Acute Sciatic Neuritis following Lumbar Laminectomy

It is commonly accepted that the common cause of acute/chronic pain in the distribution of the lumbosacral nerve roots is the herniation of a lumbar intervertebral disc, unless proven otherwise. The surgical treatment of lumbar disc herniation is successful in radicular pain and prevents or limits neurological damage in the majority of patients. Recurrence of sciatica after a successful disc surgery can be due to many possible etiologies. In the clinical setting we believe that the term sciatica might be associated with inflammation. We report a case of acute sciatic neuritis presented with significant persistent pain shortly after a successful disc surgery. The patient is a 59-year-old female with complaint of newly onset sciatica after complete pain resolution following a successful lumbar laminectomy for acute disc extrusion. In order to manage the patient’s newly onset pain, the patient had multiple pain management visits which provided minimum relief. Persistent sciatica and consistent physical examination findings urged us to perform a pelvic MRI to visualize suspected pathology, which revealed right side sciatic neuritis. She responded to the electrical neuromodulation. Review of the literature on sciatic neuritis shows this is the first case report of sciatic neuritis subsequent to lumbar laminectomy

Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis

ObjectivesPatients with rheumatoid arthritis (RA) have an excess risk of cardiovascular disease (CVD). We aimed to assess the impact of CVD risk factors, including potential sex differences, and RA-specific variables on CVD outcome in a large, international cohort of patients with RA.MethodsIn 13 rheumatology centres, data on CVD risk factors and RA characteristics were collected at baseline. CVD outcomes (myocardial infarction, angina, revascularisation, stroke, peripheral vascular disease and CVD death) were collected using standardised definitions.Results5638 patients with RA and no prior CVD were included (mean age: 55.3 (SD: 14.0) years, 76% women). During mean follow-up of 5.8 (SD: 4.4) years, 148 men and 241 women developed a CVD event (10-year cumulative incidence 20.9% and 11.1%, respectively). Men had a higher burden of CVD risk factors, including increased blood pressure, higher total cholesterol and smoking prevalence than women (all p<0.001). Among the traditional CVD risk factors, smoking and hypertension had the highest population attributable risk (PAR) overall and among both sexes, followed by total cholesterol. The PAR for Disease Activity Score and for seropositivity were comparable in magnitude to the PAR for lipids. A total of 70% of CVD events were attributable to all CVD risk factors and RA characteristics combined (separately 49% CVD risk factors and 30% RA characteristics).ConclusionsIn a large, international cohort of patients with RA, 30% of CVD events were attributable to RA characteristics. This finding indicates that RA characteristics play an important role in efforts to reduce CVD risk among patients with RA

Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models

Background: In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics. Methods: RA patients aged 30?70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusión criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up. Results: A total of 1974 patients were included in the main analyses, and 144 events were observed during followup, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15?32% of patients. C-statistics ranged 0.68?0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results. Conclusions: The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive

Smoking cessation is associated with lower disease activity and predicts cardiovascular risk reduction in rheumatoid arthritis patients

Objectives: Smoking is a major risk factor for the development of both cardiovascular disease (CVD) and RA and may cause attenuated responses to anti-rheumatic treatments. Our aim was to compare disease activity, CVD risk factors and CVD event rates across smoking status in RA patients. Methods: Disease characteristics, CVD risk factors and relevant medications were recorded in RA patients without prior CVD from 10 countries (Norway, UK, Netherlands, USA, Sweden, Greece, South Africa, Spain, Canada and Mexico). Information on CVD events was collected. Adjusted analysis of variance, logistic regression and Cox models were applied to compare RA disease activity (DAS28), CVD risk factors and event rates across categories of smoking status. Results: Of the 3311 RA patients (1012 former, 887 current and 1412 never smokers), 235 experienced CVD events during a median follow-up of 3.5 years (interquartile range 2.5-6.1). At enrolment, current smokers were more likely to have moderate or high disease activity compared with former and never smokers (P < 0.001 for both). There was a gradient of worsening CVD risk factor profiles (lipoproteins and blood pressure) from never to former to current smokers. Furthermore, former and never smokers had significantly lower CVD event rates compared with current smokers [hazard ratio 0.70 (95% CI 0.51, 0.95), P = 0.02 and 0.48 (0.34, 0.69), P < 0.001, respectively]. The CVD event rates for former and never smokers were comparable. Conclusion: Smoking cessation in patients with RA was associated with lower disease activity and improved lipid profiles and was a predictor of reduced rates of CVD events

Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models

Background In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics. Methods RA patients aged 30–70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusion criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up. Results A total of 1974 patients were included in the main analyses, and 144 events were observed during follow-up, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R 2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15–32% of patients. C-statistics ranged 0.68–0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results. Conclusions The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive

Risk Factors for Supplementary Posterior Instrumentation After Anterolateral Decompression and Instrumentation in Thoracolumbar Burst Fractures.

BACKGROUND: In spite of the established benefits of anterolateral decompression and instrumentation (ALDI) for thoracolumbar burst fractures (TLBF), the indications for supplementary posterior instrumentation remain unclear. METHODS: A retrospective review of clinical and radiographic data of a prospective cohort of 73 patients who underwent ALDI for TLBF from T12 to L4. RESULTS: The mean age of the cohort was 42 ± 15 years, with 49 males and 24 females. Forty-six patients had neurological deficit, and 27 were intact. Owing to symptomatic settling, supplemental posterior instrumentation was performed in 7 out of 73 patients. The age of patients requiring supplemental posterior instrumentation (59 ± 14 years) exceeded that of patients who did not (41 ± 16, p=0.004). Otherwise, the patients who required posterior instrumentation were comparable to those treated with ALDI in terms of body mass index (BMI), American Spinal Injury Association (ASIA) scores on admission and follow-up, residual spinal canal, and local kyphosis on admission and follow-up. The posterior ligamentous complex (PLC) integrity was assessed in 38 patients in whom the MRI scans were retrievable, 31 successfully treated with ALDI, and all 7 undergoing supplementary posterior instrumentation. Subgroup analysis demonstrated that there was no difference in the incidence of PLC disruption between the 2 groups (p=0.257). CONCLUSIONS: Secondary supplemental posterior instrumentation was deemed necessary in 10% of cases following ALDI. Age was the only significant risk factor predicating supplemental posterior instrumentation

Post-Traumatic Syringomyelia: Outcome Predictors.

OBJECTIVE: To identify risk factors that predispose to post-traumatic syringomyelia (PTS) and describe the outcome of surgical management. METHODS: Retrospective cohort study of 27 patients with post-traumatic syringomyelia. Spinal cord injury of these patients spanned the period from 1963 to 2008. All data were collected retrospectively using available medical records and radiological images. RESULTS: There were 24 males and 3 females. The level of initial spine injury was thoracic in 21, cervical in 4, and lumbar in 2. The average age (±SD) at diagnosis of PTS was 40±13 years. The mean follow-up ±SD from injury was 18±11 years. On admission after injury, there were 14 patients with American Spinal Injuries Association (ASIA) disability scores of A, 3 with ASIA C, and 10 with ASIA score of D. At the time of diagnosis of PTS, local kyphosis at the site of injury measured 28±12°, and the residual canal was 67±19% compared to the average rostral and caudal anteroposterior diameter. Fourteen patients underwent a single operation for PTS, and 13 needed two or more procedures. In the 11 patients in whom the initial surgery included a duraplasty, 3 required reoperation for unsuccessful reduction in the size of the syrinx and failure to improve symptoms. In the 16 patients in whom the initial procedure was that of a shunt alone, 10 required revision (p=0.0718 rate of revision between shunting and duraplasty). As a result of treatment for PTS, improvement in symptoms of PTS occurred in 14, symptoms were unchanged in 10, and progressed in 3. In the 11 patients with sequential MRI scans, a significant correlation was shown between the reduction in the size of the syrinx and clinical improvement (p\u3c0.001). CONCLUSION: PTS is often the result of severe spinal cord injuries, with over half of patients having an ASIA disability score of A. Our review corroborates other published reports showing that PTS is associated with significant deformity and stenosis. Irrespective of treatment, over half of the patients required reoperation for their PTS. Duraplasty and arachnolysis are the preferred treatment for PTS over shunting alone. Treatment was associated with cessation of symptoms or improvement in nearly 90% of the patients

Clinical diagnostic and radiographic features of primary spinal atypical teratoid rhabdoid tumor in a pediatric patient: A case report and review of the literature

Atypical teratoid rhabdoid tumors (ATRTs) are rare embryonal tumors comprising 1-2% of all pediatric CNS neoplasms. Spinal ATRTs are even more uncommon, accounting for 2% of all reported ATRT cases. Despite their rarity, ATRTs affect young children disproportionately and are characterized by a high malignant potential due to a heterogeneous cellular composition and inactivating mutations in the SMARCB1 (90%) and SMARCA4 (10%) genes. A 15-month-old female presented with a 2-week history of decreased lower extremity movement and new-onset need for assistance with ambulation. MRI lumbar spine revealed a contrast-enhancing intradural mass at the L3-L4 level with iso-intensity on T1 and T2 sequences. The patient subsequently underwent subtotal tumor resection (∼80%) given concerns for maintaining neurological function. Final pathology was consistent with spinal ATRT, and she later underwent adjuvant chemoradiation therapy per ACNS0333 protocol. She has since remained in remission with age-appropriate developmental milestones over the past 2 years. ATRTs should be considered in the differential diagnosis of intradural spinal lesions, especially in the pediatric patient population. Clinical course, presentation, and diagnosis is often delayed due to the rarity of these tumors, but contrasted craniospinal MRI is key for diagnosis and histopathology with IHC staining showing loss of INI is confirmatory. While gross total resection is the goal, maximal safe tumor resection should be prioritized in order to preserve neurological function. Adjuvant chemoradiation following gross total/subtotal resection has been shown to significantly improve overall survival

Microvascular Decompression and MRI Findings in Trigeminal Neuralgia and Hemifacial Spasm. A Single Center Experience.

OBJECTIVE: For patients with medically unresponsive trigeminal neuralgia (TIC) and hemifacial spasm (HS), surgical microvascular decompression (MVD) is the procedure of choice. The authors of this report sought to review their outcomes with MVD in patients with TIC and HS, and the success of preoperative magnetic resonance imaging (MRI) in identifying the offending vascular compression. METHODS: Since 2004, there were a total of 51 patients with TIC and 12 with HS with available MRI scans. All patients underwent preoperative MRI to rule out non-surgical etiologies for facial pain and facial spasm, and confirm vascular compression. Follow-up after surgery was 13 ± 22 months for the patients with TIC and 33 ± 27 months for the patients with HS. RESULTS: There were 45 responders to MVD in the TIC cohort (88%), with a Visual Analog Score (VAS) of 1 ± 3. All patients with HS responded to MVD between 25 and 100%, with a mean of 75 ± 22%. Wound complications occurred in 10% of patients with MVD for TIC, and 1 patient reported hearing loss after MVD for HS, documented by audiogram. The congruence rate between the preoperative MRI and operative findings of vascular compression was 84% in TIC and 75% in HS. CONCLUSION: MVD is an effective and safe modality of treatment for TIC and HS. In addition to ruling out structural lesions, MRI can offer additional information by highlighting vascular loops associated with compressions. On conventional scans as obtained here, the resolution of MRI was congruent with operative findings in 84% in TIC and 75% in HS. This review emphasizes that the decision to undertake MVD in TIC or HS should be based on clinical diagnosis and not visualization of a compressing vessel by MRI. Conversely, the presence of a compressing vessel by MRI demands perseverance by the surgeon until the nerve is decompressed