Traumatic Lumbosacral Dislocation Treated with Posterior Lumbar Interbody Fusion Using Intersomatic Cages

A 35-year-old man was struck by a car on his right side and presented with paraparesis of both lower extremities. Radiographic examination revealed multiple transverse process fractures and anterior displacement of L5 on S1. Computed tomography revealed a bilateral anterior facet dislocation of the fifth lumbar vertebra on the sacrum. MRI showed rupture of the posterior ligamentous complex. A posterior lumbar interbody fusion using two intersomatic cages and pedicle screw instrumentation and posterior fusion were performed. Although no major disc lesion was found at the level of L5-S1 on preoperative MRI, a severely collapsed L5-S1 disc was found intraoperatively. Two years after surgery, the patient was asymptomatic with normal neurological findings, and has resumed normal activity. We believe that lumbosacral dislocation can be considered a three-column injury with an L5-S1 disc lesion, and, therefore, requires a solid circumferential segmental arthrodesis to improve fusion rate

Percutaneous Drainage Combined with Hyperbaric Oxygen Therapy for Pyogenic Spondylitis with Iliopsoas Abscess

Study DesignA retrospective study.PurposeThe purpose of this study was to evaluate outcomes in patients with pyogenic spondylitis accompanied by iliopsoas abscess who were treated by percutaneous drainage combined with hyperbaric oxygen (HBO) therapy.Overview of LiteratureTo the best of our knowledge, there have been no previous reports of the use of percutaneous drainage combined with HBO therapy for the treatment of this condition.MethodsTwenty-three patients (13 men, 10 women; mean age, 69.0 years; range, 45-85 years) were treated with percutaneous drainage combined with HBO therapy in addition to commonly used conservative therapy. Mean follow-up duration was 27.7 months (range, 12-48 months). Clinical outcomes and imaging examinations were retrospectively investigated.ResultsSymptoms such as low back pain, radicular pain, and hip pain resolved in all patients immediately after treatment. Mean time from the start of treatment to the return of C-reactive protein levels to normal or baseline values recorded before the onset of spondylitis was 28.3 days (range, 8-56 days). In the final set of follow-up radiographic studies, all patients were free from progressive destructive changes. Follow-up magnetic resonance images or computed tomography with contrast enhancement confirmed the disappearance or near-total resolution of the iliopsoas abscess cavity with healing of the pyogenic spondylitis in all 23 patients. No recurrences were observed during follow-up.ConclusionsThe present study suggests that patients with pyogenic spondylitis accompanied by iliopsoas abscess can be cured without a prolonged period of therapy or recurrence using this treatment

Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report

Abstract Introduction Although uncommon, selective cervical nerve root blocks can have serious complications. The most serious complications that have been reported include cerebral infarction, spinal cord infarction, transient quadriplegia and death. Case presentation A 40-year-old Japanese woman with a history of severe right-sided cervical radicular pain was scheduled to undergo a right-sided C6 selective cervical nerve root block using a transforaminal approach under fluoroscopic guidance. An anterior oblique view of the C5-C6 intervertebral foramen was obtained, and a 23-gauge spinal needle, connected to the normal extension tube with a syringe filled with contrast medium, was introduced into the posterior-caudal aspect of the C5-C6 intervertebral foramen on the right side. In the anteroposterior view, the placement of the needle was considered satisfactory when it was placed no more medial than halfway across the width of the articular pillar. Although the spread of the contrast medium along the C6 nerve root was observed with right-sided C6 radiculography, the subdural flow of the contrast medium was not observed with real-time fluoroscopy. The extension tube used for the radiculography was removed from the spinal needle and a normal extension tube with a syringe filled with lidocaine connected in its place. We performed a negative aspiration test and then injected 1.5 mL of 1.0% lidocaine slowly around the C6 nerve root. Immediately after the injection of the local anesthetic, our patient developed acute flaccid paralysis, complained of breathing difficulties and became unresponsive; her respiratory pattern was uncoordinated. After 20 minutes, she regained consciousness and became alert, and her muscle strength in all four limbs returned to normal without any sensory deficits after receiving emergent cardiorespiratory support. Conclusions We believe that confirming maintenance of the appropriate needle position in the anteroposterior view by injecting local anesthetic is important for preventing central needle movement. Because the potential risk of serious complications cannot be completely eliminated during the use of any established selective cervical nerve root block procedure, preparation for an emergency airway, ventilation and cardiovascular support is indispensable in cases of high spinal cord anesthesia.</p

Facet arthrography in an unusual presentation of a lumbar hemorrhagic synovial cyst

ABSTRACT An 84-year-old man experienced right buttock pain that radiated gradually to his right lower extremity over a few months before admission. MRI revealed a space occupying intraspinal lesion that was close to the rightsided L4eL5 facet joint and an extraspinal lesion posterior to the right-sided L5 lamina. The lesions appeared as hyperintense areas on T1 weighted images and heterogeneous areas on T2 weighted images. Facet arthrography under CT guidance revealed peripheral infiltration of the contrast medium only in the intraspinal lesion at early stages; subsequently, the contrast medium diffused into the extraspinal lesion, establishing a continuity of the right L4eL5 facet joint with both lesions, which were connected through the interlaminar space. A connection between the intraspinal and extraspinal lesions at the right-sided interlaminar space at the L4eL5 level was clearly noted during intraoperative examination. Histological examination revealed a hemorrhagic synovial cyst. Synovial cysts of the lumbar spine are now widely recognized in advanced imaging studies. In general, lumbar synovial cysts can be easily diagnosed on MRI and CT scans because of their typical location and characteristic morphological features. However, hemorrhage into synovial cysts occurs much less frequently. To our knowledge, there are no previous reports on lumbar hemorrhagic synovial cyst with an intraspinal lesion that extended into the extraspinal paravertebral tissue through the interlaminar space. We present an extremely rare case of lumbar hemorrhagic synovial cyst with an unusual presentation in which an intraspinal lesion extended into the extraspinal paravertebral tissue through the interlaminar space. It was preoperatively diagnosed by facet arthrography under CT guidance. CASE REPORT An 84-year-old man experienced right buttock pain that radiated gradually to his right lower extremity over a few months before admission. He had no history of trauma, excess of activity or anticoagulation treatment. Physical examination revealed muscle weakness in the right tibialis anterior and extensor hallucis longus (grade 4/5, as determined by manual muscle testing), hypesthesia in the L5 distribution of the right lower extremity and urinary disturbance. The results of the straight leg raising test and femoral nerve stretch test were both negative. Radiography showed degenerative changes in the L4eL5 facet joint. MRI scans revealed a space occupying intraspinal lesion that was close to the right-sided L4eL5 facet joint and an extraspinal lesion posterior to the right-sided L5 lamina, which appeared as hyperintense areas on T1 weighted images and heterogeneous areas on T2 weighted images (figure 1). CT myelography showed an extradural lesion that was adjacent to the right L4eL5 facet joint and medial displacement of the dural sac. L4eL5 facet arthrography was performed on the right side through a posterior approach with the patient in the prone position under CT guidance. CT facet arthrography revealed peripheral infiltration of the contrast medium only in the intraspinal lesion at the early stages; subsequently, the contrast medium diffused into the extraspinal lesion, resulting in continuity of the right L4eL5 facet joint with both lesions, which were connected through the interlaminar space (figure 2). The patient underwent resection of the intraspinal and extraspinal lesions with laminectomy of L4 and L5. The cyst was found to contain both partially fresh and coagulated hematoma. A connection between the intraspinal and extraspinal lesions at the right-sided interlaminar space at the L4eL5 level was clearly noted during intraoperative examination. Histological examination revealed dense fibrous tissue with inflammatory cells and hemosiderin deposition. Neoangiogenesis was also observed. Synovial lining cells were not observed but synovial-like tissue was found, and this was consistent with the findings of synovial cysts. After surgery, the neurological symptoms improved and the patient could walk without support 1 week after surgery (figure 3)