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Wild-type transthyretin (ATTRwt) amyloid deposits have been found in the ligamentum flavum of patients undergoing surgery for spinal stenosis. The relationship between ATTRwt and ligamentum flavum thickness is unclear. We used pre-operative magnetic resonance imaging (MRI) to analyze ligamentum flavum thickness in lumbar spinal stenosis patients with and without ATTRwt amyloid.We retrospectively identified 178 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 253 specimens was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and ATTRwt was confirmed using mass-spectrometry and gene sequencing.Twenty four of the 178 patients (13.5%) were found to have ATTRwt in the ligamentum flavum. Forty ATTRwt specimens and 213 non-ATTRwt specimens were measured. Mean ligamentum flavum thickness was 4.92 (±1.27) mm in the ATTRwt group and 4.00 (±1.21) mm in the non-ATTRwt group (p 0.01). The ligamentum flavum was thickest at L4-L5, with a thickness of 5.15 (±1.27) mm and 4.23 (±1.29) mm in the ATTRwt and non-ATTRwt group, respectively (p = 0.007). There was a significant difference in ligamentum flavum thickness between ATTRwt and non-ATTRwt case for both patients younger than 70 years (p = 0.016) and those older than 70 years (p = 0.004). ATTRwt patients had greater ligamentum flavum thickness by 0.83 mm (95% confidence interval (CI): 0.41-1.25 mm, p 0.001) when controlled for age and lumbar level.Patients with ATTRwt had thicker ligamentum flavum compared to patients without ATTRwt. Further studies are needed to investigate the pathophysiology of ATTRwt in ligamentum flavum thickening.

Background Wild-type transthyretin amyloid (ATTRwt) has been noted to deposit in the ligamentum flavum of the spine. Prior studies have focused on ATTRwt in the lumbar region, but studies discussing its presence in other levels of the spine are lacking. We report on the presentation of patients with confirmed amyloid in the cervicothoracic regions and discuss the literature to date. Methods We retrospectively identified patients at a single institution who underwent surgery for spinal stenosis and had pathologic specimens sent for amyloidosis testing with Congo red staining. ATTRwt was confirmed by the presence of transthyretin amyloid by typing and the absence of mutations in the TTR gene sequence. A final study group of patients with ATTRwt and spinal involvement was established (n = 27). Results Of 27 patients with amyloid in the spine, 24 (89%) had amyloid present in the lumbar region, 2 (7%) had amyloid in the cervical region, and 1 (4%) had amyloid in the thoracic region. The median age at which patients in the study underwent surgery was 71 years (interquartile range: 9). Spinal stenosis was the indication for surgery in 26 of 27 (96%) patients. Surgery involved 1 or 2 spinal levels in 24 of 27 (89%) patients. Conclusions ATTRwt amyloid predominantly deposits in the lumbar region, but it can also be present in the cervical and thoracic regions. While the lumbar regions should remain a focus for evaluation of ATTRwt amyloidosis, the cervicothoracic region should not be ignored.

Objective Traditionally surgery for degenerative lumbar pathology is performed under general anesthesia (GA). There have been several studies that have pointed to the negative cognitive effects of general anesthesia, and patients often frequently request alternatives. Considering this, it is advantageous to offer alternative anesthesia strategies. Studies have demonstrated spinal anesthesia (SA) being utilized successfully in decompressive lumbar surgeries; however, there is limited data evaluating use in fusion surgeries. This study presents a single institution’s experience with spinal anesthesia for minimally invasive transforaminal lumbar interbody fusions. Methods This is a retrospective review of a prospectively collected database analyzing 67 patients undergoing SA for lumbar fusion surgeries. Outcomes including data on safety, adverse events, and efficacy of SA were reviewed. In addition, patient demographics, complications, length of stay (LOS), disposition, and OR utilization time were recorded. Comparison to a similar cohort undergoing GA the year prior was completed. Results There was no difference in length of stay (GA 3.2d vs SA 2.9d, p = 0.104). More patients in the SA group were discharged home compared to the GA group (SA-76% vs GA-56%, p = 0.02). There were no occurrences of pneumonia (PNA) or deep vein thromboses/pulmonary embolus (DVT/PE). There was no difference in incidence of urinary tract infections (UTI) (GA-5% vs SA-1%, p = 0.27). Total OR time was decreased in the SA group(SA-164 min vs GA-200 min, p Conclusions SA is a safe alternative to GA and is time-efficient when compared to GA. SA can safely be considered as an option for patients undergoing lumbar instrumented fusion surgeries.

Wild-type transthyretin (ATTRwt) amyloid deposition has been found in the ligamentum flavum (LF) of patients undergoing spinal stenosis surgery. Our group previously reported that ATTRwt amyloid is associated with an increased lumbar ligamentum flavum thickness at symptomatic levels that required surgery. A comprehensive evaluation of LF thickness at asymptomatic levels in addition to symptomatic, treated levels has never been performed in ATTRwt patients. In this study, we compare the total LF thickness of all lumbar levels (lumbar LF burden) in ATTRwt and non-ATTRwt patients.We retrospectively identified 177 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 885 lumbar levels was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and subtype of ATTRwt was confirmed using mass-spectrometry and gene sequencing.Of the 177 patients, 30 (16.9%) were found to have ATTRwt in the ligamentum flavum. One hundred and fifty ATTRwt levels and 735 non-ATTRwt levels were measured by four different reviewers, with an intraclass coefficient (ICC) of 0.79. Mean ligamentum flavum thickness was 4.64 (±1.31) mm in the ATTRwt group and 3.99 (±1.45) mm in the non-ATTRwt group (p 0.001). The lumbar LF burden (sum of ligamentum flavum thickness at all lumbar levels) for ATTRwt patients was 23.22 (±4.48) mm, and for non-ATTRwt patients was 19.96 (±5.49) mm (p = 0.003) CONCLUSION: The lumbar LF burden is greater in patients with ATTRwt amyloid compared to non-ATTRwt patients. This supports prior evidence that ATTRwt amyloid deposition might be associated with increased LF thickness and lumbar stenosis. This potential association requires more research and could be an important finding, as medications have recently become available that can treat patients with ATTRwt amyloid deposition.

Background Transthyretin wild-type (ATTRwt) amyloidosis is a systemic process resulting in deposition of misfolded transthyretin protein in several different tissues throughout the body. It is known to be a cause of progressive, life-threatening cardiomyopathy and lumbar spinal stenosis and carpal tunnel syndrome. Case Description Here we present the case of a 71-year-old man who has clinical manifestations of all 3 entities over several years, providing a picture of the natural history of ATTRwt amyloidosis. This patient eventually underwent a heart transplant because of progressive cardiac amyloidosis (CA) resulting in end-stage heart failure. However, symptoms in carpal tunnel and lumbar spine manifested years before the symptoms of heart failure. ATTRwt amyloidosis may present as a clinical triad of lumbar stenosis, carpal tunnel syndrome, and heart failure. Recently developed medications have shown efficacy in slowing the progress of systemic and cardiac amyloidosis. Conclusions Knowing that extracardiac symptoms may occur first, we propose that sending ligamentum flavum and flexor tenosynovium for pathologic evaluation may be a unique opportunity to screen and treat a population of patients at risk for developing CA and heart failure.

Since antiquity, philosophers, theologians, and scientists have been interested in human memory. However, researchers today are still working to understand the capabilities, boundaries, and architecture. While the storage capabilities of long-term memory are seemingly unlimited (Bahrick, J Exp Psychol 113:1–2, 1984), working memory, or the ability to maintain and manipulate information held in memory, seems to have stringent capacity limits (e.g., Cowan, Behav Brain Sci 24:87–185, 2001). Individual differences, however, do exist and these differences can often predict performance on a wide variety of tasks (cf. Engle What is working-memory capacity? 297–314, 2001). Recently, researchers have promoted the enticing possibility that simple behavioral training can expand the limits of working memory which indeed may also lead to improvements on other cognitive processes as well (cf. Morrison and Chein, Psychol Bull Rev 18:46–60 2011). However, initial investigations across a wide variety of cognitive functions have produced mixed results regarding the transferability of training-related improvements. Across two experiments, the present research focuses on the benefit of working memory training on visual short-term memory capacity—a cognitive process that has received little attention in the training literature. Data reveal training-related improvement of global measures of visual short-term memory as well as of measures of the independent sub-processes that contribute to capacity (Awh et al., Psychol Sci 18(7):622–628, 2007). These results suggest that the ability to inhibit irrelevant information within and between trials is enhanced via n-back training allowing for selective improvement on untrained tasks. Additionally, we highlight a potential limitation of the standard adaptive training procedure and propose a modified design to ensure variability in the training environment.