Paralumbar Spine Disease as a Cause of Low Back Pain in Older Adults.

Introduction Low back pain (LBP) is a major contributor to decreases in the ability to perform activities of daily living (ADL) in older adults. Paralumbar spine disease (PLSD) is a common cause of LBP. We aimed to investigate the causes of LBP, including PLSD, among older adults. Methods Among 744 consecutive patients with LBP, 75 patients (10.1%) aged >80 years (25 males and 50 females) were included. The average patient age was 83.9 years. All patients were evaluated using lumbar magnetic resonance imaging (MRI) and radiography to diagnose the causes of LBP. PLSD was diagnosed based on clinical symptoms, palpation, and the effects of the block. Results Eleven patients (11/75, 14.7%) had acute osteoporotic vertebral fractures. Twenty-eight of the remaining 64 patients exhibited decreased LBP with oral medication, and six (6/75, 8.0%) exhibited lumbar spinal canal stenosis on MRI. PLSD was suspected in 19 of the remaining 30 cases based on clinical symptoms and palpation. Blocks were effective in 16 patients with PLSD, which involved superior cluneal nerve entrapment (SCN-E) in eight patients (10.7%), middle cluneal nerve entrapment (MCN-E) in nine patients (12.0%), sacroiliac joint (SIJ) pain in five patients (6.7%), and gluteus medius muscle (GMeM) pain in three patients (4.0%). The average numerical rating scale (NRS) scores for pain changed from 7.5 ± 1.5 before treatment to 1.3 ± 0.9 at discharge (p < 0.05). Conclusion Osteoporotic acute vertebral fracture (14.7%) was identified as the cause of LBP in older adults. Block therapy for PLSD may aid in the diagnosis and treatment of non-specific LBP.

Middle cluneal nerve entrapment sites in the surgical field.

INTRODUCTION: Middle cluneal nerve (MCN) entrapment around the sacroiliac joint elicits low back pain (LBP). For surgical decompression to be successful, the course of the MCN must be known. We retrospectively studied the MCN course in 15 patients who had undergone MCN neurolysis. METHODS: Enrolled in this retrospective study were 15 patients (18 sides). We inspected their surgical records and videos to determine the course of the entrapped MCN. The area between the posterior superior- and the posterior inferior iliac spine was divided into areas A-D from the rostral side. The MCN transit points were identified at the midline and the lateral edge connecting the posterior superior- and posterior inferior iliac spine. Before and 6 months after surgery, the patients recorded the degree of LBP on the numerical rating scale and the Roland-Morris Disability Questionnaire. RESULTS: We decompressed 24 MCNs. The mean number was 1.3 nerves per patient (range 1-2). The MCN course was oblique in the cranio-caudal direction; the nerve tended to be observed in areas C and D. In six patients (40%), we detected two MCN branches, they were in the same area and adjacent. Postoperatively, LBP was improved significantly in all patients. CONCLUSION: Between the posterior superior- and the posterior inferior iliac spine, the MCN ran obliquely in the cranio-caudal direction; it was prominent in areas on the caudal side. In six (40%) patients, we decompressed two adjacent MCNs. Our findings are useful for MCN decompression surgery.

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.