Cord Signal Changes Research Articles

Cervical Spondylolysis

Case report. To describe a rare case of cervical spondylolysis with an adjacent secondary dysplastic change, and to review the current literature regarding cervical spondylolysis. Three patients presented with minor trauma history and radiographical C6 level spondylolysis. Cervical spines were analyzed with plain radiography, multidetector computerized tomography, and magnetic resonance imaging. In all 3 patients, plain radiographs revealed a bilateral cleft of the C6 articular mass. The patients presented with long-term minimal discomfort of the posterior neck. In 2 patients, a trauma event increased the pain and produced neurologic deficits. In addition, an adjacent dysplastic change was present on imaging studying in 2 of the patients, 1 of whom also presented with a cord signal change above the spondylolytic level. Early diagnosis and appropriate management of cases of spondylolysis are important. In addition, surgical plans for cervical spondylolysis should be considered if the adjacent levels are unstable or fragile.

The challenge of acute non-compressive transverse myelopathies

The challenge of acute non-compressive transverse myelopathies

Guillain-Barré Syndrome Combined with Acute Cervical Myelopathy

Authors describe a patient who developed a myelopathy associated with Guillain-Barré syndrome and cervical myelopathy. We provide radiological evidence of non-compressive herniated cervical intervertebral disc with cord signal changes and show the clinical and electrophysiological result of coexisting Guillain-Barré syndrome and cervical myelopathy. We tried to introduce and review the case of Guillain-Barré syndrome which was combined with cervical myelopathy to let us recollect the presumptive cause.

The management in the c2-c3 disc herniations. a clinical study

Cervical disc herniation at C2-C3 level is an uncommon condition. In this paper, the management C2-C3 disc herniation and long-term follow-up data of 5 cases is reported. 1100 patients who have been operated in our department for cervical disc herniation between 2000 and 2009 were studied retrospectively. A total of 5 patients were found to have been operated for C2-C3 herniation in that period . The preferred procedure was anterior cervical discectomy with fusion via retropharyngeal approach. The incidence of C2-C3 disc herniations was 0.45%. The mean patient age was 63 years (41- 82 years). Upper extremity paresis was the predominant neurological sign. Magnetic resonance images (MRI) revealed central, large and hard disc herniations in 4 cases and accompanying cord signal changes in 4 cases. Successful anterior decompresion was performed in 5 patients. Correct fusion was achieved in 4 patients, and one patient died of an operation unrelated cause early in the follow-up period. C2-C3 disc herniation is rare but may result with severe myelopathy. This kind of herniations tend to be central and large. The present study demonstrates that diagnosis and adequate anterior decompression in C2-C3 disc herniations may provide an excellent outcome.

Posttraumatic subacute ascending myelopathy in a 24-year-old male patient

Posttraumatic subacute ascending myelopathy is a rare late complication of spinal trauma. We present a case of 24-year-old male patient of motor vehicle accident who initially presented with T12 vertebral fracture and associated cord compression and signal changes in lower dorsal cord causing paraplegia with bladder and bowel involvement. In the subsequent week, he developed complete paraplegia with cord signal abnormality on magnetic resonance imaging extending cephalad from the injury site to involve the cervicomedullary junction. The patient clinically and radiologically improved over 6 weeks on steroid treatment.

Leukoencephalopathy in adults: Is it adrenoleukodystrophy? A case report and molecular analysis

Adult onset cerebral X-ALD (AOCALD) is a rare disease, but should be considered an important differential diagnosis in adults presenting with leukencephalopathy. We here report the case of a 40-year-old man with a history of progressive cognitive decline who presented with a first-time seizure. Initial workup included magnetic resonance imaging (MRI) of the brain which showed extensive frontotemporal leukoencephalopathy. A subsequent brain biopsy showed demyelination and perivascular macrophages. Further workup included serum very long chain fatty acid concentration (VLCFA), which was found to be elevated. An MRI of the total spine showed diffuse atrophy, but no intrinsic cord signal changes, and the diagnosis of AOCALD was established. Genomic sequencing revealed a nonsense mutation in exon 8 (2188G→A, W601X), to our knowledge not reported in context with AOCALD. A family pedigree was obtained, and other family members at risk were identified and underwent genetic counseling. In conclusion, AOCALD is an important differential diagnosis in adults presenting with cognitive decline. While treatment for affected patients is often supportive only, molecular diagnosis serves as a basis for genetic counseling, identification of relatives at risk and timely referral to a treatment program.

Thoracic Disc Herniation in a Patient With Tethered Cord and Lumbar Syringomyelia and Diastematomyelia

Case report. To describe the diagnostic challenges in a patient suffering from thoracic disc herniation (TDH) and spina bifida complicated by multiple lumbar spinal cord abnormalities, i.e., tethered cord, lumbar syringomyelia, and diastematomyelia. Advances in neuroimaging, i.e., magnetic resonance imaging, increase the sensitivity to disclose both clinically relevant but also other spine and spinal cord abnormalities. TDH accounts for less than 1% of all surgically treated disc herniations. Syringomyelia and diastematomyelia are comparably rare and present with varying degrees of spinal cord dysfunction. A 54-year-old women presented with progressive pain and sensorimotor symptoms in the lower back and limbs. Neurologic examination revealed lower limb spastic motor deficits and spinal ataxia. Magnetic resonance imaging revealed a T6-T7 disc herniation, with spinal cord signal change in addition to a spina bifida with sacral tethered cord, lumbar syringomyelia, and diastematomyelia. Combined neurophysiological testing identified a neurologic lesion in the mid thoracic cord, with normal lower limb nerve conduction and reflex recordings, but pathologic somatosensory-evoked potential and T6 paravertebral electromyography. The patient was diagnosed with a clinically relevant T6-T7 disc herniation and underwent successful surgical decompression resulting in electrophysiological improvements. This unique case highlights the value of electrophysiology in the evaluation of a complex spinal disorder in a patient suffering from acquired TDH in the presence of extensive congenital spine and spinal cord abnormalities. Clinical symptoms and signs can be complemented by neurophysiological techniques to improve diagnostic accuracy and improve the basis for treatment recommendations. In cases involving multiple spinal abnormalities, a comprehensive neurophysiological assessment beyond paravertebral electromyography studies, including nerve conduction and somatosensory-evoked potential recordings, is recommended to assist in confirming the diagnosis.

The use of flexion-extension magnetic resonance imaging for evaluating signal intensity changes of the cervical spinal cord

The authors present 2 cases involving patients who presented with myelopathy. Magnetic resonance imaging of the cervical spine showed spinal cord signal changes on T2-weighted images without any spinal cord compression. Flexion-extension plain radiographs of the spine showed no instability. Dynamic MR imaging of the cervical spine, however, showed spinal cord compression on extension. Compression of the spinal cord was caused by dynamic anulus bulging and ligamentum flavum buckling. This report emphasizes the need for dynamic MR imaging of the cervical spine for evaluating spinal cord changes on neutral position MR imaging before further workup for other causes such as demyelinating disease.

Prevalence of Physical Signs in Cervical Myelopathy

Prospective case-control study. To determine the prevalence and utility of commonly tested myelopathic signs in surgically treated patients with cervical myelopathy (CM). Although physical signs are sought in making the diagnosis of CM, their importance remains unclear, as patients with CM may have normal examinations while those without CM can demonstrate "myelopathic" signs. Patients presenting with cervical complaints and advanced imaging were evaluated over a 6-month interval in a single surgical practice. The CM group consisted of those with (1) a history of myelopathic symptoms and (2) correlative spinal cord compression on imaging, who then (3) underwent surgery and (4) improved Nurick score by > or = 1 grade after surgery. The controls consisted of patients with neck/radicular complaints but no myelopathic symptoms and no cord compression on imaging. Myelopathic signs included hyperreflexia or provocative signs (Hoffman inverted brachioradialis reflex, clonus, Babinski). There were 39 CM patients and 37 controls. Myelopathic signs were more prevalent in the CM group (79% vs. 57%; P = 0.05), with significantly higher rates of all provocative signs but not hyperreflexia. Overall, myelopathic signs were not highly sensitive in diagnosing the presence of CM, as 21% of CM patients failed to demonstrate any myelopathic signs. There was no correlation between the presence of myelopathic signs and diabetes or preoperative Nurick score. However, those with cord signal changes were significantly more likely to demonstrate myelopathic signs. Although myelopathic signs are significantly more common in CM patients, they may be negative in approximately one-fifth and can not be relied on to make the diagnosis. In patients who lack myelopathic signs but otherwise seem myelopathic with no alternative explanations, symptoms combined with correlative imaging studies must be used to base treatment decisions, as the absence of signs does not preclude the diagnosis of myelopathy nor its successful surgical treatment.

Acute symptomatic cerebellar tonsillar herniation following intraoperative lumbar drainage

Complications of tonsillar herniation associated with lumbar drainage have been reported in the literature. However, acutely symptomatic tonsillar herniation after intraoperative lumbar drainage is rare. The following case illustrates the risk associated with cerebrospinal fluid (CSF) drainage in the setting of tonsillar herniation. The use of lumbar drainage during cranial surgery is a common practice for reducing intracranial pressure and enhancing exposure, but is not without complications. In addition to the complications of the insertion procedure itself, the change in pressure gradient between the intracranial and the suboccipital compartments is of key importance. The authors present the case of a patient who underwent a subtemporal craniotomy for resection of mesial temporal cavernous malformation with intraoperative lumbar drainage. The patient had a preexisting, asymptomatic 4-mm Chiari malformation and progressive neurological deficits resulting from further cerebellar tonsillar herniation in the early postoperative period developed, which required a lumbar blood patch, decompressive suboccipital craniectomy, and C-1 laminectomy with duroplasty. After placement of the lumbar drain and subsequent CSF drainage, the change in CSF pressure gradient above and below the foramen magnum probably led to the herniation. Unfortunately, the patient has lasting neuropathic pain and cervical cord signal changes on MR images.

The Efficacy of the Modified Classification System of Soft Tissue Injury in Extension Injury of the Lower Cervical Spine

To classify comprehensively the severity of soft tissue injury for extension injuries of the lower cervical spine by magnetic resonance imaging (MRI). To investigate severity of extension injuries using a modified classification system for soft tissue injury by MRI, and to determine the possibility of predicting cord injury by determining the severity of soft tissue injury. It is difficult to diagnose extension injuries by plain radiography and computed tomography. MRI is considered to be the best method of diagnosing soft tissue injuries. The authors examined whether an MRI based diagnostic standard could be devised for extension injuries of the cervical spine. MRI was performed before surgery in 81 patients that had experienced a distractive-extension injury during the past 5 years. Severities of soft tissue injury were subdivided into 5 stages. The retropharyngeal space and the retrotracheal space were measured, and their correlations with the severity of soft tissue injury were examined, as was the relation between canal stenosis and cord injury. Cord injury developed in injuries greater than Grade III (according to our devised system) accompanied by posterior longitudinal ligament rupture (P < 0.01). As the severity of soft tissue injury increased, the cord signal change increased (P < 0.01), the retropharyngeal space and the retrotracheal space increased, and swelling severity in each stage were statistically significant (P < 0.01). In canal stenosis patients, soft tissue damage and cord injury were not found to be associated (P = 0.45). In cases of distractive-extension injury, levels of soft tissue injury were determined accurately by MRI. Moreover, the severity of soft tissue injury was found to be closely associated with the development of cord injury.

GUILLAIN‐BARRÉ SYNDROME IN ELDERLY PEOPLE

To the Editor: A 92-year-old woman presented with reduced mobility following an Escherichia coli urinary tract infection. She had previously ambulated independently using a cane. On presentation, she ambulated using a four-wheeled frame. Apart from mild weakness in both legs and generalized brisk reflexes in all limbs, her neurological examination was unremarkable. Computed tomography of the brain showed small vessel ischemia but no acute changes. During the following 10 days, she developed several episodes of diarrhea. Fecal microscopy, culture, and viral polymerase chain reaction were negative. She became progressively weak in all limbs and nonambulatory. Upper limb and knee reflexes remained brisk, but ankle jerks and plantar responses were absent. Sensation was impaired in glove and stocking distribution. Mild weakness in facial movement was noted. On Day 10, a magnetic resonance imaging scan of the cervical cord showed severe central canal stenosis from C3/4 to C5/6 without cord signal change. A nerve conduction study demonstrated markedly reduced compound motor action potentials in all limbs consistent with acute motor axonal neuropathy (a variant of Guillain-Barré syndrome). She declined lumbar puncture. Anti-GM1 antibody was negative. It was concluded that Guillain-Barré syndrome accounted for her rapid neurological decline, and cervical myelopathy contributed to hyperreflexia and to some degree of her baseline limb weakness. She was treated with a 5-day course of intravenous immunoglobulin, which she tolerated without complications. She ambulated independently with a four-wheeled frame after 6 weeks of rehabilitation. Guillain-Barré syndrome is an immune-mediated neuropathy. The age-specific curve shows a bimodal distribution, with peaks in incidence in young adults (aged 15–34) and in elderly people (aged 60–74). The first peak correlates with the increased risk of cytomegalovirus and Campylobacter jejuni infection in young adults. The peak in elderly people may be related to failing immune suppressor mechanisms, resulting in increased susceptibility to autoimmune disorders.1 In one study, Guillain-Barré syndrome was found to be the third most common cause of polyneuropathy in people aged 65 and older (11% of cases), after diabetes mellitus and neoplasm.2 Diagnosis of Guillain-Barré syndrome in elderly people is easily overlooked. The coexistence of other neurological and nonneurological diseases may alter the manner in which the syndrome presents. Early symptoms and signs are more likely to be dismissed in elderly people. Delayed presentation may occur because of difficulty in obtaining access to referral services.3 Antecedent illness, occurring in approximately two thirds of younger patients, is reported less frequently and is of shorter duration in elderly people. The interval between onset and peak severity was shorter in elderly patients, but no significant differences in disease severity have been reported.3,4 The most common manifestation is acute onset of symmetrical limb weakness with areflexia (in 90%). Symptoms related to peripheral nerve damage, such as paraesthesia, myalgia, and limb weakness, occur with similar frequency in younger and older patients, whereas ophthalmoplegia and facial weakness occurred less often in elderly people.3 Guillain-Barré syndrome has several variant forms, with acute inflammatory demyelinating polyradiculoneuropathy being the most common (85–90% of cases). Acute motor axonal neuropathy, accounting for 5% to 10% of cases, occurs with higher frequency in elderly people (up to 40%).5 Immunomodulation is the first-line therapy, with trials showing similar effectiveness of plasmapheresis and intravenous immunoglobulin (IVIg). Elderly patients treated with IVIg tend to take longer to reach nadir of neurological deficits and have longer hospital stays than those treated with plasmapheresis. Severe complications, such as hypotension, abnormal clotting, and complications related to central venous access, are noticed in 30% of patients treated with plasmapheresis. Patients treated with IVIg usually do not experience major complications.4 Based on these findings, IVIg is preferable to plasmapheresis in elderly people, because it is safer, more convenient, equally effective, and of comparable overall cost.6 Age of 60 and older is a poor prognostic factor.7 Of patients admitted to intensive care units, those who die are older and more likely to have underlying pulmonary disease.8 The duration of hospital stay is greater, and the number of days needed for functional improvement is longer in elderly people.3,9 It has not been found that age affects the relapse rate.7 Guillain-Barré syndrome is underrecognized in elderly people, warranting a high index of suspicion. Large multicenter prospective studies are needed to provide better understanding of Guillain-Barré syndrome in elderly people, particularly in the oldest-old. Conflict of Interest: The editor in chief has reviewed the financial and personal conflict of interest checklist and has determined that the author has no conflicts of interest related to this letter. Author Contributions: Author is sole contributor for this letter. Sponsor's Role: None.

STAB INJURIES TO THE SPINAL CORD

This study was undertaken to document changes on magnetic resonance imaging (MRI) scans after a stab to the spinal cord. The aim of the study was to determine if routine MRI scans for this type of injury would lead to a change in management. All patients with a stab wound to the spinal cord sustained between November 2004 and July 2005 were retrospectively enrolled. All of the patients were examined, a data form was completed, and MRI was performed within 72 hours on arrival at Groote Schuur Hospital. Twenty-two patients were imaged during the study period. MRI results were reported by a neuroradiologist. The most common change seen on MRI scans was a spinal cord tract and cord signal change. Other imaging findings that were documented included cord swelling and extra-axial collections. Progressive neurological deficits developed in two patients, both as a result of sepsis. An intramedullary abscess was found on contrast follow-up imaging in only one of the two patients, and this was surgically drained. Five patients had extradural collections visible on MRI scans; however, all of these patients either had complete cord transection on MRI scans at the time of injury or in cases of incomplete injury (Brown Sequard syndrome), a tract was visibly affecting the hemicord that explained the injury and there was no mass effect from the extradural collection. Routine MRI scans performed on admission of patients with stab injuries to the spinal cord did not lead to surgical intervention unless there was progressive neurological deficit. In such cases, a contrast MRI scan should be performed to rule out sepsis as the most likely cause of deterioration.

Prognostic relevance of the postoperative evolution of intramedullary spinal cord changes in signal intensity on magnetic resonance imaging after anterior decompression for cervical spondylotic myelopathy

Object Areas of intramedullary signal intensity changes (hypointensity on T1-weighted magnetic resonance [MR] images and hyperintensity on T2-weighted MR images) in patients with cervical spondylotic myelopathy (CSM) have been described by several investigators. The role of postoperative evolution of these alterations is still not well known. Methods A total of 47 patients underwent MR imaging before and at the end of the surgical procedure (intraoperative MR imaging [iMRI]) for cervical spine decompression and fusion using an anterior approach. Imaging was performed with a 1.5-tesla scanner integrated with the operative room (BrainSuite). Patients were followed clinically and evaluated using the Japanese Orthopaedic Association (JOA) and Nurick scales and also underwent MR imaging 3 and 6 months after surgery. Results Preoperative MR imaging showed an alteration (from the normal) of the intramedullary signal in 37 (78.7%) of 47 cases. In 23 cases, signal changes were altered on both T1- and T2-weighted images, and in 14 cases only on T2-weighted images. In 12 (52.2%) of the 23 cases, regression of hyperintensity on T2-weighted imaging was observed postoperatively. In 4 (17.4%) of these 23 cases, regression of hyperintensity was observed during the iMRI at the end of surgery. Residual compression on postoperative iMRI was not detected in any patients. A nonsignificant correlation was observed between postoperative expansion of the transverse diameter of the spinal cord at the level of maximal compression and the postoperative JOA score and Nurick grade. A statistically significant correlation was observed between the surgical result and the length of a patient's clinical history. A significant correlation was also observed according to the preoperative presence of intramedullary signal alteration. The best results were found in patients without spinal cord changes of signal, acceptable results were observed in the presence of changes on T2-weighted imaging only, and the worst results were observed in patients with spinal cord signal changes on both T1- and T2-weighted imaging. Finally, a statistically significant correlation was observed between patients with postoperative spinal cord signal change regression and better outcomes. Conclusions Intramedullary spinal cord changes in signal intensity in patients with CSM can be reversible (hyperintensity on T2-weighted imaging) or nonreversible (hypointensity on T1-weighted imaging). The regression of areas of hyperintensity on T2-weighted imaging is associated with a better prognosis, whereas the T1-weighted hypointensity is an expression of irreversible damage and, therefore, the worst prognosis. The preliminary experience with this patient series appears to exclude a relationship between the time of signal intensity recovery and outcome of CSM.

Prognostic relevance of the postoperative evolution of intramedullary spinal cord changes in signal intensity on magnetic resonance imaging after anterior decompression for cervical spondylotic myelopathy

Areas of intramedullary signal intensity changes (hypointensity on T1-weighted magnetic resonance [MR] images and hyperintensity on T2-weighted MR images) in patients with cervical spondylotic myelopathy (CSM) have been described by several investigators. The role of postoperative evolution of these alterations is still not well known. A total of 47 patients underwent MR imaging before and at the end of the surgical procedure (intraoperative MR imaging [iMRI]) for cervical spine decompression and fusion using an anterior approach. Imaging was performed with a 1.5-tesla scanner integrated with the operative room (BrainSuite). Patients were followed clinically and evaluated using the Japanese Orthopaedic Association (JOA) and Nurick scales and also underwent MR imaging 3 and 6 months after surgery. Preoperative MR imaging showed an alteration (from the normal) of the intramedullary signal in 37 (78.7%) of 47 cases. In 23 cases, signal changes were altered on both T1- and T2-weighted images, and in 14 cases only on T2-weighted images. In 12 (52.2%) of the 23 cases, regression of hyperintensity on T2-weighted imaging was observed postoperatively. In 4 (17.4%) of these 23 cases, regression of hyperintensity was observed during the iMRI at the end of surgery. Residual compression on postoperative iMRI was not detected in any patients. A nonsignificant correlation was observed between postoperative expansion of the transverse diameter of the spinal cord at the level of maximal compression and the postoperative JOA score and Nurick grade. A statistically significant correlation was observed between the surgical result and the length of a patient's clinical history. A significant correlation was also observed according to the preoperative presence of intramedullary signal alteration. The best results were found in patients without spinal cord changes of signal, acceptable results were observed in the presence of changes on T2-weighted imaging only, and the worst results were observed in patients with spinal cord signal changes on both Tl- and T2-weighted imaging. Finally, a statistically significant correlation was observed between patients with postoperative spinal cord signal change regression and better outcomes. Intramedullary spinal cord changes in signal intensity in patients with CSM can be reversible (hyperintensity on T2-weighted imaging) or nonreversible (hypointensity on T1-weighted imaging). The regression of areas of hyperintensity on T2-weighted imaging is associated with a better prognosis, whereas the T1-weighted hypointensity is an expression of irreversible damage and, therefore, the worst prognosis. The preliminary experience with this patient series appears to exclude a relationship between the time of signal intensity recovery and outcome of CSM.

One-year clinical and magnetic resonance imaging follow-up of Doberman Pinschers with cervical spondylomyelopathy treated medically or surgically

To evaluate progression of clinical signs and magnetic resonance imaging (MRI) findings in dogs with cervical spondylomyelopathy (wobbler syndrome) treated medically or surgically. Prospective cohort study. 12 Doberman Pinschers. Neurologic examinations and MRI were performed before medical (n = 9) or surgical treatment (ventral slot, 3) and a minimum of 12 months later. Mean follow-up time was 14.5 months. Clinically, 2 dogs improved after surgical treatment and 5 improved after medical treatment. Magnetic resonance imaging of surgically treated dogs revealed adequate spinal cord decompression. Spinal cord signal changes were seen in 2 dogs before surgery, both of which had new signal changes at the same and adjacent sites during follow-up examination. One dog treated surgically developed 3 new areas of spinal cord compression. In the medically treated dogs, the severity of spinal cord compression at the time of follow-up examination was unchanged in 4 dogs, worse in 2 dogs, and improved in 3 dogs, but spinal cord atrophy was observed on transverse images. Four medically treated dogs had changes in spinal cord signal initially, but none developed new signal changes or compressions. Medical and surgical treatment improved or stabilized the clinical condition of most dogs. Surgical treatment appeared to hasten the development of additional areas of spinal cord compression and lesions in dogs with preoperative cord changes; however, the clinical importance of these changes was not determined. The progression of pathologic MRI abnormalities was notably less in medically treated dogs, compared with surgically treated dogs.

Magnetic resonance imaging of traumatic intervertebral disc extension in dogs

This retrospective study evaluated the magnetic resonance (mr) images of traumatic disc extrusions in 11 dogs. The findings included a reduction in the volume and signal intensity of the nucleus...

Surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients

Significant numbers of patients with spinal tuberculosis (TB), especially in developing countries, still present late after disease onset with severe neurological deficits. The authors conducted a study to assess the outcome in these patients. Fifty-nine patients with spinal TB and severe motor deficits underwent surgery at the authors' center during the past 10 years. Data obtained in 48 patients with a minimum of 3 months of follow up (mean follow-up period 12.8 months) were analyzed. The disease in 34 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5) and in 14 patients by Frankel Grade C (unable to walk even with support) at admission. Thirty (88%) of the 34 patients with Frankel Grade A/B status and 13 (92.8%) of the 14 patients with Frankel Grade C status at admission experienced improvement to Frankel Grade D/E (walking with or without support) at the last follow-up examination 3 or more months after surgery. The degree of improvement exhibited by patients with a Frankel Grade A/B spinal cord injury was comparable to that shown by patients with Frankel Grade C status. Even patients with flaccid paraplegia, gross sensory deficit, prolonged weakness, spinal cord signal changes demonstrated on magnetic resonance imaging, and bladder involvement have experienced dramatic improvement in motor function since surgery. A significant number of the patients have shown remarkable improvement in other symptoms such as pain (91.6%), spasticity (88%), and bladder symptoms (88%). A significant proportion of patients with spinal TB and severe motor deficits experience remarkable improvement after surgical decompression and hence should undergo surgery even though they may be suffering from paraplegia of considerable duration.

Ultra-early MRI showing no abnormality in a fall victim presenting with tetraparesis

Case report. Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital and Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan. A patient presented to us with complete C4 tetraplegia after a 3-m fall. MRI performed 120 min after his fall showed spinal canal stenosis due to disk protrusion at the C3/4 level without spinal cord signal changes on T1- and T2-weighted images. He underwent laminoplasty between C2 and C6. Intraoperative ultrasound, performed 6 h after his fall, disclosed a hyperechoic lesion at the C3/4 level of the cervical cord; postoperative T2-weighted MRI, obtained at 8 h after his fall, showed high intensity at the same level. In patients with cerebral infarction, approximately 6 h between the insult and the acquisition of T2-weighted MRI are required to detect signal changes. We postulate that the time course on MRI scans obtained immediately after spinal cord injury is similar in patients with spinal cord injury and cerebral infarction and suggest that the absence of spinal cord abnormalities in the ultra-early post-injury stage is not always predictive of a good prognosis.

Myelopathy Caused by Soft Cervical Disc Herniation : Surgical Results and Prognostic Factors

The purpose of this study was to investigate the surgical results and prognostic factors for patients with soft cervical disc herniation with myelopathy. During the last 7 years, 26 patients with cervical discogenic myelopathy were undertaken anterior discectomy and fusion. Clinical and radiographic features were reviewed to evaluate the surgical results and prognostic factors. The clinical outcome was judged using two grading systems (Herkowitz's scale and Nurick's grade). Male were predominant (4:1), and C5-6 was the most frequently involved level. Gait disturbance, variable degree of spasticity, discomfort in chest and abdomen, hand numbness were the most obvious signs. Magnetic resonance(MR) images showed that central disc herniation was revealed in 16 cases, and accompanying cord signal changes in 4. Postoperatively, 23 patients showed favorable results (excellent, good and fair) according to Herkowitz's scale. Anterior cervical discectomy and fusion effectively reduced myelopathic symptoms due to soft cervical disc herniation. The authors assured that the shorter duration of clinical attention, the lesser the degree of myelopathy and better outcome in discogenic myelopathy.