Extradural Compression Research Articles

Neoplastic Myelopathies.

This article discusses the diagnosis and management of neoplasms that affect the spinal cord as well as spinal cord disorders that can occur due to cancer treatments. Neoplastic myelopathies are uncommon neurologic disorders but cause significant morbidity when they occur. Primary spinal cord tumors can be classified into intramedullary, intradural extramedullary, or extradural tumors. Diffuse gliomas and ependymal tumors are the most common intramedullary tumors. Diffuse gliomas include the World Health Organization (WHO) grade II and grade III astrocytomas, the grade II and grade III oligodendrogliomas, the grade IV glioblastomas, and newly recognized pediatric diffuse midline gliomas with H3 K27M mutation. The majority of diffuse and anaplastic astrocytomas are IDH-mutant tumors, whereas only 10% of glioblastomas are IDH-mutant. Oligodendrogliomas are typically IDH-mutant and are characterized by the molecular signature of 1p/19q codeletion. Nine distinct molecular subgroups of ependymomas have been identified based on their genetic features and location. NF2 mutations are frequently found in spinal cord ependymomas. Metastatic tumors are the most common tumors of the spine and can be extradural, leptomeningeal, or, rarely, intramedullary. Extradural metastatic spinal cord compression is a neurologic emergency and should be promptly diagnosed as pretreatment neurologic status dictates the posttreatment outcome. Neoplastic myelopathies encompass many diagnoses ranging from benign and malignant spinal tumors to paraneoplastic syndromes heralding cancers. The knowledge of the clinical features and management of neoplastic myelopathies is essential to practicing neurologists as early diagnosis and treatment can prevent devastating neurologic sequelae.

Extragonadal germ cell tumor of the posterior mediastinum in a child complicated with spinal cord compression: a case report

BackgroundGerm cell tumors (GCTs) in children are rare neoplasms with diverse pathological findings according to the site and age of presentation. The most common symptoms in children with mediastinal GCTs, which are nonspecific, are dyspnea, chest pain, cough, hemoptysis, vena cava occlusion syndrome, and fatigue/weakness. Because of these nonspecific symptoms, it is difficult to suspect a mediastinal mass. A posterior mediastinal tumor causing spinal cord compression is an important example of an oncologic emergency arising from a neurogenic tumor.Case presentationChildren with posterior mediastinum GCTs can be easily mistaken as having a neurogenic tumor because of site of tumor origin. We treated our 7-year-old patient with emergency decompression surgery and high-dose steroid pulse therapy to prevent secondary injury to the spinal cord. Primary injury was a result of spinal cord compression due to the initial manifestation of GCT in the posterior mediastinum. Cisplatin-based chemotherapy was also administered. The patient was followed up regularly for 3 years and is undergoing rehabilitation without any signs of recurrence.ConclusionsWe present an extremely rare case of a child with paraparesis caused by extradural spinal cord compression as the initial manifestation of GCT in the posterior mediastinum. The child was treated with emergency decompression surgery and high-dose pulse steroid therapy to prevent secondary injury to the spinal cord.

Free radical scavenger edaravone produces robust neuroprotection in a rat model of spinal cord injury

We used a multimodal approach to evaluate the effects of edaravone in a rat model of spinal cord injury (SCI). SCI was induced by extradural compression of thoracic spinal cord. In experiment 1, 30 min prior to compression, rats received a 3 mg/kg intravenous bolus of edaravone followed by a maintenance infusion of 1 (low-dose), 3 (moderate-dose), or 10 (high-dose) mg/kg/h edaravone. Although both moderate- and high-dose edaravone regimens promoted recovery of spinal motor-evoked potentials (MEPs) at 2 h post-SCI, the effect of the moderate dose was more pronounced. In experiment 2, moderate-dose edaravone was administered 30 min prior to compression, at the start of compression, or 10 min after decompression. Although both preemptive and coincident administration resulted in significantly improved spinal MEPs at 2 h post-SCI, the effect of preemptive administration was more pronounced. A moderate dose of edaravone resulted in significant attenuation of lipid peroxidation, as evidenced by lower concentrations of the free radical malonyldialdehyde in the spinal cord 3 h post-SCI. Malonyldialdehyde levels in the high-dose edaravone group were not reduced. Both moderate- and high-dose edaravone resulted in significant functional improvements, evidenced by better Basso-Beattie-Bresnahan (BBB) scores and better performance on an inclined plane during an 8 week period post-SCI. Both moderate- and high-dose edaravone significantly attenuated neuronal loss in the spinal cord at 8 weeks post-SCI, as evidenced by quantitative immunohistochemical analysis of NeuN-positive cells. In conclusion, early administration of a moderate dose of edaravone minimized the negative consequences of SCI and facilitated functional recovery.

Myelographic and low-field magnetic resonance imaging findings in dogs with presumptive acute hydrated non-compressive nucleus pulposus extrusion

MRI is considered gold standard for the diagnosis of presumptive acute hydrated non-compressive nucleus pulposus extrusions (AHNCNPE). This retrospective study describes the myelographic findings in dogs with AHNCNPE diagnosed by...

Fumaric Acid Esters Attenuate Secondary Degeneration after Spinal Cord Injury.

Spinal cord injury (SCI) causes permanent changes in motor, sensory, and autonomic functions. Unfortunately, there are no stable cures and current treatments include surgical decompression, methylprednisolone, and hemodynamic control that lead to modest function recovery. Fumaric acid esters (FAEs) were firstly used in the management of an immunological skin disorder, such as psoriasis. Because of their potent anti-inflammatory effects, they have been introduced in multiple sclerosis (MS). Investigation has shown not only an anti-inflammatory, but also supposed neuroprotective mechanism of action. The goal of the present work was to evaluate the potential beneficial effects of dimethyl fumarate (DMF) and monomethyl fumarate (MMF) in a mouse model of traumatic SCI. SCI was produced by extradural compression for 1 min of the spinal cord at the T6-7 level using an aneurysm clip, and DMF and MMF (both at 30 mg/kg) were administered by oral gavage to the mice 1 and 6 h after SCI. For locomotor activity, study mice were treated with FAEs once daily for 10 days. We observed that mice treated with DMF exhibited a significant and sustained recovery of motor function. FAEs significantly reduced the severity of inflammation by a modulation of pro-inflammatory cytokines and apoptosis factors, and increased neutrophic factors such as anti-brain-derived neurotrophic factor (BDNF), anti-glial cell-derived neurotrophic factor (GDNF), and neurotrophin-3 (NT3). Our results showed important protective effects of DMF in an animal model of SCI, considerably improving recovery of motor function, possibly by reducing the secondary inflammation and tissue injury that characterize this model. DMF may constitute a promising target for future SCI therapies.

Necrotizing sarcoid granulomatosis causing compressive myelopathy at cranio-vertebral junction

Necrotizing Sarcoid Granulomatosis is the term given to a variant of Sarcoidosis in which the granulomas show necrosis and evidence of angitis. This variant of sarcoidosis tends to involve the lungs primarily; however central nervous system (CNS) involvement has also been reported. We report here a case of extra-dural cord compression at cranio-vertebral junction with no other systemic involvement and excellent clinical response to corticosteroids alone. Recognition of this rare variant of sarcoidosis by the pathologist and prompt institution of corticosteroids by the clinician will generally give very gratifying results, as was seen in the present case.

Detection of compressive hydrated nucleus pulposus extrusion in dogs with multislice computed tomography

Compressive hydrated nucleus pulposus extrusion (HNPE) in dogs is defined as acute extradural compression by hydrated nucleus pulposus material at the level of the associated intervertebral disc. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosis of HNPE. The aims of this study were to determine the usefulness of unenhanced computed tomography (CT) and contrast enhanced CT (CE-CT), and the sensitivity and specificity of CE-CT, for detection of compressive HNPE. Using CE-CT, HNPE was visualised as a hypodense extradural compressive lesion with rim enhancement immediately dorsal to the intervertebral disc space, with a sensitivity of 91% and a specificity of 100%. CE-CT is a useful technique to detect compressive HNPE in dogs. However, if no clear lesion is identified with CE-CT, or if additional information about intramedullary changes is required, MRI still needs to be performed.

Paraparesis secondary to erratic migration of Dioctophyma renale in a dog

ABSTRACT: A 4 years old mongrel stray bitch, weighing 16kg was submitted to physical examination to demonstrated inability of locomotion with the pelvic limbs. Extradural spinal cord compression was observed in myelotomography of the thoracolumbar segment. The patient was submitted to exploratory hemilaminectomy of T13-L1 and L1-L2, in an attempt to decompress the medullar segments. During the surgery was observed one adult parasite, identified as Dioctophyma renale , located in the extradural space and causing spinal cord compression. The patient was submitted to postoperative physical therapy, presenting clinical improvement 15 days after surgery, remaining on prone position and able to move the pelvic limbs, but not yet able to walk unassisted. It started walking naturally 60 days after the surgery. With the present clinical report, the erratic migration of the parasite Dioctophyma renale should be added to the list of differential diagnoses for patients with paraparesis and extramedullary lesion pattern, especially in endemic areas.

Interventions for the treatment of metastatic extradural spinal cord compression in adults.

Interventions for the treatment of metastatic extradural spinal cord compression in adults.

Computed tomographic myelography of a foal with discospondylitis and extradural spinal cord compression due to a vertebral abscess

SummaryA one‐month‐old Quarter Horse colt presented with progressive gait abnormalities and weakness. The foal was ataxic at presentation. Radiography identified focal endplate irregularities and lysis at C6–7. Radiographic diagnosis was discospondylitis. Computed tomographic myelography was performed immediately following euthanasia and identified an extradural compressive spinal cord lesion corresponding to the site of discospondylitis. Post mortem examination findings included abscess formation at the C6–7 intervertebral space with osteomyelitis extending into the adjacent physes and subchondral bone of caudal C6 and cranial C7. The vertebral abscess extended into the ventral spinal canal at C6–7 and was identified as the cause of extradural spinal cord compression. Salmonella sp. was cultured and isolated from purulent exudate at the intervertebral space. Computed tomographic myelography has not been previously reported for assessment of discospondylitis in horses and was successful at accurately characterising spinal cord compression in addition to osteolytic changes associated with discospondylitis.

Factors that delay treatment of symptomatic metastatic extradural spinal cord compression.

Treatment delays of metastatic extradural spinal cord compression (MESCC) sometimes have been reported, but reasons for its delay have remained unclear. The purpose of this study was to assess which clinical factors are associated with treatment delays in neurologically symptomatic MESCC in the hospital settings. We reviewed medical records of MESCC patients in our institute who had at least one progressive neurological symptom (weakness, sensory changes, urinary retention, or nerve root pain), were diagnosed by magnetic resonance imaging (MRI), and were treated with at least radiotherapy. The number of days prior to treatment initiation were counted and defined as follows: from the patients' first physician visit to our hospital until MRI diagnosis [T1 (days)], from MRI diagnosis to treatment [T2 (days)], and from patients' first visit to treatment [T1+2 (days)]. Nine clinical factors that could potentially delay treatment were analyzed for each period. Forty-three episodes of MESCC met the inclusion criteria. Median days in T1+2 was 3 days (range: 0-22). T1 and T1+2 were significantly higher in patients with normal walking status than in those with deterioration or inabilities to walk (T1+2, 7 days versus 3 days, median, p<0.001). The number of days was higher in all periods when it included weekends (T1+2, 7 days versus 2 days, median, p<0.001). Our findings suggest that normal walking status at the first physician visit and inclusion of weekends during the pretreatment periods were factors that resulted in treatment delays even for MESCC patients with emergency neurological symptoms.

Partial lateral corpectomy associated with pediculectomy to treat extradural chondroma in a dog: technique description

This study aimed to describe in detail the surgical technique of partial lateral corpectomy (PLC) associated with pediculectomy to treat an in vitroextradural chondroma. A 12-year old female Cocker Spaniel was seen in the hospital with proprioceptive ataxia of hind limbs associated with extradural compression between the 1st and 2nd lumbar vertebrae. The owner opted for euthanasia since the patient's condition changed due to simultaneous illnesses that culminated in a poor prognosis. The patient's body was formally ceded to perform experimental spinal decompression. The technique was effective to completely remove the epidural mass with minimal manipulation of the spinal cord.

Mielografia lombar no diagnóstico de extrusão do disco intervertebral toracolombar em cães: estudo prospectivo

Thoracolumbar disk extrusion is the most common cause of extradural compression of the spinal cord in dogs. Myelography is one of the most commonly performed techniques for the diagnosis of this affection. This study aimed to evaluate the applicability and effectiveness of lumbar myelography in the diagnosis of thoracolumbar intervertebral disk extrusion in dogs, as well as its major complications. Twenty dogs were used in this study. Animals were included when neurological examination suggested thoracolumbar spine lesion, myelography was used as a complementary diagnostic method, and diagnosis of disk extrusion was surgically confirmed. The accuracy of the exam to predict location and lateralization of extruded disk material were evaluated, as well as complications associated to the procedure. Lumbar myelography exhibited 95% and 60% accuracy for location and lateralization of the lesion, respectively, with minimal complications.

Intradural schwannoma complicated by lumbar disc herniation at the same level: A case report and review of the literature.

Intradural tumours of the spine are usually benign and have a good prognosis, if they are diagnosed and removed early. Lumbar disc herniation is a common cause of chronic, acute, or recurrent lumbar radiculopathy. However, to date, there have been no reports of progressive neurological deficiencies due to the co-existence of two significant pathologies contributing to intradural and extradural compression. The current study reports the rare case of a patient with simultaneous extradural and intradural compression of the nerve root due to co-existent intervertebral disc herniation and an intradural schwannoma at the same level. A 71-year-old female suffering from lower back pain and radiating pain of the right lower extremities was admitted to Busan Korea Hospital (Busan, Korea). Magnetic resonance imaging revealed lumbar disc herniation at L4–5 and a mass occupying the intradural space at the same level of the compressed dural sac. Using the posterior approach, surgical excision of the two pathologies was performed. Pathological diagnosis confirmed schwannoma and the symptoms markedly improved.

Surgical management of vertebral synovial cysts in a rabbit (Oryctolagus cuniculus)

An approximately 8-month-old female Miniature Lop rabbit (Oryctolagus cuniculus) was evaluated because of an acute onset of progressive paraparesis. The rabbit was ambulatory paraparetic, and results of neurologic examination were consistent with a myelopathy localizing to the T3-L3 spinal cord segments. Evaluation with CT myelography revealed focal extradural spinal cord compression bilaterally at the level of the articular process joints of T12-L1. A Funkquist type A dorsal laminectomy was performed at T12-L1, and the vertebral column was stabilized with pins and polymethylmethacrylate-based cement. Multiple vertebral synovial cysts were confirmed on histologic evaluation of the surgically excised tissues. The rabbit was nonambulatory with severe paraparesis postoperatively and was ambulatory paraparetic at a recheck examination 7 weeks after surgery. Fourteen weeks after surgery, the rabbit appeared stronger; it walked and hopped slowly but still fell and dragged its hindquarters when moving faster. Thirty-seven weeks after surgery, the neurologic status was unchanged. Although thoracolumbar myelopathy in rabbits is commonly secondary to vertebral fracture, vertebral synovial cysts should be considered a differential diagnosis for rabbits with slowly progressive paraparesis. Decompressive surgery and stabilization can result in a good outcome for rabbits with this condition.

Spontaneous regression of lumbar Hansen type 1 disk extrusion detected with magnetic resonance imaging in a dog

A 3-year-old French Bulldog was evaluated because of acute signs of back pain and spastic paraparesis. Neuroanatomic localization indicated a lesion in the T3-L3 spinal cord segment. Magnetic resonance imaging revealed extradural spinal cord compression at the ventral right aspect of the intervertebral disk space L3-4. On the basis of these findings, a diagnosis of sequestrated Hansen type 1 disk extrusion without extradural hemorrhage was made. The dog was treated conservatively with cage rest, restricted exercise on a leash, and NSAIDs. Results of follow-up examination 5 weeks later indicated complete resolution of clinical signs, and results of repeated MRI indicated a 69% reduction in the volume of the herniated disk material. Findings for the dog of this report indicated spinal cord compression attributable to extruded intervertebral disk material resolved. Functional improvements in dogs with such problems may be partly attributable to spontaneous regression of intervertebral disk extrusions.

Paraparesis as initial manifestation of a Prototheca zopfii infection in a dog

A case of protothecosis causing non-ambulatory paraparesis in a dog without clinical evidence of disseminated infection is described. A five-year-old female Labrador retriever was referred with a 10-day history of progressive non-ambulatory paraparesis and lumbar pain as the only physical and neurological abnormalities. Lumbar myelography revealed severe extradural spinal cord compression extending from L4 to L7 vertebrae, and a right hemilaminectomy was performed. Surgical findings included an adherent whitish hard ill-defined mass. Cytology and biopsy results disclosed the presence of algae enclosed in a matrix of chronic inflammatory infiltrate. Culture confirmed the presence of Prototheca species. Neurological improvement occurred within a month, and the dog received antifungal treatment without evidence of clinical disseminated disease for 6 months, but died after a generalised tonic-clonic seizure. Post-mortem examination revealed multiple foci of inflammatory granulomatous infiltrate and algae-like structures in the brain, lumbar intumescence and cauda equina. Prototheca zopfii was identified using molecular biology methods.

Paraparesis and pleural effusion in a young patient: A road less travelled

Intrapulmonary teratoma is a rare tumor of the lung, which is scarcely reported to have metastasis at presentation. Here, we report a case of a 14-year-old patient admitted with paraparesis and heaviness of the right side of the chest and was found to have compressive myelopathy along with pleural effusion. He had elevated alpha fetoprotein and beta human chorionic gonadotropin. Imaging revealed a heterogeneous, massive space lesion occupying the right hemithorax and collapse of D12 vertebra with altered marrow signal causing extradural spinal compression. Cytopathology from the tumor revealed immature teratoma cells. The patient was diagnosed as a case of intrapulmonary teratoma with vertebral metastasis. He was started on bleomycin, etoposide, cyclophosphamide chemotherapy and spinal irradiation, which was unsuccessful.

Teaching Neuro Images : Snake eyes appearance in MRI in patient with ALS

A 17-year-old girl presented with 6 months of progressive asymmetrical distal weakness of upper limbs with fasciculation. There were no bulbar symptoms, weakness in lower limbs, or sensory symptoms. There was no history of neck injury or pain. Deep tendon reflexes were all brisk. MRI of cervical spine revealed symmetrical T1 hypointense, T2 hyperintense signal in the anterior horns (“snake eyes” appearance) (figure, A and B) without evidence of extradural compression. EMG showed diffuse denervation changes in both upper and lower limb muscles. Sensory nerve action potentials were normal. A diagnosis of amyotrophic lateral sclerosis (ALS) was made. Snake eyes appearance has been described in disorders like ALS, cervical spondylotic amyotrophy, Hirayama disease, and ossification of posterior longitudinal ligament.1,2

IMAGING DIAGNOSIS—SPINAL EPIDURAL HEMANGIOSARCOMA IN A DOG

An 8-year-old, male Boxer was examined for an acute onset of ambulatory paraparesis. Neurologic examination was consistent with a T3-L3 myelopathy. Myelography revealed an extradural spinal cord compression in the region of the T10-T13 vertebrae. On magnetic resonance (MR) imaging, a well-defined epidural mass lesion was detected. The mass was mildly hyperintense on T1-weighted, hyperintense on T2-weighted and STIR images compared to normal spinal cord and enhanced strongly and homogenously. Postmortem examination confirmed a primary epidural hemangiosarcoma. Findings indicated that the MRI characteristics of spinal epidural hemangiosarcoma may mimic other lesions including meningioma and epidural hemorrhages/hematomas of non-neoplastic etiology.