L5 nerve root injury caused by anterolateral malpositioning of loosened S1 pedicle screws: illustrative cases

BACKGROUND: Although malpositioning of pedicle screws into the spinal canal and intervertebral foramen can cause spinal nerve root injuries, there are few reports of L5 nerve root injuries when S1 pedicle screws have been inserted anterolaterally. The authors report two cases of L5 nerve root injury caused by anterolateral malpositioning of loosened S1 pedicle screws. OBSERVATIONS: In both patients, S1 pedicle screws were inserted toward the outside of the S1 anterior foramen, and the tip of the screws perforated the anterior sacral cortex. L5 nerve root impairment was not observed immediately after surgery. However, severe leg pain in the L5 area was observed after the S1 pedicle screws became loosened. In case 1, the symptoms could not be controlled with conservative treatment. Reoperation was performed 3 months after the initial surgery. In case 2, the symptoms gradually improved with conservative treatment because the area around the loosened S1 screw was surrounded by newly formed bone that stabilized the screws, as observed with computed tomography 1 year after surgery. LESSONS: Surgeons should recognize that anterolateral malpositioning of S1 pedicle screws can cause L5 nerve root injury. The screws should be inserted in the correct direction without loosening.