Herpes zoster sciatica mimicking lumbar canal stenosis: a case report.

BACKGROUND: Symptom of herpes zoster is sometimes difficult to distinguish from sciatica induced by spinal diseases, including lumbar disc herniation and spinal canal stenosis. Here we report a case of sciatica mimicking lumbar canal stenosis. CASE PRESENTATION: A 74-year-old Chinese male patient visited our hospital for left-sided sciatic pain upon standing or walking for 5 min of approximately 1 month's duration. At the first visit to our hospital, there were no skin lesions. A magnetic resonance imaging showed spinal canal stenosis between the 4th and 5th lumbar spine. Thus, we diagnosed the patient with sciatica induced by spinal canal stenosis. We considered decompression surgery for the stenosis of 4th and 5th lumbar spine because conservative therapy failed to relieve the patient's symptom. At that time, the patient complained of a skin rash involving his left foot for several days. A vesicular rash and erythema were observed on the dorsal and plantar surfaces of the great toe and lateral malleolus. The patient was diagnosed with herpes zoster in the left 5th lumbar spinal nerve area based on clinical findings, including the characteristics of the pain and vesicular rash and erythema in the 5th lumbar spinal dermatome. The patient was treated with famciclovir (1,500 mg/day) and non-steroidal anti-inflammatory drugs. After 1 week of medication, the skin rash resolved and pain relief was obtained. CONCLUSION: In conclusion, spinal surgeons should keep in mind herpes zoster infection as one of the possible differential diagnoses of sciatica, even if there is no typical skin rash.

Radiograms Obtained during Anterior Cervical Decompression and Fusion Can Mislead Surgeons into Performing Surgery at the Wrong Level.

A 68-year-old woman who suffered from C5 nerve palsy because of a C4-5 disc herniation was referred to our hospital. We conducted anterior cervical decompression and fusion (ACDF) at the C4-5 level. An intraoperative radiogram obtained after exposure of the vertebrae showed that the level at which we were going to perform surgery was exactly at the C4-5 level. After bone grafting and temporary plating, another radiogram was obtained to verify the correct placement of the plate and screws, and it appeared to show that the plate bridged the C5 and C6 vertebrae at the incorrect level. The surgeon was astonished and was about to begin decompression of the upper level. However, carefully double-checking the level with a C-arm image intensifier before additional decompression verified that the surgery was conducted correctly at C4-5. Cautiously double-checking the level of surgery with a C-arm image intensifier is recommended when intraoperative radiograms suggest surgery at the wrong level.

Painful lumbar spondylolysis among pediatric sports players: a pilot MRI study.

INTRODUCTION: For children and adolescents who are very active athletes, fresh lumbar spondylolysis is the main pathologic cause of lower back pain (LBP). However, regarding the terminal-stage spondylolysis (pars defect), there have been few studies to clarify the pathomechanism of LBP. The purpose of this study is to clarify the cause of LBP associated with pars defects in athletes. This is the first report showing a possible pathomechanism of LBP in active athletes with painful pars defect. METHOD: Six pediatric athletes (5 boys and 1 girl) below 18 years old with painful bilateral lumbar spondylolysis were evaluated. In all cases, spondylolysis was identified as terminal stage (pseudoarthrosis) on CT scan. To evaluate the inflammation around the pars defects, short time inversion recovery (STIR) MRI was performed along with the sagittal section. Fluid collection, which is an indicator of inflammatory events, was evaluated in 12 pars defects as well as in 12 cranial and caudal adjoining facet joints. RESULTS: Inflammation (i.e., fluid collection) was observed in all 12 pars defects in six subjects at the pseudoarthrotic pars defects. In terms of facet joints, 7 of 12 (58%) pars defects showed fluid collection at the cranial and/or caudal adjoining joints on STIR MRI. CONCLUSION: The present study showed that inflammation was always present at the pars defects and in some cases at the adjoining facet joints. Thus, it is not difficult to understand how, during sports activity, inflammation may first occur at the pseudoarthrotic site and then spread to the adjoining facet joints. This mechanism could cause LBP associated with terminal-stage (pseudoarthrotics) spondylolysis in athletes.

Intraoperative spinal subarachnoid hematoma in a patient with cervical ossification of the posterior longitudinal ligament.

STUDY DESIGN: Case report. OBJECTIVE: To report a surgically treated case of cervical ossification of the posterior longitudinal ligament (OPLL), in which a spinal subarachnoid hematoma (SSAH) developed intraoperatively but was successfully treated. SUMMARY OF BACKGROUND DATA: Previous reports have indicated that trauma, lumbar puncture, vascular lesions such as arteriovenous malformation, neoplastic lesions, and coagulopathy can cause SSAH. To the best of our knowledge, there has been no report that describes the occurrence of SSAH during anterior decompression surgery of the cervical spine. METHODS: A 52-year-old man with cervical myelopathy caused by OPLL underwent surgery for anterior decompression from C2/3 to C6/7. Immediately after the OPLL floating procedure, cerebrospinal fluid leakage and massive bleeding occurred at right edge of the OPLL at the C3-C4 level. After hemostasis, the dura mater at the C5-C6 levels bulged rapidly and became cyanotic. Intraoperative ultrasonographic images showed a high-intensity mass lesion on the ventral side of the spinal cord, indicating an intrathecal hematoma. RESULTS: We incised the dura, found the hematoma under the intact arachnoid, and removed it. We then found that the bleeding occurred from the radicular artery along the right C4 root. After hemostasis, we performed anterior spine fusion from C2-C7. After surgery, the patient's myelopathy was improved, and no neurologic deficit related to the subarachnoid hematoma was found. CONCLUSION: This experience suggests that when anterior decompression surgery is performed for cervical OPLL patients, we should consider the possible occurrence of an SSAH. Intraoperative ultrasonography is a useful tool for detecting SSAHs.