Subdural hematoma (SDH) is a rare complication in patients after lumbar puncture. We report two patients receiving hematopoietic stem cell transplantation (HSCT) who developed post-dural puncture headache (PDPH) and SDH following intrathecal methotrexate (MTX). Both patients initially had normal computed tomography (CT) scan findings at the onset of headache. The diagnosis was established only when a repeat CT brain scan was performed for deteriorating neurological signs coinciding with improving platelet counts. These cases demonstrate the importance of continued vigilance for the early recognition of this salvageable entity. A normal initial CT finding and platelet count do not exclude the occurrence of SDH. A repeat CT scan, or even magnetic resonance imaging (MRI), are indicated if the clinical suspicion remains strong.

An 18-year-old male was admitted with severe back pain and inability to move both his lower limbs for the past two months. Back pain was insidious in onset, progressive and pain was present during rest. Two months back, patient noticed weakness of both lower limbs while walking which progressed to complete inability to move both lower limbs for the past one month. Patient gave history of intermittent low grade fever and weight loss in the past two months. He also gave history of bowel and bladder incontinence for the past one month. There was no contact history for tuberculosis. He had tenderness in the lower back and neurological examination revealed Grade 0 power in both lower limbs with hypotonia. Sensory loss started from mid thigh to involve the legs, ankles and feet of both lower limbs. The knee jerk and ankle jerk were absent and there was no response for plantar reflex. Patient had stage three pressures sore over his sacrum. His hemoglobin was 10.5 gm% with increase in the total WBC count and erythrocyte sedimentation rate. Other laboratory investigations were normal.His radiographs showed no significant abnormality, MRI [ Fig-4] showed hyperintense T2 signal from L4 body with soft tissue enhancement involving both the psoas muscles, fluid collection in the paraspinal muscles and an extension into the spinal canal from L2 to L5 vertebrae causing a complete block in the myelogram. The disc spaces were normal and there were no skip lesions on the MRI. The radiologist had given a differential diagnosis with infective spondylitis being the first diagnosis and malignant pathology being the subsequent diagnosis.Patient was taken up for posterior spinal surgery, through a posterior midline incision L2 to L5 vertebra were exposed and there was frank pus in the paraspinal region which was collected for culture and sensitivity. Decompressive laminectomy was performed at L3 and L4 vertebra to enter the spinal canal. There was a layer of granulation tissue covering the dura as in tuberculosis pathology, which was carefully separated from the dura and sent for histopathological analysis. Transpedicular bone sample obtained from L4 vertebra and was sent for histopathological analysis. The levels were stabilized Postoperatively the patient had good pain relief and was made to sit up with a brace on the second postop day. Neurology was reassesed and the motor power in both lower limbs were zero and sensory loss remained the same too. However, the patient had full recovery of bowel and bladder function. HistopatHology Microscopic DescriptionSections show fibrocollagenous stroma and skeletal muscle fibres infiltrated by a malignant neoplasm arranged in diffuse sheaths, nests and pseudo acinar pattern. Ewing's sarcoma is a primary malignancy of the bone affecting individuals in the second decade of life. Primary sarcomas of the spine are rare and the occurrence of Primary Ewing's sarcoma in the spine is very rare. Ewing's sarcoma occurring in the spine is divided into two types, Ewing's sarcoma of sacral spine which are v...

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INTRODUCTIONDifferentiated thyroid cancer (DTC) account for the vast majority (90%) of all thyroid cancers and includes papillary (70-75%) and follicular (15-20%) cancers. 1,2 Follicular carcinoma of thyroid is a slow growing tumour with peak incidence in fifth decade and three times more common in females.3 Differentiated thyroid cancer metastasis to the lung (49%) followed by bone (25%). Bone metastasis is commonly seen in follicular carcinoma (7-28%) than in papillary carcinoma (1-7%). 4,5 Spine is the most common part of bone metastasis of follicular carcinoma and is primarily osteolytic. The primary concern with metastasis is pathologic fracture and/or spinal cord compression, which may lead to intractable pain, sensory alterations, weakness, and/or paralysis.6,7 Management is curative or palliative and includes surgery, radioiodine ablation, selective embolization, and medical management. 8,9 In this study, we present a retrospective analysis of five patients with follicular carcinoma of thyroid with spinal metastasis treated surgically. ABSTRACTBackground: Spine is the most common part of bone metastasis of follicular carcinoma and is primarily osteolytic. The primary concern with metastasis is pathologic fracture and/or spinal cord compression, which may lead to intractable pain, sensory alterations, weakness, and/or paralysis. Management is curative or palliative and includes surgery, radioiodine ablation, selective embolization, medical management. In this study, we present a retrospective analysis of five patients with follicular carcinoma of thyroid with spinal metastasis treated surgically. Methods: With the approval of the institutional review board, we retrospectively analyzed all the patients who underwent surgery for follicular carcinoma of thyroid with spinal metastasis from Jan 2011 to Jan 2015 at Sri Ramachandra Medical Centre. Patients were considered for spine surgery, when they had severe pain and/or neurological deficit, spinal instability and Tokuhashi score of at least 9. Total of 5 patients with follicular carcinoma underwent spinal surgery. Results: Three patients had improvement in KPS scores; one had no change and remaining one had lower KPS score at final follow up. Four out of the five patients (80%) had improvement in VAS pain scores. Conclusions: Even though there are no established regimens in treating spinal metastasis from follicular carcinoma of thyroid and very few reports published in this regard, curative/palliative spine surgery along with radioiodine ablation gives short to midterm remission and clinical improvement in this patient group.

Objective: To do a retrospective evaluation of clinical outcome of the patients with spinal metastases treated with minimally invasive posterior spinal stabilization and vertebroplasty. Methods and results:We retrospectively analyzed 22 patients with biopsy proven metastatic thoracolumbar spinal lesion treated with percutaneous posterior stabilization with pedicle screws and vertebroplasty operated in Ramachandra Medical University from June 2006 to May 2012. Neurologically intact patients with Tokuhashi's score of 9 or and Spine instability neoplastic score of more than 6 were included. Average age group was 61.8 years with 14 males and eight females. Clinical outcome was assessed using pre-and postoperative visual analog score (VAS), intraoperative blood loss, duration of surgery, time taken to mobilize the patients after surgery and length of hospital stay.The average VAS decreased from 9.2 preoperatively to 4.1 postoperatively (p < 0.001) and 2.2 (< 0.04) at 3 months postoperative period. The mean Karnofsky's performance index increased from 45% preoperatively to 70% postoperatively. Average blood loss was 80 ml and the average duration of surgery was 85 minutes. Fifteen patients were mobilized on the second postoperative day with most patients discharged on 4th day. No patients had evidence of implant loosening and failure. Three patients had radiological evidence of cement extravasation. No patient had neurological deficit postope ratively and none had radiological evidence of deformity or adjacent level fracture in follow-up X-rays. Conclusion:Percutaneous pedicle screw stabilization with vertebroplasty provided good pain relief and short-term clinical improvement in patients with thoracolumbar spinal metastasis with minimal postoperative morbidity.