Patient-controlled sublingual sufentanil tablet system versus intravenous opioid analgesia for postoperative pain management after lumbar spinal fusion surgery.

PURPOSE: This retrospective cohort study investigated the efficacy of a sublingual sufentanil tablet system (SSTS) in comparison to intravenous patient-controlled analgesia (IV-PCA) with piritramide for the management of postoperative pain following lumbar spinal fusion surgery. METHODS: This was a retrospective analysis of patients undergoing single- or two-level lumbar spinal fusion surgery and receiving the SSTS or IV-PCA for postoperative pain relief as part of multimodal pain management that included IV paracetamol and oral metamizole. The following variables were collected: postoperative pain intensity and frequency scores using the numerical rating scale (NRS), hospital anxiety and depression scale (HADS), occurrence of nausea, postoperative mobilization, and patient satisfaction (MacNab criteria). RESULTS: Sixty-four patients were included. Those receiving the SSTS (n = 30) had significantly lower pain intensities on the operative day (NRS: 4.0, CI: 3.6-4.3 vs. 4.5, CI: 4.2-4.9; p < 0.05) and one day postoperatively (NRS: 3.4, CI: 3.1-3.8 vs. 3.9 CI: 3.6-4.3; p < 0.05) compared to patients receiving IV-PCA (n = 34). No differences were observed on postoperative days 2 to 5. SSTS patients experienced more nausea than IV-PCA patients (p = 0.027). Moreover, SSTS patients had a higher percentage of early mobilization following surgery than IV-PCA patients (p = 0.040). Regarding patient satisfaction, no significant differences were seen between the groups. CONCLUSION: The SSTS is a potentially advantageous alternative to opioid IV-PCA for use within a multimodal approach to managing postoperative pain after lumbar fusion surgery. Furthermore, the potentially higher emetic effect of SSTS should be considered, and the patient should be able to perform the application.

Lumbar hemivertebra resection in congenital scoliosis utilizing cone-beam navigation: less radiation, more accuracy-proof of concept.

PURPOSE: To present the first known pediatric utilization of cone-beam navigation system (CBNS) for hemivertebra resection and spondylodesis CASE PRESENTATION: A 14-year-old female with congenital scoliosis, diagnosed at 8 years of age, presenting with progressive symptoms, a Cobb angle (L3-5) of 38° at time of surgery, treated historically with conservative measures. Presence of spinal intramedullary disease was excluded prior to operation via whole spine MRI. RESULTS: Patient successfully underwent surgical correction utilizing the CBNS (O-arm™, Medtronic®). Post-operative Cobb angle (L3-5) was restored to 8°. Following four different pediatric patient's radiation exposures (two receiving correction via the O-arm platform and two via the traditional method employing fluoroscopy), we show a reduction in radiation exposure using the CBNS system. CONCLUSION: We present the first known pediatric case of the utilization of the CBNS system for hemivertebra correction. We demonstrate that utilizing the CBNS platform can not only increase surgical accuracy but also decrease pediatric patient's radiation exposure as a preoperative CT scan is not needed. Future studies should continue to explore additional benefits of implementing the system into surgical practice.

Leonardo da Vinci (1452-1519) and his depictions of the human spine.

INTRODUCTION: Few individuals in history have exerted so great an influence and made such extensive contributions to so many disciplines as Leonardo da Vinci. Da Vinci's inquisitive, experimental mentality led him to many discoveries, such as spinal cord function and the proper anatomy of several organ systems. Respected not only as an artist but also as an anatomist, he made many significant contributions to the field. CONCLUSIONS: This article explores da Vinci's drawings, in relation to the anatomy of the human spine.

Against the odds: what to expect in rehabilitation of chronic spinal cord injury with a neurologically controlled Hybrid Assistive Limb exoskeleton. A subgroup analysis of 55 patients according to age and lesion level.

Objective Age and lesion level are believed to represent outcome predictors in rehabilitation of patients with chronic spinal cord injury (SCI). The Hybrid Assistive Limb (HAL) exoskeleton enables patients to perform a voluntary controlled gait pattern via an electromyography-triggered neuromuscular feedback system, and has been introduced as a temporary gait training tool in patients with SCI. The aim of this prospective pre- and postintervention study was to examine functional outcomes as a function of age and lesion level in patients with chronic incomplete SCI (iSCI) or chronic complete SCI (cSCI) with zones of partial preservation (ZPP) by using the HAL as a temporary training tool. Methods Fifty-five participants with chronic iSCI or cSCI (mean time since injury 6.85 ± 5.12 years) were classified according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) and divided by age (< 50 or ≥ 50 years), independent of lesion level, and also into 4 homogeneous groups according to lesion level. The subgroups were as follows: Subgroup 1, tetraplegic iSCI (n = 13) (C2-8, AIS C [n = 8] and AIS D [n = 5]); Subgroup 2, paraplegic iSCI with spastic motor behavior (n = 15) (T2-12, AIS C [n = 8] and AIS D [n = 7]); Subgroup 3, paraplegic cSCI with complete motor paraplegia and absence of spastic motor behavior (n = 18) (T11-L4 [AIS A], and ZPP from L-3 to S-1); and Subgroup 4, paraplegic iSCI with absence of spastic motor behavior (n = 9) (T12-L3, AIS C [n = 8] and AIS D [n = 1]). The training paradigm consisted of 12 weeks of HAL-assisted treadmill training (5 times/week). Baseline status was documented prior to intervention by using the AIS grade, Walking Index for SCI II (WISCI II) score, the 10-meter walk test (10MWT), and the 6-minute walk test (6MinWT). Training effects were assessed after 6 and 12 weeks of therapy, without HAL assistance. Results Overall, a time reduction of 47% in the 10MWT, self-selected speed (10MWTsss) (< 50 years = 56% vs ≥ 50 years = 37%) and an increase of 50% in the 6MinWT were documented. The WISCI II scores showed a mean gain of 1.69 levels. At the end of the study, 24 of 55 patients (43.6%) were less dependent on walking aids. Age had a nonsignificant negative influence on the 10MWTsss. Despite a few nonsignificant subgroup differences, participants improved across all tests. Namely, patients with iSCI who had spastic motor behavior improved to a nonsignificant, lesser extent in the 6MinWT. Conclusions The HAL-assisted treadmill training leads to functional improvements in chronic iSCI or cSCI, both in and out of the exoskeleton. An improvement of approximately 50% in the 10MWTsss and in gait endurance (6MinWT) can be expected from such training. The influences of SCI lesion level and age on functional outcome were nonsignificant in the present study. Older age (≥ 50 years) may be associated with smaller improvements in the 10MWTsss. An iSCI in paraplegic patients with spastic motor behavior may be a nonsignificant negative predictor in gait endurance improvements. Clinical trial registration no.: DRKS00010250 ( https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_DE.do ).

Historical Perspective of Split Cord Malformations: A Tale of Two Cords.

INTRODUCTION: Our appreciation and understanding of what is now known as the split cord malformation (SCM) have a long history. The oldest known example of SCM is from roughly AD 100. Other isolated examples can be found in the large body of work of the pathologists of the 1800s, where the SCMs were found incidentally during autopsies. CONCLUSIONS: SCM has a rich history and has intrigued physicians for over 200 years. Many well-known figures from the past such as Chiari and von Recklinghausen, both pathologists, made early postmortem descriptions of SCM. With the advent of MRI, these pathological embryological derailments can now often be detected and appreciated early and during life. Our understanding and ability to treat these congenital malformations as well as the terminology used to describe them have changed over the last several decades.

Pediatric Hangman's Fracture: A Comprehensive Review.

PURPOSE: Over 170 years ago, traumatic spondylolisthesis of the axis or hangman's fracture was described. Most descriptions of this entity have focused on adult presentations. METHODS: We review the literature on pediatric cases of hangman's fracture emphasizing the embryological as well as presentation aspects. RESULTS: The majority of cervical spine fractures in children occur at C1 and C2 vertebrae. A normal anterolisthesis of C2 can be seen in younger children and can mimic the anterolisthesis seen after traumatic spondylolisthesis. CONCLUSIONS: Traumatic spondylolisthesis of the axis in children requires further investigation due to the current emphasis in the literature on adult clinical findings and diagnostic challenges from the developmental immaturity of the pediatric skeleton.

Cervical Spine Aneurysmal Bone Cysts in the Pediatric Population: A Systematic Review of the Literature.

Cervical spine aneurysmal bone cysts (ABCs) in pediatric patients have not been thoroughly studied. Using PubMed and Google Scholar, a systematic review of the literature was conducted for publications that included patients aged ≤15 years with a confirmed diagnosis of ABC in the cervical spine. Thirty-five studies with a total of 71 patients met the inclusion criteria. Nearly 80% of patients presented with neck or shoulder pain. The axis was the level most frequently involved (34.28%), followed by C5 (24.28%). Posterior elements were most likely to be affected (88.46%) while exclusive involvement of the body was uncommon. To our knowledge, this is the first systematic review of the literature regarding ABCs of the cervical spine in a pediatric population. Spinal ABCs are rarely found in the cervical region, and their treatment remains challenging due to their location, vascularization, and a high overall recurrence rate even with surgical resection.

Skull Base and Cervical Spine Involvement in Jansen Syndrome: Case Report.

INTRODUCTION: Metaphyseal chondrodysplasia, Jansen type (JMD), is a rare form of endochondral ossification resulting in short limbs and dwarfism. CASE REPORT: A child presented with JMD and was found to have involvement of the cervical spine. Conservative treatment was given to the patient who at the long-term follow-up continues to have no neurological findings or cervical spine instability. CONCLUSIONS: To our knowledge, this case represents the first report of involvement of the superior cervical spine in a patient with JMD. Clinicians should be aware of this potential albeit rare finding.

Parotid Branches of the Auriculotemporal Nerve: An Anatomical Study With Implications for Frey Syndrome.

The auriculotemporal nerve is one of the many branches of the mandibular division of the trigeminal nerve. Of these, its superficial temporal branch has been most described. Although the parotid branches, secretomotor fibers to the parotid gland, are well known as the cause of Frey syndrome, there have been almost no descriptions of their anatomy. In this study, the authors dissected the parotid branches of the auriculotemporal nerve to elucidate their anatomy. A total of 10 sides from 7 adult and embalmed cadaver heads were used in this study. The specimens were derived from 3 males and 4 females, the age of cadavers at death ranged from 65 to 92 years old. Measurements included their diameter and the distance of their branching point from the main trunk of the auriculotemporal nerve from the middle of the tragus. Three of 10 sides had 2 parotid branches and 7 sides were found to have 1 parotid branch. The vertical distance between middle of the tragus to branching point of the parotid branch ranged from 1.79 to 16.17 mm. The horizontal distance between middle of the tragus to branching point of the parotid branch ranged from 3.03 to 12.62 mm. The diameter of the parotid branch ranged from 0.31 to 0.49 mm. An improved knowledge of the parotid branch of the auriculotemporal nerve might decrease injury to these structures with the potential for postoperative.

Anatomical complications of epidural anesthesia: A comprehensive review.

Epidural anesthesia is a versatile technique widely used in treating lumbar spinal pain syndromes. Complications during these procedures can arise either from needle placement or from administration of medication. Potential risks include infection, hematoma, intravascular or subdural injections of medication, direct nerve trauma, air embolism, entry into a disc space, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar epidural injections and discuss the potential pitfalls related to these procedures. We searched Medline comprehensively for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all of them can be avoided by careful techniques with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging. Clin. Anat. 30:342-346, 2017. © 2017 Wiley Periodicals, Inc.

A novel treatment for keratitis sicca (Dry eye): Anatomical feasibility study.

Chronic dry eye (keratitis sicca) is a significant problem that in certain populations can result in corneal desiccation and the potential for blindness. Therefore, novel treatments for such disorders might decrease patient morbidity. The present study aimed to investigate a potential treatment for chronic dry eye via a cadaveric feasibility study. On 10 cadaveric sides, the parotid gland branch of the auriculotemporal nerve (ATN) was identified and anastomosed to an anterior superficial temporal branch (STb) of this same nerve. The STb was then transposed anteriorly and sutured to the lacrimal gland. The parotid branch of the ATN was easily identified on all sides. The STb of the ATN was easily identified and mobilized on all sides. This latter nerve had adequate length to be moved to the ipsilateral lacrimal gland on all sides. Rerouting parotid gland secretomotor fibers to the superficial branch of the ATN and then moving this branch to the lacrimal gland is a feasible surgical maneuver based on our cadaveric study. Clinical studies are now necessary to show utility of this procedure in patients with chronic dry eye. Clin. Anat. 30:839-843, 2017. © 2017Wiley Periodicals, Inc.

New supplemental landmark for the greater palatine foramen as found deep to soft tissue: application for the greater palatine nerve block.

PURPOSE: Many researches have investigated the morphology of the greater palatine foramina using dry skulls and cone-beam computed tomography. In most studies, some structures in the hard tissue have been measured and statistically analyzed. However, none of the studies has analyzed this foramen in regard to its location with overlying soft tissues, which is so clinically relevant. Therefore, this study was performed to provide the knowledge about relationship between the greater palatine foramen and foveola palatina for a better understanding of dental procedures such as greater palatine nerve block. METHODS: Thirty sides, from fifteen fresh cadaveric heads, were used in this study. The specimens were derived from eight males and seven females. A 27-gauge needle was inserted into the fossa, which was palpated at the edge of a dental mirror at a 45° angle to the occlusal plane and parallel to the sagittal plane. The anteroposterior distance, which was parallel to the midline, between the penetration site and foveola palatina was measured. RESULTS: All the penetrations advanced to the greater palatine foramen. The distances ranged from 2.0 to 8.3 mm on right sides, and 1.1 to 8.2 mm on left sides, respectively. CONCLUSION: The results of this study could help dentists identify the correct location of the greater palatine foramen with a supplemental landmark.

Communicating branches between lingual and hypoglossal nerve: observation using Sihler's staining technique.

PURPOSE: Many dental procedures are at risk of injuring the lingual nerve. We performed this study to better elucidate the microanatomy that exists between the ipsilateral lingual and hypoglossal nerves so that iatrogenic injury can be avoided. METHODS: Adult human cadaveric tongues (ten sides) underwent Sihler's staining to identify the microanatomy between the lingual and hypoglossal nerves. RESULTS: The lingual nerve entered the middle part of the anterior two-thirds of the tongue from its lateral side and divided into two to four thick branches. These branches were then disseminated to the anterior, middle, and posterior parts of the anterior two-thirds of the tongue via 7-14 thin nerve bundles as terminal branches. The hypoglossal nerve entered the tongue at the posterior border of its anterior two-thirds and traveled forward to the apex of the tongue on all sides. All specimens were found to have communicating branches between the lingual and hypoglossal nerves at its anterior, middle, and posterior thirds. CONCLUSIONS: Our results indicate that the ipsilateral lingual and hypoglossal nerves constantly have three connections on each side between them. This knowledge might aid the dentist in minimizing iatrogenic nerve injury.

Bergmann's ossicle (ossiculum terminale persistens): a brief review and differentiation from other findings of the odontoid process.

PURPOSE: The purpose of this paper was to review the literature on Bergmann's ossicle and provide an overview on its development, etiology, and clinical presentation while also differentiating it from similar structural anomalies. METHODS: A thorough review of the literature available on Bergmann's ossicle was performed. RESULTS: Bergmann's ossicle, also referred to as ossiculum terminale persistens, was defined as a developmental anomaly of the odontoid process in which an ossification center that gives rise to the tip of the dens fails to fuse properly with the body of the axis. CONCLUSION: Bergmann's ossicle is most often a benign condition, although it rarely may present with clinical symptoms such as neck pain and neurological signs. It may be associated with Down's syndrome and contribute to atlantoaxial instability.

Hemivertebrae: a comprehensive review of embryology, imaging, classification, and management.

PURPOSE: The purpose of this paper was to comprehensively review hemivertebrae in regard to their classification, embryology, etiology, diagnosis, clinical manifestations, and management of this developmental anomaly. METHODS: This subject review of hemivertebrae was composed after conducting a thorough review of the available literature on this topic using PubMed and other standard search engines. RESULTS: Hemivertebrae are incomplete vertebral column segments that can result in congenital scoliosis and be associated with a range of other structural anomalies. Presentations may differ and based on location and classification, treatments may vary. CONCLUSION: Hemivertebrae are structural anomalies of the vertebral column that can potentially disrupt the spine's normal curvature. Their clinical impact depends on factors such as degree of segmentation and concurrence with other structural anomalies. It is hoped that this review will provide the clinician who treats patients with hemivertebrae a resource in better understanding this finding and its subsequent pathological effects.

The Chiari 3.5 malformation: a review of the only reported case.

INTRODUCTION: In 1894, Giuseppe Muscatello described what we believe to be the only case of an occipitocervical encephalocele with a communication to the stomach. This case and its history and context compared to the Chiari 3 malformation as described 3 years earlier by Hans Chiari are presented. CONCLUSIONS: Based on the uniqueness of this case, we propose the term Chiari 3.5 malformation be used to describe its anatomical derailment.

A history of the autonomic nervous system: part I: from Galen to Bichat.

INTRODUCTION: The development of our current understanding of the autonomic nervous system has a rich history with many international contributors. CONCLUSIONS: Although our thoughts of an autonomic nervous system arose with the Greeks, the evolution and final understanding of this neural network would not be fully realized until centuries later. Therefore, our current knowledge of this system is based on hundreds of years of hypotheses and testing and was contributed to by many historic figures.

A history of the autonomic nervous system: part II: from Reil to the modern era.

INTRODUCTION: The history of the study of the autonomic nervous system is rich. At the beginning of the nineteenth century, scientists were beginning to more firmly grasp the reality of this part of the human nervous system. CONCLUSIONS: The evolution of our understanding of the autonomic nervous system has a rich history. Our current understanding is based on centuries of research and trial and error.

Next Level in Computed Tomography-Guided Periradicular Infiltration Therapy: Same Efficiency with Less Radiation Exposure.

OBJECTIVE: This retrospective cohort study investigated the radiation exposure and clinical efficiency of a new institutional low-dose protocol for computed tomography (CT)-guided lumbar periradicular infiltration (PRI). METHODS: This was a retrospective matched-pair comparison of patients undergoing single-level lumbar PRI therapy employing a new low-dose CT protocol consisting of a helical scan with reduced energy levels and tube current versus the institutional standard CT protocol. The following variables were collected: dose-length product for the planning step, interventional step, and total examination, number of CT guidance scans, examination time, and postprocedural improvement on the numerical rating scale for radicular pain. RESULTS: Forty-five patients were allocated to each group. A sufficient radiation dose reduction of 30% during PRI was achieved with the low-dose protocol with a median dose-length product of 9.8 mGy∗cm compared to 32.9 mGy∗cm with the standard protocol (P < 0.001). No need for additional multiple scans during the interventional mode was observed in the low-dose group, resulting in a comparable procedure time between the groups. Furthermore, the short-term pain-reducing effect of PRI was comparable between the low-dose and standard protocols (median delta numerical rating scale = 4 in both groups). CONCLUSIONS: Our low-dose protocol with less tube voltage and lower electric current leads to less radiation exposure with the same safety and efficiency. In conclusion, every facility that performs CT-based procedures should check whether a further dose reduction is applicable to avoid stochastic radiation damage to the patient.