Journal of neurosurgery. Spine
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In this, the first of two articles regarding C1-2 transarticular screw fixation, the authors assessed the rate of fusion, surgery-related complications, and lessons learned after C1-2 transarticular screw fixation in an adult patient series. ⋯ Based on this series, the authors have learned important lessons that can improve outcomes and safety. These include techniques to improve screw-related patient positioning, development of optimal instrumentation, improved screw materials and design, and defining the role for stereotactic navigation. Atlantoaxial transarticular screw fixation is highly effective in achieving fusion, and the complication rate is low when performed by properly trained surgeons.
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The pathophysiology of syringomyelia is still not well understood. Current prevailing theories involve the assumption that cerebrospinal fluid (CSF) flows into the syrinx from the subarachnoid space through the perivascular space of Virchow-Robin. Reported here is the case of a patient with syringomyelia in which this course is clearly contradicted. ⋯ The medium-pressure shunt valve was replaced with an adjustable valve with a higher closing pressure setting, thus increasing the CSF pressure in the subarachnoid space. Contrary to prevailing theories, this procedure markedly reduced the size of the syrinx. This case provides direct evidence that the syrinx size is inversely related to subarachnoid CSF pressure and supports the hypothesis that the pressure gradient across the spinal cord parenchyma is the force that generates syringes in syringomyelia.
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Because lumbar magnetic resonance (MR) imaging fails to identify a treatable cause of chronic sciatica in nearly 1 million patients annually, the authors conducted MR neurography and interventional MR imaging in 239 consecutive patients with sciatica in whom standard diagnosis and treatment failed to effect improvement. ⋯ This Class A quality evaluation of MR neurography's diagnostic efficacy revealed that piriformis muscle asymmetry and sciatic nerve hyperintensity at the sciatic notch exhibited a 93% specificity and 64% sensitivity in distinguishing patients with piriformis syndrome from those without who had similar symptoms (p < 0.01). Evaluation of the nerve beyond the proximal foramen provided eight additional diagnostic categories affecting 96% of these patients. More than 80% of the population good or excellent functional outcome was achieved.
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Recurrent laryngeal nerve (RLN) palsy is a well-known complication of cervical spine surgery. Nearly all previous studies were performed without laryngoscopy in asymptomatic patients. This prospective study was undertaken to discern the true incidence of RLN palsy. Because not every RLN palsy is associated with hoarseness, the authors conducted a prospective study involving the use of pre- and postoperative laryngoscopy. ⋯ Laryngoscopy revealed that the true incidence of initial and persisting RLN palsy after anterior cervical spine surgery was much higher than anticipated. Especially in cases without hoarseness this could be proven, but the initial incidence of hoarseness was higher than expected. Only one third of new RLN palsy cases could be detected without laryngoscopy. Resolution of hoarseness was approximately 70% in those with preoperative hoarseness. The true rate of RLN palsy underscores the necessity to reevaluate the surgery- and intubation-related techniques for anterior cervical spine surgery and to reassess the degree of presurgical patient counseling.
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Despite the fact that gout is a common metabolic disorder, because its involvement of the axial skeleton is rare the diagnosis is often delayed, even in patients with long-standing gout who present with neurological deficits. The authors report the case of a woman with a history of extensive gout, emphasizing the clinical, radiological, and pathological features of a lumbar spinal stenosis.