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PubMed1997

Neurologic complications of 603 consecutive continuous spinal anesthetics using macrocatheter and microcatheter techniques. Perioperative Outcomes Group.

Recent case reports of cauda equina syndrome after continuous spinal anesthesia have led to a reevaluation of the indications and applications of this regional anesthetic technique. However, few large studies have formally investigated the frequency of neurologic complications using macro- and microcatheter (smaller than 24 gauge) techniques. This retrospective review examines 603 continuous spinal anesthetics, including 127 administered through a 28-gauge microcatheter, performed between June 1987 and May 1992. The surgical procedure was orthopedic in 397 of 476 (83.4%) macrocatheter patients. All microcatheter patients were parturients. Three patients reported pain (persistent paresthesia) postoperatively. In two patients, the symptoms resolved in 4 days; the other patient was discharged 8 days postoperatively with residual foot pain. There was also one patient with aseptic meningitis and one patient with a sensory cauda equina syndrome (still present after 15 mo). There were 58 (9.6%) patients with a postdural puncture headache (PDPH), including 42 of 127 (33.1%) patients in the microcatheter group. An epidural blood patch was performed in 41 (6.8%) patients. The frequency of neurologic complications, excluding PDPH, is similar to those in published reviews. However, PDPH in microcatheter patients is more frequent than previously reported.

Adolescent↗
PubMed2006

Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation.

PURPOSE: To report results of sacral decompression and lumbopelvic fixation in neurologically impaired patients with highly displaced, comminuted sacral fracture-dislocations resulting in spino-pelvic dissociation. DESIGN: Retrospective clinical study. SETTING: Regional level one trauma center. PATIENTS: Nineteen patients with highly displaced, comminuted, irreducible Roy-Camille type 2-4 sacral fractures with spino-pelvic instability patterns and cauda equina deficits were identified over a 6-year period, 18 of which met the 12-month minimum follow-up criterion. INTERVENTION: All were treated with open reduction, sacral decompression, and lumbopelvic fixation. Radiographic and clinical results were evaluated. Neurological outcome was measured by Gibbons' criteria. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation with computed tomography scan and antero-posterior, lateral, and oblique views of the pelvis to assess alignment, hardware position and decompression. Clinical evaluation emphasizing neurological outcome as described by Gibbons' criteria. RESULTS: Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 43 to 21 degrees. Fifteen patients (83%) had full or partial recovery of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons score improved from 4 to 2.8 at 31-month average follow-up (range: 12 to 57 mo). Wound infection (16%) was the most common complication. Complete recovery of cauda equina function was more likely in patients with continuity of all sacral roots (86% vs. 0%, P = 0.00037) and incomplete deficits (100% vs. 20%, P = 0.024). Although not statistically significant, recovery of bowel and bladder function specifically was more closely associated with absence of any sacral root discontinuity (86% vs. 36%, P = 0.066) than on completeness of the injury (100% vs. 47%, P = 0.21). CONCLUSIONS: Lumbopelvic fixation provided reliable fracture stability and allowed consistent fracture union without loss of alignment. Neurological outcome was, in part, influenced by completeness of injury and presence of sacral root disruption.

Adolescent↗
PubMed1983

[Diagnostic value of CT in spinal cord neurinomas].

The computed tomography (CT) in examination of the spine and spinal cord has rapidly advanced and its diagnostic value has been well documented. It is widely accepted that CT is very useful for the diagnosis of the spinal neurinomas, especially of dumb-bell tumors. In the last two years we have experienced with 11 cases of spinal neurinomas. These include 1 accessory neurinoma, 7 cervical neurinomas of dumb-bell type, 2 thoracic dumb-bell neurinomas, 1 intradural neurinoma in the conus medullaris and multiple neurofibromas in the cauda equina in one patient. The age distributed from 24 to 52 years, with an average of 41.5. In all of these patients except one, metrizamide CT was performed following a total myelography. In most of the cases, CT with and without an intravenous contrast medium injection was also carried out. The conventional radiologic examinations including plain radiography, tomography and angiography were done in most of the patients. Comparing with the results of those examinations, we reached the following conclusions: (1) metrizamide CT can disclose the superior border of the tumor which is often not visualized by conventional ascending myelography. The reconstruction CT clearly outlines the whole extent of the tumor. (2) The bony changes associated with a dumb-bell neurinoma, for example, the widening of the intervertebral foramen, can be found by plain CT in much earlier stage than by the plain roentgenogram. The findings can be more clearly using a "ReView" software program. (3) The extraspinal part of the dumb-bell tumor is shown in CT by an intravenous enhancement as a slightly high-dense, homogeneous mass with CT-number of approximately 70 HU. The capsule of the tumor is a little more enhanced in the most cases. (4) It is recommended to do a metrizamide CT with "ReView" technique when a tumor in the cauda equina is suspected on conventional myelography. (5) A tumor near the foramen magnum or in the upper cervical region is often overlOoked on metrizamide myelography. When a tumor in these regions is highly suspected on neurological examinations, it is also recommended to perform a metrizamide CT about 3 hours after conventional myelography.

Adult↗
PubMed1991

Cervical paraganglioma with subsequent intracranial and intraspinal metastases. Case report.

Paragangliomas, tumors derived from the extra-adrenal paraganglion system, have commonly been found in the retroperitoneum, abdomen, mediastinum, skull base, and neck. Rare intraspinal cases have included involvement of the cauda equina and filum terminale, and a recent case has been reported of thoracic cord paraganglioma with metastasis to the cauda equina. The authors present the case of a patient with a cervical paraganglioma who underwent subtotal resection followed by postoperative irradiation; she subsequently developed multiple intracranial and intraspinal metastases 7 months following the first decompression procedure.

Adult↗
PubMed1995

[Clinicopathological report of cisplatin encephalopathy].

A 61-year-old woman was treated with cisplatin and etoposide for ovarian carcinoma. After the second course of chemotherapy she developed acute encephalopathy which manifested itself as headache, fever, a partial seizure, confusion, and mild right hemiparesis, although no evidence of a central nervous system infection was found. Ten days after the onset of neurological symptoms, she experienced a sudden loss of vision in both eyes. Neurological findings were compatible with cortical blindness. Neurological symptoms subsided and visual acuity completely returned over the next months. The total cumulative dose of cisplatin was 325 mg/m2. She died of aspiration pneumonia on the 43rd day. Postmortem examination revealed severe nerve cell loss, gliosis and spongy changes in the bilateral occipital cortex including visual field, and slight to moderate demyelination in the subcortical white matter of the occipital cortex, Goll's tract, and dorsal root ganglia. As far as we know this encephalopathy is the second report in which the neuropathological changes associated with cisplatin therapy have been demonstrated by autopsy findings. The first was a case report of leukoencephalopathy, which differed significantly from our case in the primary lesions of the brain. We measured the platinum level in several parts of the cerebrum and cerebellum, optic nerve, spinal cord, and cauda equina by using an atomic absorption spectrophotometric technique. Platinum was detected in the bilateral occipital cortex, spinal cord, and cauda equina. These results were consistent with the distribution of pathological lesions. The mechanism of cisplatin-induced focal encephalopathy remains speculative.(ABSTRACT TRUNCATED AT 250 WORDS)

Blindness↗
PubMed1985

Primary spinal cord tumors treated with surgery and postoperative irradiation.

Between 1954 and 1979, 37 patients with a primary spinal cord tumor received postoperative irradiation after laminectomy. There were 26 intramedullary and 11 tumors of the conus/cauda equina. The 26 intramedullary tumors were divided as follows: 14 astrocytomas, eight ependymomas, three unbiopsied tumors, and one diffuse histiocytic lymphoma. Of the cauda equina tumors, 10 were ependymomas and one was an astrocytoma. Patients were followed until death or for a minimum of 4 years. The 5- and 10-year actuarial survivals for the entire group were 70 and 58%, respectively. Anatomic location of the tumor was the most important predictor of both survival and neurologic function. Patients with tumors of the cauda equina had superior neurologic function and a significantly better survival than those with tumors at other sites. Recurrent tumor was the cause of death in 82% of the patients dead at the time of analysis. Of the patients alive at the conclusion of the study, 10 were completely normal or had only mild neurologic deficit; the remaining 10 patients were severely disabled. Increasing radiation dose correlated with an increase in tumor control and survival. Of those receiving less than 40 Gy, 77% died of recurrent tumor, while 83% of those who received greater than 40 Gy are alive 4.1 to 28.9 years after treatment.

Adolescent↗
PubMed1998

Epidural spinal cord stimulation for treatment of chronic pain--some predictors of success. A 15-year experience.

BACKGROUND: We have used epidural spinal cord stimulation (SCS) for pain control for the past 15 years. An analysis of our series of 235 patients has clarified the value of specific prognostic parameters in the prediction of successful SCS. METHODS: Patients were followed up for periods ranging from 6 months to 15 years with a mean follow-up of 66 months. The mean age of the 150 men and 85 women in the study was 51.4 years. Indications for SCS included failed back syndrome (114 patients), peripheral vascular disease (39 patients), peripheral neuropathy (30 patients), multiple sclerosis (13 patients), reflex sympathetic dystrophy (13 patients), and other etiologies of chronic intractable pain (26 patients). RESULTS: One hundred and eighty-nine patients received permanent devices; 111 (59%) of these patients continue to receive satisfactory pain relief. Pain attributable to failed back syndrome, reflex sympathetic dystrophy, peripheral vascular disease of lower limbs, multiple sclerosis, and peripheral neuropathy responded favorably to spinal cord stimulation. In contrast, paraplegic pain, cauda equina syndrome, stump pain, phantom limb pain, and primary bone and joint disease pain did not respond as well. Cases of cauda equina injury had promising initial pain relief, but gradually declined after a few years. After long-term follow-up, 47 of the 111 successfully implanted patients were gainfully employed, compared with 22 patients before implantation. The successful patients reported improvements in daily living as well as a decrease in analgesic usage. Multipolar stimulation systems were significantly more reliable (p < 0.001) than unipolar systems. Complications included hardware malfunction, electrode displacement, infection, and tolerance. CONCLUSION: Aside from etiologies of pain syndromes as a prognostic factor, we have identified other parameters of success. In patients who have undergone previous surgical procedures, the shorter the duration of time to implantation, the greater the rate of success (p < 0.001). The diagnosis of failed back syndrome must be considered a confounding factor in our analysis. Those patients whose pain did not follow a surgical procedure had better responses to SCS than patients who had multiple surgical procedures prior to their first implant. The advent of multipolar systems has significantly improved clinical reliability over unipolar systems. Age, sex, and laterality of pain did not prove to be of significance.

Adult↗
PubMed1990

[Erection while walking and stenosis of the lumbar canal].

Lumbar channel stenosis is frequently manifested by a Cauda Equina intermittent claudication. Only exceptionally erections during walking have been described. We have observed two patients with severe lumbar channel stenosis and a Cauda Equina syndrome with intermittent erections during walking. One patient was laminectomized presenting a clinical improvement. There does not exist a satisfactory explanation for this strange affectation.

Aged↗
PubMed1977

Intraspinal dermoids.

Eight cases of spinal dermoids are presented. Four were in the cauda equina region, 2 were intramedullary, one was in the subdural space in the thoracic region, one was intramedullary and extended into the conus and cauda equina. Two patients had an associated dermal sinus. Intracapsular evacuation of the contents was the treatment of choice.

Adult↗
PubMed1991

Misdiagnosis of intraspinal lesions in childhood.

Three children with intraspinal mass lesions in whom the diagnosis was initially missed are described. Their case histories highlight the specific clinical features of and diagnostic difficulties with the syndromes produced by lesions of the craniocervical junction, the mid-thoracic spinal cord and the cauda equina.

Cauda Equina↗
PubMed2002

[Urodynamics of neurogenic lower urinary tract disfunction caused by spinal cord injury].

OBJECTIVES: To improve the diagnosis of patients with neurogenic lower urinary tract dysfunction and to provide a basis for proper selection of rehabilitation methods. METHODS: The urodynamics was tested with Assend Urodynamic Instrument in 220 patients with spinal cord injury. Of these patients, 100 received regular cystometrograrhy (CMG) and urethal pressure profile (UPP) test, and the remaining patients were measured by bladder/ external sphincter pressure profile. The detrusor pressure, maximum detrusor voiding pressure, and maximum urethral pressure were recorded. The date from the tests were processed with SPSS 8.0 (independent samples T test). RESULTS: The maximum urethal pressure (83 +/- 39) cm H(2)O (1 cm H(2)O = 0.098 kPa) and maximum voiding detrusor pressure (12 +/- 10) cm H(2)O were lower in coda-equina group than in other groups (t = 2.096,P < 0.05). The group with different spinal cord injury had almost an equal ratio of low bladder compliance (51.2%, 52.4% and 50% separately). Statistical differences were found between complete injury and incomplete injury in each group(t = 1.023, P > 0.05). In bladder/external sphincter cystometry, urethral pressure profile could be classified into four types. CONCLUSIONS: The maximum urethral pressure and maximum pressure of detrusor contractile were lower in the cauda-equina injury group than in other groups. The cauda-equina injury group showed a lower incidence of detrusor sphincter because most of these patients were incompletely injured. The features of urethral pressure profile in bladder/external sphincter cystometry resulted from the abnormal contraction of external sphincter and periurethral striated muscles.

Adolescent↗
PubMed1986

Spinal pain made worse by recumbency: a clue to spinal cord tumors.

In the absence of physical findings, pain in the low back, cervical or thoracic spine, or the extremities presents a diagnostic problem. On occasion the pain is present or made worse only when the patient lies down. We have attended four patients with underlying extradural tumors of the spinal canal. A 75-year-old woman with chronic back pain was treated for multiple myeloma with intravenous dexamethasone and 400 rads of x-ray irradiation to the lumbar spine and experienced marked pain relief in 24 hours. A 76-year-old woman with neck pain had complete pain relief after a vascular, calcified meningioma was removed surgically from under the 2nd and 3rd cervical nerve roots. A 38-year-old male with constant pain in the lumbar area and right leg and foot experienced marked relief from pain after a neurolemmoma of the cauda equina was surgically removed. A 57-year-old woman with knee pain became pain free 24 hours after radiation therapy to an enlarged nodular cauda equina. These four cases illustrate a diagnostic clue rarely mentioned in the literature.

Adult↗
PubMed1997

Severe complications associated with epidural and spinal anaesthesias in Finland 1987-1993. A study based on patient insurance claims [see comment].

BACKGROUND: The Patient Injury Act has been in effect in Finland since 1 May 1987. This legislation is a no-fault compensation scheme and implies that if a patient during the course of medical treatment suffers any injury as a result of that treatment he or she may file a claim to the Patient Insurance Association (PIA). From 1 May 1987 to 31 December 1993, 23,500 claims for compensation were made. METHODS: All claims made to PIA involving spinal and epidural anaesthesias during the above period were collected and reviewed and a data base was prepared. The total number of anaesthetics given during this period was estimated by sending questionnaires to every hospital in the country. RESULTS: Eighty-six claims were associated with spinal and/or epidural anaesthesia. Respectively, the total the number of spinal and epidural anaesthesias administered was 550,000 and 170,000. There were 25 serious complications associated with spinal anaesthesia: cardiac arrests (2), paraplegia (5), permanent cauda equina syndrome (1), peroneal nerve paresis (6), neurological deficits (7), and bacterial infections (4). The 9 serious complications which were associated with epidural anaesthesia were: paraparesis (1), permanent cauda equina syndrome (1), peroneal nerve paresis (1), neurological deficit (1), bacterial infections (2), acute toxic reactions related to the anaesthetic solution (2), and overdose of epidural opioid (1). CONCLUSIONS: According to this material the incidence of serious complications was 0.45:10,000 following spinal and 0.52:10,000 following epidural anaesthesia. Atraumatic technique, careful patient selection and early diagnosis and treatment of complications are essential in avoiding permanent injury.

Adult↗
PubMed1995

[Function-controlled neurosurgery. Neurophysiologic and neuropsychological monitoring during surgery of the nervous system].

Neuromonitoring of neural structures has become increasingly common during surgery near cortical areas representing sensorimotor and language function (epilepsia, tumors), in the brain stem and the spinal cord (tumors), near cranial nerves (cerebellopontine angle tumors, trigeminal neuralgia, hemifacial spasm), and in the cauda equina (tumors, tethered spinal cord). The technical spectrum to monitor these operations includes electrical cortical stimulation to evoke sensorimotor phenomena and language disturbances, electroneurography and -myography of the cauda equina, motor cranial nerves and nuclei, and somatosensory, motor and acoustic evoked potentials. The goals of intraoperative neuromonitoring are: (1) minimizing the risk of suffering neurological and neuropsychological injury as a result of surgery; (2) extending the surgical spectrum to lesions that have previously been considered inoperable or hazardous to operate upon; (3) intraoperative electrophysiological documentation that the goal of surgery has been achieved; (4) intraoperative basic research.

Brain↗
PubMed1996

Spinal cord and nerve root monitoring in spine surgery and related procedures.

Intensive research in the field of intraoperative neurophysiologic monitoring has been performed directed at finding reliable stimulating and recording techniques and adequate anesthetic regimes applicable to spinal procedures. The aim is a comprehensive monitoring not only of afferent and efferent spinal cord pathways but also of sensory and motor nerve roots and cauda equina fibers. Conventional somatosensory evoked potentials (SEPs) are complemented by motor evoked potentials, dermatomal sensory evoked potentials, spinal cord evoked potentials, evoked electromyography, sensory and motor fiber mapping of the cauda equina, bulbocavernosus reflex testing, and neurogenic evoked potentials. Apart from describing the essentials of these techniques and their indications and limitations, this article deals with the influence of anesthetic management on the production and interpretation of evoked potentials.

Humans↗
PubMed1997

Neurological impairment during long-term intrathecal infusion of bupivacaine in cancer patients: a sign of spinal cord compression.

Adequate pain relief in patients with far advanced cancer sometimes requires intrathecal (IT) administration of a combination of opioids and local anesthetics. Tumor progression as well as the IT administration of local anesthetics can lead to neurologic dysfunction during treatment. Five patients showed symptoms of compression of the cauda equina or spinal cord shortly after the start of combined IT administration of morphine and bupivacaine in a dosage usually not associated with neurologic symptoms. Unexpectedly, neurologic evaluation suggested compression of the cauda equina and spinal cord, which was confirmed radiographically. Manifestation of new neurologic symptoms during low dose bupivacaine infusion intrathecally might therefore be an early indicator of space-occupying processes within the spinal canal in cancer patients.

Aged↗
PubMed1986

Morphological studies of the spinal cord in tetraodontiformes fishes.

The spinal cord of two tetraodontiform fishes, the Japanese file fish (Navodon modestus) and the panther puffer (Takifugu pardalis), are unusual among vertebrates in having a markedly abbreviated spinal cord with a long and flattened filum terminale. Only the rostral short part of the cord of both species is cylindrical; the greater part of the cord is markedly flat. The majority of the spinal nerve roots leave the short cylindrical part. The flattened part of the cord contains the central canal, myelinated nerve fibers, and a few motoneurons surrounding the cauda equina, and it is histologically similar to the filum terminale of amphibians and mammals. The spinal cords of other teleosts, the sun-fish and angler, also are abbreviated and possess a filum terminale and cauda equina. These orders possess an enormous head and short trunk. However, the correlation between this body form and an abbreviated cord is not causal, since the tetraodontiform species described here show ordinary body proportions. The spinal cord may be abbreviated in tetraodontiform fishes in general.

Animals↗
PubMed1982

[A study of spinal evoked potentials recording from surface electrodes].

With non-invasive method, spinal evoked potentials to the stimulation of the posterior tibial nerve at the ankle were studied in 20 normal subjects. Lumbosacral spinal evoked potentials, with a reference electrode on the contralateral shoulder or ear, demonstrated two well-defined negative peaks. The first peak originated from a traveling wave of depolarization in afferent fibers in the cauda equina, and the second peak originated in the spinal cord. But, with the use of a knee reference contralateral to the side of stimulation, it consisted of only one negative peak, which originated in the cauda equina. These findings suggest that the entire trunk and head are "active" electrophysiologically and not suitable for use as a reference. Furthermore, segmental conduction velocities between S1 and L2, L2 and T10, T10 and C2 are 58.2, 106.7, 62.3 m/sec, respectively. Thus "traveling wave" between L2 and T10 is different from that in other levels. This leads to the assumption that a "generator" may exist in conus medullaris and that it many influence above and below the T12.

Adolescent↗