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Lemon RN, Morecraft RJ. The evidence against somatotopic organization of function in the primate corticospinal tract. Brain 2023; 146:1791-1803. [PMID: 36575147 PMCID: PMC10411942 DOI: 10.1093/brain/awac496] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022] Open
Abstract
We review the spatial organization of corticospinal outputs from different cortical areas and how this reflects the varied functions mediated by the corticospinal tract. A long-standing question is whether the primate corticospinal tract shows somatotopical organization. Although this has been clearly demonstrated for corticofugal outputs passing through the internal capsule and cerebral peduncle, there is accumulating evidence against somatotopy in the pyramidal tract in the lower brainstem and in the spinal course of the corticospinal tract. Answering the question on somatotopy has important consequences for understanding the effects of incomplete spinal cord injury. Our recent study in the macaque monkey, using high-resolution dextran tracers, demonstrated a great deal of intermingling of fibres originating from primary motor cortex arm/hand, shoulder and leg areas. We quantified the distribution of fibres belonging to these different projections and found no significant difference in their distribution across different subsectors of the pyramidal tract or lateral corticospinal tract, arguing against somatotopy. We further demonstrated intermingling with corticospinal outputs derived from premotor and supplementary motor arm areas. We present new evidence against somatotopy for corticospinal projections from rostral and caudal cingulate motor areas and from somatosensory areas of the parietal cortex. In the pyramidal tract and lateral corticospinal tract, fibres from the cingulate motor areas overlap with each other. Fibres from the primary somatosensory cortex arm area completely overlap those from the leg area. There is also substantial overlap of both these outputs with those from posterior parietal sensorimotor areas. We argue that the extensive intermingling of corticospinal outputs from so many different cortical regions must represent an organizational principle, closely related to its mediation of many different functions and its large range of fibre diameters. The motor sequelae of incomplete spinal injury, such as central cord syndrome and 'cruciate paralysis', include much greater deficits in upper than in lower limb movement. Current teaching and text book explanations of these symptoms are still based on a supposed corticospinal somatotopy or 'lamination', with greater vulnerability of arm and hand versus leg fibres. We suggest that such explanations should now be finally abandoned. Instead, the clinical and neurobiological implications of the complex organization of the corticospinal tract need now to be taken into consideration. This leads us to consider the evidence for a greater relative influence of the corticospinal tract on upper versus lower limb movements, the former best characterized by skilled hand and digit movements.
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Affiliation(s)
- Roger N Lemon
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, UCL, London WC1N 3BG, UK
| | - Robert J Morecraft
- Division of Basic Biomedical Sciences, Laboratory of Neurological Sciences, The University of South Dakota, Sanford School of Medicine, Vermillion, SD 57069, USA
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Zygogiannis K, Georgoulis JD, Antonopoulos SI, Gourtzelidis G, Chatzikomninos I. Cruciate Paralysis Following a Displaced Type II Odontoid Fracture: A Case Report. Cureus 2022; 14:e25181. [PMID: 35747018 PMCID: PMC9207996 DOI: 10.7759/cureus.25181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Morecraft RJ, Stilwell-Morecraft KS, Ge J, Kraskov A, Lemon RN. Lack of somatotopy among corticospinal tract fibers passing through the primate craniovertebral junction and cervical spinal cord: pathoanatomical substrate of central cord syndrome and cruciate paralysis. J Neurosurg 2022; 136:1395-1409. [PMID: 34624846 PMCID: PMC10193491 DOI: 10.3171/2021.4.jns202464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 04/21/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In some cases of incomplete cervical spinal cord injury (iSCI) there is marked paresis and dysfunction of upper-extremity movement but not lower-extremity movement. A continued explanation of such symptoms is a somatotopic organization of corticospinal tract (CST) fibers passing through the decussation at the craniovertebral junction (CVJ) and lateral CST (LCST). In central cord syndrome, it has been suggested that injury to the core of the cervical cord may include selective damage to medially located arm/hand LCST fibers, without compromising laterally located leg fibers. Because such somatotopic organization in the primate CST might contribute to the disproportionate motor deficits after some forms of iSCI, the authors made a systematic investigation of CST organization in the CVJ and LCST using modern neuroanatomical techniques. METHODS High-resolution anterograde tracers were used in 11 rhesus macaque monkeys to define the course of the corticospinal projection (CSP) through the CVJ and LCST from the arm/hand, shoulder, and leg areas of the primary motor cortex (M1). This approach labels CST fibers of all sizes, large and small, arising in these areas. The CSP from the dorsolateral and ventrolateral premotor cortex and supplementary motor area were also studied. A stereological approach was adapted to quantify labeled fiber distribution in 8 cases. RESULTS There was no evidence for somatotopic organization of CST fibers passing through the CVJ or contralateral LCST. Fiber labeling from each cortical representation was widespread throughout the CST at the CVJ and LCST and overlapped extensively with fibers from other representations. This study demonstrated no significant difference between medial versus lateral subsectors of the LCST in terms of number of fibers labeled from the M1 arm/hand area. CONCLUSIONS This investigation firmly rejects the concept of somatotopy among CST fibers passing through the CVJ and LCST, in contrast with the somatotopy in the cortex, corona radiata, and internal capsule. All CST fibers in the CVJ and LCST would thus appear to be equally susceptible to focal or diffuse injury, regardless of their cortical origin. The disproportionate impairment of arm/hand movement after iSCI must therefore be due to other factors, including greater dependence of hand/arm movements on the CST compared with the lower limb. The dispersed and intermingled nature of frontomotor fibers may be important in motor recovery after cervical iSCI.
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Affiliation(s)
- Robert J. Morecraft
- Division of Basic Biomedical Sciences, Laboratory of Neurological Sciences, The University of South Dakota, Sanford School of Medicine, Vermillion, South Dakota
| | - Kimberly S. Stilwell-Morecraft
- Division of Basic Biomedical Sciences, Laboratory of Neurological Sciences, The University of South Dakota, Sanford School of Medicine, Vermillion, South Dakota
| | - Jizhi Ge
- Division of Basic Biomedical Sciences, Laboratory of Neurological Sciences, The University of South Dakota, Sanford School of Medicine, Vermillion, South Dakota
| | - Alexander Kraskov
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; and
| | - Roger N. Lemon
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, United Kingdom
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Levi AD, Schwab JM. A critical reappraisal of corticospinal tract somatotopy and its role in traumatic cervical spinal cord syndromes. J Neurosurg Spine 2022; 36:653-659. [PMID: 34767532 DOI: 10.3171/2021.7.spine21546] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Allan D Levi
- 1The Miami Project to Cure Paralysis, and Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Jan M Schwab
- 2Belford Center for Spinal Cord Injury, The Ohio State Neurological Institute, Department of Neurology, The Ohio State University, Columbus, Ohio
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Shields LBE, Iyer VG, Zhang YP, Shields CB. Person-in-the-barrel syndrome following cervical spine surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20165. [PMID: 35855313 PMCID: PMC9241343 DOI: 10.3171/case20165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/30/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Person-in-the-barrel syndrome is characterized by bilateral brachial diplegia, intact cranial nerves, and preserved lower-extremity strength. Most cases are due to bilateral supratentorial brain lesions at the border zone of the anterior and middle cerebral artery vascular territories. This condition has been observed with spinal pathology, primarily involving vascular dissection and thromboembolism. OBSERVATIONS The authors’ case is the first in the literature to highlight person-in-the-barrel syndrome immediately following cervical spine surgery. Weakness of the deltoids, biceps, infraspinatus, and brachioradialis was observed bilaterally postoperatively. Electromyograph (EMG)-nerve conduction velocity (NCV) studies revealed a cervical radiculopathy involving C5 and C6 bilaterally with denervation of the deltoids, biceps, and brachioradialis. Within 8 months of cervical spine surgery, the patient regained improvement of the bilateral brachial diplegia. LESSONS EMG/NCV studies play a valuable role in detecting cervical radiculopathy after cervical spine surgery in patients with bilateral brachial diplegia. The authors postulate that this condition may have occurred following neck hyperextension during cervical cage placement, increasing the foraminal stenosis at C4–5 and C5–6 and worsening the C5 and C6 radiculopathy. Spinal surgeons should be cognizant of person-in-the-barrel syndrome that may ensue following cervical spine surgery and promptly identify and treat this condition to offer the best prognosis for a favorable patient outcome.
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Affiliation(s)
| | | | - Yi Ping Zhang
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
| | - Christopher B. Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
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Soares C, Ferreira D, Araújo R. Gender analysis of 'man-in-the-barrel' syndrome: is 'person-in-the-barrel' a more adequate term? Eur J Neurol 2020; 28:341-343. [PMID: 32961582 DOI: 10.1111/ene.14551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Gender bias is a known issue in healthcare and academia. We analysed the gender of patients reported in the literature with 'man-in-the-barrel' syndrome or equivalent semiological terms. METHODS A search in the PubMed database was conducted using the terms 'man-in-the-barrel', 'person-in-the-barrel', 'woman-in-the-barrel', 'brachial diplegia', 'flail arm' and 'cruciate paralysis'. All articles published between 1969 and 2020 containing a detailed description compatible with the original description of man-in-the-barrel syndrome were included. RESULTS Ninety-five patients with a clinical picture compatible with man-in-the-barrel syndrome were included. Up to 33% of patients were female. Overall, the proportion of female patients with man-in-the-barrel syndrome was 25%. DISCUSSION AND CONCLUSIONS The term man-in-the-barrel may disenfranchise up to a third of women presenting with brachial diplegia with undesirable consequences. We propose a gender-neutral alternative such as 'person-in-the-barrel'.
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Affiliation(s)
- C Soares
- Department of Neurology, Centro Hospitalar Universitário São João, EPE, Porto, Portugal.,Department of Clinic Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - D Ferreira
- Department of Neurology, Centro Hospitalar Universitário São João, EPE, Porto, Portugal.,Department of Clinic Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - R Araújo
- Department of Neurology, Centro Hospitalar Universitário São João, EPE, Porto, Portugal.,Department of Clinic Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
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Too Aggressive Drop in Blood Pressure in a Hypertensive Male Leading to "Man-in-the-Barrel Syndrome". Case Rep Neurol Med 2020; 2020:8855574. [PMID: 33029439 PMCID: PMC7532409 DOI: 10.1155/2020/8855574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction "Man-in-the-barrel syndrome" is a neurological phenotype with brachial diplegia, normal sensation, and preserved motor function of the lower limb. It has been described in various neuropathological conditions affecting the cerebral hemispheres, pons, upper spinal cord, and peripheral neurons. Severe hypotension leading to watershed infarctions leading to this phenotype has been reported. We describe the first case of "man-in-the-barrel syndrome" in a patient with a precipitous drop in blood pressure following oral antihypertensive medications. Case Presentation. A 75-year-old Sri Lankan male presented following a generalized tonic-clonic seizure to a tertiary care hospital. Upon recovery, he was noted to have severe brachia diplegia affecting shoulder movements with preserved hand muscle power and motor functions of the lower limb. The previous day, he was newly diagnosed with markedly elevated blood pressure without acute end organ involvement. Treatment with three antihypertensives had been initiated. Noncontrast CT of the brain revealed watershed infarctions affecting both cerebral hemispheres. Conclusion It is generally unwise to lower blood pressure very rapidly, as ischemic damage can occur in vascular beds that are habituated to high levels of blood pressure in the brain. Ischemic damage caused by rapid lowering of blood pressure may rarely result in "man-in-the-barrel syndrome" leading to severe functional disability.
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Maramattom BV, Joseph S. Cruciate bibrachial diplegia due to an acutely trapped fourth ventricle. J R Coll Physicians Edinb 2018; 48:328-331. [PMID: 30488888 DOI: 10.4997/jrcpe.2018.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 20-year-old female presented to us with bibrachial diplegia and dysarthria. She had an earlier history of craniosynostosis, multiple cranial surgeries and recent meningitis followed by ventriculoperitoneal shunting. Her symptoms started with a cruciate paralysis followed by rapid descending quadriparesis. Imaging revealed a trapped fourth ventricle as the cause of her descending paralysis.
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Affiliation(s)
- B V Maramattom
- Department of Neurology, Aster Medcity, Kothad, Kochi 682023, India,
| | - S Joseph
- Department of Neurology, Aster Medcity, Kothad, Kochi, India
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Woodward JA, Adler DE. Chiari I malformation with acute neurological deficit after craniocervical trauma: Case report, imaging, and anatomic considerations. Surg Neurol Int 2018; 9:88. [PMID: 29740509 PMCID: PMC5926209 DOI: 10.4103/sni.sni_304_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/01/2018] [Indexed: 11/27/2022] Open
Abstract
Background: In patients with Chiari I malformation (CMI), the occurrence of acute neurologic deficit after craniocervical trauma is rare. However, the pathologic potential of exacerbating anatomic overcrowding of the posterior fossa has immense clinical consequences and prompt recognition is essential. Case Description: This case study describes a 41-year-old male who sustained a single blow to the face, fell, and struck the occiput. On admission, neurological examination revealed a profound paraparesis, upper extremity diplegia, a C4 sensory level and apnea that required intubation. On arrival, computerized axial tomography of the head showed a small amount of contrecoup left frontal traumatic subarachnoid hemorrhage. Magnetic resonance imaging (MRI) performed 19 h after admission was negative except for the presence of a CMI. He acutely declined on post injury day 2, prompting emergent decompression of the posterior fossa where anatomic overcrowding was observed. At 19 weeks post injury, his motor function had significantly improved. Conclusion: The constellation of severe neurologic deficit in patients with CMI after relatively minor craniocervical trauma has been previously described. In our patient, neurologic deficit disproportionate to the mechanism of injury was observed and likely in part attributed to the presence of a Chiari malformation. Unfortunately, MRI has not yet been able to clearly define the underlying pathoanatomy, help understand the mechanism of injury, and delineate when operative intervention is indicated in these patients. Here, we review similar cases from the literature, examine findings on MRI, and evaluate mechanisms of injury following craniocervical trauma in patients with CMI to help clarify these questions.
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Affiliation(s)
- Josha A Woodward
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - David E Adler
- Section of Neurological Surgery, Legacy Emanuel Hospital, Portland, Oregon, USA
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A MS, V TS, B DS. Cruciate Paralysis in a 20- year -old Male with an Undisplaced Type III Odontoid Fracture. J Orthop Case Rep 2017; 6:40-42. [PMID: 28111622 PMCID: PMC5040569 DOI: 10.13107/jocr.2250-0685.424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Mansukhani Sameer A
- Department of Orthopaedics, D.Y Patil University School of Medicine and Hospital, Navi Mumbai. India
| | - Tuteja Sanesh V
- Department of Orthopaedics, D.Y Patil University School of Medicine and Hospital, Navi Mumbai. India
| | - Dhar Sanjay B
- Department of Orthopaedics, D.Y Patil University School of Medicine and Hospital, Navi Mumbai. India
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Hopkins B, Khanna R, Dahdaleh NS. Revisiting cruciate paralysis: A case report and systematic review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:265-272. [PMID: 27891037 PMCID: PMC5111329 DOI: 10.4103/0974-8237.193262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin Hopkins
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Ryan Khanna
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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12
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Kawaguchi Y, Yasuda T, Seki S, Hori T, Nakano M, Kimura T. Monoparesis of upper extremity due to ipsilateral upper cervical cord compression: report of two cases. J Orthop Sci 2015; 20:939-942. [PMID: 24878549 DOI: 10.1007/s00776-014-0588-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 05/08/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, 930-0194, Japan.
| | - Taketoshi Yasuda
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Takeshi Hori
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Masato Nakano
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tomoatsu Kimura
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, 930-0194, Japan
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13
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Mallory GW, Halasz SR, Clarke MJ. Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity. World J Orthop 2014; 5:292-303. [PMID: 25035832 PMCID: PMC4095022 DOI: 10.5312/wjo.v5.i3.292] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 03/08/2014] [Accepted: 04/17/2014] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine. While it was initially thought that cervical involvement was innocuous, natural history studies have substantiated the progressive nature of untreated disease. Over the past 50 years, there has been further elucidation in the pathophysiology of the disease, as well as significant advancements in medical and surgical therapy. The introduction of disease modifying drugs and biologic agents has reduced the amount of patients with advanced stages of the disease needing surgery. Advancement in instrumentation techniques has improved patient outcomes and fusion rates. The introduction of endoscopic approaches for ventral decompression may further lower surgical morbidity. In this review, we give a brief overview of the pertinent positives of the disease. A discussion of historical techniques and the evolution of surgical therapy into the modern era is provided. With improved medical therapies and less invasive approaches, we will likely continue to see less advanced cases of disease and less surgical morbidity. Nonetheless, a thorough understanding of the disease is crucial, as its systemic involvement and need for continued medical therapy have tremendous impact on overall complications and outcomes even in patients being seen for standard degenerative disease with comorbid rheumatoid.
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Abstract
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.
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Affiliation(s)
- Edward C Perry
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Hazem M Ahmed
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA.
| | - Thomas C Origitano
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
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15
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Gopalakrishnan CV, Dhakoji A, Nair S. Giant vertebral artery aneurysm presenting with 'hemiplegia cruciata'. Clin Neurol Neurosurg 2013; 115:1908-10. [PMID: 23820329 DOI: 10.1016/j.clineuro.2013.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/04/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
Affiliation(s)
- C V Gopalakrishnan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum 695011, India.
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Batzdorf U, McArthur DL, Bentson JR. Surgical treatment of Chiari malformation with and without syringomyelia: experience with 177 adult patients. J Neurosurg 2013; 118:232-42. [PMID: 23176335 DOI: 10.3171/2012.10.jns12305] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Object
This study aims to show the relationship between clinical outcome in patients who underwent surgical decompression for Chiari malformation (CM) and postoperative imaging studies, with particular emphasis on the subarachnoid cisterns of the posterior fossa.
Methods
One hundred seventy-seven patients with CM, including 97 with syringomyelia, underwent posterior fossa decompressive surgery. Both the dura and arachnoid were opened in 150 of these patients, and 135 underwent reduction of the cerebellar tonsils. The patients' clinical signs and symptoms were evaluated at 2 time points after surgery. Their imaging studies were analyzed specifically for the size of the retrotonsillar and subtonsillar cisterns and the syringomyelic cavities. The authors evaluated the relationship between these imaging findings and clinical parameters.
Results
Clinical improvement correlated strongly with enlargement of the subarachnoid cisterns, and enlargement of the cisterns also correlated with reduction in size of the syrinx cavities. Symptoms related to syringomyelia responded to reduction in size of the syrinx cavities.
Conclusions
Surgical decompression of the posterior fossa should aim to create relatively large subarachnoid cisterns and reduce the size of the syrinx cavity. Reduction of the cerebellar tonsils by surgical means, together with duraplasty, achieves this goal and thereby improves the clinical outcome for patients with CM. An incidental observation of the study is that obesity increases the likelihood of headache in patients with CM.
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Affiliation(s)
| | | | - John R. Bentson
- 2Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
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Rust CL, Ching AC, Hart RA. Dropped-head syndrome resulting from injury to the central spinal cord at the upper cervical level. ACTA ACUST UNITED AC 2011; 93:503-6. [DOI: 10.1302/0301-620x.93b4.26107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There are many causes of paraspinal muscle weakness which give rise to the dropped-head syndrome. In the upper cervical spine the central portion of the spinal cord innervates the cervical paraspinal muscles. Dropped-head syndrome resulting from injury to the central spinal cord at this level has not previously been described. We report two patients who were treated acutely for this condition. Both presented with weakness in the upper limbs and paraspinal cervical musculature after a fracture of C2. Despite improvement in the strength of the upper limbs, the paraspinal muscle weakness persisted in both patients. One ultimately underwent cervicothoracic fusion to treat her dropped-head syndrome. While the cause of the dropped-head syndrome cannot be definitively ascribed to the injuries to the spinal cord, this pattern is consistent with the known patho-anatomical mechanisms of both injury to the central spinal cord and dropped-head syndrome.
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Affiliation(s)
- C. L. Rust
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, OP31, Portland, Oregon 97239, USA
| | - A. C. Ching
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, OP31, Portland, Oregon 97239, USA
| | - R. A. Hart
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, OP31, Portland, Oregon 97239, USA
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18
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Abstract
Abstract
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.
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Affiliation(s)
- David Benglis
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Allan D. Levi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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19
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Diagnostic criteria of traumatic central cord syndrome. Part 1: A systematic review of clinical descriptors and scores. Spinal Cord 2010; 48:652-6. [DOI: 10.1038/sc.2009.155] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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20
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Sweet J, Ammerman J, Deshmukh V, White J. Cruciate paralysis secondary to traumatic atlantooccipital dislocation. J Neurosurg Spine 2010; 12:19-21. [DOI: 10.3171/2009.8.spine08496] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Sweet
- 1Department of Neurological Surgery, George Washington University School of Medicine, Washington, DC; and
| | - Joshua Ammerman
- 1Department of Neurological Surgery, George Washington University School of Medicine, Washington, DC; and
| | - Vivek Deshmukh
- 1Department of Neurological Surgery, George Washington University School of Medicine, Washington, DC; and
| | - Joseph White
- 2Department of Orthopaedic Surgery, Inova Fairfax Hospital, Falls Church, Virginia
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21
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Aarabi B, Koltz M, Ibrahimi D. Hyperextension cervical spine injuries and traumatic central cord syndrome. Neurosurg Focus 2009; 25:E9. [PMID: 18980483 DOI: 10.3171/foc.2008.25.11.e9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Traumatic central cord syndrome (TCCS), regardless of its biomechanics, is the most frequently encountered incomplete spinal cord injury. Patients with TCCS present with disproportionate weakness of the upper extremities, and variable sensory loss and bladder dysfunction. Fractures and/or subluxations, forced hyperextension, and herniated nucleus pulposus are the main pathogenetic mechanisms of TCCS. Nearly 50% of patients with TCCS suffer from congenital or degenerative spinal stenosis and sustained their injuries during hyperextension as originally described by Schneider in 1954. Immunohistochemical and imaging studies indicate mild to moderate insult to axons and their ensheathing myelin in the lateral funiculi culminating in cytoskeletal injury and impaired conduction. More than one-half of these patients enjoy spontaneous recovery of motor weakness; however, as time goes on, lack of manual dexterity, neuropathic pain, spasticity, bladder dysfunction, and imbalance of gait render their activities of daily living nearly impossible. Based on the current level of evidence, there is no clear indication of the timing of decompression for relief of sustained spinal cord compression in hyperextension injuries. Future research, taking advantage of validated digital imaging data such as maximum canal compromise, maximum spinal cord compression, and lesion length on the CT and MR images, as well as more sensitive measures of bladder and hand function, spasticity, and neuropathic pain may help tailor surgery for a specific group of these patients.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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22
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Joaquim AF, Shaffrey CC, Sansur CA, Shaffrey CI. Man-in-the-barrel syndrome after thoracoilium fusion. J Neurosurg Spine 2008; 9:566-9. [DOI: 10.3171/spi.2008.8.08485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of man-in-the-barrel (MIB) syndrome occurring after an extensive revision involving thoracoilium instrumentation and fusion for iatrogenic and degenerative scoliosis, progressive kyphosis, and sagittal imbalance. Isolated brachial diplegia is a rare neurological finding often attributed to cerebral ischemia. It has not been previously reported in patients undergoing complex spine surgery. This 70-year-old woman, who had previously undergone T11–S1 fusion for lumbar stenosis and scoliosis, presented with increased difficulty walking and with back pain. She had junctional kyphosis and L5–S1 pseudarthrosis and required revision fusion extending from T-3 to the ilium. In the early postoperative period, she experienced a 30-minute episode of substantial hypotension. She developed delirium and isolated brachial diplegia, consistent with MIB syndrome. Multiple studies were performed to assess the origin of this brachial diplegia. There was no definitive radiological evidence of any causative lesion. After a few days, her cognitive function returned to normal and she regained the ability to move her arms. After several weeks of rehabilitation, she recovered completely. Man-in-the-barrel syndrome is a rare neurological entity. It can result from various mechanisms but most commonly seems to be related to ischemia and is potentially reversible.
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Affiliation(s)
- Andrei F. Joaquim
- 1University of Campinas (UNICAMP), Campinas SP, São Paulo, Brazil; and
| | | | - Charles A. Sansur
- 3Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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23
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Rughani AI, Visioni A, Hamill RW, Tranmer BI. Subclavian artery stenosis causing transient bilateral brachial diplegia: an unusual cause of anterior spinal artery syndrome. J Neurosurg Spine 2008; 9:191-5. [PMID: 18764753 DOI: 10.3171/spi/2008/9/8/191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Anand I Rughani
- Division of Neurosurgery, Department of Surgery, University of Vermont, College of Medicine, Burlington, Vermont, USA
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24
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Harrop JS, Sharan A, Ratliff J. Central cord injury: pathophysiology, management, and outcomes. Spine J 2006; 6:198S-206S. [PMID: 17097539 DOI: 10.1016/j.spinee.2006.04.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Accepted: 04/05/2006] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical spinal trauma can result in a heterogeneous collection of spinal cord injury syndromes. Acute traumatic central cord syndrome is a common category of which no uniform consensus on the etiology, pathophysiology, and treatment exists. PURPOSE To evaluate and review potential pathophysiology, current treatment options, and management of central cord injuries. STUDY DESIGN Comprehensive literature review and clinical experience. METHODS A systematic review of Medline for articles related to central cord and spinal cord injury was conducted up to and including journal articles published in September 2005. CONCLUSIONS Central cord injuries is a clinical definition which is composed of a heterogeneous population for which medical management and surgical decompression and stabilization provide improved neurologic recovery.
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Affiliation(s)
- James S Harrop
- Department of Neurosurgery, Jefferson Medical College, 909 Walnut St., 2nd Floor, Philadelphia, PA 19107, USA.
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25
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Bellabarba C, Mirza SK, West GA, Mann FA, Dailey AT, Newell DW, Chapman JR. Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during an 8-year period. J Neurosurg Spine 2006; 4:429-40. [PMID: 16776353 DOI: 10.3171/spi.2006.4.6.429] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Carlo Bellabarba
- Departments of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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26
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Kuitwaard K, Vandertop WP. A patient with an odontoid fracture and atrophy of the tongue: a case report and systematic review of the literature. SURGICAL NEUROLOGY 2005; 64:525-32, discussion 532-3. [PMID: 16293473 DOI: 10.1016/j.surneu.2005.04.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 03/28/2005] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Krista Kuitwaard
- Department of Neurosurgery, VU University Medical Center, Postbox 7057, 1007 MB Amsterdam, The Netherlands
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27
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Yayama T, Uchida K, Kobayashi S, Nakajima H, Kubota C, Sato R, Baba H. Cruciate paralysis and hemiplegia cruciata: report of three cases. Spinal Cord 2005; 44:393-8. [PMID: 16249785 DOI: 10.1038/sj.sc.3101861] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- T Yayama
- Division of Orthopaedics and Rehabilitation Medicine, Department of Surgery, University of Fukui Faculty of Medical Sciences, Japan
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28
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Abstract
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.
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Affiliation(s)
- Serge Vulliemoz
- Neurology Department, Geneva University Hospital, Geneva, Switzerland
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29
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Georgiadis D, Schulte-Mattler WJ. Cruciate paralysis or man-in-the-barrel syndrome? Report of a case of brachial diplegia. Acta Neurol Scand 2002; 105:337-40. [PMID: 11939951 DOI: 10.1034/j.1600-0404.2002.1c127.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- D Georgiadis
- Department of Neurology, Martin Luther University of Halle-Wittenberg, Halle/Saale, Germany.
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30
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Inamasu J, Hori S, Ohsuga F, Aikawa N. Selective paralysis of the upper extremities after odontoid fracture: acute central cord syndrome or cruciate paralysis? Clin Neurol Neurosurg 2001; 103:238-41. [PMID: 11714570 DOI: 10.1016/s0303-8467(01)00146-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- J Inamasu
- Department of Emergency Medicine, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, 160-8582, Tokyo, Japan.
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31
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Campbell SF, Tannenberg AE, Mowat P. Transoral resection of retro-odontoid disc sequestration: case report and review of the literature. J Clin Neurosci 2000; 7:325-7. [PMID: 10938611 DOI: 10.1054/jocn.1999.0239] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A rare case of retro-odontoid disc sequestration causing significant cord compression and progressive neurological deterioration is presented. The clinical history, radiology, treatment and pathogenesis of the case are described, along with a review of the relevant literature.
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Affiliation(s)
- S F Campbell
- Department of Neurosurgery, Neuropathology and Neuroradiology, Royal Brisbane Hospital, Herston, 4029, Australia.
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32
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Affiliation(s)
- M A Cohen
- York Hospital, Emergency Department, PA 17405, USA.
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33
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Faillace WJ, Guthrie T. Recovery from Cruciate Paralysis Due to Axial Subluxation from Metastatic Breast Carcinoma: A Case Report. Breast J 2000; 6:139-142. [PMID: 11348350 DOI: 10.1046/j.1524-4741.2000.98118.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cruciate paralysis is an uncommon and potentially life-threatening myelopathy thought to arise from injury to the corticospinal tracts at a high cervical spinal level. The authors report on the case of a woman who developed cruciate paralysis secondary to axial subluxation of the cervical spine due to invasion by metastatic breast carcinoma. Correct bedside diagnosis, prompt spinal alignment via halo traction, and surgical spinal decompression with fusion stabilization reversed the paralysis completely. Postoperative antiestrogen medication, spinal radiation, and chemotherapy promoted local tumor control, allowing the patient longevity and good quality pain control. The prompt diagnosis and treatment of cruciate paralysis could effect a good prognosis in a seemingly terminal patient with metastatic spinal breast carcinoma by resolving life-threatening myelopathy, promoting longevity, and assisting with pain control.
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Affiliation(s)
- Walter J. Faillace
- Departments of Neurosurgery and Pediatrics and Department of Internal Medicine, University of Florida Health Science Center, Jacksonville, Florida
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34
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Lai NY, Purdie G. Acute cervical cord injury complicating Klippel-Feil deformity and mimicking ‘man in the barrel’ syndrome. J Clin Neurosci 1998; 5:338-9. [DOI: 10.1016/s0967-5868(98)90073-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/1996] [Accepted: 12/03/1996] [Indexed: 12/01/2022]
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35
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Tomaras CR, Grundmeyer RW, Chow TS, Trask TW. Unusual foreign body causing quadriparesis: case report. Neurosurgery 1997; 40:1291-3; discussion 1293-4. [PMID: 9179905 DOI: 10.1097/00006123-199706000-00034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- C R Tomaras
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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36
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Gurley JP, Bell GR. The surgical management of patients with rheumatoid cervical spine disease. Rheum Dis Clin North Am 1997; 23:317-32. [PMID: 9156395 DOI: 10.1016/s0889-857x(05)70332-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- J P Gurley
- Minnesota Spine Center, Minneapolis, USA
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37
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Sonstein WJ, LaSala PA, Michelsen WJ, Onesti ST. False Localizing Signs in Upper Cervical Spinal Cord Compression. Neurosurgery 1996. [DOI: 10.1227/00006123-199603000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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38
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Abstract
Undiagnosed and untreated odontoid fractures are relatively common in developing countries where treatment for minor injuries is not considered. As a result, patients frequently present with neurological deterioration secondary to delayed odontoid dislocation. Fifty-one consecutive patients with this problem were entered into a management protocol and reviewed for this report. After diagnosis, reducibility was analyzed by extension films, and all patients who could not be reduced were initially managed in cranial long traction. Thirty-seven were reduced spontaneously or by traction alone, and 12 required transoral decompression. All underwent posterior C1-C2 fusion. Postoperatively, all were treated in external orthoses. The neurological recovery was excellent in 34 patients. Seven patients could function but had some disability, three patients had disabling spasticity, and three remained bedridden. Four deaths occurred as a result of respirator-dependent patients being taken home for social and financial reasons. As a result of this case-controlled study, we recommend that the treatment protocol first analyze reducibility by extension x-rays and then try traction for as long as 14 days to attempt reduction in patients who did not reduce in extension. Failure of reduction is indication for transoral decompression, and all patients require C1-C2 fusion. The neurological recovery is related to initial impairement but can be satisfactory in > 75% of patients.
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Affiliation(s)
- D Fairholm
- Department of Surgery, University of British Columbia, Vancouver, Canada
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39
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Levi AD, Tator CH, Bunge RP. Clinical syndromes associated with disproportionate weakness of the upper versus the lower extremities after cervical spinal cord injury. Neurosurgery 1996; 38:179-83; discussion 183-5. [PMID: 8747967 DOI: 10.1097/00006123-199601000-00039] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
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).
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Affiliation(s)
- A D Levi
- Division of Neurosurgery, Toronto Hospital, University of Toronto, Ontario, Canada
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40
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Fujimura Y, Nishi Y, Chiba K, Kobayashi K. Prognosis of neurological deficits associated with upper cervical spine injuries. PARAPLEGIA 1995; 33:195-202. [PMID: 7609975 DOI: 10.1038/sc.1995.44] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We investigated the type of injury and neurological prognosis in 82 patients with an upper cervical spine injury with neurological deficits, from a total of 247 such patients that we treated, from which 11 patients who were dead on arrival had been excluded. The incidence of neurological deficits in upper cervical spine injury was 33%. They were classified into three signs; cord, upper cervical nerve root, and cranial nerve signs. The types of injury accompanied by neurological deficits were burst fracture of the atlas, type II dens fracture, body fracture of the axis, type II traumatic spondylolisthesis of the axis, atlanto-occipital dislocation, and atlanto-axial dislocation. Most were unstable vertebral injuries. The four patients who died after arrival at hospital had complete tetraplegia with respiratory distress. The neurological deficit was one of paresis in the 78 patients who survived; in many, the paresis was mild with a resulting good neurological prognosis.
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Affiliation(s)
- Y Fujimura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
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Abstract
Spinal cord injury without radiographic abnormality and asymptomatic Chiari I malformation have an unusual coincidence. A young boy who had recently fallen from his porch was transferred to the neurosurgery service with a high cervical central cord syndrome. Careful study demonstrated no radiographic abnormality and, although the patient was previously quite well, magnetic resonance imaging revealed Chiari I malformation. Although expectedly uncommon, reports of three other similar cases support a less than independent relationship between these two processes. All four children, each aged 2 years, were premorbidly asymptomatic and were playing when they fell from low elevations; two were on a couch. All were evaluated by primary authorities 12 to 48 hours before definitive admission, and all had normal plain film examinations. Three of the four children suffered injuries in flexion, the fourth in extension. Three realized a 5-minute to 3-hour delay before the onset of symptoms, and three suffered gradual progression of deficit. Magnetic resonance imaging was the most commonly applied and productive diagnostic medium, demonstrating cerebellar ectopia in three of three cases. Two children were surgically treated, and all achieved at least a functional outcome. Similarities among these cases support a common mechanism of injury, and indicate careful counseling in children with asymptomatic Chiari I malformation and consideration of operative decompression in those children with progressive neurological injury and deficit.
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Affiliation(s)
- C P Bondurant
- Division of Neurosurgery, University of Missouri-Columbia
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Proceedings of the Society of British Neurological Surgeons with the New England Neurosurgical Society, London, September 1991. Journal of Neurology, Neurosurgery and Psychiatry 1992. [DOI: 10.1136/jnnp.55.6.513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Pappas CT, Gibson AR, Sonntag VK. Decussation of hind-limb and fore-limb fibers in the monkey corticospinal tract: relevance to cruciate paralysis. J Neurosurg 1991; 75:935-40. [PMID: 1719167 DOI: 10.3171/jns.1991.75.6.0935] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cruciate paralysis is a clinical entity in which patients with trauma to the anterior cervicomedullary junction present with weakness of the upper extremity greater than that of the lower extremity. The underlying mechanism of this paralysis is commonly thought to be selective damage affecting the upper-extremity nerve fibers in the pyramidal decussation. The authors examined the anatomical basis of cruciate paralysis in six New World squirrel monkeys and two Old World cynomolgus monkeys. No evidence for a differential decussation of fore-limb and hind-limb fibers was found. Thus, there is no obvious anatomical explanation for cruciate palsy. The results do suggest two alternative explanations for cruciate paralysis: 1) selective damage to neural areas involving the internuncial cells, the central gray area, and the cuneate nucleus, or 2) injury to the ventral corticospinal tract.
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Affiliation(s)
- C T Pappas
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Abstract
Traumatic atlanto-occipital dislocation is most often fatal. Consequently, there are only scattered case reports of patients surviving this injury, and treatment modalities are anecdotal and varied. The case of an 18-year-old woman who suffered an anterior atlanto-occipital dislocation as the result of a motor-vehicle accident is presented. Rigid posterior fixation and complete reduction of the dislocation were achieved using an anatomically contoured steel loop secured to the occiput and cervical vertebrae. The addition of cancellous bone to the graft afforded long-term stability. This operative treatment provided anatomical realignment of the dislocation and allowed early mobilization of the patient with the use of aggressive rehabilitation. Previously reported cases of patients surviving anterior atlanto-occipital dislocation are reviewed. The use of cervical traction, halo bracing, and operative stabilization is discussed.
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Affiliation(s)
- A J Belzberg
- Department of Clinical Neurosciences, Foothills Hospital, University of Calgary, Alberta, Canada
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Dickman CA, Hadley MN, Pappas CT, Sonntag VK, Geisler FH. Cruciate paralysis: a clinical and radiographic analysis of injuries to the cervicomedullary junction. J Neurosurg 1990; 73:850-8. [PMID: 2230968 DOI: 10.3171/jns.1990.73.6.0850] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Fourteen patients with superior cervical spinal cord injuries and the clinical signs and symptoms of cruciate paralysis are presented. This rare injury pattern is characterized by weakness of the upper extremities with little or no compromise of lower-extremity function following trauma to the superior spinal cord. Anatomically, cruciate paralysis is thought to represent selective injury to descending corticospinal tracts as they decussate at the cervicomedullary junction. The clinical and radiographic findings of each patient are outlined and the incidence and natural history of the injury syndrome, including a review of the literature, are presented.
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Affiliation(s)
- C A Dickman
- Spinal Cord Injury Service, Barrow Neurological Institute, Phoenix, Arizona
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Ciappetta P, Salvati M, Raco A, Artico M. Cruciate hemiplegia: a clinical syndrome, a neuroanatomical controversy. Report of two cases and review of the literature. SURGICAL NEUROLOGY 1990; 34:43-7. [PMID: 2193417 DOI: 10.1016/0090-3019(90)90171-k] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- P Ciappetta
- Department of Neurological Sciences, University of Rome La Sapienza, Italy
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48
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Abstract
The hallmark of concussion injuries of the nervous system is the rapid and complete resolution of neurological deficits. Cerebral concussion has been well studied, both clinically and experimentally. In comparison, spinal cord concussion (SCC) is poorly understood. The clinical and radiological features of 19 SCC injuries in the general population are presented. Spinal cord injuries were classified as concussions if they met three criteria: 1) spinal trauma immediately preceded the onset of neurological deficits; 2) neurological deficits were consistent with spinal cord involvement at the level of injury; and 3) complete neurological recovery occurred within 72 hours after injury. Most cases involved young males, injured during athletics or due to falls. Concussion occurred at the two most unstable spinal regions, 16 involving the cervical spinal and three the thoracolumbar junction. Fifteen cases presented with combined sensorimotor deficits, while four exhibited only sensory disturbances. Many patients showed signs of recovery with the first few hours after injury and most had completely recovered within 24 hours. Only one case involved an unstable spinal injury. There was no evidence of ligamentous instability, spinal stenosis, or canal encroachment in the remaining 18 cases. Two patients, both children, suffered recurrent SCC injuries. No delayed deterioration or permanent cord injuries occurred. Spinal abnormalities that would predispose the spinal cord to a compressive injury were present in only one of the 19 cases. This suggests that, as opposed to direct cord compression, SCC may be the result of an indirect cord injury. Possible mechanisms are discussed.
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Affiliation(s)
- T J Zwimpfer
- Division of Neurosurgery, University of Toronto, Ontario, Canada
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Lehman LB. Injury of the cervical spine. Some fundamentals of management. Postgrad Med 1987; 82:193-200. [PMID: 3615312 DOI: 10.1080/00325481.1987.11699935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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50
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Traynelis VC, Marano GD, Dunker RO, Kaufman HH. Traumatic atlanto-occipital dislocation. Case report. J Neurosurg 1986; 65:863-70. [PMID: 3772485 DOI: 10.3171/jns.1986.65.6.0863] [Citation(s) in RCA: 220] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Traumatic atlanto-occipital dislocation is a serious injury that is usually fatal. The number of patients surviving this injury, however, appears to be increasing, and most of these survivors are children. This may reflect an improvement in emergency transport services. Seventeen previously reported cases of patients surviving atlanto-occipital dislocation for more than 48 hours are reviewed and an additional case is presented. Many of these patients had an excellent neurological outcome. The radiographic criteria necessary for the diagnosis of atlanto-occipital dislocation are discussed. Cervical computerized tomography may confirm the diagnosis when necessary. It is suggested that there are three types of atlanto-occipital dislocation; utilizing this new classification, a rationale for treatment is described. Fusion is favored for long-term stability.
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