Atormac
Neurology India
Open access journal indexed with Index Medicus
  Users online: 670  
 Home | Login 
About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,668 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed98    
    Printed4    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
LETTERS TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 5  |  Page : 1499-1501

Single-stage vertebrectomy for hydatid disease involving L3 vertebra: Five year follow-up


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 Publication17-Sep-2018

Correspondence Address:
Dr. Pankaj Kandwal
Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh - - 249 203, Uttrakhand
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.241355

Rights and Permissions



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 2018 Oct 23];66:1499-501. Available from: http://www.neurologyindia.com/text.asp?2018/66/5/1499/241355




Sir,

Spinal hydatid disease may occur by direct extension from a pulmonary or pelvic foci or, rarely, it may begin primarily in the vertebral body.[1] 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

Click here to view


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


Click here to view


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

Click here to view
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

Click here to view
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

Click here to view


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.[1] Braithwaite and Lee classified spinal hyadatid disease radiologically into the intramedullary, intradural extramedullary, extradural, vertebral, and paravertebral lesions.[2] Approximately 90% of spinal hydatids are located extradurally, and the primary intradural extramedullary hydatid disease is extremely rare.[3] 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.[7] Though Govender et al., stressed on radical excision of the involved vertebra,[8] 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.[3],[9] Ten percent povidone iodine was used as the scolicidal agent in our case.

Although recurrences even after extensive surgery are as high as 40%,[3] 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 Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Charles RW, Govender S, Naidoo KS. Echinococcal infection of the spine with neural involvement. Spine 1988;13:47-9.  Back to cited text no. 1
    
2.
Braithwaite PA, Lees RF. Vertebral hydatid disease: Radiological assessment. Radiology 1981;140:763-6.  Back to cited text no. 2
    
3.
Pamir MN, Ozduman K, Elmaci I. Spinal hydatid disease. Spinal Cord 2002;40:153-60.  Back to cited text no. 3
    
4.
Işlekel S, Zileli M, Erşahin Y. Intradural spinal hydatid cysts. Eur Spine J 1998;7:162-4.  Back to cited text no. 4
    
5.
Işlekel S, Erşahin Y, Zileli M, Oktar N, Oner K, Ovül I, et al. Spinal hydatid disease. Spinal Cord 1998;36:166-70.  Back to cited text no. 5
    
6.
Pamir MN, Akalan N, Ozgen T, Erbengi A. Spinal hydatid cysts. Surg Neurol 1984;21:53-7.  Back to cited text no. 6
    
7.
Lam KS, Faraj A, Mulholland RC, Finch RG. Medical decompression of vertebral hydatidosis. Spine 1997;22:2050-5.  Back to cited text no. 7
    
8.
Govender TS, Aslam M, Parbhoo A, Corr P. Hydatid disease of the spine. A long-term followup after surgical treatment. Clin Orthop 2000;378:143-7.  Back to cited text no. 8
    
9.
Pandey M, Chaudhari MP. Primary hydatid cyst of sacral spinal canal: Case report. Neurosurgery 1997;40:407-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow