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Inadvertent intrathecal vincristine administration: a neurosurgical emergency

Case report

Maher Qweider, Joachim M. Gilsbach, and Veit Rohde

✓ Vincristine has a high neurotoxicity level. If given intrathecally by accident, it can cause ascending radiculomyeloencephalopathy, which is almost always fatal. The authors report a rare case in which vincristine was accidentally injected intrathecally into a 32-year-old man. The patient, who had Burkitt lymphoma, was neurologically intact, and it is likely that his survival was made possible due to aggressive neurosurgical therapy. After immediate cerebrospinal fluid (CSF) aspiration, external ventricular and lumbar drains were placed for CSF irrigation, which was continued for 6 days. This CSF irrigation was combined with 1) the intrathecal administration of fresh-frozen plasma to bind the vincristine and 2) an intravenous antineurotoxic therapy involving pyridoxine, folic acid, and glutamic acid. The patient's first sensorimotor deficits occurred after 2 days, led to an incomplete sensorimotor dysfunction below T-9 within the next 17 days, but progressed no further. Supported by the scarce data culled from the reviewed literature, the authors hypothesize that prolonged CSF irrigation combined with antineurotoxic therapy contributed to the patient's satisfactory outcome. In conclusion, accidental intrathecal vincristine injection requires emergency and adequate neurosurgical therapy.

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Paraplegia after contrast media application: a transient or devastating rare complication? Case report

Dorothee Mielke, Kai Kallenberg, Marius Hartmann, and Veit Rohde

The authors report the case of a 76-year-old man with a spinal dural arteriovenous fistula. The patient suffered from sudden repeated reversible paraplegia after spinal digital subtraction angiography as well as CT angiography. Neurotoxicity of contrast media (CM) is the most probable cause for this repeated short-lasting paraplegia.

Intolerance to toxicity of CM to the vulnerable spinal cord is rare, and probably depends on the individual patient. This phenomenon is transient and can occur after both intraarterial and intravenous CM application.

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Functional outcome after surgical treatment of spontaneous and nonspontaneous spinal subdural hematomas

Ruth Thiex, Armin Thron, Joachim M. Gilsbach, and Veit Rohde

Object. Because of the rarity of spinal subdural hematomas (SDHs), the literature offers scarce estimates of the outcome and predictive factors in patients suffering from these lesions. In addition, single-institution surgical series are still lacking. Therefore, the authors retrospectively evaluated the early and long-term functional outcomes measured in eight patients with spontaneous and nonspontaneous spinal SDHs in whom the clot had been evacuated.

Methods. The patients' charts were evaluated for origin of the lesion, risk factors, and neurological deficits at symptom onset and at 28 days after extirpation of the spinal SDH. Long-term clinical outcome (Barthel Index [BI]) was evaluated by administering a telephone questionnaire to the patient or a relative.

Only one patient with a spontaneous spinal SDH was identified. Four patients were undergoing anticoagulant therapy, and three patients had undergone a previous anesthetic/diagnostic spinal procedure. Twenty-eight days postoperatively, neurological deficits improved in six of eight patients; however, in two of the six patients, the improvement did not allow the patients to become independent again. In two patients, surgery did not affect the complete sensorimotor deficits. In the long-term survivors (median 45 months) a median BI of 55 was achieved. The latency between symptom onset and surgery did not correlate with functional outcome in this series. The preoperative neurological condition and location of the hematoma correlated positively with early and long-term functional outcome.

Conclusions. To the best of their knowledge, the present study is the largest single-institutional study of patients with surgically treated spinal SDHs. Despite some postoperative improvement of sensorimotor deficits in most patients, the prognosis is poor because 50% of the patients remain dependent. Their outcome was determined by the preoperative sensorimotor function and spinal level of the spinal SDH.

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Intraosseous ultrasonography to determine the accuracy of drill hole positioning prior to the placement of pedicle screws: an experimental study

Laboratory investigation

Sven Rainer Kantelhardt, Jörg Larsen, Volker Bockermann, Wolfgang Schillinger, Alf Giese, and Veit Rohde

Object

Dorsal fixation with rods and pedicle screws (PSs) is the most frequently used surgery to correct traumatic and degenerative instabilities of the human spine. Prior to screw placement, screw holes are drilled along the vertebral pedicles. Despite the use of a variety of techniques, misplacement of screw holes, and consequently of the PSs, is a common problem. The authors investigated the usefulness of an intraspinal, intraosseous ultrasonography technique to determine the accuracy of drill hole positioning.

Methods

An endovascular ultrasound transducer was used for the intraluminal scanning of bore holes in trabecular bovine bone, 12 pedicle drill holes in cadaveric human spine, and 4 pedicle drill holes in a patient undergoing thoracic spondylodesis. Seven of the experimental bore holes in the cadaveric spine were placed optimally (that is, inside the pedicle) and 5 were placed suboptimally (breaching the medial or lateral cortical surface of the pedicle). Computed tomography scans were obtained in the patient and cadaveric specimen after the procedure.

Results

The image quality achieved in examinations of native bovine bone tissue, the formalin-fixed human spine specimen, and human vertebrae in vivo was equal. The authors endosonographically identified correct intrapedicular and intravertebral positions as well as poor (cortex breached) placement of drill holes.

Conclusions

Intraosseous ultrasonography is a promising technique for the investigation of PS holes prior to screw implantation, and may add to the safety of PS placement.

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Spinal dural arteriovenous fistula associated with a spinal perimedullary fistula

Case report

Timo Krings, Volker A. Coenen, Martin Weinzierl, Marcus H. T. Reinges, Michael Mull, Armin Thron, and Veit Rohde

✓ Among spinal cord vascular malformations, dural arteriovenous fistulas (DAVFs) must be distinguished from intradural malformations. The concurrence of both is extremely rare. The authors report the case of a 35-year-old man who suffered from progressive myelopathy and who harbored both a DAVF and an intradural perimedullary fistula. During surgery, both fistulas were identified, confirmed, and subsequently obliterated. The fistulas were located at two levels directly adjacent to each other. Although the incidence of concurrent spinal DAVFs is presumed to be approximately 2%, the combination of a dural and an intradural fistula is exceedingly rare; only two other cases have been reported in the literature. One can speculate whether the alteration in venous drainage caused by the (presumably congenital) perimedullary fistula could possibly promote the production of a second dural fistula due to elevated pressure with concomitant venous stagnation and subsequent thrombosis. The authors conclude that despite the rarity of dual pathological entities, the clinician should be aware of the possibility of the concurrence of more than one spinal fistula in the same patient.

Open access

Lumbar dynamic pedicle-based stabilization versus fusion in degenerative disease: a multicenter, double-blind, prospective, randomized controlled trial

Bernhard Meyer, Claudius Thomé, Peter Vajkoczy, Victoria Kehl, Richard Dodel, Florian Ringel, and for the DYNORFUSE Study Group

OBJECTIVE

Fusion is the standard of treatment for degenerative lumbar symptomatic instabilities. Dynamic stabilization is a potential alternative, with the aim of reducing pathological motion. Potential advantages are a reduction of surgical complexity and morbidity. The aim of this study was to assess whether dynamic stabilization is associated with a higher degree of functional improvement while reducing surgical complexity and thereby surgical duration and perioperative complications in comparison with lumbar fusion.

METHODS

This was a multicenter, double-blind, prospective, randomized, 2-arm superiority trial. Patients with symptomatic mono- or bisegmental lumbar degenerative disease with or without stenosis and instability were randomized 1:1 to instrumented fusion or pedicle-based dynamic stabilization. Patients underwent either rigid internal fixation and interbody fusion or pedicle-based dynamic stabilization. The primary endpoint was the Oswestry Disability Index (ODI) score, and secondary endpoints were pain, health-related quality of life, and patient satisfaction at 24 months.

RESULTS

Of 293 patients randomized to fusion or dynamic stabilization, 269 were available for analysis. The duration of surgery was significantly shorter for dynamic stabilization versus fusion, and the blood loss was significantly less for dynamic stabilization (380 ml vs 506 ml). Assessment of primary and secondary outcome parameters revealed no significant differences between groups. There were no differences in the incidence of adverse events.

CONCLUSIONS

Dynamic pedicle-based stabilization can achieve similar clinical outcome as fusion in the treatment of lumbar degenerative instabilities. Secondary failures are not different between groups. However, dynamic stabilization is less complex than fusion and is a feasible alternative.