Cerebrovascular accidents are a leading cause of morbidity and mortality in the United States. Many conditions exist which may mimic this disease process including seizures, migraines, metabolic derangements, infections, space-occupying lesions, neurodegenerative disorders, peripheral neuropathy, cervical myelopathy, syncope, other vascular disorders, and functional neurologic disorder. Timely diagnosis and treatment are important in order to preserve functional status in these patients. A 48-year-old male presented to the emergency department with a 28-hour history of worsening left sided numbness, tingling, weakness, and feeling off balance. The patient stated that for the past several months he had noticed these symptoms, but they suddenly became worse the day prior. He also described shooting pains down the left arm with certain movements of his neck. The patient denied any difficulty with speaking, understanding words, performing mental tasks, bowel or bladder incontinence, or right sided symptoms. Physical exam showed intact cranial nerves II-XII, 5/5 strength of upper and lower extremities on the right side, 4/5 strength of upper and lower extremities on the left side. Romberg test was normal, heel to shin and finger to nose were intact bilaterally. Foot drop was noted on the left side and placement of the foot on the ground was noted to be clumsy. Initial head CT in the emergency department showed a frontal lobe hypodensity and was without intracranial hemorrhage. Computed tomography angiography of the head and neck showed no large vessel thrombosis or stenosis. Echocardiography revealed normal chamber sizes, normal left ventricular ejection fraction, no patent foramen ovale, and no left atrial or left ventricular thrombus. Telemetry monitoring throughout the stay remained sinus rhythm. Magnetic resonance imaging of brain and cervical spine was performed showing multifocal acute infarcts of the right and left frontal lobes and severe cervical spondylosis at C4-C6 with spinal cord edema in T2 sequences slightly below that level. The patient subsequently underwent a cervical spine decompression for the spinal cord compression during the hospital stay. Due to the multifocal lesions noted on the brain MRI, a vasculitis workup was performed which returned negative for any abnormal test findings. The patient was also diagnosed with diabetes mellitus type 2 during the stay as he was found to have a glycosylated hemoglobin A1C of >12. He was initially hypertensive during hospitalization, but this resolved on its own after day three of the hospitalization so anti-hypertensives were not required. The patient was discharged home on high intensity statin therapy, dual oral hypoglycemic therapy for his diabetes mellitus, home physical therapy, and he was scheduled to start dual antiplatelet therapy seven days after cervical spine surgery. This dual antiplatelet therapy with clopidogrel and aspirin was to be continued for three weeks after which continuation with low dose aspirin was advised. As seen in this case, patients that present with a cerebrovascular accident should always be evaluated for other etiology behind his or her symptoms and having a low threshold for pursing other additional diagnoses is reasonable.

No description available.

Cervical myelopathy is the most common form of spinal cord injury in North America with roughly 19,000 new cases in the US every year. It results from chronic compression of the spinal cord by osteophytes, intervertebral disc herniation, and ossified ligaments. It commonly affects adults over the age of 50 years and causes upper extremity numbness, loss of hand dexterity, gait disturbances, and decreased proprioception. Recent studies imaging studies have shown this injury is highly dependent on the dynamic motion of the spine, often worsening in extreme flexion and extension. Surgical intervention is the accepted mode of treatment with the aim of decompressing the spinal canal and stabilizing the spine. However, 25% of patients have reoccurrence of symptoms indicating that surgical treatments may not be adequately addressing the injury. A main reason for this is little data has been reported on the spinal cord mechanics during cervical spinal motion in either healthy or cervical myelopathy subjects. To address this, we utilized MR imaging and finite element modeling to investigate spinal cord mechanics. As far as we know, we are the first group to obtain in vivo 3 dimensional spinal cord displacement and strain data from human subjects and the first to develop a C2 to T1 FE model of the healthy and cervical myelopathic spine and spinal cord. Utilizing high resolution 3T MR imaging in neutral, flexion, and extension positions we were able to obtain spinal cord displacement and strain fields from both healthy subjects and cervical myelopathy subjects before and after surgical intervention. In healthy subjects, flexion motion of the spine causes the spinal cord to move superiorly and in extension the spinal cord moves inferiorly. During extension, localizations of high principal strain can be seen in healthy subjects at areas of bony impingement and dural buckling. In both flexion and extension, cervical myelopathy subjects exhibited very little spinal cord displacement due to spinal cord compression. Principal strains during flexion and extension were greater in cervical myelopathy patients than healthy patients, specifically at the C4-6 vertebral levels. Surgical treatments for cervical myelopathy did restore spinal cord motion however, not in the same pattern or direction as healthy subjects. Additionally principal strains of the spinal cord were not reduced after surgical intervention. This indicates that surgical interventions are not adequately addressing the altered mechanics of the spinal cord during cervical myelopathy. To determine the how common surgical techniques for cervical myelopathy affect spinal cord mechanics, a FE model of the cervical spine and spinal cord was developed. The spinal cord motion was validated against MR imaging data obtained from normal subjects. Once validated, the model was used to develop a FE model of cervical myelopathy and surgical interventions. The native FE model predicted spinal cord motion well and replicated bony spinal cord impingement and dural buckling seen in healthy subjects. The FE model of cervical myelopathy also replicated spinal cord motion well as compared to MR imaging data of cervical myelopathy. Principal strains obtained from the healthy and cervical myelopathy FE models were similar in flexion however in extension, principal strains were higher at the C3, C6 and C7 levels. This is different than the patterns exhibited in the MR imaging and is most likely due to the percent of spinal cord compression induced in the FE model. Three, C4 to C7 surgical interventions were introduced to the model: anterior discectomy and fusion, anterior discectomy and fusion with laminectomy, and double door laminoplasty. In flexion, all surgical treatments doubled spinal cord principal strains at the C3 level and minimally reduced tensile strain at C4. The majority of strain reduction occurred at C5-7. In extension, all surgical techniques increased principal strains at the C3 and C4 levels. Little or no reduction in principal strains was seen at the C5 and C7 levels. All surgical techniques reduced principal strains at the C6 level. Of the surgical techniques, ACDF tended to reduce spinal cord principal strains the least in both flexion and extension and tended to induce the highest von Mises stresses. Combining the data obtained from MR imaging and FE modeling we can see that cervical myelopathy alters spinal cord mechanics by limiting spinal cord motion and increasing spinal cord strain. Additionally, current surgical techniques are not addressing the change in spinal cord mechanics effectively. Specifically after surgery, and especially with ACDF, spinal cord displacements and strains are being increased and transferred to different sections of the spinal cord. This indicates not only the need and importance of further research in spinal cord mechanics but also the need to improve treatments for cervical myelopathy which adequately restore the spinal cord mechanics.

No description available.

Based on contemporary theoretical knowledge in this prospective study we outline the relationship between a chosen surgical approach (anterior or posterior approach) as it relates to the localization of spinal cord lesion (anterior or posterior spinal pathways) assessed by the use of evoked potentials (SEP, MEP) and the effect of this approach on the postoperative state of patients with cervical spondylotic myelopathy. Furthermore we evaluate clinical outcome of these patients according to several aspects of their MRI and X-ray findings. The study, from 2006 to 2010, comprised 65 patients with clinical signs of cervical myelopathy. These patients had been indicated for surgery, which subsequently was performed by using either the front (anterior - a) or back (posterior - p) approach. The patients were assessed using Nurick and mJOA scores before surgery, then at 12 months, and finally 24 months after surgery. In addition, they were preoperatively examined with a battery of evoked potentials (EP) - somatosensory evoked potential (SEP) and motor evoked potential (MEP) tests. Based on EP, principal spinal cord disability was determined: A - anterior (maximum changes in MEP), P - posterior - maximum change in SEP). The entire group was, on the basis of EP partitioning and the surgical approach used, divided...

Based on contemporary theoretical knowledge in this prospective study we outline the relationship between a chosen surgical approach (anterior or posterior approach) as it relates to the localization of spinal cord lesion (anterior or posterior spinal pathways) assessed by the use of evoked potentials (SEP, MEP) and the effect of this approach on the postoperative state of patients with cervical spondylotic myelopathy. Furthermore we evaluate clinical outcome of these patients according to several aspects of their MRI and X-ray findings. The study, from 2006 to 2010, comprised 65 patients with clinical signs of cervical myelopathy. These patients had been indicated for surgery, which subsequently was performed by using either the front (anterior - a) or back (posterior - p) approach. The patients were assessed using Nurick and mJOA scores before surgery, then at 12 months, and finally 24 months after surgery. In addition, they were preoperatively examined with a battery of evoked potentials (EP) - somatosensory evoked potential (SEP) and motor evoked potential (MEP) tests. Based on EP, principal spinal cord disability was determined: A - anterior (maximum changes in MEP), P - posterior - maximum change in SEP). The entire group was, on the basis of EP partitioning and the surgical approach used, divided...