Spinal cord stimulation for spinal cord injury - Where do we stand? A narrative review.

Recovery of function following a complete spinal cord injury (SCI) or an incomplete SCI where recovery has plateaued still eludes us despite extensive research. Epidural spinal cord stimulation (SCS) was initially used for managing neuropathic pain. It has subsequently demonstrated improvement in motor function in otherwise non-recovering chronic spinal cord injury in animal and human trials. The mechanisms of how it is precisely effective in doing so will need further research, which would help refine the technology for broader application. Transcutaneous spinal cord stimulation (TSCS) is also emerging as a modality to improve the functional outcome in SCI individuals, especially when coupled with appropriate rehabilitation. Apart from motor recovery, ESCS and TSCS have also shown improvement in autonomic, metabolic, genitourinary, and pulmonary function. Since the literature on this is still in its infancy, with no large-scale randomised trials and different studies using different protocols in a wide range of patients, a review of the present literature is imperative to better understand the latest developments in this field. This article examines the existing literature on the use of SCS for SCI individuals with the purpose of enabling functional recovery. It also examines the voids in the present research, thus providing future directions.

Ligamentum Flavum Buckling vs Hypertrophy in Cervical Myelopathy Using Dynamic Imaging: Are Instability and Loss of Disc Height the Culprits?

BACKGROUND: The literature has not distinguished between LF "hypertrophy" and "buckling" when addressing cervical spondylotic myelopathy. The identification of buckling on dynamic magnetic resonance imaging can determine the levels for decompression more accurately and modify the surgical plan accordingly. No studies have been performed in the cervical spine to analyze the factors affecting LF buckling. PURPOSE: Our objective was to investigate the factors affecting static ligamentum flavum (LF) "hypertrophy" and dynamic LF "buckling." STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective study of hospital records and imaging database from January 2014 to January 2020. The relation of age, disc height, and intervertebral instability to LF hypertrophy and buckling were assessed. RESULTS: Measurements were performed from C2-3 to C7-T1 in 169 patients who satisfied the eligibility criteria, making a total of 1014 levels. The samples were divided into 2 groups: 798 levels with buckling <1 mm (group A) and 216 levels with buckling >1 mm (group B). Of those, 161 levels satisfied the criteria for radiological instability (sagittal translation/rotation). No correlation was observed between age/disc height and buckling. Intervertebral instability showed significant association (P = 0.046) with buckling. No correlation was found between age/intervertebral instability and hypertrophy. CONCLUSION: LF buckling but not hypertrophy is related to intervertebral instability in the cervical spine. LF buckling in the cervical spine is not related to age or disc height in the cervical spine. CLINICAL RELEVANCE: Intervertebral instability on dynamic x-ray imaging of the cervical spine can be a predictor of ligamentum flavum buckling and can be utilized for surgical planning.

Two-Level Anterior Cervical Discectomy and Fusion versus Hybrid Total Disc Replacement for Bilevel Pathology with Cervical Radiculopathy/Myelopathy: A Comparative Study with a Minimum 2-Year Follow-up in an Indian Population.

STUDY DESIGN: Retrospective study. PURPOSE: To study the outcomes of two-level anterior cervical discectomy and fusion (2L-ACDF) versus hybrid total disc replacement (H-TDR) for cervical myeloradiculopathy. OVERVIEW OF LITERATURE: For bilevel disc issues of the cervical spine, 2L-ACDF has been a historical tool with numerous implants used at different time frames. Recent developments in total disc replacement at mobile level with fusion at a spondylotic level known as hybrid fixation have added a new armamentarium for such disorders. METHODS: An analysis of 49 consecutive patients who underwent 2L-ACDF (n=22) and H-TDR (n=27) from January 1, 2014 to December 31, 2017 was performed. Data were studied as retrieved from InstaPACS ver. 4.0 (Mediff Technologies Pvt. Ltd., Bengaluru, India) and medical records. RESULTS: Twenty-two patients with 2L-ACDF and 27 patients with H-TDR were included. The mean±standard deviation (SD) follow-up duration was 4.0±1.5 years in H-TDR and 3.1±1.1 years in 2L-ACDF. The mean±SD Neck Disability Index (NDI) decreased from 26.1±7.6 to 6.5±3.9 in the H-TDR group and from 27.6±7.2 to 6.4±4.8 in the 2L-ACDF group at final follow-up. Disc height at suprajacent level in the 2L-ACDF group was 4.12±0.48 mm, 4.10±0.45 mm, and 4.05±0.48 mm preoperatively, at 1-year, and final follow-up, respectively. Disc height at supradjacent level in the H-TDR group was 4.28±0.36 mm, 4.20±0.32 mm, and 4.19±0.34 mm preoperatively, at 1-year, and final follow-up, respectively. CONCLUSIONS: There was significantly improved NDI in both groups. Adjacent segment disc height loss was greater in the 2L-ACDF group than in H-TDR but not statistically significant (p =0.304). Supradjacent segment range of motion was greater in the 2L-ACDF group than in the H-TDR group (p =0.003). Both findings supported radiographic adjacent segment degeneration (ASD), but symptomatic ASD was absent in both groups.

An unusual complication of quadriparesis after trigger point injection: a case report.

ABSTRACT: Quadriparesis after intramuscular trigger point injections for myofascial pain syndrome has been rarely reported in the literature. A 37-year-old male patient presented with myofascial pain syndrome and was given trigger point injections in trapezius muscles under ultrasound guidance. The patient noticed weakness in all the 4 limbs at approximately 12 hours after the procedure, which gradually progressed to functional quadriplegia at the time of presentation to the emergency department. On examination, he had quadriparesis with no sensory involvement and superficial reflexes were normal. MRI screening of the whole spine was unremarkable, and MRI brain suggested an incidental granuloma, which could not explain his symptoms. Blood tests revealed severe hypokalemia (2.2 mEq/L) and deranged thyroid function tests. Immediate potassium correction with intravenous and oral potassium chloride was initiated, and the patient showed improvement within 6 hours of initiating correction. Stress of the procedure, use of steroids with mineralocorticoid effects such as methylprednisolone, or deranged thyroid function tests may have acted as triggers to precipitate hypokalemic paralysis in the patient. Knowledge of this complication is essential as prompt diagnosis and timely management of hypokalemia can result in complete resolution of the symptoms.

A rare case of concomitant pneumocephalus and pneumorachis after lumbar spine surgery with late presenting dural leak.

Introduction: We report a case of pneumocephalus and pneumorachis i.e., air in the cranial cavity and the spinal canal, which are rarely associated with a primary spinal cause. Their concomitant occurrence and association with a late presenting dural leak are also uncommon. Case presentation: A 70-year-old man presented 1 month after decompressive surgery for lumbar canal stenosis with leakage of cerebrospinal fluid (CSF) from the wound site and severe headache. There were no signs of surgical site infection or meningitis. There was no intraoperative or immediate postoperative evidence of dural tear. He was neurologically intact. On detailed work-up, he was found to have air collections in the subarachnoid and intraventricular spaces in the brain and intraspinal air in both the cervical and the lumbar regions. He showed gradual resolution of these findings radiologically and symptomatic improvement through conservative management with analgesics, empirical antibiotics, high flow oxygen, and maintenance of hydration within 1 month. Discussion: Pneumocephalus and pneumorachis are commonly seen after trauma. Spine surgery is a rare cause. They may present with symptoms similar to meningitis and may be erroneously diagnosed and treated. No standard treatment guidelines exist in the literature. Most cases have been managed conservatively. Early detection may allow noninvasive management leading to complete resolution.