Mielitis transversa aguda: revisión clínica y algoritmo de actuación diagnóstica / Acute transverse myelitis: a clinical review and algorithm for diagnostic intervention

Introducción. Bajo el término de mielitis transversa aguda (MTA) se engloba un grupo heterogéneo de enfermedades, con el nexo común de producir una lesión focal inflamatoria de la médula espinal, de forma aguda. Para intentar agrupar todas las etiologías que pueden cursar con dicha afectación, se intenta hoy en día definir varios grupos de patologías con un nexo común: aquellas MTA asociadas a algún proceso causante, o al menos predisponente de la MTA, como son ciertas infecciones, procesos sistémicos y/o multifocales inmunológicos, e incluso tumorales, y aquéllas en las que no llegamos a conocer dicho desencadenante, a las que llamamos entonces MTA idiopáticas. Objetivo. Conocer las distintas clases de MTA existentes, creando un algoritmo diagnóstico que ayude a dicha clasificación de forma ordenada, simplificando el trabajo al clínico que se enfrente a una MTA, y exponiendo su diagnóstico diferencial, pronóstico y posible tratamiento. Desarrollo. Se consultan las últimas guías y trabajos publicados relacionados con la MTA, sobre todo desde el punto de vista diagnóstico y terapéutico. Conclusiones. Nuestro conocimiento de la MTA se está viendo modificado constantemente con el advenimiento de nuevas técnicas diagnósticas y teorías que intentan explicar su origen, probablemente inmunológico. Desgraciadamente, el tratamiento y, por tanto, el pronóstico no han variado en la misma proporción al conocimiento que vamos adquiriendo en las otras áreas. Sin duda, queda un camino importante por recorrer, pero el futuro próximo nos puede enseñar más sobre esta enfermedad (AU)

Introduction. Under the term of acute transverse myelitis (ATM), there are included a heterogeneous group of diseases, with the nexus common to produce an inflammatory focal injury of the spinal cord, of acute form. In order to try to group all the etiologies that can provoke this affectation, it is nowadays tried to define several groups of pathologies with a common nexus: those ATM associated to some process, or at least predisposed of the ATM, like are certain infections, immunological systemic and/or multifocal processes, and inclusive tumors, but when we did not get to know this triggering factor, then calling them idiopathic ATM. Aim. To know the different classes from existing ATM, creating an algorithm diagnosis that helps to this classification of ordinate form, simplifying the work to the clinicians that faces a ATM, exposing its differential diagnosis, prognosis and possible treatment. Development. For it we consulted the last guides and works published related to the ATM, mainly from the diagnostic and therapeutic point of view. Conclusions. Our knowledge of the ATM is being constantly modified with the coming of new diagnostic techniques and theories that try to explain their origin, probably immunological. Unfortunately, the treatment, and therefore the prognosis, has not varied in the same proportion to the knowledge that we are acquiring in the other areas. Without a doubt, it is a way important to walk, but the next future can teach to us more on this disease (AU)

[Acute transverse myelitis: a clinical review and algorithm for diagnostic intervention]. / Mielitis transversa aguda: revisión clínica y algoritmo de actuación diagnóstica.

INTRODUCTION: Under the term of acute transverse myelitis (ATM), there are included a heterogeneous group of diseases, with the nexus common to produce an inflammatory focal injury of the spinal cord, of acute form. In order to try to group all the etiologies that can provoke this affectation, it is nowadays tried to define several groups of pathologies with a common nexus: those ATM associated to some process, or at least predisposed of the ATM, like are certain infections, immunological systemic and/or multifocal processes, and inclusive tumors, but when we did not get to know this triggering factor, then calling them idiopathic ATM. AIM: To know the different classes from existing ATM, creating an algorithm diagnosis that helps to this classification of ordinate form, simplifying the work to the clinicians that faces a ATM, exposing its differential diagnosis, prognosis and possible treatment. DEVELOPMENT: For it we consulted the last guides and works published related to the ATM, mainly from the diagnostic and therapeutic point of view. CONCLUSIONS: Our knowledge of the ATM is being constantly modified with the coming of new diagnostic techniques and theories that try to explain their origin, probably immunological. Unfortunately, the treatment, and therefore the prognosis, has not varied in the same proportion to the knowledge that we are acquiring in the other areas. Without a doubt, it is a way important to walk, but the next future can teach to us more on this disease.

[Spinal cord involvement by tuberculosis]. / Afectación de la médula espinal por tuberculosis.

INTRODUCTION: We are observing an increase of patients with tuberculosis in Spain. Within the forms of extrapulmonary presentation, the involvement of the central nervous system by the bacillus that cause this disease is a relatively frequent location. Although sometimes is affected the spinal cord of secondary form, rarely is observed isolated involvement. DEVELOPMENT AND CONCLUSIONS: We describe the diverse forms of spinal cord tuberculosis presentation, attending of its location within the spinal cord or adjacent annexes, in order that the clinician knows and remembers this infrequent but possible infection of the spinal cord, because their knowledge and prompt treatment modifies clearly their final prognosis. We analyze the treatment rules for each case according to the last recommendations, and finally, the differences in two groups of population, immunodepressant patients, like human immunodeficiency virus infected patients, as well as in paediatric age patients, because both groups have more possibility of tuberculosis infection generally, and therefore spinal cord involvement, with a differential clinical and therapeutic behaviour.

Afectación de la médula espinal por tuberculosis / Spinal cord involvement by tuberculosis

Introducción. Se está observando un incremento en nuestro medio de pacientes infectados por tuberculosis. Dentro de las formas de presentación extrapulmonar, la afectación del sistema nervioso central por el bacilo causante de esta enfermedad es una localización relativamente frecuente. Aunque a veces se ve implicada la médula espinal de forma secundaria, rara vez se observa afectación aislada de ésta. Desarrollo y conclusiones. Se pretende describir las diversas formas de presentación medular de la tuberculosis, atendiendo a su localización dentro de la médula o sus alrededores, a fin de que el clínico conozca y tenga presente esta infrecuente, pero posible, infección de la lesión medular, ya que su conocimiento y pronto tratamiento modifican claramente su pronóstico final. Analizamos las pautas de tratamiento para cada caso según las últimas recomendaciones y, por último, se presentan las diferencias en dos grupos de población, los pacientes inmunodeprimidos, como los infectados por el virus de la inmunodeficiencia humana, así como los pacientes en edad pediátrica, ya que ambos grupos tienen más posibilidad de afectación por tuberculosis en general y, por lo tanto, de afectación medular, con un comportamientoclínico y terapéutico diferencial

Introduction. We are observing an increase of patients with tuberculosis in Spain. Within the forms of extrapulmonary presentation, the involvement of the central nervous system by the bacillus that cause this disease is a relatively frequent location. Although sometimes is affected the spinal cord of secondary form, rarely is observed isolated involvement.Development and conclusions. We describe the diverse forms of spinal cord tuberculosis presentation, attending of its location within the spinal cord or adjacent annexes, in order that the clinician knows and remembers this infrequent but possibleinfection of the spinal cord, because their knowledge and prompt treatment modifies clearly their final prognosis. We analyze the treatment rules for each case according to the last recommendations, and finally, the differences in two groups of population, immunodepressant patients, like human immunodeficiency virus infected patients, as well as in paediatric agepatients, because both groups have more possibility of tuberculosis infection generally, and therefore spinal cord involvement, with a differential clinical and therapeutic behaviour

[Acute transverse myelitis in seven patients with systemic lupus erythematosus]. / Mielitis transversa aguda en siete pacientes con lupus eritematoso sistémico.

INTRODUCTION: Although the association between transverse myelitis and systemic lupus erythematosus is rather infrequent, it is important to take this form of clinical presentation into account because it is a serious complication, which can potentially be treated but even when dealt with in the early stages does not always have a good prognosis. PATIENTS AND METHODS: We conducted a retrospective review over the past 13 years of the cases that have been admitted to our specific centre for the treatment of spinal cord injuries that were diagnosed as suffering from myelitis associated with disseminated lupus erythematosus. Demographic and clinical data, together with data about acute phase and maintenance treatments, as well as the patients' progress and sequelae are described. RESULTS: The case reports of seven patients, all of whom were young females, are studied. In two cases, myelitis was the initial presentation of lupus. The main disorder was at the dorsal, followed by the cervical, levels. Only two patients had a favourable long-term progression from the neurological point of view (both managed to walk) despite acute treatment with high doses of intravenous corticoids, and regardless of the fact that cyclophosphamide was later used. CONCLUSIONS: Myelitis associated to lupus is a rare manifestation but, owing to its important functional repercussions, it must be taken into account when faced with an acute clinical picture involving the spinal cord; this is particularly the case when it occurs in young females, with or without a previous diagnosis of autoimmune disease.

Mielitis transversa aguda en siete pacientes con lupus eritematoso sistémico / Acute transverse myelitis is seven patients with systemic lupus erythematosus

Introducción. Aunque la asociación entre mielitis transversa y lupus eritematoso sistémico es bastante infrecuente, es importante tener en cuenta esta forma de presentación clínica, porque se trata de una complicación grave, con tratamiento potencial, que incluso con intervención temprana no siempre se asocia a un buen pronóstico. Pacientes y métodos. Revisamos de forma retrospectiva durante los últimos 13 años los casos que han ingresado en nuestro centro específico para el tratamientode lesión medular, con diagnóstico de un cuadro de mielitis asociada a lupus eritematoso diseminado. Se describen los datos demográficos, clínicos, el tratamiento realizado en la fase aguda y de mantenimiento, así como su evolución y secuelas.Resultados. Se estudian los casos clínicos de siete pacientes, todas ellas mujeres jóvenes. En dos de ellas la mielitis fue la forma de inicio del lupus. La afectación predominante fue a nivel dorsal y después cervical. Sólo dos pacientes tuvieron una evolución favorable a largo plazo desde el punto de vista neurológico, consiguiendo la deambulación, a pesar del tratamiento agudo con corticoides intravenosos en dosis altas, con independencia de que posteriormente se utilizase ciclofosfamida.Conclusión. La mielitis asociada al lupus es una manifestación infrecuente, pero debe tenerse en cuenta ante un cuadro medular agudo, sobre todo si éste ocurre en mujeres jóvenes, con o sin el diagnóstico previo de la enfermedad autoinmune, debido a su importante repercusión funcional

Introduction. Although the association between transverse myelitis and systemic lupus erythematosus is rather infrequent, it is important to take this form of clinical presentation into account because it is a serious complication, which can potentially be treated but even when dealt with in the early stages does not always have a good prognosis. Patients and methods. We conducted a retrospective review over the past 13 years of the cases that have been admitted to our specific centre for the treatment of spinal cord injuries that were diagnosed as suffering from myelitis associated with disseminated lupuserythematosus. Demographic and clinical data, together with data about acute phase and maintenance treatments, as well as the patients’progress and sequelae are described. Results. The case reports of seven patients, all of whom were young females, are studied. In two cases, myelitis was the initial presentation of lupus. The main disorder was at the dorsal, followed by the cervical, levels. Only two patients had a favourable long-term progression from the neurological point of view (both managedto walk) despite acute treatment with high doses of intravenous corticoids, and regardless of the fact that cyclophosphamide was later used. Conclusions. Myelitis associated to lupus is a rare manifestation but, owing to its important functional repercussions, it must be taken into account when faced with an acute clinical picture involving the spinal cord; this is particularly the case when it occurs in young females, with or without a previous diagnosis of autoimmune disease

[Recurrent Tolosa-Hunt syndrome with normal neuroimaging. A report of three cases]. / Síndrome de Tolosa-Hunt de repetición con neuroimagen normal. Descripción de tres casos.

INTRODUCTION: Tolosa-Hunt syndrome is caused by an unspecific inflammation in the cavernous sinus or superior orbital fissure. Recurrence occurs in 40% of cases. Magnetic resonance (MR) of the head and orbital phlebography can reveal characteristic data, although diagnosis is reached by exclusion according to International Headache Society criteria. Corticoids are the preferred treatment, since their use gives rise to the disappearance of the clinical condition in a few days. CASE REPORT: We describe the cases of three patients with recurrent Tolosa-Hunt syndrome and MR images of the head with normal contrast. Case 1: a 52-year-old male with paralysis of the oculomotor nerve with recurrence on the contralateral side. Case 2: a 42-year-old female with recurrent paralysis of the abducent nerve. Case 3: a 34-year-old male with involvement of the oculomotor nerve, optic nerve and the first branch of the trigeminal nerve with recurrence of the ophthalmoplegia. In all cases the clinical symptoms disappeared with the use of corticoid therapy. CONCLUSIONS: The oculomotor disorder is produced by nerve infiltration and not by compression. The time for recurrence varies largely, and the clinical condition in the recurrence is usually milder owing to the fact that diagnosis is reached and treatment is started earlier. The absence of alterations in the MR of the head does not rule out the existence of Tolosa-Hunt syndrome, even in cases of recurrence, and these disorders therefore should not be included in the diagnostic criteria.

Síndrome de Tolosa-Hunt de repetición con neuroimagen normal. Descripción de tres casos / Recurrent tolosa-hunt syndrome with normal neuroimaging. A report of three cases

Introducción. El síndrome de Tolosa-Hunt está causadopor una inflamación inespecífica en el seno cavernoso o fisura orbitariasuperior. La recidiva ocurre en un 40% de los casos. Laresonancia magnética (RM) cerebral y la flebografía orbitaria puedenmostrar datos característicos, aunque el diagnóstico es deexclusión, según los criterios de la International Headache Society.Los corticoides son el tratamiento de elección, ya que producen ladesaparición de la clínica en pocos días. Casos clínicos. Se describentres casos de pacientes con síndrome de Tolosa-Hunt de repeticióny RM cerebral con contraste normal. Caso 1: varón de 52 añoscon parálisis del III par con recurrencia en el lado contralateral.Caso 2: mujer de 42 años con parálisis del VI par de repetición.Caso 3: varón de 34 años con afectación del III par, nervio óptico yprimera rama del trigémino con recurrencia de oftalmoplejía. Entodos los casos la clínica desapareció tras la instauración de corticoides.Conclusiones. La afectación oculomotora se produce porinfiltración nerviosa y no por compresión. El tiempo para la recurrenciaes muy variable y la clínica en la recurrencia suele ser másleve, debido al diagnóstico y a la instauración de tratamiento mástemprana. La ausencia de alteraciones en la RM cerebral no descartala existencia de un síndrome de Tolosa-Hunt, incluso en casosde recurrencia, por lo que no se deberían incluir estas alteracionesen los criterios diagnósticos

Introduction. Tolosa-Hunt syndrome is caused by an unspecific inflammation in the cavernous sinus or superiororbital fissure. Recurrence occurs in 40% of cases. Magnetic resonance (MR) of the head and orbital phlebography can revealcharacteristic data, although diagnosis is reached by exclusion according to International Headache Society criteria.Corticoids are the preferred treatment, since their use gives rise to the disappearance of the clinical condition in a few days.Case report. We describe the cases of three patients with recurrent Tolosa-Hunt syndrome and MR images of the head withnormal contrast. Case 1: a 52-year-old male with paralysis of the oculomotor nerve with recurrence on the contralateral side.Case 2: a 42-year-old female with recurrent paralysis of the abducent nerve. Case 3: a 34-year-old male with involvement ofthe oculomotor nerve, optic nerve and the first branch of the trigeminal nerve with recurrence of the ophthalmoplegia. In allcases the clinical symptoms disappeared with the use of corticoid therapy. Conclusions. The oculomotor disorder is producedby nerve infiltration and not by compression. The time for recurrence varies largely, and the clinical condition in therecurrence is usually milder owing to the fact that diagnosis is reached and treatment is started earlier. The absence ofalterations in the MR of the head does not rule out the existence of Tolosa-Hunt syndrome, even in cases of recurrence, andthese disorders therefore should not be included in the diagnostic criteria

Percutaneous vertebroplasty: a special syringe for cement injection.

Percutaneous vertebroplasty is an effective treatment for many focal vertebral lesions. Methyl methacrylate is too viscous to be handled without difficulty in the conventional way because injection time is short. The operator is left with little time and must fumble with multiple syringes. We describe a special screw-system syringe that decreases the effort needed to inject the cement. In addition, it can standardize the injection pressures and control the injected volume because the threaded plunger affords greater control of injection pressure and volume delivered than does the conventional method.