Spinal cord ischemia as intraoperatory complication in shoulder surgery positioned in beach chair: case report

Abstract Spinal cord infarction is an uncommon phenomenon, which can be caused by different etiologies, constituting a real diagnostic challenge which can lead to devastating consequences. General anesthesia in beach chair positioning with intraoperative hypotension in order to avoid surgical bleeding are associated with hypoperfusion and potential neurological ischemia-related complications. We present a case of spinal cord ischemia in the context of shoulder surgery in a beach chair position.

Could cerebrospinal fluid biomarkers offer better predictive value for spinal cord ischaemia than current neuromonitoring techniques during thoracoabdominal aortic aneurysm repair - a systematic review

Abstract Objective: Cerebrospinal fluid (CSF) drainage is a technique that has significantly reduced the incidence of spinal cord ischaemia (SCI). We present results of a systematic review to assess the literature on this topic in relation to thoracoabdominal aortic aneurysm repair (TAAR). Methods: Major medical databases were searched to identify papers related to CSF biomarkers measured during TAAAR. Results: Fifteen papers reported measurements of CSF biomarkers with 265 patients in total. CSF biomarkers measured included S-100ß, neuron-specific endolase (NSE), lactate, glial fibrillary acidic protein A (GFPa), Tau, heat shock protein 70 and 27 (HSP70, HSP27), and proinflammatory cytokines. Lactate and S-100ß were reported the most, but did not correlate with SCI, which was also the case with NSE and TAU. GFPa showed significant CSF level rises, both intra and postoperative in patients who suffered SCI and warrants further investigation, similar results were seen with HSP70, HSP27 and IL-8. Conclusions: Although there is significant interest in this topic, there still remains a significant lack of high-quality studies investigating CSF biomarkers during TAAR to detect SCI. A large and multicentre study is required to identify the significant role of each biomarker.

Protective effect of combined melatonin and alpha-tocopherol administration in spinal cord ischemia-reperfusion injury in rat / Efecto protector de la administración combinada de melatonina y alfa-tocoferol en la lesión por isquemia-reperfusión de la médula espinal en ratas

Oxidative stress and inflammation are the key players in the development of motor dysfunction post-spinal cord ischemic reperfusion injury (SC-IRI). This study investigated the protective effect of concomitant pre-administration of melatonin and alpha-tocopherol on the early complications (after 48 hours) of spinal cord IRI injury in rats. Melatonin or α-tocopherol were preadministered either individually or in combination for 2 weeks, then rats were exposed SC-IRI. Neurological examinations of the hind limbs and various biochemical markers of oxidative stress and inflammation in the SC tissue were assessed. Solely pre-administration of either melanin or α-tocopherol significantly but partially improved motor and sensory function of the hind limbs mediated by partial decreases in SC levels of MDA, AOPP and PGE2 levels and activities of SOD, partial significant decreases in plasma levels of total nitrate/nitrite and significant increases in AC activity of GSH-Px. However, combination therapy of both drugs resulted in the maximum improvements in all neurological assessments tested and biochemical endpoints. In conclusion, by their synergistic antioxidant and antiinflammatory actions, the combination therapy of melatonin and α-tocopherol alleviates SC-IRI induced paraplegia.

El estrés oxidativo y la inflamación son claves en el desarrollo de la disfunción motora posterior a lesión isquémica de la médula espinal (SC-IRI). Este estudio investigó acerca del efecto protector de la administración previa concomitante de la melatonina y alfa-tocoferol en las complicaciones tempranas (después de 48 horas) de la lesión de IRI de la médula espinal en ratas. La melatonina o el α-tocoferol se administraron individualmente o en combinación durante 2 semanas, luego las ratas fueron expuestas a SC-IRI. Se evaluaron los exámenes neurológicos de las miembros pélvicos y diversos marcadores bioquímicos de estrés oxidativo e inflamación en el tejido subcutáneo. Solo la administración previa de melatonina o α-tocoferol mejoró parcial y significativamente la función motora y sensorial de los miembros pélvicos mediadas por disminuciones parciales en los niveles de SC de los niveles de MDA, AOPP y PGE2 y las actividades de la SOD, disminuciones significativas parciales en los niveles plasmáticos del total nitrato / nitrito y aumentos significativos en la actividad de AC de GSH-Px. Sin embargo, se observaron los mejores resultados durante la combinación de ambos fármacos en todas las evaluaciones neurológicas y en los puntos finales bioquímicos. En conclusión, debido a sus acciones antioxidantes y antiinflamatorias sinérgicas, la terapia de melatonina y α-tocoferol alivia la paraplejía inducida por SC-IRI.

Vertebral Artery Dissection Presenting with Acute Infarction in Cervical Spinal Cord and Cerebellum

We describe a case of vertebral artery dissection (VAD) presenting with acute infarctions in cervical spinal cord and cerebellum in a 78-year-old man. Diffusion-weighted magnetic resonance (MR) imaging of the brain demonstrated diffusion-restricted lesions in the right cerebellum and sagittal T2-weighted MR imaging of spinal cord showed a hyperintense lesion of the cervical spinal cord at C2-C4 level. Right VAD was identified by transfemoral cerebral angiography and computed tomography angiography which showed segmental occlusion in the right vertebral artery.

Conus Medullaris Syndrome Due to Posterior Spinal Artery Infarction

A 77-year-old female with a history of osteoarthritis visited our clinic complaining of lower back pain, paresthesia in both legs, and voiding difficulty. Her pain and temperature sensations were diminished below the L1 dermatome, and proprioception was decreased in both feet. The findings of a routine laboratory workup, echocardiogram, and cerebrospinal fluid studies were normal. Spine magnetic resonance imaging revealed high T2-weighted signal intensities and diffusion restriction in the posterior conus medullaris. The patient was diagnosed and treated for posterior spinal artery infarction.

Transient paraplegia after neurolytic splanchnic block in a patient with metastatic colon carcinoma

We present a patient with metastatic colon carcinoma who developed paraplegia following a neurolytic splanchnic block. A 41-year old man with metastatic adenocarcinoma of the colon received a splanchnic neurolytic block using alcohol because of severe abdominal pain. Bilateral motor weakness and a sensorial deficit in both legs developed after the procedure. Diffusion magnetic resonance imaging revealed spinal cord ischemia between T8 and L1. The motor and sensorial deficits were almost completely resolved at the end of the third month. We think that anterior spinal artery syndrome due to reversible spasms of the lumbar radicular arteries using alcohol have resulted in transient paraplegia. The retrograde spread of alcohol to neural structures may have also contributed.

Down-regulated miR-448 relieves spinal cord ischemia/reperfusion injury by up-regulating SIRT1

MicroRNAs play a crucial role in the progression of spinal cord ischemia/reperfusion injury (SCII). The role of miR-448 and SIRT1 in SCII was investigated in this study, to provide further insights into prevention and improvement of this disorder. In this study, expressions of miR-448 and SIRT1 protein were determined by qRT-PCR and western blot, respectively. Flow cytometry was used to analyze cell apoptosis. The endogenous expression of genes was modulated by recombinant plasmids and cell transfection. Dual-luciferase reporter assay was performed to determine the interaction between miR-448 and SIRT1. The Basso, Beattie, and Bresnahan score was used to measure the hind-limb function of rat. The spinal cord ischemia reperfusion injury model of adult rats was developed by abdominal aorta clamping, and the nerve function evaluation was completed by motor deficit index score. In SCII tissues and cells treated with hypoxia, miR-448 was up-regulated while SIRT1 was down-regulated. Hypoxia treatment reduced the expression of SIRT1 through up-regulating miR-448 in nerve cells. Up-regulation of miR-448 induced by hypoxia promoted apoptosis of nerve cells through down-regulating SIRT1. Down-regulated miR-448 improved neurological function and hind-limb motor function of rats with SCII by up-regulating SIRT1. Down-regulated miR-448 inhibited apoptosis of nerve cells and improved neurological function by up-regulating SIRT1, which contributes to relieving SCII.

Spinal cord infarction mimicking ischemic heart disease

Spinal cord infarction is a rare condition and is easily misdiagnosed owing to its initial non-specific manifestation. We report a case of a 77–year-old man who presented with chest pain and upper back pain initially, and was misdiagnosed with a myocardial infarction. Four hours after admission, he complained of numbness in his entire left leg below the knee, with rapid deterioration of neurological symptoms. After 9 hours, loss of sensation progressed up to the T4 dermatome, strength of both lower extremities deteriorated to grade 0, and decrease in anal tone and deep tendon reflex was observed. Initial magnetic resonance imaging findings were normal; however, a signal change occurred 3 days after symptom onset. When patients present with acute chest pain and neurologic symptoms, the possibility of ischemic cardiac disease as well as any neurological manifestations must be investigated. Emergency physicians must remember the value of serial physical examinations.

Surfer's Myelopathy: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare cause of non-traumatic spinal cord injury (SCI) during surfing SUMMARY OF LITERATURE REVIEW: Surfer's myelopathy is a non-traumatic SCI associated with the hyperextension posture during paddling in surfing. Although the definite pathomechanism has not been identified, cord ischemia followed by arterial infarction may be related to this injury. MATERIALS AND METHODS: A young healthy male patient presented with a SCI that occurred during his first time surfing. Magnetic resonance imaging revealed a T2-hyperintense lesion in the spinal cord from D10 to the conus medullaris. RESULTS: The patient completely recovered without any neurologic deficits after steroid therapy and other forms of supportive management. CONCLUSIONS: Since surfing is becoming more common in Korea, awareness of surfer's myelopathy is important for early diagnosis and proper management.

Myelopathy Caused by Surfing

No abstract available.

Novalis Stereotactic Radiosurgery for Spinal Dural Arteriovenous Fistula

The spinal dural arteriovenous fistula (SDAVF) is rare, presenting with progressive, insidious symptoms, and inducing spinal cord ischemia and myelopathy, resulting in severe neurological deficits. If physicians have accurate and enough information about vascular anatomy and hemodynamics, they achieve the good results though the surgery or endovascular embolization. However, when selective spinal angiography is unsuccessful due to neurological deficits, surgery and endovascular embolization might be failed because of inadequate information. We describe a patient with a history of vasospasm during spinal angiography, who was successfully treated by spinal stereotactic radiosurgery using Novalis system.

Cervical Myelopathy Caused by Intracranial Dural Arteriovenous Fistula

Intracranial dural arteriovenous fistula (dAVF) usually results in various problems in the brain. But it can be presented as a myelopathy, which may make early diagnosis and management to be difficult. We recently experienced a case of cervical myelopathy caused by intracranial dAVF. A 60-year-old man presented with a 3-year history of gait disturbance due to a progressive weakness of both legs. Neurological examination revealed spastic paraparesis (grade IV) and Babinski sign on both sides. Magnetic resonance imaging showed serpentine vascular signal voids at C2-T1 on T2-weighted image with increased signal intensity and swelling of spinal cord at C1-C4. We performed a brain computed tomography angiography and found intracranial dAVF with multiple arteriovenous shunts. Venous drainages were noted at tentorial veins and cervical perimedullary veins. After Onyx embolization, the patient showed gradual improvement in motor power and gait disturbance. The venous drainage pattern is a well-known prognostic factor of dAVF. In our case, the intracranial dAVF drained to spinal perimedullary vein, which seemed to result in the ischemic myelopathy. Although it is rare condition, it sometimes can cause serious complications. Therefore, we should keep in mind the possibility of intracranial dAVF when a patient presents myelopathy.

Paraplegia following cervical epidural catheterization using loss of resistance technique with air: a case report / 대한마취과학회지

We report a case of paraplegia without neurologic deficit of upper extremities following cervical epidural catheterization using air during the loss of resistance technique. A 41-year-old woman diagnosed with complex regional pain syndrome had upper and lower extremity pain. A thoracic epidural lead was inserted for a trial spinal cord stimulation for treating lower extremity pain and cervical epidural catheterization was performed for treating upper extremity pain. Rapidly progressive paraplegia developed six hours after cervical epidural catheterization. Spine CT revealed air entrapment in multiple thoracic intervertebral foraminal spaces and surrounding epidural space without obvious spinal cord compression before the decompressive operation, which disappeared one day after the decompressive operation. Her paraplegia symptoms were normalized immediately after the operation. The presumed cause of paraplegia was transient interruption of blood supply to the spinal cord through the segmental radiculomedullary arteries feeding the spinal cord at the thoracic level of the intervertebral foramen caused by the air.

Anatomia da circulação medular / Anatomy of spinal blood supply

A intrincada anatomia tridimensional da irrigação medular é frequentemente explanada na literatura com diferentes nomenclaturas e devido a sua alta relevância no estudo da isquemia medular, o estudo da terminologia se faz necessário para melhor compreensão do tema. A artéria de Adamkiewicz, também chamada de artéria radicular magna, é a via principal. Foi realizada a revisão da literatura com equiparação das nomenclaturas utilizadas e elaboração de descrição acurada e sumarizada do conhecimento atual sobre a vascularização medular.

The intricate three-dimensional vascular anatomy of the spinal cord is still not completely understood, and its terminology varies between studies. In view of its importance in spinal ischemia, an analysis is needed of the anatomic vocabulary used to describe the spinal cord blood supply to improve understanding of the subject. The main supply is the Adamkiewicz artery, also known as great anterior radicular artery. The literature was reviewed to equate the different nomenclatures employed and an accurate description of current knowledge on spinal cord vascularization was prepared.

The influence of low-level laser irradiation on spinal cord injuries following ischemia- reperfusion in rats

PURPOSE:To investigate if low level laser therapy (LLLT) can decrease spinal cord injuries after temporary induced spinal cord ischemia-reperfusion in rats because of its anti-inflammatory effects.METHODS: Forty eight rats were randomized into two study groups of 24 rats each. In group I, ischemic-reperfusion (I-R) injury was induced without any treatment. Group II, was irradiated four times about 20 minutes for the following three days. The lesion site directly was irradiated transcutaneously to the spinal direction with 810 nm diode laser with output power of 150 mW. Functional recovery, immunohistochemical and histopathological changes were assessed.RESULTS:The average functional recovery scores of group II were significantly higher than that the score of group I (2.86 ± 0.68, vs 1.38 ± 0.09; p<0.05). Histopathologic evaluations in group II were showed a mild changes in compare with group I, that suggested this group survived from I-R consequences. Moreover, as seen from TUNEL results, LLLT also protected neurons from I-R-induced apoptosis in rats.CONCLUSION:Low level laser therapy was be able to minimize the damage to the rat spinal cord of reperfusion-induced injury.

Neuroprotective effect of atorvastatin in spinal cord ischemia-reperfusion injury

OBJECTIVES: Prevention of the development of paraplegia during the repair of the damage caused by descending thoracic and thoracoabdominal aneurysms remains an important issue. Therefore, we investigated the protective effect of atorvastatin on ischemia-induced spinal cord injury in a rabbit model. METHOD: Thirty-two rabbits were divided into the following four equally sized groups: group I (control), group II (ischemia-reperfusion), group III (atorvastatin treatment) and group IV (atorvastatin withdrawal). Spinal cord ischemia was induced by clamping the aorta both below the left renal artery and above the iliac bifurcation. Seventy-two hours postoperatively, the motor function of the lower limbs of each animal was evaluated according to the Tarlov score. Spinal cord and blood samples were obtained for histopathological and biochemical analyses. RESULTS: All of the rabbits in group II exhibited severe neurological deficits. Atorvastatin treatment (groups III and IV) significantly reduced the level of motor dysfunction. No significant differences were observed between the motor function scores of groups III and IV at the evaluated time points. Light microscopic examination of spinal cord tissue samples obtained at the 72nd hour of reperfusion indicated greater tissue preservation in groups III and IV than in group II. CONCLUSION: This study demonstrates the considerable neuroprotective effect of atorvastatin on the neurological, biochemical and histopathological status of rabbits with ischemia-induced spinal cord injury. Moreover, the acute withdrawal of atorvastatin therapy following the induction of spinal cord ischemia did not increase the neuronal damage in this rabbit model. .

The Neuroprotective Effect of Kefir on Spinal Cord Ischemia/Reperfusion Injury in Rats

OBJECTIVE: The main causes of spinal cord ischemia are a variety of vascular pathologies causing acute arterial occlusions. We investigated neuroprotective effects of kefir on spinal cord ischemia injury in rats. METHODS: Rats were divided into three groups : 1) sham operated control rats; 2) spinal cord ischemia group fed on a standard diet without kefir pretreatment; and 3) spinal cord ischemia group fed on a standard diet plus kefir. Spinal cord ischemia was performed by the infrarenal aorta cross-clamping model. The spinal cord was removed after the procedure. The biochemical and histopathological changes were observed within the samples. Functional assessment was performed for neurological deficit scores. RESULTS: The kefir group was compared with the ischemia group, a significant decrease in malondialdehyde levels was observed (p<0.05). Catalase and superoxide dismutase levels of the kefir group were significantly higher than ischemia group (p<0.05). In histopathological samples, the kefir group is compared with ischemia group, there was a significant decrease in numbers of dead and degenerated neurons (p<0.05). In immunohistochemical staining, hipoxia-inducible factor-1alpha and caspase 3 immunopositive neurons were significantly decreased in kefir group compared with ischemia group (p<0.05). The neurological deficit scores of kefir group were significantly higher than ischemia group at 24 h (p<0.05). CONCLUSION: Our study revealed that kefir pretreatment in spinal cord ischemia/reperfusion reduced oxidative stress and neuronal degeneration as a neuroprotective agent. Ultrastructural studies are required in order for kefir to be developed as a promising therapeutic agent to be utilized for human spinal cord ischemia in the future.

Protective effect of adenosine preconditioning against spinal cord ischemia-reperfusion injury in rats / 南方医科大学学报

<p><b>OBJECTIVE</b>To study the effect of adenosine preconditioning on cell apoptosis and expressions of glucose-regulated protein (GRP-78) and cysteinyl aspartate-specific protease 12 (caspase-12) in rats with spinal cord ischemia-reperfusion injury.</p><p><b>METHODS</b>Twenty-seven rats were randomized into 3 equal groups and subjected to sham operation (group A), spinal cord ischemia-reperfusion injury (group B), or ischemia-reperfusion injury with adenosine treatment. Spinal cord ischemia-reperfusion injury was induced by cross-clamping of the abdominal aorta inferior to the left renal artery. The spinal cord function was assessed using the Modified Tarlov Scale at 6, 12, and 24 h after reperfusion. At 24 h after reperfusion, histological analysis was carried out with HE staining; cell apoptosis and viability were determined with TUNEL staining, and the expressions of GRP-78 and caspase-12 proteins were determined with Western blotting.</p><p><b>RESULTS</b>HE staining of the spinal cord showed extensive spinal cord injury such as cell edema in group B as compared with group C. Compared with group A, group B showed a significantly increased number of apoptotic cells; the number of apoptotic cells in group B was greater than that in group C. Compared with group B, group C showed significantly increased GRP-78 expression (P<0.01) and decreased caspase-12 expression (P<0.01).</p><p><b>CONCLUSION</b>Adenosine can up-regulate GRP-78 expression and down-regulate caspase-12 expression, and protects the spinal cord against ischemia-reperfusion injury by inhibiting cell apoptosis.</p>

Características da artéria de Adamkiewicz: comparação entre indivíduos com e sem aortopatia / Adamkiewicz artery characteristics: comparison between patients with and without aortopathy

Introdução: O presente estudo visa elucidar a apresentação anatômica da vasculatura medular em exame angiotomográfico e suas diferenças entre pacientes aortopatas e não aortopatas na população brasileira. Objetivos: Determinar as características da artéria de Adamkiewicz (AKA) e artéria espinhal anterior (ASA) por método não invasivo. Secundariamente, determinaremos a distribuição anatômica da AKA na população brasileira e a influência de determinadas aortopatias e comorbidades na identificação da AKA. Casuística: Cento e quinze angiotomografias elegíveis realizadas no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foram avaliadas e separadas entre pacientes aortopatas e não aortopatas. Trinta e dois (52,5%) homens e 29 mulheres constituíram o grupo não aortopata e 30 (56,6%) homens e 23 mulheres constituíram o grupo de aortopatas. Método: Análise prospectiva de angiotomografias realizadas em aparelho de 320 detectores através de software open-source OsiriX e identificação da AKA e ASA por reconstrução multiplanar tridimensional. Dados clínicos e sociodemográficos foram estratificados. Resultados: A AKA foi identificada em 78,7% dos integrantes do grupo não aortopata e em 40,7% dos pacientes aortopatas (p =< 0,0001). A ASA foi identificada em 80,3% dos integrantes do grupo não aortopata e em 46,3% dos pacientes aortopatas (p=0,0001). Em 53 (73,6%) casos a AKA originou-se do lado esquerdo. Discussão: A angiotomografia é exame de rotina no pré-operatório de doenças aórticas. O presente trabalho apresentou detecção da AKA em grupo não aortopata equiparável com a literatura, apesar do aumento de detectores no aparelho de tomografia e a identificação da AKA em grupo aortopata pouco abaixo da literatura, mas significativamente diferente do grupo não aortopata: maior proporção de identificação da AKA e ASA em pacientes não aortopatas. Houve diferença na distribuição da AKA em comparação com a literatura...

Introduction: This study investigated differences in spinal vasculature between healthy and diseased aortas among Brazilian population. Objective: The study aimed to identify and describe the spinal vascular anatomy, evaluate Anterior Spinal Artery (ASA) and Adamkiewicz artery (AKA) characteristics using non-invasive multidetector computed tomography (CT), as well as examine differences between groups with and without aortic disease. The secondary aim was to evaluate anatomic distribution of AKA level and side and the influence of clinical factors in its detection. Methods: CT scans of 115 patients from Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were evaluated in terms of detection rate and AKA level and side. The results were also compared with data compiled from a review of the English language literature on this topic. We analysed 320-detector CT scans using OsiriX open source software. Furthermore, we identified the AKA and ASA using tridimensional multiplannar reconstruction. Clinical and demographics data were retrieved. Results: AKA identification showed higher detection rate in patients with healthy aortas (78.7%) compared to diseased aortas (40.7%) p < 0.0001. ASA was identified in 80.3% of the healthy aortas patients and 46.3% of the diseased aortas patients (p=0.0001). In 53 (76.6%) cases, the AKA originated from a left intercostal artery. Discussion: CT scan is a routine preoperative exam for aorta diseases. We observed a detection rate similar to that reported in previous literature on healthy aortas, in spite of the CT having more detectors. Furthermore, AKA identification in aorta diseased group was below literature, but statistically different from the healthy aorta group, higher AKA and ASA identification was found in healthy aorta group. The results indicated significant difference between previous literatures and our study in AKA detection. Conclusions: AKA...

Spinal Cord Ischemia Secondary to Hypovolemic Shock

A 44-year-old male presented with symptoms of spinal cord compression secondary to metastatic prostate cancer. An urgent decompression at the cervical-thoracic region was performed, and there were no complications intraoperatively. Three hours postoperatively, the patient developed acute bilateral lower-limb paralysis (motor grade 0). Clinically, he was in class 3 hypovolemic shock. An urgent magnetic resonance imaging (MRI) was performed, showing no epidural hematoma. He was managed aggressively with medical therapy to improve his spinal cord perfusion. The patient improved significantly, and after one week, he was able to regain most of his motor functions. Although not commonly reported, spinal cord ischemia post-surgery should be recognized early, especially in the presence of hypovolemic shock. MRI should be performed to exclude other potential causes of compression. Spinal cord ischemia needs to be managed aggressively with medical treatment to improve spinal cord perfusion. The prognosis depends on the severity of deficits, and is usually favorable.