Central Spinal Canal Research Articles

The effectiveness of hesperidin on bisphenol A-induced spinal cord toxicity in a diabetic rat model

The potential health risks of bisphenol A (BS) and diabetes (DI) has sparked public concern due to be ubiquitous worldwide. The purpose of this study was to investigate the detrimental impact of BS (200 mg/kg) on the spinal cord tissue in a rat diabetic model. We also evaluated the antioxidant capacity of hesperidin (HS) (100 mg/kg) on spinal cord in BS-treated diabetic rat. Seventy male Wistar albino rats, weighing 180–230 g and 8 weeks old, were randomly chosen, and assigned into seven groups of 10 rats: Control (KON), BS, DI, BS + DI, HS + BS, HS + DI, HS + BS + DI. At the end of the 14-day experimental period, all samples were examined using stereological, biochemical, and histopathological techniques. Our biochemical findings revealed that the SOD level was significantly lower in the BS, DI, and BS + DI groups compared to the KON group (p < 0.05). Compared to the KON group, there was a significant decrease in the number of motor neurons and an increase in the mean volume of central canals in the BS, DI, and BS + DI groups (p < 0.05). In the HS + BC group than the BS group and in the HS + DI group than the DI group, SOD activity and the number of motor neurons were significantly higher; also, the mean volume of spinal central canal was significantly lower (p < 0.05). The novel findings gathered from the histopathological assessment supported our quantitative results. Our speculation was that the exposure to BS and DI was the main cause of neurological alteration in the spinal cord tissues. The administration of HS had the therapeutic potential to mitigate spinal cord abnormalities resulting from BS and DI. However, HS supplementation did not alleviate spinal cord complications in BS-treated diabetic rats.

Isolated lumbar myxopapillary ependymoma Case-report

INTRODUCTION Spinal ependymoma is described typically as an intramedullary tumor arising from ependymal cells lining the ventricles and the central spinal canal. Intradural extramedullary (IDEM) ependymomas subtype are extremely rare. (1) Case-report: It’s about a 32-year-old patient with no past medical history who was admitted to our neurosurgical department for non-systematized bilateral lumbocrural pain set on upon an intense sport activity limiting his ability of walking with a perimeter reduced to 50 meters deteriorating progressively over 6 months.

Lumbar Dorsal Root Ganglion Pulsed Radiofrequency for Spinal Stenosis with an Atypical Fluoroscopic Neurogram: A Case Study

Background: We present a case of an atypical fluoroscopic neurogram pattern for complex chronic axial low back pain during a lumbar dorsal root ganglia (DRG) pulsed radiofrequency stimulation. Case Report: A 70 year old female with a history of complex chronic axial low back pain with radicular leg pain. Initially her pain was described as intermittent, burning, and sharp with an intensity of 9/10 on the Numeric Rating Scale (NRS). This pain worsens with ambulation, lumbar extension, turning, weight bearing and spinal loading activities. MRI imaging noted lumbar anterolisthesis, moderate to severe central spinal stenosis, and mild bilateral neural foraminal space narrowing. From these findings, her pain is likely secondary to components of sacroiliac (SI) joint dysfunction, lumbar facetogenic pain, lumbar radiculitis, and spinal stenosis with neurogenic claudication. A multimodal and multidisciplinary rehabilitation approach involving minimally invasive interventional procedures and medication management was implemented with varying pain relief. She responded to L5 transforaminal epidural nerve root injections, SI joint prolotherapy, and sacral lateral branch radiofrequency ablation. She completed bilateral L5 DRG pulsed radiofrequency stimulation, which did not provide radicular pain relief. We performed a unilateral L4 DRG pulsed radiofrequency stimulation, which revealed an atypical L4 fluoroscopic neurogram pattern. At the 3 month follow up she reported the pain severity to have a NRS between 7-8/10. At 4 months, the pain severity was reported to have a NRS between 4-6/10 with subjective improvements with her daily activities. Conclusion: In a normal transforaminal epidural fluoroscopic neurogram, the anteroposterior view should demonstrate contrast spread medially around the pedicle and laterally following the exiting nerve root. In the case of this patient the combined anatomical presentation of anterolisthesis, central spinal canal stenosis, and circumferential disc bulging are all potential reasons for insufficient contrast passage resulting in the atypical neurogram.

Finite element mechanical analysis of ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery

BackgroundUnilateral bilateral endoscopic spine surgery (UBE) is often performed to treat lumbar spinal stenosis and disc herniation. It has become a prominent method in endoscopic spine surgery because of its very low learning curve and broader operative field of vision. Currently, the ipsilateral approach and contralateral approach have been established for disc herniation in the foraminal area, intervertebral foramen region, or pedicle region. The contralateral method offers many benefits over the ipsilateral approach, including less bone labour during microsurgical decompression and the preservation of facet joints. However, because it uses the interlaminar window approach, it inevitably involves osteotomy of the patient’s superior and inferior articular processes, which may result in corresponding deterioration in the spine’s biomechanical stability and subsequent adjacent facet joint diseases caused by facet joint degeneration postoperatively.ObjectiveAs a result, the purpose of this work is to use a finite element model to evaluate how the ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery affect spinal stability while treating identical intervertebral disc herniation.Study designIn this study, a three-dimensional lumbar-sacral spine model was built and verified. Osteotomies were conducted for armpit-type lumbar disc herniation (LDH), periradicular-type LDH, and shoulder-type LDH. Postoperative lumbar spine models of the ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery were developed. The von Mises stress on the endplate, shear force on the annulus fibrosus, pressure inside the intervertebral disc, and range of motion (ROM) of the L3 segment were all determined. The results of our well-validated model showed that osteotomy done in the ipsilateral approach deteriorated most biomechanical metrics.ResultsIn the majority of loading conditions, the contralateral approach caused the intervertebral disc’s biomechanical properties to increase, and the ipsilateral approach caused the intervertebral disc’s biomechanical properties to increase sharply more than the contralateral approach.ConclusionThe contralateral approach, which is now extensively employed in unilateral bilateral endoscopic spine surgery, may be regarded as an ideal surgical alternative for treating lumbar disc herniation without producing iatrogenic instability. This approach has a low facet joint reduction rate, minimum soft tissue injury, and precisely identifies the midline of the central spinal canal during the retraction of the thecal sac and nerve roots.

Neurological disorders imitating spinal stenosis in elderly patients. Series of clinical observations

Spinal stenosis is a pathological narrowing of the central spinal canal, lateral pocket, or intervertebral foramen due to age‑related changes, including pathology of the discs, facet joints, ligament hypertrophy, osteophyte formation and destruction of the arches. Clinically, the disease can manifest itself with pain, as well as numbness, or weakness in the arms or legs. The complexity of differential diagnosis is due to the lack of correlation between the degree of stenosis according to neuroimaging data and the severity of clinical manifestations. Spinal stenosis among 21 % of people may have an asymptomatic course.Spinal stenosis has to be differentiated from atherosclerosis of the vessels of the lower extremities, rheumatoid arthritis, piriformis syndrome, sacroiliitis, spondylitis/spondylodiscitis, amyotrophic lateral sclerosis, Guillain–Barré syndrome and other polyneuropathies. Isolated weakness should be of a particular concern in the clinical picture. Muscle hypotrophy, brisk tendon reflexes, the presence of pyramidal signs, muscle fasciculations, as well as patients’ complaints of simultaneous weakness in both the upper and lower extremities accompany them.We present and discuss three clinical cases of patients with a presumptive diagnosis of spinal stenosis. Two of them were held surgical treatment, which did not produce the expected result. Subsequently, it was found that the cause of progressive muscle weakness in the limbs was amyotrophic lateral sclerosis in two patients and the third one had Guillain–Barré syndrome, a form of acute demyelinating polyneuropathy.

Comparison of Motor Evoked Potentials Neuromonitoring Following Pre- and Postoperative Transcranial Magnetic Stimulation and Intraoperative Electrical Stimulation in Patients Undergoing Surgical Correction of Idiopathic Scoliosis.

The relationships between the results of pre- and intraoperative motor evoked potential recordings during neuromonitoring and whether idiopathic scoliosis (IS) surgical correction improves the spinal efferent transmission have not been specified in detail. This study aims to compare the results of surface-recorded electromyography (EMG), electroneurography (ENG, M, and F-waves), and especially motor evoked potential (MEP) recordings from tibialis anterior muscle (TA) bilaterally in 353 girls with right idiopathic scoliosis (types 1-3 according to Lenke classification). It has not yet been documented whether the results of MEP recordings induced by transcranial single magnetic stimulus (TMS, pre- and postoperatively) and trains of electrical stimuli (TES; intraoperatively in T0-before surgery, T1-after pedicle screws implantation, and T2-after scoliosis curvature distraction and derotation following two-rod implantation) can be compared for diagnostic verification of the improvement of spinal cord neural transmission. We attempted to determine whether the constant level of optimal anesthesia during certain surgical steps of scoliosis treatment affects the parameters of MEPs recorded during neuromonitoring procedures. No neurological deficits have been observed postoperatively. The values of amplitudes but not latencies in MEP recordings evoked with TMS in IS patients compared before and after surgery indicated a slight improvement in efferent neural transmission. The results of all neurophysiological studies in IS patients were significantly asymmetrical and recorded worse on the concave side, suggesting greater neurological motor deficits at p = 0.04. The surgeries brought significant improvement (p = 0.04) in the parameters of amplitudes of sEMG recordings; however, the consequences of abnormalities in the activity of TA motor units were still reflected. ENG study results showed the symptoms of the axonal-type injury in peroneal motor fibers improving only on the concave side at p = 0.04, in parallel with F-wave parameters, which suggests that derotation and distraction might result in restoring the proper relations of the lumbar ventral roots in the spinal central canal, resembling their decompression. There were no significant differences detected in the amplitudes or latencies of MEPs induced with TMS or TES when comparing the parameters recorded preoperatively and intraoperatively in T0. The amplitudes of TES-evoked MEPs increased gradually at p = 0.04 in the subsequent periods (T1 and T2) of observation. A reduction in MEP latency at p = 0.05 was observed only at the end of the IS surgery. Studies on the possible connections between the level of anesthesia fluctuations and the required TMS stimulus strength, as well as the MEP amplitude changes measured in T0-T2, revealed a lack of relationships. These might not be the factors influencing the efferent transmission in spinal pathways beside the surgical procedures. Pre- (TMS-evoked) and intraoperative (TES-evoked) recordings are reliable for evaluating the patient's neurological status before and during surgical scoliosis correction procedures. An increase in MEP amplitude parameters recorded on both sides after scoliosis surgery proves the immediate improvement of the total efferent spinal cord transmission. Considering comparative pre- and postoperative sEMG and ENG recordings, it can be concluded that surgeries might directly result in additional lumbar ventral root decompression. We can conclude that MEP parameter changes are determined by the surgery procedures during neuromonitoring, not the anesthesia conditions if they are kept stable, which influences a decrease in the number of false-positive neuromonitoring warnings.

Comparison of ligamentum flavum thickness between central and lateral lesions in a patient with central lumbar spinal canal stenosis.

Thickened ligamentum flavum has been considered as a major cause of central lumbar spinal canal stenosis (CLSCS). Previous studies have demonstrated that ligamentum flavum thickness (LFT) is correlated with aging, degenerative spinal stenosis, and disc degeneration. Thus, hypertrophy of the ligamentum flavum is a major cause of CLSCS, and measurement of LFT has been considered a morphologic parameter in the diagnosis of CLSCS. To our knowledge, comparison of LFT between central and lateral lesions has not been reported. In addition, no research has analyzed best clinical cutoff values of central ligament flavum thickness (CLFT) and lateral ligament flavum thickness (LLFT). This study aimed to compare CLFT with LLFT in patients with CLSCS and further compare the CLFT and LLFT findings between the 2 groups to analyze LFT variation. Both CLFT and LLFT samples were collected from 101 participants with CLSCS and from 103 participants in the control group who underwent lumbar magnetic resonance imaging without evidence of CLSCS. Axial T2-weighted lumbar magnetic resonance scans were acquired at the L4 to 5 facet joint level from each participant. Average CLFT value was 2.25 ± 0.51 mm in the control group and 4.02 ± 0.74 mm in the CLSCS group. Average LLFT value was 2.50 ± 0.51 mm in the control group and 3.38 ± 0.66 mm in the CLSCS group. CLSCS patients had significantly higher CLFT and LLFT (both P < .001). Regarding the validity of both CLFT and LLFT as predictors of CLSCS, a receiver operating characteristic estimation revealed that the most suitable cutoff value for CLFT was 3.10 mm, with sensitivity of 95.0%, specificity of 94.2%, and an area under the curve of 0.97. The best cut-off value of LLFT was 2.92 mm, with sensitivity of 78.2%, specificity of 77.7%, and area under the curve of 0.87. We have 4 important new findings: The mean CLFT is significantly lower than that of the mean LLFT in the normal control group; CLFT and LLFT are both significantly associated with CLSCS; Increase rate of CLFT is faster than that of LLFT in the CLSCS group; and CLFT is a more sensitive measurement parameter to predict CLSCS than LLFT.

A rare case of priapism secondary to intervertebral disc prolapse: Case report and literature review

Abstract Lumbar canal stenosis (LCS) is characterized by narrowing of the central spinal canal or lateral recesses and foramina, leading to compression of nerve tissues. It causes neurogenic claudication, which manifests as back pain and variety of lower limb symptoms such as pain, tingling/numbness, or paresthesia on ambulation. A rare symptom of LCS is priapism, which is thought to occur due to parasympathetic dysfunction. We describe a case of a 45-year-old man, who presented with neurogenic claudication and intermittent priapism due to lumbar intervertebral disc prolapse, which resolved completely after surgical decompression, and literature review for the same.

Meningoencephalomyelitis associated with foreign plant material in a dog: case report and brief literature review.

Neurologic disease associated with migration of plant material is reported infrequently in dogs. Here we describe meningoencephalomyelitis associated with foreign plant material in a 2-y-old castrated male West Highland White Terrier dog with acute neck pain. Magnetic resonance imaging revealed spinal meningeal contrast enhancement. Although clinical signs improved after treatment with steroids, the dog was readmitted for further evaluation 3-mo later and was euthanized after generalized epileptic seizures. Autopsy findings consisted of coalescing, pus-filled, neuroparenchymal cavitations surrounded by hemorrhage in the left caudal colliculus and rostral left cerebellar hemisphere. Histologically, lesions consisted of necrosis and suppuration, which surrounded a 1 × 2-mm foreign body morphologically consistent with plant material and clusters of gram-positive bacterial cocci. Affected areas were surrounded by reactive astrocytes, fibrous connective tissue, and mixed inflammatory infiltrates. Areas of hemorrhage and infiltration by neutrophils and foamy macrophages with fibrinoid change of small capillaries were observed in the adjacent neuroparenchyma. The inflammation extended to the perivascular spaces in the leptomeninges (mesencephalon, cerebellum, and brainstem, and spinal cord) and spinal central canal. Anaerobic bacterial culture of frozen samples of cerebellum yielded heavy growth of Bacteroides pyogenes.

Early-effectiveness of unilateral biportal endoscopic laminectomy in treatment of two-level lumbar spinal stenosis

To analyze the early effectiveness of unilateral biportal endoscopy (UBE) laminectomy in the treatment of two-level lumbar spinal stenosis (LSS). The clinical data of 98 patients with two-level LSS treated with UBE between September 2020 and December 2021 were retrospectively analyzed. There were 53 males and 45 females with an average age of 59.9 years (range, 32-79 years). Among them, there were 56 cases of mixed spinal stenosis, 23 cases of central spinal canal stenosis, and 19 cases of nerve root canal stenosis. The duration of symptoms was 1.5- 10 years, with an average of 5.4 years. The operative segments were L 2, 3 and L 3, 4 in 2 cases, L 3, 4 and L 4, 5 in 29 cases, L 4, 5 and L 5, S 1 in 67 cases. All patients had different degrees of low back pain, among of which 76 cases were with unilateral lower extremity symptoms and 22 cases were with bilateral lower extremity symptoms. There were 29 cases of bilateral decompression in both segments, 63 cases of unilateral decompression in both segments, and 6 cases of unilateral decompression and bilateral decompression of each segment. The operation time, intraoperative blood loss, total incision length, hospitalization stay, ambulation time, and related complications were recorded. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months after operation, and at last follow-up. The Oswestry disability index (ODI) was used to evaluate the functional recovery of lumbar spine before operation and at 3 months and last follow-up after operation. Modified MacNab criteria was used to evaluate clinical outcomes at last follow-up. Imaging examinations were performed before and after operation to measure the preservation rate of articular process, modified Pfirrmann scale, disc height (DH), lumbar lordosis angle (LLA), and cross-sectional area of the canal (CAC), and the CAC improvement rate was calculated. All patients underwent surgery successfully. The operation time was (106.7±25.1) minutes, the intraoperative blood loss was (67.7±14.2) mL, and the total incision length was (3.2±0.4) cm. The hospitalization stay was 8 (7, 9) days, and the ambulation time was 3 (3, 4) days. All the wounds healed by first intention. Dural tear occurred in 1 case during operation, and mild headache occurred in 1 case after operation. All patients were followed up 13-28 months with an average of 19.3 months, and there was no recurrence or reoperation during the follow-up. At last follow-up, the preservation rate of articular process was 84.7%±7.3%. The modified Pfirrmann scale and DH were significantly different from those before operation ( P<0.05), while the LLA was not significantly different from that before operation ( P=0.050). The CAC significantly improved ( P<0.05), and the CAC improvement rate was 108.1%±17.8%. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and the differences between each time points were significant ( P<0.05). According to the modified MacNab criteria, 63 cases were excellent, 25 cases were good, and 10 cases were fair, with an excellent and good rate of 89.8%. UBE laminectomy is a safe and effective technique with little trauma and fast recovery for two-level LSS and the early effectiveness is satisfactory.

The Case Files

A ruptured dermoid can have many presentations, making it hard to diagnoseFigureFigureA 45-year-old man presented after a sudden transient loss of consciousness followed by excessive crying. He was conscious and oriented upon arrival. He had no fever, and his blood pressure was 130/80 mm Hg, heart rate was 90 bpm, respiratory rate was 20 bpm, oxygen saturation level was 100 percent, and blood sugar level was 103 mg/dL. No neurological deficit was found on examination. The patient had a sinus tract on his lower back at L2-L3. The rest of the exam was normal. The patient had no significant medical history and was not taking any medication. Neuroimaging, CT, and a brain MRI revealed disseminated lipid tissue in the frontal horn of the lateral, third, and fourth ventricles. Similar extra-axial fat intensities were also found in the frontal region and left sylvian, interpeduncular, and right CP angle cisterns. Two differential diagnoses were considered: ruptured dermoid tumor and traumatic pelvic or spinal fracture. Spinal MRI suggested an intramedullary mass lesion with lobulated margin (1.6 cm by 1.1 cm by 6.8 cm) in the conus medullaris and cauda equina, extending from the L1 to L3 vertebrae. The lesion appeared hyperintense on T2W and T1W images, which were suppressed on saturated T1 images. Evidence of intramedullary T1 and T2 hyperintense multiple foci adherent to the dorso-lumbar spinal cord suggested a ruptured dermoid. A dorsal dermal sinus tract at L2 to L3 vertebrae was noted. Rupture of a spinal dermoid cyst into the central spinal canal is rare. An intradural dermoid cyst may rupture with subsequent subarachnoid dissemination of lipid droplets. Dermoid cysts are benign tumor-like lesions comprising approximately one percent of intracranial and spinal tumors and occur slightly more often in men. Their high incidence occurs in the lumbosacral region involving the conus and cauda equina. Upper thoracic (10%) and cervical (5%) lesions are rare. Dermoids are associated with a dermal sinus in 20 percent of cases. The rupture of a dermoid cyst is a well-known phenomenon and can be spontaneous, iatrogenic, or traumatic in origin. A ruptured dermoid may have myriad presentations. Chemical and aseptic meningitis are the most common features after a rupture because of the irritating effects of the disseminated cholesterol debris. The patient may be asymptomatic or experience headache, vomiting, seizures, coma, infarct, and rarely death. A headache might occur because of the compression of adjacent structures, chemical meningitis, or hydrocephalus due to obstruction of cerebrospinal fluid pathways by lipid droplet. The mean age at presentation of such lesions is 40.6, and all cases have been reported in men. Treatment includes steroids, analgesics, antibiotics, and surgical resection of the spinal lesion.

Intraoperative neurophysiological monitoring in surgery of lumbar spinal stenosis

Background. Lumbar spinal stenosis is a pathological constriction of the central spinal canal, lateral pocket or intervertebral foramen. The complication rate of lumbar spinal stenosis surgery ranges from 10 to 24 %. In order to reduce the number of intraoperative and early postoperative complications accompanied by the development of neurological deficit, various techniques of intraoperative neurophysiological monitoring are used.Aim. Study of informativity of the use of intraoperative neurophysiological monitoring during surgical treatment of degenerative lumbar spinal stenosis based on the experience of the neurosurgical department of the Republican Clinical Hospital (Yoshkar‑Ola, Mari El Republic).Materials and methods. Thus, 69 decompressive‑stabilizing surgical interventions for degenerative lumbar spinal stenosis at the L3–L5 level, performed with intraoperative neurophysiological monitoring (free‑run electromyography, transcranial motor evoked potentials, somatosensory evoked potentials, triggered electromyography were included in the retrospective study).Results. During intraoperative neurophysiological monitoring transcranial motor evoked potentials from the legs was registered in all cases. Normal somatosensory evoked potentials were recorded in most cases, in 12 cases (17.4 %) baseline somatosensory evoked potentials were not registered due to preoperative neurological deficits and the presence of concomitant somatic pathology. 308 inserted pedicular screws were examined using the triggered electromyography. Muscle responses were registered in 31 (45 %) operations, 45 (14 %) screws. True negatives were registered with 29 (64.4 %), true positives were registered with 12 (26.7 %), and false positives were registered with 4 (8.9 %) screws. In the postoperative period no increase in motor and sensory neurological deficits was observed in all patients; no neurological signs of screw malpositioning were revealed.Conclusion. The use of multimodal intraoperative neurophysiological monitoring during surgical treatment of lumbar spinal stenosis reduces the risk of postoperative neurological complications.

Hybrid surgery of percutaneous transforaminal endoscopic surgery (PTES) combined with OLIF and anterolateral screws rod fixation for treatment of multi-level lumbar degenerative diseases with intervertebral instability

BackgroundOblique lumbar interbody fusion (OLIF) has been used to treat lumbar intervertebral instability, which has some advantages including less trauma, less blood loss, faster recovery and bigger cage. However, it usually needs posterior screws fixation for biomechanical stability, and possible direct decompression for relieving neurologic symptoms. In this study, OLIF and anterolateral screws rod fixation through mini-incision were combined with percutaneous transforaminal endoscopic surgery (PTES) for the treatment of multi-level lumbar degenerative diseases (LDDs) with intervertebral instability. The purpose of study is to evaluate the feasibility, efficacy and safety of this hybrid surgery.MethodsFrom July 2017 to May 2018, 38 cases of multi-level LDDs of disc herniation, foramen stenosis, lateral recess stenosis or central canal stenosis with intervertebral instability and neurologic symptoms undergoing one-stage PTES combined with OLIF and anterolateral screws rod fixation through mini-incision were recruited in this retrospective study. The culprit segment was predicted according to the position of patient’s leg pain and PTES under local anesthesia was performed for the culprit segment in the prone position to enlarge the foramen, remove the flavum ligamentum and herniated disc for the lateral recess decompression and expose bilateral traversing nerve roots for the central spinal canal decompression through an unilateral incision. During the operation, communicate with the patients to confirm the efficacy using VAS. And then mini-incision OLIF using allograft, autograft bone harvested in PTES and anterolateral screws rod fixation were performed in the right lateral decubitus position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using VAS. And the clinical outcomes were evaluated with ODI at the 2-year follow-up. The fusion status was assessed according to Bridwell’s fusion grades.ResultsThere were 27 cases of 2-level, 9 cases of 3-level and 2 cases of 4-level LDDs with single-level instability on the X-ray, CT and MRI. Five cases of L3/4 instability and 33 cases of L4/5 instability were included. PTES was performed for 1 segment of 31 cases (25 cases of instability segment, 6 cases of no instability segment) and 2 segments including instability segment of 7 cases. Then, all instability segments were treated using mini-incision OLIF and anterolateral screws rod fixation. The average operation duration was 48.9 ± 7.3 min per level for PTES and 69.2 ± 11.6 min for OLIF and anterolateral screws rod fixation. The mean frequency of intraoperative fluoroscopy was 6 (5–9) times per level for PTES and 7 (5–10) times for OLIF. There was a mean blood loss of 30 (15–60) ml, and the incision length was 8.1 ± 1.1 mm for PTES and 40.0 ± 3.2 mm for OLIF. The mean hospital stay was 4 (3–6) days. The average follow-up duration was 31.1 ± 4.0 months. For the clinical evaluation, the VAS pain index and the ODI showed excellent outcomes. Fusion grades based on the Bridwell grading system at 2-year follow-up were grade I in 29 segments (76.3%) and grade II in 9 segments (23.7%). One patient encountered nerve root sleeves rupture during PTES and did not confront cerebrospinal fluid leakage or other abnormal clinical symptoms. There were two cases of hip flexion pain and weakness, which was relieved during 1 week after surgery. No patients had any form of permanent iatrogenic nerve damage and a major complication. No failure of instruments was observed.ConclusionsThe hybrid surgery of PTES combined with OLIF and anterolateral screws rod fixation is a good choice of minimally invasive surgery for multi-level LDDs with intervertebral instability, which can get direct neurologic decompression, easy reduction, rigid fixation and solid fusion, and hardly destroy the paraspinal muscles and bone structures.

Spinal Central Canal Dilation in MOG Antibody-Associated Disease Versus Other CNS Demyelinating Disorders

Objective To assess the frequency of spinal cord central canal dilation on magnetic resonance imaging (MRI) in patients with myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD) myelitis compared to myelitis patients with aquaporin-4-positive-neuromyelitis optic spectrum disorder (AQP4+NMOSD) and multiple sclerosis (MS). Background In MOGAD myelitis, a sagittal T2-hyperintense line accompanied by axial T2-signal restricted to the spinal cord gray matter forming an H-sign have been recognized and occur more frequently than in AQP4+NMOSD and MS myelitis. Pseudo-dilation of the ependymal canal has also been highlighted in cases of MOGAD myelitis, but detailed studies of this are lacking. Design/Methods The spinal cord MRIs of myelitis patients with MOGAD (n = 63), AQP4+NMOSD (n = 37), and MS (n = 26) were evaluated for central canal dilation, defined as T2-hyperintensity with similar consistency to cerebrospinal fluid within a myelitis T2-lesion. Clinical data were collected from the medical record for MOGAD patients. The expanded disability status scale (EDSS) was used to quantify disability at nadir. Results The median EDSS score at nadir for the MOGAD myelitis patients was 6 (range: 0-8). MOGAD patients experienced weakness (55/63[87%]), urinary retention/incontinence (50/63[79%]), numbness/paresthesias (48/63[76%]), and stool incontinence/constipation (36/63[57%]). Central canal dilation was more frequent in patients with MOGAD (23/63[37%]) than MS (0/26[0%]); p &lt; 0.001) but did not differ from AQP4+NMOSD (14/37[38%]; p = 0.89). Spinal canal dilation resolved on follow-up axial MRI for most MOGAD (29/34[85%]) and AQP4+NMOSD (13/14[93%]) patients. Conclusions Central canal dilation is a common radiologic accompaniment of acute MOGAD and AQP4+NMOSD myelitis, but not MS myelitis. The resolution of central canal dilation on follow-up MRI in most patients suggests it is transient and related to the acute inflammatory edema. Central canal dilation may differentiate MOGAD and AQP4+NMOSD from MS. Its recognition could facilitate earlier testing for MOG-IgG and AQP4-IgG, accurate diagnosis, and treatment.

Ependymomas

Ependymal neoplasms are a heterogenous group of neoplasms arising from the progenitors of the cells lining the ventricular system and the spinal central canal. During the last few years, significant novel data concerning oncogenesis, molecular characteristics and clinical correlations of these tumours have been collected, with a strong relevance for their pathological classification. The recently published 5th edition of WHO Classification of Central Nervous System Tumours integrates this novel knowledge and represents a substantial update compared to the previous edition. Concerning supratentorial ependymomas, the previous RELA fusion-positive ependymoma has been renamed into ZFTA fusion-positive and the novel YAP1 fusion-positive ependymoma subtype has been added. Posterior fossa ependymomas should now be allocated either to the Type A or Type B subtypes based on molecular profiling or using the H3 K27me3 immunohistochemical surrogate. Regarding spinal ependymomas, a novel subtype has been added based on a distinctive molecular trait, presence of MYCN amplification, and on the unfavourable outcome. Finally, myxopapillary ependymoma is now classified as a grade 2 tumour in accordance with its overall prognosis which mirrors that of conventional spinal ependymomas. The aim of this review is to present these changes and summarize the current diagnostic framework of ependymal tumours, according to the most recent updates.

P6. Normal anatomy of the lumbar sublaminar ridge in the lateral recess with potential implications to surgical technique in degenerative spinal stenosis: a cadaveric study

<h3>BACKGROUND CONTEXT</h3> The lateral extent of the lumbar sublaminar ridge – the bony, superior insertion site of the ligamenta flava – and its topological relationship to the nerve root are not yet described in the literature. In the setting of degenerative lumbar stenosis this structure can hypertrophy and impinge the nerve root within the lateral recess even after excision of the corresponding ligamentum flavum. Failure to address this may contribute to failed lateral recess decompression. <h3>PURPOSE</h3> To provide anatomic descriptions of the normal lumbar sublaminar ridge in the lateral recess and it's potential to impact on the exiting nerve root there, with implications to surgical technique in lumbar spinal stenosis. <h3>STUDY DESIGN/SETTING</h3> This was a dissection study of preserved cadaver donor specimes from the McMaster University Department of Anatomy. <h3>PATIENT SAMPLE</h3> Fifteen donor cadavers from the McMaster University Department of Anatomy. <h3>OUTCOME MEASURES</h3> Observed anatomy of the lumbar sublaminar ridge in the lateral recess and its relations to the exiting nerve root there. <h3>METHODS</h3> Fifteen lumbar vertebrae, not obviously degenerated, were resected en bloc from three fixed adult human cadavers and then transected through the ventral base of the pedicles immediately dorsal to the floor of the central spinal canal and the PLL, leaving the posterior column and neural elements intact and articulated. The shape of the sublaminar ridge in each of these 30 lateral recesses and its relationship to the exiting nerve root were carefully examined from the ventral aspect of these specimens (ie, from the deep surface of the [laminas and] lateral recesses). <h3>RESULTS</h3> The exiting nerve root consistently crosses the sublaminar ridge immediately inferior to the mid-pedicle, lateral to the subarticular gutter and on the medial aspect of the true intervertebral foramen. A hypertrophic ridge can compress the exiting root by elevating the nerve root superiorly against the bony underside of the pedicle or displacing it anteriorly against the disc or vertebral body. <h3>CONCLUSIONS</h3> The sublaminar ridge in the lateral recess commony crosses or underscores the exiting nerve root and so if hypertrophied might potentially contribute to degenerative lumbar stenosis. Comprehensive appreciation of this anatomy and the need at surgery in the lateral recess to confirm that the exit nerve root is not compressed or elevated by the sublaminar ridge may facilitate thorough lateral recess decompression. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Magnetic Resonance Imaging Characteristics Associated with Treatment Success from Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trials Data.

ObjectiveInvestigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP).DesignAggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials.MethodsBaseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA.ResultsThe presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success.ConclusionsIn patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA.

Indirect decompression of the central lumbar spinal canal by means of simultaneous bilateral transforaminal lumbar interbody fusion for severe degenerative lumbar canal stenosis with 3 years minimum follow-up

Study designGiven the drawbacks of direct decompression for LCS, indirect decompression techniques such as oblique lateral interbody fusion from anterior/lateral approaches are gaining popularity. However, anterior/lateral approaches to the spine have risks of their own.We performed a retrospective analysis of a prospective cohort of LCS patients surgically treated in our facility. Objectives1) Reduce the technical demands of indirect decompression for severe LCS;2) Establish a reliable and simple indirect decompression technique for severe and extreme stenosis. MethodsSixty-eight spinal segments of 50 patients were operated for LCS with instability. Bilateral screw distractors were attached to pedicle screws and bilateral TLIF was performed. Laminae and ligamentum flavum were preserved. Forty-five segments with pre-op cross-sectional thecal sack area (CSA) below 100 mm2 on T2 axial MRI were sampled for this study. ResultsDecompressed levels were L2/3 in 3 cases, L3/4 in 19 cases, L4/5 in 20 cases, L5/S in 3 cases.There were no complications and no reoperations. Mean CSA increase was 75.8 mm2 (166% increase, from 58.6 mm2 pre-op to 134.4 mm2 at follow-up, p < 0.001). Mean disk space height increase was 5 mm (p < 0.001). Mean lower extremity pain visual analog scale (VAS, 10 points) improvement was 4.9 (p < 0.001), mean lower extremity paresthesia VAS improvement was 3.8 (p < 0.001). Union rate was 96%.Minimum follow-up is 3 years post-op. ConclusionPosterior approach indirect decompression by bilateral TLIF is safe, effective for treatment of lower extremity symptoms of severe and extreme LCS, not technically demanding, and has high fusion rate.

Changes in pain scores and walking distance after epidural steroid injection in patients with lumbar central spinal stenosis.

Lumbar spinal stenosis is a common degenerative disorder that is characterized by pain and neurogenic claudication. Previous studies have evaluated the effects of an epidural steroid injection (ESI) on spinal stenosis, based on changes to the spinal canal diameter.This study aimed to examine the impact of the ESI on pain scores and walking distance in patients with lumbar central spinal stenosis, stratified based on disease severity, which was graded according to the degree of cauda equina separation.We reviewed the medical records of patients who received the ESI for lumbar spinal central canal stenosis. A total of 128 patients were divided into moderate and severe groups, based on the degree of cauda equina separation.Relative to baseline values, 2 weeks after the ESI, the moderate group showed a significant decrease in the numeric rating scale (NRS) scores and an increase in walking distance. Meanwhile, the severe group showed a significant decrease in the NRS scores and no significant change in walking distance. The moderate group had lower NRS scores and a longer walking distance than did the severe group 2 weeks after the ESI. The proportion of patients with improved levels of satisfaction was higher in the moderate group than in the severe group.Lumbar interlaminar ESI may reduce pain scores and increase walking distance in patients with moderate lumbar spinal central canal stenosis. Patients with moderate spinal stenosis achieved better outcomes than did patients with severe stenosis.

Paraganglioma of the Cauda Equina – Case Report and Literature Review

AbstractParagangliomas of the cauda equina are tumors of rare incidence, with ~ 220 cases described in the world literature. They are benign lesions, grade I by the World Health Organization (WHO), whose definitive diagnosis can only be made by immunohistochemical analysis. Its neuroendocrine nature is evidenced by the presence of chromogranin. The relevance of reporting this case is because paragangliomas of the cauda equina should be included among the differential diagnoses of intradural and extramedullary tumors, and especially because they can cause perioperative and intraoperative hypertensive crises by adrenergic discharge.The present study presents the case of a 36-year-old male patient diagnosed with a lumbar spine tumor located in the central spinal canal that presented as cauda equina syndrome involving 4 months of bilateral sciatica, paraparesis, urinary and fecal retention. The diagnosis of paraganglioma was confirmed by immunohistochemical positivity for chromogranin after microsurgical resection of the tumor.