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Open access

Splenic rupture following prone lateral discectomy and arthrodesis: illustrative case

Alexandra Echevarria, Benjamin Hershfeld, Emily Arciero, and Rohit Verma

BACKGROUND

The prone lateral approach to lumbar spine surgery is known to have a multitude of potential complications, including damage to neurovascular structures, surrounding viscera, and intra-abdominal structures near the surgical site. However, iatrogenic injury to the spleen following prone lateral lumbar discectomy and arthrodesis as a potential complication has not yet been described in the literature.

OBSERVATIONS

The authors present the case of a 71-year-old female with a history of L3–S1 laminectomy and L3–5 arthrodesis who underwent a prone lateral discectomy of L2–3 with arthrodesis of the endplates for chronic lower-back pain. On postoperative day 1, the patient developed hypotension unresponsive to pressor medications, significant abdominal pain, and anemia requiring 2 transfusions. Bedside ultrasound revealed free fluid in the abdomen. She then underwent an exploratory laparotomy for splenic injury.

LESSONS

Although rare, splenic rupture should be considered as part of the differential diagnosis for patients with hemodynamic instability after lateral surgical approaches to the lumbar spine. Any patient with evidence of hypotension, anemia, and/or abdominal pain following lumbar surgery should be evaluated for splenic injury with an abdominal computed tomography scan and considered for surgical intervention.

https://thejns.org/doi/10.3171/CASE23639

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

The complex treatment paradigms for concomitant tethered cord and scoliosis: illustrative case

Rose Fluss, Riana Lo Bu, Andrew J Kobets, and Jaime A Gomez

BACKGROUND

Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections.

OBSERVATIONS

A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3–4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved.

LESSONS

Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

Open access

A new surgical method to treat intracanal lumbar disc herniation using the unilateral biportal endoscopic transforaminal approach: patient series

Tomohide Segawa, Hiroki Iwai, Hirohiko Inanami, Yuichi Takano, Yohei Yuzawa, Takeshi Kaneko, Kenta Taniguchi, Kazuyoshi Yanagisawa, Junichi Yokosuka, Ryoji Tominaga, Hideki Nakamoto, Katsuyuki Sasaki, and Hisashi Koga

BACKGROUND

Unilateral biportal endoscopic lumbar discectomy (UBELD) is a new minimally invasive spine surgery. The purpose of this study is to describe a new surgical method to treat intracanal lumbar disc herniation (LDH) using the unilateral biportal endoscopic transforaminal approach (UBE-TFA). The first 15 patients who had undergone UBELD for single-level LDH were included in this study. Operative time, intraoperative blood loss, postoperative stay, and intraoperative complications were recorded. The Oswestry Disability Index (ODI), numeric rating scale (NRS) score for leg pain, and modified MacNab criteria were assessed at 3 months postoperatively.

OBSERVATIONS

The mean operative time was 52.0 ± 13.8 minutes. The mean intraoperative blood loss was 10.5 ± 10.2 mL. The mean postoperative stay was 1.1 ± 0.3 days. There were no complications. The postoperative mean ODI was significantly improved from 44.9 ± 14.4 to 7.7 ± 11.2 at the final follow-up (p < 0.001). There was a significant decrease in the postoperative mean NRS score for leg pain, from 6.1 ± 1.9 to 0.8 ± 1.3 at the final follow-up (p < 0.001). Based on the modified MacNab criteria, good to excellent results were obtained in 86.7% of the patients.

LESSONS

We considered UBELD-TFA as not only one of the promising surgical methods for UBELD, but also a new surgical implementation of the TFA.

Open access

Long-term survival after cordectomy in a case of spinal cord diffuse midline glioma, H3K27-altered: illustrative case

Daisuke Sato, Hirokazu Takami, Shota Tanaka, Shunsaku Takayanagi, Masako Ikemura, and Nobuhito Saito

BACKGROUND

Spinal cord diffuse midline glioma, H3K27-altered, is an extremely rare entity with a poor prognosis. However, its optimal treatment remains poorly defined. Although cordectomy was introduced in the early 20th century, its efficacy has been questioned and shrouded behind the scenes.

OBSERVATIONS

A 76-year-old male with recent-onset paraparesis of the lower extremities and paresthesia presented to our outpatient clinic. Magnetic resonance imaging revealed an intra-axial spinal cord tumor extending from T12 to L2. The patient underwent laminectomy and partial tumor resection, and the surgical specimen was histologically diagnosed as a diffuse midline glioma, H3K27-altered. Although standard chemoradiotherapy was implemented, the patient experienced local tumor recurrence 2 years later and underwent cordectomy at T9. The patient was alive at the 4-year follow-up after cordectomy without tumor recurrence. According to the literature, patients with lesions in the lower thoracic cord below T8 achieved a longer survival than those with lesions in the upper thoracic cord above T5.

LESSONS

Cordectomy benefits selected cases of high-grade spinal cord gliomas. Maximal prevention of cerebrospinal fluid dissemination by tumor cells is indisputably important, and tumors located below the lower thoracic spine may be the key to success in establishing a long-term prognosis after cordectomy.

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

Combined endoscopic and microsurgical approach for the drainage of a multisegmental thoracolumbar epidural abscess: illustrative case

Vincent Hagel, Felix Dymel, Stephan Werle, Vera Barrera, and Mazda Farshad

BACKGROUND

Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches.

OBSERVATIONS

The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage.

LESSONS

The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.

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

Robot-assisted screw fixation in a cadaver utilizing magnetic resonance imaging–based synthetic computed tomography: toward radiation-free spine surgery. Illustrative case

A. Daniel Davidar, Brendan F. Judy, Andrew M. Hersh, Carly Weber-Levine, Safwan Alomari, Arjun K. Menta, Kelly Jiang, Meghana Bhimreddy, Mir Hussain, Neil R. Crawford, Majid Khan, Gary Gong, and Nicholas Theodore

BACKGROUND

Synthetic computed tomography (sCT) can be created from magnetic resonance imaging (MRI) utilizing newer software. sCT is yet to be explored as a possible alternative to routine CT (rCT). In this study, rCT scans and MRI-derived sCT scans were obtained on a cadaver. Morphometric analysis was performed comparing the 2 scans. The ExcelsiusGPS robot was used to place lumbosacral screws with both rCT and sCT images.

OBSERVATIONS

In total, 14 screws were placed. All screws were grade A on the Gertzbein-Robbins scale. The mean surface distance difference between rCT and sCT on a reconstructed software model was –0.02 ± 0.05 mm, the mean absolute surface distance was 0.24 ± 0.05 mm, and the mean absolute error of radiodensity was 92.88 ± 10.53 HU. The overall mean tip distance for the sCT versus rCT was 1.74 ± 1.1 versus 2.36 ± 1.6 mm (p = 0.24); mean tail distance for the sCT versus rCT was 1.93 ± 0.88 versus 2.81 ± 1.03 mm (p = 0.07); and mean angular deviation for the sCT versus rCT was 3.2° ± 2.05° versus 4.04°± 2.71° (p = 0.53).

LESSONS

MRI-based sCT yielded results comparable to those of rCT in both morphometric analysis and robot-assisted lumbosacral screw placement in a cadaver study.

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.