Paravertebral Structures Research Articles

Investigation of the Relationship Between Cervical Vertebral Column Degeneration and Posterior Circulation Perfusion Area Ischemia

Aim: The primary objective of this study was to establish whether degeneration of the cervical vertebrae and paravertebral structures serves as a predisposing factor for ischemic processes by disrupting hemodynamics in the posterior system through mechanical effects on the vertebral arteries. Material and Method: We conducted a retrospective analysis of 180 patients who underwent various imaging tests between January 2017 and October 2023. These tests included cervical magnetic resonance imaging (MRI), cervical computed tomography (CT), carotid-vertebral neck CT angiography (CTA), cranial CT, and cranial MRI. Of the 180 patients, 90 had mild degeneration or no significant degeneration, with a mean age of 58 years, and 90 had significant cervical spondylosis (CS) with a mean age of 64 years. The radiological findings were statistically analyzed, and a p-value of less than 0.05 was considered statistically significant. Results: There was no significant difference between age and parenchymal density in the control group (p=0.09). There was no statistically significant difference between the age and parenchymal density in the CS group (p=0.07). As CS became more severe, there was a statistically significant increase in the incidence of atrophic enlargement of the cerebellar folia and loss of density in the posterior fossa (p=0.03) and posterior circulation infarcts (POCI) (p=0.04). Conclusion: When severe, CS can adversely affect vascular hemodynamics in the posterior system, predisposing perfused neural parenchyma to ischemia.

Spondylodiscitis revisited.

Spondylodiscitis may involve the vertebral bodies, intervertebral discs, paravertebral structures and spinal canal, with potentially high morbidity and mortality rates.A rise in the susceptible population and improved diagnosis have increased the reported incidence of the disease in recent years.Blood cultures, appropriate imaging and biopsy are essential for diagnosis and treatment.Most patients are successfully treated by conservative means; however, some patients may require surgical treatment.Surgical indications include doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain.Cite this article: EFORT Open Rev 2017;2:447–461. DOI: 10.1302/2058-5241.2.160062

Clinical efficacy of "Shamrock" ultrasound images-guided lumbar sympathetic ganglion blockade

Objective To evaluate the clinical efficacy of Shamrock ultrasound images-guided lumbar sympathetic ganglion blockade (LSGB). Methods Sixty patients of both sexes, aged 18-60 yr, weighing 50-70 kg, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing unilateral LSGB, were divided into groupⅠ(n=30) and group Ⅱ (n=30) using a random number table.In group Ⅰ, unilateral LSGB was performed at the L2 level under ultrasound guidance with paramedian transverse scanning.In group Ⅱ, unilateral LSGB was performed at the L2 level under ultrasound guidance with Shamrock ultrasound images.After final needle position was confirmed, 2% lidocaine 6.0 ml was administered in each patient.At 20 min before and after LSGB, the visual analogue scale scores and skin temperature of the big toe of the affected foot were recorded, and the successful blockade and visibility of important paravertebral structures on ultrasound images were recorded during puncture. Results The visual analogue scale scores were significantly lower, and the skin temperature on the affected side was significantly higher after LSGB than before LSGB in both groups (P<0.05). The important paravertebral structures such as erector spinae, quadratus lumborum, psoas major, transverse process of L2 vertebrae, and the curved edge of L2 vertebrae were visible in both groups.The visibility rate of the inferior vena cava or abdominal aorta on ultrasound images and the success rate of blockade were significantly lower in group Ⅰ than in group Ⅱ (P<0.01). Conclusion Compared with paramedian transverse scanning, LSGB has some advantages such as real-time monitoring, higher success rate of blockade, better efficacy and avoiding damage to great vessels when performed under Shamrock ultrasound image guidance. Key words: Ultrasonography; Ganglia, sympathetic; Nerve block

Ultrasound-Guided Lumbar Sympathetic Ganglion Blockade Using Shamrock Method: A Prospective Case Series

Background: Lumbar sympathetic ganglion blockade (LSGB) is traditionally performed using x-ray in either the fluoroscopy suite, or CT in the radiology department. This case series evaluated the feasibility of using the‘Shamrock method’ to perform LSGB under ultrasound guidance in patients.Methods: A total of 16 patients with postherpetic neuralgia received a real-time LSGB under the guidance of Shamrock ultra-sonogram for pain management. The blocks were performed using the in-plane needle insertion. Ultrasound visibility of the lumbar paravertebral structures was assessed in real time during the scout scan. Sympathetic block after LSGB was considered successful when changes in ipsilateral skin temperature between preblock and postblock were >2℃.Results: The lumbar paravertebral region was successfully visualized in all patients with a median ultrasound visibility score of 15 (range, 8-18). The skin temperature of the big toe before LSGB was significantly lower than that 20 minutes after LSGB. Additionally, the changes in skin temperature between preblock and postblock were >2℃ in 15 (93.8%) of 16 patients.Conclusions: Ultrasound-guided LSGB can be reliably accomplished using the Shamrock method. Citation: Dan-Xu Ma, Yun Wang, Meng-Meng Bao, Chen Zhang, Xue-Yang Li, An-Shi Wu, et al. Ultrasound-guided lumbar sympathetic ganglion blockade using shamrock method: a prospective case series. J Anesth Perioper Med 2016; 3: 114-118. doi: 10.24015/JAPM.2016.0015This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Sonoanatomy Relevant for Lumbar Plexus Block in Volunteers Correlated With Cross-sectional Anatomic and Magnetic Resonance Images

Ultrasound imaging of the anatomy relevant for lumbar plexus block (LPB) is challenging because of its deep anatomic location and the "acoustic shadow" of the overlying transverse processes. A paramedian transverse scan (PMTS) of the lumbar paravertebral region with the ultrasound beam being insonated through the intertransverse space (ITS) and directed medially toward the intervertebral foramen (PMTS-ITS) may overcome the problem of the "acoustic shadow" and allow clear visualization of the anatomy relevant for LPB. This study assessed the feasibility of using PMTS-ITS for imaging the anatomy relevant for LPB in healthy volunteers. Thirty young volunteers underwent a PMTS-ITS of the right lumbar paravertebral region. The sonoanatomy was defined in corresponding cadaver anatomic sections and magnetic resonance images. Visibility of the paravertebral structures in the sonograms was assessed by 4 independent observers using a 4-point Likert scale (0, not visible; 1, hardly visible; 2, well visible; 3, very well visible), and the mean total ultrasound visibility score (UVS; maximum score possible, 30) was determined. Overall ultrasound visibility was judged as good if the total UVS was greater than 20, average if it was 10 to 20, and poor if it was less than 10. Ultrasound imaging of the right lumbar paravertebral region at the L3-L4-L5 vertebral level was successfully performed through the PMTS-ITS scan window in all volunteers studied. The lumbar nerve root, lumbar paravertebral space, lumbar plexus, and the psoas compartment were delineated in 57%, 27%, 57%, and 87% of volunteers, respectively. Overall ultrasound visibility of the lumbar paravertebral structures was judged as "good" (mean [SD] total UVS, 20.4 [3]). A PMTS-ITS can be used to image the sonoanatomy relevant for LPB including the lumbar nerve root, lumbar paravertebral space, lumbar plexus, and the psoas compartment.

Assessment of a single-operator real-time ultrasound-guided epidural technique in a porcine phantom

To the Editor, Recent correspondence in the Journal highlighted the usefulness of a porcine carcass phantom for teaching and learning ultrasound-guided paravertebral techniques because of the notable similarity of spinal and paravertebral structures in pigs and humans. We have previously described a method of deodorizing and curing a porcine model for lumbar sonoanatomy. We have now used the porcine model to assess the feasibility of a singleoperator ultrasound-guided epidural technique. The phantom was a T12-L5 section of pork spine with associated musculature cured in 66% alcoholic gel (Aqium Gel, Ego Pharmaceuticals Pty Ltd, Australia). The Sir Charles Gairdner Group Human Research Ethics Committee approved the project (No. 2010-179), and all participants gave written informed consent. Ten anesthesiologists were recruited who were experienced in ultrasound-guided regional anesthesia but were non-expert in spinal sonography. They were shown a technique of paramedian epidural insertion using ultrasound assistance (Sonosite M-Turbo, 13-8 MHz linear array, Bothel, WA, USA) with a 17G echogenic Tuohy needle (Pajunk TuohySono, Geisingen, Germany) and an Epidrum device (Exmoor Innovations, UK) that provides visual confirmation of loss of resistance (LOR) when the air-filled diaphragm deflates. The Tuohy-Epidrum-syringe assembly was introduced in-plane from the caudal end of the transducer, and the needle was advanced until the tip approached the ligamentum flavum. At this point, the Epidrum device was inflated (Figure). Deflation occurred as the needle tip entered the epidural space, and the Epidrum and syringe were removed. The primary endpoint was successful threading of the catheter and appearance in the epidural space at the cephalad end of the phantom. Each anesthesiologist performed the task twice. Their attempts were recorded and timed by one of the authors (S.B.). Participants made a subjective assessment of the technique using a structured questionnaire. Secondary endpoints included time taken from needle first on view to visual LOR and percentage of time the needle was in view. The catheter was threaded successfully in 19 out of 20 attempts. One failure occurred due to premature Epidrum deflation prior to the needle entering the epidural space. This was clearly imaged but protocol dictated an attempt at catheter insertion. Mean (standard deviation) time to LOR was 51 (27) sec. The needle was visible 90 (10)% of the time corresponding with 90% of participants assessing visibility as excellent on a three-point rating scale. The task was evaluated as easy or intermediate by 60% of participants. While the other 40% of participants performed equally well, they expressed their natural caution over a new technique that others have labelled as ‘‘advanced’’. All participants would consider performing the technique on a patient, which suggests that phantom practice allowed participants to gain confidence that could result in changes to clinical practice. The echogenic TuohySono overcame the needle visibility difficulties at steep insertion angles that have previously been highlighted. Stiffness of the Tuohy allowed the needle rather than the transducer to be manipulated to preserve an in-plane view. The stationary transducer maintained an optimal image of the target at all times. The Epidrum made a single-operator Parts of the data have been presented as a poster at the Australian New Zealand College of Anaesthetists Annual Scientific Meeting in Hong Kong, May 2011.

Facet joint injections as a means of reducing the need for vertebroplasty in insufficiency fractures of the spine

Recent publications compared treatment of vertebral fractures reporting improvement in the majority but with no significant difference between the local anaesthetic and vertebroplasty groups. Potential explanations include placebo response or therapeutic response to the "control procedure". We investigated whether preliminary facet joint injection can identify those patients whose pain arises from paravertebral structures rather than the vertebral insufficiency fracture itself. Patients referred for treatment by vertebroplasty were first offered local anaesthetic and steroid facet joint injection (FJI) at the most painful level. Those who failed to respond were offered a vertebroplasty. Ninety one patients referred, 16 went straight to vertebroplasty. Sixty one of 75 were initially offered FJI. Twenty one were successful; two relapsed, had further FJIs with good results; three declined treatment; 5 had temporary benefit; 1 died from unrelated causes. Of 29 who failed to respond to FJIs, 24 underwent vertebroplasty and 23 had a successful outcome. A third of patients technically suitable for vertebroplasty responded beneficially to FJI. In this group the pain mediator maybe one of instability and overload on the facet joints produced by adjacent wedge fracture. This protocol allows more selective and more successful vertebroplasty.

Prevalence and risk factors of osteoporosis and vertebral fractures in patients with ankylosing spondylitis

Ankylosing spondylitis (AS) is characterized by inflammation of the entheses and paravertebral structures, leading in time to bone formation at those sites. As well, vertebral bone loss is also a recognized feature of ASObjective: To calculate the prevalence and risk factors of osteoporosis and vertebral fractures in patients with AS.Methods: Eighty patients with AS were enrolled in the study. Clinical, biological and radiological status was assessed by the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), ESR and C-reactive protein (CRP), Bath AS Radiology Index (BASRI) and modified stoke AS spine score (mSASSS). BMD of the hip and spine was measured and vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry by VFA (fracture vertebral assessment).Results: The years±11.8. The mean BMI was 22.8 kg/m2±4.1 and the mean disease duration was 10.8 years±6.6. Prevalence of osteoporosis was 25%. 18.8% of patients had a vertebral fracture (grades 2 and 3). Factors associated with osteoporosis were low weight and BMI and longer disease duration, higher ESR, CRP, BASFI and BASDAI. Vertebral fractures were associated with advanced age, longer disease duration, higher BASFI, BASRI and mSASSS and reduced BMD and T-score at the hip site, presence of osteoporosis at any site. Multiple logistic regression analysis (Table 4) revealed that parameters significantly associated with osteoporosis were BASDAI (OR=1.05, 95% confidence interval [CI]: 1.03–1.09); disease duration (OR=1.13, 95%CI: 1.03–1.25); and BMI (OR=0.82, 95%CI: 0.69–0.93). The presence of VFs (grades 2 and 3) were independently associated with disease duration (OR=1.50, 95%CI: 1.07–2.10); and mSASSS (OR=1.17, 95%CI: 1.05–1.30).Conclusion: Osteoporosis is common in patients with AS and seems to be related to disease activity while vertebral fractures appear to be related to the duration and structural severity of the disease rather than BMD.

Is every chronic low back pain benign?: Case report

Background There is a well-recognized association between chronic back pain and the existence of an AAA. In literature, there are few reported AAA cases that describe patients with extensive pressure erosion of the vertebral body. Case Description The authors present the case of a 38-year-old woman with chronic low back pain for the last 2 years in whom an AAA was formed during the follow-up period. The patient presented with an episode of low back pain following hard work 2 years ago. MR imaging of the lumbar spine was reported as disc degeneration at the L4-5 and L5-S1 levels. She was given medical treatment and was doing well with occasional back pain for a year. One year later, she suffered another disabling pain attack, and MR imaging revealed an additional focal disc protrusion at the L4-5 level. She was again medically treated. In August 2004, she presented with severe low back pain, and this time, MR imaging showed edema and erosion at the anterior part of L3 vertebra body. MR imaging studies (2- and 3-dimensional) depicted AAA as the cause. She was operated on, and the aneurysm was resected with graft repair of the site. She was pain-free in the postoperative period. Conclusions The evaluation of a patient with chronic back pain needs a thorough clinical and radiological workup. Limited evaluation of the bony and nervous structures of the spinal canal radiologically is insufficient. Pre- and paravertebral structures as well as vertebral body should carefully be evaluated to diagnose other causes of pain.

Localized Mycobacterium avium Complex Infection of Vertebral and Paravertebral Structures in an HIV Patient on Highly Active Antiretroviral Therapy

Localized Mycobacterium avium Complex Infection of Vertebral and Paravertebral Structures in an HIV Patient on Highly Active Antiretroviral Therapy

Anterior Stabilization of the Upper Thoracic Spine via an “Interaortocaval Subinnominate Window”

Because of the limitations imposed by the thoracic cage and the paravertebral structures, anterior access to T3 remains a challenge, particularly for the application of anterior fixation devices. Specifically, the appropriate trajectory for the correct placement of T3 screws requires significant caudal access; this may necessitate the addition of a high-level thoracotomy to the traditional combined neck exposure/sternotomy approach to the cervicothoracic junction (ie, the "trap door" exposure). The authors describe a technique for the placement of the T3 screws of a T1-T3 spinal titanium alloy plate via an "interaortocaval subinnominate window" in a patient who underwent a T2 vertebrectomy and polymethylmethacrylate reconstruction. The case history, imaging studies, illustrations, and intraoperative photographs are presented. This novel technique allows for the optimal placement of anterior fixation devices in the upper thoracic spine without the need to extend the caudal exposure with an anterolateral thoracotomy.

Ultrasonography of the equine cervical region: a descriptive study in eight horses

In equine patients, the cause of clinical signs possibly related to the cervical region is often difficult to diagnose. Ultrasonography allows quick and noninvasive visualisation, but reference material of the normal equine neck is needed. To describe and document the normal ultrasonographic appearance of transverse scans in the cervical region with emphasis on the synovial articular facet joints, cervical vertebrae and paravertebral structures; and further, to provide images of frozen cross-sections for anatomical reference. A study describing the normal ultrasonographic appearance of the cervical anatomy was performed. Transverse scans were obtained from second cervical vertebra (C2) to first thoracic vertebra (T1). Post mortem photographs of frozen cross-sections were obtained as anatomical reference. The structures were clearly visualised by ultrasonography and consistency was found between ultrasonographic images and corresponding cross-sectional anatomy. The articular facets varied between horses and facets (C2 to T1). Discrepancy in the existing anatomical descriptions was found. The anatomical and ultrasonographic description provides a reference for ultrasonographic evaluation of equine cervical facet joints, vertebrae and paravertebral structures. The findings and variations found are considered to reflect the naturally occurring variations in horses.

Paravertebral abscess formation due to brucellosis in a patient with ankylosing spondylitis

It is occasionally difficult to distinguish the features of spinal brucellosis from those of ankylosing spondylitis (AS), and the resultant delayed diagnosis may allow insidious progression of the complications of the brucella infection. The case of a 33-year-old male HLA-B27-positive patient with known diagnosis of AS for 7 years, who developed a paravertebral abscess in the left erector spinae muscle due to brucellosis, is presented in this paper. This case report illustrates two important points; first, co-occurrence of AS and brucellosis in the same patient, and second, posterior element involvement with abscess formation in erector spinae muscle, which has not been previously reported. Magnetic resonance imaging is a sensitive method for detecting spinal brucellosis and extent of infection throughout paravertebral structures. Clinicians serving patients from areas with endemic brucellosis should not overlook the possibility of this infection in the presence of axial musculoskeletal symptoms, even among patients with AS.

A posterior parasagittal approach to thoracic paravertebral neural structures with curved cannulae

The clinical value of percutaneous diagnostic and therapeutic interventions in modern spine care has increased in proportion to growing knowledge regarding specific sites and structures responsible for chronic spinal pain. Although the information gained from noninvasive technologies continues to improve, correlation of morphologic abnormalities with clinical symptoms can often only be achieved with target-specific analgesic or provocative testing. Cervical and lumbar percutaneous techniques abound, but relatively little has been published on target-specific approaches to the thoracic paravertebral structures. The anatomic juxtaposition of vital viscera, limited access due to bony structures, and the small volume of the thoracic paravertebral space have likely limited widespread accession of structures specifically involved in thoracic nociception. This report reviews the relevant regional anatomy of the thoracic paravertebral region and basic neurophysiologic principles and rationale for targeting paravertebral structures and outlines a new method of accessing thoracic paravertebral neural structures with curved cannulae and real-time fluoroscopic guidance. Clinical applications and indications are also discussed. This method has permitted the performance of more than 1,000 thoracic percutaneous paravertebral procedures of varying levels of complexity to be performed by the author without a single case of clinically evident or documented pneumothorax. Copyright © 2001 by W.B. Saunders Company

Is Indomethacin Harmful in Spinal Cord Injury Treatment?

This study was designed to analyze the effect of early indomethacin on the lipid peroxidation after spinal cord injury in rats. The use of anti-inflammatory drugs to affect delayed and secondary injury after trauma to the spinal cord has now become a matter of standard clinical practice. However, spinal cord injury remains an enormous clinical problem and research that may lead to improved treatment is to be encouraged and commended. Three experimental groups consisting of 40 rats each were formed. Using microsurgical technique, total laminectomy between T5 and T10 was performed. Spinal cord injury was achieved with an epidural aneurysm clip, and pharmacological treatment immediate after the injury was performed by injecting indomethacin intraperitoneally (i.p.) at a dose of 3 mg/kg to indomethacin-treated group. The three main groups were divided into subgroups of 8 rats each. It was planned to stop the biochemical reactions at a different time in each of these subgroups, by the application of liquid nitrogen to the spinal cord and paravertebral structures at the end of the 1st, 15th, 30th, 60th, and 90th minutes. All the spinal cords were removed and protected from further reactions by immersing in the liquid nitrogen tank. The lipid peroxidation levels were assessed by determining thiobarbituric acid reactive substances formation. The results of the study showed that the administration of 3 mg/kg indomethacin immediately after spinal cord injury induces lipid peroxidation to a significant degree (p < 0.05 one-way ANOVA and Tukey HSD tests) when compared to the saline-treated group. This result suggests that early posttraumatic indomethacin treatment may be harmful in spinal cord injury.

Spinal chondroma of the lumbar tract: Case report

Cartilage-forming tumors are benign cartilaginous tumors that rarely affect the spinal canal: they account for 2% of all spinal tumors and 2.6% of all benign bone tumors. Pathologically, they may be classified as chondromas, osteochondromas, chondroblastomas, and chondromyxoid fibromas. This oncotype may remain asymptomatic (it is confined within the vertebral structure) or may present as a hard paravertebral swelling (it invades the paravertebral structures) or more rarely, with a slowly-developing neurologic syndrome (it extends into the vertebral canal). Thirty-one cases have been reported (including our case) of benign cartilage-forming tumors localized in the lumbar column. Only three cases of chondroma of the lumbar spine presented with lumbar radicular pain. We report a fourth case and review clinical and radiologic characteristics of these lesions. Eleven out of the 31 cases were diagnosed as chondromas, 17 as osteochondromas, while in three cases the histopathologic diagnosis was not reported. Seventeen cases originated from the neural arch, seven from the vertebral body, two from the spinous process, and in five cases the exact localization was not reported. This tumor is more frequent in males (21 cases out of 31), than in females (five cases); in five cases the sex was not reported. Mean duration of symptoms was 23 +/- 5.1 months (range: 1-96); chondromas have a short clinical history before diagnosis (13.8 +/- 3.4 months) compared to osteochondromas (28.6 +/- 7.6). Clinical presentation with local swelling is reported in 10 cases, in 10 cases local pain without radicular irradiation, in six cases lumbar pain with sciatica, in two cases signs and symptoms of cord compression, one case of cauda syndrome, while in four cases no clinical details are reported. Among the six cases presenting with sciatica, four were chondromas (in all cases the L4 level was involved), and one osteochondroma, while in one case the histopathologic diagnosis was not reported. Computed tomography is important and indispensable for preoperative diagnosis, giving a precise indication of tumor extent and location and its relationship to the adjacent structures; while MRI is helpful in detecting patterns related to histologic malignancy. It is important to examine the whole tumor histologically because it is known that there may be small areas that show signs of malignancy; thus is more likely in chondromas than osteochondromas.

Pediatric Spinal Blastomycosis

A 5-year-old male patient presented with flank pain, limping, weight loss, and cachexia. Magnetic resonance imaging revealed destructive vertebral changes, an epidural mass, psoas abscesses, and lack of involvement of the disc spaces. Blastomyces dermatitidis was isolated from a needle aspiration specimen. Sparing of the disc spaces, an unusual finding, suggested that the spread of infection was by way of paravertebral structures and surrounding potential spaces. Management was simplified by using gadolinium contrast-enhanced magnetic resonance imaging, which indicated that the epidural mass was mainly solid, thereby obviating abscess drainage.

Operative and Nonoperative Management of Esophageal Perforations

During a 21-year period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had "spontaneous" perforation, nine patients (11%) had foreign body related perforation, and seven patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus eight thoracic perforations, contained in the mediastinum, were treated with antibiotics, intravenous hydration, and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the nine patients who died had been operated on more than 24 hours after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).