Neurological Improvement after Omental Transplantation on the Upper Cervical Cord

admission to the Instituto Nacional de Salud del Niño (Peru), she was connected to a ventilator. During 11 months before surgery, she suffered of pain in the neck, as well as several episodes of pneumonia and urinary tract infection. During these months, she was attended by several peruvian and foreign neurosurgeons and all of them concluded that the patient is not neurosurgical. The examination showed a patient confined to bed, with tracheotomy and connected to an automatic fan. She suffered severe pain in the neck, slight dysarthria and severe weak voice (she was heard at one meter). She presented spastic tetraplegia predominantly in extension, patellar hyperreflexia and clonus at the ankles. The patient ́s sensory level was at C4, ciliospinal response in both sides, Babinski ́s sign on the right foot and doubtful on the left. An omental transplantation (free graft with vascular microanastomoses by invagination) was performed on July 2011, in two stages [4,6-10]. First, by means of laparotomy, a 4 x 15 cm segment of omentum was obtained, which contained vascular elements of good caliber. Second, the upper cervical cord was located through a laminectomy at the C2C3 level.


Background
To date, the sequelae of traumatized spinal cord is a challenging condition that only receives rehabilitation as treatment, in spite of previous neurosurgical experiences by means of omental transposition [1][2][3] or transplantation [4][5][6] on the affected zone. We report to a patient with severe sequelae in the upper cervical cord caused by a gunshot wound. The patient received an omental transplantation.

Case Report
A 4-year-old girl received a gunshot wound on August 8,2010 at the upper cervical cord, which was followed immediately by loss of alert, tetraplegia and loss of respiratory automatism. Ten days later, a magnetic resonance imaging (MRI) scans revealed a severe ischemic infarct in the cervical cord between C2 to C3 ( Figure 1). Since her

Discussion
Since November 20, 1987 and to date, we have transplanted omental tissue into about 400 patients with late sequelae in the spinal cord and cauda equina. All of them had dyscomplete or incomplete transection corroborated by means of clinical data [8] and/or MRI scans [4,8]. No patient with complete transection (Table 1) was operated.
The first 192 patients with traumatic spinal cord injury were not selective cases [11] and at the 4.5 year follow-up examination, approximately 40 percent of these operated patients experienced neurological improvement in various aspects of their motor, sensory, tone and sphincters functions. Meanwhile other authors [1,3,12] with selective patients and by means of omental transposition (pedicled graft), they observed a neurological improvement in about 65 percent of the cases [8,12].
Like our patient reported here, two patients were reported previously. Case 1, A 27-year-old man was admitted with a 3-years history of spastic paraplegia and sensory level at T6, caused by a gunshot wound. He received rehabilitation and suffered on various occasions from urinary tract infection. On November 29, 1987, he received an omental transplantation on the thoracic cord at the T4-T6 level [6]. During surgery we found: 1)leptomeningeal adhesions; 2) intramedullary fibrosis ; 3)reduction of blood vessels ; 4)medullar hypotropy of 40 percent and 2.5 cm of height, and 5) absence of two roots and hypotrophy of anothers four. The residual cord found corresponded to the anterior and right lateral parts of the spinal cord. After surgery, during the first days, the temperature of the lower limbs increased, the spasticity diminished and the voluntary movement of the toes of the right foot began. Likewise, he began to have anal sphincter control, followed by vesical control two weeks later. About 3 years later on, the sphincters control was almost normal and he presented motor improvement in right lower limbs. During whole postoperative evolution, he received only rehabilitation. Case 2, A 42-year-old man was admitted with a 21-year history of flaccid paraplegia by a gunshot wound at T6-T7. About 26-years of age, he acquired control of both sphincters by 80 percent, as well as penile erection under normal sexual stimulation. For this reason, he contracted marriage and procreated 4 children of 10, 8,4 and 1 year of age, respectively. On October 1988, he received an omental transplantation on the thoracic cord (4). During surgery we found: 1) abundant scar tissue peridural and left intradural; 2) spinal cord reduced to 25 percent of 6 cm length; 3) severe vascular alterations, and 4) absence of two roots and hypotrophy of anothers. The residual spinal cord corresponded to the anterior and right lateral portion of the thoracic cord. After surgery, he conserved the sphincters control and experienced motor improvement in the muscles of the lumbar region, and the tactile sensation in the right scrotum reappeared. Moreover, he acquired better control of both sphincters, as well as penile erection and ejaculation. After 10 years of follow-up, motor and sensory evolution in lower limbs remained without changes. Thus, our 3 patients presented incomplete anatomical transection of the spinal cord and with variable height of lesion; however, all of them demonstrated neurological improvement after surgery. In base to these results, we believe that all patients which incomplete transection must receive omental transplantation to recover the function of the residual nervous tissue in ischemia and ischemic penumbra in the traumatized spinal cord. Because through the omentum, the glia, neurons and axons in the residual spinal cord in ischemia and ischemic penumbra can improve if receives an increase in blood flow, oxygen, neurotrophic factors, adipocytokines and omental stem cells [8,[12][13][14][15]. Likewise, we anastomoses by invagination [10] between the right occipital vessels and the gastroepiploic vessels from the omentum, a small segment was placed on the anterior, right lateral and posterior surface of the residual cervical cord, as well as on a part of the superior and inferior normal cord. During the first days after surgery, the temperature of the limbs increased and the spasticity diminished. About 48 hours after surgery, she began with respiratory automatism, voice more intense and with voluntary movement of shoulders and neck. Ten days later, she presented sensory in her hands and voluntary movement, ocasionally, in the right limbs. Two months later, the voluntary movement in the right forearm and leg was evident and the pain in the neck disappeared. Four months after surgery, the motor improvement was better and she could stand up and to walk with aid of orthopedic devices (Figure 2). This postoperative picture is recorded on videotape.
One year after surgery, the voluntary movement of shoulders and neck improved by 70 percent and in less degree, in upper limbs and right leg. Moreover, the intensity of the voice to be heard to 15 meters of distance and she tolerated the respiration without ventilator until by 2 minutes in the daytime and 5 minutes during to sleep. It is two years since she suffered a severe respiratory complication by 2 weeks, which was attended at intensive care unit. Postoperative MRI scans (February 2014) showed small omentum at the C2 level and severe degenerative changes in the vertebral body of C3. At present, four years after surgery, she (a 9-year-old girl) present partial control of sphincters and the sensory is still deficient up to the T3 level. The voluntary movement in the right limbs is approximately by 40 percent, specially of proximal predominance. By contrast, the voice and movement of shoulders and neck is better. During whole postoperative evolution she has received rehabilitation, electrical stimulation in the cervical cord and she has been oriented to tolerate the respiration without ventilator.  confirm that the clinical analysis in patients with injured spinal cord is most important than the auxiliary studies, A similar conclusion was used for the diagnosis of the spinal or bulbar form of amyotrophic lateral sclerosis [9,16]. Because in this disease, with exception of electrodiagnostic studies, no another auxiliary study can demonstrate minute arteries less than 1 mm in diameter, in the spinal cord and /or medulla oblongata [9].
Finally, we wish to comment on the neurosurgical management in patients with traumatized spinal cord. The first part of the approach should be surgical liberation of the spinal cord and its roots, and second, omental transplantation to the affected zone of the spinal cord and part of the normal cord [4,11]. Besides this, during whole postoperative evolution the patient should receive rehabilitation, especially electrical stimulation of the superior and inferior cord to the affected zone [4,17,18].

Conclusions
Based in our wide experience with omental transplantation on the injured spinal cord, we have not doubt that the function of neurons and axons in the residual spinal cord can improve if circulation is restituted through the omentum and later on, because of neuronal regeneration, gliogenesis and neurogenesis. Besides this, the patients should receive rehabilitation and electrtical stimulation of the superior and inferior normal cord to the affected zone.