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1/12. Multiple spinal "miliary" hemangioblastomas in von Hippel-Lindau (vHL) disease without cerebellar involvement. A case report and review of the literature.

    We report on a 57-year-old male presenting with radicular pain in the nerve roots of L5 and S1 on the right side and dysuria. magnetic resonance imaging (MRI) of the lumbar spine showed multiple (up to 20) small, intradural enhancing nodules attached to the cauda equina down to the sacrum, the largest 1 cm in diameter at the level Th12/L1 compressing the conus. Additionally, small nodules in the cervico-thoracal region adjacent to the cord, but no cerebellar or cerebral abnormalities, were detected in a consecutive MRI of the remaining neuroaxis. The histology of a resected lesion at Th12/L1 revealed hemangioblastoma of the reticular type. Together with a history of left eye enucleation performed 17 years ago for angiomatosis of the retina and the immunohistochemical detection of von Hippel-Lindau (vHL) protein within the removed spinal hemangioblastoma, a diagnosis of vHL disease was established. family history and screening for visceral manifestations of vHL disease were negative. In contrast to cerebellar or solitary spinal hemangioblastomas, multiple spinal hemangioblastomas without cerebellar involvement in vHL represent unusual manifestations. Unlike the case for solitary lesions in non-syndromic patients, a surgical cure does not seem feasible in this case. The role of treatment modalities is discussed.
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2/12. Complications in the surgical treatment of lumbar stenosis.

    The authors analyze the complications which may occur in the surgical treatment of lumbar stenosis. They report 4 cases of cauda equina syndrome and 8 dural tears in 96 patients aged from 21 to 81 years submitted to multiple bilateral laminectomy. Based on a review of the patients some considerations on surgery for the treatment of lumbar stenosis are discussed. The advanced age of the patients, hypertension, diabetes, vasculopathies in general, severe neurological deficit dating back some time contraindicate surgery. When surgery is indicated a correct preoperative evaluation by MRI from T12 to the sacrum is required to determine the extent of the laminectomy and a safe and accurate intra- and postoperative bleeding control is mandatory. Dural laceration may be repaired by a thoracolumbar fascia patch.
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3/12. osteochondroma of the sacrum: a case report and review of the literature.

    STUDY DESIGN: A case report and review of the literature. OBJECTIVES: To describe the en bloc excision and postoperative outcome of an osteochondroma of the sacrum compressing the neural elements, as well as review the literature on solitary osteochondroma involving the sacrum. SUMMARY OF BACKGROUND DATA: osteochondroma is the most common primary benign bone tumor. However, this tumor rarely involves the spine and even more rarely involves the sacrum. To the best of our knowledge, en bloc excision of a solitary osteochondroma of the sacrum has not been previously reported. methods: An 11-year-old male presented with disabling radicular pain in the right lower extremity. Radiologic studies showed a lesion occurring from the sacral lamina that was compressing the S2 nerve root. The tumor was excised en bloc through a posterior approach. The cavitary defect within the sacrum was reconstructed with crushed cancellous allograft and demineralized bone matrix putty. A literature review of solitary sacral osteochondroma was conducted of the English-based medical literature. RESULTS: Histologic studies showed the tumor to be an osteochondroma. After surgery, pain was completely relieved, and neurologic function was normal. At the last follow-up, the sacroiliac joint remained intact, and there was no evidence of local recurrence. A literature review revealed 4 previous cases addressing osteochondroma of the sacrum. CONCLUSIONS: osteochondroma is a rare primary benign bone tumor that can occur in the sacrum. Local contamination and, therefore, the likelihood of local recurrence, are decreased when an en bloc, as opposed to an intralesional, excision is performed.
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4/12. Piriformis syndrome: a rational approach to management.

    Although rarely recognized, the piriformis syndrome appears to be a common cause of buttock and leg pain as a result of injury to the piriformis muscle. Four cases representing a broad spectrum of presentations are described here. The major findings include buttock tenderness extending from the sacrum to the greater trochanter and piriformis tenderness on rectal or pelvic examination. Symptoms are aggravated by prolonged hip flexion, adduction, and internal rotation, in the absence of low back or hip findings. Minor findings may include leg length discrepancy, weak hip abductors, and pain on resisted hip abduction in the sitting position. Myofascial involvement of related muscles and lumbar facet syndromes may occur concurrently. The diagnosis is primarily clinical as no investigations have proved definitive. The role of MRI of the piriformis muscle is assessed and other investigative tools are discussed. A rational management schema is demonstrated: (1) underlying biomechanical factors and associated conditions should be corrected; (2) the patient is instructed in a home program of prolonged piriformis muscle stretching which may be augmented in physical therapy by preceding ultrasound or Fluori-methane (dichlorodifluoromethane and trichloromonofluoromethane spray); (3) a trial of up to three steroid injections is attempted; and (4) if all these measures fail, consideration should be given to surgical sciatic nerve exploration and piriformis release.
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5/12. cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction.

    Relative stretching of the cauda equina over the posterosuperior border of the sacrum can be found in all patients who have Grade-III or IV spondylolisthesis at the lumbosacral junction. We identified twelve patients, all less than eighteen years old, who had cauda equina syndrome after in situ arthrodesis for Grade-III or IV lumbosacral spondylolisthesis. In all twelve patients, posterolateral arthrodesis had been done bilaterally through a midline or paraspinal muscle-splitting approach. Nothing in the operative reports suggested that the cauda equina had been directly injured during any of the procedures. Five of the twelve patients eventually recovered completely. The remaining seven patients had a permanent residual neurological deficit, manifested by complete or partial inability to control the bowel and bladder. If dysfunction of the root of the sacral nerve is noted preoperatively in a patient who has lumbosacral spondylolisthesis, decompression of the cauda equina concomitant with the arthrodesis should be considered. An acute cauda equina syndrome that follows a seemingly uneventful in situ arthrodesis for spondylolisthesis is best treated by an immediate decompression that includes resection of the posterosuperior rim of the dome of the sacrum and the adjacent intervertebral disc. In addition, posterior insertion of instrumentation and reduction of the lumbosacral spondylolisthesis should be considered.
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6/12. Sacral fracture with compression of cauda equina: surgical treatment.

    Fractures of the sacrum are rare and generally accompany fractures of the pelvis. Isolated transverse sacral fractures are even less frequent, and extensive neurologic deficits may accompany these injuries. This report describes an unusual case of extradural hemorrhage accompanying a complex fracture of the sacrum. The reversal of a serious neurologic deficit was notably aided by sacral laminectomy.
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7/12. Unilateral S-1 root compression syndrome caused by fracture of the sacrum.

    Unilateral S-1 nerve root compression after an S-1 sacral fracture was found in an 18-year-old man after a motor vehicle accident. The positive myelogram, myelogram-computed tomogram, and magnetic resonance studies led to surgical intervention. Marked bony callous formation contiguous with the S-1 alar fracture protruded into the canal and was responsible for tethering the S-1 nerve root. A right L-5 hemilaminectomy, an L-4, L-5 and L-5, S-1 medial facetectomy, and foraminotomy facilitated nerve root decompression. Postoperatively, the patient was markedly improved. The authors suggest a more aggressive attitude in the diagnostic, radiographic, and surgical management of sacral fractures now that more specific technical facilities are available to define the precise character of the lesions involved.
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8/12. Partial cauda equina compromise: result of sacral stenosis.

    Although partial or complete cauda equina compromise due to lumbar stenosis is a recognized entity, cauda equina compromise due to sacral stenosis is extremely uncommon. We present a patient with a three-week history of right thigh and buttock pain who developed right scrotal and buttock numbness, urinary retention, and difficulty with bowel evacuation. The patient had diminished sensation to right buttock and anus pinprick with decreased anal sphincter tone and absent bulbocavernosus reflex. Lumbosacral spine films revealed only minimal degenerative changes, while lumbar myelogram showed L4-L5 and L5-S1 ventral extradural defects. Only a drop of pantopaque descended caudally below the level of the L5-S1 interspace. Operatively, significant stenosis and thickening of the posterior sacrum with compromise of the lower sacral nerve roots was noted. Bilateral sacral laminectomy was performed and the symptoms resolved postoperatively. This case illustrates an unusual clinical entity: partial cauda equina compromise due to sacral stenosis.
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9/12. cauda equina syndrome with pagetic vertebral fusion. Clinical recovery under calcium-vitamin d supplementation plus clodronate after apparent failure of pamidronate and acquired resistance to etidronate.

    A patient with an osteolytic L2-L3 pagetic block and pagetic lesions of L1 and the sacrum seen only as increased radionuclide activity became resistant to etidronate after the fifth course (5 mg/kg/d six months per year) and developed severe cauda equina syndrome (reduction in walking distance to 30 m and sphincter dysfunction) due primarily to vertebral hypertrophy. Five months after a ten-day course of intravenous pamidronate (22.5 mg/d), the clinical symptoms were unchanged, although the alkaline phosphatase level was down 50%. Oral clodronate (1,600 mg/day for six months per year) in combination with calcium and vitamin d supplementation dramatically improved the walking distance and sphincter disorders. Resolution of the neurological manifestations was complete after the second clodronate course. At last follow-up nine months after the fourth clodronate course, there was no evidence of a relapse and the alkaline phosphatase level was normal. The time course of events in this patient does not allow to affirm that pamidronate was ineffective and suggests that calcium and vitamin d supplementation improved mineralization of the pagetic block and enhanced the effect of bisphosphonate therapy.
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10/12. Acute cauda equina syndrome secondary to lumbar disc herniation mimicking pure conus medullaris syndrome--case report.

    A 49-year-old male presented with a rare case of acute cauda equina syndrome secondary to a sequestrated lumbar disc mimicking pure conus medullaris syndrome. He consulted the emergency room of Otsu Municipal Hospital because saddle anesthesia and complete urinary retention which had started 2 days before admission. Additionally, he complained of constipation and impotence. Abnormality of the deep tendon reflexes, sciatica, and leg weakness were not organized. Emergent myelography and subsequent computed tomography revealed a sequestrated disc in the sacrum compressing the lower cauda equina, but not the conus medullaris. Emergent surgical decompression was performed about 60 hours after the onset. The patient almost fully recovered from sphincter dysfunction, impotence, and saddle anesthesia 3 months after the operation. When a syndrome like conus medullaris compression is encountered, the lower cauda equina should be examined as well as the conus level. Such cases require urgent diagnosis and treatment.
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