Zig-Zag Skin Incision for Treatment of Tarsal Tunnel Syndrome.

BACKGROUND: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy of the posterior tibial nerve. Surgery can be performed less invasively under local anesthesia. We adopted zig-zag skin incision to prevent postoperative wound complications. METHODS: Between July 2022 and June 2023, we operated on 19 legs of 14 consecutive TTS patients (5 males, 11 females; average age 73.3 years). We made a 2- to 3-cm zig-zag skin incision on the tarsal tunnel. After posterior tibial nerve decompression by posterior tibial artery (PTA) transposition, the subcutaneous layer was tightly sutured with 4-0 PDS and the skin was closed with Dermabond Advanced. We investigated adverse events that developed during the first 30 postoperative days and recorded surgical outcomes at the final visit. RESULTS: In all patients the nerves were successfully decompressed with PTA transposition. There were no intraoperative complications. During the 30 postoperative days there were no adverse events, including wound complications, and patients' symptoms improved significantly. CONCLUSION: Zig-zag skin incision was easy and convenient for surgical TTS treatment and may be useful for preventing postoperative wound complications.

Reliability of PainDETECT for Evaluating Low Back Pain Caused by Cluneal Nerve Entrapment.

BACKGROUND: Superior/middle cluneal nerve entrapment (CN-E) is an elicitor of low back pain (LBP). The painDETECT questionnaire is used to characterize CN-E symptoms. METHODS: Nineteen consecutive patients with LBP caused by CN-E (superior CN-E = 7; middle CN-E = 12) participated in a Japanese language painDETECT questionnaire survey before surgery. A score of 12 or lower was recorded as 'neuropathic component unlikely', a score of 19 or higher as 'neuropathic pain likely', and scores between 13 and 18 as 'neuropathic pain possible'. LBP severity was recorded on a numerical rating scale, the Roland-Morris Disability Questionnaire, and the EuroQol-5 dimension-5 level. RESULTS: The mean painDETECT score was 11.8 and did not significantly differ between the superior CN-E and middle CN-E groups. We classified low back pain as unlikely to have a neuropathic component in 13 patients, as likely to have a neuropathic component in 2 patients, and as possibly neuropathic in 4 patients. There was no significant difference in the pain level of patients with scores of ≤12 and ≥13 on painDETECT. All patients reported trigger pain; the positive rate was high for electric shock pain, radiating pain, and pain attacks and low for a burning or tingling sensation, pain elicited by a light touch, and pain caused by cold or hot stimulation. CONCLUSION: The painDETECT questionnaire may not reliably identify LBP caused by superior/middle CN-E as neuropathic pain. A diagnosis of LBP due to CN-E must be made carefully because symptoms resemble nociceptive pain.

A Patient with Tarsal Tunnel Syndrome Associated with the Flexor Digitorum Accessorius Longus Muscle.

The flexor digitorum accessorius longus muscle (ALM) can be overlooked as the eliciting factor in patients with tarsal tunnel syndrome (TTS), an entrapment neuropathy of the posterior tibial nerve that elicits sole numbness and pain. Most elicitations are idiopathic, however, mass lesions within the tarsal tunnel can be also implicated. We report an 80-year-old woman whose flexor digitorum ALM led to the onset of bilateral TTS. She had suffered numbness in both soles for 3 years. Magnetic resonance imaging (MRI) of the bilateral tarsal tunnel showed that the posterior tibial nerve was compressed by the arteriovenous complex and in contact with the flexor digitorum ALM. We diagnosed bilateral TTS based on her symptoms and imaging findings, and performed bilateral decompression surgery of the posterior tibial nerve under local anesthesia. The artery on both sides was dislocated for nerve decompression. Because the posterior tibial nerve on the right side was strongly compressed in ankle plantar flexion we excised a portion of the tendon compressing the nerve. Postoperatively her symptoms gradually improved and she reported surgical satisfaction 6 months after the operation. In patients with flexor digitorum ALM-related TTS, the effect of dynamic factors on MRI findings and on surgical treatment decisions must be considered. Intraoperatively, not only the flexor digitorum ALM, but also other potential etiologic factors eliciting TTS must be kept in mind.

Ganglia-Induced Tarsal Tunnel Syndrome.

BACKGROUND: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel. METHODS: Between August 2020 and July 2022, we operated on 117 sides with TTS. This retrospective study examined data from 8 consecutive patients (8 sides: 5 men, 3 women; average age 67.8 years) with an extraneural ganglion in the tarsal tunnel. We investigated the clinical characteristics and surgical outcomes for these patients. RESULTS: The mass was palpable through the skin in 1 patient, detected intraoperatively in 1 patient, and visualized on MRI scanning in the other 6 patients. Symptoms involved the medial plantar nerve area (n = 5), lateral plantar nerve area (n = 1), and medial and lateral plantar nerve areas (n = 2). The interval between symptom onset and surgery ranged from 4 to 168 months. Adhesion between large (≥20 mm) ganglia and surrounding tissue and nerves was observed intraoperatively in 4 patients. Of the 8 patients, 7 underwent total ganglion resection. There were no surgery-related complications. On their last postoperative visit, 3 patients with a duration of symptoms not exceeding 10 months reported favorable outcomes. CONCLUSIONS: Because ganglia eliciting TTS are often undetectable by skin palpation, imaging studies may be necessary. Early surgical intervention appears to yield favorable outcomes.

Identification and decompression of superior cluneal nerve implicated in low back pain.

INTRODUCTION: Low back pain (LBP) can be attributable to entrapment of the superior cluneal nerve (SCN) around the iliac crest. Surgical decompression is a useful treatment; however, finding all entrapped SCNs involved in patients with LBP can be difficult. We performed a retrospective study to help identify entrapped SCNs in the narrow surgical field. METHODS: We enrolled 20 LBP patient (22 sides) with SCN entrapment. They were 9 males and 11 females; their mean age was 72.5 years. We developed a 3-step procedure for successful SCN decompression surgery. In step 1, the thoracolumbar fascia is exposed and the SCN penetrating the fascia is released. In step 2, the fascia is opened and the SCN is released. In step 3, the fascia above the iliac crest is opened and the SCN is released. RESULTS: We successfully released 66 nerves; the average was 3.0 ± 0.8 (1-4) per patient. Step 1 detected 18 nerves (27.3%), step 2 identified 35 (53.0%), and in step 3, 13 (19.7%) were recognized. By tracing the thin nerves branching off the SCN, we found 7 nerves (10.6%). We performed 22 operations; step 1 identified 16 SCNs (72.7%), step 2 identified 21 (95.5%), and step 3 found 12 nerves (54.5%). CONCLUSIONS: The SCN is most readily identified upon opening of the thoracolumbar fascia. To identify as many SCN branches as possible, our 3-step method may be useful.

Transarticular Fixation Using Bioabsorptive Screws for Cervical Lesions.

Transarticular screw fixation is a method for posterior cervical fixation. It is ergonomic because neither connectors nor rods are needed. Biomechanical studies have shown that its fixation force is not inferior to that of lateral mass screws. More information is needed on the surgical outcome of procedures using bioabsorptive screws. We investigated the long-term surgical and radiological outcomes of posterior cervical decompression and fusion using bioabsorptive screws for transarticular fixation.Of 10 patients who underwent cervical spine transarticular fixation using bioabsorptive screws, nine presented with cervical degenerative spondylosis and one with a traumatic cervical spine injury. The mean postoperative follow-up period was 57.1 months. Transarticular screw fixation was successful in all 10 patients; no intraoperative complications were encountered. Bilateral screw breakage was discovered in a patient with cervical spine instability and associated dystonia due to cerebral palsy; there was no symptom deterioration, facet joint breakage, or instability exacerbation. Facet fusion was obtained in the nine other patients. At the patients' last visit, their clinical symptoms were significantly improved. Whole cervical spine alignment (-4.21 ± 7.2 to -5.2 ± 8.7) and the fused segment angle (mean, -0.1 ± 9.9 to -1.2 ± 13.7) did not significantly worsen postoperatively (mean: -0.1 ± 9.9 to -1.2 ± 13.7). Transarticular fixation using bioabsorptive screws is safe and associated with good long-term outcomes. In patients with exacerbation of local instability after posterior decompression, additional transarticular fixation using bioabsorbable screws is a treatment option.

Metastatic Spinal Tumor from Benign Pleomorphic Adenoma: Case Report and Literature Review.

PURPOSE: Pleomorphic adenomas tend to arise in the salivary glands. They are rare and histologically benign but can result in distant metastasis, and their characteristics need further investigation. We report a case of locally recurring benign primary palatal pleomorphic adenoma that resulted in spinal metastases and review the relevant literature. CASE REPORT: A 58-year-old woman had undergone surgery for a palatal pleomorphic adenoma 22 years earlier and 6 subsequent operations for local recurrences. During follow-up, metastases to multiple organs, including the spine, were diagnosed and 4 CyberKnife treatments were performed. She suffered right flank pain and slight paralysis of the right leg; radiological findings showed a growing metastatic spinal tumor. She underwent removal of a thoracic vertebral tumor and posterolateral fusion. Postoperatively, her symptoms improved. Histopathological analysis indicated a pleomorphic adenoma and no evidence of malignancy. Although there was no local recurrence, 23 months after surgery, a fifth CyberKnife procedure was performed for a growing salivary gland tumor and she is currently being followed up. CONCLUSION: We described a rare case of benign pleomorphic adenoma that metastasized to the spine. Long-term follow-up for recurrence and metastasis is required for patients with benign pleomorphic adenoma.

Patient Satisfaction with Surgery for Tarsal- and Carpal- Tunnel Syndrome - Comparative Study.

We compared the treatment satisfaction of patients who had undergone surgery for tarsal tunnel syndrome (TTS) and carpal tunnel syndrome (CTS). We enrolled 44 patients in this study; 23 were operated for CTS and 21 for TTS. All patients had received surgery under a microscope and under local anesthesia. Using the numerical rating scale (NRS) for numbness/pain (range 0-10) we compared their preoperative outcome expectations with their satisfaction with our treatment 6 months after the operation. We also recorded their pre- and postoperative EuroQol 5-dimension 5-level (EQ-5D-5L) scale for their health-related quality of life (QOL). The subjective assessment of their QOL showed that it was significantly lower in TTS- than CTS patients both pre- and postoperatively. Six months after the operation, the NRS for symptoms and the (EQ-5D-5L) scale for the QOL were significantly improved in TTS- and CTS patients; however, these scores were significantly better after CTS- than TTS surgery. Also, the postoperative NRS was significantly lower in the CTS- than the TTS patients. Our comparison of the patients' expected- and actual surgical outcome showed that the result was better than expected after CTS- and TTS surgery; in CTS patients the difference was significant. Overall, CTS- were more satisfied than TTS patients with the treatment outcome. Satisfaction with the treatment was greater after CTS- than TTS surgery. TTS- experienced less symptom relief than CTS patients although the actual- exceeded the expected outcome in patients operated for TTS.

Paralysis Immediately after Surgical Decompression for Common Peroneal Nerve Entrapment.

OBJECTIVE: Common peroneal nerve (C-PN) entrapment neuropathy is the most common peripheral nerve neuropathy of the legs. C-PN decompression surgery is less invasive but may result in neurological complications. We report a rare case of nerve paralysis immediately after C-PN decompression surgery. CASE REPORT: An 85-year-old man presented with leg numbness and pain. An electrophysical study revealed C-PN entrapment in the affected area and he underwent surgical decompression. Immediately after the procedure he complained of slight paralysis without pain (manual muscle test: 3/5), which gradually worsened and was complete at 60 min after surgery. We re-opened the skin incision 3 hours after the first operation and found that a subcutaneous suture had been applied to the connective tissue near the C-PN, resulting in marked compression of the nerve. After release of the suture his paralysis improved immediately. We confirmed that there was no other nerve compression and finished the operation. His paralysis disappeared completely. CONCLUSION: Peripheral nerve surgery, including C-PN decompression surgery, is less invasive, and the risk of complications is low. However, because the C-PN is located in the shallow layer under the skin, an excessively deep suture in the subcutaneous layer may compress the nerve and elicit nerve palsy. Therefore, careful postoperative follow-up is necessary because early decompression leads to good surgical results.

Magnetic Resonance Imaging Findings in Patients with Tarsal Tunnel Syndrome.

Tarsal tunnel syndrome (TTS) is a common entrapment syndrome whose diagnosis can be difficult. We compared preoperative magnetic resonance imaging (MRI) and operative findings in 23 consecutive TTS patients (28 sides) whose mean age was 74.5 years. The 1.5T MRI sequence was 3D T2* fat suppression. We compared the MRI findings with surgical records and intraoperative videos to evaluate them. MRI- and surgical findings revealed that a ganglion was involved on one side (3.6%), and the other 27 sides were diagnosed with idiopathic TTS. MRI visualized the nerve compression point on 23 sides (82.1%) but failed to reveal details required for surgical planning. During surgery of the other five sides (17.9%), three involved varices, and on one side each, there was connective tissue entrapment or nerve compression due to small vascular branch strangulation. MRI studies were useful for nerve compression due to a mass lesion or idiopathic factors. Although MRI revealed the compression site, it failed to identify the specific involvement of varices and small vessel branches and the presence of connective tissue entrapment.

Patient satisfaction with cluneal nerve entrapment surgery.

INTRODUCTION: Low back pain (LBP) from superior or middle cluneal nerve entrapment has been addressed surgically. We recorded patient satisfaction with this treatment. METHODS: We included 22 consecutive patients who had undergone surgery for unilateral cluneal nerve entrapment (superior: n = 17, middle: n = 5). The numerical rating scale (NRS) for LBP, the Oswestry Disability Index (ODI) score, and the EuroQOL 5-dimension, 5-level (EQ-5D-5L) scale before and 6 months after the operation were compared. Using these scores, the treatment outcome was compared with the patients' preoperative expectations. RESULTS: LBP was ameliorated in all 22 patients; their NRS, ODI, and EQ-5D-5L were significantly improved after surgery. Surgical satisfaction based on the postoperative NRS scores was recorded as 8.8 ± 1.1 (range 7-10). While the postoperative was significantly better than the expected NRS, the postoperative ODI was significantly higher than expected by the patients (both: p < 0.05). There was a moderate correlation between the postoperative NRS and ODI and postoperative patient satisfaction. CONCLUSION: Patient satisfaction with the surgical result was rated as acceptable.

Perioperative Complications and Adverse Events after Surgery for Peripheral Nerve- and Para-lumbar Spine Diseases.

Peripheral nerve diseases are common. Para-lumbar spine diseases (PLSDs) include peripheral neuropathy around the lumbar spine, e.g., cluneal nerve entrapment and gluteus medius muscle pain. While these diseases can be treated by less invasive surgery, postoperative complications have not been sufficiently investigated. We document complications after surgery for peripheral nerve diseases and PLSDs. Between July 2014 and December 2020, 678 consecutive patients with peripheral nerve diseases and PLSDs underwent 1068 surgical procedures (upper limb 200 sites, lower limb 447 sites, para-lumbar spine 394 sites, and tumor 27 sites). After excluding 27 procedures to address tumors, we examined the remaining 1,041 procedures undergone by 672 patients (average age 68.2 years) and recorded the complication rate observed within 30 days after the procedures. The overall surgical complication rate was 3.9% (41/1041 procedures); 6 procedures required surgical salvage and 35 were treated conservatively. There were no long-term sequelae from complications. The complication rate was high after surgery for lateral femoral cutaneous-, saphenous-, and common peroneal nerve entrapment and tarsal tunnel syndrome; all sites involved the lower limbs. As a result, intergroup comparison showed that the complication rate was significantly higher for the upper limb (3.0%) procedures than the lower limb (6.7%) and PLSD (1.3%) procedures. It was significantly lower for PLSD operations than lower and upper limb operations. The patient age and diabetes mellitus were significant risk factors for postoperative complications. Their rate was low in patients treated for peripheral nerve diseases and PLSDs; 34 of the 41 complications (82.9%) were related to the surgical wound.

Meralgia Paresthetica Caused by Surgery in the Park-Bench Position.

OBJECTIVE: Meralgia paresthetica (MP) is an entrapment neuropathy of the lateral femoral cutaneous nerve (LFCN). We report a rare case of MP after microvascular decompression (MVD) surgery in the park-bench position in a patient with hemifacial spasm. CASE: The patient was a nondiabetic 46-year-old woman (height: 155 cm, weight: 42 kg) who consumed alcohol infrequently. After a first MVD for right hemifacial spasm, the symptom recurred and she underwent a second MVD procedure in the park-bench position, after which hemifacial spasm resolved. However, she reported right anterolateral thigh pain and dysesthesia without motor weakness. The pain was limited to the LFCN area, and a pelvic compression test elicited a positive Tinel-like sign. Our preliminary diagnosis was MP. Because conservative therapy was ineffective, she underwent LFCN block 9 months after the second MVD procedure. Her pain improved dramatically and we made a definitive diagnosis of MP. There has been no recurrence after 30 months of observation, although she reported persistent mild dysesthesia in the LFCN area. CONCLUSION: MP is a rare complication after MVD surgery in the park-bench position. LFCN block can resolve symptoms and hasten diagnosis.

[Carpal Tunnel Syndrome:Diagnosis and Treatment].

Carpal tunnel syndrome(CTS)is a common entrapment neuropathy caused by compression of the median nerve around the wrist. The risk factors of CTS include female sex, diabetes mellitus, hypothyroidism, obesity, arthritis, hemodialysis, acromegaly, and pregnancy. CTS is characterized by paresthesia in the distribution of the median nerve. Patients are often unaware of ring-finger splitting and the combination of Tinel's sign and Phalen's test improves diagnostic accuracy. In addition, electrophysiological assessments can help to confirm a CTS diagnosis; their sensitivity ranges from 57-94% and their specificity from 51-97%. CTS negatively affects the quality of life but improvement by surgery can be expected. For conservative treatment, a neutral wrist splint worn at night or oral medication such as nonsteroidal anti-inflammatory drugs, vitamin B12, and pregabalin have been shown to be effective against CTS. CTS surgery may be indicated in patients with thenar muscle atrophy and when conservative treatment is ineffective. The surgery involves a small skin incision under a microscope and local anesthesia. Long-term outcomes with respect to pain, numbness, function, symptomatology relapse, and frequency of re-surgery do not significantly differ between patients subjected to open or endoscopic surgery.

High-flow bypass surgery using a radial artery graft for an extracranial internal carotid artery aneurysm: Case reports and literature review.

BACKGROUND: Extracranial carotid artery aneurysms are rare. Surgery may be difficult when vessels are tortuous and on a high cervical level. We report two patients whose tortuous extracranial internal carotid artery (ICA) aneurysm located on a high cervical level was successfully treated by ICA ligation and a high-flow bypass using a radial artery (RA) graft between the external carotid- and the middle cerebral artery. CASE DESCRIPTION: (Case 1) A 47-year-old man suffered a recurrent cerebral infarct despite medical treatment. His right extracranial ICA aneurysm measured 33 mm; it was tortuous and located at a high cervical level. We ligated the ICA after placing a high-flow bypass using an RA graft. The aneurysm was not repaired. (Case 2) A 59-year-old woman noticed pulsatile swelling on her left neck. It was due to an extracranial ICA aneurysm that was large (36 mm), tortuous, and located at a high cervical level. We performed ICA ligation after placing a high-flow bypass using an RA graft without direct aneurysmal repair. Six months after the operation she noted a pulsatile bulge on the left oropharynx. We confirmed recurrence of an aneurysm from retrograde blood flow and performed internal trapping by occluding the distal portion of the ICA aneurysm using an intravascular procedure. CONCLUSION: ICA ligation after placing a high-flow bypass with an RA-graft is a technically demanding, but safe procedure to address extracranial ICA aneurysms that are tortuous and located at a high cervical level.

Systematic Review of Spinal Lymphomatoid Granulomatosis Cases.

Lymphomatoid granulomatosis (LYG) is a rare Epstein-Barr virus-associated systemic angiocentric and angiodestructive lymphoproliferative disorder. It commonly involves the lungs and can also affect the skin, liver, kidney, and central nervous system. It can rarely occur in the spine, however, the details are unclear. We performed a systematic review of published cases (including our 1 case) of spinal LYG. We performed a systematic search of studies in English on spinal LYG, focusing on its clinical features, imaging, and treatments, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on the PubMed database. We identified 14 patients from the literature. We also found 1 case of isolated cervical LYG (grade 3) who was treated with steroid and radiation therapy for the spinal lesion after pathologic diagnosis. We performed a pooled analysis of these 15 cases. The mean age was 43.4 years, and 13 of the 15 patients were male. Brain lesions were present in 11 of 12 intramedullary spinal lesions, and only 1 was an isolated spinal LYG case. Regarding the diagnostic methods, 1 case was not described. Of the 14 cases described, 12 patients underwent biopsies (7 brain, 4 lung, and 1 spinal cord lesion) and 2 underwent surgical removal for an extramedullary lesion. In the overall prognosis from a mean follow-up period of 21.6 months, 4 patients died despite several treatments. Spinal LYG, particularly isolated spinal LYG, is rare. Thus further accumulation of cases may be necessary to better understand its characteristics.

Less Invasive Combined Micro- and Endoscopic Neurolysis of Superficial Peroneal Nerve Entrapment: Technical Note.

As superficial peroneal nerve (S-PN) entrapment neuropathy is relatively rare, it may be an elusive clinical entity. For decompression surgery addressing idiopathic S-PN entrapment, narrow-area decompression may be insufficient and long-area decompression along the S-PN from the peroneus longus muscle (PLM) to the peroneal nerve exit site may be required. To render it is less invasive, we performed S-PN neurolysis in a combined microscope/endoscope procedure. We report our surgical procedure and clinical outcomes. We microsurgically decompressed the affected S-PN under local anesthesia without a proximal tourniquet. We made a small linear skin incision at the distal portion of the S-PN, performed distal decompression of the S-PN where it penetrated the deep fascia, and then performed proximal decompression under an endoscope. At the site where the S-PN exited the PLM, we placed additional small incisions and proceeded to microscopic decompression. We surgically treated three patients with S-PN entrapment. They were two men and one woman ranging in age from 66 to 85 years. The mean postoperative follow-up was 22 months. Their symptoms before treatment and at the latest follow-up visit were recorded on the numerical rating scale (NRS). The mean incision length was 5.5 cm and 17.3 cm of the S-PN was decompressed. All three patients reported postoperative symptom improvement. There were no complications. In patients with idiopathic S-PN entrapment, long-site neurolysis under local anesthesia using a microscope/endoscope combination is useful.

Therapeutic Effect of Mirogabalin on Peripheral Neuropathic Pain due to Lumbar Spine Disease.

STUDY DESIGN: Retrospective study. PURPOSE: This study aims to evaluate the effectiveness of mirogabalin in treatment of peripheral neuropathic pain due to lumbar spine disease. OVERVIEW OF LITERATURE: Mirogabalin is a novel selective ligand for the α2δ subunit of voltage-gated Ca channels. METHODS: Between April and December 2019, we used mirogabalin to treat 60 consecutive patients (mean age, 67.6 years) with leg symptoms due to lumbar disease. The treatment outcome after 8 weeks of mirogabalin therapy was evaluated by comparing the preand post-administration Numerical Rating Scale (NRS) for leg symptoms and sleep disturbance, the NRS and Roland-Morris Disability Questionnaire for low back pain (LBP), and the quality of life (QOL) score (based on EuroQol five-dimension five-level scale). RESULTS: Mirogabalin treatment was stopped at less than eight weeks in eight patients. The remaining 52 patients for evaluation were divided as group 1 (17 patients who presented with leg symptoms that lasted for less than 3 months) and group 2 (35 patients with leg symptoms that lasted longer than 3 months). The leg symptoms and LBP in both groups significantly improved at 4 and 8 weeks of treatment, and sleep disturbance and QOL were improved at 8 weeks as well. Compared to group 2, the pretreatment leg symptoms and QOL were significantly worse in group 1, and their improvement after 8 weeks of mirogabalin treatment was significantly better (p<0.05). Of the 60 original patients, 17 suffered adverse effects, which were mild in 16 patients and required treatment cessation due to excessive weight gain in one patient. CONCLUSIONS: We have validated the effect of mirogabalin on neuropathic pain due to lumbar spine disease, which has effectively addressed the associated leg symptoms, LBP, and sleep disturbance.

High-frequency thermal coagulation to treat middle cluneal nerve entrapment neuropathy.

OBJECTIVE: Middle cluneal nerve entrapment (MCN-E) around the sacroiliac joint can elicit low back pain (LBP). Pain control can be obtained with anesthetic nerve blocks; however, when their effectiveness is transient, surgical release may be necessary. We investigated the efficacy of radiofrequency thermocoagulation (RFTC) in patients with MCN-E. METHODS: Between December 2018 and August 2019, 11 consecutive patients (4 men, 7 women; mean age 76.4 years) with intractable medial buttock pain due to MCN-E underwent MCN RFTC. The mean symptom duration was 49.5 months; pre-RFTC local MCN blocks provided pain relief for a mean of 7.7 days. The severity of pain in the medial buttock due to MCN-E was recorded before and 2, 6, 12, and 24 weeks after RFTC on the numerical rating scale (NRS) and the Roland-Morris Disability Questionnaire (RDQ). RESULTS: All patients reported pain alleviation; there were no complications. While there was a significant difference in the pre- and post-RFTC treatment NRS (p < 0.05), the RDQ scores were significantly lower only after 12 weeks. The duration of pain relief was significantly prolonged by RFTC (p < 0.05). Two patients suffered pain relapse 10 weeks post-RFTC; pain alleviation was obtained by re-RFTC performed 2 weeks after pain recurrence. Two other patients relapsed 20 and 21 weeks post-RFTC; their symptoms also disappeared by MCN block administered 24 weeks after they had undergone RFTC. CONCLUSION: RFTC may safely control intractable LBP due to MCN-E.

Recurrent Cervical Spinal Epidural Hematoma: Case Report and Literature Review.

Spinal epidural hematoma (SEDH) is an uncommon pathology. Here, we report a case of SEDH with recurrences, along with a literature review of relevant cases to identify characteristics of SEDH recurrence. A 13-year-old girl experienced sudden-onset of back pain and bilateral leg weakness. She was diagnosed with a cervical idiopathic epidural hematoma, and the symptoms subsided with conservative management. Four months after the event, she again experienced back pain due to recurrence of the cervical epidural hematoma, but she was observed because no neurological deficits could be detected. Fifteen months after the initial SEDH, she experienced severe back pain and tetra-paresis due to recurrence. The SEDH was located in the left ventral and dorsal aspect at the C6-T1 level, with severe spinal cord compression. The hematoma was removed through left hemilaminectomy. Bleeding was noted from the epidural venous plexus along the left C6 spinal root, which had coagulated. After hematoma resection, her symptoms gradually improved, and she was discharged 3 weeks after surgery without any neurological deficits. No hematoma recurrence has since been experienced. Recurrent SEDH is relatively rare, with only 11 cases previously reported. Recurrent hematoma cases are more common in young, female patients, while SEDH, in general, is more common in males in their late forties. The recurrence interval is shorter in non-surgical cases than those requiring surgery. Knowledge of these characteristics may be useful in the future management of SEDH.