Alessandro Ramieri

Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature.

A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown-Séquard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patients preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.

Spinal arachnoiditis ossificans: Report of three cases

OBJECTIVE AND IMPORTANCE:Although the clinical and histological features of the pathological entity of spinal arachnoiditis ossificans (AO) have been established for some time, less attention has been paid to the treatment. We propose a classification of spinal AO evaluating the possibilities and indications for surgical or conservative treatment. CLINICAL PRESENTATION:Type III has a lumbar localization, presents with less neurological involvement, and usually requires conservative treatment. In Types I and II, which are usually thoracic, clinical worsening justifies surgical decompression or partial removal, whereas total removal is rarely achievable. INTERVENTION:The literature was reviewed, and the reports on three patients were added to the published cases. On the basis of a reappraisal of the computed tomographic and magnetic resonance imaging documentation and the surgical descriptions, the cases of AO were classified into three types: semicircular (Type I), circular (Type II), and englobing the caudal fibers (Type III). The indications for treatment were evaluated in terms of surgical possibilities and outcome. CONCLUSION:The classification proposed on the basis of radiological findings allows sufficient clinical differentiation of AO and evaluation of the possibilities for surgical treatment. The latter is conditioned by the type of arachnoiditis, degree of neurological involvement, and presence of any concomitant pathological findings.

Blunt abdominal aortic disruption (BAAD) in shear fracture of the adult thoraco-lumbar spine: case report and literature review

To present a rare case of association of abdominal aorta rupture and flexion-distraction fracture of thoracolumbar spine and to review the literature on this condition. In non-penetrating abdominal traumatic injuries with flexion-distraction fractures of the thoracolumbar spine, rupture of the abdominal aorta is an extremely rare occurrence but its outcome is potentially lethal. This association of skeletal and vascular lesions mainly affects young patients and involves the thoraco-lumbar junction and the portion of the aorta that lies in front of it. The authors analyze the pertinent literature and describe a case, operated in two sittings, of a traumatic lesion of the aorta attributable to a fracture of L1, focusing on mechanism of damage, diagnosis and surgical treatment. At 2-year follow-up examination, there were no neurological deficits. A review of the pertinent literature has shown that mortality can be reduced by a meticulous clinical and radiological work-up for a correct diagnosis followed by surgical repair of any damaged vessels. The possibility of performing a rapid diagnosis by means of total-body CT-scan plus CT-angiography allows repair of vascular damage, stabilization of the patient’s hemodynamic conditions and, subsequently, surgical treatment of the vertebral fracture.

Pseudo-aneurysm of a lumbar artery after flexion-distraction injury of the thoraco-lumbar spine and surgical realignment: rupture treated by endovascular embolization.

Study Design. A unique case of pseudo-aneurysm of a lumbar artery after injury of the thoracolumbar spine was presented. Objective. To describe the exceptional occurrence of pseudo-aneurysm of a lumbar artery after flexion-distraction fracture of thoracolumbar junction and to discuss the mechanism of formation and the therapeutic solution. Summary of Background Data. Injury of a lumbar artery represents a potential cause of massive, life-threatening, retroperitoneal bleeding. It may be associated with lesions of the abdomen, lower limbs, pelvic bones, and spinal column. Fracture of a transverse process may be responsible for direct laceration of a lumbar artery, but formation of a pseudo-aneurysm is an uncommon event. The diagnosis is difficult and often delayed. The treatment of choice is endovascular embolization. Methods. In a patient who had a posttraumatic severe thoracolumbar vertebral dislocation with complete spinal cord lesion after road accident, we performed surgical reduction and stabilization via posterior approach. After 7 days, he developed a progressive anemia due to retroperitoneal hemorrhage and formation of a pseudo-aneurysm of the lumbar artery at L1 level. Results. Endovascular embolization achieved resolution of the pseudo-aneurysm, regression of the hematoma and progressive recovery of the patient during a period of 6 months. Conclusion. Pseudo-aneurysm of a lumbar artery has never previously been described in association with flexion-distraction type vertebral fracture, in which the spinal column is subjected to greater, shear-type, forces. Stretching of the arterial wall due to the traumatic dislocation of the spine and subsequent surgical realignment may be considered as the mechanism of formation and rupture of the pseudo-aneurysm. Dangerous bleeding in the retroperitoneal space and in the operative field can be effectively managed by endovascular intervention.

Rapid, symptomatic enlargement of a lumbar juxtafacet cyst: case report.

Study Design. A case is reported in which a 45-year-old man developed cauda equina syndrome caused by enlargement of an L4–L5 juxtafacet cyst diagnosed 4 months earlier. Objectives. To highlight the short interval that can elapse between the discovery of a juxtafacet cyst and its remarkable progression. Summary of Background Data. Although juxtafacet cysts are acquired lesions, how long they take to develop remains unclear. Hemorrhage is a well-known cause of rapid or even dramatic cyst enlargement. This is the first report providing magnetic resonance imaging evidence of rapid, remarkable enlargement of a nonhemorrhagic juxtafacet cyst. Methods. The patient underwent conservative treatment for an L4–L5 right juxtafacet cyst diagnosed by magnetic resonance imaging during evaluation of posttraumatic lower back pain. Four months later, the patient presented with severe pain radiating down the right lateral leg, urinary retention, and impaired dorsal flexion of the right foot. Repeat magnetic resonance imaging showed the cyst now markedly enlarged and occupying almost the entire width of the canal. Results. The cyst was removed, and the patient’s symptoms abated. At 15 months after surgery, he is symptom-free. Conclusions. Juxtafacet cyst may occasionally enlarge and cause severe symptoms within months.

Spine surgery in neurological lesions of the cervicothoracic junction: multicentric experience on 33 consecutive cases.

Surgical treatment of the cervico-thoracic junction (CTJ) in the spine require special evaluation due to the anatomical and biomechanical characteristics of this spinal section. The transitional zone between the mobile cervical and the relatively rigid thoracic spine can be the site of serious unstable traumas or neoplastic lesions. Frequently, injury is associated with neurological impairment due to the small caliber of the spinal canal and/or spinal cord vascular insufficiency. The authors considered 33 neurologic lesions of the CTJ (21 traumas, 10 tumors, 2 infections) treated by means of decompression, fixation, and fusion by different type of instrumentation. Surgical procedure was posterior in 26 cases, anterior in 1 and combined in 6. Major general complications were not found in patients undergoing anterior approach. Biomechanical failure was found in two patients operated by T1 body replacement and C7-T2 anterior plate. Serious cardio-respiratory complications were related to 2 polytrauma patients who underwent posterior surgery. Follow-up evaluation showed spinal stability and fusion in 88% of cases, improvement of the neurological deficits in 42% (19% improved to ASIA E), no or only occasional pain in 75% of patients. In the experience, recovery of spinal realignment and stability is essential to avoid disability due to back pain in trauma patients. In spinal tumors, back pain was related to local recurrence. Neurological outcomes can be unsatisfactory due to the initial serious impairment. There is no type of instrumentation more effective than other. In each single lesion, the most suitable type of instrumentation should be employed, considering morphology, biomechanics, and familiarity of the spinal surgeon with different implants and constructs. Therefore, we prefer to use posterior cervicothoracic fixation in T1 lesions with involvement of the vertebral body and subsequently replace the body with cage without anterior stabilization.

Three-dimensional computed tomographic imaging in the diagnosis of vertebral column trauma: Experience based on 21 patients and review of the literature

OBJECTIVE To compare standard x-ray films, two-dimensional computed tomographic reconstructions and three-dimensional (3-D) computed tomographic reconstructions for assessing the grade, extent, and severity of vertebral fracture. PATIENTS AND METHODS 3-D images were created from standard computed tomographic scans obtained using a General Electric PACE scanner. In 21 patients (17 men and four women) these images were obtained during both the acute phase and at long-term follow-up; there were six cervical, four dorsal, five dorso-lumbar, and six lumbar fractures. RESULTS The 3-D images supplied useful information in complex traumas with rotation and/or dislocation of the vertebral body and in cases with loss of spinal alignment. The 3-D images also proved to be useful as an adjunctive imaging method for evaluation of bone fusion integrity. CONCLUSION 3-D images produced by recently available software provide a 3-D understanding much more readily than do multiple two-dimensional images. Because it would be very difficult to standardize this method of imaging, it seems best that the specialist (orthopedic surgeon, neurosurgeon, neuroradiologist) be present during the investigation to decide the viewing angles. An important limitation to this method is the presence of degenerative disease or osteoporosis, mainly in elderly patients.

Spinal epidural hematomas: personal experience and literature review of more than 1000 cases

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patients clinical and neurological status at admission, age, and the craniocaudal site.

Non-Posterior Subtraction Osteotomy Surgery to Restore Lumbar Lordosis in the Hidden Sagittal Imbalance of the Adult Degenerative Spine

Purpose: Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative kyphoscoliosis by a nonposterior subtraction osteotomy technique. Extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion were used to restore lumbar lordosis and mobilize the coronal curve, while grade 2 osteotomy (SPO) was useful to further decrease kyphosis. Methods: We operated 22 thoraco-lumbar and lumbar degenerative deformities, characterized by a sagittal compensated (hidden) imbalance (SVA<50 mm), with or without coronal deformity, and distinguished according to the SRS-Schwab classification. All patients were submitted to X-ray screening during pre, post-operative and follow-up periods. Results: Mean age was 65.3 (50-74; M/F 1: 4). Sixteen deformities were type L and 6 type N. Loss of LL was moderate (+) in 14 cases and marked (++) in 8. We performed 39 XLIFs, 8 TLIFs, 32 SPOs. Complication rate was minimal. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p<0.05), post-operative values were similar to those pre-operatively calculated in 90% of cases and clinical follow-up (mean 20.5; range 18- 24), scored using VAS and ODI, was satisfactory in all cases, except for two due to sacro-iliac pain. Conclusion: Current follow-up does not allow definitive conclusions. However, the surgical approach reported seems to be a viable choice usable in these compensated adult deformities, avoiding risks and complications of more aggressive pedicle subtraction osteotomies.

Conservative Treatment of Neural Arch Fractures of the Axis: Computed Tomography Scan and X-Ray Study on Consolidation Time

BACKGROUND Computed tomography (CT) scan and X-ray study on consolidation time of C2 neural arch fractures treated conservatively were examined. METHODS A prospective study was undertaken: 28 conservatively treated fractures of the neural arch of the axis (11 hanged-man type I, 5 type II, and 12 miscellaneous fractures) were monitored during the period of orthosis by means of CT scan and plain X-rays performed on admission, and then at intervals between 2 and 120 days afterward. In patients treated with a halo vest (20 cases), a CT scan of the skull was performed to make sure that the pins were correctly positioned and to evaluate the osteolytic processes at the pin-bone interface. RESULTS Two patients died as a result of other severe brain or thoracoabdominal injuries, and the remaining 26 fractures healed in an average time of 109 days (range 90-120). The process of bone consolidation was documented in detail by CT, which showed how the newly formed osteofibrous tissue (iso-hypodense) progressively filled the interfragmentary space. In 2 cases of cranial pin loosening, CT demonstrated an osteolytic rim at the interface, which prompted early removal of the halo system. At clinical follow-up (mean 32 months; range 24-84), functional status was evaluated: all of the patients were neurologically intact with the exception of one, who presented with persistent paresthesias. The most frequent disturbance was cervical pain (12 cases, 46%). CONCLUSIONS CT with two- and three-dimensional reconstructed images has been shown to be the most reliable method for clarifying the evolution of bone consolidation and to show any osteolytic processes at the pin-bone interface during halo vest immobilization. Follow-up results of our series suggest that surgical treatment would not have improved the quality of life in these patients.