Lumbar Segments Research Articles

Dose–effect of long-snake-like moxibustion for chronic fatigue syndrome: a randomized controlled trial

BackgroundThe dose–effect relationship of Long-snake-like moxibustion for chronic fatigue syndrome (CFS) remains poorly understood. In order to address this gap, we designed this trial to assess the association between different treatment duration of Long-snake-like moxibustion and its effects on CFS based on the combination measurements of the subjective patient-reported scales with objective medical infrared imaging technology─Thermal Texture Maps (TTM).MethodsFrom December 2020 to January 2022, 60 female CFS patients were recruited and equally allocated to two groups: Group A, receiving 60-min Long-snake-like moxibustion per treatment, and Group B, receiving 30-min Long-snake-like moxibustion per treatment. The treatment was administered 3 times per week for a total of 4 weeks. The primary outcome was defined as the improvement of symptoms measured by the Fatigue scale-14 (FS-14), and secondary outcomes were designated as the improvement in Symptoms Scale of Spleen-Kidney Yang Deficiency, Self-rating depression scale, and Self-rating anxiety scale. TTM scanning was employed twice for CFS patients (before and after 4-week treatment) and once for Healthy control subjects (HCs).ResultsAt week 4, the scores of FS-14 and Symptoms Scale of Spleen-Kidney Yang Deficiency in Group A were significantly lower than those in Group B (physical fatigue: 5.00 vs. 6.00, with 95%CI − 2.00 to 0.00, p = 0.003; FS-14 total score: 8.00 vs. 9.00, with 95%CI − 3.00 to 0.00, p = 0.012; total score of Symptoms Scale of Spleen-Kidney Yang Deficiency: 9.80 vs. 13.07, with 95%CI − 5.78 to − 0.76, P = 0.012). All thermal radiation values of the two groups increased, and statistical differences in ΔTs between Group A and HCs were not obtained. More significant correlations between symptoms improvements and ΔT changes were observed in Group A, and its ΔT changes in Upper Jiao, Shenque (CV8), Zhongwan (CV12), Danzhong (CV17), Zhiyang (GV9), Dazhui (GV14), upper arm, thoracic segments, lumbar segments, renal region, popliteal fossa strongly correlated with the improvement of Spleen-Kidney Yang Deficiency symptoms.ConclusionsIn the same course of treatment, the positive dose–effect relationship was found between the treatment duration of Long-snake-like moxibustion and CFS effect assessment. 60-min Long-snake-like moxibustion per treatment were associated with optimal clinical response and TTM improvement.Trial registrationChinese Clinical Trail Registry (No. ChiCTR2000041000, date of registration: 16 December 2020), http://www.chictr.org.cn/showproj.aspx?proj=62488

Bioinspired Intervertebral Disc with Multidirectional Stiffness Prepared via Multimaterial Additive Manufacturing

AbstractDegenerative disc disease (DDD) has become a significant public health issue worldwide. This can result in loss of spinal function affecting patient health and quality of life. Artificial total disc replacement (A‐TDR) is an effective approach for treating symptomatic DDD that compensates for lost functionality and helps patients perform daily activities. However, because current A‐TDR devices lack the unique structure and material characteristics of natural intervertebral discs (IVDs), they fail to replicate the multidirectional stiffness needed to match physiological motions and characterize anisotropic behavior. It is still unclear how the multidirectional stiffness of the disc is affected by structural parameters and material characteristics. Herein, a bioinspired intervertebral disc (BIVD‐L) based on a representative human lumbar segment is developed. The proposed BIVD‐L reproduces the multidirectional stiffness needed for the most common physiological kinematic behaviors. The results demonstrate that the multidirectional stiffness of the BIVD‐L can be regulated by structural and material parameters. The results of this research deepen knowledge of the biomechanical behavior of the human lumbar disc and may provide new inspirations for the design and fabrication of A‐TDR devices for both engineering and functional applications.

The role of an active muscular subsystem in prone instability test during rest and leg raise conditions.

Clinicians commonly used prone instability test (PIT) by assessing the posterior-to-anterior (PA) displacement to identify lumbar instability. Most studies focusing on passive subsystem found greater mobility in lower lumbar (L4-L5) than upper lumbar (L1-L3) spine. However, there is still a lack of evidence to demonstrate the role of active subsystem. Additionally, it is unclear whether sex affects PA displacements. To determine differences in displacement among five lumbar segments, between two testing positions (rest and leg raise), and between male and female during PIT in individuals with chronic non-specific low back pain (CNLBP). A cross-sectional study design. Spine biomechanics laboratory. Individuals with CNLBP. An electromagnetic tracking system was used to measure PA displacement with sensors attached at T12, S2 and a hand-held dynamometer. Participants were asked to perform PIT, while a 100N force was applied to each lumbar segment during resting and leg raise positions. Significantly less PA displacement (P<0.05) was seen in lower compared to upper lumbar spine and in leg raise compared to rest at L1 to L4. No significant interaction of sex with different lumbar levels and conditions (P>0.05) during PIT was found. Although previous studies have reported that the lower lumbar spine had greater mobility, the lower amount of displacement during the rest position suggests the role of an active subsystem contributing to lumbar stability regardless of sex. A reduction in displacement during the leg raise position across L1 to L4 suggesting an interaction of stabilizing subsystems of the spine to provide lumbar stability.

Prediction of nature of hysteresis and hysteresis based extraction of viscoelastic material model parameters

As almost all materials exhibit viscoelastic behaviour, it is important to understand the material behaviour which would help in its application in different fields. The current research work firstly focuses on understanding the dissipating behaviour of any viscoelastic material through operator-based multi-element model from the experimental hysteresis subject to cyclic or periodic displacement loading. Genetic algorithm-based constrained optimization technique is used as an extraction technique by curve fitting. Further, the technique is used to predict the model parameters of a pig’s lumbar spinal motion segment subjected to periodic displacement loading. Following the derived model parameters, the effect of varying periodic loading on the calculated hysteresis is also compared.

DISTRIBUTION OF PARVALBUMIN-EXPRESSING NEURONAL POPULATIONS IN THE CAT CERVICAL AND LUMBAR SPINAL CORD GRAY MATTER

Parvalbumin is a classical marker of interneuronal populations in the central nervous system. Analyzing the cervical and lumbar spinal cord segments of cats (Felis catus), both individual cells and entire populations of neurons expressing parvalbumin were identified in most of the gray matter laminae. These populations have strict laminar and nuclear localization. Numerous neuronal clusters are located in the medial part of lamina V–VI and in laminae VII of cervical and lumbar enlargements. We believe that the first one located in segments C4–C8 and L4–L7 may participate in the modulatory mechanisms of locomotor activity via the convergence of cutaneous and proprioceptive afferentation from the limbs. Neuronal populations in lamina VII consist of Ia interneurons and Renshaw interneurons that participate in the motoneuron inhibition. Less numerous populations of parvalbumin-immunopositive cells found in laminae III possibly participated in the regulation of cutaneous sensitivity. Another population located in lamina VIII possibly forms commissural and propriospinal connections and participates in modulating the activity of motoneurons. Immunopositive interneurons also revealed in the precerebellar nuclei: central cervical nucleus and Clarke’s nucleus; unlike the general population of these nuclei, neurons revealed are interneurons. Scarce immunopositive cells are found in lamina I of L6–L7 segments, as well as in laminae II, IV, and X of all segments investigated.

Potential effects of brain lipid binding protein in the pathogenesis of amyotrophic lateral sclerosis.

Current studies suggest that the abnormal alteration of brain lipid binding protein (BLBP) might participate in the pathogenesis of amyotrophic lateral sclerosis (ALS). However, the detailed understanding of ALS pathogenesis been yet to be elucidated. Therefore, this research intended to explore the potential effects of BLBP in ALS. The observation and analysis of BLBP-altered features in various anatomical areas and different spinal segments was conducted at the pre-onset, onset, and progression stages of Tg(SOD1*G93A)1Gur (TG) mice and the same periods of age-matched SOD1 wild-type (WT) mice by fluorescence immunohistochemistry and western blotting. BLBP-positive cells were comprehensively distributed in various spinal anatomical areas, especially in both the anterior and posterior horn, around the central canal and in anterior, lateral, and posterior funiculi. Overall, BLBP expression tended to increase from the pre-onset to the onset to the progression stages of the same periods of age-matched WT mice. Furthermore, in TG mice, BLBP expression in the entire spinal cord significantly increased from onset to the progression stage. BLBP was expressed in neurons, astrocytes, and radial glial cells, and at the early and late stages of neural precursor cells (NPCs) and was predominantly distributed outside the cell nucleus. The increase of BLBP-positive cells was closely related to neural cell reduction in TG mice. The distribution and increased expression of BLBP among the cervical, thoracic, and lumbar segments of the spinal cord might participate in the development of ALS and exert potential effects in the pathogenesis of ALS by regulating NPCs.

Immunohistochemical characteristics of the gray matter of the human spinal cord in the late prenatal period

The study is dedicated to the relevant problem of studying the patterns of age-related (prenatal) restructuring in the brain and spinal cord and provides opportunities for predicting and correcting the occurrence of congenital defects. The aim of the research was to establish the nature of immunohistochemical marker expression in the gray matter structures of the human spinal cord during the late prenatal period. The material for the study consisted of spinal cord preparations from 27 human fetuses at gestational age 35-40 weeks. The following methods were used during the research: anatomical, general histological, special histological, immunohistochemical, morphometric, and statistical analysis of the obtained data. It was found that at 35-36 weeks of the gestational period, the proliferation of neural stem cells (NSCs) occurs more intensively in the ventral neuroepithelium of spinal cord segments compared to the dorsal neuroepithelium. In the ventral neuroepithelium, there are 5-6 mitotic or post-mitotic NSCs, while in the dorsal part, there are only 2-3 cells. In fetuses at 39-40 weeks, the proliferative activity of neural stem cells in the dorsal neuroepithelium is higher in cervical and lumbar segments, where Ki-67 expression is detected in 6 % of cells (reactive in 7-8 cells), and in thoracic and sacral segments, it is 4 % (reactive in 3-4 cells). In contrast to the dorsal neuroepithelium, in the ventral part of the neuroepithelium of the segments, the proliferative activity of neural stem cells is slightly less intense. In cervical and lumbar segments, Ki-67 expression occurred in 4 % of cells (reactive in 3-4 cells), and in thoracic and sacral segments, it was 2 % (reactive in 1-2 cells). At 35-36 weeks of gestation, high vimentin expression was observed around the neuroepithelium, at the base of the posterior horns, and along the posterior median septum. Vimentin expression in the mantle layer was relatively weak and persisted along blood vessels and in the area of spinal cord root formation. Before birth, relatively weak vimentin expression was detected in the remnants of radial glia surrounding the neuroepithelial layer. Vimentin expression was absent in the neuroepithelium proper, but focal vimentin expression was observed around blood vessels. The absence of vimentin expression in the neuroepithelium indicates the disappearance of radial cells. At 35-40 weeks of the gestational period, relatively strong synaptophysin expression was observed in the mantle layer of spinal cord segments, indicating the intensity of neuronal connectivity establishment and myelination of nerve fibers. These processes continue after birth. Synaptophysin expression was absent in the neuroepithelium proper.

Novel Standalone Motion-Sparing Pelvic Fixation Prevents Short-Term Insufficiency Fractures After Midsacrectomies Without Sacrificing Normal, Mobile Lumbar Segments Traditionally Used for Stabilization.

Sacrectomy is often the treatment of choice to provide the greatest chance of progression-free and overall survival for patients with primary malignant bone tumors of the sacrum. After midsacrectomy, the stability of the sacropelvic interface is diminished, resulting in insufficiency fractures. Traditional stabilization involves lumbopelvic fixation but subjects normal mobile segments to fusion. The purpose of this study was to determine whether standalone intrapelvic fixation is a safe adjunct to midsacrectomy, avoiding both sacral insufficiency fractures and the morbidity of instrumenting into the mobile spine. A retrospective study identified all patients who underwent resection of sacral tumors at 2 comprehensive cancer centers between June 2020 and July 2022. Demographic, tumor-specific, operative characteristics and outcome data were collected. The primary outcome was presence of sacral insufficiency fractures. A retrospective data set of patients undergoing midsacrectomy without hardware placement was collected as a control. Nine patients (5 male, 4 female), median age 59 years, underwent midsacrectomy with concomitant placement of standalone pelvic fixation. No patients developed insufficiency fractures during the 216 days of clinical and 207 days of radiographic follow-up. There were no adverse events attributable to the addition of standalone pelvic fixation. In our historical cohort of partial sacrectomies without stabilization, there were 4/25 patients (16%) with sacral insufficiency fractures. These fractures appeared between 0 and 5 months postoperatively. A novel standalone intrapelvic fixation after partial sacrectomy is a safe adjunct to prevent postoperative sacral insufficiency fractures in patients undergoing midsacrectomy for tumor. Such a technique may allow for long-term sacropelvic stability without sacrificing mobile lumbar segments.

Lumbar Extensor and Flexor Muscle Structural Changes in Young Female Nurses with Chronic Bilateral Non-Specific Low Back Pain: A Case-Control Study.

Muscle structural studies on non-specific low back pain in young female nurses are rare. This study aimed to investigate the changes of lumbar extensor and flexor muscle cross-sectional area and fatty infiltration in young female nurses with chronic bilateral non-specific low back pain by lumbar spine magnetic resonance imaging to speculate on the possible pathogenesis. The magnetic resonance imaging (MRI) data of 58 female nurses with chronic bilateral non-specific low back pain and 60 healthy female controls were analyzed retrospectively. The lumbar extensor and flexor muscle cross-sectional area/intervertebral disc cross-sectional area ratio, as well as magnetic resonance imaging signal intensity of lumbar extensor (erector spinae; multifidus) and flexor muscles (psoas muscle) were measured, calculated and compared between nurses and healthy controls by independent samples t-test. In addition, each mean MRI signal intensity of lumbar extensor or flexor muscles in nurses at different anatomical segments from lumbar vertebrae 2 (L2)-L3 to L5-sacral vertebrae 1 (S1) was also compared, and one-way Analysis of Variance (ANOVA) analyzed the mean MRI signal intensity between muscles in nurses with multiple comparisons. There was no significant difference in lumbar extensor and flexor muscle cross-sectional area/intervertebral disc cross-sectional area ratio between nurses with chronic bilateral non-specific low back pain and healthy controls, p > 0.01. The magnetic resonance imaging signal intensity in lumbar extensor and flexor muscle was significantly higher in nurses with chronic bilateral non-specific low back pain than in healthy controls, p < 0.01. The MRI signal intensity of lumbar extensor muscle at the lower lumbar segments was higher than at the upper ones. The magnetic resonance imaging signal intensity of the extensor muscle (erector spinae; multifidus) was significantly higher than that of the flexor muscle (psoas muscle), p < 0.01. This study showed that young nurses with chronic bilateral non-specific low back pain have lumbar extensor and flexor muscle fatty infiltration without muscle atrophy. We hypothesized that muscle fatty infiltration may occur prior to muscle atrophy. Therefore, the high fatty infiltration of the lumbar extensor and flexor muscle may be a cause or a result of chronic bilateral non-specific low back pain in young nurses.

A Modified Unilateral Extrapedicular Approach Applied to Percutaneous Kyphoplasty to Treat Lumbar Osteoporotic Vertebral Compression Fracture: A Retrospective Analysis

BACKGROUND: In recent years, many extrapedicular puncture methods have been applied to percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCFs). However, these techniques were generally complex and had the risk of some puncture-related complications, which greatly limited the wide applications in PKP. Finding a safer and more feasible extrapedicular puncture method was rather important. OBJECTIVES: To evaluate the treatment effect of modified unilateral extrapedicular PKP in patients with lumbar OVCFs clinically and radiologically. STUDY DESIGN: Retrospective study. SETTING: Department of Orthopedic Surgery, an affiliated hospital of a medical university. METHODS: Patients who were treated by modified unilateral extrapedicular PKP in our institution, from January 2020 to March 2021, were retrospectively enrolled. The degree of pain relief and functional recovery were evaluated by the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI), respectively. Radiologic results were assessed including anterior vertebral height (AVH) and kyphotic angle. In addition, volumetric analysis was performed to evaluate bone cement distribution. And the intraoperative data and complications were also recorded. RESULTS: A total of 48 patients with lumbar OVCFs were successfully treated by modified unilateral extrapedicular PKP. All patients experienced a significant decrease in VAS and ODI scores after surgery (P &lt; 0.01) and maintained the statistical significance until the last follow-up (P &lt; 0.01), as well as significant AVH restoration (P &lt; 0.01) and kyphotic angle correction (P &lt; 0.01) compared with preoperative corresponding values. Volumetric analysis showed that all cases of bone cement diffused across the midline of the vertebral body (VB), in which 43 patients (89.6%) presented optimal contralateral distribution with good or excellent bone cement spread. In addition, 8 patients (16.7%) experienced asymptomatic cement leakage, and no other severe complications, such as injuries to segmental lumbar arteries and nerve roots, were found. LIMITATIONS: A noncontrol study with a small patient population and short follow-up duration. CONCLUSIONS: Modified unilateral extrapedicular PKP, in which the puncture trajectory was advanced through the bottom of Kambin’s triangle to or across the midline of VB for proper bilateral cement distribution, greatly alleviated back pain and restored the morphology of fractured vertebrae. It seemed to be a safe and effective alternative applied to treat lumbar OVCFs with appropriate patient selection. KEY WORDS: Lumbar, osteoporotic vertebral compression fractures, extrapedicular, percutaneous kyphoplasty

Risk of further surgery after decompression in patients with diffuse idiopathic skeletal hyperostosis extending to the lumbar segments: focus on the number of residual lumbar/lumbosacral and sacroiliac mobile segments.

Patients with diffuse idiopathic skeletal hyperostosis (DISH) that extends to the lumbar segments (L-DISH) have a high risk of further surgery after lumbar decompression. However, few studies have focused on the ankylosis status of the residual caudal segments, including the sacroiliac joint (SIJ). We hypothesized that patients with more ankylosed segments beside the operated level, including the SIJ, would be at a higher risk of further surgery. A total of 79 patients with L-DISH who underwent decompression surgery for lumbar stenosis at a single academic institution between 2007 and 2021 were enrolled. The baseline demographics and radiological findings by CT imaging focusing on the ankylosing condition of the residual lumbar segments and SIJ were collected. Cox proportional hazard analysis was conducted to investigate the risk factors for further surgery after lumbar decompression. The rate of further surgery was 37.9% during an average of 48.8months of follow-up. Cox proportional hazard analysis demonstrated that the presence of fewer than three segments of non-operated mobile caudal segments was an independent predictor for further surgery (including both the same and adjacent levels) after lumbar decompression (adjusted hazard ratio 2.53, 95%CI [1.12-5.70]). L-DISH patients with fewer than three mobile caudal segments besides index decompression levels are at a high risk of further surgery. Ankylosis status of the residual lumbar segments and SIJ should be thoroughly evaluated using CT during preoperative planning.

Commentary: Risk Factors for Adjacent Segment Disease in Short Segment Lumbar Interbody Fusion-A Case Series.

Chanbour, Hani MD*; Younus, Iyan MD*; Zuckerman, Scott L. MD, MPH*,‡ Author Information

Ultrasound-Guided Lumbar Peri-Facet Joint Blocks: A Therapuetuic Approach to Chronic Lower Back and Referred Leg Pain Management

Intra-articular fluoroscopically-guided facet joint (FJ) blocks are performed with diagnostic-therapeutic aims, whereas the main focus of ultrasound guided peri-facet joint blocks (USG-PFJB) is pain relief. USG-PFJB will therefore typically utilize higher injection volumes to potentially offer injection spread to other pain-generating structures. This study explores the potential role of USG-PFJBs in the outpatient management of chronic low back pain with our without leg symptoms in patients with MRI-confirmed mild to severe lower lumbar FJ arthrosis. USG-PFJBs were performed on 19 patients, (4 male and 15 females, mean age 55) at the L4/5 and/or L5/S1 segments at paraspinal points of palpable focal pain. All procedures were performed by the same clinician. One patient was lost to follow up and telephone reviews at 2-6 months on the remaining 18 patients, noted that 59.73% experienced significant &amp; sustained pain relief. In conclusion, lower lumbar segment USG-PFJBs appear to be effective treatment option in patients with mild to severe MRI-confirmed FJ degeneration and palpable paraspinal lower back pain and with or without lower limb pain.

Naloxone could limit morphine hypersensitivity: Considering the molecular mechanisms

BackgroundNaloxone has been used as an opioid antagonist to prevent multiple adverse side effects of opioid-like tolerance and hyperalgesia. This study has investigated naloxone combined with morphine to limit pain hypersensitivity. In addition, the expression of brain-derived neurotrophic factor (BDNF) and K+ Cl− cotransporter2 (KCC2) were also studied. MethodsForty-eight adult male Wistar rats (180–220 g) were divided into eight groups, with six rats in each group. Rats were divided into two tolerance and hyperalgesia groups; the sham group, the morphine group, the treatment group (naloxone along with morphine), and the sham group (naloxone along with saline) for eight consecutive days. Tail-flick test was performed on days 1, 5, and 8, and the plantar test on days 1 and 10. On days 8 and 10, the lumbar segments of the spinal cord were collected, and BDNF and KCC2 expression were analyzed using western blotting and immunohistochemistry, respectively. ResultsResults showed that tolerance and hyperalgesia developed following eight days of repeated morphine injection. BDNF expression significantly increased, but KCC2 was downregulated. Co-administration of naloxone and morphine decreased tolerance and hyperalgesia by decreasing BDNF and increasing KCC2 expression, respectively. ConclusionThis study suggests that BDNF and KCC2 may be candidate molecules for decreased morphine tolerance and hyperalgesia.

Morphology and deformity of the shoulder and pelvis in the entire spine radiographs of adolescent idiopathic scoliosis.

To investigate the deformity and asymmetry of the shoulder and pelvis in adolescent idiopathic scoliosis (AIS) patients. This retrospective cross-sectional study enrolled 223 AIS patients with a right thoracic curve or left thoracolumbar/lumbar curve who underwent spine radiographs at the Third Hospital of Hebei Medical University between November 2020 and December 2021. The following parameters were measured: Cobb angle, clavicular angle, glenoid obliquity angle, acromioclavicular joint deviation, femoral neck-shaft projection angle, iliac obliquity angle, acetabular obliquity angle, coronal trunk deviation distance, and spinal deformity deviation distance. The Mann-Whitney U test, Kruskal-Wallis H test were used for inter-group comparisons, and Wilcoxon signed-rank test were used for intra-group left and right sides comparisons. Shoulder and pelvic imbalances were found in 134 and 120 patients, respectively, and there were 87, 109, and 27 cases of mild, moderate, and severe scoliosis, respectively. Compared with mild scoliosis patients, the difference in the acromioclavicular joint offset on bilateral sides was significantly increased in moderate and severe scoliosis [11.04, 95% confidence interval (CI): 0.09-0.14 for mild, 0.13-0.17 for moderate, and 0.15-0.27 for severe scoliosis, P=0.004], and the difference in the femoral neck-shaft projection angle on bilateral sides was significantly enhanced with scoliosis aggravation (14.14, 95% CI: 2.34-3.41 for mild, 3.00-3.94 for moderate, and 3.57-6.43 for severe scoliosis, P=0.001). The acromioclavicular joint offset was significantly larger on the left than that on the right in patients with a thoracic curve or double curves (thoracic curve -2.75, 95% CI: 0.57-0.69 for the left and 0.50-0.63 for the right, P=0.006; double curve -3.27, 95% CI: 0.60-0.77 for the left and 0.48-0.65 for the right, P=0.001). The femoral neck-shaft projection angle was significantly larger on the left than right in patients with a thoracic curve (-4.46, 95% CI: 133.78-136.20 for the left and 131.62-134.01 for the right, P<0.001), but larger on the right than left in patients with thoracolumbar/lumbar curve (thoracolumbar -2.98, 95% CI: 133.75-136.70 for the left and 135.13-137.82 for the right, P=0.003; lumbar -3.24, 131.97-134.56 for the left and 133.76-136.26 for the right, P=0.001). In AIS patients, shoulder imbalance has a greater impact on coronal balance and spinal scoliosis above the lumbar segment, whereas pelvic imbalance has a greater impact on sagittal balance and spinal scoliosis below the thoracic segment.

Spinal Dorsal Intradural Arteriovenous Fistulas: Natural History, Imaging, and Management.

In this review, we describe the pathophysiology, diagnosis, and treatment of spinal dorsal intradural arteriovenous fistulas (DI-AVFs), focusing on novel research areas. DI-AVFs compose the most common subgroup of spinal arteriovenous lesions and most commonly involve the thoracic spine, followed by lumbar and sacral segments. The pathogenesis underlying DI-AVFs is an area of emerging understanding, thought to be attributable to venous congestion and hypertension that precipitate ascending myelopathy. Patients with DI-AVFs typically present with motor, sensory, or urinary dysfunction, although a wide swath of other less common symptoms has been reported. DI-AVFs can be subdivided by spinal region, which in turn is associated with 4 distinct clinical phenotypes: craniocervical junction (CCJ), subaxial cervical, thoracic, and lumbosacral. Patients with CCJ and lumbosacral DI-AVFs have particularly interesting presentations and treatment considerations. High-value diagnostic findings on MRI include flow voids, missing-piece sign, and T2-weighted intramedullary hyperintensity. However, digital subtraction angiography is the gold standard for diagnosis and localization of DI-AVFs and for definitive treatment planning. Surgical disconnection of DI-AVFs is almost universally curative and frontline treatment, especially for CCJ and lumbosacral DI-AVFs. Endovascular techniques evolve in promising ways, such as improved visualization, distal access, and liquid embolic techniques. The pathophysiology of DI-AVFs is better understood using newly identified radiologic diagnostic markers. Despite new techniques and devices introduced in the endovascular field, surgery remains the gold-standard treatment for DI-AVFs.

Clinical and Electrophysiological Presentation of a Patient with Multisystem Proteinopathy Associated with Valosin-Containing Protein Mutation (P5-8.005)

<h3>Objective:</h3> Present a rare case of multisystem proteinopathy (MSP) of apparently unrelated multisystem conditions caused by mutation in valosin-containing protein (VCP). <h3>Background:</h3> Multisystem proteinopathy (MSP) is a dominantly inherited disorder causing bone, muscle, central and peripheral nervous systems disease. Mutations within the gene encoding valosin-containing protein (VCP) cause MSP. Such mutations present with a vast phenotypical variability and are associated with inclusion body myopathy, Paget’s disease of bone, frontotemporal dementia, and amyotrophic lateral sclerosis. We present a case of MSP caused by c.464G&gt;A, p. arg155his mutation in VCP. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 65-year-old woman presented with proximal muscle weakness and unsteady gait. The symptoms started four years ago when she experienced progressive weakness of the upper and lower extremities leading to recurrent falls. She has no family history of similar symptoms or genetic disease. Examination revealed dropped head, scapular winging, inability to raise the arms above her shoulders, hand weakness, and bilateral foot drop. Her gait was unsteady with a mix of waddling and steppage. Creatine kinase and alkaline phosphatase levels were normal. MRI of spine revealed mild degenerative disc disease from C4–C7 and disc bulges at L3–L4 through L5–S1. The nerve conduction studies showed mixed myopathic and neurogenic changes with ongoing denervation in cervical and lumbar segments suggestive of motor neuronopathy. Genetic testing was remarkable for a heterozygous pathogenic mutation in VCP (c.464G&gt;A, p. arg155his). <h3>Conclusions:</h3> This case highlights the need to consider MSP in patients with a complex neurological presentation and combined myopathic and neurogenic electrodiagnostic findings. The absence of MSP-related symptoms in the patient’s family may indicate the variable severity associated with the same VCP mutation, interaction with environmental factors as well as presence of genetic modifiers.. <b>Disclosure:</b> Mr. Halber has nothing to disclose. Sabrina Bulancea has nothing to disclose. Dr. Treidler has nothing to disclose.

Biomechanics after spinal decompression and posterior instrumentation

PurposeThe aim of this study was to elucidate segmental range of motion (ROM) before and after common decompression and fusion procedures on the lumbar spine.MethodsROM of fourteen fresh-frozen human cadaver lumbar segments (L1/2: 4, L3/4: 5, L5/S1: 5) was evaluated in six loading directions: flexion/extension (FE), lateral bending (LB), lateral shear (LS), anterior shear (AS), axial rotation (AR), and axial compression/distraction (AC). ROM was tested with and without posterior instrumentation under the following conditions: 1) native 2) after unilateral laminotomy, 3) after midline decompression, and 4) after nucleotomy.ResultsMedian native ROM was FE 6.8°, LB 5.6°, and AR 1.7°, AS 1.8 mm, LS 1.4 mm, AC 0.3 mm. Unilateral laminotomy significantly increased ROM by 6% (FE), 3% (LB), 12% (AR), 11% (AS), and 8% (LS). Midline decompression significantly increased these numbers to 15%, 5%, 21%, 20%, and 19%, respectively. Nucleotomy further increased ROM in all directions, most substantially in AC of 153%. Pedicle screw fixation led to ROM decreases of 82% in FE, 72% in LB, 42% in AR, 31% in AS, and 17% in LS. In instrumented segments, decompression only irrelevantly affected ROM.ConclusionsThe amount of posterior decompression significantly impacts ROM of the lumbar spine. The here performed biomechanical study allows creation of a simplified rule of thumb: Increases in segmental ROM of approximately 10%, 20%, and 50% can be expected after unilateral laminotomy, midline decompression, and nucleotomy, respectively. Instrumentation decreases ROM by approximately 80% in bending moments and accompanied decompression procedures only minorly destabilize the instrumentation construct.

Lowest instrumented vertebrae selection in posterior fusion of Lenke 3C/6C adolescent idiopathic scoliosis: L3 versus L4, when LEV is L4.

In structural thoracolumbar/lumbar (TL/L) curves, lowest instrumented vertebra is selected mostly as the lower end vertebra (LEV). To save more lumbar mobile segments, fusion may be stopped one level proximal. This study aimed to compare the radiologic and functional outcomes of Lenke type 3C and 6C adolescent idiopathic scoliosis patients according to distal fusion level. 109 patients with Lenke 3C and 6C AIS, which had L4 as LEV and underwent posterior fusion were retrospectively evaluated. Lowest instrumented vertebra (LIV) was selected intraoperatively either as L3 or L4 depending on the disc alignment below LIV. In 49 patiens LIV was L3, while 60 patients were fused to L4. Two groups were compared according to radiologic and clinical outcomes preoperatively and two years postoperatively. Operation times were recorded. Preoperative values of both groups were similar. Regarding postoperative radiographic values, only LIV disc angle was different between groups, which was significantly higher in L3 group at two years follow-up. Coronal or sagittal imbalance was not observed. Surgical times and postoperative clinical outcomes were also similar. In TL/L curves which have L4 as LEV, satisfactory results can be achieved with stopping the fusion at L3, if a proper disc alignment below LIV can be obtained intraoperatively. Higher amount of LIV disc angle in L3 group did not cause coronal and sagittal imbalance. Although clinical outcomes are similar with stopping at L3 or L4, fusion to L3 may be prefered to save one more mobile disc.

Lumbar multiunit activity power spectrum during air stepping in the spinal cat: evidence for a flexor-dominated rostrocaudally distributed locomotor center.

Clues about the organization of spinal networks responsible for rhythmic motor behaviors have come from the examination of reflex circuitry, lesioning studies, and single-cell recordings. Recently, more attention has been paid to extracellularly recorded multiunit signals thought to represent the general activity of local cellular potentials. Focusing on the gross localization of spinal locomotor networks, we used multiunit signals of the lumbar cord to classify the activation and organization of those networks. We employed power spectral analysis to compare multiunit power across rhythmic conditions and locations and to infer patterns of activation based on coherence and phase measures. We found greater multiunit power in midlumbar segments during stepping, supportive of previous lesioning studies isolating rhythm-generating capabilities to these segments. We also found much greater multiunit power during the flexion phase of stepping than during the extension phase for all lumbar segments. Greater multiunit power at flexion indicates increased neural activity during this phase and is suggestive of previously reported asymmetries between flexor- and extensor-related interneuronal populations of the spinal rhythm-generating network. Finally, the multiunit power showed no phase lag at coherent frequencies throughout the lumbar enlargement indicative of a longitudinal standing wave of neural activation. Our results suggest that the multiunit activity may be representative of the spinal rhythm-generating activity that is distributed in a rostrocaudal gradient. Additionally, our results indicate that this multiunit activity may operate as a flexor-dominant standing wave of activation that is synchronized throughout the rostrocaudal extent of the lumbar enlargement.NEW & NOTEWORTHY We report on the power spectral analysis of multiunit activity (MUA) of lumbar spinal interneurons during a locomotor task. In line with prior studies, we found evidence of greater power at the frequency of locomotion in high lumbar segments and during the flexion phase. Our results also confirm prior observations from our laboratory that the rhythmically active MUA behaves as a longitudinal standing wave of neural activation that is flexor dominant.