The surgical management of dysphagia secondary to diffuse idiopathic skeletal hyperostosis.

OBJECTIVE: This study reviews the management pathway and surgical outcomes of patients referred to and operated on at a tertiary neurosurgical centre, for dysphagia associated with anterolateral cervical hyperostosis (ACH) in diffuse idiopathic skeletal hyperostosis (DISH). PATIENTS & METHODS: Electronic patient records for 6 patients who had undergone anterior cervical osteophytectomy for dysphagia secondary to ACH were reviewed. ACH diagnosis was made by an Ear, Nose and Throat (ENT) specialist and patients were referred to a neurosurgical-led multidisciplinary team (MDT) for review. A senior radiologist performed imaging measurements and vertebral level localization was confirmed via barium-swallow video-fluoroscopy. Speech and language therapists (SLTs) determined the suitability of pre-operative conservative management. Patients were followed-up post-operatively with clinical and radiological assessments. RESULTS: 6 patients (Male to female ratio, 6:0; mean age, 59 years) were referred to a tertiary neurosurgical centre with DISH related dysphagia, an average of 25 months after ENT review (range, 14-36 months) between 2005 and 2016. The vertebral levels implicated in dysphagia ranged from C2 to T1 with a median of 4 vertebral levels involved. The most frequently affected vertebral levels were C4-6 (all 6 patients). The average antero-posterior height (as measured on axial images) of the most prominent osteophyte was 15.9 mm (range 12.0-20.0 mm). Patients underwent elective cervical osteophytectomy on average 10.8 months after neurosurgical review (range, 3-36 months). One patient had a post-operative haematoma needing evacuation and prolonged hospital stay. The average duration of follow-up was 42.3 months. All our patients maintained good symptomatic resolution without osteophyte recurrence. CONCLUSIONS: All our patients experienced significant and sustained clinical improvement. Anterior cervical osteophytectomy consistently leads to improvement in symptomatic ACH patients without recurrence. Early referral to a neurosurgical multi-disciplinary team (MDT) is indicated in ACH related dysphagia, once conservative management has failed.

Recovery of severe motor deficit secondary to herniated lumbar disc prolapse: is surgical intervention important? A systematic review.

INTRODUCTION: The natural history of motor deficit due to lumbar disc herniation has been thought to be favourable. However, on closer analysis of seminal articles on this topic, this is not the case for patients with severe motor deficits (MRC grade ≤3). The aim of this study is to answer the following questions: (1) Is surgical intervention beneficial in patients with severe motor weakness (defined by MRC grade of 3 or less) due to herniated lumbar nucleus pulposus? (2) Does time to surgery from onset of motor weakness influence the outcome? (3) Are there any other prognostic factors? MATERIALS AND METHODS: A comprehensive search was conducted in MEDLINE and EMBASE from 1970 upto July 2013. Inclusion criteria for studies are: (1) minimum of three patients aged 18 and older, who had symptomatic herniated lumbar disc prolapse and underwent surgery, (2) description of pre and post-operative muscle weakness utilising the Medical Research Council (MRC) muscle power grade or equivalent, such that both reviewers could confidently identify a cohort of patients with at least grade three motor weakness or worse, (3) a minimum of 6 months follow-up. RESULTS: Seven studies were identified with a total of 354 patients. Complete recovery was seen in 38.4% of patients following surgery and 32% following non-operative treatment. Age and grade of motor deficit were identified as significant prognostic factors in some of the studies. CONCLUSION: The current available evidence is not robust enough to address the questions posed. We have proposed a framework for future studies.

Giant paravertebral myxoma.

The study design includes case report and clinical discussion. The objective was to describe a rare case of a giant intramuscular myxoma (IMM) presenting as a mass in the paravertebral muscles. Myxoma is a rare benign soft tissue tumour of mesenchymal origin. Although intramuscular presentation is common, they are rare in the paravertebral muscles and are characteristically <5 cm in length. We report the clinical and imaging features in a 70-year-old woman presenting with back pain, asymmetry of the waist and a mass in right paravertebral region. This was originally misdiagnosed as a juxtafacet synovial cyst after CT-guided biopsy. The mass was excised en bloc and sent for histology. This revealed a low-grade myxoid neoplasm with features of an IMM. The patient went on to make a complete recovery. To our knowledge, this is only the fifth case of paravertebral IMM reported in the literature and at approximately 15 cm in length may be the largest encountered in clinical practice.

The lateral approach to intraspinal reimplantation of the brachial plexus: a technical note.

Intraspinal re-implantation after traumatic avulsion of the brachial plexus is a relatively new technique. Three different approaches to the spinal cord have been described to date, namely the posterior scapular, anterolateral interscalenic multilevel oblique corpectomy and the pure lateral. We describe an anatomical study of the pure lateral approach, based on our clinical experience and studies on cadavers.

Thoracolumbar spinal fixation for camptocormia in Parkinson's disease.

A man with early non-fluctuating Parkinson's disease developed disabling camptocormia. The patient was treated with posterior thoracolumbar fixation, which subsequently had to be augmented with anterior interbody fusion. Although the patient ultimately achieved excellent sagittal correction, his postoperative course was complicated and prolonged. Therefore, although this case demonstrates that spinal fixation surgery can be successful, it should probably only be offered after subthalamic nucleus deep brain stimulation has been unsuccessful, or for well motivated patients who express a strong wish for this major reconstructive surgery.

Modification of Wright's technique for C2 translaminar screw fixation: technical note.

PURPOSE: To describe a modification of Wright's technique for C2 translaminar screw fixation. METHODS: Bilateral crossing C2 laminar screws have recently become popular as an alternative technique for C2 fixation. This technique is particularly useful in patients with anomalous anatomy, as a salvage technique where other modes of fixation have failed or as a primary procedure. However, reported disadvantages of this technique include breach of the dorsal lamina and spinal canal, early hardware failure and difficulty in bone graft placement due to the position of the polyaxial screw heads. To address some of these issues, a modified technique was used in six patients. In this technique, the upper part of the spinous process of C2 was removed and the entry point of the screw was in the base of this removed spinous process. RESULTS: The screw position was satisfactory in all patients. There were no intraoperative or early postoperative complications. CONCLUSIONS: Our modification enables placement of a bone graft on the C2 lamina and is also less likely to cause inadvertent cortical breach. Because of these advantages, it is especially suitable for patients with advanced rheumatoid arthritis with destruction of the lateral masses of C2 or as part of a hybrid construct in patients with a unilateral high-riding vertebral artery. This technique is not suitable for bilateral translaminar screw placement.

Primary atypical sacral meningioma--not always benign.

We present a case of an atypical recurrent meningioma of the sacrum with pulmonary metastasis in a 31-year-old man. He presented with deep-seated buttock pain and urinary hesitancy for 3 months. MRI revealed a lesion occupying the central and left side of the sacral canal at the S1-S2 level. Surgical excision of the lesion via a posterior approach was undertaken, and the patient became symptom-free post-operatively. Histology confirmed atypical meningioma. Eight months later he re-presented with similar symptoms, and MRI confirmed local recurrence. The patient underwent left hemisacrectomy. Six months later he again presented with low back pain and MRI confirmed a second local recurrence. A CT scan of the chest showed multiple lung metastases. The patient died of a severe chest infection 18 months later.

Familial chordoma. A report of two cases.

We have treated 175 patients with a chordoma over a ten-year period. Only two had a family history of the condition and we describe these in this paper. In one patient the tumour was at the craniocervical junction and in the other the lesion affected the sacrum. We have undertaken a literature review of familial chordoma and have identified chromosomal abnormalities associated with the condition.

Use of quantitative assessment scales in cervical spondylotic myelopathy--survey of clinician's attitudes.

BACKGROUND: There is considerable uncertainty regarding the selection criteria of patients and timing of surgery for cervical spondylotic myelopathy (CSM). Attempts have been made to quantify CSM severity using various assessment scales to provide an adjunct to clinical decision-making. The aim of the present study was to determine, by means of a 7-item questionnaire the attitudes of clinicians regarding the importance of quantitative assessment scales in the management of CSM, their actual use in clinical practice and how current scales fall short of the ideal. FINDINGS: Clinical history, examination, radiological imaging and quantitative functional assessment were regarded by 117 clinicians as being almost equally important in the management of CSM. However, only 22 (19%) of clinicians admitted to using an assessment scale in clinical practice and 4 (3%) believed there was a 'gold-standard' assessment scale. These clinicians also considered 'ease of use' to be the most important attribute of an ideal assessment scale, followed by 'reproducibility', 'sensitivity to change' and 'validity'. CONCLUSIONS: The discrepancy between the importance attached to quantitative measurement and its actual use suggests that current scales are under-utilised or unsuitable for clinical practice. A new easy-to use scale may be required that better reflects clinical requirements.

The Bryan cervical disc prosthesis as an alternative to arthrodesis in the treatment of cervical spondylosis: 46 consecutive cases.

We present data relating to the Bryan disc arthroplasty for the treatment of cervical spondylosis in 46 patients. Patients with either radiculopathy or myelopathy had a cervical discectomy followed by implantation of a cervical disc prosthesis. Patients were reviewed at six weeks, six months and one year and assessment included three outcome measures, a visual analogue scale (VAS), the short form 36 (SF-36) and the neck disability index (NDI). The results were categorised according to a modification of Odom's criteria. Radiological evaluation, by an independent radiologist, sought evidence of movement, stability and subsidence of the prosthesis.A highly significant difference was found for all three outcome measurements, comparing the pre-operative with the post-operative values: VAS (Z = 6.42, p < 0.0001), SF-36 (mental component) (Z = -5.02, p < 0.0001), SF-36 (physical component) (Z = -5.00, p < 0.0001) and NDI (Z = 7.03, p < 0.0001). The Bryan cervical disc prosthesis seems reliable and safe in the treatment of patients with cervical spondylosis.

Paroxysmal raised intracranial pressure associated with spinal meningeal cysts.

Raised intracranial pressure in association with spinal meningeal cysts has rarely been reported. We describe four patients in whom evidence of paroxysmal raised intracranial pressure was found in association with spinal meningeal cysts. Cerebrospinal fluid diversion procedures have previously been shown to relieve local symptoms due to spinal cysts. In our patients symptoms of paroxysmal headache were alleviated by this method, suggesting a causal relationship with the raised pressure. This association may be an under diagnosed cause of paroxysmal headaches. We review the medical literature on the classification of spinal meningeal cysts, evaluate the theories of their origin and offer suggestions on the pathogenesis of the abnormal CSF dynamics that may allow an interplay between raised intracranial pressure and spinal meningeal cysts to produce paroxysmal symptoms.

Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection.

STUDY DESIGN: Case report. OBJECTIVES: To report a rare case of spinal cord infarction following therapeutic computed tomography-guided nerve root injection. SUMMARY OF BACKGROUND DATA: Diagnostic and therapeutic image-guided nerve root injection is commonly performed in the management of low back pain and sciatica. The severe complication of spinal cord infarction has been reported in only 3 cases previously. METHODS: Retrospective review of case records and imaging. RESULTS: A 71-year-old woman presented with symptoms and signs of left L2 nerve root compression. She was managed with computed tomography-guided left L2 nerve root injection using bupivacaine and triamcinolone and developed immediate bilateral sensory loss and paraplegia. Magnetic resonance imaging demonstrated diffuse hyperintensity within the distal thoracic cord and conus on T2-weighted images, consistent with spinal cord infarction. CONCLUSIONS: We report the fourth case of spinal cord infarction following nerve root injection. The severity of this complication warrants that it should be considered during patient consent for this procedure.

Is there a role for surgery in the management of dropped head syndrome?

We present a 50-year-old chronic epileptic man with a long-standing head drop, who fell sustaining multilevel thoracic vertebral body fractures. The antiepileptic medication was thought to be responsible for his osteoporosis and dropped head. We review the aetiology of the dropped head and report on our experience of surgery for this rare and disabling condition.

Meningeal melanocytoma: clinical features and review of the literature.

A case of meningeal melanocytoma in the posterior fossa of a 16-year-old male is reported. Computed tomographic and magnetic resonance imaging features are presented. Pathological investigation including light and electron microscopy, and immunohistochemical staining are discussed. Current literature is reviewed and differentiating criteria from meningioma and other pigmented tumours of the nervous system are discussed.

Failure to administer methylprednisolone for acute traumatic spinal cord injury-a prospective audit of 100 patients from a regional spinal injuries unit.

OVERVIEW: The National Acute Spinal Cord Injury Studies (NASCIS II and III) and the Cochrane review advocate the administration of high dose methylprednisolone following acute traumatic spinal cord injury. OBJECTIVE: To determine the actual use and correct implementation of the NASCIS protocols in patients referred to a regional spinal injuries unit. DESIGN: Observational study on the timing and correct dosage of methylprednisolone. The admission Frankel grade, American Spinal Injury Association (ASIA) neurological classification were recorded prospectively. SUBJECTS: The 100 consecutive patients with complete or incomplete spinal cord injuries (Frankel grade A-D) were studied over a 2 years period. MAIN OUTCOME MEASURE: Correct administration of methylprednisolone according to the NASCIS protocols. RESULTS: During the study period only 25% of the patients admitted to our spinal injuries unit received methylprednisolone at the referring hospital according to the NASCIS protocols. An additional 10 patients were given methylprednisolone incorrectly. CONCLUSION: Evidence based medicine is not being practiced in the management of patients with acute spinal cord injury.

Neuromodulation through sacral nerve roots 2 to 4 with a Finetech-Brindley sacral posterior and anterior root stimulator.

STUDY DESIGN: Investigation of five patients receiving an implant, using laboratory cystometry and self-catheterisation at home. OBJECTIVES: To use the established Finetech-Brindley sacral root stimulator to increase bladder capacity by neuromodulation, eliminating the need for posterior rhizotomy, as well as achieving bladder emptying by neurostimulation. SETTING: Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. METHODS: Five patients underwent implantation of a Finetech-Brindley stimulator without rhizotomy of the posterior roots. This was either a two channel extradural device (four cases) or a three channel intrathecal device (one case). In each patient, the implant was configured as a Sacral Posterior and Anterior Root Stimulator (SPARS). Postoperatively, repeated provocations using rapid instillation of 60 ml saline were used to determine the relative thresholds for neuromodulation using each channel. The effect of continuous neuromodulation was examined in the laboratory using slow fill cystometrograms, and conditional stimulation was also studied (neuromodulation for 1 min to suppress hyperreflexic contractions as they occurred). In one patient, neuromodulation was applied continuously at home, and volumes at self catheterisation recorded in a diary. RESULTS: Reflex erections were preserved in each patient. In three patients, detrusor hyperreflexia persisted postoperatively and neuromodulation via the implant was studied. In these three patients, the configuration was: S2 mixed roots bilaterally (channel B), and S34 bilaterally (channel A). Both channels could be used to suppress provoked hyperreflexic contractions, with the S2 channel effective at a shorter pulse width than S34 in a majority of cases. Continuous stimulation more than doubled bladder capacity in two out of three patients during slow fill cystometry. Conditional stimulation was highly effective. In the one patient who used continuous stimulation at home, bladder capacity was more than doubled and the effect was comparable with anticholinergic medication. Bladder pressures >70 cm water could be achieved with intense stimulation in three patients, but detrusor-external urethral sphincter dyssynergia (DSD) prevented complete emptying. CONCLUSIONS: Neuromodulation via a SPARS was effective and may replace the need for posterior rhizotomy. However, persisting DSD may prevent complete bladder emptying and warrants further investigation.

Questionnaire survey of the views of the delegates at the European Cervical Spine Research Society meeting on the administration of methylprednisolone for acute traumatic spinal cord injury.

STUDY DESIGN: A questionnaire survey. OBJECTIVES: To collate and analyze the views of the delegates who attended the European Cervical Spine Research Society (CSRS) meeting on the use of methylprednisolone for acute traumatic spinal cord injury. SUMMARY OF BACKGROUND DATA: The NASCIS II and III studies reported improved neurologic recovery in patients who were treated with methylprednisolone within 8 hours of their acute traumatic spinal cord injury. A number of reported commentaries have criticized these trials. A recent audit in the authors' regional spinal injuries unit in the United Kingdom found that a large percentage of patients were not receiving methylprednisolone. The authors decided to collate the views of the delegates at the CSRS regarding the use of steroids for acute traumatic spinal cord injury. METHODOLOGY: A questionnaire was created that took into account the positive reported findings as well as the criticisms of the NASCIS studies. Delegates who attended the European CSRS meeting completed this questionnaire. RESULTS: Seventy-five percent of the delegates answered that they used or recommended methylprednisolone in the treatment of acute traumatic spinal cord injury. Nevertheless, the delegates had an average of 1.5 reservations about administering methylprednisolone. The most common reservation was that they did not think the improvement conferred to the patients by administering methylprednisolone had been clinically or functionally proven. There were reservations about the validity of the statistical analysis used in the NASCIS studies and by the omission of a placebo group in NASCIS III. The majority of the delegates thought it was not medicolegally negligent to withhold the administration of methylprednisolone in the treatment of acute traumatic spinal cord injury. CONCLUSION: The use of methylprednisolone in the treatment of acute traumatic spinal cord injury is still controversial. It would appear from a recent prospective audit at the authors' spinal injuries unit that a large percentage of patients in the United Kingdom are not receiving methylprednisolone. Because so much doubt exists, the NASCIS studies should be repeated.