Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5–S1: case series and review of the literature

Dowlati, Ehsan; Alexander, Hepzibha; Voyadzis, Jean-Marc

doi:10.3171/2020.6.focus20315

Cited by 16 publications

(22 citation statements)

References 47 publications

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“…The article notes an outcome of postoperative neuropraxia in their patient series due to potential direct iatrogenic injury to the nerve roots during discectomy or disk preparation. 22 Such are injuries which may be detected by IONM. The described patient example provides evidence of the benefit of IONM to avoid irreversible iatrogenic nerve root injury.…”

Section: Discussionmentioning

confidence: 99%

Prevention of Neurological Deficit With Intraoperative Neuromonitoring During Anterior Lumbar Interbody Fusion

Farooq

Pressman²,

Elsawaf³

et al. 2021

Clinical Spine Surgery: A Spine Publication

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Objective: While intraoperative neuromonitoring (IONM) has been increasingly used in spine surgery to have a real-time evaluation of the neurological injury, we aim here to assess its utility during anterior lumbar interbody fusion (ALIF) and its association with postoperative neurological deficit.Summary of Background Data: ALIF is a beneficial surgical approach for patients with degenerative disease of the lower lumbar spine who would benefit from increased lordosis and restoration of neuroforaminal height. One risk of ALIF is iatrogenic nerve root injury. IONM may be useful in preventing this injury. Materials and Methods:We performed a retrospective cohort study of 111 consecutive patients who underwent ALIF at a tertiary care academic center by 6 spine surgeons. We aimed to describe the association between IONM, postoperative weakness, and factors that predispose our center to using IONM. Results:The 111 patients had a median age of 62 years [interquartile range (IQR): 53-69 y]. Neuromonitoring was used in 67 patients (60.3%) and not used in 44 patients. Seven neuromonitoring patients had IONM changes during the surgery. Three of these patients' surgeries featured intraoperative adjustments to reduce iatrogenic neural injury. The IONM cohort underwent significantly more complex procedures [5 levels (IQR: 3-7) vs. 2 levels (IQR: 2-5), P = 0.001]. There was no difference in rates of new or worsened postoperative weakness (IONM: 20.6%, non-IONM: 20.5%). Conclusions:We demonstrate evidence of the potential benefits of IONM for patients undergoing ALIF. Intraoperative changes in neuromonitoring signals resulted in surgical adjustments that likely prevented neurological deficits postoperatively. IONM was protective so that more complex surgeries did not have a higher rate of postoperative weakness.

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Section: Discussionmentioning

confidence: 99%

Prevention of Neurological Deficit With Intraoperative Neuromonitoring During Anterior Lumbar Interbody Fusion

Farooq

Pressman²,

Elsawaf³

et al. 2021

Clinical Spine Surgery: A Spine Publication

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show abstract

“…Other causes were suggested for motor weakness in one study. Dowlati et al [ 14 ] suggested that an excessive increase in the height of the disc space causes stretching of the nerve roots, resulting in neuropraxia. In their study of patients with nerve root injury, the anterior and posterior disc heights increased by 134% and 92%, respectively, while the foraminal height increased by 50%.…”

Section: Discussionmentioning

confidence: 99%

Neurologic deficit due to vertebral body osteophytes after oblique lumbar interbody fusion

Lee¹,

Han²,

Lee³

et al. 2021

Medicine

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Rationale: In recent years, oblique lumbar interbody fusion (OLIF), which uses a window between the peritoneum and the iliopsoas muscle to split the muscle to access the lumbar spine, is known as an effective and safe treatment for spinal diseases, such as degenerative disc disease, spondylolisthesis, recurrent disc herniation, and spinal deformity. Despite this fast and useful surgical method, there were often cases of new neurological symptoms or worsening of symptoms after surgery. We analyzed the preoperative risk factors in a patient with neurologic symptoms, such as motor weakness and exacerbation of radiating pain, after OLIF. Patient concerns: A 78-year-old man presented with complaints of numbness in the soles of both feet. L4–5 stenosis was diagnosed on MRI. We performed bilateral L4 laminotomy and L4–5 percutaneous posterior screw fixation after L4–5 OLIF. Postoperatively, his radiating pain improved, and there were no other neurologic symptoms. In the 6th week after surgery, he complained of pain in both ankles, while in the 10th week, the pain progressively worsened, and there was a decrease in motor performance of the right ankle. Diagnosis: Magnetic resonance imaging findings indicated that L4–5 stenosis was resolved. On the basis of the computed tomography findings, the cage was well inserted, the disc height and foramen height increased, and the alignment was good. However, a nerve root injury due to the protruding osteophyte from the inferior endplate of the L4 body was suspected, necessitating exploration of both L4 nerve roots by focusing on the right side. Interventions: We performed right facetectomy and right foraminotomy. During surgery, it was confirmed that the right L4 nerve root was entrapped by the osteophyte. Outcomes: Postoperatively, his radiating pain improved, and motor performance of his right ankle was restored. Lessons: A prominently protruding osteophyte is assessed as a possible risk factor for the development of new neurologic deficits after OLIF. In patients with confirmed osteophytes, surgery should be planned taking into consideration the shape of the osteophytes and their relationship to the nerve root.

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“…A review article on iatrogenic neurologic deficits after lumbar spine surgery reported a 4.1% rate of newonset neurologic injury after anterior or lateral lumbar fusion surgery [10]. Postoperative L5 radiculopathies after L5-S1 ALIF procedures have been described [14,15]. The postoperative deficit has most commonly been attributed to a stretch neuropraxia from over distraction of the disk L5-S1 space.…”

Section: Discussionmentioning

confidence: 99%

“…Oversizing the graft and aggressive malleting with the cage trial should be avoided. These maneuvers have been associated with L5 radiculopathy after L5-S1 ALIF [14,15]. The surgeon should also account for the geometric shape of the interbody cage.…”

Section: Discussionmentioning

confidence: 99%

“…The ALIF procedure has been associated with diverse complications such as vascular injuries, injuries to other structures in the peritoneal compartment, fractures, pseudoarthrosis, and neural injury [9][10][11][12][13]. At the L5-S1 level, the ALIF has been associated with L5 radiculopathies [14,15]. Most commonly, L5 radiculopathy has been contributed to a stretch neuropraxia.…”

Section: Introductionmentioning

confidence: 99%

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A Technical Nuance to Avoid Lumbar Five Radiculopathy with Anterior Lumbar Fusion and Posterior Instrumentation

Neal

Kalani

Lyons

2021

Case Reports in Orthopedics

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The anterior lumbar interbody fusion (ALIF) is a well-established procedure used to treat a multitude of spinal pathologies. When performed at the L5-S1 level, the ALIF is often supplemented with posterior pedicle screw and rod fixation. Because the interbody device can restore disk and foraminal height, one benefit of the ALIF procedure is indirect neural decompression in the spinal canal and neural foramina. If the contour of the posterior rod is not matched to the exact position of the tulip heads on the pedicle screws, spondylolisthesis can be introduced, leading to foraminal stenosis and nerve compression. This concern is particularly germane when the posterior instrumentation is placed percutaneously without any direct foraminal decompression. In this report, we describe a patient who had an L4-S1 ALIF, resulting in new L5-S1 retrolisthesis and worsening L5 radiculopathy. Technical nuances and avoidance strategies are discussed.

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Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5–S1: case series and review of the literature

Cited by 16 publications

References 47 publications

Prevention of Neurological Deficit With Intraoperative Neuromonitoring During Anterior Lumbar Interbody Fusion

Prevention of Neurological Deficit With Intraoperative Neuromonitoring During Anterior Lumbar Interbody Fusion

Neurologic deficit due to vertebral body osteophytes after oblique lumbar interbody fusion

A Technical Nuance to Avoid Lumbar Five Radiculopathy with Anterior Lumbar Fusion and Posterior Instrumentation

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