[Adolescent radiculopathy associated with extradural intraspinal tumor]. / Radiculopatía asociada a tumor intrarraquídeo extradural en adolescente.

INTRODUCTION: Expansive intra-spinal processes usually have an insidious course that makes their early diagnosis difficult. Intra-spinal tumors are classified according to their location in the spinal canal: extradural and intradural, and these are classified as extramedullary and intramedullary. At the beginning, they can cause non-specific pain conditions and, sometimes, root-type pain. The patient may have symptoms such as: loss of strength, loss of balance, loss of sensation, sphincter disorders. Intra-spinal neoplasms, when diagnosed, have an indication for surgical treatment. MATERIAL AND METHODS: The clinical case of a 14-year-old male adolescent is described, pain in the lumbar region for four years, of insidious onset, intermittent, progressive, exacerbated six months ago, with radiation to the lower extremities, which is accompanied by progressive paresthesia and paresis predominantly in the lower right limb. RESULTS: Bilateral L4 and L5 laminotomy is performed, exploration and resection of the tumor and release of nerve roots. Tumor with characteristics similar to adipose tissue is obtained, where a wide vascular network is observed inside, with an approximate size of 14 × 10 × 4 mm, ovoid in shape, flattened with a smooth and shiny surface. CONCLUSION: Spinal tumors are relatively rare tumors, however, of these tumors, the extradural intraspinal location accounts for half of the cases. In our patient, the diagnosis of lipoma of the filum terminale was integrated, which corresponds to less than 1% of all tumors of the spine.

INTRODUCCIÓN: Los procesos expansivos intrarraquídeos suelen tener una evolución insidiosa que dificultan su diagnóstico precoz. Los tumores intrarraquídeos son clasificados de acuerdo con su localización en el conducto raquídeo: extradural e intradural, y éstos se clasifican en extramedular e intramedular. Al comienzo, pueden provocar cuadros de dolor poco específicos y, a veces, dolores de tipo radicular. El paciente podrá tener síntomas como: pérdida de fuerza, pérdida de equilibrio, pérdida de sensibilidad y disturbios esfinterianos. Las neoplasias intrarraquídeas, cuando son diagnosticadas, tienen indicación de tratamiento quirúrgico. MATERIAL Y MÉTODOS: Se describe el caso clínico de adolescente masculino de 14 años, dolor en región lumbar desde hace cuatro años, de inicio insidioso, intermitente, progresivo, que se exacerba hace seis meses, con irradiación a extremidades inferiores, que se acompaña de parestesias y paresias progresivas de predominio en extremidad inferior derecha. RESULTADOS: Se realiza laminotomía L4 y L5 bilateral, exploración y resección de tumoración y liberación de raíces nerviosas. Se obtiene tumor de características similares a tejido adiposo en donde se observa amplia red vascular en su interior, con tamaño aproximado de 14 × 10 × 4 mm de forma ovoide, aplanada con superficie lisa y brillante. CONCLUSIÓN: Los tumores raquimedulares son tumores relativamente raros; sin embargo, de estos tumores, la localización intrarraquídea extradural corresponde a la mitad de los casos. En nuestro paciente, se integró el diagnóstico de lipoma del filum terminale, el cual corresponde a menos de 1% de todos los tumores de la columna vertebral.

Patient Factors Impacting Baseline Motor Evoked Potentials (MEPs) in Patients Undergoing Cervical Spine Surgery for Myelopathy or Radiculopathy.

STUDY DESIGN: Retrospective review of 2532 adults who underwent elective surgery for cervical radiculopathy or myelopathy with intraoperative neuromonitoring (IONM) with motor evoked potentials (MEPs) between 2017 and 2019. OBJECTIVE: Evaluate attainability of monitorable MEPs across demographic, health history, and patient-reported outcomes measure (PROM) factors. SUMMARY OF BACKGROUND DATA: When baseline IONM responses cannot be obtained, the value of IONM on mitigating the risk of postoperative deficits is marginalized and a clinical decision to proceed must be made based, in part, on the differential diagnosis of the unmonitorable MEPs. Despite known associations with baseline MEPs and anesthetic regimen or preoperative motor strength, little is known regarding associations with other patient factors. METHODS: Demographics, health history, and PROM data were collected preoperatively. MEP baseline responses were reported as monitorable or unmonitorable at incision. Multivariable logistic regression estimated the odds of having at least one unmonitorable MEP from demographic and health history factors. RESULTS: Age [odds ratio (OR)=1.031, P <0.001], sex (male OR=1.572, P =0.007), a primary diagnosis of myelopathy (OR=1.493, P =0.021), peripheral vascular disease (OR=2.830, P =0.009), type II diabetes (OR=1.658, P =0.005), and hypertension (OR=1.406, P =0.040) were each associated with increased odds of unmonitorable MEPs from one or more muscles; a history of thyroid disorder was inversely related (OR=0.583, P =0.027). P atients with unmonitorable MEPs reported less neck-associated disability and pain ( P <0.036), but worse SF-12 physical health and lower extremity (LE) and upper extremity function ( P <0.016). Compared with radiculopathy, unmonitorable MEPs in myelopathy patients more often involved LE muscles. Cord function was monitorable in 99.1% of myelopathic patients with no reported LE dysfunction and no history of hypertension or diabetes. CONCLUSION: Myelopathy, hypertension, peripheral vascular disease, diabetes, and/or symptomatic LE dysfunction increased the odds of having unmonitorable baseline MEPs. Unmonitorable baseline MEPs was uncommon in patients without significant LE weakness, even in the presence of myelopathy.

Lumbar disc herniation with contralateral radiculopathy: a systematic review on pathophysiology and surgical strategies.

Lumbar disc herniation (LDH) is a relatively common pathology usually presenting with unilateral radiculopathy ipsilateral to the disc herniation. Some patients can present with contralateral radicular symptoms. The objective of this article is to review the current literature on lumbar disc herniations with contralateral radiculopathy regarding its pathophysiology and surgical strategies. A systematic review of the literature on LDH with contralateral radiculopathy was performed using MEDLINE (via PubMed) using MeSH terms. This review was done following recommendations of PRISMA statement and PICOT strategy of search. Initial electronic search identified 126 papers. Finally, 18 articles were reviewed. None of the included papers was described as comparative. Pathophysiological processes underlying contralateral pain may include prominent spondylotic changes and the accompanying stenosis; hypertrophic yellow ligament; dural attachments along the posterior longitudinal ligament; nerve root traction forces; and friction radiculitis, migrated epidural fat, nerve root anomaly, and venous congestion inside the vertebral canal. In our pooled analysis, 11 patients reported were treated by bilateral approach with 100% of clinical success and no complications. Eight patients were treated by unilateral approach ipsilateral to pain with 100% of clinical success and no complications. Forty-eight patients were treated by unilateral approach ipsilateral to herniation with 100% of clinical success and no complications. Pathophysiology underlying contralateral pain in LDH is probably multifactorial. There is not enough scientific evidence to define the best surgical approach for patients with LDH and contralateral pain.

Do Preoperative Epidural Steroid Injections Increase the Risk of Infection After Lumbar Spine Surgery?

STUDY DESIGN: Retrospective study. OBJECTIVE: To elucidate an association between preoperative lumbar epidural corticosteroid injections (ESI) and infection after lumbar spine surgery. SUMMARY OF BACKGROUND DATA: ESI may provide diagnostic and therapeutic benefit; however, concern exists regarding whether preoperative ESI may increase risk of postoperative infection. METHODS: Patients who underwent lumbar decompression alone or fusion procedures for radiculopathy or stenosis between 2000 and 2017 with 90 days follow-up were identified by ICD/CPT codes. Each cohort was categorized as no preoperative ESI, less than 30 days, 30 to 90 days, and greater than 90 days before surgery. The primary outcome measure was postoperative infection requiring reoperation within 90 days of index procedure. Demographic information including age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI) was determined. Comparison and regression analysis was performed to determine an association between preoperative ESI exposure, demographics/comorbidities, and postoperative infection. RESULTS: A total of 15,011 patients were included, 5108 underwent fusion and 9903 decompression only. The infection rate was 1.95% and 0.98%, among fusion and decompression patients, respectively. There was no association between infection and preoperative ESI exposure at any time point (1.0%, P = 0.853), ESI within 30 days (1.37%, P = 0.367), ESI within 30 to 90 days (0.63%, P = 0.257), or ESI > 90 days (1.3%, P = 0.277) before decompression surgery. There was increased risk of infection in those patients undergoing preoperative ESI before fusion compared to those without (2.68% vs. 1.69%, P = 0.025). There was also increased risk of infection with an ESI within 30 days of surgery (5.74%, P = 0.005) and when given > 90 days (2.9%, P = 0.022) before surgery. Regression analysis of all patients demonstrated that fusion (P < 0.001), BMI (P < 0.001), and CCI (P = 0.019) were independent predictors of postoperative infection, while age, sex, and preoperative ESI exposure were not. CONCLUSION: An increased risk of infection was found in patients with preoperative ESI undergoing fusion procedures, but no increased risk with decompression only. Fusion, BMI, and CCI were predictors of postoperative infection.Level of Evidence: 3.

The Outcomes of Patients With Neck Pain Following ACDF: A Comparison of Patients With Radiculopathy, Myelopathy, or Mixed Symptomatology.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy. SUMMARY OF BACKGROUND DATA: Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF. METHODS: Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain. RESULTS: Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025). CONCLUSION: Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements. LEVEL OF EVIDENCE: 3.

Radiculopathy Following Vertebral Body Compression Fracture: The Role of Percutaneous Cement Augmentation.

BACKGROUND: Vertebral cement augmentation is a commonly used procedure in patients with vertebral body compression fractures from primary or secondary osteoporosis, metastatic disease, or trauma. Many of these patients present with radiculopathy as a presenting symptom, and can experience symptomatic relief following the procedure. OBJECTIVES: To determine the incidence of preprocedural radiculopathy in patients with vertebral body compression fractures presenting for cement augmentation, and present their postoperative outcomes. STUDY DESIGN: Retrospective cohort study. SETTING: Interventional pain practice in a tertiary care university hospital. METHODS: In this cohort study, all patients who underwent kyphoplasty (KP) or vertebroplasty (VP) procedures in a 7-year period within our practice were evaluated through a search of the electronic medical records. The primary endpoint was to evaluate the prevalence of noncompressive preprocedural radiculopathy in our patients. Evaluation of each patient's relative improvement following the procedure, respective to the initial presence or absence of radicular symptoms (including and above T10, above and below T10, and below T10) was included as a secondary endpoint. Additional subanalysis was performed with respect to patients demographics, fracture location, and primary indication for the procedure (osteoporosis, trauma, etc.). RESULTS: A total of 302 procedures were performed during this time period, encompassing 544 total vertebral body levels. After exclusion criteria were applied to this cohort, 31.6% of patients demonstrated radiculopathy prior to the procedure that could not be explained by nerve impingement. Nearly half of patients demonstrated an optimal clinical outcome (48.5% nearly complete/complete resolution of symptoms, 40.1% partial resolution of symptoms, 11.4% little to no resolution of symptoms). Patients with fractures above T10 were more likely to see complete resolution, whereas patients with fractures above and below T10 were likely to not see any resolution. Men and women without initial radiculopathy symptoms were more likely to see little to no resolution, regardless of fracture location. LIMITATIONS: This retrospective study used an electronic chart review of clinicians' notes to determine the presence of radiculopathy and their relative improvement following the procedure. CONCLUSIONS: Preprocedural radiculopathy is a common symptom of patients presenting for the evaluation of VP or KP. The presence of radiculopathy in the absence of nerve impingement may be an important marker for those patients who may experience greater benefit from the procedure. KEY WORDS: Radiculopathy, kyphoplasty, vertebroplasty, osteoporosis, compression fracture, spine, cement augmentation.

Clinical Course of Motor Deficits from Lumbosacral Radiculopathy Due to Disk Herniation.

BACKGROUND: The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies. OBJECTIVE: To determine if motor weakness and patient-reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months. DESIGN: Prospective observational cohort. SETTING: Outpatient academic spine practice. PARTICIPANTS: Adults with acute radicular weakness due to disk herniation. METHODS: Forty patients with radiculopathy and strength deficit were followed over a 12-month period. Objective strength and performance tests as well as survey-based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado. MAIN OUTCOME MEASUREMENTS: Testing of strength was through MMT, handheld dynamometer, and performance-based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) were used to measure pain and disability outcomes. RESULTS: Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty-four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R-C]), and 9 (22%) did not have surgery and lacked at least one follow-up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R-I]). No statistically significant differences were found on baseline measures of strength deficits and SF-36 domains between the CPM&R-C, Surgery, and CPM&R-I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R-C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12-month follow-up to baseline in the CPM&R-C group. CONCLUSIONS: Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year. LEVEL OF EVIDENCE: II.

Longer Preoperative Duration of Symptoms Negatively Affects Health-related Quality of Life After Surgery for Cervical Radiculopathy.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: The effect of DOS has not been extensively evaluated for cervical radiculopathy. METHODS: A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated. RESULTS: A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (P = 0.037) and Short Form-12 Mental Component Score (P = 0.029), and higher postoperative Neck Disability Index (P = 0.003), neck pain (P = 0.001), and arm pain (P = 0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (P = 0.041; 0.005; 0.044) and more than 2 years (P = 0.016; 0.014; 0.002), respectively. CONCLUSION: Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms. LEVEL OF EVIDENCE: 3.

Extraforaminal compression of the L5 nerve: An anatomical study with application to failed posterior decompressive procedures.

This anatomical study was performed to elucidate the pertinent foraminal and lateral L5 nerve anatomy to enhance our understanding of possible neurologic causes of failed decompression surgery. Persistent extraforaminal L5 nerve compression is a possible cause of persistent symptoms following lumbosacral surgery. The amount of extraforaminal space for the L5 ventral ramus was examined in fifty adult human skeletons (100 sides). Based on morphology, the specimens were then categorized (types I-IV) on the basis of the bony space available for the nerve at this location. Next, 25 embalmed adult cadavers (50 sides) underwent bilateral dissection of the lower lateral lumbar region. The type of bony extraforaminal outlet was documented for each cadaver on the basis of our skeletal analysis. Lastly, segments (intra- and extra-foraminal) of the L5 ventral ramus were excised and examined histologically. Types I-IV outlets were found in 43, 31, 20 and 6 skeletal sides, respectively. For cadavers, 22,15, 10 and 3 sides were found to have types I-IV bony outlets, respectively. In cadavers, all type IV outlets and 70% of the type III bony configurations adjacent to the L5 ventral ramus had signs of neural irritation/injury including vascular hyalinization and increased fibrosis distal to the intervertebral foramen. No distal segments of type I and type II outlets showed histological signs of neural compromise. Patients with symptoms referable to L5 nerve compression for whom no proximal pathology is identified could warrant investigation of the more distal extraforaminal segment of this nerve.

Transgenic human embryonic stem cells overexpressing FGF2 stimulate neuroprotection following spinal cord ventral root avulsion.

Ventral root avulsion (VRA) triggers a strong glial reaction which contributes to neuronal loss, as well as to synaptic detachment. To overcome the degenerative effects of VRA, treatments with neurotrophic factors and stem cells have been proposed. Thus, we investigated neuroprotection elicited by human embryonic stem cells (hESC), modified to overexpress a human fibroblast growth factor 2 (FGF-2), on motoneurons subjected to VRA. Lewis rats were submitted to VRA (L4-L6) and hESC/FGF-2 were applied to the injury site using a fibrin scaffold. The spinal cords were processed to evaluate neuronal survival, synaptic stability, and glial reactivity two weeks post lesion. Then, qRT-PCR was used to assess gene expression of ß2-microglobulin (ß2m), TNFα, IL1ß, IL6 and IL10 in the spinal cord in vivo and FGF2 mRNA levels in hESC in vitro. The results indicate that hESC overexpressing FGF2 significantly rescued avulsed motoneurons, preserving synaptic covering and reducing astroglial reactivity. The cells were also shown to express BDNF and GDNF at the site of injury. Additionally, engraftment of hESC led to a significant reduction in mRNA levels of TNFα at the spinal cord ventral horn, indicating their immunomodulatory properties. Overall, the present data suggest that hESC overexpressing FGF2 are neuroprotective and can shift gene expression towards an anti-inflammatory environment.

Patterns of Brachial Plexus Stretch Palsy in a Prospective Series of 565 Surgically Treated Patients.

PURPOSE: To report the distribution of the different patterns of stretch brachial plexus injuries (BPIs) in a retrospective cohort of patients operated at our institution during an 11-year period. METHODS: From September 2002 to June 2012, we evaluated and operated on 565 patients with traction injuries of the brachial plexus. Average age was 26.8 years (SD ±9.3 years); the interval between the injury and surgery was 5.4 months (SD ±2.8 months). The pattern of injury was defined based on data obtained from a standardized clinical examination, preoperative helical computed tomography myelography after intradural contrast injection, surgical findings, and intraoperative electric stimulation. RESULTS: Supraclavicular injuries accounted for 91% of all cases (N = 512) whereas 9% of injuries were infraclavicular. Within the supraclavicular injuries, 50% of cases involved the entire plexus and in 12% there was avulsion of all 5 roots. Among them, 94% involved the upper plexus (C5 to C6 ± C7 ± C8), and 6% the lower plexus (C8 to T1 ± C7). C5 to C6 injuries accounted for 23% of partial BPI, C5 to C7 19%, C5 to C8 52%, C7 to T1 4%, and C8 to T1 2%. CONCLUSIONS: The most relevant findings of this study were that most panplexal BPIs showed at least one graftable root, there was a high prevalence of C5 to C8 BPI, C7 to T1 root injury was the most common pattern of lower type of injury, and infraclavicular BPI was uncommon. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

The Effect of Dynamic Versus Static Plating Systems on Fusion Rates and Complications in 1-Level and/or 2-Level Anterior Cervical Discectomy and Fusion: A Systematic Review.

STUDY DESIGN: A systematic review. OBJECTIVE: To determine the effect of plate design on fusion rates in patients undergoing a 1- and 2-level anterior cervical discectomy and fusion (ACDF). METHODS: Articles published between January 1, 2002 and January 1, 2015 were systematically reviewed to determine the fusion rate of 1- and 2-level ACDFs using either a fully constrained or semiconstrained locking plate. Additional variables that were collected included the number of levels, the type of graft/cage used, the study design, the method for determining fusion, and complications. RESULTS: Fifty-two articles and 3053 patients were included. No significant difference in the fusion rate for 1- and 2-level ACDF using a fully constrained plate (96.1%) and a semiconstrained plate (95.29%) was identified (P=0.84). No difference (P=0.85) in the total complication rate between fully constrained plates (3.20%) and semiconstrained plates (3.66%), or the rate of complications that required a revision (2.17% vs. 2.41%, P=0.82) was identified. However, semiconstrained plates had a nonsignificant increase in total dysphagia rates (odds ratio=1.660, P=0.28) and short-term dysphagia rates (odds ratio=2.349, P=0.10). CONCLUSIONS: In patients undergoing a 1- or 2-level ACDF, there is no significant difference in the fusion or complication rate between fully constrained plates and semiconstrained plates. LEVEL OF EVIDENCE: Level II-systematic review.

The Timing of Surgery and Symptom Resolution in Patients Undergoing Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disk Disease and Radiculopathy.

OBJECTIVE: Success rates of surgical interventions for lumbar disorders vary significantly depending on multiple factors and, among them, the duration of symptoms. It is not clear whether there is a "cutoff" time when decompression and fusion surgery becomes less effective in the conditions with chronic nerve root compression symptomatology. The main objective of this study was to analyze whether duration of symptoms has any effect on clinical outcomes and primarily resolution of radicular pain symptoms due to degenerative disk disease and stenosis with spondylolisthesis in patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS: The prospective observational study was performed. Eighty-four patients with radicular symptoms due to degenerative disk disease and stenosis with spondylolisthesis with no previous fusion surgeries and undergoing 1- to 3-level TLIF surgery were enrolled. Fifteen patients (18%) were lost to follow-up and were excluded from this analysis leaving a total of 69 patients. Standardized questionnaires were used to analyze clinical outcomes and were administered preoperatively within 3 months of scheduled surgery, and postoperatively at 3, 6, 12, and 24 months. To emphasize the change in clinical outcome scores, the relevant scores were calculated as the ratio of minimal clinically important difference values and change scores. The change scores were calculated by subtracting the postoperative scores from the baseline scores. Multiple regression analyses were conducted to examine the relationship of the duration of symptoms and relevant minimal clinically important difference ratio values while controlling for independent variables. Further, a comparison between 2 groups of patients was performed to analyze the changes of clinical outcomes for the patients who underwent fusion within <24 months versus ≥24 months. RESULTS: It was determined that the duration of symptoms was a significant predictor of better leg pain resolution (P=0.018), but not back pain resolution (P=0.27), or improvement in ODI (P=0.10) and SF-36 PCS scores (P=0.19). The patients with shorter duration of symptoms had significantly better radicular symptom resolution (P=0.032) compared with patients who waited at least 24 months or longer to undergo fusion. CONCLUSIONS: A shorter duration of symptoms was found to be a statistically significant predictor for better resolution of radicular symptoms in patients undergoing TLIF for painful degenerative disk disease and stenosis with spondylolisthesis.

Change in Angular Alignment Is Associated With Early Dysphagia After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective analysis of a prospective cohort. OBJECTIVE: Change in cervical angular alignment may be associated with dysphagia. SUMMARY OF BACKGROUND DATA: Bony deformities of the cervical spine may be associated with secondary contractures of soft tissues in the neck. Acute surgical deformity correction causes in changes in soft tissue tension in the anterior neck, resulting in dysphagia. METHODS: The study population included patients undergoing 1 and 2 level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at 2 weeks were measured by a blinded observer for C2-C7 endplate angle, C2-C7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. RESULTS: The study population included 25 patients with complete radiographs. The mean change in C2-C7 angle was -0.6 degrees (SD 9), the mean change in C2-C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2.3 mm (SD 20).Multiple linear regression analysis was performed including operative time, age, sex, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2-C7 angle and operative time were the only statistically significant predictors of change in dysphagia at 2 and 6 weeks postoperatively. CONCLUSIONS: These results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.

Can lumbar hemorrhagic synovial cyst cause acute radicular compression? Case report / O cisto sinovial hemorrágico lombar pode causar compressão radicular aguda? Relato de caso

Lumbar synovial cysts are an uncommon cause of back pain and radiculopathy, usually manifesting with gradual onset of symptoms, secondary to involvement of the spinal canal. Rarely, intracyst hemorrhage occurs, and may acutely present as radicular - or even spinal cord - compression syndrome. Synovial cysts are generally associated with degenerative facets, although the pathogenesis has not been entirely established. We report a case of bleeding complication in a synovial cyst at L2-L3, adjacent to the right interfacet joint, causing acute pain and radiculopathy in a patient on anticoagulation therapy who required surgical resection.

Cistos sinoviais da coluna lombar são uma causa incomum de dor na coluna e radiculopatia, geralmente com evolução gradual dos sintomas, que são secundários ao comprometimento do canal vertebral. Raramente, há hemorragia intracística, que pode se manifestar de forma aguda com síndrome compressiva radicular ou mesmo medular. Habitualmente, os cistos sinoviais associam-se a doença degenerativa facetária, embora a patogênese não esteja completamente estabelecida. Relatamos aqui um caso em que uma complicação hemorrágica em um cisto sinovial no nível L2-L3, adjacente à interfacetária direita, causou dor lombar e radiculopatia em um paciente em terapia anticoagulante, sendo necessária a ressecção cirúrgica.

Long-term spinal ventral root reimplantation, but not bone marrow mononuclear cell treatment, positively influences ultrastructural synapse recovery and motor axonal regrowth.

We recently proposed a new surgical approach to treat ventral root avulsion, resulting in motoneuron protection. The present work combined such a surgical approach with bone marrow mononuclear cells (MC) therapy. Therefore, MC were added to the site of reimplantation. Female Lewis rats (seven weeks old) were subjected to unilateral ventral root avulsion (VRA) at L4, L5 and L6 levels and divided into the following groups (n = 5 for each group): Avulsion, sealant reimplanted roots and sealant reimplanted roots plus MC. After four weeks and 12 weeks post-surgery, the lumbar intumescences were processed by transmission electron microscopy, to analyze synaptic inputs to the repaired α motoneurons. Also, the ipsi and contralateral sciatic nerves were processed for axon counting and morphometry. The ultrastructural results indicated a significant preservation of inhibitory pre-synaptic boutons in the groups repaired with sealant alone and associated with MC therapy. Moreover, the average number of axons was higher in treated groups when compared to avulsion only. Complementary to the fiber counting, the morphometric analysis of axonal diameter and "g" ratio demonstrated that root reimplantation improved the motor component recovery. In conclusion, the data herein demonstrate that root reimplantation at the lesion site may be considered a therapeutic approach, following proximal lesions in the interface of central nervous system (CNS) and peripheral nervous system (PNS), and that MC therapy does not further improve the regenerative recovery, up to 12 weeks post lesion.

The revision rate and occurrence of adjacent segment disease after anterior cervical discectomy and fusion: a study of 672 consecutive patients.

LEVEL III: retrospective cohort study. OBJECTIVE: The aim of this study was to determine the rate of revision surgery and the occurrence of adjacent segment disease of patients undergoing ACDF for cervical radiculopathy and myelopathy using more modern-day instrumentation techniques. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and fusion (ACDF) has long been the preferred treatment for cervical radiculopathy and myelopathy. METHODS: All patients undergoing ACDF between January of 2000 and December of 2010 were included. Age, sex, height, weight, body mass index, symptoms at presentation, number of levels fused, graft type, and smoking status were recorded. Outcomes included revision rate, reason for revision surgery, time to revision surgery, presence and grade of adjacent segment disease, distance from the instrumentation to the cranial and caudal endplate (plate-to-disc distance), and reporting of symptoms of adjacent segment disease at the final follow-up. RESULTS: A total of 672 patients were included in this study. The average duration of follow-up was 31 months. One hundred one (15%) patients underwent revision surgery. The reason for revision surgery was adjacent segment disease in 47 (47.5%), pseudarthrosis in 45 (45.5%) and a new problem at a nonadjacent level in 7 (7.1%) of those patients. The need for revision surgery was not affected by patient age, sex, body mass index, smoking status, symptoms at presentation, number of levels fused, plate-to-disc distance or graft type. CONCLUSION: The revision rate after ACDF is 15%. Most revisions were done for either adjacent segment disease or pseudarthrosis. No specific risk factors for revision surgery were identified in this study. LEVEL OF EVIDENCE: 3.

Can lumbar hemorrhagic synovial cyst cause acute radicular compression? Case report.

Lumbar synovial cysts are an uncommon cause of back pain and radiculopathy, usually manifesting with gradual onset of symptoms, secondary to involvement of the spinal canal. Rarely, intracyst hemorrhage occurs, and may acutely present as radicular - or even spinal cord - compression syndrome. Synovial cysts are generally associated with degenerative facets, although the pathogenesis has not been entirely established. We report a case of bleeding complication in a synovial cyst at L2-L3, adjacent to the right interfacet joint, causing acute pain and radiculopathy in a patient on anticoagulation therapy who required surgical resection.