Spontaneous thoracic spinal cord herniation through an anterior dural defect

A 44-year-old woman was examined for progressive left lower extremity weakness and spasticity. Thoracic spine MR imaging and CT myelography showed a ventral dural defect at T7-T8 with an extradural subarachnoid fluid collection and extradural herniation of the spinal cord. Intraoperative sonography confirmed the appropriate level for dural entry and the finding of spinal cord herniation. After reduction of the herniated spinal cord, the patient experienced gradual improvement in neurologic function.     

A case of idiopathic spinal cord herniation

The authors experienced a case of idiopathic spinal cord herniation with duplicated dura mater. A 63-year-old woman presented right dominant slowly progressive spastic paraplegia and dissociated sensory disturbance. Magnetic resonance imaging (MRI) demonstrated an enlarged dorsal arachnoid space associated with an apparently focally narrowed thoracic cord. The cord was kinked towards the anterior and closely applied to vertebral body at the level of Th3-4. Computed tomographic myelography (CTM) revealed homogeneous filling at dorsal arachnoid space immediately after injection and no defects. At operation multilocular arachnoid cyst and duplicated dura mater was respectively observed dorsally, and ventrally. From defected area of the inner layer, a ventral part of the spinal cord was incarcerated between the two dural layers. After rejection of arachnoid cyst and inner layer was performed, the patient recovered neurologically. Idiopathic spinal cord herniation is a rare disease that shows slowly progressive myelopathy at middle age. The herniations were observed at ventral thoracic cord in all reported cases. The mechanism of this disease is still uncertain. But at least three successive factors seem to be necessary for formation of herniation, 1) abnormal structure of the dura mater such as defect, diverticulum and duplication; 2) adhesion between the cord and the destructive dura mater, and 3) continuous cerebrospinal fluid (CSF) pressure pushing the cord outward from subdural space. In the thoracic spine, mobility is limited compared with the cervical and lumbar spine, and because of physiological curvature the cord situates rather ventrally. For these reasons the incidence of adhesion might be higher at ventral thoracic spine. Although neuroradiological imagings especially MRI and CTM were useful, operative findings were necessary for definitive diagnosis in many reported cases. Considering the effectiveness of surgical treatment, study of the ventral side of the cord should be important to avoid misdiagnosis.     

Spontaneous spinal epidural hematoma with spinal cord compression complicating plasma cell myeloma. A case report

STUDY DESIGN: A case is reported in which a patient had acute paraplegia with sensory loss caused by a spontaneous epidural hematoma that was ascribed to bleeding of pre-existing myeloma lesions of the thoracic vertebrae. OBJECTIVES: To highlight the causes of secondary epidural hematomas with special attention to pre-existing vertebral or epidural lesions. SUMMARY OF BACKGROUND DATA: There are no apparent previous reports of epidural spinal hematomas ascribed to underlying malignant diseases. Benign dysplasia, such as hemangioma or Paget's disease, has been implicated in a few cases. METHODS: A case of spontaneous dorsal epidural hematoma is reported in a patient followed up for plasma cell myeloma with osteolytic lesions in the lower thoracic spine. There was no history of major trauma or coagulation disorders. Complete loss of motor and sensory function in both lower limbs was noted, with sphincter dysfunction. Magnetic resonance imaging of the thoracic spine showed a large posterolateral epidural hematoma responsible for spinal cord compression. RESULTS: The patient failed to improve despite surgical decompression within 6 hours of symptom onset. He died 13 days later of refractory bacterial pneumonia. A large epidural hematoma adjacent to myelomatous lesions of the thoracic vertebrae was found at autopsy. CONCLUSIONS: This is the first reported case of spontaneous epidural hematoma ascribed to underlying malignant disease, with confirmation of the diagnosis by postmortem examination. Possible mechanisms include tumor-related epidural inflammation and fragility of epidural venous plexuses.     

Virtual reality in rehabilitation of spinal cord injuries: A case report.

Advances in information technology offer new opportunities for rehabilitation. In particular, the immersion capability provided by a synthetic environment could be exploited to design novel assistive devices. In virtual reality (VR), users navigate and interact with 3-D, computer-generated environments that are highly flexible and programmable, enabling the therapist to present a variety of controlled stimuli and to measure and monitor responses. VR provides a powerful means of increasing levels of environmental interaction in a highly controlled and structured manner. In this article, an overview is given of the design issues of a VR-enhanced orthopedic appliance used in rehabilitation of a person with spinal cord injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Compression of the upper cervical spinal cord causing symptoms of brainstem compromise. A case report

STUDY DESIGN: A case is reported in which a flexion-induced compression of the upper cervical spinal cord caused symptoms of brainstem compromise in the absence of radiographic evidence of osseous instability. OBJECTIVES: A 41-year-old woman developed postoperative cervical instability with flexion-induced neurologic symptoms referable to the brainstem. The instability was caused by direct compression at the third cervical vertebral body, which in turn was caused by differential movements between the neuraxis and skeletal elements in the upper cervical spine. SUMMARY OF BACKGROUND DATA: Pathologic processes at the craniocervical junction may cause brainstem compromise with neurologic symptoms. The mechanism of brainstem involvement is usually either vertebrobasilar insufficiency or direct mechanical compression. In cases where the brainstem is compressed by skeletal elements, the compressing osseous structures usually are the walls of the foramen magnum or the odontoid process, or, less frequently, the atlas or axis vertebrae. Symptoms of brainstem dysfunction caused by dynamic compression at the level of the third cervical vertebra in the absence of hindbrain herniation are unusual and, to the best of the authors' knowledge, have not been described previously. METHODS: The patient underwent initial examination, evaluation, and periodic follow-up examination with magnetic resonance imaging from the time of her first visit until 26 months after the surgical treatment. The patient experienced postsurgical instability with dynamic compression by the C3 vertebral body, which caused brainstem compromise. Surgical treatment consisted of decompressive C3 corpectomy and fusion of C2 to C6, supplemented by anterior fixation. RESULTS: After undergoing surgical decompression of C3, reconstruction, and anterior internal fixation of C2 to C6, the patient had dramatic neurologic improvement. Diplopia, paresthesia, and nystagmus disappeared immediately after surgery. Swallowing difficulties, hoarseness, and vertigo improved gradually. At follow-up examination 26 months after surgery, the patient was asymptomatic. Magnetic resonance imaging showed good position of the construct, with no evidence of compression of the spinal cord or brainstem. CONCLUSIONS: Instability of the cervical spine may result in symptoms of brainstem dysfunction, even in the absence of hindbrain herniation. This instability is explained by the differential movement between the bony structures and neuraxis in the upper cervical region. Diagnosis and adequate management of this instability alleviates the neurologic symptoms and prevents possible hazardous complications.     

Lumbar disk herniation combined with epidural hematoma. A case report

We examined the protective effect of nicotine against neuronal cell death in the model system of serum- and nerve growth factor (NGF)-free cultures of PC12 cells. Serum deprivation induced massive death of undifferentiated PC12 cells, which was inhibited by the addition of NGF, but not by the addition nicotine (100 microM). Even after PC12 cells had been differentiated by the treatment with NGF, serum and NGF deprivation induced rapid and massive death of these cells. The addition of nicotine (1-100 microM) to the deprivation system prevented such cell death almost completely. The protective effect of nicotine was abolished by hexamethonium or mecamylamine, inhibitors of nicotinic acetylcholine (nACh) receptors. Treatment with reserpine to deplete intracellular catecholamines did not influence the effect. The results suggest that the protective effect of nicotine against neuronal cell death is exerted through nACh receptors.     

Gas in the spinal canal associated with injury of the cervical spinal cord: a diagnostic dilemma. A case report

This pilot study compared haloperidol, fluoxetine, and placebo for reduction of agitation in 15 outpatients with AD. The two drugs were no more effective than placebo at reducing agitation in these subjects; however, both drugs produced more toxicity than did placebo.     

Transdural spinal cord herniation: imaging and clinical spectra

OBJECTIVE: Many diseases induce asymmetric delays in the visual pathway, resulting in a spontaneous Pulfrich phenomenon (PP). The PP is a visual stereoillusion that may cause difficulties in persons when traveling in cars, crossing the road, or playing ball games. The authors developed and tested a simple new bedside procedure to detect PP. DESIGN: A case series. PARTICIPANTS: Disease simulation in 2 normal subjects and 18 patients with optic neuritis (ON) was examined. Ninety normal subjects were studied to determine normal range of PP. INTERVENTION: The new test, called swinging pen test (SPT), is performed by oscillating a pen by hand. The SPT was compared to a gold standard, a mechanical pendulum (MP). MAIN OUTCOME MEASURES: The authors measured simulated PP in two normal subjects and PP in 18 patients with ON and 90 normal control subjects. The Pearson product-moment correlation (r) and the Spearman rank correlation (rs) between SPT and MP were calculated. RESULTS: The magnitudes of simulated PP determined with the SPT and the MP correlated well (r = 0.92, P < 0.005, and r = 0.96, P < 0.001). Correlation also was good in patients with ON (rs = 0.90, P < 0.05). The positive predictive value of the SPT was 100%, and the negative predictive value was 92%. The PP was absent in all control subjects testing with either pendulum. The normal range for PP varied from -1.40 to 1.52 msec. For the SPT, the intraobserver variability coefficient was 8.2%, and the interobserver variability coefficient was 10.5%. CONCLUSIONS: The authors believe that SPT will be of value to clinicians on bedside evaluation of motion stereopsis dysfunctions. The normal range of PP was approximately +/- -1.5 msec (approximately +/- -1.5 cm), corresponding to a 0.3-log unit neutral density filter).     

Peridiscal metastatic carcinoma associated with lumbar disc herniation. A case report

Primary pulmonary tumors are infrequent in children. Bronchioloalveolar carcinoma has been documented rarely in the pediatric population. Before this report, there have been only three cases of bronchioloalveolar carcinoma in patients less than 16 years of age. Our two cases represent two of the youngest cases (ages 6 and 15 years) reported with bronchioloalveolar carcinoma. They illustrate many of the typical findings of this disease including clinical presentation, diagnostic difficulty, and better prognosis compared with other pulmonary malignancies. This neoplasm appears to have a favorable outcome in childhood.     

Sweet's syndrome associated with spinal surgical intervention. A case report

STUDY DESIGN: A patient with a medical history of Sweet's Syndrome, an acute neutrophilic dermatosis, was seen at the authors' institution for cervical pain. After undergoing a thorough history-taking and physical examination and after experiencing no relief with conservative therapy, the patient underwent cervical spine surgery. After the surgical procedure, the patient developed multiple cutaneous lesions that were consistent with the findings associated with an acute recurrence of Sweet's Syndrome. OBJECTIVES: To characterize the authors' experience with this unusual histologically documented dermatologic disorder. SUMMARY OF BACKGROUND DATA: Sweet's Syndrome is a rare form of neutrophilic dermatosis characterized by recurrent eruptions of painful, edematous, red, tender plaques that are found predominantly on the torso in middle-aged women. After an extensive literature search, it was noted that this rare and unusual disorder has not been reported previously in association with surgical intervention of any type, including spinal operations. METHODS: The patient's postoperative course was documented, and all medical records were reviewed retrospectively. RESULTS: The patient's rash resolved spontaneously. Solid fusion of C5-C6 occurred. The patient remained neurovascularly intact, and her axial cervical pain decreased significantly from its preoperative levels. CONCLUSIONS: Sweet's Syndrome remains a rare dermatologic disorder, which may complicate a routine postoperative course. Patients with Sweet's Syndrome have an exceedingly high rate of other serious medical illness. The effect of Sweet's Syndrome on physiologic bone healing is unknown. In this patient, there was nonunion of the cervical spine, with eventual solid bony union. Perioperatively, patients with this disorder are treated with oral prednisone and oral antibiotics to prevent secondary complications at the surgical wound.     

Spontaneous long-term remyelination after traumatic spinal cord injury in rats

The capability of the central nervous system to remyelinate axons after a lesion has been well documented, even though it had been described as an abortive and incomplete process. At present there are no long-term morphometric studies to assess the spinal cord (S.C.) remyelinative capability. With the purpose to understand this phenomenon better, the S.C. of seven lesionless rats and the S.C. of 21 rats subjected to a severe weight-drop contusion injury were evaluated at 1, 2, 4, 6, and 12 months after injury. The axonal diameter and the myelination index (MI = axolemmal perimeter divided by myelinated fiber perimeter) were registered in the outer rim of the cord at T9 SC level using a transmission electron microscope and a digitizing computer system. The average myelinated fiber loss was 95.1%. One month after the SC, 64% of the surviving fibers were demyelinated while 12 months later, only 30% of the fibers had no myelin sheath. The MI in the control group was 0.72 +/- 0.07 (X +/- S.D.). In the experimental groups, the greatest demyelination was observed two months after the lesion (MI = 0.90 +/- 0.03), while the greatest myelination was observed 12 months after the injury (MI = 0.83 +/- 0.02). There was a statistical difference (p < 0.02) in MI between 2 and 12 months which means that remyelination had taken place. Remyelination was mainly achieved because of Schwann cells. The proportion of small fibers (diameter = 0.5 micron or less) considered as axon collaterals, increased from 18.45% at 1 month to 27.66% a year after the contusion. Results suggest that remyelination is not an abortive phenomenon but in fact a slow process occurring parallel to other tissue plastic phenomena, such as the emission of axon collaterals.     

Fatal cardiac tamponade associated with posterior spinal instrumentation. A case report

STUDY DESIGN: Case report of a fatal complication of pedicle screw instrumentation and review of the literature. OBJECTIVE: To describe the clinical and postmortem findings in a 35-year-old man who sustained a T11 burst fracture that was managed by transpedicular posterior instrumentation and who died 12 days after surgery of cardiac tamponade caused by a prick injury of the right coronary artery. SUMMARY OF BACKGROUND DATA: Posterior pedicle screw instrumentation is considered a safe and effective method for stabilizing a spinal motion segment. Nevertheless, there are several rare but significant complications that may occur. This is the first report of a heart tamponade after transpedicular screw insertion. METHODS: A 35-year-old man was treated for a T11 burst fracture with posterior transpedicular stabilization. The surgery was uncomplicated. RESULTS: Twelve days after the intervention, the patient died of cardiogenic shock. Postmortem examination showed a heart tamponade of 350 mL blood originating in a prick injury of the right coronary artery. Histologic findings showed evidence that the injury was caused during surgery by a Kirschner wire. CONCLUSION: There are numerous possible intraoperative complications in posterior pedicle screw fixation, such as nerve root and spinal cord injuries. This case of a fatal heart tamponade after transpedicular screw insertion is rare. It shows that the surgeon must be aware of potential risks associated with such a procedure and have a comprehensive three-dimensional understanding of the anatomic structures involved.     

Acupuncture for urinary incontinence in patients with chronic spinal cord injury. A preliminary report

PURPOSE: We investigated the possible use of acupuncture for the treatment of urinary incontinence caused by detrusor hyperflexia in patients with chronic spinal cord injury. METHOD: A total of 8 male chronic spinal cord injured patients with urinary incontinence were treated by acupuncture. Their ages ranged from 20 to 33 years (mean 27). The level of lesion was cervical in 4 and thoracic in 4. Detrusor hyperreflexia with uninhibited bladder contraction was confirmed by urodynamic studies in all of them. Acupuncture was performed using a disposable stainless needle (0.3 mm in diameter, 60 mm in length), which was inserted into bilateral BL-33 (Zhongliao) points and was rotated manually for 10 minutes. The treatment was conducted every week for 4 weeks. Urodynamic studies were repeated, immediately after the beginning of and a week after the completion of the treatment. Urinary symptoms were also checked before and after the treatment. RESULTS: No side effects were recognized throughout the treatment period. Among 8 patients, incontinence was controlled completely in 3 (38%) and partially in 3 (38%). The average maximum cystometric bladder capacity increased significantly, from 42.3 +/- 37.9 ml to 148.1 +/- 101.2 ml by the treatment (p < 0.05), while the average maximum bladder pressure was not changed. CONCLUSIONS: These data suggest that acupuncture could be a promising alternative for conventional therapies for urinary incontinence caused by detrusor hyperreflexia in patients with chronic spinal cord injuries.     

Spontaneous spinal extradural hematomas: report of two cases

INTRODUCTION AND CLINICAL CASES: We present two cases of spontaneous spinal extradural hematoma, which occurred in 1996 and were admitted to and operated on by our Department. Both patients were women. No cause for the bleeding was found in either case. Both presented with the site of the lesion in the thoracic spine, although at different levels. There was acute onset of the clinical condition. The best diagnostic procedure was MR. The treatment of choice was surgical and the results related to the rate of onset of the clinical picture and the time elapsed before operation. CONCLUSION: The form of presentation is discussed, together with the importance of early diagnosis and the relation to emergency surgical treatment.     

Spontaneous intracranial hypotension syndrome. A case

We report a 49-year-old woman with spontaneous intra-cranial hypotension. this characteristic syndrome associates postural headache and a low cerebro-spinal fluid pressure. It was confirmed by lumbar puncture and magnetic resonance imagery. We describe the clinical and the cerebro-spinal fluid features, the radiological appearances, and the clinical and radiological course. The interests of this diagnosis are, first, its spontaneous benign course and, second, to avoid unnecessary invasive investigations.