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.

A Case of Septic Arthritis of the Shoulder Joint That Developed after Suprascapular Nerve Block

Septic arthritis of the shoulder is uncommon in the immunocompetent patient with no previous risk factors for joint infection. We treated an immunocompetent patient who developed septic arthritis of the shoulder after suprascapular nerve block for pain due to rotator cuff tear. An 80-year-old man with no underlying disease visited a nearby orthopedics clinic with complaint of left shoulder joint pain. Left suprascapular nerve block was performed, but the pain gradually aggravated. On the day after the block, he had a fever of 39°C and came to our department. On examination, enlargement and tenderness were present at the injection site. Cellulitis at the site was suspected. He was admitted and administration of a cephem anti-biotic was started. Pain subsequently decreased. Magnetic resonance imaging (MRI) performed 4 days after hospitalization showed massive effusion close to the injection site. The effusion spread into the joint cavity through the tear site of the supraspinatus. Septic arthritis of the shoulder was strongly suspected, open irrigation and debridement were performed 11 days after hospitalization. After surgery, pain immediately improved. In our case the extra-articular infection caused by suprascapular nerve block considered to spread into the shoulder joint cavity through the site of rotator cuff tear, although there have been no reports of such cases. This case suggests the possibility that patients with rotator cuff tear may easily develop septic arthritis because extra-articular infection may spread into the joint cavity through the site of tear.

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.

Cerebral Infarction after Spine Surgery: Report of Two Cases

There has been an increase in spinal surgery for the elderly, with a corresponding potential increase in perioperative complications. In our department, 1833 patients underwent spinal surgery under general anesthesia from April 2001 to October 2012, and 2 of 260 patients aged ≥75 years old had postoperative cerebral infarction. An analysis of the pathogenic mechanism and potential risk factors showed that a history of cerebral infarction was a significant risk factor. Blood pressure rapidly increased on arousal from anesthesia, and particularly on extubation. The change in blood pressure was examined as a potential risk factor for cerebral infarction, but no significant relationship was observed. This result requires further examination in more patients with cerebral infarction after spinal surgery.