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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 -
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 -
World Neurosurgery: X Apr 2024To formulate the most current, evidence-based recommendations regarding the epidemiology, clinical diagnosis, and radiographic diagnosis of lumbar herniated disk (LDH). (Review)
Review
OBJECTIVE
To formulate the most current, evidence-based recommendations regarding the epidemiology, clinical diagnosis, and radiographic diagnosis of lumbar herniated disk (LDH).
METHODS
A systematic literature search in PubMed, MEDLINE, and CENTRAL was performed from 2012 to 2022 using the search terms "herniated lumbar disc", "epidemiology", "prevention" "clinical diagnosis", and "radiological diagnosis". Screening criteria resulted in 17, 16, and 90 studies respectively that were analyzed regarding epidemiology, clinical diagnosis, and radiographic diagnosis of LDH. Using the Delphi method and two rounds of voting at two separate international meetings, ten members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated eleven final consensus statements.
RESULTS
The lifetime risk for symptomatic LDH is 1-3%; of these, 60-90% resolve spontaneously. Risk factors for LDH include genetic and environmental factors, strenuous activity, and smoking. LDH is more common in males and in 30-50 year olds. A set of clinical tests, including manual muscle testing, sensory testing, Lasegue sign, and crossed Lasegue sign are recommended to diagnose LDH. Magnetic resonance imaging (MRI) is the gold standard for confirming suspected LDH.
CONCLUSIONS
These eleven final consensus statements provide current, evidence-based guidelines on the epidemiology, clinical diagnosis, and radiographic diagnosis of LDH for practicing spine surgeons worldwide.
PubMed: 38440379
DOI: 10.1016/j.wnsx.2024.100279 -
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 -
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 -
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 -
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