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Complications of epidural spinal stimulation: lessons from the past and alternatives for the future.Spinal Cord Oct 2020Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVES
Over the past decade, an increasing number of studies have demonstrated that epidural spinal cord stimulation (SCS) can successfully assist with neurorehabilitation following spinal cord injury (SCI). This approach is quickly garnering the attention of clinicians. Therefore, the potential benefits of individuals undergoing epidural SCS therapy to regain sensorimotor and autonomic control, must be considered along with the lessons learned from other studies on the risks associated with implantable systems.
METHODS
Systematic analysis of literature, as well as preclinical and clinical reports.
RESULTS
The use of SCS for neuropathic pain management has revealed that epidural electrodes can lose their therapeutic effects over time and lead to complications, such as electrode migration, infection, foreign body reactions, and even SCI. Several authors have also described the formation of a mass composed of glia, collagen, and fibrosis around epidural electrodes. Clinically, this mass can cause myelopathy and spinal compression, and it is only treatable by surgically removing both the electrode and scar tissue.
CONCLUSIONS
In order to reduce the risk of encapsulation, many innovative efforts focus on technological improvements of electrode biocompatibility; however, they require time and resources to develop and confirm safety and efficiency. Alternatively, some studies have demonstrated similar outcomes of non-invasive, transcutaneous SCS following SCI to those seen with epidural SCS, without the complications associated with implanted electrodes. Thus, transcutaneous SCS can be proposed as a promising candidate for a safer and more accessible SCS modality for some individuals with SCI.
Topics: Electrodes, Implanted; Epidural Space; Forecasting; Humans; Neurological Rehabilitation; Spinal Cord Compression; Spinal Cord Injuries; Spinal Cord Stimulation
PubMed: 32576946
DOI: 10.1038/s41393-020-0505-8 -
Neurosurgical Review Apr 2021Pneumorrhachis (PR) refers to free air in the spinal canal. We aim to describe a case report and conduct a systematic review focused on the clinical presentation,...
Pneumorrhachis (PR) refers to free air in the spinal canal. We aim to describe a case report and conduct a systematic review focused on the clinical presentation, diagnosis, and management of traumatic PR. We conducted a language-restricted PubMed, SciELO, Scopus, and Ovid database search for traumatic PR cases published till June 2019. Categorical variables were assessed by Fisher's exact test. In addition to our reported index case, there were 82 articles (96 individual cases) eligible for meta-analysis according to our inclusion/exclusion criteria. Eighty per cent of patients had blunt trauma, while 17% had penetrating injuries. Thirty-four per cent of cases were extradural PR, 21% intradural PR, and unreported PR type in 43%. Nine per cent of patients presented with symptoms directly attributed to PR: sensory radiculopathy (2%), motor radiculopathy (1%), and myelopathy (6%). CT had a 100% sensitivity for diagnosing PR, MRI 60%, and plain radiograph 48%. Concurrent injuries reported include pneumocephalus (42%), pneumothorax (36%), spine fracture (27%), skull fracture (27%), pneumomediastinum (24%), and cerebrospinal fluid leak (14%). PR was managed conservatively in every case, with spontaneous resolution in 96% on follow-up (median = 10 days). Prophylactic antibiotics for meningitis were given in 13% PR cases, but there was no association with the incidence of meningitis (overall incidence: 3%; prophylaxis group (0%) vs non-prophylaxis group (4%) (p = 1)). Occasionally, traumatic PR may present with radiculopathy or myelopathy. Traumatic PR is almost always associated with further air distributions and/or underlying injuries. There is insufficient evidence to support the use of prophylactic antibiotic in preventing meningitis in traumatic PR patients.
Topics: Aged; Humans; Male; Pneumocephalus; Pneumorrhachis; Radiography; Spinal Canal; Spinal Cord Injuries; Thoracic Vertebrae
PubMed: 32307638
DOI: 10.1007/s10143-020-01300-8 -
World Neurosurgery Jul 2020Transdural disc herniations represent about 0.3% of all herniated discs. Preoperative imaging rarely demonstrates this condition. Therefore, diagnosis of transdural disc...
BACKGROUND
Transdural disc herniations represent about 0.3% of all herniated discs. Preoperative imaging rarely demonstrates this condition. Therefore, diagnosis of transdural disc herniation is usually made intraoperatively. We describe the clinicopathologic features of extremely rare cases of thoracic and lumbar interdural disc herniations mimicking spinal intradural en plaque tumors.
METHODS
This is a retrospective case series with a systematic literature review. Clinical presentation, imaging, differential diagnosis, intraoperative microsurgical findings, and possible pathogenesis were reviewed according to published guidelines. All patients underwent a posterior approach for microsurgical excision of disc herniation, but no epidural lesion was found. At intradural exploration, a tumor-like en plaque lesion was discovered. The surface of the lesion was incised, and multiple friable, cartilaginous white-yellow fragments were removed to achieve complete intralesional excision.
RESULTS
The postoperative course was characterized by progressive neurologic improvement in all cases. In peculiar anatomic (adhesions between the anulus fibrosus, posterior longitudinal ligament, and ventral surface of dura mater) and pathologic (calcified giant disc herniation, spinal canal stenosis, previous lumbar spine surgery) conditions, penetration of disc fragment in the thickness of spinal dura mater can occur.
CONCLUSIONS
Interdural disc herniations constitute a rare pathologic condition characterized by the migration of the herniated disc in neither the epidural nor the subdural spinal space, but rather in the thickness of the spinal dura mater. Further advances are necessary in neuroradiologic investigations to achieve a correct preoperative diagnosis, which is essential, as spine surgeons must be aware of these rare pathologies.
Topics: Aged; Calcinosis; Dura Mater; Female; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Male; Microsurgery; Middle Aged; Retrospective Studies; Treatment Outcome
PubMed: 32305597
DOI: 10.1016/j.wneu.2020.04.015 -
European Spine Journal : Official... Jul 2020To summarize the recommendations from the national clinical guideline published by the Danish Health Authority, regarding cemental augmentation as treatment for painful... (Review)
Review
PURPOSE
To summarize the recommendations from the national clinical guideline published by the Danish Health Authority, regarding cemental augmentation as treatment for painful vertebral lesions, in patients with malignant disease.
METHODS
A multidisciplinary working group formulated recommendations based on the GRADE approach.
RESULTS
Two of the questions were based on randomized studies and one on professional consensus. The guideline recommends cemental augmentation for painful vertebral lesions in patients with malignant diagnosis, either hematological or non-hematological. Fracture of the posterior wall is not a contradiction to cemental augmentation, but care should always be taken while injecting the cement, to decrease the risk of cemental leaks into the spinal canal.
CONCLUSION
The recommendations are based on low-to-moderate quality of evidence or professional consensus as well as patient preferences and positive and harmful effects of the intervention. The working group recommends more randomized studies on patients with different malignant diseases and painful vertebral lesions comparing percutaneous vertebroplasty/kyphoplasty and conservative treatment to confirm the conclusion in this guideline. These slides can be retrieved under Electronic Supplementary Material.
Topics: Bone Cements; Denmark; Fractures, Compression; Humans; Kyphoplasty; Osteoporotic Fractures; Spinal Fractures; Treatment Outcome; Vertebroplasty
PubMed: 32246231
DOI: 10.1007/s00586-020-06392-w -
Journal of Anesthesia Jun 2020Neuraxial anesthesia is a common practice in obstetrics. Evidence suggests that preprocedural ultrasound versus the conventional landmark location method accurately... (Meta-Analysis)
Meta-Analysis
Could preprocedural ultrasound increase the first-pass success rate of neuraxial anesthesia in obstetrics? A systematic review and meta-analysis of randomized controlled trials.
Neuraxial anesthesia is a common practice in obstetrics. Evidence suggests that preprocedural ultrasound versus the conventional landmark location method accurately identifies a given intervertebral space and predicts the needle insertion depth required to reach the spinal canal. However, whether the preprocedural ultrasound examination improves the first-pass success (FPS) rate remains elusive. Major databases were systematically searched for all relevant studies published in English up to June 2019. Eighteen randomized controlled trials including 1844 patients were enrolled. The quality of eligible studies was assessed, and predefined outcomes were synthesized by meta-analysis. The primary results showed that preprocedural ultrasound increased the FPS rate in patients with predicted puncture difficulty but not in patients who were easily punctured. Preprocedural ultrasound reduced the number of redirections and punctures and decreased the incidence of vascular puncture and backache. There was no evidence of a reduction in failed punctures. We also noted that preprocedural ultrasound prolonged the identification time but not the procedure time. Thus, this systematic review provides evidence that preprocedural ultrasound does not improve the FPS rate of neuraxial anesthesia in patients who are easily palpated, although it increases the FPS rate in patients who are difficult to palpate.
Topics: Anesthesia, Spinal; Female; Humans; Obstetrics; Pregnancy; Randomized Controlled Trials as Topic; Ultrasonography; Ultrasonography, Interventional
PubMed: 32133540
DOI: 10.1007/s00540-020-02750-6 -
Journal of Pediatric Hematology/oncology Apr 2020Primitive myxoid mesenchymal tumor of infancy is a rare soft tissue tumor. The present case is one of the most invasive primitive myxoid mesenchymal tumor of infancy...
Primitive myxoid mesenchymal tumor of infancy is a rare soft tissue tumor. The present case is one of the most invasive primitive myxoid mesenchymal tumor of infancy reported to date. To our knowledge, it is the first case described with extensive involvement of pelvis and the third described developing metastasis and with an invasion of the spinal canal without evidence of transformation into undifferentiated sarcoma. The patient failed to respond to chemotherapy (CHT). According to the few available data, CHT seems to be more effective in the presence of metastatic disease or increased cellularity. However, CHT, including high-dose ifosfamide, resulted ineffective even after lung metastasis development with pathologic evidence of increased mitotic rate. The management of this case and the data in the literature confirm surgery as the gold standard treatment in this pathology.
Topics: Antineoplastic Combined Chemotherapy Protocols; Fatal Outcome; Humans; Infant; Male; Soft Tissue Neoplasms
PubMed: 32118811
DOI: 10.1097/MPH.0000000000001764 -
Pain Physician Nov 2019Symptomatic lumbar spinal stenosis is a condition affecting a growing number of individuals resulting in significant disability and pain, leading to a multitude of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Symptomatic lumbar spinal stenosis is a condition affecting a growing number of individuals resulting in significant disability and pain, leading to a multitude of interventions ranging from simple over the counter medication to opioids, and, finally, to complex surgical fusions. After failure of conservative treatment with drug therapy, physical therapy, and other conservative modalities including epidural injections, percutaneous adhesiolysis with targeted delivery of drugs into the epidural space can be offered in lumbar central spinal stenosis prior to minimally invasive surgical options or complex surgical fusions. To date there has been only one systematic review which has assessed the role of percutaneous adhesiolysis in treating central spinal stenosis, compared to post lumbar surgery syndrome which has multiple systematic reviews and randomized controlled trials (RCTs).
STUDY DESIGN
A systematic review of RCTs and observational studies assessing the role of percutaneous adhesiolysis in managing lumbar central spinal stenosis.
OBJECTIVE
To evaluate the effectiveness of percutaneous adhesiolysis in managing central lumbar spinal stenosis, utilizing currently available literature.
METHODS
This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for literature search, Cochrane review criteria, Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB), and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) to assess methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and meta-analysis.PubMed, Cochrane library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through June 2019. The evidence was summarized utilizing principles of the best evidence synthesis on a scale of 1 to 5.
OUTCOME MEASURES
The primary outcome or hard endpoint was defined as the proportion of patients with 50% pain relief and improvement in functionality, whereas the secondary outcome measures or soft endpoints were pain relief and/or improvement in functionality. Short-term effectiveness was defined as improvement of 6 months or less, whereas long-term effectiveness was defined as more than 6 months.
RESULTS
Based on search criteria, 9 manuscripts were identified and considered for inclusion with final inclusion of 2 RCTs and 4 observational studies in this systematic review and 5 studies for single arm meta-analysis. The results showed Level II evidence for short-term and long-term improvement in pain and function with application of percutaneous adhesiolysis in managing central lumbar spinal stenosis.
LIMITATIONS
There was a significant paucity of evidence assessing the role of percutaneous adhesiolysis in managing lumbar central spinal stenosis, leading to Level II or strong evidence.
CONCLUSION
Overall, the present analysis shows Level II (moderate) evidence for percutaneous adhesiolysis in managing lumbar central spinal stenosis based on relevant high quality RCTs and observational studies.
KEY WORDS
Lumbar central spinal stenosis, percutaneous adhesiolysis, randomized controlled trials, systematic reviews, neuroplasty.
Topics: Analgesics; Disease Management; Epidural Space; Humans; Injections, Epidural; Low Back Pain; Lumbar Vertebrae; Observational Studies as Topic; Pain Management; Randomized Controlled Trials as Topic; Reproducibility of Results; Spinal Stenosis; Treatment Outcome
PubMed: 31775400
DOI: No ID Found -
Journal of Neurosurgery. Spine Sep 2019Cervical spondylotic myelopathy (CSM) has become a prevalent cause of spinal cord dysfunction among the aging population worldwide. Although great strides have been made...
OBJECTIVE
Cervical spondylotic myelopathy (CSM) has become a prevalent cause of spinal cord dysfunction among the aging population worldwide. Although great strides have been made in spine surgery in past decades, the optimal timing and surgical strategy to treat CSM have remained controversial. In this article the authors aimed to analyze the current trends in studies of CSM and to summarize the recent advances of surgical techniques in its treatment.
METHODS
The PubMed database was searched using the keywords pertaining to CSM in human studies that were published between 1975 and 2018. Analyses of both the bibliometrics and contents, including the types of papers, authors, affiliations and countries, number of patients, and the surgical approaches were conducted. A systematic review of the literature was also performed with emphasis on the diagnosis and treatment of mild CSM.
RESULTS
A total of 1008 papers published during the span of 44 years were analyzed. These CSM studies mainly focused on the natural history, diagnosis, and treatment, and only a few prospective randomized trials were reported. For the authors and affiliations, there was a shift of clustering of papers toward Asian countries in the past decades. Regarding the treatment for CSM, there was an exponential growth of surgical series published, and there was a trend toward slightly more anterior than posterior approaches through the past decade. Patients with CSM had increased risks of neurological deterioration or spinal cord injury with nonoperative management. Because surgery might reduce the risks, and early surgery was likely to be correlated with better outcomes, there was a trend toward attention to mildly symptomatic CSM.
CONCLUSIONS
There is emerging enthusiasm for research on CSM worldwide, with more publications originating in Asian countries over the past few decades. The surgical management of CSM is evolving continuously toward early and anterior approaches. More prospective investigations on the optimal timing and choices of surgery are therefore needed.
Topics: Bibliometrics; Cervical Vertebrae; Disease Management; Humans; Spinal Cord Diseases; Spondylosis
PubMed: 31473666
DOI: 10.3171/2019.5.SPINE18769 -
Child's Nervous System : ChNS :... Feb 2020While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With...
OBJECT
While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With special implications regarding technique, radiation dose, and pathology, we sought to review our single-center experience with pediatric spinal vascular pathology and use a systematic review of the literature to further identify its role in pediatrics.
METHODS
A retrospective chart review was conducted under IRB approval for all patients age 0-18 years old who underwent spinal angiography at our institution between 2007 and 2018 for concern for spinal vascular pathology. A simultaneous systematic review was conducted via dedicated search terms in two distinct databases and reviewed to identify all studies referring to spinal angiography or angiograms in pediatric patients.
RESULTS
Six patients were included. Three patients (50%) had vascular malformations confirmed on diagnostic angiography and underwent subsequent endovascular treatment. Two patients (33.3%), one with hematomyelia and one with spinal cord infarction, had negative diagnostic angiograms. One patient (16.7%) had a spinal tumor and underwent angiography for further evaluation preoperatively. Spinal angiography was used to aid in diagnosis, preoperative planning, and treatment in these cases. It was demonstrated to be safe in this patient population, with no untoward events, minimal radiation dose, and possible therapeutic applications in select cases. The systematic review identified 11 studies regarding pediatric spinal angiography. These ranged from single case reports to case series of up to 38 patients and highlighted the role of spinal angiography in diagnosis, endovascular treatment, preoperative planning, and postoperative follow-up.
CONCLUSIONS
Spinal angiography may be used in a variety of scenarios to better understand the architecture of vascular spinal lesions and facilitate endovascular intervention. While its application in both adult and pediatric pathology is limited to select cases, spinal angiography remains a key diagnostic procedure when approaching vascular lesions or tumors of the spine, assessing for etiology of spinal cord infarcts, and in the evaluation of unexplained hemorrhage in the spinal canal.
Topics: Adolescent; Adult; Angiography; Central Nervous System Vascular Malformations; Child; Child, Preschool; Embolization, Therapeutic; Humans; Infant; Infant, Newborn; Pediatrics; Retrospective Studies; Spinal Cord; Spine
PubMed: 31414169
DOI: 10.1007/s00381-019-04329-3 -
Medicine Aug 2019Lumbar spinal stenosis (LSS) is caused by neural compression due to narrowing of the lumbar spinal canal or neural foramen. Surgical intervention is a standard treatment... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Lumbar spinal stenosis (LSS) is caused by neural compression due to narrowing of the lumbar spinal canal or neural foramen. Surgical intervention is a standard treatment for LSS; however, the steep increase in the surgical rate, post-operative complications, and comparatively low long-term satisfaction are considered to be limitations of this surgical approach. Conversely, acupotomy is a minimally invasive technique that combines the effects of conventional acupuncture with micro-incision, which may offer an alternative to surgery for the treatment of LSS. This review was conducted to investigate and critically review the current evidence on the efficacy and safety of acupotomy for LSS.
METHODS
Eleven databases were searched from their respective inception dates to December 28, 2018. Randomized controlled trials (RCTs) comparing acupotomy and wait-list, sham treatment, or active controls were included. The quality of the included studies was assessed using risk-of-bias tool.
RESULTS
Seven RCTs were included in this review and meta-analysis. The methodological quality of the included studies was generally poor. The acupotomy treatment group was associated with significantly lower visual analogue scale scores (range 0∼10) (5 RCTs; mean difference [MD] -1.55, 95% confidence interval [CIs] -2.60 to -0.50; I = 94%) and higher Japanese Orthopedic Association Score (3 RCTs; MD 4.70, 95% CI 3.73 to 5.68; I = 0%) compared to the active control group. In subgroup analysis based on the type of active controls, acupotomy retained significant benefits over lumbar traction and acupuncture, as well as over lumbar traction, spinal decompression, and acupuncture. Safety data were reported in only 1 study, and no adverse events occurred in either the acupotomy or the acupuncture control group.
CONCLUSION
According to current evidence, acupotomy might be beneficial for treating LSS. Acupotomy showed consistent superiority over lumbar traction, but the results were mixed in comparisons with other interventions, such as spinal decompression and acupuncture. However, the findings should be interpreted cautiously, given the poor methodological quality of the included studies, and potential small-study effects. Further larger, high-quality, rigorous RCTs should be conducted on this topic and rigorous reporting of acupotomy procedures and safety data should be encouraged.
Topics: Acupuncture Therapy; Humans; Lumbosacral Region; Randomized Controlled Trials as Topic; Spinal Stenosis
PubMed: 31393365
DOI: 10.1097/MD.0000000000016662