Sacral Tarlov cysts: Neurophysiology abnormalities and correlation with pelvic sensory and visceral symptoms.

BACKGROUND AND PURPOSE: Recent studies suggest a possible association between Tarlov cysts (TCs), usually considered as incidental radiological findings, and neurological symptoms such as pain, numbness and urogenital complaints. The aim was to explore the relationship between TCs and sacral nerve root functions using pelvic neurophysiology tests, and to correlate changes with clinical symptoms and magnetic resonance imaging (MRI) findings. METHODS: Consecutive patients with sacral TCs, referred for pelvic neurophysiology testing and presenting with at least one symptom related to the pelvic area, participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamics testing were collected retrospectively. The relationship between neurophysiology, MRI findings and patients' symptoms was assessed using Fisher and ANOVA tests. RESULTS: Sixty-five females were included (mean age 51.2 ± 12.1 years). The commonest symptom was pain (92%). Urinary (91%), bowel (71%) and sexual (80%) symptoms were also frequently reported. Thirty-seven patients (57%) had abnormal neurophysiology findings reflecting sacral root dysfunction. No association was seen between MRI findings (size, location of the cysts, severity of compression) and neurophysiology. A negative association was observed between neurophysiology abnormalities and occurrence of urgency urinary incontinence (p = 0.03), detrusor overactivity (p < 0.01) and stress urinary incontinence (p = 0.04); however, there was no association with voiding difficulties. CONCLUSIONS: Contrary to current understanding, TCs are associated with injury to the sacral somatic innervation in the majority of patients with presumed symptomatic cysts. However, urinary incontinence is unlikely to be related to TC-induced nerve damage.

Cervical sagittal balance: a predictor of neck pain after anterior cervical spine surgery?

PURPOSE: To determine the possible relation between cervical sagittal balance and neck pain in patients having anterior cervical spine (ACS) surgery. MATERIALS AND METHODS: Retrospective monocentric study on 85 patients who underwent ACS surgery between 2014 and 2016. Clinically, all patients were assessed using the Neck Disability Index (NDI). Radiological assessment was achieved by MRI or CT-scan of the cervical spine allowing measurement of radiological parameters for preoperative cervical sagittal balance. These same criteria were measured postoperatively using X-rays. RESULTS: There is a statistically significant increase in the Cobb angle postoperatively (10.34 degrees) compared to preoperatively (6.68 degrees) (p < 0.05). Concomitantly, there is a statistically significant decrease in NDI postoperatively (22.69%) compared to preoperatively (42.31%) (p < 0.01). There is a negative correlation between Cobb angle and NDI (r= -0.31) (p < 0.05). CONCLUSION: An improvement in the cervical sagittal balance after ACS surgery is accompanied by a reduction of neck pain. Radiological parameters of cervical sagittal balance may be taken into account when planning surgery in order to maintain cervical alignment and thereby limit the occurrence of neck pain.

Fibrin-coated collagen fleece versus absorbable dural sealant for sellar closure after transsphenoidal pituitary surgery: a comparative study.

Various surgical methods to prevent postoperative cerebrospinal fluid (CSF) leaks during transsphenoidal surgery have been reported. However, comparative studies are scarce. We aimed to compare the efficacy of a fibrin-coated collagen fleece (TachoSil) versus a dural sealant (DuraSeal) to prevent postoperative CSF leakage. We perform a retrospective study comparing two methods of sellar closure during endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenoma resection: TachoSil patching versus DuraSeal packing. Data concerning diagnosis, reconstruction technique, and surgical outcomes were analyzed. The primary endpoint was postoperative CSF leak rate. We reviewed 198 consecutive patients who underwent 219 EETS for pituitary adenoma from February 2007 and July 2018. Intraoperative CSF leak occurred in 47 cases (21.5%). A total of 33 postoperative CSF leaks were observed (15.1%). A reduction of postoperative CSF leaks in the TachoSil application group compared to the conventional technique using Duraseal was observed (7.7% and 18.2%, respectively; p = 0.062; Pearson exact test) although non-statistically significant. Two patients required lumbar drainage, and no revision repair was necessary to treat postoperative CSF rhinorrhea in Tachosil group. Fibrin-coated collagen fleece patching may be a valuable method to prevent postoperative cerebrospinal fluid (CSF) leaks during EETS for pituitary adenoma resection.

Midline sacral meningeal cyst decompression and repair.

BACKGROUND: Symptomatic midline sacral meningeal cysts (MSMC) are rare, and, as a consequence, so are reports on the surgical techniques to address these lesions. Here we provide a description of the senior author's (ATC) technique. METHOD: A sacral laminectomy is performed. The cyst's relation with the dural sac and sacral nerves is inspected; it is then opened and drained. Its lumen is explored for its point of communication with the dural sac, and this ostium is closed off with non-penetrating clips. A lumbar drain is inserted in select cases. CONCLUSION: Cyst wall resection is unnecessary and closing the ostium is sufficient to treat MSMC.

Surgical Management of Giant Thoracic Paraspinal Schwannomas.

BACKGROUND: Giant paraspinal thoracic schwannomas (GPTSs) are benign, slow-growing, encapsulated lesions. They can be intracanalicular, span more than 2 vertebral bodies, and/or have a foraminal component with extraspinal extension >2.5 cm. They pose surgical challenges because of the often unfamiliar complex regional anatomy. We report the largest series of GPTSs and discuss regional surgical strategies for tumors in the thoracic spine. METHODS: We conducted a retrospective review of GPTSs operated at a national spinal referral center between December 2008 and October 2019. Inclusion criteria included World Health Organization grade 1 GPTS. Patient demographics, clinical features, radiology, and histopathology were assessed. RESULTS: Seventeen patients (12 females, 5 males) had a mean age of 48.1 years (range 21-65 years). Five GPTS (29%) were located at T1-T3, 6 (35%) at T4-6, and 6 (35%) below T6. The mean maximum diameter was 58.5 ± 19.1 mm (range 30-91 mm). Mean volume was 90.9 cm3 (range 19.1-350.6 cm3). Twelve (70%) had a fluorodeoxyglucose positron emission tomography scan showing low (25%) or moderate to high (75%) uptake. Six patients (35%) had preoperative computed tomography-guided biopsy. Surgical approaches included 1) manubriotomy and variations (4/17); 2) high lateral thoracotomy (4/17); 3) posterior parascapular (1/17); 4) standard lateral thoracotomy (3/16); 5) posterior/posterolateral (2/17); and 6) combined posterior and thoracotomy (3/17). All patients had gross total resection and were grade 1 cellular schwannomas. No recurrence at final follow-up (mean 36.1 months, range 8-130 months). CONCLUSIONS: A number of approaches are available to resect GPST in specific locations in the thoracic spine. Total resection is achievable despite complex regional anatomy, location, and tumor extension but often requires anterior or combined approaches.

Hybrid Minimally Invasive Technique for Treatment of Thoracolumbar Spondylodiscitis and Vertebral Osteomyelitis.

OBJECTIVE: Spondylodiscitis and vertebral osteomyelitis cause significant morbidity and mortality, and typically occur in patients with multiple comorbidities. The use of minimally invasive spinal surgery in the previous decade has offered the advantages of reduced intraoperative blood loss and postoperative pain for patients. In the present report, we have described our experience with using a hybrid minimally invasive (HMI) technique (combining percutaneous fixation with a mini-open approach for decompression and debridement) for the treatment of thoracolumbar spondylodiscitis, reporting the patient demographics, intraoperative measures, and 12-month outcomes. METHODS: The data from patients presenting to a tertiary referral neurosurgical center with thoracolumbar spondylodiscitis and osteomyelitis who had undergone HMI from 2016 to 2018 were retrospectively evaluated. Patient demographics, intraoperative factors, estimated blood loss, and immediate postoperative complications were recorded. The patient outcomes were evaluated using EuroQOL 5-dimension questionnaire and visual analog scale in the immediate postoperative period and at 12 months postoperatively. RESULTS: A total of 13 patients were included in the present study, 12 with spontaneous infection and 1 with infection secondary to recent microdiscectomy at another institution. All the patients had systemic comorbidities with an American Society of Anesthesiologists class of ≥2. Of the 13 patients, 11 had pyogenic infections and 2 had spinal tuberculosis. The mean estimated blood loss was 546.2 mL. The mean time for patients to sit out of bed was 2.2 days, and the mean time to start mobilizing was 4.5 days. The EuroQOL 5-dimension questionnaire scores showed improvement in all modalities at 12 months postoperatively. CONCLUSIONS: In our cohort, HMI was a safe and effective treatment of thoracolumbar spondylodiscitis, with the potential benefits of reduced blood loss, operative duration, and postoperative pain.

Intraosseous Thoracic Schwannoma: Case Report and Review of the Literature.

BACKGROUND: Intraosseous locations are extremely rare when it comes to schwannomas and account for 0.2% of primary bone tumors. The most common intraosseous locations include the mandible and sacrum, while cervical, thoracic, and lumbar spine lesions are even more uncommon. CASE DESCRIPTION: We describe a 56-year-old female patient with incidental finding of an intraosseous lytic lesion within the vertebral body of T1. Complete surgical excision was performed with instrumented fusion. Histopathology results confirmed a World Health Organization grade I schwannoma. CONCLUSIONS: Our case is the fourth case of purely intraosseous schwannoma described in the mobile spine in the literature, with good results both clinically and radiologically after complete surgical resection.

Inhibition of KCa3.1 by depolarisation and 2-aminoethoxydiphenyl borate (2-APB) during Ca²âº release activated Ca²âº (CRAC) entry in human erythroleukemia (HEL) cells: Implications for the interpretation of 2-APB inhibition of CRAC entry.

In the present experiments in HEL cells, we have investigated the requirement for a hyperpolarised resting membrane potential for the initial activation of the Ca(2+) activated K(+) channel, KCa3.1, following activation of the Ca(2+) release activated Ca(2+) (CRAC) entry pathway. In intact cells, fluorimetric measurements of [Ca(2+)]i following thapsigargin-mediated activation of CRAC entry revealed a sustained increase in [Ca(2+)]i. Block of KCa3.1 by application of charybdotoxin resulted in a 50% reduction in the steady-state [Ca(2+)]i, consistent with the well established role for KCa3.1-mediated hyperpolarisation in augmenting CRAC entry. Interestingly, subsequent depolarisation to 0mV by application of gramicidin resulted in a fall in steady-state Ca(2+) levels to values theoretically below that required for activation of KCa3.1. Whole cell patch clamp experiments confirmed the lack of KCa3.1 activation at 0mV following activation of the CRAC entry pathway, indicating an absolute requirement for a hyperpolarised resting membrane potential for the initial activation of KCa3.1 leading to hyperpolarisation and augmented Ca(2+) entry. Current clamp experiments confirmed the requirement for a hyperpolarised resting membrane potential in KCa3.1 activation by CRAC entry. Given the critical role played by KCa3.1 and membrane potential in general in the control of CRAC-mediated [Ca(2+)]i changes, we investigated the hypothesis that inhibition of the CRAC-mediated changes in [Ca(2+)]i observed following 2-APB addition may in part arise from direct inhibition of KCa3.1 by 2-APB. Under whole cell patch clamp, 2-APB, at concentrations typically used to block the CRAC channel, potently inhibited KCa3.1 in a reversible manner (half maximal inhibition 14.2 µM). This block was accompanied by a marked shift in the reversal potential to depolarised values approaching that set by endogenous membrane conductances. At the single channel level, 2-APB applied to the cytosolic face resulted in a significant reduction in open channel probability and a fall in the mean open time of the residual channel activity. Our data highlight the absolute requirement for a hyperpolarising resting membrane conductance for the initial activation of KCa3.1 by CRAC entry. Additionally, our results document direct inhibition of KCa3.1 by 2-APB, thus highlighting the need for caution when ascribing the site of inhibition of 2-APB exclusively to the CRAC entry pathway in experiments where membrane potential is not controlled.