1.

Spnial meningioma

a. Definition: Meningiomas arising from the coverings of the spinal cord.1

b. Epidemiology:2

i. Spinal meningiomas account for approximately 12% of meningiomas of

the central nervous system and 25–46% of the primary spinal tumors

ii. These tumors are usually benign, slow growing and well-circumscribed

neoplasms located in the intradural – extramedullary compartment of

the spinal canal and result in compression of the spinal cord

iii. Only a few meningiomas (about 4.5–13%) may have an additional

extradural component or can be entirely confined to the extradural

space

c. Classification2

1) Staging System (Table 2) to categorize the size of the tumor bulk at that

site (Fig. 1).

2) Typing System: based on the location of tumor and the direction of the

displacement of the spinal cord (table 3 and fig 2)

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 d. Clinical finding: Despite usually being small, due to the confines of the

spinal canal, spinal meningiomas can result in significant neurologic

dysfunction. The majority of patients present with motor deficits as a result

of compression of the spinal cord. Less common presentations include

sensory deficits, pain and sphincter dysfunction.3

e. Prognosis: Spinal meningiomas are typically slow-growing.3

f. Surgical prognosis: Surgery is the treatment of choice and complete tumor

removal is achieved in the vast majority of patients. Less than 10%

experience recurrence.3

2. Neurogenic bladder- detrusor sphincter dyssynergy

a. Definition: Detrusor sphincter dyssynergia (DSD) is the urodynamic

description of bladder outlet obstruction from detrusor muscle contraction

with concomitant involuntary urethral sphincter activation. DSD is

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 associated with neurologic conditions such as spinal cord injury, multiple

sclerosis, and spina bifida.4

b. DSD in SCI: above the level of conus medullaris

c. Clinical manifestation: Symptoms to be investigated specifically include

storage and voiding LUTs, such as NDO and DSD, respectively21, in

addition to symptoms indicating possible complications such as

haematuria, fever, pain, and autonomic dysreflexia.4

d. Pathophysiology: During storage of urine, afferent nerves carry

information regarding bladder wall pressure (A fibers) and

pain/temperature in the bladder (C fibers) through the

pelvic/hypogastric/pudendal nerves to the lumbosacral spinal cord (1).

Information is then relayed up the spinal cord spinothalamic tracts to the

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 midbrain periaqueductal grey region. Input from the limbic system and

pre-frontal cortex feeds back to the midbrain to either facilitate further

bladder storage or to transition to micturition.5

3. Prolonged immobilization effect in spinal cord injury’s patient.6,7

a. Cardiovascular

i. The resting heart rate increases one beat per minute for every two days of

rest, with this increase resulting in a shorter diastolic time and shorter

systolic ejection time, leaving the heart less able to respond to demands

above baseline. Increased resting heart rate and the response of the heart

rate to exercise is known as cardiac deconditioning.

ii. Postural hypotension is one of the most common cardiovascular

complications of immobility and can be observed after 20 hours of bed rest

iii. Deep vein thrombosis is another common complication of prolonged

bedrest (approximately 13%). The Virchow triad refers to the combination

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 of three factors: venous stasis, hypercoagulability and damage to blood

vessels; which together dramatically increase the chances of developing

deep vein thrombosis.

b. Respiratory

i. In the supine position the body weight restricts the movement of the rib

cage, reducing the tidal volume. This restriction of the movement of the

chest cavity leads to an increase in mechanical resistance, which,

together with the increase in blood volume in the chest, leads to a

reduction in total lung capacity and residual volume

ii. Predisposes the patient to pneumonia, tendency for the mucus to

accumulate, under the influence of gravity and the diminution of the tidal

volume; this effect can be aggravated when the person is dehydrated, as

the mucus becomes thicker and expectoration more difficult.

c. Skeletal-muscle metabolic and structural abnormalities.

i. Specific alterations in morphologic and contractile properties of skeletal

muscle with chronic SCI have been shown using electromyography

studies, biopsy, and magnetic resonance imaging. These alterations

include lower protein content, an increase in myosin heavy-chain

isoforms, reduced fiber cross-sectional area, and reduced force and

fatigue characteristics with functional electrical stimulation.

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Reference

1. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott

Williams & Wilkins (2006).

2. Bayoumi, Ahmed B., et al. "Proposal of a new radiological classification

system for spinal meningiomas as a descriptive tool and surgical guide."

Clinical neurology and neurosurgery 162 (2017): 118-126.

3. Hohenberger, Christoph, et al. "Functional outcome after surgical

treatment of spinal meningioma." Journal of Clinical Neuroscience 77

(2020): 62-66.

4. Wyndaele, Jean-Jacques. "The management of neurogenic lower urinary

tract dysfunction after spinal cord injury." Nature Reviews Urology 13.12

(2016): 705-714.

5. Stoffel, John T. "Detrusor sphincter dyssynergia: a review of physiology,

diagnosis, and treatment strategies." Translational andrology and urology

5.1 (2016): 127.

6. Guedes, Luana Petruccio Cabral Monteiro, Maria Liz Cunha de Oliveira,

and Gustavo de Azevedo Carvalho. "Deleterious effects of prolonged bed

rest on the body systems of the elderly-a review." Revista Brasileira de

Geriatria e Gerontologia 21 (2018): 499-506.

7. Myers, Jonathan, Matthew Lee, and Jenny Kiratli. "Cardiovascular disease

in spinal cord injury: an overview of prevalence, risk, evaluation, and

management." American journal of physical medicine & rehabilitation

86.2 (2007): 142-152.

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