SUMMARY After noting the rarity of papers describing the pathology of delayed radiation necrosis of the spinal cord, the clinical and pathological findings from four cases are presented. The main pathological features are asymmetric demyelination of the lateral columns and to a lesser degree the posterior and anterior columns of white matter, with coagulative necrosis at the level of irradiation which affected the grey matter to a lesser degree. There is ascending and descending secondary tract degeneration, and poor glial response in the lesions themselves. Vascular changes, mainly hyaline thickening of arteriolar walls, are present, but not in degree sufficient to explain the primary lesion. The discussion of the pathogenesis of the myelopathy weighs the merits of a primary vascular lesion against those of a primary effect of the radiation on neural tissue. The latter is favoured.The clinical syndrome of radiation myelopathy is well documented (Malamud, Boldrey, Welch, and Fadell, 1954; Itabashi, Bebin, and De Jong, 1957;Dynes and Smedal, 1960;Pallis, Louis, and Morgan, 1961;Atkins and Tretter, 1966;Baldus, 1966;Hughes, 1966; Kristensson, Moulin, and Sourander, 1967;Reagan, Thomas, and Colby, 1968; Van den Brenk, Richter, and Hurley, 1968;Lehmann, Zett, and Neumeister, 1968;Locksmith and Powers, 1968;Maier, Perry, Saylor, and Sulak, 1969; Philips and Buschke, 1969;Tan and Khor, 1969;Coy, Baker, and Dolman, 1969;Eyster and Wilson, 1970). It occurs invariably as an iatrogenic lesion due to irradiation of malignant tissues in the vicinity of the spinal cord. The cervical region is the commonest part of the cord to be affected, and most reports of the pathology of radiation myelopathy have been of lesions at this site.The type of malignancy irradiated seems to have no bearing on the subsequent development of myelopathy. The exact incidence of radiation myelopathy is not known. The factors which appear to be especially important in the development of the myelopathy are total dose, field size, and dose rate. The dose-incidence relationship has been given a mathematical description by Van den Brenk et al. (1968), who also suggest that treatment in hyperbaric oxygen increases 888
Radiation myelopathy of the cervical cord may be revealed by Lhermitte's sign of electrical paraesthesia on neck flexion. A transient syndrome is described, occurring some three to four months after therapeutic irradiation, with electrical paraesthesia as the sole manifestation. This is contrasted with the features of progressive radiation myelopathy which usually appears after a longer latent period of one to two years. Transient radiation myelopathy does not (unless the evocative dose is above the accepted tolerance level) herald later and progressive cord degeneration. The pathogenesis of the condition is discussed in relation to the radiosensitivity of oligodendroglia, together with its significance in clinical neurology and radiotherapeutics.
Acute lymphoblastic leukemia is characterized by the occurrence of meningeal relapse in 50 % of cases within one year. Recent studies have shown that craniospinal irradiation or cranial irradiation and intrathecal methotrexate are effective in preventing CNS relapse and prolonging survival in this condition.
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