The reflex sympathetic dystrophy syndrome in patients who have had a spinal cord injury

Patients suffering from a spinal cord injury often present with a pain syndrome. Although the reflex sympathetic syndrome is a common diagnosis in some forms of neurological disease such as patients with a stroke, it is less frequent in those with a spinal lesion. The authors report eight patients with reflex sympathetic dystrophy who had a spinal cord injury. The diagnosis and treatment are discussed along with a review of literature.     

Fibro-cartilaginous embolism in a cat

A nine-year-old cat was presented with a history of an acute onset of paraplegia. On the basis of the neurological examination, the lesion was localised between the fourth lumbar and third sacral segments (L4 to S3) of the spinal cord. Investigations included radiography, myelography, cerebrospinal fluid analysis, routine haematology and biochemistry, feline leukaemia virus testing and urinalysis. A definitive diagnosis was not achieved and the cat was euthanased 12 days after presentation. Post mortem examination revealed infarction of the spinal cord secondary to fibrocartilaginous embolisation. This is the first reported case of fibrocartilaginous embolism in the cat in the UK.     

Subarachnoid hemorrhage secondary to spinal arteriovenous malformation and aneurysm. Report of a case and review of the literature

A patient with recurrent subarachnoid hemorrhage was seen initially with intermittent signs and symptoms of intracranial and spinal cord dysfunction. Myelography and spinal angiography revealed an arteriovenous malformation (AVM) and aneurysm of the spinal cord. Extensive investigation failed to reveal any intracranial lesion. The relationship of subarachnoid hemorrhage at a spinal level to the development of remote neurological abnormalities is discussed, and previous reports of aneurysms associated with spinal AVM are reviewed.     

The SPINRPHEX club

A 3-year-old Japanese domestic cat with a diagnosis of lymphocytic leukemia showed severe generalized seizures in the course of chemotherapy after leukemic condition was improved clinically. Computed tomography (CT) and magnetic resonance (MR) imaging of the brain were carried out. Both contrast procedures disclosed enhancements at the falx cerebri and the margin of cerebral cortex. Among these procedures contrast MR imaging demonstrated the lesion most clearly. Cytological examination of cerebrospinal fluid obtained by spinal puncture showed the infiltration of malignant cells and the diagnosis of meningeal syndrome associated with lymphocytic leukemia was defined. Intrathecal administration of cytosine arabinoside partially improved the neurologic dysfunction. Autopsy and histopathological examination confirmed the infiltration of leukemic cells in the areas of meningeal lesion demonstrated with contrast CT and MR imaging. Thus these imaging techniques, especially contrast MR imaging, are useful tools for rapid and precise diagnosis of meningeal syndrome.     

Cyclosporin A and FK506 inhibit activation-induced cell death in the murine WEHI-231 B cell line

The patient presenting with a spinal meningioma usually has a slow indolent course of symptoms but at the time of diagnosis will have a range of neurological deficits. The diagnosis is most commonly secured with MR imaging. Safe resection of spinal meningiomas mandates a clear understanding of their growth characteristics as well as of regional anatomy. Surgical treatment of spinal meningiomas is gratifying, and the severity of preoperative neurological deficits should never deter one from withholding therapy.     

Neurological outcome after surgery for thoracolumbar fractures. A retrospective study of 93 consecutive cases, treated with dorsal instrumentation

Surgical reconstruction and fusion form the treatment of choice for unstable thoracolumbar fractures. It remains difficult, however, to prove that surgical treatment provides an increased potential for neurological recovery. Also, the role of a decompressive laminectomy is still unclear. To address these issues, 93 consecutive cases of thoracolumbar fractures treated with dorsal instrumentation were reviewed. The neurological status at the time of admission and at a mean of 26 months postinjury was graded according to a modified Frankel scale. By using preoperative radiographs and computed tomography scans, we differentiated between fracture-dislocation lesions, dislocation lesions, flexion-distraction lesions, complete and incomplete burst fractures. Spinal stenosis was classified from grade 0 (no stenosis) to grade 3 (> 66% stenosis). All thoracolumbar fractures were treated with posterior instrumentation, using Dick's fixateur interne and Steffee's VSP plates and screws. During this procedure, laminectomy was performed in 33 patients (35%). In 17 cases (52% of the laminectomies), a surgically treatable lesion (dural tear, trapped nerve root, etc.) was found, especially in patients with a combination of a neurological deficit and a dislocation lesion, a fracture-dislocation lesion or a complete burst fracture with spinal stenosis grade 2 or 3. The neurological and functional outcome was excellent: none of the patients deteriorated, 68% made a complete neurological recovery, and 61% regained their previous level of activity.     

Pituitary apoplexy after spinal anaesthesia

We report the case of a previously healthy 51-yr-old male who underwent an uneventful total hip replacement under spinal anaesthesia. His immediate postoperative course was complicated by the development of a severe frontal headache. Initial conservative treatment included oral analgesics and an epidural blood patch. The headache persisted and was followed by progressive vision loss and a right partial third nerve palsy. The patient was almost blind at the time of transfer to our neurosurgical unit. Relevant investigations revealed marked hyponatraemia (serum sodium concentration 122 mmol litre-1) and second-degree heart block (Mobitz I). A CT scan showed a pituitary tumour and confirmed the clinical diagnosis of pituitary apoplexy. Urgent craniotomy was scheduled and a large necrotic pituitary adenoma was excised. The postoperative course was uneventful with return of near normal vision at the time of discharge. Clinicians should consider this diagnosis when focal neurological deficits occur with post-dural puncture headache.     

Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients

The aim of this paper is to review the incidence and characteristics found in traumatic spinal cord injury (SCI) occurring in patients with long-standing ankylosing spondylitis (AS). The incidence of patients with traumatic SCI admitted to our unit from January 1984 to February 1996 was 2% (15 out of 893). They were all men with a mean age of 56 years. Most frequently the etiology of the lesion was a motor vehicle accident and the injury was mainly due to a hyperextension mechanism. Acute spinal fracture occurred in 13 patients, all involving the cervical region. No fracture was observed in two patients with thoracic neurological level. Three patients presented with an interval free period of neurological symptoms in whom a spinal epidural hematoma was visualized with magnetic resonance imaging. On admission eight patients were diagnosed as having complete SCI and the other seven an incomplete SCI. In the acute phase, respiratory complications were most frequent, causing six patients to die. Treatment was conservative in 14 patients. Multidisciplinary management of these patients should be implemented in an institution equipped with both a Spinal Injury Unit and an Intensive Care Unit.     

Neuroimaging and pathology of the spinal cord in compressive cervical myelopathy

Magnetic resonance imaging (MRI) has enabled us to see the spinal intramedullary pathology as differences in signal intensity. Intramedullary high intensity lesions were observed on T2-weighted MRI in patients with cervical spondylotic myelopathy (20.0%) and ossification of the posterior longitudinal ligament (OPLL) of the cervical spine (25.7%). The frequency of this findings was proportional to the clinical severity of myelopathy and degree of spinal cord compression. The pathophysiological basis of such signal abnormality was presumed to vary from acute edema to chronic myelomalacia. The intramedullary lesion on MRI is considered to be the main site of lesion responsible for the neurological symptom because of a good correlation between the neurological level and high intensity level. We found from nine autopsy cases of OPLL that there are distinct differences in severity and extent of pathological changes between the spinal cord with a boomerang-shaped cross-section and that with a triangular-shaped cross-section. In the boomerang-shaped cases, major pathological changes were restricted to the gray matter and the white matter was relatively well preserved. Secondary wallerian degeneration was restricted to the fasciclus cuneatus the fibers of which were derived from the affected segments. In the cases of a triangular shape, pathological changes were more severe, both white and gray matter were involved. There were severe pathological changes over more than one segment, and both descending degeneration of the lateral pyramidal tracts and ascending degeneration of the posterior column, including the fasciclus gracilis, were observed. In conclusion, it is clinically very important to understand the pathological basis of the compressed spinal cord on neuroimages.     

Dorsal sensory level as a false localizing sign in cervical myelopathy

INTRODUCTION: Cervical myelopathy is a common disorder of the spinal cord. The most frequent symptoms are muscle weakness and spasticity starting in the legs. Occasionally the sensory levels are several spinal cord segments below the cervical lesion which makes diagnosis difficult. CLINICAL CASE: We present the case of a 31 year old man who presented (after exercise) with paresthesia and numbness below the left costal margin in the left hemiabdomen and the left leg. On physical examination there was painful superficial tactile thermic hypoaesthesia at the level of D10 on the left side, together with brisk myotatic reflexes of the legs and indifferent bilateral plantar reflexes. Blood and CSF studies were normal. On cervical MR there was a large hernia of the intervertebral disk at C5-C6 and marked involvement of the spinal cord. Progress after surgery was good. Two months after operation he was symptom free and neurological examination was normal. CONCLUSIONS: Diagnosis of cervical myelopathy may be difficult because of the varied symptoms. There may be a dorsal or lumbar sensory level acting as a false localizing sign. The physiopathological mechanism for this is not clear. Different hypotheses have been put forward based on anatomical distribution of the spino-thalamic tract and on indirect factors (vascular, demyelinization, etc.). In a patient with a dorsal sensory level and normal radiological findings at this level, it is important to study levels above this as well to avoid errors of diagnosis and treatment.     

Precision of plasma clearance of iohexol for estimation of GFR in patients with renal disease

Dural spinal cysts are exceedingly rare lesions. The authors are aware of only seven cases reported in the literature. This report comprises three patients with dural cysts of the cervical spinal canal who presented with atypical neurological signs and symptoms, including a long history of dysesthesias and atrophic pareses in the proximal upper extremities. Surgical intervention disclosed two ventrally and one dorsally located cystic lesions of the spinal dura mater. The cystic wall was fenestrated and kept open by a silicone catheter in each case. Histological examination of the excised lesions revealed fibrous connective tissue consistent with dural tissue. No epithelial lining was detected. The lesions were classified as dural cysts. The patients' postoperative courses were uneventful. Although dural cysts are rare lesions, they must be considered in the differential diagnosis of spinal cystic lesions. Because they are nonaggressive and can be safely drained by microsurgical techniques, patients have a favorable prognosis. Early surgical intervention is mandatory to prevent severe neurological deficits.     

Syngeneic grafting of adult rat DRG-derived Schwann cells to the injured spinal cord

A subdural inflatable micro-balloon was used to induce closed traumatic contusion to adult rat spinal cord. This spinal cord injury model was associated with reproducible and graded neurological deficits and histopathological alterations. At various delays after injury, transplantations of syngeneic adult cultured dorsal root ganglion-derived Schwann cells were performed into the spinal cord lesion. The transplants were well integrated and reduced the microcystic posttraumatic cavitation as well as the gliosis. Schwann cells transplants were invaded by numerous regenerating neurites most of which, based upon their neurotransmitter contents, seem to originate from the dorsal root ganglion.     

Analysis of 59 cases of non-traumatic sudden death in various neurological diseases]

Sudden death is a common complication of myocardial infarction, necrotic pancreatitis and other diseases. Physicians usually neglect the possibility of neurological disorders. 59 cases of sudden death among 314 autopsied cases with neurological diseases were analyzed. The most frequent cause of neurological sudden death was cerebrovascular disease (CVD). It was present in 53 (89.9%) cases. 48 of them had hemorrhagic CVD. 37 of these 48 cases were due to hypothalamic lesions. In 37 cases general autopsy was performed; pathological abnormalities of heart, lungs, stomach etc, were found in 28 of them. In conclusion, the size and location of the lesion correlated with the prognosis of the disease. Concomitant multiple organ damage may deteriorate the lesion. Awareness of sudden death resulting from CVD may elevate the rate of correct diagnosis.     

Haspeslagh syndrome without severe mental retardation and pterygia?

Male infertility is a well recognised problem following spinal cord injury. The techniques of vibration induced ejaculation and transrectal electroejaculation have significantly increased the likelihood of sperm retrieval in spinal cord injured males; however, the reproductive capacity remains markedly reduced due to poor semen quality. The Spinal Injuries Unit at Royal North Shore Hospital has developed a programme to achieve seminal emission and enhance fertility. This study analysed the results of the first sample obtained at stimulation in 70 spinal cord injured males with respect to procedure performed, neurological level, completeness of lesion, bladder management, infection, age and duration since injury. Our study demonstrated that bladder management and neurological level were significant factors affecting the presence of motile sperm. Individuals managing their neuropathic bladder by catheter (intermittent self-catheterisation, indwelling urethral or suprapubic catheter) had significantly enhanced semen quality compared to those voiding by reflex or straining. Differences were also noted within the catheter group itself with intermittent self-catheterisation achieving a higher percentage of motile sperm present.     

Vertebral body infarction as a confirmatory sign of spinal cord ischemic stroke: report of three cases and review of the literature

BACKGROUND: Acute spontaneous spinal cord syndromes often remain etiologically ambiguous despite extensive diagnostic efforts. In the previous literature five cases are described with acute spinal cord syndromes interpreted as spinal cord ischemic strokes because of association with vertebral body infarctions on MRI. CASE DESCRIPTIONS: Three cases are presented, and the literature is reviewed. In addition to an extensive diagnostic battery including an initial MRI without pathological signs, follow-up MRI at different time intervals from the onset of symptoms showed T2 hyperintense signals in vertebral bodies. Patient 1, who had plaques in the abdominal aorta, had suffered a thoracolumbar spinal infarction; this and a concomitant infarction of the left portion of T-12 could be demonstrated on follow-up MRI on day 12. Patient 2, who had incomplete transverse spinal artery syndrome below T-3, had an abnormal signal at the T-2 level of the spinal cord on follow-up MRI on day 5; this was one segment above infarction of the dorsal area of T-3, corresponding to the ascending course of the medullary artery. The spinal cord of patient 3, who had a posterior spinal artery syndrome below T-11, was unremarkable on follow-up MRI on day 14, but a T2 hyperintense signal was noted in the dorsal area of T-10. CONCLUSIONS: Vertebral body infarction represents the only confirmatory sign for the otherwise exclusionary diagnostic procedure for spinal cord ischemic stroke and must be searched for on follow-up MRI as a key to correct diagnosis.     

Unusual fibro-osseous lesion of the spinal cord with positive staining for glial fibrillary acidic protein and radiological progression: a case report

A rare intradural lesion of the lumbar spine producing leg pain and minimal neurological deficits is described in a 48-year-old man. Previous reports of similar lesions have been described under the designation "fibro-osseous lesions" and "calcifying pseudoneoplasms." This is the first report of an unusual fibro-osseous lesion with an intradural spinal location as well as the first to show immunohistochemical positivity for glial fibrillary acidic protein (GFAP) within cellular components of this process and crystal formation suggestive of calcium pyrophosphate. This case also shows radiographic progression suggesting the possibility that this entity may be a form of low grade neoplasm.     

Experience with radio isotope myelography from neurosurgical aspects (author's transl)

Experience with Radio Isotope Myelography is reported here. 169Yb-DTPA as a tracer was intrathecally injected at lumbar region in twenty three patients with various spinal cord lesions. The first scanning is perfomed after comfirming by gamma-camera that the tracer reaches to the lesion, the second and the third scannings are done according to the ascending rate of the tracer. (I) Normal scintimyelogram (A) In normal case, the shape of the Radio Isotope Myelogram well corresponds the shape of anatomical subarachnoid space. (B) In normal adult cases, the tracer comes up to the cisterna magna in 20-25 minutes after the lumbar injection. Therefore, the scintimyelographic diagnosis should be made not only by the shape but also by the ascending rapidity of the tracer. (II) Abnormal scintimyelogram Abnormal scintimyelograms could be summarized as following three categories. (A) "Delay": It means delay of the ascending of the tracer. Besides, "Transient delay" found in a case of Arnord-Chiari's malformation was proposed. (B) "Partial block": It meas a defect at the level of the lesion. This "Partial block" were observed in cases of spinal cord angioma, cervical spondylosis and spinal cord tumor etc. (C) "Complete block": It means the stagnation of the tracer below the lesion. To sum up, Rario Isotope Myelography, especially in partial block, can more easily and more sensitively represent the maximum extent of the spinal cord lesion than other myelographic study or angiographic one. On the other hand, we can not qualitatively diagnose about the lesions by its indistinct border.     

Sphenoid sinus brown tumor of secondary hyperparathyroidism: case report

OBJECTIVE AND IMPORTANCE: Brown tumor is a misnomer for a reparative cellular process caused by primary or, less commonly, secondary or tertiary hyperparathyroidism. Atypical involvement of the base of the cranium in the area of the sphenoid sinus and the orbit is exceedingly rare and may produce a neurological deficit as a primary clinical presentation. Those neurosurgeons dealing with cranial base and pituitary lesions should be aware of this disease entity, and it should be listed in the differential diagnosis. CLINICAL PRESENTATION: A 21-year-old woman with end-stage renal failure on chronic dialysis was referred to the Department of Neurosciences at King Faisal Specialist Hospital and Research Centre with a 4-month history of progressive impairment of vision, associated with headache and nausea. Computed tomography and magnetic resonance imaging demonstrated an expansive mass lesion in the sphenoid sinus with erosion of the sellar floor and posterior medial wall of the orbit causing compression of the optic nerves. The biochemical laboratory studies showed elevation of parathyroid hormone and confirmed the diagnosis of hyperparathyroidism. INTERVENTION: The transnasal-transsphenoidal approach was used for extensive microsurgical removal of the lesion. The postoperative course was uneventful, and the improvement in vision was dramatic. CONCLUSION: Brown tumor, although rare, should be listed in the differential diagnosis of expansive mass lesions in the area of the sphenoid sinus and cranial base. The management is multidisciplinary, and therapeutic options should target the underlying cause.     

Spinal metastases of malignant gliomas

PURPOSE: Extracranial metastases of malignant gliomas are rare. We report 2 cases with spinal metastases in patients suffering from glioma. PATIENTS AND METHOD: Two patients (33 and 57 years old) developed spinal canal metastases of a glioblastoma multiforme and anaplastic astrocytoma Grade III respectively 25 and 9 months after surgical resection and radiotherapy. Both metastases were confirmed pathohistologically. RESULTS: Intraspinal metastases were irradiated with a total dose of 12.6 Gy and 50 Gy. Treatment withdrawal was necessary in one patient due to reduced clinical condition. Regression of neurological symptoms was observed in the second patient. CONCLUSIONS: Spinal spread of malignant glioma should be considered during care and follow-up in glioma patients with spinal symptoms.     

Primary spinal leptomeningeal gliomatosis presenting visual disturbance as the initial symptom: case report

We report a case of diffuse leptomeningeal gliomatosis which spread from the cervical to the sacral spine. A 60-year-old man was admitted with visual disturbance due to papilledema. Magnetic resonance imaging revealed holocord leptomeningeal gliomatosis without a definite intraparenchymal lesion, and the patient's neurological examination was unremarkable except for papilledema. Intracranial hypertension secondary to spinal tumor is well known but unusual, and the mechanism is still unclear. In our case, an elevated protein concentration of cerebrospinal fluid is suggested as the cause of intracranial hypertension.