Radicular Symptoms Research Articles

Long Term Outcomes of Pain, Disability and Quality of Life in Open vs Minimally Invasive Surgery of Transforaminal Lumbar Interbody Fusion

Objective: This study aims to evaluate the short- and long-term outcomes—specifically in terms of pain, disability, and quality of life—between minimally invasive surgery (MIS) and open transforaminal lumbar interbody fusion (TLIF) for treating lumbar spondylolisthesis. Study Design and Setting: A prospective cohort study was carried out at Liaquat National Hospital & Medical College, Karachi, and a teaching institution in South Asia. The study included patients with chronic back pain for over three months, unresponsive to medical treatment or accompanied by radicular symptoms, with MRI-confirmed grade I and II degenerative lumbar spondylolisthesis, lateral recess stenosis, and unilateral disc herniation. Patients with spinal metastasis, previous surgeries, inflammatory arthritis, or metabolic bone diseases were excluded. Methodology: The outcomes of MIS-TLIF and open-TLIF were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and SF-36 quality of life scores at 1, 6, and 24 months postoperatively. Results: Among 93 patients, 35 underwent open-TLIF and 58 received MIS-TLIF. MIS-TLIF resulted in significantly less blood loss and faster recovery. At four weeks, the MIS group had lower VAS and ODI scores, and higher SF-36 scores. Similar trends continued at six months, with improvements in ODI and SF-36. By 24 months, the MIS group maintained lower ODI scores, though VAS and SF-36 scores were comparable. Conclusion: MIS-TLIF shows superior outcomes, especially in the early postoperative phase, with reduced morbidity and improved quality of life, making it a preferable option in resource-limited settings.

7949 Unraveling a Unique Presentation of Paget’s Disease of Bone

Abstract Disclosure: S. Puri: None. L. Bovee: None. R. Narla: None. Background: Paget's Disease of Bone (PDB) is a disorder characterized by rapid bone destruction and repair, which results in distortion of bone architecture. PDB occurs most commonly in adults over 55 and of European descent. PDB presents with both lytic and sclerotic lesions, predominantly in the axial skeleton. Serum alkaline phosphatase (ALP) levels and bone turnover markers (BTMs) are typically elevated in PDB. Clinical Case: A 53-year-old African-American woman with a history of breast cancer, PTSD, depression, and obesity (BMI 37) presented with worsening back pain over the past six months. Her pain would start at the center of her back and radiate to her left lower extremity. She endorsed rapid weight loss and night sweats and had lumbar bony tenderness on exam, prompting a spinal MRI. Spinal MRI was significant for diffuse sclerosis of the L3 vertebral body only. The radiology report provided a broad differential for this finding, including metastases, lymphoma, infection, PDB, and hemangioma. Due to progression of the patient’s back pain and concern for possible malignancy, a whole-body SPECT was completed which showed isolated tracer uptake into the L3 vertebral body extending into the pedicles and spinous process. Similar findings were noted on bone scans dating back to 2001. Per the radiology report, the presence of sclerosis with minimal expansion is most suggestive of PDB. Endocrinology was consulted for guidance on treatment and surveillance imaging for this patient. The endocrinology team discussed the case with radiology, who confirmed that the patient’s imaging findings had classic features of PDB. Bone specific ALP (B-ALP) and procollagen type 1 amino-terminal propeptide (P1NP) as bone turnover markers (BTMs) were within normal limits. A DEXA scan is pending to evaluate for concurrent osteoporosis. Clinical Lessons: PDB was favored as the most likely diagnosis primarily due to the sclerotic appearance of the patient’s vertebral lesion on imaging, radicular symptoms, and exam finding of bony point tenderness. Other diagnoses, such as metastatic disease, were considered and were thought to be unlikely given that the vertebral lesion is monostotic and stable. This case highlights the necessity of carefully evaluating radiographic findings and clinical history in the diagnosis of PDB. In this case, the patient was from a demographic group unlikely to have PDB and, unexpectedly, did not have elevated BTMs. It is important to consider PDB on the differential diagnosis in cases such as this because PDB can present in myriad ways and in a variety of patient populations. Presentation: 6/2/2024

Filum terminale infected epidermoid cysts in pediatric age group; A case series

BackgroundEpidermoid cysts are rare and account for only 1 % of primary spinal tumors. It's due to inclusion of ectodermal tissue during the third and fourth weeks of gestation. Infected epidermoid cysts are exceedingly rare with very few reports in literature. The clinical presentations include radicular symptoms, motor weakness, sphincteric disturbance, and repeated chemical meningitis. Surgery of this kind of tumor remained a challenge and of a considerable recurrence rate. MethodsThis is a retrospective study reviewing the records of six children who were treated for filum terminale infected epidermoid cysts. All patients underwent microsurgery, and the surgical outcomes were studied through a follow up period of at least 24 months. ResultsAll children had a low back dermal sinus with purulent discharge. One child was a recurrent presentation after the previous two surgeries for evacuation of pus collection, and the other five children were operated for the first time. All the six children had an associated neurological deficit; one child presented with active central nervous system infection, and one child had a history of meningitis and admission to hospital prior to our surgery. Regular follow up revealed no recurrence in any of the six patients. The five patients, who presented with motor weakness, showed significant improvement of the motor power with regular post-operative physical therapy. ConclusionEpidermoid cysts are rare benign lesions that may lead to significant morbidity when infected. The aim of microsurgical excision is to remove the cyst content and its capsule without inducing or increasing neurological deficit by the aid of intraoperative neuromonitoring and microsurgery techniques.

C5 Palsy after Cervical Disc Arthroplasty: Two Case Reports and Literature Review

Cervical disc arthroplasty (CDA), also known as cervical artificial disc replacement, has become an alternative for the treatment of cervical spondylosis with radicular or myelopathic symptoms. However, there is limited literature regarding its complications and outcomes. We present two cases that developed C5 nerve palsy (C5P) following two-level CDA. Both patients presented with C5P in a delayed fashion with 2/5 and 1/5 deltoid weakness on MMT, respectively. Postoperative imaging did not demonstrate any spinal cord compression and symptoms resolved (5/5 on MMT) with conservative management in both cases. To our knowledge, these represent the first cases of delayed C5P after cervical arthroplasty reported in the literature. We performed a literature review to further enhance our knowledge regarding CDA. By understanding its pathophysiology and response to treatment, these cases can serve as a guide for spine surgeons and improve their future outcomes.

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

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

An Optimized CT Protocol for Detecting Suspected Cauda Equina Syndrome: A Comparative Analysis with MRI.

Lumbar disc herniation, potentially leading to nerve root compression and cauda equina syndrome, is typically evaluated using MR imaging. However, the limited availability of MR imaging outside regular hours in certain health care systems poses considerable challenges. This purpose of this study was to prospectively evaluate the diagnostic accuracy of an optimized CT lumbar spine protocol as a potential alternative to MR imaging in assessing suspected neural compression. Patients presenting to the emergency department with suspected cauda equina syndrome or acute radicular symptoms secondary to lumbar disc herniation referred for MR imaging were prospectively enrolled for an additional CT optimized to assess spinal stenosis. An expert radiologist, blinded to clinical data, graded canal stenosis at each lumbar level on CT. The same grading process was applied to MR imaging after a 4-week interval to maintain blinding. Fifty-nine individuals were included in the final analysis. In 22 (39%) cases, no significant stenosis was identified. In a further 22 (37%) cases, disc pathology was identified that was managed conservatively. Thirteen (22%) individuals proceeded to urgent surgical decompression. In 1 (2%) instance, an alternative diagnosis was identified. Compared with MR imaging, the sensitivity, specificity, and positive and negative predictive values for CT in detecting disc pathology in patients presenting with symptoms suggestive of acute neural compression were 97% (95% CI, 82%-99%), 97% (95% CI, 83%-99%), 97% (95% CI, 92%-99%), and 97% (95% CI, 83%-99%), respectively. CT accurately identified all cases requiring urgent decompression. CT accurately predicted MR imaging findings in patients with suspected cauda equina and nerve root compression, demonstrating its utility as an adjunct tool for patient triage in emergency settings with limited MR imaging access. This protocol could enhance the allocation of emergency resources by appropriately selecting patients for emergent MR imaging.

Cervical stenosis-Diagnostics and treatment of symptomatic spinal canal stenosis and neuroforaminal stenosis

Cervical stenosis is aclinical picture that is regularly encountered by both hospital physicians and orthopedic surgeons in the daily clinical practice. While advanced cervical spinal canal stenosis may lead to myelopathic symptoms in cases of sufficient manifestation and spinal cord injury, neuroforaminal stenosis leads to radicular symptoms due to compression of the nerve roots. The clinical examination can provide initial clues as to the suspected cause of the patient's symptoms; however, reliable diagnostics are based only on sectional imaging of the cervical spine. Depending on the extent of the symptoms, the treatment options vary between nonsurgical treatment for moderate symptoms without neurological deficits and surgical decompression of the spinal cord or nerve roots. The surgical treatment can be performed from anterior or posterior depending on the findings. Surgery can lead to an improvement of the neurological symptoms; however, the primary aim of surgical treatment is to avoid deterioration of the neurological deficits.

Comparison of the effects between oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal interbody fusion (MIS-TLIF) in the treatment of adult degenerative lumbar scoliosis

BackgroundManaging adult degenerative lumbar scoliosis (ADLS) presents a complex challenge, requiring advanced, minimally invasive surgical techniques. ObjectiveThis study aims to evaluate and compare the efficacy and outcomes of oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in treating ADLS, with an emphasis on surgical methods, recovery times, and spinal correction results. MethodsWe reviewed 42 patients with ADLS who did not respond to conservative treatments. These patients underwent either OLIF or MIS-TLIF procedures. Key factors analyzed included surgical duration, blood loss, complications, and changes in preoperative and postoperative lumbar lordosis (LL), anterior and posterior disc height (ADH, PDH), and Cobb angles. Statistical analysis was conducted using SPSS software, with significance determined at p < 0.05. ResultsThe OLIF technique showed notable benefits in multi-segment spinal corrections, particularly in enhancing intervertebral disc height and correcting Cobb angles. While both surgical methods effectively addressed spinal deformities, OLIF was less invasive, resulting in reduced blood loss, shorter surgery times, and fewer complications. No significant differences were found between the two techniques for single-segment corrections. ConclusionFor multi-segment spinal corrections in ADLS, OLIF is a superior choice due to its minimal invasiveness and favorable recovery profile. However, for patients with primarily radicular symptoms and no significant postural alterations, MIS-TLIF may be more appropriate.

Evaluation and Treatment of Lumbar Spine Extradural Cysts: A Narrative Review.

The main objective was to describe the different types and characteristics of lumbar spine extradural cysts and their optimal treatment options with a focus on endoscopic technique.We searched Pubmed, EMBASE, Medline, and Google Scholar for articles published between 1967 and 2020 using the keywords "Spinal Cyst,""Extradural Cyst," and "Lumbar Cyst."The various anatomical and histological types of the extradural cysts with their presentations, etiologies, imaging, and optimal treatment with a focus on endoscopic techniques were reviewed from the articles. Lumbar spinal cysts are relatively rare pathologies that might cause radicular symptoms similar to lumbar disc herniation. Spinal extradural cysts are classified either histologically based on the cyst lining tissues (synovial cysts or non-synovial, ganglion cysts) or anatomicallybased on the structure of origin (epidural cysts, ligamentum flavum cysts, discal cysts, post-discectomy pseudocysts, posterior longitudinal ligament cysts, facet cysts). Surgical excision is the recommended treatment of symptomatic cysts with endoscopic techniques being a viable option. Extradural lumbar cysts can be identified based on their histological structure or depending on their structure of origin. Regardless of their classification, they could all give similar clinical findings, and the optimal treatment would be surgical excision with endoscopic technique being a viable option with a satisfactory outcome.

Interrater reliability of the modified prone instability test for lumbar segmental instability in individuals with mechanical low back pain

ABSTRACT Objective The purpose of this study was to establish the interrater reliability of measures obtained with a novel Modified Prone Instability Test (mPIT), which, like the original Prone Instability Test (PIT), is proposed to identify lumbar segmental instability. The mPIT has clinical feasibility advantages to the PIT, but its psychometric properties are yet to be determined. Design Repeated measures (test-retest) design, methods study Methods The mPIT was administered by two blinded testers, an orthopedic physical therapy resident with < 1 year experience and board-certified orthopedic specialist physical therapist with >25 years’ experience. Procedures were administered at an outpatient physical therapy clinic of a tertiary Medical Center. Participants included 50 adults (≥18 years old) with mechanical low back pain and no radicular (below the knee) symptoms (mean age 50.7 years, 66% female, 76% reported previous episodes of low back pain). Interrater reliability was measured via Fleiss’ kappa coefficient. Results Assessments of the mPIT had moderate interrater agreement (κ = .579 [95% CI = .302 to .856], p < .001.) Conclusion Measures obtained using the mPIT demonstrated moderate interrater reliability between a new graduate and an experienced clinician, which aligns with several studies examining interrater reliability of the original PIT. Further study examining comparative validation of the mPIT with other lumbar instability measures is warranted.

Manual traction is effective in alleviating lumbosacral spine pain: Evidence from a randomized controlled trial

BackgroundManual traction, a therapeutic technique frequently employed in healthcare, involves applying controlled pulling force by hand, usually to the spine, to stretch muscles and decompress joints, thereby alleviating pain. This method can be particularly beneficial for addressing lumbosacral spine pain exacerbated by radicular symptoms, characterized by pain radiating from the lower back due to compression or irritation of spinal nerves. PurposeThis study aimed to compare the effects of manual traction against control group in alleviating the lumbosacral spine pain caused by radicular symptoms. MethodsA randomized controlled study design was utilized with a sample of 60 patients experiencing lumbosacral spine pain, evenly distributed between an experimental group (n = 30; receiving manual traction) and a control group (n = 30). Patients underwent assessments before and after six treatment sessions, which included the Straight Leg Raise test, modified Bragard's test, Kernig's test, and the visual analogue scale for pain perception. ResultsBetween-group significant differences were found at post-intervention, favoring the experimental group on SLR – Left (°) (p = 0.004; medium effect size), SLR – Right (°) (p = 0.004; medium effect size), Modified Bragard test – Left (°) (p = 0.024; small effect size), Modified Bragard test – Right (°) (p = 0.003; medium effect size), Kernig's Test – Left (°) (p = 0.013; medium effect size) and Kernig's Test – Right (°) (p = 0.010; medium effect size). Additionally, between-group significant differences were found at post-intervention, favoring the experimental group on VAS scores at SLR left (p < 0.001; medium effect size), and right (p < 0.001); medium effect size, Modified Bragard test left (p < 0.001; medium effect size) and right (p < 0.001; medium effect size) and at Kernig's Test left (p < 0.001; medium effect size) and right (p < 0.001; medium effect size). ConclusionsIn conclusion, manual traction is recommended as an effective approach for alleviating lumbosacral spine pain in patients experiencing symptoms resulting from irritation or compression of a spinal nerve root.

Computed Tomography-Guided Facet Synovial Cyst Aspiration

Abstract Lumbar facet joint cysts are the benign collections of fluid at or around the facet joints, which may lead to pain and radicular symptoms. They may be associated with spinal stenosis, nerve root compression, neurogenic claudication, and many other neurological disturbances, as they can encroach on the adjacent neural foramen. Although the recommended treatment is surgical excision, percutaneous interventions provide an effective, acceptable, and safe alternative that may be considered. Hereby, we present the case of a 78-year-old patient known diabetic, hypertensive, and with deranged renal function, with left-sided L5 radiculopathy due to an L4-5 facet synovial cyst. He was treated through computed tomography (CT)-guided percutaneous aspiration and got long-term relief. The technique we used was different from the regular facet cyst aspiration, and the precision offered by CT guidance helped us provide optimum treatment leading to long-term relief. Thus, tailor-made treatment options rather than standard protocols for all patients allow a better risk–benefit ratio, in the field of pain management.

Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice.

Retrospective multicenter cohort study. Recurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France. This retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively. The study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups. The decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.

Medication recommendations for treatment of lumbosacral radiculopathy: A systematic review of clinical practice guidelines.

The purpose of this systematic review was to ascertain guideline-recommended pharmaceutical approaches to lumbosacral radicular symptoms, assess the quality of the clinical practice guidelines (CPGs) with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool, and qualitatively synthesize the guideline recommendations. Literature searches were performed in PubMed, Cochrane Database of Systematic Reviews, Index to Chiropractic Literature, Allied and Complementary Medicine Database (AMED), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro). We included guidelines published between January 1, 2017, and January 9, 2022, written in the English language, related to radiculopathy, sciatica, and/or low back pain with leg pain, and that provided recommendations on oral medication. The review was performed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) and the protocol was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO). Eligibility screening, full-text review, extraction of information pertaining to pharmacological management, and synthesis of results were performed independently by two authors and a third investigator was recruited to arbitrate any disagreements. The AGREE II tool was administered by four authors to appraise CPG quality. After screening 413 citations and assessing 37 full-text articles, 11 CPGs met the inclusion criteria. They represented seven countries (Belgium, Canada, England, France, Japan, Korea, and United States) and three continents (Asia, Europe, and North America), as well as the Global Spine Care Initiative aimed at a worldwide presence. The mean overall AGREE II score was 87.1% (standard deviation [SD] 12.6%), generally reflecting high-quality CPGs. The highest domain mean score was for Clarity of Presentation (96.7%, SD 4.4%), and the lowest was Applicability (75.6%, SD 22.8%). Five classes of medications were recommended by at least one CPG: anticonvulsants, antidepressants, oral corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. The most common medication class recommended by the CPGs for lumbar radiculopathy was antidepressants. No CPGs recommended prescribing acetaminophen, benzodiazepines, muscle relaxants, or antibiotics. There was very little agreement between the CPGs, and all the medication classes had at least one CPG recommended against its use. Three guidelines reviewed did not recommend any medications due to lack of supporting literature, and instead recommended nonpharmacologic therapy.

Age is Associated with Level of First-Time Anterior Cervical Discectomy and Fusion: An Ordinal Analysis of Factors Influencing Timing of Cervical Degeneration

Symptomatic cervical spondylosis is often treated with anterior cervical decompression and fusion (ACDF). However, few factors can predict which cervical level will degenerate and require intervention. This analysis evaluates pre-procedural factors associated with level of first-time single-level ACDF. We performed a retrospective analysis of patients who underwent single-level ACDF without prior history of spine surgery. Mann Whitney U-tests and Spearman rank-order correlation were performed for analyses of associations between variables of interest and ACDF level. Adjusted odds-ratios were calculated by proportional-odds logistic regression, with age, sex, body mass index (BMI), current tobacco use, history of neck trauma, preoperative radicular symptoms, and preoperative myelopathic symptoms as covariates. 141 patients met inclusion criteria, and age demonstrated a negative correlation with ACDF level, such that younger patients tended to have ACDF performed at inferior subaxial levels (p=0.0006, rho = -0.31, moderately strong relationship). Patients with pre-operative radicular symptoms and myelopathic symptoms were more likely to have ACDF performed at inferior (p=0.0001) and superior (p<0.0001) levels, respectively. Patient sex, BMI, current tobacco use, and history of neck trauma were not predictive of ACDF level. When adjusting for the above variables in a proportional-odds ordinal logistic regression model, a one year increase in age conferred a 4% increase in the odds of requiring an ACDF at a given superior level compared to the adjacent inferior level. Age is correlated with level of first-time single level ACDF. Individual subaxial levels may have unique biomechanical properties that influence degeneration.

Migratory schwannoma of the cauda equina with a change in radicular pattern: illustrative case.

Intradural spinal tumors are an uncommon entity with a variety of pathologies and symptom patterns. Few cases reports in the literature have described tumor migration within the spinal canal. A 38-year-old male presented with bilateral upper lumbar radicular symptoms of anterior thigh pain, with an enhancing tumor of the cauda equina initially located at L1-2. He declined surgery initially, and at a follow-up 3 years later, his symptoms were unchanged but the tumor was now located at T12-L1. He again declined surgery, but 3 months later, he had a significant change in his pain distribution, which was now along his posterolateral right leg to his foot with associated dorsiflexion and extensor hallicus longus weakness. At this time, the tumor had migrated to L2-3. He underwent laminectomy and tumor resection with resolution of his radicular symptoms and improvement in his strength back to baseline by the 1-month follow-up. Pathology was consistent with a World Health Organization grade I schwannoma. Migratory schwannoma is a rare entity but should be considered when radicular symptoms acutely change in the setting of a known intradural tumor. Repeat imaging should be performed to avoid wrong-level surgery. Intraoperative imaging can also be used for tumor localization.

Post-traumatic hemorrhage in a large sacral Tarlov cyst causing acute radiculopathy

Symptomatic Tarlov cysts (TCs) are an under-recognized clinical entity that should be considered in the differential for lower back pain. These are more common in women and can also be a cause of pelvic pain. Hemorrhagic TCs have been rarely reported in the literature, with symptoms ranging from lower back pain and radiculopathy to symptoms of cauda equina syndrome. We report on a female patient in her 50s who presented with radicular symptoms as a consequence of TC hemorrhage. Magnetic resonance imaging is the gold standard investigation, and this showed post-traumatic hemorrhage causing irritation of the sciatic nerve. Hemorrhagic TC is an important differential to consider in the setting of acute radicular pain, and the symptoms can be resolved with conservative management.

Cervical Spinal Cord Stimulation for Failed Neck Surgery Syndrome.

Cervical spine pain with or without radicular symptoms is a common condition leading to high utilization of the healthcare system with over 10 million medical visits per year. Many patients undergo surgical interventions and unfortunately are still left with neck and upper extremity pain, sometimes referred to as "Failed Neck Surgery Syndrome." When these options fail, cervical spinal cord stimulation can be a useful tool to decrease pain and suffering as well as reduce prescription medication use. Spinal cord stimulation is a well-established therapy for chronic back and leg pain and is becoming more popular for neck and upper extremity pain. Recent studies have explored cervical spinal cord stimulation with successful outcomes regarding improved pain scores, functional outcomes, and reduction of prescription medication use. Continued research into cervical spinal cord stimulation is essential for maximizing its therapeutic potential for patients with chronic neck and upper extremity pain. This review highlights the importance of cervical spinal cord stimulation as an option for patients with failed neck surgery syndrome.

Return to flight duty (RTFD) after posterior lumbar spine surgery for symptomatic lumbar disc herniation (LDH) and lumbar isthmic spondylolisthesis (LIS) in Chinese military pilots

BackgroundSymptomatic lumbar disc herniation (LDH) and lumbar isthmic spondylolisthesis (LIS) present significant challenges for military pilots, which may result in grounding if not effectively managed. Surgical treatment for LDH and LIS may offer a pathway to return to flight duty (RTFD), but recent data on this crucial topic is lacking. This study seeks to address this gap by investigating the RTFD outcomes among Chinese military pilots who have undergone lumbar spine surgery for symptomatic LDH and LIS.MethodsA retrospective review was conducted on active-duty military pilots who underwent isolated decompressive or fusion procedures at an authorized military medical center from March 1, 2007, to March 1, 2023. The analysis utilized descriptive statistics to examine demographic, occupational, surgical, and outcome data, with a particular focus on preoperative flight status, recommended clearance by spine surgeons, and actual RTFD outcomes and time.ResultsAmong the identified cases of active-duty military pilots with LDH or LIS treated by lumbar surgery (n = 24), 70.8% (17 of 24) consistently maintained RTFD status without encountering surgical complications or medical issues during the follow-up period. Of the seven pilots who did not RTFD, one retired within a year of surgery, two had anterior cruciate ligament injuries, three had residual radicular symptoms, and one had chronic low back pain. Excluding pilots who retired and did not RTFD for reasons unrelated to their lumbar conditions, the RTFD rate stood at 81.0% (17 of 21). The median time for recommended clearance by spine surgeons was 143.0 days (inter-quartile range, 116.5–196.0), while the median duration for actual RTFD attainment was 221.0 days (inter-quartile range, 182.0–300.0). The median follow-up post-lumbar surgery was 1.7 years (inter-quartile range, 0.4–2.9).ConclusionMost military pilots diagnosed with symptomatic LDH and LIS can continue their careers and regain active-duty flight status following lumbar spine surgery, as reflected by the high RTFD rate. Lumbar spine surgery can successfully alleviate the physical constraints associated with spinal conditions, facilitating the return of military pilots to their demanding profession.

SINTOMAS RADICULARES ASSOCIADOS COM A COLOCAÇÃO EXTRAPEDICULAR DE PARAFUSOS

ABSTRACT Objective: Transpedicular fixation has rapidly evolved over the last 100 years. A common complication is screw misplacement which can lead to neurological deficits, vascular damage, or organ perforation. We intend to assess the correlation between screw misplacement and radicular symptoms through the Gertzbein scale. Methods: We conducted an observational longitudinal retrospective study on patients who underwent free-hand lumbar instrumentation surgery with fluoroscopy assistance. The patients were evaluated with postoperative CT scans, and screw positions were classified with the Gertzbein scale. Results: The initial sample included 99 patients who underwent surgery. Of the 317 screws placed, 201 did not show cortical damage, 105 screws exhibited variable invasion, and 11 screws displayed severe invasion. 96.5% screws were placed in the safe zone, with 8.6% of patients (n=5.0) exhibiting transitory weakness. 3.47% of screws (n=11) with severe invasion were seen in 7 patients of which two patients suffered from motor deficient and persistent radicular pain. Conclusion: It is of the utmost importance to pay attention to the precise insertion of the screws to minimize the risk of radicular manifestations. We recommend performing control CT scans after the procedure to ensure the correct insertion of the screws, and in case of finding a screw in a no-safe zone or Getsbein 3 position, considering screw repositioning due to high-risk neurologic damage is highly encouraged. Level of Evidence II; Observational Retrospective Study.