Transpedicular lag screw placement in traumatic cervical spondylolisthesis: Case report and systematic review of the literature.

Traumatic spondylolisthesis of C2-C3 is an unstable fracture. Posterior fixation techniques can be employed with intraoperative navigation, however this tool is not available to all spine surgeons. Furthermore, the evidence for posterior surgical stabilization of C2, while adhering to motion preservation principles is currently unknown. The authors describe a patient who had fractures of the pedicle and vertebral body of C2 and C3, which was successfully stabilized with freehand placement of C2 pedicle lag screws and subsequent C2-C5 fixation. Subsequently, a systematic review was performed to evaluate studies that utilized C2 lag screw placement in patients with traumatic spondylolisthesis of the axis (TSA). Eight retrospective case series were identified (N = 63 patients). Five studies evaluated an open posterior cervical approach and 3 investigated a percutaneous approach. Follow-up time ranged from 2 to 48 months and fusion was successful in most cases. No intra-operative complications were reported. On final follow-up, 2 patients had unintentional C2-C3 fusion, and 3 had C2-C3 instability. Three minor complications (urinary tract infection, surgical site hematoma, respiratory infection) were also reported, that resolved with medical management. Freehand placement of C2 pedicle lag screws may be a viable option in select cases. While posterior C2 lag-screw fixation demonstrated successful fusion in most patients with TSA, the supporting evidence is limited to level IV studies.

Spine Surgery Complicated by an Engorged Lumbar Epidural Venous Plexus from Cerebrospinal Fluid Overshunting: A Case Report and Review of the Literature.

BACKGROUND: Overshunting of cerebrospinal fluid may lead to intracranial hypotension and dilation of spinal epidural veins. Radiculopathy may rarely occur secondary to engorged spinal epidural veins. In addition, the cause of radiculopathy may be obscured by concomitant spinal degenerative changes. We present a case and review the pathogenesis as well as the current clinical literature. CASE DESCRIPTION: A 29-year-old woman presented with positional headaches from intracranial hypotension in the setting of cerebrospinal fluid overshunting. The patient also had back pain and lumbar radiculopathy, which became more severe after lumboperitoneal shunt placement. On radiographic work-up, there was evidence of right L5 nerve root impingement secondary to a disc bulge and an engorged lumbar epidural venous plexus secondary to overshunting. The patient underwent surgery for a planned L4-5 decompression with a transforaminal lumbar interbody fusion. The operation was complicated by rapid blood loss originating from the epidural venous plexus, and we were unable to safely place the interbody graft. CONCLUSIONS: Spinal surgeons need to be aware of the rare diagnosis of radiculopathy secondary to epidural venous plexus engorgement, as it may change the treatment approach or lead to deleterious intraoperative consequences, such as hemorrhage.