Factors influencing slippage after microsurgical single level lumbar spinal decompression surgery - Are the psoas and multifidus muscles involved?

PURPOSE: Patients with lumbar spinal stenosis (LSS) require microsurgical decompression (MSD) surgery; however, MSD is often associated with postoperative instability at the operated level. Paraspinal muscles support the spinal column; lately, paraspinal volume has been used as a good indicator of sarcopenia. This study aimed to determine preoperative radiological factors, including paraspinal muscle volume, associated with postoperative slippage progression after MSD in LSS patients. METHODS: Patients undergoing single-level (L3/4 or L4/5) MSD for symptomatic LSS and followed-up for ≥ 5 years in our institute were reviewed retrospectively to measure preoperative imaging parameters focused on the operated level. Paraspinal muscle volumes (psoas muscle index [PMI] and multifidus muscle index [MFMI]) defined using the total cross-sectional area of each muscle/L3 vertebral body area in the preoperative lumbar axial CT) were calculated. Postoperative slippage in the form of static translation (ST) ≥ 2 mm was assessed on the last follow-up X-ray. RESULTS: We included 95 patients with average age and follow-up periods of 69 ± 8.2 years and 7.51 ± 2.58 years, respectively. PMI and MFMI were significantly correlated with age and significantly larger in male patients. Female sex, preoperative ST, dynamic translation, sagittal rotation angle, facet angle, pelvic incidence, lumbar lordosis, and PMI were correlated with long-term postoperative worsening of ST. However, as per multivariate analysis, no independent factor was associated with postoperative slippage progression. CONCLUSION: Lower preoperative psoas muscle volume in LSS patients is an important predictive factor of postoperative slippage progression at the operated level after MSD. The predictors for postoperative slippage progression are multifactorial; however, a well-structured postoperative exercise regimen involving psoas muscle strengthening may be beneficial in LSS patients after MSD.

Risk Factors for Distal Junctional Problems Following Long Instrumented Fusion for Degenerative Lumbar Scoliosis: Are they Related to the Paraspinal Muscles.

PURPOSE: Although the incidence of distal junctional problems (DJPs) following long construct-based treatment for degenerative lumbar scoliosis (DLS) is lower, affected patients are more likely to require revision surgery when they occur. So the aim of this study is to identify risk factors associated with DJPs to avoid its occurrence by at least 1-year follow-up. METHODS: A total of 182 DLS patients undergoing long instrumented fusion surgery (≥4 levels) between February 2011 and March 2022 were retrospectively analyzed. Patients were placed into the DJP group if a DJP occurred at the final follow-up; patients without mechanical complications were matched 1:2 according to age, sex and BMI as the control group. Patient characteristics, surgical variables, radiographic parameters, lumbar muscularity and fatty degeneration were analyzed statistically. The statistical differences in the results between the two groups (p values <0.05) and other variables selected by experts were entered into a multivariate logistic regression model, and the forwards likelihood ratio method was used to analyze the independent risk factors for DJPs. RESULTS: Twenty-four (13.2%) patients suffered a DJP in the postoperative period and the reoperation rate was 8.8%. On univariate analysis, the lowest instrumented vertebra (LIV) CT value (p = 0.042); instrumented levels (p = 0.030); preoperative coronal vertical axis (CVA) (p = 0.046), thoracolumbar kyphosis (TLK) (p = 0.006), L4-S1 lordosis (p = 0.013), sacral slop (SS) (p = 0.030), pelvic tilt (PT) classification (p = 0.004), and sagittal vertical axis (SVA) (p = 0.021); TLK correction (p = 0.049); post-operative CVA (p = 0.029); Overall, There was no significant difference in the paraspinal muscle parameters between the two groups. On multivariate analysis, instrumented levels (OR = 1.595; p = 0.035), preoperative SVA (OR = 1.016; p = 0.022) and preoperative PT (OR = 0.873; p = 0.001) were identified as significant independent risk factors for DJP. CONCLUSION: Longer instrumented levels, a greater preoperative SVA and a smaller PT were found to be strongly associated with the presence of DJPs in patients treated for DLS. The degeneration of the paraspinal muscles may not be related to the occurrence of DJPs. For DLS patients, the occurrence of DJP can be reduced by selecting reasonable fusion segments and evaluating the patient's sagittal balance and spino-pelvic parameters before operation.

Atraumatic Acute Paraspinal Compartment Syndrome in a Patient With McArdle's Disease.

A 60-year-old male presented to the emergency room with complaints of back pain overlying the left lumbar area and ipsilateral thigh numbness. The left erector spinae musculature was rigid, tense, and painful to palpation. An elevated serum creatine kinase was identified, and a computed tomography scan showed evidence of left paraspinal musculature congestion. Past medical/surgical history was significant for McArdle's disease and bilateral forearm fasciotomies. The patient underwent lumbosacral fasciotomy with no obvious myonecrosis. The patient was discharged home after skin closure and has since been seen in clinic with no residual pain or change in baseline functional status. This case may represent the first reported atraumatic exertional lumbar compartment syndrome in a patient with McArdle's disease. Prompt operative intervention was effective in this case of acute atraumatic paraspinal compartment syndrome and resulted in an excellent functional outcome.

Retrospective Analysis of Paraspinal Muscle-Splitting Microscopic-Assisted Discectomy Versus Percutaneous Endoscopic Lumbar Discectomy for the Treatment of Far-Lateral Lumbar Disc Herniation.

AIM: To compare percutaneous endoscopic lumbar discectomy (PELD) and the microscopic tubular technique, and to evaluate the outcomes of surgery. MATERIAL AND METHODS: We collected information through retrospective analysis of patients with far-lateral lumbar disc herniation (FLLDH) from June 2015 to October 2018. Twenty-six patients underwent paraspinal muscle-splitting microscopicassisted discectomy (MD) and thirty patients underwent PELD surgery by the same surgical team. Data included the duration of the operation, duration of intraoperative radiation exposure, and average duration of hospitalization. Pre- and postoperative pain scores and neurological functions were recorded using the visual analog scale (VAS) score and Oswestry disability index (ODI). RESULTS: Fifty-six patients remained in the study over the 12-24 months period. The mean operating time was 65.83 ± 16.64 min in the PELD group, mean duration of radiation exposure was 154.98 ± 64.26 mGy, and average of hospitalization was 3.43 days. The mean operating time was 44.96 ± 16.87 min in the MD group, duration of radiation exposure was 42.12 ± 17.28 mGy, and duration of hospitalization was 4.12 days. There were two patients with postoperative transient dysesthesia and one underwent reoperation seven months after surgery in the PELD group. One patient had postoperative transient dysesthesia in the MD group. Except low back pain at three months (p > 0.05), all patients in both groups showed significant improvement in VAS and ODI scores compared with pre-operation and until final follow-up (p < 0.05). CONCLUSION: Both techniques are minimally invasive, effective, and safe for treating FLLDH in selected patients. Compared with the PELD technique, the MD procedure offers a wider field of vision during operation, shorter operation time, fewer postoperative complications, and shorter learning curve.

THE COMPARATIVE EFFECTIVENESS OF ERECTOR SPINE PLANE BLOCK AND PARAVERTEBRAL BLOCK FOR EARLY REHABILITATION AFTER TOTAL HIP ARTHROPLASTY.

OBJECTIVE: The aim: To evaluate the effectiveness of erector spine plane block vs lumbar paravertebral block for early rehabilitation after total hip arthroplasty. PATIENTS AND METHODS: Materials and methods: The study included 60 ASA ІΙ-ΙΙΙ patients (female/male = 35/25) aged 41-82 years, undergone total hip arthroplasty under spinal anesthesia. The patients randomly divided into two groups (n=30 in each) according to postoperative regional analgesia technique: paravertebral block (PVB) and erector spine plane block (ESPB). The time interval to meet three criteria: adequate analgesia (<4 points of VAS), opioid-free period longer than 12 h, and possibility to cover walking 30 m distance without time restriction was analyzed. We also analyzed opioid requirement postoperatively. RESULTS: Results: The time interval to meet the three criteria after surgery was shorter to 9.4 h for patients in PVB group 36.3 h 95% CI 31.8 to 40.8 h than for patients in ESPB group 45.7 h 95% CI 40.1 to 51.3 h, (p = 0.016). During the first 24 h after surgery the total dose of nalbuphine per patient was significantly higher in ESPB group (10.7 95% CI 7.0 to 14.3) compared to PVB group (6.3 95% CI 3.7 to 9.0). CONCLUSION: Conclusions: The paravertebral block and erector spine plane block provide quite effective pain relieve in patients undergone total hip arthroplasty (<4 points of VAS). PVB has more opioid-preserving effect than ESPB. The paravertebral block is superior to erector spine plane block for early rehabilitation after total hip arthroplasty (the time required for patients to meet the three criteria was shorter PVB than ESPB).

Multifidus Sarcopenia Is Associated With Worse Patient-reported Outcomes Following Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The present study is the first to assess the impact of paraspinal sarcopenia on patient-reported outcome measures (PROMs) following posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA: While the impact of sarcopenia on PROMs following lumbar spine surgery is well-established, the impact of sarcopenia on PROMs following PCDF has not been investigated. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing PCDF from C2 to T2 at a single institution between the years 2017 and 2020. Two independent reviewers who were blinded to the clinical outcome scores utilized axial cuts of T2-weighted magnetic resonance imaging sequences to assess fatty infiltration of the bilateral multifidus muscles at the C5-C6 level and classify patients according to the Fuchs Modification of the Goutalier grading system. PROMs were then compared between subgroups. RESULTS: We identified 99 patients for inclusion in this study, including 28 patients with mild sarcopenia, 45 patients with moderate sarcopenia, and 26 patients with severe sarcopenia. There was no difference in any preoperative PROM between the subgroups. Mean postoperative Neck Disability Index scores were lower in the mild and moderate sarcopenia subgroups (12.8 and 13.4, respectively) than in the severe sarcopenia subgroup (21.0, P <0.001). A higher percentage of patients with severe multifidus sarcopenia reported postoperative worsening of their Neck Disability Index (10 patients, 38.5%; P =0.003), Visual Analog Scale Neck scores (7 patients, 26.9%; P =0.02), Patient-Reported Outcome Measurement Information System Physical Component Scores (10 patients, 38.5%; P =0.02), and Patient-Reported Outcome Measurement Information System Mental Component Scores (14 patients, 53.8%; P =0.02). CONCLUSION: Patients with more severe paraspinal sarcopenia demonstrate less improvement in neck disability and physical function postoperatively and are substantially more likely to report worsening PROMs postoperatively. LEVEL OF EVIDENCE: 3.

The Intersection Between the Sternocleidomastoid and Splenius Capitis as the Anatomical Landmark to Facilitate Occipital Artery Harvest: A Retrospective Clinical Study.

BACKGROUND: Occipital artery (OA)-posterior inferior cerebellar artery (PICA) bypass is a challenging procedure and is not frequently performed owing to the difficulty of OA harvest. To facilitate harvest, the intersection between the sternocleidomastoid and splenius capitis (the OA triangle) is used as the anatomical landmark to identify the OA segment that carries the highest risk of damage. This clinical study aimed to demonstrate efficacy and safety of OA harvest using this landmark. METHODS: The study included 18 patients who underwent OA harvest using the OA triangle as a landmark for treatment of vertebral artery and PICA aneurysms. Patients were retrospectively evaluated for safety and patency of OA after harvest and OA-PICA bypass. RESULTS: Of 18 patients with ruptured and unruptured vertebral artery and PICA aneurysms, 13 (72.2%) underwent OA-PICA bypass and 5 (27.8%) did not undergo bypass. The OA was completely harvested without damage in all patients. After harvest, the OA was patent in 17 patients (94.4%) and was occluded in 1 patient owing to vasospasm; this patient then underwent recanalization resulting in good patency of the OA-PICA bypass. The patency rate of the OA-PICA bypass was 100%. CONCLUSIONS: The OA triangle, which is the anatomical landmark of the proximal end of the transitional segment of the OA, facilitated OA harvest using the distal-to-proximal harvest technique with safety and good patency. To the best of our knowledge, this is the first study of OA harvest in clinical cases.

Repair of Delayed Meningeal Cyst after Spinal Surgery with Paraspinal Muscle Flap under Microscope.

BACKGROUND: Delayed meningeal cyst (DMC) is a rare complication after spinal surgery that is often ignored by clinicians, and its in-depth research is infrequent. In particular, no consensus has been reached about its surgical treatment. We found that patients with a DMC failed after conservative treatment, epidural blood patch, subarachnoid drainage, and initial attempts to eliminate the meningeal cyst. Therefore, we introduce the application of a paraspinal muscle flap repair under a microscope for the treatment of DMC. METHODS: In this study, 13 patients who were repaired by a paraspinal muscle flap under a microscope for DMC from January 2007 to January 2017 were retrospectively reviewed. Their ages were 18-68 years old (mean age 48.7 years). The course of the disease ranged from 3 weeks to 28 months after the operation for the primary disease, with an average of 10.6 months. Length >5 cm was called a large DMC and length >8 was called a giant DMC. By analyzing the effect of surgical treatment, we summarized the treatment experience of DMC and evaluated the risk factors for the formation of DMC. RESULTS: All patients were treated with paraspinal muscle flap repair under a microscope, and they healed well after the operation. There was no cerebrospinal fluid leakage or other operation-related complication. The mean follow-up was 16.5 months. Reexamination of the spine MRI showed no recurrence of the DMC. CONCLUSIONS: The application of paraspinal muscle flap under a microscope combined with glue, bedrest, and CSF drain, was an effective option for the patients with DMC.

Erector Spinae Blocks for Spine Surgery: Fact or Fad? Systematic Review of Randomized Controlled Trials.

BACKGROUND: Patients undergoing spine surgery may experience substantial postoperative pain. The aim of this systematic review is to examine the clinical efficacy of a newly introduced regional anesthetic block, the erector spinae plane block (ESPB), for adults undergoing posterior spine surgeries. METHODS: A formal systematic database search was conducted in PubMed, Ovid Medline, Embase, Cochrane library, and Google Scholar for randomized controlled trials comparing ESPB with control or placebo. RESULTS: Our systematic review demonstrates a reduction of postoperative pain and opioid consumption in patients who had ESPB compared with control groups for lumbar spine surgery. However, the effect obtained revealed only a short-term benefit. CONCLUSIONS: Current evidence is insufficient to support the widespread use of ESPB for spine surgery. More studies are warranted to confirm or refute its role in clinical practice.

The Clinical Effect of Manual Reduction Combined with Internal Fixation Through Wiltse Paraspinal Approach in the Treatment of Thoracolumbar Fracture.

OBJECTIVE: To evaluate the clinical outcome of manual reduction combined with pedicle fixation through Wiltse paraspinal approach (WPA) in the treatment of thoracolumbar fractures. METHODS: From May 2017 to May 2019, 48 thoracolumbar fractures patients without neurological symptoms were enrolled in this study. Forty-eight patients were randomly divided into two groups based on the different surgical treatment. Group 1 was manual reduction combined with pedicle screw fixation through Wiltse paraspinal approach treatment group. Group 2 was pedicle screw fixation through traditional posterior approach treatment group. The operation time (OT), intraoperative blood loss (BL), postoperative drainage (PD), time of brace (TB) and the cobb angle recovery of the injured kyphosis in the prone position were obtained and compared between the two groups, respectively. Comparison of cobb angle changes, serum creatine kinase (CK) level, pain visual analogue score (VAS), Oswestry disability index (ODI), and multifidus cross-sectional (MCS) area changes were achieved between the two groups, respectively. RESULTS: Forty-eight patients were enrolled in this study and each group had 24 patients. There was no significant difference between the two groups in patient's age, height, weight, and body mass index (BMI). There were 20 males and four females in group 1. The mean age, height, weight, and BMI of patients were 61.99 ± 11.00 years (range, 42-75 years), 175.21 ± 4.49 cm, 76.71 ± 4.87 kg, and 24.98 ± 1.03 kg/m2 in group 1, respectively. Group 2 had 18 males and six females, and the mean age, height, weight, and BMI of patients were 57.95 ± 9.22 years (range, 44-77 years), 176.37 ± 4.56 cm, 77.42 ± 4.61 kg, and 24.87 ± 1.10 kg/m2 in group 2, respectively. The mean bleeding volume of group 1 was significantly less than group 2 (64.13 ± 9.77 ml and 152.13 ± 10.73 ml, respectively) (P < 0.05). The mean operation time, postoperative drainage, and time of brace were 62.95 ± 9.80 min, 66.25 ± 12.75 ml, and 3.62 ± 0.97 days in group 1, respectively, and they were significantly better than those of group 2 (69.29 ± 6.82min, 162.96 ± 14.55ml and 7.88 ± 1.94 days, respectively) (P < 0.05). The mean multifidus cross-sectional area was significantly smaller than per-operation after surgery in two groups (P < 0.05). The mean creatine kinase of group 1 was 403.13 ± 39.78 U/L and 292.12 ± 45.81 U/L at 1 and 3 days after surgery, respectively, which was significantly smaller than those in group 2 (654.25 ± 53.13 U/L and 467.67 ± 44.25 U/L, respectively) (P < 0.05). The Oswestry disability index of group 1 were significantly better than those in group 2 especially at 1 month and final follow-up after surgery (P < 0.05). Moreover, group 1 also had better outcomes in postoperative Cobb angle change than those in group 2, with significant difference on intra-operation, 1 day and 1 month post-operation (P < 0.05). CONCLUSION: In short, this operation is suitable for thoracolumbar fractures without neurologic symptoms. Preoperative manual reduction had advantages of restoring the height of injured vertebrae. Wiltse intermuscular approach can reduce intraoperative blood loss, shorten operation time, and reduce paraspinal muscle damage. Using the traditional posterior approach, it is easy for surgeons to grasp this technique and it should be recommended as conforming with the minimally invasive approach of recent years.

Continuous erector spinae plane block for postoperative analgesia in robotic lung lobectomy: a case report.

BACKGROUND: Erector spinae plane block (ESPB) has been described as an effective regional anesthesia technique in thoracic parenchymal surgery. Evidence highlighting the use of this technique continuously via perifascial catheter is lacking. CASE PRESENTATION: In this case report, we present the case of a patient scheduled for robotic-assisted thoracic surgery for a pulmonary neoformation in the lower right lobe. We decided to manage this patient with a multimodal approach in order to have an opioid-sparing effect. This is the first reported case of continuous ESPB in robot-assisted thoracic surgery. CONCLUSIONS: Anesthesiologists should consider this method in surgery that is slower than conventional surgery, such as robot-assisted, and less invasive than thoracotomy, which does not warrant the use of neuroaxial or paravertebral techniques that increase the risk of iatrogenic complications.

Pedicled Multifidus Muscle Flap To Treat Inaccessible Dural Tear In Spine Surgery: Technical Note And Preliminary Experience.

OBJECTIVE: To assess the usefulness, feasibility, and limitations of pedicled multifidus muscle flaps (PMMFs) for the treatment of inaccessible dural tears during spine surgery. METHODS: The technique of PMMF harvesting was investigated together with relevant anatomy. We prospectively evaluated 8 patients treated with the PMMF technique between January 2017 and December 2019. Results were compared with a retrospective series of 9 patients treated with a standard technique between January 2014 and December 2016. Inclusion criteria were inaccessible dural tear or dural tear judged not amenable to direct repair because of tissue loosening. Exclusion criteria were surgical treatment of intradural disease. Clinical and demographic data of all patients were collected. Clinical evaluations were performed according to American Spinal Injury Association criteria and Oswestry Disability Index. Preoperative and postoperative computed tomography was performed in all patients. The primary end point was wound healing (cerebrospinal fluid leakage, infection, and fluid collection); secondary end points were neurologic outcome and complications. RESULTS: Control group: 1 death as a result of wound infection secondary to cerebrospinal fluid fistula and 2 patients needed lumbar subarachnoid drain; neurologic outcome: 3 patients improved and 6 were unchanged. Flap group: no wound-related complications were observed; neurologic outcome: 3 patients improved and 5 were unchanged. No flap-related complications were described. Flap harvesting was feasible in all cases, with an average 20 minutes adjunctive surgical time. CONCLUSIONS: The PMMF technique was feasible and safe; in this preliminary experience, its use is associated with lower complications as a result of dural tears but larger series are needed to confirm its effectiveness.

A Novel Magnetic Resonance Imaging-based Lumbar Muscle Grade to Predict Health-related Quality of Life Scores Among Patients Requiring Surgery.

STUDY DESIGN: Retrospective cross-sectional cohort. OBJECTIVE: The aim of this sudy was to determine whether muscle health measurements are associated with health-related quality of life scores (HRQOLs) for patients with lumbar spine pathology. SUMMARY OF BACKGROUND DATA: Poor muscle health has been implicated as a source of pain/dysfunction for patients with lumbar spine pathology. Our aim was to quantify the relationship using muscle health measurements and HRQOLs. METHODS: Three hundred and eight patients were included (mean age 57.7 ±â€Šstandard deviation 18.2 years' old). We randomly selected patients into a derivation cohort (200) and validation cohort (108) to create our muscle health grade. We measured muscle health by the lumbar indentation value (LIV), goutallier classification (GC), and ratio of paralumbar muscle cross-sectional area over body mass index (PL-CSA/BMI). A muscle health grade was derived based on whether a measurement showed a statistically significant impact on visual analog scale back and leg pain (VAS-leg and VAS-leg), Oswestry Disability Index (ODI), short-form 12 physical health score (SF-12 PHS), short-form 12 mental health score (SF-12 MHS) and Patient-reported Outcomes Measurement Information System (PROMIS). A variety of statistical tools were used to determine whether there was a relationship between a measurement and HRQOLs. RESULTS: In the derivation cohort, a muscle health grade was created based on the GC and PL-CSA/BMI ratio. For patients with a GC ≤2, one point was given. For patients with a PL-CSA/BMI ≥130, one point was given. Patients with 2 points were graded as "A" and 0 or 1 point were graded "B." Within the validation cohort of patients, there was a statistically significant higher PROMIS (mean 34.5 ±â€Šstandard deviation 12.6 vs. 27.6 ±â€Š14.0, P = 0.002), ODI (38.8 ±â€Š18.3 vs. 45.8 ±â€Š18.1, P = 0.05) and SF-12 PHS (34.7 ±â€Š11.3 vs. 29.1 ±â€Š6.3, P = 0.002) for patients with a good muscle health grade of "A." CONCLUSION: This study offers an objective measurement of muscle health that correlates with HRQOLs for patients with lumbar spine pathology.Level of Evidence: 3.

Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature.

OBJECTIVE: The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS: The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS: The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS: The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.

Intramuscular hemangioma with hemorrhagic transformation arising from paraspinal muscles of posterior neck: A case report.

RATIONALE: Hemangiomas are usually found in cutaneous or mucosal layers, less than 1% of hemangiomas develop in skeletal muscles. Intramuscular hemangioma (IH) in the head and neck areas is relatively infrequent, accounting for 15% of IH. Most of them are identified as a benign mass, and rapid changes in size or internal bleeding are rare. PATIENT CONCERNS: A 60-year-old female patient presented with a 2-week history of sudden onset posterior neck pain. There was no neurological deficit except limited neck motion due to pain. The palpable mass was noted on the paraspinal muscles of cervicothoracic junction, which was located midline to left side portion with tenderness. DIAGNOSES: Magnetic resonance imaging demonstrated a round shaped, multi-lobulated, and well-defined mass lesion (4.1 × 2.6 × 0.9 cm) embedded from the inter-spinous space of T1-2 to the left paraspinal muscles. The lesion was iso-intense on T2-weighted images (WI), iso- to slightly low-intense on T1-WI, heterogeneous enhancement of intra- and peri-mass lesion on contrast-enhanced T1-WI. Vascular structures presented as signal voids were identified internally and around the mass lesion. Histological examination revealed a mixed-type hemangioma. INTERVENTIONS: The mass was removed completely including some of the surrounding muscles where boundaries were unclear between the mass and surrounding muscles with ligation of peritumoral vessels. Dark-brown colored blood was drained from the ruptured tumor capsule during the dissection. There was no bony invasion. OUTCOMES: The preoperative symptoms improved immediately after the operation. There is no residual or recurrence lesion by the 15-months follow-up. LESSONS: IH with hemorrhagic transformation in the head and neck is extremely rare. In the case of intramuscular tumors accompanied by a sudden onset of severe acute pain, we recommend considering a differential diagnosis of IH with hemorrhagic transformation. Complete resection of the tumor mass including surrounding muscles is required to prevent recurrence.

Comparison of paraspinal muscle degeneration and decompression effect between conventional open and minimal invasive approaches for posterior lumbar spine surgery.

Laminotomy and transforaminal lumbar interbody fusion (TLIF) is usually used to treat unstable spinal stenosis. Minimally invasive surgery (MIS) can cause less muscle injury than conventional open surgery (COS). The purpose of this study was to compare the degree of postoperative fatty degeneration in the paraspinal muscles and the spinal decompression between COS and MIS based on MRI. Forty-six patients received laminotomy and TLIF (21 COS, 25 MIS) from February 2016 to January 2017 were included in this study. Lumbar MRI was performed within 3 months before surgery and 1 year after surgery to compare muscle-fat-index (MFI) change of the paraspinal muscles and the dural sac cross-sectional area (DSCAS) change. The average MFI change at L2-S1 erector spinae muscle was significantly greater in the COS group (27.37 ± 21.37% vs. 14.13 ± 19.19%, P = 0.044). A significant MFI change difference between the COS and MIS group was also found in the erector spinae muscle at the caudal adjacent level (54.47 ± 37.95% vs. 23.60 ± 31.59%, P = 0.016). DSCSA improvement was significantly greater in the COS group (128.15 ± 39.83 mm2 vs. 78.15 ± 38.5 mm2, P = 0.0005). COS is associated with more prominent fatty degeneration of the paraspinal muscles. Statically significant post-operative MFI change was only noted in erector spinae muscle at caudal adjacent level and L2-S1 mean global level. COS produces a greater area of decompression on follow up MRI than MIS with no statistical significance on clinical grounds.

Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review.

BACKGROUND: Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series. METHODS: The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient. RESULTS: This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up. CONCLUSIONS: This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.

Acute Paraspinal Compartment Syndrome After Deadlifting: A Case Report.

CASE: A 27-year-old African man was admitted with acute right-sided loin pain that had started 4 hours after deadlifting. Renal colic was suspected, but clinical and radiological examination revealed no pathology of the urinary system. Further investigation revealed rhabdomyolysis. The back pain worsened with flexion, and both loins were hard on palpation 24 hours later. High intracompartmental pressures confirmed acute paraspinal compartment syndrome. CONCLUSIONS: We performed fasciotomy of the back muscles 28 hours after the onset of pain. Eighteen months after surgery, the patient no longer performed deadlifts but returned to pain-free exercise.

Nonfusion Muscle-Sparing Technique to Treat Long-Segment Thoracolumbar Extradural Arachnoid Cyst in a Child: A Case Report and Review of the Literature.

BACKGROUND: Spinal extradural arachnoid cyst is an uncommon cause of spinal cord compression. It results from a small dural defect that leads to cerebrospinal fluid (CSF) accumulation in the cyst and subarachnoid space, and the cyst can compress the spinal cord and nerve roots. Surgery is the treatment of choice in symptomatic patients, and most cases have an immediately satisfying outcome after surgery. CASE DESCRIPTION: A 10-year-old Thai boy presented with progressive weakness in both legs. Magnetic resonance imaging (MRI) demonstrated a giant cystic lesion 23 cm in length from T1-L2 level. To our knowledge, this is the longest arachnoid cyst that has been reported in children. The operation included unilateral paraspinal muscle dissection with spinous process translation techniques, T1-L4 laminectomy, total cyst excision, and dural defect repair at the T4 level. The symptoms were fully resolved within 2 months after surgery. However, thoracic kyphosis was slightly increased, but the patient still has a normal sagittal profile. CONCLUSIONS: Spinal arachnoid cyst is rare, especially in children. Early diagnosis and treatment are essential for improving the chance of full recovery, and for avoiding complication and irreparable defect. Total cyst removal with dural repair remains the best treatment alternative; however, potential complications, especially spinal malalignment after extensive laminectomy, must be considered. Postoperative MRI showed normal CSF flow and no spinal cord compression. The muscle-sparing technique with multiple-level laminectomy without spinal fusion that we used in this case provided a satisfying outcome.

Primary Giant Hydatid Cyst of Lumbar Paraspinal Muscles.

BACKGROUND: Hydatid cyst disease, commonly caused by Echinococcus granulosus, rarely occurs in paraspinal muscles. Among the few reported cases, the current case is the largest paraspinal hydatid cyst disease ever reported in literature with a review of management of such large lesions. CASE DESCRIPTION: A 38-year-old male presented with lower back swelling for 1 year. Ultrasonography and magnetic resonance imaging scans suggested hydatidosis, following which the patient was taken up for surgery after preoperative medical therapy. En bloc resection was done, and histopathologic examination of the resected specimen confirmed the diagnosis. Postoperative albendazole was also used, and no recurrence was noted at 24 months post operation. CONCLUSIONS: Hydatid disease should be kept as one of the differential diagnoses for back swelling, especially in endemic regions. Giant-sized hydatid cysts of paraspinal muscles, though rare, cannot be ruled out on clinical ground alone. Thorough history taking and detailed examination should be aided with radiologic investigations like magnetic resonance imaging for an accurate diagnosis. En bloc excision of the cyst combined with preoperative and postoperative medical therapy is an effective method of treating this condition and significantly reducing complication rates.