Management of gunshot wound to the lumbosacral spine in a 17-year-old girl without neurological impairment.

We report the case of a young girl (17-year-old) wounded by an accidental gunshot. The bullet entered through the skin midline over the navel area, passed through the stomach perforating the vena cava and, by breaking the right pedicle of L4, moved inside the vertebral canal (bridging the cauda equina) stopping just in front of the body of S2. Because of the sudden onset of acute abdomen due to a massive retroperitoneal hematoma, the patient underwent emergency explorative laparotomy with the evacuation of the hematoma and the suture of the perforated cava vein, the peritoneum, and the stomach. No neurological deficits were observed after the gunshot. Two weeks later, the patient underwent spinal surgery to remove the bullet from the spinal canal, which was performed successfully without any instrumentation and with no onset of new neurological signs and symptoms or surgery-related complications. Patient was discharged on day 9 after surgery in good general conditions.

Video-assisted anterior retroperitoneal approach to the lumbar spine. A minimally invasive technique improved by the use of an endoscopic camera to treat lumbar spinal diseases. Consideration over 269 patients.

We describe the technique we routinely use to perform the retroperitoneal anterior approach using a rigid endoscope coupled to a HDD screen to assist mini-open retroperitoneal anterior approach. Our experience was compared to those reported in the literature for the standard mini-open retroperitoneal approach. We retrospectively analyzed a total of 269 consecutive patients, 109 males and 160 females, underwent anterior lumbar approach in our department, using video-assisted anterior retroperitoneal approach to the lumbar spine. 202 patients had a single L5-S1 or L4-5 ALIF (75.09%), 14 patients received a double level ALIF (5.3%), while 53 patients underwent a double anterior and posterior approach (19.8%). The average preoperative VAS and Oswestry Disability Index (ODI) scores were 9.1±6.3 and 79.3±11.9. At least 16 months follow-up (from 16 months to 5 years), the average VAS and ODI values had improved to 1.6±1.5 and 13.1±13.2, respectively (p <0.05). The mean length of stay was 4.3±3.5 days. There were 6 major complications (2.2%) related to the approach: major vascular injuries (iliac vein injury) occurred in a total of 3 patients (1.1% of cases), whereas retrograde ejaculation occurred in 3 patients (2,75% of male cases in the series). No wound or deep infections occurred. In our opinion, this technique, compared with other mini-open approach, potentially reduces perioperative morbidity, length of surgery, surgical approach-related complications, and hospitalization.

Modifications of spinopelvic parameters and acetabular orientation after spinal surgery for adult deformity in patient who underwent bilateral total hip arthroplasty.

The spine and the hip are two anatomical districts that have close biomechanical relationship. The management of their degenerative disorders involves an in-depth biomechanical analysis of the patient, in order to define the proper hip-spine relation, using different biomechanical classifications that have been proposed in recent years. The changes in the spino-pelvic and acetabular parameters induced by prosthetic hip surgery and spinal surgery must be carefully evaluated, calculated and foreseen in the pre-operative phase, as they play a crucial role in defining the clinical success or failure of the operations. In this paper we present a case of a patient who underwent spinal surgery after a bilateral THA analyzing both spino-pelvic parameters and acetabular orientation and highlighting the strict relations between spine and hip.

Use of lordotic cages in L5-S1 Anterior Lumbar Interbody Fusion (ALIF) procedures

Anterior Lumbar Interbody Fusion (ALIF) has gained popularity in the last few years, thanks to its numerous advantages. Recently the use of lordotic cages has been described, allowing theoretically a better lordosis restoration of the lumbar disc space. We described the results obtained with the use of lordotic cages in 27 patients who underwent ALIF procedure for L5-S1 disc degenerative disease, in terms of segmental lordosis and global lumbar lordosis changes.

Bilateral THA in the same sitting for avascular necrosis of the head of the femur in sickle cell patient: our African experience.

Sickle cell anemia is protective against the malaria protozoan. The heterozygous form of the disease is not fatal, and may cause musculoskeletal disorders when sickling occurs, and small vessels are occluded. When the head of the femur is involved, this may result in hip arthritis, often bilateral, at a young age. This article describes three patients in whom bilateral total hip arthroplasty (THA) was performed in the context of a humanitarian mission in Togo, Africa.

Periprosthetic joint infection from Mycobacterium Tuberculosis in Togo, Africa.

Mycobacterium Tuberculosis infections are moderately frequent in developing countries. Because of migratory flows, these diseases will always have an increasing prevalence even in those countries that do not usually present these types of cases. Extra-pulmonary tuberculosis often affects the musculoskeletal system. The sites most involved are the spine (Pott's disease) and the large joints, especially hips and knees. We describe a patient with tuberculosis of the hip, who underwent total hip arthroplasty.

One-stage Bilateral Total Hip Arthroplasty in patient with sickle cell disease and previous Girdlestone procedure on the right side: First presentation in Togo.

80% of Sickle Cell Disease cases are estimated to be in Sub-Saharan Africa. It can lead to various acute and chronic complications and osteonecrosis of the femoral head is one of these. Girdlestone procedure is an option to treat osteonecrosis in patients who could not afford arthroplasty. We report here the first case of bilateral total hip arthroplasty in a patient with a previous Girdlestone procedure on the right side and an osteonecrosis of the femoral hip on the left side.

Total hip arthroplasty for osteonecrosis of the femoral head in sickle cell disease: a case series from our African experience.

Sickle cell disease causes osteonecrosis (20% to 50% of patients) and collapse of the femoral head that result in secondary osteoarthritis. Total hip arthroplasty (THA) is a valid alternative for these patients. We define the difficulties that can be encountered when undertaking THA in sickle cell disease patients and give advice on how to deal with these technically demanding procedures. We undertook total hip arthroplasty procedures on 12 patients (4 females and 8 males) with osteonecrosis of the femoral head. Two bilateral prostheses were performed. We had only one type of stem, only one type of acetabular cup and only 28 mm cobalt chrome heads. The procedures were performed through either an anterior or a direct lateral approach. The average size of the Cup was 46 (Versafit, Medacta), the average size of the femoral stem was 0 (Amistem, Medacta), the most used size of the modular head was a S. Standard stem that was used in nine patients, while three patients received a lateralizing stem. Three patients had periprosthetic fracture, treated by cerclage. Total hip replacement is an excellent alternative for patients with osteonecrosis from sickle cell disease. The preparation of the acetabulum and the femur is difficult and requires attention, time and appropriate equipment.

A new "keyhole" approach for multilevel anterior lumbar interbody fusion: the perinavel approach-technical note and literature review.

PURPOSE: The purpose of this study is to evaluate the feasibility and the safety of a new skin incision for minimally invasive anterior lumbar interbody fusion (ALIF): the perinavel incision. METHODS: Demographic and clinical data from patients who underwent ALIF with the perinavel incision were collected. Indications to surgery, preoperative symptoms, radiological data, number of treated levels, intraoperative and early postoperative complications and wound-related problems were analysed. RESULT: Ninety-seven patients underwent ALIF with this new skin incision. One hundred fifty-seven levels were treated (mean 1.7 level per patient) being L4-L5 the most frequently treated. Intraoperative complications were represented only by the venous injury with a rate of 3.09% (3 cases). Postoperative complications were all linked to skin incision issues: a case of wound dehiscence and a case of superficial infection. No case of skin necrosis occurs at 3-month follow-up. CONCLUSIONS: In this paper, the perinavel skin incision was demonstrated to be as safe as traditional approaches for ALIF. Furthermore, with this incision it is possible to perform multilevel (L3-S1) ALIF, which means a good option in minimally invasive surgery as well as revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Crying spells triggered by thumb-index rubbing after thalamic stroke: a case report.

BACKGROUND: Pathologic crying, devoid of any emotional counterpart, is known to occur as a consequence of various brain stem, cortical hemispheric and cerebellar lesions or, quite exceptionally, of "dacrystic" epilepsy. The case reported here suggests that thalamic lesions may also cause crying spells, under the special circumstances described below. CASE PRESENTATION: After a mild left thalamic stroke a caucasian 77 years old man presented with crying spells with no emotional counterpart, triggered by thumb-index rubbing of his right hand. Only a modest sensation loss on right infra-orbital and nose-labial areas and the first three right fingers could be detected at clinical examination. The circumstances and processes leading to the crying spells were investigated, together with their neural substrate. Brain computerized tomography (CT), magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) were conducted. Neurophysiologic studies included Video-Electroencephalography, Electromyography, motor and sensory Evoked potentials. Active thumb-index rubbing, passive fingertips stimulation and interaction of sensory-motor stimulation with cognitive/speech activities were tested under different paradigms. A treatment with pregabalin (75 mg twice a day) was attempted. CT and MRI showed a small ischemic infarct in the left ventral postero-lateral thalamus, while fMRI led to the expected findings, i.e. a bilateral activation of the hand motor representation during the crying-triggering right-hand finger rubbing activity. Sensory potentials evoked from stimulation of the right upper limb were the only abnormal neurophysiologic test. Crying spells could be invariably evoked by both real and imagined active finger rubbing, in either the left of right hemi-space. Rubbing by an examiner was ineffective. Immersion in water (18 °C) but not oiling of the fingertips prevented the symptom. Administration and discontinuation of pregabalin 75 mg daily could be associated with suppression and reappearance of the symptom, respectively. CONCLUSIONS: In this patient loss of sensation seemed to generate crying spells rather than the more common allodynia. As a matter of speculation, both symptoms might represent responses to a sensory loss, but in this case the pathway might have been selectively affected providing inhibition from the lateral to the medial segment of the VPLT, which is linked to the anterior cingulate (limbic) cortex engaged in emotional behaviour.

Osteotomies in proximal junctional kyphosis in the cervicothoracic area.

INTRODUCTION: Proximal junctional kyphosis (PJK) of the cervicothoracic spine is a deformity that can affect patients who have undergone long thoracolumbar instrumented fusion. Preoperative hyperkyphosis of the thoracic spine and changes of more than 30° in lumbar lordosis are independent risk factors for the onset of PJK. METHODS: When PJK occurs in the cervicothoracic spine, extension of the fusion with eventual application of osteotomy techniques is frequently necessary to treat symptomatic patients or in case a neurological deficit occurs. Ponte osteotomy and pedicle subtraction osteotomy (PSO) are the two most used techniques to restore a good cervicothoracic alignment, although they are still demanding procedures even for expert surgeons. In junctional fractures, a vertebral column resection can be performed to support the anterior column. Ponte osteotomy ideally restores 10° at each treated level, while PSO allows a segmental correction up to 30°-35°. Adequate preoperative planning is fundamental for outlining the correct surgery and choosing the appropriate osteotomy. CONCLUSIONS: The aim of corrective surgery is to restore the cervicothoracic alignment, obtaining an adequate postoperative sagittal balance and decreasing the risk of further complications and new revision surgeries.

Variations of cervical lordosis and head alignment after pedicle subtraction osteotomy surgery for sagittal imbalance.

INTRODUCTION: The variations of the cervical lordosis after correction of sagittal imbalance have been poorly studied. The aim of our study is to verify whether the cervical lordosis changes after surgery for sagittal imbalance. MATERIALS AND METHODS: Thirty-nine patients were included in the study. Cervical, thoracic and lumbar spine, pelvic and lower-limb sagittal parameters were recorded. The cranial alignment was measured by the newly described Cranial Slope. RESULTS: The global cervical kyphosis (preop -43°, postop -31.5°) and the upper (preop -24.1°, postop -20.2°) and lower cervical kyphosis (preop -18.1°, postop -9.2°) were significantly reduced after surgical realignment of the trunk. A positive linear correlation was observed between the changes in T1 slope and the lower cervical lordosis, and between T1 slope and the global cervical alignment. CONCLUSIONS: The cervical lordosis is reduced by surgical correction of malalignment of the trunk, suggesting an adaptive role to maintain the head's neutral position.

Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure.

INTRODUCTION: Sagittal imbalance is an important risk factor for spinal disability, pain and loss of health related quality of life. Its correction has a positive impact on these outcomes. Still, it is a very aggressive surgery, with a high revision rate. The aim of this study is to analyze the most important causes of failure of surgery for correction of sagittal imbalance. DESIGN AND METHODS: In this retrospective observational cohort study twelve patients who previously underwent surgery for sagittal imbalance correction were revised in the period 2009-10. We analyzed angular parameters of sagittal balance before and after primary surgery, type of instrumentation, modality of fusion, implant density, instrumented levels, modality of failure, time from first surgery and angular parameters after revision. RESULTS AND CONCLUSION: Causes of failure were insufficient correction, junctional kyphosis, screw loosening and pseudoarthrosis with rod breakage. In every case, patients presented a new onset or a worsening of sagittal imbalance and pain.

Pendular nystagmus in hypomyelinating leukodystrophy.

We report the case of a 49-year old woman affected by hypomyelinating leukodystrophy. She presented with typical pendular nystagmus that was analyzed with video-oculography which is provided in the supplementary material of the report. The pendular nystagmus was accompanied by upper limb ataxia on the index-to-nose test. The video was partly recorded with a slow-motion technique in order to better demonstrate the ataxia and the pendular nystagmus. The brain MRI demonstrated a characteristic pattern of hypomyelination. Pendular nystagmus is a key clinical sign that contributes to the diagnosis of CNS hypomyelination when a leukodystrophic pattern is observed on brain MRI.

Functional antagonism of ß-adrenoceptor subtypes in the catecholamine-induced automatism in rat myocardium.

BACKGROUND AND PURPOSE: Myocardial automatism and arrhythmias may ensue during strong sympathetic stimulation. We sought to investigate the relevant types of adrenoceptor, as well as the role of phosphodiesterase (PDE) activity, in the production of catecholaminergic automatism in atrial and ventricular rat myocardium. EXPERIMENTAL APPROACH: The effects of adrenoceptor agonists on the rate of spontaneous contractions (automatic response) and the amplitude of electrically evoked contractions (inotropic response) were determined in left atria and ventricular myocytes isolated from Wistar rats. KEY RESULTS: Catecholaminergic automatism was Ca(2+) -dependent, as it required a functional sarcoplasmic reticulum to be exhibited. Although both α- and ß-adrenoceptor activation caused inotropic stimulation, only ß(1) -adrenoceptors seemed to mediate the induction of spontaneous activity. Catecholaminergic automatism was enhanced and suppressed by ß(2) -adrenoceptor blockade and stimulation respectively. Inhibition of either PDE3 or PDE4 (by milrinone and rolipram, respectively) potentiated the automatic response of myocytes to catecholamines. However, only rolipram abolished the attenuation of automatism produced by ß(2) -adrenoceptor stimulation. CONCLUSIONS AND IMPLICATIONS: α- and ß(2) -adrenoceptors do not seem to be involved in the mediation of catecholaminergic stimulation of spontaneous activity in atrial and ventricular myocardium. However, a functional antagonism of ß(1) - and ß(2) -adrenoceptor activation was identified, the former mediating catecholaminergic myocardial automatism and the latter attenuating this effect. Results suggest that hydrolysis of cAMP by PDE4 is involved in the protective effect mediated by ß(2) -adrenoceptor stimulation.