Cervical laminoplasty versus laminectomy and fusion: An umbrella review of postoperative outcomes.

While multiple studies exist comparing cervical laminoplasty (CLP) and posterior cervical laminectomy with fusion (PCF), no clear consensus exists on which intervention is better. An umbrella review helps provide an overall assessment by analyzing a given condition's multiple interventions and outcomes. It integrates all available information on a topic and allows a consensus to be reached on the intervention of choice. A literature search was conducted using specific search criteria in PubMed, Scopus, and Web of Science databases. Titles and abstracts were screened based on inclusion criteria. A full-text review of articles that passed the initial inclusion criteria was performed. Nine meta-analyses were deemed eligible for the umbrella review. Data was extracted on reported variables from these meta-analyses. Subsequent quality assessment using AMSTAR2 and data analysis using the R package metaumbrella were used to determine the significance of postoperative outcomes. When the meta-analyses were pooled, statistically significant differences between CLP and PCF were found for postoperative overall complications rate and postoperative JOA score. PCF was associated with a lower overall complication rate and a higher postoperative JOA score, both supported by a weak level of evidence (class IV). Data regarding all other outcomes were non-significant. Our umbrella review investigates CLP and PCF by providing a comprehensive overview of existing evidence and evaluating inconsistencies within the literature. This umbrella review revealed that PCF had better outcomes for overall complications rate and postoperative JOA than CLP, but they were classified as being of weak significance.

Surgical outcome of a patient with Bertolotti's syndrome in whom the established Castellvi classification system failed: illustrative case.

BACKGROUND: Bertolotti's syndrome is a condition of the lower back and/or L5 distribution leg pain caused by a lumbosacral transitional vertebra (LSTV). Diagnosing the LSTV as the cause of the symptoms and condition is essential for accurate management of this syndrome. Castellvi's classification system is widely accepted for LSTV anatomy, but it measures only one aspect of transitional anatomy and was intended primarily to identify target-level disk herniations. OBSERVATIONS: In this case, the Castellvi classification system failed to identify the patient (with 2 years of back and L5 pain) as having an LSTV, even though he displayed LSTV-like anatomy because both L5 transverse process heights measured less than 19 mm. He attained brief but significant relief from bilateral injections into the L5-S1 transverse/ala region and underwent a minimally invasive bilateral decompression of L5-S1 with almost complete relief of his symptoms maintained more than 6 months postoperatively. LESSONS: Given that the patient gained significant relief from treatment of transitional anatomy that failed to be identified using Castellvi's classification system, this case suggests that transverse process height may not be adequate or even the most clinically relevant indicator in identifying LSTV anatomy, which is a precursor to the diagnosis of Bertolotti's syndrome.

Redefining the Classification for Bertolotti Syndrome: Anatomical Findings in Lumbosacral Transitional Vertebrae Guide Treatment Selection.

OBJECTIVE: We present the Jenkins classification for Bertolotti syndrome or symptomatic lumbosacral transitional vertebra (LSTV) and compare this with the existing Castellvi classification for patients presenting for treatment. METHODS: We performed a retrospective cohort study of 150 new patients presenting for treatment of back, hip, groin, and/or leg pain from July 2012 through February 2022. Using magnetic resonance imaging, computed tomography, and radiography, the patients with a radiographic finding of LSTV, an appropriate clinical presentation, and identification of LSTV as the primary pain generator via diagnostic injections were diagnosed with Bertolotti syndrome. Patients for whom conservative treatment had failed and who underwent surgery to address their LSTV were included in the present study. RESULTS: The Castellvi classification excludes 2 types of anatomic variants: the prominent anatomic side and the potential transverse process and iliac crest contact. Of 150 patients with transitional anatomy, 103 (69%) were identified with Bertolotti syndrome using the Jenkins classification and received surgery (46 men [45%] and 57 women [55%]). Of the 103 patients, 90 (87%) underwent minimally invasive surgery. The patients presented with pain localized to the back (n = 101; 98%), leg (n = 79; 77%), hip (n = 51; 49%), and buttock (n = 52; 50%). Only 84 of the Jenkins classification patients (82%) met any of the Castellvi criteria. All 19 patients for whom the Castellvi classification failed had had type 1 anatomy using the Jenkins system and underwent surgery (decompression, n = 16 [84%]; fusion, n = 1 [5%]; fusion plus decompression, n = 2 [11%]). Of these 19 patients, 17 (89%) had improved pain scores. The 19 patients exclusively diagnosed via the Jenkins classification had no significant differences in improved pain compared with those diagnosed using the Castellvi classification. CONCLUSIONS: The Jenkins classification improves on the prior Castellvi classification to more comprehensively describe the functional anatomy, identify uncaptured anatomy, and better predict optimal surgical procedures to treat those with Bertolotti syndrome.

Redefining the Treatment of Lumbosacral Transitional Vertebrae for Bertolotti Syndrome: Long-Term Outcomes Utilizing the Jenkins Classification to Determine Treatment.

OBJECTIVE: Using the Jenkins classification, we propose a strategy of shaving down hypertrophic bone, unilateral fusion, or bilateral fusion procedures to achieve pain reduction and improve quality of life for patients with Bertolotti syndrome. METHODS: We reviewed 103 patients from 2012 through 2021 who had surgically treated Bertolotti syndrome. We identified 56 patients with Bertolotti syndrome and at least 6 months of follow-up. Patients with iliac contact preoperatively were presumed to be more likely to have hip pain that could respond to surgical treatment, and those patients were tracked for those outcomes as well. RESULTS: Type 1 patients (n = 13) underwent resection. Eleven (85%) had improvement, 7 (54%) had good outcome, 1 (7%) had subsequent surgery, 1 (7%) was suggested additional surgery, and 2 (14%) were lost to follow-up. In Type 2 patients (n = 36), 18 underwent decompressions and 18 underwent fusions as a first line. Of the 18 patients treated with resection an interim analysis saw 10 (55%) with failure and needing subsequent procedures. With subsequent procedure, 14 (78%) saw improvement. For fusion surgical patients, 16 (88%) saw some improvement and 13 (72%) had a good outcome. In Type 4 patients (n = 7), 6 (86%) did well with unilateral fusion, with durable benefit at 2 years. In patients who had hip pain preoperatively (n = 27), 21 (78%) had improvement of hip pain postoperatively. CONCLUSIONS: The Jenkins classification system provides a strategy for patients with Bertolotti syndrome who fail conservative therapy. Patients with Type 1 anatomy respond well to resection procedures. Patients with Type 2 and Type 4 anatomy respond well to fusion procedures. These patients respond well in regard to hip pain.

Intramedullary spinal cord metastasis treated with prophylactic laminoplasty prior to radiation to the spinal cord: a case report.

Background: A cervical laminoplasty is a surgical procedure used to treat moderate-to-severe cervical stenosis resulting in cervical myelopathy. It is performed to widen the spinal canal and reduce compression on the spinal cord and surrounding nerves. Though often performed electively on patients presenting with varying degrees of neurologic dysfunction including weakness and imbalance, it may also be used prophylactically when spinal cord inflammation or edema is anticipated. Radiotherapy in the spinal cord is known to produce radiation-induced damage leading to radiation myelopathy. Case Description: We present the case of a 62-year-old male diagnosed with both cervical stenosis and an intramedullary cervical spinal cord metastatic tumor. This patient presented with significant symptoms including limited mobility, numbness, lower back pain, paresthesia, and spasms in both legs as well as worsening sexual function. Given that the patient was to undergo radiotherapy, a cervical laminoplasty was performed to eliminate ongoing spinal cord compression as well to prevent future neurologic decline resulting from post-radiation inflammation and edema. Conclusions: This case highlights that cervical laminoplasty can be performed safely and effectively with significant improvement in patients with metastatic disease. By treating the underlying symptomatic stenosis, and protect the patient from the potential for spinal cord edema from radiation to a spinal cord lesion in an already narrow spinal canal.

A novel two-layer, intradural and extradural patch graft approach to treating dural defects and tears: illustrative case.

BACKGROUND: Dural tears must be quickly addressed to avoid the development of positional headaches and pseudomeningoceles, among other complications. However, sizeable areas of friable or absent dura create unique challenges when attempting to achieve a watertight seal. We have developed a two-layer subdural and epidural fibrous patch technique to treat expansive or challenging dural tears as a result of our experience treating spinal fluid leaks. OBSERVATIONS: The authors present the treatment of a large necrotic (5 × 1.5 cm) dural defect refractory to initial attempts at standard primary repair with dural patch grafting and requiring a revision with a dual-layer patch to manage persistent cerebrospinal fluid leakage. LESSONS: The use of a two-layer (subdural and epidural) patch is both a safe and effective dural repair technique for creating a watertight seal in challenging large areas in which the dura may be damaged, scarred, or absent. We also propose that this technique may be able to be used for smaller challenging tears, as well as potentially for repairs of large blood vessels or other fluid-filled structures in the body.

Minimally invasive endoscopic approach to perform complete coccygectomy in patients with chronic refractory coccydynia: illustrative case.

BACKGROUND: Coccydynia refers to debilitating pain in the coccygeal region of the spine. Treatment strategies range from conservative measures (e.g., ergonomic adaptations, physical therapy, nerve block injections) to partial or complete removal of the coccyx (coccygectomy). Because the surgical intervention is situated in a high-pressure location close to the anus, a possible complication is the formation of sacral pressure ulcers and infection at the incision site. OBSERVATIONS: In this case report, the authors presented a minimally invasive, fully endoscopic approach to safely perform complete coccygectomy for treatment of refractory posttraumatic coccydynia. LESSONS: Although this is a single case report, the authors hope that this novel endoscopic approach may achieve improved wound healing, reduced infection rates, and lower risk of penetration injury to retroperitoneal organs in patients requiring coccygectomy.

Minimally Invasive Resection of Symptomatic Cervical Rib for Treatment of Thoracic Outlet Syndrome.

BACKGROUND: Neurogenic thoracic outlet syndrome treatments have high morbidity and recurrence rates. We present for the first time to our knowledge a minimally invasive spine surgery technique for complete resection of a cervical rib via a costotransversectomy approach. CASE DESCRIPTION: A patient with an 8-year history of progressive thoracic outlet syndrome presented with right C8 pain, weakness, and atrophy of her right forearm and thenar eminence. After neurogenic thoracic outlet syndrome was confirmed via electromyography and imaging revealed bilateral cervical ribs (right more than left), the patient underwent a minimally invasive spine surgery resection of the rib via a costotransversectomy and was discharged home the same day. The patient's pain and weakness gradually improved over a 2-year follow-up period. CONCLUSIONS: Resection of a cervical rib via minimally invasive spine surgery costotransversectomy is safe and well tolerated compared with existing surgical treatments such as transaxillary, supraclavicular, and infraclavicular approaches.

Obesity and Insulin Resistance Are Inversely Associated with Serum and Adipose Tissue Carotenoid Concentrations in Adults.

BACKGROUND: Low tissue concentrations of carotenoids have been suggested to contribute to insulin resistance in obesity. OBJECTIVES: The objectives of the study were to 1) evaluate the relations of adipose tissue and serum carotenoids with body fat, abdominal fat distribution, muscle, adipose tissue and liver insulin resistance, and dietary intake; 2) evaluate the relations and distributions of carotenoids detected in adipose tissue and serum; and 3) compare serum carotenoids and retinol concentrations in subjects with and without obesity. METHODS: Post hoc analysis of serum and adipose tissue carotenoids in individuals [n = 80; 31 men, 49 women; age (mean ± SEM): 51.4 ± 1.1 y] who participated in 2 separate studies conducted at the Clinical Research Facility at the Garvan Institute of Medical Research (Sydney) between 2008 and 2013. Retinol, α-carotene, ß-carotene, ζ-carotene, lutein, lycopene, phytoene, and phytofluene were measured using HPLC. Body composition was measured by dual-energy X-ray absorptiometry. Insulin resistance was measured by 2-step hyperinsulinemic-euglycemic clamps with deuterated glucose (n = 64), and subcutaneous and visceral abdominal volume and liver and pancreatic fat by MRI (n = 60). Periumbilical subcutaneous fat biopsy was performed and carotenoids and retinol measured in the tissue (n = 16). RESULTS: We found that ζ-carotene, phytoene, and phytofluene were stored in considerable amounts in adipose tissue (25% of adipose tissue carotenoids). Carotenoid concentrations in adipose tissue and serum correlated significantly, but they followed different distributions: ζ-carotene was 3-fold higher in adipose tissue compared with serum, while lutein and lycopene made up 20% and 21% of serum carotenoids compared with 2% and 12% of adipose tissue carotenoids, respectively. Liver (P ≤ 0.028) and adipose tissue (P = 0.023), but not muscle (P ≥ 0.16), insulin resistance correlated inversely with many of the serum carotenoids. CONCLUSIONS: Multiple serum and adipose tissue carotenoids are associated with favorable metabolic traits, including insulin sensitivity in liver and adipose tissue in humans.

Plastic Surgeon Closure of Index Spinal Cases: A Single-Institution Review of 928 Cases.

PURPOSE: The role of the plastic surgeon in wound management following complications from prior spinal surgeries is well established. The present study evaluates wound complications following plastic surgeon closure of the primary spinal surgery in a large patient population. METHODS: Spinal surgeries closed by a single plastic surgeon at a large academic hospital were reviewed. Descriptive statistics were applied and outcomes in this sample were compared with previously published outcomes using 2-sample z tests. RESULTS: Nine hundred twenty-eight surgeries were reviewed, of which 782 were included. Seven hundred fifteen operations were for degenerative conditions of the spine, 22 for trauma, 30 for neoplasms, and 14 for congenital conditions. Four hundred twenty-one were lumbosacral procedures (53.8%) and 361 (46.2%) cervical. Fourteen patients (1.8%) required readmission with 30 days. This compares favorably to a pooled analysis of 488049 patients, in which the 30-day readmission rate was found to be 5.5% (z=4.5, P<0.0001). Seven patients (0.89%) had wound infection and 3 (0.38%) wound dehiscence postoperatively, compared with a study of 22,430 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who had an infection incidence of 2.2% (z=2.5, P=0.0132) and 0.3% dehiscence rate (z=0.4, P=0.6889). The combined incidence of wound complications in the present sample, 1.27%, was less than the combined incidence of wound complications in the population of 22,430 patients (z=2.2, P=0.029). CONCLUSIONS: Thirty-day readmissions and wound complications are intensely scrutinized quality metrics that may lead to reduced reimbursements and other penalties for hospitals. Plastic surgeon closure of index spinal cases decreases these adverse outcomes. Further research must be done to determine whether the increased cost of plastic surgeon involvement in these cases is offset by the savings represented by fewer readmissions and complications.

New Predictive Index for Survival in Symptomatic Spinal Metastases.

OBJECTIVE: Patients with spinal metastases have broad variability in morbidity, mortality, and survival. Existing prognostic scoring systems have limited predictive value. Our aim is, given recent advances in surgical and medical care for patients with cancer and spinal metastases, to develop a new survival index with superior prognostic value. METHODS: We completed a retrospective analysis on 77 patients who received surgery for metastatic tumors to the spine, of patient factors like pathologic subtype, age, neurologic examination, type of surgical procedure, Hauser Ambulation Index, and a novel scoring system for degree of tumor burden in several organ systems, among others. A survival index will be derived from the patient factors that, when measured preintervention, best predicted survival post intervention. RESULTS: Although primary organ or pathologic type was not predictive of survival for patients with metastatic disease in this population, the degree of lung tumor burden (LTB) and preoperative Hauser Ambulation Index were predictive of survival. After a multivariable analysis of >20 different patient factors, the Jenkins Survival Index (JSI, a 0-21 scale) was constructed using a machine-learning system as the sum of the HAI (0-9 scale) and LTB score (0-3 scale) multiplied by 4 (JSI = HAI + 4 · LTB, Rho = -0.588, P < 0.0001). The JSI had a positive predictive value of 92% compared with 54.1% and 56.9% for Tokuhashi and Tomita scales, respectively. CONCLUSIONS: The JSI predicts in a meaningful way survival outcomes for patients symptomatic from spinal metastases, which will be of value to oncologists and other clinicians treating patients with metastatic disease.

Deletion distal to the PAX6 coding region reveals a novel basis for familial cosegregation of aniridia and diabetes mellitus.

AIMS: Analyze cosegregation of aniridia and diabetes to identify genetic criteria for detection and early treatment of diabetes-susceptible aniridia patients. METHODS: We assessed a two-generation family: three individuals with aniridia, two previously diagnosed as type 2 diabetes. One individual with aniridia, with unknown diabetes status, was evaluated by oral glucose tolerance test. Genetic analysis of aniridia-associated genes was performed on all available family members. Candidate genes were functionally tested by gene silencing in MIN6 pancreatic ß-cells. RESULTS: A 25 year old male with aniridia had a diabetic oral glucose tolerance test despite a normal fasting blood glucose. A 484-630 kb deletion ∼120 kb distal to PAIRED BOX 6 (PAX6) showed dominant cosegregation with aniridia and diabetes in all affected family members. The deleted region contains regulatory elements for PAX6 expression and four additional coding regions. Knockdown of two of the deleted genes (Dnajc24 or Immp1l) with Pax6 impaired glucose-stimulated insulin secretion. CONCLUSIONS: We demonstrate dominant cosegregation of diabetes and aniridia with a deletion distal to PAX6, which is clinically distinct from the mild glucose intolerance previously reported with PAX6 coding mutations. Asymptomatic aniridia individuals appear at risk of diabetes (and its complications) and could benefit from earlier diagnosis and treatment.

Surgical Treatment of a Rare Presentation of Bertolotti's Syndrome from Castellvi Type IV Lumbosacral Transitional Vertebra: Case Report and Review of the Literature.

Background Advancements in radiological imaging and diagnostic criteria enable doctors to more accurately identify lumbosacral transitional vertebrae (LSTV) and their association with back and L5 distribution leg pain. It is considered the most common congenital anomaly of the lumbosacral spine with an incidence between 4 and 35%, 3 although many practitioners describe 10 to 12% overall incidence. LSTVs include sacralization of the L5 vertebral body and lumbarization of the S1 segment while demonstrating varying morphology, ranging from broadened transverse processes to complete fusion. 5 The most common types of LSTV that present with symptomatic Bertolotti's syndrome are the Castellvi type I and type II; type III and type IV variants rarely present with symptoms referable with confirmatory and provocative testing to the transitional vertebra itself, and therefore there is limited experience and no case reports of treatment toward this particular entity. Case Description We illustrated a case of a 37 years old female in which a computed tomography scan demonstrated type III LSTV on the left and a type I anomaly on the right. The patient presented with right-sided leg pain and left-sided sacroiliac (SI) region low back pain, worse with rotation and standing, for several years, and had been on daily narcotic pain medications for more than 2 years. The patient had temporary relief of her leg pain with a transverse/ALA injection on the right, but no improvement in her back pain, whereas a left-sided injection into the region around the type III interface on the left did transiently alleviate her SI pain without improvement in her leg pain. We proposed that this particular anomaly induced mechanical back pain on the left side by flexion of the bone bridge (a form of stress-fracture, with associated sclerotic changes in the interface in the transverse/ALA junction) with associated irritation of the right L5 nerve from the type I anomaly on the right in conjunction with her typical radiating leg pain on the right. A patent, but somewhat hypoplastic L5/S1 disk space was also present. Nonsegmental pedicle screw instrumentation with low-profile screws was implanted on the right side with fusion induced using allograft and off label use of infuse rh-BMP2 bone graft substitute, and the patient was discharged the same day. The patient noted immediate improvement in her preoperative symptoms, and by 2 weeks after her surgery noted complete resolution of the preoperative symptoms, and required no narcotic medications to control her incisional pain. Conclusion Patients who present with symptoms consistent with Bertolotti's syndrome, even if they have a type III or type IV LSTV, should be considered for surgical treatment of their LSTV. These patients can respond well, even if symptoms have been present for years. Given the prevalence of these anatomic variants in the general population (10-12% in most series), Bertolotti's syndrome should be considered in the differential diagnosis of any patient with a presentation of L5 radiculopathy and/or back pain.

Emerging Safety of Intramedullary Transplantation of Human Neural Stem Cells in Chronic Cervical and Thoracic Spinal Cord Injury.

BACKGROUND: Human central nervous system stem cells (HuCNS-SC) are multipotent adult stem cells with successful engraftment, migration, and region-appropriate differentiation after spinal cord injury (SCI). OBJECTIVE: To present data on the surgical safety profile and feasibility of multiple intramedullary perilesional injections of HuCNS-SC after SCI. METHODS: Intramedullary free-hand (manual) transplantation of HuCNS-SC cells was performed in subjects with thoracic (n = 12) and cervical (n = 17) complete and sensory incomplete chronic traumatic SCI. RESULTS: Intramedullary stem cell transplantation needle times in the thoracic cohort (20 M HuCNS-SC) were 19:30 min and total injection time was 42:15 min. The cervical cohort I (n = 6), demonstrated that escalating doses of HuCNS-SC up to 40 M range were well tolerated. In cohort II (40 M, n = 11), the intramedullary stem cell transplantation needle times and total injection time was 26:05 ± 1:08 and 58:14 ± 4:06 min, respectively. In the first year after injection, there were 4 serious adverse events in 4 of the 12 thoracic subjects and 15 serious adverse events in 9 of the 17 cervical patients. No safety concerns were considered related to the cells or the manual intramedullary injection. Cervical magnetic resonance images demonstrated mild increased T2 signal change in 8 of 17 transplanted subjects without motor decrements or emerging neuropathic pain. All T2 signal change resolved by 6 to 12 mo post-transplant. CONCLUSION: A total cell dose of 20 M cells via 4 and up to 40 M cells via 8 perilesional intramedullary injections after thoracic and cervical SCI respectively proved safe and feasible using a manual injection technique.

Contemporary spinal oncology treatment paradigms and outcomes for metastatic tumors to the spine: A systematic review of breast, prostate, renal, and lung metastases.

Metastatic spinal disease most frequently arises from carcinomas of the breast, lung, prostate, and kidney. Management of spinal metastases (SpM) is controversial in the literature. Recent studies advocate more aggressive surgical resection than older studies which called for radiation therapy alone, challenging previously held beliefs in conservative therapy. A literature search of the PubMed database was performed for spinal oncology outcome studies published in the English language between 2006 and 2016. Data concerning study characteristics, patient demographics, tumor origin and spinal location, treatment paradigm, and median survival were collected. The search retrieved 220 articles, 24 of which were eligible to be included. There were overall 3457 patients. Nine studies of 1723 patients discussed parameters affecting median survival time with comparison of different primary cancers. All studies found that primary cancer significantly predicted survival. Median survival time was highest for primary breast and renal cancers and lowest for prostate and lung cancers, respectively. Multiple spinal metastases, a cervical location of metastasis, and pathologic fracture each had no significant influence on survival. Survival in metastatic spinal tumors is largely driven by primary tumor type, and this should influence palliative management decisions. Surgery has been shown to greatly increase quality of life in patients who can tolerate the procedure, even in those previously treated with radiotherapy. Surgery for SpM can be used as first-line therapy for preservation of function and symptom relief. Future studies of management of SpM are warranted and primary tumor diagnosis should be studied to determine contribution to survival.

Muscle Sympathetic Nerve Activity Is Associated with Liver Insulin Sensitivity in Obese Non-Diabetic Men.

Introduction: Muscle sympathetic nerve activity (MSNA) may play a role in insulin resistance in obesity. However, the direction and nature of the relationship between MSNA and insulin resistance in obesity remain unclear. We hypothesized that resting MSNA would correlate inversely with both muscle and liver insulin sensitivity and that it would be higher in insulin-resistant vs. insulin-sensitive subjects. Materials and methods: Forty-five non-diabetic obese subjects were studied. As no significant relationships were found in women, the data presented in on 22 men aged 48 ± 12 years. Two-step (15 and 80 mU/m2/min) hyperinsulinaemic-euglycaemic clamps were performed using deuterated glucose to determine liver and muscle insulin sensitivity. Clinical and metabolic parameters were assessed. MSNA was measured via a microelectrode inserted percutaneously into the common peroneal nerve. Results: MSNA burst frequency correlated inversely with liver insulin sensitivity (r = -0.53, P = 0.02) and positively with the hepatokines C-reactive protein (CRP) and fibroblast growth factor (FGF)-19 (r = 0.57, P = 0.006, and r = -0.47, P = 0.03, respectively). MSNA burst frequency was lower in Liversen compared to Liverres (27 ± 5 vs. 38 ± 2 bursts per minute; P = 0.03). Muscle insulin sensitivity was unrelated to MSNA. Discussion: Sympathetic neural activation is related to liver insulin sensitivity and circulating hepatokines CRP and FGF-19 in non-diabetic obese men. These results suggest a potential hepato-endocrine-autonomic axis. Future studies are needed to clarify the influence of MSNA on liver insulin sensitivity in men.

Cyclic Sciatica and Back Pain Responds to Treatment of Underlying Endometriosis: Case Illustration.

BACKGROUND: Multiple causes outside the spine can mimic spinal back pain. Endometriosis is an important gynecologic disorder, which commonly affects the lower region of the female pelvis and less frequently the spine and soft tissues. The lumbosacral trunk is vulnerable to pressure from any abdominal mass originating from the uterus and the ovaries. Therefore symptoms of endometriosis include severe reoccurring pain in the pelvic area as well as lower back and abdominal pain. CASE DESCRIPTION: We report on a 39-year-old gymnast with cyclic sciatica and back pain, whose initial presentation initially led to a spinal fusion at L4/5 and L5/S1, but that procedure did not change her symptoms. Her diagnosis of endometriosis was not made until 2 years after her spinal fusion. Ultimately, once diagnosed with endometriosis of the retroperitoneal spinal and neural elements, her back and leg pain responded completely to hormonal therapy and then to a hysterectomy and a bilateral salpingo-oophorectomy. Because her true diagnosis of endometriosis was unknown and she had some degenerative changes in her spine, she underwent a spinal fusion that would probably not have been done if the diagnosis of endometriosis had been suggested. CONCLUSIONS: It is critical for any clinician who deals with back pain to at least consider the diagnosis of endometriosis in female patients who have a history of pelvic pain. The diagnosis of endometriosis should be considered in candidate patients by asking whether there is a significant hormonal cyclic nature to the symptoms, to prevent such unnecessary surgical adventures.

Effects of dietary fat subtypes on glucose homeostasis during pregnancy in rats.

BACKGROUND: Dietary n-3 and n-6 polyunsaturated fatty acids (PUFAs) have an impact on insulin secretion and sensitivity but whether and how these may be related to maternal glucose homeostasis during pregnancy is unclear. METHODS: Female Wistar rats (240-250 g) were assigned to laboratory CHOW or high fat diets rich in either n-6 (safflower oil; n-6 group) or n-6 + n-3 (safflower oil + fish oil; n-3 group) PUFAs. After 10 days half of the animals in each diet group were inseminated and confirmed pregnant. An overnight fasted intravenous glucose tolerance test (500 mg glucose/kg body weight) was performed on chronically cannulated non-pregnant and 20-day pregnant rats. Indices of insulin secretion (ß) and insulin sensitivity (S) were calculated from the plasma glucose and insulin responses. The fatty acid composition of phospholipids was determined in samples of liver and two skeletal muscles (soleus and red quadriceps). RESULTS: Pregnancy in the CHOW group significantly increased ß (P < 0.001) and decreased S (P < 0.01). In contrast, both n-6 and n-3 diets abolished both the pregnancy-induced decrease in S and pregnancy-induced increase in ß with the n-3 diet having a more potent effect on both S and ß. S was positively correlated with the sum of n-3 fatty acids, with docosahexaenoic acid (22:6 n-3) the major contributor, in liver (r = 0.485; P < 0.001), red quadriceps (r = 0.421; P = 0.004) and soleus (r = 0.476; P < 0.001). In contrast S was inversely related to arachidonic acid (20:4n-6) levels in liver and red quadriceps across all groups and these relationships were particularly powerful in pregnancy (liver: r = -0.785; red quadriceps: r = -0.754, both P < 0.0001). CONCLUSIONS: The results demonstrate potent effects of dietary fat amount and profile on glucoregulation during pregnancy and emphasize the importance of the balance between dietary n-3 and n-6 PUFAs.

Minimally Invasive Surgical Approach for Odontoid Lesions: A Technical Description in a Case of High Cervical Osteomyelitis and Abscess.

BACKGROUND: Cervical approaches to the dens are limited by the presence of several structures, including the spinal cord, vertebral arteries, C1 articular pillars, and C2 nerves. Surgical approaches to access the high anterior cervical spine classically encompass the extended anterior retropharyngeal route, transoral route, and extreme lateral route, each of which has its own pattern of morbidity or complications. Percutaneous procedures to drain infections in this area have a limited yield. Osteomyelitis of the dens is a rare but serious condition that is associated with significant mortality. Patients with cervical osteomyelitis and epidural abscess are likely to have significant coexistent medical comorbidities and are often poor candidates for extensive surgical procedures. A minimally invasive approach that gives access to the entire odontoid process would allow for more aggressive treatments and potentially even a complete odontoidectomy without resection of the C1 anterior arch. CASE DESCRIPTION: We describe a minimally invasive approach to drainage and debridement of an atlantoaxial epidural abscess and osteomyelitis. Using minimally invasive techniques from a posterolateral trajectory in a cadaveric specimen, we were able to safely access the anterior epidural space, odontoid, and retropharynx. We then performed this approach in our patient who was unable to tolerate a large surgical procedure. CONCLUSIONS: We developed, tested, and then applied a minimally invasive approach that combined tubular retractors with positioning of the head and neck to optimize the exposure in a patient with a complex abscess that involved the ventral epidural space, odontoid process, and retropharyngeal space. The abscesses were successfully drained along with local tissue debridement without complication. A posterolateral minimally invasive approach is a safe alternative in patients with an atlantoaxial epidural abscess, odontoid osteomyelitis, or retropharyngeal abscess with significant medical comorbidities who are unlikely to tolerate a more extensive surgery. It can also be used for resections of lesions of an oncologic nature and could even be used to resect pannus or os odontoideum, without necessitating an anterior approach or resection even of the C1 arch.