Manipulation under epidural anesthesia with corticosteroid injection: two case reports

OBJECTIVE: To discuss the combined use of selective epidural steroid injection (ESI) and spinal manipulative therapy (SMT) in treating recalcitrant lumbar radiculopathy. CLINICAL FEATURES: In a first case, a patient suffered from numbness and pain in an S1 dermatome distribution 6 months after undergoing lumbar discectomy. Clinical correlation with advanced imaging led to the diagnosis of L5 intervertebral disc (IVD) syndrome with peridural scar formation. In a second case, a patient suffered from low-back and right-leg pain of 9 months' duration. Various forms of conservative treatment were not effective. A diagnosis of L4 IVD syndrome with radiculopathy was made. INTERVENTION AND OUTCOME: The first patient received conventional treatments, including physical therapy, SMT, fluoroscopically guided ESI and oral medications, with consistent but short-lived response. A team consisting of an anesthesiologist (dedicated spinal injectionist) and chiropractor performed manipulation under epidural anesthesia (MUEA) with corticosteroid injection. Follow-up at 60 days showed marked improvement in visual analogue scale, pain drawing and Oswestry pain and disability index. The second patient received all of the same conventional care except ESI before the combined procedure. The patient underwent MUEA, followed up with eight sessions of stretching and manipulation over the ensuing 3 wk. At 45 days after the combined procedure, the patient had a negative SLR (previously positive at 70 degrees), no leg pain and a marked reduction in back pain. CONCLUSION: This article discusses an integrated procedure that combines two standard treatments that may act synergistically. Our positive results are consistent with other reports, both published and anecdotal. The technique of MUEA warrants further investigation by the health care industry.     

Spontaneous spinal epidural hematoma with spinal cord compression complicating plasma cell myeloma. A case report

STUDY DESIGN: A case is reported in which a patient had acute paraplegia with sensory loss caused by a spontaneous epidural hematoma that was ascribed to bleeding of pre-existing myeloma lesions of the thoracic vertebrae. OBJECTIVES: To highlight the causes of secondary epidural hematomas with special attention to pre-existing vertebral or epidural lesions. SUMMARY OF BACKGROUND DATA: There are no apparent previous reports of epidural spinal hematomas ascribed to underlying malignant diseases. Benign dysplasia, such as hemangioma or Paget's disease, has been implicated in a few cases. METHODS: A case of spontaneous dorsal epidural hematoma is reported in a patient followed up for plasma cell myeloma with osteolytic lesions in the lower thoracic spine. There was no history of major trauma or coagulation disorders. Complete loss of motor and sensory function in both lower limbs was noted, with sphincter dysfunction. Magnetic resonance imaging of the thoracic spine showed a large posterolateral epidural hematoma responsible for spinal cord compression. RESULTS: The patient failed to improve despite surgical decompression within 6 hours of symptom onset. He died 13 days later of refractory bacterial pneumonia. A large epidural hematoma adjacent to myelomatous lesions of the thoracic vertebrae was found at autopsy. CONCLUSIONS: This is the first reported case of spontaneous epidural hematoma ascribed to underlying malignant disease, with confirmation of the diagnosis by postmortem examination. Possible mechanisms include tumor-related epidural inflammation and fragility of epidural venous plexuses.     

Visceral aneurysms. Two case reports

The authors report two case stories of visceral aneurysm: a 54 year-old man presenting recurrent gastrointestinal bleeding caused by a splenic artery aneurysm, and a 57 year-old man presenting with acute abdomen due to rupture of a hepatic artery aneurysm. Visceral aneurysms often present with classical gastrointestinal symptoms. They are connected with considerable mortality. Rupture requires instant surgery. In the elective phase the literature recommends embolization or resection.     

Leiomyomatosis peritonealis disseminata. Two case reports

AIM: To study the action of quercetin (Que) on inhibiting platelet aggregation. METHODS: Active oxygen free radicals produced by xanthine/xanthine oxidase (Xan/XO) reaction was used, platelet aggregation was determined by the turbidimetric method, and the Xan/XO oxyradicals generating reaction by luminol-dependent chemiluminescence (Che) method. RESULTS: Active oxygen free radicals enhanced the platelet aggregation induced by ADP 1.6 mumol.L-1. The rate of maximal aggregation increased from 29%-38% for ADP to 59%-70% for ADP + Xan/XO. The enhancement was abolished by the treatment of platelet-rich plasma (PRP) with Que 650 mumol.L-1 or hydrocortisone (Hyd) 900 mg.L-1. Both Que and Hyd scavenged the active oxyradicals in vitro. The Che was decreased by 75.7% (Que 4 mumol.L-1) and 79.0% (Hyd 900 mg.L-1) as compared with control. CONCLUSION: Active oxygen free radicals participated in the platelet aggregation, and scavenging oxyradicals by Que was one of mechanisms of inhibiting platelet aggregation.     

Polyarthralgia disclosing hyperthyroidism. Two case reports

BACKGROUND: We report two cases of rheumatism associated with hyperthyroidism. In both cases, arthralgia totally regressed after thyroid treatment. CASE REPORTS: Two 79-year-old and 59-year-old women developed manifestations of polymyalgia rheumatica and psoriasis arthritis respectively. Corticosteroid therapy was ineffective and followed by manifestations of hyperthyroidism. The first patient was treated with carbimazole and the second with thyroidectomy. Once the hyperthyroidism was controlled, both patients experienced a dramatically rapid cure of their arthralgias. DISCUSSION: Scalpulo-humeral periarthritis is the main articular complication of hyperthyroidism. True manifestations of "thyrotoxicosis rheumatism" are unusual and may be linked with a direct toxicity of the thyroid hormones on joint cartilage or with an autoimmune manifestation of hyperthyroidism.     

Misdiagnosis of asthma. Two paradigmatic case reports

We present two children, respectively five and six years old, misdiagnosed and treated as asthmatics in allergological centers. After admission to our department, endobronchial inflammatory pseudotumor and lung tuberculosis were diagnosed respectively. While endobronchial pseudotumor is rather rare, lung tuberculosis is a less rare diagnosis that must be considered in patients with a history of persistent and recurrent coughing with or without wheezing, especially when there is no family history of atopical diseases and skin allergic tests are negative, and the social and economic conditions at risk.     

Cervical spinal cord compression caused by ossification of the posterior vertebral ligament. Apropos of a case

In eight Japanese patients, three different laparoscopic procedures were used to excise an early gastric carcinoma; partial resection in four, intragastric resection of the gastric mucosa in two, and laparoscopic-assisted distal partial gastrectomy with the abdominal wall-elevating method in two patients. Histological examinations revealed that the lesions were completely resected, and there was no evidence of lymphatic metastasis. The operation time ranged from 2 to 4 h. These forms of laparoscopic gastric surgery for patients with early gastric carcinomas may be useful from the standpoint of minimal access, rapid recovery, less pain, and good cosmesis.     

Spontaneous thoracic spinal cord herniation. A case report

STUDY DESIGN: This is a case report. OBJECTIVE: To focus attention on spontaneous spinal cord herniation as a rare cause of myelopathy that can be diagnosed preoperatively and can be corrected surgically. SUMMARY OF BACKGROUND DATA: A 34-year-old woman presented with spastic paraparesis. Magnetic resonance imaging scan of the thoracic spine revealed anterior displacement and tethering of the cord at T6-T7 and a dorsal intradural arachnoid cyst. Excision of the cyst was performed without improvement in symptomatology. During reoperation the thoracic spinal cord hernia was discovered and was reduced intradurally. METHODS: The authors describe the clinical, radiographic, and surgical findings of this patient and review the findings from other reported cases. They discuss the proposed theories for the pathophysiology of the cord herniation and the surgical management. RESULTS: The patient had idiopathic thoracic spinal cord herniation as there was no history of previous spine surgery or injury. The authors believe that the cord herniated through a congenital dural defect, which resulted in the development of a pseudoarachnoid cyst dorsally to the hernia. The patient improved after intradural reduction of the hernia and closure of the dural defect. CONCLUSION: Idiopathic spinal cord herniation should be recognized as a cause of progressive myelopathy that can be managed successfully with microsurgical techniques.     

Cervical spinal cord compression in hereditary multiple exostoses. Report of a case and a review of the literature

Spinal cord compression is an extremely serious complication of hereditary multiple exostoses (HME). A case of HME with compression of the cervical spinal cord is reported. Complete recovery following surgery was achieved. A review of the relevant literature revealed 51 previous cases of HME with cord/cauda equina compression. Most patients were under 30 years of age with more men affected than women. The family history was positive in 60%. The cervical and thoracic areas were predominantly affected, with the symptoms usually developing slowly. Recovery following surgery is to be expected in the majority of cases. In patients with HME and suffering from neurological symptoms, the possibility of spinal cord compression should be considered. Prompt diagnosis and surgical excision provide the best prognosis.     

Solitary plasmacytoma in the thoracic spine. Two case reports

Where a leptomeningeal carcinomatosis is clinically diagnosed, evidence should be provided of tumor cells in the CSF. Not necessarily in the first specimen, but in the course of the illness. The staining of the cells with the Pappenheim method generally provides sufficient information about the cells. The identification of cells in metastases of epithelial tumours is not difficult for anyone with some experience. Identifying cells from primary brain tumours - which however only rarely cause meningosis - can sometimes be more difficult. Attention should be paid to whether the cells occur in clusters or singly. However, extreme caution is called for. The cytological monitoring of the CSF is an essential part of chemotherapy or radiation treatment.     

Prenatal management of fetal cardiac tumors. Two case reports

Although primary cardiac tumors are extremely rare, their prenatal and neonatal management is very important because fetal arrhythmia is a frequent complication and such tumors may be the only manifestation of tuberous sclerosis. We present 2 cases of fetal cardiac tumor in which cardiac function was assessed by color Doppler ultrasonography. In both cases, there was no evidence of tuberous sclerosis or cardiac failure and tumor regression was noted 8 months after birth. Ultrasonographic examination of fetal cardiac function was useful in the management of these tumors.     

In vivo desensitization of nyctophobia: Two case reports.

A 21-yr-old male and a 13-yr-old female underwent treatment involving a gradual increase of the walking distance and the time spent in the dark in the continuous presence of the therapist, repetition of the previous phase with the exception that the therapist was present only intermittently, an attention shifting procedure, and self practice. Falling asleep in the dark required a separate treatment. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A case of systemic lupus erythematosus associated with spinal epidural hematoma

A 47 year-old Japanese female who showed transverse myelopathy (TM) due to spinal epidural hematoma diagnosed by MRI in the course of systemic lupus erythematosus (SLE) was reported. She was admitted to Keio University Hospital due to paraplegia, anesthesia of lower extremity, urinary disturbance. Neurological examination revealed transverse disturbance of Th 10. Lumbar spinal cord MRI showed irregular mass that located at epidural region of 9th-11th thoracic vertebrae. When the laminectomy of 9th-11th thoracic vertebrae was performed, hematoma (4.5 cm x 1.5 cm in size) was confirmed and removed completely. Post operative condition was stable and symptoms had been improving gradually. It has been reported that TM associated with SLE was closely related to myelitis. In this case, epidural hematoma was a major cause of TM and MRI was very useful for her diagnosis and treatment. This is the rare case of SLE associated with spinal epidural hematoma and was thought as a important case to consider the cause of neurological complication of SLE.     

Reconstruction of chest wall after full-thickness resection. Two case reports

Full-thickness reconstruction to repair defects in the chest wall was performed with a new method, using Marlex mesh, artificial bones and musculocutaneous flap. The artificial bones were constructed from ceramic iliac crest spacers connected by wires and methyl methacrylate. The advantage of the method is that the artificial bone can be created in various lengths and curves, tailored for the individual defect.     

Chondronecrosis of the cricoid cartilage after intubation. Two case reports

Chondronecrosis of the cricoid cartilage is a rare complication of intubation. The records of two children were reviewed. An 8-month-old girl with myelomonocytic leukaemia developed chondronecrosis 10 days after a 2-day period of ventilation. A 4-year-old girl comatose after poisoning by the histamine antagonist, alimemazine, developed chondronecrosis after a 2-day period of intubation. The complication was suspected when extubation led to dyspnoea owing to laryngeal stridor and was confirmed by direct laryngoscopy. We review the development of the condition, the causative factors, treatment and prevention.     

A case of idiopathic spinal cord herniation

The authors experienced a case of idiopathic spinal cord herniation with duplicated dura mater. A 63-year-old woman presented right dominant slowly progressive spastic paraplegia and dissociated sensory disturbance. Magnetic resonance imaging (MRI) demonstrated an enlarged dorsal arachnoid space associated with an apparently focally narrowed thoracic cord. The cord was kinked towards the anterior and closely applied to vertebral body at the level of Th3-4. Computed tomographic myelography (CTM) revealed homogeneous filling at dorsal arachnoid space immediately after injection and no defects. At operation multilocular arachnoid cyst and duplicated dura mater was respectively observed dorsally, and ventrally. From defected area of the inner layer, a ventral part of the spinal cord was incarcerated between the two dural layers. After rejection of arachnoid cyst and inner layer was performed, the patient recovered neurologically. Idiopathic spinal cord herniation is a rare disease that shows slowly progressive myelopathy at middle age. The herniations were observed at ventral thoracic cord in all reported cases. The mechanism of this disease is still uncertain. But at least three successive factors seem to be necessary for formation of herniation, 1) abnormal structure of the dura mater such as defect, diverticulum and duplication; 2) adhesion between the cord and the destructive dura mater, and 3) continuous cerebrospinal fluid (CSF) pressure pushing the cord outward from subdural space. In the thoracic spine, mobility is limited compared with the cervical and lumbar spine, and because of physiological curvature the cord situates rather ventrally. For these reasons the incidence of adhesion might be higher at ventral thoracic spine. Although neuroradiological imagings especially MRI and CTM were useful, operative findings were necessary for definitive diagnosis in many reported cases. Considering the effectiveness of surgical treatment, study of the ventral side of the cord should be important to avoid misdiagnosis.     

Permanent paraplegia following epidural and general anesthesia: two case reports

Two strains of rats, Sprague-Dawley and Wistar, were assayed in order to determine which strain is the more suitable experimental model for the study of pharmacokinetic alterations induced by spinal cord injury. Animals were submitted to spinal cord contusion at the T8-T9 level by the weight drop method. A single acetaminophen oral dose (100 mg/ kg) was administered 24 h after injury and blood samples were drawn for a period of 4 h. Acetaminophen concentration in whole blood was determined by high performance liquid chromatography and pharmacokinetic parameters were estimated. For both strains, Cmax and AUC were significantly lower, whereas tmax remained unchanged, in injured animals compared to sham-injured controls. Circulating acetaminophen concentrations were higher; therefore, pharmacokinetic alterations were more easily discerned, in Sprague-Dawley than in Wistar rats. It is concluded that the Sprague-Dawley strain is a more suitable model for the study of pharmacokinetic alterations induced by spinal cord injury.     

Multiple epidural metastases and development of secondary metastatic spinal cord compression]

The purpose was to examine the frequency of initial multiple epidural metastases, and the occurrence of secondary spinal cord compression (SCC). One hundred and seven patients with SCC from a histologically verified solid tumour were followed prospectively with regular neurological examinations until death. Multiple metastases were demonstrated in 37 (35%). Eight (7.5%) patients developed a second occurrence of SCC all in a new location within the spinal canal. The second occurrence of SCC was found with the same frequency in patients with single metastases (7.1%) compared to patients with multiple metastases (8.1%). The median survival time after the diagnosis of spinal cord compression was 3.4 months, while in the group of patients who developed a second occurrence of SCC the median survival time was 9.2 months. We concluded that only symptomatic epidural metastases should be irradiated, and that all patients treated for SCC should be followed regularly and observed for development of a second SCC.     

Post-traumatic epidural and subdural hematomas of the spinal cord in MR imaging

Diagnostics of epi- and subdural haematomas of the spinal cord is discussed on the basis of 1992 records of Konstancin Rehabilitation Center. Fifty-four patients with symptoms of partial or complete cord injury were submitted to MR imaging. In four cases (7.5 per cent) epi- or subdural haematoma was found to contribute to neurological condition of the patient. MRI determines indications for surgical intervention.