Complete Paraplegia Research Articles

Spinal cord injury: time to move

Progress continues in the development of reparative interventions to enhance recovery after experimental spinal cord injury (SCI) in animal models. 1 Thuret S Moon LD Gage FH Therapeutic interventions after spinal cord injury. Nat Rev Neurosci. 2006; 7: 628-643 Crossref PubMed Scopus (790) Google Scholar Although some of these treatments might be translatable to patients with moderate SCI, and are entering phase 1 or 2 clinical trials, evidence for the efficacy of any intervention designed to repair the injured human spinal cord is still lacking. 2 Dietz V Ready for human spinal cord repair?. Brain. 2008; 131: 2240-2242 Crossref PubMed Scopus (17) Google Scholar Instead, improvement of ambulatory function is routinely observed with activity-based rehabilitation in individuals who retain voluntary movements of the legs after SCI. 3 Dietz V Colombo G Jensen L Locomotor activity in spinal man. Lancet. 1994; 344: 1260-1263 Summary PubMed Scopus (329) Google Scholar , 4 Behrman AL Harkema SJ Locomotor training after human spinal cord injury: a series of case studies. Phys Ther. 2000; 80: 688-700 PubMed Google Scholar However, even intense training programmes have not resulted in functional recovery in patients with clinically motor complete SCI. 5 Harkema SJ Plasticity of interneuronal networks of the functionally isolated human spinal cord. Brain Res Rev. 2008; 57: 255-264 Crossref PubMed Scopus (132) Google Scholar Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case studyTask-specific training with epidural stimulation might reactivate previously silent spared neural circuits or promote plasticity. These interventions could be a viable clinical approach for functional recovery after severe paralysis. Full-Text PDF

Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case study

Repeated periods of stimulation of the spinal cord and training increased the ability to control movement in animal models of spinal cord injury. We hypothesised that tonic epidural spinal cord stimulation can modulate spinal circuitry in human beings into a physiological state that enables sensory input from standing and stepping movements to serve as a source of neural control to undertake these tasks. A 23-year-old man who had paraplegia from a C7-T1 subluxation as a result of a motor vehicle accident in July 2006, presented with complete loss of clinically detectable voluntary motor function and partial preservation of sensation below the T1 cord segment. After 170 locomotor training sessions over 26 months, a 16-electrode array was surgically placed on the dura (L1-S1 cord segments) in December 2009, to allow for chronic electrical stimulation. Spinal cord stimulation was done during sessions that lasted up to 250 min. We did 29 experiments and tested several stimulation combinations and parameters with the aim of the patient achieving standing and stepping. Epidural stimulation enabled the man to achieve full weight-bearing standing with assistance provided only for balance for 4·25 min. The patient achieved this standing during stimulation using parameters identified as specific for standing while providing bilateral load-bearing proprioceptive input. We also noted locomotor-like patterns when stimulation parameters were optimised for stepping. Additionally, 7 months after implantation, the patient recovered supraspinal control of some leg movements, but only during epidural stimulation. Task-specific training with epidural stimulation might reactivate previously silent spared neural circuits or promote plasticity. These interventions could be a viable clinical approach for functional recovery after severe paralysis. National Institutes of Health and Christopher and Dana Reeve Foundation.

Abstract 2237: Nelarabine is safe and effective in adult relapsed or refractory T cellacute lymphoblastic leukemia (T-ALL) and lymphoblastic lymphoma (T-LBL): The Bologna experience

Abstract Background. Nelarabine (N) is approved for the treatment of T-ALL and T-LBL that have not responded to or has relapsed after treatment with at least 2 chemotherapy regimens. Aim. To evaluate safety profile and efficacy of N as savage therapy in 16 adult relapsed or refractory T-ALL or T-LBL. Methods. After obtaining an informed consent, 16 patients (median age 33 years, range 19-45, M/F = 13/3) affected by T-ALL (n=10) and T-LBL (n=6) received savage therapy with N (median cycle=1, range 1-3), administered at standard adult dosage (1500 mg/sqm on days 1, 3 and 5, every 21). Four patients were primary resistant to induction treatment, 7 patients were relapsed after two previous chemotherapy regimens (including allogeneic BMT in 4 cases and autologous SCT in 1 case); the remaining 6 patients had a molecular relapsed disease (MRD positive). Molecular characterization was performed, including NOTCH and WT-1 genes mutational status. GEP analysis, according to Ferrando A. stratification (Cancer Cell 2002), is still ongoing. Results. Currently, 12 out of 16 patients are evaluable, due to a too short follow up in the other 4 cases. Seven out of 12 patients obtained a complete remission (CR) (5 T-ALL 2 T-LBL);a partial remission (PR) was documented in 2 cases, with an overall response rate (ORR) of 75%. Median duration of CR was 10 weeks (range 2.8-54+). Among these, 2 out of 4 patients in molecular relapse reached a molecular CR and underwent an allogenic BMT (currently in CR after a median follow up of 12 months). Extra- hematological toxicity, not clearly related to the drug, occurred in 3 cases, determining, a complete and irreversible paraplegia, a condition of mental confusion, and a peripheral neuropathy, respectively. Conclusions. N showed a strong efficacy also in cases with low levels of residual disease, in addition to a good safety profile. Neurological toxicity needs to be strictly monitored. Acknowledgments. European LeukemiaNet, AIL, AIRC, Fondazione Del Monte di Bologna e Ravenna, FIRB 2006, PRIN 2008, Ateneo RFO grants, Project of integrated program (PIO), Programma di Ricerca Regione – Università 2007 – 2009. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2237. doi:10.1158/1538-7445.AM2011-2237

Spinal angiolipoma in a pregnant woman presenting with acute epidural hemorrhage

A 26-year-old woman in week 31 of pregnancy presented to the emergency room with acute onset of paraplegia. Her medical history was unremarkable. Neurological examination revealed complete paraplegia, total sensory loss below the T7 dermatome, and significant vesicorectal dysfunction. MRI revealed an intraspinal mass from T3 to T4, which was hyperintense on both T1-weighted and T2-weighted images. Blood examination found no abnormality. She underwent emergent hemilaminectomy and removal of the hematoma. Intraoperatively, unusually ectatic venous vessels were found adhered to the lower surface of the epidural clot. No concurrent vascular malformations were identified and the dura mater was intact. The histological diagnosis was angiolipoma. Postoperatively her neurological deficits showed remarkable improvement, and she gave birth to a healthy baby. Spinal angiolipoma in a pregnant woman may be complicated with acute epidural hemorrhage. Emergent surgical evacuation can be performed safely with a good functional prognosis.

Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel

An acute spontaneous spinal epidural hematoma (SSEH) is a rare spinal pathology. A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity. Magnetic resonance imaging revealed an epidural hematoma, and the patient underwent emergency hemilaminectomy for evacuation. However, the symptoms worsened, and complete paraplegia developed. A second procedure to remove the recurrent hematoma was performed. No vascular malformation or other possible cause for SSEH was found other than the aspirin and clopidogrel medication. This case report describes relapsed SSEH caused by the combination of aspirin and clopidogrel medication and urges caution in prescribing dual antiplatelet agents.

Suicide bombing as an unusual cause of spinal cord injury: a case series from Pakistan

Descriptive case series. Describe the unusual etiology and pattern of spinal cord injury due to terrorist suicide bombings in Pakistan. Spinal Rehabilitation Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. Hundreds of suicide attacks on civil and military forces have occurred over the last 6 years in Pakistan. These have resulted in thousands of death and many more injured. Six victims of terrorist suicide bombings were admitted over the years 2006 to 2009, who had a spinal cord injury (SCI). This is the first case series of SCI, secondary to terrorist suicide blast. All patients were males. The mean age was 30±11 years. Most (five) were injured directly due to splinters from the blast. On admission to rehabilitation, all patients had thoracic complete paraplegia and their SCI was managed conservatively for their spinal injuries. Associated injuries included intestinal perforations, fracture metatarsals, humerus and brachial plexus injury. Pressure ulcer was the commonest complication (3 patients). Two patients had neurological improvement at 1-year follow-up. Suicide bombing is an effective weapon of terrorists in the modern world of today. The resulting injuries can be diverse and devastating. Spinal cord injury is an uncommon sequel of suicide bombing, which should be kept in mind while dealing with victims of suicide bombing.

Surgical management of post-SCIWORA spinal deformities in children

Patients with spinal cord injury without radiographic abnormality (SCIWORA) are prone to develop spinal deformities. The purpose of this study is to report on the clinical and radiological features of post-SCIWORA spinal deformities. Four patients with SCIWORA and spinal deformities requiring surgery were analyzed clinically and radiographically. All four SCIWORA patients developed progressive neuromuscular scoliosis. There were 2 males and 2 females. The mean age at spinal cord injury was 3.9years (range 6months to 7years). Spinal deformity was first noticed at a mean of 17months after their initial injury (range 9months to 2years), and surgical intervention was performed at a mean of 6.5years following their injury (range 4-11years). The mean preoperative curve was 54° (range 50-62°). The mean postoperative curve was 9.5° (range 5-16°). The level of injury was T5 in two patients, and T10 and L2 in one patient each. All but the lumbar level injury patient had complete paraplegia. One patient with complete injury (T10) and another with incomplete injury (L2) improved neurologically and were able to walk with the aid of orthoses and crutches. Pelvic obliquity improved in all patients following spinal reconstruction surgery, and none of the patients required additional surgery for spinal deformity. The mean postoperative follow-up was 51.75months (range 24-93months). Long scoliotic curves extending to the pelvis should be expected in SCIWORA. Early intervention may prevent severe deformities. Modern instrumentation techniques employing pedicle screws provided satisfactory correction, improved hip subluxation, and did not adversely affect the ambulatory ability or functional level of the patients in this series.

Surgical treatment of lower lumbar fracture with mini-incision via retroperitoneal anterior approach

Objective To investigate the clinical effects of surgical treatment of lower lumbar fracture with mini-incision via retroperitoneal anterior approach. Methods The data of 21 cases with serious lower lumbar burst fracture were analyzed retrospectively. There were 15 males and 6 females with an average age of 35.9 years （ranged, 19-65 years）. The lesion was located in L3 in 10 cases, L4 in 8 and L5 in 3cases. According to Magerl classification, there was type A （burst in 12 cases, type B （distraction） in 2 and type C （retortion） in 7 cases. All the 21 cases were treated with anterior decompression, bone graft fusion and internal fixation with mini-incision via retroperitoneal anterior approach. The changes of radiograph and neurologic status were recorded respectively. Results All the cases had been followed up for an average of 41.9 months （12-86 months）. The radiograph showed obvious improvement on the injured body height （from 42.62% preoperatively to 94.33% postoperatively, P〈0.01） and the canal encroachment index （from 2.67 preoperatively to 0.14 postoperatively, P〈0.01）. Significant improvement in neurological function were achieved in all patients with the improvement of one grade except for 1 case with L3, T11 fracture and complete paraplegia. No failure of implants was found during the follow-up period. Conclusion Anterior decompression and internal fixation with mini-incision via retroperitoneal anterior approach are successful in treating serious lower lumbar burst fractures. Key words: Spinal fractures; Surgical procedures,minimally invasive; Fracture fixation

The effect of adrenergic β2 receptor agonist on paraplegia following clamping of abdominal aorta

IntroductionSurgical repair of an aortic aneurysm might be complicated by spinal cord injury and paraplegia. Since β-adrenoreceptor agonists showed neuroprotective effects, the study was designed to investigate the effect of clenbuterol on post-aortic clamping paraplegia and to identify if there is hyperemia associated with paraplegia.Material and methodsMaterial and methods: Thirty rabbits were divided into two groups: 15 control and 15 experimental (given clenbuterol 9 mg in drinking water 24 h prior to surgery). All the animals were subjected to laparotomy whereas the abdominal aorta was identified. Using a vascular clamp, the abdominal aorta was clamped just distal to the renal arteries. Abdominal aortic blood flow was recorded with a transonic flow meter. The neurological assessment was made according to Tarlov’s Neurological Scale upon recovering from anesthesia. Anal sphincter tonus and bladder sphincter function were also checked.ResultsFour rabbits (2 control and 2 experimental) developed complete paraplegia within 30 min of cross-clamping of the aorta. Of the 13 controls, 77% developed paraplegia, and of the 13 experimental rabbits administered clenbuterol 24 h prior to surgery with 22 min of aortic cross-clamping, 38% developed paraplegia The rabbits which did not develop paraplegia had a minimal increase in aortic blood flow, whereas the rabbits which developed paraplegia had a significant increase in aortic blood flow measurements after aortic decamping.ConclusionsPost-aortic clamping paraplegia is associated with hyperemia and clenbuterol has a significant neuroprotective effect, obviously by preventing an increase in aortic blood flow following unclamping.

Tuberculosis of spine with neurological deficit in advanced pregnancy: a report of three cases

Background context Early decompression in spinal tuberculosis (TB) with complete paraplegia has a better prognosis in relation to the neurological recovery and deformity progression. Advanced pregnancy can complicate this picture in view of the various fetomaternal factors. The prevalent literature is inconclusive regarding the time and extent of surgical intervention. Delay in the surgical intervention may adversely affect the prognosis. Purpose To emphasize the importance of early decompression in spinal TB complicated by neurological deficit in advanced pregnancy. Study design A case report of three patients to analyze the surgical management of neurological deficit because of spinal TB in pregnancy. Outcome measures Neurological recovery, progression of deformity, healing of the TB lesion, and outcome of the pregnancy. Methods Three patients presented with spinal TB with neurological deficit complicating third trimester of pregnancy. The first patient was initially managed conservatively but was operated after a spontaneous abortion. The remaining two patients were managed by urgent Caesarean section followed by spinal decompression and fusion. Results The first patient who underwent delayed decompression showed good healing of the TB lesion but continued to have spastic paraparesis with kyphosis. This was later managed by repeat decompression and instrumented fusion, without neurological recovery. The other two patients treated by early decompression and fusion showed complete healing with neurological recovery. Conclusions Early decompression and instrumented fusion in spinal TB, complicated by neurological deficit in advanced pregnancy, can give good results with respect to neurological recovery, healing of the lesion, and arrest of deformity progression. Neonatal prognosis depends on the fetal maturity. Antitubercular therapy is an essential component of the management; it poses little hazard of inducing congenital anomalies, but possibility of maternal drug toxicity should be considered.

Treatment-resistant sensory motor symptoms in persons with SCI may be signs of restless legs syndrome

Case report on the successful treatment with pramipexole in four men with chronic spinal cord injury (SCI) suffering from refractory symptoms that were previously considered to be manifestations of a post-traumatic spastic syndrome or neuropathic pain. To raise awareness among health professionals regarding the diagnostic and therapeutic possibility of restless legs syndrome (RLS) and periodic limb movements (PLMs) in some patients with SCI responding poorly to conventional treatment for spasticity or neuropathic pain. Neurorehabilitation department of the Rehabilitation Medicine Center of Northern University Hospital, Umeå, Sweden. Medical records and clinical data were retrospectively reviewed. All cases obtained treatment with pramipexole, initially 0.09-0.72 mg day(-1). Two of the cases had RLS and PLMs, one RLS only and one PLMs only. All four reported symptoms in the lower extremities and one also in the upper extremities. Three patients with residual gait function reported RLS score with/without treatment as follows: 32/11, 37/12 and 33/12. One patient with complete paraplegia (with incomplete RLS score) reported 22/10. After a follow-up period of 16, 20, 43 and 49 months, respectively, all four still reported excellent outcomes. Two remained on initial dosage; one had increased dosage from 0.09 to 0.18 mg day(-1) and one from 0.27 to 0.80 mg day(-1) during the follow-up period. In persons with SCI suffering from infralesional involuntary movements and/or dysesthesia and with poor response to conventional antispastic or analgesic treatment, the possibility of RLS or PLMs should be considered, as these conditions seem eminently treatable.

Efficacy and Feasibility of Nelarabine Savage Therapy In Adult Relapsed or Refractory T Cell Acute Lymphoblastic Leukemia (T-ALL) and Lymphoblastic Lymphoma (T-LBL) Strongly Indicates the Introduction of a Nelarabine-Based First Line Regimen

AbstractAbstract 4335 Background.T-ALL represents 15% of childhood and 25% of adult ALL. Despite a cure rate of almost 80% in children and adolescents, adult ALL remains a difficult disease to cure, due to a high risk of relapse. Effective treatment of relapsed acute T-ALL is limited with a low CR rate, a high treatment-related mortality, and a very low prolonged disease-free survival.Nelarabine is a pro-drug of ara-G, approved by the FDA for the treatment of T-ALL and T-LBL that have not responded to or has relapsed after treatment with at least 2 chemotherapy regimens. Similar to other nucleoside analogues, Nelarabine acts by inhibiting DNA synthesis and inducing apoptosis in malignant cells. Aims of the study.To evaluate the safety profile and the efficacy of Nelarabine treatment as savage therapy, administered to 9 out of 13 adult relapsed or refractory T-ALL or T-LBL patients. Patients and Methods.After obtaining an informed consent, nine patients (median age 31 years, range 19–37, M/F= 9/0) affected by T-ALL (N=6) and T-LBL (N=3) received a savage therapy with Nelarabine (median cycle=1, range 1–3). Nelarabine was administered at standard adult dosage (1500 mg/sqm on days 1, 3 and 5, every 21). Seven patients were relapsed after two previous chemtotherapy regimens, including allogeneic bone marrow transplantation; the remaining two patients were primary resistant to standard induction treatment. Results.Five out of nine patients obtained a complete morphological remission (4 T-ALL patients and 1 T-LBL patient), whereas a partial remission was documented in two cases, with an overall response rate of 78%. Median duration of complete response was 6 weeks (range 3–6 weeks). Nelarabine was well tolerated, and no significant adverse events were registered. Extra- hematological neurological toxicity, not clearly related to the drug, occurred in two cases, determining, in one patient a complete and irreversible paraplegia, and in the second one a condition of mental confusion (grade III), which resolved after few days. Conclusion.In our experience Nelarabine was successfully administered in such a high risk patients population. The drug showed a relevant efficacy and a good safety profile, strongly suggesting a good rational for its introduction in first-line chemotherapeutic regimens. This strategy is being explored in our Institution as well as in other ones (Faderl S, MD Anderson). Acknowledgments.This work was supported by European LeukemiaNet, AIL, AIRC, Fondazione Del Monte di Bologna e Ravenna, FIRB 2006, PRIN 2008, Ateneo RFO grants, Project of integreted program (PIO), Programma di Ricerca Regione – Università 2007 – 2009. Disclosures:Baccarani:NOVARTIS: Honoraria; BRISTOL MYERS SQUIBB: Honoraria. Martinelli:Novartis: Consultancy, Honoraria; BMS: Honoraria; Pfizer: Consultancy.

Complications of one stage posterior vertebral column resection for the treatment of severe rigid spinal deformities

to summarize the complications of posterior vertebral column resection (pVCR) and pedicle screw fixation for the treatment of rigid thoracic and lumber spinal deformity. fifty four patients from a single center from February 2000 to February 2009 were included in this study. There were 23 males and 31 females with an average age of 28.3 years (range, 16-58 years). Patients were divided into 4 diagnostic categories: severe scoliosis (n = 9, mean Cobb angle, 91.7°), kyphoscoliosis (n = 22, mean scoliosis, 101.5°, and mean kyphosis, 69.4°), angular kyphosis (n = 21, mean kyphosis, 72.2°), global kyphosis (n = 2, mean kyphosis, 93.6°). All of the patients received one stage pVCR combined correction with pedicle screws and circumferential fusion. Radiographs and hospital charts were reviewed to analyze the outcomes of correction. a mean of 1.4 vertebral levels were resected, the mean operative time was 470 min, and the mean blood loss was 4180 ml. All the patients were followed-up for an average time of 26 months (range, 12 - 66 months). At the latest follow-up, the major curve correction averaged: severe scoliosis 61.4° (67%), kyphoscoliosis 59.7° (56%)/kyphosis 42.3° (59%), angular kyphosis 48.5° (71%), global kyphosis 62.7° (67%). A total of 21 complications (38.9%) occurred in 17 patients, including 5 (9.3%) neurological complications happened in early stage and one case of delayed complete paraplegic. There were 11 (20.4%) non-neurological complications happened in early stage and 5 (9.3%) cases in late stage. one stage posterior-only vertebral column resection can achieve satisfactory correction of severe deformities with limited flexibility. Given its technically demanding and exhausting features, its potential risk of significant complications should be paid more attention.

Cordotomy for patients with thoracic malignant astrocytoma

The optimal management of malignant astrocytomas remains controversial, and the prognosis of these lesions has been dismal regardless of the administered treatment. In this study the authors investigated the surgical outcomes of cordotomy in patients with thoracic malignant astrocytomas to determine the effectiveness of this procedure. Cordotomy was performed in 5 patients with glioblastoma multiforme (GBM) and 2 with anaplastic astrocytoma (AA). A Kaplan-Meier survival analysis was performed, and the associations of the resection level with survival and postoperative complications were retrospectively examined. Cordotomy was performed in a single stage in 2 patients with GBM and in 2 stages in 3 patients with GBM and 2 patients with AA. In the 2 patients with GBM, cordotomy was performed 2 and 3 weeks after a partial tumor resection. In the 2 patients with AA, the initial treatment consisted of partial tumor resection and subtotal resection combined with radiotherapy, and rostral tumor growth and progressive paralysis necessitated cordotomy 2 and 28 months later. One patient with a secondary GBM underwent cordotomy; the GBM developed 1 year after subtotal resection and radiotherapy for a WHO Grade II astrocytoma. Four patients died 4, 5, 24, and 42 months after the initial operation due to CSF dissemination, and 3 patients (2 with GBM and 1 with AA) remain alive (16, 39, and 71 months). No metastasis to any other organs was noted. One-stage cordotomy should be indicated for patients with thoracic GBM or AA presenting with complete paraplegia preoperatively. In patients with thoracic GBM, even if paralysis is incomplete, cordotomy should be performed before the tumor disseminates through the CSF. Radical resection should be attempted in patients with AA and incomplete paralysis. If the tumor persists, radiotherapy and chemotherapy are indicated, and cordotomy should be reserved for lesions growing progressively after such second-line treatments.

A disarticulating spinal lesion

A 54-year-old man with quadriparesis presented with 2 months of vague abdominal pain and 1 week of fever. He sustained a horse-riding accident as a teenager that resulted in a cervical spinal cord injury with complete lower extremity paraplegia and incomplete motor and sensory loss below C6. According to the patient his baseline neurologic function was unchanged since the onset of the abdominal pain. He was found to have complete motor loss in the lower extremities, symmetric moderate weakness of the arms appropriate to his mid-cervical cord injury, and a sensory level below T10.

Prognostic factors for the outcome of surgical and conservative treatment of symptomatic spinal cord cavernous malformations: a review of a series of 20 patients

In this study, the authors present a review of a series of 20 intramedullary spinal cord cavernous malformations (SCCMs) with particular focus on MR imaging and prognostic factors. Between 1994 and 2009, 20 patients with SCCM were treated under the care of the senior author. The diagnosis was made in all patients after the onset of clinical symptoms. The age of the 9 men and 11 women ranged between 26 and 71 years (median 38.5 years). The duration of symptoms prior to referral ranged from 1 week to 9 years (median 6.5 months). At the time of referral, 4 patients had no significant neurological deficits, 10 patients suffered significant functional restrictions, and 6 patients presented with severe paraparesis and loss of functional strength. None of the patients had complete paraplegia. Seventeen patients underwent microsurgical removal, while 3 patients opted for conservative therapy. For the present analysis, the medical records and MR images and/or reports were reviewed. Classification of length of history, pretreatment status, MR imaging pattern, and treatment modality was done and correlated with outcome. The cavernoma was located at the cervical level in 8 patients and between T-1 and L-1 in 12 patients. The cavernoma appeared as mainly T2 hyperintense on MR images in 7 patients, mainly T2 hypointense in 2 patients, and mixed in the remaining 10 patients. The craniocaudal extension of the core varied between 5 and 45 mm. In 2 patients with cervical cavernomas, a distinct T2 signal of the spinal cord cranial and distal to the cavernoma was seen, and in a patient with a large thoracic cavernoma, T2 extinction cranial and caudal to the cavernoma was seen as a sign of hemosiderosis. Neurological deficits improved postoperatively in 12 of the surgically treated patients, remained stable in 2, and deteriorated in 3. The 3 patients who were conservatively treated remained stable over a follow-up of 3-9 years. Postoperative improvement was seen in 5 of 7 surgical patients with a history of symptoms of 2 months or less, 5 of 6 patients with a history of 2-24 months, and in 2 of 4 patients with a history of more than 2 years. Two of the 3 patients with postoperative deterioration had a history of more than 2 years and the third a short history of 1 month. Although a satisfactory outcome can be achieved through surgical treatment of SCCMs, some patients worsen after surgery or during the postoperative course. Long-term stability is possible in oligosymptomatic conservatively treated patients. The prevalence and pathophysiological importance of segmental spinal cord edema and hemosiderosis is incompletely understood at the present time.

A Case of Spontaneous Spinal Epidural Haematoma in the Emergency Department Associated with Warfarin Therapy

Spontaneous spinal epidural haematoma (SSEH) is a neurosurgical emergency that requires early diagnosis and treatment. An 88-year-old man presented to the emergency department with complaints of weakness in the legs, walking deficit, incontinence and back pain for the last two days. He had been on warfarin therapy for 5 years for atrial fibrillation. There was no antecedent trauma. The neurological examination revealed hypoesthesia below the T6 level, anaesthesia below the T10 level and complete paraplegia of both lower extremities. The INR level was 7.81 on admission. Magnetic resonance imaging revealed a posterolateral epidural haematoma extending from T2 to L5. He was given fresh frozen plasma and vitamin K in the emergency department. Emergency thoracic and lumbar laminectomy was performed by neurosurgeons. The probability of SSEH should be investigated in any patient under anticoagulation therapy who presents with signs of spinal compression in the emergency department.

Somaesthetic perception of the vertical in spinal cord injured patients: A clinical study

PurposeThe perception of verticality results from the integration of vestibular, visual and somatosensory information. Spinal cord injured patients with complete paraplegia have total somatosensory deafferentation below a certain metameric segment. In our study, we were interested in the implication of somatosensory signal in the construction of verticality and in the possible effect of somatosensory loss on spatial representation. MethodWe analysed haptic and postural aspects of perceived verticality in 14 spinal cord injured patients with complete paraplegia and in an age- and gender-matched group of 13 controls. We also conducted a structured interview on the existence of vertigo or postural instability in daily life. ResultsThe spinal cord injured patients perceived verticality without any significant directional bias in the orientation of the vertical but with a greater uncertainty than control subjects, both in haptic and postural modalities. If paraplegic did not report vertigo, half described an altered spatial perception without vision. ConclusionThe present results confirm the importance of sensory input from the trunk and the lower limbs in the perception of the vertical. However, visual and vestibular information appear to compensate for somatosensory deafferentation.

Gunshot injury without direct injury to the cord may lead to complete paraplegia.

Paraplegia following gunshot injury without direct injury to the cord is extremely rare. We describe the case of a 31-year-old woman who was admitted to our trauma resuscitation unit for a penetrating gunshot wound to the abdomen with hemorrhagic shock and paraplegia. Computed tomography (CT) scan of the abdomen showed severe hepatic and pulmonary injuries, with the trajectory of the missile away from the spinal canal. Magnetic resonance imaging (MRI) confirmed a spine contusion from T8 to T10. After 24months, no significant neurologic improvement occurred. Physicians managing severe trauma should be aware of the possibility to observe severe neurologic deficit following gunshot wounds even without violation of the spinal canal. These injuries might be in relation to the kinetic energy emission to the surrounding tissue by the missile.

Traumatic Pediatric Pneumorachis

Case report. To report on a case of traumatic pneumorachis in a child and to review the existing literature. Pneumorachis, the presence of air in the spinal canal, is an extremely rare finding. It may be caused by diverse pathologies such as incidental durotomy, barotrauma, pneumothorax, and trauma. In the polytrauma patient, it may be an indication of an occult spinal fracture. The case of a 15-year old with complete paraplegia presenting with pneumorachis is presented. The initial computed tomography scan showed air in the spinal canal as well as surrounding subpleural and intramuscular spaces. However, there was near normal vertebral alignment with no fractures seen. Magnetic resonance imaging taken after the patient was stabilized showed a complete transaction of the spine at T3-T4 with ligamentous injury. A posterior instrumentation and fusion was performed. In the pediatric patient presenting with neurologic deficits and pneumorachis, ligamentous injury of the spine, even in the absence of bony injury, should be suspected.