Signs Of Spinal Cord Compression Research Articles

Efficacy of spinal fusion in treatment of splintered fracture of the C6 vertebral body with spinal cord compression in an adolescent (case history)

Fractures and dislocation fractures of C5‑Th1 vertebrae account for about 70 % of all spinal injuries. The article describes a case history of the successful treatment of the fractured C6 vertebra by means of spinal fusion with an autogenous bone. The SCT (spiral computed tomography) and MRI (magnetic resonance imaging), performed for diagnostic purposes, showed a splintered fracture of the C6 vertebra with spinal cord compression and mild spinal cord swelling. The clinical picture indicated acute pain in the cervical spine, quadriplegia, and functional disorder of the pelvic organs caused by the severity and level of the injury. The patient underwent two simultaneous surgeries: during the first operation, a fragment of autologous bone from the left iliac wing was taken, and during the second surgery, spinal fusion of C5‑C7 with autologous bone and fixation with a titanium plate were performed. After the interventions, the follow-up SCT of the C-spine showed no signs of spinal cord compression, and the wedge-shaped deformation of the vertebral canal was remedied. No displacement of the vertebral bodies and changes in the height of the vertebrae and vertebral discs is present. After treatment, the patient will undergo long-term rehabilitation measures. The obtained result proves the efficacy of autobone spinal fusion with anterior low-profile titanium plate fixation with four screws. Due to correct and timely medical care provided to the patient, all of the treatment objectives (minimizing secondary injuries of the spinal cord and ensuring optimal conditions for recovery of neurons and axons in the area of disturbed blood supply, spine stabilization) were accomplished.

Spontaneous Epidural Hematoma: A rare neurological complication in a patient following routine coronary angiography

Spinal epidural hematoma is an uncommon but potentially devastating complication associated with various medical interventions. We present a case report of this rare neurological complication following a routine coronary angiography. A 69-year-old male with Aortic Stenosis presented for a scheduled coronary angiography to assess his cardiac status before valve replacement. The procedure was uneventful but approximately 15 minutes after the angiography, he developed sudden-onset of rapidly progressing weakness and numbness in bilateral lower extremities. An urgent neurologic evaluation revealed signs of spinal cord compression, prompting a magnetic resonance imaging (MRI) scan which showed an extensive spinal epidural hematoma spanning multiple levels within the cervicothoracic spine. This case highlights the importance of recognizing this rare but a potential complication following routine coronary angiography even in the absence of signifcant procedural complications. Timely diagnosis and prompt surgical intervention are crucial for achieving favorable outcomes and minimizing morbidity associated with this condition.

Retrospective analysis of mediastinal tumors in childhood

Background: The aim of this study was to determine etiologic distribution, epidemiologic properties, treatment, clinical course and late effects of the treatment of the patients diagnosed with mediastinal tumor. Methods: Patients under 18 years old diagnosed with mediastinal tumors between January 1990 and June 2011 at the 19 Mayis university department of child oncology were examined retrospectively. Results: There were 50 (61%) males, 32 (39%) females with mediastinal tumor. Median age at diagnosis was 9.28 years (30 days-17.4 years). Most common symptoms were respiratory distress (29.2%) and cough (23.1%). Sixty eight cases (82.9%) were malignant. Two cases died before diagnosis. Thirty seven cases (45.1%) were located in anterior followed by 16 (19.5%) in middle and 23 (28%) in posterior mediastinum. Most common malignant tumors were lymphomas (n=46, 67.6%), followed by sarcomas (n=12, 17.6%), neural crest tumors (n=8, 11.8%) and germ cell tumors (n=2, 2.9%). Thirteen cases had vena cava superior syndrome and 4 cases had signs of spinal cord compression at the time of diagnosis. Forty eight cases (58.5%) were alive and symptom free on follow-up (mean 39.5 months, 3-139 months), and 22 (26.8%) were died. Sixteen cases (23.5%) had late effects. Overall survival for all malignant tumors were 60.5±7.8%. Conclusions: Mediastinal tumors should be considered in children with acute progressive respiratory distress and cough. Early diagnosis is still most important factor for prognosis.

Occipitocervical fusion as treatment of instability in Chiari malformation

Introduction. Occipitocervical (OC) fusion is a method for fixation of the OC junction when there is instability of that segment. Arnold Chiari malformation is a congenital disorder where cerebellar tonsils descend through the foramen magnum, which can lead to corticomedullar compression and formation of a syrinx. While treating this condition, for the purpose of decompression, the foramen magnum is expanded, which can potentially harm the stability of the OC junction. Case outline. We are presenting the case of a 16-year-old female who was surgically treated (suboccipital craniectomy and decompression) because of Arnold Chiari malformation type I. One-year post-op multislice computed tomography verified a slight enlargement of basion-axial and basion-dens intervals, with signs of spinal cord compression. Surgery was performed ? OC fusion, canal decompression on C1 and C2 levels with a plate on occipital bone and screws placed in the third, fourth, and fifth cervical vertebra. Conclusion. OC fusion is a complex surgical procedure (vital neurovascular structures), but it is a reliable method for treatment of instability of the OC junction.

Solitary manifestations of primary B-lymphoblastic lymphoma of the spine: Systematic literature review with case illustration

BackgroundGiven the locally destructive osteolytic nature of primary B-cell lymphoblastic lymphoma (B-LBL) of the spine, careful attention is needed to identify clinical signs and symptoms as well as radiological findings of spinal instability because these lesions may warrant resection, decompression, and instrumentation with posterolateral fusion. Our objective was to summarize the presenting symptoms, clinical features, potential treatment modalities, and clinical outcome of cases described in the literature. MethodsWe undertook a systematic literature review to identify all relevant cases and case series describing primary manifestations B-LBL of the spine using Pubmed/Medline. We summarized the findings in accordance with the PRISMA guidelines. We also present a case illustration. ResultsTogether with our case, 9 cases of primary B-LBL of the spine were identified in 6 male and 3 female patients (age 8–58 years, median 31 years). Back pain was the most common symptom, and five patients also had neurological signs of spinal cord compression. T1-weighted MRI contrast enhancement was seen in 5 cases. Surgery was performed in 5 patients with progression of neurological deficits. Steroid treatment was also given in 3 patients preoperatively. Seven patients had chemotherapy after diagnosis. During follow-up of 1 month to 1 year, 2 cases of recurrence and 4 cases of complete remission were noted; however, with the short follow-up time, patient prognosis overall remains unclear. ConclusionsPrimary B-LBL of the spine represents a rare clinical entity whose management mandates a multidisciplinary approach. Careful attention must be paid to the neurological status of the patient, as well as to imaging that may highlight potential local instability of the spine.

POS1277 NON-CONTIGUOUS MULTIFOCAL SPONDYLODISCITIS: A CASE SERIES AND REVIEW OF LITERATURE

Background:Spondylodiscitis is an infective process of the disc and the two adjacent vertebrae. It is quite a rare disease accounting for 2–7% of all cases of septic osteomyelitis. These spinal infections touch commonly a single level, the lumbar spine being the most affected. Non-contiguous spine level involvement is seldom reported in the literature. This last group is for the most part imputable to granulomatous organisms [1,2].Objectives:Study the clinical, microbiological, radiological, therapeutic and evolutional characteristics of non-contiguous multi-levels spondylodiscitis.Methods:We conducted a retrospective descriptive study over twenty-one years in the Department of Rheumatology. The diagnosis of spondylodiscitis was based on combination of clinical, biological and radiological arguments.Results:Eight patients had non-contiguous multi-levels infectious spondylodiscitis. There were 6 men and 2 women. The mean age was 53.3±26.2 years. The mean delay from onset of symptoms to diagnosis was 134.6±77.6 days. Back pain was the most common symptom. All patients had spinal syndrome. The Signs of spinal cord compression were observed in 3 patients. C-reactive protein levels were elevated in 6 patients (mean: 56 ± 30.8 mg/L). Plain radiography, performed in all cases, showed pathological pictures in 7 patients. Magnetic resonance imaging was performed in 6 patients. Vertebral levels affected were thoracic / lumbar in 6 cases, cervical/thoracic in 1 case and cervical/lumbar in 1 case. The paravertebral abscess was associated to the disc involvement in 3 cases. Epiduritis was associated in 3 cases. Pathogens were isolated in all cases. Tuberculosis was the most common cause. The leading causative agents in non-tuberculosis spondylodiscitis were staphylococcus aureus, brucella and streptococcus B. Two microorganisms combined were found in two cases (mycobacterium tuberculosis associated to Escherichia coli in one case and mycobacterium tuberculosis associated to Brucella in another). Medical treatment was adapted to the microbial culture and the sensitivity profile of the etiological agent. After therapy, 7 patients had regression of symptoms and 1 patient had a permanent neurological impairment.Conclusion:Multilevel spondylodiscitis involving non-contiguous spine segments is rare. Although atypical organisms are generally held to be responsible, the common bacteria such as Streptococcus B or Staphylococcus aureus should not be overlooked.

Morquio-like dysostosis multiplex presenting with neuronopathic features is a distinct GLB1-related phenotype.

BackgroundMorquio B disease (MBD) is a distinct GLB1‐related dysostosis multiplex presenting a mild phenocopy of GALNS‐related Morquio A disease. Previously reported cases from European countries carry the W273L variant on at least one GLB1 allele and exhibit a pure skeletal phenotype (pure MBD). Only a minority of MBD cases have been described with additional neuronopathic findings (MBD plus).Objectives and MethodsWith the aim to further describe patterns of MBD‐related dysostosis multiplex, we analyzed clinical, biochemical, and genetic features in 17 cases with GLB1‐related dysostosis multiplex living and diagnosed in Brazil.ResultsAbout 14 of the 17 individuals had three or more skeletal findings characteristic of Morquio syndrome. Two had no additional neuronopathic features (pure MBD) and 12 exhibited additional neuronopathic features (MBD plus). Three of the 17 cases had mild dysostosis without distinct features of MBD. Seven of the 12 MBD plus patients had signs of spinal cord compression (SCC), as a result of progressive spinal vertebral dysostosis. There was an age‐dependent increase in the number of skeletal findings and in the severity of growth impairment. GLB1 mutation analysis was completed in 10 of the 14 MBD patients. T500A occurred in compound heterozygosity in 8 of the 19 alleles.ConclusionOur study extends the phenotypic spectrum of GLB1‐related conditions by describing a cohort of patients with MBD and GM1‐gangliosidosis (MBD plus). Targeting the progressive nature of the skeletal manifestations in the development of new therapies for GLB1‐related conditions is warranted.

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.

A report of two children with Gorham-Stout disease

BackgroundGorham-Stout disease is a rare condition characterized by unifocal and massive type IV osteolysis (variant of idiopathic nonhereditary osteolytic disease) with a slow progression, which is self-limiting for some years. It is characterized by recurrent vascular tumors with disruption of the anatomical architecture and intraosseous proliferation of vascular channels that leads to the destruction and resorption of the bone matrix. The aim of this study is to present the clinical features of this disease, as well as the importance of prompt diagnosis and treatment, with a review of the reported cases.Case reportsWe describe two cases of Gorham-Stout disease between 2013 and 2017 with surgical interventions, follow-up and results. Case one involves an 11-year-old male with involvement of the left iliac bone, with adequate evolution after a surgical procedure with a lyophilized cadaveric tricortical bone allograft. Case two involves a 6-year-old male with cervical spine C1-C3 repercussion; in the protocol for surgical treatment, he presented with signs of spinal cord compression and died.ConclusionDiagnosis of Gorham-Stout disease is made by exclusion, and its clinical presentation varies widely, from spontaneous remission to a fatal outcome.

Conservative Treatment of Tuberculosis of the Spine in Patients with no Neurological Deficits

Background: Patients who have both neurological impairment and kyphotic deformity can be treated medically, and this treatment can be achieved with anti-tuberculous drugs alone.
 Objective: To evaluate conservative medical management of patients with tuberculosis of the spine (Pott disease). The prognostic significance of various clinical, radiological, and long-term follow-up findings in these patients was also evaluated.
 Methods: Between January 2009 and January 2018 data were collected prospectively at The Neurosciences Hospital/ Baghdad/ Iraq in 44 patients with Pott disease in the thoracic and lumbar spine. These patients had no major neurological deficits or severe spinal deformities. The study population consisted of 21 male (48%) and 23 female (52%) patients, with a mean age of 42.1 years (range 10–70 years). The most common region of Pott disease was the thoracolumbar junction (18 cases; 41%), followed by the thoracic (16 cases; 36%) and lumbar (10 cases; 23%) regions. With the exception of two cases, all had kyphotic angles less than 30°. At presentation, 20 patients had neurological signs of spinal cord compression during clinical examination. Clinical , radiological, and laboratory investigations findings were used in all cases for diagnosis. All patients were treated with anti-tuberculous drugs, and the disease in only two (4.5%) was resistant to the regimen. The follow up period was 24 months.
 Forty-two (95.4%) of the 44 patients were successfully treated with conservative medical management and attained acceptable spinal deformity angles, and none of these patients had any residual instability, radiculopathy, or neurological compromise. Only 4.5% of the patients experienced residual spine deformity (as much as a 30° kyphotic angle), which was clinically obvious but biomechanically stable.
 Conclusions: Patients with Pott disease in the lumbar and thoracic regions, without neurological deficits or kyphosis, can be treated conservatively in the vast majority of cases. Indications for surgery need to be redefined given these new data.

A critical assessment of the quality of radiation therapy in Israel: time to initiation of treatment of spinal cord compression as an index of efficiency.

Radiotherapy departments function under workload pressure. We examined the process from referral to treatment initiation for spinal cord compression (SCC), one of the most daunting clinical scenarios in oncology. We identified 235 patients with SCC, treated between 2013-2015. Two physicians classified cases as "emergent" or "urgent" (treatment within 24 or 72h, respectively). The distribution of referrals over the week was uniform for inpatients. In contrast, there was a referral peak (62.27%) during the first two workdays for emergency ambulatory patients (p = 0.011). There were few weekend referrals in all groups (3.0%). There was a statistically shorter interval between referral and treatment for emergent versus urgent cases (0.94days vs. 4.17days; p < 0.0001, Bonferroni correction p < 0.0005). Time elapsed between referral and treatment of SCC may constitute a quality index in neuro-oncology. Modern departments of radiotherapy should determine the degree to which they can successfully implement such treatment. Patients with cancer and their physicians should be taught to recognize signs of SCC to expedite intervention.

Clinical Improvement with Non-Surgical Management of Tuberculous Spondylitis

Background: Tuberculosis is the second most common fatal infectious disease after Acquired Immunodeficiency Syndrome (AIDS) in the world. The spine is involved in 50% of osteoarticular tuberculosis cases. Tuberculous Spondylitis (TS) is the most dangerous form of osteoarticular tuberculosis, because of its ability to destroy the vertebral body with subsequent permanent kyphosis and neurological deficits such as paraplegia. The treatment goals of TS are to eradicate the infection and provide stability for the affected spine. There is little information in the literature about systemic non-surgical treatment under the condition of spinal cord compression in TS. We report two cases of TS which was improved with non-surgical treatment. We believe that the clinico-radiological signs of spinal cord compression in these cases are not an emergency indication for surgery. Clinical Presentation and Intervention: Two women aged 34 and 26 years were hospitalized because of the upper motor neuron type weakness in both legs worsened gradually, descending numbness, without urinary or defecation problems. Magnetic resonance imaging depicted lesions on vertebral bodies supporting the diagnosis of TS. Both patients were received oral antituberculous therapy and their muscle force improved despite the kyphotic deformity in the first patient. Conclusion: Neuro-radiological evidence of spinal cord compression is not an emergency indication of surgery in the management of TS and clinical improvement can be obtained by non-surgical treatment.

An Atypical Presentation of Spinal Epidural Hematoma-Case Report and Literature Review

Spinal epidural hematoma can occur spontaneously or as a secondary condition and it represents less than of space occupying lesions within the spinal canal The incidence of spontaneous epidural bleeding is estimated to be cases per populations per year Typical clinical manifestations include acute onset of back pain sometimes associated with radicular paresthesia and signs of spinal cord compression in some cases The clinical presentation with hemiparesis is rare and it may hinder the diagnosis especially in emergency situations The purpose of this article is to present a clinical case of acute epidural hematoma with atypical clinical presentation followed by literature review of spinal epidural hematoma

Retrospective Study of Anesthesias in Dogs and Cats Underwent to Neurosurgery

Background: The goal of anesthesia in patients with neurological diseases is to maintain the homeostasis of the central nervous system, focusing on intracranial pressure and pain during the intraoperative period. The purpose of this study was to evaluate the anesthesia performed between January 2010 and January 2016 at the Veterinary Clinical Hospital at the Federal University of Rio Grande do Sul and correlate the types of surgeries, drugs used in the pre-anesthetic medication, induction, pain control, and the development of complications during the procedure.Materials, Methods &amp; Results: The medical records of 242 patients, who presented with neurological signs of spinal cord compression or traumatic brain injury, were assessed. Only 70 patients who underwent surgery had properly documented and detailed anesthesia records. Of these 70, there were 32 male and 38 female animals, with one feline and 69 canines. Their weights on the day of surgery ranged between 1.5 kg and 38 kg and their ages ranged from six months up to 13 years. We evaluated 74 surgeries because four patients underwent two separate surgeries. There were 38 hemilaminectomies, 14 ventral slots, seven vertebral stabilizations (one atlantoaxial instability and six vertebral fractures), six dorsal laminectomies, four pediculectomies, two fenestrations with hemilaminectomy, one durotomy with hemilaminectomy, one minihemilaminectomy, and one tumor removal. The complications observed were bradycardia (25/74), systemic hypotension (49/74), systemic hypertension, (21/74) and death (4/74). There was a great variation in the pre-anesthetic medication; either combinations of two or more drugs, one drug, or no medication was used. The most common drug used for induction of the patient was propofol, which was used in 46 cases as single agent and in 26 cases in combination with other drugs. In 43 patients, the majority of nociception control during the intraoperative period was achieved with continuous infusions of fentanyl combined with lidocaine, while some used ketamine. Pain control for the remaining 15 patients was accomplished with drug boluses. In two cases, the choice of opioid in the pre-anesthetic medication was repeated. Fourteen patients had remained without analgesia during surgery. No correlation was observed between the frequency of complications and the type of surgery performed, the medications used for induction of the patient, or the method of control of nociceptive stimuli during surgery. Continuous infusions were used frequently for pain control during surgery, however no significant correlation with complications was observed.Discussion: The high prevalence of neurological diseases that affect the spinal cord makes spinal surgery one of the most frequent neurosurgeries. The risk of complications in spinal surgery is affected by hemodynamics of the patient and may lead to death during the procedure. The most frequent complications are bradycardia, hypotension, cardiac electrophysiological changes, apnea, hemorrhage, and death. The survey identified bradycardia, hypotension, hypertension, and death as the major complications. The most frequent method of intraoperative analgesia was a continuous infusion, due to its benefits when compared to other methods of analgesia. When compared to previous studies, the present study showed similar complications that had no correlation wtih the type of surgery or anesthesia protocol.

Diffusion Tensor Tractography (DTT) – An Objective Method of Determining Clinically-Relevant, Compressive, Spinal Cord Myelopathy

We commonly come across cases of compressive spinal cord myelopathy (CSCM) due to variety of clinical conditions in our day-to-day radiological practice. Magnetic resonance imaging (MRI) has long been considered as the gold-standard imaging tool for evaluation of such cases. These cases reveal signs of spinal cord compression with or without alteration in spinal cord parenchymal signal alteration. Though, diffusion tensor imaging especially fiber-tracking or tractography has been described to be superior to routine MRI in predicting prognosis and urgency of decompression yet fewer studies have been conducted to demonstrate it especially in developing world. Hence, this study aims to evaluate diffusion tensor tractography (DTT) as an advanced dimension of MRI in patients with CSCM in predicting necessity of decompression management, predicting prognosis and evaluating post-decompression outcome objectively in simplified manner.

Extrusão de disco intervertebral em mão-pelada (Procyon cancrivorus) – relato de caso

The crab-eating raccoon (Procyon cancrivorus) is a wild carnivore widely distributed in Brazil, but information about the anatomy and main diseases that affect this species is scarce. This paper describes the clinical and diagnostic aspects of a 12-year-old female raccoon referred to a CT scan of the thoracolumbar spinal segment after presenting signs of acute pain and paralysis of hind limbs. Analysis of the images revealed the presence of mineralized material within the vertebral canal at the level of the T13-L1 intervertebral space, with signs of spinal cord compression. We opted for surgical treatment. However, post-operative care was difficult, there was no significant improvement in neurological deficits, and secondary complications worsened the clinical status, which eventually led to the death of the animal. It is worth noting that descriptions of intervertebral disc extrusions in wild animals are rarely mentioned in the literature, and there are no descriptions of their occurrence in raccoons.

Abstract 5149: An orthotopic model of human chordoma in rats

Abstract Introduction. Chordoma (CHO) is a relatively rare, slow-growing, malignant, locally aggressive cancer that constitutes 1% to 4% of all primary bone tumors. It arises from notochordal remnants along the neuraxis at developmentally active sites. CHO causes significant damage through local bone destruction and compromise of surrounding neurologic and neurovascular structures. CHO in the lumbar spine results in devastating effects that include pain, paralysis, bowel/bladder dysfunction, and decreased ambulation. These effects are minimally responsive to conventional chemotherapy and radiotherapy and as such, surgical resection is the mainstay of treatment. Pre-clinical models that better recapitulate the clinical symptoms observed in patients diagnosed with CHO are needed to increase the understanding of this disease and to develop strategies to develop new therapeutic strategies. Here we developed the first orthotopic animal model of human CHO in the lumbar spine of immunocompromised rats. Methods. 11 immunocompromised rats were implanted in the lumbar spine with human CHO tumor tissue. A group of 6 sham rats (surgical approach without tumor implantation) and another with 6 intact rats were used as control groups. This tumor was obtained from a donor rat that was previously injected with UCH1CHO cells in the flank. Nociceptive response was conducted every week after the first neurological deficits were present using Randal-Sellito. Locomotion gait analysis was used to evaluate gait impairment. Rats were clinically observed for neurological impairment in the lumbar spine and/or hind limbs. Spines were collected after euthanasia, and inspected for signs of spinal cord compression followed by H&amp;E staining to evaluate the histology. Results. In CHO-implanted rats, the threshold for a mechanic nociceptive response was significantly reduced in time and pressure applied. Locomotion gait analysis showed a disruption in the normal pattern of the rats’ gait. At D25-35 after tumor implantation rats showed impairment in the flexion and extension of the knees, ankles, and toes. At the gross morphology level, the spinal cord showed signs of compression at upper and lower levels related with the implanted CHO tumor. Histology revealed tumor invasion in the spinal canal that was related with deficit in the flexion and extension of the toes. The tumor showed typical CHO morphology: physaliferous cells filled with vacuolated cytoplasm of mucoid matrix. Conclusions. We have developed a novel orthotopic human CHO model in rats. This model reproduces cardinal clinical signs such as locomotor and sensory deficits present in human patients. To our knowledge, this is the first orthotopic animal model of human CHO. Its use and further study will be essential for pathophysiology research and the development of new therapeutic strategies. Citation Format: Rachel Sarabia-Estrada, Alejandro Ruiz-Valls, Courtney R. Goodwin, Sagar Sha, Alfredo Quiñones-Hinojosa, Ziya L. Gokaslan, Daniel M. Sciubba. An orthotopic model of human chordoma in rats. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5149. doi:10.1158/1538-7445.AM2015-5149

Multiple spinal metastases from a well-differentiated liposarcoma of the iliac wing: a case report.

A case report. To report an unusual case of multiple spinal metastases from an undiagnosed well-differentiated liposarcoma (WDLPS) of the iliac wing and to stress the need of a meticulous clinical examination and further screening of patients with chronic and asymptomatic bony lesions. University of medicine of Monastir, Department of neurological surgery, Fattouma Bourguiba University Hospital, Monastir, Tunisia and University of Medicine of Tunis EL Manar, Department of neurological surgery, Tunisian National Institute of Neurology, Tunis, Tunisia. A 39-year-old man presented with signs of spinal cord compression for the past 2 weeks. His medical history was consistent for an asymptomatic right iliac wing mass that appeared 3 years ago and for which he has not consulted. Magnetic resonance imaging revealed multiple bony lesions of the thoraco-lumbar spine associated with a 6-cm right paravertebral mass at the T4 level extending posteriorly through the intervertebral foramina to the spinal canal causing major spinal cord compression. An emergent T2-T6 laminectomy allowed for a complete resection of the epidural mass. Pathological examination confirmed the diagnosis of well-differentiated liposarcoma. Adjunctive radiation therapy was administered. The patient's neurological status improved remarkably under an intensive care and rehabilitation program. He was ambulatory without assistance in the second postoperative week. The case reported in this paper represents a genuine example of the possible metastatic potential of WDLPSs of the bone and underscores the importance of examining patients thoroughly, especially when they have chronic and asymptomatic lesions.

Osteomyelitis and Destruction of the Atlas and Axis in a 4-Week-Old Infant: 4-Year Follow-Up

Introduction Neonatal vertebral osteomyelitis is not an uncommon condition, but osteomyelitis simultaneously involving the atlas and the axis is distinctly unusual and no other infant case has been published so far in the literature. We present the case of an infant with retropharyngeal abscess, which led to the destruction of the C1–C2 vertebrae. Materials and Methods MRI examination revealed a multilocular abscess in the right mastoidal area penetrating to the cervical region and causing destruction of the C1 and C2 vertebrae, and an epidural abscess with signs of spinal cord compression at the level of the Th5–Th7 vertebrae. The retropharyngeal and thoracic abscesses were surgically removed and the therapy was completed with antibiotics. The child was placed in a custom-made fixation device for 8 weeks. Follow-up was performed with MRI, CT scans, and functional X-ray diagnostics. Results CT scans with 3D reconstruction demonstrated the absence of normal osseous structures at the craniospinal region, but undamaged ossification centers in the C3 vertebra and below. Functional X-ray diagnostics, performed in general anesthesia showed no significant instability of the cervical spine. Normal motor development and independent walking were allowed. During a 4-year long follow-up period, no signs of neurological impairment were observed, neck movements were limited but painless. It is assumed that the remnants of the bony elements of C1–C2 vertebrae and the massive interconnecting postinflammatory scar tissue make some degree of neck movements possible. His development was undisturbed, similar to his age group. Conclusion C1–C2 osteomyelitis is a very rare entity even in children. There is limited experience with treatment and rehabilitation, but the temporary immobilization of the neck, surgical debridement, antibiotic treatment, and continuous physiotherapy can be recommended. Close follow-up is required to check the reconstitution of affected bones and ligaments, any development of instability, and the necessity of surgical stabilization.

Foregut reduplication cyst: Anaesthetic implications of the rare anomaly.

Sir, Congenital duplications can occur anywhere in the gastrointestinal tract and one-third of all duplications are foregut duplications.[1] A 6-month-old male child weighing 4 kg was admitted in our hospital with the history of recurrent productive cough with intermittent fever for 4 months. He was born full term by normal vaginal delivery. The child was apparently well till 2 months of age after which he started developing repeated episodes of cough and cold with fever. Child was febrile (102° F), lethargic with respiratory rate of 28-30/min. Breath sounds were markedly decreased on the right side of the chest. X-ray chest showed a homogenous opacity in mid-thoracic region compressing the right lung. The computed tomography [Figure 1] scan of chest revealed a large cystic mass (7 cm × 4 cm × 4 cm) in posterior mediastinum extending from the lung apex to base and reaching the opposite mediastinum posterior to oesophagus causing displacement of oesophagus and bronchus anteriorly. It also showed mild pleural effusion on the right side. A provisional diagnosis of foregut duplication cyst was made, and cyst excision via right thoracotomy was planned. Figure 1 Computed tomography scan of the thorax showing the cyst His pre-operative blood investigations were all normal. Once the patient arrived, monitors including electrocardiography (ECG), oxygen saturation (SpO2) and non-invasive blood pressure were placed. No sedative premedication was given. After pre-oxygenation, anaesthesia was induced with sevoflurane in graded concentration and an intravenous line secured. Intubation was performed under sevoflurane with a 4 mm uncuffed flexometallic endotracheal tube. Injection fentanyl 10 μg and injection vecuronium 0.4 mg were then given, and anaesthesia maintained with isoflurane and O2/N2O (50:50). Right internal jugular and right radial arterial cannulation were performed. Intraoperative monitoring included ECG, intra-arterial blood pressure, SpO2, nasopharyngeal temperature, end-tidal carbon dioxide, airway pressures, urine output, central venous pressure and intermittent arterial blood gas (ABG) analysis. The cyst was removed after mobilization that took 3 h. Warming mattress and radiant warmer were used to maintain normothermia. The estimated blood loss was around 300 ml, which was replaced with packed cells. Intercostal block was given with 6 ml of injection bupivacaine 0.125% and rectal suppository of paracetamol 80 mg inserted for post-operative analgesia. The patient was extubated uneventfully in the end and shifted to post-operative care unit. The post-extubation ABG was normal with pH - 7.4; pCO2-38 mmHg; HCO3-20 mmol/L; PaO2-98 mm Hg and SpO2-97% on oxygen by mask at 4 L/min. The post-operative course was uneventful, and the child was discharged after 15 days. The biopsy report later confirmed the diagnosis. Foregut malformation cysts are the second most common cause of posterior mediastinal mass after the neural tumours.[2] An embryonic defect in vacuolization of the oesophagus results in duplication and normally occurs in the 6th week of gestation.[1] The fusion anomalies of cervical and upper thoracic vertebral bodies are encountered in 80% of these cases due to the defect in their embryological development.[2] Although the mean age of onset of symptoms was 49.4 months in a study by Cohen et al., it ranges from 1 month to 18 years.[2] Most cases present with respiratory distress, which may be present from birth. Sometimes the symptoms may be delayed with sudden onset cough, wheeze or recurrent respiratory infections. In rare cases the cyst may perforate into the bronchial tree.[1] Extension of the cyst into the infradiaphragmatic area may cause gastrointestinal symptoms and extension into the neural canal can cause signs of spinal cord compression.[3] Cysts require total excision, to prevent cancer development or recurrence of symptoms.[2] The incidence of complications with the induction of anaesthesia in patients with mediastinal masses has been reported to be 7-18% including refractory cardio-respiratory collapse.[4,5] Inhalational induction with sevoflurane was chosen with a hope that the spontaneous ventilation will preserve the diaphragmatic movements in a caudal direction, and a normal transpleural pressure gradient will be maintained preventing airway collapse. Intubation was also carried out without muscle relaxants with a flexometallic tube to cause splinting of the trachea beyond the obstruction.[6,7] Successful use of femoro-femoral cardiopulmonary bypass (CPB) has been described in patients with mediastinal masses to restore the oxygenation in the event of severe life-threatening hypoxia.[4] Tempe et al. have recommended femoral vessel cannulation under local anaesthesia and CPB circuit primed and kept ready before induction of GA in symptomatic patients with a mediastinal mass.[8] Invasive haemodynamic monitoring is mandatory in these cases as severe cardiorespiratory embarrassments are noted. Good post-operative analgesia is a must after thoracotomy to hasten recovery. We used intercostal block, and rectal acetaminophen as thoracic epidural in infants is not a technique that is commonly practiced in our institution. We could successfully extubate the patient on the table after end of surgery, and he had an uneventful recovery.