Dynamic anterior cervical plates for multilevel anterior corpectomy and fusion with simultaneous posterior wiring and fusion: efficacy and outcomes.

STUDY DESIGN: To prospectively evaluate major complications associated with the application of dynamic ABC plates (Aesculap, Tuttlingen, Germany) to multilevel Anterior Corpectomy/Fusion (ACF) followed by posterior fusion (C2-C7 PF). OBJECTIVES: To determine whether dynamic ABC (Aesculap, Tuttlingen, Germany) plates would minimize major complications (plate/graft extrusion, pseudarthrosis) while maximizing neurological outcomes in 40 consecutive patients undergoing simultaneous multilevel ACF/PF with halo application. SETTING: USA. METHODS: Patients averaged 53 years of age and preoperatively exhibited severe myeloradiculopathy (Nurick Grade 3.9). MR/CT studies documented marked ossification of the posterior longitudinal ligament/spondylostenosis. Surgery included two to four level ACF utilizing fibula strut allograft and ABC plates. Posterior spinous process wiring/fusions utilized braided titanium cables. The average operative time was 8.9 h. Fusion was confirmed on dynamic X-rays/CTs (3-12 months postoperatively). The average follow-up interval was 2.7 years. Outcomes (3 months-2 years postoperatively) were assessed utilizing Odom's Criteria, Nurick Grades, and SF-36 questionnaires. RESULTS: Major complications included one pseudarthrosis requiring secondary PWF. Minor complications in six patients included two pulmonary emboli (PE), two tracheostomies, and five superficial wound infections. At 1 year postoperatively, marked improvement was observed in all patients utilizing Odom's criteria (38 excellent/good), Nurick Grades (mild radiculopathy 0.4), and the SF-36 (3 Health Scales; Role Physical (12.5-38.6), Bodily Pain (39.9-65.5), and Role Emotional (53.8-75.8)]. The 2-year postoperative data showed minimal additional improvement. The average time to fusion was 6.3 months. CONCLUSION: Patients undergoing multilevel ACF/PF demonstrated marked neurological improvement (SF-36), and only one of 40 developed a delayed pseudarthrosis.

Fixed vs dynamic plate complications following multilevel anterior cervical corpectomy and fusion with posterior stabilization.

STUDY DESIGN: Comparison of fixed vs dynamic plate complications in cervical surgery. SETTING: : New York, USA. METHODS: Anterior cervical plate-related complications were evaluated following 66 anterior cervical corpectomy and fusion (ACF) with posterior stabilization (PWF) procedures performed in patients with ossification of the posterior longitudinal ligament (OPLL). Clinical data were comparable for both patient populations. Patients averaged between 52 and 53 years of age. The male to female ratio was approximately 2:1. Surgery addressed MR and CT documented multilevel OPLL in all patients accompanied by spondylosis and stenosis. Preoperatively average Nurick Grades ranged from 3.6 to 3.7. Anterior cervical corpectomies included an average of 2.6-3.0 vertebral bodies, while PWF covered seven levels. Fixed plates were applied in the initial 38 patients, while the latter 28 patients had dynamic plates (ABC, Aesculap, Tuttlingen, Germany) applied. Halo devices were used until fusion was documented on both X-ray and 2D-CT studies. Patients were followed-up for an average of 5.4 years in the fixed-plated groups, and 2.7 years in the dynamic-plated population. RESULTS: CT and dynamic X-ray confirmed that fusion occurred an average of 4.5-4.9 months postoperatively. Five (13%) fixed plates (Medtronic, Sofamor Danek, Memphis, TN, USA) failed warranting secondary surgery, while only one (3.6%) dynamic-plated patient developed a pseudarthrosis and required secondary posterior fusion. DISCUSSION/CONCLUSION: Higher failure rates follow multilevel ACF as compared with anterior diskectomy and fusion required to resect multilevel OPLL. Vaccaro et al observed a 9% failure rate following two-level ACFs and 50% failure rate following three-level ACFs performed with fixed plates. In this series, the plate extrusion rate was reduced to 3.6% when dynamic plates were applied.

Laminectomy for cervical myelopathy.

STUDY DESIGN: Cervical laminectomy with or without fusion, or laminoplasty, successfully address congenital or acquired stenosis, multilevel spondylosis, ossification of the posterior longitudinal ligament (OPLL), and ossification of the yellow ligament (OYL). To optimize surgical results, however, these procedures should be applied to carefully selected patients. OBJECTIVES: To determine the clinical, neurodiagnostic, appropriate posterior cervical approaches to be employed in patients presenting with MR- and CT-documented multilevel cervical disease. To limit perioperative morbidity, dorsal decompressions with or without fusions should be performed utilizing awake intubation and positioning and continuous intraoperative somatosensory-evoked potential monitoring. SETTING: United States of America. METHODS: The clinical, neurodiagnostic, and varied dorsal decompressive techniques employed to address pathology are reviewed. Techniques, including laminectomy, laminoforaminotomy, and laminoplasty are described. Where preoperative dynamic X-rays document instability, simultaneous fusions employing wiring or lateral mass plate/screw or rod/screw techniques may be employed. Nevertheless, careful patient selection remains one of the most critical factors to operative success as older individuals with prohibitive comorbidities or fixed long-term neurological deficits should not undergo these procedures. RESULTS: Short- and long-term outcomes following dorsal decompressions with or without fusions vary. Those with myelopathy over 65 years of age often do well in the short-term, but demonstrate greater long-term deterioration. Factors that correlated with greater susceptibility to deterioration include advanced age (>70 years at the time of the first surgery), severe original myelopathy, and recent trauma. CONCLUSIONS: Success rates of laminectomy with or without fusion, or laminoplasty may be successfully employed to address multilevel cervical pathology in a carefully selected population of patients.

Anterior cervical dynamic ABC plating with single level corpectomy and fusion in forty-two patients.

STUDY DESIGN: Forty-two consecutive patients undergoing dynamic ABC plated one-level ACF utilizing iliac crest autograft (38 patients) and fibula allografts (four patients) were evaluated. The unique ABC slotted plate design allows for up to 10 mm of cephalad and 10 mm of caudad plate migration. OBJECTIVES: To evaluate the incidence and etiology of complications in forty-two patients undergoing anterior cervical dynamic ABC plating (Aesculap, Tuttlingen, Germany), during one level anterior corpectomy with fusion (ACF). SETTING: New York, USA. METHODS: Serial dynamic X-ray and 2 Dimensional CAT Scan (2D-CT) studies, obtained 3, 6, and up to 12 months postoperatively, in 42 patients documented the presence of fusion or complications including plate or graft extrusion or pseudarthrosis. RESULTS: Four (9.5%) of 42 patients developed postoperative plate or graft-related complications during the average follow up interval of 34 months. One patient, with a plate/graft extrusion, required a second two level ACF with posterior wiring and fusion (PWF). Two patients with pseudarthroses and one patient with a delayed iliac crest strut fracture required secondary PWF. CONCLUSIONS: Effective arthrodesis and a low incidence of complications following one level ACF performed utilizing dynamic ABC plates were attributed to reduced stress shielding and greater graft compression afforded by the unique plate design. Applying dynamic ABC plates for one level ACF was biomechanically advantageous with low morbidity.

Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures.

Far lateral disc herniations constitute 7-12% of all disc herniations. They may be purely far lateral or extraforaminal in location, located beyond the pedicles, or may include intraforaminal and even intracanalicular components. Occurring predominantly at the L4-L5 and L3-L4 levels in almost equal numbers, they are occasionally noted at L5-S1. Clinical syndromes reflect compression of the superiorly exiting nerve root and ganglion; ie an L4-L5 far lateral disc produces a L4 root syndrome. Clinical complaints often include severe radicular pain accompanied by very positive mechanical signs; Laségue and reverse Laségue (femoral stretch test) maneuvers. Neurological deficits, including motor, reflex, and sensory findings, are seen over 75% of the time. Although conservative management is occasionally successful (10%), surgery is usually required. The extent of stenosis and attendant degenerative changes dictate whether laminectomy, hemilaminectomy or laminotomy are required along with one of several facet resection options; full facetectomy, the intertransverse approach, medial facetectomy, or an extreme lateral procedure. Postoperatively, patients' neurological outcomes based on both surgeon and patient based outcome measures (SF-36), were comparable for the different surgical procedures which had been based on the individual patient's pathology.

Technical note: unilateral posterior resection of cervical disc and spondylostenosis with contralateral fusion for instability.

BACKGROUND: Posterior cervical unilateral diskectomy and decompression for stenosis with instability may be successfully stabilized with contralateral diskectomy and fusion. METHODS: A 49-year-old male with a left-sided C8 radiculopathy had dynamic X-ray, MR, and CT studies that documented an old anterior diskectomy and fusion at the C5-C6 level, and a new left-sided foraminal disc herniation at the C7-T1 level with instability, accompanied by C6-T1 spondylostenosis. Following left-sided C6-T1 laminectomies with excision of C7-T1 disc, a contralateral right-sided C5-T2 fusion was performed with fibula strut allograft wired to the spinous processes using titanium cable and iliac crest autograft. RESULTS: X-ray and 2D CT studies performed 3 and 6 months postoperatively confirmed adequate unilateral decompression of stenosis with disc removal and contralateral fusion. Within three weeks of surgery, the patient had no residual neurological deficit. Three years later, he remained intact, and X-ray studies continued to demonstrate spinal stability. CONCLUSIONS: A unilateral C7-T1 disc herniation with instability accompanied by C6-T1 spondylostenosis were successfully managed with unilateral decompression and disc excision followed by contralateral fusion.

Reoperation rates for acute graft extrusion and pseudarthrosis after one-level anterior corpectomy and fusion with and without plate instrumentation: etiology and corrective management.

BACKGROUND: Reoperation rates after one-level anterior cervical corpectomy with fusion (ACF) performed without and with plates need further evaluation. METHODS: Reoperation rates for graft extrusion and symptomatic pseudarthrosis were analyzed following 48 nonplated (1989-1996) and 35 plated (1997-2000) one-level ACF. Preoperatively, patients typically exhibited mild/moderate myelopathy attributed to spondylostenosis and ossification of the posterior longitudinal ligament (OPLL). Thirty-five ACF were performed with plates: 3 Orion, 12 Atlantis, and 20 ABC Aesculap plates. Fusion was documented on both dynamic X-rays and 2- or 3-dimensional CT studies 3 and 6 months postoperatively, or until fusion occurred. Follow-up averaged 82 months for the nonplated patients, and 21 months for the plated patients. RESULTS: Out of 48 nonplated patients, 3 developed immediate graft extrusions within 24 hours of surgery requiring graft replacement. Another 2 exhibited symptomatic pseudarthrosis 6 months postoperatively, and required secondary posterior wiring with fusion (PWF). In comparison, 1 of the 35 patients with plated one-level ACF developed plate displacement 6 weeks postoperatively, while 3 exhibited symptomatic pseudarthrosis 6 months after surgery, and required secondary posterior wiring and fusion (PWF). CONCLUSIONS: Comparison of one-level ACF performed with and without plates showed that plating did not appear to reduce pseudarthrosis or graft extrusion rates.

Can airway complications following multilevel anterior cervical surgery be avoided?

OBJECT: The authors conducted a study to determine how to avoid emergency postoperative reintubation and its associated morbidity in patients who have undergone multilevel anterior-posterior cervical spine surgery. METHODS: In a group effort between the departments of anesthesia and neurosurgery, a protocol was developed to avoid having to reintubate patients postoperatively. As a preventative measure, patients remained intubated overnight; on the 1st postoperative day or thereafter, based on direct fiberoptic visualization of reactive tracheal swelling, an anesthesiologist extubated the patients. Fifty-eight patients underwent multilevel anterior corpectomy with fusion (ACF; with 41 receiving plates and 17 not receiving plates), posterior wiring and fusion (PWF), and application of a halo. On average, ACF involved three levels, whereas PWF included 6.5 levels. Surgery typically lasted 10 hours, and an average 2.6 U of blood was required. Forty patients were successfully extubated on the 1st, five on the 2nd, three on the 3rd, two on the 4th, two on the 5th, and three on the 7th postoperative day. Three elective tracheostomies were performed on the 7th postoperative day. Risk factors associated with delayed extubation or tracheostomy in 18 patients included: operative time longer than 10 hours (12 patients), obesity greater than 220 lbs (12 patients), transfusion of more than 4 U of blood (10 patients), ACF reoperations (nine patients), ACF including C-2 (seven patients), four-level ACF (five patients), and asthma (five patients). In the only case in which emergency reintubation was required, three risk factors were present. CONCLUSIONS: Emergency reintubation following anterior-posterior cervical surgery and fusion can be avoided by maintaining intubation overnight and subsequently having an anesthesiologist remove the tube after healing is fiberoptically confirmed. Familiarity with major risk factors contributing to airway compromise, combined with this protocol, should minimize the significant morbidity associated with reintubation following multilevel anterior-posterior cervical fusion.

Identification of ossification of the posterior longitudinal ligament extending through the dura on preoperative computed tomographic examinations of the cervical spine.

STUDY DESIGN: To establish the diagnosis of dural penetration on preoperative computed tomographic studies of the cervical spine in patients with ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: To define before surgery the pathognomonic computed tomographic findings of OPLL extending to and through the dura. SUMMARY OF BACKGROUND DATA: On preoperative computed tomographic studies, Hida et al have described the single-layer sign characterized by a solid mass of hyperdense OPLL and the double-layer sign defined by two (anterior and posterior) ossified rims surrounding a central nonossified but hypertrophied posterior longitudinal ligament. Only 1 of the 9 patients exhibiting the single-layer sign but 10 of 12 patients showing the double-layer sign had no separate dural plane identified at surgery. METHODS: Only 2 of 54 patients undergoing multilevel cervical circumferential OPLL procedures had absent dura at surgery. Computed tomographic examinations for all patients were retrospectively reviewed to determine unique signs of dural penetration. RESULTS: Dura was absent in 1 of 12 patients who had the single-layer CT sign that was additionally characterized by an irregular C angular configuration. Only 1 of 4 patients exhibiting the double-layer computed tomographic sign had absent dura at surgery. The remaining 38 patients had the smooth-layer sign, characterized by more regular margins of classic (22 patients) or early OPLL (16 patients). CONCLUSIONS: The double-layer computed tomographic sign is more pathognomonic for dural penetration than the single-layer sign. The smooth-layer sign, indicating a clean dural plane, is more typical in North American patients.

The management of one-level anterior cervical corpectomy with fusion using Atlantis hybrid plates: preliminary experience.

To limit high pseudarthrosis rates encountered after cervical procedures for adjacent two-level disease, one-level anterior corpectomy with fusion was performed using the newly available Atlantis hybrid plates (fixed screws placed superiorly and variable screws placed inferiorly). Eight one-level anterior corpectomies with fusion were performed using iliac autografts and Atlantis hybrid plates. Nurick and Medical Outcomes Trust Short Form 36 scores were recorded before operation (Nurick grade 2.3) and 6 months after operation. Fusion status was followed an average of 9 months (range, 8 to 11 months). Fusion was confirmed an average of 6 months after operation in seven patients, when the mean Nurick grade was 0.2 and all had improved on the eight Medical Outcomes Trust Short Form 36 health scales. Atlantis plates contributed to successful fusion in seven of eight patients undergoing one-level anterior corpectomy with fusion using Atlantis hybrid plates.

Simultaneous cervical diffuse idiopathic skeletal hyperostosis and ossification of the posterior longitudinal ligament resulting in dysphagia or myelopathy in two geriatric North Americans.

BACKGROUND: Cervical diffuse idiopathic skeletal hyperostosis (DISH) and ossification of the posterior longitudinal ligament (OPLL) rarely coexist in the North American population. Here, different surgical strategies were used to manage simultaneous DISH and OPLL resulting in dysphagia or myelopathy in two geriatric patients. METHODS: A 74-year-old male with esophageal compression and dysphagia attributed to DISH, and cord compression with myelopathy due to OPLL, was treated with a cervical laminectomy followed by anterior DISH resection. On the other hand, an 80-year-old male with asymptomatic DISH but moderate myelopathy (Nurick Grade III) secondary to OPLL required only a cervical laminectomy. RESULTS: In the first patient, dysphagia resolved within 3 months of surgery, while in the second individual, myelopathy improved to Nurick Grade I (mild myelopathy) within 6 months postoperatively. Improvement in both patients was maintained 1 year after surgery. CONCLUSIONS: While DISH and OPLL may coexist in geriatric patients, only those with dysphagia should undergo DISH resection, while others demonstrating myelopathy should have laminectomy alone.

Anterior cervical diskectomy and fusion without plate instrumentation in 178 patients.

Between 1989 and 1996, fusion, pseudarthrosis, repeated operation rates, and outcomes were studied in 178 patients undergoing one- to four-level (average, 2.2 levels) anterior cervical diskectomy and fusion (ADF) without plating. Dynamic radiographs taken 3 and 6 months after operation showed fusion or pseudarthrosis without motion in 99% of patients after one-level ADF (78 patients), in 90% after two-level ADF (84 patients), and in 100% after three-level ADF (12 patients) and four-level ADF (4 patients). Pseudarthrosis with motion was noted in 1% after one-level ADF and in 10% after two-level ADF (statistically significant with a lower pseudarthrosis rate in the 1-level; by Fisher's exact test, p = 0.0351). Three patients required secondary posterior wiring and fusion. Good or excellent outcomes (by Odom's criteria) were achieved in 96% of patients within an average of 82 months. Although fusion rates for one-level ADF without plates appear adequate, high pseudarthrosis rates after two-level ADF warrant that plating be considered.

The value of anterior cervical plating in preventing vertebral fracture and graft extrusion after multilevel anterior cervical corpectomy with posterior wiring and fusion: indications, results, and complications.

Anterior cervical plates were added to anterior corpectomy and fusion (ACF) with posterior wiring and fusion (PWF) to prevent vertebral fracture and graft extrusion in patients with ossification of the posterior longitudinal ligament and spondylostenosis. From January 1989 to March 1997, 22 patients had an average 2.5-level ACF without plates and an average 5-level PWF with halo placement (average follow-up, 4 years). From April 1997 to October 1998, 22 patients had an average 2.8-level ACF with Orion plating and an average 5.4-level PWF with halo devices (patients were followed for an average of 11 months). Vertebral fracture and graft extrusion requiring revision developed in three (14%) patients without plates within 24 hours of surgery, whereas neither of these occurred in patients with plates (by Fisher's test: nonsignificant p value = 0.2326). Ultimately, all 44 patients had fusion. Thus far, vertebral fractures and graft extrusions have not been observed for 22 patients undergoing plated circumferential cervical surgery.

Anterior cervical micro-dural repair of cerebrospinal fluid fistula after surgery for ossification of the posterior longitudinal ligament. Technical note.

BACKGROUND: Cerebrospinal fluid (CSF) fistulas may occur during anterior cervical surgery performed for the resection of ossification of the posterior longitudinal ligament (OPLL), as OPLL occasionally erodes to and through the dura. These fistulas have been variously managed with gelfoam, dural substitutes sutured in place, fibrin glue, lumbar drains, and lumboperitoneal shunts. However, more adequate dural repair is now feasible with the 1.4-mm microdural titanium stapler. METHODS: A 59-year-old female with OPLL and moderate to severe myelopathy (Nurick Grade IV) had a C3-C7 anterior corpectomy with fusion using Orion plates followed by a C3-T1 posterior wiring and fusion with halo application. During the anterior approach, a 5-mm CSF fistula at C4-C5 was directly repaired under the operating microscope using a 1.4-mm microdural stapler, bovine pericardial graft, and fibrin glue. Immediately postoperatively, a lumboperitoneal shunt was also placed. RESULTS: Postoperatively, her myelopathy improved to a mild to moderate level (Nurick Grade II). Her acute left deltoid plegia resolved within 3 months. CONCLUSIONS: The 1.4-mm microdural stapler makes "watertight" closure of anterior cervical CSF fistulas more feasible.

Laminectomy with posterior wiring and fusion for cervical ossification of the posterior longitudinal ligament, spondylosis, ossification of the yellow ligament, stenosis, and instability: a study of 5 patients.

Cervical laminectomy with posterior wiring and fusion is valuable for the management of cervical ossification of the posterior longitudinal ligament (OPLL), spondylosis, ossification of the yellow ligament (OYL), stenosis, and instability. Within 1.5 years, five patients averaging 73 years of age developed severe myelopathy. Dynamic radiographs confirmed an intact cervical lordosis with active subluxation and instability at one or two levels, whereas magnetic resonance and computed tomography scans showed OPLL, spondylosis, OYL, and stenosis. After multilevel laminectomy with posterior wiring and fusion and immobilization in cervicothoracic orthoses, patients fused in an average of 3.6 months. All patients improved, showing mild to moderate residual postoperative myelopathy an average of 13 months later (range, 6-19 months). With an intact cervical lordosis, laminectomy with posterior wiring and fusion was used successfully to manage five patients with OPLL, spondylosis, OYL, stenosis, and instability.

Circumferential cervical surgery for spondylostenosis with kyphosis in two patients with athetoid cerebral palsy.

BACKGROUND: Patients with athetoid cerebral palsy may develop severe degenerative changes in the cervical spine decades earlier than their normal counterparts due to abnormal cervical motion. METHODS: Two patients, 48 and 52 years of age, presented with moderate to severe myelopathy (Nurick Grades IV and V). MR and 3-dimensional CT studies demonstrated severe spondylostenosis with kyphosis in both patients. This necessitated multilevel anterior corpectomy with fusion (C2-C7, C3-C7) using fibula and iliac crest autograft and Orion plating, followed by posterior wiring, fusion using Songer cables, and halo placement. RESULTS: Postoperatively, both patients improved, demonstrating only mild or mild to moderate (Nurick Grades II and III) residual myelopathy. Although both fused posteriorly within 3.5 months, the patient with the fibula graft developed a fracture of the anterior C7 body with mild anterior graft migration, and inferior plate extrusion into the C7-T1 interspace. However, because he has remained asymptomatic for 9 months postoperatively, without dysphagia, removal of the plate has not yet been necessary. CONCLUSIONS: Patients with athetoid cerebral palsy should undergo early prospective cervical evaluations looking for impending cord compromise. When surgery is indicated, circumferential surgery offers the maximal degree of cord decompression and stabilization with the highest rate of fusion.

Ossification of the yellow ligament and spondylosis and/or ossification of the posterior longitudinal ligament of the thoracic and lumbar spine.

Combinations of varying degrees of spondylosis and/or ossification of the posterior longitudinal ligament (OPLL), and ossification of the yellow ligament (OYL) contribute to thoracic and lumbar neural compression in North Americans. Preoperative magnetic resonance and computed tomography examinations dictated the surgical approaches used to address spondylosis/OPLL in 11 patients, OYL in 12 patients, and spondylosis/OPLL and OYL in 3 patients. Myelopathy (4 patients), radiculopathy (13 patients), and cauda equina dysfunction (11 patients) were observed, 2 patients showing combined deficits. Outcomes (Odom's criteria) after laminectomy (24 patients) and circumferential thoracic procedures (2 patients) were good to excellent in the 73% of patients with spondylosis/OPLL, in 83% with OYL, and excellent for all 3 with spondylosis/OPLL and OYL. Full recognition of thoracic or lumbar spondylosis/OPLL and OYL ensure optimal surgical planning and outcomes.

Ossification of the cervical anterior longitudinal ligament contributing to dysphagia. Case report.

The authors evaluated the clinical, radiological, and surgical management of ossification of the anterior longitudinal ligament (OALL) that contributed to dysphagia in a patient with simultaneous cervical ossification of the posterior longitudinal ligament (OPLL). A 57-year-old man presented with increasing dysphagia and moderate myelopathy. Imaging studies, including esophagoscopy, revealed marked esophageal compression due to OALL that extended between the C2-5 levels and significant C5-7 OPLL that compressed the distal cervical spinal cord. The use of rongeurs and a high-speed drill facilitated excision of the C2-5 OALL mass, and a routine anterior corpectomy with fusion was performed at the C5-7 level. Postoperatively, the patient's dysphagia and symptoms of myelopathy immediately resolved. The strut graft became fully fused 3 months postoperatively, as demonstrated on dynamic x-ray films, and the patient has remained asymptomatic 4 months postoperatively. Patients with dysphagia and coexisting myelopathy benefit from simultaneous surgery for resection of OALL and OPLL masses.

Laser-assisted diskectomy performed by an internist resulting in cauda equina syndrome.

An internist performed percutaneous laser-assisted diskectomies (PLADs) on a patient with a sequestrated disc and stenosis. Subspecialists who perform PLADs should be trained in patient selection and lumbar diskectomy techniques. Chymopapain, percutaneous nucleotome-assisted diskectomy, and PLADs are alternatives to microdiskectomy for the management of lumbar disc herniations. PLADs were performed at the L4-5/L5-S1 levels in a 38-year-old woman with magnetic resonance (MR)-documented L4-5 stenosis and disc disease. After PLADs, she developed a subacute cauda equina syndrome. Two months later, a neurosurgeon performed an L4-5 coronal hemilaminectomy with diskectomy. Within 6 postoperative weeks, she was neurologically intact. Only specialists trained in the selection, neurodiagnostic, and surgical management of lumbar disc disease should perform PLADs.