Neglected cervical meningocele in an adult: illustrative case.

BACKGROUND: Posterior cervical meningoceles are rare in adults because most are surgically excised early in life. Such meningoceles in adults are mostly presented as a cystic mass and their presentation as a solid mass is very rare. OBSERVATIONS: An asymptomatic adult with cervical meningocele presented as a congenital midline skin covered solid mass in the posterior aspect of the neck is presented. Neuroradiological surveys showed attachment of the mass to intradural spinal cord. With diagnosis of a cervical meningocele, after excision of the solid sac, the stalk extending from the core of the mass to the dura was isolated. This was followed by intradural spinal cord detethering. The mass was compatible with rudimentary meningocele in pathology. LESSONS: Neglected cervical meningocele is quite rare in adults. Surgical removal of the mass in adults is usually for cosmetic reasons rather than neurological impairment. However, surgical removal of the mass without intradural cord detethering is not sufficient. In such cases, late onset quadriparesis may be appear due to the spinal cord tethering scenario.

Symptomatic thoracic ossified ligamentum flavum in achondroplasia: A case report and literature review.

BACKGROUND: In a patient with achondroplasia, it is rare to encounter thoracic cord compression due to both spinal stenosis and ossification of the yellow ligament (OYL). CASE DESCRIPTION: A 33-year-old achondroplastic female presented with a progressive spastic paraparesis attributed to thoracic stenosis combined with T10-T11 OYL. Following a laminectomy, the patient demonstrated a marked recovery of neurological function. CONCLUSION: This case and 12 others from the literature demonstrated that achondroplastic patients who present with myelopathy secondary to thoracic stenosis and OYL can be readily diagnosed with MR/CT and successfully treated utilizing decompressive laminectomies with/without fusions (i.e., for those crossing the thoracolumbar junction).

Symptomatic thoracic ossification of the ligamentum flavum in a patient with ankylosing spondylitis: Report of a case and review.

BACKGROUND: Thoracic spinal cord compression due to both ankylosing spondylitis (AS) and ossification of the ligamentum flavum (OLF) is rare. CASE DESCRIPTION: A 33-year-old male with AS presented with a paraparesis attributed to MR documented T9-T10 OLF/stenosis. He was successfully managed with a decompressive laminectomy; this resulted in marked improvement of his deficit. CONCLUSION: Thoracic OLF and AS rarely contribute T9-T10 spinal cord compression that may be readily relieved with a decompressive laminectomy.

Double-level myelopathy due to atlantoaxial dislocation (os odontoideum) and subaxial cervical spondylosis with angular kyphosis.

BACKGROUND: The surgical management of cervical spondylotic myelopathy (CSM) attributed to os odontoideum (OO with atlantoaxial instability atlantoaxial instability) and subaxial kyphosis together pose significant surgical challenges. CASE DESCRIPTION: An elderly male presented with CSM/myelopathy and severe quadriparesis attributed to an unstable OO and 87° fixed, subaxial cervical kyphosis. After performing a 540° spinal cord decompression with atlantoaxial fixation, the patient did well. CONCLUSION: Double-level CSM due to an unstable OO and subaxial kyphosis is rare and typically requires combined 540° decompression and stabilization.

Painful torticollis due to tubercular atlantoaxial rotatory fixation: A case report.

BACKGROUND: Tubercular atlantoaxial, rotary dislocation warranting fixation (AARF) is an extremely rare event. CASE DESCRIPTION: AARF was suspected in a 23-year-old female with painful torticollis. When diagnostic studies documented unilateral destruction of the left lateral mass of the atlas, she underwent removal of the lateral mass, reduction of the deformity, and C1-C2 fusion/reconstruction utilizing an iliac bone graft. Laboratory tests and the pathologic surveys were all consistent with the diagnosis of underlying tuberculosis. CONCLUSION: We present a case of tubercular atlantoaxial, rotary dislocation (AARF) in a patient who warranted C1-C2 decompression, reduction, and fusion.

Septic cavernous sinus thrombosis secondary to halo vest pin site infection.

BACKGROUND: Pin site infection is one of the frequent complications of the halo crown application which can be easily handled if addressed early. However, if this issue is neglected then serious infectious events may quickly transpire. Among all of the medical literature that the previously described scenarios have illuminated; we did not encounter a case involving infectious cavernous sinus thrombosis. CASE DESCRIPTION: The authors present a middle age man who arrived at our clinic with an acute left peri-orbital swelling, proptosis, and ophthalmoplegia which had occurred subsequent to an untreated halo pine site infection. With a diagnosis of septic cavernous sinus thrombosis (CST), appropriate antibiotics and anticoagulant therapies were administered. OUTCOME: With the continuation of this conservative treatment regimen, he was successfully managed with no residual neurological consequences. CONCLUSION: Halo vest orthosis is an appropriately tolerated upper cervical spinal stabilizing device that is a commonly used worldwide. Septic CST that is secondary to a halo vest pin site infection has not been previously described within medical literature. In the case of a neglected pin site infection, with demonstration of ipsilateral eyelid edema and proptosis, septic CST should be immediately considered and treated vigorously with antibiotics and anticoagulant therapies.

Congenital cervical isthmic spondylolisthesis: A case report.

BACKGROUND: There are only 20 reported cases of cervical isthmic spondylolisthesis in literature that have been surgically managed either anteriorly or posteriorly. Herein, we report such a case managed with circumferential fusion. CASE DESCRIPTION: A 27-year-old male became progressively quadriparetic due to cervical isthmic spondylolisthesis at the C6-C7 level. Removal of the posterior arch of C6 with subsequent C5-C7 pedicle screw/rod fixation and anterior interbody fusion resulted in marked recovery and adequate cervical realignment. CONCLUSION: For patients with cervical isthmic spondylolisthesis, circumferential fusion provides the best surgical option to achieve stability and sagittal balance.

Intermittent penile erection in lumbar spinal stenosis: Report of four new cases and review.

BACKGROUND: Lumbar spinal stenosis (LSS) classically presents with intermittent neurogenic claudication. Rarely, however, it may cause unanticipated, unpleasant, involuntary, and transient penile erections without sexual stimulation along with urinary urgency and claudication. CASE DESCRIPTION: The authors present four males with LSS whose principal symptoms were intermittent neurogenic claudication and unanticipated erections while walking, accompanied by urinary urgency. CONCLUSION: There is scant literature on the topic of LSS presenting with unanticipated penile erections, urinary urgency, and neurogenic claudication.

Rivaroxaban-induced acute cervical spine epidural hematoma: Report of a case and review.

BACKGROUND: Spontaneous spinal epidural hematomas (SEHs) due to the utilization of factor Xa inhibitors are rare. CASE DESCRIPTION: A 66-year-old female presented with a Brown-Sequard syndrome attributed to a cervical epidural hematoma secondary to the utilization of rivaroxaban, one of the factor Xa inhibitors. Following a cervical laminectomy for the evacuation of the hematoma, the patient completely recovered. CONCLUSION: A spinal hemorrhagic event should be suspected in patients receiving factor Xa inhibitor drugs. Here, we had an elderly female on rivaroxaban experienced the acute onset of neck/back pain associated with a Brown-Sequard syndrome. A literature review showed that this is the seventh example of SEH occurring as a result of the use of anticoagulation drugs (OACDs; e.g., including Xa inhibitors).

Posterior Tibial Neuropathy Secondary to Pseudoaneurysm of the Proximal Segment of the Anterior Tibial Artery with Delayed Onset.

Anterior tibial artery is a nonvital artery which is one of the three arteries of the leg. This artery has a short proximal l segment in the popliteal region and a long segment in the anterior compartment of the leg designated as distal segment. With consideration of the deep location of the proximal segment in the popliteal fossa, it is less susceptible to trauma and subsequent formation of an aneurysm. On the contrary, the superficial long distal segment is more susceptible to trauma with high chance of pseudoaneurysm formation at the site of unrecognized injury. In this article, a 38-year-old military man being manifested about a decade after a trivial missile fragment injury with progressive posterior tibial neuropathy is presented. A giant pseudoaneurysm arising from the proximal segment of the anterior tibial artery was confirmed with angiography and the exact size of this pathology was documented with contrasted computed tomographic scan. The aneurysmal sac removal was accomplished after ligation of the corresponding artery proximal and distal to the sac followed by tibial nerve neurolysis which result in full recovery. In careful review we found that neither pseudoaneurysm arising from the proximal tibial artery nor posterior tibial neuropathy due to the compressive effect of the aneurysmal sac of this segment has been reported previously. Our primary purpose for reporting this case is not to describe the rarity of pseudoaneurysm formation at proximal segment of this artery but rather to describe delayed-onset posterior tibial vascular compressive neuropathy due to such an aneurysm. Eventually due to the potential sequel of a pseudoaneurysm, it is important for the surgeons to have high index of suspicion to prevent a missed or delayed diagnosis.

Ossification of the cervical ligamentum flavum and case report with myelopathy.

BACKGROUND: Ossification of the ligamentum flavum (OLF) occurs mostly in adult males, typically in the thoracolumbar spine where it may contribute to neurological deficits. Here we reviewed 68 cases of cervical OLF resulting in progressive quadriparesis. METHODS: The literature on cervical OLF was reviewed between 1962 and 2018 along with the case of an 81-year-old male with progressive quadriparesis attributed to cervical OLF. RESULTS: Most patients with cervical OLF are Asian, with Caucasians constituting the second most frequently impacted population. CONCLUSIONS: Cervical OLF is typically reported in the Asian, followed by the Caucasian population, and is most often found in the thoracolumbar spine. Here we presented an 81-year-old male with cervical OLF contributing to quadriparesis.

Atlantoaxial Subluxation Secondary to Unstable Os Odontoideum in a Patient With Arrested Hydrocephalus Due to Congenital Aqueductal Stenosis: A Case Report.

BACKGROUND: In a small percentage of children born with congenital hydrocephalus, enlargement of the head and the presence of ventriculomegaly may halt and ultimately stabilize the condition designated as arrested hydrocephalus. Arrested hydrocephalus in children is typically due to congenital aqueduct stenosis, which can be described appropriately as a stasis existing within the channel between the third and fourth ventricles. Os odontoideum (OO) is an uncommonly occurring pathology at the craniovertebral junction. Although the clinical and radiologic features of its existence and the therapeutic options for its pathology have been widely discussed within the medical literature, its true etiology has been a source of divisive debate, proposing both a traumatic as well as a congenital mechanism. The etiology of OO has been heartily debated in the literature for several years as well. Most authors have come to support a posttraumatic causality. However, strong evidence exists to support a congenital origin to this rarely observed malformation. METHODS: Within this case study we present a 24-year-old woman with atlantoaxial subluxation that exists secondary to an orthotropic OO. The patient had a history of arrested hydrocephalus due to congenital aqueductal stenosis beginning in early childhood. She presented with normal intelligence and was neurologically without deficits before the occurrence of an atlantoaxial dislocation. Unfortunately, the pathology was initially misdiagnosed as a decompensation state of the arrested hydrocephalus, and after 8 months the patient became wheelchair bound. Following this unfortunate event the correct diagnosis was ultimately uncovered. Subsequently a C2-1 instrumentation procedure resulted in excellent alignment and fusion. CONCLUSIONS: To the best of our knowledge, this is the first example of an aqueduct stenosis in the setting of an existing OO, a combination that might be another clue in favor of a congenital etiology.

Remote Cervical Pseudomeningocele Following Anterior Cervical Corpectomy and Fusion: Report of a Case and Review of the Literature.

Iatrogenic cervical pseudomeningocele is a rare event and majority are located posteriorly as a delayed complication of inadvertent dural tear after decompressive laminectomy. However, iatrogenic anterior cervical pseudomeningocele subsequent to discectomy or corpectomy is a rare pathology. The time necessary for formation of pseudomeningocele varies and depend on the width of the dural tear and the flow of cerebrospinal fluid leakage. Large tears with high CSF flow usually result in early collection of the cerebrospinal fluid in anterior compartment of the neck designated acute pseudomeningoceles. Micro-tears of dura mater, with low flow of cerebrospinal fluid may lead to late formation of a pseudomeningocele known as chronic ones. Herein a 49- year-old woman in whom cervical pseudomeningocele appeared clinically as a mass on the anterior aspect of the neck, six months after anterior cervical corpectomy for cervical spondylotic myelopathy is presented. Otherwise, she was neurologically stable. Cystoperitoneal shunt was proposed which she refused. Surprisingly, at 2-year follow-up, the cyst had remained of the same size. To the best of our knowledge, this is the first example of post-operative chronic cervical pseudomeningocele in the literature, the event that might propose the self-limited natural course of this rare pathology in chronic cases.

Transforaminal retrieval of intradiscal retained broken surgical knife blade.

STUDY DESIGN: Case report. OBJECTIVE: To report a middle-aged female in whom a knife blade was broken and lodged in the disc space during lumbar discectomy. Transforaminal route as an alternative corridor for its removal is proposed. SUMMARY OF BACKGROUND DATA: Lumbar discectomy is being done in increasing frequency worldwide. One risk associated with this procedure is breaking of the surgical knife during discectomy. Most of the broken blades can be removed during the initial surgery. However, in a few cases, surgeon's attempts might be unsuccessful, resulting in retained foreign body in the disc space. Literature regarding this issue is scarce, and there are no unique guidelines to address this complication. METHODS: A 69-year-old female in whom a surgical knife blade was inadvertently broken and retained in the disc space during lumbar discectomy. The broken blade could not be removed during the first surgery. In the second surgery, it was retrieved through the initial midline incision but via transforaminal route. RESULTS: The patient was discharged a day after blade removal and is doing well now. CONCLUSION: Retrieval of a broken knife blade unintentionally buried in the intervertebral disc space can be a challenge and even impossible to achieve, despite hours of attempts. In the second surgery, the retained blade in the disc space is traditionally removed via the anterior approach. The transforaminal corridor might be a simple alternative route that does not carry inherent difficulties and risks associated with the anterior corridor. Eventually, removal of a broken blade via this route does not require the collaboration of an access surgeon.

Spinal extradural arachnoid cysts / Cistos aracnóideos extradurais da coluna / Quistes aracnoideos extradurales de la columna

OBJECTIVE: Extradural arachnoid cysts (EACs) are rare causes of spinal cord compression and cauda equina. These benign lesions appear in the literature mainly as single case reports. In this article, we present the largest series found in literature, with four new cases of spinal extradural arachnoid cysts. The characteristic imaging features, details of surgical steps and strategies to prevent postoperative kyphosis in this cystic pathology will be discussed.

OBJETIVO: Os cistos aracnóideos extradurais (EAC) são causa rara de compressão da medula espinal e de cauda equina. Essas lesões benignas aparecem na literatura principalmente como relatos de casos isolados. Neste artigo, é apresentada a maior série encontrada na literatura, com quatro novos casos de cistos aracnóideos extradurais da coluna. DISCUSSÃO: São discutidas as características das imagens, os detalhes dos passos cirúrgicos e as estratégias para prevenir a cifose pós-operatória nessa patologia cística.

OBJETIVO: Los quistes aracnoideos extradurales (EAC) son causa rara de compresión de la médula espinal y de cauda equina. Estas lesiones benignas aparecen en la literatura principalmente como relatos de casos aislados. En este artículo, es presentada la mayor serie encontrada en la literatura, con cuatro nuevos casos de quistes aracnoideos extradurales de la columna. Son discutidas las características de las imágenes, los detalles de los pasos quirúrgicos y las estrategias para prevenir la cifosis postoperatoria en esa patología quística.