Left C2 Research Articles

Giant cell arteritis with cervical radiculopathy mimicking polymyalgia rheumatica and elderly-onset rheumatoid arthritis: a case report

BackgroundGiant cell arteritis has a wide variety of clinical symptoms, one of them being cervical radiculopathy, which mainly involves the C5 nerve root. If the patient does not develop typical clinical symptoms of giant cell arteritis but has C5 radiculopathy, it may be misdiagnosed as polymyalgia rheumatica or elderly-onset rheumatoid arthritis due to old age, high serum inflammatory markers, and difficulty in raising both upper limbs.Case presentationA 72-year-old Japanese man with a month-long history of dyspnea on exertion and with difficulty in raising both upper limbs was referred to our hospital because of elevated serum C-reactive protein (12.62 mg/dL). He had no typical symptoms of giant cell arteritis such as headache, jaw claudication, visual loss, and fever. The patient tested negative for rheumatoid factor and anti-cyclic citrullinated peptide antibody, and matrix metalloproteinase-3 was within the normal range (54.3 ng/mL). Musculoskeletal ultrasound examination showed absence of tenosynovitis, bursitis, and synovitis, and the patient did not meet the classification criteria of polymyalgia rheumatica or rheumatoid arthritis; hence, those two diseases were unlikely. A precise neurological examination suggested bilateral C5 and C6 anterior radiculopathy and left C4 radiculopathy. Since cervical magnetic resonance imaging showed no mechanical causality, cervical radiculopathy of unknown origin was suggested. Fluorodeoxyglucose positron emission tomography/computed tomography revealed increased fluorodeoxyglucose lineal uptake along the vessel walls, including temporal arteries, vertebral arteries, and axillary arteries. Results of the biopsy of the left superficial temporal artery were compatible with giant cell arteritis. He was successfully treated with 30 mg of prednisolone, and both upper limbs could be elevated.ConclusionsIf the patient was misdiagnosed with polymyalgia rheumatica or elderly-onset rheumatoid arthritis based on only clinical symptoms and laboratory data, his symptoms might not improve due to insufficient steroid dose and vascular complications may occur later. Although rare, peripheral neuropathy in giant cell arteritis may include cervical radiculopathy. The musculoskeletal ultrasound and precise neurological examination were the turning points for the diagnosis of this case, and making a careful diagnosis using these methods was important.

Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report

BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.

Combining task-based rehabilitative training with PTEN inhibition promotes axon regeneration and upper extremity skilled motor function recovery after cervical spinal cord injury in adult mice

BackgroundConditional deletion of Pten in corticospinal neurons promotes axon sprouting and regeneration after spinal cord injury (SCI). However, regeneration studies targeted on PTEN inhibition seldom show motor function recovery. The promotion of functional recovery can be improved by rehabilitative training under a use-dependent plasticity mechanism. PurposeTo investigate the combined effects of PTEN inhibition and rehabilitative training on axon regeneration and subsequent motor functional improvement after cervical spinal cord injury. MethodsLentiviral particles (Lenti-PTEN-RNAi or Lenti-Scrambled-EGFP) were injected into the right sensorimotor mouse cortex in four experimental groups (PTEN RNAi + Training, PTEN RNAi, Control + Training, Control). Two weeks after injection, all mouse groups received a left C5 crush injury. We performed task-based rehabilitative training for 4 weeks on the PTEN RNAi + Training and Control + Training groups. Biotinylated dextran amine (BDA) was used for anterograde tracing of the dorsal corticospinal tract (dCST). We analysed axonal regeneration through immunohistochemical methods. A battery of behavioral tests was employed to assess functional recovery at Day3 and every other week after injury. ResultsCombining rehabilitative training with PTEN inhibition induced more axon regeneration and synapse reformation in the spinal cord caudal to the lesion site. Rostral to the lesion, the transected dCST axons sprouted into gray matter upon contact. Furthermore, forelimb function was found to be improved after combination therapy during behavioral testing. ConclusionCombining task-based rehabilitative training with PTEN inhibition further promotes axon regeneration, synaptic plasticity and reorganization of the neural network, with significant improvement in forelimb skilled motor function after cervical spinal cord injury. Our study provides new therapeutic insights for spinal cord injury management in the future.

A case of hemichorea in RNF213-related vasculopathy

BackgroundInternal carotid artery (ICA) stenosis has been recently reported to cause hemichorea, mainly in East Asia. The East Asian-specific p.R4810K variant of RNF213, a susceptibility gene for moyamoya disease (MMD), accounts for up to 25% of sporadic ischemic stroke with ICA stenosis cases in East Asia. However, as RNF213-related vasculopathy does not meet the diagnostic criteria for MMD, the creation of a new disease category has been suggested. Here, we report the first case of hemichorea in RNF213-related vasculopathy.Case presentationAn 81-year-old woman was admitted to our hospital with choreic movements in the periphery of the right extremities at rest. Though head magnetic resonance imaging showed no fresh or old cerebral infarction, 123I-iodoamphetamine-single photon emission computed tomography showed cerebral blood flow of < 80% in the anterior territory of the left middle cerebral artery (MCA) in a resting state and cerebrovascular reactivity of < 10% in the broader area supplied by the left MCA after acetazolamide challenge. Head magnetic resonance angiography and digital subtraction angiography revealed left ICA C1 portion stenosis with compromised collateral vessels. Involuntary movements resolved with haloperidol administration within 3 days, without apparent recurrence from continuation of the medication for a year. Genetic testing revealed the presence of the heterozygous RNF213 p.R4810K variant.ConclusionsChorea is thought to be caused by damage to circuitry connecting the basal ganglia with the cerebral cortex, as found in cases of MMD, which possess aberrant vessels in the basal ganglia. However, aberrant vessels and cerebral infarctions were not observed in the basal ganglia in the current case, decreasing the likelihood of a role in chorea. Alternatively, as RNF213 regulates vascular endothelial function and angiogenesis, dysregulation may impair the neurovascular unit and damage basal ganglia circuitry, contributing to the development of chorea. This case may renew interest in the concept of RNF213-related vasculopathy and the pathophysiological mechanisms behind chorea in ICA stenosis.

Fractured cervical facet osteophyte causing acute traumatic myelopathy: Case report

A 52-year-old gentleman presented with acute onset quadriparesis of ten days duration after a trivial fall. Both extremities had grade-2 power. Bilateral hand grip was poor with interossei weakness. The sensation was reduced below C6 with positive Lhermitte’s sign. Deep tendon reflexes were exaggerated except absent bilateral biceps jerk. The bowel and bladder had urgency and frequency. Neck movements were terminally painful. CT and MRI showed a floating bony spicule adjacent to left C5-6 facet joint encroaching the spinal canal causing cord compression. A focal left C5 hemi-laminectomy and foraminotomy were performed. A onecm floating bony spicule adjoining to left C5-6 facet joint was excised. Biopsy ruled out osteochondroma and synovial cyst. The power improved to grade-4 in both extremities with moderate grip and he became dependent ambulatory within three months of surgery. At the end of two years, he recovered almost completely with residual mild left-hand grip weakness.

Phrenic nerve palsy after cervical laminectomy and fusion

BackgroundPhrenic nerve palsy is a rare complication of cervical spine surgery. There are no previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. Here, we present a case of a 69 year-old Caucasian male with severe cervical stenosis with myelopathy who underwent posterior spinal instrumentation and fusion (PSIF) from C2 to T2, with laminectomies at C3-C7. OutcomeThe patient developed respiratory distress post-operatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. He was also noted to have a left C5 palsy affecting his deltoid function and proximal upper extremity sensation which gradually improved. ConclusionsThis is the first reported case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

Analysis of three-dimensional facet joint displacement during two passive upper cervical mobilizations

BackgroundUnderstanding the 3D-kinematics of the upper cervical spine during manual mobilization is essential for clinical examination and therapy. Some information about rotational motion is available in literature but translational components are often ignored, complicating the understanding of the complex inter-segmental motions. ObjectivesThis study aims to describe the amount, trajectories and reproducibility of atlanto-occipital facet joints’ displacement during a flexion-extension mobilization and of the atlanto-axial facet joints during an axial rotation mobilization. DesignOriginal research using quantitative data. Methods20 fresh frozen human cervical specimens were examined with a Zebris® CMS20 ultrasound-based motion tracking system. Two physiotherapists performed regionalmobilizations in flexion-extension and axial rotation. The amount of displacement and the trajectories were calculated along the XYZ axes. Difference between measurements was evaluated with the Friedman two-way ANOVA test. Intra- and inter-rater reliability were estimated through ICC scores. Results3D-displacement (2.6–23.4 mm) was larger at C1–C2 during axial rotation, Atlanto-occipital flexion displayed the greatest variability in the C0 trajectory. During a right rotation, the left C1 facet moved mainly forward, and the right C1 facet moved backward. During a left rotation, the left C1 facet moved backward, while the right C1 facet moved forward. Intra-tester and Inter-tester ICCs varied between 0.5 and 0.90 (p < 0.005). ConclusionsDuring passive spinal motion, there is an important variability in magnitude and trajectory of joints’ displacement. Nevertheless, different clinicians may be able to achieve the same position at the end of the mobilization.

Microsurgical Technique for Treatment of Perimedullary Spinal Arteriovenous Fistulae: 2-Dimensional Operative Video

The case is of a 49-yr-old female admitted after acute onset lower cervical/upper thoracic region pain with left hemi-body hypoesthesia below the C7 level. Magnetic resonance imaging showed a spinal cord intraparenchymal hemorrhage at the C6/7 levels. Physical exam revealed hypoesthesia on the left from C7 and below with associated 3/5 wrist and finger extensor and 4/5 triceps strength on the left. The remainder of the neurological exam was normal including lower extremity strength and bowel/bladder function. A craniocervical angiogram showed a perimedullary arteriovenous fistula on the left, ventrolateral aspect of the spinal cord with a single feeding artery that originated from the thyrocervical trunk and entered through the left C6 nerve root sleeve. Venous drainage was cephalad to cortical cerebellar veins and to the suboccipital plexus. A branch of the thyrocervical trunk supplying the ventral spinal cord originated close to the fistula, which precluded endovascular embolization. The patient underwent C6-T1 laminectomies for microsurgical treatment of the fistula. This case demonstrates multiple key concepts in the surgical management of these rare lesions as follows: the ventral aspect of the cervical spinal cord can be safely approached from posterior. The venous anatomy is often confusing and intraoperative angiography utilizing both indocyanine green and conventional digital subtraction techniques are of paramount importance. Unlike arteriovenous malformations, the venous drainage can be pruned to gain visualization and trace the venous anatomy retrograde to the point of the fistula. The patient awoke from surgery at her neurological baseline. The patient consented to de-identified publication of this case.

C1 hypertrophic lateral mass resection and occiput-C2 fusion.

This case involved a 6-year-old boy with Down syndrome, left C1 lateral mass hypertrophy, C1–2 rotatory subluxation, and spinal cord compression. He presented after falling down some stairs at his home. Torticollis, dysphagia, and speech delay were noted on examination. Vascular imaging showed impingement on the left vertebral artery by the anomalous C1 lateral mass. Through a posterior approach, the hypertrophic C1 lateral mass was resected, and an occiput–C2 fusion was performed. Postoperatively, his torticollis and brainstem symptoms were resolved.The video can be found here: https://youtu.be/1U0GLdw6c70

MO068A KIDNEY-ON-THE-CHIP APPROACH USING PRIMARY HUMAN TUBULAR CELLS IN A 3D CO-CULTURE SYSTEM

Abstract Background and Aims Conventional 2D mono-culture in vitro models using immortalized cell lines are still widely used in experimental nephrology, although their value is limited by poor translatability and predictive value for the in vivo or even human situation. The implementation of more sophisticated in vitro assays as routine cell culture systems is often limited by complex protocols and long lasting procedures. We aimed to establish and validate a relatively easy-to-use but yet (patho-) physiologically relevant cell culture assay that mimics key aspects of the in vivo situation of renal tubules, including a leak-thight epithelium with a luminal and baso-lateral side, interstitial matrix, a peri-tubular capillary and circulating blood cells inside its lumen. Method We utilized the 3-lane OrganoPlate® system (Mimetas, Leiden, Netherlands) as a scaffold. After infusing a collagen I matrix in the middle channel (C2), primary human renal progenitor cells are seeded into the upper channel (C1), adhering to the C2-matrix. The plate is put on a perfusion rocker (Mimetas), that facilitates continuous gravity-triggered bi-directional perfusion of C1. Within 48h the cells form a leak-tight tubular structure with a continuous lumen. Next, human endothelial cells are seeded into the bottom channel (C3), which adhered to the opposite site of the C2-matrix and – upon continuous perfusion – formed a vessel-like structure with a continuous lumen, as well. Finally, primary human white blood cells were isolated and seeded into C3 (see figure). Results Establishing the whole tubule-on-the-chip as described above takes on average three days. We investigated its operational life span by monitoring the barrier integrity of the tubular structure in C1 using a fluorescence-labeled dextran (150 kDa). Over a course of 5 days the tubular integrity did not decline, suggesting that the co-culture system remains stable and functional for at least 5 days. In accordance with other studies, the primary human tubular cells constituting the 3D tubule-on-the-chip expressed higher levels of functionally relevant proteins, e..g the tight-junction protein ZO-1 and the sodium-potassium-pump Na-K-ATPase, compared to standard 2D settings without perfusion. This emphasizes, that even primary cells show a physiologically reduced phenotype in standard 2D settings, which possibly impedes the identification and representative quantification of physiologically and hence also patho-physiologically relevant mechanisms in vitro. To study the interaction of cells in the tubule-on-the-chip, we investigated the recruitment of immune cells from C3 (vessel) across C2 (interstitium) to C1 (renal tubule), which - in vivo - represents a detrimental mechanism of action in intrarenal forms of AKI. Under baseline conditions the immune cells inserted into C3 did not leave their compartment. Upon damaging the tubular cells in C1 with extracellular histones, neutrophils and monocytes left C3 (extravasation), migrated through C2 and could be found in close contact with epithelial cells of C1. This serves as a proof of principle, that the tubule-on-the-chip is applicable to study complex cell-cell and cell-substrate interactions, such as chemokine-mediate immune cell homing. Measuring lactate dehydrogenase release for a number of known nephrotoxic agents revealed, that tubular cells forming a 3D-structure while kept under perfusion show significantly different responses to the same dose compared to standard 2D conditions, suggesting that dose-response studies using target cells out of their tissues context can be misleading when extrapolating results from in vitro to in vivo. Conclusion The results of this study suggest, that sophisticated 3D co-culture models of a renal tubule including an interstitial compartment, a peri-tubluar capillary and circulating immune cells are feasible and potentially suited to allow for in depth mechanistic studies in vitro.

A Cervical Spinal Cord Hemi-Contusion Injury Model Based on Displacement Control in Non-Human Primates (Macaca fascicularis).

Non-human primate (NHP) spinal cord injury (SCI) models can be informative in the evaluation of treatments that show promise in rodent models prior to translation to humans. In the present study, we aimed to establish a cervical spinal hemi-contusion model with controlled displacement and evaluate the abnormalities in behavior, electrophysiology, histology, and magnetic resonance imaging. Twelve adult NHPs were divided into an SCI group (n = 8, 24 and 48 weeks) and a control group (n = 4). An impactor (Φ = 4 mm) was driven to compress the left C5 cord at 800 mm/sec. The contusion displacement and peak force was 4.08 ± 0.17 mm and 19.8 ± 4.6 N. The behavioral assessment showed a consistent dysfunction below the wrist and spontaneous recovery of limb function after injury. Lesion length and lesion area at the epicenter based on T2 hyperintensity were 5.68 ± 0.47 mm and 5.99 ± 0.24 mm2 at 24 weeks post-injury (wpi), and 5.29 ± 0.17 mm and 5.95 ± 0.24 mm2 at 48 wpi. The spared spinal cord area immuno-positive for glial fibrillary acidic protein was significantly reduced, while the staining intensity increased at 24 wpi and 48 wpi, compared with the sham group. Ipsilateral somatosensory and motor evoked potentials were dynamic, increasing in latency and decreasing in amplitude compared with pre-operative values or the contralateral values, and correlated to varying degrees with behavioral outcomes. A shift in size-frequency distribution of sensory neurons of the dorsal root ganglia (DRG) was consistent with a loss of large-diameter cells. The present study demonstrated that the NHP SCI model resulted in consistent unilateral limb dysfunction and potential plasticity in the face of loss of spinal cord and DRG tissue.

A 30-year-old patient with a C8 nerve root lesion: question

•A very uncommon case of cervical nerve root Ewing sarcoma was presented.•The preoperative diagnosis of such lesion is challenging.•The correct diagnosis of Ewing sarcoma is essential to plan an effective chemoradiotherapy. A 30-year-old woman presented with a 3-week history of pain and hypoesthesia of the ulnar side fingers of the left hand. The symptoms spread to the ipsilateral whole arm and shoulder, associated with weakness of the triceps brachialis. Neurological examination revealed also reduction of triceps and biceps brachialis reflexes. Magnetic resonance imaging (MRI) showed a 5 × 7 × 9 mm low-enhancement lesion, localized at the left C8 nerve root (Fig. 1A, B). The patient underwent hemi-laminectomy with total removal of the lesion. a.Schwannomab.Non-Hodgkin’s lymphomac.Solitary fibrous tumord.Ewing sarcomae.Neurofibroma Answer on page: 240. Patient details and images have been anonymised. No conflict of interests by any of the authors. A 30-year-old patient with a C8 nerve root lesion: AnswerJournal of Clinical NeuroscienceVol. 77PreviewHistological examination showed nerve root fascicles infiltrated by a small round cell tumor (Fig. 2A) positive for vimentin, synaptophysin, CD99 and FL1, and negative for S-100, AE1/AE3, CD45 and CD56. Ki-67 labeling index reached 15%. FISH analysis revealed EWSR1 rearrangement (Fig. 2B), confirming the diagnosis of Ewing sarcoma. Postoperative course was uneventful, characterized by decrease of the pain and improvement of the neurological symptoms. A total-body CT and PET scans were negative, suggesting a primitive origin of the tumor from the C8 nerve root. Full-Text PDF

Extirpation of a Ruptured Anterior Spinal Artery Aneurysm Accompanied by Dural Arteriovenous Fistula at the Craniovertebral Junction via a Posterolateral Approach: The Management of Extradural Venous Congestion.

Objective This study was aimed to discuss how to control extradural venous congestion with an increased pressure in cases of arteriovenous shunt disease of the craniovertebral junction. Design The study is presented through an operative video. Results A 77-year-old patient with subarachnoid hemorrhage had a dural arteriovenous fistula located at the C1–C2 level. Left vertebral angiography showed a fistula between the left C2 radiculomeningeal muscular artery and perivertebral plexus. Furthermore, right vertebral angiography showed a ruptured aneurysm at the aberrant branch of the anterior spinal artery originating from the contralateral vertebral artery (VA), possibly formed because of the concurrently increased pressure of the perimedullary veins. Aneurysm extirpation was planned through a posterolateral approach. To reduce venous bleeding during the approach, preoperative embolization of the radiculomeningeal muscular artery was performed. During surgery, the suboccipital triangle was exposed following layer-by-layer dissection of the suboccipital muscles ( Figs. 1 and 2 ). Subperiosteal dissection of the paravertebral plexus surrounding the VA around the C1 lamina was effective to avoid venous bleeding. A bloodless operative field was achieved, and key anatomical structures, such as the C2 nerve root, feeder, and V3 portion of the left VA, were clearly identified. With a sufficient amount of lateral exposure, the ruptured anterior spinal artery aneurysm was successfully extirpated with bipolar coagulation. The patient was discharged with no neurologic deficit. Fig. 1 ( A ) The initial CT scan showing the subarachnoid hemorrhage. ( B ) Left vertebral angiogram demonstrating a dural arteriovenous fistula at the craniovertebral junction. ( C ) Right vertebral angiogram showing an aneurysm (arrow) arising at the aberrant branch of the anterior spinal artery. ( D ) The postoperative angiogram demonstrating the extirpation of the aneurysm (arrowhead). Fig. 2 ( A ) Intraoperative photograph showing the subperiosteal dissection technique to protect the vertebral artery and minimize the bleeding from the paravertebral plexus. ( B ) The sufficient posterolateral exposure was obtained with minimal bleeding. C1, C1 lamina; C2, C2 lamina; Occ, occipital bone. Conclusion Controlling extradural venous congestion is essential to obtain a clear operative field in cases of arteriovenous shunt disease at the craniovertebral junction. The link to the video can be found at: https://youtu.be/fCT69WtAQbo .

Transient neurologic deficit with complete recovery due to cervical spinal cord infarction after preoperative embolization for metastatic lesion of malignant pheochromocytoma at proximal thoracic spine

Spinal cord infarction after preoperative transarterial embolization for metastatic spinal lesions is uncommon and usually leads to complete paralysis. Transient neurologic deficit due to spinal cord infarction after preoperative embolization for spinal metastases has never been reported in the literature. A 30-year-old female patient was diseased with malignant pheochromocytoma and multiple metastases to lung and bones. She suffered from refractory pain at upper back and numbness at her body below xiphoid process but no motor deficit was noted at extremities. Magnetic resonance imaging (MRI) revealed paraspinal and epidural lesions originating from T2 to T4 vertebrae with compression to spinal cord. Preoperative embolization was executed to the spinal metastases with the intent to reduce intraoperative bleeding. Embolization procedure was performed to bilateral costocervical trunk, 3rd and 4th intercostal arteries with 400 μm Embozene® microsphere under local anesthesia. The procedure was discontinued immediately after development of severe hypertension that might be related to the pheochromocytoma and was treated with intravenous antihypertensive drug. There was no neurologic deficit until 6.5 hours after the procedure when weakness at right lower extremity and hypesthesia at left arm developed. Emergent MRI showed focal infarcts in spinal cord at right aspect of C5 and left C4 levels. With adequate hydration but no administration of steroid, muscle power gradually recovered in a few hours. Posterior instrumentation, neural decompression and tumor debulking were performed 2 days after embolization as scheduled. One week after the event of spinal cord infarction, she could stand up and walk without aid. Even though it is rare, spinal cord infarction is an important differential diagnosis for sudden decrease of muscle power after preoperative embolization for spinal metastases. Although complete paralysis is more common, transient neurologic deficit with complete recovery could happen in patients with minor infarcts in the spinal cord.

Transient neurologic deficit with complete recovery due to cervical spinal cord infarction after preoperative embolization for metastatic lesion of malignant pheochromocytoma at proximal thoracic spine

Spinal cord infarction after preoperative transarterial embolization for metastatic spinal lesions is uncommon and usually leads to complete paralysis. Transient neurologic deficit due to spinal cord infarction after preoperative embolization for spinal metastases has never been reported in the literature. A 30-year-old female patient was diseased with malignant pheochromocytoma and multiple metastases to lung and bones. She suffered from refractory pain at upper back and numbness at her body below xiphoid process but no motor deficit was noted at extremities. Magnetic resonance imaging (MRI) revealed paraspinal and epidural lesions originating from T2-4 vertebrae with compression to spinal cord. Preoperative embolization was executed to the spinal metastases with the intent to reduce intraoperative bleeding. Embolization procedure was performed to bilateral costocervical trunk, 3rd and 4th intercostal arteries with 400 μm Embozene® microsphere under local anesthesia. The procedure was discontinued immediately after development of severe hypertension that might be related to the pheochromocytoma and was treated with intravenous antihypertensive drug. There was no neurologic deficit until 6.5 hours after the procedure when weakness at right lower extremity and hypesthesia at left arm developed. Emergent MRI showed focal infarcts in spinal cord at right aspect of C5 and left C4 levels. With adequate hydration but no administration of steroid, muscle power gradually recovered in a few hours. Posterior instrumentation, neural decompression and tumor debulking were performed 2 days after embolization as scheduled. One week after the event of spinal cord infarction, she could stand up and walk without aid. Even though it is rare, spinal cord infarction is an important differential diagnosis for sudden decrease of muscle power after preoperative embolization for spinal metastases. Although complete paralysis is more common, transient neurologic deficit with complete recovery could happen in patients with minor infarcts in the spinal cord.

The benefits of radiological imaging for postoperative orthostatic headache: a case report

BackgroundTraditionally, the diagnosis of post-dural puncture headache (PDPH) relied upon the patient’s history regarding dural puncture and symptoms, such as orthostatic headache. However, such evidence may not always be reliable or specific. We report an unexpected diagnosis with spontaneous intracranial hypotension (SIH), which was confirmed upon examination of Magnetic Resonance (MR) images in a patient who was initially suspected to have PDPH because he had recently undergone a uncertain dural puncture.Case presentationA 45-year-old man had undergone a thoracic epidural catheter insertion for perioperative analgesia prior to general anesthesia induction. Due to intermittent dripping of fluid while the epidural needle was being advanced, a dural puncture was suspected. The patient complained of an orthostatic headache after recovery from surgery, therefore a PDPH was suspected. MR images revealed signs of SIH: dural sinus engorgement, contrast enhancement along the neural sleeves of the left C6–7, bilateral C7-T1, T1–2, T2–3, T3–4, T4–5, and T5–6. Computed tomography-guided epidural blood patching (EBP) was performed the following day, with the patient experiencing immediate relief of the headache.ConclusionThe benefits of radiological imaging in this case included confirming the correct diagnosis, guiding the accurate level and proper approach of EBP, distinguishing the epidural space from the intrathecal space, and ultimately increasing the likelihood of successful EBP.

Suboccipital neuralgia after C1 pedicle screw insertion: do we neglect atlantooccipital joint violation? - Case report and literature review

BackgroundOccipital neuralgia is one of the postoperative complications of C1 lateral mass screw insertion, which was deemed to be related with the C2 nerve root dysfunction.Case presentationA 52-year-old female patient presented with gradually progressive numbness and weakness in her extremities for 6 months. X-ray and computed tomography (CT) scan revealed obvious anterior atlantoaxial dislocation (ADD), which was reducible on extensive view. Atlantoaxial pedicle screw fixation and bone graft was performed. Immediately after the operation, the neurological symptom significantly improved. The patient complained of restricted cervical rotation and suboccipital neuralgia which was exacerbated by rotation with an intensity of 7 on a visual analog scale (VAS) ranging from 0 to 10 at postoperative day 5. While a satisfactory reduction was detected in the postoperative CT, violation of the left atlantooccipital joint was observed in the left C1 screw. Nimesulide (daily dosage of 0.2 g) and bracing were recommended immediately. At the 2 month follow-up, both the neurological improvement and reduction were maintained. The VAS of suboccipital neuralgia is 3 and decreased to 1 at 6 months postoperative. Bony fusion of the left atlantooccipital joint was confirmed by CT scan at 6 months postoperative. The patient complained that the suboccipital neuralgia was tolerable without the assistance of braces or medications for pain. At the 18 month follow-up, only stiffness of head flexion and rotation was observed without suboccipital neuralgia.ConclusionSuboccipital neuralgia after atlantooccipital joint violation of C1 pedicle screw placement most likely results from C1 nerve root irritation. As the corresponding dermatome differs from the distributing region and aggravated factor of C2 nerve root dysfunction, neuralgia due to C1 irritation was only localized at suboccipital region and exacerbated by rotation.

Applying Pulse Spectrum Analysis to Facilitate the Diagnosis of Coronary Artery Disease.

Not all patients with angina pectoris have coronary artery stenosis. To facilitate the diagnosis of coronary artery disease (CAD), we sought to identify predictive factors of pulse spectrum analysis, which was developed by Wang and is one technique of modern pulse diagnosis. The patients suffered from chest pain and received cardiac catheterization to confirm the CAD diagnosis and Gensini score were recruited. Their pulse waves of radial artery were recorded. Then, by performing a fast Fourier transform, 10 amplitude values of frequency spectrum harmonics were obtained. Each harmonic amplitude was divided by the sum of all harmonic amplitude values, obtaining the relative percentages of 10 harmonics (C1-C10). Subsequently, multivariate logistic regression was conducted with two models and the areas under the receiver operating characteristic curves (ROC) of these 2 models were compared to see if combining the pulse diagnosis parameters with the risk factor of CAD can increase the prediction rate of CAD diagnosis. The predictive factors of CAD severity were analyzed by multivariate linear regression. A total of 83 participants were included; 63 were diagnosed CAD and 20 without CAD. In the CAD group, C1 was greater and C5 was lower than those of the non-CAD group. The CAD risk factors were put alone in Model 1 to perform the multivariate logistic regression analysis which had a prediction rate of 77.1%; while putting the C1 and C5 harmonics together with the risk factors into Model 2, the prediction rate increased to 80.7%. Finally, the area under ROC of Model 1 and Model 2 was 0.788 and 0.856, respectively. Furthermore, left C1, left C5, gender, and presence of hyperlipidemia were predictors of CAD severity. Therefore, pulse spectrum analysis may be a tool to facilitate CAD diagnosis before receiving cardiac catheterization. The harmonics C1 and C5 were favorable predictive indicators.

Accuracy of Bony Gutter Placement in Cervical Laminoplasty Assisted by 3-D Print Modeling, and Associations with Posterior Spinal Cord Shift and Radiculopathy.

Introduction We evaluated the positioning of the bony gutter (PBG) in cervical laminoplasty aided by three-dimensional (3-D) printed models, and assessed associations between PBG accuracy¸ posterior shift of the spinal cord (PSSC), and clinical results. Methods Of 35 patients who underwent cervical laminoplasty for cervical myelopathy between January 2013 and September 2015, 20 were treated using a conventional free-hand technique (Group A). For the other 15 patients (Group B), surgeons also used 3-D printed models to select a PBG on the edge of the medial aspect of the zygapophyseal joint to maximize the angle of the opened lamina (AOL). We measured the PBG and AOL on axial computed tomography images, and the PSSC on midsagittal magnetic resonance imaging obtained before and 7 days after surgery. Clinical outcomes were evaluated by Japanese Orthopaedic Association (JOA) scores and recovery rates, and by the incidence of postoperative radiculopathy. We compared the PBG, AOL, PSSC, and clinical outcomes between the groups. Results The PBG was significantly lower in Group B than in Group A at the C4 left and right sides (P = 0.033, P < 0.0001) and C6 left side (P = 0.004), and the AOL was larger at the C4 right side, C5 left and right sides, C6 left side, and C7 right side (P = 0.040, 0.043, 0.016, 0.016, and 0.027, respectively). Group B had a higher percentage of on-target PBGs at the right sides of C4 and C5 and the left side of C7 (P = 0.005, 0.037, and 0.028), a larger PSSC at C4 and C5 (P = 0.023, 0.008), and a higher incidence of radiculopathy (P = 0.026). Groups A and B did not differ significantly in JOA score or recovery rate. Conclusions Three-dimensional modeling improved PBG accuracy. However, maximizing the spinal canal increased the PSSC and subsequent radiculopathy.

Hear Hooves, Think Zebras: A Case Report & Systematic Literature Review of Isolated Neck Node Metastases from Prostate Cancer

Most cancers that metastasize to the cervical lymph nodes are from the upper aerodigestive tract. We use a case report and systematic literature review to highlight a very rare example of atypical metastatic spread to the cervical lymph nodes from advanced prostate cancer without involvement of other lymph node groups. All possible clinical, imaging and pathological documents were collected from the patient’s chart. Those documents were subjected to an independent review and data abstraction. A literature search was performed using relevant key words and MESH headings. Additional papers were found using the ‘cited by’ and ‘related articles’ functions of the search engines, and the references section of relevant papers. In July 2012, a 56 year old man presented with PSA 8ng/ml, cT2a, Gleason 8 prostate adenocarcinoma. Metastatic workup was negative and he had a radical prostatectomy. He had extensive positive surgical margins, pT3b N0, Gleason 9, with post-operative PSA of 0.77 and underwent salvage radiotherapy to the prostate bed with 2 years of adjuvant androgen deprivation therapy (ADT). In July 2015, he developed widespread bony metastases and received 6 cycles of chemotherapy with ADT. He subsequently developed castrate-resistant disease. In December 2017, the patient reported a painful lump in his left neck. PSA was 0.22 ng/ml. Ultrasound-guided aspiration confirmed metastasis from prostate cancer. CT revealed a level 3 neck node, 3cm in diameter. Whole body imaging indicated no other lymph node or visceral metastases. The patient then received 3 of 5 cycles in a phase 1 trial of an oncolytic virus plus monoclonal antibodies, but was removed from the study when his neck node disease progressed. Imaging showed necrotic nodes at left neck levels 2, 3, 5A. There was an infiltrative soft tissue mass surrounding the left C1 transverse process and encasing the left vertebral artery just below the skull base. There was no right-sided neck involvement. In July 2018, IMRT was used to deliver 51Gy in 20 fractions to a geometrically complex CTV in the left neck. To date, the neck nodes have reduced, but have not resolved completely. He still has no other lymph node or visceral metastases, and continues on ADT with a latest PSA of 1. An exhaustive review of the literature resulted in the identification of 13 case reports of cervical lymph node metastases from advanced prostate cancer, spanning 17 years. Misdiagnosis and delays to appropriate treatment were common due to the rarity of the phenomenon. 11 of 13 document nodes only in the left neck, and 5 of 13 report no lymphadenopathy except in the neck. All but one case were successfully palliated using ADT + chemotherapy. The remaining case saw disease progression on ADT, and received 70Gy chemo-rads to the left neck. This case report and literature review indicate that, although exceedingly rare, it is possible for advanced prostate cancer to metastasize to the left cervical lymph nodes without involvement of other lymph node groups. Improper assumptions about the site of primary disease, leading to inappropriate treatment choices, has been reported in the literature. ADT, chemotherapy and state-of-the-art radiotherapy can all be considered for palliation, on a case-by-case basis.