Venous hypertensive myelopathy as a potential mimic of transverse myelitis

Revisiting the Vertebral Venous Plexus-A Comprehensive Review of the Literature

The venous drainage of the vertebral and paravertebral regions is important for a better understanding of hematogenous disease spread. Moreover, the spine surgeon must be well acquainted with this anatomy to minimize intraoperative and postoperative complications. A comprehensive review of the vertebral venous plexus (Batson plexus) was performed with a concentration on the clinical and surgical correlations of this venous network.

Analysis of spinal angiograms that missed diagnosis of spinal vascular diseases with venous hypertensive myelopathy: the non-technical factors

PURPOSE

Spinal DSA is the "gold standard" technique to identify the spinal vascular diseases with venous hypertensive myelopathy (VHM). However, sometimes spinal DSA can find nothing in patients with confirmed spinal vascular anomalies. Many of the reasons are avoidable technical factors. Nevertheless, there are also some non-technical factors. The objective of this study was to identify the non-technical factors.

METHODS

The cause of the missed findings was found as the non-technical factors in 14 patients. The clinical records and radiological findings of the 14 patients were reviewed.

RESULTS

The so-called standard spinal angiography can found nothing in the 14 patients. Additional angiography was performed and detected the lesions. Eight patients were found lesions supplied by carotid arteries or iliac arteries, including 2 cranial DAVF with internal carotid artery blood supply, 3 cranial DAVF with external carotid artery blood supply and 2 pelvic AVF with internal iliac artery blood supply and 1 pelvic AVM with internal iliac artery blood supply. Six patients were caused by stenosis of spinal draining vein, including 3 stenosis of the third lumbar veins and 3 stenosis of left renal veins combined with the reno-spinal trunk.

CONCLUSIONS

In order to avoid the missed findings of spinal vascular diseases with VHM, the technical factors should be reduced by performing a rigorous comprehensive angiography. To reduce the non-technical factors, the angiography of the internal iliac artery, the carotid artery systems and spinal draining veins should be performed in some special cases if the routine spinal angiography can find nothing.

High field structural MRI in the management of degenerative cervical myelopathy

Introduction: This is a narrative overview of the pathophysiology, investigation and management of Degenerative Cervical Myelopathy (DCM). This review article also takes a look ahead to the impact high resolution MRI may have on treatment.Background: DCM is the most common cause of spinal dysfunction and yet it remains poorly understood. It is becoming increasingly common in our ageing population. Disc and facet joint abnormalities, osteophytes, spondylothisthesis and ligamentous hypertrophy all act together to produce spinal canal and neuronal foramina stenosis which in turn causes neural compromise. Its impact on the quality of life of this patient group and the wider economy is vast. Some patients with overt cord compression and MRI signal change in their cervical cord may only have subtle clinical signs whilst others with less striking imaging may be profoundly myelopathic. Who to operate on and when remains a neurosurgical dilemma in this group of patients.Methods: A number of articles with a broad variation in methodology were reviewed and referenced during the production of this paper.Results: This paper is a narrative review. The results presented in all the referenced articles were considered.Conclusion: The process of developing new imaging techniques will give a greater understanding of the causes of the symptoms of DCM and in a wider context facilitate further surgical and medical strategies that are more cost effective and beneficial to patients. The advent of 7T MRI or further optimisation of safer 3T MRI sequences may soon provide this opportunity and the diagnostic gap in spinal cord imaging can begin to close.

Venous hypertensive myelopathy associated with cervical spondylosis

BACKGROUND CONTEXT

Venous hypertensive myelopathy (VHM) results from spinal vascular malformations of arteriovenous shunting that increases spinal venous pressure, leading to congestive edema and neurologic dysfunction. There has been no report of VHM associated with cervical spondylotic myelopathy (CSM).

PURPOSE

The aim of this study was to report an extremely rare case of VHM likely due to CSM.

STUDY DESIGN

This study is a case report and review of the literature.

PATIENT SAMPLE

The patient was a 51-year-old man with CSM exhibiting relatively rapid neurologic deterioration with an abnormal expansion of a centromedullary hyperintense lesion on T2-weighted magnetic resonance imaging (MRI) in the absence of traumatic injury.

METHODS

Neurologic examination and radiologic imaging were taken by various means.

RESULTS

The patient developed a cervical radiculopathy, followed by gait disturbance and motor weakness. The MRI of the cervical spine demonstrated spinal canal stenosis due to disc bulging and flavum hypertrophy at the C5/C6 and C6/C7 levels as well as hyperintense area over the C5-C7 levels on T2-weighted images. Although decompression surgery was planned, an acute inflammatory process such as transverse myelitis or demyelinating disease other than cord compression was also considered, and the patient received intravenous steroids. His walking improved for several days. However, his symptoms then became significantly worse, and he had difficulty walking. Subsequent MRI demonstrated marked progression of the T2 hyperintense lesion over the C4-T1 vertebral levels. Flow voids were also noted on the dorsal surface of the upper cervical cord on T2-weighted MRI. His lab work, medical history, and the local enhancement on contrast-enhanced MRI indicated low probability of spinal inflammatory diseases. Therefore, the decision was made to perform anterior cervical discectomy and fusion surgery on two levels. Following surgery, his symptoms improved promptly.

CONCLUSIONS

Our case indicates that VHM could be caused by spondylotic cord compression in the absence of spinal vascular malformations. The diagnostic features for VHM are progressive deterioration of myelopathy, easing/worsening of symptoms associated with postural changes, and centromedullary hyperintensity over multiple segments and the flow voids on dorsal surface of the spinal cord on T2-weighted MRI.

Early and extensive spinal white matter involvement in neuromyelitis optica

OBJECTIVES

Studies of longitudinally extensive spinal cord lesions (LESCLs) in neuromyelitis optica (NMO) have focused on gray matter, where the relevant antigen, aquaporin-4 (AQP4), is abundant. Because spinal white matter pathology in NMO is not well characterized, we aimed to clarify spinal white matter pathology of LESCLs in NMO.

METHODS

We analyzed 50 spinal cord lesions from eleven autopsied NMO/NMO spectrum disorder (NMOSD) cases. We also evaluated LESCLs with three or fewer spinal cord attacks by 3-tesla MRI in 15 AQP4 antibody-positive NMO/NMOSD patients and in 15 AQP4 antibody-negative multiple sclerosis (MS) patients.

RESULTS

Pathological analysis revealed seven cases of AQP4 loss and four predominantly demyelinating cases. Forty-four lesions from AQP4 loss cases involved significantly more frequently posterior columns (PC) and lateral columns (LC) than anterior columns (AC) (59.1%, 63.6%, and 34.1%, respectively). The posterior horn (PH), central portion (CP), and anterior horn (AH) were similarly affected (38.6%, 36.4% and 31.8%, respectively). Isolated perivascular inflammatory lesions with selective loss of astrocyte endfoot proteins, AQP4 and connexin 43, were present only in white matter and were more frequent in PC and LC than in AC (22.7%, 29.5% and 2.3%, P^corr  = 0.020, and P^corr  = 0.004, respectively). MRI indicated LESCLs more frequently affected PC and LC than AC in anti-AQP4 antibody-seropositive NMO/NMOSD (86.7%, 60.0% and 20.0%, P^corr  = 0.005, and P^corr  = 0.043, respectively) and AQP4 antibody-seronegative MS patients (86.7%, 73.3% and 33.3%, P^corr  = 0.063, and P^corr  = 0.043, respectively). PH, CP and AH were involved in 93.3%, 86.7% and 73.3% of seropositive patients, respectively, and in 53.3%, 60.0% and 40.0% of seronegative patients, respectively.

CONCLUSIONS

NMO frequently and extensively affects spinal white matter in addition to central gray matter, especially in PC and LC, where isolated perivascular lesions with astrocyte endfoot protein loss may emerge. Spinal white matter involvement may also appear in early NMO, similar to cerebral white matter lesions.

Venous drainage of the spine and spinal cord: a comprehensive review of its history, embryology, anatomy, physiology, and pathology

Venous drainage of the spine and spinal cord is accomplished through a complex network of venous structures compartmentalized to intrinsic, extrinsic, and extradural systems. As the literature on this topic is scarce, the following review was performed to summarize the available literature into a single coherent format. The medical literature on the spinal venous system was reviewed using online sources as well as historical documents that were not available online in regard to history, embryology, anatomy, and physiology with a particular emphasis on the pathology affecting this system. The spinal venous system is complex and variable. Proper understanding of all aspects is critical for the management of the pathology that results from its failure.

Histologically proven venous congestive myelopathy without concurrent vascular malformation: Case reports and review of the literature

BACKGROUND

Venous congestive myelopathy is a progressive myelopathy that is generally caused by a spinal dural arteriovenous fistula.

CASE DESCRIPTION

We report a patient with histologically confirmed venous congestive myelopathy without concurrent vascular malformations in radiological and intraoperative findings.

CONCLUSIONS

The definitive underlying etiology of this congestive myelopathy was unclear. However, this case report highlights the possibility of venous congestive myelopathy with etiology other than a dural arteriovenous fistula. Further, a systematic and elaborate examination should be undertaken to explore the underlying pathology whenever this type of spinal parenchymal lesion is detected.

Subacute progressive ascending myelopathy following spinal cord injury: MRI appearances and clinical presentation

STUDY DESIGN

Retrospective Case Review.

OBJECTIVES

To describe the clinical presentation and course of patients with magnetic resonance imaging (MRI) features of subacute progressive ascending myelopathy (SPAM). A rare complication of spinal cord injury.

SETTING

National Spinal Injuries Centre, Stoke Mandeville Hospital, UK.

MATERIALS AND METHODS

A retrospective review of the case notes and MRI studies of 11 cases with typical MRI features of ascending myelopathy presenting to a tertiary Spinal Injuries centre over a 15-year period.

RESULTS

Eleven patients were identified with MRI features typical of SPAM, a median of 13 days (mean 24, range 4-86 days) following cord injury. The median number of cord segments involved above the initial insult was 6 (mean 6.2, range 4-11). MRI appearances include extension four or more segments cephalad to the initial cord injured segment, cord expansion and increased intramedullary T2 signal with a rim of cord sparing peripherally. Cord changes and neurological deficits improved over time but did not return to the initial injured level on MRI. One patient died (mortality 9%).

CONCLUSION

SPAM is a rare cause of neurological deterioration following spinal cord injury but may remain subclinical. SPAM most commonly presents as neurological deterioration but may present with shoulder pain, respiratory deterioration or remain subclinical. There are characteristic MRI appearances. It can be fatal.