Roentgen Diagnosis of Herniation of the Brain into the Spinal Canal (Arnold-Chiari Deformity) by Pantopaque Myelography

Abstract

In recent years several authors (1, 2, 3) have described the typical myelographic appearance of herniation of the brain into the spinal canal, but in only two cases was the diagnosis made preoperatively by opaque contrast myelography. We are reporting the findings of one case because the myelographic appearance is characteristic and the diagnosis was made prior to operation. Case Report E. M., a 38-year-old white male, was admitted to the Neurosurgical Service of the Temple University Hospital on Nov. 30, 1948, complaining of severe pain in the back of the neck, radiating to the vertex and into both shoulders. The pain was of eight months duration and had become more severe during the two weeks preceding entry. It was accompanied by tingling and numbness in the fingers and to a lesser extent in the lower extremities. Sneezing and coughing aggravated the nuchal and occipital discomfort. Hospital admission was precipitated by the onset of difficulty in respiration and deglutition during the twenty-four hours preceding entry. There was no history of recent trauma and the remainder of the systemic review was essentially negative. On physical examination the patient appeared well developed and well nourished, alert and in no apparent distress. Positive physical findings included a mild steppage-like gait, anesthesia over the entire occipital area, and tenderness upon pressure over the posterior aspect of the upper cervical spine. The deep tendon reflexes were hyperactive on the right. There were a questionably positive Babinski sign and a definite dysmetria, both on the right side. Bilateral nystagmus was present, being more marked on the right lateral gaze. The spinal fluid was clear and under a pressure of 80 mm. of water. There was no change in manometric pressure with jugular compression, which suggested partial or complete block. The spinal fluid protein was 101 mg. per 100 c.c. Serologic tests for syphilis were negative, as were the blood count and urinalysis. The clinical impression was that of a space-taking lesion of the upper cervical cord. A review of roentgen studies made elsewhere revealed basilar impression associated with multiple developmental abnormalities of the upper cervical spine consisting of upward displacement of the spine into the occiput and assimilation of the major anterior portion of the atlas into the occiput (Fig. 1). A small vestigial remnant of the posterior arch of the atlas was visible adjacent to and probably fused with the posterior margin of the foramen magnum, 1. There was a complete fusion of the anterior and posterior portions of the axis, 2, with the third cervical segment, 3. Cervical pantopaque myelography revealed several interesting findings. There was an almost complete block at the level of the mid portion of the fused second and third cervical vertebral bodies (Figs. 2, 3, and 4).