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Open access

An unusual case of a persistent, infected retroperitoneal fluid collection 5 years after anterior lumbar fusion surgery: illustrative case

Matthew T. Neal, Kara L. Curley, Alexandra E. Richards, Maziyar A. Kalani, Mark K. Lyons, and Victor J. Davila

BACKGROUND

Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections.

OBSERVATIONS

The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors’ knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures.

LESSONS

When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.

Open access

A minimally invasive lateral approach with CT navigation for open biopsy and diagnosis of Nocardia nova L4–5 discitis osteomyelitis: illustrative case

Bryan Zheng, Hael Abdulrazeq, Owen P. Leary, Ziya L. Gokaslan, Adetokunbo A. Oyelese, Jared S. Fridley, and Joaquin Q. Camara-Quintana

BACKGROUND

Lumbar spine osteomyelitis can be refractory to conventional techniques for identifying a causal organism. In cases in which a protracted antibiotic regimen is indicated, obtaining a conclusive yield on biopsy is particularly important. Although lateral transpsoas approaches and intraoperative computed tomography (CT) navigation are well documented as techniques used for spinal arthrodesis, their utility in vertebral biopsy has yet to be reported in any capacity.

OBSERVATIONS

In a 44-year-old male patient with a history of Nocardia bacteremia, CT-guided biopsy failed to confirm the microbiology of an L4–5 discitis osteomyelitis. The patient underwent a minimally invasive open biopsy in which a lateral approach with intraoperative guidance was used to access the infected disc space retroperitoneally. A thin film was obtained and cultured Nocardia nova, and the patient was treated accordingly with a long course of trimethoprim-sulfamethoxazole.

LESSONS

The combination of a lateral transpsoas approach with intraoperative navigation is a valuable technique for obtaining positive yield in cases of discitis osteomyelitis of the lumbar spine refractory to CT-guided biopsy.

Open access

Multifocal primary central nervous system Ewing sarcoma presenting with intracranial hemorrhage and leptomeningeal dissemination: illustrative case

Anna L. Huguenard, Yuping Derek Li, Nima Sharifai, Stephanie M. Perkins, Sonika Dahiya, and Michael R. Chicoine

BACKGROUND

Ewing sarcoma is a neoplasm within the family of small round blue cell tumors and most frequently arises from skeletal bone. Primary involvement of the central nervous system in these lesions is extremely rare, with an incidence of 1%.

OBSERVATIONS

A case is presented of a 34-year-old man who presented with left facial numbness, multiple intracranial lesions, a lumbar intradural lesion, and diffuse spinal leptomeningeal involvement. A lumbar laminectomy and biopsy were performed, which revealed the diagnosis of extraskeletal Ewing sarcoma/primitive neuroectodermal tumor. The patient had a rapidly progressive clinical decline despite total neuroaxis radiation and multiple lines of chemotherapeutic treatments, eventually dying from his disease and its sequelae 6 months after diagnosis.

LESSONS

The authors’ review of 40 cases in the literature revealed only 2 patients with isolated intraaxial cranial lesions, 4 patients with cranial and spine involvement, and an additional 34 patients with spine lesions. The unique characteristics of this patient’s case, including his presentation with diffuse disease and pathology that included a rare V600E BRAF mutation, are discussed in the context of the available literature.

Open access

Lumbar facet cyst tuberculosis: a rare cause of cauda equina compression. Illustrative case

Karlo M. Pedro, John Emmanuel R. Torio, Jonathan P. Rivera, and Ibet Marie Y. Sih

BACKGROUND

Spinal tuberculosis may present in atypical form to involve only the posterior spinal element with relative sparing of the anterior vertebral body and intervertebral disc. Recognition of this unusual pattern is important to avoid delay in diagnosis and treatment.

OBSERVATIONS

The authors report a case of a 59-year-old woman with right-sided radiculopathy and motor weakness. Her lumbosacral magnetic resonance imaging showed a large heterogeneous cyst arising from the right L4–5 facet joint. Laminectomy with excision of the cyst was performed. During surgery, the cyst contained cheese-like material that, on histopathological examination, revealed focal aggregates of tuberculous granuloma. Postoperatively, the patient recovered remarkably with no interval development of instability or any deformity.

LESSONS

Facet cyst tuberculosis is rare but should be considered in the differential diagnosis in patients coming from endemic regions. Laminectomy with excision of the cyst along with concurrent antitubercular chemotherapy is a safe and durable treatment option in this case.

Open access

Spinal arthrodesis via lumbar interbody fusion without direct decompression as a treatment for recurrent radicular pain due to epidural fibrosis: patient series

Kevin Swong, Michael J. Strong, Jay K. Nathan, Timothy J. Yee, Brandon W. Smith, Paul Park, and Mark E. Oppenlander

BACKGROUND

Lumbar radiculopathy is the most common indication for lumbar discectomy, but residual postoperative radicular symptoms are common. Postoperative lumbar radiculopathy secondary to scar formation is notoriously difficult to manage, with the mainstay of treatment focused on nonoperative techniques. Surgical intervention for epidural fibrosis has shown unacceptably high complication rates and poor success rates.

OBSERVATIONS

Three patients underwent spinal arthrodesis without direct decompression for recurrent radiculopathy due to epidural fibrosis. Each patient previously underwent lumbar discectomy but subsequently developed recurrent radiculopathy. Imaging revealed no recurrent disc herniation, although it demonstrated extensive epidural fibrosis and scar in the region of the nerve root at the previous surgical site. Dynamic radiographs showed no instability. Two patients underwent lateral lumbar interbody fusion, and one patient underwent anterior lumbosacral interbody fusion. Each patient experienced resolution of radicular symptoms by the 1-year follow-up. Average EQ visual analog scale scores improved from 65 preoperatively to 78 postoperatively.

LESSONS

Spinal arthrodesis via lumbar interbody fusion, without direct decompression, may relieve pain in patients with recurrent radiculopathy due to epidural fibrosis, even in the absence of gross spinal instability.

Open access

Short lever arm, bipedicular handlebar construct for correction of acute angular kyphosis in spondylodiscitis-induced kyphotic deformity: illustrative case

Meng Huang, Iahn Cajigas, and Steven Vanni

BACKGROUND

Pyogenic spondylodiscitis diminishes spinal structural integrity via disruption of the anterior and middle column, sometimes further compounded by iatrogenic violation of the posterior tension band during initial posterior decompressive surgeries. Although medical management is typically sufficient, refractory infection or progressive deformity may require aggressive debridement and reconstructive arthrodesis. Although anterior debridement plus reconstruction with posterior stabilization is an effective treatment option, existing techniques have limited efficacy for correcting focal deformity, leaving patients at risk for long-term sagittal imbalance, pain, and disability.

OBSERVATIONS

The authors present a case of chronic lumbar pyogenic spondylodiscitis in a patient in whom initial surgical debridement failed and pronounced angular kyphosis and intractable low back pain developed. A novel bipedicular handlebar construct was used to achieve angular correction of the kyphosis through simultaneous anterior interbody grafting and posterior instrumentation with the patient in the lateral position.

LESSONS

Leveraging both pedicle screws at the same level to transmit controlled corrective distraction forces through the segment allows for kyphosis correction without relying on long posterior constructs for cantilever reduction. Simultaneous anterior reconstruction with a posterior short lever arm, bipedicular handlebar construct is an effective technique for achieving high angular correction during circumferential reconstructive approaches to postinfectious focal kyphotic deformities.

Open access

L5 nerve root injury caused by anterolateral malpositioning of loosened S1 pedicle screws: illustrative cases

Shota Tamagawa, Takatoshi Okuda, Hidetoshi Nojiri, Rei Momomura, and Muneaki Ishijima

BACKGROUND

Although malpositioning of pedicle screws into the spinal canal and intervertebral foramen can cause spinal nerve root injuries, there are few reports of L5 nerve root injuries when S1 pedicle screws have been inserted anterolaterally. The authors report two cases of L5 nerve root injury caused by anterolateral malpositioning of loosened S1 pedicle screws.

OBSERVATIONS

In both patients, S1 pedicle screws were inserted toward the outside of the S1 anterior foramen, and the tip of the screws perforated the anterior sacral cortex. L5 nerve root impairment was not observed immediately after surgery. However, severe leg pain in the L5 area was observed after the S1 pedicle screws became loosened. In case 1, the symptoms could not be controlled with conservative treatment. Reoperation was performed 3 months after the initial surgery. In case 2, the symptoms gradually improved with conservative treatment because the area around the loosened S1 screw was surrounded by newly formed bone that stabilized the screws, as observed with computed tomography 1 year after surgery.

LESSONS

Surgeons should recognize that anterolateral malpositioning of S1 pedicle screws can cause L5 nerve root injury. The screws should be inserted in the correct direction without loosening.

Open access

Restoration of sagittal alignment in high-grade isthmic spondylolisthesis using the reverse Bohlman technique with anterior lumbar interbody fusion using a hyperlordotic cage at L4–5: illustrative case

Terrence Ishmael, Vincent Arlet, and Harvey Smith

BACKGROUND

Circumferential fusion with or without reduction is the preferred treatment for high-grade isthmic spondylolisthesis. Reduction presents significant risk of neurological injury. The authors present one case in which the “reverse Bohlman” technique was used with the addition of a hyperlordotic interbody cage at L4–5 as a means to correct sagittal malalignment while avoiding the reduction of L5 on S1.

OBSERVATIONS

The patient was a 22-year-old woman with a long-term history of lower back pain and bilateral L5 radiculopathy secondary to high-grade isthmic lumbar spondylolisthesis. She underwent anterior lumbar interbody fusion using the reverse Bohlman technique plus a hyperlordotic interbody cage at L4–5, followed by decompression and posterior spinal instrumentation and fusion from L4 to the pelvis. At 2-year follow-up, she was found to have complete resolution of symptoms with clinical and radiographic evidence of fusion. Her spinopelvic parameters had significantly improved.

LESSONS

The reverse Bohlman technique with the addition of a hyperlordotic interbody cage at L4–5 is a potential alternative treatment method to correct sagittal malalignment while avoiding possible injury to the L5 nerve roots that can be seen in the reduction of high-grade isthmic spondylolisthesis.

Open access

Symptomatic contralateral osteophyte fracture with migration causing lumbar plexopathy during oblique lumbar interbody fusion: illustrative case

Brenton Pennicooke, Jeremy Guinn, and Dean Chou

BACKGROUND

While performing lateral lumbar interbody fusion surgery, one of the surgical goals is to release the contralateral side with a Cobb elevator, allowing distraction of the interbody space. Many times, there are large osteophytes on the contralateral side, and the osteophytes can be split open with the Cobb or blunt instrument. It is extremely rare for the actual osteophyte to break off from the vertebral body into the contralateral psoas muscle and lumbar plexus.

OBSERVATIONS

The authors report a case of symptomatic lumbar plexopathy caused by an osteophyte fracture after an oblique lumbar interbody fusion requiring a right-sided anterior approach to excise the bony fragment. They illustrate the case with imaging that the radiologist did not comment on, and they also show a video of the surgical excision of the osteophyte through a right-sided anterior lumbar retroperitoneal approach. The authors also show how the patient had spontaneous right-sided electromyography (EMG) firing before excision of the osteophyte and how the EMG firing resolved after excision.

LESSONS

Although the literature is plentiful with regard to ipsilateral approach–related complications, the authors discuss the literature with regard to contralateral complications after minimally invasive lateral lumbar interbody fusion.

Open access

Sagittal adjusting screws for the correction of grade IV spondylolisthesis in a patient with Ehlers-Danlos syndrome: illustrative case

Jake Jasinski, Doris Tong, Connor Hanson, and Teck Soo

BACKGROUND

Ehlers-Danlos syndrome (EDS) and its connective tissue laxity often result in high-grade lumbosacral spondylolisthesis. Patients present with debilitating symptoms and neurological deficits. Reports of surgical techniques in non-EDS patients for the treatment of high-grade lumbosacral spondylolisthesis mainly described an open approach, multilevel fusions, and multiple stages with different circumferential approaches. Sagittal adjusting screws (SASs) can be used in a minimally invasive (MI) fashion, allowing intraoperative reduction.

OBSERVATIONS

A 17-year-old female with EDS presented to the authors’ institute with severe lower back and left L5 radicular pain in 2017. She presented with a left foot drop and difficulty ambulating. Magnetic resonance imaging showed grade IV L5–S1 spondylolisthesis. She underwent lumbar fusion for intractable back pain with radiculopathy. Intraoperatively, percutaneous SASs and extension towers were used to distract the L5–S1 disc space and reduce the spondylolisthesis. MI transforaminal lumbar interbody fusion was completed with significant symptomatic relief postoperatively. The patient was discharged to home 3 days postoperatively. Routine follow-up visits up to 3 years later demonstrated solid fusion radiographically and favorable patient-reported outcomes.

LESSONS

The authors used SASs in a MI approach to successfully correct and stabilize grade IV spondylolisthesis in an EDS patient with a favorable long-term patient-reported outcome.