Characteristics of Lumbar Spondylolysis in Adolescent Baseball Players: Relationship between the Laterality of Lumbar Spondylolysis and the Throwing or Batting Side.

Study Design: A retrospective, cross-sectional study was conducted to analyze the implications of asymmetric baseball movements on the incidence of spondylolysis. Purpose: This study aimed to evaluate the relationship between asymmetric movements and the laterality of spondylolysis. Overview of Literature: Baseball, characterized by its asymmetric throwing and batting, may disproportionately stress one side. Lumbar spondylolysis is a frequent cause of lower back pain in young athletes, particularly those involved in activities with consistent unilateral rotations such as baseball. However, whether a link exists between the laterality in spondylolysis and the dominant throwing/ batting side or whether disparities exist between pitchers and fielders remains unclear. Methods: The study included 85 players. Participants were divided into two groups: pitchers and fielders. The association between the laterality of spondylolysis and the throwing/batting side in the overall cohort and between the two groups was evaluated. Results: Among pitchers, 16 lesions appeared on the throwing side and 32 on the nonthrowing side (p =0.029). For fielders, no notable difference was observed between the two sides (p =0.363). Furthermore, batting preference did not influence the laterality of spondylolysis in either group. Conclusions: Adolescent baseball players, particularly pitchers, exhibited a higher incidence of lumbar spondylolysis on the side opposite their throwing arm. The findings of this study highlight the significant effect of asymmetrical sporting activities on the development of spondylolysis, to which pitchers are particularly susceptible.

The Effect of Axial Traction MRI on the Articular Cartilage Visibility in Thumb Carpometacarpal Arthritis.

OBJECTIVES: Thumb carpometacarpal arthritis has a high incidence. However, the degree of damage to the cartilage has not been accurately assessed. The purpose of this study was to examine the effects of axial traction of the thumb carpometacarpal joint during magnetic resonance imaging (MRI) on the visibility of articular cartilage in patients with thumb carpometacarpal arthritis and to evaluate the articular cartilage defect using MRI findings. MATERIALS AND METHODS: Forty-four patients with thumb carpometacarpal arthritis (14 males, 30 females) and a mean age of 67.3±8.6 years were classified according to Eaton Stages 1, 2, 3, and 4 in 2, 14, 24, and 4 patients, respectively. Axial traction MRI was performed with and without traction (3 kg) using 3-Tesla MRI (Siemens Magnetom Skyra) with a 3D T2* multiecho data imaging combination. The effectiveness of traction was verified using the joint space width before and after traction at five points (central, volar, dorsal, radial, and ulnar margins) and the original articular cartilage outline visibility classification (poor, intermediate, complete). The rate of remaining cartilage on each joint surface was also evaluated. Statistical significance was set at p<0.05 in this study. RESULTS: Joint space width increased significantly at all points with traction (P<0.01). The grade of articular cartilage outline visibility significantly improved from seven intermediate and 37 poor cases to 15 complete, 23 intermediate, and six poor cases (P<0.01). Significantly more articular cartilage remained in Stages 1-2 compared with Stages 3-4 arthritis of both articular surfaces (P<0.01 in first metacarpal, P=0.01 in trapezium). CONCLUSION: Axial traction of the thumb increased the joint space width and improved articular cartilage visibility in the thumb carpometacarpal joint. Our results suggested that axial traction MRI can be used for noninvasive evaluation of articular cartilage defects in patients with thumb carpometacarpal arthritis and aid in selecting the optimal surgical procedure.

Neglected Proximal Tibiofibular Joint Dislocation Treated With a Cortical Button Suspension Device: A Case Report.

Proximal tibiofibular joint dislocation is a rare knee injury. Hence, its diagnosis is often missed. Herein, we have reported a case of posterior lateral proximal tibiofibular joint dislocation that was initially missed because it was associated with a fibula diaphyseal fracture. Our patient was a 23-year-old male with a complaint of left lateral knee pain and a history of fall from a motorcycle. He was treated with a cortical button suspension device. The patient reported no symptoms or complications at the one-year follow-up. Proximal tibiofibular joint dislocation is easily neglected if not considered as a diagnosis during clinical assessment. Half of these cases present with symptoms such as chronic pain and peroneal nerve palsy that require surgical treatment. A detailed physical examination and close review of imaging findings are important to establish a definitive diagnosis. A cortical bone button suspension device could be the appropriate treatment for cases requiring surgical management.

Epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis: a single-institution experience in Japan.

BACKGROUND: Lumbar spondylolysis, a common identifiable cause of low back pain in young athletes, reportedly has a higher incidence rate in males. However, the reason for its higher incidence in males is not clear. This study aimed to investigate the epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis. METHODS: A retrospective study was conducted in 197 males and 64 females diagnosed with lumbar spondylolysis. These patients visited our institution from April 2014 to March 2020 with their main complaint being low back pain, and they were followed-up until the end of their treatment. We investigated associations between lumbar spondylosis, their background factors, and characteristics of the lesions and analyzed their treatment results. RESULTS: Males had a higher prevalence of spina bifida occulta (SBO) (p = 0.0026), more lesions with bone marrow edema (p = 0.0097), and more lesions in the L5 vertebrae (p = 0.021) than females. The popular sports disciplines were baseball, soccer, and track and field in males, and volleyball, basketball, softball in females. The dropout rate, age at diagnosis, bone union rate, and treatment period did not differ between the sexes. CONCLUSION: Lumbar spondylolysis was more common in males than in females. SBO, bone marrow edema, and L5 lesions were more frequent in males, and sports discipline varied between the sexes.

Anterior interosseous nerve syndrome following infection with COVID-19: a case report.

BACKGROUND: Various neurological manifestations associated with coronavirus disease 2019 have been increasingly reported. Herein, we report a rare case of anterior interosseous nerve syndrome, which occurred 5 days after the onset of coronavirus disease 2019. CASE PRESENTATION: A 62-year-old Asian woman with a history of coronavirus disease 2019 who developed a complete motor deficit in the left flexor pollicis longus and pronator quadratus without sensory deficits. The symptoms appeared as a sudden onset fatigue and severe pain of the left arm, 5 days after the onset of coronavirus disease 2019. She noticed paralysis of the left thumb at 2 weeks after the onset of coronavirus disease 2019. Electromyography assessment of the anterior interosseous nerve-dominated muscles revealed neurogenic changes such as positive sharp wave and fibrillation in flexor pollicis longus and pronator quadratus, confirming the diagnosis of anterior interosseous nerve syndrome. There were no other diseases that could have resulted in peripheral nerve palsy. We performed a functional reconstruction surgery of the thumb by tendon transfer from the extensor carpi radialis longus to the flexor pollicis longus. The patient reported a good patient-reported outcome (2.27 points in QuickDASH Disability/Symptom scoring and 5 points in Hand20 scoring) at final follow-up (1 year after the surgery). CONCLUSION: This case highlights the need for vigilance regarding the possible development of anterior interosseous nerve syndrome in patients with coronavirus disease 2019. Tendon transfer from extensor carpi radialis longus to flexor pollicis longus can provide good functional recovery for unrecovered motor paralysis after anterior interosseous nerve syndrome.

Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome.

The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.

Flexor Pollicis Longus Tendon Rupture and Carpal Tunnel Syndrome due to Scaphoid Nonunion Advanced Collapse: A Case Report.

CASE: We report a case of flexor pollicis longus (FPL) tendon rupture and carpal tunnel syndrome due to scaphoid nonunion advanced collapse deformity. Intraoperative findings showed disruption of the palmar joint capsule and a sharp proximal bone fragment protruding into the carpal tunnel. Removal of this proximal fragment and tendon grafting were performed. At the postoperative 2-year follow-up, the patient had no wrist pain, finger numbness, or restriction of thumb motion. CONCLUSION: Our results suggest that minimally invasive surgical procedures, such as proximal pole or osteophyte resection, might be optimal choices for early rehabilitation after tendon repair in cases of FPL tendon rupture due to asymptomatic scaphoid nonunion.

Pediatric pathological subtrochanteric fracture treated with an adult proximal humerus polyaxial locking plate: A case report.

Pediatric subtrochanteric fractures are relatively rare. There are some surgical options with various plate techniques. Here, we report the first description of a pediatric pathological subtrochanteric fracture treated with an adult proximal humerus polyaxial locking plate and describe the good clinical outcomes achieved. A 10-year-old boy had a pathological subtrochanteric fracture. A non-contact bridging proximal humerus osteosynthesis plate was used. Although this is designed for the adult proximal humerus, its size and shape were considered to fit the pediatric proximal femur. In addition, this is a polyaxial locking plate with a choice of screw insertion directions. During surgery, it was possible to determine an appropriate plate installation position and screw direction in consideration of the location of pathological lesions, the bone shape, and the femoral neck angle. Twelve months postoperatively, the fracture was healed, and pathological lesion consolidated without obvious growth failure.

Effects of Magnetic Resonance Imaging With Axial Traction of the Thumb Carpometacarpal Joint on Articular Cartilage Visibility: A Feasibility Study.

Objectives The objective of this study was to verify the usefulness of magnetic resonance imaging (MRI) with axial traction of the thumb for observing articular cartilage. Materials and methods Eleven healthy adult volunteers (39.7 ± 7.4 years) without thumb carpometacarpal joint arthritis or trauma were included in this study. A 3-tesla (3T) MRI (Magnetom Skyra, Siemens Healthineers AG, Munich, Germany) of the right thumb with axial traction applied by a finger trap with three traction weights (0, 2, and 5 kg) was performed. A 3D T2* multiecho data imaging combination (MEDIC) was selected to visualize the articular cartilage. After multiplanar reconstruction, sagittal and coronal images of the thumb carpometacarpal joint were used to evaluate the articular cartilage visibility and joint space widths at five locations. Articular cartilage visibility was evaluated using our original classification method that used the percentage of the cartilage detectable area. The Friedman test was used to compare the differences between each traction weight and location. Results Articular cartilage visibility significantly improved with axial traction. The average joint space widths with the 5-kg application were 1.9 ± 0.8, 3.9 ± 0.6, 2.0 ± 0.9, 3.9 ± 1.1, and 2.5 ± 1.4 mm at the center, volar edge, dorsal edge, radial edge, and ulnar edge, respectively. The joint space widths significantly increased proportionally with the traction weight at all locations. The joint space widths at the volar and radial edges were significantly greater than those at other locations. Conclusion Applying axial traction to the thumb increased the joint space widths and improved the visibility of the articular cartilage in the carpometacarpal joint on MRI.

Rare Presentation of Angiolipoma Affecting an Intact Achilles Tendon.

Musculoskeletal lipomatous lesions are common in soft tissues. However, these are rarely associated with tendon sheaths or tendon compartments. Moreover, angiolipoma of the Achilles tendon is yet to be described. Here, we report an angiolipoma of an intact Achilles tendon, which has not been described previously. A 54-year-old woman presented with a two-year history of a palpable mass in the posterior aspect of the left ankle. The mass caused an intermittent localized pain while walking and a catching phenomenon induced by the plantar dorsiflexion movement of the ankle joint. Magnetic resonance imaging revealed a well-circumscribed, oval lesion on the lateral aspect of the Achilles tendon. The location and shape of the lesion had changed over time, suggesting that the lesion was moving in and out around the Achilles tendon. At the surgery, the tumor was confirmed under the crural fascia. Histopathological examination revealed that the tumor comprised mature adipocytes covered peripherally with a fibrovascular capsule. Based on these features, the tumor was diagnosed as an angiolipoma. Angiolipomas are typically treated surgically by simple excision, and lipomatous lesions of the tendon sheath are not different. From this case report, angiolipomas are rare but should be considered in the differential diagnosis and treatment of Achilles tendon tumors.

Characteristics of recurrent cases after conservative therapy in adolescent lumbar spondylolysis.

Occasionally lumbar spondylolysis in adolescents will recur after conservative treatment. The goal of this study was to retrospectively review the conditions in which recurrence transpired in a subset of adolescent patients diagnosed with acute lumbar spondylolysis. A retrospective survey was conducted in 141 patients who had been treated for spondylolysis and had obtained bone union. Twenty subjects were selected who had recurrent lumbar spondylolysis after returning to sports activity following the initial spondylolysis treatment. There were 18 males and two females with an average age at the time of initial visit of 13.3 years and 14.1 years at the time of recurrence. The average period of initial treatment was 101 days, and the average time to recurrence after healing was 149 days. There were three cases at L3, two cases at L4 and 15 cases at L5. At recurrence, 18 patients had unilateral involvement and two patients presented with bilateral occurrence. Four cases did not achieve bony union. In this study, the recurrence rate was 13.2%. Eighty percent of cases had recurrence within six months after healing. After recurrence, 20% of the cases reached pseudoarthrosis. It is useful to take regular MRI images to detect recurrence within six months after returning to sports.

Union evaluation of lumbar spondylolysis using MRI and CT in adolescents treated conservatively.

BACKGROUND: This study evaluated the union rate of acute lumbar spondylolysis in patients treated conservatively, according to the protocol. METHODS: The subjects included high school students and younger patients who were diagnosed with lumbar spondylolysis presenting bone marrow edema. We investigated the union rate, the period until union, unilateral or bilateral, vertebral level, laterality (right or left), and pathological stage at the first visit. Some unilateral cases included bilateral spondylolysis with contralateral pseudarthrotic lesion; therefore, the union rate of the "true" unilateral case in which the contralateral side was normal was calculated. We excluded multi-level lesions. RESULTS: With conservative treatment for lumbar spondylolysis of 189 lesions in 142 cases, 144 healed and 45 were considered as nonunion. The average treatment period until union was 106 days. The union of "true" unilateral cases in which the contralateral side was normal was noted in 68/71 lesions, but that of bilateral cases was noted in 71/94 lesions. The union in L3, L4, and L5 vertebrae was noted in 15/17, 40/49, and 89/123 lesions, respectively. The union was observed in 63/87 on the right and 86/102 on the left. The union was noted in the pre-lysis, early, and progressive stages in 36/39, 81/97, and 27/53 lesions, respectively. Furthermore, the union was noted in stages 0, 1a, 1b, 1c, and 2 in 13/15, 47/52, 30/36, 34/42, and 20/44 lesions, respectively. CONCLUSION: Accurate union evaluation using CT and MRI showed a union rate of 76% with conservative treatment for spondylolysis. The union rate of the "true" unilateral cases in which the contralateral side was normal was 96%, which was significantly higher than that of the bilateral cases. Moreover, the union rate of lesions in the axial progressive stage and sagittal stage 2 was significantly lower than that of lesions in other stages. STUDY DESIGN: clinical retrospective study.

Features of sacral alar fatigue fractures in adolescent athletes with overuse.

Three types of sacral alar fatigue fractures are elderly, postnatal, and sport-related. They are most prevalent in athletes during adulthood; there are few reports of sacral alar fatigue fractures in young athletes. The purpose of this study was to analyze sacral alar fatigue fractures in adolescent athletes. Of the 920 patients hospitalized with low back pain, 13 were diagnosed with sacral alar fatigue fractures with magnetic resonance imaging (MRI) abnormalities. We investigated age, sex, sports discipline, span from symptom onset to consultation, laterality, complication with spondylolysis, computed tomography (CT) findings, and treatment span. The average age was 14.5 years old (8-men and 5-women). The most frequent discipline was basketball. The span to consultation was 13.2 days. The number of right-side cases was 9. Seven cases were complicated by bilateral spondylolysis. MRI abnormalities were observed in all the cases. Only two patients showed abnormal findings on CT. Averagely 67 days after treatment, participants returned to their sports. Sacral alar fatigue fractures suggest that the span from onset to consultation is short. Fracture lines are often unclear on CT, and MRI is useful for diagnosis. More than half of the cases in this study were complicated by lumbar spondylolysis.

Factors associated with failure of bony union after conservative treatment of acute cases of unilateral lumbar spondylolysis.

BACKGROUND: If bone union is expected, conservative treatment is generally selected for lumbar spondylolysis. However, sometimes conservative treatments are unsuccessful. We sought to determine the factors associated with failure of bony union in acute unilateral lumbar spondylolysis with bone marrow edema including contralateral pseudarthrosis. METHODS: This study targeted unilateral lumbar spondylolysis treated conservatively in high school or younger students. Conservative therapy was continued until the bone marrow edema disappeared on MRI and bone union was investigated by CT. We conducted a univariate analysis of sex, age, pathological stage, lesion level complicating the contralateral bone defect, lesion level, and intercurrent spina bifida occulta, and variables with p < 0.1 were considered in a logistic regression analysis. An item with p < 0.05 was defined as a factor associated with failure of bony union. RESULTS: We found 92 cases of unilateral spondylolysis with bone marrow edema and 66 cases were successfully treated conservatively. Failure of bony union in unilateral lumbar spondylolysis with bone marrow edema was associated with progressive pathological stage (p = 0.004), contralateral pseudarthrosis (p < 0.001), and L5 lesion level (p = 0.002). The odds ratio was 20.0 (95% CI 3.0-193.9) for progressive pathological stage, 78.8 (95% CI 13-846) for contralateral pseudarthrosis, and 175 (95% CI 8.5-8192) for L5 lesion level. CONCLUSIONS: Conservative therapy aiming at bony union is contraindicated in cases of acute unilateral spondylolysis when the pathological stage is progressive, the lesion level is L5, or there is contralateral pseudarthrotic spondylolysis.

Direct reduction and repair of spondylolysis with grade 1 slip using the smiley face rod: a case report.

Objective: Lumbar spondylolysis, caused by stress fracture of the pars interarticularis may lead to a bony defect or spondylolisthesis. In adolescents, its surgical treatment employs the smiley face rod method for direct reduction of pseudoarthrotic spondylolysis and spondylolisthesis. Clinical outcomes of this treatment have been occasionally described; however, implant removal has not been discussed previously. We present a patient with lumbar spondylolysis with grade 1 slip at the 5th lumbar vertebra (L5) per the Meyerding classification. Patient: A 14-year-old boy presented with chronic severe lower back pain. Since conservative therapy did not resolve pain or enable resuming sports activities, the smiley face rod repair was performed 7 months after the initial treatment. Result: Anterior slippage of the L5 was surgically reduced. The patient wore a brace for 3 months postoperatively, and partial bone fusion was noted 6 months postoperatively. He resumed his sports activity 8 months postoperatively, and absolute bone fusion was confirmed 18 months postoperatively. Implant removal was performed 3 years postoperatively. Grade 1 slip was corrected with absolute bone fusion, and long-term follow-up revealed good results in terms of healing and rehabilitation. Conclusion: Smiley face rod method that allows for implant removal after bone fusion is suitable for adolescents.

Short-Term Effects of Early Postoperative Celecoxib Administration for Pain, Sleep Quality, and Range of Motion After Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: We hypothesized that early postoperative administration of celecoxib would reduce pain scores and improve sleep quality and active range of motion after total knee arthroplasty (TKA) under general anesthesia. METHODS: Patients in the celecoxib group received 400 mg of celecoxib 2 hours after TKA, followed 6 hours later by 200 mg of celecoxib. Patients in the control group received 400 mg of celecoxib the second day after surgery. Patients in both group had access to patient-controlled analgesia fentanyl. The primary outcome measure was the patient-reported visual analog scale (VAS) pain score the second day after TKA. The secondary outcome measure was sleep quality (days 1, 2, and 7 postoperatively). Active knee joint range of motion was assessed on days 2 and 7 postoperatively, and VAS pain scores were evaluated on postoperative days 1 to 7. Total fentanyl consumption was also assessed. RESULTS: Compared to the control group, the celecoxib group had significantly lower median VAS pain scores on postoperative days 1 and 2, significantly less nocturnal awakening (in minutes) and frequency of body motion, and better sleep efficacy on postoperative day 1. The celecoxib group also had a significantly better median flexion angle (°) on postoperative days 2 and 7, and lower cumulative fentanyl consumption. CONCLUSION: Early administration of celecoxib after TKA was associated with significantly reduced early VAS pain scores and improved sleep quality and active knee flexion angles. Thus, the early administration of celecoxib after TKA under general anesthesia may reduce pain and improve sleep quality and functional recovery. LEVELS OF EVIDENCE: Level II, therapeutic study. TRIAL REGISTRATION: UMIN-CTR 000014624 (July 23, 2014).

Recurrent hemarthrosis after total knee arthroplasty in rheumatoid arthritis successfully treated with selective embolization: A case report.

Recurrent hemarthrosis after total knee arthroplasty is a rare complication. This usually occurs in osteoarthritis, but is relatively rare in rheumatoid arthritis. This is a report of recurrent hemarthrosis after total knee arthroplasty in a rheumatoid arthritis patient. An 85-year-old woman with rheumatoid arthritis had received total knee arthroplasty without acute complications. At 6 months after surgery, the first hemarthrosis occurred and an initial conservative treatment failed. Contrast computed tomography showed prominent synovial enhancement in the superior lateral suprapatellar pouch. Selective catheterization revealed an abnormal hyperemic blush supplied from the branches of the superior lateral genicular artery. After embolization with N-butyl-2-cyanoacrylate, abnormal staining of the synovium diminished and knee swelling and pain disappeared without complications. Selective embolization is favorable for successful treatment of recurrent hemarthrosis after total knee arthroplasty in patients with rheumatoid arthritis.

Characteristics of adolescent lumbar spondylolysis with acute unilateral fatigue fracture and contralateral pseudoarthrosis.

Purpose: This study aimed to examine the characteristics of lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the other, relative to acute lumbar spondylolysis on one side only. Patients and Methods: Short-tau inversion recovery images obtained through magnetic resonance imaging were used to diagnose 58 patients with acute lumbar spondylolysis with bone marrow edema on one side only. A total of 20 patients who had pars defects on the contralateral side (terminal-stage pseudoarthrotic spondylolysis) were included in the contralateral pseudoarthrosis group (P group). The remaining 38 patients with normal images for the contralateral pars interarticularis were included in the unilateral lesion group, in which the contralateral side was normal (U group). We investigated the union rate, age, sex, lesion laterality, vertebral level, pathological stage, and existing spina bifida occulta in both groups. Results: The P group was characterized by a higher proportion of right-side cases, L5 lesions, more progressed pathological stage, and spina bifida occulta and a significantly lower union rate than the U group. Conclusion: The union rate in patients with lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the opposite side was only 15%. We should inform patients with acute unilateral spondylolysis lesions and contralateral pseudoarthrosis about this poor union rate and urge them to choose their therapy accordingly.

Clinical features of spontaneous spinal epidural hematoma.

Objective: Spontaneous spinal epidural hematoma is rare and therefore difficult to diagnose. This study evaluated the clinical features of this condition in patients admitted to our hospital. Patients and Methods: We evaluated 12 patients with spontaneous spinal epidural hematoma who were treated at our hospital. We investigated the following variables in these patients: underlying diseases, medications used, initial symptoms, spinal level affected, whether transported to the hospital by ambulance, department where first evaluated, mass lesion on computed tomography with soft tissue window settings, time interval between symptom onset and diagnosis, treatment received, and Frankel classification on arrival and when last observed. Results: Five patients reported the use of antiplatelet or anticoagulant drugs. All patients in this study reported acute onset of severe pain as the initial symptom, and 10 patients reported some degree of paralysis accompanying the pain. With respect to the morbidity level, the cervical region was the most common site of involvement (n=7). Ten patients were transported to the hospital at night via ambulance. Five patients first visited the Department of Internal Medicine. Seven patients presented with a mass lesion on computed tomography with soft tissue window settings. The time interval between symptom onset and diagnosis ranged from 2 hours to 6 days. Three and 9 patients received conservative and surgical treatments, respectively. No patient showed worsening of Frankel classification. Conclusion: Acute onset of severe pain was the most characteristic clinical symptom. Spontaneous spinal epidural hematoma should be included in the differential diagnosis. Computed tomography with soft tissue window settings may rule out cerebrovascular disease and cardiovascular disease, and specifically detect a hematoma. Subsequent magnetic resonance imaging can diagnose a spontaneous spinal epidural hematoma at an early stage.

Charcot spinal arthropathy presenting as adjacent segment disease after lumbar spinal fusion surgery in Parkinson's disease: A case report.

Charcot spinal arthropathy (CSA) is a rare spinal disorder presenting neuropathic osteoarthropathy of facet joints leading to progressive destruction. After L4-5 PLIF, a 63-year-old woman with Parkinson's disease (PD) underwent L3-4 and L5-S1 PLIF for primary adjacent segment disease caused by degenerative change, which was found as facet joint osteophytes and a vacuum disc phenomenon with endplate sclerosis. However, her postural disorder from PD deteriorated, and strong opioid analgesics were administered for severe recurring low back pain. Anterior subluxation at L2-3 occurred because of destructive secondary adjacent segment disease, which was found as destruction of the endplate and the facet without degenerative change, and formation of paravertebral osteophytes and fluid collection in the intervertebral space. The appearance on imaging met that for neuroarthropathic change, which was previously reported as CSA. L2-3 PLIF following extension of posterior fusion to T10 was additionally performed, and the postoperative course was uneventful with symptomatic improvement. In this case, the important finding was in the different appearance of the disease between adjacent segments on imaging. It is possible that deterioration of PD and administration of the analgesics inhibited deep pain sensation, and concentration of mechanical stress in the proximal adjacent segment by the long lever arm because of extension of the fusion level resulted in neuroarthropathic change of the facets in the secondary adjacent segments. The pathophysiology of association of CSA and PD remains unknown. However, we recommend vigilance for destructive neuroarthropathic facet change as CSA after spinal surgery in patients with severe PD.