Non-dysraphic Subpial Intramedullary Lipoma of Cervicothoracic Spine

Intramedullary spinal cord tumors are rare and comprise less than one percentage of all central nervous system (CNS) neoplasms. When encountered, most are found in the lumbosacral region with coinciding spinal dysraphism. Here, we discuss a case of isolated non-dysraphic intramedullary lipoma of cervicothoracic spine in an adolescent who was surgically managed with posterior decompression and subtotal resection via laminoplasty. A 21-year-old male adolescent, without a history of spinal dysraphism, presented with a progressive sensory ataxia. This manifestation was attributed to magnetic resonance documented intramedullary lipoma, extending from C7 to T2 spinal level. Patient underwent subtotal surgical resection of the lesion; and histopathology report was confirmed as spinal lipoma. Surgical management of this rare pathology has a wide variety of options depending on clinical presentation. In our case, a subtotal resection and laminoplasty was achieved with no further worsening of neurologic symptoms.

Exploring hand dexterity in children with myelomeningocele

PURPOSE: To assess hand dexterity in children with myelomeningocele (MMC) and to explore factors related to hand dexterity in these children. METHODS: Ninety-four children with myelomeningocele, aged 4 to 18 years, were assessed. Demographic characteristics, disease factors, visual perception (Beery test of Visual Motor Integration), cognition (WeeFunctional Independence Measure), and self-care (Pediatric Evaluation of Disability Inventory) were assessed in relation to the Nine-Hole Peg Test (9HPT) for hand dexterity using Spearmen correlations and linear regressions. RESULTS: The children’s performance on the 9HPT in both hands was significantly slower than the norms for their age groups. Children without a shunt showed significantly better function in both hands (p = .005) than those with a shunt. Factors most related to hand dexterity were neurological spinal level of MMC, presence of shunt, age, cognitive ability, and years of mother’s education. CONCLUSION: Children with MMC appear to have poorer hand skills than typically developed children, which was related to pathology as well as functional and environmental factors. When addressing hand dexterity in children with MMC, it is important that rehabilitation professionals continue to work with these children as they get older, and put greater emphasis on parent education using materials that are adapted to varying educational levels.

Post-Surgical Recurrence of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension

Spinal CSF-venous fistulas (CVF) were described in 2014 and are now recognized as an important etiology of spontaneous intracranial hypotension (SIH) 1-3. Surgical ligation is highly effective for treating CVFs4. Given the relatively recent discovery of this entity, long-term follow up on treated cases has not been available, however, surgery has generally been considered definitive treatment. We report four cases of SIH in which CVFs have recurred or developed de novo at a different spinal level following complete surgical ligation of the primary lesion. In all cases, the new CVF was not present on any pre-surgical imaging.

Dimensional Characterization of the Human Lumbar Interlaminar Space as a Guide for Safe Application of Minimally Invasive Dilators

BACKGROUND The risk of interlaminar passage of a dilator into the lumbar spinal canal in minimally invasive approaches is currently unknown. Among anthropometric data reported in the medical literature, there is no cadaveric report of the interlaminar dimensions of the lumbar spine. OBJECTIVE To report the lumbar interlaminar dimensions in neutral, flexion, and extension postures. METHODS A total of 8 spines were sectioned into lumbar segments. Digitized coordinate data defining the locations and movements of chosen anatomic points on the laminar edges at a given spinal level were used to measure changes in the opening dimensions during static neutral posture and flexion-extension movements. Interlaminar dimensions were averaged and categorized for each vertebral level and spinal posture. RESULTS The mean interlaminar distance increased from neutral posture to flexion across all vertebral levels. The mean interlaminar distances in the neutral posture ranged from 12.21 mm (L5-S1) to 14.88 mm (L1-L2). In flexion, the range was from 17.15 mm (L5-S1) to 18.50 mm (L4-L5). These measurements are greater than the first several diameters of dilators in all minimally invasive dilator sets. CONCLUSION The precise measurements of the lumbar interlaminar space are valuable to minimally invasive spine surgeons for the dilatation phase of the operation. The risk of interlaminar passage of a minimally invasive dilator is greatest in flexion with dilators that have a diameter of 16 mm or less. There is considerably less risk of interlaminar passage in patients positioned on an extended Jackson table.

The role of periradicular infiltration in dorsal root ganglion stimulation for chronic neuropathic pain

Background Targeting the correct spinal level is essential in dorsal root ganglion (DRG) stimulation. Anatomical selection of the DRG alone is not ideal since the pain area is not necessarily confined to the borders of the dermatomes. This study aims to establish the role of periradicular infiltration therapy (PRT) in the preoperative assessment of the correct level for DRG stimulation performed under general anesthesia. Method We report a prospective study of 20 patients selected for DRG stimulation and submitted to a PRT for identification of the spinal level. Lead implantation for the stimulation trial occurred under general anesthesia: 19 patients experienced positive results and underwent implantation of the pulse generator. All patients suffered from chronic neuropathic pain unresponsive to best medical treatment. PRT levels were compared with the levels targeted with DRG leads. Patients were followed for up to 12 months; pain intensity and coverage of the painful area were assessed. Results In 12 patients, the trial leads were placed on the same level as previously tested positive by PRT. In 6 patients, leads were placed in the PRT target and additionally in adjacent spinal levels. In one case, the selected target for the trial diverged from the PRT target because of intense fibrosis in the chosen level. Coverage of the target area of at least 50% was achieved by two-thirds of the patients. For the six subjects with additional implanted leads as a consequence of the PRT results, 80% achieved a coverage of at least 50%. A total of 47.4% of the patients achieved sustained significant pain relief in the last follow-up. None of the patients needed a repeated surgery for implantation of additional leads. Conclusions PRT is a helpful tool to confirm the stimulation targets. A PRT preceding the stimulation trial is an additional opportunity to optimize the coverage of the target area with stimulation-induced paresthesia for patients operated under general anesthesia.

The Great Masquerade: A Rare Presentation of Spinal Tuberculoma

Spinal tuberculomas form a meagre fraction of cases of Tuberculosis (TB). Most common presentation of spinal tuberculoma is weakness. A 45-year-old female presented with dysthesias, gait instability and numbness involving both lower limbs for a period of 7-10 days. Patient was vitally stable (blood pressure of 128/78 mm of Hg, pulse rate of 86 beats per minute and respiratory rate of 18 breaths per minute with a normal pattern), alert and co-operative. Neurological examination suggested non length dependant sensory involvement of lower limbs, sensory ataxia and areflexia, level of lesion being at the Dorsal Root Ganglia (DRG) (sensory neuronopathy). Contrast Enhanced Magnetic Resonance Imaging (CEMRI) spine revealed tuberculoma at D9 spinal level. Patient responded to Antitubercular Therapy (ATT) and recovered. The intention of sharing the clinical experience is with the sole purpose of remembering the fact that common pathologies may at times be great mimickers. In the present case, while a lot of rare causes (autoimmune, neoplastic) were searched for, tuberculoma happened to be the culprit.

Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population

BackgroundEpidural corticosteroid injections (ESIs) are widely performed and have an unquantified risk of serious spinal adverse events (SSAEs). We sought to determine the rate of SSAEs following ESI and to compare the rates by spinal level, injection approach and corticosteroid formulation.MethodsWe included patients enrolled in Medicare parts A and B who had an ESI between 1 January 2009 and 30 September 2015. We identified potential cases as patients with spine-related diagnoses within 3 days after the first eligible ESI. Event categorization as probable, possible or non-case was based on review of medical records. The rates of probable and possible cases were expressed per 1 000 000 patients overall, and by spinal level, injection approach and corticosteroid formulation. A score test was used to compare these rates.ResultsWe identified 1 355 957 eligible ESIs during the study period. Of the 110 potential cases, 43 were selected for medical record review and 11 were categorized as probable, yielding a rate of 8.1 per 1 000 000 patients (95% CI 4.5 to 14.5). Risk of SSAEs was statistically higher with cervical/thoracic injections (29.4, 95% CI 12.5 to 68.8) compared with lumbar/sacral injections (5.1, 95% CI 2.3 to 11.0) (p value 0.001). Event rates for lumbar/sacral non-transforaminal injections was 8.8 (95% CI 4.0 to 19.1). Event rates for particulate (7.5, 95% CI 3.9 to 14.2) and non-particulate formulations (13.1, 95% CI 3.6 to 47.9) appeared similar (p value 0.47).ConclusionBetween 2009 and 2015, rates of SSAEs following ESI in the Medicare population were low. Patients receiving cervical/thoracic ESIs were at higher risk of SSAE than those receiving lumbar/sacral ESIs. Event rates were similar for each corticosteroid formulation.