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Abstract Background Cauda equina syndrome is a rare clinical condition that requires prompt diagnosis and timely surgical decompression with postoperative rehabilitation to prevent devastating complications. Case presentation A 55-year-old Sinhalese woman presented with a vulval abscess, with a history of involuntary leakage of urine for the last 7 years. Her sexual activity has been compromised due to coital incontinence, and she had also been treated for recurrent urinary tract infections during the last 7 years. On examination, a distended bladder was found. Neurological examination revealed a saddle sensory loss of S2–S4 dermatomes. There was no sensory loss over the lower limbs. Bladder sensation was absent, but there was some degree of anal sphincter tone. Motor functions and reflexes were normal in the limbs. Magnetic resonance imaging revealed L5–S1 spondylolisthesis. Ultrasound imaging confirmed the finding of a distended bladder, in addition to bilateral hydroureters with hydronephrosis. An incision and drainage with concomitant intravenous antibiotics were started for the vulval abscess. An indwelling catheter was placed to decompress the bladder and to reduce vulval excoriations due to urine. Bilateral ureteric stenting was performed later for persistent hydronephrosis and hydroureter despite an empty bladder. Conclusion This is a tragic case that illustrates the devastating long-term sequelae that ensues if cauda equina syndrome is left undiagnosed. It reiterates the importance of prompt referral and surgical decompression.

We report a case of cauda equina syndrome related to the use of fibrin glue dural sealant "TISSEEL". Incidental durotomy (ID) is not uncommon in revision spinal surgery. Augmentation of the dural repair after primary closure is gaining popularity. The use of dural sealants is not risk-free. A 65-year old man who underwent revision lumbar decompression surgery developed postoperative cauda equina syndrome. He had urinary retention, bilateral leg pain and perianal numbness on the third postoperative day. We believe this complication was related to the use of fibrin glue to manage an ID. After the urgent surgical removal of the fibrin glue patch, the patient fully recovered with no residual neurological deficit. Cauda equina syndrome development is a potential complication after the use of fibrin glue to augment intraoperative ID. Surgeons should be aware of this potential risk so it can be managed in a timely fashion. [ABSTRACT FROM AUTHOR]

Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, where all the nerves in the lower back suddenly become severely compressed. It is a serious medical emergency, and compression of the nerves in the lower portion of the spinal canal can lead to permanent loss of bowel and bladder control, paraesthesia, and paralysis of the legs if left untreated. Causes of CES include: trauma, spinal stenosis, herniated discs, spinal tumour, cancerous tumour, inflammatory and infectious conditions or due to an accidental medical intervention. CES patients typically present with symptoms of: saddle anaesthesia, pain, incontinence and numbness. Any of these are red flag symptoms and require immediate investigation and treatment. [ABSTRACT FROM AUTHOR]

"Reverse cortical sign" is a rare entity described in lumbar burst fracture that corresponds to the fracture fragment of the posterior wall of vertebral body, which has rotated 180 degrees with the cortical surface facing anteriorly and the cancellous surface facing posteriorly in the canal. Identifying this sign is crucial in deciding the line of management as it is a contraindication for ligamentotaxis. The advent of computed tomography scans with axial and sagittal reconstruction has allowed us to better describe these rare entities. We present a lumbar burst fracture with a reverse cortical sign describing its appearance in axial computed tomography scans, sagittal reconstruction, and magnetic resonance imaging. [ABSTRACT FROM AUTHOR]

The novel coronarvirus disease (COVID-19) has had a major impact on provision of spinal neurosurgery across the world, especially in the UK, with a significant fall in operating and patient volumes, and elective clinical activities. It is unclear whether the pandemic has affected the volume of urgent spinal procedures in the UK, especially surgical decompressions for cauda equina syndrome (CES). Therefore, we conducted a retrospective analysis of theatre records and electronic operation notes at our institution to identify all procedures performed for CES before (December 2019 to February 2020) and during (March 2020 to May 2020) the COVID-19 pandemic. Statistical analyses were performed on SPSS v22 (IBM). Forty-four patients underwent surgical decompressions during the study period. Over half (54.5%) were female and the median age was 45 years (range = 22–78 years). Three in four procedures were performed at L4-5 and L5-S1 levels (79.5%). There was no statistically significant difference in the number of decompressions performed each month [χ2(5)=1.818; p = 0.874]. On the other hand, the number of referrals for suspected or confirmed CES fell by 81.8% between December 2019 and April 2020. Our results did not show any statistically significant decline in the volume of surgical decompressions performed for CES despite the considerable fall in electronic referrals for CES and degenerative spinal conditions. This suggests that patients with critical neurological symptoms continued to present and were treated appropriately despite the restrictions imposed on spinal surgeons during the pandemic. [ABSTRACT FROM AUTHOR]

Spinal arachnoid cysts (SAC) are uncommon benign spinal cord lesions, particularly in children, that can result in a variety of neurologic symptoms, including neurogenic bladder. Here we present the case of a 7-year-old female with new onset, isolated urinary and stool incontinence who was found to have a T4-T7 SAC. Though this was initially believed to be an incidental imaging finding, after thorough work-up and persistence of her symptoms despite conservative measures she underwent neurosurgical intervention with complete resolution of incontinence. SAC represents a very rare but potentially reversible cause of neurogenic bladder that the urologist should be aware of.

Sacral fractures in young healthy patients are usually linked to high-energy trauma. They are often associated with multiple other injuries. Isolated sacral fractures are rare and can be easily missed in the absence of other surrounding pelvic or spinal injuries. In this article, we present a rare case of isolated U-shaped displaced sacral fracture despite the high-energy mechanism of injury being missed on initial presentation. This is a 17-year-old healthy female who presented to the emergency department after falling from five-meter height. She complained of lower back pain and inability to ambulate. Physical examination revealed significant sacral tenderness, bilateral lower limb weakness and hypoesthesia, anesthesia of the saddle area, weak anal tone and absent anal reflex. Initial radiographs showed no apparent fractures. Further imaging by pelvic computed tomography, however, revealed an isolated U-shaped displaced sacral fracture. The patient was treated by decompression and lumbopelvic fixation by triangular osteosynthesis and iliosacral screw. This fixation method restored stability of the spinopelvic junction and allowed for early mobilization. At her 18-month follow-up visit, she showed minimal disability score (10%) on the Oswestry Disability Index. In conclusion, sacral fractures are considered exceedingly rare to occur in isolation and in young healthy patients.

Background: Spinal fusion is a common surgery, in which vertebrae are fused to restore spinal stability and eliminate pain during movement. The use of an interbody cage facilitates spinal fusion. However, complete cage migration into the dura matter rarely occurs and can be challenging to manage. Case Presentation: A 44-year-old man presented at our spine center with a history of incomplete paraplegia and cauda equina syndrome that had lasted for 2 years and 4 months. This condition developed after he underwent six lumbar spine surgeries to address lower back pain and right-sided sciatica. A structural allograft kidney-shaped cage was found completely within the dura at the level of the L3 vertebra. Durotomy, cage retrieval, and pedicle screw fixation from the L2 to L4 vertebrae were performed. Numbness in both lower limbs markedly decreased within several days of the operation. After four months following the progressive physical therapy, the patient could partially control both urination and defecation. Five months postoperatively, he could stand with slight assistance. Conclusions: Complete intradural cage migration is a rare and serious complication. To the best of our knowledge, this is the first reported case with such a condition in the literature. Even if treatment is delayed, surgical intervention may salvage the remaining neurologic function and may even lead to partial recovery.

• Septic arthritis of the facet joints (SAFJ) is a severe infection, associated with infective endocarditis and neurological impairment. • Staphylococcus aureus and Streptococcus spp are the most frequent pathogens found in SAFJ. • One-year mortality was estimated to be 9.2% in our study and reached respectively 18.5% and 23% in years two and three. Septic arthritis of the Facet Joints (SAFJ) is a rare condition. Little data has been published on the subject. We aimed to describe the clinical, biological and imagery presentations, as well as the course of this rare infection. We included patients hospitalized between January 1st, 2016 and December 31th, 2019, in the Departments of Infectious Diseases or Rheumatology in 5 French centres in the CRIOGO network. We defined septic arthritis according to Newman's criteria and facet joint arthritis using imagery. Sixty-five patients were included, predominantly males (64.6%), with a mean age of 68.1 years. The mean time to diagnosis was 25.0 days. The principal symptoms at diagnosis were acute back pain (95.2%) and fever (76.9%). Neurological symptoms were present for 60.7% of the patients, including 16.4% motor deficit or cauda equina syndrome. SAFJ was located on the lumbosacral spine (73.4%) and was rarely multifocal (4.7%). Bacteriological identification was performed by blood cultures in 84.4% of the cases, and the pathogen was mainly Staphylococcus aureus (49.2%). Infective endocarditis was present for 26.9% of patients assessed by echocardiography. On MRI, soft tissue abscess or inflammation, epiduritis and epidural abscess were present in 87.1%, 66.7% and 33.9% of cases, and the pathogen was significantly more frequently Staphylococcus aureus. Mortality reached 9.2%, 18.5% and 23% at one, two, and three years respectively. SAFJ is a rare but severe disease. Microbiological diagnosis is primarily made on blood cultures, and S. Aureus was the main pathogen. Our results highlight the fact that SAFJ is associated with high morbidity and mortality, and with infective endocarditis. [ABSTRACT FROM AUTHOR]

Patients with emergency spinal pathologies such as suspected cauda equina syndrome are often admitted under non-spinal orthopaedic surgeons at district general hospitals (DGHs). Emergent investigation in the form of magnetic resonance imaging (MRI) is frequently required prior to potential referral to the tertiary spinal centre despite many DGHs not having out-of-hours MRI provision. Anecdotally, there is considerable anxiety among non-spinal orthopaedic surgeons working in DGHs around the admission and investigation of emergency spinal pathologies under their care. We sought to survey and formalise the opinions of non-spinal on-call orthopaedic consultants at three DGHs with regard to admission, investigation, local infrastructure and regional support provided to them when emergency spinal pathologies are admitted under their care. The consultants surveyed reported being very uncomfortable managing emergency spinal cases admitted under their care. It was felt that the hospitals provided inadequate infrastructure, especially in terms of obtaining timely imaging. There is a lack of local outpatient spinal provision, a lack of consistent advice from the regional centre, and a feeling of patient, personal and organisational vulnerability with the current implementation of the regional spinal pathway. There was a high preference for a restructuring of the spinal pathway as well as a desire for on-site spinal opinions. The results of this survey demonstrate the considerable unease experienced by non-spinal trauma and orthopaedic consultants at district general hospitals with regard to the management of spinal pathology. We hypothesise that this is not limited to this region but is a sentiment echoed nationally. [ABSTRACT FROM AUTHOR]

Study Design: This is a multicenter, prospective study. Purpose: This study aimed to evaluate the reproducibility of the walking test for patients with lumbar spinal stenosis (LSS). Overview of Literature: Walking test is one of the useful procedures to investigate cauda equina syndrome with lumbar spinal stenosis. One the other hands, there were few studies to investigate the reproducibility of this test. Methods: In this study, we prospectively examined 70 LSS patients with intermittent claudication symptoms at a multicenter outpatient clinic. A walking test was administered at baseline and week 4 to assess patients' walking distance and lower limb pain and numbness. Immediately after the walking test, patients were asked to use the Visual Analog Scale (VAS) to rate their pain and numbness in the front, back, outside, inside, and hip of the lower legs. The reproducibility of the walking test was evaluated using Cohen's κ analysis and intraclass correlation coefficients (ICCs). Meanwhile, the Swiss Spinal Stenosis (SSS) Questionnaire was used to evaluate the severity of the stenosis. Results: The walking distance ICC at baseline and at week 4 remained unchanged at 0.7, with acceptable interobserver reliabilities for lower limb pain and numbness in both legs. The average VAS score for lower leg pain was 23.2±25.2 mm at baseline and 27.4±28.8 mm at week 4, while the corresponding average VAS score for numbness was 23.4±26.7 mm at baseline and 24.8±25.2 mm at week 4. The ICC score was 0.7 for leg pain and 0.7 for numbness. The mean SSS was 30.2±5.5 at baseline and 29.2±5.2 at week 4, and there was no significant difference in the severity. Conclusions: The walking test for LSS has acceptable reproducibility. [ABSTRACT FROM AUTHOR]

Background: Chronic spinal epidural hematomas (SEHs) are rare clinical entities. SEH with vertebral scalloping is extremely rare, with only a few cases having been reported to date. We report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping mimicking an epidural tumor.Case Presentation: A 71-year-old man presented with a 2-month history of lumbar pain and a 3-week history of paresthesia and pain in the right lower extremity, hypesthesia in the perineal and perianal regions, and bladder dysfunction. Computed tomography following myelography revealed an epidural mass lesion on the right side that compressed the dural sac and was associated with severe bony scalloping on the posterior wall of the L4 vertebral body. Magnetic resonance imaging (MRI) on T1- and T2-weighted images revealed a space-occupying lesion with heterogeneous intensity, and T1-gadolinium images showed an intralesional heterogeneous enhancement effect. A tumoral lesion in the spinal canal was suspected, based on preoperative imaging; therefore, a total spinal tumor resection was planned. Intraoperative findings revealed that the brownish lesion adhered to the dura and epidural tissues in the spinal canal, and the space-occupying mass in the scalloped cavity of the posterior wall of the L4 vertebra was encapsulated in red-brownish soft tissues. The lesion was totally resected in a piecemeal fashion, and pathological examination revealed a mixture of tissues that contained a relatively new hematoma with hemoglobin, as well as an obsolete hematoma with hemosiderin and amyloid deposits. The mass was diagnosed as a chronic epidural hematoma with recurrent hemorrhage. The postoperative course was uneventful, and the preoperative neurological symptoms immediately improved.Conclusions: The preoperative diagnosis of chronic SEHs is challenging, as MRI results may not be conclusive, particularly in patients with scalloping of bony structures. Thus, chronic SEHs should be considered as a differential diagnosis in cases of suspected tumoral lesions in the spinal canal. To the best of our knowledge, this is the first reported case of acute exacerbation of chronic SEH with cauda equina syndrome and severe vertebral scalloping. [ABSTRACT FROM AUTHOR]

Background. Lumbar spondylolisthesis is a common clinical spinal lesion. The upper vertebral body of the patient is displaced relative to the lower vertebral body, causing spinal instability and nerve compression. The clinical manifestations are low back and leg pain, abnormal lower limb sensation, and intermittent rupture. In severe cases, cauda equina syndrome and paraplegia may occur. Minimally invasive spinal surgery has developed rapidly in recent years and become the preferred treatment for lumbar spondylolisthesis. Objective. The aim of this study is to investigate the clinical effect of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) combined with percutaneous pedicle screw fixation in the treatment of lumbar spondylolisthesis under microscope. Methods. The clinical and surgical data of 106 patients with lumbar spondylolisthesis treated in our hospital were selected and divided into research group (56 cases) according to surgical methods (MIS-TLIF combined with percutaneous pedicle screw fixation). The other 50 patients were treated with traditional open percutaneous intervertebral foramen fusion (control group). The surgical trauma-related indicators, visual analog pain scale (VAS) scores before and after surgery, modified Japanese Orthopedic Association low back pain score (JOA), bone graft fusion effect, spinal pelvic parameters, and surgical complications of the two groups were statistically analyzed in detail. Results. The incision length, intraoperative blood loss, operation time, and hospitalization time in the research group were lower than those in the control group, and the differences were statistically significant (P < 0.05). There was no significant difference in the VAS score and JOA score between the two groups before operation (P > 0.05). The VAS score and JOA score of the research group were lower than those of the control group on the first day after operation (P < 0.05). There was no significant difference in the VAS score and JOA score between the two groups at 1 month and 3 months after operation (P > 0.05). Six months, 12 months, and 18 months after operation, the bone graft fusion rates in the research group were 42.86%, 73.21%, and 94.64%, respectively, and those in the control group were 40.00%, 68.00%, and 92.00%, respectively, with no significant difference (P > 0.05). There was no significant difference in PI, PT, SS, LL, TK, LSJA, and SVA between the two groups before and 6 months after operation (P > 0.05). At 6 months after operation, the PT and TK values of the two groups were higher than those before operation (P < 0.05), and the SS, LL, LSJA, and SVA values of the two groups were lower than those before operation (P < 0.05). The complication rate of the research group was 3.57%, which was lower than 18.00% of the control group, and the difference was statistically significant (P < 0.05). Conclusion. MIS-TLIF combined with percutaneous pedicle screw fixation in the treatment of lumbar spondylolisthesis has the same effect as traditional open surgery and has the same correction effect for spinal pelvic parameters, but it has the advantages of less trauma and fewer complications. [ABSTRACT FROM AUTHOR]

Background: Symptomatic pseudarthrosis and cage migration/protrusion are difficult complications of transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). If the patient experiences severe radicular symptoms due to cage protrusion, removal of the migrated cage is necessary. However, this procedure is sometimes very challenging because epidural adhesions and fibrous union can be present between the cage and vertebrae. We describe a novel classification and technique utilizing a navigated osteotome and the oblique lumbar interbody fusion at L5/S1 (OLIF51) technique to address this problem.Methods: This retrospective study investigated consecutive patients with degenerative lumbar diseases who underwent TLIF/PLIF. Symptomatic cage migration was evaluated by direct examination, radiography, and/or computed tomography (CT) at 1, 3, 6, 12, and 24 months of follow-up. Cage migration/protrusion was defined as symptomatic cage protrusion > 5 mm from the posterior border of the over and underlying vertebral body compared with initial CT. We evaluated patient characteristics including body mass index, smoking history, fusion level, and cage type. A total of 113 patients underwent PLIF/TLIF (PLIF n = 30, TLIF n = 83), with a mean age of 71.1 years (range, 28-87 years). Mean duration of follow-up was 25 months (range, 12-47 months).Results: Cage migration was identified in 5 of 113 patients (4.4%). All cases of symptomatic cage migration involved the L5/S1 level and the TLIF procedure. Risk factors for cage protrusion were age (younger), sex (male), and level (L5/S1). The mean duration to onset of cage protrusion was 3.2 months (range, 2-6 months). We applied a new classification for cage protrusion: type 1, only low back pain without new radicular symptoms; type 2, low back pain with minor radicular symptoms; or type 3, cauda equina syndrome and/or severe radicular symptoms. According to our classification, one patient was in type 1, three patients were in type 2, and one patient was in type 3. For all cases of cage migration, revision surgery was performed using a navigated high-speed burr and osteotome, and the patient in group 1 underwent additional PLIF without removal of the protruding cage. Three revision surgeries (group 2) involved removal of the protruding cage and PLIF, and one revision surgery (group 3) involved anterior removal of the cage and OLIF51 fusion.Conclusions: The navigated high-speed burr, navigated osteotome, and OLIF51 technique appear very useful for removing a cage with fibrous union from the disc in patients with pseudarthrosis. This new technique makes revision surgery after cage migration much safer, and more effective. This technique also reduces the need for fluoroscopy. [ABSTRACT FROM AUTHOR]

Existing guidelines advocate an updated therapeutic algorithm for chronic neuropathic pain (NeP), but pharmacotherapeutic management should be individualized to pain phenotypes to achieve higher efficacy. This study was aimed to evaluate the efficacy of medications, based on NeP phenotypes, and to propose symptom-based pharmacotherapy. This retrospective study was enrolled 265 outpatients with chronic NeP related to spinal disorders. The patients were classified into three groups: spinal cord-related pain, radicular pain, and cauda equina syndrome. Data were obtained from patient-based questionnaires using Neuropathic Pain Symptom Inventory (NPSI) and the Brief Scale for Psychiatric Problems in Orthopaedic Patients, and from clinical information. The proportions of patients with ≥ 30% and ≥ 50% reduction in NPSI score for each pain subtype (spontaneous pain, paroxysmal pain, evoked pain, and paresthesia/dysesthesia) and drugs were evaluated. The pain reduction rate was significantly lower in patients with spinal cord-related pain, especially for paresthesia/dysesthesia. For spinal cord-related pain, duloxetine and neurotropin had insufficient analgesic effects, whereas mirogabalin was the most effective. Pregabalin or mirogabalin for radicular pain and duloxetine for cauda equina syndrome are recommended in cases of insufficient analgesic effects with neurotropin. The findings could contribute to better strategies for symptom-based pharmacotherapeutic management. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the incidence of complications from lumbar decompression ± discectomy surgery for cauda equina syndrome (CES), assessing whether time of day is associated with a change in the incidence of complications. Methods: Electronic clinical and operative notes for all lumbar decompression operations undertaken at our institution for CES over a 2-year time period were retrospectively reviewed. "Overnight" surgery was defined as any surgery occurring between 18:00 and 08:00 on any day. Clinicopathological characteristics, surgical technique, and peri/post-operative complications were recorded. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals. Results: A total of 81 lumbar decompression operations were performed in the 2-year period and analysed. A total of 29 (36%) operations occurred overnight. Complete CES (CESR) was seen in 13 cases (16%) in total, 7 of whom underwent surgery during the day. Exactly 27 complications occurred in 24 (30%) patients. The most frequently occurring complication was a dural tear (n = 21, 26%), followed by post-operative haematoma, infection, and residual disc. Complication rates in the CESR cohort (54%) were significantly greater than in the CES incomplete (CESI) cohort (25%) (p = 0.04). On multivariable analysis, overnight surgery was independently associated with a significantly increased complication rate (OR 2.83, CI 1.02–7.89). Conclusions: Lumbar decompressions performed overnight for CES were more than twice as likely to suffer a complication, in comparison to those performed within daytime hours. Our study suggests that out-of-hours operating, particularly at night, must be clinically justified and should not be influenced by day-time operating capacity. [ABSTRACT FROM AUTHOR]

Background: The radiological features of posteriorly migrated intervertebral discs mimic tumors, hematoma, and abscess.Objective: The aim is to analyze two cases of posteriorly migrated lumbar discs.Cases: Two males had features of cauda equina syndrome. Both had posterior lesions at L4/5 level in magnetic resonance imaging. The mass of the 41-year-old man had peripheral rim enhancement with gadolinium. The epidural mass was excised. The histopathology showed fibrocartilaginous disc. The 67-year-old man had mass with moderate enhancement. The mass had thinned the dura to appear as intradural tumor. The histopathology showed a fibrocartilaginous disc. Immunohistochemistry was negative for neoplasm.Conclusion: A migrated disc should be considered in the case of a posterior extramedullary mass. The granulation tissue around the disc produces peripheral enhancement with gadolinium. Thin enhancement is common. Thick enhancement is also reported. Neoplasms have intense enhancement and inflammatory changes are seen in abscess. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the recovery of urinary functions and the factors predicting urinary recovery, following delayed decompression in complete cauda equina syndrome (CESR) secondary to Lumbar disc herniation (LDH). Methods: Retrospective study evaluated 19 cases of CESR due to single-level LDH, all presenting beyond 72 h. Mean delay in decompression was 11.16 ± 7.59 days and follow-up of 31.71 ± 13.90 months. Urinary outcomes were analysed on two scales, a 4-tier ordinal and a dichotomous scale. Logistic regression analysis was used for various predictors including delay in decompression, age, sex, radiation, level of LDH, motor deficits, type and severity of presentation. Time taken to full recovery was correlated with a delay in decompression. using Spearman-correlation. Results: Optimal recovery was seen in 73.7% patients and time to full recovery was moderately correlated with a delay in decompression (r = 0.580, p = 0.030). For those with optimal bladder recovery, mean recovery time was 7.43 ± 5.33 months. Time to decompression and other evaluated factors were not found contributory to urinary outcomes on either scales. Three (15.8%) patients had excellent, 11 (57.9%) had good, while 3 (15.8%) and 2 (10.5%) had fair and poor outcomes respectively. Conclusions: Occurrence of CESR is not a point of no-return and complete recovery of urinary functions occur even after delayed decompression. Longer delay leads to slower recovery but it is not associated with the extent of recovery. Since time to decompression is positively correlated with time to full recovery, early surgery is still advised in the next available optimal operative setting. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Conclusions In conclusion, based on our results, PE-TLIF surgery and MIS-TLIF surgery both have obvious clinical efficacy and safety as a minimally invasive surgery for middle-aged and elderly patients with single-level lumbar disc herniation accompanied by lumbar instability, and there are certain advantages and disadvantages. Compared with conventional open surgery, either of them can achieve comparable clinical results as the traditional open surgery but with less damage and faster rehabilitation.[6],[7],[16],[21] In this retrospective study, we performed PE-TLIF and MIS-TLIF in middle-aged and elderly patients with single-level lumbar disc herniation. Results 82 patients (Group PE-TLIF, 39 patients; Group MIS-TLIF, 43 patients) who underwent the two MIS surgery between January 2019 to June 2020 were included in this retrospective study. In recent years, minimally invasive spinal surgery has evolved quickly, and conventional open surgery has gradually been replaced with minimally invasive surgery as a standard procedure in the treatment of LDH.[28] PE-TLIF and MIS-TLIF are two novel and emerging minimally invasive spinal decompression and fusion surgeries. [Extracted from the article]

Background Transforaminal epidural steroid injection (TFESI) is a conservative treatment for patients with lumbar disc herniation (LDH). However, there are reports of various complications that can occur after TFESI; among these, paraplegia is a serious complication. Case A 70-year-old woman who was unable to lie supine due to low back pain exacerbation during back extension underwent TFESI. After injection, there was pain relief and the patient was able to lie supine; however, paraplegia developed immediately. Magnetic resonance imaging confirmed cauda equina syndrome (CES) due to nerve compression from L1–2 LDH. We determined that the patient's LDH was already severe enough to be considered CES and that the TFESI procedure performed without an accurate understanding of the patient's condition aggravated the disease. Conclusions It is important to accurately determine the cause of pain and disease state of a patient to establish a correct treatment plan before TFESI is performed.

Spinal epidural hematoma (SEH) is a rare disease and may lead to spinal cord compression. It could be caused by trauma, including iatrogenic procedures such as spinal surgery or spinal anesthesia or by spontaneous events related to coagulopathy or arteriovenous malformation. Once SEH is suspected clinically and confirmed by image modalities, it should be emergently decompressed by surgical intervention. Prognosis depends on the rate of symptoms development, interval from symptom onset to surgery, level of spinal involvement, and degree of neurological deficits. Here, we report the case of a 79-year-old female who sustained a fall months before admission, presented with a 3-day history of back and bilateral lower limbs weakness. Radiography and magnetic resonance imaging demonstrated epidural hematomas at the level of T12 to L2 without associated vertebral fracture. An urgent decompressive laminectomy with blood clot removal was performed immediately. Postoperatively, her neurologic deficits improved significantly except for residual numbness.

Tuberculosis (TB) of the central nervous system accounts for only 1% of all cases of TB but 50% of these occur in the spine. Common clinical manifestations of spinal TB include fever, weight loss, back pain, lower limb weakness (either upper or lower motor neuron), and skeletal deformities such as kyphosis or gibbus. Infective pathology caused by Mycobacterium tuberculosis with epidural collection can present as acute cauda equina syndrome. Here, we describe a 28-year-old female patient who presented with low back pain and ascending weakness of both lower limbs (Medical Research Council grade 4/5 with absent ankle reflex) for 2 months with sudden-onset loss of bladder and bowel control for 1 day without any localized spinal tenderness, swelling, or discharging sinus in the back. Magnetic resonance imaging (MRI) spine was suggestive of an intraosseous collection with spondylodiscitis at the L4 level vertebral level. MRI can help identify the involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and the presence of vertebral column deformities making it a sensitive tool for the detection of spinal TB. Antituberculous treatment remains the cornerstone of treatment. Surgery is required in selected cases, for example, large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. A combined intervention of laminectomy with drainage of the collection with antitubercular therapy after microbiological evidence helped in the resolution of the patient's condition. Early diagnosis and appropriate treatment generally result in a good prognosis. [ABSTRACT FROM AUTHOR]

Lumbar disc herniation (LDH) is a common and frequently occurring disease in the Department of spine, and it often occurs in L4 / L5 and L5 / S1 intervertebral discs. Lumbar disc herniation in the treatment can be divided into surgical treatment and conservative treatment, research shows that in addition to the emergence of cauda equina syndrome or motor neuron injury in patients need surgery, the vast majority of patients with lumbar disc herniation can take conservative treatment. With the development of science and technology and modern medicine, the mechanism of traditional Chinese medicine in the treatment of lumbar disc herniation is gradually clarified, and its clinical efficacy is gradually recognized. The treatment of lumbar disc herniation with traditional Chinese medicine can not only effectively relieve the pain and other symptoms of patients, but also has the characteristics of small side effects, convenient operation and low cost. Through searching and consulting the literature reports on the treatment of lumbar disc herniation with traditional Chinese medicine at home and abroad, this paper expounds their respective therapeutic mechanisms from the aspects of traditional Chinese medicine, acupuncture and massage, bone setting, small needle knife, acupoint injection, traction, scraping and cupping, in order to provide reference for clinical treatment of lumbar disc herniation. [ABSTRACT FROM AUTHOR]

Background: Although most studies recommended that early surgery for cauda equina syndromes (CES) be performed within <48 h., the largest and most comprehensive Nationwide Inpatient Sample Database (NISC) series, involving over 25,000 CES patients recommended that time be shortened to 0-<24 h. In short, CES surgery performed "the sooner the better," was best. Methods: The 2 major variants of CES include; incomplete/partial ICES, and those with urinary retention/bowel incontinence (RCES). Those with ICES often exhibit varying combinations of motor weakness, sensory loss (i.e. including perineal numbness), and urinary dysfunction, while RCES patients typically exhibit more severe paraparesis, sensory loss including saddle anesthesia, and urinary/bowel incontinence. The pathology responsible for ICES/RCES syndromes may include; acute disc herniations/stenosis, trauma (i.e. including iatrogenic/surgical hematomas etc.), infections, abscesses, and other pathology. Surgery for either ICES/RCES may include decompressions to multilevel laminectomies/fusions. Results: Following early surgery, most studies showed that ICES and RCES patients exhibited improvement in motor weakness and sensory loss. However, recovery of sphincter function was more variable, being poorer for RCES patients with preoperative urinary retention/bowel incontinence. Conclusions: Although early CES surgery was defined in most studies as <48 h., two large NISC series involving over 25, 000 CES patients showed that CES surgery performed within 0 -< 24 h resulted in the best outcomes. [ABSTRACT FROM AUTHOR]

Background: Cauda equina syndrome (CES) following posterior lumbar decompression is rare. Here, we present four postoperative cases of L5S1 surgery resulting in CES attributed to engorged ventral epidural veins that decreased spontaneously in three cases, while the fourth warranted a laminoplasty. Case Description: Four patients underwent posterior lumbar decompressions at the L5-S1 level, but developed postoperative symptoms/signs of CES. Interestingly, in all four cases, cauda equina compression was attributed to engorgement of the ventral epidural venous plexus documented on magnetic resonance images (MRI) by the "convexity sign." Postoperatively, three patients' CES compression decreased spontaneously, but one required a laminoplasty. Conclusion: Postoperative CES occurred in four patients undergoing L5-S1 lumbar surgery. is deficit was attributed to marked engorgement of the ventral epidural plexus (i.e., yielding the "convexity sign" on MRI) that resolved spontaneously in three patients, but warranted a laminoplasty in the fourth. [ABSTRACT FROM AUTHOR]

Intradural lumbar disc herniation is a rare complication of disc disease. The mechanism by which a herniated disc tears the dura matter remains unknown. The preoperative diagnosis of an intradural lumbar disc herniation is still difficult. We report our experience dealing with a case of intradural lumbar disc herniation at level L3/4 in a 34-year-old man. Based on current experience, we found that attachment of the ventral dura to the posterior longitudinal ligament can be a favorable factor indicating intradural lumbar disc herniation. One should pay attention to those with cauda equina syndrome, as it can thereby promptly suggest a preoperative diagnosis of intradural lumbar disc herniation. Surgeons need to avoid omitting intraoperative lesions by palpating the dura mater during surgery for suspected tumor cases. [ABSTRACT FROM AUTHOR]

Introduction: Spontaneous spinal subdural hematoma as a result of coagulation deficit is a very rare and serious condition, with an overall incidence of less than 1%. Symptoms can vary according to the level of the bleed. Prompt recognition of the presence of spinal subdural hematoma is crucial for treatment. MRI is the investigation of choice for diagnosis as well as for planning the surgery. The differential diagnosis includes abscess, lipomatosis, significant discal hernia and tumours. There are no definite guidelines for the management of spinal subdural hematomas. In cases with serious neurological deficits, prompt surgical evacuation may lead to the resolution of symptoms and complete neurological recovery. Case report: We present a case of a 75-years-old man with bilateral lower limb radiculopathy, paresthesias, and spinal claudications for four days, progressing to bilateral paraplegia with urine incontinency. The patient was diagnosed with cauda equina syndrome due to spontaneous spinal subdural hematoma in the region from Th12 to L2. He was immediately operated and the subdural hematoma was evacuated. Minimal recovery was achieved and the patient was referred for further rehabilitation with severe paraparesis and urine incontinence. Conclusion: Early diagnosis of spinal subdural hematoma is essential for treatment. Any delay of correct diagnosis can lead to a devastating neurological deficit. Spontaneous spinal subdural hematoma is one of the rare conditions where an emergency MRI is indicated and crucial for diagnosis. [ABSTRACT FROM AUTHOR]

Objectives The aim of this retrospective case study was to analyze the outcomes of minimal nerve root retraction in patients with impending neurologic deficit in degenerative lumbar spine disease using the full-endoscopic spine surgery. Materials and Methods Thirty-seven consecutive patients with impending neurologic deficit underwent endoscopic spine surgery through either the transforaminal or the interlaminar approach. Their clinical outcomes were evaluated with visual analog scale (VAS) leg pain score, Oswestry Disability Index (ODI), and MacNab's criteria. The outcome of motor deficitis was evaluated with the Medical Research Council (MRC) grade. Completeness of decompression was documented with a postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan. Results A total of 40 lumbar levels of 37 patients were operated, VAS score of the leg improved from 7.7 ± 1 to 1.9 ± 0.6 (p < 0.0001). ODI score improved from 74.7 ± 6.5 to 25.4 ± 3.49 (p < 0.0001). Motor weakness improved significantly immediately after surgery. The mean MRC grade increased to 1.97, 3.65, 4.41, and 4.76 preoperatively, at 1 week, at 3 months, and at the final follow-up, respectively, and all the patients with foot drop and cauda equina syndrome symptom recovered completely. One patient with great toe drop recovered partially to MRC grade 3. Mean follow-up of the study was 13.3 ± 6.1 months. According to MacNab's criteria, 30 patients (80.1%) had good and 7 patients (18.9%) had excellent results. Three patients required revision surgery. Conclusions Minimal nerve root retraction during full-endoscopic spine surgery is safe and effective for treatment of the impending neurologic deficit. We could achieve a thorough decompression of the affected nerve root with acceptable clinical outcome and minimal postoperative morbidity. [ABSTRACT FROM AUTHOR]

Cauda equina syndrome (CES) can have devastating neurological sequelae if surgical treatment is delayed. However, out-of-hours surgery (weekdays from 6:00 pm to 8:00 am and all weekend operations) can potentially result in higher rates of intraoperative complications, resulting in worse outcomes. In the present study, we have described our outcomes for patients with CES during an 8-year period (December 2011 to October 2019) with the aim of assessing the risk of out-of-hours surgery. We performed a retrospective analysis of inpatient events and outcomes at 6 months of follow-up. Patient demographics, symptoms, and management data were extracted, and a risk factor analysis was performed using logistic regression. The outcome measures were the incidence of complications and symptom changes at follow-up. Symptom outcome changes between 2 time points were analyzed using repeated measures. A total of 278 patients were included in the present study. Surgery out-of-hours (P = 0.018) and prolonged operations (P = 0.018) were significant risk factors for intraoperative complications. Improved outcomes at 6 months of follow-up were found for lower back pain, sciatica, altered saddle sensation, and urinary sphincter disturbance, with no significant changes for the remaining symptoms. Out-of-hours surgeries did not significantly affect individual symptom outcomes. Our analysis has suggested that emergency decompressive surgery for patients with CES does not result in worsening of outcomes with out-of-hours surgery compared with in-hours. However, our findings also showed that no clear benefit exists to expediting surgery for those with severe presentations. Thus, decompressive surgery should be undertaken at the earliest possible time to safely do so. [ABSTRACT FROM AUTHOR]

Purpose: International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes.Methods: We reviewed published literature using PubMed on definition and classification of cauda equina syndrome since 2000 (21 years). Using the search terms 'cauda equina' and 'definition' or 'classification', we found and reviewed 212 papers.Results: There were 17 different definitions of CES used in the literature. There were three well-defined methods of classification of CES. The two-stage system of incomplete CES (CESI) versus CES with retention (CESR) is the most commonly used classification, and has prognostic value although the details of this continue to be debated.Conclusion: We used the existing literature to propose a clear definition of CES. We also drew on peer-reviewed published literature that has helped to amplify and expand the CESI/CESR dichotomy, adding categories that are both less severe than CESI, and more severe than CESR, and we propose clear definitions in a table form to assist current and future discussion and management of CES. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate the long-term clinical outcomes after surgical decompression in cauda equina syndrome (CES) and see if any preoperative patient-related factors contributed to this outcome. Methods: A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Data regarding outcome parameters from eligible studies were extracted. Meta-analysis was performed using a random-effect model. Results: A total of 852 patients (492 males and 360 females), with a mean age of 44.6 ± 5.5 years from 22 studies diagnosed with cauda equina syndrome and undergoing surgical decompression, were included in the meta-analysis; however, not all studies reported every outcome. The mean follow-up period was 39.2 months, with a minimum follow-up of 12 months in all included studies. Meta-analysis showed that on long-term follow-up, 43.3% [29.1, 57.5] (n=708) of patients had persistent bladder dysfunction. Persistent bowel dysfunction was observed in 31.1% [14.7, 47.6] (n=439) cases, sensory deficit in 53.3% [37.1, 69.6] (n=519), motor weakness in 38.4% [22.4, 54.4] (n=490), and sexual dysfunction in 40.1% [28.0, 52.1] (n=411). Decompression within 48 hours of the onset of symptoms was associated with a favourable outcome in terms of bladder function with 24.6% [1.6, 50.9] (n=75) patients having persistent dysfunction, whereas 50.3% [10.3, 90.4] (n=185) of patients in studies with a mean time to decompression after 48 hours had persistent bladder dysfunction. Other factors such as speed of onset and sex of the patients were not found to significantly impact long-term bladder outcomes. Conclusion: The long-term outcomes of CES after decompression are enumerated. Decompression within 48 hours of the onset of symptoms appears to result in fewer patients with persistent bladder dysfunction. However, a randomized controlled trial is required to conclusively determine whether early decompression leads to better outcomes. [ABSTRACT FROM AUTHOR]

Cauda equina syndrome is rarely seen in primary care, but advanced practitioners must be aware of the possibility. Haley Read and Gerri Mortimore highlight a case study leading to a diagnosis of the condition One of the most common symptoms managed in primary care is lower back pain, which affects approximately 20% of the UK population at any one time (National Collaborating Centre for Primary Care, 2009). There are many differential diagnoses for the cause of back pain, with one such potential diagnosis being cauda equina syndrome. In this instance, it is of paramount importance that the correct diagnosis is reached quickly with urgent referral into secondary care for the instigation of treatment to prevent paralysis. This case review will examine a patient presenting to primary care with lower back pain and diagnosed with cauda equina syndrome. [ABSTRACT FROM AUTHOR]

Introduction: This series reviews three cases of back pain where a highly morbid diagnosis was missed by an emergency physician and subsequently successfully litigated. Case Report: We review the clinical entities of spinal epidural abscess and cauda equina syndrome, challenging diagnoses that can be easily missed and lead to patient harm if not treated promptly. Here we offer suggestions for recognizing these conditions quickly, performing an adequate history and exam, and using documentation to support decision-making. Conclusion: When confronted with an unfortunate medical outcome, maintaining honesty is of paramount importance in medical-legal environments. [ABSTRACT FROM AUTHOR]

This study examined the incidence and severity of adverse events (AEs) of patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that < 1 per 100,000 SMT sessions results in a grade ≥ 3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥ 3 AEs. We identified patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints, and clinician reports, and corroborated by medical records. AEs were independently graded 1–5 based on severity (1-mild, 2-moderate, 3-severe, 4-life-threatening, 5-death). Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3, both of which were rib fractures occurring in women age > 60 with osteoporosis, while none were grade ≥ 4, yielding an incidence of grade ≥ 3 AEs of 0.21 per 100,000 SMT sessions (95% CI 0.00, 0.56 per 100,000). There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥ 3 AEs using multiple logistic regression. In this study, severe SMT-related AEs were reassuringly very rare. [ABSTRACT FROM AUTHOR]

Study Design: A prospective patient's database operated on a cauda equina syndrome (CES).Objective: The aim of our study was to identify prognosis factors for favorable functional recovery after CES.Summary Of Background Data: CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery.Methods: One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted.Results: The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery.Conclusion: CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]