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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]

Aim: This study aimed to assess the eff ectiveness of micro-vascular decompression (MVD) with or without partial sensory rhizotomy (PSR) in the treatment of trigeminal neuralgia which is refractory to medical and functional treatments. Materials and methods: Fifty-eight patients who were dia gnosed with classical trigeminal neuralgia and underwent posterior fossa decompression surgery from 2010 to 2016 by the same surgeon were included in the study. There were two groups of patients, according to operation type, with 30 (51.7%) patients treated with MVD and 28 (48.2%) treated with MVD + PSR. Records were analysed retrospectively for intraoperative fi ndings, pain intensity scores, recurrence of pain, postoperative results and complications. Results: In the early postoperative period, immediate pain relief was similar between the groups. The recurrence rate 36 months after surgery in the MVD and MVD + PSR groups was 23.3 and 7.1%, respectively. The pain-free survival time in the MVD group was 31.83 ± 1.9 (95% CI: 28.3–35.63) months, which was shorter than the 35.14 ± 1.1 (95% CI: 32.81–37.48) months in the MVD + PSR group at 36 months after surgery (P = 0.086). Concerning postoperative complications, one patient had an acute subdural haemorrhage (1.7%) and another had facial paralysis (1.7%), while hypoesthesia was experienced in 18 (31%) patients. There were no deaths in either group. Conclusion: MVD and MVD + PSR are safe and effective procedures for classical trigeminal neuralgia. [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: The relationship of pain relief from a recently presented CT-guided indirect cervical nerve root injection with local anesthetics and steroids to surgical decompression as a treatment for single-level cervical radiculopathy is not clear. This retrospective study aimed to compare the immediate and 6-week post-injection effects to the short- and long-term outcomes after surgical decompression, specifically in regard to pain relief. Methods: Patients ( n = 39, age 47 ± 10 years) who had undergone CT-guided indirect injection with local anesthetics and steroids as an initial treatment for single cervical nerve root radiculopathy and who subsequently needed surgical decompression were included retrospectively. Pain levels (VAS scores) were monitored before, immediately after, and 6 weeks after injection ( n = 34), as well as 6 weeks ( n = 38) and a mean of 25 months (SD ± 12) after surgical decompression ( n = 36). Correlation analysis was performed to find potential associations of pain relief after injection and after surgery to investigate the predictive value of post-injection pain relief. Results: There was no correlation between immediate pain relief after injection (−32 ± 27 %) and 6 weeks later (−7 ± 19 %), ( r = −0.023, p = 0.900). There was an association by tendency between immediate pain relief after injection and post-surgical pain relief at 6 weeks (−82 ± 27 %), ( r = 0.28, p = 0.08). Pain relief at follow-up remained high at −70 ± 21 % and was correlated with the immediate pain amelioration effect of the injection ( r = 0.37, p = 0.032). Five out of seven patients who reported no pain relief from injection had a pain relief from surgery in excess of 50 %. Conclusions: The amount of immediate radiculopathic pain relief after indirect cervical nerve root injection is associated with the amount of pain relief achieved at long-term follow-up after surgical decompression of single-level cervical radiculopathy. Patients can still expect sufficient pain relief from surgery even if they did not respond to the cervical infiltration. [ABSTRACT FROM AUTHOR]

Purpose. Extraforaminal decompression of the L5 nerve root remains a challenge due to anatomic constraints, severe level-degeneration, and variable anatomy. The purpose of this study is to introduce the use of navigation for transmuscular transtubular decompression at the L5/S1 level and report on radiological features and clinical outcome. Methods. Ten patients who underwent a navigation-assisted extraforaminal decompression of the L5 nerve root were retrospectively analyzed. Results. Six patients had an extraforaminal herniated disc and four had a foraminal stenosis. The distance between the L5 transverse process and the para-articular notch of the sacrum was 12.1 mm in patients with a herniated disc and 8.1 mm in those with a foraminal stenosis. One patient had an early recurrence and another developed dysesthesia that resolved after 3 months. There was a significant improvement from preoperative to postoperative NRS with the results being sustainable at follow-up. ODI was also significantly improved after surgery. According to the Macnab grading scale, excellent or good outcomes were obtained in 8 patients and fair ones in 2. Conclusions. The navigated transmuscular transtubular approach to the lumbosacral junction allows for optimal placement of the retractor and excellent orientation particularly for foraminal stenosis or in cases of complex anatomy. [ABSTRACT FROM AUTHOR]

Purpose: Total en bloc spondylectomy (TES) is accompanied by preoperative embolization of segmental arteries, which is limited to three consecutive levels to avoid the risk of spinal cord ischemia. We retrospectively examined the efficacy and safety of repeated TES with embolization of more than three levels of segmental arteries.Methods: Seven patients underwent TES twice for spinal metastases at different levels. Every patient underwent embolization of the bilateral segmental arteries before each surgery. We assessed the total number of segmental arteries embolized, the existence of Adamkiewicz arteries during the embolization procedure, intraoperative blood loss, and the motor function of the lower limbs, using the American Spinal Injury Association (ASIA) motor score.Results: No patient experienced any motor deficit after embolization. During the embolization procedure, an Adamkiewicz artery was depicted in five patients, which precluded embolization at that level. The median number of segmental arteries embolized in total was 9 (9-11). Intraoperative blood loss (median, IQR) was 480 (420-630) ml during the first surgery and 520 (280-600) ml during the second surgery. The ASIA motor scores (median, IQR) were as follows; 100 (98-100) (first admission), 100 (100-100) (first discharge), 100 (98-100) (second admission), and 97 (94-100) (second discharge). No patients had developed statistically significant neurological deterioration, and there had been no local recurrence after a median follow-up of 17.8 months (range 1-51 months).Conclusion: Repeated TES procedures can be performed safely even if more than three levels of segmental arteries are embolized. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to report the survival analysis of partial lateral facetectomy and Insall's procedure in patients with isolated patellofemoral osteoarthritis, and to assess the risk and protective factors for failure of this procedure. Methods: From 1992 to 2004, all subjects with isolated patellofemoral osteoarthritis who met the inclusion criteria and underwent this procedure were enrolled. Risk and protective factors for failure (failure considered as the need for total knee arthroplasty) were assessed by comparing obtained baseline data between failed and non-failed cases. Eighty-seven cases (mean (SD) age 61.8 (7.7) years, mean (SD) follow-up 9.6 (3.2) years) were included. Results: Twenty-three failed cases were found. Mean (SD) survival time was 13.6 (0.5) years. At 13 years (last failure case), the cumulative survival was 59.3 %. Baseline medial tibiofemoral pain, genu flexum, and worst grade of tibiofemoral osteoarthritis were significant risk factors for failure ( p < 0.0001, p = 0.02, p < 0.0001, respectively). In contrast, higher anatomical ( p = 0.02) and total ( p = 0.03) knee society score (KSS) scores, absence of knee effusion ( p = 0.03), higher value of the Caton-Deschamps index ( p = 0.03), and lateral position of the patella ( p = 0.01) were all protective factors against failure. Conclusion: The treatment for isolated patellofemoral osteoarthritis through partial lateral facetectomy and Insall's procedure demonstrated good long-term survival. The presence of preoperative medial tibiofemoral pain, genu flexum, and incipient tibiofemoral osteoarthritis increased the risk of failure of this procedure. In contrast, higher anatomical and total KSS scores, absence of knee effusion, higher value of the Caton-Deschamps index, and lateral position of the patella were found to protect against failure. Level of evidence: Prospective case series, Level IV. [ABSTRACT FROM AUTHOR]

Commentary On: Klement MR, Kleeman LT, Blizzard DJ, Gallizzi MA, Eure M, Brown CR. C5 palsy after cervical laminectomy and fusion: does width of laminectomy matter? Spine J 2016:16:462-7 (in this issue). [ABSTRACT FROM AUTHOR]