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CT examinations of the lumbar spine in 12 consecutive patients with conjoined nerve roots were reviewed. Asymmetry of the bony spinal canal, seen as slight dilatation of the ipsilateral lateral recess, was present in all cases. This finding, which is not typically associated with extruded free intervertebral disk fragments, should serve to distinguish these two entities.
Interpedicular distance, interfacet distance, midsagittal diameter, and cross-sectional area at the upper aspect of the fifth lumbar spinal canal were measured from the computed tomographic (CT) scans of the spine performed in a period of 1 year. The patients were divided into four groups. Group I (25 patients) was the normal control group. Group II comprised 29 symptomatic patients who were thought to have an L4-L5 herniated nucleus pulposus (HNP) by CT and did not undergo surgery. Group IIIA was made up of 24 patients who underwent an L4-L5 discectomy and had favorable results, and Group IIIB (3 patients) included those who failed to improve following surgery. The symptomatic patient with an L4-L5 HNP by CT who did not undergo operative treatment had a mean canal size as measured by midsagittal diameter and cross-sectional area that was smaller (P less than 0.05) than in a normal control group. In the patients who required an L4-L5 discectomy, these same measurements were smaller (P less than 0.001) when compared with the nonoperative group. In the three failure patients, all four measurements were significantly smaller than in patients in Group IIIA with the interfacet distance and the cross-sectional area differences being the greatest (P less than 0.001). The patients who are likely to undergo operative treatment have a midsagittal diameter that is less than 1.6 cm and a cross-sectional area that is less than 2.5 cm.(ABSTRACT TRUNCATED AT 250 WORDS)
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We describe 2 brothers with L-2-hydroxyglutaric aciduria who developed severe spastic tetraparesis in their 30s. They also had an underlying condition of high-grade cervical spinal canal stenosis diagnosed by magnetic resonance imaging. They were operated on to decompress the spine, and the preexisting gait disturbances slowly diminished after the decompression. Since most people with L-2-hydroxyglutaric aciduria show spastic signs in their legs and arms, we conclude that cervical spinal canal stenosis may be the underlying reason and may be linked to this rare metabolic disorder.
We retrospectively reviewed the extended myelograms of 388 patients and identified two clinically occult intradural extramedullary lesions of the thoracic region of the spinal canal. Quality evaluation of the adjacent thoracic region can be quickly and simply performed at the time of lumbar or cervical myelography with the high volumes of relatively nontoxic water soluble intrathecal contrast agents allowed today. We recommend this screen to detect otherwise occult thoracic lesions.
The syndrome of intermittent claudication can be induced not only by vascular insufficiency of the lower limbs but also by diseases of the spinal cord and cauda equina. The authors describe a sixty-year-old man with intermittent claudication due to spinal canal stenosis who was successfully treated with beraprost sodium, a stable prostaglandin I2 analogue. This drug has a long biological half-life and is orally effective in vasodilation, which is suggested to be beneficial in treating this syndrome. Beraprost sodium may become one of the major drugs for conservative therapy of intermittent claudication induced by spinal canal stenosis.
This study was designed to compare the accuracy of magnetic resonance imaging (MRI), myelography and computed tomography in the assessment of degenerative cervical spinal stenosis. We prospectively examined a total of 75 spinal segments in 18 patients with suspected cervical spinal canal stenosis, using sagittal spin-echo and axial gradient-echo sequences generated by a 1.5 Tesla imager, conventional myelography, and computed tomography with intrathecal contrast medium (CT-myelography). The degree of stenosis was often overestimated using MRI. This error was most prominent in cases of severe stenosis but was significant with minor to moderate stenosis. In these cases, the clinical consequences of such an overestimation can be serious, because treatment is misdirected. The error is probably caused by pulsation of the cerebrospinal fluid and truncation artefact (Gibbs phenomenon). MRI at 1.5 Tesla is thus frequently inadequate for diagnostic assessment of degenerative cervical spinal stenosis. Myelography and myelographic CT are still useful for decisions on operative treatment, especially in cases of moderate stenosis. This may, however, not apply to imagers operating at 0.5 Tesla as below.
The patient is placed in a slightly oblique, prone position, and the spinal needle is directed downward through the interlaminar foramen into the spinal canal under direct fluoroscopic control. This method is superior to the conventional midline interspinous approach as regards ease of positioning the needle tip, removal of contrast, and comfort of the patient.
In this retrospective study, five patients are described in whom the dural sac at the thoracic and lumbar spine was compressed by a herniated disk or stenosis, located eccentrically in the spinal canal. In all of them, the symptoms or neurologic findings were dominantly in the limb contralateral to the side of compression. All five patients were operated on and the compressing disk or lamina was removed, resulting in immediate improvement of symptoms. In only one of the patients was the compression at the common level of L4-L5. In the remaining four patients, compression was at the low thoracic or upper lumbar spine. With the exception of one patient, the area of canal compression was greater than 50%.
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To evaluate the effects of sodium nitroprusside (SNP) and partial exsanguination (EXS) on systemic hemodynamics and cerebrospinal fluid dynamics, we monitored proximal and distal blood pressure (BP), cerebrospinal fluid pressure (CSFP), spinal cord perfusion pressure (SCPP), and compliance of the spinal canal (CSC) in 10 mongrel dogs during aortic cross-clamping of the descending thoracic aorta. CSC was measured by serial injections of 2 ml of saline solution into the cisterna cerebellomedullaris via a percutaneously placed catheter with simultaneous measurements of CSFP. Data were acquired at baseline (BL), during aortic cross-clamping with proximal hypertension (AXC), and after control of proximal hypertension with EXS and SNP. During the cross-clamp interval, mean proximal aortic pressure (PxBP) rose from 114 +/- 6 to 150 +/- 3 mm Hg (P less than 0.001), whereas mean blood pressure decreased to 88 +/- 5 and 82 +/- 4 mm Hg during the SNP and EXS intervals, respectively (P less than 0.05 vs BL). EXS and SNP were equally effective in controlling PxBP (82 +/- 4 vs 88 +/- 5 mm Hg, P greater than 0.05). Mean distal aortic pressure (DsBP) decreased from systemic values to 21.5 +/- 1.9 mm Hg during AXC, and to 12.4 +/- 1.0 and to 8 +/- 0.8 mm Hg during EXS and SNP, respectively (P less than 0.05 AXC vs EXS and SNP). SNP lowered DsBP significantly more than EXS, 8 +/- 0.8 vs 12.4 +/- 1.0 mm Hg (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Spinal cord damage during interscalene brachial plexus block has been attributed to needle entry into the spinal canal. The purpose of this study was to identify the angles and depths of needle insertion that increase the likelihood of such an event, using the traditional classic interscalene approach and two more proximal entry points. METHOD: Magnetic resonance images of the neck from 10 healthy volunteers were used to obtain the three-dimensional spatial coordinates of three skin markers and the right-sided cervical nerves at the exiting neural foramina. The distance of the intervertebral foramina from the skin markers and the angles of the needle vector and the foramina were calculated. RESULTS: The distance from the skin to the intervertebral foramen may be as short as 2.5 cm with the classic approach. A caudal angulation greater than 50 degrees seemed to eliminate the risk of needle entry through the foramen. CONCLUSION: With the classic approach to the interscalene block, there is a greater possibility of the needle passing through the intervertebral foramen if the needle is advanced too deeply. More proximal entry points and techniques that use a more steeply angled needle may reduce the risk of entry into the spinal space.
Computed tomography (CT) and transverse axial tomography (TAT) were used to study the lumbar spines of 164 patients with persistent or recurrent low back pain and/or radiculopathy. Of those patients with previous spinal fusion and of those with previous disectomy, 43% and 28%, respectively, demonstrated bony stenosis of the lumbar spinal canal. Of the patients who underwent surgery for this narrowed canal, 91% showed clinical improvement.
Two patients with Down's syndrome undergoing intracardiac operations had segmental and generalized myoclonic movements postoperatively and eventual brain death. Electroencephalography in 1 patient showed no seizure despite the presence of the myoclonic movements. Computed tomographic scan showed possible cerebellar hemorrhage. Ultrasound showed cerebral edema when the pupils became fixed and dilated. Because known postoperative neurologic complications could not fully explain the clinical course, and the myoclonic movements suggested spinal origin, we considered the possibility of atlantoaxial instability causing spinal cord damage related to perioperative head and neck positioning. Postmortem study on the second patient revealed 50% reduction of the spinal canal with hyperextension and 90-degree external rotation of the head and neck. In contrast, similar maneuvers in 3 infants without Down's syndrome resulted in only mild spinal canal narrowing. Although the myoclonic movements could be explained by spinal cord compression at the atlantoaxial level, the explanation for the eventual brain death is unclear. However, kinking of the vertebral arteries related to the positioning could have caused cerebellar ischemia, hemorrhage, and increased intracranial pressure. We believe that attention to the problem might bring further answers in the future.
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The clinical findings and operation results in two series of patients with medial prolapse of an intervertebral disc with total or partial occlusion of the spinal canal are reported. In one of the series (30 patients) symptoms of cauda equina compression, with bladder and rectal disturbances, were present, and in the other series (28 patients) these symptoms were absent. The observation period was five years (median value). The late results are evaluated in relation to the time interval between the onset of symptoms and operation. In the series with caudal compression syndrome, sphincter disturbances persisted in 10 patients, six of whom underwent operation during the first week after the onset of symptoms. The prognosis was most favourale when the symptoms developed slowly. Seventeen patients have returned to work. The importance of early operation in patients with classical compression syndrome of the cauda equina is emphasized. In the series without caudal compression syndrome, the symptomatalogy varied. The duration of symptoms was strikingly long. Only 19 patients are able to work. The others are prevented from working by persistent backache and leg pains, and in four cases by pareses of the extremities. In these cases also the importance of early operation is stressed.
We would like to present a case of a 51-year-old patient with two rare co-existing diseases. The patient was suffering from two tumours in the lumbar region of the spinal canal, which caused development of hydrocephalus. Diffuse white matter hyperintensities (WMH) were observed in our patient's brain imaging. She was also suffering from headaches and she had two mild strokes. We performed some further diagnostic procedures and found out that the patient was suffering from CADASIL. CADASIL was confirmed by both ultrastructural analysis and genetic testing.