scholarly journals Double neurophysiological certification of the filum terminale during sectioning surgery in pediatric population

2020 ◽  
Vol 11 ◽  
pp. 229
Author(s):  
Juan P. Cabrera ◽  
Sebastián Vigueras ◽  
Rubén Muñoz ◽  
Eduardo López
Keyword(s):  
Anal Sphincter ◽  
Pediatric Population ◽  
Cauda Equina ◽  
Lower Limbs ◽  
Constant Current ◽  
Neurophysiological Monitoring ◽  
Filum Terminale ◽  
Nerve Roots ◽  
Short Period ◽  
Mapping Techniques

Background: Surgery of thickened-fibrolipoma filum terminale (FT) is performed routinely and without conflict but is not a risk-free surgical procedure. Intraoperative neurophysiological monitoring with mapping techniques can help to certify the FT before sectioning. However, a tailored surgical approach to cauda equina and a low threshold of surrounding nerve roots can confuse the final surgical decision. The aim is to demonstrate the usefulness of this double methodology for FT certification. Methods: A prospective study collected and reviewed retrospectively, from 2015 to 2018, 40 patients undergoing an FT surgery section were included in the study. After opening the dura mater and under the microscope, the cauda equina mapping is performed and the recording of muscles of the lower limbs and the external anal sphincter. In addition, a high-intensity stimulation of constant current of an isolated FT for a short period of time and in a dry surgical field, obtaining a bilateral-polyradicular-symmetrical response of cauda equina nerve roots. Results: Traditional motor mapping identified FT in 65% (26/40) of patients. Although, 35% (14/40) of the patients still have low-intensity stimuli response (<1 mA) of a muscle, especially anal sphincter. When this happens, the optimization of the dissection around FT is performed. After that, 25% (10/40) of the patients still having a muscle response in spite of seem isolated FT. Increasing the stimulation intensity up to 20 mA evoked a cauda equina response in all cases. No postoperative neurological impairment was observed in this series. Conclusion: This proposed methodology accurately confirms the FT so that it can be safely found and cut. The Double Neurophysiological Certification improves the gap of the traditional mapping techniques of cauda equina and can be used in a variety of more complex surgeries in this area.

CIDP PRESENTING AS MYELORADICULOPATHY

2021 ◽  
pp. 50-51
Author(s):  
Sundarachary. N.V ◽  
Mythri. A.
Keyword(s):  
Peripheral Nerves ◽  
Urge Incontinence ◽  
Cauda Equina ◽  
Cord Compression ◽  
Nerve Conduction Studies ◽  
Lower Limbs ◽  
Sensory Level ◽  
Nerve Roots ◽  
Sensory Disturbances ◽  
Progressive Disorder

Chronic inammatory demyelinating polyradiculoneuropathy (CIDP) is a relapsing or chronic progressive disorder which is one of the causes of hypertrophic neuropathy. Enlarged nerve roots were identied in few patients. We now report a case of CIDP with highly thickened or enlarged nerve roots severe enough to cause cord compression and myelopathy. A 38 year old woman presented with weakness and sensory disturbances in lower limbs with sensory level at L1 and bladder disturbances in form of urgency and urge incontinence . MRI showed a non enhancing isointense mass lesion from L1 to S1 causing compression over conus . During surgery the cauda equina nerve roots were found to be thickened , entangled with ' bag of worms' appearance. Nerve conduction studies showed all her peripheral nerves to be inexcitable. Her CSF protein was mildly elevated. Diagnosis of CIDP with thickened nerve roots was considered and she was started on steroids and subsequently showed improvement. Thus, CIDP may present with symptoms of myeloradiculopathy due to thickened nerve roots causing cord compression.

Functional variability of sacral roots in bladder control

2014 ◽  
Vol 21 (6) ◽  
pp. 961-965 ◽  
Author(s):  
Lore Carlucci ◽  
Thomas Wavasseur ◽  
Antoine Bénard ◽  
Musa Sesay ◽  
Claire Delleci ◽  
...  
Keyword(s):  
Cauda Equina ◽  
Lower Limbs ◽  
Nerve Roots ◽  
Bladder Control ◽  
Bladder Contraction ◽  
Functional Distribution ◽  
Forensic Implications ◽  
The Right ◽  
Common Association ◽  
Stimulation Of

Object Sacral roots are involved in sensory, autonomic, and motor innervation of the lower limbs and perineum. Theoretically, it can be assumed that the S-3 root level innervates the bladder; however, clinical practice shows that this distribution can vary. Few researchers have studied this variability. Methods The authors conducted a retrospective study involving 40 patients who underwent surgery requiring an electrophysiological exploration of the sacral roots. They performed stimulations for the monitoring of muscular (3 Hz, 1 V) and bladder responses under cystomanometry (30 Hz, 10 V). Results Although the S-3 roots were involved in bladder innervation in all cases, they were exclusively involved (i.e., the only nerve roots involved) in only 8 of 40 cases. In the remaining 32 cases, other sacral nerve roots were involved. The most common association was S-3+S-4 (12 cases), followed by S-2+S-3 (6 cases), S-2+S-3+S-4 (5 cases), and S-3+S-4+S-5 (2 cases). Stimulation of S-2 could sometimes induce bladder contraction (15 cases, 40%); however, the amplitude was often low. S-4 nerve roots were involved in 24 of 40 cases (60%) in the bladder motor function, whereas S-5 roots were only involved 7 times (17%). Occasionally, we noticed a horizontal asymmetry in the response, with a predominant response from the right side in 6 of 7 cases, always with a major S-3 response. Conclusions This is the first study showing a significant horizontal and vertical variability in the functional distribution of sacral roots in bladder innervation. These results show the variability of cauda equina syndromes and their forensic implications. These data should help with the monitoring of sacral roots and the performance of several tasks during surgery, including neurostimulation and neuromodulation.

Microsurgical enbloc resection of myxopapillary cauda equina ependymoma

2014 ◽  
Vol 37 (v2supplement) ◽  
pp. Video7 ◽  
Author(s):  
Paul C. McCormick
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Resection ◽  
Cauda Equina ◽  
Treatment Strategies ◽  
Filum Terminale ◽  
Nerve Roots ◽  
En Bloc ◽  
Surgical Risk ◽  
Csf Dissemination ◽  
Enbloc Resection

Benign myxopapillary filum terminale ependymomas are often poorly encapsulated and in apposition the cerebrospinal fluid (CSF). These characteristics present the potential surgical risk of CSF dissemination or injury to the delicate cauda equina nerve roots. This video details the techniques of en bloc surgical resection of a filum terminale ependymoma. Treatment strategies and techniques are illustrated to reduce the risk of CSF dissemination and cauda equina injury.The video can be found here: http://youtu.be/LK8AYg-5T7o.

Gross and microscopic study of the filum terminale: does the filum contain functional neural elements?

2012 ◽  
Vol 9 (1) ◽  
pp. 86-92 ◽  
Author(s):  
Samson Sujit Kumar Gaddam ◽  
Vissa Santhi ◽  
Srinivasa Babu ◽  
Geeta Chacko ◽  
Ramakrishna Appala Baddukonda ◽  
...  
Keyword(s):  
Cauda Equina ◽  
Conus Medullaris ◽  
Nerve Fibers ◽  
Filum Terminale ◽  
Vertebral Level ◽  
Nerve Roots ◽  
Fibrous Stroma ◽  
Dural Sac ◽  
Nerve Bundles ◽  
Immunohistochemical Studies

Object The filum terminale (FT) is considered a fibrous structure that extends from conus medullaris of the spinal cord to coccyx. Based on previous studies and from their own experience with intraoperative electrophysiological monitoring of the sacral nervous system, the authors postulate that the FT contains functional neural elements in some individuals. Methods The FT was dissected from 13 fresh stillborn cadavers (7 male, 6 female; mean gestational age 36 weeks and 1 day). The gross anatomical features were recorded, and connections between the FT and the nerve roots of the cauda equina were noted. These connections, when present, were sectioned for histological studies. The fila (both interna and externa) were also sectioned for histological and immunohistochemical studies. In addition, FT specimens were obtained from 5 patients undergoing sectioning of the FT in an untethering surgical procedure. Results There were 5 gross connections between the FT and nerve roots demonstrating nerve fibers that were positive for S100. The FT showed islands of cells that were positive for GFAP in 10 cases, synaptophysin in 3 cases, S100 in 11 cases, and nestin in 2 cases. The nerve fibers in the FT were myelinated in 2 cases. The conus ended at the L-1 or L-2 vertebral level in all 13 specimens. The dural sac terminated at the S-2 vertebral level in most of the specimens. The 5 FT specimens that were obtained from patients revealed nerve bundles that were positive for S100 in 4 cases and cells that were positive for GFAP in 3 cases. Conclusions There are gross anatomical connections between the FT and nerve roots that contain nerve fibers. Apart from fibrous stroma, the FT may contain nerve bundles and cells that stain positive for GFAP, synaptophysin, S100, and nestin. These microscopic findings and previous intraoperative electrophysiological studies suggest a probable functional role for the FT in some individuals. At birth, the conus ends at a higher vertebral level (lower L-1 or upper L-2) than L-3.

scholarly journals Intraoperative neurophysiological mapping and monitoring in spinal tumor surgery: sirens or indispensable tools?

2016 ◽  
Vol 41 (2) ◽  
pp. E18 ◽  
Author(s):  
Antonino Scibilia ◽  
Carmen Terranova ◽  
Vincenzo Rizzo ◽  
Giovanni Raffa ◽  
Adolfo Morelli ◽  
...  
Keyword(s):  
Complex Function ◽  
Spinal Tumor ◽  
Neurological Deficits ◽  
Neurological Injury ◽  
Neurophysiological Monitoring ◽  
Predictive Values ◽  
Effective Role ◽  
Mapping Techniques ◽  
Sensitivity Specificity

Spinal tumor (ST) surgery carries the risk of new neurological deficits in the postoperative period. Intraoperative neurophysiological monitoring and mapping (IONM) represents an effective method of identifying and monitoring in real time the functional integrity of both the spinal cord (SC) and the nerve roots (NRs). Despite consensus favoring the use of IONM in ST surgery, in this era of evidence-based medicine, there is still a need to demonstrate the effective role of IONM in ST surgery in achieving an oncological cure, optimizing patient safety, and considering medicolegal aspects. Thus, neurosurgeons are asked to establish which techniques are considered indispensable. In the present study, the authors focused on the rationale for and the accuracy (sensitivity, specificity, and positive and negative predictive values) of IONM in ST surgery in light of more recent evidence in the literature, with specific emphasis on the role of IONM in reducing the incidence of postoperative neurological deficits. This review confirms the role of IONM as a useful tool in the workup for ST surgery. Individual monitoring and mapping techniques are clearly not sufficient to account for the complex function of the SC and NRs. Conversely, multimodal IONM is highly sensitive and specific for anticipating neurological injury during ST surgery and represents an important tool for preserving neuronal structures and achieving an optimal postoperative functional outcome.

scholarly journals Cauda equina redundant nerve roots are associated to the degree of spinal stenosis and to spondylolisthesis

2014 ◽  
Vol 72 (10) ◽  
pp. 782-787 ◽  
Author(s):  
Leonor Garbin Savarese ◽  
Geraldo Dias Ferreira-Neto ◽  
Carlos Fernando Pereira da Silva Herrero ◽  
Helton Luiz Aparecido Defino ◽  
Marcello H. Nogueira-Barbosa
Keyword(s):  
Spinal Stenosis ◽  
Cauda Equina ◽  
Intervertebral Discs ◽  
Observer Agreement ◽  
Nerve Roots ◽  
Cross Sectional ◽  
Dural Sac ◽  
Increased Risk ◽  
Independent Risk Factors ◽  
Lumbar Spinal

To evaluate the association of redundant nerve roots of cauda equina (RNRCE) with the degree of lumbar spinal stenosis (LSS) and with spondylolisthesis. Method After Institutional Board approval, 171 consecutive patients were retrospectively enrolled, 105 LSS patients and 66 patients without stenosis. The dural sac cross-sectional area (CSA) was measured on T2w axial MRI at the level of L2-3, L3-4 and L4-5 intervertebral discs. Two blinded radiologists classified cases as exhibiting or not RNRCE in MRI. Intra- and inter-observer reproducibility was assessed. Results RNRCE were associated with LSS. RRNCE was more frequent when maximum stenosis<55 mm2. Substantial intra- observer agreement and moderate inter-observer agreement were obtained in the classification of RNRCE. Spondylolisthesis was identified in 27 patients and represented increased risk for RRNCE. Conclusion LSS is a risk factor for RNRCE, especially for dural sac CSA<55 mm2. LSS and spondylolisthesis are independent risk factors for RNRCE.

scholarly journals Late presentation of a cauda equina lesion with a vulval abscess: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Chanil Deshan Ekanayake ◽  
Deepal Weerasekera ◽  
Dilini Dissanayake ◽  
Ranga Wickramarachchi ◽  
Saman Pushpakumara ◽  
...  
Keyword(s):  
Cauda Equina Syndrome ◽  
Cauda Equina ◽  
Late Presentation ◽  
Surgical Decompression ◽  
Lower Limbs ◽  
Sensory Loss ◽  
Postoperative Rehabilitation ◽  
Indwelling Catheter ◽  
Distended Bladder ◽  
Tract Infections

Abstract Background Cauda equina syndrome is a rare clinical condition that requires prompt diagnosis and timely surgical decompression with postoperative rehabilitation to prevent devastating complications. Case presentation A 55-year-old Sinhalese woman presented with a vulval abscess, with a history of involuntary leakage of urine for the last 7 years. Her sexual activity has been compromised due to coital incontinence, and she had also been treated for recurrent urinary tract infections during the last 7 years. On examination, a distended bladder was found. Neurological examination revealed a saddle sensory loss of S2–S4 dermatomes. There was no sensory loss over the lower limbs. Bladder sensation was absent, but there was some degree of anal sphincter tone. Motor functions and reflexes were normal in the limbs. Magnetic resonance imaging revealed L5–S1 spondylolisthesis. Ultrasound imaging confirmed the finding of a distended bladder, in addition to bilateral hydroureters with hydronephrosis. An incision and drainage with concomitant intravenous antibiotics were started for the vulval abscess. An indwelling catheter was placed to decompress the bladder and to reduce vulval excoriations due to urine. Bilateral ureteric stenting was performed later for persistent hydronephrosis and hydroureter despite an empty bladder. Conclusion This is a tragic case that illustrates the devastating long-term sequelae that ensues if cauda equina syndrome is left undiagnosed. It reiterates the importance of prompt referral and surgical decompression.

scholarly journals PUBIC SYMPHYSIS DIASTASIS IN PREGNANCY AND DELIVERY (REVIEW)

2018 ◽  
Vol 24 (3) ◽  
pp. 145-156
Author(s):  
A. L. Petrushin ◽  
A. V. Pryaluchina
Keyword(s):  
Internal Fixation ◽  
Treatment Options ◽  
Pubic Symphysis ◽  
Lower Limbs ◽  
Sacroiliac Joints ◽  
Pubic Symphysis Diastasis ◽  
Partial Load ◽  
Short Period ◽  
Pregnancy And Delivery ◽  
Symphysis Diastasis

Purpose of the study— to generalize and arrange the data published in scientific literature and to present currentviews on epidemiology, diagnostics and treatment options for pubic symphysis diastasis during pregnancy and delivery. Semeiotic separation wider than 10 mm is considered pubic symphysis diastasis during pregnancy and delivery. Diastasis above 14-25 mm might be associated with ruptures of sacroiliac joints. Frequency of such pathology is reported in the range from 0,03 to 2,8%. Key risk factors of this pathology include multiparity and repeated labor. Symptoms of pubic separation include pain and signs of pelvic instability manifesting immediately after delivery or within a short period of time after the delivery. AP roentgenography is the principal diagnostics method however lately ultrasound exam is done more frequently. Conservative option prevails in treatment of pubic symphysis diastasis. Surgical procedures are recommended in case of separation above 30-50 mm, ruptures of sacroiliac joints, open lesions, failed conservative treatment and urological dysfunction. In such cases preferred option is the internal fixation by plate and screws. Some authors use external fixation. Late-term outcomes of both methods do not demonstrate significant differences. Pain regress after the surgery is observed within 3 weeks to 6 months postoperatively, walking with partial load is restored in 5-14 days, full load on the lower limbs is possible 6 months postoperatively. Indications for removal of implants after internal fixation are not clearly defined. Following surgical treatment of pubic symphysis diastasis the majority of authors incline to subsequent operative delivery.

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