Background: A 58-year-old female with a history of L2-5 fusion at an outside institution presented with 9 months of mechanical back pain, inability to achieve upright posture, subjective lower extremity weakness, and pain when ambulating. Imaging demonstrated proximal junctional failure (PJF) with resulting sagittal and coronal plane defects secondary to the formation of an L1/2 vertebral pseudoarticulation.
Case description: Surgery was undertaken to revise and extend the previous construct from T10-ilium. After subperiosteal exposure and pedicle screw replacement, left L5 laminectomy and L5-S1 total lumbar interbody fusion were performed to maximize lumbosacral lordosis. An L1/2 revision laminectomy was performed, and the disc space was distracted with laminar spreaders to reduce the pseudoarticulation. Deformity correction was finally achieved with a 4-rod construct and placement of a proximal tether to prevent recurrence of proximal junctional kyphosis (PJK). The patient recovered well initially, with maintained alignment at 6-month follow-up. At 7 months, multiple falls precipitated the development of PJK, necessitating rostral extension of the construct. Further falls led to unilateral rod fracture and loosening of pelvic pedicle screws. Another revision was performed, replacing the rod and upsizing the pelvic screws, achieving a favorable structural outcome.
Conclusion: Pathology of the uppermost instrumented vertebra is a recognized complication of spinal fusion. It can manifest as PJK or progress to PJF, in which kyphosis is accompanied by structural or instrument failure with symptoms requiring surgical revision. Presentation is variable, and reoperation requires an individualized approach. This case demonstrates the challenges inherent to adult spinal deformity surgery.
Background: Infective endocarditis (IE) could cause cerebral infarction through septic embolization, presenting challenges in both diagnosis and treatment. Because intravenous thrombolysis is contraindicated in suspected IE-related stroke, careful evaluation of cerebral perfusion and infarct extent is crucial for selecting appropriate therapy.
Case description: A 45-year-old woman was admitted to the emergency department with fever and disturbance of consciousness. Imaging revealed a cerebral infarction due to right internal carotid artery (ICA) occlusion. Echocardiography demonstrated a vegetation on the mitral valve, suggesting IE as the embolic source. As the onset time was unclear and no diffusion-weighted image-fluid-attenuated inversion recovery mismatch was observed, intravenous alteplase was considered inappropriate. Although the neurological deficit was mild, computed tomography perfusion (CTP) imaging showed extensive hypoperfusion in the right ICA-middle cerebral artery territory with a limited infarct core. Mechanical thrombectomy was therefore performed. The procedure was technically challenging, requiring a switch from aspiration thrombectomy to a combined stent retriever technique, ultimately achieving successful recanalization (thrombolysis in cerebral infarction grade 2b). Histopathological examination of the retrieved thrombus revealed fibrin-rich material containing bacterial colonies, and blood cultures were positive for Staphylococcus aureus. Subsequently, the mitral vegetation enlarged, necessitating urgent mitral valve replacement.
Conclusion: This case illustrates the usefulness of CTP imaging in guiding treatment decisions for low National Institutes of Health Stroke Scale large-vessel occlusion associated with IE. It also emphasizes that histopathological examination of retrieved thrombi could provide valuable insights into the underlying infectious etiology and inform subsequent management strategies.
Background: Viscoelastic lumbar total disc replacements (TDRs) can develop periprosthetic osteolysis likely attributable to wear debris and micromotion at the core-endplate interface. Early recognition and revision are essential to avoid prosthesis explantation. Here, we present two patients with cystic osteolysis following Elastic Spine Pad - Lumbar (ESP-L) viscoelastic lumbar disc arthroplasty.
Methods: Two patients developed symptomatic cystic osteolysis within 5 years of ESP-L implantation documented utilizing multimodal imaging (i.e., radiographs and computed tomography). Revision surgery in two cases was based on cyst morphology and implant stability. Case 1 had a large posterior osteolytic cavity and underwent posterior cortical bone trajectory (CBT) fusion with autologous bone grafting. Case 2, with a contained lesion adjacent to an otherwise stable implant, was treated with targeted percutaneous cement augmentation.
Results: Longitudinal imaging and clinical follow-up showed symptomatic improvement and radiologic stabilization in both patients. In Case 1, the osteolytic cavity fully resolved within 18 postoperative months, whereas Case 2 achieved immediate mechanical reinforcement and sustained pain reduction following cement injection.
Conclusion: Cystic osteolysis is a potential complication of viscoelastic lumbar TDRs. These cases demonstrated that posterior CBT fusion or percutaneous cement augmentation could provide effective symptomatic relief and radiologic stabilization, avoiding the need to remove the prosthesis.
Background: Atypical facial pain (AFP) differs from typical trigeminal neuralgia (TTN) in clinical features and pathophysiology. Internal neurolysis (IN) has been proposed as a treatment for refractory AFP; however, objective intraoperative assessment methods remain limited.
Methods: We retrospectively analyzed 20 consecutive patients with AFP who underwent IN. Intraoperative findings revealed superior cerebellar artery (SCA) compression in five cases, venous compression in four, and no vascular compression in 11. When vascular compression was identified, the vessel was dissected and mobilized before performing IN. For comparison, we reviewed a cohort of patients with TTN and SCA compression who underwent microvascular decompression with arterial transposition. Intraoperative sclerosis was graded (0-6 points) according to appearance, stiffness, and adhesion. Pain severity was evaluated using the Barrow Neurological Institute (BNI) pain score.
Results: A total of 20 patients underwent IN for AFP, including 12 females and eight males, with a mean age of 62.5 years (range, 32-82 years). Postoperatively, 15 patients (75%) achieved BNI I-II, indicating significant pain relief, while 5 patients (25%) achieved BNI III, reflecting moderate residual pain. Median follow-up was 18 months (range, 6-24 months). No major surgical complications were observed. Higher sclerosis scores and moderate-to-severe adhesions were significantly associated with favorable BNI outcomes (P = 0.03).
Conclusion: IN is an effective and safe treatment for refractory AFP, particularly in patients with trigeminal sclerosis. Comparison with patients with TTN highlights distinct pathophysiology and treatment strategies, while SCA transposition is curative in TTN, AFP requires dissection and IN.
Background: Pituitary hyperemia and gland enlargement can be cardinal features of intracranial hypotension secondary to cavernous sinus and epidural venous plexus distention. This phenomenon can therefore complicate radiographic interpretation of sellar lesions when both diagnoses co-exist. We report a unique case of a rapidly enlarging pituitary macroadenoma in the setting of a thoracic cerebrospinal fluid (CSF)-venous fistula causing symptomatic intracranial hypotension.
Case description: A 53-year-old female with no prior neurosurgical history presented with recurrent orthostatic headache. Magnetic resolution imaging revealed a pituitary lesion along with pathopneumonic signs of intracranial hypotension. The tumor grew rapidly on surveillance imaging, prompting consideration of surgery. Further work-up, however, revealed a thoracic CSF-venous fistula. Endovascular embolization of the fistula led to near-complete resolution of her symptoms and durable radiographic tumor regression.
Conclusion: Pituitary macroadenomas are susceptible to local hemodynamic changes occurring as a sequelae of occult CSF leak. Identification and treatment of the underlying etiology were sufficient to induce tumor regression.
Background: In this retrospective study, we analyzed postoperative cervical and lumbar symptoms following cervical laminoplasty (CLP) for degenerative cervical myelopathy (DCM).
Methods: Patients with DCM (2013-2022) were evaluated using the Japanese Orthopedic Association (JOA) score, the back pain evaluation questionnaire (BPEQ), the cervical myelopathy evaluation questionnaire (CMEQ), the neck disability index (NDI), the Oswestry Disability Index (ODI), and the visual analog scale (VAS). Preoperative and postoperative scores were compared at 1 postoperative year.
Results: The study included 155 males and 55 females with an average age of 62.66 years. Patients from both groups demonstrated significant improvement in cervical and lumbar JOAs, BPEQ (ambulation, social life, and mental status), CMEQ (cervical, upper and lower extremities, and quality of life), NDI, ODI, and VAS (neck, shoulder, and upper extremities) using the Wilcoxon signed-rank test.
Conclusion: CLP proved to be an effective treatment for alleviating cervical and lumbar symptoms associated with DCM.
Background: Adjunctive dural sealants such as BioGlue® are widely used to reinforce dural closure in cranial and spinal surgery. While generally effective, BioGlue® has been associated with inflammatory foreign-body reactions that may lead to delayed mass formation and neural compression. These delayed complications can mimic the original pathology. Here, a 66-year-old male underwent primary dural closure that included the use of BioGlue, which, 6 months later, caused the delayed onset of a cauda equina syndrome.
Case description: A 66-year-old male presented with sciatica secondary to focal L4-5 lumbar spinal canal stenosis and an intradural schwannoma at the L3 level. He underwent an L3-L5 laminectomy for resection of the tumor and decompression of the stenosis. At surgery, primary dural closure was reinforced with a muscle graft, combined with the utilization of BioGlue® and Gel-Foam®. Six months later, he developed a partial cauda equina syndrome attributed to an magnetic resonance imaging-documented heterogeneous extradural mass at the prior durotomy site. Surgical re-exploration allowed for resection of a newly occurring granulomatous mass at the prior operative site, comprised largely of residual BioGlue®. Histopathology confirmed that this represented a foreign-body granulomatous reaction to the BioGlue. Postoperatively, the patient demonstrated rapid neurological improvement.
Conclusion: BioGlue®-induced granuloma represents an important delayed complication of spinal dural repair that can closely mimic recurrent pathology (i.e., in this case, stenosis and/or tumor).
Background: Preoperative embolization for intracranial tumors is widely used to minimize intraoperative blood loss; however, it carries the risk of ischemic or cranial nerve complications, particularly in patients with anatomical variants.
Case description: A 47-year-old woman with a history of follicular thyroid carcinoma (FTC) was referred after an intracranial mass was detected on magnetic resonance imaging. The lesion was initially suspected to be a meningioma. However, contrast-enhanced computed tomography showed that the tumor was located lateral to the middle meningeal artery (MMA), suggesting an epidural lesion. Angiography confirmed a strong tumor blush from the MMA, and preoperative embolization was performed. During angiography, a branch of the MMA extending toward the orbit was identified; this branch was coil-occluded before Embosphere injection to prevent inadvertent embolization. The patient developed ipsilateral blindness immediately after the procedure. Subsequent internal carotid angiography revealed an anatomical variant in which the ophthalmic artery (OphA) did not originate from the internal carotid artery (ICA). In this context, retinal ischemia was attributed primarily to coil occlusion of the MMA branch supplying the retinal circulation, with possible exacerbation from subsequent Embosphere injection. The tumor was completely resected through craniotomy, and histopathology confirmed metastasis of FTC. At 5 years postoperatively, there was no evidence of intracranial recurrence, although the visual loss was permanent.
Conclusion: Skull metastasis of FTC is an uncommon clinical entity. This case highlights a serious complication of preoperative embolization due to a vascular variant in which the OphA was absent from the ICA and the central retinal artery originated from the MMA, leading to irreversible blindness. Thorough angiographic evaluation is essential to identify anatomical variants before embolization. When high-risk anatomy is present, alternative strategies should be considered to minimize the risk of ischemic complications.
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