C2 stentoplasty: an alternative to conventional vertebroplasty in the treatment of axis metastatic lesions: a systematic review with meta-analysis and case series.

BACKGROUND: Vertebroplasty has been recently described in the literature as a potential treatment for C2 metastatic lesions. Stentoplasty may represent a safest and equally alternative to the latter. OBJECTIVE: To describe a novel technique, stentoplasty, as an alternative for the treatment of metastatic involvement of C2 and to assess its efficacy and safety. To systematically evaluate the pertinent literature regarding the clinical outcomes and complications of C2 vertebroplasty in patients with metastatic disease. METHODS: A systematic review of C2 vertebroplasty, in the English language medical literature was conducted for the needs of this study. Additionally, a cohort of five patients, presenting with cervical instability (SINS > 6) and/or severe pain (VAS > 6) from metastatic involvement of C2 and treated with stentoplasty in our department is presented. Outcomes evaluated include, pain control, stability, and complications. RESULTS: Our systematic review yielded 8 studies that met the inclusion criteria, incorporating 73 patients that underwent C2 vertebroplasty for metastatic disease. There was a reduction in VAS scores following surgery from 7.6 to 2.1. Eleven patients had complications (15%), 3 (4%) required additional stabilization and decompression, 6 (8.2%) had odynophagia and the incidence of cement leak was 31.5% (23/73). With regard to our cohort, all 5 patients presented with severe neck pain (average VAS 6.2 (2-10)) with or without instability (average SINS 10 (6-14)) and underwent C2 stentoplasty. Mean duration of the procedures was 90 min (61-145) and 2.6 mls (2-3) of cement was injected. Postoperatively VAS improved from 6.2 to 1.6 (P = 0.033). No cement leak or other complications were recorded. CONCLUSION: A systematic review of the literature demonstrated that C2 vertebroplasty can offer significant pain improvement with a low complication rate. At the same time, this is the first study to describe stentoplasty in a small cohort of patients, as an alternative for the treatment of C2 metastatic lesions in selected cases, offering adequate pain control and improving segmental stability with a high safety profile.

Treatment of Chiari Malformation and Concomitant Paediatric Scoliosis Long-Term Follow-Up in One Major Referral Centre in the UK.

OBJECTIVE: Paediatric scoliosis (PS) and Chiari malformation type 1 (CM-1) have been reported to be associated with each other. Scoliosis curvature is a common finding among patients operated for CM-1, and curve development has been related to it. We report a cohort of PS and CM-1 patients managed with posterior fossa and upper cervical decompression (PFUCD) by a single surgeon, with an average of two years of follow-up. METHODS: We present a retrospective cohort in a single referral centre for patients with CM-1 and PS. RESULTS: From 2011 to 2018, we identified fifteen patients with CM-1 and PS; eleven underwent PFUCD, ten had symptomatic CM-1, and one had asymptomatic CM-1 but showed curve progression. The remaining four CM-1 patients were asymptomatic and were hence treated conservatively. The average follow-up post-PFUCD was 26.2 months. Scoliosis surgery was performed in seven cases; six patients underwent PFUCD prior to the scoliosis correction. One scoliosis case underwent surgery in the presence of mild CM-1 treated conservatively. The remaining four cases were scheduled for scoliosis correction surgery, while three were managed conservatively, with one case lost to follow-up. The average time between PFUCD and scoliosis surgery was 11 months. None of the cases had intraoperative neuromonitoring alerts or perioperative neurological complications. CONCLUSION: CM-1 with concomitant scoliosis can be found. Symptomatic CM-1 might require surgery, but as we discovered, PFUCD had negligible effect on curve progression and the future need for scoliosis surgery.

Dyspnoea due to spinal subarachnoid-pleural fistula.

We report a case of a 72-year-old woman who underwent transthoracic discectomy for a giant disc herniation at T9-T10 level causing significant cord compromise. Following removal of her non-suction chest drain, she was transferred to the acute spinal-orthogeriatric unit where she was under regular review by elderly care physicians as part of their spinal liaison role. Approximately four weeks after the operation, she started becoming dyspnoeic and her chest X-ray showed moderate left-sided pleural effusion which tested positive for ß2-transferrin, a sensitive marker of cerebrospinal fluid, supporting a diagnosis of subarachnoid-pleural fistula. This is a very unusual cause of breathlessness in a postoperative patient.

Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome.

STUDY DESIGN: A prospective, observational cohort study. OBJECTIVE: The aim of this study was to determine the role of pre and postvoid bladder scan in predicting cauda equina syndrome (CES). The thesis was that bladder scanning [specifically postvoid residual (PVR) volume] would have higher diagnostic accuracy than physical examination alone. SUMMARY OF BACKGROUND DATA: CES is an ill-defined condition with a spectrum of presenting symptoms. There is neither a combination of clinical symptoms and/or signs that reliably predicts cauda equina compression nor single defining clinical criterion that has 100% predictive value to confirm or exclude CES. METHODS: Patients with suspected CES admitted over a 6-month period at a single institution were prospectively assessed by physical examination (including digital rectal examination and pin prick perianal sensation) and bladder ultrasound scanning (recording pre- and PVR volume). These results were compared with the subsequent magnetic resonance imaging (MRI) scans and those patients who had emergent surgery for CES. RESULTS: Ninety-two patients were included in the study (52 women) with a mean age of 44.9 years.An MRI scan demonstrating causing compression of the cauda equina was present in only 18% (17/92).The sensitivity of anal tone to predict CES was 52.9%. Peri-anal numbness (either unilateral or bilateral) had sensitivity of 82.3% and negative predictive value of 92%.For nonoperated group (without CES), mean PVR was 199 mL (95% confidence interval ±â€Š59 mL). On the basis of receiver operating curves, the optimal bladder volume cut-off for predicting CES was ≥200 mL for PVR volume. A PVR of <200 mL gave CES probability of 3.6%. If >200 mL, then the probability of having CES is 43% (P < 0.000003). A PVR <200 mL had a negative predictive value of 97%. CONCLUSION: Bladder scanning was a useful adjunct in the diagnosis of CES. It had a better negative predictive value than physical examination. LEVEL OF EVIDENCE: 3.

Time Factor and Disc Herniation Size: Are They Really Predictive for Outcome of Urinary Dysfunction in Patients With Cauda Equina Syndrome?

BACKGROUND: Timing of surgery and the importance of the size of disc prolapse in cauda equina syndrome (CES) remain controversial. OBJECTIVE: To investigate whether there is a relationship between postoperative urinary function, preoperative duration of neurogenic lower urinary tract dysfunction (NLUTD), and the level of canal compromise. METHODS: Seventy-one patients operated for CES were prospectively identified between 2010 and 2013. Fifty-two cases with preoperative NLUTD were included. The "Prolapse: Canal ratio" (PCR) was calculated as a proportion of cross-sectional area of disc prolapse on total cross-sectional area of spinal canal. RESULTS: Median of preoperative duration of NLUTD was 72 h (48; 132) and period from first assessment to surgery 10.5 h (7; 18.5). Urinary incontinence was seen in 46.2% of patients, 38.4% had painless retention and 15.4% had painful retention. In 38.5% of cases, urinary symptoms persisted for more than 20 mo postoperatively. There was no correlation between duration of preoperative NLUTD and urinary dysfunction persistence (P = .921). The outcome was not significantly influenced by having surgery more than the 48 h after presentation (P = .135). Preoperative incontinence persisted in 58% and painless retention in 30% of cases. The mean PCR was 0.6 ± 0.18. There was no correlation between PCR and outcome (P = .537) even after adjusting for duration of preoperative NLUTD (P = .7264). CONCLUSION: No significant correlation was demonstrated between the preoperative duration of urinary dysfunction, the size of disc herniation relative to size of spinal canal, and postoperative urinary function in a large consecutive series of patients with CES.

Is the rate of re-operation after primary lumbar microdiscectomy affected by surgeon grade or intra-operative lavage of the disc space?

STUDY DESIGN. Retrospective audit of consecutive patients. OBJECTIve. To investigate the re-operation rate following elective primary lumbar microdiscectomy and to determine whether principal surgeon grade and/or disc space lavage is a factor in recurrence. SUMMARY OF BACKGROUND DATA. Recurrent herniation of disc material following lumbar microdiscecomy surgery is one of the commonest complications of the procedure. Any reduction in the number of revision microdiscectomies performed per year would have a significant impact on patients' lives and on the health service economy. We undertook this study to ascertain whether principal surgeon grade and/or disc space lavage has an impact in reducing the re-operation rate. METHODS. We undertook a retrospective audit of patients who underwent elective primary lumbar microdiscectomy, over a 3-year period (n = 971). RESULTS. The overall re-operation rate for primary elective microdiscectomy was 3.8%, consistent with the published literature. The relative risk of re-operation in patients primarily operated by registrar surgeons was 1.2 fold the risk in patients operated by consultants (95% CI: 0.62, 2.35) although not statistically significant (p = 0.568). The risk of re-operation in the 'non lavage' group was 2.15 times the risk in the 'lavage' group (95% CI: 0.63, 7.34), but it did not reach significance (p = 0.222). CONCLUSIONS. Principal surgeon grade and intervertebral disc lavage have not been found conclusively to be factors in the rate of recurrence. This information is useful to reassure patients that their outcome from such surgery is not dependent on the grade of surgeon performing the operation. There is a possible trend towards intervertebral disc lavage reducing the rate of recurrence.

Cauda equina syndrome: the importance of complete multidisciplinary team management.

A 44-year-old lady with a history of lumbar back pain presented to the emergency department complaining of severe back pain radiating to her buttocks. Positive examination findings were a loss of sensation in the perianal area and 348 ml of retained urine. An urgent MRI showed compression of the cauda equina by a herniated disc. The patient was operated upon that evening, having a lumbar 5/sacral 1 decompression and sequestrectomy. During follow-up, the patient was reviewed by a consultant spinal surgeon, a urologist and our cauda equina nurse at every appointment, as per the cauda equina pathway specifically designed and implemented by our spinal unit. This report shows the complex nature of cauda equina syndrome and broad functional deficit patients can suffer from. It shows the benefits of prompt diagnosis and surgery, together with intensive, multidisciplinary follow-up and treatment, all of which are possible by a specially created, cauda equina protocol.

A case of craniocervical abscess with sinus thrombosis in Lemierre's syndrome.

A 74-year old gentleman with a cranio-cervical abscess failed to improve after incision and drainage and standard intravenous antibiotic therapy. Imaging demonstrated thrombosis of the internal jugular vein, sigmoid sinus and transverse sinus; and microbiological analysis isolated Fusobacterium nucleatum. The diagnosis of Lemierre's syndrome was confirmed, and he was effectively treated with appropriate antibiotics and anti-coagulation.