Diagnostic and prognostic significance of preoperative evoked potential tests in degenerative cervical myelopathy.

BACKGROUND CONTEXT: Decompression surgery is a treatment option for patients with degenerative cervical myelopathy (DCM). Surgical decisions primarily depend on clinical symptoms and radiological examinations. The diagnostic and prognostic significance of evoked potential tests for surgical outcomes in patients with DCM has not been thoroughly examined. PURPOSE: To identify the diagnostic and prognostic significance of preoperative evoked potential tests in patients with DCM who underwent decompression surgery. STUDY DESIGN: This was a retrospective observational study. PATIENT SAMPLE: One hundred two consecutive patients who underwent evoked potential tests and surgical treatment between January 2016 and December 2020 in a single spine center and had a minimum follow-up of 6 months. OUTCOME MEASURES: Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery. METHODS: This study evaluated the preoperative central motor conduction time (CMCT), somatosensory evoked potentials, and Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery. RESULTS: Abnormal CMCT findings were observed in 94 patients (92.2%). Abnormal somatosensory evoked potentials were observed in 77 patients (75.5%). There was a statistically significant correlation between preoperative JOA score and abductor pollicis brevis (APB)-CMCT (r=-0.546, p=.001), tibialis anterior (TA)-CMCT (r=-0.517, p<.001), median nerve (MN)-SSEP (r=-0.353, p=.001), and tibial nerve (TN)-SSEP (r=-0.349, p=.003). There were significant differences in recovery rates associated with diabetes mellitus (DM), preoperative severity of myelopathy, TA-CMCT, MN-SSEP, and TN-SSEP. Stepwise multiple regression analysis showed that the major factors affecting the clinical outcomes were TN-SSEP (ß=0.327, p=.004), preoperative JOA score (ß=0.278, p=.012), and DM (ß=0.241, p=.025). CONCLUSIONS: Evoked potential testing is a functional diagnostic tool that can indicate the severity of myelopathic symptoms in patients with DCM. Additionally, preoperative TN-SSEP may have significant prognostic value in predicting postoperative clinical outcomes. Thus, preoperative evoked potential tests could be helpful for determining suitable surgical treatment candidates and forecasting postoperative prognosis.

Risk factors for adjacent segment disease requiring reoperation after posterior lumbar interbody fusion with screw fixation: focus on paraspinal muscle, facet joint, and disc degeneration.

PURPOSE: Adjacent segment disease (ASD) requiring revision surgery is the most serious complication that can occur in patients undergoing posterior lumbar interbody fusion (PLIF) surgery. This study aimed to determine the risk factors for surgical ASD requiring revision surgery after PLIF with screw fixation surgery. We especially focused on paraspinal muscle, facet joint, and disc degeneration. METHODS: Among the patients who underwent PLIF with screw fixation due to degenerative spinal disease from January 2010 to December 2019, patients who underwent revision surgery for the development of ASD were enrolled. To evaluate the risk factors for surgical ASD, we selected a control group. Each patient in the control group was matched by age, sex, fusion level, number of fused segments, secondary MRI follow-up interval, and follow-up duration with a patient in the surgical ASD group. The radiographic and demographic data were compared between the surgical ASD and control groups. RESULTS: There were statistically significant differences between the two groups in radiological parameters of preoperative facet degeneration, facet effusion, facet angle, and fatty degeneration of the multifidus muscle. Multivariable logistic regression analysis revealed that preoperative facet effusion (odds ratio [OR] 6.48), preoperative facet angle (OR 1.24), and progression of fatty degeneration in the multifidus muscle (OR 1.07) were significant risk factors for surgical ASD. CONCLUSIONS: Preexisting high-grade adjacent facet effusion, sagittally oriented facet joint angle, and progressive fatty degeneration of the multifidus muscle are associated with the development of surgical ASD after PLIF surgery.

Delayed diagnosis of myelitis in a patient with Vogt-Koyanagi-Harada disease: a case report.

A case of myelitis following Vogt-Koyanagi-Harada (VKH) disease is reported, in which diagnosis and treatment were delayed. A 43-year-old male patient diagnosed with VKH disease presented at the Spine Centre of Yeungnam University Hospital, Daegu, Republic of Korea, with motor weakness, sensory deficit in both lower extremities, and dysuria for the previous 3 months. VKH disease had been diagnosed 15 months previously, based on vision loss in both eyes and the presence of bilateral nontraumatic granulomatous iridocyclitis, exudates, and retinal oedema. The patient exhibited severe motor weakness (right lower extremity, Medical Research Council (MRC) muscle scale, grade 2-0; left lower extremity, MRC grade 0). On cervical magnetic resonance imaging, a high-intensity T2 signal was observed in the spinal cord C4-C7 segments. Cerebrospinal fluid analysis revealed slightly elevated white blood cell counts. The patient was diagnosed with myelitis complicating VKH disease. Intravenous and oral corticosteroid therapy was administered. After steroid treatment, the patient's motor function in the right lower extremity was significantly improved (MRC grade 4-3). However, the left lower extremity did not show any improvement (MRC grade 0). To achieve a good treatment outcome, the diagnosis and treatment of myelitis in VKH disease should not be delayed.

Fracture-dislocation of L5 Combined with Multi-level Traumatic Spondylolisthesis of the Lower Lumbar Spine Treated via the Posterior-only Approach: A Case Report.

Fracture-dislocation of the lower lumbar spine, which is commonly caused by high-impact trauma and can lead to instability in the spine, is relatively rare. Surgical treatment is indicated to restore spinal balance, weight-bearing ability, and decompression of the neural elements. There are various available surgical options, including the posterior-only or anterior-only approaches, or a combination of them. However, there is still no definite classification and treatment strategy for fracture-dislocation of the lower lumbar spine. In this report, we describe a 65-year-old man presenting cauda equina syndrome caused by a fracture-dislocation of L5 combined with multi-level traumatic spondylolisthesis of the lower lumbar spine. The patient was treated via the posterior-only approach with neural decompression and anterior reconstruction with posterior instrumentation. We discuss the reasons why the posterior-only approach was decided upon and several meaningful points during the surgery in detail.

Intramuscular hemangioma with hemorrhagic transformation arising from paraspinal muscles of posterior neck: A case report.

RATIONALE: Hemangiomas are usually found in cutaneous or mucosal layers, less than 1% of hemangiomas develop in skeletal muscles. Intramuscular hemangioma (IH) in the head and neck areas is relatively infrequent, accounting for 15% of IH. Most of them are identified as a benign mass, and rapid changes in size or internal bleeding are rare. PATIENT CONCERNS: A 60-year-old female patient presented with a 2-week history of sudden onset posterior neck pain. There was no neurological deficit except limited neck motion due to pain. The palpable mass was noted on the paraspinal muscles of cervicothoracic junction, which was located midline to left side portion with tenderness. DIAGNOSES: Magnetic resonance imaging demonstrated a round shaped, multi-lobulated, and well-defined mass lesion (4.1 × 2.6 × 0.9 cm) embedded from the inter-spinous space of T1-2 to the left paraspinal muscles. The lesion was iso-intense on T2-weighted images (WI), iso- to slightly low-intense on T1-WI, heterogeneous enhancement of intra- and peri-mass lesion on contrast-enhanced T1-WI. Vascular structures presented as signal voids were identified internally and around the mass lesion. Histological examination revealed a mixed-type hemangioma. INTERVENTIONS: The mass was removed completely including some of the surrounding muscles where boundaries were unclear between the mass and surrounding muscles with ligation of peritumoral vessels. Dark-brown colored blood was drained from the ruptured tumor capsule during the dissection. There was no bony invasion. OUTCOMES: The preoperative symptoms improved immediately after the operation. There is no residual or recurrence lesion by the 15-months follow-up. LESSONS: IH with hemorrhagic transformation in the head and neck is extremely rare. In the case of intramuscular tumors accompanied by a sudden onset of severe acute pain, we recommend considering a differential diagnosis of IH with hemorrhagic transformation. Complete resection of the tumor mass including surrounding muscles is required to prevent recurrence.

Giant intradural plexiform schwannoma of the lumbosacral spine - a case report and literature review.

BACKGROUND: Plexiform schwannoma (PS), variant of schwannoma, often involves multiple fascicles as plexiform neurofibroma, and is usually located superficially on the dermis and subcutaneous layers. Spinal PS is extremely rare, and there is insufficient information on its natural course and treatment strategy. We describe the clinical features and treatment of giant intradural PS at the lumbosacral spine. CASE PRESENTATION: A 66-year-old man presented with leg pain, paresthesia, and weakness for 2 years. Magnetic resonance imaging demonstrated a large mass lesion involving a continuous multi-lobulated bead-like mass and a cystic portion from L1 to S3. The lesion was iso-intense on T2-weighted images (WI), iso- to slightly low-intense on T1-WI, and heterogeneous enhancement on contrast-enhanced T1-WI. The large mass lesion had three portions, including a cystic mass at L1, continuous multi-lobulated bead-like mass with a cystic portion from L2 to S1, and multi-lobulated mass from S2 to S3, which were identified with severe adhesions with cauda equina on operative assessment. Grossly total extirpation was achieved at the lumbar spine, and remained three round shaped small masses at the lumbar area and a multi-lobulated round masses from S2 to S3 involving nerves related with motor function of the lower extremities and anal sphincter, respectively. Histological examination revealed multinodular or plexiform growth pattern composed of spindle-shaped tumor cells, which were diffusely and strongly positive for S100 protein with KI67 < 1%. There were no recurrence of preoperative symptoms and changes of the remained masses over a 2-year follow-up period. CONCLUSION: Subtotal extirpation to minimize neural deficits and close observation can be considered an appropriate treatment strategy for a giant spinal PS considering its benign prognosis and histological features, with a high risk of neurological damage during surgery.

Intradural extramedullary and subcutaneous tumors in neonate : atypical myxoid spindle cell neoplasm.

Tumors of the central nervous system are common in the pediatric population and constitute the second most prevalent tumor type in children. Within this group, spinal cord tumors are relatively rare and account for 1 to 10% of all pediatric central nervous system tumors. We describe a very rare case of an intradural extramedullary spinal cord tumor with a subcutaneous mass and discuss its clinical presentation, pathogenesis, and treatment. A male infant was delivered normally, with uneventful development. At 16 days post-delivery, his family took him to a pediatrician because of a mass on his upper back. Magnetic resonance imaging of the thoracic spine revealed a well-demarcated soft-tissue mass with central cystic change or necrosis at the subcutaneous layer of the posterior back (T2-7 level). Another mass was found with a fat component at the spinal canal of the T1-3 level, which was intradural extramedullary space. After six weeks, the spinal cord tumor and subcutaneous mass were grossly total resected; pathologic findings indicated an atypical myxoid spindle cell neoplasm, possibly nerve sheath in type. The final diagnosis of the mass was an atypical myxoid spindle cell neoplasm. The postoperative course was uneventful, and the patient was discharged after nine days without any neurological deficit. We report a rare case of an intradural extramedullary spinal tumor with subcutaneous mass in a neonate. It is necessary to monitor the patient's status by examining consecutive radiologic images, and the symptoms and neurological changes should be observed strictly during long-term follow-up.

Long-term follow-up result of hydroxyurea chemotherapy for recurrent meningiomas.

OBJECTIVE: Meningiomas represent 18-20% of all intracranial tumors and have a 20-50% 10-year recurrence rate, despite aggressive surgery and irradiation. Hydroxyurea, an inhibitor of ribonucleotide reductase, is known to inhibit meningioma cells by induction of apoptosis. We report the long-term follow-up result of hydroxyurea therapy in the patients with recurrent meningiomas. METHODS: Thirteen patients with recurrent WHO grade I or II meningioma were treated with hydroxyurea (1000 mg/m(2)/day orally divided twice per day) from June 1998 to February 2012. Nine female and 4 male, ranging in age from 32 to 83 years (median age 61.7 years), were included. Follow-up assessment included physical examination, computed tomography, and magnetic resonance imaging (MRI). Standard neuro-oncological response criteria (Macdonald criteria) were used to evaluate the follow-up MRI scans. The treatment was continued until there was objective disease progression or onset of unmanageable toxicity. RESULTS: Ten of the 13 patients (76.9%) showed stable disease after treatment, with time to progression ranging from 8 to 128 months (median 72.4 months; 6 patients still accruing time). However, there was no complete response or partial response in any patients. Three patients had progressive disease after 88, 89, 36 months, respectively. There was no severe (Grade III-IV) blood systemic disorders and no episodes of non-hematological side effects. CONCLUSION: This study showed that hydroxyurea is a modestly active agent against recurrent meningiomas and can induce long-term stabilization of disease in some patients. We think that hydroxyurea treatment is well tolerated and convenient, and could be considered as an alternative treatment option in patients with recurrent meningiomas prior to reoperation or radiotherapy.