Nerve Root Impingement Research Articles

Multilevel symmetric neuropathic pruritus (MSNP) presenting as recalcitrant “generalized” pruritus

Chronic itch is a disruptive and disabling condition that can lead to psychological stress and depression. We sought to describe an entity of generalized, symmetric, neuropathic pruritus, which we term "multilevel symmetric neuropathic pruritus," and offer possible explanations accounting for its pathogenesis. A case series of 14 patients was evaluated at academic institutions from 2011 to 2015. All patients exhibited detectable degenerative vertebral changes, as seen by spinal x-ray or magnetic resonance imaging. In 12 of 14 (85.7%) subjects, the radiographic imaging abnormalities directly correlated with the distribution of their cutaneous findings. Twelve of 14 (85.7%) patients had cutaneous findings along the C5 to C6 and/or C6 to C7 dermatomal distributions. Eleven of 14 (78.5%) patients were overweight or obese, and 14 of 14 (100%) patients had at least 4 risk factors for the development of atherosclerosis. Twelve of 14 (85.7%) patients noted complete or near complete resolution after treatment with gabapentin (300-1200mg daily). No healthy age-matched control group without pruritus was investigated. A combination of multilevel degenerative disc disease of the spine, spinal nerve root impingement, and/or nerve root traction may play a pivotal role in the cause of multilevel symmetric neuropathic pruritus.

C2 spondylotic radiculopathy: the nerve root impingement mechanism investigated by para-sagittal CT/MRI, dynamic rotational CT, intraoperative microscopic findings, and treated by microscopic posterior foraminotomy

C2 radiculopathy is known to cause occipito-cervical pain, but their pathology is unclear because of its rarity and unique anatomy. In this paper, we investigated the mechanism of C2 radiculopathy that underwent microscopic cervical foraminotomies (MCF). Three cases with C2 radiculopathy treated by MCF were investigated retrospectively. The mean follow-up period was 24months. Pre-operative symptoms, imaging studies including para-sagittal CT and MRI, rotational dynamic CT, and intraoperative findings were investigated. There were 1 male and 2 females. The age of patients were ranged from 50 to 79years. All cases had intractable occipito-cervical pain elicited by the cervical rotation. C2 nerve root block was temporally effective. There was unilateral spondylosis in symptomatic side without obvious atlatoaxial instability. Para-sagittal MRI and CT showed severe foraminal stenosis at C1-C2 due to the bony spur derived from the lateral atlanto-axial joints. In one case, dynamic rotational CT showed that the symptomatic foramen became narrower on rotational position. MCF was performed in all cases, and the C2 nerve root was impinged between the inferior edge of the C1 posterior arch and bony spur from the C1-C2 joint. After surgery, occipito-cervical pain disappeared. This study demonstrated that mechanical impingement of the C2 nerve root is one of the causes of occipito-cervical pain and it was successfully treated by microscopic resection of the inferior edge of the C1 posterior arch. Para-sagittal CT and MRI, rotational dynamic CT, and nerve root block were effective for diagnosis.

Invasive Aspergillosis Manifested as Lumbar Vertebral Osteomyelitis in an Immunocompetent Man

Abstract Aspergillus, a saprophytic fungus ubiquitously present in the environment, is rarely pathogenic in immunocompetent hosts, as such invasive Aspergillus osteomyelitis in immunocompetent hosts is uncommonly reported. A 50-year-old immunocompetent man, intravenous drug user with hepatitis C and diabetes mellitus, presented with lumbago and was diagnosed with L5-S1 discitis/osteomyelitis with associated phlegmon, s1 nerve root impingement, and no epidural abscess in August 2014. Needle biopsy cultures were negative. The patient was readmitted in October 2014 with worsening lumbago after completion of antibiotics. Inflammatory markers were significantly elevated (erythrocyte sedimentation rate = 97 mm in 1 hour; C-Reactive Protein = 13.5 mg/dL) and magnetic resonance imaging demonstrated ongoing acute L5-S1 discitis/osteomyelitis with involvement of vertebral bodies and endplate erosion, progressive impingement of the s1 nerve root, and no epidural abscess. Intraoperative cultures and histopathology were consistent with invasive aspergillosis and was treated successfully with voriconazole. Lumbar vertebral osteomyelitis in immunocompetent patients is a potentially life-threatening diagnosis often made late in the presentation because of nonspecific serologic test options and difficulty culturing fungal organisms. Open biopsy should be obtained when suspicion for a nonbacterial pathogen is high, especially after failure of antibacterial therapy. Aspergillosis should be considered in patients with a history of intravenous drug use, because drugs can be contaminated with Aspergillus. Voriconazole is the antifungal of choice for invasive aspergillosis osteomyelitis with excellent oral bioavailability, bone penetrance, and superior adverse effect profile compared with amphotericin B. Treatment for invasive aspergillosis osteomyelitis should involve both surgical and medical interventions.

Mineralization of the transverse ligament of the atlas causing compressive radiculopathy. Resolution following odontoidectomy and atlantoaxial arthrodesis.

To describe a case of a Boxer dog with radiculopathy due to mineralization of the transverse ligament of the atlas and subsequent resorption and resolution of clinical signs after atlantoaxial arthrodesis and odontoidectomy. A five-year-old neutered female Boxer dog was presented with a four-month history of cervical hyperaesthesia refractory to medical management. Neurological examination and magnetic resonance imaging indicated a diagnosis of radiculopathy due to cervical nerve root impingement by dystrophic mineralization of the transverse ligament of the atlas. Odontoidectomy was performed by a ventral approach and atlantoaxial arthrodesis was achieved with a ventral composite polymethylmethacrylate and pin fixation. Atlantoaxial arthrodesis and progressive resorption of the mineralization following stabilization facilitated indirect decompression. The radioclinical diagnosis and response to arthrodesis was considered analogous to retro-odontoid pannus in the human. A clinical condition similar to retro-odontoid pannus may exist in the canine and may be amenable to atlantoaxial arthrodesis.

Diagnosis of lumbosacral intervertebral disc disease and protrusion in a horse using ultrasonographic evaluation and computed tomography

SummaryThis case report describes the clinical presentation, diagnostic imaging modalities, treatment and post mortem evaluation of lumbosacral intervertebral disc protrusion in a mature Quarter Horse gelding 10 days after initial signs were noted. Grade 3 hindlimb ataxia, conscious proprioceptive deficits, urinary and faecal incontinence were present, which did not improve with anti‐inflammatories, antimicrobial therapy, corticosteroids, antioxidant therapy, cold‐laser therapy or electroacupuncture. Imaging modalities utilised ante mortem were computed radiography, transcutaneous and transrectal ultrasonography. Transrectal ultrasonography yielded findings highly suggestive of lumbosacral intervertebral disc protrusion and due to the lack of improvement and a poor prognosis, the horse was humanely subjected to euthanasia. Post mortem computed tomography, necropsy and histopathological evaluation confirmed lumbosacral intervertebral disc disease and protrusion into the spinal canal with subsequent impingement of the spinal nerve roots. Lumbosacral intervertebral disc protrusion as a clinical disease in the horse has not been previously described and should be included as a differential diagnosis in cases with acute hindlimb ataxia, proprioceptive deficits, and urinary and faecal incontinence.

Posterior unilateral vertebral column resection for old thoracolumbar compressive fracture accompa-nied with kyphotic deformity

Objective To describe a successful method by which vertebral column resection is performed through a unilateral posterior approach for old thoracolumbar compressive fracture accompanied with kyphotic deformity. Methods From February 2009 to January 2013, 49 patients with old thoracolumbar compressive fracture accompanied with kyphotic deformity were treated at our department. Twenty-three of them were treated by posterior unilateral vertebral column resection (PUVCR), and 26 by posterior vertebral column resection (PVCR). The 2 groups were compatible in general clinical data (P>0.05). Their clinical records were reviewed and compared in terms of operation time, intraoperative blood loss, postoperative drainage, correction of kyphotic deformity, neural functional improvement by Oswestry disability index (ODI), and pain by visual analogue scale (VAS). Results The operation time, intraoperative blood loss and postoperative drainage in the PUVCR group were significantly less than in the PVCR group (P 0.05). No significant differences were observed between the 2 groups either in terms of improved ODI or decreased VAS at one-year follow-up (P>0.05). Conclusions In treatment of old thoracolumbar compressive fracture accompa-nied with kyphotic deformity, PUVCR can achieve satisfactory correction of sagittal deformity, neural func-tional improvement and pain relief as well as conventional osteotomy, but it has advantages of shorter operation time, reduced blood loss and decreased incidence of nerve root impingement. Key words: Thoracic vertebrae; Lumber vertebrae; Fractures, bone; Osteotomy

Deficits in foot skin sensation are related to alterations in balance control in chronic low back patients experiencing clinical signs of lumbar nerve root impingement

Chronic low back pain (LBP) patients with radiculopathy, or sciatica, experience pain, tingling or numbness radiating down their leg due to compression of the lumbar nerve root. The resulting reduction in somatosensory information from the foot sole may contribute to deficits in standing balance control. This work was designed to investigate the relationship between foot skin sensitivity and standing balance control in chronic LBP patients with associated radiculopathy. Patients (n=9) and matched healthy controls (n=9) were recruited to the study, and were tested for balance control in both quiet standing as well as during rapid arm raise perturbation trials on a force plate. Foot skin sensitivity was tested bilaterally for vibratory threshold (3, 40 and 250Hz) and touch (monofilament) threshold.Results demonstrate that patients had reduced sensitivity to 250Hz vibration in their affected compared to unaffected foot (at the great toe and heel), as well as compared to controls (at the great toe), but there were no differences with lower frequency vibratory testing or with monofilament testing. While there were no significant between-group differences in balance measures, moderate statistically significant correlations between 250Hz sensitivity and quiet standing balance parameters were uncovered. Thus, patients demonstrate reduced high-frequency vibratory sensitivity at the foot sole, and correlations with quiet standing balance measures indicate a connection between these foot skin sensitivity deficits and alterations in balance control. Clinically, this identifies high frequency vibration testing as an important measure of skin sensitivity in patients with radiculopathy.

Lumbar nerve root mapping by the spinal cord monitoring in adult spinal deformity surgery

Objective When we perform surgical correction for spinal deformity with degenerative changes, nerve root impingement, traction, or nerve root injury could be occurred. Electromyographic (EMG) monitoring provides a real-time measure of impending spinal nerve root injury during instrumented posterior lumbar fusion. However, the utility of intraoperative EMG monitoring is still questionable because of large variance in muscle domination, morphological abnormality and the abnormal EMG signal from a nearby muscle. The aim of this study was identified clinical mapping of lumbar nerve root motor domination under EMG monitoring in the patients who had normal root morphology.

Concordant Pain Provocation During Transforaminal Epidural Steroid Injection for Lumbosacral Radiculopathy: Effect on Pain Outcome and Predictive Factors

Background: Anecdotal report suggests that provocation of pain during epidural steroid injection (ESI) that is concordant with typical radicular symptoms predicts pain outcome following injection. However, limited evidence exists that substantiates this theory. Additionally, there is a paucity of literature investigating factors associated with the provocation of pain during ESI. Objectives: The goal of this study was to determine whether provocation of concordant radicular pain during transforaminal ESI predicts pain relief immediately after injection and at short-term follow-up. Demographic, radiologic, and procedural factors associated with the pain provocation and pain outcomes at immediate and short-term follow-up were also investigated. Study Design: Longitudinal cohort study. Setting: Urban academic outpatient interventional spine clinics. Methods: Adults who underwent a fluoroscopically guided transforaminal ESI without sedation between January 1, 2006, and October 29, 2007, for the treatment of lumbosacral radicular pain were included in this study. The relationships between provocation of concordant pain, immediate post-injection, and follow-up visual analogue scale (VAS) pain scores, as well as with demographic, radiologic, and procedural factors were determined using chi-square/Fisher’s exact tests for categorical variables and t-tests or ANOVA for numerical variables. Results: One thousand twenty one patients, 42.4% (433) male/57.6% (588) female, with a mean (SD) age of 54.1 (16.7) years were included in the study. Concordant pain provocation did not predict the magnitude of pain reduction (P = 0.9255) or the frequency of achieving > 50% pain relief (P = 0.7449) at short-term follow-up. Radiologic evidence of foraminal stenosis or nerve root impingement (P < 0.0001) and the lack of a medial-superior contrast flow pattern (P = 0.0199) were associated with a greater frequency of pain provocation during transforaminal ESI. Limitations: This study is primarily limited by possible selection bias given that patients who did not follow-up in the clinic could not be studied, and an incomplete follow-up rate (66%). Conclusions regarding subacute and long-term pain outcomes cannot be determined from this study as only short-term data were available. Conclusions: Provocation of concordant radicular pain does not predict pain relief at short-term follow-up after a transforaminal ESI. Foraminal stenosis, nerve root impingement, and lack of a medial-superior contrast flow pattern are associated with pain during the transforaminal ESI. Thus, clinicians should be aware of these radiologic and procedural risk factors for inciting pain during transforaminal ESI. Key words: Epidural steroid injection, lumbar, radicular pain, outcomes, prognostic

A Case of AL Amyloidosis

Case: 45 year old lady presented with anorexia, weakness for last one year and development of deformity in her spine for last one and half years following fracture. On clinical examination she had mild bilateral pedal edema, kyphoscoliosis, tenderness over rib cage on left side. MRI spine showed diffuse marrow edema in D5 D6 D7 D9 D10 and L4 vetrbral bodies and posterior elements with subtle decrease in anterior height and associated paraspinal muscle edema seen. There was osteophytic bulge with ligamentum flavum thickening at c4-c5 and c5-c6 levels causing spinal canal and bilateral neural foraminal narrowing with nerve root impingement. Blood tests showed Hb-16.5, calcium-7.5, serum albumin-1.2, and globulin-4. Urinary albumin +++. Urinary 24hr protein was 7.81 gram. On skeletal survey no lytic lesion was found. Whole body scan showed abnormal tracer uptake involving multiple dorsal and lumber vetebrae, sternum multiple ribs on either side anteriorly. Serum electrophoresis revealed biclonal IgG and IgA and lambda light chain paraproteins. On bone marrow examination there were 50% plasma cells

Painless squeaking following cervical disc replacement: A case report.

We present a case of painless squeaking following cervical disc replacement which to our knowledge has not previously been reported in the literature. A 45 year old gentleman presented with severe right sided C6 radiculopathy. He complained of more than 6 weeks of severe dysaesthesia in the right arm with pain radiating into the hand, thumb, index, middle and ring fingers. MRI confirmed severe impingement of C6 and C7 nerve roots. After trying a period of conservative treatment he underwent anterior cervical decompression with total cervical disc replacement of C5-6 and C6-7. Being a keen athlete he started running at 6 months post operatively. At his 12 month outpatient he presented us with an audio file containing squeaking from his neck. This was recorded immediately following a 9.5 mile hard surface run. The squeak got progressively less in intensity over 12 hours and disappeared after 24 hours. All instances of squeaking occurred after exercise where impact (running) or vibration (cycling) took place. This was first noticed 6 months post operatively when he restarted exercising. All episodes were completely painless. At his 18 month outpatient review the squeaking had reduced in frequency and intensity. At his 24 month review it had abated completely. The aetiology of this painless squeaking has been elusive and is likely to be multifactorial. However we hypothesise that the audible squeak associated with the prestige LP disc maybe related to specific design characteristics and needs further evaluation.

Treating cervical radiculopathy for a one-level disc herniation using a posterior foraminotomy

Posterior cervical foraminotomy is a safe and highly effective approach to treating single-level soft, lateral disc herniations causing foraminal stenosis and nerve root impingement. This procedure can be performed using standard open or minimally invasive techniques, with the use of either the operating microscope or the endoscope. The surgical technique is described in detail and the indications, contraindications, and complication avoidance are discussed.

Consensus conference on core radiological parameters to describe lumbar stenosis - an initiative for structured reporting.

To define radiological criteria and parameters as a minimum standard in a structured radiological report for patients with lumbar spinal stenosis (LSS) and to identify criteria and parameters for research purposes. All available radiological criteria and parameters for LSS were identified using systematic literature reviews and a Delphi survey. We invited to the consensus meeting, and provided data, to 15 internationally renowned experts from different countries. During the meeting, these experts reached consensus in a structured and systematic discussion about a core list of radiological criteria and parameters for standard reporting. We identified a total of 27 radiological criteria and parameters for LSS. During the meeting, the experts identified five of these as core items for a structured report. For central stenosis, these were "compromise of the central zone" and "relation between fluid and cauda equina". For lateral stenosis, the group agreed that "nerve root compression in the lateral recess" was a core item. For foraminal stenosis, we included "nerve root impingement" and "compromise of the foraminal zone". As a minimum standard, five radiological criteria should be used in a structured radiological report in LSS. Other parameters are well suited for research. The five most important radiological criteria for standard clinical reporting were selected. The five most important quantitative radiological parameters for research purposes were selected. These core criteria could help standardize the communication between health care providers.

Characteristics and surgical results of the distal type of cervical spondylotic amyotrophy.

Cervical spondylosis that causes upper-extremity muscle atrophy without gait disturbance is called cervical spondylotic amyotrophy (CSA). The distal type of CSA is characterized by weakness of the hand muscles. In this retrospective analysis, the authors describe the clinical features of the distal type of CSA and evaluate the results of surgical treatment. The authors performed a retrospective review of 17 consecutive cases involving 16 men and 1 woman (mean age 56.3 years) who underwent surgical treatment for the distal type of CSA. The condition was diagnosed on the basis of cervical spondylosis in the presence of muscle impairment of the upper extremity (intrinsic muscle and/or finger extension muscles) without gait disturbance, and the presence of a compressive lesion involving the anterior horn of the spinal cord, the nerve root at the foramen, or both sites as seen on axial and sagittal views of MRI or CT myelography. The authors assessed spinal cord or nerve root impingement by MRI or CT myelography and evaluated surgical outcomes. The preoperative duration of symptoms averaged 11.8 months. There were 14 patients with impingement of the anterior horn of the spinal cord and 3 patients with both anterior horn and nerve root impingement. Twelve patients were treated with laminoplasty (plus foraminotomy in 1 case), 3 patients were treated with anterior cervical discectomy and fusion, and 2 patients were treated with posterior spinal fixation. The mean manual muscle testing grade was 2.4 (range 1-4) preoperatively and 3.4 (range 1-5) postoperatively. The surgical results were excellent in 7 patients, good in 2, and fair in 8. Most of the patients in this series of cases of the distal type of CSA suffered from impingement of the anterior horn of the spinal cord, and surgical outcome was fair in about half of the cases.

Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK).

BackgroundThere are few longitudinal cohort studies examining associations between incident MRI findings and incident spine-related symptom outcomes. Prior studies do not discriminate between the two distinct outcomes of low back pain (LBP) and radicular symptoms. To address this gap in the literature, we conducted a secondary analysis of existing data from the Longitudinal Assessment of Imaging and Disability of the Back (LAIDBACK). The purpose of this study was to examine the association of incident lumbar MRI findings with two specific spine-related symptom outcomes: 1) incident chronic bothersome LBP, and 2) incident radicular symptoms such as pain, weakness, or sensation alterations in the lower extremity.MethodsThe original LAIDBACK study followed 123 participants without current LBP or sciatica, administering standardized MRI assessments of the lumbar spine at baseline and at 3-year follow-up, and collecting information on participant-reported spine-related symptoms and signs every 4 months for 3 years. These analyses examined bivariable and multivariable associations between incident MRI findings and symptom outcomes (LBP and radicular symptoms) using logistic regression.ResultsThree-year cumulative incidence of new MRI findings ranged between 2 and 8%, depending on the finding. Incident annular fissures were associated with incident chronic LBP, after adjustment for prior back pain and depression (adjusted odds ratio [OR] 6.6; 95% confidence interval [CI] 1.2-36.9). All participants with incident disc extrusions (OR 5.4) and nerve root impingement (OR 4.1) reported incident radicular symptoms, although associations were not statistically significant. No other incident MRI findings showed large magnitude associations with symptoms.ConclusionsEven when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. Although incident annular fissures, disc extrusions, and nerve root impingement were associated with incident symptom outcomes, the 3-year incidence of these MRI findings was extremely low, and did not explain the vast majority of incident symptom cases.

Transforaminal epidural steroid injection in the treatment of lumbosacral radicular pain caused by epidural lipomatosis: A case series and review

Spinal epidural lipomatosis (SEL) can cause radicular pain due to spinal nerve root impingement. While SEL decompression surgery can provide symptom relief, these patients are often poor surgical candidates due to elevated BMI or immunosuppression. Transforaminal epidural steroid injection (TFESI) has been attempted as an alternative treatment for patients with SEL who are unable to tolerate conservative medical treatment. To date, only two such cases have been reported in the literature. We report three additional cases of radicular pain associated with SEL, review the current literature on this condition, and describe the risks and benefits of using TFESI to treat radicular pain due to SEL. We measured changes on the pain visual analogue scale (VAS) and pain disability index (PDI) from presentation to 1-5 weeks after treatment with sequential TFESIs. Pain VAS scores improved by 50-75% and PDI scores improved 13-44 points. This case series suggests that TFESI can provide modest short-term symptom relief of lumbosacral radicular pain and improvement in disability caused by SEL. Further study of non-operative management of SEL is warranted, given the high risk associated with surgery in this population.

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

Background contextIt is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome. PurposeTo study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients. Study designProspective nested cohort study based on a randomized controlled trial. Patient sampleOut of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study. Outcome measuresDegenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW). MethodsBy using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW. ResultsClinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes. ConclusionsThe only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.

Comparative effectiveness of surgical versus nonoperative management of unilateral, nondisplaced, subaxial cervical spine facet fractures without evidence of spinal cord injury

Facet joints are major stabilizers of cervical motion allowing for effortless and pain-free multidimensional cervical spine movements without significant linear or rotational translation, thus minimizing any chance for spinal cord or nerve root impingement. Unilateral, nondisplaced subaxial facet fractures do not meet the conventional criteria for spinal instability under physiological loads. Limited evidence indicates that even with no or minimal displacement, 20%-80% of these fractures fail nonoperative management. The risk factors for instability in isolated nondisplaced subaxial facet fractures remain uncertain. In this retrospective study of prospectively collected data, the authors attempted to identify the predictors of failure in the management of isolated, nondisplaced subaxial facet fractures admitted to their Level I trauma center over a 10-year period. Demographic, clinical, imaging, and follow-up data for 25 patients with unilateral nondisplaced subaxial facet fractures who were managed surgically (n = 10) or nonoperatively (n = 15) were statistically analyzed. The mean age of the patients was 38 years, 19 were male, and 21 of the fractures were the result of either motor vehicle accidents or falls. The mean motor score on the American Spinal Injury Association scale was 99.2, and the mean Subaxial Injury Classification (SLIC) severity score was 3 (operated 3.5, nonoperated 2.3). Allen mechanistic classification included 22 compressive-extension Stage 1 and 2 distractive-extension Stage 1 fractures. Subaxial facet fractures involved C-7 in 17 patients (68%), C-6 in 7 (28%), and C-3 in 1 (4%). The anatomical plane of fracture through the lateral mass was sagittal in 12 patients, axial in 8, and coronal in 3 patients. Nondisplaced floating lateral mass injuries were noted in 2 patients. The mean instability score, considering 7 components of the discoligamentous complex on MRI, was 3.2 (operated 3.6, nonoperated 3.0). Ten (40%) of 25 patients in this investigation did not have successful management, 9 in the nonoperated and 1 in the operated group (p = 0.018). Unsuccessful management was significantly greater in younger patients (p = 0.0008), possibly indicating selection bias (p = 0.07, Wilcoxon ranksum test). Fracture plane, instability, and SLIC scores did not play a significant role in treatment failure in this study. In this study, surgery was superior to nonoperative management of isolated, nondisplaced, or minimally displaced subaxial cervical spine facet fractures.

Partial facetectomy for lumbar foraminal stenosis.

Background. Several different techniques exist to address the pain and disability caused by isolated nerve root impingement. Failure to adequately decompress the lumbar foramen may lead to failed back surgery syndrome. However, aggressive treatment often causes spinal instability or may require fusion for satisfactory results. We describe a novel technique for decompression of the lumbar nerve root and demonstrate its effectiveness in relief of radicular symptoms. Methods. Partial facetectomy was performed by removal of the medial portion of the superior facet in patients with lumbar foraminal stenosis. 47 patients underwent the procedure from 2001 to 2010. Those who demonstrated neurogenic claudication without spinal instability or central canal stenosis and failed conservative management were eligible for the procedure. Functional level was recorded for each patient. These patients were followed for an average of 3.9 years to evaluate outcomes. Results. 27 of 47 patients (57%) reported no back pain and no functional limitations. Eight of 47 patients (17%) reported moderate pain, but had no limitations. Six of 47 patients (13%) continued to experience degenerative symptoms. Five of 47 patients (11%) required additional surgery. Conclusions. Partial facetectomy is an effective means to decompress the lumbar nerve root foramen without causing spinal instability.

Contralateral Motor Deficits After Lateral Lumbar Interbody Fusion

Retrospective case series. To report on the rare finding of motor deficits contralateral to the transpsoas approach in patients who underwent lateral lumbar interbody fusion (LLIF). Although sensorimotor deficits occurring ipsilaterally to a transpsoas approach have more fully been elucidated, there seems to be a paucity of data on motor deficits contralateral to an LLIF approach. The electronic medical records and radiographical studies of 244 patients who underwent LLIF at a single institution between 2006 and 2009 were retrospectively reviewed for reports on motor deficits contralateral to the surgical approach. Of the patients reviewed, 2.9% (7/244) presented with a postoperative contralateral motor deficit, the most severe of which was a 1/5 weakness of the quadriceps muscle. An average of 3 levels (range: 2-4) was fused in 7 patients who developed a contralateral motor deficit, and in 3 of the 7 patients, an anterior lumbar interbody fusion (ALIF) was performed in addition to the LLIF. At 1 year follow-up, 3 patients presented with complete resolution of their muscle weakness, 1 patient still had mild weakness, 1 patient had decreased range of motion in the affected joint, and 1 patient had a 2/5 foot drop. One patient was lost to follow-up. These data are among the largest reports of contralateral motor deficits after LLIF. Among possible underlying mechanisms are entrapment of the contralateral nerve root through translational correction of spondylolisthesis, front-to-back misalignment of the cage resulting in contralateral nerve root impingement, pressure on the contralateral peroneal nerve during positioning, and overdistraction neurapraxia when using ALIF at L5-S1 concomitantly. Awareness of the possibility of this rare complication can play an important role in surgical consideration and preoperative patient counseling. 4.