Redundant nerve roots on magnetic resonance imaging can predict ongoing denervation in patients with lumbar spinal stenosis

INTRODUCTION/AIMS

Redundant nerve roots (RNRs) are abnormally elongated and tortuous nerve roots that develop secondary to degenerative spinal stenosis. RNRs have been associated with poorer clinical outcomes after decompression surgery; however, studies on their clinical characteristics are limited. This study aimed to investigate the association between RNRs and denervation potentials, that is, abnormal spontaneous activity (ASA), on electromyography.

METHODS

We retrospectively reviewed data of patients who underwent an electrodiagnostic study of the lower extremities between January 2020 and March 2023. Of these, patients with lumbar central spinal stenosis, as seen on magnetic resonance imaging, were included. We analyzed clinical and imaging data, including presence of ASA, and compared them according to the presence of RNRs. Multivariable logistic regression analysis was employed to identify factors associated with development of ASA.

RESULTS

Among the 2003 patients screened, 193 were included in the study. RNRs were associated with advanced age (p < .001), longer symptom duration (p = .009), smaller cross-sectional area of the dural sac at the stenotic level (p < .001), and higher frequency of ASA (p < .001). Higher probability of ASA was correlated with greater RNR severity (p < .001). In the multivariable logistic regression analysis, ASA occurrence was associated with smaller cross-sectional area, multiple stenotic sites, and severe-grade RNRs.

DISCUSSION

The presence of RNRs, particularly severe-grade RNRs, was identified as a significant risk factor for the development of ASA on electromyography. This finding may aid physicians in estimating the prognosis of patients with central spinal stenosis.

Percutaneous Computed Tomography-Guided Oxygen-Ozone (O2O3) Injection Therapy in Patients with Lower Back Pain-An Interventional Two-Year Follow-Up Study of 321 Patients

OBJECTIVES

To assess the effect of oxygen-ozone therapy guided by percutaneous Computed Tomography (CT) compared to corticosteroids in individuals experiencing lower back pain (LBP) not attributed to underlying bone-related issues.

METHODS

A total of 321 patients (192 males and 129 females, mean age: 51.5 ± 15.1 years) with LBP were assigned to three treatment groups: group A) oxygen-ozone only, group B) corticosteroids only, group C) oxygen-ozone and corticosteroids. Treatment was administered via CT-guided injections to the intervertebral disc (i.e., intradiscal location). Clinical improvement of pain and functionality was assessed via self-reported pain scales and magnetic resonance (MR) and CT imaging.

RESULTS

At all follow-up times, the mean score of the numeric rating scale and the total global pain scale (GPS) of study groups receiving oxygen-ozone (groups A and C) were statistically significantly lower than the study group receiving corticosteroids only (group B), with p < 0.001. There was a statistically significant difference between groups A and C at 30 days for the numeric rating scale.

CONCLUSIONS

The percutaneous application of oxygen-ozone in patients with LBP due to degeneration of the lumbosacral spine showed long-lasting significant pain reduction of up to two years post-treatment when compared to corticosteroids alone. Combination therapy of oxygen-ozone and corticosteroids can be useful as corticosteroids showed statistically significant improvement in LBP earlier than the oxygen-ozone-only treatment.

Examination of Thoracic and Lumbosacral Spine Guide for Neurosurgery Residents

Background

This paper outlines a summary of examination techniques for the thoracic and lumbosacral spine. It starts with observation, palpation and a range of movements followed by various special tests to identify thoracic and lumbosacral spine pathology.

Methods

Bedside instruments used include a measuring tape, scoliometer and back range of motion instrument (BROM II).

Discussion

Back flexion-extension, lateral flexion and rotation were assessed with bedside instruments. This would aid in increasing the accuracy and precision of objective measurement while conducting a clinical examination to determine the back range motion. Specific tests were used to localise specific anatomical locations and identify the spine pathology that can help the clinician to diagnose and treat the disease.

[Analysis of preoperative risk factors of adjacent segment disease after transforaminal lumbar interbody fusion]

Currently, there is no information on the combined effect of body mass index (BMI), age, gender, main spinal-pelvic parameters and parameters of adjacent functional spinal unit (FSU) degeneration according to magnetic resonance imaging on development of adjacent segment degenerative disease (ASDd).

OBJECTIVE

To evaluate the effect of preoperative biometric and instrumental parameters of adjacent FSU on the risk of ASDd after transforaminal lumbar interbody fusion and determine personalized neurosurgical approach.

MATERIAL AND METHODS

We retrospectively studied patients after single-level transforaminal lumbar interbody fusion (group I, n=54), single-level transforaminal lumbar interbody fusion and interspinous stabilization of adjacent level (group II, n=55), preventive rigid fusion of adjacent segment (group III, n=56). Preoperative parameters and long-term clinical outcomes were assessed.

RESULTS

Paired correlation analysis established the main predictors of ASDd. Regression analysis determined absolute values of these predictors for each type of surgical intervention.

CONCLUSION

Surgical intervention at the level of asymptomatic proximal adjacent segment is recommended as interspinous stabilization for moderate degenerative lesions, BMI <25 kg/m2, difference between pelvic index and lumbar lordosis 10.5-15°, segmental lordosis 6.5-10.5°. In case of severe degenerative lesions, BMI 25.1-31.1 kg/m2, significant deviations of spinal-pelvic parameters (segmental lordosis 5.5-10.5°, difference between pelvic index and lumbar lordosis 15.2-20°), preventive rigid stabilization is indicated.

Freehand S2-Alar-Iliac Screw Placement Technique in Lumbosacral Spinal Tumors: A Preliminary Study

OBJECTIVE

S2-alar-iliac (S2AI) screw technique is widely used in spinal surgery, but it is rarely seen in the field of spinal tumors. The aim of the study is to report the preliminary outcomes of the freehand S2AI screw fixation after lumbosaral tumor resection.

METHODS

The records of patients with lumbosacral tumor who underwent S2AI screw fixation between November 2016 to November 2020 at our center were reviewed retrospectively. Outcome measures included operative time, blood loss, complications, accuracy of screws, screw breach, and overall survival. Mean ± standard deviation or range was used to present continuous variables. Kaplan-Meier curve was used to present postoperative survival.

RESULTS

A total of 23 patients were identified in this study, including 12 males and 11 females, with an average age of 47.3 ± 14.5 (range,15-73). The mean operation time was 224.6 ± 54.1 (range, 155-370 min). The average estimated blood loss was 1560.9 ± 887.0 (600-4000 ml). A total of 46 S2AI screws were implanted by freehand technique. CT scans showed three (6.5%) screws had penetrated the iliac cortex, indicating 93.5% implantation accuracy rate. No complications of iatrogenic neurovascular or visceral structure were observed. The average follow-up time was 31.6 ± 15.3 months (range, 13-60 months). Two patients' postoperative plain radiography showed lucent zone around the screw. One patient underwent reoperation for wound delayed infection. At the latest follow-up, eight patients had tumor-free survival, 11 had survival with tumor, and four died of disease.

CONCLUSION

The freehand S2AI screw technique is reproducible, safe, and reliable in the management of lumbosacral spinal tumors.

Feasibility of anterior pedicle screw fixation in lumbosacral spine: a radiographic and cadaveric study

Background

The anterior pedicle screw (APS) technique for L5 and S1 is crucial for proper anterior lumbar interbody fusion (ALIF). This study aimed to determine the projection, screw trajectory angle, and bone screw passageway length (BSPL), as well as the screw insertion regularity and the operating area within which it is safe to perform insertion.

Methods

Forty patients with low back pain, all of whom had lumbar computed tomography scans available, was included in this retrospective analysis. Radiographic parameters were measured, including: the distances from the projection to the upper endplate, lower endplate, and midline; the transverse and sagittal screw angles; and the BSPL. In addition, 10 fresh adult cadaveric lumbosacral spine segments were selected to determine the safe anatomic area in which to operate. Finally, APSs were inserted in L5 and S1 to determine the regularity of APS insertion.

Results

We measured the anterior projection parameters, including: the distances to the upper endplate (L5: 12.5±1.3 mm; S1: 4.54±0.87 mm), lower endplate (L5: 17.3±1.6 mm), and midline (L5: 6.6±0.7 mm; S1: 6.6±0.6 mm); the screw trajectory angle, including the transverse screw angle (L5: 25.3±2.8°; S1: 25.7±2.6°), sagittal screw angle (L5: 17.1±1.7°; S1: 22.4±1.1°); and the BSPL (L5: 48.6±3.5 mm; S1: 48.0±3.5 mm). The regularity of APS insertion in L5 and S1 was determined. Upon the needle reaching a point in the lateral view, it reached the corresponding point in the anteroposterior (AP) view. The anatomic parameters of the safe operating area were as follows: the distance from the abdominal aortic bifurcation to the L5 lower edge (40.50±9.40 mm); the distance from the common iliac vein confluence to the L5 lower edge (27.80±8.60 mm); and the horizontal distance from the inner edge of the common iliac vein to the L5 lower edge (37.50±1.30 mm). We also determined the distance between S1 holes (29.30±1.30 mm), the L5/S1 intervertebral height (17.20±1.50 mm), and the safe operating area (2,058.20±84.30 mm²).

Conclusions

This study has determined the projection, screw trajectory angle, and BSPL of APSs in L5 and S1, their insertion regularity, and the area in which the operation can be safely performed.

[Smoking as a risk factor of advanced heterotopic ossification in patients after lumbar total disk arthroplasty]

Smoking is an obvious risk factor of adverse events in early and long-term postoperative period after spine surgery including lumbar total disk arthroplasty. Objective. To study the effect of smoking on clinical and radiological outcomes after lumbar total disk arthroplasty.

MATERIAL AND METHODS

A single-center retrospective observational cohort study was performed. We have analyzed medical records of patients who underwent single-level lumbar total disk arthroplasty for degenerative disease.

RESULTS

The study included 57 medical records of respondents. The examined medical records were divided into two groups - smokers (n=26) and non-smokers (n=31). There were no significant between-group differences in clinical outcomes. Incidence of adverse events was similar too. Kaplan-Meier event-free survival was similar in both groups. There were no significant between-group differences in X-ray data. Development of heterotopic ossification after lumbar total disk arthroplasty was more active in smokers.

CONCLUSION

Smoking has no significant effect on clinical and radiological outcomes in patients after single-level after lumbar total disk arthroplasty. On the other hand, smoking significantly increases formation of heterotopic ossification after lumbar total disk arthroplasty.

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Spine surgery at the wrong level is an undesirable event and unique pitfall in spine surgery. It is detrimental to the relationship between the patient and the surgeon and typically results in profound medical and legal consequences. It falls under the wrong-site surgery sentinel events reporting system. This error is most frequently observed in lumbosacral spine. Several risk factors are implicated; however, anatomical variations of the lumbosacral spine are a major risk factor. The aim of this article was to provide a detailed description of these high-risk anatomical variations, including transitional vertebrae, lumbar ribs, butterfly vertebrae, hemivertebra, block/fused vertebrae, and spinal dysraphism. A literature review was performed in the database PubMed to obtain all relative English-only articles concerning these anatomical variations and their implication in the development of lumbosacral spine surgery at the wrong level. We also described patient characteristics that can lead to lumbosacral surgery at the wrong level such as tumors, infection, previous lumbosacral surgery, obesity, and osteoporosis. Certain techniques to prevent such incorrect surgery were explained. Lumbosacral spine anatomical variations are surgically significant. Awareness of their existence may provide better pre-operative planning and surgical intervention, leading to avoidance of incorrect-level surgery and potentially better clinical outcomes. In addition, collaboration with radiologists and careful examination of patient’s anatomy and characteristics should be exercised, especially in difficult cases.

Three-dimensional fluoroscopic navigation versus fluoroscopy-guided placement of pedicle screws in L4-L5-S1 fixation: single-centre experience of pedicular accuracy and S1 cortical fixation of 810 screws

Background

Three-dimensional (3D) navigation techniques can theoretically provide higher accuracy rates and increased safety for pedicle screw (PS) placement than traditional fluoroscopy (FL) guided methods. In this study, we compare the pedicular accuracy of 3D isocentric fluoroscopic navigation (3DFL) versus FL guidance in PS L4-L5-S1 fixation and evaluate the differential cortical purchase and safety of fixation of the S1 PS.

Methods

This is a single-centre retrospective study of 810 PSs placed in open L4-L5-S1 fixation between 2012 and 2017 in 39 patients using standard FL and in 96 patients under 3DFL. Pedicular screw accuracy was determined by postoperative computed tomography (CT) and graded on a 4-tiered classification system according to Gertzbein and Robbins. In addition, sacral screws were evaluated depending on the degree of cortical fixation: monocortical, bicortical or tricortical, and the degree of safety with respect to retroperitoneal structures.

Results

Grade 0 perfect pedicular screw placement was 95% for 3DFL screws compared to 85% for screws placed under fluoroscopy (P<0.05). The number of grade 0 versus grade 1 and higher (breached screws) was statistically significant (P<0.05). Higher S1 cortical screw accuracy [77% versus 51% (P<0.05)] for bi- and tricortical fixation and a lower percentage of "at risk" PSs (P<0.05) were achieved with placement under 3DFL versus FL.

Conclusions

3DFL enhances the accuracy and safety of PS placement in L4-L5-S1 fixation, reducing the rate of misplaced screws and improving S1 cortical fixation.

[Features of the new minimally invasive techniques facet fixation system «Facet Wedge» in the treatment of degenerative diseases of the lumbar spine in elderly patients.]

The aim of the study was a comparative analysis of the clinical and radiographic effectiveness of the use of interbody fusion and open pedicle screw stabilization of simultaneous and new minimally invasive techniques facet fixation system «Facet Wedge» in the treatment of degenerative diseases of the lumbar spine in elderly patients. The study included 39 elderly patients (older than 60), which carries out the transforaminal interbody fusion Cage «T-pal»: open transpedicaular stabilization was used in 1st group (n=23), ipsilateral open transpedicular stabilization with contralateral transfaset installing titanium Cage «facet Wedge» -in 2nd group (n=16). We used intraoperative interventions and specific post-operative patient management, clinical data and radiographic outcomes for a comparative analysis of the parameters. Dynamic assessment was made in a period of 8 to 36 months after surgery (median 24 mo.). As a result, it found that the use of the system «facet Wedge» allows you to achieve the best clinical outcomes and fewer postoperative complications compared with open transpedicular stabilization in similar radiographic findings of bone block formation. Low traumatic facet fixation makes it possible to use methods for the treatment of elderly patients with degenerative diseases of the lumbosacral spine.

Morphological and postural sexual dimorphism of the lumbar spine facilitates greater lordosis in females

Previous work suggests females are evolutionarily adapted to have greater lumbar lordosis than males to aid in pregnancy load-bearing, but no consensus exists. To explore further sex-differences in the lumbar spine, and to understand contradictions in the literature, we conducted a cross-sectional retrospective study of sex-differences in lumbar spine morphology and sacral orientation. In addition, our sample includes data for separate standing and supine samples of males and females to examine potential sex-differences in postural loading on lumbosacral morphology. We measured sagittal lumbosacral morphology on 200 radiographs. Measurements include: lumbar angle (L1-S1), lumbar vertebral body and disc wedging angles, sacral slope and pelvic incidence. Lumbar angle, representative of lordotic curvature between L1 and S1, was 7.3° greater in females than males, when standing. There were no significant sex-differences in lumbar angle when supine. This difference in standing lumbar angle can be explained by greater lordotic wedging of the lumbar vertebrae (L1-L5) in females. Additionally, sacral slope was greater in females than males, when standing. There were no significant sex-differences in pelvic incidence. Our results support that females have greater lumbar lordosis than males when standing, but not when supine - suggesting a potentially greater range of motion in the female spine. Furthermore, sex-differences in the lumbar spine appear to be supported by postural differences in sacral-orientation and morphological differences in the vertebral body wedging. A better understanding of sex-differences in lumbosacral morphology may explain sex-differences in spinal conditions, as well as promote necessary sex-specific treatments.

A Case of Lumbosacral Arachnoiditis Ossificans

The patient was a 13-year-old boy who complained of pain in both buttocks. Plain and reconstructive computed tomography (CT) images showed an ossified lesion within the dura mater at the L5-S2 levels, and arachnoiditis ossificans in the lumbosacral area was suspected. In the operative findings obtained after cutting the dura, a bone fragment 4.5 × 0.5 × 0.5 cm in size was observed in the center of the strongly adhesive nerve bundle of the cauda equina, which was removed en bloc. The postoperative clinical course of the patient was excellent. The case, along with a review of literature is presented.

Dysplastic spondylolysis is caused by mutations in the diastrophic dysplasia sulfate transporter gene

Spondylolysis is a fracture in part of the vertebra with a reported prevalence of about 3-6% in the general population. Genetic etiology of this disorder remains unknown. The present study was aimed at identifying genomic mutations in patients with dysplastic spondylolysis as well as the potential pathogenesis of the abnormalities. Whole-exome sequencing and functional analysis were performed for patients with spondylolysis. We identified a novel heterozygous mutation (c.2286A > T; p.D673V) in the sulfate transporter gene SLC26A2 in five affected subjects of a Chinese family. Two additional mutations (e.g., c.1922A > G; p.H641R and g.18654T > C in the intron 1) in the gene were identified by screening a cohort of 30 unrelated patients with the disease. In situ hybridization analysis showed that SLC26A2 is abundantly expressed in the lumbosacral spine of the mouse embryo at day 14.5. Sulfate uptake activities in CHO cells transfected with mutant SLC26A2 were dramatically reduced compared with the wild type, confirming the pathogenicity of the two missense mutations. Further analysis of the gene-disease network revealed a convergent pathogenic network for the development of lumbosacral spine. To our knowledge, our findings provide the first identification of autosomal dominant SLC26A2 mutations in patients with dysplastic spondylolysis, suggesting a new clinical entity in the pathogenesis of chondrodysplasia involving lumbosacral spine. The analysis of the gene-disease network may shed new light on the study of patients with dysplastic spondylolysis and spondylolisthesis as well as high-risk individuals who are asymptomatic.

Lumbosacral actinomycosis in an immunocompetent individual: An extremely rare case

Actinomycosis is a gram positive commensal bacteria. In predisposed individuals like immunocompromised patients, it can cause myriad lesions involving virtually any organ of the body. Involvement of spinal cord with its compression is rare though. We are reporting here a case of 30-year-old immunocompetent male who presented with weakness of left lower limb. Radiologically differential diagnosis was tuberculosis or lymphoma of spinal cord. Histopathology showed actinomycotic colonies that were periodic Schiff (PAS) positive and revealed gram positive filamentous bacteria.

Surgical removal of metallic foreign body (shrapnel) from the lumbosacral spine and the treatment of chronic osteomyelitis: a case report

We report a case of a retired soldier who was severely injured by an explosion in 1993 during the war in Bosnia and Herzegovina. Among other wounds, he suffered an explosive wound in the lumbosacral spine with steel foreign body (shrapnel). A year after primary wound treatment, a purulent fistula appeared which was treated and stopped with antimicrobial therapy. Subsequently, fistula which was activated several times after the antibiotic therapy was discontinued, but in the last eight years, the fistula has been continuously present so the patient decided on surgery. During surgery, the shrapnel was removed from the lumbosacral spine and there was debridement of necrotic bone. During two weeks of peri-operative and postoperative period, chronic osteomyelitis was treated by intravenous ciprofloxacin and gentamycin, and after that by a combination of rifampicin and trimethoprim-sulfamethoxazole orally, for six months. The patient did not show any signs of infection after two years of follow-up.

Influence of graded facetectomy and laminectomy on spinal biomechanics

Facetectomy and laminectomy are techniques for decompressing lumbosacral spinal stenosis. Resections of posterior bony or ligamentous parts normally lead to a decrease in stability. The degree of instability depends on the extent of resection, the loading situation and the condition of the intervertebral discs. The correlation between these parameters is not well understood. In order to investigate how these parameters relate to one another, a three-dimensional, non-linear finite element model of the lumbosacral spine was created. Intersegmental rotations, intradiscal pressures, stresses, strains and forces in the facet joints were calculated while simulating an intact spine as well as different extents of resection (left and bilateral hemifacetectomy, hemilaminectomy and bilateral laminectomy, two-level laminectomy), disc conditions (intact and degenerated) and loading situations (pure moment loads, standing and forward bending). The results of the modelling showed that a unilateral hemifacetectomy increases intersegmental rotation for the loading situation of axial rotation. Expanding the resection to bilateral hemifacetectomy increases intersegmental rotation even more, while further resection up to a bilateral laminectomy has only a minor additional effect. Hemilaminectomy and laminectomy only differ in their effect for ventriflexion and muscle-supported forward bending. Two-level laminectomy increases the intersegmental rotation only for standing. Degenerated discs result in smaller intersegmental rotations and higher disc stresses at the respective levels. Decompression procedures affect the examined biomechanical parameters less markedly in degenerated than in intact discs. Resection of posterior bony or ligamentous elements has a stronger influence on the amount than on the distribution of stresses and deformations in a disc. It has only a minor effect on the biomechanical behaviour of the adjacent region. Spinal stability is decreased after a laminectomy for forward bending, and after a two-level laminectomy for standing. For axial rotation, spinal stability is decreased even after a hemifacetectomy. Patients should therefore avoid excessive axial rotation after such a treatment.

Intervertebral disc distraction with a laparoscopic anterior spinal fusion system

The BAK spinal fusion system has been applied to laparoscopic anterior lumbar interbody fusion. The system, consisting of a pair of cylindrical implants with threads, placed symmetrically about the sagittal plane, functions by tensioning the annulus fibrosis. Cylindrical plugs of increasing size are inserted prior to the implant placement. As the procedure may affect spinal posture and disc height, we measured changes due to incremental plug insertion using human cadaveric spine specimens (L5-S1, n = 4). Multi-directional flexibility of the construct was also measured as a function of plug size. The disc height change was found to increase initially and then to level off at 13-mm diameter plugs. In the sagittal plane, the intervertebral posture first shifted towards kyphotic then came back to the initial lordotic posture with plugs of bigger size. However, changes in disc height and spine posture were not statistically significant. Comparing the neutral zone (NZ) flexibility after inserting the plugs to the intact values, neither the flexion/extension nor the axial rotation NZ showed any significant change. In lateral bending, the NZ decreased after the insertion of 13-mm plugs (p < 0.05). Insertion of plugs of increasing size from 9 mm to 12 mm decreased the range of motion (ROM) in all directions (p < 0.05). Insertion of 13-mm and 14-mm plugs decreased the flexion/extension and lateral bending ROM, but not the axial rotation ROM, probably indicating some injury to the annulus fibers.