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Cervical foraminal chondromas are benign lesions that may require surgical resection when symptomatic due to radicular and/or spinal cord compression. The aim of surgery is to achieve gross tumor removal while preserving neurological function and spine stability. The authors describe a case of subaxial foraminal chondroma with a systematic review of the literature on patients with cervical chondromas. In the reported case, the authors used a retrojugular approach to remove a C6-C7 right chondroma without the need for spinal stabilization. Literature review identified a total of 11 patients who underwent surgery for subaxial foraminal chondroma. The mean age at diagnosis is 33.6 years (range: 10–73). Most patients report neurological symptoms at the time of diagnosis. The most frequently involved vertebral level is C4-C5 (54.6%, 6/11). Preoperative foraminal enlargement is present in 63.6% (7/11) of patients. Surgical resection is performed via an anterior approach in 18.2% (2/11) of patients, with vertebral body resection and concomitant cervical instrumentation. The anterolateral approach is selected in 27.2% (3/11) of patients, and the posterior approach in 54.6% (6/11) of patients, with only one patient requiring both anterior and posterior instrumentation. The choice of surgical access for subaxial foraminal chondroma can be challenging due to the anatomical location of the tumor in relation to the cervical nerve roots and spinal cord. Accurate approach selection is key to achieving complete tumor removal while preserving cervical spine stability. [ABSTRACT FROM AUTHOR]

Background: Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature. Methods: We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review. Results: A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2 months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3–C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node. Conclusions: This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course. [ABSTRACT FROM AUTHOR]

Purpose Recent studies have demonstrated the usefulness of diffusion-weighted MR neurography (DW MRN) for assessing nerve roots. This study aimed to evaluate the utility of DW MRN with a unidirectional motion-probing gradient (MPG) for the lumbar nerve roots at 1.5T MR. Materials and Methods Sixty-four lumbar spine MRI scans with DW MRN using anteroposterior unidirectional MPG were retrospectively analyzed. Any changes in the 512 lumbar spinal nerve roots from L3 to S1 were evaluated using T2-weighted imaging (T2WI), contrast- enhanced T1-weighted imaging (CE T1WI), and DW MRN, with agreement and correlation analysis. Results T2WI revealed compression of 78 nerve roots, and CE T1WI revealed 52 instances of nerve root enhancement. Sixty-seven nerve roots showed swelling and hyperintensity on DW MRN. A total of 42 nerve roots showed changes in the CE T1WI and DW MRN sequences. Moderate to substantial agreement and moderate positive correlation were observed between DW MRN and CE T1WI, as well as DW MRN and T2WI (κ = 0.59–0.65, ρ = 0.600–0.653). Conclusion DW MRN with unidirectional anteroposterior MPG can help evaluate neuritisrelated changes in spinal nerve roots and could serve as a sequence capable of complementing or substituting gadolinium CE imaging.

We report a case where neuromonitoring, using motor evoked potentials (MEP), detected an intraoperative L5 nerve root deficit during a lumbosacral decompression and instrumented fusion procedure. Critically, the MEP changes were not preceded nor accompanied by any significant spontaneous electromyography (sEMG) activity. Presumptive L5 innervated muscles, including tibialis anterior (TA), extensor hallucis longus (EHL) and gluteus maximus, were targets for nerve root surveillance using combined MEP and sEMG techniques. During a high-grade spondylolisthesis correction procedure, attempts to align a left-sided rod resulted in repeated loss and recovery cycles of MEP from the TA and EHL. No accompanying EMG alerts were associated with any of the MEP changes nor were MEP variations seen from muscles innervated above and below L5. After several attempts, the rod alignment was achieved, but significant MEP signal decrement (72% decrease) remained from the EHL. Postoperatively, the patient experienced significant foot drop on the left side that recovered over a period of 3 months. This case contributes to a growing body of evidence that exclusive reliance on sEMG for spinal nerve root scrutiny can be unreliable and MEP may provide more dependable data on nerve root patency. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to develop an arbitrary-dimensional nerve root reconstruction magnetic resonance imaging (ANRR-MRI) technique for identifying the leakage orificium of sacral meningeal cysts (SMCs) without spinal nerve root fibres (SNRFs). Methods: This prospective study enrolled 40 consecutive patients with SMCs without SNRFs between March 2021 and March 2022. Magnetic resonance neural reconstruction sequences were performed for preoperative evaluation. The cyst and the cyst-dura intersection planes were initially identified based on the original thin-slice axial T2-weighted images. Sagittal and coronal images were then reconstructed by setting each intersecting plane as the centre. Then, three-dimensional reconstruction was performed, focusing on the suspected leakage point of the cyst. Based on the identified leakage location and size of the SMC, individual surgical plans were formulated. Results: This cohort included 30 females and 10 males, with an average age of 42.6 ± 12.2 years (range, 17-66 years). The leakage orificium was located at the rostral pole of the cyst in 23 patients, at the body region of the cyst in 12 patients, and at the caudal pole in 5 patients. The maximum diameter of the cysts ranged from 2 cm to 11 cm (average, 5.2 ± 1.9 cm). The leakage orificium was clearly identified in all patients and was ligated microscopically through a 4 cm minimally invasive incision. Postoperative imaging showed that the cysts had disappeared. Conclusion: ANRR-MRI is an accurate and efficient approach for identifying leakage orificium, facilitating the precise diagnosis and surgical treatment of SMCs without SNRFs. [ABSTRACT FROM AUTHOR]

Background: This study investigated the lumbosacral plexus (LSP) nerve root thickness and ligamentum flavum (LF) thickness and correlated them with age and sex. These findings provided a useful data for spinal nerve root micro-anastomosis surgery and lumbar decompression surgery. Materials and methods: This retrospective study was conducted with 350 individuals with ages ranging from 21 to 80 years under magnetic resonance imaging to evaluate the possible cause of a lower back pain. Results: According to the morphometric measurements of the LSP root thickness, the diameter gradually increased from L1 to S1. L1 has the thinnest root (3.9 ± ± 0.81 mm) while S1 has the thickest root (5.45 ± 0.8 mm). The measurements revealed inconsiderable differences in the LSP thickness in relation to age, sex in the study population. Regarding the LF, the thickness of the LF was found to insignificantly increase with age. Besides, the LF thickness was inconsequentially higher in female. The mean thickness of the right LF at different spinal levels was measured (L2-L3 = 3.19 ± 0.27, L3-L4 = 3.38 ± 0.11 mm, L4-L5 = 3.71 ± ± 0.29 mm, and L5-S1 = 3.64 ± 0.21 mm). The mean thickness of the left LF was non-significantly higher. Conclusions: The LSP root and LF thicknesses not related to age or sex. [ABSTRACT FROM AUTHOR]

Spinal cavernous angiomas are uncommon vascular malformations in the spine accounting for 5%-12% of all spinal vascular lesions. When present in an intradural extra-medullary location, these usually present with radicular pain and neurological deficits due to mass effect (myelopathy). Herein, we present an atypical presentation of cavernous angioma in a 54-year-old man with tinnitus, headache and sensorineural hearing loss. We have also reviewed 51 cases of intradural extramedullary cavernous angiomas including our case with respect to demographic and clinical profile. A 54-year-old man presented with tinnitus in the left ear and occipital headache with neck pain and slight weakness of left-hand grip along with atrophy of thenar muscles. His pure tone audiometry (PTA) test reveled mild left sensorineural hearing loss. Magnetic resonance imaging (MRI) of cervical spine showed T2WI heterogeneously hyperintense left intradural extramedullary lesion at C7 vertebral body level. It was avidly enhancing with contrast. The patient underwent C7 laminectomy with a midline durotomy and complete excision of the lesion under neuromonitoring with sacrifice of the C8 sensory root. His symptoms improved following the surgery. The diagnosis of a cavernoma in an unusual location in the presence of cranial nerve dysfunction needs a high degree of diagnostic suspicion. Most of these cavernomas have a nerve root origin or attachment. The optimal treatment is microsurgical en bloc resection which leads to an effective resolution of both the symptoms.

Objectives: To evaluate the feasibility of proximal nerve MR neurography with diffusion tensor imaging (DTI) for differentiating Charcot-Marie-Tooth (CMT) 1A, CMT2, and healthy controls. Methods: The diameters, fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) of L4-L5 nerve roots, femoral nerve (FN), and sciatic nerve (SN) were compared. Receiver operating characteristic (ROC) curve analyses were conducted to evaluate the diagnostic performance. DeLong's tests were applied to compare multiple ROC curves. Intraclass correlation coefficients were calculated for interobserver agreement assessment. Results: The diameters of the L4 nerve root, L5 nerve root, and SN of CMT1A patients were significantly larger than those of CMT2 patients and healthy controls. The FA values of all measured proximal nerves were significantly higher in controls (0.46 ± 0.09, 0.46 ± 0.08, 0.45 ± 0.07, and 0.48 ± 0.08) than in CMT1A patients (0.30 ± 0.09, 0.29 ± 0.06, 0.35 ± 0.08, and 0.29 ± 0.09). The FA values of the L5 nerve root, FN, and SN were significantly higher in controls (0.46 ± 0.08, 0.45 ± 0.07, and 0.48 ± 0.08) than in CMT2 patients (0.36 ± 0.06, 0.34 ± 0.07, and 0.34 ± 0.10). The MD and RD values of the L5 nerve root in CMT1A patients (1.59 ± 0.21 and 1.37 ± 0.21) were higher than those in CMT2 patients (1.31 ± 0.17 and 1.05 ± 0.14). The AUCs of the above parameters ranged from 0.780 to 1.000. For the measurements of nerve diameters, the ICC ranged from 0.91 to 0.97. For the measurements of DTI metrics, the ICC ranged from 0.87 to 0.97. Conclusions: MR neurography with DTI is able to differentiate CMT1A patients, CMT2 patients, and healthy controls. Key Points: • MR neurography with diffusion tensor imaging of the L4-5 nerve roots, proximal femoral nerve, and proximal sciatic nerve is able to discriminate CMT1A, CMT2, and healthy controls. • This method provides an alternative for the diagnosis and discrimination of CMT1A and CMT2, which is crucial for clinical management. [ABSTRACT FROM AUTHOR]

Extraskeletal Ewing’s sarcoma (EES) is a rare malignant soft tissue tumor which is morphologically indistinguishable from skeletal ES. EES usually occurs in young adults and children and there has been only one case reported in a patient aged over 70 years old. We report a case of an EES arising from the first thoracic spinal nerve root in a 73-year-old female, which was misdiagnosed as benign nerve sheath tumor in preoperative imaging evaluation.

Yuanyuan Ding,1 Hongxi Li,1 Yongqiang Zhu,1 Peng Yao,1 Guangyi Zhao2 1Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China; 2Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China Background: Lumbar disc herniation (LDH) is a common disease in clinical practice. The symptoms recur and are aggravated by time; severe pain and long-term movement disorder cause physiological and psychological problems that affect the quality of life of patients. Therefore, relieving the pain symptoms and promoting functional recovery are the primary goals that have gained increased attention. Objective: To assess the efficacy of CT-guided transforaminal epidural steroid injection (TFESI) combined with pulsed radio frequency (PRF) on spinal nerve root for the treatment of LDH. Study design: Retrospective comparative study. Setting: Shengjing Hospital of China Medical University. Methods: A total of 135 patients with LDH were selected from the Department of Pain Management in the Shengjing Hospital of China Medical University between January 2014 and December 2016. All patients were divided into three groups according to the order of entry (n=45): TFESI (group A); PRF on spinal nerve root (group B); and TFESI combined with PRF on spinal nerve root (group C). The visual analog scale (VAS), Oswestry disability index (ODI), and global perceived effect (GPE) before treatment and at different time points after treatment were observed, and patients’ satisfaction was assessed. Results: At every point of observation, the VAS and ODI decreased significantly as compared to that before treatment in all groups (P0.05). Conclusion: TFESI combined with PRF for the treatment of LDH could effectively and rapidly relieve lumbago and radicular pain and achieve long-term remission. Although the method is widely applicable, the precise selection of patients is imperative. Keywords: transforaminal epidural steroid injection, pulsed radio frequency, spinal nerve root, lumbar disc herniation, low back pain, radicular pain

Various intraspinal cysts have been described in the literature. Sometimes these cysts are difficult to recognize intraoperative and can place a surgeon in dilemma. We report a case of a degenerative intraspinal cyst with severe adhesion with dura, which was mimicking as a nerve root and posed a diagnostic dilemma during surgery. A Sixty-year-old man presented with insidious onset, gradually progressing lower back pain, right leg pain and neurological claudication of six months duration. The pain radiated to the right S1 dermatome. Right side straight leg raise test was positive at 45°. Sensations were diminished over the right L5 and S1 dermatomes. Motor function was normal. MRI showed a large cystic lesion at right L5-S1 level. The cyst appeared to compress the dural sac and traversing right S1 root at L5-S1 level. The lesion was isointense on T1-weighted image and hyperintense on T2-weighted image. While treating this condition using the uniportal full endoscopic technique the cyst appeared as nerve root. Meticulous dissection was required to separate the cyst from neural structures. Histology confirmed the diagnosis of a degenerative intraspinal cyst. The patient had significant improvement after surgery and at six months follow up he was completely asymptomatic. Various cysts can occur in the intraspinal canal, and careful attention should be paid to minimize the nerve injury in the presence of severe adhesions.

• Study shows important inter-individual variability in myotome innervation among patients. • Most muscles have multi-radicular innervation. • Root territories strongly overlap, not only under dorsal but also ventral stimulation at threshold. Most of knowledge on muscle radicular innervation was from explorations in root/spinal cord pathologies. Direct and individual access to each of the lumbar-sacral -ventral and dorsal- nerve roots during dorsal rhizotomy for spastic diplegia allows precise study of the corresponding muscle innervation. Authors report the lumbo-sacral segmental myotomal organization obtained from recordings of muscle responses to root stimulation in a 20-children prospective series. Seven key-muscles in each lower limb and anal sphincter were Electromyography (EMG)-recorded and clinically observed by physiotherapist during L2-to-S2 dorsal rhizotomy. Ventral roots (VR), for topographical mapping, and dorsal roots (DR), for segmental excitability testing, were stimulated, just above threshold for eliciting muscular response. In 70% of the muscles studied, VR innervation was pluri-radicular, from 2-to-4 roots, with 1 or 2 roots being dominant at each level. Overlapping was important. Muscle responses to DR stimulation were 1.75 times more extended compared to VR stimulation. Inter-individual variability was important. Accuracy of root identification and stimulation with the used method brings some more precise information to radicular functional anatomy. Those neurophysiological findings plead for performing Intra-Operative Neuromonitoring when dealing with surgery in the lumbar-sacral roots. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging fat suppression techniques are commonly used for diagnosis of canine spinal disease, however, studies comparing different techniques are currently lacking. This retrospective, methods comparison study aimed to evaluate water excitation and STIR MRI pulse sequences for visualization of canine lumbar spinal nerve roots. For inclusion, all dogs had to have dorsal planar MRI studies of the lumbar spine using both sequences. Visual grading analysis was used for scoring the following five criteria: degree of fat suppression; nerve root visualization; subjective tissue contrast; presence of noise; and overall better image quality. Scores were independently recorded by three board-certified veterinary radiologists on two separate occasions, 3- 6weeks apart. A total of 90 dogs were sampled. A two-tailed t-test showed that there were significant differences in all scored parameters (P<0.00001), with the exception of noise (P=0.47343), and that the water excitation sequence scored higher in all cases excluding noise. A Gwets AC kappa for intraobserver and interobserver reliability showed "almost perfect" agreement for the nerve roots in both tests (intra: k = 0.88; inter: k = 0.90). Intraobserver agreement was "substantial" for the degree of fat suppression (k = 0.68), subjective tissue contrast (k = 0.75), and overall better image quality (k = 0.76) and it was "fair" for the noise (k = 0.46). Interobserver agreement was "moderate" for the degree of fat suppression (k = 0.53), subjective tissue contrast (k = 0.63), and overall better image quality (k = 0.66) and "slight" for noise (k = 0.25). These findings supported using the water excitation pulse sequence for fat-suppressedMRI of canine lumbar spinal nerve roots. [ABSTRACT FROM AUTHOR]

Background and Study Aims A great number of unsuccessful intervertebral herniated disk surgeries in the lumbosacral region have highlighted the importance of a comprehensive knowledge of the different types of nerve root anomalies. That knowledge gained by anatomical studies (and intraoperative findings) might contribute to better results. In our study we focused on intraspinal extradural lumbosacral nerve root anomalies and their possible role in radiculopathy. Material and Methods The study was performed on 43 cadavers within 24 hours after death (32 men and 11 women). Bodies were dissected in the prone position, and a laminectomy exposed the entire spinal canal for the bilateral examination of each spinal nerve root from its origin to its exit through the intervertebral foramen or sacral hiatus. Uncommon extradural features in the lumbosacral region were pursued and documented. The spinal dural sac was also opened, aimed at recognizing the normotyped, prefixed, or postfixed type of plexus. Results A total of 20.93% of anomalies of extradural lumbosacral nerve root origins were observed, with the normotyped plexus prevailing. We observed atypical spacing of exits of lumbosacral roots (four cases), two roots leaving one intervertebral foramen (one case), extradural anastomoses (two cases), and missing extradural nerve root courses (two cases). The results were differentiated according to the normotyped, prefixed, or postfixed plexus type. Conclusion Results of similar studies dealing with anomalies of lumbosacral nerve roots were aimed at improving the results of herniated disk surgeries because ∼ 10% of misdiagnoses are related to ignorance of anatomical variability. Our observations may help explain the differences between the clinical picture and generally accepted anatomical standards. [ABSTRACT FROM AUTHOR]

To explore the effect of sevoflurane inhalation anesthesia on evoked electromyography monitoring of spinal nerve root in children associated with cerebral palsy.

Objective Peripheral nerve stimulation provides targeted stimulation and pain relief within a specific nerve distribution. This technical case report provides a method to perform selective nerve root stimulation of thoracic and lumbar spinal nerves using ultrasonography. Methods Ultrasound-guided peripheral nerve stimulation of thoracic and lumbar spinal nerves allows better visualization of soft tissue anatomy and planning of needle trajectory. Conclusions Ultrasound-guided peripheral nerve stimulation procedures may provide a safer method for neurostimulation lead placement when compared with fluoroscopic-guided techniques. [ABSTRACT FROM AUTHOR]

A 56 years old woman with a diagnosis of diffuse large B-cell lymphoma had dyspnea, weakness in the left upper extremity and vocal cord paralysis after chemotherapy. She underwent cervical, thoracal and lumbosacral magnetic resonance imaging (MRI) however findings on MRI could not entirely explain the symptoms of the patient. Therefore, the patient underwent 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography and the scan revealed focal symmetrical 18F-FDG uptake on the cervical, thoracal and lumbal spinal nerve roots. Considering the symptoms of the patient and cerebrospinal fluid cytology findings, hypermetabolic spinal nerve roots were interpreted as lymphoma involvement. [ABSTRACT FROM AUTHOR]

Adult brachial plexus injuries frequently lead to significant and permanent physical disabilities. Investigating the mechanism of the injury using biomechanical approaches may lead to further knowledge with regard to preventing brachial plexus injuries. However, there are no reports of biomechanical studies of brachial plexus injuries till date. Therefore, the present study used a complex three-dimensional finite element model (3D-FEM) of the brachial plexus to analyze the mechanism of brachial plexus injury and to assess the validity of the model. A complex 3D-FEM of the spinal column, dura mater, spinal nerve root, brachial plexus, rib bone and cartilage, clavicle, scapula, and humerus were conducted. Stress was applied to the model based on the mechanisms of clinically reported brachial plexus injuries: Retroflexion of the cervical, lateroflexion of the cervical, rotation of the cervical, and abduction of the upper limb. The present study analyzed the distribution and strength of strain applied to the brachial plexus during each motion. When the cervical was retroflexed or lateroflexed, the strain was focused on the C5 nerve root and the upper trunk of the brachial plexus. When the upper limb was abducted, strain was focused on the C7 and C8 nerve roots and the lower trunk of the brachial plexus. The results of brachial plexus injury mechanism corresponded with clinical findings that demonstrated the validity of this model. The results of the present study hypothesized that the model has a future potential for analyzing pathological conditions of brachial plexus injuries and other injuries or diseases, including that of spine and spinal nerve root. [ABSTRACT FROM AUTHOR]

Background: Recently, the use of ultrasound (US) techniques in regional anesthesia and pain medicine has increased significantly. However, the current extent of training in the use of US-guided pain management procedures in Korea remains unknown. The purpose of the present study was to assess the current state of US training provided during Korean Pain Society (KPS) pain fellowship programs through the comparative analysis between training hospitals. Methods: We conducted an anonymous survey of 51 pain physicians who had completed KPS fellowships in 2017. Items pertained to current US practices and education, as well as the types of techniques and amount of experience with US-guided pain management procedures. Responses were compared based on the tier of the training hospital. Results: Among the 51 respondents, 14 received training at first- and second-tier hospitals (Group A), while 37 received training at third-tier hospitals (Group B). The mean total duration of pain training during the 1-year fellowship was 7.4 months in Group A and 8.4 months in Group B. Our analysis revealed that 36% and 40% of respondents in Groups A and B received dedicated US training, respectively. Most respondents underwent US training in patient-care settings under the supervision of attending physicians. Cervical root, stellate ganglion, piriformis, and lumbar plexus blocks were more commonly performed by Group B than by Group A (P < 0.05). Conclusions: Instruction regarding US-guided pain management interventions varied among fellowship training hospitals, highlighting the need for the development of educational standards that mandate a minimum number of US-guided nerve blocks or injections during fellowships in interventional pain management.b [ABSTRACT FROM AUTHOR]

Study Design: We developed a spinal nerve root wrapping rodent model to evaluate the relationship between recombinant human bone morphogenetic protein 2 (rhBMP-2) dosage and the degree of inflammation.Objective: To investigate the direct effects of recombinant human bone morphogenetic protein 2 (rhBMP-2) dosage and the degree of inflammation in rodent spinal nerve roots.Summary Of Background Data: rhBMP-2 is commonly used in clinical practice to augment spinal fusion. However, complications such as postoperative leg pain, and a higher rate of postoperative neurologic deficits have been reported. These may be attributable to the exposure of adjacent nerve roots to high doses of rhBMP-2.Methods: Eighteen rats were randomized into three groups as follows: Group 1: absorbable collagen sponge (ACS) + 10 μg rhBMP-2, Group 2: ACS + 1 μg rhBMP-2, and Group 3 ACS with 20 μL saline. The ACS containing rhBMP-2 or saline were then wrapped around the L5 nerve root and secured loosely with nonabsorbable sutures. At 1-week postoperation, the rats were sacrificed, and the L5 nerve root and dorsal root ganglion harvested for reverse transcription polymerase chain reaction (RT-PCR), histology and immunohistochemical staining.Results: In our study, 10 μg rhBMP-2 induced a 10-fold increase in seroma compared with 1 μg group. Using RT-PCR, macrophage markers MIP3-α, and CD-68 were upregulated by 8- and 2-fold respectively in comparison with the saline group. Haematoxylin and eosin (H&E) images demonstrated disruption of nerve structures in the high dose 10 μg rhBMP-2, but not at 1 μg rhBMP-2 and with saline.Conclusion: High doses of rhBMP-2 induced neuroinflammation in a dose dependent manner, resulting in higher seroma volume, macrophage marker gene expressions, and higher proportions of immunohistochemically stained TNF-alpha and more macrophage infiltration.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterised by various phenotypic features like hyperpigmented spots, neurofibromas, Lisch nodules, skeletal abnormalities and tendency to develop neoplasms. Only few cases of Non-Familial Spinal Neurofibromatosis-1 (Non-FSNF1) have been described in literature with tumors involving the spinal roots at every level being even rarer. We reported an interesting case of bilateral symmetrical cervical neurofibroma with multiple spinal neurofibromas appearing as mirror image on CT, associated with non familial NF-1 as a rare presentation in a 25-year-old adult male. [ABSTRACT FROM AUTHOR]

Introduction Intraoperative neurophysiological monitoring (IONM) has proven to help reduce the probability of postoperative neurological deficit for spinal deformity correctional surgeries. However, in rare cases new deficits may still happen. We report a surgical case in which the patient had postoperative paralysis. We would like to call for more case reports with postoperative neurological deficits as they present difficult clinical cases. Presentation of case A 61-year-old male patient with severe thoracolumbar kyphoscoliosis underwent posterior spinal correction and fusion with segmental T10-L5 pedicle screws and rods instrumentation with IONM. The only intraoperative event was a pedicle breach at left L3 which was detected by triggered electromyography (EMG) testing, and the pedicle screw was repositioned. Left lower extremity paralysis was observed upon patient awakening. He received rehabilitation treatment and had limited recovery of muscle strength. Partial lumbar nerve root injury was likely the cause of the paralysis. Discussion This is a case with new lumbar nerve root deficit, with positive EMG signal change, but negative somatosensory evoked potential (SSEP) and motor evoked potential (MEP) findings. We discuss the different neurophysiological modalities for monitoring lumbar spinal nerve root function. We review journal articles from the past two decades which reported lumbar root deficits, and list neuromonitoring events during the surgeries. Conclusion Multimodality monitoring with spontaneous and electrically triggered EMG combined with SSEP and MEP may provide the best chance to detect lumbar nerve root injuries. [ABSTRACT FROM AUTHOR]

Objective: To investigate the value of three sequences in depicting normal lumbosacral nerve roots as well as in patients with lumbosacral disease. Methods: 29 volunteers and 42 patients with lumbosacral plexus lesions were enrolled in this study.Diffusion-weighted neuroimaging with background signal suppression(DWIBS) sequence, principle of selective excitation technique(PROSET) sequence and 3D short term inversion recovery(3D STIR) sequence scanning were performed in all subjects. Maximum intensity projection(MIP) of reconstruction was used for images in DWIBS sequence. Images of all subjects were observed and divided into three classes of resolution. The three methods of scanning in two groups were evaluated statistically for the imaging quality. Results:In group of volunteers, all of three MRI sequences can be implemented to show the detail of the lumbosacral plexus nerves. Chi-square test proved that there was no significant difference between the methods in L4-5 spinal nerve roots, but there were obvious differences in L2-3 spinal nerve roots. In patients, Friedman test showed that there were obvious differences among the imaging quality of three sequences. DWIBS as well as PROSET seemed superior to 3DSTIR and their difference had obvious statistical significance(P<0.05).There was no obvious statistical significance between DWIBS and PROSET. Conclusions: Further technical developments of MRI sequences provide more information in detecting nerves. Excellent depiction of 3D nerve anatomy and pathology is currently possible. By the combination of routine sequences, DWIBS and PROSET, 3D STIR can clearly display the relevant anatomy details and traumatic signs of the Lumbosacral Plexus. Furthermore, the technique of background suppression that displays high specific signal of nerves is more superior in DWIBS and PROSET than in 3DSTIR. The MIP reconstruction of DWIBS can show the multiaspect of the Lumbosacral plexus and observe nerves by different dimensions. DWIBS provide a reliable imaging data for preoperative plan, and make up for the deficiency of conventional magnetic resonance imaging. [ABSTRACT FROM AUTHOR]

Spinal nerve root enhancement in pediatric patients is generally nonspecific, and clinical and laboratory correlation is essential. Nerve root enhancement indicates lack of integrity of the blood-nerve barrier. In this review, we will present a range of pediatric conditions that can present with spinal nerve root enhancement including inflammatory, infectious, hereditary, and neoplastic causes. Familiarity with the various pathologic entities associated with spinal nerve root enhancement is important for a concise differential diagnosis in the appropriate clinical setting. This will avoid unnecessary additional investigations. [ABSTRACT FROM AUTHOR]

Background: To explore the effect of sevoflurane inhalation anesthesia on evoked electromyography monitoring of spinal nerve root in children associated with cerebral palsy. Methodology: Children with cerebral palsy (n=40) were selected and further divided into 1MAC (minimum alveolar concentration) sevoflurane group and 2MAC sevoflurane group. Following the induction of anesthesia, Nicolet Endeavor-CR16 channel electrophysiological monitor was used to implement three times of successive electrical stimulation with interval of 5 sec at 3.50 mA. Results: Our results suggested a statistical significance of amplitude retention ratio and latency in the sevoflurane inhalation time (P<0.01), with an interaction effect between the sevoflurane inhalation time and concentration for amplitude retention ratio (P<0.01), while there is no interaction effect between the sevoflurane inhalation time and concentration for latency (P>0.05). Compared to 1MAC sevoflurane group, the amplitude retention ratio of 2MAC sevoflurane group decreased remarkably (P<0.01) and the latency of 2MAC sevoflurane group extended at T3 and T4 (P<0.05 or P<0.01). Conclusions: In evoked electromyography monitoring of spinal nerve root in children with cerebral palsy, with the increasing of concentration and duration of sevoflurane inhalation, evoked electromyogram retention ratio reduces gradually, latency extends and the retention ratio has more changes than the latency. [ABSTRACT FROM AUTHOR]

Objective: Nerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series., Methods: Supra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength., Results: The LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade ≥ 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer., Conclusions: The LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.

Background Intracisternal Accessory Nerve Schwannomas (ANS) constitute a rare clinical entity with only a few cases reported so far. Their symptoms are usually due to brainstem compression and not manifested until they render of great size. Secondary neuropathy and muscle atrophy are other late signs. The hitherto reported literature advocates a suboccipital craniotomy as a suitable approach. In most of the cases the spinal root was the location tumor arose from. Gross total resection was possible to be carried out in most cases with only sporadic tolerable postoperative deficits reported. Case description We hereby present three cases of patients with intracisternal ANS treated in the same fashion. Two patients were male and one female. Two patients complained of mainly chronic headaches and neck pain, whereas in the third patient the lesion was found incidentally. Only one patient suffered post-operatively cerebrospinal fluid leakage and wound healing complication, which was treated with revision surgery and administration of antibiotics. None of the patients had postoperative neurological deficits. Furthermore, we conducted a review of the relevant literature where we noted that there is no consensus yet with regards to the appropriate surgical approach. Conclusions Based on relevant anatomical studies, we advocate that suboccipital subtonsilar approach provides a wide corridor to the area of lesion allowing complete and safe resection of intracisternal ANS. We thus support that, in most cases, the neurosurgeon should consider using this familiar approach for treating this rare lesion. [ABSTRACT FROM AUTHOR]

Disorders affecting the lumbosacral plexus (LSP) can alter root diameter. Our aim was to determine normal LSP nerve root dimensions using magnetic resonance neurography (MRN). Eleven asymptomatic patients (ages: 18-53, mean: 34 years) underwent MRN of the LSP on a 3 T scanner with an 8-channel torso-PA coil. IDEAL T2-weighted images were acquired and nerve root dimensions were measured from the second lumbar (L2) to the first sacral (S1) vertebrae on the coronal plane, 5 mm from the dorsal root ganglion (DRG). Root size was recorded by three separate groups of radiologists with different levels of expertise. Additional LSP-MRN images were acquired from a fresh-frozen cadaver specimen using the same scanner and parameters identical to those described above. Subsequently, two experienced anatomists dissected and measured the LSP roots at exactly the same distance from the DRG, using an electronic caliper. Mean root size values recorded (± standard deviation) in the asymptomatic patients were as follows: L2: 3.12 mm (±0.92), L3: 4.29 mm (±0.95), L4: 5.13 mm (±0.79), L5: 5.29 mm (±0.9), and S1: 5.38 mm (±0.7). The correlation coefficients were 0.72 between the patient and cadaver MRN results and 0.79 between the patient and dissected cadaver MRN results. Inter-observer agreements were 0.73 among the radiologist groups and 0.87 between the anatomists conducting dissections. We believe MRN provides reliable assessments of LSP root thickness. More extensive studies should be conducted to confirm the results described here. Clin. Anat. 31:782-787, 2018. © 2018 Wiley Periodicals, Inc., (© 2018 Wiley Periodicals, Inc.)

Background Granular cell tumor (GCT) is a relatively uncommon predominantly benign lesion that usually presents as a solitary, painless cutaneous or submucosal nodule. Most of these tumors are found in the tongue. Although GCT is believed to have a Schwann cell origin, reports of GCT in peripheral and spinal nerves are uncommon. Case Description We report the case of a 43-year-old man with neck pain and hand numbness who was found to have a heterogeneously enhancing left-sided C2 nerve sheath tumor on magnetic resonance imaging. He underwent C2 decompression and resection of the left-sided C2 nerve sheath tumor with subsequent C1-C2 arthrodesis and instrumentation. Histopathologic review showed GCT. Review of the literature yielded 4 other reported cases of GCT within the vicinity of a spinal nerve root. Only one of these explicitly showed spinal nerve root involvement. This is a rare case of a GCT presenting as cervical nerve root mass, and what we believe is the first reported case of this in the literature. Conclusions The surgeon should be aware of GCT when encountering spinal nerve root tumors because it may alter the surgical approach necessary for adequate resection compared with more commonly encountered nerve sheath tumors. [ABSTRACT FROM AUTHOR]

Objective: Intradural nerve anastomosis for bladder innervation has been demonstrated to be useful. However, its clinical application remains limited because of the complex surgery, its complications and extensive bony destruction. The purpose of the current study was to demonstrate the feasibility of extradural spinal root anastomosis for bladder innervation in canines., Methods: Ten beagle dogs were used. The length of the extradural segment of the nerve root, upper nerve root outlet (the point at which it emerges from the spinal dura mater) to S2 (dS2), the S3 (dS3) nerve root outlet distance, and the diameters of the extradural spinal roots were measured. The numbers of nerve fibers from L6 to S3 ventral roots were calculated using immunohistochemical staining., Results: The extradural spinal roots could be divided into a ventral root (VR) and a dorsal root (DR) before the ganglionic enlargement of the dorsal root, and the extradural motor nerve roots situate ventrally to their corresponding sensory nerve roots. The extradural nerve root lengths of S1 and parts of L7 were longer than the corresponding dS2. The numbers of nerve and motor nerve fibers, and the diameters of extradural nerve roots, were gradually descending from L6 to S3., Conclusion: The S1 VRs and parts of the L7 VRs can be extradurally anastomosed to the S2 nerves without tension. A nerve graft was needed for extradural anastomosis of L6 VRs and parts of L7 VRs to S2 VRs. This study demonstrated the feasibility of extradural spinal nerve anastomosis for treating neurogenic bladder in canines.

Objective: The aim of this study is to evaluate the values of ProSet magnetic resonance coronal source imaging (ProSet MR imaging) as a diagnostic tool for detecting symptomatic lesion in patients with multiple lumbar foraminal stenosis., Patients and Methods: From January 2011 to June 2015, 46 patients with unilateral and single-level radiculopathy developed from foraminal stenosis were enrolled in the study. These diagnoses were confirmed with transforaminal selective nerve root block (SNRB) and electrophysiological testing, including electromyography and nerve conduction velocity (EMG/NCV) tests. The detection of symptomatic lesion among multiple lumbar foraminal stenosis was done by identification of spinal nerve swelling (NS) and/or running course abnormalities (RCA) observed on ProSet MR imaging. These results were compared with those from transforaminal SNRB testing and conventional MR imaging. Evaluations were performed blinded by two independent examiners., Results: The diagnostic accuracy rates of the two examiners were 84.7% and 82.6% with a 0.835 kappa coefficient. NS (80.4%) showed a higher diagnostic accuracy rate compared to RCA (69.6%) for detecting symptomatic lesion. The presence or absence of both NS and RCA has a stronger relationship with symptomatic or non-symptomatic lesion compared to the relationship of either alone (p=0.00)., Conclusion: ProSet MR imaging is a simple and helpful method for providing additional diagnostic accuracy to detect symptomatic lesion in patients with multiple foraminal stenosis. NS representing chemical radiculitis was more reliable diagnostic factor of ProSet MR imaging., (Copyright © 2016 Elsevier B.V. All rights reserved.)