Fibrocartilaginous embolism--an uncommon cause of spinal cord infarction: a case report and review of the literature

Fibrocartilaginous embolism is a rare cause of spinal cord infarction. It is postulated that an acute vertical disk herniation of the nucleus pulposus material can lead to spinal cord infarction by a retrograde embolization to the central artery. An increased intradiskal pressure resulting from axial loading of the vertebral column with a concomitant Valsalva maneuver is thought to be the initiating event for the embolus. We present a previously healthy 16-year-old boy with sudden onset of back pain and progressive paraparesis within 36 hours after lifting exercises in a squat position. His clinical presentation and neuroimaging studies were consistent with spinal cord infarction resulting from a central artery embolus at the T8 spinal cord level. Laboratory investigation showed no evidence of infectious, autoimmune, inflammatory, or neoplastic causes. Although no histologic confirmation was obtained, lack of evidence for other plausible diagnoses in the setting of his clinical presentation and in the magnetic resonance imaging findings made fibrocartilaginous embolism myelopathy the most likely diagnosis. We postulated that some cases of transverse myelitis might actually be fibrocartilaginous embolism, making it a more prevalent cause of an acute myelopathy than commonly recognized. Relevant literature and current theories regarding the pathogenesis of fibrocartilaginous embolism myelopathy are reviewed.     

Interspinous ligament steroid injections for the management of Baastrup's disease: a case report

Mitra R, Ghazi U, Kirpalani D, Cheng I. Interspinous ligament steroid injections for the management of Baastrup's disease: a case report. Baastrup's disease has been identified as a source of axial low back pain. There has been debate as to the etiology of pain in patients with Baastrup's disease. It has been theorized that the pain may originate from degenerative disk disease and spinal stenosis associated with the disease, whereas some have identified the neoarthrosis between joints and accompanying reactive eburnation as the source of pain. We present a simple case report of an 89-year-old woman with symptomatic Baastrup's disease. The patient underwent a fluoroscopically guided interspinous process injection of 20mg of triamcinolone acetate with local anesthetic. The patient remained pain free for 3 months. The neoarthrosis in Baastrup's disease may be the primary pain generator in cases of Baastrup's disease without significant central canal stenosis.     

蝶骨平台巨大颅骨混合型血管瘤1例报告并文献复习

目的探讨蝶骨平台颅骨混合型血管瘤的临床特征和预后。方法报告1例蝶骨平台巨大混合型血管瘤,结合相关文献分析其临床、影像学及病理特点,探讨其诊断、治疗及预后。结果原发颅骨内血管瘤临床比较少见,约占颅骨肿瘤的0.7%,发生在颅底罕见。X线检查可见颅骨内蜂窝状改变,CT、MRI显示颅骨溶骨性病变并向颅内外发展,DSA造影病变常无明显染色,病理显示大小不等的异常血管、骨结构异常以及出血征象。外科治疗为首选。结论颅骨血管瘤为颅骨内破坏性病变,单发性手术疗效好,但多发性欠佳。     

Intravascular papillary endothelial hyperplasia as a rare cause of cervicothoracic spinal cord compression: A case report

BACKGROUNDIntravascular papillary endothelial hyperplasia (IPEH) is a rare benign reactive vascular lesion that grows into an expansile compressing mass. It most commonly involves the skin and subcutaneous tissue. Spinal involvement is rare, with only 11 reported cases in the literature. We report, to our knowledge, the first case of IPEH in the cervicothoracic spinal canal and present a literature review.CASE SUMMARYA 27-year-old man presented with acute-onset neck pain, numbness, and weakness in his extremities. Magnetic resonance imaging showed an epidural mass in the cervicothoracic (C6-T1) spinal canal and vertebral hemangioma (VH) involving the C7 vertebral body. C6-T1 Laminectomy and radical excision of the mass were performed. Histopathological examinations revealed papillary proliferation of vascular endothelial cells with thrombus formation, and an IPEH diagnosis was made. By his 6-mo follow-up appointment, his symptoms were relieved without recurrence. The possible pathogenesis, clinical and imaging features, differential diagnosis, and management of IPEH were reviewed.CONCLUSIONWe report, to our knowledge, the first case of IPEH in the cervicothoracic spinal canal, treated via complete resection, and showing a favorable outcome. We found a causal relationship between spinal IPEH and VH; this partly explains the mechanism of IPEH.     

Acute bacterial sacroiliitis in an adult: a case report and review of the literature

Bacterial septic sacroiliitis is an uncommon diagnosis that occurs most frequently in children and young adults. Nonspecific physical examination findings often make it difficult to diagnose the condition, thus delaying appropriate treatment. We review the case of middle-aged woman with sacroiliac joint (SIJ) pain after a torsional injury. Radiographic films showed the pelvis and left lower extremity to be normal. Despite anti-inflammatory medications, analgesics, a corticosteroid injection, and physical therapy, her pain persisted. Laboratory data showed an elevated erythrocyte sedimentation rate and C-reactive protein; otherwise, tests were normal, including negative blood cultures. Magnetic resonance imaging (MRI) revealed a left posteroinferior SIJ effusion and computed tomography (CT) showed an effusion and irregularity in the left SIJ. An SIJ biopsy revealed inflammation suggestive of osteomyelitis. After a course of intravenous antibiotics, the symptoms completely resolved, thus supporting our diagnosis of bacterial sacroiliitis. Repeat MRI and CT confirmed the complete resolution of the sacroiliitis.     

Delayed postanoxic encephalopathy: a case report and literature review

Delayed postanoxic encephalopathy is a rare condition in which patients appear to make a complete clinical recovery after an episode of anoxia or hypoxia but then develop a relapse characterized by apathy, confusion, agitation, and/or progressive neurologic deficits. The incidence of delayed postanoxic encephalopathy is unclear but has been reported to range from less than 1 to 28 per 1000 in patients who have suffered hypoxic or anoxic events. The exact pathogenesis remains unknown. We describe a case of an independently living 51-year-old woman admitted to an inpatient rehabilitation unit 11 days after a respiratory arrest. At admission, she exhibited cognitive and visual deficits that were relatively mild but prevented a safe return to independent living. Two days later, she developed the sudden onset and rapid worsening of parkinsonian symptoms and excruciating bilateral lower-extremity pain. The pain was intractable, and over the next 2 days she progressed to being unable to walk or perform her activities of daily living without maximum assistance. A diagnosis of delayed postanoxic encephalopathy was made, and the patient responded to a trial of carbidopa and levodopa as well as redirection of her physical and occupational therapy programs. This case illustrates the unusual presentation of delayed postanoxic encephalopathy during inpatient rehabilitation and suggests that this condition should be considered if patients who have suffered an anoxic or hypoxic event show a sudden neurologic deterioration.     

The effect of modafinil on self-esteem in spinal cord injury patients: a report of 2 cases and review of the literature

We report on 2 cases of the effect of modafinil on the self-esteem of patients with spinal cord injury (SCI). The first patient was a 33-year-old man with history of polysubstance abuse and a C6 American Spinal Injury Association (ASIA) grade A injury, who presented for follow-up to the outpatient rehabilitation clinic for depression, decreased motivation, and lowered self-esteem. The patient had tried a selective serotonin reuptake inhibitor (SSRI) without success, and reported increasing social and legal stressors. Within 1 month of starting on modafinil, he reported increased self-esteem and motivation, as well as decreased self-consciousness. The second patient was a 36-year-old woman with history of depression and a T11 ASIA grade A injury. She tried various SSRIs for depression and adjustment issues before she was started on modafinil. She lost weight and became more assertive and less self-conscious within 1 month after starting on modafinil. These 2 cases suggest that modafinil should be studied as a therapeutic option for treating lowered self-esteem in patients with SCI.     

Craniovertebral junction tuberculosis: a case report and review of the literature

Craniovertebral junction tuberculosis (CVJ TB) is a rare disease, potentially causing significant neurological deficits and even death. We report on a 80-year-old woman presenting with CVJ TB without pulmonary involvement. The diagnosis was made by biopsy of the cervical lymph node showing granulomatous caseation necrosis. Despite extensive erosion of the clivus, C1, and C2, and spinal cord compression, the patient was effectively managed with antituberculous drug therapy and conservative neck stabilization. Neck pain resulting from cervical spondylosis is common in elderly people. However, even if there is no obvious pulmonary involvement, CVJ TB should be considered in the differential diagnosis, especially in patients with painful neck stiffness. The most useful method available for evaluating this region is a combination of CT scan and MRI study. CVJ TB can be managed conservatively, except for a selected few cases, regardless of the extent of bony destruction.     

Recognition of prodromal cervical spondylotic myelopathy presenting in a U.S. Veteran referred to chiropractic for acute thoracic pain: A case report

ObjectiveTo highlight a patient who was referred to a VA chiropractic clinic for thoracic pain and upon physical exam was found to be myelopathic, subsequently requiring surgery.Clinical featuresA 58-year-old male attended a telephone interview with the VA chiropractic clinic for thoracic pain of 4 months duration; he denied neck pain, upper extremity symptoms or clumsiness of the feet or hands. At his in-person visit, he acknowledged frequently dropping items. The physical examination revealed signs of myelopathy including positive Hoffman's bilaterally, 3+ brisk patellar reflexes, and 5+ beats of ankle clonus bilaterally. He also had difficulty walking heel/toe.Intervention and outcomeCervical and thoracic radiographs were ordered and a referral was placed to the Physical Medicine and Rehabilitation (PM&R) Clinic for evaluation of the abnormal neurologic exam and suspicion of cervical spondylotic myelopathy (CSM). He was treated for 2 visits in the chiropractic clinic for his thoracic pain, with resolution of thoracic symptoms. No treatment was rendered to the cervical spine.The PM&R physician ordered a cervical MRI which demonstrated severe central canal stenosis and increased T2 signal within the cord at C5–C6, representing myelopathic changes. The PM&R specialist referred him to Neurosurgery which resulted in a C5-6, C6-7 anterior cervical discectomy and fusion.ConclusionThe importance of physical examination competency and routine thoroughness cannot be overstated. Swift identification of pathologic signs by the treating chiropractor resulted in timely imaging and surgical intervention.     

Myotonic dystrophy presenting as new-onset hand weakness and recurrent pneumonia in a patient with paraplegia: a case report

We describe a previously independent T11 paraplegic patient who had delayed-onset hand weakness and recurrent pneumonia caused by myotonic dystrophy. A man in his late thirties suffered a thoracic spinal cord injury (SCI) from a gunshot wound at the age of 17 years, with resultant T11 American Spinal Injury Association class A paraplegia. He lived independently until the age of 36 years when he was hospitalized multiple times for pneumonia. During a rehabilitation stay after one of the acute hospitalizations, the patient's hand weakness and diffuse muscular atrophy were noted. Electrodiagnostic testing was performed, which showed myotonic discharges. Genetic testing was consistent with myotonic dystrophy. This case shows the importance of considering causes of weakness that affect the population as a whole when evaluating a patient with SCI who presents with delayed-onset weakness.     

单发性椎体骨软骨瘤1例报告并文献复习

目的 提高对单发性椎体骨软骨瘤的认识和诊断水平.方法 回顾性分析1例第9胸椎体右后缘单发性骨软骨瘤并脊髓压迫的临床资料,并复习相关文献.结果 椎体骨软骨瘤的CT、MRI表现为椎旁骨性密度或信号影,病灶松质骨、皮质骨与椎体相应的骨松质和骨皮质相连续.结论 原发性椎体骨软骨瘤罕见,CT、MRI可以明确诊断.     

Aerophagia as a cause of ineffective phrenic nerve pacing in high tetraplegia: a case report

We report an unusual case of aerophagia after traumatic spinal cord injury (SCI), which shows the profound effects of abdominal distension on respiratory ability in such individuals. In this case, abdominal distension resulting from aerophagia reduced the effectiveness of phrenic nerve pacing on diaphragm function necessitating greater use of positive-pressure ventilatory (PPV) support. Reduction of postprandial gastric air and abdominal distension with insertion of a percutaneous endoscopic gastrostomy tube ameliorated the condition and allowed for more effective phrenic nerve pacing and greater PPV-free breathing. We are unaware of a similar case involving an individual with an SCI.     

Intracerebral hemorrhage secondary to autonomic dysreflexia in a young person with incomplete C8 tetraplegia: A case report

Intracerebral hemorrhage is an unusual complication of autonomic dysreflexia and can be fatal if massive bleeding occurs with brain herniation. We report the case of a man in his midthirties with incomplete tetraplegia who suffered right putaminal hemorrhage during an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factors of autonomic dysreflexia quickly brought his blood pressure under control and the patient had a favorable functional outcome after rehabilitation. A review of the literature suggests that the location of hemorrhage in autonomic dysreflexia-induced cases is similar to that in the general population. The most common triggering factors are bladder distension in men and labor induction in women. Hemorrhagic stroke can also occur in patients with incomplete spinal cord injury (SCI) who develop autonomic dysreflexia. The role of sympathetic skin response examination is also discussed. This life-threatening complication should be kept in mind in the case of people with SCI.     

Myelopathy associated with melorheostosis: a case report

A man in his mid thirties presented with lower-extremity weakness and spasticity because of a myelopathy caused by a rare disorder of bone known as melorheostosis. The primary pathology involved was compression of the cord at the cervicothoracic levels by dystrophic osseous formation within the vertebral bodies. Based on a review of existing literature, it was evident that the spine is an uncommon location to find melorheostosis, making this disease entity a unique cause of myelopathy. The patient's progress was closely observed during his inpatient rehabilitation program, after he underwent spinal decompression surgery. Starting from the level of complete paralysis, he was able to regain functional strength in his legs by the end of his 2-month course. Despite the lack of reported outcomes in cases of myelopathy associated with melorheostosis, our report describes a favorable prognosis with good recovery of both strength and function.     

Long-term ventilation for high-level tetraplegia: a report of 2 cases of noninvasive positive-pressure ventilation

Toki A, Tamura R, Sumida M. Long-term ventilation for high-level tetraplegia: a report of 2 cases of noninvasive positive-pressure ventilation.Ventilator-dependent patients with tetraplegia rarely use noninvasive positive-pressure ventilation (NPPV) for long-term ventilation. We report 2 patients with high-level traumatic tetraplegia who were able to return home after being changed from traditional ventilation to NPPV. When they were referred to our hospital from acute care hospitals 2 to 6 months after injury, both were on tracheostomy ventilation with a cuff inflated 24 hours a day, and tidal volume (Vt) settings were low. In case 1, a man with complete C1 tetraplegia was admitted to our hospital 6 months after injury. We changed ventilator settings to high Vt and introduced NPPV. He was discharged home with NPPV with a volume-setting ventilator. Case 2 involved a man in his late twenties with complete C1 tetraplegia who was discharged home with NPPV. After discharge, he trained in glossopharyngeal breathing by himself, enabling him to breathe up to 1900mL of maximum insufflation capacity. Both have lived nearly 1 year without pulmonary complications in the community. They use visiting nurses 3 times a week and services of visiting caregivers. Further study is needed to determine the usefulness of NPPV for long-term ventilatory management.     

Successful pregnancy achieved by intracytoplasmic sperm injection using cryopreserved electroejaculate sperm in a couple both with spinal cord injury: a case report

Anejaculation and poor semen quality are 2 major causes of infertility in men with spinal cord injury (SCI). The low motility of retrieved sperm often results in use of intracytoplasmic sperm injection (ICSI) to achieve fertilization. Pregnancy is a challenging event for women with SCI. Herein we report a pregnancy after ICSI with cryopreserved electroejaculate sperm for a couple both with SCI. The husband had T10 paraplegia with a neurogenic bladder. He underwent 2 electroejaculations. The concentration of sperm was 0.1 x 10(6)/mL to 0.3 x 10(6)/mL, with a motility of 5% to 20%. ICSI was considered the best choice for the couple. His wife had L2 paraplegia with cauda equina syndrome. She underwent controlled ovarian hyperstimulation, and 10 oocytes were retrieved. Eight mature oocytes were injected using thawed sperm, which resulted in 5 normal zygotes. Conception was achieved by the transfer of 4 embryos into the uterus. A healthy female baby was delivered vaginally at 39 weeks of gestation. This woman had never undergone any other assisted reproductive technology (ART) procedures. With the advancement of ART and prenatal care, this couple achieved a successful pregnancy. The use of cryopreserved electroejaculated sperm for ICSI can avoid the inconvenience or cost to the patient of repeated electroejaculations.     

Streptococcal infection and necrotizing fasciitis--implications for rehabilitation: a report of 5 cases and review of the literature

Five cases are presented of patients who were diagnosed with necrotizing fasciitis secondary to (1) hip disarticulation (in a paraplegic patient); (2) tooth abscess with extensive neck dissection, complicated by sepsis and hypotension with resultant dysphagia and ischemic encephalopathy; (3) below-knee amputation, anoxia, and severe debility; (4) emergent above-knee amputation; and (5) percutaneous endoscopic gastrostomy placement. The latter patient developed abdominal and chest wall necrotizing fasciitis that required skin grafting. Four patients were treated in an acute rehabilitation setting and returned home, and the fifth was rehabilitated in a subacute facility. This report emphasizes the importance of carefully monitoring rehabilitation patients, especially those with impaired sensation.