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An unusual case of intraspinal primitive neuroectodermal tumor arising from the sacral spinal nerve root is presented with the first documentation of myelographic, computed tomographic, and magnetic resonance imaging findings.
The development of alpha-adrenergic sensitivity in cutaneous nociceptors has been postulated as a mechanism for sympathetically maintained pain (SMP). In order to characterize the adrenergic receptors involved, we investigated the effects of intraplantar administration of alpha1-(prazosin) and alpha2-(yohimbine) adrenergic antagonists and systemic injection of phentolamine, a non-specific alpha-adrenergic blocker, on allodynic/hyperalgesic behavior in an animal model thought to mimic SMP in humans. Peripheral neuropathy in rats was induced by tight ligation of the L5/L6 spinal nerves. Mechanical hyperalgesia was quantified with von Frey hairs applied either for 3 s or repetitively to the plantar surface of the hindpaw. Responses to the 3 s duration stimulus were used to determine the paw withdrawal threshold with the up-down paradigm and repetitive stimuli were used to determine the response incidence of paw withdrawal to a given von Frey hair. Mechanical thresholds on the ipsilateral paw decreased significantly after ligation and were stable over the following 3 weeks. Intradermal administration of yohimbine or prazosin did not significantly alleviate mechanical hyperalgesia in L5/L6 ligated animals. Also systemic administration of phentolamine (1 and 5 mg/kg) did not alleviate the increased incidence of paw withdrawal in L5/L6 spinal nerve ligated animals. These results suggest that an alpha adrenergic interaction between sympathetic efferent and somatic afferent fibers does not play a critical role for the maintenance of mechanical hyperalgesia in this model for neuropathic pain.
Irritation, compression or tension of the 5th lumbar nerve root is a major cause of back pain. A sound knowledge of the anatomy of this nerve is necessary to understand the role it plays in the production of back pain. The anatomy of the 5th lumbar nerve root is reviewed, and demonstrated with dissections of 5 cadaveric spines. The possible anatomical sites of irritation, compression or tension of the 5th lumbar nerve root are listed and briefly discussed.
STUDY DESIGN: Biomechanical analysis of the movement of the lumbar spinal nerve roots (NRs). OBJECTIVES: The characteristics of the movement of lumbar spinal NRs corresponding to the change of posture were three-dimensionally analyzed in nonsimulated and simulated adhesion conditions using a porcine model. SUMMARY OF BACKGROUND DATA: There is a paucity of data on the movement of NRs. MATERIALS AND METHODS: Thirty two NRs of four pig cadavers were investigated. (study 1) Two tantalum beads were sutured on respective NRs from L3 to L6. Five beads were put into each bony structure as reference points. The porcine body was put on the cage designed for three-dimensional radiostereometric analysis. Two oblique radiographs were simultaneously taken at flexion, neutral, and extension. (study 2) After study 1, either L4 NR was ligated onto the adjacent bone to mimic monoradicular adhesion. Radiographs were taken in the same manner. The movements of the beads on NRs relative to immobile standard points in each vertebra were analyzed. RESULTS: The movement of NRs was characterized as a combination of stretching/slackening and pendulum motion. The distance that NRs were stretched/slackened, the excursion, and the angles that NRs moved were: 0.39 +/- 0.29 mm, 1.81 +/- 0.63 mm, and 10.46 +/- 5.93 degrees (in nonadhesion), and 0.30 +/- 0.20 mm, 1.02 +/- 0.50 mm, and 7.13 +/- 3.79 degrees (in simulated adhesion), respectively. CONCLUSION: Adhesion might play a part in the pathogenesis of lumbar spinal disorders because mechanical irritation secondary to stretching/slackening and pendulum motion might be concentrated at the distal part of NRs, adjacent to adhesion site, which has less cerebrospinal fluid and is close to dorsal root ganglion.
When surgically removing a spinal nerve schwannoma, preservation of the involved root is attempted and may be feasible. However, in large tumors, sacrifice of the nerve root is often required to achieve total removal of the tumor, and the resection does not always result in postoperative neurological deficit. The present study was designed to determine the incidence and extent of neurological deficit as correlated with resection of the root, performed between 1976 and 1987 in 86 cases at the time of total removal of spinal schwannoma. Thirty-one patients underwent sacrifice of a root critical for the function of the upper (C5-T1, 14 cases) or the lower extremities (L3-S1, 17 cases). This report is limited to these 31 cases. Only seven patients (23%) developed detachable motor or sensory deficits postoperatively. All deficits were no more than partial loss of strength or sensation. Fifteen of the 31 patients had large tumors with extradural components, which necessitated sacrifice of the entire motor and sensory radix; however, 11 (76%) of these 15 did not develop any deficits referrable to the involved myotome or dermatome. Six cases showed histological characteristics of "neurofibroma," with axons intermingled in the tumor, and none developed a postoperative deficit. Preoperative electromyography was performed in 23 cases. Of 13 patients with findings of denervation, five developed deficits after surgery; the other 10 patients showed no evidence of denervation, and none had deficits after surgery. These results indicate that the spinal roots giving origin to schwannoma are frequently nonfunctional at the time of surgery, and risks of causing disabling neurological deficit after sacrificing these roots are small.
Age peculiarities in the structure of all spinal nerve dorsal branches were studied in 70 preparations obtained from 35 corpses of fetuses (23), newborns (2) and mature persons (10). The method of anatomical macro-micropreparation by means of stereoscopic microscope MBC-2 after V. P. Vorobiov was used. It has been stated that age peculiarities of the dorsal nerves manifest themselves as uneven enlargement of their trunks, that, to some extent, corresponds to different development of deep dorsal muscles in various parts of the spinal column (it is less evident in fetuses and newborns), as well as a decreased slope angle of mature person nerves, especially in dolichomorphous type of build. The latter is mostly pronounced in the lower thoracic and lumbar areas and is combined with a predominant growth of the lumbar part of the spinal column. With age, the nerve trunks not only grow longer and thicker, but their branchings become complicated with increasing zones of their spread and enlargement of their connections.
A light and electron microscopic study was undertaken to determine pathological changes in cutaneous spinal nerves of rabbits following intradermal inoculation with alphaherpesvirus saimiri (alpha HVS) isolate KM 322. Infected rabbits were killed at 3, 10, 17, 45 days and 2 years after infection. No abnormalities were seen at 3 days postinoculation. In the nerves of the rabbits killed at 10, 17 and 45 days after infection, axonal (Wallerian-type) degeneration was the main pathological feature. Regeneration, manifested by axonal sprouting, was observed in the nerves of the rabbits killed at 45 days post-inoculation. Neural fibrosis and paucity of unmyelinated axons was the final outcome. The severity of the neural damage not only varied according to the progression of the disease but between nerves taken from the same rabbit. This was probably associated with variation in the numbers of virus particles that had reached the dorsal root ganglion of the dermatome served by a particular nerve. Since alpha HVS (isolate KM 322) provides a model system for the study of virus latency in dorsal root ganglia, and consequently for the study of varicellazoster infection in man, these findings give further insight into the pathology of herpetic neuropathy.
STUDY DESIGN: Retrospective review of 61 consecutive patients. OBJECTIVES: To determine the effectiveness of combining intraoperative monitoring of both spontaneous electromyographic activity and compound muscle action potential response to stimulation for detecting a perforation of the pedicle cortex irritation of nerve root during lumbar spine fusion surgery. SUMMARY OF BACKGROUND DATA: The complication rate from instrumentation used with lumbar spine fusion varies from 1 to 33%. To prevent neurologic complications, several monitoring techniques have been used to alert surgeons to possible neurologic damage being introduced during nerve decompression or placement of instrumentation with spine procedures. Because of different sensitivities, one monitoring technique may not be as effective for preventing complications as a combination of techniques. METHODS: Sixty-one consecutive patients who underwent instrumented posterior lumbar fusions received continuous electromyographic monitoring and stimulus-evoked electromyographic monitoring. A significant neurophysiologic event was signaled by sustained neurotonic electromyographic activity, prompting an alert and a pause in the surgical manipulations that precipitated the activity. After insertion of the transpedicular screws, the integrity of the pedicle cortex was tested by stimulating each screw head and recording compound muscle action potentials. In the presence of a pedicle breach, stimulus intensities below 7 mA were sufficient to evoke compound muscle action potentials from the muscle group innervated by the adjacent spinal nerve root, prompting a surgical alert and subsequent repositioning of the screw. RESULTS: Fourteen significant neurophysiologic events occurred in 13 of 61 patients (21%). Sustained neurotonic electromyographic discharges occurred in 5 of 40 patients during placement of interbody fusion cages, in 2 patients during placement of transpedicular screws, and in 1 patient during tightening of rods. On pedicle screw stimulation, breaches of the pedicle cortex were detected in 6 patients. After surgery, no new neurologic deficits were found in 60 of the 61 patients. One patient who experienced temporary paraparesis had sustained neurotonic electromyographic discharges during retraction of the thecal sac and distraction of the disc space before placement of the cage. CONCLUSION: These results suggest that intraoperative electromyographic monitoring provides a real-time measure of impending spinal nerve root injury during instrumented posterior lumbar fusion, allowing for timely intervention and minimization of negative postoperative sequela.
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Twelve cervical spines from C2 to T1 were harvested from embalmed cadavers to study the location of the nerve root on plain radiographs. After removal of the soft tissue, the spinal nerves just lateral to the transverse processes were exposed and injected with lead oxide. Plain radiographs including anteroposterior (AP) and left and right oblique views were taken. Angular and linear measurements were performed directly on the radiographs. Results showed that the average frontal angle of the nerve root for all levels was 155 degrees on the AP view, 108 degrees on the foraminal side of the oblique view, and 153 degrees on the opposite side of the oblique view. The nerve root height for all levels averaged 4.7 +/- 0.5 mm. The interpedicular space height increased consistently from 7.8 +/- 0.7 mm at C3-C4 to 9.0 +/- 1.3 mm at C6-C7 except at C2-C3. The nerve root height with respect to the interpedicular space height was 56.2% at C2-C3, 57.8% at C4-C5, and 53.7% at C6-C7. A knowledge of the location of the cervical nerve root related to plain radiographs may enhance the value of plain radiographs in the diagnosis and treatment of cervical spinal disorders.
Metabotropic glutamate receptor 5 (mGluR5) protein increased after sciatic nerve section in ipsilateral L4 and L5 DRG neuronal profiles, with most of the increase occurring in myelinated A-fiber somata. mGluR5 also increased in lamina II of the ipsilateral spinal cord and the proximal sciatic nerve stump in this model. After L5 spinal nerve ligation, mGluR5 immunoreactivity increased dramatically not only in damaged L5 but also in the neighboring undamaged L4. Interestingly, after partial sciatic nerve section, mGluR5 expression did not change in either L4 or L5 DRG neuronal profiles. Both spinal nerve ligation and sciatic nerve partial section produced significant mechanical and thermal hyperalgesia and tactile allodynia. After partial sciatic nerve section, the mGluR5-specific antagonist 2-methyl-6-(phenylethynyl)-pyridine (MPEP) had no effect on any of these behaviors. However, after L5 spinal nerve ligation, although MPEP failed to alter the induced tactile allodynia or mechanical hyperalgesia, it dose dependently reversed the developed thermal hyperalgesia. Therefore, reversal of thermal hyperalgesia by MPEP correlates with increased mGluR5 in lumbar DRG A-fiber somata after nerve injury. Furthermore, A-fibers in the uninjured L4 DRG after L5 spinal nerve ligation that have increased mGluR5 are the same A-fibers that newly express vanilloid receptor 1 after such injury. Together, these results suggest that, after L5 spinal nerve injury, mGluR5 expression on A-fibers is essential to the development of thermal hyperalgesia. After partial nerve section, however, it is unlikely that thermal responses are mediated through mGluR5 because no such increase in mGluR5 is detected in this model and MPEP is ineffective.
BACKGROUND: Glutamate and non-N-methyl-D-aspartate (NMDA) receptors have been implicated in the development of neuroplasticity in the spinal cord in neuropathic pain. The spinal cord has been identified as one of the sites of the analgesic action of gabapentin. In the current study, the authors determined the antiallodynic effect of intrathecal 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) in a rat model of neuropathic pain. Also tested was a hypothesis that intrathecal injection of CNQX and gabapentin produces a synergistic effect on allodynia in neuropathic rats. METHODS: Allodynia was produced in rats by ligation of the left L5 and L6 spinal nerves. Allodynia was determined by application of von Frey filaments to the left hind paw. Through an implanted intrathecal catheter, 10-100 microg gabapentin or 0.5-8 microg CNQX disodium (a water-soluble formulation of CNQX) was injected in conscious rats. Isobolographic analysis was performed comparing the interaction of intrathecal gabapentin and CNQX using the ED50 dose ratio of 15:1. RESULTS: Intrathecal treatment with gabapentin or CNQX produced a dose-dependent increase in the withdrawal threshold to mechanical stimulation. The ED50 for gabapentin and CNQX was 45.9+/-4.65 and 3.4+/-0.22 microg, respectively. Intrathecal injection of a combination of CNQX and gabapentin produced a strong synergistic antiallodynic effect in neuropathic rats. CONCLUSIONS: This study shows that intrathecal administration of CNQX exhibits an antiallodynic effect in this rat model of neuropathic pain. Furthermore, CNQX and gabapentin, when combined intrathecally, produce a potent synergistic antiallodynic effect on neuropathic pain in spinal nerve-ligated rats.
This report concerns not only anatomical study of posterior branches of the spinal nerves, but has also a clinical aim. The cutaneous territories and the sites of pain irradiation are precised. In the cervico-thoracic region emphasis is placed on the importance of the fourth cervical posterior branch and of the second dorsal posterior branch. At the lumbar and sacral levels the authors distinguish three pain pathways: from up to down and from outside to inside: the first corresponding to posterior branches of 11th and 12th dorsal nerves, the second to those of first, second and third lumbar nerves and the third to sacral nerves.
An isolation procedure for neurofilaments from ox spinal nerves is described where the triplet polypeptides (which have molecular weights of 205 000, 158 000 and 72 000) constitute more than 80% of the preparation. Soon after purification, the neurofilaments form a gel that is stable for many weeks. The purified neurofilaments disassemble in low-salt buffers at pH greater than 7.0 into soluble particles that contain all of the triplet polypeptides. Greater than 90% of the protein can reassemble to form filaments. The thiol-containing residues in the filaments can be cross-linked. Analyses of the complexes formed show that in the filament the 205 000-mol.wt. components are arranged to that they can be cross-linked to themselves and to the 158 000-mol.wt. polypeptides, and that the 72 000-mol.wt. components are arranged so that their thiol groups can be cross-linked together.
In peripheral neuropathy (PN), dorsal column (DC) fibers that synapse in the nucleus gracilis (NuGr) mediate expression of mechanical allodynia and have increased expression of brain-derived neurotrophic factor (BDNF). Neurotrophins (NTs) are implicated in pathology or repair in PN. To assess NTs in the NuGr in PN, mRNA expression of BDNF, nerve growth factor (NGF), and NT receptors TrkA, TrkB, and p75 was determined 1 week after ligation of L5 and L6 spinal nerves (SNL). Laser capture microdissection was used to collect NuGr tissue followed by reverse-transcription (RT)-PCR. TrkA, TrkB, and NGF mRNA levels decreased, whereas p75 mRNA increased, in ipsilateral SNL NuGr compared with SHAM; BDNF was undetectable. Decreased Trk mRNA may result in decreased NT activity in the NuGr. The p75 receptor influences Trk activity and cell survival, thus its role in PN warrants further investigation.
Avulsion of nerve roots from the cervical spinal cord has always been considered as an untreatable injury, even by surgeons with expertise in this area. However, numerous experimental studies in animals, as well as a human case report, showed that if continuity is restored between the spinal cord and nerve roots, axons from spinal motor neurons can regrow into the peripheral nerve graft with a subsequent recovery of motor function. The posterior subscapular approach, based on the evolution of the posterolateral approach for removal of the first rib, is the only way to expose the entire brachial plexus from C5 to T1 from the ventral and dorsal roots to the distal nerve trunks. The purpose of this study is to investigate the topographic anatomy of the brachial plexus, with particular emphasis on the relationships important to the posterior approach and reimplantation of the ventral rootlets within the cord, either directly or using peripheral nerve grafts. The major advantage of the procedure is the proximal exposure of the plexus, with evaluation of the lesions being excellent (intradural, foraminal and proximal trunks). Reimplantation of ventral roots into the cord is relatively easy from C5 to C7, more difficult for C8 and problematic for T1, whereas reimplantation of dorsal roots into the cord is easy from C5 to T1. The disadvantages of this approach for exposure of the plexus and nerve root avulsion repair are significant: the surgical technical steps are difficult mainly because of the cervical paraspinal muscle mass, which cannot be easily "elevated and retracted" despite previous descriptions; bleeding from the venous plexus can be excessive as suggested by dissection and our own experience; the stability of the cervical spine may be compromised following extensive laminectomy with total unilateral facetectomy; exposure of the plexus distal to the division of the trunks is difficult; there may be injury to the long thoracic nerve and subsequent winging of the scapula; and pneumothorax. This approach is therefore only applicable in highly selected cases involving multiple avulsed roots with proximal lesions extending as far as the division of the trunks.
Functional deficits of the striated anal sphincteric muscles without any apparent gross defect often result in a lack of ability to postpone defaecation by intention or in faecal incontinence in response to increased intra-abdominal or intra-rectal pressure. We applied electrostimulation to the sacral spinal nerves to increase function of the striated muscles of the anal sphincter. Of three patients followed for 6 months, two gained full continence and one improved from gross incontinence to minor soiling. Closure pressure of the anal canal increased in all. Preliminary data indicate that anal closure pressure increases with the duration of stimulation. Continuous stimulation of sacral spinal nerves can help some patients with faecal incontinence. It may be possible to promote continence with intermittent stimulation.
Between 1974 and 1980 the authors have performed 218 radiofrequency thermocoagulations of spinal nerve roots or posterior branches. The procedure is atraumatic and selective but requires considerable technical accuracy. Its major indications (posterior lumbalgias, spondylolisthesis, staged spinal syndromes, painful thoraco-abdominal scars, etc.) emerge from this detailed review of a large series of patients suffering from pain of spinal or extraspinal origin. Satisfactory results were obtained in 39% to 45% of these patients for whom conventional treatments had failed. This should encourage to try this strictly percutaneous technique (usually performed under local anaesthesia) before open surgery.