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|LETTERS TO EDITOR
|Year : 2018 | Volume
| Issue : 5 | Page : 1499-1501
Single-stage vertebrectomy for hydatid disease involving L3 vertebra: Five year follow-up
Pankaj Kandwal1, G Vijayaraghavan2, BN Upendra3, Arvind Jayaswal2
1 Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
2 Department of Orthopaedics, Primus Superspeciality Hospital, New Delhi, India
3 Department of Orthopaedics, Jain Institute of Spine Care and Research, Bengaluru, Karnataka, India
|Date of Web Publication||17-Sep-2018|
Dr. Pankaj Kandwal
Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh - - 249 203, Uttrakhand
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kandwal P, Vijayaraghavan G, Upendra B N, Jayaswal A. Single-stage vertebrectomy for hydatid disease involving L3 vertebra: Five year follow-up. Neurol India 2018;66:1499-501
|How to cite this URL:|
Kandwal P, Vijayaraghavan G, Upendra B N, Jayaswal A. Single-stage vertebrectomy for hydatid disease involving L3 vertebra: Five year follow-up. Neurol India [serial online] 2018 [cited 2019 Feb 16];66:1499-501. Available from: http://www.neurologyindia.com/text.asp?2018/66/5/1499/241355
Spinal hydatid disease may occur by direct extension from a pulmonary or pelvic foci or, rarely, it may begin primarily in the vertebral body. The authors report a case of hydatid disease involving the L3 vertebral body. A single-stage L3 vertebrectomy, stabilization with pedicle screws, and reconstruction with an expandable cage was carried out. After a follow-up of 5 years, the clinical symptoms significantly improved with no clinical and radiological evidence of recurrence.
A 30-year old male patient presented to the Orthopaedic outpatient clinic with a history of low back pain for 3 years with radicular pain in the left lower limb. There was one episode of severe allergic skin rashes all over the body, which subsided with medical treatment. On examination, tenderness was present over the mid-lumbar spine. There was no neurological deficit.
Plain radiographs showed well-defined, osteolytic expansile cavitatory areas without periosteal reaction or sclerosis [Figure 1]. The pattern of bone destruction was eccentric with absence of L3 pedicle shadow on the left side in the anteroposterior view. The bony involvement occurred in up to 50% of the body in the lateral view of the plain radiograph [Figure 1].
|Figure 1: Preoperative X-ray of the lumbar spine (a) AP; (b) Lateral view. Preoperative CT scans (c) coronal; (d) sagittal; (e) axial sections showing a well-defined, eccentric osteolytic lesion without periosteal reaction or sclerosis with absence of L3 pedicle on the left side|
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Magnetic resonance imaging (MRI) showed a bony destructive lesion involving the left half of the L3 body, the pedicle, and the transverse process [Figure 2]. The lesion was T2 hyperintense involving the left half of the vertebral body and posterior elements, but without significant enhancement. The Casoni's test was positive and enzyme linked immunosorbent assay (ELISA) for E. granulosis (related to immuoglubulin [Ig] G) was also positive.
|Figure 2: MRI scans (a) T2W; (b) T1W; (c) Contrast axial sections. (d) T2W; (e) T1W sagittal sections showing a bony destructive lesion involving the left half|
of the L3 body, the pedicle, and the transverse process
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The patient underwent a single-stage excision of the cyst, an L3 vertebrectomy, and posterior stabilization with pedicle screws, and reconstruction using an expandable titanium cage to support the anterior column. The posterior midline approach was used and the paraspinal muscles were elevated. Due care was taken to prevent rupture of the cyst while performing a complete L3 spondylectomy. The surrounding surgical field was packed with mops soaked with 10% betadine to prevent local spillage. The vertebral column was stabilized by pedicle screws above and below the diseased vertebra. The right half of the L3 vertebral body was removed, first keeping the cystic part intact on the left side of the body. Finally, the left half of the vertebral body was removed as a single piece without causing rupture of the cyst [Figure 3]. The anterior column was reconstructed using an expandable cage filled with autografts. There was no peri- or postoperative complications. Histopathologic confirmation of the diagnosis was obtained, and antihelminthic therapy with 400 mg of albendazole 3 times daily was prescribed for 2 years. The patient was followed-up in the postoperative period with repeat X-rays, computed tomography, and MRI scans at regular intervals to look for recurrence. There was no recurrence or residual disease at the end of the 5-year follow-up period [Figure 4] and [Figure 5].
|Figure 3: Meticulous dissection (a) followed by radical surgery in the form of vertebrectomy utilizing the posterior approach only (b) was done|
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|Figure 4: Preoperative X-.rays (a) Lateral; (b) AP view. Postoperative X-.rays at 5-.year follow-.up: (c) lateral; (d) AP view after single stage posterior only vertebrectomy and reconstruction|
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|Figure 5: Scans at 5-year follow-up. MRI (a) STIR sagittal; (b) T1W axial; (c) T2W axial sections showing no evidence of recurrence. CT scan (d) showing a good fusion and bone formation inside the expandable cage|
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Hydatid cysts of the spine constitute 1% of all cases of hydatidosis and are most commonly located in the thoracic spine and less so in the lumbar, sacral, and cervical regions. Braithwaite and Lee classified spinal hyadatid disease radiologically into the intramedullary, intradural extramedullary, extradural, vertebral, and paravertebral lesions. Approximately 90% of spinal hydatids are located extradurally, and the primary intradural extramedullary hydatid disease is extremely rare. The disease in our case was extradural and predominantly confined to the L3 vertebra. Clinical manifestations in spinal hydatidosis are either due to bone destruction, due to cord/roots compression, due to spillage of cyst fluid, or a combination of any of these features.
Surgery is currently considered the treatment of choice for spinal hydatid disease. Laminectomy for hydatid disease involving the lumbar spine is one of the standard treatments reported in the literature.[4–6] Retroperitoneal abdominal corpectomy with posterior fusion along with subsequent surgery for total destruction of the vertebral body has also been reported in lumbar disease. Though Govender et al., stressed on radical excision of the involved vertebra, a single-stage vertebrectomy, stabilization with pedicle screw system, and reconstruction with an expandable cage as the surgical treatment has not yet been documented.
The various scolicidal agents used to avoid chances of recurrence are 3% hypertonic saline, chlorhexidine, 80% alcohol, 0.5% silver nitrate, 10% formalin, and povidone iodine., Ten percent povidone iodine was used as the scolicidal agent in our case.
Although recurrences even after extensive surgery are as high as 40%, our patient was disease free at the end of 5 years, both clinically and radiologically.
The author emphasizes on the need for a meticulous surgical dissection, radical surgical excision, and the use of a good scolicidal agent during surgery to reduce the incidence of recurrence.
| » Conclusion|| |
A single-stage vertebrectomy and reconstruction for the management of spinal hydatidosis has not been reported in the literature. Recurrence can be reduced by radical surgery, the liberal use of scolicidal agents during surgery, and the long-term administration of antihelminthic drugs.
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Conflicts of interest
There are no conflicts of interest.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]