Tuberculosis of spine: neurological deficit

The most dreaded neurological complications in TB spine occur in active stage of disease by mechanical compression, instability and inflammation changes, while in healed disease, these occur due to intrinsic changes in spinal cord secondary to internal salient in long standing kyphotic deformity. A judicious combination of conservative therapy and operative decompression when needed should form a comprehensive integrated course of treatment for TB spine with neurological complications. The patients showing relatively preserved cord with evidence of edema/myelitis with predominantly fluid collection in extradural space on MRI resolve on non-operative treatment, while the patients with extradural compression of mixed or granulomatous nature showing entrapment of spinal cord should be undertaken for early surgical decompression. The disease focus should be debrided with removal of pus caseous tissue and sequestra. The viable bone should only be removed to decompress the spinal cord and resultant gap should be bridged by bone graft. The preserved volume of spinal cord with edema/myelitis and wet lesion on MRI usually would show good neural recovery. The spinal cord showing myelomalacia with reduced cord volume and dry lesion likely to show a poor neural recovery. The internal kyphectomy is indicated for paraplegia with healed disease. These cases are bad risk for surgery and neural recovery. The best form of treatment of late onset paraplegia is the prevention of development of severe kyphosis in initial active stage of disease.

     

Eosinophilic granuloma of the spine with neurological deficit

A case of a 14-year-old boy with a solitary eosinophilic granuloma of the thoracic spine, with paraplegia secondary to the collapse of the vertebra and peridural spread of tumor, is presented. It is the 14th case recorded in literature to this date. This disease is self-limiting, and there is no role of steroids or radiotherapy observed.     

Prostatic abscess: computerized tomography scanning as an aid to diagnosis and treatment

In the antibiotic era prostatic abscesses are rare and the clinical picture often can be confusing. In 2 recent cases computerized tomography scanning not only proved the diagnosis easily but it also simplified greatly the definitive surgical procedure.     

Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical spine after high-energy trauma

BACKGROUND: Current literature supports the use of the three-view plain-radiograph series supplemented, when necessary, with helical computed tomography to evaluate the cervical spine in patients who have sustained trauma injury. The purpose of this study was to determine if helical computed tomography alone can be used to evaluate the cervical spine for acute osseous injury following high-energy trauma, thus eliminating the need to make radiographs. METHODS: Patients were prospectively evaluated with helical computed tomography scanning of the cervical spine and standard three-view plain radiography. At a later date, the plain radiographs and computed tomography scans were independently reviewed by two radiologists who were blinded to both the initial interpretation and the interpretation of the corresponding study. The radiologists documented whether the plain radiographs were adequate and whether they showed an acute process. The findings in the study were compared with the initial findings and, when necessary, with the discharge summaries to determine if an injury had been identified. The accuracy of the plain radiographs, of the plain radiographs that had been deemed adequate, and of helical computed tomography used alone was ascertained. RESULTS: Plain radiographs and helical computed tomography scans were made for 407 patients, and traumatic injuries were identified in fifty-eight of them. Plain radiographs alone were adequate for 194 (48%) of the 407 patients. Plain radiographs had a sensitivity of 45%, a specificity of 97%, a positive predictive value of 74%, and a negative predictive value of 91%. Adequate plain radiographs had a sensitivity of 52%, a specificity of 98%, a positive predictive value of 81%, and a negative predictive value of 93%. Helical computed tomography had a sensitivity and specificity of 98%, a positive predictive value of 89%, and a negative predictive value of >99%. The sensitivity, positive predictive value, and negative predictive value of adequate plain radiographs differed significantly from those of helical computed tomography alone (p < 0.001). Twelve (48%) of twenty-five adequate plain radiographs of patients in whom an injury had been identified on computed tomography missed that injury. Helical computed tomography alone missed one (2%) of the fifty-eight injuries. CONCLUSIONS: Although helical computed tomography has a limited ability to detect pure ligamentous injury, it can be safely used without plain radiographs to evaluate the cervical spine for osseous abnormalities such as fractures and dislocations after high-energy trauma.     

How to interpret computed tomography of the lumbar spine

Computed tomography (CT) of the spine has remained an important tool in the investigation of spinal pathology. This article helps to explain the basics of CT of the lumbar spine to allow the clinician better use of this diagnostic tool.     

Correlation of canal encroachment with neurological deficit in tuberculosis of the spine

 CT scans of fifteen patients with tuberculosis of the spine without neurological deficit were analysed for canal encroachment. We calculated that up to 76% encroachment of the spinal canal by tubercular pathological tissue is compatible with undisturbed neural status.

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Résumé  Quinze malades atteints de tuberculose de 1a colonne vertébrale sans insuffisance neurologique (quadriplégie ou paraplégie) on été examinés par scanner pour 1e pourcentage de l’empiètement du canal. D’après cette étude, soixante seize pourcent de l’empiètement du canal vertébral par le tissu pathologique tuberculeux est compatible avec l’état neurologique non derangé ou intact.

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Accepted: 4 January 1999     

Diffusion tensor imaging observation in Pott's spine with or without neurological deficit

Background:Diffusion tensor imaging (DTI) is based upon the phenomenon of water diffusion known as “Brownian motion.” DTI can detect changes in compressed spinal cord earlier than magnetic resonance imaging and is more sensitive to subtle pathological changes of the spinal cord. DTI observation in compressed and noncompressed spinal cord in tuberculosis (TB) spine is not described. This study presents observations in Pott''s spine patients with or without neural deficit.Results:The mean canal encroachment in group A was 39.60% and group B 44.4% (insignificant). Group A mean FA values above SOL, at the lesion and below SOL were 0.608 ± 0.09, 0.554 ± 0.14, and 0.501 ± 0.16 respectively. For group B mean FA values above SOL, at the lesion and below SOL were 0.628 ± 0.09, 0.614 ± 0.12 and 0.487 ± 0.15 respectively. There was a significant difference in mean FA above the SOL as compared to the mean FA at and below SOL. P value above versus below the SOL was statistically significant for both groups (0.04), but P value for at versus below the SOL (0.01) was statistically significant only in group B. On tractography, disruption of fiber tract at SOL was found in 14/15 (93.3%) cases of group A and 14/15 cases (93.3%) of group B (6/6 grade 4, 3/3 grade 3 and 5/6 grade 2 paraplegic cases).Conclusion:The FA and MD above the lesion were same as reported for healthy volunteer hence can be taken as control. FA increases, and MD decreases at SOL in severe grade of paraplegia because of epidural collection while in milder grade, both decrease. In group A (without neurological deficit), mean FA and MD in patients with and without canal encroachment was similar. On tractography, both groups A and B (with or without neurological deficit) showed disruption of fiber tract at SOL and thickness of distally traced spinal cord was appreciably less than the upper cord. FA and MD could not differentiate between various grades of paraplegia. Although the number of patients in each group are small.     

Renal sinus lipomatosis: Differentiation from space-occupying lesion with aid of computed tomography

Forty-two cases of renal sinus lipomatosis were diagnosed by intravenous urography and nephrotomography. The differential diagnosis from a malignant process necessitated selective renal angiography in 9 cases. With the aid of computed tomography (CT), an invasive technique such as renal angiography appears to be unnecessary in the differential diagnosis of renal sinus lipomatosis. CT seems to be more accurate since it revealed a concomitant cyst in 2 of 4 cases.     

A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance

The role of CT scanning as an adjunct to plain roentgenograms of the cervical spine was reviewed in acutely injured blunt trauma patients. Following institution of a protocol to evaluate the cervical spine in all blunt trauma patients, 179 patients underwent CT scanning of their cervical spine. This was performed for patients whose x-ray findings were positive, for patients with plain x-ray films suggestive of a pathologic condition, for patients with plain x-ray films that did not reveal all of the cervical vertebrae, and for patients who had persistent pain or neurologic deficits despite normal plain x-ray films. Of 123 patients not able to have their cervical spine cleared by normal roentgenograms, 93% were cleared within 24 hours of admission based on CT scans. There were no missed injuries in this setting. A false-positive rate of 28% and a false-negative rate of 1.5% were found for plain roentgenograms. Computed tomographic scans detected 98% of the injuries in our study and when combined with a three-view plain x-ray series of the cervical spine, 100% of cervical spine injuries were detected. Computed tomographic scanning as an adjunct to plain x-ray films of the cervical spine is a highly accurate and expedient modality to clear the cervical spine of blunt trauma patients.     

Subdural effusions: Determination of contrast medium influx from CSF to the fluid accumulation by computed tomography as an aid to the indications for management

Summary In 46 patients with subdural effusions CSF dynamics and especially the influx of contrast medium from CSF to the subdural fluid accumulation was investigated by serial computed tomography (CT). In 16 cases the subdural effusion was of traumatic and in 30 cases of non-traumatic origin.The results allowed a subdivision of the patients into three groups.Group 1: patients without contrast medium influx into the subdural fluid accumulation; group 2: patients with delayed influx; group 3: patients with immediate influx.In group 1 patients the subdural effusion acted as a space-occupying process with absolute indication for surgical treatment.Also in group 2 patients the further course showed that a surgical indication was given, because the fluid accumulation did not resolve under conservative management but increased in size, and/or the neurological deficit worsened.In all group 3 patients the subdural effusions decreased and finally disappeared conservatively.Group 1 patients with effusions on traumatic origin generally had more severe injuries than the patients of the other groups.The investigations caused no serious complications.This diagnostic method proved to be a reliable means for early differentation between the possibility of conservative mangement or the indication for operative treatment in cases with subdural effusions of different origin.     

Intraspinal,extradural stab injury of the spine without neurological deficit

Summary There are many reports of stab wounds of the spinal cord with neurological deficit, but here we report an intraspinal, extradural stab injury of the spine with no neurological injury. The broken blade was removed eight months later.

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Résumé On trouve dans la littérature de nombreuses observations de plaie par arme blanche de la moëlle épinière entraînant un déficit neurologique. On présente ici un cas de plaie intrarachidienne mais extra-durale, sans atteinte neurologique. La lame brisée a été extraite huit mois plus tard.

     

Contrast-enhanced computed tomography scanning of the postoperative spine

A prospective study of contrast-enhanced computed tomography (CT) scanning was undertaken for 17 levels previously operated upon in the lumbosacral spine in 14 patients. All levels with prior operations were scanned before and after the administration of intravenous contrast medium. A standardized technique for contrast enhancement using high doses of intravenous contrast medium was employed and a specialized technique for measuring enhancement with corrections for scan artifacts was used. Results indicated that measurable contrast enhancement occurred in 16 of 17 postoperative scars up to 12 years after surgery. Enhanced scans provided more accurate delineation of the size and margins of postoperative scarring than precontrast scans. No instances of enhancement of normal disk or recurrent herniated disk were observed. In six instances recurrent herniated disks were predicted on the basis of contrast-enhanced CT scans and subsequently confirmed at reoperation. Contrast-enhanced CT scans meticulously performed appear to permit differentiation between scarring and disk herniation in patients with recurring symptoms after operations for lumbosacral disk disease.     

Traumatic dislocation of the cervical spine without neurological deficit. Eleven cases

The authors present 11 cases of traumatized patients without neurological deficit in spite of a gross dislocation of the cervical spine. In the effort of explaining this discrepancy various parameters have been taken into account. The vertebral canal has been noted to be abnormally wide in these cases (average 19.8 mm). The authors suggest that the great width of the vertebral canal has in some way prevented the spinal cord of these patients being damaged by the dislocation.     

Evaluation of systems of grading of neurological deficit in tuberculosis of spine

STUDY DESIGN: Prospective comparative study. OBJECTIVE: To compare the efficacy of the ASIA scoring system and Tuli's classification for assessment of neurological status in a typical case of Pott's paraplegia/tetraplegia and suggest a suitable classification. SETTING: Department of Orthopaedics of University College of Medical Sciences and GTB Hospital, Delhi, India. METHODS: A total of 33 cases of tuberculosis of the spine with paraplegia were evaluated serially for the severity of the neurological deficit by grading systems as suggested by Tuli and ASIA score, during the course of treatment. A total of 111 readings of neurological status were recorded and analysed. RESULTS: Tuli's grading was found to be sensitive for detection of early stage (grade I) of neurological deficit. The rest of the grades (grade II, III, IV) of Tuli's classification have a wide range of sensory-motor deficit and hence are insensitive to early detection of any deterioration/improvement in the neurological status. The ASIA score failed to grade all types of neurological deficit associated with the Pott's spine. The sensory-motor score obtained by the ASIA scale depends on the level of involvement of the spinal cord. The higher the level of the cord damage, the poorer is the score. CONCLUSION: Neither Tuli's grading nor the ASIA scale alone can effectively grade all stages of neurological deficit in tuberculosis of the spine. The neurological deficit in tuberculosis of the spine should be described in stages and each stage should have sensory and motor scoring. A new staging system of Pott's tetraplegia/paraplegia is suggested.     

Anterior versus posterior surgery for osteoporotic vertebral collapse with neurological deficit in the thoracolumbar spine

Despite the increasing number of reports on surgical treatments for thoracolumbar osteoporotic vertebral collapse with neurological deficits, the choice of surgery remains controversial. In this retrospective study, we compared the outcomes of posterior and anterior surgeries for single-level osteoporotic vertebral collapse with neurological deficit in the thoracolumbar spine. Both posterior and anterior surgical approaches were performed with a consistent procedure for a single surgical indication at one institution. Twenty-four patients treated with posterior surgery and 28 patients treated with anterior surgery were followed-up over an average of 5 years after surgery. Radiographic results (kyphotic angle, bony fusion, and instrumentation failure), neurological improvement, and surgical complications were compared between the two groups. The average correction angle after surgery was larger in the posterior group than in the anterior group (P = 0.013), but not at final follow-up (P = 0.755). The average loss of correction was also higher in the posterior group than in the anterior group (P = 0.037). There was no significant difference in neurological outcomes between anterior and posterior approaches (P = 0.080). Two-way analysis of variance (ANOVA) showed that the neurological outcome was better in wedge type than in flat type vertebral collapse, regardless of the type of surgical approach (P = 0.0093). In wedge type vertebral collapse, neurological improvement tended to be greater after anterior than after posterior surgery. In four of six cases with instrumentation failure in the anterior group, a titanium cage subsided more than 5 mm but bony fusion was eventually achieved without causing neurological problems. In the posterior group, six cases experienced instrumentation failure during the postoperative course (two cases with screws loosened from pedicles and bodies, and one case with breakage of a screw neck). None of the patients developed instrumentation-related neurological problems. Two cases in each group developed pseudoarthrosis. In single-level osteoporotic vertebral collapse with neurological deficit, anterior surgery tended to improve neurological deficit in wedge type, but not in flat type collapse, compared with posterior surgery.     

Cervical spine computed tomography utilization in pediatric trauma patients

Background

Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).

Methods

Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.

Results

5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p < 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p < 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.

Conclusions

Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.