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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.

Open access

A radiological analysis of pelvic fixation trajectories: patient series

Jonathan P Scoville, Evan Joyce, Andrew T Dailey, and Marcus D Mazur

BACKGROUND

Three well-defined methods for pelvic fixation are used for biomechanical support in spine fusion constructs: iliac, recessed iliac, and S2-alar-iliac (S2AI) screws. The authors compared the maximum screw sizes that could be placed with these techniques by using image-guidance software and high-resolution computed tomography scans from 20 randomly selected patients. Six trajectories were plotted per side, beginning at recognized starting points (standard or recessed posterior superior iliac spine [PSIS] or S2AI screw) and ending at the anterior inferior iliac spine (AIIS) or supra-acetabular notch (SAN).

OBSERVATIONS

The mean maximum screw length and width ranged from 80.0 ± 32.2 mm to 140.8 ± 22.6 mm and from 8.25 ± 1.2 mm to 13.0 ± 2.7 mm, respectively, depending on the trajectory. Statistically significant differences in length were found between the standard and recessed PSIS trajectories to the AIIS (p < 0.001) and between the standard PSIS-to-AIIS trajectory and the S2AI-to-AIIS (p = 0.007) or S2AI-to-SAN (p < 0.001) trajectories. The most successful trajectory was the PSIS to SAN (95%, 38/40).

LESSONS

The traditional iliac screw trajectory enabled the longest and widest screw trajectories and highest rate of successful screw placement with the fewest theoretical breaches more reliably than recessed and S2AI trajectories. These findings may help surgeons plan for maximum screw purchase for pelvic fixation.

Open access

Percutaneous lumbopelvic fixation for pathologic sacral fractures and spinopelvic dissociation: patient series

Nikolas Baksh, Caleb Yeung, and Max Vaynrub

BACKGROUND

Because patients with advanced cancer live longer, the number of patients with the sequelae of metastatic spine disease has increased. Pathologic instability of the mobile spine has been classified, and minimally invasive surgery has been well described. However, pathologic sacral instability is uncommon and often underdiagnosed. Although most sacral fractures are stable, patients with unstable U- or H-type fractures have spinopelvic dissociation and can experience progressive pain, sacral kyphosis, and neurological injury. Open lumbopelvic fusion carries a high perioperative risk for this patient population, which has often been previously radiated and is medically frail. The authors investigated the utility and safety of percutaneous lumbopelvic fixation, as previously described for traumatic spinopelvic dissociation, in the oncological setting. The authors retrospectively reviewed five consecutive patients with unstable pathologic sacral fractures who had undergone percutaneous lumbopelvic fixation after conservative management failed.

OBSERVATIONS

Patients experienced significant improvement between pre- and postoperative visual analog scale scores (9.2 and 1.6, respectively) and Eastern Cooperative Oncology Group grades (median 3 and 1, respectively). All patients were independently ambulatory at the final follow-up. Sagittal alignment remained stable in four patients and worsened in one. There were no major medical or surgical complications.

LESSONS

Percutaneous lumbopelvic fixation shows promising results for palliation, durability, and safety for pathologic sacropelvic instability.

Open access

Traumatic bilateral lumbosacral facet dislocation without fracture: illustrative case

Jose Castillo, Khadija Soufi, Freddie Rodriguez, and Julius O. Ebinu

BACKGROUND

Traumatic bilateral lumbosacral facet dislocations without fractures are extremely rare. Only 7 cases have been documented since the first description by Watson-Jones in 1974. Although various treatment strategies have been reported, no consensus has been reached regarding the best surgical approach.

OBSERVATIONS

A 35-year-old female presented for medical attention following a high-speed motor vehicle collision. She sustained multiple injuries, including an abdominal aortic injury requiring emergent thoracic endovascular aortic repair. She was found to have bilateral lumbosacral dislocation without fracture (L5–S1) and was noted to be neurologically intact. Once medically stabilized, the patient was taken to the operating room for minimally invasive reduction and stabilization of her lumbosacral spine. Postoperatively, the patient was neurologically intact and remained stable with no deficits and appropriate lumbosacral alignment throughout her 2-year follow-up.

LESSONS

The authors report a minimally invasive approach to the management of bilateral lumbosacral facet dislocation without fracture. Although conventional open approaches have been described previously, consideration should be given to minimally invasive strategies in select patients to facilitate their rehabilitative postoperative course.

Open access

Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case

Jon Raso, Jialun Chi, Lawal A. Labaran, Charles Frank, and Francis H. Shen

BACKGROUND

The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated.

OBSERVATIONS

This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction.

LESSONS

Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.

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

Spinal epidural lipomatosis in a pediatric patient with a malignant brain tumor: illustrative case

Reed Berlet, Daphne Li, and John Ruge

BACKGROUND

Spinal epidural lipomatosis (SEL) in pediatric patients with concomitant malignant brain neoplasms is rare and can present with rapid deterioration in neurological function.

OBSERVATIONS

A 4-year-old boy with SEL became paraplegic 4 months after completion of chemoradiation for his previously resected, intracranial atypical teratoid rhabdoid tumor. The patient presented with rapid deterioration in lower extremity sensory and motor function, which, given his oncological history, was concerning for disease progression. Of note, 8 months prior, the patient was started on corticosteroid therapy for respiratory dysfunction. Magnetic resonance imaging revealed significant progression of lumbosacral SEL requiring surgical decompression with subsequent neurological improvement.

LESSONS

When evaluating pediatric patients with primary or metastatic brain tumors with new or worsening myelopathy and motor or sensory deficits, it is important to consider SEL.

Open access

Pineal parenchymal tumor of intermediate differentiation with late spinal dissemination 13 years after initial surgery: illustrative case

Hiroyuki Kato, Takafumi Tanei, Yusuke Nishimura, Yoshitaka Nagashima, Motonori Ishii, Tomoya Nishii, Nobuhisa Fukaya, Takashi Abe, and Ryuta Saito

BACKGROUND

Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare in the pineal gland. A case of PPTID that disseminated to the lumbosacral spine 13 years after the total resection of a primary intracranial tumor has been reported.

OBSERVATIONS

A 14-year-old female presented with headache and diplopia. Magnetic resonance imaging revealed a pineal tumor that induced obstructive hydrocephalus. A biopsy and endoscopic third ventriculostomy were performed. Histological diagnosis revealed a grade II PPTID. Two months later, the tumor was removed via craniotomy because the postoperative Gamma Knife surgery was ineffective. Histological diagnosis confirmed PPTID, although the grade was revised from II to III. Postoperative adjuvant therapy was not performed, because the lesion had been irradiated and gross total tumor removal was achieved. She has had no recurrence in 13 years. However, pain around the anus newly appeared. Magnetic resonance imaging of the spine revealed a solid lesion in the lumbosacral spine. The lesion was subtotally resected, and histological diagnosis revealed grade III PPTID. Postoperative radiotherapy was performed, and she had no recurrence 1 year after radiotherapy.

LESSONS

Remote dissemination of PPTID can occur several years after the initial resection. Regular follow-up imaging, including the spinal region, should be encouraged.

Open access

Surgical outcome of a patient with Bertolotti’s syndrome in whom the established Castellvi classification system failed: illustrative case

Richard J. Chung, Camryn Harvie, John O’Donnell, Sarah Jenkins, and Arthur L. Jenkins III

BACKGROUND

Bertolotti’s syndrome is a condition of the lower back and/or L5 distribution leg pain caused by a lumbosacral transitional vertebra (LSTV). Diagnosing the LSTV as the cause of the symptoms and condition is essential for accurate management of this syndrome. Castellvi’s classification system is widely accepted for LSTV anatomy, but it measures only one aspect of transitional anatomy and was intended primarily to identify target-level disk herniations.

OBSERVATIONS

In this case, the Castellvi classification system failed to identify the patient (with 2 years of back and L5 pain) as having an LSTV, even though he displayed LSTV-like anatomy because both L5 transverse process heights measured less than 19 mm. He attained brief but significant relief from bilateral injections into the L5–S1 transverse/ala region and underwent a minimally invasive bilateral decompression of L5–S1 with almost complete relief of his symptoms maintained more than 6 months postoperatively.

LESSONS

Given that the patient gained significant relief from treatment of transitional anatomy that failed to be identified using Castellvi’s classification system, this case suggests that transverse process height may not be adequate or even the most clinically relevant indicator in identifying LSTV anatomy, which is a precursor to the diagnosis of Bertolotti’s syndrome.

Open access

Presacral mature cystic teratoma associated with Currarino syndrome in an adolescent with androgen insensitivity: illustrative case

Grant Koskay, Patrick Opperman, Frank M. Mezzacappa, Joseph Menousek, Megan K. Fuller, Linden Fornoff, and Daniel Surdell

BACKGROUND

Currarino syndrome is a rare disorder that classically presents with the triad of presacral mass, anorectal malformation, and spinal dysraphism. The presacral mass is typically benign, although malignant transformation is possible. Surgical treatment of the mass and exploration and repair of associated dysraphism are indicated for diagnosis and symptom relief. There are no previous reports of Currarino syndrome in an androgen-insensitive patient.

OBSERVATIONS

A 17-year-old female patient presented with lack of menarche. Physical examination and laboratory investigation identified complete androgen insensitivity. Imaging analysis revealed a presacral mass lesion, and the patient was taken to surgery for resection of the mass and spinal cord untethering. Intraoperative ultrasound revealed a fibrous stalk connecting the thecal sac to the presacral mass, which was disconnected without the need for intrathecal exploration. The presacral mass was then resected, and pathological analysis revealed a mature cystic teratoma. Postoperatively, the patient recovered without neurological or gastrointestinal sequelae.

LESSONS

Diagnosis of incomplete Currarino syndrome may be difficult but can be identified via work-up of other disorders, such as androgen insensitivity. Intraoperative ultrasound is useful for surgical decision making and may obviate the need for intrathecal exploration during repair of dysraphism in the setting of Currarino syndrome.