The pathogenesis of thoracic ventral intradural spinal arachnoid cyst (ISAC) is unknown due to its extremely low incidence. In addition, its surgical treatment is complicated because of the ventral location, large craniocaudal extension, and frequent coexistence of syringomyelia. The optimal surgical strategy for thoracic ventral ISAC remains unclear and continues to be a matter of debate. In this report, the authors describe an extremely rare case presenting with a compressive thoracic ventral ISAC associated with syringomyelia that was successfully treated with a simple cyst-pleural shunt. The patient’s medical history revealed bacterial spinal meningitis along with an extensive spinal epidural abscess, suggesting the incidence of extensive adhesive arachnoiditis (AA) to be a plausible cause for this pathology. Thoracic ventral ISAC reportedly occurs secondary to AA and is commonly associated with syringomyelia. Placement of a cyst-pleural shunt is an effective, safe, and uncomplicated surgical strategy, which can provide sufficient cyst drainage regardless of the coexistence of AA, and thus should be considered as primary surgical treatment. Syrinx drainage could be reserved for a later attempt in case the cyst-pleural shunt fails to reduce the extent of syringomyelia.
Shoichi Haimoto, Yusuke Nishimura and Howard J. Ginsberg
Yusuke Nishimura, Atsushi Natsume and Howard J. Ginsberg
The authors describe a case of a 79-year-old man with a lumbar spinal dural arteriovenous fistula (DAVF) and isthmic spondylolisthesis at the same level. The patient's thoracic spine MRI study demonstrated swelling and increased T2 signal in the spinal cord and regional dilated perimedullary vessels. Lumbar spine MRI showed L-4 isthmic spondylolisthesis with severe bilateral L4–5 foraminal stenoses. Spinal angiography revealed a fistulous connection at the left L-4 nerve root sleeve between perimedullary veins and a dural branch of the L-4 radicular artery. Based on previous reports about secondary spinal DAVFs, the abnormal vascular communication likely developed secondary to the microtrauma and inflammation on the left L-4 nerve root sleeve, which was attributable to the isthmic spondylolisthesis. The authors performed disconnection of the arteriovenous shunt as well as an L4–5 decompression and posterior instrumented fusion with pedicle screws. The patient's postoperative course was uneventful, and he improved neurologically. It is important to bear in mind that a spinal DAVF may develop as a consequence of any sort of trauma or inflammation involving nerve roots. One should consider the concomitant treatment of both the spinal DAVF and the underlying pathology that may have given rise to the spinal DAVF.
Mostafa Fatehi, Christopher S. Ahuja, Shelly Wang and Howard J. Ginsberg
Tumoral calcinosis is an uncommon condition characterized by the calcification of periarticular soft tissue. In uremic patients the disease is secondary to metabolic disturbances in predisposed patients. The authors report the case of a 73-year-old woman who presented with a new painful cervical mass while undergoing continuous ambulatory peritoneal dialysis for long-standing end-stage renal disease (ESRD). A CT scan of the neck showed a lobulated, calcified mass in the left paraspinal soft tissue at C2–3. This mass affected the facet joint and also extended into the neural foramen but did not cause any neurological compromise. Due to the patient's significant medical comorbidities, resection was deferred and the patient was followed in the clinic. Subsequent repeat imaging has shown a significant decrease in the size of the mass. In the context of ESRD, a diagnosis of uremic tumoral calcinosis (UTC) was made. The authors conducted a search of the PubMed and EMBASE databases and identified 7 previously reported cases of UTC of the cervical spine. They present a summary of these cases and discuss the etiology, diagnosis, and management of the condition.
Although the metabolic disturbances seen in patients undergoing dialysis can lead to tumoral calcinosis, most reported cases involve large joints such as the shoulder or the hip; however, the spine can also be affected and should be considered in the differential diagnosis of patients with uremia as it can mimic aggressive bone-forming neoplasms.
Shoichi Haimoto, Ralph T. Schär, Yusuke Nishimura, Masahito Hara, Toshihiko Wakabayashi and Howard J. Ginsberg
Recent studies have demonstrated the efficacy of subfascial intrawound application of vancomycin powder in spine surgery in reducing the rate of surgical site infections (SSIs). However, to date no study has evaluated the efficacy and safety of suprafascial application of vancomycin powder in spine surgery. The purpose of this study was to quantify the rate of SSIs after open instrumented posterior spinal fusion with and without application of suprafascial vancomycin powder and to evaluate the rate of vancomycin powder–related local adverse effects.
The authors conducted a single-center retrospective case-control study of adult patients undergoing open instrumented posterior fusion of the cervical, thoracic, or lumbar spine performed by a single surgeon from January 2010 through December 2016. In March 2013, routine application of 1 g of suprafascial vancomycin powder was started for all cases in addition to standard systemic antibiotic prophylaxis. Baseline demographics and operative data as well as the SSI rates were compared between the study groups. The incidence of vancomycin powder–related adverse effects was analyzed.
A total of 515 patients (268 in the untreated group and 247 in the treated group) were included in the study. The mean age was significantly higher in the treated group than in the untreated group (58.4 vs 54.4 years, p < 0.01). Operative variables were similar between the study groups. Patients receiving vancomycin powder had a significantly lower infection rate (5.6% in the untreated group vs 0% in the treated group, p < 0.001). No vancomycin powder–related adverse effects were identified in the treated group.
Routine application of suprafascial intrawound vancomycin powder in addition to systemic antibiotic prophylaxis is an easy-to-use, safe, and effective strategy for preventing SSIs after instrumented posterior spinal fusion. Suprafascial application of vancomycin powder could be a valuable alternative to previously reported subfascial distribution, minimizing the risk of local adverse drug reactions.
José Enrique Cohen, Howard J. Ginsberg, Eve C. Tsai, Michael L. Schwartz and Sergio Petrocelli
Karim Mithani, Ying Meng, David Pinilla, Nova Thani, Kayee Tung, Richard Leung and Howard J. Ginsberg
A 52-year-old man with a 10-year history of treatment-resistant asthma presented with repeated exacerbations over the course of 10 months. His symptoms were not responsive to salbutamol or inhaled corticosteroid agents, and he developed avascular necrosis of his left hip as a result of prolonged steroid therapy. Physical examination and radiography revealed signs consistent with diffuse idiopathic skeletal hyperostosis (DISH), including a C7–T1 osteophyte causing severe tracheal compression. The patient underwent C6–T1 anterior discectomy and fusion, and the compressive osteophyte was removed, which completely resolved his “asthma.” Postoperative pulmonary function tests showed normalization of his FEV1/FVC ratio, and there was no airway reactivity on methacholine challenge. DISH is a systemic, noninflammatory condition characterized by ossification of spinal entheses, and it can present with respiratory disturbances due to airway compression by anterior cervical osteophytes. The authors present, to the best of their knowledge, the first documented case of asthma as a presentation of DISH.
Yusuke Nishimura, Nova B. Thani, Satoru Tochigi, Henry Ahn and Howard J. Ginsberg
Symptomatic thoracic disc herniations (TDHs) are relatively uncommon, and the technical challenges of resecting the offending disc are formidable due to the location of spinal cord that has relatively poor perfusion characteristics within a narrow canal. The majority of disc herniations are long-standing calcified discs that can be adherent to the ventral dura. Real-time intraoperative ultrasound (RIOUS) visualization of the spinal cord during the retraction and resection of the disc greatly enhances the safety and efficacy of disc resection. The authors have adopted the posterior laminectomy with pedicle-sparing transfacet approach with real-time ultrasound guidance in their practice, and they present the clinical outcome in their patients to illustrate the safety profile of this technique.
Sixteen consecutive patients undergoing operative management of TDHs were identified from the authors' database. All patients underwent microdiscectomy through a posterior transfacet pedicle-sparing approach under RIOUS. Outcomes and complications were retrospectively assessed in this patient series. Clinical records and pre- and postoperative imaging studies were scrutinized to assess levels and types of disc herniation, blood loss, surgical time, pre- and postoperative Nurick grades, Japanese Orthopaedic Association (JOA) scores, and complications.
All patients had single-level symptomatic TDHs. The patients presented with symptoms including thoracic myelopathy, axial back pain, urinary symptoms, and thoracic radiculopathy. Thoracic disc herniations involved levels T2–3 to T12–L1. Discs were classified as central or paracentral, and as calcified or noncalcified. All discs were successfully removed with no incidence of neural injury or CSF leak. The mean estimated blood loss was 523 ml, and the mean surgical time was 159 minutes. Nurick grades improved on average from 3.3 to 1.6. The mean JOA scores improved from 5.7 to 8.3 out of 11. The mean Hirabayashi recovery rate of the JOA score was 57%. All patients reported improvement in symptoms compared with preoperative status except for 1 patient with an American Spinal Injury Association Grade A spinal cord injury prior to surgery. The average duration of follow-up was 10.5 months. One patient developed postoperative wound infection that required additional operative debridement and revision of hardware.
Thoracic discectomy via a posterior pedicle-sparing transfacet approach is an adequate method of managing herniations at any thoracic level. The safety of the operation is significantly enhanced by the use of realtime intraoperative ultrasonography.
Christopher D. Witiw, Jonathan S. Citow, Howard J. Ginsberg, Julian Spears, Richard G. Perrin, Michael D. Cusimano and R. Loch Macdonald
Intraoperative radiographic localization within the cervical spine can be a challenge because of the anatomical relation of the musculoskeletal structures of the pectoral girdle. On standard cross-table lateral radiographs, these structures can produce shadowing that obscure the anatomical features of the cervical vertebrae, particularly at the caudal levels. Surgical guidelines recommend accurate intraoperative localization as a means to reduce wrong-level spine surgery, and unobstructed visualization is needed for fluoroscopy-guided placement of spinal instrumentation. In this article, the authors describe and evaluate a novel device designed to provide transient intraoperative caudal displacement of the shoulders to improve and simplify radiographic visualization of the cervical spine.
A 2-center prospective study was conducted to evaluate the device. The study included a total of 80 patients undergoing cervical spine surgery. The device was evaluated in a cohort of 50 patients undergoing elective single-level anterior discectomy and fusion and also in a second cohort of 30 patients at an independent institution. The patients in this second cohort were undergoing a variety of cervical spine procedures for multiple indications and were included in the study to allow the authors to assess the effectiveness of the device in a general neurosurgical practice. After the patients were anesthetized and positioned, consecutive standard cross-table lateral radiographs or intraoperative fluoroscopic were obtained before and after use of the device. The images were compared in order to determine the difference in lowest vertebral level visible.
There was an average difference in cervical spine visualization of +2.8 ± 0.9 vertebral levels in the first cohort, while in the second the improvement was +1.2 ± 0.7 levels (p < 0.0001 between cohorts, unpaired t-test). There was one complication, a minor shoulder abrasion, which required no specific management.
This device is safe and effective for increasing the radiographic visualization of the cervical spine for intraoperative localization.
Yusuke Nishimura, Masahito Hara, Atsushi Natsume, Yasuhiro Nakajima, Ryuichi Fukuyama, Toshihiko Wakabayashi and Howard J. Ginsberg
A spinal intradural extramedullary venous angioma is extremely rare and has not been previously reported. In this paper, the authors report on this entity with morphological and immunohistochemical evidence, and discuss the surgical strategy for its treatment. A 54-year-old woman presented to Nagoya University Hospital complaining of left-sided pain in the hip, thigh, and inguinal and perianal regions, with progressive worsening during the previous 2 weeks. Lumbar spine MRI showed an intradural extramedullary cyst at the level of T12–L1, which extended from the conus medullaris to the cauda equina. The cyst wall was not enhanced on T1-weighted MRI with Gd. Intraoperatively, a midline dural opening allowed the authors to easily visualize a dark-reddish cyst behind the spinal nerve rootlets in the cauda equina adjacent to the conus medullaris. The cyst was believed to originate from one of the spinal nerve rootlets in the cauda equina and a cluster of veins was identified on the cyst wall. The cyst was resected with the affected nerve rootlet. The surgery left no detectable neurological deficit. Based on the morphological and immunohistochemical evidence, the lesion was diagnosed as a venous angioma. No tumor recurrence was confirmed based on MRI at the time of the 2-year follow up. This is the first report of an intradural extramedullary cystic venous angioma that was successfully resected.