Adult Congenital Lumbar Kyphosis Requiring Anteroposterior Correction and Fusion: A Case Report with 32-Year Follow-Up

Congenital pure kyphosis due to failure of vertebral body segmentation is a relatively rare entity, and surgical intervention is infrequent compared to that for failure of vertebral body formation [1] [2]. There are very few reports of long-term follow-up of surgical treatment in patients with congenital pure kyphosis, and all the reported cases were diagnosed as failure of formation and had an age at the time of surgery of less than 18 years. It is important for orthopedic surgeons to follow the postoperative course of rare cases over 30 years. Here, we present a surgically treated case with ultra-long term follow-up of a 50-year-old patient with congenital pure kyphosis of the lumbar spine. Imaging of the lumbar spine showed six vertebrae and an unsegmented bar at L3-4 causing a pure kyphosis of 54°. The wedge-shaped block vertebra had 4 pedicles with the neural foramen between the pedicles without concomitant disc space, with compensatory thoracic hypokyphosis and lower lumbar hyperlordosis. One-stage correction and fusion surgery using anterior opening and posterior closing osteotomy was successfully performed. Both clinical and radiographic results were excellent and have been maintained for over 30 years postoperatively. The basic principle in the surgical treatment of adult spinal deformity is to achieve and maintain a good global sagittal balance over time. This case reaffirms the importance of spinopelvic harmony.

Evaluation of Percutaneous Pedicle Screw Fixation in Patients with Pyogenic Spondylitis of the Thoracolumbar Spine

Background: Basic principle for the treatment of pyogenic spondylitis (PS) is conservative care, but surgical intervention is often required when conservative treatment may fail. We have experienced many conservative cases of various complications due to long-term bed rest and poor pain control. Recently we have adopted percutaneous pedicle screw (PPS) fixation for the treatment of PS as a minimally invasive spine stabilization (MISt) fusion to reduce such morbidity of the conservative care. Objective: To evaluate the impact of PPS fixation in patients with PS. Study Design: A retrospective analysis of the medical records. Subjects, Methods: We reviewed 54 consecutive patients who underwent treatment in our hospital for PS during 2005-2018 and observed for more than 12 months. Of those we excluded cases showing effectiveness to initial treatment (it was defined fever relief or C-reactive protein (CRP) inversion in 3 weeks of antibiotics) so that this study is a retrospective study in cases showing initial treatment resistance. Finally, this study included 29 cases. Medical records of these 29 cases were reviewed for baseline, organism isolated and its detection rate, the clinical outcome in 12 months (Discharge, Transfer, Death), the period from the first visit to our hospital to fever relief, CRP inversion, ambulation, and Discharge or Transfer. Results: These cases were divided into two groups, the conservative group (C-group): 17 cases, and the PPS group (P-group): 12 cases. There is no statistically significant difference in fever relief (p = 0.051) and CRP inversion (p = 0.208). The period to ambulation and discharge or transfer was significantly shorter in group P (p = 0.020, p = 0.031). 1-Year survival rate was 92% in the P-group, and 71% in the C-group. There is no statistically significant difference (p = 0.354) between the two groups. The rate of Discharge to home and care facility is 58% in P-group, and 47% in C-group. And the rate of Transfer is 34% in P-group, and 35% in C-group. Conclusion: PPS fixation was effective to achieve shortening the period to ambulation and discharge or transfer. But it was not effective in infection control. This suggests that PPS fixation should be aggressively administered to patients who can expect pain relief and early ambulation by PPS fixation in the patient of PS showing resistance to initial treatment.

A Patient with Spinal Arteriovenous Malformation Treated with Lumbar Vertebral Surgery Due to Misdiagnosis

Spinal arteriovenous malformation (AVM) is a rare disease that arises more commonly from the lower thoracic and upper lumbar spine. It is classified based on the development pattern and the shunt location. The developmental mechanism of the symptoms is thought to be as follows. Spinal venous return is impaired by high-pressure arterial blood flowing into the coronary sinus via a shunt and venous pressure is promoted, which causes spinal cord symptoms to progress gradually. Listlessness, pain, and an abnormal sensation of the lower limb are possible initial symptoms. Spinal AVM may cause intermittent claudication and bladder and rectal disturbance, and differentiation from lumbar degenerative diseases and arteriosclerosis obliterans is required, which may cause difficulty with diagnosis. We encountered a patient in whom intermittent claudication was treated with lumbar decompression and fixation at another hospital, but symptoms did not improve. The patient was diagnosed with spinal AVM at our hospital and symptoms were improved by surgery. Because the symptoms did not improve despite being treated with surgery for spinal canal stenosis, we strongly suspected spinal intermittent claudication, and we performed a spinal CT and MRI after myelography for the entire spinal cord, and identified the lesion in the thoracic spinal cord. Regarding the postoperative outcome and prognosis of spinal dural AVF, early diagnosis and early treatment have been proposed as prognostic factors because the postoperative outcome is poor in patients with high preoperative severity and a long duration of illness. In our patient, the preoperative JOA score was 6, showing high preoperative severity, and the duration of illness was 1.5 years before diagnosis, which may explain the limited improvement of the JOA score to 20 at final follow-up. In a case with these characteristics, we suggest that close examination of the entire spinal cord is needed for effective treatment.

A Case Report of Synovial Osteochondromatosis of the Knee Joint with neither Calcification nor a Synovial Lesion on Imaging

Synovial osteochondromatosis is a rare, benign condition of unknown etiology in which the synovium undergoes metaplasia, leading to cartilaginous nodules that ultimately break free, mineralize, and even ossify. The most commonly involved joint is the knee. Typically, radiographs can be diagnostic and mineralized nodules are pathognomonic. In as many as one-third of cases, however, no calcification or ossification of the cartilage occurs in the early stage of the disease because mineralization is time-dependent. In such cases, gadolinium-enhanced MRI can be useful. Unmineralized nodules are typically peripherally enhanced because they are attached to and derive a vascular supply from the synovium. We experienced an unmineralized case of synovial osteochondromatosis of the right knee joint, in which imaging diagnosis was difficult. Neither calcification nor ossification was observed, but all nodules were released from the synovium as loose bodies and there was no vascular supply. Therefore, MRI did not show a typical appearance. These findings suggest that synovial osteochondromatosis should be considered as a differential diagnosis in a case in which unmineralized loose bodies without a synovial lesion are found in an imaging examination.

A Case of Acute Cauda Equina Syndrome for Combined Lumbar Ossification of the Posterior Longitudinal and Yellow Ligament

Acute cauda equina syndrome is known as a symptom of lumbar disc herniation, but to date, there have been no reports of cases caused by lumbar vertebral ligament ossification. We encountered a 61-year-old female patient with acute cauda equina syndrome associated with lumbar vertebral OPLL and OLF. The symptoms were improved by emergency laminectomy. One year after the surgery, the disturbances of gait and urination have been resolved.

A Patient with Malignant Spinal Epidural Lymphoma with Initial Rapidly Aggravating Paraplegia

We report the case of a 51-year-old female with rapid neurological deterioration as an initial presentation of non-Hodgkin’s lymphoma. Paraplegia occurred suddenly after a 4-day history of weakness and numbness of the lower extremity. MRI revealed a dorsal epidural mass from T10 to T11 that compressed the spinal cord. There was neither bone destruction nor a paravertebral mass. Emergency decompressive laminectomy and tumor resection were performed. Histological analysis of the surgical specimen indicated diffuse large B cell lymphoma. The clinical stage was IV on CT and complete remission was achieved by subsequent chemotherapy. Spinal cord compression occurs in the course of non-Hodgkin’s lymphoma in 0.1% - 6.5% of cases, but this situation usually develops in the late phase with bone destruction and/or a paravertebral mass. Cord compression and especially the severe symptoms such as paraplegia are rare as the initial presentation of lymphoma.

Spinal Epidural Cavernous Hemangioma of the Thoracic Spine: A Case Report

Cavernous hemangiomas can arise in any region of the body, including the central nervous system. Spinal cavernous hemangiomas account for 5% - 12% of all cases of vertebral vascular malformation. Most of these are of vertebral origin, and cases that are non-vertebral in origin are rare. We encountered a patient with a relatively rare spinal epidural cavernous hemangioma of the thoracic spine that was non-vertebral in origin. The patient was a 63-year-old man. He had become aware of bilateral leg pain and numbness about 2 months earlier, and gait disturbance appeared gradually thereafter. On MRI, a lesion showing iso-intensity on T1-weighted imaging and high intensity on T2-weighted imaging was detected at the 7th thoracic vertebra. On gadolinium contrast-imaging, the lesion was found to be a homogenously-enhanced dumbbell-shaped extradural spinal neoplasm protruding from the left 7th/8th thoracic intervertebral foramen. A neurogenic tumor was suspected based on myelography and MRI findings, and complete tumorectomy was performed, which improved the lower limb symptoms and gait disturbance. The histopathological diagnosis was cavernous hemangioma. Epidural hemangiomas arise from the vertebra in many cases, and pure spinal epidural cavernous hemangiomas are rare. It is difficult to make a preoperative diagnosis because there are no specific imaging findings that can differentiate these tumors. It may be important to consider this disease before surgery in the differential diagnosis of epidural tumors.

Evaluation of Conservative Treatment of Acute Fracture of the Odontoid Process of Axis with a Halo-Vest

We fitted a halo-vest on patients with a fracture of the odontoid process of the axis and evaluated the effects of conservative treatment on cervical muscular atrophy and the number and type of patient complaints after bone union. Four patients had Anderson Type II fractures and 6 patients had Type III fractures. Bone union was observed in all patients within 3 months after injury. After halo-vest fitting, cervical muscular atrophy increased with time, however, it gradually improved after removal of the halo-vest. Patients fixed with a halo-vest for more than 10 weeks complained of cervical discomfort and limited range of motion. No patients with fixation for less than 10 weeks had problems in bone union or had cervical complaints. Thus, less than a 10-week fixation period was considered to be appropriate.

A Case of Thoracic Disc Herniation Extruded to the Dorsal Epidural Space

We encountered a patient with thoracic disc herniation that extruded to the dorsal epidural space. The patient was a 78-year-old man in whom listlessness of the lower limbs developed without an inducer and walking became difficult. The patient was diagnosed as having a thoracic spinal cord tumor on MRI by a physician, and was referred to our hospital. Since ring enhancement was observed on contrast MRI performed at our hospital, the patient was diagnosed with disc herniation and surgery was performed. A hernia continuous with the intervertebral space that extruded to the dorsal epidural space was excised. At the final follow up, 1 year and 4 months after surgery, the patient could walk with a cane. Among thoracic disc herniation cases, hernia extruded to the dorsal epidural space is rare and difficult to diagnose by imaging before surgery, but evaluation using contrast MRI is useful in the diagnosis. When a space-occupying lesion is observed in the spinal canal in the lower thoracic spinal region, it is necessary to evaluate it by contrast MRI in consideration of thoracic disc herniation.

Successful Treatment of Spine Fracture for Diffuse Idiopathic Skeletal Hyperostosis with Teriparatide—A Report of Two Cases

We experienced 2 cases of spinal fracture in patients aged 80 years or older with diffuse idiopathic skeletal hyperostosis (DISH). Since they decided not to undergo surgical treatment, we provided conservative treatment with teriparatide. There has been no previous study on teriparatide for spine fracture in DISH. This is the first report of the successful use of teriparatide to treat spine fracture in DISH without surgical intervention. Our patients were treated with teriparatide for 8-9 months after diagnosis of the fracture. Union was obtained in two cases and no adverse events were observed during treatment. Our report showed that teriparatide could be an alternative to conventional intervention in spinal fracture of DISH.

Femoral Nerve Pulsy due to Iliopsoas Muscle Hematoma: A Mini Literature Review

We encountered a patient who developed femoral nerve paralysis due to iliopsoas muscle hematoma. Surgical removal of the hematoma is recommended for such cases, but conservative treatment may also be sufficient and there are no clear judgment criteria. An investigation of past reports showed that recovery was faster after surgery than after conservative treatment, regardless of the severity of paralysis, and that hematoma removal was especially effective for cases with severe paralysis. In our case, pain of the femoral nerve-innervated region was rapidly relieved by removal of the hematoma.