Pneumocephalus Secondary To Cerebrospinal Fluid Leak Associated With A Lumbar Pressure Ulcer In A Man With Paraplegia

Abstract

Background: Pneumocephalus is a well-known condition following head trauma, but is uncommon in injuries or surgeries of the spine. Even more unusual is its occurrence in association with an eroding pressure ulcer and the subsequent penetration of the intrathecal space. This article reports such a case in a man with spinal cord injury. No previously reported cases of pneumocephalus and subarachnoid- pleural fistula secondary to a pressure ulcer are known.

Methods: Case presentation and literature review.

Findings: A 75-year-old man with with paraplegia, T2-level spinal cord injury, impairment score on the American Spinal Injury Association (ASIA) scale of ASIA A, and multiple pressure ulcers developed dural leak via a tract extending from a thoracolumbar ulcer to the T11 -T1 2 vertebrae. The resultant pneumocephalus was diagnosed based on acute neurologic symptoms and computed tomography scan. He underwent excision of the pressure ulcer and a T1 0 through L 1 laminectomy, during which the dural leak was located and sealed with fibrin glue.

Conclusion: Deep pressure ulcers overlying the spine should be managed aggressively to avoid life-threatening complications. Signs of meningeal irritation and/or mental status change in a patient with a deep posterior midline pressure ulcer with drainage suggestive of cerebrospinal fluid may indicate invasion of the intramedullary canal. Imaging studies are diagnostic of pneumocephalus and surgical closure of the spinal fluid leak is imperative when meningeal or other adverse neurologic signs are present.     

American Spinal Injury Association A (sensory and motor complete) is not different from American Spinal Injury Association B (sensory incomplete,motor complete) in gunshot-related spinal cord injury

Background Context

We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers.

Dural puncture and iatrogenic pneumocephalus with subsequent transverse myelitis in a parturient

PURPOSE: To report a case of transverse myelitis following inadvertent dural puncture and iatrogenic pneumocephalus and any possible causal relationship is explored. CLINICAL FEATURES: A 32-yr-old primigravida developed a severe headache associated with pneumocephalus following accidental dural puncture when the loss of resistance to air technique was used to locate the epidural space. She was treated with oxygen 100% to promote resorption of the air and the headache resolved. One month later she developed a sensory disturbance in her feet. Neurological examination revealed reduced sensation to cold and pain to ankle level and bilateral suppressed knee and ankle reflexes but was otherwise normal. A spinal cord lesion (epidural abscess/hematoma) was excluded with an emergency T1 and T2 weighted magnetic resonance imaging (MRI) scan of the lumbar spine. Over the next 48 hr the sensory disturbance worsened to involve her legs and waist. Examination revealed a sensory loss to waist level, reduced joint position sense and vibration sense in her lower limbs and absent knee and ankle reflexes bilaterally, but normal power in both her legs. A further full length T2 weighted MRI scan of the spine showed a small area of high signal at the level of T3 compatible with transverse myelitis. This was treated with high dose corticosteroids and her symptoms resolved over the next three months. CONCLUSION: The etiology of transverse myelitis after dural puncture in a parturient could not be identified nor could any causal link be established between the dural puncture, pneumocephalus, and subsequent transverse myelitis.     

Lower cervical spine injury treated with lateral mass plates and pedicle screws through posterior approach

Theincidenceofspinalinjuryislessinthelowercervicalsegments(C6 C7)thanintheC3 C6segments.Operationthroughanteriorapproachiscommonlyusedfortheseinjures,butfewerreportsofthelowercervicalspineandspinalcordinjurytreated withcervicallateralmassplatesandT1pedicl…     

非手术治疗无骨折脱位型颈脊髓损伤预后的多因素分析

目的 :探讨影响非手术治疗无骨折脱位型颈脊髓损伤预后的因素。方法 :回顾性分析2009年1月至2012年12月接受非手术治疗的122例无骨折脱位型颈脊髓损伤患者的临床资料,其中男84例,女38例;平均年龄(52.37±13.27)岁(18~83岁)。选择年龄、性别、受伤原因、受伤至治疗时间、脊髓损伤ASIA分级、MRI脊髓损伤类型、脊髓损伤范围、有效颈椎管率、椎间盘突出Pfirrmann分级、椎间盘突出节段、椎间盘韧带复合体损伤、大剂量甲基强的松龙冲击治疗12个可能对非手术治疗预后产生影响的因素,应用单因素和多因素Logistic回归分析,研究其对预后的影响。结果:单因素分析显示MRI脊髓损伤类型、脊髓损伤范围、有效颈椎管率、椎间盘突出Pfirrmann分级、椎间盘突出节段及脊髓损伤ASIA分级均对预后有显著影响(P均0.05)。进一步行多因素分析,按照其作用强度,影响预后的主要因素依次为:MRI脊髓损伤类型、脊髓损伤范围、有效颈椎管率、椎间盘突出Pfirrmann分级、脊髓损伤ASIA分级(P均0.05)。结论 :影响非手术治疗无骨折脱位型颈脊髓损伤预后的主要因素是MRI脊髓损伤类型及范围,同时与有效椎管率、椎间盘突出程度及脊髓损伤ASIA分级相关。对于选择非手术治疗需谨慎,仅适用MRI检查提示脊髓信号无改变或水肿程度轻且范围局限者,其余则建议积极手术治疗。     

Nontraumatic myelopathy associated with surfing

BACKGROUND/OBJECTIVE: Ischemic nontraumatic spinal cord injury associated with surfing is a novel diagnosis believed to be related to prolonged spine hyperextension while lying prone on the surfboard. Only 9 cases have been documented. This report features possible risk factors, etiology, diagnostic imaging, and outcomes of surfer's myelopathy. DESIGN: Case report. RESULTS: A 37-year-old man developed T11 American Spinal Injury Association (ASIA) A paraplegia shortly after surfing. The clinical history and magnetic resonance imaging findings were compatible with an ischemic insult to the distal thoracic spinal cord. Our patient did not have any of the proposed risk factors associated with this condition, and, contrary to most reports, he sustained a complete spinal cord lesion without neurological recovery by 8 weeks post injury. CONCLUSIONS: Surfer's myelopathy, because of its proposed mechanism of injury, is amenable to medical intervention. Increased awareness of this condition may lead to early recognition and treatment, which should contribute to improved neurological outcomes.     

影响无骨折脱位型颈脊髓损伤手术疗效的多因素分析

目的：探讨影响无骨折脱位型颈脊髓损伤手术疗效的相关因素。方法：对2010年11月至2016年11月被诊断为无骨折脱位型颈脊髓损伤且接受手术治疗69例患者的临床资料进行回顾性分析,其中男37例,女32例;年龄32~76（51.6±7.3）岁。选择年龄、性别、脊髓损伤ASIA分级、MRI中脊髓损伤长度、Pavlov比值、后纵韧带骨化、椎间盘突出、MRI中脊髓损伤类型、受伤至手术时间、大剂量激素冲击治疗、手术时间、术中出血量12个因素,应用SPSS 22.0软件对数据进行Logistic单因素和多因素分析,筛选出影响手术疗效的各因素,并确定主要影响因素。结果：单因素分析显示脊髓损伤ASIA分级、MRI中脊髓损伤长度、Pavlov比值、后纵韧带骨化、椎间盘突出、MRI中脊髓损伤类型均与手术疗效相关（P<0.05）。对筛选出的因素行多因素分析显示：按照作用强度,影响手术疗效的因素依次为MRI中脊髓损伤类型、MRI中脊髓损伤长度、Pavlov比值、脊髓损伤ASIA分级（P<0.05）。结论：影响无骨折脱位型颈脊髓损伤手术疗效的因素为MRI中脊髓损伤类型、MRI中脊髓损伤长度、Pavlov比值、脊髓损伤ASIA分级,其中最主要的因素为MRI中脊髓损伤类型和长度。相较于其他患者,术前MRI提示脊髓损伤类型为水肿+出血或者损伤长度≥ 45 mm的患者,手术疗效欠佳的风险更高,术前需与患者及家属充分沟通。     

Simple wound care facilitates full healing in post-earthquake Haiti

The author provides an insight into the basic health care needs of two spinal cord injury patients who were cared for in a specially set up 25-bedded spinal cord injury unit in Haiti. While focusing on their extreme wound care requirements, the author highlights the need for adequate fluid, nutrition, hygiene and aseptic technique. Both patients were victims of the January 2010 earthquake in Port au Prince, Haiti. The author describes the basic wound care strategy for a patient with a category IV sacral pressure ulcer and another with a broken down thoracic spine surgical wound with visible metal work. This article describes how simple wound care effected the complete healing of large sacral pressure ulcers and broken down spinal surgical wounds without the need for further surgical intervention.     

Intracranial hypotension with spinal pathology.

BACKGROUND CONTEXT: Intracranial hypotension (IH) is a syndrome in which volume depletion of the cerebrospinal fluid (CSF) results in various neurological symptoms. Most commonly, a small tear or defect in the spinal dural sac is the underlying lesion that results in a CSF leakage and IH. Causes of IH can be classified as 1) spontaneous (primary), and 2) secondary. Knowledge of IH is essential to spine surgeons, because a small proportion of patients with spontaneous IH require spine surgery, and secondary causes of IH include spine trauma, various spine-related diagnostic/therapeutic procedures (iatrogenic), and degenerative spine disorders. PURPOSE: The purpose of this review is to update knowledge of IH pertinent to spine surgery. STUDY DESIGN/SETTING: Review of the literature. METHODS: A systematic review of the literature was conducted using PUBMED. The literature regarding IH with spinal pathology published from 1966 to 2005 was searched and reviewed comprehensively. RESULTS/CONCLUSIONS: The lower cervical and upper thoracic spine are the predilection sites for a CSF leak in patients with spontaneous IH. Mechanical stress may have a role in the pathogenesis of spontaneous IH, and meningeal diverticula and connective tissue disorders may be important risk factors. Iatrogenic causes of IH include lumbar puncture, spine surgery, and chiropractic manipulation. Rarely, degenerative spine disorders are the secondary cause of IH. Although orthostatic headache is the characteristic symptom of IH, a small proportion of patients present with neck pain or radicular symptoms of the upper extremity. Imaging studies of the spine have contributed significantly to elucidation of the pathophysiology of IH as well as identification of the site of a CSF leak. Typical spinal radiographic findings of IH include extra-arachnoid or extradural fluid collections, meningeal enhancement, engorgement of the epidural venous plexus, and tonsilar descent into the foramen magnum. Most patients with spontaneous IH respond favorably to conservative management, including autologous epidural blood patch. Surgical intervention is reserved for those who fail the conservative management. Although immediate clinical improvement is usually achieved by surgery, the long-term outcomes of surgical patients need to be investigated further. In patients who have a secondary cause of IH, treatment of the underlying lesion or condition may terminate a CSF leak and result in reversal of symptoms.     

Management of an unstable lumbar fracture with a laminar split.

This is a case report describing the injury sustained by a 36-year-old man injured in a motorcycle crash who sustained a fracture dislocation of L2 upon L3, associated with a split in the lamina of L3. His neurologic lesion was T12 ASIA B: with a motor score of 52 but with preservation of sensory function (sensory score 96) in most parts of his lower extremities. He also suffered a lower extremity fracture. Imaging of the spine is presented showing a multiplanar fracture associated with translation and with a defect in the lamina that may be seen in certain AO type B or type C fractures, that may entrap the lumbar spinal nerve roots. Discussants of this case comment on the classification and clinical significance of this fracture pattern. and present their operative approaches, both for management of this particular fracture pattern and for any associated dural tear. The issues of steroid use and the place of rehabilitation are also discussed.     

下颈椎损伤改良Moore分类的临床应用研究

目的：探讨改良Moore分类法在下颈椎损伤中的临床应用。方法：2006年8月至2010年3月收治下颈椎损伤患者200例,男165例,女35例;年龄19-88岁,平均52岁。应用下颈椎损伤改良Moore分类全面地描述下颈椎损伤的状态,颈椎损伤严重程度（稳定性）量化评分与有否神经症状表现相结合,根据骨折类型和稳定性、脊髓或神经根受压损伤情况、韧带损伤后的稳定程度及其他参考因素进行分类诊治,选择治疗方法。其中伴有脊髓神经损伤者130例（ASIA评分：A级6例,B级13例,C级43例,D级68例）,不伴有脊髓神经损伤者70例。对伴有脊髓神经损伤的下颈椎损伤患者,根据ASIA评分进行疗效评定;对不伴有脊髓神经损伤的患者,根据影像学检查对颈椎的序列和高度进行观察。结果：前、左、右侧和后柱均损伤35例;前柱损伤33例;前、后柱均损伤90例;前、左侧和后柱均损伤5例;前、右侧和后柱均损伤3例;前、左侧和右侧柱均损伤3例;前、右侧柱损伤2例;前、左侧柱损伤5例;后柱损伤12例;左侧柱损伤7例;右侧柱损伤5例。200例患者中手术治疗98例,非手术治疗102例（其中可以手术而患者家属要求非手术治疗39例）。完全性脊髓损伤患者中3例行手术后脊髓功能无恢复迹象,ASIA分级无变化,但其肢体麻木、疼痛等症状有不同程度的缓解,另3例未手术患者脊髓功能及肢体症状均无变化。不完全性脊髓损伤患者手术后脊髓功能均有一定程度恢复,ASIA评分平均提高1．2级。未手术的不完全性脊髓损伤患者非手术治疗后ASIA评分平均提高0.3级。不伴有脊髓神经损伤者手术后经影像学检查显示均恢复了颈椎的正常序列和高度。结论：根据改良Moore分类法,稳定性量化评分值大于等于4分有下颈椎不稳可能,需要手术治疗,分值越大,手术指征越明显,若伴有脊髓或神经根受压损伤表现者则有绝对手术指征。稳定性量化评分为3分且伴有脊髓或神经根受压损伤表现者一般也有手术指征。稳定性量化评分为3分不伴有脊髓或神经根受压损伤表现者或3分以下者均不需要手术治疗。应用改良Moore分类法有利于下颈椎损伤患者的临床规范化、标准化诊治,以获得较满意的疗效。     

Effectiveness of a multi‐layer foam dressing in preventing sacral pressure ulcers for the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel mattress

Individuals with spinal cord injury are at risk of sacral pressure ulcers due to, among other reasons, prolonged immobilisation. The effectiveness of a multi‐layer foam dressing installed pre‐operatively in reducing sacral pressure ulcer occurrence in spinal cord injured patients was compared to that of using a gel mattress, and stratified analyses were performed on patients with complete tetraplegia and paraplegia. Socio‐demographic and clinical data were collected from 315 patients admitted in a level‐I trauma centre following a spinal cord injury between April 2010 and March 2016. Upon arrival to the emergency room and until surgery, patients were transferred on a foam stretcher pad with a viscoelastic polymer gel mattress (before 1 October 2014) or received a multi‐layer foam dressing applied to their sacral‐coccygeal area (after 1 October 2014). The occurrence of sacral pressure ulcer during acute hospitalisation was similar irrespective of whether patients received the dressing or the gel mattress. It was found that 82% of patients with complete tetraplegia receiving the preventive dressing developed sacral ulcers as compared to only 36% of patients using the gel mattress. Although multi‐layer dressings were suggested to improve skin protection and decrease pressure ulcer occurrence in critically ill patients, such preventive dressings are not superior to gel mattresses in spinal cord injured patients and should be used with precaution, especially in complete tetraplegia.     

颈椎脊髓损伤并呼吸功能不全的诊治

目的研究在基层医院对颈髓损伤并呼吸功能不全的诊断和治疗。方法15例患者采用颈前路椎体次全切除、植骨融合及钛钢板内固定术治疗，手术前后辅以机械通气。结果不完全损伤者6例，ASIA分级平均提高2级，5例生活可自理，其中2例恢复工作。完全损伤者9例，其中3例死亡，其余呼吸功能恢复正常，但ASIA分级无变化。结论早期诊断、早期手术减压并辅以机械通气法是治疗颈髓损伤并呼吸功能不全的关键。     

强直性脊柱炎合并颈椎无骨折脱位型脊髓损伤

目的 总结强直性脊柱炎合并颈椎无骨折脱位型脊髓损伤的临床特征、诊断和手术治疗。方法 1986～2004年，笔者手术治疗累及颈椎的强直性脊柱炎合并无骨折脱位型脊髓损伤27例。结果 本组27例中椎管内韧带骨化18例，脊髓损伤的原因依次为韧带骨化所致的椎管狭窄，椎间盘损伤和椎体后骨刺及椎间不稳定。术前均为不完全性损伤，非手术治疗不提高脊髓功能。术后脊髓ASIA分级平均改善1级。后路手术椎板切除率、出血量、手术时间、术后引流量明显高于不合并强直性脊柱炎的患者。前路手术可达到骨性融合。结论 强直性脊柱炎合并颈椎无骨折脱位型脊髓损伤一般为不完全性损伤，损伤的内因依次为椎管内韧带骨化所致的椎管狭窄、椎间盘损伤、椎间骨赘和椎间不稳定。适当的手术可改善脊髓功能。手术难度大，风险高。     

Postpartum spinal cord injury in a woman with HELLP syndrome

OBJECTIVE: To report a rare cause of spinal cord injury. STUDY DESIGN: Case report. CASE REPORT: A 36-year-old woman presented with acute onset of paresis of the upper and lower extremity (level C5, ASIA B) the day after delivering a healthy daughter (39 weeks' gestation). Prior to giving birth, she was admitted with gestational hypertension. Directly postpartum, blood pressure increased markedly, and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome was diagnosed. The next day, tetraplegia developed. Magnetic resonance imaging showed multiple epidural and subdural hematomas in the cervical and thoracic spinal canal extending from C2 to T8, with displacement and compression of the cord. Three weeks after treatment with intravenous labetalol, she made a significant recovery (level T1, ASIA D). CONCLUSIONS: This rare cause of spinal cord injury shows the importance of closely monitoring pregnant patients with hypertension complicated with HELLP syndrome both pre- and postpartum.     

An unusual stab wound of the cervical spinal cord: a case report

STUDY DESIGN: A rare case of a laterally directed stab wound injury of the cervical spinal cord is reported. OBJECTIVE: To describe the unusual mechanism of injury of this case and its clinical features. The surgical indications for penetrating injuries of the spinal cord are discussed. SUMMARY OF BACKGROUND DATA: Spinal stab wound injuries are rare, and the literature on the subject is scant. There has been only one large clinical review from South Africa, published in 1977. The clinical features and the injury mechanism of a laterally directed stab wound to the cervical spine have not been previously described. METHODS: An 18-year-old man was stabbed in the right side of the neck at C1-C2. The blade penetrated the spine laterally and went through the ligaments without affecting the bony structures. On admission the patient had tetraplegia and was in respiratory failure. Radiologic investigation showed the retained blade passing through the cord but showed no bony or vascular injuries. RESULTS: Before extraction, the knife was followed to its tip with careful dissection. Because no cerebrospinal fluid leak was noted in the area, the dura was not exposed. After surgery, magnetic resonance images showed a complete transection of the spinal cord at C1-C2. The patient was neurologically unchanged in follow-up examinations. CONCLUSION: Laterally directed horizontal stab wounds of the spine are particularly dangerous because the blade can pass between two vertebrae to transect the cord. The neurologic injury that results is irreversible. The more common stab wounds, inflicted from behind, usually produce incomplete cord damage.     

脐带间充质干细胞联合渗液吸收贴治疗Ⅱ、Ⅲ期压疮研究

目的探讨脐带间充质干细胞联合渗液吸收贴治疗Ⅱ、Ⅲ期压疮的临床效果。方法将36例脊髓损伤合并Ⅱ、Ⅲ期压疮患者随机分为对照组(Ⅱ期18处、Ⅲ期13处)和观察组(Ⅱ期24处、Ⅲ期压疮11处)。对照组采用常规治疗与护理方法;观察组采用脐带间充质干细胞联合渗液吸收贴治疗的方法,即局部清创、消毒后将1mL脐带间充质干细胞混悬液均匀涂抹于创面,并外敷渗液吸收贴。所有患者每2天换药1次,直至创面愈合。结果两组疗效比较,差异有统计学意义(P<0.05);两组显效时间和治愈时间比较,差异有统计学意义(均P<0.01)。结论脐带间充质干细胞联合渗液吸收贴可有效治疗Ⅱ、Ⅲ期压疮,并显著缩短创口治愈时间。     

脊柱脊髓锐器伤合并异物存留的救治

[目的] 探讨脊柱脊髓锐器伤合并异物存留的诊疗特点及预后。[方法] 回顾了1995年1月～2005年11月本科收治的128例脊柱脊髓锐器伤的临床资料，对其中19例合并有异物存留患者的诊治、术后恢复情况进行分析总结。[结果] 19例均行急诊手术清创，术后死亡1例（5．3％），椎管内感染1例，发生脑脊液漏1例。14例合并有脊髓损伤患者中，13例术后经综合康复治疗脊髓损害程度ASIA评分较手术前提高（P〈0．05）。[结论] 脊柱脊髓锐器伤合并异物存留时需在充分地术前准备下急诊手术治疗，必要的术前检查，制定详细的手术计划是提高抢救成功率的关键。     

Treatment of severe double spinal cord injuries

This is a case report describing an injury--sustained by a 25-year-old man during a car accident, and characterized by fracture dislocation of the spine at the level of C7 and T4 accompanied by pulmonary contusion. He had an incomplete spinal cord lesion at the level of C7 and a complete lesion at the level of T4 (T4 ASIA A). Imaging of the spine showed three column fractures with ventral spinal cord compression at both levels. Discussants of this case comment on the concept of acute treatment of severe double spinal cord injuries, and present their chosen way of management in this particular case.