Neurosarcoidosis involving cervical nerve root with unusual MRI findings: a case report and systematic literature review.

BACKGROUND: Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature. METHODS: We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review. RESULTS: A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2 months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3-C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node. CONCLUSIONS: This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course.

Anatomical damages in the spinal nerve roots and the spinal cord after brachial plexus injury: descriptive study from a cohort of consecutive patients who underwent DREZ-lesioning for pain-practical implications.

BACKGROUND: Systematic descriptions of anatomical damage after brachial plexus injury (BPI) at the intradural level have been scarcely reported in detail. However, considering these damages, not only in the spinal nerve roots but also in the spinal cord itself, is crucial in determining the appropriate surgical approach to restore upper limb function and address refractory pain. Therefore, the authors present a descriptive study focusing on intradural findings observed during microsurgical DREZ-lesioning. METHODS: This study enrolled 19 consecutive patients under the same protocol. Microsurgical observation through exposure of C4 to Th1 medullary segments allowed to describe the lesions in spinal nerve roots, meninges, and spinal cord. Electrical stimulation of the ventral roots checked the muscle responses. RESULTS: Extensive damage was observed among the 114 explored roots (six roots per patient), with only 21 (18.4%) ventral (VR) and 17 (14.9%) dorsal (DR) roots retaining all rootlets intact. Damage distribution varied, with the most frequent impairments in C6 VRs (18 patients) and the least in Th1 VRs (14 patients), while in all the 19 patients for the C6 DRs (the most frequently impaired) and in 14 patients for Th1 DRs (the less impaired). C4 roots were found damaged in 12 patients. Total or partial avulsions affected 63.3% and 69.8% of DRs and VRs, respectively, while 15.8% and 14.0% of the 114 DRs and VRs were atrophic, maintaining muscle responses to stimulation in half of those VRs. Pseudomeningoceles were present in 11 patients but absent in 46% of avulsed roots. Adhesive arachnoiditis was noted in 12 patients, and dorsal horn parenchymal alterations in 10. CONCLUSIONS: Knowledge of intradural lesions post-BPI helps in guiding surgical indications for repair and functional neurosurgery for pain control.

Primary neurolymphomatosis diagnosed by spinal nerve root biopsy.

Primary neurolymphomatosis is the direct infiltration of lymphomatous neoplastic cells into nerve roots and/or peripheral nerves. A 67-year-old man had a 24-month history of progressive and severe left lower limb neuropathic pain, ipsilateral ankle dorsiflexion weakness and gait disturbance. Gadolinium-enhanced MRI showed thickening and enhancement of the cauda equina, L5, S1 and S2 nerve roots. 18Fluorodeoxyglucose positron emission tomography showed concordant hypermetabolism. L5 nerve root biopsy confirmed diffuse large B-cell lymphoma. One cycle of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) chemotherapy resulted in remission, but this was not sustained. Primary neurolymphomatosis is rare and diagnostically challenging, and often the diagnosis is delayed. While biopsy is the gold standard for diagnosis, neuroimaging helps to characterise lesions and to determine the feasibility of biopsy.

Sacral nerve root metastasis in a patient with lung carcinoma resembling neurinoma - a case report and literature review.

Intradural extramedullary metastases from systemic neoplasms are very rare, with an incidence ranging from 2% to 5% of all secondary spinal diseases. We present the case of a 53-year-old man diagnosed with lung adenocarcinoma with symptoms of severe back pain and tibial paresis. The magnetic resonance imaging (MRI) revealed an intradural lesion originating from the right S1 nerve root mimicking neurinoma. Total tumor removal was achieved via posterior midline approach. The histological examination was consistent with lung carcinoma metastasis. Due to the rarity of single nodular nerve root metastases, MRI images may be misinterpreted as nerve sheath tumors, such as schwannomas or neurofibromas. We performed a brief literature review outlining the mainstay of diagnosis, therapeutic approach, and the prognosis of these rare lesions.

Application of Magnetic Resonance Diffusion Tensor Imaging in Diagnosis of Lumbosacral Nerve Root Compression

OBJECTIVE: The aim of this study was to assess the value of 3.0T magnetic resonance (MR) Diffusion tensor imaging (DTI) in the diagnosis of lumbosacral nerve root compression. METHODS: The radiology reports, and clinical records of 34 patients with nerve root compression caused by lumbar disc herniation or bulging and 21 healthy volunteers who had undergone magnetic resonance imaging (MRI) and DTI scan were retrospectively reviewed. The differences in fractional anisotropy (FA) and apparent diffusion coefficient (ADC) between compressed and non-compressed nerve roots from patients and the normal nerve roots from healthy volunteers were compared. Meanwhile, the nerve root fiber bundles were observed and analyzed. RESULTS: The average FA and ADC values of the compressed nerve roots were 0.254 ± 0.307 and 1.892 ± 0.346 10^-3mm2/s, respectively. The average FA and ADC values of the non-compressed nerve roots were 0.377 ± 0.659 and 1.353 ± 0.344 10^-3mm2/s, respectively. The FA value of compressed nerve roots was significantly lower than that of non-compressed nerve roots (P < 0.01). The ADC value of compressed nerve roots was significantly higher than that of non-compressed nerve roots. There were no significant differences between the left and right nerve roots of normal volunteers in FA and ADC values (P > 0.05). The nerve roots at different levels of L3-S1 had significantly different FA and ADC values (P < 0.01). Incomplete fiber bundles with extrusion deformation, displacement or partial defect were observed in the compressed nerve root fiber bundles. The real diagnosis of the clinical situation of the nerve can provide neuroscientists with an important computer tool to help them infer and understand the possible working mechanism from the experimental data of behavior and electrophysiology. CONCLUSION: The compressed lumbosacral nerve roots can be accurately localized through 3.0T magnetic resonance DTI, which is instructive for accurate clinical diagnosis and preoperative localization.

The radio anatomical arrangement of nerve roots at L3 level in cauda equina sac is it affected by diseases?

An observational study to discover the common conditions affecting the lumbosacral region that may affect lumbosacral position and tension. All the patients, underwent MRI exaamination (magnetic resonance imaging) in the supine position, were examined by the same consultant radiologist. The article was revised by the institutional ethical approval committee. The position of the nerve roots was observed, and the number of nerve roots was calculated anterior to a line passing between the mid-transvers process of L3(third lumbar vertebra). The number of nerve roots ahead of this line was calculated by the radiologist at the level of the right intervertebral foramen and at the left one. This procedure was applied to the normal group, and 5 common pathological diseases were repeated including single-level lumbar disc prolapse, multiple-disc prolapse, multiple bulge, spinal stenosis and spondylolisthesis (at the level of L45 (fourth to fifth lumbar vertebrae) or L5S1 (fifth lumbar to first sacral vertebrae) being outside the study area, i.e., L3). We noticed significant difference in the number of the nerve roots between the cases with herniated discs, spinal stenosis, and spondylolisthesis with the normal group and the significance was in ascending increment in significance being the highest in cases with spondylolisthesis, and even in the groups of other pathologies which are statistically not significant, we noticed that the significance is proportional to the severity of the disease being the least in single level cases (p 0.427), to be more significant on cases with multiple prolapses(p 0.319) to be more in cases with multiple bulges to start to be statistically significant in herniated, higher significance in cases with spinal stenosis to be the highest in cases with spondylolisthesis.

Brachial plexus tumors extending into the cervicothoracic spine: a review with operative nuances and outcomes

Background The rarity and anatomical complexity of brachial plexus tumors (BPTs) impose many challenges onto surgeons performing surgical resections, especially when these tumors invade the cervicothoracic spine. Treatment choices and surgery outcomes heavily depend on anatomical location and tumor type. Methods The authors performed an extensive review of the published literature (PubMed) focusing on “brachial plexus tumors” that identified invasion of the cervicothoracic spine. Result The search yielded 2774 articles pertaining to “brachial plexus tumors”. Articles not in the English language or involving cervicothoracic spinal invasion were excluded. Conclusions Recent research has shown that the most common method used to resect tumors of the proximal roots is the dorsal subscapular approach. Despite its association with high morbidity rate, this technique offers excellent exposure to the spinal roots and intraforaminal portion of the spinal nerve. The dorsal approach is used to resect recurrent lower trunk tumors and dumbbell-shaped neurofibromas, yet it is also the least common overall approach used in brachial plexus tumor resections. The ventral or anterior technique is commonly used to resect tumors at the cord to division level, and root to trunk level. Motor complications, transient nerve palsy, and bleeding are among the most common complications of the anterior supraclavicular approach. Further controlled studies are needed to fully determine the optimal surgical approach used to obtain the best outcomes and least complications for each type of brachial plexus tumor (AU)

Notalgia parestésica: a propósito de dos casos / Notalgia paresthetica: two clinical cases

La notalgia parestésica es una neuropatía sensorial que afecta a los nervios dorsales espinales. Se caracteriza por prurito en la zona media de la espalda, ocasionalmente cursa con dolor, parestesias y/o hiperestesia, y aparición de una macula hiperpigmentada. Los casos publicados sugieren que los síntomas se deben a neuropatía sensorial, y los tratamientos en este sentido son más efectivos que la terapia clásica para el prurito. A veces no es necesario ningún tratamiento, pero para los casos más sintomáticos se han utilizado gran variedad de terapias con resultados muy irregulares. Se necesitan más estudios para evaluar que tratamientos pueden ser más efectivos para mejorar la sintomatología (AU)

Notalgia paresthetica is a sensory neuropathy involving the dorsal spinal nerves. The characteristic symptom is pruritus on the back, occasionally accompanied by pain, paresthesia and/or hyperesthesia, which results in a well-circumscribed hyper pigmented patch in the symptomatic area. The published cases and studies suggest symptoms of notalgia paresthetica are due to a cutaneous sensory neuropathy and treatments addressing the condition as such are more successful than traditional itch therapies. In many cases treatment is no needed, however some therapies have been used with irregular effectiveness certain distressing cases. Further studies are needed to evaluate which treatments have the greatest potential for providing symptom relief (AU)

Quiste de Tarlov: diagnóstico durante el puerperio / Tarlov cyst: diagnosis during the postpartum period

Los quistes de Tarlov, también llamados quistes extradurales, son una ectasia del espacio perineural de las raíces nerviosas espinales, situadas de manera habitual distalmente al ganglio dorsal o en la unión con este. Su localización más frecuente es la región sacra y son de etiología incierta. La mayoría de las veces son asintomáticos, aunque pueden ser responsables de síntomas irritativos lumbares o radiculares. A continuación se presenta un caso clínico de un quiste de Tarlov que se manifiesta con síntomas radiculares durante el puerperio

Tarlov cysts, also called extradural cysts, consist of perineural space ectasia of the spinal nerve roots, usually located distal to the dorsal root ganglia or in the junction with this structure. The most frequent location is in the sacral region. The etiology remains uncertain. Most Tarlov cysts are asymptomatic, but they can cause lumbar or root irritative symptoms1. We describe a case of Tarlov cyst presenting as radicular symptoms during the postpartum period

Cauda equina redundant nerve roots are associated to the degree of spinal stenosis and to spondylolisthesis / Associação entre a presença de raízes redundantes na cauda equina e a área seccional do saco dural avaliada por meio de ressonância magnética

To evaluate the association of redundant nerve roots of cauda equina (RNRCE) with the degree of lumbar spinal stenosis (LSS) and with spondylolisthesis. Method After Institutional Board approval, 171 consecutive patients were retrospectively enrolled, 105 LSS patients and 66 patients without stenosis. The dural sac cross-sectional area (CSA) was measured on T2w axial MRI at the level of L2-3, L3-4 and L4-5 intervertebral discs. Two blinded radiologists classified cases as exhibiting or not RNRCE in MRI. Intra- and inter-observer reproducibility was assessed. Results RNRCE were associated with LSS. RRNCE was more frequent when maximum stenosis<55 mm2. Substantial intra- observer agreement and moderate inter-observer agreement were obtained in the classification of RNRCE. Spondylolisthesis was identified in 27 patients and represented increased risk for RRNCE. Conclusion LSS is a risk factor for RNRCE, especially for dural sac CSA<55 mm2. LSS and spondylolisthesis are independent risk factors for RNRCE. .

Avaliar associação entre raízes nervosas redundantes da cauda eqüina (RNRCE) com grau de estenose do canal lombar (ECL) e espondilolistese. Método Após aprovação do Comitê de Ética, 171 pacientes foram selecionados retrospectivamente, 105 com ECL e 66 sem estenose. Foram realizadas mensurações da área seccional do saco dural em imagens axiais de RM ponderadas em T2 em L2/L3, L3/L4 e L4/L5. Presença ou não de RRNCE foi classificada de forma independente por dois radiologistas, às cegas. Concordância intra e inter-observador foi analisada. Resultados RNRCE foi associada à ECL e foi mais freqüente quando a máxima estenose encontrada foi <55mm2. Houve grande concordância intra-observador e moderada inter-observador na classificação das RRNCE. Espondilolistese foi identificada em 27 pacientes e representou maior risco para desenvolvimento de RNRCE. Conclusão ECL é fator de risco para RNRCE, especialmente com áreas seccionais <55mm2. ECL e espondilolistese representam fatores de risco independentes para desenvolvimento de RNRCE. .

Polirradiculopatía inflamatoria crónica sensitiva / Chronic inflammatory sensory polyradiculopathy

La polirradiculopatía inflamatoria crónica sensitiva es una entidad definida, frecuentemente subdiagnosticada y potencialmente tratable. Debe ser sospechada en pacientes con ataxia sensitiva, estudios de conducción nerviosa normales y una resonancia magnética que muestre engrosamiento y realce con gadolinio de las raíces lumbosacras. Presentamos el caso de un hombre de 57 años de edad con marcada ataxia sensitiva en pierna izquierda. Al examen físico presentaba fuerza conservada, reflejos osteotendinosos disminuidos, tacto fino y superficial reducidos por debajo de las rodillas; abatiestesia y apalestesia en ambos pies. Los estudios de conducción nerviosa eran normales, los potenciales evocados somatosensitivos tibiales con ausencia de respuesta bilateral. El líquido cefalorraquídeo presentaba hiperproteinorraquia sin células. La resonancia magnética mostró engrosamiento y realce con gadolinio de las raíces lumbosacras. El paciente fue tratado con inmunoglobulina endovenosa (IgEV) a 2 g/kg durante 5 días, con buena respuesta. La evolución clínica, la hiperproteinorraquia, el realce de raíces en la resonancia magnética, la buena respuesta a la inmunoterapia y la exclusión de otras causas de ataxia sensitiva fueron compatibles con el diagnóstico de polirradiculopatía inflamatoria crónica sensitiva. Para el diagnóstico de esta enfermedad se requiere la identificación del compromiso aislado de las raíces sensitivas.

Chronic inflammatory sensory polyradiculopathy is a defined entity, frequently underdiagnosed, and potentially treatable. It must be suspected in patients with sensory ataxia, normal nerve conduction studies, and MRI with thickened lumbosacral nerve roots and gadolinium enhancement. We present the case of a 57-year-old man with marked sensory ataxia on his left leg. Examination showed normal strength, decreased knee and ankle jerks. Light touch and pinprick sensations were reduced below the knees. Vibration and joint position sense were absent at the feet. Nerve conduction studies were normal. Tibial sensory evoked potentials disclosed absent responses bilaterally. CSF was acellular with elevated protein. Lumbosacral magnetic resonance showed thickening of roots, with gadolinium enhancement. The patient was treated with IV-Ig, 2 g/kg, for 5 days with improvement of symptoms. The clinical course, elevated CSF protein, the evidence of root enhancement on the MRI, good response to immunotherapy, and the exclusion of other causes of sensory ataxia, were compatible with the diagnosis of chronic inflammatory sensory polyradiculopathy. To diagnose this disease the identification of isolated involvement of the sensory roots is required.

Efeitos antinociceptivos, analgésicos e histopatológicos de dexmedetomidina e bupivacaína intratecal em rato / Anti-nociceptive, analgesic and pathohistological effects of intrathecal dexmedetomidine and bupivacaine in rats / Efectos antinociceptivos, analgésicos e histopatológicos de dexmedetomidina y bupivacaína intratecal en ratones

JUSTIFICATIVA E OBJETIVOS: Este estudo investigou os efeitos analgésicos e nociceptivos da adição de dexmedetomidina à bupivacaína em anestesia do neuroeixo usando os testes de retirada da cauda (tail-flick [TF]) e da placa quente (hot-plate [HP]) e microscopia de luz para as alterações histopatológicas de nervos espinhais e raízes nervosas. MÉTODOS: Quarenta ratos Sprague-Dawley anestesiados, machos, foram cateterizados intratecalmente. Os valores basais dos testes TF e HP foram medidos antes e depois do cateterismo. Trinta e seis ratos cateterizados com sucesso foram distribuídos em quatro grupos. O Grupo B recebeu 10 µg de bupivacaína, o Grupo BD3 recebeu 10 µg de bupivacaína + 3 µg de dexmedetomidina, o Grupo BD10 recebeu 10 µg de bupivacaína + 10 µg de dexmedetomidina e o Grupo Controle recebeu 10 µL de líquido cefalorraquidiano artificial. Os testes TF e HP foram feitos entre cinco e 300 minutos a partir da administração das drogas. Vinte e quatro horas após a administração, os ratos foram sacrificados e retiradas as medulas espinhais e raízes nervosas para investigação patológica. RESULTADOS: Os valores basais dos testes TF e HP não foram estatisticamente diferentes entre os grupos (6,8 ± 0,15 s). As latências de TF e HP no Grupo Controle não apresentaram alteração significativa durante o estudo. Os resultados dos testes TF e HP mostraram que a adição de 3 e 10 µg de dexmedetomidina causou um aumento dose-dependente na duração e amplitude do efeito analgésico e nociceptivo de bupivacaína (TF: 37,52 ± 1,08%, 57,86 ± 1,16%, respectivamente; HP: 44,24 ± 1,15%, 68,43 ± 1,24%, respectivamente). CONCLUSÕES: Não houve alterações histopatológicas aparentes em pelo menos 24 horas após a administração intratecal da dose única de dexmedetomidina (3 µg e 10 µg). Dexmedetomidina adicionado à bupivacaína para raquianestesia melhora a analgesia e prolonga a duração do bloqueio.

BACKGROUND AND OBJECTIVES: This study investigates analgesic and nociceptive effects of adding dexmedetomidine to bupivacaine neuraxial anesthesia through Tail-flick (TF) and Hot-plate (HP) tests and the pathohistological changes on spinal nerves and nerve roots through light microscopy. METHODS: Forty anesthetized, male Sprague-Dawley rats were intrathecally catheterized. Basal values of TF and HP tests were measured before and after catheterization. Thirty-six successfully catheterized rats were assigned to four groups. Group B received 10 µg bupivacaine, Group BD3 received 10 µg bupivacaine + 3 µg dexmedetomidine, Group BD10 received 10 µg bupivacaine + 10 µg dexmedetomidine and Control group received 10 µL volume of artificial cerebrospinal fluid. TF and HP tests were performed between the 5th and 300th minutes of drug administration. Twenty-four hours after administration of drugs, rats were sacrificed and spinal cord and nerve roots were removed for pathological investigation. RESULTS: Baseline values of the TF and HP tests were not statistically different among the groups (6.8 ± 0.15 s). TF and HP latencies in the Control group did not change significantly during the study. TF and HP test results showed that adding 3 and 10 µg dexmedetomidine caused a dosedependent increase in duration and amplitude of analgesic and nociceptive effect of bupivacaine (TF: 37.52 ± 1.08%, 57.86 ± 1.16% respectively, HP: 44.24 ± 1.15%, 68.43 ± 1.24% respectively). CONCLUSIONS: There were no apparent pathohistological changes at least 24 hours after the intrathecal administration of a single dose of dexmedetomidine 3 µg and 10 µg. Dexmedetomidine added to bupivacaine for spinal block improves analgesia and prolongs block duration.

JUSTIFICATIVAS Y OBJETIVOS: Este estudio investigó los efectos analgésicos y nociceptivos de la adición de dexmedetomidina a la bupivacaína en anestesia del neuro eje, usando los test de retirada de la cola (tail-flick [TF]) y de la placa caliente (hot-plate [HP]) y microscopía de luz para las alteraciones histopatológicas de nervios espinales y raíces nerviosas. MÉTODOS: Cuarenta ratones anestesiados, Sprague-Dawley machos, fueron cateterizados intratecalmente. Los valores basales de los testes TF y HP fueron medidos antes y después del cateterismo. Treinta y seis ratones cateterizados con éxito fueron distribuidos en cuatro grupos. El Grupo B recibió 10 µg de bupivacaína, el Grupo BD3 recibió 10 µg de bupivacaína + 3 µg de dexmedetomidina, el Grupo BD10 recibió 10 µg de bupivacaína + 10 µg de dexmedetomidina y el Grupo Control recibió 10 µL de líquido cefalorraquídeo artificial. Los test TF y HP se hicieron entre cinco y 300 minutos a partir de la administración de los fármacos. Veinte y cuatro horas después de la administración, los ratones fueron sacrificados y se les retiraron las médulas espinales y las raíces nerviosas para investigación patológica. RESULTADOS: Los valores basales de los test TF y HP no fueron estadísticamente diferentes entre los grupos (6,8 ± 0,15 s). Las latencias de TF y HP en el Grupo Control no tenían ninguna alteración significativa durante el estudio. Los resultados de los test TF y HP mostraron que la adición de 3 y 10 µg de dexmedetomidina causó un aumento dosis dependiente en la duración y en la amplitud del efecto analgésico y nociceptivo de bupivacaína (TF: 37,52 ± 1,08%, 57,86 ± 1,16%, respectivamente; HP: 44,24 ± 1,15%, 68,43 ± 1,24%, respectivamente). CONCLUSIONES: No hubo alteraciones histopatológicas aparentes en por lo menos 24 horas después de la administración intratecal de la dosis única de dexmedetomidina (3 µg y 10 µg). Dexmedetomidina añadido a la bupivacaína para raquianestesia mejora y prolonga la duración del bloqueo.

Diagnosing neuroleukemiosis: is there a role for 18F-FDG-PET/CT? / Diagnosticando la neuroleucemiosis: ¿existe un papel para la PET/TC con 18F-FDG?

An imaging case is presented on a patient referred to our department for an 18F-FDG-PET/CT, as a paraneoplastic syndrome was suspected due to his clinical situation. He had a history of acute myeloid leukemia (AML) treated two years earlier, with sustained complete remission to date. 18F-FDG-PET/CT findings revealed hypermetabolism in almost all nerve roots, suggesting meningeal spread, consistent with the subsequent MRI findings. Cerebrospinal fluid (CSF) findings confirmed a leptomeningeal reactivation of AML. Although not many studies have evaluated the role of 18F-FDG-PET/CT in leukemia, it is a noninvasive tool for detecting extramedullary sites of disease and a good imaging alternative for those patients on whom an MRI cannot be performed (AU)

Presentamos el caso de un paciente remitido a nuestro servicio para la realización de una PET/TC con 18F-FDG por sospecha clínica de un síndrome paraneoplásico Entre sus antecedentes destacaba el de una leucemia mieloide aguda tratada 2 años antes y en remisión completa en los controles sucesivos. La PET/TC con 18F-FDG mostró hipermetabolismo en prácticamente todas las raíces nerviosas, apuntando a enfermedad meníngea diseminada, en concordancia con los hallazgos de la RM realizada posteriormente. El análisis del líquido cefalorraquídeo confirmó una reactivación leptomeníngea de la leucemia mieloide aguda. A pesar de los pocos estudios existentes sobre el papel de la PET/TC con 18F-FDG en la leucemia, es una herramienta no invasiva para localizar recidivas extramedulares de la enfermedad y una buena técnica de imagen alternativa para aquellos pacientes a los que no se les puede realizar una RM (AU)

Hemangioblastoma radicular extraforaminal de la raíz L4 derecha / Hemangioblastoma of the right L4 nerve root with radicular extraforaminal involvement

Los hemangioblastomas son tumores benignos, hipervasculares, cuya localización más frecuente es a nivel de la fosa posterior o la médula espinal. Los hemangioblastomas radiculares representan menos del 2% del total. Presentamos el caso de un paciente con un cuadro de dolor radicular en el territorio de la raíz L4 derecha a consecuencia de un hemangioblastoma radicular dependiente de dicha raíz. El diagnóstico primario de esta patología suele ser erróneo, sospechándose esta entidad únicamente durante el acto quirúrgico. Dada la gran vascularización que presentan, es aconsejable intentar una embolización prequirúrgica para disminuir así el sangrado intraoperatorio y evitar lesiones en raíces elocuentes. En nuestro caso, tras la devascularización del tumor y bajo control neurofisiológico, se consiguió una extirpación completa de la lesión sin evidenciarse déficit neurológico posterior

Hemangioblastomas are benign hypervascular tumours, which are frequently located at the posterior fossa or the spinal cord. Nerve root hemangioblastomas account for less than 2%of total cases. Sometimes the initial diagnosis can be inaccurate and the final diagnosis is not reached until the surgical procedure is performed. Given the high vascularisation of this particular kind of tumour, preoperative embolisation of the tumour is recommended to reduce surgical bleeding and minimise the risk of injuries to motor nerve roots. In this particular case, the patient presented with radicular pain in the right L4 nerve root territory originated by a radicular extraforaminal hemangioblastoma. After tumour devascularization and under neurophysiological control, total excision of lesion was achieved without posterior neurological deficit

Neurofibromas plexiformes voluminosos de cuello en la neurofibromatosis tipo 1 / Voluminous plexiform neurofibromas of the neck region in neurofibromatosis 1

Objetivo. Presentar las características clínicas, de imagen y evolutivas de una serie de pacientes con neurofibromatosis tipo 1 que desarrollaron durante la infancia neurofibromas plexiformes voluminosos en el cuello (NFPVC). Pacientes y métodos. Nueve pacientes (cinco mujeres y cuatro varones) con edades entre 3 y 15 años en el momento del diagnóstico de los tumores, que podían extenderse también a la fosa posterior y a la zona torácica superior. El diagnóstico estuvo basado fundamentalmente en la clínica, la imagen y la histología. Resultados. Un tumor era intralaríngeo y causaba problemas respiratorios. Los otros ocho casos tenían su origen en varias raíces espinales de uno o de ambos lados y podían crecer también hacia el interior de la fosa posterior y de la región torácica en algunos pacientes, y desplazaban a las estructuras anatómicas vecinas, especialmente en tres casos, todos niñas, en las que el tumor creció hasta alcanzar gran volumen, especialmente por un lado, parándose el crecimiento entre los 11 y 12 años y no volviendo a crecer más tarde. Conclusiones. Los NFPVC son tumores histológicamente benignos. La extirpación es necesaria cuando están localizados en la laringe por los problemas respiratorios que causan, pero no en los de las otras regiones, pese a que el voluminoso tamaño que alcanzan en algunos casos puede causar exagerados desplazamientos de las estructuras vecinas. El estudio de nuestra serie parece indicar que al menos los tumores extralaríngeos sólo crecen hasta los 11-12 años. Puede ser recomendable retrasar la cirugía tanto como sea posible si no existe sintomatología aguda que la haga necesaria (AU)

Aim. To present the clinic, imaging and evolutive characteristics of a series of patients with neurofibromatosis 1 with voluminous plexiform neurofibromas in the neck (VPNFN) during childhood. Patients and methods. Nine patients (five females and four males) who were diagnosed as VPNFN at ages between 3 and 15 years. The VPNFN widespread to the posterior fossa or the upper thoracic region in some cases. The diagnosis was based on the clinical, imaging and histological findings. Results. One of the tumors was intralaryngeal and caused respiratory difficulties. The other eight patients had the origin of the tumor in several spinal roots of one or both sides and could growth to the posterior fossa and to the upper thoracic region in some cases with displacement of the surrounding organs, especially in three patients, all girls, in whom the tumor reached a voluminous size on one side, that was observed only until 10 to 11 years when the growth ceased. Conclusions. The VPNFN are histologically benign tumors. Those located in the larynx must be removed because of therespiratory problems, but it is not necessary in cases with other locations despite the voluminous size that can reach in some patients with great displacement of the surrounding organs. The analysis of the results of our series may demonstrate that al least the extralaryngeal tumors only grow to 11-12 years of age. This possibility may make recommendable to retard the surgical treatment as much as possible in cases that it is not necessary (AU)

Conjoined lumbosacral nerve roots: observations on three cases and review of the literature

Las anomalías congénitas de los nervios raquídeos lumbares no son muy frecuentes y suelen ser difíciles de detectar en TAC sin contraste. Las raíces lumbares pueden ser conjuntas o bífidas y frecuentemente son descubiertas en las autopsias clínicas. Cursan habitualmente con dolor (episodios de lumbalgia y lumbociatalgia) y sin déficit motor ni sensitivo. Las raíces conjuntas frecuentemente se aprecian en la RM. Presentamos tres casos de raíces lumbares conjuntas intervenidos en el Servicio de Radiología del Hospital Addolorata de Roma y en el Servicio de Neurorradiología del Hospital Universitario de Roma La Sapienza” entre 2001 y 2004, representando 0.25%de todos los 1200 pacientes evaluados mediante TAC y RM, y revisamos los aspectos diagnósticos presentados en la literatura mundial. La RM es, en muchas ocasiones, superior a la TAC simple en el diagnóstico de las anomalías de las raíces nerviosas; además la RM tiene la ventaja de los planos sagitales y coronales. La visualización de la médula y la cola de caballo, sin necesidad de contraste intratecal, hace que la RM sea el examen ideal para identificar las raíces nerviosas conjuntas, ofreciendo una ventaja clara sobre la TAC

Lumbosacral nerve root anomalies are a rare groupof congenital anatomical anomalies. Various types of anomalies of the lumbosacral nerve roots have been documented in the available international literature. Generally speaking, these anomalies may consist of a bifid, conjoined structure, of a transverse course or of a characteristic anastomized appearance. Firstly described as an incidental finding during autopsies or surgical procedures performed for lumbar disk herniations and often asymptomatic, lumbosacral nerve root anomalies have been more frequently described in the last years due to the advances made in radiological diagnosis(metrizamide myelography and CT, MRI).Our study comprised three patients with conjoined lumbosacral nerve roots, representing 0.25% of a total of 1200 patients who underwent lumbosacral CT/MRI procedures in the Addolorata Hospital and in the Serviceof Neuroradiology of the University of Rome "La Sapienza" during the last three years (March 2001-March 2004). We report our experience with three cases of conjoined lumbosacral nerve roots and analyze the most important literature on this topic.MR imaging is a better diagnostic procedure (incomparison to CT) for the differentiation of nerve root anomalies and, in particular, coronal sections furnish a precise definition of the profile of the conjoined/enlarged rootlets. In fact, the accurate information derived from MRI of multiple planes may be priceless for the preoperative and diagnostic evaluation of lumbosacral nerve root anomalies

Chronic inflammatory demyelinating polyradiculoneuropathy: two cases with cervical spinal cord compression

A polirradiculoneuropatia desmielinizante inflamatória crônica (PDIC) é uma afecção dos nervos periféricos de natureza autoimune, com evolução por surtos de exacerbação e remissão ou de evolver progressivo. O acometimento motor é predominante, com fraqueza proximal e distal nos membros inferiores. A eletroneuromiografia é do tipo desmielinizante com bloqueio de condução nervosa em dois ou mais nervos. Há aumento de proteínas do líquor. Com a evolução da doença pode haver espessamento dos nervos distal e/ou proximalmente. Excepcionalmente ocorre compressão da medula espinhal em qualquer segmento por raízes próximas hipertrofiadas. Foram estudadas duas mulheres de 66 e 67 anos respectivamente com quadro de PDIC de longa evolução. A primeira tinha evolução por surtos e na segunda o evolver era progressivo. Nos dois casos o espessamento proximal dos nervos provocou síndrome de compressão medular alta. Esta complicação deve ser pensada em casos de PDIC de longa duração.

Drematomal somatosensory evoked potentials (DSSEP) in patients with proved lumbosacral radiculopathies

Se llevó a cabo el estudio de potenciales evocados dermatómicos en 14 pacientes con afectación probada de raíces L5 o S1 o ambas unilateralmente. El estímulo se produjo en el área de piel correspondiente a la metamera deseada y el registro se efectuó en la corteza parietal de recepción contralateral. Los resultados fueron comparados con un grupo control sano, se observó que la técnica fue capaz de identificar a la lesión a través de dos tipos de hallazgos, uno fue el retraso en la latencia de la onda N1 y el segundo la ausencia de respuesta evocada

Algunos aspéctos del Sindrome de la Región Lumbar / Aspects in Lumbar Syndrome

Se analiza el Sindrome Lumbar en sus tre variantes: hernia del disco, canal estrecho y anomalia radicular. El trabajo se fundamenta en 3200 casos de hernia del nucleo pulposo operados en los 50 años de funcionamiento del Servicio de Neurocirugia del Hospital Nacional Guillermo Almenara Irigoyen. Se destaca la importancia de la cirugia con la tecnica de Love en la patologia lumbar que hasta 1946 era considerada patrimonio de la traumatologia y ortopedia. Luego se valora el diametro del canal raquideo señalado por Verbiest con la descripcion del sindrome del canal estrecho congenito y adquirido, relevando el trayecto radicular y extradural de la raiz. Finalmente se resalta la importancia de las anomalias radiculares señaladas por Cannon con el trascendente aporte de la imagenologia, en especial la tomografia axial computarizada y la resonancia magnetica. Estos avances tecnologicos y de procedimientos han disminuido la persistencia del dolor lumbar post quirurgico de 30-35 por ciento hasta 2-5 por ciento. Se destaca la importancia de las intervenciones antes del sufrimiento radicular. No se ha considerado los sindromes dolorosos por inestabilidad del segmento ni por listesis congenita