Treatment of restenosis after lumbar decompression surgery: decompression versus decompression and fusion

OBJECTIVE The aim of this study was to compare perioperative complications and postoperative outcomes between patients with lumbar recurrent stenosis without lumbar instability and radiculopathy who underwent decompression surgery and those who underwent decompression with fusion surgery. METHODS For this retrospective study, the authors identified 2606 consecutive patients who underwent posterior surgery for lumbar spinal canal stenosis at eight affiliated hospitals between April 2017 and June 2019. Among these patients, those with a history of prior decompression surgery and central canal restenosis with cauda equina syndrome were included in the study. Those patients with instability or radiculopathy were excluded. The patients were divided between the decompression group and decompression with fusion group. The demographic characteristics, numerical rating scale score for low-back pain, incidence rates of lower-extremity pain and lower-extremity numbness, Oswestry Disability Index score, 3-level EQ-5D score, and patient satisfaction rate were compared between the two groups using the Fisher’s exact probability test for nominal variables and the Student t-test for continuous variables, with p < 0.05 as the level of statistical significance. RESULTS Forty-six patients met the inclusion criteria (35 males and 11 females; 19 patients underwent decompression and 27 decompression and fusion; mean ± SD age 72.5 ± 8.8 years; mean ± SD follow-up 18.8 ± 6.0 months). Demographic data and perioperative complication rates were similar. The percentages of patients who achieved the minimal clinically important differences for patient-reported outcomes or satisfaction rate at 1 year were similar. CONCLUSIONS Among patients with central canal stenosis who underwent revision, the short-term outcomes of the patients who underwent decompression were comparable to those of the patients who underwent decompression and fusion. Decompression surgery may be effective for patients without instability or radiculopathy.

Case Report: Five Adult Cases of H3K27-Altered Diffuse Midline Glioma in the Spinal Cord

BackgroundDiffuse midline glioma with H3K27-altered (DMG-H3K27a) is a novel tumor entity of the pediatric-type diffuse high-grade tumor in the latest WHO CNS 5. It mostly affects children and is only rarely found in adults. The tumor has a high level of aggressiveness, with a rapid progression and bad prognosis. In adults, the spinal cord is the most common site of DMG-H3K27a. Rare adult cases of primary DMG-H3K27a in the spinal cord were reported in this study, together with clinico-histopathologico-radiographic data.MethodsFrom January 2016 to December 2020, we conducted a retrospective study of five adults with primary DMG-H3K27a in the spinal cord, analyzing their clinical, pathohistological, and radiographic datasets from the first diagnosis to follow-up.ResultsAll five patients were diagnosed for the first time and were given full treatment. In three of the five patients, post-operative follow-up revealed tumor recurrence. The longest survival of the five patients was 45 months at the time of report submission, while the longest progression-free survival (PFS) following surgery was 20 months. Immunohistochemical studies showed the tumors featured aggressive behavior (grade 4) and were positive for the H3K27M mutation. The radiographic appearances were varied, but they were all initially mistaken as benign. DMG-H3K27a in the spinal cord was characterized by isointense/hyperintense on T1WI and isointense/hyperintense on T2WI, as well as cystic necrosis and peripheral spinal cord edema, as well as central canal enlargement and other types of enhancement.ConclusionThis is the first case report focusing on adult DMG-H3K27a of the pediatric-type diffuses high-grade gliomas in the spinal cord. In our cases, we discovered the following: 1) adults had a better prognosis with a longer PFS compared with prior pediatric reports; 2) despite aggressive behavior under the microscope, radiographic appearances of the tumors were less aggressive; and 3) adjuvant treatment, including TCM, may have played a role in the prognosis.

Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for treating elderly patients with lumbar central canal stenosis

OBJECTIVE Surgical decompression via a posterior interlaminar approach is widely used for treating lumbar central canal stenosis (LCCS). However, this surgical approach poses a challenge for elderly patients with comorbidities. Thus, the authors tried a new surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia to treat such patients. The aim of this study was to evaluate the safety and effectiveness of surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for patients with LCCS. METHODS Patients with LCCS who underwent surgical decompression, performed by a single surgeon, between January 2016 and March 2019 were retrospectively analyzed. All patients received decompression via the unilateral intervertebral foraminal approach with local anesthesia. Visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, modified Macnab criteria, walking distance, and Schizas classification were used as outcome predictors. Additionally, a decompression evaluation method was designed for use after spinal endoscopic surgery. RESULTS Overall, 23 patients with a mean age of 69 years were included in this study, with a mean follow-up of 28 months. Low-back and leg pain were significantly improved after decompression surgery. Postoperative ODI scores and walking distances were statistically significantly better than before surgery. Postoperatively, the Schizas classification for all patients was improved by at least 1 grade compared with the preoperative grade. No complications occurred during the follow-up period. According to the novel decompression evaluation method, all patients had at least achieved decompression in part 123+B. CONCLUSIONS Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia showed promising outcomes in the treatment of elderly patients with LCCS. Additionally, a proposed postoperative decompression evaluation method can help guide surgical decompression.

Progressive Bilateral Arm Pain, Gait Disturbance, Constipation, and Urinary Retention

A 48-year-old woman sought care for progressive right arm and hand pain with radial nerve–distribution sensory loss. She had a past history of multiple prior athletics-associated, musculoskeletal, upper cervical spine injuries. Her symptoms were initially attributed to a right C6 radiculopathy. Over the next several months, the sensory loss spread to involve the entire right hand and subsequently the entire left hand. She had development of diffuse right hand weakness and a sense of imbalance that was particularly prominent while in the dark. Finally, she experienced progressive constipation and urinary retention. Magnetic resonance imaging of the cervical spine showed an expanded cervical spinal cord from C3 through C7-T1 with diffuse T2-hyperintense changes and heterogeneous gadolinium enhancement most prominent at C5-6. In combination with a congenitally small central canal, severe central canal narrowing was seen at C5-6 and moderate narrowing at C4-5. Magnetic resonance imaging of the brain and thoracic spine were normal, and magnetic resonance imaging of the lumbar spine indicated only mild lumbar spondylosis. On suspicion of a spinal cord neoplasm with a secondary compressive myelopathy, C3 through C7 laminectomy and posterior instrumented fusion from C2 through T1 was performed, with a biopsy obtained at the C5-6 level. Postoperatively, her gait and right upper extremity pain improved. The biopsy showed atypical glial cells. Neurofilament staining demonstrated an infiltrative pattern. Atypical cells were positive for glial fibrillary acidic protein, oligodendrocyte transcription factor 2, and a Lys27Met sequence variation of histone H3, with overexpression of p53 on immunohistochemical staining. There was loss of H3 K27-trimethylation on the infiltrating cells, corresponding to the presence of Lys27Met sequence variation of histone H3. These findings were diagnostic for diffuse midline glioma with Lys27Met sequence variation of histone H3 (World Health Organization grade IV). A total of 5,400 cGy of photon radiation was delivered in 30 fractions over 42 days. She was subsequently treated with an oral histone deacetylase inhibitor, panobinostat, for 12 months. During this time, she had clinical response to treatment and reported improvement in balance and numbness. Follow-up magnetic resonance imaging at 3 months showed a slight decrease in the size of the mass, and this response was sustained 1 year post radiotherapy. Diffuse midline gliomas that contain Lys27Met sequence variation of histone H3are incurable, often inoperable, midline brain tumors that are most commonly seen in the pediatric population. These tumors can also occur in adult patients and are considered high grade, even in the absence of features such as necrosis or microvascular proliferation.

Exploring University-Community Collaborations

The Riverside neighborhood bears multiple burdens of environmental harm. Running the gamut from groundwater contamination in subsurface waters to lead in soils and dust and paint to particulate matter in the air from highways and industry, these environmental insults harm the physical, mental, and economic well-being of the community. The community has also faced an information gap where data was scarce, hard to locate, and sometimes wrong. Activists have long worked to improve the quality of life in the neighborhood, but faced barriers in the form of policies (e.g. Red Lining, zoning variances, disinvestment in public services such as street lights and sidewalks) and practices (e.g. absentee landlords, illegal dumping). Features such as the Central Canal that were developed into recreational amenities in other parts of the city were minimally maintained or restricted from use by residents. In the face of these challenges, IUPUI faculty, students, and community members have partnered on multiple projects to document the history of environmental harms, assess exposure and risk of residents’ exposomes, and share information in ways that are accessible and relevant for residents. The work supports the agency and activism of the community, particularly as it faces pressures of gentrification and university encroachment with the prospect of 16 Tech project expansion. The work also takes place in the context of contested interests and harmful legacies as representatives of an urban university that displaced longtime residents work to partner ethically and transparently with those same communities. As a result, current faculty-community collaborations operate within a space complicated by the problematic legacy of harm and ongoing structural racism. However well-intentioned, faculty, students and community members have to navigate that history and enduring power dynamics as they design their research, identify relevant questions, and share results in ways that are accessible and meaningful to community members.

Percutaneous transforaminal endoscopic discectomy for different types of lumbar disc herniation: A retrospective study

Objective To introduce the concept of ‘nerve root as the core’ and to investigate the surgical procedure and curative effect of percutaneous translaminar endoscopic discectomy (PTED) surgery in the treatment of different types of lumbar disc herniation (LDH). Methods This retrospective study analysed the clinical data from patients with LDH that underwent single-segment PTED surgery. They were divided into three groups based on LDH location: central canal zone group, lateral recess zone group and foraminal/far lateral zone group. Different working cannula placement methods were used for the different types of LDH. All patients were followed for at least 12 months. Clinical and follow-up data were compared between the three groups. Results A total of 130 patients were enrolled in the study: 44 (33.8%) in the central canal zone group, 72 (55.4%) in the lateral recess zone group and 14 (10.8%) in the foraminal/far lateral zone group. All three groups of patients achieved good postoperative results. The improvements in leg pain and disability were most marked in the first postoperative month in all three groups. Conclusion PTED achieved adequate decompression for different types of LDH. The concept of ‘nerve root as the core’ facilitated the accurate placement of the working cannula.

IIIG9 inhibition in adult ependymal cells changes adherens junctions structure and induces cellular detachment

Ependymal cells have multiple apical cilia that line the ventricular surfaces and the central canal of spinal cord. In cancer, the loss of ependymal cell polarity promotes the formation of different types of tumors, such as supratentorial anaplastic ependymomas, which are highly aggressive in children. IIIG9 (PPP1R32) is a protein restricted to adult ependymal cells located in cilia and in the apical cytoplasm and has unknown function. In this work, we studied the expression and localization of IIIG9 in the adherens junctions (cadherin/β-catenin-positive junctions) of adult brain ependymal cells using confocal and transmission electron microscopy. Through in vivo loss-of-function studies, ependymal denudation (single-dose injection experiments of inhibitory adenovirus) was observed, inducing the formation of ependymal cells with a “balloon-like” morphology. These cells had reduced cadherin expression (and/or delocalization) and cleavage of the cell death marker caspase-3, with “cilia rigidity” morphology (probably vibrational beating activity) and ventriculomegaly occurring prior to these events. Finally, after performing continuous infusions of adenovirus for 14 days, we observed total cell denudation and reactive parenchymal astrogliosis. Our data confirmed that IIIG9 is essential for the maintenance of adherens junctions of polarized ependymal cells. Eventually, altered levels of this protein in ependymal cell differentiation may increase ventricular pathologies, such as hydrocephalus or neoplastic transformation.

Pediatric Extraspinal Sacrococcygeal Ependymoma: Report of Two Cases and Literature Review

Primary central nervous system (CNS) tumors represent the most common solid tumors in childhood. Ependymomas arise from ependymal cells lining the wall of ventricles or central canal of spinal cord and their occurrence outside the CNS is extremely rare, published in the literature as case reports or small case series. We present two cases of extra-CNS myxopapillary ependymomas treated at our institution in the past three years; both cases originate in the sacrococcygeal region and were initially misdiagnosed as epidermoid cyst and germ cell tumor, respectively. The first case, which arose in a 9-year-old girl, was treated with a surgical excision in two stages, due to the non-radical manner of the first operation; no recurrence was observed after two years of follow-up. The other case was a 12-year-old boy who was treated with a complete resection and showed no evidence of recurrence at one-year follow-up. In this paper, we report our experience in treating an extremely rare disease that lacks a standardized approach to diagnosis, treatment and follow-up; in addition, we perform a literature review of the past 35 years.

The Structure of the Spinal Cord Ependymal Region in Adult Humans Is a Distinctive Trait among Mammals

In species that regenerate the injured spinal cord, the ependymal region is a source of new cells and a prominent coordinator of regeneration. In mammals, cells at the ependymal region proliferate in normal conditions and react after injury, but in humans, the central canal is lost in the majority of individuals from early childhood. It is replaced by a structure that does not proliferate after damage and is formed by large accumulations of ependymal cells, strong astrogliosis and perivascular pseudo-rosettes. We inform here of two additional mammals that lose the central canal during their lifetime: the Naked Mole-Rat (NMR, Heterocephalus glaber) and the mutant hyh (hydrocephalus with hop gait) mice. The morphological study of their spinal cords shows that the tissue substituting the central canal is not similar to that found in humans. In both NMR and hyh mice, the central canal is replaced by tissue reminiscent of normal lamina X and may include small groups of ependymal cells in the midline, partially resembling specific domains of the former canal. However, no features of the adult human ependymal remnant are found, suggesting that this structure is a specific human trait. In order to shed some more light on the mechanism of human central canal closure, we provide new data suggesting that canal patency is lost by delamination of the ependymal epithelium, in a process that includes apical polarity loss and the expression of signaling mediators involved in epithelial to mesenchymal transitions.