Herniation of the cauda equina into the facet joint through a pseudomeningocele: A case report and literature review

Background

Incidental durotomy is a well-known complication of spinal surgery. It can lead to persistent cerebrospinal fluid leakage resulting in significant secondary complications. Here, we present a case in which the cauda equina herniated into a pseudomeningocele that penetrated a facet joint, leading to lower extremity radiculopathy warranting surgical correction.

Case Description

One year ago, a 67-year-old male underwent a partial left L4-L5 laminectomy. At surgery, a durotomy was repaired with a nylon suture and reinforced with a fat patch. He subsequently presented with severe left lower extremity radiculopathy and a partial cauda equina syndrome. On MR, the cauda equina had herniated into a pseudomeningocele that penetrated the left facet joint. Once the defect was repaired at surgery, the patient's symptoms improved.

Conclusion

It is critical to correctly repair an intraoperative durotomy to avoid further neurological deficits that may include cauda equina herniation into pseudomeningoceles penetrating facet joints.

Surgical treatment of complete fifth lumbar osteoporotic vertebral burst fracture: A retrospective case report of three patients

Background:

Due to its rarity, surgical treatments for a complete fifth lumbar osteoporotic vertebral burst fracture (L5 OVBF) have yet to be well documented as compared to that for osteoporotic vertebral fractures of the thoracolumbar spine. The current case report discusses details of the surgical outcomes following posterior decompression and fusion for a complete L5 OVBF.

Case Description:

Three women, ranging in age from 69 years to 82 years, were surgically treated for a complete L5 OVBF. Two of these patients were being treated for rheumatoid arthritis. Surgery was performed using the L5 shortening osteotomy or vertebroplasty, with one- or two-level posterior lumbar interbody fusion, and posterior spinal fixation for the L2 or L3 to the pelvis. Although the spinal alignment parameters, which included lumbar lordosis (LL), pelvic incidence-lumbar lordosis, T1 pelvic angle, and sagittal vertical axis, were better as compared to that observed before the surgery, these worsened at the final follow-up due to clinical fractures that occurred at the adjacent vertebral body and proximal junctional kyphosis. Compared to preoperative Japanese Orthopaedic Association (JOA) scores, postoperative JOA scores were improved and maintained at the final follow-up.

Conclusion:

Posterior surgery of a complete L5 OVBF led to improvement of both the JOA score and spinal alignment after the surgery. Despite a worsening of the spinal alignment parameters, the JOA score was maintained at the final follow-up.

Hybrid Minimally Invasive Technique for Treatment of Thoracolumbar Spondylodiscitis and Vertebral Osteomyelitis

OBJECTIVE

Spondylodiscitis and vertebral osteomyelitis cause significant morbidity and mortality, and typically occur in patients with multiple comorbidities. The use of minimally invasive spinal surgery in the previous decade has offered the advantages of reduced intraoperative blood loss and postoperative pain for patients. In the present report, we have described our experience with using a hybrid minimally invasive (HMI) technique (combining percutaneous fixation with a mini-open approach for decompression and debridement) for the treatment of thoracolumbar spondylodiscitis, reporting the patient demographics, intraoperative measures, and 12-month outcomes.

METHODS

The data from patients presenting to a tertiary referral neurosurgical center with thoracolumbar spondylodiscitis and osteomyelitis who had undergone HMI from 2016 to 2018 were retrospectively evaluated. Patient demographics, intraoperative factors, estimated blood loss, and immediate postoperative complications were recorded. The patient outcomes were evaluated using EuroQOL 5-dimension questionnaire and visual analog scale in the immediate postoperative period and at 12 months postoperatively.

RESULTS

A total of 13 patients were included in the present study, 12 with spontaneous infection and 1 with infection secondary to recent microdiscectomy at another institution. All the patients had systemic comorbidities with an American Society of Anesthesiologists class of ≥2. Of the 13 patients, 11 had pyogenic infections and 2 had spinal tuberculosis. The mean estimated blood loss was 546.2 mL. The mean time for patients to sit out of bed was 2.2 days, and the mean time to start mobilizing was 4.5 days. The EuroQOL 5-dimension questionnaire scores showed improvement in all modalities at 12 months postoperatively.

CONCLUSIONS

In our cohort, HMI was a safe and effective treatment of thoracolumbar spondylodiscitis, with the potential benefits of reduced blood loss, operative duration, and postoperative pain.

Erosion in the occipital bone caused by the fixation instrument used for posterior atlantoaxial fusion -report of 4 cases

Introduction

Conventionally, posterior C1-C2 fusion has been performed using a sublaminar wiring technique with a structural bone graft. Subsequent advent of newer fixation devices, such as the C1 lateral mass screw and C1 hook, has achieved more solid fixation with improved surgical outcome; however, in these fixation systems, the protruding end of the metal implant above the level of the atlas may result in a complication due to contact with the surrounding structures.

Case description

Two men and two women whose ages at the time of surgery ranged from 14 to 72 years. A supralaminar hook was used as a fixation device for C1 in two cases, whereas a lateral mass screw (Tan’s method) and an atlas claw hook were employed for one each of the remaining 2 cases. We retrospectively reviewed the clinical features and postoperative course of these patients using the clinical records. Moreover, we measured the protruding height of the instrument above the atlas as well as the Redlund-Johnell (R-J) value on postoperative radiographs. All patients complained of crepitus and/or pain on neck extension. Erosion in the occipital bone was detected on multiplanar reconstruction computed tomography (MPR-CT), whereas plain radiographs failed to reveal the bony change. In those cases, protruding instruments used for C1 fixation contacted the occipital bone resulting in an erosive change at the impingement point. We removed the implant in all four cases after confirmation of solid bony union.

Discussion and evaluation

Two of the four patients complained of occipital crepitus alone without pain. The management options for this condition may be controversial; however, progression of bony erosion may result in perforation of the occipital bone. This may possibly be associated with the serious complication of cerebrospinal fluid leakage. Considering this potential sequela, we removed the implants from all our reported cases after confirmation of solid bony union.

Conclusions

We treated four cases that developed erosion in the occipital bone after posterior spinal instrumentation was performed for upper cervical lesions including C1. MPR-CT was useful in detecting the erosive changes in the occipital bone.