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Sun H, Xiong S, Zhang Y, Zhao Q, Wu Z, Xiao L. Clinical significance of redundant nerve roots in patients with lumbar spinal stenosis undergoing oblique lumbar interbody fusion combined with percutaneous internal fixation. J Orthop Surg Res 2023; 18:958. [PMID: 38087350 PMCID: PMC10717461 DOI: 10.1186/s13018-023-04449-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND While there have been previous studies on the surgical efficacy of patients with redundant nerve roots (RNRs), a persistent issue is that some patients continue to experience redundancy even after surgery. Furthermore, the clinical significance of RNRs remains unclear. Notably, there is a lack of research regarding RNRs within the context of oblique lumbar interbody fusion (OLIF) combined with percutaneous internal fixation. Therefore, the primary objective of this study is to investigate the correlation between RNRs and clinical outcomes following OLIF combined with percutaneous internal fixation. METHODS Eighty-seven patients diagnosed with lumbar spinal stenosis (LSS) who underwent single-segment OLIF combined with percutaneous internal fixation were categorized into three groups. Group 1 comprised patients with positive RNRs both before and after the operation. Group 2 included patients with positive RNRs preoperatively but negative RNRs postoperatively. Group 3 consisted of patients with consistently negative RNRs before and after the operation. Comprehensive patient data were collected, including operation time, intraoperative blood loss, and any recorded complications. Radiographic parameters, both pre- and post-operative, were assessed, encompassing the number of stenosis segments, disc height (DH), lumbar lordotic angle, dural sac cross-sectional area, and the placement of the fusion cage. Furthermore, the Visual Analogue Scale was applied to gauge back and leg pain, while the Oswestry Disability Index was employed to appraise daily living activities. A comparative analysis was carried out among the three patient groups. RESULTS In this study, all 87 LSS patients successfully underwent surgery. Among them, 35 patients (40.2%) showed preoperative MRI assessment indicating positive RNRs. In the postoperative MRI assessment, 14 of these patients maintained positive RNRs status, and they were grouped into Group 1. The remaining 21 patients saw a transition to negative RNRs status and were included in Group 2. Among the 52 patients who had preoperative MRI assessments showing negative RNRs, their postoperative RNRs status remained negative, forming Group 3. All patients received follow-up, which ranged from 8 to 18 months, and no complications occurred during this period. In this study, the postoperative efficacy and parameters such as DH and Dural Sac CSA significantly improved compared to preoperative values for all 87 patients. Patients with preoperative RNRs had more stenosis segments, smaller dural sac CSA, and more severe symptoms. In all three groups, postoperative efficacy scores significantly improved compared to preoperative scores. Group 2 patients had their fusion cages placed more in the middle, while Group 1 patients had their fusion cages more anteriorly located. Group 2 patients exhibited greater recovery in dural sac CSA postoperatively compared to Group 1 patients. Additionally, Group 2 patients had better ODI efficacy scores compared to Group 1 patients. CONCLUSIONS Irrespective of the presence or absence of RNRs, patients experienced improvement after undergoing OLIF combined with percutaneous internal fixation. Preoperative RNRs appear to be linked to multi-segmental lumbar spinal stenosis, a reduction in dural sac CSA, and symptom severity. Patients with negative postoperative RNRs demonstrated better treatment efficacy. Furthermore, the placement of the fusion cage appears to have a significant impact on postoperative efficacy and RNRs outcomes.
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Affiliation(s)
- Hongzhou Sun
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Shouliang Xiong
- Department of Joint Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Yu Zhang
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Quanlai Zhao
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Zhongxuan Wu
- Department of Spine Surgery, Yijishan Hospital, The First Affliated Hospital of Wannan Medical College, Wuhu, China
| | - Liang Xiao
- Spine Research Center of Wannan Medical College, No. 22 Wenchang West Road, Wuhu, 241001, China.
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Yamakuni R, Ishii S, Kakamu T, Ishikawa H, Sekino H, Seino S, Fukushima K, Otani K, Ito H. Relationship between lumbar spinal stenosis and cauda equina movement during the Valsalva maneuver. Skeletal Radiol 2023. [PMID: 36609720 DOI: 10.1007/s00256-022-04274-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To confirm the relationship between lumbar spinal stenosis (LSS) and cauda equina movement during the Valsalva maneuver. MATERIALS AND METHODS Two radiologists at our institution independently evaluated cauda equina movement on pelvic cine MRI, which was performed for urethrorrhea after prostatectomy or pelvic prolapse in 105 patients (99 males; mean age: 69.0 [range: 50-78] years), who also underwent abdominopelvic CT within 2 years before or after the MRI. The qualitative assessment of the cine MRI involved subjective determination of the cauda equina movement type (non-movement, flutter, and inchworm-manner). The severity of LSS on abdominopelvic CT was quantified using our LSS scoring system and performed between L1/2 and L5/S1. We calculated the average LSS scores of two analysts and extracted the worst scores among all levels. RESULTS Cauda equina movement was observed in 15 patients (14%), inchworm-manner in 10 patients, and flutter in five patients. Participants with cauda equina movement demonstrated significantly higher LSS scores than those without movement (P < 0.001, Wilcoxon's rank-sum test). A significant difference was observed in the worst LSS scores between participants without movement and those with inchworm-manner movement (P < 0.001, Bonferroni's corrected). There were no significant differences between participants without movement and those with flutter movement (P = 0.3156) and between participants with flutter movement and those with inchworm-manner movement (P = 0.4843). CONCLUSION Cauda equina movement in cine MRI during the Valsalva maneuver is occasionally observed in patients with severe LSS, and may be associated with pathogenesis of redundant nerve roots.
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Papavero L, Ali N, Schawjinski K, Holtdirk A, Maas R, Ebert S. The prevalence of redundant nerve roots in standing positional MRI decreases by half in supine and almost to zero in flexed seated position: a retrospective cross-sectional cohort study. Neuroradiology 2022; 64:2191-2201. [PMID: 36083504 PMCID: PMC9576640 DOI: 10.1007/s00234-022-03047-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/28/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE This retrospective cross-sectional cohort study investigated the influence of posture on lordosis (LL), length of the spinal canal (LSC), anteroposterior diameter (APD L1-L5), dural cross-sectional area (DCSA) of the lumbar spinal canal, and the prevalence of redundant nerve roots (RNR) using positional magnetic resonance imaging (MRI) (0.6 T). METHODS Sixty-eight patients with single-level degenerative central lumbar spinal stenosis (cLSS) presenting with RNR in the standing position (STA) were also investigated in supine (SUP) or neutral seated (SIT) and flexed seated (FLEX) positions. Additionally, 45 patients complaining of back pain and without MRI evidence of LSS were evaluated. Statistical significance was set at p < 0.05. RESULTS Controls (A) and patients with cLSS (B) were comparable in terms of mean age (p = 0.88) and sex (p = 0.22). The progressive transition from STA to FLEX led to a comparable decrease in LL (p = 0.97), an increase in LSC (p = 0.80), and an increase in APD L1-L5 (p = 0.78). The APD of the stenotic level increased disproportionally between the different postures, up to 67% in FLEX compared to 29% in adjacent non-stenotic levels (p < 0.001). Therefore, the prevalence of RNR decreased to 49, 26, and 4% in SUP, SIT, and FLEX, respectively. CONCLUSION The prevalence of RNR in standing position was underestimated by half in supine position. Body postures modified LL, LSC, and APD similarly in patients and controls. Stenotic levels compensated for insufficient intraspinal volume with a disproportionate enlargement when switching from the STA to FLEX.
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Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen-Clinic Hamburg, Academic Hospital of the University Medical Center Eppendorf, Dehnhaide 120, 22081 Hamburg, Germany
| | - Nawar Ali
- Clinic for Spine Surgery, Schoen-Clinic Hamburg, Academic Hospital of the University Medical Center Eppendorf, Dehnhaide 120, 22081 Hamburg, Germany
| | - Kathrin Schawjinski
- Clinic for Spine Surgery, Schoen-Clinic Hamburg, Academic Hospital of the University Medical Center Eppendorf, Dehnhaide 120, 22081 Hamburg, Germany
| | | | - Rainer Maas
- Radiological Office Raboisen 38, Hamburg, Germany
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Goldberg JL, Wipplinger C, Kirnaz S, Xia J, Sommer F, Meng A, Schwarz J, Giantini-Larsen A, Meaden RM, Sugino R, Gadjradj P, Medary B, Carnevale JA, Navarro R, Tsiouris AJ, Hussain I, Härtl R. Clinical Significance of Redundant Nerve Roots in Patients with Lumbar Stenosis Undergoing Minimally Invasive Tubular Decompression. World Neurosurg 2022; 164:e868-e876. [PMID: 35598849 DOI: 10.1016/j.wneu.2022.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Symptomatic lumbar spinal stenosis (LSS) is a common indication for surgery in the elderly. Preoperative radiographic evaluation of patients with LSS often reveals redundant nerve roots (RNRs). The clinical significance of RNRs is uncertain. RNRs have not been studied in the setting of minimally invasive surgery. This study investigates the relationship between RNRs and clinical outcomes after minimally invasive tubular decompression. METHODS Chart review was performed for patients with degenerative LSS who underwent minimally invasive decompression. Preoperative magnetic resonance imaging parameters were assessed, and patient-reported outcomes were analyzed. RESULTS Fifty-four patients underwent surgery performed at an average of 1.8 ± 0.8 spinal levels. Thirty-one patients (57%) had RNRs. Patients with RNRs were older (median = 72 years vs. 66 years, P = 0.050), had longer median symptom duration (32 months vs. 15 months, P < 0.01), and had more levels operated on (2.1 vs. 1.4; P < 0.01). The median follow-up after surgery was 2 months (range = 1.3-12 months). Preoperative and postoperative patient-reported outcomes were similar based on RNR presence. Patients without RNRs had larger lumbar cross-sectional areas (CSAs) (median = 121 mm2 vs. 95 mm2, P = 0.014) and the index-level CSA (52 mm2 vs. 34 mm2, P = 0.007). The CSA was not correlated with RNR morphology or location. CONCLUSIONS Preoperative RNRs are associated with increased age, symptom duration, and lumbar stenosis severity. Patients improved after minimally invasive decompression regardless of RNR presence. RNR presence had no effect on short-term clinical outcomes. Further study is required to assess their long-term significance.
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Affiliation(s)
- Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.
| | - Christoph Wipplinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Jimmy Xia
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Fabian Sommer
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Alicia Meng
- Department of Neuroradiology, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Justin Schwarz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Ross M Meaden
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Rafael Sugino
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Pravesh Gadjradj
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Branden Medary
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Joseph A Carnevale
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Rodrigo Navarro
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - A John Tsiouris
- Department of Neuroradiology, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
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Gökçe E, Beyhan M. Magnetic resonance imaging findings of redundant nerve roots of the cauda equina. World J Radiol 2021; 13:29-39. [PMID: 33574992 PMCID: PMC7852347 DOI: 10.4329/wjr.v13.i1.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/26/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Redundant nerve roots (RNRs) of the cauda equina are often a natural evolutionary part of lumbar spinal canal stenosis secondary to degenerative processes characterized by elongated, enlarged, and tortuous nerve roots in the superior and/or inferior of the stenotic segment. Although magnetic resonance imaging (MRI) findings have been defined more frequently in recent years, this condition has been relatively under-recognized in radiological practice. In this study, lumbar MRI findings of RNRs of the cauda equina were evaluated in spinal stenosis patients.
AIM To evaluate RNRs of the cauda equina in spinal stenosis patients.
METHODS One-hundred and thirty-one patients who underwent lumbar MRI and were found to have spinal stenosis between March 2010 and February 2019 were included in the study. On axial T2-weighted images (T2WI), the cross-sectional area (CSA) of the dural sac was measured at L2-3, L3-4, L4-5, and L5-S1 levels in the axial plane. CSA levels below 100 mm2 were considered stenosis. Elongation, expansion, and tortuosity in cauda equina fibers in the superior and/or inferior of the stenotic segment were evaluated as RNRs. The patients were divided into two groups: Those with RNRs and those without RNRs. The CSA cut-off value resulting in RNRs of cauda equina was calculated. Relative length (RL) of RNRs was calculated by dividing the length of RNRs at mid-sagittal T2WI by the height of the vertebral body superior to the stenosis level. The associations of CSA leading to RNRs with RL, disc herniation type, and spondylolisthesis were evaluated.
RESULTS Fifty-five patients (42%) with spinal stenosis had RNRs of the cauda equina. The average CSA was 40.99 ± 12.76 mm2 in patients with RNRs of the cauda equina and 66.83 ± 19.32 mm2 in patients without RNRs. A significant difference was found between the two groups for CSA values (P < 0.001). Using a cut-off value of 55.22 mm2 for RNRs of the cauda equina, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) values of 96.4%, 96.1%, 89.4%, and 98.7% were obtained, respectively. RL was 3.39 ± 1.31 (range: 0.93-6.01). When the extension of RNRs into the superior and/or inferior of the spinal canal stenosis level was evaluated, it was superior in 54.5%, both superior and inferior in 32.8%, and inferior in 12.7%. At stenosis levels leading to RNRs of the cauda equina, 29 disc herniations with soft margins and 26 with sharp margins were detected. Disc herniation type and spondylolisthesis had no significant relationship with RL or CSA of the dural sac with stenotic levels (P > 0.05). As the CSA of the dural sac decreased, the incidence of RNRs observed at the superior of the stenosis level increased (P < 0.001).
CONCLUSION RNRs of the cauda equina are frequently observed in patients with spinal stenosis. When the CSA of the dural sac is < 55 mm2, lumbar MRIs should be carefully examined for this condition.
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Affiliation(s)
- Erkan Gökçe
- Department of Radiology, Tokat Gaziosmanpasa University, Faculty of Medicine, Tokat 60100, Turkey
| | - Murat Beyhan
- Department of Radiology, Tokat Gaziosmanpasa University, Faculty of Medicine, Tokat 60100, Turkey
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Papavero L, Ebert S, Marques CJ. The prevalence of redundant nerve roots in patients with lumbar spinal stenosis is body position dependent: a retrospective observational study with repeated measures design in an upright MRI scanner. Neuroradiology 2020; 62:979-985. [PMID: 32318772 PMCID: PMC7366595 DOI: 10.1007/s00234-020-02423-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/27/2020] [Indexed: 05/30/2023]
Abstract
Purpose Redundant nerve roots (RNRs) are a negative prognostic factor in patients with central lumbar spinal stenosis (LSS). Forty percent of candidates for surgical decompression show RNRs (RNR+) on preoperative conventional magnetic resonance imaging (MRI). We investigated the prevalence of RNRs in three functional postures (standing, neutral sitting and flexed sitting) with an upright MRI (upMRI). Methods A retrospective observational study with a repeated measures design. Thirty surgical candidates underwent upMRI. Sagittal and axial T2-weighted images of the three functional postures were evaluated. The segmental length of the lumbar spine (sLLS), the lordotic angle (LA) and the dural cross-sectional area (DCSA) were measured in each body position. Generalized linear mixed models were carried out. The 0.05 level of probability was set as the criterion for statistical significance. Results The prevalence of RNRs decreased from 80% during standing to 16.7% during flexed sitting (p < 0.001). The sLLS increased significantly from standing to neutral sitting in both RNR groups (p < 0.001). The increase from neutral sitting to flexed sitting was only significant (p < 0.001) for the group without RNRs (RNR−). The LA decreased significantly for both RNR groups from standing to flexed sitting (p < 0.001). The DSCA increased significantly in the RNR− group (p < 0.001) but not in the RNR+ group (p = 0.9). Conclusion The prevalence of RNRs is body position dependent. Increases in DCSA play a determinant role in resolving RNRs.
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Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the Medical Center Eppendorf (UKE), Hamburg, Germany
| | | | - Carlos J Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek - Science Office, Dehnhaide 120, D-22081, Hamburg, Germany.
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Papavero L, Marques CJ, Lohmann J, Fitting T, Schawjinski K, Ali N, Hillebrand H, Maas R. Redundant nerve roots in lumbar spinal stenosis: inter- and intra-rater reliability of an MRI-based classification. Neuroradiology 2019; 62:223-230. [PMID: 31836911 PMCID: PMC6971136 DOI: 10.1007/s00234-019-02337-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022]
Abstract
Purpose Patients with central lumbar spinal stenosis (LSS) have a longer symptom history, more severe stenosis, and worse postoperative outcomes, when redundant nerve roots (RNRs) are evident in the preoperative MRI. The objective was to test the inter- and intra-rater reliability of an MRI-based classification for RNR. Methods This is a retrospective reliability study. A neuroradiologist, an orthopedic surgeon, a neurosurgeon, and three orthopedic surgeons in-training classified RNR on 126 preoperative MRIs of patients with LSS admitted for microsurgical decompression. On sagittal and axial T2-weighted images, the following four categories were classified: allocation (A) of the key stenotic level, shape (S), extension (E), and direction (D) of the RNR. A second read with cases ordered differently was performed 4 weeks later. Fleiss and Cohen’s kappa procedures were used to determine reliability. Results The allocation, shape, extension, and direction (ASED) classification showed moderate to almost perfect inter-rater reliability, with kappa values (95% CI) of 0.86 (0.83, 0.90), 0.62 (0.57, 0.66), 0.56 (0.51, 0.60), and 0.66 (0.63, 0.70) for allocation, shape, extension, and direction, respectively. Intra-rater reliability was almost perfect, with kappa values of 0.90 (0.88, 0.92), 0.86 (0.84, 0.88), and 0.84 (0.81, 0.87) for shape, extension, and direction, respectively. Intra-rater kappa values were similar for junior and senior raters. Kappa values for inter-rater reliability were similar between the first and second reads (p = 0.06) among junior raters and improved among senior raters (p = 0.008). Conclusions The MRI-based classification of RNR showed moderate-to-almost perfect inter-rater and almost perfect intra-rater reliability.
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Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Carlos J Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Germany. .,Non-Medical PhD Program, Faculty of Medicine, University of Hamburg, Hamburg, Germany.
| | - Jens Lohmann
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Thies Fitting
- Department of Radiology at the Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Kathrin Schawjinski
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Nawar Ali
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Hauke Hillebrand
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Academic Hospital of the University of Hamburg, Dehnhaide 120, 22081, Hamburg, Germany
| | - Rainer Maas
- Radiology Office Raboisen 38, Hamburg, Germany
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Aggarwal V, Maheshwari C, Narang A, Atwal J, Bahadur R. Lessons Learned from a Migratory Intradural Extramedullary Schwannoma: A Case Report with Review of the Literature. World Neurosurg 2019; 126:508-512. [PMID: 30904802 DOI: 10.1016/j.wneu.2019.03.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Migratory tumors of the spinal cord are rare and can present as a missing tumor intraoperatively. This can lead to unnecessary abandonment of surgery or unnecessary laminectomies. CASE DESCRIPTION We present a case of migratory intradural extramedullary tumor of the spine, which was missing intraoperatively. The surgery was abandoned, and on reimaging the tumor was found to have migrated. Here we summarize a review of the literature of such cases and the lessons we learned from our experience, emphasizing the measures to prevent tumor displacement and the importance of intraoperative imaging. CONCLUSIONS Migratory schwannoma should be suspected in case of a missing lesion. Intraoperative ultrasonography and myelography use should be definitely considered where facility for intraoperative magnetic resonance imaging is not available. Preventive measures should be taken to avoid tumor migration in all routine cases of intradural extramedullary lesions.
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Affiliation(s)
- Varun Aggarwal
- Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India.
| | - Chandni Maheshwari
- Department of Anaesthesia, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Amit Narang
- Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Jagdeep Atwal
- Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Raj Bahadur
- Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Papavero L, Marques CJ, Lohmann J, Fitting T. Patient demographics and MRI-based measurements predict redundant nerve roots in lumbar spinal stenosis: a retrospective database cohort comparison. BMC Musculoskelet Disord 2018; 19:452. [PMID: 30579338 PMCID: PMC6303950 DOI: 10.1186/s12891-018-2364-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023] Open
Abstract
Background Up to 40% of patients diagnosed with lumbar spinal stenosis (LSS) show evidence of redundant nerve roots (RNR) of the cauda equina on their magnetic resonance images (MRI). The etiology of RNR is still unclear. Preoperative evidence of RNR is associated with a worse postsurgical outcome. Consequently, potential predictors of RNR could have a prognostic value. The aim was to test whether patient demographics and MRI-based measurements can predict RNR in LSS patients. Methods In a retrospective database-based cohort study the preoperative data of 300 patients, 150 with (RNR+) and 150 without (RNR-) evidence of RNR on their MRI were analyzed. Three independent researchers performed the MRI reads. Potential predictors were age, gender, body height (BH), length of lumbar spine (LLS), segmental length of lumbar spine (SLLS), lumbar spine alignment deviation (LSAD), relative LLS (rLLS), relative SLLS (rSLLS), number of stenotic levels (LSS-level), and grade of LSS severity (LLS-grade, increasing from A to D). Binomial logistic regression models were performed. Results RNR+ patients were 2.6 years older (p = 0.01). Weak RNR+ predictors were a two-years age increase (OR 1.06; p = 0.02), 3 cm BH decrease (OR 1.09; p = 0.01) and a 5 mm SLLS decrease (OR 1.34; p < 0.001). Strong RNR+ predictors were a 1% rLLS decrease (OR 2.17; p < 0.001), LSS-level ≥ 2 (OR 2.59; p = 0.001), LLS-grade C (OR 5.86; p = 0.02) and LLS-grade D (OR 18.4; p < 0.001). The mean rSLLS of RNR+ patients was 0.6% shorter (p < 0.001; 95% C.I. 0.4 to 0.8) indicating a disproportionate shorter lumbar spine. Conclusions We identified LSS severity grade and LSS levels as the strongest predictors of RNR. In addition to previous studies, we conclude that a shortened lumbar spine by degeneration is involved in the development of RNR.
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Affiliation(s)
- Luca Papavero
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany
| | - Carlos J Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany. .,Non-Medical PhD Program, Faculty of Medicine (UKE), University of Hamburg, Hamburg, Germany.
| | - Jens Lohmann
- Clinic for Spine Surgery, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany
| | - Thies Fitting
- Department of Radiology, Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany
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10
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Cong L, Zhu Y, Yan Q, Tu G. A Meta-Analysis on the Clinical Significance of Redundant Nerve Roots in Symptomatic Lumbar Spinal Stenosis. World Neurosurg 2017; 105:95-101. [PMID: 28559073 DOI: 10.1016/j.wneu.2017.05.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/16/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Symptomatic lumbar spinal stenosis (LSS), which leads to severe socioeconomic consequences and places a heavy burden on global healthcare system, is a relatively frequent spine disorder. Redundant nerve roots (RNRs) are a relatively common finding in which slender, serpiginous, or tortuous nerve roots are found in the subarachnoid space of the lumbar spine. Previous studies that evaluated the prognostic assessment of RNRs in patients with symptomatic LSS are composed of doubtful results. Therefore, the clinical significance of RNRs in symptomatic LSS is still uncertain. The aim of this meta-analysis is a systematic assessment of the clinical significance of RNR syndrome in symptomatic LSS. METHODS This study used a highly sensitive search strategy to identify all published studies in multiple databases up to January 1, 2017. All identified trials were systematically evaluated using specific inclusion and exclusion criteria. Cochrane methodology was also applied to the results of this study. RESULTS This study identified 4 relevant studies involving 297 patients. Compared with a non-RNR group, the RNR group results included worse clinical outcomes that were assessed using the Japanese Orthopedic Association scores after surgery (weighted mean difference [WMD], -0.78; 95% confidence interval [CI], -1.26 to -0.29; P = 0.002; I2 = 0%), for recovery rate (WMD, -9.87; 95% CI, -15.07 to -4.67; P = 0.0002; I2 = 0%), and for older age (WMD, 2.51; 95% CI, 0.45-4.57; P = 0.02; I2 = 43%). CONCLUSIONS RNR is an entity in association with symptomatic LSS, which may be viewed as a potentially powerful prognostic indicator of worse postoperative functional recovery for symptomatic LSS.
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Affiliation(s)
- Lin Cong
- Department of Orthopedic surgery, The First Hospital of China Medical University, Shenyang City, China.
| | - Yue Zhu
- Department of Orthopedic surgery, The First Hospital of China Medical University, Shenyang City, China
| | - Qi Yan
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Guanjun Tu
- Department of Orthopedic surgery, The First Hospital of China Medical University, Shenyang City, China
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11
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Chen J, Wang J, Wang B, Xu H, Lin S, Zhang H. Post-surgical functional recovery, lumbar lordosis, and range of motion associated with MR-detectable redundant nerve roots in lumbar spinal stenosis. Clin Neurol Neurosurg 2015; 140:79-84. [PMID: 26683896 DOI: 10.1016/j.clineuro.2015.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 11/17/2015] [Accepted: 11/21/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE T1- and T2-weighted magnetic resonance images (MRI) can reveal lumbar redundant nerve roots (RNRs), a result of chronic compression and nerve elongation associated with pathogenesis of cauda equina claudication (CEC) in degenerative lumbar canal stenosis (DLCS). The study investigated effects of lumbar lordosis angle and range of motion on functional recovery in lumbar stenosis patents with and without RNRs. METHODS A retrospective study was conducted of 93 lumbar spinal stenosis patients who underwent decompressive surgery. Eligible records were assessed by 3 independent blinded radiologists for presence or absence of RNRs on sagittal T2-weighted MR (RNR and non-RNR groups), pre- and post-operative JOA score, lumbar lordosis angle, and range of motion. RESULTS Of 93 total patients, the RNR group (n=37, 21/37 female) and non-RNR group (n=56; 31/56 female) had similar preoperative conditions (JOA score) and were not significantly different in age (mean 64.19 ± 8.25 vs. 62.8 ± 9.41 years), symptom duration (30.92 ± 22.43 vs. 28.64 ± 17.40 months), or follow-up periods (17.35 ± 4.02 vs. 17.75 ± 4.29 mo) (all p>0.4). The non-RNR group exhibited significantly better final JOA score (p=0.015) and recovery rate (p=0.002). RNR group patients exhibited larger lumbar lordosis angles in the neutral position (p=0.009) and extension (p=0.021) and larger range of motion (p=0.008). CONCLUSIONS Poorer surgical outcomes in patients with RNRs indicated that elevated lumbar lordosis angle and range of motion increased risks of RNR formation, which in turn may cause poorer post-surgical recovery, this information is possibly useful in prognostic assessment of lumbar stenosis complicated by RNRs.
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Affiliation(s)
- Jinshui Chen
- Department of Orthopedics, Fuzhou General Hospital, Nanjing Military Command, Fuzhou 350025, PR China
| | - Juying Wang
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou 350025, PR China
| | - Benhai Wang
- Department of Orthopedics, Fuzhou General Hospital, Nanjing Military Command, Fuzhou 350025, PR China
| | - Hao Xu
- Department of Orthopedics, Fuzhou General Hospital, Nanjing Military Command, Fuzhou 350025, PR China.
| | - Songqing Lin
- Department of Orthopedics, Fuzhou General Hospital, Nanjing Military Command, Fuzhou 350025, PR China.
| | - Huihao Zhang
- Department of Orthopedics, Fuzhou General Hospital, Nanjing Military Command, Fuzhou 350025, PR China
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12
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Yang SM, Park HK, Cho SJ, Chang JC. Redundant nerve roots of cauda equina mimicking intradural disc herniation: a case report. Korean J Spine 2013; 10:41-3. [PMID: 24757458 PMCID: PMC3941734 DOI: 10.14245/kjs.2013.10.1.41] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 02/03/2013] [Accepted: 03/22/2013] [Indexed: 12/27/2022]
Abstract
Redundant Nerve Roots (RNRs) is an uncommon clinical condition characterized by a tortuous, serpentine, large and elongated nerve root of the cauda equina. To our knowledge, most cases of RNRs are associated with lumbar stenosis, and RNRs associated with lumbar disc herniation has not been reported until now. Here we present a rare case of unusual RNRs associated with lumbar disc herniation mimicking intradural disc herniation.
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Affiliation(s)
- Sang Mi Yang
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Seoul, Korea
| | - Hyung Ki Park
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Seoul, Korea
| | - Sung Jin Cho
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Seoul, Korea
| | - Jae Chil Chang
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Seoul, Korea
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13
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Hur JW, Hur JK, Kwon TH, Park YK, Chung HS, Kim JH. Radiological significance of ligamentum flavum hypertrophy in the occurrence of redundant nerve roots of central lumbar spinal stenosis. J Korean Neurosurg Soc 2012; 52:215-20. [PMID: 23115664 PMCID: PMC3483322 DOI: 10.3340/jkns.2012.52.3.215] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/23/2012] [Accepted: 09/17/2012] [Indexed: 01/15/2023] Open
Abstract
Objective There were previous reports of redundant nerve roots (RNRs) focused on their clinical significance and pathogenesis. In this study, we investigated the significant radiologic findings that correlate with RNRs occurrence. These relations would provide an advanced clue for clinical significance and pathogenesis of RNRs. Methods Retrospective research was performed with data from 126 patients who underwent surgery for central lumbar spinal stenosis (LSS). Finally, 106 patients with common denominators (inter-observer accuracy : 84%) were included on this study. We divided the patients into two groups by MRI, patients with RNRs and those with no RNRs (NRNRs). Comparative analyses were performed with clinical and radiologic parameters. Results RNRs were found in 45 patients (42%) with central LSS. There were no statistically significant differences between the two groups in severity of symptoms. On the other hand, we found statistically significant differences in duration of symptom and number of level included (p<0.05). In the maximal stenotic level, ligamentum flavum (LF) thickness, LF cross-sectional area (CSA), dural sac CSA, and segmental angulation are significantly different in RNRs group compared to NRNRs group (p<0.05). Conclusion RNRs patients showed clinically longer duration of symptoms and multiple levels included. We also confirmed that wide segmental angulation and LF hypertrophy play a major role of the development of RNRs in central LSS. Together, our results suggest that wide motion in long period contribute to LF hypertrophy, and it might be the key factor of RNRs formation in central LSS.
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Affiliation(s)
- Junseok W Hur
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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