Onyx embolization of a spinal epidural hemorrhage caused by thoracic spinal epidural arteriovenous fistula:A case report and literature review

Spinal epidural hemorrhages(SEDH)caused by spinal epidural arteriovenous fistulas(SEAVFs)are rare;thus,their specific pathogenesis has not been explained.Furthermore,the standard treatment for SEAVFs has not yet been defined.Here we report the case of a 36-year-old Chinese man who experienced acute onset chest pain and tightness.His symptoms rapidly aggravated until the lower limbs were unable to support him.Spinal magnetic resonance angiography(MRA)revealed a localized SEAVF and a secondary spinal cord lesion at the T4 level.Digital subtraction angiography(DSA)confirmed the presence of the SEDH/SEAVF at the T3–4 level with the left radicular artery feeding the fistula.Based on DSA and MRA findings,SEDH,local spinal cord infarction,and spinal venous reflux disorder were conditionally diagnosed.Using the arterial route,Onyx-34 was injected into the fistula to embolize the feeding arteries and the venous system.Angiography was performed after the microcatheter was withdrawn,and no residual fistula or anterior spinal artery was observed.The six-week follow-up MRI showed acceptable healing of the SEAVF,and the patient improved neurologically.This case suggests that endovascular treatment with Onyx-34 embolization should be considered a promising treatment strategy for this type of complicated SEAVF.

Spinal epidural hematoma after spinal manipulation therapy:Report of three cases and a literature review

BACKGROUND Spinal manipulation therapy(SMT)has been widely used worldwide to treat musculoskeletal diseases,but it can cause serious adverse events.Spinal epidural hematoma(SEH)caused by SMT is a rare emergency that can cause neurological dysfunction.We herein report three cases of SEH after SMT.CASE SUMMARY The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT.Her symptoms persisted after 3 d of conservative treatment,and she was admitted to our hospital.Magnetic resonance imaging(MRI)demonstrated an SEH,extending from C6 to C7.The second case was a 55-year-old man with sudden back pain 1 d after SMT,numbness in both lower limbs,an inability to stand or walk,and difficulty urinating.MRI revealed an SEH,extending from T1 to T3.The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT.He was unable to stand or walk and experienced mild back pain.MRI revealed an SEH,extending from T1 to T2.All three patients underwent surgery after failed conservative treatment.The three cases recovered to ASIA grade E on day 5,1 wk,and day 10 after surgery,respectively.All patients returned to normal after 3 mo of follow-up.CONCLUSION SEH caused by SMT is very rare,and the condition of each patient should be evaluated in full detail before operation.SEH should be diagnosed immediately and actively treated by surgery.

Spinal Epidural Abscess in Patients with Sepsis Who Experienced Significant Improvements after Complete Paralysis: Two Case Reports

Spinal epidural abscess (SEA) is a rare condition, and a delay in its diagnosis causes paralysis. In this study, we report two rare cases of delayed diagnosis of SEA whose conditions improved after a state of complete paralysis. The first case was a 71-year-old diabetic man who received a corticosteroid injection for shoulder pain that caused intensified pain. Thereafter, the patient developed paralysis of both legs in stage IV according to Heusner staging. Subsequently, he was diagnosed with multiple abscesses and sepsis. He was in a poor state of health. Therefore, we treated his epidural abscess conservatively. After a month, his muscle strength had improved to Heusner stage III-A, and he was transferred to another hospital. The second case was a 64-year-old diabetic man who received an epidural corticosteroid injection for lower back pain. However, the pain intensified and was admitted to the hospital for pyelonephritis. He developed paralysis in both of his arms and legs presenting as a Heusner stage IV, caused by a cervical epidural abscess. A laminoplasty was performed and paralysis was improved. However, the patient subsequently developed a left subcortical hemorrhage. He underwent surgery. However, his right hemiplegia persisted, and on Day 21, he was transferred back to the previous hospital with a Heusner III-A. We could improve the patients’ paralysis by cooperating closely with infectious disease specialists and spine surgeons, taking intensive care, applying antibacterial agents appropriately, and operating quickly.

Effects of Combined Spinal Epidural Anaesthesia and Spinal Anaesthesia on Peri-Operative Pulmonary Status in Geriatric Patients in Lower Extremity Surgery

Background: Lower extremity surgeries performed in elderly people usually have high prevalence of peri-operative medical problems related to anaesthesia. The overall objective of peri-operative care of geriatric population is to fast recovery from anaesthesia and avoid functional decline. Objective: To compare the peri-operative pulmonary status of combined spinal epidural anaesthesia (CSEA) and spinal anaesthesia (SA) in geriatric patients underwent lower extremity surgeries. Methods: This prospective comparative study was conducted at Department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2016 to June 2018. A total of 70 geriatric cases that underwent lower extremity surgeries were included in this study. Cases were randomly allocated into two groups;35 in Group A (CSEA) and 35 in Group B (SAB). The different outcome variables between the groups like-duration of anaesthesia, respiratory rates (RR), oxygen saturation (SpO2), end tidal CO2 (EtCO2), peak expiratory flow rate (PEFR), breath holding test (BHT), peri-operative side effects of anaesthesia and post-operative visual analogue score (VAS) were analyzed and compared by statistical tests. Results: The mean age, weight, BMI of Group A and Group B patients were not significantly different (p > 0.05). No significant differences were observed in duration of surgery, gender and ASA grade between the groups (p > 0.05). Mean duration of anaesthesia, mean time to achieve target level of sensory block and mean time to achieve complete motor block were significantly higher in Group A (p < 0.001). Mean RR, SpO2, EtCO2, PEFR and BHT of both groups were not significantly different (p > 0.05). Peri-operative side effects of anaesthesia and post-operative VAS were significantly less in group A patients (p < 0.05). Conclusion: Combined spinal epidural anaesthesia is effective and safe;produces stable peri-operative pulmonary status with prolonging analgesia and fewer side effects as compared to spinal anaesthesia in geriatric patients.

Extensive Spinal Epidural Abscess: Cord Compression with Permanent Neurological Defects

Spinal epidural abscesses (SEA) are considerably rare and tend to present over two to five vertebral segments. Occasionally, there will be two or more noncontiguous areas of pyogenic collections [1]. Minimal cases have been reported to span the entire vertebral column;a meta-analysis estimates that 1% of all SEA are holospinal [2]. The triad of presenting symptoms includes fever, back pain (often midline), and neurologic defects [1] [2] [3]. Early detection is identified as a critical aspect of improved outcomes. Cases that do not present in this manner or with other masking symptoms can lead to delayed diagnosis, thus delaying treatment. In the event of cord compression, the occurrence of neurologic defects increases. Time from the onset of clinical manifestations to the operating room is crucial in reversing symptoms [2]. This article seeks to review a case of a 65-year-old male that presented to the emergency department (ED) due to a falling second to weakness and thigh pain. On presentation, he was also noted to have rhabdomyolysis causing acute kidney injury (AKI) with tubular necrosis. The patient was admitted to the hospital with a complex history of progressive leg weakness, pain in the lower back, incontinence, and elevated white blood cell count. Days into the admission, a magnetic resonance imaging (MRI) study was performed, which revealed a continuous posterior SEA from C4 to S2 with anterior mass effect causing spinal cord compression. Emergency neurosurgery was scheduled for laminectomies in the cervical, thoracic and lumbar spine to drain the abscess. Evaluation of this complex medical course, surgical approach to drainage of an incessant spinal column abscess, and sustained neurologic defects will be discussed.

Analgesic Effect of Combined Spinal-Epidural Anesthesia and its Effect on TNF-α and CRP Levels in Elderly Patients with Hip Fracture During Surgical Treatment

Objective:To observe the analgesic effect of combined spinal and epidural anesthesia on older patients undergoing hip fracture surgery.Method:One hundred and twenty elderly hip fracture surgery patients treated in our hospital from January 2021 to December 2022 were selected and randomly divided into two groups,with 60 cases in the experimental group and 60 in the control group.The experimental group was given combined spinal-epidural anesthesia intervention measures,while the control group was given epidural anesthesia intervention measures.The analgesic effect,tumor necrosis factor-alpha(TNF-α),C-reactive protein(CRP)levels,and other observation indicators were analyzed after anesthesia intervention.Result:After the intervention,the analgesic effect and the evaluation results of the subjects in the experimental group were better than those in the control group(P<0.05);the obtained values of TNF-αand CRP levels in the experimental group were higher than those of the control group(P<0.05).Conclusion:The combined spinal-epidural anesthesia intervention demonstrated positive outcomes.The analgesic effect of patients during surgery and their inflammatory factor levels improved,which makes this intervention worthy of clinical application and promotion.

Early diagnosis and treatment of acute or subacute spinal epidural hematoma

Background Despite low morbidity, acute or subacute spinal epidural hematoma may develop quickly with a high tendency to paralysis. The delay of diagnosis and therapy often leads to serious consequences. In this study we evaluated the effects of a series of methods for the diagnosis and treatment of the hematoma in 11 patients seen in our hospital. Methods Of the 11 patients （8 males and 3 females）, 2 had the hematoma involving cervical segments, 2 cervico-thoracic, 4 thoracic, 1 thoraco-lumbar, and 2 lumbar. Three patients had quadriplegia, including one with central cord syndrome; another had Brown-Sequard＇s syndrome; and the other seven had paraplegia. Five patients were diagnosed at our hospitals within 3-48 hours after appearance of symptoms, and 6 patients were transferred from community hospitals within 21-106 hours after development of symptoms. Key dermal points, key muscles and the rectal sphincter were determined according to the American Spinal Injury Society Impairment Scales as scale A in two patients, B in 5 and C in 4. Emergency MRI in each patient confirmed that the dura mater was compressed in the spinal canal, with equal intensity or hyperintensity on T1 weighted image and mixed hyperintensity on T2 weighted image. Preventive and curative measures were taken preoperatively and emergency operation was performed in all patients. Open laminoplasty was done at the cervical and cervico-thoracic segments, laminectomy at the thoracic segments, laminectomy with pedicle screw fixation at the thoraco-lumbar and lumbar segments involving multiple levels, and double-sided laminectomy with the integrity of articular processes at the lumbar segments involving only a single level. During the operation, special attention was given to hematoma evacuation, hemostasis and drainage tube placement. Results Neither uncontrollable hemorrhage nor postoperative complications occurred. All patients were followed up for 1-6 years. A marked difference was noted between postoperative and preoperative scales （u=-3.66, P〈0.01）. Most patients recovered after therapy, but the recovery of patients treated at our hospitals was superior to that of those transferred from community hospitals （t =2.95, P〈0.05）. Of the patients treated at our hospitals, 4 were cured and 1 was upgraded with scale from A to D, whereas none of those transferred from community hospitals recovered completely, even one remained scale C. Conclusions Physical examination plus MRI is essential to early diagnosis of acute or subacute spinal epidural hematoma. Preventive and curative measures including emergency operation are helpful to the recovery of patients＇ nerve function.

Spine surgery may cause more spinal epidural hematomas than spinal puncture

Background Spinal epidural hematoma （SEH） is a rare but acute and possibly devastating clinical event. The purpose of this study is to assess the multiple etiologies of SEH seen in an academic medical center over a 15-year span. We have examined the etiologies of SEH occurring in a single institution, the University of Pittsburgh Medical Center （UPMC） over the last fifteen years using an electronic record keeping system and database： the Medical Archive Retrieval System （MARS）. Methods We screened MARS from 1986-2001 using key words： epidural, hematoma and spinal. All potential SEH cases were reviewed and only those confirmed by surgical intervention were identified as positive SEH and reported in this study. Results There were 17 cases of confirmed SEH. Among them, seven cases were from spontaneous bleeding, seven cases following spinal surgery, and three cases from traumatic spinal fracture. There were no findings of SEH that were related to spinal or epidural anesthesia. Among the seven patients with spontaneous SEH; two were receiving anti-coagulants for deep venous thrombosis （DVT） and had elevated prothrombin time （PT） and activated partial thromboplastine time （APTT）, one had hemophilia （type B）, four had hypertension, and three out of seven had chronic renal or liver disease. Among postoperative SEH patients, two of the seven patients were receiving chemotherapy and radiation therapy and one had ongoing hemodialysis for renal failure. Among three patients with traumatic SEH, two had ankylosing spondylitis. Six patients had a history of alcohol abuse. Conclusions Spontaneous bleeding is by far the leading cause of SEH with spinal surgery being the second leading cause. Patients with multiple co-morbidities that result in coagulopathy from a variety of causes include liver or renal disease, alcohol abuse, radiation therapy, or chemotherapy. Neuraxial anesthesia is an extremely rare cause of SEH.

A flexible electrode array for determining regions of motor function activated by epidural spinal cord stimulation in rats with spinal cord injury

Epidural stimulation of the spinal cord is a promising technique for the recovery of motor function after spinal cord injury.The key challenges within the reconstruction of motor function for paralyzed limbs are the precise control of sites and parameters of stimulation.To activate lower-limb muscles precisely by epidural spinal cord stimulation,we proposed a high-density,flexible electrode array.We determined the regions of motor function that were activated upon epidural stimulation of the spinal cord in a rat model with complete spinal cord,which was established by a transection method.For evaluating the effect of stimulation,the evoked potentials were recorded from bilateral lowerlimb muscles,including the vastus lateralis,semitendinosus,tibialis anterior,and medial gastrocnemius.To determine the appropriate stimulation sites and parameters of the lower muscles,the stimulation characteristics were studied within the regions in which motor function was activated upon spinal cord stimulation.In the vastus lateralis and medial gastrocnemius,these regions were symmetrically located at the lateral site of L1 and the medial site of L2 vertebrae segment,respectively.The tibialis anterior and semitendinosus only responded to stimulation simultaneously with other muscles.The minimum and maximum stimulation threshold currents of the vastus lateralis were higher than those of the medial gastrocnemius.Our results demonstrate the ability to identify specific stimulation sites of lower muscles using a high-density and flexible array.They also provide a reference for selecting the appropriate conditions for implantable stimulation for animal models of spinal cord injury.This study was approved by the Animal Research Committee of Southeast University,China(approval No.20190720001) on July 20,2019.

Spontaneous Thoracic Spinal Epidural HematomaDuring Pregnancy

To editor:Spontaneous spinal epidural hematoma(SSEH)is uncom-mon,especially during pregnancy.However,SSEH is a seriousemergency that must be managed immediately to prevent per-manent neurological deficit of the mother and stillbirth.Theetiology and pathogenesis of SEEH remain unknown,al-though multiple theories and precipitating factors are de-scribed in the literature.In this report,we describe the caseof a pregnant female who developed SSEH.

Compressive Myelopathy, Spinal Shock, and a Complicated Neurological Exam

The neurological examination, developed and tested since the 1800s has provided physicians with a vital tool to rapidly assess and provide clues to many of the pathological processes lurking inside the brain and spinal cord. With the advent of magnetic resonance imaging, physicians are able to visualize the precise location of the abscess before surgical intervention. In this case report, we present a 51-year-old male with an epidural abscess with multifocal compressive myelopathy, resulting in a complicated neurological examination, making localization a diagnostic challenge. With this case, we would like to stress that complicated multifocal lesions of the cord may present with a large variation in examination findings. This patient’s neurological exam was complicated secondary to a ventrally as well as dorsally located epidural abscess with superimposed spinal shock sequelae. We would like to highlight the importance of a thorough history and the neurological examination but also mention some of its limitations. It is crucial to use clinical judgement to navigate the patient’s history, presentation, and examination to accurately diagnose and treat, particularly so in cases involving compressive myelopathies of the spinal cord.

Spontaneous Cervical Epidural Hematomas in Mild Cervical Spondylotic Myelopathy Patients：An Analysis of 8 Cases

Spontaneous cervical epidural hematoms（SCEH） complicated with mild cervical spondylotic myelopathy（CSM） is a rare but emerging condition.Early diagnosis and treatment are important for good outcomes.This study aimed to investigate the clinical characteristics of this condition and to discuss the optimal treatment.The clinical data from 8 patients with SCEH plus CSM who were divided into two groups by treatment methods were retrospectively analyzed.The neurological function of the patients was assessed by Japanese Orthopedic Association（JOA） score before and after the surgical operations.Other factors were reviewed with medical records.Among them,4 out of the 8 patients underwent emergency surgery,and the rest 3 patients experienced an initial conservative treatment and ultimately received a laminectomy.We found that the Frankel Scale scores in most of the surgical patients were increased after surgery（6/7,85.7%）.However,the JOA scores at the 6th month after onset were even lower than those before onset in 3 of the operative cases,and those in the patients who were given conservative treatment showed no significant change.It was concluded that some patients with SCEH and CSM treated with a timely operation may obtain relief from their previous CSM symptoms.However,the final neurological deficits of these patients were closely related to the progressive interval which refers to the hours between the initial onset and the occurrence of new neurological deficits or mild CSM deterioration,no matter whether they accept the operation.We found the crucial progressive interval may be in 9 h.Early MRI and prompt neurosurgical intervention are also important to improve the neurological deficits.

Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation:A case report and review of literature

BACKGROUND While most complications of cervical surgery are reversible,some,such as symptomatic postoperative spinal epidural hematoma(SEH),which generally occurs within 24 h,are associated with increased morbidity and mortality.Delayed neurological dysfunction is diagnosed in cases when symptoms present>3 d postoperatively.Owing to its rarity,the risk factors for delayed neurological dysfunction are unclear.Consequently,this condition can result in irreversible neurological deficits and serious consequences.In this paper,we present a case of postoperative SEH that developed three days after hematoma evacuation.CASE SUMMARY A 68-year-old man with an American Spinal Injury Association(ASIA)grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall.The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day.Postoperatively,the patient showed no changes in muscle strength or ASIA grade.The patient experienced neck pain and subcutaneous swelling on the third day postoperatively,his muscle strength decreased,and his ASIA score was grade A.Magnetic resonance imaging showed hypointense signals on T1 weighted image(T1WI)and T2WI located behind the epidural space,with spinal cord compression.Emergency surgical intervention for the hematoma was performed 12 h after onset.Although hypoproteinemia and pleural effusion did not improve in the perioperative period,the patient recovered to ASIA grade C on day 30 after surgery,and was transferred to a functional rehabilitation exercise unit.CONCLUSION This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery.Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.

髓核对大鼠脊神经节非压迫性损伤的组织形态学研究

目的 观察硬膜外移植自体髓核后 ,大鼠脊神经节组织形态学的变化。方法 2 0只Sprague-Dawley(SD)雄性大鼠随机分成对照组和实验组 ,分别将自体肌肉混悬液和尾椎髓核混悬液注射到腰椎硬膜外腔 ,对脊神经节组织形态学进行观察。结果 在无机械压迫情况下 ,大鼠硬膜外移植自体髓核能使脊神经节组织形态产生明显改变。结论 髓核所致的炎性反应是引起脊神经节损伤和坐骨神经痛的重要原因之一。

Regional anesthesia for orthopedic procedures:What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery.Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia.Patient evaluation for regional anesthesia should include neurological,pulmonary,cardiovascular,and hematological assessments.Neuraxial blocks include spinal,epidural,and combined spinal epidural.Upper extremity peripheral nerve blocks include interscalene,supraclavicular,infraclavicular,and axillary.Lower extremity peripheral nerve blocks include femoral nerve block,saphenous nerve block,sciatic nerve block,iPACK block,ankle block and lumbar plexus block.The choice of regional anesthesia is a unanimous decision made by the surgeon,the anesthesiologist,and the patient based on a risk-benefit assessment.The choice of the regional block depends on patient cooperation,patient positing,operative structures,operative manipulation,tourniquet use and the impact of postoperative motor blockade on initiation of physical therapy.Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity(LAST),nerve injury,falls,hematoma,infection and allergic reactions.Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications.LAST treatment guidelines and rescue medications(intralipid)should be readily available during the regional anesthesia administration.

Clinical Efficacy of Acupuncture on the Morphine-related Side Effects in Patients Undergoing Spinal-epidural Anesthesia and Analgesia

Objective： To investigate the effects of acupuncture on the morphine-related side effects （nausea, vomiting, itchiness and gastrointestinal disorders） in patients undergoing anesthesia and analgesia and try to find the clinical mechanism of acupuncture. Methods： Patients scheduled to have transurethral prostatic resection enrolled in the study （69 patients）, characterized as Grade Ⅱ or Ⅲ by the American Society of Anesthesiologists physical status classification, were randomly assigned to three groups, 23 patients in each group： the placebo group （control group）, non-anesthesia area （NAA） group, and the anesthesia area （AA） group. After spinal anesthesia, all patients received Patients Controlled Epidural Analgesia. The vital signs, bowel sounds, visual analogue scales, itchiness, nausea and vomiting, and time for first exhaust post operation were observed. Results： Altogether, nine cases were eliminated, three in each group. Finally, sixty cases completed this study, twenty in each group. There was a significant decrease of bowel sounds after morphine spinal anesthesia in the three groups. Compared with the control or AA group, the bowel sound recovered after acupuncture, the incidences of nausea and vomiting, itchiness, and time for first exhaust after operation decreased in the NAA group （P〈0.05）. There was a significant decrease of the incidence for itchiness in the NAA group compared with the control group （P〈0.05）. Conclusions： On the basis of this study, it is obviously seen that acupuncture could decrease the incidence of morphine-related side effects （nausea and vomiting, itchiness and gastrointestinal disorders） when the spinal cord conduct is normal. However, it decreases only the incidence of itchiness but not for gastrointestinal dysfunction when the spinal cord is blocked.

Neck pain and absence of cranial nerve symptom are clues of cervical myelopathy mimicking stroke:Two case reports

BACKGROUND Cervical myelopathy is a potential stroke imitator,for which intravenous thrombolysis would be catastrophic.CASE SUMMARY We herein present two cases of cervical myelopathy.The first patient presented with acute onset of right hemiparesis and urinary incontinence,and the second patient presented with sudden-onset right leg monoplegia.The initial diagnoses for both of them were ischemic stroke.However,both of them lacked cranial nerve symptom and suffered neck pain at the beginning of onset.Their cervical spinal cord lesions were finally confirmed by cervical computed tomography.A literature review showed that neck pain and absence of cranial nerve symptom are clues of cervical myelopathy.CONCLUSION The current report and the review remind us to pay more attention to these two clues in suspected stroke patients,especially those within the thrombolytic time window.