Spinal cord stimulation (SCS) is an established therapy for chronic pain of the trunk and limbs. Conventional open-loop systems are sometimes limited by habituation, positional variability, and inconsistent neural recruitment. Closed-loop SCS is an approach that uses evoked compound action potentials (ECAPs) to adjust stimulation in real time to maintain consistent therapeutic effects. A systematic review is indicated to bring clarity to the efficacy and safety of these systems. To evaluate the efficacy of closed-loop SCS for chronic back and leg pain in persistent spinal pain syndromes. A comprehensive search of MEDLINE, Embase, Scopus, ScienceDirect, Cochrane Library, Google Scholar, and clinicaltrials.gov was conducted through April 2025. Eligible studies included Randomized Controlled Trials (RCT), prospective or retrospective cohort studies, and real-world observational studies evaluating closed-loop SCS in adults with lumbar radiculopathy, chronic back and leg pain, or persistent spinal pain syndromes. Outcomes included pain intensity, percentage of pain relief, disability, health-related quality of life, mood, sleep, and opioid use. Risk of bias was assessed using the Review Manager (Revman) tool within the Cochrane Collaboration resources. Four eligible studies met inclusion criteria for chronic back and leg pain, with responder rates (≥ 50% pain reduction) ranging from 68% to 92% and high-responder rates (≥ 80% pain reduction) from 50% to 60% across follow-up periods up to 36 months. Significant improvements were observed in disability (ODI), sleep quality (PSQI), mood (POMS), and quality of life (EQ-5D-5L). The EVOKE RCT trial demonstrated closed-loop SCS superiority over open-loop stimulation in both pain reduction and functional outcomes. Opioid use decreased substantially, with up to 83% of patients reducing or discontinuing opioids at 24 months. Reported adverse events were consistent with those seen in conventional SCS, and no unexpected safety concerns were identified. Growing evidence suggests closed-loop SCS provides predictive and durable pain relief with concurrent functional improvements in chronic back and leg pain, with additional benefits in opioid reduction for persistent spinal pain syndromes. PROSPERO registration number: CRD42024580458.

Guideline implementation for low back pain in German healthcare: a tale of overuse and underuse.

Spinal spondylosis - including degenerative disc disease, facet arthropathy, and stenosis - is a leading cause of chronic spinal pain. Regenerative biologics such as platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and mesenchymal cell therapies are increasingly used, yet evidence remains inconsistent. This systematic review synthesizes randomized controlled trials (RCTs) evaluating biologic injections for degenerative spinal conditions. MEDLINE, Embase, and Cochrane CENTRAL databases were searched from inception to September 22, 2025. Only RCTs evaluating PRP, BMAC, mesenchymal stem/stromal cells (MSCs), or mesenchymal precursor cells (MPCs) for degenerative spinal pain were included. Outcomes included pain, function, imaging, and adverse events. Risk of bias was assessed using Cochrane RoB 2. Thirteen RCTs met eligibility. For lumbar radiculopathy, four trials showed that corticosteroids provided faster early relief, but PRP produced significantly greater improvement at 3-6 months, with higher proportions achieving clinically meaningful pain and ODI reduction. In facetogenic pain, lumbar facet PRP surpassed steroids at 6 months, whereas cervical facet outcomes were similar across groups. Evidence for intradiscal PRP was mixed: one large RCT showed no benefit versus saline; smaller trials reported delayed functional gains. While autologous BMAC and MSC preparations did not demonstrate superiority over sham controls for primary pain and functional outcomes (Levi 2025, Vadalà 2025), allogeneic MPCs demonstrated significant, durable improvements in both pain and disability compared to saline through 36 months, particularly when delivered in a hyaluronic acid vehicle (Amirdelfan 2021). In contrast, a large multicenter RCT demonstrated that allogeneic MPCs significantly increased the proportion of patients achieving ≥ 10-15-point ODI improvement and durable pain reduction over 12-36 months (Amirdelfan 2021). Across all studies, adverse events were minimal, though one case of spondylodiscitis followed intradiscal PRP. PRP provides durable mid-term benefit for lumbar radiculopathy and lumbar facet pain, while intradiscal PRP, BMAC, and autologous MSCs show limited efficacy. Allogeneic MPCs are the most promising cell-based therapy but remain investigational. Standardization of biologic preparation and larger, multicenter RCTs are needed.

ABSTRACTIntroductionSupraneural transforaminal epidural steroid injections (TFESI) at the L5 level are widely used to manage lumbosacral radiculopathy. However, fluoroscopic barriers such as prominent osteophytes and altered transverse process morphology can complicate needle advancement and reduce the likelihood of optimal injectate delivery. Despite these procedural challenges, no standardized grading system currently exists to objectively quantify anatomical complexity or predict technical difficulty during L5 supraneural TFESI.MethodsThis study included 584 L5 supraneural TFESI cases performed in 273 L5 radicular lesions aged above 60. All procedures were performed under standardized fluoroscopic guidance by a single experienced pain physician using a consistent supraneural approach. The LTDS comprises six fluoroscopic criteria reflecting anatomical barriers at the L5/S1 level. The patients were stratified into three LTDS groups (Low, 0–3; Middle, 4–6; High, 7–10). Procedural outcomes were assessed based on needle position and the pattern of contrast spread. Receiver operating characteristic (ROC) analysis was performed to assess the discriminative performance of the LTDS for predicting epidurogram failure.ResultsHigher LTDS scores were significantly associated with longer procedure times and lower rates of optimal TFESI execution. Each one‐point increase in LTDS decreased the odds of successful injection by approximately 40%. ROC analysis demonstrated fair discriminative ability (AUC = 0.707; 95% CI, 0.651–0.764; p < 0.001). While an LTDS threshold of ≥ 5.5 provided the optimal balance between sensitivity and specificity, higher thresholds showed markedly increased specificity, indicating that the LTDS preferentially identifies cases with a high likelihood of technical difficulty rather than serving as a sensitive screening tool. The inter‐ and intra‐rater reliabilities of the LTDS were high (Cronbach's α = 0.886 and 0.891, respectively).ConclusionsThe LTDS demonstrates meaningful discriminative performance and high reliability for stratifying technical difficulty in L5 supraneural TFESI. Rather than functioning as a rigid predictor of failure, the LTDS serves as a practical decision‐support tool that may assist in preprocedural planning, approach selection, and operator training in patients with advanced lumbar degeneration.

Background: Far lateral lumbar disc herniation (FLLDH) accounts for a small proportion of lumbar disc pathologies and often requires surgical intervention when conservative management fails. Although minimally invasive tubular approaches are widely adopted, access to advanced microsurgical equipment remains limited in many centers. This study evaluates the clinical outcomes and feasibility of midline fragment-only sequestrectomy for FLLDH in a resource-limited setting. Methods: This retrospective single-surgeon case series included 35 patients with MRI-confirmed FLLDH treated by midline fragment-only sequestrectomy between 2018 and 2023. Patients with persistent radicular leg pain refractory to conservative treatment for at least 3 weeks and without spinal instability were included, whereas those with prior lumbar surgery, infection, or malignancy were excluded. All procedures were performed through a midline incision under microscopic visualization, using limited bone removal without formal hemilaminectomy or facetectomy to access the far lateral zone. Clinical outcomes were assessed using the Visual Analog Scale (VAS) preoperatively and at 12-month follow-up, and the Macnab criteria at final follow-up. Pre- and postoperative VAS scores were compared using the Wilcoxon signed-rank test. Results: The mean age was 45 years (range: 30–60). Herniation levels were identified as follows: L2–L3 (2.8%), L3–L4 (14.3%), L4–L5 (68.6%), and L5–S1 (14.3%). The mean operative time was 30 ± 10 minutes, and the mean blood loss was 40 ± 10 ml. All patients were discharged within 16 hours post-surgery. During the 24-month follow-up period, no recurrences or instability were observed. At the final follow-up, 82.8% of the patients reported excellent outcomes, while 17.2% reported good outcomes. Conclusion: Midline sequestrectomy yields favorable short- and long-term outcomes consistent with previously reported series and is a safe, cost-effective option in resource-limited settings.

Background: Concurrent intracranial and spinal chronic subdural hematomas are rare and may be difficult to diagnose. Intracranial CSDH usually presents with headache or neurological deficits, whereas spinal SDH may cause back pain and radiculopathy. Case Presentation: A 57-year-old man presented with 10 days of severe low back pain radiating to both lower limbs, associated with weakness and abnormal gait. Lumbar MRI showed a subdural hematoma extending from T12/L1 to S1/S2 with cauda equina crowding. Brain MRI revealed bilateral chronic intracranial subdural hematomas without significant mass effect or midline shift. The patient was managed conservatively, and his symptoms resolved completely within 2 weeks. Conclusion: Severe lumbar radiculopathy may be the initial presentation of concurrent intracranial and spinal CSDH. Brain and spine imaging should be considered in older patients with unexplained spinal symptoms, especially after minor trauma or anticoagulant use.

Persistent post-lumbar pain syndrome (PSPS) type II is a frequent condition in Pain Units, with limited treatment options such as epidural corticosteroids or epidurolysis. Epidural pulsed radiofrequency (PRF) using a catheter has been reported as more effective than transforaminal PRF. This study evaluates the efficacy of epidural PRF with or without corticosteroids in patients with PSPS type II. A randomized, controlled, multicentre trial included 131 patients. Participants were allocated to either a control group receiving epidural corticosteroids alone or an experimental group receiving epidural PRF plus corticosteroids. Outcomes were assessed with the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), DN4 questionnaire, and Patient Global Impression of Improvement (PGI-I) at 1, 2, 4, and 6 months. Of the 131 patients, 72 were assigned to PRF + steroids and 59 to control. The PRF + steroids group showed significantly greater improvement in VAS (p ≤ 0.002 across follow-ups), ODI (p ≤ 0.004), DN4 (p ≤ 0.015), and PGI-I (p ≤ 0.004) compared with control. Number needed to treat for a 2-3 point reduction in VAS ranged between 2.7 and 2.9. No major complications were observed, and adverse effects were minor and transient. Epidural PRF combined with corticosteroids provides superior pain relief, functional improvement, and patient satisfaction compared with corticosteroids alone in PSPS type II. This technique appears safe, with no significant complications, and represents a promising minimally invasive option for managing persistent post-surgical lumbar radiculopathy. This randomized controlled trial provides the first multicentre evidence that epidural pulsed radiofrequency combined with corticosteroids is more effective than corticosteroids alone for persistent spinal pain syndrome type II. The study shows sustained improvements in pain, disability, and patient-reported outcomes with a favourable safety profile, supporting epidural PRF as a valuable therapeutic option for complex post-surgical lumbar pain.

Background/Objectives: Cervical and lumbar radiculopathy and carpal tunnel syndrome (CTS) are common conditions that are associated with persistent pain, functional impairment, and reduced quality of life. Nutraceutical strategies targeting neuroinflammatory and oxidative stress pathways are being investigated as adjunctive approaches in pain management. This study evaluated the clinical association between supplementation with a Gastrodiae elata Blume-based nutraceutical formulation (Assonal®) and changes in pain intensity, functional outcomes, symptom burden, and quality of life in patients with radiculopathy and CTS. Methods: A single-centre pragmatic before–after clinical study enrolled adults with cervical or lumbar radiculopathy and/or CTS. Participants received Assonal® (two tablets daily) for two months. Pain intensity was assessed using the Numerical Pain Rating Scale (NPRS) and Visual Analogue Scale (VAS). Secondary outcomes included the Back Pain Functional Scale (BPFS), the Boston Carpal Tunnel Questionnaire (BCTQ), the Neuropathic Pain Symptom Inventory (NPSI), the EuroQol-5D-5L (EQ-5D-5L), and the Global Perceived Effect (GPE). Longitudinal within-subject changes were analysed using repeated-measures statistical tests. Results: Thirty-four participants completed the study. The observed pain intensity decreased significantly from baseline to two months (NPRS: 7.2 ± 1.3 to 3.6 ± 1.2; VAS: 7.3 ± 2.1 to 3.3 ± 1.7; p < 0.0001) and functional measures showed improvements across BPFS and BCTQ assessments, accompanied by reductions in symptom burden (NPSI). Quality of life increased significantly (EQ-5D-5L index: 0.49 ± 0.23 to 0.81 ± 0.12; p < 0.0001), and most patients reported perceived clinical improvement. Conclusions: In this exploratory real-world study, Assonal® supplementation was associated with clinically relevant improvements in pain intensity, functional performance, and quality of life in patients with radiculopathy and CTS, suggesting the need for further investigation of these associations in future controlled clinical studies.

Brake time responses post therapeutic caudal epidural steroid Marcaine injections undertaken to treat low back pain with lumbar radiculopathy.

Single-blinded randomised controlled trial. To establish the effect of postoperative mobility restrictions on outcome after lumbar microdiscectomy by comparing sitting and activity restrictions to no restrictions for the first month after surgery. Lumbar microdiscectomy effectively treats lumbar radiculopathy, improving leg pain and functional outcomes. However, 20% of patients experience residual sciatica and 5% require redo discectomy. Persistent sciatica causes suffering, increases healthcare costs, and results in work absenteeism. While strategies to prevent reherniation include postoperative mobility restriction, evidence is limited regarding efficacy. Most surgeons still advise sitting or lifting restrictions after microdiscectomy. Two hundred patients (ages 18-75) undergoing unilateral microdiscectomy were randomised 1:1 to restricted (n=101) or unrestricted (n=99) groups. Restricted patients received limitations on sitting (15-30min per two hours), lifting (<5kg), and strenuous activities for two weeks. Unrestricted patients resumed normal activities as tolerated. All patients wore activity monitors (ActiV8) for one month. Assessments at baseline, day 1, and 1, 3, 6, and 12 months included VAS pain scores, Oswestry Disability Index, and quality-of-life questionnaires. The primary outcome was a composite of reduced pain, functional improvement, and absence of further interventions at 12 months. At one year, the primary composite outcome showed no significant difference between groups (restricted (41.6%) vs. unrestricted (36.4%), P=0.45). Secondary outcomes for restricted vs unrestricted groups respectively, including reherniation rates (10.1% vs. 14.1%, P=0.61), pain measures (VAS back reduction to 23.5 pts vs. 24.5 pts, P=0.83), functional improvements (SF-12 PCS 50.3 vs. 49.7 pts at 1y, P = 0.57), and reoperation rates (2.9% vs. 5.5%, P=0.68) were similar. Activity monitoring revealed poor adherence to restrictions (10%) with no significant differences in sitting duration or other activities between groups (4,102 vs. 4,140mins/wk, P=0.89). Liberalizing post-operative restrictions following lumbar microdiscectomy does not compromise outcomes. These findings support patient-driven recovery guided by comfort rather than rigid restrictions, potentially standardizing care guidelines and facilitating faster return to activities without compromising safety.

Background: Cervical and lumbar radiculopathy are prevalent neurological disorders caused by nerve root compression, leading to pain, sensory deficits, and functional impairment, significantly affecting patients’ quality of life. Objective: This review aims to summarize the pathogenesis, diagnostic approaches, and treatment strategies of cervical and lumbar radiculopathy, and to explore the possibility of their coexistence. Methods: A narrative review of published literature was conducted, focusing on etiology, pathophysiology, clinical presentation, diagnostic modalities, and management options for both conditions. Results: Cervical radiculopathy commonly results from disc herniation and cervical spondylosis, while lumbar radiculopathy is mainly associated with disc degeneration and structural changes affecting nerve roots. Diagnostic evaluation includes clinical assessment supported by imaging techniques such as MRI and CT, along with electrophysiological studies. Management primarily involves conservative approaches, including nonsteroidal anti-inflammatory drugs, muscle relaxants, physiotherapy, and lifestyle modifications. Interventional procedures such as epidural steroid injections and surgical options are considered in refractory cases. Both conditions share common inflammatory and mechanical mechanisms, and may coexist in some patients. Conclusion: Early diagnosis and appropriate multidisciplinary management are essential to improve patient outcomes. Clinicians should consider the potential coexistence of cervical and lumbar radiculopathy in complex clinical presentations.

Retrospective cohort study at a single institution. To determine the incidence of postoperative lumbar radiculopathy (PLR) following single-level anterior lumbar interbody fusion (ALIF) at L4-L5 or L5-S1, evaluate the unplanned return-to-operating-room (UPROR) rate, and assess associations of posterolateral foraminal cephalad endplate osteophytes (PFO) and superior articular process hooks (SAH) with PLR. Limited research exists on PLR incidence after ALIF or its association with PFO and SAH, which may contribute to indirect nerve root compression postoperatively. Patients undergoing single-level L4-L5 or L5-S1 ALIF from January 2022 to December 2023 were reviewed, excluding those with spinal deformity, trauma, or infection. PLR was categorized as new, persisting, or worsening. Data included PLR presence, new postoperative weakness, direct decompression history, Bone Morphogenetic Protein-2 (BMP-2) usage, PFO (>50% exiting nerve root width), and SAH (>2mm foraminal extension) on preoperative imaging. Radiographic parameters, including posterior disc height (PDH), spondylolisthesis, and lordosis at the operative level (L4-L5 or L5-S1), were measured preoperatively and 1-month postoperatively. Pearson chi-square tests assessed associations between PFO, SAH, decompression history, dynamic spondylolisthesis, and PLR. Multivariable logistic regression evaluated these as PLR predictors. Of 204 patients (mean age, 62.8y; 51% male), 37 (18.1%) developed PLR. SAH (P=.015) and PFO (P=.001) were significantly associated with PLR in chi-square analyses and remained independent predictors in multivariate regression (SAH: odds ratio [OR], 2.82; P=.017; PFO: OR, 3.25; P=.005). Among PLR patients, 27.0% had new weakness, 43.2% new radiculopathy, 24.3% worsening radiculopathy, and 32.4% persisting radiculopathy (categories not mutually exclusive). Symptoms resolved in 78.4% by 5.9 months (range, 0.07-23.7). UPROR occurred in 18 patients (8.8% total; 48.6% PLR), primarily for decompression (72.2% resolution post-reoperation). Ten patients (27.0%) received epidural steroid injections. PLR occurred in 18.1% of single-level ALIF patients; 78.4% resolved by 6 months. SAH and PFO independently predict PLR, necessitating preoperative evaluation to mitigate complications and reoperation risk.

Clinically, abdominal pain can also be caused by lesions of the vertebral bodies, intervertebral discs, and other structures. It is usually due to degenerative changes, injuries, or herniations of the intervertebral discs, as well as stimulation or compression of the sympathetic nerve plexus associated with the vertebral bodies, leading to nonspecific abdominal pain, medically referred to as "abdominal pain of spinal origin". A 70-year-old Asian female presented with a 20-year history of unexplained right lower abdominal pain, initially managed as a gastrointestinal condition. Despite extensive evaluations (including CT and colonoscopy), the etiology remained elusive. Multidisciplinary collaboration eventually identified a right-sided L4-L5 disc herniation compressing the right L4 spinal nerve root. A diagnostic selective nerve root block of the right L4 root was performed, resulting in 80% pain relief within 30minutes, confirming the spinal origin. Two days later, the patient underwent unilateral biportal endoscopic (UBE) discectomy. Postoperatively, the abdominal pain resolved significantly, and the Visual Analog Scale (VAS) score decreased to 2. At the 12-month follow-up, the patient remained pain-free. Lumbar radiculopathy can mimic visceral abdominal pain. In patients with intractable abdominal pain, spinal screening is crucial. Diagnostic nerve blocks serve as a key tool to confirm the diagnosis and guide minimally invasive surgical treatment.

The opioid epidemic and limitations of current nonopioid analgesics have created a need for safer, effective pain therapies. Suzetrigine, a first-in-class selective NaV1.8 inhibitor, was approved by the Food and Drug Administration in 2025 for the treatment of moderate to severe acute pain. The purpose of this review is to discuss the mechanism and clinical efficacy of suzetrigine and its potential for addressing existing therapeutic gaps in pain management. Phase 3 trials have demonstrated that suzetrigine provides a statistically significant and clinically meaningful reduction in acute postoperative pain compared to placebo, with efficacy similar to hydrocodone/acetaminophen and a favorable safety profile. Mechanistic studies confirm selective peripheral NaV1.8 inhibition, minimizing central nervous system effects and abuse potential. Ongoing research is evaluating suzetrigine for chronic pain conditions including diabetic peripheral neuropathy and lumbosacral radiculopathy, though long-term efficacy and safety remain to be established. Suzetrigine represents a promising nonopioid alternative for acute pain and has the potential to fill a significant gap in pain management. While initial results are encouraging, future studies are needed to define its role in chronic pain and multimodal analgesia, and to establish long-term safety.

National trends in lumbar facet cyst surgical management: rising fusion utilization without improved 5-year outcomes over decompression alone.

Background: Lumbar Radiculopathy is a widespread global concern, impacting about 70% of individuals at some point in their lives. Muscle weakness is a common contributor to Lumbar radiculopathy, and hand grip strength is a widely recognized measure of overall muscle health. This study seeks to explore the correlation between hand grip strength and varying intensities of Lumbar radiculopathy. Objective: To determine the association between hand grip strength and the severity of lumbar radiculopathy among adults aged 18–40 years diagnosed with lumbar radiculopathy in tertiary care hospitals of Peshawar. Methodology: This analytical cross-sectional study was conducted following ethical clearance from the Institutional Review Board, over a six-month duration, using a non-probability convenience sampling. Written informed consent was secured in both English and Urdu. Participants were assured that their involvement was entirely voluntary and that they had the right to withdraw from the study at any stage without facing any repercussions. About 675 males and females aged 18 to 40 years, diagnosed with lumbar radiculopathy, with a minimum duration of three months, were considered eligible. Individuals having multiple sclerosis, stroke, Guillain-Barré syndrome, carpal tunnel syndrome, recent injuries, surgeries, or amputations were excluded. For participants based on the 50th percentile, the groups were then divided into strong hand and weak hand grip strength. Pain intensity was evaluated using the Numerical Pain Rating Scale, and grip strength was assessed with a handheld dynamometer. Demographic and clinical characteristics were summarized using descriptive statistics. Categorical variables were presented as frequencies and percentages, whereas continuous variables were expressed as means with standard deviations. Associations between categorical variables were examined using the chi-square test, and statistical significance was defined at a p-value below 0.05. Result: The mean age of participants was 31(7.13) years; Pearson’s correlation coefficient (0.239) showed no significant association between Lumbar radiculopathy and hand grip strength. Conclusion: This study reported that no significant association was found between lumbar radiculopathy and hand grip strength among young adults.

Objective: To evaluate the short-term clinical efficacy and tolerability of intravenous lacosamide in orthopedic spine patients presenting with acute sciatica. Materials and Methods: This prospective observational study was conducted at the Department of Orthopedic Surgery, Akhtar Saeed Trust Teaching Hospital, Lahore, from January 2023 to January 2024. One hundred adult patients (20–65 years) with acute lumbosacral radiculopathy were included. All patients received intravenous lacosamide 200 mg diluted in 100 mL normal saline, administered twice daily for three consecutive days. Clinical outcomes were assessed at baseline and on day 4 using the Numerical Rating Scale (NRS) for pain, Oswestry Disability Index (ODI), Straight Leg Raise (SLR) test, and Claudication Distance (CD). Statistical analysis was performed using paired t-tests. Results: After 4 days of treatment, significant improvements were observed across all outcome measures. Mean NRS decreased from 8.2 ± 1.1 to 3.1 ± 1.4 (p &lt; 0.001), and mean ODI reduced from 58.7 ± 11.3% to 29.6 ± 10.8% (p&lt;0.001). Mean SLR angle increased from 42.6 ± 10.5° to 68.3 ± 11.9° (p&lt;0.001), while mean claudication distance improved from 145.2 ± 48.3 m to 266.4 ± 59.8 m (p &lt; 0.001). Adverse effects were mild and included dizziness (8%), nausea (5%), and somnolence (4%), with no serious events. Conclusion: Short-term intravenous lacosamide significantly improved pain, functional disability, and objective neurological parameters in patients with acute sciatica and was well tolerated, supporting its role as an adjunct in acute radicular pain management.

Tandem spinal stenosis involving both cervical and lumbar regions is typically degenerative and may be accelerated by chronic inflammatory arthropathies such as rheumatoid arthritis (RA). We report the case of a 71-year-old woman with a 10-year history of RA who developed progressive cervical and lumbar radiculopathy due to inflammatory changes in the vertebral canal. In 2015, she developed an acute systemic illness with high-grade fever, severe joint pain, and marked swelling of the knees and wrists on both sides. She was diagnosed with RA and initiated on disease modifying anti-rheumatic drugs. From 2024 onward, she developed progressive gait imbalance, limb weakness, and neuropathic symptoms. Magnetic resonance imaging of the spine revealed multilevel degenerative spondylosis with narrowing of the vertebral canal in cervical (C4–C7) and lumbar levels (L3–L5) with disc bulges. This case highlights the cumulative impact of RA-related inflammation and age-related degeneration on the development of tandem stenosis and the challenges of management in elderly patients

Abstract Background Benign spinal extradural vascular neoplasms are rare lesions that may present with radiculopathy and mimic common degenerative lumbar pathologies. Misinterpretation of imaging findings may lead to an incorrect preoperative diagnosis. Case presentation A 47-year-old woman presented with a three-year history of low back pain and progressive right leg pain consistent with L5 radiculopathy. Lumbar MRI demonstrated a right-sided L5–S1 lesion interpreted preoperatively as an extruded disc fragment. Surgical exploration revealed a highly vascular, hemorrhagic extradural mass compressing the L5 nerve root. The lesion was completely excised. Histopathological examination demonstrated a benign vascular neoplasm without features of arteriovenous malformation. Postoperatively, the patient experienced complete resolution of symptoms. Conclusion Benign extradural vascular neoplasms, although rare, should be considered in the differential diagnosis of lumbar radiculopathy, particularly when imaging features are atypical. Awareness of this diagnostic pitfall may help avoid intraoperative complications and optimize surgical outcomes.

Introduction: Ebstein-Barr virus (EBV) is a herpesvirus that typically causes self-limited illness, which may trigger neurological complications, especially in immunocompromised individuals, including meningitis, encephalitis, and radiculitis. We present a diagnostically challenging case of EBV-associated ganglionitis in an elderly patient on infliximab (IFX) for Crohn’s disease (CD), initially mimicking cauda equina syndrome (CES) and Guillain-Barré syndrome (GBS), successfully treated with plasma exchange (PLEX). Description: A 70-year-old male with hypertension, benign prostatic hyperplasia, and CD on IFX presented with two weeks of worsening fatigue, ambulatory dysfunction, and new-onset urinary and fecal incontinence. He endorsed perianal and bilateral plantar numbness, poor appetite, weight loss, and generalized weakness. Initial labs were unremarkable. Given the presentation, there was high clinical suspicion for CES. Cervical and thoracic spine imaging showed patchy myelomalacia and demyelination; lumbar MRI revealed no cauda equina/cord compression, disc bulging, or significant degeneration. The patient continued to have lower extremity sensory and motor deficits with fecal incontinence. A trial of intravenous immunoglobulin was initiated for presumed GBS, though autonomic dysfunction was atypical, and he showed minimal improvement. Due to immunosuppression from IFX, EBV was suspected; CSF PCR was positive. He was transferred to the intensive care unit (ICU) and treated for presumed EBV ganglionitis with PLEX and acyclovir, plus high-dose solumedrol for lumbar arachnoiditis likely causing sacral radiculopathy and neurologic bowel and bladder. He tolerated five sessions of PLEX without complications, with subsequent neurological improvement and resolution of incontinence. Discussion: This case highlights the diagnostic complexity of neurologic decline with sacral involvement in immunocompromised patients. The absence of CES radiographic evidence and atypical features of GBS prompted further evaluation. Though rare, EBV ganglionitis should be considered in the immunosuppressed and elderly population presenting with lumbosacral radiculopathy. Early antiviral and immunotherapy may lead to recovery, highlighting the importance of ICU management in complex neuroinfectious cases.