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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

Epidural lipomatosis with foci of hemorrhage and acute compression of the spinal cord in a child with CLOVES syndrome: illustrative case

Dmytro Ishchenko, Iryna Benzar, and Andrii Holoborodko

BACKGROUND

Congenital lipomatous overgrowth, vascular malformations, epidermal nevi, spinal/skeletal anomalies, and/or scoliosis (CLOVES) syndrome is the most recently described combined vascular anomaly characterized by congenital excessive growth of adipose tissue, vascular malformations, epidermal nevi, and skeletal deformities. This condition exhibits a significant variability in clinical manifestations and a tendency for rapid progression and affects extensive anatomical regions. Information regarding the association of epidural lipomatosis with low-flow venous lymphatic malformations is rare, with few reports in the literature.

OBSERVATIONS

The authors present a case of a 6-year-old girl who was admitted to the emergency department complaining of rapidly progressing weakness in her lower extremities and partial loss of sensation in the inguinal area. Radiologically, an extradural mass was identified at the T2–6 level, causing acute spinal cord compression. Urgent decompression and partial resection of the mass were performed. Despite satisfactory intraoperative hemo- and lymphostasis, postoperative lymphorrhea/seroma leakage was encountered as a delayed complication and was managed conservatively.

LESSONS

CLOVES syndrome is characterized by the combination of various clinical symptoms, not all of which are included in the abbreviation, as well as a progressively deteriorating course, the emergence of new symptoms, and complications throughout the patient’s life. This necessitates ongoing monitoring of such patients.

Open access

A rare case of atypical intradural extramedullary glioblastoma diagnosed utilizing next-generation sequencing and methylation profiling: illustrative case

William J Shelton, Andrew P Mathews, Karrar Aljiboori, J. Stephen Nix, Murat Gokden, and Analiz Rodriguez

BACKGROUND

Primary spinal cord tumors, especially primary spinal cord glioblastoma multiforme (PSC-GBM), are exceptionally rare, accounting for less than 1.5% of all spinal tumors. Their infrequency and aggressive yet atypical presentation make diagnosis challenging. In uncertain cases, a surgical approach for tissue diagnosis is often optimal.

OBSERVATIONS

A 76-year-old male presented with a rapidly progressing clinical history marked by worsening extremity weakness, urinary retention, and periodic fecal incontinence alongside diffuse changes on neuraxis imaging. The patient, in whom subacute polyneuropathy was initially diagnosed, received multiple rounds of steroids and intravenous immunoglobulin without clinical improvement. Histopathological review of the biopsy tissue yielded an initial diagnosis of spindle cell neoplasm. Next-generation sequencing (NGS) is done routinely on all neuropathology specimens at the authors’ institution, and methylation profiling is pursued in difficult cases. Ultimately, NGS and methylation profiling results were essential to an integrated final diagnosis of GBM.

LESSONS

PSC-GBM is a rare but highly aggressive occurrence of this tumor. Prolonged back pain, rapid neurological decline, and imaging changes warrant the consideration of lesional biopsy for precise disease characterization. In inconclusive cases, NGS has proved invaluable for clinical clarification and diagnosis, underscoring its importance for integrated diagnoses in guiding appropriate treatment strategies.

Open access

Successful coil embolization of a ruptured pseudoaneurysm of the superior gluteal artery after a percutaneous awake robot-assisted sacroiliac joint fusion: illustrative case

Samah Morsi, Alyssa M Bartlett, Andrew A Hardigan, Mounica Paturu, Shawn W Adams, Malcolm R DeBaun, Waleska Pabon-Ramos, and Muhammad M Abd-El-Barr

BACKGROUND

Robot-assisted sacroiliac joint (SIJ) fusion has gained popularity, but it carries the risk of complications such as injury to the superior gluteal artery (SGA). The authors present the case of an awake percutaneous robot-assisted SIJ fusion leading to an SGA pseudoaneurysm.

OBSERVATIONS

An 80-year-old male, who had undergone an awake percutaneous robot-assisted SIJ fusion, experienced postoperative left hip pain and bruising. Subsequent arteriography demonstrated an SGA branch pseudoaneurysm requiring coil embolization.

LESSONS

An SGA injury, although uncommon (1.2% incidence), can arise from percutaneous screw placement, aberrant anatomy, or hardware contact. Thorough preoperative imaging, precise robot-assisted screw insertion, and soft tissue protection are crucial to mitigate risks. Immediate angiography aids in prompt diagnosis and effective intervention. Comprehensive knowledge of anatomical variants is essential for managing complications and optimizing preventative measures in robot-assisted SIJ fusion.

Open access

Cervicothoracic ventral-dorsal rhizotomy for bilateral upper-extremity hypertonia in cerebral palsy: illustrative case

Ryan Kelly, Hanna R Kemeny, Sunny Abdelmageed, Robin Trierweiler, Tim Krater, Melissa A LoPresti, and Jeffrey S Raskin

BACKGROUND

Management of medically refractory limb-specific hypertonia is challenging. Neurosurgical options include deep brain stimulation, intrathecal baclofen, thalamotomy, pallidotomy, or rhizotomy. Cervical dorsal rhizotomy has been successful in the treatment of upper-extremity spasticity. Cervical ventral and cervical ventral-dorsal rhizotomy (VDR) has been used in the treatment or torticollis and traumatic hypertonia; however, the use of cervicothoracic VDR for the treatment of upper-extremity mixed hypertonia is not well described.

OBSERVATIONS

A 9-year-old girl with severe quadriplegic mixed hypertonia secondary to cerebral palsy (CP) underwent cervicothoracic VDR. Modified Ashworth Scale scores, provision of caregiving, and examination improved. Treatment was well tolerated.

LESSONS

Cervicothoracic VDR can afford symptomatic and quality of life improvement in patients with medically refractory limb hypertonia. Intraoperative positioning and nuances in surgical techniques are particularly important based on spinal cord position as modified by scoliosis. Here, the first successful use of cervicothoracic VDR for the treatment of medically refractory upper-limb hypertonia in a pediatric patient with CP is described.

Open access

Posterior-only 2-level vertebrectomy and fusion in a medically complex patient with lumbar metastasis: illustrative case

Ryan Johnson, Annabelle Shaffer, Ashley Tang, Kathryn Tsai, Gina Guglielmi, and Paul M Arnold

BACKGROUND

Spinal metastases are commonly seen in patients with cancer and often indicate a poor prognosis. Treatment can include curative or palliative surgery, chemotherapy, and radiation therapy. The surgical approach varies widely on the basis of the affected region of the spine, the location of the tumor (anterior versus posterior), the goal of surgery, the health of the patient, and surgeon preference.

OBSERVATIONS

The authors present a case of a 68-year-old male with intractable lower-back pain and substantially diminished ambulation. Diagnostic imaging revealed a lumbar metastasis from a cholangiocarcinoma primary at L2–3 (4.5 cm anteroposterior × 5.7 cm transverse × 7.0 cm craniocaudal). The patient underwent a 2-level vertebrectomy with expandable cage placement and T10 to S2 fusion via a posterior-only approach. The patient regained much of his mobility and quality of life after the surgery.

LESSONS

Although this was a high-risk surgery, the authors show that a posterior-only approach can be used for lumbar vertebrectomies and fusion when necessary. Palliative surgeries carrying a high risk, especially in the setting of a limited prognosis, should include multidisciplinary deliberations and a thorough discussion of the risks and outcome expectations with the patient.

Open access

Adhesive arachnoiditis, subarachnoid hemorrhage, and intradural extramedullary thoracic cavernoma: illustrative case

Agne Andriuskeviciute, Michel Gustavo Mondragón-Soto, Nicolas Penet, and Juan Barges-Coll

BACKGROUND

Spinal arachnoiditis can result from various factors, including spinal subarachnoid hemorrhage (sSAH). In this paper, the authors describe a case of intradural extramedullary cavernoma with an initial presentation of subarachnoid hemorrhage leading to multilevel spinal arachnoiditis to discuss the pathophysiology and optimal treatment strategy.

OBSERVATIONS

Spinal intradural extramedullary cavernoma manifesting with sSAH is a rare clinical presentation; therefore, there is no clear strategy for the management of sSAH. Spinal arachnoiditis is a result of chronic inflammation of the pia arachnoid layer due to hematomyelia. No effective treatment that interrupts this inflammatory cascade and would also prevent the development of spinal arachnoiditis has been described to date.

LESSONS

Lumbar drainage could aid in sSAH management, relieve spinal cord compression, and restore the normal spinal cerebrospinal fluid circulation gradient. It could help to clear the blood degradation products rapidly and prevent early inflammatory arachnoiditis development. Mini-invasive intrathecal endoscopic adhesiolysis appears to be a reasonable approach for reducing the risk of aggravating spinal arachnoiditis with a mechanical-surgical stimulus. Whether a conservative approach should be applied in these patients with mild myelopathy symptoms is still debatable.

Open access

Fusion mass to pelvis internal distraction technique using multiple-hook fixation for scoliosis correction: illustrative case

J. Manuel Sarmiento, Christina C Rymond, Abdulbaki Kozan, and Lawrence G Lenke

BACKGROUND

Internal distraction rods have been described as an alternative to halo gravity traction for the treatment of severe scoliosis. Distraction rods can be challenging to use in patients with existing fusion masses. The authors report an internal distraction, construct-to-construct rod technique using multiple-hook fixation in a patient with a sharply angulated cervicothoracic scoliosis fusion mass.

OBSERVATIONS

A 12-year-old female with previously diagnosed congenital scoliosis who had undergone cervical fusion in situ at age 2 presented to the clinic with shortness of breath exacerbated by increased levels of activity. Standing anteroposterior and lateral scoliosis radiographs revealed a left >150° cervicothoracic curve, right 140° thoracolumbar curve, and left 28° lumbosacral fractional curve with pelvic obliquity. The authors indicated this patient for a 3-stage all-posterior approach for spinal fusion and deformity correction. In the final fusion surgery, the authors set up a construct-to-construct internal distraction configuration connecting the left hemipelvis to the cervicothoracic fusion mass to aid in deformity correction.

LESSONS

A construct-to-construct internal distraction rod technique connecting a fusion mass to the pelvis can assist with curve correction in severe scoliosis.

Open access

Multiple three-column osteotomies successfully correcting cervicothoracic kyphosis in the setting of ankylosing spondylitis: illustrative case

Luke Mugge, Paul Gorka, Cristie Brewer, and Brian McHugh

BACKGROUND

Ankylosing spondylitis (AS) is an autoimmune spondylarthritis often associated with rigid kyphoscoliosis. The authors describe a surgical approach that employs multilevel three-column osteotomies for the restoration of normal global alignment.

OBSERVATIONS

A 48-year-old male with a past medical history of AS presented to the clinic with a stooped-over posture: his chin-brow vertical angle (CBVA) was 58.0°; T1 slope (T1S), 97.8°; thoracic kyphosis (TK; T1–12), 94.2°; proximal TK (T1–5), 50.8°; distal TK (T5–12), 43.5°; and sagittal vertical axis (SVA), 22.6 cm. A two-stage procedure was planned. During stage 1, instrumentation was placed from C5 to T10, followed by a T3 vertebral column resection. During stage 2, bilateral pedicle screws were placed from T11 to the pelvis. An L3 pedicle subtraction osteotomy (PSO) was completed and was followed by a T7 PSO. Postoperatively, the patient had significant postural improvement: CBVA was 29.3°; T1S, 57.8°; TK, 77.3°; proximal TK, 33.5°; distal TK, 43.8°; and SVA, 15 cm. At 6 years postoperatively, the patient continued to do well and was without evidence of construct breakdown.

LESSONS

The authors propose that multilevel three-column osteotomies, if optimally located, successfully correct spinal malalignment associated with AS.

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.