Amir Hasharoni

Preoperative embolization of hypervascular spinal tumors: current practice and center experience

Abstract Preoperative transarterial embolization of hypervascular spinal tumors has been extensively used, and is considered to be a highly effective adjuvant technique in reducing intraoperative blood loss during surgery. Moreover, it has been reported to increase the feasibility and safety of the surgical procedure, leading to better surgical outcomes. We review the English literature in an attempt to identify indications, appropriate timing of embolization in relation to surgery, technical aspects of the procedure, complications, and the contribution of embolization to the surgical management of spinal tumors. In addition, we report our experience with embolization of hypervascular metastases

Symptomatic facet cysts of the subaxial cervical spine

Subaxial cervical facet cysts are uncommon. We report two patients with intraspinal, extradural, subaxial cervical spinal facet cysts, and review the literature to describe the epidemiology, clinical presentation, imaging findings, and treatment options for these lesions. Intraspinal, extradural, cervical spinal cysts should be considered as part of the differential diagnosis in patients presenting with clinical signs of cervical radiculopathy or myelopathy.

Cauda equina syndrome after spinal epidural steroid injection into an unrecognized paraganglioma.

Objective:Clinically significant spinal hemorrhage is an extremely rare but potentially devastating complication of spinal epidural steroid injection. We report a rare case of cauda equina syndrome after spinal epidural injection that inadvertently penetrated an unrecognized spinal paraganglioma. Methods:The clinical records for a patient presenting with cauda equina syndrome were retrospectively reviewed. A literature search was performed to identify reports of cauda equina syndrome in patients undergoing spinal epidural steroid injection, as well as recent large series describing complications associated with these injections. Case Report:A 37-year-old man presented to our emergency department with severe low back pain radiating bilaterally to the lower extremities and urinary incontinence. His pain had greatly intensified 1 day after spinal epidural steroid injection. He had a 1-year history of low back pain diagnosed as disk herniation and managed conservatively but had experienced recent onset of a similar pain and new onset of nocturnal back pain causing sleep disturbance. Epidural injection had been administered based on the earlier diagnosis of disk herniation. Examination using magnetic resonance imaging revealed a previously unrecognized oval hemorrhagic mass lesion at L2-3, which had been inadvertently penetrated during epidural injection. Emergent en bloc resection resolved the patient’s neurological symptoms. At histopathologic analysis, the tumor was diagnosed as a spinal paraganglioma. Discussion:The presented case indicates the importance of a thorough history, physical examination, and imaging assessment before spinal epidural steroid injection.

Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression

BACKGROUND AND CONTEXT Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management. PURPOSE Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC. STUDY DESIGN/SETTING Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015. PATIENT SAMPLE Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression. OUTCOME MEASURES Duration of ambulation and survival. METHODS Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis. RESULTS Forty patients were included (21 male, 54%; mean age 74 years, range 65-87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0-1662) and 525 days (range 11-1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65-69, 70-79, or 80-89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0-11. CONCLUSIONS Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery.

A hard fall: an isolated fracture of lumbarized S1 spinous process: a case report and review of the literature

Study Design. A case of an isolated lumbarized S1 spinous process fracture due to direct trauma from a fall on the lower back is reported here. The patient was treated nonoperatively. Pain subsided and he returned to every day. Objective. To alert physicians of this rare fracture as part of the differential diagnosis in cases of direct trauma to the lower spine. The method of diagnosing such pathology and its treatment are described. Summary of Background Data. A 22-year-old man was admitted with lower back pain after falling down a flight of stairs during which, he sustained a direct blow to his lower back. The patient had a scrape over L5–S1 area and midline tenderness around the L5–S1 area. He was neurologically intact. Radiographs revealed a lumbarized S1 vertebra and an isolated fracture of the spinous process of S1. The fracture resulted from the direct trauma to the S1 lumbarized vertebrae. The direct trauma and the fact that the patient has a lumbarized S1 vertebra with a thin spinous process contributed to the fragility of the spinous process. Methods. Nonoperative measures, physical therapy, primarily analgesics, and local heat, were employed. Results. The patient returned to his normal routine after 3 weeks. Conclusions. Few cases of isolated spinous process fractures have been described, and, to our knowledge, this is the first reported case of an isolated fracture of a lumbarized S1 spinous process to due to direct trauma. Radiograph imaging was adequate to determine the extent of the injury. Nonoperative treatment can allow the patient to return to every day life without the need of surgery.