Lower Extremity Numbness Research Articles

Motor and Sensory Impairments of the Lower Extremities After L2 Nerve Root Transection During Total en Bloc Spondylectomy.

Retrospective study. The purpose of this study was to examine motor and sensory impairments of the lower extremities after L2 nerve root transection during total en bloc spondylectomy (TES) for spinal tumors. At our institute, for TES at L3 to L5 lumbar levels, the nerve roots are preserved. However, at the level of L1 and L2, the vertebral resection and spinal reconstruction via a posterior approach is employed with transection of the nerve roots during dissection and resection of the vertebra. This study included 13 patients who had undergone TES for spinal tumors involving L2 between 2007 and 2016. Postoperative motor function of the lower extremities was quantified using the Manual Muscle Testing grade for the iliopsoas (IP) and quadriceps femoris (QF) muscles, and a grade of the modified Frankel Classification. Postoperative sensory impairment was quantified by the sites of lower extremity pain and numbness. An initial decrease in strength of the IP and QF muscles in more than 60% of the patients, with a decline in the modified Frankel grade in 76.9%, was observed at 1-week after surgery. All patients recovered by the final follow-up, with 12 of the 13 patients walking without a gait aid. The other patient, who had undergone a bilateral dissection of L3 nerve root during TES of L2 and L3, had a mild QF muscle weakness, requiring a cane for walking. Eleven of 13 patients developed pain or numbness in the groin or thigh area after surgery, with the most common area being the anterior aspect of the thigh. Although IP and QF weakness was observed in the majority of patients who underwent bilateral transection of L2 nerve roots during TES, these deficits recovered over time and did not finally affect activities of daily living. 4.

Multiple secondary cauda equina non-Hodgkin\u2019s lymphoma: a case report and literature review

BackgroundSecondary central nervous system involvement of non-Hodgkin’s lymphoma (NHL) is rare and with poor prognosis, the most common pathological type is diffuse large B cell lymphoma (DLBCL). Although it can occur in any part of central nervous system, it rarely directly infiltrates the spinal cord or cauda equina.Case presentationWe present the case of 64-year-old immunocompetent man with a worsening pain of waist and left lower extremity, accompanied by numbness and paresis of bilateral lower extremity for 20 days. His previous medical history included a resection of painless mass in the left groin in another hospital 7 months ago, and the pathological diagnosis was non-Hodgkin small B cell lymphoma. Gd-enhanced MRI and F-18 FDG PET-CT scan demonstrated multiple infiltrations in the cauda equina. During the operation, we removed as many as 11 subdural-extramedullary bean-size lesions involving multiple nerve roots. The paralysis of his left leg recovered rapidly after the operation. During the follow-up period of more than one year, he underwent standard R-CHOP chemical therapy, no evidence of recurrence was noted until the 13th month, the patient died because of intracranial relapse.ConclusionsImaging examination is important in the diagnosis of multiple secondary cauda equina non-Hodgkin’s lymphoma, and we highlight the significance of gadolinium-enhanced MRI and F-18 FDG-PET/CT in preoperative diagnosis as well as the previous history.

Atraumatic Calf Swelling In Recreational Cyclist

HISTORY: 51 year-old male presented with intermittent left calf pain and swelling for the past 2 months. The pain and swelling became constant the week preceding his presentation. He had no known injury but first noticed the pain after a spin class 2 months ago. The pain was worse with cycling, jogging, and swimming and at the end of the day. He had no knee pain, ankle pain, or hip pain. He denied lower extremity weakness or numbness. The pain did not radiate. PHYSICAL EXAMINATION: There was a soft tissue enlargement in posterior medial aspect of left calf that was mildly tender to palpation, soft, and non-mobile. Transillumination of the area was positive. No overlying erythema or skin changes were noted. Calf musculature and strength were normal. There was no tenderness along the rest of the gastrocnemius or Achilles tendon and no pretibial edema was present. Neurovascular examination was unremarkable. DIFFERENTIAL DIAGNOSIS: 1. Deep Vein Thrombosis 2. Synovial Cyst 3. Abscess 4. Morel-Lavallée lesion 5. Lipoma 6. Hematoma TESTS AND RESULTS: - Knee x-rays: Grossly normal; generally preserved joint space, with osteophyte formation and mild patellofemoral arthritis - Bedside ultrasound of calf: Large, hypoechoic, cystic appearance; connected with a small stalk to the posterior knee joint capsule (popliteal); no vascularity seen on Color Flow Doppler - Fluid analysis: Yellow, hazy; no crystals seen; minimal nucleated cells FINAL/WORKING DIAGNOSIS: Synovial cyst connected to the popliteal aspect of the knee joint TREATMENT AND OUTCOMES: 1. Bedside ultrasound evaluation 2. Aspiration of popliteal cyst, 85cc of straw-colored fluid, sent for analysis 3. ACE wrap recommended in attempt to prevent re-accumulation of fluid 4. Orthopedic evaluation due to re-accumulation of fluid, recommended continued monitoring given asymptomatic nature 5. Could consider surgical excision if becomes symptomatic

A case of syphilitic meningomyelitis with numbness and weakness of the lower extremity as the initial presentation

A case of syphilitic meningomyelitis with numbness and weakness of the lower extremity as the initial presentation

Resection of a Lumbar Intradural Extramedullary Schwannoma: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of a lumbar schwannoma in a 57-yr-old female who presented with right lower extremity numbness, paresthesias, as well as a long history of lower back pain with rest. On magnetic resonance imaging (MRI), there was evidence of an intradural extramedullary enhancing lesion at L5, nearly completely encompassing the spinal canal. This video demonstrates the natural history, treatment options, surgical procedure, risks, and complications of treatment of these types of tumors. The patient underwent a posterior lumbar laminectomy with a midline dural opening for tumor resection. The tumor was encountered intradurally and electromyography recording confirmed that the tumor arose from a lumbar sensory nerve root. The sensory root was then divided and the tumor was then removed. The mass was removed en bloc and histopathologic analysis was consistent with a schwannoma. Postoperative MRI demonstrated gross total resection of the patient's neoplasm with excellent decompression of the spinal cord. The patient had an uneventful postoperative course with full recovery and complete resolution of her back pain and leg paresthesias.

SUN-LB098 Mimic Presentation of Neuromuscular Symptoms in Thyrotoxic Periodic Paralysis in Hispanic Male

Introduction: Thyrotoxic periodic paralysis (TPP) is a rare condition characterized by sudden paralysis with profound hypokalemia. Clinical Case: A 34 year-old obese Hispanic male presented to ED with sudden onset of generalized weakness and numbness of bilateral upper & lower extremities for one day. The patient was not able to get up when he woke up in the morning. He described having blurry vision, more severe on the right side, which was associated with right retroocular pain. He reported over twenty pounds of weight loss within past two months, accompanied with intermittent episodes of watery diarrhea, palpitations, restlessness, mild headache, and dizziness. He denied loss of consciousness, urinary or fecal incontinence, fever, cough or recent respiratory infection. Past medical history included gastritis. He reported no recent trauma, injury or hospitalization. No smoking, alcohol abuse or illicit drug use. On physical examination, the patient was having mild respiratory distress. Right eye exophthalmos and normal cardiopulmonary examination were noted. Neck examination showed no thyroid gland enlargement. Neurological findings revealed cranial nerve and sensory examination intact, but all four limbs were flaccid and motor strength of all extremities was 1/5. Deep tendon reflex was absent. Initial blood test on admission showed Potassium 1.9 mmol/l, Phosphorus 2 mg/dl, Magnesium 1.9 mg/dl, Lactic acid 4.6 mmol/l, TSH 0.005 mIU/l, Free T3: 8.80 pg/ml, Free T4: 2.3 ng/ml, and TBG 14.1 mcg/dl. Thyroid peroxidase was positive. EKG revealed sinus tachycardia. ABG indicated primary respiratory acidosis. Lumbar puncture was normal and ruled out Guillain-Barré syndrome and, viral or bacterial meningitis. Thyroid sonogram showed heterogeneous thyroid with no nodules. CT head without contrast showed no evidence of intracranial hemorrhage. MRI brain revealed no intracranial mass. MRI lumbar & thoracic spine showed a normal finding. After the aggressive replacement of potassium chloride, the muscle weakness improved significantly, and methimazole was initiated. The patient was admitted to ICU for close monitoring and electrolyte management. Conclusion: Thyrotoxicosis periodic paralysis (TPP) is a rare condition that manifests through acute paralysis, and hypokalemia in the presence of hyperthyroidism (1). It is usually found in relatively young Asian population, but also the occurrence has increased in the Hispanic population recently. Early recognition of TPP in a patient with unexplained hypokalemia and painless generalized weakness, is imperative to demand thyroid studies to rule out this condition. Close electrolyte management is important rebound hyperkalemia and life-threatening arrhythmias. Reference: (1) Meseeha M et al. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017;7(2):103-106. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

High Cervical Ependymoma Resection: 2-Dimensional Operative Video.

This operative video illustrates resection of a cervical ependymoma in a 40-yr-old female with numbness of upper and lower extremities and ataxia. Magnetic resonance imaging (MRI) demonstrated an enhancing intramedullary intradural spinal mass at C2-3. The patient underwent a posterior cervical laminoplasty for tumor resection. This video highlights the natural history of this disease, treatment options, surgical procedure, potential risks and complications, and postoperative management of ependymomas. A posterior midline skin incision was made from the inion to the level of C4 which exposed the posterolateral elements of C1-3. C2 and C3 lamina were removed as a single piece using the high-speed drill. A C1 laminectomy was then also performed to provide adequate superior exposure. The dura was opened widely in the midline. Careful midline myelotomy was then performed overlying the tumor. The tumor is noted to be densely adherent to the surrounding spinal cord. Gross total resection was completed using ultrasonic aspiration and microdissection. The dura was closed in a watertight fashion followed by a synthetic dural sealant. The bony elements of C2, C3 were then reconstructed using osteoplastic laminoplasty, titanium miniplates, and screws at C2-3. The wound was closed in multiple layers using sutures. Specimens were sent for frozen and permanent pathological analysis, eventually demonstrating WHO grade II ependymoma. There were no complications. Postoperative MRI demonstrated gross total resection. The patient had an uneventful postoperative course. The strength was at baseline at long term follow-up, with small sensory deficit.

Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale

BackgroundUnilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms.MethodsWe included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement.ResultsDetailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01).ConclusionsULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

Resection of a Thoracic Hemangioblastoma in a Patient With Von Hippel-Lindau: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of a thoracic hemangioblastoma in a 30-year-old female with a history of Von Hippel-Lindau disease. The patient presented with right lower extremity numbness and flank pain. Magnetic resonance imaging (MRI) demonstrated an enhancing intradural intramedullary lesion at T 7 consistent with a hemangioblastoma. The patient underwent a thoracic laminectomy with a midline dural opening for tumor resection. This case demonstrates the principles of intradural intramedullary spinal cord tumor resection. In this particular case, internal debulking was untenable owing to the vascular nature of hemangioblastomas. The operative video demonstrates en bloc tumor removal. Postoperative MRI demonstrated gross total resection. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.

Effects of analgesia pain relief during entire labor on maternal and neonatal outcomes under new partogram

Objective To explore the effects of whole-stage labor analgesia on maternal and neonatal outcomes after the implementation of the new partogram. Methods A retrospective cohort study was performed in Peking University First Hospital. From June to December 2016, 907 nulliparae with full-term singleton cephalic pregnancies that were expected to deliver vaginally and adhered to the new partogram were selected as the study group, and 982 cases that adhered to the old partogram (Friedman standard) from June to December 2012 were selected as the control group. Maternal basic characteristics and analgesic, obstetric and neonatal data were collected. Maternal and neonatal outcomes between the two groups were analyzed with independent sample t-test, rank sum test or Chi-square test (Fisher's exact test). Results (1) Maternal age and the proportion of gravidas of advanced maternal age in the study group were both higher than those in the control group [(30.2±3.0) vs (29.6±2.9) years, t=3.823; 8.2% (74/907) vs 4.2% (41/982), χ2=13.087; both P<0.001]. No statistically significant difference in the other basic characteristics was found between the two groups. (2) Women in the study group had significantly smaller cervical dilatation [M(P25-P75)] than that in the control group when analgesia was commenced [2(1-2) vs 2(1-3) cm, Z=-3.752]. The intensity of pain quantified with numerical rating scale (NRS) before analgesia, and during the second stage of labor in the study group were less than that in the control group [8(8-9) vs 8(8-10) points, Z=-14.441; 5(4-5) vs 6(5-7) points, Z=-16.495]. The study group had longer median duration of analgesia than the control group [520(340-750) vs 300(200-453) min, Z=-17.801, P<0.001]. The overall dose of analgesics in injection pump in the study group was significantly higher compared with that used in the control group [68 (35-84) vs 30 (18-48) ml, Z=-18.004, P<0.001]. However, there was no significant difference in the incidence of analgesia-related complications (hypotension, accidental dura puncture, lower extremity numbness, pruritus and urinary retention) between the two groups. (3) The study group showed a higher percentage of spontaneous vaginal delivery, and a lower rate of converted cesarean section compared with the control group [71.8% (651/907) vs 63.2% (621/982), χ2=15.623; 13.6% (123/907) vs 20.5% (201/982), χ2=18.831; both P<0.001]. The study group had lower forceps-assisted vaginal delivery rate than the control group without statistically significant difference [14.8% (133/907) vs 15.3% (150/982), χ2=0.093, P=0.797]. The duration of the first, second and third stage of labor in the study group were all significantly longer than that of the control group [680 (470-900) vs 480 (360-660) min, Z=-12.490; 56 (31-89) vs 37 (24-58) min, Z=-9.964; 7 (5-10) vs 6 (5-8) min, Z=-6.673; all P<0.001]. Women in the study group had a lower rate of artificial rupture of membranes when comparing with the control group [55.2% (501/907) vs 63.2% (621/982), χ2=12.516, P<0.001]. The incidence of fever, pathologically confirmed infection and postpartum hemorrhage were significantly higher in the study group than that in the control group [10.8% (98/907) vs 6.4% (63/982), χ2=11.652; 9.6% (87/907) vs 3.7% (36/982), χ2=27.201; 12.6% (114/907) vs 5.7% (56/982), χ2=27.144; all P<0.05]. There was no significant difference in the rate of oxytocin use during labor or blood transfusion between the two groups. (4) Compared with the control group, the proportion of cesarean section due to arrested active stage of labor in the study group was significantly lower [5.7% (7/123) vs 50.2% (101/201), χ2=68.173, P<0.05], but the incidences of cesarean section due to intrauterine infection and relative cephalopelvic disproportion were higher in the study group [61.0% (75/123) vs 30.8% (62/201), χ2=2.680; 20.3% (25/123) vs 8.0% (16/201), χ2=10.555; both P<0.05]. There was no significant difference in the proportion of fetal distress or other indications for cesarean section between the two groups. (5) There was no significant difference between the two groups in birth weight, macrosomia, fetal distress, neonatal asphyxia, or the proportion of neonatal intensive care unit admission. Conclusions After the implementation of the new partogram, analgesic pain relief covering the whole labor prolongs the average analgesic time and reduces the rate of cesarean section due to arrested active stage of labor. Although the risk of postpartum hemorrhage is slightly increased, analgesia itself does not pose additional risks on forceps-assisted delivery, maternal blood transfusion and neonatal asphyxia. Key words: Labor, obstetric; Analgesia, epidural; Labor stage, second; Analgesia, obstetrical; Cesarean section

An assessment of lumbar interverterbral disc prolapse surgery at northern part of Bangladesh

Introduction: Prolapse of lumbar intervertebral discs (PLID) is a major cause of morbidity. Back pain and sciatica are very common in adult persons. More careful assessment must be done to treat these patients. Injudicious treatment, whether medical or surgical, may aggravate the sufferings. Objective: This study aim was to assess the Lumbar Interverterbral Disc Prolapse (PLID) surgery at northern part of Bangladesh. Material & Methods: This was a descriptive type of study. The study period extends from October 1, 2017 to September 30, 2019 (Two years). The study was carried out in the Department of Orthopaedic Surgery, Shaheed Ziaur Rahman Medical College Hospital (SZMC), Bogura, Bangladesh. We used purposive sampling method. Among the total study population 74 (70.48%) were male and 31 (29.52%) were female. Age range was 20-59 years. Written informed consent was obtained in favor of all the participants before enrolling into the study. Results: A total of 105 patients were operated and observed periodically in outdoor. Most of them 70.48% of them were male. Majority 45.72% were aged between 30-39 years, 35.24% were in between 20-29 years age, 15.24% were in between 40-49 and 3.80% were aged between 50-59 years. preoperative symptomatology majority 47.62%) had radicular pain, 35.24% had low back pain and 17.14% patients had lower extremity numbness. Distribution of level of disk prolapse majority 55.25% were in between L4-L5 level. Outcome of operation where majority 92.38% of the patient had no pain. Conclusion: PLID surgery is not a routine surgery. Proper assessment of the patient must be done before going to operation

Clinical observation of the effects of modified Duhuo-Jisheng decoction for treatment of paresthesia after transforaminal endoscopic discectomy in patients with lumbar disk herniation

Objective To study the effects of modified Duhuo-Jisheng decoction for treatment of paresthesia after transforaminal endoscopic discectomy in patients with lumbar disk herniation. Methods A total of 89 lumbar disk herniation patients with paresthesia after transforaminal endo-scopic discectomy were divided into the control group (n=44) and the treatment group (n=45) by random number table method. The control group were treated with mecobalamin capsule, and the treatment group treated modified Duhuo-Jisheng decoction. The two groups were treated for 4 weeks. The VAS scale was used to evaluate the pain level of the lower extremities, and the nylon rope test score was used to evaluate the numbness of the lower extremities; and the Oswestry Disability Index was used to evaluate lumbar function; and the World Health Organization Quality of Life (WHOQOL-BREF) was used to evaluate the quality of life. The clinical efficacy of the two groups was compared. Results The total effective rate was 93.3% (42/45) in the treatment group and 75.0% (33/44) in the control group. There were significant differences between the two groups (χ2=5.641, P<0.05). After treatment, the VAS score and ODI score in the treatment group were significantly lower than those in the control group (t=11.440, 8.976, P<0.01). The nylon rope test score and WHOQOL-BREF score were significantly higher than those of the control group (t=10.524, 6.221, P<0.01). Conclusions The modified Duhuo-Jisheng decoction can significantly improve pain and numbness of lower extremities, lumbar function and quality of life in lumbar disk herniationpatients with paresthesia after transforaminal endo-scopic discectomy. Key words: Intervertebral disc displacement; Foraminotomy; Paresthesia; Du Huo Ji Sheng Tang; Quality of life

Syringomyelia-like syndrome in neuromyelitis optica spectrum disorder complicated with Sjogren\u2019s syndrome: a case report

BackgroundBesides CSF-flow obstruction, syringomyelia is associated with inflammatory spinal cord lesions. However, syringomyelia-like syndrome concomitant with neuromyelitis optica spectrum disorder (NMOSD) and primary Sjogren’s syndrome (pSS) is extremely rare. Here, we would like to report a case of a patient with syringomyelia-like syndrome in NMOSD complicated with Sjogren’s Syndrome.Case presentationA 64-old male Han Chinese, presented with three episodes of acute demyelinating processes in the central nervous system within 5 years. Firstly, he presented with ascending left lower extremity weakness and numbness, and initially progressive loss of vision in the right eye before 5 years, and subsequently in the right eye 2 months later. High dose corticosteroid therapy was prescribed for this attack. Second, he suffered from refractory gastrointestinal symptoms.such as nausea, vomiting, abdominal pain and early satiety. After the second episode, he received long-term azathioprine and prednisone treatment in low dosages. Six months before admission, he developed the lower back pain and numbness in lower limbs, and urinary incontinence. This time, he complained of acute onset of right lower limb paralysis, paresthesia and urinary incontinence. MRI of the spine revealed a syringomyelia extending from the C7 to T4 levels with serum positive anti-aquaporin-4 antibodies (AQP4-Ab) (indirect immunofluorescence on AQP4 transfected cells). he was serologically positive for both anti-Sjögren’s syndrome-related antigen A and B antibodies and there was reduced salivary flow on scintigraphy. Lip salivary gland (LSG) biopsies were graded (grade four lymphocytic infiltration) according to the Chisholm and Mason classification system and by morphometric analysis. And finally, diagnosed as syringomyelia-like syndrome in NMOSD complicated with Sjogren’s syndrome.ConclusionsAlthough extremely rare, This index patient highlights that syringomyelia could be associated with underlying NMOSD and pSS, and autoimmune disorders should be considered in the initial differential diagnosis, This is very helpful for the therapeutic implications and evaluating curative effect.

Many pitfalls in diagnosis of acute intermittent porphyria: a case report

BackgroundAcute intermittent porphyria is a rare autosomal dominant disorder caused by a deficiency of the enzyme, hydroxymethylbilane synthase. Recognition of acute neurovisceral attacks can be difficult due to the nonspecific nature of symptoms.Case presentationWe report a case of 33-year-old male patient who presented with recurrent episodes of severe abdominal pain, nausea, vomiting, constipation and numbness of bilateral lower limb extremities. These nonspecific neurovisceral attacks were subject to medical and surgical misdiagnoses of acute appendicitis, sinus tachycardia, renal calculi, drug-induced acute interstitial nephritis and two episodes of partial intestinal obstruction. The sixth acute attack raised the suspicion of an acute porphyria. Watson and Schwartz test was positive for porphobilinogen in urine. Mutation analysis by DNA sequencing of the extracted DNA of the proband revealed a previously reported missense mutation, c.517C>T encoding p.R173W in the HMBS gene, confirming the diagnosis of Acute Intermittent Porphyria. Four out of five family members who underwent targeted mutation analyses were mutation-positive.ConclusionThe most common clinical presentation of Acute Intermittent Porphyria is abdominal pain with neurovisceral manifestations which are common to several medical, psychiatric and surgical pathologies. This leads to underdiagnosis and misdiagnosis of this disorder, incorrect management, and severe complications. Therefore, a high index of suspicion and awareness of front line laboratory investigations are important for diagnosis. Definitive diagnosis enables implementation of strategies to prevent acute attacks, and also triggers genetic testing and genetic counseling of at-risk family members.

Vogt–Koyanagi–Harada case accompanied by polyneuropathy

AbstractVogt–Koyanagi–Harada disease (VKHD) is a systemic autoimmune disease that targets melanocyte‐rich tissues such as eye, central nervous system, inner ear, and skin. Here, we report a case of VKHD accompanied by polyneuropathy. After VKHD was diagnosed, depending on the involvement of bilateral ocular, auditory, and central nervous systems, he expressed muscle weakness, pain, and numbness in bilateral lower extremities. Nerve conduction studies suggested sensorimotor polyneuropathy, while a skin, muscle, and nerve biopsy suggested vasculitis. Steroid therapy improved his symptoms. The present case might suggest a relationship between VKHD and polyneuropathy.

Percutaneous endoscopic decompression via transforaminal approach for lumbar lateral recess stenosis in geriatric patients.

We aimed to investigate the surgical strategy, safety, and efficacy of percutaneous endoscopic decompression via transforaminal approach for lumbar lateral recess stenosis in geriatric patients. From January 2012 to June 2014, 25 elderly patients (18 males and 7 females) with symptomatic lumbar lateral recess stenosis were performed percutaneous endoscopic transforaminal decompression. The ages of patients ranged from 70 to 93years (mean 79.6years). Clinical outcomes were assessed mainly by leg pain visual analogue scale (VAS), Oswestry disability index (ODI) score, MacNab criteria, and post-operative computerized tomographic (CT) scanning. The surgery was successfully completed in all patients with an average operation time of 75 minutes (range, 50-110min). The lumbar CT images at two days after the operation demonstrated distinct enlargement of the foramen intervertebrale as well as satisfactory decompression of the lumbar lateral recess. And 24 patients of the group were followed up for a mean duration of 29 ± sixmonths (range, 12-44months). The leg pain VAS score decreased from 8.52 ± 1.11 pre-operatively to 1.80 ± 0.63, 1.33 ± 0.89, 1.05 ± 0.69, and 0.71 ± 0.50 at one, three, six and 12months after the operation, respectively. Besides, the ODI score also dropped from 59.43 ± 10.04 pre-operatively to 29.42 ± 10.33, 20.13 ± 8.18, 13.98 ± 6.16, and 9.86 ± 5.03 at one, three, six and 12months during the post-operative follow-up period. Statistically significant differences existed in both VAS score and ODI score at each follow-up time point when compared with the pre-operative scores (P < 0.05). The mean reciprocal angulation change of the operated segment in dynamic lumbar lateral view was 3.2° ± 1.6° at the last follow-up. And there were 18 excellent cases, three good cases, and three fair cases according to the MacNab criteria, and the excellent and good rate was 87.5% at 12months after the operation. There was no aggravation of the coexisting medical conditions after operation in this group. Only 1 case was found complicated with lower extremity numbness, which was recovered by conservative treatment for two weeks. No persistent neurological deficit or soft tissue infection occurred in all patients post-operatively. We considered that percutaneous endoscopic transforaminal decompression achieved satisfactory results and provided a safe, effective, and less invasive alternative for treating lumbar lateral recess stenosis in geriatric patients.

Syphilitic meningomyelitis presenting with visceral crisis

Rationale:We report a rare case of syphilitic meningomyelitis presenting with visceral crisis and possessing characteristic imaging findings.Patient concerns:The patient, a 50-year-old woman, complained of pain in the upper abdomen and back. She then developed numbness in both lower extremities and weakness in the left lower limb.Diagnosis:Magnetic resonance imaging (MRI) of the spinal cord revealed the candle guttering sign and irregular enhancement at the T6 level. Rapid plasma reagin test of the cerebrospinal fluid yielded a titer of 1:8. Thus, the patient was diagnosed with syphilitic meningomyelitis.Interventions:She was treated with ceftriaxone and dexamethasone after the failure of penicillin treatment.Outcomes:She could perform the activities of daily living, and her pain completely disappeared.Lessons:A patient with syphilitic meningomyelitis can present with visceral crisis caused by the involvement of the posterior nerve roots or the posterior horn, which usually occurs in patients with tabes dorsalis. Considering the non-specific symptoms and MRI features, we should be aware that abdominal pain may be a symptom of myelopathy, and syphilitic meningomyelitis ought to be taken into account in a patient with longitudinally extensive myelitis.

Posterior osteotomy for thoracolumbar stress fracture in ankylosing spondylitis through the gap of a pathological fracture

To evaluate the effectivity and safety of posterior osteotomy for thoracolumbar stress fracture in ankylosing spondylitis (AS) through the gap of a pathological fracture. Between April 2012 and August 2015, 8 patients with AS combined with thoracolumbar stress fracture were treated with posterior osteotomy through the gap of a pathological fracture to correct the kyphosis. There were 7 males and 1 female, with an average age of 51 years (range, 37-74 years). The history of AS was 1-40 years (mean, 21.7 years) and disease duration of stress fracture was 2-60 months (mean, 18.5 months). The segmental lesions included T 8, 9 in 1 case, T 10, 11 in 2 cases, T 11 in 2 cases, T 12, L 1 in 1 case, L 1, 2 in 1 case, and L 2, 3 in 1 case. The nerve function before operation according to Frankel grading was grade D in 3 cases and grade E in 5 cases. The pre- and post-operative X-ray films, CT three-dimensional reconstruction, and MRI were collected to measure the global kyphosis (GK), local kyphosis (LK), angle of the fusion levels (AFL), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Visual analogue scale (VAS) score was used to assess the back pain intensity. The operation time was 210-320 minutes (mean, 267 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 963 mL). Cerebrospinal fluid leakage was found in 3 patients, and the wound healed by removal of drainage tube and suturing drainage outlet after 5-7 days of operation. The wounds of the rest patients healed by first intention. Lower extremity numbness occurred in 1 case and recovered after 1 month of postoperative administration of oral mecobalamin. All the patients were followed up 20-43 months (mean, 28.4 months). No internal fixator loosening, fracture, and other complications occurred. All the fractures healed with the healing time of 3-12 months (mean, 6.8 months). At 3 months after operation, 3 cases with spinal cord injury of preoperative Frankel grade D recovered to grade E. The GK, LK, AFL, PI, PT, SVA, and VAS scores at 1 week after operation and at last follow-up were significantly improved when compared with preoperative ones ( P<0.05). Except for VAS score at last follow-up was significantly improved when compared with that at 1 week after operation ( P<0.05), there was no significant difference in the other indexes between at 1 week after operation and at last follow-up ( P>0.05). Posterior osteotomy through the gap of a pathological fracture is a safe and effective surgical procedure for kyphosis correction and relief of back pain in AS patients combined with thoracolumbar stress fracture. Successful bony fusion and good clinical outcomes can also be achieved by this surgical procedure.

Revision Surgery for Short Segment Fusion Influences Postoperative Low Back Pain and Lower Extremity Pain: A Retrospective Single-Center Study of Patient-Based Evaluation.

Introduction Patients treated with revision surgery after lumbar decompression with fusion typically have persistent low back pain and lower extremity numbness compared with patients treated with only primary surgery. No well-designed study has investigated the persistence and degree of pain after revision surgery following instrumented operation. The purpose of this study is to compare residual pain among patients who underwent reoperation and those who underwent only primary surgery for lumbar degenerative disorder using patient-based evaluation. Methods We reviewed 350 consecutive patients (143 men, 207 women, mean age 63 years) treated with primary lumbar instrumented surgery between October 2010 and February 2014 at our institution and followed up for ≥2 years postoperatively. Patients were categorized into three groups based on number of levels fused: 1-segment, 2-segment, and ≥3-segment fusion (1F, 2F, and ≥3F groups, respectively). We used the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and visual analog scales (VASs) for low back pain and lower extremity pain to evaluate pain intensity pre- and postoperatively. Results Salvage surgery for late-phase complications was required in 5 cases (2.4%), 6 cases (11.3%), and 11 cases (12.1%) in the 1F, 2F, and ≥3F groups, respectively. In the 1F and 2F groups, patients treated with revision surgery had unsatisfactory improvement in the pain domain of JOABPEQ and VASs for low back pain and lower extremity pain compared with patients with only primary short fusion surgery. The ≥3F group showed no significant differences between patients who underwent reoperation and those who underwent only primary surgery. Conclusion Low back pain and lower extremity pain often persist after revision surgery in patients treated with short fusion (≤2-segment) operation. We need to follow pain states in such patients.

The impact of sarcopenia on the results of lumbar spinal surgery

ObjectivesAs the population ages, the number of lumbar spinal surgeries performed on sarcopenic patients will increase. The purpose of this study was to investigate the prevalence of sarcopenia and evaluated its impact on the results of lumbar spinal surgery. MethodsThis study included 2 groups: One group consisted of patients who underwent whole-body dual-energy X-ray absorptiometry (DXA) scanning before the option of undergoing surgery for lumbar spinal disease (LSD group) and a second group consisted of patients underwent DXA scanning for osteoporosis screening under hospital watch at the geriatric medicine department (control group). In order to evaluate the impact of sarcopenia on the clinical outcome of lumbar spinal surgery, the Japanese Orthopedic Association (JOA) score, the recovery rate based on the JOA score, and visual analogue scale (VAS) scores for lower back pain, lower extremity pain, and lower extremity numbness were compared within the LSD group. ResultsThe prevalence of sarcopenia showed no statistical difference between groups (control group, 50.7%; LSD group, 46.5%). In the LSD group, while the changes in VAS scores showed no statistical difference between the nonsarcopenia subgroup and sarcopenia subgroup, the sarcopenia subgroup demonstrated inferior JOA scores and recovery rates at the final follow-up when compared with the nonsarcopenia subgroup (P < 0.05). ConclusionsThis study demonstrated a high prevalence of sarcopenia among the elderly populations in Japan and a negative impact of sarcopenia on clinical outcomes after lumbar spinal surgery.