Martin B. Camins

Cervical Epidural Hematoma after Chiropractic Manipulation in a Healthy Young Woman: Case Report

OBJECTIVE AND IMPORTANCEnPosttraumatic spinal epidural hematoma is an uncommon entity. We present the first report of spinal epidural hematoma occurring after chiropractic manipulation in a healthy young adult without preexisting cervical disease or any obvious predisposing factors.nnnCLINICAL PRESENTATIONnThe patient presented with radicular and myelopathic symptoms that developed 15 minutes after chiropractic manipulation. Computed tomography and magnetic resonance imaging were performed. They revealed a cervical epidural hematoma.nnnINTERVENTIONnThe hematoma was evacuated, and all of the patients neurological symptoms improved over the course of the next 3 days.nnnCONCLUSIONnAlthough cervical spinal epidural hematoma is a rare clinical entity, it must be considered in patients with pain or neurological deficit after cervical trauma.

Increased incidence of cage migration and nonunion in instrumented transforaminal lumbar interbody fusion with bioabsorbable cages: Clinical article

OBJECTnRecent advances in the field of spinal implants have led to the development of the bioabsorbable interbody cage. Although much has been written about their advantageous characteristics, little has been reported regarding complications associated with these cages. The authors conducted this prospective cohort study to compare fusion and complication rates in patients undergoing transforaminal lumbar interbody fusion (TLIF) with carbon fiber cages versus biodegradable cages made from 70/30 poly(l-lactide-co-d,l-lactide) (PLDLA).nnnMETHODSnBetween January 2005 and May 2006, 81 patients with various degenerative and/or structural pathologies affecting the lumbar spine underwent single- or multilevel TLIF with posterior segmental pedicle screw fixation using implants made of carbon fiber (37 patients) or 70/30 PLDLA (44 patients). Clinical and radiological follow-up was performed at 6 weeks, 3 months, 6 months, and 1 year, and is ongoing. The incidence of nonunion, screw breakage, and cage migration were compared between the 2 groups.nnnRESULTSnThere was no significant difference in demographic data between the 2 groups, the mean number of lumbar levels operated, or distribution of the levels operated. There was a significantly increased incidence of nonunion (8 patients, 18.2%) and cage migrations (8 patients, 18.2%) in patients receiving the PLDLA implants compared with carbon fiber implants (no patients) (p = 0.006 and 0.007, respectively). There was no significant difference in demographic data between patients with cage migration and the rest of the patient population. Five of the 8 cases of migration occurred at the L5-S1 level while the remaining 3 occurred at the L4-5 level. The mean time to implant failure was 9.3 months.nnnCONCLUSIONSnThis study showed an increased incidence of nonunion (18.2%) and postsurgical cage migration (18.2%) in patients undergoing TLIF with biodegradable cages versus carbon fiber implants (0%) (p = 0.006 and 0.007, respectively).

Acute respiratory failure from Surgifoam expansion after anterior cervical surgery

A 65-year-old woman underwent an uneventful C3-4 anterior cervical discectomy and fusion for a large, symptomatic disc herniation. On postoperative Day 1 the patient suffered a sudden, acute respiratory compromise. Emergency fiberoptic intubation revealed significant anterior neck swelling with concern for physical obstruction of the airway. Computed tomography of the neck did not demonstrate an expanding hematoma. The patient was managed with surgical wound exploration and washout. Examination of the anterior neck after incision of the prior surgical site revealed a large volume of Surgifoam under high pressure, which was greater than the amount used during the initial surgery. Thorough washout of the surgical site did not reveal any swelling of the prevertebral soft tissues or hematoma, and the Hemovac drain did not appear to be occluded. The patient was extubated on the 2nd postoperative day and is symptom free 12 months after surgery. To the authors knowledge, this report represents the first reported complication of acute respiratory failure from Surgifoam overexpansion after anterior cervical surgery.

Primary Dural Leiomyosarcoma in a Patient Infected with Human Immunodeficiency Virus

INTRODUCTION: We report the magnetic resonance imaging, angiographic, and immunohistochemical characteristics of a dural leiomyosarcoma in a patient infected with human immunodeficiency virus. METHODS AND RESULTS: A 38-year-old homosexual man presented with a recent history of headaches. Magnetic resonance imaging of the brain revealed an enhancing dural based right lateral wing mass that was thought to be a meningioma. The tumor had a signal intensity similar to the adjacent gray matter on T1-, T2-, and proton-weighted images. Angiography revealed that the tumor was vascular, supplied by the middle meningeal artery, but with contrast puddling as if there were small vascular lakes within the tumor. This evoked the possibility of a cavernous hemangioma. A craniotomy was performed, and the mass was resected. The pathological finding was consistent with a leiomyosarcoma. Immunohistochemistry revealed that the tumor was positive for alpha smooth muscle actin. Repeat testing for human immunodeficiency virus 2 months postoperatively was positive. Dural leiomyosarcomas are thought to take origin from the smooth muscles of the blood vessel walls. Another possible source is pluripotential mesenchymal cells. There may be an association with immunosuppression. CONCLUSION: Primary dural leiomyosarcomas simulate meningiomas on preoperative magnetic resonance images. They should be included in the differential diagnosis of dural based enhancing lesions.