Bryant

Spinal Deformity – a Multidisciplinary Solution

A man in his 60’s consulted me with intractable back pains associated with degeneration of his lumbar spine.  There was widespread degeneration of the lumbar facets and discs, and he presented with a significant history of narcotic use, in a vane attempt to get his pains better controlled.

Consultation at that stage and discussions regarding options for management ultimately lead to attempt at surgical correction of his pains, having failed other conservative treatment options over the years leading up to his surgical review.  A long construct fusion was undertaken with screws from T9 down to the pelvis and whilst there were initial improvements in the discomforts, the patient represented with worsening pains down low in his back roughly 12 months later.  Scans at the time revealed that the construct had failed, with the rod disengaged from the screws at the sacral level and loosening of the screws at L5.  The stress and forces applied to the spine during the attempted spinal reconstruction were excessive and failure ensued.  The lower screws were removed.

Despite improvement in his local symptoms (pains down low in his lumbar spine), he developed progressive deformity and spinal imbalance, with widespread pain and disability.  His L4/5 and L5S1 segments became kyphotic throwing his balances forward significantly.  He was back on his narcotic medication (kapanol 100mg bd) and was only able to ambulate with the assistance of a 4 wheel walker.

Standing x-rays at the time revealed the extent of his spinal deformity.  His imbalance was pronounced with his head well forward of the expected balance point over the pelvis. 

Consultation was sought from Dr Steven Yang, colleague, and expert in spinal deformity correction.  After careful consultation and consideration of the case, a combined surgical case was undertaken with Dr Yang to address the imbalance issues.

In a 10 hour procedure involving neurosurgery and orthopaedic surgery, pedicle ubtraction osteotomies were undertaken to allow for restoration of the sagittal balances – ultimately allowing the patient to be able to stand upright once again.

His pain improved considerably and his narcotic use has decreased.  He was off all Kapanol and using endone sparingly.  He was far from perfect, but was considerably better, and he considered that his major reconstruction was well worth while.

A combined approach with neurosurgeons and expert orthopaedic spinal surgeons saw a great outcome in this case.  Selected patients with spinal deformity will do very well from spinal reconstruction surgeries.  Risks of this type of surgery are considerable, but in carefully selected cases with extensive counselling, lives can be turned around.

 Dr Michael Bryant, Neurosurgeon and Spinal Surgeon 

Neck pains and occipital headaches – a rare pathology

A 69 year old male presented to his GP with a slowly progressive, 6 month history of left sided neck pains and occipital headaches. Examination was unremarkable and in particular, strengths and reflexes in all 4 limbs were normal.

CT scan revealed some degenerative changes low down in the cervical facet joints and a referral was made to an orthopaedic spinal specialist, and from here facet joint injections were undertaken.

When this procedure provided no relief, a greater occipital nerve injection was arranged under CT guidance and was on this procedure that the causative pathology was finally identified.

When the MRI scan was finally undertaken, a contrast enhancing, durally based, ventral and left sided tumour was identified behind C1 and C2.

Axial, Coronal and Sagittal MRI with gadolinium shoeing the tumour displacing and compressing the cervical cord.

With the benefit of hindsight, it was obviously the tumour causing the neck pain and occipital neuralgia.

The appearances were typical for a spinal menigioma and options were considered.

Analgesics alone were trialled initially, and whilst some improvements were seen with dexamethasone, lyrica and targin, the side effect profile was considerable, and the analgesia was incomplete.  Consideration was given to radiation therapy up front and surgery was offered. In most clinical circumstances surgery would be considered treatment of choice for mengioma, and it was indeed the way the patient elected to go.

Informed consent was undertaken for C1 and C2 laminectomy with resection of the tumour. Spinal cord monitoring of motor and sensory potentials was undertaken to ensure real time feedback of potential spinal cord injury. The tumour was able to be resected in a 4 hour procedure, with 2 surgeons (thanks to Dr Hamish Alexander) collaborating to increase safety and avoid fatigue related mistakes. Motor and Sensory potentials were unchanged throughout the procedure and the patient woke without neurological deficit. He was able to be discharged 5 days after his procedure, once the discomfort of the neck wound settled.

The spinal cord is seen superiorly and C2 and C3 nerve rootlets are seen to cross over the top of the tumour to the edge of the dural opening.

Roughly 98% of the tumour was resected.  A tiny piece of tumour was left where the C2 nerve root pierced the lateral dura. The dural attachment of the tumour ventrally was cauterised, but unable to be resected. Unfortunately, the meningioma histology was confirmed as ‘atypical’, which significantly increases the chances of tumour recurrence. For this reason, the patient has been referred on by our Neuro-Oncology Nurse Practitioner for consideration of post-operative radiation therapy.

Whilst it is acknowledged that common things occur commonly, a careful history, recognising occipital referral of pains (C2 and C3 irritation), may have prevented an unnecessary intervention into the lower cervical facets.

-By Dr Michael Bryant, Neurosurgeon and Spinal Surgeon 

Ependymomas

A 75 year old female presented to her local hospital with pains in the chest and was admitted under a Respiratory Physician with (incidental) rib fractures, that in retrospect were old.  Clinical suspicion lead to further investigation and the diagnosis of an intradural mass at the level of T6 and T7 vertebrae.

An MRI suggested showed the mass with significant spinal cord compression, but despite these rather dramatic findings on scan, the patient maintained good strength in her lower limbs and normal sensation and function of the bladder and bowel.

Commenced on dexamethasone, she was taken to theatre after transfer to St Andrew’s Hospital 3 days after her diagnosis was made.

Intraoperative findings were that of a mass arising from within the substance of the spinal cord.  Resection required careful dissection out of the cord itself.

Post-operatively function has returned quite quickly to normal.  The only deficit was some loss of joint position sense (proprioception) – as one may expect from this area of the spinal cord itself (the dorsal columns).

2 weeks after her operation she is off to rehab to regain her confidence, but currently she is walking without any assistance and has normal bladder and bowel function.

Histology revealed Anaplastic Ependymoma (WHO Grade III).  The rest of the brain and spine were clear of any obvious tumour.

A Brief Discussion 

Ependymomas are rare tumours and make up about 3% of the primary tumours that we as neurosurgeons encounter.  The more aggressive anaplastic tumour is even rarer and possibly accounts for 5-10% of ependymal tumours.

Because the numbers of this particular tumour as so low, the exact history of the disease is not entirely clear.  Almost all anaplastic ependymomas will recur and current treatment recommendations are for excision followed by radiation therapy and possible chemotherapy.

Whilst quite a “pretty” tumour histologically, their more aggressive behaviour can see them behave in a “not-so-pretty” clinical way.

This patient will be followed closely post radiation for any signs of recurrence.

– Dr Michael Bryant, Neurosurgeon and Spinal Surgeon 

Just don’t do it!

Falls off ladders are a surprisingly common injury in our community, and whilst most amount to nothing more than dented pride when they occur, some are considerably more serious – just ask Mr Ian (Molly) Meldrum.

Recently we had cause to treat yet another considerably more serious “ladder injury”.  A 56 year old man had been painting his ceilings at home when he fell off his ladder.  Whilst this may read as any other 6 foot step ladder incident, this particular event was made all that more serious by the fact that the ladder was perched precariously on the kitchen bench at the time.

The patient had actually managed to paint a considerable portion of the ceiling, but in attempting to stretch for that extra few centimeters, over balanced the ladder which proceeded to topple out from underneath him.

He struck his head on the stone bench top on the way down and sustained a hyperextension injury to his neck. 

His presenting neurology was of elbow extension weakness of the right arm in the setting of severe neck and arm pain.  Pre-operative MRI (see image above) showed evidence of disc disruption at the C5/6 and C6/7 levels with considerable nerve root compromise at each of these levels.

At operation the C6/7 was grossly disrupted and gaped open whilst the C5/6 was less affected.  A two level discectomy and fusion was undertaken (see right image) and fortunately the patient was able to be discharged without any persisting neurology 4 days later.

The moral of the story is obvious…

–  Dr Michael Bryant