Lumbar decompression and fusion for symptomatic spinal stenosis in a patient with chronic thoracic sensory level from prior transverse myelitis: a case report.

BACKGROUND: Many patients with transverse myelitis suffer from sensory loss below the spinal level of the lesion. This is commonly associated with chronic neuropathic pain. However, the presence of somatic pain below a complete thoracic sensory level after transverse myelitis is exceptionally rare, and it is unclear if surgical decompression is an effective form of treatment for these patients. CASE PRESENTATION: In this report, we describe a 22-year-old Caucasian female who suffered from chronic lumbar back pain despite a complete thoracic sensory level secondary to prior transverse myelitis. Imaging demonstrated multilevel central stenosis below the sensory level, and her pain improved after surgical decompression. To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression. CONCLUSION: This is the first reported case of a patient with symptomatic lumbar stenosis after transverse myelitis whose lower back pain and quality of life improved following surgical decompression and fusion. This case provides evidence that typical lumbago is possible in patients with sensory loss from transverse myelitis, and standard lumbar decompression may provide benefit for these patients.

A descriptive study of clinical and radiological profile of longitudinal extensive myelitis in a tertiary hospital in Rajasthan, India.

OBJECTIVES: To explore the aetiological, clinical and radiological profiles of patients with LETM presenting to this tertiary care hospital in North India. PATIENTS AND METHODS: All eligible LETM patients presenting to our hospital between April 2015 and Jan 2016 were prospectively studied. A total of 37 patients were included and after thorough history, examination, relevant laboratory and radiological investigation, were profiled according to the various aetiologies of LETM. RESULTS: Our study included 37 patients (62% males and 38% females). Most patients were young (21-30 years). Main aetiologies of LETMp were NMO (8), inflammatory (9), idiopathic (6), NMOSD (4), Vitamin B12 deficiency (4) and others (6). Most patients (62%) had acute onset of symptoms except NMOSD and B12 deficient patients who presented subacutely too. NMO group was most disabled (poor Rankin and MRC assessments) at presentation; prognostically no (87%) or minimal improvement (13%) at discharge was seen in this group compared to other aetiologies. Forty point five percent patients had thoracic sensory complaints. CSF (pleocytosis 62%) and raised protein (81%) and brain abnormalities on MRI were seen in 11% patients. Bladder and optic nerve involvement (75.7% and 35% patients respectively). Seventy five percent NMO and 67% probable inflammatory aetiology patients also had B12 deficiency. CONCLUSION: This study concludes that LETMp has varied aetiologies with NMO having more disability and poorer outcomes. Thoracic cord segment is most commonly involved. Vitamin B12 deficiency may predispose patients to inflammatory LETM including NMO syndromes.

Aspergillus Sternomyelitis Developed from Chronic Pulmonary Aspergillosis as a Late Complication to Lobectomy for Lung Cancer.

Progressive fibrobullous changes in the residual lobes are sometimes observed after lobectomy. Aspergillus osteomyelitis is an uncommon infection that rarely occurs sternally. A 70-year-old man who had undergone lobectomy 12 years earlier was admitted to our hospital for chest pain. He was diagnosed with Aspergillus sternomyelitis based on sternal bone culture after an ultrasound-guided percutaneous needle biopsy. The fibrosis and right residual lung apex volume loss had gradually progressed over 12 years, and therefore, chronic pulmonary aspergillosis (CPA) with direct invasion sternal from the CPA was considered. Aspergillus sternomyelitis can develop from CPA as a late complication of lobectomy.

[Foix-Alajouanine syndrome, what is it?].

The article contains the description of Foix-Alajouanine syndrome (FAS) from literature. Three our own cases of FAS, which developed in two men and one woman, are presented. An analysis of FAS clinical picture revealed a step-like progression of the disease with a possibility of short-term fluctuation of some focal neurological signs. Five stages of clinical course of FAS were detected. Some peculiar sings of spinal neurovisualization, together with serum and cerebro-spinal fluid (CSF) laboratory examinations, were indicated in FAS. Surgery is first-choice of FAS treatment. Pharmacological treatment with high doses of anticoagulants, together with antiviral therapy (and antibiotics, if necessary), neuroprotectors, antiedematic and symptomatic therapy must be started early. Prevention of thrombotic, trophic and purulent complications is required.

Intramedullary spinal cord metastasis from salivary ductal carcinoma of the parotid gland mimicking transverse myelitis in a patient with radiologically isolated syndrome.

Intramedullary spinal cord metastases (ISCMs) are rare lesions but their presence should not be underestimated in a cancer patient with rapidly progressive neurological compromise. Due to similar timing of clinical progression and imaging characteristics, these lesions may be misdiagnosed as transverse myelitis, an inflammatory disorder of the spinal cord that may be idiopathic or secondary to other diseases including infections, connective tissue disorders, nutritional deficiencies, and demyelinating disorders. We present a case of a 44 year-old male with a history of parotid gland metastatic salivary ductal carcinoma (SDC) and incidental demyelinating white matter lesions on brain magnetic resonance imaging (MRI) diagnosed as radiologically isolated syndrome with a CSF that was positive for oligoclonal bands. The patient initially presented with mid-thoracic dermatomal numbness, bilateral lower extremity weakness, and neurogenic bladder. MRI spine demonstrated an enhancing T5-7 intramedullary lesion initially diagnosed as transverse myelitis. After progressing to complete motor and sensory loss below T6 despite high-dose intravenous steroids and plasmapheresis, surgical biopsy was undertaken. Intraoperative findings revealed an intramedullary tumor for which a subtotal resection was performed. Pathology was consistent with a metastatic deposit from the patient's primary parotid SDC. The patient underwent postoperative chemotherapy but expired due to systemic disease progression seven months following surgery without neurological improvement. This is the first reported case of ISCM from a primary SDC. The median survival is 6 months for patients with ISCMs treated surgically. The goals of surgery are spinal cord decompression, functional preservation, and tissue diagnosis.

Transverse myelitis following spinal anesthesia.

Spinal anesthesia is widely used during surgical procedures. It is generally safe and the frequency of severe, permanent neurological complications associated with it has been reported to be extremely low. We report a patient, who developed paraplegia following spinal anesthesia. A 29-year-old male was referred with acute, flaccid, sensory motor paraplegia, with bladder and bowel involvement. He developed this immediately after an operation for inguinal hernia under spinal anesthesia. Spinal magnetic resonance imaging revealed hemorrhagic myelitis in the conus at D12. He was referred after he did not respond to intravenous methylprednisolone for 10 days. This case brings up the difficulty encountered in determination of the interspace used for spinal anesthesia and the potential for traumatic injury to the spinal cord. It also demonstrates the tragic outcome after a clinician violates some important, standard and established guidelines.

[Thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine]. / Die Akutbehandlung der traumatischen Brustmarklähmung Wird das Thoraxtrauma übersehen oder unterschätzt?

AIM: The aim of this study was to analyse the number of thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine and review the early management in respect to treatment standards. METHODS: Using a prospective study protocol, data were sampled and analyzed from 12 December 2000 to 31 March 2002 at a level 1 trauma center. RESULTS: Twenty-two consecutive patients were included in the study. Sixteen suffered severe chest traumata. Lung contusion was diagnosed in 81%, followed by haemopneumothorax (75%) and fracture of the bony chest (75%). Intubation was performed 12 times in all. Chest drainage was performed in 14 patients. The mean duration of artificial ventilation was 20 days (range 2-93) and of intensive care treatment 25 days (range 2-93). Five patients died. CONCLUSIONS: Acute traumatic paraplegia of the upper and middle thoracic spine caused by high energy trauma is highly associated with severe chest trauma. Therefore, respiratory impairment must be kept in mind during the early treatment. If respiratory failure becomes more evident, emergency procedures such as intubation and chest drainage have to be performed. Secondary transfer should be avoided.

Effect of selective posterior rhizotomy on transverse myelitis in a patient with systemic lupus erythematosus.

This report describes the case of a 26-yr-old man experiencing transverse myelitis, a rare but serious complication of systemic lupus erythematosus occurring in less than 1% of patients with systemic lupus erythematosus, 4 yr after the onset of systemic lupus erythematosus. Significant neurologic deficits, including spastic paraplegia, dysthetic pain, and impaired bladder control, which made him completely bedridden and dependent in activities of daily living, continued, despite his immediate diagnosis and treatment. The patient received bilateral L1 to S1 selective posterior rhizotomy 1 yr after the onset of transverse myelitis, and 10 mo after selective posterior rhizotomy, he was completely independent in ambulation and self-care, demonstrating that selective posterior rhizotomy can be safely performed and its goals achieved under different medical conditions, as long as thorough preoperative evaluation and every possible precaution have been taken.

Schistosoma mansoni infection involving the spinal cord. Case report.

The authors report a case of transverse myelitis caused by Schistosoma mansoni. Although this is a treatable disease if diagnosed in the early stage, it is very rarely seen in developed countries and can result in complications if diagnosis is delayed.

Bladder rehabilitation with dorsal rhizotomy and ventral neuroprosthesis.

Two patients with severe neuropathic bladders were successfully treated with selective dorsal rhizotomy in conjunction with a ventral root neuroprosthesis. Both patients achieved stabilization of their renal function, continence, resolution of vesicoureteral reflux, and relief from indwelling urethral catheters. This alternative form of management avoids the complications of other operative approaches.

"Silent" spinal dislocation in a Charcot spine occurring postlaminectomy: case report and review of literature.

A 45-year-old man with transverse myelitis developed an unstable neuropathic spinal arthropathy manifesting as a "silent" L1-L2 dislocation after laminectomy and rhizotomies performed for increased spasticity. Treatment consisted of reduction, posterolateral spinal fusion with Cotrel-Dubousset instrumentation utilizing hooks and pedicular screws, and a posterior lumbar interbody fusion. The authors conclude that laminectomy on a chronic paralytic through the insensate area should be coupled with fusion and instrumentation even if the facet joints and capsules are preserved during the laminectomy.

Transverse myelitis from intraarterial penicillin.

A child was given intramuscular benzathine penicillin and experienced manifestations of sudden, irreversible transection of the spinal cord in the lower thoracic region. The biopsy supported an intravascular injection with occlusion of the spinal vasculature as the etiological mechanism. A review of similar cases reveals a recurring pattern--intramuscular injection with standard techniques and sites into a small muscle mass without evident blood return followed by rapid progression of paralysis. The problem seems to turn upon an inability to recognize the inadvertent intraarterial injection.

Schistosomiasis of the spinal cord.

Schistosomiasis of the spinal cord is a rare presentation of a disease involving over 200 million people. A patient from an endemic area presenting as a transverse myelitis or a spinal cord tumor, and with eosinophilia, should alert the physician to the possibility of schistosomiasis of the spinal cord. Diagnosis is based on finding the characteristic eggs in the stool or urine, or if necessary, by rectal, bladder or liver biopsies. Myelography is performed to determine if decompressive laminectomy is necessary.