An outbreak of compressive myelopathy due to pyogranulomatous reaction to the oily adjuvant of the foot-and-mouth disease vaccine - case report / Surto de mielopatia compressiva associada à reação piogranulomatosa ao adjuvante oleoso da vacina contra Febre Aftosa em Minas Gerais - relato de caso

Cases of compressive myelopathy syndrome associated with post vaccinal pyogranulomas were diagnosed post mortem in three cows from a farm in Minas Gerais state, Brazil. These cows presented ataxia and bilateral paresis of the pelvic limbs, which evolved to paralysis, and sternal recumbence. On necropsy, locally extensive areas of the longissimus dorsi muscle were replaced by pyogranulomas supported by moderate amounts of fibrous connective tissue. On the cut surface, some nodules contained yellowish and viscous fluid (purulent exudate) or whitish fluid (interpreted as the oily adjuvant of a vaccine). In the spinal canal of the subjacent vertebrae, compressing the spinal cord, were pyogranulomas identical to those described in the skeletal muscle. Histologically, the pyogranulomas were composed of a central clear vacuole (consistent with the space left by the oil adjuvant droplets), surrounded by neutrophils and, more externally, by large numbers of epithelioid macrophages and fewer multinucleated giant cells. In the white matter of the spinal cord were numerous well-defined, clear vacuoles (Wallerian degeneration). The association of the clinical history and pathological findings allowed the diagnosis of compressive myelopathy associated with pyogranulomatous reaction to the oily adjuvant of the foot-and-mouth disease vaccine, in this case, due to its inadequate application.(AU)

São descritos casos de síndrome de compressão medular, associada a granulomas pós-vacinais, em bovinos Nelore, provenientes de uma propriedade em Minas Gerais. Esses bovinos apresentavam ataxia e paresia bilateral dos membros pélvicos, que evoluiu para paralisia e decúbito esternal. Na necropsia, áreas focalmente extensas da musculatura na região torácica dorsal (músculo longissimus dorsi) eram substituídas por numerosos piogranulomas, separados por tecido brancacento e firme (tecido conjuntivo fibroso). Ao corte, alguns nódulos continham material amarelado e viscoso (exsudato purulento) ou material esbranquiçado e fluido (sugestivo de adjuvante de vacina). No canal medular das vértebras subjacentes, havia granulomas idênticos aos observados no tecido muscular. Histologicamente, os piogranulomas continham, no centro, vacúolo, bem delimitado e arredondado (consistente com o espaço deixado pela gotícula de lipídio do adjuvante), circundado por variável quantidade de neutrófilos degenerados e íntegros e, mais externamente, por numerosos macrófagos epitelioides e algumas células gigantes multinucleadas. Nas áreas da medula espinhal, circundadas pelos granulomas, numerosos vacúolos, bem definidos, eram observados na substância branca (degeneração walleriana). A associação do histórico clínico e de achados patológicos permitiu o diagnóstico de mielopatia compressiva associada à reação granulomatosa ao adjuvante oleoso da vacina contra febre aftosa, no caso, induzida pela aplicação inadequada da vacina.(AU)

Acute spinal cord compression: a rare complication of dual antiplatelet therapy.

A 73-year-old woman presented with acute shortness of breath and exacerbation of chronic back pain. She was diagnosed with pulmonary oedema and a non-ST-elevation myocardial infarction following chest X-ray, ECG and high sensitivity troponin levels. She subsequently underwent coronary angioplasty with deployment of drug-eluting stents to her circumflex and left anterior descending arteries and was started on aspirin and clopidogrel for her dual antiplatelet therapy. Unfortunately, following the procedure, she gradually lost power and sensation in both lower limbs. MRI of her spine confirmed an extradural haematoma causing thoracic cord compression. She was managed conservatively following discussions with neurosurgeons and developed further complications secondary to her immobility.

A rare non-malignant cause of spinal cord compression in a young patient.

In the context of palliative medicine, spinal cord compression occurs in around 5% of patients with cancer. Ten per cent of patients with spinal metastases are affected; the commonest causes are breast, prostate, lung cancer and multiple myeloma. We describe a rare cause of spinal cord compression in a 29-year-old man resulting from a complication of long-term corticosteroid use. Spinal epidural lipomatosis is a complex disorder caused by hypertrophy of adipose tissue located in the spinal epidural space. Symptoms occur when the adipose tissue enlarges, encroaching on the spinal canal. In this case, the aetiology was long-term exogenous dexamethasone use.

Chronic compressive myelopathy and progressive neurologic signs associated with melarsomine dihydrochloride administration in a dog.

A 7 yr old castrated male Great Dane presented with a history of progressive myelopathy following the intramuscular injection of melarsomine dihydrochloride 8 wk previously. MRI revealed paraspinal and epidural abscesses at the 13th thoracic (T13) and first lumbar (L1) disc space. The dog's condition worsened despite medical management, necessitating surgical decompression. Surgical decompression resulted in rapid improvement of the patient's clinical signs. Histopathologic evaluation of the lesions revealed pyogranulomatous inflammation. Cultures of fluid and tissue within the lesions were negative for bacterial growth, and no infectious organisms were visualized histologically. Melarsomine-associated neurologic signs can be chronic and progressive in nature, presumably secondary to ongoing sterile inflammation that may result in spinal cord compression.

Resolución espontánea de paraparesia por hematoma epidural dorsolumbar asociado a anestesia subaracnoidea y analgesia postoperatoria mediante catéter epidural / Spontaneous resolution of a paraparesis due to a dorsolumbar epidural haematoma associated with subarachnoid anaesthesia and postoperative analgesia using an epidural catheter

El hematoma epidural espinal secundario a anestesia neuroaxial es una complicación grave, aunque poco frecuente. La mayoría de los casos se asocia a tratamiento anticoagulante o circunstancias que favorezcan el sangrado. Por las graves secuelas secundarias a la compresión medular se considera una urgencia quirúrgica, siendo crucial en su pronóstico la precocidad en la descompresión medular. Presentamos un caso de hematoma epidural espinal dorsolumbar asociado a anestesia intradural y analgesia epidural en una paciente con tromboprofilaxis con heparina de bajo peso molecular, con recuperación espontánea con tratamiento conservador(AU)

Spinal epidural haematoma after neuroaxial anaesthesia is a rare but serious complication. Most cases are attributed to anticoagulant therapy or bleeding tendency. It presents as an acute spinal cord compression and usually requires emergency surgical decompression. The interval between the onset of clinical signs and surgical evacuation is very important, influencing the neurological prognosis. We report a case of a spinal epidural haematoma after epidural analgesia in a patient who was treated with low molecular weight heparin for thrombo-prophylaxis in the perioperative period. In some cases, such as the one reported here, good neurological recovery can be achieved with conservative management(AU)

Symptomatic spinal epidural lipomatosis after a single local epidural steroid injection.

Spinal epidural lipomatosis is a rare disorder that can manifest with progressive neurological deficits. It is characterized by abnormal accumulation of unencapsulated epidural fat commonly associated with the administration of exogenous steroids associated with a variety of systemic diseases, endocrinopathies, and Cushing syndrome (Fogel et al. Spine J 5:202-211, 2005). Occasionally, spinal epidural lipomatosis may occur in patients not exposed to steroids or in patients with endocrinopathies, primarily in obese individuals (Fogel et al. Spine J 5:202-211, 2005). However, spinal lumbar epidural lipomatosis resulting from local steroid injection has rarely been reported. We report the case of a 45-year-old diabetic man with claudication that was probably due to symptomatic lumbar spinal lipomatosis resulting from a single local epidural steroid injection.

Sudden paraplegia following epidural lipomatosis and thoracal compression fracture after long-term steroid therapy: a case report.

Sudden paraplegia secondary to the posterior spinal epidural compression and vertebral compression fracture as a complication in corticosteroid treatment is extremely rare. The authors presented a case 49-year-old man with chronic relapsing attack of Still's disease. After the identification of pathology, the surgical evacuation of lipid tissue and pedicle-based instrumentation showed therapeutic success. To the authors' knowledge, this is the first case showing both vertebral fracture and paraplegia that required urgent surgery in the follow-up Still's disease.

[Steroid-induced spinal epidural lipomatosis in pediatric patients]. / Kortikosteroid-induzierte spinale epidurale Lipomatose bei pädiatrischen Patienten.

We describe three adolescent patients with chronic autoimmune disorders who developed back pain and, in two cases, spinal symptoms several months after initiating chronic treatment with glucocorticoids. In all cases, MRI showed extensive spinal epidural lipomatosis, a rare but classic untoward effect of chronic glucocorticoid therapy. Analysis of these three, as well as 11 other pediatric cases extracted from the international literature, revealed that spinal epidural lipomatosis manifests most commonly with back pain and within a mean of 1.3 years (range, 3 month-6.5 years) after initiation of therapy with corticosteroids. It frequently remits after reduction of the corticosteroid dose.

Cauda equina compression by hydrogel dural sealant after a laminotomy and discectomy: case report.

STUDY DESIGN: The authors present a case of cauda equina compression after laminotomy and discectomy where incidental durotomy was managed with the application of hydrogel sealant. The patient reported return of radicular symptoms on the first postoperative day, and deterioration to early cauda equina syndrome after bending on the sixth day. OBJECTIVE: To demonstrate that in addition to its recognized volume expansion properties, that the product has the ability to migrate and produce symptoms remote from where it was inserted. SUMMARY OF BACKGROUND DATA: The physical properties of DuraSeal (Confluent Surgical, Waltham, MA), a hydrogel dural sealant, make it an effective adjunct to dural closure. Its volume expansion has been associated with neural compression after posterior fossa decompression. We have found no reported migration of this product. METHODS: Sequential postoperative imaging shows swelling and migration of the hydrogel into spinal canal with resultant compression. Exploration on postoperative day 10 revealed sealant causing cauda equina compression proximal to the site of the durotomy. CONCLUSION: The authors recommend that in addition to caution regarding its potential mass effect, that cognizance be taken of the product's potential to migrate and result in symptoms at a distant site.

Intradural cement leakage: a rare complication of percutaneous vertebroplasty.

Percutaneous vertebroplasty (PV) is one of the alternative treatments for vertebral fractures. Reported significant complications include pain, radiculopathy, spinal cord compression, pulmonary embolism, infection and rib fractures. In this report, we highlight intradural cement leakage which is a rare complication of the procedure. A 49 year old man with a T12 compression fracture due to multiple myeloma was referred to the neurosurgery department from the orthopaedics and traumatology clinic after developing a right lower limb weakness following percutaneous vertebroplasty with polymethylmethacrylate. An urgent thoraco-lumbar magnetic resonance imaging was performed. The T1 and T2-weighted images demonstrated intradural extramedullary and epidural cement leakages which were hypointense on both sequences. Total laminectomy was performed at T12 and L1 and two epidural cement collections were excised on the right. Then, a dural incision from T12 to the body of L1 was done and cement material seen in front of the rootlets excised without any nerve injury. The patient was discharged after a week and referred to the haematology clinic for additional therapy of multiple myeloma. Although the cement leakage was extensive, the right leg weakness improved significantly and he began to walk with assistance 3 months later. Good quality image monitoring and clear visualisation of cement are essential requirements for PV using polymethylmethacrylate to prevent this complication from the treatment.

[Cervical myelopathy revealing bone fluorosis]. / Myélopathie cervicale révélant une fluorose osseuse.

Bone fluorosis is a rare metabolic disease characterized by massive bone fixation of fluorine. It is seen endemically around phosphate mines in North Africa. Neurologic complications, such as medullar compression may rarely reveal the disease. We report a case of cervical myelopathy due to bone fluorosis causing tetraparesis. Medullar compression was caused by posterior vertebral ligament calcification. Diagnosis was based on the characteristic radiologic aspect, and confirmed by the dosage of serum and urine levels of fluorine. Cervical laminectomy resulted in significant pain improvement, despite persistent motor deficit.

Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2).

BACKGROUND CONTEXT: Bone morphogenetic protein-2 (BMP-2) (Infuse) has been approved for use in anterior lumbar fusion in conjunction with an LT cage. However, off-label use is seen with anterior cervical fusion, posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF). The Federal Food and Drug Administration trial of BMP-2 in a PLIF application was halted because of a high incidence of ectopic bone forming in the neural canal (75%). The authors did not find a correlation between ectopic bone and increased leg pain. They concluded that the ectopic bone was a radiographic phenomenon and not associated with clinical findings. Complications using BMP in the cervical spine have been reported. Heretofore, there has not been a similar warning voiced for use of BMP in a lumbar PLIF or TLIF. PURPOSE: The purpose was to report five cases of ectopic bone in the canal associated with PLIF/TLIF off-label use of BMP-2 potentially contributing to abnormal neurologic findings. STUDY DESIGN/SETTING: This is an observational cohort study of patients referred to a tertiary care private medical center. METHODS: This was a retrospective chart review of patients referred to a tertiary spine institute with complications after surgery where BMP-2 had been used in an off-label PLIF or TLIF application. Patient demographics, operating room (OR) notes from the index BMP surgery, imaging studies, and current clinical status were reviewed. RESULTS: Five cases of ectopic bone in the spinal canal with potential neurologic compromise were identified. CONCLUSIONS: It does appear that ectopic bone in the spinal canal associated with BMP-2 use in PLIF or TLIF may contribute to symptomatic neurologic findings in rare cases. Revision surgeries are difficult. This article challenges a previous publication, which concluded that the high incidence of ectopic bone was of no clinical significance. Isolating BMP anteriorly in the disc space using layered barriers of bone graft between the BMP and the annular defect may reduce the incidence of ectopic bone in the spinal canal. Surgeons need to weigh the benefits versus risks of any technology used off label when making treatment decisions with their patients.

Incidencia de hematomas espinales con compresión medular relacionados con anestesias neuroaxiales en Cataluña / Incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia

OBJETIVO: Investigar la incidencia en Cataluña dehematomas espinales con compresión medular relacionadoscon anestesias neuroaxiales.MÉTODOS: La incidencia de hematomas se basó en loscasos publicados (Medline, Índice Médico Español, Google)o comunicados en reuniones o congresos médicospor anestesiólogos de centros hospitalarios catalanes desde la primera comunicación en 1996 hasta el 31 dediciembre de 2005. El número anual de anestesias neuroaxiales (intradural, epidural, combinadas) se estimó a partir del estudio epidemiológico ANESCAT 2003, y ese dato sirvió de base de cálculo del número total de anestesias realizadas junto con los informes de actividad quirúrgica de las instituciones sanitarias catalanas.RESULTADOS: Desde 1996 hasta 2005 (ambos incluidos)se comunicaron o publicaron 11 casos de hematomasespinales después de anestesias neuroaxiales (7 tras anestesia subaracnoidea y 4 tras anestesia epidural). En 2003 se realizaron 194.154 anestesias neuroaxiales (126.560 intradurales, 61.668 epidurales y 5.926 combinadas intra/epidurales) y en los 10 años analizados se estimó la realización de algo más de 1.700.000 anestesias neuroaxiales.La incidencia (IC95%) de hematomas sería de 0,6(0,3-1,2) por 100.000 anestesias neuroaxiales; de 0,6 (0,3- 1,3) por 100.000 anestesias subaracnoideas y de 0,7 (0,2- 1,9) por 100.000 anestesias epidurales.CONCLUSIONES: La incidencia de hematomas espinalestras anestesias neuroaxiales es ligeramente superior a 1caso cada 150.000 anestesias, similar a otros estudiosepidemiológicos. La incidencia es algo superior con anestesia epidural. Estos datos suponen un riesgo aproximado de 1 hematoma espinal por año en Cataluña

OBJECTIVE: To study the incidence in Catalonia ofspinal cord compression due to spinal hematomasecondary to neuraxial anesthesia.METHODS: The incidence of hematoma was based onpublished cases (MEDLINE, the Spanish Medical Index[Indice Médico Español], and Google) or cases reported atmedical meetings or conferences by anesthesiologists fromCatalan hospitals from 1996 to 2005, inclusive. Theannual number of neuraxial anesthesias (spinal, epidural,and combined) was estimated based on the ANESCAT2003 survey and the total number of anesthesias wascalculated using the ANESCAT 2003 survey inconjunction with the surgical reports of Catalan hospitals.RESULTS: A total of 11 cases of spinal hematoma afterneuraxial anesthesia (7 after spinal anesthesia and 4after epidural anesthesia) were reported or publishedfrom 1996 to 2005, inclusive. A total of 194 154 neuraxial anesthesias were performed in 2003 (126 560 spinal anesthesias and 5926 combined spinal-epiduralanesthesias) and it was estimated that somewhat over1 700 000 neuraxial anesthesias were performed over the10 years reviewed. The incidence (95% confidenceinterval [CI]) of hematoma was 0.6 (95% CI, 0.3-1.2) per100 000 neuraxial anesthesias, 0.6 (95% CI, 0.3-1.3) per100 000 spinal anesthesias, and 0.7 (95% CI, 0.2-1.9) per100 000 epidural anesthesias.CONCLUSIONS: The incidence of spinal hematoma afterneuraxial anesthesia is slightly more than 1 per 150 000anesthesias—a similar finding to that of otherepidemiological studies. The incidence is slightly higherin epidural anesthesia. These data imply a risk ofapproximately 1 spinal hematoma per year in Catalonia

Neurologic deficit following percutaneous vertebral stabilization.

STUDY DESIGN: A retrospective review. OBJECTIVE: The purpose of this study is to document a series of cases of neurologic deficit following percutaneous vertebral stabilization, to identify patterns of neurologic injury, and to describe potential methods for avoiding these injuries. SUMMARY OF BACKGROUND DATA: Percutaneous vertebral stabilization procedures, including vertebroplasty and kyphoplasty, have become a widely used for the treatment of osteoporotic vertebral compression fractures, primary and metastatic vertebral tumors, and traumatic burst fractures. Despite an increasing array of indications, there have been few reports of adverse events. Neurologic complications associated with vertebroplasty and kyphoplasty have been described previously as case reports and have generally been considered as infrequent and minor in severity. METHODS: The clinical course of 14 patients with documented loss of neurologic function following percutaneous vertebral cement augmentation was retrospectively reviewed. RESULTS: The average patient age was 74.9 years (range, 46-88 years) with 3 male and 11 female patients. Four patients underwent a vertebroplasty procedure while 10 were treated with kyphoplasty. Six patients developed neurologic deficits acutely (<24 hours of procedure). The remaining 8 patients developed neurologic symptoms at an average of 37.1 days (range, 3-112 days) postprocedure. Neurologic deficits were recorded as ASIA A in 4 patients, ASIA B in 2 patients, ASIA C in 1 patient, and ASIA D in 7 patients. Twelve of 14 patients (85.7%) required revision open surgical intervention for treatment of their neurologic injury. CONCLUSION: Percutaneous vertebroplasty and kyphoplasty have been reported to be safe options for the treatment of painful osteoporotic vertebral fractures. Although complications are infrequent, there remains the potential for catastrophic neurologic injury. Physicians performing these procedures need to be aware of these potential complications and be prepared to respond in an emergent manner (surgically) if a need arises.

Hydrogel-induced cervicomedullary compression after posterior fossa decompression for Chiari malformation. Case report.

The use of an absorbable hydrogel dural sealant has been approved for neurosurgical applications with no published reports of complications to date. The authors present the case of a 13-year-old girl with syringomyelia and quadriparesis who underwent posterior fossa decompression and dural augmentation for Chiari malformation Type I. Dural closure was performed with a dural substitute patch, hydrogel dural sealant, and gelatin sponge. Magnetic resonance imaging, performed after initial postoperative improvement in the patient's quadriparesis deteriorated, demonstrated an expanding epidural mass collection causing cervicomedullary compression. Exploration on postoperative Day 15 revealed an expanded layer of hydrogel underlying a layer of gelatin sponge. The authors conclude that hydrogel dural sealants should be used cautiously in spaces that cannot tolerate significant mass effect.

An unusual cause of paraparesis in a patient on chronic steroid therapy.

BACKGROUND/OBJECTIVE: Spinal epidural lipomatosis is the excessive deposition of unencapsulated fat in the epidural space. This is a rare disorder often associated with high levels of endogenous steroids or the administration of exogenous steroids. CASE DESCRIPTION: A 32-year-old man with congenital kyphosis treated with prednisolone daily for 5 months for interstitial lung disease developed compressive myelopathy. FINDINGS: Magnetic resonance imaging showed congenital kyphosis along with epidural lipomatosis compressing the cord. Cessation of steroid therapy was associated with improvement in the symptoms. CONCLUSIONS: Spinal epidural lipomatosis is a rare side effect of chronic steroid therapy that may occur with relatively short-term, low-dose regimens. In patients with congenital vertebral anomalies, spinal fat deposition may worsen the neurological status in an already compromised cord. Discontinuation of steroid therapy is beneficial; some patients may require surgical intervention for decompression.

Oxidised regenerated cellulose as a cause of paraplegia after thoracotomy: case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVE: To report an unusual case of paraplegia. SETTING: University Hospital Bursa, Turkey. CASE REPORT: A 22-year-old woman presented with paraplegia following a left-sided thoracotomy. Magnetic resonance imaging showed a dorsal epidural mass at the level of T6. The patient underwent an emergency T6/7 laminectomy and removal of a tuft of oxidised regenerated cellulose, which had migrated through the intervertebral foramen causing spinal cord compression. CONCLUSION: In cases of neurological deficits after surgery at the posterolateral edge of a thoracotomy, the clinician should be aware of the above possibility. Urgent radiological diagnosis and decompressive laminectomy is the treatment of choice.