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Neurosurgery Jun 2024The most common thoracolumbar trauma classification systems are the Thoracolumbar Injury Classification and Severity Score (TLICS) and the Thoracolumbar AO Spine Injury...
BACKGROUND AND OBJECTIVES
The most common thoracolumbar trauma classification systems are the Thoracolumbar Injury Classification and Severity Score (TLICS) and the Thoracolumbar AO Spine Injury Score (TL AOSIS). Predictive accuracy of treatment recommendations is a historical limitation. Our objective was to validate and compare TLICS, TL AOSIS, and a modified TLICS (mTLICS) that awards 2 points for the presence of fractured vertebral body height loss >50% and/or spinal canal stenosis >50% at the fracture site.
METHODS
The medical records of adult patients with acute, traumatic thoracolumbar injuries at an urban, Level 1 trauma center were retrospectively reviewed. TLICS, mTLICS, and TL AOSIS scores were calculated for 476 patients using computed tomography, MRI, and the documented neurological examination. Treatment recommendations were compared with treatment received. Standard validity measures were calculated.
RESULTS
Treatment recommendations matched actual treatments in 95.6% (455/476) of patients for mTLICS, 91.3% (435/476) for TLICS, and 92.6% (441/476) for TL AOSIS. The differences between the accuracy of mTLICS and TLICS (95.6% vs 91.3%, P < .001) and between mTLICS and TL AOSIS (95.6% vs 91.3%, P = .003) were significant. The sensitivity of mTLICS was higher than that of TLICS (96.3% vs 81.3%, P < .001), and the sensitivity of TL AOSIS was higher than that of TLICS (92.5% vs 81.3%, P < .001). The specificity of mTLICS was equal to that of TLICS (95.3%) and higher than that of TL AOSIS (95.3% vs 92.7%, P = .02). The modifier led to substantial outperformance of mTLICS over TLICS due to 38 patients (20 of whom received surgery) moving from a TLICS score of <4 to a mTLICS score equal to 4.
CONCLUSION
All systems performed well. The mTLICS had improved sensitivity and accuracy compared with TLICS and higher accuracy and specificity than TL AOSIS. The sensitivity of TL AOSIS was higher than that of TLICS. Prospective, multi-institutional reliability and validity studies of this mTLICS are needed for adoption.
PubMed: 38920381
DOI: 10.1227/neu.0000000000003055 -
Journal of Anaesthesiology, Clinical... 2024To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP),...
BACKGROUND AND AIMS
To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions.
MATERIAL AND METHODS
This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions.
RESULTS
The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm ( value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 ( value < 0.001).
CONCLUSIONS
There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.
PubMed: 38919435
DOI: 10.4103/joacp.joacp_450_22 -
Bone Jun 2024Spinal stenosis (SS) is frequently caused by spinal ligament abnormalities, such as ossification and hypertrophy, which narrow the spinal canal and compress the spinal...
Spinal stenosis (SS) is frequently caused by spinal ligament abnormalities, such as ossification and hypertrophy, which narrow the spinal canal and compress the spinal cord or nerve roots, leading to myelopathy or sciatic symptoms; however, the underlying pathological mechanism is poorly understood, hampering the development of effective nonsurgical treatments. Our study aims to investigate the role of co-expression hub genes in patients with spinal ligament ossification and hypertrophy. To achieve this, we conducted an integrated analysis by combining RNA-seq data of ossification of the posterior longitudinal ligament (OPLL) and microarray profiles of hypertrophy of the ligamentum flavum (HLF), consistently pinpointing CTSD as an upregulated hub gene in both OPLL and HLF. Subsequent RT-qPCR and IHC assessments confirmed the heightened expression of CTSD in human OPLL, ossification of the ligamentum flavum (OLF), and HLF samples. We observed an increase in CTSD expression in human PLL and LF primary cells during osteogenic differentiation, as indicated by western blotting (WB). To assess CTSD's impact on osteogenic differentiation, we manipulated its expression levels in human PLL and LF primary cells using siRNAs and lentivirus, as demonstrated by WB, ALP staining, and ARS. Our findings showed that suppressing CTSD hindered the osteogenic differentiation potential of PLL and LF cells, while overexpressing CTSD activated osteogenic differentiation. These findings identify CTSD as a potential therapeutic target for treating spinal stenosis associated with spinal ligament abnormalities.
PubMed: 38917962
DOI: 10.1016/j.bone.2024.117174 -
Asian Spine Journal Jun 2024A retrospective case-control propensity score-matching study.
Association between ligamentous stenosis at spondylolisthetic segments before fusion surgery and symptomatic adjacent canal stenosis at follow-up in patients with degenerative spondylolisthesis.
STUDY DESIGN
A retrospective case-control propensity score-matching study.
PURPOSE
This study aimed to longitudinally evaluate whether preoperative ligamentous stenosis at the spondylolisthetic segments could affect the incidence of symptomatic adjacent canal stenosis following one-segment fusion surgery.
OVERVIEW OF LITERATURE
Several risk factors for symptomatic adjacent canal stenosis following fusion surgery have been assessed. Patients with lumbar canal stenosis mainly due to ligamentum flavum (LF) hypertrophy (ligamentous stenosis) also have LF hypertrophy in other segments.
METHODS
In total, 76 patients participated in this case-control study (neurologically symptomatic adjacent canal stenosis, n=33; neurologically asymptomatic cases at follow-up, n=43). Their risk factors during surgery and magnetic resonance (MR) images before the surgery and at follow-up were evaluated. Data from the two groups (n=25 each) were matched using propensity scores for age, sex, time to MR imaging at follow-up, surgical procedure, and LF hypertrophy in adjacent segments before the surgery and analyzed.
RESULTS
Compared with the asymptomatic group, the symptomatic adjacent canal stenosis group had a significantly larger LF area/spinal canal area in the spondylolisthetic segments before the surgery. During the follow-up periods (in months), they had a larger LF area/ spinal canal area in the adjacent segments: the two values were significantly correlated. The sensitivity, specificity, and positive and negative predictive values for determining symptomatic adjacent canal stenosis were high compared with on the cutoff value for the LF area/spinal canal area at the spondylolisthetic segments before the surgery. These results were the same after matching.
CONCLUSIONS
Symptomatic adjacent canal stenosis is mainly caused by LF hypertrophy. Ligamentous stenosis at the spondylolisthetic segments before fusion surgery might be strongly associated with symptomatic adjacent canal stenosis at follow-up.
PubMed: 38917859
DOI: 10.31616/asj.2023.0064 -
Cureus May 2024Background While two-dimensional (2D) turbo spin echo (TSE) sequences offer better through-plane resolution than three-dimensional (3D) isotropic TSE sequences images,...
Evaluating the Efficacy of Volume Isotropic Turbo Spin Echo Acquisition Versus T2-Weighted Turbo Spin Echo Imaging in the Diagnosis of Nerve Root and Perineuronal Pathologies in Spinal Disorders.
Background While two-dimensional (2D) turbo spin echo (TSE) sequences offer better through-plane resolution than three-dimensional (3D) isotropic TSE sequences images, with a narrower thickness of the slice, 3D isotropic TSE sequences are known to have a weaker in-plane resolution as well as blurring of the image. These elements may make it more difficult to distinguish between nearby structures that may affect nerve roots and small nerve roots during spinal imaging. This study aimed to analyze the accuracy of T2 TSE sequence and volumetric isotropic TSE acquisition in determining the indentation of nerve roots and perineural diseases such as nerve sheath tumors and Tarlov cysts. Methods Fifty patients who attended the Department of Radiodiagnosis for magnetic resonance (MR) spine participated in this prospective study. Routine MR lumbosacral (LS) spine sequences, such as survey, coronal T2 short-tau inversion recovery (STIR), sagittal T2 TSE, sagittal T1 TSE, and axial T2 TSE, were carried out after a localizer was acquired. More sequences from volume isotropic turbo spin echo acquisition (VISTA) were acquired. For both 2D and 3D sequences, the visibility ratings for perineural cysts, spinal canal stenosis, and nerve root indentation were evaluated. Visibility ratings ranged from zero to four. Results In the cases of perineural cyst, spinal canal stenosis, and nerve root impingement, the mean difference between the VISTA and T2 TSE visibility scores was 0.04, 0.54, and 0.56, respectively. The VISTA and T2 TS had standard deviation differences of 0.006, 0.026, and 0.06, respectively. The "t" values for nerve root impingement, spinal canal stenosis, and perineural cysts were, in order, 50, 180, and 70. Because the p-value was <0.01, a statistically significant variation has been observed. Conclusion In the diagnosis of neural and perineuronal disorders, the visibility scores for 3D T2 TSE (VISTA) were considerably better than those for 2D T2 TSE in identifying perineural cysts, spinal canal stenosis, and nerve root indentation.
PubMed: 38915957
DOI: 10.7759/cureus.60988 -
Frontiers in Surgery 2024Laminotomy and laminar replantation have emerged as novel treatment modalities for intraspinal tumors, aiming to minimize postoperative complications and retain spinal...
BACKGROUND
Laminotomy and laminar replantation have emerged as novel treatment modalities for intraspinal tumors, aiming to minimize postoperative complications and retain spinal mobility. However, existing research predominantly emphasizes their application in the thoracolumbar spine. The unique anatomy of the atlantoaxial segments necessitates surgical techniques that differ from those used in other spinal regions, and the clinical effect of such procedure remains unknown.
CASE PRESENTATION
A 61-year-old male patient with intradural schwannoma at the atlantoaxial level was operated on. The patient underwent posterior laminectomy, as well as a combined replantation of the posterior arch of the atlas and bilateral axial laminae. Postoperatively, the patient experienced significant neurological improvement, with no deformities or instability on the radiological assessments during the follow-up.
CONCLUSION
Laminotomy with combined replantation of the posterior arch of the atlas and bilateral axial lamina emerges as an effective approach for managing intraspinal tumors at the atlantoaxial level. This technique not only offers ample operating space but also restores the stability of the spinal canal. Moreover, it preserves the mobility of the atlantoaxial segment, minimizes impact on adjacent segments, and mitigates the formation of postoperative fibrosis.
PubMed: 38912398
DOI: 10.3389/fsurg.2024.1374208 -
Journal of Orthopaedic Case Reports Jun 2024Vertebral body osteochondroma presenting with myelopathic symptoms is exceptionally rare entity of spinal osteochondroma which arises from the posterior surface of...
INTRODUCTION
Vertebral body osteochondroma presenting with myelopathic symptoms is exceptionally rare entity of spinal osteochondroma which arises from the posterior surface of vertebral body and leading to spinal canal stenosis and cord compression. Early definitive diagnosis and subsequent successful treatment is necessary in such cases to prevent life threatening complications.
CASE REPORT
In this context, we report a case of a 20-years old female presented with mechanical neck pain, unsteady gait, giddiness with neurological deficit for the past 3 months. An MRI of the cervical spine revealed a mass growing from the posterior aspect of the C6 vertebral body and extending toward the vertebral canal, causing marked spinal cord compression.
CONCLUSION
The following case report not only describes the rare presentations of vertebral body osteochondroma but also emphasizes on surgical management by en bloc resection of tumor and anterior cervical fusion, resulting in a favorable outcome without any recurrence.
PubMed: 38910983
DOI: 10.13107/jocr.2024.v14.i06.4494 -
Cureus May 2024Adductor canal block is a widely used regional anesthesia technique for total knee arthroplasty that helps in reducing post-surgical pain and opioid use. Anatomically,...
Adductor canal block is a widely used regional anesthesia technique for total knee arthroplasty that helps in reducing post-surgical pain and opioid use. Anatomically, the adductor canal extends from the apex of the femoral triangle proximally to the adductor hiatus distally and is roofed by the sartorius and vasto-adductor fascia. All these serve as a potential path for the spread of the local anesthetic when it is injected inside the adductor canal during the block. Subsartorial space is of unique interest as it lies between the sartorius and vasto-adductor fascia, carrying the subsartorial plexus that can provide additional analgesia to the knee when the adductor canal block injectate spreads into it. While the spread can be variable, ultrasound can be a useful tool to evaluate this spread. This is a case series of patients who underwent total knee arthroplasty under spinal anesthesia and adductor canal blocks. We present the findings of ultrasound evaluation of the injectate spread following adductor canal blocks and evaluation of their analgesia effects.
PubMed: 38910653
DOI: 10.7759/cureus.60849 -
The Spine Journal : Official Journal of... Jun 2024Lumbar spinal canal stenosis (LSCS) is the most common spinal degenerative disorder in elderly people and usually first seen by primary care physicians or orthopedic...
BACKGROUND CONTEXT
Lumbar spinal canal stenosis (LSCS) is the most common spinal degenerative disorder in elderly people and usually first seen by primary care physicians or orthopedic surgeons who are not spine surgery specialists. Magnetic resonance imaging (MRI) is useful in the diagnosis of LSCS, but the equipment is often not available or difficult to read. LSCS patients with progressive neurologic deficits have difficulty with recovery if surgical treatment is delayed. So, early diagnosis and determination of appropriate surgical indications are crucial in the treatment of LSCS. Convolutional neural networks (CNNs), a type of deep learning, offers significant advantages for image recognition and classification, and work well with radiographs, which can be easily taken at any facility.
PURPOSE
Our purpose was to develop an algorithm to diagnose the presence or absence of LSCS requiring surgery from plain radiographs using CNNs.
STUDY DESIGN
Retrospective analysis of consecutive, nonrandomized series of patients at a single institution.
PATIENT SAMPLE
Data of 150 patients who underwent surgery for LSCS, including degenerative spondylolisthesis, at a single institution from January 2022 to August 2022, were collected. Additionally, 25 patients who underwent surgery at two other hospitals were included for extra external validation.
OUTCOME MEASURES
In annotation 1, the area under the curve (AUC) computed from the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were calculated. In annotation 2, correlation coefficients were used.
METHODS
Four intervertebral levels from L1/2 to L4/5 were extracted as region of interest from lateral plain lumbar spine radiographs totaling 600 images were obtained. Based on the date of surgery, 500 images derived from the first 125 cases were used for internal validation, and 100 images from the subsequent 25 cases used for external validation. Additionally, 100 images from other hospitals were used for extra external validation. In annotation 1, binary classification of operative and nonoperative levels was used, and in annotation 2, the spinal canal area measured on axial MRI was labeled as the output layer. For internal validation, the 500 images were divided into each 5 dataset on per-patient basis and five-fold cross-validation was performed. Five trained models were registered in the external validation prediction performance. Grad-CAM was used to visualize area with the high features extracted by CNNs.
RESULTS
In internal validation, the AUC and accuracy for annotation 1 ranged between 0.85-0.89 and 79-83%, respectively, and the correlation coefficients for annotation 2 ranged between 0.53-0.64 (all P < 0.01). In external validation, the AUC and accuracy for annotation 1 were 0.90 and 82%, respectively, and the correlation coefficient for annotation 2 was 0.69, using five trained CNN models. In the extra external validation, the AUC and accuracy for annotation 1 were 0.89 and 84%, respectively, and the correlation coefficient for annotation 2 was 0.56. Grad-CAM showed high feature density in the intervertebral joints and posterior intervertebral discs.
CONCLUSIONS
This technology automatically detects LSCS from plain lumbar spine radiographs, making it possible for medical facilities without MRI or non-specialists to diagnose LSCS, suggesting the possibility of eliminating delays in the diagnosis and treatment of LSCS that require early treatment.
PubMed: 38909909
DOI: 10.1016/j.spinee.2024.06.009 -
Spinal Cord Series and Cases Jun 2024Pilocytic astrocytoma is a low-grade glioma more frequently seen in patients <20. It is pretty uncommon in the spinal cord. Rarely, astrocytoma may involve the most or... (Review)
Review
INTRODUCTION
Pilocytic astrocytoma is a low-grade glioma more frequently seen in patients <20. It is pretty uncommon in the spinal cord. Rarely, astrocytoma may involve the most or total length of the spinal cord; in that case, they are called "holo-cord astrocytoma." In this case report, we are reporting the third holo-cord pilocytic astrocytoma in an adult patient and the first with an extension to the Magendie foramen.
CASE PRESENTATION
We presented a 24-year-old woman with complaints of progressively worsening neck and back pain since one year ago. The patient's MRI showed a very large intradural and intramedullary cystic lesion with a solid component within the spinal cord extending from the medulla to the conus medullaris. Partial resection of the solid part of the cervical portion of the tumor was performed. Histopathological evaluation of the resected tumor segments was compatible with grade I pilocytic astrocytoma. After one year of follow-up, neck and back pain has reduced, and neurological functions have improved.
CONCLUSION
Spinal cord pilocytic astrocytoma may present as a holo-cord tumor and can rarely extend to the intracranial fossa. Although this tumor does not arise from the central canal, in this case, it was extended through the Magendie foramen. Symptoms could be subtle despite extensive cord involvement. On MRI, this tumor presents as an intramedullary holo-cord cystic lesion intermixed with a solid component with a variable enhancement of the solid component.
Topics: Humans; Astrocytoma; Female; Spinal Cord Neoplasms; Young Adult; Magnetic Resonance Imaging; Adult
PubMed: 38909041
DOI: 10.1038/s41394-024-00656-z