Microsurgical anatomy of the Adamkiewicz artery-anterior spinal artery junction

Clinical effect of limited posterior decompression and 13-mm titanium mesh implantation on severe thoracolumbar burst fractures: A case series

Background

Posterior incision with 270° spinal canal decompression and reconstruction surgery is a treatment option for thoracolumbar burst fractures (TLBF), but the large diameter titanium mesh placement is difficult. This study evaluated the characteristics and clinical effects of limited posterior decompression and 13-mm titanium mesh implantation to treat TLBF.

Hypothesis

13-mm titanium meshes could be used to fix thoracolumbar burst fractures.

Patients and methods

This case series included patients who underwent limited posterior decompression and 13-mm titanium mesh implantation at China Medical University Shaoxing Hospital (01/2015–12/2019). The Cobb angle, injury vertebral anterior edge height loss percentage, and spinal canal occupancy rate were analyzed. The degree of spinal cord injury was evaluated according to the ASIA grade.

Results

Fifteen patients were included (eight males and seven females). The patients were 32.2 ± 4.6 years of age. The American Association of Spinal Injury improved after surgery (A/B/C/D/E: from 2/6/5/2/0 to 0/0/2/8/5, P < 0.001). The Cobb angle decreased after surgery (from 20.1 ± 4.8° to 7.1 ± 1.4°, P < 0.001) but increased to 8.2 ± 0.9° at 1 year (P = 0.003). The percentage of loss of the anterior edge height of the injured vertebrae decreased after surgery (from 40.9% ± 6.1% to 7.5% ± 1.8%, P < 0.001) and decreased at 1 year (7.0% ± 1.5%, P = 0.044). The spinal canal occupancy rate decreased after surgery (from 64.8% ± 7.8% to 20.1% ± 4.2%, P < 0.001) but did not decrease further at 1 year (19.4% ± 3.4%, P = 0.166).

Discussion

Spinal canal limited posterior decompression, and 13-mm titanium mesh implantation in the treatment of TLBF can achieve one-stage spinal canal decompression and three-column reconstruction. The curative effect was satisfying.

Level of evidence

Level IV; case series.

Identification of the Magna Radicular Artery Entry Foramen and Adamkiewicz System: Patient Selection for Open versus Full-Endoscopic Thoracic Spinal Decompression Surgery

BACKGROUND

Casually cauterizing the radicular magna during routine thoracic discectomy may have dire consequences.

METHODS

We performed a retrospective observational cohort study on patients scheduled for decompression of symptomatic thoracic herniated discs and spinal stenosis who underwent a preoperative computed tomography angiography (CTA) to assess the surgical risks by anatomically defining the foraminal entry level of the magna radicularis artery into the thoracic spinal cord and its relationship to the surgical level.

RESULTS

Fifteen patients aged 58.53 ± 19.57, ranging from 31 to 89 years, with an average follow-up of 30.13 ± 13.42 months, were enrolled in this observational cohort study. The mean preoperative VAS for axial back pain was VAS of 8.53 ± 2.06 and reduced to a postoperative VAS of 1.60 ± 0.92 (p < 0.0001) at the final follow-up. The Adamkiewicz was most frequently found at T10/11 (15.4%), T11/12 (23.1%), and T9/10 (30.8%). There were eight patients where the painful pathology was found far from the AKA foraminal entry-level (type 1), three patients with near location (type 2), and another four patients needing decompression at the foraminal (type 3) entry-level. In five of the fifteen patients, the magna radicularis entered the spinal canal on the ventral surface of the exiting nerve root through the neuroforamen at the surgical level requiring a change of surgical strategy to prevent injury to this important contributor to the spinal cord's blood supply.

CONCLUSIONS

The authors recommend stratifying patients according to the proximity of the magna radicularis artery to the compressive pathology with CTA to assess the surgical risk with targeted thoracic discectomy methods.

Experience of the Postoperative Intensive Care Treatment of Stanford Type A Aortic Dissection

OBJECTIVE

To summarize the experience of the postoperative intensive care treatment of Stanford type A aortic dissection (STAAD) following Sun's procedure.

METHODS

A total of 124 patients with STAAD who underwent Sun's procedure from January 2014 to December 2021 at the General Hospital of Ningxia Medical University were retrospectively analyzed. All patients were admitted to the cardiac surgery intensive care unit (ICU) after surgery. According to the perioperative characteristics of the patients with STAAD, intensive care treatment was given to actively prevent the occurrence of postoperative complications.

RESULTS

In all the cases enrolled in this study, the causes of aortic dissection comprised hypertension (105 cases), trauma (six cases), Marfan's syndrome (six cases), and aorto-arteritis (seven cases). The history of past illnesses comprised hypertension (105 cases), coronary disease (25 cases), diabetes mellitus (16 cases), and chronic obstructive pulmonary disease (six cases). There were some preoperative complications, such as cardiac insufficiency, acute liver insufficiency, acute renal insufficiency, pleural effusion, pericardial effusion, pulmonary infection, lower limb ischemia, mesenteric arterial embolism, and digestive tract hemorrhage. The average cardiopulmonary bypass time was 186 ± 32.1 min, the aortic clamp time was 74 ± 12.8 min, the deep hypothermic circulatory arrest time was 21 ± 2.6 min, and the mechanical ventilation time was 34 ± 2.8 h. The average ICU and hospital residence times were 7 ± 1.6 days and 12 ± 3.6 days, respectively. Postoperative complications comprised hypoxemia (34 cases), pulmonary infections (22 cases), tracheostomy (four cases), cerebral hemorrhage (four cases), cerebral infarction (four cases), transient delirium (eight cases), secondary thoracotomies due to bleeding (two cases), alimentary tract hemorrhage (eight cases), and acute renal insufficiency (38 cases). There was no occurrence of hoarseness or chylothorax. There were 15 cases of death, and the total mortality rate was 12.1%. In four cases, the cause of death was one postoperative complication (3.2%), and in 11 cases, the cause of death was multiple postoperative complications (8.9%). The other patients were discharged from the hospital with a good prognosis for full recovery.

CONCLUSION

Postoperative intensive care treatment was an important part of the successful surgical treatment of STAAD.

Task-specific spatial resolution properties of iterative and deep learning-based reconstructions in computed tomography: Comparison using tasks assuming small and large enhanced vessels

PURPOSE

The present study aims to evaluate TTFs of deep-learning-based image reconstruction (DLIR) and iterative reconstruction (IR) in computed tomography (CT) using a conventional task with a rod object with a diameter of 30 mm and a newly-proposed task with a wire of 1 mm in diameter, simulating large and small enhanced vessels, respectively.

METHODS

The rod or wire phantom made of a material equivalent to diluted iodine that exhibits about 270 Hounsfield unit (HU) was placed inside a 30-cm water phantom. In-plane and z-directional TTFs were measured for the rod using the circular edge (CE) and plane edge (PE) methods, respectively. By using the wire (iodine wire: IW), in-plane and z-directional TTFs were measured using Fourier transform (IW method). TTFs of filtered back projection (FBP), IR, and DLIR of a 256-row CT system and FBP and IR of a 64-row CT system were evaluated with CT dose indices of 10 and 5 mGy.

RESULTS

For DLIR and IR, TTFs measured using the IW method were notably lower than those using the CE (or PE) method; moreover, they were also lower than those of corresponding FBP, indicating that the small enhanced vessels with a diameter of about 1 mm would be blurred with both DLIR and IR.

CONCLUSIONS

The proposed IW method has turned out to be effective to evaluate TTFs for small enhanced vessels, which have not been properly evaluated by the CE or PE method conventionally recommended.

Isolated aneurysms of the spinal circulation: a systematic review of the literature

Aneurysms arising in the spinal circulation are rare and underreported. The objective of this study was to systematically review the English literature on different aspects of isolated spinal aneurysms using the PubMed, Ovid MEDLINE, and Google Scholar databases. Eighty-two papers reporting 107 individual patient cases were included. Most isolated spinal aneurysms have a fusiform morphology, and are most commonly found in the anterior spinal artery at the thoracic or cervical levels. Subarachnoid hemorrhage is the most common form of presentation, and sudden onset back pain is the most common initial symptom. The diagnosis of spinal aneurysms requires a high degree of clinical suspicion. Because of their small size, they can be missed on CT/MR angiography and spinal angiogram may be employed. Treatment of spinal aneurysms should be individualized on a case-by-case basis. Conservative management can be a valid option in spinal aneurysms where the risk of treatment is high. Surgical or endovascular intervention may be indicated in cases of significant or progressive neurologic decline due aneurysmal mass effect, or progressive growth of the aneurysm despite conservative treatment.

Re-TEVAR in treatment of stent graft-induced new entry between two non-overlapping stent-grafts: a case report

Background

Progress of the aortic disease after the stent graft treatment of aortic dissection implicates the potential risks of stent graft-induced new entry (SINE). Although rarely reported, it should be vigilant in patients who might incur serious complication in early period after the thoracic endovascular aortic repair (TEVAR). Thus, the development of aortic disease-specific stent grafts would assist in achieving positive patient outcomes when suffering SINE. However, it is an extremely rare for SINE between two non-overlapping stent-grafts.

Case presentation

We here reported a 59-year-old male patient with sudden onset of chest pain for 4 h. Multi-detector computed tomography (MDCT) revealed a huge SINE formed between two non-overlapping stent-grafts. The re-TEVAR surgery was performed and the patient experienced a good recovery.

Conclusion

The SINE between two non-overlapping stent-grafts treated by re-TEVAR operation was alternative and feasible. The short-term and medium-term follow-up results were satisfactory.

The relevance of the artery of Adamkiewicz for microsurgical resection of spinal tumors- short overview and case series: Technical note

INTRODUCTION

There is of major interest to know the exact anatomical location of artery of Adamkiewicz (AKA) for many spinal microsurgical procedures, so as to avoid postoperative ischemia of the spinal cord, with further devastating clinical impact.

METHODS AND RESULTS

We detail the interest of preoperative angiography for medullary lesions in our experience. We further report two cases where the AKA was located at the same level and side with the treated lesion. The first case underwent an intracapsular decompression. The second patient undertook radiosurgery by Cyberknife.

CONCLUSION

For spinal tumor where the AKA is exactly on the same level and side, an intracapsular decompression can be safely performed, with an immediate decrease of the symptomatic mass effect, while decreasing the risk of neurological injury. A second valuable alternative in such situations can also be radiosurgery, for small to medium size tumors. In our experience, this proved safe and effective both for tumor and eventual pain control.

Origins, Courses, and Distributions of the Lumbar Arterial Branches in Relation to the Spinal Nerves: An Anatomical Study

STUDY DESIGN

Observational, anatomical, cadaveric study.

OBJECTIVE

To investigate the origins, courses, and distributions of the lumbar arterial branches in relation to the spinal nerves using Japanese cadavers.

SUMMARY OF BACKGROUND DATA

Lumbar arterial branches to the spinal nerves can be damaged during posterior lumbar column osteotomy, leading to neurological complications. Spinal cord ischemia via arterial ligation has been reported to be a major cause of neurological complications in anterior thoracolumbar surgery. Although neurological deficits have been considered the most common complications in lumbar pedicle subtraction osteotomy, there is little information on the possible neurological deficits due to spinal nerve ischemia caused by damage to the lumbar arterial branches.

METHODS

In total, 111 lumbar arteries (1 lumbar artery was damaged) from 14 embalmed cadavers (28 sides, L1-L4) were investigated. We examined the branching patterns and measured their diameter and length. Branches to the spinal nerves were classified as follows: radicular branch (Rb), spinal nerve branch (SNb), and plexus branch (Pxb).

RESULTS

The Rb was identified most frequently at L1 (21.4%) and included the main branch to supply the spinal cord. The SNb diverged from the dorsal branch (59.4%) and was mainly detected at L2 (85.7%) and L3 (85.2%). The Pxb originated from the lumbar artery (56.1%) and was found most frequently at L4 (75%). The Pxb had a larger diameter and a longer length at L3 and L4 than the SNb. Both the L3 and L4 Pxbs were the main blood suppliers to the femoral nerve.

CONCLUSION

The L3 and L4 Pxbs mainly supplied the femoral nerve. The Pxb is likely to exist in the medial side of the spinal nerve in the extraforaminal region. Thus, the Pxb should be recognized as a very important arterial branch during operation procedures.

LEVEL OF EVIDENCE

5.

Surgical treatment of thoracic disc herniation: an overview

BACKGROUND

Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord.

METHODS

Literature review.

RESULTS

Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications.

CONCLUSION

Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

Penetrating thoracic spinal cord injury with ice pick extending into the aorta. A technical note and review of the literature

Background:

Penetrating spinal cord injuries pose a great challenge to both patients and the treating physicians. Although the overall incidence of penetrating spinal cord injury is the highest in the military, the ubiquity of guns in our society continues to make penetrating spinal cord injury prevalent in the civilian population. These types of injuries are particularly complicated because, beyond the trauma to the neural elements and supporting structures, other organs can be affected and a team approach is required for successful treatment.

Case Description:

In this report, the authors present a unique case of an ice pick penetrating posteriorly through the spinal canal into the aorta. The described surgical management involved careful consideration and planning to prevent worsening vascular and neurological compromise. Among the challenges faced are neurological compromise, vascular injury, spinal instability, and cerebrospinal fluid leak.

Conclusion:

To the author’s knowledge, this challenging case represents the first description of a successful removal of a penetrating thoracic spinal foreign body that terminated within the lumen of the thoracic aorta.

Management of burst fractures in the thoracolumbar spine

The most common fractures in the spine take place in the thoracolumbar region. Currently there is no consensus regarding optimum treatment.

OBJECTIVE

Analyze the current medical literature available regarding treatment of compression fractures of the thoracolumbar spine.

METHODS

Research of current literature in medical databases.

RESULTS

Regarding current available literature, we found no consensus in the treatment of compression fractures in the thoracolumbar spine.

CONCLUSIONS

Burst fractures of the thoracolumbar junction is a very common condition, treatment of each patient must be individualized. Conservative treatment is recommended for stable fractures without neurological compromise and less than 35° of kyphosis.