Innovations in the development of endoscopic spinal surgery were classified into different generations and reviewed. Future developments and directions for endoscopic spinal surgery were discussed. ...Surgical therapy for spinal disease has been gradually changing from traditional open surgery to minimally invasive spinal surgery. Recently, endoscopic spinal surgery, which initially was limited to the treatment of soft tissue lesions, has expanded to include other aspects of spinal disease and good clinical results have been reported. As the paradigm of spinal surgery shifts from open surgery to endoscopic surgery, we discussed the evolution of endoscopic spine surgery in our literature review. Through this description, we presented possibilities of future developments and directions in endoscopic spine surgery.
Background:
Congenital absence of the lumbosacral facet joint is extremely rare, with only 26 cases reported in the literature. Here, we present a patient with the unilateral absence of the left ...fifth lumbar inferior articular process and reviewed the relevant literature.
Case Description:
A 32-year-old gentleman, who had undergone right L4-5 lumbar microdiscectomy 3 months ago now presented with acute low back and left leg pain following a fall. He is now presented with acute low back and left leg pain following a fall. Plain radiographs of the L-S spine revealed an absent left L5–S1 zygapophyseal joint. The magnetic resonance imaging and computed tomography studies additionally confirmed an absent unilateral left L5 lumbar inferior articular process.
Conclusion:
Patients presenting for lumbar surgery may have unilaterally absent lumbosacral zygapophyseal joints, which may impact the outcome of surgical treatment.
Kummell's Disease has insidious progression. Neurological deficit is usually slow in onset and progression and only few cases of acute neurological deficit have been reported. We came across a case ...of Kummell's disease which progressed to burst fracture, developed neurological deficit within two weeks. We managed patient with "pivot ligamentotaxis" and Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation.
Eighty-three years old woman following fall was on conservative management at another hospital. She had no neurological deficit. A week later her back pain aggravated and two weeks later developed bilateral buttock pain, bilateral lower limb weakness and diminished sensation in the sacral area. Radiological investigations (X-rays, Magnetic resonance imaging and Computed tomography) showed L1 vertebral body fracture with vacuum cleft and fracture fragment retropulsed into the spinal canal. A diagnosis of Kummell's disease with burst fracture of L1 vertebra & neurological deficit was made. Patient was managed with Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. The reduction of the retropulsed fragment was achieved by virtue of "Pivot ligamentotaxis". The patient got relieved of the symptoms (Preoperative VAS 8 and postoperative VAS 3) and was allowed brace assisted ambulation on first postoperative day.
This study reports acute occurrence of the burst fracture in unstable vertebra inflicted by Kummell's disease and role of spinal stability in recovery. We achieved closed reduction of the fracture fragments and relief of the cord compression by posterior compression with "pivot ligamentotaxis".
Irritation of the sinuvertebral nerve by a posterior or posterolateral disk desiccation can cause somatic referred pain that can mimic a lumbar radiculopathy. We present a case of a patient ...presenting with this condition and the positive result in pain improvement after endoscopic radiofrequency ablation of the sinuvertebral nerve.
An 18-year-old Olympic runner presented to our clinic with back pain and left leg pain in a clear L5 distribution. He did not have a history of trauma. His imaging did not demonstrate any lesion causing compression of the left L5 nerve root as expected. He was found to have a left healing L5 pedicle fracture and ipsilateral chronic L5 pars interarticularis fracture. He was also found to have an ipsilateral minor left L5-S1 disk desiccation. His visual analog scale (VAS) score was 7. After a positive provocative diskogram, the patient underwent percutaneous transforaminal endoscopic radiofrequency ablation of the left L5 sinuvertebral nerve, which was irritated by the left L5-S1 disk desiccation. At his 6-month follow-up visit, the patient's VAS score was 1.
It is important for clinicians to remember that back-associated leg pain can be caused by somatic referred pain because of irritation of the sinuvertebral nerve. Endoscopic radiofrequency of this nerve can be beneficial in pain control, but further randomized prospective trials are needed to study these techniques further.
Vertebral artery injuries during posterior cervical foraminotomy are rare, but can be fatal. Therefore, we investigated the anatomical correlation between the lateral recess and the vertebral artery.
...On axial cuts of cervical magnetic resonance imaging from 108 patients, we measured the distance between the vertebral arteries and the medial border of the facet joints. The anatomical vertebro-facet distance (AVFD), surgical vertebro-facet distance (SVFD), and vertebro-facet angle (VFA) were measured.
The mean AVFD values on the right side at the C3-4, C4-5, C5-6, and C6-7 levels showed statistically significant differences. On the right side, the mean SVFD values were equivalent to the AVFD values. The mean values of the VFA on the right side at all levels showed statistically significant differences. For all measurements, the greatest differences were seen between the C5-6 and C6-7 levels, and higher levels were associated with smaller distances from the lateral recess. The mean values of the AVFD on the right and left sides showed statistically significant differences at all levels, and the distances on the left were smaller than those on the right.
The vertebral artery is closer to the lateral recess at higher cervical levels than at lower cervical levels. The largest distances were found at the C5-6 and C6-7 levels, and the left vertebral arteries were closer to the lateral recess than the right vertebral arteries.
Double crush of a nerve at the root level is not common. We describe here a double crush of the right L4 nerve with foramina to far lateral disk (ventral) and extraforaminal (dorsal) compression. The ...double crush was managed by endoscopy with a contralateral uniportal approach from the left interlaminar space. Right lateral recess stenosis at the same level was subsequently managed with the same approach.
A 79-year-old lady presented to our clinic with a low backache, right leg pain, and weakness. On her right side, the straight leg raise test was 70 degrees, great toe dorsiflexion was grade 3/5, and hypoesthesia was present in the L4 dermatome. Her preoperative visual analog scale score was 9. Magnetic resonance imaging showed right lateral recess stenosis and a double compression of L4 nerve root from the dorsal and ventral sides. A diagnosis of right lateral recess stenosis with double crush of the right L4 nerve root was made.
The patient was managed with percutaneous endoscopic contralateral interlaminar foraminotomy from the left interlaminar approach. She got relief for the symptoms and her postoperative visual analog scale score was 2. Magnetic resonance imaging and computed tomography showed nerve root decompression and well-preserved facet joints.
We conclude that the management of double crush at the nerve root level with interlaminar contralateral approach endoscopy (percutaneous endoscopic contralateral interlaminar foraminotomy) can deal with the issue effectively with facet joint preservation and other benefits of the minimally invasive spine procedure.
Extradural benign cysts located in close proximity to the facet joints are called juxtafacetal cysts. Only about 3.5% of such cysts occur in the cervical spine. To our knowledge, there has been no ...published article on the endoscopic resection of a cervical facet cyst, and this is the first report.
A 48-year-old male presented with a chief complaint of severe axial neck pain (visual analog scale score 9) and right scapular pain. The patient had no related radiculopathy or myelopathy, and neurologic status was intact. There was severe limitation of cervical spine movements. Plain radiographs indicated age-related degenerative changes with typical features of ankylosing spondylitis with a bamboo spine appearance and gross fusion of all the vertebrae. The only mobile cervical spinal level was C6-C7. Axial magnetic resonance imaging revealed a right-sided juxtafacetal lesion at C6-C7 level that was hyperintense on T2 and hypointense on T1 imaging. A percutaneous endoscopic posterior cervical foraminotomy at right-sided C7-T1 was performed under general anesthesia. The cyst was removed, and adequate decompression of the C7 root was achieved. Postoperative magnetic resonance imaging and computed tomography scan showed adequate foraminotomy and decompression of the neural structures. The patient had gross relief of neck pain (visual analog scale score 2).
The findings suggest that ankylosing spondylitis may cause formation of a juxtafacetal cyst at the mobile levels in a relatively less mobile cervical spine. The endoscopic resection of such cysts is a minimally invasive novel procedure that can cure such patients successfully without unwanted fusion surgery.
Although spinal canal narrowing is thought to be the defining feature for the clinical diagnosis of lumbar canal stenosis, the degree of spinal canal stenosis necessary to elicit neurologic symptoms ...is not clear. Several studies have been performed to detect an association between a narrow spinal canal and clinical symptoms. Through our prospective study, we compared the radiologic criteria with the clinical criteria using the Oswestry Disability Index (ODI) and assessed how they correlate.
We used the qualitative grading (morphological classification system on magnetic resonance imaging MRI) system, dural sac cross-sectional area (DSCA), and sedimentation sign on MRI images and compared them with the Self-Paced Walking Ability (Self-Paced Walking Test) and ODI of the patients in the study. The systems were applied to 85 patients divided into three groups: group A: 43 patients with neurogenic claudication and able to walk < 30 minutes; group B: 11 patients with neurogenic claudication and able to walk > 30 minutes; and group C: 31 patients with simple back pain and no signs of neurologic claudication.
The mean ODI was 21.19 in group C, 46.50 in group B, and 61.95 in group A. The difference was statistically significant. The mean DSCA was 164.42 mm
in group C, 49.94 mm
in group B, and 35.07 mm
in group A. The difference was statistically significant. The sedimentation sign was negative in 96.8% patients in group C, 54.5% patients in group B, and 32.6% patients in group A. The difference was statistically significant. Group C had 9.3% patients in morphology grade A3, 51.6% in grade A2, and 38.7% patients in grade A1. Group B had 63.6% patients in grade C, 18.2% patients in grade B, 9.1% in grade A4, and 9.1% in grade A3. Group A had 18.6% patients in grade D, 39.5% in grade C, 27.9% in grade B, 11.6% in grade A4, and 2.3% in grade A3. The mean DSCA of group C was significantly different from group A and group B, but the difference of the mean DSCA between group A and group B was not statistically significant. The relationship of ODI to DSCA, ODI to sedimentation sign, and ODI to morphological grading for group C and group A was not statistically significant. The relationship of morphological grading to DSCA was statistically significant for all three groups.
DSCA, morphological grading, and sedimentation sign are good to excellent radiologic indicators differentiating patients with simple back pain from those with lumbar spinal stenosis. Clinically, ODI is an excellent indicator of the severity of stenosis. But ODI statistically has no significant correlation to any of these radiologic parameters.
Background:
Vertebral osteomyelitis caused by
Stenotrophomonas maltophilia
is very rare. There are only two cases reported in literature. Here, we present a 48-year-old immunocompetent male who, ...following a lumbar microdiscectomy, developed postoperative spondylodiscitis due to
S. maltophilia
that mimicked a cotton granuloma.
Case Report:
Two months ago, a 48-year-old male underwent a lumbar L4-L5 microdiscectomy, he newly presented with the left thigh and leg pain of 4 weeks duration. Laboratory studies revealed a CRP of 26 mg/l, an ESR of 6 mm (1
st
h), and total leukocyte count of 7.85 thousand/ul. The MRI T2 images showed a focal hyperintense lesion in the left lateral recesses at the L4-L5 level; the accompanying hypointense-smooth margin resembled a cotton granuloma. At surgery, we found a localized epidural collection of pus;
S. maltophilia
was isolated from the culture. His symptoms gradually improved, and symptoms fully resolved with 3 months of subsequent antibiotic therapy.
Conclusion:
S. maltophilia
causing vertebral osteomyelitis is extremely rare and can sometimes mimic a cotton granuloma. MR diagnosis, surgical decompression, and obtaining cultures are requisite to direct appropriate antibiotic therapy.
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