Resultados a largo plazo del tratamiento quirúrgico de las fístulas arteriovenosas durales espinales en un centro Argentino / Surgical treatment of spinal dural arteriovenous fistulas: Management and long-term results in a series of patients operated in an Argentinian center

Resumen Introducción: La fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular frecuentemente subdiagnosticada. El tratamiento puede ser microqui rúrgico o endovascular. Métodos: Estudio retrospectivo de una serie de pa cientes con FDAVE tratados por microcirugía entre los años 2010 y 2021. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada (mRs). Los estudios diagnósticos se utilizaron para de terminar nivel lesional y resultados quirúrgicos. Resultados: Se incluyeron doce pacientes (10 hombres y 2 mujeres) con un promedio de edad de 60 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas, 8 a nivel dorsal, 3 a nivel lumbar y una a nivel sacro. La arteria de Adamkiewicz se identificó en 5 casos en L1, 2 en D12, 2 en D10, 2 en D9 y un caso en D7. De los 12 pacientes operados, 3 fueron embolizados previamente; dos permanecieron estables en su evolución y 10 mejoraron uno o más puntos del mRs. No hubo complicaciones en el postoperatorio. Todos mostraron mejoría del edema medular en reso nancia magnética y la angiografía digital, luego de los 6 meses, fue negativa. El seguimiento promedio fue de 40 meses con un rango de 6 a 122 meses y ningún paciente presentó recidiva de la FDAVE. Conclusión: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento en dovascular.

Abstract Introduction: Spinal dural arteriovenous fistula (SDA VF) is a rare vascular disease, of unknown etiology, fre quently underdiagnosed. Treatment can be microsurgical or endovascular. Methods: Retrospective and monocentric analysis of 12 SDAVF patients treated by microsurgery between 2010 and 2021. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and Rankin scales. Diagnos tic studies such as magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA) and spinal digital subtraction angiography (DSA), were evaluated for lesion level, as were surgical results. Results: Twelve patients (10 men and 2 women), average age: 60 years, were operated. The interval from symptom onset to diagnosis was <12 months in all cases except one (32 months). SDAVF locations were thoracic in 8 cases, between T6 and T12, 3 at lumbar spine (L1- L2) and at S1 in one case, with no difference regarding side. The Adamkiewicz artery was identified in 5 cases at L1, 2 at D12, 2 at D10, 2 at D9 and 1 at D7 (7 left-sided and 5 right-sided). Three of the 12 patients operated had undergone prior embolization. Postoperative neu rological outcomes showed: 2 patients remained stable and 10 improved one or more points on the mRs; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at 6 months. Average follow-up was 40 months (range 6 to 122) and no patient presented recurrence. Conclusion: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.

The postoperative adjacent segment degeneration between the microscopically anterior cervical discectomy with fusion and anterior cervical corpectomy with fusion in the treatment of cervical spondylotic myelopathy and the influencing factors analysis of / 中国医师进修杂志

Objective:To compare the postoperative adjacent segment degeneration (ASD) between the microscopically anterior cervical discectomy with fusion (ACDF) and anterior cervical corpectomy with fusion (ACCF) in the treatment of cervical spondylotic myelopathy and its influencing factors.Methods:Fifty patients with cervical spondylotic myelopathy treatment in the Qinzhou Second People′s Hospital from July 2018 to July 2020 were selected, they were divided into two groups, 25 patients performed ACDF (ACDF group), and 25 patients performed ACCF (ACCF group). The perioperative period, efficacy and incidence of ASD were compared between the two groups, and the influencing factors of ASD were analyzed.Results:The intraoperative blood loss, operation time, length of hospital stay and postoperative drainage in ACCF group were higher than those in ACDF group: (58.34 ± 8.61) ml vs. (46.77 ± 7.24) ml, (99.57 ± 10.72) min vs. (86.14 ± 9.64) min, (8.97 ± 1.43) d vs. (7.56 ± 1.24) d, (17.92 ± 2.95) ml vs. (14.28 ± 2.66) ml, there were statistical differences ( P<0.05). The postoperative Japanese Orthopaedic Association (JOA) scores and Neck Disability Index (NDI) scores in the two groups were improved significantly ( P<0.05), but the scores of JOA and NDI in the two groups had no significant differences ( P>0.05). The incidence of ASD in the two groups had no significant differences ( P>0.05). The Cox univariate analysis showed that age >59 years, intervertebral disc degeneration, number of fusion segments >2, osteoporosis and postoperative ASD were risk factors for ASD( P<0.05). Conclusions:The effect of microscopically ACDF is similar to that of ACCF in the treatment of cervical spondylotic myelopathy, but ACDF has the advantages of less trauma and quick recovery. The risk of postoperative ASD should be vigilant for patients with age >59 years old, intervertebral disc degeneration, number of fusion segments >2 or osteoporosis.

Advances in surgical strategies for ossification of posterior longitudinal ligament involving the C 2 segment / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the application of surgical strategies for the treatment of cervical ossification of the posterior longitudinal ligament (OPLL) involving the C 2 segment.@*METHODS@#The literature about the surgery for cervical OPLL involving C 2 segment was reviewed, and the indications, advantages, and disadvantages of surgery were summarized.@*RESULTS@#For cervical OPLL involving the C 2 segments, laminectomy is suitable for patients with OPLL involving multiple segments, often combined with screw fixation, and has the advantages of adequate decompression and restoration of cervical curvature, with the disadvantages of loss of cervical fixed segmental mobility. Canal-expansive laminoplasty is suitable for patients with positive K-line and has the advantages of simple operation and preservation of cervical segmental mobility, and the disadvantages include progression of ossification, axial symptoms, and fracture of the portal axis. Dome-like laminoplasty is suitable for patients without kyphosis/cervical instability and with negative R-line, and can reduce the occurrence of axial symptoms, with the disadvantage of limited decompression. The Shelter technique is suitable for patients with single/double segments and canal encroachment >50% and allows for direct decompression, but is technically demanding and involves risk of dural tear and nerve injury. Double-dome laminoplasty is suitable for patients without kyphosis/cervical instability. Its advantages are the reduction of damage to the cervical semispinal muscles and attachment points and maintenance of cervical curvature, but there is progress in postoperative ossification.@*CONCLUSION@#OPLL involving the C 2 segment is a complex subtype of cervical OPLL, which is mainly treated through posterior surgery. However, the degree of spinal cord floatation is limited, and with the progress of ossification, the long-term effectiveness is poor. More research is needed to address the etiology of OPLL and to establish a systematic treatment strategy for cervical OPLL involving the C 2 segment.

Impact of surgical treatment on the gait of patients with cervical myelopathy / Impacto do tratamento cirurgico na marcha de pacientes portadores de mielopatia cervical / Impacto del tratamiento quirúrgico en la marcha de pacientes con mielopatía cervical

ABSTRACT: Objective: To analyze the impact of surgery on gait characteristics of individuals with Cervical Spondylotic Myelopathy (CSM) after one month of the procedure. Methods: Observational, cohort type study, with a quantitative analysis approach. Two assessments were performed, the first one week before surgery and the second 30 days after the decompression procedure. The following space-time variables were analyzed: steps per minute, step length, cycle time, speed, steps per minute, support time, swing time, step time. The kinematic variables obtained were analyzed by Gait Profile Score (GPS) and Movement Analysis Profile (MAP). Results: comparing pre and postoperative values, there was a decrease in the number of steps per minute (p=0.006), an increase in support time (p=0.011) and an increase in cycle time (p=0.004). Other variables did not present statistically significant differences. The patients' total GPS average in the pre-surgery assessment was 10.41 and 1 month after the procedure, an average of 10.56 was obtained, which does not characterize a statistical difference between the assessments. When establishing a comparison between the two assessments specifically on each joint movement of the lower limbs using the MAP, it was observed that the obliquity and rotation of the pelvis showed some improvement immediately after the surgical procedure. Knee flexion and extension were significantly (p=0.018) more compromised after the procedure when compared to the value of the same population before surgery. Conclusion: the preliminary analysis of the gait of these patients after one month of intervention did not show immediate benefits of the procedure. Level of Evidence II; Therapeutic studies - Investigation of treatment outcomes.

RESUMO: Objetivo: Analisar o impacto da cirurgia na marcha de indivíduos portadores de Mielopatia Cervical Espondilótica (MCE) após um mês do procedimento. Métodos: Estudo observacional, longitudinal, com abordagem de análise quantitativa. Foram realizadas duas avaliações, a primeira uma semana antes da cirurgia e a segunda 30 dias após o procedimento. Foram analisadas as variáveis de espaço-tempo: avanços por minuto, comprimento do passo, tempo de ciclo, velocidade, passos por minuto, tempo de apoio, tempo de balanço, tempo do passo. As variáveis cinemáticas obtidas foram analisadas pelo Gait Profile Score (GPS) e Movement Analysis Profile (MAP). Resultados: comparando os valores pré e pós-operatórios, houve diminuição do número de passos por minuto (p=0,006), aumento no tempo de apoio (p=0,011) e aumento no tempo de ciclo (p=0,004), outras variáveis não apresentaram diferenças estatisticamente significativas. A média do GPS total dos pacientes na avaliação pré-cirurgia foi de 10,41 e após 1 mês do procedimento obteve-se a pontuação média de 10,56 o que não caracteriza diferença estatística entre as avaliações. Ao estabelecer uma comparação entre as duas avaliações em cada movimento articular dos membros inferiores utilizando o MAP, observa-se que a obliquidade e a rotação da pelve apresentaram alguma melhoria imediatamente após o procedimento cirúrgico. Já a flexão e extensão do joelho mostrou-se significativamente (p=0,018) mais comprometida após o procedimento quando comparada com o valor da mesma população pré cirurgia. Conclusão: a análise preliminar da marcha dos pacientes com MCE após um mês de intervenção não evidenciou benefícios imediatos do procedimento. Nível de Evidência II; Estudos terapêuticos - Investigação dos resultados do tratamento.

RESUMEN: Objetivo: Analizar el impacto del tratamiento quirúrgico en las características de la marcha de personas con Mielopatía Cervical Espondilótica (MCE) después de un mes del procedimiento. Métodos: Estudio observacional, longitudinal, con enfoque de análisis cuantitativo. Se realizaron dos evaluaciones, la primera una semana antes de la cirugía y la segunda 30 días después del procedimiento de descompresión. Se analizaron las siguientes variables espacio-temporales: pasos por minuto, longitud de paso, tiempo de ciclo, velocidad, pasos por minuto, tiempo de apoyo, tiempo de balanceo, tiempo de paso. Las variables cinemáticas obtenidas fueron analizadas mediante Gait Profile Score (GPS) y Movement Analysis Profile (MAP). Resultados: Al comparar los valores pre y postoperatorios, hubo una disminución en el número de pasos por minuto (p=0,006), un aumento en el tiempo de soporte (p=0,011) y un aumento en el tiempo de ciclo (p=0,004), otras variables no presentaron diferencias estadísticamente significativas. La media del GPS total de los pacientes en la evaluación prequirúrgica fue de 10,41 y 1 mes después del procedimiento se obtuvo una puntuación promedio de 10,56, lo que no caracteriza diferencia estadística entre las evaluaciones. Al establecer una comparación entre las dos evaluaciones específicamente sobre cada movimiento articular de los miembros inferiores mediante el MAP, se observó que la oblicuidad y rotación de la pelvis mostraron cierta mejoría inmediatamente después del procedimiento quirúrgico. La flexión y extensión de la rodilla estuvieron significativamente (p=0,018) más comprometidas después del procedimiento en comparación con el valor de la misma población antes de la cirugía. Conclusión: Los pacientes con MCE presentan deterioro de la marcha en comparación con la población típica, el análisis preliminar de la marcha de estos pacientes después de un mes de intervención no mostró beneficios inmediatos del procedimiento. Nivel de Evidencia II; Estudios terapéuticos - Investigación de resultados del tratamiento.

Transtubular Transoral Approach for Irreducible Ventral Craniovertebral Junction Compressive Pathologies: Surgical Technique and Outcome

@#Introduction: To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods: Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results: All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions: A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.

A case report of skeletal fluorosis leading to cervical compressive myelopathy and a review of literature

Fluorosis is a public health problem that is caused by excess intake of fluoride through ground/deep bore water. It gets deposited in the bones, teeth, and soft tissues. Fluoride in the human body acts as a “double-edged sword.” Fluoride is beneficial in small amounts but toxic in large amounts. People who have consumed 10–20 mg of fluoride per day for more than 10–20 years may develop crippling skeletal fluorosis. Stiffness and pain in the major joints, including the neck, back, hips, and knees, reduce mobility. The bone structure may change and ligaments may calcify in extreme cases, resulting in muscular weakness and pain. Here, we have reported a case of chronic quadriparesis due to compressive cervical myelopathy. After extensive workup, diagnosis of skeletal fluorosis was made.

Mielopatía asociada a virus linfotrópico humano de células T tipo 1 en el Paraguay. Reporte de caso / Myelopathy associated with human T-cell lymphotropic virus type 1 in Paraguay. Case report

RESUMEN La mielopatía asociada con infección por HTLV-1 o paraparesia espástica tropical es una enfermedad crónica degenerativa del sistema nervioso central que afecta principalmente la médula espinal, una enfermedad rara en nuestro medio. El caso se trata sobre una mujer de 65 años, que acude con un cuadro de 2 años de evolución con disminución de la fuerza muscular de miembros inferiores progresiva hasta impedir la marcha, se acompaña de incontinencia urinaria y fecal, y hormigueo en miembros inferiores. Examen físico neurológico: disminución de fuerza muscular en miembros inferiores (2/5), reflejos osteotendinosos exaltados en miembros inferiores, Babisnky bilateral, hipostesia en cara lateral de piernas y dorso y planta de los pies, clonus patelar, y sin nivel sensitivo. En estudios paraclínicos: líquido cefalorraquídeo con cito químico (proteínas ligeramente aumentada) y citológico normal, ausencia de bandas oligoclonales, serología HIV negativo, perfil autoinmune negativo. Electromiografía normal, tomografía de cráneo, tórax y abdomen normal. Resonancia magnética cerebral y medular normal al principio, los cuales fueron repetidos al cabo de 8 meses y se observan lesiones inflamatorias en cerebro y médula espinal. PCR (reacción en cadena de la polimerasa) en sangre para HLTV-1 positiva. La paciente fue tratada con pulsos de metilprednisolona, seguido de prednisona oral y azatioprina por 3 meses sin respuesta favorable y con efectos secundarios a los corticoides por lo que se suspende. Se inició inmunoglobulina IV 400mg kg/p/mensual por 3 meses, sin respuesta. Se inicia rituximab 500mg cada 15 días hace 1 mes y evaluar la respuesta en los controles sucesivos. Conclusión: La mielopatía asociada a virus linfotrópico humano de células T tipo 1(HTLV-1) o paraparesia espástica tropical (MAH/PET), debe ser considerado en el diagnóstico diferencial en un paciente con mielopatia en el Paraguay.

ABSTRACT Myelopathy associated with HTLV-1 infection or tropical spastic paraparesis is a chronic degenerative disease of the central nervous system that mainly affects the spinal cord, a rare disease in our setting. The case is about a 65-year-old woman, who presented with a 2-year history of progressive decrease in muscle strength of the lower limbs until it prevented her from walking, accompanied by urinary and fecal incontinence, and tingling in the lower limbs. Neurological physical examination: decreased muscle strength in the lower limbs (2/5), increased osteotendinous reflexes in the lower limbs, bilateral Babinky, hypoesthesia in the lateral aspect of the legs and the back and soles of the feet, patellar clonus, and no sensory level. In paraclinical studies: normal cytochemical and cytological cerebrospinal. Fluid (slightly increased protein), absence of oligoclonal bands, negative HIV serology, negative autoimmune profile. Normal electromyography, tomography of the skull, thorax and normal abdomen. Magnetic resonance imaging of the brain and spinal cord was normal at the beginning, which were repeated after 8 months, and inflammatory lesions in the brain and spinal cord were observed. PCR (polymerase chain reaction) in blood for HLTV-1 positive. The patient was treated with methylprednisolone pulses, followed by oral prednisone and azathioprine for 3 months without a favorable response and with corticosteroid side effects, so she was discontinued. IV immunoglobulin 400mg kg/p/monthly for 3 months was started, with no response. Rituximab 500mg every 15 days was started 1 month ago and the response was evaluated in successive controls. Conclusion: myelopathy associated with human T-cell lymphotropic virus type 1 (HTLV-1) or tropical spastic paraparesis (MAH/PET), should be considered in the differential diagnosis in a patient with myelopathy in Paraguay.

White cord syndrome: rara complicación luego de la cirugía de descompresión cervical / White cord syndrome: a rare complication after cervical decompressive surgery

RESUMEN Introducción: el white cord syndrome, conocido como una lesión por reperfusión de la médula espinal, es una rara complicación de la cirugía espinal para descompresión. Se define como un deterioro neurológico inmediato y súbito, luego de la cirugía de descompresión cervical. Objetivo: describir los elementos clínico-imagenológicos y estrategias de tratamiento del white cord syndrome. Métodos: se realizó la revisión de la literatura en bases de datos Pubmed y EMBASE, además en los servidores de preprints BioRxiv, MedRxiv y preprint.org, así como la plataforma ResearchGate. Se seleccionaron todos los artículos en inglés y español, con texto completo disponible. Se usaron los siguientes descriptores white cord syndrome AND cervical spondylotic myelopathy. Se excluyeron artículos editoriales, libros, revisiones, meta-análisis y aquellos sin carácter open-access. Luego de excluir artículos que no cumplían nuestros criterios, fueron seleccionadas 17 publicaciones para su revisión. Resultados: Se analizaron 17 artículos, con una muestra total de 24 pacientes reportados. Todos los pacientes mostraron afectación mielopática con defecto motor variable e hiperreflexia osteotendinosa. En diez artículos, la técnica quirúrgica empleada fue la descompresión posterior, con o sin fusión. Fue muy variable el empleo de dosis de esteroides, terapia física y las re-intervenciones quirúrgicas. Solo dos casos no mostraron recuperación neurológica al término del período de observación. Conclusiones: el reconocimiento de esta rara complicación es vital, ya que constituye una causa de defecto neurológico posterior a la cirugía. El diagnóstico se realiza luego de la exclusión de complicaciones trans-operatorias, y al observar hiperintensidad del cordón medular ponderado en T2 en las imágenes de resonancia magnética. El manejo radica en adecuada descompresión, uso de esteroides y rehabilitación.

ABSTRACT Introduction: white cord syndrome, known as spinal cord reperfusion injury, is a rare complication of spinal decompressive surgery. It is defined as an immediate and sudden neurological deterioration after cervical decompression surgery. Objective: to describe the clinical-imaging elements and treatment strategies of white cord syndrome. Methods: a literature review was performed in Pubmed and EMBASE databases, as well as in the preprint servers BioRxiv, MedRxiv and preprint.org, and the ResearchGate platform. All articles in English and Spanish, with full text available, were chosen. The following descriptors were used: White cord syndrome AND cervical spondyloticmyelopathy. The editorial articles, books, reviews, meta-analyses and those without open-access characteristics were excluded. After excluding articles that did not meet the criteria established, 17 publications were chosen to be reviewed. Results: seventeen articles were analyzed, with a total sample of 24 patients reported. All patients showed myelopathic involvement with variable motor defect and osteotendinous hyperreflexia. In ten articles, the surgical technique used was posterior decompression, with or without fusion. The use of steroid doses, physical therapy and surgical re-interventions was highly variable. Only two cases did not show neurological recovery at the end of the observation period. Conclusions: recognition of this rare complication is vital, since it constitutes a cause of neurological defect after surgery. The diagnosis is made after exclusion of trans-operative complications, and after observing T2-weighted spinal cord hyper-intensity in magnetic resonance images. Management is based on adequate decompression, application of steroid treatment and rehabilitation.

Analysis of the effect and influencing factors of different surgical methods in the treatment of multi-level cervical spondylotic myelopathy / 中国综合临床

Objective:To explore the use of anterior cervical corpectomy and fusion (ACCF) combined with anterior cervical discectomy and fusion (ACDF) in patients with multilevel cervical spondylopathy myelopathy (CSM).Methods:The clinical data of 83 patients with multi-segment CSM admitted to the Department of Spinal Surgery of Hubei Liuqi2 Orthopaedic Hospital of Integrated Traditional Chinese and Western Medicine from January 2018 to January 2021 were retrospectively analyzed. According to the different surgical methods used in their treatment, they were divided into group A and group B. In group A, 44 patients were treated with anterior cervical ACCF combined with ACDF, and 39 patients in group B were treated with posterior single-door laminoplasty. The general clinical indexes such as operation time, perioperative bleeding volume and hospitalization time were collected.The neurological function and cervical dysfunction improvement effect of the patients before and 6 months after operation were evaluated by using the Japanese Orthopaedic Association (JOA) score and neck disability index (NDI) scale. The cervical curvature of the patients before and 6 months after operation was compared, The complications of the two groups were observed 6 months after operation. The patients were divided into improved group (72 cases) and non improved group (11 cases). Comparison between count data groups χ 2 inspection. Independent sample t-test was used for comparison between measurement data groups conforming to normal distribution. According to the results of univariate analysis, the meaningful factors were included in the binary Logistic regression to analyze the influencing factors related to the surgical efficacy. Result:The perioperative blood loss ((153.36±10.68) mL) and hospital stay ((10.11±2.30) d) in group A were lower than those in group B ((171.47±11.32) mL, (15.58±3.76) d). There were significant differences between the two groups ( t values were 7.50 and 8.10; both P<0.001). Six months after operation, the JOA score (13.70±1.49, 12.94±1.63) and cervical curvature (22.10±3.23, 13.38±3.12) of patients in groups A and B were all higher than those before operation (9.40±1.32, 9.36±1.51; 11.16±2.60, 11.23±2.71), and group A was higher than group B, the difference was statistically significant (JOA scores before and after operation: t values were 14.33 and 10.07, respectively; cervical curvature: t values were 17.50 and 3.25, respectively; t values between groups were 2.22 and 12.47, respectively, and the P values were <0.001, <0.001, <0.001, 0.002, 0.029 and <0.001, respectively). Six months after the operation, the NDI indexes of groups A and B (11.38±4.76, 14.79±4.85) were lower than those before the operation (39.56±9.43, 39.74±9.51), and those in group A were lower than in group B, and the difference was statistically significant ( t values were 17.70, 14.60, and 3.23; all P<0.001). Binary Logistic regression showed that the duration of disease ≥6 months ( OR=59.045, 95% CI: 6.485-537.629), the presence of cervical spinal cord MRI signal changes ( OR=0.031, 95% CI: 0.002-0.587), the surgical approach (posterior approach single-door laminoplasty) ( OR=6.300, 95% CI: 1.269-31.273) was an independent risk factor affecting the surgical outcome ( P values were <0.001, 0.021, and 0.024, respectively). Conclusion:Anterior cervical ACCF combined with ACDF has an ideal surgical effect in the treatment of patients with multi-segment CSM, which can significantly improve the cervical spinal nerve function and cervical curvature, shorten the operation time and reduce the perioperative blood loss. It isstill necessary to pay attention to the patient's disease course, MRI signals changes of cervical spinal cord and the effect of surgical methods on their surgical outcomes.

A Therapeutic Experience of Rapid Progressive HTLV-1 Associated Myelopathy in a Convalescent Rehabilitation Ward：A Case Report / The Japanese Journal of Rehabilitation Medicine

The patient was a 76-year-old woman who developed involuntary movements in both hands and gait disorder. Weakness in both lower limbs gradually worsened, and she was referred to our hospital. Neurological findings included spastic paraplegia, deep sensory disturbance, sensory ataxia, and bladder and bowel dysfunction. Approximately 4 months after the onset, she became unable to walk independently and had to use a walker. MRI showed a long spinal cord lesion extending from the cervical to thoracic spinal cord. Blood and spinal fluid samples tested positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Given these findings and subacute course, she was diagnosed with rapidly progressive HTLV-1 associated myelopathy (HAM). High levels of neopterin and CXCL10 in the cerebrospinal fluid suggested high disease activity；thus, she underwent steroid pulse therapy followed by treatment with maintenance oral prednisolone in our convalescent rehabilitation ward. After approximately 3 months of muscle strength training, mainly for the trunk muscle and the proximal muscle of the lower limbs, and balance exercise, she was able to walk independently and her activities of daily living (ADL) and instrumental ADL (IADL) improved；however, dysuria persisted. The use of clean intermittent self-catheterization instead of indwelling urethral catheter improved her quality of life (QOL). Although rapidly progressive HAM is generally associated with poor prognosis, steroid therapy combined with comprehensive rehabilitation treatment was effective in the present case.

A Therapeutic Experience of Rapid Progressive HTLV-1 Associated Myelopathy in a Convalescent Rehabilitation Ward：A Case Report / The Japanese Journal of Rehabilitation Medicine

The patient was a 76-year-old woman who developed involuntary movements in both hands and gait disorder. Weakness in both lower limbs gradually worsened, and she was referred to our hospital. Neurological findings included spastic paraplegia, deep sensory disturbance, sensory ataxia, and bladder and bowel dysfunction. Approximately 4 months after the onset, she became unable to walk independently and had to use a walker. MRI showed a long spinal cord lesion extending from the cervical to thoracic spinal cord. Blood and spinal fluid samples tested positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Given these findings and subacute course, she was diagnosed with rapidly progressive HTLV-1 associated myelopathy (HAM). High levels of neopterin and CXCL10 in the cerebrospinal fluid suggested high disease activity；thus, she underwent steroid pulse therapy followed by treatment with maintenance oral prednisolone in our convalescent rehabilitation ward. After approximately 3 months of muscle strength training, mainly for the trunk muscle and the proximal muscle of the lower limbs, and balance exercise, she was able to walk independently and her activities of daily living (ADL) and instrumental ADL (IADL) improved；however, dysuria persisted. The use of clean intermittent self-catheterization instead of indwelling urethral catheter improved her quality of life (QOL). Although rapidly progressive HAM is generally associated with poor prognosis, steroid therapy combined with comprehensive rehabilitation treatment was effective in the present case.

Buckling of the Ligamentum Flavum as a Rare Complication of Anterior Cervical Corpectomy and Fusion: A Case Report

Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5- C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed ⅘ muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, whichmay be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.

Severe cervical myelopathy: approaches and postoperative evaluation / Mielopatia cervical grave: vias de acesso e avaliação pós-operatória / Mielopatía cervical grave: vías de acceso y evaluación postoperatoria

ABSTRACT Objectives: To evaluate and compare the clinical evolution of surgical approaches used in patients with severe cervical myelopathy. Methods: Retrospective observational study in which 19 patients with myelopathy who underwent surgery were evaluated. Neurological assessments using the Frankel scale were conducted both preoperatively and one year following surgery, and the modified Japanese Orthopedic Association (JOA), Nurick, and Visual Analog Scale for pain (VAS) questionnaires were applied 1 year after the surgical procedure. Results: 89% of the participants were male and the average age was 63.9 years. No patient had postoperative neurological worsening, 12 patients (63.16%) had mild pain, and seven (36.84%) had moderate pain. The group with degenerative disease showed neurological improvement after surgery and the exclusively anterior approach was used in 84% of the cases, the exclusively posterior approach in 10% of the cases, and the dual approach in 6% of the cases. Conclusion: Surgical treatment has good results for inhibiting the unfavorable natural evolution of myelopathy within 1 year following surgery and promotes neurological improvement in degenerative cases, making it possible to use the anterior access route in most cases. Level of evidence III; Retrospective Study.

RESUMO Objetivos: Avaliar a evolução clínica em comparação com as vias de acesso cirúrgico em pacientes com mielopatia cervical grave. Métodos: Estudo observacional retrospectivo no qual foram avaliados 19 pacientes com mielopatia submetidos à cirurgia. Foram aplicados o questionário da Japanese Orthopedic Association (JOA) modificado, a Escala de Nurick e a Escala Visual Analógica (EVA) da dor um ano depois do procedimento cirúrgico e realizada avaliação neurológica pré-operatória e após um ano da cirurgia com a Escala de Frankel. Resultados: Os participantes eram 89% do sexo masculino e a média de idade foi de 63,9 anos. Nenhum paciente apresentou piora neurológica pós-operatória, 12 pacientes (63,16%) apresentaram dor leve e sete (36,84%) dor moderada. O grupo com doença degenerativa apresentou melhora neurológica depois da cirurgia e a via de acesso anterior exclusiva foi utilizada em 84% dos casos, 10% tiveram acesso exclusivamente por via posterior e 6% tiveram acesso com dupla via. Conclusões: O tratamento cirúrgico apresenta bons resultados para inibir a evolução natural desfavorável da mielopatia no período de um ano depois da cirurgia e promove melhora neurológica nos casos degenerativos, sendo possível a utilização da via de acesso anterior na maior parte dos casos. Nível de evidencia III; Estudo Retrospectivo.

RESUMEN Objetivos: Evaluar la evolución clínica en comparación con las vías de acceso quirúrgico en pacientes con mielopatía cervical severa. Métodos: Estudio observacional retrospectivo en el que se evaluaron 19 pacientes con mielopatía intervenidos quirúrgicamente. Se aplicó el cuestionario modificado de la Japanese Orthopedic Association (JOA), la escala de Nurick y la Escala Visual Analógica (EVA) del dolor 1 año después de la intervención quirúrgica y se realizó la evaluación neurológica preoperatoria y un año después de la cirugía utilizando la Escala de Frankel. Resultados: El 89% de los participantes eran hombres y la edad promedio era de 63,9 años. Ningún paciente presentó empeoramiento neurológico postoperatorio, 12 pacientes (63,16%) presentaron dolor leve y siete (36,84%) dolor moderado. El grupo con enfermedad degenerativa presentó mejoría neurológica tras la cirugía y en el 84% de los casos se utilizó la vía de acceso anterior exclusiva, el 10% la vía posterior exclusiva y el 6% la vía doble. Conclusión: El tratamiento quirúrgico presenta buenos resultados al inhibir la evolución natural desfavorable de la mielopatía en el período de un año después de la cirugía y promueve la mejoría neurológica en los casos degenerativos, posibilitando el uso de la vía de acceso anterior en la mayoría de los casos. Nivel de evidencia III; Estudio Retrospectivo.

Mielopatía cervical secundaria al consumo recreativo de óxido nitroso una afección emergente / Cervical myelopathy secondary to recreational nitrous oxide use: an emergent pathology

Resumen Se describe el caso de una paciente de 27 años que se presentó al servicio de urgencias por hipoestesia y parestesia de dos meses de evolución. El cuadro se inició en ambos pies, progresó en pocos días hasta las rodillas sin trastornos de la marcha y se acompañó de distonías en pulgar e índice de ambas manos. La analítica sanguínea incluyendo tóxicos fue negativa. La resonancia magnética medular mostró una imagen sugestiva de mielopatía o mielitis (C3-C5) sin otras anomalías sugestivas de enfermedad sistémica. El análisis bioquímico y el bacteriológico del líquido cefalorraquídeo fueron normales. Ante estos elementos se re-interrogó a la paciente en busca de consumo de tóxicos inusuales con la confirmación de consumo de óxido nitroso. La paciente fue internada para la realización de otros estudios que confirmaron la hipótesis diagnóstica del servicio de urgencias.

Abstract We describe the case of a 27-year-old female patient who presented to the emergency ward with hypoesthesia and paresthesia developing over the last two months, initially in both feet and progressing to the knees in a few days without associated gait disorders. Dystonia in the thumb and index finger of both hands was noted. Blood tests including toxic drugs were negative. The spinal magnetic resonance imaging was consistent with (C3-C5) myelopathy or myelitis without other abnormalities suggestive of systemic diseases. The biochemi cal and bacteriological analysis of the cerebrospinal fluid was normal. Because of these findings, the patient was re-interviewed to determine the consumption of unusual drugs, and nitrous oxide consumption was referred. The patient was admitted for further studies, which confirmed the diagnosis.

Subacute Post-Traumatic Ascending Myelopathy (SPAM) in a Spinal Cord Injured Patient - a Rare Presentation: A Case Report

@#The optimisation of blood pressure management is critical in managing hypotensive episodes in patients with spinal cord injury. Improper handling of this preventable factor will negatively impact the patient recovery prognosis. A 42-yearold man was admitted for a complete spinal cord injury after fell from height. He developed subacute neurological deterioration unrelated to the mechanical instability but due to multiple episodes of hypotension occurring one month after the initial injury. After proper management of blood pressure, his deterioration was halted and no further progression. Spinal cord haemodynamics play an important role in mediating the onset of subacute post-traumatic ascending myelopathy. Better education and awareness on Subacute Post-traumatic Ascending Myelopathy (SPAM) especially to the junior healthcare providers are important to hinder this rare but avoidable condition.

Effect of mecobalamine combined with mouse nerve growth factor on nerve function recovery after cervical spondylotic myelopathy surgery / 中国组织工程研究

BACKGROUND: Cervical spondylotic myelopathy is a common degenerative disease of the cervical spine in spinal surgery. Surgical decompression is the most effective method to prevent the further development of the disease. However, patients are often accompanied by residual neurological symptoms such as sensory and motor dysfunction after surgery. Currently, the drug treatment for postoperative neurological recovery of patients is still unclear clinically. OBJECTIVE: To investigate the effect of mecobalamine combined with mouse nerve growth factor on the recovery of nerve function after cervical spondylotic myelopathy surgery. METHODS: A total of 82 cases of cervical spondylotic myelopathy from June 2017 to September 2018 in the Affiliated Hospital of Xuzhou Medical University were enrolled in this study. All the patients were randomly divided into observation group and control group with 41 cases in each. Mouse nerve growth factor injection was applied to the control group, and mecobalamine injection was added to the research group. All the patients were treated for 2 weeks. The symptoms and signs in both groups were respectively recorded before and after the treatment, and postoperative residual neurological symptoms were evaluated by Neck Disability Index (NDI) scores and Japanese Orthopedic Association scores. RESULTS AND CONCLUSION: At 1 month, 3 months, 6 months and 1 year after the operation, the NDI scores of the two groups were lower than those before the treatment, and the JOA scores were both getting higher than those before the treatment. The NDI scores in the observation group at 6 months and 1 year after the operation were significantly lower than those in the control group, and as well, the Japanese Orthopedic Association scores were significantly higher than those in the control group. These findings indicate that the combination of mecobalamine and mouse nerve growth factor is helpful to the recovery of nerve function in patients after cervical spondylotic myelopathy surgery, and the effect is better than that of mouse nerve growth factor alone.

Clinical features of hepatic myelopathy: An analysis of 562 cases / 临床肝胆病杂志

ObjectiveTo investigate the clinical features of patients with hepatic myelopathy (HM) in China. MethodsThe articles on HM, published in China from January 2009 to December 2018, were collected to analyze the clinical features, laboratory examination results, diagnosis, treatment, and prognosis of HM patients. ResultsA total of 94 articles were included, with 562 patients in total, among whom there were 489 male patients and 73 female patients. Their age ranged from 17-81 years, with a mean age of 46.3±17.5 years. Hepatitis B cirrhosis was the most common etiology (64.4%), followed by alcoholic cirrhosis (10.3%) and hepatitis C cirrhosis (9.2%). The clinical manifestations of HM mainly included decline of muscle strength (89.50%), tendon hyperreflexia (76.87%), ataxia, and movement disorder (76.51%). Laboratory examination showed an increase in blood ammonia by 92.31% and a reduction in albumin by 88.96%. Imaging diagnosis mainly depended on electromyography (64.92%) and spinal cord MRI (22.82%), and abdominal color Doppler ultrasound, CT, or MRI alone has limited clinical value. After comprehensive medical treatment, no patient (0%) was cured, 106 patients (18.86%) were improved, 211 patients (37.54%) had no response, 31 patients (5.52%) worsened, 129 patients (22.95%) died, and 53 patients (9.43%) were not explained. A total of 39 patients underwent liver transplantation, with an improvement rate of 5641%. ConclusionHM is a rare complication of end-stage liver disease and is mainly observed in middle-aged men. It has the main manifestation of chronic and progressive spastic paraplegia of both lower limbs. Currently, there is no effective treatment method, and liver transplantation is feasible for some patients, with poor treatment response and poor prognosis.

Co-expression of HBZ, TAX and FOXp3 and HTLV-1-associated myelopathy/tropical spastic paraparesis development in HTLV-1-infected individuals: A systematic review

Human T-cell lymphotropic virus type 1 (HTLV-1) is associated with the development of HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). It has been reported that the HTLV-1 proteins (specifically TAX and HBZ) can modulate FOXp3, resulting in an immune imbalance that can favor the progression of HAM/TSP. This review aims to summarize the literature in order to clarify the relationship between the expression of HTLV-1 mRNAs and/or viral proteins (TAX and HBZ) with the expression of mRNA and/or protein FOXp3 and their correlation with HAM/TSP development. This systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The search strategy was performed on the Medical Literature Analysis and Retrieval System Online and Latin American and Caribbean Literature in Health Sciences Platform using subject descriptors. After screening, six articles were included in this review. The studies suggested that TAX and HBZ have a directly proportional correlation with FOXp3 in individuals with HAM/TSP, which also presented an increased expression of FOXp3 compared to asymptomatic controls and/or healthy donors. This systematic review indicates that TAX and HBZ can interact with FOXp3 and that interaction may influence HAM/TSP development.

Microscope assisted anterior cervical discectomy and fusion for the treatment of single segment cervical spondylotic myelopathy / 中国骨伤

OBJECTIVE@#To compare the efficacy of microscope assisted anterior cervical discectomy and fusion with conventional surgical approach in the treatment of single-segment cervical spondylotic myelopathy.@*METHODS@#The clinical data of 89 patients with single-segment cervical spondylotic myelopathy treated from March 2015 to March 2019 were retrospectively analyzed. There were 55 males and 34 females, with an average of (52.00±11.36) years old. Among the patients, 34 cases were treated with conventional anterior cervical discectomy with fusion (conventional group), including C@*RESULTS@#Intraoperative blood loss and hospital stay in microscope group were less than those in conventional group (@*CONCLUSION@#Both methods can achieve satisfactory effect in treating single-segment cervical spondylotic myelopathy. However, microscope-assisted anterior cervical discectomy and fusion has advantages of clear vision, less bleeding and fewer intraoperative complications.

Microcirugía de las fístulas durales arteriovenosas espinales, más un repaso de la anatomía vascular vertebromedular / Microsurgery of spinal dural arteriovenous fistulas, plus a review of the vertebromedullary vascular anatomy

Introducción: la fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular rara, de etiología desconocida y frecuentemente subdiagnosticada. El tratamiento puede ser microquirúrgico o endovascular. Material y Método: Análisis retrospectivo de una serie de 8 pacientes consecutivos con FDAVE tratados por microcirugía entre 2010 y 2020. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada. Los estudios diagnósticos con RMN (Resonancia Magnética Nuclear), ARM (Angio Resonancia Magnética) y ADM (Angiografía Digital Medular) se utilizaron para determinar nivel lesional y resultados quirúrgicos. Resultados: Fueron operados 8 pacientes (7 masculinos y 1 femenino) con un promedio de edad de 58 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas en: 6 a nivel dorsal entre D6 y D12, una en L2 y la última en S1 (5 derechas y 3 izquierdas). La arteria de Adamkiewicz se identificó en: 4 casos en L1, 2 en D12, 1 en D10 y un caso en D7 (6 izquierdas y 2 derechas). De los 8 pacientes operados, 3 fueron embolizados previamente. La evolución postoperatoria del cuadro neurológico fue: 2 de 8 permanecieron estables y 6 de 8 mejoraron uno o más puntos en la escala de Rankin modificada; no hubo complicaciones en el postoperatorio. Todos los pacientes mejoraron las imágenes en RMN diferida y la ADM luego de los 6 meses fue negativa. El seguimiento promedio fue de 48 meses con un rango de 11 a 116 meses, ningún paciente presentó recidiva de la FDAVE. Conclusiones: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento endovascular.

Introduction: Spinal dural arteriovenous fistula (SDAVF) is a rare vascular disease, of unknown etiology and frequently underdiagnosed. Treatment can be microsurgical or endovascular. Material and Method: Retrospective analysis of a series of 8 SDAVF patients treated by microsurgery between 2010 and 2020. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and modified Rankin scales. Diagnostic studies such as MRI (Magnetic Resonance Imaging), MRA (Magnetic Resonance Angiogram) and spinal DSA (Digital Subtraction Angiography), were evaluated for lesion level, as were surgical results. Results: Eight patients (7 male and 1 female), average age of 58 years were operated. The interval from symptom onset to diagnosis was less than 12 months in all cases except one (32 months). SDAVF locations were thoracic in 6 cases between T6 and T12, at L2 in one and at S1 in one case (5 on the right and 3 on the left). The Adamkiewicz artery was identified in: 4 cases at L1, 2 at D12, 1 at D10 and in one case at D7 (6 left-sided and 2 right-sided). Three of the 8 patients operated had undergone prior embolization. Postoperative neurological outcomes showed: 2 patients remained stable and 6 had improved one or more points on the modified Rankin scale; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at six months. Average follow-up was 48 months (range 11 to 116 months), no patient presented recurrence. Conclusions: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.