[Lumbar spinal stenosis--claudicatio spinalis. Pathophysiology, clinical aspects and treatment]

The lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal together with neuronal and vascular structures via circumjacent bone and soft tissue. In patients aged over 65 years, the LSS is among the most frequent causes of lumbago, either with or without sciatica. The prevalence will continue to augment because of the increased life expectancy. The leading symptom is neurogenic claudicatio with lumbogluteal or sciatic pain, which occurs while walking and leads to a limitation of the walking distance. Its typical constellation of symptoms including subjective leg weakness is leading to the tentative diagnosis. Nowadays, the imaging technique of choice for the diagnosis is magnetic resonance imaging. A conservative treatment is initially sufficient in most cases. The indication for surgery is given, if the pain and limitation of walking distance are not tolerable any more. Additional fusion should be taken into account, when degenerative spondylolisthesis or other pathomorphological alterations result in an instability. Conservative and surgical therapeutic goals imply pain relief, amelioration of the physical functionality, mobility and general quality of life.

Interventions for the treatment of metastatic extradural spinal cord compression in adults

BACKGROUND

Metastatic epidural spinal cord compression (MESCC) is often treated with radiotherapy and corticosteroids. Recent reports suggest benefit from decompressive surgery.

OBJECTIVES

To determine effectiveness and adverse effects of radiotherapy, surgery and corticosteroids in MESCC.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and CANCERLIT were searched; last search ran July 2008

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed quality of included studies and extracted data. We calculated risk ratios (RR) and numbers needed to treat to benefit (NNT) with 95% confidence intervals (CI) and assessed heterogeneity.

MAIN RESULTS

We identified six trials (n = 544). One trial (n = 276) compared radiotherapy 30 Gray in eight fractions with 16 Gray in two fractions and showed no difference. Overall ambulatory rates were 71% versus 68%, (RR 1.02, CI 0.90 to 1.15); 91% versus 89% of ambulant patients maintained ambulation (RR 1.02, CI 0.93 to 1.12); 28% versus 29% of non-ambulant patients regained ambulation (RR 0.98, CI 0.51 to 1.88). In one trial (n = 101) decompressive surgery had significantly better outcomes than radiotherapy in selected patients. Overall ambulatory rates were 84% versus 57% (RR 0.67, CI 0.53 to 0.86, NNT 3.70 CI 2.38 to 7.69); 94% versus 74% maintained ambulation (RR 0.79, CI 0.64 to 0.98, NNT 5.00 CI 2.78 to 33.33); 63% versus 19% regained ambulation (RR 0.30, CI 0.10 to 0.89; NNT 2.27 CI 1.35 to 7.69). Median survival was 126 days versus 100 days. Laminectomy offered no advantage (n = 29, 1 trial). Three trials provided insufficient evidence about the role of corticosteroids (n = 105, Overall ambulation RR 0.91, CI 0.68 to 1.23). Serious adverse effects were significantly higher in high dose corticosteroid arms (n = 77, two RCTs, RR 0.12, CI 0.02 to 0.97).

AUTHORS' CONCLUSIONS

Patients with stable spines retaining the ability to walk may be treated with radiotherapy. One trial indicates that short course radiotherapy suffices in patients with unfavourable histologies or predicted survival of less than six months. There is some evidence of benefit from decompressive surgery in ambulant patients with poor prognostic factors for radiotherapy; and in non-ambulant patients with a single area of compression, paraplegia < 48 hours, non-radiosensitive tumours and a predicted survival of more than three months. High dose corticosteroids carry a significant risk of serious adverse effects.

Spinal cord compression in patients with advanced metastatic cancer: "all I care about is walking and living my life"

As 1 of the 12,700 US cancer patients who, each year, develops metastatic spinal cord compression, Ms H wishes to walk and live her life. Sadly, this wish may be difficult to fulfill. Before diagnosis, 83% to 95% of patients experience back pain, which often is referred, obscuring the site(s) of the compression(s). Prediction of ambulation depends on a patient's ambulatory status before therapy and time between developing motor defects and starting therapy. Ambulatory patients with no visceral metastases and more than 15 days between developing motor symptoms and receiving therapy have the best rate of survival. To preserve ambulation and optimize survival, magnetic resonance imaging should be performed for cancer patients with new back pain despite normal neurological findings. At diagnosis, counseling, pain management, and corticosteroids are begun. Most patients are offered radiation therapy. Surgery followed by radiation is considered for selected patients with a single high-grade epidural lesion caused by a radioresistant tumor who also have an estimated survival of more than 3 months. Team discussions with the patient and support network help determine therapy options and include patient goals; assessment of risks, benefits, and burdens of each treatment; and discussion of the odds of preserving prognosis of ambulation and of the effect of therapy on the patient's overall prognosis. Rehabilitation improves impaired function and its associated depression. Clinicians can help patients cope with transitions in self-image, independence, family and community roles, and living arrangements and can help patients with limited prognoses identify their end-of-life goals and preferences about resuscitation and entering hospice.

[Acute low back pain--assessment and management]

Acute low back pain is a very common symptom. Up to 90% of all adults suffer at least once in their life from a low back pain episode, in the majority of cases a nonspecific lumbago. They are, with or without sciatica, usually self-limited and have no serious underlying pathology and subside in 80-90% of the concerned patients within six weeks. Beside a sufficient pain medication and physiotherapy, reassurance about the overall benign character and the favourable prognosis of the medical condition should be in the centre of the therapeutic efforts. A more thorough assessment is required for selected patients with warning signs, so called "red flags" findings, because they are associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require a closer follow-up and, in some cases, an urgent surgical intervention. Among patients with acute nonspecific mechanical low back pain, imaging diagnostic can be delayed for at least four to six weeks, which usually allows the medical condition to improve. From a therapeutic viewpoint, there is enough evidence for the effectiveness of paracetamol, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physiotherapy, and the advice to stay "active". A complete relief and protection represent an out-dated concept, because the deconditioning is stimulated and the return to the workplace is needlessly delayed. Spinal manipulative therapy may provide short-term benefits in certain patients. In a multimodal therapeutic concept, the patient education should focus on the natural history of an acute back pain episode, the overall good prognosis, and recommendations for an effective treatment.

Management of spinal cord compression caused by extramedullary hematopoiesis in beta-thalassemia

Thalassemia is a chronic hemolytic anemia, endemic around the Mediterranean basin. Extramedullary hematopoiesis (EMH) is a normal compensatory reaction that can involve many organs or tissues, including the epidural space, leading to a spinal cord compression syndrome. In almost all cases, the clinical and MR patterns are those of a lower dorsal spinal cord progressive compression secondary to an epidural expanding process. The management still remains controversial, including mainly blood transfusions, decompressive surgery and radiotherapy. We present a case of EMH in a thalassemic adolescent boy presenting with a T12 level of compression, treated successfully with blood transfusion, surgical decompression and radiotherapy.

[Juvenile muscular atrophy of unilateral upper extremity (Hirayama disease)--half-century progress and establishment since its discovery]

This disease occurs in adolescence, predominatly in male. The main clinical features include predominantly unilateral muscular weakness and wasting of the hand and forearm (the brachioradialis is spared: oblique amyotrophy). The clinical course is incidious onset and slowly progressive, followed by a spontaneous arrest within several years. Twelve patients with this disease were first reported by Hirayama and his associates in 1959, who clinically distinguished this disorder from previously known degenerative and progressive motor neuron diseases. The clinical features had been further clarified by the report on 20 patients in 1963, and completed in the report on 38 patients in 1972. A quarter of a century had passed without pathological confirmation, primarily due to the benign course of the disease. The first autopsy case was obtained in 1982. The neuropathological findings were reported by Hirayama and his associates in 1985 in Japanese, then in 1987 in English. The spinal cord showed anteroposterior flattening and ischemic necrotic changes of the anterior horns of the cervical cord at C5-T1, mostly severe at C7 and C8, predominantly on the left (the patient had bilateral muscular atrophy, predominantly on the left). These findings suggested a circulatory insufficiency of the lower cerivical cord, but the intra- and extra-medullary vessels were normal. The pathologic evidence prompted neuroradiologic (CT, MRI) studies in the late 1980s. Our studies of 73 patients revealed that dynamic compression of the lower cervical cord due to forward displacement of the cervical dural sac (especially posterior segment) and spinal cord on neck flexion was confined to an early and progressive stage of the disease. An absence of forward displacement in a later and non-progressive stage of the disease suggested that the dynamic compression had pathogenic significance. The pathologic findings and results of radiological studies suggest that sustained or repeated neck flexion might cause an anterior shift of the cervical dural sac, then the compressed cervical cord at the segments induce an increased intramedullary pressure, resulting in microcirculatory disturbance in the anterior horn, the most vulnerable structure to ischemia in the spinal cord. Based on this hypothesis, we tried cervical collar therapy for patients when they may have sustained or repeated neck flexion, and reported these data in 1991, 1992 and 2001. No one showed further progression of signs and symptoms. This favorable effect supports our pathogenic hypothesis described above. The author proposes that the etiology of this disease is disproportionate growth between the vertebral column and the contents of the spinal canal especially the dural sac during the juvenile growth. The nationwide epidemiological study in Japan was carried out from 1996 to 1998, identified 333 cases of the disease. There were fewer case reports from other countries than from Japan. As the number of patients is exceedingly large in Japan, there might be an ethnic factor in this disorder.

[Clinical features and combined treatment of the central nervous system in Hodgkin's disease]

Spinal cord compression was diagnosed in 33 patients with Hodgkin's disease. Specific involvement of the brain was identified in 17 cases of dissemination relapse. Timely use of cytostatic and/or radiotherapy resulted in sustained and complete recovery of the spinal cord. The results in cases of sustained spinal disorders were worse. Tumor-induced specific changes in the brain and spinal cord compression had worse prognosis and median of survival from time of tumor detection was approx. 12 months. In patients with spinal cord compression or cerebral involvement and with concomitant neurologic symptoms, sustained response after chemotherapy with derivatives of nitrosourea (nitrosomethylurea, lomustine and carmustine) (CCNU-OPP, NVPP/NOPP, DVCPP) was (59%) and (64%), respectively. Adequate polychemotherapy with nitrosourea and radiotherapy derivatives and surgery, if required, can improve the efficacy of treatment of Hodgkin's disease patients with spinal cord compression.

Confirmed and presumptive cervical vertebral compressive myelopathy in older horses: a retrospective study (1992-2004)

BACKGROUND

Cervical vertebral compressive myelopathy (CVCM) is a common cause of myelopathy in horses aged 6 months to 4 years. Little information is available regarding the types of lesions, treatment, and outcomes in horses with CVCM that are > or =4 years old.

ANIMALS

Twenty-two affected horses (10 with a confirmed diagnosis of CVCM and 12 presumptive cases) and 210 contemporaneous control horses.

METHODS

Horses > or =4 years old that were diagnosed with CVCM between January 1992 and January 2004 were identified from medical records at Texas A&M University and the University of Florida. Data analyzed included history, signalment, neurologic examination findings, lesion location, treatment, and outcome. Signalment was also recorded in a population of contemporaneous controls.

RESULTS

Horses identified had a median age of 8.4 years, and there was a greater percentage of male horses among the cases than among the controls. The most common breeds represented were warmblood (n=6) and quarter horse (n=5) types; warmbloods were significantly (P < .05) overrepresented relative to control horses. The caudal cervical vertebral column was the most common site of CVCM lesions, and the C5-C6 (4/9) and C6-C7 (3/9) articulations were most often identified as abnormal via myelography. The most common lesions seen with radiography and myelography were articular process osteophytes. Of the 22 affected horses, 8 were euthanized and a diagnosis of CVCM was confirmed by necropsy for all; 5 of 8 of these horses had spinal cord compression caused, entirely or in part, by articular process osteophytes. Medical management was the therapy chosen in all horses, and administration of corticosteroids and nonsteroidal anti-inflammatory drugs resulted in improvement in the greatest number of horses.

CONCLUSIONS AND CLINICAL IMPORTANCE

CVCM should be a differential diagnosis in older horses with cervical myelopathy. Articular process osteophytes are the most frequently identified cause of spinal cord compression in this group. Male horses and horses of warmblood or Tennessee Walking Horse breeds may be predisposed to this condition.

Atlantoaxial rotatory subluxation associated with cervical dystonia

STUDY DESIGN

Case report.

OBJECTIVE

To document an interesting case of cervical dystonia associated with atlantoaxial rotatory subluxation and compressive myelopathy.

SUMMARY OF BACKGROUND DATA

Dystonia is an involuntary disorder characterized by twisting, pulling, and sustained contractions, which may be extremely powerful and painful. Cervical dystonia can contribute to the development of cervical spondylosis. However, cervical dystonia with atlantoaxial rotatory subluxation is very rare. Only 2 cases of primary dystonia with atlantoaxial subluxation have been reported previously.

METHODS

We present the case of a 53-year-old man who had dystonic movements involving the neck. The head tilted to the left and rotated to the right. The subluxation was reduced by a sensory trick. Involuntary movements of the neck worsened. After 2 years, neck pain and difficulty in walking developed.

RESULT

Cervical MRI showed atlantoaxial subluxation with compression of the spinal cord at C1-C2. Computed axial tomography of the cervical spine demonstrated rotatory subluxation of the atlas on the axis. Surgical intervention combined with globus pallidus internus-deep-brain stimulation and atlantoaxial fixation successfully controlled the cervical dystonia and atlantoaxial rotatory subluxation.

CONCLUSION

Although this case is extremely rare, clinicians should be keep in mind that cervical dystonia may carry a risk of atlantoaxial subluxation, potentially progressing to myelopathy. Neurosurgery combined with globus pallidus internus-deep-brain stimulation and atlantoaxial fixation is one treatment option for cervical dystonia with atlantoaxial rotatory subluxation.

Palliative care emergencies. 2: Management

This is the second of a two-part unit on palliative care emergencies. The first part looked at the signs and symptoms of conditions classed as palliative care emergencies. This part examines treatment regimens and related nursing care to ensure patient safety and comfort.

Electro-acupuncture and Chinese herbs for treatment of cervical intervertebral disk disease in a dog

A non-ambulatory dog with tetraparesis following a pain episode that had evolved over 2 months was submitted for medical treatment and diagnosed with intervertebral disk disease at C3-C4 and dorsal extradural compression at C1-C2 and C3-C4 using myelography and computed tomography. The dog experienced ambulation recovery after 15 days of treatment with only electroacupuncture and Chinese herbal medicine, with marked improvement occurring after only 10 treatments. Six months of follow-up demonstrated that the dog was stable and had no recurrence of symptoms. Therefore, it was concluded that the combination of electroacupuncture and Chinese herbal medicine was responsible for motor rehabilitation.

Spinal cord compression, an overview for radiation oncologists

Spinal cord compression is a major cause of morbidity and or mortality in a cancer patient. This is one of the few oncologic emergencies, as delay in therapy leads to frank paralysis. Several key areas must be considered in the diagnosis and management of spinal cord compression. Because the outcome can be devastating, a diagnosis must be made early and treatment initiated promptly. The purpose of this paper is to present an overview of the important points to radiation oncologists regarding the management of spinal cord compression in an evidence-based approach.

Management of cervicomedullary compression in patients with congenital and acquired osseous–ligamentous pathologies

We present our experience in the diagnosis, surgical management and long-term follow-up of congenital and acquired osseous-ligamentous abnormalities or pathologies of the craniovertebral junction. The purpose of this study was: (i) to determine the incidence and degree of cervicomedullary compression in pediatric and young adult patients with congenital and acquired abnormalities, and (ii) to correlate cervicomedullary compression with other imaging and clinical factors to determine to what extend cervicomedullary compression is successfully treated with a posterior decompressive procedure, transoral decompression, and medical management. Between January 1995 and December 2004, 26 cases were managed in our department. These patients had: rheumatoid arthritis (RA) (3); traumatic injury (2); congenital basilar impression (5, in 2 cases a posteriorly oriented or retroflexed odontoid); infection (10); craniovertebral junction Pott's disease (9); os odonteideum (3); condylus tertius (1); and tumor (2). Six of the patients (23.1%) had syringomyelia. Only three (11.3%) were in the pediatric age group. Symptoms and signs included headache (72%), ataxia (38%), lower cranial nerve dysfunction (54%), quadriparesis (44%), hyperreflexia (76%), Hoffman positivity (72%), achilles clonus (72%) nystagmus (33%) and dysphagia (22%). The mean follow-up time was 44 months (range 3-85). Twelve (46.2%) had undergone posterior fossa decompression; seven (26.6%) had ventral decompression. Seven of the patients (26.6%) had medical management. The major morbidity included pharyngeal wound sepsis leading to dehiscence (3.8%), valopharyngeal insufficiency (3.8%), cerebrospinal fluid leakage (3.8%), postoperative macroglossia (3.8%) and inadequate anterior decompression (3.8%). Transient neurological deterioration occurred in two patients (7.6%). Our management paradigm will result in some neurologic improvements and limit the progression of symptoms. Patients with these pathologies are likely to show a good neurologic outcome when treatment, whether with or without surgery, is administered early in the course of the disease.

Thoracic spinal cord compression indicating Wegener's granulomatosis in a patient with a previous presumptive diagnosis of microscopic polyangiitis

Neurological signs are observed in 20-50% of cases of Wegener's granulomatosis consisting of peripheral and cranial neuropathy, and central nervous system involvement during the disease and rarely as initial symptom. We report here a case of thoracic spinal cord compression due to dural masses in a patient with a previous presumptive diagnosis of microscopic polyangiitis indicating Wegener's granulomatosis on histological examination. No other site of involvement was found. Slight clinical improvement was observed under immunosuppressive treatment probably because of spinal cord vessels lesions.

Skeletal metastases in non-small cell lung cancer: a retrospective study

BACKGROUND

The skeleton is one of the most common sites of metastasis in patients with advanced cancer. Bone metastases often cause SREs (skeletal-related events). Despite advances in the treatment of primary lung cancer, SREs still affect many patients. Therefore, we planned a retrospective study to investigate the clinical impact of SREs, and to compare differences in the therapeutic outcome between patients with and without skeletal metastases or SRE.

PATIENTS AND METHODS

We retrospectively investigated the charts of all 259 patients with non-small cell lung cancer (NSCLC) who consulted the Department of Medical Oncology at Kinki University School of Medicine between February 2002 and January 2005. We assessed their TNM stage, presence of skeletal metastases (on bone scintigraphy, MRI, and plain X-ray films), and outcome parameters such as SREs, analgesic use, and survival.

RESULTS

A total of 70 patients (30.4%) were found to have skeletal metastases during their clinical course and 35 patients (50%) out of all 70 patients had SREs. Among 135 stage IV patients, a total of 56 (41%) had skeletal metastases, and 25 of these 56 patients (45%) had SREs. The most common SREs were the need for radiotherapy (34.3%) and hypercalcemia (20%). Patients with SREs tended to have worse survival, while no significant difference of survival was observed between patients with and without skeletal metastases.

CONCLUSION

It seems to be important to prevent SREs during the treatment of NSCLC, so further studies evaluating bisphosphonates in combination with chemotherapy are warranted.

Extramedullary haematopoiesis in thalassaemia major causing spinal cord compression

A 33-year-old, homozygous beta-thalassaemic, Jehovah witness man presented with subacute spinal cord compression secondary to extramedullary haematopoiesis within the thoracic spinal canal. In this case, MRI showed characteristic features of extramedullary haematopoiesis, leading to an early diagnosis.

Treatment of traumatic cervical myelopathy with surgery, prolonged positive-pressure ventilation, and physical therapy in a dog

CASE DESCRIPTION

A 9-year-old dog was evaluated for traumatic cervical myelopathy after a surgical attempt to realign and stabilize the C2 and C3 vertebrae.

CLINICAL FINDINGS

The dog could not ventilate spontaneously and was tetraplegic; positive-pressure ventilation (PPV) was maintained. Myelography and computed tomography revealed spinal cord compression with subluxation of the C2 and C3 vertebrae and extrusion of the C2-3 intervertebral disk.

TREATMENT AND OUTCOME

Surgically, the protruding disk material was removed and the vertebrae were realigned with screws and wire. For PPV, assist control ventilation in volume control mode and then in pressure control mode was used in the first 6 days; this was followed by synchronized intermittent mandatory ventilation until 33 days after the injury; then only continuous positive airway pressure was provided until the dog could breathe unassisted, 37 days after the injury. Physical therapy that included passive range of motion exercises, neuromuscular electrical stimulation, and functional weight-bearing positions was administered until the dog was discharged 46 days after injury; the dog was severely ataxic and tetraparetic but could walk. Therapy was continued at home, and 1 year later, the dog could run and had moderate ataxia and tetraparesis.

CLINICAL RELEVANCE

Hypoventilation with tetraparesis in traumatic spinal cord injury can be successfully treated with PPV exceeding 30 days, surgery, and physical therapy.