Two-level reverse Bohlman transsoseous approach for treatment of symptomatic pseudarthrosis.

Surgical treatment for high-grade spondylolisthesis with high sacral slope remains controversial and no definitive gold standard procedure has been identified. The Bohlman technique, in which a fibular strut is reamed posteriorly across the L5-S1 disc space in an oblique, inferior to superior trajectory, has been increasingly utilized. Recently, a Reverse Bohlman technique has been described, in which a graft is reamed anteriorly across a single disc space in a superior to inferior trajectory. Case Report A 55 year-old male with complete lumbarization of S1 (referred to as L6) and previous L5-L6-S1 posterior instrumented fusion presented, with progressively worsening low back pain and lower extremity radicular pain. After failing conservative management, he underwent a 2-level Reverse Bohlman approach to place a titanium mesh interbody graft (cage) anteriorly from L5 to S1, crossing the L5-6 and L6-S1 disc spaces. Here we describe for the first time a Reverse Bohlman technique spanning two disc spaces in a patient with a transitional lumbosacral anomaly and high sacral slope. At 6 months post-operative follow up, the patient reported near complete resolution of symptoms.

IgG4-related disease presenting as intradural extramedullary lesion: a case report and review of the literature.

Object: IgG4-related disease (IgG4-RD) is a fibro-inflammatory disorder affecting various anatomical sites, and only recently was identified to affect the dura of the spine. The authors present the second reported case of an intradural extramedullary lesion consistent with IgG4-related spinal disease. Methods: A literature review was performed that identified 15 other cases of spinal disease, and common features of all known reported spinal IgG4-RD are discussed. Results: Spinal IgG4-RD typically affects males of approximately 50 years of age, and often presents as a T1 and T2 hypo- or isointense lesion that homogenously enhances. Surgical intervention typically involves subtotal resection or biopsy, and histopathologic findings include increased IgG4-positive cells or an IgG4:IgG ratio >40%. The disease responds well to steroids early on, and treatment can include adjuvant therapy such as azathioprine. Conclusions: Systemic involvement is possible, and, early treatment can quickly minimize disease burden. Thus, increased suspicion would result in early diagnosis and improved prognosis.