Severe Spinal Canal Stenosis Research Articles

Unilateral Biportal Endoscopic Decompression for Thoracic Spinal Stenosis Secondary to Ossification of the Ligamentum Flavum

Ossification of the ligamentum flavum (OLF) in the thoracic spine is a cause of thoracic myelopathy that is more commonly found in East Asian populations (Koreans, Japanese, Chinese) than in others. Early diagnosis and sufficient surgical decompression can improve the functional prognosis for thoracic OLF. Surgical decompression is necessary and should be done as soon as the symptoms develop. There is a wide range of possible treatments, from standard open laminectomy to endoscopic decompression surgery. This video demonstrates the least invasive technique of decompressive laminectomy with bilateral decompression and removal of thoracic OLF through unilateral biportal endoscopic spinal surgery. The authors present the case of an 81-year-old male patient who presented with bilateral lower extremity weakness, numbness, pain, and ataxia. Magnetic resonance imaging and computed tomography scans of the whole spine showed the presence of OLF with severe spinal canal stenosis and a cord signal change at the T9–10 level. He underwent biportal endoscopic decompression and removal of thoracic OLF at T9–10. On the discharge day (postoperative day 7), motor power and pain had significantly improved. He could stand and independently ambulate with a walker.

6424 From Hyperparathyroidism To Neurologic Crisis: A Tale Of Brown Tumor And Spinal Cord Compression

Abstract Disclosure: A. Kormanis: None. M. Anderson: None. M. McKnight: None. H. Darapu: None. Background/Objective: In this case, we present a rare and severe consequence of secondary hyperparathyroidism, a Brown tumor leading to spinal cord compression, in a young adult with end-stage renal disease. Case Report: A 26-year-old male with a medical history of polycystic kidney disease and IgA Nephropathy complicated by ESRD, history of brown cell tumors (s/p surgery) was admitted for hospitalization due to hypocalcemia after presenting to the Emergency Department with right lower extremity weakness. Examination revealed right hip flexor weakness and right foot clonus. Lab results showed serum calcium of 10.4 mg/dL . MRI displayed a 2.5cm X 3.7 cm soft tissue mass with circumferential encroachment of the epidural space leading to severe spinal canal stenosis of T4-T5 at the site of prior Brown tumor resection. Ultimately, the patient underwent subtotal parathyroidectomy with left cervical thymectomy, leading to an intra-operative PTH drop from >3500 to 247 pg/mL. Discussion: In the context of treating vertebral brown tumors, the consensus suggests that parathyroidectomy plays a crucial role in achieving both clinical and radiographical amelioration of the tumor. However, in cases like ours where paresis is present, surgical decompression of the tumor becomes imperative. Conclusion: The development of Brown tumors is a severe and rare long-term complication for hyperparathyroidism, and the location of a Brown tumor in the thoracic spine causing symptomatic cord compression is even more rare. Presentation: 6/2/2024

Anatomical and Radiological Findings of Abnormal Calcified Structures within and around the Foramen Transversarium and Its Clinical Implications.

The foramen transversarium is a vital anatomical structure found in the cervical vertebrae of the spine. Typically, it serves as a passageway for important neurovascular structures, including the vertebral artery and vein, as well as the vertebral nerve. However, abnormal calcification or ossification of soft tissues in and around this area can lead to various clinical implications. Understanding the presence and implications of abnormal ossified structures in and around the foramen transversarium is crucial for clinicians involved in the diagnosis and management of cervical spine disorders. Accordingly, this present study was designed to evaluate the abnormal ossified structures anatomically and radiologically within and around the foramen transversarium. This study was conducted on 182 (26 sets of cervical vertebrae) dried human cervical vertebrae obtained from the respective departments of anatomy and on 190 (95 males and 95 females) adult patients who visited the radiology department for neck-related problems such as stiff neck, neck/shoulder pain, dizziness, vertigo, imbalance, visual disturbances, and cognitive impairment. Among 182 examined cervical vertebrae, unilateral complete accessory foramen transversarium was found in 23 vertebrae (12.63%), bilateral complete in 19 (10.44%), bilateral incomplete in 6 (3.29%), unilateral complete double in 4 (2.19%), and unilateral complete absence of foramen transversarium in 3 (1.64%). Stenosis due to aberrant osteophytes was noted in 9 vertebrae (4.9%). Out of 190 patients, three males presented with cervical kyphosis, severe spinal canal stenosis, and spinal cord compression due to ossification of the posterior longitudinal ligament and osteophyte complexes at C3-C6, with the most significant compression at C5-C6. A thorough understanding of abnormal ossifications in and around the foramen transversarium is crucial for the management of cervical spine disorders; imaging modalities such as X-ray, computed tomography, and magnetic resonance imaging are crucial for recognizing and intervening in these cases, which is essential to prevent adverse neurological outcomes associated with vertebral artery involvement.

Implementing a rapid cord compression Magnetic Resonance Imaging protocol in the emergency department: Lessons learned.

(1) Evaluate efficacy of an abbreviated total spine protocol in triaging emergency department (ED) patients through retrospective evaluation. (2) Describe patient outcomes following implementation of a rapid cord compression protocol. (1) All contrast-enhanced total spine magnetic resonance imaging studies (MRIs) performed on ED patients (n = 75) between 10/1-12/31/2022 for evaluation of cord compression were included. Two readers with 6 and 5years of experience blindly reviewed the abbreviated protocol (comprised of sagittal T2w and axial T2w sequences) assessing presence of cord compression or severe spinal canal stenosis. Ground truth was consensus by a neuroradiology fellow and 2 attendings. (2) The implemented rapid protocol included sagittal T1w, sagittal T2w Dixon and axial T2w images. All ED patients (n = 85) who were imaged using the rapid protocol from 5/1-8/31/2023 were included. Patient outcomes and call-back rates were determined through chart review. (1) Sensitivity and specificity for severe spinal canal stenosis and/or cord compression was 1.0 and 0.92, respectively, for reader 1 and 0.78 and 0.85, respectively, for reader 2. Negative predictive value was 1.0 and 0.97 for readers 1 and 2, respectively. (2) The implemented rapid cord compression protocol resulted in 60% reduction in imaging time at 1.5T. The call-back rate for additional sequences was 7%. In patients who underwent surgery, no additional MRI images were acquired in 82% of cases (9/11). Implementing an abbreviated non-contrast total spine protocol in the ED results in a low call-back rate with acquired MRI images proving sufficient for both triage and treatment planning in most patients.

Spinal extramedullary hematopoiesis mimicking an epidural tumor in a patient with high-risk polycythemia vera: illustrative case.

Here the authors present the case of a 43-year-old male with a history of T-cell lymphoma, which was treated with azacitidine plus cyclophosphamide, doxorubicin, vincristine, and prednisone and autologous hematopoietic cell transplant, and high-risk polycythemia vera (PCV) presenting with severe lower-back pain radiating to the bilateral legs with associated lower-extremity weakness and splenomegaly. T2-weighted magnetic resonance imaging revealed multilevel epidural lesions involving T1-10 and S1-2. Because of severe spinal canal stenosis, the patient underwent surgical decompression of T5-7, with immediate postoperative alleviation of the lower-extremity pain and complete resolution of the lower-leg weakness. Biopsy results revealed extramedullary hematopoiesis (EMH) mimicking a spinal epidural tumor. EMH is radiosensitive and displays a rapid response to low dosages, so the patient was further treated with palliative radiation therapy for residual tumors and symptom alleviation, as well as hydroxyurea and corticosteroids as indicated for cytoreduction. EMH associated with PCV or myeloproliferative conditions occurring within the spine is a rare phenomenon without a standard treatment approach. https://thejns.org/doi/10.3171/CASE23659.

Hydroxyapatite Crystal Deposition Disease with Multiple Joint Involvement Resulting in Severe Lumbar Spinal Canal Stenosis: A Case Report

Objectives: To describe a rare complication of hydroxyapatite (HA) crystal deposition disease (HADD) – spinal canal stenosis. To discuss clinical features and surgical management of this entity.

Spinal Cord Compression Revealing a Case of Metastasis of Burkitt Lymphoma

Burkitt lymphoma is the most frequent non-Hodgkin lymphoma in children and adolescents. The disease can involve all organs, although spinal cord involvement in the Burkitt lymphoma is exceptional and only a few cases are reported. We report a case of Burkitt lymphoma revealing by spinal cord compression in a 4-year-old patient. Magnetic resonance imaging (MRI) of the spine revealed a mass in the spinal intradural extramedullary space with severe spinal canal stenosis in T6-T9. Neuromeningeal involvement in Burkitt's lymphoma often represents a secondary location and defines an advanced stage of the disease. The child responded well to chemotherapy and is on remission.

EVALUATION OF THERAPEUTIC EFFICACY OF TRANSFORAMINAL EPIDURAL STEROID INJECTION AND SUBPEDICULAR STEROID INJECTION IN PATIENTS WITH PROLAPSED INTERVERTEBRAL DISC (PIVD) WITH CORRESPONDING LEVEL RADICULOPATHY.

Background: Lumber prolapsed intervertebral disc induce radiating pain in lower limbs, for which epidural steroid injection is one of the safe and effective therapeutic option. This prospective study compares the results of 2 different techniques of transforaminal epidural steroid injection (TFESI) and subpedicular steroid injection in patients with prolapsed intervertebral disc (PIVD) in relieving lumbar radicular pain. Methods: Records of 80 patients who had undergone transforaminal and subpedicular epidural steroid injection for lumbar radicular pain were analyzed. Visual analogue scale (VAS) score were measured at before procedure and at 4th day post procedure and 2, 4, 6 and 24 weeks thereafter and straight leg raise test (SLRT) were measured before procedure, 4th day and 4 week post procedure. Results:At 24 weeks, the VAS was signicantly lower than the baseline in both groups; VAS in the TFESI group was signicantly lower than VAS in the subpedicular group at 6 and 24 weeks. SLRT score was signicantly higher in the TFESI group and subpedicular ESI group through the 4-week time point (P= 0.0021 at 4th day; P= 0.0001 at 4 weeks). At the end of 24 weeks, a signicantly greater number of patients in the TFESI group and subpedicular ESI showed difference In VAS (P = 0.0003). Conclusions: At the end of 24 weeks, TFESI appears to be a superior technique in relieving lumbar radicular pain in PIVD patients and could be an alternative to the subpedicular approach in severe spinal canal stenosis when it is hard to place the needle in the anterior epidural space through the safe triangle.

MODIFIED OSWESTRY DISABILITY INDEX (ODI) IN ASSESSING MAGNETIC RESONANCE IMAGING FINDINGS IN LUMBAR DEGENERATIVE DISEASES

INTRODUCTION: Lumbar degenerative disease is one of the common causes for low back pain may cause debilitation. Mild degenerative changes of spine are physiological and should be considered pathological only if these abnormalities are causing symptoms and clinical signs. Many structural components of spine are responsible for low backache of degenerative etiology including the intervertebral disc, vertebral periosteum, facet joints and spinal ligaments. The most frequent and common location of these changes is lumbar spine due to heavy mechanical stress. The aim of AIM: this study is to establish a relationship between the MRI changes in established lumbar degenerative disease and the severity of self-assessed modied Oswestry Disability Index in patients. MATERIALS & METHODS: Study included 120 consenting patients of all age groups irrespective of sex, having low back pain who were referred for MRI lumbar spine. Standard spine protocol sequences like T1- weighted image T2-weighted image Fluid-sensitive sequence, such as STIR or fat suppressed T2-weighted image Gradient-echo image Post gadolinium T1- weighted image were performed and the ndings were correlated with Modied Oswestry Disability Index(ODI). Disc degenerative changes is common RESULTS: among 40 – 60 years age group. Females are more commonly affected than males. Central is the most type of disc bulge. L5-S1 is the most common level to be affected by disc bulge. Annulus ssure/ tear is most common in L4-L5 intervertebral disc level. Type I degenerative end plate changes are most common in L5-S1 intervertebral disc level. Whereas typeII degenerative end plate changes are most common in L4-L5 intervertebral disc level. Facetal Arthropathy changes are common in L4- L5 levels both in grade I and II. Spinal canal stenosis is common in L4-L5 levels both in grade I and II. Oswestry disability score is higher in patients with severe spinal canal stenosis. So, there is signicant correlation between spinal canal narrowing and Oswestry disability index is seen. So ODI score acts as an invaluable tool for assessing patients' functional disability. MRI is better for the CONCLUSION: identication and grading the severity of lumbar degenerative disease. Oswestry disability index is a better tool for assessing patients' functional disability.

A comparative study on efficacies of posterior microscopic mini-open and open technique for thoracolumbar burst fractures with severe traumatic spinal stenosis

PurposeThis study compares the efficacies of minimally invasive decompression by posterior microscopic mini-open technique combined with percutaneous pedicle fixation (hereafter MOT) to traditional open surgery in patients with severe traumatic spinal canal stenosis resulting from Arbeitsgemeinschaft für Osteosynthesefragen (AO) type A3 or A4 thoracolumbar burst fractures and provides references for clinical treatment.MethodsIn total, 133 patients with severe traumatic spinal canal stenosis caused by AO type A3 or A4 thoracolumbar burst fractures who underwent MOT (group A) or traditional open surgery (group B) were retrospectively enrolled. The demographic and radiological data of the two groups were analyzed and compared.ResultsA total of 64 patients were finally recruited in this study. There were no significant differences in gender, age, follow-up time, injury mechanism, injury level, AO classification, American Spinal Injury Association (ASIA) score, visual analogue scale (VAS) score, and duration of hospital stay between the two groups (P > 0.05). After the procedures, the prevertebral height ratio (PHR), the Cobb angle, and the mid-sagittal canal diameter compression ratio (MSDCR) were significantly improved (P < 0.05) in both groups. However, group A demonstrated less intraoperative bleeding and a greater VAS score improvement postoperatively and at the last follow-up but involved a longer operation time (P < 0.05). The PHR and the Cobb angle in the two groups showed no significant difference postoperatively and at the last follow-up (P > 0.05). In contrast, a significant improvement in MSDCR was observed at the last follow-up when compared with the postoperative value (P < 0.05). However, the Cobb angle in group A was better maintained than in group B at the last follow-up (P < 0.05), while the MSDCR in group B demonstrated a greater improvement at the last follow-up than in group A (P < 0.05).ConclusionsBoth the MOT and traditional open surgery are effective treatment options for AO type A3 and A4 thoracolumbar burst fractures with severe traumatic spinal stenosis. The advantages of MOT include the minimally invasive procedure, extremely fine spinal canal decompression, less intraoperative bleeding, and significant pain relief. We suggest that MOT should be preferentially performed for AO type A3 or A4 thoracolumbar burst fractures with severe traumatic spinal stenosis.

Which factor can predict the effect of indirect decompression using oblique lumbar interbody fusion?

The aim of this study was to investigate the association between various factors of indirect decompression. Previous studies have demonstrated the effectiveness of indirect decompression. There is no consensus regarding the predictive factors for indirect decompression. Facet joint gap (FJG) and bulging disc thickness (BDT) have never been considered as factors in other studies.We retrospectively reviewed 62 patients who underwent OLIF L4/5 between April 2018 and September 2020. The relationships between cross-sectional area (CSA) change, CSA change ratio, spinal stenosis grade, and various factors were studied. Various factors related to indirect decompression, such as ligament flavum thickness (LFT), foraminal area (FA), disc height (DH), bulging disc thickness(BDT), and facet joint gap (FJG), were measured.CSA increased from 69.72 mm2 preoperatively to 115.95 mm2 postoperatively (P < .001). BDT decreased from 4.97 mm preoperatively to 2.56 mm postoperatively (P < .001). FJG (Right) increased from 2.99 mm preoperatively to 4.38 mm postoperatively (P < .001). FJG (Left) increased from 2.95 mm preoperatively to 4.52 mm postoperatively (P < .001). The improvement of spinal stenosis grade was as follows: 1 point up group, 38 patients; 2 point up groups, 19 patients; and 3 point up groups, 3 patients. The correlation factors were prespinal stenosis grade (0.723, P < .00), CSA change (0.490, P < .00), and FJG change ratio (left, 0.336, P < .008).FJG showed statistical significance with indirect decompression. Indirect decompression principles might be utilized in patients with severe spinal canal stenosis (even grade 4).

Predictive parameters for successful indirect decompression of the lateral lumbar interbody fusion (LLIF) surgery

BackgroundPreoperative radiographic parameters in selecting the best surgical candidates for indirect decompression in the lateral lumbar interbody fusion (LLIF) surgery is considered one of the important concerns; there is a paucity of literature concerning this topic. This study aimed to find preoperative radiographic parameters that correlate with successful indirect decompression. MethodsWe retrospectively reviewed patients who underwent LLIF surgery for various degenerative spine diseases at our institute. All patients included in the study had completed radiographs with preoperative and postoperative magnetic resonance imaging (MRI) within 3 months after surgery. Patients were categorized into success and failed indirect decompression using the cross-sectional area for pre and postoperative MRI scans. Various parameters were used to find an association for successful indirect decompression. ResultsSixty patients were included in our study with a total of 77 levels. Over two-thirds of patients (41/60, 68.3%) underwent oblique lateral lumbar interbody fusion or extreme lateral lumbar interbody fusion with posterior screw fixation. Of the 77 levels for which LLIF was performed, successful indirect decompression was attained in 38 levels and failed indirect decompression in 39 levels (49.3% success rate). Five parameters were significantly different between the success group and failed group. Only the cross-sectional area of the thecal sac (CSA) was significantly different as determined by a binary logistic mixed-effect regression model. Adding cut-point value to ROC curve of CSA, if CSA ≤ 106.97 mm2, it resulted in 82.14% sensitivity, and 72.41% specificity. ConclusionLLIF showed significant improvement in average postoperative parameters. However, the cross-sectional area of the thecal sac (CSA) was the only parameter that inversely correlated with successful indirect decompression with LLIF. We concluded that even patients with severe spinal canal stenosis are good candidates for LLIF surgery owing to its indirect decompression.

Navigating Neurological Recovery with NeuroAiD in Severe Spinal Cord Injury: A Noteworthy Novelty?

Background and aim: NeuroAiD is a Chinese medicinal supplement containing nine herbal ingredients. Besides neuroprotection, NeuroAiD also promotes neuroregeneration. These have been extensively investigated both in vivo and in vitro. It has gained favour, especially amongst stroke and traumatic brain injury populations, to facilitate neuro recovery. To our knowledge, the SATURN study by Kumar et al. is the only study that has shifted the focus of NeuroAiD usage to the spinal cord injury (SCI) population. We present a case of complete tetraplegia who regained some neurological recovery following NeuroAiD supplementation. Methods: A 34-year-old police officer was involved in a helicopter crash in February 2020. He sustained a C6 vertebra burst fracture with severe spinal canal stenosis, C5 and C7 vertebrae fracture, and extensive cord oedema from C4 till T1, resulting in C4 AIS A Tetraplegia. Surgical fixation was performed on day 3. Upon admission to the rehabilitation ward at the end of March 2020, the best sensory level was C4, best motor C5, and total motor score 12. He regained some recovery throughout the stay, although he remained as C4 AIS A until discharged in April 2020. He started taking 2 capsules of NeuroAiD three times daily in May 2020 for six months. We followed him up until 1-year post-event to monitor his response. Results: The best sensory level improved to C5 at six months and C6 at 1-year, whilst the best motor level improved to C6 at six months and 1-year. The total motor score increased to 17 at six months and subsequently 22 at 1-year post-event. Overall, the neurological level of injury improved from C4 at three months to C5 at six months and C6 at 1-year post-event. AIS classification, however, remained A. Conclusion: The promising role of NeuroAiD in promoting neuro recovery in SCI is noteworthy for further exploration and investigation.

Factors Associated with Treatment Success After Interlaminar Epidural Steroid Injection for Cervical Radicular Pain.

To investigate the demographic, clinical and radiological findings associated with treatment success after interlaminar epidural steroid injection (ILESI) in radicular pain induced by cervical disc herniation. In this retrospective study, the data of patients who received cervical ILESI between January 2017 and June 2021 were screened. Of 223 patients, 92 with unilateral radicular neck pain due to cervical disc herniation were included. Demographic data, symptom duration, and numerical rating scale scores at baseline, at three weeks, three months, and six months after treatment were collected from the medical records of the patients. Disc herniation level, cervical axis, disc height, presence and degree of spinal canal and neural foraminal stenosis, vertebral endplate signal change, and definitive presence of uncovertebral and facet osteoarthritis were evaluated using cervical spine magnetic resonance imaging. Treatment success was determined as ?50% reduction in pain scores at six months compared to baseline. Data of 92 patients (27 men, 65 women) were included. The mean age was 50.82 ± 10.22 years, and the median symptom duration was 12 (4.25 to 20) months. At six months after ILESI, treatment was successful in 58 (58.7%) patients and unsuccessful in 34 (41.3%) patients. Multivariable logistic regression analysis was performed to identify the factors associated with treatment success at six months post-injection. In the final model, neural foraminal stenosis (non-severe vs. severe) and spinal canal stenosis (non-severe vs. severe) were significantly associated with the treatment success (OR=3.02, 95% CI=1.40?10.95, p=0.009; OR=5.31, 95% CI=1.77?15.85, p=0.003). Treatment success of cervical ILESI at six months is favorable. However, the presence of severe neural foraminal and spinal canal stenosis is associated with a reduced likelihood of treatment success.

Osteoblastoma of the lumbar spine in an adolescent: A case report and review of literature

Introduction: Osteoblastomas are primary bone tumors representing 1% of all bone tumors and 10% of all spinal osseous neoplasms with a predilection for posterior elements. Case Report: A 13-year-old boy with insidious backache for six months presented with progressive radiating paraesthesia and claudication, restricted lumbar motion and positive straight leg test bilaterally with weakness of left ankle dorsiflexion. Radiograph showed an subtle expansile lytic lesion in the L3 posterior elements. CT and MRI revealed a space-occupying lesion of the L3 vertebra lamina, involving the left pedicle causing severe spinal canal stenosis. Excision of the posterior elements of the L3 vertebra including the facet and left pedicle and short segment fixation from L2-L4 using autogenous rib was done. At two years postoperatively, he was asymptomatic, neurologically normal, showing radiographic evidence of union with no recurrence. Conclusions: Autogenous structural rib can be used for posterolateral fusion after osteoblastoma excision with potential instability.

Non-traumatic Causes of Brown-sequard Syndrome: A Case Series and Clinical Update With Systematic Review

Background and Importance: Brown-Sequard Syndrome (BSS) is a rare neurological condition resulting from a hemisection injury to or unilateral compression on the spinal cord. The common causes of BSS that are amenable to be treated surgically can be divided into traumatic and non-traumatic injuries. Traumatic injuries are often reported as the main cause of BSS. However, non-traumatic injuries of the spinal cord are more seen in recent years. This study aims to classify and update surgically treatable causes of BSS. Case Presentation: Retrospective data of 17 patients operated for BSS between 2008 and 2020 were included. The long-term outcomes of these patients were evaluated. In addition, a comprehensive search in PubMed, Scopus, and CINAHL was conducted for the retrieval of all relevant studies. Results: Magnetic Resonance Image (MRI) of our patients revealed Cervical Disc Herniation (CDH), spinal canal stenosis with cervical spondylosis, epidural hematoma, and ossification of the posterior longitudinal ligament. The postoperative outcomes of our cases ranged from partial to complete recovery. While the patients with acute epidural hemorrhage achieved complete recovery after surgery, neurological deficits in the other patients, especially those with severe cervical spinal canal stenosis, persisted despite adequate surgical decompression. The systematic literature review revealed that CDH is the most common non-traumatic surgically treatable cause of BSS, followed by spinal cord herniation and spinal epidural hematoma. Conclusion: Non-traumatic injuries of the spinal cord accompanied by narrowed cervical spinal canal pathologies are prominent surgically treatable causes of BSS. Contrary to the definition made 100 years ago, BSS can occur spontaneously due to underlying pathologies rather than major traumatic injuries.

Conus Medullaris Syndrome due to Ligamentum Flavum Thickening and Intervertebral Disc Bulging

Abstract A 72-year-old male with past medical history of common chronic illness presented to a rehabilitation clinic with a chief complaint of trouble walking and falls over 6 months. On detailed questioning, he has developed progressive bladder incontinence and unable to achieve erection. Physical exam revealed normal rectal tone and minimal bladder retention. Lumbar spine MRI shows severe spinal canal stenosis, with posterior elements impinging on the Conus Medullaris. He underwent T9-11 laminectomy. Upon follow up nearly 2-years post-operation, he is continent of bladder and able to walk with a rolling walker. The main differential diagnosis was Cauda Equina syndrome. Although both syndromes are surgical emergencies, accurate diagnosis would affect the surgical approach and outcome.

Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part.

Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part.

Desflurane for management of decompressive laminectomy in a patient with hereditary spastic paraplegia: a case report

BackgroundHereditary spastic paraplegia (HSP) is a rare, genetic neurodegenerative condition. Thus far, ideal anesthetic management is not established for patients with HSP; therefore, careful selection and dosage of anesthetic agents is required.Case presentationA 54-year-old woman with HSP, who was diagnosed with severe lumbar spinal canal stenosis, underwent decompressive laminectomy to relieve her back pain. Preoperatively, she experienced slight difficulty in walking independently; however, she exhibited no other dysfunction. Anesthesia was maintained with desflurane after tracheal intubation. Rocuronium and sugammadex were used for neuromuscular blockade and reversal, respectively, with neuromuscular monitoring equipment. The patient showed uneventful postoperative recovery without signs of neurological deterioration after extubation.ConclusionsOur successful experience in this case implies that, for patients with neuromuscular diseases, including HSP, desflurane may be an option for anesthetic management; moreover, careful assessment (e.g., medical condition, bispectral index, and train-of-four) should be performed prior to administration of anesthesia.

Tremors as an atypical presentation of cervical myelopathy

Tremors are common especially in the elderly population. However, tremors occurring secondary to cervical myelopathy are rarely reported. We report the case of a 91-year-old gentleman who was admitted to the neurology service with chief complaints of bilateral upper- and lower-limb tremors. This had progressed rapidly over 2 weeks to the extent that he was not able to feed himself and was unable to walk without support. An initial working diagnosis of Parkinson's disease was made but was later dismissed because of the atypical features. A magnetic resonance imaging of cervical spine was subsequently performed which revealed a large disc herniation at C3–C4 level, causing severe spinal canal stenosis and cord compression. Given this radiological presentation and the absence of other objective pathologies on further investigations, we correlated his symptoms to the underlying cervical cord compression. He underwent anterior cervical discectomy and fusion which led to complete resolution of tremors by 8 weeks postsurgery. His unsteadiness eventually resolved, and there was no recurrence of tremors throughout our follow-up period. This case highlights a rare atypical presentation of cervical myelopathy as peripheral limb tremors. The diagnostic dilemma, management strategies, and hypothesis to explain this phenomenon are discussed.