Horner syndrome as an unusual presentation of cervical radiculomyelopathy associated with cervical disc herniation: A case report.

INTRODUCTION AND IMPORTANCE: Horner syndrome, an oculo-sympathetic pathway disorder, is a very rare manifestation of cervical spine pathologies which usually present with either axial neck pain, radiculopathy, or myelopathy symptoms (or combinations of these). It is more-likely to happen in the upper cervical level involvement. CASE PRESENTATION: A 44-year-old male presented with a complaint of right eyelid drop two months before admission. The symptom was accompanied by radicular neck pain and weakness of the right upper extremity (M4) since 1 month earlier. An MRI revealed a cervical herniated disc at the C5-6 spine level. CLINICAL DISCUSSION: The patient underwent open discectomy followed by cervical disc replacement. Symptoms were significantly improved following surgery. CONCLUSION: In the presence of cervical symptoms, a focused evaluation of Horner syndrome can be done, and symptom resolution can be expected after the appropriate treatment. Otherwise, a thorough examination must be obtained to find the pathology along the tract of the oculo-sympathetic pathway and prevent irreversible neurological disturbance.

A rare presentation of osteochondroma at the spinous process of the cervical spine: a case report.

Osteochondroma is a benign cartilaginous tumor that usually arises from the growth plate of the long bones. Its presentation in flat bones is uncommon. Spinal osteochondroma is a rare case, with only a 4% incidence compared to all spinal neoplasms. We report an unusual case of osteochondroma at the spinous process of the C4 spine of a 15-year-old patient with the chief complaint of neck discomfort on movement. The patient has previously been diagnosed and treated for multiple hereditary exostoses of other bones. The patient underwent surgery for the current lesion with complete excision to the base of the lesion. Histopathology revealed a benign osteochondroma with a thin layer of cartilaginous cap. The patient was healed uneventfully and had no recurrence of the lesion on the same site at the 1-year follow-up. Surgical resection remains the mainstay treatment of osteochondroma and has proved to the low recurrence. In the case of cervical osteochondroma, surgery is advisable, particularly in symptomatic patients, to prevent complications.

Particular precautions and the role of intraoperative neuromonitoring in cervical cord injury in elder recreational cyclist: A case report.

INTRODUCTION AND IMPORTANCE: The trend in cycling nowadays affects all age groups. However, special precautions must be considered in the elderly group. Minor trauma to the cervical region can cause severe neurological deterioration, leading to fatality because of the pre-existing degenerative process. CASE PRESENTATION: We present a case of a 61-year-old male recreational cyclist with acute onset of tetraplegia following a minor fall. The radiological result revealed a long-standing degenerative process. Unfortunately, the patient deceased due to the sequelae of the paralysis and cardiac event despite our prompt surgical decompression and the improvement shown on intraoperative neuromonitoring. CLINICAL DISCUSSION: The degenerative process can aggravate cervical cord injury even in its mildest form of injury. In this study, immediate improvement was detected by the intraoperative neuromonitoring (IONM) - although the clinical improvement had not improved yet as the general condition is poor. CONCLUSION: The elder cycling population is increasing. Safety measures and injury avoidance are advisable along with expert consultation before the exercise. In a pre-existing degenerative condition of the cervical, a special precaution is also needed during the exercise. If the surgery has been indicated, the use of intraoperative neuromonitoring is found to be useful to guide the decompression and potentially beneficial as a predictive value for the clinal outcome.

Freehand Pedicle Screw Insertion in Spondylitis Tuberculosis Kyphosis Correction Using Cantilever Method: A Breach Rate Analysis of 168 Consecutive Screws.

BACKGROUND: The cantilever method is a standard for two-dimensional deformity correction, as in spondylitis tuberculosis kyphotic deformity. An accurate and secured pedicle screw placement as part of the correction tools is essential to accommodate reduction while preventing screw-related complications. Many literatures have described the pedicle screw misplacement in cases with "normal" bone quality (ie, scoliosis, Scheuermann's kyphosis, ankylosing spondylitis, trauma) or in the obviously abnormal bone such as osteoporosis. However, to our knowledge, the pedicle screw accuracy in cases of deformity correction of tuberculous kyphosis was not previously reported. METHODS: This is a retrospective study of 168 pedicle screws in 14 consecutive cases of spondylitis tuberculosis with kyphotic deformity. The cantilever reduction method with freehand screw insertion technique was done in all cases to correct the deformity. Postoperative computed tomography (CT) evaluation was done to evaluate screw position and breach rates. RESULTS: Among the 168 screws, accurate pedicle screw placement was accomplished in 39.3% screws (Gertzbein-Robbins Grade A). The overall breach rate was 61.9%, which was most commonly occurred on the segment proximal to the apex of the deformity (p=0.001). The lateral breach was more common than the medial breach (52.3% vs 7.7%). The pedicle screw on the thoracal region has a greater breach incidence than those on the lumbar region especially those on T9, T10, and T11. There was no injury to the surrounding neurovascular and pleural structures. No revision surgeries were required. CONCLUSION: Freehand pedicle screw insertion in spondylitis tuberculosis kyphotic reduction has proved to be safe. However, the accuracy should be improved to prevent long-term screw-related complications.

Effectiveness of Kyphosis Reduction Using Cantilever Method in Thoracolumbar Spondylitis Tuberculosis: A Short-Term Follow-Up.

BACKGROUND: Kyphosis in spondylitis tuberculosis (STb) is more than just a cosmetic issue. It has a potentially detrimental effect on both spine-associated structures and cardiopulmonary function. It can be corrected in any stage of STb; however, the corrective surgery is challenging, especially in the late case, in which the additional stiffness of the spine can come into consideration. To date, the cantilever technique is still a gold standard for sagittal plane deformity correction. However, no study to date has explored its effectiveness for thoracolumbar kyphotic deformity, especially that caused by spondylitis tuberculosis. METHODS: This is a retrospective study of 16 consecutive cases of spondylitis tuberculosis with thoracolumbar kyphosis that underwent corrective surgery in our center in the period of 2020-2021. We aim to evaluate the effectiveness of the cantilever technique that we use for kyphotic correction in thoracolumbar STb patients. RESULTS: At the 3-months follow-up, the mean Cobb angle was 14.6°±10.27°, with the mean gain of 20.90°±12.00° and positively correlate with the thoracolumbar kyphosis (TLK) correction (68.69%, r = 0.654, p = 0.001). The mean thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis were 30.6°±13.08°, 39.4°±16.02°, and 1.4±4.09 cm, respectively, with sagittal Cobb difference of 12.70±9.85. CONCLUSION: The kyphotic Cobb angle reduction by cantilever technique in the thoracolumbar area significantly improved the thoracolumbar kyphosis and realign the spinal sagittal axis. Thus, the cantilever technique remains the gold standard for sagittal plane deformity correction which can be applied for kyphotic deformity correction in thoracolumbar STb cases.

Giant-sized primary clear cell chondrosarcoma of the thoracolumbar spine: A very rare case report.

BACKGROUND: Clear cell chondrosarcoma (CCC), a rare subtype of chondrosarcoma, is generally a low-grade tumor that arises commonly in the epiphyses of the proximal femur or humerus. The spine is an uncommon site of CCC that most commonly involves the thoracic spine with the lumbar spine as the second most common predilection. METHODS: We report an extremely rare case of a 22-year-old female with a giant-sized CCC in the thoracolumbar region that severely compressed the spinal cord on that level. Tumor removal, spinal cord decompression, and stabilization were done, followed by high-dose radiotherapy. RESULTS: Histopathology demonstrates CCC with high cellularity, some hemorrhagic areas, and scanty mitotic figures. The patient had a significant back pain improvement. There were some recoveries of neurological function by the time of the last follow-up. CONCLUSIONS: This report highlights the unusual location of this rare tumor, the unusual size, and moreover, the age at presentation. Despite its low-grade behavior, CCC needs to be treated as a true malignancy with wide resection whenever feasible. Adjuvant radiotherapy should also be considered as part of the surgical treatment because of the risk of de-differentiation, recurrence, and malignancy, especially in unresectable cases or cases with incomplete resection.

An Extremely Rare Case of Upper Thoracic Salmonella Infection.

BACKGROUND: Vertebral osteomyelitis is rare. Finding the right etiological agent is important to administer antibiotic regimen accordingly. The occurrence of this disease in endemic countries raises the susceptibility of a more common infection such as tuberculosis and pyogenic bacteria. Salmonella spp. infection is also common in endemic countries; however, extra-intestinal manifestation is very rare. METHODS: We present an extremely rare case of salmonella vertebral osteomyelitis (SVO) in the upper thoracic vertebrae of a 64-year-old patient with history of cardiac surgery and other pre-existing comorbidities. SVO was treated by antibiotics, surgical debridement and spinal stabilization. RESULTS: Three weeks after surgery and intravenous antibiotics, the patient recovered and was discharged without fever and back pain, with excellent motoric improvement. CONCLUSION: Salmonella infection must be considered to be one of possible etiological agents in patients with suggestive spondylitis in emerging countries, especially in those with comorbidities.