Christian Fisahn

The Effectiveness and Safety of Exoskeletons as Assistive and Rehabilitation Devices in the Treatment of Neurologic Gait Disorders in Patients with Spinal Cord Injury: A Systematic Review

Study Design Systematic review. Clinical Questions (1) When used as an assistive device, do wearable exoskeletons improve lower extremity function or gait compared with knee-ankle-foot orthoses (KAFOs) in patients with complete or incomplete spinal cord injury? (2) When used as a rehabilitation device, do wearable exoskeletons improve lower extremity function or gait compared with other rehabilitation strategies in patients with complete or incomplete spinal cord injury? (3) When used as an assistive or rehabilitation device, are wearable exoskeletons safe compared with KAFO for assistance or other rehabilitation strategies for rehabilitation in patients with complete or incomplete spinal cord injury? Methods PubMed, Cochrane, and Embase databases and reference lists of key articles were searched from database inception to May 2, 2016, to identify studies evaluating the effectiveness of wearable exoskeletons used as assistive or rehabilitative devices in patients with incomplete or complete spinal cord injury. Results No comparison studies were found evaluating exoskeletons as an assistive device. Nine comparison studies (11 publications) evaluated the use of exoskeletons as a rehabilitative device. The 10-meter walk test velocity and Spinal Cord Independence Measure scores showed no difference in change from baseline among patients undergoing exoskeleton training compared with various comparator therapies. The remaining primary outcome measures of 6-minute walk test distance and Walking Index for Spinal Cord Injury I and II and Functional Independence Measure–Locomotor scores showed mixed results, with some studies indicating no difference in change from baseline between exoskeleton training and comparator therapies, some indicating benefit of exoskeleton over comparator therapies, and some indicating benefit of comparator therapies over exoskeleton. Conclusion There is no data to compare locomotion assistance with exoskeleton versus conventional KAFOs. There is no consistent benefit from rehabilitation using an exoskeleton versus a variety of conventional methods in patients with chronic spinal cord injury. Trials comparing later-generation exoskeletons are needed.

Against the odds: what to expect in rehabilitation of chronic spinal cord injury with a neurologically controlled Hybrid Assistive Limb exoskeleton. A subgroup analysis of 55 patients according to age and lesion level

Objective Age and lesion level are believed to represent outcome predictors in rehabilitation of patients with chronic spinal cord injury (SCI). The Hybrid Assistive Limb (HAL) exoskeleton enables patients to perform a voluntary controlled gait pattern via an electromyography-triggered neuromuscular feedback system, and has been introduced as a temporary gait training tool in patients with SCI. The aim of this prospective pre- and postintervention study was to examine functional outcomes as a function of age and lesion level in patients with chronic incomplete SCI (iSCI) or chronic complete SCI (cSCI) with zones of partial preservation (ZPP) by using the HAL as a temporary training tool. Methods Fifty-five participants with chronic iSCI or cSCI (mean time since injury 6.85 ± 5.12 years) were classified according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) and divided by age (< 50 or ≥ 50 years), independent of lesion level, and also into 4 homogeneous groups according to lesion level. The subgroups were as follows: Subgroup 1, tetraplegic iSCI (n = 13) (C2-8, AIS C [n = 8] and AIS D [n = 5]); Subgroup 2, paraplegic iSCI with spastic motor behavior (n = 15) (T2-12, AIS C [n = 8] and AIS D [n = 7]); Subgroup 3, paraplegic cSCI with complete motor paraplegia and absence of spastic motor behavior (n = 18) (T11-L4 [AIS A], and ZPP from L-3 to S-1); and Subgroup 4, paraplegic iSCI with absence of spastic motor behavior (n = 9) (T12-L3, AIS C [n = 8] and AIS D [n = 1]). The training paradigm consisted of 12 weeks of HAL-assisted treadmill training (5 times/week). Baseline status was documented prior to intervention by using the AIS grade, Walking Index for SCI II (WISCI II) score, the 10-meter walk test (10MWT), and the 6-minute walk test (6MinWT). Training effects were assessed after 6 and 12 weeks of therapy, without HAL assistance. Results Overall, a time reduction of 47% in the 10MWT, self-selected speed (10MWTsss) (< 50 years = 56% vs ≥ 50 years = 37%) and an increase of 50% in the 6MinWT were documented. The WISCI II scores showed a mean gain of 1.69 levels. At the end of the study, 24 of 55 patients (43.6%) were less dependent on walking aids. Age had a nonsignificant negative influence on the 10MWTsss. Despite a few nonsignificant subgroup differences, participants improved across all tests. Namely, patients with iSCI who had spastic motor behavior improved to a nonsignificant, lesser extent in the 6MinWT. Conclusions The HAL-assisted treadmill training leads to functional improvements in chronic iSCI or cSCI, both in and out of the exoskeleton. An improvement of approximately 50% in the 10MWTsss and in gait endurance (6MinWT) can be expected from such training. The influences of SCI lesion level and age on functional outcome were nonsignificant in the present study. Older age (≥ 50 years) may be associated with smaller improvements in the 10MWTsss. An iSCI in paraplegic patients with spastic motor behavior may be a nonsignificant negative predictor in gait endurance improvements. Clinical trial registration no.: DRKS00010250 ( https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_DE.do ).

Leonardo da Vinci (1452–1519) and his depictions of the human spine

IntroductionFew individuals in history have exerted so great an influence and made such extensive contributions to so many disciplines as Leonardo da Vinci. Da Vinci’s inquisitive, experimental mentality led him to many discoveries, such as spinal cord function and the proper anatomy of several organ systems. Respected not only as an artist but also as an anatomist, he made many significant contributions to the field.ConclusionsThis article explores da Vinci’s drawings, in relation to the anatomy of the human spine.

Hemivertebrae: a comprehensive review of embryology, imaging, classification, and management

PurposeThe purpose of this paper was to comprehensively review hemivertebrae in regard to their classification, embryology, etiology, diagnosis, clinical manifestations, and management of this developmental anomaly.MethodsThis subject review of hemivertebrae was composed after conducting a thorough review of the available literature on this topic using PubMed and other standard search engines.ResultsHemivertebrae are incomplete vertebral column segments that can result in congenital scoliosis and be associated with a range of other structural anomalies. Presentations may differ and based on location and classification, treatments may vary.ConclusionHemivertebrae are structural anomalies of the vertebral column that can potentially disrupt the spine’s normal curvature. Their clinical impact depends on factors such as degree of segmentation and concurrence with other structural anomalies. It is hoped that this review will provide the clinician who treats patients with hemivertebrae a resource in better understanding this finding and its subsequent pathological effects.

Unilateral Laminotomy with Bilateral Spinal Canal Decompression for Lumbar Stenosis: A Technical Note

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.

Ulf Fernström (1915–1985) and his Contributions to the Development of Artificial Disc Replacements

INTRODUCTION Artificial disc replacements, which serve the function of separating vertebrae to allow for proper spinal alignment, can help treat debilitating low back pain in patients who have failed other conservative methods of treatment. A Swedish surgeon, Ulf Fernström, was the pioneer of artificial disc replacement, and his contribution in the form of Fernström balls dramatically altered spinal surgery and technique by showing the proper technique and implant that should be used for areas requiring motion in many planes. HISTORY OF THE ARTIFICIAL DISC Ulf Fernström created his artificial disc inspired by the movement of the hip and knee joints. His implants attempted to restore disc spacing and articulation in patients who had failed conservative measures of treatment. Fernström balls were the first implants of their kind and represent the first attempt at artificial disc replacement. However, many surgeons and researchers questioned Fernström balls, claiming that their lack of elastic properties could damage patients. CONCLUSIONS Of the wide range of implants on the market for the intervertebral disc space, all designs and applications of products stem from the initial discovery made by Fernström, thus making him a pioneer in disc replacement.

Communicating branches between lingual and hypoglossal nerve: observation using Sihler’s staining technique

PurposeMany dental procedures are at risk of injuring the lingual nerve. We performed this study to better elucidate the microanatomy that exists between the ipsilateral lingual and hypoglossal nerves so that iatrogenic injury can be avoided.MethodsAdult human cadaveric tongues (ten sides) underwent Sihler’s staining to identify the microanatomy between the lingual and hypoglossal nerves.ResultsThe lingual nerve entered the middle part of the anterior two-thirds of the tongue from its lateral side and divided into two to four thick branches. These branches were then disseminated to the anterior, middle, and posterior parts of the anterior two-thirds of the tongue via 7–14 thin nerve bundles as terminal branches. The hypoglossal nerve entered the tongue at the posterior border of its anterior two-thirds and traveled forward to the apex of the tongue on all sides. All specimens were found to have communicating branches between the lingual and hypoglossal nerves at its anterior, middle, and posterior thirds.ConclusionsOur results indicate that the ipsilateral lingual and hypoglossal nerves constantly have three connections on each side between them. This knowledge might aid the dentist in minimizing iatrogenic nerve injury.

Subdural Thoracolumbar Spine Hematoma after Spinal Anesthesia: A Rare Occurrence and Literature Review of Spinal Hematomas after Spinal Anesthesia

Spinal hematomas are a rare but serious complication of spinal epidural anesthesia and are typically seen in the epidural space; however, they have been documented in the subdural space. Spinal subdural hematomas likely exist within a traumatically induced space within the dural border cell layer, rather than an anatomical subdural space. Spinal subdural hematomas present a dangerous clinical situation as they have the potential to cause significant compression of neural elements and can be easily mistaken for spinal epidural hematomas. Ultrasound can be an effective modality to diagnose subdural hematoma when no epidural blood is visualized. We have reviewed the literature and present a full literature review and a case presentation of an 82-year-old male who developed a thoracolumbar spinal subdural hematoma after spinal epidural anesthesia. Anticoagulant therapy is an important predisposing risk factor for spinal epidural hematomas and likely also predispose to spinal subdural hematomas. It is important to consider spinal subdural hematomas in addition to spinal epidural hematomas in patients who develop weakness after spinal epidural anesthesia, especially in patients who have received anticoagulation.

The Dens: A Review of its Diverse Nomenclature and a Recommended Simplified Terminology

Pathology of the dens, such as fractures, demands precise terminology so that communication between physicians are succinct, diagnoses are accurate, and treatment strategies exact. This review aims to summarize the various terms used to describe the parts of the dens and recommend the ideal terminology. Using standard search engines, English language publications were searched for the many terms used to describe parts of the dens. A multitude of terms was identified with many demonstrating overlaps. Terms identified included apex, tip, apicodental, subdental, dentocentral and odontocentral junctions, peg, waist, base, neck, shaft, shoulder, and stem. Exact terminology is necessary when diagnosing or treating patients with pathology of or near the dens. The authors suggest simplified terminology for describing the parts of the dens that can be used in the future in order to be unequivocal and to avoid confusion when classifying and communicating fractures through its parts.

Anatomical complications of epidural anesthesia: A comprehensive review

Epidural anesthesia is a versatile technique widely used in treating lumbar spinal pain syndromes. Complications during these procedures can arise either from needle placement or from administration of medication. Potential risks include infection, hematoma, intravascular or subdural injections of medication, direct nerve trauma, air embolism, entry into a disc space, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar epidural injections and discuss the potential pitfalls related to these procedures. We searched Medline comprehensively for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all of them can be avoided by careful techniques with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging. Clin. Anat. 30:342–346, 2017.