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Intradural Extramedullary Spinal Metastases from Non-neurogenic Primary Tumors: A Systematic Review.Anticancer Research Jul 2022Intradural extramedullary spinal metastases (IESMs) may severely affect quality-of-life of oncological patients. Several treatments are available but their impact on... (Review)
Review
BACKGROUND/AIM
Intradural extramedullary spinal metastases (IESMs) may severely affect quality-of-life of oncological patients. Several treatments are available but their impact on prognosis is unclear. We systematically reviewed the literature on IESMs of non-neurogenic origin.
MATERIALS AND METHODS
PubMed, Ovid EMBASE, Scopus, and Web-of-Science were screened to include articles reporting patients with IESMs from non-neurogenic primary tumors. Clinico-radiological presentation, treatments, and outcomes were analyzed.
RESULTS
We included 51 articles encompassing 130 patients of a median age of 62 years (range=32-91 years). The most common primary neoplasms were pulmonary (26.2%), renal (20%), and breast (13.8%) carcinomas. Median time interval from primary tumor to IESMs was 18 months (range=0-240 months). The most common symptoms were sensory (58.3%) and motor (54.2%) deficits. Acute cauda equina syndrome was reported in 29 patients (37.7%). Lesions were diagnosed at magnetic resonance imaging (93.3%), myelography (25%), or computed tomography (16.7%). All patients underwent decompressive laminectomy with tumor resection, partial (54.6%) more frequently than complete (43.1%). Adjuvant radiation (67.5%) and/or systemic (13.3%) therapies were administered. After treatment, most patients had symptom improvement (70.8%) and optimal radiological response (64.2%). Four patients experienced IESMs recurrences (3.1%) with median local tumor control of 14.5 months (range=0.1-36 months). Deaths occurred in 50% of patients, with median overall survival of 6.7 months (range=0.1-108 months).
CONCLUSION
Patients with IESMs have significant tumor burden with poor prognoses. Resection and locoregional radiation may offer favorable clinico-radiological responses but are limited in achieving optimal local control and survival.
Topics: Adult; Aged; Aged, 80 and over; Humans; Magnetic Resonance Imaging; Middle Aged; Radiography; Spinal Cord Neoplasms; Spinal Neoplasms; Tomography, X-Ray Computed
PubMed: 35790288
DOI: 10.21873/anticanres.15814 -
The Cochrane Database of Systematic... Apr 2017Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.
OBJECTIVES
To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I = 51%).
AUTHORS' CONCLUSIONS
There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.
Topics: Back Pain; Equipment Design; Headache; Humans; Needles; Paresthesia; Post-Dural Puncture Headache; Randomized Controlled Trials as Topic; Sensitivity and Specificity; Spinal Puncture
PubMed: 28388808
DOI: 10.1002/14651858.CD010807.pub2 -
JBJS Reviews Oct 2019Neuropathic arthropathy of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Causes include...
BACKGROUND
Neuropathic arthropathy of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Causes include syringomyelia, syphilis, diabetes, chronic alcoholism, and leprosy, with syringomyelia accounting for the vast majority of upper-extremity Charcot joints. Early presentation of this rare condition includes nonspecific symptoms such as swelling, erythema, sensory symptoms, and decreased functionality, making diagnosis challenging.
METHODS
We systematically reviewed 32 case reports published between 1924 and 2016. A total of 59 shoulders from 56 patients are included in this analysis. Variables include patient demographic characteristics, presentation, etiology, diagnostic techniques, treatment, outcome, and follow-up of Charcot shoulder.
RESULTS
We compiled a total of 25 right shoulders (42%), 24 left shoulders (41%), and 10 shoulders (17%) with unspecified laterality. The mean patient age (and standard deviation) was 49 ± 11 years, and the median age was 47 years. There was a higher prevalence in men (37 shoulders [63%]) compared with women (22 shoulders [37%]). Presenting symptoms included reduced range of motion (53 shoulders [90%]), paresthesia or hypoesthesia (45 [76%]), swelling (44 [75%]), weakness (40 [68%]), pain (31 [53%]), and reduction in deep tendon reflexes (22 [37%]). Shoulder radiographs were made in all cases. The presence of a syrinx was detected in 45 shoulders (76%) with magnetic resonance imaging, myelography, or clinical diagnosis. Sixteen shoulders (27%) reported exposure to trauma, with a 69% decrease in time from presentation to diagnosis compared with non-traumatic cases. Treatment was categorized as solely nonoperative management (14 [24%]), operative management (13 [22%]), combined therapy (20 [34%]), and no treatment listed (10 [17%]). Two surgical cases (3%) were excluded from our treatment group analysis as they were treated for unrelated or misdiagnosed conditions.
CONCLUSIONS
Our study increases awareness and understanding of this complex, progressive disease to reduce delay and misdiagnosis and to contribute to the standard-of-care recommendations.
LEVEL OF EVIDENCE
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Arthropathy, Neurogenic; Humans; Shoulder Joint
PubMed: 31663919
DOI: 10.2106/JBJS.RVW.18.00155 -
British Journal of Neurosurgery Apr 2023Non-communicating extradural spinal arachnoid cysts (NEACs) are extremely rare aetiology of symptomatic spinal cord compression. The aim of this study was to address...
OBJECTIVE
Non-communicating extradural spinal arachnoid cysts (NEACs) are extremely rare aetiology of symptomatic spinal cord compression. The aim of this study was to address their pathogenesis, optimum management strategy and outcome through systematic review of existing published studies.
MATERIALS AND METHOD
We have found 13 eligible publications by searching through PubMed, ScienceDirect, and Google Scholar databases, published from inception to December 2020. We have analysed the data of 21 patients extracted from those 13 publications by IBM SPSS version 23.
RESULTS
According to our analysis congenital predisposition, trauma, and previous surgery history are the aetiology of NEAC. Clinical presentation of cyst depends upon the location and extent of compression or involvement of the neurovascular structures. Paraparesis with variable degree of sensory disturbance was seen among patients. Based on neuroimaging findings, NEACs are most commonly found at dorsal and dorsolumbar region. Magnetic resonance imaging (MRI) is the diagnostic modalities of choice and CT myelography can demonstrate the communication with the subarachnoid space. Recurrence rate of cyst after surgery is very low as only one out of twenty patients showed recurrence. If dural defect is not accurately addressed, the recurrence rate increased significantly.
CONCLUSIONS
Our study has highlighted aetiology, treatment strategies, and neurological outcome of NEAC. These findings may help neurosurgeons to manage this rare surgical entity for favourable outcome.
Topics: Humans; Arachnoid Cysts; Spinal Cord Diseases; Spinal Cord Compression; Magnetic Resonance Imaging; Tomography, X-Ray Computed
PubMed: 35766304
DOI: 10.1080/02688697.2022.2090505 -
Clinical Neurology and Neurosurgery Jan 2018Computed Tomographic Myelography (CTM) is a gold-standard imaging test for evaluating the brachial plexus and has been used for a long time. Another imaging test more...
Computed Tomographic Myelography (CTM) is a gold-standard imaging test for evaluating the brachial plexus and has been used for a long time. Another imaging test more recently used is Magnetic Resonance imaging (MRI), which is also part of the plexus evaluation. The purpose of this study was to determine the accuracy of MRI in diagnosing post-traumatic injuries of the brachial plexus. We conducted a Systematic Review with cross-sectional studies of diagnostic accuracy. Studies with populations presenting post-traumatic brachial plexus injury, over 16 years old, both genders, and examined by CT Myelography and MRI were evaluated. The trial resulted in three studies that covered the inclusion criteria. The sample consisted of 46 participants. The tool Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality of the studies, and the software RevMan was used to identify the homogeneity of the studies that entered the analysis. The study was registered in PROSPERO under the number CRD42016041720. Studies showed moderate to high risk of bias, with low or very low quality of evidence due to the limitations of studies and differences in comparing the assessment groups. The heterogeneity of the studies made it impossible to create meta-analyzes. MRI has been an excellent test for assessing traumatic brachial plexus injuries in clinical practice; however, the quantitative analysis of studies identified a lack in methodological rigor. Future studies should focus on methodological rigor, providing more accurate assessments of modalities and their benefits.
Topics: Accidents; Brachial Plexus; Cross-Sectional Studies; Humans; Magnetic Resonance Imaging; Wounds and Injuries
PubMed: 29145043
DOI: 10.1016/j.clineuro.2017.11.003 -
Academic Emergency Medicine : Official... Jun 2018Low back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and...
BACKGROUND
Low back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness of interventions aimed at reducing image ordering in the ED for LBP patients.
METHODS
A protocol was developed a priori, following the PRISMA guidelines, and registered with PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews, SCOPUS, CINAHL, and Dissertation Abstracts) and the gray literature were searched. Comparative studies assessing interventions that targeted image ordering in the ED for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility and completed data extraction. Study quality was completed independently by two reviewers using the before-after quality assessment checklist, with a third-party mediator resolving any differences. Due to a limited number of studies and significant heterogeneity, only a descriptive analysis was performed.
RESULTS
The search yielded 603 unique citations of which a total of five before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and postintervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The type of interventions utilized included clinical decision support tools, clinical practice guidelines, a knowledge translation initiative, and multidisciplinary protocols. Overall, four studies reported a decrease in the relative percentage change in imaging in a specific image modality (22.7%-47.4%) following implementation of the interventions; however, one study reported a 35% increase in patient referrals to radiography, while another study reported a subsequent 15.4% increase in referrals to CT and myelography after implementing an intervention which reduced referrals for simple radiography.
DISCUSSION
While imaging of LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation), evidence on interventions to reduce image ordering for ED patients with LBP is sparse. There is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED; however, a shift in imaging modality has also been demonstrated. Additional studies employing higher-quality methods and measuring intervention fidelity are strongly recommended to further explore the potential of ED-based interventions to reduce image ordering for this patient population.
Topics: Diagnostic Imaging; Emergency Service, Hospital; Humans; Low Back Pain; Referral and Consultation; Unnecessary Procedures
PubMed: 29315969
DOI: 10.1111/acem.13376 -
Global Spine Journal Sep 2017Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVES
To determine the preoperative computed tomography (CT) myelogram imaging parameters in patients diagnosed with degenerative cervical myelopathy (DCM) that correlate with severity of DCM and predict postoperative patients' functional outcome.
METHODS
An electronic database search was performed using Ovid Medline and Embase. CT myelogram studies investigating the correlation between imaging characteristics and DCM severity or postoperative outcomes were included. Two independent reviewers performed citation screening, selection, qualitative assessment, and data extraction using an objective and blinded protocol.
RESULTS
A total of 5 studies (402 patients) were included in this review and investigated the role of preoperative CT myelogram parameters in predicting the functional outcome after surgical treatment of DCM. All studies were retrospective cohort studies. CT myelogram characteristics included the transverse area of the spinal cord at maximum level of compression, spinal canal narrowing, number of blocks, spinal canal diameter, and flattening ratio. There is low evidence suggesting that patients with a preoperative transverse area of the spinal cord >30 mm at the level of maximum compression have better postoperative recovery and outcome. We found no studies investigating the correlation between preoperative CT myelogram parameters and DCM severity.
CONCLUSIONS
Patients with greater transverse area of spinal cord at the level of maximum compression on the preoperative CT myelogram are more likely to have better neurological outcome after surgery. There is insufficient evidence to suggest that any of the other CT myelogram parameters investigated are predictors of postoperative outcomes in patients with DCM.
PubMed: 28894681
DOI: 10.1177/2192568217701101 -
Neurological Sciences : Official... May 2024Intraspinal cerebrospinal fluid (CSF) collection has been reported as a rare cause of lower motor neuron (LMN) disorder. We report a case of bibrachial diplegia...
INTRODUCTION
Intraspinal cerebrospinal fluid (CSF) collection has been reported as a rare cause of lower motor neuron (LMN) disorder. We report a case of bibrachial diplegia associated with intraspinal CSF collection and perform a systematic literature review.
PATIENT AND METHODS
A 52-year-old man developed a bibrachial amyotrophy over 6 years, confirmed by the presence of cervical subacute neurogenic changes at electromyography (EMG). Brain magnetic resonance imaging (MRI) revealed cerebral siderosis, while spine MRI showed a ventral longitudinal intraspinal fluid collection (VLISFC) from C2 to L2. No CSF leakage was localized at myelography; a conservative treatment was chosen. We searched for all published cases until 30th April 2023 and extrapolated data of 44 patients reported in 27 publications.
RESULTS
We observed a male predominance, a younger disease onset compared to amyotrophic lateral sclerosis, and a quite long disease duration, highlighting a slow disease progression. LMN signs were more frequently bilateral, mostly involving C5-C6 myotomes. Around 61% of patients presented additional symptoms, but only three referred to a history of headache. Accordingly, CSF opening pressure was mostly normal. Spinal MRI revealed the presence of VLISFC and in some cases myelomalacia. EMG patterns displayed both chronic and subacute neurogenic change in the cervical region. The disease course mainly depended on the treatment choice, which was mostly represented by a surgical approach when a specific dural defect was detected by imaging.
CONCLUSION
Bibrachial diplegia due to VLISFC can be a treatable cause of focal amyotrophy and presents some clinical and radiological "red flags" which cannot be missed by a clinical neurologist.
Topics: Humans; Male; Middle Aged; Female; Cerebrospinal Fluid Leak; Spinal Cord Diseases; Magnetic Resonance Imaging; Motor Neuron Disease; Myelography; Intracranial Hypotension
PubMed: 37968433
DOI: 10.1007/s10072-023-07170-4