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Widening of an intervertebral foramen in the cervical spine is a striking radiogical finding and generally denotes a patient with a dumbbell spinal tumor. Other, rare causes can also produce widening, such as expansion, tortuosity or elongation of the vertebral arteries, and congenital absence of a pedicle.
Case reports of seven patients in whom unusual abnormalities caused widening of the cervical intervertebral foramen are presented. Plain roentgenographic and tomographic changes may be quite distinctive, especially in a patient with an absent pedicle or a tortuous vertebral artery. However, angiography has proved to be a useful adjunct to determine the etiology in many of these lesions.
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In experimental studies and on clinical material, behaviour was checked of intervertebral discs and vertebrae under the axial pressure: which is the being exerted by the trunk weight, as well as the behaviour of the adjacent mobile segments after "diskoplasty" operation or vertebral interbody stiffening. The material pertaining to the experimental part comprises 6 undamaged spine preparations of the lumbosacral segment, while the clinical part consists of 60 patients out of 143 subjects having been operated on by "diskoplasty" or vertebral interbody stiffening from the approach through fenestration, hemilaminectomy, or plastic laminectomy. The results of performed experimental studies and spodylometric analysis of radiograms in patients treated operatively by decompressing the vertebral canal and by "diskoplastic" stabilization of the vertebrae, or vertebral interbody stiffening permit the following observations. The most favourable localization of the transplant is the medial and posterior parts of the vertebral interbody space, since in both segments L4/L5 and L3/L4 it reproduces the height of the vertebral interbody space, the height and width of intervertebral foramen, widens the intervertebral foraminis, and reduces the lumbar lordosis, which advantageously changes the biomechanic relations, transferring loads of the posterior to the anterior vertebral column. The localization of the transplant in the anterior part of the vertebral interbody space, in fact, increases the anterior vertebral interbody space, but decreases the height of posterior interbody space, the vertebral interbody angle alpha as well as the height and width of the intervertebral foramen. The retroshifting of vertebral L4 indicates mobile segment instability. By implementing a transplant of matching height and appropriate localization in vertebral interbody space, it is possible to increase or reduce the angle between the vertebral bodies at the operative level, widening the vertebral interbody space in anterior and posterior parts. The localization of the bony transplant in the anterior part of vertebral interbody space, involving the clinical material, caused in 65% constriction of intervertebral foraminis, retroshifting of vertebrae L4 and L3, and recurrence of algesic complaints, which may be elucidated by instability of the operated on or adjacent mobile segments.
In cases of a pre-operatively diagnosed mediastinal tumour, but with no symptoms of its penetrating the vertebral canal via the intervertebral foramen, and with the surgeon suddenly discovering during anterio-lateral or lateral transpleural thoracotomy the tumor's spur going deep into the intervertebral foramen then it is a modification of the operation involving an effective removal of the mediastinal-intravertebral newgrowth, as described in this report, is most appropriate. This operation is performed in a single-stage fashion both on the level of the thoracic cavity and on that of the vertebral canal by undertaking a through examination of the intervertebral foramen from both sides. The authors believe this modification of the operative intervention to present advantages over the classical Guleke procedure, even in cases with an exactly established diagnosis of neurinoma, when one of its major node lies in the posterior mediastinum and the second--in the vertebral canal. Three cases in which this modification of the operation was applied with success are reported.
The importance of agenesis of a pedicle lies in its resemblance to a destructive lesion of the pedicle or to an expanding lesion in an intervertebral foramen. The correct diagnosis can be made roentgenologically by demonstrating a widened intervertebral foramen at the level of an absent pedicle with posterior displacement of the maldeveloped lateral mass. Two cases of agenesis of a pedicle in a cervical vertebra are presented.
Among 706 collected cases of mediastinal neurogenic tumors were 69 patients (9.8%) with extension through an intervertebral foramen, so that the composite neoplastic mass was dumbbell-shaped. Although only 10% of these dumbbell tumors were malignant, the majority of the patients presented with neurologic symptoms of spinal cord compression. In about 40% of reported cases, the intraspinal component, although present, was not clinically apparent. Such cases of asymptomatic intraspinal extension should be suspected when special roentgenologic views of the spine demonstrate erosion of the vertebral pedicle or enlargement of the intervertebral foramen adjacent to the posterior mediastinal mass. Workup of these patients should include myelographic studies to determine whether a dumbbell tumor is indeed present; if it is, surgery should be carried out by a team of thoracic surgeons and neurosurgeons in a one-stage combined resection of both the intraspinal and the mediastinal component of the tumor. With early diagnosis and surgical intervention, long-term survival is the rule. When the patient is in the pediatric age bracket, an orthopedic surgeon should be included on the team to help minimize subsequent skeletal growth deformity.
Clinical findings and operative results of 212 operated cases of disc protrusion are analyzed in this paper. The maximum age incidence is between 21 and 40 years. In our series disc prolapse was most common between the L4-L5 disc space, mostly on the left side, whereas the L5-S1 is more common in white people. Anthropologic differences may account for the discrepancy. A careful search should be made for disc protrusion by flexing the spine and also exploring the intervertebral foramen during surgery.
Twenty personal observations and 18 cases collected from the literature are analysed. The most frequently encountered anomaly were: common dural origin of 2 nerve roots and common exit of 2 nerve roots through the intervertebral foramen. Other anomalies comprised: interradicular connections and Y-shaped or horizontla course of the nerve root. Multiple anomalies were not encountered. In 9 out of 20 patients in the own series and in 6 out of 18 patients reported in the literature, history and clinical findings suggested prolapsed intervertebral disc, operation revealed only nerve root anomalies. Decompression produced improvement or complete relieve of previously existing signs and plain X-rays is not possible. The diagnosis is based on myelographic findings. The pathogenesis of the anomalies is discussed. It is suggested that they should not be considered as a causative factor of low back pain or sciatica.
The limitations of current diagnostic tools, including myelography, in localizing the anatomic lesion in spinal stenosis are well recognized. The purpose of this study is to investigate whether computerized tomography can more effectively define the normal and abnormal osseous structures compromising the boundaries of the spinal canal, nerve root canal, and intervertebral foramen. This study is a pathologic-radiographic correlation between CT scans and sections of spine specimens that were so scanned. The tomographic images investigated were multiplanar, that is, simultaneously presenting transverse, coronal, and sagittal images. Spine specimens were chosen to show how the technique applies to the normal spine, as wel as to selected specimens with spinal stenosis. The role of the discs and apophyseal joints in shaping the intervertebral foramina and lateral recesses is emphasized in both normal and abnormal specimens. This study shows that computerized tomography can precisely localize anatomic lesions and, by comparison of the image to the gross anatomic specimen, that it is a reliable portrayal of the anatomic fact.
Intrathoracic meningocoele (I.M.) consists of a bulging out of the meninges in the posterior mediastinum through an intervertebral foramen or a bone defect in the thoracic spine. It is a rare condition generally asymptomatic and often associated with von Recklinghausen's neurofibromatosis, whose aetiopathogenesis and clinical significance have not yet been completely clarified. The AA. describe a case of I.M. in a patient with neurofibromatosis who at 37 years of age presented spastic monoparesis in the left lower limb with subacute onset. In this case two abnormally wide intervertebral foramina and scalloping of the posterior rims of the vertebral bodies close to the meningocoele were observed. These changes seem to point to an alteration in bone development as the chief cause of intrathoracic meningocoele in contrast with other aetiopathogenic hypotheses. Excluding the presence of other expansive lesion, spastic monoparesis might be related to a confined medullary involvment due to compression of arterial or venous vessels by the meningocoele. Finally the AA. emphasize the importance of myeloscintigraphy, wich easily allows correct diagnosis by showing a typical pool of radioactive tracer in the meningocoele bulge lateral to the spine.
In established isolated disk resorption at the lumbo-sacral junction, nerve root canal stenosis affects predominantly the S1 nerve which becomes obstructed between the inner margin of the superior facet of S1 and the buckled ligamentum flavum behind and by the ridge of the remaining annular fibers in front. However, in addition, there may also be an intervertebral foramen stenosis involving the L5 nerve at this level. Accordingly, in planning the surgical treatment of this condition where bilateral buttock and leg pain has become intractable or frequently recurrent, and where back pain is not major concomitant of the symptom complex, the surgeon must remove the inner and superior margins of the S1 facet together with the whole of the ligamentum flavum, thereby decompressing both L5 and S1 nerve roots. The operation involves a partial facetectomy only at the affected level and spinal stability is not impaired.
A "dumbbell" neuroblastoma is a malignant neoplasm usually primary in the mediastinum or retroperitoneum with posterior extension through an intervertebral foramen to additional tumor within the spinal canal. Neurologic deficits are found in almost all cases. Nineteen patients with such tumors were reviewed with respect to diagnosis, management, and results. Treatment consisted of prompt laminectomy with total or subtotal excision of the extradural tumor. The primary tumor in the mediastinum or retroperitoneal area was removed at a second stage. All patients received postoperative radiation therapy. Eleven of the 17 patients observed more than two years are free of disease, a cure rate much higher than the overall experience with neuroblastoma. Substantial recovery of neurologic function occurred in most, but kyphoscoliotic deformities were a disturbingly frequent late complication.
Total spinal anesthesia following intrathoracic intercostal nerve blocks with bupivacaine performed for postoperative pain relief during thoracotomy is described. Possible mechanisms for this complication include: (1) inadvertent placement of the needle through an intervertebral foramen, (2) puncture of a long dural cuff, and (3) intraneural injection with central spread. Recognition of this potential complication is important, and facilities for proper support must be available.
The present case concerns an acute purulent osteomyelitis with an epidural abscess, located particularly in the intervertebral foramen between C5 and C6, which led to infection by staphylococci of the adjacent vertebral arches and vertebral bodies. An obstruction of the CSF passage was discovered by myelography at the level between C5 and C6. The bony tissue changed by inflammation was removed as far as possible by laminectomy. After irrigation of the epidural space with antibiotics and after control of the severe inflammation, the vertebral bodies C6 and C7 which were destroyed by the spreading inflammatory granulations, could be removed by a ventral approach 4 weeks later. The defect was filled with spongiosa chips. After immobilisation in a plaster shell and Crutchfield extension for 8 weeks the patient was slowly mobilized. A fusion of the vertebral bodies C5 and C6, C6/C7 and C7/C1 was achieved. A dislocation of the cervical spine did not occur and the patient recovered completely except for a paresis of the right hand. Treatment of this very rare and severe case was only possible by a combined dorsal and ventral procedure on the cervical spine.
The arrangement of extraspinal sources of the spinal cord arterial supply in man is more complicated than previously described, especially with regard to the origin and branching of the aortic segmental arteries. The fact that other arteries in the neck than the vertebral artery, such as the costo-cervical trunk and the ascending cervical artery may contribute to the supply of the cervical cord is confirmed, and also the occurrence of two or more spinal branches from different sources entering the same intervertebral foramen. Frequent occurrence of two or more segmental arteries arising from a common stem and variations in the branching of the subcostal arteries were found; their functional significance on the spinal cord circulation is not known. The fact that no significant anterior root artery was ever seen at the level of the vascular anomaly suggests that the anomaly is of no clinical importance. Nevertheless, obstruction of a common stem entail the risk of spinal cord infarction due to involvement of an important posterior root artery. On the other hand, the spinal cord seems to be fairly well protected against ischaemic injury following limited interference with the extraspinal arteries due to a profuse supply of intra- and extraspinal collaterals.
The segmental body plan of vertebrates arises from the metameric organization of the paraxial mesoderm into somites. Each mesodermal somite is subdivided into at least two distinct domains: rostral and caudal. The segmental pattern of dorsal root ganglia, sympathetic ganglia and nerves is imposed by differential properties of either somitic domain. In the present work, we have extended these studies by investigating the contribution of rostral or caudal-half somites to vertebral development using grafts of multiple somite halves. In both rostral and caudal somitic implants, the grafted mesoderm dissociates normally into sclerotome and dermomyotome, and the sclerotome further develops into vertebrae. However, the morphogenetic capabilities of each somitic half differ. The pedicle of the vertebral arch is almost continuous in caudal half-somite grafts and is virtually absent in rostral half-somite implants. Similarly, the intervertebral disk is present in rostral half-somite chimeras, and much reduced or virtually absent in caudal somite chimeras. Thus, only the caudal half cells are committed to give rise to the vertebral pedicle, and only the rostral half cells are committed to give rise to the fibrocartilage of the intervertebral disk. Each vertebra is therefore composed of a pedicle-containing area, apparently formed by the caudal half-somite, followed by a pedicle-free zone, the intervertebral foramen, derived from the rostral somite. These data directly support the hypothesis of resegmentation, in which vertebrae arise by fusion of the caudal and rostral halves of two consecutive somites.