RESUMEN
BACKGROUND: The incidence of traumatic vertebral artery injury (VAI) associated with cervical spine trauma varies widely in published trauma series. The primary aim of this study was to determine the incidence of traumatic VAI in patients who suffered cervical spine injuries by means of routine magnetic resonance imaging, and the secondary objective was to identify any associations with injury mechanism, level of injury, and neurologic injury severity. Materials and methods: A retrospective review was conducted on 96 patients who suffered cervical spine fracture dislocation with or without an associated spinal cord injury (SCI) in Indian Spinal Injuries Center (ISIC), New Delhi, India from January 2013 to April 2023. Cervical magnetic resonance imaging (MRI) was used to diagnose VAI. Patient's age, sex, cervical injury level, mechanism of injury, neurologic level of injury, association with foraminal fracture, facet dislocation, and clinical sequelae of vertebral artery injury were analyzed. RESULTS: In this study, of 96 patients who met the inclusion criteria, 18 patients (18.75%) had VAI on the MRI study. Thirteen (72.22%) of the eighteen patients had right-sided injuries, four (22.22%) had left-sided injuries, and one (5.55%) had bilateral injuries. There was an associated SCI in every VAI patient. VAI was significantly more common in patients who had ASIA A (61%, n = 11) and ASIA B (22%, n = 4) injuries, and no VAI was noted in neurologically intact patients (p<0.001). The incidence of VAI was higher in the flexion distraction type of injury (n = 12, 66%). The most commonly involved cervical spine injury level was C5-C6 (27%, n = 5), followed by 22% (n = 4) at C4-C5 and C6-C7 levels. About 27.8% (n = 5) of VAI was associated with foraminal fractures, and 72% (n = 13) of VAI was associated with facet dislocations, of which 44% (n = 8) were bifacetal and 28% (n = 5) were unifacetal dislocations. On clinical symptoms, only one (5.56%) patient had a headache, and 17 (94.4%) had no clinical features due to VAI. CONCLUSION: The incidence of traumatic vertebral artery disease is not very uncommon and requires careful and meticulous screening and management. Otherwise, complications like pseudoaneurysm, neurologic deficit, late-onset hemorrhage, infarction, and death can happen. Mostly, it is associated with high-velocity injuries and neurological injuries. MRI can be used as a good screening tool, which can be aided by a CT angiogram or digital subtraction angiography for confirmation. Proper pre-operative evaluation of vascular injury in cervical spine fracture dislocation is very important for patient counseling, patient management, and surgical planning.
RESUMEN
Introduction: Occurrence of hemorrhagic cyst inside ligamentum flavum is a very rare phenomenon and presents with back pain, radiculopathy, or neurogenic claudication. Various causes reported in the literature are trauma, anticoagulant therapy, and increased micromotion in the setting of unstable and degenerated motion segment. Case Report: We report a case of 41-year-old male patient who presented with claudication pain in both lower limbs for the past 6 months associated with bilateral calf atrophy. Plain radiograph with dynamic films showed lytic spondylolisthesis at L4-L5 level. Magnetic resonance imaging revealed a hemorrhagic cyst inside ligamentum flavum at the L3-L4 level occupying the posterior epidural space severely compressing the thecal sac. After a thorough diagnostic and therapeutic work up, we did a midline sparing decompression of L3-L4 level under microscope without fixing the listhetic segment. The patient had significant pain relief after surgery and doing well till now. Conclusion: In general, hemorrhagic cyst of ligamentum flavum is seen in a degenerated lumbar spine at the areas of increased micromotion and instability. Our case has shown that it can also occur in an adjacent segment of spondylolisthesis or instability. The obvious finding like listhesis in the adjacent segment may hinder a spine surgeon from diagnosing the cyst component and may guide to a erroneous treatment outline. Hence, it should not be missed in the imaging.
RESUMEN
Alkaptonuria is a rare autosomal recessive trait. Symptomatic lumbar disc herniation warranting surgical intervention is a rare scenario in alkaptonuria and only a few cases have been described in the literature. We present one such rare case of alkaptonuria in a 31-year-old female presenting with low back pain and left leg radiculopathy not relieved with conservative management. Roentgenograms of the lumbar spine revealed wafer-like disc calcifications and MRI showed a herniated disc at the L4-L5 level with deeply hypointense disc spaces in T2 suggestive of disc calcification and associated modic type 2 changes. During the surgery, the disc material removed was black in color, which raised a clinical suspicion of alkaptonuria. Postoperatively, the patient was re-examined and urine homogentisic acid was found to be raised. This, along with a histopathological examination, was diagnostic of alkaptonuria. The patient had excellent relief of symptoms postoperatively. In conclusion, if a 'black disc' is found during surgery, retrospective analysis and re-examination of patient clinical features and urine examination have to be done to diagnose alkaptonuria. While making a differential diagnosis of degenerative disc disease in patients with a calcified disc seen on radiography, a high index of suspicion for alkaptonuria has to be maintained.
RESUMEN
Symptomatic spinal epidural hematoma (SEH) is a rare but well-documented complication in spine surgery, often associated with risk factors such as abnormal coagulation parameters, low platelets, excessive epidural bleeding, and inadequate hemostasis. While bilateral SEH is frequently described in the literature, unilateral SEH following spine surgery is seldom reported. We present a unique case of a unilateral neurological deficit resulting from an SEH following midline-sparing spine surgery due to unilateral drain placement in an 80-year-old male patient without comorbidities and normal coagulation parameters. Subsequent evacuation of the hematoma was done leading to gradual recovery of neurology. This emphasizes the importance of bilateral drain placement in such midline-sparing spine surgeries. This report underscores the significance of early SEH diagnosis and intervention, providing valuable insights into preventive measures and the need for a high index of suspicion in managing this potentially debilitating complication.
