Cervical intradural disc herniation and cerebrospinal fluid leak

Cervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.     

Simultaneous MR neurography and apparent T2 mapping of cervical nerve roots before microendoscopic surgery to treat patient with radiculopathy due to cervical disc herniation: Preliminary results

There is no imaging modality to quantitatively evaluate compressed cervical nerve roots in cervical radiculopathy. Here we sought to evaluate the usefulness of simultaneous apparent T2 mapping and neurography with nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation-enhancement imaging (SHINKEI-Quant) to evaluate compressed nerves quantitatively in patients with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery.One patient with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery and 5 healthy subjects underwent simultaneous apparent T2 mapping and neurography with SHINKEI-Quant. The patient was a 49-year-old man with severe right upper arm pain and numbness. Based on MRI images, we suspected right C7 radiculopathy due to C6-7 cervical disc hernia. The T2 relaxation times of the cervical dorsal root ganglia of the brachial plexus bilaterally at C5–C8 were measured.We observed no significant differences in T2 relaxation times between the nerve roots on the left and right at each spinal level with values in healthy subjects. In our patient, neurography revealed swelling of the right C7 nerve, and a prolonged T2 relaxation time compared with that of the contralateral, unaffected C7 nerve. We performed microendoscopic surgery and the symptoms improved.We were able to evaluate the injured nerve root quantitatively in a patient with cervical radiculopathy using the SHINKEI-Quant technique, being the first study to our knowledge to show the usefulness of this technique to evaluate cervical radiculopathy quantitatively before microendoscopic surgery.     

Retro-odontoid pseudotumor without atlantoaxial subluxation

A retro-odontoid pseudotumor (ROP) is commonly associated with atlantoaxial subluxation (AAS). Here, we report a patient with ROP but without AAS. The patient was a 72-year-old man who did not have a history of rheumatoid arthritis or trauma to the head and neck. The patient was admitted to our hospital with gait disturbance, progressive motor weakness in both upper extremities and sensory disturbance in all four extremities. MRI showed a retro-odontoid mass with severe compression of the cervical spinal cord. A CT scan showed spondylotic changes in C5, C6, and C7 and bilateral facet fusion between C3 and C4. Dynamic radiography showed no evidence of AAS; there was loss of mobility at C2–C7 and excessive mobility at C1. Intraoperative pathological examination revealed that the lesion was a pseudotumor; therefore, posterior C1–C2 fixation was performed. MRI performed 6 months after the operation revealed that the pseudotumor was markedly reduced. To the best of our knowledge, patients with ROP without AAS are uncommon.     

Two-level artificial disc placement for spondylotic cervical myelopathy.

This report describes a 49-year-old woman who presented with a myeloradiculopathy with two-level spinal cord compression. She underwent C5-6 and C6-7 anterior cervical decompressions and placement of two Bryan disc (Medtronic Sofamor-Danek. Memphis, TN) prostheses. Whilst single-level cervical arthroplasty using the Bryan disc prosthesis has been described before, this is the first two-level case reported in the literature and opens the way for the possible future management of multilevel cervical cord compression in a way that maintains cervical motion, avoids donor site bone graft problems, and may reduce the incidence of adjacent segment disease.     

A rare anatomical variation of the C7 pedicle and intraspinal course of the C7 nerve root

We report a 58 year old man who presented with severe C7 radiculopathy which failed to respond to conservative measures. Subsequent CT and MR imaging of his cervical spine demonstrated C6/7 foraminal stenosis as well as unusual low take-off of the C7 nerve root in relation to a congenital low-set C7 pedicle, findings which were subsequently confirmed intra-operatively. The relevance of the bony and neural anatomy is described and its implications for surgical management are discussed. To our knowledge, this anatomical anomaly has not been previously highlighted in the published English literature.     

Lipidized glioblastoma: Pathological and molecular characteristics

We report a rare case of a 33‐year‐old man with a lipidized glioblastoma multiforme (GBM) in the right posterior frontal region. Histologically the tumor had all the typical features of a GBM but with the rare observation of lipidized differentiation. There were multiple mitoses, extensive vascular proliferation, focal necrosis and the tumor cells had abundant xanthomatous cytoplasm and marked nuclear pleomorphism. The tumor showed immunoreactivity with GFAP. The O⁶– methylguanine methyltransferase (MGMT) promoter was methylated and there were no isocitrate dehydrogenase (IDH)1 and IDH2 mutations. To the best of our knowledge, this is the first time MGMT promoter status and IDH mutation assessment have been reported in a case of lipidized GBM.     

Brown-Séquard Syndrome Caused by a Cervical Synovial Cyst

Synovial cysts are recognized as an uncommon cause of radicular and myelopathic symptoms. They are most frequently found in the lumbar region. The cervical spine or cervicothoracic junction is a rare location for a degenerative intraspinal synovial cyst as compared with the lumbar spine. At given cervical spinal levels, synovial cysts probably share clinical features with disc herniation and stenosis. However, the pathogenesis of synovial cysts remains still controversial. Here, we report a rare case of a synovial cyst in the lower cervical spine presented as Brown-Séquard syndrome and include a brief review of the literature. To the best of our knowledge, no previous report has been issued in the English literature on a synovial cyst presenting with Brown-Séquard syndrome. Neurologic function recovered completely after complete removal of the cyst and expansive laminoplasty.     

Computed Tomography Fluoroscopy-Guided Selective Nerve Root Block for Acute Cervical Disc Herniation

Objective

To analyze the clinical outcomes of computed tomography (CT) fluoroscopy-guided selective nerve root block (SNRB) for severe arm pain caused by acute cervical disc herniation.

Methods

The authors analyzed the data obtained from 25 consecutive patients who underwent CT fluoroscopy-guided SNRB for severe arm pain, i.e., a visual analogue scale (VAS) score of 8 points or more, caused by acute soft cervical disc herniation. Patients with chronic arm pain, motor weakness, and/or hard disc herniation were excluded.

Results

The series comprised 19 men and 6 women whose mean age was 48.1 years (range 35-72 years). The mean symptom duration was 17.5 days (range 4-56 days) and the treated level was at C5-6 in 13 patients, C6-7 in 9, and both C5-6 and C6-7 in 3. Twenty-three patients underwent SNRB in 1 session and 2 underwent the procedure in 2 sessions. No complications related to the procedures occurred. At a mean follow-up duration of 11.5 months (range 6-22 months), the mean VAS score and NDI significantly improved from 9 and 58.2 to 3.4 and 28.1, respectively. Eighteen out of 25 patients (72%) showed successful clinical results. Seven patients (28%) did not improve after the procedure, and 5 of these 7 underwent subsequent anterior cervical discectomy and fusion.

Conclusion

CT fluoroscopy-guided SNRB may play a role as a primary conservative treatment for severe arm pain caused by acute cervical disc herniation.     

Lateral C1–C2 dislocation complicating a type II odontoid fracture

We describe a unique C1–C2 lateral dislocation complicating a displaced type II odontoid fracture. We report a 63-year-old female pedestrian involved in a motor vehicle accident who required posterior open reduction and segmental C1–C2 instrumentation and fusion. Radiological examination of the cervical spine demonstrated a lateral dislocation of the atlantoaxial joint with a displaced type II fracture of the odontoid, fracture of the right lateral mass of C1 and left superior articular facet of C2. Neurological examination revealed the patient to be myelopathic and closed halo traction failed to achieve reduction. Due to the irreducible nature of the dislocation, posterior open reduction and segmental C1–C2 instrumentation and fusion was performed. The dislocated C1–C2 articulation was successfully reduced surgically with subsequent bony fusion and resolution of all neurological symptoms and signs at final follow-up. To our knowledge, this the first report of this type of injury. We also review the related literature on this unique injury pattern.     

Interval,acute onset airway obstruction associated with a fracture of the C4 vertebra in a patient with ankylosing spondylitis

We report a 92-year-old female with ankylosing spondylitis who suffered a non-displaced cervical fracture of the C4 vertebral body as the result of a mechanical fall. A rigid cervical collar was used to maintain stability. The patient later went on to develop upper airway obstruction as a result of fracture displacement. She was emergently intubated for airway protection. To our knowledge, this is the first report of interval, acute onset upper airway obstruction caused by cervical instability following trauma and fracture in a patient with ankylosing spondylitis. This example highlights one of the potential complications of rigid cervical collar immobilization in patients with spinal instability.     

人工颈椎间盘置换对下颈椎活动影响的三维有限元分析

建立人工椎间盘置入后下颈椎C3~7的三维模型,分析颈椎人工椎间盘置换后下颈椎运动情况。根据1例人工椎间盘置入患者术后6个月CT片,应用有限元方法建立其包含BryanTM人工颈椎间盘假体的下颈椎三维有限元模型,导入Ansys 9.0中,对椎体皮质骨、松质骨、椎间盘用三维十节点四面体结构实体单元进行网格划分后进行分析。对模型加载2 N•m的力矩,观察其在前屈/后伸、侧屈及旋转几种状态下的运动情况,了解其运动特性。通过与以往的研究结果比较,试验结果基本符合或趋势基本一致。结果提示,颈椎间盘置换后能基本保证下颈椎运动稳定性。     

Application of a stand-alone anchored spacer in noncontiguous anterior cervical arthrodesis with radiologic analysis of the intermediate segment

The purpose of this study was to describe the clinical features of noncontiguous cervical degenerative disc disease (cDDD), investigate the efficacy and complications of a stand-alone anchored spacer (SAAS) for patients with noncontiguous cDDD, and present radiologic analysis of the intermediate segment (IS) after skip-level fusion. Nineteen consecutive patients with noncontiguous cDDD who underwent skip-level anterior cervical discectomy and fusion (ACDF) with SAAS from January 2010 to December 2012 were enrolled in this study. Clinical outcomes were assessed preoperatively and at 24 months postoperatively using the Japanese Orthopaedic Association score, Neck Disability Index, and Visual Analog Scale. Overall cervical alignment (OCA) of the cervical spine, and the range of motion (ROM), intervertebral disc height (IDH), disc signal intensity and disc protrusion of IS were measured and compared before and after surgery. Clinical outcomes significantly improved compared to preoperative scores. The OCA was corrected and maintained at 24 months postoperatively compared with preoperative values (p < 0.05). There were no significant differences in the ROM and IDH of the IS at each follow-up (p > 0.05). However, decreased signal intensity on T2-weighted MRI was evidenced in three mobile IS at final follow-up (20.0%). Skip-level ACDF with SAAS may be an efficacious option for the treatment of noncontiguous cDDD.     

Evaluation of outcome after surgical treatment of cervical disc disease with DERO C-Disc PEEK cages

BACKGROUND AND PURPOSE: To evaluate the efficacy of surgical treatment of cervical disc disease using a relatively novel type of cage, to assess the association between changes in cervical spine curvature and pain intensity as well as quality of life, to assess how often implants of different sizes were applied, and to analyze statistically the occurrence of surgical procedures performed on each spinal level. MATERIAL AND METHODS: The study group included 30 patients (19 [63%] women and 11 [37%] men), with a mean age of 48.8 years. Clinical assessment included, among other things, the visual analogue scale (VAS) for pain and the neck disability index (NDI). In addition to these questionnaires, each patient was neurologically examined pre- and postoperatively as well as during the follow-up visits one and three months after surgery. Radiological evaluation consisted of measurements of general and local lordosis of the cervical spine based on radiographs. RESULTS: Fifty-two cages were used during surgical procedures in the studied group of patients. Cages of seven out of ten different available sizes were used. Oblique cages (for lordosis correction) sized 4/6 mm (68%) and 5/7 mm (12%) were most often used. Implants of three sizes (8 mm, 10 mm, 7/9 mm) were not used. Surgical procedures most commonly involved levels C5/C6 (39%) and C6/C7 (33%). CONCLUSIONS: Surgical treatment of cervical disc disease with DERO C-Disc PEEK cages improved neurological condition of patients, decreased pain, improved quality of life and restored pathologically changed lordotic curvature of the cervical spine to near normal values. In the analyzed group of patients no significant correlations between changes in cervical spine curvature (general and local lordosis) and intensity of pain (VAS) as well as quality of life (NDI) were observed.     

Digital nerve somatosensory evoked potentials and flexor carpi radialis H reflexes in cervical disc protrusion and involvement of the sixth or seventh cervical root: relations to clinical and myelographic findings

Peak latencies of somatosensory evoked potentials (SEPs) from nerves of the first digit (digit 1-SEP), 39 controls, and third digit (digit 3-SEP), 47 controls, and indicated for Erb's point, second cervical vertebra (Cv2) and contralateral cortical hand area correlated significantly with arm length. Single regression analysis for arm length for Erb's potentials and the Cv2 potential in digit 1-SEP, and multiple regression analysis for arm length and age for the Cv2 potential in digit 3-SEP, the cortical potentials and flexor carpi radialis H reflex were used for demonstration of root C6 or C7 pathology. Upper crossing of +3 S.D. was defined as abnormal. The combined examination yielded abnormalities in 81% of our 22 patients operated for compression of root C6 or C7 due to cervical disc protrusion. A minority of the patients showed multiple positive correlations between symptoms and electrophysiologic and myelographic findings. In others only one or the other investigative procedure provided confirmatory information, while, in a notable number (6 patients), these approaches revealed abnormalities when there were no or non-specific symptoms. The presented electrophysiological investigations are useful to determine the presence and severity of root C6 or C7 compression as well as the functional relevance of a myelographic abnormality.     

Posterolateral extrusion of C7-D1 intervertebral disc associated with intradiscal hematoma

A case of an extruded cervical intervertebral disc at C7-D1 level with intradiscal hematoma in a 68-year-old male patient is presented. MR imaging showed a posterolateral extradural hemorrhagic lesion at C7-D1 level. It was suggestive of an epidural hematoma or a bleed within a neoplasm. A posterior approach was adopted and an extruded intervertebral disc with intradiscal hematoma was found and completely excised. Extruded cervical disc with intradiscal hematoma in a 68-year-old male has never been hitherto reported in the literature. The uniqueness of the case is the extruded cervical disc with hematoma within it presenting at an advanced age and unusual radiological features on MR imaging. The clinical presentation, radiological features and surgical management of this rare condition are discussed and the relevant literature is briefly reviewed.     

颈椎病的三维CT表现

目的 探讨三维CT(3DCT)在诊断颈椎病方面的价值。方法 采用3DCT技术检查了300例颈椎病患者。其中，神经根型145例，椎动脉型41例，脊髓型40例,混合型73例．食管压迫型1例。3DCT观察颈椎病患者的颈椎骨质增生、椎间孔大小、椎动脉和颈椎骨质增生的关系、骨性椎管狭窄的改变。结果 21．3％的惠者有颈椎椎体骨质增生．42．3％的钩突关节和16．2％的小关节突柱有骨质增生，另外有12个小关节突有错位改变。在145例神经根型颈椎病惠者中，发现狭窄的椎间孔438个。其中，C6—7和C5—6椎间孔狭窄占81．3％。椎间孔狭窄的原因有钩突关节骨质增生、椎间盘突出、椎体肥大、小关节突骨质增生／错位等。椎动脉型颈椎病表现为骨赘压迫椎动脉(22．0％)和椎动脉变细或粗细不均(65．9％)，12．1％的患者未见异常。脊髓型颈椎病3DCT表现有颈椎管狭窄、椎体后缘骨质增生、后纵韧带钙化、椎闻隙狭窄和颈椎问盘突出等。结论 3DCT能全面评价颈椎问盘退变及其产生的颈椎骨质增生对神经、血管和脊髓的影响，是一种诊断颈椎病的实用影像学检查方法.     

Artificial disc insertion following anterior cervical discectomy

OBJECTIVE AND IMPORTANCE: Fusion following anterior cervical discectomy has been implicated in the acceleration of degenerative changes in the adjacent spinal segments. Discectomy followed by implantation of an artificial cervical disc maintains the functionality of the spinal unit, while still providing excellent symptomatic relief. We describe our preliminary experience with implantation of the Bryan Cervical Disc System in two cases of single-level cervical disc herniation. CLINICAL PRESENTATION: Two male patients presented with a left C6 radiculopathy, without evidence of myelopathy. Magnetic resonance imaging revealed a disc herniation at C5-6 in both cases. Pre-operative flexion and extension radiographs demonstrated preserved motion at the involved levels. INTERVENTION/TECHNIQUE: Following a standard anterior cervical decompression, precision drilling of the vertebral endplates was carried out using a drill attached to a bed-mounted, gravitationally-referenced retraction frame. An artificial cervical disc, composed of a polyurethane nucleus with titanium endplates, was fitted between the contoured endplates without fixation to the vertebral bodies. No complications were experienced during the insertion of the prosthesis, or in the postoperative course. Both patients experienced immediate postoperative resolution of their radicular pain and were discharged from hospital the following day. At nine months following surgery, both patients continue to have complete relief of radicular symptoms. Postoperative radiographs at six months following surgery confirm accurate placement of the prosthesis and preserved mobility of the functional spinal unit. CONCLUSION: Insertion of the Bryan artificial cervical disc prosthesis following anterior cervical discectomy is a relatively straightforward procedure, which appears to be safe and provides good clinical results, without requiring additional surgical time. Long-term follow-up is required to assess its safety, efficacy, and ability to prevent adjacent segment degeneration.     

Unilateral ossification of the ligamentum flavum in the cervical spine with atypical radiological appearance.

We report a case of symptomatic unilateral ossification of the ligamentum flavum with unusual radiological presentation in the cervical spine. The patient was a 64 year old man with numbness and weakness of the left upper extremity who was admitted to our hospital. Computerized tomography revealed a triangular-shaped high density mass severely compressing the spinal cord at C6. Concomitant small ossification of the posterior longitudinal ligament was noted from C3 to C6. The ossified mass was completely removed via a unilateral osteoplastic laminectomy of the left C6 and C7.     

Malignant triton tumor of cervical spine with hemorrhage

Malignant peripheral nerve-sheath tumours (MPNST) with a rhabdomyomatous component are referred to as malignant triton tumours. Cervical tritons are rare, with only one previous report. We present a 28-year-old male patient with a malignant triton tumor involving the cervical spine with neurofibromatosis Type 1 presenting with symptoms of rapidly progressive cord compression. Radiology was suggestive of a MPNST with hemorrhage at the C2-C3 level. He underwent surgery with decompression of the intradural, and a small part of the extradural, component. To our knowledge this is the first report of a cervical triton tumor presenting with an intratumoral bleed.     

Unilateral multilevel interlaminar fenestration: A minimally invasive approach for cervical intramedullary lesions

The traditional approach for cervical intramedullary lesions is laminectomy, but the procedure may result in spinal instability and spinal deformity. Unilateral multilevel interlaminar fenestration (UMIF) is an alternative minimally invasive approach that may have great advantages in preserving spinal stability. However its use in cervical intramedullary lesions is rare, and the indications, safety and limitations of this approach for cervical intramedullary lesions are still under investigation. We report five patients (three males, two females, age range 12–46 years) who were treated between 2010 and 2011 for cervical intramedullary lesions. The lesions included three ependymomas, one astrocytoma and one ependymal cyst, and the locations of the lesions were at the medulla–T2, C4–T1, C5–C7, C4–C7 and C6–C7. All of these lesions were completely removed through UMIF, and all patients had stable or improved neurological status after surgery. No recurrences or spinal deformities were detected during the follow-up period which ranged from 24 to 35 months (mean = 27.4 months). UMIF is a feasible approach for selected cervical intramedullary lesions. This approach allows complete resection of multilevel lesions without increasing the risk of injury to the spinal cord, and minimizing the risk of postoperative spinal instability. The indications for and limitations of UMIF are discussed.