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Anatomy of the human spinal cord arachnoid cisterns: applications for spinal cord surgery

Corentin Dauleac, Timothée Jacquesson, and Patrick Mertens

OBJECTIVE

The goal in this study was to describe the overall organization of the spinal arachnoid mater and spinal subarachnoid space (SSAS) as well as its relationship with surrounding structures, in order to highlight spinal cord arachnoid cisterns.

METHODS

Fifteen spinal cords were extracted from embalmed adult cadavers. The organization of the spinal cord arachnoid and SSAS was described via macroscopic observations, optical microscopic views, and scanning electron microscope (SEM) studies. Gelatin injections were also performed to study separated dorsal subarachnoid compartments.

RESULTS

Compartmentalization of SSAS was studied on 3 levels of axial sections. On an axial section passing through the tips of the denticulate ligament anchored to the dura, 3 subarachnoid cisterns were observed: 2 dorsolateral and 1 ventral. On an axial section passing through dural exit/entrance of rootlets, 5 subarachnoid cisterns were observed: 2 dorsolateral, 2 lateral formed by dorsal and ventral rootlets, and 1 ventral. On an axial section passing between the two previous ones, only 1 subarachnoid cistern was observed around the spinal cord. This compartmentalization resulted in the anatomical description of 3 elements: the median dorsal septum, the arachnoid anchorage to the tip of the denticulate ligament, and the arachnoid anchorage to the dural exit/entrance of rootlets. The median dorsal septum already separated dorsal left and right subarachnoid spaces and was described from C1 level to 3 cm above the conus medullaris. This septum was anchored to the dorsal septal vein. No discontinuation was observed in the median dorsal arachnoid septum. At the entrance point of dorsal rootlets in the spinal cord, arachnoid trabeculations were described. Using the SEM, numerous arachnoid adhesions between the ventral surface of the dorsal rootlets and the pia mater over the spinal cord were observed. At the ventral part of the SSAS, no septum was found, but some arachnoid trabeculations between the arachnoid and the pia mater were present and more frequent than in the dorsal part. Laterally, arachnoid was firmly anchored to the denticulate ligaments’ fixation at dural points, and dural exit/entrance of rootlets made a fibrous ring of arachnoidodural adhesions. At the level of the cauda equina, the arachnoid mater surrounded all rootlets together—as a sac and not individually.

CONCLUSIONS

Arachnoid cisterns are organized on each side of a median dorsal septum and compartmentalized in relation with the attachments of denticulate ligament and exit/entrance of rootlets.

In Journal of Neurosurgery: Spine Volume 31: Issue 5 (Nov 2019)

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Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients

Marc P. Sindou, Eric Blondet, Evelyne Emery, and Patrick Mertens

Object. Most patients with preganglionic lesions after brachial plexus injuries suffer pain that is hard to control through medication or neuromodulation. Lesioning in the dorsal root entry zone (DREZ) is undeniably effective. Fifty-five patients who had undergone the so-called microsurgical DREZotomy (MDT) procedure were studied with the two following objectives: 1) to describe the anatomical lesions observed during MDT in correlation with sensory deficits and pain features; and 2) to analyze the results in the 44 patients who were followed for more than 1 year (mean 6 years).

Methods. The observed lesions were severe: 79.6% of ventral and 78.2% of dorsal roots from C5—T1 were impaired. Damage extended to all five roots in 42% of patients. Strong arachnoiditis was present in 38.2%, pseudomeningoceles in 31%, spinal cord distortion and/or atrophy in 49%, and abundant gliotic tissue and/or microcavitations within the dorsal horn at the avulsed segments in 36.4% of cases. Sensory deficit corresponded to the entire territory of the dorsal root lesions in 52% of patients, but was larger in 30% most certainly due to the associated extrarachidian lesions. At the last evaluation after MDT, 66% of patients showed excellent (total relief without medication) or good (total relief with medication) pain relief and 71% experienced an improvement in activity level.

Conclusions. Apart from other indications not addressed in this article, MDT can be performed to treat refractory pain due to brachial plexus avulsions. The long-term efficacy of this procedure strongly indicates that pain after brachial plexus avulsion originates from the deafferented (and gliotic) dorsal horn.

In Journal of Neurosurgery Volume 102: Issue 6 (Jun 2005)

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A new type of microelectrode for obtaining unitary recordings in the human spinal cord

Marc Guenot, Jean-Michel Hupe, Patrick Mertens, Alan Ainsworth, Jean Bullier, and Marc Sindou

Object. In this paper the authors report on the conception and adjustment of a microelectrode used to obtain unitary recordings in the human spinal cord.

Methods. To overcome the difficulties related to intraoperative pulsations of the spinal cord, the authors opted to use a floating microelectrode. Because the recordings are obtained most often from spontaneous activities, it is difficult, with a single microelectrode, to separate spikes from electrical artifacts that are related to the switching of devices. Consequently, the authors designed a dual microelectrode made of two tungsten-in-glass—attached microelectrodes separated by 300 µm. Because the two electrodes cannot obtain recordings in the same neuron, it is possible to distinguish unambiguously spikes (recorded on one tip) from electrical artifacts (recorded simultaneously on the two tips). The dual microelectrode is 2 cm long, with a 20-µm tip length, and 800 to 1200—Ohms impedance. This microelectrode can be implanted “free hand,” in the dorsal horn, by using a microsurgical forceps under a surgical microscope. The data analysis is performed off-line with spike sorter hardware.

In the dorsal horns in 17 patients who were selected to undergo a dorsal root entry zone (DREZ) rhizotomy to treat various pathological conditions, unitary recordings were obtained using this double microelectrode. The authors recorded 57 neurons in good conditions of stability and isolation.

Conclusions. The microelectrode described in this paper was successfully used to obtain recordings in neurons in more than 85% of the patients. This simplified, floating double microelectrode can therefore be considered for use in microsurgical DREZ rhizotomy to obtain unitary recordings in the human spinal dorsal horn.

In Journal of Neurosurgery: Spine Volume 91: Issue 1 (Jul 1999)

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Biomechanical evaluation of cervical lateral mass fixation: a comparison of the Roy-Camille and Magerl screw techniques

Cédric Barrey, Patrick Mertens, Claude Rumelhart, François Cotton, Jérôme Jund, and Gilles Perrin

Object. The purpose of this study was to assess human cervical spine pullout force after lateral mass fixation involving two different techniques: the Roy-Camille and the Magerl techniques. Although such comparisons have been conducted previously, because of the heterogeneity of results and the importance of this procedure in clinical practice, it is essential to have data derived from a prospective and randomized biomechanical study involving a sufficient sample of human cervical spines. The authors also evaluated the influence of the sex, the vertebral level, the bone mineral density (BMD), the length of bone purchase, and the thickness of the anterior cortical purchase.

Methods. Twenty-one adult cervical spines were harvested from fresh human cadavers. Computerized tomography was performed before and after placing 3.5-mm titanium lateral mass screws from C-3 to C-6. Pullout forces were evaluated using a material testing machine. The load was applied until the pullout of the screw was observed. A total of 152 pullout tests were available, 76 for each type of screw fixation. The statistical analysis was mainly performed using the Kaplan—Meier survival method.

The mean pullout force was 266 ± 124 N for the Roy-Camille technique and 231 ± 94 N for the Magerl technique (p < 0.025). For the C3–4 specimen group, Roy-Camille screws were demonstrated to exert a significantly higher resistance to pullout forces (299 ± 114 N) compared with Magerl screws (242 ± 97 N), whereas no difference was found between the two techniques for the C5–6 specimen group (Roy-Camille 236 ± 122 N and Magerl 220 ± 86 N). Independent of the procedure, pullout strengths were greater at the C3–4 level (271 ± 114 N) than the C5–6 level (228 ± 105 N) (p < 0.05).

No significant correlation between the cancellous BMD, the thickness of the anterior cortical purchase, the length of bone purchase, and maximal pullout forces was found for either technique.

Conclusions. The difference between pullout forces associated with the Roy-Camille and the Magerl techniques was not as significant as has been previously suggested in the literature. It was interesting to note the influence of the vertebral level: Roy-Camille screws demonstrated greater pullout strength (23%) at the C3–4 vertebral level than Magerl screws but no significant difference between the techniques was observed at C5–6.

In Journal of Neurosurgery: Spine Volume 100: Issue 3 (Mar 2004)

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Microsurgical DREZ lesions for the control of cancer-related pain

Edoardo Mazzucchi, Andrei Brinzeu, Patrick Mertens, and Marc Sindou

Pain in patients with cancer is a major problem, and sometimes it is necessary to surgically interrupt pain pathways to effectively control refractory pain. Surgical lesion of the dorsal root entry zone (DREZ) was first performed in 1972 for the treatment of pain related to a Pancoast-Tobias tumor. The rationale of DREZotomy is to preferentially interrupt the nociceptive inputs in the lateral part of the DREZ and the ventrolateral (excitatory) part of the dorsal horn. Microsurgical DREZotomy is one technique for DREZ lesioning that is suited for tailored control of pain in patients in good general condition who are experiencing pain in a well-defined territory.

The video can be found here: https://youtu.be/JtLQDP7gYSQ

In Neurosurgical Focus: Video Volume 3: Issue 2 (Oct 2020): Surgery for Pain

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Long-term functional results of selective peripheral neurotomy for the treatment of spastic upper limb: prospective study in 31 patients

Joseph Maarrawi, Patrick Mertens, Jacques Luaute, Christophe Vial, Nicole Chardonnet, Maryse Cosson, and Marc Sindou

Object

To manage refractory upper-limb spasticity, selective peripheral neurotomy (SPN) is proposed when the spastic muscles to be treated are under the control of a single or a few peripheral nerves. The aim of this study was to assess prospectively the long-term effects of SPN.

Methods

Thirty-one patients with disabling upper-limb spasticity were selected by a multidisciplinary team using clinical, analytical, and functional scales as well as nerve block tests for assessment. Sixty-four SPNs were performed at the level of the musculocutaneous (15 SPNs), the median (25 SPNs), and the ulnar (24 SPNs) nerves. Results of a long term follow up (mean 4.5 years) showed statistically significant improvement on 1) analytical assessment (p < 0.01): resting position, active amplitude, and motor strength; 2) Ashworth Scale scoring (p < 0.01); 3) hand function assessment (p < 0.01); and 4) rating of daily activities. Four patients with severe painful spasticity experienced complete pain relief after surgery. On the basis of a Visual Analog Scale ranging from 0 to 100, the mean degree of patient satisfaction was 61.5. Complications occurred in five patients (15%): two postoperative hematomas, one (temporary) hypesthesia, and one transient paresia of the wrist and finger flexors.

Conclusions

Selective peripheral neurotomy leads to long-term satisfactory improvement in function and/or comfort with a low morbidity rate in appropriately selected patients suffering from severe harmful spasticity of the upper limb that has been refractory to conservative therapy. Patients must be selected after complete assessment by a multidisciplinary team.

In Journal of Neurosurgery Volume 104: Issue 2 (Feb 2006)

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Anatomical study of the thoracolumbar radiculomedullary arteries, including the Adamkiewicz artery and supporting radiculomedullary arteries

Jorge E. Alvernia, Emile Simon, Krishnakant Khandelwal, Cara D. Ramos, Eddie Perkins, Patrick Kim, Patrick Mertens, Raffaella Messina, Gustavo Luzardo, and Orlando Diaz

OBJECTIVE

The aim of this paper was to identify and characterize all the segmental radiculomedullary arteries (RMAs) that supply the thoracic and lumbar spinal cord.

METHODS

All RMAs from T4 to L5 were studied systematically in 25 cadaveric specimens. The RMA with the greatest diameter in each specimen was termed the artery of Adamkiewicz (AKA). Other supporting RMAs were also identified and characterized.

RESULTS

A total of 27 AKAs were found in 25 specimens. Twenty-two AKAs (81%) originated from a left thoracic or a left lumbar radicular branch, and 5 (19%) arose from the right. Two specimens (8%) had two AKAs each: one specimen with two AKAs on the left side and the other specimen with one AKA on each side. Eight cadaveric specimens (32%) had 10 additional RMAs; among those, a single additional RMA was found in 6 specimens (75%), and 2 additional RMAs were found in each of the remaining 2 specimens (25%). Of those specimens with a single additional RMA, the supporting RMA was ipsilateral to the AKA in 5 specimens (83%) and contralateral in only 1 specimen (17%). The specimens containing 2 additional RMAs were all (100%) ipsilateral to their respective AKAs.

CONCLUSIONS

The segmental RMAs supplying the thoracic and lumbar spinal cord can be unilateral, bilateral, or multiple. Multiple AKAs or additional RMAs supplying a single anterior spinal artery are common and should be considered when dealing with the spinal cord at the thoracolumbar level.

In Journal of Neurosurgery: Spine Volume 38: Issue 2 (Feb 2023)

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Microdialysis study of amino acid neurotransmitters in the spinal dorsal horn of patients undergoing microsurgical dorsal root entry zone lesioning

Technical note

Patrick Mertens, Chantal Ghaemmaghami, Lionel Bert, Armand Perret-Liaudet, Marc Guenot, Hussein Naous, Laurent Laganier, Roger Later, Marc Sindou, and Bernard Renaud

✓ The aim of this study was to develop, for the first time in the human spinal dorsal horn (DH), an in vivo method for the study of amino acids (AAs).

A microdialysis technique was used to sample AAs in the extracellular fluid of the DH apex in eight patients in whom surgery in the dorsal root entry zone (DREZ) was performed. Before making microsurgical lesions, specific concentric-type microdialysis probes were implanted over a 60-minute period in the DREZ and directed to the DH apex (10 implantations). The AA concentrations in the dialysates were determined using high-performance liquid chromatography with fluorescence detection. The concentrations of excitatory AAs (glutamate and aspartate) and inhibitory AAs (γ-aminobutyric acid and glycine) decreased and were stabilized by 45 minutes after probe implantation, whereas the levels of nonneurotransmitter AAs (alanine and threonine) were not stabilized at 60 minutes. The ability of the probe to track the changes of extracellular AAs was demonstrated. Neither intra- nor postoperative microdialysis-related complications were observed (with a follow up of 18 months).

The present study demonstrates that microdialysis can be performed safely in the human DH during DREZ lesioning. Despite technical and analytical limitations related to the intraoperative conditions, this technique offers new possibilities for clinical research on neurotransmitters involved in some relevant pathological states, especially in chronic pain and spasticity.

In Journal of Neurosurgery: Spine Volume 94: Issue 1 (Jan 2001)