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Neurology India 2021Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder. (Review)
Review
BACKGROUND
Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder.
OBJECTIVE
Update evaluation and treatment of spontaneous intracranial hypotension.
METHODS AND MATERIAL
Narrative review.
RESULTS
Traditionally, SIH is diagnosed when a headache has developed spontaneously and in temporal relation to a CSF leak (evident on imaging) and/or CSF hypotension (lumbar puncture opening pressure <60 mm CSF). However, lumbar puncture is not mandatorily required to diagnose SIH. Besides headache, other symptoms such as nausea/vomiting in 50.6%, neck pain/stiffness in 33%, tinnitus in 19%, dizziness in 14%, hearing disturbances in 10.7%, followed by visual disturbances, vertigo, back pain, and cognitive symptoms may be present. In suspected cases of SIH, brain and spine should be evaluated with MRI. Dynamic computerized tomographic myelography is required to demonstrate the site of spinal CSF leak. Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH) refractory to medical management and provides symptomatic relief in up to 90% of patients even in patients with bilateral subdural hematomas. The CSF-venous fistulas do not respond well to EBP, and the most definitive curative treatment is the surgical closure of the fistula.
CONCLUSIONS
The SIH is a distinct entity and requires a high index of suspicion for diagnosis. A post-contrast MRI should be included for evaluation of headaches. Spinal MRI should be done to demonstrate the site of leak. Epidural blood patch therapy is the most effective treatment of SIH. Most SDHs associated with SIH do not require treatment.
Topics: Blood Patch, Epidural; Brain; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Spine
PubMed: 35103002
DOI: 10.4103/0028-3886.332255 -
PM & R : the Journal of Injury,... Jan 2016To determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain and function.
DESIGN
Prospective, double-blind, randomized controlled study.
SETTING
Outpatient physiatric spine practice.
PARTICIPANTS
Adults with chronic (≥6 months), moderate-to-severe lumbar diskogenic pain that was unresponsive to conservative treatment.
METHODS
Participants were randomized to receive intradiskal PRP or contrast agent after provocative diskography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at 8 weeks were offered the option to receive PRP and subsequently followed.
MAIN OUTCOME MEASURES
Functional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey, and the modified North American Spine Society (NASS) Outcome Questionnaire were used.
RESULTS
Forty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow-up rate. Over 8 weeks of follow-up, there were statistically significant improvements in participants who received intradiskal PRP with regards to pain (NRS Best Pain) (P = .02), function (FRI) (P = .03), and patient satisfaction (NASS Outcome Questionnaire) (P = .01) compared with controls. No adverse events of disk space infection, neurologic injury, or progressive herniation were reported following the injection of PRP.
CONCLUSION
Participants who received intradiskal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared with controls. Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up. Although these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP injectate.
Topics: Adult; Double-Blind Method; Female; Follow-Up Studies; Humans; Injections, Spinal; Intervertebral Disc; Low Back Pain; Lumbar Vertebrae; Male; Myelography; Pain Measurement; Platelet-Rich Plasma; Prospective Studies; Treatment Outcome
PubMed: 26314234
DOI: 10.1016/j.pmrj.2015.08.010 -
Lakartidningen Oct 2023Spontaneous intracranial hypotension (SIH) is a disease presenting mostly with orthostatic head and neck pain due to a spontaneous cerebrospinal fluid (CSF) leak or a...
Spontaneous intracranial hypotension (SIH) is a disease presenting mostly with orthostatic head and neck pain due to a spontaneous cerebrospinal fluid (CSF) leak or a CSF-venous fistula in the spinal region. It demonstrates typical MRI findings with sagging of the brain causing tension of the meninges and sometimes the cranial nerves. It shares some clinical similarities with post puncture headache but differs in its pathophysiological cause, diagnosis, and treatment. Many patients remain misdiagnosed or wait too long for the correct diagnosis. The diagnostic work-up includes an MRI of the head and spine in search of typical SIH signs. Myelography and CT scans are performed to identify the location of the CSF leak or CSF-venous fistula. Treatment options may involve (1) initial conservative treatment with bed rest, caffein and fluids, (2) interventions such as epidural blood patch, fibrin patch, and embolization, or (3) surgical closure of the leak.
Topics: Humans; Intracranial Hypotension; Blood Patch, Epidural; Brain; Headache; Fistula
PubMed: 37782313
DOI: No ID Found -
Cureus Dec 2023Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the... (Review)
Review
Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the degeneration of the cervical spine due to various processes such as disc ageing, osteophyte formation, ligament hypertrophy or ossification, as well as coexisting congenital anomalies. This article provides an overview of the literature on DCM and considers areas of focus for future research. A patient with DCM can present with a variety of symptoms ranging from mild hand paraesthesia and loss of dexterity to a more severe presentation of gait disturbance and loss of bowel/bladder control. Hoffman's sign and the inverted brachioradialis reflex are also important signs of this disease. The gold standard imaging modality is MRI which can identify signs of degeneration of the cervical spine. Other modalities include dynamic MRI, myelography, and diffusion tensor imaging. One important scoring system to aid with the diagnosis and categorisation of the severity of DCM is the modified Japanese Orthopaedic Association score. This considers motor, sensory, and bowel/bladder dysfunction, and categorises patients into mild, moderate, or severe DCM. DCM is primarily treated with surgery as this can halt disease progression and may even allow for neurological recovery. The surgical approach will depend on the location of degeneration, the number of cervical levels involved and the pathophysiological process. Surgical approach options include anterior cervical discectomy and fusion, corpectomy, or posterior approach (laminectomy ± fusion). Conservative management is also considered for some patients with mild or non-progressive DCM or for patients where surgery is not an option. Conservative treatment may include physical therapy, traction, or neck immobilisation. Future recommendations include research into the prevalence rate of DCM and if there is a difference between populations. Further research on the benefit of conservative management for patients with mild or non-progressive DCM would be recommended.
PubMed: 38213348
DOI: 10.7759/cureus.50387 -
AJNR. American Journal of Neuroradiology Mar 2023
Topics: Humans; Myelography; Tomography, X-Ray Computed
PubMed: 36822824
DOI: 10.3174/ajnr.A7726 -
Deutsches Arzteblatt International Jul 2020Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. Its incidence is estimated at 5 per 100 000 persons per year. (Review)
Review
BACKGROUND
Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. Its incidence is estimated at 5 per 100 000 persons per year.
METHODS
This review is based on a selective literature search in PubMed covering the years 2000-2019, as well as on the authors' personal experience.
RESULTS
The diagnostic and therapeutic methods discussed here are supported by level 4 evidence. SIH is caused by spinal leakage of cerebrospinal fluid (CSF) out of ventral dural tears or nerve root diverticula, or, in 2-5% of cases, through a fistula leading directly into the periradicular veins (CSF-venous fistula). In half of all patients, no CSF leak is demonstrable. A low CSF opening pressure on lumbar puncture is present in only one-third of patients; imaging studies are thus needed to confirm and localize a spinal CSF leak. Half of all patients in whom myelographic computed tomography (CT) reveals contrast medium reaching the epidural space have ventral dural tears, which tend to be located at upper thoracic spinal levels. Epidural blood patches applied under fluoroscopic or CT guidance can seal the CSF leak in 30-70% of patients, but 90% of patients with ventral dural tears will need operative closure. Some patients who have no visible epidural contrast medium on CT presumably do not have SIH, while others do, in fact, have a CSF leak from a diverticulum or a CSF-venous fistula and will need to have the site of the leak demonstrated with the aid of further studies, such as dynamic (subtraction) myelography in the lateral decubitus position.
CONCLUSION
The management of patients with SIH calls for complementary imaging studies to demonstrate the causative spinal CSF leak. Often, successful treatment requires surgical closure of the leak. In view of the sparse evidence available to date, controlled studies should be performed.
Topics: Cerebrospinal Fluid Leak; Contrast Media; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography; Tomography, X-Ray Computed
PubMed: 33050997
DOI: 10.3238/arztebl.2020.0480 -
AJNR. American Journal of Neuroradiology Jan 2020Digital subtraction myelography is a valuable diagnostic technique to detect the exact location of CSF leaks in the spine to facilitate appropriate diagnosis and... (Review)
Review
Digital subtraction myelography is a valuable diagnostic technique to detect the exact location of CSF leaks in the spine to facilitate appropriate diagnosis and treatment of spontaneous spinal CSF leaks. Digital subtraction myelography is an excellent diagnostic tool for assessment of various types of CSF leaks, and lateral decubitus digital subtraction myelography is increasingly being used to diagnose CSF-venous fistulas. Lateral decubitus digital subtraction myelography differs from typical CT and fluoroscopy-guided myelograms in many ways, including equipment, supplies, and injection and image-acquisition techniques. Operators should be familiar with techniques, common pitfalls, and artifacts to improve diagnostic yield and prevent nondiagnostic examinations.
Topics: Cerebrospinal Fluid Leak; Female; Humans; Male; Myelography
PubMed: 31857327
DOI: 10.3174/ajnr.A6368 -
Journal of Education & Teaching in... Jan 2020The aim of this simulation case is to educate senior medical students, resident physicians, and advanced practice providers on the recognition, diagnosis, and management...
AUDIENCE
The aim of this simulation case is to educate senior medical students, resident physicians, and advanced practice providers on the recognition, diagnosis, and management of spinal epidural abscesses. This scenario is most applicable to the emergency medicine setting but can be applied to the outpatient office or urgent care settings.
INTRODUCTION
Spinal epidural abscess is an infection leading to an epidural collection of purulent material. This uncommon condition is estimated to occur less than 12 times per 100,000 hospital admissions.1,2 However, this infection can lead to devastating neurological sequelae via cord compression, spinal vascular interruption, and inflammatory etiologies;3,4 thus, prompt diagnosis is essential. Unfortunately, spinal epidural abscesses may be difficult to identify clinically due to variable clinical presentations. The goal of this scenario is to increase awareness of this critical diagnosis.Detailed history-taking to identify risk factors will aid in the recognition of spinal epidural abscesses. Many of the risk factors are related to increased infectious risk from hematogenous spread, iatrogenic inoculation, or direct extension.1 Individuals with conditions including intravenous (IV) drug use, alcohol abuse, diabetes, human immunodeficiency virus (HIV), cancer, hepatic disease, renal disease, and other immunocompromising conditions are at increased risk of developing epidural abscesses.1 Primary infectious sources include dental abscesses, endocarditis, vertebral osteomyelitis, and soft tissue infections. Spinal procedures including spinal surgeries, paraspinal injections, and placement of epidural catheters or stimulators can also predispose to infection.2,4Classic symptoms for spinal epidural abscesses include fever, back pain and neurological changes.1,5 Back pain is the most frequent presenting symptom, occurring about 70%-90% of the time.1 However, fever is the least frequent presenting symptom4 and neurological findings only occur in about one-third of cases.2 Neurological symptoms include motor weakness, sensory changes, urinary retention, overflow urinary incontinence, bowel dysfunction, hyperreflexia, radicular pain, spinal shock or cauda equina syndrome.1,4Laboratory findings may include systemic leukocytosis and elevated inflammatory markers. Whereas leukocytosis is estimated to be present in two-thirds of cases,2 Davis, et al. showed that with the concurrent presence of a risk factor, an elevated erythrocyte sedimentation rate (ESR) had 100% sensitivity and 67% specificity for spinal epidural abscesses.5Magnetic resonance imaging (MRI) with gadolinium contrast is the preferred imaging modality for diagnosing spinal epidural abscesses. Computed tomography (CT) with myelography can be considered if MRI is contraindicated.1 Given that abscesses may be multifocal, further spinal imaging beyond a single spinal segment should be considered during evaluation. Lumbar puncture is not recommended due to risk of iatrogenic infectious spread.Treatment of epidural abscesses includes obtaining blood cultures and prompt antibiotic administration with early surgical evaluation to determine if operative intervention is warranted. is the most common microbial cause, contributing to about two-thirds of cases.3,4 Other microbial causes include coagulase-negative (ie, ), , gram-negative bacilli (ie, and ), and less commonly, anaerobic bacteria, fungi, mycobacteria and parasites.1,2 Empiric antibiotic treatments generally include vancomycin and a third- or fourth- generation cephalosporin.2,4This simulation session will highlight the importance of recognizing and aggressively treating this uncommon but potentially devastating condition.
EDUCATIONAL OBJECTIVES
After this simulation case, learners will be able to diagnose and manage patients with spinal epidural abscesses. Specifically, learners will be able to:Obtain a detailed history, including past infectious, surgical, procedural and social history to evaluate for epidural abscess risk factors. Describe clinical signs and symptoms of spinal epidural abscesses and understand that initial clinical presentations can be variable.Perform a focused neurological exam including evaluation of motor, sensory, reflexes, and rectal tone.Order appropriate laboratory testing and imaging modalities for spinal epidural abscess diagnosis, including a post-void bladder residual volume.Select appropriate antibiotics for empiric treatment of spinal epidural abscess depending on patient presentation.Disposition the patient to appropriate inpatient care.
EDUCATIONAL METHODS
The authors conducted this simulation case with a standardized patient. We encourage inclusion of a standardized patient versus a mannequin to provide appropriate motor and sensory exams. For those without a standardized patient program, the authors suggest utilizing a faculty member as the patient. Regardless of individual used, it is strongly recommended that facilitators rehearse the case with the individual in the patient role ahead of time in order to ensure that their performance reflects an accurate neurologic exam. A debriefing session and small-group discussion followed the simulation to review the clinical presentation, diagnosis, management, and treatment of spinal epidural abscesses. This case can also be adapted as an oral boards case.
RESEARCH METHODS
Residents were provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as to provide qualitative feedback on the scenario. This survey is specific to our institution's simulation center.
RESULTS
While qualitative feedback from the residents was positive, it was viewed as a straightforward case. Our initial presenting symptom was difficulty ambulating with a fever at home, if asked. The residents appreciated performing a neurologic exam on a standardized patient versus attempting this on a mannequin.Our simulation center's feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received all 7 scores (extremely effective/outstanding) other than one 5 score for the element assessing if the instructor set the stage for an engaging learning experience. The learner's feedback for this 5 score was "kinda went right into the case which was ok." Our form also includes an area for general feedback about the case at the end. Comments included "Great sim. Expert case writing," "Fun case and learned a lot," and "Great case! Appreciated feedback on consulting and the difficult consultant situation."
DISCUSSION
This is a cost-effective method for reviewing epidural abscess. We chose a chief complaint and history that was slightly atypical from "classic" presentations, but not so esoteric that the residents felt cheated at the end of the scenario. When using a standardized patient in a scenario that may involve a sensitive physical exam, we review with learners and the standardized patient what expectations are during the pre-brief session. For example, residents may say, "we would like to check to see if rectal tone is intact," and then the standardized patient would verbalize back the expected physical exam findings.
TOPICS
Medical simulation, spinal epidural abscess, spinal cord compression, infectious disease.
PubMed: 37465609
DOI: 10.21980/J8T938 -
European Neurology 2020In this article, we commemorate the centenary of myelography, a neuroradiological procedure that, despite certain disadvantages, significantly contributed to the... (Review)
Review
In this article, we commemorate the centenary of myelography, a neuroradiological procedure that, despite certain disadvantages, significantly contributed to the diagnosis and localization of spinal cord lesions during the 20th century. From the start, the use of myelography was characterized by different views regarding the potential dangers associated with the prolonged exposure of a "foreign body" to the central nervous system. Such differences in attitude resulted in divergent myelography practices; its precise indications, technical performance, and adopted contrast material remaining subject to variability until the procedure were eventually replaced by MRI at the close of the 20th century.
Topics: Female; History, 20th Century; History, 21st Century; Humans; Male; Myelography; Spinal Cord Diseases
PubMed: 32871581
DOI: 10.1159/000509863 -
Radiologie (Heidelberg, Germany) Oct 2022Imaging of the postoperative spine intends to answer two main questions: It is used to assess the surgical success and to identify complications. To this end,... (Review)
Review
Imaging of the postoperative spine intends to answer two main questions: It is used to assess the surgical success and to identify complications. To this end, conventional X‑ray, computer tomography (CT), myelography, and magnetic resonance imaging (MRI) are available. The radiologist has to select the appropriate modality for sufficient diagnosis considering the preoperative situation, the performed operation, and existing postoperative symptoms. Particularly, the implantation of foreign material represents a technical challenge in the context of image acquisition. In the radiologist's report, one must differentiate between expected postoperative changes and relevant complications. Close communication with the patients and the referring clinicians is essential. Especially clinical signs of infection, new or progressive neurological deficits and cauda equina and conus medullaris syndromes require an immediate diagnosis to facilitate prompt therapy.
Topics: Cauda Equina; Humans; Musculoskeletal System; Myelography; Spinal Cord Compression; Spine; Tomography, X-Ray Computed
PubMed: 35789426
DOI: 10.1007/s00117-022-01034-2