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Open access

Incidental durotomy resulting in a postoperative lumbosacral nerve root with eventration into the adjacent facet joint: illustrative cases

Michael J Kelly, Franziska C. S Altorfer, Marco D Burkhard, Russel C Huang, Frank P Cammisa Jr., and J. Levi Chazen

BACKGROUND

Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication.

OBSERVATIONS

Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints.

LESSONS

Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.

Open access

Oblique anterior column realignment with a mini-open posterior column osteotomy for minimally invasive adult spinal deformity correction: illustrative case

Zach Pennington, Nolan J Brown, Seyedamirhossein Pishva, Hernán F. J González, and Martin H Pham

BACKGROUND

Adult spinal deformity (ASD) occurs from progressive anterior column collapse due to disc space desiccation, compression fractures, and autofusion across disc spaces. Anterior column realignment (ACR) is increasingly recognized as a powerful tool to address ASD by progressively lengthening the anterior column through the release of the anterior longitudinal ligament during lateral interbody approaches. Here, we describe the application of minimally invasive ACR through an oblique antepsoas corridor for deformity correction in a patient with adult degenerative scoliosis and significant sagittal imbalance.

OBSERVATIONS

A 65-year-old female with a prior history of L4–5 transforaminal lumbar interbody fusion and morbid obesity presented with refractory, severe low-back and lower-extremity pain. Preoperative radiographs showed significant sagittal imbalance. Computed tomography showed a healed L4–5 fusion and a vacuum disc at L3–4 and L5–S1, whereas magnetic resonance imaging was notable for central canal stenosis at L3–4. The patient was treated with a first-stage L5–S1 lateral anterior lumbar interbody fusion with oblique L2–4 ACR. The second-stage posterior approach consisted of a robot-guided minimally invasive T10–ilium posterior instrumented fusion with a mini-open L2–4 posterior column osteotomy (PCO). Postoperative radiographs showed the restoration of her sagittal balance. There were no complications.

LESSONS

Oblique ACR is a powerful minimally invasive tool for sagittal plane correction. When combined with a mini-open PCO, substantial segmental lordosis can be achieved while eliminating the need for multilevel PCO or invasive three-column osteotomies.

Open access

Bilateral L5 pedicle fracture with L5–S1 spondylolisthesis after single-level L4–5 posterior lumbar interbody fusion: illustrative case

Toshiyuki Kitaori, Masato Ota, and Jiro Tamura

BACKGROUND

Single-level posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) is a commonly performed surgical procedure for L4–5 isthmic spondylolisthesis. Postoperative L5 pedicle fracture with rapidly progressive spondylolisthesis at L5–S1 segment after L4–5 PLIF/TLIF is quite rare, and the etiology remains unclear. This report describes this rare complication and proposes a possible etiology focusing on the lumbosacral sagittal imbalance characterized by an anteriorly shifted lumbar loading axis.

OBSERVATIONS

The authors report a case complicated by L5 bilateral pedicle fractures and rapidly progressive spondylolisthesis at the L5–S1 segment very early after a single-level PLIF for L4–5 isthmic spondylolisthesis. Meyerding grade III anterolisthesis was observed at L5–S1 segment by 3 months after the initial surgery. Additional surgery was performed, and the fixation was extended to L4–ilium. Fracture healing was observed at 6 months postoperatively.

LESSONS

This complication may have been caused by abnormal local shear forces on the posterior neural arch of L5 vertebra and L5–S1 intervertebral disc, which were triggered by the fusion surgery for L4 shear-type spondylolisthesis. L4 sagittal vertical axis is considered a reasonable parameter representing lumbosacral sagittal imbalance with an anteriorly shifted loading axis and may be a candidate for the predictive parameters of this rare complication.

Open access

Contralateral lower limb radiculopathy by extraforaminal disc herniation following oblique lumbar interbody fusion in degenerative lumbar disorder: illustrative cases

Satoshi Hattori and Toru Maeda

BACKGROUND

Contralateral lower limb radiculopathy is a potential early complication of oblique lumbar interbody fusion (OLIF) in degenerative lumbar disorders. Among several pathologies related to contralateral radiculopathy following OLIF, extraforaminal disc herniation during the OLIF procedure is very rare.

OBSERVATIONS

Case 1 is a 68-year-old male underwent L4–5 and L5–6 OLIF for recurrent lumbar canal stenosis–expressed right leg pain and muscle weakness after surgery. Case 2 is a 76-year-old female on whom L4–5 OLIF was performed for L4 degenerative spondylolisthesis and who presented right leg pain and numbness postoperatively. In both patients, OLIF cages were inserted into the posterior part of the disc space or obliquely and the extraforaminal extruded disc compressed opposite exiting nerve roots (L5 root in case 1 and L4 root in case 2) as shown on magnetic resonance imaging (MRI). Surgical decompression with discectomy was required for pain relief and neurological improvement in both cases.

LESSONS

When emerging from new-onset opposite limb radiculopathy attributed to the OLIF procedure, extraforaminal disc herniation should be considered a potential pathology and MRI is useful for early diagnosis and selecting a subsequent management, including surgery.

Open access

Robotics planning in minimally invasive surgery for adult degenerative scoliosis: illustrative case

Zach Pennington, Nolan J. Brown, Saif Quadri, Seyedamirhossein Pishva, Cathleen C. Kuo, and Martin H. Pham

BACKGROUND

Minimally invasive surgical techniques are changing the landscape in adult spinal deformity (ASD) surgery, enabling surgical correction to be achievable in increasingly medically complex patients. Spinal robotics are one technology that have helped facilitate this. Here the authors present an illustrative case of the utility of robotics planning workflow for minimally invasive correction of ASD.

OBSERVATIONS

A 60-year-old female presented with persistent and debilitating low back and leg pain limiting her function and quality of life. Standing scoliosis radiographs demonstrated adult degenerative scoliosis (ADS), with a lumbar scoliosis of 53°, a pelvic incidence–lumbar lordosis mismatch of 44°, and pelvic tilt of 39°. Robotics planning software was utilized for preoperative planning of the multiple rod and 4-point pelvic fixation in the posterior construct.

LESSONS

To the authors’ knowledge, this is the first report detailing the use of spinal robotics for complex 11-level minimally invasive correction of ADS. Although additional experiences adapting spinal robotics to complex spinal deformities are necessary, the present case represents a proof-of-concept demonstrating the feasibility of applying this technology to minimally invasive correction of ASD.

Open access

Lumbar pedicle screw pseudoarthrosis salvage technique with moldable, bioabsorbable, calcium phosphate–based putty: illustrative case

Nathan Esplin, Shahed Elhamdani, Seung W. Jeong, Michael Moran, Brandon Rogowski, and Jonathan Pace

BACKGROUND

Pseudoarthrosis is a complication of spinal fixation. Risk factors include infection, larger constructs, significant medical comorbidities, and diabetes. The authors present a case report of dilated pedicle screw pseudoarthrosis salvaged with moldable, settable calcium phosphate–based putty.

OBSERVATIONS

The patient presented with back pain and radiculopathy in the setting of poorly controlled diabetes. He was taken to the operating room for laminectomy and fusion complicated by postoperative infection requiring incision and drainage. He returned to the clinic 6 months later with pseudoarthrosis of the L4 screws and adjacent segment degeneration. He was taken for revision with extension of fusion. The L4 tracts were significantly dilated. A moldable, bioabsorbable polymer-based putty containing calcium phosphate was used to augment the dilated tract after decortication back to bleeding bone, allowing good purchase of screws. The patient did well postoperatively.

LESSONS

There are several salvage options for clinically significant pseudoarthrosis after spinal fixation, including anterior or lateral constructs, extension, and revision of fusion. The authors were able to obtain good screw purchase with dilated screw tracts after addition of moldable, bioabsorbable polymer-based putty containing calcium phosphate. It appears that this may represent an effective salvage strategy for dilated pseudoarthropathy in select settings to support extension of fusion.

Open access

Utilization of lateral anterior lumbar interbody fusion for revision of failed prior TLIF: illustrative case

Ghani Haider, Katherine E. Wagner, Venita Chandra, Ivan Cheng, Martin N. Stienen, and Anand Veeravagu

BACKGROUND

The use of the lateral decubitus approach for L5–S1 anterior lumbar interbody fusion (LALIF) is a recent advancement capable of facilitating single-position surgery, revision operations, and anterior column reconstruction. To the authors’ knowledge, this is the first description of the use of LALIF at L5–S1 for failed prior transforaminal lumbar interbody fusion (TLIF) and anterior column reconstruction. Using an illustrative case, the authors discuss their experience using LALIF at L5–S1 for the revision of pseudoarthrosis and TLIF failure.

OBSERVATIONS

The patient had prior attempted L2 to S1 fusion with TLIF but suffered from hardware failure and pseudoarthrosis at the L5–S1 level. LALIF was used to facilitate same-position revision at L5–S1 in addition to further anterior column revision and reconstruction by lateral lumbar interbody fusion at the L1–2 level. Robotic posterior T10–S2 fusion was then added to provide stability to the construct and address the patient’s scoliotic deformity. No complications were noted, and the patient was followed until 1 year after the operation with a favorable clinical and radiological result.

LESSONS

Revision of a prior failed L5–S1 TLIF with an LALIF approach has technical challenges but may be advantageous for single position anterior column reconstruction under certain conditions.