The authors have no acknowledgments.

Informed consent was acquired from the patient before initiating the treatment, and the study underwent ethical review by the ethics committee.
1. Preoperative work-up for the first surgery
<ol>
	<li>CT, MRI, DR, and physical examination were performed to identify the L5/S1 affected segment and determine the surgical method (Figure 1).</li>
	<li>Lower limb vascular issues were ruled out, and the patient underwent an anesthetic assessment before selecting endoscopic L5/S1 decompression surgery.</li>
</ol>
2. Installation for the first surgery
<ol>
	<li>Patient positioning: After general anesthesia, the patient was positioned prone on a spinal surgery table, with protective pads placed on vital areas to prevent pressure sores and abdominal compression.</li>
	<li>Surgeon position: The surgeon and the assistant stood on the patient&#39;s right side, with the monitor and other equipment on the opposite side.</li>
</ol>
3. Procedure steps for the first surgery
<ol>
	<li>Routine disinfection and draping were performed, followed by the use of a C-arm fluoroscope to localize the target segment. A gradually expanding channel was then placed at the L5 inferior lamina.</li>
	<li>A working channel (10 mm) was inserted, and the lower edge of the channel was used to dissect the soft tissue of the L5 inferior lamina. An endoscope was then placed and connected to the irrigation and imaging systems. 
	NOTE: Using a ring saw for osteotomy, the position being too medial and too deep, as well as tissue adhesion, resulted in damage to the upper endplate of the L5 vertebra and a dural tear. However, under the water medium, no obvious cerebrospinal fluid leak was detected (Figure 2).</li>
	<li>To obtain a clearer view due to oozing from the bone surface, the irrigation solution was elevated to a height of 220 cm.</li>
	<li>Plasma radiofrequency was used for hemostasis. The overgrown inferior articular process of the L5 vertebra and the superior articular process of the S1 vertebra were removed using a rongeur.</li>
	<li>The hypertrophied ligamentum flavum was also excised. A nucleus pulposus forceps was utilized to clear the herniated disc tissue from the superior and axillary regions of the L5 nerve root.</li>
	<li>After completing the spinal canal decompression, the dura mater had a tear. After the assessment, an open repair was unnecessary, so a gelatin sponge was used for packing, and the incision was then closed using a size #1 non-absorbable suture.</li>
</ol>
4. Post-operative management
<ol>
	<li>After the patient regained consciousness, dexamethasone (10 mg) was administered once daily (qd) for its anti-inflammatory and analgesic effects, and cefuroxime (1.5 g) was given every 8 h (q8h) to prevent infection.</li>
	<li>After regaining consciousness, the patient was administered ibuprofen (0.4 g) once daily (qd) for its anti-inflammatory and analgesic effects, and cefoperazone and sulbactam sodium (1.5 g) every 12 h (q12h) for infection prophylaxis. The patient still had radiating pain 6 h postoperatively in the lower limbs and urinary incontinence. Cerebrospinal fluid leakage was observed in the drainage tube.</li>
	<li>On the day of the postoperative review, the patient&#39;s MRI revealed a cerebrospinal fluid leak. The suction on the drainage tube was adjusted from negative pressure to atmospheric pressure. The volume and characteristics of the drainage were monitored and recorded to ensure the tube remained unobstructed and the patient received ORT and IV therapy.</li>
	<li>The patient was given oral rehydration fluids and IV infusions of a sodium, potassium, magnesium, and calcium glucose solution, 500 mL BID.</li>
	<li>The drainage volume was less than 50 mL per day on the third day, and the drainage tube was removed. The patient experienced no discomfort, such as headache, dizziness, nausea, or vomiting.</li>
	<li>The patient underwent a 3-day period of indwelling catheterization, along with pelvic floor muscle exercises and anal sphincter exercises. 
	NOTE: After 2 weeks, the patient experienced some alleviation of lower limb pain and was discharged, although constipation still remained.</li>
</ol>
5. Preoperative work-up for the second surgery
NOTE: The patient was readmitted due to pain in the right lower limb 5 months later. Further imaging revealed a herniation of the L5/S1 dural sac (Figure 3).
<ol>
	<li>After obtaining informed consent, a total laminectomy and dural sac repair were performed using 3D microscopic guidance.</li>
</ol>
6. Installation for the second surgery
<ol>
	<li>Patient positioning: After general anesthesia, the patient was positioned prone on a spinal surgery table, with protective pads placed on vital areas to prevent pressure sores and abdominal compression.</li>
	<li>Surgeon position: The surgeon and the assistant stood on either side of the patient, with the 3D microscope positioned on the patient&#39;s left side and connected to a secondary screen to facilitate coordinated operation between the surgeon and the assistant.</li>
</ol>
7. Procedure steps for the second surgery
<ol>
	<li>Incision and exposure
	<ol>
		<li>A central incision of approximately 5 cm was made over the L5 spinous process. The skin, subcutaneous fascia, and deep fascial layers were sequentially incised, with electrocautery used for hemostasis.</li>
		<li>Subsequently, a dissector was used to bluntly separate the paraspinal muscles laterally, ensuring comprehensive exposure of the transverse processes, articular processes, and full visualization of the L5 and S1 levels, followed by meticulous hemostasis to provide optimal visibility for the surgical field.</li>
	</ol>
	</li>
	<li>Laminectomy and articular process resection
	<ol>
		<li>Under the guidance of a 3D microscope, using a rongeur and an osteotome, the bilateral laminae and a portion of the medial articular processes at L5/S1 were meticulously resected. 
		NOTE: This process exposed a section of the ligamentum flavum, as well as the nerve roots and the dura mater.</li>
		<li>During the surgery, the protruding nerve roots were observed. The small joints that were compressing the nerve roots and the spinal canal were resected.</li>
	</ol>
	</li>
	<li>Nerve root repositioning
	<ol>
		<li>Utilizing a nerve root dissector, the nerve roots and the dura mater were guided inward, facilitating the repositioning of the herniated nerve fibers back into the spinal cord.</li>
		<li>Subsequently, the dura mater and nerve roots were carefully relaxed and sutured with a 5-mm vascular suture. The effused cerebrospinal fluid was cleared, and the nerve roots and dura mater were skillfully repositioned.</li>
		<li>A drainage tube was placed, and the incision was then closed using a size #1 non-absorbable suture.</li>
	</ol>
	</li>
</ol>
8. Post-operative management
NOTE: The morning after the surgery, the patient experienced dizziness, headache, nausea, and vomiting. The body temperature was 35.7 &#176;C, with a severe headache.
<ol>
	<li>After consultation with a neurosurgeon, the suction pressure of the drainage tube was adjusted from negative to atmospheric pressure to observe and record the amount and characteristics of the drainage. When the drainage was less than 50 mL per day, the drainage tube was removed.</li>
	<li>The patient was supplemented with ample fluids and kept in a prone position. A pressure dressing was applied to the incision. The use of osmotic diuretics, such as mannitol, was avoided to alleviate headache and dizziness.</li>
	<li>On the afternoon of the second day, the patient&#39;s dizziness and headache were relieved, with lower limb muscle strength above grade 4, and fluid intake was increased to 2000 mL, continuing with anti-infection treatment. 
	NOTE: The aforementioned symptoms were alleviated by the third postoperative day. Postoperatively, the pain in both lower limbs was reduced, and normal urination and defecation were restored.</li>
</ol>

Case Report: Managing Cauda Equina Herniation Post-Laminectomy

<ol>
	<li>Shu, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nerve+root+entrapment+with+pseudomeningocele+after+percutaneous+endoscopic+lumbar+discectomy:+A+case+report.">Nerve root entrapment with pseudomeningocele after percutaneous endoscopic lumbar discectomy: A case report.</a> J Spinal Cord Med. 43 (4), 552-555 (2020).</li><li>Heo, D. H., Lee, D. C., Kim, H. S., Park, C. K., Chung, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+results+and+complications+of+endoscopic+lumbar+interbody+fusion+for+lumbar+degenerative+disease:+A+meta-analysis.">Clinical results and complications of endoscopic lumbar interbody fusion for lumbar degenerative disease: A meta-analysis.</a> World Neurosurg. 145, 396-404 (2021).</li><li>Yu, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+percutaneous+transforaminal+endoscopic+discectomy+and+microendoscopic+discectomy+for+the+surgical+management+of+symptomatic+lumbar+disc+herniation:+A+multicenter+retrospective+cohort+study+with+a+minimum+of+2+years'+follow-up.">Comparison of percutaneous transforaminal endoscopic discectomy and microendoscopic discectomy for the surgical management of symptomatic lumbar disc herniation: A multicenter retrospective cohort study with a minimum of 2 years' follow-up.</a> Pain Physician. 24 (1), E117-E125 (2021).</li><li>Ijiri, K., Hida, K., Yano, S., Komiya, S., Iwasaki, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Traumatic+spinal-cord+herniation+associated+with+pseudomeningocele+after+lower-thoracic+nerve-root+avulsion.">Traumatic spinal-cord herniation associated with pseudomeningocele after lower-thoracic nerve-root avulsion.</a> Spinal Cord. 47 (11), 829-831 (2009).</li><li>Rahyussalim, A. J., Djaja, Y. P., Saleh, I., Safri, A. Y., Kurniawati, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preservation+and+tissue+handling+technique+on+iatrogenic+dural+tear+with+herniated+nerve+root+at+cauda+equina+level.">Preservation and tissue handling technique on iatrogenic dural tear with herniated nerve root at cauda equina level.</a> Case Rep Orthop. 2016, 4903143 (2016).</li><li>Sairyo, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgery+related+complications+in+percutaneous+endoscopic+lumbar+discectomy+under+local+anesthesia.">Surgery related complications in percutaneous endoscopic lumbar discectomy under local anesthesia.</a> J Med Invest. 61 (3-4), 264-269 (2014).</li><li>Wei, S., Tao, W., Zhu, H., Li, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+intraoperative+imaging+with+o-arm+to+establish+a+working+trajectory+in+percutaneous+endoscopic+lumbar+discectomy.">Three-dimensional intraoperative imaging with o-arm to establish a working trajectory in percutaneous endoscopic lumbar discectomy.</a> Wideochir Inne Tech Maloinwazyjne. 10 (4), 555-560 (2016).</li><li>Massicotte, E. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Idiopathic+spinal+cord+herniation:+Report+of+eight+cases+and+review+of+the+literature.">Idiopathic spinal cord herniation: Report of eight cases and review of the literature.</a> Spine (Phila Pa 1976). 27 (9), E233-E241 (2002).</li><li>Moriyama, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postoperative+spinal+cord+herniation+with+pseudomeningocele+in+the+cervical+spine:+A+case+report.">Postoperative spinal cord herniation with pseudomeningocele in the cervical spine: A case report.</a> Spine J. 13 (10), e43-e45 (2013).</li><li>Miller, P. R., Elder, F. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meningeal+pseudocysts+(meningocele+spurius)+following+laminectomy.+Report+of+ten+cases.">Meningeal pseudocysts (meningocele spurius) following laminectomy. Report of ten cases.</a> J Bone Joint Surg Am. 50 (2), 268-276 (1968).</li><li>Wang, J., Hu, Y., Wang, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Acute+abdominal+aortic+injury+during+posterior+lumbar+fusion+surgery:+A+case+report.">Acute abdominal aortic injury during posterior lumbar fusion surgery: A case report.</a> Medicine (Baltimore). 101 (35), e30216 (2022).</li><li>Aktas, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spinal+CSF+flow+in+response+to+forced+thoracic+and+abdominal+respiration.">Spinal CSF flow in response to forced thoracic and abdominal respiration.</a> Fluids Barriers CNS. 16 (1), 10 (2019).</li><li>Lloyd, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Respiratory+cerebrospinal+fluid+flow+is+driven+by+the+thoracic+and+lumbar+spinal+pressures.">Respiratory cerebrospinal fluid flow is driven by the thoracic and lumbar spinal pressures.</a> J Physiol. 598 (24), 5789-5805 (2020).</li><li>Nakashima, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postoperative+iatrogenic+spinal+cord+herniation:+Three+case+reports+with+a+literature+review.">Postoperative iatrogenic spinal cord herniation: Three case reports with a literature review.</a> Nagoya J Med Sci. 82 (2), 383-389 (2020).</li><li>Suning, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+case+report+of+nerve+root+hernia+after+lumbar+disc+surgery.">A case report of nerve root hernia after lumbar disc surgery.</a> Chinese Journal of Spine and Spinal Cord. 10 (6), 347 (2000).</li><li>Wang, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+case+report+of+nerve+root+hernia+after+arthroscopic+repair+and+suture+of+lumbar+fusion.">A case report of nerve root hernia after arthroscopic repair and suture of lumbar fusion.</a> Journal of Practical Orthopaedics. 28, 4 (2022).</li><li>Vall&#232;s, M., Albu, S., Kumru, H., Mearin, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Botulinum+toxin+type-a+infiltration+of+the+external+anal+sphincter+to+treat+outlet+constipation+in+motor+incomplete+spinal+cord+injury:+Pilot+cohort+study.">Botulinum toxin type-a infiltration of the external anal sphincter to treat outlet constipation in motor incomplete spinal cord injury: Pilot cohort study.</a> Scand J Gastroenterol. 56 (7), 777-783 (2021).</li><li>Wang, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+repeat+percutaneous+endoscopic+lumbar+decompression+for+reoperation+of+lumbar+spinal+stenosis:+A+retrospective+study.">Efficacy of repeat percutaneous endoscopic lumbar decompression for reoperation of lumbar spinal stenosis: A retrospective study.</a> J Pain Res. 16, 177-186 (2023).</li><li>Feng, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+full+endoscopic+lumbar+discectomy+for+symptomatic+adjacent+segment+disease+after+lumbar+fusion+in+elderly+patients.">Percutaneous full endoscopic lumbar discectomy for symptomatic adjacent segment disease after lumbar fusion in elderly patients.</a> Orthop Surg. 15 (7), 1749-1755 (2023).</li><li>Xie, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+to+be+a+spinal+endoscopic+surgeon:+What+matters.">Training to be a spinal endoscopic surgeon: What matters.</a> Front Surg. 10, 1116376 (2023).</li><li>Siller, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+high-definition+3d+exoscope+as+an+alternative+to+the+operating+microscope+in+spinal+microsurgery.">A high-definition 3d exoscope as an alternative to the operating microscope in spinal microsurgery.</a> J Neurosurg Spine. 33 (5), 705-714 (2020).</li><li>Joh, J. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+study+of+neck+pain+in+relation+to+increase+of+cervical+epidural+pressure+during+percutaneous+endoscopic+lumbar+discectomy.">Comparative study of neck pain in relation to increase of cervical epidural pressure during percutaneous endoscopic lumbar discectomy.</a> Spine (Phila Pa 1976). 34 (19), 2033-2038 (2009).</li><li>Xie, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postoperative+intracranial+hemorrhage+after+an+endoscopic+l5-s1+laminectomy+and+discectomy:+A+case+report+and+literature+review.">Postoperative intracranial hemorrhage after an endoscopic l5-s1 laminectomy and discectomy: A case report and literature review.</a> J Pers Med. 13 (2), 196 (2023).</li><li>Kim, H. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidental+durotomy+during+endoscopic+stenosis+lumbar+decompression:+Incidence,+classification,+and+proposed+management+strategies.">Incidental durotomy during endoscopic stenosis lumbar decompression: Incidence, classification, and proposed management strategies.</a> World Neurosurg. 139, e13-e22 (2020).</li><li>Park, H. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dural+tears+in+percutaneous+biportal+endoscopic+spine+surgery:+Anatomical+location+and+management.">Dural tears in percutaneous biportal endoscopic spine surgery: Anatomical location and management.</a> World Neurosurg. 136, e578-e585 (2020).</li><li>Prasse, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Economic+implications+of+dural+tears+in+lumbar+microdiscectomies:+A+retrospective,+observational+study.">Economic implications of dural tears in lumbar microdiscectomies: A retrospective, observational study.</a> World Neurosurg. 188, e18-e24 (2024).</li><li>Kothbauer, K. F., Seiler, R. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transdural+cauda+equina+incarceration+after+microsurgical+lumbar+discectomy:+Case+report.">Transdural cauda equina incarceration after microsurgical lumbar discectomy: Case report.</a> Neurosurgery. 47 (6), 1449-1451 (2000).</li></ol>

The authors have nothing to disclose.

There are few reports documenting nerve root compression resulting from dural sac herniation1. Herniation of the spine can be categorized as spontaneous, iatrogenic, or traumatic8. In this case, the patient&#39;s condition was primarily attributed to dural injury and compromised arachnoid integrity. Long-term constipation experienced by the patient resulted from increased abdominal pressure, cerebrospinal fluid flow, arachnoid herniation, and compression of nerve roots, ult...

Iatrogenic nerve root herniation is a rare complication of lumbar endoscopic surgery and may occur due to intraoperative dural tear and cerebrospinal fluid leakage1,2,3. There are few reports on the symptoms of iatrogenic nerve root herniation, which are mainly attributed to spinal cord or nerve root compression4,5. Percutaneous endoscopic is a safe and effective minimally invasive spinal surgery6. However, due to the requirement for continuous irrigation with a water medium, identifying cerebrospinal fluid leakage and dural tear during the operation is more challenging compared to traditional open surgery conducted in air medium7. This manuscript presents a case report of a patient who developed lumbar and leg pain, along with urinary dysfunction, as a result of nerve root herniation following percutaneous endoscopic lumbar decompression surgery. The symptoms were effectively alleviated through dural sac repair conducted under 3D microscopic guidance, emphasizing the precision and effectiveness of this minimally invasive surgical approach.
CASE PRESENTATION: 
Initial surgery: A 36-year-old female presented with right L5-S1 radiculopathy (Figure 1) and underwent endoscopic lumbar decompression. An attempt at osteotomy with a ring saw led to a dural tear and CSF leakage. An experienced surgeon intervened, raising the irrigation solution to enhance visibility and employing a gelatin sponge to address the tear. Postoperatively, the patient continued to experience lower limb pain and difficulties with urination and defecation. An MRI confirmed CSF leakage and damage to the L5 endplate (Figure 2). The patient was managed with ibuprofen for anti-inflammatory and analgesic effects and cefoperazone-sulbactam for infection prophylaxis. She was also instructed in pelvic floor muscle and anal sphincter exercises.
Second Surgery: The patient was readmitted with pain in both lower limbs 5 months post-initial surgery. Radiography and magnetic resonance imaging (MRI) revealed an L5/S1 cauda equina herniation (Figure 3). A 3D microscopy-assisted total laminectomy and dural sac repair were performed, which included incision and exposure, lamina and facet joint removal, nerve root repositioning, and closure. Postoperatively, the patient experienced symptoms of dizziness, headache, and nausea, which were managed by adjusting the suction of the drainage tube and administering fluid resuscitation. By the third postoperative day, the patient&#39;s symptoms had resolved, and she showed significant improvement in bilateral lower limb pain, with the return of normal urination and bowel movements.
Diagnosis, assessment, and plan: 
The patient initially presented with right L5-S1 radiculopathy, confirmed by medical imaging and physical examination. The first surgery led to a dural tear and CSF leakage, causing persistent lower limb radiation pain and incontinence. A follow-up MRI confirmed cerebrospinal fluid leakage and L5 endplate injury, diagnosing the patient with cauda equina herniation at the L5/S1 level. The first surgery&#39;s complications necessitated further intervention. Imaging revealed cauda equina herniation at L5/S1, resulting in bilateral lower limb pain. Postoperative symptoms included dizziness, headache, nausea, and vomiting, requiring neurosurgical consultation and management. The second operation involved a total laminectomy and dural sac repair using 3D microscopy. The procedure included incision and exposure, lamina and facet joint removal, nerve root repositioning, and closure. Postoperative care involved drainage for headache and dizziness, dexamethasone treatment, increased fluid intake, anti-infective measures, and drainage clip retention. The patient experienced pain relief in both lower limbs, and normal urination and defecation were restored.

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	<tbody>
		<tr>
			<td>Kestrel View II</td>
			<td>Mitaka Kohki Co., Ltd.</td>
			<td>000 46</td>
			<td>3D Microscope</td>
		</tr>
		<tr>
			<td>Mersilk&#160;</td>
			<td>Ethicon</td>
			<td>SA87G</td>
			<td>Suture</td>
		</tr>
	</tbody>
</table>

spinal hernia repair and cauda equina repositioning after lumbar decompression under three-dimensional microscopy: a case report and literature review

Cauda equina herniation (CEH) is a relatively rare and severe perioperative complication that may occur after lumbar spine surgery. Here, we present a case report of a 36-year-old female patient who experienced CEH after an endoscopic L5-S1 laminectomy and discectomy. The patient presented with right L5-S1 radiculopathy that correlated with findings in medical imaging and physical examination. Subsequently, she underwent endoscopic L5-S1 laminotomy and discectomy. A day after the operation, the patient developed urine leakage, hematochezia, aggravated constipation, and found no relief from pain in the right lower limb. MRI revealed cerebrospinal fluid leakage at the surgical site. After consultation with the urology and anorectal department, the patient was fitted with a urinary catheter, prescribed hemorrhoid medication, and underwent anal sphincter training as recommended by the doctor. After 1 week of treatment, the patient&#39;s urinary function returned to normal, but constipation persisted while the pain in the right lower limb eased. After 5 months, the patient was hospitalized due to radiating pain in both lower limbs and constipation. An MRI revealed herniation of the L5/S1 nerve root sac. Subsequently, L5/S1 total laminectomy decompression and dural sac repair were performed under a three-dimensional (3D) microscopy. Postoperatively, lower limb pain and constipation were alleviated. CEH following spinal endoscopy, though rare, demands significant clinical attention. The successful outcome in this case illustrates the value of surgical revision under 3D microscopic guidance, offering a viable strategy for patients presenting with this complication.

Exoscopic repair of a dural hernia is a safe and effective treatment method. The surgery demonstrated that the use of 3D microscopy for dural hernia repair can improve the patient&#39;s quality of life. Figure 4 illustrates that 3D microscopy, with its microscopic assistance, provides a clear field of view and optimal lighting, ensuring the comfort of the surgeon. Its most notable feature is its ability to facilitate magnified dural repair, making it an invaluable tool in such surgical proce...

Spinal Hernia Repair and Cauda Equina Repositioning After Lumbar Decompression under Three-Dimensional Microscopy: A Case Report and Literature Review

Dural hernia following spinal endoscopic surgery is a rare complication. Here, we report a case of nerve root hernia associated with the absence of dural repair, prolonged operation time, and increased abdominal pressure due to postoperative constipation. Early dural tear repair and monitoring postoperative constipation can help prevent cauda equina herniation.

Cauda equina herniation (CEH) is a relatively rare and severe perioperative complication that may occur after lumbar spine surgery. Here, we present a ...

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194 Views.  Guangxi University of Chinese Medicine. Dural hernia following spinal endoscopic surgery is a rare complication. Here, we report a case of nerve root hernia associated with the absence of dural repair, prolonged operation time, and increased abdominal pressure due to postoperative constipation. Early dural tear repair and monitoring postoperative constipation can help prevent cauda equina herniation.

Video: Spinal Hernia Repair and Cauda Equina Repositioning After Lumbar Decompression under Three-Dimensional Microscopy: A Case Report and Literature Review

Acute and Chronic Tactile Sensory Testing after Spinal Cord Injury in Rats

Spinal cord injury (SCI) impairs sensory systems causing allodynia1-8. To identify cellular and molecular causes of allodynia, sensitive and valid sensory testing in rat SCI models is needed. However, until recently, no single testing approach had been validated for SCI so that standardized methods have not been implemented across labs. Additionally, available testing methods could not be implemented acutely or when severe motor impairments existed, preventing studies of the development of SCI-induced allodynia3. Here we present two validated sensory testing methods using von Frey Hair (VFH) monofilaments which quantify changes in tactile sensory thresholds after SCI4-5. One test is the well-established Up-Down test which demonstrates high sensitivity and specificity across different SCI severities when tested chronically5. The other test is a newly-developed dorsal VFH test that can be applied acutely after SCI when allodynia develops, prior to motor recovery4-5. Each VFH monofilament applies a calibrated force when touched to the skin of the hind paw until it bends. In the up-down method, alternating VFHs of higher or lower forces are used on the plantar L5 dermatome to delineate flexor withdrawal thresholds. Successively higher forces are applied until withdrawal occurs then lower force VFHs are used until withdrawal ceases. The tactile threshold reflects the force required to elicit withdrawal in 50% of the stimuli. For the new test, each VFH is applied to the dorsal L5 dermatome of the paw while the rat is supported by the examiner. The VFH stimulation occurs in ascending order of force until at least 2 of 3 applications at a given force produces paw withdrawal. Tactile sensory threshold is the lowest force to elicit withdrawal 66% of the time. Acclimation, testing and scoring procedures are described. Aberrant trials that require a retest and typical trials are defined. Animal use was approved by Ohio State University Animal Care and Use Committee.

We describe two tactile sensory testing methods for acute or chronic periods of spinal cord injury in rats. These validated procedures can detect the development and maintenance of allodynia-like sensations.

Spinal cord injury (SCI) impairs sensory systems causing allodynia1-8. To identify cellular and molecular causes of allodynia, sensitive and valid sensory ...

A Contusive Model of Unilateral Cervical Spinal Cord Injury Using the Infinite Horizon Impactor

While the majority of human spinal cord injuries occur in the cervical spinal cord, the vast majority of laboratory research employs animal models of spinal cord injury (SCI) in which the thoracic spinal cord is injured. Additionally, because most human cord injuries occur as the result of blunt, non-penetrating trauma (e.g. motor vehicle accident, sporting injury) where the spinal cord is violently struck by displaced bone or soft tissues, the majority of SCI researchers are of the opinion that the most clinically relevant injury models are those in which the spinal cord is rapidly contused.1 Therefore, an important step in the preclinical evaluation of novel treatments on their way to human translation is an assessment of their efficacy in a model of contusion SCI within the cervical spinal cord. Here, we describe the technical aspects and resultant anatomical and behavioral outcomes of an unilateral contusive model of cervical SCI that employs the Infinite Horizon spinal cord injury impactor.
Sprague Dawley rats underwent a left-sided unilateral laminectomy at C5. To optimize the reproducibility of the biomechanical, functional, and histological outcomes of the injury model, we contused the spinal cords using an impact force of 150 kdyn, an impact trajectory of 22.5&deg; (animals rotated at 22.5&deg;), and an impact location off of midline of 1.4 mm. Functional recovery was assessed using the cylinder rearing test, horizontal ladder test, grooming test and modified Montoya's staircase test for up to 6 weeks, after which the spinal cords were evaluated histologically for white and grey matter sparing.
The injury model presented here imparts consistent and reproducible biomechanical forces to the spinal cord, an important feature of any experimental SCI model. This results in discrete histological damage to the lateral half of the spinal cord which is largely contained to the ipsilateral side of injury. The injury is well tolerated by the animals, but does result in functional deficits of the forelimb that are significant and sustained in the weeks following injury. The cervical unilateral injury model presented here may be a resource to researchers who wish to evaluate potentially promising therapies prior to human translation.

A reliable and repeatable way to produce a cervical unilateral spinal cord injury using the Infinite Horizon impactor is described. The method takes advantage of a custom designed frame and clamp to stabilize the spine. The standardized procedure and biomechanical injury parameters result in sufficient and sustained injuries.

While the majority of human spinal cord injuries occur in the cervical spinal cord, the vast majority of laboratory research employs animal models of ...

Quantification of Breast Cancer Cell Invasiveness Using a Three-dimensional (3D) Model

It is now well known that the cellular and tissue microenvironment are critical regulators influencing tumor initiation and progression. Moreover, the extracellular matrix (ECM) has been demonstrated to be a critical regulator of cell behavior in culture and homeostasis in vivo. The current approach of culturing cells on two-dimensional (2D), plastic surfaces results in the disturbance and loss of complex interactions between cells and their microenvironment. Through the use of three-dimensional (3D) culture assays, the conditions for cell-microenvironment interaction are established resembling the in vivo microenvironment. This article provides a detailed methodology to grow breast cancer cells in a 3D basement membrane protein matrix, exemplifying the potential of 3D culture in the assessment of cell invasion into the surrounding environment. In addition, we discuss how these 3D assays have the potential to examine the loss of signaling molecules that regulate epithelial morphology by immunostaining procedures. These studies aid to identify important mechanistic details into the processes regulating invasion, required for the spread of breast cancer.

Quantification of Breast Cancer Cell Invasiveness Using a Three-dimensional 3D Model

This article provides detailed methodologies for the use of three-dimensional (3D) assays to quantify breast cancer cell invasion. Specifically, we discuss the procedures required to set up such assays, quantification, and data analysis, as well as methods to examine the loss of membrane integrity that occurs when cells invade.

It is now well known that the cellular and tissue microenvironment are critical regulators influencing tumor initiation and progression. Moreover, the ...

Three-Dimensional (3D) Tumor Spheroid Invasion Assay

Invasion of surrounding normal tissues is generally considered to be a key hallmark of malignant (as opposed to benign) tumors. For some cancers in particular (e.g., brain tumors such as glioblastoma multiforme and squamous cell carcinoma of the head and neck &#8211; SCCHN) it is a cause of severe morbidity and can be life-threatening even in the absence of distant metastases. In addition, cancers which have relapsed following treatment unfortunately often present with a more aggressive phenotype. Therefore, there is an opportunity to target the process of invasion to provide novel therapies that could be complementary to standard anti-proliferative agents. Until now, this strategy has been hampered by the lack of robust, reproducible assays suitable for a detailed analysis of invasion and for drug screening. Here we provide a simple micro-plate method (based on uniform, self-assembling 3D tumor spheroids) which has great potential for such studies. We exemplify the assay platform using a human glioblastoma cell line and also an SCCHN model where the development of resistance against targeted epidermal growth factor receptor (EGFR) inhibitors is associated with enhanced matrix-invasive potential. We also provide two alternative methods of semi-automated quantification: one using an imaging cytometer and a second which simply requires standard microscopy and image capture with digital image analysis.

Three-Dimensional 3D Tumor Spheroid Invasion Assay

Invasion of surrounding normal tissues is a defining characteristic of malignant tumors. We provide here a simple, semi-automated micro-plate assay of invasion into a natural 3D biomatrix that has been exemplified with a number of models of advanced human cancers.

Invasion of surrounding normal tissues is generally considered to be a key hallmark of malignant (as opposed to benign) tumors. For some cancers in ...

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

The Use of Mixed Reality in Custom-Made Revision Hip Arthroplasty: A First Case Report

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed reality were used to perform complex revision hip arthroplasty in January 2019. The use of mixed reality allowed for a very good visualization of the structures and resulted in precise implant fixation. According to the authors' knowledge, this is the first described case report of the combined use of these two innovations. The diagnosis preceding the qualification for the procedure was the loosening of the left hip's acetabular component. Mixed reality headset and holograms prepared by engineers were used during the surgery. The operation was successful, and it was followed by early verticalization and patient rehabilitation. The team sees opportunities for technology development in joint arthroplasty, trauma, and orthopedic oncology.

A complex revision hip arthroplasty was performed using a custom-made implant and mixed reality technology. According to the authors&#39; knowledge, this is the first report of such procedure described in the literature.

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for minimally invasive anterior lumbar interbody fusion (Mini-ALIF). This article is a technical description of anterior lumbar spine surgery under a microscope. We retrospectively collected information on patients who underwent microscope-assisted Mini-ALIF surgery at our hospital between July 2020 and August 2022. A repeated-measures ANOVA was used to compare imaging indicators between periods. Forty-two patients were included in the study. The mean volume of intraoperative bleeding was 180 mL, and the mean operative time was 143 min. The mean follow-up time was 18 months. Apart from one case of peritoneal rupture, no other serious complications occurred. The postoperative foramen and disc height were both higher on average than before surgery. The spreader-assisted micro-Mini-ALIF is simple and easy to use. It can provide good intraoperative disc exposure, good discrimination of important structures, adequate spreading of the intervertebral space, and the restoration of the necessary intervertebral height, which is very helpful for less experienced surgeons.

The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

Novel PLL-AF Suture Technique for Annulus Fibrosus Repair in Lumbar Endoscopy

A Suture Technique for Ruptured Annulus Fibrosus Following Decompression Under Percutaneous Transforaminal Endoscopic Discectomy

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full decompression has been shown to decrease the recurrence rate of lumbar disc herniation during endoscopic surgery. Traditional suture operations under endoscopy involve only simple suturing of the ruptured AF. Due to the weak and poor quality of the AF tissue around the tear portal, using this area as needle insertion points during suturing may lead to insufficient tension and a low success rate of AF closure. Currently, there is no detailed technical illustration based on video for AF tear suturing under lumbar full-endoscopy. We innovatively propose a method of covering and suturing the AF tear by pulling up the posterior longitudinal ligament (PLL) under lumbar endoscopy and using three stitches (PLL-AF suture technique). The patient who received the novel suture technique achieved satisfactory results. Six months after the operation, lumbar MRI showed no evidence of recurrence in the outpatient clinic.

Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy

This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy.

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full ...