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Kelly MJ, Altorfer FCS, Burkhard MD, Huang RC, Cammisa FP, Chazen JL. Incidental durotomy resulting in a postoperative lumbosacral nerve root with eventration into the adjacent facet joint: illustrative cases. J Neurosurg Case Lessons 2024; 7:CASE2418. [PMID: 38648675 DOI: 10.3171/case2418] [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: 01/11/2024] [Accepted: 03/06/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication. OBSERVATIONS Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints. LESSONS Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.
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Affiliation(s)
- Michael J Kelly
- 1Department of Spine Surgery, Hospital for Special Surgery, New York, New York; and
| | | | - Marco D Burkhard
- 1Department of Spine Surgery, Hospital for Special Surgery, New York, New York; and
| | - Russel C Huang
- 1Department of Spine Surgery, Hospital for Special Surgery, New York, New York; and
| | - Frank P Cammisa
- 1Department of Spine Surgery, Hospital for Special Surgery, New York, New York; and
| | - J Levi Chazen
- 2Department of Radiology and Imaging Hospital for Special Surgery, New York, New York
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Abel F, Altorfer FCS, Rohatgi V, Gibbs W, Chazen JL. Imaging of Discogenic and Vertebrogenic Pain. Radiol Clin North Am 2024; 62:217-228. [PMID: 38272616 DOI: 10.1016/j.rcl.2023.10.003] [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] [Indexed: 01/27/2024]
Abstract
Chronic low back pain is a major source of pain and disability globally involving multifactorial causes. Historically, intervertebral disc degeneration and disruption have been associated as primary back pain triggers of the anterior column, termed "discogenic pain." Recently, the vertebral endplates have been identified as another possible pain trigger of the anterior column. This "endplate-driven" model, defined "vertebrogenic pain," is often interconnected with disc degeneration. Diagnosis of vertebrogenic and discogenic pain relies on imaging techniques that isolate pain generators and exclude comorbid conditions. Traditional methods, like radiographs and discography, are augmented by more sensitive methods, including SPECT, CT, and MRI. Morphologic MRI is pivotal in revealing indicators of vertebrogenic (eg, Modic endplate changes) and discogenic pain (eg, disc degeneration and annular fissures). More advanced methods, like ultra-short-echo time imaging, and quantitative MRI further amplify MRI's accuracy in the detection of painful endplate and disc pathology. This review explores the pathophysiology of vertebrogenic and discogenic pain as well as the impact of different imaging modalities in the diagnosis of low back pain. We hope this information can help identify patients who may benefit from personalized clinical treatment and image-guided therapies.
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Affiliation(s)
- Frederik Abel
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA
| | - Franziska C S Altorfer
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA; Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland
| | - Varun Rohatgi
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, NY 10065, USA
| | - Wende Gibbs
- Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA
| | - Joseph Levi Chazen
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA.
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Altorfer FCS, Burkhard MD, Kelly MJ, Avrumova F, Sneag DB, Chazen JL, Tan ET, Lebl DR. Robot-Assisted Lumbar Pedicle Screw Placement Based on 3D Magnetic Resonance Imaging. Global Spine J 2024:21925682241232328. [PMID: 38324511 DOI: 10.1177/21925682241232328] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
STUDY DESIGN Human Cadaveric Study. OBJECTIVE This study aims to explore the feasibility of using preoperative magnetic resonance imaging (MRI), zero-time-echo (ZTE) and spoiled gradient echo (SPGR), as source data for robotic-assisted spine surgery and assess the accuracy of pedicle screws. METHODS Zero-time-echo and SPGR MRI scans were conducted on a human cadaver. These images were manually post-processed, producing a computed tomography (CT)-like contrast. The Mazor X robot was used for lumbar pedicle screw-place navigating of MRI. The cadaver underwent a postoperative CT scan to determine the actual position of the navigated screws. RESULTS Ten lumbar pedicle screws were robotically navigated of MRI (4 ZTE; 6 SPGR). All MR-navigated screws were graded A on the Gertzbein-Robbins scale. Comparing preoperative robotic planning to postoperative CT scan trajectories: The screws showed a median deviation of overall 0.25 mm (0.0; 1.3), in the axial plane 0.27 mm (0.0; 1.3), and in the sagittal plane 0.24 mm (0.0; 0.7). CONCLUSION This study demonstrates the first successful registration of MRI sequences, ZTE and SPGR, in robotic spine surgery here used for intraoperative navigation of lumbar pedicle screws achieving sufficient accuracy, showcasing potential progress toward radiation-free spine surgery.
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Affiliation(s)
| | - Marco D Burkhard
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Michael J Kelly
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Fedan Avrumova
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - J Levi Chazen
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
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Altorfer FCS, Tan ET, Sneag DB. Editorial for "Clinical Value and Reliability of Quantitative Assessments of Lumbosacral Nerve Root Using Diffusion Tensor and Diffusion Weighted MR Imaging: A Systematic Review". J Magn Reson Imaging 2024. [PMID: 38190425 DOI: 10.1002/jmri.29215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, New York, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, New York, USA
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Lebret A, Lévy S, Pfender N, Farshad M, Altorfer FCS, Callot V, Curt A, Freund P, Seif M. Investigation of perfusion impairment in degenerative cervical myelopathy beyond the site of cord compression. Sci Rep 2023; 13:22660. [PMID: 38114733 PMCID: PMC10730822 DOI: 10.1038/s41598-023-49896-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
The aim of this study was to determine tissue-specific blood perfusion impairment of the cervical cord above the compression site in patients with degenerative cervical myelopathy (DCM) using intravoxel incoherent motion (IVIM) imaging. A quantitative MRI protocol, including structural and IVIM imaging, was conducted in healthy controls and patients. In patients, T2-weighted scans were acquired to quantify intramedullary signal changes, the maximal canal compromise, and the maximal cord compression. T2*-weighted MRI and IVIM were applied in all participants in the cervical cord (covering C1-C3 levels) to determine white matter (WM) and grey matter (GM) cross-sectional areas (as a marker of atrophy), and tissue-specific perfusion indices, respectively. IVIM imaging resulted in microvascular volume fraction ([Formula: see text]), blood velocity ([Formula: see text]), and blood flow ([Formula: see text]) indices. DCM patients additionally underwent a standard neurological clinical assessment. Regression analysis assessed associations between perfusion parameters, clinical outcome measures, and remote spinal cord atrophy. Twenty-nine DCM patients and 30 healthy controls were enrolled in the study. At the level of stenosis, 11 patients showed focal radiological evidence of cervical myelopathy. Above the stenosis level, cord atrophy was observed in the WM (- 9.3%; p = 0.005) and GM (- 6.3%; p = 0.008) in patients compared to healthy controls. Blood velocity (BV) and blood flow (BF) indices were decreased in the ventral horns of the GM (BV: - 20.1%, p = 0.0009; BF: - 28.2%, p = 0.0008), in the ventral funiculi (BV: - 18.2%, p = 0.01; BF: - 21.5%, p = 0.04) and lateral funiculi (BV: - 8.5%, p = 0.03; BF: - 16.5%, p = 0.03) of the WM, across C1-C3 levels. A decrease in microvascular volume fraction was associated with GM atrophy (R = 0.46, p = 0.02). This study demonstrates tissue-specific cervical perfusion impairment rostral to the compression site in DCM patients. IVIM indices are sensitive to remote perfusion changes in the cervical cord in DCM and may serve as neuroimaging biomarkers of hemodynamic impairment in future studies. The association between perfusion impairment and cervical cord atrophy indicates that changes in hemodynamics caused by compression may contribute to the neurodegenerative processes in DCM.
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Affiliation(s)
- Anna Lebret
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
| | - Simon Lévy
- CNRS, CRMBM, Aix-Marseille University, Marseille, France
- APHM, CEMEREM, Hôpital Universitaire Timone, Marseille, France
- MR Research Collaborations, Siemens Healthcare Pty Ltd, Melbourne, Australia
| | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich, Switzerland
| | | | - Virginie Callot
- CNRS, CRMBM, Aix-Marseille University, Marseille, France
- APHM, CEMEREM, Hôpital Universitaire Timone, Marseille, France
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
- Department of Brain Repair and Rehabilitation, Wellcome Trust Center for Neuroimaging, Institute of Neurology, University College London, London, UK
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Maryam Seif
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland.
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
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Waltenspül M, Zindel C, Altorfer FCS, Wirth S, Ackermann J. Correlation of Postoperative Imaging With MRI and Clinical Outcome After Cartilage Repair of the Ankle: A Systematic Review and Meta-analysis. Foot & Ankle Orthopaedics 2022; 7:24730114221092021. [PMID: 35520475 PMCID: PMC9067057 DOI: 10.1177/24730114221092021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting. Methods: A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome. Results: Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome (P = .021, P = .028, and P = .033). Conclusion: Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle. Level of Evidence: Level III, systematic review and meta-analysis.
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Affiliation(s)
- Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Triemli Hospital, Zürich, Switzerland
| | - Christoph Zindel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Franziska C. S. Altorfer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Stephan Wirth
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jakob Ackermann
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
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Altorfer FCS, Sutter R, Farshad M, Spirig JM, Farshad-Amacker NA. MRI appearance of adjunct surgical material used in spine surgery. Spine J 2022; 22:75-83. [PMID: 34284130 DOI: 10.1016/j.spinee.2021.07.009] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Early postoperative MR images are frequently necessary after spine surgery. The appearance of commonly used adjunct hemostatic agents and dural sealants in MR images has not been systematically evaluated. PURPOSE The purpose of this experimental study was to systematically analyze and describe the characteristics of the most commonly applied hemostatic agents and dural sealants in spine surgery on early postoperative MR images. STUDY DESIGN Cadaver Study METHODS: Four commonly applied dural sealants (Duraseal, Bioglue, Tachosil, Tisseel) and five commonly used hemostatic agents (Surgiflo, Bonewax, , Spongostan, Gelfoam, Avitene) were investigated. The experimental setting involved a human cadaver where a standard left-sided laminotomy was performed on nine levels of the thoracolumbar spine, and the materials were separately applied and mixed with fresh blood or water for hemostatic and dural sealants, respectively. The cadaver model was scanned at a 3 Tesla MRI and the imaging findings for all materials were compared to the surrounding tissue and systematically reported. RESULTS All investigated dural sealants and hemostatic agents were distinguishable from the surrounding tissue on MR images with different appearances on the MR sequences. A detailed atlas for the identification of the materials in postoperative spine MRI was established. CONCLUSION Commonly used hemostatic agents and dural sealants can be successfully identified on early postoperative spine MRI. CLINICAL SIGNIFICANCE Knowledge about MRI appearances of commonly used adjunct surgical materials helps in interpretation of postoperative imaging and supports clinical decision making.
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Affiliation(s)
- Franziska C S Altorfer
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland.
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
| | - José M Spirig
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
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