Glyset
Gerard R. Manecke, Jr., MD
- Clinical Professor of Anesthesiology
- Chair, Department of Anesthesiology
- University of California, San Diego
- La Jolla, California
The myelotomy is deepened by gentle spreading with blunt microforceps and dissectors generic glyset 50mg amex. Fibrous gliosis at the polar margins of the tumor may require sharp dissection with a microknife purchase glyset 50 mg amex. The myelotomy continues until the entire rostrocaudal extent of the dorsal tumor surface has been identified order 50mg glyset visa. Although the myelotomy must extend a few millimeters beyond the solid portion of the tumor purchase 50mg glyset with mastercard, it is not necessary to completely expose polar cysts discount glyset 50mg without a prescription. Size 6-0 pial sutures are placed and clipped laterally to the dura to maintain gentle traction discount 50 mg glyset overnight delivery. Ependymomas are usually characterized by a glistening reddish or brownish-red surface that may be slightly lobulated. These tumors are clearly distinguishable from the surrounding spinal cord on the basis of color and texture. Although unencapsulated, these tumors do not infiltrate and can be easily distinguished and separated from the surrounding spinal cord. Astrocytomas are more heterogeneous with respect to physical characteristics, and they abut the spinal cord. Intratumoral cysts are quite common, but tumor color and consistency are variable. The technique of tumor removal depends on its juncture with the spinal cord and its size. The dorsal tumor surface is exposed with pial sutures and gentle, blunt lateral displacement of the overlying dorsal hemicords with dissectors. Fibrous and vascular attachments that tether the spinal cord to the tumor surface are systematically cauterized and divided. The development of the lateral and polar tumor margins is facilitated by forceps traction on the tumor and gentle pial suture and manual dissector countertraction on the spinal cord. Larger tumors require internal decompression with an ultrasonic aspirator or laser to facilitate visualization and mobilization of the lateral and ventral tumor margins. Internal decompression is continued peripherally until the clear distinction of the tumor and spinal cord is no longer obvious. Following tumor removal, the resection cavity and subarachnoid space are copiously irrigated with a warm saline solution. The deep muscles are reapproximated with a running absorbable monofilament suture over a Hemovac drain. Absorbable braided suture is used to close the deep fascia and subcutaneous tissue, and a running nonlocked nylon suture is used for the skin closure. The patient is maintained on bed rest for 36 hours after surgery, and then mobilization is begun. Hemangioblastoma the techniques and principles of removal of spinal cord hemangioblastoma are distinct from those used for the resection of the much more commonly occurring glial tumors (astrocytomas and ependymomas). Hemangioblastomas, however, are more accurately considered juxtamedullary tumors because they arise from the pia in the vast majority of cases. The surface presentation and pial origin of spinal cord hemangioblastomas provide the fundamental basis of the surgical resection strategy and technique. Circumferential release of the pial attachment at the interface of the tumor surface and spinal cord is performed to devascularize the tumor and to provide the exposure and mobility needed to access and safely remove the intramedullary component by detaching it from the adjacent neural structures. Variability in hemangioblastoma size and location, the relationship to the nerve roots, surface vascularity, edema and cyst, and surfaceto-intramedullary tumor ratio, however, may necessitate some variation in surgical technique on a case-by-case basis. After dural opening, inspection of the spinal cord under high magnification is performed to identify the surface component of the tumor. Most hemangioblastomas are located on the dorsal or dorsolateral surface of the spinal cord and are readily seen on initial inspection of the spinal cord under the microscope. The key to the initial dissection is identification of the surface component of the hemangioblastoma. The superficial tumor can be recognized by its characteristic sunset orange appearance. Large draining veins on the dorsal and dorsolateral spinal cord surface are typical and may partially or completely obscure visualization of the pial surface of the tumor. In some cases, there may be a significant exophytic tumor component ("snow cone" tumor), whereas in other cases, a very small surface tumor component belies a large underlying intramedullary extension ("iceberg" tumor). Irrespective of these variations, the subsequent step after identification of the superficial pial tumor component is identification of the interface between the pial origin of the tumor and the surrounding normal pia. Draining veins that obscure visualization of the surface component of the tumor are systematically mobilized from their epipial attachment, cauterized, and divided. One or two major draining veins, usually at the polar margins of the tumor, are left intact until the end of the tumor resection. Dorsolateral tumors typically involve the dorsal root entry zone of at least one level. Often, this dorsal root partially obscures the surface of the tumor or the margin between the normal pia and 471 a b. For tumors with limited or no intramedullary extension, the tumor is easily removed following the circumscribing pial incision. Tumors with larger intramedullary components, however, may require gentle traction on the tumor, with either tumor forceps or a suture through the pial origin, and progressive shrinkage of tumor volume through cauterization of the tumor surface with irrigating cautery on a low setting. This generally provides adequate exposure and visualization for safe resection of the intramedullary portion of the tumor. Tumors with very large intramedullary components, particularly those associated with a relatively small surface projection. The intramedullary portion of these tumors is usually associated with a readily developed tumor plane whose dissection is further facilitated by the frequent presence of syringomyelia. The vast majority of arterial feeders and the venous drainage of these tumors are located at the pial surface. Very few deep feeding vessels or draining veins are encountered during the intramedullary dissection. Cauterization of the tumor surface can shrink the tumor volume to some degree and facilitate dissection, but this should be done under a low setting with somewhat broader tipped irrigating forceps because of the fragility of the hemangioblastoma vascular stroma. Internal decompression of the tumor or periodic compartmental tumor amputation can be used in some cases to facilitate deep exposure, but these maneuvers may be problematic because of tumor vascularity. Gentle traction on the tumor can be applied with a small traction suture in the pial surface of the tumor. The well-defined plane between the tumor and the spinal cord is progressively developed with traction on the tumor with a microdissector, tumor or microcautery forceps, or suction tip, and blunt gentle countertraction on the spinal cord with a microdissector. Deep fibrous attachments and bridging vessels are systematically isolated, cauterized, and divided. Prolene pial traction 6-0 sutures may be used to provide gentle retraction to improve visualization and facilitate the intramedullary resection. Typically, at least one major draining vein is left patent at the polar margin of the tumor until dissection of the intramedullary tumor component is completed. These dorsal root fascicles must usually be mobilized and divided to facilitate tumor removal. Once the interface between the pia and the tumor is identified, it must be circumferentially detached. On its outer surface, an epipial matrix of arachnoid is loosely attached to the pia. The superficial vasculature of the spinal cord is loosely attached to the spinal cord surface within this epipial layer. Sharp dissection of the epipial arachnoid enables mobilization and isolation of surface draining veins to be cauterized and divided so that precise visualization of the interface between the tumor and the intima pia can be achieved. Unlike the brainstem and cranial pia, the spinal intima pia is a robust membrane made up of longitudinally oriented fibers that have a characteristic glistening, white, striated appearance under the operating microscope. The intima pia is densely adherent to the underlying glial outer limiting membrane of the spinal cord. Detachment of this well-defined sturdy membrane requires sharp dissection with a microknife or scissors. After the margin of the tumor has been circumferentially detached from the surrounding normal pia, removal of the intra-. Potential Complications and Precautions the most common complications relate to wound problems, infection, and thromboembolic events. Sequential compression devices, initially placed immediately prior to sur- gery, are continued postoperatively until the patient is adequately mobilized. Subcutaneous heparin (5,000 units twice a day) or low molecular weight heparin (enoxaparin 40 mg every day) may also be considered on or about postoperative day 2, but may increase the risk of wound hematomas. Delayed leaks may produce only contained pseudomeningoceles that usually spontaneously resolve over several weeks. Persistent collections, especially associated with postural headaches, may require reoperation for repair. These patients are usually returned to the operating room for repair within 24 to 36 hours if the leakage persists. Nearly all patients experience some degree of posterior column deficit following midline myelotomy. This issue should be discussed with the patient as part of the preoperative preparation. Optimization of surgical outcome, therefore, is the most important treatment consideration. Aggressive initial management, appropriate judgment and technique, and adherence to strict microsurgical techniques are the most effective methods of avoiding complications and ensuring an optimal treatment outcome. Predictors of ambulatory function after surgical resection of intramedullary spinal cord tumors. Surgical management of spinal cord hemangioblastomas in patients with von HippelLindau disease. Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors: analysis of 238 patients. Factors associated with cervical instability requiring fusion after cervical laminectomy for intradural tumor resection. Intramedullary spinal ependymomas: analysis of a consecutive series of 82 adult cases with particular attention to patients with no preoperative neurological deficit. Rosenow Open anterolateral cordotomy is predicated on the interruption of the spinothalamic and spinoreticular pathways in the anterolateral quadrant of the cord carrying pain inputs to the brain from the periphery. This procedure is intended to preserve the tracts carrying fine touch and proprioception through the dorsal columns. Within the spinothalamic tract, the sacral fibers are located more dorsolaterally and the cervical fibers more ventromedially. Moreover, at any spinal level, axons composing the spinothalamic tract are primarily projections from cells located in the contralateral cord beginning two or three spinal segments below the specific level. Therefore, a lesion should produce pain relief beginning two or three dermatomes below the level of the lesion. In 28 patients, the new pain was in the mirror-image location of the original pain and could often be abolished by blockade of the nerves subserving the original pain. Choice of Operative Approach the procedure is typically performed via a laminectomy or hemilaminectomy and intradural exposure. Patient Selection Patients selected for ablative neurosurgical procedures for the treatment of chronic pain should have significant pain that has failed to adequately respond to multiple other conservative nonsurgical treatments, such as rehabilitation, oral medications (antiinflammatories, narcotics, anticonvulsants, antidepressants), and injections. Given the advances in neurostimulation and intrathecal drug delivery, it is also reasonable to conduct a trial of these therapies prior to considering ablative procedures. This is true both for patients with pain due to late-stage malignancies (due to their higher medical risk in undergoing surgery) and those with pain from nonmalignant causes (due to the risk of permanent neurologic morbidity from the procedures). Once the patient is selected, it is just as important to carefully select the correct ablative procedure, considering both the etiology of the pain and its location within the nervous system, so as to maximize the potential pain relief. Surgical Procedure In performing an open cordotomy, intradural exposure is first accomplished after laminectomy, followed by sectioning of the dentate ligament at the appropriate level. Grasping the free end of the dentate ligament enables the surgeon to gently rotate the cord away from the operative side and expose the ventral cord. A cordotomy hook with a 45-degree angle is inserted into the anterolateral quadrant and may be taken to the medial pia before sweeping ventrally. Postoperative Care the postoperative care is similar to that for patients who have undergone other intradural spinal procedures. Indications and Contraindications Patients undergoing open cordotomy typically have intractable neuropathic pain of the lower body. Cordotomy is indicated more frequently for patients with extremity pain rather than pelvic pain. Potential Complications and Precautions It is important to restrict the lesion to the region ventral to the dentate ligament to reduce the risk of inadvertent injury to the corticospinal tract, which is located more dorsally in the lateral spinal cord. Also, care must be taken not to violate the medial pia and risk injury to the anterior spinal vessels, which could cause spinal cord infarction. Advantages and Disadvantages Cordotomy is relatively straightforward to perform and involves no device implants. Like many ablative procedures, it is 476 74 probably best suited for those patients with a short life expectancy due to malignant pain, and is typically employed only after several other levels of invasive procedures have failed. Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy. New pain following cordotomy: clinical features, mechanisms, and clinical importance. Rosenow Commisural myelotomy involves severing the fibers of the spinothalamic tract where they cross the spinal cord in the anterior commissure.
Securing an airway cheap 50 mg glyset with visa, oxygenating the blood purchase 50 mg glyset otc, and perfusing the body are prerequisites to any neurosurgical procedure glyset 50mg with visa. Subsequently cheap 50mg glyset mastercard, the goals of the neurosurgeon are decompression of neural elements and stabilization to prevent secondary neurologic injury glyset 50 mg line. Indications for surgery include reversible neurologic deficit purchase glyset overnight delivery, gross or potential instability, and dural laceration/fistula formation. The mechanism of injury must be considered, as penetrating injuries from civilian gunshot wounds have a vastly different course than blunt trauma. Evidence of decompression of neural elements in an incomplete injury is mixed, but trends currently favor surgery in such cases. Conservative management is generally accepted as first-line management in cases without neurologic injury or gross instability. Original research on the topic by Guttman et al20 and Frankel et al17 in the 1960s and 1970s demonstrated acceptable neurologic outcomes with immobilization. This entailed 6 to 12 weeks of bed rest and postural reduction; 60% of patients showed neurological improvement, but this population was at high risk for systemic complications. For this reason, modern methods focus on bracing to stabilize the affected levels and on early mobilization. Thus, a significant proportion of injuries require surgical decompression and open stabilization. Decompression of neural elements varies based on the anatomy of the injury; retropulsion of vertebral body, neural foraminal compromise causing radiculopathy, epidural hematoma, or foreign objects can each dictate approach. This must be coupled with restoration of sagittal balance, and minimizing the length of construct to maximize segment mobility. Risks of increased perioperative blood loss in hyperacute injury, intraoperative hypotension, as well as delay in treatment of concomitant injuries must be weighed against the benefits of stabilization and early mobilization after decompression and fusion. There is some evidence of decreased morbidity with interventions performed within 72 hours of injury. An incomplete neurologic injury generally requires an anterior decompression if anterior elements cause neural compression after postural or open reduction. Therefore, a combined approach is necessary 556 V Lumbar and Lumbosacral Spine if an incomplete cord injury is coupled with anterior neural compression. The anterior approach should utilize retroperitoneal access to the vertebral body to enable vertebrectomy and placement of a cage or strut graft. This approach is limited to the lower lumbar levels because of the intimate relationship of the abdominal aorta with the vertebral body prior to the bifurcation into the iliac arteries. The posterior approach enables lamina decompression along with pedicle screw fixation. Laminectomy is appropriate in cases of posterior compression, dural laceration, epidural hematoma, and radicular compression. A measure of anterior decompression may be achieved through either retraction of the thecal sac and tamping of the vertebral body or ligamentotaxis. Pedicle screw fixation has largely replaced older fixation techniques, including rod or hook techniques. Biomechanical and clinical outcomes studies have shown that pedicle screw fixation enables high fusion rates with preservation of height and lordosis and lower rates of instrumentation failure and pseudarthrosis. Additionally, these procedures typically entail increased operative blood loss and increased incidence of gastrointestinal and pulmonary complications. These techniques lay the foundation for the minimally invasive lateral approaches that utilize muscle splitting instead of open dissection. Minimally invasive and computer-assisted techniques are another advancement in the treatment of traumatic fractures. Although there is a paucity of high-level evidence in the trauma literature thus far, minimally invasive principles as supported in the degenerative spine literature should translate well to the trauma population26. Minimizing blood loss and sparing of the paraspinal musculature may expedite functional recovery in posterior percutaneous segmental pedicle screw fixation. Anterior endoscopic techniques may decrease approach-related morbidity, but they entail a steep learning curve and require experience with the diaphragm and accompanying regional anatomy at the thoracolumbar junction. For surgical treatment of isolated burst fractures, anterior and posterior approaches may have similar outcomes regarding kyphosis, pain, and function, although some studies have shown that posterior approaches entailed a higher incidence of adverse events. Some surgeons may advocate short fusion constructs spanning only two disk spaces in young patients with high fusion potential, or in lumbar fractures with anterior column integrity. Longer constructs (two above and two below) may be appropriate for patients with poor bone quality or low fusion potential, or in thoracic fractures and anterior column failure. This patient population is at great risk for adverse events in the acute setting, including urinary tract infections, neuropathic pain, pneumonia, delirium, and ileus. Early removal of indwelling urinary catheters in favor of clean intermittent catheterization should be performed. Minimizing narcotic pain medicine and the use of adjuvant pain medication may prevent delirium and ileus. Percuta- b neous pedicle screws were placed bilaterally in T8 through L1, avoiding the left T10 pedicle because of the fracture pattern (b). Ultimately, all conservative and surgical treatments are an effort to expedite rehabilitation and minimize the hospital stay. Trauma of the Lumbar Spine and Sacrum 557 of the thoracolumbar injury classification and severity score. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. International Standards for Neurological and Functional Classification of Spinal Cord Injury. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. Fusion may not be a necessary procedure for surgically treated burst fractures of the thoracolumbar and lumbar spines: a follow-up of at least ten years. Incidence, impact, and risk factors of adverse events in thoracic and lumbar spine fractures: an ambispective cohort analysis of 390 patients. Determination of the superiority of one method over the others has been difficult because of the lack of standard classification systems, despite the advancement in operative techniques for fusion. As supporting data continue to accumulate, conclusions will eventually be drawn to guide treatment decisions. Validating a newly proposed classification system for thoracolumbar spine trauma: looking to the future 28. Koski Anterior approaches to both the thoracic and lumbar spine have been utilized to treat a variety of spinal diseases since the early 20th century. The anterior approach to the lumbosacral junction thus remains an essential and powerful tool not only for exposing the anterior and middle columns of the lumbosacral junction, but also for releasing rigid spinal deformities and achieving optimal lordosis restoration in the lumbar spine. With an experienced access surgeon, straightforward anterior exposures can be performed efficiently and with minimal blood loss and relatively low morbidity through a reasonably small incision. Despite this, the fact remains that complications from this approach can be catastrophic. The inferior vena cava and iliac vessels are draped over the lumbar spine and lumbosacral junction. These vessels are typically mobilized during this operation, and can thus be injured or occluded by even the most seasoned access surgeon. Every access surgeon, therefore, should be comfortable with quickly triaging and repairing such damage with venous repair, arterial thrombectomy, or even vascular bypass techniques if necessary. Preoperative Imaging and Testing the choice of spinal imaging modality prior to performing an anterior approach to the lumbosacral spine depends on the pathology being treated. For older patients, it is often recommended to obtain preoperative bone-density testing, especially if instrumentation is planned. In the presence of known arterial disease or history of venous thromboembolism, preoperative ultrasound or angiographic studies can be useful for planning and avoidance of potential complications. Guidance from an experienced access surgeon is strongly recommended in these circumstances. This space is then carefully developed further, and the sacral promontory, left ureter, and iliac vessels are identified. Direct pressure on the left ureter is avoided by placing the retractor superficial to it, so that the ureter can be visualized during the procedure on the right side of the field (anterior to the spine and attached to the peritoneum). The position and integrity of the major vessels, ureter, and spine are identified and verified. The vasculature is then carefully dissected, employing sharp technique for arteries and blunt dissection to the relatively thin-walled veins. A gel-filled roll or foam axillary roll can be placed under the lumbosacral junction to generate a lordotic position if needed. A midline incision is made from just distal to about two thirds of the way to the pubic symphysis umbilicus. A dissection plane is then carried just deep to the left rectus muscle, allowing the endoabdominal fascia and peritoneum to fall away from the posterior rectus muscle. The endoabdominal fascia is then incised vertically using tissue scissors, and blunt dissection is used to sweep the peritoneum. Once the L5-S1 disk is properly exposed and identified, a generous annulotomy is sharply performed, releasing enough disk at the anterolateral corners to prepare for lordotic distraction. A Cobb elevator and various curettes can then be used to remove further disk material and separate the cartilaginous end plates from the vertebral bodies. It is important to remove and release enough disk to generate maximum mobilization for deformity correction and simultaneously achieve adequate arthrodesis of both end plates for fusion. Furthermore, great care must be taken to preserve the subchondral osseous structure of the end plates to prevent early graft subsidence. Screws are then introduced through the interbody device via manufactured screw holes to secure the cages and prevent dislodgment. Hemostasis is obtained via careful bipolar cautery and packing with topical hemostatic agents in the deeper spaces. The retractors are carefully removed, with thorough inspection to ensure adequate hemostasis. The peritoneum is gently swept back in place and inspected for rents, which are closed primarily with Vicryl suture. The abdominal fascia is then closed meticulously to prevent hernia formation, and the remainder of the wound is closed in anatomic layers. The vessels are then carefully mobilized circumferentially, with small branches being carefully identified, ligated, and divided. The middle sacral vessels over the L5-S1 disk are identified, encircled with an angled clamp, and double clipped before being divided. There is typically one middle sacral artery with two veins, one of which branches off the left common iliac vein and courses toward the left border of the lumbar spine. This vessel is commonly missed and can cause significant blood loss if it is avulsed. The loose areolar tissue over Postoperative Care Postoperative care after anterior approaches is centered mainly on careful diet advancement and prevention of venous thromboembolism. Potential Complications and Precautions the most common complications during anterior approaches to the lumbar spine are venous injuries. Circumferential exposure, control, and repair of the large venous structures can be exceedingly difficult due to their thin walls and the deep operative site with complex anatomy. Most small venous tears can be repaired with surgical clips deployed tangentially to the vein. Although oversewing these injuries can be dangerous (the slightest torque with a needle driver can exacerbate an injury due to the frail venous tissue) it is sometimes necessary to suture a longer tear. Risk factors for vascular thrombosis (such as atherosclerosis, fibromuscular dysplasia, or venous thromboembolism) should be identified preoperatively. When operating on a patient with atherosclerotic iliac vessels, it is important to frequently check a distal left iliac pulse throughout the operation. A pulse oximeter can also be used on both lower extremities to monitor differential oxygen saturations. If a common iliac artery thrombosis occurs, 5,000 units of intravenous heparin is given immediately while circumferential proximal and distal control of the vessel is quickly obtained and an open thrombectomy is then performed. Venous thromboembolism is typically seen in patients who sustained a venous injury during the exposure. Although rare, ureteral injuries can occur from intraoperative lacerations or ischemia due to direct pressure/stretching from retractor placement. If a particularly difficult exposure is anticipated with a high risk of such an injury, ureteral stents can be placed to facilitate intraoperative identification of the ureters. Alternatively, a transperitoneal approach can be employed to avoid the more laterally located ureters. Ureteral injuries require urologic consultation for repair and long-term management. Retrograde ejaculation occurs due to damage to the superior hypogastric nerve plexus, which courses over the left side of the sacral promontory. Disruption of these nerves causes dysregulation of the internal vesicular sphincters, resulting in ejaculation of sperm into the bladder rather than out of the penis.
The most common sealant is a mixture of polyethylene glycol and trilysine amine buy glyset 50 mg line, which polymerizes when the two compounds are mixed 50mg glyset with amex. These sealants occupy spaces in which primary closure was insufficient discount glyset line, and eventually dissolve in 4 to 8 weeks purchase glyset 50mg visa. Therehavebeen case reports in the literature of compression on the spinal cord order glyset, causing quadriparesis and cauda equina syndrome following its use in cervical and lumbar surgeries 50 mg glyset amex, respectively. Theoretically, the use of postoperative steroids arrests the process of fibroblast proliferation and incorporation; therefore, avoidance of postoperative steroids is recommended. Although some manufacturers claim that their dural substitutes do not need to be sutured down, we recommend as close to a watertight suture with the dural substitutes as possible. Following any repair, the dural closure can be tested by requesting a Valsalva maneuver of 40 mm H2O pressure from the anesthesia team. Any evidence of a seeping wound would be an indication for reopening the lumbar drain for a prolonged drainage period, or even considering permanent lumbar-peritoneal shunting. Similar to the use of lumbar drains, some institutions favor a weaning process by which the subfascial drain is clamped and the surgical wound is monitored for leaking before committing todiscontinuingthedrain. Immediately following surgery, the dural repair should be discussed with the anesthesia team, to ensure that the team is aware of the importance of a careful extubation to prevent intrathecal pressure elevation with violent coughs and vomiting. In the recovery period, vomiting can be controlled by steroids or antiemetics, and the surgeon should have a low threshold to prescribe antiemetics to stay ahead of vomiting episodes postoperatively. Pain may lead to writhing, which can increase intrathecal pressure; therefore, adequate pain control should be provided in the form of opioids and antispasmodics. Thecommonadverseeffectof constipation from use of opioid medications can raise intrathecal pressures if the patient is straining to have a bowel movement. Aggressive bowel regimens to include laxatives, stool softeners, and even more aggressive measures like enemas should be considered in the postoperative period. Flat-in-bed positioning to 686 V Lumbar and Lumbosacral Spine reduce the hydrostatic tension on the dural repair may be contraindicated in patients with positional orthopnea, and can be cumbersome for meals and rehabilitation. However, the prophylactic use of antibiotics (cefazolin or vancomycin) while a lumbar or a subfascial drain is present is essential. Postoperative cervical cord compression induced by hydrogel dural sealant (DuraSeal). Postoperative cervical cord compression induced by hydrogel (DuraSeal): a possible complication. Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks. Managing the Cerebrospinal Fluid Leaks After Spinal Surgery By Prolonged Subfascial Drainage. Management and results after a two-year-minimum follow-up of eighty-eight patients. We recommend starting the approach from normal anatomy in the cranial-caudal dimension, and working toward the previous surgical site to build planes from normal anatomy to abnormal, postsurgical anatomy. In the case of the traumatic dural violation from a spine fracture, the surgeon should anticipate the materials and procedures required to address the fracture if instability is a concern. In the setting of a suspected infection, wound cultures should be sent to the lab for analysis, and antibiotics should be held preoperatively, if tolerated, to increase diagnostic yield. Once culture specimens are obtained, empiric antibiotics should be started without delay. When conservative management fails or is deemed contraindicated, surgical correction is essential in rectifying this common problem. Conceptually, drainage from the spinal intrathecal compartment in so-called communicating hydrocephalus states could have some advantages. With a mean follow-up of 19 months, however, the revision rate was 27% with an average time to failure of 11 months. This can result in difficulty cannulating the intrathecal space, accessing the peritoneal space in the lateral body position, and assessing the patency of the shunt. In our experience, shunt patency becomes an automatic concern for patients with any return or continuance of headache symptoms, leading to frequent office or emergency room visits. Nuclear medicine shunt studies and lumbar puncture opening pressures can provide unreliable indicators of shunt failure. However, 56% of the cohort required at least one shunt revision, with the number of revisions ranging from 1 to 13. In selected cases, adjustable valves are used, but with the knowledge that it will likely be difficult to change the settings once the system is implanted. Over the flank or abdomen, the valve may not be palpable due to the degree of overlying subcutaneous fat. It has been theorized that "equal drainage" for the ventricular and cranial subarachnoid spaces would lessen the risk of subdural hematoma, but this has not been demonstrated by any clinical study. As in all procedures involving implantable hardware, there is a risk of infection of the implanted system. Overall, up to 90% of the implanted systems require revision for mechanical failure with long-term follow-up. Technique the patient is placed in the lateral decubitus position, with as much flexion as possible without obstructing access to the abdomen (Video 111. Three separate incisions are made: (1) for thecal sac access, (2) for peritoneal access, and (3) for placement of the valve in the flank area. Lack of flow typically indicates a kinked catheter or other problem (such as a broken catheter, reversed valve, etc. The lumbar incision is vertical (parallel to the spinous processes) and either in the midline or slightly paramedian at the level of the L3-4 or L4-5 interspace, which roughly corresponds to the level of the iliac crest. A paramedian location decreases frictional wear of the catheter with the spinous processes. The peritoneal cavity is accessed via a mini-laparotomy using a standard approach. In obese patients, care must be taken not to stray obliquely downward in the subcutaneous fat, missing the rectus fascia completely. At our center, laparoscopic bariatric surgeons have successfully accessed the peritoneum, although using caution because laparoscopic surgery is typically performed with the patient in the supine position. This incision has to be long enough to be able to anchor catheters on both sides of the H-V valve and accommodate the H-V valve so that it is in the vertical position when the patient is upright. A tunneler is used to pass the peritoneal catheter from the flank to the abdominal incision. The valve is secured to the subcutaneous fat with 2-0 silk sutures to ensure that the long axis of the valve is in line with the long axis of the patient. The peritoneal catheter is connected to the valve and secured with a 2-0 silk tie. If the surgeon wishes to leave a tapping reservoir, this device is typically situated near the lumbar incision in a pocket. A 14-gauge Tuohy needle is used to access the lumbar cistern, aiming medially toward midline and 30 to 45 degrees cephalad. Approximately 10 cm of catheter is advanced into the lumbar cistern, and then the needle is withdrawn, taking care not to lacerate the catheter with the sharp tip. The catheter is sutured to the lumbosacral fascia using a silicone butterfly suture clamp. All incisions are irrigated copiously with antibiotic irrigation and closed in layers in the standard fashion. Preoperative Planning There are several factors to consider prior to proceeding with operation. It is technically difficult and relatively contraindicated in patients with history of lumbar fusions or extensive abdominal operations. In those cases, fluoroscopic guidance may be required for accessing the thecal sac, and general surgery assistance may be required for accessing the peritoneum. Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal shunt: a case report. Treatment of cerebrospinal fluid rhinorrhea by percutaneous lumboperitoneal shunting: review of 15 cases. Acute subdural hematoma after lumboperitoneal shunt placement in patients with normal pressure hydrocephalus. Tonsillar herniation: the rule rather than the exception after lumboperitoneal shunting in the pediatric population. By limiting passive and active motion and in the extreme by leading to irreducible contractures and deformities, an excess of muscular tone contributes to further incapacity. When hyperspasticity becomes refractory to medical treatment and physical therapy, the recourse to functional neurosurgery may be justified. The technique consisted of dividing the entire dorsal roots from L2 to S2, excluding the "antigravity root" L4. He used intraoperative electrical stimulation to identify segmental levels and to distinguish between ventral and dorsal roots. In the 1960s, Gros and coworkers3 in Montpellier, France, separated the dorsal roots into rootlets and performed partial dorsal rhizotomies with nonselective sectioning of 80% of the rootlets of each root to limit postoperative sensory deficits. In 1976, Fasano et al5 in Turin, Italy, introduced a different concept of dorsal rhizotomy-the functional posterior rhizotomy-based on identification of abnormal muscular responses to electrical stimulation of roots and rootlets. Responses were categorized as abnormal when repetitive dorsal root and rootlets stimulation with a train at a frequency of 50 Hz and a duration of 1 second provoked sustained responses in the corresponding segmental muscles or the spread of response to other territories either ipsilaterally or contralaterally. Limited Approaches In the 1980s and 1990s we commonly used osteoplastic laminotomy limited to the T11, T12, and L1 vertebrae. Through this approach, the ventral and corresponding dorsal L2 and L3 roots can be reached just before they exit at their respective dural sheaths. The other (dorsal) lumbar and sacral roots/rootlets can be identified at their entry into the dorsolateral sulcus at the conus medullaris. At the conus medullaris, the landmark between the S1 and the S2 medullary segments is located ~ 30 mm from the exit of the (tiny) coccygeal root from the conus. The quantity per root differs with respect to the root level and function and to its involvement in the (harmful) components of the spasticity. By their technique, which they called the "single-level immediately caudal to conus medullaris approach," at the T12-L1-L2 level, the dural sac is exposed. Localization of the conus and adjacent cauda equina are confirmed by an ultrasound probe through the exposed space. The conus appears hypoechogenic and cylindrical, and the cauda equina hyperechogenic and inhomogeneous. Once identification is completed, a single-level laminectomy, or more levels if necessary, is performed. After dural and arachnoid opening, the L1 and L2 roots are identified at the exit of their corresponding foramina. The dorsal root of L2 is separated from the ventral root and followed up to the conus. From the L2 dorsal root at the dorsolateral sulcus, the subjacent dorsal rootlets, from L3 to supposedly S2, are then progressively retracted medially, while being separated from their corresponding ventral roots. Then the S3 to S5 roots are identified at their exit from the most caudal part of the conus so that they are spared. We recently developed a modality that we have termed keyhole interlaminar dorsal rhizotomy. To access the roots to be targeted individually at their exit from the intradural space to the corresponding dural sheath. Under direct vision, identification of the anatomic/topographic level can be precisely verified by electrical stimulation of the (ventral) root. Stimulation of the dorsal root can test its physiological implication in the harmful components of the spasticity and help quantify sectioning. For diplegic children who are able to ambulate, generally with the so-called scheme of Little,15 the goals are to improve functional status and autonomy, and prevent or stop the evolution of the deformities. For nonambulatory diplegic or quadriplegic children, the only realistic goal is to facilitate care, provide comfort, and ease pain. In diplegic patients the main muscles involved are the psoas-iliacus and adductors of thigh (whose corresponding roots are L2 and L3), hamstrings (L5, S1, and S2), triceps surae and tibialis posterioris (S1). Too early would be imprudent, as younger children still have the potential for developmental maturation of their central nervous system and the capacity for further locomotion skills. Too late would be unwise, due to the appearance of potentially irreducible contractures and deformities. For diplegic children who are able to ambulate, the goal of surgery is to improve the quality of locomotion, depending on the preoperative degree of incapacity. Those distant effects can be explained by reduction of the inputs originating from the spastic lower limbs onto the brainstem reticular formation, as well as through the propriospinal interneuron system. For severely affected children, complementary neuro-orthopedic surgery, especially tendon lengthening, can be useful. Preoperative Planning the roots to be targeted are those conveying abnormal hyperactivity in the circuits corresponding to the muscles that harbor "harmful" spasticity. The surgical approach is then defined based on the roots to be targeted and their anatomic spine levels as demonstrated in. The chart should specify the muscular groups to be weakened in tone and to what degree, and those whose tone must be preserved at least partially.
The diagnosis is suspected clinically in patients who present with posterior cervical or suboccipital pain and a head tilt 50mg glyset fast delivery. Atlantoaxial rotatory subluxation has been defined as more than 2 mm of subluxation of the C1 lateral masses on C2 buy generic glyset line. Also purchase glyset cheap online, a rightleft difference in rotation between C1 and C2 greater than 8 degrees represents excessive motion buy genuine glyset on-line. All of the precautions taken in patients with cranial settling should be exercised buy glyset discount. These patients are maintained in a halo vest for 10 to 12 weeks post operatively and then placed in a soft collar for an additional 6 to 8 weeks generic glyset 50 mg on line. This goal may be achieved by posterior arthrodesis combined with a decompressive procedure when needed. Although lack of uniform outcome measures in the literature makes generalizations about prognosis difficult, several factors have been shown to correlate with decreased potential for neurologic recovery after surgical stabilization. In contrast, when all rheumatoid patients were taken together, the average mortality. Maximal benefit can be realized when patients are treated early in the disease process. Miscellaneous Inflammatory Conditions Affecting the Craniovertebral Junction the seronegative spondyloarthropathies are a group of related disorders that cause inflammation and ossification of the entheses or sites of ligamentous/tendinous insertion into the bone. They commonly affect the spine and sacroiliac joints, as well as the peripheral joints. Whereas these enthesopathies typically result in stiffening or fusion of the involved joints (spondylitis), the associated arthritis can cause severe erosive changes in the ligaments and associated joints. Rheumatologic complications have been described in up to 30% of patients with inflammatory bowel disease. They concluded that inflammatory bowel disease should be added to the differential diagnosis of patients who present with isolated atlantoaxial instability. This phenomenon has been termed "pseudogout" and may present with compression of the cervicomedullary junction. Note the hypointense mass both anterior and posterior to the tectorial membrane (white arrow). Rheumatoid atlantoaxial subluxation can be prevented by intensive use of traditional disease modifying antirheumatic drugs. Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study. A prospective study of the radiological changes in the cervical spine in early rheumatoid disease. Factors predicting death, survival and functional outcome in a prospective study of early rheumatoid disease over fifteen years. Magnetic resonance imaging in the evaluation of patients with rheumatoid arthritis and subluxations of the cervical spine. Isolated atlantoaxial subluxation as the presenting manifestation of inflammatory bowel disease. Anterior atlantoaxial subluxation in patients with spondyloarthropathies: association with peripheral disease. Low-dose radiation has also proven effective in the treatment of these lesions,12 but care must be taken in children, because radiation could potentially destroy endochondral plates and injure the spinal cord. Moreover, they can be classified as either primary benign (eosinophilic granuloma, fibrous dysplasia, chondroma, giant cell tumor, osteoid osteoma, meningioma, and neurofibroma) or primary malignant (chordoma, chondrosarcoma, and plasmacytoma) tumors. Primary Benign Tumors Eosinophilic Granuloma Eosinophilic granulomas are a form of histiocytosis (proliferation of activated dendritic cells and macrophages). They most commonly present in children and adolescents,4 but cases have also been reported in adults. Due to their expansile nature, they may cause swelling, pain, bone destruction, and fractures. The best treatment in terms of prognosis is complete resection with preoperative embolization. Some patients have been reported to be cured with embolization alone,17 and other treatments such as radiation have been explored. This entity may involve only one bone (monostotic) or many bones (polyostotic), best exemplified by McCune-Albright syndrome. Monostotic fibrous dysplasia of the spine is rare, with equal incidence in men and women. The most common presenting symptom is neck pain, and conventional X-rays may demonstrate a lytic lesion. T1weighted images usually show a lesion with varying degrees of intensity compared with the brain parenchyma. Some patients may be monitored and others may be candidates only for subtotal resection. Angiography may demonstrate any major feeding vessels that can be embolized prior to surgery. These tumors are most commonly found outside the central nervous system, and when they occur in the spine (uncommonly) they tend to be extradural tumors. Lastly, cranial nerve invasion is possible with meningiomas but is very rare with schwannomas. Extension of the tumor laterally may cause unilateral deficits such as hypoglossal nerve palsy; anterior and cranial growth may cause symptoms in the pharynx, nasal cavity, or paranasal sinuses. For lesions arising in the clivus and C1 body, intralesional resection is performed. Due to the high morbidity of surgery, other potential therapies such as chemotherapy and proton beam therapy have been explored. Chemotherapeutic agents have a small role in the management of chordomas, mainly due to the difficulty of establishing adequate tumor cell lines and consequently the lack of preclinical data. The authors reported an 18% rate of unilateral hearing loss and an 86% local control rate. However, this follow-up time is exceptionally short, and with longer follow-up times most patients may tend to suffer a recurrence. Plasmacytoma Plasmacytomas belong to the spectrum of B-cell lymphoproliferative diseases along with multiple myeloma. Moreover, these tumors may engulf vertebral vessels and expand into the pedicles in 20% of cases. This can be achieved via a transoral-transpalatopharyngeal approach or from a lateral extrapharyngeal-transcervical approach. However, occipitalcervical instrumented fusion with radiation therapy may be an alternative option. Patients most commonly presented with neuro-ophthalmologic symptoms and headaches. All 10 patients with chondrosarcoma underwent surgical excision via transcondylar, transoral, and anterior cervical approaches, among others. Future studies into adjuvant treatment modalities such as biologic agents and radiotherapy are needed. Dorsal approaches to intradural extramedullary tumors of the craniovertebral junction. Primary eosinophilic granuloma of adult cervical spine presenting as a radiculomyelopathy. Langerhans cell histiocytosis of the cervical spine: a single Chinese institution experience with thirty cases. Destructive osteoblastoma with secondary aneurysmal bone cyst of cervical vertebra in an 11-year-old boy: case report. Excision of an osteoid osteoma from the body of the axis through an anterior approach. Surgical outcomes of craniocervical junction meningiomas: a series of 22 consecutive patients. Surgical management of primary spinal hemangiopericytomas: an institutional case series and review of the literature. Hemangiopericytoma invading the craniovertebral junction: First reported case and review of the literature. Hemangiopericytoma in the central nervous system: treatment, pathological features, and long-term follow up in 38 patients. Tumors at the lateral portion of the C1-2 interlaminar space compressing the spinal cord by rotation of the atlantoaxial joint: new aspects of spinal cord compression. Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients. Chordoma: natural history and results in 28 patients treated at a single institution. Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Outcome of 132 operations in 97 patients with chordomas of the craniocervical junction and upper cervical spine. Chemotherapy of skull base chordoma tailored on responsiveness of patient-derived tumor cells to rapamycin. Proton therapy for skull base chordomas: an outcome study from the university of Florida proton therapy institute. Ultimately, occiput movement is limited in extension by the posterior arch of the atlas. Similarly, in the absence of a competent posterior atlanto-occipital membrane, the odontoid tip limits hyperflexion by intersection with the opisthion. One important ligament attaching the skull to the atlas is the anterior atlanto-occipital ligament or membrane, which is an anatomic extension of the anterior longitudinal ligament. This ligament is fixed to the ventral surface of the anterior arch of the atlas and terminates on the skull base, ventral to the basion. The corresponding dorsal ligamentous attachment to the opisthion, on the dorsal aspect of the foramen magnum, is the posterior atlanto-occipital ligament (or membrane). This ligament is much thinner and less structural, articulating with the rostral aspect of the posterior arch of the atlas. A bilateral defect in this membrane transmits the vertebral arteries and suboccipital nerves. The cruciate ligament receives its name from its cross-like shape, consisting of the transverse ligament of the atlas and fibers that transmit laterally in a rostral and caudal fashion. The alar ligament serves multiple functions, mainly by restricting neck movements. These injuries often result in severe dysfunction of the brainstem, cranial nerves, spinal cord, or spinal nerve roots. It is less important to know the type and more important to have a heightened suspicion for this injury in the appropriate clinical setting. Transverse Ligament Injuries Transverse ligament disruption is an unstable injury, and should be identified promptly, especially in hyperflexion injuries where a higher index of suspicion should be maintained. Radiographi- 28 4 cally, insufficiency in the transverse ligament is suggested on lateral plain films by evidence of translation > 3 mm of C1 on C2 in adults and > 5 mm in children. This results in avulsion of the occipital condyle by the alar ligament and represents the most severe of the three types in this grading scheme. First, the atlantoaxial facets are at risk for dislocation, and there is a higher risk of canal compromise. Also, in an unstable neck allowing higher rotational motion, the ipsilateral vertebral artery is stenosed at the transverse foramen and stretched contralaterally. This modality is also useful in ruling out an occipital-atlantal rotatory dislocation, which is sometimes seen in trauma with disruption of the ligaments and soft tissue structures of the neck. Children often present without neurologic deficits, but with mainly a painful torticollis and recent history of respiratory tract infection. Atlas Fractures the atlas, or first cervical vertebra, has the most flexibility of any level of the cervical spine, enabling it to serve as the transitional vertebra from the occiput to the cervical spine. Most often, transitional segments between spinal regions have a relatively greater range of flexibility that confers a vulnerability to trauma. The wedge-shaped orientation of the superior and inferior articular facets results in a net outward moment in the setting of axial compression on the C1 ring. When this outward force exceeds the integrity of the C1 neural arch, the classic Jefferson fracture occurs. This is a burst fracture of the anterior and posterior arches and is relatively uncommon. In the absence of evidence of transverse tubercle fractures, flexion-extension films can be performed to search for subluxation of C1 on C2, with the knowledge that an atlantodental interval should not exceed 5 mm in children or 3 mm in adults. Isolated Fractures Occipital Condyle Fractures the occipital condyle articulates with the lateral masses of the atlas and is susceptible to fracture due to the relatively high range of mobility at this articulation. However, due to the strength from supporting ligaments and musculature, these injuries are seen only with a high-energy mechanism. The most widely known classification system for occipital condyle fractures is that of Anderson and Montesano, which entails a gradation of increasing severity. The hypoglossal canal may be disrupted in comminuted fractures of the occipital condyle due to its proximity, often necessitating a cranial nerve examination checking for tongue deviation, which is a rare finding. Type I fractures are through the odontoid peg, most commonly a result of an avulsion fracture of the alar ligament.