Spinal cord injury in a 14-year-old male secondary to cervical hyperflexion with exercise

Neurological Deterioration Immediately After Lumbar Surgery: Anesthetic Consideration for Co-existing Cervical Lesion: A Case Report

Most spine surgeons and anesthesiologists believe that the risk of spinal cord injury (SCI) during intubation is mainly due to mechanical compression of the spinal cord due to cervical spine movement in cases of undiagnosed but severe cervical lesions. With this reasoning, difficult intubation, which is more frequently encountered in patients with preexisting cervical diseases, is likely to result in SCI. Several reports have described SCI after non-cervical surgery in patients previously diagnosed with cervical myelopathy and a chronically compressed cervical cord; however, to date, there is less acknowledgement of SCI in patients with undiagnosed cervical myelopathy. Here, we report a painful experience of neurological deterioration that developed immediately after elective lumbar decompressive surgery in a 76-year-old man. The possible mechanism behind these unexpected complications is discussed in a review of the literature.

Addition of lateral bending range of motion measurement to standard sagittal measurement to improve diagnosis sensitivity of ligamentous injury in the human lower cervical spine

PURPOSE

This study examined the cervical spine range of motion (ROM) resulting from whiplash-type hyperextension and hyperflexion type ligamentous injuries, and sought to improve the accuracy of specific diagnosis of these injuries.

METHODS

The study was accomplished by measurement of ROM throughout axial rotation, lateral bending, and flexion and extension, using a validated finite element model of the cervical spine that was modified to simulate hyperextension and/or hyperflexion injuries.

RESULTS

It was found that the kinematic difference between hyperextension and hyperflexion injuries was minimal throughout the combined flexion and extension ROM measurement that is commonly used for clinical diagnosis of cervical ligamentous injury. However, the two injuries demonstrated substantially different ROM under axial rotation and lateral bending.

CONCLUSIONS

It is recommended that other bending axes beyond flexion and extension are incorporated into clinical diagnosis of cervical ligamentous injury.

Neurological deterioration during intubation in cervical spine disorders

Anaesthesiologists are often involved in the management of patients with cervical spine disorders. Airway management is often implicated in the deterioration of spinal cord function. Most evidence on neurological deterioration resulting from intubation is from case reports which suggest only association, but not causation. Most anaesthesiologists and surgeons probably believe that the risk of spinal cord injury (SCI) during intubation is largely due to mechanical compression produced by movement of the cervical spine. But it is questionable that the small and brief deformations produced during intubation can produce SCI. Difficult intubation, more frequently encountered in patients with cervical spine disorders, is likely to produce greater movement of spine. Several alternative intubation techniques are shown to improve ease and success, and reduce cervical spine movement but their role in limiting SCI is not studied. The current opinion is that most neurological injuries during anaesthesia are the result of prolonged deformation, impaired perfusion of the cord, or both. To prevent further neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and positioning for surgery are essential. The features that diagnose laryngoscopy induced SCI are myelopathy present on recovery, short period of unconsciousness, autonomic disturbances following laryngoscopy, cranio-cervical junction disease or gross instability below C3. It is difficult to accept or refute the claim that neurological deterioration was induced by intubation. Hence, a record of adequate care at laryngoscopy and also perioperative period are important in the event of later medico-legal proceedings.

Central cord syndrome in a 7-year-old boy secondary to standing high jump

Acute traumatic central cord syndrome is commonly associated with major trauma such as falling and motor vehicle crash, but minor or nontraumatic causes are very rare in children. As a consequence, most physicians frequently overlook children presenting with complaints of arm weakness when history of any definite major trauma does not exist, especially in the emergency department. We present the case of a 7-year-old boy who was experiencing weakness in both arms after a standing high jump with tilting his head back in school. He had no history of any definite trauma and no evidence of bone abnormalities on plain radiography and computed tomography of the cervical spine. Magnetic resonance imaging of the cervical spine revealed observable swelling with increased signal intensity at C1 to 4 levels. This case showed a spinal cord injury caused by standing high jump with neck extension alone. Therefore, the physicians have to consider the possibility of spinal cord injury even without any history of major trauma.

The effects of ligamentous injury in the human lower cervical spine

Damage is often sustained by the anterior longitudinal ligament (ALL) and ligamentum flavum (LF) in the cervical spine subsequent to whiplash or other cervical trauma. These ligaments afford substantial cervical stability when healthy, but the ability of the ALL and LF to stabilize the spine when injured is not as conclusively studied. In order to address this issue, the current study excised ALL and LF tissues from cadaveric spines and experimentally simulated whiplash-type damage to the isolated ligaments. Stiffnesses and toe region lengths were measured for both the uninjured and damaged states. These ligamentous mechanical properties were then inputted into a previously-validated finite element (FE) model of the cervical spine and the kinematic effects of various clinically relevant combinations of ligamentous injury were predicted. The data indicated three and five-fold increases in toe region length for the LF and ALL injury variants, respectively. These toe length distensions resulted in FE predictions of supra-physiologic ranges of motion, and these motions were comparable to spines with no ligamentous support. Finally, a set of cadaveric cervical spine ligament-sectioning experiments confirmed the FE predictions and supported the finding that partial injury to the relevant ligaments produces equivalent cervical kinematic signatures to spines that have completely compromised ALL and LF tissues.

Dropped-head syndrome resulting from injury to the central spinal cord at the upper cervical level

There are many causes of paraspinal muscle weakness which give rise to the dropped-head syndrome. In the upper cervical spine the central portion of the spinal cord innervates the cervical paraspinal muscles. Dropped-head syndrome resulting from injury to the central spinal cord at this level has not previously been described. We report two patients who were treated acutely for this condition. Both presented with weakness in the upper limbs and paraspinal cervical musculature after a fracture of C2. Despite improvement in the strength of the upper limbs, the paraspinal muscle weakness persisted in both patients. One ultimately underwent cervicothoracic fusion to treat her dropped-head syndrome.

While the cause of the dropped-head syndrome cannot be definitively ascribed to the injuries to the spinal cord, this pattern is consistent with the known patho-anatomical mechanisms of both injury to the central spinal cord and dropped-head syndrome.

Spinal cord infarction following cricotracheal resection

We report a case of an 18-year-old female who was referred to our institution after incurring a permanent quadriplegia resulting from spinal cord infarction following cricotracheal resection. Methods were case report and review of the literature. A tracheal stenosis had resulted from long-term intubation after premature birth, followed by tracheotomy after 1 year, surgical revision at 4 years of age and a spontaneous closure at the age of 6 after decannulation. At the age of 18, a cricotracheal resection was performed at another institution. At the termination of the procedure, a chin-to-chest suture was placed to prevent unintentional hyperextension of the neck. She was extubated on the third postoperative day, however, serious dyspnea required repeated re-intubation for 2 days thereafter. She developed paraplegia on the sixth postoperative day, prompting an MRI to be performed, which identified spinal cord edema. Intravenous administration of steroids in high doses was ineffective and unfortunately the patient has remained severely impaired since then. Permanent quadriplegia is a complication of cricotracheal resection with chin-to-chest sutures and should be included in the informed consent process. Therefore, a daily postoperative neurological examination should be performed in these patients. Immediate MRI should be performed if any abnormal findings are seen to verify the diagnosis. Quadriplegia in this setting likely resulted from compromised blood supply with concomitant edema, however, the exact cause of injury remains unclear: despite having chin-to-chest sutures, the patient's head remained in neutral position and was not in hyperflexion. Such an injury is likely more susceptible to steroid therapy if diagnosed as early as possible.

Intraperitoneal rupture of mature cystic ovarian teratoma secondary to sit-ups

A case of general peritonitis caused by sudden perforation of a mature cystic ovarian teratoma is presented. The clinical course consisted of progressive abdominal tenderness after a 1600-m run and 12 subsequent sit-ups. An exploratory laparotomy revealed massive ascites and a 10-cm linear perforation over the dome of the tumor, probably caused by a sharp elevation of intra-abdominal pressure generated during the sit-ups. Neither peritoneal granulomatous reaction nor inflammatory adhesions to adjacent bowel loops were found. A search of the English literature did not reveal any similar case.