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Journal of the Korean Society of... Jan 2024Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and... (Review)
Review
Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.
PubMed: 38362391
DOI: 10.3348/jksr.2023.0151 -
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 -
American Family Physician Dec 2020Degenerative cervical myelopathy encompasses a collection of pathologic conditions that result in progressive spinal cord dysfunction secondary to cord compression....
Degenerative cervical myelopathy encompasses a collection of pathologic conditions that result in progressive spinal cord dysfunction secondary to cord compression. Patients are typically male (3: 1 male-to-female ratio), and the average age of presentation is 64 years. The exact incidence is unclear because of differences in terminology and because radiographic findings can be present in asymptomatic individuals. Common examination findings include neck pain or stiffness, a wide-based ataxic gait, ascending paresthesia in the upper or lower extremities, lower extremity weakness, decreased hand dexterity, hyperreflexia, clonus, Babinski sign, and bowel or bladder dysfunction in severe disease. Definitive diagnosis requires correlation of physical examination findings with imaging findings. Magnetic resonance imaging of the cervical spine with and without contrast media is the preferred imaging modality. Cervical spine computed tomography, computed tomography myelography, and plain radiography are helpful in certain situations. Treatment depends on the presence and severity of symptoms. Surgery is recommended for patients with moderate to severe symptoms or rapidly progressive disease. Conservative treatments with monitoring for progression may be considered in patients with mild to moderate disease. The evidence for the effectiveness of conservative treatments is scarce and of low quality, and outcomes can vary with individual patients. Primary care physicians play a vital role in recognizing the typical presentation of degenerative cervical myelopathy, coordinating treatment as indicated, and managing comorbidities.
Topics: Cervical Vertebrae; Diagnosis, Differential; Family Practice; Female; Humans; Magnetic Resonance Imaging; Male; Neck Pain; Spinal Cord Compression; Spinal Cord Diseases; Spondylosis
PubMed: 33320508
DOI: No ID Found -
Neurological Sciences : Official... Mar 2023To review the clinical features, proposed pathophysiology, and the role of medical imaging in the diagnosis and treatment of idiopathic intracranial hypertension and... (Review)
Review
OBJECTIVE
To review the clinical features, proposed pathophysiology, and the role of medical imaging in the diagnosis and treatment of idiopathic intracranial hypertension and spontaneous intracranial hypotension.
METHODS
The authors conducted a narrative review of the current literature on intracranial hypertension and hypotension syndromes, with a focus on imaging findings and role of neurointerventional radiology as a therapeutic option for these pathologies.
RESULTS
Idiopathic intracranial hypertension commonly presents in obese women of childbearing age, being headache and papilledema the main clinical manifestations. Characteristic radiological findings consist of increased cerebrospinal fluid around the optic nerve, partially empty sella turcica and stenosis of the transverse sinuses. Transverse sinus stenting is a treatment alternative that has proven valuable utility in the recent years. Spontaneous intracranial hypotension in most of cases presents with orthostatic headache and has predilection for female population. The typical radiological features in the brain consist of subdural fluid collections, enhancement of the dura, engorgement of the venous structures, pituitary enlargement, and sagging of the brain. In this pathology, a cerebrospinal fluid leak in the spine associated with a defect in the dura, meningeal diverticulum, or a cerebrospinal fluid-venous leak must be actively ruled out.
CONCLUSIONS
Neurologic complaints secondary to changes in intracranial pressure exhibit certain clinical features that in combination with fairly specific radiological patterns allow a highly accurate diagnosis. The diverse specialists in neurosciences should be aware of the multiple image modalities in the study of these syndromes as well as the treatment alternatives by neurointerventional radiology.
Topics: Humans; Female; Intracranial Pressure; Intracranial Hypotension; Pseudotumor Cerebri; Syndrome; Neuroimaging; Intracranial Hypertension; Magnetic Resonance Imaging
PubMed: 36333629
DOI: 10.1007/s10072-022-06478-x -
Annals of Clinical and Translational... Feb 2021CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range... (Review)
Review
CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.
Topics: Central Nervous System Vascular Malformations; Cerebral Angiography; Computed Tomography Angiography; Humans; Magnetic Resonance Imaging; Myelography
PubMed: 33434339
DOI: 10.1002/acn3.51277 -
No Shinkei Geka. Neurological Surgery Nov 2021Accurate diagnosis is important for lumbar degenerative diseases. Patients' history, neurological examination, and diagnostic imaging are the three pillars for accurate...
Accurate diagnosis is important for lumbar degenerative diseases. Patients' history, neurological examination, and diagnostic imaging are the three pillars for accurate diagnosis. While collecting medical history, 5W1H of the symptoms should be considered. Muscle strength, pain and numbness, and deep tendon reflex are the basic parameters in the neurological examination. A combination of the results of each tool is needed to facilitate precise diagnosis. This should be followed by diagnostic imaging to confirm the diagnosis. We feel relieved when neurological examination and diagnostic imaging reveals congruent results. The symptoms of lumbar degenerative diseases are the results of[static factors: the stenosis of the canal/intervertebral foramen]×[dynamic factor: the instability]. The T2-weighted MRI images effectively reveal canal/intervertebral foramen stenosis. Short-T1 inversion recovery(STIR)of MRI reveals early fractures and inflammation of the spine. CT findings help to imagine the process of drilling and screw insertion. A whole spine X-ray is good to reveal spinal alignment. Roentogenkymography with anteflexion/retroflexion reveals the instability of the lumbar spine. Myelography is effective in knowing the cerebrospinal fluid flow in a standing position. Therefore, accurate diagnosis and careful treatment are needed to obtain the appropriate outcome for a prolonged period after spinal surgery.
Topics: Humans; Intervertebral Disc Degeneration; Lumbar Vertebrae; Lumbosacral Region; Magnetic Resonance Imaging; Myelography; Spinal Stenosis
PubMed: 34879343
DOI: 10.11477/mf.1436204510 -
AJNR. American Journal of Neuroradiology Apr 2023CSF-venous fistula can be diagnosed with multiple myelographic techniques; however, no prior work has characterized the time to contrast opacification and the duration... (Review)
Review
BACKGROUND AND PURPOSE
CSF-venous fistula can be diagnosed with multiple myelographic techniques; however, no prior work has characterized the time to contrast opacification and the duration of visualization. The purpose of our study was to evaluate the temporal characteristics of CSF-venous fistula on digital subtraction myelography.
MATERIALS AND METHODS
We reviewed the digital subtraction myelography images of 26 patients with CSF-venous fistulas. We evaluated how long the CSF-venous fistula took to opacify after contrast reached the spinal level of interest and how long it remained opacified. Patient demographics, CSF-venous fistula treatment, brain MR imaging findings, CSF-venous fistula spinal level, and CSF-venous fistula laterality were recorded.
RESULTS
Eight of the 26 CSF-venous fistulas were seen on both the upper- and lower-FOV digital subtraction myelography, for a total of 34 CSF-venous fistula views evaluated on digital subtraction myelography. The mean time to appearance was 9.1 seconds (range, 0-30 seconds). Twenty-two (84.6%) of the CSF-venous fistulas were on the right. The highest fistula level was C7, while the lowest was T13 (13 rib-bearing vertebral bodies). The most common CSF-venous fistula levels were T6 (4 patients) followed by T8, T10, and T11 (3 patients each). The mean age was 58.3 years (range, 31.7-87.6 years). Sixteen patients were women (61.5%).
CONCLUSIONS
This is the first study to report the temporal characteristics of CSF-venous fistulas using digital subtraction myelography. We found that on average, the CSF-venous fistula appeared 9.1 seconds (range, 0-30 seconds) after intrathecal contrast reached the spinal level.
Topics: Humans; Female; Middle Aged; Male; Myelography; Cerebrospinal Fluid Leak; Spine; Magnetic Resonance Imaging; Fistula; Intracranial Hypotension
PubMed: 36894299
DOI: 10.3174/ajnr.A7809 -
AJNR. American Journal of Neuroradiology Mar 2023Dynamic CT myelography can identify spinal CSF leaks secondary to dural tears (type 1) and ruptured meningeal diverticula (type 2), but the radiation can be high...
BACKGROUND AND PURPOSE
Dynamic CT myelography can identify spinal CSF leaks secondary to dural tears (type 1) and ruptured meningeal diverticula (type 2), but the radiation can be high secondary to multiple successive acquisitions. The purpose of this article is to discuss the procedural approach of a modified dynamic CT myelography technique with single scan acquisitions, reduced contrast volume, and condensed scan coverage and compare its radiation dose with that in traditional dynamic CT myelography.
MATERIALS AND METHODS
Retrospective review was performed for patients with spontaneous CSF leaks showing extradural collections on spine MR imaging who underwent traditional and modified dynamic CT myelography. The radiation doses between the 2 cohorts were compared.
RESULTS
Thirty-seven patients (25 women, 12 men) had a type 1 or 2 CSF leak on dynamic CT myelography. Thirty-one patients had a type 1 CSF leak, and 6 patients had type 2 leaks. The traditional dynamic CT myelography was performed in 25 patients, and the average number of acquisitions per dynamic CT myelography was 3.6. The mean total effective dose per dynamic CT myelography was 31.3 mSv (range, 11.3-68.4 mSv). The modified dynamic CT myelography was performed in 12 patients, and the average number of acquisitions was 2.8. The mean total effective dose per dynamic CT myelography was 15.1 mSv (range, 4.8-24.6 mSv). The effective dose and dose-length product between the cohorts were statistically significant ( < .0001 and .01, respectively).
CONCLUSIONS
Modified dynamic CT myelography performed with single scan acquisitions, smaller volume of contrast, and reduced scan coverage can reduce the radiation dose for type 1 and 2 CSF leak detection.
Topics: Male; Humans; Female; Myelography; Cerebrospinal Fluid Leak; Tomography, X-Ray Computed; Magnetic Resonance Imaging; Retrospective Studies; Intracranial Hypotension
PubMed: 36732032
DOI: 10.3174/ajnr.A7784 -
Clinical Spine Surgery Feb 2022Cervical spondylotic myelopathy (CSM) develops insidiously as degenerative changes of the cervical spine impact the spinal cord. Unfortunately, CSM is a form of spinal...
Cervical spondylotic myelopathy (CSM) develops insidiously as degenerative changes of the cervical spine impact the spinal cord. Unfortunately, CSM is a form of spinal cord injury in older patients that often experiences delayed treatment. This summary evaluates the pathophysiology, natural history, diagnosis, and current management of CSM. Frequently, patients do not appreciate or correlate their symptomatology with cervical spine disease, and those with radiographic findings may be clinically asymptomatic. Providers should remember the classic symptoms of CSM-poor hand dexterity, new unsteady gait patterns, new onset and progressive difficulty with motor skills. An magnetic resonance imaging is required in patients with suspected CSM, but computerized tomography myelography is an alternative in patients with implants as contraindications to magnetic resonance imaging. The management of those with CSM has continued to be a controversial topic. In general, patients with incidental findings of cervical cord compression that are asymptomatic can be managed conservatively. Those with daily moderate-severe disease that significantly affects activities of daily living should be treated operatively.
Topics: Activities of Daily Living; Aged; Cervical Vertebrae; Humans; Magnetic Resonance Imaging; Spinal Cord Compression; Spinal Cord Diseases; Spondylosis
PubMed: 34379614
DOI: 10.1097/BSD.0000000000001113 -
Journal of Minimally Invasive Gynecology Aug 2022This review aimed to compare isolated sciatic and sacral nerve root endometriosis in terms of anatomic distribution, patients' symptoms and history, diagnostics,... (Review)
Review
OBJECTIVE
This review aimed to compare isolated sciatic and sacral nerve root endometriosis in terms of anatomic distribution, patients' symptoms and history, diagnostics, treatments, and outcomes.
DATA SOURCE
We searched PubMed, MEDLINE, Web of Science, and Embase from inception to October 2021 using a combination of keywords including "sciatic nerve endometriosis," "sacral nerve root endometriosis," and associated Medical Subject Headings. Relevant publications and references were also checked for further articles.
METHODS OF STUDY SELECTION
Two independent researchers performed the study selection. We included all original research articles, case reports, and case series in English that reported on the isolated sciatic nerve and sacral nerve root endometriosis.
TABULATION, INTEGRATION, AND RESULTS
The initial search identified 92 articles, and 40 articles, mostly case reports and case series, were included. The review included 362 patients: with 256 and 106 patients in the sacral and the sciatic groups, respectively. In both groups, most patients had right-sided endometriosis. In the sciatic group, most of the patients presented with foot drop, leg motor weakness, and sciatic dermatome hypoesthesia. The frequencies of all these symptoms were significantly higher in the sciatic group (all p <.001). By contrast, in the sacral group, most of patients presented with pudendal neuralgia (p <.001). Intraoperative, early, late, and 1-year postoperative complications did not differ significantly between the 2 groups.
CONCLUSION
This study indicated that isolated sciatic and sacral nerve root endometrioses were more common on the right side. Laparoscopic surgery was more commonly performed over traditional open or transgluteal surgery techniques. Sacral nerve root endometriosis is often accompanied by deep infiltrating endometriosis. Magnetic resonance imaging and myelography may be useful diagnostic tools in the preoperative workup. There was usually no significant improvement after surgery in cases of isolated sciatic nerve endometriosis presenting with foot drop.
Topics: Endometriosis; Female; Humans; Laparoscopy; Peroneal Neuropathies; Sciatic Nerve; Spinal Nerve Roots
PubMed: 35649478
DOI: 10.1016/j.jmig.2022.05.017