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Open access

Phantom limb pain, traumatic neuroma, or nerve sheath tumor? Illustrative case

Patrick J Halloran, E. Antonio Chiocca, and Andres Santos

BACKGROUND

Phantom limb pain and traumatic neuromas are not commonly seen in neurosurgical practice. These conditions can present with similar symptoms; however, management of traumatic neuroma is often surgical, whereas phantom limb pain is treated with conservative measures.

OBSERVATIONS

A 77-year-old female patient with a long-standing history of an above-the-knee amputation experienced severe pain in her right posterior buttocks area for several years’ duration, attributed to phantom limb pain, which radiated down the stump of her leg and was treated with a variety of conservative measures. A recent exacerbation of her pain led to a prolonged hospitalization with magnetic resonance imaging of her leg stump, revealing a mass in the sciatic notch, at a relative distance from the stump. The anatomical location of the mass on the sciatic nerve in the notch led to a presumed radiological diagnosis of nerve sheath tumor, for which she underwent excision. At surgery, a neuroma of the proximal portion of the transected sciatic nerve that had retracted from the amputated stump to the notch was diagnosed.

LESSONS

Traumatic neuromas of transected major nerves after limb amputation should be considered in the differential diagnosis of phantom limb pain.

Open access

Intraoperative application of indocyanine green and temporary venous occlusion test to assess collateral flow during microvascular decompression for venous-related trigeminal neuralgia: illustrative case

Kentaro Fujimoto, Yosuke Akamatsu, Yasumasa Nishikawa, and Kuniaki Ogasawara

BACKGROUND

In microvascular decompression (MVD) for vein-related trigeminal neuralgia (TN), determining whether transection of the offending vein is safe can be challenging. Here, the authors present a case of vein-related TN successfully treated by sacrificing the offending vein on the basis of findings from indocyanine green (ICG) video angiography and a temporary venous occlusion test to assess the collateral flow of the offending vessel.

OBSERVATIONS

A 43-year-old man presented with TN, which had failed to respond to previous medical therapy. Gadolinium-enhanced magnetic resonance imaging (MRI) revealed that the transverse or superior petrosal vein was the offending vein. The patient underwent MVD. Because the transposition of the offending vein was anatomically challenging, a temporary vein occlusion test was performed using ICG video angiography. During and after temporary occlusion, bidirectional flow in the offending vein was observed, suggesting collateral flow even after vein occlusion. On the basis of these findings, the offending vein was transected, resulting in relief from pain without any complications. Postoperative MRI revealed no new lesions in the brainstem or the cerebellar hemisphere. The patient has been free from neuralgia for 6 months.

LESSONS

The temporary vein occlusion test under ICG video angiography was useful for evaluating collateral flow in the offending vein in TN.

Open access

Microvascular decompression of a vertebral artery loop causing cervical radiculopathy: illustrative case

Alexa Semonche, Lorenzo Rinaldo, Young Lee, Todd Dubnicoff, Harlan Matles, Dean Chou, Adib Abla, and Edward F Chang

BACKGROUND

Vertebral artery loops are a rare cause of cervical radiculopathy. Surgical options for nerve root decompression include an anterior or posterior approach, with or without additional microvascular decompression.

OBSERVATIONS

The authors describe a case of a 49-year-old man with a long-standing history of left-sided neck pain and migraines, who was found to have a vertebral artery loop in the left C3–4 neural foramen compressing the left C4 nerve root. The patient underwent a posterior cervical decompression with instrumented fusion and macrovascular decompression of the left C4 nerve root via Teflon felt insertion. In a literature review, we identified 20 similar cases that had also been managed surgically.

LESSONS

Although the anterior approach is more frequently described in the literature, a posterior approach for nerve compression by a vertebral artery loop is also a safe and effective treatment. The authors report the third case of this surgical approach with a good outcome.

Open access

Minimally invasive resection of a prominent transverse process in neurogenic thoracic outlet syndrome: new application for a primarily spinal approach. Illustrative case

Marc Hohenhaus, Johann Lambeck, Nico Kremers, Jürgen Beck, Christoph Scholz, and Ulrich Hubbe

BACKGROUND

The optimal surgical approach to treat neurogenic thoracic outlet syndrome (nTOS) depends on the individual patient’s anatomy as well as the surgeon’s experience. The authors present a minimally invasive posterior approach for the resection of a prominent transverse process to reduce local muscular trauma.

OBSERVATIONS

A 19-year-old female presented with painful sensations in the right arm and severe fine-motor skill dysfunction in the right hand, each of which had been present for several years. Further examination confirmed affected C8 and T1 areas, and imaging showed an elongated C7 transverse process displacing the lower trunk of the brachial plexus. Decompression of the plexus structures by resection of the C7 transverse process was indicated, owing to persistent neurological effects. Surgery was performed using a minimally invasive posterior approach in which the nuchal soft tissue was bluntly dissected by dilatators and resection of the transverse process was done microscopically through a tubular retractor. The postoperative course showed a sufficient reduction of pain and paresthesia.

LESSONS

The authors describe a minimally invasive posterior approach for the treatment of nTOS with the aim of providing indirect relief of strain on brachial plexus structures. The advantages of this technique include a small skin incision and minor soft tissue damage.

Open access

Arteriovenous malformation presenting as complex regional pain syndrome: illustrative case

Dayna C Sloane, Diego D Luy, Atul K Mallik, Joseph C Serrone, and Douglas E Anderson

BACKGROUND

Complex regional pain syndrome (CRPS) is typically described as a peripheral nerve disorder in which exaggerated allodynia and hyperalgesia follow a minor injury. Some researchers propose a central mechanism, although current evidence is lacking.

OBSERVATIONS

A 14-year-old female presented with classic CRPS symptoms of left upper-extremity weakness and hyperalgesia after a bout of sharp pain in her thumb while shoveling snow. A possible seizure prompted magnetic resonance imaging, revealing a right frontal Spetzler-Martin grade II arteriovenous malformation (AVM) adjacent to the primary motor cortex. Brodmann areas 1, 3a, and 3b, which are responsible for localizing and processing burning and painful sensations, were also involved. The patient underwent transarterial Onyx embolization in two sessions and microsurgical resection, after which her CRPS symptoms completely resolved.

LESSONS

To our knowledge, this is the first reported case of a cerebral AVM presenting as CRPS, which supports a central mechanism. The authors propose that rapid growth of the AVM led to a vascular steal phenomenon of surrounding parenchyma, which disrupted the patient’s normal motor function and nociceptive processing. Further validation in other series is needed.

Open access

Bipolar, high-voltage, long-duration pulsed radiofrequency ablation of the Gasserian ganglion for the treatment of trigeminal neuralgia in a patient with a cardiac implantable electronic device: illustrative case

Albert A Sufianov, Nargiza A Garifullina, Andrey G Shapkin, Egor S Markin, Matias Baldoncini, Luis A. B Borba, Manuel J Encarnacion Ramirez, and Rinat A Sufianov

BACKGROUND

One of the common methods of treating trigeminal neuralgia (TN) nowadays is radiofrequency therapy. However, it has serious limitations in patients with a cardiac pacemaker because of electromagnetic interference. Therefore, it is crucial to select optimal radiofrequency ablation parameters to make this procedure safe with favorable outcomes for such patients.

OBSERVATIONS

In this study, the authors present a case of a 70-year-old man with a history of cardiac pacemaker dependency and previous microvascular decompression with complaints of severe, constant facial pain. After reprogramming the cardiac implantable electronic device (CIED), the authors performed bipolar, high-voltage, long-duration pulsed radiofrequency therapy (PRFT) of the Gasserian ganglion under electrocardiography and pulse rate control in the pre-, intra-, and postoperative periods. There were no cardiovascular or neurological complications after PRFT. The patient reported relief of pain after the procedure, and at the 9-month follow-up, he was pain-free.

LESSONS

This clinical case demonstrates that the use of bipolar, high-voltage PRFT for TN treatment in patients with a CIED can be safe and effective, provided that the rules and pacemaker instructions are followed. It is necessary to use ablative treatment with caution and to guide the patient in collaboration with a cardiac surgeon and an anesthesiologist resuscitator.

Open access

Microvascular decompression for developmental venous anomaly causing hemifacial spasm: illustrative case

Margaret Tugend and Raymond F Sekula Jr.

BACKGROUND

Developmental venous anomaly (DVA) is a rare cause of hemifacial spasm (HFS). The treatment of HFS caused by a DVA varies in the literature and includes medication management, botulinum toxin injections, and microvascular decompression (MVD).

OBSERVATIONS

A 64-year-old woman presented with right-sided HFS. Preoperative magnetic resonance imaging showed a DVA in the right inferior pons, with an enlarged segment compressing the facial nerve at its root detachment point prior to drainage into the superior petrosal sinus. MVD was performed, and the facial nerve was decompressed without sacrifice of the vein. Immediately following the procedure, the patient had significantly reduced spasms. The patient became spasm-free 3 months after MVD and maintained spasm freedom for 3 months. Six months after MVD, the patient had a partial return of spasms. At 8 months, the patient continued to have reduced and intermittent spasms in the right orbicularis oculi muscle.

LESSONS

MVD for HFS caused by a DVA is a safe procedure and can be effective at reducing spasm frequency and severity.

Open access

Foraminal stenosis and radiculopathy secondary to tophaceous gout: illustrative case

Patrick Chang, Brandon C Rogowski, Khaled Abdel Aziz, Rosh Bharthi, Lance Valls, Nathan Esplin, and Richard W Williamson

BACKGROUND

Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues. Gouty tophi in the spine have a constellation of presentations that often mimic other pathologies and may not be easily discernable from more common pathologic processes.

OBSERVATIONS

A 47-year-old female with a history of chronic renal disease, obesity, gout, inflammatory polyarthritis, and multiple sclerosis presented with 6 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. A lumbar magnetic resonance imaging study revealed right foraminal stenosis and spondylolisthesis at levels L4–5. An intraspinal extradural mass was noted adjacent to the traversing right L5 and exiting right L4 nerve roots. A bilateral decompressive laminectomy, facetectomy, and foraminotomy of L4–5 was performed. A calcific, chalky-white mass was discovered in the foramen, and pathology determined the specimen to be a gout tophus. Postoperatively, the patient endorsed the resolution of her preoperative symptoms, which have not returned on follow-up.

LESSONS

Reports of gouty depositions compressing the spinal cord in the current literature are relatively rare. Although the diagnosis of gouty tophi can only be confirmed histologically, patient history may serve as a helpful diagnostic tool.

Open access

Spinal cord stimulation for chronic pain treatment following sacral chordoma resection: illustrative case

Khaled M Taghlabi, Taimur Hassan, Isuru A Somawardana, Sibi Rajendran, Ahmed Doomi, Lokeshwar S Bhenderu, Jesus G Cruz-Garza, and Amir H Faraji

BACKGROUND

Cancer-related or postoperative pain can occur following sacral chordoma resection. Despite a lack of current recommendations for cancer pain treatment, spinal cord stimulation (SCS) has demonstrated effectiveness in addressing cancer-related pain.

OBSERVATIONS

A 76-year-old female with a sacral chordoma underwent anterior osteotomies and partial en bloc sacrectomy. She subsequently presented with chronic pain affecting both buttocks and posterior thighs and legs, significantly impeding her daily activities. She underwent a staged epidural SCS paddle trial and permanent system placement using intraoperative neuromonitoring. The utilization of percutaneous leads was not viable because of her history of spinal fluid leakage, multiple lumbosacral surgeries, and previous complex plastic surgery closure. The patient reported a 62.5% improvement in her lower-extremity pain per the modified Quadruple Visual Analog Scale and a 50% improvement in the modified Pain and Sleep Questionnaire 3-item index during the SCS trial. Following permanent SCS system placement and removal of her externalized lead extenders, she had an uncomplicated postoperative course and reported notable improvements in her pain symptoms.

LESSONS

This case provides a compelling illustration of the successful treatment of chronic pain using SCS following radical sacral chordoma resection. Surgeons may consider this treatment approach in patients presenting with refractory pain following spinal tumor resection.

Open access

Techniques for restoring optimal spinal biomechanics to alleviate symptoms in Bertolotti syndrome: illustrative case

Nolan J Brown, Zach Pennington, Hania Shahin, Oanh T Nguyen, and Martin H Pham

BACKGROUND

Lumbosacral transitional vertebrae (LSTVs) are congenital anomalies that occur in the spinal segments of L5–S1. These vertebrae result from sacralization of the lowermost lumbar segment or lumbarization of the uppermost sacral segment. When the lowest lumbar vertebra fuses or forms a false joint with the sacrum (pseudoarticulation), it can cause pain and manifest clinically as Bertolotti syndrome.

OBSERVATIONS

A 36-year-old female presented with severe right-sided low-back pain. Computed tomography was unremarkable except for a right-sided Castellvi type IIA LSTV. The pain proved refractory to physical therapy and lumbar epidural spinal injections, but targeted steroid and bupivacaine injection of the pseudoarticulation led to 2 weeks of complete pain relief. She subsequently underwent minimally invasive resection of the pseudoarticulation, with immediate improvement in her low-back pain. The patient continued to be pain free at the 3-year follow-up.

LESSONS

LSTVs alter the biomechanics of the lumbosacral spine, which can lead to medically refractory mechanical pain requiring surgical intervention. Select patients with Bertolotti syndrome can benefit from operative management, including resection, fusion, or decompression of the pathologic joint.