Thoracic Spinal Canal Research Articles

Fully Endoscopic 360° Decompression Surgery for Thoracic Spinal Stenosis: Technical Note and Report of 8 Cases

Background Surgical options for treating thoracic spinal cord compression that results from circumferential stenosis typically involve instrumented fusion procedures. The authors present here an outpatient, awake, endoscopic surgical option for treating thoracic stenosis that avoids fusion. Objectives To evaluate the outcome and safety of combining fully endoscopic transforaminal and posterior approaches for ventral and dorsal decompression of thoracic spinal stenosis. Study design Retrospective case review. Setting Single-center acute-care hospital. Methods Eight patients with single-level, significant stenosis of the thoracic spinal canal were treated with fully endoscopic transforaminal and posterior approaches to achieve 360° ventral and dorsal decompression. Patients were followed up to 30 months postoperatively. Axial back pain was measured by the Visual Analog Scale (VAS) score, and paired Student t-test was used for statistical analysis. Results Successful decompression was achieved in all 8 patients. All surgeries were performed as outpatient procedures under local anesthesia with intravenous (IV) sedation. There were no intraoperative dura tears, spinal cord or nerve root injury, postoperative infections, or cases of iatrogenic-induced segmental instability. All patients had significant improvement with VAS scores significantly lower postoperatively. Limitations Small case series evaluated retrospectively with 15-month average follow-up. Conclusions Combining fully endoscopic transforaminal and posterior approaches for both ventral and dorsal decompression under local anesthesia with IV sedation is an effective and safe minimally invasive surgical treatment for thoracic spinal stenosis.

Respiratory cerebrospinal fluid flow is driven by the thoracic and lumbar spinal pressures.

Respiration plays a key role in the circulation of cerebrospinal fluid (CSF) around the central nervous system. During inspiration increased venous return from the cranium is believed to draw CSF rostrally. However, this mechanism does not explain why CSF has also been observed to move caudally during inspiration. We show that during inspiration decreased intrathoracic pressure draws venous blood from the cranium and lumbar spine towards the thorax. We also show that the abdominal pressure was associated with rostral CSF displacement. However, a caudal shift of cervical CSF was seen with low abdominal pressure and comparably negative intrathoracic pressures. These results suggest that the effects of epidural blood flow within the spinal canal need to be considered, as well as the cranial blood volume balance, to understand respiratory-related CSF flow. These results may prove useful for the treatment of CSF obstructive pathology and understanding the behaviour of intrathecal drug injections. It is accepted that during inspiration, cerebrospinal fluid (CSF) flows rostrally to compensate for decreased cranial blood volume, caused by venous drainage due to negative intrathoracic pressure. However, this mechanism does not explain observations of caudal CSF displacement during inspiration. Determining the drivers of respiratory CSF flow is crucial for understanding the pathophysiology of CSF flow disorders. To quantify the influence of respiration on CSF flow, real-time phase-contrast magnetic resonance imaging (MRI) was used to record CSF and blood flow, while healthy subjects (5:5 M:F, 25-50 years) performed either a brief expiratory or inspiratory effort between breaths. Transverse images were taken perpendicular to the spinal canal in the middle of the C3 and L2 vertebrae. The same manoeuvres were then performed after a nasogastric pressure catheter was used to measure the intrathoracic and abdominal pressures. During expiratory-type manoeuvres that elevated abdominal and intrathoracic pressures, epidural blood flow into the spinal canal increased and CSF was displaced rostrally. With inspiratory manoeuvres, the negative intrathoracic pressure drew venous blood from C3 and L2 towards the thoracic spinal canal, and cervical CSF was displaced both rostrally and caudally, despite the increased venous drainage. Regression analysis showed that rostral displacement of CSF at both C3 (adjusted R2 =0.53; P<0.001) and L2 (adjusted R2 =0.38; P<0.001) were associated with the abdominal pressure. However, with low abdominal pressure and comparably negative intrathoracic pressure, cervical CSF flowed caudally. These findings suggest that changes in both the cranial and spinal pressures need to be considered to understand respiratory CSF flow.

Spontaneous spinal epidural hematoma masquerading as atypical abdominal pain in a child

Introduction:There have been few case reports of abdominal pain as a symptom of spontaneous intraspinal hemorrhage. We herein describe a case involving a girl with paraplegia caused by spontaneous epidural hemorrhage in the thoracic spinal canal, characterized by abdominal pain.Patient concerns:An 8-year-old girl with sudden abdominal pain and back pain was misdiagnosed as having an abdominal disease until she had the symptom of paralysis.Diagnoses:The patient was diagnosed with spontaneous intraspinal hemorrhage masquerading as atypical abdominal pain.Interventions:When the patient developed symptoms of lower extremity paralysis, thoracic magnetic resonance imaging was performed and epidural hemorrhage was found in the thoracic spinal canal. Surgical treatment was performed after the diagnosis was confirmed.Outcomes:The patient could almost walk normally after 3 months. One year after surgery, the Frankel grade of spinal cord function was grade D. We continued to follow-up this patient.Conclusion:The symptoms caused by intraspinal hemorrhage are mainly back pain with or without neurological dysfunction. However, sometimes atypical symptoms, such as abdominal and chest pain, can be identified in clinical settings. Emergency surgery is recommended as the treatment of choice for intraspinal hemorrhage with neurological dysfunction.

Anterior Approach to the Thoracic and Thoracolumbar Spine: A Prospective Study in Our Hospital

Background Data: Anterior approaches to the thoracic and thoracolumbar spine have several advantages including direct access to the lesion, less surgical bleeding, low risk of infection, and shorter segment fixation devices. It provides excellent visualization and access to the anterior thoracic spine, vertebral bodies, intervertebral disks, spinal canal, and nerve roots and may improve neurological outcome. Purpose: To evaluate various outcome parameters of the anterior approach to the thoracolumbar spine of various pathologies. Study Design: Prospective clinical case study. Patients and Methods: Thirty patients were included in this study. Patients with infections, malignancy, and trauma were included, while patients with medical comorbidities, extensive several spinal levels disease, posterior tension band injury and translational or rotational injury, and severe osteopenia or osteoporosis were excluded. The evaluation included the demographic data, clinical features, level of injury, and neurological status of these patients. All patients underwent operation through the anterior thoracolumbar approach. Outcome parameters included preoperative and perioperative data and postoperative ASIA, VAS, SCIM, and ODI. Results: The age of patients was 46.06±12.2 (range, 20–70) years. Twenty patients were males and 10 were females. Most patients were 41–50 and >50 years. Thirteen patients (43%) suffered from traumatic fractures (M:F 3.3:1), 14 (47%) tuberculous spondylodiscitis (M:F 1.8:1), and 3 (10%) metastatic compression fracture. Surgical time was 213.12 and 201.43 minutes in Rt and Lt side approach, respectively, while blood loss was 609.4 and 650 ml in Rt and Lt side approach, respectively. In the whole group, pre- and postoperative sensory ASIA score was 91.53 and 105.8; motor ASIA score was 66.2 and 77.13; VAS was 5.13 and 0.63; SCIM was 30.93 and 76.13; ODI was 74 and 16.53, respectively. Complications included wound infection (N=3), kyphosis (N=3), intraoperative vascular injury (N=2), new neurological deficit (N=2), and myocardial infarction (N=1). Conclusion: Anterolateral approach in thoracic and thoracolumbar pathologies achieves adequate decompression, pathological evaluation for tissue, the possibility for instrumentation, and favorable neurological outcome. The familiarity and experience of the surgeon with the approach will always remain a cornerstone for the success of the procedure. (2020ESJ204)

A Study of Critical Events That Lead to Spinal Cord Injury and the Importance of Rapid Reversal of Surgical Steps in Improving Neurological Outcomes: A Porcine Model.

Porcine model. To quantify critical vascular and mechanical events that occur before and during an evolving spinal cord injury. Spinal cord injuries are one of the most devastating complications in spine surgery. Intraoperative neuromonitoring changes can occur as a secondary event of spinal cord compression and decrease in spinal cord blood flow (SCBF). Laser Doppler flowmetry has been well validated for measuring blood flow. Seventeen pigs were studied, 14 of which completed the experiment. Multilevel, midthoracic laminectomies were performed. Laser Doppler flowmetry electrodes were placed on the dura to measure SCBF. Spinal cord injury was induced by incremental balloon inflation in the epidural space. The animals were separated into two groups. After motor-evoked potential (MEP) loss, group A underwent medical interventions and then balloon decompression approximately 20 minutes later. Group B underwent immediate balloon decompression followed by medical interventions. After interventions, wake-up test was performed and computed tomography scan measured thoracic spinal canal volume. Median SCBF changes were seen 15.8 (5.4-25.1) minutes before MEP loss. However, the 20% threshold interval was often reached before. At the 20% threshold, median pressure was 7 psi, balloon volume was 0.5 cm, and 50% of the spinal canal was compromised. In group A, no pigs moved and all had pathology indicating ischemia. In group B, 9 of 10 were found to be moving their hind legs with 7 indicating ischemia. Compression spinal cord injury is the end of a cascade involving increasing intracanal pressure, decreasing canal volume, and hypoperfusion. Rapid relief of compression leads to MEP return. SCBF monitoring can detect ischemia preinjury, giving surgeons an opportunity for early intervention. 4.

Anesthetic management in adult patient with uncorrected tetralogy of Fallot for thoracic spinal tumor resection in prone position: a case report

Tetralogy of Fallot is a common cyanotic congenital heart disease which is often treated surgically in infants and young children. Due to long-term hypoxemia and cardiopulmonary dysfunction, adult patients with tetralogy of Fallot usually have poor tolerance to anesthesia and surgery, which brings great challenges to perioperative management. Recently, our hospital successfully completed anesthesia and perioperative management of thoracic spinal canal tumor resection in a 50-year-old female uncorrected tetralogy of Fallot in prone position. Strategies of anesthesia management were applied, including invasive blood pressure monitoring before anesthesia induction, induction with appropriate doses of intravenous agents at an appropriate rate, and precise anesthesia management through the surgery. Based on our cooperation between anesthesia, intensive care, and surgical team, we completed the operation successfully and the patient was discharged from our hospital 10 d after surgery. Key words: Tetralogy of Fallot; Spinal tumor; Anesthetic management

A mysterious risk factor for bone cement leakage into the spinal canal through the Batson vein during percutaneous kyphoplasty: a case control study

BackgroundPercutaneous kyphoplasty (PKP) can effectively treat osteoporotic vertebral compression fractures (OVCFs). Although satisfactory clinical outcomes can be achieved, bone cement leakage remains a primary complication of PKP. Previous studies have found many high risk factors for bone cement leakage into the spinal canal; however, less attention to the posterior wall morphologies of different vertebral bodies may be one reason for the leakage. Here, we investigated the effect of posterior vertebral wall morphology in OVCF patients on bone cement leakage into the spinal canal during PKP.MethodsNinety-eight OVCF patients with plain computed tomography (CT) scans and three-dimensional (3D) reconstruction images from T6 to L5 were enrolled. 3D-CT and multiplanar reconstructions (MPR) were used to measure the concave posterior vertebral wall depth (PVWCD) and the corresponding midsagittal diameter of the nonfractured vertebral body (VBSD), and the PVWCD/VBSD ratio was calculated. All subjects were divided into the thoracic or lumbar groups based on the location of the measured vertebrae to observe the value and differences in the PVWCD between both groups. The differences in PVWCD and PVWCD/VBSD between the thoracic and lumbar groups were compared. Three hundred fifty-seven patients (548 vertebrae) who underwent PKP within the same period were also divided into the thoracic and lumbar groups. The maximal sagittal diameter (BCSD), the area of the bone cement intrusion into the spinal canal (BCA), and the spinal canal encroachment rate (BCA/SCA × 100%) were measured to investigate the effect of the thoracic and lumbar posterior vertebral wall morphologies on bone cement leakage into the spinal canal through the Batson vein during PKP.ResultsThe PVWCDs gradually deepened from T6 to T12 (mean, 4.6 mm); however, the values gradually became shallower from L1 to L5 (mean, 0.6 mm). The PVWCD/VBSD ratio was approximately 16% from T6 to T12 and significantly less at 3% from L1 to L5 (P < 0.05). The rate of bone cement leakage into the spinal canal through the Batson vein was 10.1% in the thoracic group and 3.7% in the lumbar group during PKP. In the thoracic group, the BCSD was 3.1 ± 0.5 mm, the BCA was 30.2 ± 3.8 mm2, and the BCA/SCA ratio was 17.2 ± 2.0%. In the lumbar group, the BCSD was 1.4 ± 0.3 mm, the BCA was 14.8 ± 2.2 mm2, and the BCA/SCA ratio was 7.4 ± 1.0%. The BCSD, BCA and BCA/SCA ratio were significantly higher in the thoracic group than in the lumbar group (P < 0.05).ConclusionsThe PVWCD in the middle and lower thoracic vertebrae can help reduce bone cement leakage into the spinal canal by enabling avoiding bone cement distribution over the posterior 1/6 of the vertebral body during PKP. The effect of the difference between the thoracic and lumbar posterior vertebral wall morphology on bone cement leakage into the spinal canal through the Batson vein in OVCF patients during PKP is one reason that the rate of bone cement leakage into the thoracic spinal canal is significantly higher than that into the lumbar spinal canal.

140. Rapid reversal of surgical steps minimizes spinal cord injury in a porcine model

BACKGROUND CONTEXT Spinal cord injuries (SCI) are one of the most devastating in spine surgery. Intraop neuromonitoring changes can occur as a secondary characteristic of spinal cord compression and decrease in spinal cord blood flow (SCBF). Laser Doppler flowmetry has been well validated for measuring SCBF. PURPOSE To determine if critical, measurable changes occur before spinal cord injury occurs. STUDY DESIGN/SETTING Porcine model. PATIENT SAMPLE Seventeen pigs. OUTCOME MEASURES Spinal cord blood flow, MEP, MAP, neurological injury, spinal canal volume. METHODS After prone positioning and induction, multilevel laminectomies are performed in the midthoracic region. LDF electrodes were placed on the exposed dura in multiple areas to measure real-time SCBF. Spinal cord injury was induced by incremental balloon inflation in the epidural space. After MEP loss (SCI), interventions were carried out: raising the systolic BP, expanding the intravascular volume with colloids, and IV lidocaine. After interventions, wake up test is performed and CT scan was done to measure the thoracic spinal canal volume. Two groups based on intervention timing. Group A: medical interventions before balloon deflation; Group B: balloon deflated first. RESULTS Seventeenpigs were studied, 14 of which survived and completed the experiment. Recordable SCBF changes from baseline were seen 3–32 minutes before MEP loss. For this reason, we considered three minutes to be the critical time before SCI. However, the 20% threshold interval was often reached before the 3-minute mark. Three minutes before MEP loss, change in SCBF was −24.9% and balloon pressure was 9 psi. Balloon volume was 0.63 cc. The spinal canal compromise 3 minutes before MEP signals loss was 69.3%, while SCBF three minutes before MEP loss was 71. This was a 24.85% change from baseline SCBF. In Group A, no pigs moved. In Group B, 9/10 were found to be moving their hind legs. CONCLUSIONS Compression SCI is the end of a cascade involving increasing pressure, decreasing volume and hypoperfusion. Rapid relief of compression leads to MEP return and function. SCBF monitoring can detect ischemia preinjury, giving surgeons an opportunity for early intervention. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Treatment of benign tumors in thoracic spinal canal by modified replanting posterior ligament complex applying piezoelectric osteotomy

To investigate the feasibility and effectiveness of modified replanting posterior ligament complex (PLC) applying piezoelectric osteotomy in the treatment of primary benign tumors in thoracic spinal canal. The clinical data of 38 patients with primary benign tumors in thoracic spinal canal between March 2014 and March 2016 were retrospectively analyzed. There were 16 males and 22 females, aged from 21 to 72 years (mean, 47.1 years). The disease duration ranged from 6 to 57 months (mean, 32.6 months). Pathological examination showed 24 cases of schwannoma, 6 cases of meningioma, 4 cases of ependymoma, 2 cases of lipoma, and 2 cases of dermoid cyst. The lesions located in 18 cases of single segment, 15 cases of double segments, and 5 cases of three segments. The length of the tumors ranged from 0.7 to 6.5 cm. There were boundaries between the tumors and the spinal cord, cauda equina, and nerve roots. The preoperative Japanese Orthopaedic Association (JOA) score was 12.2±2.3 and the thoracic Cobb angle was (11.7±2.7)°. Modified PLC replantation and microsurgical resection were performed with piezoelectric osteotomy. Continuity of uniside supraspinal and interspinous ligaments were preserved during the operation. The PLC was exposed laterally. After removing the tumors under the microscope, the pedicled PLC was replanted in situ and fixed with bilateral micro-reconstruction titanium plate. X-ray film, CT, and MRI examinations were performed to observe spinal stability, spinal canal plasty, and tumor resection after operation. The effectiveness was evaluated by JOA score. The operation time was 56-142 minutes (mean, 77.1 minutes). The intraoperative blood loss was 110-370 mL (mean, 217.2 mL). The tumors were removed completely and the incisions healed well. Three cases complicated with cerebrospinal fluid leakage, and there was no complications such as spinal cord injury and infection. All the 38 patients were followed up 24-28 months (mean, 27.2 months). There was no internal fixation loosening, malposition, or other related complications. At last follow-up, X-ray films showed no sign of kyphosis and instability. CT showed no displacement of vertebral lamina and reduction of secondary spinal canal volume, and vertebral lamina healed well. MRI showed no recurrence of tumors. At last follow-up, the thoracic Cobb angle was (12.3±4.1)°, showing no significant difference when compared with preoperative value ( t=0.753, P=0.456). JOA score increased to 23.7±3.8, showing significant difference when compared with preoperative value ( t=15.960, P=0.000). Among them, 14 cases were excellent, 18 were good, 6 were fair, and the excellent and good rate was 84.2%. Modified replanting PLC applying piezoelectric osteotomy and micro-reconstruction with titanium plate for the primary benign tumors in thoracic spinal canal can reconstruct the anatomy of the spinal canal, enable patients to recover daily activities quickly. It is an effective and safe treatment.

Management of Giant Thoracic Disc Herniation by Thoracoscopic Approach: Experience of 53 Cases.

Giant thoracic disc herniation (gTDH) is a rare condition. It is defined by a herniation that occupies at least 40% of the thoracic spinal canal and is usually calcified. Several surgical techniques have been described to date but this surgery remains a technically difficult procedure. To report the long-term outcome of 53 patients with myelopathy due to gTDH who were operated on by a thoracoscopic approach. The technical details of the preoperative assessment and the surgical procedure are presented. We present a retrospective study of a database of 53 patients operated for symptomatic gTDH by a thoracoscopic approach. The following clinical parameters were assessed initially and used during follow-up: Frankel grade and JOA score adapted to the thoracic spine (mJOA), pain in the lower limbs and limitation of the walking perimeter to less than 500 meters. The quality of spinal cord decompression was assessed postoperatively by magnet resonance imaging (MRI). The mean follow-up was 78.1 mo (SD 49.4). At the last follow-up visit, clinical examination showed a mean improvement of 0.91 Frankel grade (P<0.001) and 2.56 mJOA score respectively (P<0.001). Lower limb pain and walking perimeter were also improved. Postoperative MRI revealed that the resection was complete in 35 cases, subtotal in 13 cases, and incomplete in 5 cases. gTDH is a condition that often evolves favorably after surgery. The thoracoscopic approach is a feasible alternative technique.

P.125 Back “pane” secondary to glass coffee table mishap: a very unusual penetrating injury to the thoracic dura without spinal cord injury

Background: Non-gunshot wound penetrating injury to the spinal canal have been known to have variable injury patterns with respect to trajectory and depth. Methods: We present a case of a penetrating glass fragment injury to the T11-12 level with a cerebrospinal fluid leak. Results: A T11-12 bilateral laminectomy and duraplasty with motor-evoked potential monitoring was performed to remove the foreign object and associated hematoma. The clinical presentation and surgical management are discussed with respect to other non-gunshot-related penetrating spine injuries in the literature. Conclusions: This case demonstrates a very rare injury pattern, as the vast majority of intradural penetrating injuries to the thoracic spine result in complete or incomplete spinal cord injury. This patient was neurologically intact, which is remarkable, given the 7cm glass fragment crossing the thoracic spinal canal transversely from the right to left.

A Spine-Specific Phased Array for Transvertebral Ultrasound Therapy: Design and Simulation.

To design and simulate the performance of two spine-specific phased arrays in sonicating targets spanning the thoracic spine, with the objective of efficiently producing controlled foci in the spinal canal. Two arrays (256 elements each, 500 kHz) were designed using multi-layered ray acoustics simulation: a four-component array with dedicated components for sonicating via the paravertebral and transvertebral paths, and a two-component array with spine-specific adaptive focusing. Mean array efficiency (canal focus pressure/water focus pressure) was evaluated using forward simulation in neutral and flexed spines to investigate methods that reduce spine-induced insertion loss. Target-specific four-component array reconfiguration and lower frequency sonication (250 kHz) were tested to determine their effects on array efficiency and focal dimensions. When neutral, two- and four-component efficiencies were [Formula: see text]% and [Formula: see text]%, respectively, spine flexion significantly increased four-component efficiency ([Formula: see text]%), but not two-component efficiency ([Formula: see text]%). Target-specific four-component re-configuration significantly improved efficiency ([Formula: see text]%). Both arrays produced controlled foci centered within the canal with similar 50% pressure contour dimensions: 10.8-11.9 mm (axial), 4.2-5.6 mm (lateral), and 5.9-6.2 mm (vertical). Simulation at 250 kHz also improved two- and four-component efficiency ([Formula: see text]% and [Formula: see text]%, respectively), but doubled the lateral focal dimensions. Simulation shows that the spine-specific arrays are capable of producing controlled foci in the thoracic spinal canal. The complex geometry of the human spine presents geometrical and acoustical challenges for transspine ultrasound focusing, and the design of these spine-specific ultrasound arrays is crucial to the clinical translation of focused ultrasound for the treatment of spinal cord disease.

Spinal Ischemia Secondary to Central Spine Thoracic Hernia

The thoracic spinal cord is most vulnerable to compression due to the space restriction between the spine and the thoracic spinal canal, and progressive neurological deficit is common. Magnetic resonance imaging (MRI) allows for the diagnosis of vascular diseases, given that the presence of neurological deficit involves other differential diagnoses. This case study’s main goal is to report a case about spinal infarct with surgical procedure of spinal decompression and bring a brief overview of current literature.

Angiopoietin-2 promotes osteogenic differentiation of thoracic ligamentum flavum cells via modulating the Notch signaling pathway.

Thoracic ossification of the ligamentum flavum (TOLF) is heterotopic ossification of spinal ligaments, which may cause serious thoracic spinal canal stenosis and myelopathy. However, the underlying etiology remains inadequately understood. In this study, the ossification patterns of TOLF were analyzed by micro-computer tomography (micro-CT). The expression profile of genes associated with angiogenesis was analyzed in thoracic ligamentum flavum cells at sites of different patterns of ossification using RNA sequencing. Significant differences in the expression profile of several genes were identified from Gene Ontology (GO) analysis. Angiopoietin-2 (ANGPT2) was significantly up-regulated in primary thoracic ligamentum flavum cells during osteogenic differentiation. To address the effect of ANGPT2 on Notch signaling and osteogenesis, ANGPT2 stimulation increased the expression of Notch2 and osteogenic markers of primary thoracic ligamentum flavum cells of immature ossification, while inhibition of ANGPT2 exhibited opposite effect on Notch pathway and osteogenesis of cells of mature ossification. These findings provide the first evidence for positive regulation of ANGPT2 on osteogenic differentiation in human thoracic ligamentum flavum cells via modulating the Notch signaling pathway.

The efficacy and safety of tranexamic acid in reducing perioperative blood loss in patients with multilevel thoracic spinal stenosis

Study Design:A retrospective study.Objective:To investigate the effectiveness and safety of intravenous tranexamic acid for reducing perioperative blood loss in patients with multilevel thoracic spinal stenosis (TSS).Methods:This is a retrospective observational study of 42 patients with multilevel TSS admitted from December 2016 to October 2017 to the spine department of Honghui Hospital who underwent posterolateral bone graft fusion with posterior laminectomy and decompression fixation. The patients were divided into 2 groups. All the surgeries were completed by the same surgeon. Group A received an intravenous infusion of 15 mg/kg 15 min prior to surgery. Continuous infuse on of tranexamic acid (TXA) at a dose of 1 mg/kg/h was provided throughout the operation until the skin was closed. Group B received no TXA as a blank control group. Group A comprised 10 males and 10 females with an average age of 53.41 ± 7.93 years; group B comprised 11 males and 11 females with an average age of 55.10 ± 8.43 years. The need for blood transfusion, volume of blood transfusion, blood coagulation function, extubation time, postoperative hospital stay and incidence of postoperative deep venous thrombosis (DVT) were recorded during and after the operation for the 2 groups.Results:There was no significant difference between the 2 groups in general characteristics, such as age, sex and body mass index (BMI) (P > .05). There was no significant difference between the 2 groups in the levels are instrumented and the laminectomy levels in each group. The average postoperative blood loss, need for blood transfusion, time to postoperative extubation and length of postoperative hospital stay in group A were lower than those in group B, and there was a significant difference between the 2 groups (P < .05). The preoperative and postoperative coagulation, and postoperative DVT did not occur 48 h after operation.Conclusion:In the treatment of multilevel thoracic spinal canal stenosis using trabeculectomy with posterior laminectomy and posterolateral bone graft fusion, TXA can reduce the amount of blood transfused and the need for blood transfusion and can shorten the extubation time and the length of postoperative hospital stay without increasing the incidence of postoperative coagulation dysfunction or postoperative DVT.Level of Evidence: 4

Penetrating spine injury bisecting thoracic spinal canal with no significant neurological deficits-The midline cord syndrome.

In India, the incidence of penetrating spine injury (PSI) is increasing because of the increased use of advanced ballistics (missile PSI) among military personnel and sophisticated tools and construction instruments like nail-guns or drills (non-missile PSI) among civilians. These injuries are associated with a risk of neurological damage, central nervous system infections, vascular injury, dural tear followed by CSF leakage, and spinal instability. A 35-year-old male presented with a non-missile PSI with retained iron nail bisecting his dorsal spinal cord, without any motor deficits. Patient presented with only left lower limb proprioceptive loss and L1-L3 paresthesia. Nail removal was done on emergent basis without any further neurological damage. To the best of our knowledge, this presentation of a non-missile PSI and has not been previously reported. The specific clinical presentation of this distinct type of injury to the midline structures of the spinal cord is hence named "midline cord syndrome".

Normal development of the fetal spinal canal and spinal cord at T12 on 3.0-T MRI.

The studies that described the dimensions of the normal fetal thoracic spinal canal and spinal cord on magnetic resonance imaging (MRI) are scarce. To determine the normal appearance of the fetal spinal canal and spinal cord at T12 across different gestational ages using 3.0-T MRI. The spines of 43 normal human fetuses, aged 15-40 weeks, were scanned by 3.0-T MRI. All specimens were scanned using a GE 3.0-T MRI scanner. Imaging of the T12 vertebrae was performed in the coronal, sagittal, and axial planes. The anterior-posterior (AP) diameter, width, and cross-sectional area of the spinal canal and spinal cord at T12 were measured. The influence of gestational age on these parameters was investigated with a scatter plot and linear regression analysis using Pearson correlation coefficient. The normal morphology of the fetal vertebra at T12 can be clearly showed by MRI; the spinal canal appeared circular, while the spinal cord was ellipsoid. Linear regression analysis showed a significant positive correlation between the AP diameter, width, and cross-sectional area of the spinal canal at T12 and gestational age. Postmortem MRI is a reliable method for understanding the growth dynamics of the spinal canal and spinal cord at T12. Findings from this study would benefit the prenatal diagnosis of congenital malformations by MRI.

Endoscopic Access to the Ventral Thoracic spine: PETD vs. Thoracoscopy

Symptomatic thoracic disc herniation (TDH) is estimated to afflict between 1 in 1,000 and 1 in 1,000,000 people; affecting men more frequently than women, with the highest incidence seen at 40-50 years of age. TDH occurs at all levels of the thoracic spine but 75% of cases occur below T8, with T11-T12 being the most common site due to spinal mobility and weakness of the posterior longitudinal ligament.Manipulation of the thoracic spinal cord through the conventional posterior approach has been associated with poor outcomes. A conventional posterior approach consisting of laminectomy, cord retraction, and disc removal was historically done to treat TDH but this causes spinal cord injury and irreversible paraplegia due to cord manipulation on the relatively rigid spinal cord.The anterior approach to the spine is also intimidating to the spine surgeon due to the unique anatomy of the thoracic spine. Conventional open approaches to the thoracic spine involve a thoracotomy, rib resection, and corpectomy to view the spinal cord anteriorly. This has been associated with perioperative morbidity due to surgical site pain, difficult/painful breathing, shoulder girdle dysfunction, and wound healing problems.In order to spare the patients suffering from these postoperative iatrogenic sequelae, the author presents two different minimally invasive approach techniques; percutaneous endoscopic thoracic discectomy (PETD) vs. thoracoscopy, each applied to a different indication or thoracic pathology, to gain an enough but safe access to the ventral thoracic spinal canal through minimized surgical damages without yielding a postsurgical morbidity.

Spontaneous thoracic epidural hematoma after normal vaginal delivery: a case report and literature review

Spontaneous spinal epidural hematoma (SSEH) is an extremely rare complication in the postpartum period. SSEH in thoracic spine after natural delivery has never been reported. A 25-year-old women presented with acute onset of paraplegia eight hours after normal vaginal delivery. MRI revealed a right lateral mass in the thoracic spinal canal extending from T1 to T2. Prompt decompressive laminectomy was performed within 12 hours after the event. Follow-up at one month post-operation showed a favorable neurological outcome of the patient. In addition, literatures of similar SSEH cases during pregnancy and postpartum period were reviewed, aiming to highlight the importance of early recognition and expedient intervention of SSEH.

Full-endoscopic uniportal decompression in disc herniations and stenosis of the thoracic spine using the interlaminar, extraforaminal, or transthoracic retropleural approach.

OBJECTIVE Surgery for thoracic disc herniation and spinal canal stenosis is comparatively rare and often challenging. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique and approach are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon's experience. The objective of the study was to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the interlaminar, extraforaminal, or transthoracic retropleural approach in patients with symptomatic disc herniation and stenosis of the thoracic spine, taking specific advantages and disadvantages and literature into consideration. METHODS Between 2009 and 2015, decompression was performed in 55 patients with thoracic disc herniation or stenosis using a full-endoscopic uniportal technique via an interlaminar, extraforaminal, or transthoracic retropleural approach. Imaging and clinical data were collected during follow-up examinations for 18 months. RESULTS Sufficient decompression was achieved in the full-endoscopic uniportal technique. One patient required revision due to secondary bleeding, and another exhibited persistent deterioration on myelopathy. No other serious complications were observed. All but one patient experienced regression or improvement of their symptoms. CONCLUSIONS The full-endoscopic uniportal technique with an interlaminar, extraforaminal, or transthoracic retropleural approach was found to be a sufficient and minimally invasive method. To cover the entire range of thoracic disc herniations and stenosis within the criteria named, all full-endoscopic approaches are required.