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Open access

Iatrogenic neurological injury after radiofrequency ablation and epidural steroid injections: illustrative cases

Lisa B. E. Shields, Vasudeva G. Iyer, Yi Ping Zhang, and Christopher B. Shields

BACKGROUND

Neck pain is often chronic and disabling. Cervical facet joint injections and epidural steroid injections are frequently used to manage chronic neck pain and cervicogenic headaches. While minimal side effects are commonly associated with these treatments, severe complications are exceedingly rare.

OBSERVATIONS

The authors report 4 cases of iatrogenic neurological injury after radiofrequency ablation (RFA) and epidural steroid injections. One patient experienced left shoulder, scapular, and arm pain with left arm and hand weakness that developed immediately after RFA for chronic neck pain. Electromyography/nerve conduction velocity (EMG/NCV) studies confirmed denervation changes in the left C8–T1 distribution. Three patients complained of numbness and weakness of the hands immediately after an interlaminar cervical epidural block. One of these patients underwent EMG/NCV that confirmed denervation changes occurring in the left C8–T1 distribution.

LESSONS

Spine surgeons and pain management specialists should be aware of neurological injuries that may occur after cervical RFA and epidural steroid injections, especially after a multilevel cervical procedure and with severe cervical spinal stenosis. EMG/NCV studies plays an important role in detecting and localizing neurological injury and in differentiating from conditions that mimic cervical root injuries, including brachial plexus trauma due to positioning and Parsonage-Turner syndrome.

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

Trigeminal neuralgia induced by brainstem infarction treated with pontine descending tractotomy: illustrative case

Rachyl M. Shanker, Miri Kim, Chloe Verducci, Elhaum G. Rezaii, Kerry Steed, Atul K. Mallik, and Douglas E. Anderson

BACKGROUND

While cases of trigeminal neuralgia induced by a brainstem infarct have been reported, the neurosurgical literature lacks clear treatment recommendations in this subpopulation.

OBSERVATIONS

The authors present the first case report of infarct-related trigeminal neuralgia treated with pontine descending tractotomy that resulted in durable pain relief after multiple failed surgical interventions, including previous microvascular decompressions and stereotactic radiosurgery. A neuronavigated pontine descending tractotomy of the spinal trigeminal tract was performed and resulted in successful pain relief for a 50-month follow-up period.

LESSONS

While many cases of ischemic brainstem lesions are caused by acute stroke, the authors assert that cerebral small vessel disease also plays a role in certain cases and that the relationship between these chronic ischemic brainstem lesions and trigeminal neuralgia is more likely to be overlooked. Furthermore, neurovascular compression may obscure the causative mechanism of infarct-related trigeminal neuralgia, leading to unsuccessful decompressive surgeries in cases in which neurovascular compression may be noncontributory to pain symptomatology. Pontine descending tractotomy may be beneficial in select patients and can be performed either alone or concurrently with microvascular decompression in cases in which the interplay between ischemic lesion and neurovascular compression in the pathophysiology of disease is not clear.

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.

Open access

Intradural cyst: intramedullary or extramedullary? Illustrative case

Timothy Kim, Brendan Judy, and Timothy Witham

BACKGROUND

Intradural spinal cord cysts are uncommon and generally benign. It can be difficult to determine whether the cyst is intramedullary or extramedullary on preoperative imaging, and the location of the cyst may be determined intraoperatively. This patient presented with intractable back pain associated with imbalance and was found to have a cystic lesion of the ventriculus terminalis (VT).

OBSERVATIONS

The patient was found to have a cystic lesion of the VT that was intramedullary rather than extramedullary, as initially expected based on preoperative imaging.

LESSONS

VT is a rare cystic expansion of the conus medullaris that can appear extramedullary on preoperative imaging. Intraoperatively, this lesion was found to be intramedullary and was successfully treated with fenestration.

Open access

Intrathecal catheter for severe low back pain during deep brain stimulation placement: illustrative case

Bryan Kunkler, Alan Tung, Parag G. Patil, Srinivas Chiravuri, and Vijay Tarnal

BACKGROUND

Deep brain stimulation (DBS) is a U.S. Food and Drug Administration–approved therapy for medically refractory Parkinson’s disease, essential tremor, and other neurological conditions. The procedure requires prolonged immobility and can result in significant patient discomfort, potentially limiting patient selection. In addition, surgical requirements necessitate avoidance of medications that may alter or suppress the patient’s arousal or baseline tremor during macrostimulation testing.

OBSERVATIONS

In this study, the authors describe the use of continuous spinal anesthesia with local anesthetic to manage a patient with severe back pain who was intolerant of semisupine position during stereotactic computed tomography and stage 1 of DBS placement.

LESSONS

Continuous spinal anesthesia is an effective strategy to manage patients with severe back pain undergoing DBS surgery for upper extremity motor symptoms.

Open access

Gamma Knife radiosurgery for cluster-tic syndrome unresponsive to medical treatment: illustrative case

Lina R. Barzaghi, Edoardo Pompeo, Luigi Albano, Antonella Del Vecchio, and Pietro Mortini

BACKGROUND

Cluster-tic syndrome is a disorder characterized by the coexistence of symptoms related to both cluster headache and trigeminal neuralgia. Etiopathogenesis is not yet well defined. Medical treatment, including drugs for both cluster headache and trigeminal neuralgia, is the first therapeutic choice, whereas more invasive treatments are indicated in the case of pharmacological therapy failure or in the presence of drug side effects. To date, no randomized and/or large cohort trials describing Gamma Knife radiosurgery (GKRS) for cluster-tic syndrome are available, probably due to the syndrome’s rarity.

OBSERVATIONS

The authors describe the case of a 76-year-old woman with refractory cluster-tic syndrome who underwent GKRS with double target (the retrogasserian portion of the trigeminal nerve and the sphenopalatine ganglion). The Numerical Rating Scale (NRS) of pain and the Barrow Neurological Institute (BNI) pain intensity score before treatment were 7 (up to 10 during paroxysmal pain attacks) and V, respectively. At last follow-up, 24 months after GKRS, the patient had discontinued her pain medications and NRS and BNI pain scores were 1 and I, respectively. No trigeminal sensory disorders were reported.

LESSONS

The present case shows that GKRS, in selected cases, could be an effective treatment in patients with refractory cluster-tic syndrome.

Open access

Utilization of anterior lumbar interbody fusion for severe kyphotic deformity secondary to Pott’s disease: illustrative case

Gabrielle Luiselli, Rrita Daci, Peter Cruz-Gordillo, Ashwin Panda, Omar Sorour, and Justin Slavin

BACKGROUND

Spinal tuberculosis may result in severe kyphotic deformity. Effective restoration of lordosis and correction of sagittal balance often requires invasive osteotomies associated with significant morbidity. The advantages of focusing on symptomatic management and staging in the initial treatment of these deformities have not been well reported to date.

OBSERVATIONS

The authors reported the case of a 64-year-old Vietnamese woman with a history of spinal tuberculosis who underwent anterior lumbar interbody fusion (ALIF) for symptomatic treatment of L5–S1 radiculopathy resulting from fixed kyphotic deformity. Postoperatively, the patient experienced near immediate symptom improvement, and radiographic evidence at 1-year follow-up showed continued lordotic correction of 30° as well as stable sagittal balance.

LESSONS

In this case, an L5–S1 ALIF was sufficient to treat the patient’s acute symptoms and provided satisfactory correction of a tuberculosis-associated fixed kyphotic deformity while effectively delaying more invasive measures, such as a vertebral column resection. Patients with adult spinal deformity may benefit from less invasive staging procedures before treating these deformities with larger surgeries.

Open access

Elective surgery for acute pain in patients with substance use disorder: lessons learned at a rural neurosurgical center. Patient series

Christopher S. Ferari, Gennadiy A. Katsevman, Patricia Dekeseredy, and Cara L. Sedney

BACKGROUND

The incidence of pain-generating degenerative spinal problems in patients who are currently using or have previously used drugs has increased as substance use disorder (SUD) becomes a chronic, lifelong condition. Health system–level data in recent years indicate a significant increase in patients with coexisting SUD and degenerative disc disease, representing an emerging population. A retrospective electronic medical record review identified seven patients with SUD who underwent elective spine surgery by orthopedic or neurosurgical staff from 2012 to 2021. The authors present two of these illustrative cases and a framework that can be used in the treatment of similar patients.

OBSERVATIONS

Substances used included opioids, benzodiazepines, barbiturates, cocaine, methamphetamines, hallucinogens, lysergic acid diethylamide, phencyclidine, and cannabis. All were abstaining from drug use preoperatively, with four patients in a formal treatment program. Five patients were discharged with an opioid prescription, and two patients deferred opioids. Three experienced a relapse of substance use within 1 year. All patients presented for follow-up, although two required additional contact for follow-up compliance.

LESSONS

Perioperative protocols focusing on patient-led care plans, pain control, communication with medication for opioid use disorder providers, family and social support, and specific indicators of possible poor results can contribute to better outcomes for care challenges associated with these diagnoses.

Open access

Targeted muscle reinnervation for a recurrent traumatic neuroma of the sural nerve: illustrative case

Mark P. van Opijnen, Hans Marten Hazelbag, and Godard C. W. de Ruiter

BACKGROUND

Traumatic neuromata often recur after resection. Recently, targeted muscle reinnervation (TMR) has been shown to be a promising alternative for the treatment of traumatic neuroma, also in nonamputees. This case shows that TMR can also be applied for this indication in recurrent traumatic neuroma.

OBSERVATIONS

A 55-year-old patient with a history of cerebral palsy presented with a painful swelling in his right knee, 40 years after multiple Achilles tendon surgeries for contractures. On imaging, the lesion was suspect for a traumatic neuroma of the posterior sural nerve. After two failed resections, TMR was performed by connecting the proximal end of the sural nerve to the motor branch of the lateral gastrocnemius muscle. During outpatient visits at 3, 6, and 12 months, the patient reported significantly less pain compared to before the TMR. He had no weakness of plantar flexion. Postoperative imaging, however, showed atrophy of the lateral gastrocnemius muscle.

LESSONS

This case shows that TMR can be a successful strategy to treat recurrent traumatic neuroma after previous failed transection of single neuromata in nonamputee cases. In the authors’ patient, TMR did not result in motor deficit, but more research is needed to investigate this consequence of TMR for this indication.