L5 Transverse Process Research Articles

Morphological Changes in the Lumbar and Abdominal Muscles in Individuals with Sacralization

Although sacralization is one of the most common congenital anomalies of the spine, its effect on surrounding muscles is still not well known. This study was conducted to determine the size of the lumbar and abdominal muscles of the individuals with sacralization and to compare with the control group. Eighty-five participants with sacralization phenomena and fifty-six asymptomatic participants were included in this study. Sacralization was classified according to the Castellvi classification. The cross-sectional area of the multifidus lumborum, erector spinae and rectus abdominis muscles, and the section thicknesses of external abdominal oblique, internal abdominal oblique and transversus abdominis muscles were measured bilaterally on axial computed tomography images at the L1-2 and L4-5 levels. ANCOVA revealed that there is no any significant group*side interaction effect regarding muscles sizes in terms of two groups in L1-L2 and L4-L5. In addition, ANCOVA revealed a both side effect [(p=.020; η2p=.038)] and group*side interaction effect [(p=.010; η2p=.049)] regarding length of the L5 transverse process (p˃.05). Regardless of low back pain, muscle sizes are not associated with the sacralization phenomenon.

L5-S1 facet joint pathology in pelvic ring injuries.

The authors believe that the L5-S1 facet joint injury in the setting of pelvic fractures is underappreciated by orthopedic traumatologists. The purpose of this study was to draw attention to the L5/S1 facet joint in the setting of pelvic ring injuries. This was a retrospective comparative study of all patients greater than or equal to 18years of age with an acute pelvic ring injury (AO/OTA 62 B to C) presenting to a single level I trauma center. The primary objective was to determine demographic and injury characteristics associated with L5-S1 facet joint injuries in patients with pelvic ring injuries. The secondary objective was to determine the proportion of L5-S1 facet joint injuries that were missed on initial radiographic workup. There were 476 patients included in the analysis, 53 (11.1%) of whom had an L5-S1 facet joint injury. Patients with an L5-S1 injury were more likely to be younger (44.1 vs. 53.2years, p = 0.001) and experience a high energy mechanism of injury (95.0% vs. 78.0%, p = 0.002). Certain injury patterns were associated with L5-S1 facet joint injuries: any sacral fracture (96.2% vs. 73.8%, p < 0.001), Denis zone 2 fractures (43.4% vs. 20.1%, p < 0.001), Denis zone 3 fractures (34.0% vs. 4.7%, p < 0.001), bilateral displaced sacral fractures (18.9% vs. 3.5%, p < 0.001), and L5 transverse process fractures (64.2% vs. 18.0%, p < 0.001). Only 16.0% of radiology reports identified an L5-S1 injury. Orthopedic traumatologists should scrutinize imaging for L5-S1 facet joint injuries in the presence of pelvic ring injuries, especially in patients with certain sacral fracture patterns.

3D-ink-extruded titanium scaffolds with porous struts and bioactive supramolecular polymers for orthopedic implants

Porous titanium addresses the longstanding orthopedic challenges of aseptic loosening and stress shielding. This work expands on the evolution of porous Ti with the manufacturing of hierarchically porous, low stiffness, ductile Ti scaffolds via direct-ink write (DIW) extrusion and sintering of inks containing Ti and NaCl particles. Scaffold macrochannels were filled with a subtherapeutic dose of recombinant bone morphogenetic protein-2 (rhBMP-2) alone or co-delivered within a bioactive supramolecular polymer slurry (SPS) composed of peptide amphiphile nanofibrils and collagen, creating four treatment conditions (Ti struts: microporous vs. fully dense; BMP-2 alone or with SPS). The BMP-2-loaded scaffolds were implanted bilaterally across the L4 and L5 transverse processes in a rat posterolateral lumbar fusion model. In-vivo bone growth in these scaffolds is evaluated with synchrotron X-ray computed microtomography (µCT) to study the effects of strut microporosity and added biological signaling agents on the bone formation response. Optical and scanning electron microscopy confirms the ∼100 µm space-holder micropore size, high-curvature morphology, and pore fenestrations within the struts. Uniaxial compression testing shows that the microporous strut scaffolds have low stiffness and high ductility. A significant promotion in bone formation was observed for groups utilizing the SPS, while no significant differences were found for the scaffolds with the incorporation of micropores. Statement of significanceBy 2050, the anticipated number of people aged 60 years and older worldwide is anticipated to double to 2.1 billion. This rapid increase in the geriatric population will require a corresponding increase in orthopedic surgeries and more effective materials for longer indwelling times. Titanium alloys have been the gold standard of bone fusion and fixation, but their use has longstanding limitations in bone-implant stiffness mismatch and insufficient osseointegration. We utilize 3D-printing of titanium with NaCl space holders for large- and small-scale porosity and incorporate bioactive supramolecular polymers into the scaffolds to increase bone growth. This work finds no significant change in bone ingrowth via space-holder-induced microporosity but significant increases in bone ingrowth via the bioactive supramolecular polymers in a rat posterolateral fusion model.

Biomechanical, Anatomical, and Neurochemical Perspectives on L3 Transverse Process Syndrome and Its Significance: A Review

Biomechanical, Anatomical, and Neurochemical Perspectives on L3 Transverse Process Syndrome and Its Significance: A Review

Calcium phosphate ceramics combined with rhBMP6 within autologous blood coagulum promote posterolateral lumbar fusion in sheep

Posterolateral spinal fusion (PLF) is a procedure used for the treatment of degenerative spine disease. In this study we evaluated Osteogrow-C, a novel osteoinductive device comprised of recombinant human Bone morphogenetic protein 6 (rhBMP6) dispersed in autologous blood coagulum with synthetic ceramic particles, in the sheep PLF model. Osteogrow-C implants containing 74–420 or 1000–1700 µm ceramic particles (TCP/HA 80/20) were implanted between L4–L5 transverse processes in sheep (Ovis Aries, Merinolaandschaf breed). In the first experiment (n = 9 sheep; rhBMP6 dose 800 µg) the follow-up period was 27 weeks while in the second experiment (n = 12 sheep; rhBMP6 dose 500 µg) spinal fusion was assessed by in vivo CT after 9 weeks and at the end of the experiment after 14 (n = 6 sheep) and 40 (n = 6 sheep) weeks. Methods of evaluation included microCT, histological analyses and biomechanical testing. Osteogrow-C implants containing both 74–420 and 1000–1700 µm ceramic particles induced radiographic solid fusion 9 weeks following implantation. Ex-vivo microCT and histological analyses revealed complete osseointegration of newly formed bone with adjacent transverse processes. Biomechanical testing confirmed that fusion between transverse processes was complete and successful. Osteogrow-C implants induced spinal fusion in sheep PLF model and therefore represent a novel therapeutic solution for patients with degenerative disc disease.

Posterior L5 Transversectomy and Decompression for Far-out Syndrome caused by Lumbosacral Transitional Vertebra: A Case Report

Far-out syndrome is an unusual type of Bertolotti’s syndrome refers to L5 nerve root compressed by osteophyte in the extraforaminal zone, which leads to radical pain of the leg by radiculopathy. Conservative treatment is generally ineffective and requires operative decompression. We present the case of a 19-years-old patient complained of pain in the right lumbosacral and lower leg, failed for 2 months of conservative treatment. The patient was confirmed as far-out syndrome by imaging examinations showed the right L5 nerve root compressed by osteophytes from pseud arthrosis between the L5 transverse process and sacral ala. The Visual analog scale (VAS) pain score was 6 and the Oswestry disability index (ODI) was 53.33%. Then the osteophytes and pseudarthrosis were surgical removed and the L5 nerve root was decompressed through a posterior approach. The patient’s symptoms were significantly relieved after surgery immediately. The VAS score was 1 and ODI was 15.56% at 1-month postoperatively. At 1-year follow up, the VAS pain score was 1 and ODI was 11.11% and complete military trainings was resumed.

Surgical outcome of a patient with Bertolotti's syndrome in whom the established Castellvi classification system failed: illustrative case.

Bertolotti's syndrome is a condition of the lower back and/or L5 distribution leg pain caused by a lumbosacral transitional vertebra (LSTV). Diagnosing the LSTV as the cause of the symptoms and condition is essential for accurate management of this syndrome. Castellvi's classification system is widely accepted for LSTV anatomy, but it measures only one aspect of transitional anatomy and was intended primarily to identify target-level disk herniations. In this case, the Castellvi classification system failed to identify the patient (with 2 years of back and L5 pain) as having an LSTV, even though he displayed LSTV-like anatomy because both L5 transverse process heights measured less than 19 mm. He attained brief but significant relief from bilateral injections into the L5-S1 transverse/ala region and underwent a minimally invasive bilateral decompression of L5-S1 with almost complete relief of his symptoms maintained more than 6 months postoperatively. Given that the patient gained significant relief from treatment of transitional anatomy that failed to be identified using Castellvi's classification system, this case suggests that transverse process height may not be adequate or even the most clinically relevant indicator in identifying LSTV anatomy, which is a precursor to the diagnosis of Bertolotti's syndrome.

Age and sex correlate with bony changes and anatomic variations of the lumbosacroiliac region of the vertebral column in a mixed population of horses.

To provide a postmortem description of anatomic variations and changes of the lumbosacroiliac region in horses. The authors hypothesized that lesion severity would increase with age and body weight and correlate to anatomic variations. Lumbosacroiliac vertebral specimens from 38 horses (mean age, 16 years; range, 5 to 30 years) that died or were euthanized for reasons unrelated to the study between November 2019 and October 2021. The lumbosacroiliac region of the vertebral column was removed from each cadaver. After dissection, disarticulation, and boiling, the anatomic specimens were examined for anatomic variations and osseous changes of the articular process joints (APJs), intertransverse joints (ITJs), and sacroiliac joints (SIJs). The lengths of L6-S1 intertransverse articular surfaces were measured and their ratios calculated. Descriptive statistics were obtained, and the χ2 test was used to assess differences in anatomic variations and abnormal changes of the APJs, ITJs, and SIJs. The most common anatomic variation was a sacrum-like shape of the transverse processes of L6 (29/38 [76%]) and converging orientation of dorsal spinous process of L6 (33/38 [87%]). The highest prevalence of bony changes was detected at L5-L6 (right, 34/38 [89%]; left, 33/38 [87%]) and L6-S1 APJs (right, 38/38 [100%]; left, 37/38 [97%]) and at SIJs (right, 32/38 [86%]; left, 31/38 [82%]). The shape of L6 transverse processes differed between breed (P = .01) and was associated with presence of L4-L5 ITJs (P < .01). Age and sex were associated with changes of the sacral dorsal spinous processes, ITJs, and APJs. The clinical significance of these findings could not be confirmed based on the study limitations.

STUDY OF RESULTS OF TRANSFORAMINAL LUMBAR INTERBODY FUSION (TLIF) IN SPONDYLOLISTHESIS IN CIVIL HOSPITAL AHMEDABAD, GUJARAT,INDIA

Introduction: Spondylolisthesis is a descriptive term derived from the Greek word spondylo (spine) and olisthesis (slip). spondylolisthesis is anterior translation of the cephalad vertebra relative to the adjacent caudal segment. For spondylolisthesis to occur there must be a failure of anatomic structures that normally resist this anteriorly directed force. These structures include the facets, annulus brosus, posterior bony arch, and pedicles. Radiological investigations are done for diagnosis and planning of treatment. Treatment includes conservative management and surgical management using different techniques. 1) To Estimate the clinical outcom Aim And Objective: e of patients who underwent Transforaminal lumbar interbody fusion (TLIF) in terms of symptoms and signs. This is a Prospecti Materials And Methods: ve Study, Sample size of 25 in which 18 were female and 7 males. After Institutional Ethics Committee approval, Study was conducted from September 2019 to December 2021 at a tertiary care Hospital. Consecutive patients with spondylolisthesis and planned for TLIF. Informed written consent was taken from all the patients. Observation And Results: Total 25 patients were included in the study out of that 7(28) % men and 18(72%) women. Majority of the study patients 16(64%) were belong to above 45 years age group. Preoperative minimum VAS scoring of back pain was 6 while the maximum was 8, with a mean of 6.8. The mean VAS scoring at 6 months follow up was 1.08 with a minimum of 0 while a maximum of 3, which is statistically signicant. In our study slip grade was reduced by 1 in 19 patients and by grade 2 in 5 patient and there was no improvement of grade in 1 patient. Out of 25 study patients, 1(4%) patient had supercial wound infection and only 1(4%) patient had complication of screw loosening. In our study Conclusion: 18(72%) patients were female while 7(28%) patients were male, with mean age of 47 years. showing that degenerative spondylolisthesis is common in females as compared to male, in age group more than 40 years. level of spondylolisthesis is L4-L5 while L5-S1 in 10(40%), indicating that L4-L5 is the more commonly involved as compared to L5-S1 due to sagittal inclination of the lower vertebra and relative stability of L5-S1 between the stout iliolumbar ligaments in the sacral ala and the L5 transverse process. Transforaminal lumbar interbody fusion is a safe and effective option to achieve circumferential fusion without sever complications. TLIF has been established as one of the most successful surgery for reducing pain and enhancing physical function in spondylolisthesis.

Сакрализация позвонка LV (синдром Бертолотти): обзор литературы

Introduction The resultant cause of pain syndrome in the lumbosacral spine in the contemporary population are dysplasia and anomalies of the development of vertebral segments, among which the sacralization of the L5 vertebra (Bertolotti syndrome) is often diagnosed. In the domestic medical literature, few publications on this pathology have been found. Methods Scientific studies for this literature review were obtained from PubMed, eLIBRARY, CYBERLENINNKA. Eighty scientific articles were used. The search for literature sources was carried out with the following keywords: sacralization of the L5 vertebra, Bertolotti Syndrome. Results and discussion In the course of the analysis, it was established that the rate of diagnosis of sacralization of the L5 vertebra ranges from 4 to 36 % of cases. It is equally detected among males and females. This pathology is frequently found in children and adolescents. Pain in the lumbar spine and sacrum is the leading clinical symptom of the disease. The severity of pain on the visual analogue scale mainly corresponds to 5 points. Scoliosis, spondylolistesis, herniated disks, spina bifida posterior may exacerbate the clinical symptoms of the associated sacralization of the L5 vertebra. During the examination of patients, plain radiography, computed tomography and magnetic resonance imaging are used. Cases of sacralization of the L5 vertebra are divided into 7 types, according to the classification of A.E. Castellvi et al. (1984). Treatment of vertebrogenic pain syndrome is carried out both conservatively (drug therapy, therapeutic blockades) and surgically (resection of the L5 transverse process, decompression of the stenotic intervertebral foramina, transpedicular fusion, radiofrequency ablation).

Peculiarities of diagnosis and treatment of transverse lumbar processes neoarthroses in outpatients

In 17 male patients, aged 18-26 years with L5 transverse processes neoarthroses clinical manifestations and X-ray data were studied. In 12 patients transverse-sacral neoarthroses were diagnosed, in 4 patients transverse-iliac neoarthroses and in 1 patient transverse-transverse neoarthroses were detected. Syndromic pattern of lumbar transverse processes neoarthroses including complaints, clinical manifestations and X-ray data was typical for spondyloartralgia. However unlike lumbar spondyarthralgia neoarthroses spondylartralgia was characterized by prevalence of monoarticular lesion symptoms with strictly local pain in neoathrosis zone at palpation, unilateral localization of painful sense and unilateral muscle tension; recurrence and increase of pain were provoked not as much by extension as by rotatory motions and inclination towards the aching side. Prevailing method of treatment of patients with transverse-sacral, transverseiliac as well as transverse-transverse neoarthroses is a conservative one with obligatory intra-articular corticosteroid blocades.

Unilateral Biportal Endoscopy for Decompression of Extraforaminal Stenosis at the Lumbosacral Junction: Surgical Techniques and Clinical Outcomes.

ObjectiveThe aims of this study were to describe the unilateral biportal endoscopic (UBE) technique for decompression of extraforaminal stenosis at L5–S1 and evaluate 1-year clinical outcomes. Especially, we evaluated compression factors of extraforaminal stenosis at L5–S1 and described the surgical technique for decompression in detail. MethodsThirty-five patients who underwent UBE decompression for extraforaminal stenosis at L5–S1 between March 2018 and February 2019 were enrolled. Clinical results were analyzed using the MacNab criteria, the visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI). Compression factors evaluated pseudoarthrosis within the transverse process of L5 and ala of sacrum, disc bulging with or without osteophytes, and the thickened lumbosacral and extraforaminal ligament. ResultsThe mean back VAS was 3.7±1.8 before surgery, which dropped to 2.3±0.8 at 1-year postoperative follow-up (p<0.001). There was a significant drop in postoperative mean VAS for leg pain from 7.2±1.1 to 2.3±1.2 at 1 year (p<0.001). The ODI was 61.5 before surgery and 28.6 (p<0.001). Pseudoarthrosis between the transverse process and the ala was noted in all cases (35 of 35, 100%). Pure disc bulging was seen in 12 patients (34.3%), and disc bulging with osteophytes was demonstrated in 23 patients. The thickened lumbosacral and extraforaminal ligament were identified in 19 cases (51.4%). No complications occurred in any of the patients. ConclusionIn the current study, good surgical outcomes without complications were achieved after UBE decompression for extraforaminal stenosis at L5–S1.

New diagnostic support tool for lumbosacral foraminal stenosis using radiographs of the lumbar spine

Detection of lumbar foraminal stenosis (LFS) is difficult using common diagnostic methods, resulting in poor outcomes after lumbar spine surgery. This study aimed to develop a new support tool to detect lumbosacral foraminal stenosis. At our hospital, the following parameters were examined on standing radiographs of the lumbar spine in 100 patients who underwent surgery for lumbar spinal canal and/or foraminal stenosis: 1) presence or absence of the inclination of L5 toward the symptomatic side, 2) distance between the pedicle of L5 and S1, 3) width of the transverse process of L5, 4) distance between the transverse process of L5 and the sacral ala, 5) length of the lateral osteophyte of L5, 6) lumbosacral angle, 7) disc height of L5-S1, and 8) presence or absence of spondylolisthesis of L5. Logistic regression analysis, using cut-off values calculated by receiver operating characteristic (ROC) curve analysis, indicated that the presence of inclination in L5, length of the lateral osteophyte (≥4 mm), distance between the transverse process of L5 and the sacral ala (≤9 mm), and disc height of L5-S1 (≤5 mm) were significantly related to LFS at L5-S1 with odds ratios of 29.07, 38.83, 5.04, and 27.84, respectively. The p-value of the support tool, consisting of the odds ratios above, was 0.724 as per the Hosmer-Lemeshow analysis. ROC analysis demonstrated a cut-off value of 62 for this scoring system with 98% sensitivity and 80% specificity. Hence, we propose that this support tool could be reliably used in clinical practice.

NOVEL PHYSIOTHERAPEUTIC APPROACH TOWARDS A CASE OF COMPLEX MULTIPLE FRACTURE

A straddle fracture of the pelvis is a fracture of the superior and inferior pubic rami which is considered an unstable injury. Injuries most often associated with straddle fracture include sacral fracture, neurological injury, pelvic ring disturbance, lumbar spine fracture, and severe soft tissue injury. A pelvic fracture can happen through the mechanism of either moderate or medium intensity effects. This can range in magnitude from relatively minor mishaps to moderately traumatic fractures that are potentially fatal. L5 transverse process fracture are often associated with pelvic ring fractures, which may indicate high energy trauma. A 35-year-old female with a left-sided straddle fracture, a sacral ala fracture associated with an L5 transverse process fracture L5 was diagnosed by orthopaedic surgeon, on X-ray after a slip and fall sustaining injury to pelvic region, on which open reduction and internal fixation with a 5-hole pre-contoured plate was placed. Temporary reduction was done by K-wire and sacral ala fracture was fixed with 2 CC screws. Post operatively the patient had impaired limb movements and inability to perform daily activities. After operation, patient was managed with physical therapy treatment comprising of static regimens, progressing to dynamic exercises, electrotherapeutic techniques, strengthening exercises, gait exercise for duration of 10 weeks. Patient was given physiotherapy regime for 5 days per week for 10 weeks. This study shows that the operative method and timely recovery in physical therapy contributed to the progress of ROM, strength of muscle, functional activities progressively, which successfully led to further recovery.

A rare case of low backache (Bertolotti’s syndrome)

Lumbosacral transition of L5 vertebra is an anatomical variation. Enlarged transverse process of L5 vertebra may form a pseudo joint with ilium or sacrum. This may lead to low back pain, especially in young adults due to change in biomechanical properties of the lumber spine. This condition is referred to as Bertolotti’s syndrome. We present a case of 40 years old male surgeon with low backache not responding to oral and intravenous pain killers which prevented him from carrying out his daily routine activities. The pain was severe, excruciating and radiating to right buttock with Visual Analogue Scale (VAS) score ranging from 8/10. There was tenderness over right sacroiliac area provoked by deep palpation. Provisional diagnosis of right sacroilitis was made. Fluoroscopy revealed anomalous articulation between right enlarged L5 transverse process with ipsilateral ala of sacrum forming a pseudo arthrosis with maximum tenderness over it. Periarticular injection at pseudo joint with 0.1 % bupivacaine and of triamcinolone 40 mg was given under fluoroscope and confirmed with dye. There was immediate relief from pain. In young individuals with chronic low back pain diagnosis of Bertolotti’s syndrome should also be kept in mind. Key words: Low back pain; Bertolotti’s syndrome; Visual Analogue Scale Citation: Ali L, Ahmad K, Ali U. A rare case of low backache (Bertolotti’s syndrome). Anaesth pain intensive care 2021;25(2):402-405. DOI: doi.org/10.35975/apic.v25i3.1508 Received: May 6, 2021, Reviewed: May 11, 2021, Accepted: May 20, 2021

Preoperative Simulation of the Trajectory for L5/S1 Percutaneous Endoscopic Transforaminal Discectomy: A Novel Approach for Decision-Making

We simulated the trajectory for an L5/S1 percutaneous endoscopic transforaminal discectomy (PETD) to guide decision-making for the surgery approach. Twenty-three patients with L5/S1 lumbar disc herniation were included in the study. The patients all underwent thin-section computed tomography scans, after which data were collected for 3-dimensional reconstruction. Simulations of the trajectory for the L5/S1 PETDs were generated and the hindrance of surrounding anatomic structures was evaluated. Preoperative simulation showed that 14 patients were considered suitable for lumbar PETD. Nine patients were not considered suitable for PETD surgery according to the simulation. Factors affecting the trajectory included high iliac crest in 5 patients, L5 transverse process in 3 patients, and hypertrophic L5-S1 facet joint in 1 patient. Preoperative simulation of the trajectory for L5/S1 PETD was helpful in the decision-making for the surgical approach.

Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases.

The pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets. Imaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured. Contralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001). Our results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.

116. Decompression of far-out syndrome using unilateral biportal endoscopy: surgical techniques and clinical outcome

BACKGROUND CONTEXT Surgical access to the L5–S1 extraforaminal region is complicated and the deep location makes the surgery technically challenging and more invasive. For this reason, some previous studies have reported a relatively high rate of persistent or recurrent radiculopathy after microsurgical foraminotomy for far-out syndrome (FOS). For FOS, the biportal endoscopic technique, which can reach deeper into the extraforaminal lesion less invasively, is becoming widespread. PURPOSE The purpose of this study is to present the unilateral biportal endoscopic (UBE) technique for complete decompression of FOS and evaluate 1-year clinical outcomes. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE Between September 2014 and August 2016, we enrolled 35 consecutive patients who underwent a single-level UBE decompression for FOS and could be followed up for at least one year postoperatively. OUTCOME MEASURES Parameters for clinical results [visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI)], compression factors of FOS (preoperative CT and MRI) and surgical complications (dural tear, nerve root injury, infection, hematoma) were analyzed. METHODS This study evaluated 3 clinical and radiological subjects: (1) clinical results, (2) compression factors of FOS, and (3) surgical complications. The clinical results were evaluated by collecting answers to a questionnaire for outcome scores (VAS for back and leg pain and ODI) preoperatively and one year postoperatively. The compression factors were evaluated using preoperative images as follows: (1) pseudarthrosis between the transverse process of L5 and ala of sacrum, (2) ventral factor (disc bulging or disc bulging with osteophytes), and (3) thickened lumbosacral ligament. The surgical complications were evaluated by the incidence of intraoperative dural tear and nerve root injury, re-operation due to the surgical hematoma, and infection within a year. RESULTS The study group consisted of 16 men and 19 women with an average age at surgery of 68.4 + 6.6 years. The mean follow-up was 15.3 months. Overall operative time ranged from 63 to 135 minutes (mean 78.5 minutes). Concomitant foraminal stenosis was found in 10 cases (28.5%). Mean VAS for back pain was 3.7 + 1.8 before surgery, and this value was decreased to 2.3 + 0.8 at 1-year follow-up postoperatively (p CONCLUSIONS In the present study, we achieved excellent surgical outcomes after the UBE decompression for patients with FOS without complications. UBE decompression can overcome certain technical challenges involved in the conventional procedures for FOS. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Extraforaminal entrapment of the fifth lumbar spinal nerve by nearthrosis in patients with lumbosacral transitional vertebrae.

Lumbosacral transitional vertebrae (LSTV) often have nearthrosis between the L5 transverse processes and the sacral ala; this causes the formation of new bone and synovial-like tissue, which can entrap L5 nerve root. The present study aimed to examine the role of nearthrosis in L5 nerve root compression in patients with LSTV. From 2008 to 2018, 65 patients were surgically treated for severe leg pain/numbness caused by L5 extraforaminal stenosis. The patients were assessed regarding the presence of LSTV, radiographic features of nearthrosis, operative/radiological findings, and clinical outcomes. CT/MRI were used to classify the patients into three groups: group A had L5 nerve root compression that was not related to nearthrosis, group B had L5 nerve root impingement due to nearthrosis with new bone formation, and group C had L5 nerve root impingement due to nearthrosis with synovial-like tissue. The relationships between the type of LSTV (based on the Castellvi's classification) and these three groups were investigated. Although 26 of 65 patients had LSTV (40%), four were excluded because of less than 1-year follow-up. The 22 patients with LSTV were classified as type IA (n = 2), IIA (n = 13), and IIB (n = 7). In accordance with the radiological findings, there were eight patients in group A, six in group B, and eight in group C; the LSTV morphology did not significantly differ between groups. L5 nerve root was compressed by nearthrosis in 64% of symptomatic patients with LSTV; this region should be carefully assessed in all symptomatic patients with LSTV.

Lumbar Erector Spinae Plane Block as a Main Anesthetic Method for Hip Surgery in High Risk Elderly Patients: Initial Experience with a Magnetic Resonance Imaging.

Since initial description by Forero for thoracic region, ultrasound guided erector spinae plane (ESP) block has experienced several surgeries for postoperative pain management, chronic pain or surgical anesthesia. Although ESP block has been reported to provide effective analgesia in the thoracic region, its effect in lumbar region still unclear. In this study we aimed to showed our successful experience with lumbar ESP block as a main anesthetic technique in fifteen high risk elderly patients undergoing hip surgery with mild propofol sedation. In this observational study high risk elderly fifteen patients received lumbar ESP block as a main anesthetic technique with mild propofol sedation. 40 mL of local anesthetic mixture (20 mL bupivacaine 0.5%, 10 mL lidocaine 2%, and 10 mL normal saline) was administered between the erector spinae muscles and transverse process at the level of the 4th lumbar vertebra. Also we demonstrate magnetic resonance images and discuss the anatomic basis of lumbar ESP block. All patients' surgeries were completed without requirement for general anesthesia or local anesthesia infiltration of the surgical site. All patients' pain scores were <2/10 in the recovery room. Significant contrast spread was observed between the Th12 and L5 transverse process and erector spinae muscle and between multifidus muscle and iliocostal muscle at the L2-4 levels. Contrast material was observed at the anterior of the transverse process spreading to the paravertebral, foraminal and partially epidural area/spaces and also in the areas where the lumbar nerves enter the psoas muscle. Lumbar ESP block when combined with mild sedoanalgesia provides adequate and safe anesthesia in high risk elderly patients undergoing hip surgery.