Emergency Decompressive Laminectomy Research Articles

Emergency Posterior Decompression for Metastatic Spine Tumors in Octogenarians: Clinical Course and Prognostic Factors for Functional Outcomes

This study aimed to describe the clinical outcome of metastatic epidural spinal cord compression in octogenarians with an acute onset of neurological illness who undergo laminectomy, further assess morbidity and mortality rates, and determine potential risk factors for a nonambulatory outcome. This retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Thirty-four patients aged 80 years and older who posterior decompression via laminectomy were enrolled in the present study. The mean Charlson Comorbidity Index was >6 (9.2 ± 2.1). The thoracic spine was the most common site of metastasis. A potentially unstable spine, determined using the Spinal Instability Neoplastic Score, was identified in 79.4% of the cases. Preoperatively, the neurological condition and functional status exhibited a notable decline (mean Motor Score of the American Spinal Injury Association grading system, 78.2 ± 16.4; mean Karnofsky Performance Index, 47.8 ± 19.5). The Motor Score of the American Spinal Injury Association grading system and Karnofsky Performance Index scores improved significantly after surgery. Motor weakness and comorbidities were unique risk factors for the loss of ambulation. Emergent decompressive laminectomy in patients with acute onset of neurological decline and potentially unstable spines improved functional outcome at discharge. Age should not be a determinant of whether to perform surgery; surgery should be performed in older patients when indicated.

Postoperative spinal cord infarction on a gravid woman with suspected IV drug use: a case report

BackgroundBack pain is common in the gravid population and spinal cord infarction (SCI) or chronic osteomyelitis are exceptionally rare underlying causes of back pain in this population. No case report to date has described this unexpected adverse event in a gravid woman with suspected history of IV drug use (IVDU). This diagnosis could potentially become more common with increasing rates of IVDU, and increased education could result in sooner recognition.CaseA 38 year old G9P0171 at 24 weeks gestation with a complex past medical history, and a suspected history of IVDU, presented repeatedly with back pain. Following cesarean delivery at 36w2d, she developed signs and symptoms of an anterior spinal artery syndrome (ASAS) and had evidence of chronic osteomyelitis at T9-T10 on imaging. This required emergent decompressive laminectomy and ultimately resulted in paraplegia.ConclusionThis case highlights the difficulties in recognizing all SCI risk factors pre-operatively and the importance of investigating back pain in pregnant patients with a suspected history of IVDU. We believe this patient’s chronic infection put her at an increased risk for SCI that was possibly compounded by the anatomical changes from its chronicity, possibly occurring in combination with several other precipitating causes of hypoperfusion. We hope this case report highlights the modern necessity to include a history, or suspected history, of IVDU as a red flag to initiate imaging in pregnant patients with acute, persistent, or unresolved back pain.

MISDIAGNOSIS OF SPONTANEOUS SPINAL EPIDURAL HEMATOMA IN A PARTURIENT: A CASE REPORT

Background: Spontaneous spinal epidural hematomais a rare clinical entity. The symptoms can be similar to Guillain Barre Syndrome, especially if it occurs at the cervicothoracic junction. Its pathophysiology is still unknown and seems to be multifactorial, which makes it a challenging situation in terms of diagnosis and treatment, mainly during pregnancy. Case report:a 22-year-old female at 31 weeks of pregnancy presented to the emergencies complaining of the sudden onset of a neurogenic syndrome with the history of influenza like symptoms six days before. Although cerebrospinal fluid analysis showed no abnormalities, the diagnosis of Guillain Barre Syndrome was suspected on the basis of a series of arguments.The next day, her case worsened as she started exhibiting tetraparesis with genital disorders. Emergency Magnetic Resonance Imaging showed a spinal epidural hematoma extending from C5 to C7. The patient underwent an emergency decompressive laminectomy with evacuation of the hematoma. No apparent vascular malformation was objectified. Despite rehabilitation, she still experienced motor sequelae. Conclusion:Each case requires individual and repetitive evaluation with the establishment of a dated diagram in order to minimize the risk of delayed diagnosis and treatment in spontaneous spinal epidural hematoma, mainly during pregnancy.

Rapidly progressive gas-forming infection involving the spine as a life-threatening fatal condition : a case report

BackgroundGas forming infection of the spine is a consequence of vertebral osteomyelitis, necrotizing fasciitis, or a gas-forming epidural abscess, which is very rare and fatal conditions. This is the rare case of necrotizing fasciitis that rapidly progressed from the lumbar area to upper thoracic area.Case presentationA 58-year-old male complained of lower back pain with fever and chills. The patient had a history of uncontrolled diabetes mellitus without diabetic medication over the previous 3 months, and he had received several local injections around the lumbar area. Laboratory data revealed white blood cell count of 19,710 /mm3, erythrocyte sedimentation of 40 mm/h, and C-reactive protein of 30.7 mg/L. Radiological findings revealed a small amount of air bubbles in the paraspinal area and lumbar epidural spaces. The patient refused emergency surgery and was discharged from the hospital. The patient re-visited the emergency department two days after discharge complaining of more severe back pain with persistent fever, and his vital signs had deteriorated, with low blood pressure and tachycardia. K. pneumoniae was isolated in cultures from ultrasound-guided aspirates and peripheral blood. The follow-up radiographs revealed aggressive dissemination of innumerable air bubbles from the lumbar area to the T5 level. The patient underwent emergent decompressive laminectomy and debridement of infected paravertebral fascia and musculature. Despite intensive care for deteriorated vital signs and his back wound, the patient died on postoperative day 3 due to multi-organ failure.ConclusionsNecrotizing fasciitis involving the spine is a very rare disease with life-threatening conditions, rapid progression, and a high mortality rate. Therefore, prompt surgical treatment with a high index of suspicion is imperative to prevent potentially fatal conditions in similar extremely rare cases.

Spontaneous spinal epidural hemorrhage due to polycythemia vera

Spontaneous spinal epidural hematoma (SSEH) as an initial presentation of polycythemia vera (PV) is rare. It can present with the features ranging from simple back pain to complete paraplegia depending on the site of the spinal compression. Herein, we describe a case of undiagnosed PV presented as back pain with radiation to the chest wall in a 46-year-old male patient and subsequently diagnosed with spontaneous spinal epidural hemorrhage. To the best of our knowledge, only one case of spinal epidural hematoma-related PV has been reported so far. Emergent decompressive laminectomy was done within 10 h of initial presentation with excellent clinical outcome. Therefore, this condition must be promptly diagnosed and treated with decompression surgery to minimize the risk of neurological complication.

Ematoma spinale epidurale spontaneo in Pediatria

The spontaneous spinal epidural haematoma (SSEH) is a rare emergency condition due to an accumulation of blood in the epidural space that can compress the spinal cord and can lead to severe neurological sequelae. The typical symptom of SSEH is severe back or neck pain, followed by symptoms and signs of spinal cord compression. A detailed history and an accurate neurologic examination are important tools for early diagnosis and magnetic resonance imaging (MRI) is currently the diagnostic method of choice. Performing a rapid decompressive surgery is very important in achieving positive clinical outcomes. The paper presents a case of a 12-year-old boy who developed severe abdominal pain and progressive weakness in his legs. MRI demonstrated an epidural mass extending from C3 through T1, causing spinal cord compression. Emergent decompressive laminectomy was performed. Optimal functional outcomes were obtained.

Thoracic Discitis in Ankylosing Spondylitis

Chronic ankylosing spondylitis can lead to several rare long-term complications including cauda equina syndrome and inflammatory discitis especially without treatment. These complications are uncommon, but there is evidence that they can be treated with anti-tumor necrosis factor (TNF) inhibitors.We present a case of a 52-year-old male with a 30-year history of undiagnosed ankylosing spondylitis with cauda equina syndrome on initial outpatient presentation with a negative lumbosacral magnetic resonance imaging (MRI). He was admitted later that month and was found to have thoracic discitis from MRI requiring emergent decompressive laminectomy. The neurosurgeon collected a culture of the surgical site which showed rare Gram-positive cocci on Gram stain. Infectious disease was consulted, and he was started on empiric vancomycin. The culture from the surgical site did not grow any organisms. Interventional radiology (IR) aspirated the T7-T8 disk area one week later. The initial Gram stain showed rare Gram-negative rods this time, and cefepime was added to the patient's antibiotic regimen. The culture from the disk aspiration again grew no organisms. Rheumatology was then consulted and hypothesized that the patient's discitis could be secondary to inflammation from long-standing ankylosing spondylitis. The hospitalist, infectious disease specialist, and rheumatologist reviewed the case and recommended a six-week course of vancomycin and cefepime despite the negative cultures as an infectious etiology could not be excluded. He did show some clinical improvement after surgery and was started on adalimumab following completion of empiric antibiotics.This case highlights the difficulty in distinguishing between an infectious and inflammatory etiology for discitis in the setting of long-standing ankylosing spondylitis. The initiation of biological therapy without completely excluding the possibility of infection could lead to devastating consequences. It will likely be necessary to empirically treat for infection with these cases for the foreseeable future until there are more definitive tests to diagnose or exclude infectious discitis.

Esophageal Rupture Due to Diving in Shallow Waters

Delayed esophageal rupture due to blunt injury is not new. However, rupture due to suspected barotrauma is very rare. We describe a case of esophageal rupture in a male 24-year-old patient after diving in shallow waters. The patient was quadriplegic and could not experience the typical chest pain related to rupture and resulting mediasti nitis. The rupture was discovered 4 days after emergency decompressive laminectomy and fusion for his cervical spine. The rupture was evidently caused by barotrauma and was discovered four days after admission. He underwent primary closure and pericar dial flap as a life-saving procedure.

Iatrogenic Spinal Subarachnoid Hematoma after Diagnostic Lumbar Puncture.

Spinal subarachnoid hematoma (SSH) following diagnostic lumbar puncture is very rare. Generally, SSH is more likely to occur when the patient has coagulopathy or is undergoing anticoagulant therapy. Unlike the usual complications, such as headache, dizziness, and back pain at the needle puncture site, SSH may result in permanent neurologic deficits if not properly treated within a short period of time. An otherwise healthy 43-year-old female with no predisposing factors presented with fever and headache. Diagnostic lumbar puncture was performed under suspicion of acute meningitis. Lumbar magnetic resonance imaging was performed due to hypoesthesia below the level of T10 that rapidly progressed after the lumbar puncture. SSH was diagnosed, and high-dose steroid therapy was started. Her neurological symptoms rapidly deteriorated after 12 hours despite the steroids, necessitating emergent decompressive laminectomy and hematoma removal. The patient’s condition improved after the surgery from a preoperative motor score of 1/5 in the right leg and 4/5 in the left leg to brace-free ambulation (motor grade 5/5) 3-month postoperative. The patient was discharged with no neurologic deficits. Critical complications such as SSH can be fatal. Therefore, a patient undergoing lumbar puncture must be carefully observed. A hematoma that convincingly compresses the spinal cord or cauda equina on imaging results requires early surgical decompression and hematoma removal.

Management of acute spontaneous thoracic spinal epidural hematoma causing paraplegia

Aim To emphasize the importance of early recognition, diagnostic processing and emergent surgical treatment of spontaneous spinal epidural hematoma (SSEH). Methods A 39-year-old female presented with sudden onset of severe pain between the shoulder blades followed by paraparesis and alerted sensibility in the lower extremities. An hour later she developed paraplegia with sensory deficits below ThIV level, absence of patellar reflex, ankle jerk reflex and sphincter dysfunction. Results Magnetic resonance imaging (MRI) demonstrated acute extensive epidural mass of thoracic spinal segments (ThI-ThIII). The patient underwent emergent decompressive laminectomy ThI-ThIII with epidural hematoma evacuation within 24 hours of symptoms onset. After the surgical treatment, because of suspicion on spinal arteriovenous malformation, complete diagnostic evaluation with spinal angiography was done and no form of vascular malformation was found. Idiopathic SSEH was diagnosed. Two months later the patient reached complete neurological improvement. Conclusion The SSEH is a rare condition that should be kept in mind in patients presenting with neurological deficit and a sudden onset of back pain like it was in our case. For early diagnosis, immediate MRI is essential. Prompt surgical decompression such as laminectomy is an absolute surgical indication widely accepted for patients with progressive neurological deficit. The SSEH should be considered as one of the important differential diagnoses in patients who have developed acute myelopathy.

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 haematoma following rivaroxaban administration after total knee replacement.

Sir, The incidence of neurologic dysfunction resulting from haemorrhagic complications following neuraxial blockade is estimated to be <1 in 150,000 epidurals, and 1 in 220,000 spinal anaesthetics.[1] The first reported case of epidural haematoma following rivaroxaban was published in 2014.[2] A 59-year-old lady was admitted for elective right total knee replacement. She was a known case of hypertension, hypothyroidism, and congenital heart block (with indwelling cardiac pacemaker), on olmesartan and levothyroxine. Her pre-operative blood investigations including coagulation profile were normal. Combined spinal epidural anaesthesia was administered with a 20 gauge epidural catheter in L2-L3 epidural space and subarachnoid block with 23 gauge spinal needle in L3-L4 space with 3 ml of 0.5% bupivacaine. These procedures were atraumatic. A continuous epidural infusion of 0.125% bupivacaine at 3–5 ml/h was used for postoperative analgesia. The same night, the surgeon decided to prescribe rivaroxaban 10 mg for venous thromboembolism (VTE) prophylaxis instead of enoxaparin (which was routinely used) without informing anaesthesiologist. The anaesthesiologist ordered the removal of epidural catheter next day (i.e., 18 h after last dose of rivaroxaban). Second dose of rivaroxaban was repeated 6 h after catheter removal. Twelve hours after administration of a second dose, the patient developed severe back pain with new onset sensory and motor blockade along with bladder incontinence. As the patient had a cardiac pacemaker, an MRI was deferred. A computerised tomography was done which showed hypodense areas in L2-L3-L4 [Figure 1], a pre-emptive diagnosis of epidural haematoma was made. The patient underwent an emergency decompressive laminectomy, and the operative findings were blood clots in the L2-L-3-L4 epidural spaces extending into the spinal canal [Figure 2]. On the next day, she regained her bladder sensations and was discharged on post-operative day 5 with complete return of sensory and motor functions. Figure 1 Sagittal computerised tomography scan showing hypodense signals Figure 2 Intraoperative finding showing epidural haematoma A number of novel oral anticoagulants that directly target factor Xa or thrombin have been developed in recent years. Among these, rivaroxaban is licensed for the prevention of VTE in patients undergoing elective hip or knee arthroplasty. Rivaroxaban was evaluated in phase III studies of the Regulation of Coagulation in Orthopaedic Surgery to prevent deep vein thrombosis and pulmonary embolism program (RECORD) in patients undergoing elective total hip or knee arthroplasty.[3] This study compared rivaroxaban with enoxaparin 40 mg once daily (OD) or 30 mg twice daily (BID). Rivaroxaban was given at a fixed dose of 10 mg OD, and the first dose was administered 6 h post-operatively. Based on the outcomes of the RECORD studies, Rivaroxaban was approved for the prevention of VTE after elective hip or knee arthroplasty. No intra-spinal bleeding events were attributed to rivaroxaban administration in phase II or phase III prospective studies of rivaroxaban use after hip and knee arthroplasty.[4] In our patient, the epidural catheter was removed 18 h after the last dose of rivaroxaban. A second dose was repeated 6 h after catheter removal. As per manufacturer's recommendation, ‘an epidural catheter should not be removed earlier than 18 h after the last administration of rivaroxaban and next dose not to be administered earlier than 6 h after removal of the catheter.‘ Surgeon and anaesthesiologist are key players in the operating room, aiming for a common goal – safety and good surgical outcome of the patient. In this particular case, a pre-operative communication about the use of rivaroxaban would have made us opt for general anaesthesia with peripheral nerve blockade instead of neuraxial anaesthesia as the evidence for its safety is limited. The early surgical intervention resulted in complete recovery of our patient. This is in agreement with Vandermeulen et al., in whose series of 55 spinal haematomas, 38% patients had satisfactory neurologic recovery following surgical intervention within 8 h of onset of symptoms.[5] We need to consider that adverse outcomes associated with concurrent use of neuraxial blockade and oral anticoagulants may be higher than those reported in clinical trials. Based on this experience, we recommend extreme caution in prescribing rivaroxaban to patients who have undergone neuraxial anaesthesia. Furthermore, we recommend that the time frame given by the manufacturer for drug administration needs reconsideration. More studies are required to prove the safety of rivaroxaban in the setting of neuraxial anaesthesia.

An Epidural Blood Patch Causing Acute Neurologic Dysfunction Necessitating a Decompressive Laminectomy

One risk with placement of an epidural blood patch (EDBP) is spinal cord or nerve root compression resulting from the epidural blood volume injected, a complication necessitating immediate surgical decompression. We could not find a previous report of this in the literature. Here, we review and discuss one such case. A patient was treated with 2 EDBPs for a presumptive cerebrospinal fluid leak 3 weeks after an epidural steroid injection. The second EDBP was performed under direct fluoroscopic guidance, yet resulted in spinal cord compression with radiologic evidence of an epidural hematoma. The patient developed acute cauda equina syndrome and required an emergent decompressive laminectomy resulting in partial resolution of neurological symptoms. One year after the procedure, the patient has recovered most of her motor function but with some persistent numbness below the left knee and a left foot drop. A cauda equina syndrome from an epidural hematoma may occur as a rare complication of an EDBP, even with direct fluoroscopic guidance. Early diagnosis of symptoms and prompt surgical evacuation of an epidural hematoma is essential and may result in the resolution of symptoms. This complication remains a rare occurrence and should not deter the performance of an EDBP, when indicated.

Isolated Involvement of the Posterior Elements in Spinal Tuberculosis

The literature on tuberculosis of the posterior spinal elements without involvement of the vertebral body is scarce. In this study we report our experience with twenty-four cases of neural arch tuberculosis that were treated at our center. We performed a retrospective review of the clinical and radiographic data of twenty-four consecutive patients who had tuberculosis of the posterior spinal elements with total sparing of the vertebral bodies and intervertebral disc space. We categorized the patients into two groups on the basis of the clinical and radiographic evaluation. The patients who had rapid onset weakness of the lower limbs or pyramidal signs or who showed evidence of epidural abscess underwent emergency decompressive laminectomy (Group A). Patients who had pyomyositis of the posterior spinal muscles without any neurological deficit, pyramidal signs, or epidural abscess were managed with antitubercular therapy alone (Group B). The common presenting features were spastic limb weakness and back pain. The majority of the patients had involvement of the thoracic spine. Epidural abscess, erosion of lamina, and pyomyositis of posterior spinal muscles were common imaging findings. Group A consisted of nineteen patients and Group B consisted of five patients. The mean period of follow-up was 16.9 months (range, nine to sixty months). Patients in Group A had a poorer outcome than those in Group B. Thirteen of the nineteen patients in Group A improved to become independent in the activities of daily living, with complete neurological recovery in eight patients and partial recovery in five patients. Six of the nineteen patients continued to have spastic paraplegia and were wheelchair-dependent. All of the patients in Group B remained neurologically intact during the follow-up period. None of the patients had recurrence of the disease or developed anterior element involvement or kyphotic deformity during the follow-up period. Neural arch tuberculosis is often missed at the time of initial presentation. In association with epidural abscess, it leads to rapid neurological deterioration. This atypical picture of spinal tuberculosis showed a high rate of neurological deficit at the time of initial presentation for medical care.

Spontaneous Cervical Spinal Epidural Hematoma in the Postpartum Period

We present the case study of a 31-year-old lady who had a spontaneous cervical spinal epidural hematoma in the postpartum period and who presented with sudden onset of neck pain and lower limb weakness for which an emergency decompressive laminectomy was performed with neurological recovery. To report on the spontaneous spinal epidural hematoma in the postpartum period, which is a rare complication during pregnancy and requires early recognition and expedient intervention to prevent permanent neurological sequelae. This complication has been described only once previously in the postpartum period. The recovery of the patient described here highlights the importance of early recognition and surgical intervention. A case report of a spontaneous cervical spinal epidural haematoma in the postpartum period is presented and the pertinent literature is then reviewed. The patient had neurological recovery at 1-year follow-up, although she required clean intermittent self-catheterization once daily for bladder dysfunction. Early recognition and intervention for our patient allowed for neurological recovery with a spontaneous cervical spinal epidural hematoma in the postpartum period.

Spontaneous idiopathic spinal epidural hematoma: two different presentations of the same disease

We report two cases of spontaneous spinal epidural hematoma with different clinical presentations without precipitating factors and a brief review of the literature. Our case first developed acute and had progressive cervical spinal cord signs that determined emergency decompressive laminectomy. On the other hand, the second patient, who was chronic, was operated almost five months after the initial symptoms and the radiological diagnosis was a large facet cyst. Early surgical intervention is the chosen treatment for spontaneous spinal epidural hematomas. Spinal surgeons should bear in mind that spontaneous spinal epidural hematomas may have different clinical presentations according to their location in order to perform a differential diagnosis.

Brown–Séquard syndrome due to penetrating injury by an iron fence point

Case report. To present an unusual type of penetrating objects causing Brown-Séquard syndrome (BSS) and its clinical character. Department of Orthopaedic Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, PR China. A 54-year-old man fell from a height of 4 m onto an iron fence, and a sharp iron fence point penetrated the right side of his back. He developed left-sided BSS. Both X-ray film and computed tomography scanning of the thoracic spine showed a right vertebral plate of Th5 fracture and metal fragments inclining through the posterior and left lateral of the spinal canal. Emergency decompressive laminectomy and removal of the foreign metal piece were performed. No improvement in neurological function was observed 10 days after surgery, and thus hyperbaric oxygen treatment was initiated twice a day for the next 1 month. Forty days after surgery, his bladder function returned to normal. The motor deficit had regressed and he could walk without assistance 70 days after the operation. One year later, his lower extremity functions recovered almost completely, except for slight numbness on the right side. As far as we know, on the basis of existing literature, the injury mechanism to BSS by a sharp iron fence point has not been reported so far. The satisfactory recovery after injury may in part be attributed to timely surgery and continuing hyperbaric oxygen treatment.

Spontaneous Spinal Subdural Hematoma: Case Study

Spinal cord hematomas are remarkably uncommon. Even more rare are spontaneous spinal subdural hematomas without underlying pathological changes. In some patients, compression of the spinal cord by spinal subdural hematoma has led to acute paraplegia. Spontaneous spinal subdural hematomas occur most often in the thoracic spine and are manifested by sudden back pain that radiates to the upper or lower extremities or to the trunk and variable degrees of motor, sensory, and autonomic disturbances. Clinicians should consider spontaneous spinal subdural hematoma when patients who are taking anticoagulants report back or radicular pain and the development of paraparesis, because early diagnosis is essential for preventing irreversible paralysis. Diagnosis of spontaneous spinal subdural hematoma requires prompt radiological assessment; magnetic resonance imaging is the preferred method. Treatment includes emergent decompressive laminectomy and evacuation of the hematoma to prevent or minimize permanent neurological damage caused by spinal cord compression, ischemia, and spinal cord injury.

Longitudinal myelitis, aseptic meningitis, and conus medullaris infarction as presenting manifestations of pediatric sysemic lupus erythematosus

A healthy boy developed subacutely progressive quadriparesis, complicated by sudden paraplegia, fever, and meningeal signs, diagnosed as longitudinal myelitis, aseptic meningitis, and conus medullaris infarction and identified as the presenting manifestations of neuropsychiatric systemic lupus erythematosus. Rapid expansion of the conus on serial neuroimaging led to emergent decompressive laminectomy and cord biopsy showing vasculitis and cord infarction. The patient had partial recovery after treatment with high-dose steroids. Increased vigilance is required when pediatric patients develop a similar subacute presentation on the ground of active systemic lupus erythematosus because it may herald the onset of a catastrophic neurological syndrome.

Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.