L5 Root Research Articles

A conservative management approach for spinal tuberculosis causing cauda equine syndrome in pregnancy

Background: Spinal tuberculosis in pregnancy leading to neurological sequelae is rare and a challenging condition to manage. The usual approach is to perform urgent decompression surgery, but patients with a more stable course of the disease may benefit from a conservative approach with anti-tuberculosis (ATT) therapy.Case presentation: A pregnant mother in her second trimester presented with a history of chronic backache exacerbated by right-sided foot drop, L5 root sensory loss and intermittent urinary retention. MRI revealed L5 vertebral collapse with para-vertebral collection causing cauda equine compression at the L5-S1 level. High ESR, strongly positive tuberculin test, and the clinical and radiological findings were compatible with a diagnosis of spinal tuberculosis. Based on the multi-disciplinary team’s decision, a conservative management approach with ATT and supportive therapy was initiated with close observation. The patient showed a remarkable response to ATT with clinical and radiological improvement. She underwent an elective caesarean section at 37 weeks and delivered a healthy baby. On the fourth week postpartum, she underwent decompressive surgery with complete neurological recovery,Discussion and conclusion: Spinal TB in pregnancy causing neurological impairment is usually managed with urgent surgical interventions. This is one of the few reported cases where a conservative approach was undertaken, with close observation and a positive outcome.Therefore, it is important to carefully select patients needing surgical interventions and those who would benefit better from a conservative approach. High suspicion, early diagnosis, prompt treatment initiation and close monitoring are vital components in achieving the best outcome.

Placement of ilio-sacral screws in fusionless technique for pediatric neuromuscular scoliosis utilizing planning software, in conjunction with intraoperative navigation, results in a safer optimal screw: a CT-based study.

The insertion of ilio-sacral (IS) screws for distal anchoring in the instrumentation of pediatric neuromuscular scoliosis (NS) presents a significant challenge, often leading to elevated rates of complications. Utilizing computed tomography (CT) navigation and preoperative planning technology is proposed as a potential solution to mitigate these challenges. This study aims to assess the precision of IS screw placement through CT-graphic measurements, both with and without preoperative planning, followed by navigated IS screw insertion, in pediatric neuromuscular scoliosis. Thirty-two treated patients were grouped based on surgical procedure: planned (P): 19 patients (n=38 screws) and non-planned (NP): 13 patients (n=26 screws). All screw placements (P and NP) took place under CT navigation. IS screw trajectories of P-group were drawn preoperatively on CT images with the cranial trajectory planning program and fused with the intraoperative CT images. There are several important anatomical structures that should be avoided when placing the IS screw (L5 root, spinal canal, L5S1 facet, SI joint, neurovascular structures anteriorly to the sacrum, S1 root in the S1 foramen and the intestines). Each trajectory was evaluated based on seven radiographical parameters whom we have enlisted partially based on the essentials of a good trajectory described by Miladi et al. (1: Ilium; 2: SI joint; 3: Promontorium; 4: Sacral plate; 5: Anterior sacral cortex; 6: S1 foramen; 7: Spinal canal). An independent sample T test was executed to compare both groups. The trajectories in the P group showed a significantly (P<0.05) higher overall similarity and optimality (12.1±2.1 vs 9.1±2.2 points) compared to the non-planned trajectory. Preoperative planning and navigated placement of IS screws on fusion images with intraoperative CT, results in a better trajectory of the ilio-sacral screws.

Surgical Options for Bertolotti Syndrome

This article provides a comprehensive examination of Bertolotti syndrome (BS), a disorder characterized by back pain due to a lumbosacral transitional vertebra, to facilitate surgical decision-making by exploring various surgical options, including the innovative approach of endoscopic spine surgery. A review of existing literature and studies on BS published until December 2023 was undertaken, utilizing databases such as PubMed and Google Scholar to identify relevant information. The review offers an integrated overview of the essential knowledge of BS and a comprehensive range of surgical treatments. Symptomatic BS can manifest as pain originating from pseudoarticulation and the facet joints, discs, adjacent segments, and the L5 root, indicating a diverse distribution of pain sources. Furthermore, various surgical strategies are tailored to the specific origin of pain, including pseudoarticulation resection, transverse processectomy, decompression, nerve root decompression, fusion, and endoscopic spine surgery. For individuals with BS contemplating surgical solutions, performing a detailed assessment of symptoms and physical evaluations is imperative to accurately identify the origin of the pain. The choice of a surgical strategy must be meticulously customized according to the identified source of pain, guaranteeing a tailored and efficacious treatment for each patient.

Lumbar clear cell meningioma mimicking schwannoma 7 years after resection of the same type of intracranial tumor: a case report

BackgroundMeningioma is the second most common intradural extramedullary tumor, following schwannoma. Meningioma is primarily categorized as benign World Health Organization grade 1, but clear cell meningioma is grade 2 of the intermediate malignant category. Clear cell meningiomas are rare, accounting for less than 1% of all meningioma tumors. There is no previous report of multiple intraspinal clear cell meningiomas without dural attachment.Case presentationA 27-year-old Asian male patient presented with lower right extremity pain, and had undergone tumor resection for intracranial clear cell meningioma 7 years previously, with re-resection and radiotherapy for local tumor recurrence at our hospital’s department of neurosurgery being carried out 4 years previously. No recurrence was observed since then. Preoperative lumbar magnetic resonance imaging showed two tumors at the L1 and L4 levels, both mimicking schwannoma with well-defined margins, no dural tail sign and homogeneous internal contrast. Intraoperative findings on tumor resection showed two tumors contiguous with the right L2 and L5 roots, which were not attached to the dura mater, similar to a schwannoma. After gross total resection, the postoperative pathology revealed no nuclear SMARCE1 antibody staining. The patient was diagnosed with clear cell meningioma. The patient’s postoperative course went well, with no symptoms of nerve dropout and no recurrence 2 years after surgery. In this case, both lumbar lesions were well demarcated and spherical in shape, occurring with single roots. Tumor characteristics suggested a primary rather than a metastatic lesion. Clear cell meningioma is characterized by a SMARCE1 mutation and is different from other types of meningiomas.ConclusionTo the best of our knowledge, this is the first report of multiple intraspinal clear cell meningiomas without dural attachment at the lumbar spine after resection of intracranial clear cell meningioma. We speculate that the two tumors were de novo lesions on the basis of the features of the tumors, although they were detected 7 years after the resection of intracranial clear cell meningioma.

Feasibility of Saphenous Nerve Somatosensory-Evoked Potential Intraoperative Monitoring during Lumbar Spine Surgery: Early Results.

Retrospective review. Assess the feasibility of saphenous nerve somatosensory evoked potentials (SN-SSEP) monitoring in lumbar spine surgeries. SN-SSEPs have been proposed for detecting lumbar plexus and femoral nerve injury during lateral lumbar surgery where tibial nerve (TN)SSEPs alone are insufficient. SN-SSEPs may also be useful in other types of lumbar surgery, as stimulation of SN below the knee derives solely from the L4 root and provides a means of L4 monitoring, whereas TN-SSEPs often do not detect single nerve root injury. The feasibility of routine SN-SSEP monitoring has not been established. A total of 563 consecutive cases using both TN and SN-SSEP monitoring were included. Anesthesia was at the discretion of the anesthesiologist, using an inhalant in 97.7% of procedures. SN stimulation was performed using 13mm needle electrodes placed below the knee using 200-400μsec pulses at 15-100mA. Adjustments to stimulation parameters were made by the neurophysiology technician while obtaining baselines. Data were graded retrospectively for monitorability and cortical response amplitudes were measured by two independent reviewers. 98% of TN-SSEPs and 92.5% of SN-SSEPs were monitorable at baseline, with a mean response amplitude of 1.35μV for TN-SSEPs and 0.71μV for SN-SSEPs. A significant difference between the stimulation parameters used to obtain reproducible TN and SN-SSEPs at baseline was observed, with SN-SSEPs requiring greater stimulation intensities. Body mass index (BMI) is not associated with baseline monitorability. Out of 20 signal changes observed, 11 involved SN while TN-SSEPs were unaffected. With adjustments to stimulation parameters, SN-SSEP monitoring is feasible within a large clinical cohort without modifications to the anesthetic plan. Incorporating SN into standard intraoperative neurophysiological monitoring (IONM) protocols for lumbar spine procedures may expand the role of SSEP monitoring to include detecting injury to the lumbar plexus. 3.

The Fate of Pre-Existing L5-S1 Degeneration following Oblique Lumbar Interbody Fusion of L4-L5 and Above

Background: Previous studies have identified various risk factors for adjacent segment disease (ASD) at the L5-S1 level after fusion surgery, including preoperative sagittal imbalance, longer fusion, and preoperative disc degeneration. However, only a few studies have explored the risk factors for ASD at the L5-S1 level after oblique lumbar interbody fusion (OLIF) at the L4-L5 level and above. This study aimed to identify the risk factors for symptomatic ASD at the L5-S1 level in patients with pre-existing degeneration after OLIF at L4-L5 and above. Methods: We retrospectively reviewed the data of patients who underwent OLIF at L4-L5 and above, with a minimum follow-up period of 2 years. Patients with central stenosis or Lee grade 2 or 3 foraminal stenosis at L5-S1 preoperatively were excluded. Patients were divided into ASD and non-ASD groups based on the occurrence of new-onset L5 or S1 radicular pain requiring epidural steroid injection (ESI). The clinical and radiological factors were analyzed. Logistic regression was used to identify the risk factors for ASD of L5-S1. Results: A total of 191 patients with a mean age ± standard deviation of 68.6 ± 8.3 years were included. Thirty-four (21.7%) patients underwent ESI at the L5 root after OLIF. In the logistic regression analyses, severe disc degeneration (OR (95% confidence interval (CI)): 2.65 (1.16–6.09)), the presence of facet effusion (OR (95% CI): 2.55 (1.05–6.23)), and severe paraspinal muscle fatty degeneration (OR (95% CI): 4.47 (1.53–13.05)) were significant risk factors for ASD in L5-S1. Conclusions: In this study, the presence of facet effusion, severe disc degeneration, and severe paraspinal muscle fatty degeneration at the L5-S1 level were associated with the development of ASD at L5-S1 following OLIF at L4-L5 and above. For patients with these conditions, surgeons could consider including L5-S1 in the fusion when considering OLIF at the L4-L5 level and above.

THU343 Potential Association Among Enteroviruses, Acute Flaccid Myelitis And Type 1 Diabetes

Abstract Disclosure: T.A. Nguyen: None. K. Huynh: None. M. Azad: None. J.P. Perdomo Rodriguez: None. Non-polio enteroviruses, like EV-D68, caused a nationwide outbreak of respiratory illness in the US in 2014, most recently in the fall of 2021. It has been shown that EV-D68 plays a role in causing acute flaccid myelitis (AFM). In addition, the association between enterovirus infections and type 1 diabetes (T1DM) has been widely studied and established. We report a case in which a 19-year-old male consulted for progressively ascending bilateral weakness in the lower extremities. Four weeks prior, he was diagnosed with T1DM and diabetic ketoacidosis (DKA). On exam, he had decreased sensation to light touch, vibration, and temperature below the knees, decreased motor strength 2/5 in bilateral lower extremities, and absence of patellar and Achille reflexes. Thyroid tests, Creatinine Kinase, Aldolase, and vitamin B12 were all normal. Spine MRI showed an enhancement along the L5 and sacral roots. CSF studies were significant for the positive oligoclonal band, the elevated protein level (87gm/dL), and no white blood cell count. CSF gram stain was negative for any organisms. EBV, HSV, and HIV testing were negative. A nonspecific respiratory panel only performed at the time of diagnosis with AFM was negative. The electromyogram did not show any type of acute inflammatory demyelinating polyneuropathy or evidence of myopathy. CT abdomen/pelvis demonstrated mild splenomegaly with small swollen lymph nodes of the periaortic and mesenteric area, which are commonly seen in viral infections. A Digital Subtraction Angiography study did not show any abnormality in spinal vessels. The patient received immunoglobulin and steroid, which was stopped early due to bradycardia and hyperglycemia. Neurology diagnosed the patient with AFM secondary to viral infection, in which the patient may have been infected prior to his diagnosis of DKA. The patient’s weakness resolved, and he was discharged with basal-bolus insulin and is to follow up with neurology and endocrinology outpatient. Enterovirus infection has been associated with T1DM and AFM. While the Respiratory PCR Panel was negative, it was only obtained several weeks after the onset of symptoms. Pathogenesis of extra-respiratory complications of enteroviruses may associate with viremia and systemic dissemination of the virus, which may not be detected by a respiratory PCR panel. Infection by an enterovirus remains the most likely etiology for both immune-mediated disorders, especially during a nationwide outbreak. We recommend providers consider enterovirus infection as a potential cause of AFM, and autoimmune diabetes in order to perform a throughout workup. In a patient with hyperglycemia and flaccid paralysis, T1DM should be suspected. Presentation: Thursday, June 15, 2023

Distinctive Characteristics of Thoracolumbar Junction Region Stenosis.

Retrospective case series and systemic literature meta-analysis. Thoracolumbar junction region stenosis produces spinal cord compression just above the conus and may manifest with symptoms that are not typical of either thoracic myelopathy or neurogenic claudication from lumbar stenosis. As few studies describe its specific pattern of presenting symptoms and neurological deficits, this investigation was designed to improve understanding of this pathology. A retrospective review assessed surgically treated cases of T10-L1 degenerative stenosis. Clinical outcomes were evaluated with the thoracic Japanese Orthopedic Association score. In addition, a systematic review and meta-analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Of 1069 patients undergoing laminectomy at 1477 levels, 31 patients (16M/15F) were treated at T10-L1 a mean age 64.4 (SD=11.8). Patients complained of lower extremity numbness in 29/31 (94%), urinary dysfunction 11/31 (35%), and back pain 11/31 (35%). All complained about gait difficulty and objective motor deficits were detected in 24 of 31 (77%). Weakness was most often seen in foot dorsiflexion 22/31 (71%). Deep tendon reflexes were increased in 10 (32%), decreased in 11 (35%), and normal 10 (32%); the Babinski sign was present 8/31 (26%). Mean thoracic Japanese Orthopedic Association scores improved from 6.4 (SD=1.8) to 8.4 (SD=1.8) ( P <0.00001). Gait subjectively improved in 27/31 (87%) numbness improved in 26/30 (87%); but urinary function improved in only 4/11 (45%). Thoracolumbar junction stenosis produces distinctive neurological findings characterized by lower extremity numbness, weakness particularly in foot dorsiflexion, urinary dysfunction, and inconsistent reflex changes, a neurological pattern stemming from epiconus level compression and the myelomeres for the L5 roots. Surgery results in significant clinical improvement, with numbness and gait improving more than urinary dysfunction. Many patients with thoracolumbar junction stenosis are initially misdiagnosed as being symptomatic from lumbar stenosis, thus delaying definitive surgery.

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.

Treatment of L1 neuralgia following traumatic spineinjury and vertebroplasty successfully treated by pulsedradiofrequency of the dorsal root ganglion case report

This article describes the use of L1 pulsed radiofrequency of the dorsal root ganglion (DRG-PRF) in a 42-year oldwoman with neuropathic pain of L1 root as a complication following L1 vertebroplasty (car accident). Immediatelyafter vertebroplasty, the patient started to feel L1 neuropathic pain. Despite using therapeutic drugs in doses appliedin the treatment of neuropathic pain, pain control was not achieved NRS (numerical rating scale) 810. The DRG-PRF(42C for 120 sec) was performed resulting in pain relief and reducing by half the doses of used drugs for a period ofabout 6 weeks. The DRG-PRF procedure was repeated with extending stimulation time to 3 5 min which resultedin pain relief and discontinuation of drugs. Pain relief lasted for 7 months. The pain relapsed, so the patient wasscheduled for repeated DRG-PRF.

Broad and Asymmetric Lower Extremity Myotomes: Results From Intraoperative Direct Electrical Stimulation of the Lumbosacral Spinal Roots.

Retrospective review of prospectively collected data. This study aimed to accurately map the lower extremity muscles innervated by the lumbar spinal roots by directly stimulating the spinal roots during surgery. Innervation of the spinal roots in the lower extremities has been estimated by clinical studies, anatomic studies, and animal experiments. However, there have been discrepancies between studies. Moreover, there are no studies that have studied the laterality of lower limb innervation. In 73 patients with lumbar degenerative disease, a total of 147 spinal roots were electrically stimulated and the electromyographic response was recorded at the vastus medialis (VM), gluteus medius (GM), tibialis anterior (TA), biceps femoris (BF), and gastrocnemius (GC). The asymmetry index (AI) was obtained using the following equation to represent the left-right asymmetry in the compound muscle action potential (CMAP) amplitude. Paired t tests were used to compare CMAP amplitudes on the right and left sides. Differences in the AI among the same spinal root groups were determined using one-way analysis of variance. The frequency of CMAP elicitation in VM, GM, TA, BF, and GC were 100%, 75.0%, 50.0%, 83.3%, and 33.3% in L3 spinal root stimulation, 90.4%, 78.8%, 59.6%, 73.1%, and 59.6% in L4 spinal root stimulation, 32.2%, 78.0%, 93.2%, 69.5%, and 83.1% in L5 spinal root stimulation, and 40.0%, 100%, 80.0%, 70.0%, and 80.0% in S1 spinal root stimulation, respectively. The most frequent muscle with maximum amplitude of the CMAP in L3, L4, L5, and S1 spinal root stimulation was the VM, GM, TA, and GM, respectively. Unilateral innervation occurred at high rates in the TA in L4 root stimulation and the VM in L5 root stimulation in 37.5% and 42.3% of patients, respectively. Even in patients with bilateral innervation, a 20% to 38% AI of CMAP amplitude was observed. The spinal roots innervated a much larger range of muscles than what is indicated in general textbooks. Furthermore, a non-negligible number of patients showed asymmetric innervation of lower limb by the lumbar spinal roots.

Contralateral lower limb radiculopathy by extraforaminal disc herniation following oblique lumbar interbody fusion in degenerative lumbar disorder: illustrative cases.

Contralateral lower limb radiculopathy is a potential early complication of oblique lumbar interbody fusion (OLIF) in degenerative lumbar disorders. Among several pathologies related to contralateral radiculopathy following OLIF, extraforaminal disc herniation during the OLIF procedure is very rare. Case 1 is a 68-year-old male underwent L4-5 and L5-6 OLIF for recurrent lumbar canal stenosis-expressed right leg pain and muscle weakness after surgery. Case 2 is a 76-year-old female on whom L4-5 OLIF was performed for L4 degenerative spondylolisthesis and who presented right leg pain and numbness postoperatively. In both patients, OLIF cages were inserted into the posterior part of the disc space or obliquely and the extraforaminal extruded disc compressed opposite exiting nerve roots (L5 root in case 1 and L4 root in case 2) as shown on magnetic resonance imaging (MRI). Surgical decompression with discectomy was required for pain relief and neurological improvement in both cases. When emerging from new-onset opposite limb radiculopathy attributed to the OLIF procedure, extraforaminal disc herniation should be considered a potential pathology and MRI is useful for early diagnosis and selecting a subsequent management, including surgery.

Lumbar Synovial Cyst: A Case Report from the Neurosurgery Department of the Idrissa Pouye General Hospital (HOGIP) in Dakar

<i>Introduction: </i>Spinal synovial cyst is a rare lesion in the general population, the frequency of symptomatic synovial cysts in the population is between 0.5 and 2.3%. They are more frequent in the lumbar region, leading to unilateral or bilateral lumboradiculalgia. Diagnosis is made on imaging and treatment involves percutaneous techniques or surgery. We report a case of lumbar synovial cyst treated surgically. <i>Observations: </i>A 54-year-old female patient, with a history of gonarthrosis, was seen in consultation for a right lumbosciatica of type L5 associated with a painful radicular claudication reducing the walking perimeter evolving for about 1 year. On admission, the patient was found to be overweight with a positive Lasègue sign on the right and pain on extension of the spine. The CT scan revealed a rounded lesion at the right L4-L5 level and conflicting with the ipsilateral L5 root at its emergence, continuous with the joint space. The indication for surgery was based on the severity of the radicular pain. The postoperative course was simple, with pain regression the day after surgery. <i>Conclusion: </i>The lumbar synovial cyst is a rare lesion most often manifested by radiculalgia. The diagnosis is made on imaging and surgical removal is the standard treatment.

Accuracy of Ultrasound-Guided Needle Placement on the L5 Lumbar Nerve Root: A Cadaveric Study.

The aims of the study are to analyze and describe the accuracy of an ultrasound-guided approach to target the L5 root in cadaveric specimens and evaluate whether gender differences exist. A cross-anatomical study on 40 cadaver L5 nerve roots was performed. A needle was introduced until contacting the L5 nerve root using ultrasound guidance. After that, specimens were frozen and studied by a cross-anatomical view to see the needle's path. The angulation, length, distance from the vertebral spine, the relevant ultrasound anatomical references, and the accuracy of the procedure were evaluated. The needle tip reached the L5 root at a 72.5% rate. The mean angulation degrees of the needle relative to the skin surface were 75.53 ± 10.17 degrees, the length of the needle inserted was 5.83 ± 0.82 cm, and the distance from the vertebral spine to the point of entry of the needle was 5.39 ± 1.44 cm. An ultrasound-guided technique can potentially be an accurate technique to perform invasive procedures on the L5 root. There were statistically significant differences between males and females in the length of the needle introduced. If the L5 root is not clearly visualized, ultrasound will not be the technique of choice.

Unexpected Bradycardia Related to Surgical Manipulation During Thoracolumbar Spinal Surgery

Although spinal surgery can offer pain relief and functional improvements in daily life, it is often associated with various perioperative complications. The incidence of cardiac complications associated with spinal surgery is relatively low. We evaluated frequency and causes for bradycardia incidents in posterior thorocolumbar spinal surgeries. We retrospectively evaluated posterior thoracolumbar spinal surgeries between 2018-2022 for bradycardic events in our tertiary general hospital. Patients operated for degenerative changes or disk herniations are included, other cases for tumors, trauma, arteriovenous (AV) fistulae or previously operated are excluded. The study reached 6 eligible patients (4 female and 2 male) aged between 45-75years (mean: 63.3) among 550 patients operated between 2018-2022. The rate of bradycardia was 1.09%. Of these, 5 patients (lumbar discectomy: one; posterior stabilization:4) exhibited it following L2 and L3 root manipulation and one presented it following L4-5 discectomy. In each of these cases, bradycardia occurred during surgical manipulation and ceased upon removal of the insult. None of the cases exhibited accompanying hypotension. The patient's heart rates were seen to drop to lowest the of 30 beats/min, and all patients exhibited favorable outcomes and no postoperative cardiac complications over a mean follow-up period of 20months (range: 10-40months). The current study examines the occurrence of unexpected bradycardia events associated with thoracolumbar spinal surgery during surgical handling of the dura mater. Awareness of such incidents among surgeons and anesthesiologists can help prevent catastrophic outcomes caused by adverse cardiac events.

Abstract #1408228: Potential Association Among Enteroviruses, Acute Flaccid Myelitis and Type 1 Diabetes

Non-polio enteroviruses, like EV-D68, caused a nationwide outbreak of respiratory illness in the US in the fall of 2021. It has been shown that EV-D68 plays a role in causing acute flaccid myelitis (AFM). In addition, the association between enterovirus infections and type 1 diabetes (T1DM) has been widely studied and established. We report a case in which a 19-year-old male consulted for progressively ascending bilateral weakness in the lower extremities. Four weeks prior, he was diagnosed with T1DM and diabetic ketoacidosis (DKA). On exam, he had decreased sensation to light touch, vibration, and temperature below the knees, decreased motor strength 2/5 in bilateral lower extremities, and absence of patellar and Achille reflexes. Thyroid tests, Creatinine Kinase, Aldolase, and vitamin B12 were all normal. Spine MRI showed an enhancement along the L5 and sacral roots. CSF studies were significant for the positive oligoclonal band, the elevated protein level (87gm/dL), and no white blood cell count. CSF gram stain was negative for any organisms. EBV, HSV, and HIV testing were negative. A nonspecific respiratory panel only performed at the time of diagnosis with AFM was negative. The electromyogram did not show any type of acute inflammatory demyelinating polyneuropathy or evidence of myopathy. CT abdomen/pelvis demonstrated mild splenomegaly with small swollen lymph nodes of the periaortic and mesenteric area, which are commonly seen in viral infections. A Digital Subtraction Angiography study did not show any abnormality in spinal vessels. The patient received immunoglobulin and steroid, which was stopped early due to bradycardia and hyperglycemia. Neurology diagnosed the patient with AFM secondary to viral infection, in which the patient may have been infected prior to his diagnosis of DKA. The patient’s weakness resolved, and he was discharged with basal-bolus insulin and is to follow up with neurology and endocrinology outpatient. Enterovirus infection has been associated with T1DM and AFM. While the Respiratory PCR Panel was negative, it was only obtained several weeks after the onset of symptoms. Pathogenesis of extra-respiratory complications of enteroviruses may associate with viremia and systemic dissemination of the virus, which may not be detected by a respiratory PCR panel. Infection by an enterovirus remains the most likely etiology for both immune-mediated disorders, especially during a nationwide outbreak. We recommend providers consider enterovirus infection as a potential cause of AFM, and autoimmune diabetes in order to perform a throughout workup. In a patient with hyperglycemia and flaccid paralysis, T1DM should be suspected.

LITERATURE REVIEW: KOMPONEN NYERI NEUROPATIK PADA NYERI PUNGGUNG BAWAH

Low back pain is a very common health problem and can affect the quality of life. Pain that arises in low back pain can be either nociceptive pain or neuropathic pain. This literature review discusses the neuropathic pain component of low back pain. This review uses a narrative review method. The articles were obtained from keyword searches in the Science Direct, PubMed, and ProQuest databases with a publication range of 2011-2021 in Indonesian or English, and research on the components of neuropathic pain in low back pain. Of the eight articles included in this literature review, the prevalence of neuropathic pain in low back pain was 2.8% - 65.3%. Neuropathic pain can be ruled out using LANSS, DN4, and PDQ. Low back pain with neuropathic pain had symptoms of burning (34.58% - 82.9%), pinpricks (31.77% - 78%), tingling (32.71% - 84.8%), numbness (42.05% - 97%), electric shock (38.97% - 78%), itching (16.82% - 42.4%), cold sensation (12.15% - 48.5%), allodynia (19.62% - 85.4%), 61% hyperalgesia, 14.6% autonomic dysfunction, 100% had dysesthesia, and 100% experienced a decrease in tenderness/prickling. Radicular low back pain is often caused by L5 or S1 root compression and rarely L4. Neuropathic low back pain can be based on an assessment of the symptom profile. Associated risk factors are older age, being a female, greater anthropometric status, the habit of drinking alcohol, smoking, and history of previous lumbar, abdominal or pelvic surgery

Nerve root signature in a cat: Presentation and treatment following acetabular fracture stabilisation and sacral fracture displacement

AbstractNerve root signature presents as discomfort and lameness in a single limb related to disease involving the spinal nerve roots or spinal nerve itself. It has been well described in dogs with disc protrusion or herniation. In this case, a 10‐month‐old, female, entire Bengal cat presented with nerve root signature and deterioration in ability to ambulate following acetabular fracture repair. The cat was reluctant to move and markedly uncomfortable on even gentle manipulation of the pelvic limb. A right sacral wing fracture was suspected to be compressing the right L7–S1 nerve root on computed tomography. Revision surgery was performed to remove the fragment, and the cat gradually made a full recovery. Compression of nerve roots L7–S1 by sacral fractures causing nerve root signature should be considered in cats presenting non‐ambulatory and exquisitely uncomfortable after surgery.

Brain Insulin Receptor Antagonism Augments The Blood Pressure Response To Activation Of The Exercise Pressor Reflex

Type 2 diabetes mellitus (T2DM) results in abnormal control of blood pressure (BP). However, the underlying mechanisms remain to be elucidated. The transport of insulin into the central nervous system is decreased in T2DM. The resultant central hypoinsulinemia reduces neuronal excitability. The nucleus tractus solitarius (NTS) is a key central integration site for incoming signals from peripheral sensory neurons including input from working skeletal muscle and arterial baroreceptors. Working skeletal muscle activates primary sensory fibers and evokes the exercise pressor reflex (EPR) to reflexively increase BP, a response modulated by the baroreflex. Central hypoinsulinemia in T2DM may influence how neurons in the NTS process this sensory information during exercise affecting BP responsiveness. PURPOSE: To determine whether acute antagonism of insulin receptors in the NTS alters EPR function in baro-intact and barodenervated rats. METHODS: L4 and L5 ventral roots were electrically stimulated in healthy decerebrated male Sprague-Dawley rats to evoke hindlimb muscle contraction and EPR activation in intact and sino-aortic barodenervated rats. Mean arterial pressure (MAP) responses to activation of the EPR were assessed before and 30 min following NTS microinjections of the insulin receptor antagonist, GSK1838705 (100uM), or vehicle, dimethyl sulfoxide (DMSO). RESULTS: In baro-intact rats, contraction-induced changes in MAP were significantly greater following GSK1838705 (Pre, 16 ± 10 mmHg vs. Post, 23 + 13 mmHg, n = 11, p < 0.01) but not DMSO (Pre, 15 ± 8 mmHg vs. Post, 15 + 8 mmHg, n = 9). In barodenervated rats, neither GSK1838705 (Pre, 27 ± 16 mmHg vs. Post, 28 ± 21 mmHg, n = 8) nor DMSO (Pre, 34 ± 17 mmHg vs. Post, 30 ± 27 mmHg, n = 9) affected the MAP response to contraction. CONCLUSIONS: The findings demonstrate that central insulin receptor antagonism augments the BP response to EPR activation, which is abolished by barodenervation. The findings also suggest that insulin in the NTS maintains the capacity to buffer EPR-mediated increases in BP via baroreflex-mediated mechanisms. Alterations in this buffering capacity due to the central hypoinsulinemia in T2DM could account, in part, for the exaggerated pressor response to exercise in this disease. Supported by NIH-NHLBI, Lawson & Rogers Lacy Research Fund.

Detection of parametrial invasion in women with uterine cervical cancer using diffusion tensor imaging at 1.5T MRI

Purpose: The purpose of this study was to prospectively evaluate the capability of diffusion tensor imaging (DTI) of the lumbosacral plexus to identify parametrial invasion by uterine cervical cancer. Materials and methods: Twenty-seven women with biopsy-proven cervical cancer were prospectively enrolled and underwent DTI at 1.5 TMRI. Fractional anisotropy (FA) values were calculated at the level of right and left L5 and S1 roots. The two sides of each patient were considered independently in two groups, according to the presence or absence of parametrial invasion. Differences between FA values of invaded parametria and those of non-invaded parametria were searched using Student t-test. Receiver operating characteristic (ROC) analysis was performed to identify the cut-off value of FA that yielded best sensitivity, specificity and accuracy for the diagnosis of parametrial invasion. Results: A total of 54 parametria in 27 participants (mean age, 52.9 ± 12 years; age range, 30–81 years) were analyzed. Invasion was present in 37/54 (68%) parametria and absent in 17/54 (31%) parametria. FA was greater in parametrial invasion (mean, 0.321 ± 0.036; range: 0.285–0.357) than in the absence of parametrial invasion (0.292 ± 0.02; range: 0.272–0.312) (P = 0.01). At ROC analysis, best cut-off value of FA for the diagnosis of parametrial invasion was >0.3099 (AUC, 0.681; 95% CI: 0.583– 0.768), yielding 62% sensitivity (95% CI: 50.3–73.64), 73% specificity (95% CI: 50.6–85.27) and 66% accuracy (95% CI: 54.62–73.91). Conclusion: Using >0.3099 as cut off-value for FA of L5-S1 roots, DTI has an accuracy of 73% in the diagnosis of parametrial invasion by uterine cervical cancer.