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Transthoracic computed tomography-guided core needle biopsy (TTNB) is a well-established method for diagnosing focal pulmonary lesions. However, the dangers associated with this method as well as the significant number of complications caused by it cannot be ignored. Systemic air embolism is a rare but potentially fatal complication that can accompany transthoracic needle biopsies of pulmonary lesions. In this study, we report nonfatal systemic air embolism as a complication of a transthoracic needle core biopsy of a subpleural nodule in the right upper pulmonary lobe of a patient with hemoptysis. Although extremely rare, the complication may result in a transient myocardial ischemia, which is presented with a transient depression of the ST segment.

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We describe a case of acute obstructive hydrocephalus as a consequence of compression of the brainstem by a large aneurysm of the basilar artery (BA) in a 62-year-old male. After the insertion of the ventriculoperitoneal shunt (VPS), we encountered the "locked-in syndrome" clinical condition. "Locked-in syndrome" is a clinical state characterized by quadriplegia and anarthria with preserved consciousness, most commonly caused by ischemia in the ventral part of pons.

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STUDY DESIGN: A prospective cohort study. OBJECTIVE: To evaluate whether an annular closure device could be implanted safely to reduce same-level recurrent disk herniation, or attenuate disk height loss and improve the outcome after lumbar discectomy. SUMMARY OF BACKGROUND DATA: Same-level recurrent disk herniation, disk height loss, and progressive degeneration are common complications and sequelae after lumbar discectomy. Techniques to reduce these consequences may improve outcomes. METHODS: Forty-six consecutive patients undergoing lumbar discectomy for single-level herniated disk at 2 institutions were followed prospectively with clinical and radiographic evaluations at 6 weeks and 3, 6, 12, and 24 months (control cohort). A second consecutive cohort of 30 patients undergoing 31 lumbar discectomies with implantation of an annular closure device was followed similarly. Incidence of recurrent disk herniation, disk height loss, the leg and back pain visual analog scale (VAS), and the Oswestry Disability Index were assessed at each follow-up. RESULTS: Cohorts were well matched at baseline. By 2 years of follow-up, symptomatic recurrent same-level disk herniation occurred in 3 (6.5%) patients in the control cohort versus 0 (0%) patients in the annular repair cohort (P=0.27). A trend of greater preservation of disk height was observed in the annular repair versus the control cohort 3 months (7.9 vs. 7.27 mm, P=0.08), 6 months (7.81 vs. 7.18 mm, P=0.09), and 12 months (7.63 vs. 6.9 mm, P=0.06) postoperatively. The annular closure cohort reported less leg pain (VAS-LP: 5 vs. 16, P<0.01), back pain (VAS-BP: 13 vs. 22, P<0.05), and disability (Oswestry Disability Index: 16 vs. 22, P<0.05) 1 year postoperatively. CONCLUSIONS: Implantation of a novel annular repair device was associated with greater maintenance of disk height and improved 1-year leg pain, back pain, and low-back disability. Recurrent disk herniation did not occur in any patient after annular repair. Closure of annular defect after lumbar discectomy may help preserve the physiological disk function and prevent long-term disk height loss and associated back and leg pain.

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OBJECTIVE: To assess the potential benefits of disk reherniation reduction and disk height maintenance in limited diskectomy combined with the implantation of the anular closure device. SUMMARY AND BACKGROUND DATA: Postoperative disk height loss is apparent in most patients undergoing lumbar diskectomy for herniated nucleus pulposus. Less favorable patient outcomes are associated with significant loss in disk height that can occur after aggressive disk tissue removal. More conservative disk removals, however, are often burdened by the increased risk of recurrent disk herniation. METHODS: Two prospective single-arm studies on patients treated with limited diskectomy and an anular closure device were conducted. Outcome measures included disk height maintenance relative to preoperative values, Oswestry Disability Index, back pain, leg pain, and complications such as reherniations. Patients were evaluated preoperatively and postoperatively at 6 weeks and at 3-, 6-, 12-, and 24-month time points. RESULTS: A total of 75 patients were included in this cohort consisting of 40 men and 35 women with an average age of 40 years. Disk height maintenance within the group overall was 90% at 24 months. Overall, 97% of the treated disks demonstrated disk height maintenance of at least 75% of preoperative levels at 12 months and 92% at 24 months. Disk height maintenance was correlated with less nucleus removal. Patient disability, back pain, and leg pain were significantly improved from preoperative levels at 6 weeks and maintained over the course of study. There was a single symptomatic reherniation requiring surgical intervention within this series. CONCLUSIONS: Limited lumbar diskectomy combined with the use of an anular closure device provided very low rates of disk reherniation and exhibited excellent disk height maintenance and sustained disability, leg pain, and back pain improvement within a 24-month postoperative study period. As with prior diskectomy studies, disk height maintenance was correlated with lower nucleus removal, although recurrence was less than in prior reports of limited diskectomy. Anular closure may allow for achievement of both objectives.

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Annular Reinforcement Device represents a modification of operative treatment of intervertebral disk herniation. It is a prosthesis that is anchored into the body of the vertebra. The intradiscal part of the implant is placed in the inner part of the annulus fibrosus defect. The aim of this technique is to reduce the incidence of reherniation and the degree of intervertebral space collapse, which is the most frequent adverse effect of diskectomy. Clinical outcomes of the treatment group indicated a statistically significant improvement with respect to the control group. Furthermore, over the period of two years, no cases of symptomatic reherniation were recorded. Considering that no serious complications occurred during the procedures, it would appear that this is an implant that, given its encouraging results, should be further verified in carefully designed future studies.

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OBJECTIVE: Same-level recurrent disc herniation is a well-defined complication following lumbar discectomy. Reherniation results in increased morbidity and health care costs. Techniques to reduce these consequences may improve outcomes and reduce cost after lumbar discectomy. In a prospective cohort study, we set out to evaluate the cost associated with surgical management of recurrent, same-level lumbar disc herniation following primary discectomy. METHODS: Forty-six consecutive European patients undergoing lumbar discectomy for a single-level herniated disc at two institutions were prospectively followed with clinical and radiographic evaluations. A second consecutive cohort of 30 patients undergoing 31 lumbar discectomies with implantation of an annular closure device was followed at the same hospitals and same follow-up intervals. Cost estimates for reherniation were modeled on Medicare national allowable payment amounts (direct cost) and patient work-day losses (indirect cost). RESULTS: Annular closure and control cohorts were matched at baseline. By 2 years follow-up, symptomatic recurrent same-level disc herniation occurred in three (6.5%) patients in the control cohort versus zero (0%) patients in the annular closure cohort. For patients experiencing recurrent disc herniation, mean estimated direct and indirect cost of management of recurrent disc herniation was $34,242 and $3,778, respectively. Use of an annular closure device potentially results in a cost savings of $222,573 per 100 primary discectomy procedures performed (or $2,226 per discectomy), based solely on the reduction of reoperated reherniations when modeled on U.S. Medicare costs. CONCLUSIONS: Recurrent disc herniation did not occur in any patients after annular closure within the 12-month follow-up. The reduction in the incidence of reherniation was associated with potentially significant cost savings. Development of novel techniques to prevent recurrent lumbar disc herniation is warranted to decrease the associated morbidity and health care costs associated with this complication.

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We have a 30-year-old female patient suffering from secondary hydrocephalus. She has had a ventriculoperitoneal shunt (VPS) implanted following a rupture and a successful clipping of the aneurysm of the anterior communicating artery (ACoA). Three weeks after implanting of the VPS, respiratory and abdominal difficulties with febrility appeared. We diagnosed cerebrospinal fluid liver pseudocyst using ultrasound (US) and computer tomography scan (CT). Given that we found bacteria in the cerebrospinal fluid (CSF), we converted VPS into an external ventricular drain (EVD). After that, we conducted a US-guided punction and drainage of the CSF liver pseudocyst. The subsequent CT of abdomen showed a regression of the cystic form. The patient died following the septic condition with multiple organ failures (MOF) a month after the cerebrospinal fluid liver pseudocyst diagnosis.The perforation of parenhimatose abdominal organs with distal part of VPS is a rare complication which is most likely a consequence of a shunt infection and of an immunological reaction that took place during the process of localizing an infection.

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AIMS: Renal arterial pseudoaneurysm is a rare complication of renal transplantation that often causes a graft loss. A recent successful outcome of the operative treatment and a reappearance of a pseudoaneurysm and a possibility of watchful followup of pseudoaneurysm encouraged us to present our modest experience with pseudoaneurysm after renal transplant. MATERIAL AND METHODS: In our series of 843 renal transplants performed during 37 years vascular complications were observed in 57 (6.76%) patients. Pseudoaneurysm occurred in three patients (0.35%). The first pseudoaneurysm was found in 1973. A 23-year-old male patient received a double renal artery kidney from HLA identical brother. The upper renal artery was anastomosed by an end-to-end way with the internal iliac artery, and and the lower renal artery by end-to-side way to the external iliac artery. Five weeks after transplant an arteriography was performed because of the bruits heard over the transplant. A 15 x 10-mm pseudoaneurysm was revealed on the end-to-end anastomosis between internal iliac and upper renal artery. Six weeks after transplant a renal arterial resection and an end-to-side anastomosis between renal artery and common iliac artery was performed. The 38-year-old male patient received his second transplant from a 17-year-old female donor dead after craniocerebral trauma in December 2004. Two renal arteries were anastomosed separately with external iliac artery using aortic patches. Two and half moths after transplant he was admitted for an increase of creatinine level and hypertension. Color Doppler, dynamic scintigraphy and an angiography revealed a 20 x 1,3 mm aneurysmatic formation at the anastomosis of upper renal artery. The flow in the belonging part of the transplant was reduced. At surgical intervention a saphenous vein graft between internal iliac artery and renal artery was performed. Ischemia time was 15 min. The pseudoaneurysm was removed. A hole on external iliac artery was closed with a saphenal patch. The 38-year-old female patient received her second transplant in January 2005 from cadaver. There were 3 arteries. The upper polar arterywas first anastomosed to principal renal artery Then both arteries were anastomosed to external iliac artery termino-laterally. RESULTS: In the first patient a lesion of the ureteral anastomosis caused an infection, thrombosis of lower artery and a graft loss 4 months and half after transplant. The second patient was admitted urgently 3.5 months after the repair of his pseudoaneurysm because of the pain in the pelvic region. He was working that day during several hours in sitting position on his terrace. Immediate examination with color Doppler revealed a large 6 x 7-cm pseudoaneurysm medially of the transplant. An arteriography demonstrated a pseudoaneurysm with a blood leakage most likely at the site of the closure of external iliac artery with a saphenal vein patch. The arteriography showed a slower and diminished blood flow in the lower part of the transplant. At intervention the pseudoaneurysm was removed. The external iliac artery was considerably damaged and replaced with Goretex prostesis 6 mm. Unfortunately the transplant lower artery could not be saved. A microbiological examination of pseudoaneurysm in both patients was negative. In the third case we chose a watchful follow-up. Last Doppler controls show reduction of psudoaneurysm. DISCUSSION AND CONCLUSIONS: The development of a pseudoaneurysm of a transplant artery is very rare complication. Since actually ultrasonography is routinely used, a pseudoaneurysm can be easily detected. Color Doppler allows a differential diagnosis from hematoma, urinoma and lymphocele. Unfortunately a pseudoaneurysm after renal transplant often causes a loss of the transplant. The first patient had successful resection of a pseudoaneurysm, but the transplant was lost because of infection. The other patient had a subsequent pseudoaneurysm after the repair of the first. Unfortunately its repair caused an exclusion of the lower part of the kidney, but the residual renal function is satisfactory. In the third patient we chose a follow-up aware that each intervention could cause a graft loss.

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Spontaneous or non-traumatic gas gangrene is a rare condition. The present report refers to a previously healthy 57-y-old male who developed gas gangrene in the left lumbar region, left flank, left scapular, inguinal and suprapubic regions. Despite surgical, intensive care treatment, and antibiotic therapy, the patient died 32 h after the onset of the first symptoms.

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