L5 Nerve Root Research Articles

Protection of L1 nerve roots by pre-relieve tension in parallel endplate osteotomy for severe rigid thoracolumbar spine deformity

BackgroundThis is a retrospective study of the use of parallel endplate osteotomy (PEO) for correction of severe rigid thoracolumbar spine deformity.MethodsFrom July 2016 to January 2019, 12 patients with severe rigid thoracolumbar spine deformity underwent PEO on T12 or L1 vertebrae were studied.ResultsFollowing PEO at T12 or L1, the mean kyphosis and scoliosis correction rates reached 77.0 ± 8.9% and 75.5 ± 8.0%, respectively and the intraoperative estimated blood loss was 1950 ± 1050 mL, and the mean operative time was 6.98 ± 4.02 h. The SF-36 scores of physical function, role-physical, bodily pain, general health, vitality, social function, role-emotional and mental health changed from 63 ± 28, 50 ± 25, 50 ± 30, 34 ± 19, 53 ± 28, 45 ± 30, 30 ± 36 and 54 ± 18 at baseline to 83 ± 18, 69 ± 19, 72 ± 12, 66 ± 21, 75 ± 15, 72 ± 22, 66 ± 34 and 76 ± 12 at 1 year postoperatively, 83 ± 8, 68 ± 32, 83 ± 17, 73 ± 17, 82 ± 18, 76 ± 26, 70 ± 37 and 88 ± 12 at 18 months postoperatively, 86 ± 6, 83 ± 33, 90 ± 16, 81 ± 16, 89 ± 14, 88 ± 25, 83 ± 17 and 94 ± 10 at 24 months postoperatively, respectively (P < 0.01). Three patients had symptoms of L1 nerve root injury, as reflected by lower limb weakness and inner thigh numbness on knee extension and hip flexion, which was further confirmed by electromyography.ConclusionsPEO is easier to operate, and the spinal cord and nerve root are under direct vision and can effectively and safely correct severe rigid thoracolumbar spine deformity with satisfactory clinical results. However, it is important to identify, separate and protect L1 nerve roots during surgery in cases where patients have symptoms of back pain, muscle weakness and leg numbness on the convex side after surgery.

Percutaneous Endoscopic Contralateral Lumbar Foraminal Decompression via an Interlaminar Approach: 2-Dimensional Operative Video.

Nerve root compression by foraminal pathology is challenging for a surgeon to decompress without violating the facet joint, which may necessitate a fusion procedure. One nonfusion approach to foraminal pathology is a combination intracanal approach for a laminotomy/foraminotomy followed by a paraspinal Wiltse approach for far lateral decompression. Unfortunately, even with the combination approach, it continues to be difficult to achieve adequate decompression without violating much of the facet joint overlying the nerve root. Spine endoscopy offers the ability to decompress the foraminal portion of the nerve without significant violation of the facet joint. We present a surgical video describing the technique for performing a percutaneous endoscopic contralateral L5-S1 foraminal decompression via an interlaminar approach, for a patient presenting with a left L5 radiculopathy due to L5-S1 foraminal stenosis. We explain the differences in the endoscopic channel docking point between ipsilateral and contralateral interlaminar approaches. The steps of an endoscopic foraminotomy are then described: dissect soft tissue and ligamentum flavum off the medial left S1 lamina and superior articulating process (SAP), undercut the superior articulating process of S1 and the inferior articulating process (IAP) of L5 with a drill, resect lateral ligamentum flavum off SAP and IAP exposing epidural fat, and finally dissect the left L5 nerve root and remove compressive lesions throughout its course in the lateral recess, foramen, and laterally. The presentation ends with an intraoperative photograph showing a decompressed L5 nerve root and postoperative imaging confirming this decompression. Appropriate patient consent was obtained.

Preliminary study on the a novel individualized 3D printing artificial vertebral body in spine reconstruction

Objective To explore the advantages of the novel individualized 3D printing artificial vertebral body in spine reconstruction and to evaluate its clinical effect. Methods From January 2017 to December 2018, the 15 patients who underwent total vertebrectomy and spine reconstruction with individualized 3D printing artificial vertebral body were analyzed retrospectively. There were 8 males and 7 females, with the mean age 39.5 years (range: 20-57), including 12 primary tumors and 3 metastatic tumors. According to tumor location and surrounding soft tissue invasion range, simple posterior or combined anterior and posterior approach were used for total vertebral resection, and the defection was reconstructed by 3D printing artificial vertebral body. The operation time, intraoperative bleeding volume, postoperative stability of artificial vertebral body and bone ingrowth of adjacent vertebral body, preoperative and postoperative neurological changes, preoperative and postoperative VAS score, local control and survival of patients were analyzed. Results The mean operation time was 412.0 min (range: 135-740 min), and the mean blood loss was 4 140.0ml (range: 100-14 000 ml). The mean follow-up time was 23.2 months (range: 12-35 months), and no one loss to follow-up. One case had pleural rupture, one case had cerebrospinal fluid leakage and one case had L5 nerve root palsy. All patients recovered after active symptomatic treatment. Compare with the preoperative VAS score (4.7±1.1), the differences of VAS score at 7 d postoperative and last follow-up (1.6±0.6 and 1.0±0.5) were significantly reduced (P<0.001). Three patients with Frankel grade C gradually recovered to grade D, and no change were found in grade D and Grade E patients, there was no significant improved at last follow-up. Preliminary bone growth was found between the artificial vertebral body and the adjacent vertebral body 3 months after operation. The bone growth was more obvious at 12 months post-operation, and the artificial vertebral body fused with the adjacent vertebral bodies to form bone integration. At 24 months post-operation, the integration of the artificial vertebral body was more accurate. During the follow-up period, there was no loosening or displacement of the artificial vertebral body and no failure of internal fixation. A case of hemangioendothelioma and a case of epithelioid angiosarcoma died at 33 months and 35 months postoperatively. One patient with chondrosarcoma had local recurrence at16 months post-operation. After treated with arotinib, the tumor did not progress. The other 12 patients had no tumor recurrence or distant metastasis. Conclusion After spinal tumor resection, individualized 3D printing artificial vertebral body can be used to accurate restoration of spinal continuity, and provide nice interface matching and bone growth between artificial vertebral body and the adjacent vertebral endplates. Moreover, the immediate and long-term stability of the artificial vertebral body can meet the needs of spinal reconstruction. Key words: Imaging, three-dimensional; Spinal neoplasms; Individualized medicine; Bone remodeling

Diffusion tensor imaging of lumbar spinal nerves reveals changes in microstructural integrity following decompression surgery associated with improvements in clinical symptoms: A case report

The outcomes from spinal nerve decompression surgery are highly variable with a sizable proportion of elderly foraminal stenosis patients not regaining good pain relief. A better understanding of nerve root compression before and following decompression surgery and whether these changes are mirrored by improvements in symptoms may help to improve clinical decision-making processes. This case study used a combination of diffusion tensor imaging (DTI), clinical questionnaires and motor neurophysiology assessments before and up to 3 months following spinal decompression surgery. In this case report, a 70-year-old women with compression of the left L5 spinal nerve root in the L5-S1 exit foramina was recruited to the study. At 3 months following surgery, DTI revealed marked improvements in left L5 microstructural integrity to a similar level to that seen in the intact right L5 nerve root. This was accompanied by a gradual improvement in pain-related symptoms, mood and disability score by 3 months. Using this novel multimodal approach, it may be possible to track concurrent improvements in pain-related symptoms, function and microstructural integrity of compressed nerves in elderly foraminal stenosis patients undergoing decompression surgery.

Etiology of Lumbosacral Radiculoplexopathy: Sacral Insufficiency Fracture on Magnetic Resonance Imaging.

Sacral insufficiency fracture (SIF) can cause lumbosacral radiculoplexopathy (LSRP) and is probably under-recognized. Symptoms may include nonspecific lumbar spine or buttock pain that is exacerbated by physical activity and alleviated with rest. The frequency of LSRP secondary to SIF has not been reported. We aimed to determine the frequency of LSRP associated with SIF using magnetic resonance imaging (MRI) of the lumbar spine. We searched a radiology database at our institution using the keywords "sacral insufficiency fracture" and "lumbar spine MRI" for patient records from January 2014 through December 2017. We assessed for the presence of LSRP, reflected by elevated T2-weighted or short tau inversion recovery (STIR) signal intensity and enlargement of the nerve on noncontrast lumbar spine MRI. An incompletely healed vertically oriented SIF was confirmed if there was a persistent bone marrow edema pattern adjacent to the fracture site; we did not include purely transverse SIFs. The final cohort comprised 57 patients (48 female; age range, 14 to 89years). Abnormalities of the extraforaminal L5 nerve root or the combined L4 and L5 nerve roots (the lumbosacral trunk) were identified in 19 (33%) of 57 patients, with a total of 23 sites (bilateral involvement in four cases). Of the 23 abnormal nerves, 19 (82.6%) had corresponding, clinically documented radicular symptoms and 16 (69.6%) had no other explanation on MRI for their radicular symptoms other than SIF. LSRP caused by SIF is an entity all radiologists should be cognizant of, especially in cases of otherwise unexplained radicular symptoms. The diagnosis of SIF can be helpful in cases involving concomitant multilevel lumbar spondylosis and neural foraminal stenosis.

The effects of foraminotomy and intervertebral distraction on the volume of the lumbosacral intervertebral neurovascular foramen: An ex vivo study

Degenerative lumbosacral stenosis in dogs frequently involves L7-S1 foraminal stenosis and L7 nerve root compression. Surgical techniques to decompress the L7 nerve root include foraminotomy and intervertebral distraction. The objective of this study was to compare the effect of foraminotomy and intervertebral distraction on the total, cranial, and caudal compartmental volumes of the L7-S1 intervertebral neurovascular foramen (NF). CT images were obtained from eight canine lumbosacral (L5-CD1) specimens in the following sequential conditions: native spine (1), after dorsal laminectomy and partial discectomy of L7-S1 (2), after L7-S1 foraminotomy (3), after distraction with an interbody cage between L7 and S1 (4), after cage distraction stabilized with pedicle screw-rod fixation in neutral (5) and flexed position (6). The volume of the complete NF and its cranial and caudal subcompartments were calculated using the CT images and statistically compared between conditions. P < 0.05 was considered statistically significant.The volume of the complete NF was significantly increased after foraminotomy (mean ± standard deviation (146.8 ± 26.5%, P < 0.01) and after distraction (Condition 4, 121.0 ± 19.1%; Condition 5, 116.6 ± 29.3 %; Condition 6, 119.0 ± 21.8 %; P = 0.01) with no difference between the distraction conditions. Foraminotomy induced a significantly larger increase in total NF volume compared to distraction. Foraminotomy, but not distraction, induced a significant increase in volume of the cranial subcompartment (158.2 ± 33.2 %; P < 0.01). Foraminotomy is more effective in increasing the foraminal volume and especially the cranial subcompartment, which is where the L7 nerve root traverses the NF. Hence, foraminotomy may be more effective in decompressing the L7 nerve root.

MR neurography of lumbosacral nerve roots: Diagnostic value in chronic inflammatory demyelinating polyradiculoneuropathy and correlation with electrophysiological parameters

PurposeMR neurography(MRN) is an advanced imaging technique to visualize peripheral nerves. Our aim was to determine the value of morphological features of lumbosacral nerve roots on MRN in diagnosing chronic inflammatory demyelinating polyradiculoneuropathy(CIDP) and analyze their correlations with electrophysiological parameters. MethodsMRN of lumbosacral plexus was performed in 21 CIDP patients and 21 healthy volunteers. The cross-sectional areas(CSAs) and signal intensities(SI) of L3 to S1 nerve roots were measured and compared between two groups. Receiver operating characteristic(ROC) curves were plotted to assess the diagnostic accuracy. All patients also underwent nerve conduction studies. Correlations between CSAs and SI of lumbosacral nerve roots and electrophysiological parameters were analyzed. ResultsCompared with control group, CIDP patients showed significantly increased CSAs and SI from L3 to S1 nerve root (P < 0.001 and P < 0.05 respectively for all nerve roots). The CSAmean and SImean were 28.04 ± 8.55mm2, 1.314 ± 0.199 for patient group and 14.91 ± 2.36mm2,1.155 ± 0.094 for control group. ROC analysis revealed the best diagnostic accuracy for the CSAmean with an area under the curve of 0.968 and optimal cut-off value of 19.20 mm2. CSAs of L5 or S1 nerve root correlated positively with central latency and negatively with conduction velocity of tibial nerve. SI of L5 also had a positive correlation with latency of sural nerve. ConclusionsEvaluation of lumbosacral nerve roots on MRN in a quantitative manner may serve as an important tool to support the diagnosis of CIDP.

A double-network hydrogel for the dynamic compression of the lumbar nerve root.

Current animal models of nerve root compression due to lumbar disc herniation only assess the mechanical compression of nerve roots and the inflammatory response. Moreover, the pressure applied in these models is static, meaning that the nerve root cannot be dynamically compressed. This is very different from the pathogenesis of lumbar disc herniation. In this study, a chitosan/polyacrylamide double-network hydrogel was prepared by a simple two-step method. The swelling ratio of the double-network hydrogel increased with prolonged time, reaching 140. The compressive strength and compressive modulus of the hydrogel reached 53.6 and 0.34 MPa, respectively. Scanning electron microscopy revealed the hydrogel's crosslinked structure with many interconnecting pores. An MTT assay demonstrated that the number of viable cells in contact with the hydrogel extracts did not significantly change relative to the control surface. Thus, the hydrogel had good biocompatibility. Finally, the double-network hydrogel was used to compress the L4 nerve root of male sand rats to simulate lumbar disc herniation nerve root compression. The hydrogel remained in its original position after compression, and swelled with increasing time. Edema appeared around the nerve root and disappeared 3 weeks after operation. This chitosan/polyacrylamide double-network hydrogel has potential as a new implant material for animal models of lumbar nerve root compression. All animal experiments were approved by the Animal Ethics Committee of Neurosurgical Institute of Beijing, Capital Medical University, China (approval No. 201601006) on July 29, 2016.

Infiltrative Lipoma Causing Lumbar Nerve Root Compression in a Dog

Background: Lipomas are benign soft tissue mesenchymal neoplasms composed of adipose cells and are usually found in the subcutaneous tissue. Occasionally, lipomas may invade muscles or grow between them, in which case they are characterized as infiltrative lipomas. Clinical signs resulting from an intermuscular lipoma compressing peripheral nerves are rarely encountered in dogs. This case report aims to describe the neurological signs, diagnosis, and clinical evaluation of a dog diagnosed with infiltrative lipoma compressing a lumbar spinal nerve root.Case: A 12-year-old neutered male Fox Paulistinha, weighing 10.5 kg, was presented with difficulties in walking for the past 15 days with no previous history of trauma. On physical examination, the presence of three cutaneous nodules was noted in the ventral thoracic region, with onset of one year and slow and progressive growth. A cytological evaluation of the nodules was performed, and lipoma was diagnosed. At the neurological examination, the patient presented ambulatory paraparesis with marked motor deficit and atrophy of the quadriceps muscles of the left pelvic limb. Conscious proprioceptive deficit, the absence of patellar reflex, and diminished withdrawal reflex were observed in the left hind limb, in addition to diffuse pain on epaxial palpation of the lumbar region. Electroneuromyography showed increased insertion activity in the left gastrocnemius muscle and moderate spontaneous activity (fibrillation). Persistence of 10% was observed in the F-wave study of the left tibial nerve. These findings indicate partial involvement of the roots of the left sciatic-tibial nerve. Magnetic resonance imaging (MRI) showed the presence of a mass measuring 3.18 × 1.04 × 1.4 cm, interspersed with the paravertebral muscles, and located adjacent to the L2 and L3 spinous processes. An ultrasound-guided fine needle aspiration biopsy of the mass was performed and the findings of the cytopathological analysis of the collected material were considered consistent with lipoma. In view of these findings, surgical removal was recommended. However, the owner chose to attempt conservative treatment to control pain. Thus, the patient was treated with gabapentin, tramadol hydrochloride, carprofen, dipyrone, omeprazole, and physiotherapy. The animal exhibited a good response to conservative treatment, regaining its hind limb mobility in approximately 30 days.Discussion: Infiltrative lipomas compressing nerve roots are rarely described, with only one report of infiltrative lipoma in the lumbar region causing nerve root compression in dogs found in the literature. MRI was beneficial in this case, since it helped in determine the shape, location, and extent of the mass causing compression of the left L2 nerve root. The history and neurological examination findings in the patient described in this report were accounted for by the presence of an infiltrative lipoma compressing the left nerve root of L2. Surgical excision is the treatment of choice for intramuscular lipomas in most cases since conservative treatment elicits only a limited response. In contradiction to the literature, the dog in this report experienced a good response to conservative treatment, returning to normal mobility approximately 30 days after starting treatment. After six months of follow-up, the dog had not experienced a recurrence of the clinical signs. However, since the tumor has not been removed, clinical relapse is expected to occur in the future. Thus, despite the good response to conservative treatment in this case, we recommend the surgical excision of the tumor in order to decompress the affected nerve root. Although infiltrative lipomas compressing nerve roots are rare, clinicians should consider them as differential diagnosis when there is a presence of subcutaneous lipomas and neurologic signs of radiculopathy.

Utility of diffusion tensor imaging for guiding the treatment of lumbar disc herniation by percutaneous transforaminal endoscopic discectomy

The purpose of this study was to evaluate the utility of diffusion tensor imaging (DTI) for guiding the treatment of lumbar disc herniation (LDH) by percutaneous transforaminal endoscopic discectomy (PTED). We collected the clinical data of a total of 19 patients: 10 with unilateral S1 nerve root injury, 6 with unilateral L5 nerve root injury, and 3 with unilateral L5 and S1 nerve root injury. All patients underwent DTI before surgery, 3 days post-surgery, 30 days post-surgery, and 90 days post-surgery. The comparison of the fractional anisotropy (FA) values of compressed lateral nerve roots before surgery and 3, 30, and 90 days post-surgery demonstrated the recovery of nerve roots to be a dynamic process. A significant difference was found in the FA values between compressed lateral nerve roots preoperatively and normal lateral nerve roots before surgery, 3 days post-surgery and 30 days post-surgery (p < 0.05). There was no significant difference in FA values between compressed lateral nerve roots and normal ones 90 days post-surgery (p > 0.05). DTI can be used for the accurate diagnosis of LDH, as well as for postoperative evaluation and prognosis, and it is thus useful for the selection of surgical timing.

Neurotization Actuating Flexion and Extension Effectively Alleviates the Hindlimb Hemiplegia Caused by Hemorrhagic Stroke

Background: Central hemiplegia led by hypertensive intracerebral hemorrhage(HICH) is prevalent, devastating, and currently unable to intervene satisfactorily. Here,to move toward the clinic,we explored whether contralateral L4 nerve transfer,centralizing at flexion and extension, reanimates fine motor function for hemiplegic hindlimbs after HICH. Methods: Eligible rat models were manufactured by injecting autologous vein blood into the posterior limb of internal capsule (PLIC).Thirty rats were randomized into three groups.Rats in group A underwent sham operation(i.e.,exposure of bi-L4 roots without severance) after injection of saline. Rats in group B and group C were infused equal blood followed by bilateral L4 nerve roots transection and contralateral L4 nerve transfer, respectively. Behavioural, ultrastructural, immunofluorescent, and electromyographic assessments were applied at a scheduled timepoint in our study. fMRI was used as localization of PLIC impact. Findings: Through neurotization, skilled motion produced by dexterous flexion and extension in major joints (hip, knee, and ankle) of the paralyzed hindlimb recovered more sharply in group C than in group B (P<0.001), with BBB scores increasing accordingly. Reinnervated potentials were significantly detected for denervated flexors or extensors in group C, compared with group B(P<0.05). Simultaneously, detached fore-hindpaw prints were converted to an approximate superposition in a temporally-improved fashion. Histological and ultra-microstructural assessments revealed that at the anastomosis point, numerous axons were generated, realigned, and remyelinated over time. Interpretation: Neurotization involving contralateral L4 transfer activates robust flexion and extension, and efficaciously repairs the hemiplegic hindlimb after HICH. Funding Statement: This study was supported by grants from the National Natural Science Foundation of China (No. 81171147), “Key Medical Talents of Qiangwei Project” Research Foundation of Health Department of Jiangsu Province (No. ZDRCA2016010), “Xingwei Project” Key Personal Medical Research Foundation of Health Department of Jiangsu Province (No. RC201156), Jiangsu Province’s Natural Science Foundation (BK20171064), Research Foundation of Jiangsu Provincial Medical Youth Talent, the Project of Invigorating Health Care through Science, Technology and Education (QNRC2016858). Jiangsu Province’s Key Discipline of Medicine (No. XK201117) and the Priority Academic Program Development of Jiangsu Higher Education Institutions (PAPD). Declaration of Interests: All authors report no disclosures relevant to the manuscript, and claim no conflict of interests. Ethics Approval Statement: Animal experiments were conducted in accordance with the principles and procedures outlined in the NIH Guide for the Care and Use of Laboratory Animals (National Academies Press, 2011). Procedures concerning animals were approved by the Institutional Animal Care and Use Committee at Nanjing Medical University (Nanjing,Jiangsu,China;approval no. IACUC-1906009).

Where do patients with MRI-confirmed single-level radiculopathy experience pain, and what is the clinical interpretability of these pain patterns? A cross-sectional diagnostic accuracy study

BackgroundClinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved.MethodsA cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test).Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes.In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists.ResultsThere was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy.ConclusionsWhile pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians’ diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected.

Comorbidity of Pain and Depression in a Lumbar Disc Herniation Model: Biochemical Alterations and the Effects of Fluoxetine.

Summary of Background Data: Depression is one of the most common comorbidities in patients with chronic low back pain. However, the mechanisms of depression in chronic low back pain patients and the effect of antidepressants on the comorbidity of pain and depression need to be further explored. The establishment of the appropriate animal models and of more effective therapies is critical for this comorbidity. Lumbar disc herniation (LDH) is the most common disease that causes low back pain. The current study examined whether an LDH model shows behavioral and biochemical alterations that are in accordance with the characteristics of the comorbidity of pain and depression and tested the effect of fluoxetine (FLX) on these measures.Objective: The current study examined whether an LDH model showed the behavioral and biochemical alterations that were in accordance with the characteristics of the comorbidity of pain and depression and tested the effect of FLX on these measures.Methods: The LDH animal model was generated by the implantation of the autologous nucleus pulposus on the left L5 nerve root just proximal to the dorsal root ganglion in Wistar rats. Pain intensity was evaluated by mechanical allodynia and thermal hyperalgesia, and changes in depressive behavior were examined by the taste preference and forced swim tests. Hippocampal serotonin (5-HT) levels were measured by liquid chromatography-mass spectrometry, and tumor necrosis factor-α (TNF-α) mRNA was quantified using real-time reverse transcriptase PCR.Results: LDH resulted in chronic pain, which further induced depressive behavior that persisted for 6 weeks after surgery. There were decreased 5-HT concentrations and upregulated TNF-α mRNA levels that were accompanied by behavioral changes. FLX treatment improved depressive behavior and moderately alleviated pain through increased 5-HT concentrations, and inhibited TNF-α mRNA expression.Conclusions: In summary, our studies provide initial evidence that the LDH chronic pain model might serve as a model of the comorbidity of low back pain and depression. The finding that FLX improved depressive behavior and pain through normalized 5-HT concentrations and TNF-α mRNA expression establishes the initial mechanism of the comorbidity of pain and depression.

Direct anterior decompression of L4 and L5 nerve root in sacral fractures using the pararectus approach: a technical note.

To describe a new surgical technique for neurolysis and decompression of L4 and L5 nerve root entrapment after vertical sacral fractures via the pararectus approach for acetabular fractures, and to present four case examples. We retrospectively evaluated four patients suffering radiculopathy from entrapment of the L4 or L5 nerve root in vertical sacral fractures between January and December 2016. The mean follow-up period after surgery was 18 (range 7-27) months. All patients underwent direct decompression and neurolysis of the L4 and L5 nerve roots via the single-incision, intrapelvic, extraperitoneal pararectus approach. In all patients, the L4 and L5 nerve root was successfully visualized and decompressed, proving feasibility of the pararectus approach for this indication. No patient presented with a neural tear. Completeneurologic recovery was present in one patient at last follow-up; two patients had incomplete recovery of their radiculopathy; and one patient had no improvement after nerve root decompression. The pararectus approach allows for sufficient visualisation and direct decompression and neurolysis of the L4 and L5 nerve root entrapped in vertical sacral fractures. Although neurologic recovery was not achieved in all patients in this small case series, the approach may be a suitable alternative to posterior approaches and other anterior approaches such as the lateral window of the ilioinguinal approach.

5. All That glitters is not gold

IntroductionInflammatory muscle disease is a rare but well-recognised manifestation of systemic vasculitis. It can present as focal myositis or symmetrical proximal muscle involvement seen in polymyositis and dermatomyositis. Investigative findings in inflammatory myositis include raised creatine kinase, abnormal electromyography and muscle biopsy. MR scans can identify muscle abnormality, oedema, fibrosis and the extent of muscle involvement, and are routinely requested to evaluate patients with suspected or definite myositis. They also guide us to the appropriate muscles to biopsy. MR scans are not diagnostic of myositis and treating clinicians must be aware of its mimics. Our case demonstrates one such mimic.Case descriptionA 59-year-old male patient under care of the renal physicians for ANCA-associated vasculitis complained of bilateral thigh pain. He had completed IV cyclophosphamide therapy (CYCLOPs protocol) for vasculitis affecting lungs, kidneys, and ENT. He was taking 30mg prednisolone and 100mg azathioprine daily. He denied muscle weakness, paraesthesia, or sensory symptoms. There was no muscle wasting, fasciculation, or sensory loss. Deep tendon reflexes were normal.8-months prior, he was investigated for right hip pain and paraesthesia with MR spine and right hip, and neurophysiological studies. Investigations confirmed lumbar disc prolapse with neurophysiology in keeping with right L4 denervation changes. He had been treated with physiotherapy and daily pregabalin, duloxetine, and co-codamol.Renal physicians requested MR thigh, which was reported as muscle oedema over the long length of the right vastus medialis and lateralis, suggesting myositis. Rheumatology referral for myositis related to vasculitis was made. He was PR3+ve-3IU/ml (improved), ESR-2, CRP-4.6mg/L, CK-94U/L. EGFR remained stable at 66ml/min. Clinical features were not supportive of myositis and systemic vasculitis was in remission. The decision was made to discuss scans at the rheumatology- radiology meeting before considering a change in immunosuppression or muscle biopsy.Radiologists felt that findings of localised muscle group involvement suggested a neurogenic cause rather than primary muscle inflammation. They had reviewed MR lumbar spine done previously which had identified degenerative changes with right foraminal stenosis at L3-4 and L4-5 disc space. Electrophysiology showed chronic neurogenic changes of moderate severity in predominately L4 innervated muscles – vastus medialis and adductor magnus of the right lower limb. Findings were supportive of chronic right L4 radiculopathy and not a vasculitic neuropathy or myositis.Hence immunosuppression was left unchanged. He responded well to physiotherapy and did not require spinal surgical intervention.DiscussionOur patient developed bilateral thigh pain in the setting of vasculitis. MR imaging was suggestive of myositis. Differential diagnoses included myositis related to vasculitis, primary focal myositis followed by vasculitic neuropathy, or denervation changes due to nerve entrapment.MRI is an excellent imaging modality for skeletal muscle due to its soft tissue resolution. It helps in narrowing differentials in skeletal muscle pathology, clinicians are able to identify individually affected muscle or muscle groups, give information about active muscle inflammation and/or damage. They can assist clinicians in targeting muscle for biopsy. Pattern and extent of muscle involvement can provide valuable clue to peripheral nerve or root lesion.Though MR suggested myositis, clinical assessment was not typical of myositis. Our patient had no systemic features of active vasculitis, which are concurrently present in 80% of vasculitic neuropathies. Neurophysiology in vasculitic neuropathy typically shows evolving multifocal axonal neuropathy with reduced compound muscle action potential amplitudes. His electrophysiology was of chronic denervation in the L4 region and explained the patient’s clinical symptoms and MR findings.For skeletal muscle pathology, three key patterns of MRI signal intensity include mass lesions, fatty infiltration and muscular oedema. In this patient, recognising unilateral muscle oedema localised to the vastus medialis and lateralis (innervated by L4) was key to diagnosis. Other muscles innervated by L4 nerve root are iliopsoas, tibialis anterior and posterior. Neurophysiology did demonstrate changes in iliopsoas muscle. In this patient, the muscle atrophy common to lower motor neurone lesions was not present. This is possible when partial denervation or reinnervation occurs, changes noted on neurophysiological studies in this patient.Our case shows MR evidence of myositis may not always equate to inflammatory myositis. In this patient, awareness of the radiological mimics of myositis avoided a muscle biopsy or further immunosuppression.Key learning pointsMyositis is an uncommon but recognised manifestation of systemic vasculitis. Chronic denervation can cause muscle abnormalities that appears similar to myositis on MR scan of the affected muscle. As such Clinicians need to be aware of this similarity and in patients with localised or focal myositis. Knowledge of the muscles innervations may help to establish a neurogenic aetiology where muscles are solely affected. Muscle atrophy can be notably absent in denervated muscle if the nerve is partially denervated or regenerating.Conflict of interestThe authors declare no conflicts of interest.

Utility of motor evoked potentials to diagnose and reduce lower extremity motor nerve root injuries during 4,386 extradural posterior lumbosacral spine procedures

BACKGROUND CONTEXTMotor evoked potentials (MEPs) have excellent sensitivity for monitoring the functional integrity of the lateral corticospinal tract of the spinal cord. The sensitivity for nerve root function, however, is not as well established; consequently, MEPs are often not utilized for posterior extradural spine procedures distal to the conus. Spontaneous electromyography (sEMG) and somatosensory evoked potentials (SSEPs) are often included for these procedures, but their limited sensitivity has been well documented. Given the risk of motor nerve root injuries during spine procedures, and specifically increased vulnerability of the L4 and L5 nerves, the sensitivity of MEPs was evaluated for diagnostic accuracy and therapeutic impact. PURPOSETo determine the diagnostic sensitivity of MEPs during lumbosacral spine procedures and the potential therapeutic impact of the resolution of MEP alerts. STUDY DESIGNA total of 4,386 posterior extradural lumbosacral spine procedures utilizing multimodality intraoperative neuromonitoring (IONM) with sEMG, SSEPs, and MEPs were abstracted from a multi-institutional database. All cases took place between October 2015 and October 2017. No external funding was provided. OUTCOME MEASURESSensitivity and specificity, as well as positive and negative likelihood ratios for new postoperative neurologic deficits were calculated for each modality individually as well as when combined (multimodality). PATIENT SAMPLEAge 18 and older METHODSData entered in the electronic medical record were analyzed. Alerts to sEMG activity, decreases in SSEP amplitude, or decreases in MEP amplitude were documented as well as the status of the alerts at closure: resolved or unresolved. The presence of an sEMG alert or an unresolved MEP or SSEP alert at closure was considered a positive diagnostic result, and these results were assessed relative to presence of new immediate onset neurologic deficits as documented in the electronic record. RESULTSThe sensitivity and specificity of multimodality IONM for new immediate-onset lower extremity motor deficits were 100.0% (95% confidence interval: [64.6, 100.0]) and 92.2% (91.1, 93.1), respectively. Looking at the modalities in isolation, the sensitivity of MEPs was considerably better than either lower extremity sEMG or posterior tibial nerve SSEPs: 100.0% (78.5, 100.0) versus just 14.3% (4.0, 39.9) and 28.6% (8.2, 64.1), respectively. Surprisingly, the specificity of lower extremity MEPs was better than sEMG, 97.9% (97.5, 98.3) versus 95.4% (94.7, 96.0) (χ2=43.0, p<.001). The specificity of lower extremity SSEPs was 99.0% (98.5, 99.3). Only 4.4% of all procedures had a lower extremity MEP alert. There were 14 significant new nerve root injuries and all 14 had unresolved MEPs at closure. Total 85.7% of those nerve root injuries were dorsiflexion foot drop injuries and all had unresolved tibialis anterior MEP alerts. Although the overall rate of nerve root injuries was 0.32% (14/4,386), the rate for procedures with unresolved isolated tibialis anterior MEP alerts was 44.4% (12/27). The therapeutic impact is evident in the 2.0% of cases (87/4,386) with lower extremity MEP alerts that were able to be fully resolved by closure and for which the rate of injury was zero. CONCLUSIONSThe diagnostic accuracy of MEPs for anterior tibialis-related nerve root dysfunction supports the inclusion of this modality during routine posterior extradural lumbosacral procedures, especially when the L4 or L5 nerve roots are at risk. Moreover, therapeutic interventions that lead to the resolution of MEP alerts avert postoperative neurologic injuries.

Motor and Sensory Impairments of the Lower Extremities After L2 Nerve Root Transection During Total en Bloc Spondylectomy.

Retrospective study. The purpose of this study was to examine motor and sensory impairments of the lower extremities after L2 nerve root transection during total en bloc spondylectomy (TES) for spinal tumors. At our institute, for TES at L3 to L5 lumbar levels, the nerve roots are preserved. However, at the level of L1 and L2, the vertebral resection and spinal reconstruction via a posterior approach is employed with transection of the nerve roots during dissection and resection of the vertebra. This study included 13 patients who had undergone TES for spinal tumors involving L2 between 2007 and 2016. Postoperative motor function of the lower extremities was quantified using the Manual Muscle Testing grade for the iliopsoas (IP) and quadriceps femoris (QF) muscles, and a grade of the modified Frankel Classification. Postoperative sensory impairment was quantified by the sites of lower extremity pain and numbness. An initial decrease in strength of the IP and QF muscles in more than 60% of the patients, with a decline in the modified Frankel grade in 76.9%, was observed at 1-week after surgery. All patients recovered by the final follow-up, with 12 of the 13 patients walking without a gait aid. The other patient, who had undergone a bilateral dissection of L3 nerve root during TES of L2 and L3, had a mild QF muscle weakness, requiring a cane for walking. Eleven of 13 patients developed pain or numbness in the groin or thigh area after surgery, with the most common area being the anterior aspect of the thigh. Although IP and QF weakness was observed in the majority of patients who underwent bilateral transection of L2 nerve roots during TES, these deficits recovered over time and did not finally affect activities of daily living. 4.

IMPROVEMENT OF DISC HERNIA THROUGH KINESITHERAPEUTIC PROGRAM - CLINICAL CASE

Disc hernias are usually the result of disc wear, especially in the exercise of heavy physical occupations, weight lifting, forced posture, overwork. The clinical case described is a 69-year-old patient, a journalist by profession. At the end of May, he went to the Mount Athos peninsula in Greece to visit and describe the Monasteries in Mount Athos. On 30th of May he made a long and difficult transition into the mountain with a heavy backpack. In the morning of the same day, he suffered sharp spontaneous motion pains. He hoped that the pain would subsist and he would continue the journey. The day after, the inflammatory process encompassed the left buttocks with numbness on the outer surface of the left thigh and lower leg with a very limited movement. The patient was very worried about his health and how he would be transported to the nearest hospital. He was transported on a stretcher to Bulgaria and on 06.06. 2016г. to the hospital MHALNP "St. Naum" in Sofia for research and treatment. The Computer tomography was performed on 07.06.2018. upon acceptance of the patient, the results from it were: Disorders of the intervertebral discs in the lumbar spine and the other parts of the spine with radiculopathy at the level L4-L5 - left-side foramen disk hernia with compression of the left L4 nerve root in intra- and extraforaminal disc herniation.This example shows that in case of problems with vertebrogenic etiology it should not be awaiting and the patient should take precautions in time to avoid complications.

Reduction versus Fusion In-Situ in High-Grade Spondylolisthesis

Background Data: Surgical management for high-grade spondylolisthesis is challenging and associated with high morbidity. There are many surgical techniques available for lumbosacral fixation and correction that differ in approaches and outcomes. The main concern during surgery is to decompress the neural element, correct focal kyphotic deformity, and restore or maintain global sagittal alignment. Purpose: The purpose of this study was to present a case series of patients with high-grade spondylolisthesis who were treated with reduction and fixation and compare the results to in situ fusion technique. Study Design: Retrospective observational study. Patients and Methods: We retrospectively reviewed patients with L5/S1 high-grade spondylolisthesis who underwent surgery at our institute in the period between March 2013 and March 2017. Patient’s demographic, preoperative, and postoperative data were collected. Taillard’s technique and Meyerding’s grade for spondylolisthesis were assessed for all cases. Additionally, we measured the pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) pre- and postoperatively. The Bridwell grading system was used to assess the degree of radiographic fusion. Preoperative and postoperative clinical outcomes were evaluated using Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). Complication rates were collected during the follow-up period. Results: We included 16 cases in the current study. Patients were divided into two groups: reduction group includes nine patients, and in situ group includes seven. There was no significant difference in demographics or radiological data between groups. Moreover, operative data demonstrated comparable results between the two groups (P<0.05). Reduction group showed significant increase in L5 palsy compared to the in situ fusion group (0.037), although reduction showed more significant changes regarding correction of deformity (PT and SS). Both techniques were efficient in relieving pain and improving disability at 3-month and last follow-up visits (P<0.001). Conclusion: The present study showed that both reduction and in situ fusion techniques are effective surgical tools in improving clinical outcomes for patients with L5/S1 high-grade spondylolisthesis. Attempt of complete reduction carries a high risk of L5 nerve root injury. Partial reduction under complete L5 nerve root decompression and visualization is crucial in reducing risk of injury. However, reduction technique demonstrated superior deformity correction at the index level of spondylolisthesis. (2019ESJ181)

Dynamic digital tomosynthesis-radiculography is useful for diagnosis of lumbar foraminal stenosis at an adjacent level after lumbar fusion surgery: A case report

After spine fusion surgery, it is difficult to evaluate the spinal canal and nerve roots using magnetic resonance imaging (MRI) because of metallic implant-related artifacts. Digital tomosynthesis is a new radiographic technique that can acquire tomographic images with reduced metallic artifact effects compared with MRI.We report a case demonstrating the visualization of nerve roots nearby metallic implants using dynamic tomosynthesis-radiculography (DTRG) after spinal fusion surgery. A 77-year-old man, who 3 years earlier underwent spine fusion surgery at L3–L5, presented complaining of newly-onset low back pain and radicular symptoms in the right fifth lumbar (L5) nerve root area. His symptoms were exacerbated when he stood upright. We suspected right L5 nerve root radiculopathy, but MRI could not depict any lesion of the nerve root because of metallic implant-related artifacts. We performed DTRG at the right L5 nerve root with the patient in both prone and upright positions. The right L5 nerve root was detected clearly, and nerve root compression at the foramina when the patient was upright was exacerbated more than when the patient was in a prone position. DTRG is helpful to diagnose lumbar foraminal stenosis nearby metallic implants after spine fusion surgery.