Root Injury Research Articles

Congenital scoliosis presenting in teenage years outcomes without hemivertebra excision.

In congenital scoliosis, the surgical strategy approach of hemivertebra excision, with or without instrumentation and fusion, is a common approach to correction of scoliosis. However, hemivertebra excisions are technically challenging, with potential complications including spinal cord injury, nerve root injury and cerebrospinal fluid leak. The purpose of this study was to determine whether correction of congenital scoliosis can be achieved using a posterior instrumentation/fusion-only approach without the need for hemivertebra excision. 35 patients with congenital scoliosis and hemivertebra operated between 2007 and 2024 were matched to 35 AIS patients by BMI, levels fused, and preoperative Cobb. Wilcoxonrank-sum tests, chi-square tests, and Fisher's Exact tests were utilized. Age (p = 0.22), BMI (p = 0.25) and preoperative Cobb (p = 0.79) were similar between hemivertebra and AIS patients. Cobb correction (HV: 71.8% vs. AIS: 70.4%; p = 0.92) and EBL (500cc vs. 400cc; p = 1.0) were similar. Operative time (310.0min vs. 242.0min; p < 0.001) and length of stay (7.0days vs. 5.0days; p < 0.001) were statistically different. Patients operated on after 2018, when the Rapid Recovery Protocol was implemented, had a similar length of stay (4.5 vs. 5.0; p = 0.92). Patients in both cohorts had similar SRS-22 scores. Choosing fusion levels in congenital patients, on similar principles to AIS, leads to avoidance of hemivertebra excision, including lumbosacral hemivertebrae. This approach is safer than hemivertebra excision and has similar, or better, curve correction than previously reported.

Early MRI Can Predict the Indication for Surgery in Brachial Plexus Birth Injury: Results of the NAPTIME Study.

Magnetic resonance imaging (MRI) has not been routinely used for infants with brachial plexus birth injury (BPBI); instead, the decision to operate is based on the trajectory of clinical recovery by 6 months of age. The aim of this study was to develop an MRI protocol that can be performed without sedation or contrast in order to identify infants who would benefit from surgery at an earlier age than the age at which that decision could be made clinically. This prospective multicenter NAPTIME (Non-Anesthetized Plexus Technique for Infant MRI Evaluation) study included infants aged 28 to 120 days with BPBI from 3 tertiary care centers. Subjects had nonsedated non-contrast rapid volumetric proton density MRI on 3-T scanners. Neuroradiologists at each site calculated the NAPTIME nerve root injury score for subjects at their site. Interrater reliability was performed on a subset of subjects. All of the subjects were evaluated with routine clinical examinations up to 6 months of age, by which time the treating surgeon determined whether to offer nerve surgery. Surgeons were blinded to the MRI results. The ability of the NAPTIME score to discriminate surgeon indication for surgery was evaluated using the receiver operating characteristic (ROC) curve, by estimating the area under the curve (AUC) across the range of NAPTIME scores. Sixty-five infants successfully completed the NAPTIME MRI; 18 (28%) ultimately met the clinical criteria for nerve surgery. The interrater reliability for the NAPTIME score was moderate at 0.703 (95% confidence interval [CI], 0.582 to 0.818). The median NAPTIME score for subjects who met the criteria for nerve surgery was 16.2 (interquartile range [IQR], 9.9 to 18.9), while the median score for those who did not was 7.0 (IQR, 5.0 to10.5). The NAPTIME score predicted meeting the criteria for surgery with an AUC of 0.812 (95% CI, 0.688 to 0.936). A score of >13 offered a specificity of 0.94 and a sensitivity of 0.61 for surgical indication. Non-contrast MRI without sedation is a useful tool in determining the severity of injury in BPBI. The NAPTIME score might distinguish which infants will meet the criteria for reconstructive nerve surgery earlier than when the decision can be made clinically. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Endoscopic transfacet Decompression for Severe Lumbar Spinal Stenosis: A Technical Note, Illustrative Clinical Series, and Surgeon Survey Regarding Post-Decompression Instability

Background: Lumbar spinal stenosis (LSS) remains a predominant cause of debilitating back and leg pain, affecting many aging populations. Traditional decompression surgeries can be invasive and pose significant risks and recovery time. This study elucidates the techniques and preliminary outcomes of endoscopic transfacet decompression in treating severe LSS. Methods: A retrospective review was performed on 65 patients with severe LSS who underwent endoscopic transfacet decompression. The patient outcomes were analyzed using the VAS for leg pain and the modified Macnab criteria. Pre-operative and post-operative scores were compared, and any complications were analyzed. An online survey was administered to 868 surgeons using Likert-scale ratings to evaluate surgeons’ experience with endoscopic decompression in patients with painful spondylolisthesis. The survey responses were analyzed using descriptive statistics and Polytomous Rasch analysis to evaluate surgeon endorsement. Results: The study included 65 patients, of which 29 (44.6%) were female and 36 (55.4%) were male, with a mean age of 65.79 ranging from 38 to 84 years. The available mean post-operative follow-up period was 31.44 months, ranging from 24 to 39 months. The VAS score for leg pain reduced significantly from pre-operative 7.54 ± 1.67 to 2.20 ± 1.45 by 5.34 ± 2.03 (p &lt; 0.001) with a large effect size (Cohen’s d = 2.626). At the final follow-up, functional Macnab outcomes were reported as excellent by 20 (30.8%), good by 37 (56.9%), fair by 5 (7.7%), and poor by 3 (4.6%) of patients. There were no incidental durotomies, nerve root injuries, wound complications, or instances of post-operative instability. Only five patients (7.7%) developed post-operative dysesthesia. Incomplete decompression led to fair and poor outcomes in 8 (12.3%) patients. No revision surgeries were performed. post-operative instability was not observed. The surgeon survey corroborated these observations, where the polytomous Rasch analysis showed consensus on the effectiveness of the percutaneous endoscopic decompression of low-grade spondylolisthesis. Differential item functioning (DIF) analysis showed no significant bias in item responses between orthopaedic and neurosurgeons. Conclusions: The endoscopic transfacet decompression technique delineated herein showcased excellent Macnab outcomes in managing severe LSS, with a combined success rate of 87.7%. Patients also experienced a statistically significant reduction in leg pain. Dysesthesia rates were lower than with the transforaminal approach, likely because of limited exiting and traversing nerve root manipulation. This technique might represent a viable, less invasive alternative to open microsurgical dissection and decompression for patients with severe LSS, where fusion may be required. This approach was found to be highly accepted among endoscopic spine surgeons.

Safe distances for transforaminal posterior lumbar interbody fusion under one-hole split endoscopy: three-dimensional reconstruction measurement of 1-degree degenerative lumbar spondylolisthesis at the L4/5 segment

BackgroundOne-hole split endoscopy (OSE) is a novel endoscopic technique that offers some advantages in spinal surgery. However, without a clear understanding of the safe zone for OSE, surgeons risk injuring nerve roots during the procedure. This study aimed to measure the safe distances among critical bone markers, the intervertebral space and nerve roots between 1-degree degenerative lumbar spondylolisthesis (DLS) and non-DLS at the L4/5 segment in patients via three-dimensional reconstruction and to compare the differences in relevant safety distances between the two groups. These findings provide a theoretical reference for the safe application of the OSE technique in transforaminal posterior lumbar interbody fusion (TPLIF).MethodsThe CT data of 56 patients were obtained, including 30 patients with 1-degree DLS at the L4/5 segment (DLS group) and 26 patients with non-DLS (non-DLS group). The bone markers were determined in a three-dimensional model. The relevant distances were as follows: (1) Vertical distance (VD): inferior articular process tip (IAPT) to the upper margin of the intervertebral space (VD1); superior articular process tip and the highest point of the mammillary process (HPMP) to the lower margin of the intervertebral space (VD2, VD3). (2) Horizontal distance (HD): the lateral boundary to the medial boundary at the upper margin of the intervertebral space (HD1) and at the lower margin of the intervertebral space (HD2); the medial margin of the articular surface in the coronal position of the superior articular process to the medial boundary at the lower margin of the intervertebral space (HD3); and the HPMP to the lateral boundary at the upper margin of the intervertebral space (HD4) and at the lower margin of the intervertebral space (HD5).ResultsIn the DLS group and non-DLS group, the VD1 were (10.97 ± 2.15) mm and (11.32 ± 1.70) mm, the VD2 were (11.06 ± 1.75) mm and (10.96 ± 0.91) mm, the VD3 were (4.76 ± 1.54) mm and (5.01 ± 1.02) mm, the HD1 were (10.54 ± 1.49) mm and (10.97 ± 1.06) mm, the HD2 were (17.43 ± 2.01) mm and (17.32 ± 1.70) mm, and the HD3 were (2.21 ± 0.99) mm and (2.11 ± 1.33) mm. These measurement distances were not significantly different between the two groups. While HD4 (4.17 ± 1.41) mm in the DLS group was significantly greater than HD4 (3.29 ± 1.78) mm in the non-DLS group, HD5 (1.89 ± 0.93) mm in the DLS group was significantly lower than HD5 (2.63 ± 1.45) mm in the non-DLS group (P < 0.05). There was no significant difference between VD1 and VD2 in the DLS group.ConclusionBone markers represent a novel positioning method for the treatment of 1-degree L4/5 segmental DLS under OSE, which will aid in avoiding nerve root injury and provide a reference for the safety of TPLIF. If HPMP is used as an auxiliary bone marker for decompression of the L4 exiting nerve root, HD4 was greater and HD5 was lower in the DLS group than in the non-DLS group during outwards fenestration and decompression. To improve safety, individualized imaging evaluation can be performed before the operation to select the appropriate grinding drill.

Endoscopic surgery for multilevel spinal stenosis: a comprehensive meta-analysis and subgroup analysis of uniportal and biportal approaches.

Minimally invasive spine surgery (MIS) has shown promising results, and endoscopic spine surgery has emerged as a less invasive approach. Although studies have examined the effectiveness of endoscopic surgery for spinal stenosis, no meta-analyses have focused on multilevel cases. This meta-analysis aimed to evaluate the efficacy and safety of uniportal and biportal endoscopy in patients with multilevel spinal stenosis. The patient, intervention, comparison, outcomes, and study criteria were established to guide study selection. Four databases were searched. The outcome measures included patient-reported outcome measures (PROMs), radiological and analytical data, complications, surgery time, length of hospital stay, and blood loss. Review Manager ver. 5.4 software (RevMan; Cochrane, UK) was used for the analysis. Heterogeneity was assessed using the chi-square and I2 tests. Ten studies (n=686) were included. PROMs showed significant improvements in Visual Analog Scale (VAS) scores for back pain (mean difference [MD], 4.07; 95% confidence intervals [CI], 3.72-4.42), leg pain (MD, 5.49; 95% CI, 5.17-5.80), and Oswestry Disability Index (MD, 35.97; 95% CI, 32.46-39.47). MacNab scale results were as follows: excellent (55.37%), good (34.93%), fair (7.58%), and poor (4.06%). C-reactive protein levels did not change significantly; however, hemoglobin levels decreased postoperatively (MD, 1.28; 95% CI, 0.91-1.65). Complications included dural tears (5.46%), hematoma (4.30%), incomplete decompression (3.12%), root injury (2.90%), reoperations/revisions (2.22%), conversion to open or microscopic surgery (1.97%), and transfusions (8.50%). Analysis by levels showed worse VAS leg pain in studies analyzing >30% multilevel stenosis (MD, 4.99; 95% CI, 4.47-5.51 vs. MD, 5.82; 95% CI, 5.63-6.01). Uniportal and biportal endoscopy had similar outcomes, except for a higher incidence of dural tears on biportal endoscopy (uniportal, 3.33%; biportal, 7.05%). This meta-analysis supports endoscopy as an effective and safe option for multilevel lumbar stenoses. It improves long-term pain and functionality, with no significant radiological changes or postoperative inflammation. Complications are few; however, dural tears are more common in biportal endoscopy. Higher multilevel stenosis rates were associated with increased leg pain and a lower likelihood of achieving incomplete decompression.

Spinal cord injury in abusive and accidental head injury in children, a neuropathological investigation.

The diagnosis of abusive head trauma (AbHT) in children is a challenging one that needs to be differentiated from natural disease and accidental head injury (AcHT). There is increasing evidence from the Neuroradiology field showing spinal cord injury in children subject to AbHT, which has, so far, been poorly investigated pathologically. In this study we retrospectively reviewed the forensic records of 110 paediatric head injury cases over an eight-year-period. The records included detailed circumstances of death and clinical history alongside neuropathology, ophthalmic pathology and osteo-articular pathology. Based on the final multidisciplinary agreement, the 110 case were grouped into AbHT (n = 40), AcHT (n = 9), not clearly accidental or abusive ("undetermined" (UHT) n = 8) and non-traumatic brain injury (NTBI, n = 53). The spinal cord pathology present within each group was compared. Spinal subdural haematoma (SDH) was present in 71% of AbHT and 50% of AcHT cases and were located predominantly at the thoracolumbar level. In AbHT cases without spinal SDH, the suspected mechanism of injury was that of head impact rather than shaking, whilst cases of AcHT with spinal SDH were associated with direct trauma to the spinal cord. Injury of spinal nerve roots in AbHT was almost three times that seen in the accidental head injury group (58% vs. 17%). The study shows that pathological examination of the spinal cord and spinal nerve roots is of high value in investigating AHT and may help in differentiating AbHT from AcHT.

Bilateral synchronous UBE for unilateral laminotomy and bilateral decompression as a potentially effective minimally Invasive approach for two-level lumbar spinal stenosis

Currently, Unilateral biportal endoscopy is widely used in the surgical treatment of lumbar spinal stenosis. To investigate the feasibility of bilateral synchronous UBE to unilateral laminotomy and bilateral decompression(BS-UBE-ULBD) for treating two-level lumbar spinal stenosis (LSS). Sixty-four patients with two-level lumbar spinal stenosis (LSS) treated with BS-UBE-ULBD from October 2022 to January 2024 were retrospectively analyzed. All patients were treated with BS-UBE-ULBD. All 64 patients successfully underwent surgery, and the duration of surgery was 95–180 min, with an average of 119.92 ± 14.79 min. The average number of fluoroscopy was 3.02 ± 0.92. The average blood loss during the surgery was 73. 44 ± 36.70 ml. Postoperative lumbar CT showed that the spinal canal and bilateral nerve roots were fully decompressed. There were no postoperative complications, such as infection, severe nerve root injury, and lumbar instability. Complete follow-up data were obtained for all 64 cases. The VAS score of low back and leg pain and the ODI of lumbar function significantly (P < 0.05) improved at each follow-up time point. MacNab evaluation at 6 months after the surgery showed that the results were excellent in 48 cases, good in 14 cases, and fair in 2 cases. The excellent and good rate was 96. 88% (62/64). So BS-UBE-ULBD is a minimally invasive, highly effective, and safe procedure for 2-level LSS.Degenerative lumbar spinal stenosis (LSS) refers to clinical symptoms caused by the compression of the cauda equina, nerve root, and vascular complex. LSS can occur due to the abnormal shape and volume of the bony or fibrous structure after degenerative changes and the stenosis of the inner diameter of one or more lumens at a single level or multiple levels. It is a common cause of lumbago or lumbago and leg pain, which is common among middle-aged and elderly people1. LSS has become the most common cause of lumbar surgery among patients over 60 years of age2. However, traditional surgery necessitates extensive stripping of paraspinal muscles, which can easily lead to the ischemic injury of paraspinal muscles and atrophy after denervation. Therefore, traditional surgery may result in intractable back pain, stiffness, and discomfort after surgery3,4. Furthermore, as the posterior bone and soft tissue structures need to be extensively resected during the surgery, epidural scar and nerve compression are highly likely after the surgery. The high risk of general anesthesia cannot be ignored among elderly and weak patients2,5.Recently, with the rapid development of minimally invasive spine surgery, endoscopic surgery has been applied in the treatment of LSS6. Unilateral biportal endoscopy (UBE ) is more popular in treating LSS and is a more flexible operation, with small trauma, quick recovery, and a gentle learning curve. In addition, many studies have proven the good clinical efficacy of unilateral biportal endoscopy7. Multilevel spinal stenosis can be done simultaneously. Previously, the same operator decompressed multiple segments in turn8,9, but the operation lasted longer, and the corresponding problems, such as bleeding, high risk of anesthesia, and fluoroscopy frequency, increased.From October 2022 to June 2024, our hospital pioneered the use of Bilateral Synchronous UBE-unilateral Laminotomy and Bilateral Decompression (BS-UBE-ULBD) for two-level degenerative LSS. Sixty-four patients with two-segment LSS were treated with BS-UBE-ULBD, and the results were satisfactory.

S8 Navigation system combined with an ultrasonic osteotome for three-dimensional real-time dynamic visualization decompression to reduce postoperative neurological deterioration in thoracic ossification of the ligamentum flavum.

Posterior laminectomy is a standard treatment for thoracic ossification of the ligamentum flavum (TOLF), but it often leads to neurological deterioration during surgery. This study aimed to reduce iatrogenic neurological deterioration by using an S8 navigation system combined with an ultrasonic osteotome for three-dimensional real-time dynamic visualization decompression. A retrospective analysis was conducted on patients who underwent laminectomy and internal fixation for TOLF in our centre from January 2016 to January 2023. Patients were divided into a visualization group (S8 navigation + ultrasonic bone scalpel) and a control group (ultrasonic bone scalpel) based on the use of three-dimensional real-time dynamic visualization decompression technology. Intraoperative multimodal neuroelectrophysiological monitoring (IONM) was used to collect somatosensory evoked potential and motor evoked potential data. We compared the incidence of intraoperative neurological deterioration indicated by IONM alarms between the two groups. Neurological and motor functions were assessed via the American Spinal Injury Association (ASIA) classification system and the modified Japanese Orthopaedic Association (m-JOA) score for thoracic myelopathy. Follow-ups were conducted at 1, 3, 6, and 12months postsurgery, and the data from both groups were compared. Other clinical indicators included decompression time per laminectomy segment, intraoperative blood loss, intraoperative dural ossification, hospitalization duration, and drainage tube placement time. We also analysed intraoperative and postoperative complications. A total of 91 patients with thoracic ossification of the ligamentum flavum were included, with a follow-up period of 12-18months. The visualization group consisted of 41 patients, and the control group included 50 patients. The incidence of neurological deterioration indicated by IONM in the visualization group (9.8%) was significantly lower than that in the control group (30.0%) (P = 0.014). The immediate postoperative ASIA grade change value ≤ - 1 was lower in the visualization group (9.8%) than in the control group (34.0%) (P = 0.006); A similar trend was observed at the 12month follow-up (2.4% vs. 20.0%, P = 0.022). The m-JOA scores at 1, 3, 6, and 12months postsurgery were higher in the visualization group than in the control group (P < 0.05). The visualization group also had shorter lamina decompression times per segment and less intraoperative blood loss (P < 0.05). The incidence of nondural ossification cerebrospinal fluid leakage was lower in the visualization group (2.4%) than in the control group (18.0%) (P = 0.018). Additionally, nerve root injury was lower in the visualization group (0%) than in the control group (10.0%) (P = 0.037). Postoperative CT scans revealed no ossification residue in the visualization group, whereas 7 cases (14.0%) were observed in the control group (P = 0.013). The S8 navigation system combined with an ultrasonic osteotome for three-dimensional real-time dynamic visualization decompression significantly reduces the incidence of intraoperative neurological deterioration, improves postoperative motor function recovery, and reduces decompression time per vertebral segment, intraoperative bleeding, and complications such as cerebrospinal fluid leakage. This technology is safe and reliable and offers a promising option for spinal surgeons in treating thoracic ossification of the ligamentum flavum.

Innovative Nerve Root Protection in Full-Endoscopic Facet-Resecting Lumbar Interbody Fusion: Controlled Cage Glider Rotation Using the GUARD (Glider Used As a Rotary Device) Technique.

This video presents a case of L4-5 unstable spondylolisthesis treated with full-endoscopic transforaminal lumbar interbody fusion (Endo-TLIF), emphasizing the GUARD (Glider Used as a Rotary Device) technique for nerve root protection. This innovative approach involves controlled rotation of the cage glider before cage insertion to minimize the risk of nerve root injury, a significant complication in Endo-TLIF procedures. The GUARD technique, validated in previous cadaveric studies, provides enhanced safety during cage insertion by protecting the nerve root. A 48-year-old woman with a 3-year history of progressive low back pain and bilateral lower extremity radiculopathy (right-sided predominance) was diagnosed with L4-5 unstable spondylolisthesis and spinal stenosis. After failure of conservative management, she underwent uniportal full-endoscopic facet-resecting transforaminal lumbar interbody fusion using the GUARD technique. Postoperatively, the patient experienced significant symptomatic improvement and resolution of radiculopathy, without any intraoperative nerve root injury or postoperative neurological deficits. This case demonstrates the effectiveness of the GUARD technique in reducing neurological complications and improving patient outcomes.

Safety Profile of Biportal Endoscopic Spine Surgery Compared to Conventional Microscopic Approach: A Pooled Analysis of 2 Randomized Controlled Trials.

To compare the safety profiles of biportal endoscopic spinal surgery (BESS) and microscopic spinal surgery (MSS) for lumbar disc herniation and spinal stenosis by analyzing the associated adverse events. We pooled data from 2 prospective randomized controlled trials involving 220 patients (110 in each group) who underwent single-level lumbar surgery. Participants aged 20-80 years with radiating pain due to lumbar disc herniation or spinal stenosis were included in this study. Adverse events were recorded and analyzed over a 12-month follow-up period. The overall adverse event rates were 9.1% (10 of 110) in the BESS group and 17.3% (19 of 110) in the MSS group, which were not statistically significantly different (p=0.133). Notably, wound dehiscence occurred in 8.2% of MSS cases but in none of the BESS cases. Both groups showed similarly low rates of complications, such as dural tears, epidural hematoma, and nerve root injury. The most common adverse event in the BESS group was recurrent disc herniation (2.7%), whereas that in the MSS group was wound dehiscence (8.2%). BESS demonstrated a safety profile comparable to that of MSS for the treatment of lumbar disc herniation and spinal stenosis, with a trend towards fewer overall complications. BESS offers particular advantages in terms of reducing wound-related complications. These findings suggest that BESS is a safe alternative to conventional MSS and potentially offers the benefits of a minimally invasive approach without compromising patient safety.

Current Research on the Diagnosis Method of Meniscus Root Injury and its Healing

Currently, meniscus injury has become a common disease among sports and fitness enthusiasts in China, with root meniscus injury accounting for a larger proportion, which damage impairs load distribution throughout the knee joint, reducing the surface area to bear the load and making patients susceptible to early degenerative changes that alter their daily activities. This injury has been ignored for a long time, and in recent years people have begun to pay more attention to it. However, the diagnosis of root meniscus injury is difficult to detect, and the current mainstream method is MRI examination, combined with X-ray and arthroscope examination. However, with people's increasing emphasis on health, some may not accept surgical treatments such as meniscus repair or meniscectomy. Therefore, non-surgical treatments such as drug injection are gradually being used. In this paper, the literature on meniscus root injury in recent years was reviewed, and the anatomy, injury mechanism and intervention of meniscus root were reviewed, so as to further understand the current progress of injury.

The Ameliorative Effect of Coumarin on Copper Toxicity in Citrus sinensis: Insights from Growth, Nutrient Uptake, Oxidative Damage, and Photosynthetic Performance.

Excessive copper (Cu) has become a common physiological disorder restricting the sustainable production of citrus. Coumarin (COU) is a hydroxycinnamic acid that can protect plants from heavy metal toxicity. No data to date are available on the ameliorative effect of COU on plant Cu toxicity. 'Xuegan' (Citrus sinensis (L.) Osbeck) seedlings were treated for 24 weeks with nutrient solution containing two Cu levels (0.5 (Cu0.5) and 400 (Cu400) μM CuCl2) × four COU levels (0 (COU0), 10 (COU10), 50 (COU50), and 100 (COU100) μM COU). There were eight treatments in total. COU supply alleviated Cu400-induced increase in Cu absorption and oxidative injury in roots and leaves, decrease in growth, nutrient uptake, and leaf pigment concentrations and CO2 assimilation (ACO2), and photo-inhibitory impairment to the whole photosynthetic electron transport chain (PETC) in leaves, as revealed by chlorophyll a fluorescence (OJIP) transient. Further analysis suggested that the COU-mediated improvement of nutrient status (decreased competition of Cu2+ with Mg2+ and Fe2+, increased uptake of nutrients, and elevated ability to maintain nutrient balance) and mitigation of oxidative damage (decreased formation of reactive oxygen species and efficient detoxification system in leaves and roots) might lower the damage of Cu400 to roots and leaves (chloroplast ultrastructure and PETC), thereby improving the leaf pigment levels, ACO2, and growth of Cu400-treated seedlings.

Strategies and Safety in Iliosacral Screw Placement

Background L5 nerve radiculopathy is a serious complication associated with iliosacral (IS) screw fixation, a procedure often performed to stabilize pelvic fractures. The proximity of the L5 nerve root to the S1 sacral segment introduces significant risk, particularly when sacral dysmorphism or complex anatomy is involved. Despite advances in surgical techniques, the potential for nerve injury remains a critical concern during IS screw placement. Purpose/Hypothesis This study aims to evaluate the risks associated with L5 nerve injury during IS screw fixation and identify factors that increase the likelihood of complications, particularly in cases involving sacral dysmorphism. The hypothesis is that proper preoperative planning, sacral anatomy assessment, and improved surgical techniques can minimize the risk of L5 nerve injury during IS screw fixation. Study/Design This is a systematic review of cohort studies, methodology papers, reviews, and cadaver studies from SCOPUS and PubMed that investigate the relationship between sacral anatomy and L5 nerve root injury during IS screw fixation. Methods A comprehensive search was conducted using the keywords “L5 nerve radiculopathy” and “Iliosacral Screw Fixation.” Studies published within the last 15 years were included. Papers involving animal models or published in languages other than English were excluded. A total of 122 studies were identified, of which 15 were selected for detailed review based on their relevance to L5 nerve injury during IS screw fixation. The studies were analyzed for sacral anatomy variations, surgical techniques, and complications. Results The studies identified key factors that increase the risk of L5 nerve injury, including sacral dysmorphism, sacral morphology, and improper preoperative planning. Malpositioning of screws in the S1 sacral segment was associated with the highest risk of L5 nerve injury, particularly in cases involving dysmorphic sacra. Cadaver studies revealed that L5 nerve root proximity to the S1 segment significantly limits the margin for error, while imaging studies highlighted the importance of preoperative identification of osseous corridors. Improved techniques, such as the use of guidewires and triangulation methods, were found to enhance the accuracy of IS screw placement. Conclusion L5 nerve root injury is a major risk during IS screw fixation, particularly in cases with complex sacral anatomy. Preoperative planning that accounts for sacral morphology, along with the adoption of advanced surgical techniques such as the triangulation method by Zheng and Zao and guidewire use, is essential to minimize the risk of nerve injury. Further research should focus on improving intraoperative navigation and refining surgical techniques to enhance patient outcomes in sacral fixation procedures.

Application of continuous intraoperative neuromonitoring in the study of spinal nerve root thermal injury in a porcine model

BackgroundA warning system to avoid potential nerve root thermal injury caused by automatic spine robot is essential. However, there is a lack of basic research to support the development of such warning system. The aims of this study are to confirm the feasibility of continuous intraoperative neuromonitoring (CIONM) in spinal nerve root monitoring and study the exposure time of spinal nerve root thermal injury at different temperature in a porcine model.MethodsThe experiment was carried out on 32 nerve roots of 4 pigs (bilateral L4-S1 nerve roots). Sham group (CIONM only), control group (Room temperature stimulation with CIONM), and 40 °C, 45 °C, 50 °C, 55 °C, 60 °C, 65 °C temperature stimulation groups were conducted at random in each pig. The change of EMG was recorded continuously. The exposure time of nerve root injury at different temperatures was recorded. Histological analysis of the nerve roots was performed to confirm the injury.ResultsThe EMG of the sham, control, 40 °C and 45 °C groups were stable during the experiment, and no significant nerve root injury was observed on histological analysis. The time of 50% EMG amplitude decrease in 50℃, 55℃, 60℃ and 65℃ groups were 277.5 ± 18.2, 59.5 ± 6.2, 20.8 ± 1.0 and 16.5 ± 1.3 s, respectively. And the nerve specimens of these groups showed varying degrees of damage.ConclusionsCIONM can be used for continuous monitoring of spinal nerve roots. For 5 min, 40℃ and 45℃ did not cause significant nerve root injury. However, when the temperature reached 50℃ and above, nerve roots appeared injury.

Comparison of Complications Between Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for The Treatment of Lumbar Disc Herniation

Background: Lumbar disc herniation (LDH), a common spinal condition causing lower back pain, requires surgical intervention, with common procedures being percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM). Objective: The study was aimed to compare the complications and outcomes of Percutaneous Endoscopic Lumbar Discectomy (PELD) and Open Lumbar Microdiscectomy (OLM) in treating lumbar disc herniation (LDH) at the L4/L5 level. Methods: A cross-sectional comparative analysis was conducted from January 1, 2022, to June 30, 2023, at the Department of Neurosurgery, National Institute of Neurosciences&amp; Hospital. Seventy patients with LDH were divided into two groups: Group-I (PELD, n=33) and Group-II (OLM, n=37). Baseline characteristics, motor examinations, reflexes, sensory integrity, gait assessments, and MRI findings were recorded. Primary outcomes included per-operative and post-operative complications such as dural tears, nerve root injuries, wound infections, disk space infections, cerebrospinal fluid (CSF) leaks, foot drop, and recurrence rates. Visual Analogue Scale (VAS) scores for lower back and leg pain, and Oswestry Disability Index (ODI) scores, were evaluated pre-operatively and at the 90th postoperative day follow-up. Statistical analysis was performed using the chi-square test in SPSS version 26. Results: Partial nerve root injury occurred in 3.03% of Group-I and 6.06% of Group-II. Post-operative wound infection was noted in 3.03% of Group-I, while no infections were reported in Group-II. CSF leak was observed in 2.7% of Group-II but none in Group-I. Recurrence of LDH occurred in 2.7% of Group-II and none in Group-I. Conclusion: PELD and OLM are both effective for treating LDH, with PELD showing fewer complications. J Rang Med Col. September 2024; Vol. 9, No. 2: 8-14

Augmenting Endoscopic Transforaminal Spinal Decompression Surgery (Full Endoscopic Spine Surgery) Using Stimulated Electromyography Neuromonitoring Dilators.

Full endoscopic spine surgery via a transforaminal approach (FESS-TFA) offers a minimally invasive approach for spinal decompression. However, it carries a risk of nerve root irritation or injury. Existing intraoperative neuromonitoring primarily provides retrospective warnings of potential nerve disturbance. To introduce the use of stimulated electromyography neuromonitoring dilators in FESS-TFA for proactive nerve protection, enhanced localization, and potential reduction in radiation exposure. This technical note describes the first use of neuromonitoring dilators in FESS-TFA. A 6-mm dilator tipped with a stimulation electrode is introduced to provide real-time directional feedback regarding nerve proximity, allowing the surgeon to actively avoid accidental injury to the exiting nerve root. With the creation of a safe tract, subsequent introduction of working instruments would theoretically reduce the risk of neural injury. The technique was successfully applied in a case of T11/T12 severe spinal stenosis, facilitating safe instrument passage and nerve localization. We describe the surgical technique and provide illustrative intraoperative details. Neuromonitoring dilators represent a promising innovation in FESS-TFA with the potential to enhance patient safety and possibly streamline the procedure. Larger-scale studies are warranted to quantify the true impact of this technique on complication rates, operative time, and radiation exposure. This technique highlights a significant advancement in reducing neural complications during minimally invasive spinal surgeries. By proactively preventing nerve irritation or injury and reducing radiation exposure, it contributes to optimizing surgical workflows and improving patient outcomes.

En bloc resection of the ligamentum flavum for bilateral decompression in unilateral biportal endoscopic transforaminal lumbar interbody fusion: a 2-year follow-up study

BackgroundUnilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) is a minimally invasive procedure for treating lumbar degenerative diseases. However, the use of endoscopic lumbar interbody fusion does not completely eliminate the risk of dural and nerve root injuries. This study has refined UBE-TLIF to incorporate en bloc resection of the ligamentum flavum for bilateral decompression and aim to detail the surgical procedure and evaluate the clinical outcomes of this modification.MethodsThis study analyzes the outcomes of 109 consecutive patients treated by a single surgeon for lumbar degenerative disease using UBE-TLIF. Patients were divided into two groups: Group A (51 patients) underwent en bloc resection of the ligamentum flavum, while Group B (58 patients) underwent routine piecemeal resection. Assessed outcomes included surgery-related complications, operation time, estimated blood loss, postoperative stay, visual analogue scale (VAS) score, and Oswestry Disability Index (ODI). The surgical technique is detailed within the study.ResultsIn Group A, no nerve root or dura injuries were observed, whereas Group B reported one case of nerve root injury and three dura tears. The average operation time for Group A was shorter than that for Group B; however, the difference was not statistically significant (P > 0.05). No significant differences were found in the VAS score, ODI, estimated blood loss, or postoperative stay between the groups during follow-up.ConclusionsEn bloc resection of the ligamentum flavum for bilateral decompression in UBE-TLIF demonstrates satisfactory clinical outcomes and low perioperative complications rates, offering a safe and innovative alternative for the treatment of lumbar degenerative disease.

Medial and Lateral Meniscus Root Tear: Etiopathogenesis and Morphological Pattern in Indian Population.

This study aims to enhance our understanding of the morphological pattern, causes and pathogenesis of meniscal root injuries in the Indian population. Sixty-four patients with meniscus root tears were included in the study. The patients were categorized into two groups based on the location of the meniscus tear: Group 1 (n = 41) comprised patients with lateral meniscus root injury (LMRI), and Group 2 (n = 23) included patients with medial meniscus root injury (MMRI). Demographic and patient-specific data, such as age, gender, BMI, history of injury, and injury type, were recorded. All patients underwent surgical treatment, and intraoperative findings (chondral damage grade, type of root injury, associated ligamentous injuries) were documented. Meniscus root tears are further classified into 5 categories depending upon their morphological types. A minimum 12-month follow-up assessed functional outcomes using the Lysholm and IKDC knee scores. The mean age for MMRI and LMRI was 50.3years and 29.4years, respectively. In the MMRI group, 48% (11/23) were female compared to only 15% (6/41) in the LMRI group. The mean BMI in the MMRI and LMRI groups was 30.1 and 25.4, respectively. Nine patients in MMRI and 4 patients in LMRI group exhibited grade 3 or higher chondral damage. Type 2 meniscus root tear was most common type in both the groups (51% in MMRI vs. 74% in LMRI). Both LMRI and MMRI groups demonstrated significant improvement in functional outcomes. Medial meniscus root injuries predominantly occur in the elderly without a significant history of trauma, often associated with a high grade of medial femoral chondral damage, suggesting a degenerative etiology. In contrast, lateral meniscus root injuries tend to occur in younger patients with a notable history of knee injury, indicative of a traumatic etiology for LMRI.

Successful retrieval of a broken pituitary rongeur tip from the lumbar intervertebral disc space using a magnetic probe: illustrative case.

Unexpected events such as instrument breakage during a routine lumbar microdiscectomy can pose a risk for nerve root injury, durotomy, infection, and anterior displacement into the retroperitoneal space. Removal of broken instruments requires planning, patience, and sometimes subsequent surgical procedures. Here, the authors explore the effectiveness of a magnetic probe for the retrieval of broken metallic (magnetic) pieces. A 47-year-old man with right leg radiculopathy due to a right L5-S1 disc extrusion had undergone a lumbar microdiscectomy that was complicated by the pituitary rongeur tip breaking in the L5-S1 disc space. The rongeur tip was successfully retrieved by widening the entry access without damaging the adjoining facet and utilizing a blunt nerve hook, a probe dissector, forceps tips, curette heads, and a magnetic probe. The use of a magnetic probe provides a safe and effective method for retrieving metallic fragments during lumbar disc surgery. This case highlights the importance of considering alternative techniques such as magnetic retrieval in the management of intraoperative instrument breakage. https://thejns.org/doi/10.3171/CASE24377.

Comparative study between unilateral biportal endoscopic discectomy and percutaneous interlaminar endoscopic discectomy for the treatment of L5/S1 disc herniation

To compare the clinical outcomes of unilateral biportal endoscopic discectomy (UBED) and percutaneous interlaminar endoscopic discectomy (PIED) for treating L5/S1 disc herniation. Patients with L5/S1 disc herniation treated with UBED (n=46) and PIED (n=50) in our hospital during the same period were retrospectively reviewed. Clinical outcome, radiographic parameters and complications of each group were collected and evaluated. The mean follow-up period was 14.11±3.47 months in UBED group, and 14.52±5.37 months in PIED group. There was no significant difference in VAS leg (P=0.836) or lumbar scores (P=0.335) between PIED and UBED group at preoperative, 1-day postoperative, and last follow-up point. Within the same group, there were significant differences in VAS leg (P<0.001) and lumbar scores (P<0.001) compared pairwise at three time points. ODI scores of both groups showed significant improvement at the last follow-up (P<0.001) (P<0.001). And there was no significant difference in patient satisfaction rates (97.8% vs 96%) between two groups based on MacNab criteria. The percentage of facet joint preservation was 96.74±9.10% in UBED group, and 99.22±1.52% in PIED group. The total blood loss and hospitalization cost was more in the UBED Group. One patient in both groups showed postoperative hematoma. A dural tear occurred in UBED group and a never root injury occurred in PIED group. UBED indicates similar short-term efficacy compared with PIED for treating L5/S1 disc herniation. No difference was found in facet joint preservation between two groups. The increased cost of UBED due to surgical consumables is believed to be resolved in the future.