Spinal epidural hematoma after a pathologic compression fracture: an unusual presentation of multiple myeloma.

BACKGROUND CONTEXT: Spinal epidural hematoma can result from traumatic and atraumatic etiologies. Atraumatic spinal epidural hematomas have been reported as an initial presentation of multiple myeloma. There are no other reports previously describing spinal epidural hematoma after a pathologic spinal fracture. PURPOSE: To present the first reported case of a spinal epidural hematoma after a pathologic fracture and a very unusual initial presentation of multiple myeloma in a young patient. STUDY DESIGN/SETTING: Case report. METHODS: A healthy asymptomatic 37-year-old male was struck in the head with a ball while playing soccer. Initial symptoms included severe back pain without neurologic symptoms. Complete motor paralysis developed over the next 24 hours in the lower extremities with a sensory level of T10. Magnetic resonance imaging evaluation of the spine revealed a T6 compression fracture with a dorsal T3 to T10 epidural hematoma. The patient underwent surgical T2 to T8 posterior spinal decompression with evacuation of the hematoma. Serum and urine electrophoresis and bone marrow biopsy were performed. RESULTS: The results of the electrophoresis revealed an immunoglobulin A monoclonal spike. The bone marrow biopsy was positive for plasma cell myeloma. Recovery of some motor function was noted in both lower extremities postoperatively. The patient was subsequently started on steroids and chemotherapy for myeloma. The patient has also undergone bone marrow transplant, and his myeloma is currently in remission. CONCLUSION: This is the first reported case of spinal epidural hematoma after a pathologic spinal fracture. Also, this case represents an unusual initial presentation of multiple myeloma in a young patient.     

Spinal epidural hematoma. Report of a case and review of the literature

We report the case of a thoracic epidural hematoma at the T7-T9 level which occurred after placement of spinal epidural catheter for continuous anaesthesia in acute pancreatitis. The male patient felt a sudden back pain after six days of successful analgesia and became paraplegic 24 hours afterwards. An emergency laminectomy and removal of the hematoma were performed; however, the patient recovered only incompletely.We discuss the clinical signs and symptoms of spinal epidural hematoma as well as its diagnostics and therapy. The controversial views from the literature concernings its etiology are critically reviewed.     

Repeated failure of epidural analgesia: an association with epidural fat?

BACKGROUND AND OBJECTIVES: To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis). CASE REPORT: A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). Analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established. CONCLUSION: We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.     

Isolated extraosseous epidural myeloma presenting with thoracic compressive myelopathy

Background contextMultiple myeloma is the commonest primary malignancy of the spine, but it rarely presents as an extraosseous epidural tumor with only five cases reported in literature so far.PurposeThe purpose of this study was to heighten awareness and treatment options of a rare case of extraosseous epidural myeloma.Study designThe study design comprises a case report and literature review.MethodsWe present a 60-year-old lady with progressive paraplegia (American Spinal Injury Association grade C) with sensory blunting below T8 level of 2 months’ duration. Magnetic resonance imaging showed an extradural tumor in the dorsal epidural space from T6 to T7 without local bony involvement. She underwent a T6 and T7 laminectomy, T5–T8 pedicle screw instrumentation, and gross total resection of tumor. Histopathological diagnosis was consistent with myeloma. After surgery, the patient underwent local irradiation and adjuvant chemotherapy.ResultsNeurological improvement of one grade (American Spinal Injury Association grade C to D) was observed at 3 weeks postoperatively.ConclusionsIsolated extraosseous epidural myeloma without destruction or collapse of vertebral bodies should be included in the differential diagnosis of epidural mass lesions causing spinal cord compression. The overall prognosis in terms of survival is poor, but early decompression can prevent neurological deterioration and improve quality of life.     

Evidence That Intravenous Vasopressors Can Affect Rostral Spread of Spinal Anesthesia in Pregnancy

Background: The authors have previously observed an apparent association between rostral spread of spinal anesthesia and choice of intravenous vasopressor given to maintain maternal systolic arterial pressure during cesarean delivery. This study tested the hypothesis that an intravenous infusion of phenylephrine can reduce rostral spread of spinal anesthesia in pregnancy, compared with ephedrine.

Methods: The study was randomized and double blind. It compared phenylephrine 100 [mu]g/ml (phenylephrine group, n = 30), and ephedrine 3 mg/ml (ephedrine group, n = 30), given by infusion, to prevent maternal hypotension during combined spinal-epidural anesthesia for cesarean delivery. Two ml intrathecal plain levobupivacaine, 0.5%, combined with 0.4 ml intrathecal fentanyl, 50 [mu]g/ml, and 10 ml epidural saline was given with the patient in the sitting position. The upper level of neural blockade to cold and light touch sensation was recorded at 10 and 20 min postspinal. Epidural space pressure was recorded at 5, 10, 15, and 20 min.

Results: At 20 min, the upper dermatome blocked to cold sensation was median T3 (interquartile range, T2-T4) for the phenylephrine group, compared with T1 (T1-T2) for the ephedrine group (P = 0.001). At 20 min, the upper dermatome blocked to light touch sensation was median T5 (T4-T8) for the phenylephrine group, compared with T3 (T2-T6) for the ephedrine group (P = 0.009). The mean epidural space pressure in the phenylephrine group was 16 (13-19) mmHg, compared with 16 (13-18) mmHg in the ephedrine group (P = 0.63).     

Evidence that intravenous vasopressors can affect rostral spread of spinal anesthesia in pregnancy

BACKGROUND: The authors have previously observed an apparent association between rostral spread of spinal anesthesia and choice of intravenous vasopressor given to maintain maternal systolic arterial pressure during cesarean delivery. This study tested the hypothesis that an intravenous infusion of phenylephrine can reduce rostral spread of spinal anesthesia in pregnancy, compared with ephedrine. METHODS: The study was randomized and double blind. It compared phenylephrine 100 microg/ml (phenylephrine group, n = 30), and ephedrine 3 mg/ml (ephedrine group, n = 30), given by infusion, to prevent maternal hypotension during combined spinal-epidural anesthesia for cesarean delivery. Two ml intrathecal plain levobupivacaine, 0.5%, combined with 0.4 ml intrathecal fentanyl, 50 microg/ml, and 10 ml epidural saline was given with the patient in the sitting position. The upper level of neural blockade to cold and light touch sensation was recorded at 10 and 20 min postspinal. Epidural space pressure was recorded at 5, 10, 15, and 20 min. RESULTS: At 20 min, the upper dermatome blocked to cold sensation was median T3 (interquartile range, T2-T4) for the phenylephrine group, compared with T1 (T1-T2) for the ephedrine group (P = 0.001). At 20 min, the upper dermatome blocked to light touch sensation was median T5 (T4-T8) for the phenylephrine group, compared with T3 (T2-T6) for the ephedrine group (P = 0.009). The mean epidural space pressure in the phenylephrine group was 16 (13-19) mmHg, compared with 16 (13-18) mmHg in the ephedrine group (P = 0.63). CONCLUSIONS: This study provides evidence that intravenous phenylephrine can decrease rostral spread of spinal anesthesia in pregnancy, compared with intravenous ephedrine. Further work is required to investigate possible mechanisms and to assess its clinical significance.     

Myelopathy with syringomyelia following thoracic epidural anaesthesia

Under general anaesthesia and muscle relaxation, a thoracic epidural catheter was inserted at the T8-T9 level in a 7-year-old boy scheduled to have a Nissen fundoplication to provide postoperative analgesia. After 4 ml of lignocaine 1.5% was injected through the catheter, hypotension resulted. Fifty-five minutes later 5 ml of bupivacaine 0.25% produced the same effect. In the recovery room a similar injection resulted in lower blood pressure and temporary apnoea. Sensory and motor deficits were noted the next day and four days later magnetic resonance imaging demonstrated spinal cord syringomyelia extending from T5 to T10. Four years later, dysaesthesia from T6 to T10 weakness of the left lower extremity and bladder and bowel dysfunction persist. The risks of inserting thoracic epidural catheters in patients under general anaesthesia and muscle relaxation are discussed, emphasising the possibility of spinal cord injury with disastrous consequences.     

A case of idiopathic spinal cord herniation with duplicated dura mater

The patient was a 48-year-old man in whom a slow progression in walking difficulty occurred over a year. Magnetic resonance imaging (MRI) and computed tomography myelography (CTM) revealed duplicated dura mater from T1 to T12 and spinal cord herniation in the inner layer of the dura at the T4-T5 level. Idiopathic spinal cord herniation with duplicated dura mater was diagnosed, and surgery was performed. Intraoperative findings were of an elliptical defect of about 1 cm in the inner layer of the dura at the T4-T5 level, into which the spinal cord was herniated. A 1.5-cm cephalocaudal incision was created in the inner layer of the dura, and the incarcerated spinal cord was released, resulting in resolution of gait disturbance and an excellent postoperative clinical course. We reviewed the reports of 11 cases of idiopathic spinal cord herniation with duplicated dura mater and summarized the clinical and imaging characteristics as follows: 1) A hernial orifice was found at the T4-T6 level, 2) cross-sectional MRI or CTM showed a "snowman-like" deformation of the spinal cord, and 3) symptoms were often improved by widening the hernia orifice.     

Cervical spinal epidural abscess: case report

Most cases of spinal epidural abscesses occur in a midthoracic or lower lumbar location. Cervical spinal epidural abscess is distinctly rare, and its prognosis is not favorable due to respiratory problems. We report a case of cervical spinal epidural abscess. A 77-year-old male was admitted because of tetraparesis and dyspnea. Two months before admission, he had been treated by femoro-femoral bypass for arteriosclerosis obliterans , and he had suffered from postoperative wound infection one month later. He had noticed neck pain two days before admission, followed by a numbness and motor weakness in both hands. Neurological examination showed flaccid tetraplegy with an absence of DTRs, paralysis of intercostal muscles, loss of sensation below the C4 dermatome, and bladder dysfunction. A spinal CT scan revealed a mass lesion in the anterior epidural space from C2 to C6, which displaced the spinal cord posteriorly. A myelogram showed complete blockage of contrast medium at the level of C7-T1. He was treated by emergency laminectomy of C3 to C6 with evacuation of the epidural abscess. Culture showed staphylococcus aureus, for which appropriate antibiotics were administered. In spite of such an intensive treatment, the patient showed poor neurological improvement and died 42 days after operation.     

Spinal epidural hematoma following epidural catheter removal in a paraplegic patient

Spinal epidural hematoma is a rare and devastating complication of epidural catheter removal in an anticoagulated patient. The diagnosis could be quite challenging, especially in patients with preexisting neurological deficits. A 35-year-old patient with remote spinal cord injury and T4 level paraplegia developed a spinal epidural hematoma on the 7th postoperative day. The hematoma developed after epidural catheter removal with concurrent administration of unfractionated heparin.     

Respiratory effects of epidural anesthesia and anesthetic level obtained in patients for cesarean section

In order to determine the optimal level of epidural anesthesia, the author examined respiratory function of 138 full-term pregnant women in sitting and supine positions without anesthesia, and in supine position under epidural anesthesia prior to the cesarean section. Vital capacity (VC) increased in the sitting position in comparison with supine position because expiratory reserve volume (ERV) and tidal volume (TV) increased. In contrast, %FFV1.0, peak expiratory flow (PEF) and V75 decreased as uterus shifted anteriorly in the sitting position. Under the epidural anesthesia with T4-T6 analgesic, TV showed a relative increase resulting in an increase in VC. This was due to lateral displacement of the uterus alleviating the depression of diaphragm. Epidural anesthesia with levels C8-T3 caused a reduction in inspiratory reserve volume (IRV) and ERV which in turn resulted in a decrease in VC and PaCO2. This change depended on the paralysis of respiratory muscles and the dyspneic feeling of patient. Generally %FFV1.0 and the data related to flow volume curve decreased under epidural anesthesia. In conclusion, epidural anesthesia with T4-T6 levels accompanied a sufficient analgesic efficacy and respiratory function comparable with that in the sitting position without anesthesia, therefore this was considered to be a method of choice for cesarean section.     

腰麻联合双管硬膜外分娩镇痛的临床效果

目的评估腰麻联合双管硬膜外分娩镇痛的效果及对母婴的影响。方法 2015年4月至2016年1月于本院要求分娩镇痛的初产妇129例,随机分为两组。D组(n=68)腰麻后双管硬膜外阻滞分娩镇痛,S组(n=61)腰麻后单管硬膜外阻滞分娩镇痛。记录镇痛前(T0)及镇痛后10min(T1)、30 min(T2)、120 min(T3)、宫口开至7~8 cm(T4)、宫口开全(T5)、第二产程用力分娩时(T6)的VAS疼痛评分,各产程时间及缩宫素使用情况,镇痛泵按压及镇痛药物使用情况,分娩方式,产时出血量,新生儿情况和镇痛不良反应。结果 T0~T4时两组VAS评分差异无统计学意义,T5、T6时D组VAS评分明显低于S组(P0.05)。镇痛泵有效按压次数及镇痛药物使用量两组差异无统计学意义,但镇痛泵总按压次数D组明显少于S组(P0.05)。各产程时间、缩宫素使用率、分娩方式、产时出血量、新生儿情况和镇痛不良反应两组差异均无统计学意义。结论腰麻联合双管硬膜外分娩镇痛效果确切,不良反应少,产妇满意度高,对母婴是安全的。     

Regional Anesthesia and Pain Targeted thoracic epidural blood patch placed under electrical stimulation guidance (Tsui test)

PURPOSE: This case report describes the use of electrical epidural stimulation (Tsui test) to confirm accurate placement of a thoracic epidural catheter when administering an epidural blood patch for headache management in a patient suffering from spontaneous intracranial hypotension. CLINICAL FEATURES: A 41-yr-old female presented to the Chronic Pain Clinic with a history of postural headache symptoms worsening in severity over several years. Two previous blood patches performed at T11-12 and T10-11 respectively provided short-term relief only. The presumed diagnosis of a spontaneous dural tear was confirmed by a nuclear flow test to be at T2-T4. The epidural site was accessed at T6 with a Tuohy needle. To accurately place the epidural blood patch at the level of the dural tear, the Arrow catheter with electrode adapter was advanced under nerve stimulation guidance to T4. Ten millilitres of autologous blood injected through the catheter was confirmed on magnetic resonance imaging, one hour postprocedure, to lie between T3 and T9. Sustained headache relief was achieved. CONCLUSION: The use of electrical stimulation guidance may be useful when precise epidural blood patch placement is required.     

Effect of thoracic epidural etidocaine 1.5% on somatosensory evoked potentials, cortisol and glucose during cholecystectomy

The effect of thoracic (T7-8) epidural etidocaine 1.5%, 9 ml, and continuous per- and postoperative epidural infusion of etidocaine 1.5%, 4 ml/h, on early (less than 500 ms) somatosensory evoked potentials (SEPs), and cortisol and glucose in plasma during cholecystectomy, was examined in ten patients. Spread of analgesia (pin-prick) was T3 (T1-T3) to L2 (T11-L3) 35 min after injection of etidocaine, and T3 (T2-T4) to T12 (T8-L4) 3 h after surgical incision (median (range)). Before operation, epidural etidocaine had no significant effects on peak-to-peak amplitude of SEPs to electrical stimulation at the L1, T10 or T6 dermatomal level (P greater than 0.09). SEPs were abolished in only two patients at T6, and no patient had SEPs abolished at T10 or L1. The plasma concentrations of cortisol and glucose were significantly increased 20 min after surgical incision and remained increased throughout the study. No correlation was found between the block-induced decrease in the peak-to-peak amplitude at T6 or T10 and increase in plasma cortisol, except for a negative correlation at T10 and the initial increase in cortisol (Rs = 0.72, P = 0.03). In conclusion, thoracic epidural administration of 9 ml of etidocaine 1.5% does not provide total afferent somatic blockade assessed by SEP and the stress response to cholecystectomy.     

Extradural thoracic arteriovenous malformation in a patient with Klippel-Trenaunay-Weber syndrome: case report

OBJECTIVE AND IMPORTANCE: Spinal cord involvement in Klippel-Trenaunay-Weber (KTW) syndrome is rare. Cases of intradural spinal cord arteriovenous malformations (AVMs) have been associated with this syndrome. Likewise, cases of epidural hemangioma and angiomyolipoma have been reported to occur at the same segmental level as cutaneous hemangioma in KTW syndrome. This report details a rare case of an extradural thoracic AVM in a patient with KTW syndrome. CLINICAL PRESENTATION: A 30-year-old man presented with a 10-month history of progressive myelopathy, bilateral lower-extremity weakness, and numbness, with the right side affected more than the left. His symptoms had progressed to the point that he was unable to walk. The patient had the characteristic manifestations of KTW syndrome, including numerous cutaneous angiomas and cavernomas, limb hypertrophy and syndactyly, and limb venous malformations. A magnetic resonance imaging scan and subsequent angiogram demonstrated a large extradural AVM causing cord compression at the T3-T4 levels. INTERVENTION: The patient underwent two separate endovascular procedures, including embolization of upper thoracic and thyrocervical trunk feeders. Subsequently, he underwent T1-T4 laminectomy and microsurgical excision of the AVM. Clinically, the patient improved such that he could walk without assistance. CONCLUSION: KTW syndrome represents a spectrum of clinical presentations. Although involvement of the spinal cord is uncommon, the manifestations of this syndrome may include both intradural and extradural AVMs in addition to various tumors.     

腹直肌运动诱发电位在诊断中下胸段脊柱脊髓损伤中的价值

目的探讨经颅磁刺激的腹直肌运动诱发电位(motor evoked potentials，MEP)检测对中下胸段脊柱脊髓损伤的定性、定位诊断价值。方法取5具成人尸体，通过解剖确定腹直肌的神经支配情况及体表定位。依据体表定位法，测定25例正常成人的双侧腹直肌MEP得出各节段的正常参考值；并应用于胸椎脊柱脊髓损伤患者23例(全瘫12例，不全瘫11例，损伤节段为T4-T12)，测定双侧腹直肌MEP。结果(1)每侧腹直肌由T6-T12共7对肋间神经支配，由此确定腹直肌7个节段的MEP体表记录点。(2)25例正常成人均可纪录到双侧腹直肌T6-T12节段的MEP，各节段MEP峰潜时的差异有显著性。(3)12例全瘫者均有与骨折部位的序列数相对应节段或以下节段的腹直肌MEP消失，信访全部截瘫无恢复；11例不全瘫者，除1例外其余均可纪录到与骨折部位的序列数相对应节段或以下节段异常的腹直肌MEP，随访9例有不同程度恢复或基本恢复正常。结论不同节段的腹直肌MEP检测有相对独立、恒定的神经解剖学基础，正常成人的引出率为100％，其各节段正常参考值的差异有统计学意义；对中下胸段脊柱脊髓损伤有定性、定位诊断价值。     

Dorsal extradural thoracic disc fragment: a diagnostic challenge

Dorsal epidural migration of an extruded disc fragment is an infrequent event, especially in the thoracic spine. An uncommon case involving a 55-year-old man is presented, with a 1-month history of paraparesis and thoracolumbar pain. Magnetic resonance imaging demonstrated a dorsally located, extramedullary mass at the T10-T11 intervertebral level. The lesion was suspected to be a tumor. The patient underwent a T10-T11 laminectomy. Intraoperatively, an encapsulated mass of soft tissue adherent to the dural sac was found. The pathologic diagnosis was inflammatory tissue and disc material. Six months after the operation, the patient remained asymptomatic, and radiologic control showed no residual mass. Although rare, a sequestered disc fragment should be included in the differential diagnosis of an enhancing posterior extramedullary thoracic mass. Preoperative diagnosis of such pathology is difficult because the clinical signs and radiologic images may not entirely exclude other more common thoracic spinal lesions, especially tumors.     

Compression médullaire lente par lipomatose épidurale thoracique idiopathique : cas clinique et revue de la littérature

We report the case of a patient with spinal cord compression evolving over 36 months with spastic paraparesis. Anatomic imagery showed epidural lipomatosis. No predisposing factors were found. Surgical treatment was decided. A T1-T10 laminectomy with excision of the surplus epidural fat was performed. Immediate and medium-term postsurgical follow-up was favorable with the disappearance of the pyramidal syndrome. Other cases found in literature and the principal predisposing factors are discussed.     

Modified transmanubrial osteomuscular sparing approach for resection of T1 vertebral tumor.

We report a technical modification of the classic transmanubrial osteomuscular sparing approach described by Grünenwald and Spaggiari for the treatment of a T1 vertebral tumor. The goal of the surgical treatment for spinal tumors of the cervico-thoracic area is to excise the vertebral tumor, reconstruct the spinal column, and place an internal fixation device to achieve immediate stabilization. The procedure was necessary for treating a patient who presented with an invasion of T1 vertebral body by multiple myeloma with initial neurological symptoms of epidural spinal cord compression. This approach requires a multidisciplinary team, essentially composed by the thoracic surgeon, who performs the anatomical dissection of the cervico-thoracic area, and the neurosurgeon, who performs the vertebrectomy and placement of a titanium prosthesis (Harm's cage). The operation was successful; the follow-up 6 months after the surgical procedure is normal.