C1-2 Level Research Articles

Minimally invasive resection of cervical schwannoma (C1-C2 level) using tubular retractors.

Cervical schwannoma excision usually involves laminectomy and violation of the facet joints that necessitates the need for fusion with consequent loss of cervical mobility. The authors present the first video demonstration of an excision of the cervical schwannoma at the C1-2 level using minimally invasive spine tubular retractors, which allows direct access to the lesion and prevents the need for any bony removal. It also preserves the paraspinal muscles, which are important for spinal stability, especially at the C2 level. Special attention is given to incision planning and preoperative image analysis for preventing injury to critical neurovascular structures at this level.

Early efficacy and safety of mini open (air/water medium) endoscopy assisted anterior cervical discectomy and fusion in the treatment of cervical spondylotic myelopathy

Objective: To investigate the efficacy and safety of mini open (air/water medium) endoscopy assisted anterior cervical discectomy and fusion (MOEA-ACDF) for the treatment of cervical spondylotic myelopathy (CSM). Methods: A follow-up study. The clinical data of 30 patients with CSM treated by MOEA-ACDF from January to December in 2021 in the Henan NO.3 Provincial People's Hospital were retrospectively analyzed. Of the patients, 20 were male and 10 were female, the mean age was (49.8±9.3) years (ranged 28-70 years). The CSM occurred at C3-4 level in 2 cases, at C4-5 level in 3 cases, at C5-6 level in 22 cases and at C6-7 level in 3 cases. Each case was compared at the moment of pre-operation and final follow-up by the Japanese Orthopedic Association (JOA) score, C2-7 Cobb angle, and anterior column height of surgical segment. The postoperative complications were recorded. Prevertebral soft tissue edema and hydrops were assessed. The fusion rate was evaluated. The JOA improvement rate was computed at the final follow-up. Results: All the operations were successfully completed and all the patients received follow-up for (12.7±2.7) months (ranged 9-20 months). The mean operation time was (85.3±11.0) min (ranged 65-110 min). The postoperative drainage volume was (16.7±7.4) ml (ranged 5-35 ml). The JOA score and the C2-7 Cobb angle both improved at the final follow-up when compared with those before the operation (15.3±1.3 vs 12.2±2.3, 15.5°±6.1° vs 12.3°±6.0°, both P<0.001). The anterior column height of surgical segment at the final follow-up was (35.6±2.5) mm, and it was higher than that before the operation [(34.1±2.4) mm](P<0.001). No postoperative complications such as dysphagia, hoarseness, cerebrospinal fluid leakage, nerve injury, hematoma occurred. Postoperative review of cervical MRI revealed 3 cases of prevertebral soft tissue edema and hydrops without obvious symptoms. At the final follow-up, cervical spine X-ray or CT showed that all fusion segments met the criteria for osseous fusion, and the fusion rate was 100%. No complications such as neurological aggravation, internal fixation failure, fusion cage sinking, and adjacent segment degeneration was recorded at the final follow-up. At the final follow-up, the comprehensive efficacy evaluated by JOA improvement rate indicated the excellent and good rate was 90.0%(27/30): 19 cases got an excellent outcome, 8 cases got good and 3 cases got medium outcome. Conclusion: MOEA-ACDF combines the endoscopic system with ACDF technology in the treatment of CSM can achieve satisfactory clinical efficacy with high safety, and effectively restore the cervical intervertebral height and physiological curvature.

Predictive Value of Preoperative Short Form-36 Survey Scale for Postoperative Axial Neck Pain in Patients With Degenerative Cervical Myelopathy.

Prospective observational study. To evaluate the predictive value of the preoperative Short Form-36 survey (SF-36) scale for postoperative axial neck pain (ANP) in patients with degenerative cervical myelopathy (DCM) who underwent anterior cervical decompression and fusion (ACDF) surgery. This study enrolled patients with DCM who underwent ACDF surgery at author's Hospital between May 2010 and June 2016. Out of 126 eligible patients, 122 completed the 3-month follow-up and 117 completed the 1-year follow-up. The results showed that the preoperative social functioning (SF) subscale score of the SF-36 scale was significantly lower in patients with moderate-to-severe postoperative ANP than in those with no or mild postoperative ANP at both follow-up timepoints (P < .05). ACDF at C4-5 level resulted in a higher ANP rate than ACDF at C5-6 or C6-7 level, both at 3-month (P = .019) and 1-year (P = .004) follow-up. Multivariate logistic regression analysis confirmed that the preoperative social functioning subscale score was an independent risk factor for moderate-to-severe postoperative ANP at 3months and 1year after surgery, and preoperative NRS was an independent risk factor at 1-year follow-up. No other demographic, clinical, or radiographic factors were found to be associated with postoperative ANP severity (P < .05). Preoperative social functioning subscale score of SF-36 scale might be a favorable predictive tool for postoperative ANP in DCM patients who underwent ACDF surgery.

Coexistence of Cervical Disc Herniation and Shoulder Soft Tissue Pathologies and the Effect of Sleeping Positions and Orthopedic Pillows.

Background/aim This study investigates the degree of coexistence of cervical disc herniation and shoulder soft tissue pathology, as well as the effect of sleeping positions and orthopedic pillow use. Materials and methods This present study was conducted on 72 patients with shoulder/arm pain operated on for cervical disc herniation. Two groups were examined according to the presence of shoulder soft tissue pathology, four common sleeping positions, and the use of an orthopedic pillow. Preoperative and postoperative shoulder/arm visual analog scale (VAS) scores were compared. Results The preoperative VASvalues were 7.35, while the postoperative VAS values were 3.32. Twenty-one patients (29.2%) had a disc at the C3-4 level, a rate equal to that for the C5-6 level. Twenty-four patients (33.3%) had a disc at the C4-5 level. Thirty-two cases (44.4%) slept in a side-lying position on the same side as their disc herniation. Among those with a herniated disc at the C3-4 level, 8 (53.3%) preferred sleeping side-lying on the opposite side of the disc. In contrast, those with a herniated disc at the C4-5 level more frequently (40.6%) slept side-lying on the same side as the disc. Mean VAS scores were significantly higher in cases with shoulder soft tissue pathology and were significantly lower in the group that used orthopedic pillows (p<0.001). Conclusion Shoulder soft tissue pathologies should be considered in postoperative shoulder pain. The use of orthopedic pillows is effective in preoperative and postoperative pain. Sleeping positions do not affect the shoulder/arm pain before and after the operation, but they affect the level of cervical disc herniations.

Successful Cervical Epidural Blood Patch as a Treatment of Spontaneous Intracranial Hypotension - A Case Report

Background: Spontaneous intracranial hypotension can be a source of headache due to a continuous cerebrospinal fluid leakage. Case: A 33-year-old male patient with unremarkable history was presented with a headache, accompanying posterior neck stiffness and tinnitus lasting for 4 days. The opening pressure from cerebrospinal fluid tapping was 60mmH2O. Magnetic resonance imaging of the neck showed fluid collection at right C1-2 level, suggesting spontaneous intracranial hypotension. The headache did not respond to conservative treatments. Epidural blood patch was performed at C4-5 level. On postoperative day 1, remnant headache was only 20 percent and patient was discharged the day after. Conclusions: In spontaneous intracranial hypotension with leakage site at high cervical level, an epidural blood patch at a different cervical level can be safely performed to relieve the symptoms.

Is laminectomy necessary for C1-C2 epidural schwannomas?

Spinal schwannomas often require laminectomy for gross total resection. However, laminectomy may not be necessary due to the unique anatomy of epidural schwannomas at the C1-2 level, even with the intradural part. This study aimed to determine the need for laminectomy by comparing factors between patients who underwent laminectomy and those who did not and to identify the benefits of not performing laminectomy. Fifty patients with spinal epidural schwannoma confined to C1-C2 level were retrospectively collected and divided into groups based on whether laminectomy was intended and performed. In all cases where laminectomy was conducted, patients underwent laminoplasty using microplate-and-screws, which deviates from the conventional laminectomy approach. Tumor characteristics were compared, and a cut-off value for laminectomy was determined. Outcomes were compared between groups, and factors influencing laminectomy were identified. Postoperative changes in cervical curves were measured. The diameter of the intradural part of the tumor was significantly longer in the laminectomy performed group, with a 14.86mm cut-off diameter requiring laminectomy. Recurrence rates did not differ significantly between groups. Surgery time was substantially longer for the laminectomy performed group. No significant changes were observed in Cobb's angles of Oc-C2, C1-C2, and Oc-C1 before and after surgery. The study showed that the diameter of the intradural part of the tumor influenced the decision to perform laminectomy for removing epidural schwannomas at C1-C2. The cut-off value of the diameter of the intradural part of the tumor for the laminectomy was 14.86mm. Not performing laminectomy can be a viable option with no significant differences in removal and complication rates.

Exclusive Spinal Epidural Arteriovenous Malformation: Taming the Serpent in the Canal

Most spinal arteriovenous malformations (AVMs) are dural arteriovenous fistulas in which a singularly intradural venous drainage emanates from an extradural nidus. A pure extradural spinal arteriovenous malformation (E-AVM), in the absence of a vertebral body (cavernous) hemangioma, is extremely rare, and full clinical, radiological, and operative descriptions are scant. We report this case and review the relevant literature to document the rare occurrence of a symptomatic E-AVM producing compressive spinal myelopathy like symptoms. Adult patient presented with 7-month progressive spastic quadriparesis, hypertonia in lower limbs and graded sensory loss below c6 level. Magnetic resonance imaging revealed a T2 hypointese extradural lesion at C4-5 level and CT angiography revealed an epidural vascular malformation.DSA revealed a Type A epidural AVM. Preoperative embolisation of the AVM with Onyx and coils was done and later a C4-5 laminectomy with excision of the entire Epidural AVM nidus with prolapsed coils was done. Surgical excision was done in view of compressive symptoms Post operatively patient had considerable improvement in power as well decrease in hypertonia. Postoperative MRI imaging after 3 months of surgery revealed complete excision of the malformation and resolution of cord edema. Based on the literature review done, ours is a first of its kind case of Exculsive Epidural AVM (EEAVMs) presenting with symptoms suggestive of Compressive spinal myelopathy. To conclude, E-AVMs may present with compressive myelopathy like symptoms. Treatment should be by tailored to benefit the patient like in our case.

Hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome: illustrative case.

Intraspinal juxta-facet cysts of the spine are known to predominate at the lumbar level and is relatively rare at the cervical level. Most cervical spinal lesions are found incidentally, but they sometimes cause myelopathy or radiculopathy in a chronic course. The authors present a rare case of hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome. An 86-year-old woman presented with acute-onset right hemiparesis following neck pain and was admitted to the local hospital. She was started on antithrombotic therapy with a suspected diagnosis of cerebral infarction, but quadriplegia progressed 2 days later. Cervical magnetic resonance imaging revealed an intraspinal mass at the C4-5 level and she was referred to the authors' hospital. Her neurological findings on admission revealed right Brown-Séquard syndrome. In emergency surgery, the mass was resected with a posterior approach. Pathological findings showed hemosiderin deposition and fibroblast proliferation, consistent with a juxta-facet cyst with intracystic hemorrhage. The patient recovered well and returned to an independent daily life. Rarely, juxta-facet cyst of the cervical spine can cause acute Brown-Séquard syndrome due to intraspinal hemorrhage. In a case of hemiparesis that develops following neck pain, hemorrhagic cervical juxta-facet cyst should be taken into consideration as a differentiation.

Functional Outcome in C2/C3 Fracture Dislocation Managed with Combined Surgical Decompression and Posterior Stabilization

Spinal cord injury is one of the main reasons for permanent paralysis and immobility till now. Spine injury is usually fatal because it involves more than one component, such as discoligamentous misconfiguration, vascular and spinal cord damage. Spine dislocation fracture at the level of C2-3 is rare and usually affects one or two vertebras. Good functional outcome in spine injury is uncommon in which death almost always happens suddenly or is caused by secondary trauma. Emergency room with a cervical spine injury. The patient was pushed by his friends from the side during playtime, causing the neck to hit the corner of a table. The dislocation fracture at the level of C2-3 and spinal cord compression directly caused tetraplegia. The condition was handled with a decompression procedure, spine fusion at the level of C1-4, and posterior stabilization with pedicle screws. A day after the operation, minimal movements were seen in both arms and legs, with motoric strength of 2/2/2/2. The score improved to 4/4/4/4 after two weeks of meds and physiotherapy. The patient started to write again in week 3. The dislocation fracture in this patient caused spinal cord compression. A retropulsion fracture fragment can be displaced to the spinal canal and potentially cause further spinal cord damage. Displacement towards the anterior horn leads to motoric dysfunction. Dislocation fracture at the level of C2-3 hinders neurotransmitter impulse, causing total paralysis on all extremities with intact sensory function. The patient had temporary external stabilization around the neck area while waiting for the procedure. The management concept in cases like this includes affected spinal cord decompression and internal fixation using pedicle screws to ensure fracture stabilization.

566 Posterior Spinal Cord Syndrome after High Voltage Electrical Injury

Abstract Introduction High voltage electrical injuries have been called “the grand masquerader”, and significant neurological sequalae have been described. Here, we report the case of a 73-year-old man who sustained a 14.5% total body surface area (TBSA) full thickness electrical burns, most significantly to his scalp (Figure 1). On initial evaluation, there was concern for loss of proprioception resulting in gait instability. A magnetic resonance image (MRI) of the cervical spine performed on post injury day 9 showed no evidence of cervical spinal cord injury. Methods A novel descriptive case report of a high-voltage electrical injury with incomplete spinal cord injury Results The patient underwent several operative interventions for wound coverage and preservation of function with the known challenges experienced with high voltage burn wounds. Despite lack of imaging confirmation, suspicion for an occult neurological injury remained high. Neurological consultation confirmed limited proprioception and loss of 2-point discrimination. Due to these specific findings that resulted in an inability to make significant rehabilitation gains, a subsequent MRI of his cervical spine performed on post-injury day 30 demonstrated T2 hyperintensity in the dorsal column in the cervical spine at the C2-3 and C5-6 levels, suggestive of myelopathy (Figure 2). Conclusions To our knowledge, this is the first reported case of an incomplete spinal cord injury (posterior spinal cord syndrome in this case) due to an electrical injury without bony abnormality the association of paralysis. With the knowledge of this injury, our burn therapists have been able to develop a rehabilitation plan with reasonable expectation and goals. While discussing prognosis with the patient and his family, we noted the absence of data regarding outcomes after injuries of this nature and sought to contribute to the literature with this case. Applicability of Research to Practice A novel case of delayed imaging confirmation of posterior cord syndrome contributes to the body of evidence for neurological sequelae due to electrical injuries.

Cervical Instability and Quadriparesis Requiring Stabilization in Pediatric Patient Caused by a Mutation in COL2A1

A 3-year-old male with no past medical history presented with flaccid plegia of his upper extremities and significant weakness in his lower extremities after wrestling with his brother. Cervical spine magnetic resonance imaging was consistent with cord edema and intraparenchymal hemorrhage at C1-C2. A nonossified tissue mass at the expected location of the upper dens created narrowing of the canal at the C1-2 level and mass effect on the cord. Head computed tomography showed periventricular leukomalacia. Initial findings favored dysplasia of the odontoid with associated soft tissue mass/pannus caused by a possible underlying genetic or metabolic bone dyscrasia. The patient underwent suboccipital craniotomy/C1 laminectomy and occiput to C4 fusion, for decompression and stabilization. Genetic testing showed a COL2A1 collagen disorder, with the child harboring a de novo mutation for c.3455 G>T (p.G1152V). The patient was discharged to inpatient acute rehabilitation, with gradual improvement in strength in all 4 extremities.

Intraoperative DSA-guided minimal approach for craniocervical junction DAVFs obliteration.

Dural arteriovenous fistulas (DAVFs) are a group of diseases involving problematic shunts between dural arteries and venous structures such as sinuses, meningeal veins, or even cortical veins. To focus on craniocervical junction dural arteriovenous fistulas (DAVFs), we introduce a minimally invasive technique with midline incision combined with intraoperative digital subtraction angiography (DSA). This hybrid technique can minimize the incision wound to an average of 6 cm which leads to less destruction and lower risk of adverse events. Using this minimally invasive approach, surgical obliteration was achieved in 6 patients with craniocervical junction DAVFs. A minimal midline incision was made over the C1-2 level, measuring approximately 5 to 7 cm in length. C1 hemilaminectomy was performed for DAVF obliteration followed by intraoperative DSA for confirmation of complete obliteration. Among these 6 patients, the radiculomedullary artery was the most common feeding artery. The mean length of the operation (including DSA performance) was 6.5 ± 1.4 h. None of these cases showed cerebrospinal fluid leakage or exacerbation of neurological symptoms after the operation. Using intraoperative DSA, the minimally invasive technique offers more precise but less destructive access than conventional far lateral suboccipital craniotomy. Most importantly, intraoperative DSA provided verification of complete closure for shunts that could not be examined for indocyanine green (ICG) dye because the microscope did not have a clear line of sight. In our experience, this technique shows encouraging results of fistula obliteration.

Teaching NeuroImages: Vertebral artery compression by head tilt around the roll axis diagnosed by transcranial Doppler

A 59-year-old man reported transient vertigo and diplopia during leftward head tilt around the roll axis. Neurologic examination was unremarkable with the head erect or tilted. Magnetic resonance angiography of the head and neck showed hypoplasia of the right vertebral artery (figure 1). Transcranial Doppler waveform was monitored during leftward head tilt. The left vertebral artery flow velocity decreased with tilt, and abruptly increased after returning to erect posture (figure 2). Vertebral artery can be stretched or kinked by head rotation or tilt,1,2 typically at the C1-2 level.1 Transcranial Doppler could be helpful in diagnosis of such cases.

Paraspinal Sarcopenia is Associated with Worse Patient Reported Outcomes following Laminoplasty for Degenerative Cervical Myelopathy.

Retrospective cohort study. The present study is the first to assess the impact of paraspinal sarcopenia on patient-reported outcome measures (PROMs) following cervical laminoplasty. While the impact of sarcopenia on PROMs following lumbar spine surgery is well-established, the impact of sarcopenia on PROMs following laminoplasty has not been investigated. We performed a retrospective review of patients undergoing laminoplasty from C4-6 at a single institution between 2010-2021. Two independent reviewers utilized axial cuts of T2-weighted MRI sequences to assess fatty infiltration of the bilateral transversospinales muscle group at the C5-6 level and classify patients according to the Fuchs Modification of the Goutalier grading system. PROMs were then compared between subgroups. We identified 114 patients for inclusion in this study, including 35 patients with mild sarcopenia, 49 patients with moderate sarcopenia, and 30 patients with severe sarcopenia. There were no differences in preoperative PROMs between subgroups. Mean postoperative NDI scores were lower in the mild and moderate sarcopenia subgroups (6.2 and 9.1, respectively) than in the severe sarcopenia subgroup (12.9, P=0.01). Patients with mild sarcopenia were nearly twice as likely to achieve MCID (88.6 vs. 53.5%; P<0.001) and six times as likely to achieve SCB (82.9 vs. 13.3%; P=0.006) compared to patients with severe sarcopenia. A higher percentage of patients with severe sarcopenia reported postoperative worsening of their NDI (13 patients, 43.3%; P=0.002) and VAS Arm scores (10 patients, 33.3%; P=0.03). Patients with severe paraspinal sarcopenia demonstrate less improvement in neck disability and pain postoperatively and are more likely to report worsening PROMs following laminoplasty. 3.

MRI Evaluation of Cervical Spondylotic Canal Stenosis and Change in its Severity on Flexion and Extension Positioning: A Cross-sectional Study

Introduction: Cervical spondylosis is a degenerative disorder of the cervical spine and has varied pathological forms of presentation. It presents as either varying degrees of intervertebral disc bulge, spinal cord compression, altered cord signals, neural exit foraminal stenosis, annular tears, facet joint degeneration and ligamentum flavum hypertrophy in combination or isolation. Magnetic Resonance Imaging (MRI) being known for its excellent soft tissue resolution helps assess and grade these pathologies efficiently. Aim: To evaluate the flexion-extension MRI in regular cervical spondylosis imaging by assessing the effect of flexion and extension positioning on the severity of cervical spondylotic canal stenosis and spinal canal dimensions. Also, to compare the change in cervical canal dimensions on flexion and extension with that of neutral positioning. Materials and Methods: A cross-sectional study was conducted in the Department of Radiodiagnosis, JSS Medical College, Mysuru, Karnataka, India, from January 2021-June 2022. A total of 50 participants, aged above 18 years with a clinical suspicion of cervical spondylosis and without history of trauma, tumour, infection, prior cervical surgery and with Nurick grade &lt;3 were included in the present study. In all the subjects, spinal canal dimension, degree of stenosis was assessed and graded, further assessment for presence of foraminal stenosis, ligamentum flavum hypertrophy and facetal arthropathy were also documented. Data were statistically analysed using Chi-square test and Mc Nemer’s test. Results: Out of total 50 cases, 26 (52%) were males and the rest were females with mean age of 46 years. Least cervical canal space dimension of 0.4 cm at C6-7 level in the neutral position and at C3-4, C5-6 and C6-7 levels in extension were noted thus, proving the importance of extension positioning in recognising maximum levels and severity of involvement. Narrowest diameter was demonstrated on flexion and extension. Additionally, the elderly was seen more affected by central disc bulge, foraminal stenosis, facetal arthropathy and ligamentum flavum hypertrophy as compared to the middle aged and the younger patients, more so in extension (12%). Conclusion: Disc bulge and grade of stenosis vary extensively and are more conspicuous on additional flexion and extension imaging. Severity of the grade of stenosis and demonstration of maximum number of levels involved on extension as compared to flexion or neutral positioning thereby, benefitting clinical management plan.

The Surgeon Ergonomic Impact of a Tubular-Based Digital Camera to Perform a Seated Posterior Cervical Foraminotomy

Posterior cervical decompression is a common spine procedure that can be performed with the patient in prone or sitting position. The sitting position provides the potential benefits of more facile retraction of surrounding soft tissues, increased operative field and fluoroscopic visualization, and decreased epidural bleeding. However, the surgeon's ergonomics of this positioning can be quite challenging when using the standard operative microscope to perform the procedure and may cause musculoskeletal harm to the surgeon. A sterile digital camera was brought into the field to perform a sitting foraminotomy completed through the tube retractor at both C6-7 and C7-T1 levels. For half of the procedure, a typical neurosurgical operative microscope was brought into the field to evaluate surgeon ergonomics using baseline Rapid Entire Body Assessment (REBA) scores for 2 surgeons of differing stature. The digital camera was inserted onto the tubular retractor, and REBA scores were calculated. With a microscope, the surgeon with taller stature scored a 5 on the initial REBA scale, and the surgeon with shorter stature scored a 6, placing both in the medium-risk category. Once the tubular-based camera was placed, repeated REBA score of both surgeons was 3, placing them in the low-risk category. Using a tubular-based digital camera system, the ergonomics of the surgery are substantially improved. The surgeon can stand closer to the operative field and look directly at a front-facing screen, allowing increased relaxation of the upper extremity and cervical musculature; improving overall ergonomic function.

Ultrasound-guided stellate ganglion block improves sleep quality in elderly patients early after thoracoscopic surgery for lung cancer: a randomized controlled study

To investigate the effects of ultrasound-guided stellate ganglion block (SGB) on sleep quality in elderly patients with lung cancer early after thoracoscopic surgery. A total of 86 patients with lung cancer (ASA class I-III, aged 60-80 years) undergoing elective thoracoscopic surgery were randomized into stellate ganglion block (SGB) group (n=43) and control group (n=43) to receive ultrasound-guided right SGB with 7 mL of 0.5% ropivacaine at the C6-7 level and injection of 7 mL saline at the same site 30 min before anesthesia induction, respectively. On the day before surgery and the first two days after the surgery, sleep duration, sleep efficiency index (SEI) and N3 sleep stage of the patients were monitored using a BIS-Vista monitor, and Athens Insomnia Scale (AIS) scores were recorded. The plasma levels of norepinephrine and cortisol of the patients were measured before SGB (T1), at 5 min after extubation (T2) and at 6:00 on the first morning after the surgery (T4). Urine levels of 6-hydroxysulfate melatonin (6-HMS) were measured at 6:00 in the morning for 3 consecutive days starting on the day of surgery (T3, T4 and T5, respectively). VAS score, incidences of postoperative delirium and depression, sufentanil consumption after surgery, and discharge time of the patients were recorded. Thirty-six patients in SGB group and 35 in the control group were analyzed. In both groups, most of the patients had insomnia after surgery, but compared with those in the control group, the patients in SGB group had significantly longer sleep duration (P < 0.05) with a higher sleep efficiency index (P < 0.05) and a longer sleep time in N3 stage (P < 0.05) on the first two nights after surgery. The mean postoperative AIS score and incidence of insomnia were significantly lower in SGB group than in the control group (P < 0.05). Compared with the control group, SGB group showed significantly lower plasma levels of norepinephrine and cortisol at T2 and T4 (P < 0.05), a higher urine level of 6-HMS at T5 (P < 0.05), and a shorter discharge time after the surgery (P < 0.05). The VAS scores, postoperative incidences of delirium and depression, or postoperative sufentanil consumption did not differ significantly between the two groups. Ultrasound-guided SGB improves objective and subjective sleep quality in elderly patients early after thoracoscopic surgery for lung cancer to alleviate stress responses and sleep disorders, reduce postoperative hospital stay, and accelerate postoperative recovery of the patients.

Spontaneous Cervical Epidural Abscess Caused by Serratia Marcescens.

Serratia marcescens infections are very rare and usually occur in the form of nosocomial and opportunistic infections. The subjects usually have severe medical comorbidities such as immunosuppression, diabetes mellitus, and renal failure. Spontaneous Serratia marcescens infection is very rare. In this case, we demonstrate that it can be seen in the spontaneous cervical epidural abscess. A 54-year female patient presented with a complaint of weakness in the left arm. Cervical magnetic resonance imaging revealed a spinal epidural abscess at the C5-6 level. Surgery was planned for this lesion. The abscess that created a cervical mass effect was totally removed and treatment with oral antibiotics was continued due to S. marcescens growth in the culture. This is the first case where S. marcescens has caused the development of a cervical epidural abscess in a patient without any medical comorbidity. Key Words: Serratia marcescens, Spinal epidural abscess, Vertebral osteomyelitis, Cervical discitis.

Deformity correction in the setting of acute cervical spine trauma in a patient with ankylosing spondylitis: A case report

Introduction: Ankylosing spondylitis (AS) is an autoimmune spondyloarthropathy marked by symptomatic alterations in skeletal anatomy and biomechanics. Ankylosis from the ossification of ligamentous structures and adjacent joints transforms the spine from flexible to rigid and brittle, easily susceptible to fracture. The pathophysiology of the condition is also notable for a progressive debilitating cervical kyphosis known as “chin-on-chest.” Ultimately, the combination of a brittle, rigid, spine can permit trivial trauma to cause catastrophic injury, and in some instances, mortality. We discuss the multi-disciplinary approach, management concerns, and deformity correction in the setting of traumatic cervical spine fracture in a patient with ankylosing spondylitis. Case Report: A 71-year-old man with ankylosing spondylitis presented to Howard University Hospital in a delayed fashion after a ground level fall at home. Neurological examination revealed loss of all motor and sensory function below the C4 level and an absence of rectal tone. Advanced imaging discovered a fracture-dislocation at the C4-5 level producing a severe hyper-lordotic angulation deformity. The profound fracture characteristics and displacement caused spinal cord compression posteriorly and tracheoesophageal stenosis anteriorly. The patient was treated operatively in a staged dual approach fashion correcting his pathologic deformity in consideration of long-term care needs. Postoperatively, upon completion of his final neurosurgical procedure, his sensory exam notable for return of sensation from C5-T1 and he was also able to appreciate and interact with the environment around him as his viewpoint was no longer rigidly caudally oriented. The patient was discharged from the hospital to a long-term care facility in stable condition. Conclusion: Cervical fractures sustained after minor trauma in a patient with ankylosing spondylitis are not uncommon. However, surgical intervention with concomitant deformity correction in the traumatic setting is substantial undertaking with a paucity of literature on such surgical techniques. Surgical deformity correction in the acute trauma setting allowed for optimization of anticipated medical care initiatives and successfully provided newfound visual awareness of his environment, improving upon his ability to interact with the world.

Segmental Zoster Paresis with Late-Onset Skin Rash Mimicking a Herniated Cervical Disc: A Case Report

Segmental zoster paresis (SZP) of the limbs, characterized by focal weakness of the extremity, is recognized as a rare complication of herpes zoster that can lead to a misdiagnosis of other radiculopathies or musculoskeletal problems. Here, we present a rare case where the patient experienced severe pain and weakness of the right upper extremity caused by SZP. A 58-year-old man came to the hospital with severe right upper extremity radicular pain. Cervical magnetic resonance imaging of the spinal cord showed disc protrusion at the C5-6 level with a high signal change. Anterior cervical discectomy and fusion was performed. On the first and second postoperative days, the patient’s symptoms showed slight improvements. However, on the fourth postoperative day, the patient experienced a right shoulder drop along with exacerbated radicular pain and presented a herpetic rash on the right extremity. The patient showed a dramatic improvement in pain and weakness after taking antiviral medication and undergoing a fluoroscopic-guided right C6 selective nerve root block. He fully recovered from his symptoms after 12 weeks of rehabilitation and physical therapy. This rare case involved SZP which was misunderstood as a herniated cervical disc. If a patient complains of severe pain with motor weakness inconsistent with radiologic findings, SZP should be discriminated from other possible diagnosis.