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Study design: Prospective multi-center trial. Objectives: To characterize the complication profile associated with modest systemic hypothermia after acute cervical SCI in a prospective multi-center study. Setting: Five trauma centers in the United States. Methods: We analyzed data from a prospective, multi-center trial on the use of modest systemic hypothermia for acute cervical SCI. Patients with acute cervical SCI were assigned to receive modest systemic hypothermia (33 C) or standard of care medical treatment. Patients in the hypothermia group were cooled to 33 C and maintained at the target temperature for 48 h. Complication profile and the rate of complications within the first 6 weeks after injury were compared between the two groups. Multiple regression analysis was performed to determine risk factors for complications after injury. Results: Fifty patients (hypothermia: 27, control: 23) were analyzed for this study. Median age was significantly lower in the hypothermia arm (39 vs 59 years, p= 0.02). Respiratory complications were the most common (hypothermia: 55.6% vs control: 52.2%, p= 0.81). The rate of deep vein thrombosis was not significantly different between the two groups (hypothermia: 14.8% vs control 17.4%, p= 0.71). The rate of complications was not statistically different between the two groups. Conclusion: In this prospective multi-center controlled trial, preliminary data show that modest systemic hypothermia was not associated with increased risk of complications within the first 6 weeks after acute cervical SCI. Trial information: The study is registered on clinicaltrials.gov NCT02991690. University of Miami IRB (Central IRB) approval No.: 20160758. Emory University IRB #IRB00093786.

The goal of the following article is to help the practicing physician learn to recognize conditions that mimic conditions requiring neurosurgical intervention. Each case vignette is presented with relevant clinical history and examination, imaging studies and findings, as well as other testing results. The management for the corresponding diagnosis is presented. Finally, the relevant mimics and differentiating features are discussed.

Neuroprotection after acute spinal cord injury is an important strategy to limit secondary injury. Animal studies have shown that systemic hypothermia is an effective neuroprotective strategy that can be combined with other therapies. Systemic hypothermia affects several processes at the cellular level to reduce metabolic activity, oxidative stress, and apoptotic neuronal cell death. Modest systemic hypothermia has been shown to be safe and feasible in the acute phase after cervical spinal cord injury. These data have provided the impetus for an active multicenter randomized controlled trial for modest systemic hypothermia in acute cervical spinal cord injury.

Spinal cord injury remains an incurable disease with an enormous impact functionally, financially, and emotionally on affected individuals and their families. Current treatment modalities are focused on minimizing secondary injury and maximizing residual function via rehabilitation. In this article, the authors discuss ambitious advancements under investigation aimed at restoring function. These promising experimental treatments focus on neuroprotection with hypothermia and pharmacologic therapies, regeneration via cell transplantation, and rewiring with electrical stimulation.

•Nerve injury following arthroscopic shoulder procedures is a rare complication.•Most patients, including both those with nerve injuries preoperatively and those with surgical complications, will have gradual resolution of symptoms.•New onset nerve injuries as a complication from surgical repair should not be overlooked.•If neurologic function is not improved by 6 weeks, a more in-depth workup should be performed.•Special attention should be paid to patients whose symptoms persist despite an adequate physical therapy regiment.

Insufficient donor nerve graft material in peripheral nerve surgery remains an obstacle for successful long-distance regeneration. Schwann cells (SCs) can be isolated from adult mammalian peripheral nerve biopsies and can be grown in culture and retain their capacity to enhance peripheral nerve regeneration within tubular repair strategies in multiple animal models. Human Schwann cells (hSCs) can be isolated, expanded in number, and retain their ability to promote regeneration and myelinate axons, but have never been tested in a clinical case of peripheral nerve injury. A sural nerve biopsy and peripheral nerve tissue from the traumatized sciatic nerve stumps was obtained after Food and Drug Administration (FDA) and Institutional Review Board (IRB) approval as well as patient consent. The SCs were isolated after enzymatic digestion of the nerve and expanded with the use of heregulin β1 (0.1 μg/ml) and forskolin (15 mM). After two passages the Schwann cell isolates were combined with sural nerve grafts to repair a large sciatic nerve defect (7.5 cm) after a traumatic nerve injury. The sural nerve and the traumatized sciatic nerve ends both served as an excellent source of purified (90% and 97%, respectively) hSCs. Using ultrasound and magnetic resonance imaging (MRI) we were able to determine continuity of the nerve graft repair and the absence of tumor formation. The patient had evidence of proximal sensory recovery and definitive motor recovery distal to the repair in the distribution of the tibial and common peroneal nerve. The patient did experience an improvement in her pain scores over time. The goals of this approach were to determine the safety and clinical feasibility of implementing a new cellular repair strategy. In summary, this approach represents a novel strategy in the treatment of peripheral nerve injury and represents the first reported use of autologous cultured SCs after human peripheral nerve injury.

Schwannomas of the brachial plexus are rare and typically present as slowly growing masses. We describe a case of a 37-year-old female who presented with acute onset of severe left upper extremity pain. Magnetic resonance imaging (MRI) showed a 2.3?×?2.1?cm peripherally enhancing centrally cystic lesion in the left axilla, along the cords of the left brachial plexus, with significant surrounding edema and enhancement. The mass was surgically removed. Pathology was consistent with a schwannoma with infarction. The pain completely resolved immediately after surgery.

To evaluate the safety and feasibility of modest hypothermia as a potential strategy for intraoperative neuroprotection during the removal of intradural spinal tumors. A retrospective review was performed for two groups of patients of a single surgeon who underwent intradural extrameduallary and intramedullary spinal tumor resection of tumors located between cervical level 1 and lumbar 2 over a 10-year period between 2001 and 2010. One cohort received intraoperative moderate hypothermia (33°C) via intravascular catheter cooling during tumor surgery and the second cohort, a historical control group of the same surgeon, underwent surgery at normothermia (≥36°C). The main outcome measured was safety as determined by surgical, medical, and neurological complications. The hypothermia (n=38) and nonhypothermia (n=34) groups were homogenous for patient demographics and baseline comorbidities. There were no differences between the groups regarding tumor level (p=0.51), tumor pathology, or intramedullary versus intradural extramedullary location (p=0.11). The hypothermia group had a lower mean body temperature (33.7°C±0.72 vs. 36.6°C±0.7, p≤0.001) longer postoperative hospital stays (10.8±14.0 vs. 7.3±4.72, p<0.001), but there were no significant differences in operative and perioperative variables such as, total anesthetic time (8.2±2.4 vs. 7.8±2.7 hours, p=0.45), total surgical time (5.9±2.1 vs. 5.7±2.5 hours, p=0.58), or estimated blood loss (483±420 vs. 420±314 mL, p=0.65). There were no statistically significant differences between the two groups with respect to the rate of surgical (3 vs. 2, p=1.0), medical (4 vs. 3, p=1.0), neurological (3 vs. 4, p=0.7), or overall complications (10 vs. 9, p=1.0). In this study, moderate hypothermia via intravascular cooling catheters was successfully performed during 38 intradural spinal tumor surgeries. Compared to the historical control group, the hypothermia patients had longer hospital stays, but did not have higher complication rates. Intraoperative moderate hypothermia during spinal tumor resection is feasible and appeared safe in this limited cohort; however, further studies with larger cohorts will be needed to determine whether peri-operative hypothermia is an effective neuroprotectant strategy in spinal tumor surgery.

Spinal cord herniation (SCH) is a rare condition that is typically of idiopathic origin. Although SCH is mostly found in the thoracic region because of a dural defect, there are some reports of cervical SCH following surgery or trauma.1-3 Spinal cord tethering can be a result of SCH or as a standalone issue.4,5 These conditions can lead to progressive neurological deficits, including numbness, gait disturbances, and decreased muscle strength, requiring surgical correction. There are limited reports of surgical procedures for ventral SCHs. Several reports exist using a ventral approach for intradural tumors, but it is not commonly employed because of the inability to obtain adequate dural closure.6 Much of the literature on SCH comes from idiopathic and congenital cases in the thoracic spine.7,8 Posterior and posterolateral approaches for a ventral thoracic SCH have been described, as well as an anterior approach for a ventral cervical SCH.9-12 In this video, we describe a posterior approach for a ventral cervical SCH. A 38-yr-old male presented with progressive cervical myelopathy 9 yr after a C2-C3 schwannoma resection requiring an anterior approach and corpectomy of C3 with partial corpectomies of C2 and C4. A preoperative magnetic resonance imaging showed a ventrally herniated spinal cord at the top of the C3 vertebral body and below the C4 vertebral body. Informed consent was obtained. The posterior surgical approach involved a C1-C5 laminectomy, sectioning the dentate ligament, ventral cord untethering, removal of residual tumor, and placement of a ventral sling. A significant improvement in sensory and motor function was observed postoperatively.

Iatrogenic spinal cord injury (SCI) is an uncommon (0%–3%), yet devastating, complication of spine surgery. Recent evidence based on small clinical studies indicates that modest hypothermia is a feasible treatment option for severe SCI. We extended this treatment modality to patients with devastating iatrogenic SCI. We conducted a retrospective case series of five male patients (cervical trauma—1, cervical degenerative—2, thoracic trauma—1, and thoracic scoliosis—1) with an age range of 16–51 years (average age of 46 years) with intraoperative motor-evoked potential/somatosensory-evoked potential loss secondary to catastrophic events during the spinal operation associated with new SCI. Modest hypothermia was instituted immediately postsurgery for 24 hours. Four patients also received methylprednisolone. Preoperative American Spinal Injury Association (ASIA) scores were D (n=3) and E (n=2), while immediate postoperative scores were A (n=1), B (n=1), C (n=2), and D (n=1). Immediate postoperative MRI revealed new cord signal change in three patients. Two patients required subsequent surgery. ASIA scores at last follow-up were C (n=1), D (n=3), and E (n=1) with an improvement of 1–2 grades per patient. Adverse events such as pulmonary embolism, deep venous thrombosis, coagulopathy, or infection were not observed. Hypothermia is a feasible treatment option for patients with iatrogenic SCI. While hypothermia has not been proven to improve outcomes in these situations, aggressive medical management, including cooling, resulted in better-than-expected outcomes in this small cohort.

AbstractBackground/Objective:To evaluate an implantable guidance channel (GC) seeded with autologous Schwann cells to promote regeneration of transected spinal nerve root axons in a primate model.Methods:Schwann cells were obtained from sural nerve segments of monkeys (Macaca fascicularis; cynomolgus). Cells were cultured, purified, and seeded into a PAN/PVC GC. Approximately 3 weeks later, monkeys underwent laminectomy and dural opening. Nerve roots of the L4 through L7 segments were identified visually. The threshold voltage needed to elicit hindlimb muscle electromyography (EMG) after stimulation of intact nerve roots was determined. Segments of 2 or 3 nerve roots (each ∼8-15 mm in length) were excised. The GC containing Schwann cells was implanted between the proximal and distal stumps of these nerve roots and attached to the stumps with suture. Follow-up evaluation was conducted on 3 animals, with survival times of 9 to 14 months.Results:Upon reexposure of the implant site, subdural nerve root adhesions were noted in all 3 animals. Several of the implanted GC had collapsed and were characterized by thin strands of connective tissue attached to either end. In contrast, 3 of the 8 implanted GC were intact and had white, glossy cables entering and exiting the conduits. Electrical stimulation of the tissue cable in each of these 3 cases led to low-threshold evoked EMG responses, suggesting that muscles had been reinnervated by axons regenerating through the repair site and into the distal nerve stump. During harvesting of the GC implant, sharp transection led to spontaneous EMG in the same 3 roots showing a low threshold to electrical stimulation, whereas no EMG was seen when harvesting nerve roots with high thresholds to elicit EMG. Histology confirmed large numbers of myelinated axons at the midpoint of 2 GC judged to have reinnervated target muscles.Conclusions:We found a modest rate of successful regeneration and muscle reinnervation after treatment of nerve root transection with a Schwann cell-seeded, implanted synthetic GC. Newer treatments, which include the use of absorbable polymers, neurotrophins, and antiscar agents, may further improve spinal nerve regeneration for repair of cauda equina injury.

Stem cells have been recognized and intensively studied for their potential use in restorative approaches for degenerative diseases and traumatic injuries. In the central nervous system (CNS), stem cell-based strategies have been proposed to replace lost neurons in degenerative diseases such as Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis (Lou Gehrig's disease), or to replace lost oligodendrocytes in demyelinating diseases such as multiple sclerosis. Stem cells have also been implicated in repair of the adult spinal cord. An impact to the spinal cord results in immediate damage to tissue including blood vessels, causing loss of neurons, astrocytes, and oligodendrocytes. In time, more tissue nearby or away from the injury site is lost due to secondary injury. In case of relatively minor damage to the cord some return of function can be observed, but in most cases the neurological loss is permanent. This review will focus on in vitro and in vivo studies on the use of bone marrow stromal cells (BMSCs), a heterogeneous cell population that includes mesenchymal stem cells, for repair of the spinal cord in experimental injury models and their potential for human application. To optimally benefit from BMSCs for repair of the spinal cord it is imperative to develop in vitro techniques that will generate the desired cell type and/or a large enough number for in vivo transplantation approaches. We will also assess the potential and possible pitfalls for use of BMSCs in humans and ongoing clinical trials.

The case reports of three pregnant patients with lumbar disc herniation causing cauda equina syndrome or severe neurologic deficits are presented to illustrate that disc surgery during gestation is a safe method of management.

Seven cadaveric cervical spines were implanted with a porous tantalum spacer and a titanium alloy spacer, and their radiographic and imaging characteristics were evaluated.

•Iatrogenic injury is a rare but known cause of common peroneal nerve palsy (CPN).•Damage to the CPN is a rare in inside-out lateral meniscus repair.•Nerve compression can occur despite tendon retraction and knee flexion.•Neurological deficits despite continued swelling may warrant nerve studies.•With appropriate diagnosis and surgical decompression, patients can recover.