Progressive spinal destruction secondary to minimal vertebral fracture in a patient with diffuse idiopathic skeletal hyperostosis: a case report.

Early operative fixation is widely recognized as essential for managing spinal fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH). However, no report to date has addressed the occurrence of minimal vertebral fractures diagnosable only through magnetic resonance imaging (MRI) in these patients and the associated temporal changes in the fracture site. In this report, we describe a rare clinical case involving an 81-year-old man who developed progressive spinal destruction secondary to a minimal vertebral fracture. MRI showed minimum-intensity changes in the T12 vertebral body, whereas X-ray and computed tomography examinations showed DISH and no spinal fracture. Despite experiencing severe low back pain, the patient did not undergo operative therapy for 2 months, resulting in progressive spinal destruction. Spinal fusion with posterior instrumentation was performed, and the patient was followed for 1 year with no symptoms and good functional status. This case emphasizes the importance of clinicians being cautious to avoid overlooking and undervaluing minimal vertebral fractures diagnosable only through MRI in patients with DISH.

Acute arm paresis with cervical spondylosis: three case reports.

BACKGROUND: The mild type of anterior spinal artery syndrome (ASAS) is characterized by motor loss with an absent or insignificant sensory deficit due to a disturbance in the blood supply to the anterior horn of the spinal cord. The clinical symptoms of cervical spondylotic amyotrophy (CSA) are motor loss or atrophy with an absent or insignificant sensory deficit or a long tract sign; however, the pathophysiology has not been clarified. METHODS: Three patients who suffered from palsy of the deltoid and biceps brachii are presented. Magnetic resonance imaging confirmed the intrinsic cord disease as the cause of the paresis. We measured the central motor conduction time (CMCT) and the latencies of the tendon reflex (T waves) of the biceps and triceps and those of the F waves of the abductor pollicis brevis and abductor digiti minimi before, 2 weeks after, and 3 months after starting intravenous injections of prostaglandin E(1) (PGE(1)). RESULTS: In these 3 cases, restoration of muscle strength began after starting injection of PGE(1). The electrophysiologic diagnosis revealed a disturbance of the motor conduction, in the CMCT and the latencies of the T waves, in the paretic muscle, which is more severe than that in other muscles. The radiological diagnosis suggested damage in the spinal cord. Improvements in the disturbance of the motor conduction and those of symptoms were parallel. CONCLUSION: From symptomatologic or radiological viewpoints, it is difficult to differentiate CSA from ASAS with cervical spondylosis. This suggests that there have been patients with ASAS whom we have diagnosed as CSA, and we may add administration of PGE(1) to the treatment for the patients with CSA. The present 3 patients showed improvement of muscle strength after starting injections of PGE(1). Although this improvement was measured by an electrophysiologic method, the mechanisms of PGE(1) require further study.

Motor conduction measurement in myelopathy hand.

We studied the relationship between intramedullary high signal intensity (IMHSI) on T2-weighted magnetic resonance images and motor conduction in the spinal cords of cervical spondylotic myelopathy (CSM) patients. There was no significant difference between the biceps or triceps central motor conduction times (CMCTs) of the patients who did and did not exhibit IMHSI, whereas the abductor pollicis brevis CMCT was significantly longer in the patients who exhibited IMHSI (p<0.05) than in those who did not. The CMCT of the abductor pollicis brevis is sensitive to the degree of damage in the cervical spinal cord. Hand dysfunction is a characteristic of CSM regardless of the cervical level affected by the condition. The motor fibers innervating the intrinsic muscles of the hand in the long tract of the cervical spinal cord are more sensitive than other motor fibers. For this reason, we consider that myelopathy hand is a characteristic impairment of CSM. Transcranial magnetic stimulation of the hand motor cortex is useful for the evaluation of cervical myelopathy.

Neurophysiological study to assess the severity of each site through the motor neuron fiber in entrapment neuropathy.

BACKGROUND: The double crush hypothesis (DCH) that had been widely accepted seems to have been dismissed recently. Prior to the DCH, retrograde changes in the proximal median nerve in carpal tunnel syndrome (CTS) were reported. There has been no report of quantitative analyzing about the effect of one site's compression on another site all through the same peripheral nerve in CTS patients. METHODS: We measured the central motor conduction time (CMCT), motor conduction latency of the cervical root region (CRL), peripheral path latency from the rootlet to the wrist (PL) and motor distal latency (MDL) in the median nerve and ulnar nerves, respectively in CTS patients. RESULTS: MDL, PL and CRL were prolonged selectively in the median nerve, but not in the ulnar nerve of CTS patients. And in the median nerve measurement, MDL was high (r = 0.59, p < 0.0001) while PL showed a significant (r = -0.28, p < 0.05) relationship with CRL. MDL was large (r = 0.58, p < 0.0001) and showed a close (r = 0.59, p < 0.0001) relationship with the amplitude of CMAP. There was no significant difference between the amplitude of the normal CRL group and that of the prolonged CRL group. This quantitative analysis showed a linear relationship among MDL, CRL and CMAP amplitude. CONCLUSION: Dual entrapment lesions did not unexpectedly exaggerate the vulnerability or total damage. The vulnerability and the damage were proportional to the severity of each lesion. If the DCH term presented to an unexpectedly exaggerated degree, the cases of double crush syndrome in the CTS patients were rare, but if the term DCH refers to only this linear relationship, the DCH should not be dismissed.

Pulsatile cerebrospinal fluid flow measurement using phase-contrast magnetic resonance imaging in patients with cervical myelopathy.

STUDY DESIGN: A technical report is presented. OBJECTIVE: To investigate the relation between the severity of myelopathy and the degree of cerebrospinal fluid flow disturbance by using magnetic resonance imaging to measure the velocity of the cerebrospinal fluid flow in patients with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Analyses of pulsatile cerebrospinal fluid flow measured by phase-contrast magnetic resonance imaging in healthy subjects and patients with Arnold-Chiari syndrome have been reported. Few studies have evaluated the change of pulsatile cerebrospinal fluid flow velocity and the waveform of the plotted velocity in patients with cervical spondylotic myelopathy. METHODS: Study 1: Pulsatile cerebrospinal fluid flow was measured at C7, positioned with cervical spine flexion and extension, to investigate the influence of cervical alignment on the pulsatile cerebrospinal fluid flow in five patients with cervical spondylotic myelopathy. Study 2: In 31 patients with cervical spondylotic myelopathy, pulsatile cerebrospinal fluid flow was measured at C3 and C7, with the neck set centrally. The relevance of cerebrospinal fluid flow disturbance and the severity of myelopathy evaluated by the Japanese Orthopedic Association scoring system also were studied. RESULTS: Study 1: The waveform of plotted pulsatile cerebrospinal fluid flow velocity showed no change resulting from the position of the cervical spine. Study 2: A high correlation between the Japanese Orthopedic Association score and the cerebrospinal fluid pulsatile flow amplitude at C7 was demonstrated (r = 0.75; P < 0.0001). The average Japanese Orthopedic Association score of 14 patients whose cerebrospinal fluid flow velocity waveforms were absent was significantly lower (P < 0.0001) than that of 17 patients whose waveforms were present. CONCLUSIONS: The disturbance of pulsatile cerebrospinal fluid flow demonstrated high correlation with the severity of myelopathy. Measurement of cerebrospinal fluid flow disturbance can quantify the degree of dural sac and spinal cord compression.