Background : Surgical treatment for tarsal tunnel syndrome (TTS) remains a topic of controversy. To address this, we performed neurovascular decompression for TTS and reported on the techniques used, as well as the patient characteristics and outcomes pre- and post-surgery.

  Method : Between April 2021 and September 2022, 43 instances of neurovascular decompression were performed in 27 patients (12 men and 15 women) in our institute. The average postoperative follow-up period was 10.9 months (2-20 months). Post-operative symptoms were assessed using a numerical rating scale (NRS). Surgery involved making a 3-cm skin incision, as well as cutting the branch of the posterior tibial artery to obtain vascular mobility. For the secure decompressing of the nerve, posterior tibial artery transfer to the malleolus or heel side was performed by suturing with 5-0 PDS. Care was taken to maintain the traction of the branches of the posterior tibial nerve by the transferred artery. Patients did not require postoperative bed rest or external fixation.

  Outcome : For the transposition of the posterior tibial artery, dissection of the arterial branch was required in all cases, while cutting of the bridging veins over the artery was required in 9 sides (21%). In 8 sides (19%), small nerve branches were observed during surgery. Twenty-five patients reported symptom abatement, while two did not improve. The mean NRS score changed from 6.8 to 1.5.

  Conclusion : Close attention must be paid to artery meandering and nerve branch traction after arterial transposition under the targeted surgical field to ensure secure nerve decompression in patients undergoing surgical treatment for TTS.

  Spinal cord stimulation (SCS) stands as an established treatment for neuropathic pain and as an intervention in cases of failed back surgery. Recent studies have highlighted its efficacy in managing failed neck surgery syndrome (FNSS). While SCS is generally regarded as a safe therapeutic option, it is not without associated complications. Here, we present a rare complication of SCS observed in a patient with myelopathy resulting from granulation tissue formation around the SCS paddle lead in the cervical region.

  A 79-year-old man underwent laminoplasty at the C3-C6 levels due to cervical myelopathy secondary to ossification of the posterior longitudinal ligament. Although his symptoms initially showed improvement, he gradually developed upper limb and upper abdominal pain. Subsequent diagnosis confirmed the presence of failed neck surgery syndrome (FNSS), prompting the initiation of an SCS trial using a percutaneous lead positioned at the upper thoracic level, where post-laminoplasty adhesions were absent. The trial proved effective, leading the patient to opt for SCS treatment. The laminoplasty scar was reopened, and a paddle lead was inserted beneath the C2 spinous process. SCS administration yielded positive outcomes, with the patient reporting a reduction in upper limb and upper abdominal pain from 60 to 20 mm on the visual analog scale score. However, eight months post-SCS placement, the patient presented with bilateral upper and lower limb motor weaknesses. Magnetic resonance imaging (MRI) revealed compression of the cervical spinal cord due to granulation tissue formation around the SCS lead, while dynamic neck radiograph illustrated mobility of the SCS lead during flexion and extension. Extraction of the SCS lead and excision of as much granulation tissue as possible led to a restoration of motor strength.

  Previous literature suggests that the majority of cases involving granulation around the SCS lead occur with the placement of a paddle lead in the cervical region. This phenomenon is attributed to the larger surface area of the paddle lead compared to the percutaneous lead, coupled with the increased mobility of the cervical spine compared to the thoracic and lumbar regions. Accordingly, we hypothesize that friction generated during SCS lead movement is a contributing factor to the formation of granulation tissue around the lead. Thus, efforts should be made to minimize lead mobility when placing the SCS lead.

  Surgical treatment of tumors at the craniocervical junction or cervical spinal cord that involve the vertebral artery (VA) carries the risk of VA injury, an important consideration given the susceptibility of the vessel to occlusion based on its hemodynamics. Despite this, there is limited literature on the indications and efficacy of balloon test occlusion (BTO) and parent artery occlusion (PAO) for surgical resection of spinal cord tumors.

  In this study, two out of three patients with tumors at the craniocervical junction or cervical spinal cord involving the VA underwent PAO prior to tumor resection. In one case, BTO preceded PAO to assess ischemic tolerance, particularly due to the anterior spinal artery had branched from the affected side. Following PAO, an asymptomatic stroke occurred with no residual deficits. The decision to forego BTO in the second patient was based on the clear identification of perforating branches of the VA on cerebral angiography. Bleeding during resection was effectively managed, and both cases achieved a stable surgical field.

  In the third case, BTO was conducted, confirming the feasibility of VA occlusion. However, PAO was declined by the patient. Consequently, during surgery, VA injury necessitated ligation, which was prolonged due to poor visibility, resulting in substantial blood loss (810 ml).

  PAO holds promise in mitigating complications associated with VA injury, facilitating more aggressive tumor resection by promoting devascularization, and ensuring a clearer surgical field.

  We present three cases of L5-S1 disc herniation accompanied by the conjoined nerve root (CNR) anomaly that affects the S1 nerve root. All patients in these cases are female and they experienced radiating pain within the L5 and S1 dermatomes. Detailed MRI scans confirmed the presence of lumbar disc herniation (LDH) specifically at the L5-S1 level. The surgical approach undertaken included a partial hemilaminectomy and facetectomy at the L5-S1 level. While two of the cases exclusively underwent decompression procedures, the third case involved not only decompression but also the extraction of the herniated disc material. Although two patients found complete relief from their pain, one patient continued to experience pain even after the surgical intervention. Subsequently, the latter patient underwent an additional procedure involving spinal cord stimulation (SCS), resulting in remarkable improvement in their symptoms. These three cases serve to underscore the significance of considering the presence of CNR, particularly in situations where even minor instances of LDH result in severe symptoms affecting the lower extremities. In addition, this consideration is important when symptoms cannot be directly attributed to a single nerve root. It is worth noting that surgical decompression alone may not always be sufficient for pain relief in patients having CNR. This case highlights the potential of SCS as an effective solution for patients with CNR suffering from LDH. Hence, the incorporation of SCS should be contemplated as an adjunct treatment for CNR, especially when standard decompression procedures fall short of providing the desired relief. This study effectively demonstrates strategic approaches to address CNR-associated symptoms evident in cases of L5-S1 disc herniation. In addition, it emphasizes the necessity of tailoring treatment strategies to suit individual patients, thereby optimizing the potential outcomes.

  Use of drugs and radiological diagnoses are restricted for lumbar disc herniation during pregnancy. Fluoroscopy is avoided as much as possible. We report a case of lumbar disc herniation in a pregnant woman who underwent surgery.

  A 32-year-old woman, 16 weeks pregnant, who presented to an orthopedic clinic with left lower back and limb pain lasting for a month. Lumbar magnetic resonance imaging showed left posterolateral lumbar disc herniation at L5/S1. Conservative management failed, and she could not tolerate this uncontrollable intense pain until delivery ; therefore, the patient was referred to our department for surgery. She was not paralyzed but was unable to walk because of severe pain. The left straight leg raising test result was <30°. The preoperative Japan Orthopedic Association (JOA) score was 8/29. After consultation with an anesthesiologist and an obstetrician/gynecologist at our hospital, we decided to check the fetal heart sounds and echo findings before and after surgery. Surgery was performed under intravenous anesthesia using the standard Love’s method. The intraoperative position was prone on a four-point trestle table. The vertebral level was checked once, taking care not to irradiate the pelvic cavity. Postoperatively, the sciatica disappeared, the JOA score improved to 29 points, and the patient was discharged without symptoms on the eighth postoperative day.

  During pregnancy, radiation exposure must be avoided as much as possible, considering its influence on the fetus. As the weeks of pregnancy progress, surgery in the left lateral position is recommended to avoid elevating the intra-abdominal pressure or compressing the inferior vena cava. In our case, the patient’s body shape was almost the same as before she became pregnant. Therefore, we concluded the patient could undergo surgery in the prone position.

  In cases of herniated discs with severe pain that do not respond to conservative treatment, surgery is extremely useful and safe even during pregnancy.