Thoracic degenerative spondylolisthesis-associated myelopathy: A case report

Rationale:The thoracic spine is stabilized in the anteroposterior direction by the rib cage and the facet joints, thus thoracic degenerative spondylolisthesis is very uncommon. Here, we report a rare case of thoracic degenerative spondylolisthesis in which the lower thoracic region was the only region involved.Patient concerns:We present the case of a 56-year-old Chinese female who suffered from thoracic degenerative spondylolisthesis. She had a 2-year history of gait disturbance and bilateral lower-extremity numbness. The initial imaging examinations revealed Grade I anterior spondylolisthesis and severe cord compression, as well as bilateral facet joint osteoarthritis at T11/12.Diagnosis:The patient was diagnosed with thoracic degenerative spondylolisthesis-associated myelopathy.Interventions:She underwent a posterior decompression with transforaminal thoracic interbody fusion (TTIF) at T11/12.Outcomes:The patient recovered well after the operation, and MRI at 12-month follow-up revealed that spinal cord compression was relieved and high signal intensity in T2-weighted image was improved.Lessons:To the best of our knowledge, this is the first reported case of thoracic degenerative spondylolisthesis in which the lower thoracic region was the only region involved. Disruption of joint capsule, instability with micromotion, and degenerative disc may contribute to this rare disease. Posterior decompression with posterolateral fusion or TTIF were the main treatment modalities, however, TTIF has its unique advantages because of sufficient decompression, immediate stability and high fusion rate.     

Manubriosternal joint dislocation in rheumatoid arthritis: the role of thoracic kyphosis.

A case report of manubriosternal joint (MSJ) dislocation in a rheumatoid patient with thoracic kyphosis is presented together with a review of the relevant literature. Variations in the anatomical nature of the MSJ between normal individuals are described. In 43% of the population its characteristics are noted to be such that it may be involved in rheumatoid arthritis (RA). A joint thus involved can be dislocated by forces generated by longstanding thoracic kyphosis and transmitted to the manubrium via the first rib. Xeroradiographs of the MSJ region in our patient showed dislocation of the joint in the upright position and its subsequent reduction on lying the patient flat. We suggest that this demonstrated reduction is secondary to the lessening of the thoracic kyphosis that occurs in the supine position. It is concluded that in RA MSJ dislocation is a function of thoracic kyphosis.     

Symptomatic noncompressive motoromyelopathy presents as early manifestation in ankylosing spondylitis

Ankylosing spondylitis (AS) is an autoimmune spondyloarthropathy involving principally the sacroiliac joint and axial skeleton. Spinal cord involvement is an infrequent and late complication. It mostly results from compressive myelopathy due to skeletal osteopathy and usually presents with radiculomyelopathic sensory and motor deficits. To report three patients who suffered a progressive paraparesis/tetraparesis compatible with motor myelopathy without typical skeletal symptom. Myelopathy of unknown origin was initially interpreted in these patients. Radiography did not show typical change at sacroiliac joint or vertebrate. Spinal magnetic resonance image revealed cord atrophy at cervical and thoracic segment. A positivity of B27 antigen was found afterward. Their spondyloarthropathic symptoms developed within six months later with radiographic sacroiliitis. Seropositive AS with noncompressive myelopathy was finally established. Patients showed a reverse of motor impairment when their pain was well undercontrolled. Motor myelopathy may be neglected or underestimated in AS, in especially when typical skeletal symptom is absent or minimal. It may progress surreptitiously to harm spinal function or superimpose to crippling disability in compressive spinal cord injury. Therefore, a careful evaluation and monitor of spinal cord function is important for AS patient despite spinal deformity is not observed.     

Abdominal pain from a thoracic epidural abscess

Spinal epidural abscesses are difficult to diagnose and are associated with high morbidity and mortality. A 61-year-old Chinese woman fell and was admitted 5 days later with constant epigastric pain and constipation. Clinical examination was initially normal. Five days after admission, she developed urinary retention and mild lower limb weakness, progressing overnight to paraplegia. Clinical examination was consistent with a thoracic myelopathy. Neuroimaging showed a paracentral fluid collection compressing the thoracic cord at T8 level. Emergent neurosurgical intervention revealed an epidural abscess, which was drained. She responded to a 9-week course of antibiotics and recovered fully. Radicular pain from thoracic pathology can mimic intraabdominal pathology, and a high index of suspicion and prompt surgical intervention are essential to avoid the potentially devastating consequences of delayed recognition of epidural abscesses.     

Thoracic myelopathy complicating acute meningococcal meningitis: MRI findings

Spinal cord dysfunction is a rare complication of Neisseria meningitidis (meningococcal) meningitis. We report a 17-year-old patient who had a 3-day history of fever, headache and vomiting, agitation, and unresponsiveness. Cerebrospinal fluid showed a marked polymorphonuclear pleocytosis. Latex particle agglutination was positive for meningococci. The patient was given intravenous antibiotics and intravenous dexamethasone. Over the next 4 days, he developed weakness of the lower extremities, with areflexia and extensor plantar responses. MRI revealed contiguous hyperintensities on T2-weighted images involving the thoracic spinal cord from T4 to T9 and 4 brain abscesses. Five months later, he recovered brain function, but the paraparesis remained. This case illustrates that myelopathy may complicate acute meningococcal meningitis, possibly due to a vasculitis, stroke, autoimmune myelopathy, or direct infection of the spinal cord. Patients with myelopathy associated with acute meningitis should receive spinal MRI. In addition, meningitis should be considered in patients presenting with acute myelopathy.     

Spinal cord syphilis associated with human immunodeficiency virus infection: a treatable myelopathy.

A 33-year-old woman, seropositive for human immunodeficiency virus type 1 (HIV-1), presented with progressive weakness and numbness of the lower extremities, gait difficulties, and urinary frequency. Physical examination revealed bilateral lower extremity weakness, a left-sided Babinski reflex, and a thoracic sensory level to pinprick at T8. Serum rapid plasma reagin was 1:64, and fluorescent treponemal antibody-absorption (FTA-ABS) was 4+. Examination of the cerebrospinal fluid showed a mononuclear pleocytosis and reactive FTA-ABS. The myelopathy responded promptly to high-dose intravenous aqueous penicillin. Syphilis needs to be considered in the differential diagnosis of any patient who develops a myelopathy in association with HIV-1 infection. Because of the diverse nature in which syphilis may affect the spinal cord, treatment with intravenous aqueous penicillin, 12 to 24 million units daily, for a minimum of 10 days, should be considered in any HIV-1-seropositive patient with a progressive, unexplained myelopathy and positive serologic studies for syphilis.     

HIV-associated myelopathy: an uncommon indicator of AIDS]

INTRODUCTION: Spinal cord lesions are an uncommon mode of discovering acquired immunodeficiency syndrome because they usually appear at a later stage. EXEGESIS: We report a 58-year-old patient who had a spastic paraparesia and sphincter dysfunction. The spinal cord magnetic resonance imaging showed spontaneous hypersignals on T2-weighted images at the cervical and thoracic levels, enhanced with gadolinium, and without swelling. No cause was found. The HIV serology was positive and allowed us to consider an HIV-associated myelopathy. The antiretroviral therapy led to functional recovery. CONCLUSION: An HIV serology is suggested whenever an unexplained intramedullary lesion is discovered. Indeed, the diagnosis of HIV-associated myelopathy implies a specific therapeutic approach.     

Magnetic resonance imaging in the evaluation of patients with rheumatoid arthritis and subluxations of the cervical spine

We used magnetic resonance imaging (MRI) to examine 21 patients with rheumatoid arthritis and vertebral subluxations of the cervical spine, in whom neurologic symptoms and signs indicated spinal cord compression. Based on neurologic signs, the patients were assigned to 1 of 3 classes: class I, no objective signs of cervical myelopathy (9 patients); class II, only 1 objective sign of cervical myelopathy (4 patients); or class III, 2 or more objective signs of cervical myelopathy (8 patients). Atlantoaxial subluxation (20 patients) and subluxations below C2 (6 patients) were detected equally well by MRI and radiography. MRI revealed physical distortion of the spinal cord in all class III patients with compressive myelopathy. This distortion was found less frequently in class II and class I patients (3 patients), and the difference was statistically significant (P less than 0.005, class III versus class I and class II). No correlation was found between the vertebral dislocation (measured in millimeters) on plain radiographs and the presence of cord distortion on MRI. Myelography in class III patients showed that passage of contrast medium was blocked at the same level as the cord distortion seen on MRI. These findings suggest that MRI can serve as a useful, noninvasive procedure in the diagnosis and management of rheumatoid arthritis patients in whom compressive cervical myelopathy is suspected.     

Development of severe longitudinal atrophy of thoracic spinal cord following lupus-related myelitis

A 26-year-old woman suffered from acute myelitis at Th 6 level associated with systemic lupus erythematosus. Methyl-prednisolone pulse therapy, intravenous high-dose immunoglobulin administration and plasmapheresis were not effective. Her neurological signs had persisted in spite of subsequent administration of oral prednisolone and azathiopurine. Magnetic resonance imaging (MRI) of spinal cord at the onset showed a marked swelling with intramedullary high intensity signals on T2WI along the whole thoracic cord. Three years later, MRI demonstrated a severe longitudinal and segmental atrophy of the mid to low thoracic cord which resulted in transverse spinal signs.     

Bilateral retrosternal dislocation and hypertrophy of medial clavicular heads with compression to brachiocephalic vein.

A 36-year-old woman with effort dyspnea for 2 years, venous congestion of the left arm for 6 months and who did not have a history of a thoracic trauma was hospitalized. Posterior bilateral dislocation of the sternoclavicular joints and compression of the brachiocephalic vein were diagnosed and conformed by computed tomography (CT). The joint could not be reduced because of the old dislocation and destruction of the joint in the operation. The heads of the clavicles were resected and the vein compression was eliminated. Six weeks later, venous congestion disappeared and the brachiocephalic vein was patent.     

Endovascular exclusion of mycotic aortic aneurysm

The presence of prohibitive risk may preclude usual surgical management. Such was the case for a critically ill, 60-year-old woman who presented with concomitant, life-threatening conditions. The patient presented with acute central cord syndrome and lower-extremity paraplegia after completing a 6-week course of intravenous antibiotics for methicillin-sensitive Staphylococcus aureus bacteremia and osteomyelitis of the thoracic spine. Radiologic examination revealed bony destruction of thoracic vertebrae T4 through T6, impingement on the spinal cord and canal by an inflammatory mass, and a separate 2.5-cm mycotic aneurysm of the infrarenal aorta. The clinical and radiologic findings warranted immediate decompression and stabilization of the spinal cord, aneurysmectomy, and vascular reconstruction. However, the severely debilitated patient could not tolerate 2 simultaneous open procedures. She underwent emergent endovascular exclusion of the mycotic aneurysm with a stent-graft, followed immediately by laminectomy and stabilization of the thoracic spine. Intraoperative microbiology specimens showed no growth. The patient was maintained on prophylactic antibiotic therapy for 6 months. Fourteen months postoperatively, her neurologic function was near full recovery, and neither surveillance blood cultures nor radiologic examinations showed a recurrence of infection or aneurysm.Although the long-term outcome of endovascular stent-grafts in the treatment of culture-negative mycotic aneurysms is unknown, the use of these grafts in severely debilitated patients can reduce operative risk and enable recovery in the short term.     

胸廓内动脉行冠脉搭桥术的应用解剖学研究

目的了解胸廓内动脉的解剖结构,为临床进行冠状动脉搭桥术提供解剖学资料。方法选取甲醛固定的成人尸体标本40具,胸廓内动脉保留完好。观察记录胸廓内动脉的起始部位和终末分支,以及胸廓内动脉与胸横肌的关系。测量胸廓内动脉的长度和各肋间隙距胸骨侧缘的距离。结果多数胸廓内动脉起自锁骨下动脉第1段,沿胸骨侧缘外侧下行;多数胸廓内动脉在第6肋间隙形成终末分支;多数胸横肌上缘与胸廓内动脉相交在第3肋软骨处。左、右侧胸廓内动脉的长度分别为（19．34±1．69）cm和（18．86±1．73）cm,平均外径为（2．81±0．39）mm和（3．08±0．44）mm。结论胸廓内动脉行冠脉搭桥术是一种可行的搭桥方式,根据解剖学数据,在术中应取用第6肋软骨以上的血管进行吻合。     

Myelopathy and HIV infection

The clinical significance of myelopathy associated with HIV infection is poorly understood. Recently, a prospective electrophysiological follow-up study of spinal-evoked potentials in HIV-seropositive men without AIDS revealed a 32% prolongation of the latency from the gluteal crease to the 12th thoracic vertebra (T12) following tibial nerve stimulation at the ankle performed after an interval of 2 years. In AIDS patients this transmission delay did not increase further. Instead, the latency prolongation took place proximal to T12. We assume that myelopathy is an integral part of HIV infection that it is asymptomatic in the early disease phase, spreads from the lumbar part the spinal cord in a rostral direction and leads to the development of leg weakness and ataxia during the later stages of the disease.     

Longitudinal myelitis associated with systemic lupus erythematosus: clinical features and magnetic resonance imaging of six cases.

Myelopathy is a rare central nervous system (CNS) complication associated with systemic lupus erythematosus (SLE). Acute transverse myelitis (ATM) is the most frequent form of SLE-related myelopathy. Magnetic resonance imaging (MRI) typically shows increased signal intensity in T2-weighted images and cord swelling. In the present paper, we describe six cases of SLE-related myelopathy with multiple increased signals in the T2-weighted images involving continuous levels of the cervical and thoracic spinal cord, a distinctive feature recently named 'longitudinal myelitis'. The clinical and laboratory findings are similar to those presented by ATM patients, including paraparesis, sensory level and sphincter disturbances. Four patients had positive antiphospholipid antibodies (aPL) suggesting that this could be a characteristic of longitudinal myelitis. Treatment in all cases included high doses of corticosteroids and immunosuppressive agents (intravenous (i.v.) cyclophosphamide). Anticoagulation therapy was given to one patient and two others received low doses of aspirin. The outcome was mainly unfavorable with slow improvement in only one case, no improvement in two and relapse of the myelopathy in the remaining three. In conclusion, longitudinal myelitis is an unusual form of SLE-related myelopathy, it might be associated with aPL and it has a poor prognosis.     

A case of chondrosarcoma originating from the rib and presenting as a posterior mediastinal tumor-like shadow]

A 66-year-old man was admitted to our hospital because of induction therapy of interferon for chronic hepatitis due to hepatitis C virus. On routine investigation, a mass-like lesion was detected at the level of the hilum of the left lung on the chest plain radiograph. On the thoracic CT, the heterogeneous tumor, including calcification, was 6 cm in diameter in the posterior mediastinal area, and the rib and vertebra had been damaged by it. The tumor extended to the descending aorta and the left main bronchus. A small nodule in the left S1 + 2 was noted on another slice section of this thoracic CT. The possible diagnoses, based on these radiological findings, for this tumor were primary lung cancer, posterior mediastinal tumor and malignant tumor originating from the chest wall. The diagnosis of chondrosarcoma was made based on the histological findings of the specimen obtained from the tumor. This tumor could not be resected in this case, because it had extensively damaged the rib and vertebra, and the nodular lesion in the left S1 + 2 was regarded as a metastasis from it. Although reports of chondrosarcoma originating from a rib and presenting as a posterior mediastinal tumor-like shadow are rare, chondrosarcoma should be considered as a possible diagnosis for such tumors-posterior mediastinal masses with characteristic findings such as a large tumor in contact with the chest wall, and containing calcification, with destruction of bone and dissection of the rib as shown in our CT findings.     

A case of SAPHO syndrome with paraplegia due to a thoracic kyphosis]

A 63-year-old man visited our hospital in January 1993 because of back pain, which had been present for a year and persisted. The patient was diagnosed compression fracture of thoracic spine by another hospital. Thoracic plain radiographs revealed destructive and sclerotic changes with reduction of height of T 8, T 9 vertebral body. He had kyphosis on this level. Radiographs of the chest revealed hyperostosis of bilateral proximal clavicle. We diagnosed SAPHO syndrome (synovitis, acne, pustlosis, hyperostosis, and osteomyelitis: SAPHO) with T 8, T 9 spondylodiscitis, however without any skin manifestations. Oral indomethacin was effective, however thoracic kyphosis progressed gradually. Spastic gait and paraplegia appeared from February 1998, at last on July he was unable to walk independently. MRI showed the compression of spinal cord on T 8, T 9 level. We performed circumferential decompression and fusion with instrumentation. His paraplegia improved after surgery. We describe a rare case of SAPHO syndrome with paraplegia due to a thoracic kyphosis.     

Progressive compressive myelopathy induced by a rare primary isolated thoracic vertebral hydatid cyst: A case report

Rationale:Hydatid cyst is a disease caused by the larvae of Echinococcus spp. The larvae often reside in the liver, lungs, and brain. Occasionally, a primary isolated thoracic vertebral hydatid cyst is reported to cause severe complications. Various diseases may lead to the development of progressive compressive myelopathy. Herein, we report a rare case of a primary isolated thoracic vertebral hydatid cyst with compressive myelopathy.Patient concerns:A 57-year-old female had numbness and weakness in the lower limbs for a span of 3-months.Diagnosis:Thoracic magnetic resonance imaging (MRI) showed that an isolated mass was observed in the T5 vertebral body, which compressed the spinal cord. The diagnosis was confirmed after surgical excision, and Echinococcus granulosus was found to be the etiologic factor.Interventions:The patient underwent laminectomy with no complications.Outcomes:After surgical decompression, the patient made slow and measurable progress. While relatively rare in the non-pastoral area, the primary isolated thoracic vertebral column hydatid cyst may be considered as a possible etiology of atypical extradural spinal compression.Lessons:This case illustrates the complexity of spinal echinococcosis manifestations and the necessity of an interdisciplinary approach.     

Radiographic measurements of occipito-atlanto-axial dislocation in rheumatoid arthritis

Atlanto-axial dislocation is frequently found in patients with rheumatoid arthritis. Vertical atlanto-axial dislocation with invagination of the dens into the foramen magnum may result in most serious myelopathy. Decompression, removal of the dens and atlanto-axial fixation have given fair results in such cases. It is our aim, however, to prevent myelopathy in our rheumatoid patients. The prerequisite for that is routine, radiographic examination of the cervical spine and prophylactic atlanto-axial fixation. For these routine controls we need a radiographic measuring method which can be used even in cases of greater destruction. Our radiographic measuring method is compared with other methods and seems to be more appropriate and also gives information about the forward or backward tilting of the atlas. In a group of non-rheumatoid patients we have measured normal figures for this method.     

Effect of lung volume reduction surgery on bony thorax configuration in severe COPD.

STUDY OBJECTIVES: Hyperinflation in patients with severe COPD is associated with an increased anteroposterior (AP) rib cage diameter. We sought to determine whether bilateral lung volume reduction surgery (LVRS) affects bony thorax configuration. DESIGN: Prospective of clinical data collection before and after LVRS. SETTING: Tertiary-care university medical center. PATIENTS: We measured multiple AP and transverse thoracic diameters, by using plain chest roentgenograms (CXRs) in 25 patients (11 men, 14 women), and thoracic CT scans in 14 patients (7 men, 7 women), preoperatively and 3 months postoperatively. A subgroup of 7 patients (reference data) also had CXR thoracic diameter measurements made, using films obtained previously within a year of their presurgical evaluation. Another subgroup of 10 patients had CT scan measurements also made 12 months postoperatively. MEASUREMENTS AND RESULTS: CXR dimensions were taken at the level of the manubrium sterni (M) and thoracic T7 and T11 levels. CT dimensions were taken at T4, T6, T8, and T10 levels. At each level, left (L), midsagittal (C), and right (R) AP and maximal transverse diameters were measured. The sum of the three AP diameters (Total) was used for calculations. Patients also underwent tests such as spirometry, lung volumes, diffusing capacity of the lung for carbon monoxide, 6-min walk distance (6MWD), and transdiaphragmatic pressures during maximum static inspiratory efforts (Pdimax sniff) measured before and 3 months after LVRS. Patients were (mean +/- SD) 58+/-8 years old, with severe COPD and hyperinflation (FEV1, 0.68+/-0.23 L; FVC, 2.56+/-7.3 L; and total lung capacity [TLC], 143+/-22% predicted). After LVRS, AP diameters were reduced at thoracic level T7 (from 24.2+/-2.0 cm to 23.3+/-2.2 cm, p = 0.0002), and transverse diameters were reduced at T7 (from 26.8+/-1.9 cm to 26.4+/-1.7 cm, p = 0.001) and T11 (from 29.9+/-2.2 cm to 29.5+/-2.2 cm, p = 0.03), as measured using the CXR. In contrast, thoracic diameters were similar in subjects with CXRs before LVRS and within 1 year before evaluation. CT-measured AP diameters were significantly reduced 3 months after LVRS at T6, (from 48.8+/-6.0 cm to 46.7+/-5.4 cm, p = 0.02), T8 (from 54.2+/-7.0 cm to 52.3+/-6.5 cm, p = 0.004), and T10 (from 53.8+/-7.5 cm to 51.2+/-8.0 cm, p = 0.001), but not at T4. These AP diameter reductions directly correlated with the postoperative reductions in TLC and residual volume, and also with the increases in Pdimax sniff and 6MWD after LVRS. The reduction in AP diameters at thoracic levels T8 and T10 seen 3 months after LVRS remained stable at 12-month follow-up, whereas those measured at T6 lost statistical significance. CT-measured transverse diameters were unchanged at all levels after LVRS. CONCLUSIONS: We conclude that LVRS decreases mid-to-lower AP rib cage diameter as assessed by CXR and thoracic CT. Although transverse diameters were reduced on CXR, the magnitude was small and was not confirmed with CT. After LVRS, AP diameter reductions are most likely the result of reduction in lung volume, and they are associated with improvements in diaphragm strength and exercise endurance.     

Activation of the inspiratory intercostal muscles by electrical stimulation of the spinal cord

Electrical stimulation of the spinal cord was evaluated as a method of activating the inspiratory intercostal muscles. Studies were performed in anesthetized dogs after hyperventilation-induced apnea. A stainless steel electrode, rubberized along its entire length except for 2 to 3 mm at the distal tip, was introduced epidurally onto the dorsal surface of the thoracic spinal cord. Stimulating electrodes were also placed in each hemidiaphragm. Intercostal electromyograms, inspired volume, and thoracoabdominal movements were monitored. The inspiratory capacity was determined in each animal as the volume required to achieve an airway pressure of +25 cm H2O during passive lung inflation. Spinal cord stimulation at the T2-T3 spinal level resulted in maximal inspired volume generation and electrical activation of the parasternal, external, and internal intercostal muscles of the upper and midrib cage regions as determined by electromyograms. Intrathoracic pressure swings increased progressively with increasing stimulus amplitude and frequency until plateaus were reached at 6 mA and 40 Hz, respectively. Postphrenicotomy spinal cord stimulation resulted in expansion of the rib cage and reduction in circumference of the abdominal compartment. Inspired volumes during spinal cord stimulation were 537 +/- 49 ml (prephrenicotomy, prone), 347 +/- 19.6 ml (postphrenicotomy, prone), and 303 +/- 30.6 ml (postphrenicotomy, supine). Bilateral diaphragm activation alone resulted in inspired volumes of 404 +/- 39 ml. Combined diaphragm and postphrenicotomy spinal cord stimulation (supine) resulted in an inspired volume of 712 +/- 72 ml, which approximated the inspiratory capacity (803 +/- 35 ml). Our results suggest that spinal cord stimulation may be a useful physiologic and clinical tool to produce coordinated contraction of the inspiratory intercostal muscles.