Patterned Disordered Cell Motion Ensures Vertebral Column Symmetry.

PubMed

Das, Dipjyoti; Chatti, Veena; Emonet, Thierry; Holley, Scott A

2017-07-24

The biomechanics of posterior embryonic growth must be dynamically regulated to ensure bilateral symmetry of the spinal column. Throughout vertebrate trunk elongation, motile mesodermal progenitors undergo an order-to-disorder transition via an epithelial-to-mesenchymal transition and sort symmetrically into the left and right paraxial mesoderm. We combine theoretical modeling of cell migration in a tail-bud-like geometry with experimental data analysis to assess the importance of ordered and disordered cell motion. We find that increasing order in cell motion causes a phase transition from symmetric to asymmetric body elongation. In silico and in vivo, overly ordered cell motion converts normal anisotropic fluxes into stable vortices near the posterior tail bud, contributing to asymmetric cell sorting. Thus, disorder is a physical mechanism that ensures the bilateral symmetry of the spinal column. These physical properties of the tissue connect across scales such that patterned disorder at the cellular level leads to the emergence of organism-level order. Copyright © 2017 Elsevier Inc. All rights reserved.

Posterior Vertebral Column Resection for Severe and Rigid Spinal Deformity Associated With Neurological Deficit After Implant Removal Following Posterior Instrumented Fusion: A Case Report and Literature Review.

PubMed

Tao, Youping; Wu, Jigong; Ma, Huasong; Zhang, Lele; Shao, Shuilin; Si, Zebing; Gao, Bo; Ji, Yong; Li, Haixia; Tao, Feifei

2015-07-01

Case report. To investigate the safety and efficacy of posterior vertebral column resection for severe and rigid spinal deformity associated with neurological deficit after implant removal following posterior instrumented fusion. Loss of correction after implant removal in patients with posterior instrumented fusion has been previously reported. However, to our knowledge, posterior vertebral column resection (PVCR) for severe and rigid spinal deformity associated with neurological deficit after implant removal following posterior instrumented fusion has not been reported. An 18-year-old female with severe and rigid spinal deformity associated with neurological deficit was classified as Frankel C, according to the Frankel grading system. She underwent posterior spinal fusion with pedicle screw fixation at 16 years, and her implants were removed after 1 year due to back pain. Seven months after removal of the implants, she began to experience weakness in her lower limbs but did not seek any treatment. She was unable to stand and had to use a wheelchair. The patient successfully underwent PVCR and posterior reinstrumentation. Within 3 months, her neurological status improved to Frankel E. The patient had no neurological deterioration and infections. There was no instrumentation failure and loosening correction at the 32 months follow-up. Our results suggest that PVCR and pedicle screw fixation is a safe and efficacious option for severe and rigid spinal deformity associated with neurological deficit after implant removal following posterior instrumented fusion. N/A.

Variations in the surface anatomy of the spinal accessory nerve in the posterior triangle.

PubMed

Symes, A; Ellis, H

2005-12-01

Iatrogenic injury to the spinal accessory nerve has been widely documented and can have medico-legal implications. The resulting syndrome of pain, paralysis and winging of the scapula are often the source of considerable morbidity. This paper researches the degree of accuracy achievable in mapping the surface anatomy of the spinal accessory nerve in the region of the posterior triangle with a view to creating a cartographical aid to surgical procedures. The necks of 25 adult cadavers were dissected bilaterally to expose the spinal accessory nerve. Variations in the course and distribution of the spinal accessory nerve in the posterior triangle were recorded along with its relationship to the borders of sternocleidomastoid and trapezius. Considerable variation was seen in the surface and regional anatomy of the nerve and in the contribution of the cervical plexus to the spinal accessory nerve in the posterior triangle. Measurements of the running course and exit point of the nerve into and from the posterior triangle differed significantly from those previously recorded. Delineation of an accurate surface anatomy was not possible. Creating a map to define the surface anatomy of the spinal accessory nerve in the posterior triangle is an unrealistic goal given its wide variations in man. Avoidance of damage to the spinal accessory nerve cannot be achieved by slavishly adhering to surface markings given in textbooks, but only by cautious dissection during operations on the posterior triangle.

Repeated posterior dislocation of total hip arthroplasty after spinal corrective long fusion with pelvic fixation.

PubMed

Furuhashi, Hiroki; Togawa, Daisuke; Koyama, Hiroshi; Hoshino, Hironobu; Yasuda, Tatsuya; Matsuyama, Yukihiro

2017-05-01

Several reports have indicated that anterior dislocation of total hip arthroplasty (THA) can be caused by spinal degenerative changes with excessive pelvic retroversion. However, no reports have indicated that posterior dislocation can be caused by fixed pelvic anteversion after corrective spine surgery. We describe a rare case experiencing repeated posterior THA dislocation that occurred at 5 months after corrective spinal long fusion with pelvic fixation. A 64-year-old woman had undergone bilateral THA at 13 years before presenting to our institution. She had been diagnosed with kyphoscoliosis and underwent three subsequent spinal surgeries after the THA. We finally performed spinal corrective long fusion from T5 to ilium with pelvic fixation (with iliac screws). Five months later, she experienced severe hip pain when she tried to stand up from the toilet, and was unable to move, due to posterior THA dislocation. Therefore, we performed closed reduction under sedation, and her left hip was easily reduced. After the reduction, she started to walk with a hip abduction brace. However, she had experienced 5 subsequent dislocations. Based on our findings and previous reports, we have hypothesized that posterior dislocation could be occurred after spinal corrective long fusion with pelvic fixation due to three mechanisms: (1) a change in the THA cup alignment before and after spinal corrective long fusion surgery, (2) decreased and fixed pelvic posterior tilt in the sitting position, or (3) the trunk's forward tilting during standing-up motion after spinopelvic fixation. Spinal long fusion with pelvic fixation could be a risk factor for posterior THA dislocation.

CUSUM method for construction of trainee spinal ultrasound learning curves following standardised teaching.

PubMed

Deacon, A J; Melhuishi, N S; Terblanche, N C S

2014-07-01

Spinal ultrasonography is a promising aid for epidural insertion. We aimed to determine the learning curve of spinal ultrasonography tasks and the number of training scans required to reach competency after undergoing standardised step-wise teaching. Trainees were required to complete a minimum of 60 assessed scans on selected non-pregnant models following attendance at two training sessions, with feedback from an expert after each scan. Learning curves were plotted using the non-risk cumulative summation technique and an acceptable failure rate of 20%. Five trainees completed between 65 and 75 scans each. All trainees were competent at identifying a randomly assigned intervertebral space after a median of five scans (range one to nine) and at measuring the depth from skin to the posterior complex after a median of 10 scans (range 1 to 42). Two trainees were competent at marking an ideal needle insertion point after 55 scans, while three trainees did not attain competency. All trainees were competent after 60 scans if the tolerance was changed from five to eight millimetre for marking the needle insertion point. The average time taken to complete a scan was 163 seconds. Our study showed that after a standardised educational intervention, anaesthetic trainees are able to identify a lumbar interlaminar space easily and can measure the depth to the posterior complex after a reasonable number of additional practice scans, but experienced difficulty accurately marking the needle insertion point whilst using spinal ultrasonography. We confirmed that it was hard to achieve competency in all aspects of spinal ultrasonography, based on assessment using our predefined competency criteria.

ASTM F1717 standard for the preclinical evaluation of posterior spinal fixators: can we improve it?

PubMed

La Barbera, Luigi; Galbusera, Fabio; Villa, Tomaso; Costa, Francesco; Wilke, Hans-Joachim

2014-10-01

Preclinical evaluation of spinal implants is a necessary step to ensure their reliability and safety before implantation. The American Society for Testing and Materials reapproved F1717 standard for the assessment of mechanical properties of posterior spinal fixators, which simulates a vertebrectomy model and recommends mimicking vertebral bodies using polyethylene blocks. This set-up should represent the clinical use, but available data in the literature are few. Anatomical parameters depending on the spinal level were compared to published data or measurements on biplanar stereoradiography on 13 patients. Other mechanical variables, describing implant design were considered, and all parameters were investigated using a numerical parametric finite element model. Stress values were calculated by considering either the combination of the average values for each parameter or their worst-case combination depending on the spinal level. The standard set-up represents quite well the anatomy of an instrumented average thoracolumbar segment. The stress on the pedicular screw is significantly influenced by the lever arm of the applied load, the unsupported screw length, the position of the centre of rotation of the functional spine unit and the pedicular inclination with respect to the sagittal plane. The worst-case combination of parameters demonstrates that devices implanted below T5 could potentially undergo higher stresses than those described in the standard suggestions (maximum increase of 22.2% at L1). We propose to revise F1717 in order to describe the anatomical worst case condition we found at L1 level: this will guarantee higher safety of the implant for a wider population of patients. © IMechE 2014.

Deformity Angular Ratio Describes the Severity of Spinal Deformity and Predicts the Risk of Neurologic Deficit in Posterior Vertebral Column Resection Surgery.

PubMed

Wang, Xiao-Bin; Lenke, Lawrence G; Thuet, Earl; Blanke, Kathy; Koester, Linda A; Roth, Michael

2016-09-15

Retrospective review of prospectively collected data. To assess the value of the deformity angular ratio (DAR, maximum Cobb measurement divided by number of vertebrae involved) in evaluating the severity of spinal deformity, and predicting the risk of neurologic deficit in posterior vertebral column resection (PVCR). Although the literature has demonstrated that PVCR in spinal deformity patients has achieved excellent outcomes, it is still high risk neurologically. This study, to our knowledge, is the largest series of PVCR patients from a single center, evaluating deformity severity, and potential neurologic deficit risk. A total of 202 consecutive pediatric and adult patients undergoing PVCRs from November 2002 to September 2014 were reviewed. The DAR (coronal DAR, sagittal DAR, and total DAR) was used to evaluate the complexity of the deformity. The incidence of spinal cord monitoring (SCM) events was 20.5%. Eight patients (4.0%) had new neurologic deficits. Patients with a high total DAR (≥25) were significantly younger (20.3 vs. 29.0 yr, P = 0.001), had more severe coronal and sagittal deformities, were more myelopathic (33.3% vs. 11.7%, P = 0.000), needed larger vertebral resections (1.8 vs. 1.3, P = 0.000), and had a significantly higher rate of SCM events than seen in the low total DAR (<25) patients (41.1% vs. 10.8%; P = 0.000). Patients with a high sagittal DAR (≥15) also had a significantly higher rate of SCM events (34.0% vs. 15.1%, P = 0.005) and a greater chance of neurologic deficits postoperatively (12.5% vs. 0, P = 0.000). For patients undergoing a PVCR, the DAR can be used to quantify the angularity of the spinal deformity, which is strongly correlated to the risk of neurologic deficits. Patients with a total DAR greater than or equal to 25 or sagittal DAR greater than or equal to 15 are at much higher risk for intraoperative SCM events and new neurologic deficits. 3.

Immune function, pain, and psychological stress in patients undergoing spinal surgery.

PubMed

Starkweather, Angela R; Witek-Janusek, Linda; Nockels, Russ P; Peterson, Jonna; Mathews, Herbert L

2006-08-15

This study was an exploratory repeated measures design comparing patients undergoing two magnitudes of surgery in the lumbar spine: lumbar herniated disc repair and posterior lumbar fusion. The present study evaluated and compared the effect of perceived pain, perceived stress, anxiety, and mood on natural killer cell activity (NKCA) and IL-6 production among adult patients undergoing lumbar surgery. Presurgical stress and anxiety can lead to detrimental patient outcomes after surgery, such as increased infection rates. It has been hypothesized that such outcomes are due to stress-immune alterations, which may be further exacerbated by the extent of surgery. However, psychologic stress, anxiety, and mood have not been previously characterized in patients undergoing spinal surgery. Pain, stress, anxiety, and mood were measured using self-report instruments at T1 (1 week before surgery), T2 (the day of surgery), T3 (the day after surgery), and T4 (6 weeks after surgery). Blood (30 mL) was collected for immune assessments at each time point. Pain, stress, anxiety, and mood state were elevated at baseline in both surgical groups and were associated with significant reduction in NKCA compared with the nonsurgical control group. A further decrease in NKCA was observed 24 hours after surgery in both surgical groups with a significant rise in stimulated IL-6 production, regardless of the magnitude of surgery. In the recovery period, NKCA increased to or above baseline values, which correlated with decreased levels of reported pain, perceived stress, anxiety, and mood state. This study demonstrated that patients undergoing elective spinal surgery are highly stressed and anxious, regardless of the magnitude of surgery and that such psychologic factors may mediate a reduction in NKCA.

Hybrid Biosynthetic Autograft Extender for Use in Posterior Lumbar Interbody Fusion: Safety and Clinical Effectiveness.

PubMed

Chedid, Mokbel K; Tundo, Kelly M; Block, Jon E; Muir, Jeffrey M

2015-01-01

Autologous iliac crest bone graft is the preferred option for spinal fusion, but the morbidity associated with bone harvest and the need for graft augmentation in more demanding cases necessitates combining local bone with bone substitutes. The purpose of this study was to document the clinical effectiveness and safety of a novel hybrid biosynthetic scaffold material consisting of poly(D,L-lactide-co-glycolide) (PLGA, 75:25) combined by lyophilization with unmodified high molecular weight hyaluronic acid (10-12% wt:wt) as an extender for a broad range of spinal fusion procedures. We retrospectively evaluated all patients undergoing single- and multi-level posterior lumbar interbody fusion at an academic medical center over a 3-year period. A total of 108 patients underwent 109 procedures (245 individual vertebral levels). Patient-related outcomes included pain measured on a Visual Analog Scale. Radiographic outcomes were assessed at 6 weeks, 3-6 months, and 1 year postoperatively. Radiographic fusion or progression of fusion was documented in 221 of 236 index levels (93.6%) at a mean (±SD) time to fusion of 10.2+4.1 months. Single and multi-level fusions were not associated with significantly different success rates. Mean pain scores (+SD) for all patients improved from 6.8+2.5 at baseline to 3.6+2.9 at approximately 12 months. Improvements in VAS were greatest in patients undergoing one- or two-level fusion, with patients undergoing multi-level fusion demonstrating lesser but still statistically significant improvements. Overall, stable fusion was observed in 64.8% of vertebral levels; partial fusion was demonstrated in 28.8% of vertebral levels. Only 15 of 236 levels (6.4%) were non-fused at final follow-up.

Traumatic Posterior Atlantoaxial Dislocation Without Associated Fracture but With Neurological Deficit

PubMed Central

Xu, Yong; Li, Feng; Guan, Hanfeng; Xiong, Wei

2015-01-01

Abstract Posterior atlantoaxial dislocation without odontoid fracture is extremely rare and often results in fatal spinal cord injury. According to the reported literature, all cases presented mild or no neurologic deficit, with no definite relation to upper spinal cord injury. Little is reported about traumatic posterior atlantoaxial dislocation, with incomplete quadriplegia associated with a spinal cord injury. We present a case of posterior atlantoaxial dislocation without associated fracture, but with quadriplegia, and accompanying epidural hematoma and subarachnoid hemorrhage. The patient underwent gentle traction in the neutral position until repeated cranial computed tomography revealed no progression of the epidural hematoma. Thereafter, the atlantoaxial dislocation was reduced by using partial odontoidectomy via a video-assisted transcervical approach and maintained with posterior polyaxial screw-rod constructs and an autograft. Neurological status improved immediately after surgery, and the patient recovered completely after 1 year. Posterior fusion followed by closed reduction is the superior strategy for posterior atlantoaxial dislocation without odontoid fracture, according to literature. But for cases with severe neurological deficit, open reduction may be the safest choice to avoid the lethal complication of overdistraction of the spinal cord. Also, open reduction and posterior srew-rod fixation are safe and convenient strategies in dealing with traumatic posterior atlantoaxial dislocation patients with neurological deficit. PMID:26512572

Periconal arterial anastomotic circle and posterior lumbosacral watershed zone of the spinal cord.

PubMed

Gailloud, Philippe; Gregg, Lydia; Galan, Peter; Becker, Daniel; Pardo, Carlos

2015-11-01

The existence of spinal cord watershed territories was suggested in the 1950s. Segmental infarcts within the junctional territories of adjacent radiculomedullary contributors and isolated spinal gray matter ischemia constitute two well-recognized types of watershed injury. This report describes the existence of another watershed territory related to the particular configuration of the spinal vasculature in the region of the conus medullaris. The anatomical bases underlying the concept of a posterior lumbosacral watershed zone are demonstrated with angiographic images obtained in a 16-year-old child. The clinical importance of this watershed zone is illustrated with MRI and angiographic data of three patients with a conus medullaris infarction. In all three cases of spinal ischemia an intersegmental artery providing a significant radiculomedullary contribution for the lower cord was compromised by a compressive mechanism responsible for decreased spinal cord perfusion (diaphragmatic crus syndrome in two cases, disk herniation in one). The ischemic injury, located at the junction of the anterior and posterior spinal artery territories along the dorsal aspect of the conus medullaris, was consistent with a watershed mechanism. This zone is at risk because of the caudocranial direction of flow within the most caudal segment of the posterior spinal arterial network which, from a functional standpoint, depends on the anterior spinal artery. The posterior thoracolumbar watershed zone of the spinal cord represents an area at increased risk of ischemic injury, particularly in the context of partial flow impairment related to arterial compression mechanisms. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Treatment of Spinal Tuberculosis by Debridement, Interbody Fusion and Internal Fixation via Posterior Approach Only.

PubMed

Tang, Ming-xing; Zhang, Hong-qi; Wang, Yu-xiang; Guo, Chao-feng; Liu, Jin-yang

2016-02-01

Surgical treatment for spinal tuberculosis includes focal tuberculosis debridement, segmental stability reconstruction, neural decompression and kyphotic deformity correction. For the lesions mainly involved anterior and middle column of the spine, anterior operation of debridement and fusion with internal fixation has been becoming the most frequently used surgical technique for the spinal tuberculosis. However, high risk of structural damage might relate with anterior surgery, such as damage in lungs, heart, kidney, ureter and bowel, and the deformity correction is also limited. Due to the organs are in the front of spine, there are less complications in posterior approach. Spinal pedicle screw passes through the spinal three-column structure, which provides more powerful orthopedic forces compared with the vertebral body screw, and the kyphotic deformity correction effect is better in posterior approach. In this paper, we report a 68-year-old male patient with thoracic tuberculosis who underwent surgical treatment by debridement, interbody fusion and internal fixation via posterior approach only. The patient was placed in prone position under general anesthesia. Posterior midline incision was performed, and the posterior spinal construction was exposed. Then place pedicle screw, and fix one side rod temporarily. Make the side of more bone destruction and larger abscess as lesion debridement side. Resect the unilateral facet joint, and retain contralateral structure integrity. Protect the spinal cord, nerve root. Clear sequestrum, necrotic tissue, abscess of paravertebral and intervertebral space. Specially designed titanium mesh cages or bone blocks were implanted into interbody. Fix both side rods and compress both sides to make the mesh cages and bone blocks tight. Reconstruct posterior column structure with allogeneic bone and autologous bone. Using this technique, the procedures of debridement, spinal cord decompression, deformity correction, bone grafting, and internal fixation can be completed with only one incision and surgical position, and the deformity correction efficiency is higher than anterior surgery. © 2016 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Intrathecal morphine for postoperative analgesia in patients with idiopathic scoliosis undergoing posterior spinal fusion.

PubMed

Tripi, Paul A; Poe-Kochert, Connie; Potzman, Jennifer; Son-Hing, Jochen P; Thompson, George H

2008-09-15

A retrospective study of postoperative pain management with intrathecal morphine. Identify the dosing regimen of intrathecal morphine that safely and effectively provides postoperative analgesia with minimal complications in patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). Postoperative pain after surgery for idiopathic scoliosis is a concern. Intrathecal morphine has been used to decrease pain. However, the most appropriate dose has not been determined. We retrospectively analyzed 407 consecutive patients with idiopathic scoliosis who underwent PSF and SSI at our institution from 1992 through 2006. Patients were divided into 3 groups based on the intrathecal morphine dose: no dose (n = 68); moderate dose of 9 to 19 microg/kg, mean 14 microg/kg (n = 293); and high dose of 20 microg/kg or greater, mean 24 microg/kg (n = 46). Data included demographics, Wong-Baker visual analog scale postoperative pain scores, postoperative intravenous morphine requirements, time to first rescue dose of intravenous morphine, and postoperative complications of pruritus, nausea/vomiting, respiratory depression, and pediatric intensive care unit (PICU) admission. The demographics of the 3 study groups showed no statistical differences. The mean Wong-Baker visual analog scale pain score in the post anesthesia care unit was 5.2, 0.5, and 0.2, and the mean time to first morphine rescue was 6.6, 16.7, and 22.9 hours, respectively. In the first 48 postoperative hours, respiratory depression occurred in 1 (1.5%), 8 (2.7%), and 7 (15.2%) patients, whereas PICU admission occurred in 0 (0%), 6 (2%), and 8 (17.4%) patients, respectively. The majority of PICU admissions were the result of respiratory depression. Frequency of pruritus and nausea/vomiting was similar in all 3 groups. Intrathecal morphine in the moderate dose range of 9 to 19 microg/kg (mean 14 microg/kg), provides safe and effective postoperative analgesia in the immediate postoperative period for patients with idiopathic scoliosis undergoing PSF and SSI. Higher doses did not result in significantly better analgesia and had a greater frequency of respiratory depression requiring PICU admission.

Reduction in surgical site infection with suprafascial intrawound application of vancomycin powder in instrumented posterior spinal fusion: a retrospective case-control study.

PubMed

Haimoto, Shoichi; Schär, Ralph T; Nishimura, Yusuke; Hara, Masahito; Wakabayashi, Toshihiko; Ginsberg, Howard J

2018-05-04

OBJECTIVE Recent studies have demonstrated the efficacy of subfascial intrawound application of vancomycin powder in spine surgery in reducing the rate of surgical site infections (SSIs). However, to date no study has evaluated the efficacy and safety of suprafascial application of vancomycin powder in spine surgery. The purpose of this study was to quantify the rate of SSIs after open instrumented posterior spinal fusion with and without application of suprafascial vancomycin powder and to evaluate the rate of vancomycin powder-related local adverse effects. METHODS The authors conducted a single-center retrospective case-control study of adult patients undergoing open instrumented posterior fusion of the cervical, thoracic, or lumbar spine performed by a single surgeon from January 2010 through December 2016. In March 2013, routine application of 1 g of suprafascial vancomycin powder was started for all cases in addition to standard systemic antibiotic prophylaxis. Baseline demographics and operative data as well as the SSI rates were compared between the study groups. The incidence of vancomycin powder-related adverse effects was analyzed. RESULTS A total of 515 patients (268 in the untreated group and 247 in the treated group) were included in the study. The mean age was significantly higher in the treated group than in the untreated group (58.4 vs 54.4 years, p < 0.01). Operative variables were similar between the study groups. Patients receiving vancomycin powder had a significantly lower infection rate (5.6% in the untreated group vs 0% in the treated group, p < 0.001). No vancomycin powder-related adverse effects were identified in the treated group. CONCLUSIONS Routine application of suprafascial intrawound vancomycin powder in addition to systemic antibiotic prophylaxis is an easy-to-use, safe, and effective strategy for preventing SSIs after instrumented posterior spinal fusion. Suprafascial application of vancomycin powder could be a valuable alternative to previously reported subfascial distribution, minimizing the risk of local adverse drug reactions.

Use of liposomal bupivacaine in the postoperative management of posterior spinal decompression.

PubMed

Grieff, Anthony N; Ghobrial, George M; Jallo, Jack

2016-07-01

OBJECTIVE The aim in this paper was to evaluate the efficacy of long-acting liposomal bupivacaine in comparison with bupivacaine hydrochloride for lowering postoperative analgesic usage in the management of posterior cervical and lumbar decompression and fusion. METHODS A retrospective cohort-matched chart review of 531 consecutive cases over 17 months (October 2013 to February 2015) for posterior cervical and lumbar spinal surgery procedures performed by a single surgeon (J.J.) was performed. Inclusion criteria for the analysis were limited to those patients who received posterior approach decompression and fusion for cervical or lumbar spondylolisthesis and/or stenosis. Patients from October 1, 2013, through December 31, 2013, received periincisional injections of bupivacaine hydrochloride, whereas after January 1, 2014, liposomal bupivacaine was solely administered to all patients undergoing posterior approach cervical and lumbar spinal surgery through the duration of treatment. Patients were separated into 2 groups for further analysis: posterior cervical and posterior lumbar spinal surgery. RESULTS One hundred sixteen patients were identified: 52 in the cervical cohort and 64 in the lumbar cohort. For both cervical and lumbar cases, patients who received bupivacaine hydrochloride required approximately twice the adjusted morphine milligram equivalent (MME) per day in comparison with the liposomal bupivacaine groups (5.7 vs 2.7 MME, p = 0.27 [cervical] and 17.3 vs 7.1 MME, p = 0.30 [lumbar]). The amounts of intravenous rescue analgesic requirements were greater for bupivacaine hydrochloride in comparison with liposomal bupivacaine in both the cervical (1.0 vs 0.39 MME, p = 0.31) and lumbar (1.0 vs 0.37 MME, p = 0.08) cohorts as well. None of these differences was found to be statistically significant. There were also no significant differences in lengths of stay, complication rates, or infection rates. A subgroup analysis of both cohorts of opiate-naive versus opiate-dependent patients found that those patients who were naive had no difference in opiate requirements. In chronic opiate users, there was a trend toward higher opiate requirements for the bupivacaine hydrochloride group than for the liposomal bupivacaine group; however, this trend did not achieve statistical significance. CONCLUSIONS Liposomal bupivacaine did not appear to significantly decrease perioperative narcotic use or length of hospitalization, although there was a trend toward decreased narcotic use in comparison with bupivacaine hydrochloride. While the results of this study do not support the routine use of liposomal bupivacaine, there may be a benefit in the subgroup of patients who are chronic opiate users. Future prospective randomized controlled trials, ideally with dose-response parameters, must be performed to fully explore the efficacy of liposomal bupivacaine, as the prior literature suggests that clinically relevant effects require a minimum tissue concentration.

Isolation and Characterization of Human Mesenchymal Stem Cells From Facet Joints and Interspinous Ligaments.

PubMed

Kristjánsson, Baldur; Limthongkul, Worawat; Yingsakmongkol, Wicharn; Thantiworasit, Pattarawat; Jirathanathornnukul, Napaphat; Honsawek, Sittisak

2016-01-01

A descriptive in vitro study on isolation and differentiation of human mesenchymal stem cells (MSCs) derived from the facet joints and interspinous ligaments. To isolate cells from the facet joints and interspinous ligaments and investigate their surface marker profile and differentiation potentials. Lumbar spinal canal stenosis and ossification of the posterior longitudinal ligament are progressive conditions characterized by the hypertrophy and ossification of ligaments and joints within the spinal canal. MSCs are believed to play a role in the advancement of these diseases and the existence of MSCs has been demonstrated within the ligamentum flavum and posterior longitudinal ligament. The aim of this study was to investigate whether these cells could also be found within facet joints and interspinous ligaments. Samples were harvested from 10 patients undergoing spinal surgery. The MSCs from facet joints and interspinous ligaments were isolated using direct tissue explant technique. Cell surface antigen profilings were performed via flow cytometry. Their lineage differentiation potentials were analyzed. The facet joints and interspinous ligaments-derived MSCs have the tri-lineage potential to be differentiated into osteogenic, adipogenic, and chondrogenic cells under appropriate inductions. Flow cytometry analysis revealed both cell lines expressed MSCs markers. Both facet joints and interspinous ligaments-derived MSCs expressed marker genes for osteoblasts, adipocytes, and chondrocytes. The facet joints and interspinous ligaments may provide alternative sources of MSCs for tissue engineering applications. The facet joints and interspinous ligaments-derived MSCs are part of the microenvironment of the human ligaments of the spinal column and might play a crucial role in the development and progression of degenerative spine conditions.

Migration of titanium cable into spinal cord and spontaneous C2 and C3 fusion: Case report of possible causes of fatigue failure after posterior atlantoaxial fixation.

PubMed

Li, Huibo; Lou, Jigang; Liu, Hao

2016-12-01

Atlantoaxial instability is a common and serious injury of the upper cervical spine. Brooks' procedure is widely used to reconstruct the unstable atlantoaxial joint. The migration into spinal cord of titanium cable and spontaneous fusion between C2 and C3 has been little reported and the management of such a patient is difficult. We describe an unusual case of fatigue failure of posterior titanium atlantoaxial cable fixation with migration into the spinal cord and spontaneous fusion between C2 and C3. A 16-year-old girl complained of cervico-occipital pain with numbness and weakness of extremities 3 months ago. The girl underwent posterior C1-C2 arthrodesis with titanium cables and autogenous iliac crest bone grafting when she was 6 years old. When presented to our emergency department, imaging revealed the cracked titanium atlantoaxial cable and the spontaneous fusion between C2 and C3. Computed tomography demonstrated a broken wire with anterior migration of the cable into the spinal cord. The patient underwent posterior approach cervical spinal surgery to remove the broken cables. She remains neurologically intact a year following the posterior approach cervical spine surgery. Brooks' posterior stabilization could not effectively control rotation at the atlantoaxial articulation, so surgeons must be aware of the potential of fatigue failure of cables as well as the possibility of its migration into the spinal cord when using Brooks' posterior stabilization. Bilateral C1 lateral mass and C2 pedicle screw fixation or transarticular screw fixation are recommended by the authors in the event of rotatory instability.

The Impact of Cage Dimensions, Positioning, and Side of Approach in Extreme Lateral Interbody Fusion.

PubMed

Alimi, Marjan; Lang, Gernot; Navarro-Ramirez, Rodrigo; Perrech, Moritz; Berlin, Connor; Hofstetter, Christoph P; Moriguchi, Yu; Elowitz, Eric; Härtl, Roger

2018-02-01

This is a retrospective single-center study. The aim of the study was to evaluate the impact of cage characteristics and position toward clinical and radiographic outcome measures in patients undergoing extreme lateral interbody fusion (ELIF). ELIF is utilized for indirect decompression and minimally invasive surgical treatment for various degenerative spinal disorders. However, evidence regarding the influence of cage characteristics in patient outcome is minimal. Patients undergoing ELIF between 2007 and 2011 were included in a retrospective study. Demographic and perioperative data, as well as cage characteristics and side of approach were extracted. Radiographic parameters including lumbar lordosis, foraminal height, and disc height as well as clinical outcome parameters (Oswestry Disability Index and Visual Analog Scale) were measured preoperatively, postoperatively, and at the latest follow-up examination. Cage dimensions, in situ position, and type were correlated with radiographic and clinical outcome parameters. In total, 84 patients with a total of 145 functional spinal units were analyzed. At the last follow-up of 17.7 months, radiographic and clinical outcome measures revealed significant improvement compared with before surgery with both, 18 and 22 mm cage anterior-posterior diameter subgroups (P≤0.05). Among cage characteristics, 22 mm cages presented superior restoration of foraminal and disc heights compared with 18 mm cages (P≤0.05). Neither position of the cage (anterior vs. posterior), nor the type (parallel vs. lordotic) had a significant impact on restoration of foraminal height and lumbar lordosis. Moreover, the side of surgical approach did not influence the amount of foraminal height increase. Cage anterior-posterior diameter is the determining factor in restoration of foraminal height in ELIF. Cage height, type, positioning, and side of approach do not have a determining role in radiographic outcome in the present study. Sustainable foraminal height restoration is achieved by implantation of wider cages. Level 3.

Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: a comparison between surgeries performed with and without a vertical exponential filtered air-flow system.

PubMed

Gruenberg, Marcelo F; Campaner, Gustavo L; Sola, Carlos A; Ortolan, Eligio G

2004-10-15

This study retrospectively compared infection rates between adult patients after posterior spinal instrumentation procedures performed in a conventional versus an ultraclean air operating room. To evaluate if the use of ultraclean air technology could decrease the infection rate after posterior spinal arthrodesis with instrumentation. Postoperative wound infection after posterior arthrodesis remains a feared complication in spinal surgery. Although this frequent complication results in a significant problem, the employment of ultraclean air technology, as it is commonly used for arthroplasty, has not been reported as a possible alternative to reduce the infection rate after complex spine surgery. One hundred seventy-nine patients having posterior spinal fusion with instrumentation were divided into 2 groups: group I included 139 patients operated in a conventional operating room, and group II included 40 patients operated in a vertical laminar flow operating room. Patient selection was performed favoring ultraclean air technology for elective cases in which high infection risk was considered. A statistical analysis of the infection rate and its associated risk factors between both groups was assessed. We observed 18 wound infections in group I and 0 in group II. Comparison of infection rates using the chi-squared test showed a statistically significant difference (P <0.017). The use of ultraclean air technology reduced the infection rate after complex spinal procedures and appears to be an interesting alternative that still needs to be prospectively studied with a randomized protocol.

Can Intraoperative Text Messages Reduce Parental Anxiety of Children Undergoing Posterior Spinal Fusion Surgery for Adolescent Idiopathic Scoliosis?

PubMed

Kwan, Mun Keong; Chiu, Chee Kidd; Gan, Chiao Chin; Chan, Chris Yin Wei

2016-02-01

A prospective, nonrandomized study. To evaluate the effectiveness of periodic intraoperative text messages (SMS) in reducing parental anxiety level during posterior spinal fusion (PSF) surgery for adolescent idiopathic scoliosis (AIS) patients. No studies have reported the use of intraoperative SMS to reduce level of anxiety in parents of patients who are undergoing AIS corrective surgery. Parents of 50 AIS patients were studied at two centers. Group 1 did not receive any SMS whereas those in Group 2 received periodic SMS. Parents' anxiety were assessed using a validated Visual Analog Scale for anxiety (VAS-A) and the anxiety component of the Hospital Anxiety Depression Score (HADS). The assessment was carried out at five different periods: (P1) 6 hours before the surgery; (P2) at separation in the operation theatre; (P3) 1 hour after commencement of surgery; (P4) immediately after completion of surgery; (P5) 1 day postsurgery. A total of 96 parents (47 fathers, 49 mothers) were involved in this study. Both groups were comparable in terms of demographics and education level. The mean VAS for Group 1 peaked at P2 and the HADS scores peaked at P3. The anxiety level of Group 1 remained high at P2, P3, and P4. There was a steady decline in parental anxiety in Group 2 from P1 to P5. There were significantly lower mean VAS score and HADS score for both father and mother in Group 2 during P3 and P4. The mean HADS scores for parents in Group 1 at P2 and P3 were higher than 8, which indicate abnormal anxiety. The anxiety levels of parents receiving the SMS were significantly lower than parents who did not receive any messages. Thus, intraoperative SMS is an effective intervention to decrease parental anxiety of AIS patients undergoing PSF surgery. 3.

Eliminating the use of allogeneic blood products in adolescent idiopathic scoliosis surgery.

PubMed

Berney, Mark J; Dawson, Peter H; Phillips, Margaret; Lui, Darren F; Connolly, Paul

2015-07-01

The aim of this study was to compare transfusion requirements in patients before and after the introduction of tranexamic acid as standard in patients undergoing spinal surgery for idiopathic scoliosis in a national orthopaedic hospital. A retrospective chart review of 56 idiopathic scoliosis patients who underwent posterior spinal instrumentation and fusion between 2009 and 2013 at our institution. Preoperative, intraoperative, and postoperative data were measured. Patients who received tranexamic acid as standard (n = 31) showed a trend towards a decrease in transfusion requirements compared with those who received no tranexamic acid (n = 25). These patients had a statistically significant decrease in operative time (223 vs 188 min, p = 0.005), and estimated intraoperative blood loss was reduced by nearly 50% in the tranexamic acid group. They also had an associated reduced decrease in haemoglobin between preoperative and postoperative levels (4 vs 5 g/dL, p = 0.01). Since February 2012, no patient has required intraoperative or postoperative allogeneic blood product transfusion in this hospital. The routine use of antifibrinolytic medications in patients undergoing surgery for adolescent idiopathic scoliosis has effectively eliminated the need for allogeneic blood products.

Population pharmacokinetics of ϵ-aminocaproic acid in adolescents undergoing posterior spinal fusion surgery.

PubMed

Stricker, P A; Gastonguay, M R; Singh, D; Fiadjoe, J E; Sussman, E M; Pruitt, E Y; Goebel, T K; Zuppa, A F

2015-04-01

Despite demonstrated efficacy of ϵ-aminocaproic acid (EACA) in reducing blood loss in adolescents undergoing spinal fusion, there are no population-specific pharmacokinetic data to guide dosing. The aim of this study was to determine the pharmacokinetics of EACA in adolescents undergoing spinal fusion surgery and make dosing recommendations. Twenty children ages 12-17 years were enrolled, with 10 children in each of two groups based on diagnosis (idiopathic scoliosis or non-idiopathic scoliosis). Previously reported data from infants undergoing craniofacial surgery were included in the model to enable dosing recommendations over a wide range of weights, ages, and diagnoses. A population non-linear mixed effects modelling approach was used to characterize EACA pharmacokinetics. Population pharmacokinetic parameters were estimated using a two-compartment disposition model with allometrically scaled weight and an age effect on clearance. Pharmacokinetic parameters for the typical patient were a plasma clearance of 153 ml min(-1) 70 kg(-1) (6.32 ml min(-1) kg(-0.75)), intercompartmental clearance of 200 ml min(-1) 70 kg(-1) (8.26 ml min(-1) kg(-0.75)), central volume of distribution of 8.78 litre 70 kg(-1) (0.13 litre kg(-1)), and peripheral volume of distribution of 15.8 litre 70 kg(-1) (0.23 litre kg(-1)). Scoliosis aetiology did not have a clinically significant effect on drug pharmacokinetics. The following dosing schemes are recommended according to patient weight: weight <25 kg, 100 mg kg(-1) loading dose and 40 mg kg(-1) h(-1) infusion; weight ≤25 kg-<50 kg, 100 mg kg(-1) loading dose and 35 mg kg(-1) h(-1) infusion; and weight ≥50 kg, 100 mg kg(-1) loading dose and 30 mg kg(-1) h(-1) infusion. An efficacy trial employing this dosing strategy is warranted. NCT01408823. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Population pharmacokinetics of ϵ-aminocaproic acid in adolescents undergoing posterior spinal fusion surgery

PubMed Central

Stricker, P. A.; Gastonguay, M. R.; Singh, D.; Fiadjoe, J. E.; Sussman, E. M.; Pruitt, E. Y.; Goebel, T. K.; Zuppa, A. F.

2015-01-01

Background Despite demonstrated efficacy of ϵ-aminocaproic acid (EACA) in reducing blood loss in adolescents undergoing spinal fusion, there are no population-specific pharmacokinetic data to guide dosing. The aim of this study was to determine the pharmacokinetics of EACA in adolescents undergoing spinal fusion surgery and make dosing recommendations. Methods Twenty children ages 12–17 years were enrolled, with 10 children in each of two groups based on diagnosis (idiopathic scoliosis or non-idiopathic scoliosis). Previously reported data from infants undergoing craniofacial surgery were included in the model to enable dosing recommendations over a wide range of weights, ages, and diagnoses. A population non-linear mixed effects modelling approach was used to characterize EACA pharmacokinetics. Results Population pharmacokinetic parameters were estimated using a two-compartment disposition model with allometrically scaled weight and an age effect on clearance. Pharmacokinetic parameters for the typical patient were a plasma clearance of 153 ml min−1 70 kg−1 (6.32 ml min−1 kg−0.75), intercompartmental clearance of 200 ml min−1 70 kg−1 (8.26 ml min−1 kg−0.75), central volume of distribution of 8.78 litre 70 kg−1 (0.13 litre kg−1), and peripheral volume of distribution of 15.8 litre 70 kg−1 (0.23 litre kg−1). Scoliosis aetiology did not have a clinically significant effect on drug pharmacokinetics. Conclusions The following dosing schemes are recommended according to patient weight: weight <25 kg, 100 mg kg−1 loading dose and 40 mg kg−1 h−1 infusion; weight ≤25 kg–<50 kg, 100 mg kg−1 loading dose and 35 mg kg−1 h−1 infusion; and weight ≥50 kg, 100 mg kg−1 loading dose and 30 mg kg−1 h−1 infusion. An efficacy trial employing this dosing strategy is warranted. Clinical trial registration NCT01408823. PMID:25586726

Serum levels of nickel and chromium after instrumented posterior spinal arthrodesis.

PubMed

Kim, Young-Jo; Kassab, Farid; Berven, Sigurd H; Zurakowski, David; Hresko, M Timothy; Emans, John B; Kasser, James R

2005-04-15

Cross-sectional study of 37 patients to measure serum levels of nickel and chromium after posterior spinal arthrodesis using stainless steel implants. To investigate the relationship between factors such as age, gender, pain, time from surgery, length of arthrodesis, and level of arthrodesis to serum metal ion levels after instrumented spinal arthrodesis. Measurable levels of metal ions in the serum can be detected after the use of stainless steel implants. There is some evidence to suggest that long-term exposure can potentially be toxic. Posterior spinal arthrodesis with stainless steel implants is a common procedure to treat spinal deformity in the adolescent population; however, the extent of metal ion exposure after posterior spinal arthrodesis is unknown. Patients that underwent posterior instrumented spinal arthrodesis with more than 6 months follow-up were recruited for this study. Patients with altered neurologic function were excluded. Serum levels of nickel and chromium were measured using inductively coupled plasma mass spectrometry. Pain was assessed using the Oswestry questionnaire. Spine radiographs were used to look for evidence of pseudarthrosis. Forty-five patients were approached, and 37 agreed to the questionnaire and blood test. Ten patients were men and 27 were women. Mean age at surgery was 14 years with mean follow-up of 6 years. Statistical correlations between serum metal ion levels and age at surgery, time from surgery, gender, number of segments fused, spinal instrument interfaces, pain, and instrumentation type were assessed. Abnormally high levels of nickel and chromium above normal levels (0.3 ng/mL for nickel, 0.15 ng/mL for chromium) could be detected in serum after posterior spinal arthrodesis using stainless steel implants. There was a significant inverse correlation between serum nickel (r = -0.61, P < 0.001) and chromium (r = -0.64, P < 0.001) levels and time from surgery. When patients were grouped based on lengths of time from surgery, 0 to 2 years (n = 7), 2 to 4 years (n = 11), and >4 years (n = 8), the mean +/- SD for nickel (ng/mL) was 3.8 +/- 2.6, 1.3 +/- 1.1, and 0.9 +/- 0.8, respectively. Analysis ofvariance revealed significant group differences (P =0.004). Similarly, the chromium levels were 2.7 +/- 2.7, 0.6 +/- 0.4, and 0.3 +/- 0.3, respectively (P = 0.018). Only time from surgery was a significant multivariate predictor of nickel and chromium serum levels. Pseudarthrosis was not seen in this cohort. Elevated levels of nickel and chromium can be measured after posterior instrumented spinal arthrodesis. The levels diminish rapidly with time from surgery but still remained above normal levels 4 years after surgery. Long-term implication of this metal ion exposure is unknown and should be studied further.

One-stage posterior focus debridement, interbody grafts, and posterior instrumentation and fusion in the surgical treatment of thoracolumbar spinal tuberculosis with kyphosis in children: a preliminary report.

PubMed

Wang, Yu-Xiang; Zhang, Hong-Qi; Tang, Ming-Xing; Guo, Chao-Feng; Deng, Ang; Wu, Jian-Huang; Liu, Jin-Yang; Deng, Zhansheng; Chen, Jing

2016-08-01

The purpose of this study was to determine the efficacy and feasibility of surgical management of children with thoracolumbar spine tuberculosis with kyphosis by using one-stage posterior focus debridement, interbody grafts, and posterior instrumentation and fusion. From October 2010 to September 2013, 21 children with thoracolumbar spinal tuberculosis accompanied by kyphosis were treated with one-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion. There were 13 males and 8 females, aged from 7 to 13 years old (average age 9.9 years). The mean follow-up was 34 months (range26-48 months). Patients were evaluated before and after surgery in terms of ESR, neurologic status, pain, and kyphotic angle. Spinal tuberculosis was completely cured, and the grafted bones were fused in all 21 patients. There was no recurrent tuberculous infection. ESR got normal within 3 months in all patients. The ASIA neurologic classification improved in all cases. Pain relief was obtained in all patients. The average preoperative kyphosis was 29.7° (range 12-42°) and decreased to 5.5° (range 2-10°), postoperatively. There was no significant loss of the correction at the latest follow-up. Our results show that one-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion were an effective treatment for children with thoracolumbar spinal tuberculosis. It is characterized as minimum surgical trauma, good neurologic recovery, good correction of kyphosis, and prevention of progressive kyphosis.

The dosimetric impact of implants on the spinal cord dose during stereotactic body radiotherapy.

PubMed

Yazici, Gozde; Sari, Sezin Yuce; Yedekci, Fazli Yagiz; Yucekul, Altug; Birgi, Sumerya Duru; Demirkiran, Gokhan; Gultekin, Melis; Hurmuz, Pervin; Yazici, Muharrem; Ozyigit, Gokhan; Cengiz, Mustafa

2016-05-25

The effects of spinal implants on dose distribution have been studied for conformal treatment plans. However, the dosimetric impact of spinal implants in stereotactic body radiotherapy (SBRT) treatments has not been studied in spatial orientation. In this study we evaluated the effect of spinal implants placed in sawbone vertebra models implanted as in vivo instrumentations. Four different spinal implant reconstruction techniques were performed using the standard sawbone lumbar vertebrae model; 1. L2-L4 posterior instrumentation without anterior column reconstruction (PI); 2. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (AIAC); 3. L2-L4 posterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (PIAC); 4. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with chest tubes filled with bone cement (AIABc). The target was defined as the spinous process and lamina of the lumbar (L) 3 vertebra. A thermoluminescent dosimeter (TLD, LiF:Mg,Ti) was located on the measurement point anterior to the spinal cord. The prescription dose was 8 Gy and the treatment was administered in a single fraction using a CyberKnife® (Accuray Inc., Sunnyvale, CA, USA). We performed two different treatment plans. In Plan A beam interaction with the rod was not limited. In plan B the rod was considered a structure of avoidance, and interaction between the rod and beam was prevented. TLD measurements were compared with the point dose calculated by the treatment planning system (TPS). In plan A, the difference between TLD measurement and the dose calculated by the TPS was 1.7 %, 2.8 %, and 2.7 % for the sawbone with no implant, PI, and PIAC models, respectively. For the AIAC model the TLD dose was 13.8 % higher than the TPS dose; the difference was 18.6 % for the AIABc model. In plan B for the AIAC and AIABc models, TLD measurement was 2.5 % and 0.9 % higher than the dose calculated by the TPS, respectively. Spinal implants may be present in the treatment field in patients scheduled to undergo SBRT. For the types of implants studied herein anterior rod instrumentation resulted in an increase in the spinal cord dose, whereas use of a titanium cage had a minimal effect on dose distribution. While planning SBRT in patients with spinal reconstructions, avoidance of the rod and preventing interaction between the rod and beam might be the optimal solution for preventing unexpectedly high spinal cord doses.

Analysis of the spinal nerve roots in relation to the adjacent vertebral bodies with respect to a posterolateral vertebral body replacement procedure.

PubMed

Awwad, Waleed; Bourget-Murray, Jonathan; Zeiadin, Nadil; Mejia, Juan P; Steffen, Thomas; Algarni, Abdulrahman D; Alsaleh, Khalid; Ouellet, Jean; Weber, Michael; Jarzem, Peter F

2017-01-01

This study aims to improve the understanding of the anatomic variations along the thoracic and lumbar spine encountered during an all-posterior vertebrectomy, and reconstruction procedure. This information will help improve our understanding of human spine anatomy and will allow better planning for a vertebral body replacement (VBR) through either a transpedicular or costotransversectomy approach. The major challenge to a total posterior approach vertebrectomy and VBR in the thoracolumbar spine lies in the preservation of important neural structures. This was a retrospective analysis. Hundred normal magnetic resonance imaging (MRI) spinal studies (T1-L5) on sagittal T2-weighted MRI images were studied to quantify: (1) mid-sagittal vertebral body (VB) dimensions (anterior, midline, and posterior VB height), (2) midline VB and associated intervertebral discs height, (3) mean distance between adjacent spinal nerve roots (DNN) and mean distance between the inferior endplate of the superior vertebrae to its respective spinal nerve root (DNE), and (4) posterior approach expansion ratio (PAER). (1) The mean anterior VB height gradually increased craniocaudally from T1 to L5. The mean midline and posterior VB height showed a similar pattern up to L2. Mean posterior VB height was larger than the mean anterior VB height from T1 to L2, consistent with anterior wedging, and then measured less than the mean anterior VB height, indicating posterior wedging. (2) Midline VB and intervertebral disc height gradually increased from T1 to L4. (3) DNN and DNE were similar, whereby they gradually increased from T1 to L3. (5) Mean PAER varied between 1.69 (T12) and 2.27 (L5) depending on anatomic level. The dimensions of the thoracic and lumbar vertebrae and discs vary greatly. Thus, any attempt at carrying out a VBR from a posterior approach should take into account the specifications at each spinal level.

[Diagnostic imaging of spinal diseases].

PubMed

Miyasaka, Kazuo

2005-11-01

With the advent of magnetic resonance imaging, diagnostic accuracy of spinal disorders has been much improved regarding their localization and histological prediction. The location of herniated disc materials is well appreciated on MR images without using contrast materials. MRI can predict the posterior longitudinal ligament is perforated or not. Kinematics of the spinal axis and CSF flow movement is evaluated on MRI with fast imaging. MR angiography with 3D reconstruction depicts the Adamkiewicz's artery and anterior spinal artery. Neuritis and neuropathy can be diagnosed by post-contrast T1 weighted image since inflammatory nerves are thick and enhance. Some intramedullary deseases tend to involve the peripheral area of the spinal cord; others are central. Edema extends longitudinally within the spinal cord by sparing the peripheral margin of the spinal cord and it is well appreciated with the T2- and proton- weighted images. The lateral and posterior funiculi are more frequently involved in multiple sclerosis.

Boomerang deformity of cervical spinal cord migrating between split laminae after laminoplasty.

PubMed

Kimura, S; Gomibuchi, F; Shimoda, H; Ikezawa, Y; Segawa, H; Kaneko, F; Uchiyama, S; Homma, T

2000-04-01

Patients with cervical compression myelopathy were studied to elucidate the mechanism underlying boomerang deformity, which results from the migration of the cervical spinal cord between split laminae after laminoplasty with median splitting of the spinous processes (boomerang sign). Thirty-nine cases, comprising 25 patients with cervical spondylotic myelopathy, 8 patients with ossification of the posterior longitudinal ligament, and 6 patients with cervical disc herniation with developmental canal stenosis, were examined. The clinical and radiological findings were retrospectively compared between patients with (B group, 8 cases) and without (C group, 31 cases) boomerang sign. Moderate increase of the grade of this deformity resulted in no clinical recovery, although there was no difference in clinical recovery between the two groups. Most boomerang signs developed at the C4/5 and/or C5/6 level, where maximal posterior movement of the spinal cord was achieved. Widths between lateral hinges and between split laminae in the B group were smaller than in the C group. Flatness of the spinal cord in the B group was more severe than in the C group. In conclusion, the boomerang sign was caused by posterior movement of the spinal cord, narrower enlargement of the spinal canal and flatness of the spinal cord.

One-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis.

PubMed

Pang, Xiaoyang; Wu, Ping; Shen, Xiongjie; Li, Dongzhe; Luo, Chenke; Wang, Xiyang

2013-08-01

Retrospective analysis of the clinical study efficacy and feasibility of one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis. A total of 21 patients with lumbosacral tuberculosis (TB) collected from January 2004 to January 2010, underwent one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation. In addition, the clinical efficacy was evaluated based on the data on the lumbo-sacral angle, neuro-logical status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at specific time points. All cases were followed up for 16-36 months (average 24.9 ± 6.44 months). 18 patients suffered from evident neurological deficits preoperatively, of which 16 patients returned to normal at the final follow-up. Two patients with neurological dysfunction aggravated postoperative, experienced significant partial neurological recovery. With an effective and standard anti-TB chemotherapy treated, the values of ESR and CRP returned to normal levels 3-month later postoperative and maintained till the final follow-up. Preoperative lumbosacral angle was 20.89 ± 2.32° and returned 29.62 ± 1.41° postoperative. During long-term follow-up, there was only 1-3° lumbosacral angle loss. There was a significant difference between preoperative and postoperative lumbosacral angles. With effective and standard anti-TB chemotherapy, one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation for lumbosacral tuberculosis can effectively relieve pain symptoms, improve neurological function, and reconstruct the spinal stability.

A case report of spondylectomy with circumference reconstruction for aggressive vertebral hemangioma covering the whole cervical spine (C4) with progressive spinal disorder.

PubMed

Nakahara, Masayuki; Nishida, Kenki; Kumamoto, Shinji; Hijikata, Yasukazu; Harada, Kei

2017-05-01

To describe the surgical experience of spondylectomy and spinal reconstruction for aggressive vertebral hemangioma (VH) induced at the C4 vertebra. No reports have described surgical strategy in cases covering an entire cervical vertebra presenting with progressive myelopathy. A 28-year-old man presented with rapidly progressing skilled motor dysfunction and gait disorder. The Japanese Orthopedic Association (JOA) score was 6. Radiography showed a honeycomb appearance for the entire circumference of the C4 vertebra. Spinal computed tomography and magnetic resonance imaging showed vertebral tumor with extraosseous extension causing spinal cord compression. Results of diagnostic imaging were strongly suggestive of VH. Transarterial embolization of the spinal body branch was performed first to decrease intraoperative bleeding, followed by cervical posterior fixation to stabilize the unstable segment and excision biopsy to obtain a definitive diagnosis. After definitive diagnosis of cavernous hemangioma, two-stage surgery (anterior and posterior) was performed to complete total spondylectomy and 360° spinal reconstruction. Despite multiple operations, JOA scores were 8.5 after posterior fixation, 10.5 after anterior surgery, 11 after final surgery and 16 on postoperative day 90. The patient acquired excellent clinical results without complications and returned to society. The present three-stage surgery comprising fixation, biopsy, and final spondylectomy with circumferential fusion from anterior and posterior approaches may offer a useful choice for aggressive VH covering the entire cervical spine with rapidly progressive myelopathy.

Obesity in Neurosurgery: A Narrative Review of the Literature.

PubMed

Castle-Kirszbaum, Mendel D; Tee, Jin W; Chan, Patrick; Hunn, Martin K

2017-10-01

Obesity is an important consideration in neurosurgical practice. Of Australian adults, 28.3% are obese and it is estimated that more than two thirds of Australia's population will be overweight or obese by 2025. This review of the effects of obesity on neurosurgical procedures shows that, in patients undergoing spinal surgery, an increased body mass index is a significant risk factor for surgical site infection, venous thromboembolism, major medical complications, prolonged length of surgery, and increased financial cost. Although outcome scores and levels of patient satisfaction are generally lower after spinal surgery in obese patients, obesity is not a barrier to deriving benefit from surgery and, when the natural history of conservative management is taken into account, the long-term benefits of surgery may be equivalent or even greater in obese patients than in nonobese patients. In cranial surgery, the impact of obesity on outcome and complication rates is generally lower. Specific exceptions are higher rates of distal catheter migration after shunt surgery and cerebrospinal fluid leak after posterior fossa surgery. Minimally invasive approaches show promise in mitigating some of the adverse effects of obesity in patients undergoing spine surgery but further studies are needed to develop strategies to reduce obesity-related surgical complications. Copyright © 2017 Elsevier Inc. All rights reserved.

Common neural structures activated by epidural and transcutaneous lumbar spinal cord stimulation: Elicitation of posterior root-muscle reflexes

PubMed Central

Freundl, Brigitta; Binder, Heinrich; Minassian, Karen

2018-01-01

Epidural electrical stimulation of the lumbar spinal cord is currently regaining momentum as a neuromodulation intervention in spinal cord injury (SCI) to modify dysregulated sensorimotor functions and augment residual motor capacity. There is ample evidence that it engages spinal circuits through the electrical stimulation of large-to-medium diameter afferent fibers within lumbar and upper sacral posterior roots. Recent pilot studies suggested that the surface electrode-based method of transcutaneous spinal cord stimulation (SCS) may produce similar neuromodulatory effects as caused by epidural SCS. Neurophysiological and computer modeling studies proposed that this noninvasive technique stimulates posterior-root fibers as well, likely activating similar input structures to the spinal cord as epidural stimulation. Here, we add a yet missing piece of evidence substantiating this assumption. We conducted in-depth analyses and direct comparisons of the electromyographic (EMG) characteristics of short-latency responses in multiple leg muscles to both stimulation techniques derived from ten individuals with SCI each. Post-activation depression of responses evoked by paired pulses applied either epidurally or transcutaneously confirmed the reflex nature of the responses. The muscle responses to both techniques had the same latencies, EMG peak-to-peak amplitudes, and waveforms, except for smaller responses with shorter onset latencies in the triceps surae muscle group and shorter offsets of the responses in the biceps femoris muscle during epidural stimulation. Responses obtained in three subjects tested with both methods at different time points had near-identical waveforms per muscle group as well as same onset latencies. The present results strongly corroborate the activation of common neural input structures to the lumbar spinal cord—predominantly primary afferent fibers within multiple posterior roots—by both techniques and add to unraveling the basic mechanisms underlying electrical SCS. PMID:29381748

A biomechanical analysis of the self-retaining pedicle hook device in posterior spinal fixation

PubMed Central

van Laar, Wilbert; Meester, Rinse J.; Smit, Theo H.

2007-01-01

Regular hooks lack initial fixation to the spine during spinal deformity surgery. This runs the risk of posterior hook dislodgement during manipulation and correction of the spinal deformity, that may lead to loss of correction, hook migration, and post-operative junctional kyphosis. To prevent hook dislodgement during surgery, a self-retaining pedicle hook device (SPHD) is available that is made up of two counter-positioned hooks forming a monoblock posterior claw device. The initial segmental posterior fixation strength of a SPHD, however, is unknown. A biomechanical pull-out study of posterior segmental spinal fixation in a cadaver vertebral model was designed to investigate the axial pull-out strength for a SPHD, and compared to the pull-out strength of a pedicle screw. Ten porcine lumbar vertebral bodies were instrumented in pairs with two different instrumentation constructs after measuring the bone mineral density of each individual vertebra. The instrumentation constructs were extracted employing a material testing system using axial forces. The maximum pull-out forces were recorded at the time of the construct failure. Failure of the SPHD appeared in rotation and lateral displacement, without fracturing of the posterior structures. The average pull-out strength of the SPHD was 236 N versus 1,047 N in the pedicle screws (P < 0.001). The pull-out strength of the pedicle screws showed greater correlation with the BMC compared to the SPHD (P < 0.005). The SPHD showed to provide a significant inferior segmental fixation to the posterior spine in comparison to pedicle screw fixation. Despite the beneficial characteristics of the monoblock claw construct in a SPHD, that decreases the risk of posterior hook dislodgement during surgery compared to regular hooks, the SPHD does not improve the pull-out strength in such a way that it may provide a biomechanically solid alternative to pedicle screw fixation in the posterior spine. PMID:17203270

Comparison of ultrasound-guided posterior transversus abdominis plane block and lateral transversus abdominis plane block for postoperative pain management in patients undergoing cesarean section: a randomized double-blind clinical trial study.

PubMed

Faiz, Seyed Hamid Reza; Alebouyeh, Mahmoud Reza; Derakhshan, Pooya; Imani, Farnad; Rahimzadeh, Poupak; Ghaderi Ashtiani, Maryam

2018-01-01

Due to the importance of pain control after abdominal surgery, several methods such as transversus abdominis plane (TAP) block are used to reduce the pain after surgery. TAP blocks can be performed using various ultrasound-guided approaches. Two important approaches to do this are ultrasound-guided lateral and posterior approaches. This study aimed to compare the two approaches of ultrasound-guided lateral and posterior TAP blocks to control pain after cesarean section. In this double-blind clinical trial study, 76 patients scheduled for elective cesarean section were selected and randomly divided into two groups of 38 and underwent spinal anesthesia. For pain management after the surgery, one group underwent lateral TAP block and the other group underwent posterior TAP block using 20cc of ropivacaine 0.2% on both sides. Pain intensity was evaluated based on Numerical Analog Scale (NAS) at rest and when coughing, 2, 4, 6, 12, 24 and 36 hours after surgery. The pain at rest in the posterior group at all hours post surgery was lower than the lateral group, especially at 6, 12 and 24 hours after the surgery and the difference was statistically significant ( p =0.03, p <0.004, p =0.001). The results of this study show that ultrasound-guided posterior TAP block compared with the lateral TAP block was more effective in pain control after cesarean section.

Pediatric Return to Sports After Spinal Surgery.

PubMed

Christman, Tyler; Li, Ying

2016-07-01

Pediatric patients who undergo spinal surgery are frequently involved in sporting activities. Return to play is often an important postoperative concern for the patient and family. A PubMed search was conducted for articles in the English language on return to play after treatment of pediatric acute disc herniation, degenerative disc disease, spondylolysis, spondylolisthesis, and scoliosis from 1980 to 2015. Reference lists were reviewed for additional pertinent articles. We included articles that focused on return to sports after surgical treatment of these conditions in this review. Clinical review. Level 4. There are no published guidelines, and most of the literature in this area has focused on return to play after spinal injury rather than after spinal surgery. Most children and adolescents have excellent outcomes with minimal pain at 1 year after lumbar discectomy. The majority of surgeons allow return to full activity once pain-free range of motion and strength are regained, typically at 8 to 12 weeks postoperatively. Pediatric patients with spondylolysis have good outcomes after direct pars repair. Satisfactory outcomes have been demonstrated after fusion for low- and high-grade spondylolisthesis. Most surgeons allow return to noncontact sports by 6 months after surgical treatment of spondylolysis and spondylolisthesis. Return to contact and collision sports is controversial. After posterior spinal fusion for scoliosis, most surgeons allow return to noncontact sports by 3 months and return to contact sports between 6 months and 1 year. Return to collision sports is controversial. There is little evidence to guide practitioners on return to sports after pediatric spinal surgery. Ultimately, the decision to allow any young athlete to resume sports participation after spinal injury or surgery must be individualized. © 2016 The Author(s).

Pediatric Return to Sports After Spinal Surgery

PubMed Central

Christman, Tyler; Li, Ying

2016-01-01

Context: Pediatric patients who undergo spinal surgery are frequently involved in sporting activities. Return to play is often an important postoperative concern for the patient and family. Evidence Acquisition: A PubMed search was conducted for articles in the English language on return to play after treatment of pediatric acute disc herniation, degenerative disc disease, spondylolysis, spondylolisthesis, and scoliosis from 1980 to 2015. Reference lists were reviewed for additional pertinent articles. We included articles that focused on return to sports after surgical treatment of these conditions in this review. Study Design: Clinical review. Level of Evidence: Level 4. Results: There are no published guidelines, and most of the literature in this area has focused on return to play after spinal injury rather than after spinal surgery. Most children and adolescents have excellent outcomes with minimal pain at 1 year after lumbar discectomy. The majority of surgeons allow return to full activity once pain-free range of motion and strength are regained, typically at 8 to 12 weeks postoperatively. Pediatric patients with spondylolysis have good outcomes after direct pars repair. Satisfactory outcomes have been demonstrated after fusion for low- and high-grade spondylolisthesis. Most surgeons allow return to noncontact sports by 6 months after surgical treatment of spondylolysis and spondylolisthesis. Return to contact and collision sports is controversial. After posterior spinal fusion for scoliosis, most surgeons allow return to noncontact sports by 3 months and return to contact sports between 6 months and 1 year. Return to collision sports is controversial. Conclusion: There is little evidence to guide practitioners on return to sports after pediatric spinal surgery. Ultimately, the decision to allow any young athlete to resume sports participation after spinal injury or surgery must be individualized. PMID:26920125

Novel spinal instrumentation to enhance osteogenesis and fusion: a preliminary study.

PubMed

MacEwan, Matthew R; Talcott, Michael R; Moran, Daniel W; Leuthardt, Eric C

2016-09-01

OBJECTIVE Instrumented spinal fusion continues to exhibit high failure rates in patients undergoing multilevel lumbar fusion or pseudarthrosis revision; with Grade II or higher spondylolisthesis; or in those possessing risk factors such as obesity, tobacco use, or metabolic disorders. Direct current (DC) electrical stimulation of bone growth represents a unique surgical adjunct in vertebral fusion procedures, yet existing spinal fusion stimulators are not optimized to enhance interbody fusion. To develop an advanced method of applying DC electrical stimulation to promote interbody fusion, a novel osteogenic spinal system capable of routing DC through rigid instrumentation and into the vertebral bodies was fabricated. A pilot study was designed to assess the feasibility of osteogenic instrumentation and compare the ability of osteogenic instrumentation to promote successful interbody fusion in vivo to standard spinal instrumentation with autograft. METHODS Instrumented, single-level, posterior lumbar interbody fusion (PLIF) with autologous graft was performed at L4-5 in adult Toggenburg/Alpine goats, using both osteogenic spinal instrumentation (plus electrical stimulation) and standard spinal instrumentation (no electrical stimulation). At terminal time points (3 months, 6 months), animals were killed and lumbar spines were explanted for radiographic analysis using a SOMATOM Dual Source Definition CT Scanner and high-resolution Microcat II CT Scanner. Trabecular continuity, radiodensity within the fusion mass, and regional bone formation were examined to determine successful spinal fusion. RESULTS Quantitative analysis of average bone density in pedicle screw beds confirmed that electroactive pedicle screws used in the osteogenic spinal system focally enhanced bone density in instrumented vertebral bodies. Qualitative and quantitative analysis of high-resolution CT scans of explanted lumbar spines further demonstrated that the osteogenic spinal system induced solid bony fusion across the L4-5 disc space as early as 6 weeks postoperatively. In comparison, inactive spinal instrumentation with autograft was unable to promote successful interbody fusion by 6 months postoperatively. CONCLUSIONS Results of this study demonstrate that novel osteogenic spinal instrumentation supports interbody fusion through the focal delivery of DC electrical stimulation. With further technical development and scientific/clinical validation, osteogenic spinal instrumentation may offer a unique alternative to biological scaffolds and pharmaceutical adjuncts used in spinal fusion procedures.

Reconstruction with fascia lata allograft of the posterior vertebra elements after resection for aneurysmal bone cyst in a child

PubMed Central

Schuster, Sergio; Biagini, Roberto; Casadei, Roberto; De Paolis, Massimiliano; Bertoni, Franco; Boriani, Stefano; Mercuri, Mario

2007-01-01

We report a case of ABC in a child where, after resection of the posterior spinal column of L1, we did a biological reconstruction using a posterior tension band with a segment of fascia lata allograft in tension between T12 and L2. After the long term follow up, X-ray and MRI controls showed a satisfactory alignment of the spine and no local recurrence. The patient now has no sign of spinal instability or deviation, with no kind of discomfort or pain, and has a normal life. In our experience this biological tension band interferes minimally with the growth of the spine, and has a less number of complications in comparison with other more aggressive methods and so is a good option for restoring the stability in young patients with benign spinal tumors that arises on the posterior column without having any kind of potential deviations. PMID:17426986

Effect of Surgical Approach on Pulmonary Function in Adolescent Idiopathic Scoliosis Patients: A Systemic Review and Meta-analysis.

PubMed

Lee, Andy C H; Feger, Mark A; Singla, Anuj; Abel, Mark F

2016-11-15

Systemic review and meta-analysis. To analyze the effect of spinal fusion and instrumentation for adolescent idiopathic scoliosis (AIS) on absolute pulmonary function test (PFTs). Pulmonary function is correlated with severity of deformity in AIS patients and studies that have analyzed the effect of spinal fusion and instrumentation on PFTs for AIS have reported inconsistent results. There is a need to analyze the effect of spinal fusion on PFTs with stratification by surgical approach. Our analysis included 22 studies. Cohen's d effect sizes were calculated for absolute PFT outcome measures with 95% confidence intervals (CI). Meta-analyses were performed at each postoperative time frame for six homogeneous surgical approaches: (i) combined anterior release and posterior fusion with instrumentation; (ii) combined video assisted anterior release and posterior fusion with instrumentation without thoracoplasty; (iii) posterior fusion with instrumentation without thoracoplasty; (iv) anterior fusion with instrumentation and without thoracoplasty; (v) video assisted anterior fusion with instrumentation without thoracoplasty; and (vi) any scoliosis surgery with additional thoracoplasty. Anterior spinal fusion with instrumentation, any scoliosis surgery with concomitant thoracoplasty, or video-assisted anterior fusion with instrumentation for AIS had similar absolute PFTs at their 2 year postoperative follow up compared with their preoperative PFTs (effect sizes ranging from -0.2-0.2 with all CI crossing "0"). Posterior spinal fusion with instrumentation (with or without an anterior release) demonstrated small to moderate increases in PFTs 2 years postoperatively (effect sizes ranging from 0.35-0.65 with all CI not crossing "0"). Anterior fusion with instrumentation, regardless of the approach, and any scoliosis surgery with concomitant thoracoplasty do not lead to significant change in pulmonary functions 2 year after surgery. Posterior spinal fusion with instrumentation (with or without an anterior release) resulted in small to moderate increases in PFTs. N/A.

Epidemiology and national trends in prevalence and surgical management of metastatic spinal disease.

PubMed

Horn, Samantha R; Dhillon, Ekamjeet S; Poorman, Gregory W; Tishelman, Jared C; Segreto, Frank A; Bortz, Cole A; Moon, John Y; Behery, Omar; Shepard, Nicholas; Diebo, Bassel G; Vira, Shaleen; Passias, Peter G

2018-07-01

Surgical treatment for spinal metastasis has benefited from improvements in surgical techniques. However, the trends in treatment and outcomes for spinal metastasis surgery have not been well-established in a pediatric population. Patients <20 years old with metastatic spinal tumors undergoing spinal surgery were identified in the KID database. Trends for spinal metastases treatment and patient outcomes were analyzed using weight-adjusted ANOVAs. 333 patients were identified in the KID database. The top five primary diagnoses were metastatic brain/spinal cord tumor (19.8%), metastatic nervous system tumor (15.9%), metastatic bone cancer (13.2%), spinal cord tumor (4.2%), and tumor of ventricles (3.0%). There was an increased incidence of spinal metastasis diagnoses from 2003 to 2012 (88.5-117.9 per 100,000; p < 0.001) and an increased trend in the incidence of surgical treatment for spinal metastasis from 2003 to 2012 (p = 0.014). The average age was 10.19 ± 6.33 years old and 38.4% were female. The average length of stay was 17.34 ± 24.36 days. Average CCI increased over time (2003: 7.87 ± 1.40, 2012: 8.44 ± 1.39; p = 0.006). The most common surgeries were excision of spinal cord/meninges lesions (69.1%) and decompression of spinal canal (38.1%). Length of hospital stay and in-hospital mortality did not change over time (17.34-18.04 days, p = 0.337; 1.6%-2.9%, p = 0.801). 10.5% of patients underwent a posterior fusion and 22.2% had at least one complication (nervous system, respiratory, dysphagia, infection). The overall complication rate remained stable over time (23.4%-21.8%, p = 0.952). Surgical treatment for spinal metastasis in the last decade has increased, though the complication rates, in-hospital mortality, and length of stay have remained stable. Copyright © 2018 Elsevier Ltd. All rights reserved.

Spinal deformity in patients with Sotos syndrome (cerebral gigantism).

PubMed

Tsirikos, Athanasios I; Demosthenous, Nestor; McMaster, Michael J

2009-04-01

Retrospective review of a case series. To present the clinical characteristics and progression of spinal deformity in patients with Sotos syndrome. There is limited information on the development of spinal deformity and the need for treatment in this condition. The medical records and spinal radiographs of 5 consecutive patients were reviewed. All patients were followed to skeletal maturity (mean follow-up: 6.6 y). The mean age at diagnosis of spinal deformity was 11.9 years (range: 5.8 to 14.5) with 4 patients presenting in adolescence. The type of deformity was not uniform. Two patients presented in adolescence with relatively small and nonprogressive thoracolumbar and lumbar scoliosis, which required observation but no treatment until the end of spinal growth. Three patients underwent spinal deformity correction at a mean age of 11.7 years (range: 6 to 15.4). The first patient developed a double structural thoracic and lumbar scoliosis and underwent a posterior spinal arthrodesis extending from T3 to L4. Five years later, she developed marked degenerative changes at the L4/L5 level causing symptomatic bilateral lateral recess stenosis and affecting the L5 nerve roots. She underwent spinal decompression at L4/L5 and L5/S1 levels followed by extension of the fusion to the sacrum. The second patient developed a severe thoracic kyphosis and underwent a posterior spinal arthrodesis. The remaining patient presented at the age of 5.9 years with a severe thoracic kyphoscoliosis and underwent a 2-stage antero-posterior spinal arthrodesis. The development of spinal deformity is a common finding in children with Sotos syndrome and in our series it occurred in adolescence in 4 out of 5 patients. There is significant variability on the pattern of spine deformity, ranging from a scoliosis through kyphoscoliosis to a pure kyphosis, and also the age at presentation and need for treatment.

[Hypobaric 0.15% bupivacaine versus hyperbaric 0.5% bupivacaine for posterior (dorsal) spinal block in outpatient anorectal surgery.].

PubMed

Imbelloni, Luiz Eduardo; Vieira, Eneida Maria; Gouveia, M A; Netinho, João Gomes; Cordeiro, José Antonio

2006-12-01

The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Mood's median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 +/- 25 minutes and in 95 +/- 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done.

Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

PubMed

Pang, Xiaoyang; Shen, Xiongjie; Wu, Ping; Luo, Chenke; Xu, Zhengquan; Wang, Xiyang

2013-06-01

Retrospective analysis of the clinical efficacy and feasibility of patients with thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. A total of 18 patients with thoracolumbar tuberculosis (TB), between February 2007 and February 2011, underwent one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. And the clinical efficacy was evaluated based on surgery duration time, the blood loss, the postural drainage of time, neurological status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, the fate of bone graft fusion, kyphosis angle, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at certain time. The average follow-up period was 34 months (range 18-48 months). 18 patients suffered from seriously neurological deficits pre-operatively, of which 16 patients returned to normal at final follow-up. The surgery duration time was 197 ± 37.9 min, and the blood loss was 815 ± 348.5 ml. The postural drainage of time was 7.2 ± 2.7 days. The psoas abscesses disappeared in all cases, within the time range of 6-9 months (mean 7.4 ± 1.2 months). All patients of the grafted bones were thoroughly fused, with a fusion time ranging from 4 to 12 months (mean 7.8 months). Kyphosis angle was 44.32 ± 7.26° on average pre-operative and returned to 11.72 ± 2.85° at 6 weeks after operation; kyphosis angle was 13.10 ± 2.39° at final follow-up. The values of ESR and CRP were significant declined at 6 weeks post-operative, and returned to normal levels at final follow-up. With standardized anti-TB chemotherapy, thoracolumbar spinal tuberculosis with psoas abscesses could be effectively treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

Protrusion of a rod into the spinal canal 10 years after segmental lumbar spine surgery.

PubMed

Cai, Siyi; Kong, Xiangyi; Yan, Chengrui; Wang, Yipeng; Wan, Xueshuai; Zhang, Jialu; Qiu, Guixing; Yu, Keyi

2017-03-01

The objective of this article is to report an unusual case of a spinal rod that protruded into the spinal canal after lumbar spine surgery.Only 4 cases of spinal rod migration with protrusion into the spinal canal have been reported. This is the first report of a case involving the use of posterior low lumbar segmental instrumentation with a screw-rod system. The left side of the rod gradually migrated and finally protruded into the canal and compressed the cord.A 60-year-old woman presented with pain and numbness of the posterior aspect of the left leg after a long-distance walk. Intermittent claudication became worse, and she developed pain and numbness in the perineal region. An x-ray showed that the left side of a spinal rod among the segmental spinal instruments that had been placed 10 years previously had protruded into the spinal canal.We removed the rod and decompressed the canal at the level of L5-S1. The patient became totally asymptomatic.Rods used as spinal instrumentation have the possibility of protruding into the spinal canal and endangering the nervous system. Long-term follow-up with radiological examinations should be conducted upon completion of spinal operations conducting using instrumentation.

Inhibitory descending rhombencephalic projections in larval sea lamprey.

PubMed

Valle-Maroto, S M; Fernández-López, B; Villar-Cerviño, V; Barreiro-Iglesias, A; Anadón, R; Rodicio, M Celina

2011-10-27

Lampreys are jawless vertebrates, the most basal group of extant vertebrates. This phylogenetic position makes them invaluable models in comparative studies of the vertebrate central nervous system. Lampreys have been used as vertebrate models to study the neuronal circuits underlying locomotion control and axonal regeneration after spinal cord injury. Inhibitory inputs are key elements in the networks controlling locomotor behaviour, but very little is known about the descending inhibitory projections in lampreys. The aim of this study was to investigate the presence of brain-spinal descending inhibitory pathways in larval stages of the sea lamprey Petromyzon marinus by means of tract-tracing with neurobiotin, combined with immunofluorescence triple-labeling methods. Neurobiotin was applied in the rostral spinal cord at the level of the third gill, and inhibitory populations were identified by the use of cocktails of antibodies raised against glycine and GABA. Glycine-immunoreactive (-ir) neurons that project to the spinal cord were observed in three rhombencephalic reticular nuclei: anterior, middle and posterior. Spinal-projecting GABA-ir neurons were observed in the anterior and posterior reticular nuclei. Double glycine-ir/GABA-ir spinal cord-projecting neurons were only observed in the posterior reticular nucleus, and most glycine-ir neurons did not display GABA immunoreactivity. The present results reveal the existence of inhibitory descending projections from brainstem reticular neurons to the spinal cord, which were analyzed in comparative and functional contexts. Further studies should investigate which spinal cord circuits are affected by these descending inhibitory projections. Copyright © 2011 IBRO. Published by Elsevier Ltd. All rights reserved.

Lumbar spine disc heights and curvature: upright posture vs. supine compression harness

NASA Technical Reports Server (NTRS)

Lee, Shi-Uk; Hargens, Alan R.; Fredericson, Michael; Lang, Philipp K.

2003-01-01

INTRODUCTION: Spinal lengthening in microgravity is thought to cause back pain in astronauts. A spinal compression harness can compress the spine to eliminate lengthening but the loading condition with harness is different than physiologic conditions. Our purpose was to compare the effect of spine compression with a harness in supine position on disk height and spinal curvature in the lumbar spine to that of upright position as measured using a vertically open magnetic resonance imaging system. METHODS: Fifteen healthy subjects volunteered. On day 1, each subject lay supine for an hour and a baseline scan of the lumbar spine was performed. After applying a load of fifty percent of body weight with the harness for thirty minutes, the lumbar spine was scanned again. On day 2, after a baseline scan, a follow up scan was performed after kneeling for thirty minutes within the gap between two vertically oriented magnetic coils. Anterior and posterior disk heights, posterior disk bulging, and spinal curvature were measured from the baseline and follow up scans. RESULTS: Anterior disk heights increased and posterior disk heights decreased compared with baseline scans both after spinal compression with harness and upright posture. The spinal curvature increased by both loading conditions of the spine. DISCUSSION: The spinal compression with specially designed harness has the same effect as the physiologic loading of the spine in the kneeling upright position. The harness shows some promise as a tool to increase the diagnostic capabilities of a conventional MR system.

Indocyanine green video-angiography as an aid to surgical treatment of spinal dural arteriovenous fistulae.

PubMed

Hettige, Samantha; Walsh, Daniel

2010-03-01

To illustrate the use of indocyanine green (ICG) video-angiography to confirm abolition of spinal dural arteriovenous fistula (SDAVF) and preserve the normal vascular anatomy intraoperatively. A 73-year-old woman presenting with progressive myelopathy was diagnosed with an SDAVF, where the origin of the fistula was in close proximity to the origin of the posterior spinal artery. ICG was injected intravenously. Using a filter on the microscope, dynamic filling of the abnormal vasculature was visualised. After applying a clip to the fistulous connection, we were able to see the successful interruption of the dural fistula, on-table in real time. ICG video angiography confirmed interruption of the fistula and preservation of the associated posterior spinal artery. We find the application of this relatively new technology has the potential to shorten operating times, gives additional reassurance of completeness of surgical treatment and preservation of normal spinal vasculature.

Patient-controlled Intermittent Epidural Bolus Versus Epidural Infusion for Posterior Spinal Fusion After Adolescent Idiopathic Scoliosis: Prospective, Randomized, Double-blinded Study.

PubMed

Erdogan, Mehmet Ali; Ozgul, Ulku; Ucar, Muharrem; Korkmaz, Mehmet Fatih; Aydogan, Mustafa Said; Ozkan, Ahmet Selim; Colak, Cemil; Durmus, Mahmut

2017-06-15

A prospective, randomized, double-blinded study. The aim of this study was to compare the efficacy and side effects of patient-controlled intermittent bolus epidural analgesia (PCIEA) and patient-controlled continuous epidural analgesia (PCCEA) for postoperative pain control in adolescent idiopathic scoliosis. Epidural analgesia is an accepted efficacious and safe procedure for postoperative pain management in scoliosis surgery. However, the PCIEA has not been adequately investigated for postoperative pain control in adolescent idiopathic scoliosis. Forty-seven patients, 8 to 18 years of age, who were undergoing posterior spinal fusion for idiopathic scoliosis were randomized to either the PCIEA or PCCEA group. An epidural catheter was inserted by a surgeon under direct visualization. The PCIEA group received 0.2 mg/mL of morphine, 0.25 mL/kg of morphine bolus, additional doses of 0.25 mL/kg morphine with a 1-hour lockout given by patient-controlled demand, and no infusion. The PCCEA group received the following: 0.2 mg/mL morphine, an initial morphine loading set at 0.1 mL/kg, followed by a 0.05 mL/kg/h continuous infusion of morphine, and a 0.025 mL/kg bolus dose of morphine. There was a 30-minute lockout interval. The primary outcome was morphine usage. The secondary outcomes were pain score, postoperative nausea and vomiting, and pruritus. Cumulative morphine consumption was lower in the PCIEA group than in the PCCEA group. Both methods provided effective pain control. There were no differences in pain scores between the groups. Postoperative nausea, vomiting, and pruritus were lower in the PCIEA group. The two epidural analgesia techniques studied are both safe and effective methods for postoperative pain control after posterior spinal fusion in idiopathic scoliosis. Nausea, vomiting and pruritus were considerably higher in the PCCEA group. Concerns regarding side effects associated with epidural opioids can be avoided by an intermittent bolus with a relatively lower amount of opioid. 2.

Angiography Before Posterior Mediastinal Tumor Resection: Selection Criteria and Patient Outcomes.

PubMed

Madariaga, Maria Lucia; Borges, Lawrence F; Rabinov, James D; Chang, David C; Lanuti, Michael; Mathisen, Douglas J; Gaissert, Henning A

2018-04-01

Resection of posterior mediastinal tumors may be complicated by bleeding or neurologic injury. Preoperative spinal angiography of mediastinal tumors has been underreported or not commonly practiced. This study evaluated the selection criteria and outcomes of patients with posterior mediastinal tumors who underwent preoperative angiography and embolization. This was a single-institution retrospective study of patients with posterior mediastinal tumors from 2002 to 2016. Multilevel spinal angiography was performed, with or without selective arterial embolization of vascular supply, in patients selected by thoracic or neurologic surgeons. Ten of 87 patients (11%) with posterior mediastinal tumors underwent preoperative angiography. A mean of 11 arteries (range, 2 to 25) were studied. Embolization in 7 of 10 patients successfully occluded 1 to 3 arteries. There was no significant difference in age, sex, body mass index, American Society of Anesthesiologists Physical Status Classification, operative time, operative blood loss, complications, or death between patients with or without angiography. Patients who underwent angiography had larger tumors (1,490 vs 97 cm 3 , p < 0.0001), involvement of the neuroforamen (44% vs 10%, p < 0.05), and a longer hospital stay (9 vs 4.5 days, p < 0.05). Angiography was complicated in 1 patient by vocal cord ulceration after intubation of a tumor-compressed trachea. Shared blood supply between the tumor and the spinal cord precluded embolization and tumor resection in 1 patient. Use of angiography increased over time. Selective preoperative angiography for evaluation of posterior mediastinal tumors identifies arterial variations, threatened spinal arteries, and targets for embolization. The specific role of angiography and embolization requires further investigation to standardize indications and protocols for the number of arteries examined. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Targeting Lumbar Spinal Neural Circuitry by Epidural Stimulation to Restore Motor Function After Spinal Cord Injury.

PubMed

Minassian, Karen; McKay, W Barry; Binder, Heinrich; Hofstoetter, Ursula S

2016-04-01

Epidural spinal cord stimulation has a long history of application for improving motor control in spinal cord injury. This review focuses on its resurgence following the progress made in understanding the underlying neurophysiological mechanisms and on recent reports of its augmentative effects upon otherwise subfunctional volitional motor control. Early work revealed that the spinal circuitry involved in lower-limb motor control can be accessed by stimulating through electrodes placed epidurally over the posterior aspect of the lumbar spinal cord below a paralyzing injury. Current understanding is that such stimulation activates large-to-medium-diameter sensory fibers within the posterior roots. Those fibers then trans-synaptically activate various spinal reflex circuits and plurisegmentally organized interneuronal networks that control more complex contraction and relaxation patterns involving multiple muscles. The induced change in responsiveness of this spinal motor circuitry to any residual supraspinal input via clinically silent translesional neural connections that have survived the injury may be a likely explanation for rudimentary volitional control enabled by epidural stimulation in otherwise paralyzed muscles. Technological developments that allow dynamic control of stimulation parameters and the potential for activity-dependent beneficial plasticity may further unveil the remarkable capacity of spinal motor processing that remains even after severe spinal cord injuries.

Coronal deformity correction in adolescent idiopathic scoliosis patients using the fulcrum-bending radiograph: a prospective comparative analysis of the proximal thoracic, main thoracic, and thoracolumbar/lumbar curves.

PubMed

Li, Jingfeng; Dumonski, Mark L; Samartzis, Dino; Hong, Joseph; He, Shisheng; Zhu, Xiaodong; Wang, Chuanfeng; Vaccaro, Alexander R; Albert, Todd J; Li, Ming

2011-01-01

The aim of the prospective, comparative radiographic analysis was to determine the role of the fulcrum-bending radiograph (FBR) for the assessment of the proximal thoracic (PT), main thoracic (MT), and the thoracolumbar/lumbar (TL/L) curves in patients undergoing posterior spinal pedicle screw fixation and fusion for adolescent idiopathic scoliosis (AIS). The FBR demonstrated statistically better correction than other preoperative methods for the assessment of frontal plane correction of the MT curves. The fulcrum-bending correction index (FBCI) has been considered a superior method than the correction rate for comparing curve correction undergoing posterior spinal fusion because it accounts for the curve flexibility. However, their applicability to assess the PT and TL/L curves in AIS patients remains speculative. The relation between FBR and correction obtained by pedicle screws fixation is still unknown. Thirty-eight consecutive AIS patients who underwent pedicle screw fixation and posterior fusion were included in this study. The assessment of preoperative radiographs included standing posterior-anterior (PA), FBR, supine side-bending, and postoperative standing PA and lateral plain radiographs. The flexibility of the curve, as well as the FBCI, was calculated for all patients. Postoperatively, radiographs were assessed at immediate (i.e. 1 week), 3-month, 6-month, 12-month, and 2-year follow-up. Cobb angles were obtained from the PT, MT, and TL/L curves. The study consisted of 9 PT, 37 MT, and 12 TL/L curves, with a mean age of 15.1 years. The mean FBR flexibility of the PT, MT, and the TL/L curves was 42.6, 61.1, and 66.2%, respectively. The mean operative correction rates in the PT, MT, and TL/L curves were 43.4, 69.3, and 73.9%, respectively, and the mean FBCI was 103.8, 117.0, and 114.8%, respectively. Fulcrum-bending flexibility was positively correlated with the operative correction rate in PT, MT, and TL/L curves. Although the correction rate in MT and TL/L curves was higher than PT curves, the FBCI in PT, MT, and TL/L curves was not significantly different (p < 0.05). The FBR can be used to assist in the assessment of PT, MT, and TL/L curve corrections in AIS patients. When curve flexibility is taken into account by FBR, the ability of pedicle screws to correct PT, MT, and TL/L curves is the same.

Effect of serum nicotine level on posterior spinal fusion in an in vivo rabbit model.

PubMed

Daffner, Scott D; Waugh, Stacey; Norman, Timothy L; Mukherjee, Nilay; France, John C

2015-06-01

Cigarette smoking has a deleterious effect on spinal fusion. Although some studies have implied that nicotine is primarily responsible for poor fusion outcomes, other studies suggest that nicotine may actually stimulate bone growth. Hence, there may be a dose-dependent effect of nicotine on posterior spinal fusion outcomes. The purpose of this study was to determine if such a relationship could be shown in an in vivo rabbit model. This is a prospective in vivo animal study. Twenty-four adult male New Zealand white rabbits were randomly divided into four groups. All groups received a single-level posterolateral, intertransverse process fusion at L5-L6 with autologous iliac crest bone. One group served as controls and only underwent the spine fusion surgery. Three groups received 5.25-, 10.5-, and 21-mg nicotine patches, respectively, for 5 weeks. Serum nicotine levels were recorded for each group. All animals were euthanized 5 weeks postoperatively, and spinal fusions were evaluated radiographically, by manual palpation, and biomechanically. Statistical analysis evaluated the dose response effect of outcomes variables and nicotine dosage. This study was supported by a portion of a $100,000 grant from the Orthopaedic Research and Education Foundation. Author financial disclosures were completed in accordance with the journal's guidelines; there were no conflicts of interests disclosed that would have led to bias in this work. The average serum levels of nicotine from the different patches were 7.8±1.9 ng/mL for the 5.25-mg patch group; 99.7±17.7 ng/mL for the 10.5-mg patch group; and 149.1±24.6 ng/mL for the 21-mg patch group. The doses positively correlated with serum concentrations of nicotine (correlation coefficient=0.8410, p<.001). The 5.25-mg group provided the best fusion rate, trabeculation, and stiffness. On the basis of the palpation tests, the fusion rates were control (50%), 5.25 mg (80%), 10.5 mg (50%), and 21 mg (42.8%). Radiographic assessment of trabeculation and bone incorporation and biomechanical analysis of bending stiffness ratio were also greatest in the 5.25-mg group. Radiographic evaluation showed a significant (p=.0446) quadratic effect of nicotine dose on spinal fusion. The effects of nicotine on spinal fusion are complex, may be dose dependent, and may not always be detrimental. The uniformly negative effects of smoking reported in patients undergoing spinal fusion may possibly be attributed to the other components of cigarette smoke. Copyright © 2015 Elsevier Inc. All rights reserved.

Challenging posterior mediastinal mass resection via a minimally invasive approach with neurological monitoring.

PubMed

Smail, Hassiba; Baste, Jean Marc; Melki, Jean; Peillon, Christophe

2013-02-01

We report a novel surgical strategy for the resection of a rare type of posterior mediastinal tumour in a young patient. A melanotic schwannoma arose from the left thoracic sympathetic chain, adjacent to the origin of the artery of Adamkiewicz. Successful excision of this tumour via a minimally invasive approach without arterial or spinal cord injury was possible with the aid of neurological monitoring using spinal-evoked potentials.

Posterior-only approach for lumbar vertebral column resection and expandable cage reconstruction for spinal metastases.

PubMed

Jandial, Rahul; Kelly, Brandon; Chen, Mike Yue

2013-07-01

The increasing incidence of spinal metastasis, a result of improved systemic therapies for cancer, has spurred a search for an alternative method for the surgical treatment of lumbar metastases. The authors report a single-stage posterior-only approach for resecting any pathological lumbar vertebral segment and reconstructing with a medium to large expandable cage while preserving all neurological structures. The authors conducted a retrospective consecutive case review of 11 patients (5 women, 6 men) with spinal metastases treated at 1 institution with single-stage posterior-only vertebral column resection and reconstruction with an expandable cage and pedicle screw fixation. For all patients, the indications for operative intervention were spinal cord compression, cauda equina compression, and/or spinal instability. Neurological status was classified according to the American Spinal Injury Association impairment scale, and functional outcomes were analyzed by using a visual analog scale for pain. For all patients, a circumferential vertebral column resection was achieved, and full decompression was performed with a posterior-only approach. Each cage was augmented by posterior pedicle screw fixation extending 2 levels above and below the resected level. No patient required a separate anterior procedure. Average estimated blood loss and duration of each surgery were 1618 ml (range 900-4000 ml) and 6.6 hours (range 4.5-9 hours), respectively. The mean follow-up time was 14 months (range 10-24 months). The median survival time after surgery was 17.7 months. Delayed hardware failure occurred for 1 patient. Preoperatively, 2 patients had intractable pain with intact lower-extremity strength and 8 patients had severe intractable pain, lower-extremity paresis, and were unable to walk; 4 of whom regained the ability to walk after surgery. Two patients who were paraplegic before decompression recovered substantial function but remained wheelchair bound, and 2 patients remained paraparetic after the surgery. No patients had lasting intraoperative neuromonitoring changes, and none died. Complications included 2 reoperations, 1 delayed hardware failure (cage subsidence that did not require revision), and 3 incidental durotomies (none of which required reoperation). No postoperative pneumonia, ileus, or deep venous thrombosis developed in any patient. A posterior-only approach for vertebral segment resection with preservation of spinal nerve roots is a viable technique that can be used throughout the entire lumbar spine. Extensive mobilization of the nerve roots is of utmost importance and allows for insertion and expansion of medium-sized, in situ expandable cages in the midline. This approach, although technically challenging, might reduce the morbidity associated with an anterior approach.

Comparison of Models for the Prediction of Medical Costs of Spinal Fusion in Taiwan Diagnosis-Related Groups by Machine Learning Algorithms.

PubMed

Kuo, Ching-Yen; Yu, Liang-Chin; Chen, Hou-Chaung; Chan, Chien-Lung

2018-01-01

The aims of this study were to compare the performance of machine learning methods for the prediction of the medical costs associated with spinal fusion in terms of profit or loss in Taiwan Diagnosis-Related Groups (Tw-DRGs) and to apply these methods to explore the important factors associated with the medical costs of spinal fusion. A data set was obtained from a regional hospital in Taoyuan city in Taiwan, which contained data from 2010 to 2013 on patients of Tw-DRG49702 (posterior and other spinal fusion without complications or comorbidities). Naïve-Bayesian, support vector machines, logistic regression, C4.5 decision tree, and random forest methods were employed for prediction using WEKA 3.8.1. Five hundred thirty-two cases were categorized as belonging to the Tw-DRG49702 group. The mean medical cost was US $4,549.7, and the mean age of the patients was 62.4 years. The mean length of stay was 9.3 days. The length of stay was an important variable in terms of determining medical costs for patients undergoing spinal fusion. The random forest method had the best predictive performance in comparison to the other methods, achieving an accuracy of 84.30%, a sensitivity of 71.4%, a specificity of 92.2%, and an AUC of 0.904. Our study demonstrated that the random forest model can be employed to predict the medical costs of Tw-DRG49702, and could inform hospital strategy in terms of increasing the financial management efficiency of this operation.

Spinal Cord Herniation After Cervical Corpectomy with Cerebrospinal Fluid Leak: Case Report and Review of the Literature.

PubMed

Guppy, Kern H; Silverthorn, James W

2017-04-01

Spinal cord herniation (SCH) is rare, is mostly idiopathic, and occurs predominantly in the thoracic spine. SCH is less common in the cervical spine and has been reported after posterior cervical spine surgery associated with the development of pseudomeningoceles. Two cases of SCH have been reported after anterior cervical corpectomies for ossified posterior longitudinal ligament with cerebrospinal fluid (CSF) leaks. We report the third such case, but the first in a patient without ossified posterior longitudinal ligament (degenerative disc disease and pseudarthrosis). A 56-year-old woman presented with bilateral arm pain and weakness. She had undergone 3 previous anterior cervical spine surgeries at an outside medical center with the most recent 7 years ago with C5 and C6 corpectomies and fusion with a persistent CSF leak. Magnetic resonance imaging and computed tomography myelography showed spinal cord herniation through the mesh cage at C6. The patient underwent a redo C5 and C6 corpectomy with untethering of the spinal cord. The patient was asymptomatic 2 years later. This is the first reported case of anterior cervical SCH in a patient without ossified posterior longitudinal ligament after multiple anterior cervical fusions including a cervical corpectomy for pseudarthrosis with a CSF leak. We hypothesize that persistent CSF leak causes a pressure gradient across the dura mater through the cage to the lower pressure in the retropharyngeal space, which led to herniation of the spinal cord into the anterior cage. We review the literature and discuss the treatment choices for anterior cervical SCH. Copyright © 2017 Elsevier Inc. All rights reserved.

Improved accuracy in Risser sign grading with lateral spinal radiography

PubMed Central

2008-01-01

Development of the ossification of the iliac crest is used to assess the remaining spinal growth. The clinical value of the Risser sign has been questioned because of its inaccuracy in grades 3 and 4. Estimation of the Risser sign based on the lateral spinal radiograph has not been reported. The aim of the study was to evaluate the course of ossification of the iliac apophysis along its full extension and to investigate relevance of the lateral spinal radiograph for more accurate Risser sign grading. Cross sectional analysis of spinal frontal and lateral long cassette standing spinal radiographs of 201 girls aged from 10.2 to 20.0 years were done. On the lateral spinal view, the ossification of the posterior part of the iliac apophysis was quantified at four grades: absent (A), partial (B), complete (C) or fused (D). The position of the posterior superior iliac spine was studied on both views as well as in pelvic specimens. The results showed that the posterior one-third portion of the iliac apophysis was sagittally oriented and obscured on the frontal radiograph by the sacroiliac junction. It could be studied on the lateral radiograph and revealed a different grading of the apophysis excursion in 58 of 201 (29%) patients, comparing to the frontal view. Both advanced or delayed ossification was observed and assessed with Lateral Risser Modifiers. Twenty-five percent of the patients at Risser 0 or 1 or 2 demonstrated a simultaneous ossification of the most anterior and the most posterior part of the iliac crest. The Risser grades of capping or fusion could be more precisely diagnosed using lateral radiograph in complement to the frontal one. The conclusions drawn from this study were: (1) Currently used Risser sign grading does not consider the actual excursion of the iliac apophysis, because one-third of the apophysis cannot be observed on the frontal radiograph. (2) Iliac apophysis full excursion or fusion can be more accurately estimated when the lateral spinal radiograph is analyzed with Lateral Risser Modifiers. Electronic supplementary material The online version of this article (doi:10.1007/s00586-008-0794-7) contains supplementary material, which is available to authorized users. PMID:18946691

Improved accuracy in Risser sign grading with lateral spinal radiography.

PubMed

Kotwicki, Tomasz

2008-12-01

Development of the ossification of the iliac crest is used to assess the remaining spinal growth. The clinical value of the Risser sign has been questioned because of its inaccuracy in grades 3 and 4. Estimation of the Risser sign based on the lateral spinal radiograph has not been reported. The aim of the study was to evaluate the course of ossification of the iliac apophysis along its full extension and to investigate relevance of the lateral spinal radiograph for more accurate Risser sign grading. Cross sectional analysis of spinal frontal and lateral long cassette standing spinal radiographs of 201 girls aged from 10.2 to 20.0 years were done. On the lateral spinal view, the ossification of the posterior part of the iliac apophysis was quantified at four grades: absent (A), partial (B), complete (C) or fused (D). The position of the posterior superior iliac spine was studied on both views as well as in pelvic specimens. The results showed that the posterior one-third portion of the iliac apophysis was sagittally oriented and obscured on the frontal radiograph by the sacroiliac junction. It could be studied on the lateral radiograph and revealed a different grading of the apophysis excursion in 58 of 201 (29%) patients, comparing to the frontal view. Both advanced or delayed ossification was observed and assessed with Lateral Risser Modifiers. Twenty-five percent of the patients at Risser 0 or 1 or 2 demonstrated a simultaneous ossification of the most anterior and the most posterior part of the iliac crest. The Risser grades of capping or fusion could be more precisely diagnosed using lateral radiograph in complement to the frontal one. The conclusions drawn from this study were: (1) Currently used Risser sign grading does not consider the actual excursion of the iliac apophysis, because one-third of the apophysis cannot be observed on the frontal radiograph. (2) Iliac apophysis full excursion or fusion can be more accurately estimated when the lateral spinal radiograph is analyzed with Lateral Risser Modifiers.

Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion.

PubMed

Esmail, Nabil; Buser, Zorica; Cohen, Jeremiah R; Brodke, Darrel S; Meisel, Hans-Joerg; Park, Jong-Beom; Youssef, Jim A; Wang, Jeffrey C; Yoon, S Tim

2018-04-01

Retrospective database review. Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males ( P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females ( P < .05). Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific.

The mechanical consequence of failure of ossified union in attempted posterior spinal fusion. A canine model.

PubMed

Stonecipher, T K; Vanderby, R; Sciammarella, C A; Lei, S S; Fisk, J R

1983-01-01

The mechanical behavior of pseudarthrosis in posterior spinal fusion was investigated. A canine model was developed in which an incompletely ossified posterior fusion mass was consistently produced. The spines were excised, and the motion segments were mechanically tested using a specially developed loading apparatus. Tests were performed to evaluate stiffness of the segments to loading with compression, torsion, and anterioposterior and lateral bending shear stiffness. Changes in other modes of loading were less consistent. The motion characteristics of the pseudarthrosis could not be predicted from the extent of the osseous defect noted on roentgenograms. These findings correlate clinically with the progression of curvature seen with pseudarthrosis in scoliosis surgery and the unpredictable results of pseudarthrosis in posterior fusion performed in treatment of degenerative disc disease.

Sequential involvement of the nervous system in subacute combined degeneration.

PubMed

Minn, Yang-Ki; Kim, Seung-Min; Kim, Se-Hoon; Kwon, Ki-Han; Sunwoo, Il-Nam

2012-03-01

Subacute combined degeneration (SCD) involves progressive degeneration of the spinal cord, optic nerve, and peripheral nerves. Vitamin B12 (VB12) is a co-factor in myelin synthesis. Because each cell that constitutes the myelin component in the central nervous system and peripheral nervous system is different, it is improbable that these cells undergo simultaneous degeneration. However, the sequence of degeneration in SCD has not been established. In this study, we analysed medical records and electrophysiological data of patients who showed neurological symptoms and whose serum VB12 levels were lower than 200 pg/mL. We enrolled 49 patients in this study. Their mean VB12 level was 68.3 pg/mL. Somatosensory evoked potential (SEP) study showed abnormal findings in 38 patients. Of the 40 patients who underwent visual evoked potential (VEP) study, 14 showed abnormal responses. Eighteen patients showed abnormal findings on a nerve conduction study (NCS). In this study, abnormal posterior tibial nerve SEPs only were seen in 16 patients, median nerve SEPs only were seen in 3 patients, abnormal VEPs only in two, and abnormal NCS responses in one patient. No patient complained of cognitive symptoms. In SCD, degeneration appears to progress in the following order: lower spinal cord, cervical spinal cord, peripheral nerve/optic nerve, and finally, the brain.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Seco, J; Giantsoudi, D; Eaton, BR

Purpose: To investigate the trade-off between vertebral column sparing and thecal-sac target coverage in craniospinal irradiation (CSI) of pediatric patients treated with passive-scattering (PS) and intensity modulated (IMPT) proton therapy. Methods: We selected 2 pediatric patients treated with PS CSI for medulloblastoma. Spinal irradiation was re-planned with IMPT. For all cases, we assumed prescription dose of 23.4 Gy(RBE), with the spinal canal receiving at least 95% of 23.4 Gy(RBE). PS planning was performed using the commercial system XiO. IMPT planning was done using the Astroid planning system. Beam arrangements consisted of (a) PS posterior-anterior (PA) field, PS-PA, (b) IMPT PAmore » field, IMPT-PA, and (c) two posterior oblique IMPT fields, IMPT2 (-35°, 35°). Dose distributions were re-calculated using TOPAS Monte Carlo, along with LET distributions, to investigate LET variations within the target and vertebra anatomy. Variable RBE-weighed dose distributions were also calculated based on a dose and LET-dependent biophysical model. Dosimetric data were compared among the plans for the target volume, spinal cord and adjacent critical organs (thecal-sac and cauda equina). Results: IMPT2 resulted in better sparing of the posterior vertebral column (entrance region posterior to thecal-sac), where planned dose was approximately 6–8Gy(RBE). For IMPT-PA and PS-PA the MC-calculated dose to the posterior vertebral column was, on average, 20Gy and 18Gy respectively. For IMPT2 higher mean-LET (5keV/µm/(g/cm3)) values were observed in anterior vertebral column (beyond the thecal-sac) relative to IMPT-PA and PS-PA, where mean-LET was 3.5keV/µm/(g/cm3) and 2.5keV/µm/(g/cm3) respectively. The higher LET region observed for both IMPT plans was in the distal end of treatment fields, where dose delivered was less 5Gy(RBE). Conclusion: The two-oblique proton beams IMPT2 best spared the spinal column, while reducing the dose to the posterior spinal column from 18–20 to 6–8 Gy(RBE). The best LET distribution was obtained with the PS-PA fields.« less

Airport metal detector activation is rare after posterior spinal fusion in children with scoliosis.

PubMed

Fabricant, Peter D; Robles, Alex; Blanco, John S

2013-12-01

Since the September 11, 2001 terrorist attacks on the World Trade Center in New York City, travel security has become an ever-increasing priority in the United States. Frequent parent and patient inquiry and recent literature reports have generated interest in the impact of heightened security measures on patients with orthopaedic implants, and have indicated increasing rates of metal detector triggering. There are no reports to date, however, evaluating children and adolescents who have undergone posterior spinal fusion for scoliosis, so responses to patient and parent inquiries are not data-driven. The purpose of this study is to determine the frequency of airport metal detector triggering by patients who have had posterior-only spinal fusion and to characterise any potential predictors of metal detector activation. A cross-sectional study was performed by interviewing 90 patients who underwent posterior-only spinal fusion for a diagnosis of juvenile or adolescent idiopathic scoliosis and have travelled by air in the past year. Demographic, clinical and surgical instrumentation data were collected and evaluated, along with patients' reports of airport metal detector triggering and subsequent screening procedures. Five patients with stainless steel instrumentation (5.6 % of the cohort) triggered an airport walkthrough metal detector, and an additional five patients who did not trigger an airport detector triggered a handheld detector at a different venue. All patients who triggered an airport metal detector had stainless steel instrumentation implanted prior to 2008, and no patient with titanium instrumentation triggered any detector in any venue. All trigger events required subsequent screening procedures, even when an implant card was presented. In this cohort of children and adolescents with posterior spinal instrumentation, airport walkthrough metal detector triggering was a rare event. Therefore, we advise patients and families with planned posterior scoliosis fusions using titanium instrumentation that airport detection risk is essentially non-existent, and only rare for those with planned stainless steel instrumentation. We no longer issue implant cards postoperatively, as these did not prevent further screening procedures in this cohort. Prognostic level 2. cross-sectional.

[One-stage total en bloc spondylectomy and reconstruction via a single posterior approach for thoracic vertebral symptomatic hemangioma associated with spinal cord dysfunction].

PubMed

Song, Ruo-xian; Zhang, Yong-gang; Zhang, Xue-song; Zheng, Guo-quan; Wang, Yan

2012-04-01

To investigate the surgical results of one-stage total en bloc spondylectomy (TES) and reconstruction via a single posterior approach for thoracic symptomatic vertebral hemangioma associated with spinal cord dysfunction and evaluate its curative effect. A total of 9 patients treated with one-stage TES (7 cases) and total vertebrectomy (2 cases) by posterior approach from March 2006 to January 2010 were retrospectively reviewed. The cases included 2 males and 7 females with a median age of 33.6 years (range 14 to 77 years), and with 1 case of Grade A, 3 cases of Grade B, 3 cases of Grade C, 2 cases of Grade D according to Frankel grade system. All patients suffered from moderate to severe pain and neurological deficit with an average symptom duration of 14.4 months (range 3 - 24 months) MRI revealed severe spinal cord compression. The spinal reconstruction was obtained by titanium mesh filled with autograft and posterior internal fixation with rod-screw system. The operation time was 210 minutes on average (180 - 270 minutes) and the average blood loss was 1800 ml (1000 - 5000 ml). The follow-up period lasted from 18 months to 5 years. All cases with preoperative pain relieved after operation. The visual analogue scale pain scores decreased to 1.1 from 8.3 at 3 months after surgery. No disruption of dural mater, cerebrospinal fluid leakage, iatrogenic spinal cord injury and major vessel damage occurred. Up to now, there was no local recurrence in all cases. Significant neurological function improvement was achieved in all patients with one to three grades in Frankel grade system. Fusion of the autograft was well achieved and no internal fixation failure in all patients. One-stage TES and spine reconstruction by a single posterior approach is feasible, safe and effective to this disease. It is favourable in decreasing the hemangioma recurrence and improvement of the neurological function.

Spinal Stiffness in Prone and Upright Postures During 0-1.8 g Induced by Parabolic Flight.

PubMed

Swanenburg, Jaap; Meier, Michael L; Langenfeld, Anke; Schweinhardt, Petra; Humphreys, B Kim

2018-06-01

The purpose of this study was to analyze posterior-to-anterior spinal stiffness in Earth, hyper-, and microgravity conditions during both prone and upright postures. During parabolic flight, the spinal stiffness of the L3 vertebra of a healthy 37-yr-old man was measured in normal Earth gravity (1.0 g), hypergravity (1.8 g), and microgravity (0.0 g) conditions induced in the prone and upright positions. Differences in spinal stiffness were significant across all three gravity conditions in the prone and upright positions. Most effect sizes were large; however, in the upright posture, the effect size between Earth gravity and microgravity was medium. Significant differences in spinal stiffness between the prone and upright positions were found during Earth gravity and hypergravity conditions. No difference was found between the two postures during microgravity conditions. Based on repeated measurements of a single individual, our results showed detectable changes in posterior-to-anterior spinal stiffness. Spinal stiffness increased during microgravity and decreased during hypergravity conditions. In microgravity conditions, posture did not impact spinal stiffness. More data on spinal stiffness in variable gravitational conditions is needed to confirm these results.Swanenburg J, Meier ML, Langenfeld A, Schweinhardt P, Humphreys BK. Spinal stiffness in prone and upright postures during 0-1.8 g induced by parabolic flight. Aerosp Med Hum Perform. 2018; 89(6):563-567.

Anterior and Posterior Instrumentation with Different Debridement and Grafting Procedures for Multi-Level Contiguous Thoracic Spinal Tuberculosis.

PubMed

Cui, Xu; Li, Li-Tao; Ma, Yuan-Zheng

2016-11-01

To evaluate the clinical outcomes of anterior and posterior instrumentation with different debridement and graft fusion methods for multi-level contiguous thoracic spinal tuberculosis. We retrospectively evaluated 81 patients with multi-level contiguous thoracic spinal tuberculosis who underwent anterior or posterior instrumentation combined with different methods of debridement, decompression, and graft fusion from January 2002 to December 2012. All patients were divided into an anterior instrumentation group and a posterior instrumentation group. In the anterior instrumentation group, there were 39 patients who underwent transthoracic debridement. In the posterior instrumentation group, there were 34 patients who underwent trans-costotransverse decompression and strut grafting with posterior instrumentation, and another 8 patients underwent combined anterior debridement and strut grafting with posterior instrumentation in a single-stage or two-stage procedure. The kyphotic angles were calculated from lateral spinal X-rays using the modified Konstam method. The symptoms and signs of tuberculosis, fusion level, fusion time of the bone graft, average kyphosis angle, average correction, average loss of correction, and clinical complications were recorded. The average follow-up period was 37 months (range, 17-72 months). The cohort consisted of 47 males and 34 females with an average age of 38 years. The mean durations of the operations were 3.5 ± 0.4 h in the anterior group and 4.0 ± 0.3 h in the posterior group ( P < 0.05). The mean blood loss volumes during surgery were 450 ± 42 and 560 ± 51 mL for the anterior group and the posterior group, respectively ( P < 0.01). The kyphotic deformities were corrected from 32.1° ± 10.3° to 10.2° ± 2.1° in the anterior group and from 33.8° ± 11.7° to 12.6° ± 2.7° in the posterior group ( P < 0.01). The neurologic statuses of the 23 patients with preoperative neurologic deficits improved in each group. Fusion was confirmed radiographically at 5.4 ± 1.2 months (range, 4-12 months) in the anterior group and 5.6 ± 1.4 months (range, 4-13 months) in the posterior group ( P > 0.05). Postoperative relapses were noted in 1 and 3 patients in the anterior and the posterior group, respectively. Posterior instrumentation was more effective than anterior instrumentation in the correction of kyphosis and the maintenance of the correction. However, postoperative sinus formation was more frequent in patients who underwent a single-stage posterior procedure. © 2016 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Effect of spinal anaesthesia on the lower urinary tract in continent women.

PubMed

Haeusler, G; Sam, C; Chiari, A; Tempfer, C; Hanzal, E; Koelbl, H

1998-01-01

To evaluate the effect of spinal anaesthesia on the bladder neck position and the urethral closure function in the resting state and during clinical stress test in healthy, continent women. Controlled clinical trial. Department of Gynaecology and Obstetrics, Vienna University Medical School. Fourteen continent women, of which seven were nulliparous and seven parous, underwent minor gynaecological procedures under spinal anaesthesia. Urodynamics and ultrasound investigations were performed before and during spinal anaesthesia. Changes in the bladder neck position and the urethral closure function before and during spinal anaesthesia. Bladder neck position was found to be lower and more posterior during spinal anaesthesia as compared with pre-operative assessment. The posterior urethrovesical angle increased significantly both at rest and during maximum straining. We observed a significant increase in bladder compliance, and all parameters of the urethral pressure profile decreased significantly. While none of the nulliparous women had a positive clinical stress test during spinal anaesthesia, 4/7 parous women demonstrated leakage (Fisher's exact test, P = 0.003). Blockage of nerve supply to the pelvic floor muscles in continent women is associated with a significant loss of support of the bladder neck region confirming the theory of an active mechanism of muscular elements providing continence.

An unusual and spectacular case of spindle cell lipoma of the posterior neck invading the spinal cervical canal and posterior cranial fossa.

PubMed

Petit, Damien; Menei, Philippe; Fournier, Henri-Dominique

2011-11-01

The authors describe the first case of spindle cell lipoma of the posterior neck invading the upper cervical spinal canal and the posterior cranial fossa. Spindle cell lipoma is an extremely rare variant of benign lipoma. It usually occurs as a solitary subcutaneous well-circumscribed lesion in the posterior neck or shoulders of adult men. Local aggressiveness is unusual. This 61-year-old man presented with an increased left cerebellar syndrome and headaches. He also had a posterior neck tumefaction, which had been known about for a long time. Computed tomography and MR imaging studies revealed a voluminous mass extending to the upper cervical canal and posterior cranial fossa and eroding the neighboring bones. The lesion was well delimited, and contrast enhancement was intense and heterogeneous. The tumor, which had initially developed under the muscles of the posterior neck, was totally resected. Histological assessment revealed numerous fat cells with spindle cells secreting collagen. The large size of the tumor and the submuscular location, bone erosion, and compression of the CNS were unusual in this rare subtype of benign adipose tumor. Its presentation could simulate a sarcoma.

Bipolar Sealer Devices Used in Posterior Spinal Fusion for Neuromuscular Scoliosis Reduce Blood Loss and Transfusion Requirements.

PubMed

Hardesty, Christina K; Gordon, Zachary L; Poe-Kochert, Connie; Son-Hing, Jochen P; Thompson, George H

2018-02-01

Reducing perioperative blood loss and the need for transfusions in patients undergoing spinal surgery is especially important for those with neuromuscular disorders. These patients require extensive spino-pelvic exposure and are often medically fragile. We have used Amicar to decrease blood loss since 2001. As an effort to further reduce blood loss and transfusions, we use a bipolar sealer device (Aquamantys) as an adjunct to electrocautery. We present the results of our first 64 neuromuscular patients to show the efficacy of the device. Using a prospectively maintained database we reviewed the operative time, estimated perioperative blood loss, cell saver use, and intraoperative and postoperative transfusion rate in patients who underwent posterior spinal fusion for neuromuscular scoliosis. Sixty-four patients were identified who fit these criteria since the use of the bipolar sealer device was instituted.We compared these patients with a control group of the preceding 65 patients in whom this device was not used for hemostasis. All patients, including those in the study group, received Amicar (infusion of 100 mg/kg over 15 to 20 min, then 10 mg/kg/h throughout the remainder of the procedure). The surgical technique did not differ between the 2 groups. Baseline characteristics between the 2 groups were similar except for the number of patients having an all-screw construct which was larger in the investigational group (25% vs. 8%, P=0.03). There were no significant differences in operative time or duration of hospital stay. Intraoperative blood loss was lower in the study group (741 mL) as compared with the control group (1052 mL, P=0.003). Total perioperative blood loss, however, showed no significant difference. Thirty-five (55%) patients in the study group and 50 (77%) patients in the control group required additional intraoperative or postoperative transfusions (P=0.01). The number of packed red cell units transfused per patient was 0.81 in the study group and 1.57 in the control group (P=0.001). Although the intraoperative cell saver transfusion was same, the total blood volume transfused, which includes cell saver and any other transfusions, was significantly lower in the study group, 425 mL versus 671 mL (P=0.002). Use of a bipolar sealer device in posterior spinal fusion for neuromuscular scoliosis significantly reduced intraoperative blood loss and transfusion rate when compared with a control group in this retrospective review. Level III-retrospective comparative study.

Cerebrospinal fluid leaks following spinal or posterior fossa surgery: use of fat grafts for prevention and repair.

PubMed

Black, P

2000-01-01

Cerebrospinal fluid (CSF) leaks are relatively common following spinal or posterior fossa surgery. A midline dural tear in the spine is readily repaired by direct application of a suture. However, far-lateral or ventral dural tears are problematic. Fat is an ideal sealant because it is impermeable to water. In this paper the author reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventral dural leak. Leaks in the posterior fossa are managed similarly to those in the spine. Dural suture lines, following suboccipital or spinal intradural exploration, are prophylactically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 150 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following posterior fossa and spinal surgery.

90-day Readmission After Lumbar Spinal Fusion Surgery in New York State Between 2005 and 2014: A 10-year Analysis of a Statewide Cohort.

PubMed

Baaj, Ali A; Lang, Gernot; Hsu, Wei-Chun; Avila, Mauricio J; Mao, Jialin; Sedrakyan, Art

2017-11-15

MINI: We assessed 90-day readmission and evaluated risk factors associated with readmission after lumbar spinal fusion surgery in New York State. The overall 90-day readmission rate was 24.8%. Age, sex, race, insurance, procedure, number of operated spinal levels, health service area, and comorbidities are major risk factors for 90-day readmission. Retrospective cohort study. The aim of this study was to assess 90-day readmission and evaluate risk factors associated with readmission after lumbar fusion in New York State. Readmission is becoming an important metric for quality and efficiency of health care. Readmission and its predictors following spine surgery are overall poorly understood and limited evidence is available specifically in lumbar fusion. The New York Statewide Planning and Research Cooperative System (SPARCS) was utilized to capture patients undergoing lumbar fusion from 2005 to 2014. Temporal trend of 90-day readmission was assessed using Cochran-Armitage test. Logistic regression was used to examine predictors associated with 90-day readmission. There were 86,869 patients included in this cohort study. The overall 90-day readmission rate was 24.8%. On a multivariable analysis model, age (odds ratio [OR] comparing ≥75 versus <35 years: 1.24, 95% confidence interval [CI]: 1.13-1.35), sex (OR female to male: 1.19, 95% CI: 1.15-1.23), race (OR African-American to white: 1.60, 95% CI: 1.52-1.69), insurance (OR Medicaid to Medicare: 1.42, 95% CI: 1.33-1.53), procedure (OR comparing thoracolumbar fusion, combined [International Classification of Disease, Ninth Revision, ICD-9: 81.04] to posterior lumbar interbody fusion/transforaminal lumbar spinal fusion [ICD-9: 81.08]: 2.10, 95% CI: 1.49-2.97), number of operated spinal levels (OR comparing four to eight vertebrae to two to three vertebrae: 2.39, 95% CI: 2.07-2.77), health service area ([HSA]; OR comparing Finger Lakes to New York-Pennsylvania border: 0.67, 95% CI: 0.61-0.73), and comorbidity, i.e., coronary artery disease (OR: 1.26, 95% CI: 1.19-1.33) were significantly associated with 90-day readmission. Directions of the odds ratios for these factors were consistent after stratification by procedure type. Age, sex, race, insurance, procedure, number of operated spinal levels, HSA, and comorbidities are major risk factors for 90-day readmission. Our study allows risk calculation to determine high-risk patients before undergoing spinal fusion surgery to prevent early readmission, improve quality of care, and reduce health care expenditures. 3.

"White Cord Syndrome" of Acute Hemiparesis After Posterior Cervical Decompression and Fusion for Chronic Cervical Stenosis.

PubMed

Antwi, Prince; Grant, Ryan; Kuzmik, Gregory; Abbed, Khalid

2018-05-01

"White cord syndrome" is a very rare condition thought to be due to acute reperfusion of chronically ischemic areas of the spinal cord. Its hallmark is the presence of intramedullary hyperintense signal on T2-weighted magnetic resonance imaging sequences in a patient with unexplained neurologic deficits following spinal cord decompression surgery. The syndrome is rare and has been reported previously in 2 patients following anterior cervical decompression and fusion. We report an additional case of this complication. A 68-year-old man developed acute left-sided hemiparesis after posterior cervical decompression and fusion for cervical spondylotic myelopathy. The patient improved with high-dose steroid therapy. The rare white cord syndrome following either anterior cervical decompression and fusion or posterior cervical decompression and fusion may be due to ischemic-reperfusion injury sustained by chronically compressed parts of the spinal cord. In previous reports, patients have improved following steroid therapy and acute rehabilitation. Copyright © 2018 Elsevier Inc. All rights reserved.

Posterior epidural disc fragment masquerading as spinal tumor: Review of the literature.

PubMed

Park, Taejune; Lee, Ho Jun; Kim, Jae Seong; Nam, Kiyeun

2018-03-09

Posterior epidural lumbar disc fragment is infrequent because of anatomical barriers, and it is difficult to diagnose posterior epidural lumbar disc fragment because of its rare incidence and the ambiguity of radiologic evaluations. And it is difficult to differentiate it from other diseases such as spinal tumors. Differential diagnosis of posterior epidural lumbar disc fragment is clinically important because its diagnosis can affect treatment and prognosis. To investigate the incidence, anatomical concern, etiology, symptom, diagnostic tool, management and prognosis of posterior epidural lumbar disc fragment, we reviewed articles including case report. We performed a search of all clinical studies of posterior epidural lumbar disc fragment published to date. The following keywords were searched: Posterior epidural lumbar disc fragment, disc migration, posterior epidural disc, extradural migration, dorsal epidural migration, sequestrated disc, and disc fragment. We identified 40 patients of posterior epidural lumbar disc fragment from 28 studies. The most common presentation of posterior epidural lumbar disc fragment was sudden onset radiculopathy (70.0%), followed by cauda equina syndrome (27.5%). The most frequently used diagnostic modality was magnetic resonance imaging (MRI), conducted in 36 cases (90.0%), and followed by computed tomography in 14 cases (35.0%). After the imaging studies, the preoperative diagnoses were 45.0% masses, 20.0% lesions, and 12.5% tumors. Characteristic MRI findings in posterior epidural lumbar disc fragment are helpful for diagnosis; it typically displays low signals on T1-weighted images and high signals on T2-weighted images with respect to the parent disc. In addition, most of the disc fragments show peripheral rim enhancement on MRI with gadolinium administration. Electrodiagnostic testing is useful for verifying nerve damage. Surgical treatment was performed in all cases, and neurologic complications were observed in 12.5%. As posterior epidural lumbar disc fragment could be masqueraded as spinal tumor, if rim enhancement is observed in MRI scans with sudden symptoms of radiculopathy or cauda equina syndrome, it should be taken into consideration. Early diagnosis can lead to early surgery, which can reduce complications.

Management of cervical myelopathy due to ossification of posterior longitudinal ligament in a patient with Alström syndrome.

PubMed

Kanna, Rishi Mugesh; Gradil, Daniela; Boszczyk, Bronek M

2012-12-01

Alström syndrome (AS) is a rare autosomal recessive genetic disorder with multisystemic involvement characterised by early blindness, hearing loss, obesity, insulin resistance, diabetes mellitus, dilated cardiomyopathy, and progressive hepatic and renal dysfunction. The clinical features, time of onset and severity can vary greatly among different patients. Many of the phenotypes are often not present in infancy but develop throughout childhood and adolescence. Recessively inherited mutations in ALMS1 gene are considered to be responsible for the causation of AS. Musculoskeletal manifestations including scoliosis and kyphosis have been previously described. Here, we present a patient with AS who presented with cervical myelopathy due to extensive flowing ossification of the anterior and posterior longitudinal ligaments of the cervical spine resulting in cervical spinal cord compression. The presence of an auto-fused spine in an acceptable sagittal alignment, in the background of a constellation of medical comorbidities, which necessitated a less morbid surgical approach, favored a posterior cervical laminectomy decompression in this patient. Postoperatively, the patient showed significant neurological recovery with improved function. Follow-up MRI showed substantial enlargement of the spinal canal with improved space available for the spinal cord. The rarity of the syndrome, cervical myelopathy due to ossified posterior longitudinal ligament as a disease phenotype and the treatment considerations for performing a posterior cervical decompression have been discussed in this Grand Rounds' case presentation.

Preclinical evaluation of posterior spine stabilization devices: can the current standards represent basic everyday life activities?

PubMed

La Barbera, Luigi; Galbusera, Fabio; Wilke, Hans-Joachim; Villa, Tomaso

2016-09-01

To discuss whether the available standard methods for preclinical evaluation of posterior spine stabilization devices can represent basic everyday life activities and how to compare the results obtained with different procedures. A comparative finite element study compared ASTM F1717 and ISO 12189 standards to validated instrumented L2-L4 segments undergoing standing, upper body flexion and extension. The internal loads on the spinal rod and the maximum stress on the implant are analysed. ISO recommended anterior support stiffness and force allow for reproducing bending moments measured in vivo on an instrumented physiological segment during upper body flexion. Despite the significance of ASTM model from an engineering point of view, the overly conservative vertebrectomy model represents an unrealistic worst case scenario. A method is proposed to determine the load to apply on assemblies with different anterior support stiffnesses to guarantee a comparable bending moment and reproduce specific everyday life activities. The study increases our awareness on the use of the current standards to achieve meaningful results easy to compare and interpret.

Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion

PubMed Central

Esmail, Nabil; Buser, Zorica; Cohen, Jeremiah R.; Brodke, Darrel S.; Meisel, Hans-Joerg; Park, Jong-Beom; Youssef, Jim A.; Wang, Jeffrey C.; Yoon, S. Tim

2017-01-01

Study Design: Retrospective database review. Objective: Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). Methods: We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. Results: Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males (P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females (P < .05). Conclusion: Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific. PMID:29662744

Anterior spinal and bulbar artery supply to the posterior inferior cerebellar artery revealed by a ruptured aneurysm: case report.

PubMed

Gabrieli, Joseph; Sourour, Nader-Antoine; Chauvet, Dorian; Di Maria, Federico; Chiras, Jacques; Clarençon, Frédéric

2017-02-01

The posterior inferior cerebellar artery (PICA) is a vessel located between the intra- and extracranial circulation. The artery is characterized by a complex embryological development and numerous anatomical variants. The authors present a case of the PICA supplied by both a hypertrophic anterior spinal artery and a hypoplastic bulbar artery. This unusual arrangement somehow completes the list of previously published variants, and the spontaneous rupture of a related aneurysm confirmed the fragility of this network. The authors discuss anatomical and treatment considerations.

Vertebral column resection for the treatment of severe spinal deformity.

PubMed

Lenke, Lawrence G; Sides, Brenda A; Koester, Linda A; Hensley, Marsha; Blanke, Kathy M

2010-03-01

The ability to treat severe pediatric and adult spinal deformities through an all-posterior vertebral column resection (VCR) has obviated the need for a circumferential approach in primary and revision surgery, but there is limited literature evaluating this new approach. Our purpose was therefore to provide further support of this technique. We reviewed 43 patients who underwent a posterior-only VCR using pedicle screws, anteriorly positioned cages, and intraoperative spinal cord monitoring between 2002 and 2006. Diagnoses included severe scoliosis, global kyphosis, angular kyphosis, or kyphoscoliosis. Forty (93%) procedures were performed at L1 or cephalad in the spinal cord (SC) territory. Seven patients (18%) lost intraoperative neurogenic monitoring evoked potentials (NMEPs) data during correction with data returning to baseline after prompt surgical intervention. All patients after surgery were at their baseline or showed improved SC function, whereas no one worsened. Two patients had nerve root palsies postoperatively, which resolved spontaneously at 6 months and 2 weeks. Spinal cord monitoring (specifically NMEP) is mandatory to prevent neurologic complications. Although technically challenging, a single-stage approach offers dramatic correction in both primary and revision surgery of severe spinal deformities. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Sequential Involvement of the Nervous System in Subacute Combined Degeneration

PubMed Central

Minn, Yang-Ki; Kim, Seung-Min; Kim, Se-Hoon; Kwon, Ki-Han

2012-01-01

Purpose Subacute combined degeneration (SCD) involves progressive degeneration of the spinal cord, optic nerve, and peripheral nerves. Vitamin B12 (VB12) is a co-factor in myelin synthesis. Because each cell that constitutes the myelin component in the central nervous system and peripheral nervous system is different, it is improbable that these cells undergo simultaneous degeneration. However, the sequence of degeneration in SCD has not been established. Materials and Methods In this study, we analysed medical records and electrophysiological data of patients who showed neurological symptoms and whose serum VB12 levels were lower than 200 pg/mL. Results We enrolled 49 patients in this study. Their mean VB12 level was 68.3 pg/mL. Somatosensory evoked potential (SEP) study showed abnormal findings in 38 patients. Of the 40 patients who underwent visual evoked potential (VEP) study, 14 showed abnormal responses. Eighteen patients showed abnormal findings on a nerve conduction study (NCS). In this study, abnormal posterior tibial nerve SEPs only were seen in 16 patients, median nerve SEPs only were seen in 3 patients, abnormal VEPs only in two, and abnormal NCS responses in one patient. No patient complained of cognitive symptoms. Conclusion In SCD, degeneration appears to progress in the following order: lower spinal cord, cervical spinal cord, peripheral nerve/optic nerve, and finally, the brain. PMID:22318813

A Novel Spinal Implant for Fusionless Scoliosis Correction: A Biomechanical Analysis of the Motion Preserving Properties of a Posterior Periapical Concave Distraction Device.

PubMed

Holewijn, Roderick M; de Kleuver, Marinus; van der Veen, Albert J; Emanuel, Kaj S; Bisschop, Arno; Stadhouder, Agnita; van Royen, Barend J; Kingma, Idsart

2017-08-01

Biomechanical study. Recently, a posterior concave periapical distraction device for fusionless scoliosis correction was introduced. The goal of this study was to quantify the effect of the periapical distraction device on spinal range of motion (ROM) in comparison with traditional rigid pedicle screw-rod instrumentation. Using a spinal motion simulator, 6 human spines were loaded with 4 N m and 6 porcine spines with 2 N m to induce flexion-extension (FE), lateral bending (LB), and axial rotation (AR). ROM was measured in 3 conditions: untreated, periapical distraction device, and rigid pedicle screw-rod instrumentation. The periapical distraction device caused a significant ( P < .05) decrease in ROM of FE (human, -40.0% and porcine, -55.9%) and LB (human, -18.2% and porcine, -17.9%) as compared to the untreated spine, while ROM of AR remained unaffected. In comparison, rigid instrumentation caused a significantly ( P < .05) larger decrease in ROM of FE (human, -80.9% and porcine, -94.0%), LB (human, -75.0% and porcine, -92.2%), and AR (human, -71.3% and porcine, -86.9%). Although no destructive forces were applied, no device failures were observed. Spinal ROM was significantly less constrained by the periapical distraction device compared to rigid pedicle screw-rod instrumentation. Therefore, provided that scoliosis correction is achieved, a more physiological spinal motion is expected after scoliosis correction with the posterior concave periapical distraction device.

Surgical treatment for old subaxial cervical dislocation with bilateral locked facets in a 3-year-old girl: A case report.

PubMed

Li, Cheng; Li, Lei; Duan, Jingzhu; Zhang, Lijun; Liu, Zhenjiang

2018-05-01

This study aimed to describe the case of a 3-year-old girl with old bilateral facet dislocation on cervical vertebrae 6 and 7, who had spinal cord transection, received surgical treatment, and achieved a relative satisfactory therapeutic effect. A 3-year-old girl was urgently transferred to the hospital after a car accident. DIAGNOSES:: she was diagnosed with splenic rupture, intracranial hemorrhage, cervical dislocation, spinal transection, and Monteggia fracture of the left upper limb. The girl underwent emergency splenectomy and was transferred to the intensive care unit of the hospital 15 days later. One-stage anterior-posterior approach surgery (anterior discectomy, posterior laminectomy, and pedicle screw fixation) was performed when the patient stabilized after 45-day symptomatic treatment. The operation was uneventful. The reduction of lower cervical dislocation was satisfactory, with sufficient spinal cord decompression. The internal fixation position was good, and the spinal sequence was well restored. The girl was discharged 2 weeks later after the operation and followed up for 2 years. The major nerve function of both upper limbs was recovered, with no obvious retardation of the growth of immature spine. A satisfactory therapeutic effect was achieved for a pediatric old subaxial cervical dislocation with bilateral locked facets using anterior discectomy, posterior laminectomy, and pedicle screw fixation. The posterior pedicle screw fixation provided a good three-dimensional stability of the spine, with reduced risk and complications caused by anterior internal fixation. The growth of immature spine was not obviously affected during the 2-year follow-up.

One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series.

PubMed

Zhang, Hong-qi; Lin, Min-zhong; Li, Jin-song; Tang, Ming-xing; Guo, Chao-feng; Wu, Jian-huang; Liu, Jin-yang

2013-03-01

The purpose of this study is to compare the clinical outcomes of surgical management by one-stage posterior debridement, transforaminal lumbar interbody fusion (TLIF) and instrumentation and combined posterior and anterior approaches for lumbar spinal tuberculosis, and determine the clinical effectiveness of the posterior only surgical treatment for lumbar spinal TB at the same time. Thirty-seven patients who suffered lumbar tuberculosis were treated by two different surgical procedures in our center from May 2004 to June 2012. All the cases were divided into two groups: 19 cases in Group A underwent one-stage posterior debridement, TLIF and instrumentation, and 18 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single-stage procedure. The operation time, blood loss, lumbar kyphotic angle, recovery of neurological function and fusion time were, respectively, compared between Group A and Group B. The average follow-up period for Group A was 46.6 ± 16.7 months, and for Group B, 47.5 ± 15.0 months. It was obvious that the average operative duration and blood loss of Group A was less than those of Group B. Lumbar tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. The average pretreatment ESR was 60.7 ± 22.5 mm/h, which became normal (9.0 ± 2.8 mm/h) within 3 months in all patients. Surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. This approach obtained better clinical outcomes than combined posterior and anterior surgeries.

Microsurgical resection of intramedullary spinal cord ependymoma.

PubMed

McCormick, Paul C

2014-09-01

Ependymomas are the most commonly occurring intramedullary spinal cord tumor in adults. With few exceptions these tumors are histologically benign, although they exhibit some biologic variability with respect to growth rate. While unencapsulated, spinal ependymomas are non-infiltrative and present a clear margin of demarcation from the surrounding spinal cord that serves as an effective dissection plane. This video demonstrates the technique of microsurgical resection of an intramedullary ependymoma through a posterior midline myelotomy. The video can be found here: http://youtu.be/lcHhymSvSqU.

Comparison of Successful Spinal Needle Placement Between Crossed-Leg Sitting Position and Traditional Sitting Position in Patients Undergoing Urology Surgery

PubMed Central

Manggala, Sidharta K.; Tantri, Aida R.; Satoto, Darto

2016-01-01

Background The patient’s position during spinal anesthesia administration plays a major role in the success of spinal needle insertion into the subarachnoid space. The traditional sitting position (TSP) is the standard position for spinal anesthesia administration, but the success rate for spinal anesthesia administration in the TSP is still quite low. The crossed-leg sitting position (CLSP) is one of the alternative positions for the administration of spinal anesthesia, which can increase the degree of lumbar flexion. Objectives This study aimed to compare successful spinal needle placement to patients in the CLSP and patients in the TSP prior to undergoing urology surgery. Methods This study was a non-blinded, randomized controlled trial in patients undergoing spinal anesthesia for urologic procedures from March-October, 2015 in the central national hospital Dr. Cipto Mangunkusumo, Indonesia. After obtaining approval from the FMUI – RSCM (Faculty of Medicine Universitas Indonesia – Rumah Sakit Dr. Cipto Mangunkusumo) Ethical Committee and informed consent from patients, 211 subjects were allocated into two groups: the CLSP group (n = 105) and the TSP group (n = 106). The proportion of successful spinal needle placement to the subarachnoid space, ease of landmark palpation, and the number of needle-bone contacts in both groups were then assessed and analyzed. Results The rate of first-time successful spinal needle insertion was not significantly different between the CLSP and TSP groups (62.9% versus 55.7%, P > 0.05). Ease of landmark palpation in the CLSP group was not significantly different from that in the TSP group (86.7% versus 76.4%, P > 0.05). The number of needle-bone contacts in both groups were not significantly different (P > 0.05). The complication rates were similar in both groups. Conclusions The rate of successful spinal needle placement in the CLSP group was not significantly different from that in the TSP group in patients undergoing urology surgery. The CLSP can be used as an alternative sitting position for administration of spinal anesthesia. PMID:27843785

Changes in CSF flow after one-stage posterior vertebral column resection in scoliosis patients with syringomyelia and Chiari malformation type I.

PubMed

Wang, Yingsong; Xie, Jingming; Zhao, Zhi; Zhang, Ying; Li, Tao; Si, Yongyu

2013-05-01

Phase contrast-cine MRI (PC-cine MRI) studies in patients with syringomyelia and Chiari malformation Type I (CM-I) have demonstrated abnormal CSF flow across the foramen magnum, which can revert to normal after craniocervical decompression with syrinx shrinkage. In order to investigate the mechanisms leading to postoperative syringomyelia shrinkage, the authors studied the hydrodynamic changes of CSF flow in the craniocervical junction and spinal canal in patients with scoliosis associated with syringomyelia after one-stage deformity correction by posterior vertebral column resection. Preoperative and postoperative CSF flow dynamics at the levels of the foramen magnum, C-7, T-7 (or apex), and L-1 were assessed by electrocardiogram-synchronized cardiac-gated PC-cine MRI in 8 adolescent patients suffering from severe scoliosis with syringomyelia and CM-I (scoliosis group) and undergoing posterior vertebral column resection. An additional 8 patients with syringomyelia and CM-I without spinal deformity (syrinx group) and 8 healthy volunteers (control group) were also enrolled. Mean values were obtained for the following parameters: the duration of a CSF cycle, the duration of caudad CSF flow (CSF downflow [DF]) and cephalad CSF flow (CSF upflow [UF]), the ratio of DF duration to CSF cycle duration (DF%), and the ratio of UF duration to CSF cycle duration (UF%). The ratio of the stationary phase (SP) duration to CSF cycle duration was calculated (SP%). The maximum downflow velocities (VD max) and maximum upflow velocities (VU max) were measured. SPSS (version 14.0) was used for all statistical analysis. Patients in the scoliosis group underwent one-stage posterior vertebral column resection for deformity correction without suboccipital decompression. The mean preoperative coronal Cobb angle was 102.4° (range 76°-138°). The mean postoperative Cobb angle was 41.7° (range 12°-75°), with an average correction rate of 59.3%. During the follow-up, 1 patient with hypermyotonia experienced a significant decrease of muscle tension and 1 patient with reduced anal sphincter tone manifested recovery. A total of 5 patients demonstrated a significant decrease (> 30%) in syrinx size. With respect to changes in CSF flow dynamics, the syrinx group was characterized by slower and shorter downflow than the control group, and the difference was more significant at the foramen magnum and C-7 levels. In patients with scoliosis, CSF downflow at the foramen magnum level was significantly restricted, and a prolonged stationary phase indicated increased obstruction of CSF flow. After posterior vertebral column resection, the peak velocity of CSF flow at the foramen magnum increased, and the downflow phase duration was markedly prolonged. The parameters showed a return to almost normal CSF dynamics at the craniocervical region, and this improvement was maintained for 6-12 months of follow-up. There were distinct abnormalities of CSF flow at the craniocervical junction in patients with syringomyelia. Abnormal dynamics of downflow could be aggravated by associated severe spinal deformity and improved by correction via posterior vertebral column resection.

Chronic Localized Back Pain Due to Posterior Cutaneous Nerve Entrapment Syndrome (POCNES): A New Diagnosis.

PubMed

Boelens, Oliver B; Maatman, Robert C; Scheltinga, Marc R; van Laarhoven, Kees; Roumen, Rudi M

2017-03-01

Most patients with chronic back pain suffer from degenerative thoracolumbovertebral disease. However, the following case illustrates that a localized peripheral nerve entrapment must be considered in the differential diagnosis of chronic back pain. We report the case of a 26-year-old woman with continuous excruciating pain in the lower back area. Previous treatment for nephroptosis was to no avail. On physical examination the pain was present in a 2 x 2 cm area overlying the twelfth rib some 4 cm lateral to the spinal process. Somatosensory testing using swab and alcohol gauze demonstrated the presence of skin hypo- and dysesthesia over the painful area. Local pressure on this painful spot elicited an extreme pain response that did not irradiate towards the periphery. These findings were highly suggestive of a posterior version of the anterior cutaneous nerve entrapment syndrome (ACNES), a condition leading to a severe localized neuropathic pain in anterior portions of the abdominal wall. She demonstrated a beneficial albeit temporary response after lidocaine infiltration as dictated by an established diagnostic and treatment protocol for ACNES. She subsequently underwent a local neurectomy of the involved superficial branch of the intercostal nerve. This limited operation had a favorable outcome resulting in a pain-free return to normal activities up to this very day (follow-up of 24 months).We propose to name this novel syndrome "posterior cutaneous nerve entrapment syndrome" (POCNES). Each patient with chronic localized back pain should undergo simple somatosensory testing to detect the presence of overlying skin hypo- and dysesthesia possibly reflecting an entrapped posterior cutaneous nerve.Key words: Chronic pain, back pain, posterior cutaneous nerve entrapment, peripheral nerve entrapment, surgical treatment for pain, anterior cutaneous nerve entrapment.

Metallic artefact reduction with monoenergetic dual-energy CT: systematic ex vivo evaluation of posterior spinal fusion implants from various vendors and different spine levels.

PubMed

Guggenberger, R; Winklhofer, S; Osterhoff, G; Wanner, G A; Fortunati, M; Andreisek, G; Alkadhi, H; Stolzmann, P

2012-11-01

To evaluate optimal monoenergetic dual-energy computed tomography (DECT) settings for artefact reduction of posterior spinal fusion implants of various vendors and spine levels. Posterior spinal fusion implants of five vendors for cervical, thoracic and lumbar spine were examined ex vivo with single-energy (SE) CT (120 kVp) and DECT (140/100 kVp). Extrapolated monoenergetic DECT images at 64, 69, 88, 105 keV and individually adjusted monoenergy for optimised image quality (OPTkeV) were generated. Two independent radiologists assessed quantitative and qualitative image parameters for each device and spine level. Inter-reader agreements of quantitative and qualitative parameters were high (ICC = 0.81-1.00, κ = 0.54-0.77). HU values of spinal fusion implants were significantly different among vendors (P < 0.001), spine levels (P < 0.01) and among SECT, monoenergetic DECT of 64, 69, 88, 105 keV and OPTkeV (P < 0.01). Image quality was significantly (P < 0.001) different between datasets and improved with higher monoenergies of DECT compared with SECT (V = 0.58, P < 0.001). Artefacts decreased significantly (V = 0.51, P < 0.001) at higher monoenergies. OPTkeV values ranged from 123-141 keV. OPTkeV according to vendor and spine level are presented herein. Monoenergetic DECT provides significantly better image quality and less metallic artefacts from implants than SECT. Use of individual keV values for vendor and spine level is recommended. • Artefacts pose problems for CT following posterior spinal fusion implants. • CT images are interpreted better with monoenergetic extrapolation using dual-energy (DE) CT. • DECT extrapolation improves image quality and reduces metallic artefacts over SECT. • There were considerable differences in monoenergy values among vendors and spine levels. • Use of individualised monoenergy values is indicated for different metallic hardware devices.

Spinal tuberculosis: the association between pedicle involvement and anterior column damage and kyphotic deformity.

PubMed

Yusof, Mohammad Imran; Hassan, Eskandar; Rahmat, Nasazli; Yunus, Rohaizan

2009-04-01

Pedicle involvement in spinal tuberculosis (TB), the prevertebral abscess formation, severity of vertebral body, and disc collapse were evaluated from magnetic resonance imaging (MRI) of the patients. To study the pedicle involvement in spine TB in relation to the degree of vertebral body and disc collapse, prevertebral abscess collection, and degree of kyphosis; and to correlate the occurrence of pedicle involvement and the degree of spinal deformity. There are a few reports describing the posterior element involvement in spinal TB. Typically, the infection resides in the anterior part of the vertebral body endplates and rarely involved the pedicles. There were 31 patients, who had been diagnosed and treated for spinal TB from 2003 to 2007 at our center. Critical evaluation of each patient's MRI was carried out for the pedicle involvement, prevertebral abscess formation, severity of vertebral body, and disc collapse. Spinal TB mostly involved the thoracic level (48.4%). Pedicle involvement was noted in 64.5% of patients, and the highest involvement was at thoracic level. The mean vertebral body, disc collapse, prevertebral abscess, and kyphosis were more severe in pedicle involved group. The posterior spinal element, specifically the pedicle is not uncommonly involved in spinal TB. Pedicle involvement is part of the disease process and usually associated with relatively severe vertebral body and disc destruction, wide prevertebral abscess, and severe kyphosis. Pedicle involvement can be detected early from MRI and need to be documented as it may influence the treatment strategy.

Factors associated with spinal fusion after posterior fossa decompression in pediatric patients with Chiari I malformation and scoliosis.

PubMed

Mackel, Charles E; Cahill, Patrick J; Roguski, Marie; Samdani, Amer F; Sugrue, Patrick A; Kawakami, Noriaki; Sturm, Peter F; Pahys, Joshua M; Betz, Randal R; El-Hawary, Ron; Hwang, Steven W

2016-12-01

OBJECTIVE The authors performed a study to identify clinical characteristics of pediatric patients diagnosed with Chiari I malformation and scoliosis associated with a need for spinal fusion after posterior fossa decompression when managing the scoliotic curve. METHODS The authors conducted a multicenter retrospective review of 44 patients, aged 18 years or younger, diagnosed with Chiari I malformation and scoliosis who underwent posterior fossa decompression from 2000 to 2010. The outcome of interest was the need for spinal fusion after decompression. RESULTS Overall, 18 patients (40%) underwent posterior fossa decompression alone, and 26 patients (60%) required a spinal fusion after the decompression. The mean Cobb angle at presentation and the proportion of patients with curves > 35° differed between the decompression-only and fusion cohorts (30.7° ± 11.8° vs 52.1° ± 26.3°, p = 0.002; 5 of 18 vs 17 of 26, p = 0.031). An odds ratio of 1.0625 favoring a need for fusion was established for each 1° of increase in Cobb angle (p = 0.012, OR 1.0625, 95% CI 1.0135-1.1138). Among the 14 patients older than 10 years of age with a primary Cobb angle exceeding 35°, 13 (93%) ultimately required fusion. Patients with at least 1 year of follow-up whose curves progressed more 10° after decompression were younger than those without curve progression (6.1 ± 3.0 years vs 13.7 ± 3.2 years, p = 0.001, Mann-Whitney U-test). Left apical thoracic curves constituted a higher proportion of curves in the decompression-only group (8 of 16 vs 1 of 21, p = 0.002). CONCLUSIONS The need for fusion after posterior fossa decompression reflected the curve severity at clinical presentation. Patients presenting with curves measuring > 35°, as well as those greater than 10 years of age, may be at greater risk for requiring fusion after posterior fossa decompression, while patients less than 10 years of age may require routine monitoring for curve progression. Left apical thoracic curves may have a better response to Chiari malformation decompression.

Ventriculoperitoneal Shunt Fracture Following Application of Halo-Gravity Traction: A Case Report.

PubMed

Blakeney, William G; D'Amato, Charles

2015-09-01

Ventriculoperitoneal (VP) shunt malfunctions are very common, and shunt fracture is one of the most common causes. Shunt fractures are often a result of calcification and tethering, which predispose the tubing to fracture when mechanical stresses are applied. This case report describes a case of shunt fracture following application of halo-gravity traction for correction of spinal deformity. Chart and imaging data for a single case were reviewed and reported in this retrospective case study. A 10-year-old female, being treated for syndromic scoliosis, underwent posterior surgical release and application of halo-gravity traction. Increasing weight of traction was applied over a period of 6 weeks, for gradual deformity correction. It was noted on the 6-week cervical spine radiograph that the VP shunt had fractured at the base of the neck. The patient was taken to the operating room and intraoperative findings confirmed shunt fracture. This was repaired without complications. This case, to our best knowledge, is the first reported occurrence of shunt fracture following application of halo-gravity traction. It demonstrates the importance of careful monitoring of patients with VP shunts, when they are undergoing traction for correction of spinal deformity. Level IV.

A Novel Spinal Implant for Fusionless Scoliosis Correction: A Biomechanical Analysis of the Motion Preserving Properties of a Posterior Periapical Concave Distraction Device

PubMed Central

Holewijn, Roderick M.; de Kleuver, Marinus; van der Veen, Albert J.; Emanuel, Kaj S.; Bisschop, Arno; Stadhouder, Agnita; van Royen, Barend J.

2017-01-01

Study Design: Biomechanical study. Objective: Recently, a posterior concave periapical distraction device for fusionless scoliosis correction was introduced. The goal of this study was to quantify the effect of the periapical distraction device on spinal range of motion (ROM) in comparison with traditional rigid pedicle screw-rod instrumentation. Methods: Using a spinal motion simulator, 6 human spines were loaded with 4 N m and 6 porcine spines with 2 N m to induce flexion-extension (FE), lateral bending (LB), and axial rotation (AR). ROM was measured in 3 conditions: untreated, periapical distraction device, and rigid pedicle screw-rod instrumentation. Results: The periapical distraction device caused a significant (P < .05) decrease in ROM of FE (human, −40.0% and porcine, −55.9%) and LB (human, −18.2% and porcine, −17.9%) as compared to the untreated spine, while ROM of AR remained unaffected. In comparison, rigid instrumentation caused a significantly (P < .05) larger decrease in ROM of FE (human, −80.9% and porcine, −94.0%), LB (human, −75.0% and porcine, −92.2%), and AR (human, −71.3% and porcine, −86.9%). Conclusions: Although no destructive forces were applied, no device failures were observed. Spinal ROM was significantly less constrained by the periapical distraction device compared to rigid pedicle screw-rod instrumentation. Therefore, provided that scoliosis correction is achieved, a more physiological spinal motion is expected after scoliosis correction with the posterior concave periapical distraction device. PMID:28811983

Lumbar Spinal Stenosis Minimally Invasive Treatment with Bilateral Transpedicular Facet Augmentation System

DOE Office of Scientific and Technical Information (OSTI.GOV)

Masala, Salvatore, E-mail: salva.masala@tiscali.it; Tarantino, Umberto; Nano, Giovanni, E-mail: gionano@gmail.com

Purpose. The purpose of this study was to evaluate the effectiveness of a new pedicle screw-based posterior dynamic stabilization device PDS Percudyn System Trade-Mark-Sign Anchor and Stabilizer (Interventional Spine Inc., Irvine, CA) as alternative minimally invasive treatment for patients with lumbar spine stenosis. Methods. Twenty-four consecutive patients (8 women, 16 men; mean age 61.8 yr) with lumbar spinal stenosis underwent implantation of the minimally invasive pedicle screw-based device for posterior dynamic stabilization. Inclusion criteria were lumbar stenosis without signs of instability, resistant to conservative treatment, and eligible to traditional surgical posterior decompression. Results. Twenty patients (83 %) progressively improved duringmore » the 1-year follow-up. Four (17 %) patients did not show any improvement and opted for surgical posterior decompression. For both responder and nonresponder patients, no device-related complications were reported. Conclusions. Minimally invasive PDS Percudyn System Trade-Mark-Sign has effectively improved the clinical setting of 83 % of highly selected patients treated, delaying the need for traditional surgical therapy.« less

Choice of surgical approach for ossification of the posterior longitudinal ligament in combination with cervical disc hernia.

PubMed

Yang, Hai-song; Chen, De-yu; Lu, Xu-hua; Yang, Li-li; Yan, Wang-jun; Yuan, Wen; Chen, Yu

2010-03-01

Ossification of the posterior longitudinal ligament (OPLL) is a common spinal disorder that presents with or without cervical myelopathy. Furthermore, there is evidence suggesting that OPLL often coexists with cervical disc hernia (CDH), and that the latter is the more important compression factor. To raise the awareness of CDH in OPLL for spinal surgeons, we performed a retrospective study on 142 patients with radiologically proven OPLL who had received surgery between January 2004 and January 2008 in our hospital. Plain radiograph, three-dimensional computed tomography construction (3D CT), and magnetic resonance imaging (MRI) of the cervical spine were all performed. Twenty-six patients with obvious CDH (15 of segmental-type, nine of mixed-type, two of continuous-type) were selected via clinical and radiographic features, and intraoperative findings. By MRI, the most commonly involved level was C5/6, followed by C3/4, C4/5, and C6/7. The areas of greatest spinal cord compression were at the disc levels because of herniated cervical discs. Eight patients were decompressed via anterior cervical discectomy and fusion (ACDF), 13 patients via anterior cervical corpectomy and fusion (ACCF), and five patients via ACDF combined with posterior laminectomy and fusion. The outcomes were all favorable. In conclusion, surgeons should consider the potential for CDH when performing spinal cord decompression and deciding the surgical approach in patients presenting with OPLL.

Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis.

PubMed

Teixeira, Pedro Gr; Woo, Karen; Beck, Adam W; Scali, Salvatore T; Weaver, Fred A

2017-12-01

Objectives Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair. Methods The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011-July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences. Results The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82-2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03-5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74-3.26), P = 0.244). Conclusion For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.

Posterior Branches of Lumbar Spinal Nerves - Part I: Anatomy and Functional Importance.

PubMed

Kozera, Katarzyna; Ciszek, Bogdan

2016-01-01

The aim of this paper is to compare anatomic descriptions of posterior branches of the lumbar spinal nerves and, on this basis, present the location of these structures. The majority of anatomy textbooks do not describe these nerves in detail, which may be attributable to the fact that for many years they were regarded as structures of minor clinical importance. The state of knowledge on these nerves has changed within the last 30 years. Attention has been turned to their function and importance for both diagnostic practice and therapy of lower back pain. Summarising the available literature, we may conclude that the medial and lateral branches separate at the junction of the facet joint and the distal upper edge of the transverse process; that the size, course and area supplied differ between the lateral and the medial branch; and that facet joints receive multisegmental innervation. It has been demonstrated that medial branches are smaller than the respective lateral branches and they have a more constant course. Medial branches supply the area from the midline to the facet joint line, while lateral branches innervate tissues lateral to the facet joint. The literature indicates difficulties with determining specific anatomic landmarks relative to which the lateral branch and the distal medial branch can be precisely located. Irritation of sensory fibres within posterior branches of the lumbar spinal nerves may be caused by pathology of facet joints, deformity of the spine or abnormalities due to overloading or injury. The anatomic location and course of posterior branches of spinal nerves should be borne in mind to prevent damaging them during low-invasive analgesic procedures.

One-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children.

PubMed

Hu, Xiongke; Zhang, Hongqi; Yin, Xinhua; Chen, Yong; Yu, Honggui; Zhou, Zhenhai

2016-03-01

The purpose of this study is to investigate the clinical efficacy and feasibility of one-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children. From December 2007 to May 2012, 13 patients (six males and seven females) suffering from lumbar spinal tuberculosis with kyphosis were admitted. All patients were treated with one-stage posterior focus debridement, fusion, and instrumentation. Then, the clinical efficacy was estimated by statistical analysis based on the data about Frankel grade, the Cobb angle of kyphosis, and erythrocyte sedimentation rate (ESR), which were collected at certain time. The age of all patients ranged from 5 to 13 years (average, 8.8 years). Operation time ranged from 120 to 190 min (average, 165 min). Intraoperative blood loss ranged from 200 to 800 ml (average, 460 ml). All patients were followed up for 24 to 57 months postoperatively (average, 33.5 months). The Cobb angle was changed significantly between preoperation and postoperation (P < 0.05), and there was no significant loss at the last follow-up. The preoperation ESR (62.5 ± 15.7) returned to normal (16.6 ± 8.1) within 3 months postoperatively in all patients (P < 0.05). Bone fusion was achieved within 3-5 months (average, 3.5 months). In the 13 cases, no postoperative severe complications occurred and neurologic function improved in various degrees. The outcomes of follow-up showed that one-stage posterior focus debridement, fusion, and instrumentation can be an effective treatment method for the lumbar spinal tuberculosis with kyphosis in children.

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral brucellosis.

PubMed

Abulizi, Yakefu; Liang, Wei-Dong; Muheremu, Aikeremujiang; Maimaiti, Maierdan; Sheng, Wei-Bin

2017-07-14

Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis. From February 2012 to April 2015, 32 consecutive patients (19 males and 13 females, mean age 53.7 ± 8.7) with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria. The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months' follow-up. VAS and ODI scores were significantly improved (P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up. Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis.

Mutations in FLVCR1 Cause Posterior Column Ataxia and Retinitis Pigmentosa

PubMed Central

Rajadhyaksha, Anjali M.; Elemento, Olivier; Puffenberger, Erik G.; Schierberl, Kathryn C.; Xiang, Jenny Z.; Putorti, Maria L.; Berciano, José; Poulin, Chantal; Brais, Bernard; Michaelides, Michel; Weleber, Richard G.; Higgins, Joseph J.

2010-01-01

The study of inherited retinal diseases has advanced our knowledge of the cellular and molecular mechanisms involved in sensory neural signaling. Dysfunction of two specific sensory modalities, vision and proprioception, characterizes the phenotype of the rare, autosomal-recessive disorder posterior column ataxia and retinitis pigmentosa (PCARP). Using targeted DNA capture and high-throughput sequencing, we analyzed the entire 4.2 Mb candidate sequence on chromosome 1q32 to find the gene mutated in PCARP in a single family. Employing comprehensive bioinformatic analysis and filtering, we identified a single-nucleotide coding variant in the feline leukemia virus subgroup C cellular receptor 1 (FLVCR1), a gene encoding a heme-transporter protein. Sanger sequencing confirmed the FLVCR1 mutation in this family and identified different homozygous missense mutations located within the protein's transmembrane channel segment in two other unrelated families with PCARP. To determine whether the selective pathologic features of PCARP correlated with FLVCR1 expression, we examined wild-type mouse Flvcr1 mRNA levels in the posterior column of the spinal cord and the retina via quantitative real-time reverse-transcriptase PCR. The Flvcr1 mRNA levels were most abundant in the retina, followed by the posterior column of the spinal cord and other brain regions. These results suggest that aberrant FLVCR1 causes a selective degeneration of a subpopulation of neurons in the retina and the posterior columns of the spinal cord via dysregulation of heme or iron homeostasis. This finding broadens the molecular basis of sensory neural signaling to include common mechanisms that involve proprioception and vision. PMID:21070897

Open Anterior Release of the Superior Transverse Scapular Ligament for Decompression of the Suprascapular Nerve During Brachial Plexus Surgery.

PubMed

Elzinga, Kate E; Curran, Matthew W T; Morhart, Michael J; Chan, K Ming; Olson, Jaret L

2016-07-01

Reconstruction of the suprascapular nerve (SSN) after brachial plexus injury often involves nerve grafting or a nerve transfer. To restore shoulder abduction and external rotation, a branch of the spinal accessory nerve is commonly transferred to the SSN. To allow reinnervation of the SSN, any potential compression points should be released to prevent a possible double crush syndrome. For that reason, the authors perform a release of the superior transverse scapular ligament at the suprascapular notch in all patients undergoing reconstruction of the upper trunk of the brachial plexus. Performing the release through a standard anterior open supraclavicular approach to the brachial plexus avoids the need for an additional posterior incision or arthroscopic procedure. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Release and repair of a ventral thoracic spinal cord herniation.

PubMed

McCormick, Paul C

2014-09-01

Ventral thoracic spinal cord herniation is a rare but increasingly recognized cause of progressive myelopathy. This video demonstrates the imaging characteristics and surgical techniques for release and reduction of the spinal cord herniation as well as primary repair and reinforcement of the ventral dural hernia defect through an extended posterior approach. An instrumented fusion was concomitantly performed. The video can be found here: http://youtu.be/6Pcokep6Tug.

Clinical application of the Panjabi neutral zone hypothesis: the Stabilimax NZ posterior lumbar dynamic stabilization system.

PubMed

Yue, James J; Timm, Jens P; Panjabi, Manohar M; Jaramillo-de la Torre, Jorge

2007-01-15

The neutral zone (NZ) is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column. The NZ appears to be a clinically important measure of spinal stability function. Its size may increase with injury to the spinal column, which in turn may result in spinal instability or low-back pain. Dynamic stabilization systems are designed to support and stabilize the spine while maintaining range of motion (ROM). The Stabilimax NZ device has been designed to reduce the NZ after spinal injury to treat pain while preserving ROM.

Parascapular mass revealing primary tuberculosis of the posterior arch

PubMed Central

Arbault, Anais; Ornetti, Paul; Chevallier, Olivier; Avril, Julien; Pottecher, Pierre

2016-01-01

We report the case of a parascapular abscess revealing primary tuberculosis of the posterior arch in a 31-year-old man. Sectional imaging is essential in order to detect the different lesions of this atypical spinal tuberculosis as osteolysis of the posterior arch extendible to vertebral body, osteocondensation, epidural extension which is common in this location, and high specificity of a zygapophysial, costo-vertebral or transverse arthritis. PMID:27709081

Asymmetrical trunk movement during walking improved to normal range at 3 months after corrective posterior spinal fusion in adolescent idiopathic scoliosis.

PubMed

Wong-Chung, Daniel A C F; Schimmel, Janneke J P; de Kleuver, Marinus; Keijsers, Noël L W

2018-02-01

To investigate the effects of posterior spinal fusion (PSF) and curve type on upper body movements in Adolescent Idiopathic Scoliosis (AIS) patients during gait. Twenty-four girls (12-18 years) with AIS underwent PSF. 3D-Gait-analyses were performed preoperatively, at 3 months and 1 year postoperatively. Mean position (0° represents symmetry) and range of motion (ROM) of the trunk (thorax-relative-to-pelvis) in all planes were assessed. Lower body kinematics and spatiotemporal parameters were also evaluated. Mean trunk position improved from 7.0° to 2.9° in transversal plane and from 5.0° to - 0.8° in frontal plane at 3 months postoperative (p < 0.001), and was maintained at 1 year. Trunk ROM in transverse plane decreased from 9.6° to 7.5° (p < 0.001) after surgery. No effects of PSF were observed on the lower body kinematics during the gait cycle. Patients with a double curve had a more axial rotated trunk before and after surgery (p = 0.013). In AIS patients, during gait an evident asymmetrical position of the trunk improved to an almost symmetric situation already 3 months after PSF and was maintained at 1 year. Despite a reduction of trunk ROM, patients were able to maintain the same walking pattern in the lower extremities after surgery. This improvement of symmetry and maintenance of normal gait can explain the rapid recovery and well functioning in daily life of AIS patients, despite undergoing a fusion of large parts of their spine.

Antimicrobial prophylaxis to prevent surgical site infection in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion: 2 doses versus antibiotics till drain removal.

PubMed

Kamath, Vijay H D; Cheung, Jason Pui Yin; Mak, Kin Cheung; Wong, Yat Wa; Cheung, Wai Yuen; Luk, Keith Dip Kei; Cheung, Kenneth Man Chee

2016-10-01

There is much variation in the choice, timing and duration of antimicrobial prophylaxis for preventing surgical site infections (SSI) but no guideline exists for scoliosis surgery. The aim of study was to compare the efficacy of two antimicrobial prophylaxis (AMP) protocols with cephazolin in preventing SSI in adolescent idiopathic scoliosis (AIS). A retrospective comparative analysis of two post-operative AMP protocols (two postoperative doses versus continued antibiotics till drain removal) was performed. Patient characteristics, pre-operative, intra- and post-operative risk factors for infection, drain use, generic drug name and number of doses administered were recorded from 226 patients with AIS who had undergone posterior spinal fusion. Details of superficial or deep SSI and wound healing aberrations, and serious adverse events were recorded. Analysis was performed to evaluate differences in the pre-, intra- and post-operative variables between the two groups. 155 patients received 2 postoperative doses of AMP and 71 patients had antibiotics till drain removal. The average follow-up was 43 months. The overall rate of SSI was 1.7 % for the spine wound and 1.3 % for the iliac crest wound. 1.9 % of patients with 2 doses of AMP and 1.4 % of patients with antibiotics till drain removal had SSI. No adverse reactions attributable to cephazolin were observed. This is the first study on the AMP protocol in scoliosis surgery for SSI prevention. Results suggest that two doses of AMP are as effective as continued antimicrobial use until drain removal. Cephazolin appears to be effective and safe for prophylaxis.

77 FR 42318 - Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee; Notice of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-18

... regarding the classification of posterior cervical screws, including pedicle and lateral mass screws. Cervical pedicle and lateral mass screws are components of rigid, posterior spinal screw and rod systems... neck pain confirmed by radiographic studies), trauma, deformity, failed previous fusion, tumor...

[Clinical efficacy of posterior intervertebral surgery for treating single-segment thoracolumbar spinal tuberculosis].

PubMed

Yang, Zongqiang; He, Jinwen; Shi, Jiandang; Niu, Ningkui; Ding, Huiqiang; Wang, Zili

2018-05-28

To determine the clinical efficacy of posterior intervertebral surgery for single-segment thoracolumbar spinal tuberculosis.
 Methods: Clinical data were retrospectively analyzed in 62 patients with thoracolumbar spinal tuberculosis who underwent posterior intervertebral surgery (A group) or posterior and anterior combined intervertebral surgery (B group) from January 2010 to January 2015 in Department of Spinal Surgery, General Hospital, Ningxia Medical University. The operative time, blood loss, length of hospital stay, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, neurological function, VAS score, vertebral Cobb angle, bone healing, and postoperative complications were compared between the 2 groups.
 Results: All patients were followed up for 10 to 30 (average 22) months after the operation. In the A group, operative time, blood loss, and hospital stay were less than those in the B group (P<0.05). In the follow-up, the pain of patients was alleviated and nervous function was improved obviously in the 2 groups compared with pre-operation. The ESR and CRP at the 6 months after operation returned to the normal range in patients of the 2 groups. There were significant differences in the ESR and CRP among the pre-operation, the 6 months after operation, and the end of follow-up within the group (P<0.05), while there were no significant differences in ESR and CRP between the 6 months after operation and the end of follow-up (P>0.05). There were no significant differences in the ESR and CRP among the pre-operation, the 6 months after operation, and the end of follow-up in the 2 group (P>0.05). The Cobb angles after the operation and the end of follow-up were significanthy smaller than those before the operation (P<0.01), while there were no significant differences in Cobb angle before operation, after the operation, and the end of follow-up between the 2 groups (P>0.05). There were no significant differences in the bone healing rate at 6 months or 1 year after operation between the A group and B group (P>0.05) and the complication rate of the A group was lower than the B group (P<0.01).
 Conclusion: Clinical efficacy of posterior intervertebral surgery is satisfatory in treating single-segment thoracolumbar spinal tuberculosis with less complications.

Widespread spinal cord involvement in progressive supranuclear palsy.

PubMed

Iwasaki, Yasushi; Yoshida, Mari; Hashizume, Yoshio; Hattori, Manabu; Aiba, Ikuko; Sobue, Gen

2007-08-01

We describe the histopathologic features of spinal cord lesions in 10 cases of progressive supranuclear palsy (PSP) and review the literature. Histologic examination revealed atrophy with myelin pallor in the anterior funiculus and anterolateral funiculus in the cervical and thoracic segments in eight of the 10 cases, whereas the posterior funiculus was well preserved. The degrees of atrophy of the anterior funiculus and the anterolateral funiculus correlated with that of the tegmentum of the medulla oblongata. Myelin pallor of the lateral corticospinal tract was observed in two of the 10 cases. Microscopic observation of the spinal white matter, particularly the cervical segment, revealed a few to several neuropil threads, particularly in the white matter surrounding the anterior horn after Gallyas-Braak (GB) staining or AT-8 tau immunostaining. However, the posterior funiculus was completely preserved from the presence of argyrophilic or tau-positive structures. In the spinal gray matter, widespread distribution of neurons with cytoplasmic inclusions and neuropil threads was observed, particularly in the medial division of the anterior horn and intermediate gray matter, especially in the cervical segment. Globose-type neurofibrillary tangles and pretangles were found. The distribution of GB- or AT-8 tau-positive small neurons and neuropil threads resembled that of the spinal interneurons. In conclusion, the spinal cord, especially the cervical segment, is constantly involved in the pathologic process of PSP. We speculate that spinal interneurons and their neuronal processes, particularly in the medial division of the anterior horn and intermediate gray matter of the cervical segment, are most severely damaged in the PSP spinal cord.

Minimally Invasive Lateral Access Surgery and Reoperation Rates: A Multi-Institution Retrospective Review of 2060 Patients.

PubMed

Nayar, Gautam; Wang, Timothy; Sankey, Eric W; Berry-Candelario, John; Elsamadicy, Aladine A; Back, Adam; Karikari, Isaac; Isaacs, Robert

2018-05-19

Risk factors for surgical revision remain important because of additional readmission, anesthesia, and morbidity for the patient and significant cost for health care systems. Although the rate of reoperation (RRO) is well described for traditional open posterior (OP) approaches, the RRO in minimally invasive lateral (MIL) surgery remains poorly characterized. This study compares the RRO in patients undergoing decompressive lumbar spine surgery via MIL versus OP approaches. Patient demographics and comorbidities were retrospectively collected for 2060 patients undergoing single-stage elective lumbar spinal surgery at multiple institutions. A subset of 1484 patients had long-term data (long-term cohort [LT cohort]). The RRO was compared between approaches through univariate and multivariate analysis. There were 1292 patients (62.7%) who underwent lateral access surgery, whereas 768 patients (37.3%) underwent OP surgery. The MIL cohort was significantly older, had a higher proportion of men, and had more comorbidities than the OP cohort. In the LT cohort, lateral patients were significantly older and had more comorbidities, with a lower body mass index and a lower proportion of men and smokers. Surgical complications between the groups trended to be similar. The MIL cohort had a significantly lower RRO at both 30 days (approximately 57% lower, MIL cohort: 1.01% vs. OP cohort: 2.36%, P = 0.02) and 2 years (approximately 61% lower, MIL cohort: 2.09% vs. OP cohort: 5.37%, P < 0.01) after surgery. On multivariate analysis, surgical approach was the only significant predictor for the RRO at both 30 days (open posterior approach odds ratio [OR], 4.47; 95% confidence interval [CI], 1.33-15.09; P = 0.02) and 2 years (open posterior approach OR, 3.26; 95% CI, 1.26-8.42; P = 0.01). This study shows that MIL surgical approaches, compared with OP approaches, have a significantly lower RRO after lumbar spine surgery. Copyright © 2018 Elsevier Inc. All rights reserved.

Cervical Fracture With Transient Tetraplegia in a Youth Football Player: Case Report and Review of the Literature

PubMed Central

Molinari, Robert; Molinari, William J

2010-01-01

Background/Objective: Serious cervical spinal injuries in organized youth football are rare. Cervical fracture with neurologic injury is rarely reported in organized youth football players with no pre-existing risk fractures for transient tetraplegia. Methods: Case report and literature review. Results: After being improperly tackled by an opponent of significantly larger body size, a player sustained a C7 posterior cervical fracture with transient tetraplegia. He was immobilized in a cervical collar and sent to a level 1 trauma center for evaluation. Initial examination showed bilateral paresthesia of the limbs with normal motor function (ASIA D). Initial radiographs of the cervical spine showed a displaced extension-compression fracture of the C7 spinous process. Magnetic resonance imaging of the cervical spine showed edema in the spinal cord in the region of the injury along with significant posterior injury. Imaging studies showed normal volumetric measurements of the spinal canal and no pre-existing risk factors for spinal stenosis or spinal cord injury. Radiographs showed that cervical fracture was healed at 9-month follow-up examination. At 1-year follow-up, the patient was asymptomatic. Radiographs showed healed fracture with no residual instability and full range of cervical spine motion on flexion–extension views. Conclusions: This case underscores the potential for serious cervical spinal injuries in organized youth sports when players are physically overmatched, and improper tackling technique is used. PMID:20486536

Is hospital information system relevant to detect surgical site infection? Findings from a prospective surveillance study in posterior instrumented spinal surgery.

PubMed

Boetto, J; Chan-Seng, E; Lonjon, G; Pech, J; Lotthé, A; Lonjon, N

2015-11-01

Spinal instrumentation has a high rate of surgical site infection (SSI), but results greatly vary depending on surveillance methodology, surgical procedures, or quality of follow-up. Our aim was to study true incidence of SSI in spinal surgery by significant data collection, and to compare it with the results obtained through the hospital information system. This work is a single center prospective cohort study that included all patients consecutively operated on for spinal instrumentation by posterior approach over a six-month period regardless the etiology. For all patients, a "high definition" prospective method of surveillance was performed by the infection control (IC) department during at least 12 months after surgery. Results were then compared with findings from automatic surveillance though the hospital information system (HIS). One hundred and fifty-four patients were included. We found no hardly difference between "high definition" and automatic surveillance through the HIS, even if HIS tended to under-estimate the infection rate: rate of surgical site infection was 2.60% and gross SSI incidence rate via the hospital information system was 1.95%. Smoking and alcohol consumption were significantly related to a SSI. Our SSI rates to reflect the true incidence of infectious complications in posterior instrumented adult spinal surgery in our hospital and these results were consistent with the lower levels of published infection rate. In-house surveillance by surgeons only is insufficiently sensitive. Further studies with more patients and a longer inclusion time are needed to conclude if SSI case detection through the HIS could be a relevant and effective alternative method. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Spondylectomy and lateral lumbar interbody fusion for thoracolumbar kyphosis in an adult with achondroplasia: A case report.

PubMed

Miyazaki, Masashi; Kanezaki, Shozo; Notani, Naoki; Ishihara, Toshinobu; Tsumura, Hiroshi

2017-12-01

Fixed thoracolumbar kyphosis with spinal stenosis in adult patients with achondroplasia presents a challenging issue. We describe the first case in which spondylectomy and minimally invasive lateral access interbody arthrodesis were used for the treatment of fixed severe thoracolumbar kyphosis and lumbar spinal canal stenosis in an adult with achondroplasia. A 61-year-old man with a history of achondroplastic dwarfism presented with low back pain and radiculopathy and neurogenic claudication. Plain radiographs revealed a high-grade thoracolumbar kyphotic deformity with diffuse degenerative changes in the lumbar spine. The apex was located at L2, the local kyphotic angle from L1 to L3 was 105°, and the anterior area was fused from the L1 to L3 vertebrae. MRI revealed significant canal and lateral recess stenosis secondary to facet hypertrophy. We planned a front-back correction of the anterior and posterior spinal elements. We first performed anterior release at the fused part from L1 to L3 and XLIF at L3/4 and L4/5. Next, the patient was placed in the prone position. Spondylectomy at the L2 vertebra and posterior fusion from T10 to L5 were performed. Postoperative radiographs revealed L1 to L3 kyphosis of 32°. No complications occurred during or after surgery. Postoperatively, the patient's low back pain and neurological claudication were resolved. No worsening of kyphosis was observed 24 months postoperatively. Circumferential decompression of the spinal cord at the apical vertebral level and decompression of lumbar canal stenosis were necessary. Front-back correction of the anterior and posterior spinal elements via spondylectomy and lateral lumbar interbody fusion is a reasonable surgical option for thoracolumbar kyphosis and developmental canal stenosis in patients with achondroplasia.

Multilevel extreme lateral interbody fusion (XLIF) and osteotomies for 3-dimensional severe deformity: 25 consecutive cases

PubMed Central

McAfee, Paul C.; Shucosky, Erin; Chotikul, Liana; Salari, Ben; Chen, Lun; Jerrems, Dan

2013-01-01

Background This is a retrospective review of 25 patients with severe lumbar nerve root compression undergoing multilevel anterior retroperitoneal lumbar interbody fusion and posterior instrumentation for deformity. The objective is to analyze the outcomes and clinical results from anterior interbody fusions performed through a lateral approach and compare these with traditional surgical procedures. Methods A consecutive series of 25 patients (78 extreme lateral interbody fusion [XLIF] levels) was identified to illustrate the primary advantages of XLIF in correcting the most extreme of the 3-dimensional deformities that fulfilled the following criteria: (1) a minimum of 40° of scoliosis; (2) 2 or more levels of translation, anterior spondylolisthesis, and lateral subluxation (subluxation in 2 planes), causing symptomatic neurogenic claudication and severe spinal stenosis; and (3) lumbar hypokyphosis or flat-back syndrome. In addition, the majority had trunks that were out of balance (central sacral vertical line ≥2 cm from vertical plumb line) or had sagittal imbalance, defined by a distance between the sagittal vertical line and S1 of greater than 3 cm. There were 25 patients who had severe enough deformities fulfilling these criteria that required supplementation of the lateral XLIF with posterior osteotomies and pedicle screw instrumentation. Results In our database, with a mean follow-up of 24 months, 85% of patients showed evidence of solid arthrodesis and no subsidence on computed tomography and flexion/extension radiographs. The complication rate remained low, with a perioperative rate of 2.4% and postoperative rate of 12.2%. The lateral listhesis and anterior spondylolisthetic subluxation were anatomically reduced with minimally invasive XLIF. The main finding in these 25 cases was our isolation of the major indication for supplemental posterior surgery: truncal decompensation in patients who are out of balance by 2 cm or more, in whom posterior spinal osteotomies and segmental pedicle screw instrumentation were required at follow up. No patients were out of sagittal balance (sagittal vertical line <3 cm from S1) postoperatively. Segmental instrumentation with osteotomies was also more effective for restoration of physiologic lumbar lordosis compared with anterior stand-alone procedures. Conclusions This retrospective study supports the finding that clinical outcomes (coronal/sagittal alignment) improve postoperatively after minimally invasive surgery with multilevel XLIF procedures and are improved compared with larger extensile thoracoabdominal anterior scoliosis procedures. PMID:25694908

Simultaneous double-rod rotation technique in posterior instrumentation surgery for correction of adolescent idiopathic scoliosis.

PubMed

Ito, Manabu; Abumi, Kuniyoshi; Kotani, Yoshihisa; Takahata, Masahiko; Sudo, Hideki; Hojo, Yoshihiro; Minami, Akio

2010-03-01

The authors present a new posterior correction technique consisting of simultaneous double-rod rotation using 2 contoured rods and polyaxial pedicle screws with or without Nesplon tapes. The purpose of this study is to introduce the basic principles and surgical procedures of this new posterior surgery for correction of adolescent idiopathic scoliosis. Through gradual rotation of the concave-side rod by 2 rod holders, the convex-side rod simultaneously rotates with the the concave-side rod. This procedure does not involve any force pushing down the spinal column around the apex. Since this procedure consists of upward pushing and lateral translation of the spinal column with simultaneous double-rod rotation maneuvers, it is simple and can obtain thoracic kyphosis as well as favorable scoliosis correction. This technique is applicable not only to a thoracic single curve but also to double major curves in cases of adolescent idiopathic scoliosis.

Outcomes of Spinal Fusion for Cervical Kyphosis in Children with Neurofibromatosis.

PubMed

Helenius, Ilkka J; Sponseller, Paul D; Mackenzie, William; Odent, Thierry; Dormans, John P; Asghar, Jahangir; Rathjen, Karl; Pahys, Joshua M; Miyanji, Firoz; Hedequist, Daniel; Phillips, Jonathan H

2016-11-02

Cervical kyphosis may occur with neurofibromatosis type I (NF1) and is often associated with vertebral dysplasia. Outcomes of cervical spinal fusion in patients with NF1 are not well described because of the rarity of the condition. We aimed to (1) characterize the clinical presentation of cervical kyphosis and (2) report the outcomes of posterior and anteroposterior cervical fusion for the condition in these children. The medical records and imaging studies of 22 children with NF1 who had undergone spinal fusion for cervical kyphosis (mean, 67°) at a mean age of 11 years and who had been followed for a minimum of 2 years were reviewed. Thirteen children presented with neck pain; 10, with head tilt; 9, with a previous cervical laminectomy or fusion; and 5, with a neurologic deficit. Two patients had spontaneous dislocation of the mid-cervical spine without a neurologic deficit. Eleven had scoliosis, with the major curve measuring a mean of 61°. Nine patients underwent posterior and 13 underwent anteroposterior surgery. Twenty-one received spinal instrumentation, and 1 was not treated with instrumentation. Preoperative halo traction was used for 9 patients, and it reduced the mean preoperative kyphosis by 34% (p = 0.0059). At the time of final follow-up, all spinal fusion sites had healed and the cervical kyphosis averaged 21° (mean correction, 69%; p < 0.001). The cervical kyphosis correction was significantly better after the anteroposterior procedures (83%) than after the posterior-only procedures (58%) (p = 0.031). Vertebral dysplasia and erosion continued in all 17 patients who had presented with dysplasia preoperatively. Thirteen patients had complications, including 5 new neurologic deficits and 8 cases of junctional kyphosis. Nine patients required revision surgery. Junctional kyphosis was more common in children in whom ≤5 levels had been fused (p = 0.054). Anteroposterior surgery provided better correction of cervical kyphosis than posterior spinal fusion in children with NF1. Erosion of vertebral bodies continued during the postoperative follow-up period in all patients who had presented with dysplastic changes preoperatively. The cervical spine should be screened in all children with NF1. Fusion should include at least 6 levels to prevent junctional kyphosis. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Choice of surgical approach for ossification of the posterior longitudinal ligament in combination with cervical disc hernia

PubMed Central

Yang, Hai-song; Lu, Xu-hua; Yang, Li–li; Yan, Wang-jun; Yuan, Wen; Chen, Yu

2009-01-01

Ossification of the posterior longitudinal ligament (OPLL) is a common spinal disorder that presents with or without cervical myelopathy. Furthermore, there is evidence suggesting that OPLL often coexists with cervical disc hernia (CDH), and that the latter is the more important compression factor. To raise the awareness of CDH in OPLL for spinal surgeons, we performed a retrospective study on 142 patients with radiologically proven OPLL who had received surgery between January 2004 and January 2008 in our hospital. Plain radiograph, three-dimensional computed tomography construction (3D CT), and magnetic resonance imaging (MRI) of the cervical spine were all performed. Twenty-six patients with obvious CDH (15 of segmental-type, nine of mixed-type, two of continuous-type) were selected via clinical and radiographic features, and intraoperative findings. By MRI, the most commonly involved level was C5/6, followed by C3/4, C4/5, and C6/7. The areas of greatest spinal cord compression were at the disc levels because of herniated cervical discs. Eight patients were decompressed via anterior cervical discectomy and fusion (ACDF), 13 patients via anterior cervical corpectomy and fusion (ACCF), and five patients via ACDF combined with posterior laminectomy and fusion. The outcomes were all favorable. In conclusion, surgeons should consider the potential for CDH when performing spinal cord decompression and deciding the surgical approach in patients presenting with OPLL. PMID:20012451

Viscoelastic properties of a spinal posterior dynamic stabilisation device.

PubMed

Lawless, Bernard M; Barnes, Spencer C; Espino, Daniel M; Shepherd, Duncan E T

2016-06-01

The purpose of this study was to quantify the frequency dependent viscoelastic properties of two types of spinal posterior dynamic stabilisation devices. In air at 37°C, the viscoelastic properties of six BDyn 1 level, six BDyn 2 level posterior dynamic stabilisation devices (S14 Implants, Pessac, France) and its elastomeric components (polycarbonate urethane and silicone) were measured using Dynamic Mechanical Analysis. The viscoelastic properties were measured over the frequency range 0.01-30Hz. The BDyn devices and its components were viscoelastic throughout the frequency range tested. The mean storage stiffness and mean loss stiffness of the BDyn 1 level device, BDyn 2 level device, silicone component and polycarbonate urethane component all presented a logarithmic relationship with respect to frequency. The storage stiffness of the BDyn 1 level device ranged from 95.56N/mm to 119.29N/mm, while the BDyn 2 level storage stiffness ranged from 39.41N/mm to 42.82N/mm. BDyn 1 level device and BDyn 2 level device loss stiffness ranged from 10.72N/mm to 23.42N/mm and 4.26N/mm to 9.57N/mm, respectively. No resonant frequencies were recorded for the devices or its components. The elastic property of BDyn 1 level device is influenced by the PCU and silicone components, in the physiological frequency range. The viscoelastic properties calculated in this study may be compared to spinal devices and spinal structures. Copyright © 2016 Elsevier Ltd. All rights reserved.

Baastrup's Disease Is Associated with Recurrent of Sciatica after Posterior Lumbar Spinal Decompressions Utilizing Floating Spinous Process Procedures

PubMed Central

Mannoji, Chikato; Murakami, Masazumi; Kinoshita, Tomoaki; Hirayama, Jiro; Miyashita, Tomohiro; Eguchi, Yawara; Yamazaki, Masashi; Suzuki, Takane; Aramomi, Masaaki; Ota, Mitsutoshi; Maki, Satoshi; Takahashi, Kazuhisa; Furuya, Takeo

2016-01-01

Study Design Retrospective case-control study. Purpose To determine whether kissing spine is a risk factor for recurrence of sciatica after lumbar posterior decompression using a spinous process floating approach. Overview of Literature Kissing spine is defined by apposition and sclerotic change of the facing spinous processes as shown in X-ray images, and is often accompanied by marked disc degeneration and decrement of disc height. If kissing spine significantly contributes to weight bearing and the stability of the lumbar spine, trauma to the spinous process might induce a breakdown of lumbar spine stability after posterior decompression surgery in cases of kissing spine. Methods The present study included 161 patients who had undergone posterior decompression surgery for lumbar canal stenosis using a spinous process floating approaches. We defined recurrence of sciatica as that resolved after initial surgery and then recurred. Kissing spine was defined as sclerotic change and the apposition of the spinous process in a plain radiogram. Preoperative foraminal stenosis was determined by the decrease of perineural fat intensity detected by parasagittal T1-weighted magnetic resonance imaging. Preoperative percentage slip, segmental range of motion, and segmental scoliosis were analyzed in preoperative radiographs. Univariate analysis followed by stepwise logistic regression analysis determined factors independently associated with recurrence of sciatica. Results Stepwise logistic regression revealed kissing spine (p=0.024; odds ratio, 3.80) and foraminal stenosis (p<0.01; odds ratio, 17.89) as independent risk factors for the recurrence of sciatica after posterior lumbar spinal decompression with spinous process floating procedures for lumbar spinal canal stenosis. Conclusions When a patient shows kissing spine and concomitant subclinical foraminal stenosis at the affected level, we should sufficiently discuss the selection of an appropriate surgical procedure. PMID:27994785

Baastrup's Disease Is Associated with Recurrent of Sciatica after Posterior Lumbar Spinal Decompressions Utilizing Floating Spinous Process Procedures.

PubMed

Koda, Masao; Mannoji, Chikato; Murakami, Masazumi; Kinoshita, Tomoaki; Hirayama, Jiro; Miyashita, Tomohiro; Eguchi, Yawara; Yamazaki, Masashi; Suzuki, Takane; Aramomi, Masaaki; Ota, Mitsutoshi; Maki, Satoshi; Takahashi, Kazuhisa; Furuya, Takeo

2016-12-01

Retrospective case-control study. To determine whether kissing spine is a risk factor for recurrence of sciatica after lumbar posterior decompression using a spinous process floating approach. Kissing spine is defined by apposition and sclerotic change of the facing spinous processes as shown in X-ray images, and is often accompanied by marked disc degeneration and decrement of disc height. If kissing spine significantly contributes to weight bearing and the stability of the lumbar spine, trauma to the spinous process might induce a breakdown of lumbar spine stability after posterior decompression surgery in cases of kissing spine. The present study included 161 patients who had undergone posterior decompression surgery for lumbar canal stenosis using a spinous process floating approaches. We defined recurrence of sciatica as that resolved after initial surgery and then recurred. Kissing spine was defined as sclerotic change and the apposition of the spinous process in a plain radiogram. Preoperative foraminal stenosis was determined by the decrease of perineural fat intensity detected by parasagittal T1-weighted magnetic resonance imaging. Preoperative percentage slip, segmental range of motion, and segmental scoliosis were analyzed in preoperative radiographs. Univariate analysis followed by stepwise logistic regression analysis determined factors independently associated with recurrence of sciatica. Stepwise logistic regression revealed kissing spine ( p =0.024; odds ratio, 3.80) and foraminal stenosis ( p <0.01; odds ratio, 17.89) as independent risk factors for the recurrence of sciatica after posterior lumbar spinal decompression with spinous process floating procedures for lumbar spinal canal stenosis. When a patient shows kissing spine and concomitant subclinical foraminal stenosis at the affected level, we should sufficiently discuss the selection of an appropriate surgical procedure.

Revisiting the segmental organization of the human spinal cord.

PubMed

Leijnse, J N; D'Herde, K

2016-09-01

In classic anatomic atlases, the spinal cord is standardly represented in its anatomical form with symmetrically emerging anterior and posterior roots, which at the level of the intervertebral foramen combine into the spinal nerves. The parts of the cord delimited by the boundaries of the roots are called segments or myelomeres. Associated with their regular repetitive appearance is the notion that the cord is segmentally organized. This segmental view is reinforced by clinical practice. Spinal cord roots innervate specific body parts. The level of cord trauma is diagnosed by the de-innervation symptoms of these parts. However, systemically, the case for a segmentally organized cord is not so clear. To date, developmental and genetic research points to a regionally rather than a segmentally organized cord. In the present study, to what degree the fila radicularia are segmentally implanted along the cord was investigated. The research hypothesis was that if the fila radicularia were non-segmentally implanted at the cord surface, it would be unlikely that the internal neuron stratum would be segmented. The visual segmented aspect of the myelomeres would then be the consequence of the necessary bundling of axons towards the vertebral foramen as the only exits of the vertebral canal, rather than of an underlying segment organization of the cord itself. To investigate the research hypothesis, the fila radicularia in the cervical-upper thoracic part of five spinal cords were detached from their spinal nerves and dissected in detail. The principal research question was if the fila radicularia are separated from their spinal nerves and dissected from their connective tissues up to the cord, would it be possible to reconstruct the original spinal segments from the morphology and interspaces of the fila? The dissections revealed that the anterior fila radicularia emerge from the cord at regular regionally modulated interspaces without systematic segmental delineations. The posterior fila radicularia are somewhat more segmentally implanted, but the pattern is individually inconsistent. The posterior and anterior roots have notable morphological differences, and hypotheses are presented to help explain these. The macroscopic observations are consistent with a regionally but not a segmentally organized cord. This conclusion was visually summarized in photographs of spinal cords with ipsilateral intact roots and contralateral individually dissected fila radicularia. It was suggested that this dual view of the spinal cord be added to the standard anatomic textbooks to counterbalance the current possibly biased view of a segmented cord. © 2016 Anatomical Society.

Continuous intravenous morphine infusion for postoperative analgesia following posterior spinal fusion for idiopathic scoliosis.

PubMed

Poe-Kochert, Connie; Tripi, Paul A; Potzman, Jennifer; Son-Hing, Jochen P; Thompson, George H

2010-04-01

A retrospective study of postoperative pain management. Evaluate the efficacy and safety of continuous intravenous morphine infusion for postoperative pain management in patients with idiopathic scoliosis (IS) undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). Postoperative pain is a common problem following surgery for IS. There are no published reports regarding the use of a continuous intravenous morphine infusion for this patient population. We retrospectively reviewed data regarding 339 consecutive patients with IS who underwent PSF and SSI between 1992 and 2006. All patients received intrathecal morphine after the induction of general anesthesia. Following surgery, preordered morphine infusion (0.01 mg/kg/h) was started at first reported pain. The infusion rate was titrated based on vital signs, visual analog scale (VAS) pain scores (0-10), and clinical status. It was continued until patients were able to take oral analgesics. We reviewed intrathecal morphine dosage, VAS pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirements in the first 48 hours, and any adverse reactions (nausea/vomiting, pruritus, respiratory depression, and pediatric intensive care unit admission). Mean intrathecal morphine dose was 15.5 +/- 3.9 microg/kg and mean interval to start of the intravenous morphine infusion was 17.5 +/- 5 hours. Mean VAS pain scores were 3.1, 4.5, 4.5, and 4.6 at 12 hours, 1, 2, and 3 days after surgery, respectively.The total mean morphine dose in the first 48 hours postoperatively was 0.03 +/- 0.01 mg/kg/h. Total morphine received was 1.44 +/- 0.5 mg/kg. Nausea/vomiting and pruritus, related to the morphine infusion occurred in 45 patients (13.3%) and 14 patients (4.1%), respectively. No patients had respiratory depression or required Pediatric Intensive Care Unit admission. A low frequency of adverse events and a mean postoperative VAS pain score of 5 or less demonstrate that a continuous postoperative morphine infusion is a safe and effective method of pain management in patients with IS following PSF and SSI.

Intraoperative visible bubbling of air may be the first sign of venous air embolism during posterior surgery for scoliosis.

PubMed

Wills, John; Schwend, Richard M; Paterson, Andrew; Albin, Maurice S

2005-10-15

Case report of two children sustaining venous air embolism (VAE) during posterior surgery for scoliosis. To report 2 cases where visible bubbling at the operative site was the first clinical indication of VAE-induced cardiovascular collapse and to raise the level of consciousness that VAE in the prone position can occur, often with serious consequences. Twenty-two cases of VAE during surgery for scoliosis in the prone position have been reported. Ten were fatal and ten were in children. Visible bubbling at the operative site was noted in two published cases. Retrospective study of 2 cases of VAE at one institution. Clinical, anesthetic, and radiographic features are presented. Details of previously published cases are reviewed and discussed. Both patients were girls with adolescent scoliosis who underwent prone positioned posterior spinal fusion with instrumentation. Visible bubbling of air at the thoracic aspect of the surgical site was noted near the completion of instrumentation and was the first indication of VAE. In both cases, this was clinically recognized and promptly treated. One patient survived normally and the other died. Visible air bubbling at the operative site may herald the onset of massive VAE during multilevel posterior spinal fusion and instrumentation. A prospective multicenter study using precordial Doppler, central venous catheter, and end-tidal CO2 is recommended to determine the true incidence of VAE in spinal deformity surgery and to evaluate monitoring and treatment methods.

Drug overdose resulting in quadriplegia.

PubMed

Wang, Teresa S; Grunch, Betsy H; Moreno, Jessica R; Bagley, Carlos A; Gottfried, Oren N

2012-06-01

To describe a case of cervical flexion myelopathy resulting from a drug overdose. A 56-year-old male presented to the emergency department unable to move his extremities following drug overdose. Neurological examination revealed him to be at C6 ASIA A spinal cord injury. The CT of his cervical spine revealed no fracture; however, an MRI revealed cord edema extending from C3 to C6 as well as posterior paraspinal signal abnormalities suggestive of ligamentous injury. The patient underwent a posterior cervical laminectomy and fusion from C3 to C7. Neurologically he regained 3/5 bilateral tricep function and 2/5 grip; otherwise, he remained at ASIA A spinal cord injury at 6 months. Our patient suffered a spinal cord injury likely due to existing cervical stenosis, and in addition to an overdose of sedating medications, he likely sat in flexed neck position for prolonged period of time with the inability to modify his position. This likely resulted in cervical spine vascular and/or neurological compromise producing an irreversible spinal cord injury. Spinal cord injury is a rare finding in patients presenting with drug overdose. The lack of physical exam findings suggestive of trauma may delay prompt diagnosis and treatment, and thus clinicians must have a high index of suspicion when evaluating patients in this setting.

Tract-Specific Volume Loss on 3T MRI in Patients with Cervical Spondylotic Myelopathy.

PubMed

Hopkins, Benjamin S; Weber, Kenneth A; Cloney, Michael Brendan; Paliwal, Monica; Parrish, Todd B; Smith, Zachary A

2018-04-11

Case-control. The aim of this study was to understand the role of high-resolution magnetic resonance (MR) in identifying regional cord volume loss in cervical spondylotic myelopathy (CSM). Preliminary studies suggest that compression of the ventral region of the cord may contribute disproportionately to CSM symptomology; however, tract-specific data are lacking in the CSM population. The current study is the first to use 3T MR imaging (MRI) images of CSM patients to determine specific volume loss at the level of detail of individual descending white matter tracts. Twelve patients with CSM and 14 age-matched were enrolled prospectively and underwent 3-Tesla MRI of the cervical spine. Using the high-resolution images of the spinal cord, straightening and alignment with a template was performed and specific spinal cord tract volumes were measured using Spinal Cord Tool-box version 3.0.7. Modified Japanese orthopedic association (mJOA) and Nurick disability scores were collected in a prospective manner and were analyzed in relation to descending spinal tract volumes. Having CSM was predicted by anterior/posterior diameter, eccentricity of the cord [odds ratio (OR) 0.000000621, P = 0.004], ventral reticulospinal tract volume (OR 1.167, P = 0.063), lateral corticospinal tract volume (OR 1.034, P = 0.046), rubrospinal tract volume (OR 1.072, P = 0.011), and ventrolateral reticulospinal tract volume (OR 1.474, P = 0.005) on single variable logistic regression. Single variable linear regression showed decreases in anterior/posterior spinal cord diameter (P = 0.022), ventral reticulospinal tract volumes (P = 0.007), and ventrolateral reticulospinal tract volumes (P = 0.017) to significantly predict worsening mJOA scores. Similarly, decreases in ventral reticulospinal tract volumes significantly predicted increasing Nurick scores (P = 0.039). High-resolution 3T MRI can detect tract-specific volume loss in descending spinal cord tracts in CSM patients. Anterior/posterior spinal cord diameter, ventral reticulospinal tract, ventrolateral reticulospinal tract, lateral corticospinal tract, and rubrospinal tract volume loss are associated with CSM symptoms. 2.

Bundled payment reimbursement for anterior and posterior approaches for cervical spondylotic myelopathy: an analysis of private payer and Medicare databases.

PubMed

Virk, Sohrab S; Phillips, Frank M; Khan, Safdar N

2018-03-01

OBJECTIVE Cervical spondylotic myelopathy (CSM) is a progressive spinal condition that often requires surgery. Studies have shown the clinical equivalency of anterior versus posterior approaches for CSM surgery. The purpose of this study was to determine the amount and type of resources used for anterior and posterior surgical treatment of CSM by using large national databases of clinical and financial information from patients. METHODS This study consists of 2 large cohorts of patients who underwent either an anterior or posterior approach for treatment of CSM. These patients were selected from the Medicare 5% National Sample Administrative Database (SAF5) and the Humana orthopedic database (HORTHO), which is a database of patients with private payer health insurance. The outcome measures were the cost of a 90-day episode of care, as well as a breakdown of the cost components for each surgical procedure between 2005 and 2014. RESULTS A total of 16,444 patients were included in this analysis. In HORTHO, there were 10,332 and 1556 patients treated with an anterior or posterior approach for CSM, respectively. In SAF5, there were 3851 and 705 patients who were treated by an anterior or posterior approach for CSM, respectively. The mean ± SD reimbursements for anterior and posterior approaches in the HORTHO database were $20,863 ± $2014 and $23,813 ± $4258, respectively (p = 0.048). The mean ± SD reimbursements for anterior and posterior approaches in the SAF5 database were $18,219 ± $1053 and $25,598 ± $1686, respectively (p < 0.0001). There were also significantly higher reimbursements for a rehabilitation/skilled nursing facility and hospital/inpatient care for patients who underwent a posterior approach in both the private payer and Medicare databases. In all cohorts in this study, the hospital-related reimbursement was more than double the surgeon-related reimbursement. CONCLUSIONS This study provides resource utilization information for a 90-day episode of care for both anterior and posterior approaches for CSM surgery. There is a statistically significant higher resource utilization for patients undergoing the posterior approach for CSM, which is consistent with the literature. Understanding the reimbursement patterns for anterior versus posterior approaches for CSM will help providers design a bundled payment for patients requiring surgery for CSM, and this study suggests that a subset of patients who require the posterior approach for treatment also require greater resources. The data also suggest that hospital-related reimbursement is the major driver of payments.

Spinal Tissue Loading Created by Different Methods of Spinal Manipulative Therapy Application

PubMed Central

Funabashi, Martha; Nougarou, François; Descarreaux, Martin; Prasad, Narasimha; Kawchuk, Gregory N.

2017-01-01

Study Design. Comparative study using robotic replication of spinal manipulative therapy (SMT) vertebral kinematics together with serial dissection. Objective. The aim of this study was to quantify loads created in cadaveric spinal tissues arising from three different forms of SMT application. Summary of Background Data. There exist many distinct methods by which to apply SMT. It is not known presently whether different forms of SMT application have different effects on spinal tissues. Should the method of SMT application modulate spinal tissue loading, quantifying this relation may help explain the varied outcomes of SMT in terms of effect and safety. Methods. SMT was applied to the third lumbar vertebra in 12 porcine cadavers using three SMT techniques: a clinical device that applies forces through a hand-held instrument (INST), a manual technique of applying SMT clinically (MAN) and a research device that applies parameters of manual SMT through a servo-controlled linear actuator motor (SERVO). The resulting kinematics from each SMT application were tracked optically via indwelling bone pins. The L3/L4 segment was then removed, mounted in a parallel robot and the resulting kinematics from SMT replayed for each SMT application technique. Serial dissection of spinal structures was conducted to quantify loading characteristics of discrete spinal tissues. Results. In terms of load magnitude, SMT application with MAN and SERVO created greater forces than INST in all conditions (P < 0.05). Additionally, MAN and SERVO created comparable posterior forces in the intact specimen, but MAN created greater posterior forces on IVD structures compared to SERVO (P < 0.05). Conclusion. Specific methods of SMT application create unique vertebral loading characteristics, which may help explain the varied outcomes of SMT in terms of effect and safety. Level of Evidence: N/A PMID:28146021

Descending aortic injury by a thoracic pedicle screw during posterior reconstructive surgery: a case report.

PubMed

Watanabe, Kei; Yamazaki, Akiyoshi; Hirano, Toru; Izumi, Tomohiro; Sano, Atsuki; Morita, Osamu; Kikuchi, Ren; Ito, Takui

2010-09-15

Case report. To describe an iatrogenic aortic injury by pedicle screw instrumentation during posterior reconstructive surgery of spinal deformity. Iatrogenic major vascular injuries during anterior instrumentation procedures have been reported by several authors, but there have been few reports regarding iatrogenic major vascular injuries during posterior instrumentation procedures. A 57-year-old woman with thoracolumbar kyphosis due to osteoporotic T12 vertebral fracture underwent posterior correction and fusion (T10-L2), using segmental pedicle screw construct concomitant with T12 pedicle subtraction osteotomy. Postoperative routine plain radiographs and computed tomography myelography demonstrated a misplaced left T10 pedicle screw, which was in contact with the posteromedial aspect of the thoracic aorta, and suspected penetration of the aortic wall. The patient underwent removal of the pedicle screw, and repair of the penetrated aortic wall through a simultaneous anterior-posterior approach. The patient tolerated the procedure well without neurologic sequelae, and was discharged several days after removal of a left tube thoracostomy. Plain radiographs demonstrated solid fusion at the osteotomy site and no loosening of hardware. Preoperative neurologic symptoms improved completely at 18-months follow-up. Use of pedicle screw instrumentation has the potential to cause major vascular injury during posterior spinal surgery, and measures to prevent this complication must be taken. Timely diagnosis and treatment are essential to prevent both early and delayed complications and death.

Intrapartum sonography for occiput posterior detection in early low dose combined spinal epidural analgesia by sufentanil and ropivacaine.

PubMed

Malvasi, A; Tinelli, A; Brizzi, A; Guido, M; Martino, V; Casciaro, S; Celleno, D; Frigo, M G; Stark, M; Benhamou, D

2010-09-01

To evaluate the incidence of occiput posterior position in labour with and without combined spinal epidural analgesia (CSE) by low dose of sufentanyl and ropivacaine. This study focused on 132 women subdivided in two groups, patients in spontaneous and in labour analgesia, administered by a low dose CSE by sufentanyl and ropivacaine; all women were evaluated by digital examinations and ultrasound till delivery. All data were collected and analyzed by an independent reviewer. In the second stage, 79 were persistent occiput posterior position (POPP) fetuses and 36 were translated from anterior to posterior position (TAPP) fetuses. Specifically, in spontaneous labour on 25 women in anterior position, there were 17 TAPP and in CSE analgesia on 28 women in anterior, there were 19 in TAPP, without significant differences. The number of asynclitisms was higher in the POPP group (84%) respect to the TAPP group (75%), so as the rate of caesarean section (67% versus 52.7%). The labour with low dose of ropivacaine and sufentanyl does not increase the occiput posterior position during fetal descent, leading to a POPP. Finally, since in the occiput anterior presentation labour analgesia significantly lengthens time to delivery, in the occiput posterior position this is significantly increased, with a prolonged second stage of labour and reduced time of descent of fetal head in obstetric pelvis.

Multimodal infiltration of local anaesthetic in total knee arthroplasty; is posterior capsular infiltration worth the risk? a prospective, double-blind, randomised controlled trial.

PubMed

Pinsornsak, P; Nangnual, S; Boontanapibul, K

2017-04-01

Multimodal infiltration of local anaesthetic provides effective control of pain in patients undergoing total knee arthroplasty (TKA). There is little information about the added benefits of posterior capsular infiltration (PCI) using different combinations of local anaesthetic agents. Our aim was to investigate the effectiveness of the control of pain using multimodal infiltration with and without infiltration of the posterior capsule of the knee. In a double-blind, randomised controlled trial of patients scheduled for unilateral primary TKA, 86 were assigned to be treated with multimodal infiltration with (Group I) or without (Group II) PCI. Routine associated analgesia included the use of bupivacaine, morphine, ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled analgesia (PCA) post-operatively. A visual analogue scale (VAS) for pain and the use of morphine were recorded 24 hours post-operatively. Side effects of the infiltration, blood loss, and length of stay in hospital were recorded. There were no statistically significant differences between the groups in relation to: VAS pain scores in the first 24 hours post-operatively (p = 0.693), the use of morphine in the PCA (p = 0.647), blood loss (p = 0.625), and length of stay (p = 0.17). There were no neurovascular complications in either group. The multimodal infiltration of local anaesthetic with infiltration of the posterior capsule did not provide significant added analgesic benefits or reduce the use of morphine after TKA. Multimodal infiltration is a satisfactory technique for the management of pain in these patients without the attendant risks of PCI. Cite this article: Bone Joint J 2017; 99-B:483-8. ©2017 The British Editorial Society of Bone & Joint Surgery.

Variability in Standard Outcomes of Posterior Lumbar Fusion Determined by National Databases.

PubMed

Joseph, Jacob R; Smith, Brandon W; Park, Paul

2017-01-01

National databases are used with increasing frequency in spine surgery literature to evaluate patient outcomes. The differences between individual databases in relationship to outcomes of lumbar fusion are not known. We evaluated the variability in standard outcomes of posterior lumbar fusion between the University HealthSystem Consortium (UHC) database and the Healthcare Cost and Utilization Project National Inpatient Sample (NIS). NIS and UHC databases were queried for all posterior lumbar fusions (International Classification of Diseases, Ninth Revision code 81.07) performed in 2012. Patient demographics, comorbidities (including obesity), length of stay (LOS), in-hospital mortality, and complications such as urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, durotomy, and surgical site infection were collected using specific International Classification of Diseases, Ninth Revision codes. Analysis included 21,470 patients from the NIS database and 14,898 patients from the UHC database. Demographic data were not significantly different between databases. Obesity was more prevalent in UHC (P = 0.001). Mean LOS was 3.8 days in NIS and 4.55 in UHC (P < 0.0001). Complications were significantly higher in UHC, including urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, surgical site infection, and durotomy. In-hospital mortality was similar between databases. NIS and UHC databases had similar demographic patient populations undergoing posterior lumbar fusion. However, the UHC database reported significantly higher complication rate and longer LOS. This difference may reflect academic institutions treating higher-risk patients; however, a definitive reason for the variability between databases is unknown. The inability to precisely determine the basis of the variability between databases highlights the limitations of using administrative databases for spinal outcome analysis. Copyright © 2016 Elsevier Inc. All rights reserved.

Projections of the optic tectum and the mesencephalic nucleus of the trigeminal nerve in the tegu lizard (Tupinambis nigropunctatus).

PubMed

Ebbesson, S O

1981-01-01

Fibers undergoing Wallerian degeneration following tectal lesions were demonstrated with the Nauta and Fink-Heimer methods and traced to their termination. Four of the five distinct fiber paths originating in the optic tectum appear related to vision, while one is related to the mesencephalic nucleus of the trigeminus. The latter component of the tectal efferents distributes fibers to 1) the main sensory nucleus of the trigeminus, 2) the motor nucleus of the trigeminus, 3) the nucleus of tractus solitarius, and 4) the intermediate gray of the cervical spinal cord. The principal ascending bundle projects to the nucleus rotundus, three components of the ventral geniculate nucleus and the nucleus ventromedialis anterior ipsilaterally, before it crosses in the supraoptic commissure and terminates in the contralateral nucleus rotundus, ventral geniculate nucleus and a hitherto unnamed region dorsal to the nucleus of the posterior accessory optic tract. Fibers leaving the tectum dorso-medially terminate in the posterodorsal nucleus ipsilaterally and the stratum griseum periventriculare of the contralateral tectum. The descending fiber paths terminate in medial reticular cell groups and the rostral spinal cord contralaterally and in the torus and the lateral reticular regions ipsilaterally. The ipsilateral fascicle also issues fibers to the magnocellular nucleus isthmi.

Spinal cord atrophy in anterior-posterior direction reflects impairment in multiple sclerosis.

PubMed

Lundell, H; Svolgaard, O; Dogonowski, A-M; Romme Christensen, J; Selleberg, F; Soelberg Sørensen, P; Blinkenberg, M; Siebner, H R; Garde, E

2017-10-01

To investigate how atrophy is distributed over the cross section of the upper cervical spinal cord and how this relates to functional impairment in multiple sclerosis (MS). We analysed the structural brain MRI scans of 54 patients with relapsing-remitting MS (n=22), primary progressive MS (n=9), secondary progressive MS (n=23) and 23 age- and sex-matched healthy controls. We measured the cross-sectional area (CSA), left-right width (LRW) and anterior-posterior width (APW) of the spinal cord at the segmental level C2. We tested for a nonparametric linear relationship between these atrophy measures and clinical impairments as reflected by the Expanded Disability Status Scale (EDSS) and Multiple Sclerosis Impairment Scale (MSIS). In patients with MS, CSA and APW but not LRW were reduced compared to healthy controls (P<.02) and showed significant correlations with EDSS, MSIS and specific MSIS subscores. In patients with MS, atrophy of the upper cervical cord is most evident in the antero-posterior direction. As APW of the cervical cord can be readily derived from standard structural MRI of the brain, APW constitutes a clinically useful neuroimaging marker of disease-related neurodegeneration in MS. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Prospective dynamic functional evaluation of gait and spinal balance following spinal fusion in adolescent idiopathic scoliosis.

PubMed

Lenke, L G; Engsberg, J R; Ross, S A; Reitenbach, A; Blanke, K; Bridwell, K H

2001-07-15

Prospective evaluation of gait and spinal-pelvic balance parameters in patients with adolescent idiopathic scoliosis undergoing a spinal fusion. To evaluate changes in gait and three-dimensional alignment and balance of the spine relative to the pelvis as a consequence of spinal fusion. Preoperative and postoperative spinal radiographs have been the major forms of outcome analysis of adolescent idiopathic scoliosis fusions. The use of optoelectronic analysis for posture and gait has gained acceptance recently. However, there is a paucity of data quantifying, comparing, and correlating structural and functional changes in patients undergoing scoliosis fusion surgery including upright posture and gait. Thirty patients with adolescent idiopathic scoliosis undergoing an instrumented spinal fusion were prospectively evaluated. Coronal and sagittal vertical alignment was evaluated on radiographs (CVA-R, SVA-R), during upright posture (CVA-P and SVA-P), and during gait (CVA-G, SVA-G). Transverse plane alignment was evaluated by the acromion-pelvis angle during gait. Gait speed was significantly decreased (P < 0.05) between preoperative (129 +/- 16 cm/sec) and 2-year postoperative (119 +/- 16 cm/sec) testing sessions. Decreasing gait speed was the result of significantly reduced cadence and decreased stride length. There were no significant differences for lower extremity kinematics over the entire gait cycle. Spinal-pelvic balance parameters showed significant improvement in mean CVA-R, CVA-G (P < 0.05), then unchanged CVA-P at 2 years postoperation. CVA-P was relatively unchanged while the mean CVA-G also showed significant improvement from preoperation (2.2 +/- 2.4 cm) to 2 years postoperation (1.3 +/- 1.3 cm)(P < 0.05). The mean SVA-R, SVA-P, and SVA-G were unchanged at 2 years postoperation (P > 0.05). The acromion-pelvis angle during gait at maximum shoulder rotation was statistically improved at 1 year (P = 0.002) and 2 years (P = 0.001) after surgery. Importantly, CVA-P correlated with CVA-G, and SVA-P correlated with SVA-G to the P < 0.05 level. Patients with adolescent idiopathic scoliosis undergoing spinal fusion show slightly decreased gait speed at 2 years postoperation without any change in lower extremity kinematics. Spinal-pelvic balance parameters are improved in the coronal plane and unchanged in the sagittal plane radiographically and during standing posture and gait. Transverse plane parameters also are improved at maximum shoulder rotation during gait.

Comparison of clinical efficacy and safety among three surgical approaches for the treatment of spinal tuberculosis: a meta-analysis.

PubMed

Yang, Pinglin; Zang, Quanjin; Kang, Jian; Li, Haopeng; He, Xijing

2016-12-01

We aimed to provide evidence for clinical choice of surgical approach in treating spinal tuberculosis, including anterior, posterior and combined approaches (combined anterior and posterior approach). A literature search up to June 2015 was performed on PubMed, Embase, Cochrane library, CNKI, Wanfang and Weipu database. Weighted mean differences (WMDs) or risk radios (RRs) and their 95 % confidence intervals (CI) were calculated. Total 26 studies with 2345 spinal tuberculosis adults were analyzed. Results showed advantages of posterior approach compared with anterior approach in operation time (WMD = 20.91; 95 % CI: 9.05-32.76), blood loss (WMD = 72.32, 95 % CI: 13.87-130.78), correction of angle (WMD = -2.47; 95 % CI: -4.04 to -0.90) and complications (RR = 1.78; 95 % CI: 1.21-2.60), and compared with combined approach in operation time (WMD = -82.76; 95 % CI: -94.38 to -71.14), blood loss (WMD = -263.63; 95 % CI: -336.85 to -190.41), hospital stay [(WMD = -4.60; 95 % CI: -5.10 to -4.10) and complications (RR = 0.36; 95 % CI: 0.23-0.58]. Meanwhile, significantly larger correction of angle (WMD = -2.25; 95 % CI: -4.35 to -0.14; P = 0.04) and less loss of correction (WMD = 3.97; 95 % CI: 2.22-5.72) were found when compared combined approach with anterior approach. However, combined approach had significantly longer operation time (WMD = -41.92; 95 % CI: -52.45 to -31.38) and more blood loss (WMD = -102.18; 95 % CI: -160.45 to -43.91) than anterior approach. Posterior approach has better clinical outcomes than anterior or combined approach for spinal tuberculosis. However, individual assessment of each case should be considered in the clinical application of these surgical approaches.

The effects of dorso-lumbar motion restriction on the ground reaction force components during running.

PubMed

Morley, Joseph J; Traum, Edward

2016-04-01

The effects of restricting dorso-lumbar spine mobility on ground reaction forces in runners was measured and assessed. A semi-rigid cast was used to restrict spinal motion during running. Subjects ran across a force platform at 3.6 m/s, planting the right foot on the platform. Data was collected from ten running trials with the cast and ten without the cast and analysed. Casted running showed that the initial vertical heel strike maximum was increased (p < .02) and that the anterior-posterior deceleration impulse was increased (p < .01). The maximum vertical ground reaction force was decreased in casted running (p < .01), as was the anterior-posterior acceleration impulse (p < .02). There was a trend for increased medial-lateral impulse in the uncasted state, but this was not statistically significant. Spinal mobility and fascia contribute to load transfer between joints and body segments. Experimentally restricting spinal motion during running results in measurable and repeatable alterations in ground reaction force components. Alterations in load transfer due to decreased spinal motion may be a factor contributing to selected injuries in runners. Copyright © 2015 Elsevier Ltd. All rights reserved.

More preoperative flexibility implies adequate neural pliability for curve correction without prophylactic untethering in scoliosis patients with asymptomatic tethered spinal cord, a retrospective study.

PubMed

Zhou, Zhenhai; Zhang, Hongqi; Guo, Chaofeng; Yu, Honggui; Wang, Longjie; Guo, Qiang

2017-06-15

Tethered spinal cord is frequently associated with scoliosis. It is still controversial whether a prophylactic untethering is necessary before correction procedure in scoliosis patients with tethered spinal cord. In this study we determined the clinical outcome of a one-stage posterior scoliosis correction without a prophylactic untethering for treating scoliosis with an asymptomatic tethered spinal cord. Seventeen (5 males and 12 females) scoliosis patients with tethered spinal cords were retrospectively reviewed. All patients underwent a one-stage posterior scoliosis correction without preventive untethering. Parameters of radiograph were used to assess correction result. The Scoliosis Research Society (SRS)-22 questionnaire was analyzed pre- and post-operatively to evaluate the clinical outcomes. The modified Japanese Orthopaedic Association (mJOA) score was used to assess the pre- and post-operative spinal cord function. The post-operative coronal Cobb angle was significantly decreased compared with preoperative. (23.8 ± 6.4° vs. 58.4 ± 12.6°, P < 0.01). The coronal Cobb angle was 22.4 ± 6.8° at the final follow-up evaluation. The apical vertebral translation (AVT) was also decreased significantly. (27.5 mm vs. 60.9 mm, P < 0.01). The SRS-22 total score was improved at the 1-year follow-up evaluation compared with the pre-operative SRS-22 total score (87 ± 4 vs. 70 ± 5, p < 0.05). The functional activities, pain, self-image, mental health, and surgery satisfactory scores at the final follow-up evaluation were all improved compared with the corresponding pre-operative scores, especially the self-image and mental health scores (p < 0.05). The spinal cord function was stable and there was no new neurological symptoms after scoliosis correction. No difference existed between the pre- and post-operative total mJOA score (26 ± 2 vs. 27 ± 2, p = 0.39), which including subjective symptom (p = 0.07), clinical symptom (p = 0.33), daily activities (p = 0.44) and bladder function (p = 0.67). One-stage posterior scoliosis correction is a safe and effective surgical procedure for scoliosis patients combined with asymptomatic tethered spinal cord who have adequate spinal cord function reserve.

Management of postoperative pseudomeningoceles: an international survey study.

PubMed

Tu, Albert; Tamburrini, Gianpiero; Steinbok, Paul

2014-11-01

Pseudomeningoceles are common complications after posterior fossa and intradural spinal surgery and are often asymptomatic. Management guidelines are lacking, and anecdotally, we have encountered radically different suggested treatments varying from observation to immediate surgical intervention. The goal of this study was to determine the prevailing opinions among neurosurgeons on the management of this condition. Neurosurgeons from around the world were invited via an International Society for Pediatric Neurosurgery (ISPN) and Neurosurgery ListServ e-blast to participate in a 33-question survey on the management of pseudomeningoceles, presented as simulated scenarios after posterior fossa and spinal intradural surgery. Two hundred forty-one responses were obtained. Pseudomeningoceles after posterior fossa tumor resection, in the absence of hydrocephalus, were typically managed nonoperatively for 7 to 14 days before re-exploration. Only 0.5 % of the surgeons would offer upfront repair of the pseudomeningocele. In the presence of hydrocephalus, 48 % of the neurosurgeons intervene initially with cerebrospinal fluid (CSF) diversion and would change therapy if the lesion did not resolve in 2 to 4 days. Ninety percent of the surgeons manage spinal pseudomeningoceles nonoperatively for 7-14 days before re-exploration is considered. The most common steps taken to prevent pseudomeningoceles are watertight closure, tissue glues, and duroplasty. The present zeitgeist suggests that, in the absence of hydrocephalus, initial observation is appropriate for cranial and spinal pseudomeningoceles. Operative revision should be reserved for failure of conservative treatment. If hydrocephalus is present, consideration should be made for CSF diversion. This study may serve as a guideline regarding acceptable management.

The use of a reconstituted collagen foil dura mater substitute in paediatric neurosurgical procedures--experience in 47 patients.

PubMed

Pettorini, Benedetta Ludovica; Tamburrini, Gianpiero; Massimi, Luca; Paternoster, Giovanna; Caldarelli, Massimo; Di Rocco, Concezio

2010-02-01

CSF leakage is a common complication of neurosurgical procedures, with defective dural suture thought to be the most frequent cause. We report our experience with a new collagen foil (TissuDura, Baxter Healthcare SA, Switzerland) utilized as dural substitute in paediatric neurosurgical procedures. TissuDura was used in children consecutively operated on at the department of paediatric neurosurgery, Catholic University, Rome, from March 2004 to August 2007. Children underwent surgical procedures in supratentorial, infratentorial and spinal compartments. In supratentorial and spinal procedures, the dural graft was used according to the overlay technique. In the posterior fossa procedures, the underlay technique was used. Forty-seven patients received TissuDura during surgery. Thirty-one patients underwent surgery for the removal of posterior fossa tumours, nine for supratentorial tumours and seven for spinal dysraphisms. No CSF leakage was observed following the use of TissuDura in supratentorial procedures. Two post-operative CSF leaks occurred in patients who had undergone spinal surgery. No post-operative hydrocephalus was noted in these two surgery groups. Three cases of CSF leakage occurred in patients who had undergone posterior cranial fossa surgery. All 3 cases had an associated supratentorial ventricular dilation present prior to the removal of the tumour (one case) or occurring after the tumour excision (two cases). No clinically evident adverse reactions directly related to TissuDura were observed. The main advantages of TissuDura were its apparent ability to prevent CSF leakage when utilized in a specific subset of patients, and the absence of reactions or postoperative infections.

Primary epidural malignant hemangiopericytoma of thoracic spinal column causing cord compression: case report.

PubMed

Mohammadianpanah, Mohammad; Torabinejad, Simin; Bagheri, Mohammad Hadi; Omidvari, Shapour; Mosalaei, Ahmad; Ahmadloo, Niloofar

2004-09-02

Hemangiopericytoma is an uncommon mesenchymal neoplasm that rarely affects the spinal canal. Primary malignant hemangiopericytoma of the spinal column is extremely rare. We report on a case of primary epidural malignant hemangiopericytoma of the thoracic spinal column that invaded vertebral bone and caused spinal cord compression in a 21-year-old man. The patient presented with progressive back pain over a four-month period that progressed to paraparesis, bilateral leg paresthesia and urinary incontinence. The surgical intervention involved laminectomy and subtotal resection of the tumor, with posterior vertebral fixation. Postoperative involved-field radiotherapy was administered. A marked neurological improvement was subsequently observed. We describe the clinical, radiological, and histological features of this tumor and review the literature.

Giant cell tumor of the sixth thoracic vertebra: case report.

PubMed

Ben Nsir, Atef; Said, Imed Ben; Badri, Mohamed; Boughamoura, Mohamed; Jemel, Hafedh

2015-01-01

Giant cell tumor is an uncommon but most aggressive benign tumour of the spine with unpredictable outcome and challenging treatment. Spinal giant cell tumors located above the sacrum are rare and treatment recommendations are still unclear. We report a rare case of this lesion in an adult and discuss the management and outcome of such uncommon tumors. A 31-year-old woman presented with progressive motor weakness of both lower limbs with back pain during the past month, associated with sphincter disturbances for the past two days. She was diagnosed with a lytic heterogeneously enhancing mass depending mainly on the T6 posterior arch with small vertebral body involvement. The tumor extent reached surrounding soft tissue and the spinal canal with marked spinal cord compression. A posterior approach was realized as an emergency. Histological examination showed evidence of a giant cell tumor and a complementary irradiation was used. The patient improved well post operatively. There was no recurrence or metastasis over 5 years of follow-up.

Spinal epidural abscesses in children: a 15-year experience and review of the literature.

PubMed

Auletta, J J; John, C C

2001-01-01

We reviewed medical records and laboratory and diagnostic evaluations for 8 pediatric patients with spinal epidural abscesses who were treated during the last 15 years at our institution. Staphylococcus aureus was isolated from 5 of 8 epidural abscesses, including 2 abscesses with methicillin-resistant S. aureus. Unusual isolates were group B Streptococcus in a patient with chronic vesicouretral reflux associated with the posterior urethral valves and Aspergillus flavus in a patient with acute myelogenous leukemia. An analysis incorporating our results and a review of the English-language literature about abscesses in children and adults revealed differences related to age. Abscesses in children were more posterior in epidural location, had greater spinal column extension, and were associated with more favorable clinical outcomes than were abscesses in adults. Magnetic resonance imaging is the diagnostic procedure of choice; however, radionuclide bone scans should be considered for associated distant osteomyelitis in children. Prompt diagnosis and combined medical and surgical treatment remain the cornerstones for the prevention of adverse outcomes.

Neurogenin3 restricts serotonergic neuron differentiation to the hindbrain.

PubMed

Carcagno, Abel L; Di Bella, Daniela J; Goulding, Martyn; Guillemot, Francois; Lanuza, Guillermo M

2014-11-12

The development of the nervous system is critically dependent on the production of functionally diverse neuronal cell types at their correct locations. In the embryonic neural tube, dorsoventral signaling has emerged as a fundamental mechanism for generating neuronal diversity. In contrast, far less is known about how different neuronal cell types are organized along the rostrocaudal axis. In the developing mouse and chick neural tube, hindbrain serotonergic neurons and spinal glutamatergic V3 interneurons are produced from ventral p3 progenitors, which possess a common transcriptional identity but are confined to distinct anterior-posterior territories. In this study, we show that the expression of the transcription factor Neurogenin3 (Neurog3) in the spinal cord controls the correct specification of p3-derived neurons. Gain- and loss-of-function manipulations in the chick and mouse embryo show that Neurog3 switches ventral progenitors from a serotonergic to V3 differentiation program by repressing Ascl1 in spinal p3 progenitors through a mechanism dependent on Hes proteins. In this way, Neurog3 establishes the posterior boundary of the serotonergic system by actively suppressing serotonergic specification in the spinal cord. These results explain how equivalent p3 progenitors within the hindbrain and the spinal cord produce functionally distinct neuron cell types. Copyright © 2014 the authors 0270-6474/14/3415223-11$15.00/0.

Bilateral spinal anterior horn lesions in acute motor axonal neuropathy.

PubMed

Sawada, Daisuke; Fujii, Katsunori; Misawa, Sonoko; Shiohama, Tadashi; Fukuhara, Tomoyuki; Fujita, Mayuko; Kuwabara, Satoshi; Shimojo, Naoki

2018-05-28

Guillain-Barré syndrome is an acute immune-mediated peripheral polyneuropathy. Neuroimaging findings from patients with this syndrome have revealed gadolinium enhancement in the cauda equina and in the anterior and posterior nerve roots, but intra-spinal lesions have never been described. Herein, we report, for the first time, bilateral spinal anterior horn lesions in a patient with an acute motor axonal neuropathy form of Guillain-Barré syndrome. The patient was a previously healthy 13-year-old Japanese girl, who exhibited acute-onset flaccid tetraplegia and loss of tendon reflexes. Nerve conduction studies revealed motor axonal damage, leading to the diagnosis of acute motor axonal neuropathy. Notably, spinal magnetic resonance imaging revealed bilateral anterior horn lesions on T2-weighted imaging at the Th11-12 levels, as well as gadolinium enhancement of the cauda equina and anterior and posterior nerve roots. The anterior horn lesions were most prominent on day 18, and their signal intensity declined thereafter. Although intravenous treatment with immunoglobulins was immediately administered, the motor function was not completely regained. We propose that anterior spinal lesions might be responsible for the prolonged neurological disability of patients with Guillain-Barré syndrome, possibly produced by retrograde progression from the affected anterior nerve roots to the intramedullary roots, and the anterior horn motor neurons. Copyright © 2018 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

Spinal pedicle subtraction osteotomy for fixed sagittal imbalance patients

PubMed Central

Hyun, Seung-Jae; Kim, Yongjung J; Rhim, Seung-Chul

2013-01-01

In addressing spinal sagittal imbalance through a posterior approach, the surgeon now may choose from among a variety of osteotomy techniques. Posterior column osteotomies such as the facetectomy or Ponte or Smith-Petersen osteotomy provide the least correction, but can be used at multiple levels with minimal blood loss and a lower operative risk. Pedicle subtraction osteotomies provide nearly 3 times the per-level correction of Ponte/Smith-Petersen osteotomies; however, they carry increased technical demands, longer operative time, and greater blood loss and associated significant morbidity, including neurological injury. The literature focusing on pedicle subtraction osteotomy for fixed sagittal imbalance patients is reviewed. The long-term overall outcomes, surgical tips to reduce the complications and suggestions for their proper application are also provided. PMID:24340276

Surgical Management of Spinal Conditions in the Elderly Osteoporotic Spine.

PubMed

Goldstein, Christina L; Brodke, Darrel S; Choma, Theodore J

2015-10-01

Osteoporosis, the most common form of metabolic bone disease, leads to alterations in bone structure and density that have been shown to compromise the strength of spinal instrumentation. In addition, osteoporosis may contribute to high rates of fracture and instrumentation failure after long posterior spinal fusions, resulting in proximal junctional kyphosis and recurrent spinal deformity. As increasing numbers of elderly patients present for surgical intervention for degenerative and traumatic spinal pathologies, current and future generations of spine surgeons will increasingly be faced with the challenge of obtaining adequate fixation in osteoporotic bone. The purpose of this review is to familiarize the reader with the impact of osteoporosis on spinal instrumentation, the broad variety of techniques that have been developed for addressing these issues, and the biomechanical and clinical evidence in support of the use of these techniques.

The Dose-response of Intrathecal Ropivacaine Co-administered with Sufentanil for Cesarean Delivery under Combined Spinal-epidural Anesthesia in Patients with Scarred Uterus

PubMed Central

Xiao, Fei; Xu, Wen-Ping; Zhang, Yin-Fa; Liu, Lin; Liu, Xia; Wang, Li-Zhong

2015-01-01

Background: Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery. This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia. Methods: Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Patients received 6, 8, 10, 12, or 14 mg intrathecal hyperbaric ropivacaine with 5 μg sufentanil. Successful spinal anesthesia was defined as a T4 sensory level achieved with no need for epidural supplementation. The 50% effective dose (ED50) and 95% effective dose (ED95) were calculated with a logistic regression model. Results: ED50 and ED95 of intrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA) were 8.28 mg (95% confidence interval [CI]: 2.28–9.83 mg) and 12.24 mg (95% CI: 10.53–21.88 mg), respectively. Conclusion: When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery, the ED50 and ED95 of intrathecal hyperbaric ropivacaine along with 5 μg sufentanil were 8.28 mg and 12.24 mg, respectively. In addition, this local anesthetic is unsuitable for emergent cesarean delivery, but it has advantages for ambulatory patients. PMID:26415793

Spondylectomy and lateral lumbar interbody fusion for thoracolumbar kyphosis in an adult with achondroplasia

PubMed Central

Miyazaki, Masashi; Kanezaki, Shozo; Notani, Naoki; Ishihara, Toshinobu; Tsumura, Hiroshi

2017-01-01

Abstract Rationale: Fixed thoracolumbar kyphosis with spinal stenosis in adult patients with achondroplasia presents a challenging issue. We describe the first case in which spondylectomy and minimally invasive lateral access interbody arthrodesis were used for the treatment of fixed severe thoracolumbar kyphosis and lumbar spinal canal stenosis in an adult with achondroplasia. Patient concerns: A 61-year-old man with a history of achondroplastic dwarfism presented with low back pain and radiculopathy and neurogenic claudication. Diagnoses: Plain radiographs revealed a high-grade thoracolumbar kyphotic deformity with diffuse degenerative changes in the lumbar spine. The apex was located at L2, the local kyphotic angle from L1 to L3 was 105°, and the anterior area was fused from the L1 to L3 vertebrae. MRI revealed significant canal and lateral recess stenosis secondary to facet hypertrophy. Interventions: We planned a front-back correction of the anterior and posterior spinal elements. We first performed anterior release at the fused part from L1 to L3 and XLIF at L3/4 and L4/5. Next, the patient was placed in the prone position. Spondylectomy at the L2 vertebra and posterior fusion from T10 to L5 were performed. Postoperative radiographs revealed L1 to L3 kyphosis of 32°. Outcomes: No complications occurred during or after surgery. Postoperatively, the patient's low back pain and neurological claudication were resolved. No worsening of kyphosis was observed 24 months postoperatively. Lessons: Circumferential decompression of the spinal cord at the apical vertebral level and decompression of lumbar canal stenosis were necessary. Front-back correction of the anterior and posterior spinal elements via spondylectomy and lateral lumbar interbody fusion is a reasonable surgical option for thoracolumbar kyphosis and developmental canal stenosis in patients with achondroplasia. PMID:29245270

Full-thickness thoracic laminar erosion after posterior spinal fusion associated with late-presenting infection.

PubMed

Tribus, Clifford B; Garvey, Kathleen E

2003-05-15

A case report describes unilateral complete laminar erosion of the caudal thoracic spine and late-presenting infection in a patient 10 years after anteroposterior reconstruction for scoliosis. To present an unusual but significant complication that may occur after implantation of spinal instrumentation. The reported patient presented with a deep infection and persistent back pain 10 years after successful anteroposterior reconstruction for adult idiopathic scoliosis. Delayed onset infections after implantation of spinal instrumentation are infrequent, yet when present, often require hardware removal. The case of a 51-year-old woman who underwent irrigation and debridement for a late-presenting infection and removal of posterior hardware 10 years after her index procedure is presented. Interoperatively, it was noted that full-thickness laminar erosion was present from T4 to T12. The patient was taken to the operating room for wound irrigation, debridement, and hardware removal. It was discovered that a Cotrel-Dubousset rod placed on the convexity of the curve had completely eroded through the lamina of T7-T12. Infectious material was found along the entire length of both the convex and concave Cotrel-Dubousset rods. Intraoperative cultures grew Staphylococcus epidermidis and Propionibacterium acnes. Intravenous and oral antibiotics were administered, resulting in resolution of the infection and preoperative pain. The exact role of late-presenting infection with regard to the laminar erosion and rod migration seen in this case remains to be elucidated. However, the authors believe the primary cause of bony erosion was mechanical in origin. Regardless, most spine surgeons will treat many patients who have had posterior spinal implants and will perform hardware removal on a significant number of these patients during their careers. A full-thickness laminar erosion exposes the spinal cord to traumatic injury during hardware removal and debridement. This case is presented as a cautionary note to help surgeons become cognizant of a potentially devastating complication.

7 Tesla 22-channel wrap-around coil array for cervical spinal cord and brainstem imaging.

PubMed

Zhang, Bei; Seifert, Alan C; Kim, Joo-Won; Borrello, Joseph; Xu, Junqian

2017-10-01

Increased signal-to-noise ratio and blood oxygenation level-dependent sensitivity at 7 Tesla (T) have the potential to enable high-resolution imaging of the human cervical spinal cord and brainstem. We propose a new two-panel radiofrequency coil design for these regions to fully exploit the advantages of ultra-high field. A two-panel array, containing four transmit/receive and 18 receive-only elements fully encircling the head and neck, was constructed following simulations demonstrating the B1+ and specific absorption rate (SAR) benefits of two-panel over one-panel arrays. This array was compared with a previously reported posterior-only array and tested for safety using a phantom. Its anatomical, functional, and diffusion MRI performance was demonstrated in vivo. The two-panel array produced more uniform B1+ across the brainstem and cervical spinal cord without compromising SAR, and achieved 70% greater receive sensitivity than the posterior-only array. The two-panel design enabled acceleration of R = 2 × 2 in two dimensions or R = 3 in a single dimension. High quality in vivo anatomical, functional, and diffusion images of the human cervical spinal cord and brainstem were acquired. We have designed and constructed a wrap-around coil array with excellent performance for cervical spinal cord and brainstem MRI at 7T, which enables simultaneous human cervical spinal cord and brainstem functional MRI. Magn Reson Med 78:1623-1634, 2017. © 2016 International Society for Magnetic Resonance in Medicine. © 2016 International Society for Magnetic Resonance in Medicine.

Cervical Laminoplasty

MedlinePlus

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Finite Element Analysis of the Effect of Epidural Adhesions.

PubMed

Lee, Nam; Ji, Gyu Yeul; Yi, Seong; Yoon, Do Heum; Shin, Dong Ah; Kim, Keung Nyun; Ha, Yoon; Oh, Chang Hyun

2016-07-01

It is well documented that epidural adhesion is associated with spinal pain. However, the underlying mechanism of spinal pain generation by epidural adhesion has not yet been elucidated. To elucidate the underlying mechanism of spinal pain generation by epidural adhesion using a two-dimensional (2D) non-linear finite element (FE) analysis. A finite element analysis. A two-dimensional nonlinear FE model of the herniated lumbar disc on L4/5 with epidural adhesion. A two-dimensional nonlinear FE model of the lumbar spine was developed, consisting of intervertebral discs, dura, spinal nerve, and lamina. The annulus fibrosus and nucleus pulpous were modeled as hyperelastic using the Mooney-Rivlin equation. The FE mesh was generated and analyzed using Abaqus (ABAQUS 6.13.; Hibbitt, Karlsson & Sorenson, Inc., Providence, RI, USA). Epidural adhesion was simulated as rough contact, in which no slip occurred once two surfaces were in contact, between the dura mater and posterior annulus fibrosus. The FE model of adhesion showed significant stress concentration in the spinal nerves, especially on the dorsal root ganglion (DRG). The stress concentration was caused by the lack of adaptive displacement between the dura mater and posterior annulus fibrosus. The peak von Mises stress was higher in the epidural adhesion model (Adhesion, 0.67 vs. Control, 0.46). In the control model, adaptive displacement was observed with decreased stress in the spinal nerve and DRG (with adhesion, 2.59 vs. without adhesion, 3.58, P < 0.00). This study used a 2D non-linear FE model, which simplifies the 3D nature of the human intervertebral disc. In addition, this 2D non-linear FE model has not yet been validated. The current study clearly demonstrated that epidural adhesion causes significantly increased stress in the spinal nerves, especially at the DRG. We believe that the increased stress on the spinal nerve might elicit more pain under similar magnitudes of lumbar disc protrusion.

Anticholinergic premedication to prevent bradycardia in combined spinal anesthesia and dexmedetomidine sedation: a randomized, double-blind, placebo-controlled study.

PubMed

Ahn, Eun Jin; Park, Jun Ha; Kim, Hyo Jin; Kim, Kyung Woo; Choi, Hey Ran; Bang, Si Ra

2016-12-01

When dexmedetomidine is used in patients undergoing spinal anesthesia, high incidence of bradycardia in response to parasympathetic activation is reported. Therefore, we aimed to evaluate the effectiveness of atropine premedication for preventing the incidence of bradycardia and the hemodynamic effect on patients undergoing spinal anesthesia with sedation by dexmedetomidine. Randomized, double-blind, placebo-controlled study. Operating room. One hundred fourteen patients (age range, 2-65 years; American Society of Anesthesiology class I-II) participated in this study, willing to be sedated and to undergo spinal anesthesia. The patients were divided into 2 groups: group A and group C. After performing spinal anesthesia, dexmedetomidine was infused at a loading dose of 0.6 μg/kg for 10 minutes, followed by an infusion at 0.25 μg/(kg h). Simultaneously with the loading dose of dexmedetomidine, patients in group A received an intravenous bolus of 0.5 mg atropine, whereas patients in group C received an intravenous normal saline bolus. Data on administration of atropine and ephedrine were collected. Hemodynamic data including heart rate, systolic blood pressure, diastolic blood pressure (DBP), and mean blood pressure (MBP) were also recorded. The incidence of bradycardia requiring atropine treatment was significantly higher in group C than group A (P=.035). However, the incidence of hypotension needing ephedrine treatment showed no significant difference between the 2 groups (P=.7). Systolic blood pressure and heart rate showed no significant differences between the 2 groups (P=.138 and .464, respectively). However, group A showed significant increases in DBP and MBP, and group C did not (P=.014 and .008, respectively). Prophylactic atropine reduces the incidence of bradycardia in patients undergoing spinal anesthesia with dexmedetomidine sedation. However, DBP and MBP showed significant increases in patients when prophylactic atropine was administrated. Therefore, atropine premedication should be administered cautiously. Copyright © 2016 Elsevier Inc. All rights reserved.

Dural ectasia associated with Mounier-Kuhn syndrome: a novel association in the context of spinal stenosis.

PubMed

Sheridan, Gerard Anthony; Godkin, Owen; Devitt, Aiden

2017-08-30

We present the case of a patient undergoing lumbar spine decompression for stenosis with a history of Mounier-Kuhn syndrome. The patient presented with axial lumbar spine pain over 6 months with progressive radicular pain to the left L3 dermatome. MRI confirmed spinal stenosis at L3/4 level with associated dural ectasia. The patient had an uneventful spinal decompression with resolution of radicular symptoms and axial spine pain. Dural ectasia poses a significant risk when operating on the lumbosacral spine. Larger cerebrospinal fluid volumes and a capacious dural canal can result in anaesthetic and orthopaedic complications such as inadequate spinal anaesthesia, complicated epidural analgesia, intraoperative dural tears and difficult pedicle screw insertion due to narrow pedicles. This is the first case in the literature detailing the association between dural ectasia and Mounier-Kuhn syndrome. We recommend adequate spinal imaging in patients with Mounier-Kuhn syndrome to exclude dural ectasia prior to undergoing lumbosacral spinal procedures. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Rod Migration Into the Spinal Canal After Posterior Instrumented Fusion Causing Late-Onset Neurological Symptoms.

PubMed

Canavese, Federico; Dmitriev, Petru; Deslandes, Jacques; Samba, Antoine; Dimeglio, Alain; Mansour, Mounira; Rousset, Marie; Dubousset, Jean

2017-01-01

Rod migration into the spinal canal after posterior instrumented fusion is a rare complication causing late-onset neurological symptoms. The purpose of the present study is to report a case of a 13-year-old boy with spastic cerebral palsy and related neuromuscular kyphoscoliosis who developed late-onset neurological deterioration secondary to progressive implant migration into the spinal canal over a 5-year period. A decision was made to remove both rods to achieve decompression. Intraoperative findings were consistent with information gained from preoperative imaging. The rods were found to have an intracanal trajectory at T9-T10 for the right rod and T12-L2 for the left rod. The cause of implant migration, with progressive laminar erosion slow enough to generate a solid mass behind, was progressive kyphosis in a skeletally immature patient with neuromuscular compromise. Fixation type, early surgery, and spasticity management contributed significantly to the presenting condition. Mechanical factors and timing of surgery played a decisive role in this particular presentation. Level IV--Case report and review of the literature.

[A survivor of Hodgkin lymphoma manifesting dropped head syndrome as a late-onset complication of radiotherapy: a case report].

PubMed

Kaido, Misako; Yuasa, Yoshihito; Ikeda, Hiroshi

2018-05-25

We report the case of a 50-year-old female survivor of Hodgkin lymphoma (HL), who developed dropped head syndrome (DHS). The patient was diagnosed with HL at 20 years of age, and underwent chemo-radiotherapy, which led to complete remission. Undergoing supplemental therapy for post-radiation hypothyroidism, she had twin babies. She noticed white stains on her neck at the age of 30, and the decolored area gradually expanded. Sixteen years after the radiotherapy (RT), her posterior neck muscle strength began to decline. She had to make considerable efforts to keep her neck straight, and came to experience a severe pain in the neck and shoulders. The patient visited our department due to DHS at the age of 50. She had leukoderma, muscle weakness, and muscle atrophy in the neck and para-spinal region, which were consistent with the area of RT. The strength was preserved in the other parts of the muscle, including the proximal upper limbs. Sensory nerve disorder was not detected. The serum creatine kinase level was slightly elevated. Cervical spine or cervical cord disease that can cause DHS was not detected by MRI examination. The MRI and CT images revealed marked atrophy in the posterior neck and para-spinal muscles. The electromyogram revealed myopathic changes, and the cause of her DHS was diagnosed as radiation-induced myopathy. DHS is a well-known late-onset radiation injury, and Japanese cases have been reported in elderly persons with laryngeal or lung cancer. However, there have been no Japanese case reports of radiation-induced DHS due to RT against HL in younger persons. The patient had visited several clinics and hospitals before she came to our hospital, but RT-induced DHS had been overlooked. Greater recognition and consideration is required for DHS as one of the various issues arising after long passage of HL survivors.

Posterior lumbar interbody fusion using non resorbable poly-ether-ether-ketone versus resorbable poly-L-lactide-co-D,L-lactide fusion devices. Clinical outcome at a minimum of 2-year follow-up.

PubMed

Jiya, Timothy U; Smit, T; van Royen, B J; Mullender, M

2011-04-01

Previous papers on resorbable poly-L-lactide-co-D,L-lactide (PLDLLA) cages in spinal fusion have failed to report adequately on patient-centred clinical outcome measures. Also comparison of PLDLLA cage with a traditionally applicable counterpart has not been previously reported. This is the first randomized prospective study that assesses clinical outcome of PLDLLA cage compared with a poly-ether-ether-ketone (PEEK) implant. Twenty-six patients were randomly assigned to undergo instrumented posterior lumbar interbody fusion (PLIF) whereby either a PEEK cage or a PLDLLA cage was implanted. Clinical outcome based on visual analogue scale scores for leg pain and back pain, as well as Oswestry Disability Index (ODI) and SF-36 questionnaires were documented and analysed. When compared with preoperative values, all clinical parameters have significantly improved in the PEEK group at 2 years after surgery with the exception of SF-36 general health, SF-36 mental health and SF-36 role emotional scores. No clinical parameter showed significant improvement at 2 years after surgery compared with preoperative values in the PLDLLA patient group. Only six patients (50%) in the PLDLLA group showed improvement in the VAS scores for leg and back pain as well as the ODI, as opposed to 10 patients (71%) in the PEEK group. One-third of the patients in the PLDLLA group actually reported worsening of their pain scores and ODI. Three cases of mild to moderate osteolysis were seen in the PLDLLA group. Following up on our preliminary report, these 2-year results confirm the superiority of the PEEK implant to the resorbable PLDLLA implant in aiding spinal fusion and alleviating symptoms following PLIF in patients with degenerative spondylolisthesis associated with either canal stenosis or foramen stenosis or both and emanating from a single lumbar segment.

Pain is the Greatest Preoperative Concern for Patients and Parents Before Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

PubMed

Chan, Priscella; Skaggs, David L; Sanders, Austin E; Villamor, Gabriela A; Choi, Paul D; Tolo, Vernon T; Andras, Lindsay M

2017-11-01

Prospective cross-sectional study. To evaluate patients' and parents' concerns so they can be addressed with appropriate preoperative counseling. Despite much research on outcomes for posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS), little is available about preoperative fears or concerns. Patients with AIS undergoing PSF, their parents, and surgeons were prospectively enrolled and asked to complete a survey on their fears and concerns about surgery at their preoperative appointment. Forty-eight patients and parents completed surveys. Four attending pediatric spine surgeons participated and submitted 48 responses. Mean age of patients was 14.2 years. On a scale of 0 to 10, mean level of concern reported by parents (6.9) was higher than that reported by patients (4.6). Surgeons rated the procedure's complexity on a scale of 0 to 10 and reported a mean of 5.2. Neither patients' nor parents' level of concern correlated with the surgeons' assessment of the procedure's complexity level (R = 0.19 and 0.12, P = 0.20 and P = 0.42, respectively). Top three concerns for patients were pain (25%), ability to return to activities (21%), and neurologic injury (17%). Top three concerns for parents were pain (35%), neurologic injury (21%), and amount of correction (17%). Top three concerns for surgeons were postoperative shoulder balance (44%), neurologic injury (27%), and lowest instrumented vertebrae selection (27%). Patients reported the same concerns 23% of the time as parents, and 17% of the time as surgeons. Parents and surgeons reported the same concerns 21% of the time. Pain was the greatest concern for both patients and parents but was rarely listed as a concern by surgeons. Parent and patient level of concern did not correlate to the surgeon's assessment of the procedure's complexity. Neurologic injury was a top concern for all groups, but otherwise there was little overlap between physician, patient, and parent concerns. 3.

The role of Amicar in same-day anterior and posterior spinal fusion for idiopathic scoliosis.

PubMed

Thompson, George H; Florentino-Pineda, Ivan; Poe-Kochert, Connie; Armstrong, Douglas G; Son-Hing, Jochen P

2008-09-15

A retrospective study of the effectiveness of Amicar (epsilon aminocaproic acid). Evaluate the effectiveness of Amicar in decreasing perioperative blood loss and transfusion requirements in same-day anterior (ASF) and posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) for idiopathic scoliosis. Preliminary prospective, prospective randomized double-blind, and fibrinogen studies have demonstrated Amicar to be effective in decreasing perioperative blood loss in patients with idiopathic scoliosis undergoing PSF with SSI. Increased fibrinogen secretion is a possible explanation. There were 73 consecutive patients divided into 3 study groups based on the administration of Amicar: Group 1 (n = 16), no Amicar; Group 2 (n = 18), Amicar for the PSF with SSI only; and Group 3 (n = 39), Amicar for both ASF and PSF with SSI. All patients were managed using the same general anesthesia technique, intraoperative procedure, postoperative care path, and indications for transfusion (hemoglobin <7 g/dL). Total perioperative blood loss (estimated intraoperative blood loss for both procedures and measured postoperative chest tube and PSF wound suction drainage) and total transfusion requirements between groups were compared using one-way ANOVA. There were statistically significant decreases in mean estimated intraoperative PSF with SSI, total perioperative blood loss, and transfusion requirements in the 2 Amicar groups. However, Amicar had no significant effect on estimated intraoperative ASF blood loss, chest tube drainage, or PSF wound suction drainage. Total perioperative blood loss and transfusion requirements (cell saver, autologous, directed, and allogeneic blood) were: 3442.8 +/- 1344.0 mL and 1537.1 +/- 905.1 mL in Group 1; 2089.8 +/- 684.0 mL and 485.2 +/- 349.8 mL in Group 2; and 2184.1 +/- 1163.7 mL and 531.5 +/- 510.5 mL in Group 3. There were no Amicar related complications. Amicar was highly effective in decreasing total perioperative blood loss and transfusion requirements in same-day ASF and PSF with SSI for idiopathic scoliosis. It results in less preoperative autologous blood donation, perioperative blood transfusion, costs, and potential transfusion-related complications. It was most effective in decreasing intraoperative estimated PSF with SSI blood loss. It had no significant effect during the ASF, postoperative chest tube, or PSF wound suction drainage. We now recommend that it be used for the PSF with SSI procedure only.

Does the presence of the nerve root sedimentation sign on MRI correlate with the operative level in patients undergoing posterior lumbar decompression for lumbar stenosis?

PubMed

Fazal, Akil; Yoo, Andrew; Bendo, John A

2013-08-01

Recent research describes the use of a nerve root sedimentation sign to diagnose lumbar spinal stenosis (LSS). The lack of sedimentation of the nerve roots (positive sedimentation sign) to the dorsal part of the dural sac is the characteristic feature of this new radiological parameter. To demonstrate how the nerve root sedimentation sign compares with other more traditional radiological parameters in patients who have been operated for LSS. A retrospective chart and image review. Preoperative magnetic resonance images (MRIs) were reviewed from 71 consecutive operative patients who presented with LSS and received spinal decompression surgery from 2006 to 2010. Preoperative T2-weighted MRIs were reviewed for each patient. One hundred thirty-four vertebral levels from L1 to L5 were measured for: sedimentation sign, cross-sectional area (CSA) and anterior/posterior (A/P) diameter of the dural sac, thickness of the ligamentum flavum, and Fujiwara grade of facet hypertrophy. Radiological measurements were made using Surgimap 1.1.2.169 software (Nemaris, Inc., New York, NY, USA). Statistical analyses were performed using the SPSS 17.0 statistical software (SPSS Inc., Chicago, IL, USA). Significance was demonstrated using unpaired t tests and chi-squared tests. Study funding was departmental. There were no study-specific conflicts of interest-associated biases. A positive sedimentation sign was determined in 120 operated levels (89.5%), whereas 14 levels (10.5%) had no sign (negative sedimentation sign). The mean CSA and A/P diameter were 140.62 mm(2) (standard deviation [SD]=53) and 11.76 mm (SD=3), respectively, for the no-sign group; the mean CSA and A/P diameter were 81.87 mm(2) (SD=35) and 8.76 mm (SD=2.2), respectively, for the sedimentation sign group (p<.001). We found that 60% of levels with Fujiwara Grade A facet hypertrophy did not have a sedimentation sign, whereas 86.3% of levels with Grade B, 93.2% of levels with Grade C, and 100.0% of levels with Grade D did have a sedimentation sign (p<.001). The sedimentation sign is a new measurement tool that can enable physicians to objectively assess and quantify spinal stenosis. The sign is most often present in patients who have clinically significant lumbar stenosis and require surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

Magnetic Resonance Characterization of Axonal Response to Spinal Cord Injury

DTIC Science & Technology

2012-10-01

frequency direction, phase FOV = 0.5, slice thickness = 10 mm. Spatial saturation bands were placed anterior and posterior to the slice of interest to...thickness = 10 mm, with spatial saturation bands placed anterior and posterior to the slice and diffusion sensitization in the right-to-left...the center frequency, and can be extracted by applying MT saturation pulses with alternating (positive/negative) off-resonance frequencies. The goal

High Incidence of Progressive Postnatal Cerebellar Enlargement in Costello Syndrome: Brain Overgrowth Associated with HRAS Mutations as the Likely Cause of Structural Brain and Spinal Cord Abnormalities

PubMed Central

Gripp, Karen W.; Hopkins, Elisabeth; Doyle, Daniel; Dobyns, William B.

2010-01-01

Costello syndrome is a rasopathy caused by germline mutations in the proto-oncogene HRAS. Its presentation includes failure-to-thrive with macrocephaly, characteristic facial features, hypertrophic cardiomyopathy, papillomata, malignant tumors, and cognitive impairment. In a systematic review we found absolute or relative macrocephaly (100%), ventriculomegaly (50%), and other abnormalities on brain and spinal cord imaging studies in 27/28 individuals. Posterior fossa crowding with cerebellar tonsillar herniation (CBTH) was noted in 27/28 (96%), and in 10/17 (59%) with serial studies posterior fossa crowding progressed. Sequelae of posterior fossa crowding and CBTH included hydrocephalus requiring shunt or ventriculostomy (25%), Chiari 1 malformation (32%) and syrinx formation (25%). Our data reveal macrocephaly with progressive frontal bossing and CBTH, documenting an ongoing process rather than a static congenital anomaly. Comparison of images obtained in young infants to subsequent studies demonstrated postnatal development of posterior fossa crowding. This process of evolving megalencephaly and cerebellar enlargement is in keeping with mouse model data, delineating abnormal genesis of neurons and glia, resulting in an increased number of astrocytes and enlarged brain volume. In Costello syndrome and macrocephaly-capillary malformation syndrome disproportionate brain growth is the main factor resulting in postnatal CBTH and Chiari 1 malformation. PMID:20425820

Does Minimally Invasive Spine Surgery Minimize Surgical Site Infections?

PubMed

Kulkarni, Arvind Gopalrao; Patel, Ravish Shammi; Dutta, Shumayou

2016-12-01

Retrospective review of prospectively collected data. To evaluate the incidence of surgical site infections (SSIs) in minimally invasive spine surgery (MISS) in a cohort of patients and compare with available historical data on SSI in open spinal surgery cohorts, and to evaluate additional direct costs incurred due to SSI. SSI can lead to prolonged antibiotic therapy, extended hospitalization, repeated operations, and implant removal. Small incisions and minimal dissection intrinsic to MISS may minimize the risk of postoperative infections. However, there is a dearth of literature on infections after MISS and their additional direct financial implications. All patients from January 2007 to January 2015 undergoing posterior spinal surgery with tubular retractor system and microscope in our institution were included. The procedures performed included tubular discectomies, tubular decompressions for spinal stenosis and minimal invasive transforaminal lumbar interbody fusion (TLIF). The incidence of postoperative SSI was calculated and compared to the range of cited SSI rates from published studies. Direct costs were calculated from medical billing for index cases and for patients with SSI. A total of 1,043 patients underwent 763 noninstrumented surgeries (discectomies, decompressions) and 280 instrumented (TLIF) procedures. The mean age was 52.2 years with male:female ratio of 1.08:1. Three infections were encountered with fusion surgeries (mean detection time, 7 days). All three required wound wash and debridement with one patient requiring unilateral implant removal. Additional direct cost due to infection was $2,678 per 100 MISS-TLIF. SSI increased hospital expenditure per patient 1.5-fold after instrumented MISS. Overall infection rate after MISS was 0.29%, with SSI rate of 0% in non-instrumented MISS and 1.07% with instrumented MISS. MISS can markedly reduce the SSI rate and can be an effective tool to minimize hospital costs.

Microsurgical anatomy of the posterior median septum of the human spinal cord.

PubMed

Turkoglu, Erhan; Kertmen, Hayri; Uluc, Kutluay; Akture, Erinc; Gurer, Bora; Cikla, Ulaş; Salamat, Shahriar; Başkaya, Mustafa K

2015-01-01

The aim of this study was to analyze the topographical anatomy of the dorsal spinal cord (SC) in relation to the posterior median septum (PMS). This included the course and variations in the PMS, and its relationship to and distance from other dorsal spinal landmarks. Microsurgical anatomy of the PMS was examined in 12 formalin-fixed adult cadaveric SCs. Surface landmarks such as the dorsal root entry zone (DREZ), the denticulate ligament, the architecture of the leptomeninges and pial vascular distribution were noted. The PMS was examined histologically in all spinal segments. The PMS extended most deeply at spinal segments C7 and S4. This was statistically significant for all spinal segments except C5. The PMS was shallowest at segments T4 and T6, where it was statistically significantly thinner than at any other segment. In 80% of the SCs, small blood vessels were identified that traveled in a rostrocaudal direction in the PMS. The longest distance between the PMS and the DREZ was at the C1-C4 vertebral levels and the shortest distance was at the S5 level. Prevention of deficits following a dorsal midline neurosurgical approach to deep-seated SC lesions requires careful identification of the midline of the cord. The PMS and septum define the midline on the dorsum of the SC and their accurate identification is essential for a safe midline surgical approach. In this anatomical study, we describe the surface anatomy of the dorsal SC and its relationship with the PMS, which can be used to determine a safe entry zone into the SC. © 2014 Wiley Periodicals, Inc.

Measurement of occlusion of the spinal canal and intervertebral foramen by intervertebral disc bulge

PubMed Central

Cuchanski, Mathieu; Cook, Daniel; Whiting, Donald M.; Cheng, Boyle C.

2011-01-01

Background Disc protrusion has been proposed to be a possible cause of both pain and stenosis in the lower spine. No previous study has described the amount of disc occlusion of the spinal canal and intervertebral foramen that occurs under different loading conditions. The objective of this study was to quantitatively assess the percent occlusion of the spinal canal and intervertebral foramen by disc bulge under different loading conditions. Methods Spinal canal depth and foraminal width were measured on computed tomography–scanned images of 7 human lumbar spine specimens. In vitro disc bulge measurements were completed by use of a previously described method in which single functional spinal units were subjected to 3 separate load protocols in a spine test machine and disc bulge was recorded with an optoelectric motion system that tracked active light-emitting diodes placed on the posterior and posterolateral aspects of the intervertebral disc. Occlusion was defined as percentage of encroachment into area of interest by maximum measured disc bulge at corresponding point of interest (the spinal canal is at the posterior point; the intervertebral foramen is at the posterolateral point). Results The mean spinal canal depth and mean foraminal width were 19 4 ± mm and 5 ± 2 mm, respectively. Mean spinal canal occlusion under a 250-N axial load, ± 2.5 Nm of flexion/extension, and ± 2.5 Nm of lateral bend was 2.5% ± 1.9%, 2.5% ± 1.6%, and 1.5% ± 0.8%, respectively. Mean intervertebral foramen occlusion under a 250-N axial load, ± 2.5 Nm of flexion/extension, and ± 2.5 Nm of lateral bend was 7.8% ± 4.7%, 9.5% ± 5.7%, and 11.3% ± 6.2%, respectively. Conclusion Percent occlusion of the spinal canal and intervertebral foramen is dependent on magnitude and direction of load. Exiting neural elements at the location of the intervertebral foramen are the most vulnerable to impingement and generation of pain. PMID:25802663

Hypobaric spinal anesthesia in the operative management of orthopedic emergencies in geriatric patients.

PubMed

Sidi, A; Pollak, D; Floman, Y; Davidson, J T

1984-07-01

Hypobaric spinal anesthesia was administered to 40 patients undergoing lower limb surgery. Twenty-nine of the patients were debilitated geriatric patients who presented with orthopedic emergencies, in most cases a fractured hip. Hypobaric spinal anesthesia was found to be a simple and safe procedure that provided adequate analgesia. Due to its inherent nature, hypobaric spinal anesthesia does not necessitate positioning of the patient on the injured, painful side (unlike hyperbaric spinal or epidural anesthesia) and, therefore, facilitates a smooth and painless transfer of the patient to the operating table. Complications encountered were similar to those following hyperbaric anesthesia.

Application of Piezosurgery in Anterior Cervical Corpectomy and Fusion.

PubMed

Pan, Sheng-Fa; Sun, Yu

2016-05-01

Anterior cervical corpectomy and fusion (ACCF) is frequently used to decompress the cervical spine; however, this procedure is risky when dealing with a hard disc or ossification of the posterior longitudinal ligament (OPLL). Piezosurgery offers a useful tool for performing this procedure. In this article, we present a 50 years old man who had cervical spondylotic myelopathy with OPLL at the C 6 level and segmental stenosis of the cervical spinal canal. When removing the posterior wall of his C 6 vertebral body and OPLL, piezosurgery was used to selectively cut hard structures piece by piece without injuring delicate soft tissues like the nerve roots and spinal cord. Because there is no bleeding from the bone surface with piezosurgery, it provides a clean operative field. © 2016 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Randomized and controlled prospective trials of Ultrasound-guided spinal nerve posterior ramus pulsed radiofrequency treatment for lower back post-herpetic neuralgia.

PubMed

Pi, Z B; Lin, H; He, G D; Cai, Z; Xu, X Z

2015-01-01

To evaluate the efficacy of ultrasound-guided spinal nerve posterior ramus pulsed radiofrequency treatment for lower back post-herpetic neuralgia. 128 cases of lower back or anterior abdominal wall acute post-herpetic neuralgia patients were selected. They were randomly divided into two groups. Group A: oral treatment only with gabapentin + celecoxib + amitriptyline. Group B: while taking these drugs, patients were treated with radiofrequency (RF) pulses using a portable ultrasound device using the paravertebral puncture technique. In both groups, sudden outbreaks of pain were treated with immediate release 10mg morphine tablets. Visual analogue scale (VAS) was used for pain score, Pittsburgh Sleep Quality Index scale (PSQI) was used to evaluate sleep quality and morphine consumption were recorded at different time points, before and after treatment. Treatment efficiency was calculated while the occurrence of complications was documented. At each time point after treatment, VAS scores were lower, but scores in the RF group was significantly lower than those of the oral-only group. In terms of sleep quality scores and morphine consumption between the two groups, the RF group was significantly lower than the oral-only group. During the procedure no error occurred with needle penetrating the abdominal cavity, chest, offal or blood vessels. Ultrasound-guided spinal nerve posterior ramus pulsed radiofrequency treatment of lower back or anterior abdominal wall post-herpetic neuralgia proved effective by reducing morphine use in patients and led to fewer adverse reactions.

The Deformity Angular Ratio: Does It Correlate With High-Risk Cases for Potential Spinal Cord Monitoring Alerts in Pediatric 3-Column Thoracic Spinal Deformity Corrective Surgery?

PubMed

Lewis, Noah D H; Keshen, Sam G N; Lenke, Lawrence G; Zywiel, Michael G; Skaggs, David L; Dear, Taylor E; Strantzas, Samuel; Lewis, Stephen J

2015-08-01

A retrospective analysis. The purpose of this study was to determine whether the deformity angular ratio (DAR) can reliably assess the neurological risks of patients undergoing deformity correction. Identifying high-risk patients and procedures can help ensure that appropriate measures are taken to minimize neurological complications during spinal deformity corrections. Subjectively, surgeons look at radiographs and evaluate the riskiness of the procedure. However, 2 curves of similar magnitude and location can have significantly different risks of neurological deficit during surgery. Whether the curve spans many levels or just a few can significantly influence surgical strategies. Lenke et al have proposed the DAR, which is a measure of curve magnitude per level of deformity. The data from 35 pediatric spinal deformity correction procedures with thoracic 3-column osteotomies were reviewed. Measurements from preoperative radiographs were used to calculate the DAR. Binary logistic regression was used to model the relationship between DARs (independent variables) and presence or absence of an intraoperative alert (dependent variable). In patients undergoing 3-column osteotomies, sagittal curve magnitude and total curve magnitude were associated with increased incidence of transcranial motor evoked potential changes. Total DAR greater than 45° per level and sagittal DAR greater than 22° per level were associated with a 75% incidence of a motor evoked potential alert, with the incidence increasing to 90% with sagittal DAR of 28° per level. In patients undergoing 3-column osteotomies for severe spinal deformities, the DAR was predictive of patients developing intraoperative motor evoked potential alerts. Identifying accurate radiographical, patient, and procedural risk factors in the correction of severe deformities can help prepare the surgical team to improve safety and outcomes when carrying out complex spinal corrections. 3.

Os Odontoideum: Rare Cervical Lesion

DTIC Science & Technology

2011-11-01

abnormality of the second cervical vertebrae in which the odontoid process is separated from the body of the axis by a transverse gap.1 This lesion... cervical region of his posterior neck. The patient was an active duty Marine Corps Private First Class with no significant medical history or history of head...within normal limits. His head was atraumatic. Patient had palpable midline posterior cervical spinal tenderness along C1 to C2 with no step-offs noted

Patterns of Failure After Proton Therapy in Medulloblastoma; Linear Energy Transfer Distributions and Relative Biological Effectiveness Associations for Relapses

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sethi, Roshan V.; Giantsoudi, Drosoula; Raiford, Michael

2014-03-01

Purpose: The pattern of failure in medulloblastoma patients treated with proton radiation therapy is unknown. For this increasingly used modality, it is important to ensure that outcomes are comparable to those in modern photon series. It has been suggested this pattern may differ from photons because of variations in linear energy transfer (LET) and relative biological effectiveness (RBE). In addition, the use of matching fields for delivery of craniospinal irradiation (CSI) may influence patterns of relapse. Here we report the patterns of failure after the use of protons, compare it to that in the available photon literature, and determine themore » LET and RBE values in areas of recurrence. Methods and Materials: Retrospective review of patients with medulloblastoma treated with proton radiation therapy at Massachusetts General Hospital (MGH) between 2002 and 2011. We documented the locations of first relapse. Discrete failures were contoured on the original planning computed tomography scan. Monte Carlo calculation methods were used to estimate the proton LET distribution. Models were used to estimate RBE values based on the LET distributions. Results: A total of 109 patients were followed for a median of 38.8 months (range, 1.4-119.2 months). Of the patients, 16 experienced relapse. Relapse involved the supratentorial compartment (n=8), spinal compartment (n=11), and posterior fossa (n=5). Eleven failures were isolated to a single compartment; 6 failures in the spine, 4 failures in the supratentorium, and 1 failure in the posterior fossa. The remaining patients had multiple sites of disease. One isolated spinal failure occurred at the spinal junction of 2 fields. None of the 70 patients treated with an involved-field-only boost failed in the posterior fossa outside of the tumor bed. We found no correlation between Monte Carlo-calculated LET distribution and regions of recurrence. Conclusions: The most common site of failure in patients treated with protons for medulloblastoma was outside of the posterior fossa. The most common site for isolated local failure was the spine. We recommend consideration of spinal imaging in follow-up and careful attention to dose distribution in the spinal junction regions. Development of techniques that do not require field matching may be of benefit. We did not identify a direct correlation between lower LET values and recurrence in medulloblastoma patients treated with proton therapy. Patterns of failure do not appear to differ from those in patients treated with photon therapy.« less

[Constitutional narrowing of the cervical spinal canal. Radiological and clinical findings].

PubMed

Ritter, G; Rittmeyer, K; Hopf, H C

1975-02-21

A constitutional narrowing of the cervical spinal canal was seen in 31 patients with neurological disorders. The ratio of the inner diameter of the spinal canal to the diameter of the vertebral body was smaller than 1 (normal greater than 1). Clinical signs were observed from 45 years upwards where reactivedegenerative changes cause additional narrowing. The majority of patients were male, predominantly heavy manual labourers. There is often a trauma preceding. On myelography multilocular deformations of the spinal subarachnoid space and nerve roots are seen. On the mechanical narrowing of the spinal canal a vascular factor supervenes, caused by exostoses, intervertebral disc protrusions, and fibrosing processes. Clinically a chronic progressive spinal transection syndrome (cervical myelopathy) dominates besides a multilocular root involvement. Posterior column sensibility is predominantly lost. Pain in the extemities and the cervical column is an early symptom. Non-specific CSF changes occur frequently. In case of root involvement the electromyogram is pathological. The prognosis is bad. Operation can only remove reactive processes but not the constitutional anomaly.

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning

PubMed Central

Lee, Su-Keon; Song, Kyung-Sub; Park, Byung-Moon; Lim, Sang-Youn; Jang, Geun; Lee, Beom-Seok; Moon, Seong-Hwan; Lee, Hwan-Mo

2016-01-01

Background To evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position. Methods Sixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5° (± 14.9°), average intraoperative lordosis was 48.8° (± 13.2°), average postoperative lordosis was 46.5° (± 16.1°) and the average change on the frame was 5.3° (± 10.6°). Results Among all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033). Conclusions Intraoperative lumbar lordosis on the OSI frame with a prone position was larger in the SS patients than the spondylolisthesis patients, which also produced a larger postoperative lordosis angle after posterior spinal fusion surgery. An increase in lumbar lordosis on the OSI frame should be considered during posterior spinal fusion surgery, especially in spondylolisthesis patients. PMID:26929801

Posterior elements disruption with hybrid constructs in AIS patients: is there an impact on proximal junctional kyphosis?

PubMed

Ghailane, S; Pesenti, Sebastien; Peltier, E; Choufani, E; Blondel, B; Jouve, J L

2017-05-01

Proximal junctional kyphosis (PJK) is a frequent proximal adjacent segment disease following spinal fusion in adolescent idiopathic scoliosis (AIS) and its rate has been estimated to 28% in the literature. The etiology is multifactorial, and risk factors associated with PJK are controversial. The aim of this study was to demonstrate that the disruption of muscular and bony tissue above the upper instrumented vertebra (UIV) during surgery does not increase the rate of PJK in patients undergoing posterior fusion for adolescent idiopathic scoliosis. 50 patients with AIS operated between June 2014 and January 2016 were included. Every patient underwent a long posterior spine arthrodesis with a hybrid construct (proximal lamino-laminar claw, thoracic sublaminar bands and lumbar screws). The dissection of posterior elements above the UIV was necessary for the placement of proximal anchors. Radiographic analysis including proximal junctional angle, spino-pelvic parameters (cervical lordosis, thoracic kyphosis TK, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope) and sagittal vertical axis were collected preoperatively and postoperatively at the last control. The numbers of fused levels, locations of upper instrumented vertebra, locations of lower instrumented vertebra, length of fusion segments were also recorded. Multiple odd ratios and other statistical analysis were performed to evaluate the relation between PJK and the potential risk factors. There were 43 females and 7 males with a mean age of 14.8 years at surgery. PJK occurred in 5 out of 50 cases with an incidence of 10%. The mean follow-up was 18 months. There was no significant difference in gender (OR 1.36, p = 0.8), decrease of TK (OR 1.63, p = 0 0.69), location of UIV (OR 2.25, p = 0.4), LIV (OR 2, p = 0.55), and SVA change (OR 1.63, p = 0.46). The disruption of ligamentous and bony tissue proximal to the UIV during the surgery does not increase the rate of PJK. Level of evidence IV.

Treatment of Spinal Epidural Abscess and Predisposing Factors of Motor Weakness: Experience with 48 Patients

PubMed Central

Ju, Min-Wook; Kwon, Hyon-Jo; Kim, Seon-Hwan; Koh, Hyeon-Song; Youm, Jin-Young; Song, Shi-Hun

2015-01-01

Objective Spinal epidural abscess (SEA) can be fatal if untreated, so early diagnosis and treatment are essential. We conducted a retrospective study to define its clinical features and evaluate the risk factors of motor weakness. Methods We retrospectively analyzed the medical records and images of patients with SEA who had been hospitalized in our institute from January 2005 to June 2012. Pyogenic SEA patients were categorized as patients without motor weakness (Group A) and with motor weakness (Group B). Abscess volume was measured using the Gamma-Plan program. Intervertebral foramen height and posterior disc height were measured to evaluate degree of spinal stenosis. Results Of 48 patients with pyogenic SEA, 33 (68%) were treated surgically, and 15 (32%) were treated with antibiotics. Eleven patients had weakness and abscess volume was unrelated to motor weakness. Old age, 'spare room' (abscess volume subtracted from spinal volume) and intervertebral foramen height and posterior disc height were statistically significant. Among the 48 patients, 43 (85%) had good outcome and erythrocyte sedimentation rate (ESR) was the only meaningful prognostic factor (p=0.014). The cut-off value of ESR was 112mm/h with 80% sensitivity and 79% specificity and had borderline significance (p=0.062). Conclusion SEA needs emergent diagnosis and treatment. Motor weakness is the most important factor in treatment decision. By careful image reading, early surgical treatment can be an option for selected patients with severe spinal stenosis for prevent motor weakness. Inflammatory markers, especially ESR, are valuable to identify worsening of SEA. PMID:26512265

Spinal epidural abscess: Report on 27 cases

PubMed Central

Khursheed, Nayil; Dar, Sultan; Ramzan, Altaf; Fomda, Bashir; Humam, Nisar; Abrar, Wani; Singh, Sarbjit; Sajad, Arif; Mahek, Masood; Yawar, Shoaib

2017-01-01

Background: Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis. Methods: In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess. Results: Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes. Conclusion: Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality. PMID:29026676

Spinal epidural abscess: Report on 27 cases.

PubMed

Khursheed, Nayil; Dar, Sultan; Ramzan, Altaf; Fomda, Bashir; Humam, Nisar; Abrar, Wani; Singh, Sarbjit; Sajad, Arif; Mahek, Masood; Yawar, Shoaib

2017-01-01

Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis. In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess. Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes. Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality.

Spinal Accessory Motor Neurons in the Mouse: A Special Type of Branchial Motor Neuron?

PubMed

Watson, Charles; Tvrdik, Petr

2018-04-16

The spinal accessory nerve arises from motor neurons in the upper cervical spinal cord. The axons of these motor neurons exit dorsal to the ligamentum denticulatum and form the spinal accessory nerve. The nerve ascends in the spinal subarachnoid space to enter the posterior cranial fossa through the foramen magnum. The spinal accessory nerve then turns caudally to exit through the jugular foramen alongside the vagus and glossopharyngeal nerves, and then travels to supply the sternomastoid and trapezius muscles in the neck. The unusual course of the spinal accessory nerve has long prompted speculation that it is not a typical spinal motor nerve and that it might represent a caudal remnant of the branchial motor system. Our cell lineage tracing data, combined with images from public databases, show that the spinal accessory motor neurons in the mouse transiently express Phox2b, a transcription factor that is required for development of brain stem branchial motor nuclei. While this is strong prima facie evidence that the spinal accessory motor neurons should be classified as branchial motor, the evolutionary history of these motor neurons in anamniote vertebrates suggests that they may be considered to be an atypical branchial group that possesses both branchial and somatic characteristics. Anat Rec, 2018. © 2018 Wiley Periodicals, Inc. © 2018 Wiley Periodicals, Inc.

General anesthesia versus segmental thoracic or conventional lumbar spinal anesthesia for patients undergoing laparoscopic cholecystectomy.

PubMed

Yousef, Gamal T; Lasheen, Ahmed E

2012-01-01

Laparoscopic cholecystectomy became the standard surgery for gallstone disease because of causing less postoperative pain, respiratory compromise and early ambulation. This study was designed to compare spinal anesthesia, (segmental thoracic or conventional lumbar) vs the gold standard general anesthesia as three anesthetic techniques for healthy patients scheduled for elective laparoscopic cholecystectomy, evaluating intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction. A total of 90 patients undergoing elective laparoscopic cholecystectomy, between January 2010 and May 2011, were randomized into three equal groups to undergo laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under segmental thoracic (TSA group) or conventional lumbar (LSA group) spinal anesthesia or general anesthesia (GA group). To achieve a T3 sensory level we used (hyperbaric bupivacaine 15 mg, and fentanyl 25 mg at L2/L3) for LSAgroup, and (hyperbaric bupivacaine 7.5 mg, and fentanyl 25 mg at T10/T11) for TSAgroup. Propofol, fentanyl, atracurium, sevoflurane, and tracheal intubation were used for GA group. Intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction were compared between the three groups. All procedures were completed laparoscopically by the allocated method of anesthesia with no anesthetic conversions. The time for the blockade to reach T3 level, intraoperative hypotensive and bradycardic events and vasopressor use were significantly lower in (TSA group) than in (LSA group). Postoperative pain scores as assessed throughout any time, postoperative right shoulder pain and hospital stay was lower for both (TSA group) and (LSA group) compared with (GA group). The higher degree of patients satisfaction scores were recorded in patients under segmental TSA. The present study not only confirmed that both segmental TSA and conventional lumber spinal anesthesia (LSA) are safe and good alternatives to general anesthesia (GA) in healthy patients undergoing laparoscopic cholecystectomy but also showed better postoperative pain control of both spinal techniques when compared with general anesthesia. Segmental TSA provides better hemodynamic stability, lesser vasopressor use and early ambulation and discharge with higher degree of patient satisfaction making it excellent for day case surgery compared with conventional lumbar spinal anesthesia.

Preliminary investigation of high-dose tranexamic acid for controlling intraoperative blood loss in patients undergoing spine correction surgery.

PubMed

Xie, Jingming; Lenke, Lawrence G; Li, Tao; Si, Yongyu; Zhao, Zhi; Wang, Yingsong; Zhang, Ying; Xiao, Jie

2015-04-01

With a significant increase in the number and complexity of spinal deformity corrective surgeries, blood loss, often requiring massive intraoperative transfusions, becomes a major limiting factor during surgery. This scenario is particularly during posterior vertebral column resection (PVCR), where extensive intraoperative blood loss may pose a major risk to the patient, preventing smooth execution of the procedure. Tranexamic Acid (TXA) has been used in cardiac and orthopedic surgeries, including major spinal surgeries, to reduce blood loss and transfusion requirements for decades. To assess the efficacy and safety of high doses of TXA in posterior spinal deformity corrective surgery, including PVCR procedures. A retrospective study from a single institution. Fifty-nine patients (age range 7 to 46 years old) with spinal deformities undergoing spinal corrective surgeries were included. The patients were divided into two groups: the TXA group (total of 26 patients, including 8 PVCR patients) and the control group (total of 33 patients, including 9 PVCR patients). The analyzed outcome measures included estimated intraoperative blood loss, real blood loss (RBL; blood loss/blood volume×100%), blood transfusion requirements, coagulation parameters, complete blood count, liver function, and renal function. Lower limb vein thrombus, symptomatic pulmonary embolism, symptomatic myocardial infarction, seizures, and acute renal failure were also recorded. Before skin incision, the patients in the TXA group received an intravenous loading dose of 100 mg/Kg over a 20-minute period, followed by a maintenance infusion of 10 mg/Kg/h until skin closure was completed. The patients in the control group received saline infusion of a similar volume. Statistics included estimated intraoperative blood loss, RBL, blood transfusion requirements, coagulation parameters, complete blood count, liver function, and renal function. All patients in this study were also carefully monitored for consciousness level, breathing status, chest tightness or pain, and urine output after surgery. These were done to detect the presence or absence of pulmonary embolism, myocardial infarction, seizures, and acute renal failure. Patients treated with TXA were examined via vascular ultrasound before and after surgery. There were no significant differences in the demographic or surgical traits between the two groups. The blood loss of the patients in the TXA group was 2,441±1,666 mL, whereas that of the control group patients was 4,789±4,719 mL. The difference was statistically significant (p<.05). The average RBL of the patients in the TXA group was 80.6%±49.6% versus 160.8%±163.1% in the control group (p<.05). The blood transfusion requirements for the patients in the TXA group were significantly less than that in the control group (p<.05). Blood loss, RBL, and blood transfusion requirements were all significantly lower in the TXA group, compared with the control group among both PVCR patients and non-PVCR patients. In the TXA group, there was an average of 57.4% reduced blood loss in patients who received PVCR and 39.8% in patients not receiving PVCR. There were no differences in liver and renal functions between the TXA and control groups. There was no lower limb vein thrombus, symptomatic myocardial infarction, symptomatic pulmonary embolism, seizures, or acute renal failure reported in the TXA group. In our study, high doses of TXA have been shown to effectively control blood loss and reduce the transfusion requirement. This effect was more apparent in patients receiving PVCR. No adverse drug reaction was recorded in the study. In the future, prospective randomized controlled trials to validate our results will be necessary. Future studies conducted on older patient cohort may also be necessary to confirm the safety of extending the use of TXA to the older patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Dorsal resection of a thoracic hemivertebra in a 4-year-old boy with endochondral gigantism. A case report.

PubMed

Zarghooni, Kourosh; Sobotrke, Rolf; Schmidt, Heinrich; Rollinghoff, Marc; Siewe, Jan; Eysel, Peer

2010-10-01

The authors present what appears to be the first case of congenital kyphosis due to a T12 hemivertebra in a four-year-old boy with endochondral gigantism syndrome of unknown origin. Because of his overgrowth, the patient had severe medical and orthopaedic problems and was almost immobile. Prior to surgery, he experienced a rapidly progressive thoracolumbar kyphosis to 600 (T10-L2). MRI of the brain and spine showed critical protraction of the spinal cord and myelopathy from compression at T12. Single-stage posterior resection of the hemivertebra with spinal shortening and dorsal transpedicular instrumentation of T10-L2 was performed. Although the bone tissue was cartilaginous and dysplastic, 420 (30%) correction was achieved along with decompression of the spinal canal. The patient experienced no neurological impairment post-operatively. At follow-up examination 1.5 year after surgery, the patient's movement disorder had improved markedly and he was able to stand and walk. This very rare case demonstrates that single-stage posterior hemivertebra resection and transpedicular instrumentation for correction of congenital kyphosis can be a safe and effective procedure even in a very challenging case.

[Anterior lumbar interbody fusion. Indications, technique, advantages and disadvantages].

PubMed

Richter, M; Weidenfeld, M; Uckmann, F P

2015-02-01

Anterior lumbar interbody fusion (ALIF) for lumbar interbody fusion from L2 to the sacrum has been an established technique for decades. The advantages and disadvantages of ALIF compared to posterior interbody fusion techniques are discussed. The operative technique is described in detail. Complications and avoidance strategies are discussed. This article is based on a selective literature search using PubMed and the experience of the authors in this medical field. The advantages of ALIF compared to posterior fusion techniques are the free approach to the anterior disc space without opening of the spinal canal or the neural foramina. This gives the possibility of an extensive anterior release and placement of the largest possible cages without the risk of neural structure damage. The disadvantages of ALIF are the additional anterior approach and the related complications. The most frequent complication is due to damage of vessels. The rate of complications is significantly increased in revision surgery. The ALIF technique meaningfully expands the repertoire of the spinal surgeon especially for the treatment of non-union after interbody fusion, in patients with epidural scar tissue at the index level and spinal infections. Advantages and disadvantages should be considered when evaluating the indications for ALIF.

Dynamic cervicomedullary cord compression and alterations in cerebrospinal fluid dynamics in children with achondroplasia: review of an 11-year surgical case series.

PubMed

Mukherjee, Debraj; Pressman, Barry D; Krakow, Deborah; Rimoin, David L; Danielpour, Moise

2014-09-01

Achondroplasia may be associated with compression at the cervicomedullary junction. Determining which patients are at greatest risk for neurological complications of cervicomedullary compression can be difficult. In the current study the authors reviewed their records to determine the incidence and clinical significance of dynamic cervicomedullary stenosis and obstruction of CSF flow along with surgical outcomes following posterior fossa decompression. The authors reviewed 34 consecutive cases involving symptomatic children with achondroplasia undergoing cervicomedullary decompression performed by a single surgeon over 11 years. Of these patients, 29 had undergone preoperative dynamic MRI of the cervicomedullary junction with cine (cinema) CSF flow studies; 13 of these patients underwent postoperative dynamic MRI studies. Clinical outcomes included changes in polysomnography, head circumference percentile, and fontanel characteristics. Radiographic outcomes included changes in dynamic spinal cord diameter, improvement in CSF flow at the foramen magnum, and change in the Evans ratio. Patients were predominantly female, with a mean age at presentation of 6.6 years and mean follow-up of 3.7 years (range 1-10 years). All patients had moderate to excellent improvement in postoperative polysomnography, slight decrease in average head circumference percentile (from 46.9th percentile to 45.7th percentile), and no subjective worsening of fontanel characteristics. The Evans ratio decreased by 2%, spinal cord diameter increased an average of 3.1 mm, 5.2 mm, and 0.2 mm in the neutral, flexed, and extended positions, respectively, and CSF flow improved qualitatively in all 3 positions. There were no postoperative infections, CSF leaks, or other major complications. None of the patients undergoing initial foramen magnum decompression performed at our medical center required reoperation. Patients with achondroplasia and symptomatic cervicomedullary compression have increased risk of dynamic stenosis at the foramen magnum evident upon dynamic cine MRI. Operative decompression may be offered with low risk of complications or need for reoperation.

Intraoperative anaphylaxis secondary to intraosseous gelatin administration.

PubMed

Luhmann, Scott J; Sucato, Daniel J; Bacharier, Leonard; Ellis, Alysa; Woerz, Cyndi

2013-01-01

FloSeal and SurgiFlo Hemostatic Matrices are commonly used in surgical procedures to promote coagulation and minimize blood loss. They are composed of bovine and porcine gelatin matrix, respectively, that can be injected into pedicles to stop osseous bleeding during pedicle screw insertion. This report details 2 pediatric spinal deformity reconstructive surgery patients who experienced intraoperative cardiovascular events after the intraosseous administration of animal-derived gelatin. Case #1 is an 11-year-old female with adolescent idiopathic scoliosis who was undergoing routine posterior spinal instrumentation and fusion. During placement of the fourth pedicle screw, the patient developed profound hypotension, tachycardia, and elevated airway pressures requiring intravenous epinephrine and phenylephrine for hemodynamic support. Surgery was aborted. Postoperative work-up demonstrated a positive ImmunoCAP study for bovine gelatin. Surgery was repeated 1 week later, without the use of FloSeal, and no episodes of hemodynamic instability. Case #2 was a 9-year-old female with juvenile idiopathic scoliosis who was undergoing a growing spine construct. As in Case #1, SurgiFlo was placed into 2 pedicle tracts after which there was profound hypotension, tachycardia, and elevated airway pressures. Resuscitative efforts included intravenous atropine and epinephrine with resolution. Surgery was aborted. Surgery was repeated 2 weeks later, without the use of SurgiFlo, with no episodes of hemodynamic instability. Given that the patient's symptoms were classic for anaphylaxis, and that the timing of the anaphylaxis immediately followed the administration of FloSeal and SurgiFlo we believe that FloSeal and SurgiFlo were the causes of the reactions. These are the first known reported cases of intraoperative anaphylaxis associated with FloSeal and SurgiFlo. On the basis of our experience, in order to avoid intraoperative cardiovascular events, we obtain preoperative ImmunoCAP testing and eliciting a thorough preoperative history about bovine-derived and porcine-derived gelatin products.

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery.

PubMed

Singla, Anuj; Yang, Scott; Werner, Brian C; Cancienne, Jourdan M; Nourbakhsh, Ali; Shimer, Adam L; Hassanzadeh, Hamid; Shen, Francis H

2017-05-01

OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion. METHODS A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI. RESULTS The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1-3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI. CONCLUSIONS Lumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.

Comparison of Functional and Radiological Outcomes Between Two Posterior Approaches in the Treatment of Multilevel Cervical Spondylotic Myelopathy.

PubMed

Ren, Da-Jiang; Li, Fang; Zhang, Zhi-Cheng; Kai, Guan; Shan, Jian-Lin; Zhao, Guang-Min; Sun, Tian-Sheng

2015-08-05

Posterior cervical decompression is an accepted treatment for multilevel cervical spondylotic myelopathy (CSM). Each posterior technique has its own advantages and disadvantages. In the present study, we compared the functional and radiological outcomes of expansive hemilaminectomy and laminoplasty with mini titanium plate in the treatment of multilevel CSM. Forty-four patients with multilevel CSM treated with posterior cervical surgery in Department of Orthopedic Surgery, Beijing Army General Hospital from March 2011 to June 2012 were enrolled in this retrospective study. Patients were divided into two groups by surgical procedure: Laminoplasty (Group L) and hemilaminectomy (Group H). Perioperative parameters including age, sex, duration of symptoms, operative duration, and intraoperative blood loss were recorded and compared. Spinal canal area, calculated using AutoCAD ® software(Autodesk Inc., San Rafael, CA, USA), and neurological improvement, evaluated with Japanese Orthopedic Association score, were also compared. Neurological improvement did not differ significantly between groups. Group H had a significantly shorter operative duration and significantly less blood loss. Mean expansion ratio was significantly greater in Group L (77.83 ± 6.41%) than in Group H (62.72 ± 3.86%) (P < 0.01). Both surgical approaches are safe and effective in treating multilevel CSM. Laminoplasty provides a greater degree of enlargement of the spinal canal, whereas expansive hemilaminectomy has the advantages of shorter operative duration and less intraoperative blood loss.

New meniscus repair technique for peripheral tears near the posterior tibial attachment of the posterior horn of the medial meniscus.

PubMed

Park, In-Seop; Kim, Sung-Jae

2006-08-01

We introduce a suture technique to repair a peripheral tear near the posterior tibial attachment of the posterior horn. A suture hook was inserted through the posteromedial portal, and the peripheral capsular rim was penetrated from superior to inferior by the sharp hook. Both relay limbs were brought out through the posteromedial portal. The outer limb of the superior peripheral capsular rim was identified with a hemostat. An 18-gauge spinal needle loaded with a No. 0 polydioxanone suture (PDS) was introduced into the joint from the anteromedial portal; it was passed through the joint space until it penetrated the inner torn meniscus. The PDS suture loaded within the needle was pushed into the joint and picked up through the posteromedial portal. The needle was pulled out of the torn meniscus and readvanced over it while the suture was kept loaded. The other limb of the suture from the tip of the spinal needle was retrieved through the posteromedial portal. The initial PDS suture limb was hooked to the shuttle-relay system; it then was passed through the inner torn meniscus and the peripheral capsular rim. The suture limb exiting from the peripheral capsular rim was used as a post and was joined to the other suture limb to form a sliding knot.

Feasibility of tomotherapy to reduce normal lung and cardiac toxicity for distal esophageal cancer compared to three-dimensional radiotherapy.

PubMed

Nguyen, Nam P; Krafft, Shane P; Vinh-Hung, Vincent; Vos, Paul; Almeida, Fabio; Jang, Siyoung; Ceizyk, Misty; Desai, Anand; Davis, Rick; Hamilton, Russ; Modarresifar, Homayoun; Abraham, Dave; Smith-Raymond, Lexie

2011-12-01

To compare the effectiveness of tomotherapy and three-dimensional (3D) conformal radiotherapy to spare normal critical structures (spinal cord, lungs, and ventricles) from excessive radiation in patients with distal esophageal cancers. A retrospective dosimetric study of nine patients who had advanced gastro-esophageal (GE) junction cancer (7) or thoracic esophageal cancer (2) extending into the distal esophagus. Two plans were created for each of the patients. A three-dimensional plan was constructed with either three (anteroposterior, right posterior oblique, and left posterior oblique) or four (right anterior oblique, left anterior oblique, right posterior oblique, and left posterior oblique) fields. The second plan was for tomotherapy. Doses were 45 Gy to the PTV with an integrated boost of 5 Gy for tomotherapy. Mean lung dose was respectively 7.4 and 11.8 Gy (p=0.004) for tomotherapy and 3D plans. Corresponding values were 12.4 and 18.3 Gy (p=0.006) for cardiac ventricles. Maximum spinal cord dose was respectively 31.3 and 37.4 Gy (p < 0.007) for tomotherapy and 3D plans. Homogeneity index was two for both groups. Compared to 3D conformal radiotherapy, tomotherapy decreased significantly the amount of normal tissue irradiated and may reduce treatment toxicity for possible dose escalation in future prospective studies. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Urinary Tract Infection Following Posterior Lumbar Fusion Procedures: An American College of Surgeons National Surgical Quality Improvement Program Study.

PubMed

Bohl, Daniel D; Ahn, Junyoung; Tabaraee, Ehsan; Ahn, Junho; Jain, Akshay; Grauer, Jonathan N; Singh, Kern

2015-11-01

Retrospective review of prospectively collected data. To determine the incidence and risk factors for the development of a urinary tract infection (UTI) after a posterior lumbar fusion procedure. UTI after surgery is common and has important clinical consequences for both patients and the health care system. Few studies have examined UTI after spinal fusion procedures. Patients undergoing posterior lumbar fusion procedures during 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Statistical comparisons were made using multivariate regression with adjustment for demographic, comorbidity, and operative characteristics. A total of 10,825 patients met inclusion criteria. The incidence of a UTI was 1.77% (95% confidence interval = 1.52%-2.02%). Independent risk factors for a UTI were greater age (for 50-59 yr, relative risk [RR] = 1.0; 60-69 yr, RR = 2.1; ≥70 yr, RR = 3.5; P < 0.001), female sex (RR = 2.2, P < 0.001), dependent functional status (RR = 2.1, P = 0.010), malnutrition (RR = 2.3, P = 0.004), diabetic status (for non-insulin-dependent diabetes, RR = 1.5; for insulin-dependent diabetes, RR = 1.9; P = 0.011), and increased operative duration (for 120-179  min, RR = 1.4; 180-239  min, RR = 2.3; and for ≥240  min, RR = 2.7; P < 0.001).Patients who developed a UTI had a greater risk for systemic sepsis than other patients (11.5% vs. 0.63%; adjusted RR = 14.4, P < 0.001). Patients who developed a UTI had a greater risk for readmission than other patients (36.7% vs. 5.0%; adjusted RR = 6.1, P < 0.001). UTIs occur in nearly 1 in 50 patients undergoing posterior lumbar fusion procedures. Patients who are older, female, dependent, malnourished, or diabetic are at greater risk and should be counseled and monitored accordingly. In addition, morbidity associated with a UTI in this population is substantial, as demonstrated by a 14-fold increase in the risk for systemic sepsis and a 6-fold increase in the risk for readmission. As such, increased preventative measures should be targeted to the patients identified here to be at greatest risk. 3.

Thoracic Aortic Stent-Graft Placement for Safe Removal of a Malpositioned Pedicle Screw

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hu Hongtao; Shin, Ji Hoon, E-mail: jhshin@amc.seoul.kr; Hwang, Jae-Yeon

2010-10-15

We describe a case of percutaneous placement of a thoracic aortic stent-graft for safe removal of a malpositioned pedicle screw in a 52-year-old man. The patient had undergone posterior thoracic spinal instrumentation for pyogenic spondylitis and spinal deformity 8 months previously. Follow-up CT images showed a malpositioned pedicle screw which was abutting the thoracic aorta at the T5 level. After percutaneous stent-graft placement, the malpositioned pedicle screw was safely and successfully removed.

Return to sports after surgery to correct adolescent idiopathic scoliosis: a survey of the Spinal Deformity Study Group.

PubMed

Lehman, Ronald A; Kang, Daniel G; Lenke, Lawrence G; Sucato, Daniel J; Bevevino, Adam J

2015-05-01

There are no guidelines for when surgeons should allow patients to return to sports and athletic activities after spinal fusion for adolescent idiopathic scoliosis (AIS). Current recommendations are based on anecdotal reports and a survey performed more than a decade ago in the era of first/second-generation posterior implants. To identify current recommendations for return to sports and athletic activities after surgery for AIS. Questionnaire-based survey. Adolescent idiopathic scoliosis after corrective surgery. Type and time to return to sports. A survey was administered to members of the Spinal Deformity Study Group. The survey consisted of surgeon demographic information, six clinical case scenarios, three different construct types (hooks, pedicle screws, hybrid), and questions regarding the influence of lowest instrumented vertebra (LIV) and postoperative physical therapy. Twenty-three surgeons completed the survey, and respondents were all experienced expert deformity surgeons. Pedicle screw instrumentation allows earlier return to noncontact and contact sports, with most patients allowed to return to running by 3 months, both noncontact and contact sports by 6 months, and collision sports by 12 months postoperatively. For all construct types, approximately 20% never allow return to collision sports, whereas all surgeons allow eventual return to contact and noncontact sports regardless of construct type. In addition to construct type, we found progressively distal LIV resulted in more surgeons never allowing return to collision sports, with 12% for selective thoracic fusion to T12/L1 versus 33% for posterior spinal fusion to L4. Most respondents also did not recommend formal postoperative physical therapy (78%). Of all surgeons surveyed, there was only one reported instrumentation failure/pullout without neurologic deficit after a patient went snowboarding 2 weeks postoperatively. Modern posterior instrumentation allows surgeons to recommend earlier return to sports after fusion for AIS, with the majority allowing running by 3 months, noncontact and contact sports by 6 months, and collision sports by 12 months. Published by Elsevier Inc.

Phrenic nerve neurotization utilizing the spinal accessory nerve: technical note with potential application in patients with high cervical quadriplegia.

PubMed

Tubbs, R Shane; Pearson, Blake; Loukas, Marios; Shokouhi, Ghaffar; Shoja, Mohammadali M; Oakes, W Jerry

2008-11-01

High cervical quadriplegia is associated with high morbidity and mortality. Artificial respiration in these patients carries significant long-term risks such as infection, atelectasis, and respiratory failure. As phrenic nerve pacing has been proven to free many of these patients from ventilatory dependency, we hypothesized that neurotization of the phrenic nerve with the spinal accessory nerve (SAN) may offer one potential alternative to phrenic nerve stimulation via pacing and may be more efficacious and longer lasting without the complications of an implantable device. Ten cadavers (20 sides) underwent exposure of the cervical phrenic nerve and the SAN in the posterior cervical triangle. The SAN was split into anterior and posterior halves and the anterior half transposed to the ipsilateral phrenic nerve as it crossed the anterior scalene muscle. The mean distance between the cervical phrenic nerve and the SAN in the posterior cervical triangle was 2.5 cm proximally, 4 cm at a midpoint, and 6 cm distally. The range for these measurements was 2 to 4 cm, 3.5 to 5 cm, and 4 to 8.5 cm, respectively. The mean excess length of SAN available after transposition to the more anteromedially placed phrenic nerve was 5 cm (range 4 to 6.5 cm). The mean diameter of these regional parts of the spinal accessory and phrenic nerves was 2 and 2.5 mm, respectively. No statistically significant difference was found for measurements between sides. To our knowledge, using the SAN for neurotization to the phrenic nerve for potential use in patients with spinal cord injury has not been previously explored. Following clinical trials, these data may provide a mechanism for self stimulation of the diaphragm and obviate phrenic nerve pacing in patients with high cervical quadriplegia. Our study found that such a maneuver is technically feasible in the cadaver.

Effect of halo-vest components on stabilizing the injured cervical spine.

PubMed

Ivancic, Paul C; Beauchman, Naseem N; Tweardy, Lisa

2009-01-15

An in vitro biomechanical study. The objectives were to develop a new biofidelic skull-neck-thorax model capable of quantifying motion patterns of the cervical spine in the presence of a halo-vest; to investigate the effects of vest loosening, superstructure loosening, and removal of the posterior uprights; and to evaluate the ability of the halo-vest to stabilize the neck within physiological motion limits. Previous clinical and biomechanical studies have investigated neck motion with the halo-vest only in the sagittal plane or only at the injured spinal level. No previous studies have quantified three-dimensional intervertebral motion patterns throughout the injured cervical spine stabilized with the halo-vest or studied the effect of halo-vest components on these motions. The halo-vest was applied to the skull-neck-thorax model. Six osteoligamentous whole cervical spine specimens (occiput through T1 vertebra) were used that had sustained multiplanar ligamentous injuries at C3/4 through C7-T1 during a previous protocol. Flexibility tests were performed with normal halo-vest application, loose vest, loose superstructure, and following removal of the posterior uprights. Average total range of motion for each experimental condition was statistically compared (P < 0.05) with the physiologic rotation limit for each spinal level. Cervical spine snaking was observed in both the sagittal and frontal planes. The halo-vest, applied normally, generally limited average spinal motions to within average physiological limits. No significant increases in average spinal motions above physiologic were observed due to loose vest, loose superstructure, or removal of the posterior uprights. However, a trend toward increased motion at C6/7 in lateral bending was observed due to loose superstructure. The halo-vest, applied normally, effectively immobilized the cervical spine. Sagittal or frontal plane snaking of the cervical spine due to the halo-vest may reduce its immobilization capability at the upper cervical spine and cervicothoracic junction.

Prospective evaluation of chronic pain associated with posterior autologous iliac crest bone graft harvest and its effect on postoperative outcome.

PubMed

Schwartz, Carolyn E; Martha, Julia F; Kowalski, Paulette; Wang, David A; Bode, Rita; Li, Ling; Kim, David H

2009-05-29

Autogenous Iliac Crest Bone Graft (ICBG) has been the "gold standard" for spinal fusion. However, bone graft harvest may lead to complications, such as chronic pain, numbness, and poor cosmesis. The long-term impact of these complications on patient function and well-being has not been established but is critical in determining the value of expensive bone graft substitutes such as recombinant bone morphogenic protein. We thus aimed to investigate the long-term complications of ICBG. Our second aim was to evaluate the psychometric properties of a new measure of ICBG morbidity that would be useful for appropriately gauging spinal surgery outcomes. Prospective study of patients undergoing spinal fusion surgery with autologous ICBG. The SF-36v2, Oswestry Disability Index, and a new 14-item follow-up questionnaire addressing persistent pain, functional limitation, and cosmesis were administered with an 83% response rate. Multiple regression analyses examined the independent effect of ICBG complications on physical and mental health and disability. The study population included 170 patients with a mean age of 51.1 years (SD = 12.2) and balanced gender (48% male). Lumbar fusion patients predominated (lumbar = 148; cervical n = 22). At 3.5 years mean follow-up, 5% of patients reported being bothered by harvest site scar appearance, 24% reported harvest site numbness, and 13% reported the numbness as bothersome. Harvest site pain resulted in difficulty with household chores (19%), recreational activity (18%), walking (16%), sexual activity (16%), work activity (10%), and irritation from clothing (9%). Multivariate regression analyses revealed that persistent ICBG complications 3.5 years post-surgery were associated with significantly worse disability and showed a trend association with worse physical health, after adjusting for age, workers' compensation status, surgical site pain, and arm or leg pain. There was no association between ICBG complications and mental health in the multivariate model. Chronic ICBG harvest site pain and discomfort is reported by a significant percentage of patients undergoing this procedure more than three years following surgery, and these complications are associated with worse patient-reported disability. Future studies should consider employing a control group that does not include autologous bone graft harvest, e.g., a group utilizing rhBMP, to determine whether eliminating harvest-site morbidity does indeed lead to observable improvement in clinical outcome sufficient to justify the increased cost of bone graft substitutes.

The effects of sufentanil added to low-dose hyperbaric bupivacaine in unilateral spinal anaesthesia for outpatients undergoing knee arthroscopy.

PubMed

Sertöz, Nezih; Aysel, İnan; Uyar, Meltem

2014-01-01

The aim of this study is to examine the effects of sufentanil added to low-dose hyperbaric bupivacaine in unilateral spinal anaesthesia for outpatients undergoing knee arthroscopy. Sixty two patients (ASA I-II) aged 20 to 50 who were planning on undergoing a knee arthroscopy were enrolled in this study. Patients were randomly divided into two groups. Unilateral spinal anaesthesia with 1ml 0.5% hyperbaric bupivacaine was administered to Group B (n=33); and unilateral spinal anaesthesia with 0.5ml (2.5µg) sufentanil added to 1ml hyperbaric bupivacaine was administered to Group BS (n=29). There were no statistically significant differences observed between the groups in terms of demographic data, hemodynamic parameters, maximum sensorial, sympathetic and motor block levels, time to motor block resolution, and time of discharge (p>0.05). There were statistically significant differences between the groups in terms of two segments regression time (Group B=52 min., Group BS=59 min.), ambulation time (Group B=147 min., Group BS=157 min.) and urination time (Group B=136 min., Group BS=149 min.) (p<0.05). In this study, no itching was observed in Group B, whereas seven patients in Group BS were observed as having postoperative itching (p<0.05). All patients were successfully given unilateral spinal anaesthesia with sufentanil added to low-dose hyperbaric bupivacaine for an outpatient knee arthroscopy, without affecting the time of discharge. However, for one-day interventions such as arthroscopy, it was concluded that administration of only low-dose hyperbaric bupivacaine was sufficient.

Cost analysis of spinal and general anesthesia for the surgical treatment of lumbar spondylosis.

PubMed

Walcott, Brian P; Khanna, Arjun; Yanamadala, Vijay; Coumans, Jean-Valery; Peterfreund, Robert A

2015-03-01

Lumbar spine surgery is typically performed under general anesthesia, although spinal anesthesia can also be used. Given the prevalence of lumbar spine surgery, small differences in cost between the two anesthetic techniques have the potential to make a large impact on overall healthcare costs. We sought to perform a cost comparison analysis of spinal versus general anesthesia for lumbar spine operations. Following Institutional Review Board approval, a retrospective cohort study was performed from 2009-2012 on consecutive patients undergoing non-instrumented, elective lumbar spine surgery for spondylosis by a single surgeon. Each patient was evaluated for both types of anesthesia, with the decision for anesthetic method being made based on a combination of physical status, anatomical considerations, and ultimately a consensus agreement between patient, surgeon, and anesthesiologist. Patient demographics and clinical characteristics were compared between the two groups. Operating room costs were calculated whilst blinded to clinical outcomes and reported in percentage difference. General anesthesia (n=319) and spinal anesthesia (n=81) patients had significantly different median operative times of 175 ± 39.08 and 158 ± 32.75 minutes, respectively (p<0.001, Mann-Whitney U test). Operating room costs were 10.33% higher for general anesthesia compared to spinal anesthesia (p=0.003, Mann-Whitney U test). Complications of spinal anesthesia included excessive movement (n=1), failed spinal attempt (n=3), intraoperative conversion to general anesthesia (n=2), and a high spinal level (n=1). In conclusion, spinal anesthesia can be performed safely in patients undergoing lumbar spine surgery. It has the potential to reduce operative times, costs, and possibly, complications. Further prospective evaluation will help to validate these findings. Copyright © 2014 Elsevier Ltd. All rights reserved.

Surgical Treatment of Angular Pott’s Kyphosis with Posterior Approach, Pedicular Wedge Osteotomy and Canal Widening

PubMed Central

Kinkpe, CV; Onimus, M; Sarr, L; Niane, MM; Traore, MM; Daffe, M; Gueye, AB

2017-01-01

Background: It has been observed that the correction of severe posttuberculous angular kyphosis is still a challenge, mainly because of the neurologic risk. Methods: Nine patients were reviewed after surgery (mean follow-up 18 months). There were 2 thoracic, 4 thoraco-lumbar and 3 lumbar kyphosis. The mean age at surgery was 23. Clinical results were evaluated by the Oswestry Disability Index (ODI) and by the neurologic evaluation. Preoperative, postoperative and final follow-up X-rays were assessed. The surgery included a posterior approach with cord release and correction by transpedicular wedge osteotomy and widening of the spinal canal. Results: Average kyphotic angulation was 72° before surgery, 10° after surgery and 12° at follow-up. Three out of four patients with neural deficit showed improvement. Neurologic complications included a transitory quadriceps paralysis, likely by foraminal compression of the root. Conclusion: A posterior transpedicular wedge osteotomy allows a substantial correction of the kyphosis, more by deflexion than by elongation, with limited neurologic risks. However it is mandatory to widely enlarge the spinal canal on the levels adjacent to the osteotomy, in order to allow the dura to expand backwards. PMID:28567156

Rare case of diffuse spinal arachnoiditis following a complicated vertebral artery dissection.

PubMed

Atallah, Elias; Dang, Sophia; Rahm, Sage; Feghali, James; Nohra, Chalouhi; Tjoumakaris, Stavropoula; Rosenwasser, Robert H; Zarzour, Hekmat; Herial, Nabeel; Gooch, Michael Reid; Jabbour, Pascal

2018-06-01

Spinal arachnoiditis (SA) is an extremely rare and delayed complication of subarachnoid hemorrhage (SAH). Little is known about its underlying pathogenesis and subsequent clinical course. A middle-aged patient presented with the worst headache of her life and a grade 3 SAH of the basal-cisterns and posterior fossa was identified on Computed Tomography scans (CT). Angiography revealed a ruptured dissecting aneurysm of the left vertebral artery (VA-V4), as well as an unruptured left Anterior Cerebral Artery (ACA-A1) aneurysm. The VA aneurysm was treated with flow diversion. The patient re-ruptured the stented aneurysm, another telescoping pipeline was placed. The patient developed polymicrobial ventriculitis, and returned several months later complaining of paraparesis and left sided weakness. Magnetic Resonance Imaging (MRI) revealed diffuse thecal dural thickening from the cervicomedullary junction to the sacrum. Loculations, diffuse edema and cord compression were noticed along the inferior surface of the cerebellum, and the cervico-thoracic spine with a T4-T6 syrinx. The patient underwent a posterior (T4-T8) spinal fusion and (T5-T7) decompression with arachnoid-cyst fenestration and placement of a subarachnoid-pleural shunt. On latest follow-up, the patient is weaning off the thoraco-lumbosacral orthosis and ambulating with a cane. SA is often a complicated two-staged disease in which a "free interval phase" separates the initial inflammatory reaction (IIR) from the late adhesive phase. Posterior fossa bleeding, warranting prolonged surveillance, additional bleeding and ventriculitis might augment the risk and the severity of arachnoiditis. Copyright © 2018 Elsevier Ltd. All rights reserved.

[Clinical observation of 5 cases of diabetes insipidus complicated with skeletal fluorosis].

PubMed

Wang, Shuan-Chi; Tao, Xiao-Bing; Wang, Fang-Fang; Zhang, Nan

2017-07-25

To investigate the mechanism of diabetes insipidus complicated with skeletal fluorosis and the surgical treatment of spinal canal stenosis caused by skeletal fluorosis. From January 2000 to November 2011, 5 patients with diabetes insipidus complicated with skeletal fluorosis were treated with drug and cervical or thoracic posterior decompression including 2 males and 3 females with age of 35, 45, 47, 49, 55 years old respectively. The symptoms was mainly limb motor sensory disturbance accompanied by polyuria and polyuria. Imaging showed that cervical and thoracic multi-segmental continuous spinal stenosis. It was diagnosed with diabetes insipidus according to the symptoms and laboratory tests. According to the symptoms, the vertebral with problems were located and treated by posterior laminectomy decompression or the expansive open-door laminectomy. The recovery of neurological symptoms were recorded and the operation result were evaluate by JOA score improvement rate. The wound healed well in 5 cases, and 1 case of cervical axial pain was improved after symptomatic treatment. Five patients were followed up for 2 to 6 years with an average of 4 years. Numbness of limb and weakness symptoms of follow-up patients were significantly improved, muscle strength and acupuncture hypothyroidism were significantly improved compared with preoperative, the JOA score was significantly improved. At the final follow-up, the improvement rate got excellent results in 2 cases, good in 2 and fair in 1. Long-term high intake of fluoride can cause skeletal fluorosis in patients with diabetes insipidus. The posterior decompression is effective for the majority of spinal canal stenosis caused by skeletal fluorosis.

Surgical technique for balancing posterior spinal fusions to the pelvis using the T square of Tolo.

PubMed

Andras, Lindsay; Yamaguchi, Kent T; Skaggs, David L; Tolo, Vernon T

2012-12-01

Correcting pelvic obliquity and improving sitting balance in neuromuscular scoliosis often requires fixation to the pelvis. We describe the use of a T square instrument to assist intraoperatively in evaluating the alignment of these curves and achieving balance in the coronal plane. The T square instrument was constructed with a vertical limb perpendicular to 2 horizontal limbs in a T formation. At the conclusion of the instrumentation and preliminary reduction maneuvers, the T square was positioned with the horizontal limbs parallel to the pelvis and the vertical limb in line with the central sacral line. If the spine and pelvis were well balanced, fluoroscopic images demonstrated that the superior aspect of the vertical limb of the T square was crossing the vertebral body of T1. If this was not shown, then some combination of compression, distraction, or a change in the contouring of the rods was performed until this balance was achieved. In this series, we describe case examples in which the T square has been successfully used to aid in achieving balance in the coronal plane. This technique helps to overcome the challenges with positioning and imaging often encountered in managing these long, rigid curves. The T square is a useful adjunct in balancing posterior spinal fusions and evaluating the correction of pelvic obliquity in cases of neuromuscular scoliosis. This novel, yet simple, T square technique can be used for any method of posterior spinal fusion with lumbopelvic fixation to assist in the intraoperative evaluation and achievement of balance in the coronal plane and has become routine at our institution. IV.

One-stage posterior approaches for treatment of thoracic spinal infection: Transforaminal and costotransversectomy, compared with anterior approach with posterior instrumentation.

PubMed

Kao, Fu-Cheng; Tsai, Tsung-Ting; Niu, Chi-Chien; Lai, Po-Liang; Chen, Lih-Huei; Chen, Wen-Jer

2017-10-01

Treating thoracic infective spondylodiscitis with anterior surgical approaches carry a relatively high risk of perioperative and postoperative complications. Posterior approaches have been reported to result in lower complication rates than anterior procedures, but more evidence is needed to demonstrate the safety and efficacy of 1-stage posterior approaches for treating infectious thoracic spondylodiscitis.Preoperative and postoperative clinical data, of 18 patients who underwent 2 types of 1-stage posterior procedures, costotransversectomy and transforaminal thoracic interbody debridement and fusion and 7 patients who underwent anterior debridement and reconstruction with posterior instrumentation, were retrospectively assessed.The clinical outcomes of patients treated with 1-stage posterior approaches were generally good, with good infection control, back pain relief, kyphotic angle correction, and either partial or solid union for fusion status. Furthermore, they achieved shorter surgical time, fewer postoperative complications, and shorter hospital stay than the patients underwent anterior debridement with posterior instrumentation.The results suggested that treating thoracic spondylodiscitis with a single-stage posterior approach might prevent postoperative complications and avoid respiratory problems associated with anterior approaches. Single-stage posterior approaches would be recommended for thoracic spine infection, especially for patients with medical comorbidities.

Satisfactory spinal anesthesia with a total of 1.5 mg of bupivacaine for transurethral resection of bladder tumor in an elderly patient.

PubMed

Namba, Yoshimichi; Yamakage, Michiaki; Tanaka, Yoshinori

2016-01-01

Spinal anesthesia is popular for endoscopic urological surgery. Many patients undergoing urological surgery are elderly. It is important to limit the dose to reduce any resultant hemodynamic effect. We present a case in which incremental administration of 0.1 % bupivacaine up to 1.5 mg was sufficient to produce satisfactory spinal anesthesia for transurethral resection of bladder tumor (TURBT).

Hotly debated topics in obstetric anesthesiology 2008: a theory of relativity.

PubMed

Birnbach, D J; Soens, M A

2008-01-01

This paper reviews and discusses three controversial subjects regarding treatment of intraoperative nausea and other complications experienced by patients undergoing cesarean delivery under spinal anesthesia: (1) the administration of supplemental oxygen, (2) prophylactic vasopressors and (3) the use of low-dose combined spinal epidural anesthesia (CSE). While not universally acknowledged, recent data suggest that the routine administration of supplemental oxygen to normal-weight, healthy patients undergoing elective cesarean delivery is unnecessary, especially when spinal hypotension is minimized. Supplemental oxygen administration does not prevent intraoperative or postoperative nausea and vomiting. Additionally, although higher inspired oxygen fractions modestly increase fetal oxygenation, they also cause a concomitant increase in oxygen free radical activity in both mother and fetus, which may weaken the infant's ability to withstand subsequent neonatal insult. The use of prophylactic vasopressor infusions may benefit some patients, but parenteral preanesthetic ephedrine administration is not warranted. Heart rate variability guided therapy could help identify patients at risk for developing severe hypotension after spinal anesthesia. High-dose phenylephrine infusion in conjunction with rapid co-hydration is efficient, but is unfortunately associated with a relatively high incidence of maternal bradycardia. Oxygen, fluid administration and prophylactic vasopressors may not be the solution to hypotension, nausea and vomiting associated with spinal anesthesia during cesarean delivery. Lower dose spinal anesthesia as part of a CSE technique reduces the incidence of maternal hypotension, and in our opinion is the best option currently available.

Change in Abdominal Morphology After Surgical Correction of Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis: A Computed Tomographic Study.

PubMed

Ji, Ming-Liang; Qian, Bang-Ping; Qiu, Yong; Wang, Bin; Mao, Sai-Hu; Zhu, Ze-Zhang; Yu, Yang

2015-12-01

A computed tomographic study. To investigate the change in abdominal morphology in surgically treated patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis. Severe thoracolumbar kyphosis in patients with AS exerts pressure on the abdominal cavity and subsequently causes intra-abdominal complications. Several spinal osteotomy techniques have been widely used to correct AS-related thoracolumbar kyphosis. To date, the changed abdominal morphology in patients with AS undergoing surgical correction of thoracolumbar kyphosis has not been addressed. A total of 29 patients with AS undergoing lumbar pedicle subtraction osteotomy for correction of thoracolumbar kyphosis were retrospectively reviewed. Computed tomographic scans of the spine were used to measure the longitudinal, transverse, and anterior-posterior diameters of the abdominal cavity. Furthermore, the abdominal cavity was considered as an ellipsoid structure, thereby allowing calculation of its volume. Radiographical evaluations included global kyphosis (GK), thoracic kyphosis, lumbar lordosis (LL), and angle of fusion levels (AFL). The longitudinal diameter of abdominal cavity significantly increased (P < 0.01), whereas the transverse and anterior-posterior diameters of the abdominal cavity did not change, postoperatively (P > 0.05). Significant changes in GK, LL, and AFL were observed (P < 0.01). The abdominal cavity volume (ACV) increased by an average of 652  mL. The change in ACV was significantly correlated with the changes in GK (r = 0.453, P = 0.014), LL (r = 0.42, P = 0.023), and AFL (r = 0.388, P = 0.037). The increased ACV after correction of thoracolumbar kyphosis was quantitatively confirmed by this study. Thus, the improvement in digestive function after correction of thoracolumbar kyphosis secondary to AS, which has been previously documented, may be because of an increase in ACV. Moreover, spine surgeons should be aware of the potential risk for the development of abdominal complications caused by the lengthening of longitudinal diameter of the abdominal cavity. 3.

Factors favoring regain of the lost vertical spinal height through posterior spinal fusion in adolescent idiopathic scoliosis.

PubMed

Shi, Benlong; Mao, Saihu; Xu, Leilei; Sun, Xu; Liu, Zhen; Zhu, Zezhang; Lam, Tsz Ping; Cheng, Jack Cy; Ng, Bobby; Qiu, Yong

2016-07-04

Height gain is a common beneficial consequence following correction surgery in adolescent idiopathic scoliosis (AIS), yet little is known concerning factors favoring regain of the lost vertical spinal height (SH) through posterior spinal fusion. A consecutive series of AIS patients from February 2013 to August 2015 were reviewed. Surgical changes in SH (ΔSH), as well as the multiple coronal and sagittal deformity parameters were measured and correlated. Factors associated with ΔSH were identified through Pearson correlation analysis and multivariate regression analysis. A total of 172 single curve and 104 double curve patients were reviewed. The ΔSH averaged 2.5 ± 0.9 cm in single curve group and 2.9 ± 1.0 cm in double curve group. The multivariate regression analysis revealed the following pre-operative variables contributed significantly to ΔSH: pre-op Cobb angle, pre-op TK (single curve group only), pre-op GK (double curve group only) and pre-op LL (double curve group only) (p < 0.05). Thus change in height (in cm) = 0.044 × (pre-op Cobb angle) + 0.012 × (pre-op TK) (Single curve, adjusted R(2) = 0.549) or 0.923 + 0.021 × (pre-op Cobb angle1) + 0.028 × (pre-op Cobb angle2) + 0.015 × (pre-op GK)-0.012 × (pre-op LL) (Double curve, adjusted R(2) = 0.563). Severer pre-operative coronal Cobb angle and greater sagittal curves were beneficial factors favoring more contribution to the surgical lengthening effect in vertical spinal height in AIS.

Spinal fusion surgery: From relief to insecurity.

PubMed

Damsgaard, Janne B; Jørgensen, Lene B; Norlyk, Annelise; Birkelund, Regner

2017-02-01

During their decision-making process patients perceive surgery as a voluntary yet necessary choice. Surgery initiates hope for a life with less pain but also creates a feeling of existential insecurity in terms of fear, isolation and uncertainty. The aim of this study was to explore how patients experience their situation from the point of making the decision to undergo spinal fusion surgery to living their everyday life after surgery. A phenomenological-hermeneutic study design was applied based on the French philosopher Paul Ricoeur's theory of interpretation. Data were collected through observations and semi-structured interviews. The recommendation and decision to undergo spinal fusion surgery felt like a turning point for the patients and brought hope of regaining their normal lives, of being a more resourceful parent, partner, friend and colleague with no or less pain. Thus, deciding to undergo surgery created a brief feeling of relief. However, life with back pain had changed the patients' understanding of themselves. Consequently, some patients postoperatively experienced insecurity and a weakened self-image with difficulties creating meaning in their lives. Being recommended and undergoing spinal fusion surgery initiates hope for a life with less pain and altered life conditions. At the same time, paradoxically, this creates a feeling of existential insecurity in terms of facing the surgery and the future to come. It is, therefore, important to recognise and include the patients' everyday life experiences concerning how they give (or may not give) meaning to their illness, i.e. their understanding of how it is affecting them. These aspects are essential for the patients' definition and re-definition of themselves and thus crucial to draw upon in the relationship and communication between patient and healthcare professional. Copyright © 2016 Elsevier Ltd. All rights reserved.

"Black butterfly" sign on T2*-weighted and susceptibility-weighted imaging: A novel finding of chronic venous congestion of the brain stem and spinal cord associated with dural arteriovenous fistulas.

PubMed

Enokizono, Mikako; Sato, Noriko; Morikawa, Minoru; Kimura, Yukio; Sugiyama, Atsuhiko; Maekawa, Tomoko; Sone, Daichi; Takewaki, Daiki; Okamoto, Tomoko; Takahashi, Yuji; Horie, Nobutaka; Matsuo, Takayuki

2017-08-15

A dural arteriovenous fistula (DAVF) with spinal perimedullary venous drainage can cause progressive myelopathy, and it is sometimes incorrectly diagnosed as another spinal cord disease. Here we report the cases of three individuals with a DAVF (one craniocervical junction DAVF and two tentorial DAVFs) with progressive myelopathy showing unique magnetic resonance (MR) imaging findings. MR T2*WI or susceptibility-weighted imaging (SWI) demonstrated symmetrical dark signal intensity lesions predominantly in the dorsal aspect of medulla and the central gray matter of cervical spinal cord that showed the "black butterfly" silhouette. Cerebral angiography revealed DAVFs draining into anterior and posterior spinal veins. Dark signals on T2*WI and SWI were presumed to be hemorrhages, which were probably caused by prolonged venous congestion. Identifying this "black butterfly" sign can facilitate the diagnosis of DAVF, differentiating DAVF from other spinal cord diseases such as demyelinating lesions and neoplasms. Copyright © 2017 Elsevier B.V. All rights reserved.

Chiropractic management of a patient with lumbar spine pain due to synovial cyst: a case report

PubMed Central

Cox, James M.

2012-01-01

Introduction The purpose of this study is to report the findings resulting from chiropractic care using flexion distraction spinal manipulation for a patient with low back and radicular pain due to spinal stenosis caused by a synovial cyst. Case Report A 75-year-old man presented with low back pain radiating to the right anterior thigh and down the left posterior leg of 3 years' duration. Physical and imaging examinations showed a synovial cyst–induced spinal stenosis at the right L3-L4 level and bilateral L4-L5 spinal stenosis. Intervention and Outcomes Flexion distraction spinal manipulation and physiological therapeutics were applied at the levels of stenosis. After 4 visits, the patient noted total absence of the right and left lower extremity pain and no adverse reaction to treatment. After 3 months of treatment and 16 visits, his low back and buttock pain were minimal; and he had no leg pain. Conclusion Lumbar synovial cyst and stenosis–generated low back and radicular pain was 80% relieved in a 75-year-old man following Cox flexion distraction spinal manipulation. PMID:22942836

The effect from different numbers of segmental arteries ligation to the spinal cord in the clinical practice of posterior vertebral column resection correction.

PubMed

Zhao, Zhi; Xie, Jingming; Wang, Yingsong; Bi, Ni; Li, Tao; Zhang, Ying; Shi, Zhiyue

2017-07-01

In using posterior vertebral column resection (PVCR) to treat severe kyphoscoliosis, it is unavoidable to ligate and cut off several segmental arteries (SAs) of the spinal cord for exposure and hemostasis, but which would raise the neurological risks. The aim of this study is to explore the changes of intraoperative spinal cord monitoring (IOM) following ligating different numbers of SAs in PVCR. Twenty-one consecutive patients with severe kyphoscoliosis were included and treated by PVCR correction. In operation, according to ligate different numbers of SAs, the IOM changes were recorded, respectively. Examinations of the covariance between different numbers of SAs ligations and IOM changes were performed to reveal the effect to the spinal cord by SAs ligations. In all the 21 cases, averaging 1.9 pairs of SAs were ligated. With the increased numbers of ligations, SSEP amplitudes and latencies were changed more obviously: from 1 to 3 pairs ligations, the mean decreased percentages of amplitudes were from 53.20 to 78.15%, the mean increased percentages of latency were from 1.23 to 1.40%, and the mean durations of decreased SSEP amplitudes were from 3.23 to 5.2 min; but without abnormal MEP changes. None occurred postoperative or delayed neurological deficit. Correlation analysis identified significant correlations between the number of SAs ligation and decreased percentage of SSEP amplitude (r = 0.945, P < 0.0001), and between the number of SAs being ligated and the duration of SSEP change (r = 0.945, P = 0.0002). Following the increased number of SAs ligation, the amplitude of SSEP is decreased more obviously with a much longer duration of recovery and the risk to spinal cord will be increased greatly. In the PVCR correction on the basis of spinal shortening, the numbers of SAs ligations should be as less as possible for neurological safety.

Body Position Influences Which Neural Structures Are Recruited by Lumbar Transcutaneous Spinal Cord Stimulation

PubMed Central

Danner, Simon M.; Krenn, Matthias; Hofstoetter, Ursula S.; Toth, Andrea; Mayr, Winfried; Minassian, Karen

2016-01-01

Transcutaneous stimulation of the human lumbosacral spinal cord is used to evoke spinal reflexes and to neuromodulate altered sensorimotor function following spinal cord injury. Both applications require the reliable stimulation of afferent posterior root fibers. Yet under certain circumstances, efferent anterior root fibers can be co-activated. We hypothesized that body position influences the preferential stimulation of sensory or motor fibers. Stimulus-triggered responses to transcutaneous spinal cord stimulation were recorded using surface-electromyography from quadriceps, hamstrings, tibialis anterior, and triceps surae muscles in 10 individuals with intact nervous systems in the supine, standing and prone positions. Single and paired (30-ms inter-stimulus intervals) biphasic stimulation pulses were applied through surface electrodes placed on the skin between the T11 and T12 inter-spinous processes referenced to electrodes on the abdomen. The paired stimulation was applied to evaluate the origin of the evoked electromyographic response; trans-synaptic responses would be suppressed whereas direct efferent responses would almost retain their amplitude. We found that responses to the second stimulus were decreased to 14%±5% of the amplitude of the response to the initial pulse in the supine position across muscles, to 30%±5% in the standing, and to only 80%±5% in the prone position. Response thresholds were lowest during standing and highest in the prone position and response amplitudes were largest in the supine and smallest in the prone position. The responses obtained in the supine and standing positions likely resulted from selective stimulation of sensory fibers while concomitant motor-fiber stimulation occurred in the prone position. We assume that changes of root-fiber paths within the generated electric field when in the prone position increase the stimulation thresholds of posterior above those of anterior root fibers. Thus, we recommend conducting spinal reflex or neuromodulation studies with subjects lying supine or in an upright position, as in standing or stepping. PMID:26797502

Complete Spinal Accessory Nerve Palsy From Carrying Climbing Gear.

PubMed

Coulter, Jess M; Warme, Winston J

2015-09-01

We report an unusual case of spinal accessory nerve palsy sustained while transporting climbing gear. Spinal accessory nerve injury is commonly a result of iatrogenic surgical trauma during lymph node excision. This particular nerve is less frequently injured by blunt trauma. The case reported here results from compression of the spinal accessory nerve for a sustained period-that is, carrying a load over the shoulder using a single nylon rope for 2.5 hours. This highlights the importance of using proper load-carrying equipment to distribute weight over a greater surface area to avoid nerve compression in the posterior triangle of the neck. The signs and symptoms of spinal accessory nerve palsy and its etiology are discussed. This report is particularly relevant to individuals involved in mountaineering and rock climbing but can be extended to anyone carrying a load with a strap over one shoulder and across the body. Copyright © 2015 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.

Posterior tibial nerve stimulation vs parasacral transcutaneous neuromodulation for overactive bladder in children.

PubMed

Barroso, Ubirajara; Viterbo, Walter; Bittencourt, Joana; Farias, Tiago; Lordêlo, Patrícia

2013-08-01

Parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation have emerged as effective methods to treat overactive bladder in children. However, to our knowledge no study has compared the 2 methods. We evaluated the results of parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation in children with overactive bladder. We prospectively studied children with overactive bladder without dysfunctional voiding. Success of treatment was evaluated by visual analogue scale and dysfunctional voiding symptom score, and by level of improvement of each specific symptom. Parasacral transcutaneous electrical nerve stimulation was performed 3 times weekly and posterior tibial nerve stimulation was performed once weekly. A total of 22 consecutive patients were treated with posterior tibial nerve stimulation and 37 with parasacral transcutaneous electrical nerve stimulation. There was no difference between the 2 groups regarding demographic characteristics or types of symptoms. Concerning the evaluation by visual analogue scale, complete resolution of symptoms was seen in 70% of the group undergoing parasacral transcutaneous electrical nerve stimulation and in 9% of the group undergoing posterior tibial nerve stimulation (p = 0.02). When the groups were compared, there was no statistically significant difference (p = 0.55). The frequency of persistence of urgency and diurnal urinary incontinence was nearly double in the group undergoing posterior tibial nerve stimulation. However, this difference was not statistically significant. We found that parasacral transcutaneous electrical nerve stimulation is more effective in resolving overactive bladder symptoms, which matches parental perception. However, there were no statistically significant differences in the evaluation by dysfunctional voiding symptom score, or in complete resolution of urgency or diurnal incontinence. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

A perspective on the use of an enhanced recovery program in open, non-instrumented day surgery for degenerative lumbar and cervical spinal conditions.

PubMed

Venkata, Hari K; van Dellen, James R

2018-06-01

A means of significantly shortening patients' length of hospital stay, improving their outcome and thereby also reducing costs is to use an enhanced recovery program (ERP) which is increasingly being used in a number of surgical sub-specialties. This paper provides a perspective on its prospective use in a wide-ranging, unselected cohort of patients undergoing open spinal surgery for degenerative lumbar and cervical spinal conditions. Selected spinal cases undergoing day surgery have been increasingly reported. A prospective, unselected, consecutive cohort of 246 cases, over an 18-month period, undergoing open, non-instrumented decompression spinal surgery and using ERP (and the concept of "bundles of care") was analyzed. Nine cases could not be included as they did not fully meet the entry criteria. No routine follow-up was arranged for the study group. The ages ranged widely, from 23-90 years (mean 57). In 187 the surgery for degenerative conditions was lumbar and in 50 cervical. The ASA (American Association of Anesthesiologists) ratings were 108=1; 107=2 and 22=3. Using the United Kingdom (UK) National Health Service (NHS) definitions of length of stay 225 (95%) could be finally classified as "ambulatory" and 12 (5%) were "short stay". A sub-cohort of 126 (53.2%) were "day cases". The follow-up was >1 year for all. There were no wound infections reported; 5 postdischarge cases (2.1%) needed to be seen in the Accident and Emergency (A&E) Department (less than 4 days postsurgery), but none needed re-admission; and there were 7 re-admissions (2.5%), between 4 and 30 days, and of these 6 required a further surgical procedure. There were no long-term instability complications reported in this cohort. ERP can be used for spinal surgery. There were identifiable and correctable medical and social factors found on analysis which could significantly increase the "day cases" number to over 90%.

The patient's experience of temporary paralysis from spinal anaesthesia, a part of total knee replacement.

PubMed

Bager, Louise; Konradsen, Hanne; Dreyer, Pia Sander

2015-12-01

The aim of this study was to describe the meaning of being temporary paralysed from spinal anaesthesia when undergoing total knee replacement. Total knee arthroplasty is a common procedure, and regional anaesthesia is used as a method for anaesthetising the patient. The experience is highly individual in substance and duration, and it can extend far beyond care settings as intraoperative care and the postanaesthesia care unit that have been investigated so far. A qualitative phenomenological hermeneutic design was chosen to gain a deeper understanding of the experience of spinal anaesthesia, as a part of having a total knee replacement. Twelve patients were interviewed in March 2014 after undergoing an elective total knee arthroplasty under spinal anaesthesia. The interviews were analysed with a Ricoeur-inspired interpretation method. Three themes were derived from the interviews: 'anaesthesia--an unavoidable necessity', 'an unrecognisable and incomprehensible body' and 'the body returns--joy and agony'. The results reveal that trust in the health care personnel and knowledge of the course of events play a key role in the experience. The trust can be breached by unforeseen events, or if the patient's experiences were not taken into account. The ability of the health care personnel to be in contact, share relevant knowledge with- and compensate for the patient is crucial in the prevention of negative experiences. The results of this study contribute to insights and deeper knowledge that can enhance staff's ability to provide care for patients undergoing total knee arthroplasty in spinal anaesthesia. The results provide perspectives that argue for care in accordance to individual needs. © 2015 John Wiley & Sons Ltd.

Effect of Epsilon Aminocaproic Acid on Red-Cell Transfusion Requirements in Major Spinal Surgery

PubMed Central

Berenholtz, Sean M.; Pham, Julius Cuong; Garrett-Mayer, Elizabeth; Atchison, Christine W; Kostuik, John P.; Cohen, David B.; Nundy, Shantanu; Dorman, Todd; Ness, Paul M.; Klag, Michael J.; Pronovost, Peter J.; Kebaish, Khaled M.

2009-01-01

Study Design Randomized, placebo-controlled trial Objective To evaluate the efficacy of epsilon aminocaproic acid (EACA) to reduce the number of red-cell (RBC) transfusions in adult patients undergoing major spinal surgery. Summary of Background Data Reconstructive spinal surgery is associated with significant blood loss. The number of studies evaluating the efficacy of EACA in adult patients undergoing spinal surgery remains scarce and limited. Methods EACA (100 mg/kg) or placebo was administered to 182 adult patients after the induction of anesthesia followed by an infusion that was continued for 8 hours postoperatively. Primary end-points included total allogeneic RBC transfusions through postoperative day (POD) 8 and postoperative allogeneic plus autologus RBC transfusions through POD 8. Results Mean total allogeneic RBC transfusions were not statistically different between the groups (5.9 units EACA versus 6.9 units placebo; P=0.17). Mean postoperative RBC transfusions in the EACA group was less (2.0 units versus 2.8 units placebo; P=0.03). There was no significant difference in mean estimated intraoperative EBL (2938 cc EACA vs. 3273 cc placebo; P=0.32). Mean intensive care unit length of stay was decreased (EACA 1.8 days versus 2.8 days placebo; P=0.04). The incidence of thromboembolic complications was similar (2.2% EACA vs 6.6% placebo; P=0.15). Conclusions The difference in total allogeneic RBC transfusions between the groups was not statistically significant. EACA was associated with a 30% (0.8 units) reduction in postoperative RBC transfusions and a one-day reduction in ICU LOS, without an increased incidence of thromboembolic events. EACA may be considered for patients undergoing major spinal surgery. Larger studies are needed to evaluate the relationship between EACA and total RBC requirements. PMID:19730217

Effect of epsilon aminocaproic acid on red-cell transfusion requirements in major spinal surgery.

PubMed

Berenholtz, Sean M; Pham, Julius Cuong; Garrett-Mayer, Elizabeth; Atchison, Christine W; Kostuik, John P; Cohen, David B; Nundy, Shantanu; Dorman, Todd; Ness, Paul M; Klag, Michael J; Pronovost, Peter J; Kebaish, Khaled M

2009-09-01

: Randomized, placebo-controlled trial. : To evaluate the efficacy of epsilon aminocaproic acid (EACA) to reduce the number of red-cell (RBC) transfusions in adult patients undergoing major spinal surgery. : Reconstructive spinal surgery is associated with significant blood loss. The number of studies evaluating the efficacy of EACA in adult patients undergoing spinal surgery remains scarce and limited. : EACA (100 mg/kg) or placebo was administered to 182 adult patients after the induction of anesthesia followed by an infusion that was continued for 8 hours after surgery. Primary end points included total allogeneic RBC transfusions through postoperative day 8 and postoperative allogeneic plus autologus RBC transfusions through postoperative day 8. : Mean total allogeneic RBC transfusions were not statistically different between the groups (5.9 units EACA vs. 6.9 units placebo; P = 0.17). Mean postoperative RBC transfusions in the EACA group was less (2.0 units vs. 2.8 units placebo; P = 0.03). There was no significantdifference in mean estimated intraoperative estimated-blood loss (2938 cc EACA vs. 3273 cc placebo; P = 0.32). Mean intensive care unit length of stay was decreased (EACA: 1.8 days vs. 2.8 days placebo; P = 0.04). The incidence of thromboembolic complications was similar (2.2% EACA vs. 6.6% placebo; P = 0.15). : The difference in total allogeneic RBC transfusions between the groups was not statistically significant. EACA was associated with a 30% (0.8 units) reduction in postoperative RBC transfusions and a 1-day reduction in ICU LOS, without an increased incidence of thromboembolic events. EACA may be considered for patients undergoing major spinal surgery. Larger studies are needed to evaluate the relationship between EACA and total RBC requirements.

Apoptosis and proliferation of oligodendrocyte progenitor cells in the irradiated rodent spinal cord

DOE Office of Scientific and Technical Information (OSTI.GOV)

Atkinson, Shelley L.; Li Yuqing; Wong, C. Shun

2005-06-01

Purpose: Oligodendrocytes undergo early apoptosis after irradiation. The aim of this study was to determine the relationship between oligodendroglial apoptosis and proliferation of oligodendrocyte progenitor cells (OPC) in the irradiated central nervous system. Methods and Materials: Adult rats and p53 transgenic mice were given single doses of 2 Gy, 8 Gy, or 22 Gy to the cervical spinal cord. Apoptosis was assessed using TUNEL (Tdt-mediated dUTP terminal nick-end labeling) staining or by examining nuclear morphology. Oligodendrocyte progenitor cells were identified with an NG2 antibody or by in situ hybridization for platelet-derived growth factor receptor {alpha}. Proliferation of OPC was assessedmore » by in vivo bromodeoxyuridine (BrdU) labeling and subsequent immunohistochemistry. Because radiation-induced apoptosis of oligodendroglial cells is p53 dependent, p53 transgenic mice were used to study the relationship between apoptosis and cell proliferation. Results: Oligodendrocyte progenitor cells underwent apoptosis within 24 h of irradiation in the rat. That did not result in a change in OPC density at 24 h. Oligodendrocyte progenitor cell density was significantly reduced by 2-4 weeks, but showed recovery by 6 weeks after irradiation. An increase in BrdU-labeled cells was observed at 2 weeks after 8 Gy or 22 Gy, and proliferating cells in the rat spinal cord were immunoreactive for NG2. The mouse spinal cord showed a similar early cell proliferation after irradiation. No difference was observed in the proliferation response in the spinal cord of p53 -/- mice compared with wild type animals. Conclusions: Oligodendroglial cells undergo early apoptosis and OPC undergo early proliferation after ionizing radiation. However, apoptosis is not likely to be the trigger for early proliferation of OPC in the irradiated central nervous system.« less

Minimally invasive trans-sacral approach to L5-S1 interbody fusion: Preliminary results from 1 center and review of the literature.

PubMed

Bradley, W Daniel; Hisey, Michael S; Verma-Kurvari, Sunita; Ohnmeiss, Donna D

2012-01-01

Lumbar interbody fusion has long been used for the treatment of painful degenerative spinal conditions. The anterior approach is not feasible in some patients, and the posterior approach is associated with a risk of neural complications and possibly muscle injury. A trans-sacral technique was developed that allows access to the L5-S1 disc space. The purposes of this study were to investigate the clinical outcome of trans-sacral interbody fusion in a consecutive series of patients from 1 center and to perform a comprehensive review of the literature on this procedure. A literature search using PubMed was performed to identify articles published on trans-sacral axial lumbar interbody fusion (AxiaLIF). Articles reviewed included biomechanical testing, feasibility of the technique, and clinical results. The data from our center were collected retrospectively from charts for the consecutive series, beginning with the first case, of all patients undergoing fusion using the AxiaLIF technique. In most cases, posterior instrumentation was also used. A total of 41 patients with at least 6 months' follow-up were included (mean follow-up, 22.2 months). The primary clinical outcome measures were visual analog scales separately assessing back and leg pain and the Oswestry Disability Index. Radiographic assessment of fusion was also performed. In the group of 28 patients undergoing single-level AxiaLIF combined with posterior fusion, the visual analog scale scores assessing back and leg pain and mean Oswestry Disability Index scores improved significantly (P < .01). In the remaining 13 patients, back pain improved significantly with a trend for improvement in leg pain. Reoperation occurred in 19.5% of patients; in half of these, reoperation was not related to the anterior procedure. A review of the literature found that the AxiaLIF technique was similar to other fusion techniques with respect to biomechanical properties and produced acceptable clinical outcomes, although results varied among studies. The AxiaLIF approach allows access to the L5-S1 interspace without violating the annulus or longitudinal ligaments and with minimal risk to dorsal neural elements. It may be a viable alternative to other approaches to interbody fusion at the L5-S1 level. It is important that the patients be selected carefully and surgeons are familiar with the presacral anatomy and the surgical approach.

Music and ambient operating room noise in patients undergoing spinal anesthesia.

PubMed

Ayoub, Chakib M; Rizk, Laudi B; Yaacoub, Chadi I; Gaal, Dorothy; Kain, Zeev N

2005-05-01

Previous studies have indicated that music decreases intraoperative sedative requirements in patients undergoing surgical procedures under regional anesthesia. In this study we sought to determine whether this decrease in sedative requirements results from music or from eliminating operating room (OR) noise. A secondary aim of the study was to examine the relationship of response to intraoperative music and participants' culture (i.e., American versus Lebanese). Eighty adults (36 American and 54 Lebanese) undergoing urological procedures with spinal anesthesia and patient-controlled IV propofol sedation were randomly assigned to intraoperative music, white noise, or OR noise. We found that, controlling for ambient OR noise, intraoperative music decreases propofol requirements (0.004 +/- 0.002 mg . kg(-1) . min(-1) versus 0.014 +/- 0.004 mg . kg(-1) . min(-1) versus 0.012 +/- 0.002 mg . kg(-1) . min(-1); P = 0.026). We also found that, regardless of group assignment, Lebanese patients used less propofol as compared with American patients (0.005 +/- 0.001 mg . kg(-1) . min(-1) versus 0.017 +/- 0.003 mg . kg(-1) . min(-1); P = 0.001) and that, in both sites, patients in the music group required less propofol (P < 0.05). We conclude that when controlling for ambient OR noise, intraoperative music decreases propofol requirements of both Lebanese and American patients who undergo urological surgery under spinal anesthesia.

Netrin1/DCC signaling promotes neuronal migration in the dorsal spinal cord.

PubMed

Junge, Harald J; Yung, Andrea R; Goodrich, Lisa V; Chen, Zhe

2016-10-26

Newborn neurons often migrate before undergoing final differentiation, extending neurites, and forming synaptic connections. Therefore, neuronal migration is crucial for establishing neural circuitry during development. In the developing spinal cord, neuroprogenitors first undergo radial migration within the ventricular zone. Differentiated neurons continue to migrate tangentially before reaching the final positions. The molecular pathways that regulate these migration processes remain largely unknown. Our previous study suggests that the DCC receptor is important for the migration of the dorsal spinal cord progenitors and interneurons. In this study, we determined the involvement of the Netrin1 ligand and the ROBO3 coreceptor in the migration. By pulse labeling neuroprogenitors with electroporation, we examined their radial migration in Netrin1 (Ntn1), Dcc, and Robo3 knockout mice. We found that all three mutants exhibit delayed migration. Furthermore, using immunohistochemistry of the BARHL2 interneuron marker, we found that the mediolateral and dorsoventral migration of differentiated dorsal interneurons is also delayed. Together, our results suggest that Netrin1/DCC signaling induce neuronal migration in the dorsal spinal cord. Netrin1, DCC, and ROBO3 have been extensively studied for their functions in regulating axon guidance in the spinal commissural interneurons. We reveal that during earlier development of dorsal interneurons including commissural neurons, these molecules play an important role in promoting cell migration.

In-vivo spinal cord deformation in flexion

NASA Astrophysics Data System (ADS)

Yuan, Qing; Dougherty, Lawrence; Margulies, Susan S.

1997-05-01

Traumatic mechanical loading of the head-neck complex results cervical spinal cord injury when the distortion of the cord is sufficient to produce functional or structural failure of the cord's neural and/or vascular components. Characterizing cervical spinal cord deformation during physiological loading conditions is an important step to defining a comprehensive injury threshold associated with acute spinal cord injury. In this study, in vivo quasi- static deformation of the cervical spinal cord during flexion of the neck in human volunteers was measured using magnetic resonance (MR) imaging of motion with spatial modulation of magnetization (SPAMM). A custom-designed device was built to guide the motion of the neck and enhance more reproducibility. the SPAMM pulse sequence labeled the tissue with a series of parallel tagging lines. A single- shot gradient-recalled-echo sequence was used to acquire the mid-sagittal image of the cervical spine. A comparison of the tagged line pattern in each MR reference and deformed image pair revealed the distortion of the spinal cord. The results showed the cervical spinal cord elongates during head flexion. The elongation experienced by the spinal cord varies linearly with head flexion, with the posterior surface of the cord stretching more than the anterior surface. The maximal elongation of the cord is about 12 percent of its original length.

Spontaneous spinal epidural haematoma: a rare cause of quadriplegia in the post-partum period.

PubMed

Bose, S; Ali, Z; Rath, G P; Prabhakar, H

2007-12-01

Spontaneous spinal epidural haematoma (SSEH) is a rare cause of neurological deficit in the pregnant and post-partum patients. However, SSEH with associated myelitis presenting as quadriplegia and respiratory paralysis in the post-partum period has never been reported. We report the development of acute onset quadriplegia progressing to respiratory arrest in a 24-yr-old woman 2 weeks after normal vaginal delivery. There was no history suggestive of any coagulopathy (inherited or acquired), eclampsia, pre-existing neurological deficit, or iatrogenic manipulations such as spinal/epidural injections. Magnetic resonance imaging revealed a posterior epidural haematoma extending from C4-C7 and areas of signal changes in spinal cord from cervicomedullary junction to D5 level (suggestive of demyelination). We highlight this rare cause of quadriplegia; focusing on the altered dynamics of the epidural vasculature in the peripartum period leading to SSEH.

Epithelioid hemangioendothelioma of the spine. Report of two cases.

PubMed

Aquilina, Kristian; Lim, Christopher; Kamel, Mahmoud Hamdy; Marks, Charles J; O'Sullivan, Michael G; Keohane, Catherine

2005-11-01

Epithelioid hemangioendothelioma (EH) is a rare tumor of vascular origin. The authors describe two cases of spinal EH, one involving the T-10 vertebra and the second involving the upper cervical spine. In the first case the patient underwent resection of the tumor; this case represents the longest reported follow-up period for spinal EH. In the second case, extensive involvement of C-2, C-3, and C-4 as well as encasement of both vertebral arteries precluded safe tumor resection, and posterior occipitocervical stabilization was performed. The patient subsequently died of metastatic disease. The findings in these two cases underscore the difficulty in predicting the clinical behavior of spinal EH based solely on histological and clinical features as well as the uncertainty of the roles of surgery, chemotherapy, and radiotherapy in the oncological management of a spinal tumor for which clinical data are very limited.

Medulloblastoma: Long-term follow-up of patients treated with electron irradiation of the spinal field

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gaspar, L.E.; Dawson, D.J.; Tilley-Gulliford, S.A.

1991-09-01

Thirty-two patients with posterior fossa medulloblastoma underwent treatment with electron irradiation to the spinal field. The 5- and 10-year actuarial survival rates were 57% and 50%, respectively. Late complications observed in the 15 patients followed up for more than 5 years were short stature (six patients), decreased sitting-standing height ratio (four patients), scoliosis (two patients), poor school performance (seven patients), xerostomia (one patient), esophageal stricture (one patient), pituitary dysfunction (four patients), primary hypothyroidism (one patient), bilateral eighth-nerve deafness (one patient), and carcinoma of the thyroid (one patient). Complications following treatment with electrons to a spinal field are compared with reportedmore » complications following treatment with photons to the spinal field. Although short-term reactions were minimal, the authors found no difference in late complications. More sophisticated treatment planning may show such a long-term benefit in the future.« less

Myosin phosphatase Fine-tunes Zebrafish Motoneuron Position during Axonogenesis

PubMed Central

Granato, Michael

2016-01-01

During embryogenesis the spinal cord shifts position along the anterior-posterior axis relative to adjacent tissues. How motor neurons whose cell bodies are located in the spinal cord while their axons reside in adjacent tissues compensate for such tissue shift is not well understood. Using live cell imaging in zebrafish, we show that as motor axons exit from the spinal cord and extend through extracellular matrix produced by adjacent notochord cells, these cells shift several cell diameters caudally. Despite this pronounced shift, individual motoneuron cell bodies stay aligned with their extending axons. We find that this alignment requires myosin phosphatase activity within motoneurons, and that mutations in the myosin phosphatase subunit mypt1 increase myosin phosphorylation causing a displacement between motoneuron cell bodies and their axons. Thus, we demonstrate that spinal motoneurons fine-tune their position during axonogenesis and we identify the myosin II regulatory network as a key regulator. PMID:27855159

[Low dose isobaric, hyperbaric, or hypobaric bupivacaine for unilateral spinal anesthesia.].

PubMed

Imbelloni, Luiz Eduardo; Beato, Lúcia; Gouveia, Marildo A; Cordeiro, José Antônio

2007-06-01

Unilateral spinal anesthesia has its advantages, especially in patients undergoing outpatient basis surgeries. Low dose, slow speed of administration, and the lateral positioning make easier the unilateral distribution in spinal anesthesia. Isobaric, hyperbaric, and hypobaric solutions of bupivacaine were compared in the unilateral spinal anesthesia in patients undergoing outpatient basis orthopedic surgeries. One hundred and fifty patients were randomly divided in three groups to receive 5 mg of 0.5% isobaric bupivacaine (Iso Group), 5 mg of 0.5% hyperbaric bupivacaine (Hyper Group), or 5 mg of 0.15% hypobaric bupivacaine (Hypo Group). The solutions were administered in the L3-L4 space with the patient in the lateral decubitus and remaining in this position for 20 minutes. Sensitive anesthesia was evaluated by the pin prick test. Motor blockade was determined by the modified Bromage scale. Both blockades were compared with the opposite side and among themselves. There was a significant difference between the side of the surgery and the opposite side in all three groups at 20 minutes, but the frequency of unilateral spinal anesthesia was greater with the hyperbaric and hypobaric solutions. Sensitive and motor blockades were observed in 14 patients in the Iso Group, 38 patients in the Hyper Group, and 40 patients in the Hypo Group. Patients did not develop any hemodynamic changes. Postpuncture headache and transitory neurological symptoms were not observed. Spinal anesthesia with hypobaric and hyperbaric solutions present a higher frequency of unilateral anesthesia. After 20 minutes, isobaric bupivacaine mobilized into cerebrospinal fluid (CSF) resulted in unilateral spinal anesthesia in only 28% of the patients.

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block.

PubMed

Yun, M J; Kim, Y H; Han, M K; Kim, J H; Hwang, J W; Do, S H

2009-11-01

In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture. The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n=20) and the IVA group (intravenous analgesia with alfentanil, n=20). Group IVA patients received a bolus dose of i.v. alfentanil 10 microg/kg, followed by a continuous infusion of alfentanil 0.25 microg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared. VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1-4) vs. 3.5 (2-6), P=0.001], and the mean (+/- SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 +/- 2.7 min vs. 10.8 +/- 5.6 min; P=0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)(P=0.008). An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.

Spinal fusion in patients with congenital heart disease. Predictors of outcome.

PubMed

Coran, D L; Rodgers, W B; Keane, J F; Hall, J E; Emans, J B

1999-07-01

The strong association between congenital heart disease and spinal deformity is well established, but data on the risks and outcome of spinal fusion surgery in patients with congenital heart disease are scarce. The purpose of this study was to identify predictors of perioperative risk and outcome in a large series of children and adolescents with congenital heart disease who underwent spinal fusion for scoliosis or kyphosis. In the authors' retrospective analysis of 74 consecutive patients with congenital heart disease undergoing spinal fusion, there were two deaths (2.7%) and 18 significant complications (24.3%) in the perioperative period. Preoperative cyanosis (arterial oxygen saturation < 90% at rest) with uncorrected or incompletely corrected congenital heart disease was associated with both deaths. Complications occurred in nine of 18 (50%) patients with cyanosis and in 11 of 56 (20%) patients without cyanosis. As judged by multivariate analysis the best predictors of perioperative outcome were the overall physical status of the patient as represented by the American Society of Anesthesiologists' preoperative score and a higher rate of intraoperative blood loss. Seventeen of 43 patients (40%) with an American Society of Anesthesiologists score of 3 or higher experienced complications including two perioperative deaths. Successful spinal fusion and correction were achieved in 97% of patients. Children and adolescents with congenital heart disease can undergo elective spinal fusion with risks that relate to overall cardiac status. Careful assessment of preoperative status by pediatric cardiologists and cardiac anesthesiologists familiar with surgical treatment of patients with congenital heart disease will assist the orthopaedic surgeon in providing the most realistic estimate of risk.

Experience-dependent development of spinal motor neurons

NASA Technical Reports Server (NTRS)

Inglis, F. M.; Zuckerman, K. E.; Kalb, R. G.; Walton, K. D. (Principal Investigator)

2000-01-01

Locomotor activity in many species undergoes pronounced alterations in early postnatal life, and environmental cues may be responsible for modifying this process. To determine how these events are reflected in the nervous system, we studied rats reared under two different conditions-the presence or absence of gravity-in which the performance of motor operations differed. We found a significant effect of rearing environment on the size and complexity of dendritic architecture of spinal motor neurons, particularly those that are likely to participate in postural control. These results provide evidence that neurons subserving motor function undergo activity-dependent maturation in early postnatal life in a manner analogous to sensory systems.

Paraspinal muscle impingement causing acute Brown-Sequard syndrome after posterior cervical decompression.

PubMed

Jost, Patrick W; Marawar, Satyajit; O'Leary, Patrick F

2010-04-01

A case report. To present a previously unreported cause of neurologic compromise after cervical spine surgery. Several different causes of postoperative neurologic deficit have been reported in the literature. The authors present a case of acute postoperative paralysis after posterior cervical decompression by a mechanism that has not yet been reported in the literature. A 54-year-old muscular, short-statured man underwent posterior cervical laminectomy from C3-C5 without instrumentation and left C5 foraminotomy. Within hours of leaving the operating room, he began to develop postoperative neurologic deficits in his extremities, which progressed to a classic Brown-Sequard syndrome. Magnetic resonance imaging revealed regional kyphosis and large swollen paraspinal muscles impinging on the spinal cord without epidural hematoma. Emergent operative re-exploration confirmed these findings; large, swollen paraspinal muscles, a functioning drain, and no hematoma were found. The patient was treated with immediate corticosteroids at the time of initial diagnosis, and emergent re-exploration and debulking of the paraspinal muscles. The patient had complete recovery of neurologic function to his preoperative baseline after the second procedure but required a third procedure in which anterior discectomy and fusion at C4-C5 was performed, which led to improvement of his preoperative symptoms. When performing posterior cervical decompression, surgeons must be aware of the potential for loss of normal lordosis and anterior displacement of paraspinal muscles against the spinal cord, especially in muscular patients.

Comparison of Functional and Radiological Outcomes Between Two Posterior Approaches in the Treatment of Multilevel Cervical Spondylotic Myelopathy

PubMed Central

Ren, Da-Jiang; Li, Fang; Zhang, Zhi-Cheng; Kai, Guan; Shan, Jian-Lin; Zhao, Guang-Min; Sun, Tian-Sheng

2015-01-01

Background: Posterior cervical decompression is an accepted treatment for multilevel cervical spondylotic myelopathy (CSM). Each posterior technique has its own advantages and disadvantages. In the present study, we compared the functional and radiological outcomes of expansive hemilaminectomy and laminoplasty with mini titanium plate in the treatment of multilevel CSM. Methods: Forty-four patients with multilevel CSM treated with posterior cervical surgery in Department of Orthopedic Surgery, Beijing Army General Hospital from March 2011 to June 2012 were enrolled in this retrospective study. Patients were divided into two groups by surgical procedure: Laminoplasty (Group L) and hemilaminectomy (Group H). Perioperative parameters including age, sex, duration of symptoms, operative duration, and intraoperative blood loss were recorded and compared. Spinal canal area, calculated using AutoCAD® software (Autodesk Inc., San Rafael, CA, USA), and neurological improvement, evaluated with Japanese Orthopedic Association score, were also compared. Results: Neurological improvement did not differ significantly between groups. Group H had a significantly shorter operative duration and significantly less blood loss. Mean expansion ratio was significantly greater in Group L (77.83 ± 6.41%) than in Group H (62.72 ± 3.86%) (P < 0.01). Conclusions: Both surgical approaches are safe and effective in treating multilevel CSM. Laminoplasty provides a greater degree of enlargement of the spinal canal, whereas expansive hemilaminectomy has the advantages of shorter operative duration and less intraoperative blood loss. PMID:26228218

Bovine Progressive Degenerative Myeloencephalopathy (Weaver Syndrome) in Brown Swiss Cattle in Canada: A Literature Review and Case Report

PubMed Central

Baird, John D.; Sarmiento, Ulla M.; Basrur, Parvathi K.

1988-01-01

A 15-month-old purebred Brown Swiss heifer was presented because of posterior paresis and ataxia. Histopathological examination of the brain and spinal cord showed evidence of a mild diffuse degenerative myeloencephalopathy. The most severe degenerative lesions were located in the white matter of the thoracic spinal cord. We believe this to be the first documented case of bovine progressive degenerative myeloencephalopathy (“weaver syndrome”) in Canada. ImagesFigure 1.Figure 2., Figure 3., Figure 4.Figure 5. PMID:17423028

General anesthesia versus segmental thoracic or conventional lumbar spinal anesthesia for patients undergoing laparoscopic cholecystectomy

PubMed Central

Yousef, Gamal T.; Lasheen, Ahmed E.

2012-01-01

Background: Laparoscopic cholecystectomy became the standard surgery for gallstone disease because of causing less postoperative pain, respiratory compromise and early ambulation. Objective: This study was designed to compare spinal anesthesia, (segmental thoracic or conventional lumbar) vs the gold standard general anesthesia as three anesthetic techniques for healthy patients scheduled for elective laparoscopic cholecystectomy, evaluating intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction. Materials and Methods: A total of 90 patients undergoing elective laparoscopic cholecystectomy, between January 2010 and May 2011, were randomized into three equal groups to undergo laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under segmental thoracic (TSA group) or conventional lumbar (LSA group) spinal anesthesia or general anesthesia (GA group). To achieve a T3 sensory level we used (hyperbaric bupivacaine 15 mg, and fentanyl 25 mg at L2/L3) for LSAgroup, and (hyperbaric bupivacaine 7.5 mg, and fentanyl 25 mg at T10/T11) for TSAgroup. Propofol, fentanyl, atracurium, sevoflurane, and tracheal intubation were used for GA group. Intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction were compared between the three groups. Results: All procedures were completed laparoscopically by the allocated method of anesthesia with no anesthetic conversions. The time for the blockade to reach T3 level, intraoperative hypotensive and bradycardic events and vasopressor use were significantly lower in (TSA group) than in (LSA group). Postoperative pain scores as assessed throughout any time, postoperative right shoulder pain and hospital stay was lower for both (TSA group) and (LSA group) compared with (GA group). The higher degree of patients satisfaction scores were recorded in patients under segmental TSA. Conclusion: The present study not only confirmed that both segmental TSA and conventional lumber spinal anesthesia (LSA) are safe and good alternatives to general anesthesia (GA) in healthy patients undergoing laparoscopic cholecystectomy but also showed better postoperative pain control of both spinal techniques when compared with general anesthesia. Segmental TSA provides better hemodynamic stability, lesser vasopressor use and early ambulation and discharge with higher degree of patient satisfaction making it excellent for day case surgery compared with conventional lumbar spinal anesthesia. PMID:25885611

Prognostic Factors for Recovery After Anterior Debridement/Bone Grafting and Posterior Instrumentation for Lumbar Spinal Tuberculosis.

PubMed

Yao, Yuan; Zhang, Huiyu; Liu, Huan; Zhang, Zhengfeng; Tang, Yu; Zhou, Yue

2017-08-01

Anterior debridement/bone grafting/posterior instrumentation is a common selection for the treatment of lumbar spinal tuberculosis (LST). To date, no study has focused on the prognostic factors for recovery after this surgery. We included 144 patients who experienced anterior debridement/bone grafting/posterior instrumentation for LST. The recovery rate based on the Japanese Orthopedic Association (JOA) score was used to assess recovery. The Kaplan-Meier method and Cox regression analysis were used to identify the prognostic factors for recovery postoperatively. For the prognostic factors worth further consideration, the changes in JOA scores within the 24-month follow-up period were identified by repeated-measures analysis of variance. Paralysis/nonparalysis, duration of symptoms (≥3/<3 months), number of involved vertebrae (>2/≤2), and posterior open/percutaneous instrumentation were identified as prognostic factors for recovery postoperatively. The prognostic factor of open/percutaneous instrumentation was then further compared for potential clinical application. Patients in the percutaneous instrumentation group achieved higher JOA scores than those in the open instrumentation group in the early stages postoperatively (1-3 months), but this effect equalized at 6 months postoperatively. Patients in the open instrumentation group experienced longer operation time and less cost than those in the percutaneous instrumentation group. Nonparalysis, shorter symptom duration, fewer involved vertebrae, and posterior percutaneous instrumentation (compared with open instrumentation) are considered favorable prognostic factors. Patients in the percutaneous instrumentation group achieved higher JOA scores than those in the open instrumentation group in the early stages postoperatively (1-3 months), but no significant difference was observed in long-term JOA scores (6-24 months). Copyright © 2017. Published by Elsevier Inc.

Trans aqueductal, third ventricle - Cervical subarachnoid stenting: An adjuvant cerebro spinal fluid diversion procedure in midline posterior fossa tumors with hydrocephalus: The technical note and case series.

PubMed

Teegala, Ramesh

2016-01-01

Persistent or progressive hydrocephalus is one of the complex problems of posterior fossa tumors associated with hydrocephalus. The author evaluated the effectiveness of single-stage tumor decompression associated with a stent technique (trans aqueductal third ventricle - Cervical subarachnoid stenting) as an adjuvant cerebro spinal fluid (CSF) diversion procedure in controlling the midline posterior fossa tumors with hydrocephalus. Prospective clinical case series of 15 patients was evaluated from July 2006 to April 2012. Fifteen clinicoradiological diagnosed cases of midline posterior fossa tumors with hydrocephalus were included in this study. All the tumors were approached through the cerebello medullary (telo velo tonsilar) fissure technique. Following the excision of the posterior fossa tumor, a sizable stent was placed across the aqueduct from the third ventricle to the cervical subarachnoid space. There were nine male and six female patients with an average age of 23 years. Complete tumor excision could be achieved in 12 patients and subtotal excision with clearance of aqueduct in remaining three patients. Hydrocephalus was controlled effectively in all the patients. There were no stent-related complications. This study showed the reliability of single-stage tumor excision followed by placement of aqueductal stent. The success rate of this technique is comparable to those of conventional CSF diversion procedures. This is a simple, safe, and effective procedure for the management of persistent and or progressive hydrocephalus. This technique may be very useful in situations where the patient's follow-up is compromised and the patients who are from a poor economic background. Long-term results need further evaluation to assess the overall functioning of this stent technique.

Modified Posterior C1 Lateral Mass Screw Insertion for Type II Odontoid Process Fractures Using Intraoperative Computed Tomography-Based Spinal Navigation to Minimize Postoperative Occipital Neuralgia.

PubMed

Ishak, Basem; Schneider, Till; Tubbs, R Shane; Gimmy, Valerie; Younsi, Alexander; Unterberg, Andreas W; Kiening, Karl L

2017-11-01

Various surgical techniques have been described for treating odontoid instability and achieving effective stabilization. The earliest technique to be described proposed a C1 lateral mass entry point including neurectomy of the C2 nerve roots to ensure hemostasis. Because C2 neurectomy remains controversial, preservation of the C2 nerve root as described in Goel-Harms technique can lead to intractable occipital neuralgia and significant blood loss. The aim of this study was to modify the Goel-Harms technique with a high C1 lateral mass screw entry point to enhance overall intraoperative safety. Sixty-three patients (average age, 70 ± 16 years) with acute traumatic odontoid fracture type II underwent posterior stabilization with a modified posterior C1 lateral mass entry point using intraoperative computed tomography (CT)-guided spinal navigation. Complications were recorded, especially bleeding from the epidural venous plexus and development of occipital neuralgia. All patients were followed up for a minimum of 6 months. None of the patients developed occipital neuralgia or numbness. Blood transfusion was necessary in 1 patient because of a coagulation disorder. There was no bleeding from the epidural venous plexus. All screws were correctly placed. Two patients needed surgical revision (wound infection, dural tear). Two developed cardiopulmonary complications. Solid bony fusion was achieved in all patients. This study confirms that changing the C1 entry point to the junction of the posterior arch and superior-posterior part of the C1 lateral mass by using intraoperative CT navigation yields a safe and effective procedure with few complications. The overall complication rate was 6%. Copyright © 2017 Elsevier Inc. All rights reserved.

[Surgical treatment of craniocervical instability. Review paper].

PubMed

Alpizar-Aguirre, Armando; Lara Cano, Jorge Giovanni; Rosales, Luis; Míramontes, Victor; Reyes-Sánchez, Alejandro Antonio

2007-01-01

The concept of spinal instability is still controversial. Anatomical, biomechanical, clinical and radiographic variants are involved and make the definition complicated. There are solid diagnostic bases in cases of fractures and degenerative disorders; however, pure spinal instability is still under study. The latter may be defined as increased mobility that goes beyond the physiological limits of one vertebra over another in at least one of the three spinal planes of motion. In the case of the craniocervical region, its understanding becomes even more challenging, since its anatomy and physiology are more complex and it is more mobile. Surgical treatment is possible with either an anterior or a posterior approach. Best results are obtained with occipitocervical or atlantoaxial stabilization through a posterior approach, since the anterior one has its limitations. For example, a transoral approach with a bone graft provides compression strength but does not enable immediate appropriate fixation and involves the risk of infection. The choice of the surgical approach must consider the patient's medical status, the specific spine levels involved, the extent of neurological compromise, the X-ray abnormalities and the individual pathology. The goals of surgery are achieved through an appropriate anatomical alignment, assuring the protection of the neural elements and achieving proper spine stabilization with as much preservation of the mobile vertebral segments as possible.

Unstable upper and middle thoracic fractures. Preliminary experience with a posterior transpedicular correction-fixation technique.

PubMed

Payer, M

2005-06-01

A number of conservative and operative approaches have been described for the treatment of unstable traumatic upper and middle thoracic fractures. The advantage of surgical correction and fixation/fusion lies in its potential to restore sagittal and coronal alignment, thereby indirectly decompressing the spinal cord. A consecutive series of 8 patients with unstable traumatic upper and middle thoracic fractures is reviewed. In all patients, polyaxial pedicle screws were inserted bilaterally into the two levels above and below the fracture. Rods that were less contoured ("undercontoured") than the regional hyperkyphosis at the injured level, were anchored to the caudal four screws. The cranial four screws, with the vertebrae to which they were inserted, were then progressively pulled posteriorly onto the undercontoured rods with rod reducers, thus correcting the hyperkyphosis and anterolisthesis. The mean follow-up was 15 months. The mean regional kyphosis was 23 degrees preoperatively, 17 degrees postoperatively and 18 degrees at follow-up. The mean anterolisthesis was 8 mm preoperatively, 1 mm postoperatively and 1 mm at follow-up. No hardware failure occurred. Five patients with complete spinal cord injury at presentation made no neurological recovery, two patients with incomplete spinal cord injury initially (ASIA B), recovered substantially (to ASIA D), and the patients who were neurologically intact at presentation remained so.

Spinal instrumentation for Duchenne's muscular dystrophy: experience of hypotensive anaesthesia to minimise blood loss.

PubMed

Fox, H J; Thomas, C H; Thompson, A G

1997-01-01

Nineteen patients with Duchenne's muscular dystrophy underwent segmental spinal instrumentation and posterior fusion between 1989 and 1994. The indication for surgery was loss of the ability to walk and development of scoliosis with sitting discomfort. Preoperative assessment included evaluation of pulmonary function. Average age at operation was 12.5 years. Instrumentation and fusion extended from upper thoracic levels to L-5 or the sacrum. A Hartshill rectangle was used in all cases, with banked allograft bone. Severe intraoperative blood loss was avoided by use of hypotensive anaesthesia. Peroperatively, systolic blood pressure was maintained between 75 and 85 mm Hg. Average blood loss was 1,246 ml (range, 400-3,100) or 30% of estimated total blood volume. Average transfusion requirements were 3 units of packed cells. Postoperative analgesia was provided by infusion via an epidural catheter. There were no postoperative wound or chest infections. Three patients required catheterisation for urinary retention. Postoperatively patients were fitted with a Neofract jacket to allow early mobilisation and discharge. Mean postoperative length of stay was 16 days. Posterior spinal fusion by using the Hartshill rectangle provided good correction and fixation. Hypotensive anaesthesia permitted surgery to be performed rapidly in a relatively dry field and avoided the complications of severe intraoperative blood loss and massive transfusion.

A bleeding assessment tool correlates with intraoperative blood loss in children and adolescents undergoing major spinal surgery.

PubMed

Anadio, Jennifer M; Sturm, Peter F; Forslund, Johan M; Agarwal, Sunil; Lane, Adam; Tarango, Cristina; Palumbo, Joseph S

2017-04-01

Screening laboratory studies for bleeding disorders are of little predictive value for operative bleeding risk in adults. Predicting perioperative bleeding in pediatric patients is particularly difficult as younger patients often have not had significant hemostatic challenges. This issue is distinctly important for high bleeding risk surgeries, such as major spinal procedures. The aim of this study was to determine if the score of a detailed bleeding questionnaire (BQ) correlated with surgical bleeding in pediatric patients undergoing major spinal surgery. A total of 220 consecutive pediatric patients (mean age 14.2years) undergoing major spinal surgery were administered the BQ preoperatively, as well as having routine screening laboratory studies (i.e., PT, aPTT, PFA) drawn. A retrospective analysis was conducted to determine if there was a correlation between either the results of the BQ and/or laboratory studies with operative outcomes. A BQ score>2 showed a strong positive correlation with intraoperative bleeding based on both univariate and multivariate analyses. In contrast, abnormalities in screening laboratory studies showed no significant correlation with operative bleeding outcomes. Relying on screening laboratory studies alone is inadequate. The BQ used here correlated with increased intraoperative hemorrhage, suggesting this tool may be useful for assessing pediatric surgical bleeding risk, and may also be useful in identifying a subset of patients with a very low bleeding risk that may not require laboratory screening. Copyright © 2017 Elsevier Ltd. All rights reserved.

Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review.

PubMed

Goldstein, Christina L; Macwan, Kevin; Sundararajan, Kala; Rampersaud, Y Raja

2016-03-01

The objective of this study was to determine the clinical comparative effectiveness and adverse event rates of posterior minimally invasive surgery (MIS) compared with open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). A systematic review of the Medline, EMBASE, PubMed, Web of Science, and Cochrane databases was performed. A hand search of reference lists was conducted. Studies were reviewed by 2 independent assessors to identify randomized controlled trials (RCTs) or comparative cohort studies including at least 10 patients undergoing MIS or open TLIF/PLIF for degenerative lumbar spinal disorders and reporting at least 1 of the following: clinical outcome measure, perioperative clinical or process measure, radiographic outcome, or adverse events. Study quality was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) protocol. When appropriate, a meta-analysis of outcomes data was conducted. The systematic review and reference list search identified 3301 articles, with 26 meeting study inclusion criteria. All studies, including 1 RCT, were of low or very low quality. No significant difference regarding age, sex, surgical levels, or diagnosis was identified between the 2 cohorts (856 patients in the MIS cohort, 806 patients in the open cohort). The meta-analysis revealed changes in the perioperative outcomes of mean estimated blood loss, time to ambulation, and length of stay favoring an MIS approach by 260 ml (p < 0.00001), 3.5 days (p = 0.0006), and 2.9 days (p < 0.00001), respectively. Operative time was not significantly different between the surgical techniques (p = 0.78). There was no significant difference in surgical adverse events (p = 0.97), but MIS cases were significantly less likely to experience medical adverse events (risk ratio [MIS vs open] = 0.39, 95% confidence interval 0.23-0.69, p = 0.001). No difference in nonunion (p = 0.97) or reoperation rates (p = 0.97) was observed. Mean Oswestry Disability Index scores were slightly better in the patients undergoing MIS (n = 346) versus open TLIF/PLIF (n = 346) at a median follow-up time of 24 months (mean difference [MIS - open] = 3.32, p = 0.001). The result of this quantitative systematic review of clinical comparative effectiveness research examining MIS versus open TLIF/PLIF for degenerative lumbar pathology suggests equipoise in patient-reported clinical outcomes. Furthermore, a meta-analysis of adverse event data suggests equivalent rates of surgical complications with lower rates of medical complications in patients undergoing minimally invasive TLIF/PLIF compared with open surgery. The quality of the current comparative evidence is low to very low, with significant inherent bias.

Spinal cord injury following operative shoulder intervention: A case report.

PubMed

Cleveland, Christine; Walker, Heather

2015-07-01

Cervical myelopathy is a spinal cord dysfunction that results from extrinsic compression of the spinal cord, its blood supply, or both. It is the most common cause of spinal cord dysfunction in patients greater than 55 years of age. A 57-year-old male with right shoulder septic arthritis underwent surgical debridement of his right shoulder and sustained a spinal cord injury intraoperatively. The most likely etiology is damage to the cervical spinal cord during difficult intubation requiring multiple attempts in this patient with underlying asymptomatic severe cervical stenosis. Although it is not feasible to perform imaging studies on all patients undergoing intubation for surgery, this patient's outcome would suggest consideration of inclusion of additional pre-surgical screening examination techniques, such as testing for a positive Hoffman's reflex, is appropriate to detect asymptomatic patients who may have underlying cervical stenosis.

Cerebral aneurysms following radiotherapy for medulloblastoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Benson, P.J.; Sung, J.H.

1989-04-01

Three patients, two males and one female aged 21, 14, and 31 years, respectively, developed cerebral saccular aneurysms several years after undergoing radiotherapy for cerebellar medulloblastoma at 2, 5, and 14 years of age, respectively. Following surgery, all three received combined cobalt-60 irradiation and intrathecal colloidal radioactive gold (/sup 198/Au) therapy, and died from rupture of the aneurysm 19, 9, and 17 years after the radiotherapy, respectively. Autopsy examination revealed no recurrence of the medulloblastoma, but widespread radiation-induced vasculopathy was found at the base of the brain and in the spinal cord, and saccular aneurysms arose from the posterior cerebralmore » arteries at the basal cistern or choroidal fissure. The aneurysms differed from the ordinary saccular aneurysms of congenital type in their location and histological features. Their locations corresponded to the areas where intrathecally administered colloidal /sup 198/Au is likely to pool, and they originated directly from a segment of the artery rather than from a branching site as in congenital saccular aneurysms. It is, therefore, concluded that the aneurysms in these three patients were most likely radiation-induced.« less

Lateral interbody fusion combined with open posterior surgery for adult spinal deformity.

PubMed

Strom, Russell G; Bae, Junseok; Mizutani, Jun; Valone, Frank; Ames, Christopher P; Deviren, Vedat

2016-12-01

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

Early and extensive spinal white matter involvement in neuromyelitis optica.

PubMed

Hayashida, Shotaro; Masaki, Katsuhisa; Yonekawa, Tomomi; Suzuki, Satoshi O; Hiwatashi, Akio; Matsushita, Takuya; Watanabe, Mitsuru; Yamasaki, Ryo; Suenaga, Toshihiko; Iwaki, Toru; Murai, Hiroyuki; Kira, Jun-Ichi

2017-05-01

Studies of longitudinally extensive spinal cord lesions (LESCLs) in neuromyelitis optica (NMO) have focused on gray matter, where the relevant antigen, aquaporin-4 (AQP4), is abundant. Because spinal white matter pathology in NMO is not well characterized, we aimed to clarify spinal white matter pathology of LESCLs in NMO. We analyzed 50 spinal cord lesions from eleven autopsied NMO/NMO spectrum disorder (NMOSD) cases. We also evaluated LESCLs with three or fewer spinal cord attacks by 3-tesla MRI in 15 AQP4 antibody-positive NMO/NMOSD patients and in 15 AQP4 antibody-negative multiple sclerosis (MS) patients. Pathological analysis revealed seven cases of AQP4 loss and four predominantly demyelinating cases. Forty-four lesions from AQP4 loss cases involved significantly more frequently posterior columns (PC) and lateral columns (LC) than anterior columns (AC) (59.1%, 63.6%, and 34.1%, respectively). The posterior horn (PH), central portion (CP), and anterior horn (AH) were similarly affected (38.6%, 36.4% and 31.8%, respectively). Isolated perivascular inflammatory lesions with selective loss of astrocyte endfoot proteins, AQP4 and connexin 43, were present only in white matter and were more frequent in PC and LC than in AC (22.7%, 29.5% and 2.3%, P corr  = 0.020, and P corr  = 0.004, respectively). MRI indicated LESCLs more frequently affected PC and LC than AC in anti-AQP4 antibody-seropositive NMO/NMOSD (86.7%, 60.0% and 20.0%, P corr  = 0.005, and P corr  = 0.043, respectively) and AQP4 antibody-seronegative MS patients (86.7%, 73.3% and 33.3%, P corr  = 0.063, and P corr  = 0.043, respectively). PH, CP and AH were involved in 93.3%, 86.7% and 73.3% of seropositive patients, respectively, and in 53.3%, 60.0% and 40.0% of seronegative patients, respectively. NMO frequently and extensively affects spinal white matter in addition to central gray matter, especially in PC and LC, where isolated perivascular lesions with astrocyte endfoot protein loss may emerge. Spinal white matter involvement may also appear in early NMO, similar to cerebral white matter lesions. © 2016 International Society of Neuropathology.

Primary Occipital Ewing's Sarcoma with Subsequent Spinal Seeding.

PubMed

Alqahtani, Ali; Amer, Roaa; Bakhsh, Eman

2017-01-01

Ewing's sarcoma is a primary bone cancer that mainly affects the long bones. This malignancy is particularly common in pediatric patients. Primary cranial involvement accounts for 1% of cases, with occipital involvement considered extremely rare. In this case study, primary occipital Ewing's sarcoma with a posterior fossa mass and subsequent relapse resulting in spinal seeding is reported. A 3-year-old patient presented with a 1-year history of left-sided headaches, localized over the occipital bone with progressive torticollis. Computed tomography (CT) imaging showed a mass in the left posterior fossa compressing the brainstem. The patient then underwent surgical excision followed by adjuvant chemoradiation therapy. Two years later, the patient presented with severe lower back pain and urinary incontinence. Whole-spine magnetic resonance imaging (MRI) showed cerebrospinal fluid (CSF) seeding from the L5 to the S4 vertebrae. Primary cranial Ewing's sarcoma is considered in the differential diagnosis of children with extra-axial posterior fossa mass associated with destructive permeative bone lesions. Although primary cranial Ewing's sarcoma typically has good prognosis, our patient developed metastasis in the lower spine. Therefore, with CNS Ewing's sarcoma, screening of the entire neural axis should be taken into consideration for early detection of CSF seeding metastasis in order to decrease the associated morbidity and mortality.

Finite element analysis and cadaveric cinematic analysis of fixation options for anteriorly implanted trabecular metal interbody cages.

PubMed

Berjano, Pedro; Blanco, Juan Francisco; Rendon, Diego; Villafañe, Jorge Hugo; Pescador, David; Atienza, Carlos Manuel

2015-11-01

To assess, with finite element analysis and an in vitro biomechanical study in cadaver, whether the implementation of an anterior interbody cage made of hedrocel with nitinol shape memory staples in compression increases the stiffness of the stand-alone interbody cage and to compare these constructs' stiffness to other constructs common in clinical practice. A biomechanical study with a finite element analysis and cadaveric testing assessed the stiffness of different fixation modes for the L4-L5 functional spinal unit: intact spine, destabilized spine with discectomy, posterior pedicle-screw fixation, anterior stand-alone interbody cage, anterior interbody cage with bilateral pedicle screws and anterior interbody cage with two shape memory staples in compression. These modalities of vertebral fixation were compared in four loading modes (flexion, extension, lateral bending, and axial rotation). The L4-L5 spinal unit with an anterior interbody cage and two staples was stiffer than the stand-alone cage. The construct stiffness was similar to that of a model of posterior pedicular stabilization. The stiffness was lower than that of the anterior cage plus bilateral pedicle-screw fixation. The use of an anterior interbody implant with shape memory staples in compression may be an alternative to isolated posterior fixation and to anterior isolated implants, with increased stiffness.

Asymmetric bone adaptations to soleus mechanical loading after spinal cord injury

PubMed Central

Dudley-Javoroski, S.; Shields, R.K.

2009-01-01

The purpose of this report is to examine longitudinal bone mineral density (BMD) changes in individuals with spinal cord injury (SCI) who began unilateral soleus electrical stimulation early after injury. Twelve men with SCI and seven without SCI underwent peripheral quantitative computed tomography assessment of distal tibia BMD. After 4.5 to 6 years of training, average trained limb BMD was 27.5% higher than untrained limb BMD. The training effect was more pronounced in the central core of the tibia cross-section (40.5% between-limb difference). No between-limb difference emerged in the anterior half of the tibia (19.2 mg/cm3 difference, p>0.05). A robust between-limb difference emerged in the posterior half of the tibia (76.1 mg/cm3 difference, p=0.0439). The posterior tibia BMD of one subject remained within the range of non-SCI values for 3.8 years post-SCI. The results support that the constrained orientation of soleus mechanical loads, administered over several years, elicited bone-sparing effects in the posterior tibia. This study provides a demonstration of the bone-protective potential of a carefully controlled dose of mechanical load. The specific orientation of applied mechanical loads may strongly influence the manifestation of BMD adaptations in humans with SCI. PMID:18799855

Posterior reversible encephalopathy syndrome following a thoracic discectomy-induced dural leak: case report.

PubMed

Shields, Lisa B E; Johnson, John R; Shields, Christopher B

2016-11-01

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery-induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4-5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.

Medical devices of the head, neck, and spine.

PubMed

Hunter, Tim B; Yoshino, Mark T; Dzioba, Robert B; Light, Rick A; Berger, William G

2004-01-01

There are many medical devices used for head, neck, and spinal diseases and injuries, and new devices are constantly being introduced. Many of the newest devices are variations on a previous theme. Knowing the specific name of a device is not important. It is important to recognize the presence of a device and to have an understanding of its function as well as to be able to recognize the complications associated with its use. The article discusses the most common and important devices of the head, neck, and spine, including cerebrospinal fluid shunts and the Codman Hakim programmable valve; subdural drainage catheters, subdural electrodes, intracranial electrodes, deep brain stimulators, and cerebellar electrodes; coils, balloons, adhesives, particles, and aneurysm clips; radiation therapy catheters, intracranial balloons for drug installation, and carmustine wafers; hearing aids, cochlear implants, and ossicular reconstruction prostheses; orbital prostheses, intraocular silicone oil, and lacrimal duct stents; anterior and posterior cervical plates, posterior cervical spine wiring, odontoid fracture fixation devices, cervical collars and halo vests; thoracic and lumbar spine implants, anterior and posterior instrumentation for the thoracic and lumbar spine, vertebroplasty, and artificial disks; spinal column stimulators, bone stimulators, intrathecal drug delivery pumps, and sacral stimulators; dental and facial implant devices; gastric and tracheal tubes; vagus nerve stimulators; lumboperitoneal shunts; and temperature- and oxygen-sensing probes. Copyright RSNA, 2004

[History of hereditary motor and sensory neuropathy with proximal dominant involvement (HMSN-P)].

PubMed

Takashima, Hiroshi

2013-01-01

We established a new disease autosomal dominant hereditary motor and sensory neuropathy with proximal dominant involvement (HMSNP) in 1997, in Okinawa, Japan. This disease is characterized by proximal dominant neurogenic atrophy with fasciculations, painful muscle cramp, obvious sensory nerve involvement, areflexia, high incidence of elevated creatine kinase levels, hyperlipidemia and hyperglycemia. (MIM %604484). HMSNP is so called or HMSNO (HMSN OKINAWA type),. These clinical features resembled those of Kennedy-Alter-Sung syndrome. Most HMSNP patients have severe muscle atrophy and finally the tracheostomy and artificial ventilation are required. Therefore, we initially thought to classify HMSNP into a subtype of motor neuron disease (MND) like familial amyotrophic lateral sclerosis (FALS) or spinal muscular atrophy (SMA). However, the general consensus for MND was no sensory involvement. Therefore, as the disease showed severe sensory involvement, we categorized HMSNP in subtype of HMSN at that time. We also reported the pathology of HMSNP, showing severely decreased anterior horn cells, decreased posterior horn cells, and loss of posterior funiculus in the spinal cord.

[Neurosurgical treatment of complications of intra-disk injections of triamcinolone hexacetonide. Value of a radio-clinical classification].

PubMed

Privat, J M; Finiels, P J

1997-01-01

Epidural granulomas following intra-discal injection of triamcinolone hexacetonide are a well-known complication of this procedure, which is still encountered, even if its utilization was discontinued several years ago. According to the results of their experience, the authors propose a new radio-clinical grading system: grade I: disc calcification with aspect of "sub-ligamentar hernia" on CT scan; grade II: ascendant or descendant retrosomatic migration of distal content; grade III: pseudotumoral epidural infiltrate producing progressive narrowing of the spinal canal with neurological disturbance. Surgical indications in these cases can be drawn from their evolution: posterior approach can be used, with or without laminectomy, for excision as complete as possible of the involved disc (grades I and II); anterior approach should be preferred in cases of multiples recurrences after medical treatment and failure of classical posterior approach, or in case of necrotico-inflammatory proliferation with narrowing of the spinal canal (grade III).

The impact of body mass index on the risk of high spinal block in parturients undergoing cesarean delivery: a retrospective cohort study.

PubMed

Lamon, Agnes M; Einhorn, Lisa M; Cooter, Mary; Habib, Ashraf S

2017-08-01

To investigate the hypothesis that the risk of high spinal block is not increased in obese parturients undergoing cesarean delivery compared to non-obese parturients. This is a retrospective study at an academic center. We searched the perioperative database for women who underwent cesarean delivery under spinal or combined spinal epidural anesthesia with hyperbaric bupivacaine ≥10.5 mg. A body mass index (BMI) ≥30 kg/m 2 was defined as obese. We categorized obesity into: obesity class I (BMI = 30-34.9 kg/m 2 ), obesity class II (BMI = 35-39.9 kg/m 2 ), obesity class III (BMI = 40-49.9 kg/m 2 ), and super obese (BMI ≥50 kg/m 2 ). The primary outcome was high spinal block defined as need to convert to general anesthesia within 20 min of spinal placement as a result of altered mental status, weakness, or respiratory distress resulting from the high block, or a recorded block height ≥T1. The analysis included 5015 women. High spinal blocks occurred in 29 patients (0.6%). The risk of high spinal was significantly different according to BMI (p = 0.025). In a multivariate model, BMI (p = 0.008) and cesarean delivery priority (p = 0.009) were associated with high blocks. BMI ≥50 kg/m 2 was associated with greater odds of high block compared to BMI <30 kg/m 2 [odds ratio (95% confidence interval): 6.3 (2.2, 18.5)]. Scheduled cesarean delivery was also associated with greater odds of high block compared with unscheduled delivery. At standard spinal doses of hyperbaric bupivacaine used in our practice (≥10.5 mg), there were greater odds of high block in those with BMI ≥50 kg/m 2 .

Influence of Alendronate and Endplate Degeneration to Single Level Posterior Lumbar Spinal Interbody Fusion

PubMed Central

Rhee, Wootack; Ha, Seongil; Lim, Jae Hyeon; Jang, Il Tae

2014-01-01

Objective Using alendronate after spinal fusion is a controversial issue due to the inhibition of osteoclast mediated bone resorption. In addition, there are an increasing number of reports that the endplate degeneration influences the lumbar spinal fusion. The object of this retrospective controlled study was to evaluate how the endplate degeneration and the bisphosphonate medication influence the spinal fusion through radiographic evaluation. Methods In this study, 44 patients who underwent single-level posterior lumbar interbody fusion (PLIF) using cage were examined from April 2007 to March 2009. All patients had been diagnosed as osteoporosis and would be recommended for alendronate medication. Endplate degeneration is categorized by the Modic changes. The solid fusion is defined if there was bridging bone between the vertebral bodies, either within or external to the cage on the plain X-ray and if there is less than 5° of angular difference in dynamic X-ray. Results In alendronate group, fusion was achieved in 66.7% compared to 73.9% in control group (no medication). Alendronate did not influence the fusion rate of PLIF. However, there was the statistical difference of fusion rate between the endplate degeneration group and the group without endplate degeneration. A total of 52.4% of fusion rate was seen in the endplate degeneration group compared to 91.3% in the group without endplate degeneration. The endplate degeneration suppresses the fusion process of PLIF. Conclusion Alendronate does not influence the fusion process in osteoporotic patients. The endplate degeneration decreases the fusion rate. PMID:25620981

Intraspinal canal rod migration causing late-onset paraparesis 8 years after scoliosis surgery.

PubMed

Obeid, Ibrahim; Vital, Jean-Marc; Aurouer, Nicolas; Hansen, Steve; Gangnet, Nicolas; Pointillart, Vincent; Gille, Olivier; Boissiere, Louis; Quraishi, Nasir A

2016-07-01

Complete intraspinal canal rod migration with posterior bone reconstitution has never been described in the adolescent idiopathic scoliosis (AIS) population. We present an unusual but significant delayed neurological complication after spinal instrumentation surgery. A 24-year-old woman presented with lower limb weakness (ASIA D) 8 years after posterior instrumentation from T2 to L4 for AIS. CT scan and MRI demonstrated intra-canal rod migration with complete laminar reconstitution. The C-reactive protein was slightly elevated (fluctuated between 10 and 20 mg/l). Radiographs showed the convex rod had entered the spinal canal. The patient was taken into the operating room for thoracic spinal decompression and removal of the convex rod. This Cotrel-Dubousset rod, which had been placed on the convexity of the thoracic curve had completely entered the canal from T5 to T10 and was totally covered by bone with the eroded laminae entirely healed and closed. There was no pseudarthrosis. Intra-operatively, the fusion mass was opened along the whole length of this rod and the rod carefully removed and the spinal cord decompressed. The bacteriological cultures returned positive for Propionibacterium acnes. The patient recovered fully within 2 months post-operatively. We opine that the progressive laminar erosion with intra-canal rod migration resulted from mechanical and infectious-related factors. The very low virulence of the strain of Propionibacterium acnes is probably involved in this particular presentation where the rod was trapped in the canal, owing to the quite extensive laminar reconstitution.

Single-stage multi-level construct design incorporating ribs and chest wall reconstruction after en bloc resection of spinal tumour.

PubMed

Xiao, Jianru; He, Shaohui; Jiao, Jian; Wan, Wei; Xu, Wei; Zhang, Dan; Liu, Weibo; Zhong, Nanzhe; Liu, Tielong; Wei, Haifeng; Yang, Xinghai

2018-03-01

Multi-level reconstruction incorporating the chest wall and ribs is technically demanding after multi-segmental total en bloc spondylectomy (TES) of thoracic spinal tumours. Few surgical techniques are reported for effective reconstruction. A novel and straightforward technical reconstruction through posterior-lateral approach was presented to solve the extensive chest wall defect and prevent occurrences of severe respiratory dysfunctions after performing TES. The preliminary outcomes of surgery were reviewed. Multi-level TES was performed for five patients with primary or recurrent thoracic spinal malignancies through posterior-lateral approach. The involved ribs and chest wall were removed to achieve tumour-free margin. Then titanium mesh with allograft bone and pedicle screw-rod system were adopted for the circumferential spinal reconstruction routinely. Titanium rods were modified accordingly to attach to the screw-rod system proximally, and the distal end of rods was dynamically inserted into the ribs. The mean surgery time was 6.7 hours (range 5-8), with the average blood loss of 3260 ml (range 2300-4500). No severe neurological complications were reported while three patients had complaints of slight numbness of chest skin (no. 1, 3, and 5). No severe respiratory complications occurred during peri-operative period. No implant failure and no local recurrence or distant metastases were observed with an average follow-up of 12.5 months. The single-stage reconstructions incorporating spine and chest wall are straightforward and easy to perform. The preliminary outcomes of co-reconstructions are promising and favourable. More studies and longer follow-up are required to validate this technique.

Oral administration of analgesia and anxiolysis for pain associated with bone marrow biopsy.

PubMed

Talamo, Giampaolo; Liao, Jason; Bayerl, Michael G; Claxton, David F; Zangari, Maurizio

2010-03-01

Medical literature provides only scarce data about the degree of pain experienced by patients undergoing a bone marrow aspiration and biopsy (BMAB), and little is known about the factors that can modify the perception of pain. In this study, we evaluated the effectiveness of a combination of analgesia and anxiolysis in reducing the pain score of patients undergoing BMAB. Eighty-four consecutive adult patients underwent BMAB after local anesthesia with 5 mL of lidocaine hydrochloride 1% aqueous solution in the left posterior superior iliac crest. Analgesia was obtained with acetaminophen 650 mg and oxycodone 10 mg, and anxiolysis was obtained with lorazepam 2 mg, all drugs given once orally 30 min before the procedure. We assessed the pain level with the Wong-Baker Faces Pain Rating Scale, which distinguishes six levels of pain, from 0 to 5. The 34 patients who received an oral administration of analgesia and anxiolysis reported pain at lower levels, i.e., in the range of 0-2, more frequently than the 50 patients who underwent BMAB without analgesia/anxiolysis (78% vs 64%, respectively). Among several predictors analyzed using a multivariate regression model, three were found to be associated with decreased pain level: the use of analgesia/anxiolysis, male sex, and increase in age (all with p values <0.05). Length of the extracted bone specimen, body mass index, and need of a spinal needle for anesthesia in obese patients did not predict for pain level. An oral administration of prophylactic regimen of analgesia and anxiolysis, at the above-mentioned doses, produced a statistically significant reduction of the perception of pain in patients undergoing BMAB, but its effect did not seem to provide a major and clinically significant reduction of pain level.

Predicting Postsurgical Satisfaction in Adolescents With Idiopathic Scoliosis: The Role of Presurgical Functioning and Expectations.

PubMed

Sieberg, Christine B; Manganella, Juliana; Manalo, Gem; Simons, Laura E; Hresko, M Timothy

2017-12-01

There is a need to better assess patient satisfaction and surgical outcomes. The purpose of the current study is to identify how preoperative expectations can impact postsurgical satisfaction among youth with adolescent idiopathic scoliosis undergoing spinal fusion surgery. The present study includes patients with adolescent idiopathic scoliosis undergoing spinal fusion surgery enrolled in a prospective, multicentered registry examining postsurgical outcomes. The Scoliosis Research Society Questionnaire-Version 30, which assesses pain, self-image, mental health, and satisfaction with management, along with the Spinal Appearance Questionnaire, which measures surgical expectations was administered to 190 patients before surgery and 1 and 2 years postoperatively. Regression analyses with bootstrapping (with n=5000 bootstrap samples) were conducted with 99% bias-corrected confidence intervals to examine the extent to which preoperative expectations for spinal appearance mediated the relationship between presurgical mental health and pain and 2-year postsurgical satisfaction. Results indicate that preoperative mental health, pain, and expectations are predictive of postsurgical satisfaction. With the shifting health care system, physicians may want to consider patient mental health, pain, and expectations before surgery to optimize satisfaction and ultimately improve clinical care and patient outcomes. Level I-prognostic study.

Sympatho-vagal balance, as quantified by ANSindex, predicts post spinal hypotension and vasopressor requirement in parturients undergoing lower segmental cesarean section: a single blinded prospective observational study.

PubMed

Prashanth, Anitha; Chakravarthy, Murali; George, Antony; Mayur, Rohini; Hosur, Rajathadri; Pargaonkar, Sumant

2017-08-01

Hypotension subsequent to spinal anesthesia occurs in a significant number of parturients undergoing lower segment caesarian section. Currently available methods to predict the incidence of hypotension, its severity and the outcome are sub-optimal. Many workers have used basal heart rate as one of the predictors. But using this method it is not possible to objectively analyze and predict the extent and severity of hypotension. We used an equipment measuring the level of sympatho-vagal balance, ANSiscope™, which derives these values from computed value of RR interval variability. We made a single measure of the value which was blinded to the patient and the anesthesiologist. We studied one hundred eight patients who underwent lower segment caesarian section under spinal anesthesia and found the variability of preoperative ANSindex (% activity displayed by the equipment) from 9 to 65 %. Higher ANSindex value was significantly associated with post spinal hypotension (p 0.017). A value of 24 % indicated the critical level above which hypotension appeared commonly. The ANSindex value might help anesthesiologist to anticipate and prepare for hypotension that is likely to ensue.

Assessment of Coronal Spinal Alignment for Adult Spine Deformity Cases After Intraoperative T Square Shaped Use.

PubMed

Kurra, Swamy; Metkar, Umesh; Yirenkyi, Henaku; Tallarico, Richard A; Lavelle, William F

Retrospectively reviewed surgeries between 2011 and 2015 of patients who underwent posterior spinal deformity instrumentation with constructs involving fusions to pelvis and encompassing at least five levels. Measure the radiographic outcomes of coronal malalignment (CM) after use of an intraoperative T square shaped instrument in posterior spinal deformity surgeries with at least five levels of fusion and extension to pelvis. Neuromuscular children found to benefit from intraoperative T square technique to help achieve proper coronal spinal balance with extensive fusions. This intraoperative technique used in our posterior spine deformity instrumentation surgeries with the aforementioned parameters. There were 50 patients: n = 16 with intraoperative T square and n = 34 no-T square shaped device. Subgroups divided based on greater than 20 mm displacement and greater than 40 mm displacement of the C7 plumb line to the central sacral vertical line on either side in preoperative radiographs. We analyzed the demographics and the pre- and postoperative radiographic parameters of standing films: standing CM (displacement of C7 plumb line to central sacral vertical line), and major coronal Cobb angles in total sample and subgroups and compared T square shaped device with no-T square shaped device use by analysis of variance. A p value ≤.05 is statistically significant. In the total sample, though postoperative CM mean was not statistically different, we observed greater CM corrections in patients where a T square shaped device was used (70%) versus no-T square shaped device used (18%). In >20 mm and >40 mm subgroups, the postoperative mean CM values were statistically lower for the patients where a T square shaped device was used, p = .016 and p = .003, respectively. Cobb corrections were statistically higher for T square shaped device use in both >20 mm and >40 mm subgroups, 68%, respectively. The intraoperative T square shaped device technique had a positive effect on the amount of spine coronal malalignment correction after its use and for lumbar and thoracic coronal Cobb angles. Level III. Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.

Impact of post-manipulation corrective core exercises on the spinal deformation and lumbar strength in golfers: a case study

PubMed Central

Shin, Chul-ho; Kim, Minjeong; Park, Gi Duck

2015-01-01

[Purpose] This study examined spinal shape in professional golfers with chronic back pain, and analyzed the effects of a 4-week regimen of semi-weekly manipulation and corrective core exercises on spinal shape. [Subjects] Two golfers with chronic back pain. [Methods] The pelvis and spinal vertebrae were corrected using the Thompson “drop” technique. Angle and force were adjusted to place the pelvis, lumbar spine, and thoracic vertebrae in neutral position. The technique was applied twice weekly after muscle massage in the back and pelvic areas. The golfers performed corrective, warmup stretching exercises, followed by squats on an unstable surface using the Togu ball. They then used a gym ball for repetitions of hip rotation, upper trunk extension, sit-ups, and pelvic anterior-posterior, pelvic left-right, and trunk flexion-extension exercises. The session ended with cycling as a cool-down exercise. Each session lasted 60 minutes. [Results] The difference in height was measured on the left and right sides of the pelvic bone. The pelvic tilt changed significantly in both participants after the 4-week program. [Conclusion] In golfers, core muscles are critical and are closely related to spinal deformation. Core strengthening and spinal correction play a pivotal role in the correction of spinal deformation. PMID:26504350

Acquisition of Involuntary Spinal Locomotion (Spinal Walking) in Dogs with Irreversible Thoracolumbar Spinal Cord Lesion: 81 Dogs.

PubMed

Gallucci, A; Dragone, L; Menchetti, M; Gagliardo, T; Pietra, M; Cardinali, M; Gandini, G

2017-03-01

Spinal walking (SW) is described as the acquisition of an involuntary motor function in paraplegic dogs and cats without pain perception affected by a thoracolumbar lesion. Whereas spinal locomotion is well described in cats that underwent training trials after experimental spinal cord resection, less consistent information is available for dogs. Paraplegic dogs affected by a thoracolumbar complete spinal cord lesion undergoing intensive physical rehabilitation could acquire an autonomous SW gait under field conditions. Eighty-one acute paraplegic thoracolumbar dogs without pelvic limb pain perception. Retrospective study of medical records of dogs selected for intensive rehabilitation treatment in paraplegic dogs with absence of pain perception on admission and during the whole treatment. Binary regression and multivariate logistic regression were used to analyze potential associations with the development of SW. Autonomous SW was achieved in 48 dogs (59%). Median time to achieve SW was of 75.5 days (range: 16-350 days). On univariate analysis, SW gait was associated with younger age (P = .002) and early start of physiotherapy (P = .024). Multivariate logistic regression showed that younger age (≤60 months) and lightweight (≤7.8 kg) were positively associated with development of SW (P = .012 and P < .001, respectively). BCS, full-time hospitalization, and type and site of the lesion were not significantly associated with development of SW. Dogs with irreversible thoracolumbar lesion undergoing intensive physiotherapic treatment can acquire SW. Younger age and lightweight are positively associated with the development of SW gait. Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain

PubMed Central

Christensen, Finn Bjarke; Christiansen, Terkel; Bünger, Cody

2006-01-01

Although cost-effectiveness is becoming the foremost evaluative criterion within health service management of spine surgery, scientific knowledge about cost-patterns and cost-effectiveness is limited. The aims of this study were (1) to establish an activity-based method for costing at the patient-level, (2) to investigate the correlation between costs and effects, (3) to investigate the influence of selected patient characteristics on cost-effectiveness and, (4) to investigate the incremental cost-effectiveness ratio of (a) posterior instrumentation and (b) intervertebral anterior support in lumbar spinal fusion. We hypothesized a positive correlation between costs and effects, that determinants of effects would also determine cost-effectiveness, and that posterolateral instrumentation and anterior intervertebral support are cost-effective adjuncts in posterolateral lumbar fusion. A cohort of 136 consecutive patients with chronic low back pain, who were surgically treated from January 2001 through January 2003, was followed until 2 years postoperatively. Operations took place at University Hospital of Aarhus and all patients had either (1) non-instrumented posterolateral lumbar spinal fusion, (2) instrumented posterolateral lumbar spinal fusion, or (3) instrumented posterolateral lumbar spinal fusion + anterior intervertebral support. Analysis of costs was performed at the patient-level, from an administrator’s perspective, by means of Activity-Based-Costing. Clinical effects were measured by means of the Dallas Pain Questionnaire and the Low Back Pain Rating Scale at baseline and 2 years postoperatively. Regression models were used to reveal determinants for costs and effects. Costs and effects were analyzed as a net-benefit measure to reveal determinants for cost-effectiveness, and finally, adjusted analysis (for non-random allocation of patients) was performed in order to reveal the incremental cost-effectiveness ratios of (a) posterior instrumentation and (b) anterior support. The costs of non-instrumented posterolateral spinal fusion were estimated at DKK 88,285(95% CI 81,369;95,546), instrumented posterolateral spinal fusion at DKK 94,396(95% CI 89,865;99,574) and instrumented posterolateral lumbar spinal fusion + anterior intervertebral support at DKK 120,759(95% CI 111,981;133,738). The net-benefit of the regimens was significantly affected by smoking and functional disability in psychosocial life areas. Multi-level fusion and surgical technique significantly affected the net-benefit as well. Surprisingly, no correlation was found between treatment costs and treatment effects. Incremental analysis suggested that the probability of posterior instrumentation being cost-effective was limited, whereas the probability of anterior intervertebral support being cost-effective escalates as willingness-to-pay per effect unit increases. This study reveals useful and hitherto unknown information both about cost-patterns at the patient-level and determinants of cost-effectiveness. The overall conclusion of the present investigation is a recommendation to focus further on determinants of cost-effectiveness. For example, patient characteristics that are modifiable at a relatively low expense may have greater influence on cost-effectiveness than the surgical technique itself—at least from an administrator’s perspective. PMID:16871387

Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80 degrees: pedicle screws versus hybrid instrumentation.

PubMed

Di Silvestre, Mario; Bakaloudis, Georgios; Lolli, Francesco; Vommaro, Francesco; Martikos, Konstantinos; Parisini, Patrizio

2008-10-01

The treatment of thoracic adolescent idiopathic scoliosis (AIS) of more than 80 degrees traditionally consisted of a combined procedure, an anterior release performed through an open thoracotomy followed by a posterior fusion. Recently, some studies have reassessed the role of posterior fusion only as treatment for severe thoracic AIS; the correction rate of the thoracic curves was comparable to most series of combined anterior and posterior surgery, with shorter surgery time and without the negative effect on pulmonary function of anterior transthoracic exposure. Compared with other studies published so far on the use of posterior fusion alone for severe thoracic AIS, the present study examines a larger group of patients (52 cases) reviewed at a longer follow-up (average 6.7 years, range 4.5-8.5 years). The aim of the study was to evaluate the clinical and radiographic outcome of surgical treatment for severe thoracic (>80 degrees) AIS treated with posterior spinal fusion alone, and compare comprehensively the results of posterior fusion with a hybrid construct (proximal hooks and distal pedicle screws) versus a pedicle screw instrumentation. All patients (n = 52) with main thoracic AIS curves greater than 80 degrees (Lenke type 1, 2, 3, and 4), surgically treated between 1996 and 2000 at one institution, by posterior spinal fusion either with hybrid instrumentation (PSF-H group; n = 27 patients), or with pedicle screw-only construct (PSF-S group; n = 25 patients) were reviewed. There were no differences between the two groups in terms of age, Risser's sign, Cobb preoperative main thoracic (MT) curve magnitude (PSF-H: 92 degrees vs. PSF-S: 88 degrees), or flexibility on bending films (PSF-H: 27% vs. PSF-S: 25%). Statistical analysis was performed using the t test (paired and unpaired), Wilcoxon test for non-parametric paired analysis, and the Mann-Whitney test for non-parametric unpaired analysis. At the last follow-up, the PSF-S group, when compared to the PSF-H group had a final MT correction rate of 52.4 versus 44.52% (P = 0.001), with a loss of -1.9 degrees versus -11.3 degrees (P = 0.0005), a TL/L correction of 50 versus 43% (ns), a greater correction of the lowest instrumented vertebra translation (-1.00 vs. -0.54 cm; P = 0.04), and tilt (-19 degrees vs. -10 degrees; P = 0.005) on the coronal plane. There were no statistically significant differences in sagittal and global coronal alignment between the two groups (C7-S1 offset: PSF-H = 0.5 cm vs. PSF-S = 0 cm). In the hybrid series (27 patients) surgery-related complications necessitated three revision surgeries, whereas in the screw group (25 patients) one revision surgery was performed. No neurological complications or deep wound infection occurred in this series. In conclusion, posterior spinal fusion for severe thoracic AIS with pedicle screws only, when compared to hybrid construct, allowed a greater coronal correction of both main thoracic and secondary lumbar curves, less loss of the postoperative correction achieved, and fewer revision surgeries. Posterior-only fusion with pedicle screws enabled a good and stable correction of severe scoliosis. However, severe curves may be amenable to hybrid instrumentation that produced analogous results to the screws-only constructs concerning patient satisfaction; at the latest follow-up, SRS-30 and SF-36 scores did not show any statistical differences between the two groups.

Pott disease in the thoracolumbar spine with marked kyphosis and progressive paraplegia necessitating posterior vertebral column resection and anterior reconstruction with a cage.

PubMed

Pappou, Ioannis P; Papadopoulos, Elias C; Swanson, Andrew N; Mermer, Matthew J; Fantini, Gary A; Urban, Michael K; Russell, Linda; Cammisa, Frank P; Girardi, Federico P

2006-02-15

Case report. To report on a patient with Pott disease, progressive neurologic deficit, and severe kyphotic deformity, who had medical treatment fail and required posterior/anterior decompression with instrumented fusion. Treatment options will be discussed. Tuberculous spondylitis is an increasingly common disease worldwide, with an estimated prevalence of 800,000 cases. Surgical treatment consisting of extensive posterior decompression/instrumented fusion and 3-level posterior vertebral column resection, followed by anterior debridement/fusion with cage reconstruction. Neurologic improvement at 6-month follow-up (Frankel B to Frankel D), with evidence of radiographic fusion. A 70-year-old patient with progressive Pott paraplegia and severe kyphotic deformity, for whom medical treatment failed is presented. A posterior vertebral column resection, multiple level posterior decompression, and instrumented fusion, followed by an anterior interbody fusion with cage was used to decompress the spinal cord, restore sagittal alignment, and debride the infection. At 6-month follow-up, the patient obtained excellent pain relief, correction of deformity, elimination of the tuberculous foci, and significant recovery of neurologic function.

Improvement of spinal alignment and quality of life after corrective surgery for spinal kyphosis in patients with osteoporosis: a comparative study with non-operated patients.

PubMed

Miyakoshi, N; Hongo, M; Kobayashi, T; Abe, T; Abe, E; Shimada, Y

2015-11-01

This study evaluated changes in spinal alignment and quality of life (QOL) after corrective spinal surgery for patients with postmenopausal osteoporosis and spinal kyphosis. Spinal global alignment and QOL were significantly improved after corrective spinal surgery but did not reach the level of non-operated controls. With the increased aging of society, the demand for corrective spinal instrumentation for spinal kyphosis in osteoporotic patients is increasing. However, previous studies have not focused on the improvement of quality of life (QOL) after corrective spinal surgery in patients with osteoporosis, compared to non-operated control patients. The purposes of this study were thus to evaluate changes in spinal alignment and QOL after corrective spinal instrumentation for patients with osteoporosis and spinal kyphosis and to compare these results with non-operated patients. Participants comprised 39 patients with postmenopausal osteoporosis ≥50 years old who underwent corrective spinal surgery using multilevel posterior lumbar interbody fusion (PLIF) for symptomatic thoracolumbar or lumbar kyphosis, and 82 age-matched patients with postmenopausal osteoporosis without prevalent vertebral fractures. Spinopelvic parameters were evaluated with standing lateral spine radiography, and QOL was evaluated with the Japanese Osteoporosis QOL Questionnaire (JOQOL), SF-36, and Roland-Morris Disability Questionnaire (RDQ). Lumbar kyphosis angle, sagittal vertical axis, and pelvic tilt were significantly improved postoperatively. QOL evaluated with all three questionnaires also significantly improved after 6 months postoperatively, particularly in domain and subscale scores for pain and general/mental health. However, these radiographic parameters, total JOQOL score, SF-36 physical component summary score, and RDQ score were significantly inferior compared with non-operated controls. The results indicate that spinal global alignment and QOL were significantly improved after corrective spinal surgery using multilevel PLIF for patients with osteoporosis and spinal kyphosis but did not reach the level of non-operated controls.

Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series.

PubMed

Parker, J W; Lane, J R; Karaikovic, E E; Gaines, R W

2000-05-01

A retrospective review of all the surgically managed spinal fractures at the University of Missouri Medical Center during the 41/2-year period from January 1989 to July 1993 was performed. Of the 51 surgically managed patients, 46 were instrumented by short-segment technique (attachment of one level above the fracture to one level below the fracture). The other 5 patients in this consecutive series had multiple trauma. These patients were included in the review because this was a consecutive series. However, they were grouped separately because they were instrumented by long-segment technique because of their multiple organ system injuries. The choice of the anterior or posterior approach for short-segment instrumentation was based on the Load-Sharing Classification published in a 1994 issue of Spine. The purpose of this review was to demonstrate that grading comminution by use of the Load-Sharing Classification for approach selection and the choice of patients with isolated fractures who are cooperative with spinal bracing for 4 months provide the keys to successful short-segment treatment of isolated spinal fractures. The current literature implies that the use of pedicle screws for short-segment instrumentation of spinal fracture is dangerous and inappropriate because of the high screw fracture rate. Charts, operative notes, preoperative and postoperative radiographs, computed tomography scans, and follow-up records of all patients were reviewed carefully from the time of surgery until final follow-up assessment. The Load-Sharing Classification had been used prospectively for all patients before their surgery to determine the approach for short-segment instrumentation. Denis' Pain Scale and Work Scales were obtained during follow-up evaluation for all patients. All patients were observed over 40 months except for 1 patient who died of unrelated causes after 35 months. The mean follow-up period was 66 months (51/2 years). No patient was lost to follow-up evaluation. Prospective application of the Load-Sharing Classification to the patients' injury and restriction of the short-segment approach to cooperative patients with isolated spinal fractures (excluding multisystem trauma patients) allowed 45 of 46 patients instrumented by the short-segment technique to proceed to successful healing in virtual anatomic alignment. The Load-Sharing Classification is a straightforward way to describe the amount of bony comminution in a spinal fracture. When applied to patients with isolated spine fractures who are cooperative with 3 to 4 months of spinal bracing, it can help the surgeon select short-segment pedicle-screw-based fixation using the posterior approach for less comminuted injuries and the anterior approach for those more comminuted. The choice of which fracture-dislocations should be strut grafted anteriorly and which need only posterior short-segment pedicle-screw-based instrumentation also can be made using the Load-Sharing Classification.

Myelography and cytology in the treatment of medulloblastoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Deutsch, M.; Reigel, D.H.

1981-06-01

Eight of 22 children with newly diagnosed medulloblastoma had asymptomatic spinal cord involvement detected by myelography. Two additional patients had demonstrable spinal cord lesions at the time of relapse in the posterior fossa. Cerebral spinal fluid (CSF) cytology results were inaccurate in predicting cord involvement. Seven patients have relapsed 9 to 69 months from completion of radiotherapy. Three had initial cord involvement and also had subsequent cord involvement at the time of intracranial relapse or afterwards. Frontal lobe involvement as the initial site of relapse occurred in 3 patients. Computerized tomography has been valuable in the early detection of intracranialmore » relapse. Three children are alive and well 10, 18 and 19 months, respectively, from time of relapse. All were retreated with radiotherapy in conjunction with misonidazole and subsequent chemotherapy.« less

Management of a case with misdiagnosed spinal dural arterio-venous fistula.

PubMed

Lien, Chia-Yi; Lui, Chun-Chung; Lu, Cheng-Hsien; Chang, Wen-Neng

2014-03-01

Spinal dural arterio-venous fistula (SDAVF) is an uncommon and easily misdiagnosed vascular malformation. We aimed to report the diagnosis and management of a case with SDAVF. A 62-year-old man suffered from acute paraparesis about 15 months before this study. He underwent a neurosurgical procedure for herniated discs of the cervical spine at that time but there was no relief and the symptoms worsened despite the surgery. Neurologically, he had spastic paraparesis and decreased vibration sensation of the lower limbs. Spinal magnetic resonance imaging (MRI) revealed intra-medullary hyper-intensity lesion at T8 to T10 levels and tubular-like signal void structures in the corresponding posterior sub-arachnoid space. Further trans-arterial angiography through right T6 intercostal artery catheterization revealed engorged veins, thereby confirming the diagnosis of SDAVF. The patient was treated via endovascular embolization (18% Onyx, EV3TM MIT, Bonn, Germany) through spinal angiography and the results showed a marked decrease in engorged veins. After a 4-month follow-up, the patient was symptomatic but stable. Follow-up MRI showed a complete disappearance of the hyper-intensity change of the spinal cord. Spinal MR angiography did not reveal any recurrence of SDAVF. This case study demonstrated the easily misdiagnosed state of SDAVF. Serial neuroimage studies including spinal MRI, endovascular embolization through spinal angiography and MR angiography can be useful tools for its diagnostic confirmation, management and follow-up study.

Preoperative retrolisthesis as a predictive risk factor of reoperation due to delayed-onset symptomatic foraminal stenosis after central decompression for lumbar canal stenosis without fusion.

PubMed

Ikegami, Daisuke; Hosono, Noboru; Mukai, Yoshihiro; Tateishi, Kosuke; Fuji, Takeshi

2017-08-01

For patients diagnosed with lumbar central canal stenosis with asymptomatic foraminal stenosis (FS), surgeons occasionally only decompress central stenosis and preserve asymptomatic FS. These surgeries have the potential risk of converting preoperative asymptomatic FS into symptomatic FS postoperatively by accelerating spinal degeneration, which requires reoperation. However, little is known about delayed-onset symptomatic FS postoperatively. This study aimed to evaluate the rate of reoperation for delayed-onset symptomatic FS after lumbar central canal decompression in patients with preoperative asymptomatic FS, and determine the predictive risk factors of those reoperations. This study is a retrospective cohort study. Two hundred eight consecutive patients undergoing posterior central decompression for lumbar canal stenosis between January 2009 and June 2014 were included in this study. The number of patients who had preoperative FS and the reoperation rate for delayed-onset symptomatic FS at the index levels were the outcome measures. Patients were divided into two groups with and without preoperative asymptomatic FS at the decompressed levels. The baseline characteristics and revision rates for delayed-onset symptomatic FS were compared between the two groups. Predictive risk factors for such reoperations were determined using multivariate logistic regression and receiver operating characteristics analyses. Preoperatively, 118 patients (56.7%) had asymptomatic FS. Of those, 18 patients (15.3%) underwent reoperation for delayed-onset symptomatic FS at a mean of 1.9 years after the initial surgery. Posterior slip in neutral position and posterior extension-neutral translation were significant risk factors for reoperation due to FS. The optimal cutoff values of posterior slip in neutral position and posterior extension-neutral translation for predicting the occurrence of such reoperations were both 1 mm; 66.7% of patients who met both of these cutoff values had undergone reoperation. This study demonstrated that 15.3% of patients with preoperative asymptomatic FS underwent reoperation for delayed-onset symptomatic FS at the index levels at a mean of 1.9 years after central decompression, and preoperative retrolisthesis was a predictive risk factor for such a reoperation. These findings are valuable for establishing standards of appropriate treatment strategies in patients with lumbar central canal stenosis with asymptomatic FS. Copyright © 2017 Elsevier Inc. All rights reserved.

Pulmonary function improvement after vertebral column resection for severe spinal deformity.

PubMed

Bumpass, David B; Lenke, Lawrence G; Bridwell, Keith H; Stallbaumer, Jeremy J; Kim, Yongjung J; Wallendorf, Michael J; Min, Woo-Kie; Sides, Brenda A

2014-04-01

Retrospective review of prospectively accrued cohorts. We hypothesized that posterior-only vertebral column resection (PVCR) would result in improved postoperative pulmonary function, avoiding pulmonary insults from combined anterior/posterior approaches. Pulmonary function after PVCR for severe spinal deformity has not been previously studied. Previous studies have demonstrated impaired pulmonary performance after combined anterior/posterior fusions. Serial pulmonary function testing (PFTs) in 49 patients (27 pediatric, 22 adult) who underwent PVCR at a single institution was reviewed. Mean age at surgery was 28.7 years (range, 8-74 yr), and mean follow-up was 32 months (range, 23-64 mo). Thoracic PVCRs (T5-T11) were performed in 31 patients and thoracolumbar PVCRs (T12-L5) in 18 patients. Pediatric patients who underwent PVCR experienced both increased mean forced vital capacity (FVC) (2.10-2.43 L, P = 0.0005) and forced expiratory volume in 1 second (FEV1) (1.71-1.98 L, P = 0.001). There were no significant differences in percent-predicted values for FVC (69%-66%, P = 0.51) or FEV1 (64%-63%, P = 0.77). In adult patients, there were no significant changes in FVC (2.73-2.61 L, P = 0.35) or FEV1 (2.22-2.07 L, P = 0.51) after PVCR; also, changes in adult percent-predicted values for FVC (79%-76%, P = 0.47) and FEV1 (78%-74%, P = 0.40) were not significant. In pediatric patients who underwent PVCR, improved PFTs were correlated with younger age (P = 0.02), diagnosis of angular kyphosis (P ≤ 0.0001), no previous spine surgery (P = 0.04), and preoperative halo-gravity traction (P = 0.02). Comparison of PFT changes between patients who underwent PVCR and a control group who underwent combined anterior/posterior approaches revealed no significant differences. In pediatric patients, PVCR resulted in small but significant improvements in postoperative FVC and FEV1. In adult patients, no significant increases in PFTs were found. Patients who have the greatest potential for lung and thoracic cage growth after spinal correction are most likely to have improved pulmonary function after PVCR.

Serum titanium, niobium and aluminium levels two years following instrumented spinal fusion in children: does implant surface area predict serum metal ion levels?

PubMed

Cundy, Thomas P; Cundy, William J; Antoniou, Georgia; Sutherland, Leanne M; Freeman, Brian J C; Cundy, Peter J

2014-11-01

Measurement of serum metal ion levels is used to determine systemic exposure to implant-derived metal debris that may be generated by processes of wear and corrosion. The aim of this study is to investigate predictors of serum metal ion levels in children undergoing instrumented spinal arthrodesis using a titanium alloy, focusing on implant characteristics and instrumentation construct design variables. This prospective longitudinal cohort study involved 33 children. Serum samples were obtained preoperatively:and at five defined interval periods over the first:two post-operative years. Samples were analysed using high resolution:inductively coupled plasma mass spectrometry to measure titanium, niobium and aluminium concentrations. Instrumentation characteristics were catalogued and construct surface area (SA) measurements calculated using an implant-specific software algorithm tool. Significantly elevated levels of serum titanium and niobium were observed (p< 0.0001), with >95 % of post-operative levels abnormally elevated. Significant predictors of serum titanium and niobium levels included time since surgery, surgical procedure (posterior or anterior fusion), number of levels fused, number of pedicle screws inserted, total rod length, total metal SA, total exposed metal SA and total metal-on-metal SA. All significant instrumentation variables were highly correlated. There is a strong relationship between implant SA and both serum titanium and niobium levels. The direct clinical implications of these findings for patients are uncertain, but remain of concern. Surgeons should be aware of the strong correlation between implant surface area of the chosen construct and the subsequent serum metal ion levels.

A computer-controlled, closed-loop infusion system for infusing muscle relaxants: its use during motor-evoked potential monitoring.

PubMed

Stinson, L W; Murray, M J; Jones, K A; Assef, S J; Burke, M J; Behrens, T L; Lennon, R L

1994-02-01

A microcomputer-controlled closed-loop infusion system (MCCLIS) has been developed that provides stable intraoperative levels of partial neuromuscular blockade. Complete neuromuscular blockade interferes with intraoperative motor-evoked potential (MEP) monitoring used for patients undergoing surgical procedures that place them at risk for spinal cord ischemia. Nine patients were studied during which the MCCLIS maintained stable levels of partial neuromuscular blockade and allowed transcranial magnetic motor-evoked potential (TcM-MEP) monitoring during thoracoabdominal aortic aneurysmectomy. The use of TcM-MEP for monitoring intraoperative spinal cord function was balanced against surgical considerations for muscle relaxation with 80% to 90% neuromuscular blockade fulfilling each requirement. Intraoperative adjustment of partial neuromuscular blockade to facilitate TcM-MEP monitoring was also possible with the MCCLIS. The MCCLIS should allow for further investigation into the sensitivity, specificity, and predictability of TcM-MEP monitoring for any patient at risk for intraoperative spinal cord ischemia including those undergoing thoracoabdominal aortic aneurysmectomy.

Spine deformities in rare congenital syndromes: clinical issues.

PubMed

Campbell, Robert M

2009-08-01

A focused review of the literature with regard to the important system abnormalities of patients with spinal deformities associated with exotic congenital syndromes with additional data from the author's own experience in assessment of patients with rare syndromes treated for thoracic insufficiency syndrome. The objectives of this study are to emphasize important medical considerations that influence the choice of surgical treatment of spinal deformity in patients with exotic congenital syndromes and point out preoperative strategies that reduce treatment morbidity and mortality of these patients. Individual experience is limited in the treatment of spine abnormality in rare exotic syndromes and the medical aspects of these syndromes that may impact spinal treatment are seldom discussed in detail in the orthopedic literature. For a successful outcome in the treatment of spinal deformity in these unique patients, a working knowledge of the unique pitfalls in their medical care is necessary in order to avoid morbidity and mortality during their treatment. The literature was reviewed for 6 exotic congenital syndromes with known or unreported spinal abnormalities and the author's personal 22-years experience of the treatment of thoracic insufficiency syndrome in the relevant congenital syndromes was summarized. Children with Marfan syndrome and spinal deformity may have serious cardiac abnormalities. Spontaneous dissection of the aortic root is a clear danger and patients should be monitored by serial echocardiograms. Prophylactic cardiac surgery may be necessary before spinal surgery is to be performed. Patients with Jeune syndrome have a high rate of proximal cervical stenosis and should undergo screening with cervical spine films at birth. Significant stenosis or instability may require decompression and cervical-occipital fusion. Arthrogryposis may be associated with a severe scoliosis and jaw contracture may make intubation difficult. Larsen syndrome may have early onset scoliosis that is very rigid and requires early intervention. Cervical kyphosis and subluxation may be lethal in these patients and screening radiographs are important. Upper airway abnormalities are an anesthesia concern. Jarcho-Levin syndrome is a thoracic volume depletion deformity due to shortness of the thorax, either a spondylocostal dysostosis variant or spondylothoracic dysplasia. The former has a chaotic congenital scoliosis with varied combination of missing and fused ribs. Although spondylocostal dysostosis has a benign reputation in the literature for respiratory complications, respiratory insufficiency is nevertheless common and 1 death is known from respiratory failure. Spondylothoracic dysplasia seldom has significant scoliosis, but has a mortality rate approaching 50% from respiratory complications due to thoracic insufficiency syndrome. In spite of severe restrictive respiratory disease, adult survivors of spondylothoracic dysplasia appear to do well clinically for unknown reasons. Cerebrocostomandibular syndrome has scoliosis, micrognathia, and thoracic insufficiency syndrome, due to an "implosion" deformity of the thorax from congenital pseudarthrosis of the posterior ribs. For optimal patient care, it is necessary to have a clear understanding of exotic congenital syndromes and how they may impact on both the presentation of spinal deformity and the response to treatment, as well as how they may introduce additional morbidity into standard treatment plans. It is clear that with this understanding that preoperative strategies can be employed to enhance the safety of spinal treatment for these unique children.

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

PubMed

Nunley, Pierce D; Mundis, Gregory M; Fessler, Richard G; Park, Paul; Zavatsky, Joseph M; Uribe, Juan S; Eastlack, Robert K; Chou, Dean; Wang, Michael Y; Anand, Neel; Frank, Kelly A; Stone, Marcus B; Kanter, Adam S; Shaffrey, Christopher I; Mummaneni, Praveen V

2017-12-01

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

Single-operator real-time ultrasound-guided spinal injection using SonixGPS™: a case series.

PubMed

Brinkmann, Silke; Tang, Raymond; Sawka, Andrew; Vaghadia, Himat

2013-09-01

The SonixGPS™ is a novel needle tracking system that has recently been approved in Canada for ultrasound-guided needle interventions. It allows optimization of needle-beam alignment by providing a real-time display of current and predicted needle tip position. Currently, there is limited evidence on the effectiveness of this technique for performance of real-time spinal anesthesia. This case series reports performance of the SonixGPS system for real-time ultrasound-guided spinal anesthesia in elective patients scheduled for joint arthroplasty. In this single-centre case series, 20 American Society of Anesthesiologists' class I-II patients scheduled for lower limb joint arthroplasty were recruited to undergo real-time ultrasound-guided spinal anesthesia with the SonixGPS after written informed consent. The primary outcome for this clinical cases series was the success rate of spinal anesthesia, and the main secondary outcome was time required to perform spinal anesthesia. Successful spinal anesthesia for joint arthroplasty was achieved in 18/20 patients, and 17 of these required only a single skin puncture. In 7/20 (35%) patients, dural puncture was achieved on the first needle pass, and in 11/20 (55%) patients, dural puncture was achieved with two or three needle redirections. Median (range) time taken to perform the block was 8 (5-14) min. The study procedure was aborted in two cases because our clinical protocol dictated using a standard approach if spinal anesthesia was unsuccessful after three ultrasound-guided insertion attempts. These two cases were classified as failures. No complications, including paresthesia, were observed during the procedure. All patients with successful spinal anesthesia found the technique acceptable and were willing to undergo a repeat procedure if deemed necessary. This case series shows that real-time ultrasound-guided spinal anesthesia with the SonixGPS system is possible within an acceptable time frame. It proved effective with a low rate of failure and a low rate of complications. Our clinical experience suggests that a randomized trial is warranted to compare the SonixGPS with a standard block technique.

Surgical treatment of scoliosis in Marfan syndrome: outcomes and complications.

PubMed

Qiao, Jun; Xu, Leilei; Liu, Zhen; Zhu, Feng; Qian, Bangping; Sun, Xu; Zhu, Zezhang; Qiu, Yong; Jiang, Qing

2016-10-01

To investigate surgical outcomes and complications of scoliosis associated with Marfan syndrome. Inclusion criteria were patients who were 10-20 years of age, had a diagnosis of Marfan syndrome by the Ghent nosology, had scoliosis and had undergone spinal fusion, and had at least 2 years of postoperative follow-up. The medical records of all patients were reviewed for age at the time of surgery, surgical procedures performed, instrumentation type, estimated blood loss (EBL) during surgery, operation time and complications related to surgery. Health-related quality-of-life measures (obtained with the SRS-22 Questionnaire before operation and at the last clinical follow-up) were also recorded. Patients were analyzed as two different groups, Group 1 and Group 2, according to the different approaches employed. Patients receiving combined anterior and posterior surgery were assigned to Group 1 and those who received posterior-only surgery to Group 2. Group 1 consisted of 30 patients (14 males, 16 females) with a mean age at surgery of 16.8 years (range: 10-20 years). Complications in Group 1 included two cases of instrumentation loosening with one removed, one case of instrumentation breakage and one case of chylothorax and hemothorax during video assisted thoracoscopic release. 66 patients (28 males, 38 females) with a mean age at surgery of years 16.4 years (range: 10-20 years) were included in Group 2. Complications in Group 2 included six cases of cerebro-spinal fluid leak, one case of deep wound infection secondary to cerebro-spinal fluid leak, one case of leg weakness and one case of pleural rupture cause by misplacement of pedicle screw. There is no difference of age at surgery, preoperative Cobb angles, and SRS-22 total scores (3.0 vs. 3.1) between the two groups (P > 0.05). Group 1 yielded larger correction rate than Group 2 for both thoracic (62.5 % vs. 56.2 %) and lumbar scoliosis (68.3 % vs. 62.7 %). Loss of correction was similar between the two groups for both thoracic (4.1° vs. 3.6°) and lumbar (4.2° vs. 4.6°) curves (P > 0.05). EBL (1972 ml vs. 1530) and operation time (669 min vs. 419 min) were significantly increased in Group 1 than in Group 2 (P < 0.05). No difference was noted for SRS-22 total scores in the last follow-up between the two groups (3.7 vs. 3.8, P > 0.05). In conclusion, as compared to anterior release combined with posterior spinal fusion, posterior-only spinal fusion could yield comparable clinical outcomes for scoliosis associated with Marfan syndrome with lower EBL, and operation time. However, longer follow-up is needed to verify these findings.

Comparison of Revision Rates of Anterior- and Posterior-Approach Ptosis Surgery: A Retrospective Review of 1519 Cases.

PubMed

Chou, Eva; Liu, Jun; Seaworth, Cathleen; Furst, Meredith; Amato, Malena M; Blaydon, Sean M; Durairaj, Vikram D; Nakra, Tanuj; Shore, John W

To compare revision rates for ptosis surgery between posterior-approach and anterior-approach ptosis repair techniques. This is the retrospective, consecutive cohort study. All patients undergoing ptosis surgery at a high-volume oculofacial plastic surgery practice over a 4-year period. A retrospective chart review was conducted of all patients undergoing posterior-approach and anterior-approach ptosis surgery for all etiologies of ptosis between 2011 and 2014. Etiology of ptosis, concurrent oculofacial surgeries, revision, and complications were analyzed. The main outcome measure is the ptosis revision rate. A total of 1519 patients were included in this study. The mean age was 63 ± 15.4 years. A total of 1056 (70%) of patients were female, 1451 (95%) had involutional ptosis, and 1129 (74.3%) had concurrent upper blepharoplasty. Five hundred thirteen (33.8%) underwent posterior-approach ptosis repair, and 1006 (66.2%) underwent anterior-approach ptosis repair. The degree of ptosis was greater in the anterior-approach ptosis repair group. The overall revision rate for all patients was 8.7%. Of the posterior group, 6.8% required ptosis revision; of the anterior group, 9.5% required revision surgery. The main reason for ptosis revision surgery was undercorrection of one or both eyelids. Concurrent brow lifting was associated with a decreased, but not statistically significant, rate of revision surgery. Patients who underwent unilateral ptosis surgery had a 5.1% rate of Hering's phenomenon requiring ptosis repair in the contralateral eyelid. Multivariable logistic regression for predictive factors show that, when adjusted for gender and concurrent blepharoplasty, the revision rate in anterior-approach ptosis surgery is higher than posterior-approach ptosis surgery (odds ratio = 2.08; p = 0.002). The overall revision rate in patients undergoing ptosis repair via posterior-approach or anterior-approach techniques is 8.7%. There is a statistically higher rate of revision with anterior-approach ptosis repair.

The cellular basis of the convergence and extension of the Xenopus neural plate.

PubMed

Keller, R; Shih, J; Sater, A

1992-03-01

There is great interest in the patterning and morphogenesis of the vertebrate nervous system, but the morphogenetic movements involved in early neural development and their underlying cellular mechanisms are poorly understood. This paper describes the cellular basis of the early neural morphogenesis of Xenopus laevis. The results have important implications for neural induction. Mapping the fate map of the midneurula (Eagleson and Harris: J. Neurobiol. 21:427-440, 1990) back to the early gastrula with time-lapse video recording demonstrates that the prospective hindbrain and spinal cord are initially very wide and very short, and thus at the beginning of gastrulation all their precursor cells lie within a few cell diameters of the inducing mesoderm. In the midgastrula, the prospective hindbrain and spinal cord undergo very strong convergence and extension movements in two phases: In the first phase they primarily undergo thinning in the radial direction and lengthening (extension) in the animal-vegetal direction, and the second phase is characterized primarily by mediolateral narrowing (convergence) and anterior-posterior lengthening (extension). These movements also occur in sandwich explants of the gastrula, thus demonstrating the local autonomy of the forces producing them. Tracing cell movements with fluorescein dextran-labeled cells in embryos or explants shows that the initial thinning and extension occurs by radial intercalation of deep cells to form fewer layers of greater area, all of which is expressed as increased length. The subsequent convergence and extension occurs by mediolateral intercalation of deep cells to form a longer, narrower array. These results establish that a similar if not identical sequence of radial and mediolateral cell intercalations underlie convergence and extension of the neural and the mesoderm tissues (Wilson and Keller: Development, 112:289-300, 1991). Moreover, these results establish that radial and mediolateral intercalation are the principal neural cell behaviors induced by the planar signals emanating from the dorsal involuting marginal zone (the Spemann organizer) in the early gastrula (Keller et al: Develop. Dynamics, 193: 218-234, 1992). Radial and mediolateral intercalation are induced among the 5 to 7 rows of cells comprising the prospective hindbrain and spinal cord, thus producing the massive convergence and extension movements that narrow and elongate these regions of the nervous system in the late gastrula. A more general significance of these results is that neural induction is best analyzed and understood in terms of the dynamics of the morphogenetic processes involved.

Higher success rate with transcranial electrical stimulation of motor-evoked potentials using constant-voltage stimulation compared with constant-current stimulation in patients undergoing spinal surgery.

PubMed

Shigematsu, Hideki; Kawaguchi, Masahiko; Hayashi, Hironobu; Takatani, Tsunenori; Iwata, Eiichiro; Tanaka, Masato; Okuda, Akinori; Morimoto, Yasuhiko; Masuda, Keisuke; Tanaka, Yuu; Tanaka, Yasuhito

2017-10-01

During spine surgery, the spinal cord is electrophysiologically monitored via transcranial electrical stimulation of motor-evoked potentials (TES-MEPs) to prevent injury. Transcranial electrical stimulation of motor-evoked potential involves the use of either constant-current or constant-voltage stimulation; however, there are few comparative data available regarding their ability to adequately elicit compound motor action potentials. We hypothesized that the success rates of TES-MEP recordings would be similar between constant-current and constant-voltage stimulations in patients undergoing spine surgery. The objective of this study was to compare the success rates of TES-MEP recordings between constant-current and constant-voltage stimulation. This is a prospective, within-subject study. Data from 100 patients undergoing spinal surgery at the cervical, thoracic, or lumbar level were analyzed. The success rates of the TES-MEP recordings from each muscle were examined. Transcranial electrical stimulation with constant-current and constant-voltage stimulations at the C3 and C4 electrode positions (international "10-20" system) was applied to each patient. Compound muscle action potentials were bilaterally recorded from the abductor pollicis brevis (APB), deltoid (Del), abductor hallucis (AH), tibialis anterior (TA), gastrocnemius (GC), and quadriceps (Quad) muscles. The success rates of the TES-MEP recordings from the right Del, right APB, bilateral Quad, right TA, right GC, and bilateral AH muscles were significantly higher using constant-voltage stimulation than those using constant-current stimulation. The overall success rates with constant-voltage and constant-current stimulations were 86.3% and 68.8%, respectively (risk ratio 1.25 [95% confidence interval: 1.20-1.31]). The success rates of TES-MEP recordings were higher using constant-voltage stimulation compared with constant-current stimulation in patients undergoing spinal surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

Evaluation of Radiation-induced Class V Dental Caries in Patients with Head and Neck Cancers Undergoing Radiotherapy.

PubMed

Mohammadi, Narmin; Seyednejad, Farshad; Oskoee, Parnian Alizadeh; Savadi Oskoee, Siavash; Ebrahimi Chaharom, Mohammad Esmaeil

2008-01-01

Salivary glands are very susceptible to radiation and any disturbances in their function are detrimental to the hard tissues in the oral cavity. The aim of this study was to evaluate posterior class V dental caries in patients with head and neck cancers undergoing radiotherapy. In this study, twenty seven patients undergoing conventional radiotherapy were included. Class V dental caries of posterior teeth in these patients were evaluated in three intervals: before treatment, 3 weeks after the initiation of the treatment, and at the end of the treatment. Differences of mean caries activity between intervals were evaluated using paired sample t-test. There were no class V decays prior to radiotherapy. Mean percentage of class V caries three weeks after radiotherapy and at the end of radiotherapy were 28.42% ± 14.41 and 67.05% ± 19.02, respectively. There were statistically signifi-cant differences in mean values among three stages (P = 0.00025). The results of the present study re-vealed that radiotherapy in patients with head and neck cancers causes class V dental caries on posteri-or teeth.

A carbon fiber reinforced polymer cage for vertebral body replacement: technical note.

PubMed

Ciappetta, P; Boriani, S; Fava, G P

1997-11-01

We analyzed the surgical technique used for the replacement of damaged vertebral bodies of the thoracolumbar spine and the carbon fiber reinforced polymer (CFRP) cages that are used to replace the pathological vertebral bodies. We also evaluated the biomechanical properties of carbon composite materials used in spinal surgery. The surgical technique of CFRP implants may be divided into two distinct steps, i.e., assembling the components that will replace the pathological vertebral bodies and connecting the cage to an osteosynthetic system to immobilize the cage. The CFRP cages, made of Ultrapek polymer and AS-4 pyrolytic carbon fiber (AcroMed, Rotterdam, The Netherlands), are of different sizes and may be placed one on top of the other and fixed together with a titanium rod. These components are hollow to allow fragments of bone to be pressed manually into them and present threaded holes at 15, 30, and 90 degrees on the external surface, permitting the insertion of screws to connect the cage to an anterior or posterior osteosynthetic system. To date, we have used CFRP cages in 13 patients undergoing corporectomies and 10 patients undergoing spondylectomies. None of our patients have reported complications. CFRP implants offer several advantages compared with titanium or surgical grade stainless steel implants, demonstrating high versatility and outstanding biological and mechanical properties. Furthermore, CFRP implants are radiolucent and do not hinder radiographic evaluation of bone fusion, allowing for better follow-up studies.

Pedicle screw fixation in spinal disorders: a European view.

PubMed

Boos, N; Webb, J K

1997-01-01

Continuing controversy over the use of pedicular fixation in the United States is promoted by the lack of governmental approval for the marketing of these devices due to safety and efficacy concerns. These implants have meanwhile become an invaluable part of spinal instrumentation in Europe. With regard to the North American view, there is a lack of comprehensive reviews that consider the historical evolution of pedicle screw systems, the rationales for their application, and the clinical outcome from a European perspective. This literature review suggests that pedicular fixation is a relatively safe procedure and is not associated with a significantly higher complication risk than non-pedicular instrumentation. Pedicle screw fixation provides short, rigid segmental stabilization that allows preservation of motion segments and stabilization of the spine in the absence of intact posterior elements, which is not possible with non-pedicular instrumentation. Fusion rates and clinical outcome in the treatment of thoracolumbar fractures appear to be superior to that achieved using other forms of treatment. For the correction of spinal deformity (i.e., scoliosis, kyphosis, spondylolisthesis, tumor), pedicular fixation provides the theoretical benefit of rigid segmental fixation and of facilitated deformity correction by a posterior approach, but the clinical relevance so far remains unknown. In low-back pain disorders, a literature analysis of 5,600 cases of lumbar fusion with different techniques reveals a trend that pedicle screw fixation enhances the fusion rate but not clinical outcome. The most striking finding in the literature is the large range in the radiological and clinical results. For every single fusion technique poor and excellent results have been described. This review argues that European spine surgeons should begin to back up the evident benefits of pedicle screw systems for specific spinal disorders by controlled prospective clinical trials. This may prevent forthcoming medical licensing authorities from restricting the use of pedicle screw devices and dictating the practice of spinal surgery in Europe in the near future.

Effect of Polyether Ether Ketone on Therapeutic Radiation to the Spine: A Pilot Study.

PubMed

Jackson, J Benjamin; Crimaldi, Anthony J; Peindl, Richard; Norton, H James; Anderson, William E; Patt, Joshua C

2017-01-01

Cadaveric model. To compare the effect of PEEK versus conventional implants on scatter radiation to a simulated tumor bed in the spine SUMMARY OF BACKGROUND DATA.: Given the highly vasculature nature of the spine, it is the most common place for bony metastases. After surgical treatment of a spinal metastasis, adjuvant radiation therapy is typically administered. Radiation dosing is primarily limited by toxicity to the spinal cord. The scatter effect caused by metallic implants decreases the accuracy of dosing and can unintentionally increase the effective dose seen by the spinal cord. This represents a dose-limiting factor for therapeutic radiation postoperatively. A cadaveric thorax specimen was utilized as a metastatic tumor model with two separate three-level spine constructs (one upper thoracic and one lower thoracic). Each construct was examined independently. All four groups compared included identical posterior instrumentation. The anterior constructs consisted of either: an anterior polyether ether ketone (PEEK) cage, an anterior titanium cage, an anterior bone cement cage (polymethyl methacrylate), or a control group with posterior instrumentation alone. Each construct had six thermoluminescent detectors to measure the radiation dose. The mean dose was similar across all constructs and locations. There was more variability in the upper thoracic spine irrespective of the construct type. The PEEK construct had a more uniform dose distribution with a standard deviation of 9.76. The standard deviation of the others constructs was 14.26 for the control group, 19.31 for the titanium cage, and 21.57 for the cement (polymethyl methacrylate) construct. The PEEK inter-body cage resulted in a significantly more uniform distribution of therapeutic radiation in the spine when compared with the other constructs. This may allow for the application of higher effective dosing to the tumor bed for spinal metastases without increasing spinal cord toxicity with either fractionated or hypofractionated radiotherapy. N/A.

High-cervical spinal cord electrical stimulation in brain low perfusion syndromes: experimental basis and preliminary clinical report.

PubMed

Broseta, J; García-March, G; Sánchez-Ledesma, M J; Gonçalves, J; Silva, I; Barcia, J A; Llácer, J L; Barcia-Salorio, J L

1994-01-01

Previous studies of our group showed that C1-C2 spinal cord stimulation increases carotid and brain blood flow in normal conditions in the goat and dog and it has a beneficial vasomotor effect in a model of vasospasm in the rat. For further clinical application it seemed rational to investigate the possible vascular changes mediated by this technique in experimental brain infarction. To this aim, 45 New Zealand rabbits were used. Brain infarction was produced by bilateral carotid ligation in 15, unilateral microcoagulation of the middle cerebral artery in 15 and by microcoagulation of the vertebral artery at the craniocervical junction in the other 15. One week later, following daily clinical scoring and cortical and posterior fossa blood flow readings by laser Doppler, a period of 120 min of right C1-C2 spinal cord electric stimulation was performed. A mean of 27% increase in previous blood flow recordings was obtained at the right hemisphere and a mean of 32% in the posterior fossa. This procedure was used in 10 patients presenting with various cerebral low perfusion syndromes. Though not constant, an increase in alertness, retention, speech, emotional lability and performance in skilled acts was achieved. No MR changes were observed, though SPECT readings showed an increase in blood flow in the penumbral perilesional area.

Spinal anesthesia in infants: recent developments.

PubMed

Tirmizi, Henna

2015-06-01

Spinal anesthesia has long been described as a well-tolerated and effective means of providing anesthesia for infants undergoing lower abdominal surgery. Now, spinal anesthetics are being used for an increasing variety of surgeries previously believed to require a general anesthetic. This, along with increasing concerns over the neurocognitive effects of general anesthetics on developing brains, suggests that further exploration into this technique and its effects is essential. Exposure to spinal anesthesia in infancy has not shown the same suggestions of neurocognitive detriment as those resulting from general anesthesia. Ultrasound guidance has enhanced spinal technique by providing real-time guidance into the intrathecal space and confirming medication administration location, as well as helping avoid adverse outcomes by identifying aberrant anatomy. Spinal anesthesia provides benefits over general anesthesia, including cardiorespiratory stability, shorter postoperative recovery, and faster return of gastrointestinal function. Early findings of spinal anesthesia exposure in infancy have shown it to have no independent effect on neurocognitive delay as well as to provide sound cardiorespiratory stability. With safer means of administering a spinal anesthetic, such as with ultrasound guidance, it is a readily available and desirable tool for those providing anesthesia to infants.

Functional MR imaging of the cervical spinal cord by use of electrical stimulation at LI4 (Hegu).

PubMed

Wang, W D; Kong, K M; Xiao, Y Y; Wang, X J; Liang, B; Qi, W L; Wu, R H

2006-01-01

The purpose is to investigate the cervical spinal cord mapping on electrical stimulation at LI4 (Hegu) by using 'signal enhancement by extravascular water protons' (SEEP)-fMRI, and to establish the response of acupoint-stimulation in spinal cord. Three healthy volunteers were underwent low-frequency electrical stimulation at LI4. Meanwhile, a single-shot fast spin-echo (SSFSE) sequence was used to perform functional MR imaging on a 1.5 T GE Signa MR system. Cord activation was measured both in the sagittal and transverse imaging planes and then analyzed by AFNI (analysis of functional neuroimages) system. In the sagittal view, two subjects had an fMRI response in the cervical spinal cord upon electrical stimulation at LI4. The localizations of the segmental fMRI activation are both at C6 through T1 and C2/3 cervical spinal cord level. In the transverse imaging plane, significant fMRI responses could be measured in the last subjects locating at C6/7 segment, the cross-sectional localization of the activity measured in the spinal cord was most in terms of the ipsilateral posterior direction. It is concluded that the fMRI technique can be used for detecting with activity in the human cervical spinal cord by a single-shot fast spin-echo sequence on a 1.5 T GE clinical system. Investigating the acupoint-stimulation response in the spinal cord using the spinal fMRI will be helpful for the further discussion on the mechanisms of acupuncture to spinal cord diseases.

Hybrid circumferential fixation for degenerative lumbosacral spine disease: posterior lumbar interbody fusion plus universal clamp rod-band instrumentation: a novel technique for lumbosacral fixation.

PubMed

Tegos, Stergios; Charitidis, Charalampos; Korovessis, Panagiotis G

2014-04-01

Retrospective study on circumferential hybrid instrumentation with posterior lumbar interbody fusion (PLIF) and the novel posterior Universal Clamp (UC) instrumentation. This study evaluated the roentgenographic and clinical outcome after PLIF with PEEK cage augmented with UC posterior sublaminar fixation without posterior fusion. Although UC has been successfully used in scoliosis surgery, to our knowledge, this is the first report on its use in degenerative lumbosacral disease. Rigid pedicle screw lumbosacral fixation is associated with several intraoperative screw-related complications. The use of sublaminar bands and rods combined with PEEK PLIF should increase fusion rate and avoid screw-related complications. From a total of 295 consecutive patients who experienced degenerative lumbosacral disease and received posterior decompression, implantation of PLIF with PEEK cages and semirigid posterior fixation with sublaminar UC bands-rods without posterolateral fusion, 150 patients were eligible for this study with a follow-up of more than 2 years. Interbody fusion rate and global plus segmental sagittal spinal lordosis restoration were recorded pre- and postoperatively. Visual analogue scale and Oswestry Disability Index were used to assess functional outcome. Hybrid instrumentation expanded over 1 to 5 levels. Surgical time ranged from 45 to 225 minutes. Only 12.6% of the patients were transfused. There was no nerve root lesion or deep wound infection. Laminar fracture occurred intraoperatively in one case during band insertion. Interbody fusion was achieved in 94% of the operated segments. Lumbar lordosis improved from -36 ± 9° preoperatively to -53 ± 6° postoperatively. Segmental lordosis improved in L4-L5 segment from -5 ± 3° preoperatively to -12 ± 2° postoperatively and in L5-S1 from -9 ± 4° to -14 ± 2° postoperation. Oswestry Disability Index score improved from 44.9 preoperatively to 2.2 postoperatively (P < 0.001). No patient required further spinal surgery until the final evaluation. UC, a novel semirigid sublaminar posterior instrumentation, combined with wedge-shaped PEEK PLIF corrected both global and segmental sagittal lumbar alignment and achieved fusion rate similar to that historically reported with pedicle screw-PLIF techniques, however, avoiding intraoperative complications associated with the use of pedicle screws.

Outbreaks of Neuroinvasive Astrovirus Associated with Encephalomyelitis, Weakness, and Paralysis among Weaned Pigs, Hungary

PubMed Central

Boros, Ákos; Albert, Mihály; Pankovics, Péter; Bíró, Hunor; Pesavento, Patricia A.; Phan, Tung Gia; Delwart, Eric

2017-01-01

A large, highly prolific swine farm in Hungary had a 2-year history of neurologic disease among newly weaned (25- to 35-day-old) pigs, with clinical signs of posterior paraplegia and a high mortality rate. Affected pigs that were necropsied had encephalomyelitis and neural necrosis. Porcine astrovirus type 3 was identified by reverse transcription PCR and in situ hybridization in brain and spinal cord samples in 6 animals from this farm. Among tissues tested by quantitative RT-PCR, the highest viral loads were detected in brain stem and spinal cord. Similar porcine astrovirus type 3 was also detected in archived brain and spinal cord samples from another 2 geographically distant farms. Viral RNA was predominantly restricted to neurons, particularly in the brain stem, cerebellum (Purkinje cells), and cervical spinal cord. Astrovirus was generally undetectable in feces but present in respiratory samples, indicating a possible respiratory infection. Astrovirus could cause common, neuroinvasive epidemic disease. PMID:29148391

Outbreaks of Neuroinvasive Astrovirus Associated with Encephalomyelitis, Weakness, and Paralysis among Weaned Pigs, Hungary.

PubMed

Boros, Ákos; Albert, Mihály; Pankovics, Péter; Bíró, Hunor; Pesavento, Patricia A; Phan, Tung Gia; Delwart, Eric; Reuter, Gábor

2017-12-01

A large, highly prolific swine farm in Hungary had a 2-year history of neurologic disease among newly weaned (25- to 35-day-old) pigs, with clinical signs of posterior paraplegia and a high mortality rate. Affected pigs that were necropsied had encephalomyelitis and neural necrosis. Porcine astrovirus type 3 was identified by reverse transcription PCR and in situ hybridization in brain and spinal cord samples in 6 animals from this farm. Among tissues tested by quantitative RT-PCR, the highest viral loads were detected in brain stem and spinal cord. Similar porcine astrovirus type 3 was also detected in archived brain and spinal cord samples from another 2 geographically distant farms. Viral RNA was predominantly restricted to neurons, particularly in the brain stem, cerebellum (Purkinje cells), and cervical spinal cord. Astrovirus was generally undetectable in feces but present in respiratory samples, indicating a possible respiratory infection. Astrovirus could cause common, neuroinvasive epidemic disease.

Preventing distal pullout of posterior spine instrumentation in thoracic hyperkyphosis: a biomechanical analysis.

PubMed

Sun, Edward; Alkalay, Ron; Vader, David; Snyder, Brian D

2009-06-01

An in vitro biomechanical study. Compare the mechanical behavior of 5 different constructs used to terminate dual-rod posterior spinal instrumentation in resisting forward flexion moment. Failure of the distal fixation construct can be a significant problem for patients undergoing surgical treatment for thoracic hyperkyphosis. We hypothesize that augmenting distal pedicle screws with infralaminar hooks or sublaminar cables significantly increases the strength and stiffness of these constructs. Thirty-seven thoracolumbar (T12 to L2) calf spines were implanted with 5 configurations of distal constructs: (1) infralaminar hooks, (2) sublaminar cables, (3) pedicle screws, (4) pedicle screws+infralaminar hooks, and (5) pedicle screws+sublaminar cables. Progressive bending moment was applied to each construct until failure. The mode of failure was noted and the construct's stiffness and failure load determined from the load-displacement curves. Bone density and vertebral dimensions were equivalent among the groups (F=0.1 to 0.9, P>0.05). One-way analysis of covariance (adjusted for differences in density and vertebral dimension) demonstrated that all of the screw-constructs (screw, screw+hook, and screw+cable) exhibited significantly higher stiffness and ultimate failure loads compared with either sublaminar hook or cable alone (P<0.05). The screw+hook constructs (109+/-11 Nm/mm) were significantly stiffer than either screws alone (88+/-17 Nm/mm) or screw+cable (98+/-13 Nm/mm) constructs, P<0.05. Screw+cable construct exhibited significantly higher failure load (1336+/-328 N) compared with screw constructs (1102+/-256 N, P<0.05), whereas not statistically different from the screw+hook construct (1220+/-75 N). The cable and hook constructs failed by laminar fracture, screw construct failed in uniaxial shear (pullout), whereas the screws+(hooks or wires) failed by fracture of caudal vertebral body. Posterior dual rod constructs fixed distally using pedicle screws were stiffer and stronger in resisting forward flexion compared with cables or hooks alone. Augmenting these screws with either infralaminar hooks or sublaminar cables provided additional resistance to failure.

Biomechanical analyses of whiplash injuries using an experimental model.

PubMed

Yoganandan, Narayan; Pintar, Frank A; Cusick, Joseph F

2002-09-01

Neck pain and headaches are the two most common symptoms of whiplash. The working hypothesis is that pain originates from excessive motions in the upper and lower cervical segments. The research design used an intact human cadaver head-neck complex as an experimental model. The intact head-neck preparation was fixed at the thoracic end with the head unconstrained. Retroreflective targets were placed on the mastoid process, anterior regions of the vertebral bodies, and lateral masses at every spinal level. Whiplash loading was delivered using a mini-sled pendulum device. A six-axis load cell and an accelerometer were attached to the inferior fixation of the specimen. High-speed video cameras were used to obtain the kinematics. During the initial stages of loading, a transient decoupling of the head occurs with respect to the neck exhibiting a lag of the cranium. The upper cervical spine-head undergoes local flexion concomitant with a lag of the head while the lower column is in local extension. This establishes a reverse curvature to the head-neck complex. With continuing application of whiplash loading, the inertia of the head catches up with the neck. Later, the entire head-neck complex is under an extension mode with a single extension curvature. The lower cervical facet joint kinematics demonstrates varying local compression and sliding. While the anterior- and posterior-most regions of the facet joint slide, the posterior-most region of the joint compresses more than the anterior-most region. These varying kinematics at the two ends of the facet joint result in a pinching mechanism. Excessive flexion of the posterior upper cervical regions can be correlated to headaches. The pinching mechanism of the facet joints can be correlated to neck pain. The kinematics of the soft tissue-related structures explain the mechanism of these common whiplash associated disorders.

Cross-sectional area of human trunk paraspinal muscles before and after posterior lumbar surgery using magnetic resonance imaging.

PubMed

Ghiasi, Mohammad S; Arjmand, Navid; Shirazi-Adl, Aboulfazl; Farahmand, Farzam; Hashemi, Hassan; Bagheri, Sahar; Valizadeh, Mahsa

2016-03-01

Iatrogenic injuries to paraspinal muscles during the posterior lumbar surgery (PLS) cause a reduction in their cross-sectional areas (CSAs) and contractile densities over time post-surgery. This study aims to quantify such alterations. Pre- and postoperative CSAs (~6 months interval) of all paraspinal muscles were measured in six patients undergoing PLS using a 3-T magnetic resonance (MR) scanner to quantify the alterations in geometrical and tissue effective contractile (non-fatty) CSAs of these muscles at all lumbar levels. To examine the presence of any confounding effects on recorded changes within ~7-month period, measurements were also carried out on ten healthy volunteers. In the healthy population, an important (~22%) portion of CSA of the erector spinae (ES) was noncontractile at the lower lumbar levels. Negligible variations over time in both the total geometrical (<1.7% in average) and contractile (<1.2%) CSAs of muscles were observed in the healthy group (i.e., no confounding effect). Following PLS, significant reductions were observed in the geometrical CSA of only multifidus (MF) muscle by ~14 and 11% as well as in its contractile CSA by ~26 and 14% at the L5-S1 and L4-L5 levels, respectively. The total CSA of ES at lower lumbar levels shows substantial noncontractile contents in both healthy and patient populations. Biomechanical models of the spine should hence account for the noncontractile contents using only the effective contractile muscle CSAs. Postoperative variations in CSAs of paraspinal muscles may have profound effects on patterns of muscle activities, spinal loading, and stability.

Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation.

PubMed

Balestrieri, P J; Hamza, M S; Ting, P H; Blank, R S; Grubb, C T

2005-10-01

After receiving a continuous spinal anesthetic for labor following an inadvertent dural puncture with a 17-gauge epidural needle, a morbidly obese parturient underwent post-partum tubal ligation 12 h after vaginal delivery. The patient received a total of 2 mL of 0.75% hyperbaric bupivacaine for the surgery. In response to moderate hypertension the patient received intravenous labetalol hydrochloride 20 mg. She subsequently was inadvertently administered approximately 15 mg of labetalol through the spinal catheter. The spinal catheter was removed immediately after the procedure. She suffered no apparent adverse neurologic effects.

The effects of massage therapy after decompression and fusion surgery of the lumbar spine: a case study.

PubMed

Keller, Glenda

2012-01-01

Spinal fusion and decompression surgery of the lumbar spine are common procedures for problems such as disc herniations. Various studies for postoperative interventions have been conducted; however, no massage therapy studies have been completed. The objective of this study is to determine if massage therapy can beneficially treat pain and dysfunction associated with lumbar spinal decompression and fusion surgery. Client is a 47-year-old female who underwent spinal decompression and fusion surgery of L4/L5 due to chronic disc herniation symptoms. The research design was a case study in a private clinic involving the applications of seven, 30-minute treatments conducted over eight weeks. Common Swedish massage and myofascial techniques were applied to the back, shoulders, posterior hips, and posterior legs. Outcomes were assessed using the following measures: VAS pain scale, Hamstring Length Test, Oswestry Disability Index, and the Roland-Morris Disability Questionnaire. Hamstring length improved (in degrees of extension) from pretreatment measurements in the right leg of 40° and left leg 65° to post-treatment measurement at the final visit, when the results were right 50° and left 70°. The Oswestry Disability Index improved 14%, from 50% to 36% disability. Roland-Morris Disability decreased 1 point, from 3/24 to 2/24. The VAS pain score decreased by 2 points after most treatments, and for three of the seven treatments, client had a post-treatment score of 0/10. Massage for pain had short-term effects. Massage therapy seemed to lengthen the hamstrings bilaterally. Massage therapy does appear to have positive effects in the reduction of disability. This study is beneficial for understanding the relationship between massage therapy and clients who have undergone spinal decompression and fusion. Further research is warranted.

Radiographic predictors for the development of myelopathy in patients with ossification of the posterior longitudinal ligament: a multicenter cohort study.

PubMed

Matsunaga, Shunji; Nakamura, Kozo; Seichi, Atsushi; Yokoyama, Toru; Toh, Satoshi; Ichimura, Shoichi; Satomi, Kazuhiko; Endo, Kenji; Yamamoto, Kengo; Kato, Yoshiharu; Ito, Tatsuo; Tokuhashi, Yasuaki; Uchida, Kenzo; Baba, Hisatoshi; Kawahara, Norio; Tomita, Katsuro; Matsuyama, Yukihiro; Ishiguro, Naoki; Iwasaki, Motoki; Yoshikawa, Hideki; Yonenobu, Kazuo; Kawakami, Mamoru; Yoshida, Munehito; Inoue, Shinsuke; Tani, Toshikazu; Kaneko, Kazuo; Taguchi, Toshihiko; Imakiire, Takanori; Komiya, Setsuro

2008-11-15

A multicenter cohort study was performed retrospectively. To identify radiographic predictors for the development of myelopathy in patients with ossification of the posterior longitudinal ligaments (OPLL). The pathomechanism of myelopathy in the OPLL remains unknown. Some patients with large OPLL have not exhibited myelopathy for a long periods of time. Predicting the course of future neurologic deterioration in asyptomatic patients with OPLL is difficult at their initial visit. A total of 156 OPLL patients from 16 spine institutes with an average of 10.3 years of follow-up were reviewed. Subjects underwent a plain roentgenogram, computed tomography (CT), and magnetic resonance imaging of the cervical spine during the follow-up. The trauma history of the cervical spine, maximum percentage of spinal canal stenosis in a plain roentgenogram and CT, range of motion of the cervical spine, and axial ossified pattern in magnetic resonance imaging or CT were reviewed in relation to the existence of myelopathy. All 39 patients with greater than 60% spinal canal stenosis on the plain roentgenogram exhibited myelopathy. Of 117 patients with less than 60% spinal canal stenosis, 57 (49%) patients exhibited myelopathy. The range of motion of the cervical spine was significantly larger in patients with myelopathy than in those of without it. The axial ossified pattern could be classified into 2 types: a central type and a lateral deviated type. The incidence of myelopathy in patients with less than 60% spinal canal stenosis was significantly higher in the lateral deviated-type group than in the central-type group. Fifteen patients of 156 subjects developed trauma-induced myelopathy. Of the 15 patients, 13 had mixed-type OPLL and 2 had segmental-type OPLL. Static and dynamic factors were related to the development of myelopathy in OPLL.

Less invasive reduction and fusion of fresh A2 and A 3 traumatic L 1-L 4 fractures with a novel vertebral body augmentation implant and short pedicle screw fixation and fusion.

PubMed

Korovessis, Panagiotis; Vardakastanis, Konstantinos; Repantis, Thomas; Vitsas, Vasilios

2014-04-01

The aim of this clinical study was to report on the efficacy in reduction and safety in PMMA leakage of a novel vertebral augmentation technique with PEEK and PMMA, together with pedicle screws in the treatment of fresh vertebral fractures in young adults. Twenty consecutive young adults aged 45 ± 11 years with fresh burst A3/AO or severely compressed A2/AO fractures underwent via a less invasive posterior approach one-staged reduction with a novel augmentation implant and PMMA plus 3-vertebrae pedicle screw fixation and fusion. Radiologic parameters as segmental kyphosis (SKA), anterior (AVBHr) and posterior vertebral body height ratio (PVBHr), spinal canal encroachment (SCE), cement leakage and functional parameters as VAS, SF-36 were measured pre- and post-operatively. Hybrid construct restored AVBHr (P < 0.000), PVBHr (P = 0.02), SKA (P = 0.015), SCE (P = 0.002) without loss of correction at an average follow-up of 17 months. PMMA leakage occurred in 3 patients (3 vertebrae) either anteriorly to the fractured vertebral body or to the adjacent disc, but in no case to the spinal canal. Two pedicle screws were malpositioned (one medially, one laterally to the pedicle at the fracture level) without neurologic sequelae. Solid posterolateral spinal fusion occurred 8-10 months post-operatively. Pre-operative VAS and SF-36 scores improved post-operatively significantly. This study showed that this novel vertebral augmentation technique using PEEK implant and PMMA reduces and stabilizes via less invasive technique A2 and A3 vertebral fractures without loss of correction and leakage to the spinal canal.

Spinal fusion for scoliosis in Rett syndrome with an emphasis on early postoperative complications.

PubMed

Gabos, Peter G; Inan, Muharrem; Thacker, Mihir; Borkhu, Buttugs

2012-01-15

Retrospective case-control study. To examine the postoperative complications of posterior spinal fusion in a population of patients with Rett syndrome (RS). Scoliosis is a common feature of RS, a progressive neurologic disorder affecting almost exclusively females. Despite this, there is little published information regarding the surgical treatment of scoliosis in this disorder. Sixteen consecutive female patients with RS treated by posterior spinal fusion and unit rod instrumentation for progressive scoliosis between 1995 and 2003 were evaluated. Only patients with a minimum of 2-year follow-up were included. Preoperative medical conditions and postoperative complications were recorded. As a control group, we randomly selected 32 spastic quadriplegic patients who underwent the identical procedure during the same time period, selected from our database and matched according to age, level of neurologic impairment, and medical complexity. There was a high rate of early medical complications in the RS patients, with 28 major and 37 minor complications. Only 1 patient did not have a major medical complication, and every patient had at least 1 minor gastrointestinal and/or respiratory complication. Major respiratory complications occurred in 10 patients (63%) and comprised 61% of all major complications. Major gastrointestinal complications occurred in 6 patients (37%) and comprised 21% of all major complications. Other major complications included disseminated intravascular coagulopathy (1 patient), subacute bacterial endocarditis (1 patient), sacral decubiti requiring surgical debridement (2 patients), and extensive bilateral heterotopic ossification of the hips (1 patient). There were no cases of instrumentation failure, pseudarthrosis, deep infection, or need for rod revision. Postoperative complication scores were similar to those in patients with spastic quadriplegic pattern cerebral palsy. Spinal fusion for scoliosis in RS can give a satisfactory technical result, but a high rate of early postoperative medical problems should be anticipated.

Resection of a cervical dumbbell schwannoma with stabilization through a single stage extended posterior approach.

PubMed

McCormick, Paul C

2014-09-01

Dumbbell tumors of the cervical spine can present considerable management challenges related to adequate exposure of both intraspinal and paraspinal tumor components, potential injury to the vertebral artery, and spinal stability. This video demonstrates the microsurgical removal of a large cervical dumbbell schwannoma with instrumented fusion via a single stage extended posterior approach. The video shows patient positioning, tumor exposure, and the sequence and techniques of tumor resection, vertebral artery identification and protection, and dural repair. The video can be found here: http://youtu.be/3lIVfKEcxss.

[Treatment of thoracolumbar tumors with total en bloc spondylectomy and the results of spinal stability reconstruction].

PubMed

Yang, Qiang; Li, Jian-min; Yang, Zhi-ping; Li, Xin; Li, Zhen-feng; Yan, Jun

2013-03-01

To investigate the therapeutic effect of total en bloc spondylectomy (TES) for thoracolumbar tumors and the results of spinal stability reconstruction. From January 2007 to June 2011 there were 18 patients with thoracolumbar tumors distributed in the thoracic vertebrae (n = 10) and lumbar vertebrae (n = 8). There were 7 haemangiomas, 5 giant cell tumors of bone, 1 malignant schwannoma, 1 solitary plasmocytoma, 1 neuroblastoma, 1 osteoblastoma, 1 metastatic malignant fibrous histiocytoma, and 1 metastasis of breast cancer. All the 18 patients were treated with improved TES under electrophysiological monitoring of spinal cord. Four patients were treated through one-stage combined anteroposterior approach and 14 patients through one-stage posterior approach. The anterior reconstructions included titanium mesh cages filled with bone or bone cement in 15 cases, titanium mesh cage with strengthened rings in 2 cases and artificial vertebral body replacement in 1 case. The posterior reconstruction included multiple segmental fixation with pedicle screw-rod system in 15 cases and short segmental fixation in 3 cases. Massive bone auto-graft was employed in 13 cases and fragmental bone graft in 5 cases. The total en bloc spondylectomy was performed successfully in 15 patients and unsuccessful in 3 whose spinal tumors were resected by piecemeal technique. In 15 patients with successfully performed TES, the duration of surgery was from 340 to 610 min (average, 450.7 min), the blood loss was from 3000 to 10 200 ml (average, 4850 ml), and the intraoperative blood transfusion was from 2800 to 9600 ml (average, 4200 ml). The operation-related complications comprised hemopneumothorax, intercostal nerve pain, stress ulcer and bleeding, and so on. One year after operation, the patients with neurological dysfunction recovered from grade A to grade D in one patient, and to grade E in the other 14 cases. The average visual analog scale (VAS) scores was 0.5. One patient with plasmacytoma and another one with L5 metastatic tumor suffered progression of the disease and were living with the diseases. The patient with metastatic malignant fibrous histiocytoma died of local recurrence and lung metastasis 16 months postoperatively. One patient with L4 neuroblastoma died of other reason and all the rest were free from relapse. The Cobb angle of upper and lower vertebral body adjacent to the involved vertebrae in sagittal plane was from -26.7° to 12.0° (average, -2.57°) just postoperatively and from -17.5° to 57.2° (average, 11.5°) at the last follow-up or before reoperation. There were 2 patients with screw-rod breakdown and 2 patients with internal fixation loosening. The measurement of titanium mesh cage subsided into adjacent vertebral bodies was average 7.5 mm. The revision surgery was performed in 3 patients, through combined anteroposterior approach in 2 and only posterior approach in 1 patient. TES significantly increases the therapeutic effect of spinal tumors, although accompanied with high difficulty and massive bleeding. In spinal stability reconstruction after total spondylectomy, it should be emphasized that posterior long segment fixation with pedicle screw-rod system, massive bone bridging graft and the application of thoracolumbosacral orthosis can achieve short-term firm fixation and long-term fusion-stabilization.

Surgical treatment and intraoperative spinal cord monitoring in scoliosis associated with chronic inflammatory demyelinating polyneuropathy: A case report

PubMed Central

Miyakoshi, Naohisa; Hongo, Michio; Kasukawa, Yuji; Ishikawa, Yoshinori; Misawa, Akiko; Shimada, Yoichi

2013-01-01

There has been only one reported case of neuromuscular scoliosis following chronic inflammatory demyelinating polyneuropathy (CIDP). However, no cases of scoliosis that were treated with surgery secondary to CIDP have been previously described. A 16-year-old boy with CIDP was consultant due to the progression of scoliosis with the coronal curve of 86° from T8 to T12. Posterior correction and fusion with segmental pedicle screws were performed under intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials. Although the latency period was prolonged and amplitude was low, the potential remained stable. Coronal curve was corrected from 86° to 34° without neurological complications. We here describe scoliosis associated with CIDP, which was successfully treated with surgery under intraoperative spinal cord monitoring. PMID:23311940

Safety of Diagnostic Cerebral and Spinal Digital Subtraction Angiography in a Developing Country: A Single-Center Experience.

PubMed

Bashir, Qasim; Ishfaq, Asim; Baig, Ammad Anwar

2018-02-01

Digital subtraction angiography (DSA) remains the gold standard imaging modality for cerebrovascular disorders. In contrast to developed countries, the safety of the procedure is not extensively reported from the developing countries. Herein, we present a retrospective analysis of the basic technique, indications, and outcomes in 286 patients undergoing diagnostic cerebral and spinal angiography in a developing country, Pakistan. A retrospective review of patient demographics, procedural technique and complication rates of 286 consecutive patients undergoing the diagnostic cerebral/spinal angiography procedure at one institution from May 2013 to December 2015 was performed. Neurological, systemic, or local complications occurring within and after 24 h of the procedure were recorded. Mean age reported for all patients was 49.7 years. Of all the 286 cases, 175 were male (61.2%) and the rest female (111, 38.8%). Cerebral DSA was performed in 279 cases (97.6%), with 7 cases of spinal DSA (2.4%). Subarachnoid hemorrhage was the most common indication for DSA accounting for 88 cases (30.8%), closely followed by stroke (26.6%) and arteriosclerotic vascular disease (23.1%). No intra- or post-procedural neurological complications of any severity were seen in any of the 286 cases. One case of asymptomatic aortic dissection was reported (0.3%) in the entire cohort of patient population. Diagnostic cerebral/spinal digital subtraction angiography was found to be safe in Pakistan, with complication rates at par with and comparable to those reported in the developed world.

Non-invasive mechanical ventilation with spinal anesthesia for cesarean delivery.

PubMed

Erdogan, G; Okyay, D Z; Yurtlu, S; Hanci, V; Ayoglu, H; Koksal, B; Turan, I O

2010-10-01

We present the successful use of perioperative non-invasive mechanical ventilation in a morbidly obese pregnant woman with bronchial asthma, severe preeclampsia and pulmonary edema undergoing an emergency cesarean delivery with spinal anesthesia. The combination of non-invasive mechanical ventilation with neuraxial anesthesia may be of value in selected parturients with acute or chronic respiratory insufficiency requiring surgery. Copyright © 2010 Elsevier Ltd. All rights reserved.

Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring for surgical hip repair in two patients with severe aortic stenosis.

PubMed

López, María Mercedes; Guasch, Emilia; Schiraldi, Renato; Maggi, Genaro; Alonso, Eduardo; Gilsanz, Fernando

2016-01-01

Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0 cm(2) or a mean aortic valve gradient >30 mmHg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Physiopathology and Pathology of Spinal Injuries in Aerospace Medicine (Second Edition)

DTIC Science & Technology

1982-01-01

the foetus in utero: - his back is rounded - his head is hyperflexed, to bring the chin against the sternum - his arms are bent and held against his...and spondylolysis never exist in the embryo, the foetus or the newborn; - the posterior arch has only one centre of ossification; - the process of

Intraoperative direct puncture and embolization (IOPE) using a glue material for spinal cord arteriovenous fistula: a case report.

PubMed

Shin, Hong Kyung; Suh, Dae Chul; Jeon, Sang Ryong

2015-05-01

Spinal arteriovenous fistula (AVF) is treated by embolization or surgery. However, transarterial embolization or surgery is difficult in rare cases when the fistula site is very complicated to access especially as in fistular nidus supplied by posterior and anterior spinal artery. We present the case which was treated with intraoperative direct puncture and embolization (IOPE) using glue material, since the usual transarterial or transvenous neurointerventional approach was difficult to embolize the AVF. A 36-year-old woman presented with progressive leg weakness and pain after a 20-year history of lower back pain. She had pelvic and spinal AVF combined with arteriovenous malformation (AVM). Despite prior treatment of the pelvic lesion with radiotherapy and coil embolization, the spinal lesion persisted and caused repeated subarachnoid hemorrhages. A spinal angiogram revealed a tortuous and long feeder of the AVF which had growing venous sac, as well as AVM. Two embolization trials failed because of the long tortuosity and associated anterior spinal artery. Four months later, drastic leg weakness and pain occurred, and IOPE was performed using a glue material. The subsequent recovery of the patient was rapid. One month later, the use of a strong opioid could be discontinued, and the patient could walk with aid. A follow-up spinal angiogram revealed that the venous sac of the AVF had disappeared. In spinal AVF which is not feasible to access by usual intervention approach and to dissect surgically, IOPE with glue material can be considered for the treatment.

Descending brain neurons in larval lamprey: Spinal projection patterns and initiation of locomotion

PubMed Central

Shaw, Albert C.; Jackson, Adam W.; Holmes, Tamra; Thurman, Suzie; Davis, G.R.; McClellan, Andrew D.

2010-01-01

In larval lamprey, partial lesions were made in the rostral spinal cord to determine which spinal tracts are important for descending activation of locomotion and to identify descending brain neurons that project in these tracts. In whole animals and in vitro brain/spinal cord preparations, brain-initiated spinal locomotor activity was present when the lateral or intermediate spinal tracts were spared but usually was abolished when the medial tracts were spared. We previously showed that descending brain neurons are located in eleven cell groups, including reticulospinal (RS) neurons in the mesenecephalic reticular nucleus (MRN) as well as the anterior (ARRN), middle (MRRN), and posterior (PRRN) rhombencephalic reticular nuclei. Other descending brain neurons are located in the diencephalic (Di) as well as the anterolateral (ALV), dorsolateral (DLV), and posterolateral (PLV) vagal groups. In the present study, the Mauthner and auxillary Mauthner cells, most neurons in the Di, ALV, DLV, and PLV cell groups, and some neurons in the ARRN and PRRN had crossed descending axons. The majority of neurons projecting in medial spinal tracts included large identified Müller cells and neurons in the Di, MRN, ALV, and DLV. Axons of individual descending brain neurons usually did not switch spinal tracts, have branches in multiple tracts, or cross the midline within the rostral cord. Most neurons that projected in the lateral/intermediate spinal tracts were in the ARRN, MRRN, and PRRN. Thus, output neurons of the locomotor command system are distributed in several reticular nuclei, whose neurons project in relatively wide areas of the cord. PMID:20510243

Comparison of Two Different Doses of Intrathecal Levobupivacaine for Transurethral Endoscopic Surgery

PubMed Central

Dizman, Secil; Turker, Gurkan; Gurbet, Alp; Mogol, Elif Basagan; Turkcan, Suat; Karakuzu, Ziyaatin

2011-01-01

Objective: To evaluate the effects of two different spinal isobaric levobupivacaine doses on spinal anesthesia characteristics and to find the minimum effective dose for surgery in patients undergoing transurethral resection (TUR) surgery. Materials and Methods: Fifty male patients undergoing TUR surgery were included in the study and were randomized into two equal groups: Group LB10 (n=25): 10 mg 0.5% isobaric levobupivacaine (2 ml) and Group LB15 (n=25): 15 mg 0.75% isobaric levobupivacaine (2 ml). Spinal anesthesia was administered via a 25G Quincke spinal needle through the L3–4 intervertebral space. Sensorial block levels were evaluated using the ‘pin-prick test’, and motor block levels were evaluated using the ‘Bromage scale’. The sensorial and motor block characteristics of patients during intraoperative and postoperative periods and recovery time from spinal anesthesia were evaluated. Results: In three cases in the Group LB10, sensorial block did not reach the T10 level. Complete motor block (Bromage=3) did not occur in eight cases in the Group LB10 and in five cases in the Group LB15. The highest sensorial dermatomal level detected was higher in Group LB15. In Group LB15, sensorial block initial time and the time of complete motor block occurrence were significantly shorter than Group LB10. Hypotension was observed in one case in Group LB15. No significant difference between groups was detected in two segments of regression times: the time to S2 regression and complete sensorial block regression time. Complete motor block regression time was significantly longer in Group LB15 than in Group LB10 (p<0.01). Conclusion: Our findings showed that the minimum effective spinal isobaric levobupivacaine dose was 10 mg for TUR surgery. PMID:25610173

Thoracic spinal anesthesia is safe for patients undergoing abdominal cancer surgery

PubMed Central

Ellakany, Mohamed Hamdy

2014-01-01

Aim: A double-blinded randomized controlled study to compare discharge time and patient satisfaction between two groups of patients submitted to open surgeries for abdominal malignancies using segmental thoracic spinal or general anesthesia. Background: Open surgeries for abdominal malignancy are usually done under general anesthesia, but many patients with major medical problems sometimes can’t tolerate such anesthesia. Regional anesthesia namely segmental thoracic spinal anesthesia may be beneficial in such patients. Materials and Methods: A total of 60 patients classified according to American Society of Anesthesiology (ASA) as class II or III undergoing surgeries for abdominal malignancy, like colonic or gastric carcinoma, divided into two groups, 30 patients each. Group G, received general anesthesia, Group S received a segmental (T9-T10 injection) thoracic spinal anesthesia with intrathecal injection of 2 ml of hyperbaric bupivacaine 0.5% (10 mg) and 20 ug fentanyl citrate. Intraoperative monitoring, postoperative pain, complications, recovery time, and patient satisfaction at follow-up were compared between the two groups. Results: Spinal anesthesia was performed easily in all 30 patients, although two patients complained of paraesthesiae, which responded to slight needle withdrawal. No patient required conversion to general anesthesia, six patients required midazolam for anxiety and six patients required phenylephrine and atropine for hypotension and bradycardia, recovery was uneventful and without sequelae. The two groups were comparable with respect to gender, age, weight, height, body mass index, ASA classification, preoperative oxygen saturation and preoperative respiratory rate and operative time. Conclusion: This preliminary study has shown that segmental thoracic spinal anesthesia can be used successfully and effectively for open surgeries for abdominal malignancies by experienced anesthetists. It showed shorter postanesthesia care unit stay, better postoperative pain relief and patient satisfaction than general anesthesia. PMID:25886230

Thoracic spinal anesthesia is safe for patients undergoing abdominal cancer surgery.

PubMed

Ellakany, Mohamed Hamdy

2014-01-01

A double-blinded randomized controlled study to compare discharge time and patient satisfaction between two groups of patients submitted to open surgeries for abdominal malignancies using segmental thoracic spinal or general anesthesia. Open surgeries for abdominal malignancy are usually done under general anesthesia, but many patients with major medical problems sometimes can't tolerate such anesthesia. Regional anesthesia namely segmental thoracic spinal anesthesia may be beneficial in such patients. A total of 60 patients classified according to American Society of Anesthesiology (ASA) as class II or III undergoing surgeries for abdominal malignancy, like colonic or gastric carcinoma, divided into two groups, 30 patients each. Group G, received general anesthesia, Group S received a segmental (T9-T10 injection) thoracic spinal anesthesia with intrathecal injection of 2 ml of hyperbaric bupivacaine 0.5% (10 mg) and 20 ug fentanyl citrate. Intraoperative monitoring, postoperative pain, complications, recovery time, and patient satisfaction at follow-up were compared between the two groups. Spinal anesthesia was performed easily in all 30 patients, although two patients complained of paraesthesiae, which responded to slight needle withdrawal. No patient required conversion to general anesthesia, six patients required midazolam for anxiety and six patients required phenylephrine and atropine for hypotension and bradycardia, recovery was uneventful and without sequelae. The two groups were comparable with respect to gender, age, weight, height, body mass index, ASA classification, preoperative oxygen saturation and preoperative respiratory rate and operative time. This preliminary study has shown that segmental thoracic spinal anesthesia can be used successfully and effectively for open surgeries for abdominal malignancies by experienced anesthetists. It showed shorter postanesthesia care unit stay, better postoperative pain relief and patient satisfaction than general anesthesia.

Posterior spinal osteosynthesis for cervical fracture/dislocation using a flexible multistrand cable system: technical note.

PubMed

Huhn, S L; Wolf, A L; Ecklund, J

1991-12-01

Cervical instability secondary to fracture/dislocation or traumatic subluxation involving the posterior elements may be treated by a variety of fusion techniques. The rigidity of the stainless steel wires used in posterior cervical fusions often leads to difficulty with insertion, adequate tension, and conformation of the graft construct. This report describes a technique of posterior cervical fusion employing a wire system using flexible stainless steel cables. The wire consists of a flexible, 49-strand, stainless steel cable connected on one end to a short, malleable, blunt leader with the opposite end connected to a small islet. The cable may be used in occipitocervical, atlantoaxial, facet-to-spinous process, and interspinous fusion techniques. The cable loop is secured by using a tension/crimper device that sets the desired tension in the cable. In addition to superior biomechanical strength, the flexibility of the cable allows greater ease of insertion and tension adjustment. In terms of direct operative instrumentation in posterior cervical arthrodesis, involving both the upper and lower cervical spine, the cable system appears to be a safe and efficient alternative to monofilament wires.

[Finite element analysis of stress changes of posterior spinal pedicle screw infixation].

PubMed

Yan, Jia-Zhi; Wu, Zhi-Hong; Xu, Ri-Xin; Wang, Xue-Song; Xing, Ze-Jun; Zhao, Yu; Zhang, Jian-Guo; Shen, Jian-Xiong; Wang, Yi-Peng; Qiu, Gui-Xing

2009-01-06

To evaluate the mechanical response of L3-L4 segment after posterior interfixation with a transpedicle screw system. Spiral CT machine was used to conduct continuous parallel scan on the L3-L4 section of a 40-year-old healthy male Chinese. The image data thus obtained were introduced into MIMICS software to reconstruct the 2-D data into volume data and obtain 3-D models of every element.. Pro/3-D model construction software system was used to simulate the 3-D entity of L3-L4 fixed by screw robs through spinal pedicle via posterior approach that was introduced into the finite element software ABAQUS to construct a 3-D finite element model. The stress changes on the vertebrae and screw under the axial pressure of 0.5 mPa was analyzed. Under the evenly distributed pressure the displacement of the L4 model was 0.00125815 mm, with an error of only 0.8167% from the datum displacement. The convergence of the model was good. The stress of the fixed vertebral body, intervertebral disc, and internal fixators changed significantly. The stress concentration zone of the intervertebral disc turned from the posterolateral side to anterolateral side. The stress produced by the fixed vertebral bodies decreased significantly. Obvious stress concentration existed in the upper and lower sides of the base of screw and the fixed screw at the upper vertebral body bore greater stress than the lower vertebral body. Integration of computer aided device and finite element analysis can successfully stimulate the internal fixation of L3-IA visa posterior approach and observe the mechanic changes in the vertebral column more directly.

Degenerative Cervical Myelopathy: A Spectrum of Related Disorders Affecting the Aging Spine.

PubMed

Tetreault, Lindsay; Goldstein, Christina L; Arnold, Paul; Harrop, James; Hilibrand, Alan; Nouri, Aria; Fehlings, Michael G

2015-10-01

Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, including tumors, infections, and degenerative changes. In this article, we review the range of degenerative spinal disorders resulting in progressive cervical spinal cord compression and propose the adoption of a new term, degenerative cervical myelopathy (DCM). DCM comprises both osteoarthritic changes to the spine, including spondylosis, disk herniation, and facet arthropathy (collectively referred to as cervical spondylotic myelopathy), and ligamentous aberrations such as ossification of the posterior longitudinal ligament and hypertrophy of the ligamentum flavum. This review summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies.

Hypobaric Unilateral Spinal Anaesthesia versus General Anaesthesia in Elderly Patients Undergoing Hip Fracture Surgical Repair: A Prospective Randomised Open Trial.

PubMed

Meuret, Pascal; Bouvet, Lionel; Villet, Benoit; Hafez, Mohamed; Allaouchiche, Bernard; Boselli, Emmanuel

2018-04-01

Intraoperative hypotension during hip fracture surgery is frequent in the elderly. No study has compared the haemodynamic effect of hypobaric unilateral spinal anaesthesia (HUSA) and standardised general anaesthesia (GA) in elderly patients undergoing hip fracture surgical repair. We performed a prospective, randomised open study, including 40 patients aged over 75 years, comparing the haemodynamic effects of HUSA (5 mg isobaric bupivacaine with 5 μg sufentanil and 1 mL sterile water) and GA (induction with etomidate/remifentanil and maintenance with desflurane/remifentanil). An incidence of severe hypotension, defined by a decrease in systolic blood pressure of >40% from baseline, was the primary endpoint. The incidence of severe hypotension was lower in the HUSA group compared with that in the GA group (32% vs. 71%, respectively, p=0.03). The median [IQR] ephedrine consumption was lower (p=0.001) in the HUSA group (6 mg, 0-17 mg) compared with that in the GA group (36 mg, 21-57 mg). Intraoperative muscle relaxation and patients' and surgeons' satisfaction were similar between groups. No difference was observed in 5-day complications or 30-day mortality. This study shows that HUSA provides better haemodynamic stability than GA, with lower consumption of ephedrine and similar operating conditions. This new approach of spinal anaesthesia seems to be safe and effective in elderly patients undergoing hip fracture surgery.

The relationship between the expression of TN and the efficiency of posterior spinal V osteotomy in patients with traumatic kyphosis

PubMed Central

Jiang, Guohua; Zhang, Yinshun; Sun, Xianjie

2018-01-01

Abstract Background: This study was conducted with the aim to investigate the relationship between Tetranectin (TN) and efficiency of posterior spinal V osteotomy in patients with traumatic kyphosis. Methods: Ninety-two patients with traumatic kyphosis admitted in our hospital from February 2014 to June 2016 were included whose serum TN levels were examined by ELISA. Using the mean level of TN as cut-off value, patients were classified into TN high level group (group I) and TN low level group (group II). The observation indexes, including operation time, intra-operational loss of blood, Cobb angle, postoperative complications and recurrence rate of kyphosis within post-operational 6 months were recorded for comparison. Results: TN level was significantly higher in group I [(6.19 ± 0.33) μmol/L] than that in group II [(5.29 ± 0.34) μmol/L] (P < .05). There was no significant difference in average age, sex, lesion site and average time from injury to operation between the two groups (all P > 0.05). Compared to group II, operation time in group I was significantly shortened (5.02 ± 1.15 VS 4.58 ± 0.53, P = .023), the intra-operational loss of blood decreased (2418.56 ± 362.06 VS 2235.84 ± 325.63, P = .013), post-operational Cobb angle decreased (11.10 ± 1.31 VS 6.93 ± 1.04, P = .000), and the incidence of postoperative complications (nail-breaking, rod-breaking and looseness) and recurrence rate decreased (18.8% VS 4.5%, P = .036; 10.4% VS 0.0%, P = .028). Conclusion: Serum TN level is proved to be related to the efficiency of posterior spinal V osteotomy in patients with traumatic kyphosis, and may serve as a possible indicator for clinical treatment. PMID:29384840

The relationship between the expression of TN and the efficiency of posterior spinal V osteotomy in patients with traumatic kyphosis.

PubMed

Jiang, Guohua; Zhang, Yinshun; Sun, Xianjie

2018-02-01

This study was conducted with the aim to investigate the relationship between Tetranectin (TN) and efficiency of posterior spinal V osteotomy in patients with traumatic kyphosis. Ninety-two patients with traumatic kyphosis admitted in our hospital from February 2014 to June 2016 were included whose serum TN levels were examined by ELISA. Using the mean level of TN as cut-off value, patients were classified into TN high level group (group I) and TN low level group (group II). The observation indexes, including operation time, intra-operational loss of blood, Cobb angle, postoperative complications and recurrence rate of kyphosis within post-operational 6 months were recorded for comparison. TN level was significantly higher in group I [(6.19 ± 0.33) μmol/L] than that in group II [(5.29 ± 0.34) μmol/L] (P < .05). There was no significant difference in average age, sex, lesion site and average time from injury to operation between the two groups (all P > 0.05). Compared to group II, operation time in group I was significantly shortened (5.02 ± 1.15 VS 4.58 ± 0.53, P = .023), the intra-operational loss of blood decreased (2418.56 ± 362.06 VS 2235.84 ± 325.63, P = .013), post-operational Cobb angle decreased (11.10 ± 1.31 VS 6.93 ± 1.04, P = .000), and the incidence of postoperative complications (nail-breaking, rod-breaking and looseness) and recurrence rate decreased (18.8% VS 4.5%, P = .036; 10.4% VS 0.0%, P = .028). Serum TN level is proved to be related to the efficiency of posterior spinal V osteotomy in patients with traumatic kyphosis, and may serve as a possible indicator for clinical treatment.

Origins of the sensory examination in neurology.

PubMed

Freeman, Cassiopeia; Okun, Michael S

2002-12-01

Formal testing of sensation as part of the neurological examination followed the improvements in examination techniques as well as advances in neuroscience. By the 1890s, the observation that temperature sense was frequently impaired at the same time that pain was appreciated led to the supposition that the two paths traveled closely. Through the works of Brown-Séquard and Edinger the existence of a crossed afferent tract was verified. The distinction between two sensory pathways was clear by 1898, when van Gehuchten reported a case of syringomyelia and suggested that the pain and temperature fibers were carried anterolaterally and the position sense fibers carried posteriorly in the spinal cord. Many authors describing patients with tabes dorsalis suspected the posterior columns of the spinal cord played a key role in position sense. It is difficult to determine in the 19th century who first employed the use of movements of joints as a test for proprioceptive function; however, Bell in 1826 recognized what he termed a sixth sense, which later was characterized as proprioceptive function. Goldscheider went on to report the degrees of movement that were considered normal for each joint. Although vibratory sense had been described by Cardano and Ingrassia in the 16th century and tests had been developed by Rinne and Rumpf by the 19th century, it was not until 1903 that Rydel and Seiffer found that vibratory sense and proprioceptive sense were closely related and that both senses were carried in the posterior columns of the spinal cord. By 1955, the sensory examination included tests for light-touch, superficial pain, temperature, position sense, vibration, muscle (deep pain), and two-point discrimination. Tests for these sensibilities still remain in use. We will review the origins of the understanding of sensation, which ultimately led to the development of the sensory examination. We will highlight individuals who made important discoveries and observations, as well as review the history of each of the elements of the sensory examination.

Myelitis: Differences between multiple sclerosis and other aetiologies.

PubMed

Presas-Rodríguez, S; Grau-López, L; Hervás-García, J V; Massuet-Vilamajó, A; Ramo-Tello, C

2016-03-01

Myelitis can appear as an initial symptom in the context of demyelinating diseases, systemic inflammatory diseases, and infectious diseases. We aim to analyse the differences between myelitis associated with multiple sclerosis (MS) and myelitis resulting from other aetiologies. Single-centre, retrospective analysis of patients with initial myelitis (2000-2013). Demographic, aetiological, clinical, radiological and prognostic variables were analysed and compared between patients with myelitis from MS and those with myelitis due to other aetiologies. We included 91 patients; mean follow-up was 7 years. Diagnoses were as follows: MS 57 (63%), idiopathic transverse myelitis 22 (24%), associated systemic diseases 6 (7%), and other diagnoses (6%). Myelitis due to MS was associated with younger age of onset (35 ± 11 vs. 41 ± 13; P = .02), more pronounced sphincter involvement (40.4 vs. 27.3%; P=.05), greater multifocal involvement in spinal MRI (77.2 vs. 26.5%; P=.001), shorter lesion extension (2.4 vs. 1.4 vertebral segments; P=.001), cervical location (82.5 vs. 64.7%; P=.05) and posterior location (89.5 vs. 41.2%; P=.001). Myelitis due to other aetiologies more frequently showed anterior location (47.1 vs. 24.6%; P=.02), and central cord involvement (47.1 vs. 14.1%; P=.001), with better recovery at one year of follow up (EDSS 2.0 vs. 1.5; P=.01). Multivariate analysis showed that multifocal spinal cord involvement (OR 9.38, 95% CI: 2.04-43.1) and posterior cord involvement (OR 2.16, 95% CI: 2.04-2.67) were independently associated with the diagnosis of MS. A high percentage of patients with an initial myelitis event will be diagnosed with MS. The presence of multifocal and posterior spinal cord lesions was significantly associated with the diagnosis of MS. Copyright © 2015 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.

Pain outcomes after surgery in patients with intramedullary spinal cord cavernous malformations.

PubMed

Deutsch, Harel

2010-09-01

The objective of the study was to quantify the improvement in pain levels for patients who have undergone surgery for intramedullary spinal cord cavernous malformations (SCCMs). The author reviewed medical records of patients who underwent surgery for an intramedullary SCCM between 2003 and 2010. Numerical pain scores (range 0-10) were recorded preoperatively and at follow-up. The follow-up period exceeded 1 year. Neurological status and subjective outcomes were assessed. Each patient underwent follow-up MR imaging. Five patients were identified with SCCMs who underwent surgery: 4 with thoracic and 1 with cervical lesions. Patients had been conservatively managed for an average of 5 years prior to surgery, and none had a history of acute hemorrhage or neurological deterioration during the observation period. The primary indication for surgery in each patient was pain, although 4 of 5 patients had some evidence of myelopathy on examination. Pain improved from a mean preoperative score of 8.6 to mean score of 2.0 (p < 0.01) at 1 month. Pain scores then increased to 3.7 (p < 0.01) at 1 year. All patients had some improvement in pain. No new motor weakness was noted, but all patients had increased symptoms of posterior-column dysfunction and numbness after surgery. Spinal cord intramedullary cavernous malformations are increasingly being diagnosed early with patients presenting with mostly pain symptoms. Removal of the lesion is reliably associated with improvement in pain scores but often the pain improvement is transient. While long-term worsening of pain scores occurs, at 1-year follow-up, patients reported pain scores were improved over preoperative scores. In all patients some degree of postoperative posterior-column dysfunction was present. Some of the immediate pain relief may be due to analgesia related to the myelotomy of newly described posterior column pain pathways. In patients with severe pain, surgery to remove SCCMs reduced the overall pain level at 1 year.

[Comparison of posterior fossa decompression with and without duraplasty for surgical management for adult Chiari malformation type Ⅰ].

PubMed

Li, H Y; Li, Y M; Chen, H; Li, Y; Shi, X W

2017-07-04

Objective: To evaluate and compare the efficacy between posterior fossa decompression without duraplasty (PFD) and posterior fossa decompression with duraplasty (PFDD) in the surgical management for adult Chiari Ⅰ malformation. Methods: Fifty-seven patients suffered from Chiari malformation type Ⅰ were treated in Department of Neurosurgery, Henan Provincial People's Hospital from August 2008 to October 2013. Twenty-three patients received posterior fossa decompression without duraplasty and the other 34 patients received posterior fossa decompression with duraplasty. The clinical results were retrospectively analyzed to compare the efficacy of two different surgical approaches. Results: There was no death or severe neurological dysfunction case in 57 patients of the two groups. Patients undergoing PFD had shorter length of hospital stay[(13.7±3.5) d vs (16.2±4.1) d, P <0.05]and surgical time[(98.7±22.1) min vs (132.3±39.6)min, P <0.05]. Cerebrospinal fluid-related complications and intracranial infection were more common in patients undergoing PFDD[(0/23, 0) vs (8/34, 23.5%), P <0.05]. Clinical improvement was comparable in two groups[(15/23, 65.2%) vs (26/34, 76.5%), P >0.05]at the one-year follow-up. The rate of syrinx regression in patients with Syringomyelia was higher in patients undergoing PFDD[(3/12, 25%) vs (17/22, 77.3%), P <0.05]. Conclusion: For adult patients with Chiari malformation type Ⅰ, PFD has the advantages of simple manipulation, short length of hospital stay and low incidence of cerebrospinal fluid-related complications and intracranial infection, compared with PFDD. It is comparable to PFDD in clinical improvement, but the effect of PFD is not as good as that of PFDD in the aspect of syrinx regression.

Segmental thoracic spinal anesthesia in patient with Byssinosis undergoing nephrectomy.

PubMed

Patel, Kiran; Salgaonkar, Sweta

2012-01-01

Byssinosis is an occupational disease occurring commonly in cotton mill workers; it usually presents with features of chronic obstructive pulmonary disease (COPD). The management of patients with COPD presents a significant challenges to the anesthetist. Regional anesthesia is preferred in most of these patients to avoid perioperative and postoperative complications related to general anesthesia. We report a known case of Byssinosis who underwent nephrectomy under segmental spinal anesthesia at the low thoracic level.

Epithelial-myoepithelial carcinoma metastasis to the thoracic spine.

PubMed

Goodwin, C Rory; Khattab, Mohamed H; Sankey, Eric W; Crane, Genevieve M; McCarthy, Edward F; Sciubba, Daniel M

2016-02-01

Epithelial-myoepithelial carcinoma (EMC) is a very rare salivary gland malignancy accounting for less than 1% of salivary gland tumors, and classically arises from the parotid gland in females. Spinal cord compression caused by EMC metastasized from the parotid gland has only been described once in the literature to our knowledge. We report the first case of a patient with parotid EMC spinal metastasis undergoing a gross total resection with instrumented fusion. This case illustrates that an en bloc resection with a planned transgression through the spinal canal may be a reasonable option for EMC metastasized to the spine. Copyright © 2015 Elsevier Ltd. All rights reserved.

[Adolescent idiopathic scoliosis].

PubMed

2016-12-01

Adolescent idiopathic scoliosis is a 3D spinal deformity in frontal, sagittal and axial planes, with high relevance in the pediatric population especially in adolescents and females between 10 years of age and the end of growth spurt and skeletal maturity. The radiographic manifestation is a curve greater than 10° measured by Cobb method associated with vertebral rotation. "Idiopathic" diagnosis has to be done after neuroanatomical anomalies of the posterior cerebral fosa and spinal canal have been ruled out. The physical finding of a thoracic or lumbar hump is the clinical manifestation of vertebral rotation seen in a forward bending test (Adam's Test). It is recommended that all curves with a magnitude greater than 20° have to be controlled and treated by a spinal surgeon being observation, bracing and surgery the different treatment options based on the extent, progression of deformity and basically the clinical condition of the patient. Sociedad Argentina de Pediatría.

Acute compressive myelopathy due to vertebral haemangioma.

PubMed

Macki, Mohamed; Bydon, Mohamad; Kaloostian, Paul; Bydon, Ali

2014-04-28

A 47-year-old woman with a history of anaemia presented to the emergency room with an acute onset of leg weakness. Physical examination of the bilateral lower extremities was significant for 0/5 muscle strength in all muscle groups with decreased pinprick and temperature sensation. A sensory level at the umbilicus was appreciated. Fine touch and proprioception were preserved. Bowel and bladder function were intact. CT revealed several thoracic, vertebral haemangiomatas. An MRI was suggestive of an epidural clot at the T8-T10-weighted posterior epidural space. At the level of the lesion, the cerebrospinal fluid space was completely effaced, and the flattened spinal cord exhibited signs of oedema and compressive myelopathy. The patient immediately underwent surgical decompression of the spinal cord. An epidural clot and vessel conglomeration were identified. A postoperative spinal angiogram confirmed the diagnosis of vertebral haemangioma. At 1-month follow-up, the patient regained strength and sensation.

Acute compressive myelopathy due to vertebral haemangioma

PubMed Central

Macki, Mohamed; Bydon, Mohamad; Kaloostian, Paul; Bydon, Ali

2014-01-01

A 47-year-old woman with a history of anaemia presented to the emergency room with an acute onset of leg weakness. Physical examination of the bilateral lower extremities was significant for 0/5 muscle strength in all muscle groups with decreased pinprick and temperature sensation. A sensory level at the umbilicus was appreciated. Fine touch and proprioception were preserved. Bowel and bladder function were intact. CT revealed several thoracic, vertebral haemangiomatas. An MRI was suggestive of an epidural clot at the T8–T10-weighted posterior epidural space. At the level of the lesion, the cerebrospinal fluid space was completely effaced, and the flattened spinal cord exhibited signs of oedema and compressive myelopathy. The patient immediately underwent surgical decompression of the spinal cord. An epidural clot and vessel conglomeration were identified. A postoperative spinal angiogram confirmed the diagnosis of vertebral haemangioma. At 1-month follow-up, the patient regained strength and sensation. PMID:24777075

Langerhans’ cell histiocytosis involving posterior elements of the dorsal spine: An unusual cause of extradural spinal mass in an adult

PubMed Central

Tyagi, Devendra K.; Balasubramaniam, Srikant; Savant, Hemant V.

2011-01-01

Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells occurring as an isolated lesion or as part of a systemic proliferation. It is commoner in children younger than 10 years of age with sparing of the posterior elements in more than 95% of cases. We describe a case of LCH in an adult female presenting with paraplegia. MRI revealed a well-defined extradural contrast enhancing mass at D2-D4 vertebral level involving the posterior elements of spine. D2-5 laminectomy with excision of lesion was performed which lead to marked improvement of patients neurological status. Histopathology was suggestive of eosinophilic granuloma. We describe the case, discuss its uniqueness and review the literature on this rare tumor presentation. PMID:23125497

Postoperative urinary tract infection and surgical site infection in instrumented spinal surgery: is there a link?

PubMed

Núñez-Pereira, S; Rodríguez-Pardo, D; Pellisé, F; Pigrau, C; Bagó, J; Villanueva, C; Cáceres, E

2014-08-01

A potential relationship between postoperative urinary tract infection (UTI) and surgical site infection (SSI) following posterior spinal fusion and instrumentation (PSFI) was investigated. A retrospective review was performed of prospectively collected demographic, clinical and microbiological data of 466 consecutive patients (median age, 53.7 years (interquartile range (IQR) 33.8-65.6); 58.6% women) undergoing PSFI to identify those with UTI in the first 4 weeks and SSI in the first 12 weeks after PSFI. Overall, 40.8% had an American Society of Anesthesiologists score of >2, and 49.8% had undergone fusion of more than three segments. Eighty-nine patients had UTI, 54 had SSI, and 22 had both conditions. In nine of the 22 (38%) cases, the two infections were caused by the same microorganism. The urinary tract was the probable source of SSI by Gram-negative bacteria in 38% (8/21) of cases. On multivariate analysis, UTI (OR 3.1, 95% CI 1.6-6.1; P 0.001) and instrumentation of more than three segments (OR 2.7, 95% CI 1.1-6.3; P 0.024) were statistically associated with SSI. Patients receiving ciprofloxacin for UTI had higher microbial resistance rates to fluoroquinolones at SSIs (46.13%) than those without ciprofloxacin (21.9%), although the difference did not reach statistical significance (p 0.1). In our series, UTI was significantly associated with SSI after PSFI. On the basis of our results, we conclude that further efforts to reduce the incidence of postoperative UTI and provide adequate empirical antibiotic therapy that avoids quinolones whenever possible may help to reduce SSI rates and potential microbial resistance. © 2014 The Authors Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases.

The Effect of Iliac Crest Autograft on the Outcome of Fusion in the Setting of Degenerative Spondylolisthesis

PubMed Central

Radcliff, Kristen; Hwang, Raymond; Hilibrand, Alan; Smith, Harvey E.; Gruskay, Jordan; Lurie, Jon D.; Zhao, Wenyan; Albert, Todd; Weinstein, James

2012-01-01

Background: There is considerable controversy about the long-term morbidity associated with the use of posterior autologous iliac crest bone graft for lumbar spine fusion procedures compared with the use of bone-graft substitutes. The hypothesis of this study was that there is no long-term difference in outcome for patients who had posterior lumbar fusion with or without iliac crest autograft. Methods: The study population includes patients enrolled in the degenerative spondylolisthesis cohort of the Spine Patient Outcomes Research Trial who underwent lumbar spinal fusion. Patients were divided according to whether they had or had not received posterior autologous iliac crest bone graft. Results: There were 108 patients who had fusion with iliac crest autograft and 246 who had fusion without iliac crest autograft. There were no baseline differences between groups in demographic characteristics, comorbidities, or baseline clinical scores. At baseline, the group that received iliac crest bone graft had an increased percentage of patients who had multilevel fusions (32% versus 21%; p = 0.033) and L5-S1 surgery (37% versus 26%; p = 0.031) compared with the group without iliac crest autograft. Operative time was higher in the iliac crest bone-graft group (233.4 versus 200.9 minutes; p < 0.001), and there was a trend toward increased blood loss (686.9 versus 582.3; p = 0.057). There were no significant differences in postoperative complications, including infection or reoperation rates, between the groups. On the basis of the numbers available, no significant differences were detected between the groups treated with or without iliac crest bone graft with regard to the scores on Short Form-36, Oswestry Disability Index, Stenosis Bothersomeness Index, and Low Back Pain Bothersomeness Scale or the percent of patient satisfaction with symptoms averaged over the study period. Conclusions: The outcome scores associated with the use of posterior iliac crest bone graft for lumbar spinal fusion were not significantly lower than those after fusion without iliac crest autograft. Conversely, iliac crest bone-grafting was not associated with an increase in the complication rates or rates of reoperation. On the basis of these results, surgeons may choose to use iliac crest bone graft on a case-by-case basis for lumbar spinal fusion. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. PMID:22878599

Geometrical properties of the human child cervical spine with a focus on the C1 vertebra.

PubMed

Yoganandan, Narayan; Pintar, Frank A; Lew, Sean M; Rao, Raj D

2014-01-01

Child dummies and injury criteria used in automotive crashworthiness environments are based on scaling from the adult and/or between children of different ages. Cartilage-to-bone ossification, spinal canal and joint developments of the spine, and strength attainments do not grow linearly from birth to maturity. Though this is known to medical professionals, age-based quantitative analyses are needed to accurately model the pediatric spine. The objective of this study was to quantify longitudinal growths of various regions of the first cervical vertebrae, responsible for transmitting the axial load from the base of the skull through the condyles to the neck/torso. Computed tomography (CT) images of 54 children from one day to 18 years of age were retrospectively used to determine the following geometrical properties: bilateral neurocentral synchondroses widths, the width of posterior synchondrosis, outer and inner anteroposterior and transverse diameters, spinal canal area, and depths of the anterior and posterior arches of the C1 vertebra. Both axial and sagittal CT images were used in the analysis. Sagittal images were used to quantify data for the anterior and posterior arches and axial images were used for all described cross-sectional parameters. Geometrical properties were extracted and reported for the various parameters at 6 months; one year; 18 months; and 3, 6, and 10 years of age corresponding to the dummy family ages routinely used in motor vehicle crashworthiness research and other applications. The outer transverse diameter ranged from 4.97 to 7.08 cm; outer and inner antero-posterior diameters ranged from 2.99 to 4.18 and 2.19 to 3.03 mm; and spinal canal area ranged from 4.34 to 6.68 mm(2). Other data are given in the body of the article. The growths of the first cervical vertebra quantified in terms of the above variables occurred nonlinearly with age and the degree of nonlinearity depended on the type of the geometrical parameter. Growths did not match with the simple scaling ratios based on the adult spine, used in different studies reported in the current literature. These early nonlinear and nonuniform age- and local geometry-specific variations should be considered in human finite element models for an accurate transfer of the external load from the atlas to the subaxial spine and to improve their fidelity and biomechanical capabilities.

The posterior skeletal thorax: rib-vertebral angle and axial vertebral rotation asymmetries in adolescent idiopathic scoliosis.

PubMed

Burwell, R G; Aujla, R K; Freeman, B J C; Dangerfield, P H; Cole, A A; Kirby, A S; Polak, F J; Pratt, R K; Moulton, A

2008-01-01

The deformity of the ribcage in thoracic adolescent idiopathic scoliosis (AIS) is viewed by most as being secondary to the spinal deformity, though a few consider it primary or involved in curve aggravation. Those who consider it primary ascribe pathogenetic significance to rib-vertebra angle asymmetry. In thoracic AIS, supra-apical rib-vertebra angle differences (RVADs) are reported to be associated with the severity of the Cobb angle. In this paper we attempt to evaluate rib and spinal pathomechanisms in thoracic and thnoracolumbar AIS using spinal radiographs and real-time ultrasound. On the radiographs by costo-vertebral angle asymmetries (rib-vertebral angle differences RVADs, and rib-spinal angle differences RSADs), apical vertebral rotation (AV) and apical vertebral translation (AVT) were measured; and by ultrasound, spine-rib rotation differences (SRRDs) were estimated. RVADs are largest at two and three vertebral levels above the apex where they correlate significantly and positively with Cobb angle and AVT but not AVR. In right thoracic AIS, the cause(s) of the RVA asymmetries is unknown: it may result from trunk muscle imbalance, or from ribs adjusting passively within the constraint of the fourth column of the spine to increasing spinal curvature from whatever cause. Several possible mechanisms may drive axial vertebral rotation including, biplanar spinal asymmetry, relative anterior spinal overgrowth, dorsal shear forces in the presence of normal vertebral axial rotation, asymmetry of rib linear growth, trunk muscle imbalance causing rib-vertebra angle asymmetry weakening the spinal rotation-defending system of bipedal gait, and CNS mechanisms.

Spinal epidural angiolipomas: Clinical characteristics, management and outcomes

PubMed Central

Bouali, Sofiene; Maatar, Nidhal; Bouhoula, Asma; Abderrahmen, Khansa; Said, Imed Ben; Boubaker, Adnen; Kallel, Jalel; Jemel, Hafedh

2016-01-01

Purpose: The spinal epidural angiolipomas are rare expansive processes made of mature lipomatous and angiomatous elements. They often have a benign character. Their etiology, pathogenesis remains uncertain, and it is a cause of spinal cord compression. The magnetic resonance imaging is the most important neuroradiological examination. Histological examination is the only examination to confirm the diagnosis. Surgery is the treatment of choice. Methods: A retrospective study of all patients operated on for a spinal epidural angiolipoma at the Department of Neurosurgery at the National Institute of Neurology of Tunis between January 2000 and December 2014 (15 years) was performed. The aim of this study is to describe the clinical, radiological, histological characteristics and the treatment of this tumor. Results: A total of nine patients were operated from January 01, 2000 to November 30, 2014. The average age of our patients was 51 years with ages that ranged from 29 to 65 with a male predominance. The period between onset of symptoms and diagnosis ranged from 24 months with an average 12 months. Posterior localization of the tumor was seen in all patients. Surgical resection was performed for all cases. The postoperative course has been satisfactory, with a complete recovery of neurological functions in all patients. Conclusions: The spinal epidural angiolipomas is rare expansive process causing spinal cord compression. Treatment is exclusively surgical resection. The functional outcome of spinal epidural angiolipomas is particularly favorable with a complete neurological recovery is if the patient was quickly operated. PMID:27695535

Spinal epidural angiolipomas: Clinical characteristics, management and outcomes.

PubMed

Bouali, Sofiene; Maatar, Nidhal; Bouhoula, Asma; Abderrahmen, Khansa; Said, Imed Ben; Boubaker, Adnen; Kallel, Jalel; Jemel, Hafedh

2016-01-01

The spinal epidural angiolipomas are rare expansive processes made of mature lipomatous and angiomatous elements. They often have a benign character. Their etiology, pathogenesis remains uncertain, and it is a cause of spinal cord compression. The magnetic resonance imaging is the most important neuroradiological examination. Histological examination is the only examination to confirm the diagnosis. Surgery is the treatment of choice. A retrospective study of all patients operated on for a spinal epidural angiolipoma at the Department of Neurosurgery at the National Institute of Neurology of Tunis between January 2000 and December 2014 (15 years) was performed. The aim of this study is to describe the clinical, radiological, histological characteristics and the treatment of this tumor. A total of nine patients were operated from January 01, 2000 to November 30, 2014. The average age of our patients was 51 years with ages that ranged from 29 to 65 with a male predominance. The period between onset of symptoms and diagnosis ranged from 24 months with an average 12 months. Posterior localization of the tumor was seen in all patients. Surgical resection was performed for all cases. The postoperative course has been satisfactory, with a complete recovery of neurological functions in all patients. The spinal epidural angiolipomas is rare expansive process causing spinal cord compression. Treatment is exclusively surgical resection. The functional outcome of spinal epidural angiolipomas is particularly favorable with a complete neurological recovery is if the patient was quickly operated.

Retrospective, Demographic, and Clinical Investigation of the Causes of Postoperative Infection in Patients With Lumbar Spinal Stenosis Who Underwent Posterior Stabilization.

PubMed

Yaldiz, Can; Yaldiz, Mahizer; Ceylan, Nehir; Kacira, Ozlem Kitiki; Ceylan, Davut; Kacira, Tibet; Kizilcay, Gokhan; Tanriverdi, Taner

2015-07-01

Owing to the increasing population of elderly patients, a large number of patients with degenerative spondylosis are currently being surgically treated. Although basic measures for decreasing postoperative surgical infections (PSIs) are considered, it still remains among the leading causes of morbidity and mortality. The aim of this retrospective analysis is to present possible causes leading to PSI in patients who underwent surgery for lumbar degenerative spondylosis and highlight how it can be avoided to decrease morbidity and mortality. The study included 540 patients who underwent posterior stabilization due to degenerative lumbar stenosis between January 2013 and January 2014. The data before and after surgery was retrieved from the hospital charts. Patients with degenerative lumbar stenosis who were operated upon in this study had >2 levels of laminectomy and facetectomy. For this reason, posterior stabilization was performed for all the patients included in this study. Determining the causes of postoperative infection (PI) following spinal surgeries performed with instrumentation is a struggle. Seventeen different parameters that may be related to PI were evaluated in this study. The presence of systemic diseases, unknown glove perforations, and perioperative blood transfusions were among the parameters that increased the prevalence of PI. Alternatively, prolene sutures, double-layered gloves, and the use of rifampicin Sv (RIS) decreased the incidence of PI. Although the presence of systemic diseases, unnoticed glove perforations, and perioperative blood transfusions increased PIs, prolene suture material, double-layered gloves, and the use of RIS decreased PIs.

Segmental thoracic spinal anesthesia in patient with Byssinosis undergoing nephrectomy

PubMed Central

Patel, Kiran; Salgaonkar, Sweta

2012-01-01

Byssinosis is an occupational disease occurring commonly in cotton mill workers; it usually presents with features of chronic obstructive pulmonary disease (COPD). The management of patients with COPD presents a significant challenges to the anesthetist. Regional anesthesia is preferred in most of these patients to avoid perioperative and postoperative complications related to general anesthesia. We report a known case of Byssinosis who underwent nephrectomy under segmental spinal anesthesia at the low thoracic level. PMID:25885628

Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery.

PubMed

Lange, Jeffrey; Karellas, Andrew; Street, John; Eck, Jason C; Lapinsky, Anthony; Connolly, Patrick J; Dipaola, Christian P

2013-03-01

Observational. To estimate the radiation dose imparted to patients during typical thoracolumbar spinal surgical scenarios. Minimally invasive techniques continue to become more common in spine surgery. Computer-assisted navigation systems coupled with intraoperative cone-beam computed tomography (CT) represent one such method used to aid in instrumented spinal procedures. Some studies indicate that cone-beam CT technology delivers a relatively low dose of radiation to patients compared with other x-ray-based imaging modalities. The goal of this study was to estimate the radiation exposure to the patient imparted during typical posterior thoracolumbar instrumented spinal procedures, using intraoperative cone-beam CT and to place these values in the context of standard CT doses. Cone-beam CT scans were obtained using Medtronic O-arm (Medtronic, Minneapolis, MN). Thermoluminescence dosimeters were placed in a linear array on a foam-plastic thoracolumbar spine model centered above the radiation source for O-arm presets of lumbar scans for small or large patients. In-air dosimeter measurements were converted to skin surface measurements, using published conversion factors. Dose-length product was calculated from these values. Effective dose was estimated using published effective dose to dose-length product conversion factors. Calculated dosages for many full-length procedures using the small-patient setting fell within the range of published effective doses of abdominal CT scans (1-31 mSv). Calculated dosages for many full-length procedures using the large-patient setting fell within the range of published effective doses of abdominal CT scans when the number of scans did not exceed 3. We have demonstrated that single cone-beam CT scans and most full-length posterior instrumented spinal procedures using O-arm in standard mode would likely impart a radiation dose within the range of those imparted by a single standard CT scan of the abdomen. Radiation dose increases with patient size, and the radiation dose received by larger patients as a result of more than 3 O-arm scans in standard mode may exceed the dose received during standard CT of the abdomen. Understanding radiation imparted to patients by cone-beam CT is important for assessing risks and benefits of this technology, especially when spinal surgical procedures require multiple intraoperative scans.

Principles of management of osteometabolic disorders affecting the aging spine.

PubMed

Hadjipavlou, Alexander G; Katonis, Paul G; Tzermiadianos, Michael N; Tsoukas, George M; Sapkas, George

2003-10-01

Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12-24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated.

α-Synuclein pathology in the cranial and spinal nerves in Lewy body disease.

PubMed

Nakamura, Keiko; Mori, Fumiaki; Tanji, Kunikazu; Miki, Yasuo; Toyoshima, Yasuko; Kakita, Akiyoshi; Takahashi, Hitoshi; Yamada, Masahito; Wakabayashi, Koichi

2016-06-01

Accumulation of phosphorylated α-synuclein in neurons and glial cells is a histological hallmark of Lewy body disease (LBD) and multiple system atrophy (MSA). Recently, filamentous aggregations of phosphorylated α-synuclein have been reported in the cytoplasm of Schwann cells, but not in axons, in the peripheral nervous system in MSA, mainly in the cranial and spinal nerve roots. Here we conducted an immunohistochemical investigation of the cranial and spinal nerves and dorsal root ganglia of patients with LBD. Lewy axons were found in the oculomotor, trigeminal and glossopharyngeal-vagus nerves, but not in the hypoglossal nerve. The glossopharyngeal-vagus nerves were most frequently affected, with involvement in all of 20 subjects. In the spinal nerve roots, Lewy axons were found in all of the cases examined. Lewy axons in the anterior nerves were more frequent and numerous in the thoracic and sacral segments than in the cervical and lumbar segments. On the other hand, axonal lesions in the posterior spinal nerve roots appeared to increase along a cervical-to-sacral gradient. Although Schwann cell cytoplasmic inclusions were found in the spinal nerves, they were only minimal. In the dorsal root ganglia, axonal lesions were seldom evident. These findings indicate that α-synuclein pathology in the peripheral nerves is axonal-predominant in LBD, whereas it is restricted to glial cells in MSA. © 2015 Japanese Society of Neuropathology.

Leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation (LBSL): assessment of the involved white matter tracts by MRI.

PubMed

Kassem, Hassan; Wafaie, Ahmed; Abdelfattah, Sherif; Farid, Tarek

2014-01-01

Leukoencephalopathy with brain stem and spinal cord involvement and lactate elevation (LBSL) is a recently identified autosomal recessive disorder with early onset of symptoms and slowly progressive pyramidal, cerebellar and dorsal column dysfunction. LBSL is characterized by distinct white matter abnormalities and selective involvement of brainstem and spinal cord tracts. The purpose of this study is to assess the imaging features of the involved white matter tracts in cases of LBSL by MRI. We retrospectively reviewed the imaging features of the selectively involved white matter tracts in sixteen genetically proven cases of leukoencephalopathy with brainstem and spinal cord involvement and elevated brain lactate (LBSL). All patients presented with slowly progressive cerebellar sensory ataxia with spasticity and dorsal column dysfunction. MRI of the brain and spine using 1.5 T machine and proton magnetic resonance spectroscopy (1H MRS) on the abnormal white matter were done to all patients. The MRI and MRS data sets were analyzed according to lesion location, extent, distribution and signal pattern as well as metabolite values and ratios in MRS. Laboratory examinations ruled out classic leukodystrophies. In all cases, MRI showed high signal intensity in T2-weighted and FLAIR images within the cerebral subcortical, periventricular and deep white matter, posterior limbs of internal capsules, centrum semiovale, medulla oblongata, intraparenchymal trajectory of trigeminal nerves and deep cerebellar white matter. In the spine, the signal intensity of the dorsal column and lateral cortico-spinal tracts were altered in all patients. The subcortical U fibers, globi pallidi, thalami, midbrain and transverse pontine fibers were spared in all cases. In 11 cases (68.8%), the signal changes were inhomogeneous and confluent whereas in 5 patients (31.2%), the signal abnormalities were spotty. MRI also showed variable signal abnormalities in the sensory and pyramidal tracts in addition to the brainstem and cerebellar connections. Proton MRS showed consistent elevation of the lactate within the abnormal white matter. Distinct MRI findings in the form of selective affection of subcortical and deep white matter tracts of the brain (involving the posterior limb of internal capsules and sparing the subcortical U fibers), dorsal column and lateral cortico-spinal tracts of the spinal cord should lead to the diagnosis of LBSL supported by the presence of lactate peak in 1H MRS. The disease can be confirmed by the analysis of the disease gene DARS2.

The effective forces transmitted by high-speed, low-amplitude thoracic manipulation.

PubMed

Herzog, W; Kats, M; Symons, B

2001-10-01

Twenty asymptomatic volunteers each received three spinal manipulative treatments to the thoracic spine. The treatments consisted of a straight posterior-to-anterior high-speed, low-amplitude thrust to the transverse process of T3-T10 using a reinforced hypothenar contact. All treatments were given by a full-time practicing clinician with 3 years of experience. The primary objective of this study was to quantify local measures of loading applied by the clinician on the volunteers during spinal manipulative treatments and to compare these local measures of loading with previously described global measures. The sparse information on the mechanics of spinal manipulative treatments deals exclusively with global force or pressure measurements. On the basis of these global data, incorrect conclusions may be drawn about the beneficial effects of spinal manipulative therapy, the loading of internal structures, and the risks associated with these treatments. Twenty asymptomatic subjects each received three posterior-to-anterior, high-speed, low-amplitude spinal manipulative treatments to the transverse process of the thoracic spine. Total force, local force, contact area, peak pressure, and average pressure at the contact interface between clinician and subject were measured continuously by use of a thin, flexible pressure pad. Local and global measures of loading were compared and analyzed by use of nonparametric statistics (alpha = 0.01). The average peak total force was 238.2 N. The average peak local force over a target area of 25 mm2 was 5 N, indicating that global measures of loading vastly overestimate the local effective forces at the target site. The peak pressure point moved, on average, 9.8 mm during the course of the manipulation. To the authors' best knowledge, this is the first study to quantify local, effective measures of loading and compare them with the global measures typically used. The conclusions are limited because the study used a single clinician. The effective loading of specific target sites is much smaller than the global measures might suggest. This result occurs because as the forces during spinal manipulative treatment increase, so does the contact area; therefore, much of the total treatment force is taken up by non-target-specific tissues. Because of the vast discrepancy between the global and local measures of loading, it is suggested that risk-benefit assessments of high-speed, low-amplitude spinal manipulative treatments should be made, including local measures of loading. Finally, because theoretical approaches and the inverse dynamics approach can provide only global measures of loading, the results of such studies should be interpreted with caution.

Feasibility of a Modified E-PASS and POSSUM System for Postoperative Risk Assessment in Patients with Spinal Disease.

PubMed

Chun, Dong Hyun; Kim, Do Young; Choi, Sun Kyu; Shin, Dong Ah; Ha, Yoon; Kim, Keung Nyun; Yoon, Do Heum; Yi, Seong

2018-04-01

This retrospective case control study aimed to evaluate the feasibility of using Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) systems in patients undergoing spinal surgical procedures. Degenerative spine disease has increased in incidence in aging societies, as has the number of older adult patients undergoing spinal surgery. Many older adults are at a high surgical risk because of comorbidity and poor general health. We retrospectively reviewed 217 patients who had undergone spinal surgery at a single tertiary care. We investigated complications within 1 month after surgery. Criteria for both skin incision in E-PASS and operation magnitude in the POSSUM system were modified to fit spine surgery. We calculated the E-PASS and POSSUM scores for enrolled patients, and investigated the relationship between postoperative complications and both surgical risk scoring systems. To reinforce the predictive ability of the E-PASS system, we adjusted equations and developed modified E-PASS systems. The overall complication rate for spinal surgery was 22.6%. Forty-nine patients experienced 58 postoperative complications. Nineteen major complications, including hematoma, deep infection, pleural effusion, progression of weakness, pulmonary edema, esophageal injury, myocardial infarction, pneumonia, reoperation, renal failure, sepsis, and death, occurred in 17 patients. The area under the receiver operating characteristic curve (AUC) for predicted postoperative complications after spine surgery was 0.588 for E-PASS and 0.721 for POSSUM. For predicted major postoperative complications, the AUC increased to 0.619 for E-PASS and 0.842 for POSSUM. The AUC of the E-PASS system increased from 0.588 to 0.694 with the Modified E-PASS equation. The POSSUM system may be more useful than the E-PASS system for estimating postoperative surgical risk in patients undergoing spine surgery. The preoperative risk scores of E-PASS and POSSUM can be useful for predicting postoperative major complications. To enhance the predictability of the scoring systems, using of modified equations based on spine surgery-specific factors may help ensure surgical outcomes and patient safety. Copyright © 2017. Published by Elsevier Inc.

Impact of Glycemic Control on Morbidity and Mortality in Adult Idiopathic Scoliosis Patients Undergoing Spinal Fusion.

PubMed

Shin, John I; Phan, Kevin; Kothari, Parth; Kim, Jun S; Guzman, Javier Z; Cho, Samuel K

2017-08-01

This is a retrospective analysis of administrative database. To elucidate the effect of glycemic control on surgical outcomes of middle-aged and elderly idiopathic scoliosis patients undergoing spinal fusion surgery. Diabetes mellitus (DM) is a condition thought to adversely affect outcomes of spine surgery. However, no study has stratified glycemic control levels and their impact on outcome for idiopathic scoliosis patients receiving a spinal fusion surgery. Previous studies may have reported higher than true rates of complications for controlled diabetic patients, who are the majority of diabetic patients. The Nationwide Inpatient Sample was queried from years 2002 to 2011. We extracted idiopathic scoliosis patients older than 45 years of age that received spinal fusion and analyzed complications and outcomes variables among 3 cohorts: nondiabetic patients, controlled diabetics, and uncontrolled diabetics. Multivariate analyses were used to assess whether glycemic control was a risk factor for adverse postoperative outcomes. Controlled diabetics had significantly increased rates of acute renal failure (ARF), while uncontrolled diabetics had significantly increased rates of acute postoperative hemorrhage. In multivariate analyses controlling for patient factors and comorbidities, controlled DM was found to be an independent predictor of ARF [odds ratio (OR), 1.863; 95% confidence interval (CI), 1.346-2.579; P=0.0002), and uncontrolled DM was found to be a significant risk factor for acute postoperative hemorrhage (OR, 2.182; 95% CI, 1.192-3.997; P=0.0115), ARF (OR, 4.839; 95% CI, 1.748-13.392; P=0.0024), deep vein thrombosis (OR, 5.825; 95% CI, 1.329-25.522, P=0.0194) and in-patient mortality (OR, 8.889; 95% CI, 1.001-78.945; P=0.0499). Controlled DM was found to be a risk factor for ARF in adult idiopathic scoliosis patients undergoing spinal fusion surgery, while uncontrolled DM was shown to be a risk factor for postoperative hemorrhage, ARF, deep vein thrombosis, and mortality. The present study provides valuable data for better informed consent for patients with diabetes considering surgery for idiopathic scoliosis. Level III.

Neuroleptic-induced "painful legs and moving toes" syndrome: successful treatment with clonazepam and baclofen.

PubMed

Sandyk, R

1990-12-01

The syndrome of "painful legs and moving toes" is characterised by spontaneous causalgic pain in the lower extremities associated with peculiar involuntary movements of the toes and feet. It has been observed after a variety of lesions affecting the posterior nerve roots, the spinal ganglia and the peripheral nerves. The pathophysiology of the syndrome is unknown. I report a patient who developed the syndrome during treatment for schizophrenia with the antipsychotic agent molindone hydrochloride. The patient's response to the combination of clonazepam and baclofen suggests that the pathophysiology of the "painful legs and moving toes" may be linked to impairment of spinal serotonergic and GABA functions.

Multiple intracranial calcifications and spinal compressions: rare complications of type la pseudohypoparathyroidism.

PubMed

Chen, H; Tseng, F; Su, D; Chen, H; Tsai, K

2005-01-01

Type la pseudohypoparathyroidism (PHP la) is an unusual inherited disease. PHP la often causes extraskeletal calcifications and even soft tissue ossifications. Patients may present neurologic symptoms and signs related to hypocalcemia and hyperphosphatemia. We report here a 38-yr-old woman with PHP la who had two uncommon neurologic complications. One was involuntary movements related to basal ganglia calcification, and the other was myelopathy owing to ossifications of the posterior longitudinal ligament and multiple herniated intervertebral disks. Aggressive body weight control and corrections of hypocalcemia, hyperphosphatemia, and elevated PTH may be important to prevent these unusual neurologic complications. Regular and careful neurologic examinations should be performed for early diagnosis and treatments of these spinal lesions.

[Anaesthesia for correction of scoliosis in pediatric patient with Friedreich's ataxia].

PubMed

Agámez Medina, G L; Pantin, E J; Lorthé, J; Therrien, P J

2015-01-01

Friedreich ataxia (FA) is an inherited autosomal recessive disease characterized by a neurological degenerative process of the cerebellum, spinal cord, and peripheral nerves. FA is associated with ataxia, dysarthria, motor and sensory impairment, scoliosis, cardiomyopathy, and diabetes. There is a significant risk of perioperative major complications during the anesthetic management of these patients. We present the case of a fourteen-year-old patient with FA, who had a posterior spinal fusion and instrumentation underwent to total intravenous anesthesia. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Does Atraucan cause more postdural puncture backache?

PubMed

Abdullayev, Ruslan; Küçükebe, Omer Burak; Çelik, Bülent; Kirman, Nihal; Hatipoğlu, Hamit Sinan; Akaltun Hatipoğlu, Filiz

2015-01-01

Postdural puncture backache (PDPB) is the most frequent complaint after spinal anesthesia. In the literature its importance is generally overshadowed by postdural puncture headache. We studied two different kinds of spinal anesthesia needles to compare their technical handling capacities and incidences of PDPB. Data of 256 pregnant female patients undergoing cesarean delivery under spinal anesthesia were collected for the study. Patients were divided into two groups as Group A (n = 109) and Group Q (n = 147) according to the spinal needle used for spinal anesthesia (i.e. 26-gauge atraumatic and 26-gauge Quincke needles, respectively). Backache incidences during a 1-week period postoperatively and handling characteristics of the needles were noted. Spinal anesthesia was successfully performed at one attempt in 92.7% and 86.4% of patients in Groups A and Q, respectively. PDPB was encountered in 62.4% and 44.2% of patients in Groups A and Q, respectively, and the difference was statistically significant (P = 0.037). Both 26-gauge Atraucan and Quincke needles have excellent handling characteristics. PDPB seems to be less common with the 26-gauge Quincke needle than with the Atraucan needle.

Pregnancy outcome using general anesthesia versus spinal anesthesia for in vitro fertilization.

PubMed

Azmude, Azra; Agha'amou, Shahrzad; Yousefshahi, Fardin; Berjis, Katayoun; Mirmohammad'khani, Majid; Sadaat'ahmadi, Farahnaz; Ghods, Kamran; Dabbagh, Ali

2013-09-01

There is a considerable rate of fertility failure and this causes a great burden of untoward effects for patients. Usually a considerable number of these patients undergo anesthesia for their treatment. This study was designed to compare the effects of general and spinal anesthesia on these patients. In a randomized clinical trial, after taking informed written consent from the patients, 200 patients entered the study; 100 in each. During a 2 year period, women aged 20 to 40 years entered the study (one group receiving spinal anesthesia and the other, receiving general anesthesia). Ovum retrieval protocols were the same. Nonparametric and parametric analyses were used for data analysis. P value less than 0.05 was considered significant. There was no difference between the two groups regarding demographic variables. 15 of 100 patients (15%) in the general anesthesia group and 27 of 100 patients (27%) in the spinal anesthesia group had successful pregnancy after IVF; so, spinal anesthesia increased significantly the chance of IVF success (P value < 0.001; Chi Square). The results of this study demonstrated that spinal anesthesia increased the chance of fertilization success.

Metabolic Syndrome and 30-Day Outcomes in Elective Lumbar Spinal Fusion.

PubMed

Chung, Andrew S; Campbell, David; Waldrop, Robert; Crandall, Dennis

2018-05-01

A retrospective cohort study. The aim of this study was to evaluate the effect of metabolic syndrome (MetS) on 30-day morbidity and mortality following elective lumbar spinal fusion. MetS is a variable combination of hypertension, obesity, elevated fasting plasma glucose, and dyslipidemia.MetS has been associated with an increased risk of postoperative morbidity and mortality in multiple surgical settings. To our knowledge, the effect of MetS on 30-day outcomes following elective lumbar spinal fusion has not been well studied. An analysis of ACS-NSQIP data was performed between 2006 and 2013. Patients undergoing elective posterior lumbar fusion were identified. Emergency procedures, infections, tumor cases, and revision surgeries were excluded. Patients were defined as having MetS if they had a history of hypertension requiring medication, diabetes, and a body mass index (BMI) ≥30 kg/m. One thousand five hundred ninety (10.2%) patients with MetS were identified. A mild increase in major (P = 0.040) and minor complications (P = 0.003) in patients with MetS was noted. MetS was associated with increased rates of pulmonary complications (1.9% compared with 1.0%; P = 0.001), sepsis (1.7% compared with 0.9%; P = 0.005), and acute post-op renal failure (0.4% compared with 0%; P < 0.001). Multivariate analysis confirmed MetS to be an independent predictor of pulmonary complications [odds ratio (OR) 1.51; 95% confidence interval (95% CI 1.00-2.27); P = 0.048], sepsis (OR 1.56; 95% CI 1.01-2.42; P = 0.039), and acute postoperative renal failure (OR 6.95; 95% CI 2.23-21.67; P = 0.001). MetS status was associated with a mild increase in total hospital length of stay (4.38 compared with 3.81 days; P < 0.001). While MetS is a predictor of postoperative acute renal failure, it only slightly increases the risk of overall complications and is not associated with increased rates of 30-day reoperations or readmissions following elective lumbar fusion. 3.

Augmentation of failed human vertebrae with critical un-contained lytic defect restores their structural competence under functional loading: An experimental study.

PubMed

Alkalay, Ron N; von Stechow, Dietrich; Hackney, David B

2015-07-01

Lytic spinal lesions reduce vertebral strength and may result in their fracture. Vertebral augmentation is employed clinically to provide mechanical stability and pain relief for vertebrae with lytic lesions. However, little is known about its efficacy in strengthening fractured vertebrae containing lytic metastasis. Eighteen unembalmed human lumbar vertebrae, having simulated uncontained lytic defects and tested to failure in a prior study, were augmented using a transpedicular approach and re-tested to failure using a wedge fracture model. Axial and moment based strength and stiffness parameters were used to quantify the effect of augmentation on the structural response of the failed vertebrae. Effects of cement volume, bone mineral density and vertebral geometry on the change in structural response were investigated. Augmentation increased the failed lytic vertebral strength [compression: 85% (P<0.001), flexion: 80% (P<0.001), anterior-posterior shear: 95%, P<0.001)] and stiffness [(40% (P<0.05), 53% (P<0.05), 45% (P<0.05)]. Cement volume correlated with the compressive strength (r(2)=0.47, P<0.05) and anterior-posterior shear strength (r(2)=0.52, P<0.05) and stiffness (r(2)=0.45, P<0.05). Neither the geometry of the failed vertebrae nor its pre-fracture bone mineral density correlated with the volume of cement. Vertebral augmentation is effective in bolstering the failed lytic vertebrae compressive and axial structural competence, showing strength estimates up to 50-90% of historical values of osteoporotic vertebrae without lytic defects. This modest increase suggests that lytic vertebrae undergo a high degree of structural damage at failure, with strength only partially restored by vertebral augmentation. The positive effect of cement volume is self-limiting due to extravasation. Copyright © 2015. Published by Elsevier Ltd.

Hypobaric Unilateral Spinal Anaesthesia versus General Anaesthesia in Elderly Patients Undergoing Hip Fracture Surgical Repair: A Prospective Randomised Open Trial

PubMed Central

Meuret, Pascal; Bouvet, Lionel; Villet, Benoit; Hafez, Mohamed; Allaouchiche, Bernard

2018-01-01

Objective Intraoperative hypotension during hip fracture surgery is frequent in the elderly. No study has compared the haemodynamic effect of hypobaric unilateral spinal anaesthesia (HUSA) and standardised general anaesthesia (GA) in elderly patients undergoing hip fracture surgical repair. Methods We performed a prospective, randomised open study, including 40 patients aged over 75 years, comparing the haemodynamic effects of HUSA (5 mg isobaric bupivacaine with 5 μg sufentanil and 1 mL sterile water) and GA (induction with etomidate/remifentanil and maintenance with desflurane/remifentanil). An incidence of severe hypotension, defined by a decrease in systolic blood pressure of >40% from baseline, was the primary endpoint. Results The incidence of severe hypotension was lower in the HUSA group compared with that in the GA group (32% vs. 71%, respectively, p=0.03). The median [IQR] ephedrine consumption was lower (p=0.001) in the HUSA group (6 mg, 0–17 mg) compared with that in the GA group (36 mg, 21–57 mg). Intraoperative muscle relaxation and patients’ and surgeons’ satisfaction were similar between groups. No difference was observed in 5-day complications or 30-day mortality. Conclusion This study shows that HUSA provides better haemodynamic stability than GA, with lower consumption of ephedrine and similar operating conditions. This new approach of spinal anaesthesia seems to be safe and effective in elderly patients undergoing hip fracture surgery. PMID:29744247

Factors Leading to Persistent Postsurgical Pain in Adolescents Undergoing Spinal Fusion: An Integrative Literature Review.

PubMed

Perry, Mallory; Starkweather, Angela; Baumbauer, Kyle; Young, Erin

Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity among children and adolescents and the most frequent reason for corrective spinal fusion (SF). Of the children and adolescents who undergo SF, a significant number will experience persistent postoperative pain (PPP). This integrative literature review was conducted to identify and synthesize perioperative factors that may contribute to risk of developing PPP. Articles which addressed PPP within the last 10years and primary research on postoperative pain outcomes in adolescents after SF were selected for review. 15 articles which met eligibility criteria were included. Preoperative pain intensity was the most significant factor identified in the development of PPP and increased postoperative pain. Social function and psychological factors also have role in the development of PPP. There were no theoretical models or frameworks for evaluating PPP incidence in adolescent with AIS after SF. Perioperative factors such as, preoperative pain, correction magnitude, pain coping, anxiety and social functioning are vital to understanding a child's risk of PPP following SF. There is a need for theoretically-based studies to assess PPP among children and adolescents with AIS after SF surgery. The Biobehavioral Pain Network (BPN) model was proposed, to encompass biological, social and psychological domains which may be responsible for incidence of PPP in children undergoing SF. Such a model can be used to systematically develop and evaluate personalized postoperative pain management strategies for this patient population. Copyright © 2017 Elsevier Inc. All rights reserved.

Evaluation of lung volumes, vital capacity and respiratory muscle strength after cervical, thoracic and lumbar spinal surgery.

PubMed

Oliveira, Marcio Aparecido; Vidotto, Milena Carlos; Nascimento, Oliver Augusto; Almeida, Renato; Santoro, Ilka Lopes; Sperandio, Evandro Fornias; Jardim, José Roberto; Gazzotti, Mariana Rodrigues

2015-01-01

Studies have shown that physiopathological changes to the respiratory system can occur following thoracic and abdominal surgery. Laminectomy is considered to be a peripheral surgical procedure, but it is possible that thoracic spinal surgery exerts a greater influence on lung function. The aim of this study was to evaluate the pulmonary volumes and maximum respiratory pressures of patients undergoing cervical, thoracic or lumbar spinal surgery. Prospective study in a tertiary-level university hospital. Sixty-three patients undergoing laminectomy due to diagnoses of tumors or herniated discs were evaluated. Vital capacity, tidal volume, minute ventilation and maximum respiratory pressures were evaluated preoperatively and on the first and second postoperative days. Possible associations between the respiratory variables and the duration of the operation, surgical diagnosis and smoking status were investigated. Vital capacity and maximum inspiratory pressure presented reductions on the first postoperative day (20.9% and 91.6%, respectively) for thoracic surgery (P = 0.01), and maximum expiratory pressure showed reductions on the first postoperative day in cervical surgery patients (15.3%; P = 0.004). The incidence of pulmonary complications was 3.6%. There were reductions in vital capacity and maximum respiratory pressures during the postoperative period in patients undergoing laminectomy. Surgery in the thoracic region was associated with greater reductions in vital capacity and maximum inspiratory pressure, compared with cervical and lumbar surgery. Thus, surgical manipulation of the thoracic region appears to have more influence on pulmonary function and respiratory muscle action.

Robot-Assisted Versus Open Liver Resection in the Right Posterior Section

PubMed Central

Cipriani, Federica; Ratti, Francesca; Bartoli, Alberto; Ceccarelli, Graziano; Casciola, Luciano; Aldrighetti, Luca

2014-01-01

Background: Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery. Methods: Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location. Results: Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts. Conclusions: Robotic and open liver resections in the right posterior section display similar safety and feasibility. PMID:25516700

Reinforcement of spinal anesthesia by epidural injection of saline: a comparison of hyperbaric and isobaric tetracaine.

PubMed

Yamazaki, Y; Mimura, M; Hazama, K; Namiki, A

2000-04-25

An epidural injection of saline was reported to extend spinal anesthesia because of a volume effect. The aim of this study was to evaluate the influence of the baricity of spinal local anesthetics upon the extension of spinal anesthesia by epidural injection of saline. Forty patients undergoing elective lower-limb surgery were randomly allocated to four groups of 10 patients each. Group A received no epidural injection after the spinal administration of hyperbaric tetracaine (dissolved in 10% glucose). Group B received an epidural injection of 8 ml of physiological saline 20 min after spinal hyperbaric tetracaine. Group C received no epidural injection after spinal isobaric tetracaine (dissolved in physiological saline). Group D received an epidural injection of 8 ml of saline 20 min after spinal isobaric tetracaine. The level of analgesia was examined by the pinprick method at 5-min intervals. The levels of analgesia 20 min after spinal anesthesia were significantly higher in hyperbaric groups than in isobaric groups [T5 (T2-L2) vs. T7 (T3-12)]. After epidural injection of saline, the levels of analgesia in groups B and D were significantly higher than in groups A and C. The segmental increases after epidural saline injection were 2 (0-3) in group B and 2 (1-7) in group D. Sensation in the sacral area remained 20 min after spinal block in one patient in group D; however, it disappeared after epidural saline injection. In this study, 8 ml of epidural saline extended spinal analgesia. However, there was no difference between the augmenting effect in isobaric and hyperbaric spinal anesthesia. We conclude that the reinforcement of spinal anesthesia by epidural injection of saline is not affected by the baricity of the spinal anesthetic solution used.

Determining clinical practice of expert physiotherapy for patients undergoing lumbar spinal fusion: a cross-sectional survey study.

PubMed

Janssen, Esther R C; Scheijen, Elle E M; van Meeteren, Nico L U; de Bie, Rob A; Lenssen, Anton F; Willems, Paul C; Hoogeboom, Thomas J

2016-05-01

To determine the content of current Dutch expert hospital physiotherapy practice for patients undergoing lumbar spinal fusion (LSF), to gain insight into expert-based clinical practice. At each hospital where LSF is performed, one expert physiotherapist received an e-mailed questionnaire, about pre- and postoperative physiotherapy and discharge after LSF. The level of uniformity in goals and interventions was graded on a scale from no uniformity (50-60 %) to very strong uniformity (91-100 %). LSF was performed at 34 of the 67 contacted hospitals. From those 34 hospitals, 28 (82 %) expert physiotherapists completed the survey. Twenty-one percent of the respondents saw patients preoperatively, generally to provide information. Stated postoperative goals and administered interventions focused mainly on performing transfers safely and keeping the patient informed. Outcome measures were scarcely used. There was no uniformity regarding advice on the activities of daily living. Dutch perioperative expert physiotherapy for patients undergoing LSF is variable and lacks structural outcome assessment. Studies evaluating the effectiveness of best-practice physiotherapy are warranted.

Intrinsic and Extrinsic Contributions to Seated Balance in the Sagittal and Coronal Planes: Implications for Trunk Control After Spinal Cord Injury.

PubMed

Audu, Musa L; Triolo, Ronald J

2015-08-01

The contributions of intrinsic (passive) and extrinsic (active) properties of the human trunk, in terms of the simultaneous actions about the hip and spinal joints, to the control of sagittal and coronal seated balance were examined. Able-bodied (ABD) and spinal-cord-injured (SCI) volunteers sat on a moving platform which underwent small amplitude perturbations in the anterior-posterior (AP) and medial-lateral (ML) directions while changes to trunk orientation were measured. A linear parametric model that related platform movement to trunk angle was fit to the experimental data by identifying model parameters in the time domain. The results showed that spinal cord injury leads to a systematic reduction in the extrinsic characteristics, while most of the intrinsic characteristics were rarely affected. In both SCI and ABD individuals, passive characteristics alone were not enough to maintain seated balance. Passive stiffness in the ML direction was almost 3 times that in the AP direction, making more extrinsic mechanisms necessary for balance in the latter direction. Proportional and derivative terms of the extrinsic model made the largest contribution to the overall output from the active system, implying that a simple proportional plus derivative (PD) controller structure will suffice for restoring seated balance after spinal cord injury.

Motor Control of Human Spinal Cord Disconnected from the Brain and Under External Movement.

PubMed

Mayr, Winfried; Krenn, Matthias; Dimitrijevic, Milan R

2016-01-01

Motor control after spinal cord injury is strongly depending on residual ascending and descending pathways across the lesion. The individually altered neurophysiology is in general based on still intact sublesional control loops with afferent sensory inputs linked via interneuron networks to efferent motor outputs. Partial or total loss of translesional control inputs reduces and alters the ability to perform voluntary movements and results in motor incomplete (residual voluntary control of movement functions) or motor complete (no residual voluntary control) spinal cord injury classification. Of particular importance are intact functionally silent neural structures with residual brain influence but reduced state of excitability that inhibits execution of voluntary movements. The condition is described by the term discomplete spinal cord injury. There are strong evidences that artificial afferent input, e.g., by epidural or noninvasive electrical stimulation of the lumbar posterior roots, can elevate the state of excitability and thus re-enable or augment voluntary movement functions. This modality can serve as a powerful assessment technique for monitoring details of the residual function profile after spinal cord injury, as a therapeutic tool for support of restoration of movement programs and as a neuroprosthesis component augmenting and restoring movement functions, per se or in synergy with classical neuromuscular or muscular electrical stimulation.

Posterior fossa scintiangiography: documentation of genetic penetrance of von Hippel--Lindau syndrome in a clinically unaffected girl and her father

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hattner, R.S.

1975-09-01

The syndrome of von Hippel and Lindau is a rare hereditary disorder constituted by retinal angiomata, posterior fossa and spinal cord hemangioblastomata, cystic and adenomatous dysplasia of major organs, and occasionally renal cell carcinomata. Although the syndrome is transmitted by an autosomal dominant gene, the penetrance is variable and affected persons may have any or all of the elements of the disease. The 16-year-old clinically normal daughter of a patient with the von Hippel--Lindau syndrome demonstrated a vascular posterior fossa lesion on /sup 99m/Tc-DTPA scintiangiography that failed detection in delayed images. Contrast arteriography corroborated the presence of a hemangioblastoma. Noninvasivemore » demonstration of the genetic penetrance of this disorder offers its victims an opportunity for low morbidity early surgical cure of the associated brain lesions. (auth)« less

Surgical Intervention for Instability of the Craniovertebral Junction

PubMed Central

TAKAYASU, Masakazu; AOYAMA, Masahiro; JOKO, Masahiro; TAKEUCHI, Mikinobu

2016-01-01

Surgical approaches for stabilizing the craniovertebral junction (CVJ) are classified as either anterior or posterior approaches. Among the anterior approaches, the established method is anterior odontoid screw fixation. Posterior approaches are classified as either atlanto-axial fixation or occipito-cervical (O-C) fixation. Spinal instrumentation using anchor screws and rods has become a popular method for posterior cervical fixation. Because this method achieves greater stability and higher success rates for fusion without the risk of sublaminar wiring, it has become a substitute for previous methods that used bone grafting and wiring. Several types of anchor screws are available, including C1/2 transarticular, C1 lateral mass, C2 pedicle, and translaminar screws. Appropriate anchor screws should be selected according to characteristics such as technical feasibility, safety, and strength. With these stronger anchor screws, shorter fixation has become possible. The present review discusses the current status of surgical interventions for stabilizing the CVJ. PMID:27041630

Lyman C. Johnston, DC, FICC, FCCS(C): Canadian chiropractic's postural research pioneer and inventive entrepreneur

PubMed Central

Brown, Douglas M.

2001-01-01

This paper profiles Dr. Lyman Johnston and his contributions in the field of chiropractic research. Postural concepts, diagnostic instruments, therapeutic devices and treatment protocols are reviewed. Set out and briefly discussed are the Posturometer, Pyramidal Man, anterior-posterior gravity line, Postural Spinal Index, tension master, Spine Power Belt and the Mini-Gym. ImagesFigure 1

Absent pedicles in campomelic dysplasia.

PubMed

McDowell, Michael M; Dede, Ozgur; Bosch, Patrick; Tyler-Kabara, Elizabeth C

2017-06-01

The objective of the present study is to report a case of campomelic dysplasia illustrating the absence of cervical and thoracic pedicles. This report reiterates the importance of this clinical peculiarity in the setting of spine instrumentation. A 10-year-old female patient with campomelic dysplasia presented with progressive kyphoscoliosis and signs of neural compromise. Imaging studies confirmed thoracic level stenosis and demonstrated absence of multiple pedicles in cervical and thoracic spine. The patient underwent decompression and instrumentation/fusion for her spinal deformity. The patient was instrumented between C2 and L4 with pedicle screws and sublaminar cables. However, pedicle fixation was not possible for the lower cervical and upper-mid thoracic spine. Also, floating posterior elements precluded the use of laminar fixation in the lower cervical spine. Cervicothoracic lumbosacral orthosis (CTLSO) was used for external immobilization to supplement the tenuous fixation in the cervicothoracic area. The patient improved neurologically with no signs of implant failure at the 2-year follow-up. Absence of pedicles and floating posterior elements present a challenge during spine surgery in campomelic dysplasia. Surgeons should prepare for alternative fixation methods and external immobilization when planning on spinal instrumentation in affected patients. Level IV Case Report.

A Comparison of Robotic, Body Weight-Supported Locomotor Training and Aquatic Therapy in Chronic Motor Incomplete Spinal Cord Injury Subject

DTIC Science & Technology

2013-10-01

continuing review, this approval will be available early November. All study personnel hold current certifications in order to participate in research...with headache and diaphoresis, but sometimes can be asymptomatic. There are reports of silent AD during voiding,7 bowel programs,8 sperm retrieval,9...dysreflexia and silent autonomic dysreflexia in men with SCI undergoing sperm retrieval: implications for clinical prac- tice. J Spinal Cord Med 2008;31(1

A Comparison of Robotic, Body Weight-Supported Locomotor Training and Aquatic Therapy in Chronic Motor Incomplete Spinal Cord Injury Subject

DTIC Science & Technology

2012-10-01

asymptomatic. There are reports of silent AD during voiding7, bowel programs 8, sperm retrieval9, and possibly accupunture10. It is unclear what long...no recent similar episodes but holds a past history of AD associated headache during voiding while dealing with renal stone disease with 1-2...autonomic dysreflexia and silent autonomic dysreflexia in men with SCI undergoing sperm retrieval: Implications for clinical practice. J Spinal

Incidence of tissue coring with the 25-gauge Quincke and Whitacre spinal needles.

PubMed

Campbell, D C; Douglas, M J; Taylor, G

1996-01-01

Tissue cores, implanted into the subarachnoid space during subarachnoid injections, can develop into intraspinal lumbar epidermoid tumors. The availability of smaller needles has made spinal anesthesia more popular. Therefore, this prospective, randomized, blinded study was undertaken to determine whether tissue coring occurs with two of the currently used 25-gauge spinal needles. Fifteen 25-gauge Quincke and seventeen 25-gauge Whitacre spinal needles, in which cerebrospinal fluid (CSF) was not identified and the local anesthetic solution not injected, were obtained from adult male patients undergoing spinal anesthesia. The needles were then evaluated by a pathologist following randomization with similar sterile, unused spinal needles. Twenty additional needles, ten of each type, in which CSF was identified and through which local anesthetic was injected, were also randomized with similar sterile, unused spinal needles and examined. Tissue cores were identified in 12 of the 15 Quincke and 7 of the 17 Whitacre spinal needles in which CSF was not identified (P < .05). Of the 20 needles in which CSF was identified and local anesthetic injected, no tissue cores were identified in the 10 Whitacre needles and only one small tissue core was identified in the 10 Quincke needles. All the tissue cores were identified as fat tissue. The 25-gauge Quincke and 25-gauge Whitacre spinal needles currently used in anesthesia can produce tissue coring.

Laparoscopic Cholecystectomy under Segmental Thoracic Spinal Anesthesia: A Feasible Economical Alternative.

PubMed

Kejriwal, Aditya Kumar; Begum, Shaheen; Krishan, Gopal; Agrawal, Richa

2017-01-01

Laparoscopic surgery is normally performed under general anesthesia, but regional techniques like thoracic epidural and lumbar spinal have been emerging and found beneficial. We performed a clinical case study of segmental thoracic spinal anaesthesia in a healthy patient. We selected an ASA grade I patient undergoing elective laparoscopic cholecystectomy and gave spinal anesthetic in T10-11 interspace using 1 ml of bupivacaine 5 mg ml -1 mixed with 0.5 ml of fentanyl 50 μg ml -1 . Other drugs were only given (systemically) to manage patient anxiety, pain, nausea, hypotension, or pruritus during or after surgery. The patient was reviewed 2 days postoperatively in ward. The thoracic spinal anesthetia was performed easily in the patient. Some discomfort which was readily treated with 1mg midazolam and 20 mg ketamine intravenously. There was no neurological deficit and hemodynamic parameters were in normal range intra and post-operatively and recovery was uneventful. We used a narrow gauze (26G) spinal needle which minimized the trauma to the patient and the chances of PDPH, which was more if 16 or 18G epidural needle had been used and could have increased further if there have been accidental dura puncture. Also using spinal anesthesia was economical although it should be done cautiously as we are giving spinal anesthesia above the level of termination of spinal cord.

Laparoscopic Cholecystectomy under Segmental Thoracic Spinal Anesthesia: A Feasible Economical Alternative

PubMed Central

Kejriwal, Aditya Kumar; Begum, Shaheen; Krishan, Gopal; Agrawal, Richa

2017-01-01

Laparoscopic surgery is normally performed under general anesthesia, but regional techniques like thoracic epidural and lumbar spinal have been emerging and found beneficial. We performed a clinical case study of segmental thoracic spinal anaesthesia in a healthy patient. We selected an ASA grade I patient undergoing elective laparoscopic cholecystectomy and gave spinal anesthetic in T10-11 interspace using 1 ml of bupivacaine 5 mg ml−1 mixed with 0.5 ml of fentanyl 50 μg ml−1. Other drugs were only given (systemically) to manage patient anxiety, pain, nausea, hypotension, or pruritus during or after surgery. The patient was reviewed 2 days postoperatively in ward. The thoracic spinal anesthetia was performed easily in the patient. Some discomfort which was readily treated with 1mg midazolam and 20 mg ketamine intravenously. There was no neurological deficit and hemodynamic parameters were in normal range intra and post-operatively and recovery was uneventful. We used a narrow gauze (26G) spinal needle which minimized the trauma to the patient and the chances of PDPH, which was more if 16 or 18G epidural needle had been used and could have increased further if there have been accidental dura puncture. Also using spinal anesthesia was economical although it should be done cautiously as we are giving spinal anesthesia above the level of termination of spinal cord. PMID:28928589

MRI Evaluation of Spinal Length and Vertebral Body Angle During Loading with a Spinal Compression Harness

NASA Technical Reports Server (NTRS)

Campbell, James A.; Hargens, Alan R.; Murthy, G.; Ballard, R. E.; Watenpaugh, D. E.; Hargens, Alan, R.; Sanchez, E.; Yang, C.; Mitsui, I.; Schwandt, D.;

The retrograde delivery of adenovirus vector carrying the gene for brain-derived neurotrophic factor protects neurons and oligodendrocytes from apoptosis in the chronically compressed spinal cord of twy/twy mice.

PubMed

Uchida, Kenzo; Nakajima, Hideaki; Hirai, Takayuki; Yayama, Takafumi; Chen, Kebing; Guerrero, Alexander Rodriguez; Johnson, William Eustace; Baba, Hisatoshi

2012-12-15

The twy/twy mouse undergoes spontaneous chronic mechanical compression of the spinal cord; this in vivo model system was used to examine the effects of retrograde adenovirus (adenoviral vector [AdV])-mediated brain-derived neurotrophic factor (BDNF) gene delivery to spinal neural cells. To investigate the targeting and potential neuroprotective effect of retrograde AdV-mediated BDNF gene transfection in the chronically compressed spinal cord in terms of prevention of apoptosis of neurons and oligodendrocytes. Several studies have investigated the neuroprotective effects of neurotrophins, including BDNF, in spinal cord injury. However, no report has described the effects of retrograde neurotrophic factor gene delivery in compressed spinal cords, including gene targeting and the potential to prevent neural cell apoptosis. AdV-BDNF or AdV-LacZ (as a control gene) was injected into the bilateral sternomastoid muscles of 18-week old twy/twy mice for retrograde gene delivery via the spinal accessory motor neurons. Heterozygous Institute of Cancer Research mice (+/twy), which do not undergo spontaneous spinal compression, were used as a control for the effects of such compression on gene delivery. The localization and cell specificity of β-galactosidase expression (produced by LacZ gene transfection) and BDNF expression in the spinal cord were examined by coimmunofluorescence staining for neural cell markers (NeuN, neurons; reactive immunology protein, oligodendrocytes; glial fibrillary acidic protein, astrocytes; OX-42, microglia) 4 weeks after gene injection. The possible neuroprotection afforded by retrograde AdV-BDNF gene delivery versus AdV-LacZ-transfected control mice was assessed by scoring the prevalence of apoptotic cells (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cells) and immunoreactivity to active caspases -3, -8, and -9, p75, neurofilament 200 kD (NF), and for the oligodendroglial progenitor marker, NG2. RESULTS.: Four weeks after injection, the retrograde delivery of the LacZ marker gene was identified in cervical spinal neurons and some glial cells, including oligodendrocytes in the white matter of the spinal cord, in both the twy/twy mouse and the heterozygous Institute of Cancer Research mouse (+/twy). In the compressed spinal cord of twy/twy mouse, AdV-BDNF gene transfection resulted in a significant decrease in the number of terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cells present in the spinal cord and a downregulation in the caspase apoptotic pathway compared with AdV-LacZ (control) gene transfection. There was a marked and significant increase in the areas of the spinal cord of AdV-BDNF-injected mice that were NF- and NG2-immunopositive compared with AdV-LacZ-injected mice, indicating the increased presence of neurons and oligodendrocytes in response to BDNF transfection. Our results demonstrate that targeted retrograde BDNF gene delivery suppresses apoptosis in neurons and oligodendrocytes in the chronically compressed spinal cord of twy/twy mouse. Further work is required to establish whether this method of gene delivery may provide neuroprotective effects in other situations of compressive spinal cord injury.

[Application of evoked potentials monitoring in total thoracoabdominal aorta aneurysm repair].

PubMed

Duan, Y Y; Zheng, J; Pan, X D; Zhu, J M; Liu, Y M; Ge, Y P; Cheng, L J; Sun, L Z

2016-04-05

To evaluate the application value of evoked potentials (EP) monitoring in patients undergoing aorta-iliac bypass for total thoracoabdominal aorta aneurysm repair (tTAAAR). A prospective study, with a total of 31 patients undergoing tTAAAR and intraoperative EP monitoring from June 2014 to April 2015 was carried out. The results of intraoperative evoked potentials, clinical outcomes and follow-up data of patients were collected for further evaluation. The EP wave disappeared [motor evoked potentials for (55.6±18.1) min, somatosensory evoked potentials for (50.3±18.7) min] after proximal descending aorta being clamped, and gradually recovered after the segment arteries of spine cord were reconstructed. The EP wave was restored to normal level at the end of operation in all the cases. The somatosensory evoked potentials remained unchanged in 2 cases (false negative). One case died after operation. No spinal cord injury occurred. The median follow-up after operation was 10 months (5-14 months). There was no delayed neurological deficit. EP provided an on-line monitoring of the condition of spinal cord function, which become an intraoperative protocol to avoid the irreversible injury of spinal cord.

Epithelioid hemangioendothelioma of the spine: case report and review of the literature

PubMed Central

Albakr, Abdulrahman; Schell, Miranda; Drew, Brian

2017-01-01

Epithelioid hemangioendothelioma (EHE) has been described as a rare vascular bone lesion with histological features between hemangioma and high-grade angiosarcoma. Spinal EHE is a quite rare disease with few case reports and series reported in the literature. The tumor cells are positive for vimentin, CD31and CD34, factor VIII related antigen, ERG, and FLI1. Radiological features are not specific; it may appear as an osteolytic lesion. It can present as a multifocal disease in 40% of cases. No clear correlation with age and sex; however, it is slightly more common in males. Focal neck or back pain is the most common presenting symptom. The natural history of spinal EHE is unpredictable, and currently, there is no standard of care for treatment. Treatment options include preoperative embolization, and surgical resection followed by radiotherapy and/or chemotherapy. A 34-year-old previously healthy male presented with mid-thoracic back pain. Magnetic resonance imaging (MRI) of the spine revealed a decrease in vertebral body height at T5 with an enhancing mass. He underwent T5 balloon kyphoplasty and needle vertebral body biopsy. Results of the biopsy samples were non-diagnostic. Approximately 3 months after surgery, the patient presented with unsteady gait. A subsequent MRI revealed progression of the T5 compression fracture with cord compression. The patient subsequently underwent T4–T6 bilateral posterior decompression for epidural tumor and T3–T7 posterior instrumentation with pedicle screws. Pathology of the lesion revealed EHE. The patient was started on local radiation therapy (RT). On follow-up, 3 months after the second surgery, the thoracic spinal pain had improved dramatically. Our review highlights the diagnosis, clinical presentation, and treatment of spinal EHE. Complete resection is associated with good outcome. Radiotherapy has been used in partially resected lesions. However, the role of radiotherapy as primary treatment is not yet defined. Further studies should develop a treatment algorithm for this rare tumour. PMID:28744509

Investigation of the Differential Contributions of Superficial and Deep Muscles on Cervical Spinal Loads with Changing Head Postures

PubMed Central

Cheng, Chih-Hsiu; Chien, Andy; Hsu, Wei-Li; Chen, Carl Pai-Chu; Cheng, Hsin-Yi Kathy

2016-01-01

Cervical spinal loads are predominately influenced by activities of cervical muscles. However, the coordination between deep and superficial muscles and their influence on the spinal loads is not well understood. This study aims to document the changes of cervical spinal loads and the differential contributions of superficial and deep muscles with varying head postures. Electromyography (EMG) of cervical muscles from seventeen healthy adults were measured during maximal isometric exertions for lateral flexion (at 10°, 20° and terminal position) as well as flexion/extension (at 10°, 20°, 30°, and terminal position) neck postures. An EMG-assisted optimization approach was used to estimate the muscle forces and subsequent spinal loads. The results showed that compressive and anterior-posterior shear loads increased significantly with neck flexion. In particular, deep muscle forces increased significantly with increasing flexion. It was also determined that in all different static head postures, the deep muscle forces were greater than those of the superficial muscle forces, however, such pattern was reversed during peak efforts where greater superficial muscle forces were identified with increasing angle of inclination. In summary, the identification of significantly increased spinal loads associated with increased deep muscle activation during flexion postures, implies higher risks in predisposing the neck to occupationally related disorders. The results also explicitly supported that deep muscles play a greater role in maintaining stable head postures where superficial muscles are responsible for peak exertions and reinforcing the spinal stability at terminal head postures. This study provided quantitative data of normal cervical spinal loads and revealed motor control strategies in coordinating the superficial and deep muscles during physical tasks. PMID:26938773

Investigation of the Differential Contributions of Superficial and Deep Muscles on Cervical Spinal Loads with Changing Head Postures.

PubMed

Cheng, Chih-Hsiu; Chien, Andy; Hsu, Wei-Li; Chen, Carl Pai-Chu; Cheng, Hsin-Yi Kathy

2016-01-01

Cervical spinal loads are predominately influenced by activities of cervical muscles. However, the coordination between deep and superficial muscles and their influence on the spinal loads is not well understood. This study aims to document the changes of cervical spinal loads and the differential contributions of superficial and deep muscles with varying head postures. Electromyography (EMG) of cervical muscles from seventeen healthy adults were measured during maximal isometric exertions for lateral flexion (at 10°, 20° and terminal position) as well as flexion/extension (at 10°, 20°, 30°, and terminal position) neck postures. An EMG-assisted optimization approach was used to estimate the muscle forces and subsequent spinal loads. The results showed that compressive and anterior-posterior shear loads increased significantly with neck flexion. In particular, deep muscle forces increased significantly with increasing flexion. It was also determined that in all different static head postures, the deep muscle forces were greater than those of the superficial muscle forces, however, such pattern was reversed during peak efforts where greater superficial muscle forces were identified with increasing angle of inclination. In summary, the identification of significantly increased spinal loads associated with increased deep muscle activation during flexion postures, implies higher risks in predisposing the neck to occupationally related disorders. The results also explicitly supported that deep muscles play a greater role in maintaining stable head postures where superficial muscles are responsible for peak exertions and reinforcing the spinal stability at terminal head postures. This study provided quantitative data of normal cervical spinal loads and revealed motor control strategies in coordinating the superficial and deep muscles during physical tasks.

Remodelling of the sacrum in high-grade spondylolisthesis: a report of two cases.

PubMed

van Ooij, André; Weijers, René; van Rhijn, Lodewijk

2003-06-01

Two young patients are described, who were operated on for high-grade spondylolisthesis. A good posterolateral fusion was achieved, without decompression and without reduction. The clinical course was favourable, the tight hamstring syndrome resolved. Disappearance of the posterior-superior part of the sacrum and of the posterior part of the L5-S1 disc was observed on comparing pre- and postoperative magnetic resonance (MR) images. This resulted in normalisation of the width of the spinal canal. Around the L5 nerve roots in the L5-S1 foramina some fat reappeared. These anatomical changes on MRI could play a role in the disappearance of clinical symptoms.

Extraskeletal Ewing's sarcoma.

PubMed

El-Essawy, Manar T

2009-06-01

We report 2 rare cases of extraskeletal Ewing's sarcoma, one is arising primarily from the posterior mediastinum in a middle-aged man (patient 1), and the other one is arising from the left kidney in a young male patient (patient 2). The CT in the first case showed a large mass of heterogeneous texture, with areas of cystic changes in the right side of the posterior mediastinum, no underlying bony changes or intra-spinal extension, and this mass was diagnosed as lymphoma. The second case showed almost complete replacement of the left kidney by a mass with extension through the renal vein and inferior vena cava, and it was diagnosed as renal cell carcinoma. The histological analysis of these lesions revealed extraskeletal Ewing's sarcoma.

Lumbar subdural cerebrospinal fluid collection with acute cauda equina syndrome after posterior fossa decompression for Chiari malformation Type I: case report.

PubMed

Darwish, Houssein A; Oldfield, Edward H

2016-09-01

This report describes the circumstances of a patient with a cauda equina syndrome due to the development of a lumbar subdural CSF collection with ventral displacement of the cauda equina shortly following posterior fossa decompression for Chiari malformation Type I (CM-I). This unusual, but clinically significant, complication was successfully treated with percutaneous drainage of the extraarachnoid CSF collection. Although there are a few cases of intracranial subdural hygroma developing after surgery for CM-I, often attributed to a pinhole opening in the arachnoid, as far as the authors can determine, a spinal subdural hygroma associated with surgery for CM-I has not been recognized.

Prevention of altered hemodynamics after spinal anesthesia: A comparison of volume preloading with tetrastarch, succinylated gelatin and ringer lactate solution for the patients undergoing lower segment caesarean section

PubMed Central

Mitra, Tapobrata; Das, Anjan; Majumdar, Saikat; Bhattacharyya, Tapas; Mandal, Rahul Deb; Hajra, Bimal Kumar

2014-01-01

Background: Spinal anesthesia has replaced general anesthesia in obstetric practice. Hemodynamic instability is a common, but preventable complication of spinal anesthesia. Preloading the circulation with intravenous fluids is considered a safe and effective method of preventing hypotension following spinal anesthesia. We had conducted a study to compare the hemodynamic stability after volume preloading with either Ringer's lactate (RL) or tetrastarch hydroxyethyl starch (HES) or succinylated gelatin (SG) in the patients undergoing cesarean section under spinal anesthesia. Materials and Methods: It was a prospective, double-blinded and randomized controlled study. Ninety six ASA-I healthy, nonlaboring parturients were randomly divided in 3 groups HES, SG, RL (n = 32 each) and received 10 ml/kg HES 130/0.4; 10 ml/kg SG (4% modified fluid gelatin) and 20 ml/kg RL respectively prior to SA scheduled for cesarean section. Heart rate, blood pressure (BP), oxygen saturation was measured. Results: The fall in systolic blood pressure (SBP) (<100 mm Hg) noted among 5 (15.63%), 12 (37.5%) and 14 (43.75%) parturients in groups HES, SG, RL respectively. Vasopressor (phenylephrine) was used to treat hypotension when SBP <90 mm Hg. Both the results and APGAR scores were comparable in all the groups. Lower preloading volume and less intra-operative vasopressor requirement was noted in HES group for maintaining BP though it has no clinical significance. Conclusion: RL which is cheap, physiological and widely available crystalloid can preload effectively and maintain hemodynamic stability well in cesarean section and any remnant hypotension can easily be manageable with vasopressor. PMID:25422601

Epinephrine administered with lidocaine solution does not worsen intrathecal lidocaine neurotoxicity in rats.

PubMed

Komatsu, Toshiaki; Takenami, Tamie; Nara, Yoshihiro; Yagishita, Saburo; Kurashige, Chie; Okamoto, Hirotsugu; Yago, Kazuo

2013-01-01

Epinephrine can potentially worsen the neurotoxic effects of local anesthetics when used for spinal or epidural anesthesia. The vasoconstrictive property of epinephrine reduces dural blood flow, which in turn reduces the clearance of local anesthetics from the subarachnoid space. This study examined the histological and neurofunctional effects of intrathecally administered lidocaine combined with epinephrine in rats. Sixty-two rats were divided into 9 treatment groups: 5% or 7.5% lidocaine in 10% glucose solution with or without 0.1 or 0.5 mg/mL epinephrine, or epinephrine alone at 0.1 or 0.5 mg/mL in 10% glucose, or 10% glucose alone. Hind-limb motor function was evaluated immediately after drug injection by walking behavior. Sensory function was assessed by the response to radiant heat stimulation at just before and 1 week after the injection. Seven days after the injection, L3 spinal cord with anterior and posterior roots, the dorsal ganglion, and cauda equina were harvested and examined histologically. Histological lesions were limited to the posterior root just at entry into the spinal cord in rats injected with 7.5% lidocaine, with and without epinephrine. No histological abnormalities were noted in other areas or other groups. There was no significant change in sensory threshold in all groups. Significantly, prolongation of gait recovery time was noted in 5% and 7.5% lidocaine with epinephrine groups compared with 5% or 7.5% lidocaine alone. Intrathecal epinephrine prolonged the action of intrathecal lidocaine but did not worsen lidocaine-induced histological damage and functional impairment.

Baricity of Bupivacaine on Maternal Hemodynamics after Spinal Anesthesia for Cesarean Section: A Randomized Controlled Trial

PubMed Central

Atashkhoei, Simin; Abedini, Naghi; Pourfathi, Hojjat; Znoz, Ali Bahrami; Marandi, Pouya Hatami

2017-01-01

Background: After spinal anesthesia, patients undergoing cesarean section are more likely to develop hemodynamic changes. The baricity of local anesthetic has an important role on spinal blockade effects. The aim of this study was to compare the isobar and hyperbaric bupivacaine 0.5% plus fentanyl on maternal hemodynamics after spinal anesthesia for C/S. Methods: In this double-blind study, 84 healthy pregnant women undergoing C/S using bupivacaine 0.5% isobar (study group, n=42) or hyperbaric (control group, n=42) for spinal anesthesia were scheduled. The study was conducted from 21 April 2014 to 21 November 2014 at Al-Zahra Hospital, Tabriz, Iran. Parameters such as maternal hemodynamics, block characteristics, side effects, and neonatal Apgar scores were recorded. Data were analyzed using the SPSS software by performing chi-square test, Fisher’s exact test, one-way ANOVA, Mann-Whitney U-test, and student’s t test. Results: The incidence of hypotension in the isobar group was lower than the hyperbaric group, although it was not statistically significant (40.47% vs. 61.9%, P=0.08). The duration of hypotension was shorter in the study group (1.6±7.8 min vs. 7.4±12.5 min, P=0.004). The dose of ephedrine was lower in the study group (2.4±6.6 mg vs. 5.3±10.7 mg, P=0.006). The main maternal side effect is sustained hypotension that was seen in 0 patients of the isobar and 7 (16.66%) of hyperbaric groups (P=0.006). None of the neonates had Apgar score≤7 at 5 min of delivery (P=1.0). Sensory and motor block duration was shorter in the study group (P=0.01). Conclusion: Isobaric bupivacaine is associated with more hemodynamic stability and shorter sensory and motor blockade in mothers under spinal anesthesia for C/S. Trial Registration Number: IRCT201401287013N7 PMID:28360439

Brown-Sequard syndrome associated with unusual spinal cord injury by a screwdriver stab wound

PubMed Central

Beer-Furlan, André Luiz; Paiva, Wellingson Silva; Tavares, Wagner Malagó; de Andrade, Almir Ferreira; Teixeira, Manoel Jacobsen

2014-01-01

Introduction: Stab wounds resulting in spinal cord injuries are very rare. In direct central back stabbings, the layers of muscles and the spinal column tends to deflect blades, rarely causing injuries to the spinal cord. We report an unusual case of traumatic spinal cord injury by a screwdriver stab, presented as Brown-Séquard syndrome and discuss possible pitfalls on the surgical treatment. Case report: A 34 year-old man was brought to the emergency department after a group assault with a single screwdriver stab wound on the back. Neurological examination revealed an incomplete Brown-Sequard syndrome, with grade IV motor deficit on the left leg and contralateral hemihypoalgesia below T9 level. Radiological evaluation showed a retained 9 cm screwdriver that entered and trespassed the spinal canal at T6 level, reaching the posterior mediastinum with close relation to the thoracic aorta. Vascular injury could not be excluded. The joint decision between the neurosurgery and the vascular surgery teams was the surgical removal of the screwdriver under direct visualization. A left mini-thoracotomy was performed. Simultaneously, a careful dissection was done and screwdriver was firmly pulled back on the opposite path of entry under direct visualization of the aorta. The neurological deficit was maintained immediately after the surgical procedure. Follow-up visit after 1 year showed minor motor deficit and good healing. Conclusions: It is important to consider all aspects of secondary injury on the surgical planning of penetrating spinal cord injury. The secondary injury can be minimized with multidisciplinary planning of the surgical procedure. PMID:24482724

The science of spinal motion palpation: a review and update with implications for assessment and intervention

PubMed Central

Nyberg, Richard Edward; Russell Smith, A

2013-01-01

Spinal motion palpation (SMP) is a standard component of a manual therapy examination despite questionable reliability. The present research is inconclusive as to the relevance of the findings from SMP, with respect to the patient’s pain complaints. Differences in the testing methods and interpretation of spinal mobility testing are problematic. If SMP is to be a meaningful component of a spinal examination, the methods for testing and interpretation must be carefully scrutinized. The intent of this narrative review is to facilitate a better understanding of how SMP should provide the examiner with relevant information for assessment and treatment of patients with spinal pain disorders. The concept of just noticeable difference is presented and applied to SMP as a suggestion for determining the neutral zone behavior of a spinal segment. In addition, the use of a lighter, or more passive receptive palpation technique, is considered as a means for increasing tactile discrimination of spinal movement behavior. Further understanding of the scientific basis of testing SMP may improve intra- and inter-examiner reliability. The significance of the findings from SMP should be considered in context of the patient’s functional problem. Methodological changes may be indicated for the performance of SMP techniques, such as central posterior-anterior (PA) pressure and passive intervertebral motion tests, in order to improve reliability. Instructors of manual therapy involved in teaching SMP should be knowledgeable of the neurophysiological processes of touch sensation so as to best advise students in the application of the various testing techniques. PMID:24421627

LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review.

PubMed

Moppett, I K; Rowlands, M; Mannings, A; Moran, C G; Wiles, M D

2015-03-01

Hip fracture is a condition with high mortality and morbidity in elderly frail patients. Intraoperative fluid optimization may be associated with benefit in this population. We investigated whether intraoperative fluid management using pulse-contour analysis cardiac monitoring, compared with standard care in patients undergoing spinal anaesthesia, would provide benefits in terms of reduced time until medically fit for discharge and postoperative complications. Patients undergoing surgical repair of fractured neck of femur, aged >60 yr, receiving spinal anaesthesia were enrolled in this single-centre, blinded, randomized, parallel group trial. Patients were allocated to either anaesthetist-directed fluid therapy or a pulse-contour-guided fluid optimization strategy using colloid (Gelofusine) boluses to optimize stroke volume. The primary outcome was time until medically fit for discharge. Secondary outcomes included postoperative complications, mobility, and mortality. We updated a systematic review to include relevant trials to 2014. We recruited 130 patients. Time until medically fit for discharge was similar in both groups, mean [95% confidence interval (CI)] 12.2 (11.1-13.5) vs 13.1 (11.9-14.5) days (P=0.31), as was total length of stay 14.2 (12.9-15.8) vs 15.3 (13.8-17.2) days (P=0.32). There were no significant differences in complications, function, or mortality. An updated meta-analysis (four studies, 355 patients) found non-significant reduction in early mortality [relative risk 0.66 (0.24-1.79)] and in-hospital complications [relative risk 0.80 (0.61-1.05)]. Goal-directed fluid therapy during hip fracture repair under spinal anaesthesia does not result in a significant reduction in length of stay or postoperative complications. There is insufficient evidence to either support or discount its routine use. ISRCTN88284896. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Is there a difference in postdural puncture headache after continuous spinal anesthesia with 28G microcatheters compared with punctures with 22G Quincke or Sprotte spinal needles?

PubMed

Lux, Eberhard Albert; Althaus, Astrid

2014-01-01

In this retrospective study, the question was raised and answered whether the rate of postdural puncture headache (PDPH) after continuous spinal anesthesia with a 28G microcatheter varies using a Quincke or a Sprotte needle. The medical records of all patients with allogenic joint replacement of the knee or hip or arthroscopic surgery of the knee joint undergoing continuous spinal anesthesia with a 22G Quincke (n=1,212) or 22G Sprotte needle (n=377) and a 28G microcatheter during the past 6 years were reviewed. We obtained the approval of the ethical committee. The rates of PDPH were statistically not different between both groups: 1.5% of patients developed PDPH after dura puncture with a Quincke needle and 2.1% with a Sprotte needle in women and men.

Is there a difference in postdural puncture headache after continuous spinal anesthesia with 28G microcatheters compared with punctures with 22G Quincke or Sprotte spinal needles?

PubMed Central

Lux, Eberhard Albert; Althaus, Astrid

2014-01-01

In this retrospective study, the question was raised and answered whether the rate of postdural puncture headache (PDPH) after continuous spinal anesthesia with a 28G microcatheter varies using a Quincke or a Sprotte needle. The medical records of all patients with allogenic joint replacement of the knee or hip or arthroscopic surgery of the knee joint undergoing continuous spinal anesthesia with a 22G Quincke (n=1,212) or 22G Sprotte needle (n=377) and a 28G microcatheter during the past 6 years were reviewed. We obtained the approval of the ethical committee. The rates of PDPH were statistically not different between both groups: 1.5% of patients developed PDPH after dura puncture with a Quincke needle and 2.1% with a Sprotte needle in women and men. PMID:25419159

Anterior spinal artery syndrome. Paraplegia following segmental ischaemic injury to the spinal cord after oesophagectomy.

PubMed

Djurberg, H; Haddad, M

1995-04-01

A case of unexpected paraplegia after oesophageal resection under general anaesthesia combined with epidural analgesia and intra-operative intercostal block is described. Patients with compromised cardiovascular and respiratory function undergoing thoracic or major abdominal surgery can benefit significantly intra-operatively from a combination of general anaesthesia and regional analgesia. The continued use of regional analgesia into the postoperative period offers even more advantages. General anaesthesia administered before regional analgesia may, however, mask complications related to the regional technique and delay the instigation of corrective measures. The blood supply to the anterior part of the spinal cord, through the artery of Adamkiewicz, may be impaired intra-operatively leading to neurological sequelae known as the anterior spinal artery syndrome, characterised by loss of motor function with intact or partially intact sensory function. Patients at risk of developing the syndrome can be identified pre-operatively.

Laparoscopic cholecystectomy under continuous spinal anesthesia in a patient with Steinert's disease.

PubMed

Correia, Mariana; dos Santos, Angela; Lages, Neusa; Correia, Carlos

2016-01-01

Steinert's disease is an intrinsic disorder of the muscle with multisystem manifestations. Myotonia may affect any muscle group, is elicited by several factors and drugs used in general anesthesia like hypnotics, sedatives and opioids. Although some authors recommend the use of regional anesthesia or combined anesthesia with low doses of opioids, the safest anesthetic technique still has to be established. We performed a continuous spinal anesthesia in a patient with Steinert's disease undergoing laparoscopic cholecystectomy using 10mg of bupivacaine 0.5% and provided ventilatory support in the perioperative period. Continuous spinal anesthesia was safely used in Steinert's disease patients but is not described for laparoscopic cholecystectomy. We reported a continuous spinal anesthesia as an appropriate technique for laparoscopic cholecystectomy and particularly valuable in Steinert's disease patients. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Posterior transpedicular approach with circumferential debridement and anterior reconstruction as a salvage procedure for symptomatic failed vertebroplasty.

PubMed

Chiu, Yen-Chun; Yang, Shih-Chieh; Chen, Hung-Shu; Kao, Yu-Hsien; Tu, Yuan-Kun

2015-02-10

Complications and failure of vertebroplasty, such as cement dislodgement, cement leakage, or spinal infection, usually result in spinal instability and neural element compression. Combined anterior and posterior approaches are the most common salvage procedure for symptomatic failed vertebroplasty. The purpose of this study is to evaluate the feasibility and efficacy of a single posterior approach technique for the treatment of patients with symptomatic failed vertebroplasty. Ten patients with symptomatic failed vertebroplasty underwent circumferential debridement and anterior reconstruction surgery through a single-stage posterior transpedicular approach (PTA) from January 2009 to December 2011 at our institution. The differences of visual analog scale (VAS), neurologic status, and vertebral body reconstruction before and after surgery were recorded. The clinical outcomes of patients were categorized as excellent, good, fair, or poor based on modified Brodsky's criteria. The symptomatic failed vertebroplasty occurred between the T11 and L3 vertebrae with one- or two-level involvement. The average VAS score was 8.3 (range, 7 to 9) before surgery, significantly decreased to 3.2 (range, 2 to 4) after surgery (p < 0.01), and continued to decrease to 2.4 (range, 2 to 3) 1 year later (p < 0.01). The average correction of Cobb's angle after surgery was 17.3° (range, 4° to 35°) (p < 0.01). The mean loss of Cobb's angle correction after 1 year of follow-up was 2.7° (range, 0° to 5°). The average allograft subsidence at 1 year after surgery was 1 mm (range, 0 to 2). The neurologic status of Frankel's scale significantly improved after surgery (p = 0.014) and at 1 year after surgery (p = 0.046). No one experienced severe complications such as deep wound infection or neurologic deterioration. All patients achieved good or excellent outcomes after surgery based on modified Brodsky's criteria (p < 0.01). Single-stage PTA surgery with circumferential debridement and anterior reconstruction technique provides good clinical outcomes and low complication rate, which can be considered as an alternative method to combined anterior and posterior approaches for patients with symptomatic failed vertebroplasty.

[Chronic pain and syringomyelic slit of the posterior horns of the spinal cord].

PubMed

Rémillard, G M; Robitaille, Y; Bertrand, G

1985-01-01

Two male patients 46 and 44 y.o. respectively, were admitted for a syndrome of chronic pain characterized by: sudden onset, spontaneous or following spasmodic coughing, of an anterior hemithoracic pain slowly progressing to involve several unilateral cervicothoracic dermatomes, a continuous burning sensation made worse by light touch, limb movements and cold water, and partially relieved by warm water or deep palpation. On examination, patient 1 revealed no sensorimotor deficit after repeated observations during 8 years. At autopsy, a syrinx localized at the cord segments corresponding to the symptoms was found without documentation of specific causal factors. It involved the posterior horn of the cord selectively. In patient 2, pain was associated with slight hypesthesia to pinprick and heat from C2 to T5 on the left without motor deficit since 18 months. A high resolution C.A.T. scan showed an intramedullary cavity 0.3 cm from the midline in the projection of the posterior horn without anomalies at the cervicomedullary junction. These observations link chronic pain syndromes with predominantly posterior horn lesions, which so far have failed to respond to conventional therapeutic measures.

Massive blood loss in elective spinal and orthopedic surgery: Retrospective review of intraoperative transfusion strategy.

PubMed

Rankin, Demicha; Zuleta-Alarcon, Alix; Soghomonyan, Suren; Abdel-Rasoul, Mahmoud; Castellon-Larios, Karina; Bergese, Sergio D

2017-02-01

To evaluate the perioperative dynamics of hematologic changes and transfusion ratio in patients undergoing a major spinal surgery accompanied with massive bleeding defined as blood loss >5 liters. Retrospective cohort study. Operating room of a university-affiliated hospital. Adult patients who underwent elective neurosurgical, orthopedic, or combined spinal surgical procedure between 2008 and 2012. Patients who underwent a major spinal or orthopedic surgery and who experienced major bleeding (>5 L) during surgery were identified and selected for final analysis. The following information was analyzed: demographics, clinical diagnoses, hematologic parameters, estimated intraoperative blood loss, blood product transfusions, and survival 1 year after surgery. During the study period, 25 patients, who underwent 28 spinal procedures, experienced intraoperative blood loss >5 L. Mean patient age was 50.5 years and 56.4% were males. The majority of patients underwent procedures to manage spinal metastases. Median estimated intraoperative blood loss was 11.25 L (IQR 6.35-22 L) and median number of units (U) transfused was 24.5 U (IQR 14.0-32.5 U) of packed red blood cells (RBCs), 24.5 U (IQR 14.0-34.0 U) of fresh frozen plasma (FFP), and 4.5 U (IQR 3.0-11.5 U) of platelets (PLTs). The blood product transfusion ratio was 1 and 4 for RBC:FFP, and RBC:PLT, respectively. Hematocrit, hemoglobin, PLTs, partial thromboplastin, prothrombin time, INR, and, fibrinogen varied significantly throughout the procedures. However, acid-base status did not change significantly during surgery. Patients' survival at 1 year was 79.17%. Our results indicate that a 1:1 RBC:FFP and 4:1 RBC:PLT transfusion ratio was associated with significant intraoperative variations in coagulation variables but stable intraoperative acid-base parameters. This transfusion ratio helped clinicians to achieve postoperative coagulation parameters not significantly different to those at baseline. Future studies should assess if more liberal transfusion strategies or point of care monitoring might be warranted in patients undergoing spinal surgery at risk of major blood loss. Copyright © 2016 Elsevier Inc. All rights reserved.

Risk Factors for Blood Transfusion With Primary Posterior Lumbar Fusion.

PubMed

Basques, Bryce A; Anandasivam, Nidharshan S; Webb, Matthew L; Samuel, Andre M; Lukasiewicz, Adam M; Bohl, Daniel D; Grauer, Jonathan N

2015-11-01

Retrospective cohort study. To identify factors associated with blood transfusion for primary posterior lumbar fusion surgery, and to identify associations between blood transfusion and other postoperative complications. Blood transfusion is a relatively common occurrence for patients undergoing primary posterior lumbar fusion. There is limited information available describing which patients are at increased risk for blood transfusion, and the relationship between blood transfusion and short-term postoperative outcomes is poorly characterized. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing primary posterior lumbar fusion from 2011 to 2013. Multivariate analysis was used to find associations between patient characteristics and blood transfusion, along with associations between blood transfusion and postoperative outcomes. Out of 4223 patients, 704 (16.7%) had a blood transfusion. Age 60 to 69 (relative risk [RR] 1.6), age greater than equal to 70 (RR 1.7), American Society of Anesthesiologists class greater than equal to 3 (RR 1.1), female sex (RR 1.1), pulmonary disease (RR 1.2), preoperative hematocrit less than 36.0 (RR 2.0), operative time greater than equal to 310 minutes (RR 2.9), 2 levels (RR 1.6), and 3 or more levels (RR 2.1) were independently associated with blood transfusion. Interbody fusion (RR 0.9) was associated with decreased rates of blood transfusion. Receiving a blood transfusion was significantly associated with any complication (RR 1.7), sepsis (RR 2.6), return to the operating room (RR 1.7), deep surgical site infection (RR 2.6), and pulmonary embolism (RR 5.1). Blood transfusion was also associated with an increase in postoperative length of stay of 1.4 days (P < 0.001). 1 in 6 patients received a blood transfusion while undergoing primary posterior lumbar fusion, and risk factors for these occurrences were characterized. Strategies to minimize blood loss might be considered in these patients to avoid the associated complications. 3.

Retrospective, Demographic, and Clinical Investigation of the Causes of Postoperative Infection in Patients With Lumbar Spinal Stenosis Who Underwent Posterior Stabilization

PubMed Central

Yaldiz, Can; Yaldiz, Mahizer; Ceylan, Nehir; Kacira, Ozlem Kitiki; Ceylan, Davut; Kacira, Tibet; Kizilcay, Gokhan; Tanriverdi, Taner

2015-01-01

Abstract Owing to the increasing population of elderly patients, a large number of patients with degenerative spondylosis are currently being surgically treated. Although basic measures for decreasing postoperative surgical infections (PSIs) are considered, it still remains among the leading causes of morbidity and mortality. The aim of this retrospective analysis is to present possible causes leading to PSI in patients who underwent surgery for lumbar degenerative spondylosis and highlight how it can be avoided to decrease morbidity and mortality. The study included 540 patients who underwent posterior stabilization due to degenerative lumbar stenosis between January 2013 and January 2014. The data before and after surgery was retrieved from the hospital charts. Patients with degenerative lumbar stenosis who were operated upon in this study had >2 levels of laminectomy and facetectomy. For this reason, posterior stabilization was performed for all the patients included in this study. Determining the causes of postoperative infection (PI) following spinal surgeries performed with instrumentation is a struggle. Seventeen different parameters that may be related to PI were evaluated in this study. The presence of systemic diseases, unknown glove perforations, and perioperative blood transfusions were among the parameters that increased the prevalence of PI. Alternatively, prolene sutures, double-layered gloves, and the use of rifampicin Sv (RIS) decreased the incidence of PI. Although the presence of systemic diseases, unnoticed glove perforations, and perioperative blood transfusions increased PIs, prolene suture material, double-layered gloves, and the use of RIS decreased PIs. PMID:26200620

Dissection and lateral mounting of zebrafish embryos: analysis of spinal cord development.

PubMed

Beck, Aaron P; Watt, Roland M; Bonner, Jennifer

2014-02-28

The zebrafish spinal cord is an effective investigative model for nervous system research for several reasons. First, genetic, transgenic and gene knockdown approaches can be utilized to examine the molecular mechanisms underlying nervous system development. Second, large clutches of developmentally synchronized embryos provide large experimental sample sizes. Third, the optical clarity of the zebrafish embryo permits researchers to visualize progenitor, glial, and neuronal populations. Although zebrafish embryos are transparent, specimen thickness can impede effective microscopic visualization. One reason for this is the tandem development of the spinal cord and overlying somite tissue. Another reason is the large yolk ball, which is still present during periods of early neurogenesis. In this article, we demonstrate microdissection and removal of the yolk in fixed embryos, which allows microscopic visualization while preserving surrounding somite tissue. We also demonstrate semipermanent mounting of zebrafish embryos. This permits observation of neurodevelopment in the dorso-ventral and anterior-posterior axes, as it preserves the three-dimensionality of the tissue.

Dissection and Lateral Mounting of Zebrafish Embryos: Analysis of Spinal Cord Development

PubMed Central

Beck, Aaron P.; Watt, Roland M.; Bonner, Jennifer

2014-01-01

The zebrafish spinal cord is an effective investigative model for nervous system research for several reasons. First, genetic, transgenic and gene knockdown approaches can be utilized to examine the molecular mechanisms underlying nervous system development. Second, large clutches of developmentally synchronized embryos provide large experimental sample sizes. Third, the optical clarity of the zebrafish embryo permits researchers to visualize progenitor, glial, and neuronal populations. Although zebrafish embryos are transparent, specimen thickness can impede effective microscopic visualization. One reason for this is the tandem development of the spinal cord and overlying somite tissue. Another reason is the large yolk ball, which is still present during periods of early neurogenesis. In this article, we demonstrate microdissection and removal of the yolk in fixed embryos, which allows microscopic visualization while preserving surrounding somite tissue. We also demonstrate semipermanent mounting of zebrafish embryos. This permits observation of neurodevelopment in the dorso-ventral and anterior-posterior axes, as it preserves the three-dimensionality of the tissue. PMID:24637734

A New Population of Parvocellular Oxytocin Neurons Controlling Magnocellular Neuron Activity and Inflammatory Pain Processing

PubMed Central

Eliava, Marina; Melchior, Meggane; Knobloch-Bollmann, H. Sophie; Wahis, Jérôme; Gouveia, Miriam da Silva; Tang, Yan; Ciobanu, Alexandru Cristian; del Rio, Rodrigo Triana; Roth, Lena C.; Althammer, Ferdinand; Chavant, Virginie; Goumon, Yannick; Gruber, Tim; Petit-Demoulière, Nathalie; Busnelli, Marta; Chini, Bice; Tan, Linette L.; Mitre, Mariela; Froemke, Robert C.; Chao, Moses V.; Giese, Günter; Sprengel, Rolf; Kuner, Rohini; Poisbeau, Pierrick; Seeburg, Peter H.; Stoop, Ron; Charlet, Alexandre; Grinevich, Valery

2017-01-01

SUMMARY Oxytocin (OT) is a neuropeptide elaborated by the hypothalamic paraventricular (PVN) and supraoptic (SON) nuclei. Magnocellular OT neurons of these nuclei innervate numerous forebrain regions and release OT into the blood from the posterior pituitary. The PVN also harbors parvocellular OT cells that project to the brainstem and spinal cord, but their function has not been directly assessed. Here, we identified a subset of approximately 30 parvocellular OT neurons, with collateral projections onto magnocellular OT neurons and neurons of deep layers of the spinal cord. Evoked OT release from these OT neurons suppresses nociception and promotes analgesia in an animal model of inflammatory pain. Our findings identify a new population of OT neurons that modulates nociception in a two tier process: (1) directly by release of OT from axons onto sensory spinal cord neurons and inhibiting their activity and (2) indirectly by stimulating OT release from SON neurons into the periphery. PMID:26948889

C11orf95-RELA fusion present in a primary supratentorial ependymoma and recurrent sarcoma.

PubMed

Cachia, David; Wani, Khalida; Penas-Prado, Marta; Olar, Adriana; McCutcheon, Ian E; Benjamin, Robert S; Armstrong, Terri S; Gilbert, Mark R; Aldape, Kenneth D

2015-04-01

Ependymomas are rare glial tumors of the central nervous system that arise from the cells lining the ventricles and central canal within the spinal cord. The distribution of these tumors along the neuroaxis varies by age, most commonly involving the spinal cord in adults and the posterior fossa in children. It is becoming evident that ependymomas of infratentorial, supratentorial, and spinal cord location are genetically distinct which may explain the differences in clinical outcomes. A novel oncogenic fusion involving the C11orf95 and RELA genes was recently described in supratentorial ependymomas that results in constitutive aberrant activation of the nuclear factor-kB signaling pathway. Ependymosarcomas are rare neoplasms in which a malignant mesenchymal component arises within an ependymoma. We here describe a case of a sarcoma developing in a patient previously treated with chemotherapy and radiation whose original ependymoma and recurrent sarcoma were both shown to carry the type 1 C11orf95-RELA fusion transcript indicating a monoclonal origin for both tumors.

Surgical management of symptomatic T8 vertebral hemangioma: case report and review of the literature.

PubMed

Tucer, Bulent; Ekici, Mehmet Ali; Menku, Ahmet; Koc, Rahmi Kemal; Guclu, Bulent

2013-01-01

Vertebral hemangiomas are benign vascular lesions of the vertebral column; only 0.9-1.2% of all vertebral hemangiomas cause spinal cord compression. We report a 34-year-old female who was admitted to the neurosurgery clinic with a history of back pain, poor quality of life and easy fatigability for 1.5 years. Her medical history revealed a fall from a height of 2 meters 1.5 years ago. Neurology examination revealed bilateral hypoesthesia below the T8 level and hyperactive deep tendon reflexes in her left leg. Computed tomography scan of the thoracic spine showed T8 vertebral hemangioma, and magnetic resonance imaging showed a T8 hemangioma compressing the spinal cord. Surgical intervention was planned and T8 total laminectomy was performed. The tumor extending into the anterior spinal cord was resected, and T8 vertebroplasty with short segment posterior stabilization and fusion was performed. We aimed to present a new treatment approach for symptomatic vertebral hemangiomas and reviewed the relevant literature.

A New Population of Parvocellular Oxytocin Neurons Controlling Magnocellular Neuron Activity and Inflammatory Pain Processing.

PubMed

Eliava, Marina; Melchior, Meggane; Knobloch-Bollmann, H Sophie; Wahis, Jérôme; da Silva Gouveia, Miriam; Tang, Yan; Ciobanu, Alexandru Cristian; Triana Del Rio, Rodrigo; Roth, Lena C; Althammer, Ferdinand; Chavant, Virginie; Goumon, Yannick; Gruber, Tim; Petit-Demoulière, Nathalie; Busnelli, Marta; Chini, Bice; Tan, Linette L; Mitre, Mariela; Froemke, Robert C; Chao, Moses V; Giese, Günter; Sprengel, Rolf; Kuner, Rohini; Poisbeau, Pierrick; Seeburg, Peter H; Stoop, Ron; Charlet, Alexandre; Grinevich, Valery

2016-03-16

Oxytocin (OT) is a neuropeptide elaborated by the hypothalamic paraventricular (PVN) and supraoptic (SON) nuclei. Magnocellular OT neurons of these nuclei innervate numerous forebrain regions and release OT into the blood from the posterior pituitary. The PVN also harbors parvocellular OT cells that project to the brainstem and spinal cord, but their function has not been directly assessed. Here, we identified a subset of approximately 30 parvocellular OT neurons, with collateral projections onto magnocellular OT neurons and neurons of deep layers of the spinal cord. Evoked OT release from these OT neurons suppresses nociception and promotes analgesia in an animal model of inflammatory pain. Our findings identify a new population of OT neurons that modulates nociception in a two tier process: (1) directly by release of OT from axons onto sensory spinal cord neurons and inhibiting their activity and (2) indirectly by stimulating OT release from SON neurons into the periphery. Copyright © 2016 Elsevier Inc. All rights reserved.

Resection of a ventral intramedullary cervical spinal cord cavernous malformation through an anterior approach.

PubMed

Weil, Alexander G; Bhatia, Sanjiv

2014-09-01

Ventrally-located intramedullary cervical spinal cord cavernomas are rare entities in the pediatric population. Surgical access to these lesions is challenging. The authors present the complete resection of a symptomatic ventral cervical intramedullary cavernoma through an anterior approach in a 15-year-old boy. The lesion was accessed following left anterolateral dissection, C3-4 discectomy and C3/C4 partial corpectomy. The authors will discuss the rationale for intervening in this patient and for selecting this anterior approach over other approaches, such as the anterolateral, posterolateral or posterior approach. The steps, pitfalls and pearls of this surgical approach will be demonstrated in a detailed video. The video can be found here: http://youtu.be/-ARTp6g13hgs.

Viral Oncolytic Therapeutics for Neoplastic Meningitis

DTIC Science & Technology

2013-07-01

infusion method, we worked with our animal vendor, Charles River Laboratories (CRL), to adopt their intrathecal catheterization service for our...traslocation of the injected material in CSF, we attempted to correlate the parameters of lumbar bolus in intrathecally catheterized rats with those in non...explained by either partial blockage of the spinal CSF compartment in catheterized animals or by variable posterior hydrodynamic compliance (or both) and

The Effect of Prophylactic Phenylephrine and Ephedrine Infusions on Umbilical Artery Blood pH in Women With Preeclampsia Undergoing Cesarean Delivery With Spinal Anesthesia: A Randomized, Double-Blind Trial.

PubMed

Higgins, Nicole; Fitzgerald, Paul C; van Dyk, Dominique; Dyer, Robert A; Rodriguez, Natalie; McCarthy, Robert J; Wong, Cynthia A

2018-06-01

Spinal anesthesia for cesarean delivery is associated with a high incidence of hypotension. Phenylephrine results in higher umbilical artery pH than ephedrine when used to prevent or treat hypotension in healthy women. We hypothesized that phenylephrine compared to ephedrine would result in higher umbilical artery pH in women with preeclampsia undergoing cesarean delivery with spinal anesthesia. This study was a randomized double-blind clinical trial. Nonlaboring women with preeclampsia scheduled for cesarean delivery with spinal anesthesia at Prentice Women's Hospital of Northwestern Medicine were randomized to receive prophylactic infusions of phenylephrine or ephedrine titrated to maintain systolic blood pressure >80% of baseline. Spinal anesthesia consisted of hyperbaric 0.75% bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg. The primary outcome was umbilical arterial blood pH and the secondary outcome was umbilical artery base excess. One hundred ten women were enrolled in the study and 54 per group were included in the analysis. There were 74 and 72 infants delivered in the ephedrine and phenylephrine groups, respectively. The phenylephrine:ephedrine ratio for umbilical artery pH was 1.002 (95% confidence interval [CI], 0.997-1.007). Mean [standard deviation] umbilical artery pH was not different between the ephedrine 7.20 [0.10] and phenylephrine 7.22 [0.07] groups (mean difference -0.02, 95% CI of the difference -0.06 to 0.07; P = .38). Median (first, third quartiles) umbilical artery base excess was -3.4 mEq/L (-5.7 to -2.0 mEq/L) in the ephedrine group and -2.8 mEq/L (-4.6 to -2.2mEq/L) in the phenylephrine group (difference -0.6 mEq/L, 95% CI of the difference -1.6 to 0.3 mEq/L; P = .10). When adjusted for gestational age and infant gender, umbilical artery pH did not differ between groups. There were also no differences in the umbilical artery pH stratified by magnesium therapy or by the severity of preeclampsia. We were unable to demonstrate a beneficial effect of phenylephrine on umbilical artery pH compared with ephedrine. Our findings suggest that phenylephrine may not have a clinically important advantage compared with ephedrine with regard to improved neonatal acid-base status when used to prevent spinal anesthesia-induced hypotension in women with preeclampsia undergoing cesarean delivery.

Life satisfaction in patients with and without spinal cord ischemia after advanced endovascular therapy for extensive aortic disease at mid-term follow-up.

PubMed

Mehmedagic, Irma; Santén, Stefan; Jörgensen, Sophie; Acosta, Stefan

2016-11-11

Advanced endovascular aortic repair can be used to treat patients with extensive and complex aortic disease who are at risk of spinal cord ischaemia. The aim of this study was to compare whether life satisfaction differs between patients with and without spinal cord ischaemia at mid-term follow-up. Nested case-control study. Among patients undergoing advanced endovascular aortic repair between 2009 and 2012, 18 patients with spinal cord ischaemia and 33 without were interviewed at home. The Life Satisfaction Questionnaire (LiSat-11) and the Satisfaction With Life Scale (SWLS) were used. LiSat-11 found that patients with spinal cord ischaemia were more dissatisfied with their activities of daily living than were patients without spinal cord ischaemia (p=0.012). Both groups had similar, very low, scores in the sexual life domain; median 2.0 (interquartile range (IQR) 1.5-3.0) and 3.0 (IQR 2.0-4.0), respectively. There was no difference in SWLS between the groups. This study cohort of patients who underwent advanced endovascular aortic repair was rather homo-genous in their rating of life satisfaction and there was little difference between mid-term survivors who had spinal cord ischaemia and those who did not.

Anterior lumbar fusion with titanium threaded and mesh interbody cages.

PubMed

Rauzzino, M J; Shaffrey, C I; Nockels, R P; Wiggins, G C; Rock, J; Wagner, J

1999-12-15

The authors report their experience with 42 patients in whom anterior lumbar fusion was performed using titanium cages as a versatile adjunct to treat a wide variety of spinal deformity and pathological conditions. These conditions included congenital, degenerative, iatrogenic, infectious, traumatic, and malignant disorders of the thoracolumbar spine. Fusion rates and complications are compared with data previously reported in the literature. Between July 1996 and July 1999 the senior authors (C.I.S., R.P.N., and M.J.R.) treated 42 patients by means of a transabdominal extraperitoneal (13 cases) or an anterolateral extraperitoneal approach (29 cases), 51 vertebral levels were fused using titanium cages packed with autologous bone. All vertebrectomies (27 cases) were reconstructed using a Miami Moss titanium mesh cage and Kaneda instrumentation. Interbody fusion (15 cases) was performed with either the BAK titanium threaded interbody cage (in 13 patients) or a Miami Moss titanium mesh cage (in two patients). The average follow-up period was 14.3 months. Seventeen patients had sustained a thoracolumbar burst fracture, 12 patients presented with degenerative spinal disorders, six with metastatic tumor, four with spinal deformity (one congenital and three iatrogenic), and three patients presented with spinal infections. In five patients anterior lumbar interbody fusion (ALIF) was supplemented with posterior segmental fixation at the time of the initial procedure. Of the 51 vertebral levels treated, solid arthrodesis was achieved in 49, a 96% fusion rate. One case of pseudarthrosis occurred in the group treated with BAK cages; the diagnosis was made based on the patient's continued mechanical back pain after undergoing L4-5 ALIF. The patient was treated with supplemental posterior fixation, and successful fusion occurred uneventfully with resolution of her back pain. In the group in which vertebrectomy was performed there was one case of fusion failure in a patient with metastatic breast cancer who had undergone an L-3 corpectomy with placement of a mesh cage. Although her back pain was immediately resolved, she died of systemic disease 3 months after surgery and before fusion could occur. Complications related to the anterior approach included two vascular injuries (two left common iliac vein lacerations); one injury to the sympathetic plexus; one case of superficial phlebitis; two cases of prolonged ileus (greater than 48 hours postoperatively); one anterior femoral cutaneous nerve palsy; and one superficial wound infection. No deaths were directly related to the surgical procedure. There were no cases of dural laceration and no nerve root injury. There were no cases of deep venous thrombosis, pulmonary embolus, retrograde ejaculation, abdominal hernia, bowel or ureteral injury, or deep wound infection. Fusion-related complications included an iliac crest hematoma and prolonged donor-site pain in one patient. There were no complications related to placement or migration of the cages, but there was one case of screw fracture of the Kaneda device that did not require revision. The authors conclude that anterior lumbar fusion performed using titanium interbody or mesh cages, packed with autologous bone, is an effective, safe method to achieve fusion in a wide variety of pathological conditions of the thoracolumbar spine. The fusion rate of 96% compares favorably with results reported in the literature. The complication rate mirrors the low morbidity rate associated with the anterior approach. A detailed study of clinical outcomes is in progress. Patient selection and strategies for avoiding complication are discussed.

Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting.

PubMed

Wodlin, Ninnie Borendal; Nilsson, Lena; Arestedt, Kristofer; Kjølhede, Preben

2011-04-01

To determine whether postoperative symptoms differ between women who undergo abdominal benign hysterectomy in a fast-track model under general anesthesia or spinal anesthesia with intrathecal morphine. Secondary analysis from a randomized, open, multicenter study. Five hospitals in south-east Sweden. One-hundred and eighty women scheduled for benign hysterectomy were randomized; 162 completed the study; 82 were allocated to spinal and 80 to general anesthesia. The Swedish Postoperative Symptoms Questionnaire, completed daily for 1 week and thereafter once a week until 5 weeks postoperatively. Occurrence, intensity and duration of postoperative symptoms. Women who had hysterectomy under spinal anesthesia with intrathecal morphine experienced significantly less discomfort postoperatively compared with those who had the operation under general anesthesia. Spinal anesthesia reduced the need for opioids postoperatively. The most common symptoms were pain, nausea and vomiting, itching, drowsiness and fatigue. Abdominal pain, drowsiness and fatigue occurred significantly less often and with lower intensity among the spinal anesthesia group. Although postoperative nausea and vomiting was reported equally in the two groups, vomiting episodes were reported significantly more often during the first day after surgery in the spinal anesthesia group. Spinal anesthesia was associated with a higher prevalence of postoperative itching. Spinal anesthesia with intrathecal morphine carries advantages regarding postoperative symptoms and recovery following fast-track abdominal hysterectomy. © 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.

Continuous spinal anaesthesia versus single dosing. A comparative study.

PubMed

De Andrés, J A; Febré, E; Bellver, J; Bolinches, R

1995-03-01

Continuous and single dose spinal anaesthesia were compared in a prospective randomized fashion in 108 patients undergoing orthopaedic surgery. Continuous spinal anaesthesia was via a 20 gauge polyamide multiperforated catheter introduced through an 18 gauge Tuohy needle. Single-dose spinal anaesthesia was performed with a 24 guage x 103 mm Sprotte spinal needle. The mean local anaesthetic dose for the continuous technique was 38.4 (SD 16.5) mg as hyperbaric lignocaine 5%, and for the single-dose spinal anaesthesia 10.8 (SD 2.2) mg as hyperbaric bupivacaine 0.5%. Segmental levels reached with the initial dose did not differ significantly between the two groups. Mean time required to perform continuous spinal anaesthesia was 6.7 (SD 3.9) min, which was longer than for single dose 4.9 (SD 2.8) min (P < 0.05). The onset time and efficacy of anaesthesia, and the duration of the operation were similar in the two groups. Analgesia was inadequate in six patients who received continuous spinal anaesthesia (11%) and one patient who received single dose (2%) (P = 0.18). Hypotension was more frequent in those receiving single doses (P < 0.05). Caudal rotation of the outlet needle orifice to advance the catheter correlated with inadequate analgesia (P < 0.01, r = 0.38). There were no significant differences in the incidence of post-operative complications.

Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF

PubMed Central

Phan, Kevin; Malham, Greg; Seex, Kevin; Rao, Prashanth J.

2015-01-01

Degenerative disc and facet joint disease of the lumbar spine is common in the ageing population, and is one of the most frequent causes of disability. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity. The surgical options for interbody fusion of the lumbar spine include: posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF). The indications may include: discogenic/facetogenic low back pain, neurogenic claudication, radiculopathy due to foraminal stenosis, lumbar degenerative spinal deformity including symptomatic spondylolisthesis and degenerative scoliosis. In general, traditional posterior approaches are frequently used with acceptable fusion rates and low complication rates, however they are limited by thecal sac and nerve root retraction, along with iatrogenic injury to the paraspinal musculature and disruption of the posterior tension band. Minimally invasive (MIS) posterior approaches have evolved in an attempt to reduce approach related complications. Anterior approaches avoid the spinal canal, cauda equina and nerve roots, however have issues with approach related abdominal and vascular complications. In addition, lateral and OLIF techniques have potential risks to the lumbar plexus and psoas muscle. The present study aims firstly to comprehensively review the available literature and evidence for different lumbar interbody fusion (LIF) techniques. Secondly, we propose a set of recommendations and guidelines for the indications for interbody fusion options. Thirdly, this article provides a description of each approach, and illustrates the potential benefits and disadvantages of each technique with reference to indication and spine level performed. PMID:27683674

Vertebral body spread in thoracolumbar burst fractures can predict posterior construct failure.

PubMed

De Iure, Federico; Lofrese, Giorgio; De Bonis, Pasquale; Cultrera, Francesco; Cappuccio, Michele; Battisti, Sofia

2018-06-01

The load sharing classification (LSC) laid foundations for a scoring system able to indicate which thoracolumbar fractures, after short-segment posterior-only fixations, would need longer instrumentations or additional anterior supports. We analyzed surgically treated thoracolumbar fractures, quantifying the vertebral body's fragment displacement with the aim of identifying a new parameter that could predict the posterior-only construct failure. This is a retrospective cohort study from a single institution. One hundred twenty-one consecutive patients were surgically treated for thoracolumbar burst fractures. Grade of kyphosis correction (GKC) expressed radiological outcome; Oswestry Disability Index and visual analog scale were considered. One hundred twenty-one consecutive patients who underwent posterior fixation for unstable thoracolumbar burst fractures were retrospectively evaluated clinically and radiologically. Supplementary anterior fixations were performed in 34 cases with posterior instrumentation failure, determined on clinic-radiological evidence or symptomatic loss of kyphosis correction. Segmental kyphosis angle and GKC were calculated according to the Cobb method. The displacement of fracture fragments was obtained from the mean of the adjacent end plate areas subtracted from the area enclosed by the maximum contour of vertebral fragmentation. The "spread" was derived from the ratio between this subtraction and the mean of the adjacent end plate areas. Analysis of variance, Mann-Whitney, and receiver operating characteristic were performed for statistical analysis. The authors report no conflict of interest concerning the materials or methods used in the present study or the findings specified in this paper. No funds or grants have been received for the present study. The spread revealed to be a helpful quantitative measurement of vertebral body fragment displacement, easily reproducible with the current computed tomography (CT) imaging technologies. There were no failures of posterior fixations with preoperative spreads <42% and losses of correction (LOC)<10°, whereas spreads >62.7% required supplementary anterior supports whenever LOC>10° were recorded. Most of the patients in a "gray zone," with spreads between 42% and 62.7%, needed additional anterior supports because of clinical-radiological evidence of impending mechanical failures, which developed independently from the GKC. Preoperative kyphosis (p<.001), load sharing score (p=.002), and spread (p<.001) significantly affected the final surgical treatment (posterior or circumferential). Twenty-two years after the LSC, both improvements in spinal stabilization systems and software imaging innovations have modified surgical concepts and approach on spinal trauma care. Spread was found to be an additional tool that could help in predicting the posterior construct failure, providing an objective preoperative indicator, easily reproducible with the modern viewers for CT images. Copyright © 2017 Elsevier Inc. All rights reserved.

Pregnancy Outcome Using General Anesthesia Versus Spinal Anesthesia for In Vitro Fertilization

PubMed Central

Azmude, Azra; Agha'amou, Shahrzad; Yousefshahi, Fardin; Berjis, Katayoun; Mirmohammad'khani, Majid; Sadaat'ahmadi, Farahnaz; Ghods, Kamran; Dabbagh, Ali

2013-01-01

Background There is a considerable rate of fertility failure and this causes a great burden of untoward effects for patients. Usually a considerable number of these patients undergo anesthesia for their treatment. Objectives This study was designed to compare the effects of general and spinal anesthesia on these patients. Patients and Methods In a randomized clinical trial, after taking informed written consent from the patients, 200 patients entered the study; 100 in each. During a 2 year period, women aged 20 to 40 years entered the study (one group receiving spinal anesthesia and the other, receiving general anesthesia). Ovum retrieval protocols were the same. Nonparametric and parametric analyses were used for data analysis. P value less than 0.05 was considered significant. Results There was no difference between the two groups regarding demographic variables. 15 of 100 patients (15%) in the general anesthesia group and 27 of 100 patients (27%) in the spinal anesthesia group had successful pregnancy after IVF; so, spinal anesthesia increased significantly the chance of IVF success (P value < 0.001; Chi Square). Conclusions The results of this study demonstrated that spinal anesthesia increased the chance of fertilization success. PMID:24282775

Real-Time Ultrasound-Guided Spinal Anaesthesia: A Prospective Observational Study of a New Approach

PubMed Central

Conroy, P. H.; Luyet, C.; McCartney, C. J.; McHardy, P. G.

2013-01-01

Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1–6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83–4.1) demonstrating the feasibility of this technique in routine clinical practice. PMID:23365568

Gastro-oesophageal reflux in large-sized, deep-chested versus small-sized, barrel-chested dogs undergoing spinal surgery in sternal recumbency.

PubMed

Anagnostou, Tilemahos L; Kazakos, George M; Savvas, Ioannis; Kostakis, Charalampos; Papadopoulou, Paraskevi

2017-01-01

The aim of this study was to investigate whether an increased frequency of gastro-oesophageal reflux (GOR) is more common in large-sized, deep-chested dogs undergoing spinal surgery in sternal recumbency than in small-sized, barrelchested dogs. Prospective, cohort study. Nineteen small-sized, barrel-chested dogs (group B) and 26 large-sized, deep-chested dogs (group D). All animals were premedicated with intramuscular (IM) acepromazine (0.05 mg kg -1 ) and pethidine (3 mg kg -1 ) IM. Anaesthesia was induced with intravenous sodium thiopental and maintained with halothane in oxygen. Lower oesophageal pH was monitored continuously after induction of anaesthesia. Gastro-oesophageal reflux was considered to have occurred whenever pH values > 7.5 or < 4 were recorded. If GOR was detected during anaesthesia, measures were taken to avoid aspiration of gastric contents into the lungs and to prevent the development of oesophagitis/oesophageal stricture. The frequency of GOR during anaesthesia was significantly higher in group D (6/26 dogs; 23.07%) than in group B (0/19 dogs; 0%) (p = 0.032). Signs indicative of aspiration pneumonia, oesophagitis or oesophageal stricture were not reported in any of the GOR cases. In large-sized, deep-chested dogs undergoing spinal surgery in sternal recumbency, it would seem prudent to consider measures aimed at preventing GOR and its potentially devastating consequences (oesophagitis/oesophageal stricture, aspiration pneumonia). Copyright © 2016 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

Functional MR imaging of the spinal cord in cervical spinal cord injury patients by acupuncture at LI 4 (Hegu) and LI 11(Quchi).

PubMed

Chen, Y X; Kong, K M; Wang, W D; Xie, C H; Wu, R H

2007-01-01

To investigate the cervical spinal cord mapping on acupuncture at LI 4 (Hegu) and LI 11 (Quchi) by using 'Signal Enhancement by Extravascular water Protons' (SEEP)-fMRI, and to establish the response of using acupuncture in the cervical spinal cord. This research may provide some laboratory evidences from the acupuncture treatment on the cervical spinal cord of injuried patients. Seven healthy volunteers (healthy group) and three cervical spinal cord injury patients (injury group) were underwent low-frequency electrical stimulation at LI 4 and LI 11. Meanwhile, a single-shot fast spin-echo (SSFSE) sequence was used to perform functional MR imaging on a 1.5 T GE Signa MR system. The signals from the cervical spinal cord activated was measured both in sagittal and transverse imaging planes and then analyzed by AFNI (Analysis of Functional Neuroimages) system. It was found that in the sagittal view, two groups had an fMRI response in the cervical spinal cord after given acupuncture treatments at LI 4 and LI 11. The localizations of the segmental fMRI activation were focused at C6 and C2 cervical spinal cord level. In the transverse imaging plane, significant fMRI responses could be measured from the four of seven healthy volunteers and from two of three cervical spinal cord injury patients. They were located at C6/7 segments. The cross-sectional localization of the activity measured in the spinal cord was most in terms of the ipsilateral posterior direction. The signal amplitude varied mainly between 6.8%17.8%. However, the difference found between the two groups had no statistical meaning. The fMRI technique had detected an activation focused at C6 and C2 cervical spinal cord levels by use of acupuncture at LI 4 and LI 11 on a 1.5T GE clinical system. This proved that the meridians and points are found to be in existence. The fMRI can be used as a harmless research method to discuss the mechanisms of acupuncture as well as study the mechanisms of spinal cord diseases. It can be used to direct or monitor the related therapy on the spinal cord injury patients.

The negotiated equilibrium model of spinal cord function.

PubMed

Wolpaw, Jonathan R

2018-04-16

The belief that the spinal cord is hardwired is no longer tenable. Like the rest of the CNS, the spinal cord changes during growth and aging, when new motor behaviours are acquired, and in response to trauma and disease. This paper describes a new model of spinal cord function that reconciles its recently appreciated plasticity with its long recognized reliability as the final common pathway for behaviour. According to this model, the substrate of each motor behaviour comprises brain and spinal plasticity: the plasticity in the brain induces and maintains the plasticity in the spinal cord. Each time a behaviour occurs, the spinal cord provides the brain with performance information that guides changes in the substrate of the behaviour. All the behaviours in the repertoire undergo this process concurrently; each repeatedly induces plasticity to preserve its key features despite the plasticity induced by other behaviours. The aggregate process is a negotiation among the behaviours: they negotiate the properties of the spinal neurons and synapses that they all use. The ongoing negotiation maintains the spinal cord in an equilibrium - a negotiated equilibrium - that serves all the behaviours. This new model of spinal cord function is supported by laboratory and clinical data, makes predictions borne out by experiment, and underlies a new approach to restoring function to people with neuromuscular disorders. Further studies are needed to test its generality, to determine whether it may apply to other CNS areas such as the cerebral cortex, and to develop its therapeutic implications. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Spinal Anesthesia in Infant Rats: Development of a Model and Assessment of Neurological Outcomes

PubMed Central

Yahalom, Barak; Athiraman, Umeshkumar; Soriano, Sulpicio G.; Zurakowski, David; Carpino, Elizabeth; Corfas, Gabriel; Berde, Charles B.

2012-01-01

Background Previous studies in infant rats and case-control studies of human infants undergoing surgery have raised concerns about potential neurodevelopmental toxicities of general anesthesia. Spinal anesthesia is an alternative to general anesthesia for some infant surgeries. To test for potential toxicity, we developed a spinal anesthesia model in infant rats. Methods Rats of postnatal ages 7, 14, and 21 days were assigned to: no treatment; 1% isoflurane for either 1 h or 6 h, or lumbar spinal injection of saline or bupivacaine, at doses of 3.75 mg/kg (low dose) or 7.5 mg/kg (high dose). Subgroups of animals underwent neurobehavioral testing and blood gas analysis. Brain and lumbar spinal cord sections were examined for apoptosis using cleaved caspase-3 immunostaining. Lumbar spinal cord was examined histologically. Rats exposed to spinal or general anesthesia as infants underwent Rotarod testing of motor performance as adults. Data were analyzed using analysis of variance (ANOVA) using general linear models, Friedman Tests, and Mann–Whitney U tests, as appropriate. Results Bupivacaine 3.75 mg/kg was effective for spinal anesthesia in all age groups, and produced sensory and motor function recovered in 40 to 60 min. Blood gases were similar among groups. Brain and spinal cord apoptosis increased in rats receiving 6 h of 1% isoflurane, but not among the other treatments. All groups showed intact motor performance at adulthood. Conclusions Spinal anesthesia is technically feasible in infant rats, and appears benign in terms of neuroapoptotic and neuromotor sequelae. PMID:21555934

18F-FDG PET/CT evaluation of children and young adults with suspected spinal fusion hardware infection.

PubMed

Bagrosky, Brian M; Hayes, Kari L; Koo, Phillip J; Fenton, Laura Z

2013-08-01

Evaluation of the child with spinal fusion hardware and concern for infection is challenging because of hardware artifact with standard imaging (CT and MRI) and difficult physical examination. Studies using (18)F-FDG PET/CT combine the benefit of functional imaging with anatomical localization. To discuss a case series of children and young adults with spinal fusion hardware and clinical concern for hardware infection. These people underwent FDG PET/CT imaging to determine the site of infection. We performed a retrospective review of whole-body FDG PET/CT scans at a tertiary children's hospital from December 2009 to January 2012 in children and young adults with spinal hardware and suspected hardware infection. The PET/CT scan findings were correlated with pertinent clinical information including laboratory values of inflammatory markers, postoperative notes and pathology results to evaluate the diagnostic accuracy of FDG PET/CT. An exempt status for this retrospective review was approved by the Institution Review Board. Twenty-five FDG PET/CT scans were performed in 20 patients. Spinal fusion hardware infection was confirmed surgically and pathologically in six patients. The most common FDG PET/CT finding in patients with hardware infection was increased FDG uptake in the soft tissue and bone immediately adjacent to the posterior spinal fusion rods at multiple contiguous vertebral levels. Noninfectious hardware complications were diagnosed in ten patients and proved surgically in four. Alternative sources of infection were diagnosed by FDG PET/CT in seven patients (five with pneumonia, one with pyonephrosis and one with superficial wound infections). FDG PET/CT is helpful in evaluation of children and young adults with concern for spinal hardware infection. Noninfectious hardware complications and alternative sources of infection, including pneumonia and pyonephrosis, can be diagnosed. FDG PET/CT should be the first-line cross-sectional imaging study in patients with suspected spinal hardware infection. Because pneumonia was diagnosed as often as spinal hardware infection, initial chest radiography should also be performed.

Concepts on the pathogenesis of adolescent idiopathic scoliosis. Bone growth and mass, vertebral column, spinal cord, brain, skull, extra-spinal left-right skeletal length asymmetries, disproportions and molecular pathogenesis.

PubMed

Burwell, R Geoffrey; Dangerfield, Peter H; Freeman, Brian J C

2008-01-01

There is no generally accepted scientific theory for the causes of adolescent idiopathic scoliosis (AIS). Encouraging advances thought to be related to AIS pathogenesis have recently been made in several fields including anthropometry of bone growth, bone mass, spinal growth modulation, extra-spinal left-right skeletal length asymmetries and disproportions, magnetic resonance imaging of vertebral column, spinal cord, brain, skull, and molecular pathogenesis. These advances are leading to the evaluation of new treatments including attempts at minimally invasive surgery on the spine and peri-apical ribs. Several concepts of AIS are outlined indicating their clinical applications but not their research potential. The concepts, by derivation morphological, molecular and mathematical, are addressed in 15 sections: 1) initiating and progressive factors; 2) relative anterior spinal overgrowth; 3) dorsal shear forces that create axial rotational instability; 4) rotational preconstraint; 5) uncoupled, or asynchronous, spinal neuro-osseous growth; 6) brain, nervous system and skull; 7) a novel neuro-osseous escalator concept based on a putative abnormality of two normal polarized processes namely, a) increasing skeletal dimensions, and b) the CNS body schema - both contained within a neuro-osseous timing of maturation (NOTOM) concept; 8) transverse plane pelvic rotation, skeletal asymmetries and developmental theory; 9) thoraco-spinal concept; 10) origin in contracture at the hips; 11) osteopenia; 12) melatonin deficiency; 13) systemic melatonin-signaling pathway dysfunction; 14) platelet calmodulin dysfunction; and 15) biomechanical spinal growth modulation. From these concepts, a collective model for AIS pathogenesis is formulated. The central concept of this model includes the body schema of the neural systems, widely-studied in adults, that control normal posture and coordinated movements with frames of reference in the posterior parietal cortex. The escalator concept has implications for the normal development of upright posture, and the evolution in humans of neural control, the trunk and unique bipedal gait.

Cervical Spinal Cord Atrophy Profile in Adult SMN1-Linked SMA

PubMed Central

El Mendili, Mohamed-Mounir; Lenglet, Timothée; Stojkovic, Tanya; Behin, Anthony; Guimarães-Costa, Raquel; Salachas, François; Meininger, Vincent; Bruneteau, Gaelle; Le Forestier, Nadine; Laforêt, Pascal; Lehéricy, Stéphane; Benali, Habib; Pradat, Pierre-François

2016-01-01

Purpose The mechanisms underlying the topography of motor deficits in spinal muscular atrophy (SMA) remain unknown. We investigated the profile of spinal cord atrophy (SCA) in SMN1-linked SMA, and its correlation with the topography of muscle weakness. Materials and Methods Eighteen SMN1-linked SMA patients type III/V and 18 age/gender-matched healthy volunteers were included. Patients were scored on manual muscle testing and functional scales. Spinal cord was imaged using 3T MRI system. Radial distance (RD) and cord cross-sectional area (CSA) measurements in SMA patients were compared to those in controls and correlated with strength and disability scores. Results CSA measurements revealed a significant cord atrophy gradient mainly located between C3 and C6 vertebral levels with a SCA rate ranging from 5.4% to 23% in SMA patients compared to controls. RD was significantly lower in SMA patients compared to controls in the anterior-posterior direction with a maximum along C4 and C5 vertebral levels (p-values < 10−5). There were no correlations between atrophy measurements, strength and disability scores. Conclusions Spinal cord atrophy in adult SMN1-linked SMA predominates in the segments innervating the proximal muscles. Additional factors such as neuromuscular junction or intrinsic skeletal muscle defects may play a role in more complex mechanisms underlying weakness in these patients. PMID:27089520

Neural Excitability and Joint Laxity in Chronic Ankle Instability, Coper, and Control Groups.

PubMed

Bowker, Samantha; Terada, Masafumi; Thomas, Abbey C; Pietrosimone, Brian G; Hiller, Claire E; Gribble, Phillip A

2016-04-01

Neuromuscular and mechanical deficiencies are commonly studied in participants with chronic ankle instability (CAI). Few investigators have attempted to comprehensively consider sensorimotor and mechanical differences among people with CAI, copers who did not present with prolonged dysfunctions after an initial ankle sprain, and a healthy control group. To determine if differences exist in spinal reflex excitability and ankle laxity among participants with CAI, copers, and healthy controls. Case-control study. Research laboratory. Thirty-seven participants with CAI, 30 participants categorized as copers, and 26 healthy control participants. We assessed spinal reflex excitability of the soleus using the Hoffmann reflex protocol. Participants' ankle laxity was measured with an instrumented ankle arthrometer. The maximum Hoffmann reflex : maximal muscle response ratio was calculated. Ankle laxity was measured as the total displacement in the anterior-posterior directions (mm) and total rotation in the inversion and eversion directions (°). Spinal reflex excitability was diminished in participants with CAI compared with copers and control participants (P = .01). No differences were observed among any of the groups for ankle laxity. Changes in the spinal reflex excitability of the soleus that likely affect ankle stability were seen only in the CAI group, yet no mechanical differences were noted across the groups. These findings support the importance of finding effective ways to increase spinal reflex excitability for the purpose of treating neural excitability dysfunction in patients with CAI.

Does the baricity of bupivacaine influence intrathecal spread in the prolonged sitting position before elective cesarean delivery? A prospective randomized controlled study.

PubMed

Loubert, Christian; Hallworth, Stephen; Fernando, Roshan; Columb, Malachy; Patel, Nisa; Sarang, Kavita; Sodhi, Vinnie

2011-10-01

Difficulties in inserting an epidural catheter while performing combined spinal-epidural anesthesia for cesarean delivery may lead to undue delays between the spinal injection of the local anesthetic mixture and the adoption of the supine position with lateral tilt. We hypothesized that this delay may affect the intrathecal distribution of local anesthetic of different baricities such that hypobaric local anesthetic would lead to a higher sensory block level. Healthy parturients with uncomplicated pregnancies undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this prospective double-blind randomized controlled trial. The subjects were allocated to receive hyperbaric (hyperbaric group), isobaric (isobaric group), or hypobaric (hypobaric group) spinal bupivacaine 10 mg. After the spinal injection, the subjects remained in the sitting position for 5 minutes (to simulate difficulty in inserting the epidural catheter) before being helped into the supine lateral tilt position. The primary outcome was the sensory block level during the 25 minutes after the spinal injection. Other end points included motor block score, maternal hypotension, and vasopressor requirements. Data from 89 patients were analyzed. Patient characteristics were similar in all groups. The median [interquartile range] (95% confidence interval) sensory levels after spinal injection were significantly higher with decreasing baricity: hyperbaric T10 [T11-8] (T10-9), isobaric T9 [T10-7] (T9-7), and hypobaric T6 [T8-4] (T8-5) (P < 0.001, Cuzick trend). All patients in the hypobaric group reached a sensory block level of T4 at 25 minutes after spinal injection compared with 80% of the patients in both the isobaric and hyperbaric groups (P = 0.04; difference 20%, 95% confidence interval of difference 4%-33%). Significantly more patients in the hypobaric group had complete lower limb motor block (Bromage score = 4) (hyperbaric 43%, isobaric 63%, and hypobaric 90%; P < 0.001). The incidences of maternal hypotension and nausea and vomiting were similar among groups, although the ephedrine requirements were significantly increased in the isobaric and hypobaric groups by factors of 1.83 and 3.0, respectively, compared with the hyperbaric group (P < 0.001, Cuzick trend). We demonstrated that when parturients undergoing cesarean delivery were maintained in the sitting position for 5 minutes after spinal injection of the local anesthetic, hypobaric bupivacaine resulted in sensory block levels that were higher compared with isobaric and hyperbaric bupivacaine, respectively, during the study period.

[Foot drop: an iatrogenic complication of spinal anesthesia].

PubMed

Goyal, Vipin Kumar; Mathur, Vijay

2018-01-16

Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores.

PubMed

Lin, Haodong; Hou, Chunlin; Chen, Aimin; Xu, Zhen

2010-08-01

Among the many difficult problems presented by patients with spinal cord injuries, management of ischial pressure ulcers remains challenging for reconstructive surgeons. This study describes the long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores. Between January 1999 and June 2003, 12 patients with ischial sores were enrolled in this study. All the patients underwent early aggressive surgical debridement followed by surgical reconstruction with a laterally based posterior-thigh fasciocutaneous flap. The follow-up period ranged from 24 months to 97 months (mean, 62 months). All the flaps survived, and there were no partial flap losses. Primary-wound healing occurred in all the cases. In two patients, Grade II ischial pressure sores recurred 24 months and 27 months after the operation. There was no recurrence in the other 10 patients. The posterior-thigh fasciocutaneous pedicled flap was a good method for treating ischial bed sores. This flap could be used to treat recurrences observed after primary bed-sore treatment with other methods. The flap was easy to raise, and it did not cause any donor-site morbidity. The long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores was generally good. (c) Thieme Medical Publishers.

The changes of lumbar muscle flexion-relaxation phenomenon due to antero-posteriorly slanted ground surfaces.

PubMed

Hu, Boyi; Ning, Xiaopeng; Dai, Fei; Almuhaidib, Ibrahim

2016-09-01

Uneven ground surface is a common occupational injury risk factor in industries such as agriculture, fishing, transportation and construction. Studies have shown that antero-posteriorly slanted ground surfaces could reduce spinal stability and increase the risk of falling. In this study, the influence of antero-posteriorly slanted ground surfaces on lumbar flexion-relaxation responses was investigated. Fourteen healthy participants performed sagittally symmetric and asymmetric trunk bending motions on one flat and two antero-posteriorly slanted surfaces (-15° (uphill facing) and 15° (downhill facing)), while lumbar muscle electromyography and trunk kinematics were recorded. Results showed that standing on a downhill facing slanted surface delays the onset of lumbar muscle flexion-relaxation phenomenon (FRP), while standing on an uphill facing ground causes lumbar muscle FRP to occur earlier. In addition, compared to symmetric bending, when performing asymmetric bending, FRP occurred earlier on the contralateral side of lumbar muscles and significantly smaller maximum lumbar flexion and trunk inclination angles were observed. Practitioner Summary: Uneven ground surface is a common risk factor among a number of industries. In this study, we investigated the influence of antero-posteriorly slanted ground surface on trunk biomechanics during trunk bending. Results showed the slanted surface alters the lumbar tissue load-sharing mechanism in both sagittally symmetric and asymmetric bending.

Comparison of two spinal needle types to achieve a unilateral spinal block.

PubMed

Kuusniemi, Kristiina; Leino, Kari; Lertola, Kaarlo; Pihlajamäki, Kalevi; Pitkänen, Mikko

2013-04-01

Unilateral spinal anesthesia is beneficial in patients undergoing unilateral leg surgery. The direction and the shape of the spinal needle are thought to influence the unilateral distribution of the local anesthetic in the intrathecal space. Therefore, to study the effects of different spinal needles we compared the effects of the Whitacre and Quincke spinal needles. This was a prospective, randomized, double-blind study of 60 consecutive outpatients scheduled for unilateral lower-limb surgery. The patients were randomized to receive spinal anesthesia with 1.2 ml of 0.5 % plain bupivacaine using either a 27-G Whitacre or a Quincke needle. One half of the local anesthetic was injected towards the nondependent side and the other half was directed cranially. The spread of spinal anesthesia, both sensory and motor blocks, was defined as the primary endpoint and was recorded at 10, 20, and 30 min after the spinal injection, at the end of the operation, 2 h after the spinal injection, and every 30 min thereafter until there was no motor block. Secondary endpoints included patient satisfaction and adverse effects. There was no difference in the spread of sensory or motor blocks between the Whitacre and the Quincke groups. However, the sensory and motor blocks on the operated and the nonoperated sides were significantly different at all testing times, as expected. There was no difference in the incidence of adverse effects or patient satisfaction scores between the Whitacre and the Quincke groups. Unilateral spinal block for outpatient surgery can be achieved with both pencil-point (Whitacre) and Quincke needles using 6.0 mg of plain bupivacaine. Neither the spread of sensory and motor blocks nor the corresponding recovery times appeared to be different between the groups. Nor was there any difference in patient satisfaction.

Predictors of failure of awake regional anesthesia for neonatal hernia repair: data from the General Anesthesia compared to Spinal anesthesia (GAS) study: comparing apnoea and neurodevelopmental outcomes

PubMed Central

Frawley, Geoff; Bell, Graham; Disma, Nicola; Withington, Davinia E.; de Graaff, Jurgen C.; Morton, Neil S.; McCann, Mary Ellen; Arnup, Sarah J.; Bagshaw, Oliver; Wolfler, Andrea; Bellinger, David; Davidson, Andrew J.

2015-01-01

Background Awake regional anesthesia (RA) is a viable alternative to general anesthesia (GA) for infants undergoing lower abdominal surgery. Benefits include lower incidence of postoperative apnea and avoidance of anesthetic agents that may increase neuroapoptosis and worsen neurocognitive outcomes. The General Anesthesia compared to Spinal anesthesia (GAS) study compares neurodevelopmental outcomes following awake RA or GA in otherwise healthy infants. Our aim was to describe success and failure rates of RA in this study and report factors associated with failure. Methods This was a nested cohort study within a prospective randomized, controlled, observer blind, equivalence trial. Seven hundred twenty two infants ≤ 60 weeks postmenstrual age, scheduled for herniorrhaphy under anesthesia were randomly assigned to receive RA (spinal, caudal epidural or combined spinal caudal anesthetic) or GA with sevoflurane. The data of 339 infants, where spinal or combined spinal caudal anesthetic was attempted, was analyzed. Possible predictors of failure were assessed including: patient factors, technique, experience of site and anesthetist and type of local anesthetic. Results RA was sufficient for the completion of surgery in 83.2% of patients. Spinal anesthesia was successful in 86.9% of cases and combined spinal caudal anesthetic in 76.1%. Thirty four patients required conversion to GA and an additional 23 (6.8%) required brief sedation. Bloody tap on the first attempt at lumbar puncture was the only risk factor significantly associated with block failure (OR = 2.46). Conclusions The failure rate of spinal anesthesia was low. Variability in application of combined spinal caudal anesthetic limited attempts to compare the success of this technique to spinal alone. PMID:26001028

Rapid activity-dependent modulation of the intrinsic excitability through up-regulation of KCNQ/Kv7 channel function in neonatal spinal motoneurons.

PubMed

Lombardo, Joseph; Sun, Jianli; Harrington, Melissa A

2018-01-01

Activity-dependent changes in the properties of the motor system underlie the necessary adjustments in its responsiveness on the basis of the environmental and developmental demands of the organism. Although plastic changes in the properties of the spinal cord have historically been neglected because of the archaic belief that the spinal cord is constituted by a hardwired network that simply relays information to muscles, plenty of evidence has been accumulated showing that synapses impinging on spinal motoneurons undergo short- and long-term plasticity. In the brain, brief changes in the activity level of the network have been shown to be paralleled by changes in the intrinsic excitability of the neurons and are suggested to either reinforce or stabilize the changes at the synaptic level. However, rapid activity-dependent changes in the intrinsic properties of spinal motoneurons have never been reported. In this study, we show that in neonatal mice the intrinsic excitability of spinal motoneurons is depressed after relatively brief but sustained changes in the spinal cord network activity. Using electrophysiological techniques together with specific pharmacological blockers of KCNQ/Kv7 channels, we demonstrate their involvement in the reduction of the intrinsic excitability of spinal motoneurons. This action results from an increased M-current, the product of the activation of KCNQ/Kv7 channels, which leads to a hyperpolarization of the resting membrane potential and a decrease in the input resistance of spinal motoneurons. Computer simulations showed that specific up-regulations in KCNQ/Kv7 channels functions lead to a modulation of the intrinsic excitability of spinal motoneurons as observed experimentally. These results indicate that KCNQ/Kv7 channels play a fundamental role in the activity-dependent modulation of the excitability of spinal motoneurons.

The increased prevalence of cervical spondylosis in patients with adult thoracolumbar spinal deformity.

PubMed

Schairer, William W; Carrer, Alexandra; Lu, Michael; Hu, Serena S

2014-12-01

Retrospective cohort study. To assess the concomitance of cervical spondylosis and thoracolumbar spinal deformity. Patients with degenerative cervical spine disease have higher rates of degeneration in the lumbar spine. In addition, degenerative cervical spine changes have been observed in adult patients with thoracolumbar spinal deformities. However, to the best of our knowledge, there have been no studies quantifying the association between cervical spondylosis and thoracolumbar spinal deformity in adult patients. Patients seen by a spine surgeon or spine specialist at a single institution were assessed for cervical spondylosis and/or thoracolumbar spinal deformity using an administrative claims database. Spinal radiographic utilization and surgical intervention were used to infer severity of spinal disease. The relative prevalence of each spinal diagnosis was assessed in patients with and without the other diagnosis. A total of 47,560 patients were included in this study. Cervical spondylosis occurred in 13.1% overall, but was found in 31.0% of patients with thoracolumbar spinal deformity (OR=3.27, P<0.0001). Similarly, thoracolumbar spinal deformity was found in 10.7% of patients overall, but was increased at 23.5% in patients with cervical spondylosis (OR=3.26, P<0.0001). In addition, increasing severity of disease was associated with an increased likelihood of the other spinal diagnosis. Patients with both diagnoses were more likely to undergo both cervical (OR=3.23, P<0.0001) and thoracolumbar (OR=4.14, P<0.0001) spine fusion. Patients with cervical spondylosis or thoracolumbar spinal deformity had significantly higher rates of the other spinal diagnosis. This correlation was increased with increased severity of disease. Patients with both diagnoses were significantly more likely to have received a spine fusion. Further research is warranted to establish the cause of this correlation. Clinicians should use this information to both screen and counsel patients who present for cervical spondylosis or thoracolumbar spinal deformity.

[Evaluation of the role of combined TES-MEP and CSEP monitoring during the spinal surgery].

PubMed

Chen, Yu-guang; Peng, Xin-sheng; Wan, Yong; Yang, Jun-lin; Zheng, Zhao-min; Zou, Xue-nong; Li, Fo-bao; Shu, Hai-hua; Xia, Jie-hua; Dou, Yun-ling

2010-02-01

To evaluate of the role of transcranial electrical stimulation motor evoked potential (TES-MEP) in combination with cortical somatosensory evoked potential (CSEP) monitoring during the spinal surgery. TES-MEP on bilateral anterior tibial muscle and flexor hallucal brevis and CSEP on bilateral posterior tibial nerve were observed simultaneously on 293 patients during spinal surgery from July 2006 to April 2009. Intravenous anesthesia was employed in all the patients, a part of which were added low dose of sevoflurane or muscle relaxant. The results of TES-MEP, CSEP and combined monitoring were analyzed statistically. Pre-operative and post-operative motor and sensory functions of spinal cord were compared. Success rate of TES-MEP, CSEP and combined monitoring was 90.8%, 96.9% and 100% respectively. For the judgment of motor function of spinal cord, the sensitivity of TES-MEP and CSEP was 100% and 89.3% respectively and the specificity of 98.4% and 96.9%. The Youden index of the two methods was 0.984 and 0.862. For sensory function, the sensitivity of them was 76.7% and 93.3% respectively and the specificity of 98.7% and 98.0%. The Youden index was 0.754 and 0.913. The sensitivity of combined monitoring was 100%, with the specificity of 96.9%. The Youden index was 0.969. The precision of monitoring motor function of spinal cord with TES-MEP is higher than that with CSEP, however, for sensory function, CSEP is more precise. The sensitivity and precision of combined monitoring for spinal cord function were apparently better than that of unitary TES-MEP or CSEP. The combined TES-MEP and CSEP monitoring is a relatively ideal method.

Metal levels in corrosion of spinal implants

PubMed Central

Beguiristain, Jose; Duart, Julio

2007-01-01

Corrosion affects spinal instrumentations and may cause local and systemic complications. Diagnosis of corrosion is difficult, and nowadays it is performed almost exclusively by the examination of retrieved instrumentations. We conducted this study to determine whether it is possible to detect corrosion by measuring metal levels on patients with posterior instrumented spinal fusion. Eleven asymptomatic patients, with radiological signs of corrosion of their stainless steel spinal instrumentations, were studied by performing determinations of nickel and chromium in serum and urine. Those levels were compared with the levels of 22 patients with the same kind of instrumentation but without evidence of corrosion and to a control group of 22 volunteers without any metallic implants. Statistical analysis of our results revealed that the patients with spinal implants without radiological signs of corrosion have increased levels of chromium in serum and urine (P < 0.001) compared to volunteers without implants. Corrosion significantly raised metal levels, including nickel and chromium in serum and urine when compared to patients with no radiological signs of corrosion and to volunteers without metallic implants (P < 0.001). Metal levels measured in serum have high sensibility and specificity (area under the ROC curve of 0.981). By combining the levels of nickel and chromium in serum we were able to identify all the cases of corrosion in our series of patients. The results of our study confirm that metal levels in serum and urine are useful in the diagnosis of corrosion of spinal implants and may be helpful in defining the role of corrosion in recently described clinical entities such as late operative site pain or late infection of spinal implants. PMID:17256156

Photothrombosis-induced Focal Ischemia as a Model of Spinal Cord Injury in Mice

PubMed Central

Zhang, Nannan; Ding, Shinghua

2015-01-01

Spinal cord injury (SCI) is a devastating clinical condition causing permanent changes in sensorimotor and autonomic functions of the spinal cord (SC) below the site of injury. The secondary ischemia that develops following the initial mechanical insult is a serious complication of the SCI and severely impairs the function and viability of surviving neuronal and non-neuronal cells in the SC. In addition, ischemia is also responsible for the growth of lesion during chronic phase of injury and interferes with the cellular repair and healing processes. Thus there is a need to develop a spinal cord ischemia model for studying the mechanisms of ischemia-induced pathology. Focal ischemia induced by photothrombosis (PT) is a minimally invasive and very well established procedure used to investigate the pathology of ischemia-induced cell death in the brain. Here, we describe the use of PT to induce an ischemic lesion in the spinal cord of mice. Following retro-orbital sinus injection of Rose Bengal, the posterior spinal vein and other capillaries on the dorsal surface of SC were irradiated with a green light resulting in the formation of a thrombus and thus ischemia in the affected region. Results from histology and immunochemistry studies show that PT-induced ischemia caused spinal cord infarction, loss of neurons and reactive gliosis. Using this technique a highly reproducible and relatively easy model of SCI in mice can be achieved that would serve the purpose of scientific investigations into the mechanisms of ischemia induced cell death as well as the efficacy of neuroprotective drugs. This model will also allow exploration of the pathological changes that occur following SCI in live mice like axonal degeneration and regeneration, neuronal and astrocytic Ca2+ signaling using two-photon microscopy. PMID:26274772

A comparison of 25 gauge Quincke spinal needle with 26 gauge Eldor spinal needle for the elective Caesarian sections: insertion characteristics and complications.

PubMed

Tabedar, S; Maharjan, S K; Shrestha, B R; Shrestha, B M

2003-01-01

The study was designed to compare the insertion characteristics and incidence of PDPH between 25 gauge Quincke needle and 26 gauge Eldor needle for spinal anaesthesia in elective c/s. 60 pregnant women (aged 19-35 yrs and weighing 58 -67 kg) undergoing elective caesarean section were randomized into group A (Quincke spinal needle group) or group B (Eldor spinal needle group). Spinal anaesthesia was performed with 2.9 ml 0.5% heavy bupivacaine using 25 gauge Quincke spinal needle in group A and 26 Gauge Eldor spinal needle in group B. Onset, time of first identification of backflow of CSF, number of attempts, level of sensory and motor blockade, failure of anaesthesia, inadequate anaesthesia and incidence of PDPH were recorded. Quincke spinal needle was found easy at insertion, first attempt was successful in 90% of cases, whereas Eldor spinal needle was successful at first attempt in only 60% of cases. Early identification of CSF was seen in Eldor spinal needle group in 3.5 seconds vs. 5.2 seconds in Quincke spinal needle group. Blood mixed CSF was seen in 8 Quincke spinal needle group vs. none in Eldor spinal needle group. Onset was similar between both groups i.e. in 6 minutes. Failure of anaesthesia was none in Eldor spinal needle group vs. 2 in quincke spinal needle group. Height of sensory block achieved was T4 level in 26 parturients,T6 in 1 ,T8 in 1 and no anaesthesia at all in another 2 parturient as compared to T4 level in 29 and T3 in 1 parturient in Eldor spinal needle group. The degree of motor block with the use of Bromage criteria showed a motor score of 1 or 2 in 26 parturients in Quincke spinal needle group vs. same in all cases in Eldor spinal needle group. The total incidence of PDPH was 8.3 % (5 out of 60 parturient) which occurred all in Quincke spinal needle group. 2 parturient who developed severe PDPH required epidural blood patch. 26 gauge Eldor spinal needle was found to be better than 25 gauge Quincke spinal needle for caesarian sections to decrease the incidence of PDPH, though not all insertion characteristics were in favour of the Eldor needle.

Surgical treatment of congenital thoracolumbar spondyloptosis in a 2-year-old child with vertebral column resection and posterior-only circumferential reconstruction of the spine column: case report.

PubMed

Gressot, Loyola V; Mata, Javier A; Luerssen, Thomas G; Jea, Andrew

2015-02-01

Spondyloptosis refers to complete dislocation of a vertebral body onto another. The L5-S1 level is frequently affected. As this condition is rare, few published reports describing its clinical features and surgical outcomes exist, especially in the pediatric patient population. The authors report the presentation, pathological findings, and radiographic studies of a 2-year-old girl who presented to Texas Children's Hospital with a history since birth of progressive spastic paraparesis. Preoperative CT and MRI showed severe spinal cord compression associated with T11-12 spondyloptosis. The patient underwent a single-stage posterior approach for complete resection of the dysplastic vertebral bodies at the apex of the spinal deformity with reconstruction and stabilization of the vertebral column using a titanium expandable cage and pedicle screws. At the 12-month follow-up, the patient remained neurologically stable without any radiographic evidence of instrumentation failure or loss of alignment. To the best of the authors' knowledge, there have been only 2 other children with congenital thoracolumbar spondyloptosis treated with the above-described strategy. The authors describe their case and review the literature to discuss the aggregate clinical features, surgical strategies, and operative outcomes for congenital thoracolumbar spondyloptosis.

Congenital cervical kyphosis in an infant with Ehlers-Danlos syndrome.

PubMed

Kobets, Andrew J; Komlos, Daniel; Houten, John K

2018-07-01

Ehler-Danlos syndome (EDS) refers to a group of heritable connective tissue disorders; rare manifestations of which are cervical kyphosis and clinical myelopathy. Surgical treatment is described for the deformity in the thoracolumbar spine in adolescents but not for infantile cervical spine. Internal fixation for deformity correction in the infantile cervical spine is challenging due to the diminutive size of the bony anatomy and the lack of spinal instrumentation specifically designed for young children. We describe the first case of successful surgical treatment in an infant with a high cervical kyphotic deformity in EDS. A 15-month-old female with EDS presented with several months of regression in gross motor skills in all four extremities. Imaging demonstrated 45° of kyphosis from the C2-4 levels with spinal cord compression. Corrective surgery consisted of a C3 corpectomy and C2-4 anterior fusion with allograft block and anterior fixation with dual 2 × 2 hole craniofacial miniplates, supplemented by C2-4 posterior fusion using four craniofacial miniplates fixated to the lamina. Radiographs at 20 months post-surgery demonstrated solid fusion both anteriorly and posteriorly with maintenance of correction. Ehlers-Danlos syndrome may present in the pediatric population with congenital kyphosis from cervical deformity in addition to the more commonly seen thoracolumbar deformities.

A systematic study of posterior cervical lymph node irradiation with electrons: Conventional versus customized planning.

PubMed

Jankowska, Petra J; Kong, Christine; Burke, Kevin; Harrington, Kevin J; Nutting, Christopher

2007-10-01

High dose irradiation of the posterior cervical lymph nodes usually employs applied electron fields to treat the target volume and maintain the spinal cord dose within tolerance. In the light of recent advances in elective lymph node localisation we investigated optimization of field shape and electron energy to treat this target volume. In this study, three sequential hypotheses were tested. Firstly, that customization of the electron fields based on the nodal PTV outlined gives better PTV coverage than conventional field delineation. Using the consensus guidelines, customization of the electron field shape was compared to conventional fields based on bony landmarks. Secondly, that selection of electron energy using DVHs for spinal cord and PTV improves the minimum dose to PTV. Electron dose-volume histograms (DVHs) for the PTV, spinal cord and para-vertebral muscles, were generated using the Monte Carlo electron algorithm. These DVHs were used to compare standard vs optimized electron energy calculations. Finally, that combination of field customization and electron energy optimization improves both the minimum and mean doses to PTV compared with current standard practice. Customized electron beam shaping based on the consensus guidelines led to fewer geographical misses than standard field shaping. Customized electron energy calculation led to higher minimum doses to the PTV. Overall, the customization of field shape and energy resulted in an improved mean dose to the PTV (92% vs 83% p=0.02) and a 27% improvement in the minimum dose delivered to the PTV (45% vs 18% p=0.0009). Optimization of electron field shape and beam energy based on current consensus guidelines led to significant improvement in PTV coverage and may reduce recurrence rates.

Surgical treatment for osteoporotic thoracolumbar vertebral collapse using vertebroplasty with posterior spinal fusion: a prospective multicenter study.

PubMed

Katsumi, Keiichi; Hirano, Toru; Watanabe, Kei; Ohashi, Masayuki; Yamazaki, Akiyoshi; Ito, Takui; Sawakami, Kimihiko; Sano, Atsuki; Kikuchi, Ren; Endo, Naoto

2016-11-01

The study aimed to investigate the clinical outcomes and limitations after vertebroplasty with posterior spinal fusion (VP+PSF) without neural decompression for osteoporotic vertebral collapse. We conducted a prospective multicenter study including 45 patients (12 men and 33 women, mean age: 77.0 years) evaluated between 2008 and 2012. Operation time, blood loss, visual analog scale (VAS) of back pain, neurological status, kyphosis angle in the fused area, and vertebral union of the collapsed vertebra were evaluated. The mean operation time was 162 min and blood loss was 381 mL. The postoperative VAS score significantly improved, and the neurological status improved in 35 patients (83 %), and none of the remaining patients demonstrated a deteriorating neurological status at two years post-operatively. The mean kyphosis angle pre-operatively, immediately post-operatively, and two years post-operatively was 23.8°, 10.7°, and 24.3°, respectively, and there was no significant difference between the angles pre-operatively and two years post-operatively. The extensive correction of kyphosis >16° was a risk factor for a higher correction loss and subsequent fracture. Union of the collapsed vertebra was observed in 43 patients (95 %) at two years post-operatively. The present study suggests that spinal stabilization rather than neural decompression is essential to treat OVC. Short-segment VP+PSF can achieve a high union rate of collapsed vertebra and provide a significant improvement in back pain or neurological status with less invasive surgery, but has a limit of kyphosis correction more than 16°.

The characteristic clinical symptoms of C-4 radiculopathy caused by ossification of the posterior longitudinal ligament.

PubMed

Katsumi, Keiichi; Yamazaki, Akiyoshi; Watanabe, Kei; Hirano, Toru; Ohashi, Masayuki; Endo, Naoto

2014-05-01

Cervical radiculopathy of the C2-4 spinal nerves is a rare condition and is poorly documented in terms of clinical symptoms, hindering its detection during initial patient screening based on imaging diagnostics. The authors describe in detail the clinical symptoms and successful surgical treatment of a patient diagnosed with isolated C-4 radiculopathy. This 41-year-old man suffered from sleep disturbance because of pain behind the right ear, along the right clavicle, and at the back of his neck on the right side. The Jackson and Spurling tests were positive, with pain radiating to the area behind the patient's ear. Unlike in cases of radiculopathy involving the C5-8 spinal nerves, no loss of upper-extremity motor function was seen. Magnetic resonance imaging showed foraminal stenosis at the C3-4 level on the right side, and multiplanar reconstruction CT revealed a beak-type ossification of the posterior longitudinal ligament in the foraminal region at the same level. In the absence of intracranial lesions or spinal cord compressive lesions, the positive Jackson and Spurling tests and the C3-4 foraminal stenosis were indicative of isolated C-4 radiculopathy. Microscopic foraminotomy was performed at the C3-4 vertebral level and the ossified lesion was resected. The patient's symptoms completely resolved immediately after surgery. To the authors' knowledge, this report is the first to describe the symptomatic features of isolated C-4 radiculopathy, in a case in which the diagnosis has been confirmed by both radiological findings and surgical outcome. Based on this case study, the authors conclude that the characteristic symptoms of C-4 radiculopathy are the presence of pain behind the ear and in the clavicular region in the absence of upper-limb involvement.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Herrington, J; Price, M; Brindle, J

Purpose: To evaluate the equivalence of spine SBRT treatment plans created in Eclipse for the TrueBeam STx (Varian Medical System, Palo Alto, CA) compared to plans using CyberKnife and MultiPlan (Accuray, Sunnyvale, CA). Methods: CT data and contours for 23 spine SBRT patients previously treated using CyberKnife (CK) were exported from MultiPlan treatment planning system into Eclipse where they were planned using static IMRT 6MV coplanar beams. Plans were created according to the original prescription dose and fractionation schedule while limiting spinal dose according to the RTOG 0631 protocol and maintaining target coverage comparable to the original CK plans. Plansmore » were evaluated using new conformity index (nCI), homogeneity index (HI), dose-volume histogram data, number of MU, and estimated treatment time. To ensure all Eclipse plans were deliverable, standard clinical IMRT QA was performed. The plan results were matched with their complimentary CK plans for paired statistical analysis. Results: Plans generated in Eclipse demonstrated statistically significant (p<0.01) improvements compared to complimentary CK plans in median values of maximum spinal cord dose (17.39 vs. 18.12 Gy), RTOG spinal cord constraint dose (14.50 vs. 16.93 Gy), nCI (1.28 vs. 1.54), HI (1.13 vs. 1.27), MU (3918 vs. 36416), and estimated treatment time (8 vs. 48 min). All Eclipse generated plans passed our clinically used protocols for IMRT QA. Conclusion: CK spine SBRT replanned utilizing Eclipse for LINAC delivery demonstrated dosimetric advantages. We propose improvements in plan quality metrics reviewed in this study may be attributed to dynamic MLCs that facilitate treatment of complicated geometries as well as posterior beams ideal for centrally located and/or posterior targets afforded by gantry-based RT delivery.« less

Glioneuronal tumor with neuropil-like islands of the spinal cord with diffuse leptomeningeal neuraxis dissemination.

PubMed

Ruppert, Bree; Welsh, Cynthia T; Hannah, Jessica; Giglio, Pierre; Rumboldt, Zoran; Johnson, Ian; Fortney, John; Jenrette, Joseph M; Patel, Sunil; Scheithauer, Bernd W

2011-09-01

A 54-year-old Caucasian female presented with a 1 year history of intermittent numbness of the left leg progressing to bilateral, lower extremity sensory loss that advanced to include impaired vibration and proprioception. The subsequent thoracic spine magnetic resonance imaging (MRI) scan revealed a heterogeneous, avidly enhancing, centrally situated spinal cord mass involving T7 through T10 in association with thick linear enhancement of the anterior and posterior cord surfaces extending both superiorly and inferiorly. Both the cervical and lumbar spine MRI demonstrated diffuse leptomeningeal disease as well. A brain MRI revealed focal leptomeningeal enhancement in the left and right sylvian fissures, the suprasellar cistern, and the posterior fossa; a pattern consistent with metastatic disease. The patient underwent a T6-T10 laminectomy for tumor biopsy and debulking. Histology revealed a WHO grade III glioneuronal tumor with rosetted neuropil-like islands. Synaptophysin and neurofilament (NF) positive staining was noted within the neural appearing component, whereas, glial fibrillary acidic protein (GFAP) immunopositivity was evident in the fibrillary astrocytoma component of the tumor. The Ki-67 labeling index was 7%. This tumor pattern, now included in the 2007 World Health Organization (WHO) classification of central nervous system tumours as a pattern variation of anaplastic astrocytoma (Kleihues et al. In: Louis et al. (eds) WHO classification of tumours of the central nervous system, 2007), was first described in a four-case series by Teo et al. in 1999. The majority of subsequently reported cases described them as primary tumors of the cerebrum. Herein, we report a unique example of a spinal glioneuronal tumor with neuropil-like islands with associated leptomeningeal dissemination involving the entire craniospinal axis.

Preliminary study into the skeletal injuries sustained to the spine from posterior non-perforating ballistic impacts into body armour.

PubMed

Jennings, Rosalind M; Malbon, C; Brock, F; Harrisson, S E; Carr, D J

2018-05-21

The aim of this paper was to examine any injuries from posterior behind armour blunt trauma ballistic impacts directly over the spine onto typical hard body armours. Due to the spine being close to the surface of the skin and a lack of any previous specific research into this topic, this study was designed to gain preliminary insight into the mechanisms involved and injuries caused. Pigs were chosen as the closest representative of human spine, tissue and skin, although their spines are deeper under the surface than humans. Baseline spine and ribs shots were conducted to ensure that the study was effective. This study used a 65 kg cadaveric pig eviscerated torso and 7.62 NATO ammunition (7.62×51; L2A2; mean velocity=838 m/s, SD=4 m/s) impacting hard body armour plates over the spine. Injuries were inspected, and sections were removed for X-ray and micro-CT assessment. There was no visible soft tissue damage under the impact point on the armour over the spine, and no bony injuries were reported. Baseline rib shots resulted in multiple rib fractures; some showed minimal displacement of the bone. Baseline spine shot resulted in damage across the spine involving spinal cord and bone. No injuries were noted from the spinal impacts, and the rib shots resulted in injuries consistent with those previously reported. The anatomical differences between pigs and humans does not preclude that bony injuries could occur in a human from these types of spinal ballistic impacts. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A study of patients with spinal disease using Maudsley Personality Inventory.

PubMed

Kasai, Yuichi; Takegami, Kenji; Uchida, Atsumasa

2004-02-01

We administered the Maudsley Personality Inventory (MPI) preoperatively to 303 patients with spinal diseases about to undergo surgery. Patients younger than 20 years, patients previously treated in the Department of Psychiatry, and patients with poor postoperative results were excluded. Patients with N-scores (neuroticism scale) of 39 points or greater or L-scores (lie scale) of 26 points or greater were regarded as "abnormal." Based on clinical definitions we identified 24 "problem patients" during the course and categorized them as "Unsatisfied," "Indecisive," "Doctor shoppers," or "Distrustful." Preoperative MPI categorized 26 patients as abnormal; 22 patients categorized as abnormal became problem patients ( p<0.001). MPI sensitivity and specificity was 84.6% and 99.3%, respectively. Preoperative MPI to patients with spinal disease was found to be useful in detecting problem patients.

How much medicine do spine surgeons need to know to better select and care for patients?

PubMed Central

Epstein, Nancy E.

2012-01-01

Background: Although we routinely utilize medical consultants for preoperative clearance and postoperative patient follow-up, we as spine surgeons need to know more medicine to better select and care for our patients. Methods: This study provides additional medical knowledge to facilitate surgeons’ “cross-talk” with medical colleagues who are concerned about how multiple comorbid risk factors affect their preoperative clearance, and impact patients’ postoperative outcomes. Results: Within 6 months of an acute myocardial infarction (MI), patients undergoing urological surgery encountered a 40% mortality rate: similar rates may likely apply to patients undergoing spinal surgery. Within 6 weeks to 2 months of placing uncoated cardiac, carotid, or other stents, endothelialization is typically complete; as anti-platelet therapy may often be discontinued, spinal surgery can then be more safely performed. Coated stents, however, usually require 6 months to 1 year for endothelialization to occur; thus spinal surgery is often delayed as anti-platelet therapy must typically be continued to avoid thrombotic complications (e.g., stroke/MI). Diabetes and morbid obesity both increase the risk of postoperative infection, and poor wound healing, while the latter increases the risk of phlebitis/pulmonary embolism. Both hypercoagluation and hypocoagulation syndromes may require special preoperative testing/medications and/or transfusions of specific hematological factors. Pulmonary disease, neurological disorders, and major psychiatric pathology may also require further evaluations/therapy, and may even preclude successful surgical intervention. Conclusions: Although we as spinal surgeons utilize medical consultants for preoperative clearance and postoperative care, we need to know more medicine to better select and care for our patients. PMID:23248752

Surgical management of spinal intramedullary tumors: radical and safe strategy for benign tumors.

PubMed

Takami, Toshihiro; Naito, Kentaro; Yamagata, Toru; Ohata, Kenji

2015-01-01

Surgery for spinal intramedullary tumors remains one of the major challenges for neurosurgeons, due to their relative infrequency, unknown natural history, and surgical difficulty. We are sure that safe and precise resection of spinal intramedullary tumors, particularly encapsulated benign tumors, can result in acceptable or satisfactory postoperative outcomes. General surgical concepts and strategies, technical consideration, and functional outcomes after surgery are discussed with illustrative cases of spinal intramedullary benign tumors such as ependymoma, cavernous malformation, and hemangioblastoma. Selection of a posterior median sulcus, posterolateral sulcus, or direct transpial approach was determined based on the preoperative imaging diagnosis and careful inspection of the spinal cord surface. Tumor-cord interface was meticulously delineated in cases of benign encapsulated tumors. Our retrospective functional analysis of 24 consecutive cases of spinal intramedullary ependymoma followed for at least 6 months postoperatively demonstrated a mean grade on the modified McCormick functional schema of 1.8 before surgery, deteriorating significantly to 2.6 early after surgery (< 1 month after surgery), and finally returning to 1.7 in the late postoperative period (> 6 months after surgery). The risk of functional deterioration after surgery should be taken into serious consideration. Functional deterioration after surgery, including neuropathic pain even long after surgery, significantly affects patient quality of life. Better balance between tumor control and functional preservation can be achieved not only by the surgical technique or expertise, but also by intraoperative neurophysiological monitoring, vascular image guidance, and postoperative supportive care. Quality of life after surgery should inarguably be given top priority.

Ultrasound-guided femoral and sciatic nerve blocks combined with sedoanalgesia versus spinal anesthesia in total knee arthroplasty

PubMed Central

Tekelioglu, Umit Yasar; Demirhan, Abdullah; Ozturan, Kutay Engin; Bayir, Hakan; Kocoglu, Hasan; Bilgi, Murat

2014-01-01

Background Although regional anesthesia is the first choice for patients undergoing total knee arthroplasty (TKA), it may not be effective and the risk of complications is greater in patients who are obese or who have spinal deformities. We compared the success of ultrasound-guided femoral and sciatic nerve blocks with sedoanalgesia versus spinal anesthesia in unilateral TKA patients in whom spinal anesthesia was difficult. Methods We enrolled 30 patients; 15 for whom spinal anesthesia was expected to be difficult were classified as the block group, and 15 received spinal anesthesia. Regional anesthesia was achieved with bupivacaine 62.5 mg and prilocaine 250 mg to the sciatic nerve, and bupivacaine 37.5 mg and prilocaine 150 mg to the femoral nerve. Bupivacaine 20 mg was administered to induce spinal anesthesia. Hemodynamic parameters, pain and sedation scores, and surgical and patient satisfaction were compared. Results A sufficient block could not be obtained in three patients in the block group. The arterial pressure was significantly lower in the spinal group (P < 0.001), and the incidence of nausea was higher (P = 0.017) in this group. Saturation and patient satisfaction were lower in the block group (P < 0.028), while the numerical pain score (P < 0.046) and the Ramsay sedation score were higher (P = 0.007). Conclusions Ultrasound-guided sciatic and femoral nerve blocks combined with sedoanalgesia were an alternative anesthesia method in selected TKA patients. PMID:25237444

An observational prospective cohort study of incidence and characteristics of failed spinal anaesthesia for caesarean section.

PubMed

Sng, B L; Lim, Y; Sia, A T H

2009-07-01

A prospective cohort study was performed in 800 parturients undergoing elective caesarean section under spinal anaesthesia from May 2005 to April 2006 in a large maternity hospital in Singapore, in order to determine the incidence of and risk factors for total and partial failure of spinal anaesthesia. A routine single-shot spinal technique using intrathecal 0.5% heavy bupivacaine 2.0 mL (10 mg) and morphine 100 microg was administered with a 27-gauge Whitacre spinal needle via a 20-gauge introducer. Demographic, surgical and anaesthetic data were collected to determine risk factors for failure of spinal anaesthesia. Incidence of total failure requiring conversion to general anaesthesia was 0.5% (4 cases) in which three cases had inadequate block (loss of sensation to cold less than T6) and one case had no sensory block. Thirty-three parturients (4.1%) required intravenous fentanyl and seven (0.9%) required Entonox for intraoperative analgesic supplementation. Postpartum sterilization (P<0.001) was an independent risk factor for partial failure requiring intravenous fentanyl and Entonox. Spinal anaesthesia using bupivacaine 10 mg with morphine 100 microg produces reliable anaesthesia for elective caesarean section. Postpartum sterilization involves exteriorisation of the uterus with additional surgical manipulation and hence may necessitate analgesic supplementation. The initial use of a combined spinal-epidural technique or the addition of intrathecal fentanyl or clonidine or an increased dose of local anaesthetic may be considered to decrease the incidence of intraoperative pain.

A telencephalospinal projection in the Tegu lizard (Tupinambis teguixin).

PubMed

Follett, K A

1989-09-04

Tegu lizards (Tupinambis teguixin) were studied to determine the presence of a homologue of the mammalian corticospinal tract. The sources of telencephalic efferent projections to the spinal cord were determined by evaluating the localization of retrogradely transported horseradish peroxidase applied in the cervical spinal cord. Labeled cells were present in subtelencephalic sites reported previously by other authors and, in addition, were found in the principal sensory and motor nuclei of the trigeminal nerve and in the nucleus of the posterior commissure. A telencephalospinal projection was identified, originating in the ventral caudal telencephalon. Histochemical staining revealed a high concentration of acetylcholinesterase in cells and neuropil in the same area. This tract is suggested to be homologous to the mammalian amygdalospinal tract. No reptilian homologue of the corticospinal tract was identified.

Neurocutaneous Melanosis in Association with Dandy-Walker Complex with Extensive Intracerebral and Spinal Cord Involvement

PubMed Central

Sung, Kyoung-Su

2014-01-01

Neurocutaneous melanosis (NCM) is a rare congenital syndrome consisting of benign or malignant melanotic tumors of the central nervous system with large or numerous cutaneous melanocytic nevi. The Dandy-Walker complex (DWC) is characterized by an enlarged posterior fossa with high insertion of the tentorium, hypoplasia or aplasia of the cerebellar vermis, and cystic dilatation of the fourth ventricle. These each two conditions are rare, but NCM associated with DWC is even more rare. Most patients of NCM with DWC present neurological symptoms early in life such as intracranial hemorrhage, hydrocephalus, and malignant transformation of the melanocytes. We report a 14-year-old male patient who was finally diagnosed as NCM in association with DWC with extensive intracerebral and spinal cord involvement. PMID:25289129

Cost Analysis of Spinal Versus General Anesthesia for Lumbar Diskectomy and Laminectomy Spine Surgery.

PubMed

Agarwal, Prateek; Pierce, John; Welch, William C

2016-05-01

Lumbar spine surgery can be performed using various anesthetic modalities, most notably general or spinal anesthesia. Because data comparing the cost of these anesthetic modalities in spine surgery are scarce, this study asks whether spinal anesthesia is less costly than general anesthesia. A total of 542 patients who underwent elective lumbar diskectomy or laminectomy spine surgery between 2007 and 2011 were retrospectively identified, with 364 having received spinal anesthesia and 178 having received general anesthesia. Mean direct operating cost, indirect cost (general support staff, insurance, taxes, floor space, facility, and administrative costs), and total cost were compared among patients who received general and spinal anesthesia. Linear multiple regression analysis was used to identify the effect of anesthesia type on cost and determine the factors underlying this effect, while controlling for patient and procedure characteristics. When controlling for patient and procedure characteristics, use of spinal anesthesia was associated with a 41.1% lower direct operating cost (-$3629 ± $343, P < 0.001), 36.6% lower indirect cost (-$1603 ± $168, P < 0.001), and 39.6% lower total cost (-$5232 ± $482, P < 0.001) compared with general anesthesia. Shorter hospital stay, shorter duration of anesthesia, shorter duration of operation, and lower estimated blood loss contributed to lower costs for spinal anesthesia, but other factors beyond these were also responsible for lower direct operating and total costs. When comparing the benefits of spinal and general anesthesia, spinal anesthesia is less costly when used in patients undergoing lumbar diskectomy and laminectomy spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Secondary damage in the spinal cord after motor cortex injury in rats.

PubMed

Weishaupt, Nina; Silasi, Gergely; Colbourne, Frederick; Fouad, Karim

2010-08-01

When neurons within the motor cortex are fatally injured, their axons, many of which project into the spinal cord, undergo wallerian degeneration. Pathological processes occurring downstream of the cortical damage have not been extensively studied. We created a focal forelimb motor cortex injury in rats and found that axons from cell bodies located in the hindlimb motor cortex (spared by the cortical injury) become secondarily damaged in the spinal cord. To assess axonal degeneration in the spinal cord, we quantified silver staining in the corticospinal tract (CST) at 1 week and 4 weeks after the injury. We found a significant increase in silver deposition at the thoracic spinal cord level at 4 weeks compared to 1 week post-injury. At both time points, no degenerating neurons could be found in the hindlimb motor cortex. In a separate experiment, we showed that direct injury of neurons within the hindlimb motor cortex caused marked silver deposition in the thoracic CST at 1 week post-injury, and declined thereafter. Therefore, delayed axonal degeneration in the thoracic spinal cord after a focal forelimb motor cortex injury is indicative of secondary damage at the spinal cord level. Furthermore, immunolabeling of spinal cord sections showed that a local inflammatory response dominated by partially activated Iba-1-positive microglia is mounted in the CST, a viable mechanism to cause the observed secondary degeneration of fibers. In conclusion, we demonstrate that following motor cortex injury, wallerian degeneration of axons in the spinal cord leads to secondary damage, which is likely mediated by inflammatory processes.

Hyperbaric versus plain bupivacaine for spinal anesthesia for cesarean delivery.

PubMed

Heng Sia, Alex Tiong; Tan, Kok Hian; Sng, Ban Leong; Lim, Yvonne; Chan, Edwin S Y; Siddiqui, Fahad Javaid

2015-01-01

Bupivacaine is an amide local anesthetic used in hyperbaric and plain forms administered as spinal anesthesia for cesarean delivery. In this systematic review, we summarized the effectiveness and safety of hyperbaric versus plain bupivacaine in providing anesthesia for cesarean delivery. We considered the adequacy of anesthesia for completion of cesarean delivery and the need for interventions to treat complications. We searched the CENTRAL, MEDLINE, and EMBASE databases. We imposed no language restriction. We included all randomized controlled trials involving patients undergoing spinal anesthesia for elective cesarean delivery that compared the use of hyperbaric bupivacaine with plain bupivacaine. We included 6 studies with a total of 394 patients in this review. These studies have small sample size, few observed events, differences in methodology, and insufficient information pertaining to assessment of risk of bias. This prevented us from calculating pooled estimates. Results show that there is no compelling evidence in favor of the use of intrathecal plain or hyperbaric bupivacaine for spinal anesthesia for cesarean delivery. There is a lack of clear evidence regarding the superiority of hyperbaric compared with plain bupivacaine for spinal anesthesia for cesarean delivery. The need for conversion to general anesthesia because of failed spinal anesthesia is an important clinical outcome, but current data are insufficient to compare spinal anesthesia induced with hyperbaric compared with plain bupivacaine for this outcome. Further research is required.

Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine.

PubMed

Mirza, Aleem K; Alvi, Mohammed Ali; Naylor, Ryan M; Kerezoudis, Panagiotis; Krauss, William E; Clarke, Michelle J; Shepherd, Daniel L; Nassr, Ahmad; DeMartino, Randall R; Bydon, Mohamad

2017-12-01

Vascular injury is a rare complication of spinal instrumentation. Presentation can vary from immediate hemorrhage to pseudoaneurysm formation. In the literature, surgical approach to repair has varied based on anatomy, acuity of diagnosis, infection, and available technology. In this manuscript, we aim to describe our institutional experience with vascular injuries in thoraco-lumbar spine surgery. We report our institutional experience of three cases of vascular injury secondary to pedicle screw misplacement and their management, as well as a review of the literature. The first case had a history of previous instrumentation and presented with back pain and fever. The patient was taken for instrumentation exploration via a posterior approach. Aortic violation was discovered at T6 intraoperatively during instrumentation removal and the patient underwent emergent endovascular repair. The second case presented with chronic back pain after multiple prior posterior fusions and CT angiogram showing screw perforation on the aorta at T10. The patient underwent elective endovascular repair with synchronous removal of the instrumentation. The third case presented with radicular leg pain 6 months after L4-S1 posterior lumbar interbody fusion, with CT scan demonstrating the left S1 screw abutting the L5 nerve root and common iliac vein. The patient underwent elective instrumentation revision with intraoperative venography. Major vascular injury is a known complication of spinal surgery, especially if it involves instrumentation with pedicle screws. Treatment approach has evolved with the advancement of endovascular technology; however, open surgery remains an option when anatomy or infection is prohibitive. In the elective setting, preoperative planning with attention to surgical approach, positioning, and contingencies, should occur in a multidisciplinary fashion. Repair with an aortic stent-graft cuff may minimize unnecessary coverage of the descending thoracic aorta and intercostal arteries. Copyright © 2017 Elsevier B.V. All rights reserved.

hmmr mediates anterior neural tube closure and morphogenesis in the frog Xenopus.

PubMed

Prager, Angela; Hagenlocher, Cathrin; Ott, Tim; Schambony, Alexandra; Feistel, Kerstin

2017-10-01

Development of the central nervous system requires orchestration of morphogenetic processes which drive elevation and apposition of the neural folds and their fusion into a neural tube. The newly formed tube gives rise to the brain in anterior regions and continues to develop into the spinal cord posteriorly. Conspicuous differences between the anterior and posterior neural tube become visible already during neural tube closure (NTC). Planar cell polarity (PCP)-mediated convergent extension (CE) movements are restricted to the posterior neural plate, i.e. hindbrain and spinal cord, where they propagate neural fold apposition. The lack of CE in the anterior neural plate correlates with a much slower mode of neural fold apposition anteriorly. The morphogenetic processes driving anterior NTC have not been addressed in detail. Here, we report a novel role for the breast cancer susceptibility gene and microtubule (MT) binding protein Hmmr (Hyaluronan-mediated motility receptor, RHAMM) in anterior neurulation and forebrain development in Xenopus laevis. Loss of hmmr function resulted in a lack of telencephalic hemisphere separation, arising from defective roof plate formation, which in turn was caused by impaired neural tissue narrowing. hmmr regulated polarization of neural cells, a function which was dependent on the MT binding domains. hmmr cooperated with the core PCP component vangl2 in regulating cell polarity and neural morphogenesis. Disrupted cell polarization and elongation in hmmr and vangl2 morphants prevented radial intercalation (RI), a cell behavior essential for neural morphogenesis. Our results pinpoint a novel role of hmmr in anterior neural development and support the notion that RI is a major driving force for anterior neurulation and forebrain morphogenesis. Copyright © 2017 Elsevier Inc. All rights reserved.

Sex-Related Differences in the Developmental Morphology of the Atlas: A Computed Tomography Study.

PubMed

Asukai, Mitsuru; Fujita, Tomotada; Suzuki, Daisuke; Nishida, Tatsuya; Ohishi, Tsuyoshi; Matsuyama, Yukihiro

2018-05-15

A retrospective study. To elucidate sex-related differences in the age at synchondroses closure, the normative size of the atlas, and the ossification patterns of the atlas in Japanese children. The atlas develops from three ossification centers during childhood. The anterior and posterior synchondroses, which are separate ossification centers, mimic fracture lines on computed tomography (CT). Sex-related differences of age dependent morphological changes of the atlas in a large sample size have not been reported. This study analyzed data of 688 subjects (449 boys) between 0 and 18 years old who underwent CT examination of the head and/or neck between January 2010 and July 2016. The age at synchondroses closure, anteroposterior outer, inner, and spinal canal widths of the atlas, and variations of the ossification centers were examined. Anterior synchondroses closed by 10 years in boys and by 7 years in girls. Significant earlier closure of anterior synchondroses was observed in girls than in boys (P < 0.05 at 4 and 5 years old). Posterior synchondrosis closed by 6 years in boys and by 5 years in girls. The outer, inner, and spinal canal widths increased up to 10 to 15 years in both sexes, although all three parameters in girls peaked 3 years earlier than those in boys. All parameters in boys were significantly larger than those in girls, except in the 10- to 12-year-old age category. Two or more ossification centers in the anterior arch were observed in 18.3% subjects, and 6% had midline ossification centers in the posterior arch of the atlas. Distinct sex-related differences in the age at anterior synchondroses closure and the size of the atlas were observed in Japanese children. Knowledge of morphological features of the atlas could help distinguish fractures from synchondroses. 3.

Using Transcranial Magnetic Stimulation to Evaluate the Motor Pathways After an Intraoperative Spinal Cord Injury and to Predict the Recovery of Intraoperative Transcranial Electrical Motor Evoked Potentials: A Case Report.

PubMed

Grover, Helen J; Thornton, Rachel; Lutchman, Lennel N; Blake, Julian C

2016-06-01

The authors report a case of unilateral loss of intraoperative transcranial electrical motor evoked potentials (TES MEP) associated with a spinal cord injury during scoliosis correction and the subsequent use of extraoperative transcranial magnetic stimulation to monitor the recovery of spinal cord function. The authors demonstrate the absence of TES MEPs and absent transcranial magnetic stimulation responses in the immediate postoperative period, and document the partial recovery of transcranial magnetic stimulation responses, which corresponded to partial recovery of TES MEPs. Intraoperative TES MEPs were enhanced using spatial facilitation technique, which enabled the patient to undergo further surgery to stabilize the spine and correct her scoliosis. This case report supports evidence of the use of extraoperative transcranial magnetic stimulation to predict the presence of intraoperative TES responses and demonstrates the usefulness of spatial facilitation to monitor TES MEPs in a patient with a preexisting spinal cord injury.

Atelectasis observed by computerized tomography after Caesarean section.

PubMed

Meira, M N C; Carvalho, C R R; Galizia, M S; Borges, J B; Kondo, M M; Zugaib, M; Vieira, J E

2010-06-01

Atelectasis after either vaginal or Caesarean delivery has not been adequately quantified. This study addresses the hypothesis that atelectasis may be worse in women who undergo Caesarean section when compared with vaginal delivery under regional anaesthesia. Twenty healthy non-smoking women submitted to a chest computed tomography (CT) 2 h after delivery in a University Hospital, who had experienced vaginal delivery (n=10) under combined spinal-epidural analgesia or a Caesarean section (n=10) under spinal anaesthesia, were evaluated. The percentage cross-sectional area of atelectasis in dependent lung regions were measured from the CT images obtained at cross-section of the xiphoid process and the top of the diaphragm. The percentage cross-sectional area of atelectasis was 3.95% in the vaginal delivery group and 14.1% in the Caesarean group (P<0.001, Mann-Whitney rank sum test). These results suggested that pulmonary atelectasis is greater after Caesarean section delivery under spinal anaesthesia than after vaginal delivery with combined spinal-epidural analgesia.

Virtual reality-based simulators for spine surgery: a systematic review.

PubMed

Pfandler, Michael; Lazarovici, Marc; Stefan, Philipp; Wucherer, Patrick; Weigl, Matthias

2017-09-01

Virtual reality (VR)-based simulators offer numerous benefits and are very useful in assessing and training surgical skills. Virtual reality-based simulators are standard in some surgical subspecialties, but their actual use in spinal surgery remains unclear. Currently, only technical reviews of VR-based simulators are available for spinal surgery. Thus, we performed a systematic review that examined the existing research on VR-based simulators in spinal procedures. We also assessed the quality of current studies evaluating VR-based training in spinal surgery. Moreover, we wanted to provide a guide for future studies evaluating VR-based simulators in this field. This is a systematic review of the current scientific literature regarding VR-based simulation in spinal surgery. Five data sources were systematically searched to identify relevant peer-reviewed articles regarding virtual, mixed, or augmented reality-based simulators in spinal surgery. A qualitative data synthesis was performed with particular attention to evaluation approaches and outcomes. Additionally, all included studies were appraised for their quality using the Medical Education Research Study Quality Instrument (MERSQI) tool. The initial review identified 476 abstracts and 63 full texts were then assessed by two reviewers. Finally, 19 studies that examined simulators for the following procedures were selected: pedicle screw placement, vertebroplasty, posterior cervical laminectomy and foraminotomy, lumbar puncture, facet joint injection, and spinal needle insertion and placement. These studies had a low-to-medium methodological quality with a MERSQI mean score of 11.47 out of 18 (standard deviation=1.81). This review described the current state and applications of VR-based simulator training and assessment approaches in spinal procedures. Limitations, strengths, and future advancements of VR-based simulators for training and assessment in spinal surgery were explored. Higher-quality studies with patient-related outcome measures are needed. To establish further adaptation of VR-based simulators in spinal surgery, future evaluations need to improve the study quality, apply long-term study designs, and examine non-technical skills, as well as multidisciplinary team training. Copyright © 2017 Elsevier Inc. All rights reserved.

The Prevalence and Phenotype of Activated Microglia/Macrophages within the Spinal Cord of the Hyperostotic Mouse (twy/twy) Changes in Response to Chronic Progressive Spinal Cord Compression: Implications for Human Cervical Compressive Myelopathy

PubMed Central

Hirai, Takayuki; Uchida, Kenzo; Nakajima, Hideaki; Guerrero, Alexander Rodriguez; Takeura, Naoto; Watanabe, Shuji; Sugita, Daisuke; Yoshida, Ai; Johnson, William E. B.; Baba, Hisatoshi

2013-01-01

Background Cervical compressive myelopathy, e.g. due to spondylosis or ossification of the posterior longitudinal ligament is a common cause of spinal cord dysfunction. Although human pathological studies have reported neuronal loss and demyelination in the chronically compressed spinal cord, little is known about the mechanisms involved. In particular, the neuroinflammatory processes that are thought to underlie the condition are poorly understood. The present study assessed the localized prevalence of activated M1 and M2 microglia/macrophages in twy/twy mice that develop spontaneous cervical spinal cord compression, as a model of human disease. Methods Inflammatory cells and cytokines were assessed in compressed lesions of the spinal cords in 12-, 18- and 24-weeks old twy/twy mice by immunohistochemical, immunoblot and flow cytometric analysis. Computed tomography and standard histology confirmed a progressive spinal cord compression through the spontaneously development of an impinging calcified mass. Results The prevalence of CD11b-positive cells, in the compressed spinal cord increased over time with a concurrent decrease in neurons. The CD11b-positive cell population was initially formed of arginase-1- and CD206-positive M2 microglia/macrophages, which later shifted towards iNOS- and CD16/32-positive M1 microglia/macrophages. There was a transient increase in levels of T helper 2 (Th2) cytokines at 18 weeks, whereas levels of Th1 cytokines as well as brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF) and macrophage antigen (Mac) −2 progressively increased. Conclusions Spinal cord compression was associated with a temporal M2 microglia/macrophage response, which may act as a possible repair or neuroprotective mechanism. However, the persistence of the neural insult also associated with persistent expression of Th1 cytokines and increased prevalence of activated M1 microglia/macrophages, which may lead to neuronal loss and demyelination despite the presence of neurotrophic factors. This understanding of the aetiopathology of chronic spinal cord compression is of importance in the development of new treatment targets in human disease. PMID:23717624

Spinal analgesia and auditory functions: a comparison of two sizes of Quincke needle.

PubMed

Malhotra, S K; Iyer, B A; Gupta, A K; Raghunathan, M; Nakra, D

2007-01-01

Spinal anaesthesia may produce complications ranging from minor problems such as pain on injection, backache and urinary retention to more serious consequences such as post-dural puncture headache (PDPH), neurological complications like meningitis, cranial and peripheral nerve palsies and even cardiac arrest. Impaired auditory function is a relatively lesser-recognized complication of spinal analgesia. The objective of this study was to investigate the effects of spinal analgesia on vestibular dysfunction, using different sizes of the same type of spinal needle. The study included 30 ASA I patients who had received spinal analgesia for lower abdominal surgery. Pure tone audiometry was performed before surgery and on postoperative day 2. In addition, any patient with hearing impairment of >15 dB was scheduled to undergo electrocochleography. Hearing levels were measured from 250 Hz to 8 kHz. In group 1 (n=15), a 26gauge Quincke needle was used. In group 2 (n=15), a 23-gauge Quincke needle was used. Comparison of hearing thresholds showed a significant reduction in the hearing level (P<0.05) in 2 patients in group 2 but none in group 1. The use of a 23-gauge Quincke needle is associated with a greater reduction in the mean hearing level compared to a 26-gauge needle of the same type.

Fatty Acid Binding Protein 5 Modulates Docosahexaenoic Acid-Induced Recovery in Rats Undergoing Spinal Cord Injury

PubMed Central

Figueroa, Johnny D.; Serrano-Illan, Miguel; Licero, Jenniffer; Cordero, Kathia; Miranda, Jorge D.

2016-01-01

Abstract Omega-3 polyunsaturated fatty acids (n-3 PUFAs) promote functional recovery in rats undergoing spinal cord injury (SCI). However, the precise molecular mechanism coupling n-3 PUFAs to neurorestorative responses is not well understood. The aim of the present study was to determine the spatiotemporal expression of fatty acid binding protein 5 (FABP5) after contusive SCI and to investigate whether this protein plays a role in n-3 PUFA–mediated functional recovery post-SCI. We found that SCI resulted in a robust spinal cord up-regulation in FABP5 mRNA levels (556 ± 187%) and protein expression (518 ± 195%), when compared to sham-operated rats, at 7 days post-injury (dpi). This upregulation coincided with significant alterations in the metabolism of fatty acids in the injured spinal cord, as revealed by metabolomics-based lipid analyses. In particular, we found increased levels of the n-3 series PUFAs, particularly docosahexaenoic acid (DHA; 22:6 n-3) and eicosapentaenoic acid (EPA; 20:5 n-3) at 7 dpi. Animals consuming a diet rich in DHA and EPA exhibited a significant upregulation in FABP5 mRNA levels at 7 dpi. Immunofluorescence showed low basal FABP5 immunoreactivity in spinal cord ventral gray matter NeuN+ neurons of sham-operated rats. SCI resulted in a robust induction of FABP5 in glial (GFAP+, APC+, and NG2+) and precursor cells (DCX+, nestin+). We found that continuous intrathecal administration of FABP5 silencing with small interfering RNA (2 μg) impaired spontaneous open-field locomotion post-SCI. Further, FABP5 siRNA administration hindered the beneficial effects of DHA to ameliorate functional recovery at 7 dpi. Altogether, our findings suggest that FABP5 may be an important player in the promotion of cellular uptake, transport, and/or metabolism of DHA post-SCI. Given the beneficial roles of n-3 PUFAs in ameliorating functional recovery, we propose that FABP5 is an important contributor to basic repair mechanisms in the injured spinal cord. PMID:26715431

A minimally invasive technique for percutaneous lumbar facet augmentation: Technical description of a novel device

PubMed Central

Smith, Zachary A.; Armin, Sean; Raphael, Dan; Khoo, Larry T.

2011-01-01

Background: We describe a new posterior dynamic stabilizing system that can be used to augment the mechanics of the degenerating lumbar segment. The mechanism of this system differs from other previously described surgical techniques that have been designed to augment lumbar biomechanics. The implant and technique we describe is an extension-limiting one, and it is designed to support and cushion the facet complex. Furthermore, it is inserted through an entirely percutaneous technique. The purpose of this technical note is to demonstrate a novel posterior surgical approach for the treatment of lumbar degenerative. Methods: This report describes a novel, percutaneously placed, posterior dynamic stabilization system as an alternative option to treat lumbar degenerative disk disease with and without lumbar spinal stenosis. The system does not require a midline soft-tissue dissection, nor subperiosteal dissection, and is a truly minimally invasive means for posterior augmentation of the functional facet complex. This system can be implanted as a stand-alone procedure or in conjunction with decompression procedures. Results: One-year clinical results in nine individual patients, all treated for degenerative disease of the lower lumbar spine, are presented. Conclusions: This novel technique allows for percutaneous posterior dynamic stabilization of the lumbar facet complex. The use of this procedure may allow a less invasive alternative to traditional approaches to the lumbar spine as well as an alternative to other newly developed posterior dynamic stabilization systems. PMID:22145084

Minimally invasive posterior cervical decompression using tubular retractor: The technical note and early clinical outcome

PubMed Central

Hur, Jung-Woo; Kim, Jin-Sung; Shin, Myeong-Hoon; Ryu, Kyeong-Sik

2014-01-01

Background: The aim of this work is to present a novel decompression technique that approaches cervical spine posteriorly, but through minimal invasive method using tubular retractor avoiding detachment of posterior musculature. Methods: Six patients underwent minimally invasive posterior cervical decompression using the tubular retractor system and surgical microscope. Minimally invasive access to the posterior cervical spine was performed with exposure through a paramedian muscle-splitting approach. With the assistance of a specialized tubular retraction system and deep soft tissue expansion mechanism, multilevel posterior cervical decompression could be accomplished. This approach also allows safe docking of the retractor system on the lateral mass, thus avoiding the cervical spinal canal during exposure. A standard operating microscope was used with ×10 magnification and 400 mm focal length. The hospital charts, magnetic resonance imaging studies, and follow-up records of all the patients were reviewed. Outcome was assessed by neurological status and visual analog scale (VAS) for neck and arm pain. Results: There was no significant complication related to operation. The follow-up time was 4-12 months (mean, 9 months). Muscle weakness improved in all patients; sensory deficits resolved in four patients and improved in two patients. Analysis of the mean VAS for radicular pain and VAS for neck pain showed significant improvement. Conclusions: The preliminary experiences with good clinical outcome seem to promise that this minimally invasive technique is a valid alternative option for the treatment of cervical spondylotic myelopathy. PMID:24778922

A late neurological complication following posterior correction surgery of severe cervical kyphosis.

PubMed

Hojo, Yoshihiro; Ito, Manabu; Abumi, Kuniyoshi; Kotani, Yoshihisa; Sudo, Hideki; Takahata, Masahiko; Minami, Akio

2011-06-01

Though a possible cause of late neurological deficits after posterior cervical reconstruction surgery was reported to be an iatrogenic foraminal stenosis caused not by implant malposition but probably by posterior shift of the lateral mass induced by tightening screws and plates, its clinical features and pathomechanisms remain unclear. The aim of this retrospective clinical review was to investigate the clinical features of these neurological complications and to analyze the pathomechanisms by reviewing pre- and post-operative imaging studies. Among 227 patients who underwent cervical stabilization using cervical pedicle screws (CPSs), six patients who underwent correction of cervical kyphosis showed postoperative late neurological complications without any malposition of CPS (ND group). The clinical courses of the patients with deficits were reviewed from the medical records. Radiographic assessment of the sagittal alignment was conducted using lateral radiographs. The diameter of the neural foramen was measured on preoperative CT images. These results were compared with the other 14 patients who underwent correction of cervical kyphosis without late postoperative neurological complications (non-ND group). The six patients in the ND group showed no deficits in the immediate postoperative periods, but unilateral muscle weakness of the deltoid and biceps brachii occurred at 2.8 days postoperatively on average. Preoperative sagittal alignment of fusion area showed significant kyphosis in the ND group. The average of kyphosis correction in the ND was 17.6° per fused segment (range 9.7°-35.0°), and 4.5° (range 1.3°-10.0°) in the non-ND group. A statistically significant difference was observed in the degree of preoperative kyphosis and the correction angles at C4-5 between the two groups. The diameter of the C4-5 foramen on the side of deficits was significantly smaller than that of the opposite side in the ND group. Late postoperative neurological complications after correction of cervical kyphosis were highly associated with a large amount of kyphosis correction, which may lead foraminal stenosis and enhance posterior drift of the spinal cord. These factors may lead to both compression and traction of the nerves, which eventually cause late neurological deficits. To avoid such complications, excessive kyphosis correction should not be performed during posterior surgery to avoid significant posterior shift of the spinal cord and prophylactic foraminotomies are recommended if narrow neuroforamina were evident on preoperative CT images. Regardless of revision decompression or observation, the majority of this late neurological complication showed complete recovery over time.

Redistribution of hematoma to spinal subdural space as a mechanism for the rapid spontaneous resolution of posttraumatic intracranial acute subdural hematoma: case report.

PubMed

Wong, Sui To; Yuen, Ming Keung; Fok, Kam Fuk; Yuen, Shing Chau; Yam, Kwong Yui; Fong, Dawson

2009-01-01

Rapid spontaneous resolution of posttraumatic intracranial ASDH has been reported in the literature since 1986. We report a case to demonstrate that redistribution of hematoma to the spinal subdural space is a mechanism for the rapid spontaneous resolution of posttraumatic intracranial ASDH. A 73-year-old woman with a slipped-and-fell injury had a worst GCS score of 8/15. Computerized tomography of the brain demonstrated a large intracranial ASDH with mass effect. Conservative management was decided because of her poor premorbid general condition. Rapid clinical improvement was observed within 5 hours after the CT. Progress CT of the brain at 45 hours postinjury showed that the size of the intracranial ASDH was markedly diminished. The CT findings apparently demonstrated a caudal distribution of the intracranial ASDH over the tentorium and then into the posterior fossa. To investigate this further, an MRI of the spine was performed, which showed that there was spinal SDH in the cervical and thoracic spine. This is the first report demonstrating that redistribution of posttraumatic intracranial ASDH to the spinal subdural space is one of the mechanisms behind the rapid spontaneous resolution of posttraumatic intracranial ASDH in the acute phase.

Low back pain tied to spinal endometriosis.

PubMed

Dongxu, Zhao; Fei, Yin; Xing, Xiao; Bo-Yin, Zhang; Qingsan, Zhu

2014-05-01

Case report. We present a case of endometriosis of lumbar vertebrae. The literatures are reviewed with endometriosis of spine. Endometriosis is a common condition, which is defined as endometrial tissue lying outside the endometrial cavity. It is usually found within the peritoneal cavity, predominantly within the pelvis, commonly on the uterosacral ligaments. It can also be found in other sites such as umbilicus, abdominal scars, nasal passages and pleural cavity. But it is very rarely seen in the spine, with no report of endometriosis found in the lumbar vertebrae. A 33-year-old woman presented with severe low back pain. She had the low back pain periodically for 3 years, and the pain was associated with menstruation. Radiographs showed a lesion in the posterior L3 body. After surgery, tissue biopsy indicated the presence of endometrial tissue in the lesion and thus confirmed endometriosis. Most cases of spine endometriosis that have been reported are usually found inside spinal canal, endorachis or spinal cord. But spinal vertebrae can also be involved in endometriosis. Although endometriosis is a rare possible cause of periodical low back pain in women of childbearing age, we suggest that if a woman suffering from periodical low back pain is encountered, do not ignore the possibility of endometriosis in the spine.

Merkel Cell Spinal Metastasis: Management in the Setting of a Poor Prognosis.

PubMed

Goodwin, C Rory; Mehta, Ankit I; Adogwa, Owoicho; Sarabia-Estrada, Rachel; Sciubba, Daniel M

2015-08-01

Study Design Case report. Objective Merkel cell carcinoma is an aggressive neuroendocrine carcinoma with a poor prognosis. Metastatic epidural spinal cord compression (MESCC) is a debilitating disease causing neurologic deficits. The surgical management for MESCC depends on pathology. Methods We report a case of Merkel cell carcinoma of the spine and evaluate the treatment paradigms utilized in the prior reports. Result A 76-year-old man with a history of Merkel cell carcinoma presented with 2-week history of progressive difficulty ambulating and a solitary T5 epidural mass encasing the spinal cord. The patient underwent a T5 corpectomy with cage placement and T3 to T7 posterior fusion with postoperative neurologic improvement and a return to ambulation. Three weeks postoperatively, the patient re-presented with new-onset weakness and widespread metastatic spinal disease with epidural compression at the T8 level. Six weeks postoperatively, he was placed in hospice care. Conclusion Prior reports in the literature demonstrated a poor prognosis for Merkel cell carcinoma metastasis to the spine with survival ranging from 1 to 9 months after diagnosis. Although neurologic decline necessitates a surgical intervention, the assessment of operative benefit should take into account the prognosis associated with the primary tumor subtype.

Epidural meperidine for control of autonomic hyperreflexia in a quadriplegic undergoing cystoscopy.

PubMed

Baraka, A; Noueihid, R; Sibai, A N; Baroody, M; Louis, F; Hemady, K

1989-06-01

Epidural meperidine was used to control autonomic hyperreflexia (AH) during cystoscopy and transuretheral sphincterotomy, in a quadriplegic patient who had chronic spinal cord transection at C6 level. Meperidine 100 mg diluted in 10 ml saline was injected in the epidural space at L3-L4 level. Within 10 minutes and throughout the surgical procedure, the blood pressure stabilized at 125/70-140/80 mmHg. Epidural meperidine produces selective blockade of the spinal opiate receptors and hence may block the nociceptive reflexes below the level of cord transection and prevent AH.

Adult Spinal Deformity Patients Recall Fewer Than 50% of the Risks Discussed in the Informed Consent Process Preoperatively and the Recall Rate Worsens Significantly in the Postoperative Period.

PubMed

Saigal, Rajiv; Clark, Aaron J; Scheer, Justin K; Smith, Justin S; Bess, Shay; Mummaneni, Praveen V; McCarthy, Ian M; Hart, Robert A; Kebaish, Khaled M; Klineberg, Eric O; Deviren, Vedat; Schwab, Frank; Shaffrey, Christopher I; Ames, Christopher P

2015-07-15

Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively. To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity surgery, assess for differences between patients and family members, and correlate with mental status. Given high rates of complications in adult spinal deformity surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall preoperative discussion of possible complications to mitigate medical legal risk. Patients undergoing adult spinal deformity surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination-brief version. Patients subjectively scored the informed consent process and video. After surgery, the recall test and mini-mental status examination-brief version were readministered at 5 additional time points: hospital discharge, 6 to 8 weeks, 3 months, 6 months, and 1 year postoperatively. Family members were assessed at the first 3 time points for comparison. Fifty-six patients enrolled. Despite ranking the consent process as important (median overall score: 10/10; video score: 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement and subsequently declined to 18% at 6 to 8 weeks and 1 year postoperatively. Median family recall trended higher at 55% immediately and 36% at 6 to 8 weeks postoperatively. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from preoperation to discharge but were significantly higher at 1 year. Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention. 3.

Dexmedetomidine-related polyuria in a pediatric patient.

PubMed

Adams, Phillip S; Cassara, Antonio

2016-04-01

Polyuria related to pharmacologic α2-adrenoreceptor agonism has been well described in vitro and in animal models and is thought to be the result of functional antagonism of arginine vasopressin. Despite its widespread use as a sedative and anesthetic adjunct, very few reports of dexmedetomidine-related polyuria in humans exist in the literature. We present the first description of a pediatric patient manifesting polyuria and hypernatremia in association with dexmedetomidine infusion for posterior spinal fusion.

Variables Affecting the Reporting of Pain Following an Acute Myocardial Infarction

DTIC Science & Technology

1991-05-01

research found which investigated the phenomenon of unreported CP. The experience of pain is a highly complex human experience with a multiplicity of...occur, and is persistent (Greer & Hoyt, 1990). Nociceptive fibers have cell bodies in the spinal ganglia , which enter the dorsal horn posteriorly, and...via the spinothalamic pathway, and stimulate somatic motor neurons on the anterior horn, or preganglionic neurons of the autonomic nervous system in the

Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.

PubMed

Pugely, Andrew J; Martin, Christopher T; Gao, Yubo; Mendoza-Lattes, Sergio; Callaghan, John J

2013-02-06

Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias. The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty. Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.

[Paradigm shift in the management of metastatic epidural spinal cord compression: the importance of preserving ambulation].

PubMed

Itshayek, Eyal

2013-12-01

In 2005, a Landmark study showed that direct decompressive surgery, followed by postoperative external beam radiotherapy (EBRT) is superior to EBRT alone in patients with metastatic epidural spinal cord compression (MESCC). Patients undergoing both surgery and EBRT had similar median survival but experienced longer ambulation than with EBRT alone. Additional studies have shown improvements in quality-of-life, higher cost-effectiveness, improved pain control, and higher functional status with surgery plus EBRT. Improved neurological outcome also improved the patients' ability to undergo postoperative adjuvant therapy. According to our experience, even patients over 65 or patients with aggressive primary tumors and additional metastases have benefited from surgical intervention, living longer than expected with preservation of ambulation and sphincter control until death or shortly before. Preserving ambulation is critical. With current surgical devices and techniques, patients with MESCC who present with a single area of cord compression, back pain, neurological deficit, or progressive deformity, may benefit from surgery prior to adjuvant radiation-based treatment or chemotherapy.

Classification of High Intensity Zones of the Lumbar Spine and Their Association with Other Spinal MRI Phenotypes: The Wakayama Spine Study.

PubMed

Teraguchi, Masatoshi; Samartzis, Dino; Hashizume, Hiroshi; Yamada, Hiroshi; Muraki, Shigeyuki; Oka, Hiroyuki; Cheung, Jason Pui Yin; Kagotani, Ryohei; Iwahashi, Hiroki; Tanaka, Sakae; Kawaguchi, Hiroshi; Nakamura, Kozo; Akune, Toru; Cheung, Kenneth Man-Chee; Yoshimura, Noriko; Yoshida, Munehito

2016-01-01

High intensity zones (HIZ) of the lumbar spine are a phenotype of the intervertebral disc noted on MRI whose clinical relevance has been debated. Traditionally, T2-weighted (T2W) magnetic resonance imaging (MRI) has been utilized to identify HIZ of lumbar discs. However, controversy exists with regards to HIZ morphology, topography, and association with other MRI spinal phenotypes. Moreover, classification of HIZ has not been thoroughly defined in the past and the use of additional imaging parameters (e.g. T1W MRI) to assist in defining this phenotype has not been addressed. A cross-sectional study of 814 (69.8% females) subjects with mean age of 63.6 years from a homogenous Japanese population was performed. T2W and T1W sagittal 1.5T MRI was obtained on all subjects to assess HIZ from L1-S1. We created a morphological and topographical HIZ classification based on disc level, shape type (round, fissure, vertical, rim, and enlarged), location within the disc (posterior, anterior), and signal type on T1W MRI (low, high and iso intensity) in comparison to the typical high intensity on T2W MRI. HIZ was noted in 38.0% of subjects. Of these, the prevalence of posterior, anterior, and both posterior/anterior HIZ in the overall lumbar spine were 47.3%, 42.4%, and 10.4%, respectively. Posterior HIZ was most common, occurring at L4/5 (32.5%) and L5/S1 (47.0%), whereas anterior HIZ was most common at L3/4 (41.8%). T1W iso-intensity type of HIZ was most prevalent (71.8%), followed by T1W high-intensity (21.4%) and T1W low-intensity (6.8%). Of all discs, round types were most prevalent (anterior: 3.6%, posterior: 3.7%) followed by vertical type (posterior: 1.6%). At all affected levels, there was a significant association between HIZ and disc degeneration, disc bulge/protrusion and Modic type II (p<0.01). Posterior HIZ and T1W high-intensity type of HIZ were significantly associated with disc bulge/protrusion and disc degeneration (p<0.01). In addition, posterior HIZ was significantly associated with Modic type II and III. T1W low-intensity type of HIZ was significantly associated with Modic type II. This is the first large-scale study reporting a novel classification scheme of HIZ of the lumbar spine. This study is the first that has utilized T2W and T1W MRIs in differentiating HIZ sub-phenotypes. Specific HIZ sub-phenotypes were found to be more associated with specific MRI degenerative changes. With a more detailed description of the HIZ phenotype, this scheme can be standardized for future clinical and research initiatives.

Improved vacuum sealing drainage for treatment of surgical site infection following posterior spinal internal fixation

PubMed Central

Zhang, Hengyan; Li, Qiyi

2018-01-01

Abstract Rationale: Surgical site infection (SSI) following spine surgeries involving internal fixation often require removing the instrument; however, this can cause spinal instability. Previous reports have demonstrated the usefulness of vacuum sealing drainage (VSD) therapy, but the cases require wound opening, aseptic condition to replace the VSD device, and a secondary operation to close the wound. Thus, to improve the VSD treatment and develop a maneuverable procedure, make sense in spine surgery. Patients concerns: A 59-year-old male patient with a T12 vertebral fracture was affected by SSIs after spinal osteotomy with internal fixation. Diagnoses: The patient complained of wound exudation and had a fever 3 weeks after posterior spinal surgery. Initial serum investigations showed elevated white blood cell count and bacterial cultures of wound exudate were positive for Enterococcus faecalis. Therefore, SSI is confirmed. Interventions: The infection was not controlled after 2 debridements, so the patient was treated with VSD treatment. The VSD foam dressings containing a drainage tube were placed into the wound from the exudation site of the wound until they contacted the internal fixation devices. After covering external fixation devices, continuous drainage was performed for 24 h. The VSD device was replaced every 4 to 5 days until the wound effusion stopped. All of the operations were performed at the bedside without complex manipulation or secondary closure under harsh aseptic condition. Outcomes: Wound exudation decreased remarkably and the infection was controlled 2 weeks after the application of VSD treatment. After 5 weeks, inflammatory indicators all decreased to normal levels and the exudate of the wound had stopped. The VSD treatment was then terminated and the drainage site of the wound was sutured. After 7 weeks, complete wound healing was achieved and no infection recurred during the 6-month follow-up. Lessons: VSD could be a reliable treatment for SSIs that require preservation of internal fixation. Complete opening of the wound during the VSD treatment and secondary wound closure surgery were avoided. PMID:29443786

Radiographic and Clinical Outcome of Silicate-substituted Calcium Phosphate (Si-CaP) Ceramic Bone Graft in Spinal Fusion Procedures.

PubMed

Alimi, Marjan; Navarro-Ramirez, Rodrigo; Parikh, Karishma; Njoku, Innocent; Hofstetter, Christoph P; Tsiouris, Apostolos J; Härtl, Roger

2017-07-01

Retrospective cohort study. To evaluate the radiographic and clinical outcome of silicate-substituted calcium phosphate (Si-CaP), utilized as a graft substance in spinal fusion procedures. Specific properties of Si-CaP provide the graft with negative surface charge that can result in a positive effect on the osteoblast activity and neovascularization of the bone. This study included those patients who underwent spinal fusion procedures between 2007 and 2011 in which Si-CaP was used as the only bone graft substance. Fusion was evaluated on follow-up CT scans. Clinical outcome was assessed using Oswestry Disability Index, Neck Disability Index, and the visual analogue scale (VAS) for back, leg, neck, and arm pain. A total of 234 patients (516 spinal fusion levels) were studied. Surgical procedures consisted of 57 transforaminal lumbar interbody fusion, 49 anterior cervical discectomy and fusion, 44 extreme lateral interbody fusion, 30 posterior cervical fusions, 19 thoracic fusion surgeries, 17 axial lumbar interbody fusions, 16 combined anterior and posterior cervical fusions, and 2 anterior lumbar interbody fusion. At a mean radiographic follow-up of 14.2±4.3 months, fusion was found to be present in 82.9% of patients and 86.8% of levels. The highest fusion rate was observed in the cervical region. At the latest clinical follow-up of 21.7±14.2 months, all clinical outcome parameters showed significant improvement. The Oswestry Disability Index improved from 45.6 to 13.3 points, Neck Disability Index from 40.6 to 29.3, VAS back from 6.1 to 3.5, VAS leg from 5.6 to 2.4, VAS neck from 4.7 to 2.7, and VAS arm from 4.1 to 1.7. Of 7 cases with secondary surgical procedure at the index level, the indication for surgery was nonunion in 3 patients. Si-CaP is an effective bone graft substitute. At the latest follow-up, favorable radiographic and clinical outcome was observed in the majority of patients. Level-III.

Compression and contact area of anterior strut grafts in spinal instrumentation: a biomechanical study.

PubMed

Pizanis, Antonius; Holstein, Jörg H; Vossen, Felix; Burkhardt, Markus; Pohlemann, Tim

2013-08-26

Anterior bone grafts are used as struts to reconstruct the anterior column of the spine in kyphosis or following injury. An incomplete fusion can lead to later correction losses and compromise further healing. Despite the different stabilizing techniques that have evolved, from posterior or anterior fixating implants to combined anterior/posterior instrumentation, graft pseudarthrosis rates remain an important concern. Furthermore, the need for additional anterior implant fixation is still controversial. In this bench-top study, we focused on the graft-bone interface under various conditions, using two simulated spinal injury models and common surgical fixation techniques to investigate the effect of implant-mediated compression and contact on the anterior graft. Calf spines were stabilised with posterior internal fixators. The wooden blocks as substitutes for strut grafts were impacted using a "pressfit" technique and pressure-sensitive films placed at the interface between the vertebral bone and the graft to record the compression force and the contact area with various stabilization techniques. Compression was achieved either with posterior internal fixator alone or with an additional anterior implant. The importance of concomitant ligament damage was also considered using two simulated injury models: pure compression Magerl/AO fracture type A or rotation/translation fracture type C models. In type A injury models, 1 mm-oversized grafts for impaction grafting provided good compression and fair contact areas that were both markedly increased by the use of additional compressing anterior rods or by shortening the posterior fixator construct. Anterior instrumentation by itself had similar effects. For type C injuries, dramatic differences were observed between the techniques, as there was a net decrease in compression and an inadequate contact on the graft occurred in this model. Under these circumstances, both compression and the contact area on graft could only be maintained at high levels with the use of additional anterior rods. Under experimental conditions, we observed that ligamentous injury following type C fracture has a negative influence on the compression and contact area of anterior interbody bone grafts when only an internal fixator is used for stabilization. Because of the loss of tension banding effects in type C injuries, an additional anterior compressing implant can be beneficial to restore both compression to and contact on the strut graft.

White matter and information processing speed following treatment with cranial-spinal radiation for pediatric brain tumor.

PubMed

Scantlebury, Nadia; Bouffet, Eric; Laughlin, Suzanne; Strother, Douglas; McConnell, Dina; Hukin, Juliette; Fryer, Christopher; Laperriere, Normand; Montour-Proulx, Isabelle; Keene, Daniel; Fleming, Adam; Jabado, Nada; Liu, Fang; Riggs, Lily; Law, Nicole; Mabbott, Donald J

2016-05-01

We compared the structure of specific white matter tracts and information processing speed between children treated for posterior fossa tumors with cranial-spinal radiation (n = 30), or with surgery +/- focal radiation (n = 29), and healthy children (n = 37). Probabilistic diffusion tensor imaging (DTI) tractography was used to delineate the inferior longitudinal fasciculi, optic radiation, inferior frontal occipital fasciculi, and uncinate fasciculi bilaterally. Information processing speed was measured using the coding and symbol search subtests of the Wechsler Intelligence Scales, and visual matching, pair cancellation, and rapid picture naming subtests of the Woodcock-Johnson Test of Cognitive Ability, 3rd revision. We examined group differences using repeated measures MANOVAs and path analyses were used to test the relations between treatment, white matter structure of the tracts, and information processing speed. DTI indices of the optic radiations, the inferior longitudinal fasciculi, and the inferior fronto-occipital fasciculi differed between children treated with cranial-spinal radiation and children treated with surgery +/- focal radiation, and healthy controls (p = .045). Children treated with cranial-spinal radiation also exhibited lower processing speed scores relative to healthy control subjects (p = .002). Notably, we observed that group differences in information processing speed were related to the structure of the right optic radiation (p = .002). We show that cranial-spinal radiation may have a negative impact on information processing speed via insult to the right optic radiations. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Multiple spinal metastases from a well-differentiated liposarcoma of the iliac wing: a case report.

PubMed

Ben Nsir, A; Boubaker, A; Kassar, A Z; Abderrahmen, K; Kchir, N; Jemel, H

2015-01-01

A case report. To report an unusual case of multiple spinal metastases from an undiagnosed well-differentiated liposarcoma (WDLPS) of the iliac wing and to stress the need of a meticulous clinical examination and further screening of patients with chronic and asymptomatic bony lesions. University of medicine of Monastir, Department of neurological surgery, Fattouma Bourguiba University Hospital, Monastir, Tunisia and University of Medicine of Tunis EL Manar, Department of neurological surgery, Tunisian National Institute of Neurology, Tunis, Tunisia. A 39-year-old man presented with signs of spinal cord compression for the past 2 weeks. His medical history was consistent for an asymptomatic right iliac wing mass that appeared 3 years ago and for which he has not consulted. Magnetic resonance imaging revealed multiple bony lesions of the thoraco-lumbar spine associated with a 6-cm right paravertebral mass at the T4 level extending posteriorly through the intervertebral foramina to the spinal canal causing major spinal cord compression. An emergent T2-T6 laminectomy allowed for a complete resection of the epidural mass. Pathological examination confirmed the diagnosis of well-differentiated liposarcoma. Adjunctive radiation therapy was administered. The patient's neurological status improved remarkably under an intensive care and rehabilitation program. He was ambulatory without assistance in the second postoperative week. The case reported in this paper represents a genuine example of the possible metastatic potential of WDLPSs of the bone and underscores the importance of examining patients thoroughly, especially when they have chronic and asymptomatic lesions.

Intraoperative monitoring of somatosensory (SSEPs) and transcranial electric motor-evoked potentials (tce-MEPs) during surgical correction of neuromuscular scoliosis in patients with central or peripheral nervous system diseases.

PubMed

Pastorelli, F; Di Silvestre, M; Vommaro, F; Maredi, E; Morigi, A; Bacchin, M R; Bonarelli, S; Plasmati, R; Michelucci, R; Greggi, T

2015-11-01

Combined intraoperative monitoring (IOM) of transcranial electric motor-evoked potentials (tce-MEPs) and somatosensory-evoked potentials (SSEPs) is safe and effective for spinal cord monitoring during scoliosis surgery. However, the literature data regarding the reliability of spinal cord monitoring in patients with neuromuscular scoliosis are conflicting and need to be confirmed. We reviewed IOM records of 40 consecutive patients with neuromuscular scoliosis related to central nervous system (CNS) (29 pts) or peripheral nervous system (PNS) (11 patients) diseases, who underwent posterior fusion with instrumentation surgery for spinal deformity. Multimodalitary IOM with SSEPs and tce-MEPs was performed. Spinal cord monitoring using at least one modality was attempted in 38/40 (95 %) patients. No false-negative results were present in either group, but a relatively high incidence of false-positive cases (4/29, 13.8 %) was noted in the CNS group. Two patients in the CNS group and one patient in the PNS group presented transient postoperative motor deficits (true positive), related to surgical manoeuvres in two cases and to malposition in the other one. Multimodalitary IOM is safe and effective to detect impending spinal cord and peripheral nerves dysfunction in neuromuscular scoliosis surgery. However, the interpretation of neurophysiological data may be challenging in such patients, and the rate of false-positive results is high when pre-operatory motor deficits are severe.

Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients

PubMed Central

Sutter, Martin A.; Grob, Dieter; Jeszenszky, Dezsö; Porchet, François; Dvorak, Jiri

2007-01-01

A prospective study of 246 patients who received multimodal intraoperative monitoring during cervical spine surgery between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during cervical spine surgery. It is appreciated that complication rate of cervical spine surgery is low, however, there is a significant risk of neurological injury. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information and/or alert regarding any neurological changes during the operation to the surgeon. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor-evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 246 consecutive patients with cervical pathologies, majority spinal stenosis due to degenerative changes of cervical spine were monitored by means of MIOM during the surgical procedure. About 232 patients presented true negative while 2 patients false negative responses. About ten patients presented true positive responses where neurological deficit after the operation was predicted and two patients presented false positive findings. The sensitivity of MIOM applied during cervical spine procedure (anterior and/or posterior) was 83.3% and specificity of 99.2%. MIOM is an effective method of monitoring the spinal cord functional integrity during cervical spine surgery and can help to reduce the risk of neurological deficit by alerting the surgeon when monitoring changes are observed. PMID:17610090

The comfort and safety of a novel rolling mechanical indentation device for the measurement of lumbar trunk stiffness in young adults.

PubMed

Brown, Benjamin T; Blacke, Alexandra; Carroll, Vanessa; Graham, Petra L; Kawchuk, Greg; Downie, Aron; Swain, Michael

2017-01-01

The measurement of Posterior-Anterior (P-A) spinal stiffness is a common component of the physical examination of patients presenting with spinal disorders. The aim of this assessment is to provoke pain and/or to determine the degree of resistance or compliance of these structures and the associated soft-tissues to loading. This information, combined with other patient-specific history and examination findings, is integrated into the clinical reasoning process and is used to guide treatment decisions. Unfortunately, there are inter-rater reliability and standardisation issues associated with the manual performance of this type of assessment. In an attempt to remedy these issues researchers have developed mechanical devices for the measurement of spinal stiffness. The aim of this research is to investigate the comfort and safety of a novel device for measuring P-A trunk stiffness in a sample of young adults. A sample of young adults from a general population was recruited in May 2016 from Sydney, Australia. Demographic, anthropometric and clinical variables were collected prior to participants undergoing a lumbar P-A trunk stiffness assessment involving a mechanical indentation device called the VerteTrack. The primary outcomes for the study were key feasibility items; overall assessment time, perceived comfort measured both during and after the procedure, and adverse events. Univariate ordinal logistic regression was used to identify key variables associated with a participant's subjective report of comfort both during and after the VerteTrack assessment. Eighty four participants (35% female) with a median age of 23 years (IQR = 3) took part in the research. The mean assessment time for the Vertetrack assessment was 11.6 min (SD = 2.1). Increasing load ( p  < 0.001) and increasing number of days with lower back pain ( p  = 0.009) were associated with decreased comfort ratings during the procedure. The vast majority 63/84 (75%) of participants rated the overall assessment experience as comfortable. There were two minor, short-lived adverse events recorded leading to an adverse event rate of 2.4% (2/84). The results of this study suggest that the VerteTrack device is well-tolerated and can be used safely and efficiently when measuring P-A stiffness of the lumbar trunk in young adults. Not applicable.

Design limitations of Bryan disc arthroplasty.

PubMed

Fong, Shee Yan; DuPlessis, Stephan J; Casha, Steven; Hurlbert, R John

2006-01-01

Disc arthroplasty is gaining momentum as a surgical procedure in the treatment of spinal degenerative disease. Results must be carefully scrutinized to recognize benefits as well as limitations. The aim of this study was to investigate factors associated with segmental kyphosis after Bryan disc replacement. Prospective study of a consecutively enrolled cohort of 10 patients treated in a single center using the Bryan cervical disc prosthesis for single-level segmental reconstruction in the surgical treatment of cervical radiculopathy and/or myelopathy. Radiographic and quality of life outcome measures. Static and dynamic lateral radiographs were digitally analyzed in patients undergoing Bryan disc arthroplasty throughout a minimum 3-month follow-up period. Observations were compared with preoperative studies looking for predictive factors of postoperative spinal alignment. Postoperative end plate angles through the Bryan disc in the neutral position were kyphotic in 9 of 10 patients. Compared with preoperative end plate angulation there was a mean change of -7 degrees (towards kyphosis) in postoperative end plate alignment (p=.007, 95% confidence interval [CI] -6 degrees to -13 degrees). This correlated significantly with postoperative reduction in posterior vertebral body height of the caudal segment (p=.011, r2=.575) and postoperative functional spine unit (FSU) kyphosis (p=.032, r2=.46). Despite intraoperative distraction, postoperative FSU height was significantly reduced, on average by 1.7 mm (p=.040, 95% CI 0.5-2.8 mm). Asymmetrical end plate preparation occurs because of suboptimal coordinates to which the milling jig is referenced. Although segmental motion is preserved, Bryan disc arthroplasty demonstrates a propensity towards kyphotic orientation through the prosthesis likely as a result of intraoperative lordotic distraction. FSU angulation tends towards kyphosis and FSU height is decreased in the postoperative state from lack of anterior column support. Limitations of Bryan cervical disc arthroplasty should be carefully considered when reconstruction or maintenance of cervical lordosis is desirable.

The impact of direct vertebral rotation (DVR) on radiographic outcome in surgical correction of idiopathic scoliosis.

PubMed

Urbanski, Wiktor; Wolanczyk, Michal J; Jurasz, Wojciech; Kulej, Miroslaw; Morasiewicz, Piotr; Dragan, Szymon Lukasz; Sasiadek, Marek; Dragan, Szymon Feliks

2017-07-01

Recent developments of spinal instruments allow to address nearly all components of idiopathic scoliosis. Direct vertebral rotation (DVR) maneuver was introduced to correct apical axial vertebral rotation. It is however still not well established how efficiently DVR affects results of scoliosis correction. The object of the study was to evaluate en bloc apical vertebral rotation (DVR) and its impact on coronal and sagittal correction of the spine in patients undergoing surgical scoliosis treatment. Thirty-six consecutive patients who underwent posterior spinal fusion with pedicle screws only constructs for idiopathic scoliosis. Fifteen patients (20 curves) were corrected by rod derotation only and 21 patients (26 curves) had both rod derotation and DVR. Curve measurements were performed on x-rays obtained before and postoperatively-coronal curves, kyphosis (T2-T12, T5-T12). Spine flexibility was assessed on prone bending x-rays. Apical axial rotation was determined on CT scans obtained intraoperatively and postoperatively. Rotation angle (RAsag) was measured according to Aaro and Dahlborn. We observed reduction of RAsag in all patients; however, in DVR group, decrease was greater, by 31.8% comparing to non-DVR group, by 8.6% (p = 0.0003). Mean coronal correction in DVR group was 68.8% and in rod derotation group without DVR 55% (p = 0.002). No significant correlation was found between degree of derotation obtained and coronal correction. In DVR group T2-T12 kyphosis has increased in 28 (65%) patients whereas in non-DVR group in 31 (69%) cases. Mean value of T2-T12 kyphosis growth was 16.7% in DVR and 22.1% in non-DVR group. These differences however did not occur statistically significant. Direct vertebral rotation (DVR) maneuver reduces significantly apical rotation of the spine, enhances ability of coronal correction, and it does not reduce thoracic kyphosis.

A rare cause of late onset neurological deficit in post tuberculous kyphotic deformity—case report

PubMed Central

Shetty, Ajoy Prasad; Kanna, Rishi M.; Rajasekaran, Shanmuganathan

2017-01-01

Late onset neurological deficit is a rare complication of spinal tuberculosis. Reactivation of the disease and compression by internal gibbus are the common causes for late onset neurological deficit. We report a rare cause of late onset paraplegia in a patient with post tubercular kyphotic deformity. The late onset neurological deficit was due to the adjacent segment degeneration proximal to the kyphotic deformity. Posterior hypertrophied ligamentum flavum and anterior disc osteophyte complex caused the cord compression. The increased stress for prolonged period at the end of the deformity was the reason for the accelerated degeneration. Patient underwent posterior decompression, posterolateral and interbody fusion. Deformity correction was not done. To our best knowledge, this is only the second report of this unusual cause of late onset paraplegia. PMID:29354759

A rare cause of late onset neurological deficit in post tuberculous kyphotic deformity-case report.

PubMed

Subramani, Suresh; Shetty, Ajoy Prasad; Kanna, Rishi M; Rajasekaran, Shanmuganathan

2017-12-01

Late onset neurological deficit is a rare complication of spinal tuberculosis. Reactivation of the disease and compression by internal gibbus are the common causes for late onset neurological deficit. We report a rare cause of late onset paraplegia in a patient with post tubercular kyphotic deformity. The late onset neurological deficit was due to the adjacent segment degeneration proximal to the kyphotic deformity. Posterior hypertrophied ligamentum flavum and anterior disc osteophyte complex caused the cord compression. The increased stress for prolonged period at the end of the deformity was the reason for the accelerated degeneration. Patient underwent posterior decompression, posterolateral and interbody fusion. Deformity correction was not done. To our best knowledge, this is only the second report of this unusual cause of late onset paraplegia.

Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients.

PubMed

Theologis, Alexander A; Mundis, Gregory M; Nguyen, Stacie; Okonkwo, David O; Mummaneni, Praveen V; Smith, Justin S; Shaffrey, Christopher I; Fessler, Richard; Bess, Shay; Schwab, Frank; Diebo, Bassel G; Burton, Douglas; Hart, Robert; Deviren, Vedat; Ames, Christopher

2017-02-01

OBJECTIVE The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.

Physical Therapy for a Child With Infantile Idiopathic Scoliosis and Motor Delay.

PubMed

Hall, Rhea K; Rapport, Mary Jane

2017-07-01

The purpose of this case report is to describe physical therapy (PT) for a child with infantile idiopathic scoliosis and motor delay. A 10-month-old boy with a 28° left thoracolumbar scoliosis was referred for PT and was seen weekly in his home over a 6-month period following a diagnosis of scoliosis and delayed gross motor milestones. Before the initiation of PT, the child was scheduled to undergo serial casting for correction of the spinal curve and was not yet rolling or transitioning in or out of sitting. By the end of the 6-month intervention period, the spinal curve had resolved to 12° without the need for serial casting and the child was walking independently. PT appeared to have a positive effect on reduction of the spinal curve and achievement of gross motor milestones.

MR imaging evaluation of inferior olivary nuclei: comparison of postoperative subjects with and without posterior fossa syndrome.

PubMed

Patay, Z; Enterkin, J; Harreld, J H; Yuan, Y; Löbel, U; Rumboldt, Z; Khan, R; Boop, F

2014-04-01

Posterior fossa syndrome is a severe postoperative complication occurring in up to 29% of children undergoing posterior fossa tumor resection; it is most likely caused by bilateral damage to the proximal efferent cerebellar pathways, whose fibers contribute to the Guillain-Mollaret triangle. When the triangle is disrupted, hypertrophic olivary degeneration develops. We hypothesized that MR imaging patterns of inferior olivary nucleus changes reflect patterns of damage to the proximal efferent cerebellar pathways and show association with clinical findings, in particular the presence or absence of posterior fossa syndrome. We performed blinded, randomized longitudinal MR imaging analyses of the inferior olivary nuclei of 12 children with and 12 without posterior fossa syndrome after surgery for midline intraventricular tumor in the posterior fossa. The Fisher exact test was performed to investigate the association between posterior fossa syndrome and hypertrophic olivary degeneration on MR imaging. The sensitivity and specificity of MR imaging findings of bilateral hypertrophic olivary degeneration for posterior fossa syndrome were measured. Of the 12 patients with posterior fossa syndrome, 9 had bilateral inferior olivary nucleus abnormalities. The 12 patients without posterior fossa syndrome had either unilateral or no inferior olivary nucleus abnormalities. The association of posterior fossa syndrome and hypertrophic olivary degeneration was statistically significant (P < .0001). Hypertrophic olivary degeneration may be a surrogate imaging indicator for damage to the contralateral proximal efferent cerebellar pathway. In the appropriate clinical setting, bilateral hypertrophic olivary degeneration may be a sensitive and specific indicator of posterior fossa syndrome.