Cruciate paralysis: a clinical and radiographic analysis of injuries to the cervicomedullary junction

Craniovertebral Junction Instability after Oncological Resection: A Narrative Review

The craniovertebral junction (CVJ) is a complex transition area between the skull and cervical spine. Pathologies such as chordoma, chondrosarcoma and aneurysmal bone cysts may be encountered in this anatomical area and may predispose individuals to joint instability. An adequate clinical and radiological assessment is mandatory to predict any postoperative instability and the need for fixation. There is no common consensus on the need for, timing and setting of craniovertebral fixation techniques after a craniovertebral oncological surgery. The aim of the present review is to summarize the anatomy, biomechanics and pathology of the craniovertebral junction and to describe the available surgical approaches to and considerations of joint instability after craniovertebral tumor resections. Although a one-size-fits-all approach cannot encompass the extremely challenging pathologies encountered in the CVJ area, including the possible mechanical instability that is a consequence of oncological resections, the optimal surgical strategy (anterior vs posterior vs posterolateral) tailored to the patient's needs can be assessed preoperatively in many instances. Preserving the intrinsic and extrinsic ligaments, principally the transverse ligament, and the bony structures, namely the C1 anterior arch and occipital condyle, ensures spinal stability in most of the cases. Conversely, in situations that require the removal of those structures, or in cases where they are disrupted by the tumor, a thorough clinical and radiological assessment is needed to timely detect any instability and to plan a surgical stabilization procedure. We hope that this review will help shed light on the current evidence and pave the way for future studies on this topic.

Cruciate Paralysis Following a Displaced Type II Odontoid Fracture: A Case Report

A 54-year-old male was admitted to our emergency department by air transport after being hit as a pedestrian by a motorcycle. He presented with impaired motor function in the upper extremities bilaterally while sensation was spared. He presented no motor or sensory impairment of the lower extremities. A computed tomography scan revealed a displaced type II odontoid fracture. Treatment consisted of open reduction and internal fixation of the odontoid with a single screw. The patient’s functional outcome was excellent during the two-month follow-up.

Cruciate paralysis is a relatively rare although well-defined neurological condition which results from injury at pyramid decussation. In this case, the presence of a posterior bony spike of the fractured dens was responsible for the development of cruciate paralysis. Early diagnosis and adequate treatment can have successful results.

A critical reappraisal of corticospinal tract somatotopy and its role in traumatic cervical spinal cord syndromes

The corticospinal tract (CST) is the preeminent voluntary motor pathway that controls human movements. Consequently, long-standing interest has focused on CST location and function in order to understand both loss and recovery of neurological function after incomplete cervical spinal cord injury, such as traumatic central cord syndrome. The hallmark clinical finding is paresis of the hands and upper-extremity function with retention of lower-extremity movements, which has been attributed to injury and the sparing of specific CST fibers. In contrast to historical concepts that proposed somatotopic (laminar) CST organization, the current narrative summarizes the accumulated evidence that 1) there is no somatotopic organization of the corticospinal tract within the spinal cord in humans and 2) the CST is critically important for hand function. The evidence includes data from 1) tract-tracing studies of the central nervous system and in vivo MRI studies of both humans and nonhuman primates, 2) selective ablative studies of the CST in primates, 3) evolutionary assessments of the CST in mammals, and 4) neuropathological examinations of patients after incomplete cervical spinal cord injury involving the CST and prominent arm and hand dysfunction. Acute traumatic central cord syndrome is characterized by prominent upper-extremity dysfunction, which has been falsely predicated on pinpoint injury to an assumed CST layer that specifically innervates the hand muscles. Given the evidence surveyed herein, the pathophysiological mechanism is most likely related to diffuse injury to the CST that plays a critically important role in hand function.

Efficacy of Early (≤ 24 Hours), Late (25-72 Hours), and Delayed (>72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis

The therapeutic significance of timing of decompression in acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis remains unsettled. We retrospectively examined a homogenous cohort of patients with ATCCS and magnetic resonance imaging (MRI) evidence of post-treatment spinal cord decompression to determine whether timing of decompression played a significant role in American Spinal Injury Association (ASIA) motor score (AMS) 6 months following trauma. We used the t test, analysis of variance, Pearson correlation coefficient, and multiple regression for statistical analysis. During a 19-year period, 101 patients with ATCCS, admission ASIA Impairment Scale (AIS) grades C and D, and an admission AMS of ≤95 were surgically decompressed. Twenty-four of 101 patients had an AIS grade C injury. Eighty-two patients were males, the mean age of patients was 57.9 years, and 69 patients had had a fall. AMS at admission was 68.3 (standard deviation [SD] 23.4); upper extremities (UE) 28.6 (SD 14.7), and lower extremities (LE) 41.0 (SD 12.7). AMS at the latest follow-up was 93.1 (SD 12.8), UE 45.4 (SD 7.6), and LE 47.9 (SD 6.6). Mean number of stenotic segments was 2.8, mean canal compromise was 38.6% (SD 8.7%), and mean intramedullary lesion length (IMLL) was 23 mm (SD 11). Thirty-six of 101 patients had decompression within 24 h, 38 patients had decompression between 25 and 72 h, and 27 patients had decompression >72 h after injury. Demographics, etiology, AMS, AIS grade, morphometry, lesion length, surgical technique, steroid protocol, and follow-up AMS were not statistically different between groups treated at different times. We analyzed the effect size of timing of decompression categorically and in a continuous fashion. There was no significant effect of the timing of decompression on follow-up AMS. Only AMS at admission determined AMS at follow-up (coefficient = 0.31; 95% confidence interval [CI]:0.21; p = 0.001). We conclude that timing of decompression in ATCCS caused by spinal stenosis has little bearing on ultimate AMS at follow-up.

Cruciate Paralysis in a 20- year -old Male with an Undisplaced Type III Odontoid Fracture

Introduction:

Cruciate Paralysis is a rare incomplete spinal cord syndrome presenting as brachial diplegia with minimal or no involvement of the lower extremities. It occurs as a result of trauma to the cervical spine and is associated with fractures of the axis and/or atlas. Diagnosis is confirmed on MRI and is managed by treatment of the underlying pathology. Prognosis depends on the extent of spinal cord injury and the exact cause.

Case Presentation:

A 20-year-old male presented to the casualty with a history of an injury to the back of the head as a result of a fall. He had severe pain in the neck and shoulder region and experienced difficulty in raising both arms and gripping objects. On examination, he had weakness of both arms, more on the right, involving the C5 to T1 distribution and brisk reflexes. There was no sensory deficit. Radiograph and a computed tomography (CT) scan of the cervical spine showed a type III undisplaced odontoid fracture. MRI showed a signal abnormality in the spinal cord at the level of the cervicomedullary junction extending up to the body of C2 vertebra.

The patient was treated with traction in Gardner Wells tongs for six weeks and a sterno-occipital-mandibular immobilizer immobilizer (SOMI) brace thereafter. At three-month follow-up, he had attained complete neurological recovery.

Conclusion:

Cruciate Paralysis is an important cause of brachial diplegia and must be differentiated from Acute Central Cord syndrome which can have similar clinical features.

Revisiting cruciate paralysis: A case report and systematic review

Objective:

Cruciate paralysis is a rare, poorly understood condition of the upper craniovertebral junction that allows for selective paralysis of the upper extremities while sparing the lower extremities. Reported cases are few and best treatment practices remain up for debate. The purpose of this study was to conduct a systemic literature review in an attempt to identify prognostic predictors and outcome trends associated with cases previously reported in the literature.

Materials and Methods:

We conducted a systematic literature review for all cases using the term “Cruciate Paralysis,” reviewing a total of 37 reported cases. All outcomes were assigned a numerical value based on examination at the last follow-up. These numerical values were further analyzed and tested for statistical significance.

Results:

Of the 37 cases, 78.4% were of traumatic causes. Of these, there were considerably worse outcomes associated with patients over the age of 65 years (P < 0.001). Those patients undergoing surgical treatment showed potentially worse outcomes, with a P value approaching significance at P = 0.08.

Conclusion:

Numerous cases of trauma-associated cruciate paralysis have been reported in the literature; however, there remains a strong need for further study of the condition. While certain risk factors can be elicited from currently reported studies, insignificant data exist to make any sound conclusion concerning whether surgical intervention is always the best method of treatment.

New Posterior Atlantoaxial Restricted Non-Fusion Fixation for Atlantoaxial Instability: A Biomechanical Study

BACKGROUND

Loss of axial rotation and lateral bending after atlantoaxial fusion reduces a patient's quality of life. Therefore, effective, nonfusion fixation alternatives are needed for atlantoaxial instability.

OBJECTIVE

To evaluate the initial stability and function of posterior atlantoaxial restricted nonfusion fixation (PAARNF), a new protocol, using cadaveric cervical spines compared with the intact state, destabilization, and posterior C1-C2 rod fixation.

METHODS

Cervical areas C0 through C3 were used from 6 cadaveric spines to test flexion-extension, lateral bending, and axial rotation range of motion (ROM). With the use of a machine, 1.5-Nm torque at a rate of 0.1 Nm/s was used and held for 10 seconds. The specimens were loaded 3 times, and data were collected in the third cycle and tested in the following sequence: (1) intact, (2) destabilization (using a type II odontoid fracture model), (3) destabilization with PAARNF (PAARNF group), and (4) rod implantation (rod group). The order of tests for the PAARNF and rod groups was randomly assigned.

RESULTS

The average flexion-extension ROM in the PAARNF group was 7.44 ± 2.05°, which was significantly less than in the intact (P = .00) and destabilization (P = .00) groups but not significantly different from that of the rod group (P = .07). The average lateral bending ROM (10.59 ± 2.33°; P = .00) and axial rotation ROM (38.79 ± 13.41°; P = .00) of the PAARNF group were significantly greater than in the rod group. However, the values of the PAARNF group showed no significant differences compared with those of the intact group.

CONCLUSION

PAARNF restricted atlantoaxial flexion-extension but preserved axial rotation and lateral bending at the atlantoaxial joint in a type II odontoid fracture model. However, it should not be used clinically until further studies have been performed to test the long-term effects of this procedure.

Neurotraumatology

Neurotraumatology has its roots in ancient history, but its modern foundations are the physical examination, imaging to localize the pathology, and thoughtful medical and surgical decision making. The neurobiology of cranial and spinal injury is similar, with the main goal of therapies being to limit secondary injury. Brain injury treatment focuses on minimizing parenchymal swelling within the confined cranial vault. Spine injury treatment has the additional consideration of spinal coumn stability. Current guidelines for non-operative and operative management are reviewed in this chapter.

Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis

Object

The objective of this study was to elucidate the relationship between admission demographic data, validated injury severity measures on imaging studies, and clinical indicators on the American Spinal Injury Association (ASIA) motor score, Functional Independence Measure (FIM), manual dexterity, and dysesthetic pain at least 12 months after surgery for acute traumatic central cord syndrome (ATCCS) due to spinal stenosis.

Methods

Over a 100-month period (January 2000 to April 2008), of 211 patients treated for ATCCS, 59 cases were due to spinal stenosis, and these patients underwent surgical decompression. Five of these patients died, 2 were lost to follow-up, 10 were not eligible for the study, and the remaining 42 were followed for at least 12 months.

Results

In the cohort of 42 patients, mean age was 58.3 years, 83% of the patients were men, and 52.4% of the accidents were due to falls. Mean admission ASIA motor score was 63.8 (upper extremities score, 25.8 and lower extremities score, 39.8), the spinal cord was most frequently compressed at skeletal segments C3–4 and C4–5 (71%), mean midsagittal diameter at the point of maximum compression was 5.6 mm, maximum canal compromise (MCC) was 50.5%, maximum spinal cord compression was 16.5%, and length of parenchymal damage on T2-weighted MR imaging was 29.4 mm. Time after injury until surgery was within 24 hours in 9 patients, 24–48 hours in 10 patients, and more than 48 hours in 23 patients. At the 1-year follow-up, the mean ASIA motor score was 94.1 (upper extremities score, 45.7 and lower extremities score, 47.6), FIM was 111.1, manual dexterity was 64.4% of baseline, and pain level was 3.5. Stepwise regression analysis of 10 independent variables indicated significant relationships between ASIA motor score at follow-up and admission ASIA motor score (p = 0.003), MCC (p = 0.02), and midsagittal diameter (p = 0.02); FIM and admission ASIA motor score (p = 0.03), MCC (p = 0.02), and age (p = 0.02); manual dexterity and admission ASIA motor score (p = 0.0002) and length of parenchymal damage on T2-weighted MR imaging (p = 0.002); and pain level and age (p = 0.02) and length of parenchymal lesion on T2-weighted MR imaging (p = 0.04).

Conclusions

The main indicators of long-term ASIA motor score, FIM, manual dexterity, and dysesthetic pain were admission ASIA motor score, midsagittal diameter, MCC, length of parenchymal damage on T2-weighted MR imaging, and age, but different domains of outcome were determined by different predictors.

Neurologic Findings of Craniovertebral Junction Disease

IN THIS REVIEW, we explain the origins of central cord syndrome and Bell's cruciate paralysis and the intricate detail of neural pathways located in this region and their influence on motor and sensory function. Although lesion studies and tract tracing studies on primates over the past 50 years refute the theory of a somatotopically organized corticospinal tract, this concept continues to pervade many neuroanatomic texts. We categorized the various pathologies of the craniovertebral junction and their unique neurologic presentations. New developments in the fields of neuroscience of spinal tract lesioning are also discussed.

Cruciate paralysis secondary to traumatic atlantooccipital dislocation

Cruciate paralysis is a clinical phenomenon thought to result from injury to decussating pyramidal tract fibers at the cervicomedullary junction, producing clinical findings of upper-extremity weakness out of proportion to the lower extremities. The authors present, to their knowledge, the first reported case of cruciate paralysis resulting from atlantooccipital dislocation.

Identifying survivors with traumatic craniocervical dissociation: a retrospective study

BACKGROUND

Traumatic craniocervical dissociation (CCD), which includes atlanto-occipital dissociation and vertical distraction between C1-C2, is often an immediately fatal injury that has increasingly been associated with survival to the hospital. Our aim was to identify survivors of CCD based on clinical presentation.

METHODS

We retrospectively reviewed the Harborview Medical Center Trauma Registry and the King County Medical Examiners database from 2001 to 2006. Patients>or=12 y old were identified by ICD-9 code, radiographic diagnosis on lateral cervical spine films, and CT. We examined age, gender, mechanism of injury, presentation and prehospital and hospital interventions, and radiographic findings to distinguish survivors and non-survivors.

RESULTS

Of 69 patients with CCD, 47 were diagnosed post mortem, 22 were diagnosed in hospital, and seven survived to discharge. When comparing survivors and non-survivors, age, gender, and injury severity score were not significant. Survivors had significantly higher GCS, and were more likely to be normotensive; none had cervical cord injury; 80% of non-survivors had a basion-dental interval (BDI) of >or=16mm.

CONCLUSIONS

Trauma patients diagnosed with CCD in the ED, with cervical cord injury, requiring CPR, and with GCS of 3 will not survive their injury. Wider BDI is associated with mortality.

Subclavian artery stenosis causing transient bilateral brachial diplegia: an unusual cause of anterior spinal artery syndrome

The author report a case of a 74-year-old man who had presented with transient bilateral brachial diplegia. Investigations led to the diagnosis and treatment of subclavian artery stenosis. There are no known published cases of subclavian artery stenosis associated with transient bilateral arm weakness, and the authors believe that a steal phenomenon leading to vertebrobasilar artery insufficiency and subsequent anterior spinal artery insufficiency may have caused these symptoms, which resolved after correction of the patient's stenosis.

Diagnosis and treatment of a chronic atlanto-occipital subluxation in a dog

A 6-year-old Labrador retriever-cross was evaluated for an abnormal gait and head carriage 6 weeks after suffering trauma. The dog was presented with an ambulatory tetraparesis and was reluctant to move his head. Myelography and computed tomography demonstrated a subluxation of the atlanto-occipital joint with compression of the spinomedullary junction and the brain stem by the occipital bone. Removal of the compressive part of the occipital bone resulted in improvement of the clinical signs within 6 weeks, and resolution of clinical signs occurred 8 months after surgery.

Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates

OBJECT

Although rare, traumatic occipitoatlantal dislocation (OAD) injuries are associated with a high mortality rate. The authors evaluated the imaging and clinical factors that determined treatment and were predictive of outcomes, respectively, in survivors of this injury.

METHODS

The medical records and imaging studies obtained in 33 patients with OAD were reviewed retrospectively. Clinical factors that predicted outcomes, especially neurological injury at presentation and imaging findings, were evaluated. The most sensitive method for the diagnosis of OAD was the measurement of basion axial-basion dens interval on computed tomography (CT) scanning. Five patients with severe traumatic brain injuries (TBIs) were not treated and subsequently died. Of the 28 patients in whom treatment was performed, 23 underwent fusion and five were fitted with an external orthosis. Abnormal findings of the occipitoatlantal ligaments on magnetic resonance (MR) imaging, associated with no or questionable abnormalities on CT scanning, provided the rationale for nonoperative treatment. Of the 28 patients treated for their injuries, perioperative death occurred in five, three of whom had presented with severe neurological injuries. The mortality rate was highest in patients with a TBI at presentation. The mortality rate was lower in patients presenting with a spinal cord injury, but in this group there was a higher rate of persistent neurological deficits.

CONCLUSIONS

The spines in patients with CT-documented OAD are most likely unstable and need surgical fixation. In patients for whom CT findings are normal and MR imaging findings suggest marginal abnormalities, nonoperative treatment should be considered. The best predictors of outcome were severe brain or upper cervical injuries at initial presentation.

Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during an 8-year period

OBJECT

Craniocervical dissociation (CCD) is a highly unstable and usually fatal injury resulting from osseoligamentous disruption between the occiput and C-2. The purpose of this study was to elucidate systematic factors associated with delays in diagnosing and treating this life-threatening condition and to introduce an injury-severity classification with therapeutic implications.

METHODS

In a retrospective evaluation of institutional databases, the authors reviewed medical records and original images obtained in 17 consecutive surviving patients with CCD treated between 1994 and 2002. Images and clinical results of treatment were evaluated, emphasizing the timing of diagnosis, clinical effect of delayed diagnosis, potential clinical or imaging warning signs, and response to treatment. Craniocervical dissociation was identified or suspected on the initial lateral cervical spine radiograph acquired in two patients (12%) and was diagnosed based on screening computerized tomography findings in two additional patients (12%). A retrospective review of initial lateral x-ray films showed an abnormal dens-basion interval in 16 patients (94%). The 2-day average delay in diagnosis was associated with profound neurological deterioration in five patients (29%). Neurological status declined in one patient after a fixation procedure was performed. There were no cases of craniocervical pseudarthrosis or hardware failure during a mean 26-month follow-up period. The mean American Spinal Injury Association (ASIA) motor score of 50 improved to 79, and the number of patients with useful motor function (ASIA Grade D or E) increased from seven (41%) preoperatively to 13 (76%) postoperatively.

CONCLUSIONS

The diagnosis of CCD was frequently delayed, and the delay was associated with an increased likelihood of neurological deterioration. Early diagnosis and spinal stabilization protected against worsening spinal cord injury.

Alar, transverse, and apical ligament strain due to head-turned rear impact

STUDY DESIGN

Determination of alar, transverse, and apical ligament strains during simulated head-turned rear impact.

OBJECTIVES

To quantify the alar, transverse, and apical ligament strains during head-turned rear impacts of increasing severity, to compare peak strains with baseline values, and to investigate injury mechanisms.

SUMMARY OF BACKGROUND DATA

Clinical and epidemiologic studies have documented upper cervical spine ligament injury due to severe whiplash trauma. There are no previous biomechanical studies investigating injury mechanisms during head-turned rear impacts.

METHODS

Whole cervical spine specimens (C0-T1) with surrogate head and muscle force replication were used to simulate head-turned rear impacts of 3.5, 5, 6.5, and 8 g horizontal accelerations of the T1 vertebra. The peak ligament strains during impact were compared (P < 0.05) to baseline values, obtained during a noninjurious 2 g acceleration.

RESULTS

The highest right and left alar ligament average peak strains were 41.1% and 40.8%, respectively. The highest transverse and apical ligament average strain peaks were 17% and 21.3%, respectively. There were no significant increases in the average peak ligament strains at any impact acceleration compared with baseline.

CONCLUSIONS

The alar, transverse, and apical ligaments are not at risk for injury due to head-turned rear impacts up to 8 g. The upper cervical spine symptomatology reported by whiplash patients may, therefore, be explained by other factors, including severe whiplash trauma in excess of 8 g peak acceleration and/or other impact types, e.g., offset, rollover, and multiple collisions.

A patient with an odontoid fracture and atrophy of the tongue: a case report and systematic review of the literature

BACKGROUND

Traumatic hypoglossal nerve palsy is a rare entity and has rarely been described in association with an odontoid fracture.

CASE DESCRIPTION

We present a patient with a posttraumatic odontoid fracture who developed selective weakness of his arms and a unilateral hypoglossal nerve palsy. A systematic review of the literature is presented, and hypothetical causes for the injury are discussed.

CONCLUSION

Bell's cruciate paralysis and central cord syndrome are probably expressions of the same mechanism rather than 2 separate entities based on a preferential damage of pyramidal crossing arm fibers. C2 fractures with concomitant lower cranial nerve injury are relatively rare and have a reasonably good outcome, especially when unilateral.

Cruciate paralysis and hemiplegia cruciata: report of three cases

STUDY DESIGN

Report of three cases of cruciate paralysis and hemiplegia cruciata.

OBJECTIVE

To stress the importance of upper cervical spine lesions causing neurological symptoms and signs.

SETTING

Neuro-orthopedic service, Fukui University Hospital, Japan.

RESULTS

Three patients (all females; one with congenital anomaly at the occiput-atlas level, one with assimilation of the atlas, and one with rheumatoid arthritis-related proliferative synovium) had clinical features of cruciate paralysis and hemiplegia cruciata. All three cases underwent decompressive surgeries.

CONCLUSION

Neurological symptoms and signs of cruciate paralysis and hemiplegia cruciata should be carefully assessed, and surgical therapy should be based on the pathological condition.

Reaching beyond the midline: why are human brains cross wired?

The crossing of nerve tracts from one hemisphere in the brain to the contralateral sense organ or limb is a common pattern throughout the CNS, which occurs at specialised bridging points called decussations or commissures. Evolutionary and teleological arguments suggest that midline crossing emerged in response to distinct physiological and anatomical constraints. Several genetic and developmental disorders involve crossing defects or mirror movements, including Kallmann's and Klippel-Feil syndrome, and further defects can also result from injury. Crossed pathways are also involved in recovery after CNS lesions and may allow for compensation for damaged areas. The development of decussation is under the control of a host of signalling molecules. Growing understanding of the molecular processes underlying the formation of these structures offers hope for new diagnostic and therapeutic interventions.

Circumferential fracture of the skull base causing craniocervical dislocation. Case report

Fractures of the craniocervical junction are common in victims of high-speed motor vehicle accidents; indeed, injury to this area is often fatal. The authors present the unusual case of a young woman who sustained a circumferential fracture of the craniocervical junction. Despite significant trauma to this area, she suffered remarkably minor neurological impairment and made an excellent recovery. Her injuries, treatment, and outcome, as well as a review of the literature with regard to injuries at the craniocervical junction, are discussed.

Traumatic central cord syndrome: results of surgical management

OBJECT

The authors compare clinical outcomes demonstrated in patients with traumatic central cord syndrome (CCS) who underwent early (< or = 24 hours after injury) or late (> 24 hours after injury) surgery.

METHODS

The clinical characteristics, radiographic findings, surgery-related results, length of hospital stay (LOS), and clinical outcomes obtained in 50 patients with surgically treated traumatic CCS were reviewed retrospectively. Shorter intensive care unit (ICU) stay and LOS were observed in all patients who underwent early surgery compared with those who underwent late surgery. In patients with CCS secondary to acute disc herniation or fracture/dislocation who underwent early surgery significantly greater overall motor improvement was observed than in those who underwent late surgery (p = 0.04). Overall motor outcome in patients with CCS secondary to spinal stenosis or spondylosis who underwent early surgery was not significantly different from that in those who underwent late surgery (p = 0.51). Worse motor outcomes were found in patients who were older than 60 years of age and in whom initial bladder dysfunction was present (p = 0.03 and 0.02, respectively) compared with younger patients without bladder dysfunction.

CONCLUSIONS

Early surgery is safe and more cost effective than late surgery for the treatment of traumatic CCS, based on ICU stay and LOS and improved overall motor recovery, in patients whose CCS was related to acute disc herniation or fracture. In the setting of spinal stenosis or spondylosis, early surgery was safe but did not improve motor outcome compared with late surgery.

Cruciate paralysis or man-in-the-barrel syndrome? Report of a case of brachial diplegia

A patient who developed isolated brachial diplegia following cardiac surgery is described. The underlying cerebral lesion could not be localized using magnetic resonance imaging (MRI). Evoked potentials disclosed normal findings, while pathological latencies were seen on cortical magnetic stimulation. Their marked improvement over the following year was accompanied by almost complete clinical recovery. The preserved arm reflexes, together with the observed slow firing motor units in electromyography argued against bilateral lesions of the brachial plexus. We attribute the observed diplegia to a medullary lesion at the level of the pyramidal decussation, presumably caused by an intraoperative embolic occlusion of the anterior spinal artery. Cruciate paralysis and man-in-barrel-syndrome (MIBS) both are terms used to describe brachial diplegia; cruciate paralysis when caused by medullary lesions, MIBS when caused either by supratentorial or by medullary lesions. Exclusive use of the term MIBS for bilateral frontal lobe lesions, as in the original description, would provide more clarity in terminology.

Selective paralysis of the upper extremities after odontoid fracture: acute central cord syndrome or cruciate paralysis?

A patient presented with selective paralysis of the arms after having sustained a fall. X-ray of the cervical spine showed a type II odontoid fracture with posterior atlantoaxial dislocation. The diagnosis in the emergency room was cruciate paralysis, which is frequently associated with fractures of axis and/or atlas. However, magnetic resonance imaging (MRI) of the cervical spine revealed a lesion consistent with the acute central cord syndrome (CCS) at the C2-C6 level. The patient underwent posterior atlantoaxial arthrodesis to correct instability and was discharged, without much neurological improvement. Cruciate paralysis has been reported to be associated with fractures of axis and/or atlas, and acute CCS has rarely been associated with the fractures. However, this case illustrates that the lesion responsible for selective paralysis of the upper extremities is not as specific as it had been thought to be, and that it is difficult to accurately identify the level of the cervical cord injury by neurological diagnosis and X-rays alone. Supplementary diagnostic modalities, particularly MRI, are required to make a correct diagnosis and develop a therapeutic strategy.

The clinical presentation of uppermost cervical disc protrusion

OBJECT

The purpose of this study is to clarify the clinical presentation of the C2-C3 cervical herniation disc.

SUMMARY OF BACKGROUND DATA

Uppermost cervical disc protrusion is an uncommon condition. The pattern of large central fragments of nucleus impinging on the highest cervical disc region is often poorly localized according to its clinical presentation.

METHODS

Eight patients treated with anterior cervical discectomy with fusion for C2-C3 disc herniation participated in a detailed clinical and radiologic review to determine early detection and clarify potential hazards. Each patient's neurologic function was tested and recorded successively by a team of physicians and qualified physiotherapists.

RESULTS

Reviewing the symptomatology, most patients presented ascending radicular symptoms secondary to trivial trauma, characterized by suboccipital pain, loss of hand dexterity, and paresthesia over face and unilateral lateral arm. Six (75%) patients had remarkable improvement postoperatively in neurologic function, except for some residual sensory embarrassment in at least 6 months follow-up.

CONCLUSIONS

Clinical neurologic examination provides a less precise anatomic basis, to point to a particular upper cervical disc protrusion. Nonspecific neck and shoulder pain, a variety of cervical radiculopathy, and myelopathy may present. However, this rare spondylotic pattern is usually characterized by impairment of motor and sensory function more in the upper extremities than lower extremities and mostly starting following trauma. Radiculopathy generally outweighs the cord sign. Cruciate paralysis associated with vague diffuse and patch regions of hypesthesia over perioral distribution may help to localize this upper cervical lesion. The present study demonstrates that early detection and adequate anterior decompression may provide excellent outcome.

Unusual foreign body causing quadriparesis: case report

OBJECTIVE AND IMPORTANCE

An unusual foreign body traversing the spinal canal at the foramen magnum level is described. Interesting radiological findings and a review of nonmissile penetrating injuries are presented. This case demonstrates the importance of a thorough physical examination and the use of neurodiagnostic imaging in an inebriated, uncooperative patient with neurological dysfunction.

CLINICAL PRESENTATION

The patient presented with quadriparesis confounded by cocaine intoxication. A physical examination revealed only a small punctate lesion in the posterior occipital region.

INTERVENTION

After detection of the foreign body, the patient underwent immediate surgical exploration and removal of the object. The dura was repaired primarily, and the patient was maintained on intravenous antibiotics for 7 days.

CONCLUSION

With physical therapy, the patient was walking with assistance at 2 weeks postsurgery. Upper extremity strength, especially intrinsic hand movement, was most severely affected. At 10 months' follow-up, the patient's only deficits were mild intrinsic hand weakness and incoordination with fine finger movements. Immediate surgical exploration is indicated for patients with retained fragments and progressive neurological dysfunction.

The surgical management of patients with rheumatoid cervical spine disease

Rheumatoid arthritis is an inflammatory disease that commonly affects the cervical spine. This article reviews the incidence of spinal involvement, the clinical manifestations of spinal disease, and the types of instability patterns that may occur and their radiographic diagnosis. Appropriate guidelines for obtaining imaging studies and for surgical referral is also described. Finally, the role of surgical stabilization is discussed.

Clinical syndromes associated with disproportionate weakness of the upper versus the lower extremities after cervical spinal cord injury

Patients with cervical spinal cord injuries who present with weakness or paralysis of the hands and arms with relative preservation of lower extremity strengths are often categorized as having two clinical syndromes, cruciate paralysis and acute central cervical spinal cord injury. The explanation for the pathophysiological findings of the dissociated strength in the upper versus the lower extremities has relied on the assumption that there is a localized injury within a somatotopically organized corticospinal tract. This article summarizes the evidence that there is no somatotopic organization within the corticospinal tract in the medulla or cervical spinal cord in primates. An alternative hypothesis for these two syndromes is presented and is based on evidence that has demonstrated that the corticospinal tract in primates is critical for hand function but not for locomotion. Other prevailing theories are reviewed. Thus, we propose that a syndrome consisting of relatively greater hand and arm weakness compared with leg weakness can occur after an injury to the corticospinal tracts in the medulla or the cervical cord. The proposed mechanism, based on the function of the corticospinal tract, unifies a spectrum of injuries of the lower medulla and cervical spinal cord, which produce similar clinical syndromes (cruciate paralysis and acute central cervical spinal cord injury).

A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation

Extreme-lateral lumbar disc herniations present a surgical challenge because the conventional posterior approach requires bone resection for complete visualization of the pathology. The authors have identified constant anatomical landmarks in cadaveric dissections that facilitate access to the intervertebral foramen when combined with a posterolateral approach, as described by Watkins, for lumbar spinal fusion. The authors describe a technique that allows rapid localization and safe excision of these extreme-lateral lumbar disc herniations without the need for bone resection.

Pneumatic nerve root compression: epidural gas in association with lateral disc herniation. Report of two cases

Extreme lateral disc herniations are increasingly recognized as a cause of lumbar nerve root compression syndromes. This disorder often presents major diagnostic and therapeutic challenges, especially in the presence of multiple degenerative changes and chronic back pain in elderly patients. The authors describe two patients with presentations and findings that have not been previously described in the literature. Both patients had histories of upper lumbar back and leg pain. Degenerative spine disease, gaseous degeneration of the intervertebral discs, and epidural gas in the lateral recesses were noted on imaging studies. However, because both patients had undergone prior epidural diagnostic and therapeutic procedures, the epidural gas in the lateral recesses could be attributed either to gaseous disc degeneration or to the previous intraspinal procedures. One patient was found to have a large, far lateral extruded disc fragment that contained air. The nerve root in the second patient was impaled by an unusual combination of a small extruded disc fragment as well as an air-filled sac that was surrounded by the walled-off fragment's capsule and which freely communicated with the gaseous degenerated disc space. The suspected mechanism of root compression is illustrated and discussed. The possibility of disc herniation should be seriously considered in cases of nerve root compression in which epidural gas is present, especially those associated with gaseous degenerated discs.

Posterior inferior cerebellar artery (PICA) aneurysm presenting with SAH and contralateral crural monoparesis: a case report

A patient with contralateral monoparesis of the leg due to subarachnoid hemorrhage (SAH) from an aneurysm of the first posterior inferior cerebellar artery (PICA) segment is reported. The monoparesis may well be associated with the close anatomical relationships between the site of the aneurysm and the PICA blood supply of the corticospinal fibers to the contralateral leg.

Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability

Twenty normal human subjects and 14 patients with upper cervical spine pathology were studied with axial high-field magnetic resonance (MR) imaging to examine the transverse atlantal ligament. Gradient-echo MR imaging pulse sequences provided reliable visualization of the transverse ligament, which exhibited low signal intensity and extended behind the dens between the medial portions of the lateral masses of C-1. The MR imaging characteristics of the transverse ligament were verified in clinical studies and in postmortem specimens. The clinical MR examinations defined 27 normal ligaments, three ligament disruptions, and four stretched rheumatoid ligaments. Atlantoaxial instability associated with transverse ligament rupture or ligamentous laxity required internal fixation. In contrast, fractures of C-1 or C-2 or atlantoaxial rotatory dislocations associated with an intact transverse ligament healed without instability or nonunion. The transverse ligament is the primary stabilizing component of C-1. The treatment of atlantoaxial instability has previously been based on criteria drawn from computerized tomography or plain radiographic studies, which only indirectly assess the probability of rupture of the transverse ligament. It is concluded that MR imaging accurately depicts the anatomical integrity of the transverse ligament. After transverse ligament failure, the remaining ligaments of the craniovertebral junction are inadequate to maintain stability. The presence of ligament disruption should be considered as a criterion for early fusion.