Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report

Abstract

Vertebroplasy is considered an alternative and effective treatment of painful oncologic spine disease. Major complications are very rare, but with high morbidity and occur in less than 1% of patients who undergo vertebroplasty. Spinal subdural hematoma (SDH) is an extremely rare complication, usual developing within 12 h to 24 h after the procedure. We report the case of a tardive SDH in an oncologic patient who underwent VP for Myxoid Liposarcoma metastasis. Trying to explain the pathogenesis, we support the hypothesis that both venous congestion of the vertebral venous plexus of the vertebral body and venous congestion due to a traumatic injury can provoke SDH. To our best knowledge, only 4 cases of spinal subdural hematoma following a transpedicular vertebroplasty have been previously described in International literature and only one of them occurred two weeks after that surgical procedures. Percutaneous verteboplasty is a well-known treatment of pain oncologic spine disease, used to provide pain relief and improvement of quality life and is considered a simple surgical procedure, involving a low risk of complications, but related to high morbidity, such as SDH. Therefore it has to be performed by experienced and skilled surgeons, that should also recognize possible risk factors, making SDH more risky.

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World Journal of
Clinical Cases
World J Clin Cases 2017 August 16; 5(8): 307-348
ISSN 2307-8960 (online)

World Journal of
Clinical Cases
W
J C C
Contents Monthly Volume 5 Number 8 August 16, 2017
IWJCC
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www.wjgnet.com August 16, 2017
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Volume 5
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Issue 8
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EDITORIAL
307 Adjuvants to local anesthetics: Current understanding and future trends
Swain A, Nag DS, Sahu S, Samaddar DP
MINIREVIEWS
324 Treatment of sepsis: What is the antibiotic choice in bacteremia due to carbapenem resistant
Enterobacteriaceae
?
Alhashem F, Tiren-Verbeet NL, Alp E, Doganay M
CASE REPORT
333 Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report
Tropeano MP, La Pira B, Pescatori L, Piccirilli M
340 Pseudotumoral acute cerebellitis associated with mumps infection in a child
Ajmi H, Gaha M, Mabrouk S, Hassayoun S, Zouari N, Chemli J, Abroug S
344 Atlanto-axial langerhans cell histiocytosis in a child presented as torticollis
Tfifha M, Gaha M, Mama N, Yacoubi MT, Abroug S, Jemni H

Contents World Journal of Clinical Cases
Volume 5 Number 8 August 16, 2017
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ISSN 2307-8960 (online)
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Maria Pia Tropeano, Biagia La Pira, Lorenzo Pescatori, Manolo Piccirilli
CASE REPORT
333 August 16, 2017
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Vertebroplasty and delayed subdural cauda equina
hematoma: Review of literature and case report
Maria Pia Tropeano, Biagia La Pira, Lorenzo Pescatori, Manolo
Piccirilli, Department of Neurology and Psichiatry-Neurosurgery,
Policlinico Umberto I - Sapienza, University of Rome, 00185
Rome, Italy
Author contributions: Tropeano MP and Pescatori L designed
work and wrote the manuscript; La Pira B researched the
bibliography; Piccirilli M have supervised and corrected the
manuscript.
Institutional review board statement: This case report was
exempt from the Institutional Review Board standards at Sapienza
University of Rome.
Informed consent statement: Patient was informed about the
publication.
Conflict-of-interest statement: All the authors have no
conflicts of interests to declare.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Manuscript Source: Unsolicited Manuscript
Correspondence to: Maria Pia Tropeano, MD, Department of
Neurology and Psichiatry-Neurosurgery, Policlinico Umberto I -
Sapienza, University of Rome, Viale del Policlinico 155, 00185
Rome, Italy. mariapia.tropeano@libero.it
Fax: +39-06-49979111
Received: October 18, 2016
Peer-review started: October 23, 2016
First decision: December 20, 2016
Revised: April 30, 2017
Accepted: May 18, 2017
Article in press: May 19, 2017
Published online: August 16, 2017
Abstract
Vertebroplasy is considered an alternative and effective
treatment of painful oncologic spine disease. Major
complications are very rare, but with high morbidity
and occur in less than 1% of patients who undergo
vertebroplasty. Spinal subdural hematoma (SDH) is an
extremely rare complication, usual developing within
12 h to 24 h after the procedure. We report the case of
a tardive SDH in an oncologic patient who underwent
VP for Myxoid Liposarcoma meta stasis. Trying to
explain the pathogenesis, we support the hypothesis
that both venous congestion of the vertebral venous
plexus of the vertebral body and venous congestion
due to a traumatic injury can provoke SDH. To our best
knowledge, only 4 cases of spinal subdural hematoma
following a transpedicular vertebroplasty have been
previously described in International literature and only
one of them occurred two weeks after that surgical
procedures. Percutaneous verteboplasty is a well-
known treatment of pain oncologic spine disease,
used to provide pain relief and improvement of quality
life and is considered a simple surgical procedure,
involving a low risk of complications, but related to
high morbidity, such as SDH. Therefore it has to be
performed by experienced and skilled surgeons, that
should also recognize possible risk factors, making SDH
more risky.
Key words: Subdural hematoma; Liposarcoma; Surgery;
Radiotherapy; Vertebroplasty
© The Author(s) 2017. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: This is an original paper about a rare com-
plication of vertebroplasty: A subdural hematoma.
In literature there are only 4 cases described. To our
knowledge thid is the first case in which this complication
occur after 20 d. In this work we try to explain the
pathogenesis and the importance of a correct and rapid
diagnosis, and, if needed, an emergency treatment.
Submit a Manuscript: http://www.f6publishing.com
DOI: 10.12998/wjcc.v5.i8.333
World J Clin Cases 2017 August 16; 5(8): 333-339
ISSN 2307-8960 (online)
World Journal of
Clinical Cases
W
J C C

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Tropeano MP
et al
. Vertebroplasty and delayed subdural cauda equina hematoma
Tropeano MP, La Pira B, Pescatori L, Piccirilli M. Vertebroplasty
and delayed subdural cauda equina hematoma: Review of
literature and case report. World J Clin Cases
2017; 5(8): 333-339
Available from: URL: http://www.wjgnet.com/2307-8960/full/
v5/i8/333.htm DOI: http://dx.doi.org/10.12998/wjcc.v5.i8.333
INTRODUCTION
Myxoid liposarcoma is the most common subtype of
liposarcoma, accounting for 10% of all adult tissue
sarcomas[1]. The frequency of bone metastasis arising
from liposarcoma has been reported to be 14% and
17%[2]. In one of the largest series, which analyze
specically the development of bone metastases, the
incidence of spinal metastases was 83%[2]. Treatment
options included: Surgical excision, chemotherapy,
adjuvant radiotherapy, surgical decompression of
spinal metastasis after having their surgery elsewhere.
The rst percutaneous vertebroplasty in an oncological
patient, was performed at the University Hospital of
Amiens, France, to ll a vertebral void after the removal
of a benign spinal tumor, then it was quickly adopted also
for use in metastatic vertebral lesions and hematologic
malignancies such as multiple myeloma and lymphoma.
Clinical studies documented the effectiveness of VP
as an alternative treatment of painful oncologic spine
disease[3].
The rst vertebroplasty was performed by Galibert
in 1987 for a C2 hemangioma[4]. The first series
was reported in 1997 and since[5], it has become a
very common surgical technique for the symptomatic
treatment of painful osteoporotic vertebral fractures,
wedge-compression fractures, vertebral malignancies
and painful vertebral angiomas.
The goal is to provide pain relief and bone streng-
thening, injecting cement or calcium phosphate bone
cement into the vertebral body, via a transpedicular
or an extrapedicular approach under fluoroscopic
guidance. There is strong evidence of pain relief and
improvement in the patient’s quality life. Percutaneous
vertebroplasty is usually performed in the thoracic
and lumbar vertebrae and rarely in the cervical
vertebrae and cervico-thoracic junction. Absolute
contraindications are: Unstable fractures with posterior
element involvement, bleeding disorders, active local
infections and sepsis[6]. Relative contraindications are:
clinical conditions not allowing to lie prone, neurological
signs and symptoms due to vertebral body collapse or
tumor extension[7].
Major complications are very rare, but with high
morbidity and occur in less than 1% of patients
who undergo vertebroplasty. The most common are
anaphylaxis and hypotension due to an adverse reaction
to the cement, pneumothorax, pulmonary embolism
due to cement leakage, spinal cord compression
following the cement leakage, epidural or subdural
hematoma, vertebral injury, infections and death[8,9].
Most often, complications occur during surgery or
immediately following surgery. Late-developing
complications are infection, adjacent vertebral body
fractures and recurrent fracture; they appear within
days to weeks following surgical procedure. Spinal
subdural hematoma (SDH) is an extremely rare com-
plication, usual developing within 12 h to 24 h after the
procedure. To our knowledge, to date, only 4 cases have
been previously reported in International literature[10,11],
where only one of them occurred two weeks following
transpedicular vertebroplasty[12]. We report the case of
a tardive SDH in an oncologic patient who underwent
VP for Myxoid Liposarcoma metastasis.
CASE REPORT
We report the case of a 63-year-old man who presented
to our emergency department with bilateral inferior
limb numbness and weakness, mainly to the left leg
and complaining of bladder retention. Neurological
assessment revealed a 1/5 monoparesis of the left
inferior limb and 3/5 monoparesis of the right, as well
hypoesthesia and dysesthesia in the same region.
Perineal reflexes were absent. The patient was on
anticoagulants.
Three weeks prior to the onset of neurological
symptoms, the patient underwent percutaneous VP
of L1 and L3 vertebrae, in an oncology institute, for
pathological compression fractures, due to secondary
localization of a retroperitoneal myxoid liposarcoma,
removed several years before. VP was indicated by
an oncologist and performed at the above-mentioned
institute of oncology. Pathological anamnesis revealed
that the patient underwent surgery several times for
the removal of a retroperitoneal liposarcoma. In 1997
the patient underwent the first surgical procedure
for the removal of the lesion located in the upper left
quadrant of the retroperitoneal space. During the
same procedure, the left colon was also removed.
In 2004 a second surgical procedure was performed
for the removal of a local relapse of the lesion as well
as for the removal of the spleen. In February 2005 a
follow up abdominal magnetic resonance imaging (MRI)
showed the presence of another local relapse of the
pathology. In consequence, another surgical excision
of the lesion was performed, including excision of
the pancreatic tail. The procedure was proceeded by
the administration of a chemotherapeutic protocol
consisting of Antracicline and Ifosfamide. In November
2011 another surgical excision was performed. It
included the left part of the diaphragm as well as a
portion of the small intestine and the left half of the
transverse colon. Furthermore, on November 2013 the
patient underwent cyberknife radiotherapy.
Upon admittance at our emergency department for
paraparesis, an emergency spinal MRI with gadolinium
was obtained. Results showed the presence of a high
signal lesion in the intradural extramedullary space,
at the conus medullaris (Figure 1). Furthermore,

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the trajectory of the needle used to perform the
vertebroplasty was detected at L1 and L3 levels and
it suggested that the needle had passed through
the dura into the subarachnoid space and then into
the vertebral body (Figure 2). An emergency decom-
pressive bilateral laminectomy of L2 and L3 vertebrae
was performed. No epidural bleeding was observed.
A longitudinal durotomy revealed a blood clot, tightly
adherent to the cauda equina rootlets (Figure 3). The
hemorrhagic lesion was completely removed with the
assistance of a surgical microscope (Figure 4). After
the procedure, neurological symptoms progressively
disappeared and 5 d later, the patient completely
recovered both motor and sensory deficits, as well
as bladder functions. Postoperative MRI documented
adequate surgical decompression and removal of the
intradural lesion (Figure 5). Histological examination
confirmed the haemorrhagic origin of the lesion,
constituted by clots and fibrin, with no evidence of
tumor.
DISCUSSION
Liposarcoma is a common malignant soft tissue tumor,
accounting for 10% to 16% of all sarcomas[1]. It
typically affects patients between the fth and seventh
decade of life and usually develops in the extremities
or retroperitoneum[13]. It can be classified into five
distinct histological subtypes (WHO 1994): Well-
differentiated, dedifferentiated, mixed, round cell and
pleomorphic. Myxoid liposarcoma (MLS) is the second
most common subtype, accounting for 10% of all
adult soft tissue sarcoma, occurring more frequently
during the fourth and fifth decades of life[14]. It is
considered as a clinicopathologically and genetically
distinct type, characterized by its common occurrence
in young patient, its location in the thigh and the
presence of at translocation[12,15,16]. Specifically, it is
common associated with TLS-CHOP fusion transcript.
Differently from other soft-tissue sarcomas, that show
a tendency for metastasis to the lung, MLS has a
propensity to spread to extrapulmonary sites, including
bone. The frequency of bone metastasis is reported
at 14%[2] and 17%[16]. Furthermore, MLS presents
often as a multifocal disease, either synchronous or
metachronous. The degree to which MLS spreads to
bone has not been specifically studied and it is still
unclear if skeletal metastasis represents the usual
pattern of spread in MLS, or if it is the mark of specic
molecular subset. In a large series, including 40
patients who developed skeletal metastasis, 33 (83%)
were diagnosed with spine metastasis[2]. The spine
metastases demonstrated the typical MRI ndings of
MLP. T1 weight images were heterogenous with areas
go high signal intensity corresponding to the lipid
component and low signal to the mixed component,
as T2 images as well. The treatment of metastasis is
individualized to each patient. Surgical excision is the
treatment of choice; chemotherapy and radiotherapy
are also utilized. Percutaneous verteboplasty (VP)
is a well-known treatment of pain oncologic spine
disease, used to provide pain relief and improvement
of quality life. It was introduced for the rst time to ll
a vertebral void after a the removal of a benign spinal
tumor, since then it was introduced as a treatment
option also for primary and metastatic spinal tumor[17].
During the last few decades, improvement in surgical
Figure 1 T2 weighed magnetic resonance imaging of the lumbar tract of the spinal column on sagittal and axial planes. The images reveal the presence of
a lesion located within the spinal channel at L2-L3. It is not possible to establish if it is located within the intradural or extradural space by the mere observation of the
MRI. Note the needle trajectory inside the spinal channel at L1 on the right side.
Figure 2 T2 weighed magnetic resonance imaging of the L1 vertebra on
axial plane. As the image show, the trajectory of the needle used to perform
the vertebroplasty passes within the spinal channel on the left side.
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strategies and technologies, have increased disease-
free survival rates, in patient with a wide variety of
malignant tumors that were once considered inoperable.
Despite these advances, many patients present with
widespread tumor and minimal life expectancy and
surgical or any other aggressive treatment cannot be
medically or ethically considered[18]. Palliative strategies
are recommended in this cases, such methods include
medical management, pain management, vertebro-
plasty, radiotherapy. Vertebroplasty and Kyphoplasty
are usually indicated for the treatment of metastatic
spinal tumors without epidural compression, to improve
the anterior column stably of the spine in conjunction
with medical and radiation therapies and to obtain
pain relief[19]. In particular, these conservative pro-
cedures are recommended in elderly patients, at high
anesthetic risk, because less operating time under
anesthesia and minimal blood loss. Randomized,
multi centered and controlled trials, demonstrated
that the use of VP, specifically for spinal metastasis,
had an improvement in pain (among 73% to 100% of
patients), mobility and vertebral height restoration[20,21].
To our knowledge, Yang et al[22] conduct- ed the largest
vertebroplasty study in patients with metastatic spinal
disease. A total of 196 patients were treated during
the study and a 98.5% improvement in pain was seen,
as well as statistically significant improvements in
vertebral body height[22].
Percutaneous vertebroplasty is a therapeutic strategy,
that gained increasing popularity among the neuro-
surgical community for the treatment of refractory
axial mechanical pain due to osteoporotic fractures,
malignancy fractures and painful hemangiomas. With
time, the indications for vertebroplasty were extended
to include acute traumatic vertebral compression
fractures[23]. The therapeutic mechanism of action
consists of injecting polymethyl methacrylate into
the fractured vertebral body. There is evidence of
the ability of vertebroplasty to provide pain relief and
improvement of patient’s quality of life. Although it is a
safe procedure, the rate of major complications is from
0.5% to 1%, when it is conducted by experienced spinal
surgeons. Complications reported in literature are often
related to the cement extravasation into the epidural
space[24] (some series reported up to 20% extravasation
rates, occasionally requiring surgical decompression)
causing spinal cord compression, or related to the
cement migration through the epidural veins to the
venous system leading to pulmonary embolism[25]. To
our knowledge only 5 cases of SDH, including our own,
have been reported in literature (Table 1). Cosar et al[10]
reported two cases: An 18-year-old man with an acute
compression fracture of the L2 and L4 vertebrae (AO
Type A1.1), in whom both levels were treated with
Figure 3 Postoperative T2 weighed magnetic resonance imaging on sagittal and axial plane showing the proper execution of the bilateral laminectomy at
L2 L3 as well as the removal of the intradural lesion.
Figure 4 Intraoperative image by microscope, showing the dura mater
opened and the hematoma between the radiculae.
Figure 5 Intraoperative image by microscope, showing the complete
removal of the hematoma.
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vertebroplasty. The patient complained of severe
back pain immediately after the surgical procedure
and paraparesis developed in both his legs 12 h later.
Postoperative MRI showed spinal SDH extending
from T1 to L2, evacuated via cross-hemilaminectomy
from T-1 to L2. The second case reports a 75-year-
old woman with an osteoporotic compression fracture
at L1. The patient suffered psychosomatic symptoms
with paraparesis 24 h after the procedure. The
Postoperative MRI revealed spinal SDH extending from
T-10 to L-3, evacuated via T-12 laminectomy. Both
patients improved after the second surgical procedure,
but reported back pain after a few months, with an
MRI showing spinal arachnoiditis, controlled with
steroids and anti-inflammatory drug therapy. They
hypothesized that the spinal SDH developed after
puncture of the spinal dura mater and that venous
blood began to enter the subdural space slowly after
this trauma. This is reasonable, according to the time
of onset of symptom presentation.
Lee et al[12] reported a 40-year-old female with
an acute compression fracture of the T11 and T12
vertebrae, treated with successful transpedicular
VP, under continuous visualization with fluoroscopic
guidance. After two weeks, during which the patient’s
conditions were improving, she complained of acute
back pain. MRI imaging showed a high signal intensity
mass lesion in the intradural extra medullary space,
located at the lower thoracic, lumbar and sacral area.
No coagulation disturbances were detected. Open
surgery was recommended but she refused. Following
10 d of intravenous therapy with dexamethasone,
she improved. The authors did not give a precise
explanation and concluded that pathogenesis is still
unclear. Among possible theories explaining the
pathogenesis of SDH after vertebroplasty, the authors
hypothesize the increase in thoracic and/or abdominal
pressure, due to leakage of bone cement, increasing
the pressure within the intraspinal vessels, particularly
the valveless radiculomedullary veins, that cross
subdural and subarachnoid space (but leakage was
not enough), the development after spinal puncture
of dura mater, as Cosar et al[10] proposed and the
possibility that SDH may originate directly from the
subarachnoid space, dissecting through the arachnoid
membrane and eventually break into the spinal
subdural space.
Mattei et al[11] reported the case of a 49-year-old
woman with a T8 compression fracture, previously
treated conservatively and with a VP after 3 mo follow-
up, when she complained of severe deep axial pain. After
cannulation of the left T8 pedicle and the initial injection
of PPMA, a small posterior extravasation of cement to
the epidural veins was observed. Surgical procedure
was stopped, and, after awaking, she presented diffuse
numbness on the left side (both in the superior and
inferior limbs) and diffuse weakness in the left leg. An
emergency CT scan showed a very small posterior
leakage of PMMA towards the epidural space and into
the adjacent costotransverse joint and a hyperdense
collection anterior to the spinal cord from T7 to the
upper cervical spine. decompressive laminectomy was
performed, at T8, T7, T9. Postoperative MRI conrmed
the presence of SDH. The authors commented on the
anatomy of spinal venous drainage and focused on the
possible etiologic role of venous congestion caused by
the venous obstruction.
SDHs can be divided into traumatic and spon-
taneous. Traumatic SDHs usually occur after minor
spinal trauma, spinal anesthesia lumbar puncture
and spinal surgery, especially in the presence of
intraoperative dural tears[26,27]. Spontaneous (non
traumatic) SDHs are much more rare, with a recent
review having identified 106 cases reported in the
English literature[28]. Most of them are located anteriorly
to the spinal cord, differently from epidural haematomas
located posteriorly, at the lower thoracic region and
lumbar region. Predisposing factors are considered
coagulation abnormalities, anticoagulation therapy,
platelet disfunction, polycythemia vera, pregnancy,
arterial wall abnormalities and spinal arteriovenous
malformations[29-33], but the pathophysiology still
remains unclear. The management of SDH is still
controversial as well. Some authors propose emergency
spinal decompression and evacuation of the hematoma,
while other wait for the recovery of incomplete
Case Age, gender Fracture level Fracture cause SDH symptoms onset Symptoms SDH level Treatment Recovery
Lee et al[12] 40 yr, female T11-T12 Traumatic 2 wk Back pain,
radiating both
legs
SDH T10-L5 No surgery,
corticosteroid
therapy
Good
Cosar et al[10] 75 yr, female L1 Osteoporotic 12 h Paraparesis,
incontinence
SDH T12-L3 Laminectomy T12 Good with
arachnoiditis
Cosar et al[10] 18 yr, male L2-L4 Traumatic 12 h Paraparesis SDH T1-L2 Hemilaminectomy
T1-L2
Good with
arachnoiditis
Mattei et al[11] 49 yr, female T8 Traumatic Immediate Motor decit
left leg
SDH T9-C7 Laminectomy
T7-T9
Good
Our case 63 yr, male L1-L3 Oncological
fracture
2 wk Paraparesis SDH conus Laminectomy
L2-L3
Good
Table 1 Cases of spinal subdural hematoma following a transpedicular vertebroplasty reported in literature
SDH: Spinal subdural hematoma.
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Differential diagnosis
Haemorrhage, concussion injury, spinal contusion, Guillain- Barrè Sindrome.
Laboratory diagnosis
All labs were within normal limits.
Imaging diagnosis
A magnetic resonance imaging scan showed the presence of a high signal
lesion in the intradural extramedullary space, at the conus medullaris.
Treatment
An emergency decompressive bilateral laminectomy of L2 and L3 vertebrae
was performed. A longitudinal durotomy revealed a blood clot, tightly adherent
to the cauda equina rootlets. The hemorrhagic lesion was completely removed
with the assistance of a surgical microscope.
Related reports
Spinal subdural hematoma is an extremely rare complication, usual developing
within 12 to 24 h after the procedure. To our knowledge, to date, only 4 cases
have been previously reported in International literature.
Term explanation
Vertebroplasty is usually indicated for the treatment of metastatic spinal tumors
without epidural compression, to improve the anterior column stably of the spine
in conjunction with medical and radiation therapies and to obtain pain relief.
Experience and lessons
VP a simple surgical procedure, involving a low risk of complications, but
related to high morbidity. Therefore it has to be performed by experienced
and skilled surgeons. Furthermore, surgical iatrogenic complications must be
known, correctly and rapidly diagnosed, and, if needed, receive emergency
treatment.
Peer-review
The manuscript reports a rare case and is clear, comprehensive and convincing.
It is an interesting review about the complications following the percutaneous
vertebroplasty, mainly about the occurrence of spinal subdural hematoma.
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We denitely consider VP a simple surgical procedure,
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high morbidity. Therefore it has to be performed by
experienced and skilled surgeons. Furthermore, surgical
iatrogenic complications must be known, correctly and
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risky.
COMMENTS
Case characteristics
This is the case of a 63-year-old man who presented to our emergency
department with bilateral inferior limb numbness and weakness, mainly to the
left leg and complaining of bladder retention. Three weeks prior to the onset of
neurological symptoms, the patient underwent percutaneous vertebroplasty (VP)
of L1 and L3 vertebrae, in an oncology institute, for pathological compression
fractures, due to secondary localization of a retroperitoneal myxoid liposarcoma,
removed several years before.
Clinical diagnosis
Neurological assessment revealed a 1/5 monoparesis of the left inferior limb
and 3/5 monoparesis of the right, as well hypoesthesia and dysesthesia in the
same region. Perineal reexes were absent.
COMMENTS
Tropeano MP
et al
. Vertebroplasty and delayed subdural cauda equina hematoma

339 August 16, 2017
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P- Reviewer: Araujo AMF, Palacios-Eito A S- Editor: Kong JX
L- Editor: A E- Editor: Wang S
Tropeano MP
et al
. Vertebroplasty and delayed subdural cauda equina hematoma

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