A case of chronic spinal epidural hematoma in a thirteen-year-old male, subsequently found to have hemophilia A is reported. Following myelography, surgery was undertaken with clotting factor replacement with relief of cord compression. The patient made an uneventful recovery.
J. G. McComb
The aspecific spinal epidural abscess is an uncommon cause of the spinal cord compression. Forty eight patients presented with epidural abscess were operated on during the last 37-year-period in the National Institute of Neurosurgery Budapest. Experiences with the diagnostic methods and the results of the treatment of these patients are analysed. Based on the case history data, preoperative symptoms and operative findings 31 male and 17 female patients (their age ranged from 15-64 years) have been selected in acute, subacute and chronic groups. Localized backpain, acceleration of the blood sedimentation, leukocytosis and fever were significant findings which were followed by sings of radicular or medullary compression. This clinical picture developed rapidly in the acute group. Aspecific abscess most commonly appeared in thoracal or lumbal localisation and was rarely found in the ventral area. Staphylococcus aureus was the causative organism in nearly 100 percent of the cases. Surgery carried out before the onset of the neurological deficits according to proper CSF examination and myelography, proved to be favourable. Early diagnosis and emergency operation led to a significant improvement of the outcome. PMID:7651713
Background. Chronic sciatica can be managed by caudal steroid epidural or by targeted steroid placement during spinal endoscopy. Spinal endoscopy is a new unproven procedure. We aimed to compare the two pain management techniques and to investigate whether the site of steroid placement within the epidural space was significant. Methods. We randomized 60 patients with a 6-18 months history of
A. K. Dashfield; M. B. Taylor; J. S. Cleaver; D. Farrow
Spinal epidural hematoma and spinal epidural abscess are rare surgical emergencies resulting in significant neurologic deficits. Making the diagnosis for spinal epidural hematoma and spinal epidural abscess can be challenging; however, a delay in recognition and treatment can be devastating. The objective of this retrospective analysis study was to identify risk factors for an adverse outcome for the provider. The LexisNexis Academic legal search database was used to identify a total of 19 cases of spinal epidural hematoma and spinal epidural abscess filed against medical providers. Outcome data on trial verdicts, age, sex, initial site of injury, time to consultation, time to appropriate imaging studies, time to surgery, and whether a rectal examination was performed or not were recorded. The results demonstrated a significant association between time to surgery more than 48 hours and an unfavorable verdict for the provider. The degree of permanent neurologic impairment did not appear to affect the verdicts. Fifty-eight percent of the cases did not present with an initial deficit, including loss of bowel or bladder control. All medical professionals must maintain a high level of suspicion and act quickly. Physicians who are able to identify early clinical features, appropriately image, and treat within a 48 hour time frame have demonstrated a more favorable medicolegal outcome compared with their counterparts in filed lawsuits for spinal epidural hematoma and spinal epidural abscess cases. PMID:23276337
French, Keisha L; Daniels, Eldra W; Ahn, Uri M; Ahn, Nicholas U
A patient with chronic liver disease and portal hypertension who developed acute spinal cord compression following transjugular intrahepatic portosystemic stent shunting is described. Radiological and pathological examinations revealed an epidural haematoma. Images Figure
McLellan, S.; de Silva, R.; Sandercock, P. A.; Hayes, P. C.; Dillon, J.; Redhead, D.
We report the case of a 39-year-old woman with adolescent idiopathic scoliosis presenting with myelopathy secondary to a spinal\\u000a epidural hemangioma. MRI showed an epidural soft tissue mass within the spinal canal between T5 and T9 with severe spinal\\u000a cord compression. Symptoms had a temporal relationship to her pregnancy. Surgical removal of the epidural hemangioma rapidly\\u000a relieved her symptoms and
Gary S. Shapiro; Peter J. Millett; Edward F. DiCarlo; Douglas N. Mintz; Francis W Gamache; Bernard A. Rawlins
Spinal epidural angiolipomas are rare, benign tumors composed of mature lipocytes admixed with abnormal blood vessels. Only 128 cases of spinal epidural angiolipomas have been reported in literature till now. Spinal angiolipomas are predominantly located in the mid-thoracic region. We report a case of dorsal epidural angiolipoma in a 56-year-old male who presented with paraparesis and was diagnosed to have D4-5 epidural angiolipoma. Total surgical excision of the epidural angiolipoma was done and his paraparesis gradually improved.
Ghanta, Rajesh K; Koti, Kalyan; Dandamudi, Srinivas
Background and ObjectiveSpinal cord stimulation is the most commonly used implantable neurostimulation modality for management of pain syndromes. For treatment of lower extremity pain, the spinal cord stimulator lead is typically placed in the thoracic epidural space, at the T10–T12 levels. Typically, satisfactory stimulation can be obtained relatively easily. Anatomical variability in the epidural space, such as epidural scarring, has
Yi Zhang; Monica J. Wood; Christopher Gilligan
Epidural spinal myelolipoma was diagnosed in a 13-year-old, male Siberian husky that was referred for evaluation of progressive pelvic limb paresis and urinary incontinence. An epidural mass was detected by magnetic resonance imaging and computed tomography. The mass was removed and identified histopathologically as an epidural myelolipoma. Pelvic limb paresis improved after surgery, but urinary retention associated with neurological bladder dysfunction persisted. PMID:17339292
Ueno, Hiroshi; Miyake, Tsuyoshi; Kobayashi, Yoshiyasu; Yamada, Kazutaka; Uzuka, Yuji
Involvement of the skeletal system is a common complication of brucellosis. However, muscle involvement or paraspinal abscess formation are rare complications. Paraspinal abscess usually develops secondary to spondylitis. A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160. The diagnosis was made on MRI. The patient was treated with doxycycline and rifampin daily for 16 weeks. On day 14 of treatment, decline was observed in the patient's symptoms. In the presence of inflammatory lower back pain and fever, brucellosis should be considered particularly in the endemic areas. Furthermore, tuberculosis should be remembered in the differential diagnosis when a spinal epidural abscess is determined. PMID:24072838
Boyaci, Ahmet; Boyaci, Nurefsan; Tutoglu, Ahmet; Sen Dokumaci, Dilek
Summary We report a case of a 68-year-old woman with an acute paraplegia due to venous congestion of the spinal cord caused by an exclusive epidural arteriovenous fistula. Diagnosed by MRI and selective spinal angiography the fistula was embolized during emergency treatment via transarterial access. Immediately after the intervention the paraplegia declined and the patient recovered completely. Epidural AV fistulae are a very rare and therefore relatively unknown cause of vascular myelopathy. They may require emergency management to avoid permanent neurological deficits.
Reul, J.; Braun, V.
This is a case report of a spinal epidural abscess, caused by Staphylococcus aureus, in a 3-year-old girl. The child presented with fever and hip pain, but without any neurologic deficit. After normal plain films and a normal bone scan were obtained, the diagnosis was made via magnetic resonance imaging (MRI). The neu- rosurgery and pediatric infectious disease teams evalu-
Megan H. Bair-Merritt; Charles Chung; Albert Collier
We report the case of a man of 65 who, at 20 and 37 days from surgery of C6 corpectomy, experienced two epidural hematomas at C7-D1. We assume that the pathogenic cause of this rare disease was an overlap between three main factors: the surgical aggression of the internal anterior epidural venous plexus; a possible increase of intra-thoracic pressure due to chronic obstructive pulmonary disease; and double antiplatelet drug therapy. PMID:23351908
Caruso, R; Pesce, A; Wierzbicki, V; Marrocco, L
Objective To describe the MRI findings in ten patients of spinal epidural angiolipoma for differentiated diagnosis presurgery. Materials and Methods Ten surgically proved cases of spinal epidural angiolipomas were retrospectively reviewed, and the lesion was classified according to the MR findings. Results Ten tumors were located in the superior (n = 4), middle (n = 2), or inferior (n = 4) thoracic level. The mass, with the spindle shape, was located in the posterior epidural space and extended parallel to the long axis of the spine. All lesions contained a fat and vascular element. The vascular content, correlating with the presence of hypointense regions on T1-weighted imaging (T1WI) and hyperintense signals on T2-weighted imaging, had marked enhancement. However, there were no flow void signs on MR images. All tumors were divided into two types based on the MR features. In type 1 (n = 3), the mass was predominantly composed of lipomatous tissue (> 50%) and contained only a few small angiomatous regions, which had a trabeculated or mottled appear. In type 2 (n = 7), the mass, however, was predominantly composed of vascular components (> 50%), which presented as large foci in the center of the mass. Conclusion Most spinal epidural angiolipomas exhibit hyperintensity on T1WI while the hypointense region on the noncontrast T1WI indicates to be vascular, which manifests an obvious enhancement with gadolinium administration.
Hu, Su; Hu, Xiao-yun; Wang, Xi-ming; Dai, Hui; Fang, Xiang-ming; Cui, Lei
The combined spinal-epidural technique is a modification of epidural analgesia which combines the rapid onset of spinal analgesia\\u000a with the flexibility of an epidural catheter. We sought to evaluate the effectiveness of an intrathecal opioid — low-dose\\u000a local anaesthetic combination for parturients in advanced labour, a setting where satisfactory epidural analgesia is often\\u000a difficult to achieve. The technique was evaluated
Amr Abouleish; Ezzat Abouleish; William Camann
Pulmonary embolism during or after regional anaesthesia is although very rare, it has been reported in cases undergoing lower limb orthopedic procedures. We presenting a 48 years old male, a known smoker since 25 years, with history of road traffic accident and open fracture right femur for external fixation. Combined spinal epidural anaesthesia was given. After 35 minutes patient complained dyspnea and chest pain. SpO2 decreased to 82% from 100%. Continuous positive airway pressure with 100% oxygen was given. SpO2 increased from 82% to 96%. Suddenly he had bouts of cough and SpO2 became 79-80% with unstable haemodynamics. On chest auscultation there was decreased breath sounds on right side with limited expansion. Trachea was intubated after inducing anaesthesia with fentanyl 70 ?g and thiopental 300 mg. Chest radiograph showed right sided pneumothorax. Intercostal drain with a water seal was put. After 5 minutes HR was 80/min, BP was 110/69 mmHg and SpO2 was 97%. Pulmonary thromboembolism secondary to deep vein thrombosis was suspected and was confirmed by D-dimer Elisa and color Doppler of lower limbs. Patient was shifted to intensive care unit after completion of surgery. Anticoagulant therapy was started. He was weaned from the ventilator on 3rd day and trachea was extubated. Chest drain was removed after 9 days and he was discharged from hospital on 15th post operative day
Bansal, Shivendu; Solanki, Sohan Lal; Jain, Neena; Vijayvergia, V K
Steroids, drugs with potent antiinflammatory properties on the damaged nervous roots, have been especially used as adjuvants of local anesthetics, by spinal route, in the treatments of low-back pain. Spinal route was chosen to obtain a higher local concentration of drug, with few systemic side effects and to improve drug's action mechanism. Steroids seem to interact with GABA receptors and thus control neural excitability through a stabilising effect on membranes, modification of nervous conduction and membrane hyperpolarization, in supraspinal and spinal site. Epidural steroids are especially used in the treatment of low back pain due to irritation of nervous roots. They have been administered alone or in association with local anesthetics and/or saline solution. Slow release formulations have been generally used (methylprednisolone acetate, and triamcinolone diacetate). Other indications of epidural steroids are: postoperative hemilaminectomy pain, prevention of post herpetic neuralgia, degenerative ostheoartrithis. Intra-thecal steroids have been frequently used in the treatment of lumbar radiculopathy due to discopathy, as an alternative treatment when epidural administration is ineffective. Positive results have been obtained with methylprednisolone acetate, alone or in association with local anesthetics. Complications related to intraspinal steroids injections are due to execution of the block and side effects of drugs. Complications associated with intrathecal steroids are more frequent and severe than epidural injections and include: adhesive arachnoiditis, aseptic meningitis, cauda equina syndrome. Steroidal toxicity seems to be related to the polyethylenic glycole vehicle. Anyway, slow release formulations contain less concentrated polyethylenic glycole. The epidural administration, a correct dilution of steroid with local anesthetics solution and/or saline solution, and a limited number of injections (no more than three) allows a significant reduction of steroid neurotoxicity. PMID:12244293
Marinangeli, F; Ciccozzi, A; Donatelli, F; Paladini, A; Varrassi, G
Epidural spinal cord stimulation (ESCS) combined with partial weight bearing therapy (PWBT) has been reported to facilitate recovery of functional walking for individuals after chronic incomplete spinal cord injury (ISCI). Muscle activities were analyzed in this report to examine the modulation effect of ESCS on muscle recruitment during gait training. Two ISCI individuals participated in the study and both are
He Huang; Jiping He; Richard Herman; Michael R. Carhart
Summary Spinal cord epidural metastasis (SEM) is a common complication of systemic cancer with an increasing incidence. Prostate, breast and lung cancer are the most common offenders. Metastasis usually arises in the posterior aspect of vertebral body with later invasion of epidural space. Pathophysiologically, vascular insufficiency is more important than direct spinal cord compression. The most common complaint is pain,
Melike Mut; David Schiff; Mark E. Shaffrey
Spinal epidural lipomatosis is a rare disorder that can manifest with progressive neurological deficits. It is characterized by abnormal accumulation of unencapsulated epidural fat commonly associated with the administration of exogenous steroids associated with a variety of systemic diseases, endocrinopathies, and Cushing syndrome (Fogel et al. Spine J 5:202-211, 2005). Occasionally, spinal epidural lipomatosis may occur in patients not exposed to steroids or in patients with endocrinopathies, primarily in obese individuals (Fogel et al. Spine J 5:202-211, 2005). However, spinal lumbar epidural lipomatosis resulting from local steroid injection has rarely been reported. We report the case of a 45-year-old diabetic man with claudication that was probably due to symptomatic lumbar spinal lipomatosis resulting from a single local epidural steroid injection.
Tok, Chung Hong, E-mail: email@example.com; Kaur, Shaleen [University of Malaya, Department of Biomedical Imaging, Faculty of Medicine (Malaysia); Gangi, Afshin [University Hospital of Strasbourg, Department of Radiology B (France)
sessed the trials for the quality of their meth- ods. Subgroup analyses were performed for trials with different control groups, with different modes of epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical\\/thoracic, lumbar\\/ sacral), and with timing of outcome measure- ment (short- and long-term). Outcome Measures: The primary out- come measure was pain relief. Other out- come measures
Salahadin Abdi; Sukdeb Datta; Linda F. Lucas
Pyogenic spinal epidural abscess Is an uncommon Infectious occurrence. Clinical prospects of pyogenic spinal epidural abscess are graver if not promptly diagnosed and treated appropriately. A case of spinal epidural abscess has been presented with sinus tract formation at L4-L5 level, of pyogenic aetiology that progressed to paraplegia over the course of the disease. MRI pointed towards an epidural abscess extending from T12 vertebral level to S1 vertebral level. Surgical decompression in the form of laminectomy and evacuation of pus was done and antibiotics were given according to culture and sensitivity. Histopathological analysis revealed the acute suppurative nature of the abscess. Citrobacter kasori was isolated on pus culture. Pyogenic epidural abscess with causative organism being Citrobacter kasori has least been documented. PMID:24000517
Kumar, Ashok; Jain, Pramod; Singh, Pritish; Divthane, Rupam; Badole, C M
The first case of a spinal epidural abscess caused by Roseomonas mucosa following instrumented posterior lumbar fusion is presented. Although rare, because of its highly resistant profile, Roseomonas species should be included in the differential diagnosis of epidural abscesses in both immunocompromised and immunocompetent hosts. PMID:23596239
Maraki, Sofia; Bantouna, Vasiliki; Lianoudakis, Efstratios; Stavrakakis, Ioannis; Scoulica, Efstathia
The short term effects of epidural spinal electrical stimulation were studied in 10 patients with angina pectoris of New York Heart Association functional class III or IV. The antianginal pharmacological treatment given at entry to the study was regarded as optimal and was not changed during the study. The effects of epidural spinal electrical stimulation were measured by repeated bicycle ergometer tests. Treatment with epidural spinal electrical stimulation increased the patients' working capacity, decreased ST segment depression, increased time to angina, and reduced the recovery time. The observed effects did not seem to be correlated with any changes in myocardial oxygen demand during epidural spinal electrical stimulation and were additional to the benefits of the pharmacological treatment.
Mannheimer, C; Augustinsson, L E; Carlsson, C A; Manhem, K; Wilhelmsson, C
We present a case of a 55-year-old male with progressive neurological deficits that appeared dramatically. MRI detected a spinal epidural hematoma at the cervicothoracic junction and blood tests showed leukocytosis, mild anemia, and thrombocytosis. Spontaneous spinal epidural hematoma (SSEH) as the initial presentation of leukemia was diagnosed. Urgent posterior decompression was performed after 28 h from acute onset of backache, and the patient experienced remarkable improvement in neurological findings.
Kim, Sungdo; Tsuji, Takaaki; Uta, Soichi
We report a case of spinal epidural hematoma after removal of an epidural catheter. The patient had no background of anticoagulant therapy or coagulopathy; sudden severe back pain occurred immediately after removal of the catheter. The chance of this occurring is estimated to be between 1:150,000 and 1:190,000. We studied 40 previous reports from 1952 to 2000, and we also investigated anticoagulant therapy and pathologic states, puncture difficulties and bleeding at the point of insertion, and its onset. In 23 cases (57.5%), anticoagulant therapy had been performed, and in 5 cases (12.5%), coagulopathy or liver dysfunction had been recognized. In 20 cases (50%), the initial symptoms were recognized within 24 hours after removal of the epidural catheter. Although spinal epidural hematoma is a very rare condition, it is a serious complication of continuous epidural anesthesia. PMID:16306849
Miyazaki, Masashi; Takasita, Mitsuhiro; Matsumoto, Hirofumi; Sonoda, Hironori; Tsumura, Hiroshi; Torisu, Takehiko
We report a case of non-traumatic spinal epidural haematoma in a female vocational diver after breath-hold diving. Sudden and repetitive atmospheric changes along diving may cause venous engorgement of the valveless spinal epidural veins. We suggest that repetitive barotrauma was the cause of the spinal epidural haematoma in this patient. PMID:22803965
Yang, Tae Ki; Seo, Hye Mee; Lee, Chang Sub
Background and Purpose: Despite advances in diagnosis and treatment, spinal epidural abscess due to Staphylococcus aureus remains a challenge to clinicians. In this study, we describe the clinical features and outcomes of patients with spinal epidural abscess due to S. aureus. Methods: Thirty one cases of spinal epidural abscess due to S. aureus treated at the National Taiwan University Hospital
Wan-Chin Chen; Jiun-Ling Wang; Jann-Tay Wang; Yee-Chun Chen; Shan-Chwen Chang
Ischemic infarction is a rare cause of acute myelopathy. We report the case of a young woman admitted to Sultan Qaboos University Hospital, Oman, who developed extensive spinal cord infarction in the setting of surgical evacuation and packing of liver haematoma and post-operative epidural analgesia. She had no vascular risk factors for stroke. The vascular mechanism underlying ischemic myelopathy and the relationship to abdominal surgery and epidural analgesia are discussed.
Al-Asmi, Abdullah; John, Rosanna; Nandhagopal, Ramachandiran; Jacob, Povathoor C; Nollain, Karin; Jain, Rajeev
To examine obstetrical epidural and spinal anesthesia use in women with multiple sclerosis (MS) and the relationship with MS clinical factors. This was a retrospective cohort study, linking clinical data from women with MS in the British Columbia (BC) MS database to obstetrical data (1998-2009) from the BC Perinatal Database Registry. We compared epidural use in 431 deliveries to women with MS and 2,959 deliveries from the general population, as well as spinal use in cesarean deliveries (128 to women with MS and 846 in the general population), considering parity and using multivariate models. We also examined the association between epidural or spinal anesthesia and MS clinical factors-disease duration and disability [Expanded Disability Status Scale (EDSS) score]. Of 431 deliveries to women with MS, 116 were exposed to epidural anesthesia and of 128 cesarean deliveries, 82 were exposed to spinal anesthesia. The use of epidural anesthesia was similar in nullipara (adjusted OR = 0.86, 95 % CI = 0.63-1.18, p = 0.36), but more likely in multipara with MS (adjusted OR = 1.75, 95 % CI = 1.20-2.54, p = 0.004). Spinal anesthesia use in cesarean deliveries was comparable between the MS and general population cohorts (adjusted OR = 0.84, 95 % CI = 0.55-1.31, p = 0.45). Women who delivered 5 to <10 years after MS onset were less likely to have an epidural (adjusted OR = 0.57, 95 % CI = 0.34-0.95, p = 0.03) vs. those delivering within 5 years. EDSS was not associated with use of either type of anesthesia (adjusted p > 0.1). Contrary to previous studies, epidural anesthesia use differed between women with MS and the general population and was influenced by parity and MS disease duration; these findings warrant further investigation. PMID:23864398
Lu, Ellen; Zhao, Yinshan; Dahlgren, Leanne; Preston, Roanne; van der Kop, Mia; Synnes, Anne; Sadovnick, A Dessa; Traboulsee, Anthony; Tremlett, Helen
Regional anesthesia is currently the gold standard of practice for pain control in obstetrics. Failures and complications of regional anesthesia can be related to many causes, one of the most important being the blind nature of such techniques. The practice of epidurals and spinals relies primarily on the palpation of anatomic landmarks that are not always easy to find. Ultrasound has recently been introduced into clinical anesthesia to facilitate lumbar spinals and epidurals. The use of preprocedure ultrasound imaging or, eventually, real-time ultrasound guidance should improve not only clinical practice, but also teaching. This article describes the techniques, challenges, and benefits related to the use of ultrasound in guiding lumbar spinals and epidurals. PMID:18319185
Carvalho, Jose Carlos Almeida
Spinal epidural extramedullary haematopoiesis is very rare in thalassaemia. A 27-year-old man with thalassaemia intermedia\\u000a presented with symptoms and signs of spinal cord compression. MRI showed a thoracic spinal epidural mass, representing extramedullary\\u000a haematopoietic tissue, compressing the spinal cord. Following radiotherapy, serial MRI revealed regression of the epidural\\u000a mass and gradual resolution of spinal cord oedema.
Ü. Ayd?ngöz; A. Oto; A. Cila
Epidural abscess of the spinal column is a rare condition that can be fatal if left untreated. It promptly progresses and can cause neurologic paralysis, urinary retention or cauda equina syndrome. Compromised immune system that occurs in patients with diabetes mellitus, AIDS, chronic renal failure, alcoholism, or cancer is a predisposing factor. It mostly occurs in adults. Here we would like to report a case of spontaneous pyogenic lumbar epidural abscess with neurological deficit diagnosed in a 15 year old boy. We treated this case successfully with surgical microscopic decompression and drainage.
Sales, Jafar Ganjpour; Elmi, Asghar; Soleimanpour, Jafar; Gavidel, Ehsan
We investigated a novel treatment paradigm for developing functional ambulation in wheelchair-dependent individuals with chronic, incomplete spinal-cord injury. By coordinating epidural stimulation of the dorsal structures of the spinal cord with partial weight bearing treadmill therapy, we observed improvement in treadmill and over-ground ambulation in an individual with chronic incomplete tetraplegia. The application of partial weight-bearing therapy alone was not sufficient to achieve functional ambulation over ground, though treadmill ambulation improved significantly. Combining epidural spinal-cord stimulation (ESCS, T10-T12 vertebral levels) with partial weight-bearing therapy resulted in further improvement during treadmill ambulation. Moreover, the combination of therapies facilitated the transfer of the learned gait into over ground ambulation. Performance improvements were elicited by applying continuous, charge-balanced, monophasic pulse trains at a frequency of 40-60 Hz, a pulse duration of 800 micros, and an amplitude determined by the midpoint (50%) between the sensory and motor threshold values. The participant initially reported a reduction in sense of effort for over ground walking from 8/10 to 3/10 (Borg scale), and was able to double his walking speed. After several weeks of over ground training, he reached maximum walking speeds of 0.35 m/s, and was able to ambulate over 325 m. We propose that ESCS facilitated locomotor recovery in this patient by augmenting the use-dependent plasticity created by partial weight bearing therapy. Confirmation of these promising results in a controlled study of groups of spinal-cord-injured subjects is warranted. PMID:15068185
Carhart, Michael R; He, Jiping; Herman, Richard; D'Luzansky, S; Willis, Wayne T
Paraplegia caused by spinal haemorrhage is a very rare but disastrous complication of spinal or epidural insertion. The risk in uncomplicated surgical and obstetric patients is outlined. Bleeding disorders in pregnant patients may prevent the use of major regional anaesthesia. Factors which influence the choice of anaesthetic technique for patients with pregnancy-induced hypertension, von Willebrand's disease, and anticoagulation therapy, are discussed. PMID:2221324
Sage, D J
Radiotherapy alone is the most common treatment for metastatic epidural spinal cord compression (MESCC). Decompressive surgery followed by radiotherapy is generally indicated only in 10–15% of MESCC cases. Chemotherapy has an unclear role and may be considered for selected patients with hematological or germ-cell malignancies. If radiotherapy alone is given, it is important to select the appropriate regimen. Similar functional
Janet L. Abrahm; Dirk Rades
Spinal epidural haematomas (sEDH) can be regarded as rare events, in principle a spontaneous and a traumatic aetiology can be distinguished. Spontaneous spinal epidural haematomas can arise, e.g. from vascular malformations, coagulopathies, etc. On the other hand, traumatic sEDH are related to, e.g. spinal trauma or intraoperative vascular injuries. With regard to clinical significance, spinal epidural haematomas accompanied by transient
S. A. Padosch; R. B. Dettmeyer; P. H. Schmidt; F. Musshoff; B. Madea
An 81-year-old man was treated with intravenous antibiotics for a soft tissue infection in a finger. Despite adequate antibiotic treatment, he developed signs of spinal cord injury caused by a cervical spinal epidural abscess. An emergency laminectomy was performed. The neurological impairment appeared to be irreversible, and the patient died. Spinal epidural abscess is a rare and serious complication ofa bacteraemia. It is often caused by an infection of the skin or soft tissue with Staphylococcus aureus. Given the risk of rapidly progressive and irreversible neurological damage, this complication must be treated as soon as possible. The treatment of choice is surgery. Conservative management with intravenous antibiotics is an option only under strict conditions. PMID:18624007
Ridderikhof, M L; van den Brink, W A; van Dalsen, A D; Kieft, H
Purpose We report a case of epidural hematoma in a surgical patient with chronic renal failure who received an epidural catheter for\\u000a postoperative analgesia. Symptoms of epidural hematoma occurred about 60 hr after epidural catheter placement.\\u000a \\u000a \\u000a \\u000a Clinical features A 58-yr-old woman with a history of chronic renal failure was admitted for elective abdominal cancer surgery. Preoperative\\u000a laboratory values revealed anemia, hematocrit 26%,
Mafdy Basta; Paul Sloan
Kyphoscoliosis is a progressive disease that worsens with age. While applying anesthesia, kyphosis and/or scoliosis can lead to difficulty in both during endotracheal intubation and also performing regional interventional technics. In addition to aging and the direct effects of deformity such as neurological deficities and immobility; deterioration in cardiopulmonary functions can also develop in these patients. In this case, we aimed to report combined spinal epidural anesthesia experience in a-60-year-old woman with advanced kyphoscoliosis who underwent left femur periprostetic fracture operation. Spinal anesthesia was performed through L3-L4 intervertebral space by single dose of 10 mg %0.5 hyperbaric bupivacaine and epidural catheter was taken in for additional anesthesia and postoperative analgesia. Sufficient sensorial and motor block was provided and sensorial block was highen up to T6 dermatome level. There was no complication during the peroperative period and succesful anesthesia was established. Finally we conclude that combined spinal epidural anesthesia is a good alternative to general anesthesia in both reducing and preventing hemodynamic and respiratory complications for an elderly patient with kyphoscoliosis. PMID:22399129
Solak, Sezen; Ozyuvaci, Emine Nur; Tuluk, Gamze; Solak, Zafer; Akyol, Onat; Toprak, Naile
Spinal epidural hematoma is a well known complication of spinal surgery. Clinically insignificant small epidural hematomas develop in most spinal surgeries following laminectomy. However, the incidence of clinically significant postoperative spinal epidural hematomas that result in neurological deficits is extremely rare. In this report, we present a 33-year-old female patient whose spinal surgery resulted in postoperative spinal epidural hematoma. She was diagnosed with lumbar disc disease and underwent hemipartial lumbar laminectomy and discectomy. After twelve hours postoperation, her neurologic status deteriorated and cauda equina syndrome with acute spinal epidural hematoma was identified. She was immediately treated with surgical decompression and evacuation of the hematoma. The incidence of epidural hematoma after spinal surgery is rare, but very serious complication. Spinal epidural hematomas can cause significant spinal cord and cauda equina compression, requiring surgical intervention. Once diagnosed, the patient should immediately undergo emergency surgical exploration and evacuation of the hematoma.
Sasani, Mehdi; Oktenoglu, Tunc; Cirak, Bayram; Ozer, Ali Fahir
Spinal epidural angiolipoma is a rare benign tumor containing vascular and mature adipose elements. A slow progressive clinical\\u000a course was mostly presented and rarely a fluctuating course during pregnancy. The authors report the original case of spontaneous\\u000a spinal epidural bleeding resulting from thoracic epidural angiolipoma who presented with hyperacute onset of paraplegia, simulating\\u000a an extradural hematoma. The patient was admitted
Ali Akhaddar; Abderrahmane Albouzidi; Brahim Elmostarchid; Miloudi Gazzaz; Mohamed Boucetta
Iatrogenic meningitis is a rare but potentially fatal condition. We report a case of meningitis after combined spinal-epidural anesthesia and review previous reports of meningitis subsequent to spinal, combined spinal-epidural and epidural analgesia or anesthesia. Streptococci remain the most commonly identified agent, although cultures are frequently negative. Droplet contamination or needle contamination from incompletely sterilized skin are the major routes for infection. Strict aseptic technique and infection control measures should be employed when accessing the epidural space. PMID:19204609
Sandkovsky, Uriel; Mihu, Mircea Radu; Adeyeye, Adebisi; De Forest, Pamela M; Nosanchuk, Joshua D
Spinal epidural lipomatosis (SEL) frequently occurs as a result of long-term steroid administration for various disorders, and patients often present with osteoporosis. Acute paraplegia in patients with extensive thoracic SEL is rare. We report a case of acute paraplegia caused by osteoporotic compression fracture with extensive thoracic SEL in a 44-year-old man with rheumatoid arthritis who had received steroid therapy for 4 years. He presented initially with abdominal distension and weakness of lower limbs, and a sudden onset of paraplegia with complete motor and sensory loss below the T6 level ensued. Plain radiographs showed an osteoporotic compression fracture of the T6 vertebra. Magnetic resonance imaging showed osteoporotic compression fractures of the T5 and T6 vertebrae and SEL from T2 to T10 vertebrae. Decompressive laminectomy with epidural fat debulking was performed, and the pathology was confirmed as epidural lipomatosis. His neurological condition showed no improvement below the T6 level 3 months after surgery. Osteoporotic compression fracture is a risk factor for acute paraplegia in patients with thoracic SEL and decompressive surgery should be performed without delay. PMID:12923598
Chen, Chiu-Liang; Lee, Cheng-Hung; Lee, Tu-Sheng; Lin, Yu-Min; Chen, Yen-Jen
A 65-year-old man who had lateral cervical disc herniation underwent cervical posterior laminoforaminotomy at C5-6 and C6-7 level right side. During the operation, there was no serious surgical bleeding event. After operation, he complained persistent right shoulder pain and neck pain. Repeated magnetic resonance image (MRI) showed diffuse cervical epidural hematoma (EDH) extending from C5 to T1 level right side and spinal cord compression at C5-6-7 level. He underwent exploration. There was active bleeding at muscular layer. Muscular active bleeding was controlled and intramuscular hematoma was removed. The patient's symptom was reduced after second operation. Symptomatic postoperative spinal EDH requiring reoperation is rare. Meticulous bleeding control is important before wound closure. In addition, if patient presents persistent or aggravated pain after operation, rapid evaluation using MRI and second look operation is needed as soon as possible.
Choi, Jeong Hoon; Lee, Sang-Ho
We have recorded and characterized the spinal cord evoked potentials (SCEPs) from the epidural space in the halothane-anesthetized rats. A group of 11 adult Wistar male rats was chronically implanted with two pairs of epidural electrodes. SCEPs were repeatedly elicited by applying electrical stimuli via bipolar U-shaped electrodes to the dorsal aspect of the spinal cord at C3–4 or Th11–12
Tomáš Ondrej?ák; Ivo Vanický; Ján Gálik; Kamila Saganová
Objective To compare a newly developed minimally-invasive method for percutaneous transforaminal epidural injection (INJ group) with the existing method for lumbar epidural catheterization (CATH group). Method Through anatomical review of experimental rats, the cephalic one fourth of the neural foramen was selected as the target point for drug delivery. After the rats had undergone lumbar epidural catheterization, lidocaine, and 1% methylene blue were injected through the unilateral or bilateral L5/6 neural foramen in the INJ group, and through an epidural catheter in the CATH group. Measurement of body weight and the mechanical allodynia test before and after injection of lidocaine, and fine dissection after injection were performed. Results Results of the mechanical allodynia test of 1.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 0.5% lidocaine 100 µl injection in the INJ group. The results of 2.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 1.0% lidocaine 100 µl injection in the INJ group. After dissection, only one distal partial spinal nerve was stained by methylene blue 50 µl through the transforaminal pathway. However, the dorsal root ganglion, nerve root, and adjacent hemi-partial spinal cord were stained by methylene blue 100 µl through the transforaminal pathway. Conclusion The percutaneous transforaminal epidural injection is practical, easy, and safe, and, in particular, does not cause significant pain compared to the existing lumbar epidural catheterization. We expect this method to be effective in an animal study showing that drug delivery to the spinal epidural space is necessary.
Kim, Nack Hwan; Lee, Sang Heon
Summary Background Abnormal fat deposition in the epidural space or spinal epidural lipomatosis (SEL) due to corticosteroid treatment or obesity may cause obstruction to cerebrospinal fluid flow. Little is known about SEL in patients with hematologic malignancies who require frequent lumbar punctures and corticosteroid treatment that places them at risk. Patients and methods Records and radiologic images of patients with SEL and leukemia or non Hodgkin lymphoma (NHL) treated at a single institution from 1999–2009 were reviewed. Risk factors were compared with 405 control patients with leukemia. Results Fourteen patients with leukemia or NHL were diagnosed with SEL. The majority of patients underwent diagnostic imaging after unsuccessful lumbar punctures within one month of their primary diagnosis. Prior to SEL diagnosis, all patients received systemic and/or intrathecal corticosteroids. SEL diagnosis led to modification of intrathecal administration in 8 patients, including Ommaya reservoir placement in 4 patients. All patients completed protocol-specified chemotherapy without neurologic symptoms or surgical intervention. Risk factors for developing SEL include older age and high body mass index. Conclusions Investigation for SEL in leukemia or lymphoma patients with difficult lumbar punctures is warranted. Placement of an Ommaya reservoir may facilitate safe CNS-directed therapy in severely affected patients.
Brennan, R.C.; Helton, K.J.; Pei, D.; Cheng, C.; Inaba, H.; Metzger, M.L.; Howard, S.C.; Rubnitz, J.E.; Ribeiro, R.C.; Sandlund, J.T.; Jeha, S.; Pui, CH.; Bhojwani, D.
A 56-year-old Japanese man with hypertension presented with a 10 days history of high fever, right and left upper quadrant tenderness. An abdominal ultrasonography and computerized tomographic scan revealed a large collection in the right lobe of the liver that was consistent with an abscess. A drainage catheter was placed and purulent fluid was drained. Cultures of the fluid and blood were positive for a strain of ampicillin-resistant Klebsiella pneumoniae. Six days after admission, paraplegia and urinary retention were found. On the neurological examination, deep tendon reflexes of the lower extremities were absent bilaterally. Magnetic resonance imaging scan detected thoracic spinal epidural abscess and paraspinal abscess. He received the emergent decompressive laminectomy. Culture of surgical specimen grew ampicillin-resistant K. pneumoniae. The patient was treated with biapenem intravenously. Thereafter, clinical symptoms improved gradually and he was removed to the professional hospital to continue rehabilitation for gait disturbance on hospital day 147. PMID:15652471
Kuramochi, Gen; Takei, Shin-Ichi; Sato, Munehiro; Isokawa, Osamu; Takemae, Takashi; Takahashi, Akira
1. The segmental effects of spinal cord stimulation (SCS) were studied in twenty-four human subjects who had spinal cord stimulators implanted for the treatment of pain. The cathode was in the epidural space over the dorsum of the thoracic cord. 2. SCS generated action potentials in sensory, motor and mixed nerves which could be recorded with near-nerve electrodes. These action potentials could follow high frequencies of stimulation and appeared to be due to the antidromic activation of primary afferents in the dorsal columns. 3. Synaptic actions on single lumbosacral motoneurons were derived from peristimulus time histograms (PSTHs) of single motor units. SCS produced a brief short-latency period of increased firing probability (PIF) in motoneurons of all of the muscles examined, probably representing monosynaptic activation. It is argued that the facilitation arises from the antidromic activation of Ia afferents in the dorsal columns. This is the probable explanation for the muscle contractions that can be induced by SCS. 4. SCS inhibited short-latency group I homonymous facilitation and reciprocal inhibition. The mechanism appears to be presynaptic to the motoneurons and may represent collision in Ia afferents, presynaptic inhibition or homosynaptic depression. 5. It was difficult to demonstrate consistent effects of SCS on reflex pathways from cutaneous afferents to flexor motoneurons because the effects of stimulation of cutaneous nerves on these motoneurons were themselves variable. 6. It is concluded that SCS applied with epidural electrodes over the dorsal cord activates primary afferents in the dorsal columns. Antidromic activation of these afferents results in strong monosynaptic facilitation of motoneurons as well as reduction in transmission in some reflex pathways to motoneurons. Images Figure 1
Hunter, J P; Ashby, P
Object The introduction and utilization of motion-preserving implant systems for spinal reconstruction served as the impetus for this basic scientific investigation. The effect of unintended wear particulate debris resulting from micromotion at spinal implant interconnections and bearing surfaces remains a clinical concern. Using an in vivo rabbit model, the current study quantified the neural and systemic histopathological responses following epidural application of 11 different types of medical-grade particulate wear debris produced from spinal instrumentation. Methods A total of 120 New Zealand White rabbits were equally randomized into 12 groups based on implant treatment: 1) sham (control), 2) stainless steel, 3) titanium alloy, 4) cobalt chromium alloy, 5) ultra-high molecular weight polyethylene (UHMWPe), 6) ceramic, 7) polytetrafluoroethylene, 8) polycarbonate urethane, 9) silicone, 10) polyethylene terephthalate, 11) polyester, and 12) polyetheretherketone. The surgical procedure consisted of a midline posterior approach followed by resection of the L-6 spinous process and L5-6 ligamentum flavum, permitting interlaminar exposure of the dural sac. Four milligrams of the appropriate treatment material (Groups 2-12) was then implanted onto the dura in a dry, sterile format. All particles (average size range 0.1-50 ?m in diameter) were verified to be endotoxin free prior to implantation. Five animals from each treatment group were sacrificed at 3 months and 5 were sacrificed at 6 months postoperatively. Postmortem analysis included epidural cultures and histopathological assessment of local and systemic tissue samples. Immunocytochemical analysis of the spinal cord and overlying epidural fibrosis quantified the extent of proinflammatory cytokines (tumor necrosis factor-?, tumor necrosis factor-?, interleukin [IL]-1?, IL-1?, and IL-6) and activated macrophages. Results Epidural cultures were negative for nearly all cases, and there was no evidence of particulate debris or significant histopathological changes in the systemic tissues. Gross histopathological examination demonstrated increased levels of epidural fibrosis in the experimental treatment groups compared with the control group. Histopathological evaluation of the epidural fibrous tissues showed evidence of a histiocytic reaction containing phagocytized inert particles and foci of local inflammatory reactions. At 3 months, immunohistochemical examination of the spinal cord and epidural tissues demonstrated upregulation of IL-6 in the groups in which metallic and UHMWPe debris were implanted (p < 0.05), while macrophage activity levels were greatest in the stainless-steel and UHMWPe groups (p < 0.05). By 6 months, the levels of activated cytokines and macrophages in nearly all experimental cases were downregulated and not significantly different from those of the operative controls (p > 0.05). The spinal cord had no evidence of lesions or neuropathology. However, multiple treatments in the metallic groups exhibited a mild, chronic macrophage response to particulate debris, which had diffused intrathecally. Conclusions Epidural application of spinal instrumentation particulate wear debris elicits a chronic histiocytic reaction localized primarily within the epidural fibrosis. Particles have the capacity to diffuse intrathecally, eliciting a transient upregulation in macrophage/cytokine activity response within the epidural fibrosis. Overall, based on the time periods evaluated, there was no evidence of an acute neural or systemic histopathological response to the materials included in the current project. PMID:23808583
Cunningham, Bryan W; Hallab, Nadim J; Hu, Nianbin; McAfee, Paul C
We present a case of placental abruption necessitating emergency cesarean section in an otherwise uncomplicated patient soon after initiation of combined spinal-epidural analgesia in labor. Administration of spinal opioids has the potential to cause fetal bradycardia due to uterine hypertonicity following rapid onset of analgesia. In this case, a previously bloody show before placement of combined spinal-epidural analgesia may have been evidence of a small abruption. We hypothesize that uterine hypertonicity following administration of spinal opioids may have hastened the development of an existing placental abruption. PMID:22940265
Jaime, F; Degani, J; Lam, N; Allen, G
Epidural spinal cord stimulation (ESCS) combined with partial weight bearing therapy (PWBT) has been reported to facilitate recovery of functional walking for individuals after chronic incomplete spinal cord injury (ISCI). Muscle activities were analyzed in this report to examine the modulation effect of ESCS on muscle recruitment during gait training. Two ISCI individuals participated in the study and both are classified as ASIA C with low motor scores in the lower limbs. Stimulating electrodes were placed at the epidural space over T10-L2 spinal segments, along the midline in participant 1 (S1), and off-midline in participant 2 (S2). Surface electromyograms (EMGs) from leg muscles under both ESCS ON and OFF conditions recorded during treadmill gait were analyzed in time-frequency domains. ESCS application produced acute modulations in muscle activities in both participants, but the observed pattern, magnitude, and spectral content of the EMGs differed. In S1, ESCS induced a significant shift in the temporal pattern of muscle activity toward normal comparing with that when ESCS was OFF, though without eliciting noticeable change in frequency distribution between ESCS ON and OFF conditions. When ESCS was applied in S2, a modulation of EMG magnitude was observed and, consequently, improved joint kinematics during walking. In this case, a stimulation entrainment appeared in time-frequency analysis. The results suggest that ESCS activates neural structures in the dorsal aspect of the spinal cord and facilitates gait-related muscle recruitment. The exact effects of ESCS depend on the electrode placement and possibly injury history and residual functions, but in general ESCS produces a positive effect on improved walking speed, endurance, and reduced sense of effort in both ISCI subjects. PMID:16562627
Huang, He; He, Jiping; Herman, Richard; Carhart, Michael R
During placement of needles for combined spinal-epidural anesthesia (CSEA), patients may experience pain, pressure, paresthesia, or discomfort during skin and deeper injection of local anesthetic, needle impingement on periosteum, dural puncture by the spinal needle, and insertion of the epidural catheter. We investigated the incidence of perception of and spontaneous verbal and motor responses to insertion of a spinal needle through the dura mater and pia mater and the effect of injecting lidocaine into the epidural space through the epidural needle before inserting the spinal needle through the meninges. Forty-three patients presenting for elective cesarean delivery under CSEA were studied. After localization of the epidural space using loss of resistance to air using a 17-gauge Tuohy needle, either 3 mL preservative free normal saline or 3 mL lidocaine 2% plus epinephrine 1:200,000 was injected through the Tuohy needle. "Needle through needle" dural puncture was performed 1 min later using a 27-gauge Whitacre pencil-point needle. At the moment of dural puncture, 2 (9%) parturients given lidocaine and 17 (81%) parturients given saline (P < 0.005) responded to dural puncture by spontaneously moving (33%), spontaneously vocalizing (62%), or, in response to direct questioning, by acknowledging (76%) having perceived sensation during thecal penetration. This study reveals that dural puncture by a Whitacre 27-gauge pencil-point needle inserted through a Tuohy epidural needle sited using loss of resistance to air causes involuntary movement, spontaneous vocalization, or is perceived by the majority of patients presenting for cesarean delivery under CSEA and that lidocaine injected into the epidural space before dural puncture largely eliminates these responses and sensations. PMID:16116008
van den Berg, Anton A; Sadek, Monzer; Swanson, Steven; Ghatge, Satyajeet
Spinal epidural haematomas (sEDH) can be regarded as rare events, in principle a spontaneous and a traumatic aetiology can be distinguished. Spontaneous spinal epidural haematomas can arise, e.g. from vascular malformations, coagulopathies, etc. On the other hand, traumatic sEDH are related to, e.g. spinal trauma or intraoperative vascular injuries. With regard to clinical significance, spinal epidural haematomas accompanied by transient mild neurological symptoms up to lethal outcomes have been observed. We report on a 53-year-old male alcoholic who was found in the kitchen of his asylum in a grotesquely fixed body position, with his head and cervical spine in a maximum anteflected position. A general practitioner had ruled for a non-natural manner of death due to "broken neck" and alcohol intoxication, therefore, the prosecution authorities called for a medicolegal autopsy. At autopsy, paravertebral soft tissue haemorrhage in between the shoulder blades was disclosed. Furthermore, a spinal epidural haematoma, extending from the foramen magnum down to the middle portion of the thoracic spine was found. No fractures of vertebrae nor lesions of spine ligaments or bleedings of intervertebral discs were found. Blood alcohol concentration was determined 1.92 g/l and urine alcohol concentration was 1.76 g/l. Further morphological findings were cerebral oedema and cardiac hypertrophy; the urinary bladder was found filled to bursting. Neuropathological investigations confirmed the presence of the spinal epidural haematoma and assigned lethal significance to this finding. There were no histological signs of axonal injury. Reconstruction revealed that when sitting on a chair in a drunk condition, the individual's upper part of the body had fallen backwards in the corner and subsequently got stuck with maximum anteflection of the head and cervical spine, causing rupture of vessels and spinal epidural haematoma. Acute respiratory failure caused by impairment of the phrenic nerve following spinal epidural haematoma with potential synergism of alcohol intoxication was ascertained as the cause of death. PMID:16289414
Padosch, S A; Dettmeyer, R B; Schmidt, P H; Musshoff, F; Madea, B
Background Lumbar spinal stenosis is one of the most common causes of low back pain among older adults and can cause significant disability. Despite its prevalence, treatment of spinal stenosis symptoms remains controversial. Epidural steroid injections are used with increasing frequency as a less invasive, potentially safer, and more cost-effective treatment than surgery. However, there is a lack of data to judge the effectiveness and safety of epidural steroid injections for spinal stenosis. We describe our prospective, double-blind, randomized controlled trial that tests the hypothesis that epidural injections with steroids plus local anesthetic are more effective than epidural injections of local anesthetic alone in improving pain and function among older adults with lumbar spinal stenosis. Methods We will recruit up to 400 patients with lumbar central canal spinal stenosis from at least 9 clinical sites over 2 years. Patients with spinal instability who require surgical fusion, a history of prior lumbar surgery, or prior epidural steroid injection within the past 6 months are excluded. Participants are randomly assigned to receive either ESI with local anesthetic or the control intervention (epidural injections with local anesthetic alone). Subjects receive up to 2 injections prior to the primary endpoint at 6 weeks, at which time they may choose to crossover to the other intervention. Participants complete validated, standardized measures of pain, functional disability, and health-related quality of life at baseline and at 3 weeks, 6 weeks, and 3, 6, and 12 months after randomization. The primary outcomes are Roland-Morris Disability Questionnaire and a numerical rating scale measure of pain intensity at 6 weeks. In order to better understand their safety, we also measure cortisol, HbA1c, fasting blood glucose, weight, and blood pressure at baseline, and at 3 and 6 weeks post-injection. We also obtain data on resource utilization and costs to assess cost-effectiveness of epidural steroid injection. Discussion This study is the first multi-center, double-blind RCT to evaluate the effectiveness of epidural steroid injections in improving pain and function among older adults with lumbar spinal stenosis. The study will also yield data on the safety and cost-effectiveness of this procedure for older adults. Trial Registration Clinicaltrials.gov NCT01238536
Study design: It has been previously demonstrated that sustained nonpatterned electric stimulation of the posterior lumbar spinal cord from the epidural space can induce stepping-like movements in subjects with chronic, complete spinal cord injury. In the present paper, we explore physiologically related components of electromyographic (EMG) recordings during the induced stepping-like activity.Objectives: To examine mechanisms underlying the stepping-like movements activated
K Minassian; B Jilge; F Rattay; M M Pinter; H Binder; F Gerstenbrand; M R Dimitrijevic
BACKGROUND: Postoperative epidural fibrosis may contribute to between 5% to 60% of the poor surgical outcomes following decompressive surgery. Correlations have been reported between epidural scarring and radicular pain, poor surgical outcomes, and a lack of any form of surgical treatment. The use of spinal endoscopic adhesiolysis in recent years in the management of chronic refractory low back and lower
Laxmaiah Manchikanti; Mark V Boswell; Jose J Rivera; Vidya Sagar Pampati; Kim S Damron; Carla D McManus; Doris E Brandon; Sue R Wilson
Purpose: This report summarizes our experience with epidural cooling (EC) to achieve regional spinal cord hypothermia and thereby decrease the risk of spinal cord ischemic injury during the course of descending thoracic aneurysm (TA) and thoracoabdominal aneurysm (TAA) repair.Methods: During the interval July 1993 to Dec. 1995, 70 patients underwent TA (n = 9, 13%) or TAA (n = 61)
Richard P. Cambria; J. Kenneth Davison; Simona Zannetti; Gilbert L'Italien; David C. Brewster; Jonathan P. Gertler; Ashby C. Moncure; Glenn M. LaMuraglia; William M. Abbott
Left ventricular systolic time intervals, bupivacaine concentrations, adrenaline and noradrenaline levels were determined in 19 neonates delivered by elective cesarean section. Ten of the cesarean sections were performed under spinal and nine under epidural anesthesia. Plain bupivacaine 0.5% was used for the epidural anesthesia and bupivacaine 0.5% in glucose 8% for the spinals. The noradrenaline and adrenaline levels were higher in the neonates whose mothers received epidural anesthesia. The differences in catecholamine and bupivacaine concentrations were not associated with differences in left ventricular dynamics, or the timing of postnatal circulatory changes. The significant exposure of the neonate to bupivacaine, at maternal epidural anesthesia, seems to have no negative effect on early neonatal circulation in the healthy term infant. PMID:3364148
Hägnevik, K; Irestedt, L; Lundell, B; Sköldefors, E
Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment. However, continuous epidural block has some complications such as infection, dural puncture, and total spinal and nerve damages. We report a case of myoclonus during continuous epidural block with ropivacaine, morphine, and ketamine in an acute zoster patient.
Jeon, Younghoon; Baek, Sung Uk
Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment. However, continuous epidural block has some complications such as infection, dural puncture, and total spinal and nerve damages. We report a case of myoclonus during continuous epidural block with ropivacaine, morphine, and ketamine in an acute zoster patient. PMID:21935497
Jeon, Younghoon; Baek, Sung Uk; Yeo, Jin Seok
Twenty patients with known malignancies, back pain, abnormal roentgenograms of the spine, and normal neurological examinations were evaluated by outpatient computed tomographic (CT) myelography to determine the presence and extent of epidural tumor. Spinal CT following the intrathecal administration of low doses of water soluble contrast agents provided high quality diagnostic information. Three patients experienced adverse effects from this procedure which were mild and easily managed in the outpatient setting. Epidural tumor was identified in 15 of 20 (75%) patients. Patients were followed for 9-27 months following myelography. The 14 patients with epidural tumor treated with local radiation experienced pain relief and only one of these patients developed signs or symptoms of recurrent epidural tumor in the treated site. This study documents the high incidence of epidural tumor in selected patients without neurological deficits and the excellent palliative results of non-emergent, carefully planned radiation therapy. It also demonstrates that high resolution CT myelography can be performed safely in an outpatient setting in patients at high risk for epidural tumor. Outpatient myelography facilitates the early diagnosis of epidural tumor and provides needed information on the extent of the tumor for radiation treatment planning while conserving health care resources. For these reasons, outpatient CT myelography should be considered in selected patients with cancer who are at high risk for epidural metastases. PMID:1694089
Grossman, S A; Weissman, D E; Wang, H; Gilbert, M R; Updike, M L; Walton, V; Wharam, M
Spinal solitary epidural cavernous angiomas are rare benign vascular malformations, which occur even less frequently in children than in adults. It is uncommon to find such lesions without adjacent vertebral involvement. Occasionally, these lesions can lead to neurological symptoms through growth or due to intralesional hemorrhage. In this report the authors describe 2 children presenting with acute symptoms and neurological deficits caused by hemorrhage within solitary spinal epidural cavernous angiomas. A 13-year-old girl and a 9-year-old girl, previously healthy, were admitted to the authors' department due to acute radicular pain and neurological deficits. In both cases MR imaging revealed a solitary epidural mass with signs of bleeding and compression of the spinal cord. Complete resection of the lesion via a dorsal approach was performed in both patients. The histological examination of the lesions revealed the characteristic structures of a cavernous angioma with hemosiderin deposits and acute hemorrhage. Both patients recovered fully after surgical removal of the lesions. Review of the literature confirmed that spinal epidural cavernous angiomas are extremely rare in the pediatric patient population, described currently in only 2 instances, but without acute hemorrhage. These cases suggest that epidural cavernous angiomas also have to be considered in the pediatric patient population in the differential diagnosis of intraspinal lesions with acute or progressive neurological symptoms. Microsurgical resection of these cavernous malformations is an effective and curative treatment option. PMID:20043742
Sarikaya-Seiwert, Sevgi; Gierga, Kristin; Wessalowski, Rüdiger; Steiger, Hans-Jakob; Hänggi, Daniel
Spinal epidural angiolipoma is a rare benign tumor containing vascular and mature adipose elements. A slow progressive clinical course was mostly presented and rarely a fluctuating course during pregnancy. The authors report the original case of spontaneous spinal epidural bleeding resulting from thoracic epidural angiolipoma who presented with hyperacute onset of paraplegia, simulating an extradural hematoma. The patient was admitted with sudden non-traumatic hyperacute paraplegia during a prolonged walk. Neurologic examination showed sensory loss below T6 and bladder disturbances. Spinal MRI revealed a non-enhanced heterogeneous thoracic epidural lesion, extending from T2 to T3. A bilateral T2–T4 laminectomy was performed to achieve resection of a lipomatous tumor containing area of spontaneous hemorrhage. The postoperative course was uneventful with complete neurologic recovery. Histologic examination revealed the tumor as an angiolipoma. Because the prognosis after rapid surgical management of this lesion is favorable, the diagnosis of spinal angiolipoma with bleeding should be considered in the differential diagnosis of hyperacute spinal cord compression.
Albouzidi, Abderrahmane; Elmostarchid, Brahim; Gazzaz, Miloudi; Boucetta, Mohamed
Objective: Pediatric vertebral tumors are rare, and most of the reported series have limited numbers of cases. Diagnosis of these tumors is difficult because of the patients’ age and the rarity of the lesions. We aimed to report the clinical, radiological and pathological characteristics in a small series of pediatric vertebral and spinal epidural tumors and to discuss diagnostic and
Feyza Karagoz Guzey; Erhan Emel; Abdurrahman Aycan; N. Serdar Bas; M. Hakan Seyithanoglu; Nezih Ozkan; Cem Karabulut
Epidural spinal cord stimulation (ESCS) has been suggested to improve microcirculatory blood flow and reduce amputation rates in patients with severe peripheral arterial occlusive disease (PAOD). Pain relief, limb salvage, and skin circulation were studied in 177 patients with ischemic pain caused by nonreconstructible PAOD who were receiving ESCS. Medical or surgical therapy had failed and vascular reconstruction was impossible
Svante Horsch; Luc Claeys
We report a case of spontaneous spinal epidural abscess (SEA) with initial chief complaint of shoulder pain and no appreciable neurologic symptoms. Since outcomes of SEA appear to be related to the degree of neurologic deficit at the time of intervention, we explore opportunities for earlier diagnosis.
McDonald, Andrew M.; Rollins, Jason L.
Introduction: Spontaneous spinal epidural hematoma is rare in children. The presenting symptoms are usually pain, either local or radicular, followed by progressive bilateral weakness, and sensory loss hours and even days later. In the absence of significant precipitating factors such as severe trauma or previously known coagulopathies the diagnosis is usually delayed, and it is not until the full picture
Sarit Ravid; Steven Schneider; Joseph Maytal
Extradural spinal angiolipomas are rare benign tumors containing vascular and mature adipose elements. We report 8 cases of spinal epidural angiolipomas in 6 females and 2 males. In 7 cases, the clinical manifestation was a progressive spinal cord compression and one case had a regressive paraparesis mimicking a multiple sclerosis. In the 8 cases, the localization was thoracic with an extradural complete type of contrast block in 2 cases and partial in 5 cases. The myelo-CT achieved in 7 cases and the magnetic resonance imaging done at our last case revealed a fat-containing epidural tumor. The tumors were removed in all cases through a laminectomy with a successful outcome after an average of 9 years (range: 6 months-12 years). Sixty-seven similar cases in the international literature are reviewed. A total of 75 cases have been studied: 45 women and 30 men with a mean age of 46.3 years (range: 6-73), presenting a progressive spinal cord compression in 68 cases and in 7 cases a regressive paraparesis mimicking a multiple sclerosis. Myelography shows an extradural compression of the thecal sac. MRI is nowadays the imaging modality of choice for the diagnosis of these lesions. The surgical removal often easy of the epidural spinal angiolipomas permit a fast recovery. The etiopathogenesis of this process is still controversial between the dysembryogenetic and malformative hypothesis. PMID:11148405
Akhaddar, A; Gazzaz, M; Derraz, S; Rifi, L; Amarti, A; Aghzadi, A; El Ouahabi A; El Khamlichi A
We hypothesized that epidural spinal cord stimulation (ES) and quipazine (a serotonergic agonist) modulates the excitability of flexor and extensor related intraspinal neural networks in qualitatively unique, but complementary, ways to facilitate locomotion in spinal cord-injured rats. To test this hypothesis, we stimulated (40 Hz) the S(1) spinal segment before and after quipazine administration (0.3 mg/kg, ip) in bipedally step-trained and nontrained, adult, complete spinal (mid-thoracic) rats. The stepping pattern of these rats was compared with control rats. At the stimulation levels used, stepping was elicited only when the hindlimbs were placed on a moving treadmill. In nontrained rats, the stepping induced by ES and quipazine administration was non-weight bearing, and the cycle period was shorter than in controls. In contrast, the stepping induced by ES and quipazine in step-trained rats was highly coordinated with clear plantar foot placement and partial weight bearing. The effect of ES and quipazine on EMG burst amplitude and duration was greater in flexor than extensor motor pools. Using fast Fourier transformation analysis of EMG bursts during ES, we observed one dominant peak at 40 Hz in the medial gastrocnemius (ankle extensor), whereas there was less of dominant spectral peak in the tibialis anterior (ankle flexor). We suggest that these frequency distributions reflect amplitude modulation of predominantly monosynaptic potentials in the extensor and predominantly polysynaptic pathways in the flexor muscle. Quipazine potentiated the amplitude of these responses. The data suggest that there are fundamental differences in the circuitry that generates flexion and extension during locomotion. PMID:17855582
Gerasimenko, Yury P; Ichiyama, Ronaldo M; Lavrov, Igor A; Courtine, Gregoire; Cai, Lance; Zhong, Hui; Roy, Roland R; Edgerton, V Reggie
A 68-year-old male presented with rapidly progressive paraplegia. MR images of the thoracic spine were interpreted as being consistent with an abscess within an epidural lipomatosis compressing the spinal cord. Laminectomy was performed, and a large amount of pus was drained from the epidural lipomatosis, from which Staphylococcus aureus was isolated. This is the first reported case of an abscess involving an epidural lipomatosis.
Pipitone, Nicolo; De Carli, Nicola; Vecchia, Luigi; Bartoletti, Stefano C.
A patient received combined spinal-epidural anesthesia for a scheduled total knee arthroplasty. After an injection of spinal anesthetic and ephedrine due to a decrease in blood pressure, the patient developed a severe headache. The patient did not respond to verbal command at the completion of the operation. A brain CT scan revealed massive subarachnoid and intraventricular hemorrhages, and a CT angiogram showed a ruptured aneurysm. Severe headaches should not be overlooked in an uncontrolled hypertensive patient during spinal anesthesia because it may imply an intracranial and intraventricular hemorrhage due to the rupture of a hidden aneurysm. PMID:20376909
Chun, Duk-Hee; Kim, Na-Young; Shin, Yang-Sik
Background Anesthesia and inflammatory response have been studied in major abdominal and thoracic surgical procedures, but not in major orthopaedic reconstructive procedures such as total knee arthroplasty. Most studies have compared general anesthesia with epidural anesthesia, but none has compared epidural with spinal. Material/Methods In a prospective randomized study, 2 groups of patients scheduled for total knee arthroplasty for osteoarthritis were evaluated regarding the inflammatory response to 2 types of regional anesthesia. In 30 patients (Group A) with spinal anesthesia followed by intravenous morphine analgesia, and in 26 patients (Group B) with epidural anesthesia followed by epidural analgesia, the inflammatory response was assessed through the calculation of leucocyte concentration (WBC), C-reactive protein (CRP), monocyte chemotactic protein 1 (MCP-1), interleukins (IL-1, IL-6, IL-10, IL-18), TNF-a, and leucocyte activation molecules CD11b and CD62l, in 3 blood samples (immediately before induction to anesthesia, immediately after closure of the operative wound, and at 24 hours post-operatively). Results The MCP-1 values showed a statistically significant increase (p<0.02) in the group of patients with spinal anesthesia. Of the leucocyte activation molecules, a high statistically significant increase was noticed in the expression of CD11b on monocytes in the sample taken 24 hours post-operatively in the patients of group A. Similarly, CD62l expression on neutrophils showed a high statistically significant reduction in the sample taken 24 hours post-operatively in the group of patients with spinal anesthesia compared to the group of patients with epidural anesthesia. Conclusions Our results show that epidural anesthesia followed by epidural analgesia produced less inflammatory response compared with spinal anesthesia followed by intravenous morphine analgesia in patients operated on with total knee arthroplasty, and that the most sensitive markers of those investigated were the CD11b and CD62l leucocyte activation molecules.
Chloropoulou, Pelagia; Iatrou, Christos; Vogiatzaki, Theodosia; Kotsianidis, Ioannis; Trypsianis, Grigorios; Tsigalou, Christina; Paschalidou, Eleftheria; Kazakos, Konstantinos; Touloupidis, Stavros; Simopoulos, Konstantinos
Pure spinal epidural cavernous angiomas are extremely rare lesions, and their normal shape is that of a fusiform mass in the\\u000a dorsal aspects of the spinal canal. We report a case of a lumbo-sacral epidural cavernous vascular malformation presenting\\u000a with acute onset of right-sided S1 radiculopathy. Clinical aspects, imaging, intraoperative findings, and histology are demonstrated.\\u000a The patient, a 27-year-old man
Frank Floeth; Markus Riemenschneider; Jörg Herdmann
Background Stimulation of the spinal cord has been shown to have great potential for improving function after motor deficits caused by injury or pathological conditions. Using a wide range of animal models, many studies have shown that stimulation applied to the neural networks intrinsic to the spinal cord can result in a dramatic improvement of motor ability, even allowing an animal to step and stand after a complete spinal cord transection. Clinical use of this technology, however, has been slow to develop due to the invasive nature of the implantation procedures, the lack of versatility in conventional stimulation technology, and the difficulty of ascertaining specific sites of stimulation that would provide optimal amelioration of the motor deficits. Moreover, the development of tools available to control precise stimulation chronically via biocompatible electrodes has been limited. In this paper, we outline the development of this technology and its use in the spinal rat model, demonstrating the ability to identify and stimulate specific sites of the spinal cord to produce discrete motor behaviors in spinal rats using this array. Methods We have designed a chronically implantable, rapidly switchable, high-density platinum based multi-electrode array that can be used to stimulate at 1–100 Hz and 1–10 V in both monopolar and bipolar configurations to examine the electrophysiological and behavioral effects of spinal cord epidural stimulation in complete spinal cord transected rats. Results In this paper, we have demonstrated the effectiveness of using high-resolution stimulation parameters in the context of improving motor recovery after a spinal cord injury. We observed that rats whose hindlimbs were paralyzed can stand and step when specific sets of electrodes of the array are stimulated tonically (40 Hz). Distinct patterns of stepping and standing were produced by stimulation of different combinations of electrodes on the array located at specific spinal cord levels and by specific stimulation parameters, i.e., stimulation frequency and intensity, and cathode/anode orientation. The array also was used to assess functional connectivity between the cord dorsum to interneuronal circuits and specific motor pools via evoked potentials induced at 1 Hz stimulation in the absence of any anesthesia. Conclusions Therefore the high density electrode array allows high spatial resolution and the ability to selectively activate different neural pathways within the lumbosacral region of the spinal cord to facilitate standing and stepping in adult spinal rats and provides the capability to evoke motor potentials and thus a means for assessing connectivity between sensory circuits and specific motor pools and muscles.
A 12-year-old boy presented with backache and bilateral progressive lower extremity weakness. Radiological examination revealed a mass on the epidural space at level L(1)-L(3). The patient had laminectomy and posterior decompression. Histopathology examination revealed lymphocyte dominant type Hodgkin's disease. All other investigations (including computed tomography of the chest and abdomen, bone scan, gallium scan, bone marrow aspiration, and cerebrospinal fluid study) were negative for occult disease. The patient received combined therapy with irradiation and chemotherapy after surgery. At 7 years after the diagnosis, he had remained disease free and with normal functional status. This patient represents a rare case of primary epidural Hodgkin's disease in the lumbar region, rare also for onset in childhood. PMID:19433288
Samadian, Mohammad; Vahidi, Shifteh; Khormaee, Fatemeh; Ashraf, Haleh
A 38-year-old male was initially admitted for left leg swelling. He was diagnosed as having deep vein thrombosis (DVT) in the left leg and a pulmonary thromboembolism by contrast-enhanced chest computed tomography (CT) with delayed lower extremity CT. The DVT was treated by thrombolysis and a venous stent. Four hours later, he complained of severe back pain and a sensation of separation of his body and lower extremities; he experienced paraplegia early in the morning of the following day. Magnetic resonance imaging showed a spinal epidural hematoma between T11 and L2, which decompressed following surgery. We, therefore, report a case of a spinal epidural hematoma after thrombolysis in a case of DVT with a pulmonary thromboembolism.
Han, Young-Min, E-mail: firstname.lastname@example.org; Kwak, Ho-Sung; Jin, Gong-Young; Chung, Gyung-Ho [Chonbuk National University Medical School, Departments of Radiology (Korea, Republic of); Song, Kyung-Jin [Chonbuk National University Medical School, Departments of Orthopedic Surgery (Korea, Republic of)
Acute experiments on decerebrate cats were performed to study the mechanism of formation of the locomotor pattern in conditions of epidural stimulation of the spinal cord. These studies showed that only segments L3–L5 contributed to generating the stepping pattern in the hindlimbs. At the optimum frequency (5–10 Hz) of stimulation of these segments, formation of electromyographic burst activity in the
Yu. P. Gerasimenko; I. A. Lavrov; I. N. Bogacheva; N. A. Shcherbakova; V. I. Kucher; P. E. Musienko
We present a case of a 42-year-old male, an old case of deep vein thrombosis on warfarin and other drugs like quetiapine, aspirin, diclofenac sodium, fenofibrate, atorvastatin, propanolol and citalopram for concurrent illnesses, who presented with widespread mucocutaneous bleeding and epidural spinal hematoma. The epidural bleed presented clinically as a nontraumatic, rapidly improving myeloradiculopathy. Magnetic resonance imaging (MRI) of the spine revealed an epidural hematoma at D12-L1 level. The case was managed conservatively due lack of neurosurgical facilities. The patient gained full neurological recovery on conservative management alone. This case highlights the problem of drug interaction on warfarin therapy and also an unusual spontaneous recovery of spinal hematoma. Our case was anticoagulated in the recommended therapeutic INR range of 2.2 to 2.4. Most of the similar cases reported in literature were also anticoagulated in the therapeutic range. Thus intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient on anticoagulant agents who complains of local or referred spinal pain associated with neurological deficits. Drug interactions with warfarin are common. High suspicion and immediate intervention are essential to prevent complications from intraspinal hemorrhage.
Sagar, Amitabh; Hassan, KM
This report describes the waveform and properties of somatosensory evoked potentials recorded from various levels of the human spinal cord, with electrodes inserted into the epidural space and the stimulus delivered to the posterior tibial nerve at the knee. The object was to provide a means of monitoring spinal cord function during surgery for the correction of spinal deformities. The responses could be resolved into at least three components with different activation thresholds and different conduction velocities within the spinal cord (45-80 m/s approximately). The findings are in accord with recent studies, suggesting that the fast activity may be conducted in the dorsal spinocerebellar tract and the slower waves in the posterior columns.
Jones, S J; Edgar, M A; Ransford, A O
Congenital, spinal, epidural cysts are rare causes of transverse or radicular spinal lesions. Usually these cysts are located in the thoracal region, are oblong-shaped, and extend over several segments dorsally to the cord. Frequently, they cause no symptoms for years. They are fairly accessible to diagnostics by modern neuro-imaging methods.
Michael Langenbach; Dietmar Kiihne; Aeilke Brenner; Rodger von Wickede; Hans-Claus Leopold
OBJECTIVE: To study the efficacy, safety and patient satisfaction of psoas compartment and caudal epidural steroid injection in patients with spinal stenosis and lumbosaccral radiculopathy.METHODS: Patients with a diagnosis of spinal stenosis and lumbosaccral radiculopathy having visual analogue score (VAS) less than five were included in the study. Bilateral psoas compartment and caudal epidural injection was given to all patients.
Mueen Ullah Khan; S. Zaki Hussain
Epidural spinal cord stimulation (ESCS) combined with partial weight bearing therapy (PWBT) has been reported to facilitate recovery of functional walking for individuals after chronic incomplete spinal cord injury. This paper describes a low cost, fully implantable, advanced ESCS stimulator that can be manufactured in a research laboratory for use in small animals. The system is composed of four main parts: an external personal digital assistant (PDA), an external controller, an implantable pulse generator (IPG), lead extension and electrode. The PDA allows the experimenter to program the stimulation parameters through a user-friendly graphical interface. The external controller placed on the rat back communicates with PDA via RF telemetry. The IPG generates the biphasic charge-balanced voltage-regulated pulses, which are delivered to the bipolar electrode by the lead extension to achieve chronic ESCS in freely moving rats. A RF carrier from the Class-E amplifier in the external controller provides both data and power for the implanted circuitry through a closely coupled inductive link. The IPG is hermetically packaged using a silicon elastomer and measures 22 mm × 23 mm × 7 mm with a mass of ~3.78 g. PMID:22256007
Xu, Qi; Li, Jun; Han, Wenjuan; Zhou, Houlun
Summary Background Repeated periods of stimulation of the spinal cord and training seems to have amplified the ability to consciously control movement. Methods An individual three years post C7-T1 subluxation presented with a complete loss of clinically detectable voluntary motor function and partial preservation of sensation below the T1 cord segment. Following 170 locomotor training sessions, a 16-electrode array was surgically placed on the dura (L1-S1 cord segments) to allow for chronic electrical stimulation. After implantation and throughout stand retraining with epidural stimulation, 29 experiments were performed. Extensive stimulation combinations and parameters were tested to achieve standing and stepping. Findings Epidural stimulation enabled the human lumbosacral spinal circuitry to dynamically elicit full weight-bearing standing with assistance provided only for balance for 4·25 minutes in a subject with a clinically motor complete SCI. This occurred when using stimulation at parameters optimized for standing while providing bilateral load-bearing proprioceptive input. Locomotor-like patterns were also observed when stimulation parameters were optimized for stepping. In addition, seven months after implantation, the subject recovered supraspinal control of certain leg movements, but only during epidural stimulation. Interpretation Even after a severe low cervical spinal injury, the neural networks remaining within the lumbosacral segments can be reactivated into functional states so that it can recognize specific details of ensembles of sensory input to the extent that it can serve as the source of neural control. In addition, newly formed supraspinal input to this same lumbosacral segments can re-emerge as another source of control. Task specific training with epidural stimulation may have reactivated previously silent spared neural circuits or promoted plasticity. This suggests that these interventions could be a viable clinical approach for functional recovery after severe paralysis. Funding National Institutes of Health and Christopher and Dana Reeve Foundation.
Harkema, Susan; Gerasimenko, Yury; Hodes, Jonathan; Burdick, Joel; Angeli, Claudia; Chen, Yangsheng; Ferreira, Christie; Willhite, Andrea; Rejc, Enrico; Grossman, Robert G.; Edgerton, V. Reggie
Although epidural steroid injection has been commonly used to treat radicular pain, its clinical efficacy remains controversial. In a rat model of radicular pain induced by chronic compression of lumbar dorsal root ganglion (CCD), we examined the effect of epidural steroid on CCD-induced pain behavior. Triamcinolone [a glucocorticoid receptor (GR) agonist] or RU38486 (a GR antagonist) was given epidurally once
Xiaoping Gu; Shuxing Wang; Liling Yang; Backil Sung; Grewo Lim; Ji Mao; Qing Zeng; Yang Chang; Jianren Mao
Background. It was suggested that labor may influence the spread of intrathecal bupivacaine using combined spinal epidural (CSE) technique. However, no previous studies investigated this proposition. We designed this study to investigate the spinal block characteristics of plain bupivacaine between nonlaboring and laboring parturients using CSE technique. Methods. Twenty-five nonlaboring (Group NL) and twenty-five laboring parturients (Group L) undergoing cesarean delivery were enrolled. Following identification of the epidural space at the L3-4 interspace, plain bupivacaine 10?mg was administered intrathecally using CSE technique. The level of sensory block, degree of motor block, and hemodynamic changes were assessed. Results. The baseline systolic blood pressure (SBP) and the maximal decrease of SBP in Group L were significantly higher than those in Group NL (P = 0.002 and P = 0.03, resp.). The median sensory level tested by cold stimulation was T6 for Group NL and T5 for Group L (P = 0.46). The median sensory level tested by pinprick was T7 for both groups (P = 0.35). The degree of motor block was comparable between the two groups (P = 0.85). Conclusion. We did not detect significant differences in the sensory block levels between laboring and nonlaboring parturients using CSE technique with intrathecal plain bupivacaine.
Tang, Yu-Ying; Zhou, Jie; Ren, Xiao-Hui; Lin, Xue-Mei
It is known that after spinalization animals lose their ability to maintain lateral stability when standing or walking. A likely reason for this is a reduction of the postural limb reflexes (PLRs) driven by stretch and load receptors of the limbs. The aim of this study was to clarify whether spinal networks contribute to the generation of PLRs. For this purpose, first, PLRs were recorded in decerebrated rabbits before and after spinalization at T12. Second, the effects of epidural electrical stimulation (EES) at L7 on the limb reflexes were studied after spinalization. To evoke PLRs, the vertebrate column of the rabbit was fixed, whereas the hindlimbs were positioned on the platform. Periodic lateral tilts of the platform caused antiphase flexion–extension limbs movements, similar to those observed in intact animals keeping balance on the tilting platform. Before spinalization, these movements evoked PLRs: augmentation of extensor EMGs and increase of contact force during limb flexion, suggesting their stabilizing postural effects. Spinalization resulted in almost complete disappearance of PLRs. After EES, however, the PLRs reappeared and persisted for up to several minutes, although their values were reduced. The post-EES effects could be magnified by intrathecal application of quipazine (5-HT agonist) at L4–L6. Results of this study suggest that the spinal cord contains the neuronal networks underlying PLRs; they can contribute to the maintenance of lateral stability in intact subjects. In acute spinal animals, these networks can be activated by EES, suggesting that they are normally activated by a tonic supraspinal drive.
Musienko, P. E.; Zelenin, P. V.; Orlovsky, G. N.
Spinal epidural abscess, if especially caused by Brucellosis is a very rare disease which is usually a consequence of spondylodiscitis. The spinal column can be affected at any joint; however, the lumbar spine is the most common region, especially at the level of the L4-5 and L5-S1. The frequency of spinal involvement usually seen at the lumbar, thoracic and cervical spine respectively. As an occupational disease in farmers, veterinaries, butchers, laboratory staff and shepherds, brucellosis can also occur by direct contact to animals and infected materials or ingestion of raw cheese, milk or unpasteurized milk products. In this study, we presented two cases with cervical spinal epidural abscess caused by brucella melitensis, which was successfully treated by surgical approach. Initial treatment was combined with antibiotic therapy after the surgery for 3 months.
Ozbek, Zuhtu; Gokoglu, Abdulkerim; Menku, Ahmet
Background and Objectives: Major complications after spinal or epidural anesthesia are extremely rare. The occurrence of less serious and transient sequelae and complaints may be underestimated if there is no established organization for the systematic and continuous surveillance of patients after anesthesia. This study was designed to evaluate the possible relationship between various block-related occurrences and the intra- and postoperative
Risto Puolakka; Juhani Haasio; Mikko T. Pitkänen; Markku Kallio; Per H. Rosenberg
Design: This paper describes a treatment paradigm to facilitate functional gait in a quadriplegic, ASIA C spinal cord injured (SCI), wheelchair-dependent subject who presented with some large fiber sensation, sub-functional motor strength in all lower limb muscles, and moderate spasticity. The study utilizes partial weight bearing therapy (PWBT) followed by epidural spinal cord stimulation (ESCS) with the assumption that both
R Herman; J He; S D'Luzansky; W Willis; S Dilli
We discuss the etiology of a delayed spinal cord injury after epidural anesthesia without paresthesia. The de- scription of such a case in an awake, adult patient who underwent a Whipple resection is provided. An epi- dural was performed at approximately the T8-9 in- terspace with the patient in the sitting position after 1 mg of midazolam was administered. On
Ban C. H. Tsui; Kevin Armstrong
Most patients with insults to the spinal cord or central nervous system suffer from excruciating, unrelenting, chronic pain that is largely resistant to treatment. This condition affects a large percentage of spinal cord injury patients, and numerous patients with multiple sclerosis, stroke and other conditions. Despite the recent advances in basic science and clinical research the pathophysiological mechanisms of pain following spinal cord injury remain unknown. Here we describe a novel mechanism of loss of inhibition within the thalamus that may predispose for the development of this chronic pain and discuss a potential treatment that may restore inhibition and ameliorate pain.
Masri, Radi; Keller, Asaf
Although research on neural tissue repair has made enormous progress in recent years, spinal cord injury remains a devastating condition for which there is still no cure. In fact, recent estimates of prevalence in the United States reveal that spinal cord injury has undergone a five-fold increase in the last decades. Though, it has become the second most common neurological problem in North America after Alzheimer's disease. Despite modern trauma units and intensive care treatments, spinal cord injury remains associated with several comorbid conditions and unbearable health care costs. Regular administration of a plethora of symptomatic drug treatments aimed at controlling related-secondary complications and life-threatening problems in chronic spinal cord-injured patients has recently been reported. This article provides a thorough overview of the main drug classes and products currently used or in development for chronic spinal cord injury. Special attention is paid to a novel class of drug treatment designed to provide a holistic solution for several chronic complications and diseases related with spinal cord injury. There is clear evidence showing that new class can elicit 'on-demand' episodes of rhythmic and stereotyped walking activity in previously completely paraplegic animals and may consequently constitute a simple therapy against several physical inactivity-related comorbid problems. Understanding further pharmacological approaches to chronic spinal cord injury may improve both life expectancy and overall quality of life while reducing unsustainable cost increases associated with this debilitation condition. PMID:23360274
Steuer, Inge; Rouleau, Pascal; Guertin, Pierre A
Spinal cord stimulation (SCS) suppresses visceral response to colon distension in an animal model. In humans, it may be an effective therapy for chronic pain of pelvic origin, irritable bowel syndrome, and persistent unspecified abdominal pain. Described here is the case of SCS for 38-year-old woman with visceral pain secondary to chronic pancreatitis. Previous therapies included numerous endoscopic retrograde cholangiopancreatographies, multiple pancreatic duct stenting, chemical and surgical sympathectomies with short-lasting pain relief. After the initial evaluation, the patient underwent retrograde epidural differential block to determine possible source of pain. Delay in pain recurrence after block suggested that the origin of her pain was visceral. After the psychologic evaluation, the patient underwent SCS trial over 14 days. She had 2 trial leads placed epidurally via T9-T10 paramedian entry with the tips of both leads positioned at T6 vertebral body. During the trial, visual analog scale pain score decreased from 8 to 1 cm, Pain Disability Index from 62 to 14, and opioid use from 150 to 0 mg of morphine sulfate equivalent a day. After the completion of successful SCS trial, she was implanted with dual octrode leads and rechargeable pulse generator. Median pain scores decreased from 8 to 1 at 3 months after the implant. Pain Disability Index changed from 62 to 15. Opiate use decreased to none. It seems that SCS may have a significant therapeutic potential for the treatment of visceral pain secondary to chronic pancreatitis. PMID:18496389
Kapural, Leonardo; Rakic, Mladen
Despite widespread use, the efficacy of epidural corticosteroid injections (ESI) for osteoarthritis-associated neck or radicular pain remains uncertain, so even rare serious complications enter into discussions about use. However various factors impede investigation and publication of serious adverse events. To that end, we developed new magnetic resonance imaging (MRI) techniques for spinal cord white-matter quantification and employed best-available physiological tests to characterize a cervical spinal cord lesion caused by inadvertent intramedullary injection of Depo-Medrol. A 29-year-old woman with mild cervical osteoarthritis had 2 years of headache and neck pain (concussion and whiplash) after two minor motor-vehicle accidents. During C5–6 ESI, she developed new left-sided motor and sensory symptoms and MRI demonstrated a new left dorsal spinal cord cavity. Mild left-sided motor and sensory symptoms have persisted for more than 2 years, during which time we performed serial neurological examinations, standard electrodiagnostics, somatosensory evoked potentials, and transcranial measurement of corticospinal central motor conduction time (CMCT). We used 3 tesla MRI with a 32-channel coil developed for high-resolution cervical spinal cord structural imaging, diffusion tensor imaging (DTI) and magnetization transfer (MT). T2*-weighted signal, DTI and MT metrics showed delayed spread of the lesion across four vertebral levels rostrally, consistent with Wallerian degeneration within the ascending left dorsal columns. However only CMCT metrics detected objective correlates of her left hemiparesis and bilateral hyperreflexia. DTI and MT metrics may better distinguish between post-traumatic demyelination and axonal degeneration than conventional MRI. These tests should be considered to better characterize similar spinal cord injuries.
Cohen-Adad, Julien; Buchbinder, Bradley; Oaklander, Anne Louise
Cervical spinal epidural abscess, caused by fish bone injury and a secondary infection by Eikenella Corrodens which is part of the normal flora, has not been reported. A 72-yr-old man came to the hospital with pain in his posterior neck and both shoulders for 2 months. He also was experiencing weakness on his right side for 3 days. A fish bone had been stuck in his throat for about 2 months. Neurological examination revealed right hemiparesis, hypesthesia on the left extremities and neck stiffness. Laboratory findings showed an elevated ESR/CRP and leukocytosis, and magnetic resonance imaging revealed a retropharyngeal abscess and cervical myelitis. The patient was treated with emergency surgical decompression and antibiotics. A fish bone was removed from the C3-C4 intervertebral disc space. In the culture of chocolate blood agar and 5% sheep blood agar plate, E. corrodens was detected as a causative organism.
Jeon, Seong-Ho; Han, Dong-Chul; Lee, Sang-Gu; Park, Hyeon-Mi; Shin, Dong-Jin
Spinal epidural lipomatosis is a rare complication of chronic corticosteroid treatment. We report a new pediatric case and an analysis of this and 19 pediatric cases identified in the international literature. The youngest of these combined 20 patients was 5 years old when lipomatosis was diagnosed. Lipomatosis manifested after a mean of 1.3 (+/- 1.5) years (SD) (median, 0.8 years; range, 3 weeks - 6.5 years) of corticosteroid treatment. The corticosteroid dose at the time of presentation of the lipomatosis ranged widely, between 5 and 80 mg of prednisone/day. Back pain was the most common presenting symptom. Imaging revealed that lipomatosis almost always involved the thoracic spine, extending into the lumbosacral region in a subset of patients. Predominantly lumbosacral involvement was documented in only two cases. Although a neurological deficit at presentation was documented in about half of the cases, surgical decompression was not performed in the cases reported after 1996. Instead, reducing the corticosteroid dose (sometimes combined with dietary restriction to mobilize fat) sufficed to induce remission. In summary, pediatric spinal epidural lipomatosis remains a potentially serious untoward effect of corticosteroid treatment, which, if recognized in a timely manner, can have a good outcome with conservative treatment.
Epidural electrical stimulation (ES) at spinal cord segment L2 can produce coordinated step-like movements in completely spinalized adult rats [R.M. Ichiyama, Y.P. Gerasimenko, H. Zhong, R.R. Roy, V.R. Edgerton, Hindlimb stepping movements in complete spinal rats induced by epidural spinal cord stimulation, Neurosci. Lett. 383 (2005) 339-344]. Plantar placement of the paws, however, was rarely observed. Here, we sought to determine the dose dependence of a 5-HT agonist (quipazine) on stepping kinematics when administered in combination with ES. Six adult female Sprague-Dawley rats received a complete mid-thoracic spinal cord transection and were implanted with epidural electrodes at the L2 spinal cord level. Quipazine (i.p.) was tested at doses of 0.1, 0.2, 0.3, 0.4, and 0.5 mg/kg. Rats were placed in a body weight support system, allowing them to walk bipedally on a moving treadmill belt (7 cm/s). 3D step kinematics analysis revealed that coordinated alternating bilateral stepping was induced by L2 stimulation (50 Hz) alone and by quipazine alone. Furthermore, the combination treatment produced significantly greater numbers of plantar steps and improved quality of stepping compared to either intervention alone. Both number and quality of stepping peaked at the intermediate dose of 0.3-0.4 mg/kg. The results indicate that quipazine and ES can have complementary effects on spinal circuits and that quipazine dosage is an important factor in differentially modulating these circuitries to improve the quality of the bipedal stepping on a treadmill belt. PMID:18490105
Ichiyama, Ronaldo M; Gerasimenko, Yury; Jindrich, Devin L; Zhong, Hui; Roy, Roland R; Edgerton, V Reggie
The aim of this study was to evaluate the toxicity of chronic spinal analgesia with pethidine in a rabbit model. We introduced epidural catheters in twenty New Zealand white rabbits, divided into two groups, and we administered 0.5 mg÷kg pethidine or the same volume of normal saline through the catheters, for three consecutive days. Throughout the experiment, the animals were evaluated in terms of neurological status using the Tarlov score. After the rabbit's euthanasia, 4 ?m sections of spinal cord stained with Hematoxylin-Eosin were analyzed by a pathologist blinded to the study for neurohistopathological changes. The results were statistically analyzed with Prism 5 software for Windows. No significant differences were noticed between the two groups in as far as body temperature (p=0.295) and weight (p=0.139) were concerned. In the group of animals, which received epidural pethidine, nine rabbits showed histological changes suggestive for neurotoxicity at the lumbar level of the spinal cord. These findings were significantly different compared with the control group which received only saline (no microscopic lesions revealed; p=0.0006). When combining the data from both groups or using the pethidine group alone, there was a significant correlation between the presence of neurological injury (Tarlov score) and the presence of the histopathological lesions in the spinal cord (r=-0.709, p=0.0002 and r=-0.635, p=0.013, respectively). Based on our findings, the chronic epidural administration of pethidine in rabbits induces moderate to severe histological changes on the spinal cord, but further investigations are needed to make a definitive statement about the histological effect of pethidine on the neurological tissue. PMID:24068413
Pe?tean, C; Taulescu, M; Ober, C; C?toi, C; Micl?u?, V; Oana, L; Bodolea, C
Spontaneous spinal epidural hematoma (SSEH) is a rare condition requiring urgent diagnosis and treatment. Patients with SSEH typically present with acute onset of severe back pain and rapidly develop signs of compression of the spinal cord. The authors present a case with spontaneous resolution of SSEH which is extremely rare. We discuss a man who presented to our clinic with mild paraparesis at the seventh day of his symptoms. He had a history of poorly controlled hypertension and hypercholestrolemia requiring an antihyperlipidemic agent and anticoagulation. His upper level of hypoesthesia was at the third thoracic segment. Cervicothoracic SSEH was diagnosed by magnetic resonance imaging. Since there was a gradual recovery of the neurological deficits beginning 12 hours after the onset of symptoms, surgery was obviated and strict bed rest, serial neurological examinations, and pain controls with opiates were instituted. The neurological deficits showed complete recovery on the 25th day of the clinical course. SSEH is rare and immediate surgical decompression is suggested. Rapid neurological deterioration followed by early and progressive neurological recovery, confirmed by radiological resolution of the lesion, may indicate nonoperative treatment. PMID:20963712
Sirin, Sait; Arslan, Erhan; Yasar, Soner; Kahraman, Serdar
Clinical research indicates that the epidural spinal cord stimulation (ESCS) has shown potential in promoting locomotor recovery in patients with incomplete spinal cord injury (ISCI). This paper presents the development of a fully implantable voltage-regulated stimulator with bi-directional wireless communication for investigating underlying neural mechanisms of ESCS facilitating motor function improvement. The stimulation system consists of a computer, an external controller, an implantable pulse generator (IPG), a magnet, the extension leads and a stimulation electrode. The telemetry transmission between the IPG and the external controller is achieved by a commercially available transceiver chip with 2.4GHz carrier band. The magnet is used to activate the IPG only when necessary to minimize the power consumption. The encapsulated IPG measures 33mm×24mm×8mm, with a total mass of ?12.6g. Feasibility experiments are conducted in three Sprague-Dawley rats to validate the function of the stimulator, and to investigate the relationship between lumbar-sacral ESCS and hindlimb electromyography (EMG) responses. The results show that the stimulation system provides an effective tool for investigation of ESCS application in motor function recovery in small animals. PMID:22085835
Zhou, Hui; Xu, Qi; He, Jiping; Ren, Hangkong; Zhou, Houlun; Zheng, Kejia
Background/Objective: Transforaminal epidural steroid injection is a widely utilized nonsurgical strategy for the management of cervical radicular and axial pain. The technique has been shown to be efficacious in relieving the patients' symptoms. Although effective, there are a range of possible complications associated with this procedure. We report the case of a patient with an acute infarction of the cervical spinal cord after a multilevel transforaminal epidural steroid injection. Methods: We performed a retrospective chart review of a single case. Results: The patient suffered an acute brainstem and cervical spinal cord infarction despite the use of many techniques to minimize the occurrence of vascular injury during the procedure. The patient regained some function after medical and physical therapy. Conclusions: This complication, to our knowledge, has only been reported in the literature on 2 other occasions and serves as a reminder of the potentially devastating consequences of performing procedures in proximity to the nervous system.
Muro, Kenji; O'shaughnessy, Brian; Ganju, Aruna
The purpose of this study is to compare the effects of spinal and epidural anesthesia on a rat transverse rectus abdominus myocutaneous flap ischemia-reperfusion injury model.Forty Sprague-Dawley rats were divided into 4 experimental groups: group I (n = 10), sham group; group II (n = 10), control group; group III (n = 10), epidural group; and group IV (n = 10), spinal group. After the elevation of the transverse rectus abdominus myocutaneous flaps, all groups except for the sham group were subjected to normothermic no-flow ischemia for 4 hours, followed by a reperfusion period of 2 hours. At the end of the reperfusion period, biochemical and histopathological evaluations were performed on tissue samples.Although there was no significant difference concerning the malonyldialdehyde, nitric oxide, and paraoxonase levels in the spinal and epidural groups, the total antioxidant state levels were significantly increased, and the total oxidative stress levels were significantly decreased in the epidural group in comparison to the spinal group. The pathological evaluation showed that findings related to inflammation, nuclear change rates and hyalinization were significantly higher in the spinal group compared with the epidural group.Epidural anesthesia can be considered as a more suitable method that enables a decrease in ischemia-reperfusion injuries in the muscle flaps. PMID:23187711
Acar, Yusuf; Bozkurt, Mehmet; Firat, Ugur; Selcuk, Caferi Tayyar; Kapi, Emin; Isik, Fatma Birgul; Kuvat, Samet Vasfi; Celik, Feyzi; Bozarslan, Beri Hocaoglu
Twenty-eight consecutive patients were given high-dose dexamethasone (96 mg i.v. loading dose, decreasing doses to zero in 14 days) and radiotherapy for epidural spinal cord compression due to malignant disease. There were eight events classified as side effects of the dexamethasone treatment. Four of these were considered as serious (one fatal ulcer with haemmorhage, one rectal bleeding and one gastrointestinal
Ketil Heimdal; Henry Hirschberg; Haldor Slettebø; Kjell Watne I; Ole Nome
Symptomatic Tarlov (perineural cysts) are uncommon. In the following hemodialysis case, cauda equina syndrome was not detected after combined spinal-epidural anesthesia untilthe patient reported a lack of sensation in the perianal area 14 days postoperatively. She had normal motor function of her extremities. A laminectomy and cyst irrigation was performed. After the operation, her sphincter disturbance subsided gradually and her symptoms had disappeared. PMID:24066221
Ishiguro, Shigeo; Akeda, Koji; Tsujii, Masaya; Sudo, Akihiro
Symptomatic Tarlov (perineural cysts) are uncommon. In the following hemodialysis case, cauda equina syndrome was not detected after combined spinal-epidural anesthesia untilthe patient reported a lack of sensation in the perianal area 14 days postoperatively. She had normal motor function of her extremities. A laminectomy and cyst irrigation was performed. After the operation, her sphincter disturbance subsided gradually and her symptoms had disappeared.
Akeda, Koji; Tsujii, Masaya; Sudo, Akihiro
This review describes the changes of spinal neuronal function that occur after a motor complete spinal cord injury (cSCI) in humans. In healthy subjects, polysynaptic spinal reflex (SR) evoked by non-noxious tibial nerve stimulation consists of an early SR component and rarely a late SR component. Soon after a cSCI, SR and locomotor activity are absent. After spinal shock; however, an early SR component re-appears associated with the recovery of locomotor activity in response to appropriate peripheral afferent input. Clinical signs of spasticity take place in the following months, largely as a result of non-neuronal changes. After around 1 year, the locomotor and SR activity undergo fundamental changes, that is, the electromyographic amplitude in the leg muscles during assisted locomotion exhaust rapidly, accompanied by a shift from early to dominant late SR components. The exhaustion of locomotor activity is also observed in non-ambulatory patients with an incomplete spinal cord injury (SCI). At about 1 year after injury, in most cSCI subjects the neuronal dysfunction is fully established and remains more or less stable in the following years. It is assumed that in chronic SCI, the patient's immobility resulting in a reduced input from supraspinal and peripheral sources leads to a predominance of inhibitory drive within spinal neuronal circuitries underlying locomotor pattern and SR generation. Training of spinal interneuronal circuits including the enhancement of an appropriate afferent input might serve as an intervention to prevent neuronal dysfunction after an SCI. PMID:21060314
Hubli, M; Bolliger, M; Dietz, V
Background: Chronic persistent low back and lower extremity pain secondary to central spinal stenosis is common and disabling. Lumbar surgical interventions with decompression or fusion are most commonly performed to manage severe spinal stenosis. However, epidural injections are also frequently performed in managing central spinal stenosis. After failure of epidural steroid injections, the next sequential step is percutaneous adhesiolysis and hypertonic saline neurolysis with a targeted delivery. The literature on the effectiveness of percutaneous adhesiolysis in managing central spinal stenosis after failure of epidural injections has not been widely studied. Study Design: A prospective evaluation. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis. Methods: Seventy patients were recruited. The initial phase of the study was randomized, double-blind with a comparison of percutaneous adhesiolysis with caudal epidural injections. The 25 patients from the adhesiolysis group continued with follow-up, along with 45 additional patients, leading to a total of 70 patients. All patients received percutaneous adhesiolysis and appropriate placement of the Racz catheter, followed by an injection of 5 mL of 2% preservative-free lidocaine with subsequent monitoring in the recovery room. In the recovery room, each patient also received 6 mL of 10% hypertonic sodium chloride solution, and 6 mg of non-particulate betamethasone, followed by an injection of 1 mL of sodium chloride solution and removal of the catheter. Outcomes Assessment: Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12, 18 and 24 months post treatment. The primary outcome measure was 50% or more improvement in pain scores and ODI scores. Results: Overall, a primary outcome or significant pain relief and functional status improvement of 50% or more was seen in 71% of patients at the end of 2 years. The overall number of procedures over a period of 2 years were 5.7 ± 2.73. Limitations: The lack of a control group and a prospective design. Conclusions: Significant relief and functional status improvement as seen in 71% of the 70 patients with percutaneous adhesiolysis utilizing local anesthetic steroids and hypertonic sodium chloride solution may be an effective management strategy in patients with chronic function limiting low back and lower extremity pain with central spinal stenosis after failure of conservatie management and fluoroscopically directed epidural injections.
Manchikanti, Laxmaiah; Cash, Kimberly A.; McManus, Carla D.; Pampati, Vidyasagar
Therapeutic management of chronic pain has not been widely successful owing to a lack of understanding of factors that initiate and maintain the chronic pain condition. Efforts to delineate the mechanisms underlying pain long have focused on neuronal elements of pain pathways, and both opiate- and non–opiate-based therapeutics are thought largely to target neurons. Abnormal neuronal activity at the level
James P. O'Callaghan; Diane B. Miller
Among the multiple causes of chronic low back pain, axial and discogenic pain are common. Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections. However, there is a paucity of evidence regarding the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. In an interventional pain management practice in the US, a randomized, double-blind, active control trial was conducted. The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin. However, disc herniation, radiculitis, facet joint pain, or sacroiliac joint pain were excluded. Two groups of patients were studied, with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone. Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the, Oswestry Disability Index, Secondary outcome measurements included employment status, and opioid intake. Significant improvement or success was defined as at least a 50% decrease in pain and disability. Significant improvement was seen in 77% of the patients in Group I and 67% of the patients in Group II. In the successful groups (those with at least 3 weeks of relief with the first two procedures), the improvement was 84% in Group I and 71% in Group II. For those with chronic function-limiting low back pain refractory to conservative management, it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain. This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source.
Manchikanti, Laxmaiah; Cash, Kimberly A; McManus, Carla D; Pampati, Vidyasagar; Benyamin, Ramsin
There are only a few reports on cesarean section in a patient with cervical fracture without spinal cord injury (SCI). Such patients have high risks for deterioration of SCI following general or regional anesthesia. Here, we present a patient with a fracture of C2 vertebra who underwent cesarean section safely under combined spinal and epidural anesthesia(CSEA). A 30-year-old woman had a fracture of the C2 cervical vertebra (Hangman's fracture) due to a traffic accident at 34 weeks of gestation. Conservative immobilization of the head and neck was done with a neck collar (Philadelphia brace) in order to prevent subsequent SCI after the spine injury. Pre-viability amniorrhexis was seen at 37 weeks' gestation, and an emergency cesarean section was scheduled under combined epidural and spinal anesthesia (CSEA). Her neck and head were carefully fixed before, during and after surgery in order to prevent subsequent SCI. As a result, cesarean section under CSEA was successfully performed in the patient without any deterioration of the spine and/or SCI. PMID:23697203
Mochidome, Mariko; Sakamoto, Akiyuki; Tanaka, Hidenori; Sugiyama, Daisuke; Kawamata, Mikito
\\u000a As longevity increases for patients with spinal cord injuries (SCI), operative procedures are often necessary to further rehabilitation,\\u000a control pain, evaluate urinary dysfunction, maintain skin integrity and reverse further neurologic degeneration. Increasingly,\\u000a SCI women are completing pregnancies. Considerations for anesthetic management of patients with chronic SCI include avoiding\\u000a autonomic hyperreflexia and hyperkalemia-related to succinylcholine, preventing exacerbations of pulmonary dysfunction and
Patricia H. Petrozza
Purpose This study was designed to assess the impact of minimally invasive surgery (MIS) for the treatment of patients with metastatic\\u000a epidural spinal cord compression (MESCC) and vertebral body fracture, in terms of feasibility, clinical improvement, and morbidity.\\u000a \\u000a \\u000a \\u000a \\u000a Methods Twenty-five consecutive patients with diagnosis of MESCC from solid primary tumors were treated between January 2008 and June\\u000a 2010 at our institution. All
Flavio Tancioni; Pierina Navarria; Federico Pessina; Simona Marcheselli; Elisa Rognone; Pietro Mancosu; Armando Santoro; Riccardo Rodriguez Y. Baena
BACKGROUND: The Special Interest Group of the Canadian Pain Society has produced consensus-based guidelines for the pharmacological management of neuropathic pain. The society aimed to generate an additional guideline for other forms of neuropathic pain treatments. OBJECTIVE: To develop evidence-based recommendations for neuropathic pain interventional treatments. METHODS: A task force was created and engaged the Institute of Health Economics in Edmonton, Alberta, to survey the literature pertaining to multiple treatments. Sufficient literature existed on four interventions only: spinal cord stimulation; epidural injections; intravenous infusions; and nerve blocks. A comprehensive search was conducted for systematic reviews, randomized controlled trials and evidence-based clinical practice guidelines; a critical review was generated on each topic. A modified United States Preventive Services Task Force tool was used for quality rating and grading of recommendations. RESULTS: Investigators reviewed four studies of spinal cord stimulation, 19 studies of intravenous infusions, 14 studies of epidural injections and 16 studies of nerve blocks that met the inclusion criteria. The task force chairs rated the quality of evidence and graded the recommendations. Feedback was solicited from the members of the task force. CONCLUSION: There is sufficient evidence to support recommendations for some of these interventions for selected neuropathic pain conditions. This evidence is, at best, moderate and is often limited or conflicting. Pain practitioners are encouraged to explore evidence-based treatment options before considering unproven treatments. Full disclosure of risks and benefits of the available options is necessary for shared decision making and informed consent.
Mailis, Angela; Taenzer, Paul
Objectives: To describe an electrophysiological method for determining the relation between lumbar cord dorsal roots and cathode of epidural electrode for spinal cord stimulation (SCS).Materials and methods: Data has been collected from 13 subjects who have been under evaluation of effectiveness of SCS for control of spasticity. Induced muscle twitches from both quadriceps (Q), adductors (A), hamstrings (H), tibial anterior
M Murg; H Binder
Spinal cord stimulation (SCS) is one of the most effective modalities for management of refractory neuropathic pain unresponsive to conservative therapies. The SCS has been successful in providing analgesia, improving function, and enhancing quality of life for patients suffering from chronic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, ischaemic and phantom limb pain, and coronary artery disease. This technique has proven to be cost effective in the long term despite its high initial cost. In this review article, we discuss the history of SCS development, mechanism of action, and indications for SCS. PMID:19956823
Jeon, Younghoon; Huh, Billy K
Cardenas DD, Turner JA, Warms CA, Marshall HM. Classification of chronic pain associated with spinal cord injuries. Arch Phys Med Rehabil 2002;83:1708-14. Objectives: To determine interrater reliability of a classification system for chronic pain in persons with spinal cord injury (SCI) and to determine the frequency and characteristics of various pain types as categorized by this system. Design: Independent categorization
Diana D. Cardenas; Judith A. Turner; Catherine A. Warms; Helen M. Marshall
We describe a patient with severe scoliosis, which had been corrected partially with Harrington rods, who requested epidural analgesia for labour. With no palpable landmarks, the use of ultrasound enabled identification of the vertebral midline and allowed provision of regional anaesthesia. PMID:10673892
Yeo, S T; French, R
In 22 subjects, including normal subjects and patients with radicular or spinal cord lesions, the authors studied the spinal evoked responses recorded extradurally after stimulating mixed limb nerves. The responses obtained are discussed with particular reference to the clinical value of the changes in amplitude and latency of the spinal evoked potential with particular lesions. Images
Caccia, M. R.; Ubiali, E.; Andreussi, L.
Twenty patients with chronic pain who previously had obtained analgesia from epidural clonidine and lignocaine agreed to participate in a double-blind crossover study of lumbar epidural clonidine (150 ?g), lignocaine (40 mg) and the combination of clonidine (150 ?g) and lignocaine (40 mg), all drugs were given in a volume of 3 ml. There were 11 women and 9 men
Chris Glynn; Katrina O'Sullivan
Our objective is to develop neural prostheses based on an array of microelectrodes implanted into the sacral spinal cord, that will allow persons with spinal cord injuries to regain control of their bladder and bowels. For our chronic cat model, we have developed two microelectrode arrays, one type containing nine discrete activated iridium microelectrodes and the second utilizing silicon substrate
Douglas McCreery; Victor Pikov; Albert Lossinsky; Leo Bullara; William Agnew
The ability of glycopyrronium to reduce the severity of hypotension following subarachnoid block in parturients with a relative bradycardia was evaluated in a double-blind randomised controlled study. Women with a resting heart rate of < or = 80 beat x min(-1) presenting for elective Caesarean section were randomly allocated to receive either glycopyrronium 2 microg x kg(-1) or normal saline intravenously once positioned for combined spinal-epidural anaesthesia. Following spinal injection of 2.6 ml hyperbaric bupivacaine 0.5% and fentanyl 15 microg, women randomly allocated to the saline group were given 6 mg ephedrine so that all parturients received some prophylaxis against hypotension other than the fluid preload. Further ephedrine and fluid boluses were administered if mean arterial pressure fell 20% or more from resting values. Using a sequential analysis technique, analysis after the first 20 subjects indicated the study should be stopped, with no difference in ephedrine requirements or hypotension between the groups. We conclude that pretreatment with glycopyrronium 2 microg x kg(-1) is no more effective than 6 mg ephedrine in preventing hypotension following subarachnoid block in parturients with relatively low resting heart rates. PMID:11843734
Rucklidge, M W M; Durbridge, J; Barnes, P K; Yentis, S M
An ideal analgesic for labour would preferably be non-invasive, as effective as spinals and epidurals without their attendant complications and is safe to mother and child and should not complicate the labour process. Analgesia for labouring women ranges from the use of opioid injections to invasive methods, chiefly epidural injections. Each has its advantages and drawbacks. This article provides a review of analgesic methods and techniques for labouring women. It focuses mainly on the role of epidurals, how it is utilised by anaesthetists and the differing methods of drug delivery through the epidural route. It discusses various concoctions of local anaesthetics and adjuvants used. The epidural route is probably the most effective and most commonly used invasive route for achieving analgesia during labour. Local anaesthetics of varying concentrations are administered as intermittent boluses or as a continuous infusion. Adjuvant drugs are able to enhance the quality and duration of the analgesia. Opioids including fentanyl and sufentanil, and clonidine are discussed. The use of patient-controlled epidural analgesia and combined spinal-epidural analgesia are reviewed. Ambulatory or mobile epidurals are increasingly popular. They are known to improve maternal satisfaction because of preservation of motor power. Ambulation may help with cervical dilatation and engagement, and abolition of backpain, among other advantages. This article describes the methods of establishing mobile epidurals and offers guidelines on safe ambulation and contraindications to its use. PMID:9663317
Tan, T K
Authors present the case of a 5-year-old patient with a spinal arteriovenous fistula (AVF) and pseudoaneurysm of the anterior spinal artery (ASA) caused by a traumatic epidural needle stick injury. A discussion and relevant review of the literature follow. The boy had a remote history of a liver transplant and required neuraxial blockade for an unrelated abdominal surgical procedure. Initial insertion of the epidural needle at the T9-10 interspace yielded blood. A second attempt at T10-11 was successful. Delayed left leg weakness developed on postoperative Day 8, with an MR image showing a track injury through the cord and a ventral subarachnoid hematoma. Laminectomies from T-9 to T-11were performed emergently to decompress the spinal cord. The dura mater was opened, the ventral hematoma was evacuated, and brisk venous bleeding was controlled with cauterization. Postoperative spinal angiography demonstrated an AVF and pseudoaneurysm of the ASA. Repeat angiography at postoperative Week 4 demonstrated complete resolution of the AVF and pseudoaneurysm, probably due to intraoperative cauterization of the draining vein. The patient underwent a short course of rehabilitation and had no clinical or electrophysiological evidence of spinal cord damage at the 20-month follow-up. One should be cognizant of the possibility of a cord injury in a patient with new-onset neurological deficits following an interventional spine procedure. Neuroimaging is essential for prompt diagnosis and treatment. PMID:23311385
Alnaami, Ibrahim; Lam, Fred C; Steel, Graham; Dicken, Bryan; O'Kelly, Cian J; Aronyk, Keith; Mehta, Vivek
We report 2 cases of vertebral osteomyelitis and contiguous epidural abscess due to Bacteroides fragilis with no concomitant or past intra-abdominal infection. Decompressive surgery with laminectomy was required for both patients due to the occurrence of neurologic deficits. Clinical recovery was achieved after 8 weeks of antibiotic therapy. It included 3 weeks of intravenous therapy with clindamycin followed by an oral regimen of clindamycin for 1 patient and oral metronidazole for the other. In both cases, magnetic resonance imaging (MRI) has proved to be essential for diagnostic. The primary source of infection remained unknown despite careful investigations. PMID:18714851
de Goeij, S; Nisolle, J-F; Glupczynski, Y; Delgrange, E; Delaere, B
Mulcahey MJ, Gaughan JP, Chafetz RS, Vogel LC, Samdani AF, Betz RR. Interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury in youths with chronic spinal cord injury.
Mary Jane Mulcahey; John P. Gaughan; Ross S. Chafetz; Larry C. Vogel; Amer F. Samdani; Randal R. Betz
Spinal cord stimulation (SCS) has been suggested to improve microcirculatory blood flow to relieve ischemic pain and to reduce amputation rate in patients with peripheral arterial occlusive disease (PAOD). The aim of this study was to evaluate the specific prognostic parameters in the prediction of successful SCS, in diabetic patients, performing a retrospective data analysis. To perform this evaluation, 64
Ioannis E Petrakis; Vincenzo Sciacca
Background Chronic low back pain without disc herniation is common. Various modalities of treatments are utilized in managing this condition, including epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. Methods A randomized, double-blind, actively controlled trial was conducted. The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation, radiculitis, facet joints, or sacroiliac joints. A total of 120 patients were randomized to two groups; one group did not receive steroids (group 1) and the other group did (group 2). There were 60 patients in each group. The primary outcome measure was at least 50% improvement in Numeric Rating Scale and Oswestry Disability Index. Secondary outcome measures were employment status and opioid intake. These measures were assessed at 3, 6, 12, 18, and 24 months after treatment. Results Significant pain relief and functional status improvement (primary outcome) defined as a 50% or more reduction in scores from baseline, were observed in 54% of patients in group 1 and 60% of patients in group 2 at 24 months. In contrast, 84% of patients in group 1 and 73% in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months. Conclusion Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.
Manchikanti, Laxmaiah; Cash, Kimberly A; McManus, Carla D; Pampati, Vidyasagar
Objective The purpose of this study is to evaluate neuroprotective effect of sacral neuromodulation in rat spinal cord injury (SCI) model in the histological and functional aspects. Methods Twenty-one female Sprague Dawley rats were randomly divided into 3 groups : the normal control group (CTL, n=7), the SCI with sham stimulation group (SCI, n=7), and the SCI with electrical stimulation (SCI+ES, n=7). Spinal cord was injured by dropping an impactor from 25 mm height. Sacral nerve electrical stimulation was performed by the following protocol : pulse duration, 0.1 ms; frequency, 20 Hz; stimulation time, 30 minutes; and stimulation duration, 4 weeks. Both locomotor function and histological examination were evaluated as scheduled. Results The number of anterior horn cell was 12.3±5.7 cells/high power field (HPF) in the CTL group, 7.8±4.9 cells/HPF in the SCI group, and 6.9±5.5 cells/HPF in the SCI+ES group, respectively. Both the SCI and the SCI+ES groups showed severe loss of anterior horn cells and myelin fibers compared with the CTL group. Cavitation and demyelinization of the nerve fibers has no significant difference between the SCI group and the SCI+ES group. Cavitation of dorsal column was more evident in only two rats of SCI group than the SCI+ES group. The locomotor function of all rats improved over time but there was no significant difference at any point in time between the SCI and the SCI+ES group. Conclusion In a rat thoracic spinal cord contusion model, we observed that sacral neuromodulation did not prevent SCI-induced myelin loss and apoptosis.
Lee, Chang-Hyun; Yoon, Cheol-Yong; Lim, Jae-Young; Jahng, Tae-Ahn; Kim, Ki-Jeong
Summary Arteriovenous fistulas following vertebral fractures are probably very rare. We present a case with fistulous connection between arteries and veins within the fractured 12th thoracic vertebral body with retrograde venous drainage to perimedullary veins resulting in spinal venous hypertension and a cauda equina like symptomatology. Pre-treatment 3D CT enabled us to puncture the venous pouch within the vertebra and deposit glue in the vertebral fistula. The procedure led to a complete occlusion of the fistula and relief of pain and neurological symptoms.
Gjertsen, ?.; Nakstad, P. HJ.; Pedersen, HK; Dahlberg, D.
Objective To evaluate the short-term and long-term effects of fluoroscopically guided caudal epidural steroid injection (ESI) for the\\u000a management of degenerative lumbar spinal stenosis (DLSS) and to analyze outcome predictors.\\u000a \\u000a \\u000a \\u000a \\u000a Materials and methods All patients who underwent caudal ESI in 2006 for DLSS were included in the study. Response was based on chart documentation\\u000a (aggravated, no change, slightly improved, much improved, no
Joon Woo Lee; Jae Sung Myung; Kun Woo Park; Jin S. Yeom; Ki-Jeong Kim; Hyun-Jib Kim; Heung Sik Kang
Objective Chest illnesses commonly cause morbidity in persons with chronic spinal cord injury. Risk factors remain poorly characterized because previous studies have not accounted for factors other than spinal cord injury. Design Between 1994 and 2005, 403 participants completed a respiratory questionnaire and underwent spirometry. Participants were contacted at a median of 1.7 yrs [interquartile range: 1.3–2.5 yrs] apart over a mean (SD) of 5.1 ± 3.0 yrs and asked to report chest illnesses that had resulted in time off work, spent indoors, or in bed since prior contact. Results In 97 participants, there were 247 chest illnesses (0.12/person-year) with 54 hospitalizations (22%). Spinal cord injury level, completeness of injury, and duration of injury were not associated with illness risk. Adjusting for age and smoking history, any wheeze (relative risk = 1.92; 95% confidence interval: 1.19, 3.08), pneumonia or bronchitis since spinal cord injury (relative risk = 2.29; 95% confidence interval: 1.40, 3.75), and physician-diagnosed chronic obstructive pulmonary disease (relative risk = 2.17; 95% confidence interval: 1.08, 4.37) were associated with a greater risk of chest illness. Each percent-predicted decrease in forced expiratory volume in 1 sec was associated with a 1.2% increase in risk of chest illness (P = 0.030). Conclusions In chronic spinal cord injury, chest illness resulting in time spent away from usual activities was not related to the level or completeness of spinal cord injury but was related to reduced pulmonary function, wheeze, chronic obstructive pulmonary disease, a history of pneumonia and bronchitis, and smoking.
Stolzmann, Kelly L.; Gagnon, David R.; Brown, Robert; Tun, Carlos G.; Garshick, Eric
to be independently associated with the RBP group. These factors may predict which parturients' analge- sia may be complicated by breakthrough pain. Partu- rients who received a combined spinal\\/epidural technique were less likely to be associated with the RBP group. The combined spinal\\/epidural technique may be superior to conventional epidural anesthesia, because breakthrough pain occurred less often. It is interesting
Philip E. Hess; Stephen D. Pratt; Tanya P. Lucas; Carolyn G. Miller; Tanya Corbett; Nancy Oriol; Mukesh C. Sarna
Abstract Chronic pain following spinal cord injury (SCI) is a highly prevalent clinical condition that is difficult to treat. Using both von Frey filaments and radiant infrared heat to assess mechanical allodynia and thermal hyperalgesia, respectively, we have demonstrated that a one-time injection of fibronectin (50??g/mL) into the spinal dorsal column (1??L/min each injection for a total of 5??L) immediately after SCI inhibits the development of mechanical allodynia (but not thermal hyperalgesia) over an 8-month observation period following spinal cord dorsal column crush (DCC). DCC will only induce mechanical Allodynia, but not thermal hyperalgesia or overt motor deficits. By applying various fibronectin fragments as well as competitive inhibitors, these effects were shown to be dependent on the connecting segment-1 (CS-1) motif of fibronectin. Furthermore, we found that acute fibronectin treatment diminished inflammation and blood–spinal cord barrier permeability, which in turn leads to enhanced fiber sparing and sprouting. In particular, the reduction of serotonin (5-HT) in the superficial dorsal horn, an important descending brainstem system in the modulation of pain, was blocked with fibronectin treatment. We conclude that treatment of SCI with fibronectin preserves sensory regulation and prevents the development of chronic allodynia, providing a potential therapeutic intervention to treat chronic pain following SCI.
Lee, Yu-Shang; Lin, Vernon W.; Silver, Jerry
Purpose: To investigate the clinical and functional correlates of megacolon in individuals with chronic spinal cord injury (SCI).Patients and methods: This is a cross-sectional study of 128 patients consecutively admitted to a SCI in-patient service in a US Veterans Administration Medical Centre (mean age 57±15 years, mean years since injury 20±13, 97% male) who underwent plain abdominal radiography for study
D Harari; K L Minaker
Study design:Prospective Pilot Study.Objectives:To determine the safety and feasibility of autologous olfactory mucosal transplantation into the spinal cord in chronic spinal cord injured using the technique developed by Carlos Lima et al.Setting:Spinal Injury Center, New Delhi.Methods:Five chronic, motor complete, traumatic spinal cord injury (SCI) patients with neurological level C5–T12 underwent the procedure. Participants were assessed at baseline and at 6
H S Chhabra; C Lima; S Sachdeva; A Mittal; V Nigam; D Chaturvedi; M Arora; A Aggarwal; R Kapur; T A H Khan
Background To test the function of implantable devices for electrical stimulation of the retina, long-term registration tests of cortical-evoked potentials are required. Skin electrodes are not appropriate to provide representative recordings, due to the voluminous pneumatic frontal sinus of minipigs. Therefore, epidural electrodes were permanently implanted in minipigs and tested with visual and electrical retinal stimulation. The present study describes
Thomas Laube; Thomas Schanze; Claudia Brockmann; Ines Bolle; Thomas Stieglitz; Norbert Bornfeld
Intrathecal and epidural administration of the ?2-adrenergic receptor agonist clonidine in humans results in analgesia to both acute nociceptive and chronic neuropathic pain. The potency of clonidine increases with hypersensitivity to mechanical stimuli after nerve injury, although the reasons for this change are unknown. In the present study, we tested the hypothesis that peripheral nerve injury alters either spinal ?2-adrenergic
Carsten Bantel; James C. Eisenach; Frederic Duflo; Joseph R. Tobin; Steven R. Childers
Objective. Initial presentation with primary spinal involvement in chronic recurrent multifocal osteomyelitis of childhood (CRMO) is rare. Our objective was to review the imaging appearances of three patients who had CRMO who initially presented with isolated primary spinal involvement.Design and patients. The imaging, clinical, laboratory and histology findings of the three patients were retrospectively reviewed. Imaging included seven spinal MR
S. E. Anderson; P. Heini; M. J. Sauvain; E. Stauffer; L. Geiger; J. O. Johnston; A. Roggo; D. Kalbermatten; L. S. Steinbach
Electrical spinal neuromodulation in the form of spinal cord stimulation is currently used for treating chronic painful conditions such as complex regional pain syndrome, diabetic neuropathy, postherpetic neuralgia, peripheral ischemia, low back pain, and other conditions refractory to more conservative treatments. To date, there are very few published reports documenting the use of spinal cord stimulation in the treatment of head/neck and upper limb pain. This paper reports a case series of 5 consecutive patients outlining the use of spinal cord stimulation to treat upper extremity pain. All subjects had previously undergone cervical fusion surgery to treat chronic neck and upper limb pain. Patients were referred following failure of the surgery to manage their painful conditions. Spinal cord stimulators were placed in the cervical epidural space through a thoracic needle placement. Stimulation parameters were adjusted to capture as much of the painful area(s) as possible. In total, 4 out of 5 patients moved to implantation. In all cases, patients reported significant (70-90%) reductions in pain, including axial neck pain and upper extremity pain. Interestingly, 2 patients with associated headache and lower extremity pain obtained relief after paresthesia-steering reportedly covered those areas. Moreover, 2 patients reported that cervical spinal cord stimulation significantly improved axial low back pain. Patients continue to report excellent pain relief up to 9 months following implantation. This case series documents the successful treatment of neck and upper extremity pain following unsuccessful cervical spine fusion surgery. Given this initial success, prospective, controlled studies are warranted to more adequately assess the long term utility and cost effectiveness of electrical neuromodulation treatment of chronic neck and upper extremity pain. PMID:17387353
Vallejo, Ricardo; Kramer, Jeffery; Benyamin, Ramsin
Background To assess prospectively the incidence of chronic and neuropathic pain in patients undergoing anteroaxillary thoracotomy with postoperative epidural analgesia or controlled-release oxycodone pain regimen. Methods 77 patients who underwent anteroaxillary thoracotomy were enrolled in our observational study. 40 patients received postoperatively a standardized oral analgesic protocol with controlled-release oxycodone and IV non opioid (CRO Group), and 37 patients received epidural analgesia with ropivacaine 0.1%?+?1 ?g/ml sufentanil (EDA Group) and IV non opioid. The painDETECT questionnaire was completed from the patients with one of the authors (JL) on the 7th postoperative day and six months postoperatively. Results The data of 60 patients were eligible for statistical analysis, 28 patients in the CRO Group and 32 patients in the EDA Group. 17 patients did not reach the 6-months follow-up interval (12 drop outs in the CRO Group and 5 drop outs in the EDA Group). 79% percent of patients in the CRO Group and 74% percent of patients in the EDA Group had a numeric rating scale score (NRS)?=?0 after 6 months. 22% percent of patients in the CRO Group and 16% percent of patients in the EDA Group experienced a NRS 1–3 6-months postoperatively. No patient in the CRO Group and 9% percent of patients in the EDA Group had 6-months postoperatively a NRS 4–6. Neither in the CRO Group nor in the EDA Group we could detect a neuropathic pain 6 months postoperatively corresponding to a painDETECT score?>?18. Overall, with regard to NRS, there was no statistical difference between the two groups (p?=?0.13). 90% percent of patients in the CRO Group and 90% percent of patients in the EDA Group showed 6-months postoperatively a painDETECT score?13 (definitely no neuropathic pain), and 9% percent in the EDA Group and 11% in the CRO Group had a 6-months painDETECt score 13–18 (p?=?not significant). Conclusion These pilot data indicate that epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy.
BACKGROUND: To assess prospectively the incidence of chronic and neuropathic pain in patients undergoing anteroaxillary thoracotomy with postoperative epidural analgesia or controlled-release oxycodone pain regimen. METHODS: 77 patients who underwent anteroaxillary thoracotomy were enrolled in our observational study. 40 patients received postoperatively a standardized oral analgesic protocol with controlled-release oxycodone and IV non opioid (CRO Group), and 37 patients received epidural analgesia with ropivacaine 0.1% + 1 mug/ml sufentanil (EDA Group) and IV non opioid. The painDETECT questionnaire was completed from the patients with one of the authors (JL) on the 7th postoperative day and six months postoperatively. RESULTS: The data of 60 patients were eligible for statistical analysis, 28 patients in the CRO Group and 32 patients in the EDA Group. 17 patients did not reach the 6-months follow-up interval (12 drop outs in the CRO Group and 5 drop outs in the EDA Group).79% percent of patients in the CRO Group and 74% percent of patients in the EDA Group had a numeric rating scale score (NRS) = 0 after 6 months. 22% percent of patients in the CRO Group and 16% percent of patients in the EDA Group experienced a NRS 1--3 6-months postoperatively. No patient in the CRO Group and 9% percent of patients in the EDA Group had 6-months postoperatively a NRS 4--6. Neither in the CRO Group nor in the EDA Group we could detect a neuropathic pain 6 months postoperatively corresponding to a painDETECT score > 18. Overall, with regard to NRS, there was no statistical difference between the two groups (p = 0.13). 90% percent of patients in the CRO Group and 90% percent of patients in the EDA Group showed 6-months postoperatively a painDETECT score < 13 (definitely no neuropathic pain), and 9% percent in the EDA Group and 11% in the CRO Group had a 6-months painDETECt score 13--18 (p = not significant). CONCLUSION: These pilot data indicate that epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy. PMID:23668669
Kampe, Sandra; Lohmer, Joachim; Weinreich, Gerhard; Hahn, Moritz; Stamatis, Georgios; Welter, Stefan
\\u000a \\u000a \\u000a This study was carried out from 1986 to 1996 to evaluate the technique of translaminal epidural endoscopic discectomy in lumbar\\u000a hernias occupying over 50% of the radicular canal, foraminal hernias, and hernias invading it entirely. This minimally invasive\\u000a arthroscopic technique was applied in patients suffering from degenerative lumbar stenosis between L3 and S1. The first part\\u000a of the study
D. J. De Antoni; M. L. Claro
Objective We investigated longitudinal risk factors of hospitalization for circulatory and pulmonary diseases among veterans with chronic spinal cord injury (SCI). Circulatory and respiratory system illnesses are leading causes of death in chronic SCI patients, yet risk factors for related hospitalizations have not been characterized. Design Prospective cohort study. Setting Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts. Participants / Data Source(s) 309 veterans ? 1 year post-SCI from the VA-Boston Chronic SCI cohort who completed a health questionnaire and underwent spirometry at study entry. Baseline data was linked to 1996–2003 hospitalization records from the VA National Patient Care Database. Interventions Not applicable. Main Outcome Measure(s) Cardiopulmonary hospital admissions, the predictors of which were assessed by Multivariate Cox regression. Results Of 1,478 admissions observed, 143 were due to cardiopulmonary (77 circulatory and 66 respiratory) illnesses. Independent predictors were greater age (3% increase /year), hypertension, and if in the lowest BMI quintile (<22.4 kg/m2). A greater %-predicted FEV1 was associated with reduced risk. SCI level and completeness of injury was not statistically significant after adjusting for these risk factors. Conclusion Cardiopulmonary hospitalization risk in persons with chronic SCI is related to greater age and medical factors that, if recognized, may result in strategies for reducing future hospitalizations.
Waddimba, Anthony C.; Jain, Nitin; Stolzmann, Kelly; Gagnon, David R.; Burgess, James F.; Kazis, Lewis E.; Garshick, Eric
Background While chronic neck pain is a common problem in the adult population, with a typical 12-month prevalence of 30%–50%, there is a lack of consensus regarding its causes and treatment. Despite limited evidence, cervical epidural injections are one of the commonly performed nonsurgical interventions in the management of chronic neck pain. Methods A randomized, double-blind, active, controlled trial was conducted to evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of chronic neck pain with or without upper extremity pain in patients without disc herniation, radiculitis, or facet joint pain. Results One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain by means of controlled diagnostic medial branch blocks were randomly assigned to one of two treatment groups, ie, injection of local anesthetic only (group 1) or local anesthetic mixed with nonparticulate betamethasone (group 2). The primary outcome of significant pain relief and improvement in functional status (?50%) was demonstrated in 72% of group 1 and 68% of group 2. The overall average number of procedures per year was 3.6 in both groups with an average total relief per year of 37–39 weeks in the successful group over a period of 52 weeks. Conclusion Cervical interlaminar epidural injections of local anesthetic with or without steroids may be effective in patients with chronic function-limiting discogenic or axial pain.
Manchikanti, Laxmaiah; Cash, Kimberly A; Pampati, Vidyasagar; Malla, Yogesh
Spinal reflexes are modified by spinal cord injury (SCI) due the loss of excitatory inputs from supraspinal structures and changes within the spinal cord. The stretch reflex is one of the simplest pathways of the central nervous system and was used presently to evaluate how inputs from primary and secondary muscle spindles interact with spinal circuits before and after spinal transection (i.e., spinalization) in 12 adult decerebrate cats. Seven cats were spinalized and allowed to recover for 1 mo (i.e., chronic spinal state), whereas 5 cats were evaluated before (i.e., intact state) and after acute spinalization (i.e., acute spinal state). Stretch reflexes were evoked by stretching the left triceps surae (TS) muscles. The force evoked by TS muscles was recorded along with the activity of several hindlimb muscles. Stretch reflexes were abolished in the acute spinal state due to an inability to activate TS muscles, such as soleus (Sol) and lateral gastrocnemius (LG). In chronic spinal cats, reflex force had partly recovered but Sol and LG activity remained considerably depressed, despite the fact that injecting clonidine could recruit these muscles during locomotor-like activity. In contrast, other muscles not recruited in the intact state, most notably semitendinosus and sartorius, were strongly activated by stretching TS muscles in chronic spinal cats. Therefore, stretch reflex pathways from TS muscles to multiple hindlimb muscles undergo functional reorganization following spinalization, both acute and chronic. Altered activation patterns by stretch reflex pathways could explain some sensorimotor deficits observed during locomotion and postural corrections after SCI.
Johnson, Michael D.; Heckman, C. J.
Without intervention after spinal cord injury (SCI), paralyzed skeletal muscles undergo myofiber atrophy and slow-to-fast myofiber type transformations. We hypothesized that chronic spasticity-associated neuromuscular activity after SCI would promote recovery from such deleterious changes. We examined segmental tail muscles of chronic spinal rats with long-standing tail spasticity (7 mo after sacral spinal cord transection; older chronic spinals), chronic spinal rats that experienced less spasticity early after injury (young chronic spinals), and rats without spasticity after transection and bilateral deafferentation (spinal isolated). These were compared with tail muscles of age-matched normal rats. Using immunohistochemistry, we observed myofiber distributions of 15.9 +/- 3.5% type I, 18.7 +/- 10.7% type IIA, 60.8 +/- 12.6% type IID(X), and 2.3 +/- 1.3% type IIB (means +/- SD) in young normals, which were not different in older normals. Young chronic spinals demonstrated transformations toward faster myofiber types with decreased type I and increased type IID(X) paralleled by atrophy of all myofiber types compared with young normals. Spinal isolated rats also demonstrated decreased type I myofiber proportions and increased type II myofiber proportions, and severe myofiber atrophy. After 4 mo of complete spasticity (older chronic spinals), myofiber type transformations were reversed, with no significant differences in type I, IIA, IID(X), or IIB proportions compared with age-matched normals. Moreover, after this prolonged spasticity, type I, IIA, and IIB myofibers recovered from atrophy, and type IID(X) myofibers partially recovered. Our results indicate that early after transection or after long-term spinal isolation, relatively inactive tail myofibers atrophy and transform toward faster myofiber types. However, long-term spasticity apparently produces neuromuscular activity that promotes recovery of myofiber types and myofiber sizes. PMID:17122320
Harris, R Luke W; Putman, Charles T; Rank, Michelle; Sanelli, Leo; Bennett, David J
An epidural catheter must be placed in epidural space correctly to give sufficient epidural anesthesia for patients. Recently, as a technique to confirm the catheter placement, electrical stimulation of epidural nerve using an inserted epidural catheter was introduced. This study was conducted to evaluate the reliability of this simple technique in 13 patients. Immediately after an epidural catheter (19 G Arrow Flextip Plus) was placed, an adapter with electrode (Arrow-Johans ECG Adapter) was attached to its connector and nerve stimulation was performed using a peripheral nerve stimulator (1 Hz, 10 mA). Catheter placement was judged to be correct by both presence of muscle contraction in response to stimulation and occurrence of analgesia after the administration of a local anesthetic. In 5 patients, additional roentgen examinations were performed to identify the positions of catheters. In all patients except one, muscle contraction was observed by stimulation, and analgesia was confirmed in all patients after the injection of an anesthetic. X-ray examinations revealed that the tip of catheter placed at the vertebral level corresponded with the spinal segmental level where muscle movement occurred. Our study demonstrates that nerve stimulation can be a reliable method to confirm epidural catheter placement. Our results also suggest that the position of catheter tip can be estimated easily using this technique. PMID:11995348
Ozawa, Takehisa; Kaneko, Hideki; Nomura, Takeshi; Asano, Makoto
Epidural adhesiolysis with spinal en- doscopy is an emerging interventional pain management technique in managing chron- ic refractory low back and lower extremity pain. However, there is a lack of significant data demonstrating the effectiveness of spi- nal endoscopic adhesiolysis. This randomized, double-blind con- trolled trial was undertaken to determine the ability of spinal endoscopic adhesiolysis to reduce pain and
Laxmaiah Manchikanti; Jose J. Rivera; Vidyasagar Pampati; Kim S. Damron; Carla D. Beyer; Doris E. Brandon; Sue R. Wilson
Objective To assess factors associated with breathlessness in chronic spinal cord injury (SCI) during daily activities. Design Cross-sectional survey. Settings Veterans Affairs SCI service and the community. Participants Four hundred forty-one participants 1 or more years post-SCI, and without acute illness, were recruited between 1994 and 2003 and were categorized according to their ability to walk unassisted, walk with an aid, or to move about by either hand-propelled wheelchair or motorized wheelchair (MWC). Interventions Assessment of injury extent, respiratory symptoms, cigarette smoking, comorbid medical conditions, and spirometry. Main Outcome Measures Breathlessness during talking, eating, or dressing. Results Breathlessness was more common in MWC users (20/85 users, 24%) than in nonusers (20/356, 6%). The main activity associated with breathlessness in 15 MWC users was talking (18%). In MWC users, the risk of breathlessness was related to lifetime cigarette smoking (odds ratio [OR]=1.02; 95% confidence interval [CI], 1.00–1.03 per pack year), and reports of chronic cough (OR=7.8; 95% CI, 2.0–32.7), and wheeze (OR=3.5; 95% CI, 1.04–13.6). SCI level, percentage of predicted forced vital capacity and forced expiratory volume in 1 second, and maximal inspiratory pressures were not related to breathlessness. Conclusions Breathlessness during selected daily activities (most commonly talking) was greatest in SCI participants who were most impaired with regard to mobility and was associated with reports of coughing, wheezing, and cigarette smoking.
Grandas, Noel F.; Jain, Nitin B.; Denckla, Joan B.; Brown, Robert; Tun, Carlos G.; Gallagher, Mary Ellen; Garshick, Eric
BACKGROUND: Facet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice. METHODS: Five hundred consecutive patients with chronic, non-specific spine pain were evaluated. The
Laxmaiah Manchikanti; Mark V Boswell; Vijay Singh; Vidyasagar Pampati; Kim S Damron; Carla D Beyer
Patients with chronic pain after whiplash injury and fibromyalgia patients display exaggerated pain after sensory stimulation. Because evident tissue damage is usually lacking, this exaggerated pain perception could be explained by hyperexcitability of the central nervous system. The nociceptive withdrawal reflex (a spinal reflex) may be used to study the excitability state of spinal cord neurons. We tested the hypothesis
Borut Banic; Steen Petersen-Felix; Ole K. Andersen; Bogdan P. Radanov; P. M. Villiger; Lars Arendt-Nielsen; Michele Curatolo
Spinal infections can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, epidural infections, meningitis, polyradiculopathy and myelitis. Radiological evaluations have gained importance in the diagnosis, treatment planning, treatment and treatment monitoring of the spinal infections. Conventional radiographs are usually the initial imaging study. The sensitivity and specificity of the plain radiographs are very
E. Turgut Tali
Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V, Hornby TG. Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: a multicenter trial. Arch Phys Med Rehabil 2005; 86:672–80.
Markus Wirz; David H. Zemon; Ruediger Rupp; Anke Scheel; Gery Colombo; Volker Dietz; T. George Hornby
Objective To characterize determinants of lung volumes in chronic spinal cord injury (SCI). Design Cross-sectional. Setting VA Boston Healthcare System. Participants White men (N=330) with chronic SCI. Interventions Not applicable. Main Outcome Measures Questionnaire responses and measurements of lung volumes. Results Adjusted for SCI severity and stature, greater body mass index (BMI) was associated (all P<.05) with lower total lung capacity (TLC) (?38.7mL·kg?1·m2), functional residual capacity (FRC) (?73.9mL·kg?1·m2), residual volume (RV) (?40.4mL·kg?1·m2), and expiratory reserve volume (ERV) (?32.2mL·kg?1·m2). The effect of BMI on RV was most pronounced in quadriplegia (?72mL·kg?1·m2). Lifetime smoking was associated with a greater FRC (5.3mL/pack a year) and RV (3.1mL/pack a year). The effects of lifetime smoking were also greatest in quadriplegia (11mL/pack a year for FRC; 7.8mL/pack a year for RV). Time since injury, independent of age, was associated with a decrease in TLC, FRC, ERV, and RV (P<.05). Age was not a predictor of TLC once time since injury was considered. Conclusions Determinants of FRC, TLC, ERV, and RV in chronic SCI include factors related and unrelated to SCI. The mechanisms remain to be determined but likely involve the elastic properties and muscle function of the respiratory system and perhaps the effects of systemic inflammation related to adiposity. Addressing modifiable factors such as obesity, muscle stiffness, and smoking may improve respiratory morbidity and mortality in SCI by improving pulmonary function.
Stepp, Evan L.; Brown, Robert; Tun, Carlos G.; Gagnon, David R.; Jain, Nitin B.; Garshick, Eric
Extramedullary hematopoiesis (EMH) is a compensatory mechanism occurring in patients with chronic anemia, which occurs most frequently with thalassemia. The authors report the case of a 57-year-old man, with no history of clinical or hematological disease, presenting with spinal cord compression. Magnetic resonance (MR) imaging demonstrated a homogeneous posterior epidural mass extending from T-3 to T-6. Following decompressive surgery, the patient's symptoms improved. Histological analysis showed features consistent with a diagnosis of EMH. Subsequent workup was remarkable for an asymptomatic spherocytosis without anemia. There was no family history of anemia. An EMH-related presentation of mild spherocytosis has been described in the literature, but its epidural location led to spinal cord compression. The MR imaging features were suggestive of EMH, but in the presence of spinal cord compression and in the absence of a history of chronic anemia, the authors did not believe that nonsurgical management would have been reasonable. PMID:15871492
Jalbert, Florian; Chaynes, Patrick; Lagarrigue, Jacques
Understanding and treatment of spinal cord pathology is limited in part by a lack of longitudinal in vivo imaging strategies at the cellular level. We developed a chronically implanted spinal chamber and surgical procedure suitable for time-lapse in vivo multiphoton microscopy of mouse spinal cord without the need for repeat surgical procedures. Repeated imaging was routinely achieved for more than five weeks post-operatively with up to ten separate imaging sessions. We observed neither motor function deficit nor neuropathology in the spinal cord as a result of chamber implantation. Using this chamber we quantified microglia and afferent axon dynamics following a laser-induced spinal cord lesion and observed massive microglia infiltration within one day along with a heterogeneous dieback of axon stumps. By enabling chronic imaging studies over timescales ranging from minutes to months, our method offers an ideal platform for understanding cellular dynamics in response to injury and therapeutic interventions.
Farrar, Matthew J.; Bernstein, Ida M.; Schlafer, Donald H.; Cleland, Thomas A.; Fetcho, Joseph R.; Schaffer, Chris B.
The spinal cord is the target of many neurosurgical procedures used to treat pain. Compactness and well-defined tract separation in addition to well understood dermatomal cord organization make the spinal cord an ideal target for pain procedures. Moreover, the presence of opioid and other receptors involved in pain modulation at the level of the dorsal horn increases the suitability of the spinal cord. Neuromodulative approaches of the spinal cord are either electrical or pharmacological. Electrical spinal cord modulation is used on a large scale for various pain syndromes including; failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), neuropathic pain, angina, and ischemic limb pain. Intraspinal delivery of medications e.g. opioids is used to treat nociceptive and neuropathic pains due to malignant and cancer pain etiologies. Neuroablation of the spinal cord pain pathway is mainly used to treat cancer pain. Targets involved include; the spinothalamic tract, the midline dorsal column visceral pain pathway and the trigeminal tract in the upper spinal cord. Spinal neuroablation can also involve cellular elements such as with trigeminal nucleotomy and the dorsal root entry zone (DREZ) operation. The DREZ operation is indicated for phantom type pain and root avulsion injuries. Due to its reversible nature spinal neuromodulation prevails, and spinal neuroablation is performed in a few select cases. PMID:17691354
Raslan, A M; McCartney, S; Burchiel, K J
Inflammation is a major factor shaping outcome during the early, acute phase of traumatic spinal cord injury (SCI). It is known that pro-inflammatory signaling within the injured spinal cord drives pathological alterations in neurosensory processing and shapes functional outcome early after injury. However, it is unclear whether inflammation persists into the chronic phase of injury or shapes sensory processing long after injury. To investigate these possibilities, we have performed biochemical and behavioral assessments 9 months after moderate thoracic spinal contusion injury in the rat. We have found that levels of the pro-inflammatory lipid mediators leukotriene B4 and prostaglandin E2 are elevated in the chronic spinal cord lesion site. Additionally, using metabolomic profiling, we have detected elevated levels of pro-oxidative and inflammatory metabolites, along with alterations in multiple biological pathways within the chronic lesion site. We found that 28 d treatment of chronically injured rats with the dual COX/5-LOX inhibitor licofelone elevated levels of endogenous anti-oxidant and anti-inflammatory metabolites within the lesion site. Furthermore, licofelone treatment reduced hypersensitivity of hindpaws to mechanical, but not thermal, stimulation, indicating that mechanical sensitivity is modulated by pro-inflammatory signaling in the chronic phase of injury. Together, these findings provide novel evidence of inflammation and oxidative stress within spinal cord tissue far into the chronic phase of SCI, and demonstrate a role for inflammatory modulation of mechanical sensitivity in the chronic phase of injury. PMID:23303944
Dulin, Jennifer N; Karoly, Edward D; Wang, Ying; Strobel, Henry W; Grill, Raymond J
We report the case of a 37-year-old postpartum patient who developed a contained subacute spinal subdural hematoma causing mass effect on the cauda equina and severe spinal stenosis after undergoing an epidural blood patch for postdural puncture headache. Recovery occurred following administration of oral steroids. PMID:22317890
Verduzco, L A; Atlas, S W; Riley, E T
Editors' prefaceThe management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions
Michael J. DePalma; Curtis W. Slipman
The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to chronic low back pain, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP. PMID:18164453
DePalma, Michael J; Slipman, Curtis W
Recent reports showed that aquaporin 4 (AQP4) deficiency potentiated morphine analgesia but attenuated chronic morphine-induced tolerance in hot-plate test, predominantly reflecting supraspinal pain response. The present study investigated the effects of AQP4 deficiency on morphine analgesia and tolerance using tail flick test, primarily reflecting spinal response. It was found that (1) chronic morphine treatment resulted in decreased expression of spinal AQP4 in mice detected by Western blotting analysis; (2) in tail flick test, AQP4 knockout mice displayed significant impaired morphine analgesia without influencing the progress of chronic tolerance; and (3) the expressions of mu-opioid receptor (MuOR) and glutamate transporter 1 (GLT-1) in AQP4 knockout mice spinal cord were lower than those in wild-type mice, whereas chronic morphine-induced alteration characteristics of spinal MuOR or GLT-1 expression were not affected by AQP4 deficiency. In conclusion, AQP4 deficiency attenuated morphine acute antinociception but did not affect chronic tolerance in tail flick test, implying a role for spinal AQP4 in morphine analgesia but not in chronic tolerance. PMID:20387009
Chen, Meng-Ling; Bao, Feng; Zhang, Yu-Qiu; Zhao, Zhi-Qi
Structural equation modeling was used to examine the relationships between selected psychological variables and pain perceptions in 103 individuals experiencing chronic pain following traumatic spinal cord injury (SCI). Previous studies have suggested strong relationships between psychological variables and chronic SCI pain, but further delineation of such relationships is needed in order ultimately to develop more effective pain management strategies for
Lisa L. Conant
Cervical spinal cord injury (SCI) dramatically disrupts synaptic inputs and triggers biochemical, as well as morphological, plasticity in relation to the phrenic motor neuron (PhMN) pool. Accordingly, our primary purpose was to determine if chronic SCI induces fundamental changes in the recruitment profile and discharge patterns of PhMNs. Individual PhMN action potentials were recorded from the phrenic nerve ipsilateral to lateral cervical (C2) hemisection injury (C2Hx) in anesthetized adult male rats at 2, 4 or 8wks post-injury and in uninjured controls. PhMNs were phenotypically classified as early (Early-I) or late inspiratory (Late-I), or silent according to discharge patterns. Following C2Hx, the distribution of PhMNs was dominated by Late-I and silent cells. Late-I burst parameters (e.g., spikes per breath, burst frequency and duration) were initially reduced but returned towards control values by 8wks post-injury. In addition, a unique PhMN burst pattern emerged after C2Hx in which Early-I cells burst tonically during hypocapnic inspiratory apnea. We also quantified the impact of gradual reductions in end-tidal CO2 partial pressure (PETCO2) on bilateral phrenic nerve activity. Compared to control rats, as PETCO2 declined, the C2Hx animals had greater inspiratory frequencies (breaths?min(-1)) and more substantial decreases in ipsilateral phrenic burst amplitude. We conclude that the primary physiological impact of C2Hx on ipsilateral PhMN burst patterns is a persistent delay in burst onset, transient reductions in burst frequency, and the emergence of tonic burst patterns. The inspiratory frequency data suggest that plasticity in brainstem networks is likely to play an important role in phrenic motor output after cervical SCI. PMID:23954215
Lee, Kun-Ze; Dougherty, Brendan J; Sandhu, Milapjit S; Lane, Michael A; Reier, Paul J; Fuller, David D
Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.
Pusat, Serhat; Kural, Cahit; Aslanoglu, Atilla; Kurt, Bulent
Neuraxial anesthesia is a term that denotes all forms of central blocks, involving the spinal, epidural, and caudal spaces. Epidural anesthesia is a versatile technique widely used in anesthetic practice. Its potential to decrease postoperative morbidity and mortality has been demonstrated by numerous studies. To maximize its perioperative benefits while minimizing potential adverse outcomes, the knowledge of factors affecting successful block placement is essential. This paper will provide an overview of the pertinent anatomical, pharmacological, immunological, and technical aspects of epidural anesthesia in both adult and pediatric populations and will discuss the recent advances, the related rare but potentially devastating complications, and the current recommendations for the use of anticoagulants in the setting of neuraxial block placement.
Bauer, Maria; George, John E.; Seif, John; Farag, Ehab
Neuraxial anesthesia is a term that denotes all forms of central blocks, involving the spinal, epidural, and caudal spaces. Epidural anesthesia is a versatile technique widely used in anesthetic practice. Its potential to decrease postoperative morbidity and mortality has been demonstrated by numerous studies. To maximize its perioperative benefits while minimizing potential adverse outcomes, the knowledge of factors affecting successful block placement is essential. This paper will provide an overview of the pertinent anatomical, pharmacological, immunological, and technical aspects of epidural anesthesia in both adult and pediatric populations and will discuss the recent advances, the related rare but potentially devastating complications, and the current recommendations for the use of anticoagulants in the setting of neuraxial block placement. PMID:22174708
Bauer, Maria; George, John E; Seif, John; Farag, Ehab
The role of capsaicin-sensitive bladder afferents in micturition was studied in unanesthetized chronic spinal rats. Reflex voiding in response to tactile stimulation of the perigenital region appeared 5–9 days after spinal cord injury (SCI) whereas voiding induced by bladder distension occurred 2–3 weeks after SCI. The frequency and amplitude of reflex bladder contractions recorded under isovolumetric conditions were similar in
Chen-Li Cheng; Cheng-Ping Ma; William C. de Groat
Background Bacteria in the Streptococcus milleri group (S. anginosus, S. constellatus, and S. intermedius) are associated with bacteremia and abscess formation. While most reports of Streptococcus milleri group (SMG) infection occur in patients with underlying medical conditions, SMG infections during pregnancy have been documented. However, SMG infections in pregnant women are associated with either neonatal or maternal puerperal sepsis. Albeit rare, S. milleri spinal-epidural abscess in pregnancy has been reported, always as a complication of spinal-epidural anesthesia. We report a case of spinal-epidural abscess caused by SMG in a young, pregnant woman without an antecedent history of spinal epidural anesthesia and without any underlying risk factors for invasive streptococcal disease. Case presentation A 25 year old pregnant woman developed neurological symptoms consistent with spinal cord compression at 20 weeks gestation. She underwent emergency laminectomy for decompression and was treated with ceftriaxone 2 gm IV daily for 28 days. She was ambulatory at the time of discharge from the inpatient rehabilitation unit with residual lower extremity weakness. Conclusion To our knowledge, this is the first reported case of a Streptococcus milleri epidural abscess in a healthy, pregnant woman with no history of epidural anesthesia or invasive procedures. This report adds to the body of literature on SMG invasive infections. Treatment of SMG spinal-epidural abscess with neurologic manifestations should include prompt and aggressive surgical decompression coupled with targeted anti-infective therapy.
Lampen, Russell; Bearman, Gonzalo
Patients with chronic pain after whiplash injury and fibromyalgia patients display exaggerated pain after sensory stimulation. Because evident tissue damage is usually lacking, this exaggerated pain perception could be explained by hyperexcitability of the central nervous system. The nociceptive withdrawal reflex (a spinal reflex) may be used to study the excitability state of spinal cord neurons. We tested the hypothesis that patients with chronic whiplash pain and fibromyalgia display facilitated withdrawal reflex and therefore spinal cord hypersensitivity. Three groups were studied: whiplash (n=27), fibromyalgia (n=22) and healthy controls (n=29). Two types of transcutaneous electrical stimulation of the sural nerve were applied: single stimulus and five repeated stimuli at 2 Hz. Electromyography was recorded from the biceps femoris muscle. The main outcome measurement was the minimum current intensity eliciting a spinal reflex (reflex threshold). Reflex thresholds were significantly lower in the whiplash compared with the control group, after both single (P=0.024) and repeated (P=0.035) stimulation. The same was observed for the fibromyalgia group, after both stimulation modalities (P=0.001 and 0.046, respectively). We provide evidence for spinal cord hyperexcitability in patients with chronic pain after whiplash injury and in fibromyalgia patients. This can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain, at least in part, pain in the absence of detectable tissue damage. PMID:14715383
Banic, Borut; Petersen-Felix, Steen; Andersen, Ole K; Radanov, Bogdan P; Villiger, P M; Arendt-Nielsen, Lars; Curatolo, Michele
Chronic Spinal Nerve Ligation Induces Changes in Response Characteristics of Nociceptive Spinal Dorsal Horn Neurons and in Their Descending Regulation Originating in the Periaqueductal Gray in the Rat
We studied whether a chronic neuropathy induced by unilateral spinal nerve ligation changes the response characteristics of spinal dorsal horn wide-dynamic range (WDR) neurons or their periaqueductal gray (PAG)-induced descending modulation. Experiments were performed in rats with behaviorally demonstrated allodynia induced by spinal nerve ligation and in a group of nonneuropathic control rats. The stimulus–response functions of WDR neurons for
Antti Pertovaara; Vesa K. Kontinen; Eija A. Kalso
Not all spinal contusions result in mechanical allodynia, in which non-noxious stimuli become noxious. The studies presented use the NYU impactor at 12.5 mm drop or the Infinite Horizons Impactor (150 kdyn, 1 s dwell) devices to model spinal cord injury (SCI). Both of these devices and injury parameters, if done correctly, will result in animals with above level (forelimb), at level (trunk)
Claire E. Hulsebosch; Bryan C. Hains; Eric D. Crown; Susan M. Carlton
The spinal cord is the target of many neurosurgical procedures used to treat pain. Compactness and well-defined tract separation\\u000a in addition to well understood dermatomal cord organization make the spinal cord an ideal target for pain procedures. Moreover,\\u000a the presence of opioid and other receptors involved in pain modulation at the level of the dorsal horn increases the suitability\\u000a of
Ahmed M. Raslan; S. McCartney; K. J. Burchiel
The extent to which epidurally administered sufen- tanil acts directly on spinal opioid receptors remains controversial. We tested the hypothesis that small- dose boluses of sufentanil, given epidurally or IV, provide comparable analgesia at similar plasma sufentanil concentrations. The lipophilicity of sufen- tanil makes it likely to be absorbed into fat surround- ing the epidural space. We therefore also tested
Christophe Menigaux; Bruno Guignard; Dominique Fletcher; Daniel I. Sessler; Jean-Claude Levron; Marcel Chauvin
The effect of spinal cord injury (SCI) on the expression levels and distribution of water channel aquaporin 4 (AQP4) has not been studied. We have found AQP4 in gray and white matter astrocytes in both uninjured and injured rat spinal cords. AQP4 was detected in astrocytic processes that were tightly surrounding neurons and blood vessels, but more robustly in glia limitans externa and interna, which were forming an interface between spinal cord parenchyma and cerebrospinal fluid (CSF). Such spatial distribution of AQP4 suggests a critical role that astrocytes expressing AQP4 play in the transport of water from blood/CSF to spinal cord parenchyma and vice versa. SCI induced biphasic changes in astrocytic AQP4 levels, including its early down-regulation and subsequent persistent up-regulation. However, changes in AQP4 expression did not correlate well with the onset and magnitude of astrocytic activation, when measured as changes in GFAP expression levels. It appears that reactive astrocytes began expressing increased levels of AQP4 after migrating to the wound area (thoracic region) two weeks after SCI, and AQP4 remained significantly elevated for months after SCI. We also showed that increased levels of AQP4 spread away from the lesion site to cervical and lumbar segments, but only in chronically injured spinal cords. Although overall AQP4 expression levels increased in chronically-injured spinal cords, AQP4 immunolabeling in astrocytic processes forming glia limitans externa was decreased, which may indicate impaired water transport through glia limitans externa. Finally, we also showed that SCI-induced changes in AQP4 protein levels correlate, both temporally and spatially, with persistent increases in water content in acutely and chronically injured spinal cords. Although correlative, this finding suggests a possible link between AQP4 and impaired water transport/edema/syringomyelia in contused spinal cords.
Nesic, Olivera; Lee, Julieann; Ye, Zaiming; Unabia, Geda C.; Rafati, Danny; Hulsebosch, Claire E.; Perez-Polo, J. Regino
Summary Osteoporosis is a well acknowledged complication of spinal cord injury. We report that motor complete spinal cord injury and\\u000a post-injury alcohol consumption are risk factors for hospitalization for fracture treatment. The clinical assessment did not\\u000a include osteoporosis diagnosis and treatment considerations, indicating a need for improved clinical protocols.\\u000a \\u000a \\u000a \\u000a Introduction Treatment of osteoporotic long bone fractures often results in lengthy hospitalizations for
L. R. Morse; R. A. Battaglino; K. L. Stolzmann; L. D. Hallett; A. Waddimba; D. Gagnon; A. A. Lazzari; E. Garshick
Background and Purpose. Locomotor training (LT) enhances walking in adult experimental animals and humans with mild-to-moderate spinal cord injuries (SCIs). The animal literature suggests that the effects of LT may be greater on an immature nervous system than on a mature nervous system. The purpose of this study was to evaluate the effects of LT in a child with chronic,
Andrea L Behrman; Preeti M Nair; Mark G Bowden; Robert C Dauser; Benjamin R Herget; Jennifer B Martin; Chetan P Phadke; Paul J Reier; Claudia R Senesac; Floyd J Thompson; Dena R Howland
A total of 50 patients with chronic pain syndromes were selected for treatment with spinal cord stimulation. Correct positioning of electrodes was obtained in 44 patients, leading to an initial alleviation of pain in 25 patients. In 6 patients, electrodes (though still effective in 4) had to be removed because of surgical complications within the first 5 months of use.
H. P. Vogel; B. Heppner; N. Hümbs; J. Schramm; C. Wagner
OBJECTIVESThis prospective study was designed to assess the effects of omental transpostion in patients with a chronic spinal injury.METHODSNeurological status was established to be stable and multiple baseline across patient studies were done preoperatively and repeated postoperatively. Assessments included activities of daily living (ADL), functional ability, degree of spasticity, motor power, sensation, pain perception, urodynamic studies, electromyography, sensory evoked potentials
J Duffill; J Buckley; D Lang; G Neil-Dwyer; F McGinn; D Wade
Objective: To determine the expected vital capacity in persons with chronic spinal cord injury (SCI) in relation to injury level, completeness of injury, smoking and duration of injury, as an aid to diagnosis and management of respiratory complications.Setting: A New York City veterans' hospital and a Los Angeles public rehabilitation hospital.Methods: Case series from the two hospitals were pooled. Participants
WS Linn; AM Spungen; RH Adkins; A Bauman; RL Waters
Objective: To determine whether pulmonary function, respiratory muscle strength, and dyspnea can be improved in individuals with chronic cervical spinal cord injury (SCI).Study Design: Ten subjects participated in an 8-week resistive inspiratory muscle training (IMT) program for 15 minutes twice daily. Spirometry, lung volumes, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), and dyspnea were measured at baseline, week 4,
Alyssa Rutchik; Ann R. Weissman; Peter L. Almenoff; Ann M. Spungen; William A. Bauman; David R. Grimm
AimSpinal cord stimulation (SCS) has been shown effective as a therapy for different chronic painful conditions, but the effectiveness of this treatment for pain as a result of peripheral diabetic neuropathy is not well established. The primary objectives of this study were to evaluate the effect and safety of SCS for treatment of pain and the effects on microcirculatory blood
Cecile C. de Vos; Vinayakrishnan Rajan; Wiendelt Steenbergen; Hans E. van der Aa; Hendrik P. J. Buschman
We are one-year into the three-years of our research program into the immunogenetic and drug exposure factors that contribute to chronic pain following spinal cord injury. Owing to the planned data collection timeline of the 2 studies in this program we h...
J. Clark J. Coller J. Middleton M. Hutchinson R. Marshall
Background Spinal cord stimulation is known to be a successful treatment for chronic intractable angina pectoris. Its effect may be anti-ischemic. It is uncertain if the clinical effect is partly caused by a placebo effect of surgery for implantation of a stimulator. In this study, clinical efficacy is investigated, together with a possible placebo effect. Methods and Results Efficacy of
Raymond W. M. Hautvast; Mike J. L. DeJongste; Michiel J. Staal; Wiek H. van Gilst; K. I. Lie
Spontaneous spinal epidural hematoma is an uncommon clinical entity. Patients with this disease may present with devastating neurological deficits that can mimic other diseases. Emergency physicians should be familiar with this condition to assure appropriate therapy in a timely manner. A typical case of spontaneous spinal epidural hematoma is presented with review of appropriate differential diagnosis and management.
Scott David; Richard F Salluzzo; Joel M Bartfield; Edward T Dickinson
Summary Injury to the spinal cord is known to result in inflammation. To date, the preponderance of research has focused on the acute\\u000a neuroinflammatory response, which begins immediately and is believed to terminate within hours to (at most) days after the\\u000a injury. However, recent studies have demonstrated that postinjury inflammation is not restricted to the first few hours or\\u000a days after
Ahdeah Pajoohesh-Ganji; Kimberly R. Byrnes
Autonomic dysreflexia (AD), a potentially dangerous complication of high-level spinal cord injury (SCI) characterized by exaggerated activation of spinal autonomic (sympathetic) reflexes, can cause pulmonary embolism, stroke, and, in severe cases, death. People with high-level SCI also are immune compromised, rendering them more susceptible to infectious morbidity and mortality. The mechanisms underlying postinjury immune suppression are not known. Data presented herein indicate that AD causes immune suppression. Using in vivo telemetry, we show that AD develops spontaneously in SCI mice with the frequency of dysreflexic episodes increasing as a function of time postinjury. As the frequency of AD increases, there is a corresponding increase in splenic leucopenia and immune suppression. Experimental activation of spinal sympathetic reflexes in SCI mice (e.g., via colorectal distension) elicits AD and exacerbates immune suppression via a mechanism that involves aberrant accumulation of norepinephrine and glucocorticoids. Reversal of postinjury immune suppression in SCI mice can be achieved by pharmacological inhibition of receptors for norepinephrine and glucocorticoids during the onset and progression of AD. In a human subject with C5 SCI, stimulating the micturition reflex caused AD with exaggerated catecholamine release and impaired immune function, thus confirming the relevance of the mouse data. These data implicate AD as a cause of secondary immune deficiency after SCI and reveal novel therapeutic targets for overcoming infectious complications that arise due to deficits in immune function. PMID:23926252
Zhang, Yi; Guan, Zhen; Reader, Brenda; Shawler, Todd; Mandrekar-Colucci, Shweta; Huang, Kun; Weil, Zachary; Bratasz, Anna; Wells, Jonathan; Powell, Nicole D; Sheridan, John F; Whitacre, Caroline C; Rabchevsky, Alexander G; Nash, Mark S; Popovich, Phillip G
Diffusion tensor imaging (DTI) was performed on regions rostral to the injury site in four human subjects with chronic spinal cord injury (SCI) and equivalent regions in four neurologically intact subjects. Apparent diffusion coefficients were measured and compared between subjects. A fuzzy logic tissue classification algorithm was used to segment gray and white matter regions for morphometric analysis, including comparisons of cross-sectional areas of gray and white matter along with frontal and sagittal diameters. Results indicated a general decrease in both longitudinal and transverse diffusivity in the upper cervical segments of subjects with chronic SCI. Further, a decrease in the cross-sectional area of the entire spinal cord was observed in subjects with SCI, consistent with severe atrophy of the spinal cord. These observations have implications in tracking the progression of SCI from the acute to the chronic stages. We conclude that DTI with fuzzy logic tissue classification has potential for monitoring morphological changes in the spinal cord in people with SCI. PMID:18066663
Ellingson, Benjamin M; Ulmer, John L; Schmit, Brian D
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory disorder of the peripheral nervous system with progressive or relapsing signs in more than one limb, ending in prolonged periods of disability. There are no guidelines for anesthesia in this uncommon paralyzing disease. This report features a 19-year-old woman with CIDP scheduled for an elective cesarean section who had prolonged recovery of motor function after the administration of spinal anesthesia. Although a partial neural block in both feet persisted for 1 day, we conclude that spinal anesthesia is acceptable for cesarean delivery in CIDP-patients when reasonable precautions have been taken. PMID:22179599
Richter, Torsten; Langer, Karl-Anton; Koch, Thea
We report a case of spinal epidural lipomatosis (SEL) caused by ectopic Cushing's syndrome and give a review of the literature. The most common cause of SEL is prolonged therapy with glucocorticoids, only a very few cases are related to endogenous Cushing's syndrome. The pathophysiological mech- anism is not clear but there is a possible role for the autonomic nervous
Alexander G L Bodelier; Wim Groeneveld; Antonius N van der Linden; Harm R Haak
Peripheral nerve injury causes abnormal sensory processing, possibly due in part to neuroplastic changes in the CNS. Following chronic constriction injury of the sciatic nerve, transsynaptic degeneration is suggested by the presence of “dark neurons” found in superficial laminae of spinal cord. Previous studies in our laboratory have shown that grafts of adrenal medullary cells into the spinal subarachnoid space
Aldric T. Hama; George D. Pappas; Jacqueline Sagen
This prospective randomized controlled outcome study was designed to evaluate whether a MultiModal Cognitive—Behavioral Treatment for chronic spinal pain (MMCBT) specifically designed for women has an increased effect on well being and return to work compared to a regular MMCBT regimen. In Sweden, spinal pain is most prevalent among women. A tremendous amount of money is spent on secondary prevention
Irene B. Jensen; Catarina Dahlquist; Åke Nygren; Eva Royen; Monica Stenberg
BACKGROUND: Chronic spinal cord injury (SCI) can lead to an insidious decline in motor and sensory function in individuals even years after the initial injury and is accompanied by a slow and progressive cytoarchitectural destruction. At present, no pathological mechanisms satisfactorily explain the ongoing degeneration. METHODS: Adult female Sprague-Dawley rats were anesthetized laminectomized at T10 and received spinal cord contusion
Milan Radojicic; Gabriel Nistor; Hans S Keirstead
About 37 cases of non-traumatic spinal cord and cauda-equina compression, the authors emphasize the value of CT-scan study after intra-thecal injection of water-soluble contrast-medium. This exploration gives accurate informations about the involvement of both spinal and para-spinal spaces. These data are helpful diagnosis purpose and for the choice of therapeutic especially when surgical procedure is decided. PMID:3762833
Gaston, A; Djindjian, M; Nguyen, J P; Brugieres, P; Le Bras, F; Suppervielle, J L; Castrec-Carpo, A; Marsault, C
Summary Two of the most prevalent secondary complications following spinal cord injury (SCI), besides loss of function and\\/or sensation\\u000a below the level of injury, are uncontrolled muscle spasticity and hypertensive autonomic dysreflexia. Despite the desires\\u000a of the SCI community, there have been few advances in the treatment and\\/or management of these fundamental impediments to\\u000a the quality of life associated with chronic
Alexander G. Rabchevsky; Patrick H. Kitzman
THE childhood-onset spinal muscular atrophies (SMAs) describe a heterogeneous group of disorders that selectively affect the alpha motoneuron. We have shown that chronic childhood-onset SMA (SMA II and III) maps to a single locus on chromosome 5q (ref. 1). Acute SMA (SMA Type I\\/Werdnig-Hoffmann\\/severe\\/infantile) is the main cause of heritable infant mortality. Mapping the acute SMA locus by conventional methods
T. C. Gilliam; L. M. Brzustowicz; L. H. Castilla; T. Lehner; G. K. Penchaszadeh; R. J. Daniels; B. C. Byth; J. Knowles; J. E. Hislop; Y. Shapira; V. Dubowitz; T. L. Munsat; J. Ott; K. E. Davies
This paper reviews the clinical experience and proposed working mechanisms of spinal cord stimulation (SCS) in the treatment\\u000a of chronic critical limb ischemia (CCLI). SCS appears to provide a significant long-term relief of ischemic pain and to improve\\u000a healing of small ulcers, most likely due to effects on the nutritional skin blood flow. Despite these observations, randomized\\u000a trials were not
Luc G. Y. Claeys; W. Berg; S. Jonas
Diffusion tensor imaging (DTI) was performed on regions rostral to the injury site in four human subjects with chronic spinal\\u000a cord injury (SCI) and equivalent regions in four neurologically intact subjects. Apparent diffusion coefficients were measured\\u000a and compared between subjects. A fuzzy logic tissue classification algorithm was used to segment gray and white matter regions\\u000a for morphometric analysis, including comparisons
Benjamin M. Ellingson; John L. Ulmer; Brian D. Schmit
Spinal cord injured (SCI) persons often experience chronic pain. Methods of dealing with pain that the SCI client found helpful in the past may not be beneficial after the injury. This article describes a study of self-medication for the purpose of pain relief. Over-the-counter, prescription, or illicit drugs or alcohol are among the agents employed in self-medication. The rehabilitation nurse has a role in helping the SCI person to identify appropriate methods of managing chronic pain throughout life. PMID:1492160
Repeat computed tomography (CT) and clinical examinations, including psychologic tests, were performed in 15 chronic alcoholics. In nine controlled abstinent patients, marked decrease of cerebrospinal fluid space enlargement was visible on CT, corresponding with clinical improvement. A second CT examination after 1 year showed continued improvement in three successfully treated patients. The recovery of cortical and ventricular enlargements was encountered with equal frequency, although the more striking change was in the cortex. Possible underlying pathogenetic processes were considered. PMID:6784547
Artmann, H; Gall, M V; Hacker, H; Herrlich, J
A number of mechanisms have been elucidated that maintain neuropathic pain due to spinal cord injury (SCI). While target-based therapeutics are being developed based on elucidation of these mechanisms, treatment for neuropathic SCI pain has not been entirely satisfactory due in part to the significant convergence of neurological and inflammatory processes that maintain the neuropathic pain state. Thus, a combination drug treatment strategy, wherein several pain-related mechanism are simultaneously engaged, could be more efficacious than treatment against individual mechanisms alone. Also, by engaging several targets at once, it may be possible to reduce the doses of the individual drugs, thereby minimizing the potential for adverse side effects. Positive preclinical and clinical studies have demonstrated improved efficacy of combination drug treatment over single drug treatment in neuropathic pain of peripheral origin, and perhaps such combinations could be utilized for neuropathic SCI pain. At the same time, there are mechanisms that distinguish SCI from peripheral neuropathic pain, so novel combination therapies will be needed.
Hama, Aldric; Sagen, Jacqueline
Abstract The goal of the present study was to develop a porcine spinal cord injury (SCI) model, and to describe the neurological outcome and characterize the corresponding quantitative and qualitative histological changes at 4–9 months after injury. Adult Gottingen-Minnesota minipigs were anesthetized and placed in a spine immobilization frame. The exposed T12 spinal segment was compressed in a dorso-ventral direction using a 5-mm-diameter circular bar with a progressively increasing peak force (1.5, 2.0, or 2.5?kg) at a velocity of 3?cm/sec. During recovery, motor and sensory function were periodically monitored. After survival, the animals were perfusion fixed and the extent of local SCI was analyzed by (1) post-mortem MRI analysis of dissected spinal cords, (2) qualitative and quantitative analysis of axonal survival at the epicenter of injury, and (3) defining the presence of local inflammatory changes, astrocytosis, and schwannosis. Following 2.5-kg spinal cord compression the animals demonstrated a near complete loss of motor and sensory function with no recovery over the next 4–9 months. Those that underwent spinal cord compression with 2?kg force developed an incomplete injury with progressive partial neurological recovery characterized by a restricted ability to stand and walk. Animals injured with a spinal compression force of 1.5?kg showed near normal ambulation 10 days after injury. In fully paralyzed animals (2.5?kg), MRI analysis demonstrated a loss of spinal white matter integrity and extensive septal cavitations. A significant correlation between the magnitude of loss of small and medium-sized myelinated axons in the ventral funiculus and neurological deficits was identified. These data, demonstrating stable neurological deficits in severely injured animals, similarities of spinal pathology to humans, and relatively good post-injury tolerance of this strain of minipigs to spinal trauma, suggest that this model can successfully be used to study therapeutic interventions targeting both acute and chronic stages of SCI.
Navarro, Roman; Juhas, Stefan; Keshavarzi, Sassan; Juhasova, Jana; Motlik, Jan; Johe, Karl; Marsala, Silvia; Scadeng, Miriam; Lazar, Peter; Tomori, Zoltan; Schulteis, Gery; Beattie, Michael; Ciacci, Joseph D.
The brain stem provides most of the noradrenaline (NA) present in the spinal cord, which functions to both increase spinal motoneuron excitability and inhibit sensory afferent transmission to motoneurons (excitatory postsynaptic potentials; EPSPs). NA increases motoneuron excitability by facilitating calcium-mediated persistent inward currents (Ca PICs) that are crucial for sustained motoneuron firing. Spinal cord transection eliminates most NA and accordingly causes an immediate loss of PICs and emergence of exaggerated EPSPs. However, with time PICs recover, and thus the exaggerated EPSPs can then readily trigger these PICs, which in turn produce muscle spasms. Here we examined the contribution of adrenergic receptors to spasms in chronic spinal rats. Selective activation of the ?(1A) adrenergic receptor with the agonists methoxamine or A61603 facilitated Ca PIC and spasm activity, recorded both in vivo and in vitro. In contrast, the ?(2) receptor agonists clonidine and UK14303 did not facilitate Ca PICs, but did decrease the EPSPs that trigger spasms. Moreover, in the absence of agonists, spasms recorded in vivo were inhibited by the ?(1) receptor antagonists WB4010, prazosin, and REC15/2739, and increased by the ?(2) receptor antagonist RX821001, suggesting that both adrenergic receptors were endogenously active. In contrast, spasm activity recorded in the isolated in vitro cord was inhibited only by the ?(1) antagonists that block constitutive receptor activity (activity in the absence of NA; inverse agonists, WB4010 and prazosin) and not by the neutral antagonist REC15/2739, which only blocks conventional NA-mediated receptor activity. RX821001 had no effect in vitro even though it is an ?(2) receptor inverse agonist. Our results suggest that after chronic spinal cord injury Ca PICs and spasms are facilitated, in part, by constitutive activity in ?(1) adrenergic receptors. Additionally, peripherally derived NA (or similar ligand) activates both ?(1) and ?(2) adrenergic receptors, controlling PICs and EPSPs, respectively. PMID:21047936
Rank, M M; Murray, K C; Stephens, M J; D'Amico, J; Gorassini, M A; Bennett, D J
Background: This report describes a young woman with incomplete traumatic cervical spinal cord injury and intractable pruritus involving her dorsal forearm. Method: Case report. Findings: Anatomic distribution of the pruritus corresponded to the dermatomal distribution of her level of spinal cord injury and vertebral fusion. Symptoms were attributed to the spinal cord injury and possible cervical root injury. Pruritus was refractory to all treatments, including topical lidocaine, gabapentin, transcutaneous electrical nerve stimulation, intravenous Bier block, stellate ganglion block, and acupuncture. Conclusions: Further understanding of neuropathic pruritus is needed. Diagnostic workup of intractable pruritus should include advanced imaging to detect ongoing nerve root compression. If diagnostic studies suggest radiculopathy, epidural steroid injection should be considered. Because the autonomic nervous system may be involved in complex chronic pain or pruritic syndromes, sympatholysis via such techniques as stellate ganglion block might be effective.
Crane, Deborah A; Jaffee, Kenneth M; Kundu, Anjana
Objective To compare the nutritional intake of patients with acute and chronic spinal cord injury (SCI). Design Cross-sectional, observational study. Setting Spinal cord unit. Methods Twelve in-house patients of a spinal cord unit with acute SCI and paralysis duration of 5.3 ± 2.5 months (acute group) were compared with 12 subjects with chronic SCI (chronic group) with lesion duration of 55.5 ± 21.0 months. All subjects recorded their nutritional intake for 7 days, which was analyzed for intake of energy, proteins, fat, carbohydrates, vitamins, mineral nutrients, fluid, and dietary fiber. Resting energy expenditure (REE) and total body fat were also determined. Results The chronic group showed a significantly higher total body fat content compared to the acute group (19.4 ± 3.8 vs. 15.7 ± 4.3%). All other parameters were not significantly different between groups. Both groups ingested excessive fat and insufficient amounts of carbohydrates compared with common nutritional recommendations. Low intakes of vitamins C, D, E, biotin, folic acid, as well as potassium and iron were found. Conclusions No differences were found in the nutritional intakes of two comparable groups of subjects with acute and chronic SCI. Independent of lesion duration, subjects with SCI showed considerable deviations from the general accepted nutritional recommendations concerning macro- and micronutrients intake. Professional nutritional education for persons with SCI should start as soon as possible after injury to prevent nutrition-related secondary complications like cardiovascular diseases. Periodic determinations of body fat content and REE combined with a physical activity program might be helpful as well.
Perret, Claudio; Stoffel-Kurt, Nadine
Objective To determine whether epidural analgesia during labour is associated with long term backache. Design Follow up after randomised controlled trial. Analysis by intention to treat. Setting Department of obstetrics and gynaecology at one NHS trust. Participants 369 women: 184 randomised to epidural group (treatment as allocated received by 123) and 185 randomised to non-epidural group (treatment as allocated received by 133). In the follow up study 151 women were from the epidural group and 155 from the non-epidural group. Main outcome measures Self reported low back pain, disability, and limitation of movement assessed through one to one interviews with physiotherapist, questionnaire on back pain and disability, physical measurements of spinal mobility. Results There were no significant differences between groups in demographic details or other key characteristics. The mean time interval from delivery to interview was 26 months. There were no significant differences in the onset or duration of low back pain, with nearly a third of women in each group reporting pain in the week before interview. There were no differences in self reported measures of disability in activities of daily living and no significant differences in measurements of spinal mobility. Conclusions After childbirth there are no differences in the incidence of long term low back pain, disability, or movement restriction between women who receive epidural pain relief and women who receive other forms of pain relief. What is already known on this topicPrevious research has suggested an association between epidural analgesia during labour and low back painIt is not known whether this association is causalWhat this study addsThis long term follow up study found no evidence of a causal link between epidural analgesia during labour and low back pain
Howell, Charlotte J; Dean, Tracy; Lucking, Linda; Dziedzic, Krysia; Jones, Peter W; Johanson, Richard B
The distribution and morphology of fibrous astrocytes in the cervical spinal cord of normal horses and horses with chronic compressive myelopathy were demonstrated using immunohistochemical staining for glial fibrillary acidic protein. In the spinal cord from normal horses, astrocytes with stellate cell bodies and short processes were irregularly distributed in grey matter. In the white matter, their cell bodies were small and angular in areas adjacent to grey matter and larger and more stellate-shaped in the subpial area. Astrocyte processes were fine, and evenly distributed in a predominantly radial pattern in transverse sections of cord. Gliosis was marked in the spinal cords of horses with cervical compressive myelopathy. In the grey matter at the level of compression astrocytes were often enlarged and rounded, with short, blunt processes, but the gliosis was generally mild. In the white matter, gliosis was obvious in areas of nerve fibre swelling and degeneration at the level of compression and in areas of ascending and descending Wallerian degeneration. The fine radial pattern of astrocyte fibres was replaced by a dense, irregular arrangement. Gliosis persisted in the cords of chronically affected horses after active nerve fibre degeneration had subsided. The areas of gliosis coincided with the areas of Marchi staining for degenerating myelin and with areas of myelin loss in osmium tetroxide post-fixed tissue. Histological observations were consistent with astrocytes replacing areas of extracellular space that remained after nerve fibre degeneration. it is concluded that astrocytic gliosis is a prominent and persistent alteration of the spinal cord of horses with chronic cervical compressive myelopathy. PMID:1755785
Yovich, J V; Gould, D H; LeCouteur, R A
The pattern of remyelination after traumatic spinal cord injury remains elusive, with animal and human studies reporting partial to complete demyelination followed by incomplete remyelination. In the present study, we found that spared rubrospinal tract (RST) axons of passage traced with actively transported dextrans and examined caudally to the lesion twelve weeks after mouse spinal cord contusion injury were fully remyelinated. Spared axons exhibited a marginally reduced myelin thickness and significantly shorter internodes. Contactin-associated protein (CASPR) and Kv1.2 channels were used to identify internodes and paranodal protein distribution properties were used as an index of myelin integrity. This is the first time the CNS myelin internode length was measured in a mouse. To better understand the significance of shortened internodes and thinner myelin in spared axons, we modeled conduction properties using McIntyre’s et al. model of myelinated axons. Mathematical modeling predicted a 21% decrease in the conduction velocity of remyelinated RST axons due to shortened internodes. To determine whether demyelination could be present on axons exhibiting a pathological transport system we utilized the retroviral reporter system. Virally delivered GFP unveiled a small population of dystrophic RST axons that persist chronically with evident demyelination or abnormal remyelination. Collectively these data show that lasting demyelination in spared axons is rare and that remyelination of axons of passage occurs in the chronically injured mouse spinal cord.
Lasiene, Jurate; Shupe, Larry; Perlmutter, Steve; Horner, Philip
OBJECTIVES—This prospective study was designed to assess the effects of omental transpostion in patients with a chronic spinal injury.?METHODS—Neurological status was established to be stable and multiple baseline across patient studies were done preoperatively and repeated postoperatively. Assessments included activities of daily living (ADL), functional ability, degree of spasticity, motor power, sensation, pain perception, urodynamic studies, electromyography, sensory evoked potentials (SEPs), and infrared thermography to measure peripheral and general skin vascular responses. Each patient had MRI. Assessments were done at 3, 6, and 12 months after omental transposition in 17patients.?RESULTS—The detailed assessments failed to show significant improvement, although some patients showed minor objective and subjective change in some categories. Neurological deterioration occurred in one patient. There were 20 surgical complications including urinary tract infection, deep vein thrombosis, wound infection, and incisional hernia.?CONCLUSIONS—Omental transposition has not been shown to improve neurological function in 17 patients with chronic spinal cord injury, and continued use of this operation in this situation is not supported by this study. Further advances in spinal cord repair may utilise the pedicled omental graft to provide an alternative vascular supply, but its current use should be limited to experimental models.??
Duffill, J; Buckley, J; Lang, D; Neil-Dwyer, G; McGinn, F; Wade, D
BACKGROUND AND PURPOSE: Spinal cord injury (SCI) results in a number of conse- quences; one of the most difficult to manage is chronic neuropathic pain. Thus, defining the potential neural and biochemical changes associated with chronic pain after SCI is important because this may lead to development of new treatment strategies. Prior studies have looked at the thalamus, because it
Pradip M. Pattany; Robert P. Yezierski; Eva G. Widerstrom-Noga; Brian C. Bowen
Chronic neuropathic pain is a disabling condition observed in large number of individuals following spinal cord injury (SCI). Recent progress points to an important role of neuroinflammation in the pathogenesis of central neuropathic pain. The focus of the present study is to investigate the role of proinflammatory molecules IL-1?, TNF-?, MCP-1, MMP-9 and TIMP-1 in chronic neuropathic pain in a rodent model of SCI. Rats were subjected to spinal cord contusion using a controlled linear motor device with an injury epicenter at T10. The SCI rats had severe impairment in locomotor function at 7 days post-injury as assessed by the BBB score. The locomotor scores showed significant improvement starting at day 14 and thereafter showed no further improvement. The Hargreaves’ test was used to assess thermal hyperalgesia for hindpaw, forepaw and tail. A significant reduction in withdrawal latency was observed for forepaw and tail of SCI rats at days 21 and 28, indicating the appearance of thermal hyperalgesia. Changes in expression of mRNAs for IL-1?, TNF-?, MCP-1, MMP-9 and TIMP-1 were assessed using real-time polymerase chain reaction in spinal cord including the injury epicenter along with regions above and below the level of lesion at day 28 post-injury. A significant increase was observed in the expression of MCP-1, TNF-?, TIMP-1 and IL-1? in the injury epicenter, whereas only TIMP-1 was upregulated in the area below the injury epicenter. The results of the study suggest that prolonged upregulation of inflammatory mediators might be involved in chronic neuropathic pain in SCI, and that TIMP-1 may play a role in maintenance of chronic below level pain.
Sandhir, Rajat; Gregory, Eugene; He, Yong-Yue
We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered. Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves.
Miyagi, Masayuki; Eguchi, Yawara; Orita, Sumihisa; Suzuki, Miyako; Sakuma, Yoshihiro; Oikawa, Yasuhiro; Yamauchi, Kazuyo; Takahashi, Kazuhisa
Summary Epidural opiates were administered to 139 patients with pain due to malignant diseases via a chronic indwelling catheter inserted percutaneously. So far, 9,716 days of treatment can be evaluated. In 87% of the patients whose pain previously could not be controlled with conventional analgesic approaches, epidural opiates resulted in remarkable pain relief. With a mean daily dose of 15.6
M. Zenz; S. Piepenbrock; M. Tryba
Panspinal epidural abscess is an extremely rare condition that can potentially lead to major permanent neurological deficits if treatment is delayed or suboptimal. Most patients with spinal epidural abscess have a short segment of vertebrae involved and classically present with fever, low back pain, and focal neurologic deficit. In severe cases, meningitis and septic shock may occur and lead to death. Therefore, the condition requires prompt recognition and proper intervention. Herein, we report the case of a 41-year-old diabetic man who presented at our hospital with the symptoms of headache, quadriplegia with respiratory distress and low back pain. Panspinal epidural abscess and meningitis were diagnosed by carrying out detailed neurologic examinations and neuroimaging studies, which expedited the correct diagnosis and treatment. PMID:23685059
Lin, Wen-Sou; Kao, Hung-Wen; Cheng, Chun-An
This is a rare case of persistent Horner's syndrome following epidural anesthesia and Caesarean section. A 33-year-old female presented with persistent ptosis and miosis following epidural anesthesia and Caesarian section several months prior. Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of head, neck, and chest were unremarkable. Medline search using terms Horner’s, epidural, spinal anesthesia, delivery, childbirth, Caesarian, and pregnancy identified 31 articles describing Horner's syndrome in obstetric epidural anesthesia, of which 11 were following Caesarean section. The increased incidence of Horner's syndrome in the setting of epidural anesthesia in pregnancy may be related to epidural venous engorgement and cephalic spread of the local anaesthetic, with disruption in the oculosympathetic pathway. It is important to include recent epidural anesthesia within the differential diagnosis of acute Horner's syndrome in a postpartum female. Rarely, the ptosis may be permanent and require surgical intervention.
Goel, Shubhra; Burkat, Cat Nguyen
This is a rare case of persistent Horner's syndrome following epidural anesthesia and Caesarean section. A 33-year-old female presented with persistent ptosis and miosis following epidural anesthesia and Caesarian section several months prior. Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of head, neck, and chest were unremarkable. Medline search using terms Horner's, epidural, spinal anesthesia, delivery, childbirth, Caesarian, and pregnancy identified 31 articles describing Horner's syndrome in obstetric epidural anesthesia, of which 11 were following Caesarean section. The increased incidence of Horner's syndrome in the setting of epidural anesthesia in pregnancy may be related to epidural venous engorgement and cephalic spread of the local anaesthetic, with disruption in the oculosympathetic pathway. It is important to include recent epidural anesthesia within the differential diagnosis of acute Horner's syndrome in a postpartum female. Rarely, the ptosis may be permanent and require surgical intervention. PMID:21836349
Goel, Shubhra; Burkat, Cat Nguyen
Sudden paraplegia secondary to the posterior spinal epidural compression and vertebral compression fracture as a complication in corticosteroid treatment is extremely rare. The authors presented a case 49-year-old man with chronic relapsing attack of Still's disease. After the identification of pathology, the surgical evacuation of lipid tissue and pedicle-based instrumentation showed therapeutic success. To the authors' knowledge, this is the first case showing both vertebral fracture and paraplegia that required urgent surgery in the follow-up Still's disease. PMID:20012627
Celik, Suat Erol; Erer, Sait B; Güleç, Ilker; Gökcan, Recai; Naderi, Sait
Although reactive oxygen species (ROS) are involved in neuropathic pain, the direct relationship between these species and chronic constriction of sciatic nerve (CCI) has not been studied in spinal cord. Thus, this study induced CCI in rats and these animals were sacrificed 3 and 10 days after the surgical procedure to determine the superoxide dismutase (SOD) and catalase activities, as well as ascorbic acid, hydrogen peroxide (H(2)O(2)) and lipid hydroperoxide levels in lumbosacral spinal cord. Von Frey Hair and hot plate tests were performed to assess the degree of mechanical and thermal hyperalgesia at days 0, 3 and 10. The results showed that CCI significantly induced mechanical and thermal hyperalgesia at days 3 and 10. Parallel there was increase in spinal cord lipid hydroperoxide at days 3 and 10 in rats submitted to CCI. In Sham rats a significant increase in this parameter occurred at day 10. H(2)O(2) decreased at day 10 only in CCI group. SOD activity was decreased in Sham and CCI groups at day 3, while catalase activity was increased in CCI rats at days 3 and 10. Ascorbic acid levels were reduced only in CCI rats at day 3. Although the role of such changes is unclear, many were not specific to neuropathic pain and the differences could be related to different degrees of central sensitization in Sham and CCI rats. PMID:22674084
Goecks, Cristina S B; Horst, Andréa; Moraes, Maira S; Scheid, Taína; Kolberg, Carolina; Belló-Klein, Adriane; Partata, Wania A
Potentially noxious stimuli are sensed by specialized nerve cells named nociceptors, which convey nociceptive signals from peripheral tissues to the central nervous system. The spinal dorsal horn and the trigeminal nucleus serve as first relay stations for incoming nociceptive signals. At these sites, nociceptor terminals contact a local neuronal network consisting of excitatory and inhibitory interneurons as well as of projection neurons. Blockade of neuronal inhibition in this network causes an increased sensitivity to noxious stimuli (hyperalgesia), painful sensations occurring after activation of non-nociceptive fibers (allodynia), and spontaneous pain felt in the absence of any sensory stimulation. It thus mimics the major characteristics of chronic pain states. Diminished inhibitory pain control in the spinal dorsal horn occurs naturally, e.g., through changes in the function of inhibitory neurotransmitter receptors or through altered chloride homeo-stasis in the course of inflammation or nerve damage. This review summarizes our current knowledge about endogenous mechanisms leading to diminished spinal pain control and discusses possible ways that could restore proper inhibition through facilitation of fast inhibitory neurotransmission. PMID:21854227
Zeilhofer, Hanns Ulrich; Benke, Dietmar; Yevenes, Gonzalo E
Remyelination following spinal cord injury (SCI) is thought to be incomplete; demyelination is reported to persist chronically and is proposed as a compelling therapeutic target. Yet most reports do not distinguish between the myelin status of intact axons and injury-severed axons whose proximal stumps persist but provide no meaningful function. We previously found full remyelination of spared, intact rubrospinal axons caudal to the lesion in chronic mouse SCI. However, the clinical concept of chronically demyelinated spared axons remains controversial. Since mouse models may have limitations in clinical translation, we asked whether the capacity for full remyelination is conserved in clinically relevant chronic rat SCI. We determined myelin status by examining paranodal protein distribution on anterogradely labeled, intact corticospinal and rubrospinal axons throughout the extent of the lesion. Demyelination was evident on proximal stumps of severed axons, but not on intact axons. For the first time, we demonstrate that a majority of intact axons exhibit remyelination (at least one abnormally short internode, < 100 ?m). Remarkably, shortened internodes were significantly concentrated at the lesion epicenter and individual axons were thinned by 23% compared to their rostral and caudal zones. Mathematical modeling predicted a 25% decrease in conduction velocity at the lesion epicenter due to short internodes and axonal thinning. In conclusion, we do not find a large chronically demyelinated population to target with remyelination therapies. Interventions may be better focused on correcting structural or molecular abnormalities of regenerated myelin.
Powers, Berit E.; Lasiene, Jurate; Plemel, Jason R.; Shupe, Larry; Perlmutter, Steve I.; Tetzlaff, Wolfram; Horner, Philip J.
Remyelination following spinal cord injury (SCI) is thought to be incomplete; demyelination is reported to persist chronically and is proposed as a compelling therapeutic target. Yet most reports do not distinguish between the myelin status of intact axons and injury-severed axons whose proximal stumps persist but provide no meaningful function. We previously found full remyelination of spared, intact rubrospinal axons caudal to the lesion in chronic mouse SCI. However, the clinical concept of chronically demyelinated spared axons remains controversial. Since mouse models may have limitations in clinical translation, we asked whether the capacity for full remyelination is conserved in clinically relevant chronic rat SCI. We determined myelin status by examining paranodal protein distribution on anterogradely labeled, intact corticospinal and rubrospinal axons throughout the extent of the lesion. Demyelination was evident on proximal stumps of severed axons, but not on intact axons. For the first time, we demonstrate that a majority of intact axons exhibit remyelination (at least one abnormally short internode, <100 ?m). Remarkably, shortened internodes were significantly concentrated at the lesion epicenter and individual axons were thinned by 23% compared with their rostral and caudal zones. Mathematical modeling predicted a 25% decrease in conduction velocity at the lesion epicenter due to short internodes and axonal thinning. In conclusion, we do not find a large chronically demyelinated population to target with remyelination therapies. Interventions may be better focused on correcting structural or molecular abnormalities of regenerated myelin. PMID:22496557
Powers, Berit E; Lasiene, Jurate; Plemel, Jason R; Shupe, Larry; Perlmutter, Steve I; Tetzlaff, Wolfram; Horner, Philip J
Background and Objectives. Peripheral nerve and spinal cord stimulation techniques have been used for many years. However, electrical stimulation methods rarely have been used to confirm epidural catheter placement. This study examines the practicality of this technique to confirm epidural catheter placement in obstetric patients. Methods. Thirty-nine obstetric patients in labor were studied. An electrocardiography (ECG) adapter (Arrow-Johans) was attached
Ban C. H. Tsui; Sunil Gupta; Brendan Finucane
Epidural hematoma is a rare cause of spinal cord compression, which usually provokes severe neurological deficits. It is presumed to originate from venous or, more probably, arterial bleeding. Thrombocytopenia and other disorders of coagulation may precipitate the onset of epidural hematoma and facilitate the evolution of the disease. We report the case of a patient suffering from a non-Hodgkin's lymphoma
L. Mastronardi; S. Carletti; D. Frondizi; C. Spera; G. Maira
This study investigated the feasibility of chronically recording descending signals from the rat spinal cord using microwire electrodes. Eight 25?m diameter Pt-Ir microwires were implanted in the dorsolateral rubrospinal tract (RST) bilaterally at the c5 level in each of the four adult Long Evans rats trained for food reach-to-grasp task. Signal stability was assessed by calculating the signal-to-noise ratio (SNR) and mean signal amplitude during the four week recording period. The results of ANOVA did not suggest significant difference between sessions for any of the electrodes, indicating stability. Immunohistology suggested minimal tissue response to these microwires during the four week implant period. The results of this study show that microwire electrodes can be used for short-term chronic recordings of signals from the descending motor tracts in experimental animals.
Prasad, Abhishek; Sahin, Mesut
A variety of tests of sensorimotor function are used to characterize outcome after experimental spinal cord injury (SCI). These tests typically do not provide information about chemical and metabolic processes in the injured CNS. Here, we used 1H-magnetic resonance spectroscopy (MRS) to monitor long-term and short-term chemical changes in the CNS in vivo following SCI. The investigated areas were cortex, thalamus/striatum and the spinal cord distal to injury. In cortex, glutamate (Glu) decreased 1 day after SCI and slowly returned towards normal levels. The combined glutamine (Gln) and Glu signal was similarly decreased in cortex, but increased in the distal spinal cord, suggesting opposite changes of the Glu/Gln metabolites in cortex and distal spinal cord. In lumbar spinal cord, a marked increase of myo-inositol was found 3 days, 14 days and 4 months after SCI. Changes in metabolite concentrations in the spinal cord were also found for choline and N-acetylaspartate. No significant changes in metabolite concentrations were found in thalamus/striatum. Multivariate data analysis allowed separation between rats with SCI and controls for spectra acquired in cortex and spinal cord, but not in thalamus/striatum. Our findings suggest MRS could become a helpful tool to monitor spatial and temporal alterations of metabolic conditions in vivo in the brain and spinal cord after SCI. We provide evidence for dynamic temporal changes at both ends of the neuraxis, cortex cerebri and distal spinal cord, while deep brain areas appear less affected.
Erschbamer, Matthias; Oberg, Johanna; Westman, Eric; Sitnikov, Rouslan; Olson, Lars; Spenger, Christian
Histological examination was performed on the cervical spinal cord from 13 horses with chronic cervical compressive myelopathy of 4 to 29 months duration. Structural alterations were correlated with clinical features. At the level of compression, the spinal cord was grossly deformed. Histological alterations included nerve fibre swelling and degeneration, occasional spheroids, astrocytic gliosis, increased macrophage activity and increased perivascular collagen. Myelin degeneration or loss at the level of the compressive lesion was greatest in the ventral and lateral funiculi and less consistently present in the dorsal funiculi. Asymmetry of lesions in the dorsal funiculi was associated with asymmetry of clinical signs in 5 horses. Histological alterations in areas of Wallerian degeneration were similar to that at the level of spinal cord compression, except that perivascular collagen was not increased. Wallerian degeneration was present cranial to the compressed site in the superficial portions of the lateral funiculi and in the middle of the dorsal funiculi. Caudal to the compressed site it was present in the ventral funiculi adjacent to the ventral median fissure and in the middle of the lateral funiculi. Deformation of the spinal cord did not correlate with the severity or duration of clinical signs but was positively correlated with the amount of perivascular collagen increase. The amount of nerve fibre swelling was not correlated with the severity of clinical signs but was negatively correlated with their duration. A rapid loss of nerve fibres apparently occurred early in the course of compression, since there was a marked decrease in the amount of nerve fibre swelling and Marchi stained degenerating myelin with increasing clinical duration.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1755784
Yovich, J V; leCouteur, R A; Gould, D H
In the majority of spinal cord injuries (SCIs) some axonal projections remain intact. We examined the functional status of these surviving axons, since they represent a prime therapeutic target. Using a novel electrophysiological preparation, adapted from techniques used to study primary demyelination, we quantified conduction failure across a SCI and studied conduction changes over time in adult rats with a moderate severity spinal contusion (150 kilodyne, Infinite Horizon impactor). By recording antidromically activated single units from teased dorsal root filaments we demonstrate complete conduction block in ascending dorsal column axons acutely (1-7 days) post-injury, followed by a period of restored conduction over the sub-acute phase (2-4 weeks), with no further improvements in conduction at chronic stages (3-6 months). By cooling the lesion site additional conducting fibres could be recruited, thus revealing a population of axons that are viable but unable to conduct under normal physiological conditions. Importantly, this phenomenon is still apparent at the most chronic (6 month) time point. The time course of conduction changes corresponded with changes in behavioural function, and ultrastructural analysis of dorsal column axons revealed extensive demyelination during the period of conduction block, followed by progressive remyelination. A proportion of dorsal column axons remained chronically demyelinated, suggesting that these are the axons recruited with the cooling paradigm. Thus, using a clinically relevant SCI model we have identified a population of axons present at chronic injury stages which are intact but fail to conduct and are therefore a prime target for therapeutic strategies to restore function.
James, Nicholas D.; Bartus, Katalin; Grist, John; Bennett, David L. H.; McMahon, Stephen B.; Bradbury, Elizabeth J.
Pneumorrhachis, which involves the entrapment of air or gas within the spinal canal, is a rare clinical entity, and the pathogenesis and etiologies of this uncommon entity are various and can present a diagnostic challenge. Usually, pneumorrhachis represents an asymptomatic epiphenomenon but it can produce symptoms associated with its underlying pathology. Here, we report a rare case of symptomatic epidural pneumorrhachis accompanying pneumothorax. Possible pathogenic mechanisms are discussed and a review of the literature is included. PMID:24044086
Kim, Seok Won; Seo, Hong Ju
Pneumorrhachis, which involves the entrapment of air or gas within the spinal canal, is a rare clinical entity, and the pathogenesis and etiologies of this uncommon entity are various and can present a diagnostic challenge. Usually, pneumorrhachis represents an asymptomatic epiphenomenon but it can produce symptoms associated with its underlying pathology. Here, we report a rare case of symptomatic epidural pneumorrhachis accompanying pneumothorax. Possible pathogenic mechanisms are discussed and a review of the literature is included.
Seo, Hong Ju
Summary To analyze MR manifestations of postoperative spinal complications and investigate the value of MRI in the diagnosis and differentiated\\u000a diagnosis, 114 cases of spinal postoperative complications were analyzed retrospectively and compared with the clinical data.\\u000a The results showed that the main postoperative spinal complications included spinal stenosis (n=33, consisting of 21 cases of epidural fibrosis and 12 cases of epidural
Haitao Yang; Renfa Wang; Tianyou Luo; Yu Ouyang; Fajin Lv; Liming Xia; Chengyuan Wang
Epidural spinal myelolipoma was diagnosed in an 11.5-year-old castrated male Husky-cross that was evaluated at the veterinary teaching hospital due to progressive thoracolumbar spinal hyperaesthesia and mild proprioceptive pelvic limb ataxia. A focal, ill-defined mildly inhomogenous extradural mass lesion was detected by MRI. The dog was euthanized. At necropsy an extradurally located reddish mass of about 2.5 cm in diameter was present in the vertebral canal. The mass was identified histopathologically as an epidural myelolipoma.
Diverse mechanisms including activation of NMDA receptors, microglial activation, reactive astrogliosis, loss of descending inhibition, and spasticity are responsible for ?40% of cases of intractable neuropathic pain after spinal cord injury (SCI). Because conventional treatments blocking individual mechanisms elicit only short-term effectiveness, a multimodal approach with simultaneous actions against major pain-related pathways may have value for clinical management of chronic pain. We hypothesize that [-]-huperzine A (HUP-A), an alkaloid isolated from the club moss Huperzia serrata, that is a potent reversible inhibitor of acetylcholinesterase and NMDA receptors, could mitigate pain without invoking drug tolerance or dependence by stimulating cholinergic interneurons to impede pain signaling, inhibiting inflammation via microglial cholinergic activation, and blocking NMDA-mediated central hypersensitization. We tested our hypothesis by administering HUP-A i.p. or intrathecally to female Sprague-Dawley rats (200-235 g body weight) after moderate static compression (35 g for 5 min) of T10 spinal cord. Compared with controls, HUP-A treatment demonstrates significant analgesic effects in both regimens. SCI rats manifested no drug tolerance following repeated bolus i.p. or chronic intrathecal HUP-A dosing. The pain-ameliorating effect of HUP-A is cholinergic dependent. Relative to vehicle treatment, HUP-A administration also reduced neural inflammation, retained higher numbers of calcium-impermeable GluR2-containing AMPA receptors, and prevented Homer1a up-regulation in dorsal horn sensory neurons. Therefore, HUP-A may provide safe and effective management for chronic postneurotrauma pain by reestablishing homeostasis of sensory circuits. PMID:23386718
Yu, Dou; Thakor, Devang K; Han, Inbo; Ropper, Alexander E; Haragopal, Hariprakash; Sidman, Richard L; Zafonte, Ross; Schachter, Steven C; Teng, Yang D
Diverse mechanisms including activation of NMDA receptors, microglial activation, reactive astrogliosis, loss of descending inhibition, and spasticity are responsible for ?40% of cases of intractable neuropathic pain after spinal cord injury (SCI). Because conventional treatments blocking individual mechanisms elicit only short-term effectiveness, a multimodal approach with simultaneous actions against major pain-related pathways may have value for clinical management of chronic pain. We hypothesize that [-]-huperzine A (HUP-A), an alkaloid isolated from the club moss Huperzia serrata, that is a potent reversible inhibitor of acetylcholinesterase and NMDA receptors, could mitigate pain without invoking drug tolerance or dependence by stimulating cholinergic interneurons to impede pain signaling, inhibiting inflammation via microglial cholinergic activation, and blocking NMDA-mediated central hypersensitization. We tested our hypothesis by administering HUP-A i.p. or intrathecally to female Sprague–Dawley rats (200–235 g body weight) after moderate static compression (35 g for 5 min) of T10 spinal cord. Compared with controls, HUP-A treatment demonstrates significant analgesic effects in both regimens. SCI rats manifested no drug tolerance following repeated bolus i.p. or chronic intrathecal HUP-A dosing. The pain-ameliorating effect of HUP-A is cholinergic dependent. Relative to vehicle treatment, HUP-A administration also reduced neural inflammation, retained higher numbers of calcium-impermeable GluR2-containing AMPA receptors, and prevented Homer1a up-regulation in dorsal horn sensory neurons. Therefore, HUP-A may provide safe and effective management for chronic postneurotrauma pain by reestablishing homeostasis of sensory circuits.
Yu, Dou; Thakor, Devang K.; Han, Inbo; Ropper, Alexander E.; Haragopal, Hariprakash; Sidman, Richard L.; Zafonte, Ross; Schachter, Steven C.; Teng, Yang D.
Objectives: To measure changes in pain and disability for chronic low-back pain patients receiving treatment with medication-assisted manipulation (MAM) and to compare these to changes in a group only receiving spinal manipulation. Study Design: Prospective cohort study of 68 chronic low-back pain patients. Methods: Outcomes were measured using the 1998 Version 2.0 American Association of Orthopaedic Surgeons\\/Council of Musculoskeletal Specialty
Frank J. Kohlbeck; Scott Haldeman; Eric L. Hurwitz; Simon Dagenais
Idiopathic spinal cord herniation is a rare disease that presents with slowly progressive myelopathy. This article describes the clinical findings of a patient with a chronic history. A 68-year-old woman initially presented at the age of 32 years with left leg weakness. After slowly progressive neurological deterioration over 34 years, she became completely paraplegic. At the age of 66 years,
Taku Saito; Yorito Anamizu; Kozo Nakamura; Atsushi Seichi
Severe bone loss commonly occurs in individuals with chronic spinal cord injury who are non-weightbearing and leads to an increased risk of lower extremity fractures. This multi-site, double-blind, randomized, placebo- controlled study evaluates the effic...
T. J. Schnitzer
Paralyzed skeletal muscle sometimes becomes faster and more fatigable after spinal cord injury (SCI) because of reduced activity. However, in some cases, pronounced muscle activity in the form of spasticity (hyperreflexia and hypertonus) occurs after long-term SCI. We hypothesized that this spastic activity may be associated with a reversal back to a slower, less fatigable muscle. In adult rats, a sacral (S2) spinal cord transection was performed, affecting only tail musculature and resulting in chronic tail spasticity beginning 2 wk later and lasting indefinitely. At 8 mo after injury, we examined the contractile properties of the segmental tail muscle in anesthetized spastic rats and in age-matched normal rats. The segmental tail muscle has only a few motor units (<12), which were easily detected with graded nerve stimulation, revealing two clear motor unit twitch durations. The dominant faster unit twitches peaked at 15 ms and ended within 50 ms, whereas the slower unit twitches only peaked at 30-50 ms. With chronic injury, this slow twitch component increased, resulting in a large overall increase (>150%) in the fraction of the peak muscle twitch force remaining at 50 ms. With injury, the peak muscle twitch (evoked with supramaximal stimulation) also increased in its time to peak (+48.9%) and half-rise time (+150.0%), and decreased in its maximum rise (-35.0%) and decay rates (-40.1%). Likewise, after a tetanic stimulation, the tetanus half-fall time increased by 53.8%. Therefore the slow portion of the muscle was enhanced in spastic muscles. Consistent with slowing, posttetanic potentiation was 9.2% lower and the stimulation frequency required to produce half-maximal tetanus decreased 39.0% in chronic spinals. Interestingly, in spastic muscles compared with normal, whole muscle twitch force was 81.1% higher, whereas tetanic force production was 38.1% lower. Hence the twitch-to-tetanus ratio increased 104.0%. Inconsistent with overall slowing, whole spastic muscles were 61.5% more fatigable than normal muscles. Thus contrary to the classical slow-to-fast conversion that is seen after SCI without spasticity, SCI with spasticity is associated with a mixed effect, including a preservation/enhancement of slow properties, but a loss of fatigue resistance. PMID:16282205
Harris, R Luke W; Bobet, Jacques; Sanelli, Leo; Bennett, David J
Background While acute effects of stress on pain are well described, those produced by chronic stress are still a matter of dispute. Previously we demonstrated that chronic unpredictable stress results in antinociception in the tail-flick test, an effect that is mediated by increased levels of corticosteroids. In the present study, we evaluated nociception in rats after chronic treatment with corticosterone (CORT) and dexamethasone (DEX) in order to discriminate the role of each type of corticosteroid receptors in antinociception. Results Both experimental groups exhibited a pronounced antinociceptive effect after three weeks of treatment when compared to controls (CONT); however, at four weeks the pain threshold in CORT-treated animals returned to basal levels whereas in DEX-treated rats antinociception was maintained. In order to assess if these differences are associated with altered expression of neuropeptides involved in nociceptive transmission we evaluated the density of substance P (SP), calcitonin gene-related peptide (CGRP), somatostatin (SS) and B2-?-aminobutiric acid receptors (GABAB2) expression in the spinal dorsal horn using light density measurements and stereological techniques. After three weeks of treatment the expression of CGRP in the superficial dorsal horn was significantly decreased in both CORT and DEX groups, while GABAB2 was significantly increased; the levels of SP for both experimental groups remained unchanged at this point. At 4 weeks, CGRP and SP are reduced in DEX-treated animals and GABAB2 unchanged, but all changes were restored to CONT levels in CORT-treated animals. The expression of SS remained unaltered throughout the experimental period. Conclusion These data indicate that corticosteroids modulate nociception since chronic corticosteroid treatment alters the expression of neuropeptides involved in nociceptive transmission at the spinal cord level. As previously observed in some supraspinal areas, the exclusive GR activation resulted in more profound and sustained behavioural and neurochemical changes, than the one observed with a mixed ligand of corticosteroid receptors. These results might be of relevance for the pharmacological management of certain types of chronic pain, in which corticosteroids are used as adjuvant analgesics.
Pinto-Ribeiro, Filipa; Moreira, Vitor; Pego, Jose M; Leao, Pedro; Almeida, Armando; Sousa, Nuno
Recent studies have documented the importance of psychological factors in the experience of chronic pain in persons with spinal cord injury (SCI). The current study sought to replicate and extend previous work demonstrating associations among specific pain-related beliefs, coping, mental health, and pain outcomes in persons with SCI. A return-by-mail survey assessing psychological functioning and pain was completed by 130 individuals with SCI. Measures included short forms of the Survey of Pain Attitudes and the Chronic Pain Coping Inventory. After factor analysis, multiple regression was used to predict pain outcomes (psychological functioning and pain interference) after controlling for pain intensity. Results indicated that psychological factors, particularly beliefs about pain (including catastrophizing) and pain-related coping strategies (including passive coping), were significant predictors of pain outcomes and accounted for 21% to 25% of unique variance. Zero-order correlations suggested that the specific variables most closely associated with negative pain outcomes were perception of oneself as disabled, perceptions of low control over pain, and tendency to catastrophize. In general, negative attributions and coping were stronger predictors of pain adjustment than were positive ones. Results highlight the importance of psychological factors in understanding chronic pain in persons with SCI and provide further support for the biopsychosocial model. PMID:19533518
Molton, Ivan R; Stoelb, Brenda L; Jensen, Mark P; Ehde, Dawn M; Raichle, Katherine A; Cardenas, Diana D
It is known that, in spite of meeting appropriate clinical criteria for spinal cord stimulation (SCS) and having undergone flawless procedures, a significant number of patients who fail the therapy continues to exist. It is the purpose of this article to focus on the development of psychosocial indicators of success for SCS, if any. Referring to specialist literature authors present a review of what is known, what is not known, and what remains controversial on this topic. After reading this article we hope the reader will understand the importance of a psychological evaluation as part of the development of standards for identifying appropriate patients for this therapy. To improve treatment outcomes of SCS, seems to be essential to perform psychosocial evaluations on all persons clinically indicated for SCS to exclude those patients, who most probably, on a psychosocial level, will fail the procedure. To maximize treatment efficacy, authors believe spinal cord stimulation for chronic pain control must be part of a comprehensive program. An accurate preoperative psychosocial assessment and a course of psychological assistance both before and after therapy seems to be crucial for improving outcomes. PMID:17173602
Beltrutti, Diego; Lamberto, Aldo; Barolat, Giancarlo; Bruehl, Stephen P; Doleys, Daniel; Krames, Elliot; Meglio, Mario; North, Richard; Olson, Kern; Reig, Enrique; Simpson, Brian; Turk, Dennis; Aronoff, Gerald; Melzack, Ronald
Background and Purpose: Locomotor training (LT) enhances walking in adult experimental animals and humans with mild-to-moderate spinal cord injuries (SCIs). The animal literature suggests that the effects of LT may be greater on an immature nervous system than on a mature nervous system. The purpose of this study was to evaluate the effects of LT in a child with chronic, incomplete SCI. Subject: The subject was a nonambulatory 4½-year-old boy with an American Spinal Injury Association Impairment Scale (AIS) C Lower Extremity Motor Score (LEMS) of 4/50 who was deemed permanently wheelchair-dependent and was enrolled in an LT program 16 months after a severe cervical SCI. Methods: A pretest-posttest design was used in the study. Over 16 weeks, the child received 76 LT sessions using both treadmill and over-ground settings in which graded sensory cues were provided. The outcome measures were ASIA Impairment Scale score, gait speed, walking independence, and number of steps. Result: One month into LT, voluntary stepping began, and the child progressed from having no ability to use his legs to community ambulation with a rolling walker. By the end of LT, his walking independence score had increased from 0 to 13/20, despite no change in LEMS. The child's final self-selected gait speed was 0.29 m/s, with an average of 2,488 community-based steps per day and a maximum speed of 0.48 m/s. He then attended kindergarten using a walker full-time. Discussion and Conclusion: A simple, context-dependent stepping pattern sufficient for community ambulation was recovered in the absence of substantial voluntary isolated lower-extremity movement in a child with chronic, severe SCI. These novel data suggest that some children with severe, incomplete SCI may recover community ambulation after undergoing LT and that the LEMS cannot identify this subpopulation.
Behrman, Andrea L; Nair, Preeti M; Bowden, Mark G; Dauser, Robert C; Herget, Benjamin R; Martin, Jennifer B; Phadke, Chetan P; Reier, Paul J; Senesac, Claudia R; Thompson, Floyd J; Howland, Dena R
Brain-derived neurotrophic factor (BDNF) is involved in neuronal survival and synaptic plasticity of the central and peripheral nervous system. In chronic pain, plastic changes in dorsal horn neurons contribute to a phenomenon of hypersensitivity to pain sensation that is maintained over time, known as central sensitization. This process is accompanied by BDNF overexpression, but the role of BDNF in the generation and maintenance of the hyperalgesic phenomenon is still unclear. The present study was aimed to investigate if exogenous BDNF administered to the rat spinal cord, in addition to trigger pain, participates in the maintenance of the central sensitization process (i.e., pain persistence) and to determine if the pain generated is comparable to that observed in a neuropathic pain model. Results showed that a single intrathecal injection of 0.003 ng of BDNF was able to decrease the nociceptive threshold (Randall-Selitto test) in normal rats, for at least a 42-day period. Furthermore, the hyperalgesia generated was comparable to that observed in rats with a 42-day history of mononeuropathy. Increasing the dose or administering additional doses of BDNF resulted neither in additional effectiveness in reducing the pain threshold nor in the prolongation of the hyperalgesic effect, thus showing that central sensitization induced by BDNF is a dose-independent, all-or-none process. It is concluded that BDNF alone is sufficient for generating a long-lasting neural excitability change in the spinal cord via tyrosine kinase B receptor signaling, similar to that observed in chronic pain models such as neuropathy. PMID:21864655
Constandil, Luis; Aguilera, Rodrigo; Goich, Mariela; Hernández, Alejandro; Alvarez, Pedro; Infante, Claudio; Pelissier, Teresa
Objective: The objective of this outcome analysis was to determine the frequency, effectiveness, and complications of epidural anesthesia performed during labor by attending obstetricians at Minden Medical Center from January 1993 through December 1995.Methods: Each of the 1,851 obstetrical patient charts for the 3-year time period was reviewed and data were obtained from the 1,565 charts of the patients who received epidural anesthesia in labor.Results: During the 3-year period studied 1,851 patients had obstetrical delivery at Minden Medical Center. There were 147 planned cesareans and 1,704 patients who experienced labor. Among the patients who experienced labor 1,565 (91.8%) received epidural anesthesia performed by their attending obstetrician. Epidural anesthesia was effective for adequate pain relief in 1,484 patients (94.8%). Hypotension requiring ephedrine occurred in 24 patients (1.5%). Subarachnoid puncture requiring a blood patch for treatment of postural headache occurred in 4 patients (0.26%) and inadvertent spinal anesthesia occurred in 3 patients (0.2%). All of the inadvertent spinals were recognized with the test dose of 5 mL of 1.5% lidocaine and no high or total spinals resulted. A high level of anesthesia, above T5 dermatome, occurred in 16 patients (1.0%). No seizures, neurological sequelae, toxicity to the anesthesia agent, anaphylaxis, or deaths occurred. There were no cases of urinary retention secondary to an epidural anesthetic requiring patient use of a retention catheter on discharge from the hospital.Conclusion: Outcome analysis of patients who received epidural anesthesia performed during labor by obstetricians at Minden Medical Center indicated obstetricians at this hospital provided epidural anesthesia for a high percentage (91.8%) of laboring patients effectively (94.8% had adequate pain relief), and with no serious complications. PMID:10838375
Kemmerly; Lambard; Russell
Multiple myeloma is a hematopoetic disorder and multicentric disease, with the most common localisation being the spine. A 47-year-old male presented with progressive paraplegia, superficial and deep sensory disturbance below the level of T4. Spinal magnetic resonance image showed an epidural mass compressing the spinal cord at the level of T4–T6 with intact bone structure. The patient underwent surgical T4–T6
Naama Okacha; Elasri Chrif; Elmostarchid Brahim; Akhaddar Ali; Elbouzidi Abderrahman; Miloudi Gazzaz; Belhachmi Adil; Kadiri Bouchaib; Boucetta Mohamed
Spinal cord injury (SCI) results in immune depression. To better understand how injury inhibits humoral immunity, the effects of chronic thoracic SCI on B cell development and immune responses to thymus-independent (TI) type-2 and thymus-dependent (TD) antigens were determined. Mice received complete crush injury or control laminectomy at either thoracic level 3 (T3), which disrupts descending autonomic control of the spleen, or at T9, which conserves most splenic sympathetic activity. Although mature B cell numbers were only mildly reduced, bone marrow B cell production was transiently but profoundly depressed immediately after injury. Despite the return of normal B cell production four weeks after SCI, mice receiving T3-injury showed a significant reduction in their ability to mount primary TI-2 or TD immune responses. The latter were marked by decreases in germinal center B cells as well as class switched high-affinity antibody secreting cells. Importantly, injury did not affect affinity maturation per se, pre-existing B cell memory, or secondary humoral immune responses. Together, these findings show that chronic high thoracic SCI impairs the ability to mount optimal antibody responses to new antigenic challenges, but spares previously established humoral immunity.
Oropallo, Michael A.; Held, Katherine S.; Goenka, Radhika; Ahmad, Sifat A.; O'Neill, Patrick J.; Steward, Oswald; Lane, Thomas E.; Cancro, Michael P.
The effect of capsaicin (10-80 mg/kg sc) on reflex activity of the urinary bladder was examined in anesthetized normal as well as anesthetized and awake chronic spinal cord-injured (SCI) cats. In normal cats, capsaicin elicited a transient increase in the frequency of isovolumetric bladder contractions and reduced the volume threshold for inducing micturition, but did not depress the amplitude of bladder contractions or the reflex firing on bladder nerves. In anesthetized SCI cats, capsaicin depressed reflex bladder activity and firing on bladder nerves. In awake SCI cats, capsaicin initially decreased the volume threshold for inducing micturition; however, after a delay of 3-6 h the volume threshold increased and intravesical voiding pressure decreased. This effect persisted for 4-12 days. It is concluded that capsaicin-sensitive C fiber bladder afferents are not involved in initiating reflex micturition in normal cats, but play an essential role in triggering automatic micturition in chronic SCI cats. The results are consistent with the clinical data indicating that C fiber bladder afferents contribute to bladder hyperactivity and incontinence in patients with neurogenic bladder dysfunction. PMID:10484496
Cheng, C L; Liu, J C; Chang, S Y; Ma, C P; de Groat, W C
Although magnetic resonance imaging has dramatically enhanced the ability to diagnose spinal mass lesions, some lesions remain difficult to diagnose. We report a spinal chronic subdural hematoma that comprised the cauda equina ventrally in the lumbar area in a 51-year-old man who was under anticoagulant therapy. Low back pain was the only symptom of the patient after sports activity. Surgical
Serdar Kahraman; Sait ?irin; Hakan Kayali; Ilker Solmaz; Altay Bedük
Administration of epidural and intrathecal opioids may provide excellent postoperative analgesia, but a minority of patients\\u000a will suffer dangerous respiratory depression. This review discusses the detection and measurement of respiratory depression\\u000a and summarizes the relevant literature as it pertains to epidural and intrathecal opioid administration. The respiratory depressant\\u000a effects and pharmacokinetics of spinal opioids are reviewed. The clinical implications and
Richard C. Etches; Alan N. Sandler; M. Denise Daley
Background: Pediatric otitis media with effusion is a common and costly condition. Although chiropractors have anecdotally claimed success in treating otitis media, there is little research to support their claims. Objective: A pilot study was undertaken for the purpose of assessing the feasibility of conducting a full-scale randomized clinical trial investigating the efficacy of chiropractic spinal manipulative therapy (SMT) for
Charles E. Sawyer; Roni L. Evans; Patrick D. Boline; Richard Branson; Anne Spicer
Spinal anesthesia is widely regarded as a reasonable anesthetic option for cesarean delivery in severe preeclampsia, provided there is no indwelling epidural catheter or contraindication to neuraxial anesthesia. Compared with healthy parturients, those with severe preeclampsia experience less frequent, less severe spinal-induced hypotension. In severe preeclampsia, spinal anesthesia may cause a higher incidence of hypotension than epidural anesthesia; however, this hypotension is typically easily treated and short lived and has not been linked to clinically significant differences in outcomes. In this review, we describe the advantages and limitations of spinal anesthesia in the setting of severe preeclampsia and the evidence guiding intraoperative hemodynamic management. PMID:23868886
Henke, Vanessa G; Bateman, Brian T; Leffert, Lisa R
Human muscles paralysed chronically by spinal cord injury (SCI) fatigue excessively. Whether these reductions in force reflect a decrease in the fatigue resistance of the motor units is unknown. Our aim was to determine the fatigability of thenar motor units paralysed chronically (10 ± 2 years) by cervical SCI. Surface electromyographic activity (EMG) and force were recorded from 17 paralysed motor units (n = 7 subjects) in response to intraneural motor axon stimulation (13 pulses at 40 Hz, 1 s?1 for 2 min). Unit force decreased progressively, reaching 8–60% of initial after 2 min, whereas both the amplitude and area of the first EMG potentials in the trains increased significantly (both P < 0.05). Thus, transmission of neural signals to the sarcolemma was effective and the reduction in force must reflect impaired processes in the muscle fibres. The median fatigue index for paralysed units (0.31), the ratio of the force at 2 min compared to the initial force, was significantly lower than that for units from control subjects (0.85, P < 0.05), but the distribution of fatigue indices for each population had a similar shape (ranges: 0.08–0.60 and 0.41–0.95, respectively). Hence, chronic paralysis did not limit the range of fatigability typically found for thenar units, only its magnitude. These findings suggest that all paralysed units underwent similar reductions in fatigue resistance. After fatigue, paralysed unit forces were reduced at all frequencies (1–100 Hz, P < 0.05). Twitch contraction and half-relaxation times were increased, as was the frequency needed to produce half maximal force (P < 0.05). Thus, stimulation protocols used to produce functional movements in paralysed muscles need to accommodate the significant and rapid fatigue of the motor units.
Klein, C S; Hager-Ross, C K; Thomas, C K
Baclofen, a gamma-aminobutyric acid receptorB agonist, is used to reduce symptoms of spasticity (hyperreflexia, increases in muscle tone, involuntary muscle activity), but the long-term effects of sustained baclofen use on skeletal muscle properties are unclear. The aim of our study was to evaluate whether baclofen use and paralysis due to cervical spinal cord injury change the contractile properties of human thenar motor units more than paralysis alone. Evoked electromyographic activity and force were recorded in response to intraneural stimulation of single motor axons to thenar motor units. Data from three groups of motor units were compared: 23 paralysed units from spinal cord injured subjects who take baclofen and have done so for a median of 7 years, 25 paralysed units from spinal cord injured subjects who do not take baclofen (median: 10 years) and 45 units from uninjured control subjects. Paralysed motor unit properties were independent of injury duration and level. With paralysis and baclofen, the median motor unit tetanic forces were significantly weaker, twitch half-relaxation times longer and half maximal forces reached at lower frequencies than for units from uninjured subjects. The median values for these same parameters after paralysis alone were comparable to control data. Axon conduction velocities differed across groups and were slowest for paralysed units from subjects who were not taking baclofen and fastest for units from the uninjured. Greater motor unit weakness with long-term baclofen use and paralysis will make the whole muscle weaker and more fatigable. Significantly more paralysed motor units need to be excited during patterned electrical stimulation to produce any given force over time. The short-term benefits of baclofen on spasticity (e.g. management of muscle spasms that may otherwise hinder movement or social interactions) therefore have to be considered in relation to its possible long-term effects on muscle rehabilitation. Restoring the strength and speed of paralysed muscles to pre-injury levels may require more extensive therapy when baclofen is used chronically.
Hager-Ross, Charlotte K.; Klein, Cliff S.
A 23-year-old man with Klippel-Trenaunay-Weber syndrome (KTWS) was scheduled for left lower limb amputation. He had complained of severe lower limb pain. Oral administration of acetaminophen, duloxetine, and morphine did not alleviate the pain. Epidural block was performed preoperatively after confirming there were no abnormal angiomas in the lumbar spinal canal on CT scan. The pain was alleviated by the epidural block. The epidural block was also useful during the operation and postoperative pain management. There were no complications related to the epidural block. KTWS is a rare congenital malformation characterized by the triad of varicose veins, capillary malformations, and bony or soft tissue hypertrophy in affected limbs. Some patients with KTWS have epidural hemangioma and cerebral or spinal cord arteriovenous fistulas. There have been some reports of rupture of epidural hemangioma resulting in progressive paraplegia. When epidural block is scheduled for patients with KTWS, CT scan should be performed to investigate abnormal vessels in the lumbar spinal canal. PMID:23479928
Yamada, Yuki; Yamada, Keisuke; Yamamoto, Ken; Takeuchi, Akihiko; Tsuchiya, Hiroyuki
Study design:A prospective, non-randomized clinical series trial.Objective:To evaluate the effect of autogenous undifferentiated stem cell infusion for the treatment of patients with chronic spinal cord injury (SCI) on somatosensory evoked potentials (SSEPs).Setting:A public tertiary hospital in São Paulo, Brazil.Methods:Thirty-nine consecutive patients with diagnosed complete cervical and thoracic SCI for at least 2 years and with no cortical response in the
A F Cristante; T E P Barros-Filho; N Tatsui; A Mendrone; J G Caldas; A Camargo; A Alexandre; W G J Teixeira; R P Oliveira; R M Marcon
Transplants of fibroblasts genetically modified to express BDNF (Fb\\/BDNF) have been shown to promote regeneration of rubrospinal axons and recovery of forelimb function when placed acutely into the injured cervical spinal cord of adult rats. Here we investigated whether Fb\\/BDNF cells could stimulate supraspinal axon regeneration and recovery after chronic (4 week) injury. Adult female Sprague-Dawley rats received a complete
Ying Jin; Itzhak Fischer; Alan Tessler; John D. Houle
Study design:A cross-sectional survey.Objectives:To document bowel care practices of chronic spinal cord injury (SCI) patients in Pakistan.Settings:Outpatient Department, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan.Methods:A total of 50 adult patients (18–65 years) with SCI of duration >12 months were sampled by convenience sampling. Medical record was reviewed, detailed neurological examination was performed and face-to-face semistructured interviews were conducted. Data
R Yasmeen; F A Rathore; K Ashraf; A W Butt
Study design:Cross-sectional.Objective:To determine the association between leisure-time physical activity (LTPA) and adherence to Eating Well with Canada's Food Guide (CFG) in community-dwelling adults with chronic Spinal Cord Injury (SCI).Setting:Ontario, Canada.Methods:Participants were recruited as part of the Study of Health and Activity in People with SCI (SHAPE-SCI). Dietary data were collected using 24-h recalls and analysed for adherence to CFG recommendations
K H Knight; A C Buchholz; K A Martin Ginis; R E Goy
Paralysis is the most feared postoperative complication of ACDF and occurs most often due to an epidural hematoma. In the absence of a clear etiology, inadequate decompression or vascular insult such as ischemia/reperfusion injury are the usual suspects. Herewith we report a case of complete loss of somatosensory evoked potentials (SSEPs) during elective ACDF at C4-5 and C5-6 followed by postoperative C6 incomplete tetraplegia without any discernible technical cause. A postoperative MRI demonstrated a large area of high signal changes on T2-weighted MRI intrinsic to the cord “white cord syndrome” but no residual compression. This was considered consistent with spinal cord gliosis with possible acute edema. The acute decompression of the herniated disc resulted in cord expansion and rush-in reperfusion. We postulate that this may have led to disruption in the blood brain barrier (BBB) and triggered a cascade of reperfusion injuries resulting in acute neurologic dysfunction. At 16 months postoperatively our patient is recovering slowly and is now a Nurick Grade 4.
Chin, Kingsley R.; Seale, Jason
Chronic spinal cord injury (SCI) results in an accelerated trajectory of several cardiovascular disease (CVD) risk factors and related aging characteristics, however the molecular mechanisms that are activated have not been explored. Adipokines and leptin signaling are known to play a critical role in neuro-endocrine regulation of energy metabolism, and are now implicated in central inflammatory processes associated with CVD. Here, we examine hypothalamic adipokine gene expression and leptin signaling in response to chronic spinal cord injury and with advanced age. We demonstrate significant changes in fasting-induced adipose factor (FIAF), resistin (Rstn), long-form leptin receptor (LepRb) and suppressor of cytokine-3 (SOCS3) gene expression following chronic SCI and with advanced age. LepRb and Jak2/stat3 signaling is significantly decreased and the leptin signaling inhibitor SOCS3 is significantly elevated with chronic SCI and advanced age. In addition, we investigate endoplasmic reticulum (ER) stress and activation of the uncoupled protein response (UPR) as a biological hallmark of leptin resistance. We observe the activation of the ER stress/UPR proteins IRE1, PERK, and eIF2alpha, demonstrating leptin resistance in chronic SCI and with advanced age. These findings provide evidence for adipokine-mediated inflammatory responses and leptin resistance as contributing to neuro-endocrine dysfunction and CVD risk following SCI and with advanced age. Understanding the underlying mechanisms contributing to SCI and age related CVD may provide insight that will help direct specific therapeutic interventions.
Bigford, Gregory E.; Bracchi-Ricard, Valerie C.; Nash, Mark S.; Bethea, John R.
Purpose: The consequences from the injection of different types of drugs in the epidural space remains unknown. Increasing evidence suggests that localized inflammation, fibrosis, and arachnoiditis can complicate sequential epidural blockades, or even epidural contrast injection. We investigate the in vivo effect of epidural injections in the epidural space in an animal model. Materials and Methods: A group of ten male adult pigs, five punctures to each at distinct vertebral interspaces under general anesthesia, were examined, testing different drugs, used regularly in the epidural space (iopamidol, methylprednisolone acetate, ropivacaine). Each site was marked with a percutaneous hook wire marker. Histological analysis of the epidural space, the meninges, and the underlying spinal cord of the punctured sites along with staining for caspase-3 followed 20 days later. Results: The epidural space did not manifest adhesions or any other pathology, and the outer surface of the dura was not impaired in any specimen. The group that had the contrast media injection showed a higher inflammation response compared to the other groups (P = 0.001). Positive staining for caspase-3 was limited to <5% of neurons with all substances used. Conclusion: No proof of arachnoiditis and/or fibrosis was noted in the epidural space with the use of the above-described drugs. A higher inflammation rate was noted with the use of contrast media.
Kitsou, Maria-Chrysanthi; Kostopanagiotou, Georgia; Kalimeris, Konstantinos [University of Athens, 2nd Department of Anesthesiology-Pain Unit, School of Medicine, Attikon University Hospital (Greece); Vlachodimitropoulos, Demetrios [University of Athens, Department of Forensic Medicine, School of Medicine (Greece); Soultanis, Konstantinos [University of Athens, 1st Department of Orthopaedics, School of Medicine, Attikon University Hospital (Greece); Batistaki, Chrysanthi [University of Athens, 2nd Department of Anesthesiology-Pain Unit, School of Medicine, Attikon University Hospital (Greece); Kelekis, Alexis, E-mail: email@example.com [University of Athens, 2nd Radiology Department, Attikon University Hospital (Greece)
Spinal symptoms in acute bacterial meningitis are rare. In a series of 10 cases of neurolisteriosis, we observed 2 spinal complications, one due to an acute intramedullary abscess, the other caused by chronic spinal arachnoiditis. Therefore, if spinal symptoms develop in acute bacterial meningitis,Listeria monocytogenes infection should be considered and early adequate antibiotic treatment be implemented.
Karl Pfadenhauer; Tilman Rossmanith
Administration of lumbar epidural analgesia in a parturient with previous spinal surgery presents a unique challenge to the anesthesiologist. These challenges (difficulties) range from inability to identify the epidural space, multiple attempts before catheter insertion, vascular trauma, and\\/or subdural local anesthetic injection to accidental dural puncture. The literature documenting management of labor analgesia in pregnant women with prior spinal surgery
Krzysztof M. Kuczkowski
ObjectivesTo determine the efficacy of treating neuropathic pain in spinal cord injury (SCI) patients by psychological, cognitive or behavioral therapies and suggest recommendations for clinical practices.
D. Gault; M. Morel-Fatio; T. Albert; C. Fattal
Summary Background: Mycobacterium abscessus is a member of the Rapidly Growing Mycobacterium (RGM). The incidence of Mycobacterium abscessus infections has steadily been increasing over the last decade. We report the case of an epidural abscess caused by Mycobacterium abscessus. RGM’s have infrequently been reported as spinal infections and we found no prior cases reporting M. abscessus as the definitive etiologic agent of an epidural abscess. Case Report: A 50 year old female presented with significant back pain and was found to have an epidural abscess by magnetic resonance imaging. The abscess was drained via needle. Initial cultures were negative for bacterial pathogens, and the patient was discharged to a skilled nursing facility for empiric antibiotic treatment. Eventually the culture grew Mycobacterium abscessus. The patient had unfortunately left the nursing facility and was lost to follow up. Conclusions: Mycobacterium abscessus is an increasingly recognized pathogen with particular risk factors that physicians should be aware of. Central nervous system infections are rare, but do occur. Treatment is difficult, though multiple antibiotic regimens have been reported successful. Surgical debridement is often needed.
Edwards, Charles; Diveronica, Matthew; Abel, Erika
Background Chronic spinal cord injury (SCI) can lead to an insidious decline in motor and sensory function in individuals even years after the initial injury and is accompanied by a slow and progressive cytoarchitectural destruction. At present, no pathological mechanisms satisfactorily explain the ongoing degeneration. Methods Adult female Sprague-Dawley rats were anesthetized laminectomized at T10 and received spinal cord contusion injuries with a force of 250 kilodynes using an Infinite Horizon Impactor. Animals were randomly distributed into 5 groups and killed 1 (n = 4), 28 (n = 4), 120 (n = 4), 450 (n = 5), or 540 (n = 5) days after injury. Morphometric and immunohistochemical studies were then performed on 1 mm block sections, 6 mm cranial and 6 mm caudal to the lesion epicenter. The SPSS 11.5 t test was used to determine differences between quantitative measures. Results Here, we document the first report of an ascending central canal dilation and progressive ependymal disruption cranial to the epicenter of injury in a contusion model of chronic SCI, which was characterized by extensive dural fibrosis and intraparenchymal cystic cavitation. Expansion of the central canal lumen beyond a critical diameter corresponded with ependymal cell ciliary loss, an empirically predictable thinning of the ependymal region, and a decrease in cell proliferation in the ependymal region. Large, aneurysmal dilations of the central canal were accompanied by disruptions in the ependymal layer, periependymal edema and gliosis, and destruction of the adjacent neuropil. Conclusion Cells of the ependymal region play an important role in CSF homeostasis, cellular signaling and wound repair in the spinal cord. The possible effects of this ascending pathology on ependymal function are discussed. Our studies suggest central canal dilation and ependymal region disruption as steps in the pathogenesis of chronic SCI, identify central canal dilation as a marker of chronic SCI and provide novel targets for therapeutic intervention.
Radojicic, Milan; Nistor, Gabriel; Keirstead, Hans S
More than 90% of hepatocellular carcinoma (HCC) arise in a chronical hepatitis. When HCC is diagnosed, most of the patients have symptoms in relation to cirrhosis of the liver. Spread metastases are not frequent and the extension to soft tissues is exceptional. We reported a 55 year old patient who had alcoholic cirrhosis and HCC with quickly development. The onset was a spinal cord compression due to soft tissues epidural metastases, seated at paravertebral zone. Plain radiographs and radionuclide bone scans were normal; diagnosis was achieved by magnetic resonance imaging and fine-needle aspiration cytology of the tumor. We have found no bibliographic reference on spinal cord compression due to soft tissues metastases from HCC. We want to point out the importance of including soft tissues metastases in differential diagnosis for radiculopathies with normal radiography and radionuclide scanning in patients at risk, considering also patients with hepatocellular carcinoma. PMID:10638003
Pinazo Serón, M J; Benet i Català, A; Ferrer i Santaularia, J; Clotas i Sancho, L; Gens i Barbera, M; Cartanyà i Benet, A
Objective: Magnesium has been used as an adjuvant by various routes, including intravenous, intrathecal, and epidural in different dosage regimens. The effect of single bolus dose of magnesium as an adjuvant to fentanyl for postoperative analgesia has not been studied. This prospective randomized controlled trial was done to evaluate the efficacy of single bolus administration of magnesium epidurally as an adjuvant to epidural fentanyl for postoperative analgesia in patients undergoing total hip replacement under combined spinal epidural anesthesia. Methods: Sixty patients received combined spinal–epidural anesthesia with 2 mL of 0.5% hyperbaric bupivacaine intrathecally. After the surgery, patients were randomized into Group F [epidural fentanyl (1 ?g/kg) in 10 mL saline] and Group FM [epidural magnesium (75 mg) along with fentanyl (1 ?g/kg) in 10 mL saline]. Supplementary analgesia was provided by 50 mg intravenous tramadol if Verbal Rating Score (VRS) >4. Patient's first analgesic requirement and duration of analgesia were recorded. Results: The duration of analgesia was significantly longer for Group FM, 340±28.8 min, compared with Group F, 164±17.1 min (P=0.001). The frequency of rescue analgesics required in 24-h postoperative period in Group FM (2.3±0.5) was significantly less than that in Group F (4.3±0.5) (P=0.001). VRS was significantly lower in Group FM up to 4 h in the postoperative period (P=0.001). Bromage scale was statistically insignificant at all points of time. Conclusions: The administration of magnesium (75 mg) as an adjuvant to epidural fentanyl (1 ?g/ kg) for postoperative analgesia results in significantly lower VRS with prolonged duration of analgesia as compared with epidural fentanyl (1 ?g/kg) alone. Concomitant administration of magnesium also reduces the requirement of breakthrough analgesics with no increased incidence of side effects.
Banwait, Sonali; Sharma, Sujata; Pawar, Mridula; Garg, Rakesh; Sood, Rajesh
Spinal cord injury (SCI) is a lifelong condition affecting over 40,000 people in the UK. When an individual with established SCI is admitted to hospital for a procedure or because of illness, hospital teams need to manage both the acute condition and the spinal cord injury. These guidelines aim to assist in their assessment and management to avoid the common
Angela Gall; Lynne Turner; Stokes FRCP
Diffusion tensor imaging (DTI) using a combination of direct anisotropy measurements provided a more anatomically accurate morphological representation of the human spinal cord than traditional anisotropy indices. Furthermore, the use of a fuzzy logic algorithm to segment regions of gray and white matter within the spinal cord based on these anisotropy measurements allowed for morphometric analyses. Results indicated a significant
Benjamin M. Ellingson; John L. Ulmer; Robert W. Prost; Brian D. Schmit
There has been only one reported case of neuromuscular scoliosis following chronic inflammatory demyelinating polyneuropathy (CIDP). However, no cases of scoliosis that were treated with surgery secondary to CIDP have been previously described. A 16-year-old boy with CIDP was consultant due to the progression of scoliosis with the coronal curve of 86° from T8 to T12. Posterior correction and fusion with segmental pedicle screws were performed under intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials. Although the latency period was prolonged and amplitude was low, the potential remained stable. Coronal curve was corrected from 86° to 34° without neurological complications. We here describe scoliosis associated with CIDP, which was successfully treated with surgery under intraoperative spinal cord monitoring.
Miyakoshi, Naohisa; Hongo, Michio; Kasukawa, Yuji; Ishikawa, Yoshinori; Misawa, Akiko; Shimada, Yoichi
In order to investigate the role of spinal glutamate transporter 1 (GLT-1) in the neuropathic pain and morphine tolerance, rat chronic constriction injury (CCI) of sciatic nerve was performed, and the mechanical allodynia was evaluated by mechanical withdrawal threshold (MWT), the expression of GLT-1 was measured by real-time PCR and Western blotting analysis. The results showed that compared to sham group, the MWT of CCI group had decreased approximately 80%. Administration of morphine alone could develop tolerance rapidly in initial two days, and then had no significant difference with CCI group, the expression of GLT-1 was down-regulated. Ceftriaxone sodium alone could improve mechanical allodynia. Co-administration of ceftriaxone sodium with morphine attenuated morphine tolerance and up-regulated GLT-1 expression, and the MWT remained at high level after 6 days. In conclusion, change of spinal GLT-1 expression and function has close correlation with the development of neuropathic pain and morphine tolerance. PMID:19806886
Yan, Hui; Li, Cheng-Min; Li, Yu-Lei; Gong, Ze-Hui
Vascular disease affecting the spinal can cause substantial neurologic morbidity. Several vascular spinal cord ailments present as neurologic emergencies, and should thus be recognizable to the practicing neurologist. We review the epidemiology, presentation, management strategies, and prognosis of various pathologies, including infarction, dural arteriovenous fistula, arteriovenous malformation, cavernous malformation, compressive epidural hematoma, vasculitis, and genetic abnormalities. PMID:23186899
Rubin, Mark N; Rabinstein, Alejandro A
Spinal cord injury (SCI) impairs sensory systems causing allodynia. To identify cellular and molecular causes of allodynia, sensitive and valid sensory testing in rat SCI models is needed. However, until recently, no single testing approach had been validated for SCI so that standardized methods have not been implemented across labs. Additionally, available testing methods could not be implemented acutely or when severe motor impairments existed, preventing studies of the development of SCI-induced allodynia(3). Here we present two validated sensory testing methods using von Frey Hair (VFH) monofilaments which quantify changes in tactile sensory thresholds after SCI. One test is the well-established Up-Down test which demonstrates high sensitivity and specificity across different SCI severities when tested chronically. The other test is a newly-developed dorsal VFH test that can be applied acutely after SCI when allodynia develops, prior to motor recovery. Each VFH monofilament applies a calibrated force when touched to the skin of the hind paw until it bends. In the up-down method, alternating VFHs of higher or lower forces are used on the plantar L5 dermatome to delineate flexor withdrawal thresholds. Successively higher forces are applied until withdrawal occurs then lower force VFHs are used until withdrawal ceases. The tactile threshold reflects the force required to elicit withdrawal in 50% of the stimuli. For the new test, each VFH is applied to the dorsal L5 dermatome of the paw while the rat is supported by the examiner. The VFH stimulation occurs in ascending order of force until at least 2 of 3 applications at a given force produces paw withdrawal. Tactile sensory threshold is the lowest force to elicit withdrawal 66% of the time. Acclimation, testing and scoring procedures are described. Aberrant trials that require a retest and typical trials are defined. Animal use was approved by Ohio State University Animal Care and Use Committee. PMID:22508401
Detloff, Megan Ryan; Fisher, Lesley C; Deibert, Rochelle J; Basso, D Michele
Preliminary Results of Spinal Cord Compression Recurrence Evaluation (Score-1) Study Comparing Short-Course Versus Long-Course Radiotherapy for Local Control of Malignant Epidural Spinal Cord Compression
Purpose: To compare the results of short-course vs. long-course radiotherapy (RT) for metastatic spinal cord compression. Methods and Materials: A total of 231 patients who underwent RT between January 2006 and August 2007 were included in this two-arm prospective nonrandomized study. Patients received short-course (n = 114) or long-course (n = 117) RT. The primary endpoint was progression-free survival (PFS). The secondary endpoints were local control (LC), functional outcome, and overall survival (OS). An additional 10 potential prognostic factors were investigated for outcomes. PFS and LC were judged according to motor function, not pain control. Results: The PFS rate at 12 months was 72% after long-course and 55% after short-course RT (p = 0.034). These results were confirmed in a multivariate analysis (relative risk, 1.33; 95% confidence interval, 1.01-1.79; p = 0.046). The 12-month LC rate was 77% and 61% after long-course and short-course RT, respectively (p = 0.032). These results were also confirmed in a multivariate analysis (relative risk, 1.49; 95% confidence interval, 1.03-2.24; p = 0.035). The corresponding 12-month OS rates were 32% and 25% (p = 0.37). Improvement in motor function was observed in 30% and 28% of patients undergoing long-course vs. short-course RT, respectively (p = 0.61). In addition to radiation schedule, PFS was associated with the interval to developing motor deficits before RT (relative risk, 1.99; 95% confidence interval, 1.10-3.55; p = 0.024). LC was associated only with the radiation schedule. Post-RT motor function was associated with performance status (p = 0.031), tumor type (p = 0.013), interval to developing motor deficits (p = 0.001), and bisphosphonate administration (p = 0.006). OS was associated with performance status (p < 0.001), number of involved vertebrae (p = 0.007), visceral metastases (p < 0.001), ambulatory status (p < 0.001), and bisphosphonate administration (p < 0.001). Conclusion: Short-course and long-course RT resulted in similar functional outcome and OS. Long-course RT was significant for improved PFS and improved LC.
Rades, Dirk [Department of Radiation Oncology, University Hospital Lubeck, Lubeck (Germany)], E-mail: Rades.Dirk@gmx.net; Lange, Marisa [Department of Radiation Oncology, University Hospital Lubeck, Lubeck (Germany); Veninga, Theo [Department of Radiation Oncology, Dr. Bernard Verbeeten Institute, Tilburg (Netherlands); Rudat, Volker [Department of Radiation Oncology, Saad Specialist Hospital, Al Khobar (Saudi Arabia); Bajrovic, Amira [Department of Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf (Germany); Stalpers, Lukas J.A. [Department of Radiotherapy, Academic Medical Center, Amsterdam (Netherlands); Dunst, Juergen [Department of Radiation Oncology, University Hospital Lubeck, Lubeck (Germany); Schild, Steven E. [Department of Radiation Oncology, Mayo Clinic Scottsdale, Scottsdale, AZ (United States)
Objective To investigate whether higher resilience level predicts low levels of psychological distress in chronic SCI patients living in the community. Method Thirty seven patients (mean age 41.5±10.9, male : female=28 : 9) with chronic spinal cord injury (duration 8.35±7.0 years) living in the community are included, who were hospitalized for annual checkups from November, 2010 to May, 2011. First, their spinal cord injury level, completeness and complications were evaluated. The patients completed questionnaires about their educational status, religion, employment status, marital status, medical and psychological history and also the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Connor-Davidson Resilience Scale (CD-RISC), Alcohol Use Disorders Identification Test-alcohol consumption questions (AUDIT-C) and Health-related quality of life (EQ-5D). The patients were divided into two subgroups: patients with HADS ?13 are classified as high psychological distress group and others as low psychological distress group. We compared the two groups to find statistically significant differences among the variables. Results CD-RISC, EQ-5D and employment status are significantly different between two groups (p<0.05). In a forward stepwise regression, we found that EQ-5D had a greater contribution than CD-RISC to the psychological distress level. Conclusion In addition to health-related quality of life, resilience can be suggested as a possible predictor of psychological distress in chronic SCI patients.
Shin, Jung-In; Min, Jung-Ah; Lee, Chang-Uk; Hwang, Sung-Il; Lee, Bum-Suk; Han, Sang-Hoon; Ju, Hye-In; Lee, Cha-Yeon
Na(+)-K(+)-ATPase is an integral membrane protein crucial for the maintenance of ion homeostasis and skeletal muscle contractibility. Skeletal muscle Na(+)-K(+)-ATPase content displays remarkable plasticity in response to long-term increase in physiological demand, such as exercise training. However, the adaptations in Na(+)-K(+)-ATPase function in response to a suddenly decreased and/or habitually low level of physical activity, especially after a spinal cord injury (SCI), are incompletely known. We tested the hypothesis that skeletal muscle content of Na(+)-K(+)-ATPase and the associated regulatory proteins from the FXYD family is altered in SCI patients in a manner dependent on the severity of the spinal cord lesion and postinjury level of physical activity. Three different groups were studied: 1) six subjects with chronic complete cervical SCI, 2) seven subjects with acute, complete cervical SCI, and 3) six subjects with acute, incomplete cervical SCI. The individuals in groups 2 and 3 were studied at months 1, 3, and 12 postinjury, whereas individuals with chronic SCI were compared with an able-bodied control group. Chronic complete SCI was associated with a marked decrease in [(3)H]ouabain binding site concentration in skeletal muscle as well as reduced protein content of the ?(1)-, ?(2)-, and ?(1)-subunit of the Na(+)-K(+)-ATPase. In line with this finding, expression of the Na(+)-K(+)-ATPase ?(1)- and ?(2)-subunits progressively decreased during the first year after complete but not after incomplete SCI. The expression of the regulatory protein phospholemman (PLM or FXYD1) was attenuated after complete, but not incomplete, cervical SCI. In contrast, FXYD5 was substantially upregulated in patients with complete SCI. In conclusion, the severity of the spinal cord lesion and the level of postinjury physical activity in patients with SCI are important factors controlling the expression of Na(+)-K(+)-ATPase and its regulatory proteins PLM and FXYD5. PMID:22275761
Boon, Hanneke; Kostovski, Emil; Pirkmajer, Sergej; Song, Moshi; Lubarski, Irina; Iversen, Per O; Hjeltnes, Nils; Widegren, Ulrika; Chibalin, Alexander V
Presented in abstract form at the annual meeting of the American Spinal Injury Association, Tampa, Florida (June, 2007). Correspondence: Eric Garshick, MD, MOH VA Boston Healthcare System Pulmonary and Critical Care Medicine Section 1400 VFW Parkway West Roxbury, MA 02132
Kelly L Stolzmann; David R. Gagnon; Robert Brown; Carlos G. Tun; Eric Garshick
Recent medical advances have substantially improved longevity for spinal cord injured (SCI) individuals. This fact, combined with the numerous physiologic and metabolic changes that accompany SCI result in increased risks for the development of the same o...
Spinal surgery, particularly spinal fu- sion surgery, alters the anatomy of the spine and hence, may increase the difficulty of per - forming an interventional spine procedure. Transforaminal epidural procedures have gained popularity as an alternative to in- terlaminar epidural steroids in the manage- ment of radicular pain syndromes. Patients with failed back surgery syndrome are of- ten excluded or
Rinoo V. Shah; Wesley Merritt; Dwayne Collins; Gabor B. Racz
Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar\\u000a spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication.\\u000a Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection\\u000a of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity
Bradly S. Goodman; Lyle W. F. Posecion; Srinivas Mallempati; Matt Bayazitoglu
Chronic neuropathic pain is a common and debilitating consequence of spinal cord injury (SCI). In a rat contusion injury model, we observed that chronic neuropathic pain is present on day 7 after SCI and persists for the entire 56-day observation period. However, currently available pain therapies are inadequate for SCI-induced neuropathic pain. In this study, we show that spinal transplantation of mouse embryonic stem cell-derived oligodendrocyte progenitor cells (OPCs) enhances remyelination in the injured spinal cord and reduces SCI-induced chronic neuropathic pain. Moreover, we found that SCI reduces the protein level of neuregulin-1 and ErbB4 in the injured spinal cord and that OPC transplantation enhances the spinal expression of both proteins after SCI. Finally, intrathecal injection of neuregulin-1 small interfering RNA, but not the control nontarget RNA, diminishes OPC transplantation-produced remyelination and reverses the antinociceptive effect of OPC transplantation. Our findings suggest that the transplantation of embryonic stem cell-derived OPCs is an appropriate therapeutic intervention for treatment of SCI-induced chronic neuropathic pain, and that neuregulin-1/ErbB signaling plays an important role in central remyelination under pathological conditions and contributes to the alleviation of such pain. PMID:23097328
Tao, Feng; Li, Qun; Liu, Su; Wu, Haiying; Skinner, John; Hurtado, Andres; Belegu, Visar; Furmanski, Orion; Yang, Ya; McDonald, John W; Johns, Roger A
X ray dynamic study of cerevical spine movements in 12 patients with neurological impairment has shown an abnormal mobility between two vertebrae in the anterior or posterior direction. This abnormal mobility which has been called functional dislocation, is situated usually over major discarthrosic lesions rather than under. This dislocation, which appears during voluntary and automatic movements of the head and neck has been qualified chronic. A discectomie through an anterior surgical approach and a bony fusion of vertebral bodies without any graft at the dislocation site lead to 10 good results. 2 failures have been imputed to the fact that there was a 10 years evolution of a tetraplegia before operation. The pathogenesis of chronic functional dislocation of the cervical spine is discussed with regard to compression and stretching of the spinal cord, roots and arteries of both. Traumatism of vertebral arteries during dislocation remain under discussion. PMID:1013573
Pertuiset, B; Lyon-Caen, O
Forty patients with chronic pain below the waist level were evaluated in a multidisciplinary pain clinic using a refined differential spinal block (DSB) technique. The refinements consisted of verbal instructions to prevent biasing the patients, coupled with a thorough evaluation of verbal and physiologic responses to the block. When demographic and psychologic data were assessed according to pain mechanisms, a pattern of patient groups emerged along a chronic pain continuum. Stress, anxiety, depression, and hysteria, as well as the neurophysiologic and demographic factors, modified the responses to the block. Long-term follow-up of these patients, including repeat DSB procedures and confirmatory anatomic blocks of sympathetic and somatic nerves, validated these impressions. The findings indicate a link between pain mechanisms and psychosocial factors that may directly influence responses to DSB. PMID:760599
Ghia, J N; Toomey, T C; Mao, W; Duncan, G; Gregg, J M
Background Epidural anesthesia is widely used to provide pain relief, whether for surgical anesthesia, postoperative analgesia, treatment of chronic pain, or to facilitate painless childbirth. In many cases, however, the epidural catheter is inserted blindly and the indwelling catheter position is almost always uncertain. Methods In this study, the loss-of-resistance technique was used and an imaging agent was injected through the indwelling epidural anesthesia catheter to confirm the position of its tip and examine the migration rate. Study subjects were patients scheduled to undergo surgery using general anesthesia combined with epidural anesthesia. Placement of the epidural catheter was confirmed postoperatively by injection of an imaging agent and X-ray imaging. Results The indwelling epidural catheter was placed between upper thoracic vertebrae (n = 83; incorrect placement, n = 5), lower thoracic vertebrae (n = 123; incorrect placement, n = 5), and lower thoracic vertebra-lumbar vertebra (n = 46; incorrect placement, n = 7). In this study, a relatively high frequency of incorrectly placed epidural catheters using the loss-of-resistance technique was observed, and it was found that incorrect catheter placement resulted in inadequate analgesia during surgery. Conclusions Although the loss-of-resistance technique is easy and convenient as a method for epidural catheter placement, it frequently results in inadequate placement of epidural catheters. Care should be taken when performing this procedure.
Hagiwara, Satoshi; Iwasaka, Hideo; Kudo, Kyosuke; Takatani, Junji; Mizutani, Akio; Miura, Masahiro; Noguchi, Takayuki
Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder caused by defective levels of the survival motor neuron (SMN) protein. SMA causes spinal motoneuron (MN) loss, and progressive muscle weakness and paralysis. Currently, there is no effective therapy to cure this disease. Although different strategies focused on increasing the expression of functional SMN protein have been assayed, numerous SMN-independent therapeutic approaches have been demonstrated to have potential effectiveness in improving the SMA phenotype in mouse models and clinical trials. Recent works have shown that compounds which inhibit GSK-3? activity are effective in promoting MN survival and ameliorating lifespan in models of MN diseases including SMA. Taking into account the reported neuroprotective actions of lithium (Li) through the inhibition of GSK-3? in different studies, we tested here its potential efficiency as a therapeutic agent in a mouse model of severe SMA (SMN?7 mice). We show that the chronic treatment with Li initiated before the appearance of disease symptoms, although inhibited GSK-3?, did not improve the median survival, motor behavior, and spinal MN loss linked to SMA. Li administration did not either ameliorate the microglial and astroglial reaction in the spinal cord or the depletion of glutamatergic synapses on MNs observed in SMN?7 animals. Moreover, Li treatment did not mitigate muscle atrophy or calcitonin gene-related peptide (CGRP) downregulation in the neuromuscular junctions linked to the disease. However, a significant reduction in apoptotic cell death found in the skeletal muscle of SMA mice was observed after Li treatment. PMID:23876328
Dachs, E; Piedrafita, L; Hereu, M; Esquerda, J E; Calderó, J
Objective Chronic neck or back pain can be managed with various procedures. Although these procedures are usually well-tolerated, a variety of side effects have been reported. In this study we reviewed cases of unexpected temporary adverse events after blocks and suggest possible causes. Methods We reviewed the records of patients treated with spinal pain blocks between December 2009 and January 2011. The types of blocks performed were medial branch blocks, interlaminar epidural blocks and transforaminal epidural blocks. During the first eight months of the study period (Group A), 2% mepivacaine HCL and triamcinolone was used, and during the last six months of the study period (Group B), mepivacaine was diluted to 1% with normal saline. Results There were 704 procedures in 613 patients. Ten patients had 12 transient neurologic events. Nine patients were in Group A and one was in Group B. Transient complications occurred in four patients after cervical block and in eight patients after lumbar block. Side effects of lumbar spine blocks were associated with the concentration of mepivacaine (p<0.05). The likely causes were a high concentration of mepivacaine in five patients, inadvertent vascular injection in three patients, intrathecal leak of local anesthetics in one, and underlying conversion disorder in one. Conclusion Spinal pain blocks are a good option for relieving pain, but clinicians should always keep in mind the potential for development of inevitable complications. Careful history-taking, appropriate selection of the anesthetics, and using real-time fluoroscopy could help reduce the occurrence of adverse events.
Lee, Han-Il; Park, Yong-Sook; Cho, Tack-Geun; Park, Seung-Won; Kwon, Jeong-Taik
Brain-derived neurotrophic factor (BDNF) is a neurotrophin (NT) known to participate in chronic somatic pain. A recent study has indicated that BDNF may participate in chronic cystitis at the peripheral level. However, the principal site of action for this NT is the central nervous system, most notably the spinal cord. The effects of centrally-acting BDNF on bladder function in normal animals and its central role during chronic cystitis are presently unknown. The present study was undertaken to clarify this issue. For that purpose, control non-inflamed animals were intrathecally injected with BDNF, after which bladder function was evaluated. This treatment caused short-lasting bladder hyperactivity; whereas chronic intrathecal administration of BDNF did not elicit this effect. Cutaneous sensitivity was assessed by mechanical allodynia as an internal control of BDNF action. To ascertain the role of BDNF in bladder inflammation, animals with cyclophosphamide-induced cystitis received intrathecal injections of either a general Trk receptor antagonist or a BDNF scavenger. Blockade of Trk receptors or BDNF sequestration notably improved bladder function. In addition, these treatments also reduced referred pain, typically observed in rats with chronic cystitis. Reduction of referred pain was accompanied by a decrease in the spinal levels of extracellular signal-regulated kinase (ERK) phosphorylation, a marker of increased sensory barrage in the lumbosacral spinal cord, and spinal BDNF expression. Results obtained here indicate that BDNF, acting at the spinal cord level, contributes to bladder hyperactivity and referred pain, important hallmarks of chronic cystitis. In addition, these data also support the development of BDNF modulators as putative therapeutic options for the treatment of chronic bladder inflammation. PMID:23313710
Frias, B; Allen, S; Dawbarn, D; Charrua, A; Cruz, F; Cruz, C D
A 20-year-old male presented with an extremely rare spontaneous epidural pneumocephalus which was successfully treated by a single neurosurgical intervention. The patient had a habit of nose blowing and a 1-year history of progressive headache and nausea. Cranial computed tomography (CT) revealed a 2 x 7 cm right temporo-occipital epidural pneumocephalus with extensive hyperpneumatization of the mastoid cells. Right temporo-occipital craniotomy with a right superficial temporal artery and vein flap repair resulted in radiographic resolution of the pneumocephalus, and he remained neurologically free of symptoms at 1-year follow-up examination. Early identification and monitoring of symptomatic pneumocephalus followed by decompression and prevention of infection via closure of the bone defect can avoid possible serious consequences. The underlying mechanisms may involve a congenital petrous bone defect and a ball-valve effect due to excessive nose blowing in our case. PMID:18948684
Tucker, Adam; Miyake, Hiroji; Tsuji, Masao; Ukita, Tohru; Nishihara, Kentaro; Ito, Seiko; Ohmura, Takehisa
Background Traumatic spinal cord injury (SCI) induces secondary tissue damage that is associated with astrogliosis and inflammation. We previously reported that acute upregulation of a cluster of cell-cycle-related genes contributes to post-mitotic cell death and secondary damage after SCI. However, it remains unclear whether cell cycle activation continues more chronically and contributes to more delayed glial change. Here we examined expression of cell cycle-related proteins up to 4?months following SCI, as well as the effects of the selective cyclin-dependent kinase (CDKs) inhibitor CR8, on astrogliosis and microglial activation in a rat SCI contusion model. Methods Adult male rats were subjected to moderate spinal cord contusion injury at T8 using a well-characterized weight-drop model. Tissue from the lesion epicenter was obtained 4?weeks or 4?months post-injury, and processed for protein expression and lesion volume. Functional recovery was assessed over the 4?months after injury. Results Immunoblot analysis demonstrated a marked continued upregulation of cell cycle-related proteins???including cyclin D1 and E, CDK4, E2F5 and PCNA???for 4?months post-injury that were highly expressed by GFAP+ astrocytes and microglia, and co-localized with inflammatory-related proteins. CR8 administrated systemically 3?h post-injury and continued for 7?days limited the sustained elevation of cell cycle proteins and immunoreactivity of GFAP, Iba-1 and p22PHOX???a key component of NADPH oxidase???up to 4?months after SCI. CR8 treatment significantly reduced lesion volume, which typically progressed in untreated animals between 1 and 4?months after trauma. Functional recovery was also significantly improved by CR8 treatment after SCI from week 2 through week 16. Conclusions These data demonstrate that cell cycle-related proteins are chronically upregulated after SCI and may contribute to astroglial scar formation, chronic inflammation and further tissue loss.
Traumatic injury to the central nervous system results in the disruption of the blood brain/spinal barrier, followed by the invasion of cells and other components of the immune system that can aggravate injury and affect subsequent repair and regeneration. Although studies of chronic neuroinflammation in the injured spinal cord of animals are clinically relevant to most patients living with traumatic injury to the brain or spinal cord, very little is known about chronic neuroinflammation, though several studies have tested the role of neuroinflammation in the acute period after injury. The present study characterizes a novel cell preparation method that assesses, quickly and effectively, the changes in the principal immune cell types by flow cytometry in the injured spinal cord, daily for the first 10 days and periodically up to 180 days after spinal cord injury. These data quantitatively demonstrate a novel time-dependent multiphasic response of cellular inflammation in the spinal cord after spinal cord injury and are verified by quantitative stereology of immunolabelled spinal cord sections at selected time points. The early phase of cellular inflammation is comprised principally of neutrophils (peaking 1 day post-injury), macrophages/microglia (peaking 7 days post-injury) and T cells (peaking 9 days post-injury). The late phase of cellular inflammation was detected after 14 days post-injury, peaked after 60 days post-injury and remained detectable throughout 180 days post-injury for all three cell types. Furthermore, the late phase of cellular inflammation (14–180 days post-injury) did not coincide with either further improvements, or new decrements, in open-field locomotor function after spinal cord injury. However, blockade of chemoattractant C5a-mediated inflammation after 14 days post-injury reduced locomotor recovery and myelination in the injured spinal cord, suggesting that the late inflammatory response serves a reparative function. Together, these data provide new insight into cellular inflammation of spinal cord injury and identify a surprising and extended multiphasic response of cellular inflammation. Understanding the role of this multiphasic response in the pathophysiology of spinal cord injury could be critical for the design and implementation of rational therapeutic treatment strategies, including both cell-based and pharmacological interventions.
Beck, Kevin D.; Nguyen, Hal X.; Galvan, Manuel D.; Salazar, Desiree L.; Woodruff, Trent M.
It has been demonstrated that the infusion of bone marrow stromal cells (BMSCs) through the cerebrospinal fluid (CSF) has beneficial effects on acute spinal cord injury (SCI) in rats. The present study examined whether BMSC infusion into the CSF is effective for subacute (1- and 2-week post-injury), and/or chronic (4-week post-injury) SCI in rats. The spinal cord was contused by dropping a weight at the thoracic 8-9 levels. BMSCs cultured from GFP-transgenic rats of the same strain were injected three times (once weekly) into the CSF through the fourth ventricle, beginning at 1, 2 and 4 weeks post-injury. At 4 weeks after initial injection, the average BBB score for locomotor assessment increased from 1.0-3.5 points before injection to 9.0-10.9 points in the BMSC-injection subgroups, while, in the PBS (vehicle)-injection subgroups, it increased only from 0.5-4.0 points before injection to 3.0-5.1 points. Numerous axons associated with Schwann cells extended longitudinally through the connective tissue matrices in the astrocyte-devoid lesion without being blocked at either the rostral or the caudal borders in the BMSC-injection subgroups. A small number of BMSCs were found to survive within the spinal cord lesion in SCI of the 1-week post-injury at 2 days of injection, but none at 7 days. No BMSCs were found in the spinal cord lesion at 2 days or at 7 days in the SCI of the 2-week and the 4-week post-injury groups. In an in vitro experiment, BMSC-injected CSF promoted the survival and the neurite extension of cultured neurons more effectively than did the PBS-injected CSF. These results indicate that BMSCs had beneficial effects on locomotor improvement as well as on axonal regeneration in both subacute and chronic SCI rats, and the results also suggest that BMSCs might function as neurotrophic sources via the CSF. PMID:24039961
Nakano, Norihiko; Nakai, Yoshiyasu; Seo, Tae-Beom; Homma, Tamami; Yamada, Yoshihiro; Ohta, Masayoshi; Suzuki, Yoshihisa; Nakatani, Toshio; Fukushima, Masanori; Hayashibe, Miki; Ide, Chizuka
Ectopic extramedullary hematopoiesis (EMH), defined as the formation of blood cells outside the bone marrow, usually occurs in a scenario of chronic anemia when, even after conversion of the bony yellow marrow to red marrow, the body is still unable to meet the demand for red blood cells. Ectopic extramedullary hematopoiesis most commonly occurs in the liver and spleen but may, in fact, occur almost anywhere in the body. Although previous reports have documented EMH presenting as paraspinal masses, such lesions have almost always been associated with a predisposing hematological disorder such as hemolytic anemia, myelofibrosis or myelodysplastic syndromes, thalassemia, polycythemia vera, leukemia, or lymphoma. The authors of this report describe the first reported instance of EMH in a patient presenting with a symptomatic epidural and paraspinal cervical lesion arising from the posterior spinal elements and no known predisposing hematological disease. Initial radiographs revealed a bony lesion arising posteriorly from the C2-3 laminae and spinous processes. Subsequent imaging suggested the diagnosis, which was confirmed by CT-guided biopsy, peripheral blood smears, and bone marrow aspirate. Despite epidural compression and slight displacement of the cervical cord and thecal sac, the patient's symptoms were limited to pain and diminished cervical range of motion. Therefore, surgery was deferred in favor of nonsurgical therapy. Several alternative modalities for the treatment of EMH have been suggested in the literature, including cytotoxic agents and radiotherapy. The authors opted for an approach utilizing directed low-dose radiotherapy of a total of 25 Gy divided in 2.5-Gy fractions. At the 3-month follow-up, the patient continued to be asymptomatic, and MRI demonstrated a significant reduction in the dimensions of the lesion. Extramedullary hematopoiesis with spinal cord compression in the absence of a preexisting hematological disorder has not been described in the context of clinical neurosurgical practice. Recognizing that EMH may present as an epidural or paraspinal lesion is important since chemotherapy and radiotherapy are effective therapeutic options in the majority of patients who suffer few if any symptoms. Extensive evaluation for underlying hematological disorders is necessary before undertaking directed therapy. Inadvertent resection of these highly vascularized masses may risk catastrophic intraoperative hemorrhage with no proven benefit as compared with medical treatment, which usually provides excellent long-term outcomes. PMID:23330877
Mattei, Tobias A; Higgins, Michael; Joseph, Flynn; Mendel, Ehud
Aim: To evaluate the effect of hypogonadism on temporal characteristics of ventricular repolarization (VR) and QT\\/RR coherence in men with spinal cord injury (SCI). Methods: Thirty-four men with SCI (>1 year postinjury) were studied. After clinical evaluation, 20 subjects were diagnosed as hypogonadal and 14 as eugonadal. QT and RT time, heart rate (HR), and Bazett QTc were determined from
Michael F. La Fountaine; Jill M. Wecht; Christopher M. Cirnigliaro; Steven C. Kirshblum; Ann M. Spungen; William A. Bauman
ObjectiveNeuropathic pain (NP) is a common symptom following spinal cord injury (SCI). NP may be associated with altered processing of somatosensory pathways in dermatomes rostral to the injury level. To explore this possibility, the characteristics of contact heat evoked potentials (CHEPs) and quantitative thermal testing (QTT) were studied at and above the lesion level in SCI patients with NP. The
Hatice Kumru; Dolors Soler; Joan Vidal; Josep Maria Tormos; Alvaro Pascual-Leone; Josep Valls-Sole
Injury to the lower spine is common in working men. Fifty men with lumbar spinal injury who were in receipt of worker's compensation benefits were interviewed, along with the spouse, to ascertain the effects of the injury on marital harmony and sexual functioning. All subjects reported disruption of sexual activity and increasing marital disharmony which they directly attributed to the
Rosemary Coates; Paola A. Ferroni
To establish whether the reported increased cardiovascular (CV) morbidity in spinal cord injury (SCI) patients is due to increased levels of established CV risk factors, we assessed overall CV risk in 102 consecutive patients aged 25-64 by calculation of a 'risk factor score' (RFS) derived from the MRFIT study (age, diastolic blood pressure (DBP), total cholesterol (TC) level, cigarettes\\/day, sex),
H Krum; L G Howes; D J Brown; G Ungar; P Moore; J J McNeil; W J Louis
The long-term objective of this study is to develop neural prostheses for people with spinal cord injuries who are unable to voluntarily control their bladder. This feasibility study was performed in 22 adult cats. We implanted an array of microelectrodes into locations in the sacral spinal cord that are involved in the control of micturition reflexes. The effect of microelectrode stimulation was studied under light Propofol anesthesia at monthly intervals for up to 14 months. We found that electrical stimulation in the sacral parasympathetic nucleus at S2 level or in adjacent ventrolateral white matter produced bladder contractions insufficient for inducing voiding, while stimulation at or immediately dorsal to the dorsal gray commissure at S1 level produced strong (at least 20 mmHg) bladder contractions as well as strong (at least 40 mm Hg) external urethral sphincter relaxation, resulting in bladder voiding in 14 animals. In a subset of three animals, spinal cord transection was performed. For several months after the transection, intraspinal stimulation continued to be similarly or even more effective in inducing the bladder voiding as before the transection. We speculate that in the absence of the supraspinal connections, the plasticity in the local spinal circuitry played a role in the improved responsiveness to intraspinal stimulation.
Pikov, Victor; Bullara, Leo; McCreery, Douglas B.
Spinal cord injuries disrupt the communication between the brain and peripheral nerves, but leave motoneurons and networks of interneurons below the level of the lesion intact. It is therefore possible to restore some function following injury by providing an artificial stimulus to the surviving neurons below the level of the lesion. We report here on a novel approach for generating
Vivian K. Mushahwar; David F. Collins; Arthur Prochazka
BackgroundTherapy with diverse cell types has been proposed to regenerate spinal cord injuries seeking to minimize the consequences for the lives of chronic patients. The types considered are: mononuclear and mesenchymal adult stem cells, embryonic stem cells, and Schwann cells.
K. A. T. Carvalho; E. N. Vialle; G. H. G. Moreira; R. C. Cunha; R. B. Simeoni; J. C. Francisco; L. C. Guarita-Souza; L. Oliveira; L. Zocche; M. Olandoski
With the use of in vitro receptor autoradiography, this study aims at determining whether the higher level of kinin B(2) receptor density in the spinal cord of the spontaneously hypertensive rat (SHR) is secondary to arterial hypertension and whether chronic treatment with angiotensin I-converting enzyme inhibitors (ACEI) can regulate neuronal B(1) and B(2) receptors. SHR received, from the age of 4 wk, one of the two ACEI (lisinopril or zofenopril, 10 mg x kg(-1) x day(-1)) or for comparison, the selective AT(1) antagonist (losartan, 20 mg x kg(-1) x day(-1)) in their drinking water for a period of 4, 12, and 20 wk. Age-matched untreated SHR and Wistar-Kyoto rats (WKY) were used as controls. B(2) receptor binding sites in most laminae were higher in SHR than in WKY from the age of 8 to 24 wk. Whereas B(1) receptor binding sites were significantly present in young SHR and WKY, they were barely detectable in adult rats. ACEI (16 and 24 wk) and AT(1) antagonist (24 wk) enhanced the number of B(2) without changing B(1) receptor binding sites. However, at 8 wk the three treatments significantly increased B(1) and decreased B(2) receptors in lamina I. It is concluded that 1) the higher density of B(2) receptors in the spinal cord of SHR is not due to hypertension, 2) kinin receptors are regulated differently by ACEI in neuronal and vascular tissues, and 3) aging may have a profound impact on levels of B(1) and B(2) receptors in the rat spinal cord. PMID:12586640
Ongali, Brice; Buck, Hudson de Sousa; Cloutier, Frank; Legault, Francine; Regoli, Domenico; Lambert, Chantal; Thibault, Gaétan; Couture, Réjean
Multiple sclerosis and experimental autoimmune encephalomyelitis (EAE) result in inflammatory white matter lesions in the CNS. However, information is sparse with regard to the effects of autoimmune demyelinating disease on gray matter regions. Therefore, we studied the late effects of chronic EAE in C57BL/6 mice on the spinal cord gray matter using immunohistochemistry. Here, EAE induced marked astrocytic, microglial, and macrophage activation in the ventral horn gray matter, without any motoneuron loss. Activated caspase-3 was also increased in the ventral horn gray matter. Furthermore, activated poly (ADP-ribose) polymerase (PARP), another apoptotic marker, co-localized with myelin basic protein (MBP) of oligodendrocyte processes, but not with the oligodendroglial cell body marker, adenomatous polyposis coli gene clone CC1 (APC-CC1), or with neurofilament marker (RT-97) or synaptophysin of axonal arbors. However, there was no associated increase in the number of terminal deoxynucleotidyl transferase (TdT) mediated-dUTP nick end labeling positive nuclei in the spinal cord gray matter of EAE mice. In addition, co-localization of MBP and the low-affinity neurotrophin receptor, p75, was demonstrated, further supporting the notion of apoptotic oligodendrocyte process degeneration in the gray matter of EAE mice.
Wu, J.; Ohlsson, M.; Warner, E. A.; Loo, K. K.; Hoang, T. X.; Voskuhl, R. R.; Havton, L. A.
After spinal cord injury (SCI), alterations in intrinsic motoneuron properties have been shown to be partly responsible for spastic reflex behaviors in human SCI. In particular, a dysregulation of voltage-dependent depolarizing persistent inward currents (PICs) may permit sustained muscle contraction after the removal of a brief excitatory stimulus. Windup, in which the motor response increases with repeated activation, is an indicator of PICs. Although windup of homonymous stretch reflexes has been shown, multijoint muscle activity is often observed following imposed limb movements and may exhibit a similar windup phenomenon. The purpose of this study was to identify and quantify windup of multijoint reflex responses to repeated imposed hip oscillations. Ten chronic SCI subjects participated in this study. A custom-built servomotor apparatus was used to oscillate the legs about the hip joint bilaterally and unilaterally from 10° of extension to 40° flexion for 10 consecutive cycles. Surface electromyograms (EMGs) and joint torques were recorded from both legs. Consistent with a windup response, hip and knee flexion/extension and ankle plantarflexion torque and EMG responses varied according to movement cycle number. The temporal patterns of windup depended on the muscle groups that were activated, which may suggest a difference in the response of neurons in different spinal pathways. Furthermore, because windup was seen in muscles that were not being stretched, these results imply that changes in interneuronal properties are also likely to be associated with windup of spastic reflexes in human SCI. PMID:21753029
Onushko, Tanya; Hyngstrom, Allison; Schmit, Brian D
Until recently it was thought that children do not suffer as much from postoperative pain as adults. Coupled with the fear of administering systemic opiates to young children, this meant that babies were often left "to cry it out." Lately it has been acknowledged that children and even babies not only feel pain, but similar to adults, suffer from the physiologic consequences of the untreated stress response. It has also been shown that preventing this response improves the postoperative period in babies after undergoing cardiac surgery. Regional analgesia is commonly used to provide postoperative pain control in adults and children. Following minor lower abdominal surgery, pain relief is often provided by caudal analgesia or specific nerve blocks. Epidural and spinal anesthesia are also gaining popularity for young children and even babies. We describe 3 cases of continuous epidural analgesia in babies, and review other methods for postoperative pain relief. These cases are representative of the many which we have treated over the past 2 years. We use epidural analgesia in children who undergo major thoracic, abdominal, pelvic and major lower limb surgery, and are expected to suffer significant postoperative pain for more than 24 hours. We have not encountered any major complications or inadvertent dural punctures. We judiciously monitor these children, especially their respiratory function, as long as they receive epidural narcotics. PMID:8707171
Efrat, R; Oppenheim, A; Weiss, Y; Kedari, A
Echocardiography revealed a left atrial tumor in a 59-year-old man with back pain that concurrently worsened with left foot drop and loss of the left ankle reflex soon after admission to our hospital. Magnetic resonance imaging of the spine revealed an epidural tumor extending from Th5 with spinal cord compression. The patient was immediately treated by emergency Th4-5 laminectomy and epidural decompression. One month later, a cardiac tumor excised via the left atrial approach was histopathologically diagnosed as myxosarcoma, and the Th5 tumor was consistent with this finding. This is the first report to describe spinal metastasis of cardiac myxosarcoma. PMID:23677508
Kimura, Mitsuhiro; Kikuchi, Chizuo; Takahashi, Yoshiki; Kanazawa, Hiroshi; Nakazawa, Satoshi
Study design:Case reportBackground\\/objective:Myasthenia gravis (MG) complicating spinal cord injury (SCI) is extremely rare. We report a patient with SCI developing MG leading to death. There are no similar articles at present on literature search.Case report:A 54-year-old man, paralysed at the T12 level (ASIA A) for 40 years, was admitted for surgical repair of his grade IV sacral pressure sore. During
S Kolli; K M Mathew; P Thumbikat; M R McClelland; K P S Nair
The high clinical relevance of models of incomplete cervical spinal cord injury (SCI) creates a need to address the spontaneous neuroplasticity that underlies changes in functional activity that occur over time after SCI. There is accumulating evidence supporting long projecting propriospinal neurons as suitable targets for therapeutic intervention after SCI, but focus has remained primarily oriented toward study of descending pathways. Long ascending axons from propriospinal neurons at lower thoracic and lumbar levels that form inter-enlargement pathways are involved in forelimb-hindlimb coordination during locomotion and are capable of modulating cervical motor output. We used non-invasive magnetic stimulation to assess how a unilateral cervical (C5) spinal contusion might affect transmission in intact, long ascending propriospinal pathways, and influence spinal cord plasticity. Our results show that transmission is facilitated in this pathway on the ipsilesional side as early as 1 week post-SCI. We also probed for descending magnetic motor evoked potentials (MMEPs) and found them absent or greatly reduced on the ipsilesional side as expected. The frequency-dependent depression (FDD) of the H-reflex recorded from the forelimb triceps brachii was bilaterally decreased although Hmax/Mmax was increased only on the ipsilesional side. Behaviorally, stepping recovered, but there were deficits in forelimb–hindlimb coordination as detected by BBB and CatWalk measures. Importantly, epicenter sparing correlated to the amplitude of the MMEPs and locomotor recovery but it was not significantly associated with the inter-enlargement or segmental H-reflex. In summary, our results indicate that complex plasticity occurs after a C5 hemicontusion injury, leading to differential changes in ascending vs. descending pathways, ipsi- vs. contralesional sides even though the lesion was unilateral as well as cervical vs. lumbar local spinal networks.
Cote, Marie-Pascale; Detloff, Megan R.; Wade, Rodel E.; Lemay, Michel A.; Houle, John D.
The high clinical relevance of models of incomplete cervical spinal cord injury (SCI) creates a need to address the spontaneous neuroplasticity that underlies changes in functional activity that occur over time after SCI. There is accumulating evidence supporting long projecting propriospinal neurons as suitable targets for therapeutic intervention after SCI, but focus has remained primarily oriented toward study of descending pathways. Long ascending axons from propriospinal neurons at lower thoracic and lumbar levels that form inter-enlargement pathways are involved in forelimb-hindlimb coordination during locomotion and are capable of modulating cervical motor output. We used non-invasive magnetic stimulation to assess how a unilateral cervical (C5) spinal contusion might affect transmission in intact, long ascending propriospinal pathways, and influence spinal cord plasticity. Our results show that transmission is facilitated in this pathway on the ipsilesional side as early as 1 week post-SCI. We also probed for descending magnetic motor evoked potentials (MMEPs) and found them absent or greatly reduced on the ipsilesional side as expected. The frequency-dependent depression (FDD) of the H-reflex recorded from the forelimb triceps brachii was bilaterally decreased although H(max)/M(max) was increased only on the ipsilesional side. Behaviorally, stepping recovered, but there were deficits in forelimb-hindlimb coordination as detected by BBB and CatWalk measures. Importantly, epicenter sparing correlated to the amplitude of the MMEPs and locomotor recovery but it was not significantly associated with the inter-enlargement or segmental H-reflex. In summary, our results indicate that complex plasticity occurs after a C5 hemicontusion injury, leading to differential changes in ascending vs. descending pathways, ipsi- vs. contralesional sides even though the lesion was unilateral as well as cervical vs. lumbar local spinal networks. PMID:22934078
Côté, Marie-Pascale; Detloff, Megan R; Wade, Rodel E; Lemay, Michel A; Houlé, John D
Study Design:Cross-sectional comparison.Objective:The mortality rate is higher in individuals with spinal cord injury (SCI), and one major cause is cardiovascular disease (CVD). In the general population, the metabolic syndrome (MetS) is associated with an increased risk of CVD, and abdominal obesity is a major feature. Adipokines, secreted by adipose tissue, contribute to obesity-linked metabolic diseases. The aim of this study
Y Maruyama; M Mizuguchi; T Yaginuma; M Kusaka; H Yoshida; K Yokoyama; Y Kasahara; T Hosoya
Objective To determine pain levels, function, and psychological symptoms in relation to predominant sidedness of pain (right or left) and gender in patients being treated for chronic spinal pain. Design Prospective cohort study Patients Patients with chronic neck or low back pain undergoing a nerve block procedure in a speciality pain medicine clinic Interventions/Outcomes Patients completed the Hospital Anxiety and Depression Scale and the Brief Pain Inventory just prior to the procedure. Pain history and demographic variables were collected from a chart review. Chi-square, Pearson correlations, and multivariate statistics were used to characterize the relationships between side of pain, gender, pain levels, pain interference, and psychological symptoms. Results Among 519 subjects, men with left-sided pain (n=98) were found to have significantly greater depression and anxiety symptoms and worse pain-related quality of life (p<.01), despite having similar pain levels as men with right-sided pain (n=91) or women with left or right-sided pain (n=289). In men, psychological symptoms had a significantly greater correlation with pain levels than in women (p<.01). Conclusion In this sample, men with left-sided spinal pain report worse quality of life and more psychological symptoms than women. These data provide clinical evidence corroborating basic neuroscience findings indicating that the right cerebral hemisphere is preferentially involved in the processing of pain and negative affect. These data suggest that men appear more right hemisphere dominant in pain and affect processing. These findings have implications for multidisciplinary assessment and treatment planning in men.
Wasan, Ajay D.; Anderson, Nina K.; Giddon, Donald B.
Intrathecal and epidural administration of the alpha2-adrenergic receptor agonist clonidine in humans results in analgesia to both acute nociceptive and chronic neuropathic pain. The potency of clonidine increases with hypersensitivity to mechanical stimuli after nerve injury, although the reasons for this change are unknown. In the present study, we tested the hypothesis that peripheral nerve injury alters either spinal alpha2-adrenergic receptor-mediated G-protein activity or alpha2-adrenergic receptor number. Rats were randomized to left spinal nerve ligation (SNL) or sham surgery. Tactile hypersensitivity in the hindpaw was confirmed and lumbar spinal cords were removed for binding assays. To examine agonist-induced G-protein coupling, [35S]GTP gamma S binding experiments were performed in spinal cord membranes and sections using norepinephrine as an alpha2-adrenergic agonist. SNL was associated with an increase in maximal efficacy, but not potency, of norepinephrine-stimulated [35S]GTP gamma S binding in dorsal horn. SNL had no effect on basal [35S]GTP gamma S binding or on muscarinic cholinergic-stimulated [35S]GTP gamma S binding. [35S]GTP gamma S autoradiography showed that this increase in alpha2-adrenergic-activated G-proteins occurred both ipsilateral and contralateral to SNL surgery. SNL did not alter total alpha2-adrenergic receptor number or affinity to [3H]-rauwolscine binding, and displacement studies with the alpha2A-adrenergic antagonist BRL44408 revealed that most of the binding was associated with the alpha2A-adrenergic subtype. These data suggest that the increased potency of clonidine in neuropathic pain could reflect increased efficiency of G-protein coupling from spinal alpha2-adrenergic receptors. PMID:15748875
Bantel, Carsten; Eisenach, James C; Duflo, Frederic; Tobin, Joseph R; Childers, Steven R
Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated
Kinya Nakanishi; Takuya Uchiyama; Naoki Nakano; Norihito Fukawa; Kimito Yamada; Tomonari Yabuuchi; Amami Kato
Opioids are the most potent centrally acting analgesic drugs for the treatment of pain. For the past years, since the discovery of spinal opioid receptors, the use of spinal opioids has been adopted in clinical practice in the hope of producing intense segmental analgesia that was devoid of the dose-limiting side effects associated with systemic opioid administration. Experimental studies have demonstrated that after their perispinal administration, liposolubility is inversely proportional to their spinal selectivity, which is higher for the most water-soluble drug, morphine, than for other more lipophilic drugs, such as fentanyl and sufentanil. Clinical trials have shown that epidural morphine in the form of extended-release liposome injections gives good analgesia for a period of 48 hours, with no need for epidural catheterization. Conversely, fentanyl is the most appropriate opioid in ambulatory surgery and seems to have the strongest effect at the spinal cord administered epidurally as a bolus and supraspinally using continuous epidural infusion. Epidural methadone and hydromorphone are suitable alternatives for analgesia in the postoperative period, given that they have intermediate pharmacokinetic characteristics with respect to the two aforementioned groups of opioids. All opioids administered intrathecally will produce some degree of spinally mediated analgesia. The main differences are related to their duration of action, rate of clearance, and the pathways by which the drugs reach their receptors in the brain. In general, lipophilic opioids produce short-term analgesia (1-4 hours), which is very useful for immediate postoperative pain. However, morphine produces intense analgesia for up to 24 hours with doses as low as 100 ?g. PMID:22798178
Bujedo, Borja Mugabure; Santos, Silvia González; Azpiazu, Amaia Uría
Spinal muscular atrophy (SMA) is an autosomal recessive disorder that affects motor neurons. It is caused by mutations in the survival motor neuron gene 1 (SMN1). The SMN2 gene, which is the highly homologous SMN1 copy that is present in all the patients, is unable to prevent the disease. An SMN2 dosage method was applied to 45 patients with the three SMA types (I-III) and to four pairs of siblings with chronic SMA (II-III) and different phenotypes. Our results confirm that the SMN2 copy number plays a key role in predicting acute or chronic SMA. However, siblings with different SMA phenotypes show an identical SMN2 copy number and identical markers, indicating that the genetic background around the SMA locus is insufficient to account for the intrafamilial variability. In our results, age of onset appears to be the most important predictor of disease severity in affected members of the same family. Given that SMN2 is regarded as a target for potential pharmacological therapies in SMA, the identification of genetic factors other than the SMN genes is necessary to better understand the pathogenesis of the disease in order to implement additional therapeutic approaches. PMID:15981080
Cuscó, I; Barceló, M J; Rojas-García, R; Illa, I; Gámez, J; Cervera, C; Pou, A; Izquierdo, G; Baiget, M; Tizzano, E F
Time-tested treatments for chronic osteomyelitis involve prolonged courses of costly antibiotic treatment. Although such treatment remains unquestioned in acute osteomyelitis, it is an excessive regiment for chronic osteomyelitis. With appropriate surgical debridement and careful operative care, antibiotic treatment can be truncated in diagnoses of chronic osteomyelitis. This study represents the clinical practice of the pressure ulcer management program at Rancho Los Amigos National Rehabilitation Center in dealing with this difficult problem. One hundred fifty-seven patients with similar pressure ulcer wounds were studied retrospectively. Three groups of patients with pathologic diagnoses of acute osteomyelitis, chronic osteomyelitis, and negative osteomyelitis were compared for (1) postoperative stay, (2) wound infection, (3) wound breakdown requiring reoperation, and (4) same-site ulcer recurrence. In all cases, shallow bone shavings were sent for diagnosis via histologic study, and deep shavings were also sent to ensure adequate bone debridement and microbiologic study. All ulcers were subsequently closed with muscle and/or myocutaneous flaps. The negative and chronic osteomyelitis groups were treated with 5 to 7 days of IV antibiotics, whereas the acute group underwent a full 6-week course according to bone bacteriological culture and sensitivity. There was no statistical difference between the chronic osteomyelitis group and the control (negative) osteomyelitis group with respect to postoperative stay (70 days for chronic group, 72.4 for control), wound breakdown rate (10.7% for chronic, 10.2% for control), or ulcer recurrence (1.8% for chronic, 4.1 for control). The acute osteomyelitis group incurred longer hospital stays, greater incidence of wound breakdown, and statistically significantly greater ulcer recurrence (78.6 days, 13.2% and 17.0%, respectively). In cases of pressure ulcer management with bony involvement, bone pathologic diagnosis of chronic osteomyelitis allows for a shorter antibiotic course with better results when the offending tissue has been adequately debrided and closed with viable tissue flap coverage, than simple long-term (4-6 weeks) antibiotic treatment. Because of the extreme contaminated nature of these wounds, if such therapy works in these patients, it may be applicable to chronic osteomyelitis in more varied contaminated surgical cases involving bone. PMID:18812715
Marriott, Robert; Rubayi, Salah
We describe two patients suffering from sciatica for the presence of epidural gas compressing the nerve root. Previously,\\u000a only one patient had undergone spinal surgery. The aim of this report is to describe the origin and the treatment of radiculopathies\\u000a caused by epidural gas.
Pietro Lisai; Carlo Doria; Leonardo Crissantu; Gabriele Spano; Tomas Dore; Carlo Fabbriciani
Objective The purpose of this case study is to describe the treatment using acupuncture and spinal manipulation for a patient with a chronic tension-type headache and episodic migraines. Clinical Features A 32-year-old woman presented with headaches of 5 months' duration. She had a history of episodic migraine that began in her teens and had been controlled with medication. She had stopped taking the prescription medications because of gastrointestinal symptoms. A neurologist diagnosed her with mixed headaches, some migrainous and some tension type. Her headaches were chronic, were daily, and fit the International Classification of Headache Disorders criteria of a chronic tension-type headache superimposed with migraine. Intervention and Outcome After 5 treatments over a 2-week period (the first using acupuncture only, the next 3 using acupuncture and chiropractic spinal manipulative therapy), her headaches resolved. The patient had no recurrences of headaches in her 1-year follow-up. Conclusion The combination of acupuncture with chiropractic spinal manipulative therapy was a reasonable alternative in treating this patient's chronic tension-type headaches superimposed with migraine.
Ohlsen, Bahia A.
In parturients, extension of epidural analgesia to include the sacral roots is necessary for adequate analgesia during the second stage of labour and for vacuum extraction and forceps delivery. There is clinical evidence that if the sitting position is adopted after local anaesthetic administration, it impairs the sacral spread of analgesia. An in vitro model representing the lumbar spinal canal has been used to demonstrate how, in the vertical position, a CSF plug can prevent downward spread of local anaesthetic. With the model tilted 25 degrees to the horizontal and also in the full horizontal position downward spread occurs. The effect of a 25 degrees head up tilt on sacral spread of epidural analgesia was compared clinically with the horizontal position. Women requesting epidural analgesia during labour were randomly allocated to receive the first epidural dose either with the head end of the bed tilted 25 degrees head up (n = 30) or remaining horizontal (n = 30). All epidurals were sited at L3/4, a test dose of 2 ml of 0.5% bupivacaine was followed by a main dose of 6 ml of 0.5% bupivacaine. Sacral sensory blockade was greater in the head up group. The difference was significant on the left side (P < 0.05) at 15, 20, and 30 minutes after the main dose. There were more patients with blocks extending to S5 (on either the left or right sides) in the head up group at 15, 20 and 30 minutes (P < 0.05 at 20 and 30 minutes on left side). PMID:15636907
Griffin, R; Barklamb, M; Reynolds, F
Objective To assess clinical determinants of systemic inflammation in persons with chronic spinal cord injury (SCI). Design Cross-sectional survey. Setting Veterans Affairs medical center. Participants As part of an epidemiologic study assessing SCI-related health conditions, 63 men with chronic SCI provided a blood sample and information regarding locomotive mode and personal habits. Interventions Not applicable. Main Outcome Measure Plasma high-sensitivity C-reactive protein (CRP). Results The mean ± standard deviation age was 56±14y, and participants were assessed 21±13y after injury. Adjusting for heart disease, hypertension, and body mass index (BMI), the mean CRP in 12 motorized wheelchair users (5.11mg/L) was not significantly greater than 23 participants who used a manual wheelchair (2.19mg/L) (P=.085) but was significantly greater than the 17 who walked with an assistive device (1.41mg/L) (P=.005) and the 12 who walked independently (1.63mg/L) (P=.027). CRP was significantly greater in participants with obesity but was not related to age, smoking, or SCI level and severity. CRP was elevated in participants reporting a urinary tract infection (UTI) or pressure ulcer within a year, but adjustment for this did not account for the elevated CRP in motorized wheelchair users. Conclusions These results suggest that CRP in chronic SCI is independently related to locomotive mode, BMI, and a history of pressure ulcers and UTI. It is suggested that future studies in SCI investigate whether modifying these factors influence systemic inflammation and cardiovascular health.
Morse, Leslie R.; Stolzmann, Kelly; Nguyen, Hiep P.; Jain, Nitin B.; Zayac, Cara; Gagnon, David R.; Tun, Carlos G.; Garshick, Eric
Context/objectives To describe the relationships between secondary health conditions and health preference in a cohort of adults with chronic spinal cord injury (SCI). Study design Cross-sectional telephone survey. Setting Community. Participants Community-dwelling adult men and women (N = 357) with chronic traumatic and non-traumatic SCI (C1-L3 AIS A-D) who were at least 1 year post-injury/onset. Interventions Not applicable. Outcome measures Health Utilities Index-Mark III (HUI-Mark III) and SCI Secondary Conditions Scale-Modified (SCS-M). Results SCS-M responses for different secondary health conditions were used to create “low impact = absent/mild” and “high impact = moderate/significant” secondary health condition groups. Analysis of covariance was used to examine differences in HUI-Mark III scores for different secondary health conditions while controlling for impairment. The mean HUI-Mark III was 0.24 (0.27, range, ?0.28 to 1.00). HUI-Mark III scores were lower (P < 0.001) in high impact groups for spasms, bladder and bowel dysfunction, urinary tract infections, autonomic dysreflexia, circulatory problems, respiratory problems, chronic pain, joint pain, psychological distress, and depression compared with the low impact groups. As well, HUI-Mark III scores were lower (P < 0.05) in high impact groups for pressure sores, unintentional injuries, contractures, heterotopic bone ossification, sexual dysfunction, postural hypotension, cardiac problems, and neurological deterioration than low-impact groups. Conclusion High-impact secondary health conditions are negatively associated with health preference in persons with SCI. Although further work is required, the HUI-Mark III data may be a useful tool for calculating quality-adjusted life years, and advocating for additional resources where secondary health conditions have substantial adverse impact on health.
Craven, Catharine; Hitzig, Sander L.; Mittmann, Nicole
c-Fos expression was studied in the lumbar and sacral spinal cord regions involved in processing afferent input from the lower\\u000a urinary tract and a comparison was made between spinal cord-injured (SCI) animals and control animals with intact neuraxes.\\u000a Afferent pathways from the lower urinary tract were activated either by insertion of a catheter through the urethra into the\\u000a urinary bladder
Peter Callsen-Cencic; Siegfried Mense
The present study examined the antinociceptive effects of gelsemine, the principal alkaloid in Gelsemium sempervirens Ait. A single intrathecal injection of gelsemine produced potent and specific antinociception in formalin-induced tonic pain, bone cancer-induced mechanical allodynia, and spinal nerve ligation-induced painful neuropathy. The antinociception was dose-dependent, with maximal inhibition of 50% to 60% and ED50 values of 0.5 to 0.6?g. Multiple daily intrathecal injections of gelsemine for 7days induced no tolerance to antinociception in the rat model of bone cancer pain. Spinal gelsemine was not effective in altering contralateral paw withdrawal thresholds, and had only a slight inhibitory effect on formalin-induced acute nociception. The specific antinociception of gelsemine in chronic pain was blocked dose-dependently by the glycine receptor (GlyR) antagonist strychnine with an apparent ID50 value of 3.8?g. Gelsemine concentration-dependently displaced H(3)-strychnine binding to the membrane fraction of rat spinal cord homogenates, with a 100% displacement and a Ki of 21.9?M. Gene ablation of the GlyR ?3 subunit (?3 GlyR) but not ?1 GlyR, by a 7-day intrathecal injection of small interfering RNA (siRNA) targeting ?3 GlyR or ?1 GlyR, nearly completely prevented gelsemine-induced antinociception in neuropathic pain. Our results demonstrate that gelsemine produces potent and specific antinociception in chronic pain states without induction of apparent tolerance. The results also suggest that gelsemine produces antinociception by activation of spinal ?3 glycine receptors, and support the notion that spinal ?3 glycine receptors are a potential therapeutic target molecule for the management of chronic pain. PMID:23886522
Zhang, Jing-Yang; Gong, Nian; Huang, Jin-Lu; Guo, Ling-Chen; Wang, Yong-Xiang
BACKGROUND: Despite an elevated obesity risk in people with spinal cord injury (SCI), investigation on the effects of age, obesity predictors, and injury related factors is yet to be unknown within the SCI population. METHODS: Obesity predictors were measured in 162 patients. RESULTS: 27.5% of the participants were overweight and 5.6% of them were obese. Mean BMI was different between patients with tetraplegia and paraplegia (p < 0.01). More than 20% of participants had central obesity, significantly patients with higher age and time since injury. CONCLUSIONS: Significant positive relationship was found between level of injury and BMI. Participants with higher age and time since injury had higher waist circumference.
Sabour, Hadis; Javidan, Abbas Noroozi; Vafa, Mohammad Reza; Shidfar, Farzad; Nazari, Maryam; Saberi, Hooshang; Rahimi, Abbas; Razavi, Hasan Emami
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that primarily affects the vertebral column and sacroiliac joints. Over time, the disease process promotes extensive remodeling of the spinal axis via ligamentous ossification, vertebral joint fusion, osteoporosis, and kyphosis. These pathological changes result in a weakened vertebral column with increased susceptibility to fractures and spinal cord injury (SCI). Spinal cord injury is often exacerbated by the highly unstable nature of vertebral column fractures in AS. A high incidence of missed fractures in the ankylosed spine as well as an increased incidence of spinal epidural hematoma also worsens the severity of SCI. Spinal cord injury in AS is a complex problem associated with high morbidity and mortality rates, which can be attributed to the severity of the injury, associated medical comorbidities, and the advanced age of most patients with AS who suffer an SCI. In this paper the authors outline the factors that increase the incidence of vertebral column fractures and SCI in AS and discuss the management of SCI in patients with AS. Primary prevention strategies for SCI in patients with AS are outlined as well. PMID:18290738
Jacobs, W Bradley; Fehlings, Michael G
We report a case of a 44-year-old patient with paralysis of the left leg who had a thoracic epidural catheterization after general anesthesia for abdominal surgery. Sensory losses below T10 and motor weakness of the left leg occurred after the surgery. Magnetic resonance image study demonstrated a well-defined intramedullary linear high signal intensity lesion on T2-weighted image and low-signal intensity on T1-weighted image in the spinal cord between T9 and L1 vertebral level, and enhancements of the spinal cord below T8 vertebra and in the cauda equina. Electrodiagnostic examination revealed lumbosacral polyradiculopathy affecting nerve roots below L4 level on left side. We suggest that the intrinsic spinal cord lesion and nerve root lesion can be caused by an epidural catheterization with subsequent local anesthetic injection.
Jeon, Byoung Hyun; Bang, Heui Je; Lee, Gyung Moo; Kwon, Oh Pum
Study design:Prospective study.Objective:To evaluate the formation of venous gas bubbles following open-sea scuba dives in persons with chronic spinal cord injury (SCI) and in able-bodied diving instructors (C) and to assess the risk for decompression sickness (DCS).Setting:Field study at the Island of Krk, Croatia.Methods:Gas bubbles were monitored with an ultrasound scanner 40 min after surfacing. The probability of DCS (P(DCS))
T Breskovic; P Denoble; I Palada; A Obad; Z Valic; D Glavas; D Bakovic; Z Dujic
Pharmacological studies have implicated the spinal activation of excitatory amino acids, nitric oxide, and prostaglandins systems in the development of tactile and thermal hypersensitivity and central sensitization after peripheral inflammation. In the present study, using a chronically placed loop dialysis catheter, we examined in the unanesthetized rat the effect of carrageenan\\/kaolin (C\\/K)-induced knee joint inflammation on the time course of
Lin Ch. Yang; Martin Marsala; Tony L. Yaksh
The present study aimed to investigate the role of spinal p38 mitogen-activated protein kinase (p38 MAPK) activation in chronic constriction injury (CCI) of the sciatic nerve induced neuropathic pain. CCI model was produced by loosely ligating the left sciatic nerve proximal to the sciatica's trifurcation with 4-0 silk thread in male Sprague-Dawley rat. SB203580, a specific inhibitor of the p38
ZHANG Fei-E; CAO Jun-Li; ZHANG Li-Cai; ZENG Yin-Ming
This article presents a case of multiple vertebral hemangiomas in a 58-year-old man with pain in the dorsal region and bilateral progressive foot numbness. Magnetic resonance imaging revealed multiple vertebral hemangiomas. One hemangioma at the T7 level demonstrated epidural extension, causing spinal cord compression. After treatment with radiotherapy, the patient's symptoms improved significantly. PMID:19292199
Aksu, Gorkem; Fayda, Merdan; Saynak, Mert; Karadeniz, Ahmet
Editors' prefaceThe management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions
Gert Bronfort; Mitch Haas; Roni Evans; Greg Kawchuk; Simon Dagenais
Intraspinal microstimulation (ISMS) employs elec- trical stimulationoftheventralgrey matterto reactivateparalyzed skeletal muscle. This work evaluated the transformations in the quadriceps muscle that occurred following complete transec- tion and chronic stimulation with ISMS or a standard nerve cuff (NCS). Stimulation was applied for 30 days, 4 h\\/day. Both methods induced significant increases in time-to-peak tension (ISMS 35%, NCS 25%) and half rise-time
Jeremy A. Bamford; Charles T. Putman; Vivian K. Mushahwar
The present study compared epidural tramadol with epidural morphine for postoperative analgesia in 20 patients undergoing\\u000a major abdominal surgery. Intraoperatively, the patients were anaesthetized by a balanced technique of general anaesthesia\\u000a combined with lumbar epidural lidocaine. In ten of the patients 100 mg tramadol diluted in 10 ml normal saline was also injected\\u000a epidurally, while 4 mg epidural morphine was
Anis Baraka; Samar Jabbour; Maroun Ghabash; Antoun Nader; Ghattas Khoury; Abla Sibai
Spinal cord injury (SCI) causes chronic peripheral sensitization of nociceptors and persistent generation of spontaneous action potentials (SA) in peripheral branches and the somata of hyperexcitable nociceptors within dorsal root ganglia (DRG). Here it is proposed that SCI triggers in numerous nociceptors a persistent hyperfunctional state (peripheral, synaptic, and somal) that originally evolved as an adaptive response to compensate for loss of sensory terminals after severe but survivable peripheral injury. In this hypothesis, nociceptor somata monitor the status of their own receptive field and the rest of the body by integrating signals received by their peripheral and central branches and the soma itself. A nociceptor switches into a potentially permanent hyperfunctional state when central neural, glial, and inflammatory signal combinations are detected that indicate extensive peripheral injury. Similar signal combinations are produced by SCI and disseminated widely to uninjured as well as injured nociceptors. This paper focuses on the uninjured nociceptors that are altered by SCI. Enhanced activity generated in below-level nociceptors promotes below-level central sensitization, somatic and autonomic hyperreflexia, and visceral dysfunction. If sufficient ascending fibers survive, enhanced activity in below-level nociceptors contributes to below-level pain. Nociceptor activity generated above the injury level contributes to at- and above-level sensitization and pain (evoked and spontaneous). Thus, SCI triggers a potent nociceptor state that may have been adaptive (from an evolutionary perspective) after severe peripheral injury but is maladaptive after SCI. Evidence that hyperfunctional nociceptors make large contributions to behavioral hypersensitivity after SCI suggests that nociceptor-specific ion channels required for nociceptor SA and hypersensitivity offer promising targets for treating chronic pain and hyperreflexia after SCI.
Walters, Edgar T.
Despite the indisputable and well-known advantages of general anesthesia in thoracic surgery, this can trigger some adverse effects including an increased risk of pneumonia, impaired cardiac performance, neuromuscular problems, mechanical ventilation-induced injuries, which include barotrauma, volotrauma, atelectrauma, and biotrauma. In order to reduce the adverse effects of general anesthesia, thoracic epidural anesthesia has been recently employed to perform awake thoracic surgery procedures including coronary artery bypass, management of pneumothorax, resection of pulmonary nodules and solitary metastases, lung volume reduction surgery, and even transsternal thymectomy. The results achieved in this early series have been encouraging, although indications and many pathophysiologic aspects remain to be elucidated. In this review we have tried to provide a first-step analysis of the anecdotal reports available in the literature on this topic. We also desired to provide insights into the main physiologic effects of awake thoracic surgery with epidural anesthesia, with particular attention to the several issues raised by its application in patients with chronic obstructive pulmonary disease, which can represent one of the most stimulating challenges in this setting. PMID:17467287
Mineo, Tommaso Claudio
Epidural analgesia is regarded as the gold method for controlling post-thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post-thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated
Hui Ju; Yi Feng; Ba-xian Yang; Jun Wang
An ambulatory multimodal cognitive-behavioural treatment programme (MMCBT) for Swedish workers with chronic spinal pain was formally evaluated. The design was a matched cohort study with three repeated measures done in two groups of 35 referred patients (one exposed to MMCBT and controls exposed to usual care). The MMCBT package includes standardised modules of physical treatment, cognitive-behavioural treatment, education of worker patients, and education of subjects' supervisors. The primary outcome variables assessed were absenteeism, disability, pain, and depression. Because of a change in Swedish sick leave compensation laws affecting records of absence during the study period, absenteeism could not be reliably measured among controls. The trend, however, suggested a reduction of absenteeism among the subjects in the MMCBT cohort. The findings for disability, pain, and depression all showed clinically important and significant beneficial changes (ANOVA for repeated measures: disability p = 0.05; pain p = 0.001; depression p = 0.01). The direction of the improvements and the size of effect were coherent and clinically plausible. The benefits were only among the women in the study. These comprised 74% of each group. Further research on larger sample sizes and in cohorts more representative of the whole country are needed to confirm these encouraging findings and to explore how the benefits might be extended to men.
Jensen, I B; Nygren, A; Lundin, A
Objective Determine the effects of body-weight-supported treadmill training (BWSTT) and tilt-table standing (TTS) on clinically assessed and self-reported spasticity, motor neuron excitability, and related constructs in individuals with chronic spinal cord injury (SCI). Design Random cross-over. Methods Seven individuals with chronic SCI and spasticity performed thrice-weekly BWSTT for 4 weeks and thrice-weekly TTS for 4 weeks, separated by a 4-week wash-out. Clinical (Modified Ashworth Scale, Spinal Cord Assessment Tool for Spinal reflexes) and self-report (Spinal Cord Injury Spasticity Evaluation Tool, Penn Spasm Frequency Scale) assessments of spasticity, quality of life (Quality of Life Index Spinal Cord Injury Version – III), functional mobility (FIM Motor Subscale), plus soleus H-reflex were measured at baseline, after the first training session and within 2 days of completing each training condition. Results In comparison with TTS, a single session of BWSTT had greater beneficial effects for muscle tone (effect size (ES) = 0.69), flexor spasms (ES = 0.57), and the H/M ratio (ES = 0.50). Similarly, flexor spasms (ES = 0.79), clonus (ES = 0.66), and self-reported mobility (ES = 1.27) tended to benefit more from 4 weeks of BWSTT than of TTS. Participation in BWSTT also appeared to be favorable for quality of life (ES = 0.50). In contrast, extensor spasms were reduced to a greater degree with TTS (ES = 0.68 for single session; ES = 1.32 after 4 weeks). Conclusion While both BWSTT and TTS may provide specific benefits with respect to spasticity characteristics, data from this pilot study suggest that BWSTT may result in a broader range of positive outcomes.
Adams, Melanie M.; Hicks, Audrey L.
Background: Chronically compromised uterine perfusion may lead to placental insufficiency and subsequent intrauterine growth restriction (IUGR). Various therapeutic approaches (e.g. vasodilators, low-dose aspirin, intravenous glucose infusion, and hemodilution) are often of limited efficacy. Local anesthetics have been shown to improve placental blood flow in pre-eclamptic women. We hypothesized that epidural administration of local anesthetics might improve outcome in IUGR independent
D. Strümper; F. Louwen; M. E. Durieux; H. F. Gramke; J. Stuessel; D. Marcus-Soekarman; H. Van Aken; M. A. E. Marcus
Summary: We report a case of a purely epidural capillary hemangioma of the thoracic spine with foraminal exten- sion. Epidural hemangiomas are rare; only a few cases of dumbbell-shaped ones have been reported, and all were cavernous. MR imaging showed characteristic findings of a capillary hemangioma, which are also consistent with other epidural lesions such as neuromas or meningiomas. Hemangiomas
Bruno Badinand; Christophe Morel; Nicolas Kopp; A. Tran; Francois Cotton
Nursing literature concerned with epidural anesthesia in obstetrics is scant and does not offer a synopsis of the pharmacology of local anesthetic agents employed in epidural block. A comprehensive review of the pharmacology and clinical uses of the common agents used in obstetrical epidural anesthesia is presented. Implications for nursing care are also described. PMID:6560045
Smith, C M
The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP. PMID:18164469
Bronfort, Gert; Haas, Mitch; Evans, Roni; Kawchuk, Greg; Dagenais, Simon
Objective Epidural fibrosis and adhesion are the main reasons for post-laminectomy sustained pain and functional disability. In this study, the authors investigate the effect of irradiated freeze-dried human amniotic membrane on reducing epidural adhesion after laminectomy on a rat model. Methods A total of 20 rats were divided into two groups. The group A did not receive human amniotic membrane implantation after laminectomy and group B underwent human amniotic membrane implantation after laminectomy. Gross and microscopic findings were evaluated and compared at postoperative 1, 3 and 8 weeks. Results The amount of scar tissue and tenacity were reduced grossly in group of rats with human amniotic membrane implantation (group B). On a microscopic evaluation, there were less inflammatory cell infiltration and fibroblast proliferation in group B. Conclusion This experimental study shows that implantation of irradiated freeze-dried human amniotic membrane reduce epidural fibrosis and adhesion after spinal laminectomy in a rat model.
Choi, Hyu Jin; Kim, Kyoung Beom
The proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. We analyze 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System; Medtronic Neurological, Inc Minneapolis, MN, USA) by a single satisfactory diagnosis 1992 through 1995. A rigid selection protocol was used: 1. A satisfactory diagnosis of the pathologic process resulting in pain was made. 2. A corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, e.g., vascular peripheral nerve, spine. 3. Lack of satisfactory response to noninterventional pain management modalities by an interdisciplinary pain clinic. 4. Independent psychological evaluation, including a structured interview was performed by a psychologist specialized in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. Fifteen patients were female and twelve were male. All were Caucasian. Their ages ranged from 27 to 84 years (mean:48). The average follow-up was 21 months (range: 48-6). All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trial (three cervical and twenty-one thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continue to use the stimulator. The same number would choose to receive in an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography was documented in the patients with RSD. We conclude that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction. PMID:9664583
Segal, R; Stacey, B R; Rudy, T E; Baser, S; Markham, J
Results following fusion for chronic low back pain (CLBP) are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with pain, if present, in a motion segment of the spine. Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful. If discogenic pain exists, it should be possible to select these patients from all others within the CLBP population. Even if this selection were 100% perfect, however, identification of the painful segment would remain, and at present there is no reliable test for doing so. Regardless of whether an anterior or posterior type of fusion is performed, or even if artificial discs are used, solving the puzzle of pain associated with the presumed segmental disorder must be the primary goal.
Executive Summary Objective The objective of this health technology policy assessment was to determine the effectiveness of spinal cord stimulation (SCS) to manage chronic intractable neuropathic pain and to evaluate the adverse events and Ontario-specific economic profile of this technology. Clinical Need SCS is a reversible pain therapy that uses low-voltage electrical pulses to manage chronic, intractable neuropathic pain of the trunk or limbs. Neuropathic pain begins or is caused by damage or dysfunction to the nervous system and can be difficult to manage. The prevalence of neuropathic pain has been estimated at about 1.5% of the population in the United States and 1% of the population in the United Kingdom. These prevalence rates are generalizable to Canada. Neuropathic pain is extremely difficult to manage. People with symptoms that persist for at least 6 months or who have symptoms that last longer than expected for tissue healing or resolution of an underlying disease are considered to have chronic pain. Chronic pain is an emotional, social, and economic burden for those living with it. Depression, reduced quality of life (QOL), absenteeism from work, and a lower household income are positively correlated with chronic pain. Although the actual number is unknown, a proportion of people with chronic neuropathic pain fail to obtain pain relief from pharmacological therapies despite adequate and reasonable efforts to use them. These people are said to have intractable neuropathic pain, and they are the target population for SCS. The most common indication for SCS in North America is chronic intractable neuropathic pain due to failed back surgery syndrome (FBSS), a term that describes persistent leg or back and leg pain in patients who have had back or spine surgery. Neuropathic pain due to complex regional pain syndrome (CRPS), which can develop in the distal aspect of a limb a minor injury, is another common indication. To a lesser extent, chronic intractable pain of postherpetic neuralgia, which is a persistent burning pain and hyperesthesia along the distribution of a cutaneous nerve after an attack of herpes zoster, is also managed with SCS. For each condition, SCS is considered as a pain management therapy only after conventional pain therapies, including pharmacological, nonpharmacological, and surgical treatments, if applicable, have been attempted and have failed. The Technology The SCS technology consists of 3 implantable components: a pulse generator, an extension cable, and a lead (a small wire). The pulse generator is the power source for the spinal cord stimulator. It generates low-voltage electrical pulses. The extension cable connects the pulse generator to the lead. The lead is a small, insulated wire that has a set of electrodes at one end. The lead is placed into the epidural space on the posterior aspect of the spinal cord, and the electrodes are positioned at the level of the nerve roots innervating the painful area. An electrical current from the electrodes induces a paresthesia, or a tingling sensation that masks the pain. Before SCS is initiated, candidates must have psychological testing to rule out major psychological illness, drug habituation, and issues of secondary gain that can negatively influence the success of the therapy. Successful candidates will have a SCS test stimulation period (trial period) to assess their responsiveness to SCS. The test stimulation takes about 1 week to complete, and candidates who obtain at least 50% pain relief during this period are deemed suitable to receive a permanent implantation of a spinal cord stimulator Review Strategy The Medical Advisory Secretariat (MAS) reviewed all published health technology assessments of spinal cord stimulation. Following this, a literature search was conducted from 2000 to January, 2005 and a systematic review of the literature was completed. The primary outcome for the systematic review was pain relief. Secondary outcomes included functional status and quality of life. After applying the predetermined inclusion and exclus
Birth injuries occur occasionally but, in contrast, perinatally acquired epidural and intracerebral hematomas as well as neonatal skull fractures are extremely rare. The appropriate diagnostic and therapeutic modalities depend on the size and site of the injury as well as any accompanying diseases. We report the case of a neonatal epidural and intracerebral haematoma with skull fracture following secondary caesarean section. There was no evidence for trauma during pregnancy, birth injury or other possible causes of bleeding. The haematoma was decompressed surgically. One year after surgery the boy suffers from moderate neurological compromise and focal seizures. PMID:16138273
Haase, R; Sauer, H; Brucke, M; Lieser, U; Horneff, G
We present the technique of combined posterior decompression and spinal instrumentation, and surgical (open) vertebroplasty using a novel system called vertebral body stenting (VBS) during a single session in a patient with metastatic vertebral and epidural cauda equina compression. PMID:20082355
Mavrogenis, Andreas F; Papadopoulos, Elias C; Starantzis, Konstantinos; Korres, Demetrios S; Papagelopoulos, Panayiotis J
Study design:?Prospective study.Study rationale:?A recurrent phenomenon, the lifetime prevalence of low back pain has been reported as 54%-80%, while annual prevalence ranges from 15%-45%.1 It is also associated with enormous economic, societal, and health impact.2 India, being a developing country, has its problem compounded by the occupational compulsions in parts of the rural areas.3For some interventional therapies, like epidural steroid injections, utilization rates have increased dramatically.4,5,6,7,8,9 They have become one of the most commonly performed interventions in the United States for low back pain with radiculopathy.10Clinical question:?Multiple systematic reviews,11 a meta-analysis,12 several guidelines,13 health technology assessments by insurers, and local medical review policies and coverage decisions have been published. However, controversy continues regarding the effectiveness of epidural steroid injections. In addition three types of epidurals, namely interlaminar, transforaminal, and caudal, with variable results complicate the picture for practice of interventional pain management. The underlying mechanism of action of epidurally administered steroid and local anesthetic injections is still not well understood and compounds the problem.14Objective:?To evaluate and update the effects of caudal epidural injection in the management of chronic low back pain and sciatica.Final Class of evidence-treatmentYesStudy design: RCT• Cohort Case control Case seriesMethods Concealed allocation (RCT)• Intention to treat (RCT)• Blinded/independent evaluation of primary outcome• F/U ? 85%• Adequate sample size•Control for confoundingOverall class of evidenceIIThe definiton of the different classes of evidence is available here. PMID:23230402
Murakibhavi, V G; Khemka, Aditya G
With the new developments in traumatology medicine, the majority of spinal cord injuries sustained are clinically incomplete and the proportion is likely to continue to rise. Thus, it is necessary to continue to develop new treatment and rehabilitation strategies and understand the factors that can enhance recovery of walking following spinal cord injury (SCI). One new development is the use
Hugues Barbeau; Michel Ladouceur; Mehdi M Mirbagheri; Robert E Kearney
Objective: Periodic limb movement in sleep (PLMS) is a common dysfunction of motor control during sleep, occurring either in isolation or associated with a variety of neurological disorders including restless legs syndrome (RLS). Although the PLMS generators have not been established, their occurrence in patients with spinal cord injury and their clinical resemblance to the spinal cord flexor withdrawal reflex
Murat Aksu; William Bara-Jimenez
PURPOSE: Sacral spinal nerve stimulation is a new therapeutic approach for patients with severe fecal incontinence owing to functional deficits of the external anal sphincter. It aims to use the morphologically intact anatomy to recruit residual function. This study evaluates the long-term results of the first patients treated with this novel approach applying two techniques of sacral spinal nerve stimulator
Klaus E. Matzel; Uwe Stadelmaier; Markus Hohenfellner; Werner Hohenberger
Human GH (hGH) secretion is stimulated by vigorous physical activity, whereas immobilization reduces its release. In paralyzed subjects with spinal cord injury (SCI), it has recently been shown that the release of hGH to provocative stimulation and plasma insulin-like growth factor-I (IGF-I) levels are reduced. The acute administration of baclofen, a gamma-aminobutyric acid derivative, has been shown to stimulate hGH release. The present study investigated the effect of chronic administration of baclofen on the provocative testing of hGH secretion and plasma IGF-I levels. Sixteen subjects with SCI were studied; eight subjects were treated (40-80 mg/day; > 6 months) with baclofen (Bac+), and eight were not (Bac-). Additionally, 8 non-SCI subjects were studied as controls. The groups were matched for gender and age. The subjects were not receiving any medications known to influence hGH secretion. After an overnight fast, arginine hydrochloride (30 g/subject) was infused iv over 30 min, with blood drawn for hormone determinations at baseline and 30, 60, 90, and 120 min. In the Bac- group compared with the Bac+ group, the arginine-stimulated mean plasma hGH levels at 30 and 60 min (P < 0.05) and peak and sum plasma hGH levels (P < 0.01) were reduced. There were no significant differences in the plasma hGH response between the Bac+ group and the control group. Plasma IGF-I levels may reflect the integrated tissue response to hGH. A significant inverse relationship was present between age and plasma IGF-I levels for the control and Bac+ groups, but not for the Bac- group. The mean plasma IGF-I level was significantly reduced in the Bac- compared with the Bac+ group. No significant differences in mean plasma IGF-I levels were noted between the Bac+ and control groups. SCI is associated with body composition changes and metabolic alterations that may be exacerbated by reduced activity of the hGH-IGF-I axis. Oral chronic baclofen therapy appears to reverse the deleterious effects of paralysis and immobilization on hGH physiology. PMID:8175969
Bauman, W A; Spungen, A M; Zhong, Y G; Tsitouras, P D
Background While there is growing evidence for the efficacy of SM to treat LBP, little is known on the mechanisms and physiologic effects of these treatments. Accordingly, the purpose of this study was to determine whether SM alters the amplitude of the motor evoked potential (MEP) or the short-latency stretch reflex of the erector spinae muscles, and whether these physiologic responses depend on whether SM causes an audible joint sound. Methods We used transcranial magnetic stimulation to elicit MEPs and electromechanical tapping to elicit short-latency stretch reflexes in 10 patients with chronic LBP and 10 asymptomatic controls. Neurophysiologic outcomes were measured before and after SM. Changes in MEP and stretch reflex amplitude were examined based on patient grouping (LBP vs. controls), and whether SM caused an audible joint sound. Results SM did not alter the erector spinae MEP amplitude in patients with LBP (0.80 ± 0.33 vs. 0.80 ± 0.30 ?V) or in asymptomatic controls (0.56 ± 0.09 vs. 0.57 ± 0.06 ?V). Similarly, SM did not alter the erector spinae stretch reflex amplitude in patients with LBP (0.66 ± 0.12 vs. 0.66 ± 0.15 ?V) or in asymptomatic controls (0.60 ± 0.09 vs. 0.55 ± 0.08 ?V). Interestingly, study participants exhibiting an audible response exhibited a 20% decrease in the stretch reflex (p < 0.05). Conclusions These findings suggest that a single SM treatment does not systematically alter corticospinal or stretch reflex excitability of the erector spinae muscles (when assessed ~ 10-minutes following SM); however, they do indicate that the stretch reflex is attenuated when SM causes an audible response. This finding provides insight into the mechanisms of SM, and suggests that SM that produces an audible response may mechanistically act to decrease the sensitivity of the muscle spindles and/or the various segmental sites of the Ia reflex pathway.
Background: Various options are available for the provision of analgesia following major surgical procedures including systemic opioids and regional anesthetic techniques. Regional anesthetic techniques offer the advantage of providing analgesia while avoiding the deleterious adverse effects associated with opioids including nausea, vomiting, sedation and respiratory depression. Although used commonly in infants and children, there is a paucity of experience with the use of caudal epidural blockade in adolescents. Methods: We retrospectively reviewed the perioperative care of adolescents undergoing major urologic or orthopedic surgical procedures for whom a caudal epidural block was placed for postoperative analgesia. Results: The cohort for the study included 5 adolescents, ranging in age from 13 to 18 years and in weight from 42 to 71 kilograms. Caudal epidural analgesia was accomplished after the induction of anesthesia and prior to the start of the surgical procedure using 20-25 mL of either 0.25% bupivacaine or 0.2% ropivacaine with clonidine (1 ?g/kg). The patients denied pain the recovery room. The time to first request for analgesia varied from 12 to 18 hours with the patients requiring 1-3 doses of analgesic agents during the initial 24 postoperative hours. Conclusions: Our preliminary experience demonstrates the efficacy of caudal epidural block in providing analgesia following major urologic and orthopedic surgical procedures. The applications of this technique as a means of providing postoperative analgesia are discussed.
Schloss, Brian; Jayanthi, Venkata R.; Bhalla, Tarun; Tobias, Joseph D.
Background Identify variables associated with intrapartum epidural use. Methods Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009. Results Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~50% lower odds of epidural use compared with secondary/teritiary perinatal units, urban hospitals or for-profit hospitals, respectively. Conclusion Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery. Keywords Epidural use; Foreign birth; Labor; Racial disparities
Lancaster, Samuel M.; Schick, Ursula M.; Osman, Morwan M.; Enquobahrie, Daniel A.
Transcutaneous electrical nerve stimulation (TENS) has been shown to be an effective measure for pain relief. The aim of the present study was to determine the optimal intensity and interval of repeated 100 Hz TENS for the treatment of chronic inflammatory hyperalgesia in a monoarthritic pain model of the rat, and to assess the changes of the spinal substance P (SP) release in response to TENS treatment. A reliable, reproducible chronic monoarthritic pain model was produced by intra-articular injection of complete Freund's adjuvant (CFA) at single ankle joint. The efficacy of 100 Hz TENS treatments with different frequencies and intensities was compared. In the acute period (within 3 weeks) of monoarthritis, twice-a-week schedule of TENS reduced the swelling of the inflamed ankle significantly. In the stable period (4–9 weeks), however, once-a-week schedule produced a significantly better therapeutic effect on both inflammation and arthritic hyperalgesia than that of twice- or five-times-a-week schedule. Using three levels of intensity of TENS, we found that the weaker (1-1-2 mA) stimulation produced significantly better therapeutic effects. Repeated TENS produced a reduction of SP content in spinal perfusate in parallel with the progressive reduction of the arthritic pain scores. Our results suggest that (i) consecutive TENS treatments produced cumulative effect for chronic hyperalgesia, (ii) for chronic inflammatory hyperalgesia, a weaker intensity and more sparsely arranged treatment schedule may produce better therapeutic effect and (iii) a decrease in SP release may serve as one of the possible neurochemical mechanisms underlying the therapeutic effects of multiple TENS treatments on chronic inflammatory hyperalgesia.
Liu, Hong-Xiang; Tian, Jin-Bin; Luo, Fei; Jiang, Yu-Hui; Deng, Zu-Guo; Xiong, Liang; Liu, Cheng; Wang, Jin-Shu
Objective To determine whether epidural analgesia during labour is associated with long term backache. Design Follow up after randomised controlled trial. Analysis by intention to treat. Setting Department of obstetrics and gynaecology at one NHS trust. Participants 369 women: 184 randomised to epidural group (treatment as allocated received by 123) and 185 randomised to non›epidural group (treatment as allocated received
Charlotte J Howell; Tracy Dean; Linda Lucking; Krysia Dziedzic; Peter W Jones; Richard B Johanson
1 Epidural administration of opiates for analgesia has recently generated widespread interest and would theoretically be advantageous as a method for relief of pain in labour. 2 Plasma pethidine concentrations were measured after intravenous, intramuscular and epidural administration of pethidine to women in labour and after epidural administration to non-pregnant female surgical patients. 3 Kinetic parameters were derived from the plasma concentration data in each group of subjects and the relationship between plasma kinetics and analgesia in labour were examined. 4 Absorption of pethidine from the epidural space in pregnant women in rapid and excepting the lower initial values, the average plasma concentration and area under the plasma concentration v time curve did not differ significantly (P less than 0.01) from those obtained with intravenous dosage, but were significantly higher (P less than 0.01) during the first 2 h after dosage than the results after intramuscular administration. The analgesia provided by the epidural route of administration was greater than with intravenous or intramuscular administration. 5 It is postulated that the analgesic efficacy of epidural pethidine in women in labour is due to a combination of systemic and local effects and that the local effect is attributable to the local anaesthetic properties of pethidine rather than a selective anti-nociceptive action on the spinal cord.
Husemeyer, R P; Cummings, A J; Rosankiewicz, J R; Davenport, H T
Epidural spinal injections can be administered via a translaminar or transforaminal route, depending on the clinical scenario. When it is more desirable to target a specific nerve root, a transforaminal approach is typically used, and when the target is more diffuse, a translaminar method is chosen. Both are commonly used and can be utilized similarly in the lumbar or cervical spine. However, it is essential that the clinician understand the risks and benefits of these injections. In the lumbar spine, both translaminar epidural steroid injections (TLESI) and transforaminal epidural steroid injections (TFESI) have been shown to provide up to 6 months of pain relief, though long-term benefits are less reliable. In the cervical spine, translaminar injections may provide longer relief and have a lower complication rate than cervical transforaminal injections. Proper technique is essential to minimize the rate of these rare but occasionally severe complications. PMID:22894690
Landa, Joshua; Kim, Yong
Mechanisms underlying chronic pain that develops after spinal cord injury (SCI) are incompletely understood. Most research on SCI pain mechanisms has focused on neuronal alterations within pain pathways at spinal and supraspinal levels associated with inflammation and glial activation. These events might also impact central processes of primary sensory neurons, triggering in nociceptors a hyperexcitable state and spontaneous activity (SA) that drive behavioral hypersensitivity and pain. SCI can sensitize peripheral fibers of nociceptors and promote peripheral SA, but whether these effects are driven by extrinsic alterations in surrounding tissue or are intrinsic to the nociceptor, and whether similar SA occurs in nociceptors in vivo are unknown. We show that small DRG neurons from rats (Rattus norvegicus) receiving thoracic spinal injury 3 d – 8 mo earlier and recorded 1 d after dissociation exhibit an elevated incidence of SA coupled with soma hyperexcitability compared to untreated and sham-treated groups. SA incidence was greatest in lumbar DRG neurons (57%) and least in cervical neurons (28%), and failed to decline over 8 mo. Many sampled SA neurons were capsaicin sensitive and/or bound the nociceptive marker, isolectin B4. This intrinsic SA state was correlated with increased behavioral responsiveness to mechanical and thermal stimulation of sites below and above the injury level. Recordings from C and A? fibers revealed SCI-induced SA generated in or near the neurons’ somata in vivo. SCI promotes the entry of primary nociceptors into a chronic hyperexcitable-SA state that may provide a useful therapeutic target in some forms of persistent pain.
Bedi, Supinder S.; Yang, Qing; Crook, Robyn J.; Du, Junhui; Wu, Zizhen; Fishman, Harvey M.; Grill, Raymond J.; Carlton, Susan M.; Walters, Edgar T.
ObjectivesIn spite of all the scientific advances in pharmacological research, a great number of patients cannot efficiently manage their chronic pain with conventional pharmacological treatments. Brain stimulation techniques have considerably improved these last 10 years. These techniques could be an interesting option after a rigorous selection of patients. We aim to evaluate the efficacy of brain stimulation (deep brain stimulation [DBS
J.-G. Prévinaire; J. P. Nguyen; B. Perrouin-Verbe; C. Fattal
A review of the experience with spinal analgesia for vaginal delivery and other low abdominal or perineal procedures in the Birmingham Maternity Hospital, and of the recent literature relating to the provision of spinal anesthesia for caesarean section, leads to the conclusion that the latter technique is too unreliable, and involves too great an incidence of potentially dangerous complications, to be an acceptable alternative choice to epidural analgesia. PMID:3195305
Crawford, J S
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare inflammatory disease characterized by hypertrophic inflammation of the dura mater and various clinical courses that are from myelopathy. Although many associated diseases have been suggested, the etiology of IHSP is not well understood. The ideal treatment is controversial. In the first case, a 55-year-old woman presented back pain, progressive paraparesis, both leg numbness, and voiding difficulty. Initial magnetic resonance imaging (MRI) demonstrated an anterior epidural mass lesion involving from C6 to mid-thoracic spine area with low signal intensity on T1 and T2 weighted images. We performed decompressive laminectomy and lesional biopsy. After operation, she was subsequently treated with steroid and could walk unaided. In the second case, a 45-year-old woman presented with fever and quadriplegia after a spine fusion operation due to lumbar spinal stenosis and degenerative herniated lumbar disc. Initial MRI showed anterior and posterior epidural mass lesion from foramen magnum to C4 level. She underwent decompressive laminectomy and durotomy followed by steroid therapy. However, her conditions deteriorated gradually and medical complications occurred. In our cases, etiology was not found despite through investigations. Initial MRI showed dural thickening with mixed signal intensity on T1- and T2-weighted images. Pathologic examination revealed chronic nonspecific inflammation in both patients. Although one patient developed several complications, the other showed slow improvement of neurological symptoms with decompressive surgery and steroid therapy. In case of chronic compressive myelopathy due to the dural hypertrophic change, decompressive surgery such as laminectomy or laminoplasty may be helpful as well as postoperative steroid therapy.
Kim, Jee Hee; Park, Young Mok
Sustained administration of opioid antagonists to rodents results in an enhanced antinociceptive response to agonists. We investigated the changes in spinal ?-opioid receptor signalling underlying this phenomenon. Rats received naltrexone (120 ?g/h; 7 days) via osmotic minipumps. The antinociceptive response to the ?-agonist sufentanil was tested 24 h after naltrexone withdrawal. In spinal cord samples, we determined the interaction of ?-receptors with G? proteins (agonist-stimulated [(35)S]GTP?S binding and immunoprecipitation of [(35)S]GTP?S-labelled G? subunits) as well as ?-opioid receptor-dependent inhibition of the adenylyl cyclase (AC) activity. Chronic naltrexone treatment augmented DAMGO-stimulated [(35)S]GTP?S binding, potentiated the inhibitory effect of DAMGO on the AC/cAMP pathway, and increased the inverse agonist effect of naltrexone on cAMP accumulation. In control rats, the inhibitory effect of DAMGO on cAMP production was antagonized by pertussis toxin (PTX) whereas, after chronic naltrexone, the effect became resistant to the toxin, suggesting a coupling of ?-receptors to PTX-insensitive G?(z) subunits. Immunoprecipitation assays confirmed the transduction switch from G?(i/o) to G?(z) proteins. The consequence was an enhancement of the antinociceptive response to sufentanil that, in consonance with the neurochemical data, was prevented by G?(z)-antisense oligodeoxyribonucleotides but not by PTX. Such changes in opioid receptor signalling can be a double-edged sword. On the one hand, they may have potential applicability to the optimisation of the analgesic effects of opioid drugs for the control of pain. On the other hand, they represent an important homeostatic dysregulation of the endogenous opioid system that might account for undesirable effects in patients chronically treated with opioid antagonists. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'. PMID:21903117
Valdizán, Elsa M; Díaz, Alvaro; Pilar-Cuéllar, Fuencisla; Lantero, Aquilino; Mostany, Ricardo; Villar, Ana V; Laorden, María L; Hurlé, María A
Summary In order to assess the actual incidence of gas bubbles trapped within acute intracranial epidural haematomas, as revealed by computed tomography (CT) of the skull, a series of 204 patients with surgically verified epidural haematomas was retrospectively reviewed. Gas bubbles were observed on CT scan in 22.5% of the cases, with the incidence rising to 37% when CT scanners
M. Cossu; T. Arcuri; B. Cagetti; M. Brambilla Bas; D. Siccardi; A. Pau
tions have been used for more than half a century in the management of lumbosacral radicular pain. At this writ- ing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herni- ated nucleus pulposus. Methods. Randomized by patient choice, patients re- ceived either a transforaminal epidural steroid
Vijay B. Vad; Atul L. Bhat; Gregory E. Lutz; Frank Cammisa
The averaged electrical potentials evoked by the stimulation of the peripheral nerves were recorded with surface electrodes over the lumbosacral, lower thoracic and cervical spine and with epidurally placed electrodes in the cervical area. The waveforms of the lumbosacral and cervical spinal cord potentials show similar complexity reflecting peripheral and central generators. The larger negative wave with at least two
M. R. Dimitrijevic; L. D. Lehmkuhl; E. M. Sedgwick; A. M. Sherwood; W. B. McKay
Dorsal root ganglion (DRG) afferent terminals were identified, using electrophysiological tech- niques, within fetal mouse spinal cord cross-sections cultured in vitro. Afferent distribution patterns were monitored in explants grown for 3 to 6 weeks either in a serum-supplemented or in a serum- free, chemically defined medium (CDM). Bioelectrically active control explants from both series were compared with explants which had
R. E. BAKER; M. A. CORNER; A. M. M. C. HABETS
Study design: Oral glucose tolerance testing was performed prospectively in 201 subjects with spinal cord injury (SCI). The dependent variables included the values from the oral glucose tolerance test (glucose and insulin) and diagnostic classification (i.e., diabetes mellitus, impaired glucose tolerance, normal glucose tolerance); the independent variables consisted of study group, gender, ethnic group, age, age at onset of SCI,
WA Bauman; RH Adkins; AM Spungen; RL Waters
Objective: To determine the existence of homogeneous spinal cord injury (SCI) pain subgroups. Design: Prospective longitudinal design. Participants: Persons with traumatic onset SCI (N = 1,334) with self-reported pain, pain interference, and depression. Outcome Measures: Pain (Numerical Rating Scale); pain interference (item from the Short Form-12); and depression (Brief Patient Health Questionnaire). Results: Multivariate clustering revealed 4 SCI pain subgroups:
Michael W. Wilson; J. Scott Richards; Joshua C. Klapow; Michael J. DeVivo
Thirty-three dogs were anesthetized, laminectomized in the lower thoracic, upper lumbar region, and exposed to simulated 220 ft air dives of 5 to 60 minutes. Cinephotomicrography of the epidural vertebral venous system and dorsal pial vessels was done predive and postdive. The epidural vertebral venous system became blocked by bubbles in 24 animals. Eighteen animals evaluated for clinical and/or pathologic signs of cord damage all manifested positive signs. In 10 dives made by eight dogs, epidural vertebral venous system obstruction did not occur, and signs of cord damage were absent after nine of these dives. After one dive, a dog manifested cervical cord damage remote to the region of epidural vertebral venous system under observation. Acute pulmonary hypertension and central venous congestion were not essential prerequisites for epidural vertebral venous system occlusion to occur. These experiments permit further analysis of the pathogenesis of spinal cord damage in decompression sickness. PMID:943072
Hallenbeck, J M
A full-term neonate, born by caesarean section, presents with focal seizures. EEG and cranial ultrasound are normal. MRI of the cerebrum shows an epidural haematoma. Perinatal intracranial haemorrhage in the full-term newborn is an important cause of morbidity and mortality. Most perinatal intracranial haemorrhages are located either subdural or intracerebral, rarely epidural. Epidural haemorrhage is usually a complication of assisted delivery, however it may also occur without forcipal or vacuum extraction, as demonstrated in this case. An epidural haemorrhage should be suspected on clinical findings, even in the absence of an assisted delivery. As cranial ultrasound sonography often misses epidural haemorrhage due to parietal location of the haemorrhage, the diagnosis needs either cerebral CT or MRI. PMID:22665463
Kroon, Elke; Bok, Levinus A; Halbertsma, Feico
Study design:Case report of a 64-year-old man with psoas abscesses, epidural abscess and spondylitis after acupuncture.Objective:To report a case of paraplegia caused by spinal infection after acupuncture.Setting:Seoul, Korea.Case report:A 64-year-old man came to an emergency room because of severe back pain. At 3 days prior to visit, the patient received acupuncture therapy to the low back with a needle about
M S Bang; S H Lim; Bang
Although extravasations of polymethylmetharylate during percutaneous vertebroplasty are usually of little clinical consequence, surgical decompression is occasionally required if resultant neurologic deficits are severe. Surgical removal of epidural polymethylmetharylate is usually necessary to achieve good neurologic recovery. Because mobilizing the squeezed spinal cord in a compromised canal can cause further deterioration, attempts to remove epidural polymethylmetharylate in the thoracic region need special consideration. A 66-year-old man had incomplete paraparesis and radicular pain on the chest wall after percutaneous vertebroplasty for osteoporotic compression fracture of T7. Radiological studies revealed polymethylmetharylate extravasations into the right lateral aspect of spinal canal that caused marked encroachment of the thecal sac and right neuroforamina. Progressive neurologic deficit and poor responses to medical managements were observed; therefore, surgical decompression was performed 4 months later. After laminectomy and removal of facet joints and T7 pedicle on the affected side, extravasated polymethylmetharylate posterior and anterior to the thecal sac was completely removed without retracting the dura mater. Spinal stability was reconstructed by supplemental spinal instrumentation and intertransverse arthrodesis with banked cancellous allografts. Myelopathy and radicular pain gradually resolved after decompression surgery. The patient was free of sensory abnormality and regained satisfactory ambulation two years after surgical decompression.
Wu, Chang-Chin; Lin, Mu-Hung; Chen, Po-Quang; Shih, Tiffany Ting-Fang
Due to their involvement in neuro-modulatory processes, the endogenous cannabinoid system and chemokine network, which were shown to interact which each other, are potential key elements in the cascades underlying central neuropathic pain development after spinal cord injury (SCI). Expression profiles of cannabinoid receptor type-1 (CB(1)), and of the chemokines chemokine ligand 2 (C-C motif?) (CCL2), chemokine ligand 3 (C-C motif?) (CCL3), plus their main receptors CCR2 and CCR1, were investigated in brain regions related to pain, emotion, learning, and memory in a rat SCI paradigm of post-traumatic neuropathic pain. Immunoreactivity (IR) was investigated 7 days and 42 days after sham operation, and moderate (100-kdyn), and severe (200-kdyn) thoracic spinal cord contusion lesions. Hippocampal (HC) subregions, amygdaloid complex, anterior cingulate cortex (ACC), periaqueductal gray (PAG), and thalamic nuclei were analyzed. Seven days after lesioning, CB(1) IR was induced in thalamic nuclei and HC subregions (CA3 and dentate gyrus), and downregulated in amygdaloid nuclei, ACC, and PAG. On day 42, CB(1) IR remained elevated in the HC and thalamic areas, and was induced in ACC after 100-kdyn, but downregulated after 200-kdyn lesions. It remained reduced in the PAG of severely lesioned animals, paralleling their prolonged neuropathic pain-related behavior. Double-labeling revealed partial co-expression of CB(1) with the pain-related vanilloid receptor transient receptor potential vanilloid receptor 1 (TRPV1), and chemokines (CCL2 and CCL3). These chemokines were induced in the PAG, thalamus, and HC, especially in the chronic time course after severe SCI. Thus interactions of CB(1), C-C chemokines, and TRPV1 likely play a role in SCI-induced plastic changes in the brain, underlying emotional-affective pain responses and central pain development after spinal cord lesions. PMID:21265596
Knerlich-Lukoschus, Friederike; Noack, Malte; von der Ropp-Brenner, Beata; Lucius, Ralph; Mehdorn, Hubertus Maximilian; Held-Feindt, Janka
Chronic low back pain (CLBP) is one of the main causes of disability in the western world with a huge economic burden to society. As yet, no specific underlying anatomic cause has been identified for CLBP. Imaging often reveals degenerative findings of the disc or facet joints of one or more lumbar motion segments. These findings, however, can also be observed in asymptomatic people. It has been suggested that pain in degenerated discs may be caused by the ingrowth of nerve fibers into tears or clefts of the annulus fibrosus or nucleus pulposus, and by reported high levels of pro-inflammatory mediators. As this so-called discogenic pain is often exacerbated by mechanical loading, the concept of relieving pain by spinal fusion to stabilise a painful spinal segment, has been developed. For some patients lumbar spinal fusion indeed is beneficial, but its results are highly variable and hard to predict for the individual patient. To identify those CLBP patients who will benefit from fusion, many surgeons rely on tests that are assumed to predict the outcome of spinal fusion. The three most commonly used prognostic tests in daily practice are immobilization in a lumbosacral orthosis, provocative discography and trial immobilization by temporary external transpedicular fixation. Aiming for consensus on the indications for lumbar fusion and in order to improve its results by better patient selection, it is essential to know the role and value of these prognostic tests for CLBP patients in clinical practice. The overall aims of the present thesis were: 1) to evaluate whether there is consensus among spine surgeons regarding the use and appreciation of prognostic tests for lumbar spinal fusion; 2) to verify whether a thoracolumbosacral orthosisis (TLSO) truly minimises lumbosacral motion; 3) to verify whether a TLSO can predict the clinical outcome of fusion for CLBP; 4) to assess whether provocative discography of adjacent segments actually predicts the long-term clinical outcome fusion; 5) to determine the incidence of postdiscography discitis, and whether there is a need for routine antibiotic prophylaxis; 6) to assess whether temporary external transpedicular fixation (TETF) can help to predict the outcome of spinal fusion; 7) to determine the prognostic accuracy of the most commonly used tests in clinical practice to predict the outcome of fusion for CLBP. The results of a national survey among spine surgeons in the Netherlands were presented in Study I. The surgeons were questioned about their opinion on prognostic factors and about the use of predictive tests for lumbar fusion in CLBP patients. The comments were compared with findings from the prevailing literature. The survey revealed a considerable lack of uniformity in the use and appreciation of predictive tests. Prognostic factors known from the literature were not consistently incorporated in the surgeons' decision making process either. This heterogeneity in strategy is most probably caused by the lack of sound scientific evidence for current predictive tests and it was concluded that currently there is not enough consensus among spine surgeons in the Netherlands to create national guidelines for surgical decision making in CLBP. In Study II, the hypothesized working mechanism of a pantaloon cast (i.e., minimisation of lumbosacral joint mobility) was studied. In patients who were admitted for a temporary external transpedicular fixation test (TETF), infrared light markers were rigidly attached to the protruding ends of Steinman pins that were fixed in two spinal levels. In this way three-dimensional motion between these levels could be analysed opto-electronically. During dynamic test conditions such as walking, a plaster cast, either with or without unilateral hip fixation, did not significantly decrease lumbosacral joint motion. Although not substantiated by sound scientific support, lumbosacral orthoses or pantaloon casts are often used in everyday practice as a predictor for the outcome of fusion. A systematic review of the literature supplemented with a prospec
Introduction Over 70% of people in resource-rich countries develop low back pain (LBP) at some time. But recovery is not always favourable: 82% of non-recent-onset patients still experience pain one year later. Many chronic patients who were initially told that their natural history was good spend months or years seeking relief. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments? What are the effects of injection therapy? What are the effects of non-drug treatments? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 74 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural steroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulative therapy, traction, and transcutaneous electrical nerve stimulation (TENS).
Low back pain is the most common cause of disability under the age of 45. The annual incidence of back pain is estimated to be 5% and the lifetime prevalence is 80%. Majority of the patients with persistent symptoms are suffering from radiculopathy that is mainly caused by a herniated nucleus pulposus (HNP). HNP can heal spontaneously due to spontaneous resorption. Besides pressure nucleus pulposus, without any compression, may induce similar changes when applied epidurally to the nerve roots. Nevertheless, combination of chronic mechanical compression and application of nucleus pulposus causes a more pronounced nerve injury. When dual pathophysiology (pressure and inflammatory reaction), spontaneous resorption, and natural course of HNP are taken into account, any treatment modality that eliminates both the pressure and contact of the nucleus pulposus with the nerve root via creating extra time for healing to take place might prove beneficial. These requirements can be provided by spinal balloon nucleoplasty (SBN), which can be used in combination with other treatment modalities such as chymopapain injection. In this hypothetical method, epidural access to the subarachnoid space is established via epidural needles, thereafter a specially designed balloon tipped catheter is advanced. When the catheter is ideally placed with the help of CT or MRI, the balloon at the tip is inflated to relieve pressure and to prevent contact of the nerve root with HNP. The answer to the question, will SBN find a place in clinical practice? is obscure. But a homology can be established with uterine fibroid embolization, which has found clinical use in a period of 30 years approximately. PMID:18096323
Basaran, Ahmet; Topatan, Sena
Background Several studies have shown that in diabetic patients, the glycemic profile was disturbed after intra-articular injection of corticosteroids. Little is known about the impact of epidural injection in such patients. The goal of this study was double, at first comparing the glycaemic profile in diabetic patients after a unique injection of 80 mg of acetate methylprednisolone either intra-articular or epidural and secondly to compare the amount of systemic diffusion of the drug after both procedures. Methods Seventeen patients were included. Glycemic changes were compared in 9 diabetic patients following intra-articular (4 patients) and epidural injections (5 patients). Epidural injections were performed using the sacral route under fluoroscopic control in patients with lumbar spinal stenosis. Diabetes control had to stable for more than 10 days and the renal function to be preserved. Blood glucose was monitored using a validated continuous measuring device (GMS, Medtronic) the day before and for two days following the injection. Results were expressed in the form of daily glycemic profiles and as by mean, peak and minimal values +/- SD. The urinary excretion of methylprednisolone after the 2 routes of injection was analyzed in 8 patients (4 in each group). Urine samples were cropped one hour before the injections, then 4 times during the first day and 3 times a week for 2 weeks. The measurements included the free and conjugated fraction Results The glycaemic profile remains unchanged with no significant changes in the group of the 5 diabetic patients receiving epidural injections. On the other end, the average peak and and mean values were enhanced up to 3 mmol/l above baseline two days after the infiltration in the groups of the 4 diabetic patients infiltrated intra-articular. The mean urinary excretion of the steroid was about ten times higher in the intra-articular versus epidural group: 7000 ng/ml versus 700 ng/ml. Looking at each individual there were marked differences especially after intra-articular injections. Conclusion This is the first study to show that a single epidural steroid injection of 80 mg depot methylprednisolone had no effect on the glycemic control in diabetic patients. The absence of glycemic control changes correlated well with the very low urinary excretion of the drug after epidural injection. Trial registration NCT01420497
Background/Objective: Spinal angiolipoma (SAL) is an uncommon clinico-pathological entity. Design: Single case report. Methods: Retrospective data analysis. Findings: An obese woman with a 1-year history of progressive spastic paraparesis and acute deterioration underwent magnetic resonance imaging of the thoracic spine, the results of which suggested a tumor compressing the thoracic spinal cord. The histopathological examination of the completely resected tumor revealed an epidural angiolipoma. Conclusions: This case report offers a reminder that SAL should be considered in the differential diagnosis of long-standing, slowly progressive paraparesis. It remains unclear whether an increased body mass index might be a contributing factor to the development of SAL.
Hungs, Marcel; Pare, Laura S
BackgroundA large solitary amyloidoma in the cervical epidural space without bony connection and with minimal spinal cord compression and no myelopathy, as a first manifestation of disseminated amyloidosis in a multiple myeloma patient, has not been reported previously; this case is thereby distinct from the seven prior reports in the world literature, of a solitary amyloidoma of the cervical spine.
Carl J. Belber; David L. Graham
Many therapeutic roles have been proposed for sigma-1 receptor (Sig-1R), but the involvement of Sig-1R in neuropathic pain has currently not been well explored. The present study aimed to evaluate the anti-nociceptive effect of Sig-1R antagonist (BD1047) in a rat model of chronic compression of the dorsal root ganglion (CCD), which is a model of human foraminal stenosis and radicular pain. When stainless steel rods were inserted into the intervertebral foramen of lumbar vertebrae 4 and 5, the CCD developed reliable mechanical (from 3 day) and cold allodynia (from 1 day) as compared with the sham operation group. The spinal expressions of Sig-1R and phosphorylation of extracellular signal-regulated kinase (pERK) were significantly increased from day 3 to day 14 after CCD surgery, as is consistent with the manifestation of allodynia. The BD 1047 (10, 30, 100 mg/kg) administered on postoperative days 0~5 dose-dependently suppressed both the induction of allodynia and the elevation of the spinal pERK expression in a manner comparable with that of gabapentin (100 mg/kg). At 7 days post-CCD surgery, BD1047 (10, 30, 100 mg/kg) administration also produced anti-nociceptive effects on the mechanical and cold allodynia similar with those of gabapentin (100 mg/kg). Therefore, this data suggested that Sig-1R may play an important role in both the development and maintenance of CCD-induced neuropathy.
Son, Ji Seon
Thirty-seven adults with spinal-cord injury and chronic pain were randomly assigned to receive 10 sessions of self-hypnosis (HYP) or EMG biofeedback relaxation (BIO) training for pain management. Participants in both treatment conditions reported sub-stantial, but similar, decreases in pain intensity from before to after the treatment sessions. However, participants in the HYP condition, but not the BIO condition, reported statistically significant decreases in daily average pain pre- to posttreatment. These pre- to posttreatment decreases in pain reported by the HYP participants were maintained at 3-month follow-up. Participants in the HYP condition, but not the BIO condition, also reported significant pre- to posttreatment increases in perceived control over pain, but this change was not maintained at the 3-month follow-up.
Jensen, Mark P.; Barber, Joseph; Romano, Joan M.; Hanley, Marisol A.; Raichle, Katherine A.; Molton, Ivan R.; Engel, Joyce M.; Osborne, Travis L.; Stoelb, Brenda L.; Cardenas, Diana D.; Patterson, David R.
Study design:Literature review.Objective:To describe quantitatively some of most important anatomic, systemic, and metabolic changes occurring soon (one month) after spinal cord trauma in mice.Setting:University Laval Medical Center.Results:Significant changes in weight, mechanical and contractile muscle properties, bone histomorphometry and biomechanics, deep-vein morphology, complete blood count, immune cell count, lipid metabolism and anabolic hormone levels were found occurring within 1 month in
R-V Ung; N P Lapointe; P A Guertin; PA Guertin
The objective of the study was to determine whether physical exercise combined with epidural spinal cord magnetic stimulation could improve recovery after injury of the spinal cord. Spinal cord lesioning in mice resulted in reduced locomotor function and negatively affected the muscle strength tested in vitro. Acrobatic exercise attenuated the behavioral effects of spinal cord injury. The exposure to magnetic fields facilitated further this improvement. The progress in behavioral recovery was correlated with reduced muscle degeneration and enhanced muscle contraction. The acrobatic exercise combined with stimulation with magnetic fields significantly facilitates behavioral recovery and muscle physiology in mice following spinal cord injury. PMID:18986227
Ahmed, Zaghloul; Wieraszko, Andrzej
Background: The authors have previously demonstrated that human herniated disc material contains high concentrations of free glutamate. In an experimental model, elevated epidural glutamate concentrations in the lumbar spine can cause a focal hyperesthetic state. Methods: Rats underwent epidural glutamate infusion in the lumbar spine by a miniosmotic pump over a 72-hour period. Some rats underwent coinfusion with glutamate and ionotropic glutamate antagonists. Nociception was assessed by von Frey fibers and by assessment of glutamate receptor expression in the corresponding dorsal horn of the spinal cord. Results: The kainic acid antagonist, UBP 301, decreased epidural glutamate-based hyperesthesia in a dose dependent manner. Concordant with these findings, there was significant decrease in kainate receptor expression in the dorsal horn. The N-Methyl-4-isoxazoleproionic acid (NMDA) antagonist Norketamine also significantly diminished hyperesthesia and decreased receptor expression in the dorsal horn. Conclusions: Both UBP 301, the kainic acid receptor antagonist and Norketamine, an NMDA receptor antagonist, dampened epidural glutamate-based nociception. Focal epidural injections of Kainate or NMDA receptor antagonists could be effective treatments for disc herniation-based lumbar radiculopathy.
Osgood, Doreen B.; Harrington, William F.; Kenney, Elizabeth V.; Harrington, J. Frederick
We describe the rare simultaneous occurrence of epidural lipomatosis and a perineural cyst at the same level, lumbar kyphosis, osteoporotic vertebral fractures, and neurological deficits. A 75-year-old corticosteroid-dependent female farmer presented with severe low back pain, progressive lumbar kyphosis, and inability to stand because of numbness and muscle weakness of both legs. Plain radiographs displayed markedly decreased bone density, significant lumbar kyphosis, and vertebral compression fractures of L2, L3, and L4. Magnetic resonance imaging of the lumbar spine revealed a perineural cyst at the L2-3 level, extensive epidural lipomatosis, and spinal canal stenosis. Laminectomy from L3 to L5 with resection of epidural fatty tissue restored her walking ability. We postulate that the osteoporotic fractures and epidural lipomatosis were induced by corticosteroid therapy. Preexisting degenerative lumbar kyphosis of the type commonly seen in elderly farmers could have promoted osteoporotic lumbar vertebral fractures at points where bending stress had been strongly exerted. The combination of a perineural cyst and epidural lipomatosis at the same level has not been reported previously. PMID:12486480
Miyakoshi, Naohisa; Shimada, Yoichi; Murai, Hajime; Suzuki, Tetsuya; Hongo, Michio; Itoi, Eiji
Objectives.? Although the load impedance of a pulse generator has a significant effect on battery life, the electrical impedance of contact arrays in spinal cord stimulation (SCS) has not been extensively studied. We sought to characterize the typical impedance values measured from common quadripolar percutaneous SCS contact arrays. Methods.? In 36 patients undergoing percutaneous trial stimulation for various chronic pain conditions, bipolar impedance between adjacent contacts of 64 leads with 9 mm center-to-center spacing was measured in two different vertebral level regions, cervical (C3-C7) and lower-thoracic (T7-T12). Multiple linear regression was applied to analyze the contribution of six variables to the biological tissue portion of the impedance (excluding the resistance of the lead wires). Results.? The median impedance in the cervical region (351 ± 90 ?) was significantly lower (36%, p < 0.001) than in the lower-thoracic region (547 ± 151 ?). In addition, time since implant had a weaker but still significant effect on tissue impedance. Conclusions.? Results from finite-difference mathematical modeling of SCS suggest that the difference in tissue impedance related to vertebral level may be due to the dorsoventral position of the lead in the epidural space. The presence of a larger space between the triangularly shaped dorsal part of the vertebral arch and the round shape of the dural sac in the lower-thoracic region increases the likelihood that the stimulating lead will not make dural contact, and thus "see" an increased impedance from the surrounding epidural fat. This implies that the energy requirements for stimulation in the thoracic region will be higher than in the cervical region, at least during the acute phase of implant. PMID:22151637
Alò, Kenneth; Varga, Clayton; Krames, Elliot; Prager, Joshua; Holsheimer, Jan; Manola, Ljubomir; Bradley, Kerry
Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard
Emmanuel Antok; Fabienne Bordet; Sabine Lansiaux; Sylvie Combet; Patricia Taylor; Agnes Pouyau; Brigitte Paturel; Robert James; Bernard Allaouchiche; Dominique Chassard
Objectives To investigate possible short and long term side effects of epidural analgesia, compared with non-epidural analgesia for pain relief in labour.Design Randomised controlled study, with long term follow up by questionnaire. Analysis by intention-to-treat.Setting Busy maternity unit within a district general hospital in England.Participants Three hundred and sixty nine primigravid women in labour were included (randomised allocation: epidural n=184,
C. J Howell; C Kidd; W Roberts; P Upton; L Lucking; P. W Jones; R. B Johanson
Epidural catheterization is routinely used by anaesthesiologists to provide labour and post-operative analgesia. In most cases, catheter placement is without serious side effects and uneventful. However, epidural abscess is a rare complication that may result in severe morbidity. We present a case of epidural abscess after labour epidural catheter placement in a healthy 36-year-old female who presented on post-partum d 10 with complaints of fever and back pain. She was treated with intravenous antibiotics and fully recovered.
Tumber, Sundeep S.; Liu, Hong
Pregnancy is considered a period of high risk for cardiovascular complications in patients with Marfan syndrome. Therefore the choice of anesthetic technique for delivery should be focused on minimizing hemodynamic fluctuations, and preferably provide adequate post-operative pain control. For this purpose, neuraxial blocks, such as spinal or epidural anesthesia, may be deemed a safe option. However, dural ectasia is present in 63-92% of patients with Marfan syndrome, and the increased amount of cerebrospinal fluid volume is thought to be one of main reasons for spinal anesthesia failure. We report herein the peri-operative management of a patient with Marfan syndrome and dural ectasia for cesarean section using epidural anesthesia.
Kim, Gahyun; Ko, Justin Sangwook
During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination is disrupted by spinal cord injury (SCI), control of respiratory muscles innervated below the injury level is compromised leading to respiratory muscle dysfunction and pulmonary complications. These conditions are among the leading causes of death in patients with SCI. Standard pulmonary function tests that assess respiratory motor function include spirometrical and maximum airway pressure outcomes: Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV1), Maximal Inspiratory Pressure (PImax) and Maximal Expiratory Pressure (PEmax). These values provide indirect measurements of respiratory muscle performance(6). In clinical practice and research, a surface electromyography (sEMG) recorded from respiratory muscles can be used to assess respiratory motor function and help to diagnose neuromuscular pathology. However, variability in the sEMG amplitude inhibits efforts to develop objective and direct measures of respiratory motor function. Based on a multi-muscle sEMG approach to characterize motor control of limb muscles, known as the voluntary response index (VRI), we developed an analytical tool to characterize respiratory motor control directly from sEMG data recorded from multiple respiratory muscles during the voluntary respiratory tasks. We have termed this the Respiratory Motor Control Assessment (RMCA). This vector analysis method quantifies the amount and distribution of activity across muscles and presents it in the form of an index that relates the degree to which sEMG output within a test-subject resembles that from a group of healthy (non-injured) controls. The resulting index value has been shown to have high face validity, sensitivity and specificity. We showed previously that the RMCA outcomes significantly correlate with levels of SCI and pulmonary function measures. We are presenting here the method to quantitatively compare post-spinal cord injury respiratory multi-muscle activation patterns to those of healthy individuals. PMID:23912611
Aslan, Sevda C; Chopra, Manpreet K; McKay, William B; Folz, Rodney J; Ovechkin, Alexander V
Introduction Subarachnoid hemorrhage is one of the most feared acute neurologic events. Accurate diagnosis of subarachnoid hemorrhage is essential, and computed tomography of the brain is the first diagnostic imaging study. However, in rare circumstances, a similar appearance may occur in the absence of blood in the subarachnoid space. The contrast enhancement of subarachnoid space is a rare complication after lumbar percutaneous epidural neuroplasty, with, to the best of our knowledge, no previous report in the literature. Case presentation A 42-year-old Korean male patient, who underwent a spinal operation five years previously at the level of L4 to S1, visited our clinic with persistent and aggravating low back pain. An imaging study revealed the focal and diffuse disc protrusion at the level of L4/5 and L5/S1. The clinician decided to perform a lumbar percutaneous epidural neuroplasty. During the procedure, dural adhesion was suspected at the previously operated level, and the neuroplasty catheter was malpositioned into the intradural space on the first attempt. After the catheter was repositioned, the scheduled epidural neuroplasty was completed. Our patient had no definite abnormal neurological signs. But, after a day, our patient complained of severe headache with sustained high blood pressure without neurological disorientation. Computed tomography of his brain showed a subarachnoid hemorrhage-like appearance with intracranial air. Sequential angiography, subtractional magnetic resonance imaging and examination of the cerebrospinal fluid revealed no abnormalities. Follow-up computed tomography after one day revealed no definite intracranial hemorrhage, and our patient was discharged with improved low back pain without neurological deficit. Conclusion We report a rare case of contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty. The physician should keep in mind a rare case like this, and the supine position with head elevation is necessary to avoid a similar complication after lumbar percutaneous epidural neuroplasty.
A 56-year-old Japanese man with hypertension presented with a 10 days history of high fever, right and left upper quadrant tenderness. An abdominal ultrasonography and computerized tomographic scan revealed a large collection in the right lobe of the liver that was consistent with an abscess. A drainage catheter was placed and purulent fluid was drained. Cultures of the fluid and
Gen Kuramochi; Shin-ichi Takei; Munehiro Sato; Osamu Isokawa; Takashi Takemae; Akira Takahashi
Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials. PMID:23662750
Tzimas, P; Prout, J; Papadopoulos, G; Mallett, S V
Dental infection as a cause of epidural abscess is rare compared with other forms of intracranial suppurations. A 10-year-old boy was seen because of headaches and fever. There was no history of otitis media or sinusitis, but he had sought care for dental complaints. The patient was from an upper-middle-class family, was not immunocompromised, and had no other risk factor for a major infection. A CT brain scan confirmed a frontal epidural abscess. The patient underwent emergency surgery for evacuation of the epidural abscess, followed by antimicrobial therapy. His condition improved remarkably following surgery, with complete resolution of symptoms. He subsequently underwent extraction of 2 teeth following dental review. Dental infection as a cause of intracranial epidural abscess is rare, but should be considered when evaluating patients for intracranial infections. A review of the literature sheds light on the causal relationship and possible pathogenesis of this condition. PMID:21361773
Kanu, Okezie Obasi; Ukponmwan, Efosa; Bankole, Olufemi; Olatosi, John Olutola; Arigbabu, Sarajudeen Oladele
The purpose of this article is to review the literature on the side effects of intrathecal and epidural opioids. English-language\\u000a articles were identified through a MEDLINE search and through review of the bibliographies of identified articles. With the\\u000a increasing utilization of intrathecal and epidural opioids in humans during the 1980s, a wide variety of clinically relevant\\u000a side effects have been
Mark A. Chaney
We report a case of epidural hydatid cyst in the posterior fossa in a 5-year-old child. The disease was revealed by raised intracranial pressure with torticollis. The diagnosis was based on the brain CT scan and MRI, and confirmed surgically. The course was uneventful. Cranial epidural hydatid cysts are very rare: only 18 cases have been reported previously in the literature. PMID:11015677
Gazzaz, M; Bouyaakoub, F A; Akhaddar, A; Derraz, S; Elkhamlichi, A
We evaluated in analgesic and sedative effects of continuous epidural infusion of two analgesic regimens in ventilated patients\\u000a following esophagectomy. Fortysix patients, divided into two treatment groups, received postoperative continuous epidural\\u000a infusion of morphine, or that of a combination of bupivacaine and morphine. Assessments were made with the following indices:\\u000a pain relief score, somnolence score, patient ventilator coordination score, and
Shinichi Sakura; Mariko Sumi; Yoji Saito; Jyunken Koh; Makoto Asano; Akio Tanaka; Yoshihiro Kosaka
Cervical epidural steroid injections, administered either interlaminarly or transforaminally, are common injection therapies used in many interventional pain management practices to treat cervicalgia or cervicobrachial pain secondary to spondylosis or intervertebral disc displacement of the cervical spine. Among the risks associated with these procedures are the risk for inadvertent dural puncture and the development of positional headache from intracranial hypotension. We report the case of a 31-year-old woman with a history of migraine and cervicalgia from cervical spine spondylosis and cervical disc degenerative disease that developed an intractable orthostatic headache accompanied by nausea and vomiting after a therapeutic high cervical intralaminar epidural steroid injection was administered directly to the C1-C2 spinal level. Although the initial magnetic resonance imaging of the brain was unremarkable, a computed tomography myelogram study revealed a massive cerebrospinal fluid (CSF) leak from the cervical spine. Repeated cervical epidural blood patches using a catheter targeted to the high cervical spine (C2) to inject 15 mL of autologous blood was required to totally alleviate her symptoms after she failed conservative therapy. Determining the optimal location or approach to administer an epidural blood patch can be a challenge depending on the location of the CSF leak. Our case demonstrates that targeted cervical epidural blood patch placement using an easily manipulated catheter under fluoroscopic guidance is a safe and effective approach to treat a massive CSF leak in the high cervical spine region caused by prior therapeutic cervical spine epidural steroid injection. PMID:23877456
Sykes, Kenneth T; Yi, Xiaobin
Although delivery is a normal physiologic process, it causes a certain level of pain in women. Today, the most frequently preferred and the most used method is epidural anesthesia. The objective of the present study was to review the reasons, effects, and risks associated with epidural analgesia for pain relief. The study was conducted at Akdeniz University Hospital, Antalya, Turkey, between October 2004 and July 2005. Epidural analgesia was administered to 51 pregnant women in the experimental group, and 51 pregnant women in the control group did not receive analgesia. Data were collected by questionnaire and observation forms. Epidural anesthesia was chosen by 76.5% of the participants because they wanted to experience a pain-free childbirth, 66.7% because they were afraid of