Technological innovation in spinal cord stimulation: use of a newly developed delivery device for introduction of spinal cord stimulation leads.

OBJECTIVE: The use of multiple cylindrical leads and multicolumn and single column paddle leads in spinal cord stimulation offers many advantages over the use of a single cylindrical lead. Despite these advantages, placement of multiple cylindrical leads or a paddle lead requires a more invasive surgical procedure. Thus, the ideal situation for lead delivery would be percutaneous insertion of a paddle lead or multiple cylindrical leads. This study evaluated the feasibility and safety of percutaneous delivery of S-Series paddle leads using a new delivery device called the Epiducer lead delivery system (all St. Jude Medical Neuromodulation Division, Plano, TX, USA). MATERIALS AND METHODS: This uncontrolled, open-label, prospective, two-center study approved by the AZ St. Lucas (Ghent) Ethics Committee evaluated procedural aspects of implantation of an S-Series paddle lead using the Epiducer lead delivery system and any adverse events relating to the device. Efficacy data during the patent's 30-day trial also were collected. RESULTS: Data from 34 patients were collected from two investigational sites. There were no adverse events related to the Epiducer lead delivery system. The device was inserted at an angle of either 20°-30° or 30°-40° and was entered into the epidural space at T12/L1 in most patients. The S-Series paddle lead was advanced four vertebral segments in more than 50% of patients. The average (±standard deviation [SD]) time it took to place the Epiducer lead delivery system was 8.7 (±5.0) min. The average (+SD) patient-reported pain relief was 78.8% (+24.1%). CONCLUSIONS: This study suggests the safe use of the Epiducer lead delivery system for percutaneous implantation and advancement of the S-Series paddle lead in 34 patients.

A musculatura epaxial e a fibrose epidural na compressão medular em cães submetidos à laminectomia dorsal modificada / Epaxial musculature and epidural fibrosis in the spinal compression in dogs submitted modified dorsal laminectomy

O objetivo deste experimento foi isolar a musculatura epaxial da medula espinhal de cães submetidos à laminectomia dorsal modificada (LDM) e averiguar se os músculos influenciaram na formação da fibrose epidural, na compressão medular e no aparecimento dos sinais neurológicos. Para isso, dez cães hígidos foram submetidos à LDM entre as vértebras T13 e L1 e distribuídos aleatoriamente em dois grupos denominados controle (I) onde a medula espinhal permaneceu exposta sem a presença de implante, e tratado (II)onde foi colocado um im-plante a base de alumínio entre a musculatura epaxial adjacente e a medula espinhal exposta pela LDM. As avaliações constaram de exames neurológicos diários até 180 dias de pós-operatório (PO); mielografia, decorridos 15, 30 e 60 dias de PO; e avaliação macroscópica mediante a reintervenção cirúrgica. Não houve diferença durante as avaliações neurológicas. Aos 15 dias de PO, foi verificado na mielografia, que o grau de compressão da linha de contraste foi maior no grupo tratado (P<0,05) quando comparado ao grupo controle, não havendo diferença dos demais tempos estudados. Na avaliação macroscópica, pode-se observar que no Grupo II, a musculatura epaxial adjacente à medula espinhal não estava em contato com a fibrose epidural, diferentemente do grupo controle. O implante pôde ser removido facilmente e apresentava discreto grau de deformidade crânio-dorsal. Pode-se concluir que a musculatura epaxial adjacente é isolada da medula espinhal pelo implante à base de alumínio em cães submetidos à LDM, e esta não influencia na formação da fibrose epidural, compressão medular e no aparecimento dos sinais neurológicos.

The purpose of this study was to isolate the adjacent epaxial musculature from exposed spinal cord by modified dorsal laminectomy in dogs with aluminum implant and to verify whether the muscles contribute to form epidural fibrosis, spinal cord compression, and development of neurological signs. Ten dogs were submitted to modified dorsal laminectomy between T13 and L1 and then distributed along two groups. Dogs in the group 1 remained with the spinal cord exposed without the implant; dogs in the group 2 had an aluminum implant inserted between the epaxial muscles and the exposed spinal cord. Neurological examination was daily performed until 180 days post surgery. Additionally, myelography at 15, 30, and 60 days post surgery and macroscopic evaluation of the implant at six months post surgery were done. There was no difference between groups in the neurological examination. A statistical difference in the degree of spinal compression was observed at day 15 post surgery in the group 2. In this group, the epaxial musculature adjacent to the spinal cord was not in contact with the epidural fibrosis, differently to what was observed in the control group. The implant was removed easily with some degree of deformity. The results showed that the adjacent musculature of the spinal cord submitted to a modified dorsal laminectomy in dogs can be isolated by aluminum implant, without any contact with epidural fibrosis or influence in the development of neurological signs.

Spinal cord herniation into pseudomeningocele after traumatic nerve root avulsion: case report and review of the literature.

We present an extremely rare case of traumatic spinal cord herniation due to a brachial plexus avulsion injury and provide a review of the literature of spinal cord herniation. Spinal cord herniation is an uncommon condition that can occur spontaneously or as a result of surgery or trauma. This condition often presents with symptoms and signs as Brown-Séquard syndrome. Traumatic pseudomeningoceles after a brachial plexus avulsion injury have been reported. But transdural herniation of the spinal cord into this pseudomeningocele is an extremely rare and poorly documented condition. There is only two reports of this condition in a thoracic case. The authors report the case of a 22-year-old man presented with a 2-year history of quadriplegia. He was involved in a motorcycle accident, 3 years prior to his presentation. Four years after the initial right brachial plexus injury, he was not able to walk independently. Magnetic resonance imaging (MRI) and computerized tomography (CT) myelography revealed a lateral pseudomeningocele arising from the right C6-7 and C7-T1 intervetebral foramen and cervical spinal cord herniation into this pseudomeningocele. The patient underwent primary closure of pseudomeningocele to prevent spinal cord reherniation. He can walk with cane and use left arm unrestrictedly at the 2-year follow-up examination. Spinal cord herniation following traumatic nerve root avulsion is extremely rare but it should be considered in the differential diagnosis of patients presenting with delayed myelopathy or Brown-Séquard syndrome.

Delayed symptomatic presentation of epidural hematoma after epidural catheter anesthesia: case report.

STUDY DESIGN: The authors present a case report of a 70-year-old woman who presented with delayed symptoms of epidural hematoma after epidural catheter anesthesia. OBJECTIVE: We intend to report a unique case of delayed presentation of epidural hematoma after epidural catheter anesthesia. SUMMARY OF BACKGROUND DATA: The authors present a case of a 70-year-old woman who received epidural anesthesia via spinal catheter infusion before right knee replacement surgery. After an unremarkable postoperative course, she presented 6 weeks later with worsening middle and lower back pain, prompting a workup and lumbar MR imaging. MRI of her lumbar spine demonstrated a lower thoracic epidural fluid collection with significant radiographic mass effect on the thoracic spine. The fluid was diagnosed as chronic breakdown of an initially asymptomatic epidural hematoma. Symptomatic epidural hematoma formation after epidural block is rare but commonly reported in the literature. The incidence of asymptomatic hematoma formation is probably much higher and unrecognized. METHODS: This is a retrospective review of a case seen at our institution. RESULTS: A persistent epidural fluid collection in a normocoagulable patient presenting with symptoms of back pain more than a month after spinal block has not been reported in the literature. CONCLUSION: In the absence of focal neurologic symptoms, conservative therapy and observation are appropriate.

Cicatrización epidural en presencia de dos sellantes durales: Duraseal® y Tissucol®. Estudio experimental / Epidural scar formation in presence of two dural sealants: Duraseal® and Tissucol®. An experimental study

Objetivo: Comparar la cicatrización epidural inducida por la presencia de Duraseal®, un material biológico generalmente utilizado como sellante dural, con respecto a la cicatriz epidural en animales control y en presencia de otro sellante dural (Tissucol®). Métodos: Se utilizaron 15 ratas Wistar, sometidas a laminectomía D6-D8. En los grupos de Duraseal® y Tissucol ®, se colocaron estos materiales en espacio epidural. Tres meses después se realizó un estudio histológico de la cicatriz epidural, comparándose el grosor de la cicatriz en los diferentes grupos experimentales. Resultados: No existen diferencias significativas en el grosor de la cicatriz epidural a nivel raquídeo inducida por Duraseal ® respecto al grupo control o al grupo de Tissucol®. Conclusión: Los dos sellantes biológicos utilizados en este estudio pueden ser utilizados en espacio epidural raquídeo, sin que aumenten la fibrosis epidural postquirúrgica

Objective: To study epidural scar induced by the presence of Duraseal® and Tissucol® after laminectomy. Methods: 15 Wistar rats were used to perform a D6-D8 laminectomy with dural exposure. In control groups no sealants were used after laminectomy and in the other two groups Duraseal® and Tissucol® were used, respectivetly. Three months after laminectomy, the width of the scar was measured in each goup, and compared. Results: No statistical differences were found in the width of the epidural scar produced by Duraseal® when compared to controls or Tissucol®. Conclusions: Duraseal® and Tissucol® can be used in space epidural space after a laminectomy, without the epidural scarring increases

Lipomatose epidural lombar: relato de dois casos / Lumbar epidural lipomatosis: report of two cases

Objetivo: descrever e relatar uma patologia relativamente rara, que deve ser sugerida no diagnóstico diferencial das lombalgias e síndromes radicuylares lombossacrais. Método: análise e descrição de dois casos de lipomatose epidural lombar operados no Serviço de Neurocirurgia da Santa casa de Santos pelos autores no período de três anos. Resultados: os pacientes operados evoluíram com melhora dos sintomas realcionados à lipomatose epidural lombar. Conclusão: a lo]ipomatose epidural deve sempre ser incluída no diagnóstico diferencial diante de queixa de lombalgia e ciática, ou ainda compressão medular dorsal. Obesidade e uso de corticóides devem ser considerados como sinais de suspeita para tal patologia, que, quando correta e rapidamente descoberta e tratada, pode evitar graves consequências para o doente.

Establishment of a canine spinal cord injury model induced by epidural balloon compression.

A model that provides reproducible, submaximal yet sufficient spinal cord injury is needed to allow experiments leading to development of therapeutic techniques and prediction of clinical outcome to be conducted. This study describes an experimental model for spinal cord injury that uses three different volumes of balloon inflation and durations of compression to create a controlled gradation outcome in adult dogs. Twenty-seven mongrel dogs were used for this study. A 3-french embolectomy catheter was inserted into the epidural space through a left hemilaminectomy hole at the L(4) vertebral arch. Balloons were then inflated with 50, 100, or 150 microgl of a contrast agent at the L1 level for 6, 12, or 24 h and spinal canal occlusion (SCO) measured using computed tomography. Olby score was used to evaluate the extent of spinal cord injury and a histopathologic examination was conducted 1 week after surgery. The SCO of the 50, 100, and 150 microgl inflations was 22-46%, 51-70%, and 75-89%, respectively (p < 0.05). Olby scores were diminished significantly by a combination of the level of SCO and duration of inflation in all groups. Olby scores in the groups of 150 microgl-12 h, 150 microgl-24 h, and 100 microgl-24 h were 0.5, 0, and 1.7, respectively. Based on these results, a SCO > 50% for 24 h, and > 75% for 12 h induces paraplegia up to a week after spinal cord injury.

Establishment of a canine spinal cord injury model induced by epidural balloon compression

A model that provides reproducible, submaximal yet sufficient spinal cord injury is needed to allow experiments leading to development of therapeutic techniques and prediction of clinical outcome to be conducted. This study describes an experimental model for spinal cord injury that uses three different volumes of balloon inflation and durations of compression to create a controlled gradation outcome in adult dogs. Twenty-seven mongrel dogs were used for this study. A 3-french embolectomy catheter was inserted into the epidural space through a left hemilaminectomy hole at the L4 vertebral arch. Balloons were then inflated with 50, 100, or 150 microliter of a contrast agent at the L1 level for 6, 12, or 24 h and spinal canal occlusion (SCO) measured using computed tomography. Olby score was used to evaluate the extent of spinal cord injury and a histopathologic examination was conducted 1 week after surgery. The SCO of the 50, 100, and 150 microliter inflations was 22-46%, 51-70%, and 75-89%, respectively (p 50% for 24 h, and > 75% for 12 h induces paraplegia up to a week after spinal cord injury.

Profundidad del espacio epidural en pacientes obstétricas / Depth of epidural space in obstetric patients

No disponible

Inadvertent extra-epidural catheter placement in an infant.

We report the inadvertent passage of an epidural catheter threaded from the caudal space out of a lumbar intervertebral foramen and into the lower thoracic paravertebral space in an infant. We identified the errant catheter by radiography and removed it without sequelae.

Traumatic epidural emphysema.

STUDY DESIGN: This is a case report. OBJECTIVE: A rare case of epidural emphysema secondary to traumatic pneumomediastinum in the absence of pneumothorax is reported. SUMMARY OF BACKGROUND DATA: Epidural air secondary to traumatic pneumomediastinum in the absence of pneumothorax has only been reported previously by Willing. Other causes of traumatic epidural emphysema include pneumothorax, pelvic fracture, dural enteric fistula, and herniation of a spinal disc. METHODS: A young man who sustained blunt cervical and chest trauma after a basketball game accident was found to have pneumomediastinum and surgical emphysema on a chest radiograph and underwent computed tomography (CT). RESULTS: The CT scan demonstrated surgical emphysema, pneumomediastinum, and epidural emphysema with no pneumothorax. The patient was managed conservatively, and the epidural emphysema and pneumomediastinum resolved spontaneously. CONCLUSION: Epidural emphysema secondary to traumatic pneumomediastinum is benign and self-limiting. However, the life-threatening causes should be considered and ruled out.

[Inadvertant epidural placement of a psoas compartment catheter. Case report of a rare complication]. / Epidurale Fehllage eines Psoaskompartmentkatheters. Fallbericht einer seltenen Komplikation.

Due to total knee replacement, a 67-year-old female patient had received a combination of general anesthesia and continuous psoas compartment block. An epidural block was detected postoperatively. An X-ray after the injection of contrast medium showed a typical epidurography with the catheter tip projecting into the epidural space. After drawing back the catheter, another X-ray showed a correct placement of the catheter and a typical spreading of the contrast medium and the catheter could be used for pain relief. In retrospect, it turned out that the catheter had been placed too far over the tip of the stimulation needle. The recommendations of different authors on this problem vary and are actually quite contradictive. We would recommend not to place the catheter further than 5 cm over the tip of the needle. After the first injection the quality of monitoring should correspond with that of an epidural anesthesia. In doubtful cases an injection of contrast medium and an X-ray can be performed.

A simple and reproducible model of spinal cord injury induced by epidural balloon inflation in the rat.

This paper describes a modification of a balloon-compression technique to produce spinal cord injury in adult rats. A 2-French Fogarty catheter is inserted into the dorsal epidural space through a small hole made in T10 vertebral arch, advanced cranially to T8-9 spinal level, and inflated for 5 min. Spinal cord damage is graded by increasing the volume of saline used to inflate the balloon. Quantitative neurological and histopathological outcomes are presented with three different volumes (10, 15, and 20 microl of saline) to characterize the gradation of injury. Volume of 15 microl produced complete paraplegia followed by gradual recovery, finally reaching approximately the middle of the scale used to quantitate the locomotor performance. With these animals, after 4 weeks, the center of the lesion shows complete loss of grey matter and partial sparing of the white matter. We conclude that 15 microl volume produced submaximal injury that will be useful for studying the pathophysiology and effects of protective therapies with this compression-injury model.

[Subperiostal hematoma of the orbit and epidural hematoma in patients with skull-brain trauma]. / Subperiostales Orbitahämatom und epidurales Hämatom bei Patienten mit Schädel-Hirn-Trauma.

Subperiostal hematomas (SPOH) of the orbit are mostly of traumatic origin, but may occur spontaneously. In patients with frontal and temporal extradural hematomas, concomitant SPOH of the ipsilateral orbit have sporadically been observed. We report clinical and radiological findings of a patient and a review of the literature and discuss the development of SPOH.