Appendico-ileal knotting mimicking adhesive bowel disease.

Appendico-ileal knotting is a very rare and widely unknown cause of closed loop bowel obstruction. In most cases it is discovered incidentally during surgery. We report a 59 year old female with a previous history of a total abdominal hysterectomy who presented with features of intestinal obstruction and was thought to suffer from postoperative adhesions. At laparotomy, appendico-ileal knotting was found; after appendectomy, she made a full recovery. Appendico-ileal knotting should be known as a possible differential diagnosis when managing patients with features of intestinal obstruction and symptoms or signs of appendicitis.

Calcium pyrophosphate dehydrate crystal deposition in the ligamentum flavum of the cervical spine: histopathological and immunohistochemical findings.

OBJECTIVE: To investigate the histopathological and immunohistochemical properties of degenerative changes in the ligamentum flavum of the cervical spine with calcium crystal deposition. METHODS: Sections of the calcified ligamentum flavum harvested from 26 patients who required cervical decompression were examined by scanning electron microscopy (SEM), energy dispersive X-ray microanalysis, immunohistochemical staining [for transforming growth factor (TGF)-Beta, vascular endothelial growth factor (VEGF), Sox9, and Msx2] and terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick end labelling (TUNEL) method (for cell apoptosis). RESULTS: Energy dispersive x-ray microanalysis and SEM confirmed the deposited calcium to be calcium pyrophosphate dihydrate (CPPD) crystals. The calcified ligamentum flavum showed disorganisation of the elastic fibre bundles together with increased collagen fibrils in the matrix. Abundant hypertrophic chondrocytes were noted around the calcified lesions, which were strongly immunoreactive to TGF-Beta and VEGF. Staining for Sox9 was positive in metaplastic chondrocytes but negative in hypertrophic chondrocytes. Both chondrocytes and mesenchymal cells were positive for Msx2. TUNEL-positive hypertrophic chondrocytes were significantly more noticeable in nodular than diffusely scattered type of CPPD deposition. CONCLUSIONS: Calcium crystal deposition in the cervical ligamentum flavum seems to progress with reduction in elastic fibres, increase in collagen fibrils in the matrix, and migration of metaplastic hypertrophic chondrocytes, whose differentiation is controlled by cytokines and transcriptional factors, and potentially regulate crystal formation. The presence of abundant TUNEL-positive hypertrophic chondrocytes around CPPD deposition suggests that materials from apoptotic cells play some role in crystal deposition.

Microsurgical intraneural extracapsular resection of neurinoma around the cervical neuroforamen: a technical note.

Dumb-bell tumours often require extended resection of osseous structures of the spine and subsequent anterior and/or posterior stabilization. Minimally addressed microsurgical intraneural extracapsular resection of a neurinoma originating from around the neuroforamen often provides immediate benefits. We describe our experience with microsurgical intraneural extracapsular resection of four cervical dumb-bell neurinomas in four patients. After a 4- to 7-cm skin incision, a small resection of the laminae and neuroforamen allowed visualisation of the tumour. The procedure was followed by microsurgical intraneural extracapsular complete "enucleation" resection of the tumour, without sacrificing motor funiculi or causing damage to surrounding arteries and radicular veins. One patient had a giant neurinoma at the C5-C6 and C6-C7 foraminal levels that required simultaneous anterior fusion at C5-C6 level only. The average blood loss during surgery was 35 mL (range: 11-59) and all showed neurological improvement immediately after surgery. Minimally addressed microsurgical intraneural extracapsular "enucleating" resection of tumours around the neuroforamen may be beneficial for patients, is not associated with vascular morbidity, and avoids the subsequent need for extensive spinal instrumentation.

Microsurgical excision of ganglioneuroma arising from the C8 nerve root within the neuroforamen.

Ganglioneuromas are benign, slow-growing tumors originating from sympathetic nerves or peripheral nerves, often associated with multiple tumor syndromes. They occasionally occur as spinal lesions and grow within the spinal canal or as paraspinal lesions. In this report, we describe a rare solitary ganglioneuroma arising from the cervical nerve root (C8) within the intervertebral foramen in adults. The tumor could be detected as a mass limited to the neuroforamen at an early stage by MR images. Unilateral microsurgical foraminotomy and EN BLOC resection of the tumor resulted in disappearance of the symptoms. Microsurgical resection of the relevant nerve root through limited medial foraminotomy at an intricate anatomical region of the cervico-thoracic junction was appropriate in the current case for complete resection of the tumor as well as to prevent postoperative structural weakness that could result in late segmental instability.