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George M. Ghobrial, Sara Beygi, Matthew J. Viereck, Joshua E. Heller, Ashwini Sharan, Jack Jallo, James S. Harrop, and Srinivas Prasad

Syringomyelia is a potentially debilitating disease that involves abnormal CSF flow mechanics; its incidence after traumatic spinal cord injury (SCI) is approximately 15%. Treatment consists of restoration of CSF flow, typically via arachnoidolysis and syrinx decompression. The authors present a case of pronounced syringomyelia in a patient with concomitant severe cervical myelomalacia to demonstrate unilateral C-5 palsy as a potential complication of aggressive syrinx decompression at a remote level.

A 56-year-old man with a remote history of SCI at T-11 (ASIA [American Spinal Injury Association] Grade A) presented with complaints of ascending motor and sensory weakness into the bilateral upper extremities that had progressed over 1 year. MRI demonstrated severe distortion of the spinal cord at the prior injury level of T10–11, where an old anterior column injury and prior hook-rod construct was visualized. Of note, the patient had a holocord syrinx with demonstrable myelomalacia. To restore CSF flow and decompress the spinal cord, T-2 and T-3 laminectomies, followed by arachnoidolysis and syringopleural shunt placement, were performed. Postoperatively on Day 1, with the exception of a unilateral deltoid palsy, the patient had immediate improvement in upper-extremity strength and myelopathy. He was discharged from the hospital on postoperative Day 5; however, at his 2-week follow-up visit, a persistent unilateral deltoid palsy was noted. MRI demonstrated a significant reduction in the holocord syrinx, no neural foraminal stenosis, and a significant positional shift of the ventral spinal cord. Further motor recovery was noted at the 8-month follow-up.

Syringomyelia is a debilitating disease arising most often as a result of traumatic SCI. In the setting of myelomalacia with a pronounced syrinx, C-5 palsy is a potential complication of syrinx decompression.

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Shannon Hann, Nohra Chalouhi, Ravichandra Madineni, Alexander R. Vaccaro, Todd J. Albert, James Harrop, and Joshua E. Heller

Adult degenerative cervical kyphosis is a debilitating disease that often requires complex surgical management. Young spine surgeons, residents, and fellows are often confused as to which surgical approach to choose due to lack of experience, absence of a systematic method of surgical management, and today's plethora of information regarding surgical techniques. Although surgeons may be able to perform anterior, posterior, or combined (360°) approaches to the cervical spine, many struggle to rationally choose an appropriate approach for deformity correction. The authors introduce an algorithm based on morphology and pathology of adult cervical kyphosis to help the surgeon select the appropriate approach when performing cervical deformity surgery. Cervical deformities are categorized into 5 different prevalent morphological types encountered in clinical settings. A surgical approach tailored to each category/type of deformity is then discussed, with a concrete case illustration provided for each. Preoperative assessment of kyphosis, determination of the goal for surgery, and the complications associated with cervical deformity correction are also summarized. This article's goal is to assist with understanding the big picture for surgical management in cervical spinal deformity.

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Eli M. Baron, Howard B. Levene, Joshua E. Heller, Jack I. Jallo, Christopher M. Loftus, and Devanand A. Dominique

Neuroendoscopy has grown rapidly in the last 20 years as a therapeutic modality for treating a variety of spinal disorders. Spinal endoscopy has been widely used to treat patients with cervical, thoracic, and lumbosacral disorders safely and effectively. Although it is most commonly used with minimally invasive lumbar spine surgery, endoscopy has gained widespread acceptance for the treatment of thoracic disc herniations and for anterior release and rod implantation in the correction of thoracic spinal deformity. The authors review the use of endoscopy in spine surgery and in the treatment of spinal disorders as well as in the treatment of intrathoracic nonspinal lesions. Endoscopy has some significant advantages over open or other minimally invasive techniques in that it can allow for better visualization of the lesion, smaller incision sizes with reduced morbidity and mortality, reduced hospital stays, and ultimately lower cost. In addition, spinal endoscopy allows observers and operating room staff to be more involved in each case and fosters education. Spinal endoscopy, like any novel modality, carries with it additional risks and the surgeon must always be prepared to convert to an open procedure. The learning curve for spinal endoscopy is steep and the procedure should not be attempted alone by a novice surgeon. Nevertheless, with training and experience, the spine surgeon can achieve better outcomes, reduced morbidity, and better cosmesis with spinal endoscopy, and the operating times are comparable to open procedures. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve further roles as a mainstay in spine surgery.

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Woojin Cho, Jonathan R. Mason, Justin S. Smith, Adam L. Shimer, Adam S. Wilson, Christopher I. Shaffrey, Francis H. Shen, Wendy M. Novicoff, Kai-Ming G. Fu, Joshua E. Heller, and Vincent Arlet


Lumbopelvic fixation provides biomechanical support to the base of the long constructs used for adult spinal deformity. However, the failure rate of the lumbopelvic fixation and its risk factors are not well known. The authors' objective was to report the failure rate and risk factors for lumbopelvic fixation in long instrumented spinal fusion constructs performed for adult spinal deformity.


This retrospective review included 190 patients with adult spinal deformity who had long construct instrumentation (> 6 levels) with iliac screws. Patients' clinical and radiographic data were analyzed. The patients were divided into 2 groups: a failure group and a nonfailure group. A minimum 2-year follow-up was required for inclusion in the nonfailure group. In the failure group, all patients were included in the study regardless of whether the failure occurred before or after 2 years. In both groups, the patients who needed a revision for causes other than lumbopelvic fixation (for example, proximal junctional kyphosis) were also excluded. Failures were defined as major and minor. Major failures included rod breakage between L-4 and S-1, failure of S-1 screws (breakage, halo formation, or pullout), and prominent iliac screws requiring removal. Minor failures included rod breakage between S-1 and iliac screws and failure of iliac screws. Minor failures did not require revision surgery. Multiple clinical and radiographic values were compared between major failures and nonfailures.


Of 190 patients, 67 patients met inclusion criteria and were enrolled in the study. The overall failure rate was 34.3%; 8 patients had major failure (11.9%) and 15 had minor failure (22.4%). Major failure occurred at a statistically significant greater rate in patients who had undergone previous lumbar surgery, had greater pelvic incidence, and had poor restoration of lumbar lordosis and/or sagittal balance (that is, undercorrection). Patients with a greater number of comorbidities and preoperative coronal imbalance showed trends toward an increase in major failures, although these trends did not reach statistical significance. Age, sex, body mass index, smoking history, number of fusion segments, fusion grade, and several other radiographic values were not shown to be associated with an increased risk of major failure. Seventy percent of patients in the major failure group had anterior column support (anterior lumbar interbody fusion or transforaminal lumbar interbody fusion) while 80% of the nonfailure group had anterior column support.


The incidence of overall failure was 34.3%, and the incidence of clinically significant major failure of lumbopelvic fixation after long construct fusion for adult spinal deformity was 11.9%. Risk factors for major failures are a large pelvic incidence, revision surgery, and failure to restore lumbar lordosis and sagittal balance. Surgeons treating adult spinal deformity who use lumbopelvic fixation should pay special attention to restoring optimal sagittal alignment to prevent lumbopelvic fixation failure.