Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach.
Cage; Transforaminal lumbar interbody fusion; Spondylolisthesis; Lumbosacral spine; Transitional vertebra
Lumbar discal cyst is a rare cause of radiculopathy. Their exact pathogenesis and the optimal treatment modality remain unidentified. Depending on their location, discal cysts cannot always be easily identified intraoperatively. We describe 2 patients with discal cysts and introduce an intraoperative discography technique for discal cyst location. Both patients were treated with surgical excision; with intraoperative discography, the cystic lesions could easily be detected and removed.
Discal cyst; Intraoperative discography
A 65-year-old man who had lateral cervical disc herniation underwent cervical posterior laminoforaminotomy at C5-6 and C6-7 level right side. During the operation, there was no serious surgical bleeding event. After operation, he complained persistent right shoulder pain and neck pain. Repeated magnetic resonance image (MRI) showed diffuse cervical epidural hematoma (EDH) extending from C5 to T1 level right side and spinal cord compression at C5-6-7 level. He underwent exploration. There was active bleeding at muscular layer. Muscular active bleeding was controlled and intramuscular hematoma was removed. The patient's symptom was reduced after second operation. Symptomatic postoperative spinal EDH requiring reoperation is rare. Meticulous bleeding control is important before wound closure. In addition, if patient presents persistent or aggravated pain after operation, rapid evaluation using MRI and second look operation is needed as soon as possible.
Cervical epidural hematoma; Posterior laminoforaminotomy; Cervical disc herniation; Postoperative bleeding; Reoperation
This consecutive retrospective study was designed to analyze and to compare the efficacy and outcomes of anterior cervical discectomy and fusion (ACDF) using a fibular and femur allograft with anterior cervical plating.
A total of 88 consecutive patients suffering from cervical degenerative disc disease (DDD) who were treated with ACDF from September 2007 to August 2010 were enrolled in this study. Thirty-seven patients (58 segments) underwent anterior interbody fusion with a femur allograft, and 51 patients (64 segments) were treated with a fibular allograft. The mean follow-up period was 16.0 (range, 12-25) months in the femur group and 19.5 (range, 14-39) months in the fibular group. Cage fracture and breakage, subsidence rate, fusion rate, segmental angle and height and disc height were assessed by using radiography. Clinical outcomes were assessed using a visual analog scale and neck disability index.
At 12 months postoperatively, cage fracture and breakage had occurred in 3.4% (2/58) and 7.4% (4/58) of the patients in the femur group, respectively, and 21.9% (14/64) and 31.3% (20/64) of the patients in the fibular group, respectively (p<0.05). Subsidence was noted in 43.1% (25/58) of the femur group and in 50.5% (32/64) of the fibular group. No difference in improvements in the clinical outcome between the two groups was observed.
The femur allograft showed good results in subsidence and radiologic parameters, and sustained the original cage shape more effectively than the fibular allograft. The present study suggests that the femur allograft may be a good choice as a fusion substitute for the treatment of cervical DDD.
Anterior cervical discectomy and fusion; Femur allograft; Fibular allograft; Radiological parameter
The authors report 2 cases of nerve root herniation after discectomy of a large lumbar disc herniation caused by an unrecognized dural tear. Patients complained of the abrupt onset of radiating pain after lumbar discectomy. Magnetic resonance imaging showed cerebrospinal fluid signal in the disc space and nerve root displacement into the disc space. Symptoms improved after the herniated nerve root was repositioned. Clinical symptoms and suggestive radiologic image findings are important for early diagnosis and treatment.
Nerve root herniation; Dural tear; Lumbar disc heniation; Discectomy; Lumbar spinal stenosis
To compare radiographic analysis on the sagittal lumbar curve when standing, sitting on a chair, and sitting on the floor.
Thirty asymptomatic volunteers without a history of spinal pathology were recruited. The study population comprised 11 women and 19 men with a mean age of 29.8 years. An independent observer assessed whole lumbar lordosis (WL) and segmental lordosis (SL) between L1 and S1 using the Cobb's angle on lateral radiographs of the lumbar spine obtained from normal individuals when standing, sitting on a chair, and sitting on the floor. WL and SL at each segment were compared for each position.
WL when sitting on the floor was reduced by 72.9% than the average of that in the standing position. Of the total decrease in WL, 78% occurred between L4 to S1. There were significant decreases in SL at all lumbar spinal levels, except L1-2, when sitting on the floor as compared to when standing and sitting on a chair. Changes in WL between the positions when sitting on a chair and when sitting on the floor were mostly contributed by the loss of SL at the L4-5 and L5-S1 levels.
When sitting on the floor, WL is relatively low; this is mostly because of decreasing lordosis at the L4-5 and L5-S1 levels. In the case of lower lumbar fusion, hyperflexion is expected at the adjacent segment when sitting on the floor. To avoid this, sitting with a lordotic lumbar curve is important. Surgeons should remember to create sufficient lordosis when performing lower lumbar fusion surgery in patients with an oriental life style.
Lumbar lordosis; Floor-sitting; Chair-sitting; Segmental lordosis
To analyze the clinical outcomes of computed tomography (CT) fluoroscopy-guided selective nerve root block (SNRB) for severe arm pain caused by acute cervical disc herniation.
The authors analyzed the data obtained from 25 consecutive patients who underwent CT fluoroscopy-guided SNRB for severe arm pain, i.e., a visual analogue scale (VAS) score of 8 points or more, caused by acute soft cervical disc herniation. Patients with chronic arm pain, motor weakness, and/or hard disc herniation were excluded.
The series comprised 19 men and 6 women whose mean age was 48.1 years (range 35-72 years). The mean symptom duration was 17.5 days (range 4-56 days) and the treated level was at C5-6 in 13 patients, C6-7 in 9, and both C5-6 and C6-7 in 3. Twenty-three patients underwent SNRB in 1 session and 2 underwent the procedure in 2 sessions. No complications related to the procedures occurred. At a mean follow-up duration of 11.5 months (range 6-22 months), the mean VAS score and NDI significantly improved from 9 and 58.2 to 3.4 and 28.1, respectively. Eighteen out of 25 patients (72%) showed successful clinical results. Seven patients (28%) did not improve after the procedure, and 5 of these 7 underwent subsequent anterior cervical discectomy and fusion.
CT fluoroscopy-guided SNRB may play a role as a primary conservative treatment for severe arm pain caused by acute cervical disc herniation.
Cervical vertebrae; Intervertebral disc; Nerve block
We reviewed 9 cases of pyogenic spondylodiscitis following percutaneous endoscopic lumbar discectomy (PELD). Microbiologic cultures revealed 6 causative organisms. Five patients were managed conservatively and four were treated surgically. The mean follow-up period was 20.6 months and the average length of hospitalization was 24 days. Radiological evidence of spinal fusion was noted and infection was resolved in all patients. Although PELD is a safe and effective procedure, the possibility of pyogenic spondylodiscitis should always be considered.
Pyogenic spondylodiscitis; Percutaneous endoscopic lumbar discectomy
Vertebral artery loop formation causing encroachment on cervical neural foramen and canal is a rare cause of cervical radiculopathy. We report a case of 61-year-old woman with vertebral artery loop formation who presented with right shoulder pain radiating to her arm for 2 years. Plain radiograph and computed tomography scan revealed widening of the right intervertebral foramen at the C5-6 level. Magnetic resonance imaging and angiogram confirmed the vertebral artery loop formation compressing the right C6 nerve root. We had considered microdecompressive surgery, but the patient's symptoms resolved after conservative management. Clinician should keep in mind that vertebral artery loop formation is one of important causes of cervical radiculopathy. Vertebral artery should be visualized using magnetic resonance angiography in suspected case.
Vertebral artery; Vertebral artery loop; Vascular compression; Vascular anomaly; Cervical radiculopathy; Magnetic resonance angiography
Gas pseudocysts are a rare cause of lumbar radiculopathy and most symptomatic gas pseudocysts are found within the confines of the spinal canal. A gas pseudocyst in the foramen causing lumbar radiculopathy is very rare. We present a case of a 67-year-old woman suffering from severe pain in the right leg. Computed tomography and magnetic resonance imaging revealed a gas pseudocyst compressing the L2 root at the right L2-3 foramen. The patient underwent cyst excision using the lateral transmuscular approach and her leg pain was improved after the operation.
Gas pseudocyst; Radiculopathy; Lumbar vertebra
A 73-year-old male presented with a rare dorsally sequestrated lumbar disc herniation manifesting as severe radiating pain in both leg, progressively worsening weakness in both lower extremities, and urinary incontinence, suggesting cauda equina syndrome. Magnetic resonance imaging suggested the sequestrated disc fragment located in the extradural space at the L4-L5 level had surrounded and compressed the dural sac from the lateral to dorsal sides. A bilateral decompressive laminectomy was performed under an operating microscope. A large extruded disc was found to have migrated from the ventral aspect, around the thecal sac, and into the dorsal aspect, which compressed the sac to the right. After removal of the disc fragment, his sciatica was relieved and the patient felt strength of lower extremity improved.
Lumbar disc herniation; Dorsal; Intradural; Migrated
Although very rare, a few cases of intradural extramedullary (IDEM) spinal tumor migration have been reported since Tomimatsu first reported a mobile schwannoma of the cervical cord in 1974. Schwannoma is a neurogenic tumor which originates from nerve sheath that it is relatively well-marginated tumor with little attachment or adhesion to surrounding tissue. Mobility of tumor in spinal canal sometimes can result in negative exploration at the expected area. We found three interesting cases in which different tumor locations observed in repeated magnetic resonance image (MRI) findings. All tumors were intradural and extramedullary schwannoma. We reviewed the literature about moving tumor in the spine through PUBMED search.
Intradural extramedullary; Schwannoma; Mobility
On the basis of preoperative computed tomography (CT) scans, we studied the change of the size of anterior primary division (APD) of the L5 spinal root in the presence of foraminal/extraforaminal entrapment of the L5 spinal root.
Two independent radiologists retrospectively reviewed the preoperative CT scans of 27 patients treated surgically and compared the sizes of the APDs on bilateral L5 spinal roots. If one side APD size was larger than the other side APD size, it was described as left or right "dominancy" and regarded this as "consensus (C)" in case that there was a consensus between the larger APD and the location of sciatica, and regarded as "non-consensus (NC)" in case that there was not a consensus. Oswestry Disability Index (ODI) scores were used for preoperative and postoperative evaluation.
On CT scans, twenty-one (77%) of 27 patients were the consensus group (APD swelling) and 6 (22%) were a non-consensus group (APD no swelling). In 9 patients with acute foraminal disc herniations, asymmetric enlargement of the APD on L5 spinal root was detected in all cases (100%) and detected in 11 (64%) of 17 patients with stenosis. Preoperative ODI score was 75-93 (mean 83) and postoperative ODI scores were improved to 13-36 (mean 21). The mean follow-up period was 6 months (range, 3-11 months).
An asymmetric enlargement of the APD on L5 spinal root on CT scans is meaningfully associated with a foraminal or extraforaminal entrapment of the L5 spinal root on the lumbosacral junction.
Computed tomography; Foraminal-extraforaminal entrapment; Lumbosacral junction; Radiculopathy; Surgery
The purpose of this study was to compare clinical and radiological outcomes of percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM) for recurrent disc herniation.
Fifty-four patients, who underwent surgery, either PELD (25 patients) or repeated OLM (29 patients), due to recurrent disc herniation at L4-5 level, were divided into two groups according to the surgical methods. Excluded were patients with sequestrated disc, calcified disc, severe neurological deficit, or instability. Clinical outcomes were assessed using Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI). Radiological variables were assessed using plain radiography and/or magnetic resonance imaging.
Mean operating time and hospital stay were significantly shorter in PELD group (45.8 minutes and 0.9 day, respectively) than OLM group (73.8 minutes and 3.8 days, respectively) (p < 0.001). Complications occurred in 4% in PELD group and 10.3% in OLM group in the perioperative period. At a mean follow-up duration of 34.2 months, the mean improvements of back pain, leg pain, and functional improvement were 4.0, 5.5, and 40.9% for PELD group and 2.3, 5.1, and 45.0% for OLM group, respectively. Second recurrence occurred in 4% after PELD and 10.3% after OLM. Disc height did not change after PELD, but significantly decreased after OLM (p = 0.0001). Neither sagittal rotation angle nor volume of multifidus muscle changed significantly in both groups.
Both PELD and repeated OLM showed favorable outcomes for recurrent disc herniation, but PELD had advantages in terms of shorter operating time, hospital stay, and disc height preservation.
Reherniation; Discectomy; Lumbar spine
The possible causes of Brown-Séquard Syndrome (BSS) have been frequently observed with spinal trauma and extramedullary spinal tumors, but the cervical disc herniation to cause BSS is rare. The authors present five cases of patients who were diagnosed with BSS resulting from cervical disc herniation, and the results of the literature in view of their distinctive symptoms and clinical outcomes. Postoperatively, the patients showed complete or almost complete recovery from their motor and sensory deficits. On the basis of our cases, it is important to diagnose it early by cervical magnetic resonance imaging, especially in the absence of the typical symptoms of cervical disc herniation or other obvious etiology of extremity numbness. Immediate surgical treatment is also essential for a favorable functional neurological recovery.
Brown-Séquard Syndrome; cervical disc herniation; anterior cervical discectomy and fusion
Two cases of dynamic lumbar spinal stenosis were identified by the authors using axial loaded magnetic resonance image (MRI). In both cases, the patients presented with neurogenic claudication but MRI in decumbency showed no definite pathologic condition associated with their symptoms. In contrast, axial loaded MRI demonstrated constrictive spinal stenosis and a significantly decreased dural sac caused by epidural fat buckling and thickening of the ligamentum flavum in both cases. In the second case, a more prominent disc protrusion was also demonstrated compared with decumbent MRI. After decompressive surgery, both patients had satisfactory outcomes. Axial loaded MRI can therefore give decisive information in dynamic spinal disorders by allowing simulation of an upright position.
Axial loaded MRI; Dynamic lumbar spinal stenosis; Neurogenic claudication
Two findings easily found at coronal source images of MR myelography (MRM) were evaluated : dorsal root ganglion (DRG) swelling and running course abnormality (RCA) of L5 exiting root at foramen or extraforamen. We tried to find the sensitivity of each finding when root was compressed.
From 2004 July to 2006, one hundred and ten patients underwent one side paraspinal decompression for their L5 root foraminal or extraforaminal compression at L5-S1 level. All kinds of conservative treatments failed to improve leg symptom for several months. Before surgery, MRI, CT and MRM were done. Retrospective radiologic analysis for their preoperative MRM coronal source images was done to specify root compression sites and L5 root morphologic changes.
DRG swelling was found in 66 (60%) of 110 patients. DRG swelling has statistically valuable meaning in foraminal root compression (chi-square test, p < 0.0001). Seventy-two (66%) in 110 patients showed abnormal alteration of running course. Abnormal running course has statistically valuable meaning in foraminal or extraforaminal root compression (chi-square test, p < 0.0001).
Three-dimensional MRM provides precise thin sliced coronal images which are most close to real operative views. DRG swelling and running course abnormality of L5 exiting root are two useful findings in diagnosing L5 root compression at L5-S1 foramen or extraforamen. MRM is thought to provide additional diagnostic accuracy expecially in L5-S1 foraminal and extraforaminal area.
MR myelography; Foraminal or extraforaminal; Lumbar disc herniation
The authors report two cases of spontaneous regression of disc herniation at the level adjacent to the anterior lumbar interbody fusion (ALIF) level. This phenomenon may be due to the increased tension on the posterior longitudinal ligament (PLL) by appropriate restoration of the disc height and lumbar lordosis, which is a mechanism similar to ligamentotaxis applied to the thoracolumbar burst fracture.
Ligamentotaxis; Herniated disc; Anterior lumbar interbody fusion
Spontaneous spinal subarachnoid hematoma (SSH) is a rare entity to cause spinal cord or nerve root compression and is usually managed as surgical emergencies. We report a case of spontaneous SSH manifesting as severe lumbago, which demonstrated nearly complete clinical resolution with conservative treatment. A 58-year-old female patient developed a large SSH, which was not related to blood dyscrasia, anticoagulation, lumbar puncture, or trauma. Patient had severe lumbago but no neurologic deficits. Because of absence of neurologicl deficits, she was treated conservatively. Follow-up magnetic resonance (MR) image showed complete resolution. Conservative treatment of SSH may be considered if the patient with spontaneous SSH has no neurologic deficits.
Spinal subarachnoid hematoma; Spinal cord; Spontaneous
We report on a case of thrombosis of the left common iliac artery following anterior lumbar interbody fusion (ALIF) of L4-5 in a 79-year-old man with no previous medical problems, including peripheral vascular disease. After completing the ALIF procedure, the surgeon could not feel the pulsation of the left dorsalis pedis artery, and the oxygen saturation (SaO2) had fallen below 90% from pulse oxymetry on the left great toe. Thrombectomy was successfully performed after confirming the thrombus in the left common iliac artery using Computed Tomography (CT) angiography. Thrombosis of the common iliac artery is very rare following ALIF. However, delayed diagnosis can lead to disastrous outcome. Although elderly patients have no cardio-vascular disease or vessel calcification in pre-op evaluation, the possibility of a complication involving L4-5 should be considered.
Thrombosis; Common iliac artery; Anterior lumbar interbody fusion
To evaluate clinical and radiological results of two different fusion techniques in adult low-grade isthmic spondylolisthesis.
Between November 2003 and December 2004, 46 consecutive patients underwent instrumented mini-transforaminal lumbar interbody fusion (mini-TLIF) (group I) at Wooridul Spine Hospital, Seoul, Korea. Between February 2003 and October 2006, 32 consecutive patients underwent instrumented circumferential fusion (group II) at Leon Wiltse Memorial Hospital, Suwon, Korea. The mean follow-up periods were 29.7 and 26.1 months, respectively.
Mean visual analog scale (VAS) scores for back and leg pain decreased, respectively, from 6.98 and 6.33 to 2.3 and 2.2 in group I and from 7.38 and 6.00 to 1.7 and 1.0 in group II. Mean Oswestry disability index (ODI) improved from 51.85% to 14.4% in group I and from 60% to 9.1% in group II. In both groups, VAS and ODI scores significantly changed from pre- to postoperatively (p<0.001), but postoperative outcome between groups was statistically not significant. Radiologic evidence of fusion was noted in 95.7% and 100% of the patients in group I and II, respectively. In both groups, changes in disc height, segmental lordosis, degree of listhesis, and whole lumbar lordosis between the pre- and postoperative periods were significant except whole lumbar lordosis in both groups.
Clinical and functional outcomes demonstrate no significant differences between groups in treating back and leg pain of adult patients with low-grade isthmic spondylolisthesis. However, in terms of operative data (i.e. operation time and hospital stay), instrumented mini-TLIF demonstrated better results.
Low-grade isthmic spondylolisthesis; Instrumented transforaminal lumbar interbody fusion; Instrumented circumferential
To evaluate the risk factors that may be responsible for the development of contralateral reherniations from ipsilateral ones after open lumbar microdiscectomy (OLM), and to compare surgical outcomes of revision OLM for contralateral reherniations with those for ipsilateral ones.
Seventeen patients who underwent revision OLM for contralateral reherniation were enrolled into Group I, and 35 patients who underwent revision OLM for ipsilateral reherniation were enrolled into Group II. Using medical charts and imaging study results, the differences in the clinical and radiological factors were evaluated between the two groups. Clinical outcomes of each group were compared between the two groups.
Significant differences were found in the interval to reherniation from initial surgery (33 months for Group I and 18.6 months for Group II, p=0.009), as well as in the incidences of both protruded disc (35.3% for Group I and 8.6% for Group II, p=0.045) and mild disc degeneration (29.4% for Group I and 5.7% for Group II, p=0.031) at initial surgery. On binary multi-logistic regression analysis, significant differences were found in the interval to reherniation (p=0.027, Odds ratio=1.051) and incidence of mild disc degeneration (p=0.025, Odds ratio=12.03) between the two groups. There were no significant differences in the improvement of clinical outcomes after revision OLM between the two groups.
The interval to reherniation from initial surgery and the grade of disc degeneration at initial surgery were key factors that distinguished the development of contralateral reherniations from ipsilateral ones. Surgical outcomes of revision OLM were similar in both groups.
Reherniation; Discectomy; Lumbar spine
To analyze the relationship of concomitant foraminal lumbar disc herniation (FLDH) with postoperative leg pain after microdecompression for extraforaminal lumbar disc herniation (EFLDH) at the L5-S1 level.
Sixty-five patients who underwent microdecompression for symptomatic EFLDH at the L5-S1 level were enrolled. According to the severity of accompanying FLDH, EFLDH was classified into four categories (Class I : no FLDH; Class II : mild to moderate FLDH confined within a lateral foraminal zone; Class III : severe FLDH extending to a medial foraminal zone; Class IV : Class III with intracanalicular disc herniation). The incidence of postoperative leg pain, dysesthesia, analgesic medication, epidural block, and requirement for revision surgery due to leg pain were evaluated and compared at three months after initial surgery.
The incidences of postoperative leg pain and dysesthesia were 36.9% and 26.1%, respectively. Pain medication and epidural block was performed on 40% and 41.5%, respectively. Revision surgery was recommended in six patients (9.2%) due to persistent leg pain. The incidences of leg pain, dysesthesia, and requirement for epidural block were higher in Class III/IV, compared with Class I/II. The incidence of requirement for analgesic medication was significantly higher in Class III/IV, compared with Class I/II (p=0.02, odds ratio=9.82). All patients who required revision surgery due to persistent leg pain were included in Class III/IV.
Concomitant FLDH seems related to postoperative residual leg pain after microdecompression for EFLDH at the L5-S1 level.
Extraforaminal; Intervertebral disc; Lumbosacral spine