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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

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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 NEUROSURGICAL FOCUS Neurosurg Focus 49 (3):E7, 2020 Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5–S1: case series and review of the literature Ehsan Dowlati, MD,1 Hepzibha Alexander, MD,2 and Jean-Marc Voyadzis, MD1 1Department of Neurosurgery, MedStar Georgetown University Hospital; and 2Georgetown University School of Medicine, Washington, DC OBJECTIVE Nerve root injuries associated with anterior lumbar interbody fusion (ALIF) are uncommonly reported in the literature. This case series and review aims to describe the etiology of L5 nerve root injury following ALIF at L5–S1. METHODS The authors performed a single-center retrospective review of prospectively collected data of patients who underwent surgery between 2017 and 2019 who had postoperative L5 nerve root injuries after stand-alone L5–S1 ALIF. They also reviewed the literature with regard to nerve root injuries after ALIF procedures. RESULTS The authors report on 3 patients with postoperative L5 radiculopathy. All 3 patients had pain that improved. Two of the 3 patients had a neurological deficit, one of which improved. CONCLUSIONS Stretch neuropraxia from overdistraction is an important cause of postoperative L5 radiculopathy after L5–S1 ALIF. Judicious use of implants and careful preoperative planning to determine optimal implant sizes are para- mount. https://thejns.org/doi/abs/10.3171/2020.6.FOCUS20315 KEYWORDS anterior lumbar; interbody fusion; L5–S1; L5 nerve root; complications; neuropraxia; spinal fusion NTERIOR lumbar interbody fusion (ALIF) is an where access is limited by bony, ligamentous, or muscular effective surgical technique for the treatment of structures. The efficient access allows for a comprehensive a wide range of pathologies of the lumbosacral discectomy, increased distraction, foraminal decompres- Aspine. Evolution in surgical technique, approach, cage de- sion, and deformity correction, including restoration of sign, and biological implants has enhanced its safety pro- lumbar lordosis, reduction of anterolisthesis, and achieve- file and expanded the clinical utility since its introduction ment of coronal and sagittal balance.5–12 ALIF restores fo- in the early 1930s.1,2 ALIF is currently the second most raminal height, local disc angle, and lordosis better than common method of spinal fusion performed in patients transforaminal lumbar interbody fusion.13 Fusion potential with degenerative disc disease (DDD), herniated nucleus is also enhanced due to the larger surface area that is in pulposus, or back pain.3 Clinical and radiological out- contact with the graft.8,14–17 Other reported benefits include comes are particularly favorable for DDD, spondylolisthe- reduced blood loss, short operating times, and reduced sis, and failed posterior fusion.4 hospital stay.8,18–21 The adoption of ALIF in degenerative disorders can be Despite the clear benefits, ALIF is not without associ- attributed to the unique advantages conferred by the ante- ated risks. The proximity of the anterior spinal column to rior approach and its ideal application to the L5–S1 level. major blood vessels places them at significant risk of iatro- The bifurcation of the aorta and vena cava above this level genic injury. Venous injuries are the predominant compli- provides direct and unobstructed access to the anterior cation, with deep venous thrombosis occurring in 2%–11% disc space at L5–S1, resulting in a wide working corri- of patients. Damage to the sympathetic (superior hypogas- dor. This is in contrast to posterior and lateral approaches, tric) plexus can result in leg and groin dysesthesias as well ABBREVIATIONS ALIF = anterior lumbar interbody fusion; AP = anteroposterior; DDD = degenerative disc disease; EMG = electromyography; NCS = nerve conduction study; SSEP = somatosensory evoked potential. SUBMITTED April 15, 2020. ACCEPTED June 9, 2020. INCLUDE WHEN CITING DOI: 10.3171/2020.6.FOCUS20315. ©AANS 2020, except where prohibited by US copyright law Neurosurg Focus Volume 49 • September 2020 1 Unauthenticated | Downloaded 10/04/21 09:42 AM UTC Dowlati et al. FIG. 1. Case 1, preoperative imaging. A: Lateral (left) and AP (right) radiographs of the lumbar spine. B: Lumbar CT myelograms showing severe disc degeneration at L5–S1, loss of disc height, and vacuum disc phenomenon. There is no evidence of canal stenosis. as retrograde ejaculation (1%–4.3%).22–24 Visceral com- for extensive cardiac disorders and bilateral hip replace- plications include postoperative ileus, hernia, and bowel ments. His past surgical history was also notable for a pri- perforation. Prosthesis-related injuries such as graft mi- or multilevel laminectomy and L3–4 fusion and extensive gration or subsidence and infection represent 1% and 2% spondylotic disease with large bridging osteophytes from of complications, respectively. Nerve root injuries, while the thoracic spine to L5. On examination, motor strength more prevalent in the posterior and lateral approaches, and sensation were intact and symmetric in the bilateral are scarcely reported in the anterior approach due to spar- lower extremities. Imaging studies, including CT myelog- ing of neural elements.25 Paresthesias and weakness are raphy and dynamic radiography, revealed multilevel an- more common in lateral lumbar interbody fusion and vary kylosis throughout the lumbar spine with large bridging widely in frequency (0.7%–30% and 3.4%–23.7%, respec- osteophytes from the thoracic spine to L5, severe disc de- tively). 26–33 generation at L5–S1, loss of disc height, and vacuum disc We conducted a retrospective review of all L5–S1 phenomenon (Fig. 1). ALIF procedures performed at our institution between The patient underwent many sessions of physical ther- 2017 and 2019 specifically evaluating for nerve root in- apy and steroid injections without relief. He was admitted jury. We present the cases of 3 patients with postoperative to the hospital with intractable back pain and an inabil- L5 nerve root injuries. An explanation of the anatomical ity to walk. He underwent a stand-alone ALIF at L5–S1 basis of this injury based on current literature and recom- (Sovereign, Medtronic). A large implant was placed, with mendations to mitigate this complication are discussed. dimensions of 42 mm in width and 16 mm in height with 12° of lordosis (Table 1). A right-sided approach was uti- lized given the patient’s history of a sole kidney on the Summary of Cases left side. Postoperatively, his back pain resolved; however, A total of 352 ALIF procedures were performed at our he developed new right hip and lateral thigh pain along institution from 2017 to 2019. Of the 352 procedures, 111 with weakness in dorsiflexion. On examination, his mo- were stand-alone ALIFs at L5–S1 with no posterior in- tor strength had decreased to 4+/5 in the quadriceps, 3/5 strumentation or fusion. Seven patients within this cohort in tibialis anterior, and 2/5 in extensor hallucis longus were identified as having experienced symptomatic nerve muscles in the right lower extremity. Sensation remained root injuries within 60 days of surgery. Two patients had intact. Postoperative CT scanning of the lumbar spine re- cage subsidence causing nerve impingement. One patient vealed an intact appearance of the instrumentation with- developed osteodiscitis leading to radiculopathy. The out evidence of canal or foraminal compromise and an other 4 patients developed L5 nerve root injuries without increased disc height at L5–S1 (Fig. 2). MRI could not obvious etiology. Three of these cases for which preop- be performed due to the presence of a cardiac pacemaker. erative and postoperative imaging was available are illus- At 3 months postoperatively, the patient was free of back trated here. pain but right dorsiflexion weakness remained. Electro- myography (EMG) and nerve conduction studies (NCSs) Case 1 demonstrated an active and chronic right L5 radiculopathy An 80-year-old man presented with complaints of pro- and mild polyneuropathy. gressive lumbosacral pain accompanied by radiation to the lateral calves and buttocks along with hip pain and Case 2 stiffness. The pain was severe and occurred daily and sig- A 51-year-old woman with a history of right-sided nificantly limited his ability to stand or walk for extended L4–5 discectomy and obesity presented with diffuse, bi- periods. The patient’s past medical history was significant lateral pain in the lumbosacral region. The back pain radi- 2 Neurosurg Focus Volume 49 • September 2020 Unauthenticated | Downloaded 10/04/21 09:42 AM UTC Dowlati et al. TABLE 1. Implant sizes and comparison of preoperative and postoperative disc and foraminal height restoration Implant Size Anterior Disc Height Posterior Disc Height L5 Foraminal Height Height Width Lordosis Preop Postop Preop Postop Preop Postop (mm) (mm) (°) (mm) (mm) Increase (mm) (mm) Increase (mm) (mm) Increase Case no. 1 16 42 12 7.5 18.8 150% 5.0 9.8 96% 13.9 22.1 59% 2 13 36 12 7.2 14.9 107% 4.8 9.1 90% 14.2 20.1 42% 3 16 42 8 5.8 14.3 147% 4.5 8.6 91% 12.9 19.3 50% Mean for study cases 15 40 10.7 7.0 16.0 134% 4.8 9.2 92% 13.7 20.4 49% Mean for 10 cases w/ no L5 injury 14.1 36.4 12.6 9.5 19.4 105% 5.8 10.1 78% 13.4 18.2 40% ated into the buttocks and posterior aspect of the leg down desiccation at L4–5. Her symptoms were refractory to to the ankle and was refractory to conservative measures conservative measures. over a period of 18 months. On examination, gross motor The patient underwent a stand-alone ALIF at L5–S1 strength was diminished (4+/5) in the right anterior tibi- (Centinel Spine). A medium-sized implant was placed, alis muscle but was otherwise intact. Sensation was sym- with dimensions of 36 mm in width and 13 mm in height metric and equal bilaterally.
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