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Open access

Microvascular decompression of a vertebral artery loop causing cervical radiculopathy: illustrative case

Alexa Semonche, Lorenzo Rinaldo, Young Lee, Todd Dubnicoff, Harlan Matles, Dean Chou, Adib Abla, and Edward F Chang

BACKGROUND

Vertebral artery loops are a rare cause of cervical radiculopathy. Surgical options for nerve root decompression include an anterior or posterior approach, with or without additional microvascular decompression.

OBSERVATIONS

The authors describe a case of a 49-year-old man with a long-standing history of left-sided neck pain and migraines, who was found to have a vertebral artery loop in the left C3–4 neural foramen compressing the left C4 nerve root. The patient underwent a posterior cervical decompression with instrumented fusion and macrovascular decompression of the left C4 nerve root via Teflon felt insertion. In a literature review, we identified 20 similar cases that had also been managed surgically.

LESSONS

Although the anterior approach is more frequently described in the literature, a posterior approach for nerve compression by a vertebral artery loop is also a safe and effective treatment. The authors report the third case of this surgical approach with a good outcome.

Open access

“Winged” Eagle’s syndrome: neurophysiological findings in a rare cause of spinal accessory nerve palsy. Illustrative cases

Eric C Mitchell, Kitty Y Wu, Fawaz Siddiqi, John Yoo, Pavlo Ohorodnyk, Douglas Ross, and Thomas A Miller

BACKGROUND

Eagle’s syndrome (ES) classically describes dysphagia, globus sensation, and otalgia from an elongated and calcified styloid process or stylohyoid ligament. Compression of the spinal accessory nerve (SAN) has not been reported as an associated feature of ES or related variants.

OBSERVATIONS

The authors describe two cases of an atypical “winged” variant with SAN palsy resulting from compression by a posteriorly angulated or calcified styloid process. Both patients exhibited lateral scapular winging and atrophy of the trapezius and sternocleidomastoid muscles. Electrophysiological studies demonstrated motor unit preservation; therefore, surgical exploration, styloidectomy, and SAN decompression were performed through a transcervical approach. Postoperatively, both patients had improvements in pain and shoulder mobility, the return of muscle strength, and electrophysiological evidence of trapezius reinnervation.

LESSONS

Compression of the SAN, which can be identified both clinically and on electrodiagnostic testing, is an atypical finding that can result from a posteriorly angulated or calcified styloid process. This winged variant of ES should be included in the differential for SAN palsy, and a multidisciplinary approach is recommended for assessment and management.

Open access

Blood pressure cuff–induced radial nerve palsy following minimally invasive lateral microdiscectomy: illustrative case

Ziad Rifi, Jasmine A Thum, Margaret S Sten, Timothy J Florence, and Michael J Dorsi

BACKGROUND

The authors describe a rare case of transient postoperative wrist and finger drop following a prone position minimally invasive surgery (MIS) lateral microdiscectomy.

OBSERVATIONS

Hand and wrist drop is an unusual complication following spine surgery, especially in prone positioning. The authors’ multidisciplinary team assessed a patient with this complication following MIS lateral microdiscectomy. The broad differential diagnosis included radial nerve palsy, C7 radiculopathy, stroke, and spinal cord injury. Given the patient’s supinator weakness, intact pronation and wrist flexion, and transient recovery within 4 weeks, the most likely diagnosis was radial nerve neuropraxia secondary to ischemic compression. After careful consideration of the operative environment and anatomical constraints, the patient’s blood pressure cuff was found to be the most probable source of compression.

LESSONS

Blood pressure cuff–induced peripheral nerve injury may be a source of postoperative radial nerve neuropraxia in patients undergoing spine surgery. Careful considerations must be given to the blood pressure cuff location, which should not be placed at the distal end of the humerus due to higher susceptibility of peripheral nerve compression. Spine surgeons should be aware of and appropriately localize postoperative deficits along the neuroaxis, including central versus proximal or distal peripheral injuries, in order to guide appropriate postoperative management.

Open access

Pedicle subtraction metallectomy with complex posterior reconstruction for fixed cervicothoracic kyphosis: illustrative case

Harman Chopra, José Manuel Orenday-Barraza, Alexander E. Braley, Alfredo Guiroy, Olivia E. Gilbert, and Michael A. Galgano

BACKGROUND

Iatrogenic cervical deformity is a devastating complication that can result from a well-intended operation but a poor understanding of the individual biomechanics of a patient’s spine. Patient factors, such as bone fragility, high T1 slope, and undiagnosed myopathies often play a role in perpetuating a deformity despite an otherwise successful surgery. This imbalance can lead to significant morbidity and a decreased quality of life.

OBSERVATIONS

A 55-year-old male presented to the authors’ clinic with a chin-to-chest deformity and cervical myelopathy. He previously had an anterior C2–T2 fixation and a posterior C1–T6 instrumented fusion. He subsequently developed screw pullout at multiple levels, so the original surgeon removed all of the posterior hardware. The T1 cage (original corpectomy) severely subsided into the body of T2, generating an angular kyphosis that eventually developed a rigid osseous circumferential union at the cervicothoracic junction with severe cord compression. An anterior approach was not feasible; therefore, a 3-column osteotomy/fusion in the upper thoracic spine was planned whereby 1 of the T2 screws would need to be removed from a posterior approach for the reduction to take place.

LESSONS

This case highlights the devastating effect of a hardware complication leading to a fixed cervical spine deformity and the complex decision making involved to safely correct the challenging deformity and restore function.

Open access

Delayed myelopathy after remote C1–2 sublaminar wire fixation: illustrative case

Aaron Miller, David A. Paul, Prasanth Romiyo, and Jonathan J. Stone

BACKGROUND

Atlantoaxial sublaminar wiring complications, both early and delayed, have been documented. However, delayed neurological compromise 27 years after successful fusion is a rare but possible occurrence.

OBSERVATIONS

A 76-year-old male, who had undergone C1–2 sublaminar wire fusion for atlantoaxial instability in 1995, presented with symptoms of progressive right arm weakness, falls, and incontinence of bowel and bladder over a 1-week period. Initial imaging workup revealed bowing of the C1–2 sublaminar wires resulting in cervical spinal cord compression and T2-weighted signal changes. A C1–2 laminectomy was performed to remove the wires and decompress the spinal cord with improvement in the patient’s neurological status.

LESSONS

This rare case highlights the potential for delayed cervical myelopathy and cord compression from sublaminar wires, even after a successful fusion. In patients with a history of sublaminar wiring who experience new neurological deficits, it is essential to evaluate the hardware for migration.

Open access

Etiology of spastic foot drop among 16 patients undergoing electrodiagnostic studies: patient series

Lisa B. E. Shields, Vasudeva G. Iyer, Yi Ping Zhang, and Christopher B. Shields

BACKGROUND

Differentiating foot drop due to upper motor neuron (UMN) lesions from that due to lower motor neuron lesions is crucial to avoid unnecessary surgery or surgery at the wrong location. Electrodiagnostic (EDX) studies are useful in evaluating patients with spastic foot drop (SFD).

OBSERVATIONS

Among 16 patients with SFD, the cause was cervical myelopathy in 5 patients (31%), cerebrovascular accident in 3 (18%), hereditary spastic paraplegia in 2 (12%), multiple sclerosis in 2 (12%), chronic cerebral small vessel disease in 2 (12%), intracranial meningioma in 1 (6%), and diffuse brain injury in 1 (6%). Twelve patients (75%) had weakness of a single leg, whereas 2 others (12%) had bilateral weakness. Eleven patients (69%) had difficulty walking. The deep tendon reflexes of the legs were hyperactive in 15 patients (94%), with an extensor plantar response in 9 patients (56%). Twelve patients (75%) had normal motor and sensory conduction, 11 of whom had no denervation changes of the legs.

LESSONS

This study is intended to raise awareness among surgeons about the clinical features of SFD. EDX studies are valuable in ruling out peripheral causes of foot drop, which encourages diagnostic investigation into a UMN source for the foot drop.

Open access

Extraoral anterior approach for the treatment of os odontoideum: illustrative case

Jacob M. Farrar, Mackenzie Grasso, and Rick J. Placide

BACKGROUND

Os odontoideum is typically treated with instrumented fusion through a posterior cervical approach. When this approach fails, limited options for revision are available. Occipitocervical fusion and transoral anterior fusions have been utilized in the past but are associated with high morbidity and complications.

OBSERVATIONS

Here the authors report a case of os odontoideum that was treated with an anterior cervical extraoral approach after failed posterior instrumented fusion. They discuss the challenges that can be encountered with the failure of fusion and the limited options when it comes to approach and fixation of os odontoideum.

LESSONS

To the authors’ knowledge and based on a review of the literature, this case represents the first use of an anterior extraoral prevascular approach to the high cervical spine to address os odontoideum. They demonstrate that this approach can be utilized as a reasonable alternative to transoral surgery and should be considered in cases where additional or alternative fixation is desired without the morbidity and complications associated with occipitocervical fusion or a transoral approach, especially in a younger patient population.

Open access

Rare case of extracranial chordoid meningioma adjacent to the carotid sheath: illustrative case

Seung W. Jeong, Michael Moran, Shahed Elhamdani, Dorian M. Kusyk, Chen Xu, Kymberly Gyure, and Richard Williamson

BACKGROUND

Chordoid meningioma is a rare World Health Organization (WHO) grade 2 variant of meningioma with histological features resembling those of a chordoma. This tumor type is known for having an aggressive clinical course with a propensity for local recurrence. Most cases occur within the cranium, more specifically around the cerebral convexities. Although extracranial meningiomas of various subtypes have been documented, extracranial meningioma with a chordoid subtype is an extremely rare entity.

OBSERVATIONS

The authors herein report the case of a 51-year-old female who presented with a chief complaint of dysphagia and was found to have a neck mass abutting the carotid sheath. The patient underwent resection and final pathology results revealed a WHO grade 2 chordoid meningioma.

LESSONS

This case report demonstrates an atypical case of an extracranial chordoid meningioma adjacent to the carotid sheath. To the authors’ knowledge, this is the first reported case of a chordoid meningioma occurring within the soft tissue of the neck.

Open access

En bloc resection of a high cervical chordoma followed by reconstruction with a free vascularized fibular graft: illustrative case

Zachariah W. Pinter, Eric J. Moore, Peter S. Rose, Ahmad N. Nassr, and Bradford L. Currier

BACKGROUND

Wide excision of chordoma provides better local control than intralesional resection or definitive radiotherapy. The en bloc excision of high cervical chordomas is a challenging endeavor because of the complex anatomy of this region and limited reconstructive options.

OBSERVATIONS

This is the first case report to describe reconstruction with a free vascularized fibular graft following the en bloc excision of a chordoma involving C1–3.

LESSONS

This report demonstrates the durability of this construct at 10-year follow-up and is the first case report demonstrating satisfactory long-term oncological outcomes after a true margin-negative resection of a high cervical chordoma.

Open access

Traumatic cervical spine subarachnoid hemorrhage with hematoma and cord compression presenting as Brown-Séqüard syndrome: illustrative case

Bernardo de Andrada Pereira, Benjamen M. Meyer, Angelica Alvarez Reyes, Jose Manuel Orenday-Barraza, Leonardo B. Brasiliense, and R. John Hurlbert

BACKGROUND

Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related.

OBSERVATIONS

A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review.

LESSONS

Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.