1
|
Park S, Hong SH, Chung SG, Kim K. Redundant nerve roots on magnetic resonance imaging can predict ongoing denervation in patients with lumbar spinal stenosis. Muscle Nerve 2024; 69:691-698. [PMID: 38545741 DOI: 10.1002/mus.28094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION/AIMS Redundant nerve roots (RNRs) are abnormally elongated and tortuous nerve roots that develop secondary to degenerative spinal stenosis. RNRs have been associated with poorer clinical outcomes after decompression surgery; however, studies on their clinical characteristics are limited. This study aimed to investigate the association between RNRs and denervation potentials, that is, abnormal spontaneous activity (ASA), on electromyography. METHODS We retrospectively reviewed data of patients who underwent an electrodiagnostic study of the lower extremities between January 2020 and March 2023. Of these, patients with lumbar central spinal stenosis, as seen on magnetic resonance imaging, were included. We analyzed clinical and imaging data, including presence of ASA, and compared them according to the presence of RNRs. Multivariable logistic regression analysis was employed to identify factors associated with development of ASA. RESULTS Among the 2003 patients screened, 193 were included in the study. RNRs were associated with advanced age (p < .001), longer symptom duration (p = .009), smaller cross-sectional area of the dural sac at the stenotic level (p < .001), and higher frequency of ASA (p < .001). Higher probability of ASA was correlated with greater RNR severity (p < .001). In the multivariable logistic regression analysis, ASA occurrence was associated with smaller cross-sectional area, multiple stenotic sites, and severe-grade RNRs. DISCUSSION The presence of RNRs, particularly severe-grade RNRs, was identified as a significant risk factor for the development of ASA on electromyography. This finding may aid physicians in estimating the prognosis of patients with central spinal stenosis.
Collapse
Affiliation(s)
- Seoyeong Park
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Hwan Hong
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Gun Chung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Institute on Aging, Seoul National University, Seoul, Republic of Korea
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| |
Collapse
|
2
|
Sun H, Xiong S, Zhang Y, Zhao Q, Wu Z, Xiao L. Clinical significance of redundant nerve roots in patients with lumbar spinal stenosis undergoing oblique lumbar interbody fusion combined with percutaneous internal fixation. J Orthop Surg Res 2023; 18:958. [PMID: 38087350 PMCID: PMC10717461 DOI: 10.1186/s13018-023-04449-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND While there have been previous studies on the surgical efficacy of patients with redundant nerve roots (RNRs), a persistent issue is that some patients continue to experience redundancy even after surgery. Furthermore, the clinical significance of RNRs remains unclear. Notably, there is a lack of research regarding RNRs within the context of oblique lumbar interbody fusion (OLIF) combined with percutaneous internal fixation. Therefore, the primary objective of this study is to investigate the correlation between RNRs and clinical outcomes following OLIF combined with percutaneous internal fixation. METHODS Eighty-seven patients diagnosed with lumbar spinal stenosis (LSS) who underwent single-segment OLIF combined with percutaneous internal fixation were categorized into three groups. Group 1 comprised patients with positive RNRs both before and after the operation. Group 2 included patients with positive RNRs preoperatively but negative RNRs postoperatively. Group 3 consisted of patients with consistently negative RNRs before and after the operation. Comprehensive patient data were collected, including operation time, intraoperative blood loss, and any recorded complications. Radiographic parameters, both pre- and post-operative, were assessed, encompassing the number of stenosis segments, disc height (DH), lumbar lordotic angle, dural sac cross-sectional area, and the placement of the fusion cage. Furthermore, the Visual Analogue Scale was applied to gauge back and leg pain, while the Oswestry Disability Index was employed to appraise daily living activities. A comparative analysis was carried out among the three patient groups. RESULTS In this study, all 87 LSS patients successfully underwent surgery. Among them, 35 patients (40.2%) showed preoperative MRI assessment indicating positive RNRs. In the postoperative MRI assessment, 14 of these patients maintained positive RNRs status, and they were grouped into Group 1. The remaining 21 patients saw a transition to negative RNRs status and were included in Group 2. Among the 52 patients who had preoperative MRI assessments showing negative RNRs, their postoperative RNRs status remained negative, forming Group 3. All patients received follow-up, which ranged from 8 to 18 months, and no complications occurred during this period. In this study, the postoperative efficacy and parameters such as DH and Dural Sac CSA significantly improved compared to preoperative values for all 87 patients. Patients with preoperative RNRs had more stenosis segments, smaller dural sac CSA, and more severe symptoms. In all three groups, postoperative efficacy scores significantly improved compared to preoperative scores. Group 2 patients had their fusion cages placed more in the middle, while Group 1 patients had their fusion cages more anteriorly located. Group 2 patients exhibited greater recovery in dural sac CSA postoperatively compared to Group 1 patients. Additionally, Group 2 patients had better ODI efficacy scores compared to Group 1 patients. CONCLUSIONS Irrespective of the presence or absence of RNRs, patients experienced improvement after undergoing OLIF combined with percutaneous internal fixation. Preoperative RNRs appear to be linked to multi-segmental lumbar spinal stenosis, a reduction in dural sac CSA, and symptom severity. Patients with negative postoperative RNRs demonstrated better treatment efficacy. Furthermore, the placement of the fusion cage appears to have a significant impact on postoperative efficacy and RNRs outcomes.
Collapse
Affiliation(s)
- Hongzhou Sun
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Shouliang Xiong
- Department of Joint Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Yu Zhang
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Quanlai Zhao
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Zhongxuan Wu
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Liang Xiao
- Spine Research Center of Wannan Medical College, No. 22 Wenchang West Road, Wuhu, 241001, China.
| |
Collapse
|
3
|
Zhong D, Wang Y, Lin L, Cheng S, Zhao GS, Wang LY, Liu Y, Ke ZY. Development and Validation of a Nomogram to Predict the Risk of Recurrent Lower Extremity Radiating Pain Within 1 Week Following Full-Endoscopic Lumbar Discectomy. World Neurosurg 2023; 179:e348-e358. [PMID: 37634669 DOI: 10.1016/j.wneu.2023.08.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Accurately predicting the risk of lower extremity (LE) radiating pain after surgery is an important endeavor for spinal surgeons. Our study aimed to identify risk factors for LE radiating pain after decompression with full-endoscopic lumbar discectomy (FELD) and develop a nomogram. METHODS We retrospectively reviewed the medical data of patients with lumbar disc herniation who underwent FELD. Two hundred thirty-five patients diagnosed at our hospital from January 2015 to December 2020 were used for model development. The independent risk factors for LE radiating pain after surgery were determined by least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis. A nomogram was developed to predict the risk of LE radiating pain based on independent risk factors. Receiver operating characteristic curve, calibration curve, and decision curve analyses were used to evaluate the predictive performance. The nomogram was further verified by an independent cohort. RESULTS Three hundred seventy-five patients were enrolled in this study, with 102 patients in the training cohort reporting LE radiating pain after FELD, while 133 patients did not. In the validation cohort, 57 patients reported LE radiating pain after FELD, while 83 patients did not. The model was established by multivariate logistic regression analysis. The risk factors included a higher Michigan State University classification of herniated discs, increased disease course, increased time of surgery, reduced lateral recess width, and an interlaminar surgical approach, compared to transforaminal approach. The C-indices and the area under the receiver operating characteristic curve of the predictive model demonstrated good discrimination. Good predictive performance and accuracy were also observed in the validation cohort. CONCLUSIONS A novel nomogram for predicting recurrent LE radiating pain within 1 week after FELD was established and validated. More aggressive pain management strategies should be considered for patients at high risk of LE radiating pain after surgery, as predicted by this model.
Collapse
Affiliation(s)
- Dian Zhong
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Lu Lin
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Si Cheng
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guo Sheng Zhao
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Yuan Wang
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Liu
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Yong Ke
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
4
|
Nathani KR, Barakzai MD, Rai HH, Naeem K, Mubarak F, Iftikhar H, Khan SA, Enam SA. Redundant nerve roots indicate higher degree of stenosis in lumbar spine stenotic patients. Acta Neurol Belg 2023; 123:1781-1787. [PMID: 35934759 DOI: 10.1007/s13760-022-02040-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/14/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Redundant Nerve Root (RNR) is a tortuous and elongated radiological appearance of cauda equina on Magnetic Resonance Imaging (MRI) in Lumbar Spinal Canal Stenosis (LSCS) patients. This study evaluated preoperative spinal morphometry associated with the development of RNR. METHODS The retrospective cohort was conducted at The Aga Khan University Hospital, and included patients undergoing decompressive spinal surgery secondary to degenerative LSCS in 2015. The patients were divided into two groups with respect to the presence of preoperative RNR. Spinal morphometry was defined by several radiological parameters, including areas of dural sac (DSA), spinal canal, spinal foramen, facets, and spinal joints, and bilateral angles based on vertebral anatomy. RESULTS A total of 55 patients were enrolled with a mean age of 57.1 years, in which 22 (40%) expressed RNR in their MRI. The RNR group had significantly lower mean DSA (59.64 vs 84.01 mm2; p = 0.028), bilateral posterior facet angle (Right: 33.84 vs 46.21, p = 0.004; Left: 36.43 vs 43.80, p = 0.039) and higher bilateral anterior facet angles (Right: 54.85 vs 44.57, p = 0.026; Left: 55.27 vs 46.36, p = 0.050) compared to the non-RNR group. The other bidimensional and angular parameters did not observe any statistical difference between the two groups. CONCLUSION RNR was associated with a higher degree of stenosis in patients with LSCS. Bilateral anterior and posterior facets angles contribute to its development, indicating particular spinal morphology to be vulnerable to the stenotic disease.
Collapse
Affiliation(s)
- Karim Rizwan Nathani
- Section of Neurosurgery, Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | | | - Hamid Hussain Rai
- Section of Neurosurgery, Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | - Komal Naeem
- Section of Neurosurgery, Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | - Fatima Mubarak
- Department of Radiology, The Aga Khan University, Karachi, Pakistan
| | - Haissan Iftikhar
- Section of ENT, Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | - Saad Akhtar Khan
- Section of Neurosurgery, Department of Surgery, The Liaquat National Hospital, Stadium Road, Karachi, 74800, Pakistan.
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, The Aga Khan University, Karachi, Pakistan
| |
Collapse
|
5
|
Han YA, Kwon HJ, Lee K, Son MG, Kim H, Choi SS, Shin JW, Kim DH. Impact of Sarcopenia on Percutaneous Epidural Balloon Neuroplasty in Patients with Lumbar Spinal Stenosis: A Retrospective Analysis. Medicina (Kaunas) 2023; 59:medicina59050847. [PMID: 37241078 DOI: 10.3390/medicina59050847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: With the aging population, the incidence of degenerative lumbar spinal stenosis (LSS) is increasing. Sarcopenia is an age-related muscular decrease. Although epidural balloon neuroplasty is effective in patients with LSS refractory to conventional treatments, its effect has not been assessed in patients with sarcopenia. Therefore, this study evaluated the effect of epidural balloon neuroplasty in patients with LSS and sarcopenia. Materials and Methods: This retrospective study reviewed the following details from the electronic medical records: patient characteristics, including sex, age, body mass index, diabetes, hypertension, stenosis grading, pain duration, location, pain intensity, and medications. Back and leg pain intensity was evaluated before and after the procedure at one, three, and six months during the follow-up period. A generalized estimating equations model was used at six months follow-up. Patients were divided into sarcopenia and non-sarcopenia groups using the cross-sectional area of the psoas muscle at the level of L3 on magnetic resonance imaging. Results: A total of 477 patients were included (sarcopenia group: 314 patients, 65.8%; non-sarcopenia group: 163 patients, 34.2%). Age, sex, body mass index, and medication quantification scale III were statistically different between both groups. The generalized estimating equations analyses-with unadjusted and adjusted estimation-revealed a significantly reduced pain intensity after the procedure compared to the baseline in both groups. The difference in pain intensity between both groups was not statistically different. Conclusions: Percutaneous epidural balloon neuroplasty may be considered for patients with chronic lumbar LSS regardless of accompanying sarcopenia.
Collapse
Affiliation(s)
- Yun-A Han
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul 05715, Republic of Korea
| | - Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Kunhee Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Min-Gi Son
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Hotaek Kim
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul 05715, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| |
Collapse
|
6
|
Kawakami M, Takeshita K, Inoue G, Sekiguchi M, Fujiwara Y, Hoshino M, Kaito T, Kawaguchi Y, Minetama M, Orita S, Takahata M, Tsuchiya K, Tsuji T, Yamada H, Watanabe K. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication. J Orthop Sci 2023; 28:46-91. [PMID: 35597732 DOI: 10.1016/j.jos.2022.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine. METHODS The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members. RESULTS Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided. CONCLUSIONS The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.
Collapse
Affiliation(s)
| | | | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | - Yasushi Fujiwara
- Department of Orthopaedic Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City General Hospital, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, Japan
| | | | - Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University, Japan
| | | |
Collapse
|
7
|
Gökşen A, Kocaman H, Merve Arman G, Lütfi Selçuk M. Comprehensive analysis of muscles wasting in disc herniation. J Biomech 2022; 145:111391. [PMID: 36435096 DOI: 10.1016/j.jbiomech.2022.111391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/30/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
Neuromuscular reeducation of the muscles that stabilize the spine is the basis of conservative treatment of disc herniation. Therefore, it is important to investigate how these muscles are affected by disc herniation. The aim of this study was to investigate the effect of disc herniation, herniation severity, patient age, and biomechanics on the lumbar stabilizer muscles. A total of 330 individuals, including 261 patients with disc herniations and 69 without disc herniation participated in this study. The cross-sectional areas (CSAs) of the lumbar stabilizer muscles and the lumbar lordosis angle were evaluated by magnetic resonance imaging (MRI), according to the severity of the disc herniation and the patient's age. In the patients with disc herniation, the CSAs of the quadratus lumborum (QL) and the multifidus (MF) muscles were decreased. The psoas major (PM) muscle CSA was higher in the patients with sequestered discs than in those with protruded and extruded discs. A negative relationship between the sagittal curve and the PM muscle CSA was found. In addition, MF muscle CSA was found to decrease at age 45 years and over. Although disc herniation negatively affects muscle CSAs, no linear relationship was found between the severity of the herniation and the muscle CSA. In addition, the PM muscle was found to be a strong compensatory muscle in disc herniation.
Collapse
Affiliation(s)
- Ayşenur Gökşen
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Tarsus University, Mersin, Turkey.
| | - Hikmet Kocaman
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Gökçe Merve Arman
- Department of Radiology, Karamanoglu Mehmetbey University Karaman Education and Research Hospital, Karaman, Turkey
| | - Muhammet Lütfi Selçuk
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Karamanoglu Mehmetbey University, Karaman, Turkey
| |
Collapse
|
8
|
Bae IS, Moon BG, Kang HI, Kim JH, Kim DR. The serpentine pattern on MRI as an early prognostic factor after fusion for lumbar spinal stenosis. Medicine (Baltimore) 2022; 101:e31573. [PMID: 36451492 PMCID: PMC9704933 DOI: 10.1097/md.0000000000031573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This study aimed to determine the relationship between the serpentine pattern nerve roots (SNR) and prognosis after lumbar fusion for lumbar spinal stenosis (LSS) by comparing clinical outcomes in patients with or without a serpentine pattern. LSS patients with neurological symptoms often present with SNRs. Several studies have shown that LLS symptoms are worse in patients with SNRs. However, the relationship between SNR and outcome after spinal fusion surgery has not yet been established. A total of 332 patients who underwent spinal fusion surgery between January 1, 2010, and December 31, 2019, were enrolled. Patients were divided into those with a serpentine pattern (S group) and those without a serpentine pattern (N group). The prognosis of the 2 groups was compared using visual analog scale (VAS), Oswestry disability index, claudication distance, medication dose for leg dysesthesia, and glucose tolerance. A total of 113 patients had a serpentine pattern, while the remaining 219 did not. Symptom duration and presence of diabetes mellitus were significantly different between the 2 groups (N = 25.4, S = 32.6, P < .05). Changes in the VAS score for lower extremity pain between the 2 groups at 1 year after surgery showed that patients without a serpentine pattern had significantly better outcomes than those with a serpentine pattern (N: 2.7 ± 1.1 vs S: 4.1 ± 1.3; P < .001), despite the score change at 1 month showing no difference (N: 3.5 ± 0.9 vs S: 3.8 ± 1.0; P = .09). SNRs on MRI are more prevalent in diabetic patients and are a negative prognostic factor in lumbar fusion surgery for LSS. Our insights may help physicians decide the optimal surgical plan and predict the postoperative prognosis of patients with LSS.
Collapse
Affiliation(s)
- In-Suk Bae
- Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University, Korea
| | - Byung Gwan Moon
- Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Korea
- * Correspondence: Byung Gwan Moon Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, 712, Dongil-ro, Uijeongbu-si, Gyeonggi-do 11749, Korea (e-mail: )
| | - Hee In Kang
- Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University, Korea
| | - Jae Hoon Kim
- Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University, Korea
| | - Deok Ryeong Kim
- Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Korea
| |
Collapse
|
9
|
Papavero L, Ali N, Schawjinski K, Holtdirk A, Maas R, Ebert S. The prevalence of redundant nerve roots in standing positional MRI decreases by half in supine and almost to zero in flexed seated position: a retrospective cross-sectional cohort study. Neuroradiology 2022; 64:2191-2201. [PMID: 36083504 PMCID: PMC9576640 DOI: 10.1007/s00234-022-03047-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/28/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE This retrospective cross-sectional cohort study investigated the influence of posture on lordosis (LL), length of the spinal canal (LSC), anteroposterior diameter (APD L1-L5), dural cross-sectional area (DCSA) of the lumbar spinal canal, and the prevalence of redundant nerve roots (RNR) using positional magnetic resonance imaging (MRI) (0.6 T). METHODS Sixty-eight patients with single-level degenerative central lumbar spinal stenosis (cLSS) presenting with RNR in the standing position (STA) were also investigated in supine (SUP) or neutral seated (SIT) and flexed seated (FLEX) positions. Additionally, 45 patients complaining of back pain and without MRI evidence of LSS were evaluated. Statistical significance was set at p < 0.05. RESULTS Controls (A) and patients with cLSS (B) were comparable in terms of mean age (p = 0.88) and sex (p = 0.22). The progressive transition from STA to FLEX led to a comparable decrease in LL (p = 0.97), an increase in LSC (p = 0.80), and an increase in APD L1-L5 (p = 0.78). The APD of the stenotic level increased disproportionally between the different postures, up to 67% in FLEX compared to 29% in adjacent non-stenotic levels (p < 0.001). Therefore, the prevalence of RNR decreased to 49, 26, and 4% in SUP, SIT, and FLEX, respectively. CONCLUSION The prevalence of RNR in standing position was underestimated by half in supine position. Body postures modified LL, LSC, and APD similarly in patients and controls. Stenotic levels compensated for insufficient intraspinal volume with a disproportionate enlargement when switching from the STA to FLEX.
Collapse
Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen-Clinic Hamburg, Academic Hospital of the University Medical Center Eppendorf, Dehnhaide 120, 22081 Hamburg, Germany
| | - Nawar Ali
- Clinic for Spine Surgery, Schoen-Clinic Hamburg, Academic Hospital of the University Medical Center Eppendorf, Dehnhaide 120, 22081 Hamburg, Germany
| | - Kathrin Schawjinski
- Clinic for Spine Surgery, Schoen-Clinic Hamburg, Academic Hospital of the University Medical Center Eppendorf, Dehnhaide 120, 22081 Hamburg, Germany
| | | | - Rainer Maas
- Radiological Office Raboisen 38, Hamburg, Germany
| | | |
Collapse
|
10
|
Goldberg JL, Wipplinger C, Kirnaz S, Xia J, Sommer F, Meng A, Schwarz J, Giantini-Larsen A, Meaden RM, Sugino R, Gadjradj P, Medary B, Carnevale JA, Navarro R, Tsiouris AJ, Hussain I, Härtl R. Clinical Significance of Redundant Nerve Roots in Patients with Lumbar Stenosis Undergoing Minimally Invasive Tubular Decompression. World Neurosurg 2022; 164:e868-e876. [PMID: 35598849 DOI: 10.1016/j.wneu.2022.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Symptomatic lumbar spinal stenosis (LSS) is a common indication for surgery in the elderly. Preoperative radiographic evaluation of patients with LSS often reveals redundant nerve roots (RNRs). The clinical significance of RNRs is uncertain. RNRs have not been studied in the setting of minimally invasive surgery. This study investigates the relationship between RNRs and clinical outcomes after minimally invasive tubular decompression. METHODS Chart review was performed for patients with degenerative LSS who underwent minimally invasive decompression. Preoperative magnetic resonance imaging parameters were assessed, and patient-reported outcomes were analyzed. RESULTS Fifty-four patients underwent surgery performed at an average of 1.8 ± 0.8 spinal levels. Thirty-one patients (57%) had RNRs. Patients with RNRs were older (median = 72 years vs. 66 years, P = 0.050), had longer median symptom duration (32 months vs. 15 months, P < 0.01), and had more levels operated on (2.1 vs. 1.4; P < 0.01). The median follow-up after surgery was 2 months (range = 1.3-12 months). Preoperative and postoperative patient-reported outcomes were similar based on RNR presence. Patients without RNRs had larger lumbar cross-sectional areas (CSAs) (median = 121 mm2 vs. 95 mm2, P = 0.014) and the index-level CSA (52 mm2 vs. 34 mm2, P = 0.007). The CSA was not correlated with RNR morphology or location. CONCLUSIONS Preoperative RNRs are associated with increased age, symptom duration, and lumbar stenosis severity. Patients improved after minimally invasive decompression regardless of RNR presence. RNR presence had no effect on short-term clinical outcomes. Further study is required to assess their long-term significance.
Collapse
Affiliation(s)
- Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.
| | - Christoph Wipplinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Jimmy Xia
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Fabian Sommer
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Alicia Meng
- Department of Neuroradiology, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Justin Schwarz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Ross M Meaden
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Rafael Sugino
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Pravesh Gadjradj
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Branden Medary
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Joseph A Carnevale
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Rodrigo Navarro
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - A John Tsiouris
- Department of Neuroradiology, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
11
|
Abstract
Introduction: Redundant nerve roots (RNRs) are common finding in lumbar spinal stenosis patients. Up to now, many relevant studies were carried out on the mechanism, pathogenic factors, and clinical features of redundant nerve roots. However, there are few studies on the surgical methods. In this study, posterior lumbar interbody fusion and internal fixations were used in 30 patients with RNRs in our hospital. Moreover, we also proposed new ideas about different types and subtypes of RNRs using patterns and their corresponding MRI images. Methods: Thirty patients with lumbar spinal stenosis and RNRs were enrolled in this study and underwent surgery between January 2009 and December 2014. Redundant nerve roots are identified as elongated, tortuous, or serpiginous nerve roots present in the subarachnoid space on sagittal T2-weighted magnetic resonance imaging (MRI) studies. Patients were treated with posterior decompression, intervertebral disc resection, and instrumented interbody fusion. The age, sex, disease course, operative time, intraoperative blood loss, operative segments were recorded. Outcome measures recorded to identify symptom improvement included pre-operative and post-operative visual analog scale (VAS), pre-operative and post-operative Oswestry Disability Index (ODI) and pre-operative and post-operative Japanese Orthopedic Association (JOA) scores. Results: VAS back pain, VAS leg pain VAS, ODI, and JOA with standard deviations were 6.4 ± 0.9, 7.1 ± 0.8, 43.0 ± 2.2, and 10.3 ± 2.6, respectively. At 3 months post-operatively, VAS back pain, VAS leg pain VAS, ODI, and JOA with standard deviations were 1.4 ± 0.5, 1.6 ± 0.6, 13.0 ± 1.6, and 25.0 ± 1.8, respectively. Nerve redundancy resolved in all cases on post-operative MRI. Conclusion: Posterior lumbar laminectomy and instrumented interbody fusion relieves low back and leg pain in patients with lumbar spinal stenosis and RNRs and can alleviate the tortuous appearance of the cauda equina in the decompressed segment.
Collapse
Affiliation(s)
- Jianzhong Xu
- Department of Spinal Surgery, Ningbo No.6 Hospital, Ningbo, China
| | - Yong Hu
- Department of Spinal Surgery, Ningbo No.6 Hospital, Ningbo, China
| |
Collapse
|
12
|
Nathani KR, Naeem K, Rai HH, Barakzai MD, Iftikhar H, Khan SA, Mubarak F, Enam SA. Role of redundant nerve roots in clinical manifestations of lumbar spine stenosis. Surg Neurol Int 2021; 12:218. [PMID: 34084645 PMCID: PMC8168691 DOI: 10.25259/sni_59_2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/15/2021] [Indexed: 12/11/2022] Open
Abstract
Background Redundant nerve roots (RNRs) are defined as elongated, thickened, and tortious appearing roots of the cauda equina secondary to lumbar spinal canal stenosis (LSCS). The study compared the clinical and radiological features of patients with LSCS with versus without RNR. Methods This retrospective study was performed on 55 patients who underwent decompressive surgery for degenerative LSCS. Patients were divided into two groups based on the presence of RNR in their preoperative magnetic resonance imaging, as evaluated by a radiologist blinded to the study design. Medical records were reviewed for basic demographic, clinical MR presentation, and outcomes utilizing Japanese Orthopaedic Association (JOA) scores. Results The mean age of enrolled patients was 57.1, with mean follow-up of 4.0 months. RNR was found in 22 (40%) of patients with LSCS. These patients were older than those patients without RNR (62.2 vs. 53.7). Interestingly, there were no statistically significant differences in clinical presentations, duration of symptoms, and outcomes using JOA scores between the two groups. Conclusion RNR is a relatively common radiological finding (i.e., 40%) in patients with LSCS. It is more likely to be observed in older patients. However, no significant differences were noted in clinical presentation and functional outcomes with respect to the presence or absence of RNR.
Collapse
Affiliation(s)
| | - Komal Naeem
- Department of Neurosurgery, Aga Khan University, Karachi, Sindh, Pakistan
| | - Hamid Hussain Rai
- Department of Neurosurgery, Aga Khan University, Karachi, Sindh, Pakistan
| | | | - Haissan Iftikhar
- Department of ENT, Aga Khan University, Karachi, Sindh, Pakistan
| | - Saad Akhtar Khan
- Department of Neurosurgery, Aga Khan University, Karachi, Sindh, Pakistan
| | - Fatima Mubarak
- Department of Radiology, Aga Khan University, Karachi, Sindh, Pakistan
| | - S Ather Enam
- Department of Neurosurgery, Aga Khan University, Karachi, Sindh, Pakistan
| |
Collapse
|
13
|
Papavero L, Ebert S, Marques CJ. The prevalence of redundant nerve roots in patients with lumbar spinal stenosis is body position dependent: a retrospective observational study with repeated measures design in an upright MRI scanner. Neuroradiology 2020; 62:979-985. [PMID: 32318772 PMCID: PMC7366595 DOI: 10.1007/s00234-020-02423-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/27/2020] [Indexed: 05/30/2023]
Abstract
Purpose Redundant nerve roots (RNRs) are a negative prognostic factor in patients with central lumbar spinal stenosis (LSS). Forty percent of candidates for surgical decompression show RNRs (RNR+) on preoperative conventional magnetic resonance imaging (MRI). We investigated the prevalence of RNRs in three functional postures (standing, neutral sitting and flexed sitting) with an upright MRI (upMRI). Methods A retrospective observational study with a repeated measures design. Thirty surgical candidates underwent upMRI. Sagittal and axial T2-weighted images of the three functional postures were evaluated. The segmental length of the lumbar spine (sLLS), the lordotic angle (LA) and the dural cross-sectional area (DCSA) were measured in each body position. Generalized linear mixed models were carried out. The 0.05 level of probability was set as the criterion for statistical significance. Results The prevalence of RNRs decreased from 80% during standing to 16.7% during flexed sitting (p < 0.001). The sLLS increased significantly from standing to neutral sitting in both RNR groups (p < 0.001). The increase from neutral sitting to flexed sitting was only significant (p < 0.001) for the group without RNRs (RNR−). The LA decreased significantly for both RNR groups from standing to flexed sitting (p < 0.001). The DSCA increased significantly in the RNR− group (p < 0.001) but not in the RNR+ group (p = 0.9). Conclusion The prevalence of RNRs is body position dependent. Increases in DCSA play a determinant role in resolving RNRs.
Collapse
Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the Medical Center Eppendorf (UKE), Hamburg, Germany
| | | | - Carlos J Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek - Science Office, Dehnhaide 120, D-22081, Hamburg, Germany.
| |
Collapse
|
14
|
Park JH, Chung SG, Kim K. Electrodiagnostic characteristics of upper lumbar stenosis: Discrepancy between neurological and structural levels. Muscle Nerve 2020; 61:580-586. [PMID: 32096875 DOI: 10.1002/mus.26844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 02/21/2020] [Accepted: 02/23/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Radiculopathies caused by spinal stenosis in the upper lumbar spinal canal (L1/2, L2/3, L3/4) have not been comprehensively investigated. METHODS This retrospective study reviewed 14 patients from a tertiary hospital outpatient clinic. The inclusion criteria were upper lumbar stenosis seen on MRI and radiculopathies with active denervation confirmed on electromyography. Patients with any other conditions that could explain the clinical or electrophysiological manifestations were excluded. RESULTS Neurogenic findings were predominantly observed in L5 or S1 myotomes on electromyography. Abnormal spontaneous activity was observed in distal muscles in all patients and in proximal muscles in eight patients. Axonal involvement was bilateral in 10 patients and unilaterally in 4 patients. MRI showed redundant nerve roots in 13 patients with chronic reinnervation on electromyography. CONCLUSIONS Upper lumbar spinal stenosis usually causes L5 or S1 radiculopathies with diverse patterns. This discrepancy may cause diagnostic confusion.
Collapse
Affiliation(s)
- Jae Hyeon Park
- Department of Rehabilitation Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, Republic of Korea
| | - Sun G Chung
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| |
Collapse
|
15
|
Papavero L, Marques CJ, Lohmann J, Fitting T, Schawjinski K, Ali N, Hillebrand H, Maas R. Redundant nerve roots in lumbar spinal stenosis: inter- and intra-rater reliability of an MRI-based classification. Neuroradiology 2019; 62:223-230. [PMID: 31836911 PMCID: PMC6971136 DOI: 10.1007/s00234-019-02337-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022]
Abstract
Purpose Patients with central lumbar spinal stenosis (LSS) have a longer symptom history, more severe stenosis, and worse postoperative outcomes, when redundant nerve roots (RNRs) are evident in the preoperative MRI. The objective was to test the inter- and intra-rater reliability of an MRI-based classification for RNR. Methods This is a retrospective reliability study. A neuroradiologist, an orthopedic surgeon, a neurosurgeon, and three orthopedic surgeons in-training classified RNR on 126 preoperative MRIs of patients with LSS admitted for microsurgical decompression. On sagittal and axial T2-weighted images, the following four categories were classified: allocation (A) of the key stenotic level, shape (S), extension (E), and direction (D) of the RNR. A second read with cases ordered differently was performed 4 weeks later. Fleiss and Cohen’s kappa procedures were used to determine reliability. Results The allocation, shape, extension, and direction (ASED) classification showed moderate to almost perfect inter-rater reliability, with kappa values (95% CI) of 0.86 (0.83, 0.90), 0.62 (0.57, 0.66), 0.56 (0.51, 0.60), and 0.66 (0.63, 0.70) for allocation, shape, extension, and direction, respectively. Intra-rater reliability was almost perfect, with kappa values of 0.90 (0.88, 0.92), 0.86 (0.84, 0.88), and 0.84 (0.81, 0.87) for shape, extension, and direction, respectively. Intra-rater kappa values were similar for junior and senior raters. Kappa values for inter-rater reliability were similar between the first and second reads (p = 0.06) among junior raters and improved among senior raters (p = 0.008). Conclusions The MRI-based classification of RNR showed moderate-to-almost perfect inter-rater and almost perfect intra-rater reliability.
Collapse
Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Carlos J Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Germany. .,Non-Medical PhD Program, Faculty of Medicine, University of Hamburg, Hamburg, Germany.
| | - Jens Lohmann
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Thies Fitting
- Department of Radiology at the Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Kathrin Schawjinski
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Nawar Ali
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Hauke Hillebrand
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Rainer Maas
- Radiology Office Raboisen 38, Hamburg, Germany
| |
Collapse
|
16
|
Kawasaki Y, Seichi A, Zhang L, Tani S, Kimura A. Dynamic Changes of Cauda Equina Motion Before and After Decompressive Laminectomy for Lumbar Spinal Stenosis With Redundant Nerve Roots: Cauda Equina Activation Sign. Global Spine J 2019; 9:619-623. [PMID: 31448195 PMCID: PMC6693060 DOI: 10.1177/2192568218821344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
STUDY DESIGN Cross-sectional observational study (consecutive case series). OBJECTIVES The aim of this study was to define a criterion for achieving successful decompression of lumbar spinal stenosis (LSS) using intraoperative ultrasonography (IOUS) and to investigate the pathogenesis of redundant nerve roots (RNRs) based on the ultrasonographic findings. METHODS A total of 100 LSS patients (71 males, 29 females, mean age, 71 ± 8 years) with RNRs were enrolled as subjects in this study. IOUS was performed to evaluate pulsatile motion of the cauda equina (PMCE) just before and after decompressive laminectomy. To determine the decompression status of the cauda equina, the ultrasonographic findings were classified into 3 types on the basis of the presence or absence of PMCE: type 1, predecompression PMCE (-) to postdecompression PMCE (+); type 2, pre- and postdecompression PMCE (+); and type 3, pre- and postdecompression PMCE (-). The pathogenesis of RNRs was also investigated based on the ultrasonographic findings. RESULTS Around the stenosis, PMCE was almost always absent before decompression and appeared after decompression (type 1 in 94 patients, type 2 in 6, type 3 in 0). IOUS showed that, before decompression, the cauda equina was held at the stenosis and could not pulsate beyond the stenotic site, and after decompression, PMCE recovered in the craniocaudal direction, leading to the resolution of RNRs. CONCLUSIONS The emergence of PMCE can be a sign of successful decompression for LSS. Ultrasonographic findings support the notion that disturbance of PMCE around the stenosis is a basic component of the pathogenesis of RNRs.
Collapse
Affiliation(s)
- Yosuke Kawasaki
- Mitsui Memorial Hospital, Tokyo, Japan,Yosuke Kawasaki, Department of Orthopedic Surgery,
Mitsui Memorial Hospital, 1 Kandaizumicho, Chiyodaku, Tokyo 101-8643, Japan.
| | | | | | | | | |
Collapse
|
17
|
Papavero L, Marques CJ, Lohmann J, Fitting T. Patient demographics and MRI-based measurements predict redundant nerve roots in lumbar spinal stenosis: a retrospective database cohort comparison. BMC Musculoskelet Disord 2018; 19:452. [PMID: 30579338 PMCID: PMC6303950 DOI: 10.1186/s12891-018-2364-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023] Open
Abstract
Background Up to 40% of patients diagnosed with lumbar spinal stenosis (LSS) show evidence of redundant nerve roots (RNR) of the cauda equina on their magnetic resonance images (MRI). The etiology of RNR is still unclear. Preoperative evidence of RNR is associated with a worse postsurgical outcome. Consequently, potential predictors of RNR could have a prognostic value. The aim was to test whether patient demographics and MRI-based measurements can predict RNR in LSS patients. Methods In a retrospective database-based cohort study the preoperative data of 300 patients, 150 with (RNR+) and 150 without (RNR-) evidence of RNR on their MRI were analyzed. Three independent researchers performed the MRI reads. Potential predictors were age, gender, body height (BH), length of lumbar spine (LLS), segmental length of lumbar spine (SLLS), lumbar spine alignment deviation (LSAD), relative LLS (rLLS), relative SLLS (rSLLS), number of stenotic levels (LSS-level), and grade of LSS severity (LLS-grade, increasing from A to D). Binomial logistic regression models were performed. Results RNR+ patients were 2.6 years older (p = 0.01). Weak RNR+ predictors were a two-years age increase (OR 1.06; p = 0.02), 3 cm BH decrease (OR 1.09; p = 0.01) and a 5 mm SLLS decrease (OR 1.34; p < 0.001). Strong RNR+ predictors were a 1% rLLS decrease (OR 2.17; p < 0.001), LSS-level ≥ 2 (OR 2.59; p = 0.001), LLS-grade C (OR 5.86; p = 0.02) and LLS-grade D (OR 18.4; p < 0.001). The mean rSLLS of RNR+ patients was 0.6% shorter (p < 0.001; 95% C.I. 0.4 to 0.8) indicating a disproportionate shorter lumbar spine. Conclusions We identified LSS severity grade and LSS levels as the strongest predictors of RNR. In addition to previous studies, we conclude that a shortened lumbar spine by degeneration is involved in the development of RNR.
Collapse
Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany
| | - Carlos J Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany. .,Non-Medical PhD Program, Faculty of Medicine (UKE), University of Hamburg, Hamburg, Germany.
| | - Jens Lohmann
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany
| | - Thies Fitting
- Department of Radiology, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany
| |
Collapse
|
18
|
Marques CJ, Hillebrand H, Papavero L. The clinical significance of redundant nerve roots of the cauda equina in lumbar spinal stenosis patients: A systematic literature review and meta-analysis. Clin Neurol Neurosurg 2018; 174:40-7. [DOI: 10.1016/j.clineuro.2018.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/09/2018] [Accepted: 09/01/2018] [Indexed: 12/13/2022]
|
19
|
Cong L, Zhu Y, Yan Q, Tu G. A Meta-Analysis on the Clinical Significance of Redundant Nerve Roots in Symptomatic Lumbar Spinal Stenosis. World Neurosurg 2017; 105:95-101. [PMID: 28559073 DOI: 10.1016/j.wneu.2017.05.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/16/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Symptomatic lumbar spinal stenosis (LSS), which leads to severe socioeconomic consequences and places a heavy burden on global healthcare system, is a relatively frequent spine disorder. Redundant nerve roots (RNRs) are a relatively common finding in which slender, serpiginous, or tortuous nerve roots are found in the subarachnoid space of the lumbar spine. Previous studies that evaluated the prognostic assessment of RNRs in patients with symptomatic LSS are composed of doubtful results. Therefore, the clinical significance of RNRs in symptomatic LSS is still uncertain. The aim of this meta-analysis is a systematic assessment of the clinical significance of RNR syndrome in symptomatic LSS. METHODS This study used a highly sensitive search strategy to identify all published studies in multiple databases up to January 1, 2017. All identified trials were systematically evaluated using specific inclusion and exclusion criteria. Cochrane methodology was also applied to the results of this study. RESULTS This study identified 4 relevant studies involving 297 patients. Compared with a non-RNR group, the RNR group results included worse clinical outcomes that were assessed using the Japanese Orthopedic Association scores after surgery (weighted mean difference [WMD], -0.78; 95% confidence interval [CI], -1.26 to -0.29; P = 0.002; I2 = 0%), for recovery rate (WMD, -9.87; 95% CI, -15.07 to -4.67; P = 0.0002; I2 = 0%), and for older age (WMD, 2.51; 95% CI, 0.45-4.57; P = 0.02; I2 = 43%). CONCLUSIONS RNR is an entity in association with symptomatic LSS, which may be viewed as a potentially powerful prognostic indicator of worse postoperative functional recovery for symptomatic LSS.
Collapse
Affiliation(s)
- Lin Cong
- Department of Orthopedic surgery, The First Hospital of China Medical University, Shenyang City, China.
| | - Yue Zhu
- Department of Orthopedic surgery, The First Hospital of China Medical University, Shenyang City, China
| | - Qi Yan
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Guanjun Tu
- Department of Orthopedic surgery, The First Hospital of China Medical University, Shenyang City, China
| |
Collapse
|