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Background: Leiomyosarcoma (LMS) is a rare malignancy that originates from smooth muscle. The most common sites of metastases include the lungs, liver, kidney, and skin. Notably, metastases of LMS to the central nervous system/or spine are extremely rare. When a cervical spinal LMS lesion was encountered, the patient successfully underwent gross total tumor resection with negative margins. Case Description: A 63-year-old female had undergone an anterior cervical C5-C7 diskectomy and fusion 18 years ago and resection of a retroperitoneal LMS 3 years ago. She newly presented with right-sided numbness and pain of 2 months duration that correlated with a focal right-sided C5-level hemiparesis (i.e., 4/5 motor strength). When the cervical magnetic resonance demonstrated a right-sided C5 intralaminar mass with extension into the C5-C6 foramen, she underwent posterior tumor resection; pathologically, this proved to be an LMS metastasis. Respectively, 1- and six months postoperatively, follow-up magnetic resonance imaging scans showed no tumor recurrence; she tolerated adjuvant oncological treatment accompanied by physical therapy. However, in one postoperative year, the lesion recurred, and she is presently under consideration for additional surgical management. Conclusion: Gross total surgical resection is the first line of treatment for patients with metastatic LMS. Here, a patient with a C5 laminar/C5-C6 foraminal bony LMS metastasis underwent posterior tumor resection accompanied by adjuvant oncological treatment but exhibited disease recurrence within one postoperative year. [ABSTRACT FROM AUTHOR]

Background: Lumbar discal pseudocysts are uncommon complications that can arise following lumbar spine surgery. It manifests as a fluid-filled sac near the intervertebral disc, causing pain and discomfort. Understanding its causes, symptoms, and management is crucial for patients and healthcare professionals involved in postoperative spinal care. Case Description: A 35-year-old female developed a discal pseudocyst after undergoing laminectomy and discectomy for lumbar disc herniation. The patient presented with recurrent lower back pain, radiculopathy, and neurological deficit two months post-surgery. Imaging revealed a discal pseudo cyst causing compression of the traversing right L5 nerve root. Given the refractory nature of her symptoms, an endoscopic procedure was offered. Using the transforaminal endoscopic technique, the pseudo cyst was identified and removed, leading to immediate symptomatic relief. Conclusion: This article reports the rare occurrence of discal pseudocyst and highlights the use of endoscopic techniques in its surgical management. Surgeons should be aware of the minimally invasive techniques, as they can offer less morbidity, shorter recovery times, and reduced healthcare costs compared to traditional open surgery. [ABSTRACT FROM AUTHOR]

Background: Extradural arteriovenous fistulas (AVFs) of the cervical spine are extremely rare, and typically manifest as slowly progressive myelopathy caused by mass effect. This is a unique case of extradural AVF of the cervical spine manifesting with purely radicular symptoms and treated endovascularly with coil and liquid embolization. Case Description: A 55-year-old woman presented with neck pain and right upper extremity radiculopathy persisting for 9 months. Imaging studies demonstrated an AVF spanning from C4-C6 with extension into the C5-C6 foramen supplied primarily from the deep cervical branch of the costocervical trunk. The patient underwent successful coil and liquid (Onyx) embolization. Six-week postoperatively, the patient's symptoms completely resolved and magnetic resonance imaging and angiographic imaging confirmed complete obliteration of the fistula. Conclusion: While extradural AVFs typically present with myelopathic symptoms, they may present with solely radicular symptoms and can be successfully treated endovascularly. [ABSTRACT FROM AUTHOR]

Background: Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system that may present with a wide variety of clinical presentations. However, there can be substantial overlap between symptoms from MS and those caused by lumbar spondylosis and/or postviral plexopathies. Case Description: A 33-year-old female with a history of an L5-S1 anterior lumbar interbody fusion and exposure to the SARS-CoV-2 virus developed postoperative worsening of her symptoms interpreted as “radiculopathy.” Despite a subsequent L5-S1 fusion, she continued to neurologically deteriorate and was ultimately diagnosed with MS. Conclusion: The initial symptoms/signs of MS may mimic lumbar radiculopathy and or postviral plexopathy (i.e., due to recent COVID-19). This report should serve as a warning to future spinal surgeons to better differentiate between radicular and other “complaints,” sufficient to avoid unnecessary repeated spinal surgery. [ABSTRACT FROM AUTHOR]

Background: Intrasacral occult sacral meningoceles (OSM) are uncommon congenital lesions that rarely become symptomatic, even over a patient's life time. Methods: We operated on six patients with symptomatic OSM diagnosed on MR studies (all six) and/or CT examinations (four cases). Results: All six patients had uneventful postoperative recoveries. Nevertheless, despite the resolution of low back pain and radiculopathy, preoperative bladder dysfunction improved postoperatively in only one patient. Conclusion: Few cases of patients undergoing surgery for symptomatic OSM are reported in the literature. Here, we recount our experience with six patients with symptomatic OSM who demonstrated significant postoperative neurological recoveries except for rare improvement in bladder function. [ABSTRACT FROM AUTHOR]

Background: A wide variety of conditions can cause recurrent postoperative lumbar radiculopathy. Case Description: A 49-year-old female developed sudden recurrent postoperative right leg pain after a rightsided L5S1 microdiskectomy for a herniated disc. Emergent magnetic resonance and computed tomography studies demonstrated migration of the drainage tube into the right L5S1 lateral recess compromising the S1 nerve root. Following drain removal, the patient's right reg pain immediately resolved. Conclusion: Migration of a lumbar wound drain into the operated lateral recess following a lumbar diskectomy may result in acute, recurrent/intractable radicular pain that was readily resolved with drain removal. [ABSTRACT FROM AUTHOR]

Background: A postoperative discal/annular cyst following lumbar discectomy may reproduce the symptoms/signs of a recurrent lumbar disc herniation (i.e., back pain and radiculopathy). Case Description: A 21-year-old rugby player developed leg pain after an uncomplicated lumbar microdiscectomy. The repeat lumbar magnetic resonance imaging confirmed a postoperative lumbar annular/discal cyst, for which he underwent repeat surgery. The diagnosis was further confirmed histopathologically at surgery. Conclusion: Although rare, postoperative discal/annular cysts may be potential causes of recurrent postoperative pain and lumbar radiculopathy mimicking recurrent disc herniations. [ABSTRACT FROM AUTHOR]

Background: There are only a few reports that utilize computed tomography myelogram (CTM) to define cervical nerve rootlet compromise in patients with radiculopathy. Here, we assessed the characteristic morphological changes in nerve rootlets in 32 cases with cervical radiculopathy by analyzing CTMs warranting anterior foraminotomy. Methods: CTMs were analyzed to elucidate morphological changes in nerve rootlets in 31 patients/32 cases with cervical radiculopathy. Notably, three of the four neurosurgeons evaluating these CTM had to agree on the presence of "significant" changes consisting of contrast-enhanced defects near the entrance of the intervertebral foramen on axial sections. Results: Our findings included; posterior deviation of the ventral rootlet on the sagittal section (63%), ventral rootlet meandering or horizontalization (52%), and dorsal rootlet meandering (39%) on the coronal section. Furthermore, 16% of cervical nerve rootlets may exhibit an abnormal course proximal to the compression site (i.e., the definition of the "rootlet stagnation sign"). Conclusion: CTM better defines the anatomy, pathology, and radiology impacting the anterior or posterior cervical roots in patients presenting with cervical radiculopathy. [ABSTRACT FROM AUTHOR]

Background: T1-T2 intervertebral disc prolapse (IVDP) is a rare clinical condition. Horner's syndrome is an extremely rare clinical finding in these patients. Case Description: A 56-year-old man presented with the left C8 T1 radiculopathy, left hand grip weakness, and ipsilateral Horner's syndrome. Magnetic resonance imaging of the spine showed a contrast-enhancing lesion in the left T1 foramen compressing the left T1 nerve root. He underwent left T1 hemilaminectomy, upper half of left T2 hemilaminectomy and removal of the left foraminal lesion. A biopsy of the lesion was sent for histopathological diagnosis which revealed tissue consistent with disc material. Postoperatively, he had near-complete recovery with residual minimal Horner's syndrome. Conclusion: T1-T2 IVDP should be considered in the differential diagnosis when a patient presents with C8 T1 radiculopathy and Horner's syndrome. [ABSTRACT FROM AUTHOR]

Background: Sustained compression of the spinal cord by cervical spondylosis may induce arachnoid fibrotic changes and trigger local syrinx formation. Cases Description: Here, we describe 13 cases of syrinx formation in association with cervical spondylosis. In 12 out of 13 patients, the syrinx was incidental finding while screening for simple neck pain. In one case, it was discovered during an evaluation of upper extremity radiculopathy. Over the 3-8-year follow-up period, the syrinx size did not change in 11 cases (i.e., 10 asymptomatic and one with radiculopathy) even after surgical decompression. In the other two cases, the syrinx spontaneously resolved. Conclusion: With the increased utilization of cervical MR imaging, more cases of incidental asymptomatic syrinx formation versus symptomatic lesions contributing to radiculopathy have been discovered. [ABSTRACT FROM AUTHOR]

Background: Pseudotumor of the tensor fascia lata (TFL) consists of a rare, benign soft tissue mass/hypertrophy of the TFL that appears on the anterolateral aspect of the proximal thigh. Notably, this condition often mimics a malignant tumor and may be misdiagnosed as a sarcoma. Case Description: A 45-year-old male presented with left hip/groin pain, swelling, and a painful mass on the anterolateral aspect of the left hip/thigh. The symptoms had started 3 months ago following an L1-S1 lumbar laminectomy/fusion. The initial diagnosis was hip disease, and the patient underwent a left MR arthrogram. When this study demonstrated a tear of the left anterosuperior acetabular labrum plus an increased alpha angle causing femoroacetabular impingement, the patient then underwent a left hip arthroscopy. However, as he continued to complain of the hip mass, he was referred to an orthopedic oncologist whose presumptive diagnosis favored a sarcoma. Nevertheless, the pelvic MRI scan and ultrasound (US) confirmed the diagnosis of hypertrophy of the left TFL (US left 33.4 mm vs. right 14.4 mm). The patient was first treated with 50 units of locally injected botulinum. As there was no symptomatic relief, the plan was to repeat the injection within the next few months. Conclusion: Hypertrophy of TFL may mimic a neoplasm such as a sarcoma and contributes to what appears to be a lumbar radiculopathy. However, MR and US imaging should readily identify TFL and rule out malignant lesions such as sarcomas. [ABSTRACT FROM AUTHOR]

Background: Lumbar disc herniation (LDH)/radiculopathy is the most frequent cause of lost workdays in people under 50 years of age. Although there is consensus about how to assess these patients, the optimal management strategy is still debated. Methods: An online survey was sent to spine surgeons who are members of the Iberian-Latin American Spine Society to assess how they treat LDH with radiculopathy. Results: There were 718 surgeons who answered the survey; 66% reported that 76-100% of their monthly clinic work was due to spine issues. The most frequently used conservative treatment modalities included non-opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) (90.5%), followed by physical therapy (55.2%) and pregabalin (41.4%). Notably, 40% of surgeons in the public sector believed that conservative treatment failed if symptoms persisted beyond 6-12 weeks, while 39% of private surgeons deemed conservative management insufficient if it had failed to provide symptomatic relief with 3-6 weeks. Of interest, 78% utilized epidural steroid injections (ESI); 51.7% preferred the transforaminal, 27.2% the interlaminar, and 7.5% the caudal approaches. The most frequent indications for surgery included: cauda equina syndrome, progressive neurological deficits, and intractable pain. Traditional microdiscectomy was the most common technique (68.5%) utilized, followed by 7.5% advocating endoscopic disc resection, and just 6.4% favoring the tubular discectomy. Conclusion: There is considerable heterogeneity among Iberian and Latin American spine surgeons in the treatment of LDH/radiculopathy. Although most begin with the utilization of NSAIDs and non-opioid analgesics, followed by ESI (88%), surgery was recommended for persistent symptoms/signs for those failing between 3 and 6 weeks (private sector) versus 6-12 weeks (public sector) of conservative therapy. [ABSTRACT FROM AUTHOR]

Background: Redundant nerve roots (RNRs) are defined as elongated, thickened, and tortious appearing roots of the cauda equina secondary to lumbar spinal canal stenosis (LSCS). The study compared the clinical and radiological features of patients with LSCS with versus without RNR. Methods: This retrospective study was performed on 55 patients who underwent decompressive surgery for degenerative LSCS. Patients were divided into two groups based on the presence of RNR in their preoperative magnetic resonance imaging, as evaluated by a radiologist blinded to the study design. Medical records were reviewed for basic demographic, clinical MR presentation, and outcomes utilizing Japanese Orthopaedic Association (JOA) scores. Results: The mean age of enrolled patients was 57.1, with mean follow-up of 4.0 months. RNR was found in 22 (40%) of patients with LSCS. These patients were older than those patients without RNR (62.2 vs. 53.7). Interestingly, there were no statistically significant differences in clinical presentations, duration of symptoms, and outcomes using JOA scores between the two groups. Conclusion: RNR is a relatively common radiological finding (i.e., 40%) in patients with LSCS. It is more likely to be observed in older patients. However, no significant differences were noted in clinical presentation and functional outcomes with respect to the presence or absence of RNR. [ABSTRACT FROM AUTHOR]

Background: As spinal surgeons, we have all likely seen cases in which lumbar disc herniations regressed/resolved on successive MR studies. Here, we present a patient whose original cervical MR showed a large C4-C5 cervical disc herniation that completely resolved on the follow-up MR obtained 9 months later, thus avoiding cervical surgery. Case Description: A young patient (e.g. <30 years old) sustained multiple prior traumatic events over the past 3 years. The last episode 9 months ago resulted in the performance of an MR scan that demonstrated a significant central C4-C5 disc herniation with cord/root compression. Despite pain and mild radiculopathy, the patient had no focal neurological deficit, and did not undergo surgery. When the patient recently consulted multiple spinal orthopedists and neurosurgeons, the uniform recommendation was for a C4-C5 anterior cervical discectomy/fusion (ACDF). However, a telemedicine consultation with a spinal neurosurgeon resulted in a follow-up cervical MR scan that demonstrated cervical disc resorption, and, therefore, no need for cervical surgical intervention. When the new study showed full resolution of the C4-C5 disc, the telemedicine and local neurosurgeon agreed that cervical surgery was unnecessary. Conclusion: The spinal literature shows that predominantly lumbar disc herniations (LDH) spontaneously regress on MR studies 34.7-95% of the time over 6-17 month intervals, with full resolution being seen in 43-75% of cases. As cervical disc herniations likely demonstrate similar resorption/resolution on successive MR studies, old cervical MR examinations should probably be updated/repeated in patients who are being considered for cervical surgical intervention. If/when cervical discs have resorbed, cervical surgery may be avoided. [ABSTRACT FROM AUTHOR]

Background: We describe a rare case of idiopathic lower cervical vertebro-vertebral arteriovenous fistula (VVAVF) with compression of the nerve roots and spinal cord, successfully treated with detachable coils utilizing the transarterial balloon-assisted technique without complication of coil mass. Case Description: A 68-year-old woman was admitted for numbness of the left upper limb and pain in the left neck. Cervical magnetic resonance imaging (MRI) revealed compression of nerve roots and spinal cord by a large vascular lesion. The left vertebral angiography demonstrated a VVAVF draining into the vertebral venous plexus at C5 level. Under general anesthesia, the fistula site was accessed with a microcatheter through the right femoral artery, and successful embolization performed by compactly placing several detachable coils using balloonassisted technique. The patient made a full recovery, with long-term MRI-documented left vertebral artery patency and no fistular leakage, and without postoperative complications. Conclusion: Target occlusion utilizing the balloon-assisted technique in this case of VVAVF with compression of nerve roots and spinal cord, was effective in improving neurological symptoms, and achieved long-term occlusion when preservation of the VA was desired. [ABSTRACT FROM AUTHOR]

Background: Alkaptonuria (AKU) is a rare hereditary disorder in which excess homogentisic acid (HGA) deposits in connective tissues (ochronosis). Here, we report the unusual presentation of a lumbar disc herniation occurring in a patient with AKU warranting surgical intervention. Case Description: A 28-year-old male presented with 1 year of low back pain. The lumbar magnetic resonance imaging showed an extruded disc at the L4-L5 level accompanied extensive disc space narrowing and osteophyte formation. At surgery, the interspinous ligaments, facet joints, and disc herniation were black. In addition, the postoperative re-examination revealed a black discoloration of the nasal and ear cartilage. Finally, the diagnosis of AKU was confirmed when the urine specimen was positive for HGA. Conclusion: Rarely, younger patients with AKU who develop excess black deposits of HGA in connective tissues (i.e., ochronosis) may present with lumbar disc herniations and spondylosis. [ABSTRACT FROM AUTHOR]

Background: Spinal catheter insertion in lumboperitoneal shunt (LPS) surgery for normal pressure hydrocephalus (NPH) can result in radiculopathy due to mechanical irritation of the nerve roots of the cauda equina. Here, we analyzed the position of LPS shunts placed without portable fluoroscopy in 72 patients, a subset of whom developed postoperative radiculopathy. Methods: We retrospectively analyzed how frequently 72 consecutive NPH patients experienced radiculopathy following LPS catheter placement performed without intraoperative fluoroscopy. Results: The rate of incorrect catheter placement was 15.3% (11/72 cases). We observed that is, downward placement in 6.9% (5/72 cases), hyperflexion in 6.9% (5/72 cases), and subcutaneous migration in 1.4% (1/72 cases) patients. One patient with initial correct LPS placement developed radicular pain 5-day postoperatively attributed to 1-cm of catheter movement; they recovered simply by utilizing oral analgesics for 1-month duration. Conclusion: LPS insertion without fluoroscopic guidance resulted in a 15.3% risk of spinal catheter displacement. We suggest, therefore, that intraoperative imaging guidance be utilized for the placement of LPS in patients with NPH and/or for other pathology to avoid the 15.3% risk of postoperative radiculopathy. [ABSTRACT FROM AUTHOR]

Background: Lumbar microdiscectomy is one of the most frequently performed neurosurgical procedures. In this review, we ask why patients' outcomes vary so widely even within the same unit, with the same surgeon performing the procedure and utilizing the technique? Methods: In a cohort of 87 patients, we investigated how/whether multiple patient variables impacted outcomes following single-level lumbar microdiscectomy. We studied whether early surgical intervention improved the patients' quality of life (QOL) versus late intervention. Furthermore, we assessed other variables that could influence patient-perceived improvement. Preoperatively and postoperatively, we additionally utilized the following internationally standardized questionnaires (EQ-5D, Oswestry, and Core Outcome Measures Index [COMI]). Results: A generalized substantial improvement in QOL was identified throughout the cohort population (<0.05). There was no difference in health measurement scores for those undergoing early versus late surgery. However, there was a statistically significant improvement in all QOL scores for privately insured patients versus publicly insured patients (e.g., on COMI, EQ-5D, and ODI Scores). Conclusion: There was no objective statistically significant difference in QOL health scores between patients undergoing early versus late surgical lumbar microdiscectomy. This would suggest that the length of time patients is symptomatic before surgery did not significantly impact postoperative outcome. Of interest, however, was the difference in QOL health scores for private versus public patients suggesting that there are more subjective, complex, and psychosocial issues that influence outcome. [ABSTRACT FROM AUTHOR]

Background: Klippel-Feil syndrome (KFS) is defined by multiple abnormal segments of the cervical spine with congenital synostosis of two or more cervical vertebrae. KFS patients who demonstrate progressive symptomatic instability and/or neurologic sequelae are traditionally managed with operative decompression and arthrodesis. Case Description: A 44-year-old female with chronic neck pain and radiculopathy and a C7-T1 KFS presented with adjacent segment degenerative disc disease at the C5-6 and C6-7 levels. She was successfully managed with a two-level cervical disc arthroplasty (CDA). Conclusion: Patients with KFS and disease at two contiguous, adjacent levels (e.g., cervical disc disease) may be safely and effectively managed with two-level CDA. [ABSTRACT FROM AUTHOR]

Background: An engorged venous plexus may mimic nerve compression from a herniated disk on the magnetic resonance (MR) studies as they both have similar signal intensities. During a laminectomy, if an engorged venous plexus is encountered instead of a disk herniation, there may be marked unanticipated bleeding. Case Description: A 58-year-old female who had a prior anterior lumbar interbody fusion later returned with recurrent radiculopathy. Adjacent segment disease from a spinal disk herniation was suspected based on the surgical history, physical examination, and imaging (MRI) findings. Rather than a disk, an engorged venous plexuses (EVP) was encountered intraoperatively. Conclusion: Here, we discussed our findings regarding a lumbar EVP rather than a herniated disk and reviewed the current literature. Although rare, a higher index of suspicion for these vascular malformations based on combined historical information and MRI studies should allow one to better detect and/or anticipate an EVP rather than a routine disk. [ABSTRACT FROM AUTHOR]

Background: Primary spinal tumors are rare and include schwannomas. In the cervical region, these lesions can cause pain, radiculopathy, and/or myelopathy. Case Description: A 53-year-old male presented with 9 months of chronic neck pain and left upper extremity radiculopathy/myelopathy. The MRI revealed an intradural extramedullary C6-C7 mass left-sided mass with foraminal extension. Following a C5-C7 laminectomy with C5-T2 instrumented fusion, the diagnosis of schwannoma with evidence of recent hemorrhage was confirmed by biopsy. Three weeks postoperatively, the patient was pain free, no longer taking opioids, and neurologically intact. Although the MR 6 months later showed no tumor, the MRI 15 months later documented a recurrent enhancing C6-C7 lesion. The patient elected to be treated with external beam radiotherapy and remained asymptomatic. Conclusion: A 53-year-old underwent resection of a cervical C6-C7 schwannoma with intratumoral hemorrhage. Fifteen months following C5-C7 laminectomy with C5-T2 fusion, the tumor recurred and required external beam radiation therapy. [ABSTRACT FROM AUTHOR]

Background: Factors that are known to cause lumbar epidural venous plexus (EVP) engorgement include inferior vena cava (IVC) obstruction, portal hypertension, vascular agenesis, morbid obesity, and/or hypercoagulable states. Here, we present a 32-year-old female admitted with the new onset of lumbar radiculopathy attributed to a gastric balloon causing compression of the IVC and engorgement of the EVP. Case Description: A 32-year-old female was admitted with a left L5 radiculopathy. She had a history of morbid obesity and had undergone intragastric balloon insertion 4 months ago. The abdominal/pelvic CT documented an intragastric balloon producing a voluminous gastric mass with resultant compression of the IVC. The lumbar MRI showed the resultant marked multilevel engorgement of the lumbar EVP. Here, following balloon removal, the patient was immediately symptom free and remained asymptomatic over the next postoperative year. Conclusion: An intragastric balloon can produce a voluminous gastric mass that can result in IVC occlusion and engorgement of the EVP, leading to lumbar radiculopathy. Removal of the balloon results in immediate and permanent resolution of the compressive symptoms. [ABSTRACT FROM AUTHOR]

Background: Lumbar disc herniation (LDH) usually presents with lower extremity symptoms and signs, but rarely with bladder and bowel complaints. Here, we present a 61-year-old female who suffered solely from fecal incontinence (FI) attributed to a large LDH. Case Description: The patient presented with FI, but had a normal neurological examination. When the lumbar magnetic resonance imaging of showed a large central L5S1 LDH, the patient underwent an urgent diskectomy. Six months later, her symptoms had improved. Conclusion: Patients with large central LDHs may present with FI alone warranting urgent/emergent disc removal. [ABSTRACT FROM AUTHOR]

Background: Patients with cauda equina schwannomas usually present with slowly progressive radiculopathy. Herein, we describe a 34-year-old male who presented with acute radiculopathy attributed to a small L4 ventral root schwannoma. Case Description: A 34-year-old male suddenly developed left leg pain. Magnetic resonance imaging (with/without contrast) revealed a small intradural mass lesion involving the L4 nerve root that was enhanced with contrast (size: 9 × 12 × 12 mm). The computed tomography myelogram revealed that the tumor had originated from the L4 ventral root and compressed the dorsal root in the lateral recess. Following a decompressive laminectomy for tumor removal, the patient's radicular pain improved. The histological diagnosis was consistent with a schwannoma. Conclusion: Small cauda equina schwannomas involving ventral nerve roots can cause acute radiculopathy readily relieved with decompressive laminectomies for tumor excision. [ABSTRACT FROM AUTHOR]

Background: A spinal dural defect caused by needle placement for spinal level localization is an uncommon complication of cerebrospinal fluid leak with the potential for the development of intracranial hypertension. Case Description: Our 48-year-old patient underwent unilateral fenestration and sequestrectomy for intractable L5 radiculopathy due to disc herniation at the level L4-5 on the right side. The spinal level was identified with fluoroscopy after placement of a 24-gauge Sprotte spinal needle on the right side. Intraoperatively, a submillimeter spinal dural defect was visualized on the ipsilateral side. Conclusion: Caution is needed when needle placement is used to localize the spinal level for unilateral surgery. [ABSTRACT FROM AUTHOR]

Background: Symptomatic T1-T2 disc herniations are rare and, in most cases, are located posterolaterally. Posterior approaches may utilize transfacet pedicle-sparing techniques, while the less frequent central/anterolateral discs may warrant anterior surgery. Case Description: Here, we reviewed four cases of symptomatic T1-T2 disc herniations; two patients were paraparetic due to central discs and underwent anterior surgery utilizing a cage construct. The latter two cases had posterolateral discs contributing to a Brown-Sequard syndrome and radiculopathy, respectively; one patient required a transfacet pediclesparing procedure, while the second case was managed conservatively. All surgically treated patients recovered fully. Conclusions: We reviewed 4 cervical T1-T2 disc herniations; two central/anterolateral lesions warranting anterior surgical approaches/cages, and 2 lateral discs treated with a posterolateral transfacet, pedicle-sparing procedure and no surgery respectively. Follow-up magnetic resonance studies documented full resolution for the patient with radiculopathy and a posterolateral disc. [ABSTRACT FROM AUTHOR]

Background: Tortuous/abnormal vertebral arteries (VAs) sometimes cause neurovascular compression syndromes (NVCs), such as trigeminal neuralgia, hemifacial spasm, and, rarely, myelopathy/radiculopathy. Abnormalities/tortuosity of the VA at the level of the atlas and axis are of particular note; these may be characterized by a persistent first intersegmental artery (PFIA) and C2 segmental type of VA. Herein, we report a 72-year-old male who presented with cervical myelopathy/radiculopathy due to bilateral tortuosity of the PFIA resulting in spinal cord compression at the craniocervical junction. Case Description: A 72-year-old male presented with cervical pain when turning his neck and progressive gait disturbance. The neurological examination demonstrated a moderate myeloradicular syndrome (Nurick Grade III). The magnetic resonance revealed compression of the medulla and spinal cord due to tortuosity of both dorsal VA at the C1 vertebral level. The three-dimensional computed tomography angiogram confirmed bilateral PFIA running medially. In addition, the left side of VA forms fenestration. Surgery through a C1 laminectomy and midline small suboccipital craniectomy, both VAs were transposed and tethered to the ipsilateral dura utilizing Aron Alpha and vinyl prostheses. In addition, a large vinyl prosthesis was inserted between both VAs to protect them from contacting the spinal cord. Following this decompressive procedure, the patient's symptoms fully resolved, and he remains asymptomatic 10 years later exhibiting no recurrent vascular pathology. Conclusion: Microvascular decompression of anomalous VAs contributing to cord compression at the C1 level was safe and effective in a 72-year-old male. [ABSTRACT FROM AUTHOR]

Background: Athletic pubalgia is a painful complex syndrome encountered by many athletes involved in sports. Multiple pathologies often coexist, and many systems can refer pain to the groin. The current case reflects the failure to distinguish pubalgia from lumbar radiculopathy. Case Description: Originally, a 47-year-old male with left-sided inner thigh pain was diagnosed as having a L3-4-disc herniation and spinal stenosis; he underwent a L3-4 and L4-5 laminectomy/discectomy. For 2 years postoperatively, the pain persisted. Ultimately, he underwent surgical reinsertion of the adductor muscle and experienced immediate and sustained pain relief. Conclusion: This case report highlights how pubalgia may be misdiagnosed as a lumbar disc herniation and may inadvertently lead to unnecessary lumbar surgery. [ABSTRACT FROM AUTHOR]

Background: Extensive studies have been performed about the synovial cyst and intraspinal extradural ganglion cyst. Here, we describe a new type of the cyst with entirely different histological characteristics, which we are now calling a "Spontaneous Degenerative Epidural Cyst". Case Description: A 74-year-old male presented with low back pain, bilateral lower extremity radiculopathy, and a cauda equina syndrome. He exhibited a partial left foot drop (Grade 3/5) and hypoesthesia in the sacral region. The magnetic resonance imaging (MRI) showed two cysts at the L4-L5 level; Cyst I was in the left foramen and Cyst II was within the epidural space between the dura and ligamentum flavum. Cyst I was removed through an endoscopic transforaminal approach; it originated from the left facet joint and with synovial lining was confirmed to be a synovial cyst. Cyst II required an endoscopic interlaminar approach, and pathology revealed granulation tissue with microcalcification, woven bone formation, hemosiderin pigment, and focal cystic change consistent with our designation "Spontaneous Degenerative Epidural Cyst". Conclusion: "Spontaneous Degenerative Epidural cyst" should be considered among the differential diagnostic consideration for the different lumbar cysts. High-resolution MRI is the most useful in diagnosing these lesions, while full endoscopic treatment provides for adequate resection of these lesions. [ABSTRACT FROM AUTHOR]

Background: Myeloid sarcoma (MS) is a malignant tumor that usually occurs concomitantly with or following acute myeloid leukemia (AML). Cavernomas are benign congenital malformations that are unusual in the spine and exceedingly rare in pure extradural locations. Case Description: We report a 73-year-old female with a previous medical history of AML in remission for 3 years who presented with symptoms of low back pain and right lower extremity radiculopathy. A magnetic resonance scan showed an extradural, foraminal lesion centered at the L2 level involving the right L2 nerve root. In view of the history of AML, this lesion was potentially considered MS, a form of AML relapse. Surgery consisting of a right L1 and L2 hemilaminectomy facilitated gross total resection of the purely extradural lesion the proved histologically to be a cavernoma. Conclusion: In patients with a history of leukemia, MS must be considered in the differential diagnosis for any epidural or nerve root lesion that appears following treatment. Although rare, cavernomas must be considered among the differential diagnoses for epidural nerve root lesions in the setting of AML. [ABSTRACT FROM AUTHOR]

Background: Transverse fractures of the sacrum are rare, and surgical treatment for these fractures ranges from conservative to challenging. Transverse stress fractures of the sacrum after placement of lumbartosacral instrumentation have been previously described. We report a new technique to repair a transverse Type2 RoyCamille fracture with spondylolisthesis of S1 over S2 in a previously fused instrumented highgrade L4L5, L5S1 spondylolisthesis. Case Description: A 64yearold female who previously had an L4L5, L5S1 fusion for spondylolisthesis presented with excruciating lower back pain and radiculopathy for over 6 months. She was found to have an S1S2 transverse fracture caused by previous implantation of pedicle screws. She underwent repositioning of several failed right lumbar and sacral screws and then had bilateral S1S2 screws placed directly across the fracture line. The patient had an unremarkable postoperative course. She discontinued most of her pain medications within 6 weeks postoperatively. In the months following surgery, she reported only minimal lower back pain and no radiculopathy with the last appointment 5 years postoperatively. Conclusions: We describe a novel technique to reduce an iatrogenic transverse type2 RoyCamille fracture at S1S2 in a previously instrumented highgrade L4L5, L5S1 spondylolisthesis. The patient's fracture achieved adequate reduction and fusion with symptomatic relief. [ABSTRACT FROM AUTHOR]

Background: Another rare cause of lower back pain with radiculopathy is the discal cyst. It is believed to arise from degeneration of a herniated disc, although many other theories of its origin have been proposed. Here, we report a patient with lower back pain/radiculopathy attributed originally to a herniated lumbar disc, which transformed within 6 months into a discal cyst. Case Description: A 42-year-old male had a magnetic resonance (MR) documented herniated lumbar disc at the L4-5 level. It was managed conservatively for 6 months, after which symptoms recurred and progressed. The follow-up MR study revealed a discal cyst at the L4-5 without residual herniated disc. Of interest, the cyst communicated with the L4-5 intervertebral disc, which was herniated under the posterior longitudinal ligament and the disc space. During surgery, the cyst was completely removed, and his symptoms/signs resolved. Conclusion: A discal cyst develops as pathological sequelae of a degenerated herniated disc. Although rare, these lesions must be considered among the differential diagnoses in young patients with radicular back pain. MR study clearly documents these lesions, and surgical excision of the cyst is the treatment of choice. [ABSTRACT FROM AUTHOR]

Background: Bone morphogenic protein (BMP) for instrumented lumbar fusion was approved in 2002, and since then has led to an increasing incidence of BMP-related neuropathic pain. These patients are usually resistant to conventional medical therapy and frequently undergo multiple surgical revisions without any pain relief. Case Description: A 58-year-old male was referred to the author's outpatient clinic after four lumbar surgeries did not provide satisfactory pain relief. During his 10 years of suffering from low back pain after an injury, the patient was resistant to conventional and interventional treatment options. He was experiencing severe back pain rated 10/10, as well as right lower extremity pain, numbness, tingling, and motor deficits. Outside spine specialists had performed revision surgeries for BMP-related exuberant bone formation at L5-S1, which included the removal of the ipsilateral hardware and debridement of intradiscal and intraforamina heterotrophic exuberant bony formation. The author implanted the patient with a permanent continuous spinal cord stimulator, after which he achieved complete pain relief (0/10) and restoration of motor, sensory, autonomic, and sphincter functions. Conclusion: This is the first reported case of restorative function with neuromodulation therapy in a BMP-induced postoperative complication, which is considered as a primarily inflammatory process, rather than nerve root compression due to exuberant bony formation. We hypothesize that neuromodulation may enhance blood flow and interfere with inflammatory processes, in addition to functioning by the accepted gate control theory mechanism. The neuromodulation therapy should be strongly considered as a therapeutic approach, even with confirmed BMPinduced postoperative radiculitis, rather than proposing multiple surgical revisions. [ABSTRACT FROM AUTHOR]

Background: Chronic low back pain (LBP) is highly prevalent and costly in our society. The use of epidural steroid injections (ESIs) for the treatment of radicular LBP is very widespread and continues to rise. The most popular injection is the lumbar/sacral transforaminal epidural steroid injection (TFESI). Here, we present a serious neurological complication resulting from such a TFESI that was only reversed by timely neurosurgical intervention. Case Description: A 49-year-old male presented with a 5-year history of progressive neurogenic claudication and right lower extremity pain/radiculopathy. He had previously received multiple lumbar ESIs and other conservative therapy. Due to a recent exacerbation of his radiculopathy associated with MRI-documented lumbosacral spondylosis, he underwent a right L5/S1 TFESI under fluoroscopic guidance. This resulted in acute right lower extremity weakness accompanied by a right-sided foot drop and sphincter dysfunction. Although the follow-up MRI was noncontributory, the EMG showed L5/S1 denervation, and the patient underwent an L4-5, L5-S1 laminectomy with discectomies at the L4-5 and L5-S1 levels. Immediately after the surgery, the patient's weakness and sensory deficits improved. Two years later, the patient continued to do well without evidence of recurrence of signs or symptoms of lumbosacral radiculopathy. Conclusion: Patients should be counseled about the risk and benefits of TFESI. Surgical treatment may be warranted in patients who develop acutely progressive worsening following these non-FDA (Food/Drug Administration) approved injections. [ABSTRACT FROM AUTHOR]

Background: Mobile schwannomas of the cauda equina are rare. Preoperative planning should take into consideration the possibility of tumor migration, avoiding unnecessary additional laminectomy or second operation. Case Description: A patient with a previously known lumbar schwannoma was being managed conservatively until symptoms exacerbated and led to a new MR. When this study revealed caudal migration of the schwannoma from L3 to the L4-L5 levels, a right hemilaminectomy was performed for tumor resection. Conclusion: Great care must be taken in the surgical resection of schwannomas as they may migrate from their initial location. [ABSTRACT FROM AUTHOR]

Background: Decompression of an anomalous vertebral artery (VA) may effectively treat cervical myelopathy/radiculopathy due to resultant spinal cord or nerve compression. Here we report a case of C2 radiculopathy induced by neck flexion due to cord compression of the C2 segmental type VA relieved by microvascular decompression. Case Description: A 30-year-old female presented with left occipitalgia, sensory abnormalities in the left upper and lower extremities, and neck pain induced by neck flexion. The magnetic resonance imaging (MRI) revealed an abnormal flow void, confirming that the VA was compressing the spinal cord at the C1 level. Three-dimensional computed tomography (3D-CT) showed an anomalous course of the left VA, which entered the spinal canal between the axis and atlas. Microvascular decompression was performed by transposing the artery (e.g., anchoring it to the dura using PTEF): this effectively relieved cord compression. Case Description: A 30-year-old female presented with left occipitalgia, sensory abnormalities in the left upper and lower extremities, and neck pain induced by neck flexion. The magnetic resonance imaging (MRI) revealed an abnormal flow void, confirming that the VA was compressing the spinal cord at the C1 level. Three-dimensional computed tomography (3D-CT) showed an anomalous course of the left VA, which entered the spinal canal between the axis and atlas. Microvascular decompression was performed by transposing the artery (e.g., anchoring it to the dura using PTEF): this effectively relieved cord compression. [ABSTRACT FROM AUTHOR]

Background: Rhabdomyolysis results from the release of large quantities of muscle cell contents into plasma resulting in a classic triad of symptoms - muscle pain, weakness, and brown urine. Only a handful of rhabdomyolysis cases occurring after spinal surgery have been reported. Case Description: A 36-year-old male underwent an uneventful right-sided, minimally invasive transforaminal lumbar interbody fusion (miTLIF) for intractable lower back pain and right lower extremity radiculopathy attributed to L4-S1 degenerative spondylosis (DS). Postoperatively, the patient complained of intractable lower extremity pain resistant to medical management. He was subsequently diagnosed with rhabdomyolysis, and aggressive intravenous fluid resuscitation resulted in complete recovery. Conclusions: Rhabdomyolysis should be diagnosed and treated promptly with aggressive intravenous fluid resuscitation to avoid acute kidney injury following miTLIF surgery. [ABSTRACT FROM AUTHOR]

Background: The surgical treatment of cervical radiculopathy has centered around anterior cervical discectomy and fusion (ACDF). Alternatively, the posterior cervical laminoforaminotomy/microdiscectomy (PCF/PCM), which results in comparable outcomes and is more cost-effective, has been underutilized. Methods: Here, we compared the direct/indirect costs, reoperation rates, and outcome for ACDF and PCF vs. PCM using PubMed, Medline, and Embase databases. Results: There were no significant differences between the re-operative rates of PCF/PCM (2% to 9.8%) versus ACDF (2% to 8%). Direct costs of ACDF were also significantly higher; the 1-year cost-utility analysis demonstrated that ACDF had $131,951/QALY while PCM had $79,856/QALY. Results: There were no significant differences between the re-operative rates of PCF/PCM (2% to 9.8%) versus ACDF (2% to 8%). Direct costs of ACDF were also significantly higher; the 1-year cost-utility analysis demonstrated that ACDF had $131,951/QALY while PCM had $79,856/QALY. [ABSTRACT FROM AUTHOR]

Background: The objective of this study is to determine the clinical and surgical outcomes following lumbar laminectomy. Methods: We retrospectively reviewed medical records of neurosurgical patients who underwent firsttime, bilateral, 13 level laminectomies for degenerative lumbar disease. Patients with discectomy, complete facetectomy, and fusion were excluded. Results: Five hundred patients were followed for an average of 46.79 months. Following lumbar laminectomy, patients experienced statistically significant improvement in back pain, neurogenic claudication, radiculopathy, weakness, and sensory deficits. The rate of intraoperative durotomy was 10.00%; however, 1.60% experienced a postoperative cerebrospinal fluid leak. The risk of experiencing at least one postoperative complication with a lumbar laminectomy was 5.60%. Seventytwo patients (14.40%) required reoperations for progression of degenerative disease over a mean of 3.40 years. The most common symptoms prior to reoperation included back pain (54.17%), radiculopathy (47.22%), weakness (18.06%), sensory deficit (15.28%), and neurogenic claudication (19.44%). The relative risk of reoperation for patients with postoperative back pain was 6.14 times higher than those without postoperative back pain (P < 0.001). Of the 72 patients undergoing reoperations, 55.56% underwent decompression alone, while 44.44% underwent decompression and posterolateral fusions. When considering alltime reoperations, the lifetime risk of requiring a fusion after a lumbar laminectomy based on this study (average followup of 46.79 months) was 8.0%. Conclusion: Patients experienced statistically significant improvements in back pain, neurogenic claudication, radiculopathy, motor weakness, and sensory deficit following lumbar laminectomy. Incidental durotomy rate was 10.00%. Following a firsttime laminectomy, the reoperation rate was 14.4% over a mean of 3.40 years. [ABSTRACT FROM AUTHOR]

Background: Lower back pain with radiculopathy due to a disc herniation occurs in about 0.01% of pregnant females. Surgical intervention is seldom required unless there is intractable pain, and for a significant neurological deficit. Further, the use of intraoperative ionizing radiation may adversely affect the developing fetus. Case Description: A 25-year-old female, 17-weeks pregnant, presented with right lower extremity sciatica due to a L4-5 unilateral disc herniation. She underwent a microdiscectomy that required just one intraoperative C-arm fluoroscopic image. Postoperatively, her leg pain resolved, and she delivered a healthy baby at term. Conclusion: Using single-image C-arm fluoroscopy in a pregnant female undergoing an emergent lumbar discectomy, employing as low as reasonably achievable/shielding, did not adversely impact the developing fetus. [ABSTRACT FROM AUTHOR]

Background: The efficacy and safety of cervical laminoforaminotomy (FOR) in the treatment of cervical radiculopathy has been demonstrated in several series with follow-up less than a decade. However, there is little data analyzing the relative effectiveness of FOR for radiculopathy due to soft disc versus osteophyte disease. In the present study, we review our experience with FOR in a single-center cohort, with long-term follow-up. Methods: We examined the charts of patients who underwent 1085 FORs between 1990 and 2009. A cohort of these patients participated in a telephone interview designed to assess improvement in symptoms and function. Results: A total of 338 interviews were completed with a mean follow-up of 10 years. Approximately 90% of interviewees reported improved pain, weakness, or function following FOR. Ninety-three percent of patients were able to return to work after FOR. The overall complication rate was 3.3%, and the rate of recurrent radiculopathy requiring surgery was 6.2%. Soft disc subtypes compared to osteophyte disease by operative report were associated with improved symptoms (P < 0.05). The operative report of these pathologic subtypes was associated with the preoperative magnetic resonance imaging (MRI) interpretation (P < 0.001). Conclusions: These results suggest that FOR is a highly effective surgical treatment for cervical radiculopathy with a low incidence of complications. Radiculopathy due to soft disc subtypes may be associated with a better prognosis compared to osteophyte disease, although osteophyte disease remains an excellent indication for FOR. [ABSTRACT FROM AUTHOR]

Background: Spinal manipulation is widely used for low back pain treatments. Complications associated with spinal manipulation are seen. Lumbar epidural hematoma (EDH) is one of the complications reported in the literature. If lumbar chronic EDH symptoms are present, which are similar to those of a herniated nucleus pulposus, surgery may be considered if medical treatment fails. Percutaneous endoscopic discectomy utilizing an interlaminar approach can be successfully applied to those with herniated nucleus pulposus. We use the same technique to remove the lumbar chronic EDH, which is the first documented report in the related literature. Methods: We present a case with chronic lumbar EDH associated with spinal manipulation. Neurologic deficits were noted on physical examination. We arranged for a full-endoscopic interlaminar approach to remove the hematoma for the patient with the rigid endoscopy (Vertebris system; Richard Wolf, Knittlingen, Germany). Results: After surgery, the patient's radiculopathy immediately began to disappear. Magnetic resonance imaging (MRI) follow-up 10 days after the surgery revealed no residual hematoma. No complications were noted during the outpatient department follow up. Conclusions: Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. A percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits. [ABSTRACT FROM AUTHOR]

Background: Spinal catheter insertion in lumboperitoneal shunt (LPS) surgery for normal pressure hydrocephalus (NPH) can result in radiculopathy due to mechanical irritation of the nerve roots of the cauda equina. Here, we analyzed the position of LPS shunts placed without portable fluoroscopy in 72 patients, a subset of whom developed postoperative radiculopathy., Methods: We retrospectively analyzed how frequently 72 consecutive NPH patients experienced radiculopathy following LPS catheter placement performed without intraoperative fluoroscopy., Results: The rate of incorrect catheter placement was 15.3% (11/72 cases). We observed that is, downward placement in 6.9% (5/72 cases), hyperflexion in 6.9% (5/72 cases), and subcutaneous migration in 1.4% (1/72 cases) patients. One patient with initial correct LPS placement developed radicular pain 5-day postoperatively attributed to 1-cm of catheter movement; they recovered simply by utilizing oral analgesics for 1-month duration., Conclusion: LPS insertion without fluoroscopic guidance resulted in a 15.3% risk of spinal catheter displacement. We suggest, therefore, that intraoperative imaging guidance be utilized for the placement of LPS in patients with NPH and/or for other pathology to avoid the 15.3% risk of postoperative radiculopathy., Competing Interests: There are no conflicts of interest, (Copyright: © 2022 Surgical Neurology International.)