Is Kambin's Triangle Safe or Not for Percutaneous Endoscopic Transforaminal Oblique Fixation from the Posterior Corner in the Lumbar Spine: A Neuroimaging Anatomic Assessment.

BACKGROUND: Nerve root injury and dural tears are important complications in endoscopic spine techniques. Whether Kambin's triangle is safe or not is unknown for percutaneous endoscopic transforaminal oblique fixation from the posterior corner (PETOFPC) in lumbar spine. This study aimed to verify neural safety of PETOFPC and to define and evaluate the ideal operating target and actual safe working area in Kambin's triangle for PETOFPC. METHODS: Lumbar magnetic resonance imaging was performed in 60 outpatients. The distances from the working targets to exiting nerve roots and dural sac/traversing nerve roots in the coronal and sagittal planes (c1-c6, s1-s6) and the distances from the exiting roots to the dural sac/traversing nerve roots in the upper and lower endplate planes (d1 and d2) were measured and statistically analyzed. RESULTS: All coronal planes (c1-c6) first increased and then decreased; they gradually increased from L1-2, maximized in L4-5, and decreased slightly in L5-S1. In L1-2 through L5-S1, d1 and d2 gradually increased (F = 249.7, P < 0.0001; F = 511.7, P < 0.0001), d2 > d1 (P < 0.05). Values of d1 and d2 were smallest in L1-2 (6.71 ± 2.10 mm and 11.89 ± 2.55 mm) and largest in L5-S1 (13.37 ± 4.09 mm and 22.05 ± 3.96 mm). With the outward shift of the targets in the sagittal plane, both s1, s3, s5 and s2, s4, s6 gradually decreased (s1 > s3 > s5, s2 > s4 > s6). CONCLUSIONS: We calculated the ideal operating target and actual safe area and further proved that Kambin's triangle is safe enough for PETOFPC. PETOFPC is a promising technology and may have great clinical significance.

The relationship between the degeneration and asymmetry of the lumbar multifidus and erector spinae muscles in patients with lumbar disc herniation with and without root compression.

BACKGROUND: The determination of muscle pathologies in lumbar disc herniation (LDH) and other conditions with low back pain is important for understanding low back problems and determining appropriate treatment methods. In patients with lumbar disc herniation with radiculopathy, elucidating the effect of root compression on the severity of muscle degeneration may predict the importance of alleviating root compression. For this purpose, magnetic resonance imaging (MRI) was used to compare the degeneration and asymmetries of the lumbar musculus multifidus (MF) and lumbar musculus erector spinae (ES) muscles in patients with lumbar discopathy without root compression (radiculopathy) and in patients with lumbar discopathy with root compression (radiculopathy). METHODS: The patients were examined in two groups: 56 patients with lumbar discopathy and no radiculopathy (Non-rad group) and 51 patients with lumbar discopathy and radiculopathy (Rad group). On axial MRI sections passing through the centre of the disc at the L3-S1 level, the asymmetry, cross-sectional area (CSA), fat infiltration, and total CSA (TCSA = MF + ES) of the MF and ES muscles were measured and compared. RESULTS: No difference was seen between the groups with respect to the CSA values of the right and left MF and left ES, but a significant difference was found in the right ES CSA (p = 0.021). The CSA and TCSA of the MF and ES showed no asymmetry according to group. Severe fat infiltration of > 50% in the right and left MF and left ES was found in the Rad group at a higher rate than in the Non-rad group. Fat infiltration was significantly positively correlated with age, body mass index, and the duration of pain (p < 0.001, p < 0.001, p = 0.004, respectively). CONCLUSIONS: The study results showed a correlation between LDH and paraspinal muscle degeneration, while no correlation was found with asymmetry. Severe (> 50%) fat infiltration is associated with root compression, and the severity of fat filtration increases in the presence of root compression. The development of more severe degeneration due to denervation associated with root compression plays a role in the emergence of this situation. Therefore, in patients with lumbar disc herniation with radiculopathy, it can be foreseen that to stop and correct severe fat infiltration and muscle degeneration, first, nerve root compression should be corrected with appropriate medical treatment methods, and in patients in whom there is no response, the pressure should be alleviated with appropriate surgical methods.

Posterior Endoscopic Cervical Decompression in Metastatic Cervical Spine Tumors: An Alternative to Palliative Surgery.

Metastatic spinal cord compression of the cervical spine is a well-known consequence of cancer that generally manifests as an oncological emergency. This study presents and describes an alternative to the minimally invasive posterior full-endoscopic approach for direct decompression and tumor debulking from the metastasis of hepatocellular carcinoma (HCC) in the cervical spine. A 54-year-old man presented with progressive cervical radiculopathy that had persisted for 3 months. The underlying disease was HCC. Radiographic examination revealed evidence of metastatic spinal cord compression with an epidural mass at the C4-C5 levels, which compressed the C4-C5 spinal cord without bony destruction. The modified Tomita score was 6 to 8 points based on palliative surgery. A posterior full-endoscopic approach to remove the tumor from the metastasis of HCC in the cervical spine was done. A postoperative radiographic study revealed adequate tumor mass resection and spinal decompression. The patient was extremely satisfied with this alternative treatment and achieved complete neurologic recovery at 1 month and no recurrent symptoms at the 6-month follow-up. The technique of posterior full-endoscopic decompression of cervical metastasis causing unilateral radiculopathy, presented in this study, is feasible. This surgical intervention seems to be optional minimally invasive and acts as an alternative to palliative surgery.

Changes and clinical correlation of diffusion tensor imaging parameters of compressed spinal cord and nerve root in patients with cervical spondylosis.

BACKGROUND: Diffusion tensor imaging (DTI) was used to quantitatively study the characteristics of the related spinal cord and nerve root compression parameters in patients with cervical spondylosis (CS), and diffusion tensor tractography (DTT) was used to visualize the spinal cord and nerve root and analyze their relevance to clinical evaluation. METHODS: A total of 67 patients with CS and 30 healthy volunteers received 3.0 T magnetic resonance imaging. Cervical DTI and DTT were performed in all the participants, where the b value of DTI was set at 800 s/mm2. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of the spinal cord and cervical nerve roots were measured by using DTI. Patients with CS were scored according to the modified Japanese Orthopedic Association (mJOA) score. RESULTS: In all the participants, the spinal cord and cervical nerve roots were clearly visible by DTT. Compared to the healthy volunteers, the FA values were significantly decreased and ADC values were significantly increased in patients with CS. mJOA score was significantly correlated with the DTI index (ADC and FA) values. Receiver operator characteristic curve analysis revealed that FA and ADC could identify mild, moderate, and severe CS. CONCLUSIONS: DTI parameters of cervical spinal cord and nerve root compression are associated with the clinical evaluation of patients with CS and may be helpful in assessing the severity of CS.

Nerve Imaging in the Wrist.

Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.

Heterogeneous macrophages contribute to the pathology of disc herniation induced radiculopathy.

BACKGROUND CONTEXT: Macrophages play important roles in the progression of intervertebral disc herniation and radiculopathy. PURPOSE: To better understand the roles of macrophages in this process, we developed a new mouse model that mimics human radiculopathy. STUDY DESIGN/SETTING: A preclinical randomized animal study. METHODS: Three types of surgeries were performed in randomly assigned Balb/c mice. These were spinal nerve exposure, traditional anterior disc puncture, and lateral disc puncture with nerve exposure (n=16/group). For the nerve exposure group, the left L5 spinal nerve was exposed without disc injury. For the traditional anterior puncture, L5/6 disc was punctured by an anterior approach as previously established. For lateral puncture with nerve exposure, the left L5 spinal nerve was exposed by removing the psoas major muscle fibers, and the L5/6 disc was punctured laterally on the left side with a 30G needle, allowing the nucleus to protrude toward the L5 spinal nerve. Mechanical hyperalgesia (pain sensitivity) of hind paws was assessed with electronic von Frey assay on alternative day for up to 2 weeks. MRI, histology, and immunostaining were performed to confirm disc herniation and inflammation. RESULTS: Ipsilateral pain in the lateral puncture with nerve exposure group was significantly greater than the other groups. Pro-inflammatory cytokines IL-1ß and IL-6 were markedly elevated at the hernia sites of both puncture groups and the spinal nerve of lateral puncture with never exposure group on postoperative day 7. Heterogeneous populations of macrophages were detected in the infiltration tissue of this mouse model and in tissue from patients undergone discectomy. CONCLUSIONS: We have established a new mouse model that mimics human radiculopathy and demonstrated that a mixed phenotype of macrophages contribute to the pathogenesis of acute discogenic radiculopathy. CLINICAL SIGNIFICANCE: This study provides a clinically relevant in vivo animal model to elucidate complex interactions of disc herniation and radicular pain, which may present opportunities for the development of macrophage-anchored therapeutics to manage radiculopathy.

Diagnostic performance of diffusion-weighted MR neurography as an adjunct to conventional MRI for the assessment of brachial plexus pathology.

OBJECTIVE: To investigate the diagnostic performance of diffusion-weighted (DW) MR neurography as an adjunct to conventional MRI for the assessment of brachial plexus pathology. METHODS: DW MR neurography scans (short tau inversion recovery fat suppression and b-value of 800 s/mm2) of 15 consecutive patients with and 45 randomly selected patients without brachial plexus abnormalities were independently and blindly reviewed by a 5th year radiology resident, a junior neuroradiologist, and a senior neuroradiologist. RESULTS: Median interpretation times ranged between 20 and 30 s. Interobserver agreement was substantial (κ coefficients of 0.715-0.739). For the 5th year radiology resident, sensitivity was 53.3% (95% CI, 30.1-75.2%) and specificity was 100% (95% CI, 92.1-100%). For the junior neuroradiologist, sensitivity was 66.7% (95% CI, 41.7-84.8%) and specificity was 100% (95% CI, 92.1-100%). For the senior neuroradiologist, sensitivity was 73.3% (95% CI, 48.1-89.1%) and specificity was 95.6% (95% CI, 85.2-98.8%). Traumatic injury, metastases, radiation-induced plexopathy, schwannoma, and inflammatory process of unknown cause could be detected by the majority of readers (100% detection rate for each disease entity by at least two readers). Neuralgic amyotrophy, iatrogenic injury after first rib resection, and cervical disc herniation causing root compression were not detected by the majority of readers (0% detection rate for each disease entity by at least two readers). CONCLUSION: DW MR neurography may be a useful adjunct when assessing for brachial plexus abnormalities, because interpretation time is relatively short and the majority of abnormalities can be detected. KEY POINTS: • DW MR neurography interpretation time of the brachial plexus is relatively short (median interpretation times of 20 to 30 s). • Interobserver agreement between three readers with different levels of experience is substantial (κ coefficients of 0.715 to 0.739). • DW MR neurography can detect brachial plexus abnormalities with moderate sensitivity (53.3 to 73.3%) and high specificity (95.6 to 100%).

A novel dual nerve transfer for restoration of shoulder function and sensory recovery of the hand, in patients with C567 traumatic root avulsion of the brachial plexus.

OBJECTIVE: The objective of our study is to determine the anatomical viability in cadavers of a novel doble nerve transfer technique for simultaneous reanimation of shoulder abduction and sensory recovery of the hand, in patients with brachial plexus injuries sustaining a C5-C6-C7 roots avulsion. These new transfers should be complemented in the clinical setting with other classic nerve transfers, i.e.: (1) a spinal accessory to suprascapular for shoulder abduction and stability, (2) ulnar nerve fascicles to the biceps branches of the musculocutaneous for elbow flexion, and (3) intercostal to triceps branches for elbow extension. METHODS: The proposed surgical technique includes (1) transferring motor fascicles of the median nerve (MNF), as donors to the axillary nerve (AN), and (2) the whole medial antebrachial cutaneous nerve (MACN) to the lateral contribution (sensory) of the median nerve (LCMN), both without the use of interposed nerve grafts. These techniques were performed in eight cadaveric upper extremities. Analyzed variables were: donor and receptor nerves diameter, length and distance of donor and receptors nerves, and axonal count. RESULTS: The mean distance between the MNF and its point of coaptation to the AN was 19 mm. The average length of each one of the MNF, after distal dissection, was 46.5 mm. The average diameter of each fascicle of the median nerve at its coaptation point with the axillary nerve was 0.8 mm, while the average diameter of the latter was 3.9 mm. The average distance between the MACN and its point of coaptation to the LCMN, was 16.5 mm. The average diameter of the MACN and the LCMN at their point of coaptation, were 2.7 mm and 3.5 mm, respectively. CONCLUSION: These nerve transfers are anatomically viable and could be a complement for other currently used techniques that can be employed in severely injured C567 brachial plexus patients.

A national snapshot of the impact of clinical depression on post-surgical pain and adverse outcomes after anterior cervical discectomy and fusion for cervical myelopathy and radiculopathy: 10-year results from the US Nationwide Inpatient Sample.

Depression is associated with poorer outcomes in a wide spectrum of surgeries but the specific effects of depression in patients undergoing cervical spine surgery are unknown. This study aimed to evaluate the prevalence and impact of pre-surgical clinical depression on pain and other outcomes after surgery for cervical degenerative disc disease using a national representative database. Data of patients with cervical myelopathy and radiculopathy were extracted from the 2005-2014 US Nationwide Inpatient Sample (NIS) database. Included patients underwent anterior discectomy and fusion (ACDF). Acute or chronic post-surgical pain, postoperative complications, unfavorable discharge, length of stay (LOS) and hospital costs were evaluated. Totally 215,684 patients were included. Pre-surgical depression was found in 29,889 (13.86%) patients, with a prevalence nearly doubled during 2005-2014 in the US. Depression was independently associated with acute or chronic post-surgical pain (aOR: 1.432), unfavorable discharge (aOR: 1.311), prolonged LOS (aOR: 1.152), any complication (aOR: 1.232), respiratory complications/pneumonia (aOR: 1.153), dysphagia (aOR: 1.105), bleeding (aOR: 1.085), infection/sepsis (aOR: 1.529), and higher hospital costs (beta: 1080.640) compared to non-depression. No significant risk of delirium or venous thrombotic events was observed in patients with depression as compared to non-depression. Among patients receiving primary surgery, depression was independently associated with prolonged LOS (aOR: 1.150), any complication (aOR:1.233) and postoperative pain (aOR:1.927). In revision surgery, no significant associations were found for prolonged LOS, any complication or pain. In conclusion, in the US patients undergoing ACDF, pre-surgical clinical depression predicts post-surgical acute or chronic pain, a slightly prolonged LOS and the presence of any complication. Awareness of these associations may help clinicians stratify risk preoperatively and optimize patient care.

When Clinical Diagnosis Differs From Advanced Imaging: A Case Series of Disc Herniations Causing Radiculopathy and Review of Aberrant Nerve Root Innervation.

ABSTRACT: Radiculopathy is diagnosed using a combination of history, physical examination, and imaging. Unfortunately, well-established dermatomal and myotomal maps are an oversimplification of the convoluted nature of spinal sensory and motor innervation. When clinical presentation and imaging seemingly contradict one another, it is important to consider variant innervation patterns. This article presents three patients with objective dermatomal and/or myotomal deficits due to disc herniations whose clinical presentations are "textbook" for nerve root pathology that is adjacent to the nerve root that is actually compromised. In addition, the literature is reviewed to discuss the history of dermatomal and myotomal maps, the effectiveness of a clinician's ability to determine the precise pathologic disc and nerve root level in patients presenting with radiculopathy, and anatomical explanations as to why inconsistencies such as those seen in the patients in these cases exist.

Strong association of type 2 diabetes with degenerative lumbar spine disorders.

Tantalizing connections between type 2 diabetes and degenerative lumbar spine disorders have become increasingly evident. However, the association of type 2 diabetes with degenerative lumbar spine disorders remains unclear. We sought to clarify the association between type 2 diabetes and lumbar spine disorders using nationwide data in Korea. Furthermore, we explored the association of diabetes with the prevalence of spinal procedures. The data in this study was obtained from Korean health claim database. Between 2016 and 2019, totals of 479,680 diabetes and 479,680 age- and sex-matched control subjects were enrolled. Patients with diabetes had more likely to have degenerative lumbar spine disorders and spinal procedures than controls. Using multivariate-adjusted analysis, patients with diabetes were at increased risk of being concomitantly affected by lumbar disc disorder [adjusted odds ratio 1.11 (95% confidence interval 1.10-1.12)], lumbar spondylotic radiculopathy [1.12 (1.11-1.13)], spondylolisthesis [1.05 (1.02-1.08)] and spinal stenosis [1.16 (1.15-1.18)], compared to controls. Furthermore, diabetic patients had an increased risk of undergoing lumbar spinal injection [1.13 (1.12-1.14)], laminectomy [1.19 (1.15-1.23)], and fusion surgery [1.35 (1.29-1.42)]. We demonstrated that type 2 diabetes was significantly associated with lumbar spine disorders and frequent spinal procedures. Our results suggest diabetes as a predisposing factor for lumbar spine disorders.

Examining the Accuracy of Ultrasound-Guided Lumbar Transforaminal Injection Controlled by Fluoroscopic Imaging in Patients with Lumbar Radiculopathy: A Modified Technique.

AIM: To present a new sonographic approach for lumbar transforamianal injection and compared it with traditional fluoroscopicguided approach. MATERIAL AND METHODS: This interventional clinical study was conducted on 30 patients with a history of radicular lowback pain and a recent MRI indicating root compression. On the prone position, with the curve of ultrasound transducer on the parasagittal oblique position, a peripheral venous catheter (# 16) was advanced to the lamina through out-of-plane technique. Then, the transducer position was changed to axial position and an epidural catheter was placed about 8 cm away from midline and advanced under sonography guide with the in-plane technique to the intervertebral foramen. The level and the situation of needle was controlled with fluoroscopy and documented when the corticosteroid (triamcinolone) was injected. Also, pain scores for patients were documented and analyzed with SPSS-22 software. RESULTS: After controlling with fluoroscopy, from all 38 levels of injection, 36 levels were correctly achieved. Of all 36 injections on right levels, all injections were performed in the correct position (in intervertebral foramen). The patients? pain dramatically decreased during the first month after injection (p < 0.001), but after that, it remained unchanged. CONCLUSION: In our study, transforaminal injection was administered using the modified new technique, which was found to be safe and accurate in comparison with the fluoroscopy, as the popular gold standard technique.

MRI evaluation of nerve root avulsion in neonatal brachial plexus palsy: understanding the presence of isolated dorsal/ventral rootlet disruption.

OBJECTIVE: The evaluation, treatment, and prognosis of neonatal brachial plexus palsy (NBPP) continues to have many areas of debate, including the use of ancillary testing. Given the continued improvement in imaging, it is important to revisit its utility. Nerve root avulsions have historically been identified by the presence of pseudomeningoceles or visible ruptures. This "all-or-none" definition of nerve root avulsions has many implications for the understanding and management of NBPP, especially as characterization of the proximal nerve root as a potential donor remains critical. This study examined the ability of high-resolution MRI to more specifically define the anatomy of nerve root avulsions by individually examining the ventral and dorsal rootlets as they exit the spinal cord. METHODS: This is a retrospective review of patients who had undergone brachial plexus protocol MRI for clinical evaluation of NBPP at a single institution. Each MR image was independently reviewed by a board-certified neuroradiologist, who was blinded to both established diagnosis/surgical findings and laterality. Each dorsal and ventral nerve rootlet bilaterally from C5 to T1 was evaluated from the spinal cord to its exit in the neuroforamen. Each rootlet was classified as avulsed, intact, or undeterminable. RESULTS: Sixty infants underwent brachial plexus protocol MRI from 2010 to 2018. All infants were included in this study. Six hundred individual rootlets were analyzed. There were 49 avulsed nerve rootlets in this cohort. Twenty-nine (59%) combined dorsal/ventral avulsions involved both the ventral and dorsal rootlets, and 20 (41%) were either isolated ventral or isolated dorsal rootlet avulsions. Of the isolated avulsion injuries, 13 (65%) were dorsal only, meaning that the motor rootlets were intact. CONCLUSIONS: A closer look at nerve root avulsions with MRI demonstrates a significant prevalence (approximately 41%) of isolated dorsal or ventral nerve rootlet disruptions. This finding implies that nerve roots previously labeled as "avulsed" but with only isolated dorsal (sensory) rootlet avulsion can yet provide donor fascicles in reconstruction strategies. A majority (99%) of the rootlets can be clearly visualized with MRI. These findings may significantly impact the clinical understanding of neonatal brachial plexus injury and its treatment.

Fibrous Connection Between Cervical Nerve and Zygapophysial Joint and Implication of the Cervical Spondylotic Radiculopathy: An Anatomic Cadaveric Study.

STUDY DESIGN: Observational, anatomical, cadaveric study. OBJECTIVE: We anatomically investigated the fibrous connection between the cervical nerves and the zygapophysial joint capsules. SUMMARY OF BACKGROUND DATA: Cervical spondylotic radiculopathy is caused by the compression of the cervical nerves as the static factor and head and neck movements as the dynamic factor. To understand the dynamic pathology of cervical spondylotic radiculopathy, the anatomic relationship between the cervical nerves and the zygapophysial joints needs to be investigated in detail. METHODS: In 11 cadavers, we dissected both sides from the C5 to C7. For macroscopic examination, we observed structures connecting the cervical nerves and the zygapophysial joints in 18 cervical nerves from three cadavers. In 14 sides of eight cadavers, we histologically analyzed the fibrous structures and their attachments. RESULTS: Macroscopically, the fibrous band connected the cranial surface of the cervical nerve to the lateral and inferior aspects of the transverse process. In four of 18 nerves, the fibrous bands were divided into two fascicles by loose connective tissues. In addition, the fibrous bands extended along the dorsal aspect of the posterior tubercle of the transverse process and attached to the zygapophysial joint capsule. Histologically, densely stained fibrous tissues overlaid the zygapophysial joint capsule and extended to the recess between the posterior tubercle and inferior articular process on the cranial vertebral body. CONCLUSION: We macroscopically and histologically clarified the fibrous bands connecting the cervical nerve to the zygapophysial joint capsule. The fibrous bands may help clarify the pathology of cervical spondylotic radiculopathy associated with the zygapophysial joints as dynamic factors.Level of Evidence: N/A.

Low prevalence of end plate junction failure in danish patients with lumbar disc herniation.

The present study was undertaken to determine the prevalence of endplate junction failure in a smaller cohort of Danish patients with lumbar disk herniation and compare this to the previously published data from India. Consecutive patients seen in a large regional hospital spine-care unit, with a clinical presentation suggesting a lumbar disk herniation with concomitant radiculopathy and confirmatory recent MRI were included. Additional imaging by CT was performed as part of the study and these were analyzed with specific attention to endplate junction failures. For ethical reasons, the number of participants was kept to a minimum and a total of 26 patients were included. The prevalence (n = 5) of endplate junction failure was found to be statistically significantly lower than that previously reported. Our findings do not echo those previously reported in an Indian population: Endplate junction failure was indeed observed, but at a significantly lower rate. We discuss potential reasons for the difference in findings with due attention to the weaknesses of the current study.

Surgical Interventions for Cervical Radiculopathy without Myelopathy: A Systematic Review and Meta-Analysis.

BACKGROUND: The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs). METHODS: A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I2 ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias. RESULTS: A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity. CONCLUSIONS: This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

New methods for diagnosing lumbar foraminal stenosis using dynamic digital tomosynthesis radiculography.

The symptoms of lumbar radiculopathy, in particular foraminal stenosis, often exacerbated when the patient is upright. However, it is difficult to detect the compression of nerve roots while the patient is upright using conventional MRI. In this study, we analyzed the compression of lumbar nerve roots using dynamic digital tomosynthesis radiculography (DTRG) in patients diagnosed with lumbar radiculopathy. And we determined the relationship between leg pain and nerve compression while the patients are either prone or upright. We evaluated 30 patients with unilateral leg pain diagnosed as lumbar radiculopathy by physical examination and MRI. The patients were divided in two groups, one with foraminal stenosis (17 patients) and the other with canal stenosis (13 patients), based on MRI findings. All patients underwent DTRG to determine the diameter of their nerve roots in the foramen while prone and upright. Pain while prone or upright was assessed using a 100-point visual analogue scale (VAS) questionnaire. The VAS for leg pain while upright was significantly higher in the foraminal stenosis group (58 ± 24.7) than it was in the canal stenosis group (19.6 ± 13.2; p = 0.0002)). The nerve root diameter while prone or upright was significantly smaller in the foraminal stenosis group (1.2 ± 0.2 mm) than it was in the canal stenosis group (0.2 ± 0.1 mm; p < 0.0001). DTRG has the potential to visualize nerve compression while the patient is upright to reveal the relevance of foraminal stenosis to clinical findings. DTRG is useful for diagnosis of lumbar foraminal stenosis.

Locally invasive giant spinal paraganglioma.

Cauda equina paragangliomas are neuroendocrine tumours rarely encountered in neurosurgical practice. Large cauda equina paragangliomas with an intradural and extradural component, dense adhesion to nerve roots and high vascularity are surgically challenging and mandate meticulous operative dissection. The presence of extensive bony erosion can lead to spinal instability requiring solid instrumentation and fixation. We recommend resection of large cauda equina paragangliomas in a staged fashion with the aim of gross total resection and spinal stabilisation.