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Background: The epidural ligaments (ELs) (of Hofmann) were described as fibrous bands interconnecting the ventrolateral spinal dura and the posterior longitudinal ligament below L1. They are hardly ever discussed in the literature or considered in hypothesis-driven basic science experiments or spine biomechanical models. Methods: Intraoperative photographs were obtained to illustrate a group of posterolateral spinal ELs. In addition, electronic database searches (PubMed, Ovid Embase, and SCOPUS) were utilized to summarize the anatomy, and relevant clinical and surgical factors impacting these ELs. Results: ELs attach circumferentially at most spinal levels. They anchor the nerve root sleeves ventrally, and therefore, may play a role in the some idiopathic neurologic deficits (e.g., postoperative radiculopathies, C5 palsies) in patients without radiological compression. The posterolateral ELs originate on the dura dorsal to the nerve root sleeves and insert on the ipsilateral lamina, interlaminar ligament, and facet capsule. They appear to be continuous with the peridural membrane, a fibrovascular sheath that surrounds the thecal sac and serves as a scaffold for the internal vertebral venous plexus of Batson and epidural fat. Conclusion: The spinal ELs should be divided sharply during surgery to prevent durotomies, especially in patients with advanced spondylosis and facet arthropathy. Disconnecting these ligaments releases the thecal sac laterally and ventrally, allowing for medial mobilization when performing discectomies or for working in the ventral epidural space. [ABSTRACT FROM AUTHOR]

Background: The epidural ligaments (ELs) (of Hofmann) were described as fibrous bands interconnecting the ventrolateral spinal dura and the posterior longitudinal ligament below L1. They are hardly ever discussed in the literature or considered in hypothesis-driven basic science experiments or spine biomechanical models. Methods: Intraoperative photographs were obtained to illustrate a group of posterolateral spinal ELs. In addition, electronic database searches (PubMed, Ovid Embase, and SCOPUS) were utilized to summarize the anatomy, and relevant clinical and surgical factors impacting these ELs. Results: ELs attach circumferentially at most spinal levels. They anchor the nerve root sleeves ventrally, and therefore, may play a role in the some idiopathic neurologic deficits (e.g., postoperative radiculopathies, C5 palsies) in patients without radiological compression. The posterolateral ELs originate on the dura dorsal to the nerve root sleeves and insert on the ipsilateral lamina, interlaminar ligament, and facet capsule. They appear to be continuous with the peridural membrane, a fibrovascular sheath that surrounds the thecal sac and serves as a scaffold for the internal vertebral venous plexus of Batson and epidural fat. Conclusion: The spinal ELs should be divided sharply during surgery to prevent durotomies, especially in patients with advanced spondylosis and facet arthropathy. Disconnecting these ligaments releases the thecal sac laterally and ventrally, allowing for medial mobilization when performing discectomies or for working in the ventral epidural space. [ABSTRACT FROM AUTHOR]

Occipital spur is an abnormal bony outgrowth of the external occipital protuberance (EOP). We describe an interesting and previously unreported case of fracture of an occipital spur following trauma. Our 20-year-old male patient was treated in the emergency department (ED) and discharged home without complication. Neurosurgical consultation was obtained but is not requisite for these injuries. Greater awareness of this unique presentation may help to expedite future emergency department treatment. [ABSTRACT FROM AUTHOR]

Introduction: Historically, the use of subfascial drains for the management of durotomies was avoided due to concerns about the creation of cerebrospinal fluid (CSF) fistulas. Currently, there are limited series utilizing subfascial drainage for CSF leak management, many of which utilize suction drainage. We report our experience with the use of subfascial passive drainage in the management of such leaks., Objective: To demonstrate the efficacy of a passive subfascial bile bag for diversion of CSF post-operatively in concert with a post-operative head of bed (HOB) protocol for the management of durotomies in spine surgery., Methods: We performed a retrospective chart review of patients who underwent spinal surgery at a single institution performed by one surgeon. Cases utilizing a passive subfascial bile bag for durotomies were identified. A total of 1,882 consecutive surgeries were reviewed, and 108 met the inclusion criteria. The primary outcome was return to the operating room (OR) and/or the need for lumbar drain placement. Patient sociodemographic information and pre-, intra-, and post-operative clinical characteristics were reviewed., Results: A total of 108 patients underwent subfascial bile bag CSF diversion after intra-operative durotomy. Four patients (3.7%) experienced post-operative CSF leakage requiring lumbar drain placement, while only two (1.9%) patients required a return to the OR. One patient returned to the OR for symptomatic pseudomeningocele and the other for ongoing CSF drainage from their wound., Conclusion:  Durotomies are known to increase complication rates, including reoperation. The use of subfascial passive bile bag drainage in concert with a post-operative HOB protocol is a safe and effective manner to manage durotomies while minimizing the need for reoperation., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Medical University of South Carolina’s Institutional Review Board issued approval Pro00113249. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Stephen P. Kalhorn declare(s) royalties from Medical University of South Carolina (MUSC) Zucker Institute. Royalty payments received on devices licensed through the MUSC Zucker Institute. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Bauerle et al.)

Objective: Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs., Methods: A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores., Results: A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade., Conclusions: The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon's arsenal for the confident tackling of all TDHs.

Background: Thoracic disk herniations (TDHs) represent only 0.15% to 1.8% of surgically managed disk herniations but have posed a particular challenge to spine surgeons. Numerous surgical approaches have been cited in the literature with varying degrees of success, technical complexity, and complication profiles., Objective: To report a case of a combined lateral retropleural and dorsal transdural approach for complex thoracic discectomy., Methods: In this report, we describe a combined lateral/retropleural and posterior transdural approach for a patient with a giant calcified TDH that was not amenable to safe removal using a single approach., Results: In complex situations such as this, a dual corridor approach allows for improved visualization and maximal resection opportunity and opens up yet another option to address recalcitrant TDH., Conclusion: The staged dual corridor approach is safe and represents a further surgical option for extremely difficult TDH., (Copyright © 2018 by the Congress of Neurological Surgeons.)