Spinal Cord Rotation Research Articles

Neuronavigation-Guided Implantation of a Surgical Spinal Cord Stimulation Lead in a Patient With Chronic Pain With Scoliosis and Severe Spinal Cord Rotation: A Technical Note

Neuronavigation-Guided Implantation of a Surgical Spinal Cord Stimulation Lead in a Patient With Chronic Pain With Scoliosis and Severe Spinal Cord Rotation: A Technical Note

Regeneration Potential of Stem Cell in the Treatment of IVD

Abstract: Degenerative disc disease is a prevalent musculoskeletal disorder in which damaged spinal discs cause pain upon aging, accidental injuries. Spinal discs connect adjacent vertebrae and help in maintaining mobility, flexibility and rotation of spinal cord. Spinal discs also act as shock absorbers. Intervertebral disc (IVD) degeneration is often associated with low back and neck pain, which accounts for disability worldwide. Physical therapy, spinal fusion surgeries reduce severity and symptoms of degenerative disc disease but they are not complete cure for this disease. Current preclinical studies show that mesenchymal stem cells have the capacity to repair degenerative disks by differentiation to chondrocyte-like cells, which produce proteoglycans and type II collagen. Mesenchymal stem cells (MSCs) isolated from bone marrow (BM-MSCs), adipose tissue (AD-MSCs) and umbilical cord (UC-MSCs) show potential use in cartilage and intervertebral disc (IVD) repair. Regenerative medicine and stem cell therapy hold great promise for treatment of intervertebral disc (IVD) disease. This review discusses about progression of degenerative disc disease, various types of stem cells, potential use of mesenchymal stem cells (MSCs) and embryonic stem cells (ESCs) for the treatment of degenerative disc disease. This review also focuses upon challenges encountered by the application of stem cell therapy for treating degenerative disc disease as well as future perspectives. Keywords: IVD, Stem cell therapy, AF & NP cells, MSCs, Scaffolds, Cell therapy

Combined surgical and endovascular approach to treat a ventrally located perimedullary arteriovenous fistula

Perimedullary arteriovenous fistulae (PMAVFs) (also called type IV spinal cord arteriovenous malformations) are rare lesions. They are located in the subarachnoid space or just under the pia. The shunt occurs between the anterior spinal artery (ASA) and/or posterior spinal artery (PSA) and a network of perimedullary veins. The aim of the treatment, surgical or endovascular, is to occlude the fistula. This article presents a unique treatment strategy of a demanding strictly ventral PMAVF in the lower thoracic cord. A posterior surgical approach with spinal cord rotation followed by direct puncture of a distally located arterial feeder was achieved. Precise identification of the fistula with superselective contrast injections was obtained and accurate catheterization of the venous pouch with a microcatheter was performed. Complete occlusion of the PMAVF was achieved with coils.

Impact of Multifidus Muscle Swelling on C5 Palsy After Cervical Laminoplasty.

Retrospective radiological analysis OBJECTIVE.: The aim of this study was to identify the effects of posterior cervical muscle swelling on C5 palsy (C5P) by evaluating early postoperative magnetic resonance (MR) images. Cervical laminoplasty is an established technique, but the risk of C5P after surgery has not been fully resolved. Studies have reported that lateral stretching and postoperative swelling of the multifidus muscle may cause stretching of the medial branches and cervical nerves. A total of 214 C5 nerves of 107 consecutive patients who underwent laminoplasty were examined. We reviewed their demographic and surgical data and radiographic and MR images as parameters, including the axial cross-sectional area (CSA) of the posterior muscles. The patients and C5 nerves were divided into C5P and non-C5P groups. The parameters and changes were compared between the two groups to examine correlations with C5P. In demographic data, age, sex, history of smoking, diabetes mellitus, and preoperative Japanese Orthopedic Association scores were not significantly different between the groups. Only body mass index (BMI) was significantly higher in the C5P group. Regarding the surgical and imaging data, the number of laminoplasty, operative time, decompression trough width, cervical sagittal alignment, preoperative spinal cord rotation, and posterior shift of the spinal cord were not significantly different, but the multifidus CSA change ratio was significantly higher in the C5P group. Multiple logistic regression analyses revealed that the multifidus CSA change ratio and BMI were significant independent factors. Multifidus swelling is associated with C5P, possibly through traction of the C5 nerve via the medial branches of the cervical dorsal rami. The medial branch is the shortest of the dorsal rami and may have the largest effect by traction force. Therefore, a gentle maneuver of the deep posterior muscles during surgery is a potential countermeasure to prevent C5P. 3.

Surgical Resection of Cervical Meningioma: 3-Dimensional Operative Video.

Spinal cord meningiomas are rare, benign lesions typically found at the cervical or thoracic spinal region. They can cause symptoms through compression of the spinal cord and nerve roots. These tumors often have a challenging surgical course due to their location in relation to spinal cord and nerve rootlets. We present a 33-yr-old female who presented with cervical radicular and myelopathy symptoms. MRI of the cervical spinal demonstrated an anterolateral, 3 cm intradural, extrameduallary tumor causing significant cord compression at C6-7 level. The patient was taken to surgery for cervical laminoplasty and microsurgical tumor removal. The current 3-dimensional video demonstrates the steps involved during the microsurgical resection of the tumor. In order to facilitate spinal cord rotation without compromising blood supply the dentate ligaments at 3 levels (C5-C7) were identified and transected, the anterolateral-situated tumor was separated from the exiting right C6 and C7 nerve rootlet followed by circumferential dissection, and subsequent en bloc resection. No complications were encountered during the procedure; somatosensory and motor evoked potential registration remained intact. The patient recovered well from the procedure and was discharged on postoperative day three with improvement in her presenting symptoms.

Surgical Outcomes After Anterior Controllable Antedisplacement and Fusion Compared with Single Open-Door Laminoplasty: Preliminary Analysis of Postoperative Changes of Spinal Cord Displacements on T2-Weighted Magnetic Resonance Imaging

This retrospective cohort study aimed to investigate the change of spinal cord displacements and the occurrence of C5 palsy between anterior controllable antedisplacement and fusion (ACAF) (group A) and single open-door laminoplasty (group L). From January 2016 to December 2017, a total of 80 patients with cervical ossification of the posterior longitudinal ligament (OPLL) were enrolled. All patients underwent computed tomography and magnetic resonance imaging. The types and extent of OPLL, spinal cord rotation, deviation angle, and distance between the vertebral arteries line and spinal cord (DVS) were measured. Patients with postoperative C5 palsy were recorded. Neurologic function was evaluated by Japanese Orthopaedic Association (JOA) score. Three days after surgery, patients in group A had better recovery (6.7° ± 2.4°) of spinal cord rotation than group L (3.1° ± 0.8°; P < 0.05). Deviation angle showed similar changes to spinal cord rotation. At the final follow-up, patients in group A had decreased DVS (11.0 ± 0.7 mm), whereas patients in group L had increased DVS (15.1 ± 0.8 mm) compared with preoperation (P < 0.05). Five patients (1in group A and 4 in group L) developed postoperative C5 palsy (P > 0.05). Patients in group A had a higher JOA score at the final follow-up than those in group L (P < 0.05). ACAF could achieve in situ decompression in terms of spinal cord rotation, deviation angle, and spinal cord shift with better clinical outcomes and relatively lower incidence of C5 palsy compared with single open-door laminoplasty.

Spinal Cord Rotation by Denticulate Ligamental Stay-sutures for Anteriorly Placed Intradural Lesions&amp;mdash;Technical Note

Spinal Cord Rotation by Denticulate Ligamental Stay-sutures for Anteriorly Placed Intradural Lesions&amp;mdash;Technical Note

Predicting Postoperative C5 Palsy Using Preoperative Spinal Cord Rotation.

The development of C5 nerve palsy after cervical decompression surgery has been well documented. The goal of this study was to determine whether preoperative spinal cord rotation could be used as a predictor of C5 palsy in patients who underwent posterior cervical decompression at C4-C6. The authors reviewed the records of 72 patients who had posterior decompression and 77 patients who had anterior decompression. With the patients undergoing anterior decompression used as a control group, magnetic resonance imaging scans were analyzed for area of the spinal cord, anterior-posterior diameter, and cord rotation relative to the vertebral body. The rate of C5 palsy was 7.3%. Average degrees of rotation were 3.83°±2.47° and 3.45°±2.23° in the anterior and posterior groups, respectively. A statistically significant association was detected between degree of rotation and C5 palsy. Point-biserial correlations were 0.58 (P<.001) and 0.60 (P<.001) in the anterior and posterior groups, respectively. With a diagnostic cutoff of 6°, the sensitivity and specificity of identifying patients with C5 palsy in the posterior group were 0.67 (95% confidence interval, 0.24-0.94) and 0.95 (95% confidence interval, 0.86-0.98), respectively. The results suggested that preoperative spinal cord rotation may be a valid predictor of C5 nerve palsy after posterior cervical decompression. With mild rotation defined as less than 6°, moderate rotation as 6° to 10°, and severe rotation as greater than 10°, the prevalence of C5 palsy in the posterior group was 2 of 65 for mild rotation, 3 of 6 for moderate rotation, and 1 of 1 for severe rotation.

Intraoperative neurophysiological monitoring for intradural extramedullary tumors: Why not?

BackgroundWhile intraoperative neurophysiological monitoring (IOM) for intramedullary tumors has become a standard in neurosurgical practice, IOM for intradural extramedullary tumors (IDEMs) is still under debate. The aim of this study is to evaluate the role of IOM during surgery for IDEMs. MethodsFrom March 2008 to March 2013, 68 patients had microsurgery with IOM for IDEMs (31 schwannomas, 25 meningiomas, 6 ependymomas of the cauda/filum terminalis, 4 dermoid cysts and 2 other lesions). The IOM included somatosensory evoked potentials (SEPs), motor evoked potentials (MEPs), and – in selected cases – D-waves. Also preoperative and postoperative neurophysiological assessment was performed with SEPs and MEPs. All patients were evaluated at admission and at follow up (minimum 6 months) with the Modified McCormick Scale (mMCs). ResultsThree different IOM patterns were observed during surgery: no change in evoked potentials (63 cases), transitory evoked potentials change (3 cases) and loss of evoked potentials (2 cases). In the first setting surgery was never stopped and a radical tumor removal was achieved (no stop surgery group). In 3 cases of transitory evoked potentials change, surgery was temporarily halted but the tumors were at the end completely removed (stop and go surgery group). In 2 more patients the loss of evoked potentials led to an incomplete resection (stop surgery group). No patients presented a worsening of the pre-operative clinical conditions (at admission 47 patients presented mMCs 1–2 and 21 patients mMCs 3–5, while at follow up 62 patients are mMCS 1–2 and 6 patients mMCs 3–5). ConclusionsIn our series significant IOM changes occurred in 5 out of 68 patients with IDEMs (7.35%), and it is conceivable that the modification of the surgical strategy – induced by IOM – prevented or mitigated neurological injury in these cases. Vice versa, in 63 patients (92.65%) IOM invariably predicted a good neurological outcome. Furthermore this technique allowed a safer tumor removal in IDEMs placed in difficult locations as cranio-vertebral junction or in antero/antero-lateral position (where rotation of spinal cord can be monitored) and even in case of tumor adherent to the spinal cord without a clear cleavage plane.

Posterolateral approach for spinal intradural meningioma with ventral attachment.

Background:Spinal meningioma with ventral attachment is a challenging pathology. Several technical modifications have been proposed to secure safe and precise resection of these tumors.Materials and Methods:This retrospective study focused on the precise and safe surgery of spinal meningiomas with strictly ventral attachment of cervical or thoracic spine. The surgical technique included a lateral oblique position for the patient, laminectomy with unilateral medial facetectomy on the tumor side, and spinal cord rotation with the dentate ligament. The neurological status of patients was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS) before and at least 3 months after surgery. Patients were followed-up for a mean of 23.7 months. Tumor removal was graded using the Simpson grade for removal of meningiomas, and the extent of excision was confirmed using early postoperative magnetic resonance imaging.Results:Simpson grade 1 or 2 resections were achieved in all cases. No major surgery-related complications were encountered, postoperatively. The mean mMFS score before surgery was 3.1, improving significantly to 1.7 after surgery (P < 0.05). The mean SPS score before surgery was 2.4, improving significantly to 1.6 after surgery (P < 0.05).Conclusions:This surgical technique offers a posterolateral surgical corridor to the ventral canal of both cervical and thoracic spine. The present preliminary analysis suggests that functional outcomes were satisfactory with minimal surgery-related complications, although considerable surgical experience is needed to achieve a high level of surgical confidence.

Preoperative Spinal Cord Rotation as a Predictor of Postoperative C5 Palsy in Posterior Cervical Procedures

Preoperative Spinal Cord Rotation as a Predictor of Postoperative C5 Palsy in Posterior Cervical Procedures

The Association Between Preoperative Spinal Cord Rotation and Postoperative C5 Nerve Palsy

C5 nerve palsy is a known complication of cervical spine surgery. The development and etiology of this complication are not completely understood. The purpose of the present study was to determine whether rotation of the cervical spinal cord predicts the development of a C5 palsy. We performed a retrospective review of prospectively collected spine registry data as well as magnetic resonance images. We reviewed the records for 176 patients with degenerative disorders of the cervical spine who underwent anterior cervical decompression or corpectomy within the C4 to C6 levels. Our measurements included area for the spinal cord, space available for the cord, and rotation of the cord with respect to the vertebral body. There was a 6.8% prevalence of postoperative C5 nerve palsy as defined by deltoid motor strength of ≤ 3 of 5. The average rotation of the spinal cord (and standard deviation) was 2.8° ± 3.0°. A significant association was detected between the degree of rotation (0° to 5° versus 6° to 10° versus ≥ 11°) and palsy (point-biserial correlation = 0.94; p < 0.001). A diagnostic criterion of 6° of rotation could identify patients who had a C5 palsy (sensitivity = 1.00 [95% confidence interval, 0.70 to 1.00], specificity = 0.97 [95% confidence interval, 0.93 to 0.99], positive predictive value = 0.71 [95% confidence interval, 0.44 to 0.89], negative predictive value = 1.00 [95% confidence interval, 0.97 to 1.00]). Our evidence suggests that spinal cord rotation is a strong and significant predictor of C5 palsy postoperatively. Patients can be classified into three types, with Type 1 representing mild rotation (0° to 5°), Type 2 representing moderate rotation (6° to 10°), and Type 3 representing severe rotation (≥ 11°). The rate of C5 palsy was zero of 159 in the Type-1 group, eight of thirteen in the Type-2 group, and four of four in the Type-3 group. This information may be valuable for surgeons and patients considering anterior surgery in the C4 to C6 levels.

Surgical management of ventral intradural spinal lesions

Access to the ventral intradural spinal canal may be required for treatment of a variety of lesions affecting the spinal cord and adjacent intradural structures. Adequate exposure is usually achieved through a standard posterior laminectomy or posterolateral approaches, although formal anterior approaches are used to access lesions in the subaxial cervical spine. Modifications of the standard posterior exposure as well as ventral or ventrolateral approaches are increasingly being used for treating intradural spinal pathologies. In this study, the authors review their experience with 35 consecutive cases of ventral intradural spinal lesions. Only patients with intradural lesions located completely ventral to the dentate ligament attachments were included in this retrospective study. Patients with the following lesions were excluded from the study: lesions at the level of the filum terminale/cauda equina, lesions with any component that extended dorsally to the dentate ligament, or lesions with extradural extension (that is, dumbbell tumors) below the C-2 level. Between January 2000 and September 2009, a total of 35 patients (age range 17-72 years, mean 42.6 years) with ventral intradural spinal pathology underwent surgery at the authors' institution. There were 28 intradural extramedullary mass lesions: 15 meningiomas, 12 solitary schwannomas, and 1 neuroenteric cyst. Surgical approaches to these lesions included 23 posterior or posterolateral approaches, 4 anterior approaches with corpectomy followed by tumor resection and reconstruction, and 1 lateral transforaminal resection. No patient had evidence of instability at follow-up, which ranged from 6 months to 8 years in duration. One patient had worsened spinal cord function following surgery. There were 7 patients with intramedullary lesions: 2 hemangioblastomas, 2 cavernous malformations, 2 perimedullary fistulas, and 1 astrocytoma. All but 1 were superficial pia-based lesions arising ventral to the dentate ligament. Five of the 6 pia-based lesions were successfully resected via a standard posterior laminectomy, partial facetectomy with dentate section, and spinal cord rotation. One midline pial lesion was successfully removed with a minimally invasive retropleural thoracotomy. The astrocytoma was resected through an anterior cervical corpectomy, which was followed by instrumented reconstruction. There were no significant complications or neurological morbidity at follow-up (range 9 months-6 years). Most intradural spinal lesions can be treated with contemporary microsurgical techniques with long-term control or cure of the lesion and preservation of neurological function. Standard posterior approaches provide adequate exposure to safely remove the vast majority of these lesions without the need for a potentially destabilizing resection of the facet or pedicle. Posterior exposures with varying degrees of lateral bone resection, dentate ligament division, and gentle cord rotation may also provide adequate exposure for safe removal of nonmidline ventrolateral superficial pial presenting spinal cord lesions. Nevertheless, in certain cases of ventral intradural lesions, anterior approaches are necessary and should be considered under appropriate circumstances.

Assessing the rotation of the spinal cord in idiopathic scoliosis: a preliminary report of MRI feasibility

Magnetic resonance imaging (MRI) quantification of the rotation of the spinal cord in patients with thoracic idiopathic scoliosis could also be used to detect different spinal cord rotational patterns. Ten patients with a thoracic or thoracolumbar scoliosis had axial T2-weighted MRI. The rotation of the spinal cord and vertebra were measured. The rotational data of the spinal cord and vertebra was compared to other collated data using non-parametric tests. The vertebral tile was measured from 3 degrees to 32 degrees and the spinal cord tilt was measured from 3 degrees to 39 degrees. The spinal cord tilt was statistically correlated with the Cobb angle and the antero-posterior or and transverse diameter of the spinal cord. We showed that, even in case of moderate curve with very limited angular values and vertebral rotation, a significant spinal cord rotation occurred. However, our findings are very limited to discuss some hypothesis about scoliosis pathogeny or progression mechanism.

Posterolateral cervical or thoracic approach with spinal cord rotation for vascular malformations or tumors of the ventrolateral spinal cord.

This report describes a technique for exposing the ventrolateral quadrant of the spinal cord through an extended posterolateral approach that can be used in both cervical and thoracic regions. The surgical technique includes the following: 1) a midline skin incision with a transverse extension at the level of pathology; 2) unilateral division and retraction of the paraspinous muscles; 3) laminectomy and unilateral removal of facets and pedicles; 4) dural incision over the dorsal root entry zone; 5) multilevel division of the ipsilateral dentate ligaments; and 6) elevation and rotation of the spinal cord with dentate traction stiches. This technique provides exposure of the ventral root entry zone, the ipsilateral half of the ventral surface of the cord, and the anterior spinal artery. The surface of the spinal cord beyond the anterior spinal artery is not seen. This approach has been used for the treatment of seven ventrolateral spinal cord lesions: five spinal arteriovenous malformations (two Type II, one Type III, two Type IV), one hemangioblastoma, and one cavernous angioma. All the lesions were completely excised. Two patients had mild new neurological deficit after surgery, and one adolescent developed mild asymptomatic thoracic kyphosis, but no other spinal instability was observed over a follow-up period of 1 to 4 years. This operative approach provides significant advantages for ventrolateral perimedullary or intramedullary lesions of the cervical or thoracic spinal cord.