Intramedullary spinal capillary hemangioma with secondary neurulation defect in children

Intramedullary spinal capillary hemangioma is a rare occurrence in pediatric patients, and only limited cases have been reported. This study presents the first two cases of spinal capillary hemangioma co-present with retained medullary cord and one case of spinal capillary hemangioma with lumbosacral lipomatous malformation. Previous literature on ten patients with this pathology was reviewed. We speculated pathogenesis, imaging features, and histopathologic findings of the disease.

Intraoperative High-Resolution Color-Coded Ultrasound to Identify the Posterior Median Sulcus for Midline Myelotomy in Intramedullary Spinal Cord Surgery

A 14-year-old boy presented with a 2-year history of slowly increasing weakness and atrophy in the right forearm and leg. Magnetic resonance imaging (MRI) revealed an intramedullary diffusely infiltrating lateralized tumor at C3-7. An extended biopsy was planned. After laminotomy and durotomy, the swollen spinal cord was noted to be rotated by 45° with the right dorsal root entry zone being in the midline. A 15 MHz linear ultrasound probe was used to identify the midline by visualizing the dorsal median sulcal vein within the midline raphe. A myelotomy was made in that zone without deterioration of somatosensory evoked potentials (SEPs) and an extended biopsy was performed. Histological examination revealed a pilocytic astrocytoma. Modern intraoperative high-resolution color-coded ultrasound enables the identification of the midline in intramedullary spinal cord lesions even when the spinal cord anatomy is distorted.

Spinal Cord Injury: Emerging Technologies

The mainstay of treatment for spinal cord injury includes decompressive laminectomy and elevation of mean arterial pressure. However, outcomes often remain poor. Extensive research and ongoing clinical trials seek to design new treatment options for spinal cord injury, including stem cell therapy, scaffolds, brain-spine interfaces, exoskeletons, epidural electrical stimulation, ultrasound, and cerebrospinal fluid drainage. Some of these treatments are targeted at the initial acute window of injury, during which secondary damage occurs; others are designed to help patients living with chronic injuries.

In-vivo testing of a novel wireless intraspinal microstimulation interface for restoration of motor function following spinal cord injury

BACKGROUND

Spinal cord injury causes a drastic loss in motor and sensory function. Intraspinal microstimulation (ISMS) is an electrical stimulation method developed for restoring motor function by activating the spinal networks below the level of injury. Current ISMS technology uses fine penetrating microwires to stimulate the ventral horn of the lumbar enlargement. The penetrating wires traverse the dura mater through a transdural conduit that connects to an implantable pulse generator.

OBJECTIVE

A wireless, fully intradural ISMS implant was developed to mitigate the potential complications associated with the transdural conduit, including tethering and leakage of cerebrospinal fluid.

METHODS

Two wireless floating microelectrode array (WFMA) devices were implanted in the lumbar enlargement of an adult domestic pig. Voltage transients were used to assess the electrochemical stability of the interface. Manual flexion and extension movements of the spine were performed to evaluate the mechanical stability of the interface. Post-mortem 9T MRI imaging was used to confirm the location of the electrodes.

RESULTS

The WFMA-based ISMS interface successfully evoked extension and flexion movements of the hip joint. Stimulation thresholds remained stable following manual extension and flexion of the spine.

CONCLUSION

The preliminary results demonstrate the surgical feasibility as well as the functionality of the proposed wireless ISMS system.

Exoscope Efficacy and Feasibility in Pediatric Spinal Neurosurgery: A Single-Institution Cohort Case Series

BACKGROUND

The exoscope has emerged as an efficacious microscope in adult spinal neurosurgery providing improved operative field visibility and surgeon ergonomics. However, outcome data and feasibility are underrepresented in the pediatric literature. We present the largest case series aimed at assessing operative and clinical outcomes in pediatric patients undergoing various exoscope-assisted spinal surgeries.

METHODS

A retrospective review was conducted on all consecutive pediatric (age <18 years) spinal surgeries performed with the use of an exoscope by 3 senior surgeons at a single institution from 2020-2023. Demographics and clinical and operative outcomes were reviewed and analyzed.

RESULTS

Ninety-six exoscope-assisted pediatric spine surgeries were performed on 89 unique patients, 41 (42.7%) of which were male. The mean age at surgery was 12 (±5.3) years. Spinal cord detethering (55.8%) was the most common procedure performed. The overall mean operative time for all procedures was 155 (±86) minutes, and the mean estimated blood loss was 18 (±41) mL. The mean length of stay was 5.4 (±6.5) days. There were 14 (14.6%) patients with complications in this cohort. At final follow-up, 64 (83.1%) of symptomatic patients reported neurologic symptom improvement.

CONCLUSIONS

Using the exoscope in a variety of pediatric spinal surgeries resulted in an acceptable average operative time, estimated blood loss, length of stay, and rate of neurologic symptom improvement. The exoscope appears to be an efficacious option for pediatric neurosurgical spinal procedures.

Evaluating the diagnostic accuracy of 3D contrast-enhanced magnetic resonance angiography versus digital subtraction angiography in spinal dural arteriovenous fistulas

OBJECTIVE

Spinal dural arteriovenous fistulas (SDAVFs) often go undiagnosed, leading to irreversible spinal cord dysfunction. Although digital subtraction angiography (DSA) is the gold standard for diagnosing SDAVF, DSA is invasive and operator dependent, with associated risks. MR angiography (MRA) is a promising alternative. This study aimed to evaluate the performance of MRA as an equal alternative to DSA in investigating, diagnosing, and localizing SDAVF.

METHODS

Prospectively collected data from a single neurosurgeon at a large tertiary academic center were searched for SDAVFs. Eligibility criteria included any patient with a surgically proven SDAVF in whom preoperative DSA, MRA, or both had been obtained. The eligible patients formed a consecutive series, in which they were divided into DSA and MRA groups. DSA and MRA were the index tests that were compared to the surgical SDAVF outcome, which was the reference standard. Accurate diagnosis was considered to have occurred when the imaging report matched the operative diagnosis to the correct spinal level. Comparisons used a two-sample t-test for continuous variables and Fisher-Freeman-Halton's exact test for categorical variables, with p < 0.05 specifying significance. Univariate, bivariate, and multivariate analyses were conducted to investigate group associations with DSA and MRA accuracy. Positive predictive value, sensitivity, and accuracy were calculated.

RESULTS

A total of 27 patients with a mean age of 63 years underwent surgery for SDAVF. There were 19 male (70.4%) and 8 female (29.6%) patients, and the mean duration of symptoms at the time of surgery was 14 months (range 2-48 months). Seventeen patients (63%) presented with bowel or bladder incontinence. Bivariate analysis of the DSA and MRA groups further revealed no significant relationships between the characteristics and accuracy of SDAVF diagnosis. MRA was found to be more sensitive and accurate (100% and 73.3%) than DSA (85.7% and 69.2%), with a subanalysis of the patients with both preoperative MRA and DSA showing that MRA had a greater positive predictive value (78.6 vs 72.7), sensitivity (100 vs 72.7), and accuracy (78.6 vs 57.1) than DSA.

CONCLUSIONS

In surgically proven cases of SDAVFs, the authors determined that MRA was more accurate than DSA for SDAVF diagnosis and localization to the corresponding vertebral level. Incomplete catheterization at each vertebral level may result in the failure of DSA to detect SDAVF.

Spinal Cord Stimulation Paddle-to-Percutaneous Revision: Case Series and Technical Description

OBJECTIVE

Spinal cord stimulators (SCSs) can be implanted via a percutaneous or paddle approach, the latter technique requiring a laminotomy or laminectomy. Revision surgery may be necessary in instances of migrated, misplaced, or failed stimulators. When revision of a percutaneous system is necessary, it is common to replace the electrodes with a paddle SCS. This study aims to describe a case series of patients with failed paddle SCS electrodes who underwent revision with percutaneous SCS hardware.

METHODS

A series of 5 patients were retrospectively analyzed. Medical records were reviewed for demographic data, operative technique, postoperative follow-up, and complications.

RESULTS

Five patients were included in this series. The median age was 63 (range 51-84), and the median duration from initial implantation to revision surgery was 19 months (range 5-60). The median operative duration was 92 minutes (mean 99 ± 19.6 minutes). The median length of follow-up after surgery was 24 months (mean 21.8 ± 6.0 months). All patients had improved pain relief and therapeutic coverage with no complications.

CONCLUSIONS

Paddle-to-percutaneous SCS surgery is a feasible and durable revision option in appropriately selected patients.

Complex split cord malformation with split conus

Split cord malformations are disorders of gastrulation. Disorders of secondary neurulation occur later and are traditionally considered separate from the former. Complex split cord malformations involving both the cord and the conus and encompassing the epochs of gastrulation, primary neurulation, junctional neurulation, and secondary neurulation have not been described in literature. We present a four-year-old boy with such a malformation and postulate the embryological mechanism involved. The clinical vignette of this unique case has been described. We report a good clinical outcome in this patient with surgical management.

Risk factors for C5 palsy: a systematic review and multivariate analysis

OBJECTIVE

Postoperative C5 palsy (C5P) is a known complication in cervical spine surgery. However, its exact pathophysiology is unclear. The authors aimed to provide a review of the current understanding of C5P by performing a comprehensive, systematic review of the existing literature and conducting a critical appraisal of existing evidence to determine the risk factors of C5P.

METHODS

A systematic search of PubMed/MEDLINE (January 1, 2019, to July 2, 2021), EMBASE (inception to July 2, 2021), and Cochrane (inception to July 2, 2021) databases was conducted. Preestablished criteria were used to evaluate studies for inclusion. Studies that adjusted for one or more of the following factors were considered: preoperative foraminal diameter (FD) at C4/5, posterior spinal cord shift at C4/5, preoperative anterior-posterior diameter (APD) at C4/5, preoperative spinal cord rotation, and change in C2-7 Cobb angle. Studies were rated as good, fair, or poor based on the Quality in Prognosis Studies (QUIPS) tool. Random effects meta-analyses were done using methods outlined by Cochrane methodologists for pooling of prognostic studies. Overall quality (strength) of evidence was based on Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods for prognostic studies. The protocol for this review was published on the PROSPERO (CRD264358) website.

RESULTS

Of 303 potentially relevant citations of studies, 12 met the inclusion criteria set a priori. These works provide moderate-quality evidence that preoperative FD substantially increases the odds of C5P in patients undergoing posterior cervical surgery. Pooled estimates across 7 studies in which various surgical approaches were used indicate that the odds of C5P approximately triple for each millimeter decrease in preoperative FD (OR 3.05, 95% CI 2.07-4.49). Preoperative APD increases the odds of C5P, but the confidence is low. Across 3 studies, each using different surgical approaches, each millimeter decrease in preoperative APD was associated with a more than 2-fold increased odds of C5P (pooled OR 2.51, 95% CI 1.69-3.73). Confidence that there is an association with postoperative C5P and posterior spinal cord shift, change in sagittal Cobb angle, and preoperative spinal cord rotation is very low.

CONCLUSIONS

The exact pathophysiological process resulting in postoperative C5P remains an enigma but there is a clear association with foraminal stenosis, especially when performing posterior procedures. C5P is also related to decreased APD but the association is less clear. The overall quality (strength) of evidence provided by the current literature is low to very low for most factors. Systematic review registration no.: CRD264358 (https://www.crd.york.ac.uk/prospero/).

Spinal cord schistosomiasis in a 6-year-old child with complete recovery after spine surgery and medical treatment: case report and discussion

Spinal cord schistosomiasis is a rare and severe form of schistosomiasis. The prognosis is largely conditioned by early diagnosis and treatment. The authors present a case of spinal cord schistosomiasis complicated by spinal cord compression syndrome. This is the case of a 6-year-old patient who presented with febrile gastroenteritis followed by complete paralysis of both lower limbs of sudden onset following a brief stay in a village setting with notion of multiple baths at a stream. Spinal cord MRI revealed an enlarged spinal cord spanning D10 to D12 with heterogeneous contrast enhancement and a syrinx cavity above the lesion. Biological workup revealed an inflammatory syndrome. Treatment consisted of decompressive laminectomy with biopsy of the lesion and a syringo-subarachnoid shunt. Pathological analysis revealed fragments of central nervous system tissues with an infiltrate composed of lymphocytes, plasmocytes, and macrophages producing granulomatous foci lined with areas of necrosis in addition to a large contingent of polynuclear eosinophils, agglutinating around or covering in some places elongated ovoid structures, with relatively thick eosinophilic shells and presenting a terminal spur. Adjuvant treatment consisted of praziquantel and corticotherapy for 1 month. The evolution showed marked improvement in the neurological deficits. She now walks unassisted and has good sphincter control. Spinal cord schistosomiasis is rare in our context; its diagnosis is difficult. The treatment is both medical and surgical.

Intraoperative Neurophysiologic Monitoring and Mapping During Surgery on Intramedullary Spinal Cord Tumors in Children and Adolescents

SUMMARY

Surgical resection of intramedullary spinal cord tumors carries significant risks of neurologic deficits, especially in cases of infiltrative tumors. In pediatric patients, this type of surgery may be associated with a high risk of poor neurologic outcome. Intraoperative neurophysiologic monitoring has been adopted as part of the clinical routine by many centers as a useful adjunct for intraoperative assessment of neurologic integrity. To what extent intraoperative neurophysiologic mapping strategies may further support intraoperative decision-making is still a matter of debate. Here, we report on a small cohort of five pediatric patients in whom mapping with the double-train paradigm was used to identify the dorsal column and corticospinal tract and to guide the surgical resection. We also discuss the possible benefits and challenges regarding the available literature.

Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.

Limited exposure to preserve stability and achieve complete excision of limited dorsal myeloschisis - the "Skip-Hop Laminectomy" technique: a technical note

OBJECTIVE

The fibroneural stalk of an LDM has variable thickness, complexity, and length, which can span 5 to 6 vertebral segments from its skin attachment to its "merge point" with the dorsal spinal cord. Therefore, complete resection may require extensive multi-level laminotomies. In this technical note, a modification of the procedure is presented that avoids long segment laminectomies while ensuring complete excision of long LDM stalks.

RESULTS

An illustrative case of resection of LDM is presented using skip laminectomies. The technique ensures complete removal of the stalk, thus reducing the risk of future intradural dermoid development, while at the same time minimizes the risk for delayed kyphotic deformity.

CONCLUSIONS

A technique of "skip-hop" proximal and distal short segment laminectomies in cases of LDM optimizes the objectives of complete stalk resection with preservation of spinal integrity.

Concomitant Thoracic Spinal Dural Arteriovenous Fistula and Spinal Cavernous Malformation

Both spinal dural arteriovenous fistula (SDAVF) and spinal cavernous malformation (SCM) are uncommon vascular malformations. To our knowledge, such a case of SDAVF concomitant with SCM has not been reported. We encountered a case of a 55-year-old man who had weakness and numbness in both lower extremities. Magnetic resonance imaging showed a round-shape lesion identified as a cavernous malformation in the middle segment of the thoracic spine, with spinal edema and obvious flow voids. Diagnostic angiography revealed an SDAVF fed by the right T7 radicular artery with venous drainage. The intramedullary venous hypertension due to fistula was suspected of inducing the formation of SCM. This case may provide new insight into the pathogenesis of SCM.

Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation

OBJECTIVES

Placement of a standard paddle lead for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a "skip" laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified.

MATERIALS AND METHODS

Participants who underwent SCS paddle placement at Albany Medical Center between 2016 and 2017 were identified. Operative reports were reviewed to identify the paddle type, level of initial laminotomy, target level, and skip laminotomy level. Preoperative thoracic magnetic resonance images (MRIs) were reviewed, and spinal canal diameter, interpedicular distance, and dorsal cerebral spinal fluid thickness were measured for each participant when available.

RESULTS

A total of 106 participants underwent thoracic SCS placement. Of these, 97 had thoracic MRIs available for review. Thirty-eight participants required a skip laminotomy for placement of the paddle compared with 68 participants who did not. There was no significant difference in demographic features including age, sex, body mass index, and surgical history. Univariate analyses that suggested trends were selected for further analysis using binary logistic regression. Level of initial laminotomy (odds ratio [OR] = 1.51, p = 0.028), spinal canal diameter (OR = 0.71, p = 0.015), and dorsal cerebrospinal fluid thickness (OR = 0.61, p = 0.011) were correlated with skip laminotomy. Target level (OR = 1.27, p = 0.138) and time from trial (1.01, p = 0.117) suggested potential association. The multivariate regression was statistically significant, X2(10) = 28.02, p = 0.002. The model explained 38.3% of the variance (Nagelkerke R2) and predicted skip laminectomy correctly in 73.3% of cases. However, for the multivariate regression, only a decrease in spinal canal diameter (OR = 0.59, p = 0.041) was associated with a greater odds of skip laminotomy.

CONCLUSIONS

This study aims to characterize the patient and radiographic factors that may predict the need to perform a skip laminotomy during the initial placement of SCS paddles. Here, we show that radiographic and anatomic variables, primarily spinal canal diameter, play an important role in predicting the need for a skip laminotomy. Furthermore, we suggest that target level for placement and level of initial laminotomy also may contribute. Further investigation of the predictive factors for performing a skip laminotomy would help optimize surgical planning and preoperative patient selection and counseling.

Changes in the Lumbosacral Angle after Spinal Cord Untethering in 23 Children with Tethered Cord Syndrome

AIM

To analyze changes in the lumbosacral angle in children with tethered cord syndrome before and after spinal cord untethering surgery, and to determine the clinical value of such changes at the last follow-up.

MATERIAL AND METHODS

We retrospectively analyzed 23 children over 5 years old who were treated with spinal cord untethering in our hospital from January 2010 to January 2021 and who had complete medical data. X-rays were used to examine the child's spine preoperatively, postoperatively, and at follow-up with frontal and lateral radiographs, and lumbosacral angle data were measured and analyzed.

RESULTS

A total of 23 children aged 5-14 years had their lumbosacral angles measured and analyzed with a postoperative followup of 12-48 months. The mean preoperative lumbosacral angle was 70.30 ± 9.04°, the mean postoperative lumbosacral angle was 63.34 ± 5.60°, and the mean lumbosacral angle at the last follow-up was 61.61 ± 9.14°. There was a statistically significant reduction in the lumbosacral angle in the children postoperatively and at the last follow-up compared to the preoperative period (p=0.002; p=0.001).

CONCLUSION

Spinal cord untethering can improve the inclination of the lumbosacral angle in children older than 5 years with tethered cord syndrome.

Comparison study of anterior cervical zero-profile fusion cage (ROI-C) and traditional titanium plate plus fusion technique for the treatment of spinal cord type cervical spondylosis

A retrospective comparative study. To compare and analyze the differences in the efficiency and safety of ROI-C and traditional titanium plate with fusion cage for the treatment of CSM patients. Clinical data of 105 patients with CSM who underwent surgical treatment at our hospital from January 2019 to December 2020 were retrospectively reviewed. Patients were divided into ROI-C and traditional groups according to the different fusion methods. The operation time, intraoperative blood loss, preoperative and postoperative JOA score, NDI score, cervical Cobb angle, intervertebral space height, and postoperative complications were recorded and compared between the 2 groups. A total of 105 patients were included in this study, with 57 patients in the ROI-C group and 48 patients in the traditional group. The baseline data were similar between the 2 groups (P > .05). The operative time, intraoperative blood loss, and the incidence of postoperative dysphagia were significantly lower in the ROI-C group than in the traditional group (P < .05). There were no significant differences in the JOA score, NDI score, cervical Cobb angle, intervertebral space height, the incidence of postoperative axial symptoms, and adjacent segment degeneration between the 2 groups (P > .05). However, both groups showed significant improvement in the JOA score, NDI score, cervical Cobb angle, and intervertebral space height compared with before surgery (P < .05). The ROI-C zero-profile internal fixation system and traditional titanium plates with fusion cages can achieve satisfactory clinical treatment results for CSM patients. However, ROI-C has advantages of a shorter operative time, less blood loss, and less postoperative dysphagia. Therefore, the ROI-C zero-profile internal fixation system can be safely and effectively used to treat patients with CSM.

The Effect of Posterior Fossa Decompression Surgery on Brainstem and Cervical Spinal Cord Dimensions in Adults with Chiari Malformation Type 1

OBJECTIVE

Posterior fossa decompression (PFD) surgery creates more space at the skull base, reduces the resistance to the cerebrospinal fluid motion, and alters craniocervical biomechanics. In this paper, we retrospectively examined the changes in neural tissue dimensions following PFD surgery on Chiari malformation type 1 adults.

METHODS

Measurements were performed on T2-weighted brain magnetic resonance images acquired before and 4 months after surgery. Measurements were conducted for neural tissue volume and spinal cord/brainstem width at 4 different locations; 2 width measurements were made on the brainstem and 2 on the spinal cord in the midsagittal plane. Cerebellar tonsillar position (CTP) was also measured before and after surgery.

RESULTS

Twenty-five adult patients, with a mean age of 38.9 ± 8.8 years, were included in the study. The cervical cord volume increased by an average of 2.3 ± 3.3% (P = 0.002). The width at the pontomedullary junction increased by 2.2 ± 3.5% (P < 0.01), while the width 10 mm caudal to this junction increased by 4.2 ± 3.9% (P < 0.0001). The spinal cord width at the base of second cervical vertebra and third cervical vertebra did not significantly change after surgery. The CTP decreased by 60 ± 37% (P < 0.0001) after surgery, but no correlation was found between CTP change and dimension change.

CONCLUSIONS

The brainstem width and cervical cord volume showed a modest increase after PFD surgery, although standard deviations were large. A reduction in compression after PFD surgery may allow for an increase in neural tissue dimension. However, clinical relevance is unclear and should be assessed in future studies with high-resolution imaging.

Sacral dural arteriovenous fistula supplied by bilateral lateral sacral arteries: case report and literature review

Sacral dural arteriovenous fistulas (DAVFs) with bilateral arterial supplies are extremely rare. To date, only two cases with arterial supply from bilateral lateral sacral arteries (LSAs) were reported. We report a rare case of sacral DAVF with arterial supply from bilateral LSAs. A 56-year-old man presented with a 2-month history of progressive weakness and numbness in his lower extremities, along with urinary incontinence. Spinal magnetic resonance imaging (MRI) showed extensive edema of the spinal cord, vascular flow voids, and intraparenchymal enhancement. Spinal angiography revealed a spinal DAVF at the level of S1 supplied by bilateral LSAs and drained ascending into the perimedullary venous plexus. The fistula was successfully treated with endovascular embolization. Sacral DAVFs present various diagnostic and treatment difficulties because of the complex angioarchitecture. Successful management of these lesions requires a profound understanding of the variable patterns of arterial supply in this region.

Microsurgical disconnection of a T12/L1 ventral intradural perimedullary arteriovenous fistula (type IV) via instrumented trans-pedicular approach

CASE DESCRIPTION

We present a case of microsurgical disconnection of a PMAVF supplied by the artery of Adamkiewicz with fistulation at the ventral spinal cord.

Spinal Cord Stimulators and Intrathecal Pain Pump Removal Versus Retention During Posterior Lumbar Fusion: A Matched Cohort Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine risks associated with posterior lumbar arthrodesis after spinal cord stimulator (SCS) and intrathecal pain pump (IPP) insertion.

SUMMARY OF BACKGROUND DATA

SCS and IPPs aid in the management of chronic back and radicular pain. Little is known regarding the risks of subsequent fusion with these devices in place.

METHODS

The PearlDiver Mariner database was queried for spinal fusion between 2010 and 2020. Study groups were created for indwelling SCS or IPP and matched to a separate cohort without SCS or IPP. Subgroups were created for those who had their device removed and those who retained their device at the time of surgery. Complications up to 2 years postoperatively were reviewed and confounding variables were controlled using multivariable logistic regression.

RESULTS

Four thousand five hundred three patients had an indwelling SCS/IPP and underwent posterior lumbar fusion. Compared with patients without history of an SCS/IPP, patients undergoing a lumbar fusion with an SCS/IPP which was removed or retained had higher rates of revision surgery at 1 year [7.3% vs. 5.0%, odds ratio (OR) =1.48, P <0.001] and 2 year (10.8% vs. 7.0%, OR =1.59, P <0.001). For all time intervals, there were higher odds of instrumentation failure (2 y: OR =1.65, P <0.001), and pulmonary complications (2 y: OR =1.18, P <0.001). At 2 years, there were higher odds of surgical site complications (OR 1.15, P =0.02) and urinary complications (OR=1.07, P =0.04). There were no differences in complications up to 2 years postoperatively in patients with an SCS/IPP who had their devices retained or removed ( P >0.05).

CONCLUSIONS

Patients with a history of spinal cord stimulators and intrathecal pain pumps are at increased risk of mechanical complications and revision fusion compared with patients without these devices. Patients with an SCS or IPP have similar rates of complications during lumbar fusion whether the device is removed or retained.

Intraspinal canal platform system for coil embolization of anterior spinal artery aneurysm associated with spinal cord arteriovenous malformation: a case report and literature review

BACKGROUND

The prognosis for spinal artery aneurysms associated with spinal cord arteriovenous malformations (AVMs) is poor because of the high rupture rate of aneurysms. However, endovascular treatment remains technically difficult because the catheter system must be constructed via the small-caliber anterior spinal artery (ASA) or posterior spinal artery (PSA), which feeds functionally eloquent spinal cord. A 2.6F Carnelian HF-S microcatheter (Tokai Medical Products, Aichi, Japan) has been specifically designed to assist a 1.6F Carnelian MARVEL S microcatheter (Tokai Medical Products) as a small-profile 'platform catheter' close to the target lesion. Here we present a prenidal ASA aneurysm treated using a 2.6F Carnelian HF-S microcatheter as an intraspinal canal platform catheter and review related literature.

CASE PRESENTATION

A 50-year-old man presented with a subarachnoid haemorrhage due to cervical spinal cord AVM. Diagnostic vertebral angiography revealed the AVM supplied by the PSA originated from the right C2 segmental artery and ASA arising from the right V4 segment. Superselective angiography for each feeder was achieved through a 2.6F Carnelian HF-S microcatheter, and a prenidal ASA aneurysm was diagnosed, which was clinically consistent with haemorrhagic origin. A 1.6F Carnelian MARVEL S microcatheter was cannulated into the aneurysm through the 2.6F Carnelian HF-S microcatheter positioned at the ASA. The aneurysm coiling was successfully performed without system instability or periprocedural complications.

CONCLUSIONS

Only a few cases have described endovascular treatment for spinal artery aneurysms. To date, no reports have been published regarding the use of an intraspinal canal platform catheter to treat spinal artery aneurysms. A 2.6F Carnelian HF-S microcatheter served as a useful intraspinal canal platform catheter for coil embolization of the ASA aneurysm. This system can provide excellent accessibility and controllability for endovascular treatment of spinal artery lesions.

Transient spinal cord dysfunction after surgery for intraspinal tumors: A case report

RATIONALE

Limb dysfunction is not uncommon clinically after intramural tumor surgery. However, there are no relevant literature reports on the recovery of unilateral motor function caused by spinal cord dysfunction after short-term observation and treatment. The report of such cases is of great value for improving the cognition of postoperative complications of meningioma reducing misdiagnosis and providing reference for clinical treatment.

PATIENT CONCERNS

A 73-year-old female patient with numbness and weakness in both lower limbs accompanied by unstable walking for 2 months. Combined with imaging data and postoperative pathological diagnosis, it was diagnosed as thoracic spinal meningioma. The patient experienced transient unilateral limb dysfunction after surgery.

DIAGNOSES

Magnetic resonance imaging and its enhanced magnetic resonance imaging suggest a space occupying lesion on the left side of the spinal canal at the level of the thoracic 3 to 4 vertebral body, possibly a meningioma. The postoperative pathology was grade I meningioma.

INTERVENTION

Administer 10 mL of dexamethasone, 1 g of methylprednisolone, and 250 mL of mannitol for treatment.

OUTCOMES

After 3 hours, the patient's muscle strength gradually recovered, and after 12 hours, it was better than the preoperative level.

CONCLUSION

Spinal cord dysfunction may occur after surgery for intraspinal meningioma in the upper thoracic spine. Unlike spinal cord dysfunction caused by spinal cord injury, this dysfunction is short-term and transient. The use of hormones and diuretics is a feasible solution that can quickly restore patient limb function.

Implantation of Surgical Paddle Electrodes Using Percutaneous Biportal-Endoscopic Technique for Spinal Cord Stimulation: An Anatomical Feasibility Study in Human Cadavers

BACKGROUND

Spinal cord stimulation is a technique in which different types of electrodes are placed in the spinal epidural space for neuromodulation. Surgical paddle electrodes (SEs) are usually implanted by a surgeon by performing open surgery with laminectomy. Recent advances in endoscopic spine surgery provide another option for minimally invasive SE implantation.

OBJECTIVES

This anatomical study aims to examine the feasibility of implanting SEs in thoracic and cervical spine segments, discussing the specific advantages and disadvantages compared with previously reported methods.

STUDY DESIGN

Laboratory study with Institutional Review Board No B2023-056.

METHODS

Four fresh adult cadavers (2 women, 2 men) were operated on in this study. The posterior unilateral biportal endoscopic surgical approach, the accessibility to the intraspinal epidural space, and the technical possibilities and limitations of implantation of SEs were evaluated, as well as the surgical duration and complications.

RESULTS

All the planned steps of the operation were successfully accomplished in all 4 cadavers. A total of 8 electrodes were successfully implanted through the working portal. Among them, 4 were located in the cervical segment and 4 in the thoracic segment. The proper position of the electrodes was also verified by fluoroscopy. No rupture of dura occurred during the operation. Except for the first cadaver, the duration of surgery did not exceed 1 hour.

LIMITATIONS

Anatomical study on human cadavers, the quantity of cadavers, and the steep learning curve.

CONCLUSIONS

The results of this anatomical study show that the SEs can be satisfactorily implanted in cervical and thoracic segments using the unilateral biportal endoscopic technique.

Ventral anchoring of the conus medullaris: a new surgical technique preventing the radiographic recurrence of retethering after surgery for tethered spinal cord

OBJECTIVE

Retethering is not an unusual operation for a congenital lumbosacral dysraphic spinal lesion. The present study aimed to assess a new surgical technique for preventing retethering.

SURGICAL TECHNIQUE

After untethering the spinal cord, the pia mater or scar tissue at the caudal end of the conus medullaris is anchored to the ventral dura mater loosely using 8-0 thread, and the dura mater is closed directly. This technique is called ventral anchoring.

RESULTS

Ventral anchoring was performed in 15 patients (aged 5 to 37 years old, average age: 12.1 years old) between 2014 and 2021. All but one patient showed improvement or stabilization of the preoperative symptoms. No complication directly related to the procedure was observed. Postoperative MRI demonstrated that the dorsal subarachnoid space was restored in 14 patients but was undetectable or absent in three patients on follow-up MRI. No patients have experienced a recurrence of the tethered cord syndrome during the follow-up period.

CONCLUSION

Ventral anchoring is effective for restoring the dorsal subarachnoid space after untethering the spinal cord. This preliminary study suggested that ventral anchoring has the potential to prevent the postoperative radiographic recurrence of tethered spinal cord in patients with a congenital lumbosacral dysraphic spinal lesion.

Dorsal column mapping in resection of intramedullary spinal cord tumors: a prospective comparison of two methods and neurological follow-up

PURPOSE

In surgery for intramedullary spinal cord tumors (imSCT), distortion of the anatomy challenges the visual identification of dorsal columns (DC) for midline myelotomy. Dorsal column mapping (DCM) and spinal cord stimulation (SCS) can identify DC neurophysiologically. We compare application and feasibility of both methods.

METHODS

Patients with surgically treated imSCT were prospectively included between 04/2017 and 06/2019. The anatomical midline (AM) was marked. SSEPs at the DC after stimulation of tibial/median nerve with an 8-channel DCM electrode and cortical SSEP phase reversal at C3/C4 after SCS using a bipolar concentric probe were recorded. Procedural and technical aspects were compared. Standardized neurological examinations were performed preoperatively, 1 week postoperatively and after more than 12 months.

RESULTS

The DCM electrode detected the midline in 9/13 patients with handling limitations in the remaining patients. SCS was applicable in all patients with determination of the midline in 9/13. If both recordings could be acquired (6/13), concordance was 100%. If baseline SSEPs were poor, both methods were limited. SCS was less time-consuming (p = 0.001), cheaper, and easier to handle. In 92% of cases, the AM and neurophysiologic midlines were concordant. After myelotomy, 3 patients experienced > 50% reduction in amplitude of SSEPs. Despite early postoperative worsening of DC function, long-term follow-up showed significant recovery and improvement in quality of life.

CONCLUSION

DCM and SCS may help confirm and correct the AM for myelotomy in imSCT, leading to a favorable long-term neurological outcome in this cohort. SCS evolved to be superior concerning applicability, cost-effectiveness, and time expenditure.

A Review of Strategies Associated with Surgical Decompression in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (TSCI) is frequent. Timely diagnosis and treatment have reduced the mortality, but the long-term recovery of neurologic functions remains ominous. After TSCI, tissue bleeding, edema, and adhesions lead to an increase in the intraspinal pressure, further causing the pathophysiologic processes of ischemia and hypoxia and eventually accelerating the cascade of secondary spinal cord injury. Timely surgery with appropriate decompression strategies can reduce that secondary injury. However, disagreement about the safety and effectiveness of decompression surgery and the timing of surgery still exists. The level and severity of spinal cord injury do have an impact on the timing of surgery; therefore, TSCI subpopulations may benefit from early surgery. Early surgery perhaps has little effect on recovery from complete TSCI but might be of benefit in patients with incomplete injury. Early decompression should be considered in patients with incomplete cervical TSCI. Patient age should not be used as an exclusion criterion for early surgery. The best time point for early surgery is although influenced by the shortest duration to thoroughly examine the patient's condition and stabilize the patient's state. After the patient's condition is fully evaluated, we can perform the surgical modality of emergency myelotomy and decompression. Therefore, a number of conditions should be considered, such as standardized decompression methods, indications and operation timing to ensure the effectiveness and safety of early surgical intervention, and promotion of the functional recovery of residual nerve tissue.

Microsurgical approach for resection of the filum terminale internum in tethered cord syndrome-a case demonstration of technical nuances and vignettes

BACKGROUND

In tethered cord syndrome due to filum terminale pathology, the surgical approach to achieve detethering of the spinal cord may vary. Traditionally, sectioning the filum through a laminectomy at the lumbosacral level is performed.

METHOD

A microsurgical technique at a higher level to approach the filum below the conus tip is performed. This allows for removal of the entire distal portion of the filum through a limited interlaminar approach and dural opening.

CONCLUSION

We propose a technique to transect the filum terminale below the conus tip and extract the distal filum by releasing it from its intradural attachments to minimize any remnants of the filum terminale.

Clinical outcomes and prognostic factors in the surgical treatment of spinal dural arteriovenous fistulas: a retrospective study of 118 patients

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformations (AVMs), constituting approximately 70% of all spinal AVMs. The impact of various clinical and radiologic features on the outcomes in patients with SDAVFs is still controversial. The purpose of the study is to investigate the clinical outcomes and prognostic factors in patients with surgically treated SDAVFs in a single center. A retrospective review was performed for all patients with SDAVFs from January 2013 to September 2021 who underwent surgery at our institution. Medical records and pre- and postoperative imaging data were analyzed. Neurological function status was evaluated by modified Aminoff-Logue Scale (mALS). Student's t-test, Wilcoxon rank sum test, χ2 test and logistic regression were used to find significant prognostic factors. P values < 0.05 were considered significant. One hundred and eighteen patients were ultimately included in the study. By comparing preoperative and postoperative mALS, 69 (58.5%) patients experienced improvement, and 49 (41.5%) patients showed no improvement (worse or unchanged). Wilcoxon rank sum test showed that there was a difference between the improvement group and the no improvement group in preoperative mALS Micturition score and preoperative mALS Defecation score. The logistic regression revealed that preoperative mALS Gait score was associated with clinical improvement after surgery in patients with SDAVFs. Surgical treatment of SDAVFs is a safe and effective procedure and can lead to symptom improvement or stabilization in most patients. Preoperative neurological function status was the only factor associated with clinical prognosis.

Cryopreserved human umbilical cord as a meningeal patch during in utero spina bifida repair in a modified ovine model

OBJECTIVE

Despite in utero spina bifida (SB) repair, more than two-thirds of patients with SB are unable to ambulate independently, and 1 in 4 children need surgery for tethered cord by school age. The objective of this study was to test the cryopreserved human umbilical cord (HUC) as an antiscarring material to reduce tethering and improve function in a modified in utero SB repair model.

METHODS

An SB defect (L2-6 levels) without myelotomy was created in fetuses of timed-pregnant ewes at gestational day (GD) 75. On GD 96, the fetal defect was exposed, and the arachnoid layer was removed to disrupt the barrier and expose the spinal cord to simulate human in utero SB repair. The fetuses were randomly assigned to two groups according to the method used to cover the spinal cord: the conventional repair (CR) group, for which myofascial closure was used (n = 7), and the HUC meningeal patch group, for which HUC was used as a meningeal patch (n = 6), followed by primary skin closure. The lambs were delivered at GD 140. Blinded clinical assessment of spinal cord function was performed using the Texas Spinal Cord Injury Scale (TSCIS). Histology of the spine was performed for quantitative assessment of spinal cord tethering, inflammatory markers, and arachnoid layer regeneration.

RESULTS

The TSCIS scores were significantly lower in the CR than the HUC meningeal patch group (p = 0.0015) and the controls (p = 0.0018). The loss of spinal cord function in the CR group was mainly due to ataxia and loss of proprioception (p = 0.01 and 0.005 vs control and HUC, respectively). The histology at the repair site showed higher rates of spinal cord tethering in the CR lambs than the HUC lambs at all levels of the repair site (p = 0.01 and 0.02 vs control and HUC, respectively). In the CR with tethering compared with the HUC repair, there was a lower arachnoid layer covering at the repair site (p = 0.001). There was greater astrocyte activation in the posterior column in the CR than in the HUC repair group (p = 0.01).

CONCLUSIONS

In a modified ovine SB model, the HUC as a meningeal patch allows regeneration of the arachnoid layer, prevents spinal cord tethering, and improves spinal cord function after in utero SB repair.

Surgery for spina bifida occulta: spinal lipoma and tethered spinal cord

The technical evolution of the surgery for spina bifida occulta (SBO) over the course of a half-century was reviewed with special foci placed on the spinal lipoma and tethered spinal cord. Looking back through history, SBO had been included in spina bifida (SB). Since the first surgery for spinal lipoma in the mid-nineteenth century, SBO has come to be recognized as an independent pathology in the early twentieth century. A half-century ago, the only option available for SB diagnosis was the plain X-ray, and pioneers of the time persevered in the field of surgery. The classification of spinal lipoma was first described in the early 1970s, and the concept of tethered spinal cord (TSC) was proposed in 1976. Surgical management of spinal lipoma with partial resection was the most widely practiced approach and was indicated only for symptomatic patients. After understanding TSC and tethered cord syndrome (TCS), more aggressive approaches became preferred. A PubMed search suggested that there was a dramatic increase of publications on the topic beginning around 1980. There have been immense academic achievements and technical evolutions since then. From the authors' viewpoint, landmark achievements in this field are listed as follows: (1) establishment of the concept of TSC and the understanding of TCS; (2) unraveling the process of secondary and junctional neurulation; (3) introduction of modern intraoperative neurophysiological mapping and monitoring (IONM) for surgery of spinal lipomas, especially the introduction of bulbocavernosus reflex (BCR) monitoring; (4) introduction of radical resection as a surgical technique; and (5) proposal of a new classification system of spinal lipomas based on embryonic stage. Understanding the embryonic background seems critical because different embryonic stages bring different clinical features and of course different spinal lipomas. Surgical indications and selection of surgical technique should be judged based on the background embryonic stage of the spinal lipoma. As time flows forward, technology continues to advance. Further accumulation of clinical experience and research will open the new horizon in the management of spinal lipomas and other SBO in the next half-century.

Bilateral mirror image lumbar spinal dural arterial venous fistula: a rare case and systematic review of the literature

BACKGROUND

Spinal dural arteriovenous fistulas (SDAVF) are rare with an incidence of 5-10/million annually. They can be difficult to diagnose causing a delay in treatment with significant morbidity. We describe the first case in the literature of a symptomatic mirror lumbar SDAVF which may go unnoticed due to its unique vascular anatomy.

CASE DESCRIPTION

A 78-year-old gentleman presented with a progressive deterioration in his walking distance and urinary retention. An initial MRI scan of the whole spine did not show features suggestive of an underlying vascular malformation. During further investigations of neurological causes, the patient continued to have progressive symptoms over a 10-month period resulting in a repeat MRI scan. This showed a new finding of cord oedema without abnormal flow voids. He went on to have vascular imaging which demonstrated a mirror L3 SDAVF and underwent subsequent surgical management. At follow up there was a significant improvement in symptoms.

CONCLUSIONS

Completing a systematic review of the literature we find that the mirror lumbar SDAVF in our patient presented in a more aggressive manner with symptoms progressing faster than in single or multi-level SDAVF. Our case demonstrates how this unique vascular anatomy may result in a diagnostic challenge, behaving in an occult way where typical findings are not seen on initial MRI scanning. We provide an argument for early vascular imaging which can result in the treatment of these lesions in a timely manner.

Prophylactic Spinal Cord Untethering in Children with Spinal Dysraphism Undergoing Thoracolumbar Fusion for Scoliosis

BACKGROUND

It remains unclear whether spinal cord untethering is necessary to reduce the chances of neurologic decline in children with myelomeningocele and complex closed spinal dysraphism who undergo thoracolumbar fusion for scoliosis. We sought to determine the neurologic and functional outcomes of children with spinal dysraphism undergoing spinal fusion for scoliosis with and without prophylactic spinal cord untethering.

METHODS

Retrospective, single-center review of patients with spinal dysraphism treated with thoracolumbar fusion over the last 10 years (2009-2019) with or without prophylactic spinal cord untethering.

RESULTS

Seventeen patients with myelomeningocele and complex closed spinal dysraphism underwent spinal fusion for scoliosis. Mean age at time of surgery was 13.9 years. Prophylactic spinal cord untethering was performed in 8 of 17 (47%) patients. The change in Cobb angle after surgery was similar between the 2 groups (19.4° untethered vs. 19.9° no untethering). The ambulatory status was similar between the groups, with 37% of the untethered cohort and 44% of the non-untethered cohort being community or household ambulators. There were no changes in intraoperative motor or sensory evoked potentials in any patient during fusion surgery. No patient had a change in motor level or ambulatory status after scoliosis surgery.

CONCLUSIONS

Our data suggest that prophylactic spinal cord untethering in children with spinal dysraphism undergoing thoracolumbar fusion for scoliosis may not be necessary in patients with moderate curvatures. Our conclusions are limited by the small sample size. A larger review of registry data may yield more powerful conclusions on the necessity of prophylactic spinal cord untethering in this patient population.

The role of intraoperative extensor digitorum brevis muscle MEPs in spinal surgery

PURPOSE

Intraoperative muscle motor evoked potentials (m-MEPs) are widely used in spinal surgery with the aim of identifying a damage to spinal cord at a reversible stage. Generally, lower limb m-MEPs are recorded from abductor hallucis [AH] and the tibialis anterior [TA]. The purpose of this work is to study an unselected population by recording the m-MEPs from TA, AH and extensor digitorum brevis (EDB), with the aim of identifying the most adjustable and stable muscles responses intraoperatively.

METHODS

Transcranially electrically induced m-MEPs were intraoperative recorded in a total of 107 surgical procedures. m-MEPs were recorded by a needle electrode placed in the muscle from TA, AH and EDB muscles in the lower extremities.

RESULTS

Overall monitorability (i.e., at least 1 Lower Limb m-MEP recordable) was 100/107 (93.5%). In the remaining 100 surgeries in 3 cases, the only muscle that could be recorded at baseline was one AH, and in other 2 the EDB. Persistence (i.e., the recordability of m-MEP from baseline to the end of surgery) was 88.7% for TA, 89.8% for AH and 93.8% for EDB.

CONCLUSION

In our series, EDB m-MEPs have demonstrated a recordability superior to TA and a stability similar to AH. The explanations may be different and range from changes in the excitability of the cortical motor neuron to the different sensitivity to ischemia of the spinal motor neuron. EDB can be used alternatively or can be added to TA and AH as a target muscle of the lower limb in spinal surgery.

The evolution of spinal cord surgery: history, people, instruments, and results

INTRODUCTION

Spinal cord surgery has and always will be a challenging operation with satisfying results, but also with potentially devastating results. Over the last century, there has been an evolution in the way we perceive and conduct spinal cord surgery. The phenomenal evolution in technology from the very first x-ray pictures helps to localize the spinal pathology through the use of high-resolution MRI and ultrasonography that allows for high precision surgery with relatively minimal exposure.

METHODS

The advancements in the surgical technique and the utilization of neuromonitoring allow for maximal safe resection of these delicate and intricate tumors. We also are beginning to understand the biology of spinal cord tumors and vascular lesions, as in the recent 2021 WHO classification which identifies specific entities such as spinal ependymomas, MYCN-amplified, as separate entity from the other subtypes of ependymomas. Surgeons have also accepted the importance of maximal safe resection for most of the spinal cord pathologies rather than just performing biopsy and adjuvant treatment.

CONCLUSION

There have been significant advances since the first resection of an intramedullary tumor including diagnosis, imaging, and surgical technique for children. These advances have improved the prognosis and outcome in these children.

Neurologic outcomes for adult spinal cord ependymomas stratified by tumor location: a retrospective cohort study and 2-year outlook

Determine whether craniocaudal spinal cord tumor location affects long-term neurologic outcomes in adults diagnosed with spinal ependymomas (SE). A retrospective cohort analysis of patients aged ≥ 18 years who underwent surgical resection for SE over a ten-year period was conducted. Tumor location was classified as cervical, thoracic, or lumbar/conus. Primary endpoints were post-operative McCormick Neurologic Scale (MNS) scores at < 3 days, 6 weeks, 1 year, and 2 years. One-way ANOVA was performed to detect significant differences in MNS scores between tumor locations. Twenty-eight patients were identified. The average age was 44.2 ± 15.4 years. Sixteen were male, and 13 were female. There were 10 cervical-predominant SEs, 13 thoracic-predominant SEs, and 5 lumbar/conus-predominant SEs. No significant differences were observed in pre-operative MNS scores between tumor locations (p = 0.73). One-way ANOVA testing demonstrated statistically significant differences in post-operative MNS scores between tumor locations at < 3 days (p = 0.03), 6 weeks (p = 0.009), and 1 year (p = 0.003); however, no significant difference was observed between post-operative MNS scores at 2 years (p = 0.13). The mean MNS score for patients with thoracic SEs were higher at all follow-up time points. Tumors arising in the thoracic SE are associated with worse post-operative neurologic outcomes in comparison to SEs arising in other spinal regions. This is likely multifactorial in etiology, owing to both anatomical differences including spinal cord volume as well as variations in tumor characteristics. No significant differences in 2-year MNS scores were observed, suggesting that patients ultimately recover from neurological insult sustained at the time of surgery.

Split Spinal Cord Malformation Fed by Bilateral, Enlarged Radiculopial Arteries

Anatomical variations of the spinal cord are seen in many manifestations; one rare variant that does not stem from a neural tube defect is known as a split cord malformation (SCM). In this variation, a deviation from normal development causes the spinal cord to divide into two hemicords, typically in the lumbar region. In the case described here, a SCM was observed with large, bilateral, radiculopial arteries. To our knowledge, such large vessels in conjunction with a SCM has not previously been documented in the literature. Such variants could be problematic during surgical approaches to the lumbar spine. Herein, we report the case and discuss the development of the findings with relevant clinical applications.

Updates in the Early Management of Acute Spinal Cord Injury

Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.

A clinical clue toward recognition of split cord malformation type-I resembling meningocele in neonates

This is a letter to share the clinical experience we had with neonates born with a specific feature of spina bifida. The lesion is like a meningocele containing skim amount of fluid, with a tiny dimple around the center of the cutaneous lesion which causes inward retraction of the dysplastic coverage. This feature is in favor of accompanied split cord malformation (SCM) type I, and the central nidus is in continuous with the dural sleeve around the bony septum of SCM. By recognition of this clinical clue, surgical repair can be planned to perform with appropriate provision, particularly foreseeing the amount of intraoperative bleeding and duration of anesthesia in the newborn patients.

Dorsal bony spur in pediatric split cord malformations: eight-year experience from a tertiary care hospital

INTRODUCTION

Dorsal spurs in Type I split cord malformations (SCM-I) are infrequent findings. The pathogenesis of the same is debatable. The objective of this study is to analyze our experience with SCM-I patients having dorsal bony spurs.

METHODOLOGY

Retrospective analysis of SCM patients operated from 2010 to 2017 was performed. Their demographic profile, clinic-radiological features, operative findings, and outcome following surgery were recorded.

RESULTS

Twenty-four cases of Type I SCM harboring dorsal bony spurs were identified with mean age of 4.96 years. The commonest split site was lumbar, documented in 62.5%. Scoliosis was observed in 58.3%. Pre-operative neurological deficits were seen in 66.6% cases with asymmetric weakness of limbs seen in 16.6%. There was no new neurological deficit observed post-operatively.

CONCLUSIONS

This is the largest series of dorsal spurs occurring in SCM, reported in literature so far. Meticulous pre-operative evaluation and imaging are important to identify dorsal spurs for appropriate management and good clinical outcome. Differentiating dorsal spur from ventral spur is important as it has a bearing on surgical approach.

Biplane fluoroscopy-guided percutaneous spinal cord stimulation

OBJECTIVE

Fluoroscopy is useful for spinal cord stimulation (SCS) lead placement. We employed biplane fluoroscopy for SCS lead placement. In this study, we sought to confirm the validity of using biplane fluoroscopy for SCS lead placement and to establish whether biplane fluoroscopy safely reduces the duration of surgery.

METHODS

Clinical data were retrospectively collected from the medical records of patients who underwent SCS lead placement under local anesthesia from 2015 to 2022. The duration of the surgical phase and the total radiation exposure time per case were recorded.

RESULTS

Forty-six patients underwent percutaneous SCS lead implantation. Recording was completed in 41 cases: one lead was placed in 13 cases and two leads were placed in 28 cases. Monoplane and biplane fluoroscopy was used in 15 and 26 patients, respectively. Although the type of fluoroscopy did not significantly affect the mean duration of the surgical phase in patients in which one lead was placed, biplane fluoroscopy was associated with a significant reduction in the mean duration of the surgical phase in patients that underwent placement of two leads (P=0.002). No significant differences in the total radiation exposure time were observed between patients in the monoplane and biplane fluoroscopy groups that were implanted with one (P=0.21) or two leads (P=0.62).

CONCLUSIONS

The use of biplane fluoroscopy reduced the duration of surgery necessary for the placement of two SCS leads. Biplane fluoroscopy represents a practical and safe adjustment to the current practice of SCS lead implantation.

Development of a Modified Bayonet Forceps for Improving Steerability of Paddle Lead Electrodes During Spinal Cord Stimulator Surgery: A Technical Note

BACKGROUND AND OBJECTIVE

Despite recent advancements in spinal cord stimulation (SCS) technology, the surgical instrumentation for placement of SCS paddle leads remains suboptimal. Therefore, we developed a novel instrument to improve the steerability of SCS paddle leads during surgical placement.

METHODS

A review of existing literature was performed to analyze workflow deficiencies in the standard instrumentation of SCS paddle lead placement. After a period of adaptation and iterative feedback with a medical instrument company, a new instrument was developed, tested at benchtop, and successfully incorporated into the surgical routine.

RESULTS

A standard bayonet forceps was modified to include hooked ends and a ribbed surface, providing the surgeon with greater control over the paddle lead. The new instrument also included bilateral metal tubes starting approximately 4 cm proximal from the edge of the forceps. The bilateral metal tubes, through which the SCS paddle lead wires are passed, serve as anchors to keep the wires away from the incision site. In addition, it permitted the paddle lead to assume a bent configuration, reducing its overall size and allowing it to be placed through a smaller incision and laminectomy. The modified bayonet forceps was successfully used intraoperatively for placement of SCS paddle lead electrodes in several surgeries.

CONCLUSION

The proposed modified bayonet forceps increased steerability of the paddle lead, facilitating optimal midline placement. The bent configuration of the device facilitated a more minimally invasive surgical approach. Future studies are needed to validate our single-provider experience and evaluate the impact of this new instrument on operating room efficiency.

Advances in Imaging Modalities for Pediatric Brain and Spinal Cord Tumors

BACKGROUND

Neuroimaging has evolved from anatomical imaging toward a multi-modality comprehensive anatomical and functional imaging in the past decades, important functional data like perfusion-weighted imaging, permeability imaging, diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI), tractography, metabolic imaging, connectomics, event-related functional imaging, resting state functional imaging, and much more is now being offered.

SUMMARY

Precision diagnostics has proven to be essential for precision treatment. Many minimal invasive techniques have been developed, taking advantage of digital subtraction angiography and interventional neuroradiology. Furthermore, intraoperative CT and/or MRI and more recently MR-guided focused ultrasound have complemented the diagnostic and therapeutic armamentarium.

KEY MESSAGES

In the current manuscript, we discuss standard imaging sequences including advanced techniques like DWI, DTI, susceptibility-weighted imaging, and 1H magnetic resonance spectroscopy, various perfusion weighted imaging approaches including arterial spin labeling, dynamic contrast enhanced imaging, and dynamic susceptibility contrast imaging. Pre-, intra, and postoperative surgical imaging including visualize imaging will be discussed. The value of connectomics will be presented for its value in neuro-oncology. Minimal invasive therapeutic possibilities of interventional neuroradiology and image-guided laser ablation and MR-guided high-intensity-focused ultrasound will be presented for treatment of pediatric brain and spinal cord tumors. Finally, a comprehensive review of spinal cord tumors and matching neuropathology has been included.

Thoracic Anterior Spinal Cord Herniation: Treatment and Prognosis Outcome of Seven Patients

BACKGROUND

This study aimed to investigate the diagnosis and treatment of thoracic anterior spinal cord herniation, a rare condition.

METHODS

Clinical data of 7 patients diagnosed with thoracic anterior spinal cord herniation were analyzed. All patients were diagnosed with a complete preoperative examination and scheduled for surgical treatment. In addition, regular follow-up was performed after the surgery, and the operation's efficacy was evaluated according to clinical symptoms, imaging findings, and improvement in neurologic function.

RESULTS

All patients underwent spinal cord release with an anterior dural patch. Notably, no severe postoperative surgical complications were observed. All patients were followed up for 12-75 months, with an average duration of approximately 46.5 months. Post-operative pain symptoms were controlled, neurological dysfunction and related symptoms improved to varying degrees, and anterior spinal cord herniation did not recur. The modified Japanese Orthopedic Association score at the last follow-up was significantly higher than the preoperative score.

CONCLUSIONS

Clinicians should avoid misdiagnosing patients with thoracic anterior spinal cord herniation with intervertebral disc herniation, arachnoid cysts, and other related diseases, and patients should undergo surgical treatment as early as possible. In addition, surgical treatment can protect the neurologic function of patients and effectively prevent the aggravation of clinical symptoms.

Open thoracic cordotomy for intractable cancer pain: a how I do it

BACKGROUND

Some cancers of the lower extremity involve nerves and plexuses and can produce extreme drug-resistant noceptive pain. In these cases, open thoracic cordotomy can be proposed.

METHOD

This procedure involves disruption of the spinothalamic tract, which sustains nociceptive pathways. After placement in the prone position, selection of the side to be operated on (contralateral to the pain), and dura exposure, microsurgery is used to section the anterolateral spinal cord quadrant previously exposed by gently pulling on the dentate ligament.

CONCLUSION

Open thoracic cordotomy is a moderate invasive, safe, and effective option for the management of drug-resistant unilateral lower extremity cancer pain in well-selected patients.

Spinal cord tethering and syringomyelia after trauma: impact of age and surgical outcome

Posttraumatic spinal cord tethering and syringomyelia frequently lead to progressive neurological loss. Although several studies demonstrated favourable outcome following spinal cord detethering with/without shunting, additional research is required as no clear consensus exists over the ideal treatment strategy and knowledge about prognostic demographic determinants is currently limited. In this investigation, we retrospectively investigated 67 patients (56 men, 11 women) who were surgically treated and followed for symptomatic spinal cord tethering and syringomyelia from 2012 to 2022 at our center. Age (B-coefficient 0.396) and severity of trauma to the spinal cord (B-coefficient - 0.462) have been identified as independent predictors for the rate of development of symptomatic spinal cord tethering and syringomyelia (p < 0.001). Following untethering surgery including expansion duraplasty with/without shunting, 65.9% of patients demonstrated an improvement of neurological loss (p < 0.001) whereas 50.0% of patients displayed amelioration of spasticity and/or neuropathic pain (p < 0.001). Conclusively, active screening for symptomatic spinal cord tethering and syringomyelia, particularly in younger patients with severe spinal trauma, is crucial as surgical untethering with/without shunting is able to achieve favourable clinical outcomes. This knowledge may enable clinicians to tailor treatment strategies in spinal cord injury patients suffering from progressive neurological loss towards a more optimal and personalized patient care.

Spontaneous spinal epidural hematoma in a toddler presenting with torticollis: case report and literature review

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare entity, especially in toddlers and infants. The nonspecificity of its presenting symptoms in children may be a source of delayed diagnosis.

CASE DESCRIPTION

We report the case of a 20-month-old young boy without medical history who presented with irreducible torticollis, worsened a few days later by severe tetraplegia and respiratory distress. Spinal magnetic resonance imaging (MRI) showed a posterior epidural hematoma, extending from C3 to T1 and compressing the spinal cord. An urgent decompressive surgery via an extensive laminectomy and evacuation of the clot was performed. The patient demonstrated a partial neurological recovery on follow-up.

CONCLUSION

SSEH is a rare and serious condition that may compromise the functional and vital prognosis of the patient, hence the importance of prompt diagnosis and urgent treatment.