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

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

Anatomical Relationship of the Vertebral Artery With the Lateral Recess: Clinical Importance for Posterior Cervical Foraminotomy

Objective 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. Methods 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. Results 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. Conclusion 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

Evolution of Spinal Endoscopic Surgery

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