Unique case of successful surgical treatment of recurrent spinal epidural hematoma after lumbar disc surgery in a Glanzmann thrombasthenia patient.

We report a case of recurrent postoperative spinal hemorrhage after lumbar disc surgery in a Glanzmann thrombasthenia patient.

A Simultaneous Rupture of the Patellar Tendon and the Con-tralateral Quadriceps Tendon in a Patient with Chronic Renal Failure Undergoing Long Term Hemodialysis.

BACKGROUND: Quadriceps or patellar tendon rupture incidence is relatively low, especially simultaneous bilateral rupture, which usually reported as a complication of chronic systemic disorders such as renal failure. OBJECTIVE: Herein, we report a case of bilateral knee extensor mechanism ruptured in a patient with chronic renal failure on long standing hemodialysis. CASE PRESENTATION: A 38-year-old white male, a known case of chronic renal failure on long term hemodialysis, presented to our clinic with clinical signs of bilateral simultaneous knee extensor tendons rupture. After proper workup simultaneous quadriceps and contralateral patellar tendons rupture diagnosis was made. The patient was managed with surgical repair of the tendons and within few days after the surgery he started physiotherapy and rehabilitation program, using walking crutches partial weight bearing mobilization was allowed, and a gradual increase of knee flexion within brace was applied. He used the knee braces and the walking crutches for two months, to ensure complete healing of the repaired tendon with a sufficient strength to allow full weight bearing. At four-year follow-up, complete bilateral knee extensor tendons healing and both knees functional outcome was satisfactory. CONCLUSION: A simultaneous rupture of quadriceps and contralateral patellar tendons is a rare event in patients with chronic renal failure undergoing long term hemodialysis. With early surgical intervention and good physiotherapy, the patient usually has good recovery of both knees function.

Severe thoracolumbar congenital kyphosis treated with single posterior approach and gradual "in situ" correction.

BACKGROUND: Congenital kyphosis results from the failed formation of the vertebrae during the embryonic period and may be associated with cardiac, urogenital, or spinal cord anomalies. Surgical treatment is the best choice through anterior, posterior, or both approaches. OBJECTIVES: This study aims to evaluate the effect of posterior gradual correction using the "in situ" bender to correct severe thoracolumbar congenital kyphosis with or without osteotomy or excision of the vertebra. METHODS: Twenty-five patients with an age range of 2-23 (mean ± SD = 12.58 ± 6.03) years with severe thoracolumbar kyphosis were treated surgically at our institution between 2004 and 2013. Pedicle screwing, osteotomy, and gradual "in situ" bending through the single posterior approach were the choices of treatment. Cobb's angle, patient's height, and SRS-22r were used to evaluate the patients preoperatively and postoperatively. Follow-up periods were 35-136 months. RESULT: Cobb's angle pre-surgery range was 35-180 (81.48 ± 39.1) degrees improved post-surgery to 0-45 (21.72 ± 13.47) degrees (p-value <0.0001). The range of patients' standing height pre-surgery was 79-170 (142.42 ± 24.85) centimeters increased after surgery to 81-175 (147.76 ± 26.33) centimeters (p-value <0.0001). SRS-22r pre-surgery range was between 2.12 and 3.904 (3.2 ± 0.77) and improved post-surgery to 4.16 and 4.96 (4.59 ± 0.29) (p-value = 0.046). CONCLUSION: Gradual correction with the "in situ" bender with or without osteotomy through the single posterior approach can give satisfying clinical (patients' standing height and SRS-22r scores) and radiological (Cobb's angle) results to treat severe congenital thoracolumbar kyphosis.

Giant cell tumor of bone: Unusual features of a rare tumor.

Giant cell tumor of bone is a benign tumor with an aggressive behavior. Its typical subarticular location and high recurrence risk can be associated with significant morbidity. Although benign, it can rarely metastasize especially to the lungs. Also, it can be multicentric in less than 1% of patients. Late malignant transformation, although rare, can occur with a very poor prognosis. This series reports on these unusual and challenging features and management considerations of giant cell tumor of bone. This retrospective study included review of the medical records of patients with a confirmed histopathological diagnosis of giant cell tumor of bone. A total of 25 patients (16 females and 9 males) with a mean age of 34.5 years were included; 22 had primary tumors, while 3 were referred with recurrent tumors. Pain was the most common presenting symptom. Most patients had grade III tumors. Tumors around the knee were the most common. Multicentric tumors were detected in three patients. Twenty-three patients (20 primary giant cell tumor of bone and 3 with recurrence) received treatment. Most patients (15/23) were treated with intralesional curettage with or without adjuvants. Seven patients had wide excision. Recurrence was seen in 45% (9/20) of primary giant cell tumor of bone especially with difficult anatomical locations. Most recurrences occurred more than 4 years after treatment. Pulmonary nodules were detected in four patients; two of them showed resolution during follow-up. One patient developed secondary sarcoma transformation with a fatal outcome. Giant cell tumor of bone was more common in females. Long bones were more affected, especially around the knee. Intralesional curettage was the most frequently used treatment. Recurrence was associated with inadequate tumor resection (especially in difficult anatomical location), younger age, male gender, and advanced local tumor grade. Denosumab can be used in the treatment of pulmonary metastasis, multicentric and recurrent giant cell tumor of bone. Due to late recurrence and malignant transformation, a prolonged follow-up is warranted.

Epidermal inclusion cyst of the knee.

Epidermoid cysts are asymptomatic, slowly enlarging, firm to fluctuant, dome-shaped lesions. Epidermoid cysts frequently appear on the trunk, neck, face, and scrotum, behind the ears and in the palmoplantar region. We review all the cases of epidermoid cyst of the knee and present a case of non-traumatic-induced epidermal cyst in the popliteal fossa of a 66-year-old male with 10-year history of right knee swelling, which appeared firstly as a small mass 2 × 2 cm in the popliteal aspect of the knee. The mass was increasing gradually in size until 2 years ago when it increased suddenly to gain the dimensions of 4 × 6 cm. MRI of the right knee revealed a well-defined cystic lesion in the subcutaneous tissue measuring about 7 × 5 × 5 cm containing internal debris and septations. He underwent complete surgical excision of the mass. The pathological results revealed an epidermal inclusion cyst. To the best of our knowledge, this is the second description for epidermal inclusion cyst involving the popliteal fossa. We were able to retrieve three cases of epidermal cyst of the knee from the literature since its first description in 2004. Including our case, we had a total of four cases of epidermal cyst of the knee. Three males and one female constituted the patients' sample. The mean age for the patients is 55. The epidermal cyst occurred equally in both knees. The popliteal fossa was the location for two epidermal cysts. Similarly, the prepatellar region was the location for another two cysts.

Horizontal gaze palsy and progressive scoliosis with two novel ROBO3 gene mutations in two Jordanian families.

BACKGROUND: Horizontal gaze palsy and progressive scoliosis (HGPPS) is a rare autosomal recessive disorder due to mutations in ROBO3 gene. Patients have characteristic clinical and imaging findings. We report six patients from two families with this disorder with two novel mutations. MATERIALS AND METHODS: One patient from a non-consanguineous family and five patients from extended consanguineous families were clinically and radiologically examined. Blood samples from the patients and their parents were obtained and all the coding exons and flanking intronic sequences of the ROBO3 gene were amplified and subjected to bidirectional DNA sequencing. RESULTS: All six patients had the characteristic clinical and radiological findings of HGPPS. Genetic testing showed two novel mutations including frame-shift and nonsense. CONCLUSION: Two novel mutations in the ROBO3 gene were identified in two Jordanian families with six affected individuals. To our knowledge, this is the first molecular study of HGPPS in Jordan.

Anterior versus posterior approach to treat cervical spondylotic myelopathy, clinical and radiological results with long period of follow-up.

BACKGROUND: Cervical spondylotic myelopathy increases with age, but not all cases are symptomatic. It is usually diagnosed clinically and radiologically (X-ray and magnetic resonance imaging). Surgical treatment is indicated in severe symptomatic cases, while treatment controversy exists in the presence of less severe cases. Anterior and posterior approaches are generally used for decompression with no significant differences in the results of both. METHODS: A total of 287 patients of cervical spondylotic myelopathy were treated at our hospital between January 2004 and December 2015. Only 140 patients were eligible for our study. They had at least 5 years of follow-up using full clinical scores and radiological evaluation. They were divided into two groups: group I with 73 patients (aged 23-79 years) underwent posterior decompression, lateral mass instrumentation, and fusion, while group II with 67 patients (aged 33-70 years) underwent anterior decompression, instrumentation, and fusion. Neck Disability Index, local score, and X-ray were used in the evaluation of the patients. RESULTS: Preoperative mean ± standard deviation of Neck Disability Index of both the groups was 32.06 ± 6.33 and 29.88 ± 5.48, which improved in the last visit (>5 years) to 5.81 ± 7.39 and 2.94 ± 5.48 for groups I and II, respectively (p value <0.05). The local score of groups I and II was (P = 1, F = 21, G = 31, E = 19) and (P = 1, F = 12, G = 36, E = 18), which on discharge day improved to (P = 1, F = 4, G = 12, E = 55) and (P = 0, F = 3, G = 6, E = 58) at last follow-up, respectively. Fusion rate was nearly equal for both the groups during all the follow-up intervals and it was 91.1% and 91.7% in the last follow-up. CONCLUSION: There were no significant differences in the clinical and radiological results between the anterior and posterior approaches used in the surgical treatment of spondylotic cervical myelopathy. However, statistically significant results of Neck Disability Index of anterior approach were not clinically important and may be due to changes in the size and shape of the neck in group II.

Functional and Radiological Results of Proximal Femoral Nail Antirotation (PFNA) Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures.

Pertrochanteric femur fractures are considered amongst the most commonly encountered fractures in the geriatric age group. We evaluated radiographic and functional outcomes of patients with unstable pertrochanteric fractures treated with the proximal femur nail antirotation (PFNA). Between March 2013 and December 2015, fifty patients (28 male and 22 females with a mean age of 72.8 years (range, 20-94)) with unstable pertrochanteric fractures (AO 31.A2 and 31.A3) were fixed with the PFNA at our institution, and they were retrospectively evaluated. Forty one patients were treated with short PFNA and nine with long PFNA. Operative time ranged between 30 and 150 (average 73.60) min, blood loss ranged between 50 and 250 (average 80) milliliter and hospital stay ranged between 3 and 18 (6.86) days. The mean follow-up period was 18 months (range, 11-31). At final follow-up, solid union of all fractures had been achieved without any implant-related complications, the mean Harris Hip Score (HHS) was 79.34 ± 9.10 points and the mean neck-shaft angle was 127.2° ± 5.07°. No significant differences were encountered between the functional and radiographic outcomes of the PFNA with regards to the AO fracture classification and the implant version. PFNA is a recommended option for the treatment of unstable pertrochanteric fractures owing to its easy insertion, reduced blood loss, stable fixation and satisfactory functional and radiological outcomes.

Talar Neck Fracture with Dislocation Combined with Bimalleolar Ankle Fracture: A Case Report.

BACKGROUND Fractures of the talus are uncommon injuries that usually involve the talar neck, rather than the talar body. This report is of a rare case of combined left talar neck fracture and adjacent joint dislocation with an ipsilateral bimalleolar ankle fracture. CASE REPORT A 37-year-old man presented with an injury to his left foot following a motor vehicle accident. When he presented to the hospital emergency department, his left foot and ankle were swollen, the overlying skin was intact but badly contused, and there was no neurovascular deficit. Radiographs of the left ankle showed a fracture of the talar neck and bimalleolar fracture. An initial closed reduction under anesthesia failed. Therefore, open reduction and rigid stabilization of all fractures were achieved surgically, followed by the application of an external fixator spanning the ankle and the subtalar joints. The external fixator was removed at six weeks, range of motion (ROM) exercises were commenced, and a non-weight-bearing mobilization protocol was continued for 12 weeks. At four-year follow-up, radiographs confirmed solid union of all fractures, and although avascular necrosis (AVN) of the talus and secondary ankle arthritis developed, the functional outcome was satisfactory. CONCLUSIONS The immediate management of talar neck fracture with dislocation combined with a bimalleolar fracture is important to prevent soft tissue complications and to improve the functional ROM of the ankle. However, AVN and post-traumatic osteoarthritis at both the ankle and the subtalar joints are still common sequelae of talus fracture.

Intracardiac Leakage of Cement During Kyphoplasty and Vertebroplasty: A Case Report.

BACKGROUND: Intracardiac leakage of bone cement after kyphoplasty and vertebroplasty is a rare and life-threatening complication. Cortoss, which is an injectable, non-absorbable, polymer composite that is designed to mimic cortical bone, can be used instead of cement. Here, we present the case of a patient with right intra-cardiac Cortoss embolization. CASE REPORT: A 28-year-old man known to have ulcerative colitis since the age of 15 and treated with corticosteroids for more than 4 years and with anti-immune drugs presented to our hospital complaining of back pain and decreased body height due to osteomalacia with failed conservative treatment. Kyphoplasty and vertebroplasty of the thoracic 10-12 and first lumbar vertebrae were done with any complications. Three months later, the patient underwent kyphoplasty and vertebroplasty of lumbar 2-5 vertebrae by injecting Cortoss instead of cement, which was complicated with paravertebral intravascular leakage. We stopped surgery and transferred him to the recovery room, where he had slight chest pain that resolved spontaneously without neurological deficit. Two days later he developed severe chest pain and chest X-ray showed a large white shadow at the right side of the heart and another 2 small shadows just lateral to it. Sudden deterioration of patient status necessitated an emergency echocardiogram, which showed pericardial tamponade and a perforated right ventricle. Aspiration of pericardial blood and emergency open heart surgery were done. He was discharged 4 days later and was followed up at an outpatient clinic. CONCLUSIONS: Cardiac embolism is a serious condition that can complicate vertebral kyphoplasty; it requires a high level of suspicion and immediate action, and may need open heart surgery to save the patient's life.

Comparison if the addition of multilevel vertebral augmentation to conventional therapy will improve the outcome of patients with multiple myeloma.

BACKGROUND: This was a prospective study to evaluate the effect of multilevel vertebral augmentation in addition to conventional therapy in multiple myeloma patients. METHODS: We treated 27 patients, whom were recently diagnosed to have multiple myeloma by two ways of treatment. Thirteen patients (group I) were treated with conventional therapy and 14 patients (group II) with adding vertebroplasty and kyphoplasty. Patients were evaluated pre-treatment and at half, one, two and 3-years post-treatment by using Oswestry Disability Index (ODI), the Stanford Score (SS) and the Spinal Instability Neoplastic Score (SINS). RESULTS: Mean values of ODI, SS and SINS were 31.9 (63.8%), 4.3 and 13.8 for group I and 33.2 (66.4%), 4.6 and 12.8 for group II before starting treatment. Group II showed improvement better than group I at all follow-up intervals with best results at first 6 months. P-values at the end of the study were ODI = 0.047, SS = 0.180 and SINS = 0.002. Mortality rates were equal of both groups (four patients of each group). CONCLUSION: Adding vertebral augmentation to conventional therapy improves multiple myeloma patients' quality of life, but didn't affect the mortality rate.

Osteoblastoma is a metabolically active benign bone tumor on 18F-FDG PET imaging.

We describe a case of a 9-y-old girl who on (18)F-FDG PET imaging was found to have a highly metabolically active sacral tumor with an average standarized uptake value of 6.2. The tumor was proven to be osteoblastoma by pathologic examination. Osteoblastoma is a relatively rare benign primary bone tumor and occurs predominantly in patients younger than 20 y. The most common area of involvement is the spine. Osteoblastoma has been reported to be metabolically active on (18)F-FDG PET imaging, with an average standarized uptake value of 3.2, which renders (18)F-FDG PET imaging unable to differentiate benign from malignant primary bone tumors. To our knowledge, only 5 cases of osteoblastoma evaluated by (18)F-FDG PET imaging have been reported in the literature; all were metabolically active on (18)F-FDG PET imaging. The objective of this case report is to show that a metabolically active primary bone tumor on (18)F-FDG PET imaging might be benign and not necessarily malignant.

Posterior cervical decompressive laminectomy and lateral mass screw fixation.

OBJECTIVE: To review the results and complications of cervical decompressive laminectomy and lateral mass screw fixation. METHODS: This retrospective study was carried out between October 2006 and January 2010 at King Abdullah University Hospital, Irbid, Jordan. Over 40 months, 405 lateral mass screws were placed in 50 patients aged 22-65 years (17 females, and 33 males) for variable cervical pathologies including degenerative disease, trauma, and neoplasm. All cases were performed with a polyaxial screw/rod construct. Most patients had 14 mm length and 3.5 mm diameter screws placed. The screw location was evaluated by postoperative plain x-ray and CT. The facet joint, foraminal and foramen transversarium violation were also assessed. RESULTS: All screws were placed using the Anderson or Sekhon methods. No patients experienced neural or vascular injury as a result of screw position. One patient needed screw repositioning. Three patients experienced superficial wound infection. Five patients experienced pain around the shoulder of C5 distribution that subsided over time. No patients had screw pullouts or symptomatic adjacent segment disease. Postoperative CT scanning showed no compromise of the foramen transversarium or neural foramen in the vast majority of the patients. CONCLUSION: Lateral mass screw stabilization is a safe and effective surgical technique. This study exhibits the safety and effectiveness of lateral mass fixation for a variety of subaxial cervical spine disease.

Decompressive cervical laminectomy and lateral mass screw-rod arthrodesis. Surgical analysis and outcome.

BACKGROUND: This study evaluates the outcome and complications of decompressive cervical Laminectomy and lateral mass screw fixation in 110 cases treated for variable cervical spine pathologies that included; degenerative disease, trauma, neoplasms, metabolic-inflammatory disorders and congenital anomalies. METHODS: A retrospective review of total 785 lateral mass screws were placed in patients ages 16-68 years (40 females and 70 males). All cases were performed with a polyaxial screw-rod construct and screws were placed by using Anderson-Sekhon trajectory. Most patients had 12-14-mm length and 3.5 mm diameter screws placed for subaxial and 28-30 for C1 lateral mass. Screw location was assessed by post operative plain x-ray and computed tomography can (CT), besides that; the facet joint, nerve root foramen and foramen transversarium violation were also appraised. RESULTS: No patients experienced neural or vascular injury as a result of screw position. Only one patient needed screw repositioning. Six patients experienced superficial wound infection. Fifteen patients had pain around the shoulder of C5 distribution that subsided over the time. No patients developed screw pullouts or symptomatic adjacent segment disease within the period of follow up. CONCLUSION: decompressive cervical spine laminectomy and Lateral mass screw stabilization is a technique that can be used for a variety of cervical spine pathologies with safety and efficiency.