Vascular diseases of the spinal cord: a review. Curr Treat Options Neurol. 2012;14:509-520. [PMID: 22875306 DOI: 10.1007/s11940-012-0190-9]

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Imaging of Common Spinal Cord Diseases

Spinal cord evaluation is an integral part of spine assessment, and its reliable imaging work-up is mandatory because even localized lesions may produce serious effects with potentially irreversible sequelae. Spinal cord alterations are found both incidentally during spine evaluation in otherwise neurologically asymptomatic patients or during neurologic/neuroradiologic assessment in myelopathic patients. Myelopathy (an umbrella term for any neurologic deficit that refers to spinal cord impairment) can be caused by intrinsic lesions or extrinsic mechanical compression, and its etiology may be both traumatic and/or nontraumatic. The symptoms largely depend on the size/extension of lesions, ranging from incontinence to ataxia, from spasticity to hyperreflexia, from numbness to weakness. Magnetic resonance imaging is the reference imaging modality in spinal cord evaluation, ensuring the best signal and spatial resolution. We provide an overview of the most common spinal cord disorders encountered by radiologists and describe the technical measures that offer optimal spinal cord visualization.

Spontaneous spinal cord infarction: a practical approach

Spontaneous spinal cord infarction is significantly less common than cerebrovascular disease. Because of the tight anatomical distribution of pathways in the cord, small spinal cord infarcts usually give more obvious symptoms and signs than similar lesions in the brain. Large epidemiological stroke studies have generally not included spinal cord stroke and so the incidence of vascular syndromes in the spinal cord is unknown. Management and prevention strategies for spontaneous spinal cord infarcts stem from small case series and case reports. Patient outcomes from spinal cord infarction are better with prompt recognition, timely management and prevention of associated medical complications arising from paraplegia, tetraplegia, neurogenic bladder and bowel dysfunction. The process of rehabilitation following spinal cord infarction is an evolving area.

Spontaneous spinal cord infarction in Austria: a two-center comparative study

Background:

Spinal cord infarction (SCI) is a neurological emergency associated with high rates of persistent neurological deficits. Knowledge about this rare but potentially treatable condition needs to be expanded.

Objective:

To describe the characteristics of spontaneous SCI in a large retrospective series of patients treated at two tertiary care centers in Austria.

Methods:

We performed a descriptive and comparative analysis of spontaneous SCI treated at the University Hospitals of Salzburg and Graz between the years 2000 and 2020. The analysis included pre- and in-hospital procedures, clinical presentation, etiology, diagnostic certainty, reperfusion therapy, and functional outcome at discharge.

Results:

We identified 88 cases, 61% were ascertained in the second half of the study period. The median age was 65.5 years [interquartile range (IQR) = 56–74], 51.1% were women. Anterior spinal artery infarction was the predominant syndrome (82.9%). Demographics, vascular comorbidities, and clinical presentation did not differ between the centers. The most frequent etiology and level of diagnostic certainty were distinct, with atherosclerosis (50%) and definite SCI (42%), and unknown (52.5%) and probable SCI (60%) as front runners in Salzburg and Graz, respectively. Patients arrived after a median of 258.5 min (IQR = 110–528) at the emergency room. The first magnetic resonance imaging (MRI) of the spinal cord was performed after a median of 148 min (IQR = 90–312) from admission and was diagnostic for SCI in 45%. Two patients received intravenous thrombolysis (2.2%). The outcome was poor in 37/77 (48%).

Conclusion:

Demographics, clinical syndromes, and quality benchmarks for spontaneous SCI were consistent at two Austrian tertiary care centers. Our findings provide the foundation for establishing standards for pre- and in-hospital care to improve outcomes.

3D Digital Anatomic Angioarchitecture of the Rat Spinal Cord: A Synchrotron Radiation Micro-CT Study

Comprehensive analysis of 3D angioarchitecture within the intact rat spinal cord remains technically challenging due to its sophisticated anatomical properties. In this study, we aim to present a framework for ultrahigh-resolution digitalized mapping of the normal rat spinal cord angioarchitecture and to determine the physiological parameters using synchrotron radiation micro-CT (SRμCT). Male SD rats were used in this ex vivo study. After a proportional mixture of contrast agents perfusion, the intact spinal cord covered the cervical spinal from the upper of the 1st cervical vertebra to the 5th lumbar vertebra was harvested and cut into proper lengths within three distinct regions: Cervical 3–5 levels, Thoracic 10–12 levels, Lumbar 3–5 levels spinal cord and examined using SRμCT. This method enabled the replication of the complicated microvasculature network of the normal rat spinal cord at the ultrahigh-resolution level, allowing for the precise quantitative analysis of the vascular morphological difference among cervical, thoracic and lumbar spinal cord in a 3D manner. Apart from a series of delicate 3D digital anatomical maps of the rat spinal cord angioarchitecture ranging from the cervical and thoracic to the lumbar spinal cord were presented, the 3D reconstruction data of SRμCT made the 3D printing of the spinal cord targeted selected microvasculature reality, that possibly provided deep insight into the nature and role of spinal cord intricate angioarchitecture. Our data proposed a new approach to outline systematic visual and quantitative evaluations on the 3D arrangement of the entire hierarchical microvasculature of the normal rat spinal cord at ultrahigh resolution. The technique may have great potential and become useful for future research on the poorly understood nature and function of the neurovascular interaction, particularly to investigate their pathology changes in various models of neurovascular disease.

Application of hybrid operating rooms for treating spinal dural arteriovenous fistula

BACKGROUND

A hybrid operating room (hybrid-OR) is a surgical space that combines a conventional operating room with advanced medical imaging devices.

AIM

To explore and summarize the technical features and effectiveness of the application of a hybrid-OR in dealing with spinal dural arteriovenous fistulas (SDAVFs).

METHODS

Eleven patients with SDAVFs were treated with the use of a hybrid-OR at the Department of Neurosurgery of our hospital between January 2015 and December 2018. The dual-marker localization technique was used in the hybrid-OR to locate the SDAVFs and skin incision, and the interoperative digital subtraction angiography (DSA) technique was used before and after microsurgical ligation of the fistulae in the hybrid-OR to verify the accuracy of obliteration. The patients were followed for an average of 2 years after the operation, and the preoperative American Spinal Cord Injury Association (ASIA) score and postoperative ASIA score at 6 mo after the operation were compared.

RESULTS

The location and skin incision of the SDAVFs were accurately obtained by using the dual-marker localization technique in the hybrid-OR in all patients, and there were no cases that required expansion of the range of the bone window in order to expose the lesions. Intraoperative error obliteration occurred and was identified in two patients by using the intraoperative DSA technique; therefore, the findings provided by the intraoperative DSA system significantly changed the surgical procedure in these two patients. With the assistance of the hybrid-OR, the feeding artery was correctly ligated in all cases, and the intraoperative error obliteration rate decreased from 18.2% (2/11) to 0%. All 11 patients were followed for an average of 2 years. The ASIA score at 6 mo after the operation was significantly improved compared with the preoperative ASIA score, and there were no patients with late recurrence during the follow-up.

CONCLUSION

Compared with intra-arterial embolization for the treatment of SDAVFs, hybrid-ORs can solve the problem of a higher incidence of initial failure and late recurrence. Compared with direct occlusion of SDAVFs in microsurgery, hybrid-ORs can take advantage of the intraoperative DSA system for locating the shunt and verifying the obliteration of fistulae in order to reduce the error obliteration rate. At this point, our experience suggests that the safety and ease of use make hybrid-ORs combined with microsurgery and intraoperative DSA systems an attractive modality for dealing with SDAVFs.

Epidural Corticosteroids, Lumbar Spinal Drainage, and Selective Hemodynamic Control for the Prevention of Spinal Cord Ischemia in Thoracoabdominal Endovascular Aortic Repair: A New Clinical Protocol

INTRODUCTION

In patients undergoing thoracoabdominal aorta repair, spinal cord ischemia (SCI) remains one of the most common and important complications resulting in transient paraparesis through to permanent flaccid paraplegia. In this manuscript, after a brief introduction to spinal cord ischemia complication and its prevention in thoracoabdominal endovascular aortic repair (TEVAR), we propose a new clinical protocol potentially able to prevent such complication.

METHODS

The proposed protocol suggests the use of high dosages of corticosteroids by epidural route, along with drainage of cerebrospinal fluid and controlled vascular hypertension, to reduce the incidence of SCI in TEVAR. Moreover, we paid particular attention to the control of the hemodynamic parameters to obtain adequate peripheral tissue perfusion (oxygen delivery), including in the spinal cord.

RESULTS

We applied this new protocol in 50 consecutive patients treated with TEVAR for thoracoabdominal aortic aneurysms (TAAs); 47 patients completed the procedure: 27 patients Crawford type I and 20 Crawford type II. Three patients died during surgery because of untreatable aneurysm rupture. The results show that in all patients there were no cases of SCI, after 5 days from TEVAR.

DISCUSSION

To the best of our knowledge, there are no clinical studies on the use of epidural corticosteroids in patients undergoing treatment of aortic syndrome (both in "open surgery" and endovascular aortic repair). This initial study on 50 consecutive patients has shown that the clinical protocol used could be of great interest to prevent one of the worse complications of TEVAR. Its limitations are the low number of patients studied till now, and the non-randomized protocol adopted. Further studies would be necessary.

CONCLUSION

Our experience and the results obtained with this new perioperative protocol with epidural corticosteroid and accurate hemodynamic control have been encouraging and it seems a valid proposal to be explored in future by well-structured prospective, randomized protocols.

Spinal Cord Infarcts: Risk Factors, Management, and Prognosis

OPINION STATEMENT

There are no standard guidelines for treatment of spinal cord ischemia due to how rare it is and the diverse etiology and presentations involved. In addition, to date, there have been no large clinical trials examining ideal pharmacologic treatment options for spinal cord infarct. In our practice, we rely on hemodynamic augmentation initiated as soon as possible. Otherwise, treatment is usually geared towards the etiology of spinal cord ischemia. For instance, spinal cord ischemia occurring after aortic aneurysmal repair may improve with CSF drainage through a lumbar catheter in the periprocedural setting. Vertebral artery dissection should be treated with antithrombotics. If no clear etiology is found and there is evidence of atherosclerosis in other vascular beds, then management is focused on risk factor modification with blood pressure and glucose control, statins, and antithrombotics.

Delayed Hospital Presentation and Neuroimaging in Non-surgical Spinal Cord Infarction

BACKGROUND

Lack of timely recognition and neuroimaging may be a barrier to reperfusion efforts in acute spinal cord infarction.

METHODS

We performed a retrospective study of patients diagnosed with acute non-surgical spinal cord infarction at our tertiary academic center from 2001 to 2015. We studied parameters associated with time from symptom onset to initial hospital presentation and magnetic resonance imaging (MRI) of the spinal cord.

RESULTS

We identified 39 patients among whom anterior spinal artery syndrome was the most frequent presentation (87.2%) and atherosclerosis the most common etiology (56.4%). Nearly, half of the patients presented to the emergency department on the same day of symptom onset (48.7%) but only nine (23.1%) within the first 6 h. Average time from symptom onset to spinal cord MRI was 3.2 days. We could not identify clinical, radiological, or outcome patterns associated with early vs. delayed presentation and imaging.

DISCUSSION

Our study found a time lag from symptom onset to hospital presentation and spinal cord MRI in patients with acute spinal cord infarction. These findings point at low clinical suspicion of spinal cord syndromes and limited recognition as a potentially treatable medical emergency.

Current and emerging treatment options for spinal cord ischemia

Spinal cord infarction (SCI) is a rare but disabling disorder caused by a wide spectrum of conditions. Given the lack of randomized-controlled trials, contemporary treatment concepts are adapted from guidelines for cerebral ischemia, atherosclerotic vascular disease, and acute traumatic spinal cord injury. In addition, patients with SCI are at risk for several potentially life-threatening but preventable systemic and neurologic complications. Notably, there is emerging evidence from preclinical studies for the use of neuroprotection in acute ischemic injury of the spinal cord. In this review, we discuss the current state of the art for the therapy and prevention of SCI and highlight potential emerging treatment concepts awaiting translational adoption.

Nontraumatic spinal cord injury at the neurological intensive care unit: spectrum, causes of admission and predictors of mortality

OBJECTIVE

Nontraumatic spinal cord injuries (NTSCIs) form a heterogeneous group of diseases, which may evolve into a life-threatening condition. We sought to characterize spectrum, causes of admission and predictors of death in patients with NTSCI treated at the neurological intensive care unit (NICU).

METHODS

We performed a retrospective observational analysis of NTSCI cases treated at a tertiary care center between 2001 and 2013. Among the 3937 NICU admissions were 93 patients with NTSCI (2.4%). Using multivariate logistic regression analysis, we examined predictors of mortality including demographics, etiology, reasons for admission and GCS/SAPS (Glasgow Coma Scale/Simplified Acute Physiology Score) scores.

RESULTS

Infectious and inflammatory/autoimmune causes made up 50% of the NTSCI cases. The most common reasons for NICU admission were rapidly progressing paresis (49.5%) and abundance of respiratory insufficiency (26.9%). The mortality rate was 22.6% and 2.5-fold higher than in the cohort of all other patients treated at the NICU. Respiratory insufficiency as the reason for NICU admission [odds ratio (OR) 4.97, 95% confidence interval (CI) 1.38-17.9; p < 0.01], high initial SAPS scores (OR 1.04; 95% CI 1.003-1.08; p = 0.04), and the development of acute kidney injury throughout the stay (OR 7.25, 1.9-27.5; p = 0.004) were independent risk factors for NICU death.

CONCLUSIONS

Patients with NTSCI account for a subset of patients admitted to the NICU and are at risk for adverse outcome. A better understanding of predisposing conditions and further knowledge of management of critically ill patients with NTSCI is mandatory.

Spinal cord hemorrhage in a patient with neurosarcoidosis on long-term corticosteroid therapy: case report

BACKGROUND

Central nervous system bleeding is a rare complication of neurosarcoidosis: only 18 cases of spontaneous cerebral hematoma have been reported. We present the first recorded case of spinal cord hemorrhage in neurosarcoidosis.

CASE PRESENTATION

A 48-year-old Caucasian woman had relapsing neurosarcoidosis for 5 years, with inflammatory spinal and cerebral lesions. While on 20 mg corticosteroids, she experienced subacute paraparesia with right leg pain. A spine MRI revealed a low thoracic hematomyelia at the T10-T11 level. Despite high doses of corticosteroids, her condition continued to worsen. Surgical evacuation of the hematoma was performed 10 days after the onset of bleeding, and she partially recovered.

CONCLUSION

This report highlights the possibility of spinal cord hemorrhage secondary to sarcoid vasculitis. The patient improved after surgical evacuation of the intramedullary hematoma. Immuno-modulating agents must be envisaged in severe neurosarcoidosis, to prevent complications.

Completely extradural intraspinal arteriovenous malformation in the lumbar spine: a case report

Introduction

Spinal vascular malformations can be classified in arteriovenous malformations, cavernomas, and capillary telangiectasias. Arteriovenous malformations are the most common spinal vascular anomaly and may be located intra- and/or perimedullary. According to their nidus type and hemodynamic flow patterns, they can be differentiated into fistulous, glomerular and juvenile categories. In our case, a hyperintense extradural mass was misinterpreted as a neurinoma. The histological analysis revealed typical signs of an arteriovenous malformation.

Case presentation

A 57-year-old Caucasian woman presented with back pain and hypesthesia in digiti two to four of her left foot. Magnetic resonance imaging showed a long-segment intraspinal extradural soft-tissue mass in the left L4 - S1 paravertebral region with homogeneous enhancement of contrast medium. Due to another similar lesion in the lower ankle and additional cutaneous manifestations, the suspected diagnosis was a systemic disease with neurinomas (e.g. Recklinghausen’s disease). To clear up the origin and type of this lesion exploratory surgery with a hemilaminectomy of L5 was performed. This showed abnormally arterialized, dilated, and tortuous vessels. After complete resection, the intra-operative impression of an arteriovenous malformation was confirmed by a neuropathologist.

Conclusions

Completely extradural intraspinal arteriovenous malformations in the lumbar spine are extremely rare. In magnetic resonance imaging they are often misinterpreted as a tumor. Arteriovenous malformations can cause compression and venous congestion, or mask symptoms like a spinal disk herniation.

In cases presenting with these symptoms and magnetic resonance imaging findings, an extradural intraspinal arteriovenous malformation should be considered as a possible diagnosis. Pre-operative angiography or magnetic resonance imaging angiography can be used to verify the diagnosis.

Comparison of surgical and endovascular approach in management of spinal dural arteriovenous fistulas: A single center experience of 27 patients

Background:

Spinal dural arteriovenous fistula (SDAVF) is a rare spinal vascular malformation with an annual incidence of 5-10 cases per million. The data on efficacy, recurrence rates and complications of endovascular versus surgical treatment of SDAVF is limited.

Methods:

We conducted a retrospective chart review of 27 adult patients with a diagnosis of SDAVF and who underwent treatment at Duke University Hospital between January 1, 1993 and December 31, 2012. We compared the outcome measures by Aminoff–Logue score (ALS) in patients who underwent treatment with endovascular embolization versus surgical ligation of fistula. We compared complication rates, recurrence rates as well as data on long-term follow up in these patients.

Results:

Out of 27 patients in the study, 10 patients underwent endovascular embolization (Onyx was used in 5 patients and NBCA in 5 patients) as the first line therapy. Seventeen patients underwent surgical ligation as initial therapeutic modality. Patients in both groups showed significant improvement in clinical status (ALS) after treatment. One patient in endovascular group developed spinal infarction due to accidental embolization of medullary artery. Three patients in embolization group had recurrence of fistula during the course of follow up requiring surgical ligation. Two patients in surgical group developed local wound infection. None of the patients in surgical group had recurrence of fistula during the course of follow up.

Conclusions:

Endovascular embolization and surgical ligation are effective treatment strategies for SDAVF. Our observations show that surgical ligation may offer permanent cure without any recurrence. Endovascular approach is associated with higher incidence of recurrence, especially with use of onyx.