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OBJECTIVE There have been no accurate surveillance data regarding the incidence rate of spinal arteriovenous shunts (SAVSs). Here, the authors investigate the epidemiology and clinical characteristics of SAVSs. METHODS The authors conducted multicenter hospital-based surveillance as an inventory survey at 8 core hospitals in Okayama Prefecture between April 1, 2009, and March 31, 2019. Consecutive patients who lived in Okayama and were diagnosed with SAVSs on angiographic studies were enrolled. The clinical characteristics and the incidence rates of each form of SAVS and the differences between SAVSs at different spinal levels were analyzed. RESULTS The authors identified a total of 45 patients with SAVSs, including 2 cases of spinal arteriovenous malformation, 5 cases of perimedullary arteriovenous fistula (AVF), 31 cases of spinal dural AVF (SDAVF), and 7 cases of spinal epidural AVF (SEAVF). The crude incidence rate was 0.234 per 100,000 person-years for all SAVSs including those at the craniocervical junction (CCJ) level. The incidence rate of SDAVF and SEAVF combined increased with advancing age in men only. In a comparative analysis between upper and lower spinal SDAVF/SEAVF, hemorrhage occurred in 7/14 cases (50%) at the CCJ/cervical level and in 0/24 cases (0%) at the thoracolumbar level (p = 0.0003). Venous congestion appeared in 1/14 cases (7%) at the CCJ/cervical level and in 23/24 cases (96%) at the thoracolumbar level (p < 0.0001). CONCLUSIONS The authors reported detailed incidence rates of SAVSs in Japan. There were some differences in clinical characteristics of SAVSs in the upper spinal levels and those in the lower spinal levels.

The article reports an example of the simultaneous use of brachial plexus block and combined two-segment spinal-epidural anesthesia with fixation of an epidural catheter in the subcutaneous canal in an 81-year-old patient after receiving a household injury - closed fracture of the olecranon of the right ulna with displacement of fragments and closed transtrochanteric fracture with a fracture of the right femur fragments. After preoperative preparation and examination, the patient underwent two consecutive surgical interventions within a day: open reduction of comminuted transtrochanteric fracture of the right hip, dynamic femoral screw osteosynthesis and open reduction of fracture of the right olecranon, Weber’s osteosynthesis. Surgical interventions were carried out under regional anesthesia: block of the brachial plexus via supraclavicular access and combined two-segment spinal-epidural anesthesia with a method developed in our clinic for fixing an epidural catheter in the subcutaneous canal using a modified spinal needle. After the operation, the patient underwent postoperative pain relief in the form of epidural analgesia for 72 hours. The postoperative period passed without complications. On the 13th day, the patient was discharged for outpatient treatment by a traumatologist. The use of local anesthesia in the form of two methods of regional anesthesia during two consecutive surgical interventions, in an elderly patient with a high anesthetic risk, followed by long-term postoperative anesthesia in the form of epidural analgesia with a reliable method of epidural catheter fixation in the subcutaneous canal without the use of narcotic analgesics, contributed to the successful carrying out two surgical interventions at once, early activation of the patient, absence of complications in the postoperative period. Reliable catheter fixation is very important for the quality of epidural analgesia. Dislocation of catheters by more than 2 cm can lead to migration of catheters from the epidural space, changing the course of anesthesia, deteriorating its quality, or even interrupting it altogether. The new method of catheter fixation in the subcutaneous canal developed by us made it possible to prevent catheter dislocation.

Objective: The objective of this systematic review was to state and analyze all the case reports published on extraskeletal extradural Ewing’s Sarcoma to date. Material and Methods: We searched PubMed, MEDLINE, EMBASE, and Google Scholar using the following search term, including Boolean operators AND and OR. We only included published case reports and series about Ewing's Sarcoma that were Extra-skeletal and Extradural. We excluded the intradural EWS cases and those that did not have both components, i.e. extraskeletal and extradural. Conference articles, commentaries, and unpublished articles were also not included. A PRISMA flowchart was also formed. Results: After the first case of EES in 1969, around 40 case reports and series have been reported, which sheds light on the rarity of this disease. Age of presentation varies from as early as two months, with the oldest report being 49 years of age, and most cases presenting in adolescents and young adults. Spinal Epidural extraskeletal Ewing's sarcoma has been more frequently reported in males. The level of occurrence of the tumor also varies among cases, with cervical, thoracic and lumbar regions being more frequently affected than sacral regions. Conclusion: Extraskeletal extradural ES is an exceedingly rare anomaly. Multicentric collaborative work is the need of the hour for such orphan illnesses, to optimize treatment paradigms as a single-center is exceedingly unlikely to amass cases.

Spinal cavernous angiomas are lesions formed by vessels lined by closely clustered endothelial cells. They are common in the vertebral body and less common in an intradural location. However, these are very rare in the extra-osseous and epidural region. Less than 100 cases have been reported. Here, we report a case of dorsal spinal extradural cavernous angioma in a 52-year-old man who presented with back pain and difficulty in walking. Magnetic resonance imaging brain showed D7–D8 (thoracic) extradural spinal lesion, enhancing homogeneously on contrast administration. He underwent D7–D8 hemilaminectomy and tumor decompression. The tumor was extradural, tightly adherent to the dura, and highly vascular. He recovered completely after surgical removal with no recurrence 2 years after removal. He was not administered adjuvant radiotherapy. In this article, we review the literature regarding clinical features, imaging findings, and outcome of spinal epidural cavernous angioma.

Laminectomy, a common neurosurgical procedure that decompresses the spinal cord, is the definitive surgical treatment for spinal epidural abscesses. Although complications after laminectomy occur infrequently, they can cause significant morbidity and health care resource usage. These complications include soft tissue collections like a persistent and/or new abscess or a hematoma. The preferred method of diagnosis for spinal soft tissue collections is magnetic resonance imaging. However, traditional neuroimaging poses significant challenges in patients with spinal hardware due to metallic artifact precluding appropriate visualization of anatomy and pathology. This was a case of a patient with extensive spinal hardware where visualization of the spinal cord by postoperative sonography was made feasible by a lack of bone after a laminectomy. Point-of-care ultrasound, a convenient bedside tool with the ability to detect soft tissue collections easily, was used to monitor for postoperative recurrence of a spinal epidural abscess in this patient. Patients with an intact spine do not have adequate acoustic windows due to posterior vertebral anatomy. In postlaminectomy patients without posterior vertebral structures, sonography may offer a diagnostic modality for postoperative monitoring. Ultrasonographers can employ spinal cord sonography, particularly when the indication for decompressive laminectomy was a localized fluid collection or abscess.

Background Steroid-related spinal epidural lipomatosis (SEL) is a well-known condition most commonly encountered in patients taking chronic steroid medications. Endogenous Cushing syndrome is a rare cause of SEL. The authors report an unusual presentation of acute thoracic myelopathy due to SEL with osteoporotic vertebral compression fractures in a patient with Cushing disease. Case Description A 33-year-old man presented with thoracic myelopathy due to SEL and multiple vertebral compression fractures. He had Cushingoid clinical features, and investigations revealed a pituitary microadenoma as the cause of hypercortisolism. The diagnosis was missed on multiple occasions before the onset of paraparesis. The patient was treated with urgent thoracic laminoplasty followed by transsphenoidal surgery on the same day. Although normalization of the serum cortisol levels was delayed by 6 months, he had a complete neurologic recovery and remains symptom free at 2 years follow-up. Conclusions This is a rare presentation of Cushing disease and has been reported only twice before in the 1990s. This case highlights the need to keep a high degree of suspicion for development of thoracic myelopathy in a patient with Cushing syndrome who develops thoracic compression fractures associated with SEL. Early recognition of this clinical association and addressing the primary endocrine problem urgently could have prevented spinal cord involvement and the subsequent spine surgery. This scenario is also documented in previous published case reports of this association where the diagnosis of Cushing syndrome has been revealed retrospectively after the development of neurologic symptoms.

Introduction: Spinal epidural abscess is uncommon but potentially debilitating infection. Delay in early diagnosis may be associated with increased morbidity and mortality despite recent advances in medicine. Aim: To present the clinical course and outcome of treatment of spontaneous spinal epidural abscesses. Materials and methods: Thirty-four patients (20 men and 14 women) with clinical, neuroimaging and/or histological data for spinal epidural abscess were treated at the Clinic of Neurosurgery at St George University Hospital, Plovdiv, Bulgaria, for the period 2009-2018. Results: The average age of patients was 62 years (21-76 years) and the ratio of men to women was 1.4:1. All patients (100%) presented with vertebralgia, 13 patients (38.2%) had additional radiculalgia, and 10 patients (29.4%) presented with sensory or motor deficit. The duration of complaints varied from 4 to 180 days. At hospital admission, only 9 patients (26.4%) had intact neurological status. The most common localization of the spinal epidural abscess was in the lumbar and lumbosacral area (52.9%), concomitant spondylodiscitis was present in 31 patients (91.2%). Twenty-four patients (70.6%) underwent emergency surgery within 24 hours, and the rest had planned surgery. Decompressive interlaminotomy or hemilaminectomy was performed in 9 patients (26.5%). The remaining 25 patients (73.5%) underwent laminectomy, in 15 patients (44.1%) it was combined with posterior pedicle screw fixation. After the treatment, 23 patients (67.6%) had a good outcome, the remaining 11 (32.4%) had a poor outcome, and 3 patients died (8.8%). Conclusion: In patients with spinal epidural abscess, emergency surgery is the treatment method of choice. It allows decompression of neural structures, correction of the spinal deformity, segmental stabilization and rapid mobilization of patients.

We present a rare case of symptomatic cystic lumbar spinal epidural lipomatosis that required surgical treatment via a minimally invasive tubular laminectomy. To our knowledge this is the first pathology confirmed report of compressive cystic lumbar spinal epidural lipomatosis available in literature.

The spinal epidural and posterior ligamentous complex spaces are important anatomic regions which are the target of various radiologic procedures in the cervical, thoracic and lumbar spine for the purpose of analgesia and anaesthesia. Given the frequency with which procedures are performed in and around the epidural space, a sound understanding of the associated anatomy is paramount to ensure the safety and efficacy of procedural intervention.

Epidural Arterio-venous fistulae (EDAVF) are rare. They occur as abnormal Arterio-Venous or Capillary communications arising from major arteries of the neck or viscera and anastomose with intracranial venous sinuses or intradural spinal venous plexi, thereby short-circuiting the blood flow pathway and causing sudden and sustained venous hypertension. The retrograde flow results in venous bleeds, which may range from small petechiae on the cortical surface to major venous bleeds resulting in severe disability and even death. The shift of blood flow also can result in a steal phenomenon, serious enough to cause infarcts. Mechanical compression of the spinal cord remains thankfully the commonest symptom and is caused by the high flow fistulae leading to medullary and radicular symptoms, especially in conjunction with neurofibromatosis 1. Proper Identification and management depend on understanding the pathology, location and flow dynamics of the fistula. We present our experience with a large cervical epidural fistula with a review of literature and analysis of management protocols.

Blood loss of over 40 percent of total blood volume (approx. 2800 ml) is typically considered a’ life danger.’ It seems rational to introduce PPH protocols at an average blood loss far below this level, as the aim of management is to prevent hemorrhage from rising to the point that it is life-threatening Objectives Caesarean anesthetic treatment, which involves general anesthesia and spinal / epidural anesthesia, was seldom examined for the risks associated with postpartum hemorrhage and was focused on only a small number of cases from single hospital data sets. The function of different types of anesthesia in postpartum hemorrhage therefore needs to be further explained. Patients and methods This are a retrospective study on patients complicated by postpartum hemorrhage after cesarean section with history of type of anesthesia used; general or spinal or epidural to improve outcome of cesarean section. We included all women complicated by postpartum hemorrhage after cesarean section and collect data about the anesthesia used during cesarean section and also recorded other risk factors for postpartum hemorrhage if recorded in files in antenatal care sheet and the intraoperative circumstances as recorded in the operative sheet of the patient. Heart rates and blood pressures of patients of both groups were measured before delivery and at 1 min interval for 15 min after injection of oxytocin. Uterine contractility was assessed for both groups at 1,2,4,6,8,10 and 15 min after oxytocin injection. Results Our results showed that the age of the studied group ranged from 18 to 40 years with mean 23.97 years. Regarding parity 44.5% of them had one child and 36.7% of them had two, 42.3% of the studied group had general anesthesia and 57.7% of them had spinal. Also 82.2% of the cases were previous and 17.8% of them were emergent. Conclusion Anesthetic techniques might be affected by the possibility of bleeding or concern. We found that women who have undergone general anesthesia have a higher risk of postpartum hemorrhage compared with women who have received epidural, spinal anesthesia

Background Spinal arachnoid cysts are a rare cause of compressive myelopathy. Spinal extradural arachnoid cysts (SEACs) are even rarer. Methods We retrospectively reviewed the SEACs operated on in our hospital between 2015 and 2019, according to their clinical and radiologic findings, treatments performed, and outcomes. Results We identified 5 cases (2 males and 3 females), ranging in age from 21 months to 78 years. Except for the pediatric case, all patients presented with pain and 3 had some grade of neurologic impairment. Preoperative magnetic resonance imaging showed multiloculated cyst in 4 cases, and the communication with the dura was properly identified in only 1 case. The patients were operated through a laminectomy or laminoplasty and total removal of the cyst, and the communication with the dura was identified and repaired in all cases. In all cases, the defect was near the exit of a nerve root, and rootlets were seen through it, producing a ball-like valve mechanism. Histology of the cyst wall showed true dura in every case. One patient needed a reoperation for evacuation of a fluid collection (related to the dural sealant). Following Odom's criteria, 3 patients had an excellent outcome and 2 had a fair outcome. Conclusions Total excision of a symptomatic SEAC through either laminectomy or laminoplasty is a safe and effective treatment option. Although isolated repair of the dural communication without cyst removal may seem appealing, we have found it very difficult to identify the point of communication preoperatively.

The aim of the study is to assess the advantages of a new technique for conducting a combined two-level spinal-epidural anesthesia with fixation of an epidural catheter in the subcutaneous canal using a modified spinal needle among elderly and senile patients during operations for fracture of the lower extremity bones. Material . We analyzed 44 cases of combined two-level spinal-epidural anesthesia with epidural catheter fixation in the subcutaneous canal using a modified cerebrospinal needle in lower limb bone fracture surgeries among elderly and senile patients over 2019. The developed technique of combined two-level spinal-epidural anesthesia with fixation of the epidural catheter in the subcutaneous canal using a modified cerebrospinal needle made it possible to exclude cases of catheter migration by more than 1 cm and avoid development of local inflammatory reaction. Conclusion . Combined two-level spinal-epidural anesthesia with the fixation of an epidural catheter in the subcutaneous canal using a modified cerebrospinal needle is a reliable, effective and safe anesthesia technique for operations for hip fracture among elderly and senile patients and makes it possible to perform long-term postoperative analgesia without the risk of infectious complications and complications associated with dislocation of the epidural catheter.

Spinal epidural and psoas abscesses have been found to occur together. Most cases described in the literature have been secondary to either hematogenous spread or direct invasion. Risk factors include intravenous drug use and immunosuppression. This case highlights the risk of the use of unsterile subcutaneous insulin injections leading to psoas abscess, which can be complicated by a spinal epidural abscess.

Background and Aims Obesity is a growingly impacting human health. Laparoscopic sleeve gasterectomy is one of successful management procedures for morbid obesity. However, general anesthesia (GA) used in this major surgery has its documented drawbacks in such patients with high risk. Combined thoracic spinal epidural anesthesia (CTSEA), a modern regional anesthesia procedure, has the advantages of both spinal and epidural anesthesia, with the avoidance of their shortcomings. Aim of the study:This study is a case experience to assess the feasibility of CTSEA as an anesthesia option for LSG. Methods 100 patients recruited for LSG as amanagement procedure of morbid obesity were performed under CTSEA. Perioperative events, functional parameters and patients satisfaction scores were recorded Results Our study showed successful use of CTSEA in 91% of the patients, one patient (1%) was converted to GA due to severe pain and anxiety. Few adverse events occurred, and they were managed accordingly. Satisfaction score revealed that 94% of the patients were satisfied. Conclusions CTSEA was successful anesthetic alternative procedure for LSG surgery.

Spontaneous spinal epidural hematoma (SSEH) as an initial presentation of polycythemia vera (PV) is rare. It can present with the features ranging from simple back pain to complete paraplegia depending on the site of the spinal compression. Herein, we describe a case of undiagnosed PV presented as back pain with radiation to the chest wall in a 46-year-old male patient and subsequently diagnosed with spontaneous spinal epidural hemorrhage. To the best of our knowledge, only one case of spinal epidural hematoma-related PV has been reported so far. Emergent decompressive laminectomy was done within 10 h of initial presentation with excellent clinical outcome. Therefore, this condition must be promptly diagnosed and treated with decompression surgery to minimize the risk of neurological complication.

Introduction: Sedative protocols are a topic of current research, especially for establishment of extensive monitoring systems for sedative agents. Bispectral index (BIS) is one of the main indicators for measuring the anaesthesia depth. Hence; present study was planned to comparatively assess the dose requirement of propofol with and without bispectral monitoring in patients scheduled to undergo spinal epidural anaesthesia. Materials and Methods: We planned the present research to comparatively assess the dose requirement of propofol with and without bispectral monitoring in subjects scheduled to undergo spinal epidural anaesthesia. For the present study, we evaluated a total of 60 patients and broadly divided them into group 1 and group 2, based on the absence and presence of BIS monitoring respectively. We maintained and compiled the complete demographic, clinical and anaesthetic data of all the patients and analyzed the results by SPSS software. Results: While comparing the average time needed for reaching the adequate level of sedation in between the two study groups, significant results were obtained. We also obtained significant results while comparing the average recovery time in between subjects of both the study groups. Conclusion: For assessing the level of sedation in regional anaesthesia cases, BIS monitoring should be done. Keywords: Bispectral monitoring, Propofol, Spinal anaesthesia.

With the advent of real-time MRI, the motion and passage of cerebrospinal fluid can be visualized without gating and exclusion of low-frequency waves. This imaging modality gives insights into low-volume, rapidly oscillating cardiac-driven movement as well as sustained, high-volume, slowly oscillating inspiration-driven movement. Inspiration means a spontaneous or artificial increase in the intrathoracic dimensions independent of body position. Alterations in thoracic diameter enable the thoracic and spinal epidural venous compartments to be emptied and filled, producing an upward surge of cerebrospinal fluid inside the spine during inspiration; this surge counterbalances the downward pooling of venous blood toward the heart. Real-time MRI, as a macroscale in vivo observation method, could expand our knowledge of neurofluid dynamics, including how astrocytic fluid preloading is adjusted and how brain buoyancy and turgor are maintained in different postures and zero gravity. Along with these macroscale findings, new microscale insights into aquaporin-mediated fluid transfer, its sensing by cilia, and its tuning by nitric oxide will be reviewed. By incorporating clinical knowledge spanning several disciplines, certain disorders-congenital hydrocephalus with Chiari malformation, idiopathic intracranial hypertension, and adult idiopathic hydrocephalus-are interpreted and reviewed according to current concepts, from the basics of the interrelated systems to their pathology.

BACKGROUND: The spinal epidural space, covering the dural sac, is located along the posterior longitudinal ligament anteriorly, the ligamentum flavum and the periosteum of laminae posteriorly, and the pedicles of the spinal column by the intervertebral foramina containing their neural elements laterally. It could be affected variably by different types of diseases, either as primary lesions or as an extension from a disease process in the nearby tissues and organs. AIM: We aimed to present clinically and surgically patients with spinal epidural masses operated in the Neurosurgery Department of Cairo University Hospitals, Cairo, Egypt, along a time interval of one year. METHODS: In this prospective cohort study, we analysed motor deficits, sensory deficits, and bowel and bladder dysfunction. We have performed decompressive laminectomy on 19 patients with spinal epidural masses together with mass excision as long as the tumour was accessible, with or without fixation. RESULTS: All patients were radiologically assessed by MRI over the affected side of the spine. D10 was the commonest site in our study to be affected in 10 cases of our participants (23%), followed by D5, D7, and D12 each of them was affected in 6 cases (14%), in another word spinal segments by order of frequency to be affected were dorsal followed by lumbar spine. All patients included in this study (100%) showed an obvious improvement as regard pain and tenderness. CONCLUSION: Surgical interventions have improved the quality of life for our patients with spinal epidural masses.

Spinal epidural angiolipomas are rare lesions composed of mature lipomatous and angiomatous elements. In this paper, the authors review a surgical series of ten patients with epidural angiolipomas. All patients had performed preoperative and postoperative magnetic resonance imaging. The diagnosis of angiolipoma was based on pathology. All the follow-up data were obtained during office visits. There were 5 males and 5 females with a mean age of 53.6 years. One tumor was located in the cervicothoracic, six in the thoracic, and three in the lumbar spine. The most common symptom was progressive motor deficit. Gross total resection of the tumor was achieved in nine cases, and subtotal resection was obtained in one case. No recurrence or regrowth of the residual tumor was observed during a follow-up period of 50.8 months. At the last follow-up, 90% of patients experienced improvement in the neurological function. Epidural angiolipomas are benign but clinically progressive lesions. Early surgery should be performed to prevent irreversible neurological deficits. Postoperative radiotherapy is not recommended. The risk of long-term recurrence/regrowth of the lesions is low, and a good clinical outcome after total or subtotal removal can be expected.

To understand the typical presentation, risk factors, location and size, treatment, neurological recovery and survival of spontaneous spinal epidural haematomas (SSEH) in children. A systematic review of the English literature from 1 January 1960 to 1 March 2018 was performed on children aged 18 years and younger. Individual patient data were extracted and collated. Outcome measures were mode of presentation, risk factors, initial neurological findings, initial presumed diagnosis, diagnostic investigations, site and size of the SSEH, treatment, neurological recovery and survival. Thirty-one publications and 36 patients were reviewed. All age groups were affected. 83% of patients did not have a known risk factor. Back pain was reported in 61% and neurological dysfunction in 97% of patients, although not all articles defined these parameters. Initially 28% of patients were suspected of having an alternative diagnosis. All patients had an MRI and/or CT scan confirming the diagnosis. The cervical-thoracic region was most commonly affected, and the average haematoma size extended across 6.3 vertebral levels. Surgical decompression was performed in 72% of patients. Neurological function improved in 83% of patients. Two patients died as a consequence of their SSEH. SSEHs affect all paediatric age groups and typically present with neurological dysfunction and/or back pain. The initial diagnosis is incorrect in up to 28% of cases, but cross-sectional spinal imaging is diagnostic. Most SSEHs are located in the cervico-thoracic region and affect multiple spinal levels. The treatment depends on whether the patient has a bleeding disorder and their neurological status. These slides can be retrieved under Electronic Supplementary Material.

Spinal epidural abscess (SEA) presents with vertebral body involvement. SEA is mostly pyogenic in developed countries, but in developing countries, tuberculosis is more common cause. Young female presented with fever, neck, and right upper limb pain for 1 month followed by acute onset weakness in the right upper limb. Magnetic resonance imaging study of cervical spine showed contrast-enhancing lesion in C2–C3 epidural region. Surgery-aided by initiation of antibacterial and antitubercular treatment based on culture and histopathological study of pus helped us to get good clinical outcome. One should always keep in mind possibility of tubercular abscess while treating cases of spinal epidural lesions, though it is rare in the absence of osseous involvement. Pyogenic and tubercular abscess can present concurrently and sending pus for culture and sensitivity is must as it plays important role in identifying dual organisms.

This is a meta-analysis.Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016.Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications.PubMed was queried for studies reporting neurological outcomes from patients undergoing conservative or surgical management for spontaneous SEA. Inclusion criteria included outcomes data measured ≥6 months after presentation, ≥10 human subjects, and diagnosis by magnetic resonance imaging or Computed tomography-myelogram. Where available, demographic data, abscess location, comorbidities, pretreatment neurological deficits, treatment methods, bacterial speciation, and complications were extracted from each study. Potential outcome predictors represented by continuous variables were compared using student t test and categorical variables were compared using the Pearson χ test. Variables identified as potentially associated with outcome (P≤0.05) were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to calculate odds ratios (ORs) and 95% confidence intervals (CIs).In total, 808 patients were analyzed from 20 studies that met inclusion criteria. 456 (56.3%) patients were treated with surgery and antibiotics, and 353 (43.7%) patients were managed with antibiotics alone. Neither surgical intervention (OR=1.01, 95% CI=0.40-2.59), lumbosacral location (OR=1.51, 95% CI=0.23-9.79), nor neurological deficit on presentation (OR=0.88, 95% CI=0.40-1.92) were significantly associated with good (stable or improved) or bad (worsened) neurological outcome, whereas delayed surgery was significantly associated with bad outcome (OR=0.01, 95% CI=0.02-0.62) and cervicothoracic location approached significance for predicting bad outcome (OR=0.41, 95% CI=0.15-1.09).Current literature does not definitively support or oppose surgical intervention in all SEA cases. Therefore, until better evidence exists, the decision to operate must be made on an individual case-by-case basis with the goals of preventing neurological decline, obtaining source control after failed conservative treatment, or restoring spinal stability.

The purpose of this article is to describe the use of MRI to safely monitor cryoablation for the treatment of spinal epidural malignancies.Use of MRI guidance to monitor percutaneous cryoablation allows ablation margins more distinct than those allowed by heat-based ablation modalities. MRI-guided cryoablation is a feasible option for treating epidural tumors involving the spinal canal, resulting in successful decompression of the tumor away from the spinal cord with regrowth of previously eroded bone around the spinal canal.

BACKGROUND AND PURPOSE: Spinal epidural arteriovenous fistulas are rare vascular malformations. We present 13 patients with spinal epidural arteriovenous fistulas, noting the various presenting symptom patterns, imaging findings related to bone involvement, and outcomes. MATERIALS AND METHODS: Among 111 patients with spinal vascular malformations in the institutional data base from 1993 to 2017, thirteen patients (11.7%) had spinal epidural arteriovenous fistulas. We evaluated presenting symptoms and imaging findings, including bone involvement and mode of treatment. To assess the treatment outcome, we compared initial and follow-up clinical status using the modified Aminoff and Logue Scale of Disability and the modified Rankin Scale. RESULTS: The presenting symptoms were lower back pain (n = 2), radiculopathy (n = 5), and myelopathy (n = 7). There is overlap of symptoms in 1 patient (No. 11). Distribution of spinal epidural arteriovenous fistulas was cervical (n = 3), thoracic (n = 2), lumbar (n = 6), and sacral (n = 2). Intradural venous reflux was identified in 7 patients with congestive venous myelopathy. The fistulas were successfully treated in all patients who underwent treatment (endovascular embolization, n = 10; operation, n = 1) except 2 patients who refused treatment due to tolerable symptoms. Transarterial glue (n = 7) was used in nonosseous types; and transvenous coils (n = 3), in osseous type. After 19 months of median follow-up, the patients showed symptom improvement after treatment. CONCLUSIONS: Although presenting symptoms were diverse, myelopathy caused by intradural venous reflux was the main target of treatment. Endovascular treatment was considered via an arterial approach in nonosseous types and via a venous approach in osseous types.

This case series reviews previous publications and reports four feline spinal epidural empyema cases that presented with non‐ambulatory thoracolumbar myelopathy. Two cats underwent myelography and two MRI. Bacteria were obtained in three cases, in two from epidural abscesses and from a tail base wound in one; histopathological examination of epidural tissue showed pyogranulomatous changes in the remaining cat. Three cats were treated by surgical decompression plus antimicrobial therapy and one cat was treated medically. All cats showed satisfactory improvement following treatment over a follow‐up period of 3 months. Spinal epidural empyema is a rare condition but all cats in this series had favourable outcomes.

ObjectiveSpinal epidural cavernous hemangiomas are very rare vascular lesions and are, therefore, seldom reported and easily misdiagnosed. Herein, we present a series of 9 cases with spinal epidural cavernous hemangiomas and discuss their pathogenesis, clinical characteristics, radiological findings, differential diagnosis, surgical interventions, pathological characteristics, and prognosis.MethodsWe retrospectively retrieved and analyzed the data of patients with pure epidural cavernous hemangiomas, who underwent spinal magnetic resonance imaging, and surgical intervention at the First Hospital of Jilin University, China, between January 2005 and December 2019. The data on patients’ clinical manifestations, imaging characteristics, surgical intervention, histopathological findings, and postoperative follow-up were also recorded and analyzed.ResultsIn all, 5 men and 4 women with the mean age of 61 years (range, 41–78 years) were recruited. All patients experienced a gradual onset of symptoms and a slowly progressive clinical course, and no patient presented an acute onset of symptoms. The clinical manifestations include myelopathic signs in 8 patients (88.9%) and radicular symptoms in 3 patients (33.3%). On T1-weighted imaging, 6 lesions appeared isointense (55.6%), and 4 lesions exhibited hypointense (44.4%) signals. On T2-weighted imaging, 8 lesions appeared hyperintense (88.9%), and 1 lesion was heterogeneously intense (11.1%). Following gadolinium administration, 5 lesions appeared homogeneous with significant enhancement (55.6%), 1 lesion was homogeneous and mild enhancement (11.1%), and 3 lesions were heterogeneous with mild enhancement (33.3%). All patients received early microsurgery assisted by intraoperative electrophysiologic monitoring and neuronavigation in the lateral position via the posterior midline approach. Five patients underwent total laminectomy (55.6%), and 4 underwent hemilaminectomy (44.4%). Total excision was achieved in all cases. The average follow-up period was 55.1 months (ranging 10–123 months). All patients exhibited significant clinical improvement of their neurological deficits and achieved a favorable outcome with no recorded recurrence at last follow-up.ConclusionsSpinal epidural cavernous hemangiomas are rare vascular malformations. Early surgical treatment with total resection is an optimum treatment, particularly for patients with an acute exacerbation onset. The prognosis is mostly good and depends predominantly on the severity of the preoperative status.

Objective Spinal epidural arteriovenous fistulas (SEAVFs) are the rarest variety of spinal vascular malformation and are often misdiagnosed as type 1 spinal dural fistula. This retrospective study highlights the salient anatomic differentiating points of these entities and also highlights the importance of a planned endovascular treatment approach using different routes of access. Efficacy of the endovascular treatment at 3 months follow-up was also studied. Methods We retrospectively reviewed 11 treated patients with SEAVF. Existence of epidural arteriovenous fistula in all these patients was confirmed by spinal angiography. The Aminoff-Logue Scale score was assigned both before and after the procedure. The statistical results were expressed as percentages, and the preprocedure scale was compared with the postprocedure scale at 3 months by using a nonparametric Wilcoxon signed-rank test. Results The patients ranged in age from 7 to 53 years, with male predominance. Paraparesis was the commonest symptom, and 1 patient had congestive cardiac failure caused by a large fistula. Location was mostly dorsolumbar with intradural venous reflux into the perimedullary venous system (Castilla type A) noted in 3/11(27%) patients, and the remaining 73% patients had Castilla type B1 with an enlarged epidural venous sac. Therapeutic embolization was performed from arterial, venous, or combined routes. The 3-month postprocedure clinical assessment showed statistically significant (P Conclusions The differentiating points between SEAVF compared with type 1 spinal dural fistula are emphasized. The study also highlights the importance of a good angiographic assessment to best access the fistula by arterial, venous, percutaneous, or combined routes. Endovascular treatment resulted in statistically significant clinical improvement at 3 months follow-up.

Background: Many studies have investigated the relationship between spinal epidural lipomatosis and obesity, no meta-analysis of studies have provided definitive evidence. To summarize the evidence of associations between obesity factors and spinal epidural lipomatosis (SEL) and to evaluate the strength and validity of these associations. Methods: Electronic databases such as Wiley Online Library, PubMed, Embase, Cochrane Library were searched and manual retrieval of references, the time limit was from the establishment of the database to May 2020. The included literature was case-control studies that reported body mass index (BMI) and SEL correlation, and excluded any primary and secondary tumors or other compression diseases in the spinal canal. Methodological quality evaluations of the included studies were assessed using the bias risk assessment tool recommended by the Cochrane Guidelines. The RevMan 5.3 software was used for meta-analysis. Results: Finally, ten studies were included for systematic review, all of which were observational studies with mixed bias risk. These studies involved 1,541 patients, with an average age of 54.9 to 73.6 years, and 60.2 percent of the participants were male. The sample sizes for the included studies ranged from 28 to 398. The results of meta-analysis showed that high BMI was one of the factors affecting SEL. All reviews had a high risk of bias, and the most common source of bias was that there was no strict unified case diagnosis standard between researches, and some studies (four items) did not clearly describe the confounders that they controlled. Conclusions: We suggest that physicians should consider obesity as a factor leading to SEL, and to control body mass index actively should be considered as the preferred treatment strategy before surgical intervention is conducted.

Objective : Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. Methods All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. Results 108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. Conclusions 21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

To investigate the accuracy of computed tomography (CT) in evaluating spinal epidural adipose tissue compared to magnetic resonance imaging (MRI). CT scan images and matched magnetic resonance images of total 368 patients between July 2014 and July 2016 were evaluated. Hounsfield units (HU) of epidural fat (EF), dural sac (DuS), ligamentum flavum, bone of facet joints, and paraspinal muscles were measured for comparison. Anteroposterior diameter of the EF, anteroposterior diameter of the DuS, transverse diameter of the DuS, cross-sectional area of the EF, and cross-sectional area of the DuS were measured at each disc level from L1–2 to L5–S1. Fat tissue showed exclusive negative HU significantly different from all other periphery tissues. Pearson correlation coefficient analyses showed significant positive correlations between CT and MRI measurements; Bland–Altman plots also depicted satisfied agreement. Overgrowth of spinal EF was more commonly found at L2–3 and L3–4 levels in present study, and body weight, age, and gender were significantly associated with amounts of EF both on CT and MRI. The CT scan is a satisfied alternative of MRI for the evaluation of spinal epidural adipose tissue.

Spinal epidural angiolipoma is an uncommon finding; this case is presented to display the medical and legal implications of MRI scout imaging. In this case, a preceding period of ambiguous and non-focal symptoms led to an MRI of the lumbar spine without contrast with a scout image that captured a thoracic lesion. Review of the scout film led to a subsequent MRI of the thoracic spine with and without contrast that aided clinical decision making leading to surgical resection of the identified lesion and resolution of symptoms for this patient. The use of scout imaging has been described in the literature, but no concise agreement among physicians or professional medical societies exists regarding what utility, if any, may be obtained from the review of scout imaging. A discussion of medical legal implications of MRI scout imaging follows.

Objectives: To compare the efficacy of bupivacaine 2.5 mg and fentanyl 25 ìgwith bupivacaine 1.25 mg and fentanyl 25ìg for spinal-epidural analgesia in the first stage oflabor. Study Design: Double-blind randomized controlled trial. Setting: Anesthesia Department,Surgical Intensive Care Unit, and Pain management clinic, Peoples Medical College HospitalNawabshah. Period: August 2014 to July 2015. Methodology: All the participants meeting theeligibility criteria were randomly allocated into two groups i.e. intervention (I) and control (II),with the allocation ratio of 1:1. Patients in the Group I (intervention) received intrathecal Inj.Bupivacaine 1.25 mg (0.5% Bupivacaine 0.25ml) and Inj. Fentanyl 25 ìg whereas the GroupII (control) was given intrathecal Inj. Bupivacaine 2.5 mg (0.5% Bupivacaine 0.5ml) and Inj.Fentanyl 25 ìg for combined spinal epidural analgesia, both made up of total volume of 2 ml ofnormal saline. Mean±SD (standard deviation) was computed for continuous data (age, weight,VAS). Frequency and percentages was calculated categorical data. Independent t test and Chisquare test were used for the differences between the groups. Results: The age of all the caseswas 27.64±4.07 years. Moreover, groups were homogenous at baseline (p

Here, the authors present an extremely rare case of an extensive spinal epidural teratoma (SET) in an infant and provide a review of the cases in the literature. In this report, the authors focused on the clinical manifestation and management of extensive SET. A 64-day-old girl presented with severe dyspnea and paraparesis caused by a large thoracic mass. Imaging studies revealed that the mass originated from the epidural space of the thoracic spine and extended from C7 to L1. The tumor extended bilaterally through the intervertebral foramina and formed a large posterior mediastinal mass. The tumor was partially resected via laminotomy after an emergency thoracotomy. The remnant grade I immature teratoma grew rapidly. After a re-laminotomy and bilateral thoracotomy, the residual tumor stopped growing. However, the patient’s paraparesis improved very little, and her scoliosis progressed gradually. Therefore, SET should be included in the differential diagnosis when an infant patient with paraparesis of the lower extremities is encountered. Timely diagnosis, aggressive treatment, and close monitoring are of critical importance to successful recovery in such patients.