Neurosarcoidosis involving cervical nerve root with unusual MRI findings: a case report and systematic literature review

BACKGROUND

Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature.

METHODS

We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review.

RESULTS

A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2 months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3-C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node.

CONCLUSIONS

This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course.

Proximal nerve MR neurography with diffusion tensor imaging in differentiating subtypes of Charcot-Marie-Tooth disease

OBJECTIVES

To evaluate the feasibility of proximal nerve MR neurography with diffusion tensor imaging (DTI) for differentiating Charcot-Marie-Tooth (CMT) 1A, CMT2, and healthy controls.

METHODS

The diameters, fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) of L4-L5 nerve roots, femoral nerve (FN), and sciatic nerve (SN) were compared. Receiver operating characteristic (ROC) curve analyses were conducted to evaluate the diagnostic performance. DeLong's tests were applied to compare multiple ROC curves. Intraclass correlation coefficients were calculated for interobserver agreement assessment.

RESULTS

The diameters of the L4 nerve root, L5 nerve root, and SN of CMT1A patients were significantly larger than those of CMT2 patients and healthy controls. The FA values of all measured proximal nerves were significantly higher in controls (0.46 ± 0.09, 0.46 ± 0.08, 0.45 ± 0.07, and 0.48 ± 0.08) than in CMT1A patients (0.30 ± 0.09, 0.29 ± 0.06, 0.35 ± 0.08, and 0.29 ± 0.09). The FA values of the L5 nerve root, FN, and SN were significantly higher in controls (0.46 ± 0.08, 0.45 ± 0.07, and 0.48 ± 0.08) than in CMT2 patients (0.36 ± 0.06, 0.34 ± 0.07, and 0.34 ± 0.10). The MD and RD values of the L5 nerve root in CMT1A patients (1.59 ± 0.21 and 1.37 ± 0.21) were higher than those in CMT2 patients (1.31 ± 0.17 and 1.05 ± 0.14). The AUCs of the above parameters ranged from 0.780 to 1.000. For the measurements of nerve diameters, the ICC ranged from 0.91 to 0.97. For the measurements of DTI metrics, the ICC ranged from 0.87 to 0.97.

CONCLUSIONS

MR neurography with DTI is able to differentiate CMT1A patients, CMT2 patients, and healthy controls.

KEY POINTS

• MR neurography with diffusion tensor imaging of the L4-5 nerve roots, proximal femoral nerve, and proximal sciatic nerve is able to discriminate CMT1A, CMT2, and healthy controls. • This method provides an alternative for the diagnosis and discrimination of CMT1A and CMT2, which is crucial for clinical management.

Muscle responses to radicular stimulation during lumbo-sacral dorsal rhizotomy for spastic diplegia: Insights to myotome innervation

OBJECTIVE

Most of knowledge on muscle radicular innervation was from explorations in root/spinal cord pathologies. Direct and individual access to each of the lumbar-sacral -ventral and dorsal- nerve roots during dorsal rhizotomy for spastic diplegia allows precise study of the corresponding muscle innervation. Authors report the lumbo-sacral segmental myotomal organization obtained from recordings of muscle responses to root stimulation in a 20-children prospective series.

METHODS

Seven key-muscles in each lower limb and anal sphincter were Electromyography (EMG)-recorded and clinically observed by physiotherapist during L2-to-S2 dorsal rhizotomy. Ventral roots (VR), for topographical mapping, and dorsal roots (DR), for segmental excitability testing, were stimulated, just above threshold for eliciting muscular response.

RESULTS

In 70% of the muscles studied, VR innervation was pluri-radicular, from 2-to-4 roots, with 1 or 2 roots being dominant at each level. Overlapping was important. Muscle responses to DR stimulation were 1.75 times more extended compared to VR stimulation. Inter-individual variability was important.

CONCLUSIONS

Accuracy of root identification and stimulation with the used method brings some more precise information to radicular functional anatomy.

SIGNIFICANCE

Those neurophysiological findings plead for performing Intra-Operative Neuromonitoring when dealing with surgery in the lumbar-sacral roots.

Neurophysiological monitoring of lumbar spinal nerve roots: A case report of postoperative deficit and literature review

INTRODUCTION

Intraoperative neurophysiological monitoring (IONM) has proven to help reduce the probability of postoperative neurological deficit for spinal deformity correctional surgeries. However, in rare cases new deficits may still happen. We report a surgical case in which the patient had postoperative paralysis. We would like to call for more case reports with postoperative neurological deficits as they present difficult clinical cases.

PRESENTATION OF CASE

A 61-year-old male patient with severe thoracolumbar kyphoscoliosis underwent posterior spinal correction and fusion with segmental T10-L5 pedicle screws and rods instrumentation with IONM. The only intraoperative event was a pedicle breach at left L3 which was detected by triggered electromyography (EMG) testing, and the pedicle screw was repositioned. Left lower extremity paralysis was observed upon patient awakening. He received rehabilitation treatment and had limited recovery of muscle strength. Partial lumbar nerve root injury was likely the cause of the paralysis.

DISCUSSION

This is a case with new lumbar nerve root deficit, with positive EMG signal change, but negative somatosensory evoked potential (SSEP) and motor evoked potential (MEP) findings. We discuss the different neurophysiological modalities for monitoring lumbar spinal nerve root function. We review journal articles from the past two decades which reported lumbar root deficits, and list neuromonitoring events during the surgeries.

CONCLUSION

Multimodality monitoring with spontaneous and electrically triggered EMG combined with SSEP and MEP may provide the best chance to detect lumbar nerve root injuries.

The feasibility study of extradural nerve anastomosis technique for canine bladder reinnervation after spinal cord injury

OBJECTIVE

Intradural nerve anastomosis for bladder innervation has been demonstrated to be useful. However, its clinical application remains limited because of the complex surgery, its complications and extensive bony destruction. The purpose of the current study was to demonstrate the feasibility of extradural spinal root anastomosis for bladder innervation in canines.

METHODS

Ten beagle dogs were used. The length of the extradural segment of the nerve root, upper nerve root outlet (the point at which it emerges from the spinal dura mater) to S2 (dS2), the S3 (dS3) nerve root outlet distance, and the diameters of the extradural spinal roots were measured. The numbers of nerve fibers from L6 to S3 ventral roots were calculated using immunohistochemical staining.

RESULTS

The extradural spinal roots could be divided into a ventral root (VR) and a dorsal root (DR) before the ganglionic enlargement of the dorsal root, and the extradural motor nerve roots situate ventrally to their corresponding sensory nerve roots. The extradural nerve root lengths of S1 and parts of L7 were longer than the corresponding dS2. The numbers of nerve and motor nerve fibers, and the diameters of extradural nerve roots, were gradually descending from L6 to S3.

CONCLUSION

The S1 VRs and parts of the L7 VRs can be extradurally anastomosed to the S2 nerves without tension. A nerve graft was needed for extradural anastomosis of L6 VRs and parts of L7 VRs to S2 VRs. This study demonstrated the feasibility of extradural spinal nerve anastomosis for treating neurogenic bladder in canines.

Diagnostic values of ProSet magnetic resonance coronal source imaging for detecting symptomatic lesion in multiple lumbar foraminal stenosis

OBJECTIVE

The aim of this study is to evaluate the values of ProSet magnetic resonance coronal source imaging (ProSet MR imaging) as a diagnostic tool for detecting symptomatic lesion in patients with multiple lumbar foraminal stenosis.

PATIENTS AND METHODS

From January 2011 to June 2015, 46 patients with unilateral and single-level radiculopathy developed from foraminal stenosis were enrolled in the study. These diagnoses were confirmed with transforaminal selective nerve root block (SNRB) and electrophysiological testing, including electromyography and nerve conduction velocity (EMG/NCV) tests. The detection of symptomatic lesion among multiple lumbar foraminal stenosis was done by identification of spinal nerve swelling (NS) and/or running course abnormalities (RCA) observed on ProSet MR imaging. These results were compared with those from transforaminal SNRB testing and conventional MR imaging. Evaluations were performed blinded by two independent examiners.

RESULTS

The diagnostic accuracy rates of the two examiners were 84.7% and 82.6% with a 0.835 kappa coefficient. NS (80.4%) showed a higher diagnostic accuracy rate compared to RCA (69.6%) for detecting symptomatic lesion. The presence or absence of both NS and RCA has a stronger relationship with symptomatic or non-symptomatic lesion compared to the relationship of either alone (p=0.00).

CONCLUSION

ProSet MR imaging is a simple and helpful method for providing additional diagnostic accuracy to detect symptomatic lesion in patients with multiple foraminal stenosis. NS representing chemical radiculitis was more reliable diagnostic factor of ProSet MR imaging.

Spinal Nerve Root Enhancement on MRI Scans in Children: A Review

Spinal nerve root enhancement in pediatric patients is generally nonspecific, and clinical and laboratory correlation is essential. Nerve root enhancement indicates lack of integrity of the blood-nerve barrier. In this review, we will present a range of pediatric conditions that can present with spinal nerve root enhancement including inflammatory, infectious, hereditary, and neoplastic causes. Familiarity with the various pathologic entities associated with spinal nerve root enhancement is important for a concise differential diagnosis in the appropriate clinical setting. This will avoid unnecessary additional investigations.

The Efficacy and Persistence of Selective Nerve Root Block under Fluoroscopic Guidance for Cervical Radiculopathy

STUDY DESIGN

Retrospective study.

OBJECTIVES

To investigate the outcomes of fluoroscopically guided selective nerve root block as a nonsurgical treatment for cervical radiculopathy.

OVERVIEW OF LITERATURE

Only a few studies have addressed the efficacy and persistence of cervical nerve root block.

METHODS

This retrospective study was conducted on 28 consecutive patients with radicular pain due to cervical disc disease or cervical spondylosis. Myelopathy was excluded. Cervical nerve root blocks were administered every 2 weeks, up to 3 times. Outcomes were measured by comparing visual analogue scale (VAS) scores, patient satisfaction, and medication usage before the procedure and at 1 week and 3, 6, and 12 months after the procedure. In addition, complications associated with the procedure and need for other treatments were evaluated.

RESULTS

The average preoperative VAS score was 7.8 (range, 5 to 10), and this changed to 2.9 (range, 1 to 7) at 3 months and 4.6 (range, 2 to 7) at 12 months. Patient satisfaction was 71% at 3 months and 50% at 12 months. Five patients used medication at 3 months, whereas 13 used medication at 12 months. Average symptom free duration after the procedure was 7.8 months (range, 1 to 12 months). Two patients were treated surgically. Only two minor complications were noted; transient ptosis with Horner's syndrome and transient causalgia.

CONCLUSIONS

Although selective nerve root block for cervical radiculopathy is limited as a definitive treatment, it appears to be useful in terms of providing relief from radicular pain in about 50% of patients at 12 months.

Differentiation between symptomatic and asymptomatic extraforaminal stenosis in lumbosacral transitional vertebra: role of three-dimensional magnetic resonance lumbosacral radiculography

OBJECTIVE

To investigate the role of lumbosacral radiculography using 3-dimentional (3D) magnetic resonance (MR) rendering for diagnostic information of symptomatic extraforaminal stenosis in lumbosacral transitional vertebra.

MATERIALS AND METHODS

The study population consisted of 18 patients with symptomatic (n = 10) and asymptomatic extraforaminal stenosis (n = 8) in lumbosacral transitional vertebra. Each patient underwent 3D coronal fast-field echo sequences with selective water excitation using the principles of the selective excitation technique (Proset imaging). Morphologic changes of the L5 nerve roots at the symptomatic and asymptomatic extraforaminal stenosis were evaluated on 3D MR rendered images of the lumbosacral spine.

RESULTS

Ten cases with symptomatic extraforaminal stenosis showed hyperplasia and degenerative osteophytes of the sacral ala and/or osteophytes at the lateral margin of the L5 body. On 3D MR lumbosacral radiculography, indentation of the L5 nerve roots was found in two cases, while swelling of the nerve roots was seen in eight cases at the exiting nerve root. Eight cases with asymptomatic extraforaminal stenosis showed hyperplasia and degenerative osteophytes of the sacral ala and/or osteophytes at the lateral margin of the L5 body. Based on 3D MR lumbosacral radiculography, indentation or swelling of the L5 nerve roots was not found in any cases with asymptomatic extraforaminal stenosis.

CONCLUSION

Results from 3D MR lumbosacral radiculography Indicate the indentation or swelling of the L5 nerve root in symptomatic extraforaminal stenosis. Based on these findings, 3D MR radiculography may be helpful in the diagnosis of the symptomatic extraforaminal stenosis with lumbosacral transitional vertebra.

Transient quadriplegia after fluoroscopic-guided selective cervical nerve root block in a patient who received cervical interbody fusion -A case report-

Selective cervical nerve root block is executed for patients who have symptoms of cervical radiculopathy for diagnostic and therapeutic purposes. However several catastrophic complications caused by this procedure have been reported including neurological complications. A 43-year-old male received a C5 selective cervical nerve root block procedure due to continuous radiating pain even after cervical discectomy and interbody fusion was performed. At the time of the procedure, the contrast outline revealed reflux of the nerve root and epidural space. But after the procedure was performed, the patient experienced decreased sensation in the upper and low extremities as well as motor paralysis of both extremities. Our sspecting diagnosis was anterior spinal artery syndrome but both sensory and motor functions were subsequently recovered within a few hours after the procedure was completed. Due to the difficult nature of this case, we reported these complications and reviewed current literature related to this study.