Journal of neurosurgery. Spine
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Review Case Reports
Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples.
The aim of this study was to review the Thoracolumbar Injury Classification and Severity Score (TLICS) and to demonstrate its application through a series of spine trauma cases. ⋯ By addressing both the posterior ligamentous integrity and the patient's neurological status, the TLICS system attempts to overcome the limitations of prior thoracolumbar classification systems. The TLICS system has demonstrated both validity and reliability and has also been shown to be readily learned and incorporated into clinical practice.
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Review Case Reports
Isolated unilateral hypoglossal nerve palsy secondary to an atlantooccipital joint juxtafacet synovial cyst.
Juxtafacet cysts of the atlantooccipital joint that present with isolated hypoglossal nerve palsy are rare and may mimic more common pathological entities. The authors report on the third such case in the literature and discuss the differential diagnosis, imaging hallmarks, preoperative recognition, and surgical management of this lesion, and provide a review of the literature. The authors discuss their experience with the treatment of a 67-year-old woman who presented with an isolated hypoglossal nerve palsy caused by a nonenhancing cystic septated lesion abutting the lateral medulla just medial to the left hypoglossal canal. ⋯ Failure to recognize this rare entity preoperatively resulted in unnecessary intradural exploration and cranial nerve morbidity. In retrospect, the preoperative diagnosis of this lesion was suggested by lack of central enhancement, absence of dumbbell formation and the presence of erosive synovial changes. Regardless, the extreme rarity of this lesion at this location will always make its recognition challenging.
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Randomized Controlled Trial
Intrathecal pressure monitoring and cerebrospinal fluid drainage in acute spinal cord injury: a prospective randomized trial.
Ischemia is an important factor in the pathophysiology of secondary damage after traumatic spinal cord injury (SCI) and, in the setting of thoracoabdominal aortic aneurysm repair, can be the primary cause of paralysis. Lowering the intrathecal pressure (ITP) by draining CSF is routinely done in thoracoabdominal aortic aneurysm surgery but has not been evaluated in the setting of acute traumatic SCI. Additionally, while much attention is directed toward maintaining an adequate mean arterial blood pressure (MABP) in the acute postinjury phase, little is known about what is happening to the ITP during this period when spinal cord perfusion pressure (MABP - ITP) is important. The objectives of this study were to: 1) evaluate the safety and feasibility of draining CSF to lower ITP after acute traumatic SCI; 2) evaluate changes in ITP before and after surgical decompression; and 3) measure neurological recovery in relation to the drainage of CSF. ⋯ The insertion of lumbar intrathecal catheters and the drainage of CSF were not associated with significant adverse events, although the cohort was small and only a limited amount of CSF was drained. Intraoperative decompression of the spinal cord results in an increase in the ITP measured caudal to the injury site. Increases in intrathecal pressure are additionally observed in the postoperative period. These increases in intrathecal pressure result in reduced spinal cord perfusion that will otherwise go undetected when measuring only the MABP. Characteristic changes in the observed intrathecal pressure waveform occur after surgical decompression, reflecting the restoration of CSF flow across the SCI site. As such, the waveform pattern may be used intraoperatively to determine if adequate decompression of the thecal sac has been accomplished.
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The use of pedicle screws (PSs) for stabilization of unstable thoracolumbar fractures has become the standard of care, but PS efficacy has not been reported in the upper thoracic spine. The primary outcome of this study was to determine the efficacy of PS fixation to achieve and maintain reduction of unstable upper thoracic spine fractures (T1-5). Secondary outcomes included scores on a 1-year postoperative generic health-related quality of life (QOL) questionnaire and postoperative complications. ⋯ In the hands of fellowship-trained spinal surgeons, PS fixation for reduction and stabilization of upper thoracic spine fractures is a safe and efficacious technique. Health-related QOL outcome data are deficient for spine trauma patients and should be an essential component of quantifying treatment outcomes.
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Magnetic resonance spectroscopy is commonly used to provide cellular and metabolic information in the management of a variety of pathological processes that affect the brain, and its application recently has been expanded to the cervical spine. The majority of radiographic investigations into the pathophysiology of cervical spondylotic myelopathy (CSM) have been focused on the spinal cord macrostructure. The authors sought to determine the feasibility of using MR spectroscopy to analyze spinal cord biochemical function in patients with CSM. ⋯ Data in this study demonstrated the feasibility of using MR spectroscopy to evaluate the cellular biochemistry of the spinal cord in patients with CSM. Patients with CSM had a significantly lower NAA/Cr ratio than healthy controls, likely because of axonal and neuronal loss. The presence of Lac peaks in one-third of the patients in the CSM cohort further supports the role of ischemia in the pathophysiology of CSM.