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Pseudo-aneurysm of a lumbar artery after flexion-distraction injury of the thoraco-lumbar spine and surgical realignment: rupture treated by endovascular embolization
No full textA unique case of pseudo-aneurysm of a lumbar artery after injury of the thoracolumbar spine was presented. 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.
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.
Endovascular embolization achieved resolution of the pseudo-aneurysm, regression of the hematoma and progressive recovery of the patient during a period of 6 months.
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
Microsurgical approach for the treatment of juxtafacet synovial cysts of the lumbar spine.
No full textSurgical management of coronal and sagittal imbalance of the spine without PSO: a multicentric cohort study on compensated adult degenerative deformities
No full textPurpose 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
thoracolumbar and lumbar kyphoscoliosis by a non posterior
subtraction osteotomy technique.
Methods We operated 22 painful thoracolumbar and lumbar
compensated degenerative deformities by anterior
(ALIF), extreme lateral (XLIF) and transforaminal (TLIF)
interbody fusion and grade 2 osteotomy (SPO) to restore
lumbar lordosis and mobilize the coronal curve. Two-stage
surgery, first anterior and after 2 or 3 weeks posterior, was
proposed when the Oswestry Disability Index (ODI) was
equal to or greater than 50% and VAS more than 5. All
patients were submitted to X-ray and clinical screening
during pre, post-operative and follow-up periods.
Results We performed 5 ALIFs, 39 XLIFs, 8 TLIFs, 32
SPOs. No major complications were recorded and complication
rate was 18% after lateral fusion and 22.7% after
posterior approach. Pelvic tilt, lumbar lordosis, sagittal
vertical axis and thoracic kyphosis improved (p\0.05).
Clinical follow-up (mean 20.5; range 18–24) was
satisfactory in all cases, except for two due to sacroiliac
pain. Mean preoperative VAS was 7.7 (range 6–10), while
ODI was 67% on average (range 50–78). After two-stage
surgery, VAS and ODI decreased, respectively, to 2.4 (range
2–4) and 31% (range 25–45), while their values were 4
(range 2-6) and 35% (range 20–55) at the final follow-up.
Conclusion Current follow-up does not allow definitive
conclusions. However, the surgical approach adopted in
this study seems promising, improving balance and clinical
condition of adult patients with a compensated sagittal
degenerative imbalance of the thoracolumbar spine
Thoraco-lumbar fractures with blunt traumatic aortic injury in adult patients. correlations and management
No full textPurpose: Traumatic thoraco-lumbar spine fracture spine with a concomitant blunt aortic injury is uncommon but potentially a fatal association. Our aim was to clarify: morphology of spinal fractures related to vascular damages and vice versa, diagnostic procedures and decision-making process for the best treatment options for spine and vessels. Methods: We enrolled 42 cases culled from the literature and five personal ones, reviewing in detail by AO Spine Classification, Society of Vascular Surgery classification and Abbreviated Injury Scale for neurological evaluation. Results: Most fractures were at T11–L2 (29 cases; 62%) and type C (17; 70%). 17 (38%) were neurological. Most common vascular damage was the rupture (20; 43%), followed by intimal tear (13; 28%) and pseudoaneurysm (9; 19%). Vascular injury often required open or endovascular repair before spinal fixation. Distraction developed aortic intimal damage until rupture, while flexion–distraction lumbar artery pseudoaneurysm and rotation–torsion full laceration of collateral branches. CT and angio-CT were investigations of choice, followed by angiography. Neurological condition remained unchanged in 28 cases (90%). Overall mortality was 30%, but it was higher in AIS A. Conclusion: Relationship between thoraco-lumbar fracture and vascular lesion is rare, but potentially fatal. Comprehension of spinal biomechanics and vascular damages could be crucial to avoid poor results or decrease mortality. Frequently, traction of the aorta and its vessels is realized by C-dislocated fractures. CT and angio-CT are recommended. Spine stabilization should always follow the vascular repair. Early severe deficits worse the prognosis related to neurological recovery and survival. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material
Neurological L5 burst fracture: posterior decompression and lordotic fixation as treatment of choice.
No full textPurpose: We report our experience and literature review concerning surgical treatment of neurological burst fractures of the fifth lumbar vertebra. Materials and methods: Nineteen patients with L5 neurological burst fractures were consecutively enrolled; 6 patients had complete motor deficits, and 12 had sphincter dysfunction. We performed 18 posterior and one combined approaches. To avoid kyphosis, posterior internal fixation was achieved by positioning patients on the operating table with hips and knees fully extended. At the latest follow-up (mean 22 months, range 10-66), neurological recovery, canal remodeling and L4-S1 angle were evaluated. Results: Vertebral body replacement was difficult, which therefore resulted in an oblique position of the cage. Vertebral bodies still remained deformed, even though fixation allowed for an acceptable profile (22°, range 20-35). We observed three cases of paralysis, five complete, and three incomplete recoveries. In the remaining eight patients, sphincter impairment was the only finding. In 15 patients, pain was absent or occasional; in four individuals, it was continuous but not invalidating. Remodeling was visible by X-ray and/or CT, without significant secondary stenosis. Conclusions: The L5 burst fractures are rare and mostly due to axial compression. Cauda and/or nerve root injuries are absolute indications for surgery. If an anterior approach is technically difficult, laminectomy can allow for decompression, and it can be easily combined with transpedicular screw fixation. Posterior instrumented fusion, also performed with the aim to restore sagittal profile, when associated with an accurate spinal canal exploration and decompression, may be looked at as an optimal treatment for neurological L5 burst fractures. © Springer-Verlag 2012
Conservative treatment of neural arch fractures of the axis: computed tomography scan and x-ray study on consolidation time
No full textComputed tomography (CT) scan and X-ray study on consolidation time of C2 neural arch fractures treated conservatively were examined. 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. 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 (isohypodense) 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%)
Functional anatomy and biomechanics of the cervical spine
No full textThe head-neck system consists of seven cervical vertebrae and has a unique anatomy and motion to accommodate the needs of a highly mobile head-torso transitory zone. From a kinematical point of view, this system is very complex. Normally, the spine mainly functions as a coupled unit, and neck kinematics can be analyzed by studying head movement relative to the upper body. Cervical motion in every plane is checked by anatomic restraints that protect the spinal cord and accompanying vascular structures. The head can be regarded as a platform that houses the sensory apparatus for hearing, vision, smell, taste: the cervical spine constitutes a device that support this sensory platform, moving and orientating it in the three-dimensional space . Any disturbance of anatomy and mechanical properties can lead to clinical symptoms. Also age- related changes can modifi ed cervical anatomy and alignment, drastically reducing range of motio
Lumbar hemorrhagic synovial cysts: diagnosis, pathogenesis, and treatment. Report of 3 cases
No full textTo define the etiologic, clinical, histological, and surgical features of lumbar hemorrhagic synovial cysts (LHSCs). Three personal cases are reported together with a review of the pertinent literature. We identified 3 cases of LHSC treated in our departments and 20 cases culled from the literature. A total of 23 cases of LHSC were selected. All the patients underwent surgical treatment because of untreatable radicular pain and/or neurological deficits. The amount of bleeding, either massive or minor but repeated, influenced the timing of surgery. In our cases, the histological examinations showed an inflammatory reaction within the cyst and the consequent formation of neoangiogenic vessels. Hemorrhagic synovial cyst of the spine is rare and its most common localization is lumbar. Bleeding within the cyst leads to an increase of its volume, accompanied by neurological deficits and/or painful symptoms that are violent and generally intractable
Spinal subarachnoid hematomas: our experience and literature review
No full textSpinal subarachnoid hematomas are unusual and difficult to diagnose and the outcome of treatment is influenced by the lesions that frequently accompany them. To clarify the neuroradiological diagnostic aspects of spinal subarachnoid hematoma as well as the results of treatment. Only recently has subarachnoid hematoma been clearly distinguished from more common subarachnoid hemorrhage and its characteristics have still not been dealt with in detail. METHODS: A total of 69 cases (3 personal case, 66 published cases) were revised in terms of etiology, diagnostic imaging and the results of both surgical and conservative treatment. The most common causes of spinal subarachnoid hematoma are coagulopathies (either pharmacologically-induced or resulting from systemic diseases) (40.5%), lumbar puncture for diagnostic or anesthesiological purposes (44.9%) and traumatic injuries (15.9%): these factors may be present singly or variously combined. They may be spontaneous (17.3%) or, in rare cases, associated with aortic coarctation or degenerative vascular diseases. Overall mortality is 25.7%. In the 50 cases in whom long-term follow-up was possible, the outcome of treatment, which is almost exclusively always surgical, was good in 93.5% of 31 patients in whom neurological status on admission was satisfactory and in 15.8% of 19 cases with severe neurological deficits
Spinal arachnoiditis ossificans: Report of three cases
No full textAlthough 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. 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. 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
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