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PubMed2000

AANA Journal course: transient neurologic symptoms and spinal anesthesia.

A universal goal of anesthesia providers is to provide the safest, most effective anesthesia and analgesia for their patients. When reports emerge showing problems or complications with an agent or technique that previously was thought safe, recommendations often are adopted in anesthesia departments to avoid or abandon the agent or technique, or alternatives are sought. Hyperbaric 5% lidocaine has been an effective and safe spinal anesthetic agent for short procedures for years. During the past decade, controversy arose over its use because it was implicated as the cause of transient neurologic symptoms and cauda equina syndrome. Use of bupivacaine or tetracaine results in a much lower incidence, but these agents are not as well suited to brief or outpatient procedures as is the shorter acting lidocaine. Substantial research has been conducted detailing the search for reasons these complications occur and how to prevent them. A sample of the findings is summarized in an attempt to present current knowledge about the apparent causes and prevention of transient neurologic symptoms. There is promising research showing that safe and effective short-acting intrathecal anesthesia can be accomplished with procaine, prilocaine, meperidine, and sufentanil.

Anesthesia, Spinal↗
PubMed1978

[Early diagnosis of staphylococcic infection in epidural space : radiologic contribution (author's transl)].

Infection of the épidural space was demonstrated on clinic (cauda equina compression) and radiology. Three investigations are considered and compared : Dimer X radiculography, lumbar phlebography, duroliopaque myelography. The transfemoral arcending lumbar catheterization of the epidural veins precise the compression by staphylococcic external pachymeningitis. No liquid is introduced in cerebro spinal fluid : there is not risk of infectious arachnoiditis. Myelography with positive contrast (duroliopaque: ethyl monoiodostearate) is much attractive but it is a procedure not easy to perform, even badly tolerated by the patient. For these reasons the lumbar phlebography, easily performed, can be realised in first intention.

Catheterization↗
PubMed1988

[Intramedullary mature teratoma associated with an attached cord and an intradural lipoma. Apropos of a surgically treated case. Review of the literature].

The authors report the case of a 33 year-old male with urinary disturbances referred for removal of a spinal intradural mass associated with a L4 spina bifida occulta. At operation three types of lesions were present: a tethered cord, an intradural lipoma of the cauda equina and conus medullaris and an intramedullary mature teratoma. A total removal of teratoma and lipoma and a section of the filum terminale achieved a normalization of urological function. Such mature teratoma that consists of all three germ layers only represent 2% of all intramedullary tumors. Pathogenesis is dysembryoplastic but still remains unclear: germinal cells might have been displaced into the dorsal midline during their normal migration from yolk sac to gonadal ridges. Their association with other dysgenetic lesions such as lipoma or spina bifida is not rare but the links between these different pathologies remain unknown.

Adult↗
PubMed1993

Monitoring of lumbosacral nerve roots during spinal instrumentation.

A technique is described for intraoperative, multimodality electrophysiologic monitoring of the spinal cord and lumbosacral nerve roots (cauda equina). Simultaneous monitoring with the techniques of electromyography, compound muscle action potentials, and somatosensory evoked potentials is found to provide highly useful information to the surgeon during lumbar spine instrumentations. Compound muscle action potential recordings are used to identify nerve roots in the lumbosacral region, especially when visual identification of the nerve is hindered by scarring or distortion of the anatomy. Electromyography continuously monitors nerve roots at risk by revealing neurotonic discharges when the nerve roots are irritated during surgical dissection or placement of the fixation device. The early warning provided by this technique enables the surgeon to avoid irreversible neurologic damage.

Adult↗
PubMed1969

The effects of saxitoxin and tetrodotoxin on nerve conduction in the presence of lithium ions and of magnesium ions.

1. It has been shown that nerve fibres from rat cauda equina will conduct action potentials after immersion in saline in which lithium chloride is substituted for sodium chloride.2. Both saxitoxin and tetrodotoxin inhibit lithium-generated action potentials. The concentration of toxin needed to inhibit the lithium-generated action potentials is similar to that needed to inhibit sodium-generated action potentials.3. If magnesium chloride is added to the saline to give a concentration of 10-15 mM there is usually a slight fall in amplitude of the compound action potential. Saxitoxin and tetrodotoxin now inhibit the action potential to a greater degree than in the absence of magnesium ions.

Action Potentials↗
PubMed1977

[Spinal subdural abscess-report of a case (author's transl)].

A successfully treated case with a spinal subdural abscess in the lumbar region is reported. The patient, a 58-year-old male, had been suffered from fever and pain in the back for 2 months prior to the visit to a hospital, where pus was obtained through a lumbar puncture. He was then admitted to the Neurosurgical Clinic, Gunma University Hospital on September 6, 1974. On admission, neurological examination revealed an alert patient with flaccid paraparesis, sensory disturbance in bilateral lower limbs and urinary retention. Stiffness of the neck and Lasègue's sign were observed. The body temperature was 38.7 degrees C, white blood cell count 18,900/mn3, and erythrocyte sedimentation rate 118 mn per hour. Pus was again obtained from the spinal canal through a lumbar puncture between the fourth and fifth lumbar vertebrae. Cerebrospinal fluid obtained by a cisternal puncture was colorless clear, and the cell count was 60 WBCs/mn3, protein 154 mg/dl, and glucose 90 mg/dl. Plain roentgenograms of the spine were normal. Myelography showed a block at the level of the first thoracic vertebra, being accompanied with irregular subarachnoid defects. A lumbar laminectomy was performed on September 12, and an abscess adhering to the cauda equina was totally extirpated from the subdural space. Smear of the pus contained Gram-positive bacilli, but the culture was negative. Postoperative course was uneventful, and the neurological deficits were gradually improved. Fifteen months later, the patient could walk with a stick. A review of the available literature, including the present report, lists 14 cases with spinal subdural abscesses which have been induced via hematogenous spread. The symptomotology, clinical diagnosis, treatment and prognosis are briefly discussed. It should be emphasized that early diagnosis and emergency treatment are of choice in order to obtain an excellent operative morbidity.

Abscess↗
PubMed1993

Ependymoma of the filum terminale: treatment and prognostic factors in a series of 28 cases.

A series of 28 ependymomas arising in the filum terminale was divided into two groups based on the presence/absence of connections with the conus medullaris and/or roots of the cauda equina. Group A comprised ependymomas having no connections with the contiguous structures and group B those either infiltrating or adhering to such structures. Factors having a positive influence on the prognosis (risk of recurrence) were: 1) clinical history under one year (p < 0.01); 2) confinement of tumour to the filum terminale (p < 0.01); 3) total tumour removal (p < 0.05). Postoperative radiotherapy had no appreciable effect on outcome. The combination of significant factors was in turn significantly influenced by the mode of tumour growth, which proved to be the cardinal factor in prognosis. This point is examined in the light of the published work.

Adolescent↗
PubMed1989

[Neurogenic bladder disorders].

The past 15 years have witnessed an explosion of new knowledge concerning the anatomy, neurophysiology, and pharmacology of the lower urinary tract. Knowledge of the localization of a neurologic lesion-suprapontine, suprasacral, cauda equina, or peripheral nerves-rather than the type of disease allows a more "rational approach" to the diagnosis and therapy of neurogenic voiding disorders. More specifically, advances in pharmacological understanding enable us, at least in theory, to treat voiding disorders according to their types of dysfunction: drugs to promote bladder emptying that exert their predominant effect on bladder and bladder outlet respectively, and those promoting bladder storage with the corresponding objectives. We discuss the problem that many theoretically sound drugs are, in fact, not clinically efficacious, probably due to incomplete understanding of the physiology of normal micturition and its neurogenic disorders.

Brain↗
PubMed1999

Lumbar spinal subdural hematoma following craniotomy--case report.

A 52-year-old female complained of lumbago and weakness in the lower extremities 6 days after craniotomy for clipping an aneurysm. Neurological examination revealed symptoms consistent with lumbosacral cauda equina compression. The symptoms affecting the lower extremities spontaneously disappeared within 3 days. Magnetic resonance (MR) imaging 10 days after the operation demonstrated a lumbar spinal subdural hematoma (SSH). She had no risk factor for bleeding at this site, the symptoms appeared after she began to walk, and MR imaging suggested the SSH was subacute. Therefore, the SSH was probably due to downward movement of blood from the cranial subdural space under the influence of gravity. SSH as a complication of cranial surgery is rare, but should be considered if a patient develops symptoms consistent with a lumbar SSH after craniotomy.

Brain↗
PubMed1998

Spinal hamartomas: a distinct clinical entity.

OBJECT: Congenital spinal hamartomas are defined as tumors of well-differentiated mature elements situated in an abnormal location. In this report, the authors document the clinical and pathological features of spinal hamartomas in 10 patients. METHODS: Ten patients presented with midline dorsal malformations at birth, initially diagnosed as teratomas or myelomeningoceles. The locations of the masses were variable: two were located in the thoracic region, four at the thoracolumbar junction, two in the lumbar region, one at the lumbosacral junction, and one in the sacral region. The results of the neurological examination were normal in nine patients. All but one mass had intact skin and seven had palpable bone components. Neuroimaging studies revealed widening of the spinal canal, heterotopic bone located dorsally in some patients, and varying degrees of involvement of the intraspinal contents. During surgery, six patients were found to have involvement of the spinal cord or cauda equina. The pathological characteristics of the masses included three or more of the following: bone, cartilage, synovial membrane, urinary tract tissue, cyst wall, yellow or brown fat, and nerves. The well-differentiated cellular elements, which formed mature structures, along with the absence of primitive cellular components and neoplastic characteristics are more consistent with a diagnosis of hamartoma than teratoma. CONCLUSIONS: In this series, the authors describe a lesion that is overt on physical examination, yet can have occult spinal canal involvement. Complete neurosurgical evaluation is essential to provide appropriate treatment and prognosis.

Adipose Tissue↗
PubMed1993

Magnetic stimulation for monitoring of motor pathways in spinal procedures.

Transcranial magnetic stimulation was used for intraoperative motor evoked potential monitoring during surgery of intramedullar, extramedullar, and extradural spinal tumors in 13 patients. Anesthesia was based on etomidate. Magnetic stimulation for motor evoked potential monitoring was successful in 10 of 13 patients, 12 of whom were neurologically impaired. Motor evoked potentials were recorded from limb muscles or from the fibers of the cauda equina. Amplitudes of baseline recordings (the initial recording obtained after induction of anesthesia) were decreased by 64 +/- 34% (mean +/- SD) and baseline latencies were increased by 7 +/- 8% compared with the preoperative recordings. Subsequent recordings were analyzed for amplitude and latency changes in comparison to baseline. Amplitude changes exceeding 50% and latency changes higher than 3 ms compared with the baseline correctly indicated an impending lesion of motor pathways with increased paresis postoperatively. In cases where motor evoked potential monitoring was successful prediction of short-term postoperative motor outcome was always correct. There were no "false-negatives" or "false-positives."

Adult↗
PubMed1992

Spinal cord compression in prostate cancer. A 10-year experience.

Of 478 patients treated at a single institution for prostate cancer, 29 developed spinal cord or cauda equina compression. In 5 patients, spinal cord compression was the first evidence of malignancy. Clinical features were predominantly pain, weakness, sensory and sphincter disturbance. The median duration of symptoms was 2 weeks, although the diagnosis was made rapidly at presentation. Clinical diagnosis correlated well with myelographic findings. Only 1 patient suffered neurological deterioration as a consequence of myelography. The functional outcome was dependent on the ability to walk prior to treatment. The median survival in those who were bedridden following treatment was 6 weeks (range 3.5-13) and 21 weeks (range 7-110+) in those who were ambulant following therapy.

Cauda Equina↗
PubMed1982

Reinnervation of the urinary bladder after microsurgical reconstruction of transsected caudal fibres. An experimental study in pigs.

Reinnervation of the urinary bladder after transsection of cauda equina fibres and their microsurgical reconstruction was studied. In five pigs a partial reconstruction with end-to-end suture of the transsected roots was performed inside the dura mater spinalis; four of these, which had a denervated bladder after the transsection, reestablished the micturition reflex 6 months after the reconstructive operation. The results demonstrate that the reestablished micturition reflex was due to a functional regeneration of transsected and sutured motor fibres. Although a regeneration was proved in sensory as well as in motor neurons by morphologic methods, it is doubtful whether the regenerated sensory fibres took part in the reestablishment of the micturition reflex after contact with the spinal cord.

Animals↗
PubMed1985

Sacral meningeal arteriovenous fistula fed by branches of the hypogastric arteries and drained through medullary veins.

The authors report a new case of intraspinal extra-medullary meningeal arteriovenous fistula draining through medullary veins. Discovered in a 33-year-old black man suffering from a cauda equina syndrome, this malformation suspected in myelography was confirmed by a selective angiographic procedure of both internal iliac arteries. This investigation specified the sacral site of the fistula as well as its feeding arteries from several branches of the left and right internal iliac arteries and its posterior and intra-meningeal venous medullary drainage. An embolization procedure followed by a surgical approach and a second embolization session brought a fair improvement to this young patient who could walk again. The acquired traumatic origin of the fistula is discussed for this patient who had been previously operated at his L5-S1 level.

Adult↗
PubMedDate not supplied

Sensitivity and specificity of MRI in detecting malignant spinal cord compression and in distinguishing malignant from benign compression fractures of vertebrae.

The accuracy of magnetic resonance (MR) imaging in the detection of metastatic compression of the spinal cord and the cauda equina (MCCE) in 75 patients with known primary malignancy outside the central nervous system is determined retrospectively by comparing the MR results with findings of myelography, surgery, clinical follow-up and autopsy. The sensitivity is 93%, the specificity 97% and the overall accuracy 95%. The signal intensity measured in the sagittal MR images of a collapsed vertebral body is divided by that of an average of three adjacent normal vertebrae to form a signal intensity ratio (SIR). The SIRs of 41 metastatic and 15 post-traumatic collapsed vertebrae are calculated. A ratio of 0.8 has the most differentiating power. All benign and one malignant compressed vertebrae have SIRs greater than 0.8.

Cauda Equina↗
PubMedDate not supplied

Complications in the surgical treatment of lumbar stenosis.

The authors analyze the complications which may occur in the surgical treatment of lumbar stenosis. They report 4 cases of cauda equina syndrome and 8 dural tears in 96 patients aged from 21 to 81 years submitted to multiple bilateral laminectomy. Based on a review of the patients some considerations on surgery for the treatment of lumbar stenosis are discussed. The advanced age of the patients, hypertension, diabetes, vasculopathies in general, severe neurological deficit dating back some time contraindicate surgery. When surgery is indicated a correct preoperative evaluation by MRI from T12 to the sacrum is required to determine the extent of the laminectomy and a safe and accurate intra- and postoperative bleeding control is mandatory. Dural laceration may be repaired by a thoracolumbar fascia patch.

Age Factors↗
PubMedDate not supplied

Extradural myxopapillary ependymoma: report of two cases and review of the literature.

The cauda equina is the most frequent location for ependymomas, particularly the myxopapillary variant, which generally arises from the filum terminale. These tumors have a characteristic histopathologic pattern and are usually easily recognized. The occurrence of these tumors in an extradural, sacrococcygeal, or subcutaneous location may prove challenging, particularly in the absence of any obvious central nervous system connection. We describe two such extradural cases, one with multiple regional and distant metastases and the other with multiple recurrences. The origin of these tumors from subcutaneous sacrococcygeal ependymal rests is postulated on the basis of earlier reports. Clinical and histopathological features are described and a review of the literature is presented.

Adult↗
PubMed1994

The European Spine Society AcroMed Prize 1994. Acute thermal nerve root injury.

Bone cement is sometimes used for vertebral body reconstruction following tumor removal. During such procedures, the polymerization of the methyl-metacrylate in the bone cement generates heat. Such temperature increase might cause damage to the nerve roots within the spinal canal. In the present study, pig cauda equina nerve roots were subjected to controlled temperature increases by means of a heat-generating probe. A temperature of 40 degrees C applied for 5 min did not cause any changes in nerve root function. However, 70 degrees C resulted in a complete block of nerve root function within 5 min. Histological nerve fiber damage was seen after exposure to 60 degrees C and 70 degrees C. The present study provides basic knowledge of heat-resistance properties of spinal nerve roots that might be directly applicable as guidelines for safety margins during surgical spine reconstruction procedures using bone cement.

Action Potentials↗