Dural tear with multiple nerve root entrapment simultaneously after unstable spine injury: Intraoperative finding

Spinal cord injuries (SCIs) caused by trauma that frequently occur are dural tears and cerebrospinal fluid (CSF) leaks. They are not always detected with neuroimaging. Hence, the authors reported two cases of the dural tear with multiple nerve root entrapment after spine injury and described how managed. This case report was about two patients who had unstable spinal fractures. All patients have an asymmetrical neurological deficit. The following magnetic resonance imaging features have analyzed the presence of CSF leakage, epidural haematoma, and spine fractures. Both cases revealed intraoperative finding dural tear with multiple nerve root entrapment. We performed decompression with spinal fixation with a posterior approach, and then the patients were sent home without complication. During the follow-up period, none of the patients developed complications. The severe neurological deficit, fracture of laminar, and ligamentum flavum disruption on the MRI in patients were predictable factors in our cases.

SCIATICA (IRQ-UN-NASA) IN MODERN AND UNANI PERSPECTIVE

Sciatica is a type of neuropathic pain and commonest variation of low back pain. It is known by a range of terms in the literature, such as lumbo sacral radicular syndrome, radiculopathy, nerve root pain and nerve root entrapment or irritation etc. The intense leg pain may be accompanied by neurological changes of muscle weakness and wasting, sensory changes in the nerve root distribution. There may be intra-spinal, intra-pelvic and extra-pelvic causes compressing the nerve and producing inflammation. In Unani medicine the term “Irq-un-Nasa” is used to describe such pain that initiates from lower back and radiates up 4,5 to knee or ankle joint posterolaterally. Most of the Unani scholars have mentioned it as a subtype of Wajaul Mafasil. The most common cause is the infiltration (nufooz) of abnormal homours in the fluid of hip joint, such as Ghair tabayi Balgham, Safra or Dam or admixture of Balgham and Safra, such infiltration for a prolonged period result into Tahajjur-e-Mafasil and even Irq-un-Nasa. Whenever the nerve becomes weak due to any reason the susceptibility for the accumulation of any morbid matter is increased. There may be sue mizaj damwi/ safravi/ balghami/ saudawi as active cause of Irq-un-Nasa. By now it is understood that this is the disease of nerve, and it is diagnosed and managed accordingly.

Cervical transforaminal ligaments on MRI and its clinical significance

Background This study examined cervical transforaminal ligament(TFL) displays in cadavers and living bodies using magnetic resonance imaging (MRI) and evaluated the correlation between nerve entrapment in the brachial plexus by the TFL and cervical radiculopathy(CR). Methods First, 6 normal intact adult cervical specimens were used to calculate the relevant capacity in displaying the cervical TFLs by the three-dimensional fast imaging employing steady-state acquisition (3D-FIESTA). Second, 10 patients with CR and 10 healthy subjects were selected to perform the 3D-FIESTA sequence scan at the C4-T1 intervertebral foramina. The TFL display rate was calculated, and its correlation with CR was analysed. Results The microscopic anatomical results showed that the cervical TFL incidence was 39.6%. The relative capacity of the 3D-FIESTA sequence in displaying cervical TFLs showed a 96.6% specificity and a 73.7% sensitivity. In the 10 patients with CR, cervical TFLs were present in 17 intervertebral foramina, of which, 10 cases showed hypertrophy of the TFLs causing nerve entrapment, and corresponding symptoms of CR were found in 8 cases of cervical TFLs. The correlation between nerve root entrapment by the cervical TFL and CR showed a 96.8% specificity and an 80% sensitivity. In the 10 healthy subjects, cervical TFLs were present in 13 intervertebral foramina. Conclusions The MR 3D-FIESTA sequence has high clinical value in displaying cervical TFLs in both cadavers and living bodies. If 3D-FIESTA sequencing shows nerve entrapment by the TFL, the possibility of CR caused by this TFL is approximately 80.0%. Conversely, the possibility of CR remains at 3.2%.

Cervical transforaminal ligaments on MRI and its clinical significance

Background This study examined cervical transforaminal ligament(TFL) displays in cadavers and living bodies using magnetic resonance imaging (MRI) and evaluated the correlation between nerve entrapment in the brachial plexus by the TFL and cervical radiculopathy(CR). Methods First, 6 normal intact adult cervical specimens were used to calculate the relevant capacity in displaying the cervical TFLs by the three-dimensional fast imaging employing steady-state acquisition (3D-FIESTA). Second, 10 patients with CR and 10 healthy subjects were selected to perform the 3D-FIESTA sequence scan at the C4-T1 intervertebral foramina. The TFL display rate was calculated, and its correlation with CR was analysed. Results The microscopic anatomical results showed that the cervical TFL incidence was 39.6%. The relative capacity of the 3D-FIESTA sequence in displaying cervical TFLs showed a 96.6% specificity and a 73.7% sensitivity. In the 10 patients with CR, cervical TFLs were present in 17 intervertebral foramina, of which, 10 cases showed hypertrophy of the TFLs causing nerve entrapment, and corresponding symptoms of CR were found in 8 cases of cervical TFLs. The correlation between nerve root entrapment by the cervical TFL and CR showed a 96.8% specificity and an 80% sensitivity. In the 10 healthy subjects, cervical TFLs were present in 13 intervertebral foramina. Conclusions The MR 3D-FIESTA sequence has high clinical value in displaying cervical TFLs in both cadavers and living bodies. If 3D-FIESTA sequencing shows nerve entrapment by the TFL, the possibility of CR caused by this TFL is approximately 80.0%. Conversely, the possibility of CR remains at 3.2%.

Thoracic Nerve Root Entrapment by Intrathecal Catheter Coiling: Case Report and Review of the Literature

Background: Intrathecal catheter placement has long-term therapeutic benefits in the management of chronic, intractable pain. Despite the diverse clinical applicability and rising prevalence of implantable drug delivery systems in pain medicine, the spectrum of complications associated with intrathecal catheterization remains largely understudied and underreported in the literature. Objective: To report a case of thoracic nerve root entrapment resulting from intrathecal catheter migration. Study Design: Case report. Setting: Inpatient hospital service. Results/Case Report: A 60-year-old man status post implanted intrathecal (IT) catheter for intractable low back pain secondary to failed back surgery syndrome returned to the operating room for removal of IT pump trial catheter after experiencing relapse of preoperative pain and pump occlusion. Initial attempt at ambulatory removal of the catheter was aborted after the patient reported acute onset of lower extremity radiculopathic pain during the extraction. Noncontrast computed tomography (CT) subsequently revealed that the catheter had ascended and coiled around the T10 nerve root. The patient was taken back to the operating room for removal of the catheter under fluoroscopic guidance, with possible laminectomy for direct visualization. Removal was ultimately achieved with slow continuous tension, with complete resolution of the patient’s new radicular symptoms. Limitations: This report describes a single case report. Conclusion: This case demonstrates that any existing loops in the intrathecal catheter during initial implantation should be immediately re-addressed, as they can precipitate nerve root entrapment and irritation. Reduction of the loop or extrication of the catheter should be attempted under continuous fluoroscopic guidance to prevent further neurosurgical morbidity. Key words: Implantable drug delivery system, intrathecal, catheter migration, postoperative complications, looping, fluoroscopy