Vertebral Involvement Research Articles

Zoster Sine Herpete, Vertebral Artery Stenosis, and Ischemic Stroke

Although a previous or recent history of varicella-zoster virus (VZV) infection is known to increase the risk of stroke in both children and adults, the influence of zoster sine herpetic remains unclear. We report an immunocompetent man with common cold symptoms and conjunctivitis, followed by an acute onset of bulbar weakness and hemihypesthesia without preceding skin rash. Acute medullary infarction and left vertebral artery stenosis were detected. VZV infection was finally identified. Zoster sine herpetic interferes with accurate diagnosis of infectious stroke, and vertebral artery involvement is unusual in ischemic stroke in this situation. An unexplained course of ischemic stroke event should be suspected in patients with VZV cerebrovasculopathy, especially in those without conventional stroke risk factors and those exhibiting concomitant infectious complications.

Spinal metastasis from acinic cell carcinoma of the parotid gland: a case report

Acinic cell carcinoma is the fourth most common tumor of the parotid gland, and spinal metastases are thought to be exceedingly rare. Only two other reported presentations are found in the literature, both presumably secondary to incomplete surgical resections. To present the first known case of metastasis to the lumbar spine causing vertebral body involvement, after complete resection of the parotid gland. Case report. A case of a patient who presented with low back pain and had imaging studies showing an expansive destructive lesion of the L4 vertebral body. The patient underwent a radical parotidectomy and radiation therapy for dedifferentiated, high-grade acinic cell carcinoma 2 years prior. The patient underwent anterior L4 corpectomy and strut cage placement and posterior pedicle screw fixation from L2 to L5 on the same day, followed by radiation and oral chemotherapy 3 weeks later. Histopathologic examination confirmed metastatic dedifferentiated acinic cell carcinoma, present in the L4 vertebral body and overlying psoas muscle. This case report underscores the importance of careful evaluation of patients presenting with back pain with a history of malignancy. It also calls into question the traditional low-grade classification ascribed to these tumors, given their ability to metastasize after complete excision and adjuvant therapy.

Moyamoya Vascular Pattern in Alagille Syndrome

We describe a girl with Alagille syndrome and a moyamoya angiographic pattern on magnetic resonance angiography. She was referred for genetic consultation because of posterior embryotoxon and peripheral pulmonary stenosis. Her facial appearance was typical, but she had no cholestasis or vertebral involvement. A heterozygous duplication of one nucleotide (a c.715dupA mutation) not previously described was identified in exon 5 of the JAG1 gene. We review similar cases in the literature and possible pathophysiologic mechanisms (e.g., the Jagged 1 and Notch signaling pathway) of this association.

Extramedullary tumors and leukemia

To describe neurologic presentations and radiologic findings of extramedullary myeloid tumor (EMT). This is a retrospective case series of patients with neurologic presentations of EMT from January 1, 1981, until May 30, 2011. Clinical data abstracted included demographics, presentation, bone marrow involvement, history of hematologic malignancy, complete blood count at presentation, EMT location, imaging findings, treatments, and outcomes. Of 21 patients, EMT was the initial presentation of underlying hematologic disorder in 12 (57%). Six patients (29%) presented with primary EMT (no bone marrow involvement at presentation). The most common location was the thoracic spine (n = 9), usually manifesting as an epidural mass with vertebral body involvement. The initial diagnosis was incorrect in most (n = 17 [81%]). Treatments included radiation (n = 17 [ 81%]), chemotherapy (n = 14 [67%]), and surgery (n = 6 [29%]). Fifteen patients (71%) died. Estimated Kaplan-Meier median survival from diagnosis for 20 patients with adequate follow-up was 8 months. Of the 6 patients with primary EMT (no known systemic leukemia at diagnosis), 5 died at a median of 24 months (range 8-36 months) and 1 is still alive at 1 year. Of the 6 patients whose leukemia was diagnosed upon presenting with EMT, 3 are still alive. EMT affecting the nervous system can present in patients without a known hematologic disorder and is often not recognized. Thoracic paraspinal masses are the most common presentation. The prognosis for patients with neurologic presentation of EMT is generally poor, but longer survival is possible in patients presenting with isolated EMT or leukemia first diagnosed at the time of EMT presentation.

Plasmacytoma: 10 years experience at a tertiary care center in India.

e18573 Background: To evaluate the clinical features, diagnoses, prognostic factors, progression to MM of the patients of solitary plasmacytoma (SP) treated at AIIMS in last 10 years(2001-2010). Methods: From 2001-2010, we identified 57 patients with SP. OS, EFS, progression to myeloma were calculated using the Kaplan-Meier method and log rank test. Results: Out of 57 patients; 48 patients were evaluable. The M:F ratio was 3.5:1 with the median age of 49 years. The primary site was osseous(SBP) in 49 patients, extramedullary(EMP) in 8; 5 lesions were located in the upper respiratory passages, ie nasal cavity and maxillary sinus and rest of the 3 were one each in bronchus, gluteal region and intracranial. 43.8% of the lesions involved the vertebral column. The thoracic spine was the single most commonly involved site (12/57 patients). Out of 25 patients with lesions in vertebral column, 12 presented with paraparesis. Monoclonal protein was present in 48% patients and Urine M- Band in additional 2 patients. Treatment consisted of RT [45 Gy (8-50 Gy)] alone in 27, excision in 2 and excision and RT(n=9) and combined modality(n=10). The median follow-up was 28 months(range 3-160 months). Local control was achieved in 41(85%) while progressive disease was seen in 4. Serum M protein became undetectable after treatment in 60% patients. 17(41%) patients progressed to MM after initial response. The median duration of progression to MM was 21 months. Even though there was a trend towards a better EFS and OS for EMP than SBP, in univariate analysis this was not statistically significant. Patients having vertebral lesion showed trend towards progression to MM (p=.057). 5 yr EFS & OS were 44.4% and 89 % respectively. Median EFS and OS were 38 and 122 months respectively. 5 yr survival rate in patients who developed MM and those who did not were 81% and 100% respectively. None of the baseline characteristics were predictive of survival. Conclusions: Out of 1129 patients of plasma cell dyscrasias registered between 2001-2010; 5% were of SP. Bone was the most common site. Attainment of local control is the predictor of significant EFS (p<0.0001) and OS (p<0.05). Progression to MM is the commonest pattern of failure. Vertebrae involvement was predictor for disease progression to MM.

Severe Kyphosis With Spinal Cord Compression After Resection of a Superior Sulcus Tumor

Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors. We describe a patient who developed a kyphoscoliosis with spinal cord compression after resection of a superior sulcus tumor that invaded the vertebral column. Risk factors for spinal instability and indications for stabilization are discussed.

Enfermedad de Gorham como causa de lesión medular en la infancia: a propósito de un caso

Gorham-Stout syndrome is a rare skeletal disorder of unknown etiology and pathogenesis. It can affect any bone of the skeleton, involvement of the spine being a rare finding. Myelopathy, when it appears, is considered a serious complication.The case is presented of an 11- year old boy who had been diagnosed 1 year earlier of Gorham disease with multiple bone involvement on the chest and spine level. Secondary bone marrow damage appeared during the course of the disease. He was referred to our hospital where was underwent surgery, performing spinal fusion to halt the spinal deformity progression and the clinical course. In the immediate postoperative period, a complete motor and incomplete sensory spinal cord injury was observed, which required early rehabilitation treatment.In Gorham-Stout syndrome, vertebral involvement is uncommon, myelopathy being a serious complication. Neurologic recovery requires a comprehensive rehabilitation program adapted to its severity.

Skin infection and progressive paraparesis

A 35-year-old female agricultural worker presented with a 4 month history of productive cough, fever, and left subcostal pain, followed by progressive paraparesis and urinary incontinence. 10 years previously, she had been treated for a skin infection on her back at another centre for 3 years, without further follow-up. Examination showed more than one irregular scars, hyperpigmented papules, and few skin sinuses with scanty purulent discharge, without erythema, on the middle and left side of the upper back. The patient was afebrile and did not have palpable cervical or supraclavicular lymphadenopathy. We heard no rales, rhonchi, or substantial wheezing. The patient had fl accid paraplegia with complete sensory loss at T4 level and urinary sphincter incontinence. Laboratory tests showed a leucocyte count of 9·1 cells per μL, a normal liver enzyme profi le, a C-reactive protein concentration of 59·1 mg/dL (normal range 0–0·5 mg/dL), and no evidence of venereal disease or HIV. Protein concentration in her cerebrospinal fl uid was 800 mg/dL, glucose was 32 mg/dL, and no cells were present. Cerebrospinal fl uid stains, bacterial culture, and PCR for Mycobacterium tuberculosis were negative. Chest radiography showed a paravertebral mass with a fragmentary pattern of osseous patchy destruction and periosteal reaction (fi gure, A). Spiral CT showed a left paravertebral extensive osteolytic lesion involving vertebral bodies and costovertebral unions (fi gure, B). T2-weighted MRI (fi gure, C–E) showed widespread hyperintense lesions that infi ltrated vertebral bodies without involvement of intersomatic spaces (arrow), pleural thickening, and lung consolidation of the left lower lobe (asterisks). Gram stain and modifi ed acid-fast stain (Kinyoun) of sinus discharge showed variably Gram-positive and faintly acid-fast positive, slender, non-branching fi lamentous bacilli, consistent with a diagnosis of Nocardia sp. Intravenous amikacin, co-trimoxazole, and an orthopaedic corset were indicated. Surgery for debridement was off ered, but the patient did not choose to have the procedure. The patient attended our neurological care centre 2 months after discharge and showed a discrete amelioration of neurological symptoms, but did not return for further follow-up. Initially, diff erential diagnosis included extramedullary neoplasms and granulomatous infections (aspergillosis, histoplasmosis, tuberculosis, chromomycosis, blastomycosis, coccidiodomycosis, botryomycosis, sporotrichosis, frambesia, and syphilis). Gadolinium MRI is especially useful because it could help the practitioner to diff erentiate between vertebral intraosseous abscesses, meningeal involvement, subligamentous spread, and paraspinal abscess.

Central skeletal sarcoidosis: a case report with sustained remission only on methotrexate, and a literature review on the imaging approach, treatment, and assessment of disease activity

We report a case of multifocal involvement of the central skeleton in a patient with long-term stage I pulmonary sarcoidosis who experienced sustained clinical remission of musculoskeletal symptoms while on methotrexate (MTX) alone. Concomitant normalization of laboratory tests [inflammatory markers and angiotensin-converting enzyme (ACE) levels] was observed, and improvements were seen in follow-up magnetic resonance imaging (MRI) of the lumbar spine and bone scintigraphy. To date, there are no specific tools for the assessment of skeletal disease activity in sarcoidosis. Our case suggests that inflammatory markers and ACE levels, when initially elevated, bone scintigraphy, and-in the case of vertebral involvement-MRI could serve as such tools. A literature review on the imaging approach, treatment, and disease activity monitoring of skeletal sarcoidosis is also provided.

Varón de 45 años con tumoración lumbar

A 45 year old Filipino male, with history of Hepatitis B virus infection, was seen in his primary care clinic with a lumbar mass for the past three months. On physical examination the lower limbs showed decrease strength, chest X-rays showed bilateral thickening of the apical pleura, the Mantoux skin test was positive and a lumbar magnetic resonance imaging study showed a compression fracture of D4 vertebral body and soft-tissue abscess in L1. Microbiological examination was positive for M. tuberculosis complex, and with the diagnosis of Pott́s disease, he began treatment. With the advent of anti-tuberculosis drugs, spinal involvement of tuberculosis is rare, but it continues to have a high impact on morbidity. Treatment of vertebral involvement is based on anti-tuberculosis drugs and surgery.

Abstract No. 188: Peek endovertebral implant assisted vertebroplasty in painful ostelytic metastases with vertebral wall involvement: clinical experience on 30 patients

Abstract No. 188: Peek endovertebral implant assisted vertebroplasty in painful ostelytic metastases with vertebral wall involvement: clinical experience on 30 patients

Primary clear cell chondrosarcoma of the spine: a case report of a rare entity and a review of the literature.

Chondrosarcoma is the third most common primary malignant bone tumor after osteosarcoma and Ewing's sarcoma. Clear cell chondrosarcoma is a rare subtype variant of chondrosarcoma, most commonly encountered in the proximal part of the femur or humerus. Vertebral involvement is exceedingly rare and shows a predilection for the thoracic spine. We report the case of a woman with clear cell chondrosarcoma of the thoracic spine, which has been surgically excised, and review the pertinent literature (PubMed). Although it has a reasonably benign biological behavior, clear cell chondrosarcoma needs to be treated as a malignancy. The best treatment for spinal chondrosarcoma is surgery. It should be promptly and adequately resected. Gross-total resection should be the ultimate surgical goal. Radiation therapy should also be considered, especially in the case of subtotal resection or inoperable lesions. In conclusion, it is important to keep in mind this entity in the differential diagnosis of spinal tumors, in order to optimize treatment planning. With adequate treatment, local recurrence rates as low as 20% can be achieved.

Continuous multiple vertebral compression fractures in multiple myeloma patient.

Multiple myeloma is a B-cell origin tumor characterized by hypercalcemia, osteolytic bony lesions, and pathologic fractures. Back pain is one of the most common presenting symptoms of multiple myeloma and about 60% of patients have vertebral involvement at the time of diagnosis7). Minimally invasive surgeries such as vertebroplasty and kyphoplasty are effective to relieve pain and improve the quality of life when a compression fracture occurs in multiple myeloma patients. We report a case of continuous multiple compression fractures associated with multiple myeloma. We should check for the possibility of pathologic vertebral fractures resulting from multiple myeloma in non-osteoporotic compression fracture patients, and especially in cases of continuous fracture occurring in relatively non-elderly patients, even though a history of trauma may be present.

Squash(ed): Craniofacial and vertebral injury from collision on squash court

Squash is a popular racquet sport not usually associated with severe head or spinal injury. The incidence of squash-related injury ranges from 35.5 to 80.9 per 100,000 players, with the most common sites being the lower-limbs and eyes. We present a case of extensive traumatic craniomaxillofacial and vertebral injury resulting from collision on a squash court, without use of protective gear. The patient sustained fractures of the frontal bone, orbits, maxillae, zygomas, the first and second cervical vertebrae and the spinous process of the seventh cervical vertrebra. This is the first case of squash-related injury with such extensive craniofacial and vertebral involvement. This unique case required multiple surgical procedures as well as an extensive admission to the intensive care unit and highlights the risk of significant craniomaxillofacial trauma in sports not usually associated with such injuries.

The clinicpathologic features and MRI manifestations of the thoracic lumbar tuberculosis

Objective: To explore the clinicpathologic features and MRI manifestations of the thoracic lumbar tuberculosis by underwenting MRI and pathological examinations. Methods: 34 cases of Thoracic lumbar tuberculosis were collected which underwent MRI examination and confirmed by pathology or treatment of anti-TB drugs, the clinical cure from June 2008 to June 2012 in our hospital. The first MRI was performed on all patients, to determine the MRI findings, and surgical treatment for pathological examination in order to determine the pathological features. Results: 34 patients with 81 vertebral involvement, in which two adjacent vertebral involvement is the common, accounting for 72.25%, vertebral showed uneven long T1, long T2 signal. Intervertebral disc abnormalities accounted for 90.17%, the performance showed long T1, long T2 signal changes in the intervertebral disc damage, often accompanied by disc space narrowing or disappear. Paraspinal abscess accounted for 90.67%, often more than vertebra, up and down across one or more vertebral bodies showed long T1, long T2 signal. The vertebrae were damaged kyphosis or (and) the posterior longitudinal ligament abscess caused by the dural sac and spinal column with pressure accounted for 74.72%. In enhanced scan, vertebrae, intervertebral discs showed heterogeneous enhancement, paraspinal abscess was curved or ring enhancement. The pathological diagnosis may be obvious to confirm the degree of swelling and lesions. Conclusion: By doing the MRI and pathologic examinations, it can determine the clinical and pathological features and MRI findings of spinal tuberculosis patients with Thoracic lumbar spinal tuberculosis, and lay a reliable foundation for the treatment of the subsequent treatment.

Psoas abscess like metastasis mimicking Koch′s spine

In endemic country like India, psoas abscess is commonly associated with dorsolumbar tuberculosis. A 56-year-old HIV-negative female treated case of carcinoma of cervix presented to rural hospital with psoas abscess like lesion and vertebral involvement. Patient was managed as tuberculosis of lumbar spine. Patient presented to us after 1 year with progressive neurodefecit and huge psoas abscess. USG-guided FNAC of psoas abscess revealed squamous malignant cell. This was recurrence of the operated FIGO stage 1b carcinoma of cervix, presenting as metastasis to lumbar spine and psoas muscle. We report a rare case of cervical carcinoma in HIV-negative women presenting as lumbar vertebra involvement and psoas abscess like metastasis initially managed as tuberculosis of spine. This case report also highlights possible errors that could be made in such rare cases.

Evaluation of Role of Anterior Debridement and Decompression of Spinal Cord and Instrumentation in Treatment of Tubercular Spondylitis

Study DesignProspective study with simple randomization.PurposeTo evaluate the results of anterior spinal instrumentation, debridement and decompression of cord and compare it with results of a similar procedure done without the use of anterior instrumentation.Overview of LiteratureUse of anterior spinal instrumentation in treatment of tubercular spondylitis is still an infrequently followed modality of treatment and data regarding its usefulness are still emerging.MethodsThirty-two patients of tubercular paraplegia with involvement of dorsal and dorso-lumbar vertebrae were operated with anterior spinal cord decompression, autofibular strut grafting with anterior instrumentation in 18 patients and no implant in 14 patients. Results were compared on the basis of improvement in Frankel grade, correction of local kyphosis, decrease in canal compromise and further progression of kyphosis.ResultsThe mean local kyphosis correction in the immediate postoperative period was 24.1° in the instrumented group and was 6.1° in the non instrumented group. The mean late loss of correction of local kyphosis at 3 years follow-up was 1.7° in the instrumented and 6.7° in the non instrumented group. The mean improvement in canal compression was 39.5% in the instrumented group and 34.8% in the non instrumented group.ConclusionsIn treatment of tubercular spondylitis by anterior debridement and decompression of the spinal cord and autofibular strut grafting, the use of instrumentation has no relation with the improvement in neurological status, however the correction of local kyphosis and prevention of further progression of local kyphosis was better with the use anterior spinal instrumentation.

Inter-Rater Reliability between Musculoskeletal Radiologists and Orthopedic Surgeons on Computed Tomography Imaging Features of Spinal Metastases

The primary objective of this pilot study was to examine the inter-rater reliability in scoring the computed tomography (ct) imaging features of spinal metastases in patients referred for radiotherapy (rt) for bone pain. In a retrospective review, 3 musculoskeletal radiologists and 2 orthopedic spinal surgeons independently evaluated ct imaging features for 41 patients with spinal metastases treated with rt in an outpatient radiation clinic from January 2007 to October 2008. The evaluation used spinal assessment criteria that had been developed in-house, with reference to osseous and soft tissue tumour extent,presence of a pathologic fracture,severity of vertebral height loss, andpresence of kyphosis.The Cohen kappa coefficient between the two specialties was calculated. Mean patient age was 69.2 years (30 men, 11 women). The mean total daily oral morphine equivalent was 73.4 mg. Treatment dose-fractionation schedules included 8 Gy/1 (n = 28), 20 Gy/5 (n = 12), and 20 Gy/8 (n = 1). Areas of moderate agreement in identifying the ct imaging appearance of spinal metastasis included extent of vertebral body involvement (κ = 0.48) and soft-tissue component (κ = 0.59). Areas of fair agreement included extent of pedicle involvement (κ = 0.28), extent of lamina involvement (κ = 0.35), and presence of pathologic fracture (κ = 0.20). Areas of poor agreement included nerve-root compression (κ = 0.14) and vertebral body height loss (κ = 0.19). The range of agreement between musculoskeletal radiologists and orthopedic surgeons for most spinal assessment criteria is moderate to poor. A consensus for managing challenging vertebral injuries secondary to spinal metastases needs to be established so as to best triage patients to the most appropriate therapeutic modality.

Isolated extradural tuberculous granuloma of the cervical spine: a case report

Isolated intraspinal extradural tuberculous granuloma (IETG) without radiological evidence of vertebral involvement is uncommon, especially rare in cervical spine. We report a case of cervical IETG without bone involvement in a patient with neurological deficit. The patient suffered from progressive neurological dysfunction. MRI of cervical spine revealed an intraspinal extradural mass, and the spinal cord was edematous because of the compression. Thus C2-C4 laminectomy was performed and extradural mass was excised. The excised extradural mass was confirmed to be tuberculous granuloma through pathologic examination. Antituberculous drugs were administrated with a regular follow-up. Excellent clinical outcomes were achieved. The isolated IETG, although a rare entity, should be considered in the differential diagnosis of the intraspinal mass, especially in patients with spinal cord compression and a history of tuberculosis. If there is a progressing neurological deficit, a combination of surgical and anti-tuberculous treatment should be the optimal choice.

Determinants of Neurologic Deterioration and Stroke-Free Survival After Spontaneous Cervicocranial Dissections: A Multicenter Study

Patients with spontaneous cervicocranial dissection (SCCD) may experience new or recurrent ischemic events despite antiplatelet or anticoagulant therapy. Treatment with stent placement is an available option; however, the literature on patient selection is limited. Thus, identifying patients at high risk for neurologic deterioration after SCCD is of critical importance. The present study examined the rate of neurologic deterioration in medically treated patients with SCCD and evaluated demographic, clinical, and radiologic factors affecting this deterioration. We retrospectively identified consecutive patients with SCCD over a 7-year period from 3 medical institutions, and evaluated the relationships between demographic data, clinical characteristics, and angiographical findings and subsequent neurologic outcomes. Neurologic deterioration was defined as transient ischemic attack (TIA), ischemic stroke, or death occurring during hospitalization or within 1 year of diagnosis. Kaplan-Meier curves were used to determine neurologic event-free survival up to 12 months. A total of 69 patients (mean age, 47.8 ± 14 years; 45 males) with SCCD were included in the study. Eleven patients (16%) experienced in-hospital neurologic deterioration (TIA in 9, ischemic stroke in 1) or death (1 patient). An additional 8 patients developed neurologic deterioration within 1 year after discharge (TIA in 5, ischemic stroke in 2, and death in 1). The overall 1-year event-free survival rate was 72%. Women (P = .046), patients with involvement of both vertebral arteries (P = .02), and those with intracranial arterial involvement (P = .018) had significantly higher rates of neurologic deterioration. Our findings indicate that neurologic deterioration is relatively common after SCCD despite medical treatment in women, patients with bilateral vertebral artery involvement, and those with intracranial vessel involvement.