Spinal dural arteriovenous fistula formation after scoliosis surgery: case report

Spinal dural arteriovenous fistulas are diagnostically challenging lesions, and they are not well described in patients with a history of a spinal deformity correction. The authors present the challenging case of a 74-year-old woman who had previously undergone correction of a spinal deformity with subsequent revision. Several years after the last deformity operation, she developed a progressive myelopathy with urinary incontinence over a 6-month period. After evaluation at the authors\u27 institution, an angiogram was obtained, demonstrating a fistula at the T12-L1 region. Surgical ligation of the fistula was performed with subsequent improvement of the neurological symptoms. This case is thought to represent the first fistula documented in an area of the spine that had previously been operated on, and to the authors\u27 knowledge, it is the first case report to be associated with spinal deformity surgery. A brief historical overview and review of the pathophysiology of spinal dural arteriovenous fistulas is also included

Posterior Cervical Decompression and Instrumented Fusion for Cervical Spondylotic Myelopathy: 2-Dimensional Operative Video

Cervical spondylotic myelopathy is a common cause of progressive quadriparesis in adults. It is characterized by compression of the cervical spinal cord due to degenerative changes including intervertebral disc protrusion, ligamentum flavum hypertrophy, and osteophyte formation. Clinically, patients can present with declining motor control in the extremities, gait imbalance, spasticity, hyperreflexia, or possibly frank weakness. Surgical treatment options include ventral and dorsal approaches, whose indications vary depending on spinal alignment, number of levels requiring decompression, the dorsal/ventral/circumferential location of compression, and patient-specific anatomic constraints. Posterior cervical decompression and instrumented fusion is a mainstay of treatment for cervical spondylotic myelopathy when a dorsal approach is indicated. In this video, we present a case of a 60-yr-old female who presented with signs and symptoms of cervical myelopathy, with MRI findings of C3 on C4 anterolisthesis and circumferential central stenosis worst at C4-5 and C5-6. We demonstrate the operative steps to complete a C3 to C6 decompression and instrumented fusion with lateral mass screws. Appropriate patient consent was obtained

Repair of Thoracic Spinal Cord Herniation: 2-Dimensional Operative Video

Spinal cord herniation is an uncommon surgically treatable cause of thoracic myelopathy and progressive paraplegia. The thoracic spinal cord focally protrudes through a defect in the dura, resulting in progressive weakness, numbness, and spasticity affecting the lower extremities, in addition to possible urinary symptoms. In this video, we present the case of a 69-yr-old female who presented with 3 yr of progressive thoracic myelopathy due to a thoracic spinal cord herniation at T4-T5. We demonstrate the surgical steps to lyse arachnoid webs, mobilize the spinal cord, reduce the spinal cord herniation, and repair the dural defect. Appropriate patient consent was obtained

Repair of Thoracic Spinal Cord Herniation: 2-Dimensional Operative Video

Spinal cord herniation is an uncommon surgically treatable cause of thoracic myelopathy and progressive paraplegia. The thoracic spinal cord focally protrudes through a defect in the dura, resulting in progressive weakness, numbness, and spasticity affecting the lower extremities, in addition to possible urinary symptoms. In this video, we present the case of a 69-yr-old female who presented with 3 yr of progressive thoracic myelopathy due to a thoracic spinal cord herniation at T4-T5. We demonstrate the surgical steps to lyse arachnoid webs, mobilize the spinal cord, reduce the spinal cord herniation, and repair the dural defect. Appropriate patient consent was obtained

Lumbar Laminoplasty for Resection of Myxopapillary Ependymoma of the Conus Medullaris: 2-Dimensional Operative Video

Myxopapillary ependymomas are slow-growing tumors that are located almost exclusively in the region of the conus medullaris, cauda equina, and filum terminale of the spinal cord. Surgical intervention achieving a gross total resection is the main treatment modality. If, however, a gross total resection cannot be achieved, surgery is augmented with radiation therapy. In this video, we present the case of a 27-yr-old male with persistent back pain and radiculopathy who was found to have a myxopapillary ependymoma that was adherent to the conus. Preoperative imaging demonstrated that the tumor was displacing the conus and nerve roots ventrally. A laminoplasty at L1-L2 was performed with near-total resection because of the intimate involvement of neural tissue. The key features of the video include performing laminoplasty and rationale, and performing maximum safe tumor resection with a combination of bipolar cautery, suction, and ultrasonic aspiration augmented with frequent stimulation, gel foam pledgets intradurally, and achieving a watertight closure of the dura and fascia. The patient tolerated the surgery well without any complications. Given his gross residual disease along the conus and young age, he was at a high risk for continued tumor growth without adjuvant therapy, with a recurrence rate of roughly 33% to 45% in patients who underwent subtotal resection. With the addition of adjuvant radiation therapy, the recurrence rate is 20% to 29%.1,2 He was discharged to home with a plan for conventional fractionated external beam radiation. At the most recent follow-up, he reported decreased back pain and radiculopathy. Appropriate patient consent was obtained

Lumbar Lateral Recess Decompression: 2-Dimensional Operative Video

Lateral recess stenosis is a common cause of lumbar radiculopathy in adults. A lumbar nerve root travels in the lateral recess prior to exiting the spinal canal via the neural foramen. In the lateral recess, the traversing nerve root is susceptible to compression by the degenerative hypertrophy of the medial facet in addition to hypertrophied ligamentum flavum and herniated intervertebral disc.1 These degenerative changes are also typically associated with neural foraminal stenosis. Surgical treatment in unilateral cases consists of hemilaminectomy, medial facetectomy, foraminotomy, and, if applicable, microdiscectomy. In this video, we present a case of a 64-yr-old male presenting with progressive left L5 radiculopathy refractory to conservative management, with magnetic resonance imaging (MRI) findings of left L4-5 foraminal and lateral recess stenosis. We demonstrate the operative steps to complete a left L4-5 hemilaminectomy, medial facetectomy, foraminotomy, and microdiscectomy. Appropriate patient consent was obtained

The impact of blood pressure management after spinal cord injury: a systematic review of the literature

OBJECTIVE Spinal cord injury (SCI) results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, blood pressure (BP) augmentation has been advocated. The objective of this study was to review the evidence behind BP management after SCI. METHODS This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using the PubMed database, the authors identified studies that investigated BP management after acute SCI. Information on BP goals, duration of BP management, vasopressor selection, and neurological outcomes were analyzed. RESULTS Eleven studies that met inclusion criteria were identified. Nine studies were retrospective, and 2 were single-cohort prospective investigations. Of the 9 retrospective studies, 7 reported a goal mean arterial pressure (MAP) of higher than 85 mm Hg. For the 2 prospective studies, the MAP goals were higher than 85 mm Hg and higher than 90 mm Hg. The duration of BP management varied from more than 24 hours to 7 days in 6 of the retrospective studies that reported the duration of treatment. In both prospective studies, the duration of treatment was 7 days. In the 2 prospective studies, neurological outcomes were stable to improved with BP management. The retrospective studies, however, were contradictory with regard to the correlation of BP management and outcomes. Dopamine, norepinephrine, and phenylephrine were the agents that were frequently used to augment BP. However, more complications have been associated with dopamine use than with the other vasopressors. CONCLUSIONS There are no high-quality data regarding optimal BP goals and duration in the management of acute SCI. Based on the highest level of evidence available from the 2 prospective studies, MAP goals of 85-90 mm Hg for a duration of 5-7 days should be considered. Norepinephrine for cervical and upper thoracic injuries and phenylephrine or norepinephrine for mid- to lower thoracic injuries should be considered