Editorial Comment on the Article by Mushkin M.A. et al. “Effect of Prehospital Pause on the Outcomes of Emergency Decompression and Stabilization Procedures in Patients with Tumor and Infectious Spine Diseases”

The editorial comment evaluates the current state of issue of medical care at urgent states caused by pathological vertebral fractures and spinal cord compression in patients with spine destructive diseases. The rare occurrence of pathology and the deficiency of objective data determine the lack of consensus on the medical care for this category of patients. The article by M.A. Mushkin et al helps to understand how the prehospital pause affects the outcomes of emergency decompression and stabilization procedures in patients with tumor and infectious diseases of the spine, as well as to determine how much time the surgeon has at his disposal. The author of the comment believes that close cooperation of orthopedic surgeons, neurosurgeons, oncologists is necessary to solve this problem. Even despite the absence of oncologists in the staff of emergency hospitals, telemedicine allows to receive methodological support in a timely manner for making a correct decision for each patient. Interaction between clinicians, radiologists and pathologists is equally important. An important aspect is continuity in patient care. An urgently performed spinal cord decompression is only a stage of the complex treatment. Such patients should be provided with accurate routing depending on the diagnosis and the treatment early outcome.

Coexisting protruding osteocyte and arachnoid cyst mimicking spinal cord herniation in a patient with Brown Sequard syndrome

This 68-year-old man presented with progressive spastic paraparesis of 2-month duration. The diagnosis was Brown-Sequard syndrome(BSS). Magnetic resonance imaging (MRI) revealed ventral displacement of the spinal cord at Th 7–8. The spinal cord deformity was dominant on the left side. He underwent surgery under the preoperative diagnosis of spinal cord herniation at Th 7–8. Intraoperatively we detected an arachnoid cyst and an osteophyte that compressed the spinal cord at Th 7–8 dorsally and ventrally rather than spinal cord herniation. Postoperative MRI showed successful spinal cord decompression. His neurological findings improved remarkably just after surgery. Although the misdiagnosis of spinal hernia in the actual presence of arachnoid cysts has been reported, ours is the first case of both, a lateralized osteophyte and an arachnoid cysts mimicking spinal cord herniation.

Minimally Invasive Approach for Dorsal Arachnoid Web: 2-Dimensional Operative Video

A 67-yr-old patient presented with severe paraparesis and lower limb spasticity. The spinal cord magnetic resonance imaging (MRI) revealed the “scalpel sign” 1,2 at the T7 level, suggesting a diagnosis of a dorsal arachnoid web. This video demonstrates a microsurgical technique for the excision of a dorsal arachnoid web with a minimally invasive approach. A paramedian skin incision, understanding the muscular aponeurosis, was performed from T7 to T8. Then, we inserted the tubular dilators until the lamina, to perform a muscle-sparing approach. An expandable tubular retractor of adequate length was passed over the widest dilator and docked into place along the subperiosteal plane. The T7 lamina was drilled, and the resection of the superior and inferior adjacent spine levels was completed with a rongeur. Additional contralateral bone resection was performed after tubular retractor tilt to the midline.3 After dura mater opening, it was carefully suspended and the dorsal arachnoid leaflet was cut to drain the dorsolateral and lateral spinal cisterns.4 The dorsal arachnoid web was, first, disconnected from its lateral anchorages. It was then gently removed with microsurgical forceps, to help its microdissection from the spinal cord surface. At this step, peculiar attention was paid to limit the traction or displacements of the spinal cord and surrounding vessels. Once the dorsal arachnoid web was removed, the quality of the spinal cord decompression was confirmed by its re-expansion. In conclusion, the minimally invasive approach is a safe and appropriate technique for dorsal arachnoid web excision.2,5,6-7 The patient gave her informed and signed consent for the writing and publication of this article. Image at 1:00 reused with permission from Castelnovo G et al, Spontaneous transdural spinal cord herniation, Neurology, 2014;82(14):1290.

Percutaneous endoscopic limited-lumbosacral-dorsal laminectomy in eight dogs – A cadaveric study

This study aimed to investigate the technical feasibility of a percutaneous endoscopic limited-dorsal laminectomy (PELDL) and to evaluate if the decompression and examination of the lumbosacral vertebral canals could be achieved using an endoscope in small dogs. A total of eight fresh canine cadavers were used for the study. Following the injection of a barium and agarose mixture (BA-gel), which simulates intervertebral disc herniation, a PELDL was performed over L7–S1 in these animals. Computed tomography (CT) scans were obtained pre- and postoperatively to evaluate the surgical outcomes. All the procedures were completed with a clear visualisation of the spinal cord and removal of the BA-gel. The mean surgery time for the PELDL was 30.00 ± 12.01 minutes. In two dogs, iatrogenic nerve root injuries were caused by the surgical instruments during the operation. The CT scans showed that the amount of BA-gel removed was sufficient for a spinal-cord decompression. A PELDL could be used for the BA-gel removal to decompress the spinal cord and provide a clear view of the spinal canal. Therefore, it could be used as an alternative surgical option to treat lumbosacral disc disease in dogs.

Echinococcosis of the spine

Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine. More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord. As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely. Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization. This article summarizes the clinical findings of echinococcosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients’ outcomes. The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas. Cite this article: EFORT Open Rev 2021;6:288-296. DOI: 10.1302/2058-5241.6.200130

Spinal cord decompression sickness in an inside attendant after a standard hyperbaric oxygen treatment session

Medical personnel in hyperbaric treatment centres are at occupational risk for decompression sickness (DCS) while attending patients inside the multiplace hyperbaric chamber (MHC). A 51-year-old male hyperbaric physician, also an experienced diver, was working as an inside attendant during a standard hyperbaric oxygen therapy (HBOT) session (70 minutes at 253.3 kPa [2.5 atmospheres absolute, 15 metres’ seawater equivalent]) in a large walk-in MHC. Within 10 minutes after the end of the session, symptoms of spinal DCS occurred. Recompression started within 90 minutes with an infusion of lignocaine and hydration. All neurological symptoms resolved within 10 minutes breathing 100% oxygen at 283.6 kPa (2.8 atmospheres absolute) and a standard US Navy Treatment Table 6 was completed. He returned to regular hyperbaric work after four weeks of avoiding hyperbaric exposures. Transoesophageal echocardiography with a bubble study was performed 18 months after the event without any sign of a persistent (patent) foramen ovale. Any hyperbaric exposure, even within no-decompression limits, is an essential occupational risk for decompression sickness in internal hyperbaric attendants, especially considering the additional risk factors typical for medical personnel (age, dehydration, tiredness, non-optimal physical capabilities and frequent problems with the lower back).

Comparison of prognostic scales for patients with metastatic spine disease

This is one-centre retrospective study with the aim to identify the scale, which provides the most accurate prediction of life expectancy in patients with metastatic lesions in spine. A retrospective analysis of clinical data of 138 patients with metastatic spinal tumors. Patients underwent spinal cord decompression and instrumented stabilization of affected area. We evaluated the general condition according to the Karnofsky and ECOG scales, the presence of metastases in the visceral organs, spine and other bones, the neurological status and conduction of the medical therapy before spinal surgery. Observed clinical parameters were converted to Tokuhashi, Tomita, and Katagiri scales. For statistical analysis, software environment R 3.4.1 was used. Assessment of prognostic accuracy was performed using ROC analysis. The Tokuhashi scale showed AUC 0.605 (95% CI 0.586-0.616), Tomita scale showed AUC 0.708 (95% CI 0.573-0.842), Katagiri scale showed AUC 0.650 (95% CI 0.508-0.792). The best results for survival rate predicting after surgical treatment for metastatic spinal lesions were shown the Tomita scale.