L4-L5 Level Research Articles

A comparative analysis of lumbar paraspinal muscle morphology between two movement system impairment subgroups of chronic nonspecific low back pain

BackgroundBased on the kinesiopathologic model, the Movement System Impairment (MSI) classification of LBP has shown that repetitive movements could contribute to pathoanatomic tissue changes. However, these changes have not been evaluated in different MSI classification subgroups of patients with LBP. ObjectiveThis study compared the grades of fatty infiltration as one of the muscle's pathologic changes in the lower lumbar paraspinal and psoas muscles between the two subgroups of patients diagnosed with MSI syndromes having opposite movement direction impairments. DesignObservational cross-sectional study. MethodForty-five participants with chronic LBP were enrolled in the study, with 23 patients in the lumbar flexion-rotation (FlexRot) subgroup and 22 in the lumbar extension-rotation (ExtRot) subgroup of MSI. Magnetic resonance imaging (MRI) and the Goutallier Classification System (GCS) were used for fatty grading of lumbar paraspinal and psoas muscles. After the reliability of this grading scale was evaluated, the results were compared between the two subgroups. ResultsThe Mann–Whitney U Test showed significantly higher fat infiltration of lower lumbar multifidus and erector spinae muscles in the lumbar ExtRot subgroup, with no significant difference between the two subgroups in terms of psoas muscles (P ≤ 0.05). Inter-rater reliability of GCS was acceptable to excellent, and intra-rater reliability was good to excellent. ConclusionThe fatty infiltration grade of lumbar paraspinal muscles in L4-L5 and L5-S1 levels are significantly different between the two LBP subgroups of MSI that have two opposite movement direction impairments. The lumbar paraspinal muscles, which contribute to extension, have a higher grade of fat in the ExtRot subgroup, whose symptoms are aggravated by lumbar extension.

A magnetic resonance imaging-based morphometric analysis of bilateral L1-L5 oblique lumbar interbody fusion corridor: feasibility of safe surgical approach and influencing factors.

Retrospective cross-sectional study. To investigate the size and local anatomy of the right and the left-sided oblique corridors between L1-L5 levels and identify the potential impact of increasing age and sex on corridor size. The oblique lumbar interbody fusion (OLIF) was introduced by Silvestre and his colleagues as a solution to the approach-related complications associated with anterior lumbar interbody fusion and lateral lumbar interbody fusion. Limited data were available describing the local anatomy and morphology of this approach. Imaging data of 300 patients (150 males and 150 females) who underwent 1.5T magnetic resonance imaging (MRI) scans of the lumbar spine at Indian Spinal Injuries Centre, New Delhi, India between January 2023 and January 2024 were retrospectively reviewed. The cohort was stratified into six age groups (21-30, 31-40, 41-50, 51-60, 61-70, and >70 years) with 25 patients in each age group for both sexes. T2 weighted axial MRI images were analyzed from the L1-L5 level at the mid-disc level to calculate the corridor size. The local anatomical differences were recorded. At L1-L2, L2-L3, L3-L4, and L4-L5 levels, the mean corridor sizes in males were 17.48, 15.50, 13.41, and 9.32 mm on the left side, and 11.48, 7.12, 4.34, and 1.64 mm on the right side, respectively. The corresponding mean corridor sizes in females were 10.34, 12.94, 12.64, and 7.22 mm on the left side and 2.66, 3.52, 3.69, and 1.64 mm on the right side, respectively. For both sides, the corridor size was significantly affected by sex, increased with age, and decreased at the lower lumbar disc levels. A left-sided OLIF approach is more feasible for both sexes. The right-sided approach is less likely to be performed effectively.

Assessing the Correlation Between the Lumbar Disc Herniation Degree and Multifidus Muscle Fatty Degeneration in Chronic Low Back Pain.

Chronic low back pain (LBP) is a common condition primarily associated with lumbar disc herniation. Fatty degeneration of the multifidus muscle is also observed in the majority (>80%) of patients with LBP. This retrospective study included 140 patients (72 females and 68 males) with chronic LBP. 3T lumbar magnetic resonance imaging (MRI) T1- and T2-weighted fast spin-echo sequences were used for radiological evaluation. Disc herniations were graded according to the degree of bulging, protrusion, extrusion, and sequestration. Multifidus fatty infiltration was semiquantitatively graded from grade 1 (normal) to grade 4 (severe). Multifidus fatty degeneration was more common in females compared to males at the L4-L5 and L5-S1 levels (p-values <000.1 and <000.1, respectively). There was no correlation between disc herniation at the L4-L5 and L5-S1 levels and fatty degeneration of the multifidus muscle (p values 0.426 and 0.170). There was a statistically significant positive correlation between multifidus fatty degeneration at L4-L5 and L5-S1 levels and increasing age (p<000.1, r-values 0.462 and 0.357, respectively). In contrast, there was no correlation between age and L4-L5 and L5-S1 herniation grades (p values 0.167 and 0.723, respectively). Fatty degeneration grades were generally higher in females and increased with age at L4-L5 and L5-S1 levels in both genders (p<0.001). The frequency and degree of fatty degeneration of the multifidus muscle increasewith age, especially in women, and donot correlate with the presence of a herniated disc.

Validity of IMU sensors for assessing features of walking in laboratory and outdoor environments among older adults

IntroductionIMU sensors (three-dimensional accelerometer, gyroscope and magnetometer) enable assessment of walking in older adults outside the laboratory. We studied whether IMUs are valid for detecting walking parameters (step events, time, length, and cadence) in a laboratory and outdoors on a level surface in older adults. MethodsThis validation study is part of a larger cross-sectional study. Twenty-six participants (mean age 76 years, 65 % female) walked on a treadmill indoors and on a sport track outdoors at self-selected speed. IMUs were attached laterally on the shanks and on the lower back at the level of L3-L4. Initial contact (IC) and step lengths were also estimated using acceleration signals (vertical, antero-posterior) from the pelvic IMU. Terminal contact (TC) was determined from the shank IMU sagittal angular velocity. For step length, inverted pendulum model and participant’s leg length (0.53 x height) was used. Step duration was calculated from IC to the opposite leg IC and stride duration from IC to next ipsilateral IC. Cadence was calculated as steps/min. As reference data, 3D motion capture was used in the laboratory and a high-speed video camera outdoors. Intraclass correlation coefficients (ICC), root mean squared errors (RMSE), typical errors and Bland-Altman plots were calculated and drawn. ResultsWhen comparing IC timing between IMU and reference data, mean bias was 0.031 s in the laboratory and −0.004 s outdoors, and for TC −0.057 s and −0.070 s respectively. Step and stride duration and cadence showed ICC values >0.80 and mean bias was <0.005 s for step and stride durations and <0.05 steps/min for cadence in both environments. Step length ICC values were <0.40 in the laboratory and outdoors. SignificanceIMUs can be used to monitor temporal walking variables in older adults and may be useful for rehabilitation interventions and functional capacity assessment.

Experience of use of intraoperative computed tomography and navigation systems in minimally invasive surgery for lumbosacral spondylolisthesis

This article discusses the minimally invasive surgical technique for lumbosacral spondylolisthesis. The use of intraoperative computed tomography (iCT) and a navigation system significantly enhances the accuracy of screw placement and reduces the extent of soft tissue damage. From March 2018 to February 2024, 246 patients with lumbosacral spondylolisthesis underwent minimally invasive surgery with the use of iCT and navigation systems at the N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation. Of the above-mentioned cases, spondylolisthesis was most commonly observed at the L4-L5 (126 cases) and L5-S1 (98 cases) levels. This article presents two clinical cases from this series demonstrating successful use of these technologies.

Cauda equina syndrome successfully treated with microdiscectomy and methylprednisolone therapy: A case report

Cauda equina syndrome (CES) caused by lumbar disc herniation is a rare neurosurgical emergency in young adults that requires immediate decompression. A surgical delay over 48 hours may result in irreversible ramifications, underscoring a crucial timeframe for managing this condition. We presented a 26-year-old man with lower limb weakness persisting for one week, accompanied with exacerbating bowel and bladder issues after massage. The patient had a history of low back pain and tingling sensations radiating to the left leg over the past year. His physical examination showed right motor strength of 5/4 and left motor strength of 5/3, with weakened bowel peristalsis, loose anal sphincter and saddle anaesthesia. A spinal MRI revealed protruded discs extending to the intervertebral levels of L4-L5 and L5-S1, implicating herniated discs as the likely cause of CES. He underwent a microdiscectomy with a posterior approach, and intravenous methylprednisolone was administered before the procedure. The next surgery demonstrated enhancements in motor strength, bowel and bladder function, and it also reduced pain. He was discharged with persistent tingling sensations in his both legs. We concluded that CES represents a critical neurosurgical emergency, which is diagnosed through clinical symptoms and neuroimaging. Rapid decompression and intravenous administration of methylprednisolone are associated with better prognosis.

Percutaneous treatment of lumbar synovial cysts with bleomycin: A case report.

Lumbar synovial cysts (LSC) that protrude into the spinal canal can cause lower back pain, neurogenic claudication, and radiculopathy. Often diagnosed in the elderly population (typically ∼60 years of age) with a slight preponderance for females, their underlying etiology is thought to be due to degeneration of the adjacent facet joint, with the most common location at the level of L4-L5. Treatment of LSC can be conservative (with NSAIDs and physical therapy), percutaneous (with rupture), or surgically (with decompression with or without fusion). Percutaneous treatment of LSC involves rupturing the cyst by injecting it with steroids and local anesthetics. Although this option is less invasive than surgery, multiple studies have documented recurrence with this method and patients eventually undergoing surgical intervention. In this report, we document a case where a patient who presented with a symptomatic LSC underwent successful percutaneous treatment with bleomycin.

Navigation and Robotic Single-Position Prone LLIF: First Cases in Brazil

has been rapid technological advancement in navigation-guided minimally invasive surgery over the past two decades, making these advancements an invaluable aid for surgeons by essentially providing real-time virtual reconstruction of patient anatomy. The objectives of these navigation- and robot-guided procedures are to reduce the likelihood of neural and vascular injury, minimize hospitalization time, decrease bleeding and postoperative pain, shorten healing time, and lower infection rates. A unicentric, retrospective cohort study was conducted to evaluate the preoperative and postoperative clinical and radiographic outcomes of the first Latin American patients diagnosed with lumbar degenerative disease who underwent lumbar interbody fusion at the L4-L5 level via prone-position lateral lumbar interbody fusion-single position prone access. A total of 80 patients (40 assisted by fluoroscopy, 40 assisted by robotics) with 320 percutaneous pedicle screws were evaluated. The primary outcomes analyzed and compared were radiation exposure per screw (seconds), skin-to-skin operative time (minutes), and recovery time (days). Secondary outcomes included lumbar pain intensity (visual analog scale), reported functional disability (Oswestry Disability Index), and any potential complications. All secondary outcomes were collected at the postoperative time. Comparing minimally invasive spine interventions with free-hand instrumentation and robotic instrumentation, a statistically significant difference was identified in radiation exposure per screw and surgical time. The literature on Cirq Robotic is limited; however, minimally invasive spine surgery with robotic assistance appears advantageous in terms of radiation exposure and surgical time.

Post-dural Puncture Headache: A Comparative Study Using 25 G Quincke's Needle in Midline and Paramedian Approaches in Patients Undergoing Elective Cesarean Section.

Background and objectives Spinal anesthesia (SA) has become a preferred anesthetic technique for elective cesarean sections due to its rapid onset, profound sensory and motor blockade, and minimal impact on the newborn. It lowers the risk of development of thrombus in the veins and pulmonary vessels and permits early ambulation. The most popular technique used to reach the subarachnoid space is the midline technique, though it can be challenging to use in some cases, including those involving elderly patients with degenerative abnormalities in the vertebral column, patients who are unable to flex the vertebral column, noncooperative patients, and hyperestheticpatients. The paramedian technique resolves the challenges posed by the midline technique. It is also relatively easy to carry out. Based on the midline technique's inadequacies, we hypothesized that the paramedian method of SA would be less complicated than the midline approach, with a relatively low occurrence of post-dural puncture headaches (PDPH). Methodology Using the midline and paramedian approaches during cesarean surgeries, we performed an observational descriptive longitudinal study to assess the occurrence and magnitude of PDPH. During an elective cesarean delivery, the seated patient received 2.0-2.5 ml of hyperbaric bupivacaine using the midline or paramedian approaches and a 25 G Quincke's needle at the L3-L4 level. Eighty-four pregnant females with American Society of Anesthesiologists (ASA) physical status II, aged 18 to 35 (n = 42 in each group), were included in this research. The occurrence and severity of PDPH were compared among thegroups during a period of five days. Result In comparison to the paramedian group (7.1%), the midline group had a higher incidence of PDPH (14.3%). There was a significant correlation between the technique and the occurrence of PDPH (p = 0.041). The visual analogue scale (VAS) was employed to quantify pain five days after surgery. Pain levels in Group B (paramedian) were consistently less than those in Group A (midline). On day 1, Group B had a mean score of 0.49 ± 1.16 (p = 0.030) compared to Group A's mean VAS score of 1.27 ± 1.95. Day 5 (p = 0.032): Because this tendency persisted through day 5, the p-values for days 2, 3, 4, and 5 remained significant. These findings suggest that the midline technique is linked to a higher occurrence and magnitude of PDPHthan the paramedian approach. Conclusion Employing a paramedian technique has been associated with a noteworthy decline in the frequency of PDPH and a decrease in the need for additional analgesics, which could lead to a less severe case of PDPH. The paramedian approachneeded fewer attempts and needle passes, which leads to a lower incidence of headache, backache, and injection site pain and better patient satisfaction.

Morphometry and skeletopy of kidneys and renal vessels in marmoset (Callithrix spp.).

Marmosets, Callithrix spp, are small New World monkeys that have gained importance as an experimental animal model for human. Despite its use, information on its renal morphometry, vascularization, and location are limited. Therefore, this study will supply basic anatomy for applied studies and for comparative anatomy. Fifty cadavers of Callithrix spp were collected on highways from the Atlantic Forest biome, identified and injected with a 10% formaldehyde solution. Later, the specimens were dissected and the measurements and topography of the kidneys and renal vessels were recorded. Both left and right kidneys were significantly larger in females. In the specimens studied, the average body length was 20.00 ± 2.46 cm in males and 20.50 ± 1.98 cm in females (p = .43). The kidneys of the Callithrix spp. were symmetrical in shape and resembled a "bean." They were also pale brown with a smooth surface. In males, the most frequent location of the right kidney was at the L1-L2 level (92%), while the location of the left kidney was between L2 and L3 (76%). In females, the most frequent location of the right kidney was at the L1-L2 level (56%), while the location of the left kidney was between L2 and L3 (32%) (Table1). However, in seven (28%) males and nine (36%) females, the kidneys were at the same level. In both sexes, there was a positive and significant linear correlation between body length and kidney length. Regardless of the variable location of the kidneys in both sides and in either sexe, the right kidney was always located more cranially than the left, similar to observations in other non-human primates.

Uniportal Full-endoscopic Foraminotomy for Lumbar Foraminal Stenosis: Clinical Characteristics and Functional Outcomes.

Uniportal full-endoscopic foraminotomy offers a promising alternative to conventional surgical methods for individuals afflicted by lumbar foraminal stenosis. This study aims to evaluate the efficacy and clinical outcomes of uniportal full-endoscopic foraminotomy in patients diagnosed with lumbar foraminal stenosis. A comprehensive retrospective analysis was conducted on individuals who underwent full-endoscopic foraminotomy in our medical center, between January 2018 and December 2019. The investigation encompassed the demographic data of patients and key clinical metrics such as the visual analogue scale of leg (VAS-L) and back pain (VAS-B), Oswestry disability index (ODI) scores, the Short Form-36 Health Survey physical component summary (SF-36 PCS) and the mental component summary (SF-36 MCS), as well as modified MacNab grades, were systematically assessed and compared. Furthermore, radiological parameters: Coronal Cobb angle (CCA), Intervertebral angle changes (IAC), Disc height index (DHI), the foraminal cross-sectional area (FCSA) and the FCSA enlargement ratio were also compared. A variety of statistical analyses including Student t-test, chi-square tests, Fisher's exact tests, Pearson's and Spearman's correlation analyses, and Interclass Correlation Coefficients (ICCs) were employed. 64 patients, including 34 males and 30 females were enrolled. The mean follow-up period extended to 22.66 ± 7.05 months. Distribution by affected segments revealed 26.6% at L4-5, 67.1% at L5-S1 level, and 6.25% at both L4-L5 and L5-S1 levels. At the final follow-up, VAS-L decreased from 7.26 ± 1.19 to 1.37 ± 1.25, while VAS-B decreased from 6.95 ± 0.54 to 1.62 ± 1.13 (p < 0.001). ODI score also demonstrated a substantial decrease from 74.73 ± 8.68 to 23.27 ± 8.71 (p < 0.001). Both SF-36 PCS and SF-36 MCS scores improved significantly (p < 0.001). Modified MacNab criteria revealed 58 excellent-good patients (90.7%), and 6 fair-poor patients (9.3%). No significant differences were founded in the CCA (p = 0.1065), IAC (p = 0.5544), and DHI (p = 0.1348) between pre-operation and the final follow-up. However, the FCSA significantly increased from 73.41 ± 11.75 to 173.40 ± 18.62 mm2 (p < 0.001), and the enlargement ratio was 142.9% ± 49.58%. Notably, the final follow-up FCSA and the FCSA enlargement ratio were found to be larger in the excellent and good group compared to the fair and poor group, according to the modified MacNab criteria. The utilization of uniportal full-endoscopic foraminotomy has demonstrated its safety and efficacy in addressing lumbar foraminal stenosis. The clinical success of this procedure appears to be closely associated with the radiological decompression of the intervertebral foramen area. Importantly, the application of this technology does not seem to compromise the overall stability of the lumbar region.

Relationship between Lumbar Foraminal Stenosis and Multifidus Muscle Atrophy - A Retrospective Cross-Sectional Study.

Retrospective cross-sectional study. To evaluate the relationship between lumbar foraminal stenosis (LFS) and multifidus muscle atrophy. The multifidus muscle is an important stabilizer of the lumbar spine. In LFS, the compression of the segmental nerve can give rise to radicular symptoms and back pain. LFS can impede function and induce atrophy of the segmentally innervated multifidus muscle. Patients with degenerative lumbar spinal conditions who underwent posterior spinal fusion for degenerative lumbar disease from December 2014 to February 2024 were analyzed. Multifidus fatty infiltration (FI) and functional cross-sectional area (fCSA) were determined at the L4 upper endplate axial level on T2- weighted MRI scans using dedicated software. Severity of LFS was assessed at all lumbar levels and sides using the Lee classification (Grade: 0 - 3). For each level, Pfirrmann and Weishaupt gradings were used to assess intervertebral disc disease (IVDD) and facet joint osteoarthritis (FJOA), respectively. Multivariable linear mixed models were run for the LFS grade of each level and side separately as the independent predictor of multifidus FI and fCSA. Each analysis was adjusted for age, sex, BMI, as well as FJOA and IVDD of the level corresponding to the LFS. A total of 216 patients (50.5% female) with a median age of 61.6 years (IQR=52.0 - 69.0) and a median BMI of 28.1kg/m2 (IQR=24.8 - 33.0) were included. Linear mixed model analysis revealed that higher multifidus FI (Estimate [Confidence interval]=1.7% [0.1 - 3.3], P=0.043) and lower fCSA (-18.6mm2 [-34.3 - -2.6], P=0.022) were both significantly predicted by L2-L3 level LFS severity. The observed positive correlation between upper segment LFS and multifidus muscle atrophy points towards compromised innervation. This necessitates further research to establish the causal relationship and guide prevention efforts.

Preoperative Radiographic Predictors of Subsequent Fusion After Lumbar Decompression Surgery.

Retrospective cohort study. The purpose of this study is to determine which demographic, surgical, and radiographic preoperative characteristics are most associated with the need for subsequent fusion after decompression lumbar spinal surgery. There is a relatively high rate of the need for repeat decompression or fusion after an index decompression procedure for degenerative spine disease. Nevertheless, there is a dearth of literature identifying risk factors for lumbar fusion following decompression surgery. Patients 18 years or older receiving a primary lumbar decompression surgery within the levels of L3-S1 between 2011 and 2020 were identified. All patients had preoperative radiographs and 2 years of follow-up data. Chart review was performed for surgical characteristics and demographics. The sagittal parameters included lumbar lordosis (LL), segmental lordosis (SL), anterior disk height (aDH), posterior disk height (pDH), sacral slope (SS), and pelvic tilt (PT). Pelvic incidence (PI=PT+SS) and pelvic incidence minus lumbar lordosis (PI-LL) were calculated. In addition, the Roussouly classification was determined for each patient. Bivariant and multivariant analyses were performed. Of the 363 patients identified in this study, 96 patients had a fusion after their index decompression surgery. Multivariable analysis identified involvement of L4-L5 level in the decompression [odds ratio (OR)=1.83 (1.09-3.14), P =0.026], increased L5-S1 segmental lordosis [OR=1.08 (1.03-1.13), P =0.001], decreased SS [OR=0.96 (0.93-0.99), P =0.023], and decreased endplate obliquity [OR=0.88 (0.77-0.99), P =0.040] as significant independent predictors of fusion after decompression surgery. This is one of the first studies to assess preoperative sagittal parameters in conjunction with demographic variables to determine predictors of the need for fusion after index decompression. We demonstrated that decompression at L4-L5, greater L5-S1 segmental lordosis, decreased sacral slope, and decreased endplate obliquity were associated with higher rates of fusion after decompression surgery.

Transforaminal Epidural Neuroplasty for Chronic Low Back Pain due to Spinal Canal Stenosis

People all over the world suffer from persistent low back pain, often caused by spinal canal stenosis. In long term cases of spinal canal stenosis, perineural adhesions can form and that further exacerbates the pain. Transforaminal epidural adhesiolysis is beneficial as it breaks down the adhesions and allows more precise delivery of drug to the targeted area. We present a case of 57 years lady with complaint of low back pain for 2 years radiating to left leg and associated with heaviness of left leg after walking for 5 minutes. MRI report and her clinical features were suggestive of canal stenosis at L4 and L5 level. Percutaneous epidural neuroplasty was done using Racz catheter via transforaminal subpedicular approach at L4-L5 level. The numeric pain rating scale before procedure was 7/10 and after procedure decreased to 3/10. Her walking distance also increased to 45 minutes in 1 month after the procedure.

Precision in practice: Exploring the impact of AI and machine learning on ultrasound guided regional anaesthesia.

Ultrasound Guided Regional Anaesthesia (UGRA) is a commonly utilized practice in both elective and emergency situations during surgical procedures and for pain management. Its benefits include, being non-invasive, cost-effective, readily accessible, and providing the anaesthetist with clear visualization of essential anatomical landmarks, needle progression, and the spread of local anaesthetic. Ultrasonography has been shown to increase success rates for regional anaesthesia and decrease complications. One of the critical steps during UGRA is identifying relevant anatomical structures like nerves or vertebras. However, this aspect can be hindered by external influences such as variations in nerve structure and position, interference from noise, and positional instability. Machine learning is a promising branch of artificial intelligence. It is used to conduct predictive tasks without programming instructions by creating algorithms. Extensive research has been conducted to evaluate the influence of machine learning on innovative anaesthesia methods. In 2023, Lopez et al. published a systematic review on how Artificial Intelligence could positively impact traditional anaesthesia practices.1 Various studies included in the review employed different models to achieve variable targets during the induction of anaesthesia. In one experiment, Alkhatib et al. used Convolutional neural network (CNN) based deep trackers to track the median and sciatic nerve with a surprising accuracy of 0.87.2 Another study employed the same CNN model to locate and discriminate accurate images of sacrum, vertebral levels and intervertebral gaps during percutaneous spinal needle insertion.3 Another study used a different AI model called SVM (support vector machine) classification, image processing, and template matching to locate lumbar level L3-L4 and the ideal puncture site for epidural anaesthesia in real-time. In this experiment, anaesthetists with minimal experience in ultrasonography were able to successfully determine needle puncture sites accurately.4 All these studies utilizing AI models not only yielded beneficial results but also led to significant time savings. Considering this, anaesthesiologists nationwide must integrate effective AI models to improve their clinical practice. This would minimize adverse outcomes in regional anaesthesia and ultimately enhance patient care and satisfaction.

Percutaneous Epidural Neuroplasty for Symptomatic Lumbar Juxtafacet Cysts.

Background and Objectives: The term "Juxtafacet cyst" refers to both synovial cysts and ganglion pseudocysts associated with the lumbar facet joint. As conservative treatment for the juxtafacet cyst has a minimal effect, complete excision through surgery is considered the first choice of treatment. In this study, we retrospectively reviewed the clinical outcomes of percutaneous epidural neuroplasty for symptomatic lumbar juxtafacet cysts. Materials and Methods: We conducted a retrospective review of 34 patients with symptomatic juxtafacet cysts who visited a single institute from January 2010 to September 2023. Patients who received conservative treatment for at least 6 weeks but experienced no or insufficient effects were eligible for this study. After neuroplasty, a medical history check and neurological examination were performed during follow-up at 2 weeks, 1 month, 2 months, 3 months, 6 months, and once a year thereafter. Results: The pain improved for all patients to a VAS score of 3 or less immediately after neuroplasty; however, four of those patients (11%) had pain that worsened eventually to the same level as before the procedure and required surgery. The results showed that, regardless of cyst size, in cases with severe stenosis of the spinal canal, the outcome of neuroplasty was poor and often eventually required surgery. The cyst size was not associated with the procedure results. In addition, if the cyst was present at the L4-L5 level, or if diabetes mellitus was present, the likelihood of future surgery was significant (p-value = 0.003). Conclusions: Percutaneous neuroplasty showed a better success rate than other non-surgical treatments. In addition, severe spinal stenosis (Schizas grade C or higher), L4-L5 level, or diabetes mellitus produced a high possibility of surgery due to recurrence.

Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series.

Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery. A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity. Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted. 95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.

First incidence of extrarenal wilms tumor within the spinal canal in the adult population: a novel case report and literature review

BackgroundWilms tumor (WT), also known as nephroblastoma, is rare in adults, accounting for merely 3% of all nephroblastomas or 0.2 cases per million individuals. Extrarenal Wilms tumor (ERWT) emerges outside the renal boundaries and comprises 0.5 to 1% of all WT cases, with even rarer incidences in adults. Oncogenic mutations associated with ectopic nephrogenic rests (NR) may contribute to ERWT development. Diagnosis involves surgical resection and pathology examination. Due to scarce cases, adults often rely on pediatric guidelines. We thoroughly searched PubMed, Scopus, and Web of Science databases to establish our case’s uniqueness. To the best of our knowledge, this is the first documented incidence of extrarenal Wilms tumor within the spinal canal in the adult population.Case presentationA 22-year-old woman with a history of congenital lipo-myelomeningocele surgery as an infant presented with a 6-month history of back pain. This pain gradually resulted in limb weakness, paraparesis, and loss of bladder and bowel control. An MRI showed a 6 × 5 × 3 cm spinal canal mass at the L4-S1 level. Consequently, a laminectomy was performed at the L4-L5 level to remove the intramedullary tumor. Post-surgery histopathology and immunohistochemistry confirmed the tumor as ERWT with favorable histology without any teratomatous component.ConclusionThis report underscores the rarity of extrarenal Wilms tumor (ERWT) in adults, challenging conventional assumptions about its typical age of occurrence. It emphasizes the importance of clinical awareness regarding such uncommon cases. Moreover, the co-occurrence of spinal ERWTs and a history of spinal anomalies warrants further investigation.

The Effect of Gray Ramus Communicans Nerve Block on Radicular Pain in Patients With Lumbosacral Radicular Pain Who Underwent Transforaminal Epidural Block

Lumbosacral radicular pain (LRP) is usually caused by herniation of intervertebral discs and is characterized by pain arising in the back and radiating to the lower extremities. The current study evaluated the efficacy of gray ramus communicans nerve block (GRCNB) in decreasing LRP in patients with intervertebral disc herniation who underwent transforaminal epidural block. Thirty patients with magnetic resonance imaging indicating a disc herniation on the L4-L5 level participated in this study. All patients were randomly divided into two groups: one whose members underwent GRCNB (n=15) after transforaminal epidural block, and a second group (n=15) whose members underwent only transforaminal epidural block on L4-L5 on the affected side. Follow-up after the procedure ran for a period ranging from 6 to 10 months (mean=8.2±2.1 months) for radicular pain score and the need for analgesics. The mean age of the patients was 54.8±18.4 years (range: 30-65 years). LRP duration in all patients before the procedure was 6-24 months (mean: 12±10.9 months), and there was no significant difference between the two groups. A greater reduction in the numerical rating scale (NRS) one week, 1, and 6 months after the procedure was observed in the group with GRCNB compared to the other group. The reduction in need for analgesics one week, 1, and 6 months after the procedure was statistically significant in the group with GRCNB compared to the group without GRCNB. No major complications were observed in any of the patients in either group. GRCNB is effective in reducing radicular pain and the need for analgesics in patients with lumbosacral radicular pain.

Is there a relationship between low back pain and ligamentum flavum hypertrophy?

A condition known as ligamentum flavum (LF) hypertrophy occurs when the ligamentum flavum (LF) swells as a result of pressures applied to the spine. Among the elderly population, lumbar spinal stenosis is a major cause of pain and disabilities. Numerous studies indicate that lumbar spinal stenosis etiology involves the ligamentum flavum in a major way. This study looks into the relationship between low back pain and ligamentum flavum thickening. The imaging tests and case histories of all patients with low back pain who had consecutive magnetic resonance imaging exams performed at the Prince Sattam University and King Khalid hospitals in Al Kharj City will serve as the basis for this retrospective observational study. A radiologist utilized the Pfirrmann grading system, which is based on spinal levels starting from the first lumbar to the first sacral vertebrae, to measure the thickness of the ligamentum flavum in all cases who underwent magnetic resonance imaging (MRI). A correlation between age, hypertrophy of LF, and low back pain was investigated. There were 79 participants in the study, ages ranging from 21 to 82, 49 of which were men. The patients' average age was 54 years, and 62% of them were men. We found no appreciable variations in LF thickness according to gender. At the L4-L5 and L5-S1 levels, the left LF was noticeably thicker than the right. Moreover, there was a significant difference (p < 0.05) in the bilateral LF thicknesses at L5-S1 compared to the comparable sides at L4-L5. By evaluating the thickness of LF on magnetic resonance images, we discovered that it may be closely associated with the etiology of pain processes in the spine.