Spinal Dura Mater Research Articles

Evaluation of replantation of spinous process and lamina and autogenous bone fusion after resection of intraspinal tumors

Objective To evaluate the replantation of lamina and spinous process and autogenous bone fusion after resection of intraspinal tumors. Methods Twenty-two cases of intraspinal canal tumors, including 5 cervical, 5 thoracic and 12 lumbar, were operated through posterior median approach with removing 2-3 segments of spinous process and lamina complex in the lesion area. During operation, the spinous process and lamina complex was replanted in situ after the intraspinal tumor was removed, and was fixed by titanium bar and titanium screw, along with autogenous bone fusion to restore the normal anatomy of spinal canal. Japanese Orthopedic Association (JOA) scale was used to evaluate the spinal function before and after operation. Results Tumors were totally removed in all of the cases, and 2-3 (2.50 on average) laminae were removed in each case. After 3-17 months (10 months on average) follow-up, imaging findings showed good reposition of replanted lamina and spinous process with partly bony fusion in all cases. No syndromes of spinal stenosis or compression on spinal dura mater owing to canal cicatrix were seen. Conclusion Replantation of lamina and spinous process and autogenous bone fusion can keep the anatomic integrality of the spine, reconstruct the spinal canal structure, maintain the spinal stability and avoid nerve root compression due to spinal canal scar. doi：10.3969/j.issn.1672-6731.2013.12.006 Video: http://www.cjcnn.org/index.php/cjcnn/pages/view/v13n12a6

Idiopathic hypertrophic pachymeningitis: Clinical, laboratory and neuroradiologic features in China

Hypertrophic pachymeningitis is a rare chronic inflammatory disorder characterized by marked fibrous thickening of the cerebral and/or spinal dura mater. Clinical, laboratory, neuroradiologic and therapeutic data from 12 patients with idiopathic hypertrophic pachymeningitis (IHP) from our department were retrospectively studied. There were four men and eight women with a mean age of 49±15.3years, and more than half of the patients (58%) were aged 40–60years. Headache was the most common symptom, occurring in 92% of patients. Headache improved markedly and rapidly after glucocorticoid treatment. Optic nerve involvement was noted in seven patients (58%). C-reactive protein levels increased in 80% and the erythrocyte sedimentation rate increased in 71% of patients. Three patients were positive for autoantibodies, including antinuclear antibodies (ANA), perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA), anti-cardiolipin antibodies (ACA) and rheumatoid factor (RF). Cerebrospinal fluid showed inflammatory changes, and protein levels were low to moderately elevated. MRI revealed a thickened dura in all patients, and five patients (42%) were diagnosed with sinus stenosis/occlusion. IHP is a chronic inflammatory disorder of the dura with three groups of symptoms, namely headache, cranial nerve palsy and symptoms due to sinus stenosis/occlusion. However, IHP has different features in China in that it predominantly affects women and the age of onset is younger. Sinus stenosis/occlusion is relatively common in IHP patients in China.

Perfusion imaging of spinal cord contusion: injury-induced blockade and partial reversal by β2-agonist treatment in rats

Traumatic injury to the spinal cord results in considerable delayed tissue loss. The authors investigated the extent to which ischemia occurs following contusion-induced spinal cord injury and whether ischemia exacerbates tissue damage that leads to the loss of locomotor function. They also determined if ischemia is reversed with β2-adrenoceptor agonist treatment, which has been established to be neuroprotective following contusion injury. The extent and role of circulation loss in spinal cord injury was determined in an established experimental model of contusion injury. The spinal cord dura mater of Wistar rats was exposed by performing a laminectomy at T-8 to T-11. Laser Doppler perfusion imaging was then used to measure microcirculation in the exposed spinal cord. After imaging, a moderately severe contusion injury was produced using a weight-drop device unto the exposed dura at T-10. Perfusion imaging was again performed, scans were quantitated, and integrated intensities were compared. Postinjury imaging revealed an 18%-27% reduction in perfusion in regions rostral and caudal to the injury site, and a 68% reduction was observed at the contusion epicenter. These perfusion losses persisted for at least 48 hours. At 24 hours after injury, some rats were intraperitoneally injected with 2 mg/kg of the β2-adrenoceptor agonist clenbuterol, which has been shown to promote the partial recovery of locomotor function and spare spinal cord tissue when administered within 2 days after contusion injury. Clenbuterol injection caused a gradual increase in perfusion, which was detectable at 30 minutes postinjection and continued over time, resulting in an 127% overall increase in perfusion at the epicenter 24 hours after treatment. These results suggest that the occurrence of chronic perfusion loss after contusion contributes to delayed damage and tissue loss. In contrast, β2-adrenoceptor agonist treatment may exert neuroprotection by restoring perfusion, thereby preventing ischemic neurodegeneration. The ability of laser Doppler imaging to measure the loss of perfusion and its restoration upon treatment suggests that it may have clinical utility in the assessment and treatment of spinal cord injury.

Epithelioid malignant peripheral nerve sheath tumor: a case report and review of literature

Background Epithelioid malignant peripheral nerve sheath tumor (EMPNST) is a rare malignant soft tissue tumor, and is more common in adult male. EMPNST originates from nerve, mainly located in the limbs, head and neck, and spine. It is an aggressive tumor with high tendency for local recurrence, and about half of the cases appear distant metastasis. This paper aims to investigate the clinicopathological features of cervial EMPNST. Methods and Results A 48-year-old male mainly presented weakness of limbs, expecially left lower extremty with ankle swelling. MRI showed space-occupying lesion in segment C3-5, considering recurrence of intraspinal tumor 2 years after operation. Tumor resection, repairing of spinal dura mater and laminectomy were made from inion to C7 level. It was found during the surgery that most part of the tumor was located in front of C3-5 spinal nerve, left intraspinal and outside of dura mater. Because part of the tumor grew through the opening of titanium plate, the tumor could not be totally removed. According to postoperative histomorphological observation, tumor cells arranged in sheets or nests, and were separated by fibrous tissue. Most tumor cells were epithelioid, while small part of tumor cells were fusiform. Frequent mitotic activity was found, and part of the region appeared focal necrosis. Immunohistochemical staining showed that tumor cells were positive for pan cytokeratin (PCK), epithelial membrane antigen (EMA), vimentin (Vim), synaptophysin (Syn), chromogranin A (CgA), and S-100 protein (S-100); and were negative for actin, desmin (Des), progestrone receptor (PR), glial fibrillary acidic protein (GFAP), CD34, CD31 and HMB45; Ki-67 labeling index was above 25% . Reticular fiber staining showed that the epithelioid cell nests were surrounded by reticular fibers. Fluorescence in situ hybridization (FISH) detection showed negative for SS18 gene translocation. Combining with the history, the final pathological diagnosis was cervical EMPNST. Conclusion EMPNST lacks of morphological characteristics, and needs to be differentiated from a variety of benign or malignant tumors exhibiting epithelioid features. It is considered that clinical materials, morphological features and immunophenotype are helpful to avoid confusion with other similar lesions. S-100 is not a specific marker, but is a valuable diagnostic index. PCK and EMA can present strongly positive expression. doi：10.3969/j.issn.1672-6731.2013.11.008

A nationwide survey of hypertrophic pachymeningitis in Japan

ObjectivesTo clarify the prevalence, frequent causes and distinct features of hypertrophic pachymeningitis (HP) according to background conditions in a nationwide survey in Japan.MethodsThe study began with a preliminary survey to...

Simulated Spinal Cerebrospinal Fluid Leak Repair

In the era of surgical resident work hour restrictions, the traditional apprenticeship model may provide fewer hours for neurosurgical residents to hone technical skills. Spinal dura mater closure or repair is 1 skill that is infrequently encountered, and persistent cerebrospinal fluid leaks are a potential morbidity. To establish an educational curriculum to train residents in spinal dura mater closure with a novel durotomy repair model. The Congress of Neurological Surgeons has developed a simulation-based model for durotomy closure with the ongoing efforts of their simulation educational committee. The core curriculum consists of didactic training materials and a technical simulation model of dural repair for the lumbar spine. Didactic pretest scores ranged from 4/11 (36%) to 10/11 (91%). Posttest scores ranged from 8/11 (73%) to 11/11 (100%). Overall, didactic improvements were demonstrated by all participants, with a mean improvement between pre- and posttest scores of 1.17 (18.5%; P = .02). The technical component consisted of 11 durotomy closures by 6 participants, where 4 participants performed multiple durotomies. Mean time to closure of the durotomy ranged from 490 to 546 seconds in the first and second closures, respectively (P = .66), whereby the median leak rate improved from 14 to 7 (P = .34). There were also demonstrative technical improvements by all. Simulated spinal dura mater repair appears to be a potentially valuable tool in the education of neurosurgery residents. The combination of a didactic and technical assessment appears to be synergistic in terms of educational development.

Compute Three-Dimensional Reconstruction of Brachial Plexus and its Surrounding Tissues by Using Chinese Visible Human (CVH) Data Anatomical Foundation for Brachial Plexus Entrapment

We selected cervical cross section image from CVH-F1 (Chinese Visible Human Female, No.1) database. After labeling the relative structures, we made 3D reconstruction of brachial plexus and surrounding tissue by computer reconstruction technique. In cervical cross section image, tissues like vertebrae, disc, spinal dura mater, spinal cord, vertebral artery, nerve root and muscles can be recognized, which ensure the ideal effect of 3-D reconstruction. In conclusion, we can make 3-D reconstruction of brachial plexus through computer technique which may serve for anatomical study of brachial plexus compression. After that we made vertical section on the nerve and calculate the ratio between area of nerve and its gap. In result, it is suggested that the nerve passage for root and strand is comparatively narrower.

Extraction of Three-Dimensional Information of Biological Membranous Tissue with Scanning Confocal Infrared Laser Microscope Tomography

The "LEXT" confocal laser scanning microscope has been used for the three-dimensional (3D) imaging of the surface of specimens, especially in materials science fields, by the penetration of near-infrared (NIR) light without mechanical cutting, deposition, or other specimen pretreatment. Noninvasive investigation of various biological tissues such as human spinal dura mater, rat aorta, and cornea without the dehydration process was successfully carried out with the "LEXT," in order to access both surface and internal topographic images of the biological structures at a good status of the wet tissue such as in vivo, especially in measuring tissue thickness. The confocal NIR laser microscopy offers the viable means to visualize tissue architecture and its thickness in microdomain to integrate 3D images efficiently. We believe that the "LEXT" has a good application for biological researchers to study biomaterials, and it would be useful as a diagnostic tool in the near future.

Microsurgical anatomy of the denticulate ligaments and their relationship with the axilla of the spinal nerve roots

The denticulate ligaments (DL), 20 or 21 pairs of meningeal extensions, spread from the lateral aspect of the spinal cord to the internal aspect of the spinal dura mater. The aim of this study is to define the specific relationship of the DL with adjacent axilla of the spinal nerve roots and to investigate the anatomical features of the DLs and their variations. The topographical anatomy of the DLs and their relationships with the adjacent axilla of the spinal nerve roots was examined on 16 formalin-fixed adult cadaveric spinal cords. The distances from the dural attachment of the DL to the axilla of the superior and inferior spinal nerve roots were measured bilaterally at every spinal level. Also the distances from the dural attachment of the DL to the lateral aspect of the spinal cord were measured bilaterally. Cervical DLs showed a triangular shape, while in the thoracic segment the ligament changes the shape to "Y." Also the most caudal DL was identified to be at the L1-2 level. Our study revealed that the distances from the dural attachment of the DL to the superior and inferior spinal nerve root axilla were different at the cervical, upper thoracic and the lower thoracic segments. Both distances to the superior and inferior spinal nerve root axilla were shown to increase from cervical to lower thoracic segments. This study provides a detailed anatomy of the DLs and their relationship with the adjacent spinal nerve root axilla.

Transesophageal Echocardiography

Transesophageal Echocardiography

Use of gelatin sponge in "sandwich" method for prevention of cerebrospinal fluid leakage after repair of spinal dura mater

Objective To investigate the therapeutic effect of the sandwich method (medical glue +gelatin sponge+medical glue) in the repair of spinal dura mater to prevent the cerebrospinal fluid leakage.Methods From February 2007 to June 2011,54 patients with spinal subdural tumors underwent excision of tumor in our hospital.According to manner of repairing spinal dura mater,all patients were classified into two groups:routine group and sandwich group.There were 16 males and 7 females with an average age of 45.2±7.2 years in the routine group,while 19 males and 12 females with an average age of 44.2±6.4 years in sandwich group.In routine group,the spinal dura mater was repaired through running locked suture.In sandwich group,the spinal dura mater was repaired through running locked suture,painting medical glue around the dural incision,covering with gelatin sponge,and painting medical glue on the surface and margin of gelatin sponge successively.Results Compared with the routine group,the total volume of postoperative drainage in sandwich group decreased significantly on the very day,the first day,the second day,and the third day,and the incidence of cerebrospinal fluid leakage decreased significantly.Before discharge,hydrops happened in 3 cases in the routine group,and got well through aspiration,continuous pressure by sandbag,and prone position.Three months after operation,5 cases from the routine group got deep hydrops under the incision and no treatment was applied to them.There was no obvious abnormality in the sandwich group.Conclusion The sandwich method can improve the repair effect of spinal dura mater injury,reduce the volume of postoperative drainage,and decrease the incidence of cerebrospinal fluid leakage Key words: Subdural effusion; Epidural neoplasms; Gelatin sponge, absorbable

Efficacy of Spinal Pia Mater Incision and Laminoplasty Combined with Internal Fixation for Old Spinal Cord Injury

To evaluate the clinical efficacy of incising spinal pia mater to relieve pressure and unilateral open-door laminoplasty with internal screw fixation for treatment of the dated spinal cord injury. From March, 2009 to July, 2010, 16 cases with chronic cervical cord injury underwent spinal dura mater incision and unilateral open-door laminoplasty with internal screw fixation. Nerve functions of pre- and postoperation were evaluated by Frankel classification and the Japanese Orthopaedic Association (JOA) scale.The improvement rate of JOA score at the indicated time was recorded. Postoperative Frankel classification rating of 16 patients improved obviously.JOA scores at the 1st month, 3rd month, 6th month, and 12th month after surgery were 7.9 ± 2.3, 8.5 ± 1.6, 8.9 ± 2.1, and 12.4 ± 2.5, respectively, and significantly increased compared with that prior to surgery (5.5 ± 0.6). At the end of follow-up period, JOA score was significantly higher than that of pre-treatment (P<0.05). The recovery was relatively rapid during the first 3 months following the surgery, then entered a platform period. It is effective for patients with dated spinal cord injury to undergo spinal decompression and laminoplasty.

Ultrasonographic quantification of spinal cord and dural pulsations during cervical laminoplasty in patients with compressive myelopathy

Pulsatile movements of the dura mater have been interpreted as a sign that the cord is free within the subarachnoid space, with no extrinsic compression. However, the association between restoration of pulsation and adequate decompression of the spinal cord has not been established. The present study investigated the relationship between the extent of spinal cord decompression and spinal cord and dural pulsations based on quantitative analysis of intraoperative ultrasonography (US). Eighty-five consecutive patients (55 males, 30 females; mean age, 64 ± 13 years) who underwent cervical double-door laminoplasty to relieve compressive myelopathy were enrolled. Spinal cord decompression status was classified as: Type 1 (non-contact), the subarachnoid space was retained on the ventral side of the cord, Type 2 (contact and apart), the cord showed both contact with and separation from the anterior element of the cervical spine, or Type 3 (contact), the cord showed continuous contact with the anterior element of the cervical spine. Spinal cord and dura mater dynamics were quantitatively analyzed using automatic video-tracking software. Furthermore, the intensity of spinal and dural pulsation was compared with the recovery of motor function at 1 year after surgery as measured by increase in the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). Spinal cord pulsation amplitude ranged from 0.01 to 0.84 mm (mean 0.30 ± 0.16 mm) and dural pulsation amplitude ranged from 0.01 to 0.38 mm (mean 0.14 ± 0.08 mm). Average spinal cord pulsation amplitude in Type 2 patients was significantly larger than that in the other groups, whereas, average dural pulsation amplitudes were similar for all three groups. There was a significant correlation between spinal cord and dural pulsation amplitudes in Type 1 patients, but not in Type 2 or Type 3 patients. Type 3 patients showed a particularly poor correlation between spinal cord and dural pulsations. Spinal cord pulsation amplitude was moderately correlated with the recovery of motor function evaluated by JOACMEQ. The present results suggest that restoration of dural pulsation is not an adequate indicator of sufficient decompression of the spinal cord following a surgical procedure.

Pathological Findings in a Case of Equine T-Cell Lymphoma Associated with Ataxia

A 15-year-old Dutch Warmblood gelding suddenly developed incoordination and hindlimb stumbling. The horse had a history of eyelid lymphoma. Necropsy revealed yellow-white or dark reddish-brown masses adhering to the outer surface of the spinal dura mater from the first cervical vertebra to the seventh thoracic vertebra. The spinal cord close to the first cervical vertebra and the seventh thoracic vertebra was markedly compressed by the masses filling the epidural space. The masses were also observed in the larynx, eyelids, and adipose-rich tissues, including the joints and orbits. They appeared similar in shape. The mandibular, retropharyngeal, axillary, superficial inguinal, deep inguinal, and lateral iliac lymph nodes were solid and enlarged. Histologically, the masses were composed of small or medium-sized lymphocyte-like tumor cells, but atypical cells and mitotic figures were rare. There were moderate infiltrations of macrophages and multinucleated giant cells, which were occasionally ingesting the surrounding tumor cells. Immunohistochemically, the tumor cells were classified as T-cell-derived cells. Throughout the spinal cord, enlargement or loss of nerve axons, dilation of periaxonal spaces, and macrophage infiltration into periaxonal spaces were observed, mainly in the ventral funiculus. Spinal cord compression by the tumor mass was suggested as a cause of the locomotive dysfunction. This is the first report of equine lymphoma with ataxia located from the proximal cervical to middle thoracic dura mater and in joint cavities.

Spinal Subdural Effusion – An Additional Sonographic Sign of Child Abuse

To assess the suitability of spinal ultrasound for the detection of spinal subdural hematoma in infants with sustained non-accidental trauma. Six infants (mean age± SD3.3±1.5 months) admitted to our hospital because of suspected non-accidental trauma were examined radiologically with ultrasound, CT and/or MRI and skeletal radiography. Twelve healthy infants (mean age± SD2.5±1.4 months) in whom an ultrasound of the spine was performed to exclude spinal dysraphism served as controls. All six patients with non-accidental trauma (NAT) presented with cranial subdural hematoma visualized by ultrasound and CT scan or MRI. Spinal ultrasound detected echogenic effusions with floating particles that displaced the undulating arachnoidea from the dura mater spinalis in all six patients with NAT. The size of the spinal subdural hematoma varied and extended from the cervical spine to the cauda equina. The anatomic landmarks (dura mater spinalis, arachnoidea spinalis) were identified and confirmed the subdural location. All spinal subdural hematomas were asymptomatic and detected by diagnostic ultrasound. None of the infants had a pre-existing neurological or hemorrhagic disorder. The plain X-rays of the spine in these infants showed no osseous lesion. Spinal subdural hematoma was not observed in any of the controls. The presence of spinal subdural hematoma is a valuable sign of sustained non-accidental trauma in infants that can be quickly and easily detected using spinal ultrasound without the need for sedation or general anesthesia. Thus, spinal ultrasound should be part of the imaging examinations performed in infants with suspected abuse.

Connection between the spinal dura mater and suboccipital musculature: Evidence for the myodural bridge and a route for its dissection—A review

A connective tissue link between the spinal dura mater and the rectus capitis posterior minor muscle was first described in 1995 and has since been readily demonstrated via dissection, magnetic resonance imaging, and plastinated cross-sections of the upper cervical region (Hack et al. [1995] Spine 20:2484-2486). This structure, the so-called "myodural bridge," has yet to be included in any of the American anatomy textbooks or dissection guides commonly used in medical education. This direct anatomic link between the musculoskeletal system and the dura mater has important ramifications for the treatment of chronic cervicogenic headache. This article summarizes the anatomic and clinical research literature related to this structure and provides a simple approach to dissect the myodural bridge and its attachment to the posterior atlanto-occipital membrane/spinal dura mater complex and summarizes the case for its possible inclusion in medical anatomy curricula.

Psammomatous melanotic schwannoma with cystic changes from old hemorrhages in the cervical spinal canal: a case report

Psammomatous melanotic schwannoma with cystic changes from old hemorrhages in the cervical spinal canal: a case report

Clinical experience with a novel bovine collagen dura mater substitute

Dural substitutes are used to achieve watertight closure of the dura mater when adequate closure is not possible. The purpose of this study was to evaluate the efficacy and safety of a new collagen matrix dural substitute (Duradry, Technodry, Belo Horizonte MG) in the repair or expansion of cranial and spinal dura mater. Thirty patients, operated on between March and September, 2008, were studied. Surgical records were reviewed for sex, age, location of graft, technique, and presence of fistula or infection. The patients were followed up for at least 3 months, and presence of complications, such as cerebrospinal fluid leakage, infection, aseptic meningitis hydrocephalus, pseudomeningocele, was analyzed. Only one patient presented cerebrospinal fluid fistula. No patients presented wound infections, hydrocephalus, pseudomenigocele, meningitis, brain abscesses or signs of toxicity related to the dural substitute. The new dural substitute used in this study is effective and safe, and the initial results are similar to those of other dural substitutes reported in the literature.

The anatomic study of transferring thoracic nerve roots to lumbar nerve root inside the spinal canal of paraplegia

To study the fundamental anatomy of transferring T(9-12) nerve roots to L(2-4) nerve root for the quadriceps function recovery inside the spinal canal of paraplegia. Thoracic and lumbar spinal canal and spinal dura mater of 5 adult cadavers (male 2 and female 3) were opened and explored. Investigated including: the position which T₉-L₄ nerve root generated from spinal cord; the relation between the position which T₉-L₄ nerve root generated from spinal cord and T₁₂ vertebrae and L₁ vertebrae; The length beginning part of T₉-L₄ nerve root inside the spinal canal. The diameter of T₉-L₄ nerve root. The distance between the T₉-L₄ nerve root separately. The distance between the position which T(9-12) nerve root separately generated from dura mater and the middle of L₂ vertebrae. T₉ nerve root generated from the middle part of T₉ vertebrae; L₄ nerve root generates from middle part of L₂ vertebrae. The average length of T₉-L₄ nerve root inside the spinal canal separately was 16.12, 22.97, 30.43, 43.47, 56.02, 70.03, 88.70 and 113.65 mm. The average diameter of T₉-L₄ nerve root separately was 2.45, 2.04, 1.96, 2.18, 2.32, 2.56, 3.10 and 3.26 mm. The average distance between the beginning part of T₉-L₄ nerve root separately was 22.87, 25.08, 28.47, 27.38, 29.78, 31.93 and 31.00 mm. The average distance between the position which T(9-12) nerve root separately generated from dura mater and the middle of L₂ vertebrae was 118.69, 95.82, 70.74, and 42.27 mm. T(9-12) nerve root can be used as donor nerve for repair L(2-4) nerve root. The level of L₂ vertebrae can be anastomose site of the recipient nerve.

Thermal Damage Assessment of Novel Bipolar Forceps in a Sheep Model of Spinal Surgery

Heat transfer from bipolar tips to adjacent tissue presents a risk of thermal injury during spine surgery. The present study was designed to determine wither bipolar forceps using a novel heat pipe thermal regulation technology resulted in decreased collateral thermal injury of adjacent tissue compared with traditional bipolar forceps (control). Eight sheep underwent multilevel laminectomy and controlled bipolar coagulation of the dorsal spinal dura mater at multiple levels using forceps with or without heat pipe technology (24 spinal segments tested; heat pipe, n=11; non-heat pipe, n=11; sham, n=2). The severity (range, 1-5) and size of thermal injury to the spinal cord resulting from forceps with vs without heat pipe were assessed via histological analysis at 8 days postoperatively. Macroscopic occlusion of the pial vein underlying the segment of epidural coagulation occurred at surgery in 64% of segments (7 of 11) coagulated with control forceps but did not occur in any segments coagulated with heat pipe forceps (P<.005). The mean width (0.58+/-0.58 vs 1.4+/-0.77 mm; P<.05) and cross-sectional area of unintended thermal injury (1.2+/-1.7 vs 4.9+/-3.2 mm2; P<.05) were decreased in segments treated with heat pipe forceps compared with control. The severity of thermal injury was decreased in segments coagulated with (median, grade 1) vs without (median, grade 3) heat pipe forceps (P<.05). Bipolar forceps that incorporate heat pipe technology limited thermal spread and reduced the extent of unintended injury to the spinal cord and collateral vessels.