Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature.

Cauda equina syndrome (CES) is a rare neurologic condition that is caused by compression of the cauda equina. Cauda equina consists of spinal nerves L2-L5, S1-S5 and the coccygeal nerve. The compression of these nerve roots can be caused mainly by lumbar disc herniation (45% of all causes). The diagnosis consists of two critical points: a) detailed history and physical examination and b) MRI or CT. The gold standard of the treatment of this syndrome is the surgical approach in combination with the timing of onset of symptoms. The surgery as an emergency situation is recommended in the fi rst 48 hours of onset of symptoms. Any delay in diagnosis and treatment leads to a poor prognosis of CES.

Surgical management of complex lumbosacral anomaly with minimally invasive spinal fusion: A clinical image.

Key Clinical Message: Lumbosacral junction anomalies represent a rather frequent finding in patients with low back pain. Involved healthcare professionals should be familiar with these dysplasias, in order to achieve proper diagnosis and optimize clinical outcomes. Abstract: Dysplastic alterations in lumbosacral junction represent a frequent finding in patients with low back pain. Lumbosacral transitional vertebra (LSTV), spina bifida occulta (SBO) and isthmic spondylolisthesis (IS) present recognized etiologies of low back pain. Herein, we present a rare case of concurrent presence of LSTV, SBO and IS in a middle-aged male individual who was presented with low back pain in our department. Considering the resistant to conservative treatment symptomatology in conjunction with clinical-radiologic presence of segmental instability, patient was subjected to uneventful minimally invasive lumbosacral fusion featuring complete recession of symptomatology directly postoperatively with no signs of recurrence until 6 months follow-up. To our best knowledge, coexistence of LSTV, IS and SBO in lumbosacral junction has never been described in contemporary literature. Whenever surgery is indicated, minimally invasive spinal fusion may be considered as a safe and effective alternative in these cases.

Posterolateral Instrumented Fusion in Elderly Patients With a Single Osteoporotic Vertebral Fracture: Evaluation of Health-Related Quality of Life.

Introduction Treatment of osteoporotic vertebral fractures (OVFs) is a factor that affects the quality of life and should be considered during management. In patients with a single OVF and neurologic deficit, surgical procedures aiming at neural decompression with instrumented fusion should be considered in elderly individuals. Posterolateral instrumented fusion (PLF) constitutes a largely performed fusion surgery for patients featuring indications for fusion surgery. The aim of this study was to determine the safety, effectiveness, and impact on health-related quality of life (HRQoL) of PLF surgery in elderly patients diagnosed with a single OVF. Methods This study was conducted at Interbalkan European Medical Center, Thessaloniki, Greece. Eighty (80) consecutive individuals with OVFs were subjected to PLF and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at one, three, six, and 12 months and two years. The assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. Results No major perioperative complications were observed. All parameters of SF-36 presented significant improvement over the entire follow-up period with VAS scores reaching a plateau at six months. Depicted improvement of these parameters proves the beneficial role of PLF in elderly patients who suffered from a single OVF with or without referable neurological deficit. Conclusion OVFs have a significant impact on the quality of life of elderly patients, and surgical treatment with PLF with or without decompression can lead to functional recovery, pain relief, and HRQoL amelioration. Our results demonstrated that the outcomes of PLF in the surgical treatment of these patients are remarkably favorable, demonstrating the safety and efficacy of the technique.

Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management.

Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.

Post-Discectomy Infection: A Critical Review and Suggestion of a Management Algorithm.

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.

Pure Ankle Dislocation: A Case Report and a Narrative Literature Review.

Pure dislocation of the ankle is an extremely rare injury accounting for only 0.065% of all ankle injuries and 0.46% of all ankle dislocations. The mechanism of the injury generally consists of high-energy trauma which is associated with a combination of plantar flexion and inversion or eversion of the foot. We present a case of a 22-year-old male patient who sustained a closed pure ankle dislocation after a fall from a small height. He was treated conservatively with closed reduction and circumferential cast immobilization for six weeks, followed by a functional rehabilitation program. The patient presented to the emergency department with an acutely painful and deformed right ankle after falling from a height of 1 m (stairs). Radiographs showed a posteromedial ankle dislocation without fracture. Urgent closed reduction of the dislocation was performed and a posterior below-knee back slab was applied to immobilize the ankle. Dorsalis pedis and posterior tibial arteries were intact. Check X-rays confirmed proper reduction of the ankle joint. Post reduction computed tomography (CT) scan did not show any associated fractures. Magnetic resonance imaging (MRI) revealed a multiligamentous ankle injury and a small osteochondral lesion of the anteromedial talar dome. The back slab was changed to a below-knee circular cast two weeks later, as soon as the soft tissue swelling subsided. The cast was removed at the six-week follow-up and physiotherapy was initiated in order to gain functional rehabilitation and improve the range of motion. At the final follow-up (12 months), the ankle range of motion (ROM) was the same as the pre-injury status and the patient was able to return to his work. Pure ankle dislocation is a rare injury. A satisfactory outcome can be expected, provided that the appropriate conservative treatment followed by a strict rehabilitation protocol is applied.

Percutaneous fixation of displaced intraarticular fractures of the calcaneus. A retrospective case series study and a review of the literature.

PURPOSE: To evaluate the outcome of displaced intraarticular calcaneal fractures (DIACFs) of a case series of patients who were treated with a percutaneous fixation technique. MATERIALS AND METHODS: Eight patients were operated for DIACFs and they were evaluated for the outcome and complications in a mean follow up of 9 months (range: 6 - 12 months). At the last follow up the AOFAS score, the Boehlers' angle and the presence of any complication were noted. The time from injury to surgery was also reported. The correlation of the AOFAS score and the development of post traumatic subtalar arthritis to the type of fracture, to the post operative Boehler's angle and to the time from injury to surgery were investigated. RESULTS: The overall mean AOFAS (Americal Orthopaedic Foot and Ankle Society) score was 84,625 (Range: 73 - 96). The mean AOFAS score of type II and type III fractures was 87,667 and 75,500 respectively. The mean AOFAS score for fractures with a postoperative Boehler's angle of less than 10° and more or equal to 10° was 76,750 and 92,500 respectively. This difference was found to be statistically significant. The mean AOFAS score for fractures who were treated less or equal to six days and more than six days post injury was 91,250 and 78 respectively. Two out of four patients with a post operative Boehler's angle less than 10° developed post traumatic subtalar arthritis. No patient out of four for whom a Boehler's angle of more than 10° has been achieved, developed subtalar arthritis. No infection occurred in any of the patients. CONCLUSION: Percutaneous fixation is a safe and effective way of treating DIACFs. The outcome is directly related to the quality of reduction, which is significantly dependent to the timing of surgery. The earlier the fracture is operated the better the reduction by closed means is.

Quadriceps Tendon Delamination Tear: A Case Report.

Partial quadriceps tendon ruptures are rare and they are usually managed non-operatively, provided that the extensor mechanism is intact. In case the extension mechanism is compromised, a more aggressive treatment is required, which includes surgical repair of the tendon. We present an extremely rare case of a 42-year-old male lifter who sustained a quadriceps tendon delamination tear, after lifting weights. Careful clinical examination revealed a compromised extension mechanism of the knee. Proper imaging confirmed the diagnosis of partial but significant rupture of the undersurface of the quadriceps tendon, which was treated operatively (standard tendon repair with the Krakow technique and three transosseous tunnels) with a very good outcome.

Lower Limb Paralysis as Initial Presentation of Arterial Embolism Secondary to Heparin-Induced Thrombocytopenia after Hip Fracture - a Case Report.

Introduction: Prophylactic anticoagulation (AC) with low molecular weight heparins (LMWHs) following hip fracture has reduced the incidence of severe thromboembolic events. However, heparin-induced thrombocytopenia (HIT) remains a serious complication in these patients. Clinical case: We report an unusual case of thrombosis due to severe HIT in a 75-year-old female patient following intramedullary nailing for a hip fracture. The patient was taking Verapamine. On the fourth postoperative day she developed paralysis, paresthesia and mild pain over the right lower extremity; faint pulses were palpated. Computed tomography angiogram identified superficial artery occlusion leading to limb ischemia. Anti-platelet factor 4 (PF4) heparin antibody positivity confirmed the diagnosis of HIT. Urgent embolectomy was performed and the patient achieved full recovery. Discussion: Arterial embolism presenting with severe neurological deficits is a rare complication of HIT. Conclusion:A high index of suspicion and close platelet count monitoring is warranted for early diagnosis and treatment of this devastating condition that can be limb and life threatening.

Capitellum and trochlea fractures. A systematic review of the literature.

Purpose: To investigate the outcome of capitellum and trochlea fractures through a systematic review of the contemporary literature. The effect on the outcome, of the posterolateral column comminution and the surgical approach used for fixation, was also evaluated. Methods: PUBMED, SCOPUS and MENDELEY databases were searched for capitellum and trochlea fractures and a systematic review was conducted according to PRISMA guidelines. The minimum one year clinical outcome and the flexion extension arc of these fractures, as well as the risk of developing degenerative arthritis were evaluated. The studies included to the meta - analysis were assessed based on the Newcastle Ottawa score. A fixed effect model was performed to compare the outcome and range of motion among Dubberley type A and type B fractures as well as between the extended lateral approach and the posterior transolecranon approach which were performed for Dubberley type B fractures. Furthermore the relative risk of degenerative arthritis (DA) among type A and type B fractures was also estimated. Chi square test was used to test heterogenity among studies. Results: Ten nonrandomized case series were eligible to our inclusion criteria, including 76 patients in total. The fixed overall Mayo Elbow Performance Score (MEPS) and the Range of Motion (ROM) of the Dubberley type A fractures was 86 (95% C.I.: 85,1-86,9) and 124 0 (95% C.I.: 122 0-124 0) respectively. The fixed overall MEPS and ROM of the Dubberley type B fractures was 84 (95%C.I.: 79,9-88,1) and 122 0 (95% C.I.: 120 0-123 0) respectively. Significant heterogenity was found though between studies regarding MEPS of type B fractures. The fixed overall MEPS and ROM for fractures treated with an extended lateral approach was 89,4 (95% C.I.: 85,36-93,44) and 123 0 (120 0-126 0) respectively. The fixed overall MEPS and ROM for fractures treated with a posterior transolecranon approach was 68,75 (95% C.I.: 67,89-69,6) and 122 0 (114 0-130 0) respectively. The degenerative arthritis relative risk (RR) of type B compared to type A fractures was 3,91 (95% C.I.: 0,84-18,13). Conclusion: There is no statistically significant difference among type A and type B fractures, in terms of outcome and ROM. The posterior transolecranon approach leads to a lower MEPS as opposed to the extended lateral approach. High quality studies comparing directly the outcome of type A and type B fractures are required, in order for safe conclusions to be extracted.

Distal Humerus Fracture Malunion in Adults: A Case Report and a Review of the Literature.

Introduction: Neglected distal humerus fractures are rare injuries, which the orthopaedic surgeon will not deal many times in his career. We present a case of a young patient with such an injury, who was treated with a corrective osteotomy and fixation, resulting in a very good outcome. This case report highlights the importance of surgical intervention for distal humerus fracture malunion. A narrative review of the literature regarding this topic is presented as well. Case Report. A 42-year-old female patient presented to our department nine weeks after a displaced distal humerus fracture, which was treated conservatively in another institution. Ulnar nerve neuropathy, pain, and severe stiffness of the elbow were her main symptoms. Open correction of the deformity, anatomical reduction of the articular surface, and realignment of the metaphyseal level of the fracture were performed. Six months postoperation, a painless flexion-extension arc of 110° and a normal rotation of the forearm was achieved. Conclusion: Distal humerus fracture malunion is a challenge. The operation needed for this purpose is much more demanding, and postsurgical complications are more likely to occur as opposed to the treatment of acute fractures. If a proper surgery is performed though, a good clinical outcome can be expected.

Percutaneous Transforaminal Endoscopic Discectomy for the Treatment of Lumbar Disc Herniation in Obese Patients: Health-Related Quality of Life Assessment in a 2-Year Follow-Up.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive surgical technique used principally for the treatment of lumbar disc herniation (LDH). LDH is a frequent spinal ailment in obese individuals. The aim of this prospectively designed study was to assess for the first time in the literature the impact of PTED in postoperative parameters of health-related quality of life (HRQoL) in obese patients with LDH within a 2-year follow-up period, to further evaluate the effectiveness of PTED. METHODS: Patients with surgically treatable LDH were divided into 2 groups. Group A constituted 20 obese patients, and group B was composed of 10 patients with normal body mass index (BMI). A visual analog scale was used for pain evaluation, and the Short Form SF-36 Medical Survey Questionnaire contributed to HRQoL assessment. Follow-up was conducted preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively. RESULTS: Two of the 20 patients (10%) presented with severe postoperative pain, necessitating conventional microdiscectomy. All studied parameters exhibited maximal improvement at 6 months in group A and at 6 weeks in group B, with subsequent stabilization. Obese patients scored lower in all parameters compared with their healthy counterparts with normal BMI, acquiring a less favorable clinical benefit. CONCLUSIONS: PTED appears to be a generally safe and effective method for treating obese patients with LDH. However, major technical challenges that lead to a higher frequency of complications, as well as the lesser acquired clinical benefit, in obese patients may contribute to the further consideration for PTED in specific obese patients, especially on the grounds of low surgical experience.

An Unusual Case Report of Bertolotti's Syndrome: Extraforaminal Stenosis and L5 Unilateral Root Compression (Castellvi Type III an LSTV).

INTRODUCTION: Castellvi Type III lumbosacral transitional vertebrae (LSTV) is an unusual case of Bertolotti's syndrome (BS) due to extraforaminal stenosis, especially manifesting in elderly patients. CASE REPORT: We report a case of BS in a 62 years old Greek female. The signs of the clinical examination are low back pain, sciatica, hypoesthesia, and pain to the contribution of L5 nerve. Imaging techniques revealed an LSTV Type III a (complete sacralization between LSTV and sacrum). CONCLUSION: Despite the fact that LSTV is a congenital lesion, the clinical manifestation of BS may present in the elderly population. The accumulative effect of the gradual degeneration of intervertebral foramen (stenosis) may lead to the compression of extraforaminal portion of the nerve root.