Dural Sac Research Articles

A horizontal and perpendicular interlaminar approach for intrathecal nusinersen injection in patients with spinal muscular atrophy and scoliosis: an observational study

BackgroundLumbar puncture is challenging for patients with scoliosis. Previous ultrasound-assisted techniques for lumbar puncture used the angle of the probe as the needle trajectory; however, reproducing the angle is difficult and increases the number of needle manipulations. In response, we developed a technique that eliminated both the craniocaudal and lateromedial angulation of the needle trajectory to overall improve this technique. We assessed the feasibility and safety of this method in patients with scoliosis and identify factors related to difficult lumbar puncture.MethodsPatients with spinal muscular atrophy and scoliosis who were referred to the anesthesia department for intrathecal nusinersen administrations were included. With a novel approach that utilized patient position and geometry, lumbar puncture was performed under ultrasound guidance. Success rates, performance times and adverse events were recorded. Clinical-demographic and spinal radiographic data pertaining to difficult procedures were analyzed.ResultsSuccess was achieved in all 260 (100%) lumbar punctures for 44 patients, with first pass and first attempt success rates of 70% (183/260) and 87% (226/260), respectively. Adverse events were infrequent and benign. Higher BMI, greater skin dural sac depth and smaller interlaminar size might be associated with greater difficulty in lumbar puncture.ConclusionsThe novel ultrasound-assisted horizontal and perpendicular interlaminar needle trajectory approach is an effective and safe method for lumbar puncture in patients with spinal deformities. This method can be reliably performed at the bedside and avoids other more typical and complex imaging such as computed tomography guided procedure.

Arthroscopic-assisted uni-portal spinal surgery combined with modified unilateral laminotomy with bilateral decompression for the treatment of lumber epidural lipomatosis: Case report and new therapeutic method

BackgroundLumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by the pathological proliferation of adipose tissue in the epidural space of the spinal canal. This study presents the case of a 59-year-old male with lumbar SEL treated effectively in the short term through arthroscopic-assisted uniportal spinal surgery (AUSS) combined with a modified circle-drawing unilateral laminotomy with bilateral decompression (ULBD) technique. MethodsA modified circle-drawing ULBD procedure was executed via AUSS for a patient with SEL. The procedure involved the excision of diseased adipose tissue from the spinal canal, enlargement and decompression of the spinal canal, liberation of nerves, and post-operative evaluation of imaging results and clinical outcomes. ResultsThe patient exhibited improvements in the dural sac cross-sectional area, low back pain Visual Analogue Score (VAS, leg pain VAS, lumbar spine Japanese Orthopaedic Association (JOA), and EQ-5D post-surgery. ConclusionsAUSS offers comprehensive visualization, straightforward positioning, facilitating a broad field of view and precise lesion management. The modified circle-drawing ULBD technique characterized by its simplicity, operational freedom, and extensive decompression range, contributes to symptom alleviation and patient recovery.

Reirradiation of metastases of the central nervous system: part 2-metastatic epidural spinal cord compression.

An increasing number of patients irradiated for metastatic epidural spinal cord compression (MESCC) experience an in-field recurrence and require a second course of radiotherapy. Reirradiation can be performed with conventional radiotherapy or highly-conformal techniques such as intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), and stereotactic body radiation therapy (SBRT). When using conventional radiotherapy, a cumulative biologically effective dose (BED) ≤120 calculated with an α/β value of 2 Gy (Gy2) was not associated with radiation myelopathy in a retrospective study of 124 patients and is considered safe. In that study, conventional reirradiation led to improvements of motor deficits in 36% of patients and stopped further symptomatic progression in another 50% (overall response 86%). In four other studies, overall response rates were 82-89%. In addition to the cumulative BED or equivalent dose in 2 Gy fractions (EQD2), the interval between both radiotherapy courses <6 months and a BED per course ≥102 Gy2 (corresponding to an EQD2 ≥51 Gy2) were identified as risk factors for radiation myelopathy. Without these risk factors, a BED >120 Gy2 may be possible. Scoring tools have been developed that can assist physicians in estimating the risk of radiation myelopathy and selecting the appropriate dose-fractionation regimen of re-treatment. Reirradiation of MESCC may also be performed with highly-conformal radiotherapy. With IMRT or VMAT, rates of pain relief and improvement of neurologic symptoms of 60-93.5% and 42-73%, respectively, were achieved. One-year local control rates ranged between 55% and 88%. Rates of myelopathy or radiculopathy and vertebral compression fractures were 0% and 0-9.3%, respectively. With SBRT, rates of pain relief were 65-86%. Two studies reported improvements in neurologic symptoms of 0% and 82%, respectively. One-year local control rates were 74-83%. Rates of myelopathy or radiculopathy and vertebral compression fractures were 0-4.5% and 4.5-13.8%, respectively. For SBRT, a cumulative maximum EQD2 to thecal sac ≤70 Gy2, a maximum EQD2 of SBRT ≤25 Gy2, a ratio ≤0.5 of thecal sac maximum EQD2 of SBRT to maximum cumulative EQD2, and an interval between both courses ≥5 months were associated with a lower risk of myelopathy. Additional prospective trials are required to better define the options of reirradiation of MESCC.

Quantification of cauda equina nerve root dispersion through radiomics features in weight-bearing MRI in normal subjects and spinal canal stenosis patients.

To quantify the distribution of cauda equina nerve roots in supine and upright positions using manual measurements and radiomics features both in normal subjects and in lumbar spinal canal stenosis (LSCS) patients. We retrospectively recruited patients who underwent weight-bearing MRI in supine and upright positions for back pain. 3D T2-weighted isotropic acquisition (3D-HYCE) sequences were used to develop a 3D convolutional neural network for identification and segmentation of lumbar vertebrae. Para-axial reformatted images perpendicular to the spinal canal and parallel to each vertebral endplate were automatically extracted. From each level, we computed the maximum antero-posterior (AP) and latero-lateral (LL) dispersion of nerve roots; further, radiomics features were extracted to quantify standardized metrics of nerve root distribution. We included 16 patients with LSCS and 20 normal subjects. In normal subjects, nerve root AP dispersion significantly increased from supine to upright position (p < 0.001, L2-L5 levels), and radiomics features showed an increase in non-uniformity. In LSCS subjects, in the upright position AP dispersion of nerve roots and entropy-related features increased caudally to the stenosis level (p < 0.001) and decreased cranially (p < 0.001). Moreover, entropy-related radiomics features negatively correlated with pre-operative Pain Numerical Rating Scale. Comparison between normal subjects and LSCS patients showed a difference in AP dispersion and increase of variance cranially to the stenosis level (p < 0.001) in the upright position. Nerve root distribution inside the dural sac changed between supine and upright positions, and radiomics features were able to quantify the differences between normal and LSCS subjects. The distribution of cauda equina nerve roots and the redundant nerve root sign significantly varies between supine and upright positions in normal subjects and spinal canal stenosis patients, respectively. Radiomics features quantify nerve root dispersion and correlates with pain severity. • Weight-bearing MRI depicts spatial distribution of the cauda equina in both supine and upright positions in normal subjects and spinal stenosis patients. • Radiomics features can quantify the effects of spinal stenosis on the dispersion of the cauda equina in the dural sac. • In the orthostatic position, dispersion of nerve roots is different in lumbar spinal stenosis patients compared to that in normal subjects; entropy-related features negatively correlated with pre-operative Pain Numerical Rating Scale.

A Rare Case of Idiopathic Ventral Cord Herniation with Spastic Paraparesis Treated with Microsurgery and Intraoperative Neurophysiological Monitoring

Abstract Idiopathic ventral spinal cord herniation is an exceedingly rare and progressive cause of myelopathic presentation and is usually seen in the thoracic spinal cord. Our report here presents a typical clinical picture, the diagnosis, and surgical management of ventral cord herniation. The imaging shows ventral herniation of the dura through a formed defect in the ventral thecal sac. This herniation causes slow and progressive damage to the herniated cord and leads to the typical myelopathic picture with or without bowel and bladder involvement. Ventral cord herniation is a rare but treatable condition. It’s natural progression and methods of management need further research due to its rarity. Surgical treatment is needed in symptomatic cases and carries high risks, but the outcome is usually favourable. IONM is also useful during surgery to reduce deficits.

Hirayama Disease: Neutral and Flexion Magnetic Resonance Imaging Manifestations and Single Tertiary Care Center Analysis on 3T Scanner.

Hirayama disease (HD) is a rare benign type of cervical cord myelopathy occurring commonly in young males as unilateral or bilateral asymmetrical amyotrophy of the hand and forearm muscles in C8-T1 distribution. Magnetic resonance imaging (MRI) is the best technique for the evaluation and imaging of this entity. This is a retrospective review of cervical magnetic resonance images of patients that were taken for clinically suspected and diagnosed HD on 3T MRI in postcontrast neutral and flexion (30°-40°) positions from July 2019 to January 2024 at Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly. Fourteen patients included in the study were males less than 34 years of age. MRI findings of cord atrophy in the lower cervical region/cervico-dorsal junction, abnormal cervical curvature, loss of attachment of the dorsal dural sac and subjacent laminae with anterior displacement, and a prominent intense enhancing posterior epidural space were observed in all 14 patients. The minimum anteroposterior cord diameters in the neutral and flexion positions were 2.9 and 2.8 mm, respectively (mean thickness of laminodural space on flexion - 5.2 mm). Other MRI findings showed variable representations. Flexion-position MRI has emerged as the gold standard for establishing and validating the diagnosis of HD in clinically suspected cases and should be an essential part of the protocol for the screening of clinically suspected cases of HD to aid in early treatment and therapeutic intervention. Complimentary newer sequences such as the Three-dimensional (3D)-Constructive interference in Steady State (CISS)/Fast Imaging Employing Steady-state Acquisition Cycled Phases (FIESTA-C) may reinforce better appreciation of epidural flow voids.

The Quantitative Evaluation of Automatic Segmentation in Lumbar Magnetic Resonance Images.

This study aims to overcome challenges in lumbar spine imaging, particularly lumbar spinal stenosis, by developing an automated segmentation model using advanced techniques. Traditional manual measurement and lesion detection methods are limited by subjectivity and inefficiency. The objective is to create an accurate and automated segmentation model that identifies anatomical structures in lumbar spine magnetic resonance imaging scans. Leveraging a dataset of 539 lumbar spinal stenosis patients, the study utilizes the residual U-Net for semantic segmentation in sagittal and axial lumbar spine magnetic resonance images. The model, trained to recognize specific tissue categories, employs a geometry algorithm for anatomical structure quantification. Validation metrics, like Intersection over Union (IOU) and Dice coefficients, validate the residual U-Net's segmentation accuracy. A novel rotation matrix approach is introduced for detecting bulging discs, assessing dural sac compression, and measuring yellow ligament thickness. The residual U-Net achieves high precision in segmenting lumbar spine structures, with mean IOU values ranging from 0.82 to 0.93 across various tissue categories and views. The automated quantification system provides measurements for intervertebral disc dimensions, dural sac diameter, yellow ligament thickness, and disc hydration. Consistency between training and testing datasets assures the robustness of automated measurements. Automated lumbar spine segmentation with residual U-Net and deep learning exhibits high precision in identifying anatomical structures, facilitating efficient quantification in lumbar spinal stenosis cases. The introduction of a rotation matrix enhances lesion detection, promising improved diagnostic accuracy, and supporting treatment decisions for lumbar spinal stenosis patients.

Lateral atlanto-axial joint access using the C2 pedicle

Abstract Background Neck pain and headaches can arise from the lateral atlanto-axial (LAA) joint. This pain can be diagnosed with intra-articular injections of local anesthetic. A widely used technique for access to the lateral atlanto-axial joint uses a posterior approach, but this approach can be hazardous because of the proximity of the vertebral artery, the dural sac, and the C2 spinal nerve and dorsal root ganglion. Objective The objective was to describe and test a new technique for accessing the LAA joint that avoids structures that lie behind the joint. Interventions The new technique was described and tested for tolerance in 10 patients with unilateral suboccipital pain and tenderness over the LAA joint, along with evidence of LAA joint arthropathy on SPECT CT. The technique requires inserting a needle along a trajectory tangential to the dorsal surface of the C2 lamina. It involves obtaining a declined view of the C2 lamina and C2 pedicle. Conclusions In all cases, the C2 pedicle was easily identified and allowed the needle to pass asymptomatically underneath the neurovascular structures behind the joint. The tactile response of the lamina of C2 provided important feedback regarding needle depth caudal to the LAA joint.

MRI-Derived Dural Sac and Lumbar Vertebrae 3D Volumetry Has Potential for Detection of Marfan Syndrome

Purpose: To assess the feasibility and diagnostic accuracy of MRI-derived 3D volumetry of lower lumbar vertebrae and dural sac segments using shape-based machine learning for the detection of Marfan syndrome (MFS) compared with dural sac diameter ratios (the current clinical standard). Materials and methods: The final study sample was 144 patients being evaluated for MFS from 01/2012 to 12/2016, of whom 81 were non-MFS patients (46 [67%] female, 36 ± 16 years) and 63 were MFS patients (36 [57%] female, 35 ± 11 years) according to the 2010 Revised Ghent Nosology. All patients underwent 1.5T MRI with isotropic 1 × 1 × 1 mm3 3D T2-weighted acquisition of the lumbosacral spine. Segmentation and quantification of vertebral bodies L3-L5 and dural sac segments L3-S1 were performed using a shape-based machine learning algorithm. For comparison with the current clinical standard, anteroposterior diameters of vertebral bodies and dural sac were measured. Ratios between dural sac volume/diameter at the respective level and vertebral body volume/diameter were calculated. Results: Three-dimensional volumetry revealed larger dural sac volumes (p &lt; 0.001) and volume ratios (p &lt; 0.001) at L3-S1 levels in MFS patients compared with non-MFS patients. For the detection of MFS, 3D volumetry achieved higher AUCs at L3-S1 levels (0.743, 0.752, 0.808, and 0.824) compared with dural sac diameter ratios (0.673, 0.707, 0.791, and 0.848); a significant difference was observed only for L3 (p &lt; 0.001). Conclusion: MRI-derived 3D volumetry of the lumbosacral dural sac and vertebral bodies is a feasible method for quantifying dural ectasia using shape-based machine learning. Non-inferior diagnostic accuracy was observed compared with dural sac diameter ratio (the current clinical standard for MFS detection).

Multilevel interlaminar fenestration with soft tissue decompression in lumbar canal stenosis

Introduction: Lumbar Canal Stenosis is the narrowing of the Spinal Canal and/or the intervertebral foramina, which causes compression of the thecal sac and/or caudal roots at a single vertebral level. Stenosis may be local, segmental, or generalised; bone or soft tissue can cause it. Stenosis can involve the bony canal, dural sac or both.[9] Aim: Assessment of outcomes of multilevel fenestration with soft tissue decompression in lumbar canal stenosis. Material and method: A prospective study comprised patients with two or more lumbar canal stenosis levels. The Study eliminated patients with infective pathology or recurrent surgery on identical levels. The surgical technique of canal decompression via multilevel fenestrations was used in this study, which enables the decompression of the neural structures while preserving as much of the bony and ligamentous structures as possible. Post-op clinical measures such as motor, sensory, post-op complications, and VAS score improvement assessed study outcomes. Result: Studies showed improvement in symptoms of pain, motor power and sensory deficit, post-operative improvement in VAS score for pain, and improved quality of life in almost all the patients from day 7 to day 60 after surgery. Conclusion: The study shows that “Multilevel interlaminar fenestration with Soft Tissue Decompression in Lumbar Canal Stenosis” is a feasible, safe, and effective approach to lumbar canal stenosis and is associated with minimal complications and minimal perioperative morbidity.

Predicting the presence of 4th ventricular outlet obstruction in Chiari I Malformation

IntroductionA subset of children with Chiari 1 malformation (CM-1) have a 4th ventricle arachnoid veil—a thin membrane covering the outlet of the 4th ventricle. Studies suggest that failure to disrupt this veil during posterior fossa decompression can reduce the likelihood of syringomyelia resolution. However, there is no reliable method for predicting the presence of the veil without direct surgical exploration. This study aims to evaluate the association between pre-operative symptoms, radiographic measurements, and the arachnoid veil.MethodsA retrospective review of an institutional database of children evaluated for CM-I was conducted. For patients treated with surgery, operative notes were reviewed to determine if an arachnoid veil was present. Logistic regression was used to test for relationship of clinical variables and radiographic measurements with the presence of an arachnoid veil.ResultsOut of 997 children with CM-1, 226 surgical patients were included in the analysis after excluding those with inadequate documentation. An arachnoid veil was found in 23 patients (10.2%). Larger syrinx, spinal canal, and thecal sac diameters were significantly associated with the presence of a veil, with odds ratios of 1.23 (95% CI 1.2–1.48; p = 0.03), 1.27 (95% CI 1.02–1.59; p = 0.03), and 1.35 (95% CI 1.03–1.77; p = 0.03), respectively. No significant associations were found with any signs or symptoms.ConclusionsArachnoid veil was present in 10% of cases. Radiographic measurements indicating larger syrinx size were the only variables found to be significantly associated with an arachnoid veil. Exploration of the 4th ventricular outlet is recommended for CM-I decompression in the setting of expansile syringomyelia.

Inadequate Spinal Anesthesia in Lumbar Spine Surgery Is Related to Volume of the Thecal Sac

Spinal anesthesia (SA) is used in lumbar surgery but initial adequate analgesia fails in some patients. In these cases, spinal redosing or conversion to general endotracheal anesthesia is required, both of which are detrimental to the patient experience and surgical workflow. We reviewed cases of lumbar surgery performed under spinal anesthesia from 2017 - 2021. We identified 12 cases of inadequate first dose, then selected 36 random patients as controls. We used a measurement tool to approximate the volume of the dural sac for each patient using T2-weighted sagittal MRI sequences. Patients who had an inadequate first dose of anesthesia had a significantly larger dural sac volume, 22.8 ± 7.9 cm3 in the inadequate dose group, and 17.4 ± 4.7 cm3 in controls (p=0.043). The inadequate dose group was significantly younger, 54.2 ± 8.8 years in failed first dose, and 66.4 ± 11.9 years in control (p=0.001). The groups did not differ by surgical procedure (p=0.238), level (p=0.353), ASA score (p=0.546), or co-morbidities. We found that age, larger height, and dural sac volume are risk factors for an inadequate first dose of SA. The availability of spinal MRI in patients undergoing spine surgery allows the preoperative measurement of their thecal sac size. In the future, this data may be used to personalize spinal anesthesia dosing based on individual anatomic variables and potentially reduce the incidence of failed spinal anesthesia in spine surgery.

Association Between Radiological Severity of Lumbar Spinal Stenosis and Spinopelvic Parameters in Adult Patients With Achondroplasia.

Adults with achondroplasia are more vulnerable to suffer from neurogenic claudication because of a congenital narrow spinal canal, which makes them susceptible to lumbar spinal stenosis (LSS). The study aims to investigate the correlations between sagittal alignment parameters and the degree of LSS in patients with achondroplasia with LSS. The radiological data of adult achondroplasts presented to the neurosurgical clinic of our medical center from 2019 to 2022 were collected. Lumbar stenosis was graded using the Schizas scale, and the dural sac cross-sectional area (DSCA) was measured. The angles defining the spinopelvic parameters comprising lumbar lordosis, thoracolumbar kyphosis, sagittal vertical axis, pelvic tilt, sacral slope, and pelvic incidence were measured. Spearman or Pearson correlation was used to investigate the association between sagittal misalignment and LSS. A total of 34 achondroplastics were enrolled, with a median age of 44.3 ± 15.5 years, ranging from 18.6 to 78.5 years. Larger thoracolumbar kyphosis was associated with more severe stenosis according to the Schizas scale of the L12 lumbar level (r = 0.44, P = .020, 95% CI [0.08, 0.70]). Larger sagittal vertical axis correlated with a smaller DSCA at L23 (r = -0.53, P = .036, 95% CI [-0.81, -0.04]) and L45 (r = -0.66, P = .004, 95% CI [-0.87, -0.26]). Larger pelvic tilt was demonstrated to be associated with a smaller DSCA of the L34 lumbar level (r = -0.42, P = .027, 95% CI [-0.68, -0.05]) and the L45 lumbar level (r = -0.47, P = .011, 95% CI [-0.71, -0.12]). The upper LSS may be attributed to an increased kyphosis of the thoracolumbar spine. On the contrary, the lower LSS seemed to be correlated with a more backward tilt of the pelvis.

Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR).

Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality (AR). Materials and Methods: All patients who underwent surgery for calcified thoracic herniated disc via a transthoracic transpleural approach at our Department using iCT and microscope-based AR were included in the study. Results: Six consecutive patients (five female, median age 53.2 ± 6.4 years) with calcified herniated thoracic discs (two patients Th 10-11 level, two patients Th 7-8, one patient Th 9-10, one patient Th 11-12) were included in this case series. Indication for surgery included evidence of a calcified thoracic disc on magnet resonance imaging (MRI) and CT with spinal canal stenosis of >50% of diameter, intractable pain, and neurological deficits, as well as MRI-signs of myelopathy. Five patients had paraparesis and ataxia, and one patient had no deficit. All surgeries were performed in the lateral position via a transthoracic transpleural approach (Five from left side). CT for automatic registration was performed following the placement of the reference array, with a high registration accuracy. Microscope-based AR was used, with segmented structures of interest such as vertebral bodies, disc space, herniated disc, and dural sac. Mean operative time was 277.5 ± 156 min. The use of AR improved orientation in the operative field for identification, and tailored the resection of the herniated disc and the identification of the course of dural sac. A control-iCT scan confirmed the complete resection in five patients and incomplete resection of the herniated disc in one patient. In one patient, complications occurred, such as postoperative hematoma, and wound healing deficit occurred. Mean follow-up was 22.9 ± 16.5 months. Five patients improved following surgery, and one patient who had no deficits remained unchanged. Conclusions: Optimal surgical therapy in patients with calcified thoracic disc disease with compression of dural sac and myelopathy was resectioned via a transthoracic transpleural approach. The use of iCT-based registration and microscope-based AR significantly improved orientation in the operative field and facilitated safe resection of these lesions.

The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology

The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space. In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded. A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, BMI 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (p < 0.001). Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.

Treatment Outcomes of Lower Urinary Tract Symptoms due to Fragility Sacral Fractures: A Review of Eight Patients and Literature

Sacral fractures can cause lower urinary tract symptoms (LUTS) due to damage to the cauda equina. While several studies have reported on sacral fractures due to high-energy trauma, those due to fragility fractures have only been reported in case reports and their clinical differences are not well known. This study aimed to investigate the clinical characteristics of LUTS caused by fragility sacral fractures and propose a novel treatment strategy. This study is retrospective, uncontrolled, clinical case series. The inclusion criteria were sole sacral fractures due to low-energy trauma and appearance of LUTS after injury. Patients with additional spinal fractures or combined abdominal or pelvic organ injuries that could cause LUTS were excluded. Improvement in LUTS, period from onset to improvement, and imaging findings were recorded. Eight patients met the inclusion criteria (4 surgical and 4 conservative treatment cases). Six patients showed improvement in LUTS. In surgical cases, the mean period from onset of LUTS to surgery and from onset of LUTS to improvement was 14.5 and 21.5days, respectively. Intraoperative rupture or laceration of the dural sac was not observed. In 2 conservatively improved cases, the period from onset to improvement of LUTS was 14 and 17days. LUTS can improve even with conservative treatment and should be utilized as the primary choice. LUTS caused by severe sacral canal deformity and stenosis can be reversible, and the decision to perform surgical treatment is still timely if LUTS do not improve with conservative treatment for several weeks.

Predictive value of nerve root sedimentation sign in diagnosis of lumbar spinal stenosis

To explore the predictive value of the nerve root sedimentation sign in the diagnosis of lumbar spinal stenosis (LSS). Between January 2019 and July 2021, 201 patients with non-specific low back pain (NS-LBP) who met the selection criteria were retrospectively analyzed. There were 67 males and 134 females, with an age of 50-80 years (mean, 60.7 years). Four intervertebral spaces (L 1, 2, L 2, 3, L 3, 4, L 4, 5) of each case were studied, with a total of 804. The nerve root sedimentation sign was positive in 126 intervertebral spaces, and central canal stenosis was found in 203 intervertebral spaces. Progression to symptomatic LSS was determined by follow-up for lower extremity symptoms similar to LSS, combined with central spinal stenosis. Univariate analysis was performed for gender, age, visual analogue scale (VAS) score for low back pain at initial diagnosis, treatment, dural sac cross-sectional area at each intervertebral space, number of spinal stenosis segments, lumbar spinal stenosis grade, positive nerve root sedimentation sign, and number of positive segments between patients in the progression group and non-progression group, and logistic regression analysis was further performed to screen the risk factors for progression to symptomatic LSS in patients with NS-LBP. All patients were followed up 17-48 months, with an average of 32 months. Of 201 patients with NS-LBP, 35 progressed to symptomatic LSS. Among them, 33 cases also had central spinal stenosis, which was defined as NS-LBP progressing to symptomatic LSS (33 cases in progression group, 168 cases in non-progression group). Univariate analysis showed that CSA at each intervertebral space, the number of spinal stenosis segments, lumbar spinal stenosis grade, whether the nerve root sedimentation sign was positive, and the number of nerve root sedimentation sign positive segments were the influencing factors for the progression to symptomatic LSS ( P<0.05); and further logistic regression analysis showed that positive nerve root sedimentation sign increased the risk of progression of NS-LBP to symptomatic LSS ( OR=8.774, P<0.001). The nerve root sedimentation sign may be associated with the progression of NS-LBP to symptomatic LSS, and it has certain predictive value for the diagnosis of LSS.

Automatic segmentation of dura for quantitative analysis of lumbar stenosis: A deep learning study with 518 CT myelograms.

The diagnosis of lumbar spinal stenosis (LSS) can be challenging because radicular pain is not often present in the culprit-level localization. Accurate segmentation and quantitative analysis of the lumbar dura on radiographic images are key to the accurate differential diagnosis of LSS. The aim of this study is to develop an automatic dura-contouring tool for radiographic quantification on computed tomography myelogram (CTM) for patients with LSS. A total of 518 CTM cases with or without lumbar stenosis were included in this study. A deep learning (DL) segmentation algorithm 3-dimensional (3D) U-Net was deployed. A total of 210 labeled cases were used to develop the dura-contouring tool, with the ratio of the training, independent testing, and external validation datasets being 150:30:30. The Dice score (DCS) was the primary measure to evaluate the segmentation performance of the 3D U-Net, which was subsequently developed as the dura-contouring tool to segment another unlabeled 308 CTM cases with LSS. Automatic masks of 446 slices on the stenotic levels were then meticulously reviewed and revised by human experts, and the cross-sectional area (CSA) of the dura was compared. The mean DCS of the 3D U-Net were 0.905±0.080, 0.933±0.018, and 0.928±0.034 in the five-fold cross-validation, the independent testing, and the external validation datasets, respectively. The segmentation performance of the dura-contouring tool was also comparable to that of the second observer (the human expert). With the dura-contouring tool, only 59.0% (263/446) of the automatic masks of the stenotic slices needed to be revised. In the revised cases, there were no significant differences in the dura CSA between automatic masks and corresponding revised masks (p=0.652). Additionally, a strong correlation of dura CSA was found between the automatic masks and corresponding revised masks (r=0.805). A dura-contouring tool was developed that could automatically segment the dural sac on CTM, and it demonstrated high accuracy and generalization ability. Additionally, the dura-contouring tool has the potential to be applied in patients with LSS because it facilitates the quantification of the dural CSA on stenotic slices.

Sublaminar Decompression and Fusion Versus Sublaminar Trimming Laminoplasty: A Retrospective Cohort

Background: Many surgical options for treating lumbar degenerative disorders have been used to improve health related outcome of those patients. The aim of the study is to compare the functional and radiological outcome of the two techniques in management of Lumbar spinal stenosis (LSS). Methods: Sixty patients with Lumbar spinal stenosis were included in a retrospective cohort study at zagazig university hospital. The inclusion criteria were patients with single level LSS with back and /or leg pain with instability on dynamic radiology not responding to medical treatment. Patients were divided into two groups according to the method of treatment done. Group1 included patients with sublaminar trimming Laminoplasty. group 2 included patients with sublaminar decompression. (VAS) for back and leg pain and the (ODI) for the disability. we measured AP-thecal sac area, foraminal height and the thecal sac area for all patients (pre- and post-operative). Results: no difference in relation to demographic data nor in the diagnosis of the spinal stenosis. Group-2 had longer hospital stay. Both groups improved clinically postoperatively with no statistical difference between them. However, the rate of improvement in group-2 in relation to leg pain was better. Both groups improved radiologically, but AP-thecal sac area, foraminal height and the thecal sac area were much improved in group-2 (p-value&lt;0.001). Conclusion: Sublaminar decompression can particularly achieve better central, foraminal and lateral recess decompression together with a better fusion rate and hence, can be used as alternative to different laminotomy decompression techniques for treating different lumbar degenerative disorders.

Management of giant posterior meningocele lombosacral: about three case report

Meningoceles are one of the most common malformations of the nervous system, accounting for around 10% of all neural tube defects. It is a complex congenital malformation of the spine, characterized by protrusions or expansions of one or more layers of the thecal sac through a canal or foramen of the spine in which there is a defect. Children usually show no neurological signs at birth, but surgical exploration is warranted to prevent future neurological deterioration. These malformations are frequently found in a posterior position, with dysraphic vertebrae in the lumbosacral region. Their management is associated with multiple challenges in our regions, including difficulties with perioperative and anesthetic care. We report these to highlight and share our experiences in the perioperative management of meningocele.