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Kato T, Imai K, Yamada T, Cho M, Sai T, Ioku T. [Early diagnosis of a long spinal cord infarction lesion based on concurrent erector spinae muscle infarction: a case report]. Rinsho Shinkeigaku 2024; 64:890-897. [PMID: 39566962 DOI: 10.5692/clinicalneurol.cn-002029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2024]
Abstract
We present a case of a 53-year-old man who was admitted with lower back pain and bilateral lower limb weakness. Neurologically, he exhibited paralysis of both lower limbs, complete sensory loss below the 10th thoracic spinal level, and bladder and rectal dysfunction. Spinal MRI revealed intramedullary high-signal lesions extending from the 10th vertebral level to the conus medullaris on diffusion-weighted and T2-weighted images. By the 10th day, the extensive intramedullary lesion had progressed to the 2nd vertebral level. Although aortic angiography on the 3rd day showed no vascular abnormalities, concurrent infarction of the paraspinal muscles at the 2nd lumbar vertebral level was confirmed. Based on the spinal vascular anatomy, it was deduced that both the spinal cord and the paraspinal muscle lesions had the same vascular etiology. Therefore, the spinal cord lesion was diagnosed early as spinal cord infarction. In cases of acute spinal symptoms, the coexistence of paraspinal muscle infarction observed on contrast-enhanced CT can assist in diagnosing spinal cord infarction.
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Affiliation(s)
- Takuma Kato
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital
| | - Keisuke Imai
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital
| | - Takehiro Yamada
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital
| | - Masanori Cho
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital
| | - Toshi Sai
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine
| | - Tetsuya Ioku
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital
- Department of Stroke Center, Aichi Medical University
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Lipid signature of neural tissues of marine and terrestrial mammals: consistency across species and habitats. J Comp Physiol B 2021; 191:815-829. [PMID: 33973058 DOI: 10.1007/s00360-021-01373-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/24/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
Marine mammals are exposed to O2-limitation and increased N2 gas concentrations as they dive to exploit habitat and food resources. The lipid-rich tissues (blubber, acoustic, neural) are of particular concern as N2 is five times more soluble in lipid than in blood or muscle, creating body compartments that can become N2 saturated, possibly leading to gas emboli upon surfacing. We characterized lipids in the neural tissues of marine mammals to determine whether they have similar lipid profiles compared to terrestrial mammals. Lipid profiles (lipid content, lipid class composition, and fatty acid signatures) were determined in the neural tissues of 12 cetacean species with varying diving regimes, and compared to two species of terrestrial mammals. Neural tissue lipid profile was not significantly different in marine versus terrestrial mammals across tissue types. Within the marine species, average dive depth was not significantly associated with the lipid profile of cervical spinal cord. Across species, tissue type (brain, spinal cord, and spinal nerve) was a significant factor in lipid profile, largely due to the presence of storage lipids (triacylglycerol and wax ester/sterol ester) in spinal nerve tissue only. The stability of lipid signatures within the neural tissue types of terrestrial and marine species, which display markedly different dive behaviors, points to the consistent role of lipids in these tissues. These findings indicate that despite large differences in the level of N2 gas exposure by dive type in the species examined, the lipids of neural tissues likely do not have a neuroprotective role in marine mammals.
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Kesserwani H. Difficulty Standing on the Tiptoes? Think of an Epiconus Syndrome: A Case Report and a Review of the Pathobiology of the Conus and Epiconus. Cureus 2021; 13:e12724. [PMID: 33614327 PMCID: PMC7883561 DOI: 10.7759/cureus.12724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The motor deficits, urogenital dysfunction and perineal numbness of the conus medullaris syndrome are well known. Less well known is the disease of the epiconus, the spinal cord immediately above the conus medullaris. The disease is quite unique with ankle plantar-flexion weakness that usually exceeds ankle dorsi-flexion weakness. The epiconus syndrome can present with both upper and lower motor neuron findings and manifest unique findings on nerve conduction/electromyography studies. Intriguingly, lumbo-sacral corticospinal tract disease can involve trans-synaptic degeneration of the anterior horn motor neurons and lead to acute denervation, as recorded with electromyography. The conus medullaris also contains Onuf’s nucleus, which controls penile erection, ejaculation, the external urethral and the external anal sphincter and is the basis of the bulbo-cavernosus reflex. Extension of a lesion from the epiconus to the conus can lead to urogenital dysfunction. We seize upon a case of an epiconus syndrome in order to outline some of these fascinating observations including the pathobiology of the conus and epiconus. In order to understand the epiconus, one must be versed with the conus medullaris.
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Abstract
The arterial supply of the spinal cord is provided by the spinal branch of the cervical, thoracic, and lumbar intersegmental arteries. While supply is initially provided at each embryonic segment, only a few prominent anterior radiculomedullary arteries remain at the adult stage, including the arteries of the cervical and lumbosacral enlargements as well as a constant upper thoracic contributor. The spinal cord is surrounded by the vasocorona, an arterial network that includes several longitudinal anastomotic chains, notably the anterior and posterior spinal arteries, which respectively supply the central and peripheral components of the intrinsic vascularization. The intrinsic venous circulation is also divided into central and peripheral components. The perimedullary venous system includes several longitudinal anastomotic chains interconnected by the coronary plexus. The radiculomedullary veins loosely follow the spinal nerve roots on their way to the epidural plexus. Their point of passage through the thecal sac forms an important valve-like structure, the antireflux mechanism.
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Affiliation(s)
- Lydia Gregg
- Division of Interventional Neuroradiology and Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philippe Gailloud
- Division of Interventional Neuroradiology and Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Ischemic damage may play an important role in spinal cord injury during dancing. Spinal Cord 2020; 58:1310-1316. [PMID: 32561846 PMCID: PMC7708299 DOI: 10.1038/s41393-020-0503-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective analysis. SETTING China Rehabilitation Research Center, Beijing, China. OBJECTIVE To explore possible mechanisms underlying spinal cord injury (SCI) in children caused by hyperextension of the spine while dancing. METHODS The clinical records of 88 children with SCI (mean age, 5.97 years; age range, 4-10 years) admitted to our hospital from January 1989 to October 2019 were retrospectively reviewed. Computed tomography and magnetic resonance imaging were performed on the day of injury. The time from injury to development of paralysis, as well as post-injury activities were surveyed, while abnormal patterns on images, the range of the involved vertebrae, and the extents of edema and atrophy were assessed. RESULTS Among the 88 patients, 6 (6.8%) were unable to move immediately after SCI, while paralysis occurred in 42, 23, and 17 patients at <30, 30-60, and >60 min after SCI, respectively. The neurological level of injury of 84 patients was between T4 and T12. On sagittal T2-weighted images (T2WIs), the longitudinal range of spinal cord edema was more than one vertebral body in 65 patients, while spinal cord atrophy below T8 was found in 40 patients. On axial T2WIs, although three patients had none, long T2 signals were found in the central gray matter of seven patients. Meanwhile, necrosis of the central area combined with the peripheral white matter was observed in 57 patients, while three patients had total involvement on a cross section. CONCLUSION Ischemia-related damage, rather than direct trauma to the spinal cord, may play an important role in SCI due to spinal hyperextension during dancing.
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Cai JB, He M, Wang FL, Xiong JN, Mao JQ, Guan ZH, Li LJ, Wang JH. Paraplegia after transcatheter artery chemoembolization in a child with clear cell sarcoma of the kidney: A case report. World J Clin Cases 2020; 8:2332-2338. [PMID: 32548164 PMCID: PMC7281067 DOI: 10.12998/wjcc.v8.i11.2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Transcatheter arterial chemoembolization (TACE) is a common treatment for inoperable malignant renal tumors. However, a series of complications may follow the TACE treatment. Spinal cord injury caused by the embolization of intercostal or lumbar arteries is extremely rare.
CASE SUMMARY We describe a case with quite uncommon spinal cord injury after TACE in a 3-year-old child with clear cell sarcoma of the kidney. Sensory impairment beneath the T10 dermatomes and paraplegia on the day after TACE were found in this patient. Unfortunately, sustained paraplegia still existed for more than 2 mo after TACE despite the large dose of steroids and supportive therapy.
CONCLUSION We should draw attention to an uncommon complication of paraplegia after TACE treatment in malignant renal tumors. Although it is rare, the result is disastrous.
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Affiliation(s)
- Jia-Bin Cai
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Min He
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Fa-Liang Wang
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Jie-Ni Xiong
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Jun-Qing Mao
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Zhong-Hai Guan
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Lin-Jie Li
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
| | - Jin-Hu Wang
- Department of Surgical Oncology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310053, Zhejiang Province, China
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Rojas S, Ortega M, Rodríguez-Baeza A. Anatomical study of the pial arterial network in human spinal cords. Clin Anat 2020; 34:596-604. [PMID: 32427384 DOI: 10.1002/ca.23622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/10/2020] [Accepted: 05/10/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Multiple collaterals originate from three main longitudinal vessels to perfuse the human spinal cord. Only a few classic studies published in the last century have investigated these collaterals. The current work proposes a possible classification of these vessels and analyzes their relative abundance along spinal cord segments. MATERIALS AND METHODS Human spinal cords (n = 30) from male and female cadavers were injected with colored latex through the vertebral, ascending cervical, costocervical trunk and segmental arteries and then fixed in formaldehyde solution. Afterwards, spinal vessels were dissected and the relative abundances of each type of collateral were quantified and compared between different spinal cord segments. RESULTS Collaterals of the anterior longitudinal pathway can be classified as central arteries and arteries for the anterior and lateral columns. Collaterals for the anterior column can be classified into two types: anteromedial and anterolateral. Arteries for the lateral column can be classified, according to their relationship with the dentate ligament, as either preligamentous or post-ligamentous. The collaterals of posterior longitudinal pathways can be divided between those for the posterior and those for the lateral column. In turn, the arteries for the posterior column can be classified into three types: median posterior, posteromedial and posterolateral. The collaterals for the lateral column were also classified as either pre- or post-ligamentous. CONCLUSION The relative abundance of the various types of collateral and anastomoses between longitudinal pathways was inhomogeneous along the spinal cord, with several statistically significant differences observed between spinal segments.
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Affiliation(s)
- Santiago Rojas
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Serra Húnter Fellow, Universtitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Marisa Ortega
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institute of Legal Medicine and Forensic Sciences of Catalonia, Hospitalet de Llobregat, Spain
| | - Alfonso Rodríguez-Baeza
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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Hernandez-Gerez E, Fleming IN, Parson SH. A role for spinal cord hypoxia in neurodegeneration. Cell Death Dis 2019; 10:861. [PMID: 31723121 PMCID: PMC6853899 DOI: 10.1038/s41419-019-2104-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 01/12/2023]
Abstract
The vascular system of the spinal cord is particularly complex and vulnerable. Damage to the main vessels or alterations to the regulation of blood flow will result in a reduction or temporary cessation of blood supply. The resulting tissue hypoxia may be brief: acute, or long lasting: chronic. Damage to the vascular system of the spinal cord will develop after a traumatic event or as a result of pathology. Traumatic events such as road traffic accidents, serious falls and surgical procedures, including aortic cross-clamping, will lead to an immediate cessation of perfusion, the result of which may not be evident for several days, but may have long-term consequences including neurodegeneration. Pathological events such as arterial sclerosis, venous occlusion and spinal cord compression will result in a progressive reduction of blood flow, leading to chronic hypoxia. While in some situations the initial pathology is exclusively vascular, recent research in neurodegenerative disease has drawn attention to concomitant vascular anomalies in disorders, including amyotrophic lateral sclerosis, spinal muscular atrophy and muscular sclerosis. Understanding the role of, and tissue response to, chronic hypoxia is particularly important in these cases, where inherent neural damage exacerbates the vulnerability of the nervous system to stressors including hypoxia.
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Affiliation(s)
- Elena Hernandez-Gerez
- Institute of Medical Sciences University of Aberdeen Foresterhill Aberdeen, AB25 2ZD, Scotland, UK
| | - Ian N Fleming
- Institute of Medical Sciences University of Aberdeen Foresterhill Aberdeen, AB25 2ZD, Scotland, UK
| | - Simon H Parson
- Institute of Medical Sciences University of Aberdeen Foresterhill Aberdeen, AB25 2ZD, Scotland, UK.
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Abstract
This article reviews the arterial and venous anatomy of the spine and spinal cord. Special emphasis is placed on vessels critical to the conduct and interpretation of spinal angiography, notably the intersegmental artery and its cranial and caudal derivatives: the vertebral, supreme intercostal, and sacral arteries.
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Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, 1800 East Orleans Street, Baltimore, MD 21287, USA.
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Rojas S, Ortega M, RodríGuez‐Baeza A. Variable anatomic configuration of the posterior spinal arteries in humans. Clin Anat 2018; 31:1137-1143. [DOI: 10.1002/ca.23213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/03/2018] [Accepted: 05/09/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Santiago Rojas
- Unit of Human Anatomy and Embryology. Department of Morphological Sciences. Faculty of MedicineUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
| | - Marisa Ortega
- Unit of Human Anatomy and Embryology. Department of Morphological Sciences. Faculty of MedicineUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
- Institute of Legal Medicine and Forensic Sciences of Catalonia, Hospitalet de Llobregat Spain
| | - Alfonso RodríGuez‐Baeza
- Unit of Human Anatomy and Embryology. Department of Morphological Sciences. Faculty of MedicineUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
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Rojas S, Ortega M, Rodríguez-Baeza A. Vascular configurations of anastomotic basket of conus medullaris in human spinal cord. Clin Anat 2017; 31:441-448. [PMID: 28906042 DOI: 10.1002/ca.22986] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/29/2017] [Accepted: 09/11/2017] [Indexed: 11/12/2022]
Abstract
The arterial basket of the conus medullaris is one of several anastomoses between the anterior and posterior spinal arteries. The anatomy of this structure has attracted little attention. This work sought to investigate its configuration in human spinal cords. Spinal cords from male and female cadavers (n = 32) were injected with colored latex through the intercostal, lumbar, medial sacral and the posterior trunks of the hypogastric arteries. After injection, specimens preserving the dural sac were obtained and fixed in formaldehyde solution. Finally, the spinal arteries were microdissected. In 18.75% of the specimens, the anterior spinal artery divided symmetrically and formed anastomoses with the posterior spinal arteries. In 81.25%, the branching pattern observed was asymmetrical. In 21.87% there were differences in the diameter of the anastomotic arteries, and 40.63% originated at different levels along the craniocaudal axis. Interestingly, 12.5% of the specimens presented an intraparenchymatous anastomosis that has not been described previously. True unilateral anastomosis was only observed in 6.25% of the spinal cords. The most frequent configuration of the anastomotic basket of the conus medullaris is a bilateral asymmetric anastomosis. The asymmetry of the branches could be caused by differences in their diameters or in their origins along the craniocaudal axis. Symmetrical patterns are less frequent, and unilateral anastomoses are rare. In reality, some cases of apparently unilateral anastomosis present an intramedullary course of the anastomotic artery. Clin. Anat. 31:441-448, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Santiago Rojas
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Marisa Ortega
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institute of Legal Medicine of Catalonia, Barcelona, Spain
| | - Alfonso Rodríguez-Baeza
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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Martirosyan NL, Kalani MYS, Lemole GM, Spetzler RF, Preul MC, Theodore N. Microsurgical anatomy of the arterial basket of the conus medullaris. J Neurosurg Spine 2015; 22:672-6. [PMID: 25746117 DOI: 10.3171/2014.10.spine131081] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The arterial basket of the conus medullaris (ABCM) consists of 1 or 2 arteries arising from the anterior spinal artery (ASA) and circumferentially connecting the ASA and the posterior spinal arteries (PSAs). The arterial basket can be involved in arteriovenous fistulas and arteriovenous malformations of the conus. In this article, the authors describe the microsurgical anatomy of the ABCM with emphasis on its morphometric parameters and important role in the intrinsic blood supply of the conus medullaris. METHODS The authors performed microsurgical dissections on 16 formalin-fixed human spinal cords harvested within 24 hours of death. The course, diameter, and branching angles of the arteries comprising the ABCM were then identified and measured. In addition, histological sections were obtained to identify perforating vessels arising from the ABCM. RESULTS The ASA tapers as it nears the conus medullaris (mean preconus diameter 0.7 ± 0.12 mm vs mean conus diameter 0.38 ± 0.08 mm). The ASA forms an anastomotic basket with the posterior spinal artery (PSA) via anastomotic branches. In most of the specimens (n= 13, 81.3%), bilateral arteries formed connections between the ASA and PSA. However, in the remaining specimens (n= 3, 18.7%), a unilateral right-sided anastomotic artery was identified. The mean diameter of the right ABCM branch was 0.49 ± 0.13 mm, and the mean diameter of the left branch was 0.53 ± 0.14 mm. The mean branching angles of the arteries forming the anastomotic basket were 95.9° ± 36.6° and 90° ± 34.3° for the right- and left-sided arteries, respectively. In cases of bilateral arterial anastomoses between the ASA and PSA, the mean distance between the origins of the arteries was 4.5 ± 3.3 mm. Histological analysis revealed numerous perforating vessels supplying tissue of the conus medullaris. CONCLUSIONS The ABCM is a critical anastomotic connection between the ASA and PSA, which play an important role in the intrinsic blood supply of the conus medullaris. The ABCM provides an important compensatory function in the blood supply of the spinal cord. Its involvement in conus medullaris vascular malformations makes it a critical anatomical structure.
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Affiliation(s)
- Nikolay L Martirosyan
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and.,2Division of Neurological Surgery, University of Arizona, Tucson, Arizona
| | - M Yashar S Kalani
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - G Michael Lemole
- 2Division of Neurological Surgery, University of Arizona, Tucson, Arizona
| | - Robert F Spetzler
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Mark C Preul
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Nicholas Theodore
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
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Störtebecker TP. Disturbances of Arterial Blood Supply to the Spinal Cord and Brain Stem Caused by Spondylosis, Disc Protrusions and Root-Sleeve Fibrosis: A Concept Concerning Factors Eliciting Amyotrophic Lateral Sclerosis. ACTA ACUST UNITED AC 2014. [DOI: 10.3109/ort.1959.30.suppl-42.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Gailloud P, Gregg L, Galan P, Becker D, Pardo C. Periconal arterial anastomotic circle and posterior lumbosacral watershed zone of the spinal cord. J Neurointerv Surg 2014; 7:848-53. [PMID: 25280570 DOI: 10.1136/neurintsurg-2014-011408] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/10/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND The existence of spinal cord watershed territories was suggested in the 1950s. Segmental infarcts within the junctional territories of adjacent radiculomedullary contributors and isolated spinal gray matter ischemia constitute two well-recognized types of watershed injury. This report describes the existence of another watershed territory related to the particular configuration of the spinal vasculature in the region of the conus medullaris. METHODS The anatomical bases underlying the concept of a posterior lumbosacral watershed zone are demonstrated with angiographic images obtained in a 16-year-old child. The clinical importance of this watershed zone is illustrated with MRI and angiographic data of three patients with a conus medullaris infarction. RESULTS In all three cases of spinal ischemia an intersegmental artery providing a significant radiculomedullary contribution for the lower cord was compromised by a compressive mechanism responsible for decreased spinal cord perfusion (diaphragmatic crus syndrome in two cases, disk herniation in one). The ischemic injury, located at the junction of the anterior and posterior spinal artery territories along the dorsal aspect of the conus medullaris, was consistent with a watershed mechanism. This zone is at risk because of the caudocranial direction of flow within the most caudal segment of the posterior spinal arterial network which, from a functional standpoint, depends on the anterior spinal artery. CONCLUSIONS The posterior thoracolumbar watershed zone of the spinal cord represents an area at increased risk of ischemic injury, particularly in the context of partial flow impairment related to arterial compression mechanisms.
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Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lydia Gregg
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Peter Galan
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Becker
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Kobayashi S. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis. World J Orthop 2014; 5:134-45. [PMID: 24829876 PMCID: PMC4017306 DOI: 10.5312/wjo.v5.i2.134] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/17/2013] [Accepted: 03/03/2014] [Indexed: 02/06/2023] Open
Abstract
Spinal nerve roots have a peculiar structure, different from the arrangements in the peripheral nerve. The nerve roots are devoid of lymphatic vessels but are immersed in the cerebrospinal fluid (CSF) within the subarachnoid space. The blood supply of nerve roots depends on the blood flow from both peripheral direction (ascending) and the spinal cord direction (descending). There is no hypovascular region in the nerve root, although there exists a so-called water-shed of the bloodstream in the radicular artery itself. Increased mechanical compression promotes the disturbance of CSF flow, circulatory disturbance starting from the venous congestion and intraradicular edema formation resulting from the breakdown of the blood-nerve barrier. Although this edema may diffuse into CSF when the subarachnoid space is preserved, the endoneurial fluid pressure may increase when the area is closed by increased compression. On the other hand, the nerve root tissue has already degenerated under the compression and the numerous macrophages releasing various chemical mediators, aggravating radicular symptoms that appear in the area of Wallerian degeneration. Prostaglandin E1 (PGE1) is a potent vasodilator as well as an inhibitor of platelet aggregation and has therefore attracted interest as a therapeutic drug for lumbar canal stenosis. However, investigations in the clinical setting have shown that PGE1 is effective in some patients but not in others, although the reason for this is unclear.
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Blood supply to the human spinal cord: Part I. Anatomy and hemodynamics. Clin Anat 2013; 28:52-64. [DOI: 10.1002/ca.22281] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 05/13/2013] [Accepted: 05/23/2013] [Indexed: 11/07/2022]
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Bosmia AN, Tubbs RS, Hogan E, Bohnstedt BN, Denardo AJ, Loukas M, Cohen-Gadol AA. Blood Supply to the human spinal cord: Part II. Imaging and pathology. Clin Anat 2013; 28:65-74. [DOI: 10.1002/ca.22284] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 05/15/2013] [Accepted: 05/27/2013] [Indexed: 12/20/2022]
Affiliation(s)
- Anand N. Bosmia
- Pediatric Neurosurgery, Children's Hospital of Alabama; Birmingham Alabama
| | - R. Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital of Alabama; Birmingham Alabama
| | - Elizabeth Hogan
- Pediatric Neurosurgery, Children's Hospital of Alabama; Birmingham Alabama
| | - Bradley N. Bohnstedt
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine; Indianapolis Indiana
| | - Andrew J. Denardo
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine; Indianapolis Indiana
| | - Marios Loukas
- Department of Anatomical Sciences; St. George's University; Grenada
| | - Aaron A. Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine; Indianapolis Indiana
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Abstract
BACKGROUND During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury. OBJECTIVES To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 31 2012) and CENTRAL (2012, Issue 5) for publications describing randomised controlled trials of cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Reference lists of relevant articles were checked. SELECTION CRITERIA Randomised trials involving CSFD during thoracic and TAAA surgery. DATA COLLECTION AND ANALYSIS Both authors assessed the quality of trials independently. SNK extracted data and GS verified the data. MAIN RESULTS Three trials with a total of 287 participants operated on for Type I or II TAAA were included.In the first trial of 98 participants, neurological deficits in the lower extremities occurred in 14 (30%) of CSFD group and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from three to 22 days in 10 (32%) participants. CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord.The second trial of 33 participants used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (P = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial.In the third trial TAAA repair was performed on 145 participants. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 participants (12.2%) in the control group versus 2 of 82 participants (2.7%) receiving CSFD (P = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (95 % confidence interval (CI) 0.25 to 0.92). For CSFD-only trials, OR was 0.57 (95% CI 0.28 to 1.17) and for intention-to-treat analysis in CSFD-only studies, the OR remained unchanged. AUTHORS' CONCLUSIONS There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.
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Vascular disruption and the role of angiogenic proteins after spinal cord injury. Transl Stroke Res 2011; 2:474-91. [PMID: 22448202 PMCID: PMC3296011 DOI: 10.1007/s12975-011-0109-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 09/20/2011] [Accepted: 09/25/2011] [Indexed: 02/06/2023]
Abstract
Spinal cord injuries (SCI) can result in devastating paralysis, for which there is currently no robustly efficacious neuroprotective/neuroregenerative treatment. When the spinal cord is subjected to a traumatic injury, the local vasculature is disrupted and the blood–spinal cord barrier is compromised. Subsequent inflammation and ischemia may then contribute to further secondary damage, exacerbating neurological deficits. Therefore, understanding the vascular response to SCI and the molecular elements that regulate angiogenesis has considerable relevance from a therapeutic standpoint. In this paper, we review the nature of vascular damage after traumatic SCI and what is known about the role that angiogenic proteins—angiopoietin 1 (Ang1), angiopoietin 2 (Ang2) and angiogenin—may play in the subsequent response. To this, we add recent work that we have conducted in measuring these proteins in the cerebrospinal fluid (CSF) and serum after acute SCI in human patients. Intrathecal catheters were installed in 15 acute SCI patients within 48 h of injury. CSF and serum samples were collected over the following 3–5 days and analysed for Ang1, Ang2 and angiogenin protein levels using a standard ELISA technique. This represents the first description of the endogenous expression of these proteins in an acute human SCI setting.
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Martirosyan NL, Feuerstein JS, Theodore N, Cavalcanti DD, Spetzler RF, Preul MC. Blood supply and vascular reactivity of the spinal cord under normal and pathological conditions. J Neurosurg Spine 2011; 15:238-51. [DOI: 10.3171/2011.4.spine10543] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a review of spinal cord blood supply, discussing the anatomy of the vascular system and physiological aspects of blood flow regulation in normal and injured spinal cords. Unique anatomical functional properties of vessels and blood supply determine the susceptibility of the spinal cord to damage, especially ischemia. Spinal cord injury (SCI), for example, complicating thoracoabdominal aortic aneurysm repair is associated with ischemic trauma. The rate of this devastating complication has been decreased significantly by instituting physiological methods of protection. Traumatic SCI causes complex changes in spinal cord blood flow, which are closely related to the severity of injury. Manipulating physiological parameters such as mean arterial blood pressure and intrathecal pressure may be beneficial for patients with an SCI. Studying the physiopathological processes of the spinal cord under vascular compromise remains challenging because of its central role in almost all of the body's hemodynamic and neurofunctional processes.
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Stafa A, Barbara C, Boriani S, Simonetti L, Leonardi M. A Little Talk on Adamkiewicz's Artery. Some Practical Considerations on the Pre-Operative Identification of this Artery Starting from a Single Team Experience in Pre-Surgical Selective Embolization of Vascularized Spinal Lesions. Neuroradiol J 2010; 23:225-33. [PMID: 24148543 DOI: 10.1177/197140091002300213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 03/17/2010] [Indexed: 11/15/2022] Open
Abstract
The major radicular artery eponymically named "Adamkiewicz's artery" (AKA) is an important vessel supplying the spinal cord, especially the lumbar enlargement. This report emphasizes the importance of anatomical knowledge of this artery and highlights the concept of the potential risk of neurological complications during different procedures: spine orthopedic/neurosurgery, aortic repair (vascular surgery) and endovascular selective embolizations performed by interventional neuro/radiologists. Anatomical considerations are made on the spinal cord arterial circulation with a special focus on the AKA. Our review of the literature considered this anatomical element essential to compare the potential risk of spinal cord ischemic damage during orthopedic/neurosurgical spine procedures, aortic vascular surgery repair procedures and endovascular selective arterial embolizations. Evaluation of the endovascular selective arterial spine embolization risk was based on our series of 410 embolization procedures. Spinal cord infarction and transient or permanent paraplegia may result from inadvertent interruption of the AKA. The presence of intersegmental collaterals may decrease the risk of spinal cord ischemia: this is an important element to bear in mind that may help in spine surgery or aortic repair procedures performed by vascular surgeons. Nevertheless, during aortic repair (open surgery or stent-graft procedures) interruption of bilateral segmental arteries at multiple consecutive levels including that of the AKA may occur thereby increasing the ischemic spinal cord risk, annulling the benefit of intersegmental collaterals. Accidental embolizations of the AKA during endovascular spine procedures (i.e. selective arterial embolizations) performed by interventional neuro/radiologists will cause an almost certain spinal cord infarction due to the consequent embolizations of the anterior spinal artery (ASA).
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Affiliation(s)
- A Stafa
- Neuroradiology Unit, Maggiore Hospital; Bologna, Italy -
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Juvonen T, Biancari F, Rimpiläinen J, Satta J, Rainio P, Kiviluoma K. Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review. SCAND CARDIOVASC J 2009. [DOI: 10.1080/cdv.36.3.136.160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Colli BO, Carlotti CG, Assirati JA, Lopes LDS, Marques W, Chimelli L, Neder L, Barreira AA. Dorsal root ganglionectomy for the diagnosis of sensory neuropathies. Surgical technique and results. ACTA ACUST UNITED AC 2007; 69:266-73; dicussion 273. [PMID: 17597195 DOI: 10.1016/j.surneu.2007.01.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 01/11/2007] [Indexed: 11/15/2022]
Abstract
BACKGROUND Inflammatory diseases stand out among sensory neuronopathies because, in their active phase, they can be treated with immunosuppressive agents. Immunosuppressive therapy may present severe adverse effects and requires previous inflammatory activity confirmation. Sensory neuronopathies are diagnosed based on clinical and EMG findings. Diagnostic confirmation and identification of inflammatory activity are based on sensory ganglion histopathological examination. We describe the surgical technique used for dorsal root ganglionectomy in patients with clinical/EMG diagnosis of sensory neuronopathies. METHODS The sensory ganglion was obtained from 15 patients through a small T7-T8 hemilaminectomy and foraminotomy to expose the C7 root from its origin to the spinal nerve bifurcation. In 6 patients, the dural cuff supposed to contain the ganglion was resected en bloc; and in 9 patients, the ganglion was obtained through a longitudinal incision of the dural cuff and microsurgical dissection from the ventral and dorsal roots and radicular arteries. All ganglia were histopathologically examined. RESULTS No ganglion was found in the dural cuff in 2 patients submitted to en bloc removal, and the ganglion was removed in all patients who underwent microsurgical dissection. All but 2 patients that had ganglion examination presented a neuronopathy of nerve cell loss, 3 with mononuclear inflammatory infiltrate. These patients underwent immunosuppressive therapy, and 2 of them presented clinical improvement. No surgical complications were observed. CONCLUSIONS Microsurgical dorsal root ganglionectomy for diagnosing inflammatory sensory ganglionopathies was effective and safe. Although safe, en bloc resection of the proximal dural cuff was not effective for this purpose.
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Affiliation(s)
- Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paolo, Brazil.
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Khan SN, Stansby G. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane Database Syst Rev 2004:CD003635. [PMID: 14974026 DOI: 10.1002/14651858.cd003635.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury. OBJECTIVES To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury. SEARCH STRATEGY The reviewers searched the Cochrane Peripheral Vascular Diseases Group Specialised Trials Register (last searched October 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2003), MEDLINE and EMBASE, and reference lists of relevant articles. Recent conference proceedings were scanned. SELECTION CRITERIA Randomised trials involving CSFD during thoracic and TAAA surgery. DATA COLLECTION AND ANALYSIS Both reviewers assessed the quality of trials independently. One reviewer (SNK) extracted data and the other reviewer (GS) verified the data. MAIN RESULTS Three trials, with a total of 287 participants operated on for type I or II TAAA, were included. In the first trial of 98 patients, neurological deficits in the lower extremities occurred in 14 (30%) CSFD and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from 3 to 22 days in 10 (32%). CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord. The second trial of 33 patients used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (p = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial. In the third trial TAAA repair was performed on 145 patients. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 patients (12.2%) in the control group versus 2 of 82 patients (2.7%) with CSFD (p = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (0.25 to 0.92; confidence interval (CI) 95%). For CSFD trials only OR was 0.57 (0.28 to 1.17) and for intention-to-treat in CSFD only studies OR remained unchanged. REVIEWER'S CONCLUSIONS There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.
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Affiliation(s)
- S N Khan
- Dept. of Surgery, University of Newcastle upon Tyne, Framlington Place, Newcastle upon Tyne, UK, NE2 4HH
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Kleopa KA, Zamba-Papanicolaou E, Kyriakides T. Compressive lumbar myelopathy presenting as segmental motor neuron disease. Muscle Nerve 2003; 28:69-73. [PMID: 12811775 DOI: 10.1002/mus.10405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Four patients presented with slowly progressive, bilateral, asymmetric weakness and muscle atrophy in the lower extremities, accompanied by cramps and fasciculations. Sensory symptoms were insignificant. There was no bladder or bowel disturbance. Upper extremities and cranial nerves were normal. Weakness was found in lumbosacral myotomes, ranging from L2 to S1. The tendon reflexes varied, and extensor plantar responses were found in one case with proximal leg involvement. Nerve conduction studies were normal, but segmental chronic and often active denervation confined to the weak myotomes in the lower extremities was found in the electromyogram. Magnetic resonance imaging showed evidence of spondylotic lumbosacral myelopathy associated with disc herniation or osteophytic arthropathy at the T11/T12 spinal level in all patients, with increased signal within the adjacent cord. This unusual purely motor presentation may result from ischemic myelopathy secondary to compression of the anterior spinal artery.
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Affiliation(s)
- Kleopas A Kleopa
- Department of Clinical Neurosciences, The Cyprus Institute of Neurology and Genetics, PO Box 23462, 1683 Nicosia, Cyprus
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Abstract
STUDY DESIGN Experimental investigation of the dynamics of nerve root circulation. OBJECTIVES To study the dynamics of lumbosacral nerve root circulation by using seriography in dogs. SUMMARY OF BACKGROUND DATA The vascular distribution to the nerve root has been discussed mainly from the morphologic aspects, and no adequate elucidation has been presented concerning the kinetics of the blood supply to the nerve root. METHODS To investigate the direction of blood flow in the nerve roots, a series of photographs of the cauda equina were taken using a motor-driven camera immediately after 3 mL of india ink was injected through the aortic catheter manually. The changes in the blood flow direction caused by compression of the nerve root also were observed. After the dog was killed, the nerve roots were cleared by the Spalteholz technique to identify the vessels observed during the experiment. RESULTS The blood flow in the radicular arteries was descending in the proximal part and ascending in the distal part of the nerve roots. This observation supports the suggestion that there is a so-called watershed of the blood flow in the radicular arteries themselves. However, when the ascending radicular artery of the nerve root was cramped, the radicular blood flow on the proximal side was downward. The microangiograms also showed that there were abundant anastomoses of intrinsic vessels in the nerve roots. CONCLUSIONS There is no relatively hypovascular region in the nerve root that is vulnerable in the course of degenerative changes in the lumbosacral spine. Therefore, it is unlikely that the watershed represents a weak point of the blood flow in the nerve root.
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Affiliation(s)
- S Kobayashi
- Department of Orthopedics, Fujita Health University School of Medicine, Aichi, Japan
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SCHNEIDER RC, SCHEMM GW. Vertebral artery insufficiency in acute and chronic spinal trauma, with special reference to the syndrome of acute central cervical spinal cord injury. J Neurosurg 1998; 18:348-60. [PMID: 13748252 DOI: 10.3171/jns.1961.18.3.0348] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
BACKGROUND Although rare, paralysis secondary to spinal cord ischaemia after aortic aneurysm surgery is a devastating complication. Many papers have been published on this topic but without a clear consensus on the best way of minimizing the problem. Recent articles have included advanced pharmacological approaches and the literature has been reviewed in light of these. METHODS Relevant papers were identified by an extensive text word search of the Medline database and a review of quoted articles. RESULTS Spinal cord complications are commoner after the repair of Crawford type II aneurysms than less extensive aneurysms. The presence of dissection, rupture and prolonged clamp times are associated with an increased incidence. About a quarter of all cord problems develop over 24 h after surgery and this may be due to a reperfusion type injury, although the exact mechanisms are by no means clear. CONCLUSION A combination of rapid surgery, left heart bypass for the repair of more extensive aneurysms, free spinal drainage and the avoidance of postoperative hypoxia and hypotension help to minimize spinal cord ischaemia. No pharmacological agent has yet been shown conclusively to improve outcome in the clinical setting.
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Affiliation(s)
- P Lintott
- Academic Surgical Unit, Imperial College School of Medicine at St Mary's, St Mary's Hospital, London, UK
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31
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Abstract
Vascular injury plays an important role in the primary and secondary injury mechanisms that cause damage to the acutely traumatized spinal cord. To understand the pathophysiology of human spinal cord injury, the authors investigated the vascular system in three uninjured human spinal cords using silicone rubber microangiography and analyzed the histological findings related to vascular injury in nine acutely traumatized human spinal cords obtained at autopsy. The interval from spinal cord injury to death ranged from 20 minutes to 9 months. The microangiograms of the uninjured human cervical cords demonstrated new information about the sulcal arterial system and the pial arteries. The centrifugal sulcal arterial system was found to supply all of the anterior gray matter, the anterior half of the posterior gray matter, approximately the inner half of the anterior and lateral white columns, and the anterior half of the posterior white columns. Traumatized spinal cord specimens in the acute stage (3-5 days postinjury) showed severe hemorrhages predominantly in the gray matter, but also in the white matter. The white matter surrounding the hemorrhagic gray matter showed a variety of lesions, including decreased staining, disrupted myelin, and axonal and periaxonal swelling. The white matter lesions extended far from the injury site, especially in the posterior columns. There was no evidence of complete occlusion of any of the larger arteries, including the anterior and posterior spinal arteries and the sulcal arteries. However, occluded intramedullary veins were identified in the degenerated posterior white columns. In the chronic stage (3-9 months postinjury), the injured segments showed major tissue loss with large cavitations, whereas both rostral and caudal remote sites showed well-demarcated necrotic areas indicative of infarction mainly in the posterior white columns. Obstruction of small intramedullary arteries and veins by the initial mechanical stress or secondary injury mechanisms most likely produced these extensive white matter lesions. Our studies implicate damage to the anterior sulcal arteries in causing the hemorrhagic necrosis and subsequent central myelomalacia at the injury site in acute spinal cord injury in humans.
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Affiliation(s)
- C H Tator
- Canadian Paraplegic Association Spinal Cord Injury Research Laboratory, Toronto Hospital, Ontario, Canada
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32
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Tator CH, Koyanagi I. Vascular mechanisms in the pathophysiology of human spinal cord injury. Neurosurg Focus 1997. [DOI: 10.3171/foc.1997.2.1.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vascular injury plays an important role in the primary and secondary injury mechanisms that cause damage to the acutely traumatized spinal cord. To understand the pathophysiology of human spinal cord injury, the authors investigated the vascular system in three uninjured human spinal cords using silicone rubber microangiography and analyzed the histological findings related to vascular injury in nine acutely traumatized human spinal cords obtained at autopsy. The interval from spinal cord injury to death ranged from 20 minutes to 9 months. The microangiograms of the uninjured human cervical cords demonstrated new information about the sulcal arterial system and the pial arteries. The centrifugal sulcal arterial system was found to supply all of the anterior gray matter, the anterior half of the posterior gray matter, approximately the inner half of the anterior and lateral white columns, and the anterior half of the posterior white columns. Traumatized spinal cord specimens in the acute stage (3-5 days postinjury) showed severe hemorrhages predominantly in the gray matter, but also in the white matter. The white matter surrounding the hemorrhagic gray matter showed a variety of lesions, including decreased staining, disrupted myelin, and axonal and periaxonal swelling. The white matter lesions extended far from the injury site, especially in the posterior columns. There was no evidence of complete occlusion of any of the larger arteries, including the anterior and posterior spinal arteries and the sulcal arteries. However, occluded intramedullary veins were identified in the degenerated posterior white columns. In the chronic stage (3-9 months postinjury), the injured segments showed major tissue loss with large cavitations, whereas both rostral and caudal remote sites showed well-demarcated necrotic areas indicative of infarction mainly in the posterior white columns. Obstruction of small intramedullary arteries and veins by the initial mechanical stress or secondary injury mechanisms most likely produced these extensive white matter lesions. Our studies implicate damage to the anterior sulcal arteries in causing the hemorrhagic necrosis and subsequent central myelomalacia at the injury site in acute spinal cord injury in humans.
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Brockstein B, Johns L, Gewertz BL. Blood supply to the spinal cord: anatomic and physiologic correlations. Ann Vasc Surg 1994; 8:394-9. [PMID: 7947069 DOI: 10.1007/bf02133005] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although the subject has been studied for many years, the clinician's understanding of the blood supply to the spinal cord is complicated by both confusing nomenclature and conflicting data. This review attempts to clarify prevailing thoughts on the arterial and venous structures in this clinically important area.
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Affiliation(s)
- B Brockstein
- Department of Surgery, University of Chicago, IL 60637
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Abstract
Four patients developed infarction of the lumbar cord as a result of induced hypotension. All patients showed a lesion in the territory of the artery of Adamkiewicz. The pathophysiology of the blood supply of the spinal cord is discussed, and in particular the anatomy of the artery of Adamkiewicz. The reason why this artery is so vulnerable to hypotension is discussed.
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Affiliation(s)
- U Singh
- Department of Rehabilitation All India Institute of Medical Sciences, New Delhi
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Gorecki JP, Ameli FM. Ischemic damage to the spinal cord following end-to-side aortobifemoral bypass. Ann Vasc Surg 1993; 7:569-76. [PMID: 8123460 DOI: 10.1007/bf02000153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A patient presenting with urinary retention was found to have progressive spinal cord ischemia subsequent to an end-to-side aortobifemoral bypass for atherosclerotic disease. This serves as a vivid reminder of the possibility of this complication even in ischemic disease and that urinary retention may be the initial symptom of cord ischemia. A review of the literature on spinal cord ischemia following abdominal aortic surgery is presented.
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Affiliation(s)
- J P Gorecki
- Division of Vascular Surgery, Wellesley Hospital, University of Toronto, Ontario, Canada
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36
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Three-Dimensional Analysis of the Vascular System in the Rat Spinal Cord with Scanning Electron Microscopy of Vascular Corrosion Casts. Part 1. Neurosurgery 1993. [DOI: 10.1097/00006123-199308000-00015] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Koyanagi I, Tator CH, Lea PJ. Three-Dimensional Analysis of the Vascular System in the Rat Spinal Cord with Scanning Electron Microscopy of Vascular Corrosion Casts. Part 1. Neurosurgery 1993. [DOI: 10.1227/00006123-199308000-00015] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Izumi Koyanagi
- Canadian Paraplegic Association Spinal Cord Injury Research Laboratory, Division of Neurosurgery and Playfair Neuroscience Unit, Toronto Western Division, The Toronto Hospital (IK, CHT) and Department of Anatomy and Cell Biology, Faculty of Medicine (PJL), University of Toronto, Toronto, Ontario, Canada
| | - Charles H. Tator
- Canadian Paraplegic Association Spinal Cord Injury Research Laboratory, Division of Neurosurgery and Playfair Neuroscience Unit, Toronto Western Division, The Toronto Hospital (IK, CHT) and Department of Anatomy and Cell Biology, Faculty of Medicine (PJL), University of Toronto, Toronto, Ontario, Canada
| | - Peter J. Lea
- Canadian Paraplegic Association Spinal Cord Injury Research Laboratory, Division of Neurosurgery and Playfair Neuroscience Unit, Toronto Western Division, The Toronto Hospital (IK, CHT) and Department of Anatomy and Cell Biology, Faculty of Medicine (PJL), University of Toronto, Toronto, Ontario, Canada
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Sliwa JA, Maclean IC. Ischemic myelopathy: a review of spinal vasculature and related clinical syndromes. Arch Phys Med Rehabil 1992; 73:365-72. [PMID: 1554311 DOI: 10.1016/0003-9993(92)90011-k] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This article provides a comprehensive review of spinal vascular anatomy (arterial and venous) and clinical syndromes that result from the disruption of blood flow to or from the spinal cord. Blood is supplied to the spinal cord through three longitudinal channels: one anterior and two posterior spinal arteries. These vessels, which originate as branches of the vertebral arteries and run caudally along the spinal cord, are augmented by a variable number of medullary arteries. A vascular ring, or vasa coronae, surrounds the cord and connects these longitudinal channels. Central arteries from the anterior spinal artery and penetrating vessels from the vasa coronae provide blood directly to the cord. Venous flow from the spinal cord is also accomplished through a system of anterior and posterior spinal vessels draining through a variable number of medullary veins and an extensive valveless vertebral venous plexus. The disruption of blood flow to or from the spinal cord can result in infarction, with permanent neurologic loss and physical impairment. The clinical presentation in cases of ischemic myelopathy can be variable. Discrete syndromes based on the occlusion of specific vessels are reported and include venous infarction, anterior and posterior spinal artery syndrome, and central infarction.
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Affiliation(s)
- J A Sliwa
- Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, Chicago, IL
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Luyendijk W, Cohn B, Rejger V, Vielvoye GJ. The great radicular artery of Adamkiewicz in man. Demonstration of a possibility to predict its functional territory. Acta Neurochir (Wien) 1988; 95:143-6. [PMID: 3228004 DOI: 10.1007/bf01790776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A women in her early sixties suffered from a malignant intramedullary astrocytoma. It had caused a nearly complete neurological deficit extending from the 12th thoracic segment downward. Since progressive tumour growth caused excruciating pain it was decided to remove the tumorous non-functional part of the spinal cord. As the great radicular artery was located in the region of the tumour it was feared that it might have to be sacrificed during surgery. In order to be informed as to its vascularization and the clinical consequence of interrupting it, an anaesthetic agent (Etomidate) was injected through this vessel. This resulted in a temporary increase in the neurological deficit by two dermatomes. Fortunately during surgery the Adamkiewicz artery was preserved. This intervention completely abolished the patient's complaints.
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Affiliation(s)
- W Luyendijk
- Department of Neurosurgery, University Medical Centre, Leiden, The Netherlands
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Naka Y, Itakura T, Nakai K, Nakakita K, Imai H, Okuno T, Kamei I, Komai N. Microangioarchitecture of the feline spinal cord. Three-dimensional observation of blood vessel corrosion casts by scanning electron microscopy. J Neurosurg 1987; 66:447-52. [PMID: 3819839 DOI: 10.3171/jns.1987.66.3.0447] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The microangioarchitecture of corrosion casts of the cat spinal cord was studied by scanning electron microscopy. On the ventral surface of the spinal cord, the anterior spinal artery and the anterior spinal vein ran parallel along the anterior median fissure. Many central arteries branching from the anterior spinal artery coursed in a wavelike manner in the anterior median fissure. The number of central arteries was lowest in the thoracic spinal cord. Central arteries at some spinal cord levels revealed well-developed anastomoses with other central arteries in the anterior median fissure. These well-developed anastomotic central arteries were frequently observed in the thoracic spinal cord, in which the number of central arteries was lowest. On the dorsal surface of the spinal cord, the posterior spinal vein ran longitudinally at the midline and was drained by circumferential veins and posterior central veins. This vein formed a characteristic anastomotic plexus. Small arterioles (20 microns in diameter) in the spinal parenchyma revealed a ring-like compression at the branching site.
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Lesoin F, Rousseaux M, Martin HJ, Petit H, Jomin M. Astereognosis and amyotrophy of the hand with neurinoma of the second cervical nerve root. J Neurol 1986; 233:57-8. [PMID: 3950667 DOI: 10.1007/bf00313995] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A case of astereognosis and amyotrophy of the right hand is reported, which was caused by a large extradural neurinoma of the C2 nerve root. The quick and complete recovery which followed surgery suggested a vascular mechanism as the cause of the neurological deficits.
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Picone AL, Green RM, Ricotta JR, May AG, DeWeese JA. Spinal cord ischemia following operations on the abdominal aorta. J Vasc Surg 1986. [DOI: 10.1016/0741-5214(86)90072-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lifschultz BD, Leestma JE, Stryker S. Multiple mycotic aneurysms and transverse myelopathy complicating repair of aortic coarctation. Ann Thorac Surg 1982; 33:192-6. [PMID: 7039535 DOI: 10.1016/s0003-4975(10)61909-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The case of an 18-year-old man with coarctation of the aorta discovered on routine physical examination and subsequently surgically repaired is reported. Four months postoperatively, aneurysms developed at the repair site and thrombosis of both femoral arteries was noted. Following an attempt to repair the aneurysm and remove the thrombi, the patient became paraplegic; Aspergillus fumigatus was found infecting the aorta and femoral vessels. After additional operations and a course of amphotericin B to control the fungal infection, the patient died of intrathoracic bleeding originating from infected, aneurysmally dilated intercostal vessels in the area of the original coarctation repair. The complicating fungal infection of the operative site and the paraplegia are discussed. This report is among the first to present a patient with fungal endarteritis complicating operation for coarctation of the aorta.
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Minatogawa T, Kumoi T, Hosomi H, Kokan T. The blood supply of the facial nerve in the human temporal bone. Auris Nasus Larynx 1980; 7:7-18. [PMID: 7305766 DOI: 10.1016/s0385-8146(80)80009-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The gross blood supply and intrinsic vascular anatomy of the facial nerve in the temporal bone are described, and their significance is discussed. At the vertical part of the facial nerve, the stylomastoid artery lies on its anteromedial side as far as the upper third of the nerve. The artery then loops around the lateral or medial side of the nerve, and divides into several branches. At the convex aspect of the genu, these branches anastomose with one another to form an arterial network, passing to the horizontal part. The petrosal branch of the middle meningeal artery reaches the geniculate ganglion and forms a profuse, fine arterial network. The main arterial trunk extends toward the second bend in the nerve, but it never reaches the vertical part. Studies on the draining veins are also described. Duplication of blood vessels from different sources was seen at the horizontal part of the nerve. This would suggest a special vulnerability of this area to vascular injury, since in our topographical study of Bell's palsy within two weeks of its onset, 72 out of 117 cases (61.5%) were found to have suprastapedial lesions.
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Abstract
Ischemic myelopathy and Angiology of the Spinal Cord have recently drawn the attention of both paraplegists and angiologists, and their details are now fairly well known. Ischemic myelopathies increased with the rise of vascular surgery, but the means of prevention have been carefully studied and the incidence is now decreasing. Twenty-five hundred cases of cord injury have been reviewed, and among 92 nontraumatic cases, 16 ischemic myelopathies have been tabulated. The anatomy and physiology of the spinal cord circulation have been described.
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Direkze M, Parsons-Smith BG. Cervical cord atrophy--a pattern of presentation. Acta Neurol Scand 1977; 55:330-40. [PMID: 857575 DOI: 10.1111/j.1600-0404.1977.tb05652.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This paper introduces the concept of veno-occlusive disease of the upper cervical cord by way of clinical report on 7 patients in whom a remarkable sequence of clinical events was encountered, commencing with weakness of an upper limb, followed by similar symptoms in the ipsilateral lower limb, the contralateral lower limb and finally the contralateral upper limb. In each patient there was wasting of the small muscles of both hands due to a lower motor neuron lesion at a level of the eighth cervical segment. In each case a tumour in the region of the foramen magnum was excluded.
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Abstract
The lumbosacral spinal cords of 28 patients with atheromatous emboli to abdominal viscera and/or grafts to the abdominal aorta were examined by serial sections. In 12 patients, atheromatous emboli were found in spinal arteries, most commonly in the sacral cord, and most frequently in the anterior spinal artery. The general absence of spinal cord infarctions was attributed to the nature of the emboli, apparent good collateral circulation, and the absence of diffuse atherosclerosis. However, 38% of the patients had arteriosclerosis; this was generally focal and not associated with significant luminal narrowing. Only one patient had infarction, which was limited primarily to the gray matter. It would appear that hypoperfusion must exist in conjunction with atheromatous emboli in order for infarction to develop. Organized atheromatous emboli also caused focal ischemic atrophy of neurons. It is postulated that this change may be the morphological basis for some of the atypical lower motor neuron diseases found in the elderly.
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Liveson JA, Ransohoff J, Goodgold J. Electromyographic studies in a case of foramen magnum meningioma. J Neurol Neurosurg Psychiatry 1973; 36:561-4. [PMID: 4731326 PMCID: PMC494409 DOI: 10.1136/jnnp.36.4.561] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Atrophy of muscles innervated by the lower cervical cord is a well-known feature in patients with foramen magnum tumours. Electromyographic evidence of denervation in the atrophic muscles is presented. The significance and possible mechanisms are reviewed and discussed.
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