Clinical presentation of patients with acute cervical spine injury

A retrospective review of 67 patients with acute cervical spine fracture and/or dislocation was conducted at two suburban community hospital emergency departments. The mean age was 39, and two-thirds of the patients were male. Motor vehicle accidents and falls accounted for more than 80% of all injuries. On emergency department evaluation, it was found that there was no history of loss of consciousness in 42 patients (63%), no associated cranio-facial injuries in 31 patients (46%), and a normal sensorimotor examination in 59 patients (88%). Thirty-four patients (50%) were evaluated for cervical range of motion, which was found to be normal in one-third of the cases. The absence of mental status changes, cranio-facial injuries, range of motion abnormalities, and focal neurological findings is, therefore, not uncommon in patients who have sustained cervical spine injury.     

老年人急性中央颈脊髓损伤预后的临床研究

目的探讨年龄对急性中央颈脊髓损伤预后的影响以及老年人急性中央颈脊髓损伤的临床特点。方法回顾性对比分析８９例急性中央颈脊髓损伤，其中老年患者（６０～８１岁）２９例，占３２．６％；非老年患者（２５～５９岁）６０例。结果老年组中，四肢型２７例，发生率为９３．１％，高于非老年组的６６．７％（４０／６０）（χ２＝５．９９１，Ｐ＜０．０５）。年龄与初诊及最后随访时美国脊柱损伤协会（ＡＳＩＡ）评分（老年组分别为３７．４及７６．６分，非老年组为４３．８及８７．６分）呈负相关，差异有显著性（ｒ＝－０．２６３，Ｐ＝＜０．０５及ｒ＝－０．３４７，Ｐ＜０．０１）。２例死亡者为老年患者。老年组四肢型损伤２７例中，合并严重颈椎退行性变２４例，发生率（８８．９％）明显高于非老年组（Ｐ＜０．０５）。结论老年人急性中央颈脊髓损伤预后较差。     

Emergency evaluation of cervical spine injuries: CT versus plain radiographs

The recognition and appropriate initial management of the patient with an acute cervical spine injury in the ED is important because of the devastating and catastrophic effects of spinal cord injury. The use of computed tomography (CT) scan compared with initial plain radiographs in the detection of acute blunt traumatic cervical spine injury was evaluated in 20 patients. There was a disparity between the plain film and the CT scan as read by an attending radiologist in 12 patients (60%). In five patients (25%) the plain radiograph suggested a fracture or dislocation that was confirmed by CT scan. In eight patients (40%) the cervical spine film was read as a fracture, dislocation, or soft tissue widening between the cervical spine vertebrae. CT scan done later after admission was normal. In the remaining seven patients the plain film was read as "normal." CT scan, however, was normal in only three, and in four of these seven patients there was a discrepancy between the plain radiograph and the CT. Thus in four of 20 patients (20%) the plain film was read as "normal," while CT scan showed a fracture in our study. CT scan was superior to plain films in diagnosing cervical spine trauma, and it eliminated the false-positive (40%) and false-negative (20%) results obtained by relying on plain radiographs alone.     

Gerstmann-Sträussler-Scheinker syndrome misdiagnosed as cervical spondylotic myelopathy: A case report with 5-year follow-up

Rationale:Gerstmann-Sträussler-Scheinker syndrome (GSS) is a rare autosomal dominant disease caused by a mutation in the prion protein gene (PRNP) that is not well known among neurologists and is therefore easily misdiagnosed.Patient concerns: A 49-year-old man was admitted for the first time because of an unsteady walk with mogilalia for 1 year. He underwent a cervical discectomy and a plate-screw fixation 6 months prior, although postoperative gait instability did not improve.Diagnosis:Whole exome sequencing identified a pathogenic and heterozygous mutation in the PRNP 4 years after onset. The patient was eventually diagnosed with GSS.Interventions:Symptomatic treatment to improve cerebrocirculation and cerebrometabolism was provided.Outcomes:The neurological decline continued. The Mini-Mental State Examination and modified Rankin Scale scores changed from 19 to 11 and 2 to 5, respectively. Progressive cerebral and cerebellar atrophy on magnetic resonance imaging was observed.Lessons:Cerebral and cerebellar atrophy are neuroimaging features symptomatic of GSS that become more apparent as the disease progresses. This atrophy is positively correlated with the severity of symptoms and reduced quality of life. Neurologists treating middle-aged patients with progressive ataxia, cognitive impairment or dysarthria, and brain atrophy need to consider the possibility of GSS.     

国人颈髓角的MRI影像测量及临床意义

目的观察国人颈髓角（CMA）大小,提供其正常值范围,并探讨其临床意义。方法选择301例枕颈区正常的国人MRI片,测量CMA,其中99例同时测量脑干脊髓角。结果 301例受检者的CMA为137.7°～180.0°（163.73°±6.88°）,95%可信区间为150.24°～177.22°,不同性别及不同年龄者的CMA相比,P均〉0.05。其中99例受检者的脑干脊髓角为147.0°～177.7°（162.53°±6.17°）,与CMA相比,P〉0.05。结论国人CMA正常值为137.7°～180.0°,与脑干脊髓角相近,CMA超出正常值范围有助于颅底病变的诊断,对脑干、延髓、颈脊髓压迫程度的评价也有重要参考价值。     

Injury alters intrinsic functional connectivity within the primate spinal cord

Recent demonstrations of correlated low-frequency MRI signal variations between subregions of the spinal cord at rest in humans, similar to those found in the brain, suggest that such resting-state functional connectivity constitutes a common feature of the intrinsic organization of the entire central nervous system. We report our detection of functional connectivity within the spinal cords of anesthetized squirrel monkeys at rest and show that the strength of connectivity within these networks is altered by the effects of injuries. By quantifying the low-frequency MRI signal correlations between different horns within spinal cord gray matter, we found distinct functional connectivity relationships between the different sensory and motor horns, a pattern that was similar to activation patterns evoked by nociceptive heat or tactile stimulation of digits. All horns within a single spinal segment were functionally connected, with the strongest connectivity occurring between ipsilateral dorsal and ventral horns. Each horn was strongly connected to the same horn on neighboring segments, but this connectivity reduced drastically along the spinal cord. Unilateral injury to the spinal cord significantly weakened the strength of the intrasegment horn-to-horn connectivity only on the injury side and in slices below the lesion. These findings suggest resting-state functional connectivity may be a useful biomarker of functional integrity in injured and recovering spinal cords.Resting-state functional connectivity (rsFC) has been widely used to identify and characterize neural circuits in the brain (1–3), and its presentation at various spatial scales and its changes with specific physiological conditions confirm its fundamental role in maintaining normal brain function (4, 5). More importantly, alterations of rsFC networks in various disease conditions have altered our view about the functional significance of spontaneous baseline neural activity (3). Two very recent reports of success in detecting intrinsic functional circuits in human spines using resting-state fMRI once more suggest that rsFC is a fundamental, common feature of the entire nervous system (6, 7).Despite these exciting findings in human subjects, the functional and behavioral relevance of the intrinsic functional networks within the spine gray matter remains largely obscure, and there have been no previous reports attempting to understand their significance. One way to address this question is to manipulate the network and then examine how the network reacts to the manipulation. This type of approach is impossible to execute in humans but can be performed in nonhuman primates in a very well-controlled manner. Thus, this study aimed to better understand the functional and behavioral relevance of newly identified rsFC in the spinal cord by first determining whether similar intrinsic rsFC networks can be detected in the spinal cords of anesthetized monkeys. We also sought to determine the relationship between stimulus-evoked fMRI activation patterns and the intrinsic rsFC networks in the spine, and whether and how unilateral injury to the cord changes the pattern or strength of rsFC. To address the above-mentioned critical questions, we conducted our research in a well-established unilateral spinal cord injury (SCI) model (8, 9) and used high-resolution fMRI at high field (10, 11) and tracer histology to quantify resting-state networks.Traumatic SCI is a devastating medical condition that disrupts neural pathways, can lead to severe sensory impairment and motor deficits, and generally severely impairs the quality of life of SCI patients (12). Considerable research efforts and clinical trials have been devoted to attempts to restore impaired spinal cord function by promoting regeneration of disrupted neural pathways (13) or developing effective functional electrical stimulations (14) that assist the regaining of sensation and motor control. However, there has long existed a need for objective, noninvasive metrics of the effects of interventions. To date, behavioral assessments have been the gold-standard outcome measures of interventions, in both animals and humans studies (15). The strength or pattern of intrinsic rsFC within the spine may be a more sensitive noninvasive indicator of the states of local circuits both within and across spinal segments. Quantification of the intrinsic functional connectivity within the spine before and after injury has considerable potential to be a more objective imaging biomarker of spinal cord functional integrity. The knowledge gained in this fMRI study should be valuable for directing the use of fMRI for evaluating clinical prognosis and the effectiveness of therapeutic interventions.     

Traumatic central cord syndrome in a patient with os odontoideum

We report the case of a 33-year-old man who presented to the emergency department the morning after a motor vehicle accident with physical findings consistent with central cord syndrome. Radiographs of the cervical spine revealed os odontoideum. This abnormality of the odontoid process has not previously been described in association with central cord syndrome.     

Endoscopic dilatation and surgical myectomy of symptomatic cervical esophageal webs

During a 10-year period a cervical esophageal web or stricture was diagnosed at rigid endoscopy in 57 patients. Of these patients 72% had restricted their dietary habits because of their symptoms of dysphagia. Cineradiography of the pharynx had revealed abnormalities in 90% of the patients. Dilatation of the webs was performed with semisolid bougies, the endoscope itself, or with balloon inflation. Twelve patients were treated by myectomy of the cricopharyngeal muscle because of unsatisfactory results from the dilatation treatment. Cineradiographic outcome and improvement in dietary habits as a result of the treatment are reported.     

Cervical cord compression due to ossified posterior longitudinal ligament associated with diffuse idiopathic skeletal hyperostosis

We describe a case of cervical cord compression due to ossified posterior longitudinal ligament in association with diffuse idiopathic skeletal hyperostosis, in a young female. Characteristic CT findings are described.     

Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile(C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.     

多发性骨髓瘤合并脊髓压迫症6例临床分析

目的:探讨多发性骨髓瘤(MM)椎管内浸润导致脊髓压迫症(SCCS)的临床表现、诊断及治疗方法。方法:分析6例MM合并SCCS患者的临床特点、MRI及CT表现、不同治疗方法及疗效,并相关文献复习。结果:6例MM合并椎管内髓外浆细胞瘤(EMP)均发生在胸椎节段。患者从感觉双下肢麻木、腰背部疼痛起,在数小时至3 d内即进展至截瘫状态。经MRI或CT检查诊断为椎管内硬膜外占位性病变。6例中5例接受了治疗。2例接受手术及术后化疗者,1例肌力改善,另1例无效;单纯接受化疗1例无效;2例接受放疗者,均恢复行走,其中1例肌力恢复至5级,另1例4级。结论:MM合并SCCS多发生在胸椎节段,病情进展快,需尽快治疗。MRI可明确病变部位,以放疗效果最佳。     

Klippel–Feil syndrome: A very unusual cause of severe aortic regurgitation visualized by multimodality imaging

A 51‐year‐old man with Klippel–Feil syndrome (KFS) and immunodeficiency syndrome, status postintravenous immunoglobulin therapy, presented with shortness of breath. He was found to have severe aortic regurgitation in the setting of a trileaflet aortic valve with thickened leaflets and mild prolapse of the right coronary cusp with left ventricular dilation and borderline left ventricular ejection fraction. Although various cardiac anomalies have been described in KPS, otherwise unexplained severe aortic regurgitation has not been previously reported to the best of our knowledge. The patient underwent an uncomplicated surgical aortic valve replacement with a 25‐mm Medtronic Avalus pericardial tissue valve resulting in symptomatic improvement. Intra‐operative management and transesophageal echocardiography can be particularly challenging in KFS patients. We describe the first reported case of severe aortic regurgitation in KPS, review the cardiac anomalies associated with the syndrome, and highlight the clinical challenges in intra‐operative management of these patients.