A 28-year-old male-to-female transsexual patient presented with severe headache and visual disturbances; clinical examination showed visual impairment, with bitemporal inferior visual-field defects, papilledema of the left eye, and optic atrophy of the right eye. The patient was euphoric and confused. Personality changes noted during the previous 4 months had been attributed by family members to the new gender identity of the patient. The patient had been taking a feminizing endocrine regimen of ethinyl estradiol (100 μg per day orally) and cyproterone acetate (100 mg per day orally) for the previous 5 years. After 2 years of hormone treatment, the patient underwent gonadectomy for sex reassignment, and estradiol-17-undecanoate (100 mg twice weekly administered intramuscularly) was added to the patient's therapy for the following 2 years. A cerebral magnetic resonance imaging (MRI) scan obtained 3 years before presentation to evaluate an increased prolactin level (42 ng per milliliter) was negative ( Figure 1A ). On admission, a contrast-enhanced MRI scan revealed a giant olfactory-groove meningioma ( Figure 1B ). After a radical tumor resection, the histologic diagnosis was meningothelial meningioma (World Health Organization grade I), which was negative for estrogen receptors, with a Ki-67 index of 5% and an MIB-1 index of 3.4% per high-power field ( Figures 1C and 1D , respectively). At 1 year of follow-up, the patient was continuing with the hormone therapy at a lower dose (50 μg of ethinyl estradiol per day and 100 mg of spironolactone per day), and a contrast-enhanced MRI scan showed no recurrence of the tumor. The patient's behavioral changes had regressed, and the visual impairments were ameliorated.

A large number of interspinous process devices (IPD) have been recently introduced to the lumbar spine market as an alternative to conventional decompressive surgery in managing symptomatic lumbar spinal pathology, especially in the older population. Despite the fact that they are composed of a wide range of different materials including titanium, polyetheretherketone, and elastomeric compounds, the aim of these devices is to unload spine, restoring foraminal height, and stabilize the spine by distracting the spinous processes. Although the initial reports represented the IPD as a safe, effective, and minimally invasive surgical alternative for relief of neurological symptoms in patients with low back degenerative diseases, recent studies have demonstrated less impressive clinical results and higher rate of failure than initially reported. The purpose of this paper is to provide a comprehensive overview on interspinous implants, their mechanisms of action, safety, cost, and effectiveness in the treatment of lumbar stenosis and degenerative disc diseases.

OBJECT: Spacers placed between the lumbar spinous processes represent a promising surgical treatment alternative for a variety of spinal pathologies. They provide an unloading distractive force to the stenotic motion segment, restoring foraminal height, and have the potential to relieve symptoms of degenerative disc disease. The authors performed a retrospective, multicenter nonrandomized study consisting of 1108 patients to evaluate implant survival and failure modes after the implantation of 8 different interspinous process devices (IPDs). METHODS: The medical records of patients who had undergone placement of an IPD were retrospectively evaluated, and demographic information, diagnosis, and preoperative pain levels were recorded. Preoperative and postoperative clinical assessments in the patients were based on the visual analog scale. A minimum of 3 years after IPD placement, information on long-term outcomes was obtained from additional follow-up or from patient medical and radiological records. RESULTS: One thousand one hundred eight patients affected by symptomatic 1- or 2-level segmental lumbar spine degenerative disease underwent placement of an IPD. The complication rate was 7.8%. There were 27 fractures of the spinous process and 23 dura mater tears with CSF leakage. The ultimate failure rate requiring additional surgery was 9.6%. The reasons for revision, which always involved removal of the original implant, were acute worsening of low-back pain or lack of improvement (45 cases), recurrence of symptoms after an initial good outcome (42 cases), and implant dislocation (20 cases). CONCLUSIONS: The IPD is not a substitute for a more invasive 3-column fusion procedure in cases of major instability and spondylolisthesis. Overdistraction, poor bone density, and poor patient selection may all be factors in the development of complications. Preoperatively, careful attention should be paid to bone density, appropriate implant size, and optimal patient selection.

Case report and clinical discussion. To describe a rare case of spinal cervical screw migration into the gastrointestinal tract 11 years after surgery. Anterior cervical spine fusion and stabilization with plating is a well-established procedure for cervical myelopathy, cervical spinal trauma, and spinal infectious disease. Esophageal injury has been related to screw or plate extrusion. We present a 45-year-old white man suffering from severe quadriparesis and neck pain. Cervical spine magnetic resonance images showed spondylodiscitis and spinal fracture of C4 and C5 vertebral bodies. He underwent anterior surgical decompression consisting of C4 and C5 corpectomies and fusion with fibular allograft fixated with a cervical plate. The patient's neurologic examination gradually improved during his follow-up. The patient returned 11 years after cervical spine graft and plating, complaining of severe dysphagia and high fever. Radiographs of the cervical spine showed a screw back-out. Three days later, a new radiograph of the cervical spine revealed a progression of the screw's extrusion. In a new cervical spine radiograph, obtained immediately before surgical intervention, the displaced screw was no more visible. Abdominal radiograph showed the missed screw in the right lower abdominal quadrant. Barium meal swallowing test showed no leakage on the cervical area. At 6 months follow-up, the patient is in good condition and symptom free. In this case, the delayed esophageal perforation occurred 11 years after initial surgery: the rapid progression of the screw extrusion after initial pull-out (6 days) was documented by several radiographs and spontaneous closure of the fistula was achieved.