Inciting Events Associated With Lumbar Facet Joint Pain.

BACKGROUND: Low back pain is the leading cause of years lost to disability with approximately 15%-25% of the chronic back pain population suffering from lumbar facet arthropathy. No large-scale study has sought to systematically identify inciting events for lumbar facet arthropathy. The aim of this study is to quantify the proportion of individuals with lumbar facetogenic pain who report a specific precipitating event(s) and to determine if there is a correlation between these events and treatment outcome. METHODS: Institutional electronic medical records were searched based on the current procedural terminology (CPT) codes representing lumbar facet joint radiofrequency ablation for procedures performed between January 2007 and December 2015. All patients had obtained >=50% pain relief based on 6-hour pain diaries after 1 or more diagnostic facet blocks. A positive outcome was defined as >=50% pain relief sustained for longer than 3-month after procedure, without additional procedural interventions. RESULTS: One thousand sixty-nine people were included in analysis. In the 52% of individuals who described an inciting event, the most commonly reported causes were falls (11%), motor vehicle collisions (11%), sports-related injuries (11%, of which weightlifting accounted for 62%), nonspine postsurgical injuries (2%), and "other" (17%). Six hundred seventeen (57.7%) individuals experienced >=50% pain relief sustained for >3 months. Patients whose pain was preceded by an inciting event were more likely to have a positive outcome than those who could not recall a specific precipitating factor (odds ratio, 1.5; confidence interval, 1.02-2.1, P = .01). Another factor associated with outcome was shorter duration of pain (8.1 +/- 9.2 vs 9.7 +/- 10.1 years, P = .02), with an observed modifier effect of age on outcomes. For a 1-year increase in age, there was a 10% increase in the odds of a positive response. CONCLUSIONS: Inciting events are common in patients diagnosed with lumbar facetogenic pain and may be associated with a positive outcome. (C) 2017 International Anesthesia Research Society

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The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-analysis.

BACKGROUND: The objective of this meta-analysis was to determine the efficacy of glycopyrrolate at reducing spinal hypotension during cesarean delivery. METHODS: A literature search was performed to identify randomized controlled trials investigating the effect of glycopyrrolate on spinal-induced hypotension during cesarean delivery. Primary outcomes were intraoperative hypotension and vasopressor requirement (phenylephrine equivalents). Secondary outcomes included heart rate (HR), nausea and vomiting, dry mouth, and Apgar scores. Risk ratios (RRs), and mean differences (MDs) were calculated using random-effects modeling with 95% confidence intervals for primary outcomes and 99% confidence intervals for secondary outcomes. RESULTS: Five randomized controlled trials met our inclusion criteria. A total of 311 patients were included: 153 received glycopyrrolate and 158 placebo. The incidence of spinal-induced hypotension was no different with prophylactic glycopyrrolate compared to control (RR, 0.93 [0.71 1.21]; P = .59), but the total phenylephrine dose required was significantly reduced with glycopyrrolate (MD, -62.64 [micro]g [-107.61 to .17.66 [micro]g]; P = .006). The maximal HR achieved in the glycopyrrolate group was significantly higher compared to controls (MD, 15.85 bpm [5.40- 26.31]; P

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Comparison of Registered and Reported Outcomes in Randomized Clinical Trials Published in Anesthesiology Journals.

BACKGROUND: Randomized clinical trials (RCTs) provide high-quality evidence for clinical decision-making. Trial registration is one of the many tools used to improve the reporting of RCTs by reducing publication bias and selective outcome reporting bias. The purpose of our study is to examine whether RCTs published in the top 6 general anesthesiology journals were adequately registered and whether the reported primary and secondary outcomes corresponded to the originally registered outcomes. METHODS: Following a prespecified protocol, an electronic database was used to systematically screen and extract data from RCTs published in the top 6 general anesthesiology journals by impact factor (Anaesthesia, Anesthesia & Analgesia, Anesthesiology, British Journal of Anaesthesia, Canadian Journal of Anesthesia, and European Journal of Anaesthesiology) during the years 2007, 2010, 2013, and 2015. A manual search of each journal's Table of Contents was performed (in duplicate) to identify eligible RCTs. An adequately registered trial was defined as being registered in a publicly available trials registry before the first patient being enrolled with an unambiguously defined primary outcome. For adequately registered trials, the outcomes registered in the trial registry were compared with the outcomes reported in the article, with outcome discrepancies documented and analyzed by the type of discrepancy. RESULTS: During the 4 years studied, there were 860 RCTs identified, with 102 RCTs determined to be adequately registered (12%). The proportion of adequately registered trials increased over time, with 38% of RCTs being adequately registered in 2015. The most common reason in 2015 for inadequate registration was registering the RCT after the first patient had already been enrolled. Among adequately registered trials, 92% had at least 1 primary or secondary outcome discrepancy. In 2015, 42% of RCTs had at least 1 primary outcome discrepancy, while 90% of RCTs had at least 1 secondary outcome discrepancy. CONCLUSIONS: : Despite trial registration being an accepted best practice, RCTs published in anesthesiology journals have a high rate of inadequate registration. While mandating trial registration has increased the proportion of adequately registered trials over time, there is still an unacceptably high proportion of inadequately registered RCTs. Among adequately registered trials, there are high rates of discrepancies between registered and reported outcomes, suggesting a need to compare a published RCT with its trial registry entry to be able to fully assess the quality of the study. If clinicians base their decisions on evidence distorted by primary outcome switching, patient care could be negatively affected. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. (C) 2017 International Anesthesia Research Society

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Low End-Tidal Carbon Dioxide at the Onset of Emergent Trauma Surgery Is Associated With Nonsurvival: A Case Series.

BACKGROUND: End-tidal carbon dioxide (EtCO2) is a valuable marker of the return of adequate circulation following cardiac arrest due to medical causes. Previously, the prognostic value of capnography in trauma has been studied among limited populations in prehospital and emergency department settings. We aimed to investigate the relationship between early intraoperative EtCO2 and nonsurvival of patients undergoing emergency surgery at a level 1 academic trauma center as a case series. If there is a threshold below which survival was extremely unlikely, it might be useful in guiding decision-making in the early termination of futile resuscitative efforts. METHODS: Following institutional review board approval, a data set was created to investigate the relationship between EtCO2 values at the onset of emergent trauma surgery and nonsurvival. Patients who were admitted and transferred to the operating room (OR) directly from a resuscitation bay were identified using the Ryder Center trauma registry (October 1, 2013, to June 30, 2016). Electronic records from the hospital's anesthesia information management system were queried to identify the matching anesthesia records. The maximum EtCO2 values within 5 and 10 minutes of the onset of mechanical ventilation in the OR were determined for patients undergoing general anesthesia with mechanical ventilation. Patients were divided into 2 groups: those who were discharged from the hospital alive (survivors) and those who died in the hospital prior to discharge (nonsurvivors). The threshold EtCO2 giving a positive predictive value of 100% for in-hospital mortality was determined from a graphical analysis of the data. Association of determined threshold and mortality was analyzed using the 2-tailed Fisher exact test. RESULTS: There were 1135 patients who met the inclusion criteria. Within the first 5 minutes of the onset of mechanical ventilation in the OR, if the maximum EtCO2 value was

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Patient Survey of Referral From One Surgeon to Another to Reduce Maximum Waiting Time for Elective Surgery and Hours of Overutilized Operating Room Time.

BACKGROUND: Studies of shared (patient-provider) decision making for elective surgical care have examined both the decision whether to have surgery and patients' understanding of treatment options. We consider shared decision making applied to case scheduling, since implementation would reduce labor costs. METHODS: Study questions were presented in sequence of waiting times, starting with 4 workdays. "Assume the consultant surgeon (ie, the surgeon in charge) you met in clinic did not have time available to do your surgery within the next 4 workdays, but his/her colleague would have had time to do your surgery within the next 4 workdays. Would you have wanted to discuss with a member of the surgical team (eg, the scheduler or the surgeon) the availability of surgery with a different, equally qualified surgeon at Mayo Clinic who had time available within the next 4 workdays, on a date of your choosing?" There were 980 invited patients who underwent lung resection or cholecystectomy between 2011 and 2016; 135 respondents completed the study and 6 respondents dropped out after the study questions were displayed. RESULTS: The percentages of patients whose response to the study questions was "4 days" were 58.8% (40/68) among lung resection patients and 58.2% (39/67) among cholecystectomy patients. The 97.5% 2-sided confidence interval for the median maximum wait was 4 days to 4 days. Patients' choices for the waiting time sufficient to discuss having another surgeon perform the procedure did not differ between procedures (P = .91). Results were insensitive to patients' sex, age, travel time to hospital, or number of office visits before surgery (all P >= .20). CONCLUSIONS: Our results indicate that bringing up the option with the patient of changing surgeons when a colleague is available and has the operating room time to perform the procedure sooner is being respectful of most patients' individual preferences (ie, patient-centered). (C) 2017 International Anesthesia Research Society

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Abnormal Calcium Levels During Trauma Resuscitation Are Associated With Increased Mortality, Increased Blood Product Use, and Greater Hospital Resource Consumption: A Pilot Investigation.

BACKGROUND: Admission hypocalcemia predicts both massive transfusion and mortality in severely injured patients. However, the effect of calcium derangements during resuscitation remains unexplored. We hypothesize that any hypocalcemia or hypercalcemia (either primary or from overcorrection) in the first 24 hours after severe injury is associated with increased mortality. METHODS: All patients at our institution with massive transfusion protocol activation from January 2013 through December 2014 were identified. Patients transferred from another hospital, those not transfused, those with no ionized calcium (Ca2+) measured, and those who expired in the trauma bay were excluded. Hypocalcemia and hypercalcemia were defined as any level outside the normal range of Ca2+ at our institution (1-1.25 mmol/L). Receiver operator curve analysis was also used to further examine significant thresholds for both hypocalcemia and hypercalcemia. Hospital mortality was compared between groups. Secondary outcomes included advanced cardiovascular life support, damage control surgery, ventilator days, and intensive care unit days. RESULTS: The massive transfusion protocol was activated for 77 patients of whom 36 were excluded leaving 41 for analysis. Hypocalcemia occurred in 35 (85%) patients and hypercalcemia occurred in 9 (22%). Mortality was no different in hypocalcemia versus no hypocalcemia (29% vs 0%; P = .13) but was greater in hypercalcemia versus no hypercalcemia (78% vs 9%; P

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Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High-Stakes Environment, 3rd ed.

No abstract available

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Implementation of a Standardized Transfusion Protocol for Cardiac Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Decreased Blood Component Utilization and May Improve Clinical Outcome.

BACKGROUND: Extracorporeal membrane oxygenation supplies oxygenated blood to the body supporting the heart and lungs. Survival rates of 20% to 50% are reported among patients receiving ECMO for cardiac arrest, severe cardiogenic shock, or failure to wean from cardiopulmonary bypass following cardiac surgery. Bleeding is one of the most common complications in ECMO patients due to coagulopathy, systemic anticoagulation, and the presence of large bore cannulas at systemic pressure. Absence of a standardized transfusion protocol in this population leads to inconsistent transfusion practices. Here, we assess a newly developed dedicated transfusion protocol in this clinical setting. METHODS: Data were retrospectively reviewed for the first 30 consecutive cardiac ECMO patients prior and post implementation of the ECMO transfusion protocol. Diagnoses, laboratory results, blood component utilization, and outcomes were collected and analyzed. RESULTS: Comorbidities were similar between the 2 eras, as well as the pre-ECMO ejection fraction (P = .568) and duration on ECMO (P = .278). Transfusion utilization data revealed statistically significant decreases in almost all blood components and a savings in blood component acquisition costs of 51% ($175, 970). In addition, an almost 2-fold increase in survival rate was observed in the post-ECMO transfusion protocol era (63% vs 33%; relative risk = 1.82; 95% confidence interval, 1.07-3.10; P = .028). CONCLUSIONS: Our data indicate that implementation of a standardized transfusion protocol, using more restrictive transfusion indications in cardiac ECMO patients, was associated with reduced blood product utilization, decreased complications, and improved survival. This multidepartmental approach facilitates better communication and adherence to consensus clinical decision making between intensive care unit, surgery, and transfusion service and optimizes care of complicated and acutely ill patients. (C) 2017 International Anesthesia Research Society

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The combination of CYP3A4*22 and CYP3A5*3 single-nucleotide polymorphisms determines tacrolimus dose requirement after kidney transplantation.

Introduction: Tacrolimus (Tac) has a narrow therapeutic window and shows large between-patient pharmacokinetic variability. As a result, over-immunosuppression and under-immunosuppression are frequently encountered in daily clinical practice. Unraveling the impact of genetic polymorphisms on Tac pharmacokinetics may help to refine therapy. In this study, the associations of single-nucleotide polymorphisms (SNPs) in drug-metabolizing enzymes (CYP3A) with Tac pharmacokinetics were investigated in renal transplant recipients. Participants and methods: In a cohort of 272 kidney transplant recipients, associations between functional genetic variants (CYP3A4*22 and CYP3A5*3) and dose-adjusted predose Tac concentrations (C0) and daily doses of Tac at days 5-7 and 15 and 1, 3, 6 and 12 months after renal transplantation were evaluated. Patients were genotyped and clustered according to both CYP3A4*22 and CYP3A5*3 allelic status: poor (PM) (CYP3A4*22 carriers with CYP3A5*3/*3), intermediate (IM) (CYP3A4*1/*1 with CYP3A5*3/*3 or CYP3A4*22 carriers with CYP3A5*1 carriers) and extensive CYP3A-metabolizers (EM) (CYP3A4*1/*1 and CYP3A5*1 carriers). Results: EM had an 88% lower dose-adjusted C0 compared with IM. PM had a 26% higher dose-adjusted C0 compared with IM. The percentage of patients with supratherapeutic Tac exposure (C0>15 ng/ml) was significantly higher in PM (43.5%) compared with EM (0%) at days 5-7 after transplantation (P=0.01). About 30% of EM had subtherapeutic exposure (C0

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Patient-reported outcomes after surgical stabilization of spinal tumors: symptom-based validation of the spinal instability neoplastic score (SINS) and surgery

Neoplastic spinal instability is movement-related pain or neurologic compromise under physiologic loads with the Spinal Instability Neoplastic Score (SINS) developed to facilitate diagnosis. There is a paucity of evidence that mechanical instability correlates with patient-reported symptoms and that surgical stabilization significantly improves these patient-reported outcomes (PRO).

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The biomechanical impact of the facet tropism on the intervertebral disc and facet joints in the cervical spine

The facet tropism is defined as the angular difference between the left and right facet orientation. The facet tropism was suggested to be associated with the disc degeneration and facet degeneration in the lumbar spine. However, little is known about the relationship between the facet tropism and pathological changes in the cervical spine and the mechanism behind.

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Perils of intraoperative neurophysiologic monitoring: analysis of ‘false negative’ results in spine surgeries

Although some authors published case reports describing false negatives in intraoperative neurophysiologic monitoring (IONM), systematic review of causes of false negative IONM results is lacking.

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3D visualization and pathological characteristics of cartilage and subchondral bone changes in the lumbar facet joint of an Ovariectomized mouse model

Low back pain (LBP) is more prevalent among postmenopausal women than men. Ovariectomy (OVX) is an established animal model that mimics the estrogen deficiency of postmenopausal women. Little is known about the morphological properties of cartilage and subchondral bone changes in the lumbar facet joint (LFJ) of an OVX mouse model.

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Advice for acute low back pain: A comparison of what research supports and what guidelines recommend

BackgroundAdvice is widely considered an effective treatment for acute low back pain (LBP) however details on what and how to deliver this intervention is less clear.PurposeWe assessed and compared clinical trials which test advice for acute LBP to practice guidelines for their completeness of reporting and concordance on the content, method of delivery and treatment regimen of advice interventions.Study Design/SettingSystematic ReviewMethodsAdvice RCTs were identified through a systematic search.

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Acute facial nerve paralysis in children,............................................................................................................................................ Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature by Latha M Sneha via CHRISMED Journal of Health and Research : 2014 - 1(4) Latha M Sneha, Raichel Priyanka, Shanthini Thanga Tamilselvan, Julius Xavier Scott CHRISMED Journal of Health and Research 2017 4(3):209-211 Infections, inflammatory, and autoimmune conditions are the well-recognized etiologies of acute facial nerve paralysis in children. Bell's palsy is idiopathic peripheral facial nerve palsy. Cranial neuropathies do occur in children due to the central nervous system involvement by malignancies but uncommon in pediatric acute lymphoblastic leukemias and even rarer in acute myeloid leukemias (AMLs). We report a case of a 13-year-old girl who presented with acute facial nerve palsy, wa

The common etiology associated with acute facial nerve paralysis in children are otitis media, mastoiditis, viral infections such as herpes, varicella, mumps, HIV, meningitis, encephalitis, mycoplasma, Lyme disease, and inflammatory conditions such as vasculitis, Henoch–Schonlein purpura, Kawasaki syndrome, Gullain–Barre syndrome, and hypertension.[3]

Seventy percent of the children with acute lower motor neuron facial paralysis have a favorable prognosis and it resolves spontaneously within 3 months without any sequela. In 40%–75% of children, cause of unilateral facial paralysis is idiopathic, described as Bell's palsy and most of them have a positive history of viral illness 2–3 weeks preceding the neurological manifestations. The use of steroids to reduce the duration of paralysis and reduce the risk of long-term impairment was based on adult studies though the benefits of steroids in children is yet to be proven.[4] Due to the self-resolving nature of the idiopathic variety of the facial palsy seen in children, the neurological manifestations of leukemia as an etiology is never thought of. Steroids, when commonly prescribed in such cases causes a partial recovery thereby masking the primary pathology and adds to the diagnostic dilemma.

The frequency of symptomatic facial palsy has been found to be higher in the younger age group when compared to the idiopathic variety.[5]

AML accounts for 15% of all leukemia and presents with symptoms of prolonged fever, hepatosplenomegaly, and skin or mucocutaneous bleeds. When focal masses of immature myeloid cells from the granulocytic lineage infiltrate the soft tissues and bones, they are called granulocytic sarcomas or chloromas and occur in 5% of cases of AML. It is postulated that the granulocytic sarcomas traverse through the haversian canals from the bone marrow and gets deposited in the subperiosteum to form soft tissue masses.[6]

Granulocytic sarcomas may manifest concurrently with the disease or during remission or relapse. However, when sarcomas precede the disease in peripheral blood or marrow, it often poses a diagnostic challenge, more so, if cranial neuropathies are caused by unidentifiable chloromas as in our case. Facial paralysis resulting from leukemic infiltration, though rare, occurs during the relapse of the disease or as a complication primary disease, but it is not a well-recognized presenting symptom of childhood leukemia. Diagnostic delays of 1 month have been reported when facial nerve palsy was the isolated manifestation of AML in children.[7] Otomastoiditis due to the leukemic infiltration of the temporal bone has been attributed to the facial nerve paralysis. MRI with contrast of the facial nerve canal helps in identifying the facial nerve enhancement. However, the clinical findings of facial nerve paralysis were not always associated with radiological findings in most of the cases.[7]

Baek et al. have reported 11 children who had facial nerve paralysis as isolated feature of AML. Brain imaging studies showed mastoiditis in four of them and chloroma was identified in five of them. Six of them did not have blast in the CSF. Facial nerve palsy improved within a mean period of 1–6 months of chemotherapy.[7] Rohit et al. have reported a case of 13-year-old girl-AML with t(8:21) positivity who presented with bilateral proptosis and facial nerve palsy.[8]

When leukemic children presented with cranial neuropathies, the treatment included systemic and intrathecal chemotherapy with whole brain irradiation. However, Baek et al. recommend allogenic bone marrow transplant, avoiding whole brain irradiation in children to reduce the development of secondary malignancies and to prevent the long-term sequelae on cognitive and endocrine function.

Due to the self-resolving nature of the idiopathic variety of facial nerve palsy, when these children present to general physicians or neurologists, the diagnosis of leukemia is overlooked. Gradual progression of the paralysis beyond 3 weeks should warrant additional investigations to rule out the etiology.

CASE REPORT

Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 209-211

Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature

Latha M Sneha¹, Raichel Priyanka², Shanthini Thanga Tamilselvan², Julius Xavier Scott^3
1 Department of Pediatrics, Division of Pediatric Hemato Oncology, Sri Ramachandra University, Chennai, Tamil Nadu, India
² Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu, India
³ Division of Pediatric Hemato Oncology, Sri Ramachandra University, Chennai, Tamil Nadu, India

Date of Web Publication

13-Jul-2017

Correspondence Address:
Latha M Sneha
Division of Pediatric Hemato Oncology, Sri Ramachandra University, No. 1, Ramachandra Nagar, Porur, Chennai - 600 116, Tamil Nadu 
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/cjhr.cjhr_123_16

Abstract

Infections, inflammatory, and autoimmune conditions are the well-recognized etiologies of acute facial nerve paralysis in children. Bell's palsy is idiopathic peripheral facial nerve palsy. Cranial neuropathies do occur in children due to the central nervous system involvement by malignancies but uncommon in pediatric acute lymphoblastic leukemias and even rarer in acute myeloid leukemias (AMLs). We report a case of a 13-year-old girl who presented with acute facial nerve palsy, was being treated as Bell's palsy elsewhere and was later diagnosed to have AML.

Keywords: Acute myeloid leukemia, Bell's palsy, child

How to cite this article: Sneha LM, Priyanka R, Tamilselvan ST, Scott JX. Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature. CHRISMED J Health Res 2017;4:209-11

How to cite this URL: Sneha LM, Priyanka R, Tamilselvan ST, Scott JX. Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature. CHRISMED J Health Res [serial online] 2017 [cited 2017 Jul 14];4:209-11. Available from: http://www.cjhr.org/text.asp?2017/4/3/209/210478

Introduction

Acute, peripheral facial palsy can be presenting feature of infections, inflammatory, and autoimmune conditions and has a good prognosis in children. The incidence of facial paralysis in children <10 years of age is reported to be 2.7/100,000.^[1] Majority of them are unilateral, idiopathic, and termed Bell's palsy. A diagnosis of exclusion, Bell's palsy accounts for 42%–85% of cases in children with facial nerve paralysis.^[2] Although association of facial palsies in malignancies is well reported, facial paralysis is not a well-recognized presenting feature of leukemias in children, especially in acute myeloid leukemia (AML). The presence of Bell's palsy in children warrants a complete evaluation to rule out leptomeningeal diseases. We report a case of an adolescent girl who presented with acute facial nerve palsy, treated as Bell's palsy elsewhere and was later diagnosed to have AML.

Case Report

A 13-year-old girl presented with acute onset of right-sided facial nerve palsy of 2 weeks duration. She was diagnosed to have idiopathic Bell's palsy elsewhere and was being treated symptomatically with physiotherapy and oral steroids with no improvement in symptoms. She had no constitutional symptoms of fever, anorexia or fatigue, bone pain, mucocutaneous, or skin bleeds. In view of persistent symptoms, she was referred to a higher center for further evaluation. Examination revealed a right-sided lower motor neuron facial nerve palsy [Figure 1], without hepatosplenomegaly or lymphadenopathy. Central nervous system examination and rest of the systemic examination were normal. Investigations revealed hemoglobin 5.9 g/dl, total leukocyte count 14,900/μL (polymorphs: 64.1%, lymphocytes 30.3%), and platelet count 83,000/μL. Peripheral smear revealed leukocytosis with increase in blasts (50%) with  Auer rods ^{More Details} along with thrombocytopenia [Figure 2].

Figure 1: Right-sided lower motor neuron palsy Click here to view

Figure 2: Peripheral smear showing blasts with Auer rods Click here to view

Bone marrow aspiration showed hypercellular marrow with 58% blasts, promyelocytes - nil, myelocytes - 9, metamyelocytes - 9, neutrophil - 3, eosinophil - 2, band - 4, lymphocytes - 9, monocytes - nil, and plasma cells - 1 [Figure 3]. Cerebrospinal fluid (CSF) analysis was negative for malignant cells. Flow cytometry revealed blasts positive for CD33, cytoplasmic myeloperoxidase, and Human leukocyte antigen –D related (HLA-DR). Magnetic resonance imaging (MRI) brain, MRI angiogram, and venogram were normal. Cytogenetics was negative for t(8:21), inversion 16, t(9:11), and t(15:17). The girl was diagnosed as AML M0. She was started on chemotherapy and after the first cycle of chemotherapy, the bone marrow is in remission and she had partial resolution of facial nerve palsy.

Figure 3: Bone marrow aspirate showing hypercellular marrow with increased blasts 58% Click here to view

Discussion

The common etiology associated with acute facial nerve paralysis in children are otitis media, mastoiditis, viral infections such as herpes, varicella, mumps, HIV, meningitis, encephalitis, mycoplasma, Lyme disease, and inflammatory conditions such as vasculitis, Henoch–Schonlein purpura, Kawasaki syndrome, Gullain–Barre syndrome, and hypertension.^[3]

Seventy percent of the children with acute lower motor neuron facial paralysis have a favorable prognosis and it resolves spontaneously within 3 months without any sequela. In 40%–75% of children, cause of unilateral facial paralysis is idiopathic, described as Bell's palsy and most of them have a positive history of viral illness 2–3 weeks preceding the neurological manifestations. The use of steroids to reduce the duration of paralysis and reduce the risk of long-term impairment was based on adult studies though the benefits of steroids in children is yet to be proven.^[4] Due to the self-resolving nature of the idiopathic variety of the facial palsy seen in children, the neurological manifestations of leukemia as an etiology is never thought of. Steroids, when commonly prescribed in such cases causes a partial recovery thereby masking the primary pathology and adds to the diagnostic dilemma.

The frequency of symptomatic facial palsy has been found to be higher in the younger age group when compared to the idiopathic variety.^[5]

AML accounts for 15% of all leukemia and presents with symptoms of prolonged fever, hepatosplenomegaly, and skin or mucocutaneous bleeds. When focal masses of immature myeloid cells from the granulocytic lineage infiltrate the soft tissues and bones, they are called granulocytic sarcomas or chloromas and occur in 5% of cases of AML. It is postulated that the granulocytic sarcomas traverse through the haversian canals from the bone marrow and gets deposited in the subperiosteum to form soft tissue masses.^[6]

Granulocytic sarcomas may manifest concurrently with the disease or during remission or relapse. However, when sarcomas precede the disease in peripheral blood or marrow, it often poses a diagnostic challenge, more so, if cranial neuropathies are caused by unidentifiable chloromas as in our case. Facial paralysis resulting from leukemic infiltration, though rare, occurs during the relapse of the disease or as a complication primary disease, but it is not a well-recognized presenting symptom of childhood leukemia. Diagnostic delays of 1 month have been reported when facial nerve palsy was the isolated manifestation of AML in children.^[7] Otomastoiditis due to the leukemic infiltration of the temporal bone has been attributed to the facial nerve paralysis. MRI with contrast of the facial nerve canal helps in identifying the facial nerve enhancement. However, the clinical findings of facial nerve paralysis were not always associated with radiological findings in most of the cases.^[7]

Baek et al. have reported 11 children who had facial nerve paralysis as isolated feature of AML. Brain imaging studies showed mastoiditis in four of them and chloroma was identified in five of them. Six of them did not have blast in the CSF. Facial nerve palsy improved within a mean period of 1–6 months of chemotherapy.^[7] Rohit et al. have reported a case of 13-year-old girl-AML with t(8:21) positivity who presented with bilateral proptosis and facial nerve palsy.^[8]

When leukemic children presented with cranial neuropathies, the treatment included systemic and intrathecal chemotherapy with whole brain irradiation. However, Baek et al. recommend allogenic bone marrow transplant, avoiding whole brain irradiation in children to reduce the development of secondary malignancies and to prevent the long-term sequelae on cognitive and endocrine function.

Due to the self-resolving nature of the idiopathic variety of facial nerve palsy, when these children present to general physicians or neurologists, the diagnosis of leukemia is overlooked. Gradual progression of the paralysis beyond 3 weeks should warrant additional investigations to rule out the etiology.

Conclusion

While managing young children with acute lower motor neuron facial nerve palsy, neurologists and general physicians should have an index of suspicion for the neurological manifestations of acute leukemia and hence complete blood counts, peripheral smear and a bone marrow study if needed should be a part of the work up for etiology in such cases. The routine use of steroids may result in partial remission and can cause diagnostic delays.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

References

1.	Singhi P, Jain V. Bell's palsy in children. Semin Pediatr Neurol 2003;10:289-97.   [PUBMED]
2.	May M, Fria TJ, Blumenthal F, Curtin H. Facial paralysis in children: Differential diagnosis. Otolaryngol Head Neck Surg 1981;89:841-8.
3.	Ciorba A, Corazzi V, Conz V, Bianchini C, Aimoni C. Facial nerve paralysis in children. World J Clin Cases 2015;3:973-9.
4.	Unüvar E, Oguz F, Sidal M, Kiliç A. Corticosteroid treatment of childhood Bell's palsy. Pediatr Neurol 1999;21:814-6.
5.	Krishnamurthy S, Weinstock AL, Smith SH, Duffner PK. Facial palsy, an unusual presenting feature of childhood leukemia. Pediatr Neurol 2002;27:68-70.
6.	Stein-Wexler R, Wootton-Gorges SL, West DC. Orbital granulocytic sarcoma: An unusual presentation of acute myelocytic leukemia. Pediatr Radiol 2003;33:136-9.
7.	Baek HJ, Han DK, Kim YO, Choi IS, Hwang TJ, Kook H. Facial palsy as the presenting symptom of acute myeloid leukemia in children: Three cases with stem cell transplantations. Korean J Pediatr 2009;52:713-6.
8.	Rohit K, Jitender MK, Atul S, Soumya S. The paradox of recurrent with rare: A rare case of bilateral proptosis and facial palsy in acute myeloid leukemia with recurrent cytogenetic translocation t(8:21). Int J Appl Basic Med Res 2015;5:76-8.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Two cases of early recurrence after transabdominal preperitoneal inguinal hernia repair

Abstract

We performed transabdominal preperitoneal inguinal hernia repair in 46 patients (58 diseases), two of whom experienced early recurrence after mesh repair. Case 1 was a 76-year-old man with a bilateral inguinal hernia (recurrence site, left indirect hernia) after appendectomy. The recurrence occurred 1 month after transabdominal preperitoneal inguinal hernia repair. The mesh was dislocated to the lateral side, and we repaired it using the direct Kugel® patch with an anterior technique. Case 2 was a 79-year-old man with a bilateral inguinal hernia (recurrence site, right direct hernia with an orifice >3 cm) after appendectomy. The recurrence occurred 3 months after transabdominal preperitoneal inguinal hernia repair. The mesh was dislocated to the lateral side, and we repaired it using an ULTRAPRO® Plug with an anterior technique under laparoscopic observation. We believe the recurrences resulted from insufficient internal exfoliation and fixation affected by complicated exfoliation of the preperitoneal space with omental adhesion after intraperitoneal surgery.

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Iodine Supplementation for Premature Infants Does Not Improve IQ

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 277-279.


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Extrathyroidal Extension Predicts Decreased Survival in Thyroid Cancer Patients

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 271-273.


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Teprotumumab, an Antibody that Blocks the IGF-I Receptor, Causes Dramatic Improvement in Graves’ Orbitopathy

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 261-263.


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Thyrotoxicosis Increases Cardiovascular Mortality: Strengths and Limitations of Registry Cohort Studies

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 257-260.


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For Papillary Thyroid Cancer Discovered During Pregnancy, Delayed Thyroid Surgery with Active Surveillance Is Appropriate

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 264-266.


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Low and High Maternal Iodine Intake During Pregnancy Are Associated with Child Neurobehavioral Outcomes

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 274-276.


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Can Imaging with FDG-PET Help Exclude Malignancy in Cytologically Indeterminate Thyroid Nodules?

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 267-270.


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Postsurgically Hypothyroid Patients on Stable L-T4 Doses in Temperate Climates Have Higher Serum TSH Concentrations During the Coldest Months of the Year

Clinical Thyroidology Jul 2017, Vol. 29, No. 7: 280-282.


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Genome-Wide Transcriptional Dynamics in the Companion Bacterial Symbionts of the Glassy-Winged Sharpshooter (Cicadellidae: Homalodisca vitripennis) Reveal Differential Gene Expression in Bacteria Occupying Multiple Host Organs

The agricultural pest the Glassy-winged sharpshooter, Homalodisca vitripennis (Hemiptera: Cicadellidae: GWSS), harbors two bacterial symbionts, "Candidatus Sulcia muelleri" and "Ca. Baumannia cicadellinicola", that provide the ten essential amino acids (EAAs) limited in the host plant-sap diet. Although differing in origins and symbiotic age, both bacteria have experienced extensive genome degradation resulting from their ancient restriction to specialized host organs (bacteriomes) that provide cellular support and ensure vertical transmission. GWSS bacteriomes are of different origins and distinctly colored red and yellow. While Sulcia occupies the yellow bacteriome, Baumannia inhabits both. Aside from genomic predictions, little is currently known about the cellular functions of these bacterial symbionts, particularly whether Baumannia in different bacteriomes perform different roles in the symbiosis. To address these questions, we conduct a replicated, strand-specific RNA-seq experiment to assay global gene expression patterns in Sulcia and Baumannia. Despite differences in genomic capabilities both symbionts exhibit similar profiles of their most highly expressed genes, including those involved in nutrition synthesis and protein stability (chaperonins dnaK and groESL) that likely aid impaired proteins. Baumannia populations in separate bacteriomes differentially express genes enriched in essential nutrient synthesis, including EAAs (histidine and methionine) and B-vitamins (biotin and thiamine). Patterns of differential gene expression further reveal complexity in methionine synthesis. Baumannia's capability to differentially express genes is unusual as ancient symbionts lose the capability to independently regulate transcription. Combined with previous microscopy, our results suggest that the GWSS may rely on distinct Baumannia populations for essential nutrition and vertical transmission.

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Early Pliocene anuran fossils from Kanapoi, Kenya, and the first fossil record for the African burrowing frog Hemisus (Neobatrachia: Hemisotidae)

Publication date: Available online 13 July 2017
Source:Journal of Human Evolution
Author(s): Massimo Delfino
Isolated amphibian bones from the early Pliocene of Kanapoi (West Turkana, Kenya) help to improve the scarce fossil record of the late Neogene and Quaternary amphibians from East Africa. All currently available 579 bones are referable exclusively to the Anura (frogs and toads). More than half of the remains (366) are identified as Hemisus cf. Hemisus marmoratus, an extant species that still inhabits Kenya, but apparently not the northwest of the country and the Turkana area in particular. The rest of the remains are identified simply as Anura indet. because of poor preservation or non congruence with the relatively few African extant taxa whose osteology is known in detail. The Hemisus material represents the first fossil record for Hemisotidae, an endemic African family of peculiar, head-first burrowing frogs, whose sister taxon relationships indicate a divergence from brevicipitids in the Late Cretaceous or early Paleocene. The ecological requirements of extant H. marmoratus suggest that the Kanapoi area surrounding the fluvial and deltaic settings, from where the fossil remains of vertebrates were buried, was likely a grassland or relatively dry, open low tree-shrub savanna.



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Safe Life Defense Body Armor – Trusted by professionals

Safe Life Defense is a company on a mission. In the past year, the popularity of their Multi-Threat Body Armor has grown exponentially and it's not hard to see why. Safe Life Defense body armor offers unparalleled protection – defending against bullets, strikes, stabs, and slashes – and is known for being comfortable, an elusive quality in armor! Without question, Safe Life Defense ...

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Sensorimotor Learning: Neurocognitive Mechanisms and Individual Differences

Here we provide an overview of findings and viewpoints on the mechanisms of sensorimotor learning presented at the 2016 Biomechanics and Neural Control of Movement (BANCOM) conference in Deer Creek, OH. This f...

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California Casualty gives back to first responders with the Work Hard/Play Hard contest

SAN MATEO, Calif. — Whether it's facing down 40 foot flames in a raging wildfire, performing lifesaving treatment to accident victims, stopping criminals or charging into a smoke-filled home to rescue children, you work hard to make our communities safer and better. California Casualty has supported first responders for over 40 years and we realize the tough work that you do. We want to ...

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Examination of Routine Use of Prenatal Weight Gain Charts as a Communication Tool for Providers

Abstract

Objectives In 2009 the IOM revised prenatal weight gain guidelines. The primary purpose of this pilot study was to assess if provider education and use of prenatal weight gain charts to track weight gain and counsel patients was associated with better patient and provider knowledge and communication about the guidelines. Methods A prospective non-randomized study conducted in four OB practices (two control, two intervention). Data sources included provider surveys (n = 16 intervention, 21 control), patient surveys (n = 332), and medical records. Intervention clinics received provider education on the IOM guidelines and used patient education materials and prenatal weight gain charts to track weight gain and as a counseling tool. Comparison clinics received no education and did not use the charts or patient education information. Results More patients at intervention clinics (92.3%) reported that a provider gave them advice about weight gain, compared to patients from comparison clinics (66.4%) (p < 0.001). Intervention patients were also more likely to report satisfaction discussions with their provider about weight gain (83.1 vs. 64.3%, p = 0.007). Intervention clinic patients were more likely to have knowledge of the guidelines indicated by 72.3% reporting a target weight gain amount within the guidelines versus 50.4% of comparison patients (p < 0.001). Conclusion Provider education and use of weight gain charts resulted in higher patient reported communication about weight gain from their provider, higher patient satisfaction with those discussions, and better knowledge of the appropriate target weight gain goals.

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Staff Nurse – Vitalink - New Hanover Regional Medical Center

Staff Nurse – Vitalink Full-Time, Rotating Schedule New Hanover Regional Medical Center Wilmington, NC New Hanover Regional Medical Center's Emergency Transport Services (ETS) is a recognized leader at both state and national levels. Recent awards include: the 2016 American Heart Association Mission Lifeline Gold Award Recognition for EMS, AirLink, and VitaLink, the 2016 EMS National Association ...

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Critical Care Transport Paramedic – Vitalink - New Hanover Regional Medical Center

Critical Care Transport Paramedic – Vitalink Full-Time, Rotating Schedule New Hanover Regional Medical Center Wilmington, NC New Hanover Regional Medical Center's Emergency Transport Services (ETS) is a recognized leader at both state and national levels. Recent awards include: the 2016 American Heart Association Mission Lifeline Gold Award Recognition for EMS, AirLink, and VitaLink, the ...

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ImageTrend announces finalists for third annual Hooley Awards

LAKEVILLE, Minn. — ImageTrend, Inc. announced the nine finalists for this year's Hooley™ Awards. The winners will be announced at the company's ImageTrend Connect 2017 conference on July 19, 2017. The Hooley Awards recognize innovators and thought leaders, honoring their involvement, creativity and passion in three categories: Innovation, Service and New Frontier. "Great ...

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Introducing the HAMILTON-T1 Transport Ventilator for Armed Forces

Fully-featured ICU ventilation for military patient transports under the world's toughest conditions Specially modified for military compliance to meet the highest demands in the most challenging environments worldwide, Hamilton Medical's transport ventilator is now available for use by armed forces to safely accompany critical care patients in the air, on land, and at sea. After successfully ...

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Perceptions and Practices Related to Obesity in Adolescent Students and Their Programmatic Implications: Qualitative Evidence from Ho Chi Minh City, Vietnam

Abstract

Background Prevalence of obesity in children in Ho Chi Minh City is rising in the last 10 years. We conducted a formative study to explore the perceptions and practices related to obesity, diet and physical activity among the students in two junior high schools in two suburbs in Ho Chi Minh City to aid in the design of an intervention in preventing obesity among adolescent school children. Method We conducted in-depth interviews with twenty participants including students, their parents, physical education teachers and a representative of the Department of Education. Manually coded and organized data were analysed applying a thematic analysis approach to divulge trends, diversities and similarities among the emerging themes. Results The study revealed diversified perceptions of obesity, diet and physical activity and their relationship with adolescent obesity. The findings indicated low practice of physical activity among almost all students who participated in the study. The major barriers to obesity prevention included knowledge gaps, food environment in the school, devaluation of physical activity and academic burden. Conclusion The findings provide contextual insights to design a culturally appropriate and feasible intervention to tackle child and adolescent obesity by harnessing the perspectives of the target populations.

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Table of Contents, Volume 173A, Number 8, August 2017

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23andMe resumes giving consumers genetic health information

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In this issue

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Publication schedule for 2017

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Greater focus on patient data sharing urged

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Cover Image, Volume 173A, Number 8, August 2017

The cover image, by Monica H. Wojcik et al., is based on the Clinical Report A new diagnosis of Williams-Beuren syndrome in a 49-year-old man with severe bullous emphysema, DOI: 10.1002/ajmg.a.38289.

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The response to Trendelenburg position is minimally affected by underlying hemodynamic conditions in patients with aortic stenosis

Abstract

Purpose

Trendelenburg positioning is commonly used to temporarily treat intraoperative hypotension. The Trendelenburg position improves cardiac output in normovolemic or anesthetized patients, but not hypovolemic or non-anesthetized patients. Therefore, the response to Trendelenburg positioning may vary depending on patient population or hemodynamic conditions. We thus tested the hypothesis that the effectiveness of the Trendelenburg position, as indicated by an increase in cardiac output, improves after replacement of a stenotic aortic valve. Secondarily, we evaluated whether measurements of left ventricular preload, systolic function, or afterload were associated with the response to Trendelenburg positioning.

Methods

This study is a secondary analysis of a clinical trial which included patients having aortic valve replacement (AVR) who were monitored with pulmonary artery catheters (NCT01187329). We examined changes in thermodilution cardiac output with Trendelenburg positioning before and after AVR. We also examined whether echocardiographic and hemodynamic measurements of preload, afterload, and systolic function were associated with changes in cardiac output during Trendelenburg positioning.

Results

Thirty-seven patients were included. The median [IQR] cardiac output change with Trendelenburg positioning was −3% [−10%, 5%] before AVR versus +4% [−4%, 15%] after AVR. Estimated median difference in cardiac output with Trendelenburg was 5% (95% CI 1, 15%, P = 0.04) greater after AVR. The response to Trendelenburg positioning was largely independent of hemodynamic conditions.

Conclusion

The response to Trendelenburg positioning improved following AVR, but by a clinically unimportant amount. The response to Trendelenburg positioning was independent of hemodynamic conditions.

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Editorial Board

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Cardiac arrest research funding dwindles

American Heart Association DALLAS — National Institutes of Health funding to conduct cardiac arrest research has dwindled in the last decade and is a fraction of what the government spends to study other leading causes of death, according to new research in Journal of the American Heart Association, the Open Access Journal of the American Heart Association/American Stroke Association. Study authors ...

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The Use of ACOG Guidelines: Perceived Contraindications to IUD and Implant Use Among Family Planning Providers

Abstract

Objectives The uptake and actual use of the current guidelines from the American College of Obstetrics and Gynecology (ACOG) is unknown. Methods Family planning providers across Colorado and Iowa were surveyed as part of statewide initiatives to reduce unintended pregnancy in 2010 and 2012, both before and after the release of the guidelines. These initiatives focused on the promotion of intrauterine devices (IUDs) and implants. These surveys included questions on providers' views regarding the suitability and safety of the copper T IUD, hormonal IUD, and single rod implant for various subgroups of clients. The results are contrasted with guidelines provided in July of 2011 by ACOG. This strategy provides both baseline and follow-up models about the methods promoted in these guidelines. Results Findings show that there is some improvement in beliefs that IUDs are suitable and safe for women who are post-partum, post-abortion, have had an ectopic pregnancy, are nulliparous, teenagers, or have a history of STIs. However, these clinicians' views are not entirely in alignment with ACOG recommendations in their beliefs that these methods should not be used immediately post-partum or post-abortion. Notable percentages of these clinicians were hesitant to recommend these effective methods for other groups of patients, approved for use by ACOG. Conclusions While the cost of these methods is a barrier to adoption, these data suggest that there are continuing provider barriers to their use as well. The paper concludes with suggestions for further training for family planning providers.

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Using indocyanine green fluorescent imaging to successfully resect metachronous regional lymph node recurrence of rectosigmoid cancer

Abstract

A 39-year-old female patient underwent anterior resection with locoregional lymph node dissection for rectosigmoid cancer at another hospital. The procedure involved transection of the superior rectal artery just below the origin of the left colic artery. Postoperative diagnosis was stage III B. The patient received adjuvant chemotherapy with oxaliplatin plus capecitabine for 6 months. Sixteen months after the operation, PET-CT scans revealed regional lymph node metastases around the root of the inferior mesenteric artery. The patient was referred to our hospital with a recurrence of rectosigmoid cancer. We performed laparoscopic lymph node dissection with real-time indocyanine green fluorescent images superimposed on color images to prevent intraoperative vascular insufficiency. We were able to successfully observe the sufficient blood flow in the descending colon. Postoperative pathological findings showed lymph node recurrence after initial surgery. She was discharged 7 days after the operation. In the 8 months since the second operation, the patient has not had any indication of further recurrence.

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Laparoendoscopic single-site surgery in inguinal hernia repair

Abstract

Laparoendoscopic single-site surgery (LESS) for laparoscopic inguinal hernia repair (IHR) offers the potential for excellent cosmetic outcomes and maximization of the inherent advantages of minimally invasive surgery. LESS IHR is associated with a steep learning curve, which is attributable to both the IHR technique itself and the single-site technique. The technical obstacles in the single-site technique may be mitigated by employing certain maneuvers and strategies that minimize clashing between instruments and improve freedom of movement. The current literature consistently points out the inherent challenges in LESS IHR, with its longer operative time compared to that of conventional laparoscopic IHR. LESS IHR performed by capable operators has comparable complication rates, duration of hospital stay, and incidence of recurrence as conventional laparoscopic IHR. LESS IHR is both feasible and safe. Given its excellent cosmetic outcome, it is likely to be sought by younger patients who are concerned with scar formation. The use of robotics may bypass the technical challenges in LESS, but cost considerations in their usage will likely persist.

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Robotic mitral valve plasty for mitral regurgitation after blunt chest trauma in Barlow's disease

Abstract

We successfully treated a case of mitral regurgitation due to chest trauma in Barlow's disease. A 71-year-old man was admitted with severe mitral regurgitation after blunt compression of the chest by a heavy object 5 months earlier. Preoperative examination revealed wide chordae tendineae rupture and myxomatous changes to the bileaflets. Neo-chordae reconstruction of the anterior mitral leaflet using loop technique, triangular resection of the posterior mitral leaflet, and ring annuloplasty was performed via surgical robot. Robotic mitral valve plasty for severe mitral regurgitation due to chest trauma in Barlow's disease was achieved safely with good clinical and excellent cosmetic results.

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Successful laparoscopic treatment of advanced rectal cancer in an extremely elderly man (101 years and 9 months)

Abstract

An extremely elderly man (age, 101 years and 9 months) visited our hospital because of recurrent and worsening anal bleeding. Type 2 rectal cancer was found in his rectum during colonoscopy. He did not have any severe coexisting diseases and had not suffered any episodes of dementia. Laparoscopy-assisted anterior resection combined with D2 lymph node dissection was performed with minimal bleeding. The operation time was 128 min. The patient suffered mild reflux pneumonia on postoperative day 6 and was administered additional antibiotics. He recovered within 2 days. He was discharged on postoperative day 17, at which point he was able to walk.

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Laparoscopic surgery to remove a cage that migrated to the retroperitoneal space during posterior lumbar interbody fusion: A case report

Abstract

Introduction

Cage migration into the retroperitoneal space during posterior lumbar interbody fusion rarely occurs. Here, we report a patient who underwent laparoscopic surgery to remove a migrated cage from the retroperitoneal space.

Case Presentation

A 76-year-old woman had a cage that had migrated into the retroperitoneal space during posterior lumbar interbody fusion. On abdominal CT, the migrated cage appeared at the front of the promontorium, just below the aortic and vena caval bifurcations. One day later, the patient underwent laparoscopic surgery using intraoperative fluoroscopy to extract the migrated cage. The patient's postoperative course was uneventful, and she was discharged on the fifth postoperative day.

Discussion

A cage that migrates during posterior lumbar interbody fusion can have serious consequences. In cases where the patient remains in stable condition, laparoscopic surgery is a useful and suitable method for removing the cage from the retroperitoneal space.

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