Chih-Ju Chang

Thoracic Vertebral Osteomyelitis Caused by Burkholderia cepacia in an Immunocompetent Adult

To the Editor: Apreviously healthy 71-year-old female complained of back pain 2 mo before admission to the hospital. She was a farmer and worked with vegetables and plants on a daily basis. A physical examination at the time of her admission revealed no remarkable findings except for local tenderness in her mid-thoracic region. Her body temperature on admission was 37.5 C. Laboratory examination demonstrated a white blood cell (WBC) count of 20,640/ mcL, with 80% segmented neutrophils, and a C-reactive protein concentration of 5.6 mg/dL. Plain radiographs of the patient’s spine revealed an osteolytic lesion of the T5 vertebral body. Magnetic resonance (MR) images of the thoracolumbar spine revealed a destructive lesion in the T5 and T6 vertebral bodies (Figs. 1A,B), which appeared as a hypointensity on T1-weighted MR images and a hyperintensity on T2-weighted MR images. Initially, cefazolin and gentamicin were prescribed. A computed tomography (CT)-guided biopsy of the T6 vertebral body was performed through the right pedicle of T6 on the day after the patient’s admission. Pathology examinations confirmed a chronic inflammatory reaction. Serial cultures of blood, urine, sputum, and biopsy tissues revealed no growth. Because of persistent fever and back pain, the patient was treated empirically with oxacillin 1.5 g q6h beginning on day four after her admission. The patient experienced persistent fever and weakness in her left leg, and more severe destructive osteomyelitis with epidural extension and cord compression were found on the MR images of her thoraco-lumbar spine (Fig. 2A). Decompression surgery, consisting of posterior laminectomies of T5 and T6 and a transpedicular biopsy, were done on day 18 of hospitalization. Tissue culture revealed no growth. The patient’s antibiotic therapy was then changed to ceftriaxone 2 g q12 h. However, progressive bilateral weakness of the patient’s lower limbs, and urinary retention were noted. Progressive extension of the epidural abscess, together with collapse of the T5–T6 vertebral bodies (which compressed the spinal cord) were demonstrated in MR images (Fig. 2B). The patient then underwent transthoracic corpectomies at T5 and T6, with internal fixation of an autologous bone graft (from the iliac crest) on day 36 after her first operation. Tissue culture confirmed Burkholderia cepacia infection. After antibiotic susceptibility tests showed the infecting organism to be sensitive to ceftazidime, meropenem, trimethoprim-sulfamethoxazole, and levofloxacin, the patient’s antibiotic therapy was changed again, to levofloxacin 250 mg q8h. However, her pulmonary compliance and function were poor after open chest surgery, and she succumbed about 2 wk after her second operation from septic shock and respiratory failure. Burkholderia cepacia, a gram-negative bacillus, is an important pathogen that infects patients particularly with cystic fibrosis (CF) and chronic granulomatous diseases, and immunocompromised patients [1,2]. This bacterium is found commonly in moist environments in association with soil, water, and plant roots [3]. The types of infection caused most commonly by B. cepacia are bacteremia, urinary tract infection, surgical site infection, septic arthritis, peritonitis, softtissue infection, endocarditis, and respiratory tract infection [4,5]. Several predisposing factors, including CF, chronic granulomatous diseases, indwelling intravascular catheters, assisted ventilation, and intravenous drug abuse increase the risk of infection with B. cepacia [1,6]. Contaminated fluids, such as tap water and nebulizer, irrigation, and dialysis fluids, have also been reported as sources of B. cepacia infection [1,7,8]. Vertebral osteomyelitis caused by B. cepacia is described rarely, with only three cases, consisting of two cases of cervical and one case of lumbar osteomyelitis, reported in the literature [3,6,8]. The diagnosis of B. cepacia infection in these three cases was confirmed by CT-guided biopsy or open surgery. All of the patients recovered gradually after the prescription of suitable antibiotics, possibly aided by decompressive surgery. The sources of the patients’ infections were probably intravenous drug abuse, previous rhinoplasty with contaminated fluid, and an unnoticed external wound that occurred either during a fall on an icy road or from intramuscular stimulation therapy. Antimicrobial resistance of B. cepacia has been considered a great challenge in treating infection caused by the organism [1]. To the best of our knowledge, B. cepacia infection involving the thoracic spine in

Chronic subdural hematoma: Differences between unilateral and bilateral occurrence

Chronic subdural hematoma (CSDH) is one of the most common neurological diseases. However, bilateral CSDH is more infrequent than unilateral CSDH, and the clinical and radiological characteristics are not well-defined. We aimed to investigate the clinical and radiological differences between bilateral and unilateral CSDH. A retrospective study was performed on 75 surgically-treated CSDH patients from January 2011 to December 2015. These patients were divided into unilateral and bilateral CSDH groups. The clinical features, radiological findings, surgical outcome, occurrence of postoperative intracranial bleeding, and recurrence were analyzed. 30.7% of patients had bilateral CSDH. The mean age was 79years and 68.8years for the bilateral and unilateral CSDH patients, respectively (p=0.001). The presence of a history of alcohol abuse was 8.7% and 32.7% in the bilateral and unilateral CSDH patients, respectively (p=0.028). The patients with bilateral CSDH were more likely to present with nausea or vomiting (p=0.048). A lesser degree of midline shift on computed tomographic (CT) scan was also observed in the bilateral group (p=0.001). Most patients had a favorable postoperative outcome, even with bilateral CSDH. In this study, we found that the patients with bilateral CSDH were older, had a lower prevalence of a history of alcohol abuse, presented more commonly with nausea or vomiting, and had a lesser degree of midline shift on CT. Burr-hole craniostomy with a closed-drainage system is a feasible and effective surgical technique for the treatment of unilateral or bilateral CSDH.

Accuracy and Safety of Using Customized Guiding Templates for Cervical Pedicle Screw Insertion in Severe Cervical Deformity, Fracture, and Subluxation: A Retrospective Study of 9 Cases

OBJECTIVE To assess accuracy and safety of self-developed customized guiding templates for cervical pedicle screw (CPS) insertion surgery. METHODS From July 2016 to December 2017, 57 screws were implanted in 9 patients with the assistance of customized guiding templates. Customized guiding templates were manufactured from acrylonitrile-butadiene-styrene plastic material using a three-dimensional printer after establishing pedicle screw trajectories for each vertebra with the assistance of a virtual surgical planning software program, developed by our team, for the insertion of CPSs. RESULTS CPSs were evaluated using the following grading system: grade 0 (contained), grade 1 (exposure), grade 2 (perforation), and grade 3 (penetration). Each patient underwent postoperative computed tomography to evaluate accuracy of screw position. Of 57 screws, 54 were graded 0, and 3 were graded 1; no screws were graded 2 or 3. No vascular or nerve injuries were noted after the operations. CONCLUSIONS CPSs, which provide strong biologic strength, are especially suitable for treating osteoporosis and severe deformity. However, CPS insertion remains a challenging procedure with high incidences of vascular and nerve injuries reported. The results of this study indicate that use of customized guiding templates can improve safety of CPS insertion surgery.

Rendering a ruptured arteriovenous malformation more susceptible to spontaneous obliteration as a possible treatment strategy for cerebral AVM

Abstract Spontaneous regression of cerebral arteriovenous malformation (AVM) is a rare phenomenon, but its occurrence is an important consideration in treatment planning. A 58-year-old male was found to have a high-flow AVM of Spetzler–Martin Grade III. Before his scheduled treatment, the AVM ruptured with a large parenchymal hemorrhage. Following emergency decompressive surgery, a targeted embolization procedure was performed to obliterate the ruptured weak point and to reduce the shunting flow. The residual AVM became a malformation harboring angio-architectural factors favoring spontaneous obliteration. Together with other favorable clinical factors, including prior parenchymal hemorrhage and neurosurgical intervention, the residual AVM spontaneously regressed in 2 months. This case highlighted a possible treatment strategy in that, for a ruptured AVM in which definite treatment is not possible, an alternative is to treat the AVM into a situation in which as many favorable factors as possible for spontaneous AVM regression are present.

Post-herpetic like Median Nerve Neuralgia by Brachial Artery Pseudoaneurysm Impingement: A Case Report

Brachial artery pseudoaneurysms are exceedingly uncommon but should be considered in the workup of a patient with median neuralgia and/or neuropathy following arterial punctures in the cubital fossa. We reported on a case in which the prodromal symptoms of median nerve compression caused by a brachial artery pseudoaneurysm led to the misdiagnosis of post-herpetic neuralgia before the occurrence of full blown neuropathy symptoms.This 63 year-old male patient, who suffered from spontaneous subarachnoid hemorrhage, received continuous arterial pressure monitoring at right brachial artery in intensive care unit. Following removal of the arterial catheter, the patient developed dysesthetic burning pain in the right forearm along median nerve dermatome, which was initially diagnosed as post-herpetic neuralgia by dermatologists. In the following weeks, a pulsatile swelling at cubital fossa was noticed, and signs of median neuropathy also occurred. Nerve conduction studies (NCS) showed no responses in the median motor and sensory nerves. Both ultrasonography and arterial angiography confirmed the presence of a large pseudoaneurysm. Surgical excision of pseudoaneurysm was then performed, followed by brachial artery reconstruction using interposition basilic vein graft. After surgery, median neuropathy remained, but dysesthetic pain resolved. One year after operation, NCS still failed to show responses in median nerve. Our case demonstrated that, in the presence of median neuralgia following medical procedures in the cubital fossa, the importance of early suspicion and treatment of pseudoaneurysm formation cannot be overemphasized in order to avoid permanent palsies of median nerve.