Cauda equina syndrome after use of dural sealant in revision lumbar decompression surgery.

OBJECTIVE: We report a case of cauda equina syndrome related to the use of fibrin glue dural sealant "TISSEEL". BACKGROUND: Incidental durotomy (ID) is not uncommon in revision spinal surgery. Augmentation of the dural repair after primary closure is gaining popularity. The use of dural sealants is not risk-free. METHOD: A 65-year old man who underwent revision lumbar decompression surgery developed postoperative cauda equina syndrome. He had urinary retention, bilateral leg pain and perianal numbness on the third postoperative day. We believe this complication was related to the use of fibrin glue to manage an ID. RESULT: After the urgent surgical removal of the fibrin glue patch, the patient fully recovered with no residual neurological deficit. CONCLUSION: Cauda equina syndrome development is a potential complication after the use of fibrin glue to augment intraoperative ID. Surgeons should be aware of this potential risk so it can be managed in a timely fashion.

Facet joint cyst haematoma: a rare cause of cauda equina syndrome.

Facet joint cysts are a feature of lumbar spondylosis and are an uncommon cause of radiculopathy. Facet joint cyst haematoma is a very rare entity and has previously been reported as a subacute cause of leg pain, back pain, sensory deficit and lower limb weakness. We present the unique case of facet joint cyst haematoma presenting as cauda equina syndrome. An 81 year old lady presented with a 7 day history of back pain and left foot drop, a 1 day history of perineal numbness and urinary retention with absent rectal tone, perianal anaesthesia and left leg hypoaesthesia. Emergency MRI scan demonstrated spinal canal stenosis as the aetiology of her cauda equina syndrome. She was taken to theatre for emergency lumbar decompression. At operation a facet joint haematoma compressing the cauda equina was found and extirpated with complete resolution of symptoms. In this case, the aetiology of cauda equina compression was not demonstrated effectively on pre-operative MRI scanning.

Spinal subdural hematoma as a complication of spinal surgery: can it happen without dural tear?

Post spinal surgery subdural hematoma is a rare entity. This is a report of a case of acute post-operative spinal subdural hematoma, without any dural injury. The case was managed expectantly and went on to complete resolution of the hematoma and full clinical recovery.

A study investigating the validity of modified Tokuhashi score to decide surgical intervention in patients with metastatic spinal cancer.

PURPOSE: Predicted survival of a patient is the most important parameter that helps to guide the treatment of a patient with metastatic spinal cancer. We aimed to investigate the reliability of modified Tokuhashi score in the decision-making process in patients with metastatic spinal cancer. METHODS: We performed a review of our prospectively collected Metastatic Cancer Database over a period of 4 years (2007-2010). Ninety consecutive patients who were treated for metastatic spinal cancer were enrolled. Data review included demographic details, source of primary cancer, duration of symptoms, location of metastases, calculated Karnofsky's performance status, and calculated survival based on modified Tokuhashi score. We divided the patients into 3 groups. Group A included patients with expected survival less than 6 months. Group B included patients with expected survival between 6 and 12 months. Group C included patients whose expected survival was more than 12 months. We compared the calculated expected survival to the actual survival in all three groups with all patients following up to a minimum of 1 year or until death. Statistical analysis was done by Chi-square test and the Fisher Exact test. RESULTS: The survival prediction in group C was significantly accurate in 80.9 % patients (P = 0.027). However, in groups A and B, only 36.1 and 9.1 % patients survived, respectively, as per predicted. (P > 0.05). CONCLUSIONS: We can conclude from this study that, when used alone, modified Tokuhashi score may not be a reliable tool to predict survival in all patient groups.

Intracranial Mimics of Cauda Equina Syndrome: Heads or Tails?

BACKGROUND: To report cases of extraspinal mimics of cauda equina syndrome (CES) to enable prompt diagnosis and treatment in the future. CES results from compression of spinal nerve roots. Current practice mandates lumbosacral magnetic resonance imaging (MRI) scanning to diagnose CES. However, it may not reveal compression or provide an explanation for the presentation. We present 3 cases of suspected CES who went on to have intracranial pathology. METHODS: Retrospective review of all patients presenting with CES-type features who were subsequently found to have causative intracranial pathology over a 6-month period. RESULTS: Three cases were found, and these are hereby presented. CASE PRESENTATION: Case 1: A 57-year-old lady presented with urinary retention and bilateral leg weakness. She underwent an MRI spine which showed no evidence of CES. She was diagnosed with haemorrhagic intracranial metastases. Case 2: A 52-year-old lady presented with lower back and right buttock pain, with right-sided leg numbness, saddle hypoesthesia, and bowel and bladder incontinence. MRI spine showed no cauda equina compression. MRI neuraxis revealed a subdural haematoma. Case 3: A 69-year-old lady presented with a 6-day history of urinary incontinence, right foot drop, and leg weakness. MRI spine was negative for CES. She was diagnosed with an intraparenchymal haematoma of posterior left frontal lobe. CONCLUSIONS: Negative lumbosacral MRI will not exclude extraspinal mimics of CES and, although rare, these cases should be considered.

A technique for temporary control of hemorrhage.

Traumatic injury to blood vessels is a common presentation in the Emergency Department. Control of hemorrhage is generally attempted using tight absorbent compression dressings. This may be a cause of inefficient control of hemorrhage and also contributes to tissue ischemia. We present a simple technique to control hemorrhage that does not cause tissue ischemia, which frequently accompanies the tight compression bandages applied for vascular injuries.

Cervical epidural abscess mimicking as stroke - report of two cases.

BACKGROUND: Stroke is a common provisional diagnosis in patients presenting to the emergency department (ED) with unilateral neurological deficit. Cervical epidural abscess (CEA) may also present clinically with a unilateral neurological deficit. OBJECTS: To highlight the inherent problems with diagnosing cervical epidural abscess and possible consequences of delay in diagnosis. CASE REPORT: We would like to highlight two cases provisionally diagnosed as stroke. Both cases turned out to be cervical epidural abscesses. The delay in diagnosis and treatment led to suboptimal outcome in both cases. SUMMARY: Cases with suspected stroke who deteriorate while under treatment or whose diagnosis is doubtful should have MRI whole spine in order to avoid potential complications.

Role of intraoperative red cell salvage and autologus transfusion in metastatic spine surgery: a pilot study and review of literature.

STUDY DESIGN: Prospective cohort study. PURPOSE: There has been no research examining the use of intraoperative cell salvage during metastatic spinal surgery. The present work is a pilot study investigating the role of cell salvage during metastatic spine surgery. OVERVIEW OF LITERATURE: There is no spinal literature about role of cell salvage and autologus transfusion in metastatic spinal cancer. METHODS: Sixteen spinal metastases patients who received red cell salvage using a leucocyte depletion filter were enrolled. Of these, ten patients who received salvaged blood transfusion were included in the final analysis. Data collection involved looking at the case notes, operating room records and the prospectively updated metastatic spinal cancer database maintained in the spinal department. Cell salvage data was recovered from the central cell salvage database maintained in the anesthetic department. RESULTS: Amount of salvaged blood ranged from 120 to 600 mL (average, 318 mL). The average drop in hemoglobin was 1.65 units (range, 0.4-2.7 units). Three patients (30%) required postoperative allogenic blood transfusion. The average follow up was 9.5 months (range, 6-6 months). One patient developed new lung metastasis, at seven months. No patient developed new liver metastases. Preoperatively, six patients had diffuse skeletal metastases. Of this subgroup, three developed new skeletal metastases. No cases showed any wound related problems in the postoperative period. CONCLUSIONS: In our study transfusion of intraoperatively salvaged blood did not result in disseminated metastatic cancer. We would suggest that red cell salvage might have a role during metastatic spine surgery.