7th GENEVA SPINE COURSE Sagittal balance Master course

Anatomical workshop
SWISS Foundation for Innovation
and Training in Surgery
Sagittal balance is a complex topic. In order to understand the concepts, a different type of educational course is needed. This course is modeled on a European program, designed by Professor Jean Charles Le Huec, teaching at Bordeaux university medical school and past Eurospine (Spine Society of Europe) president and Dr Antonio Faundez, consultant at Geneva University Hospital.
A comprehensive approach of the balance concept will be presented.
The course is designed to introduce concepts slowly with adequate time for questioning and discussion before moving on to more advanced concepts.
It is mandatory for all participants to visit an e-learning website. You will receive an access code with the payment of your registration. There will be 5 sessions of 10 to 15 min each, which will provide you the basic knowledge that you should have, to be able to actively participate during the course.
There is a ‘hands on’ approach to measuring parameters on spinal X Rays and the use of a software for digital images. The speakers will provide their expertise through didactic presentations and clinical cases precisely selected.
The program will also include breakout session to discuss clinical cases and their treatment options, according to sagittal balance parameters.
All participants are requested to bring their own cases well documented in a ppt format for open discussion.

EANS Basic Spine Course

January 10, 2019 — January 11, 2019

LyonFrance

Message from Course Chairmen Prof. Torstein R. Meling and Prof. Cédric Barrey:

It is our pleasure to welcome you to the inaugural EANS Spinal Step II Hands-On Course in Lyon. The event will be held from January 10th – 11th 2019 and is organized in the Laboratoire d’Anatomie de la Faculté de Médecine de Lyon.

This dissection course is most suitable for neurosurgical residents in their last years of training as it will focus on the essential neurosurgical anatomy, the planning of surgical procedures, the handling of neurosurgical equipment, and the advanced neurosurgical spinal approaches.

This course will be limited to 24 participants.

Course dates: 10-11 January 2019

For more information please contact petra.koubova@eans.org.

Venue: Département Universitaire d’Anatomie, Faculté de Médecine Lyon Est, 8 avenue Rockefeller, 69373 Lyon Cedex 08

Curriculum: Participants will learn essential neurosurgical anatomy, planning of surgical procedures, handling of neurosurgical equipment, and advanced neurosurgical spinal approaches.

Preliminary programme available HERE.

Registration fees:
EANS Individual Member: €700
Non-Member: €800

The registration fee includes all tuition costs, subsitence during the course, two night accommodation and one networking event.

Accommodation:
Lagrange City Apparthotel
Lyon Lumiere
81-85, cours Albert Thomas
69003 LYON
France

View: The hotel website

NB: This is course is not part of the EUROSPINE equivalence programme. 

Neurologic Injury after Lateral Lumbar Interbody Fusion

Since the first description of LLIF in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications 1).

Hijji et al. published a systematic review analyzing the complication profile of LLIF. Their study included a total of 63 articles and 6819 patients. The most commonly reported complications were transient neurologic injury (36.07%). The clinical significance of those transient findings, however, is unclear since the rate of persistent neurologic complications was much lower (3.98%) 2)

The risk of lumbar plexus injury is particularly concerning at the L4-5 disc space. Although LLIF is associated with an increased prevalence of anterior thigh/groin pain as well as motor and sensory deficits immediately after surgery, our results support that pain and neurologic deficits decrease over time. The level treated appears to be a risk factor for lumbosacral plexus injury 3).

Interestingly, the use of rhBMP-2 was associated with higher rates of persistent motor deficits, which might be explained by a direct deleterious effect of this agent on the lumbosacral plexus 4).

In a retrospective chart review of 118 patients, Cahill et al. determined the incidence of femoral nerve injury, which is considered one of the worst neurological complications after LLIF. The authors reported an approximate 5% femoral nerve injury rate of all the LLIF procedures performed at L4-5. There were no femoral nerve injuries at any other levels 5).

During a 6-year time period of performing LLIF Aichmair et al., noted a learning curve with a decreasing proportional trend for anterior thigh pain, sensory as well as motor deficits 6)

Le et al. also observed a learning curve with a significant reduction in the incidence of postoperative thigh numbness during a 3-year period (from 26.1 to 10.7%) 7).

Levi AD from the University of Miami Hospital, adopted an exclusive mini-open muscle-splitting approach in LLIF with first-look inspection of the lumbosacral plexus nerve elements taht may improve motor and sensory outcomes in general and the incidence of postoperative groin/thighsensory dysfunction and psoas-pattern weakness in particular 8).

References

1)

Salzmann SN, Shue J, Hughes AP. Lateral Lumbar Interbody Fusion-Outcomes and Complications. Curr Rev Musculoskelet Med. 2017 Dec;10(4):539-546. doi: 10.1007/s12178-017-9444-1. Review. PubMed PMID: 29038952; PubMed Central PMCID: PMC5685966.
2)

Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J. 2017 Oct;17(10):1412-1419. doi: 10.1016/j.spinee.2017.04.022. Epub 2017 Apr 26. Review. PubMed PMID: 28456671.
3)

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.
4)

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.
5)

Cahill KS, Martinez JL, Wang MY, Vanni S, Levi AD. Motor nerve injuries following the minimally invasive lateral transpsoas approach. J Neurosurg Spine. 2012 Sep;17(3):227-31. doi: 10.3171/2012.5.SPINE1288. Epub 2012 Jun 29. PubMed PMID: 22746272.
6)

Aichmair A, Lykissas MG, Girardi FP, Sama AA, Lebl DR, Taher F, Cammisa FP, Hughes AP. An institutional six-year trend analysis of the neurological outcome after lateral lumbar interbody fusion: a 6-year trend analysis of a single institution. Spine (Phila Pa 1976). 2013 Nov 1;38(23):E1483-90. doi: 10.1097/BRS.0b013e3182a3d1b4. PubMed PMID: 23873231.
7)

Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi: 10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.
8)

Sellin JN, Brusko GD, Levi AD. Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach. World Neurosurg. 2019 Jan;121:e647-e653. doi: 10.1016/j.wneu.2018.09.180. Epub 2018 Oct 3. PubMed PMID: 30292030.

Traumatic spinal cord injury treatment

Early decompression surgery post-SCI can enhance patient outcomes, but does not directly facilitate neural repair and regeneration. Currently, there are no U.S. Food and Drug Administration-approved pharmacological therapies to augment motor function and functional recovery in individuals with traumatic SCI.

Acute traumatic spinal cord injury (SCI) is a devastating event with far-reaching physical, emotional, and economic consequences for patients, families, and society at large. Timely delivery of specialized care has reduced mortality; however, long-term neurological recovery continues to be limited. In recent years, a number of exciting neuroprotective and regenerative strategies have emerged and have come under active investigation in clinical trials, and several more are coming down the translational pipeline. Among ongoing trials are RISCIS (riluzole), INSPIRE study (Neuro-Spinal Scaffold), MASC (minocycline), and SPRING (VX-210). Microstructural MRI techniques have improved our ability to image the injured spinal cord at high resolution. This innovation, combined with serum and cerebrospinal fluid (CSF) analysis, holds the promise of providing a quantitative biomarker readout of spinal cord neural tissue injury, which may improve prognostication and facilitate stratification of patients for enrollment into clinical trials. Given evidence of the effectiveness of early surgical decompression and growing recognition of the concept that “time is spine,” infrastructural changes at a systems level are being implemented in many regions around the world to provide a streamlined process for transfer of patients with acute SCI to a specialized unit. With the continued aging of the population, central cord syndrome is soon expected to become the most common form of acute traumatic SCI; characterization of the pathophysiologynatural history, and optimal treatment of these injuries is hence a key public health priority. Collaborative international efforts have led to the development of clinical practice guidelines for traumatic SCI based on robust evaluation of current evidence 1).

1)

Badhiwala JH, Ahuja CS, Fehlings MG. Time is spine: a review of translational advances in spinal cord injury. J Neurosurg Spine. 2018 Dec 20;30(1):1-18. doi: 10.3171/2018.9.SPINE18682. Review. PubMed PMID: 30611186.

5 aminolevulinic acid fluorescence guided resection of spinal tumor

Multiple studies have attempted to evaluate the utility of 5-ALA-aided resection of spinal neoplasms.

Wainwright et al., from the Westchester Medical CenterTohoku University Hospital, reviewed the existing literature on the use of 5-ALA and PpIXfluorescence as an aid to resection of primary and secondary spinal neoplasms by searching the PUBMED and EMBASE database for records up to March 2018. Data was abstracted from all studies describing spinal neurosurgical uses in the English language.

In the reviewed studies, the most useful fluorescence was observed in meningiomas, ependymomas, drop metastases from cerebral gliomas, and spinal hemangiopericytoma, which is consistent with applications in cerebral neoplasms.

The available literature is significantly limited by a lack of standardized methods for measurement and quantification of 5-ALA fluorescence. The results of the reviewed studies should guide future development of rational trial protocols for the use of 5-ALA guided resection in spinal neoplasms1).


Three hours before the induction of anesthesia, 5-ALA was administered to patients with different intra- and extradural spinal tumors. In all patients a neurosurgical resection or biopsy of the spinal tumor was performed under conventional white-light microscopy. During each surgery, the presence of Protoporphyrin IX fluorescence was additionally assessed using a modified neurosurgical microscope. At the end of an assumed gross-total resection (GTR) under white-light microscopy, a final inspection of the surgical cavity of fluorescing intramedullary tumors was performed to look for any remaining fluorescing foci. Histopathological tumor diagnosis was established according to the current WHO classification.

Fifty-two patients with 55 spinal tumors were included in this study. Resection was performed in 50 of 55 cases, whereas 5 of 55 cases underwent biopsy. Gross-total resection was achieved in 37 cases, STR in 5, and partial resection in 8 cases. Protoporphyrin IX fluorescence was visible in 30 (55%) of 55 cases, but not in 25 (45%) of 55 cases. Positive PpIX fluorescence was mainly detected in ependymomas (12 of 12), meningiomas (12 of 12), hemangiopericytomas (3 of 3), and in drop metastases of primary CNS tumors (2 of 2). In contrast, none of the neurinomas (8 of 8), carcinoma metastases (5 of 5), and primary spinal gliomas (3 of 3; 1 pilocytic astrocytoma, 1 WHO Grade II astrocytoma, 1 WHO Grade III anaplastic oligoastrocytoma) revealed PpIX fluorescence. It is notable that residual fluorescing tumor foci were detected and subsequently resected in 4 of 8 intramedullary ependymomas despite assumed GTR under white-light microscopy.

In this study, 5-ALA-PpIX fluorescence was observed in spinal tumors, especially ependymomas, meningiomas, hemangiopericytomas, and drop metastases of primary CNS tumors. In cases of intramedullary tumors, 5-ALA-induced PpIX fluorescence is a useful tool for the detection of potential residual tumor foci 2).


A study included 10 patients who underwent surgical resection of an intramedullary ependymoma. Nine patients were orally administered 5-ALA (20 mg/kg) 2 hours before the induction of anesthesia. 5-ALA fluorescence was visualized with an operating microscope. Tumors were removed in a standardized manner with electrophysiological monitoring. The extent of resection was evaluated on the basis of intraoperative findings and postoperative magnetic resonance imaging. Histopathological diagnosis was established according to World Health Organization 2007 criteria. Cell proliferation was assessed by Ki-67 labeling index.

5-ALA fluorescence was positive in 7 patients (6 grade II and 1 grade III) and negative in 2 patients (grade II). Intraoperative findings were dichotomized: Tumors covered by the cyst were easily separated from the normal parenchyma, whereas tumors without the cyst appeared to be continuous to the spinal cord. In these cases, 5-ALA fluorescence was especially valuable in delineating the ventral and cranial and caudal margins. Ki-67 labeling index was significantly higher in 5-ALA-positive cases compared with 5-ALA-negative cases. All patients improved neurologically or stabilized after surgery.

5-ALA fluorescence was useful for detecting tumor margins during surgery for intramedullary ependymoma. When combined with electrophysiological monitoring, fluorescence-guided resection could help to achieve maximum tumor resection safely 3).

References

1)

Wainwright JV, Endo T, Cooper JB, Tominaga T, Schmidt MH. The role of 5-aminolevulinic acid in spinal tumor surgery: a review. J Neurooncol. 2018 Dec 29. doi: 10.1007/s11060-018-03080-0. [Epub ahead of print] Review. PubMed PMID: 30594965.
2)

Millesi M, Kiesel B, Woehrer A, Hainfellner JA, Novak K, Martínez-Moreno M, Wolfsberger S, Knosp E, Widhalm G. Analysis of 5-aminolevulinic acid-induced fluorescence in 55 different spinal tumors. Neurosurg Focus. 2014 Feb;36(2):E11. doi: 10.3171/2013.12.FOCUS13485. PubMed PMID: 24484249.
3)

Inoue T, Endo T, Nagamatsu K, Watanabe M, Tominaga T. 5-aminolevulinic acid fluorescence-guided resection of intramedullary ependymoma: report of 9 cases. Neurosurgery. 2013 Jun;72(2 Suppl Operative):ons159-68; discussion ons168. doi: 10.1227/NEU.0b013e31827bc7a3. PubMed PMID: 23149963.

Chlorhexidine shower

Surgical site infections (SSI) are common spine surgery complicationsPrevention is critical to maintaining safe patient care and reducing additional costs associated with treatment.

To determine the efficacy of preoperative chlorhexidine (CHG) showers on SSI rates following fusion and nonfusion spine surgery Chan et al., implemented a shower protocol at UCSF Medical CenterMilwaukee in November 2013. A cohort comparison of 4266 consecutive patients assessed differences in SSI rates for the pre- and postimplementation periods. Subgroup analysis was performed on the type of spinal surgery (eg, fusion vs nonfusion). Data represent all spine surgeries performed between April 2012 and April 2016.

The overall mean SSI rate was 0.4%. There was no significant difference between the pre- (0.7%) and postimplementation periods (0.2%; P = .08). Subgroup analysis stratified by procedure type showed that the SSI rate for the nonfusion patients was significantly lower in the post- (0.1%) than the preimplementation group (0.7%; P = .02). There was no significant difference between SSI rates for the pre- (0.8%) and postimplementation groups (0.3%) for the fusion cohort (P = .21). In multivariate analysis, the implementation of preoperative CHG showers were associated with significantly decreased odds of SSI (odds ratio = 0.15, 95% confidence interval [0.03-0.55], P < .01).

This is the largest study investigating the efficacy of preoperative Chlorhexidine showers on SSI following spinal surgery. In adjusted multivariate analysis, Chlorhexidine showers was associated with a significant decrease in SSI following spinal surgery 1).


In 2013 a search of electronic databases was undertaken to identify prospective controlled trials evaluating whole-body preoperative bathing with chlorhexidine versus placebo or no bath for prevention of SSI. Summary risk ratios were calculated using a DerSimonian-Laird random effects model and a Mantel-Haenzel dichotomous effects model.

Sixteen trials met inclusion criteria with a total of 17,932 patients: 7,952 patients received a chlorhexidine bath, and 9,980 patients were allocated to various comparator groups. Overall, 6.8% of patients developed SSI in the chlorhexidine group compared with 7.2% of patients in the comparator groups. Chlorhexidine bathing did not significantly reduce overall incidence of SSI when compared with soap, placebo, or no shower or bath (relative risk, 0.90; 95% confidence interval: 0.77-1.05, P = .19).

Meta-analysis of available clinical trials suggests no appreciable benefit of preoperative whole-body chlorhexidine bathing for prevention of SSI. However, most studies omitted details of chlorhexidine application. Better designed trials with a specified duration and frequency of exposure to chlorhexidine are needed to determine whether preoperative whole-body chlorhexidine bathing reduces SSI 2).

References

1)

Chan AK, Ammanuel SG, Chan AY, Oh T, Skrehot HC, Edwards CS, Kondapavulur S, Miller CA, Nichols AD, Liu C, Dhall SS, Clark AJ, Chou D, Ames CP, Mummaneni PV. Chlorhexidine Showers are Associated With a Reduction in Surgical Site Infection Following Spine Surgery: An Analysis of 4266 Consecutive Surgeries. Neurosurgery. 2018 Dec 22. doi: 10.1093/neuros/nyy568. [Epub ahead of print] PubMed PMID: 30590721.
2)

Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control. 2013 Feb;41(2):167-73. doi: 10.1016/j.ajic.2012.02.014. Epub 2012 Jun 19. Review. PubMed PMID: 22722008.

Minimally invasive lateral lumbar interbody fusion for adult spinal deformity

A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex.

No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P > .05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P = .17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups.

Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach 1).


Park et al., evaluated the clinical and radiological efficacies of supplementing minimally invasive lateral lumbar interbody fusion (LLIF) with open posterior spinal fusion (PSF) in adult spinal deformity (ASD).

To evaluate the advantages of minimally invasive LLIF for ASD, patients who underwent minimally invasive LLIF followed by open PSF (combined group) were compared with patients who only underwent PSF (only PSF group). The clinical and radiological outcomes for deformity correction and indirect decompression were assessed. The occurrence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) were also evaluated.

No significant differences were observed in the clinical outcomes of the Oswestry Disability Index (ODI), visual analog scale, and major complications including reoperations between the groups. No additional advantage was found for coronal deformity correction, but the restoration of lumbar lordosis in the combined group was significantly higher postoperatively (15.3° vs. 8.87°, P = 0.003) and last follow-up (6.69° vs. 1.02°, P = 0.029) compared to that of the only PSF group. In the subgroup analysis for indirect decompression for the combined group, a significant increase of canal area (104 vs. 122 mm) and foraminal height (16.2 vs. 18.5 mm) was noted. The occurrence of PJK or PJF was significantly higher in the combined group than in the only PSF group (P = 0.039).

LLIF has advantages of indirect decompression and greater improvements of sagittal correction compared to only posterior surgery. LLIF should be conducted considering the above-mentioned benefits and complications including PJK or PJF in ASD 2).

References

1)

Kanter AS, Tempel ZJ, Agarwal N, Hamilton DK, Zavatsky JM, Mundis GM, Tran S, Chou D, Park P, Uribe JS, Wang MY, Anand N, Eastlack R, Mummaneni PV, Okonkwo DO. Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy. Neurosurgery. 2018 Dec 1;83(6):1219-1225. doi: 10.1093/neuros/nyx612. PubMed PMID: 29361052.
2)

Park HY, Ha KY, Kim YH, Chang DG, Kim SI, Lee JW, Ahn JH, Kim JB. Minimally Invasive Lateral Lumbar Interbody Fusion for Adult Spinal Deformity: Clinical and Radiological Efficacy With Minimum Two Years Follow-up. Spine (Phila Pa 1976). 2018 Jul 15;43(14):E813-E821. doi: 10.1097/BRS.0000000000002507. PubMed PMID: 29215493.

Traumatic cervical spinal cord injury outcome

Injury to the spine and spinal cord is one of the common cause of disability and death. Several factors affect the outcome; but which are these factors (alone and in combination), are determining the outcomes are still unknown.

Based on parameters from the International Standards, physicians are able to inform patients about the predicted long-term outcomes, including the ability to walk, with high accuracy. In those patients who cannot participate in a reliable physical neurological examination, magnetic resonance imaging and electrophysiological examinations may provide useful diagnostic and prognostic information. As clinical research on this topic continues, the prognostic value of the reviewed diagnostic assessments will become more accurate in the near future. These advances will provide useful information for physicians to counsel tSCI patients and their families during the catastrophic initial phase after the injury 1).

Preclinical and class III clinical data suggest improved outcomes by maintaining the mean arterial pressure > 85 mm Hg and avoiding hypoxemia at least for 7 days following cervical SCI, and this level of monitoring and support should occur in the ICU 2).


100 cases of patients under 18 years at accident with acute traumatic cervical spinal cord injury admitted to spinal cord injury SCI centers participating in the European Multi-center study about SCI (EMSCI) between January 2005 and April 2016 were reviewed. According to their age at accident, age 13 to 17, patients were selected for the adolescent group. After applying in- and exclusion criteria 32 adolescents were included. Each adolescent patient was matched with two adult SCI patients for analysis.

ASIA Impairment scale (AIS) grade, neurological, sensory, motor level, total motor score, and Spinal Cord Independence Measure (SCIM III) total score.

Mean AIS conversion, neurological, motor and sensory levels as well as total motor score showed no significantly statistical difference in adolescents compared to the adult control group after follow up of 6 months. Significantly higher final SCIM scores (p < 0.05) in the adolescent group compared to adults as well as a strong trend for a higher gain in SCIM score (p < 0.061) between first and last follow up was found.

Neurological outcome after traumatic cervical SCI is not superior in adolescents compared to adults in this cohort. Significantly higher SCIM scores indicate more functional gain for the adolescent patients after traumatic cervical SCI. Juvenile age appears to be an independent predictor for a better functional outcome. 3).


A prospective observational study at single-center with all patients with cervical spinal cord injury (SCI), attending our hospital within a week of injury during a period of October 2011 to July 2013 was included for analysis. Demographic factors such as age, gender, etiology of injury, preoperative American Spinal Injury Association (ASIA) grade, upper (C2-C4) versus lower (C5-C7) cervical level of injury, imageological factors on magnetic resonance imaging (MRI), and timing of intervention were studied. Change in neurological status by one or more ASIA grade from the date of admission to 6 months follow-up was taken as an improvement. Functional grading was assessed using the functional independence measure (FIM) scale at 6 months follow-up.

A total of 39 patients with an acute cervical spine injury, managed surgically were included in this study. Follow-up was available for 38 patients at 6 months. No improvement was noted in patients with ASIA Grade A. Maximum improvement was noted in ASIA Grade D group (83.3%). The improvement was more significant in lower cervical region injuries. Patient with cord contusion showed no improvement as opposed to those with just edema wherein; the improvement was seen in 62.5% patients. Percentage of improvement in cord edema ≤3 segments (75%) was significantly higher than edema with >3 segments (42.9%). Maximum improvement in FIM score was noted in ASIA Grade C and patients who had edema (especially ≤3 segments) in MRI cervical spine.

Complete cervical SCI, upper-level cervical cord injury, patients showing MRI contusion, edema >3 segments group have worst improvement in neurological status at 6 months follow-up 4).


A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International standards for neurological classification of spinal cord injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group).

A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44±8.08, 15.19±19.39 and 10.84±11.49, respectively) than those of the SCI group (10.76±9.86, 24.79±19.65 and 17.76±15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI.

Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for accurate prognosis of cervical SCI patients in the rehabilitation unit 5).

References

1)

van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and prognosis of traumatic spinal cord injury. Global Spine J. 2011 Dec;1(1):1-8. doi: 10.1055/s-0031-1296049. PubMed PMID: 24353930; PubMed Central PMCID: PMC3864437.
2)

Schwartzbauer G, Stein D. Critical Care of Traumatic Cervical Spinal Cord Injuries: Preventing Secondary Injury. Semin Neurol. 2016 Dec;36(6):577-585. Epub 2016 Dec 1. Review. PubMed PMID: 27907962.
3)

Geuther M, Grassner L, Mach O, Klein B, Högel F, Voth M, Bühren V, Maier D, Abel R, Weidner N, Rupp R, Fürstenberg CH; EMSCI study group, Schneidmueller D. Functional outcome after traumatic cervical spinal cord injury is superior in adolescents compared to adults. Eur J Paediatr Neurol. 2018 Dec 11. pii: S1090-3798(18)30247-2. doi: 10.1016/j.ejpn.2018.12.001. [Epub ahead of print] PubMed PMID: 30579697.
4)

Srinivas BH, Rajesh A, Purohit AK. Factors affecting outcome of acute cervical spine injury: A prospective study. Asian J Neurosurg. 2017 Jul-Sep;12(3):416-423. doi: 10.4103/1793-5482.180942. PubMed PMID: 28761518; PubMed Central PMCID: PMC5532925.
5)

Kim SY, Kim TU, Lee SJ, Hyun JK. Prognosis for patients with traumatic cervical spinal cord injury combined with cervical radiculopathy. Ann Rehabil Med. 2014 Aug;38(4):443-9. doi: 10.5535/arm.2014.38.4.443. Epub 2014 Aug 28. PubMed PMID: 25229022; PubMed Central PMCID: PMC4163583.

Spinal primitive neuroectodermal tumor

Epidemiology

Primary spinal primitive neuroectodermal tumor (PNET) of the central nervous system has a low incidence. The intraspinal case is very rare. Around 30 cases have been reported so far 1).

Outcome

Spinal PNETs, like their cranial counterparts, are aggressive tumors and patients with these tumors typically have short survival times despite maximal surgery, chemotherapy, and radiation. Because no standard management guidelines exist for treating these tumors, a multitude of therapeutic strategies have been employed with varying success 2)

Case series

Ma et al. from the Beijing Tiantan Hospital summarized the cases of primary spinal PNET available in the database of the institute, either intramedullary or extramedullary cases. Then they did literature review of the same disease.

There were eight cases of primary spinal PNET available in there database, with one intramedullary case and seven extramedullary cases. Surgical resection was performed. The histology diagnosis was PNET. Peri-operative image examinations of the whole central nervous system (CNS) were performed to exclude tumors other than spinal cord origin. Then during literature review, 33 reports of the disease were included. The pre-operative diagnosis rate was low. The disease had a high recurrence rate and poor prognosis given available treatment 3).

Case reports

A 14-year-old teenage girl had suffered from progressive left upper back pain with bilateral lower legs weakness and numbness for 1 year. After treatment, left neck mass was noted 3 years later.

Initially, magnetic resonance imaging (MRI) showed neurogenic tumor involving intradural extramedullary space of T5-T10. Pathology report showed PNET (World Health Organization grade IV) featuring lobules of neoplastic cells with round regular nuclei, high nucleus-to-cytoplasm ratio, and fibrillary cytoplasm. At the time of tumor recurrence, chest MRI then showed recurrent tumor at T2-T3 level of the epidural space with right neural foramina invasion. Brain MRI showed extensive bilateral calvarial metastases and leptomeningeal metastases in the right frontoparietal regions. Bone scan showed multiple bone metastases.

T-spine tumor removal and adjuvant radiotherapy (RT) to T-spine tumor bed were performed in the initial treatment. After clinical tumor recurrence, tumor removal was done again. She then received chemotherapy followed by whole brain irradiation with hippocampal sparing with 35 gray in 20 fractions.

After treatment, follow-up images showed that the disease was under control. There was no neurological sequela. She has survived more than 7 years from diagnosis and more than 4 years from recurrence to date 4).


A 5-year-old Moroccan boy, who presented with torticollis for 1 month. Computed tomography scan and Magnetic resonance imaging of the cervical spine revealed an extradural, dumbbell-shaped mass with extra-spinal extension at the left C1-C6 level. Multiple biopsy specimens were obtained. Histological examination revealed a highly cellular neoplasm composed of diffuse sheets of tumor cells having monomorphic, round to oval, finely vesicular nuclei. Immunohistochemical findings confirmed the diagnosis of intraspinal peripheral primitive neuroectodermal tumor.

After this illustrative case, they reviewed the literature on clinicopathological and therapeutic aspects. In practice, it is important to consider the diagnosis of peripheral primitive neuroectodermal tumor in children and adolescents with an apparent soft-tissue mass located in the spine 5).


A 60-year-old female, which presented clinically as an intraspinal tumor, causing symptoms of lower back pain, numbness and pain in the right lower extremity. The patient underwent tumorectomy. Following primary therapy, the symptoms of spinal cord compression were relieved. The patient underwent several courses of radiotherapy following surgery but refused to continue with chemotherapy. After a further four months, the tumors recurred and the patient succumbed to the disease 6).


A two years old female child presented with weakness both lower limbs. Preoperative MRI of the spine and paravertebral regionIso – hyper intense posterior placed extradural lesion, non contrast enhancing from D11-L2 levels with cord compression D9 to L3 laminectomy done. Granulation tissue found from D11 to L2. with cord compression. The granulation tissue removed in toto. The pathological findings were consistent with PNET. Post operative neurological improvement was minimal. Cranial screening ruled out any intracranialtumour. Hence a diagnosis of primary spinal PNET was made. A review of the literature shows that only 19 cases of primary intraspinal PNETs have been reported to date and the present case extradural in location. Primary intraspinal PNETs are rare tumors and carry a poor prognosis 7).


Multimodal therapy of an intramedullary cervical primitive neuroectodermal tumor in an adult. 8).


A 22-year-old woman with history of severe progressive neck pain, without radiation, associated with paresthesia in the right arm, and palpable right posterior cervical mass. Neurological examination showed increased reflexes in all four limbs, bilateral Hoffman’s sign, right Babinski’s sign, and right hemi-hypoesthesia. Neuroimaging revealed a right posterior cervical lesion with heterogeneous contrast enhancement extending to the neural foramina of the atlas and axis. Patient underwent microsurgical removal of the lesion, and histopathological and immunohistochemical analysis confirmed the diagnosis of peripheral primitive PNET (pPNET). The patient had adjuvant treatment with radiotherapy and chemotherapy. After twelve months, neuroimaging showed no signs of tumor regrowth and the patient had no neurological deficits. However, three months later, the patient developed hydrocephalus and cerebrospinal fluid (CSF) was positive for neoplastic cells. No other treatment was administered and the patient died.

pPNET is a rare malignant tumor with poor prognosis, although promising results with multimodal treatment-surgery, radiotherapy, and chemotherapy. Diagnosis requires immunohistochemical analysis, with identification of neuronal differentiation markers 9).


A 18-year-old female with conus intramedullary tumor diagnosed to be primary spinal primitive neuroectodermal tumor following histopathological examination after surgery 10).


A female who presented at age 21 with diffuse involvement of the lower spinal cord. After biopsy and successful treatment with radiation and chemotherapy, she recurred 10 years later with disease in her cerebellum. She was reinduced with chemotherapy and subsequently received high-dose chemotherapy with autologous stem cell support. She is alive and free of disease 11 years after her initial presentation. This represents the longest survival ever documented for a primary spinal PNET 11).


A 15-year-old girl who presented with gradual onset, over 1 month, of upper back pain and bilateral lower leg weakness. A thoracic spine MRI showed a dumbbell-shaped epidural mass at T2-4 with right paraspinal and posterior mediastinal extension. Surgical resection of the epidural tumor for decompression was performed. The pathologic examination revealed a PNET. Primary spinal PNETs typically have a poor prognosis and optimal therapy has not yet been defined. Surgical resection, with the combination of chemo-radiotherapy or radiotherapy, leads to better outcomes. However, primary epidural PNETs may be classified as a subtype of spinal PNETs because they are free from intrathecal invasion. For these patients, surgery alone and surgery combined with radiotherapy or chemo-radiotherapy remain controversial. Our patient received surgery alone and, 1y ear later, has experienced no local recurrence within the epidural space but the mediastinal part of the tumor has enlarged 12).


A 45-year-old man with a peripheral primitive neuroectodermal tumour arising in the cervical spine. Alexander et al., believed this to be the first report of this type of tumour in the cervical spine 13).


A 25-year-old male patient presented with an extremely rare primary spinal peripheral primitive neuroectodermal tumor (pPNET) manifesting as acutely progressive paraparesis and back pain. Neuroimaging and intraoperative examination showed that the tumor was confined to the epidural space of the thoracic spine. The patient was treated successfully by gross total resection of the tumor followed by chemotherapy and local radiotherapy. The present case illustrates the unexpected occurrence and important differential diagnosis of primary epidural pPNET of the thoracic spine in young patients presenting with progressive paraparesis and back pain 14).


A 29-year-old male with a dumbbell-shaped pPNET at the T9-10 spine level, including details of his examination, surgical procedures applied, histological and genetic findings, and his subsequent treatment. They discussed the clinical course, the pathology and treatment for this disease, the surgical approach to thoracic dumbbell tumors and reviewed the literature. This is the first report of a case of a dumbbell-shaped intradural and spinal peripheral PNET 15).


A 54-year-old woman who presented with quadriplegia and bladder and bowel dysfunction. The patient had suffered symptoms of neck pain for 1 month and left shoulder weakness for 10 days. Magnetic resonance imaging of the cervical spine revealed an intramedullary mass extending from C-2 to C-5 with an exophytic component in the adjacent left subarachnoid space. Multiple biopsy specimens were obtained, and a partial excision was performed. Histological examination revealed nodular growth and neuronal differentiation, with a striking resemblance to desmoplastic medulloblastoma. A positron emission tomography scan did not reveal uptake at any site. These findings confirmed the diagnosis of a primary intramedullary PNET. Postoperatively, the patient was given craniospinal radiotherapy with a radiation boost to the tumor bed 16).

References

1) , 3)

Ma J, Ma S, Yang J, Jia G, Jia W. Primary spinal primitive neuroectodermal tumor: A single center series with literature review. J Spinal Cord Med. 2018 Dec 18:1-9. doi: 10.1080/10790268.2018.1547862. [Epub ahead of print] PubMed PMID: 30561250.
2)

Ellis JA, Rothrock RJ, Moise G, McCormick PC 2nd, Tanji K, Canoll P, Kaiser MG, McCormick PC. Primitive neuroectodermal tumors of the spine: a comprehensive review with illustrative clinical cases. Neurosurg Focus. 2011 Jan;30(1):E1. doi: 10.3171/2010.10.FOCUS10217. Review. PubMed PMID: 21194274.
4)

Chen F, Chiou SS, Lin SF, Lieu AS, Chen YT, Huang CJ. Recurrent spinal primitive neuroectodermal tumor with brain and bone metastases: A case report. Medicine (Baltimore). 2017 Nov;96(46):e8658. doi: 10.1097/MD.0000000000008658. PubMed PMID: 29145292; PubMed Central PMCID: PMC5704837.
5)

Khmou M, Malihy A, Lamalmi N, Rouas L, Alhamany Z. Peripheral primitive neuroectodermal tumors of the spine: a case report and review of the literature. BMC Res Notes. 2016 Sep 9;9(1):438. doi: 10.1186/s13104-016-2246-5. Review. PubMed PMID: 27613377; PubMed Central PMCID: PMC5016941.
6)

Meng XT, He SS. Primitive neuroectodermal tumor in the spinal canal: A case report. Oncol Lett. 2015 Apr;9(4):1934-1936. Epub 2015 Jan 27. PubMed PMID: 25789071; PubMed Central PMCID: PMC4356409.
7)

Venkataraman S, Pandian C, Kumar SA. Primary spinal primitive neuroectodermal tumour – a case report. Ann Neurosci. 2013 Apr;20(2):80-2. doi: 10.5214/ans.0972.7531.200211. PubMed PMID: 25206019; PubMed Central PMCID: PMC4117112.
8)

Coumans JV, Walcott BP, Nahed BV, Oh KS, Chi AS. Multimodal therapy of an intramedullary cervical primitive neuroectodermal tumor in an adult. J Clin Oncol. 2012 Jan 10;30(2):e15-8. doi: 10.1200/JCO.2011.38.6474. Epub 2011 Dec 5. PubMed PMID: 22147740.
9)

Cabral GA, Nunes CF, Melo JO Jr, Guimarães RD, Gonçalves MB, Rodrigues RS, Correa JL, Teixeira OM Jr, Klescoski J Jr, Lapenta MA, Landeiro JA. Peripheral primitive neuroectodermal tumor of the cervical spine. Surg Neurol Int. 2012;3:91. doi: 10.4103/2152-7806.99938. Epub 2012 Aug 21. PubMed PMID: 23050205; PubMed Central PMCID: PMC3463148.
10)

Harbhajanka A, Jain M, Kapoor SK. Primary spinal intramedullary primitive neuroectodermal tumor. J Pediatr Neurosci. 2012 Jan;7(1):67-9. doi: 10.4103/1817-1745.97631. PubMed PMID: 22837786; PubMed Central PMCID: PMC3401662.
11)

Gollard RP, Rosen L, Anson J, Mason J, Khoury J. Intramedullary PNET of the spine: long-term survival after combined modality therapy and subsequent relapse. J Pediatr Hematol Oncol. 2011 Mar;33(2):107-12. doi: 10.1097/MPH.0b013e3181f84b7f. PubMed PMID: 21228722.
12)

Chang SI, Tsai MC, Tsai MD. An unusual primitive neuroectodermal tumor in the thoracic epidural space. J Clin Neurosci. 2010 Feb;17(2):261-3. doi: 10.1016/j.jocn.2009.05.018. Epub 2009 Dec 29. PubMed PMID: 20036552.
13)

Alexander HS, Koleda C, Hunn MK. Peripheral Primitive Neuroectodermal Tumour (pPNET) in the cervical spine. J Clin Neurosci. 2010 Feb;17(2):259-61. doi: 10.1016/j.jocn.2009.05.020. Epub 2009 Dec 29. PubMed PMID: 20036553.
14)

Kiatsoontorn K, Takami T, Ichinose T, Chokyu I, Tsuyuguchi N, Ohsawa M, Ohata K. Primary epidural peripheral primitive neuroectodermal tumor of the thoracic spine. Neurol Med Chir (Tokyo). 2009 Nov;49(11):542-5. PubMed PMID: 19940407.
15)

Hrabálek L, Kalita O, Svebisova H, Ehrmann J Jr, Hajduch M, Trojanec R, Kala M. Dumbbell-shaped peripheral primitive neuroectodermal tumor of the spine–case report and review of the literature. J Neurooncol. 2009 Apr;92(2):211-7. doi: 10.1007/s11060-008-9744-9. Epub 2008 Dec 3. Review. PubMed PMID: 19050994.
16)

Jain A, Jalali R, Nadkarni TD, Sharma S. Primary intramedullary primitive neuroectodermal tumor of the cervical spinal cord. Case report. J Neurosurg Spine. 2006 Jun;4(6):497-502. PubMed PMID: 16776362.

SagittalMeter Pro

A study of Lee et al., from the Department of Neurosurgery, St. Vincent`s Hospital, Catholic University of Korea, SuwonGangneung Asan HospitalSouth Korea aimed to compare the validityreproducibilityprecision, and efficiency of a picture archiving and communication system (PACS) and a smartphone application which is an educative app to easily measure sagittal balance parameters (SagittalMeter Pro) for measuring spinopelvicsagittal parameters.

Three spine surgeons measured lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) on standing postero-anterior radiographs of 30 patients using PACS and SagittalMeter Pro. Measurements were repeated a week after original measurements. Intra-observer and inter-observer variabilities and reliabilities of each parameter (LL, PI, SS, and PT) were calculated for both techniques. Comparisons were performed using the paired t test. Results are expressed as means ± SDs and p values of <0.05 were considered significant.

PACS to SagittalMeter Pro differences between the mean absolute values of LL, PI, SS, PT were 0.50°, 0.82°, 0.81°, 0.34°, respectively, and intra- and inter- observer variabilities were similar. Excellent intra- and inter- observer reliabilities were obtained for PACS and SagittalMeter Pro as demonstrated by values greater than 0.86 and 0.84, respectively. Measurement times for PACS and SagittalMeter Pro were 36.63±7.55 and 14.57±1.96 seconds, respectively, and this difference was significant (p=0.001).

The study shows PACS and SagittalMeter Pro are equivalent in terms of their abilities to measure spinopelvic sagittal parameters, and that the time required to take measurements was significantly less for SagittalMeter Pro. We believe SagittalMeter Pro may be helpful when planning spinal surgery 1).

1)

Lee JB, Kim IS, Lee JJ, Park JH, Cho CB, Yang SH, Sung JH, Hong JT. Validity of a smartphone application (SagittalMeter Pro) for the measurement of sagittal balance parameters. World Neurosurg. 2018 Dec 14. pii: S1878-8750(18)32808-0. doi: 10.1016/j.wneu.2018.11.242. [Epub ahead of print] PubMed PMID: 30557655.
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