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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

Robot-assisted revision of sacroiliac joint fusion using a triangular titanium implant in an S2-alar-iliac trajectory: illustrative case

Matthew Triano, Islam Fayed, and Faheem A. Sandhu

BACKGROUND

Sacroiliac joint (SIJ) dysfunction can lead to significant pain and disability, greatly impairing quality of life. Arthrodesis may take up to 1 year to occur, after which revision can be considered. There is a need for highly accurate and reproducible techniques for revision that allow for purchase through undisturbed bone to prevent prolonged pain and disability. Moreover, a minimally invasive technique for revision would be favorable for recovery, particularly in elderly patients.

OBSERVATIONS

An 84-year-old man with a prior history of lumbar fusion presented with severe buttock pain limiting ambulation and sitting because of the failure of arthrodesis after SIJ fusion 1 year earlier. He underwent revision using a triangular titanium implant (TTI) in an S2-alar-iliac (S2-AI) trajectory under robotic guidance, which is a novel technique not yet described in the literature. The patient’s pain largely resolved, he was able to ambulate independently, and his quality of life improved tremendously. There were no complications of surgery.

LESSONS

Placement of a TTI using an S2-AI trajectory is a safe and effective method for revision that can be considered for elderly patients. Robot-assisted navigation can be used to facilitate an accurate and reproducible approach using a minimally invasive approach.

Open access

Nerve preservation during partial sacrectomy by two-stage anterior and posterior approach: illustrative case

Parménides Guadarrama-Ortíz, Ingrid Montes de Oca-Vargas, José Alberto Choreño-Parra, André Garibay-Gracián, Deyanira Capi-Casillas, Alondra Román-Villagomez, Citlaltepetl Salinas-Lara, Ulises Palacios-Zúñiga, and Ángel Daniel Prieto-Rivera

BACKGROUND

Preserving the neurological function of sacral nerves during total or partial sacrectomy is challenging.

OBSERVATIONS

The authors describe a case of an osseous desmoplastic fibroma of the sacrum in a 51-year-old woman. The patient attended the authors’ institution with loss of muscle strength and sensitivity impairment in both legs, gait instability, bowel constipation, urinary incontinence, and weight loss. Preoperative magnetic resonance imaging and positron emission tomography/computed tomography showed intrapelvic and posterior extension of the tumor but sparing of S1 and the sacroiliac and lumbosacral joints. After a multidisciplinary discussion of the case, a staged anterior–posterior approach to the sacrum was chosen. The abdominal approach allowed full mobilization of the uterus, ovaries, bladder, and colon and protection of iliac vessels. After tumor resection, a synthetic surgical mesh was placed over the sacrum to minimize soft tissue defects. Then, the posterior stage allowed the authors to perform a bicortical osteotomy, achieving wide tumor excision with minimal nerve root injury. Spinopelvic fixation was not necessary, because both sacroiliac and lumbosacral joints remained intact. A few days after the surgery, the patient restarted ambulation and recovered sphincter control.

LESSONS

Multidisciplinary planning and a staged abdominal and posterior approach for partial sacrectomy were fundamental to preserve neurological function in this case.

Open access

Radiculopathy with concomitant sacroiliac dysfunction and lumbosacral degenerative disease: illustrative case

Jeffrey D. Oliver, Noah L. Lessing, Harry M. Mushlin, Joshua R. Olexa, Kenneth M. Crandall, and Charles A. Sansur

BACKGROUND

The sacroiliac joint (SIJ) is an important cause of low back pain and referred leg pain (RLP). Pain from SIJ dysfunction may occur in isolation or may result from a combination with lumbosacral area–mediated pain. SIJ fusion is one treatment modality for medically refractory symptoms and may also have a role in the treatment of RLP.

OBSERVATIONS

The authors present a challenging case of concomitant lumbosacral degenerative disease and SIJ dysfunction in a patient with radiculopathy. They provide clinical characteristics and imaging findings and discuss difficulties in dealing with the intersection of these two distinct diagnoses. In addition, the authors offer a review of the relevant literature, elucidating the role of SIJ dysfunction in causing radicular lower extremity pain, the relationship to concomitant lumbosacral degenerative disease, and outcome data for SIJ fusion as it relates to RLP.

LESSONS

With increasing numbers of patients undergoing spinal instrumentation in the setting of degenerative lumbosacral arthritis, as well as randomized controlled trial data demonstrating the efficacy of SIJ fusion for medically refractory SIJ dysfunction, it is important to recognize the challenges in understanding how both of these patient groups may present with radiculopathy. Failure to do so may result in incorrect patient selection, poor outcomes, and increased morbidity for at-risk patients.

Open access

Total resection of presacral giant schwannoma via minimally invasive dorsal approach: illustrative case

Guenther C. Feigl, Domagoj Jugovic, Daniel Staribacher, Rolf Buslei, and Dzmitry Kuzmin

BACKGROUND

Giant presacral schwannomas are extremely rare in neurosurgery. There are various approaches to the surgical treatment of symptomatic giant presacral schwannomas. The least traumatic is the one-stage surgery with a dorsal approach.

OBSERVATIONS

The authors describe a case of a 52-year-old male with pain in the sacral region and partial urinary dysfunction. A total tumor resection through a minimally invasive dorsal approach was performed, and anatomical and functional preservation of all sacral nerves with no postoperative complications was achieved.

LESSONS

The authors have shown the possibility of total tumor resection with a minimally invasive dorsal approach without the development of intra- and postoperative complications. Operative corridors that have been created by a tumor can be used and expanded for a minimally invasive dorsal approach to facilitate resection and minimize tissue disruption.

Open access

Acute piriformis syndrome mimicking cauda equina syndrome: illustrative case

Jan Lodin, Štěpánka Brušáková, David Kachlík, Martin Sameš, and Ivan Humhej

BACKGROUND

This report depicts a rare case of acutely developed urinary retention as well as sensory and motor disturbances caused by formation of a large hematoma within the piriformis muscle, which caused compression of nerves within the suprapiriform and infrapiriform foramina, thus imitating cauda equina syndrome. Although cases of acute lumbosacral plexopathy have been described, this case is the first time both urinary retention and sensory and motor disturbances were present.

OBSERVATIONS

The most useful tools for diagnosis of acute piriformis syndrome are detailed patient history, magnetic resonance imaging (MRI) of the pelvic region, and electrophysiological testing performed by an experienced electrophysiologist. As a result of diligent rehabilitation, including physiotherapy and electrostimulation, the patient was able to successfully recover, regardless of acute compression of the sacral plexus that lasted 6 days.

LESSONS

Clinicians should actively ask about previous pelvic trauma when taking a patient history in similar cases, especially if the patient is receiving anticoagulation treatment. If MRI of the lumbar spine does not reveal any pathologies, MRI of the pelvic region should be performed. Acute surgical decompression is crucial for preserving neurological function. In similar cases, it is possible to differentiate between spinal cord, cauda equina, and pelvic lesions using electrophysiological studies.

Open access

Sacral insufficiency fractures are a risk of massive bleeding during sacrectomy: patient series

David C. Kieser, Scheherezade Soltani, Niels Hammer, Amir Koutp, Eleanor Hughes, and Jeremy J. Reynolds

BACKGROUND

Sacrectomy carries significant risk of bleeding; however, specific risk factors, apart from medical comorbidities and tumor type, for this life-threatening complication remain unclear. This study describes two cases of massive bleeding, including one death during sacrectomy attributable to adherence of the internal iliac vein (IIV) and its neuroforaminal tributaries from sacral insufficiency fractures.

OBSERVATIONS

The authors presented two cases involving patients who received sacrectomy for a chordoma and experienced massive bleeding from the IIV due to adherence of the IIV and its neuroforaminal tributaries around sacral insufficiency fractures. They assessed their institution’s previous two decades’ experience of sacrectomies to determine risk factors for massive bleeding and performed anatomical dissection of 20 hemipelvises, which revealed the close proximity of the IIV to the sacral foraminae and the consistency of neuroforaminal tributaries arising from the foraminae.

LESSONS

Sacral insufficiency fractures may cause scarring that adheres to the IIV and its neuroforaminal tributaries, which risks massive bleeding during sacrectomy.

Open access

Traumatic sacral dermoid cyst rupture with intracranial subarachnoid seeding of lipid particles: illustrative case

Alexander Perdomo-Pantoja, Hesham Mostafa Zakaria, Brendan F. Judy, Jawad M. Khalifeh, Jose L. Porras, Tej D. Azad, Brian Y. Hwang, Timothy F. Witham, Chetan Bettegowda, and Nicholas Theodore

BACKGROUND

Intracranial deposits of fat droplets are an unusual presentation of a spinal dermoid cyst after spontaneous rupture and are even more uncommon after trauma. Here, the authors present a case with this rare clinical presentation, along with a systematic review of the literature to guide decision making in these patients.

OBSERVATIONS

A 54-year-old woman with Lynch syndrome presented with severe headache and sacrococcygeal pain after a traumatic fall. Computed tomography of the head revealed multifocal intraventricular and intracisternal fat deposits, which were confirmed by magnetic resonance imaging (MRI) of the neuroaxis; in addition, a ruptured multiloculated cyst was identified within the sacral canal with proteinaceous/hemorrhagic debris, most consistent with a sacral dermoid cyst with rupture into the cerebrospinal fluid (CSF) space. An unruptured sacral cyst was later noted on numerous previous MRI scans. In our systematic review, we identified 20 similar cases, most of which favored surgical treatment.

LESSONS

Rupture of an intraspinal dermoid cyst must be considered when intracranial fat deposits are found in the context of cauda equina syndrome, meningism, or hydrocephalus. Complete tumor removal with close postoperative follow-up is recommended to decrease the risk of complications. CSF diversion must be prioritized if life-threatening hydrocephalus is present.

Open access

Minimally invasive endoscopic approach to perform complete coccygectomy in patients with chronic refractory coccydynia: illustrative case

Jorge A. Roa, Sarah White, Ernest J. Barthélemy, Arthur Jenkins III, and Konstantinos Margetis

BACKGROUND

Coccydynia refers to debilitating pain in the coccygeal region of the spine. Treatment strategies range from conservative measures (e.g., ergonomic adaptations, physical therapy, nerve block injections) to partial or complete removal of the coccyx (coccygectomy). Because the surgical intervention is situated in a high-pressure location close to the anus, a possible complication is the formation of sacral pressure ulcers and infection at the incision site.

OBSERVATIONS

In this case report, the authors presented a minimally invasive, fully endoscopic approach to safely perform complete coccygectomy for treatment of refractory posttraumatic coccydynia.

LESSONS

Although this is a single case report, the authors hope that this novel endoscopic approach may achieve improved wound healing, reduced infection rates, and lower risk of penetration injury to retroperitoneal organs in patients requiring coccygectomy.

Open access

Pseudogout, an unconventional imitator of the lumbosacral spine with associated chronic epidural hematoma: illustrative cases

Stephen Jaffee, Seung Won Jeong, Rocco Dabecco, Shahed Elhamdani, and Alexander Yu

BACKGROUND

Pseudogout, or calcium pyrophosphate dihydrate (CPPD) disease, is an inflammatory joint disease that most commonly involves the joints of the knees, ankles, and wrists. Pseudogout has also been known to involve the spine, especially the atlanto-occipital joint of the cervical spine, but there is limited documentation of its involvement in the lumbar spine. Though the atypical presentation of spinal pseudogout with findings consistent with discitis and epidural abscess has been documented, its presentation with associated chronic spinal epidural hematoma is a rare entity.

OBSERVATIONS

The authors present two separate cases of pseudogout involvement of the lumbar spine, one case presenting with a clinical and radiographic picture consistent with discitis and epidural abscess and the other with radiographic and operative findings consistent with a chronic epidural hematoma.

LESSONS

This case series demonstrates rare and atypical presentations of pseudogout within the lumbosacral spine.