"Ossification of the transverse atlantal
ligament (OTAL) is extremely rare and may cause upper cervical
canal stenosis and spastic quadriparesis... Each of the
two cases of OTAL (Ossification of the transverse atlantal ligament)
presented here had been diagnosed with fluorosis. As previously
discussed, the etiology of OTAL may be of multiple origins, such
as injury, and acquired or congenital abnormalities. Although
there have been no English articles reporting that OTAL can be
caused by fluorosis, we would argue that, together
with many other ligaments and membranes, the atlantal transverse
ligament may be ossified (in fluorosis)."
SOURCE: Wang W, et al. (2004). Ossification of the transverse
atlantal ligament associated with fluorosis: a report of two cases
and review of the literature. Spine 29 :E75-8.
"A sizeable number of patients suffering
from ossified
posterior longitudinal ligament (OPLL) may have fluoride intoxication
as the underlying cause."
SOURCE: Reddy DR, et al. (1993). Neuro-radiology
of skeletal fluorosis. Annals of the Academy of Medicine, Singapore
22(3 Suppl):493-500.
"A 70 years old farmer from Yemen was referred
as a case of osteoarthritis of both knees for preoperative rehabilitation
procedures. Six years before he developed skeletal stiffness.
By 70 years he became dependent for ambulation and many other
self-care activities. He showed quadriparesis
resulting from compression of spinal cord and nerve roots
at multiple levels associated with multiple joint involvement."
(This patient was diagnosed by the authors
as suffering from skeletal fluorosis.)
SOURCE: Khamees MF, et al. (1995). An uncommon
presentation of fluorosis. Electroncephalography & Clinical
Neurophysiology 97: S229.
"Two cases of ossification
of the posterior longitudinal ligamentum with cervical myelopathy
are reported. The radiologic
studies determined the etiology, in the first case, it was fluorosis
and the second DISH disease."
SOURCE:Chaabane M, et al. (1995). [Rare
causes of ossification of the posterior common vertebral ligament
causing cervical compression. Apropos of 2 cases]. [Article in
French] J Radiol. 76(1):43-6.
"The authors report four
cases of spinal cord compression (three at cervical level and
one at dorsal level) due to vertebral osteosclerosis secondary
to chronic fluoride intoxication. Roentgenograms
showed typical diffuse densification of vertebral bodies, calcifications
of bony insertions of many ligaments, discs and interosseous membranes...
Spinal computed tomography showed severe cord compression due
to posterior osteophytes."
SOURCE: Mrabet A, et al. (1995). [Spinal
cord compression in bone fluorosis. Apropos of 4 cases] [Article
in French]. Rev Med Interne.16(7):533-5.
"A case of skeletal fluorosis
with spinal cord compression from Kekirawa following consumption
of water with high fluoride content for about 20 years is described."
SOURCE:Disanayake JK, et al. (1994). Skeletal
fluorosis with neurological complications. Ceylon Med J.
39(1):48-50.
"Plain roentgenology of the skull was normal,
but of the cervical spine revealed marked fluorotic changes and
a fracture of C6. Ossification of the posterior longitudinal ligament
(OPLL) was seen. He was suspected of having
fluorotic cervical canal stenosis with compressive myelopathy,
precipitated by trauma... At operation, the characteristic
changes of a fluorotic spine were observed in the form of ossified
spinal ligaments and hardened bone... The spine was like a continous
column of bone, typical of fluorosis... Neurological
sequelae in skeletal fluorosis manifest as radiculomyelopathy,
principally due to mechanical compression of the spinal cord and
nerve roots... Though the disease develops slowly with
relentless progression, the neurological manifestations may sometimes
be precipitated by minor trauma."
SOURCE: Prasad VS, Reddy DR. (1994). Posttraumatic
pseudomenigocoele of cervical spine in a patient with skeletal
fluorosis: Case report. Paraplegia 32:627-30.
"A lumbar computer tomographic scan demonstrated
severe calcification of the posterior longitudinal
ligament and ligamentum flavum extending from T7 though
L3 resulting in marked stenosis of the spinal
canal and secondary spinal cord atrophy."
SOURCE: Dhuna AK, et al. (1992). Skeletal
fluorosis. An unusual cause of progressive radiculomyelopathy.
Spine 17:842-4.
"In advanced stages of neurofluorosis, the
clinical picture is rather uniform, with complete incapacitation
and the bedridden state of severe spastic paraparesis, or quadriparesis
with incontinence of urine and flexor spasms... [F]luorotic
changes resulted in considerable encroachment on the diameter
of the intervertebral foramina and spinal canal. These changes
tend to be most marked in the cervical region. This explains
the clinical similarity of neurofluorosis to cervical spondylosis."
SOURCE: Haimanot RT. (1990). Neurological
complications of endemic skeletal fluorosis, with special emphasis
on radiculo-myelopathy. Paraplegia 28:244-51.
"A middle-aged male resident of Benghazi, northeastern Libya,
with radiological features of skeletal fluorosis
associated with cervical radiculomyelopathy is reported...
His problem is of special interest because he lived in a non-tropical,
non-endemic area [1-2 ppm] where cases of advanced fluorosis would
not be expected."
SOURCE:Maloo JC, et al. (1990). Fluorotic
radiculomyelopathy in a Libyan male. Clinical Neurology and
Neurosurgery 92(1):63-5.
"We report a case of spinal cord compression
with paraplegia as a result of endemic skeletal fluorosis... Kyphosis
of the spine was present without other apparent bone deformity...
[M]yelography demonstrated partial spinal cord compression at
the level of T2 and T3 vertebrae.. A radiographic
skeletal survey revealed osteosclerosis of the axial skeleton
with sparing of the skull and prominent calcification of the interosseous
membranes and ligamentous insertions... Magnified computed tomographic
scan images of the thoracic vertebrae demonstrated marked
narrowing at the T2 and T3 levels due to bony exostoses protruding
into the spinal canal... Neruologic symptoms are a late
occurrence and signify far advanced disease... Involvement of
the peripheral and central nervous system has led to the description
of neurologic manifestations as a radiculomyelopathy. Radicular
features include muscle weakness with asymmetric atrophy, fasciculation,
nerve root pain, and acroparesthesias. Onset of these symptoms
is usually insidious. Myelopathic features are characterized by
a more abrupt onset and include spastic paraplegia or quadriplegia,
hyperreflexia, Babinski reflex, clonus, or a variety of sensory
deficits. The course is usually progressive, and there is predilection
for cervical spine involvement. Neurogenic bladder or bowel
incontinence has been reported as a conequence of spinal cord
involvement."
SOURCE: Fisher RL, et al. (1989). Endemic
fluorosis with spinal cord compression. A case report and review.
Archives of Internal Medicine 149: 697-700.
"All five cases of fluorosis in this
study had the clinical picture suggestive of cervical myelopathy.
The diagnosis of fluorosis was based on the residence in the endemic
area and the radiological features of fluorosis, which included
osteosclerosis, calcification of the interosseous membrane/ligaments,
periosteal bone formation, and irregular osteophytes... The
spinal cord involvement is commonest in the cervical region and
has been reported to constitute 56% of 136 patients of fluorosis
with neruological complication. Although
the lumbar vertebrae are the first to show the changes caused
by fluorosis, the compression of cauda equina rarely occurs because
its roots are easily accomodated."
SOURCE:Misra UK, et al. (1988). Endemic
fluorosis presenting as cervical cord compression. Archives
of Environmental Health 43:18-21.
"The mean canal body ratio was higher in fluorosis at every
level of the vertebra as compared to that of normal controls.
In other words, the spinal canal was narrow
at every level in fluorosis as compared to normal controls."
SOURCE: Kapila
AK, et al. (1983). Measurement of spinal canal body ratio in fluorotic
spine. Fluoride 16: 11-19.
"X-ray examination revealed generalized increased bone density
of the spine, ribs, and pelvis, suggestive of skeletal fluorosis.
Extensive accompanying osteophytosis was
present... The sagittal diameters of both the cervical
and lumbar spine were below the 90 per cent tolerance levels...
A diagnosis of fluorotic radiculomyopathy was made and confirmed
by the consulting rheumatologist... The characteristic
vertebral changes of
skeletal fluorosis and severe osteophytosis were probably
the basis for his neurological deficits. Although trauma
may have precipitated his radiculomyopathy, the neurological symptoms
are adequately explained by the marked narrowing of the sagital
diameter of the spinal canal and vertebral osteophytosis secondary
to fluorosis. Any trauma which might have caused edema of the
spinal cord could have produced neurological damage because of
the narrowed bony spinal canal. Thus, the role of trauma is equivocal
since bony encroachment on the spinal cord was probable. Wolf
has stated that cord compression is likely to occur when the cervical
canal is 10 mm or less. The bony canal at C-4 in this patient
was 9.5 mm."
SOURCE: Goldman SM, et al. (1971). Radiculomyelopathy
in a southwestern indian due to skeletal fluorosis. Arizona
Medicine 28: 675-677.
"A series of 70 cases of skeletal fluorosis
with neurological manifestations was studied... The F concentration
of water consumed by the patients varied between 1.2 and 11.8
ppm... In 50 cases there was evidence of involvement of the cervical
cord... The lowest F concentration in water
causing skeletal fluorosis and quadriplegia was 1.35 ppm.
Singh et al (1961) recorded spastic paraplegia
in a 50 year old male who consumed water containing 1.2 ppm F."
SOURCE:Siddiqui AH. (1970). Neurological
complications of skeletal fluorosis with special reference to
lesions in the cervical region. Fluoride 3:91-96.
"The case of a 57-year-old man with
skeletal fluorosis leading to spinal cord compression is described.
Myelography showed a partial block at T11, and following
decompression of the lower thoracic cord there was considerable
improvement in symptoms and signs. The diagnosis of fluorosis
was confirmed by the radiological appearances, by the histology
of the bone removed at operation, and by the raised level of the
bone fluoride."
SOURCE:Webb-Peploe MM, Bradley WG. (1966).
Endemic fluorosis with neurological complications in a Hampshire
man. Journal of Neurology, Neurosurgery and Psychiatry
29:577-583.
"A 64-year-old white male was admitted to the Veterans Administration
Hospital, McKinney, Tex, on May 11, 1962, because of severe respiratory
distress and semicoma. He had been a complete invalid
in a nursing home for a year... This case
of a patient with chronic fluoride intoxication, extensive osteosclerosis,
and fluorotic radiculomyelopathy is believed to be the first reported
from the United States."
SOURCE:Sauerbrunn BJ, et al. (1965). Chronic
fluoride intoxication with fluorotic radiculomyelopathy. Annals
of Internal Medicine 63: 1074-1078.
"compression of the cord (in fluorosis)
is almost inevitable."
SOURCE:Singh
A, et al. (1963). Endemic fluorosis. Epidemiological, clinical
and biochemical study of chronic fluoride intoxication in Punjab.
Medicine 42: 229-246.
"The earliest symptom of spinal cord involvement, present
in all cases, was weakness of both lower limbs. This usually started
in one leg, with later progression to the other. In 18 cases,
after a variable interval, the upper limbs became involved, producing
a spastic quadriplegia... The pattern resembled in many ways that
of spondylitic myelopathy...The signs of
fluorotic myelopathy result chiefly from narrowing of the spinal
canal or intervertebral foramina and compression may occur at
a single or at multiple sites."
SOURCE:Singh A, et al. (1963). Endemic fluorosis.
Epidemiological, clinical and biochemical study of chronic fluoride
intoxication in Punjab. Medicine 42: 229-246.
"The neurological complications of
endemic fluorosis have received scant attention, and we first
became interested in this aspect while investigating obscure cases
of paraplegia, associated with increased density of the
spine and other bones, in Punjab - a northern state of India.
Almost all the patients came from a small
area of Punjab and had in fact skeletal fluorosis with compression
paraplegia... The neurological complications
are the result of deposition of fluoride in the spine, leading
to narrowing of the spinal canal and compression of the cord...
It did not differ significantly from other compression paraplegias."
SOURCE:Singh A, et al. (1961). Skeletal
fluorosis and its neurological complications. Lancet 1:
197-200.
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