Spinal epidural hematoma caused by pseudogout: a case report and literature review

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis

Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.

Lumbar Extradural Pseudogout Mass Manifesting as Radiculopathy: A Case Report

BACKGROUND

Calcium pyrophosphate dihydrate (CPPD) disease, also known as pyrophosphate arthropathy or pseudogout, is defined as CPPD deposition within the articular cartilage. It was first described in 1962. The representative locations where CPPD disease occurs include the most common knee joint, followed by the wrist joint. Joint swelling and pain are the most common clinical presentations, and the typical differential diagnosis is degenerative arthritis. Microscopically, the specimen demonstrates numerous positively birefringent rhomboid shaped crystals when examined under polarized light.

CASE REPORT

We present a 70-year-old female with right painful sciatica accompanied by coexisting affected limb soreness and clumsiness. Her final diagnosis was unusual lumbar extradural tumoral pseudogout that was worth noticing. Tumoral CPPD deposition was excised after laminectomy. Subsequently, her symptoms were abated postoperatively without a need for more analgesics. Her neurological function was properly recovered.

CONCLUSION

This is a rare report to proffer pseudogout in an unfamiliar lumbar extradural location, which is an unexpected diagnosis. Making a precise tentative diagnosis for the ongoing disease entity might be difficult for the clinicians because the clinical manifestations of this pathology are similar to those of other common degenerative lumbar spinal diseases.

The Role of Calcium Pyrophosphate Dihydrate Deposition in the Postoperative Outcome of Lumbar Spinal Stenosis Patients

Study Design

Retrospective study.

Purpose

This study aimed to investigate the association of surgical intervention with clinical and quality of life (QoL) outcomes in patients who underwent posterior spinal surgery for lumbar spinal stenosis (LSS) with spinal calcium pyrophosphate dihydrate deposition (SCPPD) versus that in those who underwent the surgery for LSS without SCPPD.

Overview of Literature

Calcium pyrophosphate (CPP)-associated arthritis is one of the most common types of arthritis. The clinical outcomes are well studied in CPP-associated arthritis of the appendicular joints. However, few studies have investigated SCPPD.

Methods

A single-institution database was reviewed. LSS patients were categorized as those who did and did not have SCPPD, based on histologic identification. Clinical presentations and postoperative results were analyzed. Disability and QoL were assessed using the Oswestry Disability Index (ODI) and the 36-item Short-Form Health Survey.

Results

Thirty-four patients were enrolled, with 18 patients being allocated to the SCPPD group and 16 being allocated to the non- SCPPD group. Preoperative and postoperative pain scores were not significantly different between the groups (p=0.33 and p=0.48, respectively). The average preoperative ODI score in the SCPPD group was slightly higher than that in the non-SCPPD group (57 vs. 51, p=0.33); however, the postoperative ODI score was significantly lower (15 vs. 43, p=0.01). The postoperative physical function, vitality, and mental health of the SCPPD patients were also significantly improved (p=0.03, p=0.022, and p=0.022, respectively).

Conclusions

Surgical intervention resulted in good clinical outcomes in SCPPD patients. As per our findings, total removal of CPPinvolved tissue is unnecessary. As such, surgery should be performed as indicated according to clinical presentation without considering the presence of CPPD.

Spinal epidural hematomas: personal experience and literature review of more than 1000 cases

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patient's clinical and neurological status at admission, age, and the craniocaudal site.

The classification of recurrent spinal epidural hematoma: a review of the literature and a comparison with the cases

Symptomatic postoperative spinal epidural hematoma (SEH) and spontaneous spinal epidural hematoma (SSEH) are both rare conditions, and recurrent SEH occurs even less frequently. Therefore, we describe a case of symptomatic postoperative SEH after surgical evacuation of SSEH, which was diagnosed using magnetic resonance imaging (MRI) and managed with negative pressure wound therapy (NPWT). The authors classified the reported recurrent SEHs into two types based on the cause of their previous hematoma, which can be classified as spontaneous or postoperative. The characteristics, diagnosis, managements, and results of recurrent SEHs were analyzed. The authors suggest that the postoperative SEH in the Type II will be treated with NPWT, and the new classification will be helpful for prognosis, diagnosis, and management of the recurrent SEHs.