Faculty Bibliography

Objective: To describe a spinal cord infarct masquerading as brown-sequard syndrome. Background: Spinal cord infarcts have historically been difficult to diagnose both clinically and radio-graphically. For appropriate treatment, infarcts must be differentiated early from infectious or demyelinating etiologies. Improved MRI resolution and pattern recognition can separate these entities, even in atypical cases. Design/Methods: Clinical case, diagnostics, imaging and literature review. Results: A 64-year-old woman with history of uncontrolled type II diabetes presented with urinary retention, left lower extremity (LLE) pain and progressive LLE weakness over 10 hours. Upon arrival, exam showed isolated LLE plegia, decreased pain and temperature sensation in the right lower extremity, and a T5 sensory level. Reflexes were symmetric except for a left Babinski sign. Spinal cord MRI revealed asymmetric abnormal signal in the upper thoracic cord with minimal edema and no enhancement. Diffusion sequencing was consistent with infarct. CT angiogram of the neck showed no dissection or large-vessel disease. Within 36 hours of hospitalization patient developed acute hypoxemia and was found to have bilateral saddle pulmonary emboli leading to cardiac arrest. She was resuscitated, received thrombolytics and underwent surgical thrombectomy. It was theorized that brief immobility on background of hypercoagulable state caused a large embolic burden. Neurologic exam remained stable despite her complicated course. She was treated with high-dose statin and anticoagulation. Hypercoagulability panel, including genetic and antiphospholipid antibody testing, was negative. Conclusions: Clinical symptoms of sub-acute LLE plegia and brown-sequard-like sensory disturbance initially forced us to consider infectious and inflammatory etiologies. Although spinal anatomy is notoriously variable, hemi-cord localization was still difficult to explain with an anterior spinal artery infarct. Lack of enhancement, minimal expansion and diffusion restriction on MRI are useful in differentiating infarct from demyelination. With this knowledge and patient's propensity to clot, we felt confident calling this an atypical spinal cord infarct explained by unique collateral circulation

Objetive: We report a unique case of a 60-year-old man with ictal whistling after being injured in a serious motorcycle accident. Methods: Clinical presentation, neurologic examination, neuroimaging, video-EEG (electroencephalogram) analysis, and therapeutic options were defined. A review of relevant literature was also performed. Case summary: Our patient experienced frequent complex partial seizures after the head trauma. His neurologic examination was nonfocal. Magnetic resonance imaging of the brain did not reveal any lesion. Video-EEG captured 2 stereotyped complex partial seizures with a rare ictal vocalization, ictal whistling. The ictal onset showed poorly sustained diffuse bitemporal theta-delta rhythms, which made it difficult to determine lateralization from the scalp EEG but favored possible right hemispheric onsets. Conclusions: Ictal vocalizations are common in temporal lobe epilepsy, though ictal whistling has been reported in both frontal and temporal lobe cases. The very few reported cases show a strong male predominance. Clear lateralization at ictal onset was not possible in our patient, but peri-ictal and interictal discharges suggested possible right temporal lobe focus.

PURPOSE/OBJECTIVE:The purpose of this study was to test whether low-grade Lachman test (i.e. Grade 0-1+) and a negative pivot shift at 6-12 weeks post-ACL rupture in recreational alpine skiers can be used to predict good function and normal knee laxity in nonoperated patients at minimum 2 years after the injury. METHODS:Office registry was used to identify 63 recreational alpine skiers treated by the senior author within 6 weeks of a first-time ACL injury between 2003 and 2008. Of these, 34 had early ACL reconstruction but 29 patients were observed and re-evaluated. Office charts and MRI were reviewed. Inclusion criteria for this study were as follows: ACL rupture documented on MRI after the injury, and minimum 2-year follow-up. Exclusion criterion was contralateral knee ligament injury. Of the 29 patients treated nonoperatively, 17 had low-grade Lachman and negative pivot shift tests within 6-12 weeks after the injury and were recommended to continue follow-up without surgery. Of these 17 patients, 6 were lost to follow up, but 11 patients were recalled and evaluated at more than 2 years after the injury. They completed Marx and Tegner activity level and IKDC subjective scores, physical examination of the knee and KT-1000 anterior laxity assessment. RESULTS:Median age at injury was 43 years (range 29-58). Median follow-up was 42 months (range 30-68). Mean IKDC subjective score at latest follow-up was 91.6 ± 6.7. Median Tegner score was 6 (range 6-9) before the injury and 6 (range 4-6) at latest follow-up (p = n.s). Median Marx score was 6 (range 0-16) before the injury and 4 (range 0-12) at latest follow-up (p = 0.03). Ten patients had Lachman Grade 0-1+, and one had Lachman Grade 2+ at latest follow-up. KT-1000 showed mean side-to-side difference of 0.8 ± 1.6 mm, and less than 3 mm difference in the 10 patients with Lachman Grade 0-1+. CONCLUSION/CONCLUSIONS:Recreational alpine skiers who sustain ACL injury should be re-evaluated at 6-12 weeks after the injury rather than being operated acutely. If they have negative Lachman and pivot shift tests at that point, they can be treated without surgery since good outcome and normal knee anterior laxity at more than 2 years after the injury is expected. LEVEL OF EVIDENCE/METHODS:Case series, Level IV.

PURPOSE/OBJECTIVE:To describe clinical characteristics, surgical findings, and functional outcome after arthroscopic repair of a unique type of meniscocapsular separation. METHODS:We retrospectively reviewed office charts, magnetic resonance imaging (MRI) scans, operative reports, and arthroscopic images of 6 patients who underwent surgery between January 2007 and May 2009, in whom a medial meniscocapsular separation measuring less than 5 mm in length was identified and treated. Inclusion criteria were medial-side knee pain unresponsive to nonoperative management, negative MRI findings, and an isolated meniscocapsular separation injury detected on arthroscopy and repaired with 1 stitch. Patients were contacted and completed questionnaires that included subjective International Knee Documentation Committee, Tegner, and Marx scores. RESULTS:Of the 6 patients, 5 were female patients aged 14 to 18 years who were involved in sports. All patients recalled an acute twisting knee injury. Symptoms were related mainly to sports and were absent or very minimal during activities of daily living. On physical examination, the medial joint line was tender in all patients, whereas medial-side knee discomfort while squatting (i.e., baseball catcher's position) and McMurray tests were positive only in some. The negative MRI scans used a 3-T magnet in 5 cases and a 1.5-T magnet in 1 case. The duration of symptoms from injury to surgery was between 6 months and 9 years in 5 cases. On arthroscopy, all patients had a medial meniscocapsular separation measuring less than 5 mm in length that was identified when the tip of the arthroscopic probe was inserted into the lesion. This was repaired with a single all-inside stitch. The mean latest follow-up was 31 months (range, 15 to 38 months). The mean subjective International Knee Documentation Committee score was 87 at latest follow-up. Tegner and Marx scores showed that after surgery, 5 patients regained their preinjury level of activity. CONCLUSIONS:Meniscocapsular separation can involve a segment of less than 5 mm in length, be occult on MRI, be challenging to visualize on arthroscopy, and lead to chronic medial-side knee pain. Critical evaluation with a history, physical examination, and careful arthroscopic inspection of the medial meniscus can lead to appropriate treatment with a good to excellent outcome after repair. LEVEL OF EVIDENCE/METHODS:Level IV, therapeutic case series.