Brain & spine最新文献

Introduction: Primary dedifferentiated liposarcomas of the spine mark a rare tumor entity.

Research question and case description: We present a rare case of a primary dedifferentiated liposarcoma of the thoracic spine. A 36-year-old previously completely healthy woman presented with a sudden ascending paresthesia of both legs, persistently increasing over the course of two days before initial presentation.

Case report: Computed tomography and magnetic resonance imaging revealed an expansively growing tumor mass extending from T5 to T6 and absolutely compressing the dural sac and spinal cord. The patient's neurological function completely recovered after emergency posterior decompression via laminectomy with intralesional tumor debulking. The tumor was histologically classified as primary grade 2 dedifferentiated liposarcoma (DDLPS) of the spine and after referral to a sarcoma center, the patient was treated with three courses of polychemotherapy (doxorubicin plus ifosfamide). Chemotherapy was followed by aggressive resection by en-bloc spondylectomy in cooperation with a spine tumor center. Subsequently, the patient also underwent radiation therapy.

Results: The patient still undergoes structured tumor aftercare and is tumor- and metastasis-free 53 months after tumor resection.

Discussion and conclusion: DDLPS rarely occur in the spine, with definitive resection of the tumor being the treatment of choice. Surgery should be accompanied by other (radio-) oncological treatment options in cases where only subtotal resection is possible. Also, referral of patients with primary sarcomas of the spine to specialized sarcoma centers is essential, so they can be provided with individual treatment options and structured interdisciplinary aftercare, that ensure the best possible outcome.

Introduction: Epimuscular fat (EF) has rarely been studied in the context of low back pain (LBP).

Research question: This study aims to assess the presence and extent of EF in the lumbar muscles and its association with vertebral level in patients with low back disorders and to explore correlations between EF, demographics, BMI, and LBP.

Material and methods: T2 axial MRIs from L1 to L5 were manually segmented to analyze the cross-sectional area (CSA) of EF (mm²), and fat infiltration (FI,%) of 40 patients (23 females, 17 males; mean age:65.9 years) with lumbar degenerative pathologies awaiting a surgical procedure. COMI, LBP, demographic, and clinical data were extracted from the institutional registry. Statistical analyses included Wilcoxon and Mann-Whitney tests for differences in EF between sides and sexes, the Friedman test for EF size differences among lumbar levels, and Spearman's correlation for associations, adjusted for BMI, age, and sex.

Results: EF was found in 77.5% of subjects at L1, 92.5% at L2, 100% at L3 and L4, and 95.0% at L5. EF was significantly larger at L4 (253.1 ± 183.6 mm²) and L5 (220.2 ± 194.9 mm²) than at L1 (36.1 ± 37.8 mm²) and L2 (72.2 ± 84.4 mm²). No significant EF differences were found between sides and sexes. EF correlated strongly with BMI (r_s = 0.65,p < 0.001) and moderately with FI (r_s = 0.31,p = 0.04), though its correlation with FI was not significant after adjustment. EF did not correlate with COMI scores but correlated with LBP in the adjusted analysis (r_s:0.31,p = 0.04).

Discussion and conclusion: EF is present across all lumbar levels, with higher concentrations at L4 and L5, and a significant correlation between EF and LBP intensity was observed. The present findings are limited to a specific subset of patients with lumbar degenerative disorders who are awaiting surgical procedures.

Introduction: Neurosurgery is one of the rapidly evolving specialities of medical science, where the neurosurgeons have to provide evidence-based interventions in life threatening conditions maintaining the ethical standards.

Research question: This narrative review sheds light on the current hindrances of the ethical aspects of neurosurgical practice in low and middle-income countries (LMICs) and provide some feasible solutions for future.

Material and methods: A literature search was conducted using PubMed, Scopus and ISI web of knowledge focused on articles in English with the words "medical ethics" together with the words "neurosurgery", "ethical practice", "low and middle-income countries", "surgical innovation", "randomized clinical trials" and "outcome" alone or in combination.

Results: Due to the lack of neurosurgeons and essential infrastructures in LMICs, the practical application of medical ethics is more complicated in the field of neurosurgery. Main obstacles to conduct preclinical and clinical research in the LMICs are the lack of proper ethics committees, quality data, trained manpower and sufficient research funding. Implementation of randomized clinical trials (RCTs) is also difficult for the neurosurgeons working in LMICs.

Discussion and conclusion: To improve the situation, socio-economic development, including educating the citizens of these countries about their rights, functional regulatory bodies like medical and dental councils, teaching the neurosurgeons about the internationally recognized medical ethics, quality control regulations by the ministry of health and welfare, and more funding for the health care sectors are urgently needed. Global collaboration is needed to help the LMICs to provide their patients international but "customized" standard care.

Introduction: The integration of machine learning (ML) algorithms into the field of neurosurgery has the potential to facilitate the decision-making process for the surgeons, improve the surgical outcomes and the overall patient satisfaction rates. Reoperations for same level lumbar disc reherniation are associated with poorer outcomes and greater rate of complications.

Research question: Proper preoperative patient evaluation could reveal the individuals at higher risk of reherniation. A novel machine learning algorithm was used for the creation of a predictive scoring system for lumbar disc reherniation for patients requiring microdiscectomy without fusion.

Material and methods: Retrospective chart review was completed of all adult patients that underwent microdiscectomy without fusion for symptomatic single level LDH, in a single center, over the last 3 years. 230 patients met the inclusion criteria. 19 of them required a second surgical intervention due to same level reherniation.

Results: Utilizing the Risk-SLIM model, the Lumbar Reherniation Score (LRS) was created. The score's accuracy was tested against other model architectures, and a standard five-fold cross-validation was performed. The LRS has AUC of 0.87, confusion matrix accuracy of 0.74, Matthews correlation coefficient of 0.36 and informedness of 0.62. The LRS individual reherniation risk probability ranges from 0% to 88.1%.

Discussion and conclusion: The LRS is a novel, easy-to-use, patient-specific tool for preoperative prediction of the individual patient-specific risk of same level symptomatic reherniation following microdiscectomy. Further validation and testing of the model is needed before it can be used in real-life patient treatment.

Introduction: Lumbar disc herniation (LDH) and disc degeneration (DD) are associated with low back pain (LBP) and sciatica, which are common health problems. Emerging evidence suggests a link between vascular health, specifically abdominal aortic calcification (AAC) and systemic lipid profiles, and these spinal conditions.

Research question: This study investigates the associations between AAC, systemic lipid profiles, lumbar Modic Changes (MC), DD/LDH, and the occurrence of LBP or sciatica.

Material and methods: A literature search was performed (up to August 2023) in PubMed, Embase, Web of Science, Emcare, Cochrane Library, and Academic Search Premier utilizing a sensitive search strategy. Studies were chosen based on predefined criteria and assessed for bias using an adapted Cochrane checklist. Specifically, studies exploring the relationship between AAC or lipid status and DD/LDH and/or LBP/Sciatica were included.

Results: Twenty-seven studies were included. Eight studies assessed the association between atherosclerosis or lipid status and clinical LBP/sciatica, with four showing a positive association between AAC/lumbar artery stenosis and these conditions. Twenty-one studies assessed atherosclerosis and DD/LDH, with seven showing a positive association between AAC and DD/LDH. Eight trials found a positive association between lipid status and DD/LDH, and two trails identified ApoL1 as a biomarker for LDH recovery.

Discussion and conclusion: Evidence supports the hypothesis that inadequate blood supply contributes to disc degeneration, inflammation and clinical symptoms. Both local vascular issues and systemic lipid profiles appear to influence lumbar degeneration, highlighting the need for further research to better understand these relationships and develop preventive and therapeutic strategies.

Introduction: Postoperative spinal epidural hematoma (SEH) is a potentially devastating complication for patients and caregivers, and a leading cause for litigation in spine surgery. This article provides a literature review and the consensus statement of the Belgian Society of Neurosurgery (BSN) on the management of postoperative SEH.

Research question: Can we implement current evidence to establish a framework on the management of postoperative SEH?

Material and methods: Based on a Pubmed search, abstracts were screened for topics covering incidence, pathophysiology, risk factors, surveillance, diagnosis, treatment, and outcome. Relevant topics are presented in a narrative review format, followed by a consensus statement of the BSN with emphasis on rapid diagnosis and treatment.

Results: Symptomatic SEH is rare (0.3-1%) and can have an insidious onset with rapid progression to neurological deficits. Recurring risk factors are coagulation deficiencies and multilevel surgery. The protective effect of a postoperative drainage system is uncertain, and early thrombo-embolic prophylaxis does not increase the risk of SEH. Prognosis is dependent on residual neurological function and critically, on the time to reintervention. There is a need for structured neurological observation formats after spine surgery.

Discussion and conclusion: Symptomatic SEH after surgery is an unpredictable and severe complication requiring rapid action to maximize outcomes. The BSN proposes three nuclear terms central to SEH management, converging on a triple 'S': 1) high level of suspicion 2) speed of diagnosis and 3) immediate surgery. All spine centers can benefit from an institutional protocol in which SEH should be treated as an emergency.

Introduction: IgG4-related disease is an immune-mediated condition characterized by tissue infiltration of IgG4-positive plasma cells. Involvement of the spinal meninges results in hypertrophic spinal pachymeningitis (HSP), causing spinal cord and nerve root compression.

Research question and case description: In this review, we present a case of IgG4-related hypertrophic spinal pachymeningitis. Furthermore, we provide an updated literature review on IgG4-related HSP.

Materials and methods: We describe the case of a 45-year-old male presenting with cervical myelopathy. MR-imaging showed a ventrodorsal thickening of the meninges resulting in spinal cord compression. The patient underwent surgical decompression through laminectomy and excision of the dural thickening. The pathological findings demonstrated hypertrophic pachymeningitis with further examination showing large-scale dural infiltration of IgG4-positive lymphocytes. Adjuvant therapy with methylprednisolone and rituximab resulted in full neurological recovery with no signs of recurrence on MRI or clinically 12 months postoperatively.An updated review of the literature regarding IgG4-related HSP was performed according to PRISMA-guidelines. Relevant articles were searched from the PubMed, Web of Science and Embase databases. Patient characteristics, MRI- and histopathological findings, treatment modality and outcome were reviewed.

Results: The literature review provided a summary of 52 available cases, which included the one cases from our centre. Progressive worsening of neurological impairment was observed in 28 patients (58%). The lesions involved the thoracic spine (n = 33, 62.2%), cervical spine (n = 35, 70%), lumbar spine (n = 10, 20%), and sacral spine (n = 1, 2.2%). The dural thickening typically appeared as striated, fusiform, or oval changes, with homogeneous and patterns being the most common. Surgical decompression followed by immunosuppressive treatment was the main choice of therapy. The disease proved fatal in one case.

Discussion and conclusion: IgG4-related HSP usually affects the cervical and thoracic dura and therefore often presents with myelopathy. Surgical decompression in cases of neurological deficits may prevent permanent neurological impairment. Immunosuppressive therapy constitutes the cornerstone in the treatment IgG4-related HSP.