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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6042_Библиотеки_им_академика_М_И_Перельмана.pdf
113
© Springer International Publishing Switzerland 2016
I.M. Eltorai, Rare Diseases and Syndromes of the Spinal Cord,
DOI 10.1007/978-3-319-45147-3_36
3 6
Myelopathy due to Acupuncture
36.1 Definition
Acupuncture is an ancient oriental modality of healing, which stood the test of time
in the orient and that contributed to its survival. In the last several decades it has
been introduced to the West and like other modalities of treatment it has been scrutinized scientifi cally and technologically. Like all therapeutic measures it is not free
from complications.
36.2 Incidence and Etiology
Ernest and White ( 1997 ) published the adverse reaction after acupuncture after thor-
ough review. These are summarized as follows:
36.2.1 Infection
Infection due to lack of sterility and the reuse of the needles. Transmitted diseases reported
include: hepatitis B or C, H.I.V., subacute bacterial endocarditis. Hepatitis was seen more
in endemic areas or in asymptomatic patients or carriers especially after tattooing or blood
transfusion. Bacterial infections resolved and were asymptomatic. Septicemias due to
staphylococous aureus infection were also reported and resolved. Local infections, as a
complication of acupuncture included cellulitis, and abscesses. Distant infection, e.g. in
bilateral lumbar paraspinal acupuncture, bilateral psoas abscesses developed. Epidural
infection will be discussed in detail.
Abstracted from numerous sources please see references
114
36.2.2 Trauma
1. local tissue injury
2. pneumothorax unilateral or bilateral
3. puncture of the heart through a formen in the sternum (10 % in males and 4 % in
females leading to fatal cardiac tamponade
4. abdominal injuries were reported to the kidney, intestine, and urinary bladder
5. peripheral nerve injuries e.g. the median in the carpal tunnel and the lateral pop-
liteal (fi bula) behind the knee
6. vascular injuries e.g. arterial puncture leads to thromobosis or false aneurysm,
injuries to the vein leads to iatrogenic venous thrombosis
7. injuries to the spinal cord will be discussed separately
36.2.3 Spinal Cord Injuries Due to Acupuncture
According to Perker et al., 10 cases of injuries to the spinal cord or the spinal nerve
roots. In four cases migration of the needle fragments were responsible for the
lesions and six were caused by direct injury. The level of injury C1-C2 in four cases,
C6 in one case, L4-L5 in two cases, S1 in one case. Focal neurological signs up to
paraplegia were reported. Spinal epidural hematoma and subarachnoid hemorrhage
was reported (Keane et al. 1993 ). Spinal epidural hematoma leading to paraplegia
(Chen et al. 2006 ). Needle migration to the cord or even the medulla.
36.2.4 Spinal Cord Infection Due to Acupuncture
A long needle may penetrate into the spinal canal and may carry bacteria from the
skin especially staphylococcus aureus. In some cases the needle penetrated the
colon and rectum, resulting in bacteremia and septicemia especially in those with
low immunity, e.g. diabetics. In the lumbar region paravertebral acupuncture may
lead to iliopsoas abscess and vertebral osteomyelitis, diskitis (Bang and Lim
2006 ).
Epidural abscess may also develop leading to paraplegia or tetraplegia (Yazawa
et al. 1998 ). Abdominal symptoms may be the source of spinal infection (Studd
et al.) or retroperitoneal suppuration may be the source (Cho et al.).
36.3 Pathology
The spinal cord may be injured in different ways, just as seen in the myelopathy due
to cervical manipulation entry
1. Injury causing contusion, edema, or hematoma, partial Brown Séquard syn-
drome or subtotal injury
2. Epidural abscess
36 Myelopathy due to Acupuncture
115
Epidural abscess causes cord compression and if not treated early enough isch-
emia will cause permanent pathological changes.
36.4 Clinical Picture
In cases of epidural hematoma will lead to cord compression immediate or late. In
subarachnoid, hemorrhage the picture is that of headache, painful neck stiffness,
nausea, and vomiting (Keane et al.
1993 ). In infection, epidural abscess starts by
back pains. If the epidural abscess is lumbar, neck pain and stiffness; if it is in the
cervicothoracic region fever may be low or high grade, chills may be present, and
stiffness of the neck in high abscesses. If left untreated weakness of the extremities
inability to walk, then paraplegia; in cervical cases tetraplegia. In high lesions there
may be shortness of breath, which may require ventilator assistance. Septicemia
may lead to septic shock and paresis may be late in diagnosis.
36.5 Diagnosis
Diagnosis is based on:
1. History of acupuncture
2. Physical examination for needle puncture sites especially with signs of infection,
spinal stiffness, tenderness, edema in paraspinal soft tissue
3. Neurological signs: sensory, motor defi cits, increased refl exes, loss of tempera-
ture sensation, proproception, touch
4. Lumbar puncture: granulocyte pelocytosis and increased proteins in infective
cases. Culture may be positive for cocci and/or bacilli. In hemorrhagic cases
anthochromatisis, high number of red cells, and also white cells.
5. Radiography: may show osteomyelitic changes
6. CT scan: may show a block to the cord
7. MRI: in abscess an epidural mass with an increased high intensity on T2-weighted
images and the periphery of the mass is low intensity on T1-weighted images.
The spinal cord may be swollen or displaced and may be delineated by peripheral enhancement with gadolinium. In epidural hematoma, MRI shows hyperintensive mass in the epidural space with compression and/or displacement of the
cord
36.6 Management
Epidural infection should be treated very early by triple antibiotics and may abort the
infection. In rare cases may reverse neurological defi cit. Short course of intravenous
methylprednisolone sodium will help resolve the infl ammatory edema. MRI follow
up is important. If the cord remains compressed surgical drainage is indicated.
36.6 Management
116
For subarachnoid hemorrhage conservative treatment is adopted. For the epidural
hematoma compression of the cord leading to paraplegia intravenous methylprednisolone sodium with large bolus 30 mg/kg body weight followed by 1 mg/kg/h
(Chen et al. (Chen et al. 2006 )). Decompressive laminectomy and evacuation of the
hematoma with thorough hemostasis may help neurological recovery.
36.7 Prophylactic Management
Licensure of acupuncturists should be based on good anatomical knowledge, thorough theoretical education and application of the bylaws of the medical boards to
acupuncturists whether physicians or technicians. Strict asepsis is required.
Publication and education of complications however minor they may be. This is
essential as almost all complications are avoidable.
References
Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol. 2007;28(4):714–5.
Bang MS, Lim SH. Paraplegia caused by spinal infection after acupuncture. Spinal Cord.
2006;44(4):258–9.
Chen JC, Chen Y, Lin SM, Yang HJ, Su CF, Tseng SH. Acute spinal epidural hematoma after
acupuncture. J Trauma. 2006;60(2):414–6.
Ernst E, White A. Life-threatening adverse reactions after acupuncture? A systematic review. Pain.
1997;71(2):123–6.
Filshie J. Safety aspects of acupuncture in palliative care. Acupunct Med. 2001;19(2):117–22.
Keane JR, Ahmadi J, Gruen P. Spinal epidural hematoma with subarachnoid hemorrhage caused
by acupuncture. AJNR Am J Neuroradiol. 1993;14(2):365–6.
Yazawa S, Ohi T, Sugimoto S, Satoh S, Matsukura S. Cervical spinal epidural abscess following
acupuncture: successful treatment with antibiotics. Intern Med. 1998;37(2):161–5.
36 Myelopathy due to Acupuncture
117
© Springer International Publishing Switzerland 2016
I.M. Eltorai, Rare Diseases and Syndromes of the Spinal Cord,
DOI 10.1007/978-3-319-45147-3_37
3 7
Bronchial Artery Embolization (BAE) for Severe Hemoptysis
37.1 Definition
This is an acute paraplegia due to infarction of the spinal cord due to embolization
of the anterior spinal artery (ASA) during embolization of the bronchial artery for
severe recurrent hemoptysis.
37.2 Incidence
The complication of BAE occurs in 1.4–6.5 % of various reports.
37.3 Etiology
• Inadvertent embolization of the artery of Adamkiewicz
• Abnormal migration of the gel foam used for embolization
• Stagnation of spinal artery circulation
• Prolonged hypotension
• Contributory factors are
– Atherosclerosis
– Polycythemia
– Severe kyphoscoliosis, which changes the anatomical course of the vessels
– Arteriovenous malformation (AVM)
– Hypercoagulability with malignancy Hypercoagulability
– The presence of an epidural hematoma
– Bronchopulmonary dilatation or Rasmussen’s aneurysm
Abstracted and reported by Lekhra and Dosi ( 2013 ).
118
37.4 Pathology
Inadvertent embolization of the ASA will lead to acute ischemia of the spinal cord
with consequent infarction, resulting in paraplegia (ASA syndrome) i.e. loss of
motor functions below the level of injury with intact or partially impaired sensory
functions. The substances used for embolization are:
• Gel foam
• PVA (polyvinyl alcohol)
• Tris-acryl gelatin microspheres
• thrombin
BAE is approached through the descending aorta via the femoral or subclavian
artery through angiography.
37.5 Case Report
A 56-year-old man presenting with expectorant streaked with blood for 5 months.
He received medical treatment, viz. styptics, antibiotics for tuberculosis, antiinfl ammatory drugs, and hematinics. Six months later he developed severe hemoptysis. CT scan showed right upper lobe fi brocavitory with a possible Rasmussen’s
aneurysm. The bronchial tree was normal on bronchoscopy. Microbiology showed
methicillin sensitive streptococcus pneumonia for which he received antibiotics.
The bronchial artery leading to the cavity was embolized. A few hours post-op he
developed numbness and weakness of the lower extremities. Twenty-four hour
hours later he developed full paraplegia, 50 % sensory loss, deep tendon refl ex
(DTR) absent. Differential diagnosis included: epidural hematoma, epidural
abscess, and spinal cord infarction. MRI revealed ASA syndrome. He was put on
full rehabilitation program. Three months later he recovered reasonably well and
hemoptysis did not recur.
Reference
Lekhra OP, Dosi R. Bronchial artery embolization – an unusual cause of paraplegia and review of
literature. IOSR J Dent Med Sci (IOSR-JDMS). 2013;6(5):11–4.
37 Bronchial Artery Embolization (BAE) for Severe Hemoptysis
119
© Springer International Publishing Switzerland 2016
I.M. Eltorai, Rare Diseases and Syndromes of the Spinal Cord,
DOI 10.1007/978-3-319-45147-3_38
3 8
Spinal Cord Infarction Following Central Line Insertion
38.1 Definition
This is a condition of spinal cord infarction resulting in tetraplegia after central line
insertion in acute dialysis patient.
38.2 Incidence
Unique case by Williams et al.
38.3 Etiology
Central line insertion for dialysis is liable to complications presented by the authors:
The internal jugular vein is the fi rst choice for catheter insertion in acute dialysis setting.
There is 6.2 % rate of complications in this setting.
Some of the complications are pneumothorax, hemothorax, brachial plexus
injury, thoracic duct damage, air embolism, laryngeal hematoma, cardiac tamponade, ruptured superior thyroid artery; and the authors added spinal cord infarction.
38.4 Pathology
The patient reported, was on peritoneal dialysis complicated by peritonitis. Acute
hemodialysis was planned by insertion of double lumen dialysis catheter in the left
internal jugular vein. He developed a hemothorax, which was aspirated and a
A unique case reported by Williams et al. ( 2003 )
120
femoral hemodialysis was conducted. Recurrence of the left hemothorax took place
with marked hypotension, which is common in dialysis patients. The mediastinal
shift and the hypotension lead to spinal cord infarction in the distribution to the
anterior spinal artery.
38.5 Clinical Picture
With the extensive left hemothorax resulting from the internal subclavian perforators and mediastinal shift and the severe hypotension, the patient developed tetraplegia with a sensory level at T4. Thoracotomy was done to evacuate the blood and
to repair the leaking left subclavian vein.
38.6 Diagnosis
Diagnosis is based on the following criteria:
1. X-rays: massive left hemothorax and shift of the mediastinum
2. MRI: below T4 there was increased signal within the cord ill-defi ned on
T2-weighted images. The lower cord was swollen and occupied almost all of the
spinal canal
38.7 Management
Dialysis was continued, but the paralysis was permanent.
Reference
Williams A, Little M, Gibbs J, Warwicker P, Farrington K. Spinal cord infarction following central-
line insertion. Ren Fail. 2003;25(2):327–9.
38 Spinal Cord Infarction Following Central Line Insertion
121
© Springer International Publishing Switzerland 2016
I.M. Eltorai, Rare Diseases and Syndromes of the Spinal Cord,
DOI 10.1007/978-3-319-45147-3_39
3 9
Chemical Myelopathy due to Cervical M y e l o g r a p h y
39.1 Definition
This is an iatrogenic condition secondary to intramedullary injection of a contrast
material during cervical myelography.
39.2 Incidence
Simon et al., collected 26 cases from the literature and added a case of their own.
39.3 Etiology
Cervical myelography is now replaced by MRI; however, there are a few cases in
which it may be indicated:
• Patients who are unable to undergo MRI
• Those whose pathology is inadequately demonstrated as to explain the patient’s
symptoms.
The procedure is risky due to the possible injection of contrast into the cord.
Abstracted from Simon et al. ( 2002 )
122
39.4 Pathology
There is spinal cord damage due to:
• Kinetic element depending on the injected amount and its pressure
• Neurotoxicity of the contrast
The injection of contrast, lohexol, through a lateral approach between C1-2 gives
an adequate dye load with a minimum contrast dose and it reduces the need to reposition of the patient during the procedure for contrast dispersion throughout the
subarachnoid space. But sill intramedullary injection is a risk leading to cord injury
although it may be reversed by methylpredinisolone.
39.5 Clinical Picture
During the procedure there is intense neck pain, which may radiate to the ipsilateral
side of the face, arm, or leg. Neurologic defi cit appears soon after the injection and
usually do not progress due to the discontinuing the injection instantly. With the use
of high does of predisolone there is resolution of neural defi cit, but these may persist
even after a small dose of contrast. It also depends on the type of contrast and the
location of the injection in the cord parenchyma. More persistent neural defi cit follows melizemide injection.
39.6 Diagnosis
Diagnosis is based on the following criteria:
1. History of cervical myelography with instant pain.
2. Neurological defi cit: sensory and motor with hyperrefl exia, Babinski’s sign,
Hoffman’s refl ex etc.
3. Post myelography CT scan and MRI show: intraparenchymal contrast and edema
of the spinal cord.
39.7 Management
High dose of methylpredinsolone IV or bolus of 30 mg/kg followed by 5.4 mgm/kg
IV per hour for 48 h. Neurological resolution may occur to a greater or lesser degree.
Some defi cits may persist as well as some physical signs. Oral prednisone may
continue for weeks with tapering. Rehabilitation is recommended for permanent
disability. MRI follow-up is recommended.
39 Chemical Myelopathy due to Cervical Myelography