Intradural Space Research Articles

MR-imaging of chronic spinal cord injury. Association with neurologic function

Twenty-two para- and tetraplegic patients with chronic spinal cord injuries were examined with magnetic resonance imaging (MRI). The clinical course in the entire rehabilitation period was recorded and an attempt was made to associate the functional status of the patients with the morphologic findings on MRI. Small and large spinal cord cysts and syringomyelia, cord atrophy, and spinal stenosis were found. Additionally, in a number of patients regions of increased signal intensity within the cord, interpreted as myelomalacia, and obliteration of the intradural extramedullary space, interpreted as arachnopathy, were noted. The large number (13/22) of cystic lesions in our patients was unexpected. It was in contrast to the rate reported in autopsy studies of paraplegics which note only few cysts. Whereas a direct association of morphologic findings with neurologic symptoms and the clinical course was difficult, it was found that patients with large cysts and spinal cord atrophy generally showed no tendency to improve in spite of the measures taken during the rehabilitation period. It is difficult to decide whether the initial trauma with cord hemorrhage is limiting the chance of neurological improvement or if a sequence of events leading from hemorrhage to gliosis and cystic necrosis is the determining factor.

The distribution pattern of the sympathetic nerve fibers to the cerebral arterial system in rat as revealed by anterograde labeling with WGA-HRP

To clarify the projection route and the expansion of the terminal plexus of the sympathetic nerve fibers innervating the cerebral arterial system in rat, we labeled the postganglionic fibers originating in the superior cervical ganglion and traced their entire course by anterograde labeling with wheat germ agglutinin-horseradish peroxidase. Sympathetic innervation of the internal cerebral artery by labeled fibers actually began just at the portion where it enters the intradural space, and innervated it up to the small pial arteries located in the subarachnoid space, but not the intracerebral arterioles. On the main arteries in the circle of Willis, bundles of nerve fibers ran parallel to the long axis of the vessels and branched perpendicularly their terminal twigs with regular intervals to form a rib-structure pattern. On the arterial branches derived from the circle of Willis, a fine nerve bundle and delicate terminal axons formed a meshwork instead of a rib-structure pattern. These observations confirmed the existence of differences in the distribution pattern of the nerve plexus, which strongly affects the strength and quality of vasoconstriction by sympathetic activation in each level of the cerebral arterial system.

Concurrent Intradural and Extradural Meningiomas of the Cervical Spine

Abstract A case of an extradural spinal meningioma presenting with a separate intradural meningioma at the same cord level is reported. Review of the English literature on spinal epidural meningiomas reveals a high incidence of concurrent intradural tumors in patients with epidural meningiomas. This leads to the conclusion that the intradural space should be evaluated carefully when an epidural meningioma is encountered.

Concurrent intradural and extradural meningiomas of the cervical spine

A case of an extradural spinal meningioma presenting with a separate intradural meningioma at the same cord level is reported. Review of the English literature on spinal epidural meningiomas reveals a high incidence of concurrent intradural tumors in patients with epidural meningiomas. This leads to the conclusion that the intradural space should be evaluated carefully when an epidural meningioma is encountered.

Adrenal Cortical Adenoma in the Spinal Canal of an 8-Year-Old Girl

An ectopic adrenal cortical adenoma containing high levels of androstenedione but without clinically detectable virilizing effects was found in the spinal intradural space of an 8-year-old girl. The tumor, which was located at the L2 level, manifested itself clinically by a short history of bilateral leg pain. It was well encapsulated; therefore, total surgical removal was accomplished. The light microscopic appearance of the tumor was typical of adenomatous adrenal cortical tissue. Ultrastructurally, it also showed characteristic features of steroid-producing tumors, including very abundant smooth endoplasmic reticulum and giant mitochondria with tubulovesicular and circular cristae. Frozen tissue analyzed by radioimmunoassay was found to contain almost 20 times the normal tissue level of androstenedione. There was no elevation of cortisol or aldosterone levels in the tumor. Postoperative magnetic resonance imaging (MRI) scan of the retroperitoneum showed no abnormalities in the patient's adrenal glands. Serum androstenedione levels were normal. We postulate that the adenoma developed from congenital ectopic rests of intraspinal adrenal tissue. Although ectopic occurrence of adrenal cortical tissue has been recorded in other areas, neither such rests nor tumors developing from them have been previously reported within the spinal canal.

腰部硬膜下腔ヘルニアの２症例

Since the first discription of intrathecally prolapsed disc by Dan dy (1942), the papers have been rarely reported. We have experienced intradural disc prolapse in two cases out of 1556 cases with surgical in tervention for the lumbar disc herniation. 86 cases found in litera tures were reviewed. Intrathecally prolapsed disc on the average acc ounted for about 0.2% according to literatures. Intradural disc prolapse was mostly encountered at the L4/5 disc level, and more frequently localized at the upper lumbar disc (L1/2-L3/4) levels than commonly experienced herniation. The first patient in this series was difficult to be differentiated from cauda equina tumor in myelogram and magnetic resonance imaging. Because intradural herniated disc in the first case was enhanced with Gd-DTPA. But retrospectively, iso-intensity lesion in intradural space was mostly valuable as the diagnostic examination. The second patient showed the myelogram like a massive epidural disc prolapse. That is, the myelogram of both patients revealed a regularly marginated manifestation, this feature was different from the previously reported cases. And the second case was found at an uncommon L5/S disc level postoperatively.Anterior dura mater had fastly adhered with posterior longitudinal ligament in these two cases.

Spinal lesions: quantitative and qualitative temporal evolution of gadopentetate dimeglumine enhancement in MR imaging.

Seventy gadolinium-enhanced magnetic resonance imaging studies were reviewed, and 36 were selected for quantitative and qualitative analysis of the temporal evolution of contrast medium enhancement of spinal lesions. In the extradural space, lesions often showed mild increase of enhancement on delayed images, but enhancement was always visible on immediate postcontrast images. In the intradural extramedullary space, tumor nodules demonstrated most prominent enhancement on early images, although subtle, strandlike enhancement of the nerve roots showed some delayed uptake of contrast medium on later images. In the intramedullary space, enhancement often increased on delayed images, although this increase was usually mild. For clinical purposes, immediate postcontrast imaging should be sufficient to depict the majority of spinal lesions, regardless of location. However, selected cases, such as necrotic spinal cord tumors, will require delayed imaging.

Gadolinium-DTPA in the evaluation of intradural extramedullary spinal disease.

Gadolinium-DTPA was used in MR imaging of the spine to determine the ability of a contrast agent to increase the detection and characterization of disease in the intradural extramedullary space. Although MR imaging, especially with recent technological improvements, has been shown to be at least competitive with, and often superior to, myelography and postmyelography CT in the study of intramedullary and extradural disease, its use in the assessment of intradural extramedullary disease has been questioned. We selected 12 patients with intradural extramedullary disease as demonstrated by positive CSF cytology and/or myelographic findings and performed MR examinations on them before and after administering gadolinium-DTPA (0.1 mmol/kg). Gadolinium-DTPA was extremely effective in depicting intradural extramedullary disease of the spine. Small nodules of 3 mm, virtually invisible on noncontrast MR scans, enhanced strongly and were easily detected. In addition, leptomeningeal spread of tumor along nerve roots was also visualized, sometimes more readily than by myelography and postmyelography CT. The remarkable sensitivity of gadolinium-DTPA to intradural extramedullary disease assures its role in future MR examinations of the spine.

１５年後に再発した胸髄腫ようの１例

We reported a case of the thoracic spinal cord tumor recurred 15 years after operation. The tumor lies both in extradural and intradural spaces and has a contiguity through dura mater.Macroscopically neurinoma and meningioma are suspected in the same region, but histologically the tumor was not apparently diagnosed.After operation the patient's symptoms gradually subsided and now she can walk alone and is hardly aware of any difficulty in active daily life.

Spinal Dermoid Cyst: Characteristic CT Findings after Metrizamide Myelography

A 25-year-old male complained of intermittent, sharp pains about the left eye and in the left side of the chest. Neurological examination revealed paresthesia and impaired perception of touch and pin-pricks in the dermatomes of Th8 and Th9 on the left side. In all four extremities, the muscle stretch reflexes were equal and slightly hyperactive, without weakness or sensory deficits. Metrizamide myelography showed defective filling at the level between the upper 8th and 9th thoracic vertebrae. The lesion was also demonstrated by computed tomography (CT) scan performed 1 hour later, appearing as an oval, radiolucent mass in the left dorsal spinal canal, which compressed the spinal cord forward and toward the right. Serial sections of the spinal canal revealed the lesion to be partly filled with contrast medium. Repeat CT scan 24 hours after metrizamide myelography showed more contrast medium in the periphery of the lesion, giving it a doughnut-shaped appearance. At surgery a smooth-surfaced cyst containing sebum and white hair was totally removed from the intradural extramedullary space. The histological diagnosis was dermoid cyst. There have been a few reported cases of intracranial epidermoid cyst in which filling of the cyst was suggested on metrizamide CT myelography. These findings may complicate the differential diagnosis of arachnoid cyst and dermoid or epidermoid cyst when only CT is used.

Traumatic extradural and intradural herniation of cervical disk treated surgically

Intradural diskal herniation is a very rare condition, particularly in the cervical region, with few reports in the literature. A case is described of a young man who developed transient quadriparesia immediately after a car accident. Three months later when bending his neck he suddenly experienced a sense of numbness and vibration over his whole body; this sense reappeared every time he bent his neck. Myelography disclosed an extensive ventral extradural cervical defect. An operation was performed anteriorly with removal of the C-4 vertebral body and adjacent disks, disclosing an extruded disk in the extradural and intradural spaces.

CHRONIC CANNULATION OF THE INTRADURAL OR EXTRADURAL SPACE IN THE RAT

An animal preparation has been developed to test therapeutic agents in the extradural and intradural spaces. Under anaesthesia a hole was drilled in the penultimate lumbar vertebra of male Wistar rats and the appropriate space cannulated. The catheter was tunnelled subcutaneously to emerge at the neck. There was no spinal cord or meningeal reaction after 1 month. Catheters remained patent for 3 months. The method of cannulation allowed free rostral spread of drugs. Using plain 2% lignocaine, paralysis and anesthesia of the hind limbs required an intradural volume of 32 +/- 3 mulitre: the required volume on extradural injection was 46 +/- 2 mulitre (P less than 0.01). Paralysis of all limbs required an intradural volume of 115 +/- 12 mulitre. Respiratory arrest and death required a mean intradural volume of 179 +/- 15 mulitre.

L<SUB>5</SUB>-S<SUB>1</SUB>椎間レベルを中心とした実験的ミエログラフィー

Using Y. Mori's procedure (1981), the author performed an experimental study of myelography of the lumbar spine at L5-S1. The normal lumbo-sacral spine of a human cadaver was sectioned in a coronal plane passing the pedicles and devided it into the two parts. The anterior part was a vertebral body and the posterior part was a laminar portion. The intradural space was filled with a physiologic saline solution and about 3 ml of myodil as a contrast medium was introduced in it, then the dural sac was closed with a clamp at its top. A series of experiments were then performed by narrowing the space of the spinal canal under the following conditions.

Expansive open-door laminoplasty for cervical spinal stenotic myelopathy.

Although the operative results have been improving since the air drill was introduced for cervical laminectomy instead of an ordinary rongeur, post-laminectomy complications, such as postoperative fragility of the cervical spine to acute neck trauma, posterior spur formation at the vertebral body, and malalignment of the lateral curvature have still remained as unsolved problems. In order to avoid these disadvantages, a new surgical technique called "expansive open-door laminoplasty" was devised by the author in 1977, which is relatively easier, safer, and better than the ordinary laminectomy from the standpoint of structural mechanics of the cervical spine. The operative procedure is described in detail. Operative results in the patients with cervical OPLL, spondylosis, and canal stenosis were satisfactory, and optimal widening of the AP diameter of the spinal canal is considered to be over 4 mm. From this procedure a bilateral, open-door laminoplasty has been devised for extensive exploration at the intradural space.

Spinal intradural extraarachnoid metastasis

A case of carinomatous metastasis at the L2-3 level localized in the intradural extraarachnoid space is presented. The anatomy of the subarachnoid angle where the transition occurs from peripheral nerve to nerve root is reviewed. Anatomic evidence suggests that the spread of the tumor to the potential intradural extraarachnoid space might be via the perineural sheath.

Intraoperative ultrasound imaging of the spinal cord: Syringomyelia, cysts, and tumors — A preliminary report

Dynamic intraoperative imaging of the spinal cord was done using a real-time ultrasound scanner. Prior to opening the dura mater the neurosurgeon is able to “explore” the intradural space and with a 7.5 MHz transducer visualize the normal spinal cord, including the central canal and the dentate ligaments. Anterior and posterior spinal arteries may be seen in certain patients. In syringomyelia the fluid-filled cavities may be visualized with ultrasound and drained or shunted with intraoperative ultrasound guidance. Spinal cord cysts or cystic components of tumors can be precisely identified and drained using ultrasound. Intramedullary tumors can be demonstrated sonographically, as can the location and extent of intradural extramedullary tumors and tumors that have both extradural and intradural components. Experience to date with intraoperative imaging of the spinal cord and with the real-time ultrasound scanner is very encouraging, and in the future it should allow for a more precise characterization of and operative approach to lesions of the spinal cord.

Spinal Cord Tumors In our Clinic

Eight cases of Spinal cord tumors (four cases of Schwannomas, two of plasmacytomas, one of psammomatous osteogenic meningeoma and ganglioneuroma) were treated in our clinic for these four years.In this paper, two of them are reported.Case 1; 41 year-old male of plasmacytoma, he had fallen into paraplegia following acute back pain. On the myelogram, extradural tumor was suggested at the 6th thoracic level. At operation, the tumor adhered to the surface of dura and was seemed originated from it. Serum immunological study revealed abnormally high Ig. D value, 320mg/dl, but he had no hyperproteinemia nor M-protein.Case 2; 49 year-old female of psamonomatous osteogenic meningioma, she had worried about paraplegia and lower limbs' pain for five years. She had been treated as lumber disc hernia but was not ftee from her symptoms. By Myelography, contrast medium stopped at 8th thoracic level. At operation, an ossicle (7×12×3mm in size) and tumorous soft tissue around it were found in the intradural space. The bone chip had tight adhesion to dura. Histologically, the ossicle was made of mature bone tissue.After the operations, these two cases recovered but incompletely, the former can walk without a cruch but the latter with a cruch.

A Report of a Case of Myxo-papillary Ependymoma

A case of Myxo-papillary ependymoma of the cauda equina is reported herein.The patient is a ten-year-old girl who complained of coccyalgia, low back pain and urinary disturbance.In physical examination, muscle weakness of lower extremities and positive stretch leg raising test were observed, but sensibility and tendon reflexes were normal.There were observed xanthochromy and an increase of protein in the celebro-spinal fluid.By myelogram, complete block at the L4 level was seen. A diagnosis of an intradural tumor, laminectomy and removal of the tumor were performed. The tumor in th intradural space was dark-red and gelatious.Histologically the tumor was diagnosed as myxo-papillary ependymoma which is very rare in childhood. After operation the symptoms and pathologic disappeared quickly.

Three Cases of the Spinal Cord Tumor

Three cases of the spinal cord tumor of special interest, that we have recently experienced, were reported.Case 1. a male, aged 45 years, was removed neurinoma located in the extradural space of C2-3 with bulky deposits of Calcium in the center of the tumor.Case 2. a female, aged 43 years, was operated for neurinoma located in the extradural space of Th2-3 continued to the large tumor of the right extravertebral, extrapleural space, which compressed the lung.Case 3. a female, aged 23 years, was removed epidermoid cyst located in the intradural space of L3-4.Those tumors were almost completely removed with successful results. The second case needed simultaneous thoracotomy.

Radiation Therapy for Lymphoma of the Spinal Canal

There is a paucity of reports concerning lymphomatous involvement of the spinal canal. Review of the literature leaves one confused as to the incidence of primary central nervous system involvement by lymphoma, its best management, and the results to be expected from it. In an attempt to clarify these points, we have reviewed the experience of the Division of Radiotherapy of the Columbia-Presbyterian Medical Center and New York Neurological Institute with 53 histologically proved cases of spinal canal lymphoma. This discussion is limited to involvement of the spinal canal; intracranial and peripheral nerve involvement is excluded. By the term lymphoma, we include Hodgkin's disease, lymphosarcoma, and reticulumcell sarcoma, but exclude leukemia and myeloma. Fifty-eight patients with lymphoma of the spinal canal were registered between January 1935 and December 1964. The hospital charts were not available for review in 5 cases, leaving 53 for analysis. Histologic proof of epidural disease was obtained in 48. In 5 the histologic diagnosis was made from biopsy of another site. In addition, the clinical course, roentgenographic and laboratory data, and treatment response were consistent with spinal canal lymphoma. The sex ratio was 34 males to 19 females, and the age at presentation ranged from nine to seventy-one years, the mean age being forty-three and a half years (Fig. 1). Local or radiating pain was experienced by all patients and was the most frequent initial symptom. Other initial symptoms were : paraparesis (6 cases) , bowel disturbance (1 case), nonspecific respiratory symptoms (6 cases), and pruritus (1 case). Forty-seven patients had a sensory deficit on admission; 42 had motor weakness or paralysis. Sphincteric disturbance was present in 26. The duration of symptoms prior to hospitalization averaged six weeks, with 7 patients noting symptoms for less than two weeks and 5 for more than one year. In contrast with other series, spinal canal involvement was the first manifestation of lymphoma in 45 patients (7). No histological type demonstrated a predilection for a particular area of the spinal canal (Fig. 2). Roentgenographic studies showed adjacent bony involvement in 29 patients. A paravertebral soft-tissue mass was noted radiographically or at the time of surgery in 30 cases. In 32 patients myelography was performed; in all the findings were abnormal and showed an extradural mass constricting the intradural space. Laboratory studies proved of little diagnostic aid except that the cerebrospinal fluid protein value was elevated in all 47 patients in whom the test was performed. The mode of treatment, clinical response, and survival in 51 cases are shown in Figure 3. Thirty-nine patients (77 per cent) benefited from therapy. Although the therapeutic result was generally inversely proportional to delay between onset of symptoms and institution of treatment, several patients made an excellent recovery despite sphincteric disturbance for periods of several days.