Post Herpetic Neuropathy of Sinuvertebral Nerve: A Case Report

Varicella-Zoster virus is a neurotropic virus of the herpes virus family that primarily affects sensory nerves. Herpes zoster causing sinuvertebral neuropathy has not been mentioned in the literature. A 55 years old man presented with low back pain, both buttocks, posterior thigh and leg pain over last 3 months. A straight leg raising test was positive on both sides. A left great toe dorsiflexion was decreased to 4/5. The VAS score at admission for back and leg pain was 7/10. The patient MRI was showing disc degeneration at L5-S1 level. We performed endoscopic interlaminar annuloplasty using radiofrequency ablation to denervate the sinuvertebral nerve attached to the annulus under epidural anesthesia. Patient symptoms completely relieved at the postoperative period and continued upto recent follow up of 6 months. The classical presentation of the patient after herpes zoster infection as back pain with referred leg pain, disc degeneration on MRI, intraoperative evidence of chronic neuropathy and almost complete improvement in patient symptoms after radiofrequency ablation makes it a first reported case of sinuvertebral neuropathy following herpes zoster infection

Get Ready for 100 Years of Active Spine Life Using Percutaneous Endoscopic Spine Surgery (PESS)

Lumbar spinal stenosis is the most common indication for spinal surgery in patients older than 65 years. After the introduction of Kambin's safety triangle, percutaneous endoscopic spine surgery has started through transforaminal approach for discectomy and is now being extended to spinal stenosis through interlaminar approach, which is an important part of the degenerative spinal disease. With the increase in human longevity, the development of effective treatment for degenerative diseases is inevitable, and future percutaneous endoscopic spine surgery (PESS) will play a very important role in maintaining the health of this ‘super-aged’ population. Endoscopic techniques impart minimal approach related disruption of normal spinal anatomy and function while concomitantly increasing functional visualization and correction of degenerative stenosis. Advantages of full endoscopic spine surgeries are less soft tissue dissection, less blood loss, reduced hospital admission days, early functional recovery and enhancement in the quality of life. With proper training and advancement in equipment and technologies, percutaneous endoscopic spine surgery will be able to successfully treat the aging spine

Safety and Efficacy of Endoscopic Posterior Cervical Discectomy and Foraminotomy Using Three-Point Plaster Traction Technique

The endoscopic posterior cervical foraminotomy and discectomy have been continuously developed and are considered widely performed minimally invasive procedures while maximally preserving patients’ anatomical structures. In posterior cervical spine surgery, the Mayfield head clamp is commonly used to provide a rigid, stable position of the head throughout the procedure. The use of the Mayfield head clamp has been associated with skull fractures, lacerations, air embolisms and epidural hematoma. However, we have performed 12 surgeries without Mayfield head clamp, in order to reduce the amount of equipment preparation needed and the additional risk of complications resulting from skeletal traction during surgery. These 12 patients were operated between January 2016 and February 2017 with full-endoscopic posterior discectomy or foraminotomy for posterolateral disc herniation or foraminal stenosis by osteophytes. In all 12 patients, preoperative average VAS scores were 7.67±1.4 for the neck and 8.33±1.1 for the arm, while postoperative VAS scores were 1.8±0.7 for the neck and 1.4±2 for the arm. All patients underwent a 6-month follow-up, during which improvement in VAS scores was maintained. There was no compromise in endoscopic view during surgery due to our positioning technique. Our results show that posterior cervical endoscopic spine surgery can be performed safely and effectively with three-point plaster traction technique without risks associated with skeletal traction

Knuckling Down on Predictive Factors for Early Relapse after Posterolateral Percutaneous Endoscopic Lumbar Discectomy

Objective Percutaneous endoscopic lumbar discectomy (PELD) has several advantages, but it is not used routinely due to early relapse and steep learning curve. We have studied the factors associated with early relapse in patients who underwent posterolateral PELD at or above the L4-5 level. Methods In this retrospective study, we have enrolled 200 cases and divided them into 4 groups (A, B, C, and D) with 50 patients in each group, that had undergone PELD by 2 different techniques (inside-out and outside-in with or without anti-adhesive agent) and operated by 2 different surgeons between May 2009 and November 2010. The factors studied were - Age, gender, disc (degeneration grade, location, level), associated adjacent level herniated nucleus pulposus (HNP), episode (first or recurrent), anti-adhesive agent, annulus preservation, approach, disc height and segmental dynamic motion (discrepancy in flexion and extension). Statistical analysis was done by Pearson’s chi-square test and p value (significance). The clinical results were evaluated by visual analogue scale (VAS). Results The mean age and mean follow-up period was comparable in all four groups. The overall recurrence rate was 9.5% (19/200). Average early relapse time was 3.26 months. Factors like Age of the patient, multilevel HNP and degeneration grade showed significant correlation with relapse rate. The change in VAS pre-operatively to post-operatively was significant across all groups (p<0.001). Conclusion Based on the results of this study, high grade disc degeneration, multilevel disc herniation, and early postoperative activity are significantly associated with early relapse after PELD

A Degenerative Intraspinal Cyst Mimicking a Nerve Root: A Case Report on an Intraoperative Challenge

Various intraspinal cysts have been described in the literature. Sometimes these cysts are difficult to recognize intraoperative and can place a surgeon in dilemma. We report a case of a degenerative intraspinal cyst with severe adhesion with dura, which was mimicking as a nerve root and posed a diagnostic dilemma during surgery. A Sixty-year-old man presented with insidious onset, gradually progressing lower back pain, right leg pain and neurological claudication of six months duration. The pain radiated to the right S1 dermatome. Right side straight leg raise test was positive at 45°. Sensations were diminished over the right L5 and S1 dermatomes. Motor function was normal. MRI showed a large cystic lesion at right L5-S1 level. The cyst appeared to compress the dural sac and traversing right S1 root at L5-S1 level. The lesion was isointense on T1-weighted image and hyperintense on T2-weighted image. While treating this condition using the uniportal full endoscopic technique the cyst appeared as nerve root. Meticulous dissection was required to separate the cyst from neural structures. Histology confirmed the diagnosis of a degenerative intraspinal cyst. The patient had significant improvement after surgery and at six months follow up he was completely asymptomatic. Various cysts can occur in the intraspinal canal, and careful attention should be paid to minimize the nerve injury in the presence of severe adhesions

Congenital absence of a lumbosacral facet joint: A case report

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

Progressive dysphagia and dysphonia secondary to DISH-related anterior cervical osteophytes: A case report

Background: Dysphagia due to diffuse idiopathic skeletal hyperostosis (DISH)-related anterior cervical osteophytes is not uncommon. However, this rarely leads to dysphonia and/or dysphagia along with life- threatening airway obstruction requiring emergency tracheotomy. Case Description: A 56-year-old male presented with progressive dysphagia and dysphonia secondary to DISH-related anterior osteophytes at the C3–C4 and C4–C5 levels. The barium swallow, X-ray, magnetic resonance imaging, and computed tomography scans confirmed the presence of DISH. Utilizing an anterior cervical approach, a large beak-like osteophyte was successfully removed, while preserving the anterior annulus. After clinic-radiological improvement, the patient was discharged with a soft cervical collar and nonsteroidal anti-inflammatory drug (NSAID). Conclusion: Large anterior osteophytes in Forestier disease/DISH may cause dysphagia and dysphonia. Direct anterior resection of these lesions yields excellent results as long as other etiologies for such symptoms have been ruled out

Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature

Background: The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4–L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management). Case Description: A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4–L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4–L5 level. This was treated with a L4–L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection. Conclusion: Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions

Lumbar Canal Stenosis: A Prospective Clinicoradiologic Analysis

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; 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