Spinal Canal Research Articles

Lumbar fusion efficacy with local bone grafting and platelet-rich plasma: a clinical investigation in treating degenerative lumbar spinal stenosis in the elderly.

The focus of this study was to comprehensively assess the clinical outcomes of lumbar fusion utilizing autogenous bone grafting and platelet-rich plasma (PRP) for the management of degenerative lumbar spinal stenosis (DLSS) in elderly individuals. A cohort of 40 senior individuals diagnosed with DLSS, who underwent treatment at our hospital between January 2020 and March 2022. The control group consisted of 20 participants who underwent local bone grafting for intervertebral fusion, while the observation group comprised 20 individuals who received a combination of local bone grafting and PRP for lumbar fusion. MRI imaging was employed for a comprehensive assessment of spinal structure. The efficacy of spinal fusion was evaluated through MRI imaging. Clinical treatment outcomes were assessed using the Japanese Orthopaedic Association (JOA) and Oswestry Disability Index (ODI) scoring systems. Postoperative low back pain was quantified using a Visual Analog Scale (VAS). During the final follow-up, the observation group demonstrated a significant increase in the inner diameter of the spinal canal and the height of the disc space compared to the control group (P < 0.05).Moreover, the observation group displayed a larger spinal canal than the control group (P < 0.05).A reduced lesion score in the bone grafting region was observed in the observation group compared to the control group during the final follow-up (P < 0.05). Furthermore, the observation group displayed a higher intervertebral fusion continuity score than the control group (P < 0.05).The JOA score in the observation group was significantly higher than in the control group (P < 0.05), while the ODI score was significantly lower (P < 0.05). Of note, the back pain VAS score in the observation group was lower than in the control group at both the three months post-surgery mark and the final follow-up (P < 0.05).The satisfaction rate and overall satisfaction rate in the observation group were significantly higher than those in the control group (P < 0.05), while the dissatisfaction rate in the observation group was evidently lower than in the control group (P < 0.05). In the management of DLSS in elderly individuals, the utilization of local bone grafting and PRP in lumbar spinal fusion yields notable outcomes.

Risk factors and clinical significance of posterior slip of the proximal vertebral body after lower lumbar fusion.

Adjacent segment disease (ASD) after fusion surgery is frequently manifests as a cranial segment instability, disc herniation, spinal canal stenosis, spondylolisthesis or retrolisthesis. The risk factors and mechanisms of ASD have been widely discussed but never clearly defined. To investigate the risk factors and clinical significance of retrograde movement of the proximal vertebral body after lower lumbar fusion. This was a retrospective analysis of the clinical data of patients who underwent transforaminal lumbar interbody fusion surgery between September 2015 and July 2021 and who were followed up for more than 2 years. Ninety-one patients with degenerative lumbar diseases were included (22 males and 69 females), with an average age of 52.3 years (40-73 years). According to whether there was retrograde movement of the adjacent vertebral body on postoperative X-rays, the patients were divided into retrograde and nonretrograde groups. The sagittal parameters of the spine and pelvis were evaluated before surgery, after surgery, and at the final follow-up. At the same time, the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were used to evaluate the patients' quality of life. Nineteen patients (20.9%) who experienced retrograde movement of proximal adjacent segments were included in this study. The pelvic incidence (PI) of the patients in the retrograde group were significantly higher than those of the patients in the nonretrograde group before surgery, after surgery and at the final follow-up (P < 0.05). There was no significant difference in lumbar lordosis (LL) between the two groups before the operation, but LL in the retrograde group was significantly greater than that in the nonretrograde group postoperatively and at the final follow-up. No significant differences were detected in terms of the |PI-LL|, and there was no significant difference in the preoperative lordosis distribution index (LDI) between the two groups. The LDIs of the retrograde group were 68.1% ± 11.5% and 67.2% ± 11.9%, respectively, which were significantly lower than those of the nonretrograde group (75.7% ± 10.4% and 74.3% ± 9.4%, respectively) (P < 0.05). Moreover, the patients in the retrograde group had a greater incidence of a LDI < 50% than those in the nonretrograde group (P < 0.05). There were no significant differences in the ODI or VAS scores between the two groups before the operation, but the ODI and VAS scores in the retrograde group were significantly worse than those in the nonretrograde group after the operation and at the last follow-up, (P < 0.05). The incidence of posterior slippage after lower lumbar fusion was approximately 20.9%. The risk factors are related to a higher PI and distribution of lumbar lordosis. When a patient has a high PI and insufficient reconstruction of the lower lumbar spine, adjacent segment compensation via posterior vertebral body slippage is one of the factors that significantly affects surgical outcomes.

Geometric target margin strategy of proton craniospinal irradiation for pediatric medulloblastoma.

In proton craniospinal irradiation (CSI) for skeletally immature pediatric patients, a treatment plan should be developed to ensure that the dose is uniformly delivered to all vertebrae, considering the effects on bone growth balance. The technical (t) clinical target volume (CTV) is conventionally set by manually expanding the CTV from the entire intracranial space and thecal sac, based on the physician's experience. However, there are differences in contouring methods among physicians. Therefore, we aimed to propose a new geometric target margin strategy. Nine pediatric patients with medulloblastoma who underwent proton CSI were enrolled. We measured the following water equivalent lengths for each vertebra in each patient: body surface to the dorsal spinal canal, vertebral limbus, ventral spinal canal and spinous processes. A simulated tCTV (stCTV) was created by assigning geometric margins to the spinal canal using the measurement results such that the vertebral limb and dose distribution coincided with a margin assigned to account for the uncertainty of the proton beam range. The stCTV with a growth factor (correlation between body surface area and age) and tCTV were compared and evaluated. The median values of each index for cervical, thoracic and lumber spine were: the Hausdorff distance, 9.14, 9.84 and 9.77mm; mean distance-to-agreement, 3.26, 2.65 and 2.64mm; Dice coefficient, 0.84, 0.81 and 0.82 and Jaccard coefficient, 0.50, 0.60 and 0.62, respectively. The geometric target margin setting method used in this study was useful for creating an stCTV to ensure consistent and uniform planning.

Cervical Spinal Stenosis - Modern Approaches to Diagnosis and Treatment

The article analyzes in detail the scientific literature on the etiology, classification, diagnosis, clinical picture and treatment of spinal canal stenosis in the cervical spine. Special attention is paid to the clinical picture, diagnosis and differential diagnosis of the causes of cervical myelopathy. Further, the work presents all modern methods of treatment of cervical spinal stenosis. The researchers divided the methods into ventral and dorsal. The advantages and disadvantages of each type of operation are described. In conclusion, the authors summarized the indications and contraindications for each type of surgical aid.

A breakthrough in lumbar surgery: ipsilateral interlaminar endoscopy and its impact on spinal stability and patient outcomes.

Lumbar stenosis (LS) often leads to debilitating symptoms due to nerve compression in the spinal canal. As this condition becomes increasingly prevalent among the elderly, innovative surgical techniques are crucial. This letter examines a recent advancement introduced by Marco Aurélio Moscatelli et al., who have developed an ipsilateral interlaminar endoscopic approach for decompression at the L5-S1 level. Their study, involving 30 patients with degenerative stenosis, reports significant improvements in quality-of-life metrics, including the Oswestry Disability Index (ODI) and visual analog scales (VAS) for pain. The new approach not only overcomes anatomical challenges specific to the L5-S1 region but also offers enhanced visualization and extensive decompression without destabilizing the spine. This letter highlights the promising results of this technique, the utility of the FAPDIS algorithm in guiding surgical choices, and the broader implications for minimally invasive lumbar surgery. The findings underscore a potential shift towards more effective and safer interventions for lumbar stenosis, paving the way for better patient outcomes in spinal decompression.

Percutaneous endoscopic transforaminal decompression surgery for symptomatic double-level lumbar spinal stenosis with ossification.

This study aimed to explore the short-term effects of percutaneous endoscopic transforaminal decompression (PETD) for the treatment of symptomatic double-level lumbar spinal stenosis (LSS) with ossification. Twenty-eight patients diagnosed with double-level lumbar spinal stenosis who underwent double-level PETD surgery between January 2021 and January 2023 at our institution. General information, such as age, sex, disease duration, hospitalization time, and operation time, was recorded. Magnetic resonance imaging (MRI) dural sac cross-sectional area (DSCA) was recorded to assess the degree of spinal canal decompression. The White-Panjabi scoring system (WP) was used to assess preoperative and postoperative lumbar spine stability. Pre- and postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were recorded to assess symptom improvement, and surgical efficacy was evaluated using the modified Macnab evaluation criteria at the 1-year postoperative follow-up. The types and risks of complications were also recorded. The patient's 1-year postoperative follow-up MRI showed that both L3/4 and L4/5 DSCA were significantly enlarged compared with preoperative values (P < .001). There was no significant difference in the WP scores at 3 months postoperatively compared with those preoperatively (P > .05). The VAS scores for hip and lower extremity pain at 3 days, 3 months, and 1 year postoperatively were significantly lower than those preoperatively (P < .001), and the ODI scores at 3 months and 1 year postoperatively were significantly lower than those preoperatively (P < .001). There were no significant differences in hip pain, lower extremity pain VAS scores, or ODI scores between the postoperative follow-up time points (P > .05). There was 1 case of lower limb numbness and 1 case of neuroedematous pain in the postoperative period, and all patients had no complications, such as dural sac tear, infection, or recurrence. The 1-year postoperative follow-up was assessed as excellent in 17 cases, good in 9 cases, and possible in 2 cases using the modified Macnab criteria, with an excellent rate of 92.9%. The efficacy of double-level PETD for symptomatic double-level LSS is clear, the local stability of the lumbar spine is less affected, and the risk is low, which can reduce the chances of reoperation in patients. Thus, it is a recommended surgical procedure.

Lumbar laminectomy and washout of emphysematous osteomyelitis infection of the spine: illustrative case.

Emphysematous osteomyelitis (EO) is a rare, rapidly progressing infection characterized by gas within bones, leading to severe morbidity if untreated. In the spine, EO can cause significant bone destruction and instability, requiring urgent surgical and medical intervention. Early diagnosis and a multidisciplinary approach are crucial for effective management and improved patient outcomes. The authors present a unique case of EO involving the lumbar spine in a 40-year-old male patient with a medical history of diabetes mellitus, hyperlipidemia, and hypertension. Magnetic resonance imaging and computed tomography revealed the formation of gas within the L4 vertebral body and spinal canal, which led to the diagnosis of EO. Blood cultures grew Streptococcus dysgalactiae. The patient underwent laminectomy, discectomy, and vertebral body abscess washout to prevent further spread of the infection and successfully recovered. The authors report the first case of spinal EO caused by S. dysgalactiae, treated using laminectomy with debridement of the affected disc spaces. https://thejns.org/doi/10.3171/CASE24434.

Cervical Disc Arthroplasty Device Failure Causing Progressive Cervical Myelopathy and Requiring Revision Cervical Corpectomy.

Cervical disc arthroplasty is a well-established alternative to anterior cervical fusion but requires precise placement for optimal outcomes. We present the case of a 2-level cervical disc arthroplasty with suboptimal implantation of the interbody devices, requiring revision corpectomy. Supplemental video, Supplemental Digital Content 1 (http://links.lww.com/CLINSPINE/A358) content of the revision surgery is also provided. This report highlights the importance of proper implant sizing and position and reviews the nuances of surgical revision. A retrospective review of the clinical and radiographic data was performed from prior to the index operation through the 3-month postoperative period after the surgical revision. The patient presented approximately 2 years post-cervical arthroplasty with increasing neck pain and early cervical myelopathy. An imaging workup revealed severe cervical stenosis at the caudal level with cord compression and concern for device failure. Intraoperatively, the core of the caudal device was found to have ejected into the spinal canal. A cervical corpectomy of the intervening vertebra with the removal of both devices was performed. The patient had a complete neurologic recovery. Although failure of a cervical disc arthroplasty device is rare, the likelihood can be significantly increased with poor sizing (over or under sizing), asymmetric placement, endplate violation, or poor patient selection. In the case presented herein, early device failure was unrecognized, and the patient went on to develop progressive cervical myelopathy requiring revision corpectomy.

Surgical treatment of spinal neurenteric cysts

Background. Spinal neurenteric cysts are very rare benign space-occupying lesions in the vertebral canal emerging due to anomalies of neural tube development during prenatal development of the fetus. Clinically, neurenteric cysts can manifest both in childhood and adulthood.Aim. To evaluate the results of surgical treatment of adult patients with spinal neurenteric cysts who were operated on at the Neurosurgery Division of the Clinic of Nervous System Diseases of the I.M. Sechenov First Moscow State Medical University.Materials and methods. The study group included 3 patients (2 women and 1 man) with mean age of 33 years. The main diagnosis method was magnetic resonance imaging. In all cases, radical cyst resection was performed with subsequent histological examination of cyst walls.Results. In all observations, cyst walls had local areas of increased density and thickness: a distinctive solid component accumulating the contrast agent in magnetic resonance images. This type of structure is considered extremely rare per descriptions presented in literature, but in our case series it was detected in all patients. Cyst resection led to pain syndrome regression and almost full regression of clinical manifestations of spinal cord compression which justifies active surgical tactics in this pathology.Conclusion. Neurenteric cyst of the vertebral canal can cause spinal cord compression. The main diagnostic method of this pathology is magnetic resonance imaging, however magnetic resonance semiotics of these cyst has not been standardized. The presence of constant pain syndrome without marked clinical signs of compression myelopathy is sufficient reason for cyst resection surgery. Cyst resection allowsto achieve regression of pain syndrome and neurological abnormalities caused by spinal cord compression.

Resection of a giant intraspinal and extraspinal schwannoma with cystic change using a two-step surgery: a case report

BackgroundSchwannomas originating from the intravertebral canal rarely extend into the paravertebral region or form large masses. There are few reports on such medical cases, and their clinical diagnosis and management are poorly understood. Here, we report a case of an intraspinal schwannoma with a giant extraspinal mass in a middle-aged Chinese woman and the clinical implications of the symptoms, diagnosis, and treatment of thoracic vertebral schwannoma.Case presentationA 59-year-old female patient who presented with sudden lower limb numbness and difficulty in walking was referred to our department. Magnetic resonance imaging (MRI) revealed a tumor compressing the T11-T12 spinal canal and extensively invading the left thoracic cavity to form a giant paravertebral mass. Schwannoma was diagnosed after intraoperative pathological examination, in which tumor cells were immunoreactive to S100 and Sox10 but negative for smooth muscle actin (SMH). Intraspinal mass resection through the posterior approach and extraspinal chest mass resection under video-assisted thoracoscopy through the left lateral approach were performed simultaneously, and instrumentation was used to maintain thoracic spinal stability.ConclusionIn patients with large schwannomas, customized treatment plans are crucial. Tailoring the approach to an individual’s specific condition by considering factors such as tumor size and location is essential for optimal outcomes.

Single-Center Experience and Literature Review of Radiotherapy Outcomes for Adult Ependymomas

Objective: To retrospectively determine the long-term outcome of adult intracranial and spinal ependymoma patients treated with postoperative radiation therapy after surgery. Methods: Fourteen adult patients who underwent radiotherapy after surgery at a single center between 1999 and 2022 were included. The endpoints analyzed were overall survival and progression-free survival, together with prognostic factors. Results: The median (range) age was 29.5 (23–58) years. The majority (71.4%) of the tumors were located in the spinal canal and gross total resection was performed in nine (64.3%) patients. Six patients were irradiated after recurrence (spinal n=4, intracranial n=2) of whom three had myxopapillary and two had anaplastic histology. Patients were followed up for a median duration of 106.5 (13-172) months. Overall, 4 patients (intracranial n=3, spinal n=1) had recurrences and died after radiotherapy as a direct result of disease progression during the follow-up period. All of these intracranial tumors exhibited anaplastic histology and the spinal tumor was myxopapillary type. Patients with intracranial lesions had a 5-year survival of 50% and no patient was alive on the 10th year, compared with 5- and 10-year overall survival of 87.5 % for patients with spinal tumors. Patients with spinal tumors had a 5- and 10-year progression-free survival rate of 52.5%, while those with intracranial lesions had a rate of 25%. Conclusion: In low-grade spinal ependymomas radiotherapy appears to control disease, even after recurrence. For myxopapillary ependymoma patients, in subtotally resected intracranial and all high-grade tumors, regardless of the extent of resection, adjuvant radiotherapy should be administered.

Ischemia-reperfusion injury after spinal cord decompressive surgery-An invivo rat model.

Although decompression surgery is the optimal treatment for patients with severe degenerative cervical myelopathy (DCM), some individuals experience no improvement or even a decline in neurological function after surgery, with spinal cord ischemia-reperfusion injury (SCII) identified as the primary cause. Spinal cord compression results in local ischemia and blood perfusion following decompression is fundamental to SCII. However, owing to inadequate perioperative blood flow monitoring, direct evidence regarding the occurrence of SCII after decompression is lacking. The objective of this study was to establish a suitable animal model for investigating the underlying mechanism of spinal cord ischemia-reperfusion injury following decompression surgery for degenerative cervical myelopathy (DCM) and to elucidate alterations in neurological function and local blood flow within the spinal cord before and after decompression. Twenty-four Sprague-Dawley rats were allocated to three groups: the DCM group (cervical compression group, with implanted compression material in the spinal canal, n = 8), the DCM-D group (cervical decompression group, with removal of compression material from the spinal canal 4 weeks after implantation, n = 8), and the SHAM group (sham operation, n = 8). Von Frey test, forepaw grip strength, and gait were assessed within 4 weeks post-implantation. Spinal cord compression was evaluated using magnetic resonance imaging. Local blood flow in the spinal cord was monitored during the perioperative decompression. The rats were sacrificed 1 week after decompression to observe morphological changes in the compressed or decompressed segments of the spinal cord. Additionally, NeuN expression and the oxidative damage marker 8-oxoG DNA were analyzed. Following spinal cord compression, abnormal mechanical pain worsened, and a decrease in forepaw grip strength was observed within 1-4 weeks. Upon decompression, the abnormal mechanical pain subsided, and forepaw grip strength was restored; however, neither reached the level of the sham operation group. Decompression leads to an increase in the local blood flow, indicating improved perfusion of the spinal cord. The number of NeuN-positive cells in the spinal cord of rats in the DCM-D group exceeded that in the DCM group but remained lower than that in the SHAM group. Notably, a higher level of 8-oxoG DNA expression was observed, suggesting oxidative stress following spinal cord decompression. This model is deemed suitable for analyzing the underlying mechanism of SCII following decompressive cervical laminectomy, as we posit that the obtained results are comparable to the clinical progression of degenerative cervical myelopathy (DCM) post-decompression and exhibit analogous neurological alterations. Notably, this model revealed ischemic reperfusion in the spinal cord after decompression, concomitant with oxidative damage, which plausibly underlies the neurological deterioration observed after decompression.

Deep learning model for automated diagnosis of degenerative cervical spondylosis and altered spinal cord signal on MRI

BACKGROUND CONTEXTA deep learning (DL) model for degenerative cervical spondylosis on MRI could enhance reporting consistency and efficiency, addressing a significant global health issue. PURPOSECreate a DL model to detect and classify cervical cord signal abnormalities, spinal canal and neural foraminal stenosis. STUDY DESIGN/SETTINGRetrospective study conducted from January 2013 to July 2021, excluding cases with instrumentation. PATIENT SAMPLEOverall, 504 MRI cervical spines were analyzed (504 patients, mean=58 years±13.7[SD]; 202 women) with 454 for training (90%) and 50 (10%) for internal testing. In addition, 100 MRI cervical spines were available for external testing (100 patients, mean=60 years±13.0[SD];26 women). OUTCOME MEASURESAutomated detection and classification of spinal canal stenosis, neural foraminal stenosis, and cord signal abnormality using the DL model. Recall(%), inter-rater agreement (Gwet's kappa), sensitivity, and specificity were calculated. METHODSUtilizing axial T2-weighted gradient echo and sagittal T2-weighted images, a transformer-based DL model was trained on data labeled by an experienced musculoskeletal radiologist (12 years of experience). Internal testing involved data labeled in consensus by two musculoskeletal radiologists (reference standard, both with 12-years-experience), two subspecialist radiologists, and two in-training radiologists. External testing was performed. RESULTSThe DL model exhibited substantial agreement surpassing all readers in all classes for spinal canal (κ=0.78, p<0.001 vs. κ range=0.57-0.70 for readers) and neural foraminal stenosis (κ=0.80, p<0.001 vs. κ range=0.63-0.69 for readers) classification. The DL model's recall for cord signal abnormality (92.3%) was similar to all readers (range: 92.3-100.0%). Nearly perfect agreement was demonstrated for binary classification (normal/mild vs. moderate/severe) (κ=0.95, p<0.001 for spinal canal; κ=0.90, p<0.001 for neural foramina). External testing showed substantial agreement using all classes (κ=0.76, p<0.001 for spinal canal; κ=0.66, p<0.001 for neural foramina) and high recall for cord signal abnormality (91.9%). The DL model demonstrated high sensitivities (range:83.7%–92.4%) and specificities (range:87.8%–98.3%) on both internal and external datasets for spinal canal and neural foramina classification. CONCLUSIONSOur DL model for degenerative cervical spondylosis on MRI showed good performance, demonstrating substantial agreement with the reference standard. This tool could assist radiologists in improving the efficiency and consistency of MRI cervical spondylosis assessments in clinical practice.

Anterior Cervical Discectomy and Fusion for the Treatment of Pincer Cervical Spondylotic Myelopathy: A Single-Center Retrospective Study

BackgroundAnterior and posterior compression of the cervical spinal cord is usually called pincer cervical spondylotic myelopathy (p-CSM), and surgery is generally recommended; however, there is some controversy about the choice of surgical approach because single anterior or posterior surgery cannot effectively relieve contralateral compression, and combined surgery may cause problems related to trauma and effects on cervical spine function. ObjectiveTo investigate the feasibility and indications of single anterior cervical discectomy and fusion (ACDF) for the treatment of p-CSM. MethodsThe data of twenty-one p-CSM patients who were treated with ACDF at a single center from 2019 to 2022 were collected. Neurological status was evaluated by the Japanese Orthopedic Association (JOA) scoring system. The radiological parameters included the percentage of space occupied by the spinal canal, the cervical sagittal Cobb angle, and the cross-sectional area of the spinal cord before and after the operation. Complications and spinal cord compression rates were also observed. Correlations between the decompressive effects and various prognostic factors were statistically analyzed. ResultsThe mean follow-up period was 24.1±3.55 months. The average JOA score significantly increased, with a mean recovery rate of 65.88±8.97%. The fusion rate was satisfactory. Correlation analysis revealed that the number of operation segments and age were important predictors of decompressive effects. There was no further deterioration of spinal cord function after the operation. ConclusionACDF is an effective method for treating pincer spinal cord compression in terms of neurological recovery, radiological parameters, fusion rates, and complications, especially for patients younger than 60 years of age with single operative segments.

Age as a predictor of reoperations and complications in surgically managed pediatric Chiari malformation type I

OBJECTIVE Chiari malformation type I (CM-I) is defined by the herniation of the cerebellar tonsils into the spinal canal. When symptomatic, surgical decompression is recommended. Reported CM-I reoperation rates have ranged from 3% to 30%. However, the relationship between patient age at first surgical intervention and the likelihood of reoperation and postoperative complications remains poorly characterized. Therefore, this study aimed to determine whether patient age was associated with reoperation and complication rates. METHODS Patients 0–21 years old with a diagnosis of CM-I and surgical decompression were queried from the 2007–2021 MarketScan databases. Patient sex, age at time of first procedure, comorbidities, 90-day postoperative complications, and reoperations were identified. Bootstrap-augmented binary classifiers were constructed to determine the optimal timing of first surgical decompression with respect to all-cause 90-day postoperative complications and reoperation. Multivariate logistic regression models were built to assess the relationship between age, sex, and comorbidities and the likelihood of reoperation and complications following surgical decompression. RESULTS A total of 2675 patients were included for analysis of 90-day postoperative complications, and 1157 were included in the reoperation analysis cohort. A total of 524 patients (19.6%) experienced a complication within 90 days of surgical decompression, and 84 patients (7.3%) had reoperations. On multivariate regression, increased age was an independent predictor of a reduced likelihood of both reoperations (OR 0.94, 95% CI 0.90–0.98; p &lt; 0.01) and 90-day postoperative complications (OR 0.96, 95% CI 0.94–0.98; p &lt; 0.01). The optimal age cutoff to predict both complications and reoperations was 4 years. For patients ages 4 years and older, both the reoperation rate (5.5% vs 13.2%, p &lt; 0.01) and 90-day postoperative complication rates (18.4% vs 27.7%; p &lt; 0.01) were significantly less than those for children 3 years and younger. CONCLUSIONS In a national cohort of pediatric patients undergoing surgically managed CM-I, there was a significantly increased likelihood of reoperation and complications in patients ages 3 years and younger. Although CM-I decompression should not be postponed in the face of progressive neurological deficits, the authors’ findings suggest that delaying surgery until after the age of 3 years, when medically feasible, may help mitigate adverse events.

What Degree of Radiological Compression Predicts Cauda Equina Syndrome: A Retrospective Study at a National Tertiary Center

ObjectiveCauda Equina Syndrome (CES) is diagnosed both clinically and radiologically. However, it's unclear if a specific degree of cauda equina compression (CEC) on imaging can confirm the diagnosis. This study aimed to identify an optimal percentage of prolapse to canal ratio (PCR) on MRI that correlates with CEC, facilitating reliable decision-making for CES symptoms. MethodsA single-center retrospective case series analysis was conducted from 2020 to 2021. Sixty-one patients who underwent emergency lumbar discectomy within 48 hours of presentation were included, divided into a CES group and a disc prolapse (DP) group. CES cases were identified using ICD-10 code G83.4. PCR was calculated by dividing the width of the disc herniation by the total width of the spinal canal at the level of the herniation on single mid-sagittal T2 MRI scans, using the IC Measure software on Windows. ResultsCES most frequently occurred at the L4/5 level (37/61). The median PCR in CES cases was 76.19% (66.67 – 85.71), significantly higher than in DP cases, 48.08% (31.33 – 55.56) (p<0.001). A PCR threshold of 40% maximized sensitivity at 100% but had a specificity of 45%. Conversely, a threshold of 75% maximized specificity at 100% with a sensitivity of 50%. The optimal PCR, determined by the Youden index, was 66%, yielding a sensitivity of 75% and specificity of 97%, with an area under the curve (AUC) of 0.923. ConclusionsSimple radiological measurements of PCR can potentially triage CES patients and guide their management. Future studies should correlate PCR with clinical signs and symptoms for a comprehensive assessment.

Types of high-riding vertebral artery: a classification system for preoperative planning of C2 instrumentation based on 908 potential screw insertion sites

BACKGROUND CONTEXTOur recent studies indicated that a high-riding vertebral artery (HRVA) is a common variant posing a risk of injuring the vessel during C2 instrumentation. However, several different types fit in the current definition of HRVA, which may require a different strategy for C2 screw placement. PURPOSETo classify HRVA and provide a clinical aid for preoperative planning of C2 instrumentation. A secondary goal was to estimate coexistence of each HRVA type with the ipsilateral narrow C2 pedicle (NP). STUDY DESIGNA retrospective observational study involving radiologic measurements of the estimated number of anonymized cervical computed tomography (CT) scans. STROBE checklist was applied. PATIENT SAMPLEA total of 908 potential screw insertion sites (PSIS) of 454 consecutive cervical CT scans were analyzed. The sample size was estimated using ScalaR SP function in RStudio. OUTCOME MEASURESThree types of HRVA based on a series of C2 vertebral morphological parameters including the C2 isthmus height (C2IsH) and C2 internal height (C2InH). Also, the prevalences of each HRVA type and coexisting NP based on the C2 pedicle width (C2PW). METHODSHRVA was defined as C2IsH of ≤5 mm and/or C2InH of ≤2 mm measured 3 mm lateral to the lateral border of the spinal canal. A narrow pedicle was defined as C2PW of ≤4 mm. Measurements were done using Syn.govia software. Interobserver, intraobserver, and inter-software agreement coefficients for C2IsH, C2InH, and C2PW parameters were adopted from our previous study. K-means cluster analysis was applied. RESULTSPrevalence of at least 1 HRVA was 24.9% (n=113 subjects) and 16.2% of PSIS (n=147 sites). Based on the measurements and K-means clustering, the following 3 types of HRVA have been distinguished: type 1—isthmic with only C2IsH being reduced and normal C2InH; type 2—internal with only C2InH being reduced and C2IsH within normal limits; type 3—isthmo-internal with both C2IsH and C2InH being reduced. Kruskal-Wallis test followed by unadjusted and Bonferroni-adjusted post-hoc multiple comparison analysis detected significant differences across the types. The prevalences of the newly identified types were as follows: 78.2%, 8.8%, and 12.9% for type 1, type 2, and type 3, respectively. 73.9% of type 1 HRVA, 53.8% of type 2 HRVA, and 100% of type 3 HRVA had a concomitant ipsilateral NP. Prediction of the HRVA types by the K-means clustering has been evaluated. Screw placement techniques for each type are proposed and discussed. CONCLUSIONWe present the first classification system for the high-riding vertebral artery distinguishing 3 types based on the large homogenous cohort, which may serve as an adjunct to preoperative planning of C2 instrumentation. External validation of this classification scheme shall determine its further clinical utility.

Correlation of interpedicular distance widening and spinal canal narrowing to neurological status of thoracolumbar burst fracture

Correlation of interpedicular distance widening and spinal canal narrowing to neurological status of thoracolumbar burst fracture

CSF dynamics throughout the ventricular system using 4D flow MRI: associations to arterial pulsatility, ventricular volumes, and age

BackgroundCerebrospinal fluid (CSF) dynamics are increasingly studied in aging and neurological disorders. Models of CSF-mediated waste clearance suggest that altered CSF dynamics could play a role in the accumulation of toxic waste in the CNS, with implications for Alzheimer’s disease and other proteinopathies. Therefore, approaches that enable quantitative and volumetric assessment of CSF flow velocities could be of value. In this study we demonstrate the feasibility of 4D flow MRI for simultaneous assessment of CSF dynamics throughout the ventricular system, and evaluate associations to arterial pulsatility, ventricular volumes, and age.MethodsIn a cognitively unimpaired cohort (N = 43; age 41–83 years), cardiac-resolved 4D flow MRI CSF velocities were obtained in the lateral ventricles (LV), foramens of Monro, third and fourth ventricles (V3 and V4), the cerebral aqueduct (CA) and the spinal canal (SC), using a velocity encoding (venc) of 5 cm/s. Cerebral blood flow pulsatility was also assessed with 4D flow (venc = 80 cm/s), and CSF volumes were obtained from T1- and T2-weighted MRI. Multiple linear regression was used to assess effects of age, ventricular volumes, and arterial pulsatility on CSF velocities.ResultsCardiac-driven CSF dynamics were observed in all CSF spaces, with region-averaged velocity range and root-mean-square (RMS) velocity encompassing from very low in the LVs (RMS 0.25 ± 0.08; range 0.85 ± 0.28 mm/s) to relatively high in the CA (RMS 6.29 ± 2.87; range 18.6 ± 15.2 mm/s). In the regression models, CSF velocity was significantly related to age in 5/6 regions, to CSF space volume in 2/3 regions, and to arterial pulsatility in 3/6 regions. Group-averaged waveforms indicated distinct CSF flow propagation delays throughout CSF spaces, particularly between the SC and LVs.ConclusionsOur findings show that 4D flow MRI enables assessment of CSF dynamics throughout the ventricular system, and captures independent effects of age, CSF space morphology, and arterial pulsatility on CSF motion.

The effect of using synthetic vs. biological dural substitutes during prenatal and postnatal repair of spina bifida on spinal cord tethering-a review of literature.

Spina bifida is a congenital neural tube closure defect, with myelomeningocele being the most clinically significant open neural tube defect occurring in one in 1000 births worldwide as reported by Phillips LA et al. (Curr Probl Pediatr Adolesc Health Care 47(7):173-177, 2017) and Zerah M and Kulkarni AV (Handb Clin Neurol 112:975-991, 2013). With advances in fetal surgery, this condition can be corrected in utero. Despite such precision surgery, many complications may still arise, with consequent spinal cord tethering being a major one. When the roots of the spinal cord adhere to the spinal canal instead of floating freely within the dural sleeve within the canal, it is termed as "tethering" as discussed by Martínez-Lage JF et al. (Neurocirugia (Astur) 18(4):312-319, 2007). Tethering has a variety of complications, which are best avoided by analyzing the outcomes of the different dural substitutes and improving surgical techniques. This literature review evaluates the use of different dural substitutes in fetal and postnatal surgery, with their effects on spinal cord tethering. Finding a significant difference in spinal cord adherence outcomes between these two groups can help one introspect on the impact of ideal surgical techniques to be implemented, thus reducing subsequent tethering and other future surgical interventions.