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Background: Cervical epidural hematoma (CEH) is a rare but potentially devastating condition, characterized by the accumulation of blood within the epidural space of the cervical spine, leading to spinal cord compression (Perron AD, Huff JS. Spinal cord disorders. In: Marx JA, et al. editors. Rosen's emergency medicine: concepts and clinical practice. 8th ed. Philadelphia: Saunders; 2013. pp. 1419–27.); (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Ryo Yamamoto M, Ito H, Shimuzu K, Wakabayashi H, Oyama. Two cases of cervical epidural hematoma presenting with left-sided hemiplegia and requiring surgical drainage. Cureus. 2022;14(4):e23915. https://doi.org/10.7759/cureus.23915.). While trauma and iatrogenic causes are well-documented, cases attributed to neck strain and acupuncture are uncommon. (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. Spinal cord injury as a complication of an acupuncture. Neurology. 1979;29(8):1188–90. https://doi.org/10.1212/wnl.29.8.1188.) Here, we present two cases of CEH secondary to these unusual aetiologies. Both cases highlight the importance of considering uncommon causes of CEH to ensure early recognition and prompt treatment. Case presentations: Case 1 is an 81-year-old lady who presented with left hemiparesis and paraesthesia following a fall with neck strain. Magnetic resonance imaging (MRI) of cervical spine revealed left C3-C7 epidural haematoma with severe cord compression. In Case 2, a 35-year-old gentleman experienced sudden onset numbness and weakness in all limbs just 10 minutes after receiving acupuncture. MRI showed an epidural hematoma at the C2-C4 levels. Both patients underwent immediate surgical decompression and had significant recovery. Conclusion: Although CEH is a rare occurrence, it can potentially be a neurosurgical emergency. Physicians must remain cognizant of the diverse aetiologies associated with CEH and the necessity for early recognition and immediate treatment. [ABSTRACT FROM AUTHOR]

Background: We discuss the diagnostic benefit of pulsed radiofrequency (PRF) of the dorsal root ganglion (DRG) in a case series of patients with different pathologies. We expand the diagnostic potential of DRG stimulation beyond paresthesia mapping by using DRG stimulation to help determine the role of the DRG in the patient's pain and narrow down the etiology. In some cases, DRG stimulation was also part of the treatment plan. Methods: Six patients underwent DRG radiofrequency as a diagnostic/therapeutic step before considering implantation of a DRG neurostimulator. First, patients underwent a basic bedside neurological evaluation. Next, an electrode was placed in the epidural space through the sacral hiatus or between vertebral laminae. Then, sensory stimulation was applied at 50 Hz and gradually increased from 0.1 V until the patient reported paresthesia or until a maximum intensity of 2 V was reached. Patients were asked to describe where the stimulation was felt and outline the anatomical area the paresthesia covered. Then a motor stimulation was applied at 2 Hz until muscle twitching was reported by the patient or observed by the physician. Results: The information obtained helped diagnose the type of lesion as principally preganglionic, ganglionic, or postganglionic. This information guided patient management. Conclusion: PRF of the DRG can provide valuable diagnostic information and is a useful step before ganglionic electrode implantation. In all cases, PRF of the DRG provided valuable diagnostic information and guided management options. [ABSTRACT FROM AUTHOR]

Little is known about the electrophysiologic activity of the intact human spinal cord during volitional movement. We analyzed epidural spinal recordings from a total of five human subjects of both sexes during a variety of upper extremity movements and found that these spinal epidural electrograms contain spectral information distinguishing periods of movement, rest, and sensation. Cervical epidural electrograms also contained spectral changes time-locked with movement. We found that these changes were primarily associated with increased power in the theta (4–8 Hz) band and feature increased theta phase to gamma amplitude coupling, and this increase in theta power can be used to topographically map distinct upper extremity movements onto the cervical spinal cord in accordance with established myotome maps of the upper extremity. Our findings have implications for the development of neurostimulation protocols and devices focused on motor rehabilitation for the upper extremity, and the approach presented here may facilitate spatiotemporal mapping of naturalistic movements. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Epidural lymphoma of the lumbosacral region is a rare condition that manifests with back pain and nonspecific neurological symptoms. Our case which was diagnosed with diffuse large B‐cell lymphoma, highlights the importance of recognizing early lymphoma symptoms to enable timely treatment and improved outcomes. Lymphoma rarely presents in the lumbosacral epidural space. Initial presentations of lymphoma are of paramount importance in the timely diagnosis and management of the disease. We report a 42‐year‐old woman presented with 4 years of low back pain and progressive right lower extremity paresthesia. Lumbar MRI revealed an epidural soft tissue lesion compressing nerves at L4 to the coccyx. Laminectomy and tumor resection were performed. Pathologic findings confirmed diffuse large B‐cell lymphoma. We systematically reviewed the literature on lymphomas with lumbar epidural space involvement reported since 1990. Twenty‐four cases from 19 reports were identified. The mean age of lumbar epidural lymphoma cases was 39.5 ± 17.8 years, and 72% were male. The most common subtype was diffuse large B‐cell lymphoma, and common presentations included back pain, lower extremity neurological deficits, and bowel/bladder dysfunction. Overall, lymphomas presenting in the spine can pose diagnostic challenges owing to nonspecific initial symptoms. Our case highlights the importance of recognizing early lymphoma symptoms to enable timely treatment and improved outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Spinal cord injury (SCI) animal models often utilize an open surgical laminectomy, which results in animal morbidity and also leads to changes in spinal canal diameter, spinal cord perfusion, cerebrospinal fluid flow dynamics, and spinal stability which may confound SCI research. Moreover, the use of open surgical laminectomy for injury creation lacks realism when considering human SCI scenarios. Methods: We developed a novel, image-guided, minimally invasive, large animal model of SCI which utilizes a kyphoplasty balloon inserted into the epidural space via an interlaminar approach without the need for open surgery. Results: The model was validated in 5 Yucatán pigs with imaging, neurofunctional, histologic, and electrophysiologic findings consistent with a mild compression injury. Discussion: Few large animal models exist that have the potential to reproduce the mechanisms of spinal cord injury (SCI) commonly seen in humans, which in turn limits the relevance and applicability of SCI translational research. SCI research relies heavily on animal models, which typically involve an open surgical, dorsal laminectomy which is inherently invasive and may have untoward consequences on animal morbidity and spinal physiology that limit translational impact. We developed a minimally invasive, large animal model of spinal cord injury which utilizes a kyphoplasty balloon inserted percutaneously into the spinal epidural space. Balloon inflation results in a targeted, compressive spinal cord injury with histological and electrophysiological features directly relevant to human spinal cord injury cases without the need for invasive surgery. Balloon inflation pressure, length of time that balloon remains inflated, and speed of inflation may be modified to achieve variations in injury severity and subtype. [ABSTRACT FROM AUTHOR]

Background: To explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC). Methods: One-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance. Results: The accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: − 1–3) vs. 3 (IQR: − 1–7), p = 0.006), while not reached at both 1- (1 (IQR: 0–2) vs. 1 (IQR: − 1–3), p = 0.086) or 3-month follow-up (0 (IQR: − 1–1) vs. 1 (IQR: 0–2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up. Conclusions: The novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury. [ABSTRACT FROM AUTHOR]

Background: Spinal cord stimulation (SCS) has demonstrated multiple benefits in treating chronic pain and other clinical disorders related to sensorimotor dysfunctions. However, the underlying mechanisms are still not fully understood, including how electrode placement in relation to the spinal cord neuroanatomy influences epidural spinal recordings (ESRs). To characterize this relationship, this study utilized stimulation applied at various anatomical sections of the spinal column, including at levels of the intervertebral disc and regions correlating to the dorsal root entry zone. Method: Two electrode arrays were surgically implanted into the dorsal epidural space of the swine. The stimulation leads were positioned such that the caudal-most electrode contact was at the level of a thoracic intervertebral segment. Intraoperative cone beam computed tomography (CBCT) images were utilized to precisely determine the location of the epidural leads relative to the spinal column. High-resolution microCT imaging and 3D-model reconstructions of the explanted spinal cord illustrated precise positioning and dimensions of the epidural leads in relation to the surrounding neuroanatomy, including the spinal rootlets of the dorsal and ventral columns of the spinal cord. In a separate swine cohort, implanted epidural leads were used for SCS and recording evoked ESRs. Results: Reconstructed 3D-models of the swine spinal cord with epidural lead implants demonstrated considerable distinctions in the dimensions of a single electrode contact on a standard industry epidural stimulation lead compared to dorsal rootlets at the dorsal root entry zone (DREZ). At the intervertebral segment, it was observed that a single electrode contact may cover 20-25% of the DREZ if positioned laterally. Electrode contacts were estimated to be ~0.75 mm from the margins of the DREZ when placed at the midline. Furthermore, ventral rootlets were observed to travel in proximity and parallel to dorsal rootlets at this level prior to separation into their respective sides of the spinal cord. Cathodic stimulation at the level of the intervertebral disc, compared to an 'off-disc' stimulation (7 mm rostral), demonstrated considerable variations in the features of recorded ESRs, such as amplitude and shape, and evoked unintended motor activation at lower stimulation thresholds. This substantial change may be due to the influence of nearby ventral roots. To further illustrate the influence of rootlet activation vs. dorsal column activation, the stimulation lead was displaced laterally at ~2.88 mm from the midline, resulting in variances in both evoked compound action potential (ECAP) components and electromyography (EMG) components in ESRs at lower stimulation thresholds. Conclusion: The results of this study suggest that the ECAP and EMG components of recorded ESRs can vary depending on small differences in the location of the stimulating electrodes within the spinal anatomy, such as at the level of the intervertebral segment. Furthermore, the effects of sub-centimeter lateral displacement of the stimulation lead from the midline, leading to significant changes in electrophysiological metrics. The results of this pilot study reveal the importance of the small displacement of the electrodes that can cause significant changes to evoked responses SCS. These results may provide further valuable insights into the underlying mechanisms and assist in optimizing future SCS-related applications. [ABSTRACT FROM AUTHOR]

Background: Cervical epidural block (CEB) is an effective intervention for managing cervical radicular pain. This study aimed to investigate the current status of performing CEB in South Korea. Methods: Pain physicians affiliated with the Korean Pain Society were asked to complete anonymous questionnaires regarding CEB between September and October 2022. The questionnaire consisted of 24 questions assessing the current status and methods of CEB in detail. Results: Of the 198 surveys collected, 171 physicians (86.4%) reported performing CEB. Among those, the majority (94.7%) used fluoroscopy during the procedure. The paramedian interlaminar (IL) approach was the most preferred method (50.3%). Respondents performing fluoroscopic-guided IL CEB were categorized into two groups based on clinical experience: those with ≤10 years of experience (≤10-year group, n = 91) and those with >10 years of experience (>10-year group, n = 71). The proportion of physicians obtaining informed consent in the ≤10-year group and >10-year group was 50.5% and 56.3%, respectively. When entering the epidural space during IL CEB, the contralateral oblique view was the second most frequently used in both groups (≤10-year group, 42.9%; >10-year group, 29.6%). In targeting the upper cervical lesions (C3--4), the proportion of respondents who used an IL space higher than C6--7 was 17.6% in the ≤10-year group and 29.5% in the >10-year experience group. Conclusions: This study demonstrated variability in the CEB technique used by pain physicians in South Korea. The findings highlight the need for education on informed consent and techniques to enhance safety. [ABSTRACT FROM AUTHOR]

Contemporary literature lacks examples of intradural, extramedullary spinal glomangiomas. Moreover, glomus tumors in general are exceedingly rare among benign spinal tumors and are mostly located within epidural space or within intervertebral foramen, and only a few cases have been documented to date. This report provides a detailed analysis of the clinical presentation, imaging characteristics, surgical intervention, and pathological findings of a 45-year-old patient experiencing progressive locomotor deterioration. The tumor was surgically excised, and subsequent histological examination identified it as a representative of glomus tumors—a glomangioma. Notably, this represents a unique case as it was the first example of such a tumor being discovered intradurally. Radical surgical excision remains the modality of choice in most benign spinal tumors of this localization. Although the malignant transformation of glomus tumors within the spine has not been documented thus far, cases have arisen in other areas. Consequently, we will investigate potential oncological treatments for cases with malignant potential and highlight advancements in surgical techniques for benign intradural spinal tumors. [ABSTRACT FROM AUTHOR]

The choice of treatment for lumbar spinal stenosis (LSS) depends on symptom severity. When severe motor issues with urinary dysfunction are not present, conservative treatment is often considered to be the priority. One such conservative treatment is epidural injection, which is effective in alleviating inflammation and the pain caused by LSS-affected nerves. In this study, Shinbaro2 (Sh2), pharmacopuncture using natural herbal medicines for patients with disc diseases, is introduced as an epidural to treat LSS in a rat model. The treatment of primary sensory neurons from the rats' dorsal root ganglion (DRG) neurons with Sh2 at various concentrations (0.5, 1, and 2 mg/mL) was found to be safe and non-toxic. Furthermore, it remarkably stimulated axonal outgrowth even under H2O2-treated conditions, indicating its potential for stimulating nerve regeneration. When LSS rats received epidural injections of two different concentrations of Sh2 (1 and 2 mg/kg) once daily for 4 weeks, a significant reduction was seen in ED1+ macrophages surrounding the silicone block used for LSS induction. Moreover, epidural injection of Sh2 in the DRG led to a significant suppression of pain-related factors. Notably, Sh2 treatment resulted in improved locomotor recovery, as evaluated by the Basso, Beattie, and Bresnahan scale and the horizontal ladder test. Additionally, hind paw hypersensitivity, assessed using the Von Frey test, was reduced, and normal gait was restored. Our findings demonstrate that epidural Sh2 injection not only reduced inflammation but also improved locomotor function and pain in LSS model rats. Thus, Sh2 delivery via epidural injection has potential as an effective treatment option for LSS. [ABSTRACT FROM AUTHOR]

Background: Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations. Case presentation: We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia. Conclusion: Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation. [ABSTRACT FROM AUTHOR]

Pituitary carcinomas are rare but associated with significant morbidity and mortality. They remain challenging to diagnose and manage. In this case, we describe a 56-year-old man who presented with erectile dysfunction and binocular vertical diplopia. He had central hypogonadism, secondary adrenal insufficiency, and central hypothyroidism on biochemical testing. His serum prolactin was 1517 mcg/L (1517 ng/mL; reference range 4-15 mcg/L), and his sellar magnetic resonance imaging showed a 2.0 × 2.2 × 3.1 cm pituitary tumor. Pathology revealed a prolactin-secreting carcinoma. Despite treatment with a high-dose dopaminergic, 2 transsphenoidal resections, and 1 course of radiation, prolactin levels continued to rise. He developed metastases to the epidural space and thecal sac from the thoracic to sacral spine, for which he received 12 cycles of temozolomide chemotherapy with initial clinical and biochemical response. This was followed by disease escape and progression. We discuss the clinical and imaging features that warrant a high index of suspicion for pituitary carcinoma and review contemporary treatment. [ABSTRACT FROM AUTHOR]

Copyright of Revista Brasileira de Higiene e Sanidade Animal is the property of Associacao Cientifica dos Medicos Veterinarios do Ceara and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

ObjectiveTo investigate the short-term changes in chest CT images of low-altitude populations after entering a high-altitude environment.MethodsChest CT images of 3,587 people from low-altitude areas were obtained within one month of entering a high-altitude environment. Abnormal CT features and clinical symptoms were analyzed.ResultsBesides acute high-altitude pulmonary edema, the incidence of soft tissue space pneumatosis was significantly higher than that in low-altitude areas. Pneumatosis was observed in the mediastinum, cervical muscle space, abdominal cavity, and spinal cord epidural space, especially the mediastinum.ConclusionIn addition to acute high-altitude pulmonary edema, spontaneous mediastinal emphysema often occurs when individuals in low-altitude areas adapt to the high-altitude environment of cold, low-pressure, and hypoxia. When the gas escapes to the abdominal cavity, it is easy to be misdiagnosed as gastrointestinal perforation. It is also not uncommon for gas accumulation to escape into the epidural space of the spinal cord. The phenomenon of gas diffusion into distant tissue space and the mechanism of gas escape needs to be further studied.

The article discusses the complications and safety of cervical interlaminar epidural block (CIEB), a procedure commonly used in Korea for the treatment of neck and upper extremity pain. While CIEB can be effective, it may also cause several complications, although they are rare. The article emphasizes the importance of using imaging guidance techniques, such as C-arm fluoroscopy with contrast media, to ensure safe and accurate CIEBs. The incidence of serious complications is low, and most complications are transient. Physicians should carefully monitor patients during and after the procedure. [Extracted from the article]

This article discusses the case of a patient who experienced progression of disc herniation after receiving a transforaminal epidural steroid injection (TFESI) for low back and leg pain. The patient initially had a positive response to the injection, but two days later, she reported increased pain and difficulty walking. An MRI revealed an increase in the size of the herniation. The article suggests that further research is needed to determine if this is a possible side effect of the treatment. [Extracted from the article]

Background: Colorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone. Case presentation: A 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma. Conclusions: Although rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended. [ABSTRACT FROM AUTHOR]

Epidural steroid injection (ESI) is a common therapeutic approach for managing sciatica caused by lumbar disc herniation (LDH). However, the short duration of therapeutic efficacy and the need for repeated injections pose challenges in LDH treatment. The development of a controlled delivery system capable of prolonging the effectiveness of ESI and reducing the frequency of injections, is highly significant in LDH clinical practice. In this study, we utilized a thiol-ene click chemistry to create a series of injectable hyaluronic acid (HA) based release systems loaded with diphasic betamethasone, including betamethasone dipropionate (BD) and betamethasone 21-phosphate disodium (BP) (BD/BP@HA). BD/BP@HA hydrogel implants demonstrated biocompatibility and biodegradability to matched neuronal tissues, avoiding artificial compression following injection. The sustained release of betamethasone from BD/BP@HA hydrogels effectively inhibited both acute and chronic neuroinflammation by suppressing the nuclear factor kappa-B (NF-κB) pathway. In a mouse model of LDH, the epidural administration of BD/BP@HA efficiently alleviated LDH-induced sciatica for at least 10 days by inhibiting the activation of macrophages and microglia in dorsal root ganglion and spinal dorsal horn, respectively. The newly developed HA hydrogels represent a valuable platform for achieving sustained drug release. Additionally, we provide a simple paradigm for fabricating BD/BP@HA for epidural injection, demonstrating greater and sustained efficiency in alleviating LDH-induced sciatica compared to traditional ESI and displaying potentials for clinical translation. This system has the potential to revolutionize drug delivery for co-delivery of both soluble and insoluble drugs, thereby making a significant impact in the pharmaceutical industry. Lumbar disc herniation (LDH) is a common degenerative disorder leading to sciatica and spine surgery. Although epidural steroid injection (ESI) is routinely used to alleviate sciatica, the efficacy is short and repeated injections are required. There remains challenging to prolong the efficacy of ESI. Herein, an injectable hyaluronic acid (HA) hydrogel implant by crosslinking acrylated-modified HA (HA-A) with thiol-modified HA (HA-SH) was designed to achieve a biphasic release of betamethasone. The hydrogel showed biocompatibility and biodegradability to match neuronal tissues. Notably, compared to traditional ESI, the hydrogel better alleviated sciatica in vivo by synergistically inhibiting the neuroinflammation in central and peripheral nervous systems. We anticipate the injectable HA hydrogel implant has the potential for clinical translation in treating LDH-induced sciatica. [Display omitted] [ABSTRACT FROM AUTHOR]

Copyright of Pferdeheilkunde is the property of Hippiatrika Verlag GmbH and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: There are no reports discussing anatomic distribution of basivertebral foramen (BVF) in the osteoporotic vertebral body, which is critical in the analysis of the risk of epidural cement leakage (ECL) after cement-augmented pedicle screw fixation (CAPSF). Methods: 371 osteoporotic patients using 1898 cement-augmented screws were included. Preoperative computed tomography (CT) was used to determine the frequency, width, height, and depth of magistral BVF in T10~L5. Additionally, we measured the distance between BVF and the left/right borders of vertebral body as well as the distance between BVF and upper/lower endplates. Following CAPSF, the severity of ECL and the position of pedicle screws were determined by postoperative CT. Finally, significant risk factors for extensive ECL were identified through binary logistic regression analysis. Results: Of 2968 vertebral bodies ranging from T10 to L5, 801 (42.2%) had a magistral BVF. From T10 to L5, the frequency of magistral BVF appeared to gradually increase. The magistral BVF was much closer to the upper endplate and the depth accounted for about a quarter of anteroposterior diameter of vertebral body. Overall, there were 19 patients (5.1%) and 32 screws (1.7%) with extensive ECL, nine of whom had neurological symptoms. The independent risk factors for extensive ECL were the magistral BVF (OR = 8.62, P < 0.001), more volume of cement injected (OR = 1.57, P = 0.031), reduced distance from screw tip to vertebral midline (OR = 0.76, P = 0.003) and vertebral posterior wall (OR = 0.77, P < 0.001) respectively. Conclusion: When planning a CAPSF procedure, it is important to consider anatomical distribution of BVF and improve screw implantation methods. [ABSTRACT FROM AUTHOR]

Background: Lumbar epidural analgesia is a safe, effective, and beneficial technique for both the parturient and the fetus. Dural puncture epidural has been claimed to be better than combined spinal epidural and epidural techniques by many. We undertook this study to compare the three techniques regarding duration, quality of analgesia, and side effects. Debate regarding the best neuraxial technique for labor analgesia continues. Materials and Methods: The parturients of ASA grade I and II of age group 20–35 years were randomly divided into three groups of 20 each. Group E (epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 μg fentanyl in the epidural space. Group CSE (combined spinal epidural group) received 2.5 mg of intrathecal isobaric levobupivacaine with 25 μg fentanyl and epidural top up of 15 ml of 0.125% levobupivacaine with 30 μg fentanyl. Group DPE (dural puncture epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 μg fentanyl in epidural space; intrathecal medication was withheld. Epidural top-up doses were given as per Visual Analog Scale (VAS). Analgesic efficacy, extent of sensory and motor block, maternal and fetal outcome, duration of analgesia, and maternal satisfaction score were compared among three groups and analyzed statistically. Results: The onset and symmetry of sensory blockade and VAS score were better in CSE group. DPE group had better sacral coverage and less asymmetric blockade. Groups CSE and DPE had superior maternal and surgeon satisfaction scores in comparison to group E. Both groups E and DPE provided analgesia with minimal motor blockade and ambulation. [ABSTRACT FROM AUTHOR]

Purpose: Spinal cord stimulation (SCS) is a highly effective treatment for chronic neuropathic pain. Despite recent advances in technology, treatment gaps remain. A small SCS system with a miniaturized implantable pulse generator (micro-IPG; < 1.5 cm3 in volume) and an externally worn power source may be preferred by patients who do not want a large, implanted battery. We report here the long-term outcomes from the first-in-human study evaluating the safety and performance of a new neurostimulation system.Patients and Methods: This was a prospective, multi-center, open-label, single-arm study to evaluate this SCS system, in the treatment of chronic, intractable leg and low-back pain. Consented subjects who passed screening continued on to the long-term phase of the study. One-year, patient-reported outcomes (PRO's) such as pain (Numeric Rating Scale, NRS), functional disability, quality of life, and mood were captured.Results: Twenty-six (26) evaluable subjects with permanent implants were included in this analysis. The average leg pain NRS score decreased from 6.8 ± 1.2 at baseline to 1.1 ± 1.2 at the end of the study (p < 0.001), while the average low-back pain NRS score decreased from 6.8 ± 1.2 to 1.5 ± 1.2 (p < 0.001). The responder rate (proportion with ≥ 50% pain relief) was 91% in the leg(s) and 82% in the low back. There were significant improvements in functional disability (Oswestry Disability Index) and in mood (Beck Depression Inventory), demonstrating a 46% and 62% improvement, respectively (p < 0.001). Eleven-point Likert scales demonstrated the wearable to be very comfortable and very easy to use.Conclusion: There were considerable challenges conducting a clinical study during the COVID-19 pandemic, such as missed study programming visits. Nevertheless, subjects had significant PRO improvements through 1-year. The small size of the implanted device, along with a proprietary waveform, may allow for improved SCS outcomes and a drop in incidence of IPG-pocket pain.Plain Language Summary: Chronic neuropathic pain of the low back and legs is a common affliction. Unfortunately, many of these cases are medically intractable and require more invasive treatments. One such treatment is spinal cord stimulation, in which very small, cylindrical electrodes (leads) are percutaneously introduced into the epidural space where they deliver mild electrical pulses to the spinal cord thereby blocking the pain signals from reaching the brain. Among the shortcomings of this general approach is the bulkiness of the implanted battery and electronics that power the electrodes, which can be as large as 44 cm3 in volume. We report here the results of a study employing a very small spinal cord stimulator implant (< 1.5 cm3 in volume) that is externally powered by a wearable device. The results of this multi-center, prospective, open-label, single-arm study are reported here. Following 1 year of spinal cord stimulation therapy, the average pain reduction was 79% in the legs and 81% in the back, both of which were statistically significant at the p< 0.001 level. At the same study endpoint, patient-reported outcomes demonstrated significant improvements in functional disability (p < 0.001) and mood (p < 0.05). These outcomes are comparable to many of the other larger, fully implantable systems. [ABSTRACT FROM AUTHOR]

Caudal epidural block is a simple and safe technique with a low complication rate commonly used for pediatric anesthesia and treatment of chronic lumbosacral pain. However, it is not exempt from some risks that, although infrequent, should be known. We describe the case of a 48-year-old female with chronic lumbosacral radicular pain who underwent caudal epidural infiltration. During the withdrawal of the catheter, accidental breakage and retention of a fragment at the level of the anterior epidural space of the sacrum occurred. We choose to have an expectant management with regular controls and a radiological lumbosacral computed tomography (CT) scan. Since the catheter was placed under sterile conditions, no prophylactic antibiotic treatment was considered. The patient showed no adverse events during the 6 months following catheter rupture. To our knowledge, there are no reports of epidural catheter breakage at the caudal level in adults. This is why there is no standardized protocol on how to proceed in these cases, and the handling of this situation must be individualized. [ABSTRACT FROM AUTHOR]

Background: CSF fluid leakage due to damage to the dura mater layer is a rare complication of spine surgery. One of the methods to control symptoms in case of failure of supportive treatments is to inject the patient's blood into the epidural space at the levels adjacent to the leakage site Case Presentation: The patient is a 56-year-old woman, who suffered a CSF leak after laminectomy of the fourth vertebra. Due to the presence of a surgical incision at the leak site, the lack of access to the epidural space from that location, and disturbing symptoms, caudal space was chosen. Method, In a prone position with vital signs monitoring, proper sedation, and local anesthetic injection, in completely sterile conditions, with the help of fluoroscopy, through the sacral hiatus Tuohy 18G needle entered into the epidural space and contrast material was injected, the exact location of the needle in the AP-Lateral view ensured, the epidural catheter was measured from the skin to the approximate location of the L4 vertebra and about 20 cm of the catheter was shortened to facilitate blood injection then the catheter was inserted into the epidural space again, the contrast material was injected into the catheter and the diffusion of the contrast material was seen at the level of the fifth vertebra. Then, in the cubital vein, a 16G IV cannula was inserted under completely sterile conditions. Then 20 cc of blood was taken from the patient's peripheral vein and slowly injected into the catheter. After the injection of 17 cc, the patient felt heaviness and pain in the lower back, the blood injection was stopped and the catheter and needle were removed. The needle insertion site was bandaged and the patient with stable vital signs and full consciousness was transferred to the recovery room and then to the ward. Conclusion: when it is not possible to access the epidural space via the interlaminar approach, the caudal space by inserting a catheter can be a good alternative.

Background: Epidural catheter placement is difficult techniques to acquire, with a success rate <60% at first attempt, and an overall success rate of nearly 90%. Availability of advanced techniques at low resource, high load settings is seldom possible making it no less than a blind technique. Hence thorough knowledge of influencing factors and ability to predict depth becomes an essential skill for an anesthetist. Objective: To study correlation of skin to lumbar epidural depth with demographic and anthropometric factors Methods: Hospital based cross-sectional study was carried among 40 cases posted for elective surgeries requiring lumbar epidural anesthesia. Age, sex, height, weight, Body mass index (BMI) were recorded. After ensuring correct position of needle by loss of resistance to air and hanging drop method, epidural catheter was threaded leaving nearly 6 cm inside epidural space. Depth at which epidural space achieved was calculated by calculating length between skin and end of needle at hub and in turn subtracting it from 8 cm. Results: There was significant correlation between weight, BMI and epidural depth. Age, sex and height were not correlated. From multiple linear regression model it can be stated that sex and weight significantly predicted epidural depth. With increase in 1 kg body weight, the epidural depth increased by 0.036 cm. Males have on an average 0.361 cm more depth compared to females. Conclusion: Skin to epidural depth depends on weight and sex. Formula derived also helps to roughly determine depth and achieve successful placement of catheter in fewer attempts. [ABSTRACT FROM AUTHOR]

Background: Spontaneous spinal epidural hematoma is an infrequent yet potentially debilitating condition characterized by blood accumulation in the epidural space, with only 300 documented cases globally. Although the exact etiology of spontaneous spinal epidural hematoma remains poorly understood, theories suggest arteriovenous malformations, rupture of epidural vessels, or epidural veins as possible causes. Case presentation: This study presents a 58-year-old Malay woman patient from Singapore with well-controlled hypertension, hyperlipidemia, type II diabetes mellitus, and microscopic hematuria. Despite a prior cystoscopy revealing no abnormalities, she presented to the emergency department with sudden-onset back pain, weakness, and numbness in both lower limbs. Rapidly progressing symptoms prompted imaging, leading to the diagnosis of a spinal epidural hematoma from thoracic (T) 9 to lumbar (L) 1. Prompt decompressive surgery was performed, and the patient is currently undergoing postoperative rehabilitation for paralysis. Conclusion: This case emphasizes the severity and life-altering consequences of spontaneous spinal epidural hematomas. Despite various proposed causative factors, a definitive consensus remains elusive in current literature. Consequently, maintaining a low threshold of suspicion for patients with similar presentations is crucial. The findings underscore the urgent need for swift evaluation and surgical intervention in cases of acute paraplegia. [ABSTRACT FROM AUTHOR]

Background: CSF fluid leakage due to damage to the dura mater layer is a rare complication of spine surgery. One of the methods to control symptoms in case of failure of supportive treatments is to inject the patient's blood into the epidural space at the levels adjacent to the leakage site Case Presentation: The patient is a 56-year-old woman, who suffered a CSF leak after laminectomy of the fourth vertebra. Due to the presence of a surgical incision at the leak site, the lack of access to the epidural space from that location, and disturbing symptoms, caudal space was chosen. Method, In a prone position with vital signs monitoring, proper sedation, and local anesthetic injection, in completely sterile conditions, with the help of fluoroscopy, through the sacral hiatus Tuohy 18G needle entered into the epidural space and contrast material was injected, the exact location of the needle in the AP-Lateral view ensured, the epidural catheter was measured from the skin to the approximate location of the L4 vertebra and about 20 cm of the catheter was shortened to facilitate blood injection then the catheter was inserted into the epidural space again, the contrast material was injected into the catheter and the diffusion of the contrast material was seen at the level of the fifth vertebra. Then, in the cubital vein, a 16G IV cannula was inserted under completely sterile conditions. Then 20 cc of blood was taken from the patient's peripheral vein and slowly injected into the catheter. After the injection of 17 cc, the patient felt heaviness and pain in the lower back, the blood injection was stopped and the catheter and needle were removed. The needle insertion site was bandaged and the patient with stable vital signs and full consciousness was transferred to the recovery room and then to the ward. Conclusion: when it is not possible to access the epidural space via the interlaminar approach, the caudal space by inserting a catheter can be a good alternative. [ABSTRACT FROM AUTHOR]

Introduction: Epidural electrical stimulation (EES) has been shown to improve motor dysfunction after spinal cord injury (SCI) by activating residual locomotor neural networks. However, the stimulation current often spreads excessively, leading to activation of non-target muscles and reducing the accuracy of stimulation regulation. Objectives: Near-infrared nerve stimulation (nINS) was combined with EES to explore its regulatory effect on lower limb muscle activity in spinal-cordtransected rats. Methods: In this study, stimulation electrodes were implanted into the rats' L3-L6 spinal cord segment with T8 cord transected. Firstly, a series of EES parameters (0.2-0.6 mA and 20-60 Hz) were tested to determine those that specifically regulate the tibialis anterior (TA) and medial gastrocnemius (MG). Subsequently, to determine the effect of combined optical and electrical stimulation, near-infrared laser with a wavelength of 808 nm was used to irradiate the L3-L6 spinal cord segment while EES was performed. The amplitude of electromyography (EMG), the specific activation intensity of the target muscle, and the minimum stimulus current intensity to induce joint movement (motor threshold) under a series of optical stimulation parameters (power: 0.0-2.0 W; pulse width: 0-10 ms) were investigated and analyzed. Results: EES stimulation with 40 Hz at the L3 and L6 spinal cord segments specifically activated TA and MG, respectively. High stimulation intensity (>2 x motor threshold) activated non-target muscles, while low stimulation frequency (<20 Hz) produced intermittent contraction. Compared to electrical stimulation alone (0.577 ± 0.081 mV), the combined stimulation strategy could induce stronger EMG amplitude of MG (1.426 ± 0.365 mV) after spinal cord injury (p < 0.01). The combined application of nINS effectively decreased the EESinduced motor threshold of MG (from 0.237 ± 0.001 mA to 0.166 ± 0.028 mA, p < 0.001). Additionally, the pulse width (PW) of nINS had a slight impact on the regulation of muscle activity. The EMG amplitude of MG only increased by ~70% (from 3.978 ± 0.240 mV to 6.753 ± 0.263 mV) when the PW increased by 10-fold (from 1 to 10 ms). Conclusion: The study demonstrates the feasibility of epidural combined electrical and optical stimulation for highly specific regulation of muscle activity after SCI, and provides a new strategy for improving motor dysfunction caused by SCI. [ABSTRACT FROM AUTHOR]

Clinically significant motor block may occur after repeated bolus doses or continuous infusion of local anaesthetic for a long time into epidural space. Extensive motor blockade may impair maternal expulsive efforts during the second stage of labour and increase the likelihood of instrumental delivery. Patients were randomized into two groups using computer generated random numbers: Group A: Received 0.1% Ropivacaine with fentanyl 2µg/ml in 10 ml total volume. Group B: Received 0.1% Ropivacaine with fentanyl 2µg/ml and neostigmine 500µg in 10 ml total volume. The APGAR score of newborn at 1 min in both group A and group B was statistically significant (p value 0.044), while the APGAR score of newborn at 5min in both groups A and B was statistically insignificant (p value 0.136).4% patients in group A and 20% patients in group B had an excellent satisfaction with regard to their experience of birth process and labour analgesia, which was statistically significant (p value 0.012). [ABSTRACT FROM AUTHOR]

Background: The role of neurostimulation-aided cervical epidural anesthesia (CEA) in shoulder surgery has been described in the literature. The use of nerve stimulators and the infusion of local anesthetic (LA) in the cervical epidural space has also been mentioned. Epidural needle rotation prior to insertion of the catheter is not described, and it is not clear if general anesthesia was administered in these cases. Case presentation: In this case series, we performed CEA at the level of C7-T1 in 12 patients undergoing various surgeries on the proximal open shoulder and mid humerus after informed consent. Ipsilateral motor responses elicited by continuous electrical stimulation were used to identify lateralization of the epidural catheter tip. The placement of catheters was confirmed under an intraoperative image intensifier. Using the median approach at the level of C7-T1, an ipsilateral twitch was noted in all patients. Neurostimulation persisted with an advancement of stimulating catheter 3–4 cm in the cervical epidural space in all patients. A cervical radiograph confirmed the placement of an ipsilateral catheter and contrast injection there upon revealing the spread of the LA agent. All patients had successful awake shoulder and mid-humerus surgeries under sole cervical epidural anesthesia as evidenced by the absence of pain response at the surgical incision. Conclusions: Ipsilateral CEA can be offered for unilateral upper limb surgeries. Low volumes of LA can be injected after precise placement of the tip of the catheter corresponding to the level of surgical incision. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare the intra and postoperative analgesic effects of sacrococcygeal epidural levobupivacaine with those of lumbosacral levobupivacaine in feline ovariohysterectomy. Thirty-six cats were premedicated with intramuscular acepromazine (0.05 mg/kg) and meperidine (6 mg/kg). Anesthesia was induced with intravenous propofol and maintained with isoflurane in oxygen. The cats were randomly assigned one of the three treatments receiving 0.33% levobupivacaine (0.3 mL/kg) into the sacrococcygeal (S-C group, n=12) or lumbosacral (L-S group, n=12) epidural space, or the same volume of 0.9% saline solution into one of the epidural approaches (Control group, n=12). Intraoperatively, cardiorespiratory variables, end-tidal isoflurane concentration (FE'ISO), and fentanyl requirements were recorded. Postoperative pain was assessed by the UNESP (Universidade Estadual Paulista)-Botucatu multidimensional composite pain scale and the Glasgow feline composite measure pain scale up to 8 hr post-extubation. Morphine was administered as rescue analgesia. Overall FE'ISO and fentanyl requirements were lower in the L-S and S-C compared to the Control (P=0.002-0.048, respectively). There was no significant difference in the cardiorespiratory variables during anesthesia, postoperative pain and rescue analgesia among groups. The time to standing after anesthesia was prolonged in the L-S and S-C groups than in the Control (P<0.001). Lumbosacral and sacrococcygeal epidural levobupivacaine resulted in similar decreases in isoflurane requirements and intraoperative fentanyl supplementation in the cats, with no postoperative benefits. [ABSTRACT FROM AUTHOR]

Background: Neuraxial ultrasound (US), a newer modality, can be used for neuraxial imaging, helping in visualizing and aiding in epidural space catheterization. The aim of this study was to evaluate the efficacy of the US for cervical epidural access and to determine the failure rate and complication associated with this technique. Methods: A prospective single-arm pilot study was conducted on 21 participants. The neuraxial US image quality assessment by Ultrasound Visibility Score (UVS), epidural space depth measurement by US and by conventional loss of resistance (LOR) technique, and post-procedure epidural catheter confirmation by real-time US were the study parameters. Any procedural complications or failure rate were recorded. The Kolmogorov–Smirnov test, paired-samples t-test, and Chi-square test were used for the statistical comparison. Results: The pre-procedural UVS by the transverse interlaminar view (x/21) was 2.81 ± 1.94 and by the oblique paramedian sagittal view was 16.66 ± 2.39 with UVS being best in the paramedian oblique sagittal view (P- value < 0.05). The comparison of depth of the epidural space identified by USG and that by the LOR technique was statistically insignificant (P = 0.83). The average puncture attempts were 1.1 ± 0.3. Post-procedure US epidural catheter confirmation score (x/3) was 1.44 ± 0.44 with either epidural space expansion or microbubbles seen or both. Conclusion: The pilot study has successfully demonstrated the implication of US for visualizing and aiding in epidural space catheterization. Also, the failure rate and procedural complications were drastically minimized with the help of US as compared to the traditional blind technique. [ABSTRACT FROM AUTHOR]

Purpose: Failed Back Surgery Syndrome (FBSS) occurs in 10-40% of patients treated surgically due to disk herniation (DH). There are several factors that can cause a predisposition to FBSS, but the exact pathomechanism has not been elucidated. The aim of this study was to investigate Metalloproteinase-2 (MMP-2) and Tissue Inhibitor of Metalloproteinase-2 (TIMP-2) activities in a homogeneous group of FBSS patients with epidural fibrosis in comparison to its activity in patients with surgically treated DH. Methods: DH, FBSS, and control (CG) groups consisted of 30 subjects. The patients were assessed clinically by the Numerical Rating Scale (NRS), McGill Pain Questionnaire (SF -MPQ), Oswestry Disability Index (ODI), and Beck Depression Inventory (BDI). Serum concentrations of MMP-2 and TIMP-2 were measured by using the immunoenzymatic method. Results: There was a significantly higher MMP-2 expression (medians: 4797.49 vs. 2656.65; p <0.0001) and TIMP-2 concentration (medians: 166.40 vs. 109.60; p < 0.0001) in the DH compared to the CG. Significantly higher MMP-2 expression (4219.95 vs. 2656.65; p <0.0001) and TIMP-2 concentration (medians: 150.17 vs. 109.60; p = 0.0003) were also found in the FBSS compared to the CG. The activity of MMP-2, measured as MMP-2/TIMP-2, did not significantly change between the DH, FBSS, and CG. MMP2 expression (p <0.0001) and TIMP-2 concentration (p <0.0001) were significantly higher in the DH than FBSS. Conclusion: Results indicate the presence of a contribution of MMP-2 and TIMP- 2 in DH and FBSS. Unchanged activity of MMP-2 can indicate an insufficiency in the MMP-2 repair system in both diseases. Lower MMP-2 expression and TIMP-2 concentration in the FBSS group can reflect the chronicity of the process. [ABSTRACT FROM AUTHOR]

In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates. [ABSTRACT FROM AUTHOR]

The article discusses Hirayama Disease, a rare myelopathy that affects the cervical spinal cord and causes muscle weakness and atrophy in one hand and forearm. The disease is characterized by asymmetric growth and does not involve sensory loss. The article emphasizes the role of neuroradiologists in confirming the diagnosis through imaging techniques such as magnetic resonance imaging (MRI) and correlating the findings with electromyography. Early diagnosis and intervention are crucial in halting the progression of the disease, although there is currently no consensus on treatment. [Extracted from the article]

Objective: Challenging differential diagnosis. Background: Thoracic epidural analgesia is a commonly applied technique for perioperative pain management in major thoraco-abdominal surgery, but is complicated by high failure rates. The epidural electrical stimulation test (EEST) or "Tsui test" is a safe and effective method whereby low electrical current is used to confirm correct epidural catheter position and decrease the variability in analgesic effectiveness of the neuraxial technique. Case Report: We present the case of a 61-year-old woman with no prior cardiac or pulmonary comorbidities who was scheduled to undergo a ventral and parastomal hernia repair with component separation. The patient was offered a low thoracic epidural for perioperative analgesia. Technical aspects of the siting of the epidural catheter were uneventful and a confirmatory Tsui test was planned. At the initiation of electrical stimulation via the epidural catheter to confirm optimal catheter positioning, the patient experienced symptomatic bradycardia and hemodynamic instability that persisted despite terminating the electrical stimulation, and required pharmacologic intervention. Conclusions: This report describes a rare case of vasovagal pre-syncope associated with the EEST or Tsui test. Although vasovagal reactions can be commonly associated with neuraxial procedures due to augmented venous return or severe emotional stress, we raise the possibility that through direct electrical stimulation in the epidural space, the EEST may have the potential to trigger such a physiologic response. [ABSTRACT FROM AUTHOR]

Epidural administration is the leading therapeutic option for the management of pain associated with lumbar spinal stenosis (LSS), which is characterized by compression of the nerve root due to narrowing of the spinal canal. Corticosteroids are effective in alleviating LSS-related pain but can lead to complications with long-term use. Recent studies have focused on identifying promising medications administered epidurally to affected spinal regions. In this study, we aimed to investigate the effectiveness of harpagoside (HAS) as an epidural medication in rats with LSS. HAS at various concentrations was effective for neuroprotection against ferrous sulfate damage and consequent promotion of axonal outgrowth in primary spinal cord neurons. When two concentrations of HAS (100 and 200 μg/kg) were administered to the rat LSS model via the epidural space once a day for 4 weeks, the inflammatory responses around the silicone block used for LSS were substantially reduced. Consistently, pain-related factors were significantly suppressed by the epidural administration of HAS. The motor functions of rats with LSS significantly improved. These findings suggest that targeted delivery of HAS directly to the affected area via epidural injection holds promise as a potential treatment option for the recovery of patients with LSS. [ABSTRACT FROM AUTHOR]

The article describes the pathologies of spinal epidural lesions encountered on magnetic resonance imaging classified according different causes. Degenerative causes include disc sequestration, facet joint osteoarthritis and synovial cysts, and ossification of the posterior longitudinal ligament. Infection or inflammatory causes include spinal epidural abscess, tuberculosis spondylitis and immunoglobulin G4-related disease. Other causes are trauma, vascular, and spinal epidural neoplasms.

Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA. [ABSTRACT FROM AUTHOR]

Background and Purpose: Optimal antibiotic prophylaxis is crucial to prevent postoperative infection in spinal surgery. Sufficient time above the minimal inhibitory concentration (fT > MIC) for relevant bacteria in target tissues is required for cefuroxime. We assessed cefuroxime concentrations and fT > MIC of 4 μg·ml−1 for Staphylococcus aureus in the intrathecal (spinal cord and cerebrospinal fluid, CSF) and extrathecal (epidural space) compartments of the lumbar spine. Experimental Approach: Eight female pigs were anaesthetized and laminectomized at L3–L4. Microdialysis catheters were placed for sampling in the spinal cord, CSF, and epidural space. A single dose of 1500 mg cefuroxime was administered intravenously over 10 min. Microdialysates and plasma were obtained continuously during 8 h. Cefuroxime concentrations were determined by ultra‐high‐performance liquid chromatography. Key Results: Mean fT > MIC (4 μg·ml−1) was 58 min in the spinal cord, 0 min in the CSF, 115 min in the epidural space, and 123 min in plasma. Tissue penetration was 32% in the spinal cord, 7% in the CSF, and 63% in the epidural space. Conclusion and Implications: fT > MIC (4 μg·ml−1) and tissue penetration for cefuroxime were lower in the intrathecal compartments (spinal cord and CSF) than in the extrathecal compartment (epidural space) and plasma, suggesting a significant effect of the blood–brain barrier. In terms of fT > MIC, a single dose of 1500 mg cefuroxime seems inadequate to prevent intrathecal infections related to spinal surgery for bacteria presenting with a MIC target of 4 μg· ml−1 or above. [ABSTRACT FROM AUTHOR]

Lumbar puncture is a minimally invasive procedure that utilizes a spinal needle to puncture the lumbar epidural space to take a sample from the cerebrospinal fluid or inject drugs for diagnostic and therapeutic purposes. Physicians rely on their expertise to localize epidural space. Due to its critical procedure, the failure rate can reach up to 28%. Hence, a high level of experience and caution is required to correctly insert the needle without puncturing the dura mater, which is a fibrous layer protecting the spinal cord. Failure of spinal anesthesia is, in some cases, related to faulty needle placement techniques since it is blindly inserted. Therefore, advanced techniques for localization of the epidural space are essential to avoid any possible side effects. As for epidural space localization, various ideas were carried out over recent years to provide accurate identification of the epidural space. Subsequently, several methodologies based on mechanical and optical schemes have been proposed. Several research groups worked from different aspects of the problem, namely, the clinical and engineering sides. Hence, the main goal of this paper is to review this research with the aim of remedying the gap between the clinical side of the problem and the engineering side by examining the main techniques in building sensors for such purposes. This manuscript provides an understanding of the clinical needs of spinal needles from an anatomical point of view. Most importantly, it discusses the mechanical and optical approaches in designing and building sensors to guide spinal needles. Finally, the standards that must be followed in building smart spinal needles for approval procedures are also presented, along with some insight into future directions. [ABSTRACT FROM AUTHOR]

In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates.

In this article, we have developed a high-accuracy and low-cost smart epidural needle system. It is based on force puncture sensing and guidance mechanism that enhances success rate and reduces the risks of accidental punctures. The design incorporates a subminiature load cell embedded in the spinal needle which measures the force exerted by each tissue layer on the needle tip. By identifying the force range for each layer, the needle can be safely inserted and accurately reach the targeted area. Accordingly, a classifier model for this identification process was developed and tested. More than a hundred experimental readings were collected and used for training the developed classifier model of the system. Furthermore, a phantom with six spinal cord layers, that mimics the properties of different spinal tissue layers, was built and utilized for testing purposes. The experimental results of the developed smart spinal epidural needle system highlight the ability of the system to identify the needle location with an accuracy of about 86.7%. Hence, it provides promising outcomes and a feasible solution for the future development of spinal epidural needle systems.

Spinal epidural fibrosis is one of the typical features attributable to failed back surgery syndrome, with excessive scar development in the dura and nerve roots. The microRNA-29 family (miR-29s) has been found to act as a fibrogenesis-inhibitory factor that reduces fibrotic matrix overproduction in various tissues. However, the mechanistic basis of miRNA-29a underlying the overabundant fibrotic matrix synthesis in spinal epidural scars post-laminectomy remained elusive. This study revealed that miR-29a attenuated lumbar laminectomy-induced fibrogenic activity, and epidural fibrotic matrix formation was significantly lessened in the transgenic mice (miR-29aTg) as compared with wild-type mice (WT). Moreover, miR-29aTg limits laminectomy-induced damage and has also been demonstrated to detect walking patterns, footprint distribution, and moving activity. Immunohistochemistry staining of epidural tissue showed that miR-29aTg was a remarkably weak signal of IL-6, TGF-β1, and DNA methyltransferase marker, Dnmt3b, compared to the wild-type mice. Taken together, these results have further strengthened the evidence that miR-29a epigenetic regulation reduces fibrotic matrix formation and spinal epidural fibrotic activity in surgery scars to preserve the integrity of the spinal cord core. This study elucidates and highlights the molecular mechanisms that reduce the incidence of spinal epidural fibrosis, eliminating the risk of gait abnormalities and pain associated with laminectomy. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to compare the actual needle depth measured during cervical epidural block (CEB) with the predicted needle depth measured through a cervical flexion x-ray image at the paramedian approach. Methods: The study was conducted based on the medical records of patients who underwent CEB at the pain clinic of Haeundae Paik Hospital. The actual needle distance (AD) was recorded after each successful CEB. The distance from the spinolaminar line to the skin, predicted median depth (PMD), was measured using lateral x-ray images. The medial to lateral distance (MLD), which is the distance from the midline of the spine to the needle insertion point, was measured using anteroposterior (AP) x-rays. The predicted paramedian depth (PPD) was calculated using the Pythagorean formula. The PMD represents the expected depth of the median approach, while the PPD represents the expected depth of the paramedian approach. The PMD, PPD, and AD were compared with each other. Results: Concordance correlation coefficient (CCC) and Bland-Altman analysis were obtained for PMD and PPD. The CCC value of PMD was measured as 0.829, and the CCC value of PPD was measured as 0.830. In the Bland-Altman analysis, PPD was measured at − 0.13 ± 8.37 mm, and PMD was measured at 1.29 ± 8.38 mm. Conclusion: When performing CEB through the paramedian approach, the depth can be predicted using a cervical flexion x-ray. At this time, the PMD can also be used to predict the depth during the paramedian approach. [ABSTRACT FROM AUTHOR]

Background and Aims: Epidural blood patch (EBP) is performed by injecting autologous blood into the epidural space using a Tuohy needle. Certain clinical scenarios mandate an epidural catheter (EC)-assisted EBP. Collecting blood in a 20-ml versus 5-ml syringe appears to influence the quality of the clot. This in vitro study compared the techniques of performing the EC-assisted EBP using 20-ml versus 5-ml syringe on clotting time (CT), clot retraction (CR) and haemolysis. Methods: This in vitro study was performed in a haematology laboratory. Five consented adult healthy male volunteers donated blood. In the 5-ml syringe technique, blood was injected through an EC, and as it flowed out of the tip, it was collected at the beginning and the end of 1 min. With the 20-ml technique, blood was collected at the beginning and end of the first, second and third minute. The samples were tested for CT, CR and haemolysis by measuring the plasma-free haemoglobin (PFHb). Results: Five injections were made using a 5-ml syringe, and another five with a 20-ml syringe. Injection time was shorter in the 5-ml technique (80.80 ± 5.89 vs. 272 ± 28.4 s, P < 0.0001). With the 20-ml technique, CT progressively increased (>15 min), whereas, with the 5-ml syringe, the CT was normal. Both techniques caused mild, insignificant haemolysis (PFHb >0.005 g/dl), without affecting the quality of CR. Conclusion: EC-assisted EBP using a 5-ml syringe technique shortens the injection time and deposits fresh blood quickly without affecting CT and CR. [ABSTRACT FROM AUTHOR]

Background and Objectives: The analgesic effectiveness of epidural adhesiolysis may be influenced by morphological changes in the paraspinal muscles, particularly in elderly patients. The objective of this study was to assess whether the cross-sectional area or fatty infiltration of the paraspinal muscles impacts the treatment outcomes of epidural adhesiolysis. Materials and Methods: The analysis included a total of 183 patients with degenerative lumbar disease who underwent epidural adhesiolysis. Good analgesia was defined as a reduction in pain score of ≥30% at the 6-month follow up. We measured the cross-sectional area and fatty infiltration rate of the paraspinal muscles and divided the study population into age groups (≥65 years and <65 years). Variables were compared between the good and poor analgesia groups. Results: The results revealed that elderly patients experienced poorer analgesic outcomes as the rate of fatty infiltration in the paraspinal muscles increased (p = 0.029), predominantly in female patients. However, there was no correlation between the cross-sectional area and the analgesic outcome in patients younger than or older than 65 years (p = 0.397 and p = 0.349, respectively). Multivariable logistic regression analysis indicated that baseline pain scores < 7 (Odds Ratio (OR) = 4.039, 95% Confidence Interval (CI) = 1.594–10.233, p = 0.003), spondylolisthesis (OR = 4.074, 95% CI = 1.144–14.511, p = 0.030), and ≥ 50% fatty infiltration of the paraspinal muscles (OR = 6.576, 95% CI = 1.300–33.268, p = 0.023) were significantly associated with poor outcomes after adhesiolysis in elderly patients. Conclusions: Fatty degeneration of paraspinal muscles is correlated with inferior analgesic outcomes following epidural adhesiolysis in elderly patients, but not in young and middle-aged patients. The cross-sectional area of the paraspinal muscles is not associated with pain relief after the procedure. [ABSTRACT FROM AUTHOR]

Background: This study used an epidural anesthesia practice kit (model) to evaluate the accuracy of epidural anesthesia using standard techniques (blind) and augmented/mixed reality technology and whether visualization using augmented/mixed reality technology would facilitate epidural anesthesia. Methods: This study was conducted at the Yamagata University Hospital (Yamagata, Japan) between February and June 2022. Thirty medical students with no experience in epidural anesthesia were randomly divided into augmented reality (-), augmented reality (+), and semi-augmented reality groups, with 10 students in each group. Epidural anesthesia was performed using the paramedian approach with an epidural anesthesia practice kit. The augmented reality (-) group performed epidural anesthesia without HoloLens2Ⓡ and the augmented reality (+) group with HoloLens2Ⓡ. The semi-augmented reality group performed epidural anesthesia without HoloLens2Ⓡ after 30 s of image construction of the spine using HoloLens2Ⓡ. The epidural space puncture point distance between the ideal insertion needle and participant's insertion needle was compared. Results: Four medical students in the augmented reality (-), zero in the augmented reality (+), and one in the semi-augmented reality groups failed to insert the needle into the epidural space. The epidural space puncture point distance for the augmented reality (-), augmented reality (+), and semi-augmented reality groups were 8.7 (5.7–14.3) mm, 3.5 (1.8–8.0) mm (P = 0.017), and 4.9 (3.2–5.9) mm (P = 0.027), respectively; a significant difference was observed between the two groups. Conclusions: Augmented/mixed reality technology has the potential to contribute significantly to the improvement of epidural anesthesia techniques. [ABSTRACT FROM AUTHOR]

Characterization of inter-regional interactions in brain is essential for understanding the mechanism relevant to normal brain function and neurological disease. The recently developed flexible micro (μ)-electrocorticography (μECoG) device is one prominent method used to examine large-scale cortical activity across multiple regions. The sheet-shaped μECoG electrodes arrays can be placed on a relatively wide area of cortical surface beneath the skull by inserting the device into the space between skull and brain. Although rats and mice are useful tools for neuroscience, current μECoG recording methods in these animals are limited to the parietal region of cerebral cortex. Recording cortical activity from the temporal region of cortex in mice has proven difficult because of surgical barriers created by the skull and surrounding temporalis muscle anatomy. Here, we developed a sheet-shaped 64-channel μECoG device that allows access to the mouse temporal cortex, and we determined the factor determining the appropriate bending stiffness for the μECoG electrode array. We also established a surgical technique to implant the electrode arrays into the epidural space over a wide area of cerebral cortex covering from the barrel field to olfactory (piriform) cortex, which is the deepest region of the cerebral cortex. Using histology and computed tomography (CT) images, we confirmed that the tip of the μECoG device reached to the most ventral part of cerebral cortex without causing noticeable damage to the brain surface. Moreover, the device simultaneously recorded somatosensory and odor stimulus-evoked neural activity from dorsal and ventral parts of cerebral cortex in awake and anesthetized mice. These data indicate that our μECoG device and surgical techniques enable the recording of large-scale cortical activity from the parietal to temporal cortex in mice, including somatosensory and olfactory cortices. This system will provide more opportunities for the investigation of physiological functions from wider areas of the mouse cerebral cortex than those currently available with existing ECoG techniques. [ABSTRACT FROM AUTHOR]