Surgical management of idiopathic acute cervical kyphosis; A case-based review of an extremely rare entity.

INTRODUCTION AND IMPORTANCE: Acute idiopathic cervical kyphosis (AICK) represents a rare entity, and its management remains controversial. Preoperative surgical planning and individual decision-making seem necessary. To date, there is a lack of sufficient evidence and clear guidelines. CASE PRESENTATION: A 21-year-old male was referred with a progressive cervical deformity detected 3 months earlier. The patient suffered from severe progressive myelopathy and represented neither neck trauma nor a familial history of similar expected conditions. His cervical imaging revealed 95 degrees of cervical kyphosis. After 3 separate surgical sessions for 360-degree fixation, the cervical kyphosis was reduced by 90 degrees. No facet dislocation was observed, and laminectomy was unnecessary. Post-operative neurological examination detected significant improvement. Six months and 2-year follow-ups were favorable. To the authors' knowledge, the current case had the most extensive degree of cervical kyphosis reported in the literature. CLINICAL DISCUSSION: Multistage correction of AICK would result in a favorable outcome and reduce the risk of complications. Particular attention should be paid to the wide inter-spinous spaces in high grades of kyphosis during sub-periosteal dissection to prevent iatrogenic spinal cord injuries. CONCLUSION: The present work may provide the first report on the role of cervical postural habits in patients with opiate substance abuse disorder, which could have triggered cervical kyphosis in this particular patient. Multistage correction of AICK would result in a favorable outcome and reduce the risk of complications.

Neglected cervical meningocele in an adult: illustrative case.

BACKGROUND: Posterior cervical meningoceles are rare in adults because most are surgically excised early in life. Such meningoceles in adults are mostly presented as a cystic mass and their presentation as a solid mass is very rare. OBSERVATIONS: An asymptomatic adult with cervical meningocele presented as a congenital midline skin covered solid mass in the posterior aspect of the neck is presented. Neuroradiological surveys showed attachment of the mass to intradural spinal cord. With diagnosis of a cervical meningocele, after excision of the solid sac, the stalk extending from the core of the mass to the dura was isolated. This was followed by intradural spinal cord detethering. The mass was compatible with rudimentary meningocele in pathology. LESSONS: Neglected cervical meningocele is quite rare in adults. Surgical removal of the mass in adults is usually for cosmetic reasons rather than neurological impairment. However, surgical removal of the mass without intradural cord detethering is not sufficient. In such cases, late onset quadriparesis may be appear due to the spinal cord tethering scenario.

Our experiences in patients with atlanto-occipital dislocation: A case series with literature review.

Atlanto-occipital dislocation (AOD) is an injury to the upper cervical spine that occurs after trauma. This injury is associated with a high mortality rate. According to studies, 8%-31% of deaths caused by accidents are due to AOD. Due to the improvement in medical care and diagnosis, the rate of related mortality has decreased. Five patients with AOD were evaluated. Two cases had type 1, one case had type 2, and two other patients had type 3 AOD. All patients had weakness in the upper and lower limbs and underwent surgery to fix the occipitocervical junction. Other complications in patients were hydrocephalus, 6 nerve palsy, and cerebellar infarction. All patients improved in follow-up examinations. AOD damage is divided into four groups: anterior, vertical, posterior, and lateral. The most common type of AOD is type 1 and the most instability is type 2. There are neurological and vascular injuries due to pressure on regional components; vascular injuries are associated with high mortality rate. In most patients, their symptoms improved after surgery. AOD requires early diagnosis and immobilization of the cervical spine along with maintaining the airway to save the patient's life. It is necessary to consider AOD in cases with neurological deficits or loss of consciousness in the emergency unit because earlier diagnosis could cause a wonderful improvement of the patient's prognosis.

Syrinx associated with cervical spondylosis: A report of 13 cases.

Background: Sustained compression of the spinal cord by cervical spondylosis may induce arachnoid fibrotic changes and trigger local syrinx formation. Cases Description: Here, we describe 13 cases of syrinx formation in association with cervical spondylosis. In 12 out of 13 patients, the syrinx was incidental finding while screening for simple neck pain. In one case, it was discovered during an evaluation of upper extremity radiculopathy. Over the 3-8-year follow-up period, the syrinx size did not change in 11 cases (i.e., 10 asymptomatic and one with radiculopathy) even after surgical decompression. In the other two cases, the syrinx spontaneously resolved. Conclusion: With the increased utilization of cervical MR imaging, more cases of incidental asymptomatic syrinx formation versus symptomatic lesions contributing to radiculopathy have been discovered.

Six cases of occult sacral meningocele.

Background: Intrasacral occult sacral meningoceles (OSM) are uncommon congenital lesions that rarely become symptomatic, even over a patient's life time. Methods: We operated on six patients with symptomatic OSM diagnosed on MR studies (all six) and/or CT examinations (four cases). Results: All six patients had uneventful postoperative recoveries. Nevertheless, despite the resolution of low back pain and radiculopathy, preoperative bladder dysfunction improved postoperatively in only one patient. Conclusion: Few cases of patients undergoing surgery for symptomatic OSM are reported in the literature. Here, we recount our experience with six patients with symptomatic OSM who demonstrated significant postoperative neurological recoveries except for rare improvement in bladder function.

Symptomatic thoracic ossified ligamentum flavum in achondroplasia: A case report and literature review.

BACKGROUND: In a patient with achondroplasia, it is rare to encounter thoracic cord compression due to both spinal stenosis and ossification of the yellow ligament (OYL). CASE DESCRIPTION: A 33-year-old achondroplastic female presented with a progressive spastic paraparesis attributed to thoracic stenosis combined with T10-T11 OYL. Following a laminectomy, the patient demonstrated a marked recovery of neurological function. CONCLUSION: This case and 12 others from the literature demonstrated that achondroplastic patients who present with myelopathy secondary to thoracic stenosis and OYL can be readily diagnosed with MR/CT and successfully treated utilizing decompressive laminectomies with/without fusions (i.e., for those crossing the thoracolumbar junction).

Peroneal/posterior tibial nerves delayed dysfunction due to traumatic popliteal artery pseudoaneurysm resulting from trivial stab wound: A case report.

BACKGROUND: Popliteal artery pseudoaneurysms due to stab wounds are extremely rate. Even more infrequently, they can contribute to the compression of multiple peripheral nerves. CASE DESCRIPTION: A 23-year-old male, following a trivial stab wound, developed the delayed occurrence of a pseudoaneurysm of the popliteal artery. This resulted in the delayed onset of a compressive popliteal/posterior tibial neuropathy. Following restoration of blood flow through the popliteal artery utilizing saphenous vein grafting, additional neurolysis resulted in resolution of the compressive neuropathy. CONCLUSION: A 23-year-old male developed a pseudoaneurysm following minor trauma that resulted in peripheral nerve dysfunction.

Anaplastic myxopapillary ependymoma of the sacrum: A case report.

BACKGROUND: Myxopapillary ependymoma (MPE) with anaplastic features is extremely rare. There are very few such case reports in the medical literature. CASE DESCRIPTION: A 23-year-old female presented with lower back pain, and both urinary and fecal dysfunction. The patient underwent gross total surgical excision of the MR documented expansile intrasacral tumor. The histology was compatible with a MPE containing anaplastic features. CONCLUSION: The medical literature contains a few comparable cases of subcutaneous sacrococcygeal MPE with anaplastic components. Here, however, we have a young female with an anaplastic intrasacral MPE treated with gross total surgical excision.

Acute traumatic sequestrated thoracic disc herniation: A case report and review.

BACKGROUND: Pure sequestrated thoracic disc herniations secondary to a traumatic event are rare. CASE DESCRIPTION: Elderly male presented with the sudden onset of severe paraparesis following a fall. The MR showed a left-sided extruded disc at the T10-T11. The patient underwent a thoracic interlaminar laminectomy, removal of one large, and several smaller sequestrated disc fragments utilizing a transfacet corridor requiring placement of an interbody Peek cage, and bilateral T10 and T11 pedicle screw instrumentation. At 6 postoperative months, he sustained a good recovery. CONCLUSION: Acute thoracic disc herniations without attendant fracture/dislocation are rare. When they result in major neurological deficits, timely surgical excision is warranted.

Paraganglioma of the filum terminal: Case report and review of the literature.

Paraganglioma of the filum terminal/cauda equina is a rare slow growing tumor which originates from the ectopic sympathetic neurons. Surgically, total excision may be difficult for this well demarcated tumor surrounded by couple of rootlets but is usually possible in nearly all cases. Actually, final diagnosis cannot be determined intraoperatively, but is possible only after an immunohistochemical staining. Herein, the authors present a middle age woman whose initial symptoms were lower back pain and radiculopathy. Her MRI was found to be compatible with a cauda equina tumor. During her excisional surgery a hard and relatively vascular tumor was fully removed. The Immunohistochemical results were compatible with paraganglioma of the filum terminale. In addition to case presentation, thorough review of the literature is also done.

Symptomatic thoracic ossification of the ligamentum flavum in a patient with ankylosing spondylitis: Report of a case and review.

BACKGROUND: Thoracic spinal cord compression due to both ankylosing spondylitis (AS) and ossification of the ligamentum flavum (OLF) is rare. CASE DESCRIPTION: A 33-year-old male with AS presented with a paraparesis attributed to MR documented T9-T10 OLF/stenosis. He was successfully managed with a decompressive laminectomy; this resulted in marked improvement of his deficit. CONCLUSION: Thoracic OLF and AS rarely contribute T9-T10 spinal cord compression that may be readily relieved with a decompressive laminectomy.

Double-level myelopathy due to atlantoaxial dislocation (os odontoideum) and subaxial cervical spondylosis with angular kyphosis.

BACKGROUND: The surgical management of cervical spondylotic myelopathy (CSM) attributed to os odontoideum (OO with atlantoaxial instability atlantoaxial instability) and subaxial kyphosis together pose significant surgical challenges. CASE DESCRIPTION: An elderly male presented with CSM/myelopathy and severe quadriparesis attributed to an unstable OO and 87° fixed, subaxial cervical kyphosis. After performing a 540° spinal cord decompression with atlantoaxial fixation, the patient did well. CONCLUSION: Double-level CSM due to an unstable OO and subaxial kyphosis is rare and typically requires combined 540° decompression and stabilization.

Anterior sacral meningocele complicated by rectothecal fistula and rectorrhea: A Case report and review of the literature.

BACKGROUND: Anterior sacral meningocele (ASM) is a rare congenital anomaly. It is characterized by herniation of the dura through a defect in the anterior sacrum. Rarely, however, it may extend to the rectal area through a rectothecal fistula with or without rectorrhea. CASE DESCRIPTION: Here, we present a case of ASM associated with a rectothecal fistula and rectorrhea. Surgical closure of the ostium of the cyst through a posterior approach resulted in long-term improvement. CONCLUSION: An ASM with both rectothecal fistula and rectorrhea is extremely rare.

Spinal intramedullary epidermoid cysts: Three case presentations and literature review.

BACKGROUND: True intramedullary epidermoid cysts (IECs) not associated with congenital anomalies or previous spinal procedures are extremely rare. In a review of the literature since 1992, only 29 such cases have been reported. Here, we add three new cases in this category. CASE DESCRIPTION: Three adults presented with spastic paraparesis attributed to thoracic IECs. Gross total microsurgical removal was achieved in two cases, while one case was a partial resection due to capsular adherence to the cord. In all three cases, patients sustained complete recoveries of neurological function and remained symptom free for an average of 5 years follow-up. CONCLUSION: IECs are rare lesions; here, the three located in the thoracic spine, contributed to slow, progressive spastic paraparesis with/without incontinence, and resolved following total (2 patients) and partial (1 patient) resection.

Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review.

BACKGROUND: In osteoporotic patients, a useful technique for significantly enhancing the strength of a pedicle screw is augmentation with polymethylmethacrylate cement. However, a rare complication of this procedure is a symptomatic pulmonary cement embolism. CASE DESCRIPTION: A pedicle screw cement augmentation was performed in a middle-aged female for the failed back syndrome. When she developed symptomatic pulmonary cement emboli, she was successfully managed with conservative measures, including anticoagulation. CONCLUSION: Despite the increased use of cement augmentation for pedicle screw placement and the relatively high incidence of cement leakage into the prevertebral venous system, symptomatic cement pulmonary embolism remains rare. The management of such symptomatic CPE should be evaluated and treated based on both the size and location of the embolism. Here, we presented this case while reviewing three symptomatic and four asymptomatic cases from the literature.

Painful torticollis due to tubercular atlantoaxial rotatory fixation: A case report.

BACKGROUND: Tubercular atlantoaxial, rotary dislocation warranting fixation (AARF) is an extremely rare event. CASE DESCRIPTION: AARF was suspected in a 23-year-old female with painful torticollis. When diagnostic studies documented unilateral destruction of the left lateral mass of the atlas, she underwent removal of the lateral mass, reduction of the deformity, and C1-C2 fusion/reconstruction utilizing an iliac bone graft. Laboratory tests and the pathologic surveys were all consistent with the diagnosis of underlying tuberculosis. CONCLUSION: We present a case of tubercular atlantoaxial, rotary dislocation (AARF) in a patient who warranted C1-C2 decompression, reduction, and fusion.

Symptomatic intraspinal lumbosacral pseudomeningocele, a late consequence of root avulsion injury secondary to a gunshot wound.

BACKGROUND: Traumatic pseudomeningocele are usually a late consequence of cervical root avulsion injury and its occurrence in lumbosacral region is rare. This pathology is mostly due to violent blunt traumatic events and usually develops outside of the spinal canal. Occasionally, a pseudomeningocele may grow inside of the spinal canal causing delayed neurological deficit due to compromise of the adjacent neural structures. CASE DESCRIPTION: Evaluation of a delayed left lower extremity weakness in a young man with a history of a gunshot wound injury revealed an extradural pseudomeningocele arising from an S1 root avulsion injury with compressive effect on the adjacent L5 root. OUTCOME: Excision of the cyst wall and reinstitution of the nerve root sheath resulted in an uneventful recovery. CONCLUSION: To the best of our knowledge, the presented case with traumatic pseudomeningocele is the first example secondary to high velocity bullet injury. Furthermore, management of traumatic intraspinal pseudomeningocele subsequent to root avulsion injury has not been paid sufficient attention. In this paper, the surgical strategy will be discussed in detail.

Septic cavernous sinus thrombosis secondary to halo vest pin site infection.

BACKGROUND: Pin site infection is one of the frequent complications of the halo crown application which can be easily handled if addressed early. However, if this issue is neglected then serious infectious events may quickly transpire. Among all of the medical literature that the previously described scenarios have illuminated; we did not encounter a case involving infectious cavernous sinus thrombosis. CASE DESCRIPTION: The authors present a middle age man who arrived at our clinic with an acute left peri-orbital swelling, proptosis, and ophthalmoplegia which had occurred subsequent to an untreated halo pine site infection. With a diagnosis of septic cavernous sinus thrombosis (CST), appropriate antibiotics and anticoagulant therapies were administered. OUTCOME: With the continuation of this conservative treatment regimen, he was successfully managed with no residual neurological consequences. CONCLUSION: Halo vest orthosis is an appropriately tolerated upper cervical spinal stabilizing device that is a commonly used worldwide. Septic CST that is secondary to a halo vest pin site infection has not been previously described within medical literature. In the case of a neglected pin site infection, with demonstration of ipsilateral eyelid edema and proptosis, septic CST should be immediately considered and treated vigorously with antibiotics and anticoagulant therapies.

Intramedullary mature teratoma with an exophytic component in an adult: Report of a case and literature review.

Background: Intramedullary mature teratomas (IMMTs) are rare. This is particularly true in the adult population. Case Description: A 49-year-old female developed progressive paraparesis due to a T6 intramedullary mature teratoma with an exophytic component. She was successfully managed, utilizing a laminectomy with microsurgical tumor removal. The literature review documented 57 similar cases. Conclusion: Here, we presented a 49-year-old female with a T6 intramedullary mature teratoma accompanied by an exophytic component who underwent total tumor resection with an incomplete recovery.

Intermittent penile erection in lumbar spinal stenosis: Report of four new cases and review.

BACKGROUND: Lumbar spinal stenosis (LSS) classically presents with intermittent neurogenic claudication. Rarely, however, it may cause unanticipated, unpleasant, involuntary, and transient penile erections without sexual stimulation along with urinary urgency and claudication. CASE DESCRIPTION: The authors present four males with LSS whose principal symptoms were intermittent neurogenic claudication and unanticipated erections while walking, accompanied by urinary urgency. CONCLUSION: There is scant literature on the topic of LSS presenting with unanticipated penile erections, urinary urgency, and neurogenic claudication.