S1 Nerve Research Articles

In toto resection of a rare intradural extramedullary cavernous malformation on the S1 nerve root: illustrative case.

Cavernous malformations (CMs) are vascular malformations that usually occur in the brain and occasionally in the spine. Most CMs are sporadic, but they can also be caused by heterozygous cerebral cavernous malformation (CCM) gene mutations. This case describes an intradural extramedullary CM in a unique location, within a fascicle of the S1 nerve root. This tumor was found to have a CCM2 mutation. An operative video demonstrates the surgical procedure used to remove this S1 intradural extramedullary CM. A 61-year-old male with an intradural extramedullary CM, located within a fascicle of the S1 nerve root, presented with pain and neurological symptoms. Additional imaging revealed two CCMs. The S1 CM was removed in toto. Subsequently, genetic screening revealed a CCM2 mutation. Given the rarity of a radicular CM, diagnosis can be challenging. CMs should be considered in patients with radicular pain and corresponding nerve root thickening. When a CM is suspected, imaging of the complete neuraxis should be performed. If multiple CMs are found, genetic screening is indicated. Complete resection of the CM yields good clinical results. The operative video in this case might help surgeons encountering this rare pathology to prepare for surgery. https://thejns.org/doi/10.3171/CASE24270.

Dural manipulation coinciding with transient asystole during lumbar spine surgery: illustrative case.

Hemodynamic disturbances during lumbar spine surgeries have proven to be exceptionally rare, with only seven published cases demonstrating instances where intraoperative dural manipulation coincided with bradycardia, hypotension, and/or asystole. The authors present the case of a 39-year-old male with a history of chronic low-back pain and leg weakness. Imaging demonstrated a disc herniation at L5-S1, resulting in impingement of the left S1 traversing nerve root. The patient agreed to surgery. The preoperative workup was unremarkable. While retracting the S1 nerve root, transient asystole occurred when the S1 nerve root was manipulated, causing the patient's heart rate to drop from 51 to 0 bpm. Manipulating the nerve root once again triggered a similar event, and upon cessation of the surgical stimulus, the patient's heart rate spontaneously returned to baseline. Other potential causes of these hemodynamic perturbations were excluded. As in other reported cases, each cardiovascular disturbance corresponded with either direct or indirect dural manipulation. Given the limited number of lumbar spinal cases reported to have undergone hemodynamic perturbances via dural manipulation, this case report provides evidence for the likelihood of a spinal-cardiac reflex between the cardiovascular system and the spinal dura mater. https://thejns.org/doi/10.3171/CASE24158.

Foot pressure transfers are altered in lumbar radiculopathy but reversible after surgery: a prospective, pedobarography study

BACKGROUND CONTEXTPatients with lower lumbar stenosis and disc herniation report disability in standing and ambulation, despite normal neurological examination. The L5 and S1 nerve roots support the entire motor and sensory function of the foot, and their radiculopathy can affect foot loading during standing and walking. This has not been quantified before. PURPOSETo quantify alterations in static and dynamic foot pressure transfers in patients with lower lumbar nerve root compression, and document any beneficial effects of surgical decompression. STUDY DESIGNProspective, case-control study. PATIENT SAMPLECases—Patients with unilateral radiculopathy (L5/S1) with normal neurology (n=50); Controls - Healthy volunteers (n=50). METHODSThe volunteers and patients underwent pedobarographic analysis during standing (static) and walking (dynamic), and fifteen (12 dynamic and three static) parameters were documented. The patient's preoperative values were compared with that of the healthy volunteers. All the 50 patients underwent surgical decompression, and clinical outcome measures (VAS/ODI at 3 months) were documented. Pedobarographic analysis was repeated in the postoperative period (48 hours) and 3-month follow-up and compared with the preoperative scores. RESULTSIn healthy controls, the mean values of all 15 parameters were comparable between the right and the left side (p>.05). When compared to controls, the patients had significantly lower maximum foot loads (p=.01) and average foot loads (p=.05) on the affected side during walking indicating lesser load transmission, in the preoperative period. Within the affected foot, the load transfer was higher on the first metatarsal/ medial arch while significantly less on the lateral metatarsals (p=.04). The percentage load on whole foot and forefoot was significantly less on standing (p=.01). Significant improvements were noted in the postoperative period, especially in the maximum foot surface area (p=.01), maximum and average foot loads, and improved weight transfers on lateral arch and forefoot (p=.02). The load on whole foot increased significantly from 46.1%±5.5% (preoperative) to 48.1%±5.5% (postoperative) and 49.9%±3.3% at follow-up (p=.01). CONCLUSIONThis is the first study using pedobarography to document altered foot pressure patterns during ambulation in patients with disc herniation and stenosis. Decreased load transfer, asymmetrical and unphysiological distribution of pressures on the affected foot were observed during weight bearing, which improved after surgical decompression.

Vacuum Disc Phenomenon Turned Gassy Disc Herniation: A Case Report

BACKGROUND: The vacuum phenomenon is a radiologic finding that results from gas accumulation within degenerated discs, joints, or vertebrae. This gas can herniate, causing back pain and/or radiculopathy. Asymptomatic imaging abnormalities can be coincidental and/or non-concordant with clinical presentation therefore warranting close evaluation. CASE REPORT: This 45-year-old man, previously diagnosed with lumbar facet arthropathy, returned to the clinic for left-sided axial low back pain. Imaging revealed that a gas filled mass in the right lateral recess was affecting the traversing right L5 and S1 nerve roots. Given the exclusive axial symptoms consistent with lumbar zygapophyseal joint arthropathy, the patient was treated with a repeat L3-4 medial branch and L5 dorsal ramus radiofrequency ablation and experienced subsequent near-complete pain resolution. CONCLUSIONS: Careful consideration must be taken when conducting clinical evaluation, imaging, diagnosis, and treatment of patients with low back pain given the significant frequency of abnormal, often nonconcordant, radiological findings. KEY WORDS: Pneumorrhachis, vacuum disc phenomenon, low back pain, case report

Conjoined Lumbosacral (L7-S1) Nerve Roots in a Dog

Vertebral and spinal cord anomalies are well known in veterinary medicine. However, nerve root anomalies are seldomly reported. In human patients, nerve root anomalies can cause back pain and radicular pain. In human medicine, nerve root anomalies are more often found in cadaveric studies than in imaging studies, representing the lack of advanced imaging in the past and the unawareness about these pathologies. Additionally, nerve root anomalies can mimic other pathologies in imaging studies. It is important to know about the anatomy of the individual patient not only for correctly localizing the pathology but also for surgical planning and to prevent iatrogenic trauma to the patient. Conjoined nerve roots are a type of nerve root anomaly described in human medicine and are defined as two nerve roots that either share a common dural envelope at some point during their course from the dural sac or that have their origin very close together in the dural sac. In humans, lumbosacral nerve roots are most commonly conjoined, and signs of pain may be associated with this anomaly. We report the magnetic resonance imaging finding of right-sided conjoined L7 and S1 nerve roots in a dog that presented with lumbosacral hyperesthesia. We postulate that it is possible that the conjoined nerve roots played a role in the clinical signs of this dog. This is an anomaly that has not been reported before in veterinary medicine.

Potential S1 Nerve Root Blocks Associated with Sacroiliac Joint Injections.

Sacroiliac (SI) joint dysfunction is a common cause of lower back pain. The diagnosis of SI joint pain remains challenging. Sacroiliac joint injection remains the gold standard of diagnosis of SI joint pain as well as providing therapeutic effect. One complication related to SI joint injection is temporary numbness and weakness of the leg. To evaluate the anatomy of the SI joint and the flow of the contrast in the sacroiliac joint and to understand how local anesthetic can affect the nerve roots and cause temporary weakness and numbness of the leg. Study Design. Retrospective case series. Setting. Academic medical center. Patients who underwent SI joint injection with three-dimensional cone beam computed tomography with fluoroscopy (3D-CBCT) imaging were identified through retrospective review of two providers' case log from the electronic medical record. The cone beam CT images were reviewed to study the contrast spread and flow in the SI joint. 27/32 patients with the mean age of 56 years (range 39-87 years), 20 females, and 7 males were included in this study. After reviewing cone beam CT images, 4/27 (14.8%) patients showed contrast spread in the SI joint and spread into the S1 posterior neuroforamen. The remainder 23/27 (85.2%) patients had contrast localized in the SI joint. Limitations. Small population size, retrospective review of medical records. Our results indicate that the injection of lower concentration of local anesthetic with less volume may be necessary to decrease the risk of S1 nerve root block and epidural block. Furthermore, to improve the specificity of a diagnostic SI injection, an appropriate evaluation should be considered to rule out any S1 nerve pathology as a significant pain generator.

Step-by-step demonstration of "sciatic-nerve-preserved beyond-LEER" in a Thiel-embalmed cadaver: a novel salvage surgery for recurrent gynecologic malignancies.

Complete resection is the curative treatment choice for recurrent gynecological malignancies. Laterally extended endopelvic resection (LEER) is an effective surgical salvage therapy for lateral recurrence. However, when a recurrent tumor occupies the ischial spine and sacrum, LEER is not indicated, and surgical salvage therapy is abandoned. Theoretically, complete resection of such a tumor is possible by additional pelvic bone resection along with the standard LEER. Nevertheless, owing to the anatomical complexities of the beyond-LEER procedure, 2 major issues should be solved: sciatic nerve injury and tumor disruption during pelvic bone amputation. To overcome these technical challenges, we applied a multidirectional beyond-LEER approach, a novel salvage surgical procedure, with an aim of demonstrating its technical feasibility. We created a simulation model of a laterally recurrent tumor that occupied the right ischial spine and sacrum in a Thiel-embalmed cadaver. Multidirectional approaches, including laparoscopic, perineal, and dorsal phases, were safely applied. We laparoscopically marked the L4-L5-S1 complex and S2 nerve with different colored tapes, and by pulling them out into a dorsal surgical field, the sciatic nerve was safely preserved. The dissection lines of the multidirectional approaches were aligned using tapes as landmarks, and complete tumor clearance without tumor disruption was accomplished. By following the cadaveric training, the first laparoscopic-assisted beyond-LEER procedure was successfully performed in a patient with recurrent ovarian cancer. Using a Thiel-embalmed cadaver, we demonstrated the technical feasibility of a sciatic nerve-preserved beyond-LEER procedure, which was successfully performed in a patient with recurrent ovarian cancer.

Macro-anatomical Investigations on the Plexus Lumbosacralis of the Aksaray Malakli Dog

Background: In this study, cadavers of 5 adult Aksaray Malakli breed dogs were used to examine the structure of the lumbosacral plexus, which provides innervation of the hindlimb and pelvic region. Objectives: This study aimed to determine the nerve root composition of the lumbosacral plexus, determine the branching patterns, map the nerve directions macro-anatomically, and collect data for future comparisons with similar breeds. Methods: The corpses were kept in a formaldehyde pool (10%) for 14 days. After this period, the anatomical area was dissected using appropriate techniques to identify the lumbosacral plexus nerves and roots. The course and origin of the nerves forming the plexus were identified and photographed. Results: In all 5 cadavers, the lumbosacral plexus originated from the L4-S3 nerves. The plexus comprised n. ischiadicus, n. tibialis, n. obturatorius, n. femoralis, n. saphenous, n. pelvini, n. pudendus, n. cutaneus femoris caudalis, n. peroneus communis, and n. gluteus caudalis. Conclusion: It was determined that n. femoralis was formed from the ventral branches of the L4 and L5 nerves and the cranial branch of the L6 nerve. N. obturatorius originated from the caudal branch of L5 and the ventral branch of L6. It was determined that n. ischiadicus originated from the L6 caudal, L7 and ventral branch of S1 nerves. The femur branched into n. tibialis and n. peroneus communis (n. fibularis) at the level of extremitas distalis.

Comparative Evaluation of Caudal Epidural Method to Ultrasound-Guided S1 Transforamen Block in Patient's Lumbar Discectomy with Failed Back Syndrome Symptoms: A Double-Blind Clinical Trial.

Post-lumbar surgery syndrome (PLSS) refers to persistent or recurrent pain following spinal surgery with an unknown cause. It is commonly associated with epidural fibrosis (EF). Some studies suggest that epidural steroid injection (ESI) can effectively alleviate pain in PLSS, particularly when targeting the S1 nerve root using S1 transforaminal epidural steroid injection (S1-TFESI). A key factor in a successful block is accurately visualizing the first dorsal sacral foramen, and the needle's destination is the dorsal S1 foramen. Although S1-TFESI is often performed under fluoroscopy through the transforaminal route, an alternative to reduce radiation exposure is ultrasound guidance. This study aimed to compare the efficacy of ultrasound-guided caudal epidural steroid injection (CESI) and S1-TFESI in PLSS patients. A randomized double-blinded clinical trial was conducted involving 52 PLSS patients who were randomly assigned to either the CESI group or the S1-TFESI group. The patients were positioned prone. A linear transducer with a curve at a low frequency (2 - 5 MHz) was used to visualize the area. An aseptically prepared puncture site was used to insert a 2- to 5-MHz curved ultrasound probe with an ultrasound gel to identify the articular processes of the lower lumbar vertebrae and the posterior sacral surface. The probe was then positioned longitudinally to the para-sacral area, about 2 cm lateral to the midline. The articular process represented the L5/S1 level at the farthest caudal side, and the S1 posterior sacral foramen was represented by the concavity at the posterior sacral surface that was somewhat caudal. The probe was angled caudally to provide enough room for the needle to enter the S1 foramen. The injection site for the needle tip was the S1 foramen. A combination of triamcinolone (40 mg, 1 mL), normal saline (2 mL), and ropivacaine (0.2%) was administered. For TFS1 ESI, 5 mL of the combination was used. For CESI, the sacral hiatus was palpated in the prone position, and a linear high-frequency transducer was placed transversely to obtain a transverse view of the sacral hiatus. A combination of triamcinolone 40 mg and ropivacaine (0.2%) totaling 10 mL was employed. The Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) were used to assess patients' preoperative and postoperative conditions, and adverse events were recorded. Follow-up was conducted one week and one month after the procedures. In both groups, NRS and ODI scores decreased at different time points after treatment, compared to baseline (P < 0.001). The CESI group had lower median ODI scores after one week and one month, although this difference did not reach statistical significance (P = 0.334). Despite similar baseline NRS ratings, the CESI group had statistically significantly lower mean NRS scores at one week and one month (P < 0.001). The current study demonstrated that both CESI and TFESI treatments for PLSS following lumbar discectomy are effective and safe. These procedures can alleviate pain and reduce disability. Although the success rates of the two procedures are comparable, CESI appears to be more successful in reducing pain at the one-week and one-month follow-up.

Anatomical Analysis of the S1 Neural Foramen Using Three-Dimensional Computed Tomography Imaging: Insights for Effective S1 Nerve Root Block

The first sacral nerve root block (S1 NRB) is used to diagnose and treat lumbosacral and radicular pain. This study aims to clarify the anatomy of the S1 neural foramen using three-dimensional (3D) computed tomography (CT) images and to establish the optimal fluoroscopic angle, localize the S1 neural foramen on fluoroscopy, and determine the safe puncture depth for S1 NRB. In this single-center cohort study, 200 patients with lumbar degenerative disease who underwent preoperative CT were enrolled. Four distinct studies were conducted using the CT data. Study 1 examined the correlation of the sacral slope angle and the supine and prone positions. Study 2 analyzed the tunnel view angle (TVA) using 3D reconstruction. Study 3 ascertained the location of the S1 neural foramen in fluoroscopy images. Study 4 investigated the safe depth for performing S1 NRB. The regression analysis in Study 1 revealed a correlation of the sacral slope angle and the supine and prone positions. Study 2 determined an optimal fluoroscopic TVA of approximately 30° for the S1 NRB. Study 3 found that the S1 neural foramen was located caudal to the L5 pedicle 1.7±0.2 times the distance between the L4 and L5 pedicles. Study 4 revealed that the depths of the S1 neural foramen and root were 27.0±2.1mm and 16.5±2.0mm, respectively. Our study suggests an optimal fluoroscopic angle, a simple method to locate the S1 neural foramen on fluoroscopy, and an ideal puncture depth for a safe and effective S1 NRB.

FRI634 Diagnostic Delay Of Diabetic Amyotrophy Is Associated With Complicated Disease Leading To Mental, Physical, And Financial Debilitation- A Case Report

Abstract Disclosure: A.J. Zaidi: None. W. Staehle: None. Introduction: Delay in diagnosis is a major problem impacting medicine, especially if pathology is not very common, like Diabetic amyotrophy. It typically presents with unilateral proximal muscle weakness and pain affecting thighs, hips and buttocks. It is relatively a rare neurological complication of Diabetes Mellitus and prediabetes, affecting approximately 1 percent of the patients. It is commonly underrecognized leading to long course to diagnosis. Case presentation: A 58 year old female presented to clinic with 5 year history of Lower back and left hip pain, slowly progressive leg weakness, with weight loss 25 pounds. Her past medical history included Type 2 diabetes mellitus with A1C 6.9, controlled by Metformin alone. She had multiple previous presentations to local primary care physicians, with unclear clinical diagnosis. She underwent several tests and imaging, was seen by neurologist, orthopedist and spine physician. Her treatments included pain regimens with N-acetylcysteine, Ibuprofen, gabapentin, tizanidine, lidocaine patch, low dose steroids, physical therapy and chiropractor visits. These provided only partial symptomatic relief. She had no other significant history, She lost her job due to being limited by her pain. Exam revealed discomfort to palpation on lower lumbar, generalized atrophy of left thigh muscles, asymmetric proximal weakness, normal sensation and reflexes. Blood work showed normal ESR, CRP, CPK, ANA, myomarker panel, Vit D levels. CSF evaluation was deferred by the patient. Imaging from previous records included Hip X-ray with mild degenerative disease, Lumbar CT with mild arthropathy on the Left L5- S1. Unremarkable lumbar and Sacral MRI. EMG revealed L4 radiculopathy with denervation of L vastus medialis and tibialis anterior, Irritation in S1 nerve root, without denervation. Based on overall investigations, and lack of evidence of alternative diagnosis, it was determined that the patient had Diabetic Amyotrophy. She refused IVIG, treated with prednisone 5mg PO oral for a month, Duloxetine and gabapentin, with significant improvement in pain and weakness. Patient was also connected with appropriate social services, physical and occupational therapy. Conclusion: Diagnostic delay of diabetic amyotrophy can lead to mental, physical, and financial debilitation. Due to low prevalence and broad differential of proximal muscle wasting, it is a challenging to diagnose and remains the diagnosis of exclusion. EMG studies with polyradiculopathy in proximal leg musculature is suggestive. Physicians should have a high clinical suspicion for diabetic amyotrophy to prevent long clinical course leading to harm to the patient. The emphasis is on creating awareness of the disease, and improving communication among clinicians and with patients, which are relatively minor investments to prevent delayed diagnosis of underrecognized complication. Presentation: Friday, June 16, 2023

OA03 Trauma secondary to a horse riding accident as a potential accelerating factor in inflammatory axial sponyloarthropathy: a case report and literature review

Abstract Introduction Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterised by axial involvement and sacroiliitis. The etiology of AS remains elusive, with genetic and environmental factors implicated in disease development and progression. This case report aims to investigate the potential association between trauma and the acceleration of AS in individuals positive for HLA-B27. Furthermore one purpose of this case-report is to ascertain any link between horse riding accidents in jockeys or professionals undertaking horse riding as a career choice. Is there a correlation between trauma and development of inflammatory axial spondyloarthropathy subsequently or not. Case description A 24-year-old female patient with a medical history of eczema and Graves' disease, currently undergoing propylthiouracil treatment, was referred to the rheumatology clinic due to persistent back pain for the past six to seven years following a horse riding accident. The patient had previously received physiotherapy and found relief with naproxen and co-codamol. The pain primarily affects her lower spine and radiates down her legs. While movement provides some relief, lying down exacerbates the pain. The patient experiences stiffness for approximately 30 minutes in the morning but does not exhibit peripheral joint symptoms. Exercise helps alleviate her symptoms. The patient reported a family history of psoriasis but denied any history of uveitis, inflammatory bowel disease, weight loss, night sweats, heartblock or achilles tendinitis. She also gave a history of joint hyper mobility with reduced flexion at the spine over the years. Blood tests revealed normal levels of ANA, CCP, ESR, rheumatoid factor, B12, HbA1c, and thyroid function. Ferritin levels were 30.2, and HLA B27 was positive. Joint examination did not reveal any signs of synovitis. The patient exhibited good range of motion in the spine. SLR's were positive on both sides and no tenderness over spine or sacroiliac joints. Systemic Examination was normal. BASDAI score was 4. Occiput to wall distance of 0 centimeters. Beighton score 4/9. Subsequently MRI whole spine/SI Joints were organised and results indicated a central disc protrusion at the L4-L5 level leading to critical spinal stenosis and likely impinging on the transitioning L5 and S1 nerve roots. Additionally, a disc protrusion at the L5-S1 which was impinging on the left S1 nerve root. Bilateral sacroiliitis was also observed. Patient was treated with NSAIDs and physiotherapy with good results with a view for a subsequent MRI, and escalation to biologics if symptoms were to worsen. Discussion The presented case raises the question of whether trauma accelerates the progression of ankylosing spondylitis (AS) in individuals who are positive for HLA-B27. Although this specific case involves a 24-year-old female patient with a history of back pain following a horse riding accident, additional research and studies would be required to draw definitive conclusions regarding the relationship between trauma and the development or acceleration of AS in HLA-B27 positive individuals. The question this case report poses and there is little in terms of research and case reports present, whether the involvement of the lady in question in a horse riding accident unmasked her ankylosing spondylitis given her HLA B27 positivity and the presence of sacroilitis on MRI scans. Literature review revealed a potential role of trauma accelerating the progression of ankylosing spondylitis in individuals who are also positive for HLA B-27, in addition in some cases it lead to detection and unmasking of chronic back pain which was inflammatory in nature rather than mechanical or a combination of both. This was revealed by the horse riding accident given the nature of the pain which had been constant and worsening which lead to a suspicion of a possible inflammatory component and hence further investigations were done. In conclusion this case report highlights the importance of a possible correlation between AS in HLA B27 positive individuals and raises the question whether trauma secondary to sports injuries like horseback riding accidents in our patients case, accelerates the progression of AS in individuals who are positive for HLA-B27. Key learning points This case report highlights the potential role of trauma following a sports injury as a contributing factor in the acceleration of AS in individuals positive for HLA-B27. Further investigations, including prospective studies, are warranted to elucidate the complex interplay between trauma, genetic predisposition, and disease progression in AS. The purpose of this case report is to remind sports medicine physicians of the prevalence of rheumatologic diseases in general and ankylosing spondylitis in particular and of the various ways in which spondyloarthropathies may present in athletes/sports personnel. Increased suspicion may lead to earlier diagnosis and treatment, potentially reducing illness severity and duration and improving the performance of athletes with this condition.

Management of Sciatica Pain in Primary and Secondary Settings

Katishoola is the term used in ayurvedic texts which resembles low back pain. The term ‘Kati’ used for lower back arises from the oldest language of human civilization, Sanskrit (4000–5000 BC). In an ancient text, Amarkosha ‘Kati’ has been related to the area of ‘Sroni’ or hip bone. Shoola (Ruja, Vyatha, Yama, or Ruk) is pain or discomfort. The earliest evidence of back pain outside the Indian subcontinent comes from an ancient Egyptian surgical text called Edwin Smith papyrus (named after Edwin Smith, who bought it in 1862. Sciatica pain is a direct result of pressure on sciatic nerve or sciatic nerve root pathology. The sciatic nerve is made up of the L4 through S2 nerve roots, which coalesce at the pelvis to form the sciatic nerve. About 2cm in diameter, the sciatic nerve is easily the largest nerve in the body. Sciatica pain often is worsened with twisting, bending, or coughing. In India most practicing doctors across all systems usually determine the cause of Sciatica pain by asking a few questions and a thorough physical examination. Imaging is initially of little value. An MRI or a non-contrast CT scan may be performed to evaluate fracture if plain films are negative. Management of Sciatica traditionally revolves around reducing pain and inflammation, strengthening supportive muscles in lower back, hips, and thighs. Laminectomy or Discectomy are attempted if the surgery is needed to relieve the pressure on the nerve. Of late a New German technology powered based on regenerating new tissue becoming popular. This article reviews about 5 patients and 6 episodes of Sciatica. Four episodes were common and two un-common conditions, of which only needed laminectomy. Their management by different systems of medical practice are described and review of the literature across the systems adds to the epidemiology, causes and management of Sciatica in India. Materials &amp; Methods: Four cases, one of them suffering twice after an interval of a decade and traditional management of these cases by allopathic, Unani system, Homeopathy and Yoga exercises, for the core content of sciatica management in Primary and secondary settings. Brief notes on two cases needing surgery and the first-hand information on latest QI based neuromodulation approach update complete the options currently available in India.

Assessment of Lumbosacral Nerve Roots in Patients with Type 2 Diabetic Peripheral Neuropathy Using Diffusion Tensor Imaging.

Diffusion tensor imaging (DTI) has found clinical applications in the evaluation of the central nervous system and has been extensively used to image peripheral neuropathy. However, few studies have focused on lumbosacral nerve root fiber damage in diabetic peripheral neuropathy (DPN). The aim of the study was to evaluate whether DTI of the lumbosacral nerve roots can be used to detect DPN. Thirty-two type 2 diabetic patients with DPN and thirty healthy controls (HCs) were investigated with a 3T MRI scanner. DTI with tractography of the L4, L5, and S1 nerve roots was performed. Anatomical fusion with the axial T2 sequences was used to provide correlating anatomical information. Mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were measured from tractography images and compared between groups. Diagnostic value was assessed using receiver operating characteristic (ROC) analysis. The Pearson correlation coefficient was used to explore the correlation between DTI parameters and clinical data and the nerve conduction study (NCS) in the DPN group. In the DPN group, FA was decreased (p < 0.001) and ADC was increased (p < 0.001) compared with the values of the HC group. FA displayed the best diagnostic accuracy, with an area under the ROC curve of 0.716. ADC was positively correlated with HbA1c level (r = 0.379, p = 0.024) in the DPN group. DTI of lumbosacral nerve roots demonstrates appreciable diagnostic accuracy in patients with DPN.

Complications of conventional percutaneous sacroiliac screw fixation of traumatic pelvic ring injuries: a systematic review and meta-analysis.

The objective of this review was to present a thorough overview of the complications associated with conventional percutaneous sacroiliac screw fixation to identify areas for improvement in surgical technique and patient selection. PubMed/Medline, Web of Science, Embase, Ovid, Cochrane library, and Google Scholar were systematically searched for original human studies reporting on complications of conventional percutaneous sacroiliac fixation in traumatic pelvic ring injuries from January 1, 2000, to April 30, 2022. The main meta-analysis was based on the random effect model to pool all complications reported in the included studies. The results were reported as weighted proportions with 95% confidence intervals. This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 56 studies with 3644 screws (2871 procedures) met the inclusion criteria, with a mean age of 40.5years. The most frequently reported complications were screw malposition with a weighted proportion of 6% (95% CI: 5-9%) and involved 189 out of 3644 screws, persistent pain following the procedure with a weighted proportion of 3% (95% CI: 2-4%) and affected 98 out of 2871 patients, and nerve injury, which had a weighted proportion of 2% (95% CI: 1-3%) and was observed in 41 out of 2871 procedures. The L5 and S1 nerve roots were more frequently affected. Revision surgery was required for 184 out of 2871 patients with a weighted proportion of 5% (95% CI: 3-7%). The primary reason for the revision was persistent pain after the initial procedure, which affected 74 out of 184 patients, with a weighted proportion of 2.0% (95% CI: 1.2-2.8%). This study showed that screw malposition, the need for revision surgery, persistent pain, and nerve injuries were the most frequent complications following conventional percutaneous sacroiliac screw fixation. However, these results must be interpreted in context due to confounding factors, including the lack of high-quality studies and the absence of uniformity in defining some complications across studies.

V12-02 SACRAL NEUROMODULATOR OPTIMAL LEAD PLACEMENT TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V12-02 SACRAL NEUROMODULATOR OPTIMAL LEAD PLACEMENT TECHNIQUE Sabrina Stair, Una Lee, and Alvaro Lucioni Sabrina StairSabrina Stair More articles by this author , Una LeeUna Lee More articles by this author , and Alvaro LucioniAlvaro Lucioni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sacral neuromodulation is an FDA approved treatment for overactive bladder. Efficacy depends on correct lead placement. The optimal lead placement technique uses real-time fluorosocpy to place the the sacral neurostimulator lead into the most superior and medial aspect of the S3 foramen. Here, we seek to provide guidance on using the optimal lead placement technique. METHODS: Using a recent sacral neurostimulator implant as an example case, we outline the critical steps and key teaching points for sacral neurostimulator implant. RESULTS: Optimal lead placement technique is demonstrated within the video. The patient is positioned in swimmer's position. Real time fluoroscopy is used to identify the most medial aspect of the sacral foramina, and then to guide the entry point of the introducer needle such that it is parallel to the bone seam. This lead placement maximizes stimulation of S3 sacral nerve roots while minimizing stimulation of S2 and S4 nerve roots. In an ideally placed lead, bellows response occurs before toe response. The lead is tested prior to full implant. CONCLUSIONS: Correct patient positioning and knowledge of target anatomy is key the optimal lead placement technique. Optimal lead placement technique uses real time imaging to place lead precisely, leading to improved clinical outcomes. This also increases the efficiency of lead placement, leading to faster operative times and increased cost-savings. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1065 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sabrina Stair More articles by this author Una Lee More articles by this author Alvaro Lucioni More articles by this author Expand All Advertisement PDF downloadLoading ...

Fluoroscopy-Guided Versus Fluoroscopy-Confirmed Ultrasound-Guided S1 Transforaminal Epidural Injection with Pulsed Radiofrequency: A Prospective, Randomized Trial.

The aim of this prospective randomized controlled study was to compare the effectiveness and accuracy of the ultrasound- and fluoroscopy-guided S1 transforaminal epidural injection combined with pulsed radiofrequency in patients with lumbosacral radicular pain caused by S1 nerve involvement. A total of 60 patients were randomized into 2 groups. Patients received S1 transforaminal epidural injection combined with pulsed radiofrequency under either ultrasound or fluoroscopy guidance. Primary outcomes were estimated with Visual Analog Scale scores at 6 months. Secondary outcomes included Oswestry Disability Index, Quantitative Analgesic Questionnaire, and patient satisfaction scores during the 6-month follow-up period and procedure-related variables including procedure time and accuracy of the needle replacement. Both techniques provided significant pain reduction and functional improvement for 6 months compared to baseline (P < .001), without statistical significance between groups at each follow-up point. There was no significant difference in pain medication consumption (P=.441) and patient satisfaction scores (P=.673) between groups. The fluoroscopy guidance for combined transforaminal epidural injection with pulsed radiofrequency at S1 provided a greater accuracy for the cannula replacement (100%) than the ultrasound (93.3%), without significant difference between groups (P=.491). The ultrasound-guided combined transforaminal epidural injection with pulsed radiofrequency at S1 level is a feasible alternative to fluoroscopy guidance. In this study, we reported that the ultrasoundguided technique resulted in similar treatment benefits including improvement in pain intensity and functionality and reduction in pain medication consumption as those in the fluoroscopy group, while reducing the risk for radiation exposure.

Conjoined nerve root in a patient with lumbar disc herniation accompanied by a lumbosacral spine anomaly: a case report

BackgroundA nerve root anomaly, typified by a conjoined nerve root, is a rare finding. Conjoined nerve root anomalies are easily missed even in preoperative advanced imaging modalities, which can be potentially troublesome during and after surgery. In this report, we present a case of conjoined right L5–S1 nerve root in a patient with lumbar disc herniation, accompanied by spina bifida occulta, which was undiagnosed on preoperative imaging studies.Case reportA 55-year-old Asian (Japanese) woman presented with low back pain and right leg radiating pain due to lumbar disc herniation at the right L5/S1. Physical examination revealed a positive Lasègue sign and the range of the straight leg raising test was 20° on the right side. The right patellar tendon reflex was normal; however, the right ankle jerk reflex disappeared. Although no obvious hypoesthesia was noted, mild muscle weakness (4/5) was observed in the right leg on the manual muscle test. We planned the lumbar discectomy under a microscope. During surgery, the conjoined right L5–S1 nerve root, which was compressed by herniated nucleus pulposus, was encountered. Although it was very thick and less mobile, some pieces of herniated nucleus pulposus could be removed piece by piece from the axillary part. After sequential decompressive procedures, the tightness of the conjoined right L5–S1 nerve root decreased but its mobility did not improve much. The laterality of the thickness and exit angle of the conjoined right L5–S1 nerve root was retrospectively confirmed on T2 coronal magnetic resonance images and magnetic resonance neurography. Postoperatively, right leg pain was immediately alleviated and complete improvement of muscle weakness was achieved 1 week later (5/5).ConclusionsMagnetic resonance neurography is extremely useful for the accurate diagnosis of anomalous nerve roots because of clear visualization of the neural tissue. Discectomy under a microscope, which enables magnified three-dimensional observation of the surgical field, must provide a valid and safe procedure to achieve not only secure resection of herniated discs but also adequate exposure of anomalous nerve roots.

Extradural contralateral S1 nerve root transfer for spastic lower limb paralysis.

The current study aims to ascertain the anatomical feasibility of transferring the contralateral S1 ventral root (VR) to the ipsilateral L5 VR for treating unilateral spastic lower limb paralysis. Six formalin-fixed (three males and three females) cadavers were used. The VR of the contralateral S1 was transferred to the VR of the ipsilateral L5. The sural nerve was selected as a bridge between the donor and recipient nerve. The number of axons, the cross-sectional areas and the pertinent distances between the donor and recipient nerves were measured. The extradural S1 VR and L5 VR could be separated based on anatomical markers of the dorsal root ganglion. The gross distance between the S1 nerve root and L5 nerve root was 31.31 (± 3.23) mm in the six cadavers, while that on the diffusion tensor imaging was 47.51 (± 3.23) mm in 60 patients without spinal diseases, and both distances were seperately greater than that between the outlet of S1 from the spinal cord and the ganglion. The numbers of axons in the S1 VRs and L5 VRs were 13 414.20 (± 2 890.30) and 10 613.20 (± 2 135.58), respectively. The cross-sectional areas of the S1 VR and L5 VR were 1.68 (± 0.26) mm 2 and 1.08 (± 0.26) mm 2, respectively. In conclusion, transfer of the contralateral S1 VR to the ipsilateral L5 VR may be an anatomically feasible treatment option for unilateral spastic lower limb paralysis.

Symptom descriptors and patterns in lumbar radicular pain caused by disc herniation: a 1-year longitudinal cohort study

ObjectiveThe objective of the present study was to explore the diversity, quality, severity and distribution of symptoms in patients with radicular pain and a lumbar disc herniation.DesignLongitudinal cohort study.SettingHospital-based back...