L5 Nerve Root Research Articles

Role of L5 Nerve Root Morphology in Identification of Lumbosacral Transitional Vertebra. Is it a Reliable Indicator?

Objective: To determine whether L5 nerve root morphology can assist in identification Lumbosacral Transitional vertebra. Study Design: Cross sectional study. Place and Duration of Study: Radiology Department, Combined Military Hospital, Multan Pakistan, Apr 2019 to Apr 2020. Methodology: Patients of both genders, 15 to 50 years age who underwent whole spine MRI were included in the study. Patients were referred from Combined Military Hospital Multan, from neighboring Combined Military Hospitals and Civil. Sagittal and axial T1WS and T2WS were performed along with coronal T2WS/FS sequences. Axial images were assessed for identification of L5 nerve root arising from LV5-SV1 level and hence vertebra was identified as LV5. Correlation was done with sagittal images for presence of Transitional vertebra, further confirmed by counting vertebral bodies from C2 vertebra upto sacrum using cross referencing tool. Results: A total of 135 patients were included in the study. Out of these, transitional vertebra was confidently labeled in 23 patients by nerve identification method which was confirmed on vertebral counting method. However, in four patients, L5 nerve root morphology was not clear and we had to rely on vertebral counting method for identification of transitional vertebra. Conclusion: Neuroanatomy and morphology of exiting L5 nerve roots can act as a reliable method for numbering of lumbosacral vertebra and identification of transitional vertebra.

Full Endoscopic Transpedicular Discectomy for a Rostrally Migrated L5-S1 Disc Herniation in the Setting of Previous Lumbar Surgery: A Case Report With Intraoperative Video.

The surgical management of rostral disc herniations at L5-S1 poses challenges for conventional endoscopic approaches, particularly in patients who have had previous lumbar surgery. We present a full endoscopic transpedicular discectomy (FETD), whereby a pediculotomy is created to pass an endoscope through the pedicle for intracanal access. This addresses anatomic obstacles and potential complications associated with other endoscopic and minimally invasive or open techniques. To date, this is the only article to highlight this approach with a case report and intraoperative video. A 76-year-old man with a history of L3-S1 laminectomy presented with left leg pain and a near-complete left foot drop. An MRI revealed a left paracentral rostrally migrated disc herniation arising from L5-S1 with impingement of the exiting left L5 nerve root at the inferomedial aspect of the pedicle of L5. The patient consented to the FETD procedure. Using sequential reamers of increasing diameter and a high-speed burr, a superolateral to inferomedial pediculotomy was performed. This approach allowed us to target the pathology at the point of maximum compression without traversing the prior operative field. A transforaminal endoscopic approach was not possible with the iliac crest obstructing rostral angulation. The disc was successfully removed without any intraoperative complications, and after surgery, the patient's radiculopathy resolved without any radiographic evidence of instability. FETD is a unique approach that demonstrates the versatility of endoscopic spine surgery, offering advantages over conventional approaches particularly for rostral disc herniations at L5-S1 in the setting of prior lumbar surgery.

Foot pressure transfers are altered in lumbar radiculopathy but reversible after surgery: a prospective, pedobarography study

BACKGROUND CONTEXTPatients with lower lumbar stenosis and disc herniation report disability in standing and ambulation, despite normal neurological examination. The L5 and S1 nerve roots support the entire motor and sensory function of the foot, and their radiculopathy can affect foot loading during standing and walking. This has not been quantified before. PURPOSETo quantify alterations in static and dynamic foot pressure transfers in patients with lower lumbar nerve root compression, and document any beneficial effects of surgical decompression. STUDY DESIGNProspective, case-control study. PATIENT SAMPLECases—Patients with unilateral radiculopathy (L5/S1) with normal neurology (n=50); Controls - Healthy volunteers (n=50). METHODSThe volunteers and patients underwent pedobarographic analysis during standing (static) and walking (dynamic), and fifteen (12 dynamic and three static) parameters were documented. The patient's preoperative values were compared with that of the healthy volunteers. All the 50 patients underwent surgical decompression, and clinical outcome measures (VAS/ODI at 3 months) were documented. Pedobarographic analysis was repeated in the postoperative period (48 hours) and 3-month follow-up and compared with the preoperative scores. RESULTSIn healthy controls, the mean values of all 15 parameters were comparable between the right and the left side (p>.05). When compared to controls, the patients had significantly lower maximum foot loads (p=.01) and average foot loads (p=.05) on the affected side during walking indicating lesser load transmission, in the preoperative period. Within the affected foot, the load transfer was higher on the first metatarsal/ medial arch while significantly less on the lateral metatarsals (p=.04). The percentage load on whole foot and forefoot was significantly less on standing (p=.01). Significant improvements were noted in the postoperative period, especially in the maximum foot surface area (p=.01), maximum and average foot loads, and improved weight transfers on lateral arch and forefoot (p=.02). The load on whole foot increased significantly from 46.1%±5.5% (preoperative) to 48.1%±5.5% (postoperative) and 49.9%±3.3% at follow-up (p=.01). CONCLUSIONThis is the first study using pedobarography to document altered foot pressure patterns during ambulation in patients with disc herniation and stenosis. Decreased load transfer, asymmetrical and unphysiological distribution of pressures on the affected foot were observed during weight bearing, which improved after surgical decompression.

Vacuum Disc Phenomenon Turned Gassy Disc Herniation: A Case Report

BACKGROUND: The vacuum phenomenon is a radiologic finding that results from gas accumulation within degenerated discs, joints, or vertebrae. This gas can herniate, causing back pain and/or radiculopathy. Asymptomatic imaging abnormalities can be coincidental and/or non-concordant with clinical presentation therefore warranting close evaluation. CASE REPORT: This 45-year-old man, previously diagnosed with lumbar facet arthropathy, returned to the clinic for left-sided axial low back pain. Imaging revealed that a gas filled mass in the right lateral recess was affecting the traversing right L5 and S1 nerve roots. Given the exclusive axial symptoms consistent with lumbar zygapophyseal joint arthropathy, the patient was treated with a repeat L3-4 medial branch and L5 dorsal ramus radiofrequency ablation and experienced subsequent near-complete pain resolution. CONCLUSIONS: Careful consideration must be taken when conducting clinical evaluation, imaging, diagnosis, and treatment of patients with low back pain given the significant frequency of abnormal, often nonconcordant, radiological findings. KEY WORDS: Pneumorrhachis, vacuum disc phenomenon, low back pain, case report

High Incidence of Spondylolisthesis in Patients with Grade 3 or 4 Osteoarthritis Knees with Spinal Symptoms

Abstract Introduction: The concerted radiographic incidence between lumbar degenerative spondylolisthesis (DS) and knee joint arthritis is not known. Hence, we analyzed the incidence of lumbar DS among severe knee arthritis cases in the outpatient department. Materials and Methods: In this observational study, we studied 499 patients (407 females and 92 males) with osteoarthritis (OA) of the knee. The X-rays of the lumbar spine and knee of patients were taken in a standing position. Patients with rheumatoid/ankylosing arthritis, trauma, and infection were excluded. Knee osteoarthritis was classified according to the Kellgren–Lawrence scale and spondylolisthesis was classified according to Meyerding’s classification. Results: Patients with knee osteoarthritis associated with DS were 30.9%. The statistical significance in the incidence of DS with knee osteoarthritis was found in our study. The level of DS and its relationship with the degree of OA were also studied. L5/S1 is the most prevalent level of listhesis and grade 4 OA is commonly associated with it. Conclusion: The DS incidence is significant in severe knee osteoarthritis patients. The degeneration of the lumbar spine leads to L4 nerve root pain that is relatively similar to the knee joint pain due to OA. For patients with knee pain, there is a probability of lumbar spine spondylolisthesis, so a complete examination of the spine and knee is required.

Instrumentation of hypoplastic pedicles with patient-specific guides

PurposeHypoplastic pedicles of the thoracolumbar spine (<5 mm diameter) are often found in syndromic deformities of the spine and pose a challenge in pedicle screw instrumentation. 3D-printed patient-specific guides might help overcome anatomical difficulties when instrumenting pedicles with screws, thereby reducing the necessity for less effective fixation methods such as hooks or sublaminar wires. In this study, the surgical feasibility and clinical outcome of patients with hypoplastic pedicles following pedicle screw instrumentation with 3D-printed patient-specific guides were assessed.MethodsHypoplastic pedicles were identified on preoperative computed tomography (CT) scans in six patients undergoing posterior spinal fusion surgery between 2017 and 2020. Based on these preoperative CT scans, patient-specific guides were produced to help with screw instrumentation of these thin pedicles. Postoperatively, pedicle-screw-related complications or revisions were analyzed.Results93/105 (88.6%) pedicle screws placed with patient-specific guides were instrumented. 62/93 (66.7%) of these instrumented pedicles were defined as hypoplastic with a mean width of 3.07 mm (SD ±0.98 mm, 95% CI [2.82–3.32]). Overall, 6 complications in the 62 hypoplastic pedicles (9.7%) were observed and included intraoperatively managed 4 cerebrospinal fluid leaks, 1 pneumothorax and 1 delayed revision due to 2 lumbar screws (2/62, 3.3%) impinging the L3 nerve root causing a painful radiculopathy. The mean follow-up time was 26.7 (SD ±11.7) months. Complications were only noted when the pedicle-width-to-screw-diameter ratio measured less than 0.62.ConclusionPatient-specific 3D-printed guides can aid in challenging instrumentation of hypoplastic pedicles in the thoracolumbar spine, especially if the pedicle-width-to-screw-diameter ratio is greater than 0.62.

Clinical and oncologic outcomes of posterior only total en bloc spondylectomy for spinal metastasis involving third lumbar vertebra: A case series.

A posterior-only total en bloc spondylectomy (TES) of the L3 level was deemed a highly intricate surgical procedure, necessitating the preservation of the L3 nerve root to prevent neurological deterioration. Despite bilateral preservation efforts of the L3 nerve roots, neurological deterioration proved unavoidable. This study aims to present the clinical, neurologic, and oncologic outcomes of spinal metastasis patients who underwent a posterior-only approach TES, encompassing the L3 vertebra. All patients with L3-involved spinal metastasis undergoing posterior TES between January 2018 and January 2022 were investigated. The primary outcomes considered were the local recurrence rate and manual muscle testing of the lumbar myotome. Secondary outcomes included Frankel neurological status, operative time, blood loss, perioperative and postoperative complications, and Eastern Cooperative Oncology Group score. Five patients with TES involving L3 (three females) met the inclusion criteria. All patients had solitary metastases (three in the lungs, 2 in the breasts). Postoperatively, all patients experienced weakness of the hip flexors, but they were able to ambulate independently 12 months after surgery. One patient exhibited adjacent segment (L2) disease progression and underwent corpectomy 18 months after TES. No local recurrences at the surgical site were detected on magnetic resonance imaging at the 1-year follow-up. Posterior-only TES for L3-involved vertebrae yielded excellent results in the local control of metastatic disease. Despite hip flexor weakness, all patients were able to regain independent ambulation after 12 months. TES can offer favorable clinical and oncological outcomes in patients with solitary spinal metastases.

Primary intradural extraosseous Ewing's sarcoma of the L3 nerve root: illustrative case.

Ewing's sarcoma is an uncommon, aggressive malignancy that typically presents as an osseous lesion, most commonly in children and adolescents. Very rarely Ewing's sarcoma can present as an intradural extramedullary mass mimicking more common tumors. A 32-year-old female had a left L3 nerve root-associated lesion identified in the setting of recent-onset radiculopathy. Contrast-enhanced magnetic resonance imaging of the lumbar spine was favored to demonstrate a schwannoma or neurofibroma. Hemilaminectomy, facetectomy, and resection of the mass led to improved radiculopathy and a tissue diagnosis of Ewing's sarcoma. Immediate referral to medical oncology facilitated expeditious initiation of adjuvant chemotherapy and radiation. The differential diagnosis for newly identified nerve root-associated tumors should remain broad, including common benign pathologies and rare malignant entities. Tissue remains the gold standard for diagnosis, as preoperative imaging suggested a nerve sheath tumor. Malignant pathologies such as Ewing's sarcoma must be considered, especially in the setting of rapidly progressive symptoms or interval growth on serial imaging. Early diagnosis allows for the timely initiation of comprehensive oncological care. Long-term multidisciplinary follow-up is necessary for the surveillance of disease progression.

Repeated L5 Nerve Root Compromise Detected with Motor Evoked Potentials (MEP), but Not Electromyography (EMG): A Case Report

ABSTRACT We report a case where neuromonitoring, using motor evoked potentials (MEP), detected an intraoperative L5 nerve root deficit during a lumbosacral decompression and instrumented fusion procedure. Critically, the MEP changes were not preceded nor accompanied by any significant spontaneous electromyography (sEMG) activity. Presumptive L5 innervated muscles, including tibialis anterior (TA), extensor hallucis longus (EHL) and gluteus maximus, were targets for nerve root surveillance using combined MEP and sEMG techniques. During a high-grade spondylolisthesis correction procedure, attempts to align a left-sided rod resulted in repeated loss and recovery cycles of MEP from the TA and EHL. No accompanying EMG alerts were associated with any of the MEP changes nor were MEP variations seen from muscles innervated above and below L5. After several attempts, the rod alignment was achieved, but significant MEP signal decrement (72% decrease) remained from the EHL. Postoperatively, the patient experienced significant foot drop on the left side that recovered over a period of 3 months. This case contributes to a growing body of evidence that exclusive reliance on sEMG for spinal nerve root scrutiny can be unreliable and MEP may provide more dependable data on nerve root patency.

Chapter 11 - Femoral and obturator neuropathies

The femoral and obturator nerves both arise from the L2, L3, and L4 spinal nerve roots and descend into the pelvis before emerging in the lower limbs. The femoral nerve's primary function is knee extension and hip flexion, along with some sensory innervation to the leg. The obturator nerve's primary function is thigh adduction and sensory innervation to a small area of the medial thigh. Each may be injured by a variety of potential causes, many of them iatrogenic. Here, we review the anatomy of the femoral and obturator nerves and the clinical features and potential etiologies of femoral and obturator neuropathies. Their necessary investigations, including electrodiagnostic studies and imaging, their prognosis, and potential treatments, are discussed in this chapter.

Foraminal stenosis and radiculopathy secondary to tophaceous gout: illustrative case.

Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues. Gouty tophi in the spine have a constellation of presentations that often mimic other pathologies and may not be easily discernable from more common pathologic processes. A 47-year-old female with a history of chronic renal disease, obesity, gout, inflammatory polyarthritis, and multiple sclerosis presented with 6 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. A lumbar magnetic resonance imaging study revealed right foraminal stenosis and spondylolisthesis at levels L4-5. An intraspinal extradural mass was noted adjacent to the traversing right L5 and exiting right L4 nerve roots. A bilateral decompressive laminectomy, facetectomy, and foraminotomy of L4-5 was performed. A calcific, chalky-white mass was discovered in the foramen, and pathology determined the specimen to be a gout tophus. Postoperatively, the patient endorsed the resolution of her preoperative symptoms, which have not returned on follow-up. Reports of gouty depositions compressing the spinal cord in the current literature are relatively rare. Although the diagnosis of gouty tophi can only be confirmed histologically, patient history may serve as a helpful diagnostic tool.

Complications Have Not Improved With Newer Generation Robots.

Retrospective cohort study. The purpose of this study was to see whether upgrades in newer generation robots improve safety and clinical outcomes following spine surgery. All patients undergoing robotic-assisted spine surgery with the Mazor X Stealth EditionTM (Medtronic, Minneapolis, MN) from 2019 to 2022 at a combined orthopedic and neurosurgical spine service were retrospectively reviewed. Robot related complications were recorded. 264 consecutive patients (54.1% female; age at time of surgery 63.5 ± 15.3years) operated on by 14 surgeons were analyzed. The average number of instrumented levels with robotics was 4.2 ± 2.7, while the average number of instrumented screws with robotics was 8.3 ± 5.3. There was a nearly 50/50 split between an open and minimally invasive approach. Six patients (2.2%) had robot related complications. Three patients had temporary nerve root injuries from misplaced screws that required reoperation, one patient had a permanent motor deficit from the tap damaging the L1 and L2 nerve roots, one patient had a durotomy from a misplaced screw that required laminectomy and intra-operative repair, and one patient had a temporary sensory L5 nerve root injury from a drill. Half of these complications (3/6) were due to a reference frame error. In total, four patients (1.5%) required reoperation to fix 10 misplaced screws. Despite newer generation robots, robot related complications are not decreasing. As half the robot related complications result from reference frame errors, this is an opportunity for improvement.

A CASE STUDY ON THE ROLE OF TIKTA KSHEERA BASTI IN THE MANAGEMENT OF KATIGATA VATA WITH SPECIAL REFERENCE TO LUMBAR SPONDYLOSIS

Katigata Vata or Lumbar spondylosis produces low back pain radiating towards the gluteal region of the leg and further towards the great toe. Symptoms include pain, stiffness, tingling numbness, difficulty walking, etc. No unique entity can be connected to Lumbar Spondylosis in Ayurveda. Under Vataja Nanatmaka vikara, it is classified as Katigraha (Stiffness in the lower back). Hereby presenting a case of 62 years old male who visited our institute with the presenting complaints of Katishool (low back ache), Sakashta Chankraman (Difficulty walking), Pain radiating towards the back, and an MRI Lumbar Spine which reported Osteoporosis at the Posterocentral disc protrusion at L2-L3, L4-L5 with L3 and L5 nerve root compression. He decided to undergo Ayurvedic panchakarma therapy along with Shaman Aushadhi. The treatment schedule of 21 days was planned to include therapy of Panchtikta Ksheera Basti along with shaman Aushadhi. Tikta Ksheera Basti tried to reduce the signs and symptoms of patients with Lumbar spondylosis after taking all these aspects into account. The following aspects of low back pain, tingling in the lower back and lower limbs, stiffness in the lower back and lower limbs, joint movements in the lower back and lower limbs, and the Straight Leg Rising Test (SLRT) were evaluated. Before and after administering Basti Karma, the data were gathered. The signs and symptoms of Lumbar Spondylosis were dramatically reduced throughout this 21-day basti, which showed significant efficacy.

OA03 Trauma secondary to a horse riding accident as a potential accelerating factor in inflammatory axial sponyloarthropathy: a case report and literature review

Abstract Introduction Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterised by axial involvement and sacroiliitis. The etiology of AS remains elusive, with genetic and environmental factors implicated in disease development and progression. This case report aims to investigate the potential association between trauma and the acceleration of AS in individuals positive for HLA-B27. Furthermore one purpose of this case-report is to ascertain any link between horse riding accidents in jockeys or professionals undertaking horse riding as a career choice. Is there a correlation between trauma and development of inflammatory axial spondyloarthropathy subsequently or not. Case description A 24-year-old female patient with a medical history of eczema and Graves' disease, currently undergoing propylthiouracil treatment, was referred to the rheumatology clinic due to persistent back pain for the past six to seven years following a horse riding accident. The patient had previously received physiotherapy and found relief with naproxen and co-codamol. The pain primarily affects her lower spine and radiates down her legs. While movement provides some relief, lying down exacerbates the pain. The patient experiences stiffness for approximately 30 minutes in the morning but does not exhibit peripheral joint symptoms. Exercise helps alleviate her symptoms. The patient reported a family history of psoriasis but denied any history of uveitis, inflammatory bowel disease, weight loss, night sweats, heartblock or achilles tendinitis. She also gave a history of joint hyper mobility with reduced flexion at the spine over the years. Blood tests revealed normal levels of ANA, CCP, ESR, rheumatoid factor, B12, HbA1c, and thyroid function. Ferritin levels were 30.2, and HLA B27 was positive. Joint examination did not reveal any signs of synovitis. The patient exhibited good range of motion in the spine. SLR's were positive on both sides and no tenderness over spine or sacroiliac joints. Systemic Examination was normal. BASDAI score was 4. Occiput to wall distance of 0 centimeters. Beighton score 4/9. Subsequently MRI whole spine/SI Joints were organised and results indicated a central disc protrusion at the L4-L5 level leading to critical spinal stenosis and likely impinging on the transitioning L5 and S1 nerve roots. Additionally, a disc protrusion at the L5-S1 which was impinging on the left S1 nerve root. Bilateral sacroiliitis was also observed. Patient was treated with NSAIDs and physiotherapy with good results with a view for a subsequent MRI, and escalation to biologics if symptoms were to worsen. Discussion The presented case raises the question of whether trauma accelerates the progression of ankylosing spondylitis (AS) in individuals who are positive for HLA-B27. Although this specific case involves a 24-year-old female patient with a history of back pain following a horse riding accident, additional research and studies would be required to draw definitive conclusions regarding the relationship between trauma and the development or acceleration of AS in HLA-B27 positive individuals. The question this case report poses and there is little in terms of research and case reports present, whether the involvement of the lady in question in a horse riding accident unmasked her ankylosing spondylitis given her HLA B27 positivity and the presence of sacroilitis on MRI scans. Literature review revealed a potential role of trauma accelerating the progression of ankylosing spondylitis in individuals who are also positive for HLA B-27, in addition in some cases it lead to detection and unmasking of chronic back pain which was inflammatory in nature rather than mechanical or a combination of both. This was revealed by the horse riding accident given the nature of the pain which had been constant and worsening which lead to a suspicion of a possible inflammatory component and hence further investigations were done. In conclusion this case report highlights the importance of a possible correlation between AS in HLA B27 positive individuals and raises the question whether trauma secondary to sports injuries like horseback riding accidents in our patients case, accelerates the progression of AS in individuals who are positive for HLA-B27. Key learning points This case report highlights the potential role of trauma following a sports injury as a contributing factor in the acceleration of AS in individuals positive for HLA-B27. Further investigations, including prospective studies, are warranted to elucidate the complex interplay between trauma, genetic predisposition, and disease progression in AS. The purpose of this case report is to remind sports medicine physicians of the prevalence of rheumatologic diseases in general and ankylosing spondylitis in particular and of the various ways in which spondyloarthropathies may present in athletes/sports personnel. Increased suspicion may lead to earlier diagnosis and treatment, potentially reducing illness severity and duration and improving the performance of athletes with this condition.

Are T1-Weighted Three-Dimensional Magnetic Resonance Images Inferior to T2-Weighted Images for Diagnosing Lumbar Foraminal Stenosis in the Fifth Lumbar Nerve Root? A Prospective, Comparative Study in Identical Patients.

Imaging analysis of foraminal stenosis in the fifth lumbar (L5) nerve root remains to be a challenge because of the anatomical complexity of the lumbosacral transition. T2-weighted three-dimensional (3D) magnetic resonance images (MRI) have been dominantly used for diagnosis of lumbar foraminal stenosis, while the reliability of T1-weighted images (WI) has also been proven. In this study, we aim to compare the reliability and reproducibility of T1- and T2-weighted 3D MRI in diagnosing lumbar foraminal stenosis (LFS) of the L5 nerve root. In this study, 39 patients with unilateral L5 radiculopathy (20 had L4-L5 intracanal stenosis; 19 had L5-S foraminal stenosis) were enrolled, prospectively. T1- and T2-weighted 3D lumbar MRI were obtained from each patient. T1WI and T2WI were blinded and then separately reviewed twice by four examiners randomly. The examiners were instructed to answer the side of LFS or absence of LFS. The correct answer rate, sensitivity, specificity, and area under the curve were analyzed and compared between T1WI and T2WI. Also, intra- and interobserver agreements were calculated using kappa (κ)-statistics and compared in the same manner. The average correct answer rate, sensitivity, specificity, and area under the curve of the T1WI/T2WI were 84.6%/80.1%, 82.9%/80.3%, 86.3%/81.3%, and 0.846/0.801, respectively. The intraobserver κ-values of the four examiners ranged from 0.692 to 0.916 (average: 0.762) and from 0.669 to 0.801 (average: 0.720) for T1WI and T2WI, respectively. The interobserver κ-values calculated in a round-robin manner (24 combinations in total) ranged from 0.544 to 0.790 (average: 0.657) and from 0.524 to 0.828 (average: 0.652), respectively. As per our findings, T1- and T2-weighted 3D MRI were determined to have nearly equivalent reliability and reproducibility in terms of diagnosing LFS of the L5 nerve root.

Cauda Equina Syndrome and the Adolescent Patient with Low Back Pain: A Case Report

Low back pain is a common complaint in adults of all ages, and is being increasingly seen in children and adolescents. The lifetime occurrence of low back pain is around 59%.1 Mechanical low back pain is globally one of the most common presentations seen by the Emergency Physician.14 Most cases of low back pain treated in the Emergency Department (ED) are not true emergencies, a notable exception being the Cauda Equina Syndrome (CES). Owing to the low occurrence and low index of suspicion in the pediatric/adolescent age group, there may be a significant delay in diagnosis of Cauda Equina Syndrome. This is concerning, because delay in diagnosis and there by treatment, runs the risk of permanent neurological damage and disability. Unequivocally, the most common predictor of a favourable outcome in CES is early diagnosis. We present the case of a 16-year-old male who presented to the ED on three separate occasions complaining of low back pain. The patient had red flag signs during the second visit; however, the relevant history and clinical findings were not elicited at the time. On the third ED visit, a clinical diagnosis of CES was made and urgent magnetic resonance imaging of the lumbo-sacral spine revealed a large right para-central herniation of the L4-L5 disc indenting the right L5 nerve root. Our aim in highlighting this case is two fold: 1. To make the Emergency Physician aware of the rare diagnosis of CES in this uncommon age group. 2. To stress the importance of early recognition of red flag signs in CES which will lead to an early diagnosis, and thereby a favourable outcome.

Morphometric measurements for potential dangers of anterior intra-pelvic approach in women: A cadaveric study.

This study aimed to improve the surgical anatomical knowledge of pelvic/acetabular trauma surgeons by providing detailed morphometric data on some of the most vulnerable arteries and nerves due to constant bony landmarks during anterior intra-pelvic approach fixation of acetabular fractures in women. Ten hemipelvis were dissected from 5 female cadavers. The following measurements relative to the symphysis were performed: (1) the distance of the corona mortis anastomosis and (2) the bisection of the external iliac vein with the pubic ramus. In addition, dis- tance to the pelvic brim at the level of pectineal convexity of the following structures was measured: (3) depth of obturatory neurovascu- lar bundle, (4) superior vesical artery, and (5) vaginal artery. Also, the clock position of the (6) gluteal superior and inferior vessels due to sciatic notch in the supine position. Due to antero-superior corner of sacroiliac joint (7) location of the common iliac artery bifurcation, (8) location of the bifurcation of internal iliac vessels to truncuses, (9) bifurcation of superior gluteal artery and lateral sacral artery, and (10) L5 nerve were measured. The descriptive statistics were given as medians and ranges as this is a descriptive anatomical study without comparisons. The median distance of corona mortis to symphysis pubis was 59.5 mm (range = 58-61). The external iliac vein bisected the pubic arm 68.5 mm (range=65-70) lateral to the symphysis pubis. At the level of pectineal convexity (about the middle of the pelvic brim), obturatory neurovascular bundle, superior vesical artery, and vaginal artery were 15 mm (range=13-16), 24 mm (range=23-25), and 36 mm (range=34-38) inferior to the pelvic brim, respectively. The superior gluteal vessels leave the sciatic notch at 12 o'clock position in supine position. Inferior gluteal vessels leave the sciatic notch at 31⁄2 o'clock position (given for left side). Common iliac artery bifurcation bisects the SI joint 5 mm (4-7) superior to antero-superior corner of the Sacro-iliac (SI) joint. The internal iliac artery gives its posterior trunk 18 mm (range=15-20) straightly anterior to antero-superior corner of the SI joint. Bifurcation of superior gluteal artery and lateral sacral artery was 11 mm (range = 10-12) away from the beginning of the posterior truncus. L5 root's medial margin was 9 mm (range = 7-10) medial to this landmark, where its lateral margin was on the SI joint (2 mm medial to 2 mm lateral). The majority of the bleeding complications of the major branches of the internal and external iliac arteries and neurologic palsies due to obturatory nerve and L5 nerve root damage within the operative field of the anterior intra-pelvic approach can be avoided or managed by utilizing morphometric data provided from this study. N/A.

Posterior L5 Transversectomy and Decompression for Far-out Syndrome caused by Lumbosacral Transitional Vertebra: A Case Report

Far-out syndrome is an unusual type of Bertolotti’s syndrome refers to L5 nerve root compressed by osteophyte in the extraforaminal zone, which leads to radical pain of the leg by radiculopathy. Conservative treatment is generally ineffective and requires operative decompression. We present the case of a 19-years-old patient complained of pain in the right lumbosacral and lower leg, failed for 2 months of conservative treatment. The patient was confirmed as far-out syndrome by imaging examinations showed the right L5 nerve root compressed by osteophytes from pseud arthrosis between the L5 transverse process and sacral ala. The Visual analog scale (VAS) pain score was 6 and the Oswestry disability index (ODI) was 53.33%. Then the osteophytes and pseudarthrosis were surgical removed and the L5 nerve root was decompressed through a posterior approach. The patient’s symptoms were significantly relieved after surgery immediately. The VAS score was 1 and ODI was 15.56% at 1-month postoperatively. At 1-year follow up, the VAS pain score was 1 and ODI was 11.11% and complete military trainings was resumed.

Imaging Findings, Fluoroscopic Time, and Results of the Lumbosacral Selective Nerve Root Block: Focus on the L5 Nerve Root Block.

Introduction Selective nerve root block (SNRB) is a valuable diagnostic and therapeutic tool. In some cases, intra-nerve root puncture is difficult and time-consuming, and radiation exposure time for the surgeon may be prolonged. The aim of this study is to examine the contrast findings, fluoroscopic time, and outcomes of SNRB. Methods A total of 139 cases of SNRB were included in the study. We investigated radiating pain presence, duration of fluoroscopic time, contrast types for nerve roots, and SNRB outcomes. Contrast patterns of nerve roots were categorized into three types, which were: type 1: the presence of contrast along the nerve roots; type 2: the presence of contrast within the intravertebral foramen but not in the nerve root; and type 3: the absence of both nerve root and intravertebral foramen contrast. Results The mean fluoroscopic time was 12.8 ± 15.3 seconds for type 1, 11.1 ± 8.9 seconds for type 2, and 23.6 ± 18.8 seconds for type 3. Statistically significant differences were found between the three groups (p = 0.007), and subsequent multiple comparisons showed significant differences between type 1 and type 2 (p = 0.010) and between type 2 and type 3 (p = 0.015). The visual analog scale (VAS) score before and 30 minutes after SNRB demonstrated a significant improvement in all patients. The mean change in VAS before and after nerve root block was 49.6 ± 21.7 mm for type 1 cases, 49.8 ± 25.2 mm for type 2 cases, and 37.8 ± 23.6 mm for type 3 cases, with no statistically significant difference between the three groups (p = 0.090). The proportion of patients with subjective symptomatic improvement before and after SNRB was 91.3% in type 1 cases, 88.5% in type 2 cases, and 85.7% in type 3 cases, with no statistically significant difference between the three groups (p = 0.641). Conclusions The above findings indicate that type 3 is beneficial for both diagnostic and therapeutic purposes.

Surgical Outcomes of Common Peroneal Nerve Entrapment Neuropathy Associated with L5 Radiculopathy.

Impingement of the common peroneal nerve, a branch of the L5 nerve root, causes common peroneal nerve entrapment neuropathy (CPNE). Although there are cases of CPNE associated with L5 radiculopathy, surgical intervention's effectiveness remains to be elucidated. This retrospective case-control study aimed to evaluate the efficacy of surgery in patients with CPNE associated with L5 radiculopathy. Twenty-two patients (25 limbs) with surgically treated CPNE between 2015 and 2022 were retrospectively reviewed. The limbs were classified into two groups: group R (limbs of CPNE associated with L5 radiculopathy) and group O (limbs of CPNE without L5 radiculopathy). The durations from onset to surgery, the nerve conduction studies (NCSs), and postoperative improvement rates for motor weakness, pain, and dysesthesia were compared between the groups. Group R included 15 limbs (13 patients), and group O included 10 limbs (9 patients). There were no significant differences in the duration from onset to surgery or abnormal findings of NCS between the two groups. The postoperative improvement rates were 88% and 100% (p = 0.62) for muscle weakness, 87% and 80% (p = 0.53) for pain, and 71% and 56% (p = 0.37) for dysesthesia in group R and group O, respectively, without significant differences between groups. CPNE associated with L5 radiculopathy is common, and the results of the present study showed that the surgical outcomes in such cases were satisfactory and comparable to those in CPNE without L5 radiculopathy.