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Dawood Sayed,1 Timothy R Deer,2,3 Vinicius Tieppo Francio,1 Christopher M Lam,1 Kamil Sochacki,4 Nasir Hussain,5 Tristan E Weaver,5 Jay Karri,6,7 Vwaire Orhurhu,8,9 Natalie Holmes Strand,10 Jacqueline Soicher Weisbein,11 Jonathan M Hagedorn,12 Ryan S D’Souza,12 Ryan R Budwany,2 Ahish Chitneni,13 Kasra Amirdelfan,14 Michael J Dorsi,15 Dan TD Nguyen,16 Christopher Bovinet,17 Alaa Abd-Elsayed18 1Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA; 3Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USA; 4Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 5Anesthesiology, the Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; 7Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA; 8Department of Anesthesiology, University of Pittsburgh Medical Center, Williamsport, PA, USA; 9Pain Medicine, MVM Health, East Stroudsburg, PA, USA; 10Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 11Interventional Pain Management, Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 12Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 13Department of Rehabilitation & Regenerative Medicine, New York Presbyterian – Columbia & Cornell, New York, NY, USA; 14Director of Clinical Research, Boomerang Healthcare, Walnut Creek, CA, USA; 15Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; 16Neuroradiology & Pain Solutions of Oklahoma, Edmond, OK, USA; 17The Spine Center of SE Georgia, Brunswick, GA, USA; 18Anesthesiology, University of Wisconsin, Madison, WI, USACorrespondence: Dawood Sayed, Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA, Tel +1 785-550-5800, Email dsayed@kumc.eduAbstract: Clinical management of sacroiliac disease has proven challenging from both diagnostic and therapeutic perspectives. Although it is widely regarded as a common source of low back pain, little consensus exists on the appropriate clinical management of sacroiliac joint pain and dysfunction. Understanding the biomechanics, innervation, and function of this complex load bearing joint is critical to formulating appropriate treatment algorithms for SI joint disorders. ASPN has developed this comprehensive practice guideline to serve as a foundational reference on the appropriate management of SI joint disorders utilizing the best available evidence and serve as a foundational guide for the treatment of adult patients in the United States and globally.Keywords: sacroiliac joint, sacroiliitis, chronic pain, best practices, radiofrequency ablation, sacroiliac joint fusion

Study Design: This study was a retrospective chart review for patients undergoing operative treatment by Dr. Harvey Cushing at the Johns Hopkins Hospital between 1896 and 1912.Objective: To illustrate the early use of peripheral nerve anastomoses for the treatment of postpoliomyelitis paralysis.Summary Of Background Data: At the turn of the 20th century, poliomyelitis was recognized as a disease of neurons; neurological surgeons sought to find a surgical cure for the paralysis occurring after the disease onset. Peripheral nerve anastomoses were an attractive option employed during this time.Methods: Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records of the Johns Hopkins Hospital from 1896 to 1912 were reviewed. A single case of peripheral nerve anastomosis for the treatment of postpoliomyelitis paralysis was selected for further analysis.Results: Cushing performed a multiple peripheral nerve anastomoses in a 3-year-old girl. Although the patient experienced no postoperative complications, there was no improvement in her function at the time of discharge from the hospital, and no long-term follow-up was available.Conclusion: While unsuccessful, Cushing's use of peripheral nerve anastomoses to restore motor function in the pediatric patient described here demonstrates his commitment to pushing the boundaries of neurological surgery at the turn of the 20th century. [ABSTRACT FROM AUTHOR]

Introduction: Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments., Methods: The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria., Results: The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis., Conclusions: There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes., (© 2024. The Author(s).)

Background: The authors describe a rare case of transient postoperative wrist and finger drop following a prone position minimally invasive surgery (MIS) lateral microdiscectomy., Observations: Hand and wrist drop is an unusual complication following spine surgery, especially in prone positioning. The authors' multidisciplinary team assessed a patient with this complication following MIS lateral microdiscectomy. The broad differential diagnosis included radial nerve palsy, C7 radiculopathy, stroke, and spinal cord injury. Given the patient's supinator weakness, intact pronation and wrist flexion, and transient recovery within 4 weeks, the most likely diagnosis was radial nerve neuropraxia secondary to ischemic compression. After careful consideration of the operative environment and anatomical constraints, the patient's blood pressure cuff was found to be the most probable source of compression., Lessons: Blood pressure cuff-induced peripheral nerve injury may be a source of postoperative radial nerve neuropraxia in patients undergoing spine surgery. Careful considerations must be given to the blood pressure cuff location, which should not be placed at the distal end of the humerus due to higher susceptibility of peripheral nerve compression. Spine surgeons should be aware of and appropriately localize postoperative deficits along the neuroaxis, including central versus proximal or distal peripheral injuries, in order to guide appropriate postoperative management.

Objective: We examined the role of intrawound vancomycin powder as prophylaxis against postoperative surgical site infection (SSI) after spinal cord stimulator (SCS) implantation., Methods: We performed a retrospective analysis of 153 consecutive patients who had undergone permanent SCS implantation surgery via open laminectomy between 2014 and 2020. We queried the patients' medical records for patient age, sex, relevant medical history, and whether intrawound vancomycin had been administered. We compared the rates of SSI (primary outcome) and seroma (secondary outcome) within 3 months after surgery between the vancomycin and no-vancomycin groups. Finally, we conducted multivariable logistic regression analyses to identify independent predictors of postoperative SSI or seroma., Results: Of the 153 patients, 59% were women, and the average age was 65.4 years. Overall, 3 patients (2%) had developed an SSI: 2 (methicillin-resistant Staphylococcus aureus, Klebsiella) in the vancomycin group and 1 (methicillin-sensitive Staphylococcus aureus) in the no-vancomycin group. This difference in SSI rate between the 2 groups was insignificant (P = 0.73). Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P = 0.04). Multivariate logistic regression failed to identify any perioperative characteristics as independent predictors of postoperative SSI or seroma., Conclusions: Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation. We failed to draw any definitive conclusions regarding its efficacy, despite referencing the largest single case series of SCS implantation to date., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Propionibacterium acnes (P. acnes), an indolent and slow-growing anaerobic gram-positive bacterium, has largely been known as a commensal organism of the normal skin flora. However, P. acnes is increasingly being recognized as the causative infectious organism complicating craniotomies and shunt insertions. To our knowledge, we present the first reported patient with an intracerebral abscess with dissecting pneumocephalus caused by P. acnes. A 58-year-old woman who was immunocompetent presented 3 weeks after a craniotomy for resection of a glioblastoma multiforme with worsening mental status, lethargy and left hemiparesis. Head CT scans and MRI demonstrated significant vasogenic edema and dissecting pneumocephalus in the resection cavity. A craniotomy was performed and purulent material was found in the subdural space and resection cavity. Cultures were positive for P. acnes. She completed a full course of intravenous antibiotics appropriate for the organism. The infection was eradicated and the patient survived albeit with persistent deficits. This case illustrates the importance of considering an underlying intracerebral abscess in patients with worsening neurological function and pneumocephalus on imaging several weeks after surgery. Our review of the literature underscores the great importance in early recognition and treatment with both surgical debridement and antibiotic therapy in achieving optimal patient recovery., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Transverse myelitis (TM) may result in permanent neurologic dysfunction. Nerve transfers have been developed to restore function after peripheral nerve injury. Here, we present a case report of a child with permanent right upper extremity weakness due to TM that underwent nerve transfers. The following procedures were performed: double fascicle transfer from median nerve and ulnar nerve to the brachialis and biceps branches of the musculocutaneous nerve, spinal accessory to suprascapular nerve, and medial cord to axillary nerve end-to-side neurorraphy. At 22 months, the patient demonstrated excellent recovery of elbow flexion with minimal improvement in shoulder abduction. We propose that the treatment of permanent deficits from TM represents a novel indication for nerve transfers in a subset of patients., (Copyright © 2011 Wiley Periodicals, Inc.)

For evaluation of thoracic outlet syndrome (TOS), 3 Tesla magnetic resonance neurography (MRN) is being increasingly used. The authors report the findings on 3 T MRN with surgical correlation in a rare case of neurologic TOS caused by anomalous costal pseudoarthrosis., (Copyright © 2011 Wiley Periodicals, Inc.)

Wrong-site surgery (WSS) is a rare occurrence that can have devastating consequences for patient care. There are several factors inherent to spine surgery that increase the risk of WSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinicians. The following review discusses important issues that can help prevent WSS during spinal procedures.

Intercostal neuralgia may develop following breast augmentation. The authors describe a woman who suffered 2 years of severe pain associated with cutaneous hypaesthesia in a T3-T5 distribution. Serial, placebo-controlled T3-T5 dorsal root nerve blocks provided temporary pain relief. The patient experienced immediate and lasting pain relief (34 months) following bilateral T3-T5 dorsal rhizotomies. This case provides anecdotal evidence that dorsal rhizotomy is a beneficial intervention for refractory intercostal neuralgia., (Copyright © 2010 Wiley-Liss, Inc.)

Prostatic adenocarcinoma presenting as metastatic disease to the nervous system is a rare pathologic entity and has infrequently been reported over the last several years. Furthermore, although its presentation as chronic subdural hematomas has been repeatedly reported previously in the literature, to our knowledge there is no report of its appearance mimicking an epidural hematoma on noncontrast head CT. Here we describe the clinical presentation, evaluation and surgical intervention of a patient with a dural prostate carcinoma metastasis with chronic subdural hematoma mimicking an epidural hematoma., (Copyright 2010 Elsevier B.V. All rights reserved.)

Object: The aim of this study was to estimate the prevalence of brachial plexus injury (BPI) in pediatric multitrauma patients., Methods: The National Pediatric Trauma Registry was queried using the ICD-9 code 953.4, injury to brachial plexus, to identify cases of BPI. The patient demographics, mechanism of trauma, and associated ICD-9 diagnoses were analyzed., Results: Brachial plexus injuries were identified in 113 (0.1%) of the 103,434 injured children entered in the registry between April 1, 1985, and March 31, 2002. Sixty-nine patients (61%) were male. Injuries were most often caused by motor vehicle accidents involving passengers (36 cases [32%]) or pedestrians (19 cases [17%]). Head injuries were diagnosed in 47% of children and included concussion in 27%, intracranial bleeds in 21%, and skull fractures in 14%. Upper-extremity vascular injury occurred in 16%. The most common musculoskeletal injuries were fractures of the humerus (16%), ribs (16%), clavicle (13%), and scapula (11%). Spinal fractures occurred in 12% of patients, and spinal cord injury occurred in 4%. The Injury Severity Score ranged from 1 to 75, with a mean score of 10, and 6 patients (5%) died as a result of injuries sustained during a traumatic event., Conclusions: Brachial plexus injuries occur in 0.1% of pediatric multitrauma patients. Motor vehicle accidents and pedestrians struck by a motor vehicle are the most common reasons for BPIs in this population. Common associated injuries include head injuries, upper-extremity vascular injuries, and fractures of the spine, humerus, ribs, scapula, and clavicle.

Cervical spondylosis is a common degenerative condition that is a significant cause of morbidity. This review discusses the pathophysiology and natural history of cervical spondylotic myelopathy and focuses on the current literature evaluating the clinical management of these patients.

Peripheral nerve injury may lead to the formation of a painful neuroma. In patients, palpating the tissue overlying a neuroma evokes paraesthesias/dysaesthesias in the distribution of the injured nerve. Previous animal models of neuropathic pain have focused on the mechanical hyperalgesia and allodynia that develops at a location distant from the site of injury and not on the pain from direct stimulation of the neuroma. We describe a new animal model of neuroma pain in which the neuroma was located in a position that is accessible to mechanical testing and outside of the innervation territory of the injured nerve. This allowed testing of pain in response to mechanical stimulation of the neuroma (which we call neuroma tenderness) independent of pain due to mechanical hyperalgesia. In the tibial neuroma transposition (TNT) model, the posterior tibial nerve was ligated and transected in the foot just proximal to the plantar bifurcation. Using a subcutaneous tunnel, the end of the ligated nerve was positioned just superior to the lateral malleolus. Mechanical stimulation of the neuroma produced a profound withdrawal behavior that could be distinguished from the hyperalgesia that developed on the hind paw. The neuroma tenderness (but not the hyperalgesia) was reversed by local lidocaine injection and by proximal transection of the tibial nerve. Afferents originating from the neuroma exhibited spontaneous activity and responses to mechanical stimulation of the neuroma. The TNT model provides a useful tool to investigate the differential mechanisms underlying the neuroma tenderness and mechanical hyperalgesia associated with neuropathic pain.

Use of computed tomography (CT) imaging for evaluation of the cervical spine following blunt trauma is both an efficient and reliable method for detecting injury. As a result, many trauma centers and emergency departments rely exclusively on CT scans to acutely clear the cervical spine of injury. Although quite sensitive for detecting bone injury, CT may be associated with a low sensitivity for detecting herniated discs, injured soft tissue or ligaments, and dynamic instability. In addition, CT-generated artifact may obscure pathological findings. In this case report, we describe the course of a patient whose CT scan harbored CT-generated artifact that suggested traumatic subluxation of the cervical spine. Clinicians should be aware of such artifact and how to recognize it when basing clinical management on such studies.

Objective: To detail a potential complication of the use of vascularized pericranial flaps in the repair of dural defects, namely, flap hypertrophy secondary to venous engorgement., Clinical Presentation: A 23-year-old man with a left parietal lobe hemangiopericytoma underwent a craniotomy for tumor resection. The resultant dural defect was repaired with a vascularized pericranial flap. On postoperative Day 3, the patient developed headache, confusion, aphasia, and right upper extremity apraxia. Imaging revealed an extra-axial collection at the craniotomy site; on reexploration, a swollen, engorged pericranial flap causing mass effect was found., Intervention: The pericranial flap was excised., Conclusion: In this case, hypertrophy of the vascularized pericranial flap is hypothesized to have occurred because of venous congestion, possibly secondary to restriction of venous outflow by the overlying bone flap.

Objective: Spinal cord stimulation, in use for more than 30 years, has evolved into an easily implemented technique involving percutaneous or laminectomy electrode placement. In a randomized comparison of four-contact percutaneous and four-contact insulated laminectomy electrodes placed at the same level in the dorsal, epidural midline, quantitative measures of stimulator performance revealed significant technical advantages for the laminectomy electrodes. Our prospective, randomized, controlled trial compares clinical results in these same patients., Methods: Impartial third parties followed our series of 24 patients with failed back surgery syndrome to gather clinical outcome data. We defined "success" as at least 50% sustained relief of pain and patient satisfaction with the result of treatment., Results: At a mean follow-up of 1.9 years, 10 of 12 patients receiving the laminectomy electrode and 5 of 12 patients receiving the percutaneous electrode reported a successful outcome (P < 0.05). Follow-up at a mean of 2.9 years showed that this result was maintained in 5 of 12 patients with the laminectomy electrode and 3 of 12 with the percutaneous electrode (not statistically significant). Many patients reported improvements in most activities of daily living, and loss of function was rare. In addition, 9 patients with laminectomy electrodes and 4 with percutaneous electrodes reducted or eliminated analgesic intake (P < 0.05), and 2 returned to work. No electrode migration was observed., Conclusion: Laminectomy electrode placement, although more invasive than percutaneous placement, yields significantly better clinical results in patients with failed back surgery syndrome at mean 1.9 years follow-up. In our small sample, however, the statistical significance of this advantage disappeared at mean 2.9 years follow-up.

Object: Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering the limb a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons as to the management of BPIs., Methods: The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians and 49 (39%) participated in the study. The respondents represent 22 different countries and multiple surgical subspecialties. They performed a mean of 33 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, treatment of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal or proximal coaptation during nerve transfer., Conclusions: Experienced peripheral nerve surgeons disagree in important ways as to the management of BPI. The decisions made by the various treating physicians underscore the many areas of disagreement regarding the treatment of BPI, including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, the treatment of neuroma-in-continuity, the choice of nerve transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

Spinal tumors compose a vast heterogeneous group of neoplasms that are classified by origin into vertebral column, spinal canal, or paraspinal region tumors. Tumors with both intraspinal (intracanalicular) and paraspinal (extracanalicular) components that communicate via an intravertebral foramen are defined as "dumbbell tumors." This article focuses on the characteristics of a few types of paraspinal tumors, with special emphasis on the management of nerve sheath dumbbell tumors.

An L5 spinal nerve ligation (SNL) in the rat leads to behavioral signs of mechanical hyperalgesia. Our recent finding that an L5 dorsal root rhizotomy did not alter the mechanical hyperalgesia following an L5 SNL suggests that signals originating from the proximal stump of the injured nerve are not essential. We postulate that Wallerian degeneration of L5 nerve fibers leads to altered properties of adjacent intact nociceptive afferents. To investigate the role of degeneration in sensory versus motor fibers, five injury models were examined concurrently in a blinded fashion. An L5 ganglionectomy produced a selective lesion of sensory fibers. An L5 ventral root rhizotomy produced a selective lesion of motor fibers. The three control lesions included: (1) SNL with L5 dorsal root rhizotomy; (2) L5 dorsal root rhizotomy; and (3) exposure of the L5 roots without transection (sham). Paw withdrawal thresholds to mechanical stimuli were measured at three sites in the rat hindpaw corresponding to the L3, L4, and L5 dermatomes. Both the ganglionectomy and the ventral rhizotomy produced a significant, lasting (>or=20 d) decrease of mechanical withdrawal thresholds that was comparable to that produced by the SNL lesion. The L5 dorsal rhizotomy, by itself, produced a short lasting (

An injury to a peripheral nerve in animals often leads to signs of neuropathic pain including hyperalgesia to heat, cold and mechanical stimuli. The role of injured and intact nerve fibers in mechanical hyperalgesia was evaluated in rats subjected to an L5 spinal nerve ligation-and-cut ('modified SNL lesion'). To assess the contribution of injured afferents, an L5 dorsal rhizotomy was performed immediately before, or 7 days after the modified SNL lesion. To study the role of adjacent intact spinal nerves, an L4 dorsal rhizotomy was performed 7 days after the modified SNL lesion. The up-down method of Dixon (Dixon WJ, Annu Rev Pharmacol Toxicol 1980;20:441-462) was used to measure the paw withdrawal threshold to mechanical stimuli at three sites on the rat hindpaw corresponding to the L3, L4, and L5 dermatomes. We found that the modified SNL lesion produced a significant, lasting (20 days) decrease of the mechanical withdrawal threshold. The severity and duration of mechanical hyperalgesia varied across testing sites. The L5 and L4 dermatome test sites developed the most severe and lasting mechanical hyperalgesia. In contrast, the L3 testing site developed significantly less severe and shorter lasting mechanical hyperalgesia. L5 dorsal rhizotomy, by itself, produced a transient decrease in mechanical withdrawal thresholds. L5 dorsal rhizotomy performed before, or 7 days after, the modified SNL lesion did not prevent or resolve the observed decrease in mechanical withdrawal thresholds. L4 dorsal rhizotomy performed 7 days after the modified SNL lesion resulted in an immediate reversal of mechanical withdrawal thresholds back to baseline values. These results suggest that, after L5 spinal nerve ligation-and-cut, mechanical hyperalgesia develops and persists independent of input from injured afferents. We propose that the Wallerian degeneration that develops after a nerve injury leads to interactions between the degenerating fibers of the injured spinal nerve and the intact fibers of adjacent spinal nerves. This leads to changes in the intact fibers that play a critical role for both initiation and maintenance of mechanical hyperalgesia.