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Zhaoyang Xu, Guoxiong Lin, Han Zhang, Shengchun Xu and Ming Zhang

OBJECTIVE

Kambin’s triangle and the safe triangle are common posterolateral approaches for lumbar transforaminal endoscopic surgery and epidural injection. To date, no consensus has been reached on the optimal transforaminal approach, in particular its underlying anatomical mechanism. The aim of this study was to investigate the 3D architecture of the neurovascular and adipose zones in the upper and lower lumbar intervertebral foramina (IVFs).

METHODS

Using the epoxy sheet plastination technology, 22 cadaveric lumbar spines (12 female and 10 male, age range 46–89 years) were prepared as a series of transverse (11 sets), sagittal (8 sets), and coronal (3 sets) slices with a thickness of 0.25 mm (6 sets) or 2.5 mm (16 sets). The high-resolution images of the slices were scanned and analyzed. The height, area, and volume of 30 IVFs from T12–L1 to L4–5 were estimated and compared. This study was performed in accord with the authors’ institutional ethical guidelines and approved by the institutional ethics committees.

RESULTS

The findings were as follows. 1) The 3D boundaries of the lumbar IVF and its subdivisions were precisely defined. 2) The 3D configuration of the neurovascular and adipose zones was different between the upper and lower lumbar IVFs; zoning in the upper lumbar IVFs was much more complex than that in the lower lumbar IVFs. 3) In general, the infraneural adipose zone gradually tapered and rotated from the inferoposterolateral aspect to the superoanteromedial aspect. 4) The average height, area, and volume of the IVF gradually increased from the upper to the lower lumbar spine. Within a lumbar IVF, the volumes below and above the inferior border of the dorsal root ganglia were similar.

CONCLUSIONS

This study highlights differences of fine 3D architecture of neurovascular and adipose tissues between the upper and lower lumbar IVFs, with related effects on the transforaminal approaches. The findings may contribute to optimization of the surgical approaches to and through the IVF at different lumbar spinal levels and also may help to shorten the learning curve for the transforminal techniques.

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Zhaoyang Xu, Lili Tu, Yanyan Zheng, Xiaohui Ma, Han Zhang and Ming Zhang

OBJECTIVE

Meralgia paresthetica is commonly caused by mechanical entrapment of the lateral femoral cutaneous nerve (LFCN). The entrapment often occurs at the site where the nerve exits the pelvis. Its optimal surgical management remains to be established, partly because the fine architecture of the fascial planes around the LFCN has not been elucidated. The aim of this study was to define the fascial configuration around the LFCN at its pelvic exit.

METHODS

Thirty-six cadavers (18 female, 18 male; age range 38–97 years) were used for dissection (57 sides of 30 cadavers) and sheet plastination and confocal microscopy (2 transverse and 4 sagittal sets of slices from 6 cadavers). Thirty-four healthy volunteers (19 female, 15 male; age range 20–62 years) were examined with ultrasonography.

RESULTS

The LFCN exited the pelvis via a tendinous canal within the internal oblique–iliac fascia septum and then ran in an adipose compartment between the sartorius and iliolata ligaments inferior to the anterior superior iliac spine (ASIS). The iliolata ligaments newly defined and termed in this study were 2–3 curtain strip–like structures which attached to the ASIS superiorly, were interwoven with the fascia lata inferomedially, and continued laterally as skin ligaments anchoring to the skin. Between the sartorius and tensor fasciae latae, the LFCN ran in a longitudinal ligamental canal bordered by the iliolata ligaments.

CONCLUSIONS

This study demonstrated that 1) the pelvic exit of the LFCN is within the internal oblique aponeurosis and 2) the iliolata ligaments form the part of the fascia lata over the LFCN and upper sartorius. These results indicate that the internal oblique–iliac fascia septum and iliolata ligaments may make the LFCN susceptible to mechanical entrapment near the ASIS. To surgically decompress the LFCN, it may be necessary to incise the oblique aponeurosis and iliac fascia medial to the LFCN tendinous canal and to free the iliolata ligaments from the ASIS.

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Jacob D. Bond, Zhaoyang Xu and Ming Zhang

OBJECTIVE

The extradural neural axis compartment (EDNAC) is an adipovenous zone that is located between the meningeal (ML) and endosteal (EL) layers of the dura mater and has been minimally investigated in the jugular foramen (JF) region. In this study, the authors aimed to explore the fine architecture of the EDNAC within the JF and evaluate whether the EDNAC can be used as a component for JF compartmentalization.

METHODS

A total of 46 cadaveric heads (31 male, 15 female; age range 54–96 years) and 30 dry skulls were examined in this study. Twelve of 46 cadaveric heads were plastinated as a series of transverse (7 sets), coronal (3 sets), and sagittal (2 sets) slices and examined using stereomicroscopy and confocal microscopy. The dural entry points of the JF cranial nerves were recorded in 34 cadaveric skulls. The volumes of the JF, intraforaminal EDNAC, and internal jugular vein (IJV) were quantified.

RESULTS

Based on constant osseous landmarks, the JF was subdivided into preforaminal, intraforaminal, and subforaminal segments. The ML-derived fascial sheath along the anteromedial wall of the IJV demarcated the “venous portion” and the “EDNAC portion” of the bipartite JF. The EDNAC did not surround the intraforaminal IJV and comprised an ML-derived dural fibrous network and an adipose matrix. A fibrovenous curtain subdivided the intraforaminal EDNAC into a small anterior column containing cranial nerve (CN) IX and the anterior condylar venous plexus and a large posterior adipose column containing CNs X and XI. In the intraforaminal segment, the IJV occupied a slightly larger space in the foramen (57%; p < 0.01), whereas in the subforaminal segment it occupied a space of similar size to that of the EDNAC.

CONCLUSIONS

Excluding the IJV, the neurovascular structures in the JF traverse the dural fibrous network that is dominant in the foraminal EDNAC. The results of this study will contribute to anatomical knowledge of the obscure yet crucially important JF region, increase understanding of foraminal tumor growth and spread patterns, and facilitate the planning and execution of surgical interventions.

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Zahid Hussain Khan, Masoud Nashibi and Seyed Amir Javadi

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Qing Zhu, Ming Qian, Jianru Xiao, Zhipeng Wu, Yu Wang and Jishen Zhang

Object

Calcified meningiomas are an uncommon type of meningioma. This study details the clinical features, treatment, and follow-up of 11 calcified meningiomas treated from 2002 to 2009, for the purpose of providing general information, describing the skill required for the surgery, and detailing the imaging study of these tumors.

Methods

Between 2002 and 2009, 11 patients underwent surgery for the treatment of calcified meningiomas. All were treated by the same group of doctors at the same institution, including surgery and rehabilitation after surgery. The minimum 3-year (> 36 months) follow-up data from the 11 patients were detailed. Neurological function was evaluated twice, based on the Frankel scale and Japanese Orthopaedic Association scoring system. The first evaluation occurred before surgery and the second 3 years after surgery.

Results

In 3 cases, the Frankel score decreased by 1 level. In a comparison of the duration of preoperative symptoms, age, degree of canal stenosis, and intraoperative blood loss, it was found that the greater the degree of canal stenosis, the poorer the outcome of the patient. Calcified meningiomas were more likely to adhere to the nerves and dura, a finding that might explain the high incidence of neurological dysfunction and CSF leakage after surgery.

Conclusions

Calcified meningiomas are the most rare of all meningiomas. It appears that a greater degree of canal stenosis can lead to a poorer outcome. Computed tomography scans and MRI with contrast enhancement are recommended for intraspinal tumors before surgery to exclude the possibility of calcification. For calcified meningiomas, precise tumor resection, dura repair during surgery, and medical care after surgery are important for achieving an acceptable outcome.

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Ang Deng, Hong-Qi Zhang, Ming-Xing Tang, Shao-Hua Liu, Yu-Xiang Wang and Qi-Le Gao

OBJECTIVE

The objective of this study was to evaluate the clinical efficacy of posterior-only surgical correction of dystrophic scoliosis in patients with neurofibromatosis Type 1 (NF1) using a multiple anchor point method (MAPM).

METHODS

From 2005 to 2014, 31 patients (mean age 13.5 years old, range 10–22 years old) suffering from dystrophic scoliosis associated with NF1 underwent posterior-only surgical correction using a MAPM. The apex of the deformity was thoracic (n = 25), thoracolumbar (n = 4), and lumbar (n = 2). The mean preoperative coronal Cobb angle was 69.1° (range 48.9°–91.4°). The mean Cobb angle on the side-bending radiograph of the convex side was 58.2° (range 40°–79.8°). The mean flexibility and apical vertebral rotation (AVR) were 15.6% (range 8.3%–28.2%) and 2.5° (range 2°–3°), respectively. The mean angle of sagittal kyphosis was 58.3° (range 34.1°–79.6°).

RESULTS

The mean follow-up period was 53 months (range 12–96 months). The mean postoperative coronal Cobb angle was 27.4° (range 16.3°–46.7°). Postoperatively, the mean AVR and angle of sagittal kyphosis were 1.2° (range 1°–2°) and 22.4° (range 4.2°–36.3°), respectively. All patients showed good correction of all indices postoperatively. The mean postoperative correction rate was 58.7% (range 46.3%–74.1%). At the final follow-up evaluation, the corrective loss rate of the Cobb angle was only 2.3%. Only 1 patient required revision surgery. No severe complications such as spinal cord, neural, or large vascular injury occurred during the operation.

CONCLUSIONS

Posterior-only surgical correction of dystrophic scoliosis in patients with NF1 using a MAPM could yield satisfactory clinical efficacy of correction and fusion.

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Min He, Heng Zhang, Ding Lei, Bo-Yong Mao, Chao You, Xiao-Dong Xie, Hong Sun, Yan Ju and Jia-Ming Zhang

Object

Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation.

Methods

Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically.

Results

Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement.

Conclusions

Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

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Peng Xu, Wei-Ming Gong, Yao Li, Tao Zhang, Kai Zhang, De-Zhen Yin and Tang-Hong Jia

Object

Chronic mechanical compression of the spinal cord, which is commonly caused by degeneration of the spine, impairs motor and sensory functions insidiously and progressively. Yet the exact mechanisms of chronic spinal cord compression (SCC) remain to be elucidated. To study the pathophysiology of this condition, the authors developed a simple animal experimental model that reproduced the clinical course of mechanical compression of the spinal cord.

Methods

A custom-designed compression device was implanted on the exposed spinal cord of female Wistar rats between the T-7 and T-9 vertebrae. A root canal screw attached to a plastic plate was tightened 1 complete turn (1 pitch) every 7 days for 6 weeks. The placement of the compression device and the degree of compression were validated every week using radiography. Furthermore, a motor sensory deficit index was also calculated every week. After 3, 6, 9, or 12 weeks, the compressed T7–9 spinal cords were harvested and examined histologically.

Results

Lateral projection of the thoracic spine showed a progressively increasing rate of mean spinal cord narrowing in the compression group. Motor and sensory deficiencies were observed from Week 3 onward; paralysis was observed in 2 rats at Week 12. Motor deficiency appeared earlier than sensory deficiency. Obvious pathological changes were observed starting at Week 6. The number of neurons in the gray matter of rats with chronic compression of the spinal cord decreased progressively in the 6- and 9-week compression groups. In the white matter, myelin destruction and loss of axons and glia were noted. The number of terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick-end labeling (TUNEL)–positive neurons increased in the ventral-to-dorsal direction. The number of TUNEL-positive cells increased from Week 6 onward and peaked at Week 9.

Conclusions

This practical model accurately reproduces characteristic features of clinical chronic SCC, including progressive motor and sensory disturbances after a latency and insidious neuronal loss.

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Ming-liang Yang, Jian-jun Li, Shao-cheng Zhang, Liang-jie Du, Feng Gao, Jun Li, Yu-ming Wang, Hui-ming Gong and Liang Cheng

The authors report a case of functional improvement of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization using a functional spinal accessory nerve. Complete spinal cord injury at the C-2 level was diagnosed in a 44-year-old man. Left diaphragm activity was decreased, and the right diaphragm was completely paralyzed. When the level of metabolism or activity (for example, fever, sitting, or speech) slightly increased, dyspnea occurred. The patient underwent neurotization of the right phrenic nerve with the trapezius branch of the right spinal accessory nerve at 11 months postinjury. Four weeks after surgery, training of the synchronous activities of the trapezius muscle and inspiration was conducted. Six months after surgery, motion was observed in the previously paralyzed right diaphragm. The lung function evaluation indicated improvements in vital capacity and tidal volume. This patient was able to sit in a wheelchair and conduct outdoor activities without assisted ventilation 12 months after surgery.

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Bing Zhou, Xiao-Chuan Wang, Jun-Yi Xiang, Ming-Zhao Zhang, Bo Li, Hai-Bo Jiang and Xiao-Dong Lu

OBJECTIVE

Mechanical thrombectomy using a Solitaire stent retriever has been widely applied as a safe and effective method in adult acute ischemic stroke (AIS). However, due to the lack of data, the safety and effectiveness of mechanical thrombectomy using a Solitaire stent in pediatric AIS has not yet been verified. The purpose of this study was to explore the safety and effectiveness of mechanical thrombectomy using a Solitaire stent retriever for pediatric AIS.

METHODS

Between January 2012 and December 2017, 7 cases of pediatric AIS were treated via mechanical thrombectomy using a Solitaire stent retriever. The clinical practice, imaging, and follow-up results were reviewed, and the data were summarized and analyzed.

RESULTS

The ages of the 7 patients ranged from 7 to 14 years with an average age of 11.1 years. The preoperative National Institutes of Health Stroke Scale (NIHSS) scores ranged from 9 to 22 with an average of 15.4 points. A Solitaire stent retriever was used in all patients, averaging 1.7 applications of thrombectomy and combined balloon dilation in 2 cases. Grade 3 on the modified Thrombolysis In Cerebral Infarction scale of recanalization was achieved in 5 cases and grade 2b in 2 cases. Six patients improved and 1 patient died after thrombectomy. The average NIHSS score of the 6 cases was 3.67 at discharge. The average modified Rankin Scale score was 1 at the 3-month follow-up. Subarachnoid hemorrhage after thrombectomy occurred in 1 case and that patient died 3 days postoperatively.

CONCLUSIONS

This study shows that mechanical thrombectomy using a Solitaire stent retriever has a high recanalization rate and excellent clinical prognosis in pediatric AIS. The safety of mechanical thrombectomy in pediatric AIS requires more clinical trials for confirmation.