Spinal Cord Edema in Atypical Cervical Spondylotic Myelopathy--the Facts Behind the Unusual MR Findings: Case Report and Review of the Literature

Purpose We report the case of a young man with a slow progression of cervical spondyloticmyelopathy (CSM). Cervical magnetic resonance imaging (MRI) revealed a mild cervical discbulgingat C5–C6 and an area of atypically enlarged intramedullary high signal intensity extending from C4–C7 (T2-weighted) with contrast enhancement at C5–C6 (T1-weighted). Therefore, neurologic and radiologic diagnoses favored demyelinating diseases. Interference occurred to the diagnosis of CSM.Methods This was a retrospective case study with follow-up examination and MRI at 3 months, 1 year and 2 years postoperatively.Results Thepatient’s symptoms improved immediately postoperatively. The functional result according to the modified Japanese Orthopedic Association (JOA) score improved from 10 to 13 within 3 months. He continued to improve neurologically over the first postoperative year. Two years postoperatively, a T2-weighted MRI showed that the edema signal had disappeared completely , and a fat-saturated T2-weighted MRI showed only slight abnormal signal. The numbness and weakness of the extremities had improved, and his JOA score was 16. Conclusions Spinal cord edema is occasionally seen with CSM. In the case presented, the contrast enhancement was localized at the site of the greatest narrowing of the spinal canal and compression of the spinal cord. This coincidence was the best indicator of a mechanical cause of the spinal cord changes. This feature should increase physician’s confidence in distinguishing CSM from intramedullary tumors and myelitis. Surgical decompression may be beneficial in improving neurologic outcomes.

Flexible thecoscopy for extensive spinal arachnoiditis

OBJECTIVE Chronic adhesive spinal arachnoiditis (SA) is a complex disease process that results in spinal cord tethering, CSF flow blockage, intradural adhesions, spinal cord edema, and sometimes syringomyelia. When it is focal or restricted to fewer than 3 spinal segments, the disease responds well to open surgical approaches. More extensive arachnoiditis extending beyond 4 spinal segments has a much worse prognosis because of less adequate removal of adhesions and a higher propensity for postoperative scarring and retethering. Flexible neuroendoscopy can extend the longitudinal range of the surgical field with a minimalist approach. The authors present a cohort of patients with severe cervical and thoracic arachnoiditis and myelopathy who underwent flexible endoscopy to address arachnoiditis at spinal segments not exposed by open surgical intervention. These observations will inform subsequent efforts to improve the treatment of extensive arachnoiditis. METHODS Over a period of 3 years (2017–2020), 10 patients with progressive myelopathy were evaluated and treated for extensive SA. Seven patients had syringomyelia, 1 had spinal cord edema, and 2 had spinal cord distortion. Surgical intervention included 2- to 5-level thoracic laminectomy, microscopic lysis of adhesions, and then lysis of adhesions at adjacent spinal levels performed using a rigid or flexible endoscope. The mean follow-up was 5 months (range 2–15 months). Neurological function was examined using standard measures. MRI was used to assess syrinx resolution. RESULTS The mean length of syringes was 19.2 ± 10 cm, with a mean maximum diameter of 7.0 ± 2.9 mm. Patients underwent laminectomies averaging 3.7 ± 0.9 (range 2–5) levels in length followed by endoscopy, which expanded exposure by an average of another 2.4 extra segments (6.1 ± 4.0 levels total). Endoscopic dissection of extensive arachnoiditis in the dorsal subarachnoid space proceeded through a complex network of opaque arachnoidal bands and membranes bridging from the dorsal dura mater to the spinal cord. In less severely problematic areas, the arachnoid membrane was transparent and attached to the spinal cord through multifocal arachnoid adhesions bridging the subarachnoid space. The endoscope did not compress or injure the spinal cord. CONCLUSIONS Intrathecal endoscopy allowed visual assessment and safe removal of intradural adhesions beyond the laminectomy margins. Further development of this technique should improve its effectiveness in opening the subarachnoid space and untethering the spinal cord in cases of extensive chronic adhesive SA.

Cervical intramedullary solitary fibrous tumor: Case report and review of the literature

Background: Solitary fibrous tumors (SFTs) are benign tumors derived from mesenchymal tissues that predominantly occur in the pleura. Establishing the diagnosis of these very rare intramedullary spinal lesions, with no clear-cut pathognomonic radiographic characteristics, is particularly challenging. Case Description: Two males, 30 and 41 years of age, presented with progressive cervical myelopathies attributed to a cervical intramedullary exophytic tumor with associated spinal cord edema. One patient showed that the lesion was highly vascularized. Both patients underwent surgical excision of firm, solid, focal, and, particularly in one of them, very vascular/hemorrhagic tumors; at surgery, there was some adherence between the tumors and the cord tissue, but gross-total resections were achieved in both cases, demonstrated on postoperative MR scans. Histological and immunohistochemical findings confirmed the diagnosis of SFT (WHO Grade I). After a 6-month postoperative period, both patients neurologically improved and had no MR evidence of tumor recurrence. Conclusion: Intramedullary cervical exophytic SFTs are extremely rare. Although these solid tumors may present with hemorrhagic features and at surgery demonstrate significant adherence to the pial/cord surface, complete surgical resections are feasible resulting in good outcomes.

Syringomyelia Associated with Spinal Dural Arteriovenous Fistula: Clinical and Radiological Improvement after Embolization

Spinal dural arteriovenous fistulae (AVF) are rare and can result in spinal cord dysfunction. We present one such case wherein the patient presented with a venous congestive myelopathy. Magnetic resonance imaging showed a syrinx formation, spinal cord edema, and flow voids. Digital subtraction angiography confirmed the dural AVF, which was treated with embolization. The syrinx disappeared, other spinal cord changes improved, and the patient had remarkable clinical improvement. The case is presented to draw attention to the rare formation of a syrinx in a spinal dural arteriovenous fistula and its disappearance after successful embolization.

Misdiagnosis of Spinal Dural Arteriovenous Fistula: An Analysis of 12 Cases

Background: Spinal dural arteriovenous fistula (SDAVF) is a rare spinal vascular disease. The clinical misdiagnosis rate is very high. The highest misdiagnosis rate is reported in orthopedics. The specific reason for misdiagnosis remains unclear. Objective: To investigate the clinical and imaging manifestations of SDAVF, analyze the causes of misdiagnosis, propose countermeasures, and improve the orthopedists and other specialists’ understanding of this disease. Methods: The clinical data, diagnosis and treatment of 12 patients who had SDAVF that was misdiagnosed as a different disease were retrospectively analyzed, and the modified Aminoff-Logue Disability Scale (ALS) scores before and during follow-up were compared. Results: From 2014 to February 2019, 15 patients were diagnosed with SDAVF at our institution. Twelve (80%) were misdiagnosed; of these, 6 (50%) were misdiagnosed more than twice, and 6 patients (50%) were misdiagnosed at least once. The initial diagnoses included lumbar spinal stenosis and lumbar disc herniation (LDH) in 6 patients, cervical spinal stenosis in one patient, benign prostatic hyperplasia (BPH) in one patient, myelitis in 2 patients, and syringomyelia in one patient. After the initial diagnosis, one patient was misdiagnosed with LDH, one was misdiagnosed with subacute combined degeneration of the spinal cord, and 4 were misdiagnosed with myelitis. The clinical manifestations mainly included weakness and numbness of the lower limbs, urinary symptoms, and numbness of the perineal area. In the 12 misdiagnosed patients, magnetic resonance imaging(MRI) showed signs of spinal cord edema and typical or atypical flow-void patterns. One patient had undergone extended cervical decompression and lumbar decompression. All patients eventually underwent microsurgical treatment. The average follow-up duration was 0.9 years. The modified ALS scores showed significant improvement in gait, bladder function and bowel movement, and the differences before and during follow-up were statistically significant (P<0.05). Conclusion: When patients, especially those with bladder and bowel dysfunction, have symptoms such as weakness of the lower limbs and/or numbness, a diagnosis of SDAVF should be considered. Furthermore, if MRI shows signs of spinal cord edema and typical or atypical flow-void patterns, the diagnosis of SDAVF should be strongly considered, and further angiography is needed to confirm the diagnosis.

Mannitol Reduces Spinal Cord Edema in Rats with Acute Traumatic Spinal Cord Injury

Background: The research about anti-edema effects of mannitol on acute traumatic spinal cord injury (SCI) in rats is rare. Objective: This study aimed to explore the effect of mannitol on spinal cord edema after SCI in rats. Methods: Seventy-eight adult female rats were assigned to three groups randomly: a sham control group (n = 18), a contusion and normal saline contrast group (n=30), and a contusion and mannitol treatment group (n=30). We used the open-field test to estimate the functional recovery of rats weekly. Spinal cord water content was measured to determine the spinal cord edema. The ultrastructure features of the injured dorsolateral spinal cord were determined on the 7th day after SCI by HE staining. Results: The mannitol group had greatly improved Basso-Beattie-Bresnahan (BBB) scores when compared with the saline contrast group. The spinal cord water content was increased significantly after SCI, and there was no significant difference in the water content between the NaCl and mannitol groups 1 day after SCI. The water content at 3 and 7 days after SCI was significantly lower in the mannitol group than in the NaCl group (p < 0.05). Mannitol can reduce spinal cord edema by increasing the number of red blood cells in the injured spinal cord and decrease the ratio (dorsoventral diameter/ mediolateral diameter) of spinal cord 7 days post-SCI. Conclusion: Mannitol increases recovery of motor function in rats, reduces spinal cord edema and increases the number of red blood cells in the injured spinal cord, decreasing the ratio of spinal cord to reduce pressure.

Spinal Tumors and Tumor-like Masses: Relevance of Initial Imaging, Karnofsky Performance Status, Age, Location, and Cord Edema

Objective: The aim of this study is to know the relevance of initial imaging, Karnofsky performance status,age,location and cord edema for future score development for radiologists. Methods: The present study was carried out on total of 32 patients who visited SRN Hospital and Kriti scanning centre between August 2009 to February 2019. General and systemic examination was done. Finally KPS score was given to each patient in accordance with their clinical status. Magnetic resonance imaging was contemplated using scanner – Magnetom SP Vision; Siemens –Supercon 1.0 Tesla system. Results: The morphologic characterization and specific assessment of various tumors and tumor like masses of spine in view of MR imaging features and their relationship with clinical features have been analyzed with Chi square test which reveal: Age versus location – χ2 = 4.32; df = 4; P > 0.36 (NS), age versus cord edema – χ2 = 4.27; df = 3; P > 0.23 (NS), and location versus cord edema – χ2 = 2.67; df = 2; P > 0.26 (NS). Chi Square test shows there is no any statistically significant association between age and location; age and spinal cord edema, and location and spinal cord edema. Correlation between clinical aggressiveness (change in follow-up KPS) and MR imaging features could not be assessed in our study because majority of patients could not be evaluated after one month because of loss of follow-up. Conclusion: Poor KPS itself lead to movement during MRI and movement related artifacts affecting initial imaging,which was managed by cotton padded neck strap. KPS depends only on general condition one of the factor for outcome so for future score development age,location and cord edema together may be useful.

Benefit of dorsal laminectomy without lumbosacral stabilization in lumbosacral traumatic cat

Two cats were diagnosed with depression of caudal equina spinal nerve and lumbosacral spinal trauma that revealed rapid improving clinical signs after 1 month of dorsal laminectomy at the region of lumbar and sacral vertebrae without internal and external stabilization devices. This report showed that dorsal laminectomy was a powerful procedure for decompression caudal equina spinal injuries in stable lumbosacral vertebral trauma in cats without ancillary fixation methods. Dorsal laminectomy is valuable technique for correction of fracture/luxation of vertebrae that this procedure can reduce spinal cord edema, and axonal disruption. Stabilization of vertebrae by the orthopedic implants may be not necessary in small cat that has enough vertebral stability as the same in two these cases.