purulent meningitis, with emphasis on schwannomas, was undertaken. RESULTS: Few cases of hypoglossal schwannoma have been reported; the association with purulent meningitis has not been previously documented. CONCLUSION: In patients presenting with sterile purulent meningitis, a necrotic tumor should be considered as a possible etiology.

Idiopathic granulomatous angiitis of the CNS manifesting as diffuse white matter disease.

A 48-year-old man presented with progressive spastic paraparesis and diffuse white matter involvement on neuroimaging that suggested a primary demyelinating disease. Brain biopsy 3 years after onset of symptoms demonstrated idiopathic granulomatous angiitis. In patients with MRI features of diffuse white matter disease of uncertain etiology, open brain biopsy of leptomeninges and parenchyma should be considered to exclude idiopathic granulomatous angiitis of the CNS.