Spine Healing Therapy

Dorn Spinal Therapy

Dorn Spinal Therapy has been in uses in the past 40 years. The credit of this method goes to Dieter Dorn, who has made a significant impact in the medical field. DORN- Method has been used on various patients where results could get witnessed instants. Due to the impact, this method has brought in the country. It has been declared the standard practice in treating Pelvical Disorders, Spinal, and Back pain. Dieter Dorn first used this method on his family, which was a sign of confidence in a method, which later gained much attention from different people in the country and also globally. Every day Dorn was able to offer treatment to 15- 20 patients in a day. His services were purely free which attracted attention both in the local and also global. The primary treatment that DORN-Method which could be treated using this method include spine healing therapy, misalignments of the spine, resolving pelvis and joints, and also solving out significant problems which could get attributed to vertebrae. More here...

Dorn Spinal Therapy Summary

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The corticospinal tract

Motor control signals from M1 and the NPMAs travel to the spinal cord via several descending tracts (Fig. 2.4). The corticospinal tract is the most direct pathway from the cerebral cortex to the spinal motoneurons. The corticospinal tract originates from multiple areas in the frontal and parietal lobes. In the frontal lobe of primates, the greatest proportion of axons originates from M1 (approximately 30 of the total corticospinal tract), with the remaining frontal lobe axons (another 30 of the total corti-cospinal tract) originating from the SMA, the pre-motor areas, and the cingulate motor areas (Dum and Strick, 1991). In the parietal lobe, corticospinal axons originate from Brodmann's areas 1, 2, 3, 5, and 7 (approximately 40 of the total corticospinal tract) and project to the dorsal horn of the spinal cord to regulate sensory inflow. Corticospinal axons arise from the large pyramid-shaped cell bodies in cortical layer V The axons leave the cortex, pass through the corona radiata,...

Further Information On Spinal Gastrointestinal And Hepatic Tb

Spinal TB TB of the spine is important.The disastrous consequence for the patient of a missed diagnosis of thoracic or cervical spinal TB is paralysis. TB starts in an intervertebral disc and spreads along the anterior and longitudinal ligaments, before involving the adjacent vertebral bodies. Where TB is common, plain X-ray of the spine is usually diagnostic.The typical appearance is erosion of the anterior edges of the superior and inferior borders of adjacent vertebral bodies. The disc space is narrowed. The sites most commonly involved are the lower thoracic, lumbar and lumbosacral areas. The main differential diagnoses are malignancy and pyogenic spinal infections. Malignant deposits in the spine tend to erode the pedicles and spinal bodies, leaving the disc intact. Pyogenic infection tends to be more acute than TB, with more severe pain.

From spinal cord to cerebral cortex

The spinal cord has a relatively simple structural organization a central region of 'grey matter' containing synapses and the cell bodies of neurons and a surrounding 'white matter' consisting of the axons transmitting information up and down the cord. The spinal cord is segmental and at each segment there are two pairs of 'roots', one dorsal and one ventral, which connect the spinal cord to the body. The ventral roots contain the outgoing axons of motor neurons and the dorsal roots contain the incoming axons of sensory neurons. The cell bodies of the sensory neurons reside in swellings called dorsal root ganglia close to the spinal cord. Cell bodies of the motor neurons are found in the ventral grey matter, clustered together in functionally related groups. Thus motor neurons that innervate a given muscle are grouped together and motor neurons of the extremities are found laterally in the cord, whereas those innervating trunk muscles are more centrally located. This grouping by...

Indirect Corticospinal Projections

Corticorubrospinal, corticoreticulospinal, and corticovestibulospinal projections contribute to limb and trunk muscle contractions, especially for sustained contractions. Such contractions of muscle are important for stabilizing the trunk and proximal muscles during actions. The reticular and vestibular descending pathways project bilaterally in the ventral and ventrolateral funiculi of the spinal cord, reaching the ven-tromedial zone of the anterior horns to contribute to postural and orienting movements of the head and body and synergistic movements of the trunk and limbs. Kuypers suggested that the interneurons of the ventromedial intermediate zone of spinal gray matter represent a system of widespread connections among a variety of motor neurons, whereas the dorsal and lateral zones, which receive direct corticospinal inputs, are a focused system with a limited number of connections.106 Other corticomotoneurons project directly and by collaterals to the upper medullary medial...

Spinal Sensorimotor Activity

The pools of spinal interneurons and mo-toneurons translate the internal commands of the brain into simple (reflexes), rhythmic (walking, breathing, swallowing), and complex (speaking, reaching for a cup) movements. These motor pools integrate descending commands with immediate access to sensory feedback about limb position, muscle length and tension, tactile knowledge about objects, and other segmental inputs. The sensory and motor pools of the cord conduct simple and poly-synaptic movement patterns, recruit motor units for movements, and participate in rhythmic activity called pattern generation. Most importantly, the spinal motor pools are an integral part of motor learning. Indeed, the spinal cord reveals a considerable degree of experience-dependent plasticity that is induced, adjusted, and maintained by descending and segmental sensory influences.143,144 Another form of spinal plasticity results in pain after a pe

Vascular Supply to the Spinal Cord

The anterior spinal artery arises from the anastomosis of two branches from the intracranial vertebral arteries. It travels in the anterior sulcus of the spinal cord and extends from the level of the olivary nucleus to the conus medullaris. It supplies the ventral surface of the medulla and the anterior two thirds of the spinal cord. The artery is continuous in the upper cervical region. However, in the segments inferior to the upper cervical region, it consists of anatomosing branches from the anterior radicular arteries. The two posterior spinal arteries most commonly arise from the vertebral arteries. However, in some instances, they arise from PICA. There are contributions from numerous posterior radicular arteries that form an anastomotic network on the posterior surface of the spinal cord. y These arteries supply the posterior one third of the spinal cord. The anterior and posterior spinal arteries join in an anastomotic loop at the conus medullaris. y The different regions of...

Plasticity in Spinal Locomotor Circuits

The cat's deafferented spinal cord below a low thoracic transection can generate alternating flexor and extensor muscle activity a few hours after surgery when DOPA or clonidine are administered intravenously or when the dorsal columns or dorsal roots are continuously stimulated. This is called fictive locomotion. Several weeks after a complete lower thoracic spinal cord transection without deafferenta-tion, adult cats and other mammals have been trained on a treadmill so that their paralyzed hindlimbs fully support their weight, rhythmically step, and adjust their walking speed to that of the treadmill belt in a manner that is similar to normal locomotion.375,376 Postural support alone is detrimental to subsequent locomotion, whereas rhythmic alternating movements of the limbs with joint loading seems critical to the recovery of locomotor output.377 Serotonergic and noradrenergic drugs enhance the stepping pattern378 and strychnine, through a glycinergic path, quickly induces it in...

Magnetic Resonance Imaging Of The Spine

Since the mid 1980s, MRI of the spine has attained acceptance as the premier modality in the evaluation of spine diseases. MRI is eloquent in the evaluation of both benign or malignant spinal processes and is unique in its inherent noninvasive ability to image the spinal cord and surrounding structures such as CSF, dura, and adjacent ligaments. The utility of spine MRI can therefore be discussed in terms of the three classic categories of spine disease extradural, intradural-extramedullary, and intramedullary processes. A frequent cause of epidural disease is intervertebral disc pathology. MRI can uniquely image the intervertebral disc directly, without the use of contrast material. Disc integrity can be assessed in terms of degeneration, abnormal disc bulges, or herniations. High-resolution T2-weighted images of the disc can diagnose annular and circumferential tears that previously required injection of contrast material (i.e., CT discography). Any affect on spinal contents, either...

Propriospinal myoclonus

These irregular jerking movements occur in the supine position during relaxed wakefulness before sleep and are inhibited by sleep 1 . Each jerk lasts 150-300 ms and involves large muscles, including those of the neck, chest and abdomen. They appear to be generated by a spreading wave of activity in the propriospinal system in the spinal cord due to loss of brainstem or higher centre inhibition.

PLMS Associated with Spinal Cord Lesions

In animals, complex motor performance such as walking behavior can still be performed in the case of a complete spinal transection, arguing in favor of complex motor pattern generators in the spinal cord (84). Also, in animals with spinal cord lesions PLM emerged during sleep (85). Spinal pathologies that have been associated with PLMS include syringomyelia (78,83) and syringobulbia (83), lum-brosacral radiculopathy (73), traumatic injuries (86), and other lesions (87). Even in completely paraplegic patients PLMS have been observed (86,88,89), strongly suggesting a spinal origin of PLMS. Interestingly, the known lower occurrence of PLMS during rapid eye movement (REM) sleep is maintained in patients with spinal pathologies and only abolished in patients with complete spinal cord transsections (86,88). Watanabe et al. (90) reported a well-documented case of an 86-year-old male who exhibited PLM during midthoracic epidural anesthesia. Careful observation in the hospital did not reveal...

Growth of Dendritic Spines

Motor learning induces genes that modify cell structures and functions, such as increasing the number of synaptic spines.259 Indeed, dendritic spines increase with the induction of LTP.265 Growing evidence points to the relationship between morphologic remodeling of the postsynaptic membrane as a late response to LTP and functional changes in synaptic strength.266 In one proposal for this remodeling process, the induction of LTP increases the number of AMPA receptors in a postsynaptic dendritic spine. The postsynaptic membrane enlarges, then splits into several spines.267 The new spines send a retrograde message to the presynaptic membrane to trigger structural changes there. The number of synapses related to the initial activity-induced signal then increases. Long-term depression may involve the inverse of this process. A decrease in AMPA receptors and membrane material leads to a decrease in the size of the postsynaptic membrane, and finally to the loss of the dendritic spine.

Spinal Muscular Atrophies

The spinal muscular atrophies are diseases of the anterior horn cells of the midbrain, pons, medulla, and spinal cord that most often present with muscle weakness in infancy and childhood. They may present with either proximal or distal weakness from the antenatal period onward. The inheritance pattern is most commonly autosomal recessive, but there are forms that are dominant and X linked ( T bJ 3.6.-2,). TABLE 36-2 -- TYPES OF SPINAL MUSCULAR ATROPHY TABLE 36-2 -- TYPES OF SPINAL MUSCULAR ATROPHY Figure 36-2 A baby with spinal muscular atrophy, showing the flaccid head lag in the supine positiifFrom Dubowitz V Muscle Disorders in Childhood. Philadelphia, W.B. Saunders, 1995.)

Cranial and Spinal Subdural Empyema

Subdural empyema is a pyogenic infection in the space between the dura mater and the arachnoid and represents 13 to 20 percent of localized intracranial infections. The arachnoid is not a very strong barrier, and subdural empyema may breach the arachnoid and cause subpial infection. y The most common predisposing condition that leads to the development of a subdural empyema is paranasal sinusitis, especially frontal sinusitis. Paranasal sinusitis is the primary cause of a subdural empyema in 50 to 80 percent of patients, and otitis media is the primary cause in 10 to 20 percent. y , y Superficial infections of the scalp and skull, craniotomy, or septic thrombophlebitis from sinusitis, otitis, or mastoiditis may extend to the subdural space causing empyema. y Subdural empyema in infants usually represents an infected subdural effusion complicating a bacterial meningitis. y , y An empyema may rarely develop in the subdural area of the spinal cord. with...

Diffuse Hypoperfusion Syndromes Cerebral and Spinal Cord

As discussed in the section on arterial anatomy, the midthoracic spinal cord is a border zone or watershed area that is susceptible to ischemia due to the unequal blood supply in this region. In situations of systemic hypoperfusion, there can be a spinal cord infarction. Conditions such as an aortic dissection can also cause a global decrease in spinal cord perfusion that results in gray matter infarction with relative sparing of the white matter tracts.

White Spot In Spinal Cord

Intramedullary Spinal Cord Tumors

The cyst causes marked expansion of the cord and appears like a regular, symmetric cyst with sharp demarcation toward the spinal cord. There are no septations inside the cyst 3. Does the pathology affect different parts of the spinal cord with time As a general rule, inflammatory and demyelinating lesions almost never displace cord tissue at all, or to an extent that would explain the clinical symptoms (Figs. 3.25-3.29) 173, 190 . Multiple spinal cord lesions maybe detected in demyelinating (Fig. 3.25) and

Problems of the Spine

Spondylolysis and spondylolisthesis may be asymptomatic or may present with low back pain occasionally radiating to the buttocks. Physical examination may show lumbosacral tenderness and accentuation of pain by hyperextension of the spine with one leg raised off the ground and flexed 90 degrees at the hip and knee (one-leg hyperextension test). Patients with significant spondylolisthesis have a classic appearance of a short torso and flat buttocks, often standing with their knees held in modest extension. Neurological status, including bladder function, must be assessed, although neurological deficit is unusual and is seen in about 35 of those with more than 50 slippage of the vertebrae.43 Radiographs should include anteroposterior, lateral, and oblique views of the lumbar spine. The pars defect is best seen on the oblique film (Fig. 7.10) and is unilateral in about 20 of patients. The pars defect appears as a band or break in the Scotty dog's neck (pars If asymptomatic, no treatment...

Pain Suppression Analgesia System in the Brain and Spinal Cord

Brain Stem Spinal Cord

The analgesia system is shown in Figure 48-4. It consists of three major components (1) The periaqueductal gray and periventricular areas of the mesencephalon and upper pons surround the aqueduct of Sylvius and portions of the third and fourth ventricles. Neurons from these areas send signals to (2) the raphe magnus nucleus, a thin midline nucleus located in the lower pons and upper medulla, and the nucleus reticularis paragigantocellularis, located laterally in the medulla. From these nuclei, second-order signals are transmitted down the dorsolateral columns in the spinal cord to (3) a pain inhibitory complex located in the dorsal horns of the spinal cord. At this point, the analgesia signals can block the pain before it is relayed to the brain. Electrical stimulation either in the periaqueductal gray area or in the raphe magnus nucleus can suppress many strong pain signals entering by way of the dorsal spinal roots. Also, stimulation of areas at still higher levels of the brain that...

Excitation of the Spinal Cord Motor Control Areas by the Primary Motor Cortex and Red Nucleus

Stimulation of the Spinal Motor Neurons Figure 55-6 shows a cross section of a spinal cord segment demonstrating (1) multiple motor and senso-rimotor control tracts entering the cord segment and (2) a representative anterior motor neuron in the middle of the anterior horn gray matter. The corti-cospinal tract and the rubrospinal tract lie in the dorsal portions of the lateral white columns. Their fibers terminate mainly on interneurons in the intermediate area of the cord gray matter. Patterns of Movement Elicited by Spinal Cord Centers. From Chapter 54, recall that the spinal cord can provide certain specific reflex patterns of movement in response to sensory nerve stimulation. Many of these same patterns are also important when the cord's anterior motor neurons are excited by signals from the brain. For example, the stretch reflex is functional at all times, helping to damp any oscillations of the motor movements initiated from the brain, and probably also providing at least part of...

Cranial and Spinal Epidural Abscess

Cranial epidural abscesses develop in the space between the dura and inner table of the skull and are usually caused by the spread of infection from the frontal sinuses, middle ear, mastoid, or orbit. y Epidural abscesses may also develop as a complication of a craniotomy or compound skull fracture. At present, the most common cause of a cranial epidural abscess is craniotomy that has been complicated by an infection of the wound, bone flap, or epidural space.y Epidural abscesses may result from or be associated with an area of osteomyelitis. A spinal epidural abscess develops in the space outside the dura mater but within the spinal canal. The spinal epidural space is only a true space posterior to the spinal cord and the spinal nerve roots. The anteroposterior width of the epidural space is greatest in the area where the spinal cord is smallest, that is from approximately T4 to T8, and from L3 to S2. 56 , y The most common location for an epidural...

Triple Flexion Is A Spinal Reflex

Bethesda Category

Spinal reflex pathways, results in positive symptoms including spasticity, hyperactive muscle stretch reflexes, abnormal cutaneous and autonomic reflexes, and co-contraction of agonist and antagonist muscles (dystonia). Immediately after an acute brain or spinal cord injury muscles generally become weak and hypotonic (O'Brien et al., 1996). This is referred to as spinal shock and is accompanied by loss of muscle stretch reflexes and impaired F-wave responses on nerve conduction testing (Hiersemenzel et al., 2000). Spasticity then often develops days to weeks after the acute injury this is thought to be due to upregu-lation of spinal cord receptors and synaptic reorganization (McGuire and Harvey, 1999). Patients with cerebral lesions tend to recover reflexes and tone within a few days of injury, while patients with spinal cord injuries may have a period of spinal shock last for weeks (Calancie et al., 2002). Generally, the longer it takes for tone to return the worse the prognosis is...

Organization of the Spinal Cord for Motor Functions

Wide Dynamic Range Neuron

We have already noted that sensory information is integrated at all levels of the nervous system and causes appropriate motor responses that begin in the spinal cord with relatively simple muscle reflexes, extend into the brain stem with more complicated responses, and finally extend to the cerebrum, where the most complicated muscle skills are controlled. Connections of peripheral sensory fibers and corticospinal fibers with the interneurons and anterior motor neurons of the spinal cord. Each segment of the spinal cord (at the level of each spinal nerve) has several million neurons in its gray matter. Aside from the sensory relay neurons discussed in Chapters 47 and 48, the other neurons are of two types (1) anterior motor neurons and (2) interneurons.

Red Nucleus Serves as an Alternative Pathway for Transmitting Cortical Signals to the Spinal Cord

Red Nucleus

As shown in Figure 55-5, it receives a large number of direct fibers from the primary motor cortex through the corticorubral tract, as well as branching fibers from the corticospinal tract as it passes through the mesencephalon. These fibers synapse in the lower portion of the red nucleus, the magnocellular portion, which contains large neurons similar in size to the Betz cells in the motor cortex. These large neurons then give rise to the rubrospinal tract, which crosses to the opposite side in the lower brain stem and follows a course immediately adjacent and anterior to the corticospinal tract into the lateral columns of the spinal cord. The corticorubrospinal pathway serves as an accessory route for transmission of relatively discrete signals from the motor cortex to the spinal cord. When Therefore, the pathway through the red nucleus to the spinal cord is associated with the corticospinal system. Further, the rubrospinal tract lies in the lateral columns of the spinal cord, along...

Reflexes and the Spinal Cord

PLM have been thought to be highly stereotyped movements, possibly resembling the Babinski sign (91) or the flexor reflex (92) and could thus be the consequence of a transitory loss of supraspinal inhibitory influences on descending motor pathway function. Another line of research has explored segmentally localized reflexes in RLS patients, especially the H-reflex, in search for a spinal hyperexcitability. Interestingly, in a case study, an injection with apomorphine abolished both the PLMS and the flexor reflex in a subject with severe PLM after dopamine withdrawal (97). There is evolving evidence, however, that PLMS are not stereotyped movements that follow a regular spinal recruitment pattern, not even in the same patient (21,98). The EMG recruitment pattern of involuntary limb movements during wakefulness might exhibit a slightly higher intraindividual stability as reported by Trenkwalder et al. (99). Together with the results of a disinhibition of the flexor reflex in RLS...

Motor Functions of the Spinal Cord the Cord Reflexes

In this chapter, we discuss the control of muscle function by the spinal cord. Without the special neuronal circuits of the cord, even the most complex motor control systems in the brain could not cause any purposeful muscle movement. To give an example, there is no neuronal circuit anywhere in the brain that causes the specific to-and-fro movement of the legs that is required in walking. Instead, the circuits for these movements are in the cord, and the brain simply sends command signals to the spinal cord to set into motion the walking process. Let us not belittle the role of the brain, however, because the brain gives directions that control the sequential cord activities to promote turning movements when they are required, to lean the body forward during acceleration, to change the movements from walking to jumping as needed, and to monitor continuously and control equilibrium. All this is done through analytical and command signals generated in the brain. But it also requires the...

Spinal Cord Stroke Syndromes

ANTERIOR SPINAL ARTERY SYNDROME The anterior spinal artery syndrome is characterized by an abrupt onset of flaccid paraplegia or tetraplegia below the level of the lesion due to bilateral corticospinal tract damage. There is thermoanesthesia and analgesia below the level of the lesion due to compromise of the spinothalamic tracts bilaterally. Position, vibration, and light touch are spared due to preservation of the dorsal columns, which are supplied by the posterior spinal arteries. Bowel and bladder function is impaired. There may be associated radicular or girdle pain. These infarctions most commonly occur in the watershed areas or boundary zones where the distal branches of the major arterial systems of the cord anastomose, between the T1 and T4 segments and at the L1 segment. Common etiologies of arterial spinal cord infarction are detailed in Table.2.2,-3. . POSTERIOR SPINAL ARTERY SYNDROME The posterior spinal artery syndrome is uncommon, probably due to the presence of...

Spinal Cord Myelopathy

Generally with transverse lesions of the spinal cord there is a demonstrable sensory level with bilateral loss of all modalities of sensation below a definite level. With involvement of the dorsal columns there is loss of proprioception, discriminative modalities, and vibration within a couple of levels caudad to the lesion site. With smaller lesions it is possible to selectively involve certain dorsal column modalities owing to the topographical distribution of the various modalities fibers carrying discriminative touch are most posterior, vibratory fibers are most anterior, and proprioceptive fibers are intermediate within the dorsal funiculi. There will be no significant loss of light touch however, pressure sensation may be impaired. Examples are a metastatic lesion to the spinal cord, cord infarction, and multiple sclerosis plaque. Central cord lesions and anterior spinal artery syndrome are discussed in Chapter20 . Brown-Sequard syndrome is discussed in Chapter l15 .

Cerebrospinal Fluid and Intracranial Pressure

Cerebrospinal Fluid and the Ventricular System The cerebrospinal fluid (CSF) has served as an aid to the diagnosis and treatment of a variety of central nervous system (CNS) disorders for more than 100 years. In 1891, Quinke first developed the technique of spinal puncture and introduced it into clinical practice. y He was the first to use a needle with a stylet, to measure opening and closing pressures, and to pioneer the measurement of CSF glucose, protein, and cell counts. Much of the CSF literature in the early part of the 20th century dealt with changes related to bacterial meningitis and neurosyphilis. y

Stress Fractures In The Lumbar Spine

The lumbar spine consists of five lumbar vertebrae joined to the sacrum at the pelvis. Stress fractures of the lumbar vertebral column are relatively common, and the site of injury depends on the direction in which the stress is applied 17 . The main components of lumbar motion are believed to occur at the L3-L4 and L5-S1 levels 7 . Fractures of the pedicle 21-23 and sacrum 24-29 occur, but fractures of the pars are most frequent 17,30,31 . Risk Factors for Stress Fractures in the Lumbar Spine in Adolescent Athletes There are several major risk factors in the adolescent spine that make it susceptible to stress fractures. The adolescent spine has immature areas of growth cartilage and ossification centers that are subject to torsion injury, compression, and distraction 4 . These areas are the weakest links in the transfer of forces through the spine 4 . There is one ossification center at each side of the neural arch at the pedicles. Ossification may be incomplete and may be...

Spinal Reconstruction and Fusion

With the introduction of approaches to the spine and increasing surgical attempts to treat spinal tumors as well as spinal trauma and degenerative disorders, little concern existed for spinal stability among neurosurgeons - not to mention for the side effects of surgery on spinal stability. First attempts to reconstruct the vertebral column were met with great scepticism by many respected neurosurgeons because reconstruction and stabilization meant longer surgery, a risk of insufficient vascularization of the reinserted laminae, and a higher risk of infection at a time without sufficient anesthetic techniques and antibiotics 29, 30, 40, 50 . Spinal stabilization was first developed to treat patients with Pott's disease. Hadra used wiring of the spinous processes to prevent kyphotic deformities 21 . In 1910, Lange suggested steel bars for fusion of a spondylitic spine 31 . Albee, Hibbs, and Ito used bone grafts to achieve bony fusion 2, 25, 28 . However, it was not until the advent of...

Lumbar Spine and Sacrum

Similarly to the thoracic vertebrae, the five lumbar vertebral bodies are rectangular in shape, with flat superior and inferior surfaces. The pedicles project posterolaterally. The neural foraminae exit almost laterally. The posterior border of each foramen is formed by the articular processes. These processes are comparably long and form the facet joints, which are oriented in the coronal plane. The lumbar laminae form an oval spinal canal in the upper lumbar spine. In the lower part, the shape becomes more triangular, with bony recesses anterolaterally these are Fig. 2.7. a Axial T2-weighted MRI scan of the lumbar spine at Th12 L1. b Axial T2-weighted MRI scan of the lumbar spine at L3. c Axial T2-weighted MRI scan of the lumbar spine at L3 4. d Axial T2-weighted MRI scan of the lumbar spine at the pedicle level of L5. AVP Anterior epidural venous plexus. e Axial T2-weighted MRI scan of the lumbar spine at forami-nal level of L5. f Axial T2-weighted MRI scan of the lumbar spine at...

RLS Associated with Spinal Cord Lesions

There are numerous case reports describing the onset of RLS in close temporal association with spinal pathologies such as lumbosacral radiculopathy (73), borrelia-induced myelitis (74), transverse myelitis (75), vascular injury of the spinal cord (76), multiple sclerosis (77), traumatic lesions (77), cervical spondylotic myelopathy (77), or syringomyelia (77). After spinal anesthesia, 8.7 of 161 patients developed transient new onset RLS (78). Many subjects in these reports responded to dopaminergic treatment (74,75,77,79), while in one subject (76) relief was obtained by a combination of tilidin and zolpidem. The autosomal-dominant spinocerebellar ataxias (SCA) are a heterogeneous group of neurodegenerative disorders, and the subtypes SCA-3 (80), SCA-2 and -3 (81), and SCA-1, -2, and -3 (82) have been linked to an increased prevalence of RLS. Although spinal processes among a range of diverse subcortical structures have been implicated in SCA, the authors focused on a possible...

Comprehensive Metabolomic Profile Analysis Of Human Cerebrospinal Fluid

CSF is found within the subarachnoid space that surrounds and protects the brain and spinal cord. In addition to physical support, the CSF functions to control excretory processes, transport metabolites within the intracerebral environment of the central nervous system (CNS), and regulate intracranial pressure. The composition of CSF is dependent on secretory processes as the fluid derives from the choroid plexus, the ependymal lining of the ventricular system, and blood vessels in the pia-arachnoid. In addition, ultrafiltration of blood plasma and various transport mechanisms contributes to the composition of CSF. Analysis of CSF has been used as the gold standard for diagnosing many neurological and CNS disorders. CSF can only be collected following a lumbar puncture (spinal tap) and is therefore a significantly less accessible surrogate tissue. The complexity and discomfort of the procedure limit the diagnostic utility of CSF to individuals who have already begun to show...

Spinal Stenosis

Spinal stenosis is a common cause of back pain among older adults. Symptoms usually begin in the sixth decade, and over time the patient's posture becomes progressively flexed forward. The mean age of patients at the time of surgery for spinal stenosis is 55 years, with an average symptom duration of 4 years.10 The symptoms of spinal stenosis are often diffuse because the disease is usually bilateral and involves several vertebrae. Pain, numbness, and tingling may occur in one or both legs. Pseudoclaudication is the classic symptom of spinal stenosis. Pseudoclaudication is differentiated from vascular claudication in that pseudoclaudication has a slower onset and a slower resolution of symptoms.7 Symptoms are usually relieved with flexion (e.g., sitting, pushing a grocery cart) and exacerbated by back extension. Plain radiographs often show osteophytes at several levels, but as mentioned earlier, caution must be used in ascribing back pain to these degenerative changes. CT or MRI may...

Spinal Cord Trauma

Damage to the spinal cord caused by automobile accidents or falls from high places or from a horse can make it impossible for the brain to control the extremities and internal organs, such as the heart and lungs. The severity of the damage depends on how close to the brain the spinal cord injury is. If the individual's neck is broken, he or she may end up being a quadriplegic (a person who is unable to move the arms and legs) and may not be able to breathe properly. If the damage to the spinal cord is near the middle of the back, the patient will be paraplegic (unable to move the legs) but will retain control over the arms and lungs. Repairing a damaged spinal cord is extremely difficult for two reasons. First, the neurons that were destroyed must be replaced, and the replacement neurons must make the proper connections to bridge the damaged area. Second, once the new neurons are in place, they must be insulated, much as an electrical wire is insulated, before they can work properly....

Spinal Cord

Locomotor synergies are present in the spinal cord. Spinally transected vertebrates, including humans, can produce coordinated stepping movements without any input from supraspinal neural structures. The spinal networks that produce patterned muscle activation, termed central pattern generators, are distributed throughout the spinal cord. The rhythmical muscle activation that is a part of coordinated stepping can be generated from even a few isolated segments of the hemitransected spinal cord. The central pattern generator has been deduced to consist of excitatory and inhibitory interneurons using glycine, glutamate, and acetylcholine as neurotransmitters. Interneurons and collaterals connect the ipsilateral and contralateral central pattern generators to produce reciprocal movements of the limbs. Propriospinal neurons connect different levels to produce coordination between the hind limbs and axial muscles and the arms or front legs. The pattern of central pattern generator...

Spinal Primitives

The motoneurons and interneurons of the lumbar cord also participate in another type of organization that appears to simplify the problem of motor contol. Bizzi and colleagues combined a spinal cord transection with electrical or chemical microstimulation of the ventral gray matter of frogs, rats, and nonhuman primates.9 The investigators found that rostral-caudal stimulation of separate volumes of gray matter produced movements that the investigators quantified as force vectors. Within each volume or module, a discrete set of synergistic limb muscle contractions was elicited that directed the limb toward an equilibrium point. In the frog, for example, they modeled the syn-ergistic coactivation of muscles that stabilized the leg in four positions within its usual work-space.197 As few as 23 out of over 65,000 possible combinations of activations of 16 limb muscles reproducibly stabilized the hindlimb within the flexion and extension synergies associated with its range of functional...

Spinal Level

Programmed in the spinal cord are local patterns of movement for all muscle areas of the body for instance, programmed withdrawal reflexes that pull any part of the body away from a source of pain. The cord is the locus also of complex patterns of rhythmical motions such as to-and-fro movement of the limbs for walking, plus reciprocal motions on opposite sides of the body or of the hindlimbs versus the forelimbs in four-legged animals.

Spinal Reflexes

Many theories of physical therapy focus on the use of brain stem and spinal reflexes as a way to retrain voluntary movement and affect hy-potonicity and hypertonicity. Tonic and phasic stimuli can modify the excitability of spinal motor pools, postural reflexes, and muscle cocontractions. Wolpaw and colleagues demonstrated activity-driven plasticity within the spinal stretch reflex, revealing that even the neurons of a seemingly simple reflex can learn when trained. The investigators operantly conditioned the H-reflex in monkeys to increase or decrease in amplitude.151 An 8 change began within 6 hours of conditioning and then gradually changed by 1 to 2 per day. This modulation of the amplitude of the H-reflex required 3000 trials daily. The alteration persisted for several days after a low thoracic spinal transection, which suggests that the spinal circuitry for the H-reflex below the transection had learned and held a memory trace. A long-term change in presynaptic inhibition...

Spinal Metastases

An epidural mass lesion can produce damage to the spinal cord either by mass effect resulting in mechanical distortion with demyelination or axonal destruction or from vascular compromise producing venous congestion and vasogenic edema of the spinal cord with resultant venous hemorrhage and loss of myelin and ischemia. Epidemiology and Risk Factors. Seventy-five percent of patients with breast cancer and one third of patients with solid tumors have spinal metastases at autopsy, though only 5 to 10 percent of patients with solid tumors ever have epidural spinal cord compression. The most commonly identified cancers causing epidural spinal cord compression are breast, lung, prostate, and renal cancers, lymphoma, sarcoma, and melanoma (.iTable 4.7. Z ). Eighty-five percent of cases of epidural spinal cord compression arise from metastases to the vertebral column. The vertebral body is the portion most frequently involved. The pedicle or posterior arch is less frequently involved. In 10...

Cervical Spine

Occipital Condyle Mri

The cervical spine consists of two special vertebrae - the atlas and axis - connecting the spine with the cranium in a complex set of joints and ligaments, and five ordinary vertebrae in a slightly lordotic curve (Figs. 2.1-2.3). In young adults, the average length of the cervical spine measures 12.5 cm from the lower border of C7 to the tip of the dens axis. In retroflexion, the average length is 11.5 cm, compared to 12.69 cm in anteflexion 9, 10 . This needs to be considered for correct intraoperative localization of intradural tumors radiological examinations are performed in a different neckposition than the operative one The posterior elements of the second to seventh vertebra form the neural arches consisting ofpedicles, the lamina, and spinous processes. The short pedicles connect the vertebral body with the facetjoints, which are formed by articular processes above and below. These processes are named according to their orientation the articular of the inferior vertebra...

Spinal Cord Strokes

Spinal cord infarcts are most often caused by interruption of the blood flow in one or more of the arteries that feed into the anterior spinal arterial system. A large anterior spinal artery runs in the ventral midline from the medullospinal junction rostrally to the conus medullaris and the filum terminale caudally. This anterior spinal artery system is supplied by five to 10 single radicular arteries. The cervical region is supplied by the anterior spinal artery branch of the intracranial vertebral artery and inferiorly by branches of the thyrocervical and costocervical branches of the subclavian arteries. The thoracic and lumbar spinal cord segments are fed by radicular arterial branches of the deep cervical and intercostal arteries and branches of the aorta. The lower thoracic cord is supplied by direct branches from the aorta, the largest of which is the artery of Adamkiewicz, which most often enters between T12 and L2. The sacral cord and cauda...

Spinal Cord Tumors

Although rare, spinal cord tumors continue to carry a grave prognosis for patients. They are difficult to resect and treat. Both the tumor itself and the treatment often lead to profound physical and neurological disability due to spinal cord damage. Spinal cord tumors represent about 7 percent of all primary tumors of the CNS and are seen more commonly in children, in whom they represent up to a fourth of all intra-axial tumors by location. The most common histological type is that of the glioma histology, especially astrocytomas and ependymomas. Their frequency is undoubtedly related to the percentage of total tissue of the spinal cord involved. Most patients are evaluated by MRI imaging, which demonstrates an enlarged or thickened cord. Frequently, the spinal canal may be enlarged around the area of the slowly expanding tumor. Once the tumor has been identified, the entire neuroaxis should be studied for any other areas of involvement. Although a tissue diagnosis may be suggested...

Spinal Sequelae

The evaluation of spinal sequelae should include the region of curvature, the magnitude of the curve, the deviation from vertical, the degree of shoulder asymmetry, the position of any rib humps or rib flare, and the type and degree of any gait abnormality. Usually the best way to examine the back is with the patient bending over with the arms touching the toes and the knees straight. At each visit, measurements should be taken of the standing and sitting heights. The spinal shortening that occurs as a direct effect of irradiation is not correctable,but,except for an ultimate decrease in height, does not usually cause major problems, unless spinal curvature develops. Anteroposterior and lateral films of the entire spine should be used to screen for this. It is also important to be able to inform the patients of the height deficit to be expected. Figure 16.5 shows a model of expected stature loss by age at treatment for three dose levels for a hypothetical male patient receiving...

The Spinal Cord

Involvement of the spinal cord in the pathophysiology of RLS is suggested by the fact that sensory and motor symptoms are bilateral and segmentally localized in the legs in most cases. Possibly, either a sensory signal from the periphery to the sensory cortex is affected at the level of the spinal cord or the abnormal input itself is generated at that level. The two major lines linking RLS and PLMS to the spinal cord are observations of both phenomena in association with spinal cord pathological processes and research findings pertaining to segmental reflexes such as the flexor reflex or the H-reflex.

Thoracic Spine

Gadolinium Enhancing Lesions

Laterally The laminae form an almost circular spinal canal of constant width throughout the thoracic spine. As this part of the spine forms a slight kyphosis, the thecal sac and spinal cord seem slightly displaced anteriorly in the upper thoracic canal (Figs. 2.4 and 2.5). The major difference in the bony anatomy of the thoracic spine is the articulation with the ribs. The heads of ribs 2-10 articulate with their posterior surfaces to the posterolateral aspects of vertebral bodies. Half of the joint surface is on the superior and half on the inferior body. Ribs 1,11, and 12 articulate only Fig. 2.4. a Sagittal T2-weighted MRI scan of the thoracic spine in the midline. b Paramedian sagittal T2-weighted MRI scan of the thoracic spine Fig. 2.4. a Sagittal T2-weighted MRI scan of the thoracic spine in the midline. b Paramedian sagittal T2-weighted MRI scan of the thoracic spine Fig. 2.5. Axial T2-weighted MRI scan of the midthoracic spine Fig. 2.5. Axial T2-weighted MRI scan of the...

Spinal Meninges

The dura mater is about 0.8 mm thick and consists of collagen and elastic fibers. At the foramen magnum, the dura mater of the head and the external periost merge into the spinal dura mater. Here, the dura mater consists of three layers (1) the innermost layer of the spinal dura is in continuity with the inner dural layer of the skull, (2) the middle spinal layer continues to form the external dural layer of the skull, and (3) the outer layer transgresses into the periost of the skull (Fig. 2.1) 10 . A complex set of fiber bundles inside the dura allows head movements without displacing the dural sac out of the midline of the spinal canal. The arachnoid membrane is the outer wall of the CSF space. It is watertight, loosely attached to the dura 13 , and ensheathes the spinal nerves toward the root sleeves, where it fuses with the dura. In the sub-arachnoid space, numerous strands run between the arachnoid membrane and cord surface, mainly in the posterior, and to a lesser degree in the...

Spinal Biomechanics

The line of the center of gravity of the erect human body lies anterior to the vertebral column. As a consequence, axial loads to the body in the upright position result in a combination of spinal axial compression and bending movements. A simple biomechanical concept of the spine is as two columns, an anterior column and a posterior column 6 . The anterior column provides the weight-bearing part of the spine. About 80 of the axial load is absorbed by this column, whereas the remaining 20 is spread to posterior elements as a shearing force. Vertebral bodies and intervertebral discs are constructed to withstand these weight-bearing forces, whereas the annulus fibrosus of the disc absorbs torque and shear movements. Thus, the anterior column acts like a distraction device. The posterior compressing forces of the muscles provide a balance between the anterior column and posterior articulation chain. Movements are possible due to deformations of the intervertebral discs and the facet...

The Spine

A stable spine is one in which normal movements will not result in displacement of the vertebrae. In an unstable spine, be it from trauma, infection, tumour, degenerative changes or inflammatory disease, alterations in alignment may occur with movement. However, the degree of bone destruction or spinal instability does not always correlate with the extent of any associated spinal cord injury. The concept of the 'three column' spine, as proposed by Holdsworth14 and refined by Denis,15 is widely accepted as a means of assessing stability. The anterior column of the spine is formed by the anterior longitudinal ligament, the anterior annulus fibrosus of the intervertebral disc and the anterior part of the vertebral body. The middle column is formed by the posterior longitudinal ligament, the posterior annulus fibrosus of the intervertebral disc and the posterior wall of the vertebral body. The posterior column is formed by the posterior arch, supraspinous and interspinous ligaments and...

Removal of Cavernomas

As a good protective layer (Fig. 3.52) 34, 216, 246 . Furthermore, some cavernomas are accompanied by large veins, so called developmental venous anomalies (DVAs). These veins have to be preserved as they drain normal tissue and do not represent tumor vessels 293 . However, it appears that DVAs are not a common feature of spinal cavernomas compared to other central nervous system locations. With anteriorly located cavernomas, several surgical options can be used. With sutures applied to dentate ligaments, the spinal cord may be rotated so that the anterolateral section of the cord becomes accessible even from a posterior approach. With resection of facet joints and pedicles, an even better access is achieved with this technique 208 . Another alternative is a ventral approach with partial or complete corpectomy and stabilization 97, 292 .

Removal of Ependymomas

In general, ependymomas are completely resectable 204,301 . They displace rather than infiltrate the spinal cord. Some ependymomas may exert such enormous pressure that they almost come out by themselves once the pia has been opened (Fig. 3.40) 217 . In such instances, the pia has to be opened quickly over the entire extension of the tumor and blunt in In all cases, tumor feeding vessels have to be identified and cut. Of particular importance are those arising from the anterior spinal artery in the midline. In any case, care should be taken to avoid too much tension on these feeding vessels as this may compromise spinal cord blood supply. Sufficient tumor deb-ulking and coagulation and transection of these feeders are required to prevent such problems (Figs. 3.33, Fig. 3.42. a This T1-weighted sagittal MRI scan shows an intramedullary ependymoma at C2-C7 (arrowheads) with small syrinx cavities above and below in a 25-year-old woman with a 1-year history of progressive tetraparesis. b...

Long Term Complications

Late complications may be associated with spinal instability or postsurgical myelopathy. To avoid instabilities, intervertebral joints should be left intact during the exposure. It is not necessary to extend the exposure so wide that these joints are compromised. However, postoperative instabilities cannot be prevented by a small laminotomy alone. This complication becomes more common the higher the spinal level and the younger the patient is 131, 234 , even though Yeh et al. 352 found a particularly high incidence of postoperative deformities in the thoraco-lumbar region. Lunardi et al. 199 observed postlam-inectomy deformities in 24 and Takahashi et al. 325 in 40 of children operated for intramedullary tumors. Jallo et al. 152 reported postoperative spinal deformities in 66 of children, with 35 requiring stabilization procedures. Within a series predominantly of adult patients we observed no spinal instabilities after removal of an intramedullary tumor that would have required an...

Removal of Hamartomas

Chest Wall Lipoma Removal

Intramedullary dermoid cysts are growing lesions due to the metabolic activity of the cells in the cyst wall. These do not proliferate, but continue to produce substances that fill the cyst causing its expansion. Thus, radical excision of the entire cyst and its wall is the goal of surgery. Otherwise, a recurrence is almost certain. Unfortunately, this may be extremely difficult to achieve. The cyst wall may be extremely adherent to the spinal cord tissue requiring sharp dissection to deliver the cyst wall. If the cyst contents spill into the subarachnoid space during surgery, aseptic meningitis may result. If the cyst had ruptured prior to surgery, severe arachnoid adhesions may have formed (Fig. 3.50) 65 or the cyst contents may gradually spread inside the expanded central The intramedullary part of a spinal lipoma does not display a cleavage plane toward the spinal cord tissue. Therefore, attempts ofradical resection are not recommended. As the lipoma does not display proliferative...

Removal of Astrocytomas

Boyun Fiti

In general, astrocytomas have to be considered as infiltrating tumors. Therefore, the identification of cleavage planes carries considerable risks and may even be outright impossible 130,204 . However, some astrocytomas do present cleavage planes, allowing a complete resection using similar dissection techniques as described for ependymomas. The strategy of choice is to remove them from inside out 80 . In tumors with ill-defined margins, CUSA is ideal to de-bulk the mass. Astrocytomas may display varying characteristics during dissection they may show a nice cleavage plane in some areas, but in other parts infiltrate surrounding tissue diffusely 152 . Tumor feeding vessels may come from all angles and do not originate from the anterior spinal artery as regularly as in ependymomas. Regardless of dissection tech Astrocytomas may extend over several spinal segments (Fig. 3.45) and may even occupy the entire spinal cord, especially in young children. Such tumors have been removed in...

Removal of Recurrent Tumors

Spinal Tumors

Before opening the dura, ultrasound maybe useful to determine areas of intradural scarring that may attach the cord to the dura posteriorly. The strongest adhesions should always be expected right underneath the dura suture line. Therefore, the dura should not be opened through the old suture line, but lateral or medial to it (Fig. 3.53). In recurrent tumors, dura retention sutures should only be set under tension very carefully as the cord maybe attached to the dura and, thus, any tension on the dura may affect the cord and its vascular supply. The arachnoid membrane should be left intact during opening of the dura to avoid injury to the spinal cord and its vessels. Once the dura is opened entirely, the arachnoid is opened with microscissors. If arachnoid adhesions exist, they should be dissected with sharp instruments to avoid tearing of small blood vessels and tension on the spinal cord (Figs. 3.50 and 3.53). If arachnoid scarring is severe, a complete arachnoid dissection should...

Surgical Approaches

Claudius Galen, born in the year 129 in Pergamon in Turkey, was probably the first anatomist to note the segmental representation of the spinal cord. He performed experiments and dissections on dogs to better understand the human anatomy and the consequences of spinal cord injuries. This was 1800 years before Darwin's evolution theory. Examining victims of gladiator fights, he observed specific neurological deficits according to the level of the spinal cord and was able to specify the spinal level of injury according to his clinical examination 10 . First attempts on spinal surgery were undertaken by the French army surgeon Ambroise Par as early as 1549 for patients with spinal dislocations. He diagnosed the level of inj'urybypalpation and crepitation, excised bony splinters compressing the cord, and applied traction for spinal dislocations with the aid of a wooden frame 35 . However, throughout the middle ages and well into the 19th century, spinal surgery was met with great...

Adjuvant Therapy

This set of figures demonstrates an alternative method for decompression of the spinal canal. a, b T1-weighted, contrast-enhanced sagittal MRI scans of an intramedullary WHO grade I astrocytoma at Th10-L5 in a 31-year-oldwoman with an incomplete paraparesis and preserved sphincter control. The tumor has grown exophyti-cally down the lumbar canal. A radical resection was judged too hazardous. We had particular concerns regarding the infiltrated caudal nerve roots (see also Fig. 3.3). c This view after dura closure shows the technique the lamina is sutured to the pedicle with a small block ofhydroxyapatite set in between. The postoperative X-ray (d) and CT image (e) demonstrate the amount of spinal canal enlargement and bonyfusion in the depicted thoracic level. The neurological status could be preserved for 3 years. With 10 years of follow up, this patient has retained significant motor function in her legs and has control of sphincter functions

Tumor Resection

Of 199 intramedullary tumors, 53 were removed completely, 32 were resected subtotally, and the remaining 15 were decompressed and underwent either a biopsy procedure or cystostomies with and without additional drains (Table 3.4). There were significant differences related to tumor histology, spinal level, and experience of the surgeon. With ependymomas (82 ), cavernomas (83 ), and with angioblasto-mas (90 ) the great majority were resected completely. Astrocytomas, however, were classified as complete removals in only 18 of cases. Among cervical tumors, 70 were resected completely compared to 51 for thoracic and 18 for conus tumors (chi square test p 0.0004). Comparing children and adults, the rate of total removal was considerably lower in children due to the higher proportion of astrocytomas (18 vs 58 for children and adults, respectively p 0.0002). But what is a complete resection of an infiltrative tumor We have classified tumor removal as complete if there was no detectable tumor...

Syringomyelia

Of 199 intramedullary tumors, 48 presented with an associated syrinx 15, 265, 267 33 were above and 11 below the tumor level, 56 exhibited a syrinx above and below the tumor, and 9 were associated with syringobulbia. A tumor-associated syrinx was found more often in adults than in children (49 and 40 , respectively). Ependymomas (65 ) and he-mangioblastomas (90 ) showed the highest proportion of syrinx formation. Astrocytomas (31 ), caver-nomas (33 ), or hamartomas (20 ) were less often accompanied by syringomyelia. The proportion of tumors associated with syringomyelia declined with the spinal level it was highest for cervical tumors (58 ), intermediate for thoracic tumors (48 ), and considerably lower for conus tumors (21 ). Most authors consider disruptions of the blood-brain barrier as the most likely mechanism based on analyses of the protein content of the syrinx fluid 194 . This, however, would imply that tumor-associated cysts are observed throughout the spinal canal in equal...

Morbidity

Cervical and thoracic tumors were associated with considerably less morbidity compared to tumors in the conus area (5.6 , 14.3 , and 26.5 , respectively log-rank test p 0.039) 38,60, 211, 289, 318, 347 . The more precarious vascular supply in the thoracic cord, the smaller size of the cord in the lower spinal segments, and the dense concentration of important neurological functions in the small confined structure of the conus may explain this observation.

Hamartomas

We have observed four dermoid cysts, four lipomas, and one patient with a combination of both in this category of intramedullary tumors. Whereas hamar-tomas are not tumors in a strict sense - they do not contain proliferating cells - they are space occupying and displace spinal cord tissue. Quite regularly, they are not completely surrounded by cord substance and protrude out of the cord. The overwhelming majority of spinal hamartomas are located extramedullarly. We have only classified them as intramedullary if the major component of the lesion was embedded inside the spinal cord. Therefore, a more detailed discussion is provided in the section on extramedullary tumors. Among intramedullary hamartomas, one dermoid cyst and four lipomas were associated with a tethered-cord syndrome.

Neuroradiology

Standard X-rays, however, should still be performed to visualize the bony anatomy of the spine, evaluate the stability in the affected segment, and to facilitate the intraoperative identification of the correct spinal level. In rare instances, slow-growing tumors may erode vertebral pedicles (Fig. 3.3), widen the spinal canal (Fig. 3.4), or even cause vertebral and spinal deformities (Fig. 3.4) 322 . The latter may be observed especially in children. Quite often, the pre-operative radiological study already demonstrates significant biomechanical problems in younger patients 68, 162, 199, 300 . 1. Imaging has to demonstrate the precise spinal level of the tumor, its upper and lower limits in Tl- and T2-weighted images. This has to be done in such a way that the surgeon can determine this level by intraoperative roentgenography the cervical or lumbar spine has to be shown in upper and lower thoracic tumors, respectively, as well 322 . Fig. 3.3. T1-weighted, contrast-enhanced, sagittal...

Glioependymal Cysts

Mri Scan L1l2

Intramedullary glioependymal cysts are observed predominantly in the area of the conus medullaris (Figs. 3.82 and 3.83), but may occur anywhere in the spinal canal (Fig. 3.84) 279 . The cyst contains fluid that is similar to CSF 279 . Some authors have called these cysts terminal ventricles or considered them to be an isolated eccentric syrinx of the conus medul-laris. The majority of them are observed in adults, with most pediatric cases being asymptomatic 50 . The differential diagnosis to cystic tumors can be made after gadolinium application. The wall of an ep-endymal cyst will not take up contrast 279, 313 . The distinction form syringomyelia, however, may pose some problems (Figs. 3.19-3.22). With cysts in the conus area that protrude out of the cord, the diagnosis of an ependymal cyst is quite easy (Fig. 3.18). However, at other spinal levels it may be not so obvious. The As far as the pathophysiology of these cysts is concerned, no widely accepted theory exists. One case...

Dermoid Cysts

Dermoid Tumor Spine

With dermoid cysts the situation is different they contain cells that produce some kind of gradually accumulating product. This will increase the size of the cyst with the potential of progressive pressure on the spinal cord. The history is considerably shorter compared to lipomas - 29 51 months in this series, ranging from 1 month to 10 years. Even acute presentations related to aseptic meningitis 65, 296 or abscess formation 49 have been described. The average age was 32 6 years (range 25-42 years), with pain in three patients and motor weakness in two patients as the major clinical problems (Table 3.27) 197 . The goal of treatment should be a radical excision. Unfortunately, the cyst wall may be extremely adherent to the cord substance, making it almost impossible to achieve a complete resection without damaging the cord. Sharp dissection is often required (Figs. 3.50 and 3.81). Furthermore, the cyst material maybe very irritating for the arachnoid membrane, with a significant risk...

Schwannomas

Intramedullary schwannomas resemble an even rarer entity. In the literature, a number of case reports have been published 33, 95, 138, 150, 191, 209, 220, 240, 248, 249 . These tumors have grown into the spinal cord originating from a nerve root right at the entry zone. We have seen one such tumor in a 28-year-old woman with a 6-year history of slightly progressive gait ataxia. She demonstrated a contrast-enhancing tumor above the conus at Th11. At surgery, more than half of this tumor was deeply embedded inside the thoracic cord and had to be dissected out of a slightly gliotic tumor bed to achieve a complete resection. Postoperatively, the patient recovered after a short period of deterioration and finally improved her condition compared to the preoperative status (Fig. 3.90).

Gangliogliomas

Gangliogliomas have been reported in pediatric series of intramedullary tumors, while adult patients are usually affected at a comparably young age 131, 153, 250, 253, 340 . Constantini et al. 54 found them in 8 out of 23 children under the age of 3 years. Of these, two patients demonstrated a recurrence after surgery. Epstein et al. 84 found them in 3 out of 25 adult patients with intramedullary tumors. In later publications, this group described the radiological features in 27 patients 253 and treatment results for 56 patients 153 . These tumors may extend over several spinal segments, contain cysts, and display mixed signal intensities on T1-weighted MRI scans 153, 223 . They show a patchy enhancement with gadolinium and enhancement of the spinal cord surface 173, 253 . Fig. 3.89. Sagittal (a) andaxial (b) T2-weightedMRI scans of a ganglioglioma at C5 6 in a 27-year-old woman with a 10-year history of pain, dysesthesias, and sensory disturbances of her right arm (see also Fig....

Metastases

Sagittal (a) and axial ( 5) T1-weighted MRI scans of a large intramedullary metastasis at C5-Th2 in a 71-year-old patient with a bronchial carcinoma and a 2-week history of progressive paraparesis. No other metastases were present at this stage, so surgery was offered to decompress the spinal cord. Postoperatively, the patient deteriorated further and died 1 week later ommend concentrating on decompressing the spinal cord with moderate debulking of the tumor and insertion of a duraplasty, followed by postoperative irradiation or chemotherapy if applicable 120 . Alternatively, radiotherapy and corticosteroid medication 41,103,114,166, 298,330,339,343 , or chemotherapy 90, 349 have been reported to benefit patients with intramedullary metastases.

Modern Advances

With good anesthetic techniques, antibiotic treatment, and reasonable diagnostic imaging established, the next major advance was the introduction of the operative microscope in the 1960s. Before the introduction of microsurgery, surgeons were most of all concerned for the patients' survival after spinal cord surgery. With the advent of the operative microscope, it became possible to preserve the patients' neurological function with increasing frequency. In 1975, Yas-argil and De Preux published the first paper on a series of microsurgically removed intramedullary angio-blastomas with excellent clinical outcomes 54 . This paper was followed by a congress report on 37 intramedullary tumors undergoing microsurgical removal. Of these, 24 had been resected completely (11 of 12 angioblastomas, 8 of 11 ependymomas, and 1 of 4 astrocytomas), of which 13 demonstrated postoperative improvement, while 6 remained unchanged and just 5 were neurologically worse. Apart from the operative microscope,...

Ependymomas

Ependymomas and astrocytomas are the most frequent intramedullary tumors. Ependymomas of the spinal canal may be located intramedullarly, attached to the filum terminale, or even extradurally originating from heterotopic ependyma cells 226, 230 . Unlike some authors, we have eliminated ependymomas of the filum terminale from the analysis of intramedullary ependymomas. They are discussed in the section on extramedullary tumors. Intramedullary ependymomas are solitary tumors that are located centrally in the spinal cord in the overwhelming majority of patients (Figs. 3.33, 3.40, 3.42, and 3.53). However, patients with intramedul-lary ependymomas and disseminated disease 195, 207 and with exophytic components 122 have been described. A significant proportion of NF-2 patients also harbor intramedullary ependymomas (Figs. 3.37 and 3.41) 189, 214, 254, 284, 301 . Analyses of the genetic features of ependymomas even disclosed links to the NF-2 gene 21,74 .

Surgery

Before describing the surgical techniques and strategies for removal of intramedullary tumors, we would like to comment on the perioperative use of cortico-steroids. Several colleagues give high-dose corticoste-roids before, during, and 24 h after surgery for an intramedullary tumor 130, 263 . In 1990 the results of the Second National Acute Spinal Cord Injury Study (NASCIS II) were published, which showed that the administration of a high-dose regimen of methyl- prednisolone could improve neurological recovery in spinal-cord-injured patients 25 . As several experimental studies demonstrated that steroids work even better if they are administered before injury, patients undergoing intramedullary surgery should benefit from such a regimen. However, the NASCIS II and III studies have also been heavily challenged 51 . This leaves a considerable amount of controversy to be resolved. At the moment, no general recommendation can be given until further studies have established a benefit. We...

Tumor Removal

So, with the technique of laminectomy, the standard approach to spinal lesions was available in the second half of the 19th century. The first spinal tumor operation is widely attributed to Victor Horsley, who described the removal of a spinal meningioma, performed on June 9th in 1887 20 . However, Lecat operated on a spinal tumor as early as 1753 32 . Mace-wen reported on two patients in whom he had removed fibrous neoplasms of the dura in 1883 and 1884, respectively 33, 34 . As he was not a neurosurgeon, however, not much credit was given to these successful operations. Furthermore, the two patients were victims of Pott's disease with spinal deformities, suggesting that granulation tissue rather than true neoplasms were probably removed 44 . Horsley himselflisted in his paper 58 patients with spinal tumors from the literature, of which 2 had been operated on previous to his own operation. Horsley's operation did not go smoothly. He opened the spine of this 42-year-old man at the...

Diagnostic Imaging

The first endeavors on spinal cord surgery were performed without any imaging of the lesions. Radiological signs of a spinal tumor, such as a widening of the spinal canal or erosion of bony elements, were rarely encountered 7, 30, 39,40,45 . Neurologists determined the spinal level of the suspected tumor clinically and the surgeon had to do the operation to confirm the diagnosis and to remove the tumor. The major differential diagnostic sign was an increased intensity of neurological deficits without an ascending spinal level 50 . Only if the preoperative assumptions and clinical evaluations were correct could the patient expect to profit from surgery. In von Eisels-berg and Ranzi's series of 17 patients operated for suspected tumors, 5 patients underwent surgery without a tumor being discovered 13 . This illustrates the enormous diagnostic difficulties faced during that Therefore, further imaging techniques were needed desperately. Dandy introduced air myelography in 1919. He...

Clinical Results

The immediate postoperative result is related to the preoperative status, the spinal level of the tumor, and the experience of the surgeon regardless of tumor histology 6, 38, 54, 60, 80, 82, 84, 85, 94, 95, 115, 118, 124, 204, 252, 271, 301, 317, 335, 346, 347 . The extent of tumor removal has only a minor influence on the short-term postoperative outcome 6, 56, 118, 215 . In our series, the postoperative course was characterized by transient worsening of neurological symptoms in 44 of patients for a few days or even months before functional recovery occurred 38, 60, 120, 215, 217 . In 68 of these, the preoperative status was reached again within 3 months, in 98 within 1 year, and for one patient it took 2 years. We attribute this transient deterioration to edema or interference with spinal cord blood flow, especially on the venous side. The transient deterioration affected gait, motor power, and bladder and bowel function. Therefore, the radiological and clinical examination after 3...

Angioblastomas

Angioblastomas represent about 2.1 145, 247 to 5 276 of spinal tumors according to the literature, and about 1.9 of all spinal and 11.8 of intramedullary tumors in our series. They tend to occupy the posterior, paramedian aspect of the spinal cord (Figs. 3.34 and 3.48) 185, 198, 223, 336 . However, centrally or anteriorly located angioblastomas do occur (Fig. 3.49) 134, 264 . We have operated on 21 intramedullary angioblas-tomas affecting nine female and eight male patients (Table 3.26). Ten tumors (48 ) were associated with VHL. Among VHL patients, between 13 202 and 38 105 harbor spinal angioblastomas. In unselect-ed series, about 22-25 ofpatients with an angioblas-toma will turn out to have VHL 105, 263 . With identification of the VHL tumor suppression gene, molecular genetic screening has become available and should be offered to patients with angioblastomas 336 . VHL patients require yearly MRI scans of the brain and spinal canal. Radiological examinations of these patients...

Complexity of Primary Afferent Effects

Human physiology texts describe some of the common connections between primary afferents and motoneurons, serving the stretch reflex, the flexor withdrawal reflex, the inverse myotatic reflex, and so forth. What is not usually addressed is that these are simple paths surrounded by extremely complex additional projections of those afferents to other motoneurons and interneurons of the spinal cord (Baldissera, Hultborn, & Illert, 1981), and powerful modulating inputs onto those paths from spinal interneuronal pools (Jankowska, 1992 Pierrot-Deseilligny, Morin, Bergego, & Tankov, 1981 Brooke et al., 1997). It is clear that specific somatosensory receptor discharge can have widespread effects over neuronal pools of the spinal cord and brain and that the strength of the effect can be modulated from profound to minimal (Brooke et al., 1997).

The Role Of Proteolytic Enzymes In Autoimmune Demyelinating Diseases An Update

In former years the ease of destruction of myelin basic protein in vitro by the acid protease cathepsin D was most emphasized (reviewed by Berlet)14. This lysosomal enzyme is probably not secreted, but may be a major effector of intracellular myelin degradation after phagocytosis of myelin in conjunction with other cathepsins such as B and L. Before myelin can be ingested, however, it must be disrupted into smaller fragments to facilitate its ingestion. This may be accomplished by several mechanisms, such as complement15, 16 and or extracellular neutral proteases secreted by activated phagocytic cells. Lampert17 first described areas of vesicular degeneration in demyelinating lesions of animals with EAE, and similar disruptive lesions have been noted in areas of the CNS in MS18, viruses19, or by various neurotoxic substances. Phagocytic cells may secrete these enzymes in the vicinity of the myelin sheath to disrupt the lamellae and to peel away the layers in MS and EAE. Traumatic...

Gain Control in Human Primary Afferent Transmission Over Ascending Paths

Excitation of primary afferents in peripheral nerves at low stimulus intensities rapidly results (from arms, in 15+ ms from legs, in 25+ ms) in somatosensory evoked potentials (SEPs) measured from scalp electrodes recording from the somatosensory reception areas of the cerebral cortex. As previously described for spinal Ia reflexes, the ascending path from fast-conducting afferents to the brain can be attenuated at spinal levels by activation of other Ia afferents (Staines, Brooke, Misiaszek, & McIlroy, 1997). The effect is observed as reduced magnitudes of SEPs, despite nonvary-ing stimulation. Further, just as the brain can centrifugally control primary afferent transmission in Ia spinal reflexes, so it can also control the transmission through the ascending path (Rudomin et al., 1998). For example, SEPs are at Baldissera, F., Hultborn, H., & Illert, M. (1981). Integration in spinal neuronal systems. In V. B. Brooks (Ed.), Handbook of physiology Section 1. The nervous system Vol....

AMPA Receptors as Pharmacotherapeutic Sites

AMPA receptors are widespread in the brain, including most regions of the cerebral cortex, hippocampus, amygdala, thalamus, hypothalamus, brain stem, and spinal cord. The regional variations in expression of the subunits, splice variants, and editing efficiency are apparent and are probably involved in local and global network function. AMPA receptors are being studied as potential therapeutic targets in diseases such as Alzheimer's disease, cerebrovascular disease (preventive and poststroke), epilepsy, schizophrenia, neural trauma, and other conditions involving cognitive impairments. Such promise has been raised by the successes reported for AMPA agonists (AMPAmimetics or AMPAkines) to enhance maze learning in age-associated memory impairment in mice and for antagonists (blockers) to prevent the spread of necrosis in ischemic events. Agonists (such as CX516 and aniracetam) and antagonists of varying specificity for AMPA receptor variants are being studied, with goals of safer and...

Pathology Do You Need Surgery What Did the Surgeon Find

It may seem strange to you, but the most important diagnostic test you will ever have in your entire life, with regard to your thyroid, is the evaluation of the body parts removed during your thyroid surgery (surgical specimen). The pathologist's decision on the name of the thyroid disease revealed by your surgical specimen will determine the course of your medical care for the rest of your life. The decision may result in the use of treatments and diagnostic tests that entail significant time, commitment, and expense. It may affect your health insurance, life insurance, and employment opportunities. If a thyroid cancer is missed by the pathologist, you may fail to receive appropriate care from other excellent physicians and you risk having that cancer reveal itself, years later, having spread to the lung, spine, bones, or brain. On the other hand, the diagnosis of thyroid cancer justifies lifelong diagnostic testing and medical follow-up, as well as possible treatments with...

Posterior Facet Syndrome

The posterior facet syndrome is caused by degenerative changes in the posterior facet joints. These are true diarthrodial joints that sometimes develop degenerative joint changes visible on plain radiographs. Degenerative changes in the posterior facet joints cause a dull achy pain that radiates to the groin, hip, or thigh, and is worsened with twisting or hyperextension of the spine.34 Steroid injection into the posterior facet joints to relieve presumed posterior facet joint pain is a popular procedure, but the placebo effect of injection in this area is significant and controlled studies have failed to demonstrate benefit from steroid injections.35,36 The presence of degenerative changes in the facet joints on plain radiographs does not imply that the posterior facets are the cause of the patient's pain. Caution must be used in ascribing the patient's symptoms to these degenerative changes. Historically, the posterior facet syndrome was diagnosed by demonstrating pain relief after...

Ankylosing Spondylitis

Decreased range of motion in the spine remains constant. Early signs of ankylosing spondylitis include limitation of chest expansion, tenderness of the sternum, and decreased range of motion and flexion contractures at the hip. Inflammatory involvement of the knees or hips increases the likelihood of spondylitis.39 The radiological hallmarks of ankylosing spondylitis include periarticular destructive changes, obliteration of the sacroiliac joints, development of syndesmophytes on the margins of the vertebral bodies, and bridging of these osteophytes by bone between vertebral bodies, the so-called bamboo spine. Laboratory analysis is negative for rheumatoid factor, but the ESR is elevated early in the course of the disease. Tests for human leukocyte antigen (HLA)-B27 are not recommended because as many as 6 of an unselected population test positive for this antigen.15

Schwann Cells Respond To Injury

Schwann cells have a pivotal role in response to PNS injury. The PNS regenerative powers are in part due to intrinsic properties of Schwann cells that encourage spontaneous regeneration and have been the focus of much investigation. PNS axonal regeneration occurs through the initiation of signalling cascades that activate Schwann cells to produce neurotrophic factors, cytokines, extracellular matrix and adhesion molecules, which aid in regrowth of the injured nerve. These abilities are in direct contrast to CNS neuroglia, particularly astrocytes, which produce a hostile environment for axonal regeneration in response to injury. In the CNS, damage results in extensive glial scarring, the production of inhibitory factors and the lack of axonal guidance, both physical and molecular. Due to these reparative qualities, Schwann cells are becoming candidates for use in cell transplantation to treat demyelinating diseases of the PNS and CNS and spinal cord injury. Schwann cells are considered...

Therapeutic Application Of Es Cell Technology By Cell Transplantation

Transplantation of ES cell-derived cell populations into normal and disease model animals has demonstrated the potential for these cells in disease control. ES-derived neurons and neural precursors (Brustle et al., 1999 McDonald et al., 1999 Arnhold et al., 2000 Kawasaki et al., 2000 Liu et al., 2000 Bjorkland et al., 2002), cardiomyocytes (Klug et al., 1996), mast cells (Tsai et al., 2000), and insulin-secreting cells (Soria et al., 2000) have been transplanted successfully into appropriate recipient sites and shown to survive integrate and, to some measurable extent, function within host tissue (Brustle et al., 1999 McDonald et al., 1999 Liu et al., 2000 Tsai et al., 2000 Bjorkland et al., 2002). For example, differentiating mouse ES cells and ES cell-derived neural precursors have been implanted to the brains of rats, into both ventricles and sites of solid tissue, and found to survive and incorporate into the recipient brain migrate away from the site of injection and...

General Theories Of Motor Control

Sherrington proposed one of the first physiologically based models of motor control. Sensory information about the position and velocity of a limb moving in space rapidly feeds back information into the spinal cord about the current position and desired position, until all computed errors are corrected. Until the past decade or two, much of what physical and occupational therapists practiced was described in terms of chains of reflexes. Later, the theory expanded to include reflexes nested within Hughling Jackson's hierarchic higher, middle, and lower levels of control. Some schools of physical therapy took this model to mean that motor control derives in steps from voluntary cortical, intermediate brain stem, and reflexive spinal levels.6 Abnormal postures and tone evolve, in the schools of Bobath and Brunnstrom (see Chapter 5), from the release of control by higher centers. These theories for physical and for occupational therapy imply that the nervous system is an elegantly wired...

Thinking about the brain

Influenced by, every corner and extremity of your body. As the spinal cord, your brain extends the length of the backbone, periodically sprouting nerves that convey information to and from every part of you. Practically nothing is out of its reach. Every breath you take, every beat of your heart, your every emotion, every movement, including involuntary ones such as the bristling of the hairs on the back of your neck and the movement of food through your guts - all of these are controlled directly or indirectly by the action of the nervous system, of which the brain is the ultimate part.

Stem Cells within the Nervous System

In repair of the brain and spinal cord that illustrate how the developmental potential of a cell may vary, depending upon its environment. NSCs arising from SVZ and SGZ share some common characteristics both are slow proliferating cells they express glial fibrillary acidic protein (GFAP) and both share morphological and electrophysiological properties of astrocytes. The origin and phenotypic nature of NSCs is still debatable, and the continuing controversy shows the difficulty in defining the developmental potential of these cells. There are a few studies that propose that NSCs are derived from radial glial cells during embryogenesis and remain in the adult SVZ as a specialized type of astrocyte with stem cell properties. During embryonic development, radial glial cells are found within the SVZ and these cells give rise to both glial and neurons however, they are not present in the adult mammalian brain. Other studies suggested that NSCs are derived from ependymal cells which line the...

Disorders of the Neck

Cervical radiculopathy is a common cause of neck pain, and can be caused by a herniated cervical disc, osteophytic changes, compressive pathology, or hypermobility of the cervical spine. The lifetime prevalence of neck and arm pain among adults may be as high as 51 . Risk factors associated with neck pain include heavy lifting, smoking, diving, working with vibrating heavy equipment, and possibly riding in cars.70 Cervical nerve roots exit the spine above the corresponding vertebral body (e.g., the C5 nerve root exits above C5). Therefore, disc herniation at the C4-C5 interspace causes symptoms in the distribution of C5.71 Radicular symptoms may be caused by a soft disc (i.e., disc herniation) or by a hard disc (i.e., osteophyte formation and foram-inal encroachment).71 The most commonly involved interspaces are C5-6, C6-7, C4-5, C3-4, and C7-T1.70

Score System For Diagnosis Of Tb In Children

Characteristic clinical features (e.g. spinal deformity, scrofula or painless ascites) supported by simple investigations often point to the diagnosis of various forms of extrapulmonary TB. These permit a confident diagnosis of TB, even if rarely confirmed microbiologically. However, the commonest type is PTB and this is the most difficult to diagnose. Score charts are least useful for PTB because they are so nonspecific in regions where malnutrition and HIV are common. Features suggestive ofTB (and commonly used in score charts) include

Other Chemospecific Neurons with Autoreceptors

GABA neurons inhibit the release of their own neuro-transmitter via GABAB autoreceptors. However, the exact role that the GABA agonist baclofen exerts on these auto-receptors to mediate the antispasmodic effect of this drug in patients with spinal cord lesions remains to be clarified.

Alcohol And Depression

Heinz et al. (79) compared Beck Depression Inventory (BDI) and HDRS scores with various neurotransmitter metabolite levels in 21 abstinent alcoholics and 11 controls. They found correlations between cerebral spinal fluid (CSF) 3-methoxy-4-hydroxyphenylglycol (MHPG) and 5-hydroxyindoleacetic acid (5-HIAA) concentrations and depressive symptoms, implicating noradrenergic abnormalities as well as serotonergic function in the onset of depressive symptoms. Serotonin deficiency was implicated in the higher suicide rate found among alcoholics with depression (80,81), in mem

Human voluntary motor control and dysfunction

Boldrey, 1937 Penfield and Rasmussen, 1950), has been interpreted to mean that different segments of the body are controlled from spatially separate regions of M1, down to the level of a different region for each finger of the hand. Second, the concept of the upper motor neuron, which can be traced to Gowers (Phillips and Landau, 1990), has been interpreted to mean that cortical neurons are simply higher order neurons whose physiologic behavior is essentially like that of lower motoneurons. Following these two concepts, M1 has previously been viewed as a somatotopically organized sheet of separate groups of upper motor neurons, each of which controls a pool of spinal motoneurons, and thereby moves a particular body segment (illustrated schematically in Fig. 2.1(a)). The current view of M1 is quite different (Schieber, 2001) such that different spinal motoneuron pools receive input from broad, overlapping cortical territories, and many M1 neurons have projections that diverge to more...

Type 1 Neurofibromatosis NF1

NF1 is more common than NF2, but the disease may be so mild that an affected individual may never present to their doctor. The main manifestations are in the skin, with the appearance of cafe au lait patches and cutaneous neurofi-bromas in the first and second decades, respectively. The most famous potential misdiagnosis of NF1 was Joseph Merrick, the 'elephant man,' who in reality probably had Proteus syndrome (Clark, 1994). One potential serious complication of NF1 is optic gliomas, which may occur in up to 15 of cases (Listernick et al., 1989). These are usually very low grade and asymptomatic and if they are not specifically sought levels of around 1.5 are found. Other CNS gliomas do occur but their frequency is probably well below 5 . Meningiomas and vestibular schwannomas do not occur in excess frequency in NF1 (McGaughran et al., 1999). Phaeochromocytoma and spinal neurofibromas may develop as well as rhabdomyosarcomas, but these are relatively rare. Malignant change in...

Sodium channel expression in DRG neurons in the CCI model of peripheral injury

The rodent chronic constriction injury (CCI) is a well-established model that has been utilized to examine the mechanisms underlying neuropathic pain 2 . CCI results in Wallerian degeneration of a substantial number of, but not all, axons distal to the loose ligatures, with greater than 80 loss of myelinated fibers and 60-80 loss of unmyelinated fibers 71 . Proximal to the loose ligatures, the proximal stumps of degenerating axons intermingle with spared axons 71, 72 , leading to injured and uninjured neurons residing in L4 and L5 DRG. Behaviorally, CCI is associated with signs of spontaneous pain and mechanical hyperalgesia 2 abnormal spontaneous activity has been recorded in vivo and in vitro in some DRG neurons following CCI 22, 57, 73, 74 . Current evidence strongly suggests that alterations in sodium channel expression contribute to the spontaneous activity observed in CCI neurons, which may play a major role in the development of ongoing and stimulus-driven neuropathic pain 75 ....

Clinical Manifestations 521 GH Deficiency

The growth rate is typically slow in children who are undergoing treatment for cancer and usually improves (or catches up) after completion of cancer therapy (Fig. 5.8). Children whose growth rate does not improve or whose growth rate is less than the mean for age and sex should be evaluated for growth failure (Fig. 5.9). Causes of slow growth other than GH deficiency include hypothyroidism, radiation damage in growth centers of the long bones or the spine, chronic unresolved illness, poor nutrition, and depression. In individuals who have attained adult height, GH deficiency is usually asymptomatic 71 , but may be associated with easy fatigability, decreased muscle with increased fat mass, and increased risk for cardiovascular disease 12,16 .

Clinical Presentation

Physical examination may be negative if the patient is seen within hours of the accident. Over time, however, patients develop tenderness in the cervical spine area, as well as decreased range of motion and muscle spasm. Neurological examination of the upper extremity should include assessment of motor function and grip strength, sensation, deep tendon reflexes, and range of motion (especially of the neck and shoulder).

The Primary Motor Cortex and Locomotion

For voluntary tasks that require attention to the amount of motor activity of the ankle movers, Ml motoneurons appear equally linked to the segmental spinal motor pools of the flexors and extensors.49 This finding suggests that the activation of Ml is coupled to the timing of spinal locomotor activity in a task-dependent fashion, but may not be an essential component of the timing aspects of walking, at least not while walking on a treadmill belt. Spinal segmental sensory inputs, described later in this chapter, may be more critical to the temporal features of leg movements during walking. The extensor muscles of the leg, such as the gastrocnemius, especially depend on polysynaptic reflexes during walking modulated by sensory feedback for their anti-gravity function.50 Primary motor cortex neurons also represent the contralateral paraspinal muscles and may innervate the spinal motor pools for the bilateral abdominal muscles.5l Potential overlapping representations between paraspinal...

Other descending motor tracts

Descending motor tracts such as the reticulospinal tract and the rubrospinal tract may contribute to voluntary movement and may assist in recovery of function after damage to the motor cortex or to the corticospinal tract (Fig. 2.4). The reticulospinal tract arises from the pontine and medullary reticular formation and descends in the ventral and ventro-lateral columns of the spinal cord. In man, the reticulospinal tract exists as scattered bundles of fibers that terminate primarily in the ventromedial portion of the spinal gray matter at or above the cervical enlargement (Nathan et al., 1996). Only a small proportion of the fibers continue into the thoracic, lumbar, and sacral levels of the spinal cord (Nathan et al., 1996). The origin of the reticulospinal tract, the reticular formation, receives input from a variety of sources, including bilateral motor cortical areas (Kuypers and Lawrence, 1967), and is heavily interconnected with other brainstem structures such as the vestibular...

Nonprimary Motor Cortices

Tribution to the corticospinal tract and have specialized functions. Each of the six cortical motor areas that interact with M1 has a separate and independent set of inputs from adjacent and remote regions, as well as parallel, separate outputs to the brain stem and spinal cord.56 Table 1-1 gives an overview of their relative contributions to the corticospinal tract and their functional roles. These motor areas also interact with cortex that does not have direct spinal motoneuron connections. For example, although motorically silent prefrontal areas do not directly control a muscle contraction, they play a role in the initiation, selection, inhibition, and guidance of behavior by representational knowledge. They do this via soma-totopically arranged prefrontal to premotor, corticostriatal, corticotectal, and thalamocorti-cal connections.57

Physiological Determinants Of Sleep

REM sleep generation is critically related to the pontomesencephalic region, as transection studies have demonstrated (55). When the mesopontine region is connected to rostral structures, REM sleep phenomena such as desynchronized EEG and ponto-geniculo-occipital (PGO) spikes are seen in the forebrain when this region is continuous with the medulla and the spinal cord, the REM sleep phenomenon of skeletal muscle atonia can be seen. The cholinergic ''REM-on'' nuclei, including the laterodorsal tegmental (LDT) nuclei and the pedunculopontine (PPT) nuclei, are found within the pontomesencephalic area (Fig. 3). The LDT and PPT nuclei project through the thalamus to the cortex, producing the EEG desynchronization of REM sleep. PGO spikes are a precursor to the REMs of REM sleep. They are formed in the cholinergic meso-pontine nuclei and propagate rostrally through the lateral geniculate and other thalamic nuclei to the occipital cortex (56). LDT and PPT nuclei project caudally via the...

Rationales for gait retraining

The hips, during the practice of stepping. Following a low thoracic spinal cord transection, cats and rats have been trained to step with their hindlimbs on a moving treadmill belt with support for the sagging trunk. Pulling down on their tails or a noxious input enhances hindlimb loading in extension. The animals are not as successful walking over ground. Training-induced adaptations within the cord in these animal models point to the potential of plasticity induced by rehabilitation to lead to behavioral gains. It seems likely that a network of locomotor spinal motoneu-rons and interneurons has been conserved in humans (Dimitrijevic et al., 1998), along with other forms of spinal organization (Lemay and Grill, 2004) that increase the flexibility of supraspinal regions to control hindlimb and lower extremity movements. Studies in patients with clinically complete SCI reveal similar responses to limb loading and hip inputs as were found in spinal transected cats (Chapter 30 Volume...

Diverse functions and dynamic expression of neuronal sodium channels

Nearly a dozen genes encode different Na+ channels, sharing a common overall motif but with subtly different amino acid sequences. Physiological signatures have now been established for some Na+ channels and it is clear that, from a functional point of view, Na+ channels are not all the same different channels can have different physiological characteristics, and they can play different roles in the physiology of excitable cells. Moreover, the expression of Na+ channels within neurons is not a static process. Plasticity of Na+ channel gene expression occurs in the normal nervous system, where it accompanies transitions between different physiological states (e.g. low-frequency versus high-frequency firing states) in some types of neurons. Maladaptive changes in Na+ channel gene expression also occur in some pathological neurons. For example, transection of the peripheral axons of spinal sensory neurons triggers down-regulation of some Na+ channel genes and up-regulation of...

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