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BackgroundGiant pseudomeningoceles are an uncommon complication of spine surgery. Surgical management and extirpation can be difficult, and guidelines remain unclear.MethodsHere, we present a 56-year-old female patient with a history of grade III L5-S1 spondylolisthesis who was treated with 2 prior spine surgeries. The patient was treated with bone grafting for pseudarthrosis and instrumentation from L4 to ilium. After unsuccessful intraoperative and postoperative cerebrospinal fluid drainage and dural repair, the patient presented to the emergency room with debilitating positional headaches.ResultsThe patient underwent dural repair with bovine pericardial patch inlay sutured with 7-0 prolene, blood patch, and a dural sealant. Plastic surgery performed a layered closure, using acellular dermal matrix over the dural closure. The bilateral paraspinal flaps were advanced medially to cover the entirety of the acellular dermal matrix, and the fasciocutaneous flaps were then advanced to the midline for a watertight closure. At 3-month follow-up, the patient was headache free and had returned to her activities of daily living.ConclusionsWe conclude that early consultation with plastic surgery can be greatly beneficial to effectively extirpate dead space and resolve giant sacral pseudomeningoceles, especially if there is concern of persistent cerebrospinal fluid leakage due to relatively immobile avascular soft tissue as a result of prior revision surgery.

In this retrospective review study, the authors systematically reviewed the literature to elucidate the efficacy and complications associated with decompression and interspinous devices (ISDs) used in surgeries for lumbar spinal stenosis (LSS). LSS is a debilitating condition that affects the lumbar spinal cord and spinal nerve roots. However, a comprehensive report on the relative efficacy and complication rate of ISDs as they compare to traditional decompression procedures is currently lacking. The PubMed database was queried to identify clinical studies that exclusively investigated decompression, those that exclusively investigated ISDs, and those that compared decompression with ISDs. Only prospective cohort studies, case series, and randomized controlled trials that evaluated outcomes using the Visual Analog Scale (VAS), Oswestry Disability Index, or Japanese Orthopedic Association scores were included. A random-effects model was established to assess the difference between preoperative and the 1-2-year postoperative VAS scores between ISD surgery and lumbar decompression. This study included 40 papers that matched our criteria. Twenty-five decompression-exclusive clinical trials with 3,386 patients and a mean age of 68.7 years (range, 31-88 years) reported a 2.2% incidence rate of dural tears and a 2.6% incidence rate of postoperative infections. Eight ISD-exclusive clinical trials with 1,496 patients and a mean age of 65.1 (range, 19-89 years) reported a 5.3% incidence rate of postoperative leg pain and a 3.7% incidence rate of spinous process fractures. Seven studies that compared ISDs and decompression in 624 patients found a reoperation rate of 8.3% in ISD patients vs. 3.9% in decompression patients; they also reported dural tears in 0.32% of ISD patients vs. 5.2% in decompression patients. A meta-analysis of the randomized controlled trials found that the differences in preoperative and postoperative VAS scores between the two groups were not significant. Both decompression and ISD interventions are unique surgical interventions with different therapeutic efficacies and complications. The collected studies do not consistently demonstrate superiority of either procedure over the other but understanding the differences between the two techniques can help tailor treatment regimens for patients with LSS.

Background:An engorged venous plexus may mimic nerve compression from a herniated disk on the magnetic resonance (MR) studies as they both have similar signal intensities. During a laminectomy, if an engorged venous plexus is encountered instead of a disk herniation, there may be marked unanticipated bleeding. Case Description:A 58-year-old female who had a prior anterior lumbar interbody fusion later returned with recurrent radiculopathy. Adjacent segment disease from a spinal disk herniation was suspected based on the surgical history, physical examination, and imaging (MRI) findings. Rather than a disk, an engorged venous plexuses (EVP) was encountered intraoperatively. Conclusion:Here, we discussed our findings regarding a lumbar EVP rather than a herniated disk and reviewed the current literature. Although rare, a higher index of suspicion for these vascular malformations based on combined historical information and MRI studies should allow one to better detect and/or anticipate an EVP rather than a routine disk.

BackgroundTreatment of spondylolisthesis can be difficult with regard to patients with high sacral slopes that may prohibit placement of interbody grafts for fusions across that segment. Here, we describe placement of a reverse Bohlman technique from an anterior approach to obtain fusion across a low-grade spondylolisthesis with a high sacral slope to obtain anterior fusion.MethodsA chart review was conducted on this single patient regarding his clinical course and outcome.ResultsA 54-year-old male presented with low-back pain associated with bilateral leg pain dating back several years. Plain films demonstrated a Grade II isthmic spondylolisthesis at L5-S1 with spinopelvic measurements of 73° sacral slope, 82° lumbar lordosis, 12° pelvic tilt, and 94° pelvic incidence. Magnetic resonance imaging showed bilateral L5 pars defects with diffuse degenerative disease from L4 through S1 and significant ligamentous and facet hypertrophy. He underwent an L4-5 anterior lumbar interbody fusion and an L5-S1 reverse Bohlman placement of a transvertebral transsacral titanium mesh cage. This was supplemented with a posterior decompression and instrumentation from L4-ilium. He had resolution of his radiculopathy and has maintained a good clinical outcome at 3 years follow up.ConclusionsWe present here a patient with low-grade spondylolisthesis and a steep sacral slope who underwent a successful reverse Bohlman approach with long-term follow up. This report highlights the potential utility of this method as a viable alternative for patients with low-grade spondylolisthesis.Level of evidenceIV.Clinical relevanceTechnical description of surgical technique.

Background: Yolk sac tumor (YST), or endodermal sinus tumor, is classically associated with pediatric populations. Metastasis to the spine rarely occurs, usually involving the lower thoracic or lumbar vertebrae. The objective of this report is to present a rare case of YST metastasis to the lower cervical and upper thoracic vertebrae in an adult male. A case-based review of the literature on metastatic YSTs was also performed as an update to the relevant literature., Case Description: A 28-year-old male with a history of YST presented to our institution with urinary retention, increasing weakness in the upper extremities, and acute onset lower extremity weakness. Computed tomography (CT) and magnetic resonance imaging (MRI) scans confirmed evidence of metastasis from a known YST with symptomatic cord compression. The patient was treated with surgical excision via decompressive laminectomies with instrumentation as described, and histopathologic analysis of the specimen confirmed YST metastasis. His disease recurred one year after index surgery. He succumbed to his disease despite repeated debulking., Conclusions: Metastasis of YST is rare, but metastasis to lower cervical and upper thoracic vertebrae is possible. YSTs are usually treated via primary surgical resection. Systemic chemotherapy and radiation may prevent recurrence. However, individualized treatment is imperative for improved patient outcomes., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-28/coif). M.H.P. reports grants from Medtronic and consulting fees from Medtronic, Globus, Thompson Surgical, and NovApproach. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)