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We are presenting this document to medical providers as a systematic approach to improve outcomes of patients with COVID-19. The following variables are considered: Autonomic nervous system viewed from the perspective of the Polyvagal Theory; Timing of interventions in terms of phase of the body’s defense ( Fight, Flight, Freeze, Faint ); The nervous system considered the context of a “ One System ” perspective; Protein/Enzyme function; Immune system; Cytokine load - activity, inflammation and metabolic response; Viral load; Angiotensin 2 load. The ARDS and multi-system organ failure of the COVID-19 is a complex problem. This approach acknowledges the complexity and presents a structure where the variables are systematically addressed. 1. The common risk factors for death are associated with baseline elevations of pro-inflammatory cytokines. Measures can be taken to lower them before being exposed to the virus–Plan A. 2. Strategies to optimize the body’s defenses should be assessed and optimized. These include nutrition, vitamins, and trace elements, sleep, exercise, and minimizing threat. 3. The body’s own resources are utilized through recruiting the autonomic nervous system to counteract elevated pro-inflammatory cytokines. The interventions are implemented in the context of what stage of defense the body is in–fight, flight, freeze, or faint. 4. Progressive pharmacological interventions are considered with the early interventions being those with minimal risk. We are asking the following: This approach is viewed as the foundation for clinical interventions. They should be implemented in a systematic and stepwise manner. Most of the treatments are already medically proven with minimal or no risk. All basic treatments are in place before more aggressive interventions are implemented. That this process be considered a framework to test clinical protocols and novel therapies. Much work needs to be done regarding dosing and timing. We are particularly interested in the potential of the following interventions, which do need to be looked at in a protocol. o Allowing ketosis in the Mid and Late Phases of the illness. o Considering the use of ketone bodies instead of glucose for fuel in Mid and Late Phases of illness. o Eliminating glucocorticosteroids in the Early and Mid-Phases the use of steroids. o Utilizing the anti-inflammatory cholinergic nervous system (vagal stimulation, nicotine patches, etc.). o Closer monitoring of IL-6 to in real time deliver the most appropriate interventions. Doi: 10.28991/SciMedJ-2020-02-SI-2 Full Text: PDF

This anatomical study was performed to elucidate the pertinent foraminal and lateral L5 nerve anatomy to enhance our understanding of possible neurologic causes of failed decompression surgery. Persistent extraforaminal L5 nerve compression is a possible cause of persistent symptoms following lumbosacral surgery. The amount of extraforaminal space for the L5 ventral ramus was examined in fifty adult human skeletons (100 sides). Based on morphology, the specimens were then categorized (types I-IV) on the basis of the bony space available for the nerve at this location. Next, 25 embalmed adult cadavers (50 sides) underwent bilateral dissection of the lower lateral lumbar region. The type of bony extraforaminal outlet was documented for each cadaver on the basis of our skeletal analysis. Lastly, segments (intra- and extra-foraminal) of the L5 ventral ramus were excised and examined histologically. Types I-IV outlets were found in 43, 31, 20 and 6 skeletal sides, respectively. For cadavers, 22,15, 10 and 3 sides were found to have types I-IV bony outlets, respectively. In cadavers, all type IV outlets and 70% of the type III bony configurations adjacent to the L5 ventral ramus had signs of neural irritation/injury including vascular hyalinization and increased fibrosis distal to the intervertebral foramen. No distal segments of type I and type II outlets showed histological signs of neural compromise. Patients with symptoms referable to L5 nerve compression for whom no proximal pathology is identified could warrant investigation of the more distal extraforaminal segment of this nerve.

The purpose of this chapter is to look at the decision-making process, outcomes, and complications of revision lumber decompressions versus primary decompressions. Decision-making and the choice of procedure is possibly the most critical factor in determining a successful outcome. The chapter will address the issues in relationship to both soft disc ruptures and spinal stenosis. The focus is pathology recurring at the same level and side and contralateral ruptures at the same level will not be considered.

The authors describe a 48-year-old woman suffering from bilateral upper-extremity numbness and axial radiating pain. Magnetic resonance imaging revealed soft-tissue edema and enhancement surrounding the dorsal tip of the C7 spinous process. Excisional biopsy of the lesion revealed a mildly inflamed bursa, with no evidence of an active infection. Removal of the inflamed bursa resulted in complete resolution of the upper-extremity numbness and improvement in her neck pain. Although similar cases have been reported to be associated with rheumatologic conditions, most notably polymyalgia rheumatica (PMR), the current report underlines the presentation of radicular-like complaints associated with interspinous bursitis in the absence of other conditions affecting the musculoskeleton.

Anatomical Study.Determine if shoulder depression (eg, taping the shoulders) might result in C5 nerve traction and subsequent injury.Postoperative C5 nerve palsy is a recognized entity that is still often enigmatic. Inferior shoulder depression is usually employed to assist with surgical visualization during cervical spine procedures.In the supine position, 10 adult fresh frozen human cadavers underwent dissection of the spinal cord and its adjacent dorsal, ventral roots, and spinal nerves from C4 to T1. In the supine position, the head was rotated ipsilaterally, contralaterally, and in lateral flexion. The shoulder was elevated, retracted, protracted, and depressed all with direct observation of nerve roots, intradural ventral/dorsal rootlets, or the spinal cord. The effects of these movements upon the cervical nerve rootlets were measured.The greatest displacement of nervous tissue was generated by shoulder depression and occurred primarily at the intradural rootlet level. The nerve rootlets that underwent the greatest average displacement were found at C5, with a decreasing gradient to C7 and no gross motion at C8 or T1. With maximal shoulder depression, C5-C7 rootlet tension produced cord movement to the ipsilateral side, touching the dura mater covering the lateral vertebral column with the C5 nerve root moving farthest.Shoulder depression is often used during cervical spine surgery. In cadavers, shoulder depression causes significant tension and displacement of the C5 nerve rootlets, and in the extreme, cord displacement to the ipsilateral side. This could be a mechanism for injury, putting patients at greater risk for postoperative C5 palsy.5.

Introduction The operating microscope (OM) has become instrumental in aiding surgeons during key microdissection with greater safety and detail. An exoscope offers similar detail with improved functionality and greater implications for live teaching and improved operating room flow. Methods Eleven senior neurosurgery residents and fellows performed unilateral, single-level laminotomies on fresh cadavers using an OM and exoscope. Three attending spine surgeons blinded for the visualization technique used then reviewed and graded each decompression. Data points gathered included time of procedure, grading of decompression (1–5), and complications, including dural tear, nerve root injury, and pars fracture. Results Operative times between the 2 systems were not significantly different (14.9 minutes OM vs. 15.6 minutes exoscope, P = 0.766). Despite high variability between evaluators in assessing complications and adequacy of decompression, there was no significant difference between either system. Postprocedural surveys indicated greater comfort with the exoscope, greater ease of use, and superior teaching potential for the exoscope over the standard OM. Conclusion In our simulated operating room model, an exoscope is a valid alternative to the standard OM that affords the surgeon greater comfort with greater teaching potential while maintaining many of the microscope's benefits.

Of patients who have undergone lateral approaches to the thoracic spine, surgical site postoperative pain appears to be greater among those who have undergone transection and removal of a rib segment than those who have not. Therefore, techniques that conserve anatomical position and minimize tissue disruption would theoretically result in less pain and a quicker recovery. Herein, we describe a rib-sparing osteoplastic technique used when rib segments need to be displaced in order to create an unobscured corridor to the operative target. Our approach minimizes soft tissue disruption and restores the anatomical function of the rib. Based on our experience, these patients report less pain, mobilize earlier, and are discharged sooner than those who have had rib segments sacrificed as part of a lateral approach to the spine.

Objective We hypothesized that the entry site of the basivertebral vein into the basivertebral foramen of C2 might localize the subdental synchondrosis between the odontoid process and body of C2, which may be helpful for odontoid fracture classification. Methods Twenty-five dry adult C2 specimens underwent thin-cut computed tomography and were sectioned sagittally. The basivertebral foramen was then correlated to internal bony anatomy. Fifty magnetic resonance images were reviewed, and the location of the subdental synchondrosis was determined. Results A basivertebral foramen was identified on the posterior surface of all dry C2 specimens. The openings were found at a distance of 30%–44% on an inferosuperior point along the vertical height of C2. For bony specimens with a subdental synchondrosis remnant (75%), entry of acupuncture needles into the basivertebral foramen was always directly at the level of the synchondrosis remnant. For magnetic resonance imaging (MRI), a subdental synchondrosis or its remnants were seen on all studies. The distance from the base of C2 to the subdental synchondrosis ranged from 9–13 mm. This equated to an inferosuperior point 32%–43% along the vertical height of C2. A strong correlation existed when comparing the location of the basivertebral foramen of bony specimens and the subdental synchondrosis location on MRI. Conclusions The basivertebral foramen is a consistently present anatomic reference point for the subdental synchondrosis even if the latter cannot be seen on conventional radiographic imaging. Our MRI data might also be useful in helping differentiate lesions affecting C2 from normal subdental cartilaginous remnants that can be encountered on imaging.

Lumbar stenosis has become one of the most common spinal pathologies and one that results in neurogenic claudication, back and leg pain, and disability. The standard procedure is still an open laminectomy, which involves wide muscle retraction and extensive removal of the posterior spinal structures. This can lead to instability and the need for additional spinal fusion. We present a systemized and detailed approach to unilateral laminotomy for bilateral decompression, which we believe is superior to the standard open laminectomy in terms of intraoperative visualization, postoperative stability, and degree of invasiveness.

Injury to the lymphatic channels is a rare and relatively unknown complication of anterior approaches to the lumbar spine and can cause fluid to build up in the retroperitoneal space, resulting in a lymphocele. If they enlarge sufficiently, these collections of chyle in the abdomen can cause pain and bowel ischemia, and can compress nearby organs. The authors report 4 cases in which anterior approaches to the lumbar spine were complicated by a postoperative retroperitoneal chylous fluid collection. They describe the anatomy of the lymphatic system and pathophysiology of this disease entity, review the sparse literature on this subject, and recommend a treatment algorithm. Maintaining a high index of suspicion for this clinical entity in patients who have recently undergone an anterior approach to the thoracic or lumbar spine is vital to avoid delays in diagnosis and treatment.

Study design Report of four collected cases. Objective The purpose of this report is to describe the presentation, diagnostic workup, treatment, and pathologic findings in four cases of lymphocytic reaction in patients receiving a metal-on-metal total disc replacement (TDR). Summary of background data Metal-on-metal designs in hip arthroplasty have gained popularity because of decreased volumetric wear rates and theoretically increased implant longevity. Systemic metal ions produced have not been associated with adverse clinical sequelae, although there have been reports of local soft-tissue reactions leading to early prosthetic failure. Histologic evaluation in these cases suggested a cell-mediated delayed-type hypersensitivity reaction. Metal-on-metal bearings have also emerged in lumbar and cervical TDR. Methods This report is on four patients, from three centers, who underwent TDR, using a metal-on-metal implant, and later presented with symptoms that were determined to be due to lymphocytic reaction. Details of their symptoms, diagnostic work-up, treatment, and outcomes were compiled. Results All four patients initially had a good surgical outcome, followed by the onset and worsening of axial pain, and/or radicular symptoms months later. All patients had imaging findings of a mass lesion with neurologic impingement. All three of the lumbar patients underwent a decompressive posterior procedure before the eventual device removal and fusion. Intraoperatively, in all the lumbar cases, a thick, yellowish, avascular soft-tissue mass was found to be responsible for an epidural-mass effect on the thecal sac. In the cervical case, there was a gray-tinged soft-tissue response around the implant, suggestive of metallosis. Independent laboratory analysis confirmed a lymphocytic reaction to the implant. Three of the patients had a good outcome after the explant and revision surgery. The remaining patient continued to have residual symptoms related to the neural compression caused by the mass. Conclusions In this group of patients from three centers, a metal-on-metal TDR resulted in a lymphocytic reaction causing subsequent failure of the surgery. This phenomenon has previously been recognized with metal bearings in hip arthroplasty. Surgeons using metal-on-metal TDRs should be aware of this possible occurrence.

Intraoperative neurophysiological monitoring is a commonly used practice during spine surgery. Complications of electromyography (EMG) needle electrode placement are very uncommon. We present a patient who was infected with necrotizing fasciitis in her left thigh due to an EMG needle electrode during a two-stage complex spine procedure. This case demonstrates that providers should continue to meticulously adhere to protocol when inserting and removing EMG needles, but also be cognizant during postoperative observation of the possibility of infection caused by EMG needles.

Background Context Injuries to the lumbar plexus during lateral approaches to the spine are not uncommon and may result in permanent deficits. However, the literature contains few studies that provide landmarks for avoiding the branches of the lumbar plexus. Purpose The present anatomical study was performed to elucidate the course of these nerves in relation to lateral approaches to the lumbar spine. Study Design This is a quantitative anatomical cadaveric study. Methods The lumbar plexus and its branches were dissected on 12 cadaveric sides. Metal wires were laid on the nerves along their paths on the posterior abdominal wall. Fluoroscopy was performed in the anteroposterior and lateral positions. The relationships between regional bony landmarks and the branches of the lumbar plexus were observed. Results When viewed laterally, the greatest concentration of nerves occurred from the posteroinferior aspect of L4, inferior along the posterior one-third of the body of L5, then at the level of the sacral promontory. On the basis of our study, approaches to the anterior two-thirds of the L4 vertebra and anterior third of L5 will result in the lowest chance of lumbar plexus nerve injury. In addition, lateral muscle dissection through the psoas major should be in a superior to inferior direction in order to minimize nerve injury. Laterally, the widest corridor between branches in the abdominal wall was between the subcostal and iliohypogastric nerves. Conclusions The findings of our cadaveric study provide surgeons who approach the lateral lumbar spine with data that could decrease injuries to the branches of the lumbar plexus, thus lessening patient morbidity.

Study Design Narrative review of the literature. Objectives Determine if the term cognitive behavioral therapy (CBT) is useful in clinical care and research. What literature supports these variables being relevant to the experience of chronic pain? What effects of CBT in treating these factors have been documented? What methods and platforms are available to administer CBT? Methods Chronic low back pain (CLBP) is a complex neurologic disorder with many components. CBT refers to a broad family of therapies that address both maladaptive thoughts and behaviors. There are several ways to deliver it. CLBP was broken into five categories that affect the perception of pain, and the literature was reviewed to see the effects of CBT on these variables. Results The term cognitive behavioral therapy has little use in future research because it covers such a wide range of therapies. CBT should always be defined by the problem it is intended to solve. The format and method of delivery should be defined because they have implications for outcomes. They are readily available even at the primary care level. The effectiveness of CBT is unquestioned regarding its effectiveness in treating each of the variables that affect CLBP. It is unclear why it is not more widely implemented. Conclusions CBT represents a family of therapies that are effective for a wide range of problems, many of which coexist with and influence CLBP. Each of the variables can be improved with focused CBT. Early, widespread adoption of CBT in treating and preventing CLBP is recommended. Future research and clinical care should focus on strategies to operationalize these well-documented treatments utilizing a public health approach.

Injury to the lymphatic channels is a rare and relatively unknown complication of anterior approaches to the lumbar spine and can cause fluid to build up in the retroperitoneal space, resulting in a lymphocele. If they enlarge sufficiently, these collections of chyle in the abdomen can cause pain and bowel ischemia, and can compress nearby organs. The authors report 4 cases in which anterior approaches to the lumbar spine were complicated by a postoperative retroperitoneal chylous fluid collection. They describe the anatomy of the lymphatic system and pathophysiology of this disease entity, review the sparse literature on this subject, and recommend a treatment algorithm. Maintaining a high index of suspicion for this clinical entity in patients who have recently undergone an anterior approach to the thoracic or lumbar spine is vital to avoid delays in diagnosis and treatment.

Study design/setting A community hospital prospective, nonrandomized chart review. March 2004 to December 2006, 58 patients were treated. Adverse events: new complaints and increasing length of stay limit early mobilization and require consultation with other physicians or reoperation. These formed the focus of the study. Objective Assess patient demographics and adverse events related to direct lateral lumbar approach. Summary of background data Clinicians advocate anterior column support for lumbar conditions. Minimally invasive stabilization of lumbar spine via direct lateral approach gained popularity owing to perceived decrease in patient morbidity. Methods Mild or major adverse events during hospital stay or within 6 weeks of discharge were considered early complications and designated as medical, approach, or implant related. A historical cohort of open posterior spinal fusion patients was used for comparison. Results Forty-three female and 15 male patients with a mean age of 61 years formed the study group. Surgery performed included 38 single level, 19 2-level, and 1 3-level case. Adverse events occurred in 13 patients (22.4%); 8 events were approach, 3 medical, and 1 implant bone interface related. Major complications occurred in 5 patients (8.6%). Two patients (3.4%) with L4 nerve injury showed residual motor effects, at 1 year postoperatively. Significant differences were noted between single and 2-level cases; Estimated blood loss (EBL) and operative time. Open posterior fusion patients experienced greater operative time and increased EBL compared with minimally invasive cases. Conclusions Major adverse events approximated 8.6% with approach-related complaints of nerve irritation nearing 3.4%. Mild complications occurred in 13.7% of patients. Meralgia paresthetica was a primary approach-related complaint. Most complaints significantly reduced by first postoperative visit. One patient (1.7%) had symptoms lasting over a year that did not adversely affect function. Significant finding related to exposure, that is, 1-versus 2-level cases. Overall morbidity reduction noted by EBL is considerably less compared with the historical cohort. Direct lateral lumbar interbody fusion has proven to be of value.

Introduction Hypothesis—A structured screening protocol including assessment of psychological well-being with subsequent self-directed physician supervised noninterventional treatment protocol can successfully avoid elective lumbar spine surgery while optimizing patient well-being. Background—Certain patients with chronic LBP without focal neurological deficits or significant instability or deformity may benefit from optimization of their psychological well-being before contemplating elective low-back surgery. In certain cases these interventions may actually ameliorate the patient symptoms to a degree that the originally planned surgery is no longer pursued while the patients experience a substantial improvement of their quality of life. Material and Methods From January 2012 onwards a routine protocol at the Swedish Neurosciences Institute required new patients presenting to our spine clinics to complete routine psychological testing for anxiety, depression, and irritability. All patients with abnormal scores in any of the categories were placed into a structured “prehab” program with a self-directed mental and physical health program. Only patients who had presented with degenerative lumbar disorders, such as central or foraminal spinal stenosis and mild degenerative spondylolisthesis that corresponded with their symptoms were considered candidates for surgery. Results During a required minimum 1-year follow-up of 25 patients selected for a formal “Prehab program” due to their abnormal psychological profiles we identified no cases of neurological decline, no conversions to surgery, and confirmed statistically significant improvement in patient-related outcomes scores (ODI, VAS, opiate index, and psychological wellness scores). Interestingly none of these patients required interventional spine management during our observation period while also increasing their functional activity profiles based on reported activity tolerances. Conclusion We identified two potential conclusions based on our early results: (1) Inclusion of psychological wellness testing including screening for anxiety, depression, and irritability may be a valuable adjuvant to routine other screening tests for elective lumbar spine surgery. (2) Emphasis on correction of abnormal psychological profiles in a formalized “Prehab program” may positively influence patients' subjective well-being to the point where surgical care may be delayed or not required anymore. Further investigation of a “mind body syndrome” in its spinal symptom manifestations may be warranted to optimize patient selection and treatment outcomes.