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Huang C, Zhang Y, Diedrich DA, Li J, Luo W, Zhao X, Guo Y, Luo Y, Zhang T, Wang X, Huang W, Xiao Y. A horizontal and perpendicular interlaminar approach for intrathecal nusinersen injection in patients with spinal muscular atrophy and scoliosis: an observational study. Orphanet J Rare Dis 2024; 19:268. [PMID: 39010073 PMCID: PMC11250962 DOI: 10.1186/s13023-024-03278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 07/03/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Lumbar puncture is challenging for patients with scoliosis. Previous ultrasound-assisted techniques for lumbar puncture used the angle of the probe as the needle trajectory; however, reproducing the angle is difficult and increases the number of needle manipulations. In response, we developed a technique that eliminated both the craniocaudal and lateromedial angulation of the needle trajectory to overall improve this technique. We assessed the feasibility and safety of this method in patients with scoliosis and identify factors related to difficult lumbar puncture. METHODS Patients with spinal muscular atrophy and scoliosis who were referred to the anesthesia department for intrathecal nusinersen administrations were included. With a novel approach that utilized patient position and geometry, lumbar puncture was performed under ultrasound guidance. Success rates, performance times and adverse events were recorded. Clinical-demographic and spinal radiographic data pertaining to difficult procedures were analyzed. RESULTS Success was achieved in all 260 (100%) lumbar punctures for 44 patients, with first pass and first attempt success rates of 70% (183/260) and 87% (226/260), respectively. Adverse events were infrequent and benign. Higher BMI, greater skin dural sac depth and smaller interlaminar size might be associated with greater difficulty in lumbar puncture. CONCLUSIONS The novel ultrasound-assisted horizontal and perpendicular interlaminar needle trajectory approach is an effective and safe method for lumbar puncture in patients with spinal deformities. This method can be reliably performed at the bedside and avoids other more typical and complex imaging such as computed tomography guided procedure.
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Affiliation(s)
- Chanyan Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuanjia Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Daniel A Diedrich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jiawen Li
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wei Luo
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuting Guo
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Yijun Luo
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Tao Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xuan Wang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Ying Xiao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Palati R, Lv J, Yu J, He L, Sun Y. Innovative Computed Tomography-Assisted Intrathecal Nusinersen Injection in a Pediatric Patient. Clin Pediatr (Phila) 2024; 63:746-749. [PMID: 37997668 DOI: 10.1177/00099228231210708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
- Reheman Palati
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Jishou Lv
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Jing Yu
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Lei He
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Yan Sun
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
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Wang Z, Feng E, Jiao Y, Zhao J, Chen X, Zhang H, Liang J, Li Z, Cui X, Chen W, Shen J. Unilateral interlaminar fenestration on the convex side provides a reliable access for intrathecal administration of nusinersen in spinal muscular atrophy: a retrospective study. Orphanet J Rare Dis 2023; 18:369. [PMID: 38031122 PMCID: PMC10685557 DOI: 10.1186/s13023-023-02972-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/18/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND As the first gene therapy for spinal muscular atrophy (SMA), nusinersen is supposed to be administrated via intrathecal injection regularly for a lifetime. However, for SMA patients with severe spinal deformities, bony fusion following posterior spinal instrumentation sets great obstacles for the application of nusinersen. Therefore, efforts have been devoted to the exploration of appropriate approach for nusinersen administration. This study aims to evaluate the safety and reliability of unilateral interlaminar fenestration on the convex side during spinal fusion surgery for intrathecal nusinersen injection in SMA. RESULTS SMA patients receiving posterior spinal fusion and interlaminar fenestration in Peking Union Medical College Hospital from January 2020 to October 2021 were retrospectively analyzed. 13 patients were included. Of the 13 patients, 10 were classified into SMA type II and 3 into SMA type III. Distal fusion to pelvis was undertaken in 11 patients; while L5 was selected as the lowest instrumented vertebra in the other 2 patients. All patients received interlaminar fenestration on the convex side only with an area of about 15 mm × 20 mm. Fenestration at L2-L3 level was performed in 6 patients; while L3-L4 level was selected for windowing in the remaining 7 patients. 9 of the 13 patients received lumbar puncture and intrathecal nusinersen administration during the 1-year follow-up, with an accumulative total of 50 times. All injections were performed successfully under ultrasound guidance, with no one transferred to radiographic assistance. No severe complications occurred after injection. CONCLUSIONS In SMA with severe scoliosis planning to receive posterior spinal fusion, unilateral lumbar interlaminar fenestration on the convex side provides a feasible and reliable access for intrathecal nusinersen administration after surgery.
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Affiliation(s)
- Zhen Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Erwei Feng
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yang Jiao
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Junduo Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xin Chen
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Haozhi Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jinqian Liang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zheng Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xulei Cui
- Department of Anesthesiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Weiyun Chen
- Department of Anesthesiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jianxiong Shen
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
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Zhang Y, Zheng K, Liang C, Zheng R, Chen J, Jiang M, Zhou Z, Zhao Y, Rao M, Yang S, Chen W, Liu L. Modified nusinersen intrathecal injection method: inclusion of a septal needle-free closed infusion connector. Front Neurol 2023; 14:1234442. [PMID: 37808480 PMCID: PMC10551161 DOI: 10.3389/fneur.2023.1234442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Objective Nusinersen, an extremely expensive biologic drug (around 100,000 US$ per dose) that needs to be administered intrathecally, is approved for the treatment of 5q-spinal muscular atrophy (SMA). Because of the low muscle tone of the back muscles of pediatric SMA patients, especially type 1 SMA patients, the safe, effective, and fast execution of sheath injection is needed. Therefore, a modified intrathecal injection method was developed accordingly. This paper aims to describe the applicability and safety of this modified method. Methods The modified intrathecal injection method (MIIM) mainly includes a septal needle-free closed infusion connector between the lumbar puncture needle and the syringe, besides the procedures of routine lumbar puncture. Its applicability and safety were evaluated through clinical observation. Results A total of 92 children with SMA have successfully received nusinersen treatment at our hospital using the modified method since 2019 without obvious adverse events related to the modified injection method. Based on the clinical feedback of operators, the advantages of the modified method include successfully injecting the total dose of nusinersen with constant injection rate and a more stable fixation of the puncture needle, as well as making the operator more relaxed. However, compared with the routine method, the procedure of the modified method has additional steps. Conclusion The modified intrathecal injection method is an effective and safe method to inject nusinersen when weighing the pros and cons, and it may also be used for administering intrathecal injections of other expensive medicines or for patients with other strict requirements for intrathecal injection.
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Affiliation(s)
- Yani Zhang
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Cuili Liang
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ruidan Zheng
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinghui Chen
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Minyan Jiang
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhizi Zhou
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuan Zhao
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Min Rao
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Sida Yang
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenxiong Chen
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Liu
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
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Walter MC, Laforêt P, van der Pol WL, Pegoraro E. 254th ENMC International Virtual Workshop Formation of a European network to initiate a European data collection, along with development and sharing of treatment guidelines for adult SMA patients 28 – 30 January 2022. Neuromuscul Disord 2023; 33:511-522. [PMID: 37245491 DOI: 10.1016/j.nmd.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/14/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023]
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Ultrasound-guided interlaminar approach for nusinersen administration in patients with spinal muscular atrophy with spinal fusion or severe scoliosis. Orphanet J Rare Dis 2023; 18:30. [PMID: 36800969 PMCID: PMC9936713 DOI: 10.1186/s13023-023-02630-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 02/06/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Intrathecal injection of medications can be challenging in spinal muscular atrophy (SMA) patients with severe scoliosis or after spine surgery. Here we report our experience with real-time ultrasound (US)-guided intrathecal administration of nusinersen in patients with SMA. METHODS Seven patients (six children and one adult) with either spinal fusion or severe scoliosis were enrolled. We performed intrathecal injections of nusinersen under US guidance. The efficacy and safety of US-guided injection were explored. RESULTS Five patients had undergone spinal fusion, while the other two presented severe scoliosis. Success was achieved in 19/20 lumbar punctures (95%), 15 of which were performed through the near-spinous process approach. The intervertebral space with a designated channel was selected for the five postoperative patients, while the interspaces with the smallest rotation angle were chosen for the other two patients with severe scoliosis. In 89.5% (17/19) of the punctures, the number of insertions was no more than two. No major adverse events were observed. CONCLUSION Given its safety and efficacy, real-time US guidance is recommended for SMA patients with spine surgery or severe scoliosis, and the near-spinous process view can be used as a interlaminar puncture approach for US guidance.
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Abstract
Spinal muscular atrophy (SMA) is a rare autosomal recessive neuromuscular disorder related to motor neuron degeneration. SMA patients present generally severe muscular weakness and atrophy, which can reduce life expectancy and lead to severe functional disability. In recent years, the management of this condition has been revolutionized by the development of innovative therapies that target alternative splicing of pre-messenger SMN2 RNA by antisense oligonucleotides or small molecules and by the approval of the first vector-based SMN1 gene therapy. The high significance of the trials in children led to fast-tracking of these therapies to all SMA patients despite the absence of data in adults. Real-life data are progressively providing a better understanding of the expected benefits and tolerability. They also highlight the difficulties of evaluating these patients and the need to take into account the patients' reported expectations and outcome. A review of the main data in adult patients is presented. The mechanisms of action of these innovative therapies are discussed as well as the limits of evaluations of these therapies in adults with longstanding severe amyotrophy.
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Affiliation(s)
- P Cintas
- Service de neurologie, CHU de Toulouse Purpan, centre de référence de pathologie neuromusculaire, place du Docteur Baylac TSA 40031, 31059 Toulouse cedex 9, France.
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Cone-beam computed tomography guided nusinersen administrations in adult spinal muscular atrophy patients with challenging access: a single- center experience. Radiol Oncol 2022; 56:319-325. [PMID: 35962954 PMCID: PMC9400441 DOI: 10.2478/raon-2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/12/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The challenging anatomic predispositions in adult patients with spinal muscular atrophy (SMA) preclude the conventional lumbar punctures. Consequently, an introduction of alternative method for intrathecal delivery of nusinersen is required. Cone-beam CT (CBCT) allows volumetric display of the area of interest, pre-procedural planning and real time needle guidance which results in accurate anatomic navigation. The aim of the study was to evaluate technical success, safety, and feasibility of CBCT lumbar intrathecal delivery of nusinersen in the adult SMA patients with challenging anatomical access. PATIENTS AND METHODS Thirty-eight adult SMA patients were treated in our institution. Patients with challenging access were selected by multidisciplinary board for image guided administration of nusinersen either due to implantation of the posterior fusion instrumentation, severe scoliosis defined as Cobb's angle > 40º or body mass index over 35. Technical success, radiation exposure and occurrence of adverse events were assessed. RESULTS Twenty patients were selected, and 108 CBCT-guided procedures were performed. Each patient underwent at least 4 administrations. Transforaminal approach was performed in 82% of patients. The technical success was 100%, with primary success of 93.5%. The median radiation effective dose of the administrations was 5 mSv, the mean value equalled 10 mSv. Only mild adverse events were reported in the study. CONCLUSIONS CBCT-guided lumbar intrathecal administrations of nusinersen in an adult SMA population with challenging access was feasible and safe image guided method.
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Papaliagkas V, Foroglou N, Toulios P, Moschou M, Gavriilaki M, Notas K, Chatzikyriakou E, Zafeiridou G, Arnaoutoglou M, Kimiskidis VK. Intrathecal Administration of Nusinersen Using the Ommaya Reservoir in an Adult with 5q-Related Spinal Muscular Atrophy Type 1 and Severe Spinal Deformity. Case Rep Neurol 2021; 13:710-715. [PMID: 34950009 PMCID: PMC8647073 DOI: 10.1159/000519831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/19/2021] [Indexed: 11/19/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a hereditary neuromuscular disorder, typically caused by survival motor neuron 1 (SMN1) gene deletion in chromosome 5q resulting in loss of SMN protein. SMA type 1 progresses rapidly leading to increased mortality usually before the age of 2 years. Nusinersen, the first approved disease-modifying treatment for all 5q-SMA types and ages, is an antisense oligonucleotide administered intrathecally via repeated lumbar punctures. However, adult SMA patients typically present with severe scoliosis and spinal deformity. We present a 28-year-old patient with SMA type 1 and severe spinal deformity, who received nusinersen via a subcutaneously implanted Ommaya reservoir connected with an intrathecal catheter at the thoracic level. The repetitive administrations were completed uneventfully, obviating the need for repeated laborious lumbar punctures and eliminating radiation exposure. In adult SMA patients, performing recurrent lumbar punctures can be technically challenging raising the need for an alternative route of administration. The use of Ommaya reservoirs is a viable, practical for repeated infusions, and safe option for the intrathecal delivery of nusinersen for select cases such as an adult SMA type 1 survivor with severe spinal deformity.
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Affiliation(s)
- Vasileios Papaliagkas
- Department of Biomedical Sciences, School of Health Sciences, International Hellenic University, Thessaloniki, Greece
| | - Nikolaos Foroglou
- 1st Department of Neurosurgery, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Maria Moschou
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Notas
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Chatzikyriakou
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgia Zafeiridou
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marianthi Arnaoutoglou
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios K Kimiskidis
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Grayev A, Schoepp M, Kuner A. A Systematic Review of Procedural Complications from Transforaminal Lumbar Puncture for Intrathecal Nusinersen Administration in Patients with Spinal Muscular Atrophy. AJNR Am J Neuroradiol 2021; 42:980-985. [PMID: 33632735 DOI: 10.3174/ajnr.a7009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spinal muscular atrophy is a progressive neurodegenerative disorder that can be treated with intrathecal antisense oligonucleotide therapy (nusinersen). However, administration is often complicated by posterior spinal fusion and neuromuscular scoliosis, necessitating a transforaminal approach. PURPOSE To assess the safety profile of the transforaminal approach for intrathecal access. DATA SOURCES Searches of the PubMed, Web of Science, and SCOPUS databases. STUDY SELECTION Thirteen articles were selected based on inclusion of transforaminal access and appropriate clinical information about the procedure. DATA ANALYSIS Complications were taken from the included articles and aggregated based on Cardiovascular and Interventional Radiological Society of Europe scale adverse event grading. DATA SYNTHESIS Total number of complications and grade of complications were analyzed, by year and in total. LIMITATIONS Selection bias in publication, small patient population size, and variability of the procedure limits the available data. CONCLUSIONS Transforaminal approach is a safe alternative for intrathecal access in patients with spinal muscular atrophy and may be applicable to a larger patient population.
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Affiliation(s)
- A Grayev
- From the School of Medicine and Public Health, University of Wisconsin, Madison, WisconsinFrom the School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.
| | - M Schoepp
- From the School of Medicine and Public Health, University of Wisconsin, Madison, WisconsinFrom the School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - A Kuner
- From the School of Medicine and Public Health, University of Wisconsin, Madison, WisconsinFrom the School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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Pediatric SMA patients with complex spinal anatomy: Implementation and evaluation of a decision-tree algorithm for administration of nusinersen. Eur J Paediatr Neurol 2021; 31:92-101. [PMID: 33711792 DOI: 10.1016/j.ejpn.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/23/2022]
Abstract
The approval of nusinersen for the treatment of spinal muscular atrophy (SMA) has significantly changed the natural history of the disease. Nevertheless, scoliosis secondary to axial muscle weakness occurs at some point in most of patients with SMA and a conventional posterior interlaminar approach for intrathecal administration of nusinersen can be particularly challenging to perform in patients with severe scoliosis and/or previous spine fusion surgeries. We developed a protocol for the administration of nusinersen in pediatric patients, which includes a decision-tree algorithm that categorizes patients according to the estimated technical difficulty for the intrathecal administration. Complex spine patients were defined as those with a Cobb angle greater than 50° and/or a history of spinal surgery, while the rest of patients were considered non-complex. Nusinersen was successfully administered through a conventional non-CT-guided lumbar puncture in all 14 non-complex spine patients (110 out of 110 procedures; 100%). The feasibility of the intrathecal injection in the 15 complex spine patients was assessed by 3D CT. Administration was considered unfeasible in 7 out of these 15 patients according to imaging. In the 8 complex spine patients in whom the administration was considered feasible, conventional non-CT-guided lumbar punctures were successful only in 19 out of 53 procedures (36%). The remaining 34 procedures (64%) were guided by CT scan, all successful. Our work demonstrates that a cut-off point of 50° in Cobb angle and history of spinal surgery can reliably be used to anticipate the need for CT guidance in nusinersen administration.
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Machida S, Miyagi M, Saito W, Matsui A, Imura T, Inoue G, Nakazawa T, Shirasawa E, Ikeda S, Kawakubo A, Kuroda A, Yokozeki Y, Mimura Y, Uchida K, Akazawa T, Takaso M. Posterior Spinal Correction and Fusion Surgery in Patients with Spinal Muscular Atrophy-Associated Scoliosis for Whom Treatment with Nusinersen Was Planned. Spine Surg Relat Res 2020; 5:109-113. [PMID: 33842719 PMCID: PMC8026202 DOI: 10.22603/ssrr.2020-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/09/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Spinal muscular atrophy (SMA) is defined as a neuromuscular disorder induced by progressive weakness of the skeletal muscle and is usually accompanied by progressive spinal deformity including scoliosis. The newly developed Nusinersen, which is the first approved drug worldwide for SMA, requires accurate intrathecal injection, which is sometimes difficult in patients with severe spinal deformity. TECHNICAL NOTE For an accurate intrathecal approach in patients who have spinal fusion surgery to treat neuromuscular scoliosis, we have combined an L3 laminectomy with spinal correction and fusion surgery. Here, we review four cases of SMA in patients who underwent the additional L3 laminectomy during surgery to treat spinal scoliosis. A successful intrathecal approach was made using fluoroscopic guidance in all four patients, who were then administered with Nusinersen. CONCLUSIONS Our findings show that additional lumbar laminectomy during surgery for spinal scoliosis has effectively allowed for intrathecal injection of Nusinersen.
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Affiliation(s)
- Shuhei Machida
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Wataru Saito
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Ayano Matsui
- Department of Orthopaedic Surgery, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Takayuki Imura
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Toshiyuki Nakazawa
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Shinsuke Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Ayumu Kawakubo
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Akiyoshi Kuroda
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yuji Yokozeki
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yusuke Mimura
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Kentaro Uchida
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Tsutomu Akazawa
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
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