Imaging Findings, Fluoroscopic Time, and Results of the Lumbosacral Selective Nerve Root Block: Focus on the L5 Nerve Root Block.

Introduction Selective nerve root block (SNRB) is a valuable diagnostic and therapeutic tool. In some cases, intra-nerve root puncture is difficult and time-consuming, and radiation exposure time for the surgeon may be prolonged. The aim of this study is to examine the contrast findings, fluoroscopic time, and outcomes of SNRB. Methods A total of 139 cases of SNRB were included in the study. We investigated radiating pain presence, duration of fluoroscopic time, contrast types for nerve roots, and SNRB outcomes. Contrast patterns of nerve roots were categorized into three types, which were: type 1: the presence of contrast along the nerve roots; type 2: the presence of contrast within the intravertebral foramen but not in the nerve root; and type 3: the absence of both nerve root and intravertebral foramen contrast. Results The mean fluoroscopic time was 12.8 ± 15.3 seconds for type 1, 11.1 ± 8.9 seconds for type 2, and 23.6 ± 18.8 seconds for type 3. Statistically significant differences were found between the three groups (p = 0.007), and subsequent multiple comparisons showed significant differences between type 1 and type 2 (p = 0.010) and between type 2 and type 3 (p = 0.015). The visual analog scale (VAS) score before and 30 minutes after SNRB demonstrated a significant improvement in all patients. The mean change in VAS before and after nerve root block was 49.6 ± 21.7 mm for type 1 cases, 49.8 ± 25.2 mm for type 2 cases, and 37.8 ± 23.6 mm for type 3 cases, with no statistically significant difference between the three groups (p = 0.090). The proportion of patients with subjective symptomatic improvement before and after SNRB was 91.3% in type 1 cases, 88.5% in type 2 cases, and 85.7% in type 3 cases, with no statistically significant difference between the three groups (p = 0.641). Conclusions The above findings indicate that type 3 is beneficial for both diagnostic and therapeutic purposes.

Bilateral persistent intersegmental artery in a patient with posterior atlantoaxial subluxation after subaxial cervical laminoplasty.

INTRODUCTION AND IMPORTANCE: To summarize the clinical manifestations and treatment of bilateral persistent first intersegmental artery (PFIA) in a patient with posterior subluxation of atlantoaxial joint. CASE PRESENTATION: A-85-year-old woman with a two-months history of aggravating of gait disturbance and finger clumsiness was referred to our hospital. Magnetic resonance imaging revealed posterior subluxation of the atlantoaxial joint and spinal cord compression at C1 level. Three-dimensional computed tomography angiography (CTA) of cervical spine showed bilateral PFIA and left side high-riding VA. Because of the high risk of vertebral artery injury with posterior arch resection and lateral mass screw insertion due to the presence of PFIA, as well as the bony fragility of the cervical spine and the fact that the posterior atlantoaxial subluxation was reduced in the flexed position, the posterior occipito-thoracic fixation without posterior arch resection in the mildly flexed cervical position was underwent. The postoperative course was uneventful and her neurological symptoms improved gradually after surgery. CLINICAL DISCUSSION: PFIA is a very rare condition representing between 0.01 % and 1.8 %. Most patients with this condition have a unilateral persistent segmental artery, but in a small minority of cases it occurs bilaterally. It may be more difficult to resect of posterior arch or insert the C1 lateral mass screw in cases of PFIA. CONCLUSION: The best way to avoid IVAI may be careful examining the abnormal running of VA preoperatively especially on 3D-CT of cervical spine with arteriography and not to choose a technique with a high risk of VA injury.

Unilateral fixation utilizing minimally invasive surgery (MIS) system for lumbosacral metastasis in a patient with stage 4 renal cell carcinoma.

INTRODUCTION AND IMPORTANCE: To summarize the clinical manifestations and treatment of a patient with lumbar metastases from renal cell carcinoma who underwent unilateral fixation of lumbosacral spine utilizing minimally invasive surgery systems. CASE PRESENTATION: A 71-year-old woman presented to a local hospital with complaints of low back pain. Computed tomography (CT) at the hospital revealed metastases to the lung, occipital bone, right ribs and fifth lumbar vertebrae from a primary left renal cancer. A lumbar Magnetic resonance imaging (MRI) performed at local clinic revealed an enlarged metastatic tumor invading the right body, transverse process and pedicle of fifth lumbar vertebra. Transmyofascial insertion of pedicle screws and connection with rod utilizing minimally invasive surgery (MIS) systems were made on the left L4.5.S1 vertebrae under fluoroscopy. The operating time was 36 min, the intraoperative blood loss was 30 g and fluoroscopic time was 56 s. Postoperative course was uneventful. She could walk with a single cane on the twenty postoperative days but passed away of systemic metastasis approximately10 months after the spinal fixation. An x-ray taken just before death showed no spinal instrumentation failure. DISCUSSION: Surgery for spinal metastasis from hypervascular tumor may result in profuse intraoperative bleeding that is difficult to control. It might be preferable to operate with MIS if patients with spinal metastases are candidate for either MIS or conventional methods. It has been reported that unilateral fixation could be as effective as bilateral fixation in up to two-segment lumbar spinal fusion. CONCLUSION: Unilateral fixation utilizing MIS systems may be effective in cases whom placing an instrumentation on the side with tumor extending posteriorly may cause massive bleeding.

Intradural disc herniation at the L1-2 level.

BACKGROUND: Intradural disc herniations (IDHs) are rare, are difficult to diagnose on preoperative MR/CT imaging, and typically, are most readily confirmed at the time of surgery. However, one of the greatest challenges posed by these lesions, is the repair of the ventral dural rent. CASE DESCRIPTION: A 55-year-old male with a 20-year history of lumbago presented with low back pain and right lower extremity sciatica of 3 months' duration. The MR and CT studies showed a compressive lesion at the L1-2 level. There was no original suspicion that this was an IDH. At surgery, performed under the operating microscope, a subtotal L1-L2 laminectomy was performed (i.e. while lysing severe adhesions between the posterior longitudinal ligament and the ventral dura, a traumatic durotomy occurred. White, spongious, friable, soft tissue, and free-floating disc fragments extruded through the durotomy site. Notably, it was initially considered to be a tumor rather than a disc. Once all fragments had been delivered, unsuccessful attempts were made to repair the ventral dura. Further efforts were curtailed due to concern that they would result in damage to multiple ventral nerve rootlets. Despite the lack of primary dural repair, the secondary measures resulted in no postoperative recurrent cerebrospinal fluid leakage (CSF) and a smooth postoperative surgical course. CONCLUSION: IDH at the L1-2 level is rare, and preoperative MR/CT studies may not always document their intradural location. Ideally, ventral dural tears attributed to these lesions should be directly repaired and/or managed with additional adjunctive CSF leak repair techniques (i.e. muscle patch grafts, microfibrillar collagen, and fibrin sealants).

Factor XI Deficiency in a Patient with Cervical Spondylotic Myelopathy.

STUDY DESIGN: Case report. OBJECTIVE: To summarize the clinical manifestations and treatment of Factor XI deficiency in a patient with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Factor XI deficiency is a rare genetic bleeding disorder caused by reduced levels and insufficient activity of a coagulation factor XI. It is claimed to be associated with prominent bleeding in case of trauma and surgery irrelevant to the FXI level. This is the first ever case of a patient with factor XI deficiency with cervical spondylotic myelopathy. METHODS: A case was investigated retrospectively and the relevant literature was reviewed. RESULTS: A 66-year-old man with a 2-months history of lack of finger dexterity and gait disturbance was referred to our department. He did not have a history of bleeding or coagulation disorder nor did his family. Magnetic resonance imaging (MRI) of the cervical spine revealed spinal canal stenosis at C3/4 to C5/6 and intramedullary hyperintensity at C3/4 on the :T2 weighted image (T2WI). Preoperative examination revealed no abnormal findings but a severe prolonged activated partial-thromboplastin time (APTT) of 139.8 seconds. Coagulation factor activity assay revealed severe deficiency of factor XI (<0.1%). In accordance with hematologist's recommendation, four units of fresh frozen plasma (FFP) were transfused on the day before surgery and APTT assayed early morning on the day of surgery was 70.5 seconds. An additional four units of FFP were transfused during the surgery and APTT was 60 seconds. The postoperative course was uneventful and the patient was discharged on the postoperative day 14. CONCLUSION: Factor XI deficiency patients may develop excessive bleeding after trauma or surgery. Preoperative examination with prolonged APTT should be pursued until a diagnosis of is made. Under diagnosis of Factor XI deficiency, meticulous attentions are required for perioperative bleeding management including postoperative hematoma in spinal surgery.Level of Evidence: 5.