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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

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.