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A previously unreported complication of a patient with Crohn's enterocolitis and internal fistulation is presented. The patient presented with meningeal signs in the lumbosacral region, fever, and sepsis. Computerized axial tomography revealed air in the epidural space, and a presumptive diagnosis of rectalepidural fistula was made. Surgical management included a diverting end sigmoid colostomy and presacral drainage.
Spinal dysraphism (SD) is characterized by maldevelopment of neural tube, notochord, mesoderm and cutaneous ectoderm. Incidence of SD is 2-4/1000 live births. One hundred and nineteen patients operated from January 1991-June 1996 at Department of Neurosurgery, All India Institute of Medical Sciences, were studied. Only 21 patients (17.6%) presented when they were less than one year old and 17 patients came in adult age group (> 16 years). Lumbar and lumbosacral region was the commonly involved site in 81 patients (74.7%). Weakness of lower limbs (74%), difficulty in walking (54%), muscle atrophy (41.2%) were the commonest indicators of motor system involvement. Loss of sensation, trophic ulcer, backache were seen in 45, 14, 10 patients respectively. Cutaneous lipoma (26%), hypertrichiosis (20%), dermal sinus (13.4%), midline dimples (7%) were the important cutaneous markers. Foot and limb deformity was seen in 25% cases. Tethering of cord, syringomyelia & split cord malformation were the most common radiological findings. Only 10% of our patients had hydrocephalus that required shunt. Out on 119 cases operated, 43 improved, Twenty had sensory improvement and 18 showed motor improvement. Fifteen patients regained continence. Twelve patients were lost to follow-up. Sixty-seven patients had no change in neurological status, post-operatively. Six cases deteriorated in terms of motor or sensory deficit and one patient lost continence. CSF leak (8%) and wound infection (6%) were the common complications. Six patients required second surgery as T.P. Shunt (4), rotation flap (1), reexploration and duraplasty (1).
Eighteen mongrel dogs were divided into three equal groups. Spinal cord and spinal dural blood flow in the cervical, thoracic and lumbosacral regions were measured using the radioactive microsphere technique. Measurements were taken before and 10 and 40 minutes after lumbar subarachnoid injection of one of the following: physiologic saline; epinephrine 200 micrograms or phenylephrine 5 mg. No significant change in spinal cord blood flow occurred in any of the groups, nor was there any difference between the groups. Dogs receiving subarachnoid phenylephrine did demonstrate a significant reduction of thoracic dural blood flow at ten minutes. Dogs receiving intrathecal epinephrine or phenylephrine demonstrated a significant reduction in lumbo-sacral dural blood flow at ten minutes after injection. The reduction in dural blood flow was still evident at 40 minutes in dogs receiving phenylephrine. Subarachnoid epinephrine (200 micrograms) and phenylephrine (5 mg) do not effect spinal cord blood flow but do produce regional dural vasoconstriction.
Secondary tethered cord syndrome following initial repair for spinal dysraphism is an important area of interest. In this study, 32 cases with spinal dysraphism in the lumbosacral region were enrolled, in whom radical repair with autologous material had been carried out in the early stage soon after birth. During the follow-up period of up to 19 years 10 months, surgery was considered to be indicated in 2 of the 8 lipomeningocele cases and in 6 of the 24 meningocele and meningomyelocele cases, because of the presence of tethered cord syndrome 4-19 years after the primary operation. In all 8 of these cases, MR imaging demonstrated tethered spinal cord in the form of low conus medullaris. In 6 of the 8 operated cases surgery was followed by improvement of the spinal neurological deterioration. According to our experience, early untethering for secondary tethered cord syndrome is essential. In addition, since the complications of Silastic duraplasty at untethering were all minor and the operative outcome was satisfactory, the use of silicone rubber sheeting as a dural substitute might be recommended to prevent adhesion of the spinal cord.
The tethered spinal cord syndrome is more often encountered in children, but does also occur in adults. Its clinical spectrum comprises low back pain, neurological deficits such as distal motor weakness and trophic and sensory disturbances in the legs, urological symptoms and such musculoskeletal signs as scoliosis or foot deformities. In addition, cutaneous lesions or subcutaneous lipomas in the lumbosacral region may be indirect signs of an intraspinal pathology. This consists in a tight, thickened and sometimes shortened filum terminale, an intraspinal lipoma, intradural scar formation or other lesions that lead to conus fixation. The common mechanism of injury of these types of pathologies is an impairment of longitudinal movement of the spinal cord, especially the conus medullaris, which subsequently leads to chronic local ischemia. Diagnosis is most readily achieved by magnetic resonance imaging. Treatment is aimed at the restoration of cord mobility by means of microsurgical release of the conus, the cauda equina and the filum terminale with the aid of cauda equina neuromonitoring. Further progression can be effectively halted; in fact almost half of the patient actually improve. Therefore, every patients presenting with the clinical diagnosis of tethered cord syndrome should be offered specialized surgical treatment.
Although peripheral nerves are used as guides in attempts to enhance regeneration in the central nervous system (CNS), surprisingly little is known about the interface that develops between the host tissue and the transplanted or implanted peripheral nerve. This study examines host-nerve interfaces following transplantation of segments of sciatic nerve into the spinal cord under two differing conditions, one in which the spinal cord contains normal numbers of glia and one in which the glial population is reduced. The depletion of the glial population is achieved by exposing the lumbosacral region of the spinal cord in 3-day-old rats to X-rays, a model developed in this laboratory. Twenty days later, segments of fresh or frozen sciatic nerves harvested from other 3-day-old rats were transplanted into the lumbar region of spinal cord in irradiated animals and in their non-irradiated littermate controls. Following a 20-day postoperative period, the interfaces between host spinal cord and sciatic nerves were examined ultrastructurally, and pronounced differences were noted. A distinct scar composed of multiple layers of astrocyte processes completely enveloped the transplant in non-irradiated host spinal cord and confined Schwann cells and fibroblasts to the area enclosed by the scar. Terminals from axons that appeared to have traversed the transplant during this 20-day period ended blindly in the astrocytic scar. In contrast, a complete astrocytic scar failed to form around the transplant in the irradiated, glia-depleted hosts, and Schwann cells intermingled with host tissue. Some Schwann cells migrated away from the transplant, which was placed in the dorsal funiculus, along a perivascular route and extended into the gray matter. In some instances Schwann cells were observed in the ventral gray surrounding blood vessels and motoneurons. From these observations, it is clear that the formation of a distinct astrocytic barrier at the host-graft interface is greatly reduced irradiated host. The effects of astrocyte reduction on enhanced regeneration within the spinal cord are discussed.
Pneumorrhachis (PR), the presence of intraspinal air, is an exceptional but eminent radiographic finding, accompanied by different aetiologies and possible pathways of air entry into the spinal canal. By reviewing the literature and analysing a personal case of traumatic cervical PR after head injury, we present current data regarding the pathoanatomy, clinical and radiological presentation, diagnosis and differential diagnosis and treatment modalities of patients with PR and associated pathologies to highlight this uncommon phenomenon and outline aetiology-based guidelines for the practical management of PR. Air within the spinal canal can be divided into primary and secondary PR, descriptively classified into extra- or intradural PR and aetiologically subsumed into iatrogenic, traumatic and nontraumatic PR. Intraspinal air is usually found isolated not only in the cervical, thoracic and, less frequently, the lumbosacral regions but can also be located in the entire spinal canal. PR is almost exceptional associated with further air distributions in the body. The pathogenesis and aetiologies of PR are multifold and can be a diagnostic challenge. The diagnostic procedure should include spinal CT, the imaging tool of choice. PR has to be differentiated from free intraspinal gas collections and the coexistence of air and gas within the spinal canal has to be considered differential diagnostically. PR usually represents an asymptomatic epiphenomenon but can also be symptomatic by itself as well as by its underlying pathology. The latter, although often severe, might be concealed and has to be examined carefully to enable adequate patient treatment. The management of PR has to be individualized and frequently requires a multidisciplinary regime.
We describe a rare case of giant cauda equina tumor in the upper lumbar spine with dural ectasia in the lumbosacral region. This patient had a long history of acromegaly due to pituitary adenoma, for which bromocriptine was administered. The cauda equina tumor was surgically resected en bloc and proved to be a benign schwannoma. Postoperatively, with the exception of the left L5 dermatome, sensory disturbance decreased markedly and motor function slowly improved. Although resection of a giant schwannoma of the cauda equina often sacrifices other cauda equina spinal nerves involved by the tumor, neurological deterioration was not observed in the case presented.
Spinal dysraphism and teratomas are well-recognized spinal cord lesions, but both entities are rare in the cervical spinal cord. Rarely, teratomas have been described within dysraphic lesions in the thoracic and lumbosacral regions. To date, teratomas contained within cervical spine dysraphic lesions have not been described. Although mature cystic teratomas are renowned for the array of organoid tissue differentiation they display, mature lung differentiation is a rarity. While pulmonary differentiation has been described in six female genital tract teratomas, it has not been reported in spinal teratomas. The clinicopathologic features of a complex cervical lesion, comprising a combination of cervical spine dysraphism with a mature cystic teratoma that exhibited pulmonary differentiation, is presented, and the literature on teratomas exhibiting pulmonary differentiation is reviewed.
Myofascial pain disorder can originate from various muscles in the body. Numerous therapeutic approaches have been used to treat myofascial pain syndrome with varying success. Botulinum toxin neurolysis may become an important treatment regimen because it sustains relaxation of muscles. There is a growing body of clinical evidence for the efficacy of botulinum toxin in the treatment of painful myofascial conditions. The conditions that have been investigated include chronic low back pain, chronic cervical-associated headache, myofascial pain, myofascial pain syndrome and pain from chronic muscle spasm, and refractory myofascial pain. One of these studies was an open-label, exploratory pilot study into the cervicothoracic and lumbosacral regions using a novel injection technique.
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Attempts were made to determine the cells of origin of the spinal projections to the PAG using retrograde axoplasmic transport techniques of HRP and fluorescent markers. Following injections limited to the lateroventral subnucleus of the PAG, labels were transported to the contralateral laminae I, III, V, VII and X primarily. A striking number of labeled neurons were found in the lumbosacral region. Discussion followed on the possible dichotomic axonal projections of the labeled spinal neurons.
Intrathecal (i.t.) injections of substance P (SP) and kainic acid in rats produced rostrally directed scratches with the hindlimbs and caudally directed bites or licks. These behaviors, together with myoclonic twitches and vocalization, were also produced by I.T. morphine and strychnine. Intrathecal valproic acid (VA) significantly reduced all behaviors when these occurred spontaneously, and VA and chlordiazepoxide both reduced these behaviors when they were evoked by a light cotton swab tap to the lumbosacral region, in rats treated with the excitatory compounds. Since neither anticonvulsant affected the thermal or mechanical pain threshold at these doses, these results suggest that (a) the behaviors elicited by i.t. injection of the excitatory compounds are not responses to perceived pain, but rather the expression of a spinal convulsive-like state, and (b), since scratching and biting were the only behaviors produced by SP, this peptide is neither necessary nor sufficient for the elicitation of pain at the spinal level. Although our experiments do not rule out other roles for SP in pain processes such as that of a neuromodulator, it is unlikely that this compound is a traditional primary afferent neurotransmitter of pain.
A study of the large subcutaneous haematoma or bursa was carried out in 85 adult patients who were mostly injured in traffic accidents as pedestrians hit by automobiles or in motocycle accidents. The lesions, mostly located at trochanteric and lumbosacral regions, were produced by direct, tangential traumatic forces splitting the subcutaneous fat from the fascia and creating a massive haematoma which was subsequently transformed into a real bursal cyst, resistant to the conventional methods of treatment. As the results of conservative measures were unsatisfactory in 74 per cent of cases, a simple operation has been developed, consisting of excision of the bursal wall and inserting cutaneofascial sutures to allow complete elimination of any dead spaces where tissue fluids could re-accumulate. As the results of this operation were favourable in 95 per cent of cases, it is recommended for the management of this condition.
Recent publications have endeavoured to differentiate between the true, or vestigial tail, and the pseudotail by clinical and pathological examination, and have indicated the benign nature of the true tail. The true tail arises from the most distal remnant of the embryonic tail, contains adipose, connective, muscle, and nerve tissue, and is covered by skin. Pseudotails represent a variety of lesions having in common a lumbosacral protrusion and a superficial resemblance to vestigial tails. A review of the case reports indicates spina bifida to be the most frequent coexisting anomaly with both. A review of occult spinal dysraphism shows it to be associated with cutaneous signs in more than 50% of instances. Three cases of spinal dysraphism with tail-like cutaneous structures are described and their radiological, operative, and pathological findings presented. The classification of each of the appendages into true tail or pseudotail remains obscure. Although the finding of these three tails was the subject of much curiosity, surgical treatment was clearly designed to adequately deal with the associated dysraphic state. The presence of a tail-like appendage in the lumbosacral region should alert the clinician to the possibility of underlying spinal dysraphism. Preoperative assessment must include a complete neurological history and examination as well as computed tomographic or magnetic resonance imaging.
To study effects of herpesvirus reactivation on the nervous system, mice with latent genital herpes simplex virus type 2 (HSV-2) infections were immunosuppressed. Reactivated infection was detected by virus isolation or by antigen screening in histological sections of spines that contained cords, roots, and dorsal root ganglia. In ganglia, viral antigen was restricted to 2 distinct groups at T9-L2, and L6-S2 levels. In some ganglia, antigen was found in up to 4% of non-contiguous neurons, in their axons, and in endoneurial and satellite cells. Nerve roots distal to ganglia contained a few antigen-positive endoneurial cells and axons, but convincing antigen was not seen in proximal roots. Rare foci of anterior horn cells in the lower cord were the only central sites found to contain antigen. Comparison of antigen-containing ganglionic neuron counts to vaginal culture data indicate that peripheral virus shedding may depend on the number of neurons with reactivated infection. In non-immunosuppressed, latently infected mice, virus recovery was restricted to ganglionic explants from lower thoracic and lumbosacral regions; these ganglia contained no infectious virus in homogenates and no detectable antigen. These mice had an inflammatory polyradiculopathy in a similar distribution to virus found in latent and reactivated infection. The data show that genital HSV-2 infection can result in more extensive ganglionic latency and peripheral nervous system disease than has previously been recognized. Immunosuppression leads to reactivation and widespread, anatomically restricted antigen expression in many ganglia, consistent with the innervation of the genitourinary tract. Decalcified spine preparations provide a sensitive and simple way to detect virus reactivations and disease in these neural tissues.
To investigate the cat as a test animal for organophosphorous compound-induced delayed neurotoxicity, tri-o-cresyl phosphate (TOCP) was applied directly on the unprotected back of the neck of young adult cats. Single dermal doses, ranging from 250 to 2000 mg/kg TOCP, or subchronic daily administration of 1 to 100 mg/kg produced delayed neurotoxic effects in the cat. Severity of delayed neurotoxicity depended on the dose and duration. Clinical signs were characterized by hindlimb weakness, ataxia, and paresis. Electromyographic abnormalities resulting from acute denervation were observed in most cats that developed a neurologic deficit. No changes were seen in the motor nerve conduction, thus suggesting that the deficits were in the terminal branch rather than being diffuse lesions in the peripheral nerves. These results correlated well with histopathologic results showing lesions in the most distal portion of the longest tracts in both central and peripheral nervous systems. In the spinal cord, histopathologic studies showed that the ascending tracts of the upper cervical levels and descending tracts of the lumbosacral regions were affected most frequently. Although this study shows that the cat, like the chicken, is susceptible to TOCP-induced delayed neurotoxicity, it demonstrates two differences between the cat and the chicken: greater sensitivity of the cat to the acute effect of TOCP, and greater extent of recovery or improvement of the cat from delayed neurotoxicity. This recovery was demonstrated by: improvement of clinical signs, gain in body weight, disappearance of electromyographic abnormalities, and regeneration of peripheral nerves. Dermal administration of a single 100-mg/kg dose or subchronic 0.5-mg/kg doses of TOCP did not produce delayed neurotoxicity.
GABA expression was investigated using biochemical analysis of spinal cord homogenates and immunocytochemical analysis of cells acutely dissociated from the embryonic and postnatal rat spinal cord. gamma-Aminobutyric acid (GABA) was detected by both methods as early as embryonic day 13 (E13). At E13, the percentage of neurons that were GABA+ was 0.5%. This value increased during embryogenesis, peaked during the first two postnatal weeks to just over 50%, and declined to approximately 20% by the third postnatal week emphasizing the transient nature of GABA expression. At E17 there was a pronounced, positive ventro-dorsal and rostro-caudal gradient of GABA+ cells that persisted until just before birth. At this time the gradients reversed in cervical and lumbosacral regions indicating that GABA immunoreactivity in discrete anatomical regions is also a transient phenomenon. During the embryonic period GABA immunoreactivity was diffusely distributed throughout cell bodies and proximal processes. At E21, both GABA and synaptophysin were present in the same cells. However the two antigens did not co-localize point for point. By postnatal day 21 GABA immunoreactivity appeared in puncta that co-localized entirely with puncta of synaptophysin immunoreactivity. The sizable percentage of neurons that transiently express GABA during development, and the fact that it can be detected prior to the synaptic form of glutamic acid decarboxylase (GAD65), suggest that the amino acid may play a significant role during differentiation before it functions as an inhibitory neurotransmitter.