L5 Nerve Root Research Articles

Small L4 ventral root schwannoma with acute onset of radicular pain: A case report

Background: Patients with cauda equina schwannomas usually present with slowly progressive radiculopathy. Herein, we describe a 34-year-old male who presented with acute radiculopathy attributed to a small L4 ventral root schwannoma.Case Description: A 34-year-old male suddenly developed left leg pain. Magnetic resonance imaging (with/without contrast) revealed a small intradural mass lesion involving the L4 nerve root that was enhanced with contrast (size: 9 × 12 × 12 mm). The computed tomography myelogram revealed that the tumor had originated from the L4 ventral root and compressed the dorsal root in the lateral recess. Following a decompressive laminectomy for tumor removal, the patient’s radicular pain improved. The histological diagnosis was consistent with a schwannoma.Conclusion: Small cauda equina schwannomas involving ventral nerve roots can cause acute radiculopathy readily relieved with decompressive laminectomies for tumor excision.

Drop foot due to lumbar degenerative disease: Painless drop foot is difficult to recover

ObjectiveTo evaluate the improvement of drop foot following lumbar decompression surgery and determine the prognostic factors that might influence the recovery of drop foot. Summary and background dateDrop foot is a common but serious problem that can lead to deteriorate patient’s daily activities. There are numerous studied regarding the prognostic factors for the recovery of drop foot. However a few reports have been described the pathophysiological etiology of not only drop foot but also Trendelenburg’s sign due to the L5 nerve root palsy. Therefore, there is a possibility drop foot caused by peroneal nerve palsy is included. In addition, none have evaluated the presence or absence of radicular leg pain with drop foot patients. The purpose of this study was to evaluate the improvement of paretic leg muscles and determine the prognostic factors that might influence the recovery of drop foot. MethodsFifty-five drop foot patients were included in the study. Prognostic factors were retrospectively studied.Patients were assessed in terms of 10 items: 1) age, 2) sex, 3) diagnosis (LDH or LSS), 4) muscle strength of tibialis anterior, 5) muscle strength of extensor halluces longus, 6) muscle strength of gluteus medius, 7) presence or absence of radicular leg pain, 8) duration before surgery, 9) surgical treatment (spinal fusion or not), 10) anamnesis of diabetes mellitus. ResultsThirty-two (58.2%) of 55 patients recovered from their drop foot (manual muscle test of tibialis anterior ≥ 4 at final follow-up), while 23 (41.8%) did not (manual muscle test of tibialis anterior ≤ 3 at final follow-up). The strength of all muscles that were innervated and controlled by the L5 nerve root had recovered at the final follow-up when evaluated as averages. Multivariate logistic regression analysis revealed significant differences in terms of 2 items: “duration before surgery” and “presence or absence of radicular leg pain”. Conclusions“Duration before surgery” and “presence or absence of radicular leg pain” are important to predict the recovery of drop foot. Painless drop foot patients with lumbar degenerative disease are difficult to recover their paralysis.

Quadriceps weakness due to disc protrusion causing nerve root compression. A case report and literature review

Most common presentation of spinal disc herniation is pain. Next common presentation is pain associated with neurological symptoms [1] . It is relatively unusual to present muscular weakness purely due to disc herniation in the absence of lower back or neuropathic pain and can be a diagnostic challenge. A male patient of 45 presented to his family physician with five days history of weakness in the left quadriceps. There was no pain in the back or leg or any sensory symptoms at this stage. There was no other significant past medical history apart of history of spontaneous disc prolapse when he was 26. (radiating pain to the left leg but no neurological symptoms at that time). Clinical examination revealed motor deficit of 4/5 in the left quadriceps and diminished knee reflex. There was no sensory deficit elicited at this stage. Patient was referred to neurologist (by this time patient had developed sensory deficit at medial lower leg) who arranged nerve conduction studies which revealed L4 radiculopathy. Patient was referred to spinal surgeon who after consultation arranged MRI of the lumbosacral spine which showed disc extrusion at L3-4 level causing root compression of L4 nerve root. Since the patient was active sportsman, it was decided to do discectomy. However, after case discussion in spinal team meeting, (and patient started to feel slight improvement in sensory symptoms after couple of weeks) it was decided to manage conservatively. Patient started physiotherapy for three months and gradually noticed complete resolution of sensory loss after a month and gradual improvement in motor weakness. Patient started light sporting activities after three months of orthopaedic consultation. Patient continued to recover and had complete resolution of motor symptoms within a year. Patient had a follow up MRI after about a year which showed subtle improvement of compression at the same level. Patient was discharged from outpatient follow up. This case illustrates diagnostic dilemma when symptoms are not typical. However, it is proven the ‘common things are common’ again. Conservative management seems to be way forward when neurological symptoms are mild especially in the absence of neuropathic pain, However, it needs to be decided on case-by-case basis

Full-endoscopic decompression for fifth lumbar radiculopathy due to a fragility sacral fracture associated with far-lateral L5/S1 disc herniation: A technical note

The prevalence of fragility sacral fractures has been increasing with the rise in the number of osteoporotic patients and the development of diagnostic imaging. Sacral fracture can cause injury to the fifth lumbar (L5) nerve, although the incidence is low. The therapeutic strategy for sacral fracture with neurological injury has not yet been established, and the surgical strategy for fragility sacral fracture is more controversial. We describe a new therapeutic method using endoscopic surgery for L5 nerve root involvement caused by far-lateral lumbar disc herniation triggered by a fragility sacral fracture. A 55-year-old woman presented with right buttock and right lower limb pain without signs of trauma. Neurological examination revealed paresis of the right lower limb and hypoesthesia in the region innervated by the right L5 nerve root. Neuroimaging demonstrated a U-shaped sacral fracture, including the sacral ala, and right L5 extra-foraminal stenosis. The L5 nerve root was located near the vertical fracture, and compressed by far-lateral L5/S1 disc herniation. Full-endoscopic spine surgery (FESS) was performed to partially remove the right S1 superior articular process and to resect the degenerated disc material. L5 radiculopathy improved partially after the surgery. We suggest that FESS is an effective and safe therapeutic method for fragility sacral fractures associated with far-lateral lumbar disc herniation.

A Rare Case of Calcifying Pseudoneoplasms of the Neural Axis in Lumbar Spine

AbstractCalcified pseudoneoplasm of the neural axis (CAPNON) is a very rare, non-neoplastic, calcified pathological entity occurring anywhere in the central nervous system (CNS). Overall, less than 100 cases were reported, of which less than 50% were from the spine. We present a case of a 53-year-old lady with a history of L4–L5 radiculopathy, known case of rheumatoid arthritis, and with no previous history of trauma, tumor or infection. MRI showed calcified intradural mass, extending into the right lateral recess, which was isointense on T1- and T2-weighted sequences. Fenestration on right side along with complete resection of the lesion was done. Mass was found adherent around the dura, extending in to right L5 nerve root foramen, and histopathological examination confirmed the diagnosis of CAPNON. At 6 months follow-up, the patient is pain-free with no radicular symptoms. This entity should be taken in as differential in cases of calcified intraspinal and intracranial lesions. Surgical resection is the treatment of choice.

Application of Extradural Nerve Root Transfer in the Restoration of Lower Limb Function in Spinal Cord Injury: Hypothesis and a Cadaver Feasibility Study.

Two fresh-frozen and six formalin-fixed cadavers were included in the study. To ascertain whether transferring T9 or T11 ventral root (VR) to L2 VR and T10 or T12 VR to L3 VR in restoring lower limb function after spinal cord injury is anatomically feasible. Lower limb paralysis impairs the quality of the life and places burden on the whole society. However, no significant improvement in this area was achieved during recent years. In the present study, two fresh-frozen and six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. A limited laminectomy was performed to expose the T9-L3 extradural nerve roots. T9 and T10 VR were anastomosed to L2 and L3 VR respectively, or T11 and T12 VR were anastomosed to L2 and L3 VR respectively. The pertinent distances between the donor and recipient nerves were measured and H&E staining was used to detect the axon number and cross-section area of each VR. The limited incision was performed to expose the T9-L3 nerve root. According to the anatomic landmark of dorsal root ganglion, each VR could be isolated from each extradural nerve root. The T9 or T11 VR needs sural nerve graft to be transferred to L2 VR, and T10 or T12 VR also needs a nerve bridge to connect to L3 VR. The nerve numbers of T9, T10, T11, T12, L2, and L3 VRs and the sural nerves were measured respectively. The cross-section areas of T9, T10, T11, T12, L2, and L3 VRs and sural nerves were measured respectively. Our study suggested that application of transferring T9 or T11 VR to L2 VR and T10 or T12 VR to L3 VR in restoring lower limb function is anatomically feasible.Level of Evidence: 5.

Conservative Management of a Foraminal Lumbar Disc Herniation

A 39-year-old college professor presented to physical therapy via direct access, with a 2-month history of progressive lower back and right buttock pain. Following examination, the patient self-referred to a physiatrist, who ordered magnetic resonance imaging of the lumbar spine. Magnetic resonance imaging revealed a moderate, broad-based right foraminal disc herniation at L5-S1 encroaching on the right L5 nerve root exit. JOSPT Cases 2021;1(1):49–50. doi:10.2519/josptcases.2021.9776

Parasitosis of the vertebral canal mimicking lumbar intervertebral disc herniation: a case report

Study designCase report.BackgroundIt is a case of dracunculiasis of the spine mimicking lumbar intervertebral disc herniation.Case presentationA 57 year-old Caucasian male was admitted to the hospital because of the left L5 radiculopathy lasting for 2 months. The pain in the left lower limb was associated with muscle weakness on dorsal flexion of the foot, paresthesia of the dorsal aspect of the foot and tingling in the big toe. Neurological examination revealed: muscle weakness on dorsal flexion of the foot, impaired light touch and pin prick test on the dorsal aspect of the foot and positive Lasègue’s sign. Magnetic resonance imaging (MRI) examination revealed L4-L5 intervertebral disc herniation with sequester compressing the left L5 nerve root. The open L4-L5 left side discectomy was performed. During the sequester evacuation 3 pieces of nematodes were removed and preserved in 10% of formaldehyde solution. After the surgery the patient was pain free with normal neurological examination. The diagnosis of dracunculiasis was based on the morphology of the nematode and on exclusion of the other parasites. DM infestation could not be confirmed with molecular testing that was impaired by the formaldehyde.ConclusionsParasite infestation should be considered even in cases with obvious MRI of lumbar intervertebral disc herniation. If a nematode was found accidentally during any surgery it should be preserved in a 0.9% saline, not in formaldehyde, not to disturb the molecular tests.

Iatrogenic L5 Nerve Injury Following Decortication of the Sacral Ala in Posterolateral Lumbosacral Fusion Surgery.

Study Design:Cadaver study.Objectives:To investigate the risk of the L5 nerve injury following sacral ala decortication performed during lumbosacral posterolateral fusion surgery.Methods:Fourteen fresh cadaver pelvises were dissected through an anterior approach and the L5 nerves on both sides were explored and macroscopically examined by direct observation. Then, the corticotomy of the sacral ala was performed at 0°, 20°, and 30° angles to the sagittal plane through the posterior approach. The site of sacral ala decortication was checked on each side and its distance to the L5 nerve root was measured.Results:The tip of the osteotome was in the danger zone (5 mm medial to 5 mm lateral to the L5 nerve) in all cases (100%) where the osteotome had 0° angle to the sagittal plane. For those with a 20° angle, the osteotome tip laid in the danger zone in 83% and intermediate zone (between 6 to 15 mm lateral to the nerve) in 17% of cases. For those with a 30° angle, the tip was in the safe zone (>15 mm lateral to the nerve) in all cases (100%).Conclusion:Osteotomy of the sacral ala with <30° angle to the sagittal plane risks injury to the L5 nerve; whereas osteotomy angle >30° would not cause any injury to the nerve. It should be considered as a possible cause of iatrogenic L5 nerve injury in patients undergoing posterolateral lumbosacral fusion.

NCMP-12. RAPIDLY PROGRESSIVE NEUROPATHIES AS THE SOLE PRESENTATION OF NEUROLYMPHOMATOSIS

Abstract Neurolymphomatosis (NL) is a rare and challenging entity characterized by hematological neoplastic infiltration of the peripheral nervous system. Only 40% of the cases have malignant cells on CSF sampling. We present a 52-year-old Caucasian male with primary refractory diffuse large B-cell lymphoma (DLBCL) who relapsed within 3 months of achieving complete remission to R-CHOP. First, he experienced right tongue numbness and lumbar pain. Initial MRI of the face, brain and entire spine, and CSF analysis were unremarkable. Three weeks later, he noticed left facial numbness, dysphonia, and left leg weakness. Neuraxis MRI revealed enhancement of left CN V3 and several cervical, thoracic, and lumbar nerve roots. PET/CT showed increased uptake at L4 nerve root. EMG/NGS showed left L5 denervation. After one week, he further developed new right CN VI palsy, left-sided ptosis, anisocoria, and right arm weakness. Repeat MRI showed worsening enhancement and thickening of multiple cranial nerves, cervical and lumbosacral plexus. Extensive testing for infectious, inflammatory, and paraneoplastic processes was negative. Patient underwent plasmapheresis with no response. Biopsy of nerve root was deferred due to potential permanent deficits that would impair his quality of life. Repeat CSF testing was negative for malignancy and PET/CT showed SUV of 23.8 at L4-5 with multiple new hypermetabolic foci in muscle and ribs. He received R-HD-methotrexate with clinical and radiographic (PET/CT) improvement following 2 cycles. He completed 4 cycles of R-HD methotrexate-based chemotherapy followed by autologous hematopoietic stem cell transplantation. Most of his symptoms resolved and he remained stable for about a year when PET/CT showed disease progression. He subsequently received CAR-T cell therapy with adequate tolerance and remains clinically stable. Even with negative initial imaging and CSF studies, a careful exam and attention to uncommon presentations along with serial advanced imaging (MRI, PET/CT) surveillance are key to early detection and timely treatment.

Lumbar Facet Joint Cyst Caused by Calcium Pyrophosphate Arthropathy of the Spine: Case Report and Review of Literature

Background Data: Calcium pyrophosphate dihydrate (CPPD) deposition disease is a metabolic disorder caused by the deposition of CPPD crystals in the articular or periarticular structures that leads to inflammation of the joints. Spine affection is rare. Purpose: To present a rare case of lumbar facet joint cyst caused by calcium pyrophosphate arthropathy. Study Design: A case report with a brief review of the literature. Patient and Methods: Seventy-three-year-old man, who underwent PLIF L5/S1 ten years ago, presented with right L4 nerve root compression symptoms that have started two months ago. Clinical examination revealed no motor function disturbance but hypoesthesia in the L4 dermatome. He has no history of crystal deposition disorder. The patient underwent decompression and fusion at this level. Results: The symptoms were completely resolved postoperatively and after one-year follow-up. Histopathological examination of the cyst revealed fibrous granulation tissue. Examination of the tissue under polarized light showed positively birefringent, short blunt crystals of calcium pyrophosphate dihydrate. Conclusion: Calcium pyrophosphate arthropathy, although rare, should be incorporated into the differential diagnosis of cystic lesions of the facet joints. (2020ESJ221)

Rare variation of the furcal nerve

Variations in the course of the lumbar plexus and lumbosacral trunk have been explored with respect to variant nerve roots being indicated in atypical sciatic pain. Typically, the furcal nerve emerges from the L4 nerve root, with a single contribution. However, we report a case where the furcal nerve was found to arise not only from the L4 nerve but also from the obturator nerve. This anatomical variation is explored in terms of its clinical significance and implications in lumbar and sacral plexus associated procedures.

Does the L5 spinal nerve move? Anatomical evaluation with implications for postoperative L5 nerve palsy.

While palsy of the L5 nerve root due to stretch injury is a known complication in complex lumbosacral spine surgery, the underlying pathophysiology remains unclear. The goal of this cadaveric study was to quantify movement of the L5 nerve root during flexion/extension of the hip and lower lumbar spine. Five fresh-frozen human cadavers were dissected on both sides to expose the lumbar vertebral bodies and the L5 nerve roots. Movement of the L5 nerve root was tested during flexion and extension of the hip and lower lumbar spine. Four steps were undertaken to characterize these movements: (1) removal of the bilateral psoas muscles, (2) removal of the lumbar vertebral bodies including the transforaminal ligaments from L3 to L5, (3) opening and removing the dura mater laterally to visualize the rootlets, and (4) removal of remaining soft tissue surrounding the L5 nerve root. Two metal bars were inserted into the sacral body at the level of S1 as fixed landmarks. The tips of these bars were connected to make a line for the ruler that was used to measure movement of the L5 nerve roots. Movement was regarded as measurable when there was an L5 nerve excursion of at least 1mm. The mean age at death was 86.6years (range 68-89years). None of the four steps revealed any measurable movement after flexion/extension of the hip and lower lumbar spine on either side (< 1mm). Flexion of the hip and lower lumbar spine revealed lax L5 nerve roots. Extension of the hip and lower lumbar spine showed taut ones. Significant movement or displacement of the L5 nerve root could not be quantified in this study. No mechanical cause for L5 nerve palsy could be identified so the etiology of the condition remains unclear.

A rare lumbar pyogenic spondylodiscitis caused by staphylococcus caprae with initial misdiagnosis: case report and literature review

BackgroundStaphylococcus caprae (Sc) is an uncommon causative organism for human. Lumbar pyogenic spondylodiscitis (LPS) of Sc is extremely rare and only a few cases have been reported. As far as we know, there is no specific literature on the diagnosis and treatment for LPS of Sc with L5 nerve root irritation.Case presentationA 65-year-old male patient complained of chronic low back pain for 10 years, acute worsening with radiating pain to left lower extremity over a month. Physical examination revealed tenderness point on his low back, 3/5 dorsiflexor strength in his left 1st toe and decreased sensation of pin prick over the left lateral shank and medial dorsal foot. The individual was initially misdiagnosed with lumbar disc herniation (LDH) without further examination in outpatient, which was then found to be LPS of Sc with L5 nerve root irritation after admission to our hospital. Magnetic resonance images (MRI) of lumbar spine exhibited inflammation signal at L4-L5 level of the vertebral body and disc with hypointense on T1-weighted images (T1-WI) and hyperintense on T2-weighted images (T2-WI). The causative organism was confirmed by the culture of irrigation fluid obtained from L5 vertebrae by needle puncture. After systemic conservative treatment including using sensitive antimicrobial agents and immobilization, the rare infection was finally cured. The patient also showed a satisfactory recovery during the 36-month follow-up period.ConclusionsConfirming the diagnosis and identifying the causative organism as soon as possible is the key point for the treatment of LPS. LPS of Sc causing nerve root irritation is rare but curable with early diagnosis and proper therapy. The culture of irrigation fluid obtained from vertebrae by needle puncture may be an effective and sensitive attempt for potential infection of spine to identify the causative organism at early stage of the disease.

Chondrosarcoma pelvis, beyond the boundaries.

Objectives: The objective of our study to find the outcome of extensive chondrosarcoma pelvis after surgery. Study Design: Case Series study. Setting: Department of Orthopaedic Surgery Dow University of Health Sciences / Civil Hospital Karachi. Period: From April 2014 to December 2018. Material &amp; Methods: Seven patients with Chondrosarcoma pelvis included in this study. Results: All Seven patients were male. 2 patient age was in 20’s, three in 40’s and two in 60’s with median age of 44. Clinically presentation of patients was variable. One patient present with groin lump, one with pain and swelling lower abdomen, three with hip pain, one patient with severe gluteal pain and lump, one with massive lump extending from the mid abdomen to groin and urine retention and constipation. Five patients have left pelvis involved and two have right side. Two patients have pubic bone and ischium (Level III) involved, two have ilium (Level I) and three have ilium, acetabulum and pubis (Level I, II, III). Two patients with have preoperatively sciatic nerve palsy. Two patients have medical comorbid. One was asthmatic and one had psychiatric illness. No patient had metastasis at presentation. Pubis and ischium with tumor resected in two cases, partial ilium resection in one case, one complete P1 resection with sciatic nerve, one patient have internal hemipelvectomy and one patient had internal hemipelvectomy that bone recycled in liquid nitrogen and pelvis re-implanted and fixed with recon plates and hip joint reconstructed with total hip replacement. One patient had external hemipelvectomy due to pus at tumor site. Total duration of surgery in patient having thirteen hours, and remaining have 3 to 5 hours. Blood loss during these surgeries was in between 1000 to 1200 ml. Three patients have wound infection, one patient had L5 nerve root injury. Patient with external hemipelvectomy develop wound dehiscence and uro-cutaneous fistula. Two patients died, one with recycled bone after 15 months due cardiac problem and 2nd due to disease related complications within 3 months of surgery. Conclusion: Pelvic chondrosarcoma must be operated by the team of surgeons including orthopaedic surgeon, urologist and general surgeon because of the tumor presents with massive lumps due to unrestricted compartment and can involve the important pelvic organ. With team any complication can be prevented and treated immediately.

New-Onset Radiculopathy on Unaffected Side Post Spine Surgery-S1 Screw Irritating L5 Nerve Root: A Case Report

Acute onset of neuropathic pain after lumbosacral fusion spine surgery can be due to multiple causes including a laterally directed bicortical S1 pedicle screw. We here are reporting a case where a laterally directed S1 pedicle screw irritating the L5 nerve root and producing a postoperative acute onset radicular pain on an unaffected side. After the failure of 1-month conservative treatment, the patient was operated and s1 screw was revised. While placing bicortical sacral screw, surgeons should stick to safe window described on cadaveric studies and MRI is a non-invasive and reliable method to identify and nerve root irritation by bicortical sacral screws.

Magnetic resonance neurography of the lumbosacral plexus at 3 Tesla – CSF-suppressed imaging with submillimeter resolution by a three-dimensional turbo spin echo sequence

PurposeTo investigate magnetic resonance neurography (MRN) of the lumbosacral plexus (LSP) with cerebrospinal fluid (CSF) suppression by using submillimeter resolution for three-dimensional (3D) turbo spin echo (TSE) imaging. Materials and methodsUsing extended phase graph (EPG) analysis, the signal response of CSF was simulated considering dephasing from coherent motion for frequency-encoding voxel sizes ranging from 0.3 to 1.3 mm and for CSF velocities ranging from 0 to 4 cm/s. In-vivo MRN included 3D TSE data with frequency encoding parallel to the feet/head axis from 15 healthy adults (mean age: 28.5 ± 3.8 years, 5 females; acquisition voxel size: 2 × 2 × 2 mm3) and 16 pediatric patients (mean age: 6.7 ± 4.1 years, 7 females; acquisition voxel size: 0.7 × 0.7 × 1.4 mm3) acquired at 3 Tesla. Five of the adults were scanned repetitively with changing acquisition voxel sizes (1 × 2 × 2 mm3, 0.7 × 2× 2 mm3, and 0.5 × 2 × 2 mm3). Measurements of the bilateral ganglion of the L5 nerve root, averaged between sides, as well as the CSF in the thecal sac were obtained for all included subjects and compared between adults and pediatric patients and between voxel sizes, using a CSF-to-nerve signal ratio (CSFNR). ResultsAccording to simulations, the CSF signal is reduced along the echo train for moving spins. Specifically, it can be reduced by over 90% compared to the maximum simulated signal for flow velocities above 2 cm/s, and could be most effectively suppressed by considering a frequency-encoding voxel size of 0.8 mm or less. For in-vivo measurements, mean CSFNR was 1.52 ± 0.22 for adults and 0.10 ± 0.03 for pediatric patients (p < .0001). Differences in CSFNR were significant between measurements using a voxel size of 2 × 2 × 2 mm3 and measurements in data with reduced voxel sizes (p ≤ .0012), with submillimeter resolution (particularly 0.5 × 2 × 2 mm3) providing highest CSF suppression. ConclusionsApplying frequency-encoding voxel sizes in submillimeter range for 3D TSE imaging with frequency encoding parallel to the feet/head axis may considerably improve MRN of LSP pathology in adults in the future because of favorable CSF suppression.

High grade isthmic spondylolisthesis – A case series illustrating three different operative instrumented fusion techniques

Adult isthmic spondylolisthesis most commonly occurs at the L5-S1 level. In adults a high-grade slip degree is rare comprising less than 1% of cases. Progressive axial lumbar backache characterizes the early stage of the disease which over time commonly complicates with the development of a super-imposed L5 radiculopathy. These are difficult cases to manage and the attending spinal surgeon must have an understanding of several different surgical options. These options include conservative treatment in those who are mildly symptomatic, decompression alone with its inherent tendency to facilitate further slip, decompression and fusion without instrumentation, decompression and fusion with instrumentation, and if so the extent of the construct both cranially and caudally. Another important consideration is whether, or not, reduction is necessary or whether fusion in situ will suffice. Regarding the surgical approach some surgeons regard an anterior approach, to perform an anterior release, as necessary if reduction is to be achieved. Others consider nerve root decompression and posterior spinal fusion in situ as the technique of choice. Others advocate a combined anterior and posterior surgical approach.We report a case series of three adult female patients with high grade isthmic spondylolisthesis complicated by L5 nerve root compression. Each patient was successfully managed with a different instrumented fusion technique. Our case series serves to highlight several of the specific surgical nuances pertaining to the management of high-grade isthmic spondylolisthesis and as such is valuable to the attending spinal surgeon who may infrequently encounter patient with the high-grade form of this disease.

Biportal Endoscopic Excision of Facetal Cyst in the Far Lateral Region of L5S1: 2-Dimensional Operative Video

Unilateral biportal endoscopy (UBE) is a recently introduced technique that utilizes 2 portals, one for endoscopy and one as a working portal, in contrast to full endoscopy, which utilizes a single portal. The advantages are a favorable learning curve and free mobility of instruments in the operative field. UBE is successful in addressing cervical and lumbar disc herniations, lumbar stenosis, and foraminal/extraforaminal pathologies, such as herniations and foraminal stenosis. However, there is no report of UBE for a far-lateral L5S1 facet cyst. The patient was an 85-yr-old female with a left lower limb radicular pain with magnetic resonance imaging evidence of the facet cyst compressing the L5 nerve root. Conventional treatment of such a condition would either be an L5S1 fusion procedure or a standalone decompression via the Wiltse paramedian approach. Because the patient had no instability, we decided to do a standalone decompression using the UBE technique. The UBE technique has the advantages of any minimal access procedure, including small incisions, minimal tissue dissection, good magnification, and preservation of anatomic structures. A written informed consent was obtained from the patient before the procedure. The procedure was done under general anesthesia using a 30° endoscope, a radiofrequency probe, and standard lumbar spine surgery instruments. The initial landing point of the endoscope and instruments is via triangulation at the lateral border of the isthmus of L5. The postoperative clinical and radiological outcomes were satisfactory (VAS Back and Leg, 0; Oswestry disability index, 15 at 3 mo).

Stereotactic Dorsolateral Irradiation of Spinal Nerve Roots: A Novel Technique for the Treatment of Spasticity and Pain

Selective dorsal rhizotomy is an established surgical treatment to improve the neurological and functional status of children with spastic cerebral palsy and adults with spasticity and pain caused by a variety of brain and spinal injuries. This procedure requires a dorsolumbar laminectomy to expose the appropriate dorsal rootlets, which are sectioned according to the presence of sustained electromiographic discharges.Image-guided robotic radiosurgery targeting the intracisternal sensory root of the trigeminal nerve has been described as a safe and effective non-invasive treatment for trigeminal neuralgia, a paroxystic pain disorder which often responds poorly to medical therapy. Image-guided radiosurgery requires no frame placement and can treat brain or spinal targets with submillimetric precision. This technique can be used to treat cervical or lumbar dorsal roots.A 44-year-old patient with von Hippel-Lindau disease developed severe spastic tetraparesis following multiple brain and spinal procedures. Spasticity and related pain mostly affected the right leg, with sustained electromiographic discharges originating from the right L4 nerve root. Response to medical therapy with baclofen and cannabinoids was poor. Due to geographical and logistical issues, the patient declined the placement of an intrathecal baclofen pump.Considering the poor general condition of the patient and his decision to avoid invasive procedures, a novel treatment option was offered to provide relief from spasticity and pain: stereotactic image-guided irradiation delivered to the sensory root. The patient underwent a right intraforaminal dorsolateral L4 root stereotactic irradiation with a delivered dose of 45 Gy prescribed to the 82% isodose.The treatment was well tolerated, without side effects. Resolution of spasticity and related pain in the right leg was found six months after the procedure. A marked reduction of spasticity and pain was also evident in the contralateral leg. These improvements have been stable over the last 18 months.So far, two additional patients underwent stereotactic dorsolateral spinal root irradiation (one delivered to a cervical, the other to a lumbar), with similar positive outcomes. These preliminary results suggest that spinal root stereotactic image-guided irradiation, a novel treatment option in the neurosurgical armamentarium, is a safe and effective procedure and deserves further investigation.