The Goutallier Classification System: How does Paravertebral Adipose Degeneration Change in Patients with Symptomatic Lumbar Spinal Stenosis?

STUDY DESIGN: Retrospective, observational study. OBJECTIVE: To determine the relationship between the Goutallier Classification System (GS) and anthropometric, clinical, and radiological features in 168 patients with lumbar spinal stenosis (LSS). BACKGROUND: There is no agreement on a classification system that is both reliable and easy to use for describing the severity of fatty degeneration in the paravertebral muscles of the lower back in patients with symptomatic lumbar spinal stenosis. This study aimed to determine the statistical relationship between the GS and anthropometric, clinical, and radiological factors in 168 patients with LSS. METHODS: This study was conducted on 168 patients with LSS scheduled for elective decompressive surgery. A control group of 110 healthy individuals was enrolled. The study assessed paralumbar musculature fatty infiltration using GS on preoperative Magnetic Resonance Imagin (MRI). We evaluated the statistical association between patient age, Body Mass Index (BMI), preoperative Oswestry Disability Index (ODI) questionnaire, and cross-sectional areas (CSAs) of the dural sac and lumbar paraspinal muscles. Multivariate analysis was performed to adjust for confounding. RESULTS: This study enrolled 168 patients with symptomatic LSS (95 men, 73 women; mean±standard deviation; range); age: 67,81±9,38; (32,78 - 92,34) years; BMI: 28,29±3,36; (19,95 - 38,10) kg/m2. The control group was comprised of 110 healthy patients (61 men and 49 women). Age, sex, BMI, and ES-CSA were not significantly different between the two groups. We found a direct relationship between GS grade and age, and an inverse relationship between GS grade and DS-, LM-, ES-, and PM-CSAs. (Table 2 and Fig. 5). Univariate analyses showed the variables statistically related to a higher GS grade included patient age, (P<0.001), ODI (P=0.136), DS-CSA (P=0.011), LM-CSA (P< 0.001), ES-CSA (P<0.001), and PM-CSA (P<0.001). Multivariate least squares analysis showed the GS grade to be influenced by patient age (P=0.01), LM-CSA (P=0.002), ES-CSA (P=0.002), and PM-CSA (P=0.003). CONCLUSIONS: GS shows great potential as a tool for evaluating fat infiltration in the paralumbar muscles. This measure does not correlate with the ODI and BMI, but is related to all radiological parameters and patient age. Further prospective studies are required to establish a link between preoperative and postoperative outcomes in the setting of paraspinal fat infiltration.

Antithrombotic therapy and spinal surgery: a retrospective cohort study of 289 consecutive elderly patients with degenerative lumbar stenosis.

OBJECTIVE: Lumbar spinal stenosis (LSS) is a disabling degenerative process of the spine, mainly affecting older patients. LSS manifests with low-back and leg pain and neurogenic claudication. Disability and impairment in activities of daily living are consequences of the progressive narrowing of the lumbar spinal canal. Surgical decompression has been shown to be superior to conservative management. Nonetheless, intraoperative and postoperative blood loss in elderly patients taking antiplatelet or anticoagulant drugs owing to cardiovascular comorbidities may be a special issue. This study describes and compares early outcomes after surgical procedures in different groups of patients receiving antithrombotic drugs. METHODS: The authors' study retrospectively recruited 289 consecutive patients aged ≥ 65 years who received lumbar decompression for spinal stenosis between January 2021 and May 2022. First, 183 patients taking antiplatelet therapy were divided into two groups according to the rationale for use: primary versus secondary prophylaxis of cardiovascular events (group 1 vs group 2). Primary prevention was stopped preoperatively, or secondary prevention was not discontinued during the perioperative period. Secondly, 106 patients who were not taking antiplatelet mediation were divided into two groups, depending on whether preoperative low-molecular-weight heparin had not been administered or had been (group A vs group B). Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed. RESULTS: No significant statistical differences were observed between groups 1 and 2 in terms of intraoperative blood loss and time of surgery, or between groups A and B in terms of all analyzed variables. No early or delayed complications were observed, perioperatively or during the postoperative 3-month follow-up period. CONCLUSIONS: The results of this study suggest that the use of anticoagulant and antiplatelet therapies in elective decompressive surgery could be devoid of early complications and could be safely continued perioperatively.

Multiple univariate analysis of radiologic and clinical features on 168 patients with lumbar spinal stenosis: what is the role of the erector spinae in the development of a patient's disability?

BACKGROUND: The weakening of paraspinal muscles in the paravertebral area may play a role in developing central lumbar spinal stenosis, resulting in lower back discomfort. OBJECTIVE: The study thoroughly examined the correlation between the Oswestry Disability Index, Dural Sac cross-sectional area, Schizas grading Scale, Body Mass Index, and the cross-sectional areas of Erector Spinae, Multifidus, and Psoas muscles. The findings were also compared between patients with central Lumbar Spinal Stenosis and healthy individuals. STUDY DESIGN: Retrospective monocentric observational study. METHODS: The study recruited 168 consecutive patients aged 60 or older diagnosed with central Lumbar Spinal Stenosis between January 2020 and July 2022. The patients' condition was evaluated by administering a preoperative Oswestry Disability Index questionnaire, measuring their Body Mass Index, and performing preoperative Magnetic Resonance Imaging. The analyzed parameters were the cross-sectional area of paraspinal muscles at the L4-L5 level, dural sac cross-sectional area, and Schizas grading Scale at the most stenotic level, using multiple linear univariate analyses. Two groups of healthy individuals were recruited: Group A (under 60 years old) and Group B (over 60 years old). The same data extrapolated from these groups were compared with those of patients with central lumbar stenosis using a two-tailed Mann-Whitney test. RESULTS: As the Erector Spinae degenerates, the Oswestry Disability Index tends to increase. Similarly, an increase in Body Mass Index is often accompanied by a decrease in the cross-sectional area of the Erector Spinae. Low dural sac cross-sectional area is statistically linked to a reduced Multifidus cross-sectional area. Interestingly, the Schizas grading scale does not appear to correlate with changes in the cross-sectional area of the paraspinal muscles. Additionally, there is no significant difference in the cross-sectional area of the Psoas muscle between individuals with central lumbar spinal stenosis and healthy individuals. CONCLUSIONS: Our study found that degeneration of the Erector Spinae plays a crucial role in the progression of perceived disability in Lumbar Spinal Stenosis. Prospective studies should investigate the long-term evolution of paraspinal muscles in decompressed patients.

A challenging recurrent thoracic disc herniation.

Background: Thoracic disc herniations are rare and occur at the rate of 1/1,000,000/year. Surgical approach must be individually tailored to the size, location, and consistency of the herniated disc. Notably, here, we report the unusual recurrence of a thoracic herniated disc. Case Description: In 2014, a 53-year-old female presented with thoracic back pain, and paraparesis, attributed to an magnetic resonance imaging/computed tomography (CT)-documented left paramedian T8-T9 calcific disc herniation. She underwent a left hemilaminectomy/costotrasversectomy following which she experienced complete regression of her symptoms. Notably, the postoperative radiological studies at that time demonstrated some residual although asymptomatic calcific disc herniation. Eight years later, she again presented, but now with the chief complaint of difficulty breathing. The new CT scan showed a new calcified herniated disc fragment superimposed on the previously documented residual disc. Through a posterolateral transfacet approach, she underwent resection of the disc complex. An intraoperative CT scan confirmed complete removal of the recurrent calcified disc herniation. Following the second surgery, the patient fully recovered and remains asymptomatic. Conclusion: A 53-year-old female first presented with a left-sided T8/T9 thoracic calcified disc herniation that was initially partially resected). When another larger fragment appeared 8 years later, superimposed on the previously documented residual disc, it was successfully removed through a posterolateral transfacet approach completed with CT guidance and neuronavigation.

Cervical spine arachnoid cyst complicated by spontaneous intracystic hemorrhage: Case report and review of the literature.

Background: Spinal intradural extramedullary arachnoid cysts represent about 1-3% of all primary spinal space-occupying lesions often causing spinal cord and/or radicular nerve compression. Spontaneous intralesional hemorrhages are extremely rare and are typically found within intracranial arachnoid cysts. Here, a 55-year-old female presented with a spontaneous hemorrhage into a cervical spine arachnoid cyst warranting surgical intervention (i.e., fenestration/excision/occlusion). Case Description: A 55-year-old female presented with 3 weeks of dull pain in the cervicothoracic region. She subsequently developed paresthesias and progressive lower extremity weakness with (urinary incontinence. The cervical magnetic resonance revealed a right anterolateral intradural extramedullary "cystic" lesion extending from C7 to T2; it contained a heterogeneous signalon T2W sequences, and a fluid-fluid level was documented on the T2-GRE and FLAIR sequences. At surgery, consisting of a laminectomy, two hemorrhagic cystic lesions were identified and removed. Histological findings were consistent with hemorrhagic into an arachnoid cyst. Conclusion: Only rarely hemorrhages develop in intraspinal intradural extramedullary spinal arachnoid cysts.

Computed Tomography-Guided Posterolateral Transsacral Ala Approach to Presacral L5 Schwannoma: Technical Note.

BACKGROUND: Presacral schwannomas are rare benign tumors that may reach large size before becoming symptomatic. Total surgical removal has been considered the best treatment option. Tumors arising from the presacral area are commonly managed through anterior approaches, whereas posterior approaches are used for pure intrasacral tumors or large lesions with both intrasacral and presacral extension, alone or in combination with anterior approaches. METHODS: We describe a quick and minimally invasive navigation-guided posterolateral approach to a right presacral L5 schwannoma. The lesion was microsurgically removed through high-speed drilling of the upper portion of the right sacral ala, under intraoperative neurophysiologic monitoring. RESULTS: The postoperative course was unremarkable, and the patient experienced improvement in his sensory disturbance. Postoperative magnetic resonance imaging and computed tomography scan showed the complete excision of the lesion and the removal of the upper sacral ala with preservation of the right L5-S1 articular complex. The histologic examination confirmed a schwannoma (World Health Organization grade I). CONCLUSIONS: The posterolateral transsacral ala approach may represent a minimally invasive option in the surgical management of presacral well-circumscribed benign tumors. Spinal navigation could be properly used to facilitate lesion exposure and to minimize the bone removal. The intraoperative neurophysiologic monitoring is an essential tool for the preservation of the lumbosacral nerve roots.

Effectiveness of Cadaveric Simulation in Neurosurgical Training: A Review of the Literature.

OBJECTIVE: Increased restrictions on working hours and the resultant decrease in theater time coupled with greater scrutiny to demonstrate proficiency at surgical tasks has resulted in the incorporation of simulators for surgical training. This literature review describes the use of cadaveric simulators in postgraduate neurosurgical training, with the aim to analyze their effectiveness in improving surgical performance. METHODS: An electronic literature search of the MEDLINE, Embase, and Cochrane Library databases was conducted to identify studies that look at the efficacy of cadaveric simulation in neurosurgical training. Studies that were eligible were those that assessed either objectively or subjectively the effectiveness of human cadaver models in cranial or spinal neurosurgical training. Studies that did not assess efficacy on training, looked at animal cadavers, or noncadaveric simulators were excluded. RESULTS: Twelve studies were deemed to meet the eligibility criteria. Only 4 of the studies used objective measures to assess the effectiveness of cadaveric simulators on training. Most studies reported a positive impact of cadaveric simulators on training. CONCLUSIONS: Most studies identified in this review failed to provide strong objective evidence for effectiveness in achieving competency and good outcomes in the theatres. Lack of use of validated skills assessment tools prevented studies from associating cadaveric training with improvement in operating skills. Future studies should aim to address these shortcomings and focus on validating cadaveric simulation, ensuring only those that improve performance of both technical and nontechnical skills are pursued.