Preoperative ODI and Intake of Analgesics Predict Outcome after Lumbar Microdiskectomy: Results from a Prospective Register

Background Lumbar disk herniation (LDH) typically causes leg pain and neurologic deficits, but can also be a source of low back pain (LBP). Lumbar microdiskectomy (LMD) is among the most common neurosurgical procedures to relieve radicular symptoms. It is important for both surgeon and patient to understand potential predictors of outcome after LMD. The aim of this study was to investigate if the presence and intensity of preoperative LBP, the ODI score, and analgesic intake can predict the outcome of patients undergoing LMD. Methods This is a single-center retrospective study based on the analysis of prospectively acquired data of patients in the SwissDisc Registry. A total of 685 surgeries on 640 patients who underwent standardized LMD at our institution to treat LDH were included in this study. We performed multivariable linear regression analysis to determine preoperative predictors for patient outcomes based on the Oswestry Disability Index (ODI) scores, recorded on average 39.77 (±33.77) days after surgery. Results Our study confirmed that surgery overall improves patient degree of disability as measured by ODI score. Following model selection using Aikake Information Criterion (AIC), we observed that higher preoperative ODI scores (β: 0.020 [95% CI: 0.008 to 0.031]) and higher number of analgesic medication usage by patients prior to surgery (β: 0.236 [95% CI: 0.057 to 0.415]) were both associated with an increased postoperative ODI score. Conclusion LDH surgery generally improves patient degree of disability. The analysis of patients with a high preoperative ODI score and increased intake of analgesics before surgery predicted a worsening of patients' disability after LMD in this subgroup.

Revision for Cage Migration After Transforaminal/Posterior Lumbar Interbody Fusion; How to Perform Revision Surgery?

BackgroundSymptomatic pseudarthrosis and cage migration/protrusion are difficult complications of transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). If the patient experiences severe radicular symptoms due to cage protrusion, removal of the migrated cage is necessary. However, this procedure is sometimes very challenging because epidural adhesions and fibrous union can be present between the cage and vertebrae. We describe a novel classification and technique utilizing a navigated osteotome and the oblique lumbar interbody fusion at L5/S1 (OLIF51) technique to address this problem.MethodsThis retrospective study investigated consecutive patients with degenerative lumbar diseases who underwent TLIF/PLIF. Symptomatic cage migration was evaluated by direct examination, radiography, and/or computed tomography (CT) at 1, 3, 6, 12, and 24 months of follow-up. Cage migration/protrusion was defined as symptomatic cage protrusion >5 mm from the posterior border of the over and underlying vertebral body compared with initial CT. We evaluated patient characteristics including body mass index, smoking history, fusion level, and cage type. A total of 113 patients underwent PLIF/TLIF (PLIF n=30, TLIF n=83), with a mean age of 71.1 years (range, 28–87 years). Mean duration of follow-up was 25 months (range, 12-47 months). ResultsCage migration was identified in 5 of 113 patients (4.4%). All cases of symptomatic cage migration involved the L5/S1 level and the TLIF procedure. Risk factors for cage protrusion were age (younger), sex (male), and level (L5/S1). The mean duration to onset of cage protrusion was 3.2 months (range, 2–6 months). We applied a new classification for cage protrusion: type 1, only low back pain without new radicular symptoms; type 2, low back pain with minor radicular symptoms; or type 3, cauda equina syndrome and/or severe radicular symptoms. According to our classification, one patient was in type 1, three patients were in type 2, and one patient was in type 3. For all cases of cage migration, revision surgery was performed using a navigated high-speed burr and osteotome, and the patient in group 1 underwent additional PLIF without removal of the protruding cage. Three revision surgeries (group 2) involved removal of the protruding cage and PLIF, and one revision surgery (group 3) involved anterior removal of the cage and OLIF51 fusion.ConclusionsThe navigated high-speed burr, navigated osteotome, and OLIF51 technique appear very useful for removing a cage with fibrous union from the disc in patients with pseudarthrosis. This new technique makes revision surgery after cage migration much safer, and more effective. This technique also reduces the need for fluoroscopy.

Novel wrapping surgery for symptomatic sacral perineural cysts

OBJECTIVE Perineural cysts, also called Tarlov cysts, are dilatations of the nerve root sleeves commonly found in the sacrum. The majority of the cysts are asymptomatic and found incidentally on routine spine imaging. Symptomatic sacral perineural cysts (SPCs) that induce intractable low-back pain, radicular symptoms, and bladder/bowel dysfunction require surgery. However, the surgical strategy for symptomatic SPCs remains controversial. The authors hypothesized that the symptoms were caused by an irritation of the adjacent nerve roots caused by SPCs, and developed a wrapping surgery to treat these cysts. METHODS Seven patients with severe unilateral medial thigh pain and ipsilateral SPCs were included. Preoperative MRI showed that the cysts were severely compressing the adjacent nerve roots in all patients. After a partial laminectomy of the sacrum, the SPCs were punctured and CSF was aspirated to reduce their size, followed by dissection of the adjacent nerve roots from the SPCs. The SPCs were then wrapped with a Gore-Tex membrane to avoid reexpansion. RESULTS All 7 patients experienced substantial relief of their symptoms. The average numeric rating scale pain score was reduced from an average preoperative value of 7.9 to 0.6 postoperatively. Postoperative MRI showed that all cysts were reduced in size and the adjacent nerve roots were decompressed. Regrowth of the treated cysts or recurrence of the symptoms did not occur during the entire follow-up period, which ranged from 39 to 90 months. No complications were noted. CONCLUSIONS The authors’ new wrapping technique was effective in relieving radicular symptoms for patients with symptomatic SPCs. The results suggested that the symptoms stemmed from compression of the adjacent nerve roots caused by the SPCs, and not from the nerve roots in the cysts.

HIGH GRADE DYSPLASTIC SPONDYLOLISTHESIS IN AN 11 YEAR OLD GIRL CHILD - A CASE REPORT

High-Dysplastic Developmental Spondylolisthesis (HDDS) is an extremely rare situation, comprising of around 5% of the total cases of spondylolisthesis. Clinical Description :- A eleven year-old girl with high-grade dysplastic L5-S1 spondylolisthesis with pain in her lower back along with radicular pain to her lower limbs (right > left). Her X-rays depicted a L5 - S1 anterolisthesis leading to an abnormal kyphosis at lumbo-sacral junction, increased lumbar lordosis and reversal of thoracic kyphosis to lordosis. Management:- A was done along with a cage insertion at the L5 - S1 level. L5 - S1 posterior - spinal fixation Outcome:- Postural correction was achieved immediately post-op and the patient also had relief from the radicular symptoms.

Comparison of SDSG and CARDS classifications for L5/S1 lumbar degenerative spondylolisthesis: an independent inter- and intra-observer agreement study

Background Lumbar degenerative spondylolisthesis (DS) has been a common disease that makes increasing patients to suffer from different degrees of low back pain and radicular symptoms. The Spinal Deformity Study Group (SDSG) and the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) systems are commonly used to classify the disease, and help to make a more detailed treatment plan. The objective of this study is to compare the reliability and reproducibility of SDSG and CARDS classifications, and to explore their clinical application value. Methods/design All 117 patients with L5/S1 lumbar DS were enrolled. Five experienced spine surgeons were selected to assess DS with SDSG and CARDS systems. Kappa (K) value was used to check the coefficient consistency for multi-factor and assess the inter- and intra-observer agreement. After 12 weeks, the analysis was repeated. Results The inter-observer reliability and intra-observer reproducibility of SDSG system were substantial with K values of 0.704 and 0.861, while those of CARDS system were substantial with values of 0.620 and 0.878. Conclusion SDSG system had better inter-observer reliability in comparison with CARDS system, and though CARDS system is more intuitive and simpler, it is more likely to produce deviations when using it. Both SDSG and CARDS systems show substantial agreement and have great significance in surgical strategy of L5/S1 lumbar DS, they can be widely used in clinical practice.

Spinal arthrodesis via lumbar interbody fusion without direct decompression as a treatment for recurrent radicular pain due to epidural fibrosis: patient series

BACKGROUND Lumbar radiculopathy is the most common indication for lumbar discectomy, but residual postoperative radicular symptoms are common. Postoperative lumbar radiculopathy secondary to scar formation is notoriously difficult to manage, with the mainstay of treatment focused on nonoperative techniques. Surgical intervention for epidural fibrosis has shown unacceptably high complication rates and poor success rates. OBSERVATIONS Three patients underwent spinal arthrodesis without direct decompression for recurrent radiculopathy due to epidural fibrosis. Each patient previously underwent lumbar discectomy but subsequently developed recurrent radiculopathy. Imaging revealed no recurrent disc herniation, although it demonstrated extensive epidural fibrosis and scar in the region of the nerve root at the previous surgical site. Dynamic radiographs showed no instability. Two patients underwent lateral lumbar interbody fusion, and one patient underwent anterior lumbosacral interbody fusion. Each patient experienced resolution of radicular symptoms by the 1-year follow-up. Average EQ visual analog scale scores improved from 65 preoperatively to 78 postoperatively. LESSONS Spinal arthrodesis via lumbar interbody fusion, without direct decompression, may relieve pain in patients with recurrent radiculopathy due to epidural fibrosis, even in the absence of gross spinal instability.

Identifying lumbosacral plexus nerve root abnormalities in patients with sciatica using 3T readout-segmented echo-planar diffusion weighted MR neurography

Objectives To investigate the accuracy of Diffusion Weighted Imaging (DWI) using the Readout Segmentation of Long Variable Echo-trains (RESOLVE) sequence in detecting lumbosacral nerve abnormalities. Methods Following institutional ethics committee approval, patients with sciatica-type lower limb radicular symptoms (n = 110) were recruited and prospectively scanned using 3T MRI. Additional participants (n = 17) who underwent neurophysiological testing (EMG/NCV), were also prospectively studied. In addition to routine lumbar spine MRI, a DWI-RESOLVE sequence of the lumbosacral plexus was performed. Two radiologists, blinded to the side of patient symptoms, independently evaluated the MR images. The size and signal intensity changes of the nerves were evaluated using ordinal 4-point Likert-scales. Signal-to-noise ratio (SNR), apparent diffusion coefficient (ADC) and size were measured for affected and normal nerves. Inter-observer agreement was determined with kappa statistics; κ. Results In patients who did not undergo EMG/NCV testing (n = 110), the DWI-RESOLVE sequence detected lumbosacral nerve abnormalities that correlated with symptoms in 36.3% (40/110). This is a similar percentage to patients who underwent EMG/NCV testing, which was positive and correlated with symptoms in 41.2% (7/17). Inter-observer agreement for evaluation of lumbosacral nerve abnormalities was excellent and ranged from 0.87 to 0.94. SNR and nerve size measurements demonstrated statistically significant differences for the L5 and S1 nerves (p value < 0.05) for patients who did not undergo EMG/NCV testing. Conclusion The DWI-RESOLVE sequence is a promising new method that may permit accurate detection and localization of lumbar nerve abnormalities in patients with sciatica.

A Rare Case of Calcifying Pseudoneoplasms of the Neural Axis in Lumbar Spine

Calcified pseudoneoplasm of the neural axis (CAPNON) is a very rare, non-neoplastic, calcified pathological entity occurring anywhere in the central nervous system (CNS). Overall, less than 100 cases were reported, of which less than 50% were from the spine. We present a case of a 53-year-old lady with a history of L4–L5 radiculopathy, known case of rheumatoid arthritis, and with no previous history of trauma, tumor or infection. MRI showed calcified intradural mass, extending into the right lateral recess, which was isointense on T1- and T2-weighted sequences. Fenestration on right side along with complete resection of the lesion was done. Mass was found adherent around the dura, extending in to right L5 nerve root foramen, and histopathological examination confirmed the diagnosis of CAPNON. At 6 months follow-up, the patient is pain-free with no radicular symptoms. This entity should be taken in as differential in cases of calcified intraspinal and intracranial lesions. Surgical resection is the treatment of choice.