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We report a case where neuromonitoring, using motor evoked potentials (MEP), detected an intraoperative L5 nerve root deficit during a lumbosacral decompression and instrumented fusion procedure. Critically, the MEP changes were not preceded nor accompanied by any significant spontaneous electromyography (sEMG) activity. Presumptive L5 innervated muscles, including tibialis anterior (TA), extensor hallucis longus (EHL) and gluteus maximus, were targets for nerve root surveillance using combined MEP and sEMG techniques. During a high-grade spondylolisthesis correction procedure, attempts to align a left-sided rod resulted in repeated loss and recovery cycles of MEP from the TA and EHL. No accompanying EMG alerts were associated with any of the MEP changes nor were MEP variations seen from muscles innervated above and below L5. After several attempts, the rod alignment was achieved, but significant MEP signal decrement (72% decrease) remained from the EHL. Postoperatively, the patient experienced significant foot drop on the left side that recovered over a period of 3 months. This case contributes to a growing body of evidence that exclusive reliance on sEMG for spinal nerve root scrutiny can be unreliable and MEP may provide more dependable data on nerve root patency. [ABSTRACT FROM AUTHOR]

Background: Total lumbar facetectomy may be advantageous for exposure or to completely free a constricted nerve root. Objective: We retrospectively reviewed a single surgeon series without fusion for short and long term outcomes regarding radicular pain relief, subsequent relevant surgeries, and any identifiable instability. Methods: All operations in which a single, total lumbar facetectomy was performed were reviewed. A total of 222 patients were identified with a minimal follow-up of 3 months; 187 (84.2%) were available for long term follow-up ≥1 year by continued accessible health care records, correspondence, or mailed questionnaire. Results: Short term success (3-month follow-up) for radicular pain relief in 222 patients found the following results: 176 patients (79.3%) had no pain or minimal pain, and 16 patients (7.2%) were improved, and thus resulting in 192 (86.5%) with no pain, or improved radicular pain. 30 patients (13.5%) were postoperative failures at 3 months. Long term follow-up ≥1 year was available for 187 patients (84.2%); (range 1–17 years; mean 7 years); found the following results: 23/30 (76.6%) short term surgical failures remained failures in long term follow-up with (7 patients) or without (16 patients) further surgery of any kind; 13/16 improved patients at long term follow-up remained improved (6), were pain free (6), or worse (1); 19/151 no or minimal pain patients at long term follow-up recurred or worsened by 1 year or longer, 12/19 pursued a second surgery with (9) or without (4) fusion and many improved. A total of 13 patients had a subsequent fusion operation (6.95%). Discussion: Most patients do well in the short term for radicular pain relief. Most patients continue to do well in long term follow-up. Surgically induced clinical instability is uncommon in this highly selected series. [ABSTRACT FROM AUTHOR]

Background: This is a unique report of 40 patients litigating in relation to the management of a cauda equina syndrome (CES), with prospective data collection. Methods: Patients were seen and examined; medical records and radiological imaging were reviewed. The following data were collected prospectively: age; sex; the level of cauda equina (CE) compression; the pathology causing the compression; the clinical picture at first presentation; the causes of any iatrogenic injury; possible breaches of duty of care and the responsible discipline; recovery of bladder control; return to work. Findings: There were possible breaches of duty of care for 39 patients initially, and for 69 patients overall. Twenty-eight patients presented with compressive degenerative pathologies (mainly central disc prolapses); all 28 had deteriorated to the point of bladder paralysis (complete CES (CESR)) at the time of treatment. Twenty-six (93%%) had voluntary bladder control at presentation. Long-term bladder paralysis was probably avoidable in over 90%% of patients. Eleven patients had iatrogenic injuries: all had long-term bladder paralysis. Thirty-four patients had bladder paralysis (CESR) at the point of decompressive surgery. Recovery of bladder function occurred in only seven patients (21%%), i.e. long-term bladder outcomes were poor. Only 22%% of patients returned to work. Conclusion: In this highly selected group of patients whose CES was not managed in an appropriate/standard fashion, 93%% of patients had long-term bladder, bowel and sexual dysfunction that was probably avoidable. Mismanagement of patients with iatrogenic injuries was associated with a universally poor outcome. [ABSTRACT FROM AUTHOR]