The spine journal : official journal of the North American Spine Society
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Acquired hyperpneumatization of the skull base and upper cervical vertebrae is extremely rare and is thought to occur in patients who habitually perform the Valsalva maneuver or engage in repetitive positive pressure activities such as scuba diving or free diving. Craniocervical hyperpneumatization has been reported to cause intracranial and extracranial pneumatoceles but is not generally considered as a cause of pneumorrhachis (air in the spinal canal). Pneumorrhachis is relatively rare, and usually occurs in a localized form, either in the cervical spine secondary to skull base fractures or in the thoracic spine secondary to pneumomediastinum or pneumothorax. Here, we report a case of extensive pneumorrhachis extending from the skull base to the thoracolumbar junction in association with marked axio-atlanto-occipital hyperpneumatization and pneumomediastinum. This unique constellation of findings likely resulted from complications of the Valsalva maneuver during strenuous exercise. ⋯ Craniocervical hyperpneumatization is a rare complication of the Valsalva maneuver. Most reported cases have involved only the skull base, or the skull base and C1, and many have been further complicated by microfractures leading to pneumocephalus or extracranial pneumatoceles. We present a unique case of extensive craniocervical hyperpneumatization that extended to the level of C2 and was complicated by microfractures causing severe pneumorrhachis. Concurrent pneumomediastinum in this case may have been an independent complication of the Valsalva maneuver, which could have contributed to pneumorrhachis. Alternatively, pneumomediastinum may have been caused by migration of gas through the neural foramen from the epidural space, driven by positive pressure generated by the one-way valve effect of the Eustachian tube during periods of exertion.
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The management of postoperative spinal wound complication remains a challenge, with surgical site infection (SSI) incidence rates ranging from 0.4% to 20% after spinal surgery. Negative pressure wound therapy (NPWT) has been highlighted as an intervention that may stimulate healing and prevent SSI. However, the wound healing mechanism by NPWT and its effectiveness in spinal wounds still remain unclear. ⋯ Published reports are limited to small retrospective and case studies, with no reports of NPWT being used as a prophylactic treatment. Larger prospective RCTs of NPWT are needed to support the current evidence that it is effective in treating spinal wound complications. In addition, future studies should investigate its use as a prophylactic treatment to prevent infection and report data relating to safety and health economics.
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Review Case Reports
Primary cervical amyloidoma: a case report and review of the literature.
Primary solitary amyloidosis or amyloidoma is a disease process characterized by the focal deposition of amyloid in the absence of a plasma cell dyscrasia with normal serum protein measurements. Solitary amyloidomas affecting the vertebrae are very uncommon but typically affect the thoracic spine. Primary cervical amyloidosis is an exceedingly rare entity with exceptionally good prognosis, but requires diligence of the treating physician to establish the diagnosis and implement the appropriate surgical intervention. ⋯ Primary solitary amyloidosis is a rare form of amyloidosis that is important to differentiate given its excellent prognosis with surgical management. Treatment should include surgical decompression and spinal stabilization. This is the first case report to clinically and radiographically demonstrate the progressive resorption of a primary amyloidoma over time after surgical stabilization in the upper cervical spine. It is imperative that surgeons encountering such lesions maintain a high suspicion for this rare disease entity and advise their pathologists accordingly to establish the correct diagnosis.
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In the instrumented fusion, adjacent segment facet joint violation or impingement by pedicle screws is unavoidable especially in cephalad segment, despite taking specific intraoperative precautions in terms of surgical approach. In such circumstances, unlike its original purpose, unilateral pedicle screw instrumentation can contribute to reduce the degeneration of cephalad adjacent segment by preventing contralateral cephalad adjacent facet joint from the unavoidable injury by pedicle screw insertion. However, to our knowledge, no long-term follow-up study has compared adjacent segment degeneration (ASD) between unilateral and bilateral pedicle screw instrumented fusion. ⋯ In a minimum 10-year follow-up retrospective study of posterolateral fusion for lumbar spinal stenosis and/or Grade 1 spondylolisthesis, unilateral pedicle screw instrumentation showed a lower rate of radiologic ASD, especially in second cephalad adjacent segment, and a better clinical outcome by ODI.
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Recombinant human bone morphogenetic protein-2 (rhBMP-2) (INFUSE, Medtronic, Memphis, TN, USA) has been used off-label for posterolateral lumbar fusions for many years. ⋯ rhBMP-2 utilization for posterolateral lumbar fusions has a low symptomatic nonunion rate. Prior rhBMP-2 exposure and male sex were related to symptomatic nonunion formation. rhBMP-2-associated neural compression acutely with seroma formation and delayed with foraminal bone formation is concerning and associated with higher rhBMP-2 concentrations.