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Cureus Mar 2024Tarlov cysts, also known as perineural cysts, are usually associated with lumbar discomfort and neurological deficits, with an uncertain etiology that may involve...
Tarlov cysts, also known as perineural cysts, are usually associated with lumbar discomfort and neurological deficits, with an uncertain etiology that may involve genetic predisposition and collagen disorders, possibly influenced by traumatic events and hemorrhagic episodes. Diagnostic methods such as magnetic resonance imaging or computed tomography myelography are commonly employed and treatment approaches range from conservative measures to more invasive interventions. This case involves a 42-year-old female with cervical pain and upper limb symptoms; a comprehensive assessment, including diagnostic imaging and physiotherapeutic interventions, resulted in significant improvements in pain intensity, range of motion, manual muscle testing, and functional scale scores after a two-week physiotherapy intervention. These findings contribute to advancing our understanding of managing Tarlov cysts associated with cervical radiculopathy, highlighting the potential efficacy of physiotherapeutic interventions in enhancing patient outcomes.
PubMed: 38681406
DOI: 10.7759/cureus.57204 -
Frontiers in Neuroscience 2024Medical imaging allows for the visualization of spinal cord compression sites; however, it is impossible to assess the impact of visible stenotic sites on neuronal...
UNLABELLED
Medical imaging allows for the visualization of spinal cord compression sites; however, it is impossible to assess the impact of visible stenotic sites on neuronal functioning, which is crucial information to formulate a correct prognosis and install targeted therapy. It is hypothesized that with the transcranial electrical stimulation (TES) technique, neurological impairment can be reliably diagnosed.
OBJECTIVE
To evaluate the ability of the TES technique to assess neuronal functional integrity in ataxic horses by recording TES-induced muscular evoked potentials (MEPs) in three different muscles and to structurally involve multiple ancillary diagnostic techniques, such as clinical neurological examination, plain radiography (RX) with ratio assessment, contrast myelography, and post-mortem gross and histopathological examination.
METHODS
Nine ataxic horses, showing combined fore and hindlimb ataxia (grades 2-4), were involved, together with 12 healthy horses. TES-induced MEPs were recorded bilaterally at the level of the trapezius (TR), the extensor carpi radialis (ECR), and tibialis cranialis (TC) muscles. Two Board-certified radiologists evaluated intra- and inter-sagittal diameter ratios on RX, reductions of dorsal contrast columns, and dural diameters (range skull-T1). Post-mortem gross pathological and segmental histopathological examination was also performed by a Board-certified pathologist.
RESULTS
TES-MEP latencies were significantly prolonged in both ECR and TC in all ataxic horses as opposed to the healthy horses. The TR showed a mixed pattern of normal and prolonged latency times. TES-MEP amplitudes were the least discriminative between healthy and ataxic horses. Youden's cutoff latencies for ataxic horses were 24.6 ms for the ECR and 45.5 ms for the TC (sensitivity and specificity of 100%). For healthy horses, maximum latency values were 22 and 37 ms, respectively. RX revealed spinal cord compression in 8 out of 9 involved ataxic horses with positive predictive values of 0-100%. All ataxic horses showed multi-segmental Wallerian degeneration. All pathological changes recorded in the white matter of the spinal cord were widely dispersed across all cervical segments, whereas gray matter damage was more localized at the specific segmental level.
CONCLUSION
TES-MEP latencies are highly sensitive to detect impairment of spinal cord motor functions for mild-to-severe ataxia (grades 2-4).
PubMed: 38665290
DOI: 10.3389/fnins.2024.1342803 -
World Neurosurgery Apr 2024Cerebrospinal fluid venous fistulas (CSF-VFs) are an uncommon, yet increasingly recognized, cause of spontaneous intracranial hypotension. The workup involves magnetic...
Cerebrospinal fluid venous fistulas (CSF-VFs) are an uncommon, yet increasingly recognized, cause of spontaneous intracranial hypotension. The workup involves magnetic resonance imaging (MRI) of the brain with and without contrast and MRI of the neuroaxis without contrast before dynamic myelography, either computed tomography or digital subtraction. The present case of an older woman with symptomatic intracranial hypotension is notable for the specific appearance of CSF-VFs on digital spinal myelography (Video 1). Among her numerous perineural cysts, it was the "disappearing" or "empty" cyst from which the fistula originated. The diagnosis was made using a second lateral fluoroscopy view, not typically used in digital spinal myelography, which demonstrated emptying of contrast from the T6 perineural cyst into the segmental vein at this level, or the "empty cyst sign." The patient then underwent transvenous onyx embolization with resolution of her orthostatic headaches and improvement of contrast-enhanced MRI of the brain with the Bern score decreasing from 7 to 0 at 3 months of follow-up. Because transvenous embolization of CSF-VFs is a relatively new procedure, the long-term outcomes of the procedure are not yet known.
PubMed: 38663740
DOI: 10.1016/j.wneu.2024.04.078 -
Asian Spine Journal Apr 2024A retrospective study at a single academic institution.
STUDY DESIGN
A retrospective study at a single academic institution.
PURPOSE
This study aimed to identify imaging risk factors for stenosis in extended neck positions undetectable in preoperative neutral magnetic resonance imaging (MRI) and improving decompression strategies for cervical spine disorders.
OVERVIEW OF LITERATURE
Cervical disorders are influenced by various dynamic factors, with spinal stenosis appearing during neck extension. Despite the diagnostic value of dynamic cervical MRI, standard practice often uses neutral-position MRI, potentially influencing surgical outcomes.
METHODS
This study analyzed 143 patients who underwent decompression surgery between 2012 and 2014, who had symptomatic cervical disorders and MRI evidence of spinal cord or nerve compression but had no history of cervical spine surgery. Patient demographics, disease type, Japanese Orthopedic Association score, and follow-up periods were recorded. Spinal surgeons conducted radiological evaluations to determine stenosis levels using computed tomography myelography or MRI in neutral and extended positions. Measurements such as dural tube and spinal cord diameters, cervical alignment, range of motion, and various angles and distances were also analyzed. The residual space available for the spinal cord (SAC) was also calculated.
RESULTS
During extension, new stenosis frequently appeared caudal to the stenosis site in a neutral position, particularly at C5/C6 and C6/C7. A low SAC was identified as a significant risk factor for the development of new stenosis in both the upper and lower adjacent disc levels. Each 1-mm decrease in SAC resulted in an 8.9- and 2.7-fold increased risk of new stenosis development in the upper and lower adjacent disc levels, respectively. A practical SAC cutoff of 1.0 mm was established as the threshold for new stenosis development.
CONCLUSIONS
The study identified SAC narrowing as the primary risk factor for new stenosis, with a clinically relevant cutoff of 1 mm. This study highlights the importance of local factors in stenosis development, advocating for further research to improve outcomes in patient with cervical spine disorders.
PubMed: 38650094
DOI: 10.31616/asj.2023.0262 -
Operative Neurosurgery (Hagerstown, Md.) Apr 2024Spontaneous intracranial hypotension is a rare but serious condition characterized by orthostatic headaches and a variety of neurological symptoms. 1,2 Spontaneous...
Spontaneous intracranial hypotension is a rare but serious condition characterized by orthostatic headaches and a variety of neurological symptoms. 1,2 Spontaneous intracranial hypotension should be considered in all patients with new onset, daily, persistent headaches, and orthostatic symptoms. It is typically caused by spontaneous spinal cerebrospinal fluid (CSF) leaks. 1,2 Traditional first-line treatments include hydration, bedrest, epidural blood patches, and fibrin glue injections. However, refractory cases often require surgical intervention, especially those caused by a small ventral osteophyte, which is classified as a type 1 leak. 3-5 The small osteophyte causes a tear in the dura of the ventral canal, usually near the cervicothoracic junction. Diagnosis of these leaks is challenging because these small osteophytes can also occur asymptomatically, or patients may have several of them at multiple levels. Typically, dynamic myelography is needed for accurate localization due to the inadequacy of standard imaging. 6 This video details a young patient with refractory spontaneous intracranial hypotension from a type 1 spontaneous CSF leak, treated successfully using a posterior transdural surgical approach with spinal cord mobilization. Our video presentation outlines the surgical technique and provides an overview of this underdiagnosed condition. Our described approach offers direct visualization, suturing of the leak site, and a multilayer repair without the need for spinal fusion. It also avoids the morbidity to the neck, chest, and mediastinal structures that is at risk with lateral or anterior approaches. A combined intradural and extradural repair may enhance the durability of repair for ventral CSF leaks. The patient consented to the procedure. This operative video did not require Institutional Review Board approval as all patient information has been anonymized, ensuring no identifiable information is disclosed. The video is a single case that does not involve interventions or pose risks beyond standard care, adhering to ethical guidelines and institutional policies.
PubMed: 38634675
DOI: 10.1227/ons.0000000000001164 -
Frontiers in Neurology 2024Spontaneous intracranial hypotension (SIH) is frequently complicated by subacute subdural hematoma (SDH) and more rarely by bilateral thalamic ischemia. Here, we report...
Case report: Simultaneous measurement of intracranial pressure and lumbar intrathecal pressure during epidural patch therapy for treating spontaneous intracranial hypotension syndrome. Spontaneous intracranial hypotension or spontaneous intraspinal hypovolume?
OBJECTIVES
Spontaneous intracranial hypotension (SIH) is frequently complicated by subacute subdural hematoma (SDH) and more rarely by bilateral thalamic ischemia. Here, we report a case of SIH-related SDH treated with three epidural patches (EPs), with follow-up of the intracranial pressure and lumbar intrathecal pressure.
METHODS
A 46-year-old man presented bilateral thalamic ischemia, then a growing SDH. After failure of urgent surgical evacuation, he underwent three saline EPs, two dynamic myelography examinations and one digital subtraction angiography-phlebography examination. However, because of no dural tear and no obstacle to the venous drainage of the vein of Galen, no therapeutic procedure was available, and the patient died.
RESULTS
The case exhibited a progressive increase in the transmission of lumbar intrathecal pressure to intracranial pressure during the three EPs. The EPs may have successfully treated the SIH, but the patient did not recover consciousness because of irreversible damage to both thalami.
CONCLUSION
Clinicians should be aware of the bilateral thalamic ischemia picture that may be the presenting sign of SIH. Moreover, the key problem in the pathophysiology of SIH seems to be intraspinal and intracranial volumes rather than pressures. Therefore, intracranial hypotension syndrome might actually be an intraspinal hypovolume syndrome.
PubMed: 38576535
DOI: 10.3389/fneur.2024.1308462 -
Neurologic Clinics May 2024Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks.... (Review)
Review
Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.
Topics: Humans; Intracranial Hypotension; Cerebrospinal Fluid Leak; Magnetic Resonance Imaging; Tomography, X-Ray Computed; Neuroimaging; Headache
PubMed: 38575260
DOI: 10.1016/j.ncl.2024.02.002 -
BMJ Case Reports Mar 2024
Topics: Humans; Myelography; Contrast Media; Tomography, X-Ray Computed
PubMed: 38553021
DOI: 10.1136/bcr-2023-259525 -
Neurology Apr 2024
Topics: Humans; Iophendylate; Myelography; Contrast Media; Brain; Head
PubMed: 38547442
DOI: 10.1212/WNL.0000000000209314 -
European Spine Journal : Official... Mar 2024Symptomatic Tarlov cysts in children with a possible underlying one-way check-valve mechanism are very rare. We aim to introduce a new variation of the surgical...
Large symptomatic sacral Tarlov cyst in a paediatric patient: case report and technical note on a new variation of surgical technique to overcome one-way check-valve mechanism.
PURPOSE
Symptomatic Tarlov cysts in children with a possible underlying one-way check-valve mechanism are very rare. We aim to introduce a new variation of the surgical technique to overcome a check-valve mechanism.
METHODS
A 15-years-old girl presented with double incontinence and anogenital numbness due to a large sacral Tarlov-cyst with possibly underlying one-way check valve mechanisms as suggested by preoperative computed tomography myelography. Intraoperatively, one-way check-valve was confirmed and could be eliminated by creating an artificial inner ostium between the Tarlov cyst and thecal sac with blunt perforation.
RESULTS
Postoperatively, the patient had established normal sphincter control and sensation in the anogenital region.
CONCLUSION
One-way check-valve mechanism might contribute to the symptomatology of large sacral Tarlov cysts in children. Our new variation of a surgical technique enables elimination of the check-valve mechanism without the necessity to open and close the typically very thin and fragile cyst surface and is therefore an efficacious and simple option in this situation.
PubMed: 38536497
DOI: 10.1007/s00586-023-08102-8