Computed Tomography Myelogram Research Articles

Spontaneous intracranial hypotension

Since the introduction of magnetic resonance imaging (MRI), spontaneous intracranial hypotension has been diagnosed much more frequently. The aim of this review is to discuss the symptoms and signs of the condition, in particular the characteristics of the associated headache, with sudden onset after sitting or standing, so that it can be included under the rubric of 'thunderclap headache'. This type of headache, like post lumbar puncture headaches, may be caused by cerebral vasodilatation and exacerbated by lowered pressure of the cerebrospinal fluid (CSF). Other symptoms include neck stiffness, nausea, vomiting, vertigo, tinnitus, deafness, and cognitive abnormalities. The clinical picture can sometimes mimic frontotemporal dementia, and the behaviour of some patients can sometimes be described as hypoactive-hypoalert, with somnolence, impaired attention, and stereotyped motor activity. Sagging of the brain, caused by leakeage of the CSF, can cause lesions in the brainstem with stupor, gaze palsies, and cranial nerve palsies. The condition can be a risk factor for cerebral venous thrombosis because of slowing of the blood flow and distortion of the blood vessels. The clinical picture may well suggest the diagnosis, but the headache may possibly indicate a subarachnoid haemorrhage. However, MRI will help to confirm the diagnosis and to localize the site of the CSF leak. MRI myelograms are of particular value, but if they are equivocal a computed tomography myelogram should be performed. The leakage of CSF is due to a tear in the dura, most frequently where the spinal roots leave the subarachnoid space. If this does not heal with bedrest, an epidural blood patch or a percutaneous injection of fibrin glue may be needed. More information is required on long-term follow-up.

Rehabilitation Considerations of a Brachial Plexus Injury With Complete Avulsion of C5 and C6 Nerve Roots in a College Football Player: A Case Study

Severe brachial plexus injuries are rare in sports, but they have catastrophic results with a significant loss of function in the involved upper extremity. Nerve root avulsions must be timely managed with prompt evaluation, accurate diagnosis, and surgical treatment to optimize the potential for a functional outcome. This case report describes the mechanism of injury, diagnostic evolution, surgical management, and rehabilitation of a college football player who sustained a traumatic complete nerve root avulsion of C5 and C6 (upper trunk of the brachial plexus). Diagnostics included clinical evaluation, magnetic resonance imaging, computed tomography myelogram, and electromyogram. Surgical planning included nerve grafting and neurotization (nerve transfer). Rehabilitation goals were to bring the hand to the face (active biceps function), to stabilize the shoulder for abduction and flexion, and to reduce neuropathic pain. Direct current stimulation, bracing, therapeutic exercise, and biofeedback were used to maximize the use of the athlete’s upper extremity. Although the athlete could not return to sport or normal function by most standards, his results were satisfactory in that he regained an ability to perform many activities of daily living.

Poster 325: Functional Decline in a Tetraplegic Patient Following CT Myelogram in the Evaluation of Discogenic Pain: A Case Report

Setting: Spinal cord injury inpatient unit. Patient: A 65-year-old man with incomplete tetraplegia. Case Description: The patient had traumatic injury in 1958, leading to incomplete tetraplegia. Patient had excellent recovery with ambulation without assistive devices and independent in most activities. For the past 10 years he has had lower back and bilateral lower-extremity pain. The pain was not relieved by physical therapy or epidural injections. It was unclear if the patient was suffering from spondylosis or lumbar radiculopathy. As the years continued, progressive weakness occurred in the bilateral lower extremities. The patient was found to have a syrinx 4 years ago and underwent decompression, which unfortunately led to worsening lower extremity weakness and spasticity. The patient was stable until October 2007, when he had a computed tomography (CT) myelogram to rule out discogenic pain. The patient suffered after the procedure from worsening functional status, lower extremity strength, and spasticity. Assessment/Results: The physical examination revealed intact sensation at the C4 level with incomplete sensory injury below this level. Examination also revealed B/L upper and lower extremity weakness. Bilateral lower extremity had 1/5 hip flexors, 3/5 knee extensors, 0/5 ankle dorsiflexors, 1/5 long toe extensors, 2/5 ankle plantar flexors. Upper extremity strength was 4/5 elbow flexors, 4/5 wrist extensors, 1/5 right elbow extensors, 3/5 left elbow extensors, 4/5 right finger flexors, 3/5 left finger flexors, 1/5 right finger abductors, 0/5 left finger abductors. Motor strength was less than had been previously observed prior to CT myelogram. Patient was admitted for full rehabilitation to the inpatient service. Conclusions: The history and physical examination indicate a likely functional decline after administration of a CT myelogram to rule out discogenic back pain. It is imperative that the risks and benefits be weighed significantly with these imaging studies, especially in cases of spinal cord injuries. Even slight decreases in strength and sensation can lead to devastating functional losses. In this situation the cost of the side effects of myelography far outweighed the potential benefits for diagnosing pain.

Development of Spontaneous Intracranial Hypotension Concurrent With Grade IV Mobilization of the Cervical and Thoracic Spine: A Case Report

Donovan JS, Kerber CW, Donovan WH, Marshall LF. Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report. Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH 2O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.

Poster 192: Treatment of Cerebrospinal Fluid Leakage-Induced Headache by Thoracic Transforaminal Epidural Blood Patch: A Case Report

Setting: Private pain management office and surgery center. Patient: A 51-year-old white man with intractable headache. Case Description: The patient developed severe headache without any prior trauma or injury on October 13, 2006. Standing aggravated his headache while laying flat alleviated some of his headache symptom. Nuclear medicine scan indicated cerebrospinal fluid (CSF) leakage. Subsequent computed tomography myelogram of cervicothoracic spine showed dilatation of right C7, bilateral C8 (left > right), and right T1 nerve root sleeves, as well as abnormal collection of contrast within the right T1-2 neural foramen. The patient underwent right paramedian T1-2 interlaminar epidural blood patch with 12mL of autologous blood. Unfortunately, this procedure provided no headache relief. He was then prescribed fentanyl patches and oxycodone (Roxicodone). 2 weeks later, he received a right T1-2 transforaminal epidural blood patch with 6mL of autologous blood via a 22-gauge, 3.5-in spinal needle. Assessment/Result: The patient reported 100% headache relief following the right T1-2 transforaminal epidural blood patch procedure. He remained headache-free at follow-up 3 weeks after the injection. He was not taking any pain medication. Discussion: To our knowledge, this is the first report of thoracic transforaminal epidural blood patch used to treat headache secondary to CSF leakage at nerve root sleeve. Although the etiology of his CSF leakage at the nerve root sleeve is of interest to study, it is also interesting that the patient did not respond to the epidural blood patch through a paramedian interlaminar approach. The transforaminal approach probably provided better seal of the hole in the nerve root sleeve with a blood clot than the interlaminar epidural blood patch did in this case. Conclusions: Transforaminal epidural blood patch is a choice for treating the headache induced by CSF leakage at the nerve root sleeve.

Pigmented villonodular synovitis originating from the lumbar facet joint: a case report

The authors successfully treated a rare case of pigmented villonodular synovitis (PVNS) that originated from the lumbar facet joint (L4-5). A 43-year-old man presented with a complaint of left severe sciatica causing difficulty in walking. Magnetic resonance imaging (MRI) demonstrated an extradural mass on the left side at L4 and the mass compressed the dural tube and was continuous with the left L4-5 facet joint. A computed tomography myelogram revealed an extradural defect of contrast medium at the L4 level and an erosion of the L4 lamina. A total synovectomy with unilateral osteoplastic laminectomy was performed. The histological findings were a diagnosis of PVNS. The patient's symptoms resolved completely and the MRI at postoperative 3 years demonstrated no recurrence of PVNS. It is important to totally remove the synovium, which is the origin of PVNS in order to prevent the recurrence. We think that our procedure is reasonable and adequate for lumbar PVNS.

Intrathecal Catheter Granuloma Associated with Isolated Baclofen Infusion

Intrathecal (IT) baclofen is an effective management strategy for controlling spasticity in patients unresponsive to maximal oral therapy. We present the case of a 57-yr-old woman who was rendered quadriplegic after a complete spinal cord transection at the C6 level. Her course was complicated by severe spasms, which were uncontrolled despite titrating orally administered baclofen to 80 mg/d. IT baclofen testing was performed with good response, and administration was commenced via an implanted intrathecal pump 6 mo after the injury at an initial dose of 200 microg/d. Catheter revision was required 2 wk later as a result of catheter displacement. The initial IT baclofen dose was gradually increased to achieve good control at a level of 400 microg/d. After a period of stability lasting 38 mo, her lower limb spasms dramatically increased in severity and remained poorly controlled despite repeated dose increases. Contrast pumpogram and computed tomography myelogram were performed to exclude a mechanical cause for this apparent increase in baclofen requirement. These investigations revealed neither catheter displacement nor fracture as suspected but, rather, displayed the presence of a catheter tip-associated mass. Catheter tip granuloma has not previously been described in a patient receiving IT baclofen alone. This suggests that although uncommon, the possibility of catheter-associated granuloma must be considered in all patients receiving IT baclofen presenting with altered neurological function or significant increase in drug requirement.

Imaging modalities for cervical myelopathy: Medical decision making and surgical outcomes

Cervical myelopathy describes the pathologic condition of spinal cord compression within the cervical spine resulting in dysfunction of spinal cord functions. This may manifest as an alteration of gait, loss offine motor skills of the hands and arms, or in more advanced cases, with alteration of normal bowel and bladder control. 1 The most common clinical scenario occurs in a patient with spondylotic changes with multilevel disc degeneration of the cervical spine (cervical spondylotic myelopathy, CSM). Other pathologic processes may include large cervical disc herniations, ossification of the posterior longitudinal ligament (OPLL), ossification of the yellow ligament (OYL), or primary or malignant tumors of the spine. Diagnostic imaging tests include plain radiographs (typically AP, lateral, flexion, and extension views), computed tomography (CT), magnetic resonance imaging (MRI), and myelography with and without CT. Each type of imaging modality offers unique information, thus frequently mandating the use of several tests to gather the necessary clinical information to make appropriate treatment decisions. Three-dimensional imaging techniques such as CT scans and MRI have greatly expanded our understanding of cervicalmyelopathy.Theuseofthesediagnostictoolscontinuesto enhance our understanding of the pathoanatomy. Positive and negative prognostic indicators are emerging from the increasing detail seen with current imaging techniques. Nurick’s natural history study has demonstrated the stepwise decline in function which is seen in untreated cervical spondylotic myelopathy. 2 Identification of risk factors which impact surgical and nonoperative treatment will give the clinician the ability to best counsel and advise patients with cervical myelopathy. Advanced age at the time of diagnosis, longer duration of myelopathy symptoms, multiple levels of spinal cord compression, and severity of spinal cord compression are all associated with diminished recovery potential following spinal cord decompression. 3-7 Each type of imaging study provides a component of information which is then combined with the patient’s history and physical examination to determine the treatment plan. Plain radiographs along with at least one form of three-dimensional imaging (CT, CT myelogram, or MRI) represent the essential basic information that is required before consideration of surgical intervention.

Carcinoma do esôfago com invasão do canal medular: relato de caso e revisão da literatura

Os autores apresentam o caso de paciente do sexo masculino, 62 anos de idade, com emagrecimento há quatro meses e diminuição da força muscular associada a parestesias em membros inferiores há dois dias. Foi submetido a mielotomografia, que demonstrou massa no mediastino posterior com destruição dos corpos vertebrais e invasão do canal medular, além de espessamento irregular das paredes do esôfago. Na evolução, foi submetido a estudo contrastado do esôfago, que demonstrou falha de enchimento irregular. A biópsia confirmou a presença de carcinoma de células escamosas. Este é o primeiro relato na literatura latino-americana (Lilacs) de carcinoma de esôfago com invasão de canal medular e manifestação inicial de síndrome de compressão medular.

Ganglion cyst in the ligamentum flavum of the cervical spine causing myelopathy: report of two cases

BACKGROUND Ganglion cyst in the ligamentum flavum is commonly found in the lower lumbar region; occurrence in the cervical region is extremely rare. We report two cases of ganglion cyst in the cervical region and the clinical, pathological, and radiological findings. METHODS The first patient was an 81-year-old man who was admitted to our hospital with gradually progressive gait disturbance and radiating pain in both arms and legs, which was dominant on the left side. The second patient was a 65-year-old man with progressive muscle weakness of the extremities who was admitted with radiating pain in the right arm. In both cases, the cervical spinal cord had been compressed by the cystic mass with degeneration of the ligamentum flavum (the former left, the latter right) at the level of C3-4. RESULTS The extradural-intraspinal cystic masses, which were revealed by computed tomography (CT) and magnetic resonance imaging (MRI) to be situated antero-laterally to the cervical laminae, were removed surgically without difficulty. After surgery, the symptoms and neurologic signs improved in both cases. CONCLUSIONS Ganglion cyst in the ligamentum flavum of the cervical spine is a very rare lesion causing radiculo-myelopathy. In both our cases, a correct diagnosis could be established preoperatively based on CT myelogram and MRI findings, and the results of surgery were excellent.

Editorial Comment

The symposium entitled “New Developments in Lumbar Spinal Stenosis”, was designed to present an update of techniques, long-term results, and surgical recommendations for difficult or associated problems in the treatment of patients with this disorder. The Guest Editors are grateful to the following authors for their immense contributions. K. Hansraj and colleagues presented a new clinical classification system describing typical and complex lumbar spinal stenoses. The authors presented clinical, outcome, and survivorship results. P. O’Leary and S. McCance presented a new minimally invasive technique for decompression of the lumbar spine. The technique of distraction laminoplasty is presented. K. Bridwell and colleagues described the surgical treatment of patients with spinal stenosis with fixed sagittal imbalance. Surgical strategies including an algorithm are presented. E. Simmons and E. Simmons discussed surgical treatment of patients with lumbar spinal stenosis with associated scoliosis. The authors emphasize decision making and surgical techniques. H. Bassewitz and H. Herkowitz presented the current concepts of surgical treatment of patients with lumbar spinal stenosis with associated spondylolisthesis. J. Jane and colleagues described the current recommendations for surgical treatment of patients with lumbar spinal stenosis from a neurosurgical point of view. Special emphasis was given to decision making regarding fusion. Considerations were made regarding safe surgical technique. R. Benz and S. Garfin discuss the current techniques and salient factors in surgical decompression of the lumbar spine. D.S. Weiss presented the current techniques of spinal cord and nerve root monitoring during surgical treatment. S. Reeg presented general recommendations for perioperative treatment based on the medical comorbidities, age-related pathophysiologic changes to the cardiovascular, pulmonary, and central nervous systems. T. Faciszewski and colleagues presented important recommendations for cardiac evaluation of patients undergoing elective spinal surgery for symptomatic spinal stenosis. R. Benz and colleagues discussed comorbid factors in predicting complications in elderly patients undergoing lumbar decompression surgery. L. St. Louis presented a discussion on the uses of the magnetic resonance imaging and computed tomography myelogram in the assessment of patients with lumbar spinal stenosis. The author focused on the evaluation of failed surgeries, instability, associated spondylolisthesis, associated scoliosis, associated junctional stenosis, and associated osteoporosis. E. Arbit and S. Pannullo provided a brief history, classification, clinical presentation, and pertinent anatomy of lumbar spinal stenosis. Emphasis was given to the etiology, pathologic features, and correlation with where the thecal sac and nerve root impingement occurs. M. Bodack and M. Monteiro described therapeutic exercises in the treatment of patients with lumbar spinal stenosis. Techniques and specific recommendations are made for the conservative treatment of these patients. A. Simotas and colleagues presented clinical results of nonoperative treatment for lumbar spinal stenosis.

Primary Intramedullary Primitive Neuroectodermal Tumor of the Spinal Cord: Case Report and Review of the Literature

Primary intraspinal primitive neuroectodermal tumors (PNETs) are rare. We report a case and review the literature. A 22-year-old woman presented with rapidly progressive paraparesis and neurogenic bladder. Preoperative computed tomography myelograms revealed a complete block at T12-L1, consistent with an intramedullary lesion. An urgent operation was performed with gross total tumor removal. The pathological findings were consistent with a PNET. Recurrence was noted within 10 weeks of surgery and has been somewhat responsive to chemotherapy and radiotherapy thus far. A review of the English literature shows that only 13 cases of primary intraspinal PNETs have been reported to date, and the present case is the second one in which the tumor was purely intramedullary. Most of the reported patients survived less than 2 years. Primary intraspinal PNETs are rare tumors and carry a poor prognosis.

Destructive spondyloarthropathy of the cervical spine in patients with chronic renal failure.

Eleven patients with chronic renal failure and destructive spondyloarthropathy of the cervical spine were evaluated with plain radiographs, flexion-extension views, computed tomography myelogram, or magnetic resonance imaging to determine the results of surgical and nonsurgical treatment. To determine if cervical spine fusion is an effective method of treatment for patients with chronic renal failure and destructive spondyloarthropathy. Several reports have described the pathogenesis and appearance of this condition, but little has been reported about the orthopedic management of destructive spondyloarthropathy of the cervical spine. Three patients had no spinal surgery, three patients had laminectomies alone, three patients had laminectomies with anterior fusions, and two patients had laminectomies with posterior fusions. Radiographs, computed tomography myelograms, and magnetic resonance images were evaluated to determine the results of treatment. Histologic examinations were performed in two patients. Patients with laminectomy alone had no improvement in pain or neurologic function (one died in the immediate postoperative period), one of three patients with anterior fusions had some improvement (one died in the immediate postoperative period), and both of those patients with posterior fusions improved, although both died within a year of surgery from unrelated causes. Even though the osteopenia present in patients with chronic renal failure tends to allow wire pull-out and makes internal fixation of the spine difficult, successful cervical spinal fusion can relieve pain and improve neurologic deficits in selected patients with chronic renal failure and destructive spondyloarthropathy, allowing them to remain more active for longer periods of time.

Routine preoperative MRI and SEP studies in adolescent idiopathic scoliosis.

In this prospective study, 72 patients with the clinical diagnosis of adolescent idiopathic scoliosis underwent routine preoperative magnetic resonance imaging (MRI) scans and neurologic consultations. Forty-eight patients also had preoperative somatosensory evoked potentials (SEPs). All patients had normal neurologic examinations. Abnormal findings included two patients with Chiari type I malformation and one with a finding of a fatty collection in a vertebral body. In four cases, interpretation of the MRI was suspicious or equivocal, necessitating a computed tomography myelogram or other additional studies for clarification. Abnormal preoperative SEP results were obtained in three patients, none of which proved significant. All surgical patients underwent instrumentation and fusion without incident. The results indicate that routine preoperative SEP is not necessary. Routine preoperative MRI is probably not indicated in adolescent idiopathic scoliosis if the patient has a normal neurologic examination.

Lombalgies retardées après rachianesthésie

A 50-year-old man had an inguinal hernia repair under spinal anaesthesia with bupivacaine. On the 2nd postoperative day, he complained of backache and paresis at the posterior part of the lower extremities, weil relieved by non-steroidal anti-inflammatory drugs. On the 6th postoperative day, he came back to hospital, because of low back pain associated with a heavy feet sensation. The hypothesis of a neurological complication of the spinal anaesthesia was considered. The Interview of the patient revealed a history of lumbar disk disease, not reported during the preoperative visit. After an in depth clinical examination, two causes seemed possible: subarachnoid haematoma and lumbar disk protusion. Against the first diagnosis were the initial clinical signs. However, in many cases, objective neurological deficit arise too late Reçu le 28 aoQt 1994, accepté après révision le 11 janvier 1995. to allow efficient neurosurgical treatment. Thus, a MRI examination was performed which is non invasive in comparison with a computed tomography myelogram. In our patient, it did not detect a true lumbar disk protusion, but a simple degenerative disease of the L5-S1 disk. In suppressing the lumbar lordosis, spinal anaesthesia probably allowed a distension of spinal capsules and tendons, responsible for the troubles.

Magnetic resonance imaging of the spine: An initial experience.

Retrospective analysis was carried out for 477 magnetic resonance imaging (MRI) studies of the spine. The overall mean age ± SD of the entire series was 38.7 ± 12.9 years. Degenerative spinal lesions and prolapsed intervertebral disks were detected in 62% and 73% of all the studies and of those which showed spinal abnormalities respectively. Postoperative granulation tissue was the third most common abnormality detected (12%). MRI was superior to computed tomography (CT) and CT myelograms in the diagnosis of disk prolapse (97% versus 66%), degenerative disease of the spine (94% versus 48%), and postsurgical granulation tissue (100% versus 6%). Comparing the numbers of CT and CT myelograms requested in the year prior to the installation of the MRI to the numbers requested during the year where the MRI was functioning did not show any change in the frequency of ordering CT studies. We conclude that our hospital-based series has shown an interesting pattern for spinal disorders. The first year experience of the utilization of MRI in various spinal diseases has been satisfactory with prevailing diagnostic superiority for that modality.

Percutaneous Nucleotomy in Lumbar Disc Herniation

Patients in percutaneous nucleotomy who met our new criteria for patient selection in 1992 showed 73% successful results. The success rate was not satisfactory in comparison with that (88%) in the open surgery through posterior approach (herniotomy), however. The purpose of this report is to re-evaluate 70 patients with follow-up more than 2 years based on imaging and clinical findings before percutaneous nucleotomy. In results, supplementary criteria such as two types of the combination of computed tomography discogram and computed tomography myelogram, continuation of the contrast medium in lateral view of discogram, and clinical findings characterized by sciatic pain were obtained to improve the success rate. Eighty-one percent of patients who met the new criteria in 1992 and the supplementary criteria were identified in the successful group. The authors believe that percutaneous nucleotomy should be considered as an independent operative procedure with results similar to open surgery, if the patient is selected strictly based on these criteria and supplementary criteria.

Acute traumatic cervical epidural hematoma from a stab wound

Cervical spinal epidural hematoma is an infrequent entity that usually requires emergency decompressive therapy because of rapid neurologic dysfunction. We present the case of a 34-year-old man who presented to the emergency department with minimal symptomatology after a stab wound to the neck. A computed tomography myelogram of the cervical spine revealed a cervical spinal epidural hematoma. This case illustrates an unusual presentation as well as etiology of cervical spinal epidural hematoma.