Neurological severity evaluation using magnetic resonance imaging in acute spontaneous spinal epidural haematomas.

PURPOSE: This study aimed to elucidate the severity of neurological deficits in a large series of patients with acute spontaneous spinal epidural haematoma (SSEH) using magnetic resonance imaging (MRI). METHODS: We included 57 patients treated for acute SSEH at 11 institutions and retrospectively analysed their demographic and MRI data upon admission. We investigated MRI findings, such as the haematoma length and canal occupation ratio (COR). The neurological severity of SSEH was assessed based on the American Spinal Injury Association score on admission. RESULTS: Of the 57 patients, 35 (61%) presented with severe paralysis. The MRI analysis showed that SSEH was often located in the cervical spine, dorsal to the spinal cord, and spread over more than three vertebrae. No differences in age, sex, and aetiology were found between patients with and without severe paralysis. The hypo-intensity layer encircling the haematoma, intra-haematoma heterogeneity, and increased CORs were observed more frequently in the severe paralysis group. Furthermore, pathological examination of a dissected haematoma from one patient with a hypo-intensity layer revealed a collagen layer around the haematoma, and patients with intra-haematoma heterogeneity were more likely to have a bleeding predisposition. CONCLUSIONS: In this large series of patients with SSEH, we identified some MRI features associated with severe paralysis, such as the hypo-intensity layer, intra-haematoma heterogeneity, and increased COR. Accordingly, patients with these MRI characteristics should be considered for early surgical intervention.

Outcomes after decompression surgery without fusion for patients with lumbar spinal stenosis and substantial low back pain.

PURPOSE: The aim of this study was to evaluate the efficacy of decompression surgery alone for patients with intolerable low back pain. METHODS: We retrospectively identified 222 patients who underwent spinal decompression without fusion surgery who had substantial preoperative low back pain (preoperative numerical rating scale score ≥ 5). Their clinical outcomes were assessed using the numerical rating scale and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) preoperatively and at 3 months and 1 year after surgery. RESULTS: At 3 months and 1 year after surgery compared with baseline, there was a significant improvement in the overall mean numerical rating scale scores for low back pain (baseline = 6.8, 3 months = 2.1, 1 year = 2.7), leg pain (6.8, 2.1, 2.7), and leg numbness (6.4, 2.9, 3.2) (P < 0.05). The efficacy rate assessed by JOABPEQ was 68.1% for pain-related disorders, 47.0% for lumbar spine dysfunction, 63.3% for walking ability, 48.2% for social life dysfunction, and 21.6% for psychological disorders. When patients were classified into three groups depending on their degree of leg pain (mild, moderate, and severe), there was no significant difference in the efficacy rate between the three groups. CONCLUSION: Decompression surgery can improve low back pain, regardless of the degree of preoperative leg pain, but the average score for LBP and leg pain slightly worsened between 3 months and 1 year after surgery. These slides can be retrieved under Electronic Supplementary Material.

Successful detection of multiple communicating holes in multiple spinal extradural arachnoid cysts by using time-spatial labeling inversion pulse magnetic resonance imaging: illustrative case.

BACKGROUND: Spinal extradural arachnoid cysts (SEACs) communicate with the subarachnoid space through small communicating dural holes. The precise preoperative detection of all communicating holes, followed by minimally invasive dural closure, is the ideal treatment to prevent postoperative spinal deformities, especially in cases of multiple SEACs. However, standard imaging methods often fail to detect communicating hole locations. Although a few cases of successful single-hole detection via cinematic magnetic resonance imaging (MRI) have been reported, this modality's ability to detect multiple holes has not been demonstrated. OBSERVATIONS: The authors describe the case of a 14-year-old male with myelopathy due to multiple SEACs at T5-8 and T8-12. Myelography revealed a complete block at the T8 level; no cephalic cyst or communicating holes were identified. Time-spatial labeling inversion pulse (T-SLIP) MRI revealed cerebrospinal fluid flow into the cyst at T10 and T7. A limited laminectomy or hemilaminectomy was performed at T7 and T10, and two dural holes were closed without a total cystectomy. The patient's gait disturbance and rectal disorder disappeared. The cysts were confirmed to have completely disappeared on conventional MRI at 1 year postoperatively. LESSONS: T-SLIP MRI, a cinematic MRI, is useful for detecting multiple communicating holes in SEACs.

Risk factors for preoperative neurological impairment in patients with spinal meningioma: A retrospective multicenter study.

BACKGROUND: Patients with spinal meningioma may present preoperatively with paralysis and sensory deficits. However, there is a paucity of detailed evaluations and a lack of consensus regarding imaging findings that are predictive of neurological symptoms in patients with spinal meningioma. METHODS: Herein, a total of 55 patients who underwent surgical resection of spinal meningiomas in eight hospitals between 2011 and 2021 were enrolled. Patient characteristics, degree of muscle weakness, sensory disturbances, and the presence of bowel/bladder dysfunction (BBD) before surgical treatment were evaluated using medical records. Patients with American Spinal Injury Impairment Scale grades A-C and the presence of BBD were classified into the paralysis (+) group. Patients with sensory disturbances were assigned to the sensory disturbance (+) group. Based on magnetic resonance (MR) and computed tomography images, the tumor location was classified according to the spinal level and its attachment to the dura mater. To evaluate tumor size, the tumor occupation ratio (OR) was calculated using the area and distance measurement method in horizontal MR images, and the maximum length and area of the tumor in the sagittal plane were measured. RESULTS: Of all patients, 85 % were women. The mean age of patients at surgery was 69.7 years. Twenty-eight (51 %) and 41 (75 %) patients were classified into the paralysis (+) and sensory disturbance (+) groups, respectively. The average tumor length and area in the sagittal plane were 19.6 mm and 203 mm2, respectively; OR-area and diameters were 70.3 % and 72.3 %, respectively. In univariate analyses, tumor length and area in the sagittal plane were significant risk factors for paralysis. OR-diameter, symptom duration, and a low MIB-1 index correlated with sensory disturbances. Multivariate logistic regression analysis demonstrated that the area and length of the tumor in the sagittal plane were significantly correlated with paralysis, whereas the OR-diameter and symptom duration significantly correlated with sensory disturbances. The cut-off values for the area and length of the tumor in the sagittal plane to predict paralysis were 243 mm2 and 20.1 mm, respectively. CONCLUSIONS: Preoperative paralysis in patients with spinal meningiomas was significantly associated with sagittal tumor size than with high tumor occupancy in the horizontal plane. Sensory disturbances were associated with high occupancy in the horizontal plane. Patients with spinal meningiomas > 20 mm in length or 243 mm2 in area in the sagittal plane are at risk of developing paralysis and could be considered for surgery even in the absence of paralysis.

Prognostic Factors for Drop Foot Due to Lumbar Degenerative Diseases: The Impact of Surgical Timing on Postoperative Recovery.

STUDY DESIGN: Retrospective clinical series. OBJECTIVE: To investigate the prognostic factors for the improvement of drop foot caused by degenerative lumbar disease after surgery. SUMMARY OF BACKGROUND DATA: Drop foot may be caused by lumbar spinal diseases and may affect daily life. There are limited data regarding predictors of drop foot, especially surgical timing. METHODS: We retrospectively reviewed data from 87 patients with drop foot. Prognostic factors and precise timing of surgery affecting drop foot improvement were examined by multivariate logistic regression analysis. RESULTS: Forty patients (46.0%) recovered from drop foot after surgery. Age [odds ratio (OR)=0.93; 95% confidence interval (CI), 0.87-0.98; P=0.01], preoperative anterior tibialis muscle strength (OR=12.0; 95% CI, 2.41-59.9; P=0.002), and duration of drop foot before surgery (OR=3.59; 95% CI, 1.09-11.8; P=0.04) were significant prognostic factors. Two months was the most appropriate cutoff for surgery after appearance of symptoms. CONCLUSIONS: Age, preoperative tibialis anterior muscle strength, and duration of drop foot were statistically significant prognostic factors of recovery from drop foot. Surgery within 2 months after the onset of drop foot may improve postoperative outcome.