Anterior Spinal Cord Syndrome in a Patient with Behçet's Disease

Although neurological involvement in Beh?et's disease is not so uncommon, isolated spinal cord disease is quite rare and reported to be observed in about 2% of all cases with neurological involvement. Here we report a Beh?et's patient with spinal cord disease presented with anterior spinal cord syndrome. This rare syndrome is caused by hypoperfusion of the anterior spinal artery and to our knowledge has not been previously reported in patients with Beh?et's disease. This report defines the characteristic clinical features of this entity and emphasizes the importance of early immunosuppressive treatment and initiation of rehabilitation.     

Dynamic electrophysiological examination of cervical flexion myelopathy

Cervical flexion myelopathy is thought to arise following compression of the spinal cord by vertebrae or intervertebral discs and dura mater, or from overstretching of the spinal cord induced by cervical spinal flexion. However, the influence of spinal flexion on the spinal cord and the detailed origins of this disease are unknown. In this article the authors report a case of cervical flexion myelopathy in which dynamic electrophysiological examination was performed using an epidural electrode. This investigation showed the real-time influence of flexion of the cervical spine on spinal cord function. This technique was considered to be useful for diagnosis and in decision making for treatment. Anterior fusion was the optimal surgical method for treating this disease.     

影响慢性压迫性颈脊髓病手术疗效的因素分析

对６６例慢性压迫性颈脊髓病患者的颈椎ＣＴＭ采用图像分析系统进行了测量研究。发现脊髓受压最重部位的脊髓横断面积（髓断面）、髓断面／椎管横断面积（管断面）比值及髓断面／椎体横断面积 （椎断面）与手术疗效密切相关。若髓断面积小于３０ｍｍ２，伴有髓断面／管断面比值＜０．２及髓断面／椎断面比值＜０．０８时，术后疗效不佳，脊髓功能有不可逆性改变的倾向。除病程、脊髓受压节段数及脊髓矢径／横径之比值等因素外，髓断面、髓断面／管断面及髓断面／推断面的比值三者是预测疗效的最可靠指标。     

Naturally occurring disk herniation in dogs: an opportunity for pre-clinical spinal cord injury research

Traumatic spinal cord injuries represent a significant source of morbidity in humans. Despite decades of research using experimental models of spinal cord injury to identify candidate therapeutics, there has been only limited progress toward translating beneficial findings to human spinal cord injury. Thoracolumbar intervertebral disk herniation is a naturally occurring disease that affects dogs and results in compressive/contusive spinal cord injury. Here we discuss aspects of this disease that are analogous to human spinal cord injury, including injury mechanisms, pathology, and metrics for determining outcomes. We address both the strengths and weaknesses of conducting pre-clinical research in these dogs, and include a review of studies that have utilized these animals to assess efficacy of candidate therapeutics. Finally, we consider a two-species approach to pre-clinical data acquisition, beginning with a reproducible model of spinal cord injury in the rodent as a tool for discovery with validation in pet dogs with intervertebral disk herniation.     

Acute experimental allergic encephalomyelitis increases lumbar spinal cord incorporation of epidurally administered [(3)H]-D-mannitol and [(14)C]-carboxyl-inulin in rabbits.

We sought to determine whether acute experimental allergic encephalomyelitis (EAE) alters the incorporation of epidurally administered [(3)H]-D-mannitol and [(14)C]-carboxyl-inulin into the lumbar spinal cord in rabbits. Acute EAE is an experimental model for demyelinating spinal cord diseases such as multiple sclerosis. It was induced in rabbits by footpad inoculation with rabbit spinal cord homogenate, resulting in hind limb paresis or paralysis. Animals were classified into four study groups: Control, Paraparesis, 1-Day Paraplegia, and 5-Day Paraplegia. Ten microCi each of [(3)H]-D-mannitol and [(14)C]-carboxyl-inulin were administered epidurally for 90 min. After infusion, animals were perfused with saline. The lumbar cord was dissected and divided into 11 segments. Compared with other groups, animals in the 5-Day Paraplegia group had greater incorporation of [(3)H]-D-mannitol and [(14)C]-carboxyl-inulin in lumbar segment 8, corresponding to the location of the epidural catheter tip. Compared with the Control group, EAE animals had increased [(3)H]-D-mannitol incorporation in various lumbar segments. Increases in the spinal cord incorporation of epidural drugs with EAE suggest that demyelination may render the spinal cord susceptible to larger amounts of substances administered in the epidural space. These findings may have implications regarding neurotoxicity in association with demyelinating spinal cord disease. IMPLICATIONS: Acute experimental allergic encephalomyelitis, a disease model for multiple sclerosis, increased spinal cord incorporation of radioactive drugs administered in the epidural space. We conclude that demyelinating disease processes may expose the spinal cord to larger amounts of substances administered neuraxially.     

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.

     

Schistosomiasis of the spinal cord--underdiagnosed in South Africa?

Schistosomiasis is endemic in many areas of South Africa, particularly the northern and eastern Transvaal. At Ga-Rankuwa Hospital in the northern Transvaal, 30 km north-west of Pretoria, spinal cord disease is common. In a substantial proportion of these cases no obvious cause for the condition can be found. In an attempt to draw attention to schistosomiasis as a possibly underdiagnosed cause of spinal cord disease, 3 cases of schistosomiasis of the spinal cord seen over a period of 3 years are reported. These 3 patients had histological evidence of spinal schistosomiasis. Because myelography of the spinal cord is often non-contributory in schistosomal involvement, it is suggested that patients with 'myelopathy of unknown origin' who come from an endemic area be given a therapeutic trial of praziquantel, especially if the serological findings are positive for schistosomiasis and the lower cord is involved.     

Ischemic damage to the spinal cord following end-to-side aortobifemoral bypass

A patient presenting with urinary retention was found to have progressive spinal cord ischemia subsequent to an end-to-side aortobifemoral bypass for atherosclerotic disease. This serves as a vivid reminder of the possibility of this complication even in ischemic disease and that urinary retention may be the initial symptom of cord ischemia. A review of the literature on spinal cord ischemia following abdominal aortic surgery is presented.     

Castleman's disease and spinal cord compression: case report

OBJECTIVE AND IMPORTANCE: Castleman's disease is a rare lymphoproliferative disorder most often found in the mediastinum. Localized forms are usually benign, whereas multicentric forms may be aggressive. We report a patient with Castleman's disease who presented with spinal cord compression, and we review previously published cases of Castleman's disease involving the central nervous system. To our knowledge, this is only the second case of Castleman's disease presenting as a spinal epidural mass with cord compression. CLINICAL PRESENTATION: A 44-year-old otherwise healthy woman presented acutely with difficulty walking. Examination revealed mild myelopathy in her legs. Magnetic resonance imaging revealed a posterior epidural mass compressing the thoracic spinal cord at T3-T5. INTERVENTION: Thoracic laminectomy and gross total resection of the lesion were performed. Pathological examination of the lesion identified the hyaline-vascular type of Castleman's disease. The patient's symptoms resolved postoperatively. CONCLUSION: Castleman's disease presenting as a spinal epidural mass lesion with cord compression is rare. Surgical treatment can result in an excellent outcome.     

The presentation of gallstones and results of biliary surgery in a spinal cord injured population.

BACKGROUND: Since spinal cord injured patients lack visceral sensation, their clinical manifestations of gallstones could be relatively occult. A higher proportion of these individuals may present with advanced biliary disease compared with the general population. Prophylactic cholecystectomy for asymptomatic stones may therefore be justified. METHODS: All spinal cord injured patients seen at the Seattle Veterans Hospital over a 5-year period were retrospectively surveyed to define a set of patients who had undergone a cholecystectomy. The operative indications and results were compared with those from a series of cholecystectomies in neurologically intact patients. RESULTS: The presentation of biliary disease in spinal cord injured patients was not more advanced than that of neurologically intact patients. Patients with high cord injuries presented in a similar fashion to those with low injuries. CONCLUSIONS: Since most spinal cord injured patients with biliary disease present with typical findings, prophylactic removal of gallstones in these patients is not warranted.     

Renal calculi presenting as hyperhidrosis in patient with spinal cord injury

Renal calculi in the spinal cord injury population present a diagnostic dilemma for urologists. However, 7% of all patients with spinal cord injury will develop renal calculi. Undiagnosed stone disease can lead to significant morbidity and mortality in this population. This case demonstrates the subtlety of the presenting symptoms of renal calculi in the patient with spinal cord injury.     

脊髓型颈椎病脊髓受压征象的MRI分级及其临床意义

目的:建立脊髓型颈椎病(cervical spondylotic myelopathy,CSM)脊髓受压征象的MRI分级系统,探讨其可靠性及其与年龄、病程和JOA评分的相关性。方法:收集2010年1月～2011年9月就诊的78例多节段CSM患者的颈椎MRI资料,男51例,女27例;年龄42～77岁,平均55.1岁;病程0.25～276个月,平均48.8个月。以颈椎MRI中脊髓形态、脊髓信号、脊髓与硬膜囊关系作为分级依据征象,将每个征象按照其严重程度分为3个等级,相应赋予0～2分,按3个征象总分划分为四级:0级,0分;Ⅰ级,1～2分;Ⅱ级,3～4分;Ⅲ级,5～6分。由3位初、中、高级职称医师对78例患者的颈椎MRI从C2/3～C6/7进行2次独立分级和1次共同分级,Kappa分析评价每位医师前后2次之间及3位医师之间分级结果的一致性。将3位医师对三个征象共同分级的结果进行Spearman相关分析,同时将患者年龄、病程、术前JOA评分与分级结果进行Spearman相关分析。结果:3位医师分别2次对78例患者的390个节段进行分级,0级82～94个(21.03%～24.10%),Ⅰ级112～126个(28.72%～32.31%),Ⅱ级111～137个(28.46%～35.13%),Ⅲ级47～70个(12.05%～17.95%)。同一医师前后2次分级一致的节段占74.6%～78.5%,Kappa值为0.657～0.706;不同级别医师分级一致的节段占71.5%～76.7%,Kappa值为0.614～0.683。三个征象分级的结果之间相关系数分别为0.552、0.603、0.577,呈显著性正相关(P<0.05)。患者年龄、病程与3位医师共同分级结果的相关系数分别为0.372～0.511、0.388～0.498,呈显著性正相关(P<0.05);术前JOA评分与3位医师共同分级结果的相关系数为-0.409～-0.546,呈显著性负相关(P<0.05)。结论:依据脊髓形态、脊髓信号、脊髓与硬膜囊关系建立的脊髓型颈椎病脊髓受压征象的MRI分级系统具有良好的一致性,其与患者年龄、病程呈正性相关,而与术前JOA评分呈负性相关,对脊髓受压后病变的严重程度评估和研究有指导意义。     

Sarcoidosis of the spinal cord. Case report.

A case of intramedullary sarcoidosis simulating a tumor of the cervical spinal cord is presented. Autopsy showed that the disease was limited to the cervical cord and hilar lymph nodes. The literature is reviewed and six cases of histologically documented spinal cord sarcoidosis are discussed.     

Gene therapy for spinal cord injury and disease

An incomplete understanding of the pathological processes involved in neurodegeneration and dysfunction of spinal cord injuries and diseases makes these disorders difficult to treat. Repair of damaged or genetically impaired spinal cord also has been limited by the complexity, cellular heterogeneity, and relative inaccessibility of the tissue. Thus, therapeutic options for the treatment of either chronic spinal cord diseases such as amyotrophic lateral sclerosis or acute spinal cord injuries have been rather limited. Potential new therapeutic targets are being identified as our understanding of the molecular pathology involved in neural injury and regeneration increases. Recent advances in gene transfer techniques have made gene therapy a more realistic and viable strategy for the treatment of a broad range of spinal cord disorders. This review summarizes the current state of knowledge regarding the limitations and recent advances in gene therapy and potential application of this technology toward spinal cord injury and disease.     

The angiosome territories of the spinal cord: exploring the issue of preoperative spinal angiography. Laboratory investigation

OBJECT: The angiosome concept has been the subject of extensive research by the senior author (G.I.T.), but its specific applicability to the spinal cord was hitherto unknown. The aim of this study was to see if the spinal cord vasculature followed the angiosome concept and to review the usefulness of preoperative spinal angiography in surgery for spinal disorders. Spinal cord infarction and permanent paraplegia may result from inadvertent interruption of the artery of Adamkiewicz. Spinal angiography, which may enable avoidance of this catastrophic complication, is still not commonly used. METHODS: Two fresh cadavers were injected with a gelatin-lead oxide mixture for detailed comparative study of spinal cord vasculature. One cadaver had insignificant vascular disease, whereas the other had extensive aortic atherosclerosis, presenting a unique opportunity for study. After removal from each cadaver, radiographs of the spinal cords were obtained, then photographed, and the vascular territories of the cords were defined. RESULTS: Four angiosome territories were defined: vertebral, subclavian, posterior intercostal, and lumbar. These vascular territories were joined longitudinally by true anastomotic channels along the anterior and posterior spinal cord. Anastomosis between the anterior and posterior vasculature was poor in the thoracolumbar region. The anterior cord relied on fewer feeder arteries than the posterior, and the anterior thoracolumbar cord depended on the artery of Adamkiewicz for its supply. In chronic aortic disease with intercostal artery occlusion at multiple levels, a rich collateral circulation supporting the spinal cord was found. CONCLUSIONS: The arterial supply of the spinal cord follows the angiosome concept. The atherosclerotic specimen supports the suggestion that the blood supply is able to adapt to gradual vascular occlusion through development of a collateral circulation. Nevertheless, the spinal cord is susceptible to ischemia when faced with acute vascular occlusion. This includes inadvertent interruption of the artery of Adamkiewicz. The authors recommend the use of preoperative spinal angiography to prevent possible paraplegia in removal of thoracolumbar spinal tumors.     

Anaesthesia for spinal surgery

Patients with and without spinal disease are at risk of neurological damage during anaesthesia, even when the surgery is not directed at the spine. Certain types of spinal surgery carry a substantial risk. Reports of spinal cord damage due to direct laryngoscopy are unconvincing. Evoked potential spinal cord monitoring is used increasingly during anaesthesia, and successful recording of potentials requires the co-operation of the anaesthetist. Airway problems are common in cervical spine disease, particularly if the disease affects the upper three vertebrae. Anterior surgical approaches to the craniocervical junction involve extensive surgery, with implications for airway management and nutrition.     

Intramedullary spinal cord metastasis of lung adenocarcinoma presenting as Brown-Sequard syndrome

BACKGROUND: It is extremely rare for cancer to present first as an intramedullary spinal cord metastasis. Furthermore, because it is unlikely for spinal cord neoplasm to present acutely, an acute presentation may signify metastatic disease and should be considered in the initial differential diagnosis. METHODS: The authors present a case of a 59-year-old man presenting with Brown-Sequard syndrome and in whom metastatic lung adenocarcinoma to the spinal cord was subsequently discovered. Review of the literature reveals this case to be one of only a very few where intramedullary tumor was the first manifestation of metastatic disease. RESULTS: The mainstay of treatment for intramedullary spinal metastases remains steroids, radiation, and chemotherapy, though no well-designed study compares these modalities by long-term survival and functional results. This patient underwent local radiation and systemic chemotherapy following surgical resection. CONCLUSIONS:This patient had no preoperative signs suggesting disease in other organs, making the diagnosis of lung adenocarcinoma metastatic to the intramedullary cord surprising, especially given the extremely rare incidence of spinal intramedullary metastatic disease. However, the patient had an acute presentation, uncommon for primary neoplasm, which may be an indication of metastatic disease.     

The optimal radiologic method for assessing spinal canal compromise and cord compression in patients with cervical spinal cord injury. Part I: An evidence-based analysis of the published literature

STUDY DESIGN: An evidence-based analysis of published radiologic criteria for assessing spinal canal compromise and cord compression in patients with acute cervical spinal cord injury. OBJECTIVES: This study was conducted to determine whether literature-based guidelines could be established for accurate and objective assessment of spinal canal compromise and spinal cord compression after cervical spinal cord injury. SUMMARY OF BACKGROUND DATA: Before conducting multicenter trials to determine the efficacy of surgical decompression in cervical spinal cord injury, reliable and objective radiographic criteria to define and quantify spinal cord compression must be established. METHODS: A computer-based search of the published English, German, and French language literature from 1966 through 1997 was performed using MEDLINE (U.S. National Library of Medicine database) to identify studies in which cervical spinal canal and cord size were radiographically assessed in a quantitative manner. Thirty-seven references were included for critical analysis. RESULTS: Most studies dealt with degenerative disease, spondylosis, and stenosis; only 13 included patients with acute cervical spinal cord injury. Standard lateral radiographs were the most frequent imaging method used (23 studies). T1- and T2-weighted magnetic resonance imaging were used to assess spinal cord compression in only 7 and 4 studies, respectively. Spinal cord size or compression were not precisely measured in any of the cervical trauma studies. Interobserver or intraobserver reliability of the radiologic measurements was assessed in only 7 (19%) of the 37 studies. CONCLUSIONS: To date, there are few quantitative, reliable radiologic outcome measures for assessing spinal canal compromise or cord compression in patients with acute cervical spinal cord injury.     

Spinal cord infarction following surgery for mesenteric vascular occlusion

We present a case of spinal cord infarction following an operation on a 64-year-old man for mesenteric vascular occlusion under combined general and epidural anesthesia. Several etiological factors, each one able to affect blood flow in the spinal cord and cause infarction, might have been present in our patient, including generalized degenerative atherosclerotic vascular disease, secondary polycythemia resulting from the patient's chronic obstructive pulmonary disease, and intraoperative hypotensive episodes. This case shows that, even with careful technique, hemodynamic monitoring, and early evaluation of neurologic status, patients can experience irreversible spinal cord ischaemia that results in permanent paraplegia.     

Non-dysraphic intramedullary spinal cord lipoma. A case report

Non-dysraphic spinal cord lipomas are rare benign lesions, accounting for approximately 1% of all spinal cord tumors. Patients usually present with long histories of disability followed by rapid progression of their symptoms. Presenting symptoms include spinal pain, dysesthesic sensory changes, gait difficulties, weakness, and incontinence. Magnetic resonance imaging is the examination of choice. The T1- and T2-weighted images show increased and decreased signal intensity, respectively. The goal of intervention is decompression and generous debulking following by duraplasty. Early diagnosis of spinal cord lipomas and early surgery is advanced prior to irreversible disease progression. One new case of true non-dysraphic cervicodorsal spinal cord lipoma is reported.