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.

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Cervical spine injury

In patients with suspected or proven cervical spine injury the above maneuvers may exaggerate any neurological insult. Therefore it is recommended that the cervical spine be protected by manual in-line axial stabilization, maintaining the head and neck in the neutral position ( Fig 2). Jaw thrust will probably be the optimal technique for improving the airway with the least likelihood of distracting the cervical spine.

Cerebrospinal fluid analysis

Cerebrospinal fluid analysis can support the clinical diagnosis of HIV-associated dementia, especially by excluding several central nervous system opportunistic infections, in particular cryptococcal meningitis. The most frequent cerebrospinal fluid findings in HIV-associated dementia are the increase of total proteins and of the IgG fraction and index. A mononuclear pleocytosis may occur. The presence of the HIV core antigen p24 can be detected, although this finding is possible also in neurologically normal subjects. HIV RNA can be demostrated in the cerebrospinal fluid by using the polymerase chain reaction the levels of HIV RNA in the cerebrospinal fluid correlate with the severity of dementia 9 Increased cerebrospinal fluid levels of neopterin, b 2-microglobulin and quinolinic acid (non-specific markers of immune activation), as well as of several cytokines (interleukin 1b, interleukin 6, tumour necrosis factor-a), have been reported, but may be detected also during central...

Lumbar Spinal Stenosis

Lumbar spinal stenosis, the most common spinal disorder in the elderly, consists of clinical signs and symptoms, which result from narrowing of the spinal canal. Lumbar spinal canal narrowing results from degenerative thickened facets, hypertrophy of the ligamentum flavum, bulging discs, or degenerative spondylolisthesis (Figure 4-2). It has been shown that the hypertrophied ligamentum flavum loses its elastic fibers and may become calcified or, at times, ossified. Reduced elasticity may lead to bulging of the ligamenta flava into the spinal canal even in the standing position. Lumbar spinal stenosis often presents with low back and bilateral lower extremity pain. Walking brings about pain in the buttocks, thighs, or legs neurogenic claudication. The pain may become severe

The anatomy of the vertebral column and spinal cord

The vertebral column consists of 30 vertebrae seven cervical, 12 thoracic, five lumbar, five sacral (fused), and the coccygeal bone. With the exception of the first two cervical and the sacral vertebrae, all the bony elements of the spinal column articulate by intervertebral disks and posterolateral joints. Capsules and strong, yet elastic, ligaments with various points of origin and termination stabilize the spine in a fashion that provides both stability and flexibility. The vertebral column serves as a protective cavity for the spinal cord, which represents the caudal continuation of the brainstem. The spinal cord is suspended by means of a series of nerve roots, dentate ligaments, and three meninges to cover the cord and form the dural cavity which is filled with cerebrospinal fluid. The dura mater is an inelastic fibrous membrane which forms the dural sac. The epidural space (i.e. the space between the vertebral column and the spinal dura) contains fat, ligaments, small arteries,...

Systemic effects of spinal cord injury

The traumatic insult causing the spinal cord injury is associated with an immediate stimulation of central and peripheral sympathetic tone. Initially, the elevated sympathetic activity increases systemic arterial blood pressure and induces cardiac arrhythmias. At the stage of spinal shock with loss of neuronal conduction, the sympathetic excitation is closely followed by decreases in systemic vascular resistance, arterial hypotension, and venous pooling. Lesions above the level of T5 additionally present with severe bradycardia and cardiac dysfunction. The decreases in cardiac output combined with systemic hypotension further aggravate spinal cord ischemia in tissues with defective autoregulation. Spinal cord injury may produce respiratory failure. The extent of respiratory complications is related to the level of the injured segments. Injuries above the level of C4 to C5 produce complete paralysis of the diaphragm with substantial decreases in tidal volume and consecutive hypoxia....

Injury to the Cervical Spine

The majority of spine injuries occur at the level of the cervical spine, the most mobile portion of the vertebral column. Motor vehicle accidents account for most of these injuries. Fractures and fracture-dislocations are the most common injury patterns, although subluxations and injuries without radiographic abnormalities (SCIWORA), although altogether uncommon, occur more frequently in younger patients 13 . About 60 of patients who have sustained cervical spine trauma have suffered an injury to another organ system which can exacerbate the effects of secondary injury to the spinal cord, such as hypoxia or hypotension. It is estimated that 15 of patients with trauma to the spine sustain a neurological injury. With the cervical spine being the most commonly affected segment, it is estimated that 40-60 of all trauma to the cervical spine will result in some kind of neurological morbidity and or mortality. As an example, studies have shown that the mortality, in the field, for patients...

Thoracic Spine Injuries

Injuries to the thoracic spine account for 15 of all spinal cord injuries 24 . Although it is difficult to injure the thoracic spine, the contained segment of the spinal cord is very susceptible to injury and has the poorest prognosis for functional recovery. Only 10 of thoracic vertebral body injuries are associated with a spinal cord injury. This is in contradistinction of 39 seen in the cervical spine. Poor collateral circulation and a small spinal-canal-to-spinal-cord ratio account for the severity of the neurological deficits frequently associated with injuries to this region. In this region, the spinal cord is protected by the ribs, the chest cage and chest wall musculature, the sternum, the back and the costoverte-bral ligaments. This also adds stability to the thoracic region in the sense that it reduces the amount of physiological movement allowed. For example, the rib cage restricts motion in extension approximately 70 25 . The rib cage also adds stiffness to the spine as...

Thoracolumbar and Lumbar Spine Injuries

The thoracolumbar junction is situated between the rigid thoracic spine and the more mobile lumbar spine. This predisposes this region to axial compression, flexion and rotational injuries. The latter ones are rare and most osseous injuries are due to axial loading and flexion forces. For example, during axial loading, the thoracic spine deforms in kyphosis while the lumbar spine deforms in lordosis. Hence, the thoracolumbar region is exposed to compressive forces. In the lumbar region, the vertebral bodies are larger and there is more musculature providing support. This makes lumbar fractures distinctly uncommon, accounting for less than 4 of all spine fractures.

Recovery Following Injury to the Spinal Cord

The mechanisms of injury and the processes of recovery following spinal cord injury are somewhat different from those of the brain 31 . The causes of injury, however, are similar to brain. Primary damage from initial injury involves the white matter tracts and gray matter horns. Secondary damage takes place as the result of vascular changes, with loss of auto-regulation and micro-hemorrhages into the white matter tracts and gray matter 31 . Impaired blood-spinal cord barrier function results in the formation of vasogenic and cytotoxic spinal cord edema that would cause spinal cord compression within the confined space of the spinal canal, leading to poor perfusion. Axonal changes consist of membrane alterations, activation of calcium-dependent proteases and arrested or impaired axonal transport. The damaged tissue elicits an inflammatory The process of recovery is similar to that of the brain in broad principles. Often, the added problem of spinal cord compression sets in motion the...

Cerebrospinal Fluid Production and Absorption

Although a small proportion of CSF may be produced from the ependyma and brain parenchyma, the predominant site of CSF production is the choroid plexus, contributing 70-80 of the daily volume. Production occurs by a combination of filtration across the capillary endothelium and active secretion of sodium by the choroidal epithelium 1 . Cerebrospinal fluid production does appear to be reduced in the presence of elevated intracranial pressure and reduced cerebral perfusion pressure however, the effect is small and production is largely independent of pressure under physiological conditions. By contrast, CSF absorption shows a linear relationship to ICP.

Spinal cord and roots

Disorders localised to the spinal cord or nerve roots are detailed below, but note that many diffuse neurological disease processes also affect the cord (see Section V, e.g. multiple sclerosis, Friedreich's ataxia). SPINAL CORD AND ROOT COMPRESSION As the spinal canal is a rigidly enclosed cavity, an expanding disease process will eventually cause cord and or root compression. Site of lesion within the spinal canal

Spinal Cord And Root Compression

Spinal meningiomas tend to occur in elderly patients and are more common in females than in males. They usually arise in the thoracic region and are almost always intradural. Slow growth often permits considerable cord flattening to occur before symptoms become evident. MRI or CT myelography will identity the lesion. Schwannomas are slowly growing benign tumours occurring at any level and arising from the posterior nerve roots. They lie either entirely within the spinal canal or 'dumbbell' through the intervertebral foramen, on occasions presenting as a mass in the thorax or posterior abdominal wall.

Spinal Trauma Investigations

In the cervical spine - note evidence of soft tissue swelling between the pharynx and the vertebrae. fracture. the uPPer thoracic spine cervical spine cervical spine -- In the lumbar spine look for the normal 'scotty dog' appearance - if misshapen, suggests a fracture dislocation. CT scanning may aid identification of a fracture and show fragments extending into the spinal canal. CT myelography or MRI may provide additional information, but these investigations only help if operative decompression and or stabilisation is considered. -- In the lumbar spine look for the normal 'scotty dog' appearance - if misshapen, suggests a fracture dislocation.

Spinal Dysraphism

TETHERED CORD in some patients the conus medullaris lies well below its normal level (LI), 'tethered' by the filum terminale. Since vertebral growth proceeds more rapidly than growth of the spinal cord, tethering may produce progressive back pain or neurological impairment as the cord is stretched. DIASTOMATOMYELIA A congenital splitting of part of the spinal cord by a bony, fibrous or cartilaginous spur. This usually lies at the upper lumbar region and extends directly across the spinal canal in an antero-posterior direction. The split cord does not always reunite distal to the spur (diplomyelia). Investigation MRI is the investigation of choice in spinal dysraphism, but straight X-ray may reveal associated congenital abnormalities spina bifida occulta, fused or hemivertebrae. CT scanning may help demonstrate the presence of a bony spur. Management Although some recommend prophylactic division of the tethered filum terminale in the absence of neurological impairment, most reserve...

Management Of Spinal Tumors

Intramedullary lipomas appear well demarcated from the adjacent spinal cord, but they are intimately adherent to the normal tissue. Therefore, total removal is impossible without incurring neurological deficits and should not be attempted. The microsurgical laser is the instrument of choice for debulking a spinal cord lipoma. The laser vaporizes fatty tissue without surgical trauma to the spinal cord. The debulk-ing of the lipoma may result in improvement of pain but rarely in improvement of neurological function. Further growth of a lipoma is unlikely or at least very slow. However, in adolescence, probably due to endocrine factors, lipomas of the cord may increase in size and may, at that time, cause progressive neurological dysfunction. Following tumor removal, hemostasis is obtained with saline irrigation and local application of microfibrillar collagen (Avitene(r), C. R. Bard, Inc., 730 Central Avenue, Murray Hill, NJ). The dura is closed primarily in a watertight fashion. If an...

Management Of Extradural Spinal Tumors

Osteoblastomas differ from osteoid osteomas in their attaining greater size (more than 2 cm). Histologically, the two lesions cannot be differentiated. Less common than osteoid osteomas, osteoblastomas represent less than 2 of primary benign bone tumors, but have a greater propensity for axial skeletal involvement. Approximately 30-40 of osteoblas-tomas involve the axial skeleton. The lesions are distributed throughout the longitudinal axis of the spine, occur most commonly in the posterior elements and have a propensity to produce spinal deformity (Fig. 30.1). In 90 of cases, osteoblastomas present in patients of 30 years of age or younger these lesions have a male to female predominance of 2 1. Clinical presentation characteristically involves a higher incidence of neurological deficit, secondary to lesion size. Treatment is en-bloc resection, usually with resolution of scoliotic deformity. Prognosis is favorable with adequate removal. Long-term recurrence rates approach 10 1-4,6 ....

Paraparesisspinal collapse

May be due to tumour in the cord, spinal dura or meninges or by extension of a vertebral tumour into the spinal canal with compression of the cord or as a result of vertebral collapse. Spinal cord compression from vertebral collapse in a haematological patient is most commonly due to myeloma (in up to 20 of patients) but may occur in a patient with Hodgkin's disease (3-8 ) or occasionally non-Hodgkin's lymphoma. Spinal cord involvement by leukaemia is most common in AML, less so in ALL and CGL and least common in CLL. Symptoms suggestive of spinal cord compression require urgent assessment by CT or MRI and referral to a neurosurgical unit for assessment for surgical decompression. Where this is not possible early radiotherapy may provide symptomatic improvement. However, if treatment is delayed until paraparesis has developed, this often proves to be irreversible despite surgery and or radiotherapy.

Degenerative Disease Of The Cervical Spine

Pain radiating to the distal aspects of the arm is highly suggestive of ongoing cervical nerve root compression. This typically results from encroachment upon the exiting nerve root in the lateral aspect of the spinal canal or the intervertebral foramen. Compression can result from a disk herniation, uncovertebral joint hypertrophy or foraminal stenosis from facet hypertrophy. If the pain clearly conforms to the distribution of an isolated nerve root, or if it is associated with neurological deficit in an appropriate distribution, the origin of the pain can be attributed to nerve root compression. Pain involving the proximal aspects of the arm is less specific with respect to origin. It may result from cervical nerve root compression, or it may represent a referred phenomenon from the osseoligamentous changes of degeneration. Cervical cord compression can result from static or dynamic factors (Fig. 31.4). The typical cause of cord compression is an accumulation of osteophyte or a disk...

Cerebrospinal Fluid Surrogates

One method that is gaining popularity is the measurement by enzyme-linked immunosorbent assays (ELISA) of markers of axonal damage released into the cerebrospinal fluid (CSF) or blood of patients with various neurological disorders. A marker that is often used is t, a phosphorylated microtubule-associated protein, considered to be important for maintaining the stability of axonal microtubules involved in the mediation of fast axonal transport of synap-tic constituents (Green et al., 2000 Jimenez-Jimenez et al., 2002). Another surrogate marker for degenerated axons that can be measured in CSF is the light subunit of the neurofilament protein (NFL) (Hagberg et al., 2000).

The physiology of spinal cord blood flow

The spinal cord is perfused by a single anterior spinal cord artery, which runs along the median fissure, and two posterior spinal cord arteries which are located posterolaterally to the cord. The spinal cord arteries run along the anterior and posterior longitudinal axes of the cord between the cervical and sacral segments. The anterior spinal cord artery originates at the level of the medulla from the vertebral arteries and supplies 75 per cent of the cord. Six to eight anterior radicular arteries form anastomoses with the anterior spinal cord artery every three to five segments. The most important radicular vessel is the artery of Adamkiewicz which contributes to the perfusion of the thoracolumbar segments. The relatively large distance between the radicular vessels results in the existence of watershed areas which have predelections for ischemic insults. The posterior spinal cord arteries originate from the posterior branch of the vertebral artery and supply 25 per cent of the...

Congenital Spinal Malformations

Split Cord Malformation

When imaging children with suspected congenital spinal malformations, one must be aware that multiple anomalies such as myelomeningocele, split-cord malformation, syringohydromyelia, and others may co-exist. Anomalies of the caudal spine must be considered in patients with urogenital or anorectal malformations. Sagittal and coronal imaging of the entire spine with MRI is recommended to identify the location of the conus medullaris (normal level T10 to L2), associated lipomas or syrinxes, anomalous segments of spinal cord, and anomalies of dorsal closure or segmentation. Transaxial T1- and T2-WI should be obtained from the conus through the bottom of the sacrum to assess for a fatty (T1 hyperintense on MRI) and or thickened filum terminale. If a split-cord malformation (diastem-atomyelia) is detected, additional transaxial T2*-WI images should be performed through the levels of the split cord to best demonstrate a bony or fibrous spur. In patients with complex bone anomalies, MRI...

Pathological Changes In Naag And Gcp Ii In Spinal Motoneuron Injury And Disease

In 1984 Koller et al.32 reported reductions in NAAG levels caudal to spinal cord transactions. Given this finding, along with the known association of NAAG with motoneurons21, its co-localization with cholinergic motoneurons33 and the report of marked reduction in choline acetyltransferase activity in the ventral horn of the spinal cord in postmortem studies of patients with amyotrophic lateral sclerosis ALS ,34 it was logical to study levels of NAAG in conditions known to affect motoneurons. NAAG was reported to be significantly decreased in the spinal cord (32 ) and in the cerebral cortex (43 ) of male mice with hereditary myodystrophy manifesting an associated hindlimb paralysis.23 Levels of NAA, Glu and aspartate (Asp) had previously been shown to be decreased in the brains of these mice.35 Several studies have been carried out in spinal cord tissue obtained at autopsy from patients that had died of ALS. The comparison groups were autopsy specimens taken from patients that had...

Evaluation Of Inhibitors Of Gcp Ii In Acute Spinal Cord Injury In The

Spinal intrathecal injection of the peptide Dynorphin A has been shown to reliably induce ischemia, neuronal injury and persistent flaccid hindlimb paralysis.57-63 Concentrations of the excitatory amino acid neurotransmitters Glu and Asp are significantly increased in lumbar cerebrospinal fluid in the rat, shortly after the onset of dynorphin A-induced hindlimb paralysis.62 In addition, a variety of competitive and noncompetitive inhibitors of the NMDA receptor complex have been shown to significantly improve recovery of hindlimb motor function following this insult.62-66 In light of these findings suggesting excitoxic mechanisms in this model, we chose to use it to assess GCP II inhibition as a means to ameliorate excitoxic injury in the rat spinal cord. For amino acid measurements, CSF (approximately 70 il) was collected on ice for approximately 10 min beginning 15 min after spinal subarachnoid injections of dynorphin A, acidified and frozen until assayed by method of Robinson...

Histogenesis of the spinal cord

The neural tube initially consists of a single layer of neuroepithelial cells surrounding a central canal filled with the cerebrospinal fluid. The outer surface of the future spinal cord has an external limiting membrane, and the inner surface bordering the central canal has an inner limiting membrane. The entire wall of the neural tube is called the ventricular zone.(2) The cells of the neural tube proliferate, and the surface of the spinal cord enlarges. The cord then thickens as cells divide further to produce a multilayered epithelium. The daughter cells have different potentialities one type of cell (the neuroblast) retains the capability for mitosis, whereas another type (the proneurone) is postmitotic and represents an immature neurone. The proliferation of neurones is almost complete around birth. However, there is evidence that new neurones can be formed in Some neuroepithelial cells develop into precursors of glial cells, glioblasts, which differentiate into astroglial,...

Benign Tumors of the Spinal Column

Osteochondromas are the most common of the benign bone tumors. Over 50 of symptomatic spinal lesions occur in the cervical region, and they almost always involve the posterior elements. Osteochondromas can be a manifestation of multiple hereditary osteo-chondromatosis, which is one of the more common skeletal dysplasias. Clinical presentation varies from individuals reporting a dull backache (smaller tumors) to decreased motion or deformity (larger tumors). Neurological compromise is rare however, when present, the cervical spine, followed by the thoracic spine, are the most common lesion locations, with resultant myelopathic symptoms. Plain radiographs demonstrate a protruding lesion, with well demarcated borders in the posterior elements. Treatment for this condition is usually observation, because the natural history is of very slow progression. On rare occasions, pain, neurological deficit or an accelerated growth pattern may necessitate surgical removal. Prognosis is...

The cerebrospinal fluid inflammatory response

Once the organism has invaded the cerebrospinal fluid, a number of bacterial components, particularly lipopolysaccharide or lipo-oligosaccharide of Gram-negative organisms and peptidoglycan are the major determinants of meningeal inflammation. The techoic acid of Gram-positive organisms and the peptidoglycan components of both Gram-positive and Gram-negative organisms have been shown to be potent inducers of inflammation in the cerebrospinal fluid and to impair blood-brain barrier function on direct intracisternal inoculation in experimental animals. Similarly, direct inoculation of lipopolysaccharide from H. influenzae or the lipo-oligosaccharide of N. meningitidis into the cerebrospinal fluid of experimental animals causes an intense inflammatory reaction with influx of leukocytes, increase in protein and lactate, and a decline in cerebrospinal fluid glucose concentration. These studies have provided overwhelming evidence that bacterial endotoxins and other bacterial cell wall...

Levels of homovanillic acid and 5hydroxyindoleacetic acid in cerebrospinal fluid

Suicide attempts represent a more varied type of behaviour than completed suicides, yet neurobiological studies of suicide attempters have shown a remarkable consistency in pointing to a serotonergic dysfunction. In a meta-analysis, which included 20 research reports, Lester (15) concluded that there is strong evidence of decreased cerebrospinal fluid levels of 5-HIAA in subjects who had previously made a suicide attempt compared to diagnostically matched non-attempters. Moreover, in three out of five studies, low cerebrospinal-fluid 5-HIAA was also able to predict future suicidal behaviour in subjects with depression or schizophrenia. Lester did not, however, find enough evidence to substantiate a relationship between suicide attempt status and the levels of homovanillic acid or 3-methoxy-4-hydroxphenylglycol (MHPG), a metabolite of noradrenaline, in cerebrospinal fluid. Nordstrom et al.(16 found that the risk of completed suicide within 1 year after a suicide attempt was 2.5 times...

Pain in the Cervical Spine

The principles of management of pain arising from the cervical spine are essentially the same as those described above for the lumbar spine. The increased mobility of this part of the spine and the greater use of paraspinal muscles for stabilization, however, place a greater emphasis on functional treatments in the management of chronic cervical spine pain. Although, theoretically, the approach to nerve root compression and irritation is the same as that for the lumbar spine, the use of invasive therapies such as epidural injections is more limited. This is at least partly because the technique of epidural injection in the cervical spine is more difficult and the potential risks (para- or quadri-paresis, secondary to epidural hemorrhage or infection) are more severe. They may be considered for the treatment of cancer-related cervical spine pain and radicular-type pain. The procedure is carried out using an 18-gauge Tuohy needle and a loss-of-resistance technique to locate the epidural...

Spinal Cord And Root Compression Investigations

If MRI is unavailable, myelography is used to screen the spinal cord and the cauda equina. This will identify the level of a compressive lesion and indicate its probable site i.e. intradural, extradural. Plain CT with axial cuts will clearly demonstrate bone erosion, osteophytic outgrowth and thickened facet joints causing narrowing of the spinal canal or intervertebral foramen. Axial cuts will also demonstrate disc disease of the lumbosacral spine, show the relationship of any paraspinal mass to the vertebral body and intervertebral foramen and identify the extraspinal extent of an intraspinal lesion, e.g. neurofibroma. CT myelography with axial cuts (CT performed either 6-12 hours after routine myelography or immediately after intrathecal injection of just a few mis of contrast) demonstrates clearly the degree of spinal cord or nerve root compression.

Spinal Trauma

In the absence of acute neurological findings, the initial evaluation of spinal trauma should begin with plain radiographs. If any fractures or other findings indicative of acute bone injury (e.g., excess paraspinous soft-tissue swelling, fractures or malalignment) are identified, this should be followed by thin-section transaxial CT sections, and should include sagittal and coronal reformations. Spinal MRI is usually reserved for patients who have new neurological deficits after trauma. The treating physician must have a low threshold for obtaining an MR study in infants or young children, even in the absence of radiographic abnormalities, if there is any clinical concern about the possibility of cord injury, because the anatomy and elasticity of the immature spine makes children more susceptible to spinal-cord injury in the absence of fractures. This is particularly true in the cervical spine. Spinal-cord contusions usually manifest as edema (T2 hyperintense) and swelling of the...

Spinal Surgery

The development of increasingly complex spinal surgical techniques and instrumentation has meant that 2D lateral intraoperative fluoroscopy is now considered to be insufficient for safe and effective insertion of implants. The application of the principles of intracranial neuronavigation to the spine is not straightforward, for several reasons. Registration of the spine cannot reliably depend on skin markers or fidu-cials, in view of the high mobility of the spinal column and the overlying skin. Indeed, registration needs to be performed intraoperatively on the exposed spinal anatomy of the segment requiring surgery, using points that are easily and accurately identifiable on the exposed spine and on the pre-operatively acquired images. These may include the superior and inferior portions of the spinous processes and the medial and lateral limits of the facet joint in the cervical spine, and the posterolateral aspect of the transverse process tips on each side in the thoracic spine....

Cerebrospinal fluid

Various cerebrospinal fluid (CSF) tests were evaluated in 15 studies60,66,68-70,78-80,86-92 reporting a total of 37 test evaluations. The DORs ranged from 0 to 378.8. In 26 (70 ) of evaluations, the DORs were less than 25, in seven (20 ) the DOR was between 25 and 100 and in four (10 ) evaluations the DOR was greater than 100. Of the evaluations reporting a DOR less than 25, 20 (77 ) included an appropriate range of patients. In comparison only half of the studies with DORs between 50 and 100 included an appropriate range of patients. However, in contrast to the studies included in the other sections, three of the four studies reporting DORs greater than 100 included an appropriate range of patients.

Spine Radiography

A lateral cervical radiograph should be obtained in the ER and will demonstrate most vertebral subluxations and facet dislocations, as well as many fractures. A complete cervical spine series in preadolescent children includes a lateral radiograph extending from the occiput to at least the cranial portion of the T1 vertebral body and an AP radiograph. In adolescents and adults, an open-mouth radiograph of the odontoid process should also be obtained. 'Tandem' cervical and thoracolumbar-sacral (TLS) injuries are not uncommon, particularly after a motor-vehicle accident (MVA). Figure 7. Lateral cervical radiographs in flexed and extended positions. Dynamic cervical radiographs may be useful in cervical-spine clearance after trauma but should not be undertaken in the presence of known fracture, instability, neck pain or neurological deficit. Limited flexion or extension due to poor cooperation or splinting, as seen here, can also limit the value of the examination. Figure 7. Lateral...

Spine Clearance

Spine clearance protocols vary from institution to institution. A conversant, oriented child without head injury, intoxication or painful distracting injury may be 'clinically cleared' based on a complete, normal neurological examination and palpation of a nontender and fully mobile spinal column. Children with tenderness or examination limitations must undergo radiographic evaluation, as described above. Comatose or sedated children must be maintained in a cervical collar with spine precautions until cleared by negative spine radiographs supplemented by MRI, to rule out ligamentous injury. It should be emphasized that 'clearing' the spine requires knowledge not only of the imaging studies but also of the clinical status of the patient.

Spine Injuries

Attention to pre-vertebral soft tissue swelling is as important as attention to bony anatomy. In some cases, it may be the only radiological sign in 30-40 of patients presenting with an acute central cord syndrome 3 . All seven cervical vertebrae, as well as the C7-T1 junction, need to be visualized 4 . Caudal traction of the arms or a swimmer's view might be necessary to visualize this junction. Contraindications to this maneuver include atlanto-occipital, atlanto-axial or other pathologies identified in the initial view. An AP view, as well as an open mouth or odontoid view, are usually all that are needed to adequately visualize the cervical spine. Limitations of plain radiographs include difficulty in identifying injuries to the ligaments, over and underexposure, as well as decreased visualization of the occipitocervical, cervicothoracic and thoracolumbar transitional areas. Areas not adequately visualized or fractures identified by plain films should be...

Spinal Anesthesia

Spinal anesthesia is a local anesthetic injected into the spinal column in the third or fourth lumbar space to produce a regional neural block. If it is given too high, the respiratory muscles could be affected and respiratory distress or failure could result. There are 4 types of spinal anesthesia subarachnoid block, epidural block, the saddle block, and a caudal block. The epidural block occurs when the anesthetic is injected into the outer covering (dura mater) of the spinal cord near the sacrum. The saddle block is given at the lower end of the spinal column to block the perineal area for procedures such as childbirth. The patient may experience headaches and hypotension as a result of these procedures because of a change in cerebrospinal fluid pressure when the needle is inserted into the spine. The patient should remain in the supine position following the procedure and increase fluid intake.

Spinal Metastases

Skeletal metastases are 25 times more common than primary bone tumors. Spinal metastases are common because they tend to develop in hematopoietic active bone marrow, which is predominantly located in the adult spine. Most spinal metastases are found in the thoracic and lumbar regions. They are frequently disseminated via the blood-hematogenous spread. Both venous dissemination and arterial dissemination may occur. Batson's plexus of valveless veins, a major source of spinal metastases, connects with venous plexuses inside the spinal canal. Pressure difference in these veins directs tumor cells from the pelvis (prostate) into the lumbar or thoracic vertebral bodies. The tumors may also get to the spine by direct dissemination or through the lymphatic system. They frequently invade the vertebral bodies or the pedicles. Metastases can also grow along nervous tissue and thus enter the epidural space inside the spinal canal. The most common sources of vertebral metastases are the breast,...

Spinal Abnormalities

As with vascular lesions, many minimally invasive spine procedures mimic those in the adult population and do not need special attention in this chapter. However, some spine pathologies are specific to children. Intrauterine myelomeningocele closures are changing the face of traditional spinal surgery and perhaps blurring the boundaries of disease as we have the opportunity to intervene so early that the sequelae of disease do not even develop. In many respects this would be minimally invasive, but the hypothesis remains to be proved. In addition, it introduces ethical issues, as what may be less invasive for the baby is clearly maximally invasive for the mother. In general, smaller incisions and exposure seem to be significantly aiding pediatric spine procedures. This is especially true because the bone healing in children is so robust that simply exposing additional levels or facets can lead to unwanted autofusion of the spinal column. Pediatric neurosurgeons often take advantage of...

MRI Spinal Column

Cervical Spine The cervical spine shows a normal degree of lordosis with normal width of the bony spinal canal. The spinal cord, including the craniocervical junction, displays normal position, configuration, width, and internal structure. The bone marrow of the vertebral bodies appears normal. The cervical spine appears normal. Bony spinal canal Spinal cord Normal range of 150 (flexion) to 180 (extension) (spinal Width of spinal cord Width of spinal canal Thoracic Spine The thoracic spine shows a normal degree of kyphosis with a normal width of the bony spinal canal. The spinal cord displays normal course, configuration, width, and internal structure. The thoracic spine appears normal. Bony spinal canal Spinal cord Width of spinal canal Lumbar Spine The lumbar spine shows a smooth lordotic curve with a normal promontory angle. The bony spinal canal displays normal width. The vertebral bodies are normal in their number, shape, and interrelationships. The articulating vertebral end...

CT Spinal Column

Cervical Spine The cervical spine shows a normal degree of lordosis in the lateral survey scan, with no segmental malalignment. The bony spinal canal shows normal sagittal diameter. The intervertebral disks show normal CT density and normal posterior concavity. The disks do not project past the posterior surface of the vertebral bodies. The spinal cord is centrally placed and of normal width. It has homogeneous density and shows no circumscribed narrowing or expansion. The examined segments of the cervical spine appear normal. Bony spinal canal Spinal cord 3 Width of spinal canal 4 Width of spinal cord Thoracic Spine The thoracic spine shows a normal degree of kyphosis in the lateral survey scan, with no segmental malalignment. The vertebral bodies show normal shape and trabecular structure. The cortical margins are of normal thickness and are free of osteophytes. The bony spinal canal has normal sagittal diameter. The intervertebral disks show normal CT density and normal posterior...

The Brain and Related Structures in CT

Bone, acute blood Enhanced tumor Subacute blood Muscle Grey matter White matter Cerebrospinal fluid Air, Fat 1-1 Computed Tomography (CT) in the axial plane of a patient with subarachnoid hemorrhage. Bone is white, acute blood (white) outlines the subarachnoid space, brain is grey, and cerebrospinal fluid in third and lateral ventricles is black.

Longitudinal Ligament

This idiopathic condition affects primarily the cervical region but may involve the thoracic region as well. The posterior longitudinal ligament gradually ossifies and thickens. It grows posteriorly into the spinal canal, gradually taking more space and eventually leading to spinal cord compression. Most patients remain asymptomatic for quite some time. When the ossified ligament occupies 60 or more of the anteroposterior diameter of the spinal canal myelopathic symptoms appear. Occasionally the condition is discovered incidentally on X-rays, CT, or MRI. Lateral cervical spine films may show sclerosed and thickened bone mass posterior to the vertebral bodies. Frequently no mass is detected posterior to the discal space. The ossified ligament can be easily missed unless the ossification is extensive. In the latter case a flowing ossified posterior longitudinal ligament is seen. Of note, the facet joints are not fused (Figure 4-16).

Tuberculous Osteomyelitis

In a significant number ofTBS patients the source of the infection is not evident but is assumed to originate from a small locus of infection within the lungs. Usually the infection reaches the spine via the arterial system and settles in the anterior portion of the vertebral bodies in the subchondral region. The disease appears mostly in the thoracic spine and less frequently in the thoraco-lumbar junction. In the majority of patients several contiguous levels may be involved. Occasionally the affected levels are not contiguous and, at times, one-level disease may be observed. The onset of symptoms is rather insidious. Pain may appear in the thoracic region in a girdle-like distribution and may be accompanied by local tenderness. The pain persists and the patient may become febrile. This may be accompanied by night sweats, especially when concomitant pulmonary tuberculosis is present. Weight loss may be documented. Most patients are diagnosed late. The evolution of symptoms is slower...

Clinical Presentation

Patients with cervical spine involvement may be initially asymptomatic. As the disease progresses neck pain may appear. Suboccipital headaches aggravated by neck movements are common, and electrical-like sensation in the torso or extremities that is precipitated by neck flexion or extension may appear. This is frequently referred to as Lhermitte'ssign. Some patients develop earache and occasionally facial pain due to compression or irritation of the sensory fibers of the greater auricular nerve or the spinal trigeminal nucleus. Neurological findings are less common than pain but may be present in up to one-third of the patients. Gait dysfunction (unstable gait, wide-based gait), decreased upper extremity dexterity and weakness, and sphincter dysfunction may develop due to cervical myelopathy.

Radiological Assessment

Several methods have been developed to identify basilar invagination on cervical spine plain films. All the methods require recognition of certain basic, simple, and important landmarks on lateral films the basion (ventral border of the foramen magnum), opisthion (dorsal border of the foramen magnum), hard palate, atlas, C2 pedicles, and the tip of the odontoid process (Figure 9-7). The following methods When basilar invagination is suspected MRI studies should be obtained. Special attention should be paid to the brain stem, spinal cord, and the cervico-medullary angle. The latter normally ranges between 135 and 175 degrees. Cranial settling and peridental pannus formation may decrease this angle and correlate well with the presence of myelopathy and neurological changes.

Intramedullary Tumors

Intramedullary gliomas usually become symptomatic in the third and fourth decades and are most often seen in the upper thoracic and cervical regions. They usually present with slow-onset myelopathy. Ependymomas tend to occur in the fourth and fifth decades, affect both genders, and in over 50 of cases are located in the thoracic spine. The initial presentation may include dysesthesia and pain and may be followed by gait dysfunction, weakness, atrophy, and myelo-pathic symptoms. Because these tumors are slow-growing they tend to be diagnosed late and by that time cause significant morbidity. Plain films in patients with longstanding intramedullary lesions such as ependymomas may show enlarged spinal canal with increased

Diffuse Idiopathic Skeletal Hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH), also known as ankylosing hyperostosis or Forestier disease, is a common degenerative condition that affects the elderly. It may be more common in diabetics and affects males more frequently. It is seen mostly in people of Caucasian origin. In many instances it is found as an incidental discovery. At times, however, it may cause symptoms. DISH most commonly affects the thoracic spine, but in many patients the cervical and lumbar regions may be affected as well.


The ligamenta flava that are adjacent to them. The relationship between the canal size and the size of its contents, the neural elements, is of paramount importance. In tight spots such as the thoracic spine region, the spinal cord fills most of the available space. Here, even a moderate-sized space-occupying lesion, such as a herniated disc or tumor, may lead to progressive, severe neurological compromise due to cord compression. In the lumbar region, however, where the canal is wider, lesions of the same size may remain asymptomatic for a long time because there is ample space left for the nerve roots to move away from the offending structure. Spinal Canal and Neural Elements The spinal canal contains the spinal cord and the nerve roots. The spinal cord, which is the continuation of the brain stem, extends from the foramen magnum to the L1-L2 level. The lower tip of the spinal cord the conus medullaris is a cone-shaped structure pointing downward that contains the centers for...

Figure 115

The five sacral vertebrae and the articular processes of the last four sacral vertebrae are fused together to form the sacrum. The superior processes of the first sacral vertebra articulate with the inferior processes of the L5 vertebra. There are four pairs of anterior and posterior sacral foraminae. The sacral spinal canal is triangular in shape and is relatively large, providing ample space for the cauda equina. The anterior rami of the S2 through S5 roots conduct the parasympathetic fibers that are responsible for the bladder and rectum.

Figure 119

Bogduk N The anatomic basis for spinal pain syndromes. J Manipulative Physiol Ther 18 603605, 1995. Ebraheim NA, Xu R, Darwich M, Yeasting RA Anatomic relations between the lumbar pedicle and the adjacent neural structures. Spine 22 2338-2341, 1997. Hasue M, Kikuchi S, Sakuyama Y, Ito T Anatomic study of the interrelation between lumbosa-cral nerve roots and their surrounding tissues. Spine 8 50-58, 1983. Macintosh JE, Bogduk N 1987 Volvo award in basic science The morphology of the lumbar erector spinae. Spine 12 658-668, 1987. Tanaka N, Fujimoto Y, An HS, Ikuta Y, Yasuda M The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine. Spine 25 286-291, 2000. Ward CV, Latimer B Human evolution and the development of spondylolysis. Spine 30 18081814, 2005.


Ent for occasions when CT and MRI are unavailable. It is performed by injecting water-soluble contrast material containing iodine into the subarachnoid space by a spinal tap. The contrast enhances the cerebrospinal fluid (CSF) and delineates the dural sac and the nerve root sleeves emanating into the intervertebral foraminae (Figures 2-9A and 2-9B). Myelography, especially combined with CT in the so-called computerized assisted myelography (CAM), or myelo-CT, can be helpful for diagnosis of disc herniation, osteophytic impingement on cervical and lumbar roots, and cord compression. Some radiologists and surgeons insist on obtaining myelo-CT prior to surgery because it depicts finer details of the patho-anatomy. It is also helpful in detecting subarachnoid tumoral spread, drop metastasis, and arachnoiditis, as well as dilated vessels indicating vascular malformation when MRI is not available or is contraindicated (Figures 2-9C-F). Finally, CAM is sometime necessary to ascertain...

Figure 29

Lumbar myelography (A) Oblique view of a normal myelogram. The cerebrospinal fluid (CSF) is enhanced following intrathecal injection of water-soluble, radio-opaque contrast material. The nerve roots are seen as elongated thread-like filling defects running through the enhanced CSF and emanating from the dural sac. Note the roots pushed away by the needle tip. (B) Drop metastasis are demonstrated as rounded filling defects of various sizes, scattered along the cauda equina in this pathological myelogram. (C) Myelo-CT at the atlantoaxial level showing the enhanced CSF in the subarachnoid space. Note the dark non-enhanced oval shape spinal cord in the center and bilateral horizontally oriented delicate roots. (D) Sagittal reconstruction of myelo-CT at the C1-C2 level. (E) Coronal reconstruction of myelo-CT through the whole cervical spine. (F) Axial cut through the tip of the conus medullaris at L1 level. Short scanning times are desirable in spinal computed tomography, because motion...

Figure 210

Traditional CT Study of the Spine Traditional CT study of the spine consists of multiple slices traversing the spinal elements in axial plains, perpendicular to the long axis of the spinal column, along its different curvatures the cervical and lumbar lordosis and the dorsal and sacral kyphosis. thicker. At a disc level, the density of the cartilage and fibrous tissues will be lower than that of the bone yet higher hyperdense to that of the perivertebral muscles and of normal intraspinal components (Figure 2-11A). A normal lumbar intervertebral disc is slightly concave posteriorly in shape, except at L5-S1, where it appears rounded. The intraspinal normal epidural fat has a very low density on CT images as compared with all other spinal components. The epidural fat is more abundant at the lumbosacral level, where it is located mainly behind the dural sac, filling the triangular shape formed by the laminae, and in the lateral aspects of the spinal canal, medial to the intervertebral...

Figure 212

(A) Sagittal CT reconstruction of the dorsal spine. Sagittal diameter of the spinal canal and the discs' height can be more accurately measured and the endplates of the vertebral body are better assessed than on X-rays. (B) Three-dimensional reconstruction of the cervical spine including vertebrae, adjacent soft tissues, and the major blood vessels. Contrast Agents in Spinal CT 1. Intravenous injection of contrast material is indicated when pathologies such as primary or secondary tumors, or inflammatory processes are looked for, as they can enhance pathologic soft tissues within the bones or inside the spinal canal. The contrast agents used with CT contain Iodine. They harbor some contraindications as they can provoke hypersensitivity reactions and cause side effects. 2. Intra-thecal injection of contrast agents into the sub-arachnoid space is performed by a spinal tap to perform CT- Myelography or CAM (Figures 2-9C, 2-9D, 2-9E, and 2-9F). Radiofrequency receiver coils are used to...

Herniated Discs

Has taken a central role in spinal pathphysiology and symptomatology. The advent of CT and MRI, however, has clearly shown that quite frequently, even in the presence of a frank disc herniation, patients remain asymptomatic. Posterolateral disc herniation will bring about radicular pain. The patient will complain of pain in the upper or lower extremity with or without axial (spine) pain. Posteriorly directed herniations in the cervical or thoracic region may compromise the spinal cord and bring about progressive neurological deficits with bilateral long-tract signs. In the lower lumbar region posterior herniation of the same size may cause axial pain without any radicular symptoms. Large fragments, however, may compress the whole cauda equina and result in severe neurological compromise. Pure lateral herniations that end up in the intervertebral foramen frequently result in unremitting pain due to compression of the dorsal root ganglion (Figures 3-6A, 3-6B, and 3-6C). In the cervical...

Ab Figure

Flexion and extension lateral plain films of the cervical spine demonstrating instability due to degenerative disc disease. A subluxation is noted at C4-C5 in (A) flexion view (arrow) with full correction on extension (B). cervical lordosis or, quite commonly, reversal of the cervical lordosis cervical kyphosis. A congenitally narrow cervical canal is a significant risk factor for the development of myelopathy once degenerative changes occur. The Torg-Pavlov ratio can be obtained by dividing the sagittal diameter of the cervical spinal canal by that of the vertebral body as obtained in lateral spine films. In normal individuals the ratio is one. A ratio of 0.8 or less helps identify patients with a high risk of developing this disease (Figure 4-5). In the lumbar region degenerative scoliosis is quite commonly seen. Oblique films of the cervical spine and lateral films of the lumbar spine frequently show single or multilevel neural foraminal narrowing. A posterior disc height of less...

Imaging Studies

T1-weighted images with fat suppression may demonstrate the bony cleft (Figure 5-4). MR is an insensitive technique for pars interarticularis defects and spondylolysis detection. The reasons are basically that the slice thicknesses of the MR sagittal sequences are relatively thick, and the fracture does not have great contrast. Frequently the cuts are not centered on the fracture and it can thus be easily missed. In routine studies the axial images are often performed with the intention of visualizing disc and spinal canal anatomy rather than pars defects.

Figure 513

Sagittal T1WI MRI demonstrating L4-L5 degenerative spondylolisthesis secondary to disc degeneration. Note that the disc seems to bulge posteriorly into the spinal canal, called pseudobulge, as it remains attached to the higher endplate of the lower vertebra (arrow). Ebraheim NA, Xu R, Darwich M, Yeasting RA Anatomic relations between the lumbar pedicle and the adjacent neural structures. Spine 22 2338-2341, 1997. Floman Y Progression of lumbosacral isthmic spondylolisthesis in adults. Spine 25 342-347, 2000. Gregory PL, Batt ME, Kerslake RW, Scammell BE, Webb JF The value of combining single photon emission computerized tomography and computerized tomography in the investigation of spondylolysis. Eur Spine J 13 503-509, 2004. Hammerberg KW New concepts on the pathogenesis and classification of spondylolisthesis. Spine 30 S4-S11, 2005. Kim KW, Chung JW, Park JB, Song SW, Ha KY, An HS The course of the nerve root in the neural foramen and its relationship with foraminal entrapment or...

Subaxial Subluxation

This deformity results from facet joints destruction and deterioration of the stabilizing ligaments. Subaxial subluxation may develop in a single level or at multiple cervical levels and may lead to stepladder or staircase deformity. It usually develops at the C2-C3 or C3-C4 levels and may lead to spinal cord compression and myelopathy (Figure 9-11). The staircase deformity can be easily spotted on X-rays in lateral views of the cervical spine (Figure 9-12). The deformity is also clearly

Vertebral Hemangioma

The prevalence of vertebral hemangiomas increases with age, peaking in the fourth through sixth decades. This is the most common benign spinal tumor it may be present in up to 10 of all spinal MRI studies. It occurs most frequently in the thoracic spine, less frequently in the lumbar region, and rarely in the cervical region. Commonly, multiple hemangiomas may be seen affecting several vertebrae. Ninety percent of hemangiomas develop within the vertebral bodies. The rest are found in the posterior elements.

Figure 1114

Angiomas tend to occur in the lower thoracic spine. The more aggressive ones grow beyond the vertebral body boundaries and may compress the spinal cord or the exiting nerve roots. As they grow within the vertebral body they may compromise its structural integrity to the point of collapse. Patients with aggressive hemangiomas present with axial pain and tenderness. Only a minority develop slowly progressive radicular symptoms or myelopathic signs. Rarely, rapid-onset, progressive neurological compromise is seen. The symptoms may be caused by epidural expansion of the tumor, expansion of the vertebral body in response to tumor expansion, sudden bleeding, or vertebral body collapse. Plain films reveal either parallel linear streaks or honeycomb appearance or vertical striation within the vertebrae (Figure 11-15). CT easily detects these lesions. The affected vertebra will show a polka dot appearance on axial cuts. Thickened trabeculae are surrounded with hypodense fatty tissue (Figure...

Figure 1120

(A) A large meningioma shown in axial T1WI. The tumor is occupying most of the spinal canal and compressing the spinal cord (star). (B) The tumor enhanced following contrast administration. Courtesy Dr. E. Ashkenazi. isodense to the spinal cord. They can be more easily detected when calcified as they appear hyperdense to the cord or following intravenous contrast administration when they usually enhance. Most spinal meningiomas are located posterolaterally within the spinal canal. The tumor may be heavily calcified and as such will appear as a hyperdense mass. On MRI most spinal meningiomas are isointense to the spinal cord on T1WI and T2WI. Heavily calcified tumors will remain hypointense in most sequences (Figures 11-20A and 11-20B). The tumors will prominently enhance (if they are not heavily calcified) following contrast material administration (Figure 11-21).

Figure 132

Sagittal T1WI MR. (A) A burst fracture (star) with a fragment displaced posteriorly into the spinal canal. Just behind and above the fractured vertebra a hyperintense mass with a hypointense core is found. (B) In another patient a hyperintense mass is seen posterior to the thoracic cord.

Figure 143

Axial T2WI of the lumbar spine in a 20-year-old patient with persistent low back pain. Within the distal cord conus a hyperintense rounded syrinx was found (arrow). The lesion did not enhance with contrast and no tumor was found. Gamache FW, Ducker TB Syringomyelia A neurological and surgical spectrum. J Spinal Disord 3 293-298, 1990. Lee J-H, Chung C-K, Kim HJ Decompression of the spinal subarachnoid space as a solution for syringomyelia without Chiari malformation. Spinal Cord 40 501-506, 2002. Medlock MD Syringomyelia. Semin Spine Surg 12 141-150, 2000. Milhorat TH, Capocelli AL, Anzil AP, Kotzen RM, Mihorat RH Pathological basis of spinal cord cavitation in syringomyelia. Analysis of 105 autopsy cases. J Neurosurg 85 802-812, 1995. Takigami I, Miyamoto K, Kodama H, Hosoe H, Tanimoto S, Shimizu K Foramen magnum decompression for the treatment of Arnold Chiari malformation type I with associated syringomyelia in an elderly patient. Spinal Cord 43 249-251, 2005. Uhlenbrock D, Henkes...

Figure 178

Disc space infection following discec-tomy. Lateral X-ray of the lumbar spine of a patient following L1-L2 discectomy, showing intervertebral disc space narrowing with endplate irregularities and anterior new bone formation suggesting postoperative disc space infection (see also MRI, Figure 17-17A). CT yields excellent images and anatomical details of the bony structures and, as such, provides important data in patients with residual central, lateral, or foraminal stenosis. Although CT is an outstanding tool in the diagnosis of lumbar disc herniations in a virgin spine, it is less effective in distinguishing between postoperative scarring and recurrent disc herniation. The previous laminectomy site is easily recognized on the axial CT images, when a portion of the lamina is missing. In cases of microdiscectomy where bone resection was not performed, the operative site may be recognized by the missing ligamentum flavum. The CT examination can reveal changes outside the spinal canal,...

Figure 1712

Stainless steel pedicle screws, and to a lesser extent titanium implants, may cause artifacts on CT scans. It is better in the latter case to evaluate the spine with bone windows or, even better, with myelog-raphy and post-myelography CT. Another advantage of CT-myelogra-phy is that it is a true dynamic examination. Although CT-myelography can also detect arachnoiditis and pseudomeningocele, both entities are better delineated on MRI. Cervical Spine There are many pitfalls with CT evaluation of the cervical spine. The cervical cord is poorly visualized, disc pathology is not clearly delineated, and beam hardening artifacts from the shoulders at the cervicothoracic junction (C6 to T2) blur most of the anatomical details. In addition, the use of metal spinal implants blurs the obtained images even further. CT-myelography may help to better visualize the anatomical details, especially in the cervicothoracic junction and in the presence of metal artifacts. Cord pathology, however, will...

Figure 1721

Epidural hematoma folowing cervical corpectomy (A) T1 and (B) T2 FSE MRI of the cervical spine following C5 corpectomy with C4 through C6 fixation, showing a compressive epidural hematoma. Note also the high signal within the spinal cord indicating myelomalacia. Selective nerve root blocks are performed to better localize the source of pain from an irritated or compressed spinal nerve root. Facet blocks or sacroiliac joint injections are used to identify the source of pain from these structures, because the radiological appearance of these joints alone is not diagnostic in localizing the pain source. Ashkenazi E, Smorgick Y, Rand N, Millgram MA, Mirovsky Y, Floman Y Anterior decompression with combined corpectomies and discectomies in the management of multilevel cervical myelopathy A hybrid decompression fixation technique. J Neurosurg Spine 3 205-209, 2005. Blumenthal SL, Gill K Can lumbar spine radiographs accurately determine fusion in postoperative patients Correlation of routine...

Epidural Lipomatosis

Crowding The Thecal Sac

Epidural lipomatosis (EL) is an uncommon but not a rare condition that frequently leads to spinal stenosis. The most common symptoms include backache and, less frequently, radicular pain. Some patients present with intermittent claudication or unilateral radiculopathy simulating spinal stenosis or herniated disc, respectively. In patients with significant cord or thecal X-rays are usually negative. Osteoporosis and compression fractures may be seen in patients on long-term steroids. The CT scan will demonstrate low attenuation mass typical for the excessive, epidur-ally deposited, fatty tissue. In cases with severe thecal sac compression axial cuts will show a dural sac deformation in stellar, trifid, or Y shapes. This has been coined the Y sign and can also be seen on axial cuts in MRI examination. It has been proposed that the Y shape found in severe cases of epidural lipomatosis is brought about by the presence of meningovertebral ligaments that anchor the outer surface of the dura...

Figure 1717


Tal T1WI of the lumbar spine showing a fat graft compressing the thecal sac. MRI is also useful after fusion surgery with instrumentation. Placement of spinal implants degrades MRI quality by producing streak artifacts that may make the evaluation of the tissues adjacent to the implants challenging. Artifacts are especially prominent with stainless steel implants. In contrast, titanium implants cause minimal distortion in homogeneity, and spine-echo and FSE sequences show the least interference with metal implants. The use of drills in spine surgery, a technique that is associated with local shedding of metallic debris, may also cause artifacts on MRI. Cervical Spine The ability of MRI to evaluate the spinal cord is unsurpassed. On gradient echo images CSF demonstrates greater signal intensity than the cord, producing a pseudomyelographic effect. On the other hand gradient echo images tend to exaggerate the severity of bony canal stenosis. A better evaluation of the latter condition...

Figure 1125

Interpedicular distance, scalloping of the posterior vertebral bodies, and at times widened foraminae and eroded pedicles. CT discloses the enlarged spinal canal and might depict an isodense intradural mass that might enhance following contrast administration. On MRI, an isointense mass on T1WI that appears hyperintense to the cord on T2WI and intensely enhances following contrast administration can be seen (Figure 11-25). Plain films in astrocytomas may be negative. Occasionally canal expansion may be noticed. On CT images cord thickening is noted, with possible mild enhancement following contrast administration. MRI will clearly demonstrate the dilated cord, which may appear on T1WI hypoin-tense or isointense to the cerebrospinal fluid. Occasionally hypointense cysts may be spotted on T1WI within the mass. The mass will appear hyperintense on T2WI and will further enhance following contrast administration. Occasionally cysts and syrinx may be observed in MRI studies. Barba D,...

Figure 1713

Marrow Edema Cervical Spine

MRI is an excellent diagnostic tool for providing detailed anatomical features of soft and neural tissues and also for depicting sagittal coronal reformation by showing the spinal canal and intervertebral foraminae. In addition, because MRI is capable of revealing not only morphological alterations but also biochemical changes, it is the imaging procedure of choice for patients following spine surgery. It also has the ability to differentiate between fat, scar tissue, and disc material by using various MR sequences with or without a magnetic contrast medium such as gadolinium diethylenetriamine penta-acetic acid (Gd-DPTA). Early Normal Postoperative Changes in the Lumbar Spine


Several important ligaments contribute to and enhance spinal stability the anterior and posterior longitudinal ligaments, the liga-menta flava, and the interspinous and supraspinous ligaments. The anterior longitudinal ligament (ALL) is more extensive than the posterior longitudinal ligament (PLL). It extends from C1 to the sacrum and attaches to the anterior aspect of the vertebral bodies, mostly at the cranial and caudal portions of the vertebral bodies, and to the anterior aspect of the intervertebral discs. The PLL extends from the axis to the sacrum, is located within the spinal canal, and is attached to the posterior wall of the vertebral bodies as well as to the discs. In the lumbar region the PLL narrows and decreases in thickness. The ligamenta flava are located just anterior to the laminae and are attached to them. They tend to get thicker and stronger in the low thoracic and lumbar regions. Spinal degeneration exposes the liga-menta flava to added stress, which causes them...

Figure 613

Initially patients present with acute neck or back pain, which is followed within hours or days by progressive neurological deficits. Within a period of up to three weeks, and usually over several days only, the patients develop the full-blown picture sensory changes including sensory level or paraesthesia and muscle paralysis or weakness. These can quickly evolve to complete paraplegia or quadriple-gia, depending on the cord region that is affected. The sphincters are commonly involved as well. The signs and symptoms are bilateral but are not necessarily symmetrical. The thoracic cord is the area most frequently affected. In the initial stages the physical examination will detect lower motor neuron findings, such as areflexia and hypotonia. Severe atrophy of the involved muscles develops within days. The diagnosis is established by excluding other known causes of myelopathy such as multiple sclerosis, anterior spinal artery infarction, infectious myelitis, cord tumors, and vascular...


Meningioma is a slow-growing benign tumor commonly found in females. The most common location for spinal meningiomas is the thoracic spine. Less frequently these tumors may be detected in the cervical region. The tumors are often attached to the dura, the nerve roots, or spinal cord.

Synovial Cysts

Synovial cysts are most commonly found in the lumbar spine, mostly at the L4-L5 level. They usually develop in patients with degenerative disc disease, facet arthropathy, and degenerative spinal stenosis. Quite frequently degenerative spondylolisthesis or facet joint instability is also found at the level of cyst formation. The latter findings, it is thought, support the notion that increased segmental motion plays a role in the pathogenesis of these cysts. Typically the cysts occupy the posterolateral aspect of the spinal canal, are adjacent to the facet joints, and are attached to the facet joint capsule. They contain serous or gelatinous fluid and measure up to two centimeters in diameter. The X-ray findings are those commensurate with age and spinal degeneration degenerative disc disease, facet arthropathy, degenerative spondylolisthesis, and spur formation. Spinal CT may detect the cyst when its wall has calcified or when its cavity contains gas or blood due to a hemorrhage. In...

Clinical Studies Indicate Ms Heterogeneity

In East Asians, MS severely and selectively affects the optic nerve and the spinal cord (opticospinal MS OS-MS). This form of MS has a higher age of onset, a higher female to male ratio, frequent relapse, and results in severe disability when compared with conventional MS. It rarely involves a secondary progressive course. MS in Africans has similar features to that in East Asians. Using spinal cord MRI, longitudinally extensive spinal cord lesions extending over several vertebral segments were shown to be relatively common in OS-MS (about 50 of all patients), but are extremely rare in the MS found commonly in Caucasian populations. Cerebrospinal fluid (CSF) in OS-MS shows an absence of oligoclonal IgG bands and marked pleocytosis with occasional CSF neutrophilia. In agreement with these CSF findings, spinal cord lesions extending into the white and gray matters show severe tissue destruction, with heavy macrophage and neutrophil infiltrations in addition to many lymphocytes. These...

Central chemoreceptors

Central chemoreceptors (through the cerebrospinal fluid and cerebral blood vessels) play a major role in the regulation of breathing through the CO 2 pressure (PCO2) and or pH. An increase in PaCO2 immediately stimulates ventilation. However, if an abnormal level of PCO2 is maintained over several days, the pH of the cerebrospinal fluid returns to normal (compensatory bicarbonate shift). Thus changes in arterial CO 2 have a very potent acute effect on respiratory control, but only weak chronic effects after adaptation. Compensatory changes in cerebrospinal fluid bicarbonate and restoration of cerebrospinal fluid pH are important in chronic respiratory or metabolic acid-base imbalances (e.g. in patients with chronic obstructive pulmonary disease (COPD)).

Investigation of the patient in coma

In general the role of the investigation in the patient in coma is to help establish the aetiology of the coma and will vary from simple blood tests through more complex blood tests, examination of the cerebrospinal fluid, electrophysiological tests, and imaging. Although the EEG has shown hierarchical value in the assessment of depth of coma and has been used, to an extent, to identify the prognosis in coma,21,22 its major role is in identifying patients who are in a subclinical status epilepticus or who have complex partial seizures, because this will significantly alter their management.23 It may also be useful in distinguishing between feigned or psychiatric coma, in which it will be normal, and genuine cerebral disease, when it shows diffuse abnormalities, or to help identify a focal lesion. The prognostic value of the EEG is probably not as great as that obtained from careful observation of clinical signs,21 though there are suggestions that a combination of clinical...

The Blood Brain Barrier

The existence of a functional barrier between the blood and the brain was first demonstrated by Paul Ehrlich at the beginning of the 20th century. He observed that, when injected into the circulation, dyes like methylene blue stained the parenchyma of most organs of the body but not the brain. Injection of dyes into the cerebrospinal fluid, however, led to a staining of the brain, but not the body. These experiments were the first demonstration that a barrier between the blood and the brain exists and that this barrier blocks all free transport, regardless of the direction from which the barrier is approached by the substance. In contrast to the common brain parenchyma, these structures are equipped with leaky fenestrated capillaries, which allow the transfer of substances through the endothelium, and a tight junction between the covering ependymal cells blocks free passage into the cerebro-spinal fluid.

Clinical Evolution and Diagnosis of Alzheimers Disease a Synopsis

There are a number of instruments to diagnose Alzheimer's and assess the deterioration of memory, cognitive functions, and the patient's ability to cope with the challenges of daily living of suspected and clinically diagnosed Alzheimer's patient (see the chapter by Gauthier in this book). Currently, the diagnosis of AD is essentially made by clinical examination. There are not, as yet, universally accepted biological tests for an unequivocal diagnoses of the disease, although the presence of Ap peptides and tau (phosphorylate unphosphorylated) in plasma and the cerebrospinal fluid has been proposed and investigated in some centers. These tools are not yet widely available and have not been shown to be of unequivocal diagnostic value (Andreasen & Blennow, 2005 Galasko, 2005 Golde, Eckman, & Younkin, 2000). Considerable effort has been made to establish imaging protocols to determine the loss of brain matter and expansion of ventricles, as well as for the application of tracer...

Magnetic Resonance Imaging MRI

MRI scans (sagittal view) of the brain at around the level of the eye produced with different sequences to emphasize different tissue type and detail. A. High-resolution T1-weighted image shows excellent differentiation between grey and white matter. B. Low resolution T1-weighted image shows less of the detail. C. Magnetic Resonance Angiography (MRA) image shows major blood vessels and spaces with cerebrospinal fluid. D. Gradient echo echoplanar image acquired within a single shot and high speed in a functional MRI study. Note the difference in resolution between the structural MRI scans (A-C) and the functional MRI image (D). Figure 2. MRI scans (sagittal view) of the brain at around the level of the eye produced with different sequences to emphasize different tissue type and detail. A. High-resolution T1-weighted image shows excellent differentiation between grey and white matter. B. Low resolution T1-weighted image shows less of the detail. C. Magnetic Resonance...

How Is Multiple Sclerosis Diagnosed

None of the symptoms described so far occurs only in MS. Strokes, tumors, or infections can cause the same disabilities when they affect the same areas of the brain and spinal cord. Therefore, the diagnosis of MS requires the exclusion of other neurologic diseases. Diagnosing MS was a greater problem in the past, before physicians could produce sophisticated images of the brain and spinal cord and test other aspects of neurologic function. In the past, the diagnosis of MS relied primarily on a patient's medical history and a physical examination. Criteria for the diagnosis required at least two verified neurologic attacks, separated in time, and caused by damage in at least two different areas of the CNS. These criteria reflected the natural history of relapsing forms of MS. Progressive MS could be diagnosed, in the absence of another known neurologic condition, after a progressive worsening of neurologic symptoms over a six-month period. These criteria have been modified in light of...

What Are The Tests For Multiple Sclerosis

Magnetic Resonance Imaging (MRI) The most revolutionary advance in diagnosis of MS, as well as other diseases of the CNS, is imaging the brain and spinal cord by magnetic resonance. The MRI has revolu Evoked potentials are useful additions to other tests, particularly the MRI when the brain scan is normal. Although MRI scanning of the brain is very sensitive in detecting MS plaques, the technique is less precise in the spinal cord or optic nerve because they are smaller areas. visual evoked potentials may be particularly helpful when demyelination in the optic nerve is not yet sufficient to cause visual complaints by individuals. Cerebrospinal Fluid Examination Cerebrospinal fluid surrounds the brain and spinal cord and often reflects disease conditions in the CNS. in MS, certain abnormalities in the spinal fluid reflect the inflammatory nature of the disease. These abnormal In MS, the number of white blood cells in the spinal fluid may be mildly elevated, but a more characteristic...

Is patient breathing spontaneously What are the vital signs

Rapid evaluation and support of airway, breathing, and circulation (ABCs) are the initial management priorities. All patients should receive 100 oxygen via face mask. Comatose patients who are apneic or have lost their protective airway reflexes require assisted ventilation with a bag-valve-mask device or endotracheal intubation. If head injury is suspected, immediately immobilize the cervical spine using in-line manual stabilization or placement of a cervical spine collar. Spine immobilization must then be maintained during airway management and endotracheal intubation. Patients in shock require rapid IV access, IV fluids, and possibly inotropic support after airway and breathing are controlled.

Direct Measures of Neuronal Output

The EEG is biased to record mainly the activity of neurons that are located in the smooth surface, or gyri, of the cerebral cortex. The EEG, as recorded from the scalp, is measured using specialised amplifiers as it is of the order of around one tenthousandth of a volt (100 i Volts). Unfortunately, the neuronal activity that is picked up in the form of electrical signals on the scalp is attenuated, distorted and 'smeared' by the fluid bathing the brain (the cerebrospinal fluid, or CSF), the skull and the scalp, so that the exact source of activity can be difficult to determine (Allison, Wood & McCarthy 1986). Recordings made direct from the surface of the brain are usually of the order of around one thousandth of a volt and are used only in specialised neurosurgical applications, most typically epilepsy surgery.

Emergency Neuroanesthesia

Neurosurgical patients who require emergency anesthetic intervention fall into two groups. There are those who present with, or who have suffered an acute deterioration of, a condition of the brain or spinal cord. These patients may have compromised ventilation or other system failure as a consequence of their primary disease. They have the potential for aspiration of stomach contents if they have lost protective airway reflexes or if they are anesthetized without specific measures to prevent regurgitation. They may be hemodynamically unstable because of dehydration, sepsis or interference with autonomic reflexes. They may have specific effects of a disease process that affects a number of organ systems (e.g. rheumatoid disease, metastatic carcinoma). The other group of neurosurgical patients are victims of trauma in whom neurological damage may be only one of a number of life- or limb-threatening conditions. In these patients there may be several injuries that compete for...

Tickborne encephalitis virus

As methods of diagnosis of the disease have improved, involving testing of sera or cerebrospinal fluid for the presence of TBE-specific IgM and IgG antibodies using commercially available kits, the extent of the public health problem posed by TBE has been recognized, with 10000-12000 hospitalized cases annually. Control of tick populations was attempted in Russia but not found to be effective, and since the 1970s, inactivated vaccines have been developed and are available for human use in Europe

Diffusionweighted imaging

The basic idea is that protons move within and between cells by random motion. Typically, a proton may travel around 20 pm in 100 ms by this Brownian motion or diffusion. The rate of diffusion will be greatest for protons that are moving freely through the cerebrospinal fluid and less for protons constrained by physical barriers such as myelinated cell membranes. The rate of diffusion affects the spin-spin relaxation time, with rapidly diffusing protons tending to relax more quickly. To acquire images that are weighted by differences in diffusion, two extra gradients are briefly applied during a spin echo sequence. (1)

Treatment of respiratory alkalosis

Elisaf, M., Theodorou, J., Pappas, H., and Siamopoulos, K.C. (1993). Acid-base and electrolyte abnormalities in febrile patients with bactaeremia. European Journal of Medicine, 2, 404-7. Javaheri, S., Corbett, W., Wagner, K., and Adams, J.M. (1994). Quantitative cerebrospinal fluid acid-base balance in acute respiratory alkalosis. American Journal of Respiratory and Critical Care

Intracranial Pressure

The skull and vertebral canal form a rigid covering for the brain, spinal cord, cerebrospinal fluid (CSF) and blood. All of these intracranial compartments are non-compressible, thus the intracranial volume is essentially constant (the Monro-Kellie doctrine ). Volume expansion of any compartment can only occur at the expense of compression of other compartments. The only buffering capacity is secondary to compression of the venous sinuses and the caudal displacement of CSF to the lumbosacral axis. Once this is exhausted, any tendency to increase volume in any of the compartments (as in an expanding mass) will result in an increased intracranial pressure (ICP).

Brain swelling and raised intracranial pressure

The consequence of raised intracranial pressure is the development of pressure gradients across the midline, between supratentorial and infratentorial compartments, and between the cranial and spinal compartments across the foramen magnum. In 1965 Langfitt showed how raised supratentorial pressure produces a rise in infratentorial pressure which subsequently plateaus and falls as the cisterna ambiens becomes blocked by tentorial herniation. The brain is shifted away from the region of higher pressure, so midline structures are pushed laterally, causing the cingulate gyrus to herniate under the fixed free edge of the falx. This distorts the pericallosal arteries, and may occlude the foramen of Munro. The cerebrospinal fluid (CSF) drainage of the contralateral ventricle is obstructed, so the ventricle dilates the ipsilateral ventricle may become compressed, giving characteristic features suggesting raised intracranial pressure (ICP) on cross-sectional imaging. Further increases in ICP...

Origins And Lineages Of Oligodendrocytes

All macroglia and neurons arise from precursor cells in the ventricular layer of the embryonic nervous system. The ventricular layer is a pseudostratified layer of cells that surrounds the ventricles and extends from the rostral tips of the lateral ventricles to the caudal end of the spinal canal. The subventricular layer immediately adjacent to the ventricular layer is also, especially in adults, a source of glial precursor cells. In adults, the subventricular layer is absent or thinned except at the dorsolateral boundary of the lateral ventricles, where it remains a highly prolif-erative zone. The origin of glia may be defined as the location or region along the neuraxis wherein glial precursors are generated. It is well established that glial precursor cells proliferate in the ventricular layer, migrate laterally from the ventricular layer into the surrounding neuropil, and continue to proliferate and or differentiate (see reviews in 32-33). However, only recently has it been...

Neuroendoscopic Procedures and Applications

The operative interventions in which neuroen-doscopy can play a definitive or supportive role can be classified by site and disease into those within the internal cerebrospinal fluid spaces -principally the cerebral ventricles, those within the brain parenchyma, and those outside the brain in the subarachnoid or subdural spaces or extracranial skull base (Table 6.3).

Immediate Questions

Is there a history or suspicion of injury to head or neck If injury is present or suspected, immobilize cervical spine and perform the jaw-thrust maneuver to open the airway. If airway remains obstructed, patient should be repositioned and maneuvers for relieving airway obstruction attempted.

Raised Intracranial Pressure

The skull is basically a rigid structure. Since its contents - brain, blood and cerebrospinal fluid (CSF) - are incompressible, an increase in one constituent or an expanding mass within the skull results in an increase in intracranial pressure (ICP) - the 'Monro-Kellie doctrine'.

Preventing AD and future treatments

A number of factors such as non-steroidal anti-inflammatory drugs, hormone replacement therapy, and the antioxidant vitamin E, might be of some use in strategies to prevent AD. Prevention could be primary before any signs of the disease or secondary after some manifestation of the process. Primary preventive measures would have to be directed at either the entire population or to groups at risk (identified by family history or genotype, for example), and therefore would have to be entirely benign and almost cost-free to be acceptable. Secondary prevention, possibly in those with memory impairments not amounting to dementia (minimal cognitive impairment), is a more realistic prospect rendering the determination of the very earliest signs of disease or evidence of a prodromal state a high priority. A biological marker for AD would have immense utility in both clinical practice and in clinical trials. Markers suggested have included platelet membrane fluidity and measurement of amyloid,...

Aetiology and pathogenesis

With dementia 9,J. ,2,0) Nigrostriatal dopamine decrease and reduction of serotonin receptors and substance P levels in substantia nigra and frontal cortex have been found in Pick's disease 5 54 Cerebrospinal fluid analysis has shown reduced somatostatin levels both in FTD and Alzheimer's disease, while delta-sleep-inducing peptide was significantly reduced in Alzheimer's disease but not in FTD, and the corticotrophin-releasing factor was significantly reduced in FTD but not in Alzheimer's disease.'55) Pathological tau proteins have been found in the frontotemporal cortex in FTD despite the absence of neurofibrillary lesions. (56)

Principles And Practice Of Imageguided Neurosurgery

Image guidance is even more valuable in pedicle screw insertion into the thoracic spine 27 . Compared with its lumbar counterpart, the thoracic pedicle is smaller, has a more complex 3D morphology and has a variable cross-section in the coronal plane. There is a high degree of variability in the diameter, shape and angle of the thoracic pedicle. Moreover, its proximity to the pleura, nerve roots and the relatively fixed spinal cord means that inappropriate insertion is less forgiving. From clinical and cadaveric studies, up to 25 of thoracic pedicle screws were found to violate the pedicular cortex when perioperative fluoroscopy alone was used. In a recent study using post-operative CT evaluation, only 5 out of 266 screws inserted at all levels of the thoracic spine in 65 patients showed a structurally significant (defined as more than 2 mm) inadvertent violation of the pedicular cortex. These tended to cluster in the mid-thoracic spine. The majority of these misplacements occurred in...

Overview Of Bloodocular Barrier Transport Biology

The blood-brain barrier (BBB), blood-cerebrospinal fluid barrier (BCSFB),and blood-ocular barrier (BOB) share similarities in microscopic structure and function (4-7,22,62). Structurally, the barriers consist of tight endothelial junctions. Functionally, the barriers regulate transfer of sugars, amino acids, organic acids, and ions according to molecular size, protein-binding affinity, lipophilicity, and degree of ionization at the relevant anatomical compartment pH (40,53,59,66-68,80,97). Furthermore, active transport systems and enzymatic degradation contribute to this barrier and regulate the effective penetration of a variety of chemotherapeutic compounds (9,22,53,86). Recent studies have shown that the pharmacokinetics of several antimicrobial agents are similar in both the eye and cerebrospinal fluid (CSF) following systemic drug administration (48,53,61). This observation may have practical as well as theoretical implications since, in the absence of data for site-specific...

Factors that may Modulate Conduction in Demyelinated Axons

The low safety factor of demyelinated axons means that conduction along the axons is not only particularly sensitive to changes in temperature but also vulnerable to chemical factors that may impair conduction. For example, conduction may be perturbed if an imbalance occurs in the normal composition of the extracellular fluid bathing axons, such as may arise from impairments in the blood-brain barrier. It is suspected that this imbalance can include the appearance of factors that directly affect axonal physiology. Historically, there has been much interest in serum-derived neuroelectric blocking factors that were found to impair different types of neurophysiological function (reviewed in Smith, 1994), but the identity of the factors remained elusive, results were inconsistent, and interest in them waned. More recently, however, interest in the topic has been revived by evidence suggesting that factors associated with inflammation may be able to produce brief exacerbations in patients...