Pure cervical radiculopathy due to spontaneous spinal epidural haematoma (SSEH): report of a case solved conservatively

Abstract Introduction: Spontaneous spinal epidural haematoma (SSEH) is widely recognised throughout the literature as a cause of myelopathy, radicular compression being very rarely reported. Surgical management is almost always recommended, especially in the cases of spinal cord compression. Conservative treatment is reported as a curiosity and only in the case of spontaneous improvement. This report presents the particular case of a 64-year-old patient undergoing anticoagulant therapy that had a cervical radiculopathy due to a SSEH confirmed by MRI. The patient improved spontaneously and symptoms were solved with unconventional conservative treatment and without stopping the anticoagulant therapy. Conclusions: Spontaneous epidural haematoma must be kept in mind when patients undergoing anticoagulant therapy have a sudden onset of cervicobrachialgia. Even though most spinal surgeons advocate surgical treatment, a conservative approach may lead to a complete recovery and may be considered as a good option in the case of radicular involvement. Discontinuation of the anticoagulant therapy may not always be needed, especially when the clinical syndrome improves spontaneously

Symptomatic Medial Exostosis of the Great Toe Distal Phalanx: A Complication Due to Over-correction Following Akin Osteotomy for Hallux Valgus Repair

The authors present the case of a 54-year-old female who developed a painful compression lesion localized to the medial aspect of the base of the distal phalanx of the great toe as a complication of hallux valgus surgery. Preoperative radiographic evaluation of the patient's foot revealed the first ray to be longer than the second, a 12 degrees first intermetatarsal angle, a 33 degrees hallux abductus angle, and an exostosis at the medial aspect of the base of the hallux that was not considered by the surgeon to be important. Correction of the hallux valgus deformity was performed with a combination of scarf and Akin osteotomies, and the intermetatarsal and hallux abductus angles reduced to 2 degrees and 8 degrees , respectively. By 2 months postoperative, the patient was complaining of pain at the medial aspect of the distal phalanx of the hallux associated with shoe pressure. The pain correlated both clinically and radiologically with the exostosis at the base of the distal phalanx, and had become symptomatic only after the hallux had been operatively realigned. At 6 months postoperative, percutaneous exostectomy was undertaken to remove the exostosis. Pain relief was complete, thereafter, and after 2 years of postoperative follow-up the patient remained pain free. The clinical importance of a medial exostosis localized to the base of the distal phalanx of the hallux must be taken into consideration whenever hallux valgus correction is undertaken, and this is particularly important whenever an Akin osteotomy is being considered. Level of Clinical Evidence: 4

Infected Vertebroplasty Due to Uncommon Bacteria Solved Surgically: A Rare and Threatening Life Complication of a Common Procedure

Case report. OBJECTIVE: The aim of this work is to describe a case of infected vertebroplasty due to uncommon bacteria solved surgically with 2 years of follow-up and to discuss 6 other cases found in literature. SUMMARY OF BACKGROUND DATA: Vertebroplasty is a well-known and useful technique for the treatment of painful osteoporotic vertebral fractures. Complications, such as cord or root compression or pulmonary embolisms, are infrequent and are mainly related with the frequent escape of cement throughout the vertebral veins. Infection is even more rare, but when it occurs is difficult to manage and can be a life-threatening complication. METHODS: A 63-year-old-man had a spondylitis of L2 after vertebroplasty. The patient was initially managed with antibiotics without clinical improvement. Surgical treatment by anterior debridement and anterior and posterior stabilization was done. The bacteria isolated from the intraoperative cultures were Serratia marcescens, Stenotrophomonas maltophilia, and Burkholderia cepacia. After surgery, the patient was treated with antibiotics for 3 month. RESULTS: After 2 years of follow-up, the patient was free of pain, without signs of infection, and a correct fusion was achieved. CONCLUSION: When facing an infected vertebroplasty, initial conservative treatment with needle biopsy culture and antibiotic administration are a rational option to start. If this treatment fails, surgical debridement is then indicated in order to remove the infected tissue and the acrylic cement and to stabilize the spine. Although this can be an effective treatment, it could be a difficult and hazardous surgical procedure

Atenuación del artefacto metálico post cirugía de columna lumbar mediante protocolo de obtención de imagen en tomografía computarizada multicorte. Estudio de cohortes.

Fundamento. Las imágenes obtenidas mediante estudios con TC pueden ser alteradas por la presencia de artefactos metálicos, induciendo en ocasiones a malinterpretación en la correcta ubicación de los tornillos pediculares en columna lumbar. El objetivo de este trabajo es desarrollar un protocolo de atenuación del artefacto metálico con el propósito de reducir el artefacto generado por los tornillos pediculares de titanio en aquellos pacientes a los que se ha requerido instrumentación lumbar, permitiendo a los cirujanos de columna realizar un diagnóstico preciso de la ubicación del tornillo pedicular instrumentado. Material y métodos. En la primera parte del trabajo se realizó un estudio observacional, analítico, longitudinal y retrospectivo en 23 pacientes (103 tornillos pediculares) a los que se requirió artrodesis lumbar por patología degenerativa. En el postoperatorio se les realizó un estudio con TC secuencial evaluando la sobredimensión generada por el artefacto del tornillo, aplicando un protocolo estándar de obtención de imágenes. En la segunda parte del estudio se diseñó un estudio observacional, analítico, longitudinal y prospectivo empleando un equipo de TCMC de 64 coronas aplicando un protocolo específico de adquisición de imagen sobre 18 pacientes (104 tornillos pediculares) intervenidos mediante artrodesis lumbar. Resultados. En la primera parte del estudio el artefacto medio a ambos lados del tornillo que se genera tras el estudio de TC es de 1,045 mm (DE: 0,45). En el grupo en el que se aplica el protocolo de atenuación del artefacto tras la TCMC la sobredimensión fue de 0,005 en la porción proximal del tornillo y de 0,025 en la parte distal del tornillo. Conclusiones. Los resultados obtenidos sugieren que tras la aplicación del protocolo de atenuación del artefacto en equipo de TCMC de 64 coronas el artefacto es reducido a unas dimensiones similares a la dimensión real del tornillo pedicular.Background. In postoperative patients with metallic implants, CT scans can become less effective due to metal-related artifacts. The purpose of our study was to evaluate the effectiveness of a specific metal artifact reduction image protocol, in order to reduce the metal artifact caused by titanium pedicular screws in patients undergoing lumbar pathology by lumbar fusion. This enables surgeons to make an accurate diagnosis of the exact placement of inserted pedicle screws, making this the preferred image modality for assessing screw position after surgery. Methods. In the first part of the study, CT scans were performed on 23 patients (103 titanium alloy pedicle screws) undergoing a lumbar instrumented fusion for treatment for degenerative disease with a standard image acquisition protocol evaluating the possible overdimension caused by the artifact. In the second part, a prospective study was performed using 64-slice multidetector-row computed tomography (MDCT) on 18 patients (104 titanium alloy pedicle screws) undergoing a lumbar instrumented fusion using a specific image acquisition protocol. Results. Our results show that in the sequential CT scan group, mean overdimension (on each side) due to brightness was 1.045 mm (SD 0.45). In the 64-slice multichannel CT group, mean overdimension (on each side) due to brightness was 0.005 mm at the proximal part of the screw and 0.025 mm at the distal part of the screw. Conclusions. The use of a specific metal artifact reduction image protocol in MDCT produces a minimal artifact following lumbar fusion with pedicle screws

Mechanical barriers and transforming growth factor beta inhibitor on epidural fibrosis in a rabbit laminectomy model

Background: TGF-β has been described as a mediator of fibrosis and scarring. Several studies achieved reduction in experimental scarring through the inhibition of TGF-β. Fibroblasts have been defined as the cell population originating fibrosis, blocking fibroblast invasion may impair epidural fibrosis appearance. For this purpose, biocompatible materials used as mechanical barriers and a TGF-β inhibitor peptide were evaluated in the reduction of epidural fibrosis. Methods: A L6 laminectomy was performed in 40 New Zealand white rabbits. Divided into four groups, each rabbit was assigned to receive either collagen sponge scaffold (CS group), gelatin-based gel (GCP group), P144® (iTGFβ group), or left untreated (control group). Four weeks after surgery, cell density, collagen content, and new bone formation of the scar area were determined by histomorphometry. Two experienced pathologists scored dura mater adhesion, scar density, and inflammatory infiltrate in a blinded manner. Results: In all groups, laminectomy site was filled with fibrous tissue and the dura mater presented adhesions. Only GCP group presented a significant reduction in collagen content and scar density. Conclusion: GCP treatment reduces epidural fibrosis although did not prevent dura mater adhesion completely

Positive culture in allograft ACL-reconstruction: what to do?

The transmission of disease or infection from the donor to the recipient is always a risk with the use of allografts. We carried out a research study on the behavioural pattern of implanted allografts, which were initially stored in perfect conditions (all cultures being negative) but later presented positive cultures at the implantation stage. Because there is no information available on how to deal with this type of situation, our aim was to set guidelines on the course of action which would be required in such a case. We conducted a retrospective study of 181 patients who underwent an ACL reconstruction using BPTB allografts. All previous bone and blood cultures and tests for hepatitis B and C, syphilis and HIV were negative. An allograft sample was taken for culture in the operating theatre just before its implantation. The results of the cultures were obtained 3-5 days after the operation. We had 24 allografts with positive culture (13.25%) after the implantation with no clinical infection in any of these patients. Positive cultures could be caused by undetected contamination while harvesting, storing or during manipulation before implantation. The lack of clinical signs of infection during the follow-up of our patients may indicate that no specific treatment-other than an antibiotic protocol-would be required when facing a case of positive culture of a graft piece after its implantation

Frozen cancellous bone allografts: positive cultures of implanted grafts in posterior fusions of the spine

We have carried out a study on the behaviour pattern of implanted allografts initially stored in perfect conditions (aseptically processed, culture-negative and stored at -80 degrees C) but which presented positive cultures at the implantation stage. There is no information available on how to deal with this type of situation, so our aim was to set guidelines on the course of action which would be required in such a case. This was a retrospective study of 112 patients who underwent a spinal arthrodesis and in whom a total of 189 allograft pieces were used. All previous bone and blood cultures and tests for hepatitis B and C, syphilis and HIV (via PCR techniques) were negative. The allografts were stored by freezing them at -80 degrees C. A sample of the allograft was taken for culture in the operating theatre just before its implantation in all cases. The results of the cultures were obtained 3-5 days after the operation. There were 22 allografts with positive culture results (12%) after implantation. These allografts were implanted in 16 patients (14%). Cultures were positive for staphylococci coagulase negative (ECN) in 10 grafts (46%), Pseudomonas stutzeri in two grafts (9%), Corynebacterium jeikeium in two grafts (9%), staphylococci coagulase positive in two grafts (9%) and for each of the following organisms in one case each (4%): Corynebacterium spp., Actinomyces odontolyticus, Streptococcus mitis, Peptostreptococcus spp., Rhodococcus equi and Bacillus spp. No clinical infection was seen in any of these patients. Positive cultures could be caused by non-detected contamination at harvesting, storing or during manipulation before implantation. The lack of clinical signs of infection during the follow-up of our patients may indicate that no specific treatment different from our antibiotic protocol is required in the case of positive culture results of a graft piece after implantation

Influencia del calzado en los ángulos del hallux y presencia de exóstosis en su falange distal

Antecedentes La parte anterior del zapato, donde se alojan los dedos, tiene muy comúnmente una forma que puede ser constrictiva y provoca presión sobre los dedos, dando lugar a alteraciones en el antepié. Sin embargo, queda en el aire si los zapatos de punta constrictiva únicamente producen dolor en los puntos de presión o si pueden causar también cambios permanentes en la morfología del hallux. El objetivo de este estudio es comparar la morfología del hallux en 3 grupos de personas clasificadas de acuerdo con su uso de zapatos de punta constrictiva o abierta. Materiales y método 424 pacientes fueron incluidos en el estudio y se clasificaron en 3 grupos: el Grupo A utilizaba sólo zapatos de punta abierta diariamente; El Grupo B utiliza zapatos de punta abierta y constrictiva indistintamente según el día; El grupo C utiliza zapatos de punta cerrada diariamente. Se utilizaron radiografías dorso-plantares para analizar los ángulos del hallux, la presencia de exóstosis y la forma de la falange distal (F2). Resultados Los pacientes que usaron zapatos con punta abierta (grupo A) presentaban un AIM, AMTF, DASA, PASA, AIF, AF1, AF2, DA de 10º (DE: 2), 8º (DE: 6), 5º (DE: 3), 4º (DE: 3), 9º (DE: 4), 3º (DE: 2), 5º (DE: 3), 3º (DE: 2) respectivamente. Los pacientes que utilizaban zapatos de punta abierta y constrictiva indistintamente (grupo B) presentaban un AIM, AMTF, DASA, PASA, AIF, AF1, AF2, DA de 10º (DE: 14), 10º (DE: 2), 4º (DE: 3), 4º (DE: 4), 12º (DE: 6), 3º (DE: 3), 8º (DE: 4), 1º (DE: 2) respectivamente. Los pacientes que usaban zapatos con punta constrictiva (grupo C) presentaban un ángulo intermetatarsal (AIM), ángulo metatarsofalángico (AMTF), DASA, PASA, ángulo interfalángico (AIF), ángulo de oblicuidad (AF1), ángulo de asimetría (AF2) y desviación de la articulación ángulo (DA) de 9º (DE: 4), 19º (DE: 11), 5º(DE: 3), 6º (DE: 4), 12º (DE: 5), 2º (DE: 2), 8º (SD ): 4), 2º (DE: 2) respectivamente. La prevalencia de exóstosis tibial en F2 fue de 22, 29 y 36% en los grupos A, B y C, respectivamente. En nuestra serie encontramos distribuciones similares en las diferentes formas de F2 (longitudinal, piramidal y clásica). Conclusiones El uso de zapatos de punta constrictiva provoca un aumento de los AMTF, AIF y AF2, incluso cuando su uso es solo ocasional. El uso de zapatos con punta constrictiva se asocia a una mayor prevalencia de exóstosis en el lado tibial en la F2 del 1er radio, incluso aunque el uso sea solo ocasional. Sin embargo, el tipo de zapatos no parece influir en la forma de F2

Influencia del calzado en los ángulos del hallux y presencia de exóstosis en su falange distal

Antecedentes La parte anterior del zapato, donde se alojan los dedos, tiene muy comúnmente una forma que puede ser constrictiva y provoca presión sobre los dedos, dando lugar a alteraciones en el antepié. Sin embargo, queda en el aire si los zapatos de punta constrictiva únicamente producen dolor en los puntos de presión o si pueden causar también cambios permanentes en la morfología del hallux. El objetivo de este estudio es comparar la morfología del hallux en 3 grupos de personas clasificadas de acuerdo con su uso de zapatos de punta constrictiva o abierta. Materiales y método 424 pacientes fueron incluidos en el estudio y se clasificaron en 3 grupos: el Grupo A utilizaba sólo zapatos de punta abierta diariamente; El Grupo B utiliza zapatos de punta abierta y constrictiva indistintamente según el día; El grupo C utiliza zapatos de punta cerrada diariamente. Se utilizaron radiografías dorso-plantares para analizar los ángulos del hallux, la presencia de exóstosis y la forma de la falange distal (F2). Resultados Los pacientes que usaron zapatos con punta abierta (grupo A) presentaban un AIM, AMTF, DASA, PASA, AIF, AF1, AF2, DA de 10º (DE: 2), 8º (DE: 6), 5º (DE: 3), 4º (DE: 3), 9º (DE: 4), 3º (DE: 2), 5º (DE: 3), 3º (DE: 2) respectivamente. Los pacientes que utilizaban zapatos de punta abierta y constrictiva indistintamente (grupo B) presentaban un AIM, AMTF, DASA, PASA, AIF, AF1, AF2, DA de 10º (DE: 14), 10º (DE: 2), 4º (DE: 3), 4º (DE: 4), 12º (DE: 6), 3º (DE: 3), 8º (DE: 4), 1º (DE: 2) respectivamente. Los pacientes que usaban zapatos con punta constrictiva (grupo C) presentaban un ángulo intermetatarsal (AIM), ángulo metatarsofalángico (AMTF), DASA, PASA, ángulo interfalángico (AIF), ángulo de oblicuidad (AF1), ángulo de asimetría (AF2) y desviación de la articulación ángulo (DA) de 9º (DE: 4), 19º (DE: 11), 5º(DE: 3), 6º (DE: 4), 12º (DE: 5), 2º (DE: 2), 8º (SD ): 4), 2º (DE: 2) respectivamente. La prevalencia de exóstosis tibial en F2 fue de 22, 29 y 36% en los grupos A, B y C, respectivamente. En nuestra serie encontramos distribuciones similares en las diferentes formas de F2 (longitudinal, piramidal y clásica). Conclusiones El uso de zapatos de punta constrictiva provoca un aumento de los AMTF, AIF y AF2, incluso cuando su uso es solo ocasional. El uso de zapatos con punta constrictiva se asocia a una mayor prevalencia de exóstosis en el lado tibial en la F2 del 1er radio, incluso aunque el uso sea solo ocasional. Sin embargo, el tipo de zapatos no parece influir en la forma de F2