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.

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.

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.

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.

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.

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.

Rivaroxaban-induced acute cervical spine epidural hematoma: Report of a case and review.

BACKGROUND: Spontaneous spinal epidural hematomas (SEHs) due to the utilization of factor Xa inhibitors are rare. CASE DESCRIPTION: A 66-year-old female presented with a Brown-Sequard syndrome attributed to a cervical epidural hematoma secondary to the utilization of rivaroxaban, one of the factor Xa inhibitors. Following a cervical laminectomy for the evacuation of the hematoma, the patient completely recovered. CONCLUSION: A spinal hemorrhagic event should be suspected in patients receiving factor Xa inhibitor drugs. Here, we had an elderly female on rivaroxaban experienced the acute onset of neck/back pain associated with a Brown-Sequard syndrome. A literature review showed that this is the seventh example of SEH occurring as a result of the use of anticoagulation drugs (OACDs; e.g., including Xa inhibitors).

Congenital cervical isthmic spondylolisthesis: A case report.

BACKGROUND: There are only 20 reported cases of cervical isthmic spondylolisthesis in literature that have been surgically managed either anteriorly or posteriorly. Herein, we report such a case managed with circumferential fusion. CASE DESCRIPTION: A 27-year-old male became progressively quadriparetic due to cervical isthmic spondylolisthesis at the C6-C7 level. Removal of the posterior arch of C6 with subsequent C5-C7 pedicle screw/rod fixation and anterior interbody fusion resulted in marked recovery and adequate cervical realignment. CONCLUSION: For patients with cervical isthmic spondylolisthesis, circumferential fusion provides the best surgical option to achieve stability and sagittal balance.

Traumatic Chronic Irreducible Atlantoaxial Rotatory Fixation in Adults: Review of the Literature, With Two New Examples.

Atlantoaxial rotatory fixation (AARF) is a rare condition in adults and is almost always due to an accompanying trauma. The first example of traumatic AARF in adults was reported by Corner in 1907 and since then only 55 adult cases with this rare traumatic scenario have been published so far. Approximately 80% of adults with traumatic AARF are diagnosed soon after the traumatic events. However, in the remaining casualties, the condition might be missed with some delay from the diagnosis to treatment. If this pathology is diagnosed early enough, the conservative attempts for a closed reduction are usually effective. After closed reduction, external immobilization is required to prevent recurrence of the dislocation. However, with delayed diagnosis, the condition may remain refractory to traction on manipulation and require an open reduction instead. In the literature, such irreducible chronic AARFs are rarely reported, being confined to only 14 adult examples, in whom surgical intervention for correction of the deformity will be required. In such cases, release of the atlantoaxial facet joints is the first surgical step. In the subsequent step, reduction of the dislocated facet joints can be done via one of the already described maneuvers. As the final step, C1-C2 fixation will be necessary for prevention of re-dislocation. Herein, 2 adult patients with chronic rotatory atlantoaxial dislocation of traumatic origin are presented. In both cases, cranial traction and manipulations were ineffective and therefore an open reduction procedure was proposed and accomplished via the posterior midline corridor. The transverse rod technique was implemented subsequent to the atlantoaxial facet release. After correction of the deformity, a C1-C2 fixation was accomplished followed by arthrodesis. In addition to the outlined procedure, an historical review of the literature on this subject from the beginning of 20th century is demonstrated.

Atlantoaxial Subluxation Secondary to Unstable Os Odontoideum in a Patient With Arrested Hydrocephalus Due to Congenital Aqueductal Stenosis: A Case Report.

BACKGROUND: In a small percentage of children born with congenital hydrocephalus, enlargement of the head and the presence of ventriculomegaly may halt and ultimately stabilize the condition designated as arrested hydrocephalus. Arrested hydrocephalus in children is typically due to congenital aqueduct stenosis, which can be described appropriately as a stasis existing within the channel between the third and fourth ventricles. Os odontoideum (OO) is an uncommonly occurring pathology at the craniovertebral junction. Although the clinical and radiologic features of its existence and the therapeutic options for its pathology have been widely discussed within the medical literature, its true etiology has been a source of divisive debate, proposing both a traumatic as well as a congenital mechanism. The etiology of OO has been heartily debated in the literature for several years as well. Most authors have come to support a posttraumatic causality. However, strong evidence exists to support a congenital origin to this rarely observed malformation. METHODS: Within this case study we present a 24-year-old woman with atlantoaxial subluxation that exists secondary to an orthotropic OO. The patient had a history of arrested hydrocephalus due to congenital aqueductal stenosis beginning in early childhood. She presented with normal intelligence and was neurologically without deficits before the occurrence of an atlantoaxial dislocation. Unfortunately, the pathology was initially misdiagnosed as a decompensation state of the arrested hydrocephalus, and after 8 months the patient became wheelchair bound. Following this unfortunate event the correct diagnosis was ultimately uncovered. Subsequently a C2-1 instrumentation procedure resulted in excellent alignment and fusion. CONCLUSIONS: To the best of our knowledge, this is the first example of an aqueduct stenosis in the setting of an existing OO, a combination that might be another clue in favor of a congenital etiology.

Implementation of an Education Program for an Ultrasound-Guided Liposomal Bupivacaine Transversus Abdominis Plane (TAP) Block Protocol for Open Abdominal Procedures.

Anesthesia practitioners at the authors' facility had varying education and training with placing transversus abdominis plane (TAP) blocks and with the use of liposomal bupivacaine limiting the utilization of this regional anesthetic technique for patients undergoing abdominal surgical procedures. An expansive literature review suggested that ultrasound-guided liposomal bupivacaine TAP blocks were safe and effective for reducing postoperative pain scores, opioid use, and no reported adverse effects. Current literature findings were used to craft an educational intervention to update current practices among anesthesia practitioners. The purpose of the project was to develop and implement an educational intervention to improve the knowledge and confidence of all anesthesia providers at our facility when placing and managing liposomal bupivacaine TAP blocks in patients undergoing abdominal surgery. We used the Ajzen Theory of Planned Behavior to create an effective practice change, combined with skill acquisition through simulation, among anesthesia providers at our facility in performing ultrasound-guided liposomal bupivacaine TAP blocks. The implementation of a multistrategy education program using simulation resulted in a significant increase in knowledge and confidence among anesthesia practitioners.

Effect of timing of fluid bolus on reduction of spinal-induced hypotension in patients undergoing elective cesarean delivery.

Spinal-induced hypotension remains the most common complication associated with spinal anesthesia for cesarean delivery. Recent evidence indicates that a 20-mL/kg bolus via pressurized infusion system administered at the time of subarachnoid block (SAB) (coload) may provide better prophylaxis than the traditional administration of a 20-mL/kg crystalloid infusion (preload) approximately 20 minutes before SAB; however, this method raises some concerns. We hypothesized that administering half of the fluid bolus (10 mL/kg) before and half immediately following injection of the SAB would provide benefit. Variables included demographics, spinal anesthetic dermatome level obtained, additional intravenous (IV) fluid bolus and vasopressor requirements, and maternal vital signs. We enrolled 87 subjects in this prospective, randomized investigation, 43 preload (control) and 44 preload/coload (experimental). There were no demographic differences between groups. The increased supplemental vasopressors required to treat maternal hypotension in the preload group were not statistically significant. Total IV fluids and supplemental IV bolus requirements were significantly higher in the preload group. No differences in neonatal outcomes were noted between groups. Maternal vital signs were not significantly different between groups; hypotension was treated as it occurred. We recommend replacing standardized prophylactic crystalloid fluid administration with the preload/coload method described herein.