Emel E. Ozcan Eksi

Multiple hemorrhages in brain after spine surgery supra- and infra-tentorial components together.

Remote cerebellar hemorrhage after cranial and spinal surgeries is a well-documented entity, so far concomitant supra- and infra-tentorial hemorrhage after spine surgery has rarely been reported in the literature. A 57-year-old woman presented with intractable low back pain and severely impaired mobility. One year ago, she underwent lumbar laminectomy and fusion with posterior spinal instrumentation between L2 and S1. She developed adjacent segment disease at the upper level of the instrumented vertebra. She had a revision surgery and underwent posterior laminectomy and fusion with bilateral transpedicular instrumentation between T10 and S1. She had severe headache, somnolence, and left hemiparesia 48 h after the surgery. Her emergent head computed tomography depicted intra-parenchymal hemorrhage in the right parietal lobe accompanying with subarachnoid hemorrhage, bilateral symmetrical cerebellar hemorrhages and pneumocephalus. She was treated nonsurgically and she got better despite some residual deficits. Symptoms including constant headache, nausea, vomiting, impaired consciousness, new onset seizure, and focal neurological deficit after spine surgeries should raise suspicion for intracranial intra-parenchymal hemorrhage.

A common pathology in an uncommon location: posterior migrated epidural disc herniation

A 56-year-old man presented with low back pain of 4 years’ duration and left leg pain. He was previously diagnosed with lumbar disc herniation. His pain improved with physical therapy. In the last 3 months his pain increased concomitantly with new onset right leg pain. His lumbar spine magnetic resonance imaging (MRI) revealed a mass lesion at the L4–L5 levels posterior to the dural sac (Figure A–C). The mass lesion had isointense signal intensity on T1and hypointense signal intensity on T2-weighted lumbar spine MRI. His contrast-enhanced lumbar spine MRI revealed homogenous attenuation. The preliminary diagnosis was meningioma. Beside the mass lesion, he also had a right-sided extruded disc herniation at the L2–L3 levels (Figure D). He underwent en bloc excision of the mass lesion via left L4 hemilaminectomy. His extruded disc fragment at the L2–L3 levels was extracted via right L2 hemilaminectomy and foraminotomy. His mass lesion was observed as a sequestered disc fragment (Figure E). Our patient had no pain after the surgery. Even though it is rare, posterior migrated epidural intervertebral disc fragment could be detected with contrast-enhanced MRI mimicking mass lesion.

Negative Impact of Modic I Degenerative Disc Disease on Lumbar Paraspinal Muscles

condition walking time interaction (P 1⁄4 .02) was observed for the changes in COMP concentration. Continuous walking was associated with a significant cumulative increase in COMP concentration from baseline to 45 minutes (23% increase, P < .05), whereas, COMP concentrations dropped to baseline levels after 30 minutes of intermittent walking with rest breaks. There were no significant associations noted in TNF-a and NPY concentrations. Conclusion: This study suggests that an increase in walking exercise of greater than 30 minutes may lead to undesirable joint loading conditions, while the addition of rest breaks may attenuate the potential negative effects of longer bouts of walking exercise on cartilage health.

Poster 139 Paraspinal Muscles and Sagittal Spinopelvic Alignment in Patients with Degenerative Spondylolisthesis

Case Description: The patient, a 74-year-old right hand dominant woman, presented for evaluation of left wrist pain and dorsal hand numbness. 3 months prior, she had been treated for left shoulder pain by an acupuncturist. During the treatment, a needle was placed subcutaneously in the anatomic snuff box of her left wrist (corresponding to the acupuncture point Yang Xi/Large Intestine 5). She immediately experienced intense pain, and the needle was removed. Since that time, the patient noted intermittent paresthesias and shooting pain along the dorsal left wrist and hand. She presented to an orthopedic hand surgery clinic, where x-rays of the wrist revealed no acute abnormalities and no retained foreign bodies. The patient was prescribed hand therapy, a wrist brace, and gabapentin; all provided minimal relief. She was then referred for electrodiagnostic testing. On the day of electrodiagnostic evaluation, physical examination of the patient was remarkable for allodynia along the radial aspect of the dorsum of the left wrist. Nerve conduction studies revealed absent left radial superficial sensory nerve action potential at the thumb and reduced left superficial sensory nerve action potential at the wrist. Corresponding evoked potentials on the right side were normal. Needle EMG examination of the left upper limb and cervical paraspinals was normal. Setting: Academic Medical Center Electrodiagnostic Laboratory. Results or Clinical Course: Electrophysiologic testing demonstrated evidence of a left superficial radial sensory neuropathy. The acute onset of neuropathic symptoms in a corresponding distribution during acupuncture treatment suggests iatrogenic superficial radial nerve injury. Discussion: There have been rare case reports of iatrogenic peripheral nerve injury from acupuncture. To our knowledge, this is the first reported case of injury to the superficial radial nerve. Physiatrists performing or prescribing acupuncture for pain management should be aware of this possible complication. Particular care should be taken when employing acupuncture points in close proximity to peripheral nerves. Conclusion: Iatrogenic nerve injury is a potential complication of acupuncture treatment.

Poster 140 The Effect of Comprehensive Non-surgical Treatments in Patients with Spondylolytic Spondylolisthesis

Case Description: The patient, a 74-year-old right hand dominant woman, presented for evaluation of left wrist pain and dorsal hand numbness. 3 months prior, she had been treated for left shoulder pain by an acupuncturist. During the treatment, a needle was placed subcutaneously in the anatomic snuff box of her left wrist (corresponding to the acupuncture point Yang Xi/Large Intestine 5). She immediately experienced intense pain, and the needle was removed. Since that time, the patient noted intermittent paresthesias and shooting pain along the dorsal left wrist and hand. She presented to an orthopedic hand surgery clinic, where x-rays of the wrist revealed no acute abnormalities and no retained foreign bodies. The patient was prescribed hand therapy, a wrist brace, and gabapentin; all provided minimal relief. She was then referred for electrodiagnostic testing. On the day of electrodiagnostic evaluation, physical examination of the patient was remarkable for allodynia along the radial aspect of the dorsum of the left wrist. Nerve conduction studies revealed absent left radial superficial sensory nerve action potential at the thumb and reduced left superficial sensory nerve action potential at the wrist. Corresponding evoked potentials on the right side were normal. Needle EMG examination of the left upper limb and cervical paraspinals was normal. Setting: Academic Medical Center Electrodiagnostic Laboratory. Results or Clinical Course: Electrophysiologic testing demonstrated evidence of a left superficial radial sensory neuropathy. The acute onset of neuropathic symptoms in a corresponding distribution during acupuncture treatment suggests iatrogenic superficial radial nerve injury. Discussion: There have been rare case reports of iatrogenic peripheral nerve injury from acupuncture. To our knowledge, this is the first reported case of injury to the superficial radial nerve. Physiatrists performing or prescribing acupuncture for pain management should be aware of this possible complication. Particular care should be taken when employing acupuncture points in close proximity to peripheral nerves. Conclusion: Iatrogenic nerve injury is a potential complication of acupuncture treatment.

Cervical myelopathy due to single level disc herniation presenting as intramedullary mass lesion: What to do first?

Cervical myelopathy (CM) is mostly a degenerative process ending in myelopathic and/or radiculopathic syndromes. On T2-weighted magnetic resonance imaging (MRI), CM appears as a hyperintense area near the spondylotic spine. This high intensity signal depends on the impact of outer forces and their duration. It also determines the prognosis of the surgical candidate. A 40-year-old male patient admitted to our clinic with right upper extremity weakness and hypoesthesia that had started 2 months earlier. On neurological examination there was 2/5 motor weakness of right biceps brachii, and hypoesthesia over right C6 dermatome. Right upper extremity deep tendon reflexes were hypoactive, but lower ones were hyperactive. After clinical and radiological work-up, preliminary diagnosis was directed to a spinal intramedullary tumor. Total resection of the herniated cervical disc fragment and the mass lesion was managed. Pathology of the mass lesion was compatible with subacute infarct tissue and inflammatory response. Final diagnosis was CM under effect of cervical disc herniation. Contrast-enhanced spinal cord myelopathic lesions are very rare and resemble much more tumors and inflammatory processes. However, the principal treatment approach totally differs depending on pathology. When there are both a disc herniation and a high clinical suspicion; biopsy should be delayed. The most probable solution will be surgery for the disc disease with thorough preoperative scanning of vascular malformations; clinical and radiological close follow-up after surgery. Biopsy or surgical resection can be performed if patient deteriorates despite the primary surgery.

Locally Aggressive De Novo Spinal Fibromatosis: Case Report and Review of the Literature.

Fibromatosis is a benign lesion, which originates from proliferating fibroblasts. Although fibromatosis is a benign tumor, it is locally aggressive and invasive. Spinal presentation of fibromatosis is very rare, and case reports are the only source of the clinical knowledge. Herein, we describe the oldest patient having spinal fibromatosis with de novo occurrence and aggressive nature. A 68-year-old female patient admitted to our outpatient clinic with low back pain and neurological claudication. On lumbar spine magnetic resonance imaging, she had spinal canal stenosis with a concomitant lesion in the left longissimus muscle. We did our best to resect the tumor, entirely. The pathology result was consistent with spindle cell lesion. The lesion recurred 6 months after the primary surgery. In the second surgery, we did en bloc resection. Pathology and immunohistochemical analysis results were consistent with fibromatosis. After the second surgery, she had adjuvant radiotherapy. There was nothing other than radionecrosis in the operation site, still after 2 years. In conclusion, radiological work-up is usually insufficient to make fibromatosis diagnosis and whole pathological specimen should be carefully evaluated to achieve the accurate diagnosis. Spinal fibromatosis is very rare and its treatment methods have not universally been conceptualized. However, adjuvant therapies are necessary after en bloc resection.