Diário da Espinha

Study design: Case Report. Objective: To present one case suffering from delayed neurologic deficit after kyphosis deformity correction and analyze its potential etiological factors, how to identify and treat it.
Summary of background data: Tardive neurologic deficits occur much less than acute ones after corrections of spinal deformities. Currently some risk factors, such as postoperative hypotension, deformity severity, and intraoperative haemorrhage are considered to be related with its occurrence and worsening though the true mechanisms are not clear. Extrinsic cord compression should be excluded by radiographic examinations before conservative treatments, such as improving blood perfusion, eliminating cord edema, suppressing local inflammation; promoting neurite outgrowth can be applied. If these don’t lead to functional recovery of spinal cord, emergency operation returning the cord to its former kyphotic position can also be considered.
Methods: This 44 year-old female patient demonstrated thoracolumbar kyphosis of 136.9° combined with incompetence of spinal cord before operation, and underwent posterior vertebra column resection with the kyphotic correction of 68.8°. No neurologic dysfunction was found during operation.
Results: Neurologic deficit appeared on the sixth day after operation, showing motion disability and sensation weakening of both lower extremities. Imaging examinations failed to reveal mechanical compression, such as haematoma or displaced implant. After use of glucocorticoid, gamma globulin, monosialotetrahexosylganglioside, alprostadil and rehabilitation therapies, her myodynamia of both lower extremities recovered greatly, especially muscles extensor, however, her sensation didn’t ameliorate. Conclusions: Delayed-onset neurologic deficit is rarely seen. Detailed history collection and meticulous physical examination are strongly recommended. Early identification and correct treatments can avert incomplete spinal cord from permanent damage.

Study background: A two patient case series describing the surgical management of upper cervical sarcoma. Due to the density of critical neurovascular structures in the upper cervical spine, these rare sarcomas require primary surgical treatment that preempts local recurrence. Recurrence secondary to tumor spillage is problematic due to scar tissue formation and radiation effect creating surgically inaccessible tissue planes. En bloc resection of sarcomas during an index procedure provides the best chance at cure and prevention of local recurrence. Meticulous planning, familiarity with anatomy and surgical technique is critical for the success of these operations.
\r\nMethods: Two patients: a 30-year-old and 36-year-old female, were referred to our institution with malignant spine tumors involving C1. The first was found to have a left sided synovial sarcoma anterolateral to C1 and C2. The second presented with metastatic alveolar soft tissue sarcoma at C1. Both patients underwent multi-stage en bloc surgical removal of their tumors.
\r\nResults: Successful en bloc tumor excision and instrumented stabilization of the cervical spine without neurovascular complication was performed. Tumor margins were negative and x-rays demonstrated adequate spinal alignment. At six month followup, MRI evaluation demonstrated no local recurrence in either patient.
\r\nConclusions: En bloc resection is a highly effective, but technically demanding method of treating upper cervical sarcomas. In conjunction with adjuvant radiotherapy, en bloc surgery has the lowest risk of local recurrence and highest quality of life outcomes. Due to the proximity of critical neurovascular structures in the upper cervical spine, meticulous planning, staging and technique is required. A multidisciplinary surgical team should be assembled that includes a head and neck, skull-base, neuro-endovascular and spine surgeon. With appropriate planning, understanding of anatomy and surgical technique, en bloc resections of upper cervical sarcomas can be successfully performed.

Pentaplegia is a spinal cord injury at or above C4 level, resulting in complete loss of motor functions below the injury level and paralysis of respiratory muscles. Facial injuries might be a factor for early identification of these patients and in implying prompt management. Here, we report a patient who was injured in a motor vehicle accident and sustained facial injury and cardiopulmonary symptoms. His imaging studies showed atlanto-axial dissociation and maxillary fracture. He survived the accident but continued to have pentaplegia. Presence of facial fractures might help in suspicion and early identification of such injuries, where prompt management remains essential for survival in complete pentaplegia and for avoiding deterioration in incomplete injuries.

Objective: To discuss an uncommon case of nerve root compression caused by synovial chondromatosis of the lumbar spine. Summary of background: Synovial chondromatosis is an uncommon, benign monoarthritic condition of the synovial lining of large joints of the body. It is considered a metaplastic process rather than a neoplastic one, in which nodules are formed from aggregates of chondrocytes in the synovium. The nodules cause non-specific symptoms such as pain and decreased range of motion in the affected joint. In rare instances, synovial chondromatosis has been known to involve the spine, with associated radiculopathy. We report a case of synovial chondromatosis of the lumbar spine, which to our knowledge is the first case with foot drop. Case presentation: A 58-year-old woman presented with symptoms of lower back pain with unilateral radiation, numbness, and tingling. After primary resection of an extradural cartilaginous mass in the region of L4-L5, her symptoms remitted. One year post-operatively, she experienced a progressive recurrence of her symptoms and the acute onset of foot drop. Re-excision provided partial symptomatic relief. Histopathology showed nodular aggregates of benign cartilage, consistent with synovial chondromatosis. Conclusion: Synovial chondromatosis of the spine is a rare but potentially challenging problem for both patients and clinicians. Due to the broad clinical presentation and vague imaging profile, preoperative diagnosis is difficult. The histopathologic findings must be correlated clinically to arrive at the correct diagnosis. Surgical removal may resolve the symptoms, though recurrence requiring re-excision is not uncommon. This is the fourth reported case of synovial chondromatosis involving the lumbar spine, and the first with recurrence resulting in an exacerbation of prior symptoms including foot drop.

Background: Open lumbar discectomy is the most commonly performed surgical procedure in the spine. Conventional microdiscectomy was developed to excise the herniated and non-herniated parts of the disc, but these results in early degeneration of the disc and spine instability. Fragmentectomy was developed to excise only the herniated disc part. Objectives: To evaluate the results of fragmentectomy and more than ten years follow up of 71 patients operated at our university hospital. Methods: Seventy one patients; 43 males and 28 females with age 17 and 63 (average 36.49) years; were operated for disc prolapsed at the lumbar area. All patients were operated by single surgeon and evaluated pre and post-surgery by many surgeons. Patients were followed up for more than 10 years (on discharge, 0.25, 0.5, 1, 2, 3, 5 and 10 years). Oswestry Disability Index and the Stanford Score were used to evaluate patient outcomes. Results: Operating time ranged between 25 and 120 (average 71) minutes, blood loss 5-70 (average 35) cubic centimeters and hospital stay ranged 3-5 (4.21) days. Intraoperative a small dural tear was seen in 6 cases and postoperative hematoma in 4 cases in whom one had permanent paralysis below the know. Seven patients (0.099) needed fusion after 1-3 years. ODI decreased from around 80/100 before surgery to 20/100 after 10 years with P-Value <0.001. The Stanford score shows dramatic improvement from around 2/10 pre operation to around 9.2/10 after 10 years of follow up, P-value < 0.001 (P-value <0.001 is considered insignificant). Conclusion: Fragmentectomy or sequesterectomy is effective with fewer complications while our study size is moderate; the utility of this study is in demonstrating the long-term results of this novel intervention.

Neurenteric cysts (NC) are rare anomalies of the central nervous system (CNS). They result from abnormal separation of the neural tube and the endodermis during the 3rd week of gestation, which leads to the persistence of endodermal elements in the spinal cord. They usually present insidiously with local spinal pain, radiculopathy, and myelopathy. We report the case of an 8-year-old boy with a high cervical neurenteric cyst who developed a progressive myelopathy after a minor neck trauma. He recovered completely after cyst removal.

Introduction: Gaps in knowledge in biomechanics on how the human spine develops itself to the adult posture still exist. It is clear that the huge increase in spinal problems do lack a sound etiologic base, on which effective preventive, conservative and surgical measurements should be based. An innovative technique to correct scoliosis and kyphosis in a non-surgical way is found in the TLI (thoracolumbar lordotic intervention) brace that is based on reversing of the external etiologic factors. Method: A search in older or neglected orthopedic and biomechanical literature around spinal deformities was done to support the clearance of `Idiopathy` in spinal deformities. Own research is described on the effectiveness of treatment by braces Results: Older literature on postural development was gathered. Environmental factors like sitting were once investigated as causes for deformities and could be revisited. The vulnerability of young tissues and early deformability of especial the thoracolumbar spine (in school and child’s labor) was known and well described. The work of Milan Roth on the essences of growth in the neuro-osseous growth relations showed itself a missing link in ongoing discussions on etiology. We related own observations on the detectable signs of raised tension in system during growth to the tension Roth described on cell biologic level. In the TLI brace technique, based on restoration of the crucial thoracolumbar lordosis in order to get healthy posture proof of the reproducibility of older knowledge could be given. The working mechanism of thoracolumbar lordotic intervention (TLI) was published and a pilot study with 91 children wearing this brace revealed good results and even true correction of scoliotic curves was reached. The events in the sagittal plane during (early) growth can be seen as decisive for the postures later in adulthood.