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Introduction: Although magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing cauda equina syndrome (CES), computerized tomography (CT) myelogram may be used in patients who are unable to undergo MRI. When inserting the needle for CT myelogram, there is a risk of cerebrospinal fluid (CSF) leak, which theoretically could lead to CES. To the best of our knowledge, there are no reports of CT myelogram resulting in cauda equina compression. Case Report: We report the case of a 38-year-old man who underwent surgical decompression for CES and developed an iatrogenic CSF leak from a pre-operative CT myelogram causing recurrent thecal sac compression requiring repeat surgery and dural repair. Conclusion: Although CT myelogram may be used to aid in the diagnosis of CES, consideration should be given to the potential risk for causing a CSF leak and resultant thecal sac compression.
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STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To evaluate the impact of computed tomography angiography (CTA) in the management of trauma patients with cervical spine fractures by identifying high-risk patients for vertebral artery injury (VAI), and evaluating how frequently patients undergo subsequent surgical/procedural intervention as a result of these findings. METHODS: All trauma patients with cervical spine fractures who underwent CTA of the head and neck at our institution between January 2013 and October 2017 were identified. Patients were indicated for CTA according to our institutional protocol based on the modified Denver criteria, and included patients with cervical fractures on scout CT. Those with positive VAI were noted, along with their fracture location, and presence or absence of neurological deficit on physical examination. Statistical analysis was performed and odds ratios were calculated comparing the relationship of cervical spine fracture with presence of VAI. RESULTS: A total of 144 patients were included in our study. Of those, 25 patients (17.4%) were found to have VAI. Two patients (1.4%) with VAI underwent subsequent surgical/procedural intervention. Of the 25 cervical fractures with a VAI, 20 (80%), were found to involve the upper cervical region (4.2 OR, 95% CI 1.5-12.0; P = .007). Of the 25 who had a VAI, 9 were unable to undergo reliable neurologic examination. Of the remaining 16 patients, 5 (31.3%) had motor or sensory deficits localized to the side of the VAI, with no other attributable etiology. CONCLUSIONS: Cervical spine fractures located in the region of the C1-C3 vertebrae were more likely to have an associated VAI on CTA. VAI should also be considered in cervical trauma patients who present with neurological deficits not clearly explained by other pathology. Despite a finding of VAI, patients rarely underwent subsequent surgical or procedural intervention.
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Vertebral compression fractures are a significant source of morbidity and mortality among patients of all age groups. These fractures result in both acute and chronic pain. Patients who sustain such fractures are known to suffer from more comorbidities and have a higher mortality rate compared with healthy people in the same age group. In recent years, balloon kyphoplasty has become a popular method for treating vertebral compression fractures. However, as longer-term follow-up becomes available, the effects of cement augmentation on adjacent spinal segments require investigation. Here, we have performed a retrospective chart review of 258 consecutive patients with pathologic vertebral compression fractures secondary to osteoporosis, treated by either conservative measures or balloon kyphoplasty with polymethylmethacrylate cement augmentation. Multivariate analysis of patient comorbidities was performed to assess the risks associated with subsequent adjacent and remote compression fracture at a minimum of 2 years follow-up. A total of 258 patients had 361 vertebral compression fractures. A total of 121 patients were treated nonoperatively and 137 underwent balloon kyphoplasty with polymethylmethacrylate cement augmentation. The mean follow-up for both cohorts was 2.7 years (range, 2-6 years). The kyphoplasty cohort was significantly older than the nonoperative cohort (mean age, 78.5 versus 74.2 years; p = 0.02), had 24 more patients with diabetes mellitus (37 versus 13; p = 0.05), and had 34 more patients with a history of smoking (50 versus 16; p = 0.05). However, the kyphoplasty cohort had less patients with a history of non-steroidal anti-inflammatory drug (NSAID) use (45 versus 71; p = 0.07). There were no demographic differences between groups in patients with secondary fractures. Nonoperative treatment was identified as a statistically significant independent risk factor for subsequent vertebral compression fracture [odds ratio (OR), 2.28]. Univariate analysis identified age, diabetes mellitus, smoking, NSAID usage, and female gender as risk factors for subsequent vertebral compression fracture. When adjusted for multivariate analysis, no individual factor demonstrated increased risk for subsequent fracture. Patients diagnosed with vertebral compression fractures secondary to osteoporosis suffer from multiple medical comorbidities. No particular comorbidity was identified as solely attributable for increased risk of subsequent remote or adjacent compression fractures. Patients in this series treated with nonoperative (conservative) management had a 2.28 times greater risk for a subsequent vertebral compression fracture than patients treated with balloon kyphoplasty and polymethylmethacrylate cement augmentation.
