Summary. Neurological deficits resulting from spinal cord compression occur infrequently. When presented with neurological compromise, the most common management was radiotherapy, with surgery only being offered to patients who developed neurological deficit or pathological fracture resulting in unresolved severe pain post radiotherapy. Introduction. Nasopharyngeal carcinoma has been reported to have a higher incidence of distant metastases to the spine. This study was conducted to evaluate the incidence, presentation and management of neurological involvement related to spinal metastasis from nasopharyngeal carcinoma. Patients and Methods. 814 patients with the diagnosis of NPC who presented to the National University Hospital (NUH), Singapore, over a 5-year period (2007–2011) were recruited for this study. Case records from clinics, wards, operating theatres at NUH and nationwide electronic records of polyclinics and Emergency Medical Department (EMD) were obtained and reviewed. The data collected included demographics, medical history, radiologic and histopathology reports. Results. Of 814 patients with NPC, 99 had spinal metastasis. 26 were treated with radiotherapy, 25 with chemotherapy, 5 with both chemo and radiotherapy and 6 with surgery. Out of 6 patients requiring spinal surgical procedure, 3 had neurological deficits in the form of focal sensory or motor deficits and 4 had symptoms of pathologic fracture. One patient had both neurological deficit and pathological fracture. All these 6 patients were treated with a spinal surgical procedure of stabilization and/or decompression. Discussion/Conclusion. Spinal metastasis is common in patients with NPC and back pain is the usual presentation. Neurological deficits resulting from nerve root or spinal cord compression occur infrequently. When presented with neurological compromise, the most common management was radiotherapy, with surgery only being offered to patients who developed neurological deficit or pathological fracture resulting in unresolved severe pain post radiotherapy

Purpose: The supracondylar fractures of the distal humerus are the second most frequent fractures of the developing skeleton. Also their immediate and late complications are very often. The aim of this study is to describe their neurological complications. Material – methods: In our department 178 children were admitted with supracondylar fracture of the distal humerus during the period 1998–2002. Their age ranged from 2 to 16 years of age (the average was 7 years old, 63 girls and 115 boys). Forty-six patients were treated conservatively and 132 surgically. Neurological complications were appeared in 18 patients that had, according to Gartland classification, II and III type fractures. Manipulations for closed reduction had been made to 6 of them. Neurological deficit of the median nerve appeared to 10 patients, of the radial nerve to 6 patients and of ulnar nerve to 2 patients. The treatment of the fractures was surgical (open reduction, internal fixation with Kirschner wires and immobilization with a long arm cast for 4 weeks). The treatment of the neurological complications was conservative (free mobilization of the elbow was followed after the removal of the arm cast and Kirschner’s wires). Results: The results of the conservative treatment of the neurological complications of the supracondylar fractures of the distal humerus were excellent and the surgical exploration on the injured nerve was not necessary on any patient. The function of the nerves recovered completely in 2–3 months after the elbow’s fracture. Conclusion: The prognosis on the neurological complications of the upper limbs due to supracondylar fracture of the distal humerus is very good. They are successfully treated conservatively and the surgical exploration on the injured nerve is rarely necessary

Introduction: The poor correlation between neurological injury and degree of retropulsion in thoracolumbar burst fractures has been identified, but not adequately explained. We have examined the possibility that variation in the termination of the conus medullaris may offer protection from neurological injury in a proportion of these fractures. Methods: A retrospective study was made of 39 patients presenting with single level thoracolumbar burst fractures between June 1998 and April 2001. Admission MRI was performed on all patients. Age, sex, ISS, neurological status, mode of treatment and any neurological recovery were recorded. From the MRI scans the levels of the conus and the fracture were noted. Transverse Spine Area(TSA) was measured at the cranial, caudal and injured levels. A predicted TSA and % TSA for the injury level was calculated from the mean of the two other levels. Analysis was of severity of neurological injury in relation to canal compromise and involvement of the conus. Results: 26 male and 13 female patients of mean age 35.9 (SD 17) years and mean ASIA motor score 90.4 (SD 23) were studied. Neither sex nor age distribution differed between 18 neurologically injured and 21 intact patients. Mean ISS was 20.2 in the neurologically injured and 10.5 in the intact (p=0.0005). Mean TSA of the canal was 218mm2 in the intact and 150mm2 in the injured groups (p=0.006) and mean %TSA was 70 and 49 respectively (p=0.007). The conus lay between T12 and L2 in all. When the conus lay cranial to the fracture (n=13), 38% were neurologically intact. When the conus lay at the level of the fracture (n=26), 62% were intact (NS). Neurological deficit did not occur in the absence of neurological compression on MRI. Conclusions: Neurological injury is not less likely when the conus lie outside the fracture zone. Canal compromise is a highly significant factor in neurological injury

Introduction. Neurological involvement occurs in 10-30% cases of caries spine. Surgical debridement and stabilisation is needed to decompress the cord and prevent progression of deformity. This prospective study was undertaken to determine the efficacy of operative treatment in the management and neurological recovery in patients with caries spine with neural deficit. Material & methods. 20 patients, 14 male, 6 female, were included and followed up for 1 year after surgery. The mean age was 39.45 years. 10 patients had complete paraplegia and 9 patients had paraparesis. 1 patient with cervical involvement had quadriplegia. Anterior decompression and stabilisation was done in all the cases. Objective of surgery was adequate debridement of diseased foci, decompression of cord and stabilisation of spine with correction of deformity. In 19 (95%) patients there with thoraco-lumbar involvement. This was addressed with a titanium mesh cage filled with impacted bone graft and supplemented with 2 Moss Miami screws and a rod construct. In the cervical spine, cervical spine locking plate was used for stabilisation after decompression and bone grafting (tricortical iliac crest graft). Results. Fifteen patients had complete and 5 patients had incomplete neurologic recovery. Neurological recovery started as early as first post-op week (range 3 days to 12 weeks). The ASIA motor score improved from 60.80 (60.80 +/− 20.206) before surgery to 73.55 (73.55 +/− 13.828) at 1 month and 95.30 (95.30+/−11.934) at 6 months after surgery. The ASIA sensory score improved from 173.30 (173.30 +/− 50.689), to 186.85 (186.65 +/− 37.452) at one month and 218.45 (218.45 +/−11.843) at 6 months. All 8 patients with bladder and bowel involvement recovered normal bladder and bowel functions at 6 months. There was no recurrence of infection. Bony fusion was achieved in all patients and there were no implant failures. Conclusion. Anterior debridement, decompression, stabilisation and anti-tubercular chemotherapy resulted in neurological recovery in the majority of the patients

Aims

Knowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs.

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department. Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children. The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination. 30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function. While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Abstract. Objectives. To evaluate the safety and efficacy of vertebroplasty with short segmented cement augmented pedicle screws fixation for severe osteoporotic vertebral compression fractures (OVCF) with posterior/anterior wall fractured patients. Methods. A retrospective study of 24 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results. A significant improvement was noted in VAS (preoperative, 7.90 ± 0.60; final follow-up 2.90 ± 0.54) and ODI (77.10 ± 6.96 to 21.30 ± 6.70), (P < 0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20 ± 5.90 to 5.30 ± 1.40 postoperative with 5% (3.30 ± 2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80 ± 11.9% to 87.6 ± 13.1% postoperative with 4.5 ± 4.0% loss at final follow-up. One case had cement leakage was found, but the patient is asymptomatic. No implant-related complication was seen. No iatrogenic dural or nerve injury. Conclusions. Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because. Vertebroplasty is viable option for restoring vertebral anterior column in patients who are considered as contraindications for vertebroplasty, like DGOU-4. It provides anterior support avoiding corpectomy, minimise blood loss and also duration of surgery. Addition of short segment fixation gives adequate support with less stress risers at the junctional area

Neurological examination in children presenting with upper limb fractures is often poorly performed. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our own hospital and performed a further 3 month clinical review to detect any resulting change in practice. In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination. Following introduction of the guideline, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. Introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice. In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment. Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Introduction We have undertaken a retrospective study to identify prognostic factors predictive of neurological recovery after spinal cord injury (SCI). Methods During the year 1999 to 2000, 403 patients with SCI were admitted and 91 patients could be followed-up for more than one year. Improvement in the motor score (ASIA) were taken as indicative of functional neurological recovery. Prognostic factors were simplified into static (which do not change with time) and dynamic (which may change with time). Variables like age, sex, mode of injury, mechanism of injury and skeletal level were static. Neurological level, sacral sparing, duration of spinal shock, reflex recovery, sensory & motor scores and complications like bedsores, flexor spasms, UTI, URTI, & DVT were dynamic. These were recorded at admission, at weekly intervals until discharge and at three monthly intervals in follow-up. They were correlated for any association with neurological recovery at one year. Regressive analysis of static and dynamic factors was done. Results No significant correlation of static variables with the neurological recovery was found. First aid and transportation, duration of spinal shock, sacral sparing, rate of reflex recovery, flexor spasms and bedsores had a significant correlation with neurological recovery. Pin-prick sparing, spinal shock of < 24 hours and early appearance of deep tendon reflexes were good prognostic factors. Complete lesion, spinal shock for > 1 week, flexor spasms within three weeks and bedsore within one week were worst prognostic factor. Initial three weeks following injury was the critical period influencing final neurological and functional outcome

Aims: Various studies could show that computer assisted pedicle screw insertion can reduce pedicle perforation rate. We conducted this study to verify if pedicle screw navigation can also avoid neurological complications. Methods: Within 20 months 112 patients were stabilised with 584 pedicle screws in the thoracolumbar spine (Th1-L5). 333 screws were inserted using a CT-based navigation system, 251 srews with conventional technique. Postoperatively, screw positons were assessed by an independent radiologist using CT-scans. Neurological complications and revision surgery were noted. Results: 47 (14.1%) of navigated screws perforated pedicle wall, 13 (28%) to medial side with 2 screws more than 4 mm. One screw (0.3%) had to be changed due to medial perforation of 6 mm in Th4. In the conventional group 60 (29.9%) screws perforated pedicle wall, 13 (22%) to medial side with 3 screws more than 4 mm. One patient had to be reoperated due to radicular deficit caused by a medial perforated screw in L1 (0.4%)Conclusion: CT-based navigation of pedicle screws decreased pedicle perforation rate significantly. However, considerable medial perforations up to 6 mm could not be avoided entirely. The rate of neurologic complicatons and revision surgery was the same in both computer assisted and conventional group

Background: It has been reported that there is poor correlation between neurological injury and degree of bony retropulsion in thoracolumbar burst fractures. 1. Wilcox et al. 2. showed biomechanically that there was poor concordance between the extent of post impact spinal canal occlusion and the maximum amount of occlusion that occurred at the moment of impact. In the current study we examined the possibility that variation in the termination of the conus medullaris may offer protection from neurological injury in a proportion of these fractures. Methods: A retrospective study was made of 39 patients (26M:13M, mean age 35.9 years, range 15 – 75 years) presenting with a single level thoracolumbar burst fracture (T12–L2) between 1998 and 2001. A whole spine MRI scan was performed on all patients and the level of the conus noted. Age, sex, injury severity score (ISS), neurological status (ASIA motor score) and the transverse spinal canal area (TSCA) of the vertebral levels either side of the fractured vertebra was measured. A predicted TSCA for the injured level was then calculated from the mean of the TSCA’s of the adjacent levels. The actual TSCA of the injured level was calculated and this enabled a percentage decrease of the TSCA to be worked out from the predicted value. Analysis was made of the presence or absence of neurological injury in relation to canal compromise and involvement of the conus. Results: Eighteen patients with neurological compromise and 21 with intact neurology (the age and sex distribution in the two groups were similar). The mean ± SD ASIA motor score of the patients studied was 90.4 ± 23. Mean ISS was 20.2 in the neurologically injured and 10.5 in the intact (p=0.0005). Mean TSCA of the canal was 218mm. 2. in the intact and 150mm. 2. in the injured groups (p=0.006) and mean %TSCA was 70 and 49 respectively (p=0.007). The conus lay between T12 and L2 in all patients. When the conus lay cranial to the fracture (n=13), 38% were neurologically intact. When the conus lay at the level of the fracture (n=26), 62% were intact (NS). Neurological deficit did not occur in the absence of neurological compression on MRI. Conclusion: Our study showed that the risk of neurological injury from a thoracolumbar burst fracture was not decreased when the conus lay outside the fracture zone. However, there was a statistically significant difference in percentage of canal compromise when the patients with neurological impairment were compared with those that were neurologically intact

Aim of study: To establish whether there was a correlation between the degree of bony spinal canal encroachment and initial neurological deficit and subsequent neurological recovery. Methodology and Results: Twenty-six Patients with Thoraco-lumbar Burst fractures presenting with Frankel Grades C, D and E were studied retrospectively. All the Patients were admitted to the spinal injury centre within seven days of injury and were managed conservatively with bed rest for six weeks (mean) followed by brace or a POP jacket for a further period of approximately six weeks. Neurological progress was assessed by Frankel Grade and American Spinal Injury Association (ASIA) motor score. The degree of spinal canal encroachment was determined from coronal sections of the CT scan by measuring the antero- posterior diameter (APD) and the surface area (Area). (APD 18.84% – 80.62%, Area 9.5% – 81.29%). Average period of follow up was 24.8 months. All Frankel Group C improved to Frankel D and six out of the 13 Frankel D patients improved to Frankel E. The other seven Frankel D patients out of the 13 patients also had improvement in motor scores but did not change Frankel grade. Conclusion: There appeared to be no statistically significant correlation between the degree of canal encroachment, the degree of initialneurological impairment or the degree of neurological recovery in patients who had motor sparing within one week of injury

Neurological scoliosis differs from idiopathic type for some peculiar features that negatively affect operative time and blood loss during surgical treatment. To reduce the rate of complications in neurological scoliosis, an hybrid construct based on combined lumbar pedicle screws and Universal Clamps (UC) at thoracic levels can be used. The aim of our study was to assess the validity of the hybrid construct in neurological scoliosis treatment respect to technical success (deformity correction), operative time and blood loss, in a prospective series of patients with preoperative Cobb angle > 100°. Between 2002 and 2008 we treated 15 patients (3 M, 12 F) affected by neurological scoliosis with preoperative Cobb angle > 100° (107±4°) by hybrid construct. The mean age was 14 years (range 10–17). The etiology was cerebral palsy in 12 cases, Friedreich’s ataxia in 2 cases and Aicardi Syndrome in one case. All patients were treated by posterior access to stabilize each affected level, combining screws (Socore TM), UC and hooks in an hybrid construct. In 3 patients a secondary posterior access was achieved in order to strengthen the UC effect, adding a concave costotomy. Skull traction by sling and pelvic countertraction to control obliquity were used in all cases. Pelvic instrumentation provided iliosacral screw fixation according to Dubousset or iliac fixation in accordance with Sponseller. Two concave rods and one convex were used in all assembly. The average percentage of correction was 70% (32±7°). Mean operative time was 4 hours with mean blood loss of 1800 ml. We used a mean of 6 transpedicular screws (range 4–11), 7 UC (5–9) and 5 hooks (4–6) in our assembly. Mean follow-up time was 36 months (range 12–84), with an average loss of correction of 7°. The hybrid construct (lumbar transpedicular screws, thoracic Universal Clamps, pedicle-transverse hooks at the upper end of the curve) appears safe and effective in treatment of neurological scoliosis > 100°. This assembly provides a good correction of the deformity and reduces operative time, radiation exposure and blood loss respect to all-screws constructs. Sublaminar acrylic loops (Universal Clamp) have the same stress resistance in comparison with steel or titanium alloy sublaminar wires. Moreover, the simplicity of implant and tensioning of the strips is associated with the possibility of re-tensioning and progressive correction, providing a better capacity of managing the kyphotic component in case of thoracic lordosis. Among neurological scoliosis treatments, the hybrid construct can be considered a valid option due to the advantages of shortening the operative time and diminishing the risks of vascular and neurological complications

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery.

The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression.

Cite this article: Bone Joint J 2013;95-B:1388–91.

Objective: To present the experience of a Deparment of Neuroorthopedics in treatment of the severe deformities of the wrist using the technique of the wrist arthrodesis very often associated to other surgical procedures such as musculotendinous lengthenings and transfers.

Materials and Methods: 20 patients with neurological sequelae of cerebral palsy, head trauma, stroke and other neurological disorders of the first motoneuron were retrospectively studied. Fusion of the wrist with an specific plate was performed on these patients.

Results: We reached the consolidation of the arthrodesis in a 100% of the cases between 8 and 12 weeks. We had some complications such as 3 cases of phlictenae and edema and 4 cases needed reoperations because of the appearance of secondary deformities previously not seen. 95% of the patient were satisfied and only one wouldn’t go under the same operation again.

Discusion: Despite many text books contraindicate wrist arthrodesis in patients with neurological sequelae because of the remote possibility that they may need the flexoextensiòn for the use of walker or crutches or manual or electric wheel-chairs, in our experience many patients benefit from this procedure to correct severe deformities that make their hands absolutely dysfunctional. Besides, the intervention provides the patients and their family with benefits in terms of hygiene, dressing, very often improvement of the pain and, why not, of the aesthetics. Some patients have also gained function, passing from a dysfunctional hand to a useful hand for the basic functions of life. Nowadays, for these kind of patients to be able to move one or two fingers, if they are correctly positioned, can be useful to manage a walker, a computer or a motorized wheel-chair.

Purpose: To study the pattern of neurological lesions and the frequency they occur in patients with cervical injuries. The relationship of these lesions with certain types of injuries and the cause of omjury.

Patients and methods: Between 1970–2001, 665 patients suffering a cervical injury were studied in our Department. There were 192 male and 73 female patients aged 42,3 years on average. Two hundred sixty-five of these cases (38,5%) were presented with neurological symptoms.The mean time of hospitalization was 43,45 days. The patients were classified according to the type and the level of injury. ASIA‘s functional classification was used (35,1% were ASIA A, 13,96% ASIA B, 10,57% ASIA C and 40,37% ASIA D). 194 were followed up for a mean period of 7 years. Conservative treatment was applied to 183 (69%) patients while 82 patients (31%) were treated operatively with anterior cervical fusion, posterior cervical fusion, or combined anterior and posterior fusion. Postoperatively, most of the patients with incomplete neurological lesion, were improved.

Conclusions: An analysis of our cases showed the following: a) There is a relationship between the type of neurological signs and the type of osseous or ligamentous injuries. b) There is relationship between type of osseous or ligamentous injury and severity of neurological lesion.. c) Burst fractures are the most severe fractures, followed by bilateral dislocations and tear-drop fractures. d) There is a relationship between mechanism of injury and severity of neurological lesion

We have studied the case records of 16 patients with dislocations of the cervical spine who deteriorated neurologically during or after reduction. The dislocations were reduced by skull traction in four patients, by manipulation in four and by operation in seven. This complication was not related to age, sex, mechanism of injury, or the level and the type of dislocation. Fourteen patients made substantial recoveries, one made a partial recovery and one patient remained totally paralysed and died three months later. The causes and prevention of spinal-cord damage at this stage of management are discussed, and the early use of MRI or CT myelography is recommended.