Intradural Space Research Articles

Two rare presentations and treatments of Ewing's sarcoma: A need for a standard treatment approach.

e21000 Background: We describe two Caucasian boys with rare presentations of non-metastatic Ewings sarcoma (ES) with atypical primary sites. One was extradural but FISH negative for 22q11.2. Another was intradural but extramedullary, and FISH positive. Literature search showed few publications which describe such cases, and there is currently no standard of care. Methods: MG, an 11 year old male, presented with a frontal skull mass, with an intracranial epidural extension of about 5 mm. Biopsy confirmed ES. MG was treated with Vincristine, Doxorubicin, and Cyclophosphamide, alternating with Ifosfamide and Etoposide every 2 weeks, for 6 weeks. He underwent tumor excision for local control with good response. Chemotherapy continued, completing 14 cycles total. He is in remission 15 months after completion. AH, a 13 year old male, presented with lower back pain and paraesthesias of feet. MRI revealed an intradural, extra-medullary L1-L3 mass. Intra-operatively, all visible tumor peeled off readily, except for the L2 nerve root. The tumor was FISH positive for EWSR1. He was treated with the same regimen as MG for 6 cycles. Local control was done with radiation. He then continued chemotherapy, completing a total of 14 cycles. MRI scans 3 months later revealed enhancing intradural lesions along the spinal cord (involving C5, T5 and T8) and two lesions along the cerebellum. He was started on cyclophosphamide and topotecan and has completed 8 cycles without disease progression. Results: MG was diagnosed based solely on histo-pathological diagnosis. While MG’s lesion was extra-osseus in nature, more unusual presentations demonstrate the importance of molecular diagnostic techniques. AH was diagnosed based on chromosomal analysis. Progression is presumably from microscopic residual disease in intradural space that invaded CSF. He is presently on salvage chemotherapy. Nine months after relapse, disease is stable, with plans to minimize disease and consolidate. Conclusions: Intradural tumors tend to progress rapidly, maybe more so than extradural tumors. Future suggestions include developing a standard approach that will improve both treatment of Ewing’s sarcoma and prognostic outcomes for rare initial presentations.

Usefulness of three-dimensional T1-weighted spoiled gradient-recalled echo and three-dimensional heavily T2-weighted images in preoperative evaluation of spinal dysraphism

The aim of this study was to evaluate the usefulness of three-dimensional T1-weighted spoiled gradient-recalled echo (3D T1-GRE) images for the preoperative anatomical evaluation of lumbosacral lipoma, thick filum terminale, and myelomeningocele as a means of compensating for the drawbacks of 3D heavily T2-weighted (3D hT2-W) images. Nine patients with lumbosacral lipomas, one patient with tight filum terminale, and five patients with myelomeningoceles were included in this study. 3D T1-GRE images were compared with 3D hT2-W images or conventional magnetic resonance images in terms of delineation of lipomas and other structures in the patients with lipomas and tight filum terminale. For patients with myelomeningoceles, 3D T1-GRE images were compared with 3D hT2-W images in terms of artifacts in the cerebrospinal fluid (CSF) space. The 3D T1-GRE images demonstrated lipomas with good contrast to the spinal cord and CSF space and more clearly delineated the anatomical relationship between lipomas and these structures than did the 3D hT2-W images. The 3D T1-GRE images delineated dural defects through which extradural lipomas penetrated into the intradural space. The 3D T1-GRE images also demonstrated the presence or absence of lipomas in the filum terminale and the absence of artifact in the myelomeningoceles. Furthermore, they were useful for differentiating artifacts observed on the 3D hT2-W images from nerve elements. The complementary use of 3D T1-GRE and 3D hT2-W images may compensate for the drawbacks of 3D hT2-W images and may eventually improve lesion visualization and surgical decision making.

Operative strategies in ventrally and ventrolaterally located spinal meningiomas and review of the literature

Meningiomas are usually benign tumors that arise from the meninges. They occur both intracranially and intraspinally. Spinal meningiomas account for 25–46 % of all spinal canal tumors [5, 7, 17, 21, 26]. Typically, these tumors are located in the intradural extramedullary space. Due to space occupying growth they become symptomatic over time. Initial clinical symptoms are not specific and comprise of pain, sensory deficits, motor weakness, and vegetative dysfunction, respectively [13, 14, 29]. If indicated, spinal meningiomas are usually treated by surgical resection only. Technological achievements such as preoperativemagnetic resonance imaging (MRI), intraoperative electrophysiological monitoring, and specialized microsurgical techniques have helped to improve the clinical outcome of patients suffering from spinal meningiomas in the last decades dramatically [9, 11, 17, 24, 26]. Similar to the treatment of dorsally attached tumors, the excision of ventrally attached tumors is usually performed via dorsal approaches as well, which is then hindered by the covering spinal cord [26]. Therefore, the surgical removal of such meningiomas is usually considered to be more difficult when compared to dorsally located tumors [21, 26]. In the present study, we thus investigate a large series of patients suffering from such ventrally located spinal meningiomas that were surgically treated in our department during a 20-year period.

Contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty: a case report

IntroductionSubarachnoid hemorrhage is one of the most feared acute neurologic events. Accurate diagnosis of subarachnoid hemorrhage is essential, and computed tomography of the brain is the first diagnostic imaging study. However, in rare circumstances, a similar appearance may occur in the absence of blood in the subarachnoid space. The contrast enhancement of subarachnoid space is a rare complication after lumbar percutaneous epidural neuroplasty, with, to the best of our knowledge, no previous report in the literature.Case presentationA 42-year-old Korean male patient, who underwent a spinal operation five years previously at the level of L4 to S1, visited our clinic with persistent and aggravating low back pain. An imaging study revealed the focal and diffuse disc protrusion at the level of L4/5 and L5/S1. The clinician decided to perform a lumbar percutaneous epidural neuroplasty. During the procedure, dural adhesion was suspected at the previously operated level, and the neuroplasty catheter was malpositioned into the intradural space on the first attempt. After the catheter was repositioned, the scheduled epidural neuroplasty was completed. Our patient had no definite abnormal neurological signs. But, after a day, our patient complained of severe headache with sustained high blood pressure without neurological disorientation. Computed tomography of his brain showed a subarachnoid hemorrhage-like appearance with intracranial air. Sequential angiography, subtractional magnetic resonance imaging and examination of the cerebrospinal fluid revealed no abnormalities. Follow-up computed tomography after one day revealed no definite intracranial hemorrhage, and our patient was discharged with improved low back pain without neurological deficit.ConclusionWe report a rare case of contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty. The physician should keep in mind a rare case like this, and the supine position with head elevation is necessary to avoid a similar complication after lumbar percutaneous epidural neuroplasty.

Operative field temperature during transnasal endoscopic cranial base procedures

BackgroundData regarding the safety of endoscopic skull base exploration are very scarce. With this method, fragile vital structures (cranial nerves, the optic complex, brainstem, hypothalamus or cerebral ventricles) are exposed to direct illumination within a closed space. Also, high-speed drills, cauterization and ultrasonic aspiration deliver a significant load of thermal energy. The aim of this study was to record the temperature close to the structures of the skull base and in the intradural space during the procedures performed using extended endoscopic transnasal approaches.MethodsThe temperature of the skull base was continuously recorded during six transnasal endoscopic procedures. Implantable copper-constantan thermocouples were inserted: one into the esophagus and another through the nostril to reach the operative field at the skull base.ResultsAt the beginning of the procedure, the temperature of the operative field was on average 36.8 °C ± 0.80 °C, i.e. only 1 °C higher than the esophageal temperature. Then it grew continuously during the whole procedure, to eventually reach a level of 42–43 °C at the final stage, whereas the esophageal temperature remained stable. Occasionally, the temperature increased up to 45 °C during cauterization and ultrasonic aspiration, and even up to 62 °C during high-speed drilling.ConclusionEndoscopic skull base surgery is associated with an incessant increase of the temperature of the intraoperative field. The temperature can peak suddenly to levels which can potentially harm neural structures and influence the rate of postoperative complications.

Spontaneous Thoracic Spinal Subarachnoid Hemorrhage Diagnosed with Brain Computed Tomography

Spontaneous thoracic spinal subarachnoid hemorrhage is rare, and thus no useful radiological findings for preoperative diagnosis have been reported. We experienced a patient with spontaneous thoracic spinal subarachnoid hemorrhage. A 37-year-old female presented with sudden-onset paraplegia and numbness in the trunk and bilateral lower extremities. The patient had no past history of trauma, lumbar puncture and bleeding disorder. T2-weighted sagittal magnetic resonance imaging (MRI) of the cervical and thoracic spines showed a mass occupied in the ventral space of spinal cord that was dorsally shifted. The mass extended from C6 to Th6 levels, with its largest size at Th2 level. Thoracic spine T2-weighted sagittal and axial MRI showed that the mass compressed spinal cord and was located in the intradural space. There was no spinal cord tumor and no spinal vascular malformation around the mass. Brain computed tomography (CT) showed a high-density area in the subarachnoid space, indicating the possibility of subarachnoid hemorrhage. Brain MRI showed no ruptured aneurysm. The patient was diagnosed as a spontaneous thoracic spinal subarachnoid hemorrhage and emergency surgery was selected. We performed right-side hemilaminectomy at Th1-Th6 and opened dura mater and arachnoid membrane. Hematoma was found in the ventral space of spinal cord and was removed. One year after surgery, numbness in the trunk and bilateral lower extremities had disappeared but paraplegia remained unchanged. Thoracic spine T2-weighted MRI confirmed no hematoma but showed a newly formed intradural cyst. Preoperative combination of brain CT and thoracic MRI is useful to diagnose thoracic spinal subarachnoid hemorrhage.

Giant cauda equina schwannoma

Schwannoma is a benign tumor that often grows from the spinal root. A 42-year-old woman first experienced lumbar pain and left-side ischiadic neuralgia at the age of 40 years. Her symptoms progressed gradually; she developed dysesthesia of the left leg and urinary incontinence 6 months before admission. Thereafter, she had gait disturbance, lumbago and pain in both legs. On admission, she had flaccid paraplegia and sensory loss below Th10. Magnetic resonance imaging showed a large tumor occupying the whole lumbar and upper sacral canal associated with thoracolumbar cord syrinx (Fig. 1a,b). The tumor was lobularly enhanced (Fig. 1c,d). A restricted biopsy of the tumor led to the diagnosis of schwannoma (Fig. 1e,f). Because schwannoma grows along with the nerve root from the intradural space to outside of the spinal canal, it sometimes presents as a dumbbell-like appearance. The tumor also grows

Epidural Anaesthesia

Titles can be deceiving; in Epidural Anaesthesia: Images, Problems and Solutions, the author does not review epidural anesthesia generally, rather the book is focused on epidurography, an imaging technique relatively unknown to many anesthesiologists. Data are derived from a series of 178 cases, collected over 30 years, and comprising mostly obstetric and gynecologic patients. The book includes the most significant findings from the series. The main objectives of the text are to review normal/abnormal epidural anatomy and epidural-related complications using epidurograms. It is well organized with an abundance of images. The book is divided into 10 chapters and the majority is written in an outline format making it easy to read. The first chapter serves as an introduction and provides a history of epidurography. It also addresses the purpose of performing an epidurogram. Initially, epidurography was used to correlate the physical spread of solution in the epidural space and the extent of observed nerve block. The author goes on to describe various other current utilizations for epidurography in clinical practice. The second chapter describes the technique of epidurography and the “typical” epidurogram is then reviewed. The images are marked with arrows identifying important components of the epidurogram, greatly aiding interpretation of the images. However, following the exposition is sometimes challenging because figures are often located several pages after the relevant text. Subsequent chapters review complications associated with epidural blocks. For each specific complication, the author provides a case history and accompanying epidurogram. Complications reviewed include intravascular injection, high epidural block, accidental subarachnoid block, multicompartment block, and Horner syndrome. The author gives particular attention to describing the subdural and intradural space anatomy, clinical presentations, and epidurograms. Next, the author describes causes of failed or inadequate blocks divided into 2 categories: those resulting from dislodgement of the catheter tip and local anesthetic from the epidural space as well as anatomical abnormalities. This latter section includes a discussion of obstructive and other septal anatomical deviations. Again, clinical case histories are used as examples for each situation and then followed by an associated epidurogram. Specific spinal deformities are subsequently addressed including scoliosis, kyphosis and lordosis, spinal pathology/spinal surgery, and spina bifida occulta. The book ends with a nice assessment of the different types of epidural catheters used throughout the 30 years of this epidurogram study and discusses advantages and disadvantages of each. Overall, the book is an interesting and informative look at epidural blocks and complications using epidurography. The clinical applicability for the majority of anesthesiologists, however, may be somewhat limited as the book is not, nor does it claim to be, a comprehensive review of epidural blockade. Those who will benefit most from this text most likely already have a comprehensive knowledge of epidural anesthesia and analgesia and are looking to further their understanding through the use of the somewhat novel imaging technique of epidurography. For these individuals, this text certainly adds a new dimension of understanding through the visual medium as there are few similar tomes available to practitioners and researchers alike. Arpita D. Badami, MD Department of Anesthesiology Medical College of Wisconsin Milwaukee, Wisconsin Brian M. Ilfeld, MD, MS Department of Anesthesiology University California San Diego San Diego, California [email protected]

A Glass Foreign Body Migrating into the Lumbar Spinal Canal: A Case Report

We report on a 12-year-old boy in whom a glass fragment migrated into the lumbar spinal canal causing low back pain and radiculopathy 6 years after injury. Computed tomography showed a foreign body in the anterior spinal canal of L5/S1. The patient underwent recapping T-saw laminoplasty to remove the foreign body. Scar formation was noted at the anterior dura. The glass fragment seemed to have penetrated into the intradural space from an anterior site. Postoperatively, the pain resolved immediately. At the 9-year follow-up, the alignment of the lumbar spine and healing of L5 was good, with no features of aseptic necrosis.

Cervical implantation of intrathecal baclofen pump catheter in children with severe scoliosis

Intrathecal baclofen (ITB) pump catheter placement is traditionally performed through entry into the spinal sac at the lumbar spine. A minority of children with cerebral palsy have severe concomitant neuromuscular scoliosis. In these children, whether surgically treated or not, access to the intradural space via the lumbar spine may prove technically challenging. The authors report on a series of children in whom, for various reasons, an ITB catheter was implanted using a posterior cervical spine approach. The records of 20 children in whom a baclofen catheter had been placed were retrospectively reviewed to assess the demographic details, indications, and outcome of this procedure. This approach was successful in all but one of the children in whom the procedure was abandoned given the presence of significant extradural scar tissue. Of the 20 children, 7 had previously undergone lumbar ITB catheter implantation, although the catheter was subsequently, iatrogenically transected during scoliosis surgery. Nine children had had corrective scoliosis surgery, and the fusion mass obviated access to the lumbar spinal sac. Four children had untreated scoliosis and corrective surgery was being contemplated. Complications included infection requiring explantation (2 patients), catheter migration (1 patient), intolerance to ITB (1 patient), and failure of implantation (1 patient). All patients who tolerated the ITB experienced improvement in spasticity. No complications were associated with the spinal level of catheter insertion. Implantation of an ITB catheter via a cervical approach is safe and feasible and should be considered in children with severe corrected or uncorrected scoliosis, and thus avoiding the lumbar spinal sac.

Isolated intramedullary spinal cord cysticercosis

We report a case of intradural, intramedullary, spinal cord neurocysticercosis at dorsal 10-11 (D10-11) level in a mentally retarded male. A 38-year-old, mentally retarded male presented with weakness and stiffness in both the lower limbs and waist since one year. Magnetic resonance imaging revealed a D10-D11 intradural space occupying lesion with cord compression. Intraoperatively, the tumor was grayish white, soft, cystic, and intramedullary with a well-defined plane with surrounding cord tissue. Gross examination revealed a cystic lesion of 1.5×1×0.8 cm, with a whitish nodule of 0.3 cm in diameter. The cyst wall was thin, shiny, and translucent. Microscopic examination revealed cysticercous cyst. Spinal neurocysticercosis should be considered in differential diagnosis of spinal mass lesion in patients residing in endemic area such as India.

CNS Complications in Immunodeficiency Syndromes Due to Mutations in Transcription Factors STAT-1 and GATA-2 (S57.003)

Objective: To describe CNS complications of immunodeficiency syndromes. Background CNS complications of patients with congenital immunodeficiencies are poorly understood. STAT1 and GATA2 are transcription factors that regulate interferon-mediated immune responses and early hematopoiesis, respectively. STAT1 mutations predispose to infection with nontuberculous mycobacteria (NTM), viruses, or mucocutaneous candida, depending on the location of the effect of the mutation. Deficiencies in GATA2 are associated with recurrent infection with NTM, monocytopenia, and transformation to myelodysplastic syndrome/acute myelogenous leukemia. Design/Methods: Three patients from the Neurology Consult Service at the NIH are described with regards to their immunodeficiency syndromes and their neurological presentations. Results: A 22 year old woman with a STAT1 mutation presented with brain lesions and an intramedullary spinal cord lesion due to disseminated coccidioidomycosis, which was refractory to antifungal therapy. Typically, coccidioidomycosis in the CNS infects the intradural and extramedullary spaces. A 3 year old boy with a STAT1 mutation presented with multiple intracranial aneurysms and subarachnoid hemorrhage. While STAT1 protein defects are associated with abdominal aneurysms in the setting of chronic inflammation, CNS aneurysms are recently recognized with gain of function STAT1 mutations. A 38 year old woman with a GATA2 mutation and myelodysplasia developed three deep vein thromboses in five years, followed by multiple cardioembolic strokes due to culture negative subacute endocarditis. The mechanism for her hypercoagulability, and that of other patients with GATA2monomac deficiency is unknown, but GATA2 regulates endothelial gene expression, as well. Conclusions: Neurological signs and symptoms in patients with recurrent infection should prompt the neurologist to consider primary immunodeficiency syndromes. STAT1 and GATA2 transcription factors may predispose patients to vascular as well as infectious CNS complications. The overlap between chronic infection and inflammatory complications, such as cord edema or an inflammatory-type vasculopathy, presents additional challenges in management, since direct immunosuppression is usually not possible. Disclosure: Dr. Kranick has nothing to disclose. Dr. Holland has nothing to disclose. Dr. Uzel has nothing to disclose. Dr. Nath has nothing to disclose.

Dose-escalated radiotherapy with helical tomotherapy to spine oligometastasis from intrahepatic malignancies.

325 Background: Traditional palliative radiotherapy of 30 Gy in 10 fractions to spine metastases often results in poor local control. This study evaluated the role of high dose helical tomotherapy (HT) to improve local control of spine oligometastasis from intrahepatic malignancies Methods: From 2006 to 2010, 11 hepatocellular carcinoma (HCC) patients and 3 intrahepatic cholangiocellular carcinoma patients were treated with HT for oligometastsis to spine. The gross tumor volume (GTV) was the tumor evident from MRI images fused with simulation CT images. Planning target volume (PTV) encompassed involved vertebral body or 1cm margin to GTV. The spinal cord contour represented a small area within the intradural space. To the adjacent spinal cord volume, 20 Gy dose constraint was used. Mega-voltage computed tomography (MVCT) images were used to maintain setup error within 1 mm. We assessed local control rate after HT for spine metastasis in this retrospective study. Pain response was scored by using a numerical rating scale (from 0 to 10). Results: Spine metastatic lesions were treated with median dose of 40 Gy (range 31-51 Gy) and median 5 Gy per fraction (range 3-6 Gy) to GTV and median dose of 29 Gy (range 22.5-42.5 Gy) and median 3.75 Gy per fraction( range 2.5-5 Gy) to PTV. Median biologically equivalent dose (BED, α/β=10 Gy) was 55.2 Gy (range 45.6-76.8) to GTV. Infield failure rate was 35.7% and outfield failure rate was 78.6%. Ten patients initially accompanied pain with spine metastasis (median NPIS 7.5), and all patients showed pain relief after tomotherapy. Complete relief was shown in 20% of patients and partial relief in 80 % of patients, with median NPIS reduction of 5. The patients treated with BED (α/β=10 Gy) over 56 Gy had no local failure. Median local recurrence free survival (LRFS) was 3 months. In the univariate analysis, BED (α/β=10 Gy) over 56 Gy was a prognostic factor associated with improved LRFS (p=0.008). Conclusions: HT was capable of delivering higher BED to metastatic lesions in close proximity of the spinal cord. Spine metastases from intrahepatic tumors were sensitive to high dose radiation, and BED (α/β=10Gy) higher than 56 Gy could improve local control.

Ocular melanoma metastasis to the cervical spine

Ocular melanoma is a rare type of malignant melanoma. Melanoma metastatic to the spine typically arises within the vertebral column, presents with back pain, and has a poor prognosis. We present a patient with a unique disease course: ocular melanoma metastasis occurred after an extended latency period of 14years, attained a large size within the spinal intradural space, presented with severe neurological deficits without additional central nervous system disease, and the tumor was amenable to surgical intervention. We also review the literature on melanoma spine metastasis.

Intradural Extramedullary and Subcutaneous Tumors in Neonate : Atypical Myxoid Spindle Cell Neoplasm

Tumors of the central nervous system are common in the pediatric population and constitute the second most prevalent tumor type in children. Within this group, spinal cord tumors are relatively rare and account for 1 to 10% of all pediatric central nervous system tumors. We describe a very rare case of an intradural extramedullary spinal cord tumor with a subcutaneous mass and discuss its clinical presentation, pathogenesis, and treatment. A male infant was delivered normally, with uneventful development. At 16 days post-delivery, his family took him to a pediatrician because of a mass on his upper back. Magnetic resonance imaging of the thoracic spine revealed a well-demarcated soft-tissue mass with central cystic change or necrosis at the subcutaneous layer of the posterior back (T2-7 level). Another mass was found with a fat component at the spinal canal of the T1-3 level, which was intradural extramedullary space. After six weeks, the spinal cord tumor and subcutaneous mass were grossly total resected; pathologic findings indicated an atypical myxoid spindle cell neoplasm, possibly nerve sheath in type. The final diagnosis of the mass was an atypical myxoid spindle cell neoplasm. The postoperative course was uneventful, and the patient was discharged after nine days without any neurological deficit. We report a rare case of an intradural extramedullary spinal tumor with subcutaneous mass in a neonate. It is necessary to monitor the patient's status by examining consecutive radiologic images, and the symptoms and neurological changes should be observed strictly during long-term follow-up.

CT evaluation of caudal versus lumbar access to the intradural space

Background: Percutaneous intraspinal navigation is a new procedure that enables visualization of the central nervous system using a lumbar puncture technique. Past research shows promising potential, but is limited by damage to expensive fiberscopes due to the sharp angle of manipulation at L3-L4. Our objective in this study is to analyse the feasibility of a novel access through the sacral hiatus to eliminate this problem.Methods: We retrospectively reviewed computed tomography images of the sacrum of 132 subjects, of which nine were excluded either secondary to incomplete imaging of the sacrum or variant anatomy that precluded any possible measurements. Of the remaining 123 patients, we measured kyphotic and lordotic curvature of the sacral canal in comparison to the angle of lumbar puncture. We also measured the anteroposterior diameters of the sacral canal at the distal, middle, and proximal portions.Results: There were no significant differences according to sex or age. The kyphotic angle was a wide angle with a mean value of 167·89±11·71°. The lordotic angle had a mean value of 133·35±7·84°, making it 25·52° more obtuse than the average angle for lumbar puncture. The smallest diameter of the sacral canal was at the sacral hiatus and had a mean value of 4·49±1·66 mm.Conclusion: The size and anatomy of the sacral canal is feasible for PIN procedure and appears more favorable as compared to entry via lumbar puncture. The canal opening is wide enough to accommodate most small-diameter fiberscopes without difficulty, and the angles are obtuse enough to limit damage to the expensive fiberscopes.

Long-term Results of Spinal Cord Injury Therapy Using Mesenchymal Stem Cells Derived From Bone Marrow in Humans

Although the transplantation of mesenchymal stem cells (MSCs) after spinal cord injury (SCI) has shown promising results in animals, less is known about the effects of autologous MSCs in human SCI. To describe the long-term results of 10 patients who underwent intramedullary direct MSCs transplantation into injured spinal cords. Autologous MSCs were harvested from the iliac bone of each patient and expanded by culturing for 4 weeks. MSCs (8 × 10) were directly injected into the spinal cord, and 4 × 10 cells were injected into the intradural space of 10 patients with American Spinal Injury Association class A or B injury caused by traumatic cervical SCI. After 4 and 8 weeks, an additional 5 × 10 MSCs were injected into each patient through lumbar tapping. Outcome assessments included changes in the motor power grade of the extremities, magnetic resonance imaging, and electrophysiological recordings. Although 6 of the 10 patients showed motor power improvement of the upper extremities at 6-month follow-up, 3 showed gradual improvement in activities of daily living, and changes on magnetic resonance imaging such as decreases in cavity size and the appearance of fiber-like low signal intensity streaks. They also showed electrophysiological improvement. All 10 patients did not experience any permanent complication associated with MSC transplantation. Three of the 10 patients with SCI who were directly injected with autologous MSCs showed improvement in the motor power of the upper extremities and in activities of daily living, as well as significant magnetic resonance imaging and electrophysiological changes during long-term follow-up.

An Anatomical Study of the Intradural Space

We have previously postulated that it is possible to accidentally insert an epidural needle or catheter into the substance of the dura during attempted epidural block, creating an intradural space. It appears that injection of local anaesthetic into an intradural space leads to an initially inadequate neuraxial block but further doses may produce an extensive life-threatening block. In the laboratory, 54 samples of human thoraco-lumbar dura were obtained from six cadavers and prepared for scanning electron microscopy. Images from these dehydrated specimens were assessed for the presence of spaces within the dura, and attempts were made to insert an epidural catheter, under optical microscopy, into the substance of the dura in 32 cases. Electron microscopy revealed the concentric laminae that compose the dura and the presence of artefactual spaces between some of these. It was possible to insert an epidural catheter into the substance of the dura in eight specimens, creating intradural spaces which remained following catheter removal. If this represents the clinical situation, it may help to explain previously reported cases of atypical neuraxial block and their associated radiological findings.

Traumatic sacral pseudomeningocele with spina bifida occulta

Pseudomeningocele arises after spinal fracture and nerve root avulsion or after complications of spine surgery. However, traumatic pseudomeningocele with spina bifida occulta is rare. In this report, a traumatic pseudomeningocele in a patient with spina bifida occulta that required surgical treatment is documented. This 37-year-old man presented to the authors' hospital with headache and a fluctuant mass in the center of his buttocks. A CT scan with myelography and MR imaging of the sacral region revealed a large subcutaneous area of fluid retention communicating with the intradural space through a defect of the S-2 lamina. Because 3 months of conservative treatment was unsuccessful, a free fat graft was placed with fibrin glue to seal the closure of the defect, followed by 1 week of CSF drainage. This is the first report on traumatic pseudomeningocele with spina bifida occulta successfully treated in this manner.

E-003 Localization of spinal dural arteriovenous fistula: diagnosis and implications

PurposeSpinal Dural Arteriovenous Fistula (SDAVF) is a rare acquired lesion that can impair spinal cord function. Early diagnosis is very important since the symptoms can be reversed if treated prior...