Late complication of surgically treated atlantoaxial instability: occipital bone erosion induced by protruded fixed titanium rod: a case report

OBJECTIVE

Polyaxial screw-rod fixation of C1-C2 is a relatively new technique to treat atlantoaxial instability, and there have been few reports in the literature outlining all possible complications. The purpose of this case report is to present the occurrence and management of occipital bone erosion induced by the protruded rostral part of a posterior atlantoaxial screw-rod construct causing headache.

CLINICAL FEATURES

A 70-year-old Asian man with rheumatoid arthritis initially presented to our institution with atlantoaxial instability causing progressive quadraparesis and neck pain.

INTERVENTION AND OUTCOME

Posterior atlantoaxial instrumented fixation using C1 lateral mass screws in conjunction with C2 pedicle screws was performed to stabilize these segments. Postoperatively, the patient regained the ability to independently walk and had no radiographic evidence of instrumentation hardware failure and excellent sagittal alignment. However, despite a well-stabilized fusion, the patient began to complain of headache during neck extension. Follow-up imaging studies revealed left occipital bone erosion induced by a protruded titanium rod fixed with setscrews. During revision surgery, the rod protrusion was modified and the headaches diminished.

CONCLUSION

This case demonstrates that occipital bone erosion after posterior atlantoaxial fixation causing headache may occur. The principal cause of bone erosion in this case was rod protrusion. Although posterior atlantoaxial fixation using the screw-rod system was selected to manage atlantoaxial instability because it has less complications than other procedures, surgeons should pay attention that the length of the rod protrusion should not exceed 2 mm.

Radical excision combined with instrumented fixation in the management of thoracic epidural angiolipoma: a case report

Introduction

Spinal angiolipoma is a benign uncommon neoplasm composed of mature lipocytes admixed with abnormal blood vessels. They account for only 0.04% to 1.2% of all spinal tumors. We present a case of thoracic epidural angiolipoma treated by combining radical resection with instrumented spinal fixation, without any surgical complication.

Case presentation

A 32-year-old Asian woman presented with dorsal epidural angiolipoma at the upper-thoracic level. She had a seven-month history of gradually worsening weakness and numbness in her lower extremities. Imaging studies of her thoracic spine demonstrated a heterogeneously well-enhancing mass, located in her posterior epidural space without surrounding bone erosion at the upper thoracic level. We also observed compression of her thoracic cord. During surgery, a reddish-gray, highly vascularized mass was excised. Her facet joints had to be resected to expose the part migrating into the intervertebral foramen. Because there was concern regarding the stability of her thoracic spine, we performed spinal fixation using pedicle screws. Histopathological study of the surgical specimen showed a typical angiolipoma.

Conclusion

Angiolipomas can be radically excised with good prognosis. Surgical removal is the preferred treatment for spinal angiolipoma, and the prognosis after surgical management is very good. Although outcomes remained favorable despite incomplete resections in a number of spinal angiolipoma, complete removal is preferred. We successfully achieved total resection without any surgical complication by combining radical resection with instrumented spinal fixation.

[Advanced breast cancer with multiple bone metastases successfully treated with combined chemoendocrine-therapy of CEF (cyclophosphamide, epirubicin, 5-fluorouracil) and 5'-DFUR (5'-deoxy-5-fluorouridine) + MPA (medroxyprogesterone acetate)--a case report]

We report the case of a 51-year-old female with stage IV advanced breast cancer accompanied by multiple bone metastases. A hard mass of about 3.0 cm in diameter was palpated just below the nipple. An excisional biopsy was performed and histological examination revealed infiltrated solid tubular adenocarcinoma. There were no estrogen or progesterone receptors in the tumor. Modified radical mastectomy was performed in October, 1998. Postoperative adjuvant therapy with 10 cycles of CEF therapy was undertaken for one year. Combined chemoendocrine therapy with 5'-DFUR and MPA was also conducted for 11 months. Bone scintigraphy showed that all bone metastatic lesions disappeared completely one year after the operation. Mild bone marrow suppression, alopecia and body weight gain were observed as side effects. It is suggested that this combination therapy may be useful for advanced breast cancer patients with multiple bone metastases.

Analysis of DNA-ploidy using laser scanning cytometer in brain tumors and its clinical application

There have been few reports on investigation of the cell kinetics of brain tumors using a laser scanning cytometer (LSC). We compared DNA analysis using a flow cytometer (FCM) with that by LSC using established cell lines of brain tumors, and we demonstrated the similarity of both analytical results. The DNA-index (DI) and proliferating index (PI) of various brain tumors were determined, and the results showed that these indices reflected the malignancy of the tumors. The DI values were higher for astrocytoma grade IV than for astrocytoma grade II, frequently showing an aneuploid pattern. The determination of DNA-ploidy using LSC, together with cryopathological diagnosis, was considered to be useful for deciding the area to be resected for glioma perioperatively and to be worth applying clinically.

[The changes of peripheral skin temperature in elderly patients under spinal anesthesia]

The purpose of this study was to evaluate the changes of body temperature in elderly compared with younger patients during spinal anesthesia. Twenty six patients, ASA I-II were divided into two groups, (13; under 30 years of age, 13; above 60 years) who received spinal anesthesia with 0.3% dibucaine at the interspace between L 3 and L 4. All patients were anesthetized below T 8 level. Central temperature was measured at the forehead, and peripheral skin temperature was measured at the finger tip and the toe tip for 25 minutes at every 5 minutes. In both groups, forehead temperature and finger tip skin temperature were unchanged, but toe tip skin temperature increased 5 minutes after spinal anesthesia. The degree of toe tip skin temperature change was significantly lower (P < 0.01) in elderly patients and the speed was also slower. We recognized that the change in peripheral skin temperature during spinal anesthesia is not different between elderly and younger patients, but the speed of temperature change is slower in elderly patients.

Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap

A combination of split latissimus dorsi musculocutaneous flap with the serratus anterior musculo-osseous flap was used to cover a very large defect of the scalp. This technique offers a new alternative for single-stage reconstruction of extensive scalp defects.

[Cyclin protein expression on malignant glioma cells]

Cyclins are key components of the cell cycle progression machinery. Immunohistochemical detection of cyclins in relation to cell position, DNA content, by multiparameter flow cytometry has provided new cell cycle studies. T98G, U373MG, and U251MG were scheduled expression of cyclin A, B1 which are maximal in late S and G2M phase cells. T98G was scheduled expression of cyclin E. being maximal in G1 and S phase cells, but U251MG, U373MG were unscheduled expression of cyclin E. The expression of cyclin D1 were not expressed a pattern. These result may mean that cyclin E in an important protein of cell cycle machinery of malignant brain tumor.

[Importance of instructing anesthesiologists in handwashing against bacterial contamination]

The importance of handwashing in preventing the spread of nosocomial infection has been stressed. Using a modified glove juice method, we have already shown the efficacy of washing of anesthesiologists' hands with alcohol based antiseptic solutions against bacterial contamination. The efficacy of handwashing, however, varied because many anesthesiologists washed only the palm and the back. In the present study, we instructed them to wash their hands using rubbing method, from finger tip to the wrist until drying the solutions completely. We compared the efficacy of handwashing, by decrease of bacteria counts after general anesthesia, between the instructed method and the customary way which was done ordinarily in the ward. The instructed method was more effective on the decrease of bacteria counts than the customary way. In the instructed method, the efficacy of handwashing was not different between the antiseptic solutions. In conclusion, doctors not only should practice handwashing with the antiseptic solutions after each contact with the patient, but also wash their hands from the finger tip to the wrist until they become completely dry.

[Bacterial contamination of anesthesiologists' hands and the efficacy of handwashing]

The purpose of this study was to examine bacterial contamination, especially by transient skin flora, that were on the hands of trainee and diplomate anesthesiologists during general anesthesia as well as to evaluate the efficacy of washing hands with running water or with three alcohol based antiseptic solutions using a modified glove juice method. The bacterial counts on the anesthesiologists' hands were 3.21 +/- 0.66 [log10 (mean +/- SD)] during induction, 255 +/- 1.15 during maintenance of anesthesia, 2.67 +/- 1.10 during extubation and 3.57 +/- 0.74 at the end of anesthesia. The diplomates' hands were more contaminated than those of the trainees during both intubation and extubation. Washing hands with running water or antiseptic solutions was effective to reduce bacterial contamination, but there was no disinfectant effect of antiseptic solutions against the bacteria that adhered to the hands after drying those solutions. Therefore to prevent nosocomial infection, anesthesiologists should wash their hands with running water or the antiseptic solution after each contact.

[A patient with Cornelia de Lange syndrome with difficulty in orotracheal intubation]

We experienced a difficult orotracheal intubation in a patient with Cornelia de Lange syndrome. The patient was an eight-year-old girl with Cornelia de Lange syndrome, cleft palate and tetralogy of Fallot who underwent emergency hemicolectomy for strangulation ileus. Orotracheal intubation using a Macintosh laryngoscope was unsuccessful. However, intubation using an endotracheal tube through the laryngeal mask airway with a fiberoptic bronchoscope was successful. The patient's condition was stable during both intubation and operation. In conclusion, we must be careful on endotracheal intubation of patients with congenital anomalies.

[Difficult adult airway and endotracheal intubation]

In 1984, Cormack and Lehane defined laryngoscopic view in four grades. As the view worsens, the difficulty of intubation may increase but it is not clear. In this study, we examined the endotracheal intubation techniques to the grade III or IV airways. Some 48 patients were determined as grade III and IV. In 26 patients the conventional endotracheal intubation technique (conventional technique) was selected. In 20 patients endotracheal intubation was performed over the gum-elastic bougie (bougie technique). In two patients laryngeal mask airway, fiberoptic bronchoscope and handmade flexible guide tube were used as aids to endotracheal intubation (guide technique). Nineteen patients with conventional technique and 6 patients with bougie technique required the external laryngeal pressure. In conclusion, the grade III or IV airways were not always difficult to intubate. But when the conventional technique failed, the gum-elastic bougie or laryngeal mask airway was a fairly useful aid to endotracheal intubation. Moreover our handmade flexible guide tube made the intubation through the laryngeal mask airway safe and reliable.