An atypical ballistic traumatic cauda equina syndrome with a positive evolution. Focus on prognostic factors

IntroductionTraumatic cauda equina syndromes due to projectile wounds often have a poor prognosis. We report on an unusual ballistic cauda equina traumatism with a good functional outcome.Clinical caseA 44-year-old man was admitted to emergency room for an incomplete cauda equina syndrome after trying to kill himself by means of a pneumatic nail gun. The nail had gone right through the third lumbar vertebra. Because of the stability of the fracture, orthopaedic surgery was not indicated. Neurological recovery was progressive. At 6 months, there was still a partial L5–S1 motor deficit on the left side but the patient could walk without crutches, and within an unlimited walking distance.DiscussionInitial imaging displayed a projectile trajectory focused on the spinal canal on level L3, which could have been considered as bad prognosis. The positive analytic and functional outcome correlates with the limited neurological tissue damage, probably explained by the ballistic properties of the projectile.ConclusionApart from the influence of a possible surgical act, the neurological and functional prognosis of a traumatic cauda equina syndrome caused by a projectile also depends on its physical characteristics.     

The clinical use of dermatomal somatosensory evoked potentials in lumbosacral spinal stenosis

DSEPs provide clinicians with a safe, noninvasive technique useful in determining which patients with anatomic spinal stenosis have the added component of neurogenic compromise. Based on physiologic principles, level-by-level prolongation of DSEP latencies, reduction of amplitude, asymmetry, or a complete absence of response is associated with dysfunction in that particular afferent neurologic pathway. This dysfunction does not correspond to the exact level of stenosis noted on MRI because the rootlets in the lumbar and sacral regions pass through multiple spinal segments as they course rostrally through the spinal canal. Given that LSSS typically develops over time, the degree of abnormality likely would correspond to the physiologic slowing occurring in the multiple rootlets of the cauda equina. These recordings are not easy to perform and interpret, but when done correctly, they provide the best evidence for the type of neurophysiologic dysfunction in LSSS that responds favorably to surgical decompression. Similarly, DSEPs might provide a means of neurophysiologically monitoring clinically significant findings in a program of conservative management.     

Dermatomal somatosensory-evoked potentials in the evaluation of lumbosacral spinal stenosis

DSEPs are very useful in determining which patients with degenerative lumbar spine disease have the added component of neurogenic compromise. Based on sound physiologic principles, level-by-level prolongation of DSEP latencies, reduction of amplitude, asymmetry, or a complete absence of response is associated with dysfunction in that particular neurologic pathway. This result does not necessarily correspond to the exact level of stenosis noted on MRI, because the rootlets in the lumbar and sacral regions pass through multiple spinal segments as they course through the spinal canal. Given that LSSS develops typically over time, it is not unlikely that the degree of abnormality will be variable between different levels. The pattern of abnormality will correspond to the physiologic slowing occurring in the multiple rootlets of the cauda equina. These recordings are not easy to perform and interpret; but, when done correctly, they provide the best evidence for the type of neurophysiologic dysfunction in LSSS that responds favorably to surgical decompression.     

Midline synovial and ganglion cysts causing neurogenic claudication

Typically situated posterolateral in the spinal canal, intraspinal facet cysts often cause radicular symptoms. Rarely, the midline location of these synovial or ganglion cysts may cause thecal sac compression leading to neurogenic claudication or cauda equina syndrome. This article summarizes the clinical presentation, radiographic appearance, and management of three intraspinal, midline facet cysts. Three patients with symptomatic midline intraspinal facet cysts were retrospectively reviewed. Documented clinical visits, operative notes, histopathology reports, and imaging findings were investigated for each patient. One patient presented with neurogenic claudication while two patients developed partial, subacute cauda equina syndrome. All 3 patients initially responded favorably to lumbar decompression and midline cyst resection; however, one patient required surgical stabilization 8 mo later. Following the three case presentations, we performed a thorough literature search in order to identify articles describing intraspinal cystic lesions in lateral or midline locations. Midline intraspinal facet cysts represent an uncommon cause of lumbar stenosis and thecal sac compression. Such entities should enter the differential diagnosis of midline posterior cystic lesions. Midline cysts causing thecal sac compression respond favorably to lumbar surgical decompression and cyst resection. Though laminectomy is a commonly performed operation, stabilization may be required in cases of spondylolisthesis or instability.     

Neurogenic claudication due to pseudospondylolisthesis

Pseudospondylolisthesis is a subluxation of the lumbar vertebrae due to incompetent facet joints. The resulting stenosis of the lumbar spinal canal may impinge on the nerve roots of the cauda equina and induce neurogenic claudication. This syndrome is difficult to distinguish clinically from lower extremity claudication of vascular etiology. Accurate diagnosis requires radiographic examination of the spine.     

马尾神经综合征实验模型的建立及其形成机制(英文)

目的:建立马尾神经综合征的实验模型,进一步探讨马尾神经综合征形成的机制。方法:将纯种健康雄性封闭群清洁级新西兰兔80只随机分为3组:对照组、模型1加压组、模型2加压组,应用改良的EirenToh马尾神经实验压迫模型,进入椎管矢状径的1/9,2/9,1/2,造成马尾神经压迫产生神经症状,对症状、骶神经功能检测,并进行定量分析、马尾神经、神经根、骶髓做组织病理学和免疫组织化学的研究,并进行定性分析。结果:模型2较模型1同等条件下,易导致马尾神经损害;各实验组马尾神经综合征发病1/2d,其马尾神经组织均出现广泛的炎性反应,骶髓前角细胞出现凋亡;骶神经功能综合测定,A1,A2,A3(1.8±0.9,2.0±1.6,6.3±2.1),B1,B2,B3(4.3±1.9,6.4±3.0,9.6±2.7)同对照组和其他时间段比较,差异有显著性差异意义(P<0.05)。结论:压迫马尾神经导致马尾神经损害,双节段压迫比单节段压迫更易出现广泛马尾神经损害;马尾神经压迫点的病理改变向头、尾两端扩散,形成广泛病理损害;骶髓前角细胞出现凋亡,且骶神经损伤症状出现1/2d时达到高峰。     

硫化氢对急性马尾神经损伤模型大鼠的神经保护作用

背景：研究发现内源性硫化氢可以作为一种新型气体信号分子,具有重要的信号传递功能和生物调节作用。目的：研究硫化氢对急性马尾神经损伤大鼠的神经保护作用。方法：将72只SD大鼠随机均分为3组,实验组、模型组咬除L4椎板,将长10 mm、厚1.0 mm、宽1.0 mm的硅胶条植入大鼠L5和L6椎管内,建立大鼠马尾神经压迫损伤模型;假手术组仅咬除L4椎板,未植入硅胶条;实验组造模前1 h腹腔注射20μmol/kg的NaHS,模型组与假手术组腹腔注射等量生理盐水。造模后12,24,48,72 h检测马尾神经组织中丙二醛和谷胱甘肽水平,同时在48 h取材进行苏木精-伊红染色和TUNEL染色。结果与结论：苏木精-伊红染色显示,假手术组马尾神经纤维致密有序,髓鞘完整,轴突无肿胀;模型组马尾神经纤维松散,脱髓鞘改变,部分轴突及髓鞘肿胀;实验组马尾神经纤维紧密,少量轴突肿胀、脱髓鞘改变。TUNEL染色显示,假手术组中脊髓和背根神经节组织中阳性细胞数量较少,模型组脊髓和背根神经节中可见大量阳性细胞,实验组阳性细胞数量显著低于模型组。假手术组、实验组丙二醛水平低于模型组（P 〉0.05, P 〉0.01）,谷胱甘肽水平高于模型组（P 〉0.05,P 〉0.01）。表明硫化氢可以降低氧化应激反应,保护急性损伤大鼠马尾神经。     

Clinical evaluation and treatment options for herniated lumbar disc

Degeneration of the intervertebral disc from a combination of factors can result in herniation, particularly at the L4-5 and L5-S1 levels. The presence of pain, radiculopathy and other symptoms depends on the site and degree of herniation. A detailed history and careful physical examination, supplemented if necessary by magnetic resonance imaging, can differentiate a herniated lumbar disc from low back strain and other possible causes of similar symptoms. Most patients recover within four weeks of symptom onset. Many treatment modalities have been suggested for lumbar disc herniation, but studies often provide conflicting results. Initial screening for serious pathology and monitoring for the development of significant complications (such as neurologic defects, cauda equina syndrome or refractory pain) are essential in the management of lumbar disc herniation.     

实验性腰椎椎管狭窄的神经功能及组织学变化

目的:旨在建立一组与临床相关联的腰椎椎管狭窄动物实验模型,探讨不同程度腰椎椎管狭窄动物神经功能(包括神经行为和脊髓诱发电位)及组织学的改变及其意义。方法:以家犬建立腰椎椎管狭窄的动物模型。实验分为A组:正常组;B组:对照组;C组:25％狭窄组;D组:50％狭窄组等4组,每组5只。分别检测各组神经功能及组织学变化。结果:50％狭窄能引起马尾神经功能改变,尤以感觉诱发电位变化更加明显。不同程度狭窄均能造成马尾神经组织学变化。结论:脊髓诱发电位和神经行为能敏感地显示马尾神经的功能改变。50％狭窄是腰椎椎管狭窄引起一系列临床表现的临界点。     

Postmyelographic cauda equina syndrome in an asymptomatic acquired spinal stenosis of a young acromegalic

Early postmyelographic cauda equina syndrome in an asymptomatic young acromegalic is presented. The patient was asymptomatic for more than 1 yr despite myelographic evidence of acquired spinal stenosis at the L2-L4 level. Radiographic and/or myelographic findings should be clinically correlated. It is postulated that, in acromegaly, the combined simultaneous bony apposition-remodeling resorption mechanism is involved in the spine as platyspondyly, hyperostosis of spinous processes and vertebral scalloping to counteract soft tissue hyperplasia within the spinal canal; entrapment myelopathy, cauda equina syndrome and/or radiculopathy are ascribed to a soft tissue edematous mechanism superimposed on congenital or degenerative spinal stenosis, traumatic or postoperative spondylolisthesis, postmyelographic and/or postoperative arachnoiditis and a traumatic swollen or protrused intervertebral disc.     

Sciatic neuropathy secondary to a uterine fibroid: a case report

Lesions of the sciatic nerve outside the pelvis have been well described. Lesions within the pelvis, however, are far less common. We report the case of a 55-yr-old woman with a history of chronic low back pain who presented with progressive right buttock and posterolateral right lower limb pain associated with right foot numbness and tingling. She denied any associated low back or left lower limb pain. The patient was initially treated for a probable right lumbosacral radiculopathy, without improvement. A subsequent magnetic resonance image of the lumbosacral spine revealed multilevel disc degeneration at L3-4 through L5-S1, without disc herniation or canal stenosis. A magnetic resonance image of the pelvis revealed a markedly enlarged uterus, with a large pedunculated myoma impinging on the right sciatic foramen. The patient underwent a subtotal abdominal hysterectomy, with resolution of her right lower limb pain. This case illustrates the importance of considering intrapelvic causes of sciatic neuropathy. To our knowledge, this is the first reported case of sciatic neuropathy secondary to a uterine fibroid.     

不同程度腰椎椎管狭窄对脊髓背角神经肽的影响

目的:探讨不同程度的腰椎椎管狭窄时,相应节段脊髓背角中P物质(SP)和血管活性肠多肽(VIP)等神经肽含量和分布的变化特点,以及该变化的临床意义。方法:以家犬建立腰椎椎管狭窄的动物模型。实验分为A组:正常组;B组:对照组;C组:25%狭窄组;D组:50%狭窄组等4组,每组6只。分别检测各组脊髓背角SP、VIP的表达及含量变化。结果:脊髓背角中SP含量25%狭窄组各时相点差异无显著性意义(P>0.05)。50%狭窄组各时相点均非常显著升高(P<0.01)。脊髓背角中VIP含量25%狭窄组术后1,4周时较正常组、对照组有显著升高(P<0.05)。50%狭窄组在各时相点均显著(P<0.05)或非常显著(P<0.01)升高。结论:椎管狭窄造成的马尾神经压迫性损害可引起脊髓背角SP、VIP显著升高;脊髓背角中SP含量的升高随狭窄程度的增加而增加。VIP含量的升高不随狭窄程度的增加而增加。SP、VIP等神经肽类物质在腰椎椎管狭窄引起的下腰部和下肢疼痛的机制中扮演了重要的角色。     

Spinal pain made worse by recumbency: a clue to spinal cord tumors

In the absence of physical findings, pain in the low back, cervical or thoracic spine, or the extremities presents a diagnostic problem. On occasion the pain is present or made worse only when the patient lies down. We have attended four patients with underlying extradural tumors of the spinal canal. A 75-year-old woman with chronic back pain was treated for multiple myeloma with intravenous dexamethasone and 400 rads of x-ray irradiation to the lumbar spine and experienced marked pain relief in 24 hours. A 76-year-old woman with neck pain had complete pain relief after a vascular, calcified meningioma was removed surgically from under the 2nd and 3rd cervical nerve roots. A 38-year-old male with constant pain in the lumbar area and right leg and foot experienced marked relief from pain after a neurolemmoma of the cauda equina was surgically removed. A 57-year-old woman with knee pain became pain free 24 hours after radiation therapy to an enlarged nodular cauda equina. These four cases illustrate a diagnostic clue rarely mentioned in the literature.     

Atypical presentation of cauda equina syndrome secondary to lumbar disc herniation

The article describes the case of 35 year old female who was admitted to the department with saddle type hypoesthesia, anal incontinence without muscle weakness of lower extremities and sciatica. Central lumbar disc herniation (LDH) was determined on level L5-S1 level and the patient was operated thereafter. In the postoperative period, the patient did not have any muscle weakness of leg but had residual saddle type sensory loss and sphincter dysfunction. This article discusses atypical presentation of cauda equina syndrome (CES) secondary to LDH. Early diagnosis and surgery are important factors for a better prognosis in CES.     

腰椎间盘突出症术后并发症的护理

目的:分析腰椎间盘突出症术后并发症发生原因与护理对策.方法:对我科296例腰椎间盘突出症术后患者进行回顾性分析,总结术后并发症发生类型及原因.结果:本组共发生术后并发症54例,其中切口感染12例,椎间隙感染1例,硬膜外血肿3例,脑脊液漏21例,深静脉血栓形成9例,神经根粘连3例,马尾神经损伤5例.结论:术前全面评估是重点;术中无菌操作,避免损伤硬脊膜、神经根及马尾神经是关键;术后规范用药、密切观察病情变化、早期功能锻炼是保障.     

3D CT imaging of the lumbo-sacral spine after surgical treatment of L5-S1 spondylolisthesis by postero-lateral spondylodesis

Background. The aim of the study is the evaluation of the spatial imaging computed tomography (3D CT) of lumbo-sacral spine after surgically treated spondylolistesis L5-S1 with the postero-lateral spondylodesis using autogenic bone grafts.
Material and methods. Material comprises 9 patients treated surgically due to I degrees spondylolistesis caused by the L5 vertebra spondylolysis. In all cases postero-lateral spondylodesis was performed using autogenic bone grafts, taken from the iliac crest, placed on the transverse processes of the L5 vertebra and the sacral bone. The CT examination was performed in the period between 6 months up to 2 years after operation due to overloading lumbar pain.
Results. The bone grafts was localized correctly in 8 patients. In 1 person the upper side of the one bone graft was localized incorrectly, on the prominent transverse processus of the S1 vertebra, instead of the L5 one. The spatial reconstruction reveal the presence of osteophytes surrounding the ends of the bone grafts or the localization the fissure of the arch. In 2 cases the bone grafts were bigger on the left side, and the wide lower ends were connected with the dorsal surface of the sacral bone and were connected with the shorten due to surgery iliac crest
Conclusions. The CT examination with the use of the spatial option is very valuable in the lumbo-sacral spine imaging in patients treated with the postero-lateral spondylodesis due to spondylolisthesis L5-S1. The spatial images 3D CT are especially useful in imaging of the localization of the bone grafts, assessment of the wide of spinal canal and intervertebral foramens. The use of spatial imaging 3D is valuable supplement of standard CT examination in diagnosis of the patients complaining of the lumbar pain, treated surgically due to spondylolistesis.     

Unusual consecutive sacral stress fractures in a female distant runner: a case report

Sacral stress fractures are rare overuse injuries predominantly perceived in female long-distance runners. Our case report describes left-sided sacral wing stress fracture followed by contralateral sacral wing fracture after return to running. A 21-year-old female amateur long-distance runner presented with nonspecific low back and left buttock pain. Plain radiograph at presentation was unremarkable. Magnetic resonance imaging (MRI) revealed extensive bone marrow oedema in the cranial part of the left sacral wing and oblique fracture line. After six weeks of moderate training and two months of tailored running program she felt sharp pain in her right buttock during landing on her right leg. MRI confirmed contralateral sacral wing stress fracture. Additional two-month program to correct lumbar hyperlordotic posture with relaxation techniques and stretching of quadratus lumborum, psoas, multifidus and rectus femoris muscles was carried out. Strengthening of the abovementioned muscles was also done together with abdominal wall muscles and gluteals to stabilize the lumbar spine. She regained full level of training six months after the second fracture. Two years after the second stress fracture of the sacral wing she is free of pain, running about 60 to 70 km per week. Despite rapid rehabilitation program after first sacral stress fracture, contralateral stress fracture occurred. After a few months of additional conditional training and strengthening of lumbar, abdominal and pelvic muscles she regains her long-distance running including four marathons without obstacles. From this case we can assume that following proper rehabilitation program with correction of hyperlordotic posture sacral stress fractures can be avoided.     

MR imaging of the traumatized lumbar spine.

MR imaging is the imaging modality of choice for evaluation of the traumatized lumbar spine, providing critical information for determination of appropriate therapy. It is superior to other modalities for evaluating the supporting ligaments, disc, spinal cord, and the cauda equina. Major fracture patterns are readily discernable. Canal compromise caused by osseous fragments, epidural hemorrhage, or disc fragments is well visualized.     

马尾神经受压致腰椎管狭窄模型大鼠脊髓P物质不同时程的表达特征

背景疼痛递质-P物质的表达变化与腰椎管狭窄症所引发的持续性腰腿痛密切相关.但缺乏对马尾神经受压所致腰椎管狭窄模型大鼠脊髓P物质不同时程变化的定性与定量参数的了解.目的探讨腰椎管狭窄时不同时程脊髓内P物质的表达变化.设计随机分组对照实验.单位中国医科大学附属第一医院骨科.对象实验于2003-02/2004-12在中国医科大学实验动物中心完成.选择成年雄性SD大鼠30只.随机分为5组,1组为正常对照组.其他4组按取材时间不同分为2,4,8,12周组,每组6只.方法制备大鼠马尾神经受压后的腰椎管狭窄模型,于2,4,8,12周进行取材.应用免疫组化染色方法检测不同时间脊髓中P物质的表达.以光镜下神经元细胞核蓝色着色,细胞浆出现棕褐色颗粒定为P物质表达阳性.每例切片在脊髓横断面随机选取5个高倍视野,计数阳性细胞数.主要观察指标不同时间脊髓后角中P物质的阳性细胞的表达.结果在整个实验过程中无动物死亡,全部进入结果分析.①正常对照组偶见神经元细胞阳性着色,但着色较浅.②术后2周组可见大量神经元细胞阳性着色,着色深,阳性细胞数5.08左右.③术后4,8,12周组P物质染色有一定波动,较2周组阳性细胞数降低.但2,4,8,12周组脊髓后角P物质阳性细胞数目均显著高于对照组[(5.08±0.41),(402±0.35),(2.58±0.33),(3.45±0.22),(0.85±0.23),t=6.85,5.90,3.49,6.85,P＜0.05或P＜0.01].结论腰椎管狭窄症中马尾神经受压后,不同时程脊髓P物质的阳性细胞数的表达均有不同程度的增高.这种表达是否与伤害性刺激持续传人导致P物质上升,对减轻脊髓水肿和发挥对神经元的保护作用是否有关,有待进一步认证.     

Pulmonary Cement Embolism after Kyphoplasty

Abstract: An 80‐year‐old female with a history of osteoporosis was evaluated for sudden onset axial low back pain with bilateral lower extremity weakness, hyperreflexia, pain, urinary retention, and decreased rectal tone. Computed tomography of the lumbar spine revealed L1 compression fracture, retropulsion of bone causing spinal canal compromise with associated severe central canal stenosis. Following cement kyphoplasty of L1 with polymethyl methacrylate, the patient developed tachycardia and dyspnea. Chest radiograph and computed tomographic pulmonary angiogram revealed a large collection of hyperdense material within the right lower lobe pulmonary artery, consistent with pulmonary cement emboli. Management and imaging are discussed.