Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases.
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Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension. (+info)
Orthopaedic features in the presentation of syringomyelia.
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The orthopaedic surgeon is often the first consultant to whom a patient with syringomyelia is referred. The disease is not as rare as he may suppose, but its early presenting features are very variable; if he relies solely on such familiar features as pes cavus and scoliosis, he may well miss the diagnosis. The commonest presenting symptom is pain in the head, neck, trunk or limbs; headache or neckache made worse by straining is particularly significant. A history of birth injury also may suggest the possibility of syringomyelia, especially if any spasticity subsequently worsens. Neurological features which may be diagnostic include nystagmus, dissociated sensory loss, muscle wasting, spasticity of the lower limbs or Charcot's joints. Radiographic features include erosion of the bodies of cervical vertebrae and widening of the spinal canal; if, at C5, the size of the canal exceeds that of the body by 6 millimetres in the adult, pathological dilatation is present. The presence of basilar invagination or other abnormalities of the foramen magnum, of spina bifida occulta and of scoliosis are further pointers. Thermography is a useful way of showing asymmetrical sympathetic involvement in early cases. A greater awareness of the prevalence of syringomyelia may lead to earlier diagnosis and to early operation, which appears to hold out the best hope of arresting what is all too commonly a severely disabling and progressive condition. (+info)
Multiple meningiomas within the spinal canal: case report with 23 tumors.
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In most series of neoplasms of the spinal canal, spinal cord and its leptomeninges, the incidence of meningioma group comprises approximately 25%. The incidence of multiple meningiomas is small when compared with the frequency of its single occurrence. In the majority of cases, their multiplicity is intracranial and spinal. Multiple meningiomas confined exclusively to the spinal canal are extremely rare. We report on a 33 years-old man, with 23 tumors located in the spinal thoracic region. (+info)
A morphological comparison of cervical spondylotic myelopathy: MRI and dissection findings.
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The number of people with functional disabilities has been increasing with the rapid changes of age structure in the overall population. One of the major causes of disturbances in daily activities is cervical spondylotic myelopathy (CSM). The transverse area and sagittal diameter of the spinal cord measured by MRI is reported to correlate with the clinical manifestations of CSM, the duration of the disease, and the speed of recovery after surgery in patients with CSM. The purpose of this research is to determine the morphological characteristics of CSM as seen in MRI findings including the spinal cord sagittal diameter, transverse diameter, transverse area and flatness ratio. Twenty-eight of several patients with CSM were treated conservatively after carrying out measurements by MRI. In addition, anatomical studies were carried out on the spinal cords after anatomical dissection of the vertebral column in seven cadavers with CSM. These results, when compared with the morphological analysis of the cervical spinal cord, show that there is a correlation between the transverse areas at C4, C5 and C6 levels, as those at every level of the cervical transverse areas of tissue sections in the dissection cadavers were 10-18% smaller than those in the MRI patients. These results should be taken into account for the treatment of CSM patients. (+info)
Objective assessment of reduced invasiveness in MED. Compared with conventional one-level laminotomy.
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Microendoscopic discectomy (MED) has been accepted as a minimally invasive procedure for lumbar discectomy because of the small skin incision and short hospital stay required for this surgery. However, there are few objective laboratory data to confirm the reduced systemic responses in the early phase after this procedure. In order to substantiate the reduced invasiveness of MED compared to microdiscectomy (MD) or procedures involved in one-level unilateral laminotomy, the invasiveness of each surgical procedure was evaluated by measuring serum levels of biochemical parameters reflective of a post-operative inflammatory reaction and damage to the paravertebral muscles. Thirty-three patients who underwent lumbar discectomy or one-level unilateral laminotomy (MED in 15 cases, MD in 11 cases and one-level unilateral laminotomy in 7 cases with lumbar spinal canal stenosis) were included in this study. The serum levels of C-reactive protein (CRP) and creatine phosphokinase (CPK) were measured at 24 h after operation. Interleukin-6 (IL-6) and Interleukin-10 (IL-10) were measured at 2, 4, 8 and -24 h following the surgery to monitor the inflammatory response to the respective surgery. The post-operative serum CRP levels from both the MD and MED groups were significantly lower than those from the open laminotomy group. However, there was no significant difference in these serum levels between the MED and MD groups. The levels of IL-6 and IL-10 in the MED group during the first post-operative day were also significantly lower than those in the laminotomy group. When the MED and MD groups were compared, the IL-6 levels in the MED group were lower than in MD group at 2, 4 and 8 h after surgery, but the differences were not statistically significant. However, the level was significantly lower in the MED group at 24 h after surgery. In terms of IL-10, no significant difference was noted between the MED and MD groups over the study period. The changes in serum levels of post-operative inflammatory: markers (CRP, IL-6 and IL-10) in the early phase indicated reduced inflammatory reactions in MED as well as in MD when compared with classical open unilateral laminotomy. These data draw a direct link between the lower level of the inflammatory response and reduced invasiveness of MED. However, an indicator for muscle damage (CPK) appeared not to be affected by the type of surgical procedure used to correct disc herniation. (+info)
Standard-risk medulloblastoma treated by adjuvant chemotherapy followed by reduced-dose craniospinal radiation therapy: a French Society of Pediatric Oncology Study.
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OBJECTIVE: The primary objective of this study was to decrease the late effects of prophylactic radiation without reducing survival in standard-risk childhood medulloblastoma. PATIENTS AND METHODS: Inclusion criteria were as follows: children between the ages of 3 and 18 years with total or subtotal tumor resection, no metastasis, and negative postoperative lumbar puncture CSF cytology. Two courses of eight drugs in 1 day followed by two courses of etoposide plus carboplatin (500 and 800 mg/m(2) per course, respectively) were administered after surgery. Radiation therapy had to begin 90 days after surgery. Delivered doses were 55 Gy to the posterior fossa and 25 Gy to the brain and spinal canal. RESULTS: Between November 1991 and June 1998, 136 patients (median age, 8 years; median follow-up, 6.5 years) were included. The overall survival rate and 5-year recurrence-free survival rate were 73.8% +/- 7.6% and 64.8% +/- 8.1%, respectively. Radiologic review showed that 4% of patients were wrongly included. Review of radiotherapy technical files demonstrated a correlation between the presence of a major protocol deviation and treatment failure. The 5-year recurrence-free survival rate of patients included in this study with all optimal quality controls of histology, radiology, and radiotherapy was 71.8% +/- 10.5%. In terms of sequelae, 31% of patients required growth hormone replacement therapy and 25% required special schooling. CONCLUSION: Reduced-dose craniospinal radiation therapy can be proposed in standard-risk medulloblastoma provided staging and radiation therapy are performed under optimal conditions. (+info)
Spinal canal narrowing during simulated frontal impact.
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Between 23 and 70% of occupants involved in frontal impacts sustain cervical spine injuries, many with neurological involvement. It has been hypothesized that cervical spinal cord compression and injury may explain the variable neurological profile described by frontal impact victims. The goals of the present study, using a biofidelic whole cervical spine model with muscle force replication, were to quantify canal pinch diameter (CPD) narrowing during frontal impact and to evaluate the potential for cord compression. The biofidelic model and a sled apparatus were used to simulate frontal impacts at 4, 6, 8, and 10 g horizontal accelerations of the T1 vertebra. The CPD was measured in the intact specimen in the neutral posture (neutral posture CPD), under static sagittal pure moments of 1.5 Nm (pre-impact CPD), during dynamic frontal impact (dynamic impact CPD), and again under static pure moments following each impact (post-impact CPD). Frontal impact caused significant (P<0.05) dynamic CPD narrowing at C0-dens, C2-C3, and C6-C7. The narrowest dynamic CPD was observed at C0-dens during the 10 g impact and was 25.9% narrower than the corresponding neutral posture CPD. Interpretation of the present results indicate that the neurological symptomatology reported by frontal impact victims is most likely not due to cervical spinal cord compression. Cord compression due to residual spinal instability is also not likely. (+info)
Lumbar disk herniation with contralateral symptoms.
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The aim of the study is to determine if leg pain can be caused by contralateral lumbar disk herniation and if intervention from only the herniation side would suffice in these patients. Five patients who had lumbar disk herniations with predominantly contralateral symptoms were operated from the side of disk herniation without exploring or decompressing the symptomatic side. Patients were evaluated pre- and postoperatively. To our knowledge, this is the first reported series of such patients who were operated only from the herniation side. The possible mechanisms of how contralateral symptoms predominate in these patients are also discussed. In all patients, the shape of disk herniations on imaging studies were quite similar: a broad-based posterior central-paracentral herniated disk with the apex deviated away from the side of the symptoms. The symptoms and signs resolved in the immediate postoperative period. Our data clears that sciatica can be caused by contralateral lumbar disk herniation. When operation is considered, intervention only from the herniation side is sufficient. It is probable that traction rather than direct compression is responsible from the emergence of contralateral symptoms. (+info)