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Michael J. Strong, Julianne Santarosa, Timothy P. Sullivan, Noojan Kazemi, Jacob R. Joseph, Osama N. Kashlan, Mark E. Oppenlander, Nicholas J. Szerlip, Paul Park, and Clay M. Elswick

, temperature probe, fluoroscopy, MRI and ultrasound), and skin marking ( Table 1 ). TABLE 1. Thoracic spine localization techniques Localization Technique Advantages Disadvantages Fiducial metallic marker (screw or gold) placement Outpatient procedure, used as reference intraoperatively, easily removed Cost of procedure, radiation exposure Metallic coil placement Outpatient procedure, used as reference intraoperatively Cost of procedure, risk for coil migration Marking wire placement Outpatient procedure, used as

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Richard M. Young, Vikram Prasad, Joshua J. Wind, Wayne Olan, and Anthony J. Caputy

Accurately localizing a spine level in the thoracic spine is often not easily achieved with the existing imaging modalities available in the operating room. The coordination of the preoperative imaging pathology with intraoperative imaging is even more difficult in patients with challenging anatomy. Using standard percutaneous techniques, the authors placed a radiopaque embolization coil into the pedicle of interest under biplanar fluoroscopy in 1 patient. Thoracic spine MRI along with scout MRI was then performed to confirm coil marker placement in relation to the actual spine pathology prior to surgical intervention. No complications were observed during placement of the radiopaque marker. Intraoperatively, the marker was immediately and easily visualized, leading to a confident identification of the correct thoracic spinal level. The preoperative placement of a radiopaque marker into the vertebral pedicle of the identified pathological level combined with postplacement MRI verification provides an advantage over previously proposed techniques in the literature.

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Wesley Hsu, Ryan M. Kretzer, Michael J. Dorsi, and Ziya L. Gokaslan

. Localization of the T-10 VB on serial radiographs. Left: Initial radiograph clearly visualizing the sacrum, demonstrating that a spinal needle is directed at the L-3 pedicle. Right: A second radiograph visualizing the same spinal needle seen in the first study, as well as a clamp affixed to the T-10 lamina. When using radiographs or fluoroscopy for midthoracic to low thoracic spine localization, it is often easier to count up from the sacrum to the level of interest instead of caudally from the occiput. The surgeon must keep in mind that the level of the lesion may

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Leonardo Rangel-Castilla, Steven W. Hwang, William E. Whitehead, Daniel J. Curry, Thomas G. Luerssen, and Andrew Jea

surgery may be necessary to decompress the spinal cord or reduce or prevent kyphotic deformity in children. Approximately 3% of children with spinal TB develop severe kyphosis (> 60°). 24 Risk factors for the development of severe kyphotic deformity are as follows: age < 10 years; involvement of ≥ 3 VBs; and thoracic spine localization. Severe kyphosis is cosmetically unacceptable and results in spinal cord compression over the apex of the deformity and cardiopulmonary dysfunction from restrictive lung disease. Any surgical approach must take into account the

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Richard B. Raynor

maintained. Dislocation has recurred during the procedure. The patient was returned to the supine position and traction increased to again effect reduction. Discussion The neurological examination and routine x-rays of the cervical spine localize the level of the lesion within one or two segments. Discography can then be done for more precise localization by studying the appropriate levels. Although myelography allows complete visualization of the spine, the manipulation required may be hazardous. 1 In all instances, the highest interspace corresponding to the

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Timothy W. Vogel, Brian J. Dlouhy, and Matthew A. Howard III

's head elevated 30° above horizontal plain. Right: Scan illustrating improvement of midline shift after patient remained in supine position. Magnetic resonance imaging of the spine was preformed to evaluate the patient's recurrent neurological decline, but did not reveal a CSF leak. Given the concern for the patient's persistent neurological fluctuations, a fluoroscopically guided intrathecal injection was performed with a 99m Tc radiopharmaceutical. Single-photon emission CT of the lumbar and thoracic spine localized an abnormal focus of CSF leakage to the right

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Aingaya J. Kaale, Nicephorus Rutabasibwa, Laurent Lemeri Mchome, Kevin O. Lillehei, Justin M. Honce, Joseph Kahamba, and D. Ryan Ormond

of these systems, however, continue to have limitations. In the spine, localization is mainly driven by CT and does not demonstrate soft tissue well. In the brain, images are affected by brain shift: parenchymal deformation occurring due to swelling, gravity, CSF egress, surgical manipulation, etc. 7 , 19 , 32 This makes the image localization less accurate over time. Additional options have been developed to overcome these challenges. Intraoperative MRI and CT, for example, have been introduced to allow an update of information intraoperatively, but come with

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Qi Jia, Xin Gao, Zhenhua Zhou, Bin Lan, Jian Zhao, Tielong Liu, Xinghai Yang, Haifeng Wei, and Jianru Xiao

segments of the spine. Localized pain in the spine was the most common complaint with a mean duration of 11.3 months (0.5–24 months). Varying degrees of cord compression including paraparesis or paraplegia were seen in 5 patients, and the mean time before admission to our center was 7.3 days. Cervical movement restriction and spinal instability were found in the patient in case 3. Laboratory values were remarkably abnormal, especially for serum PTH and AKP, with mean values of 1072.2 pg/ml and 549 U/L, respectively. TABLE 1. Summary of demographic and clinical details of

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Adetunji A. Oremakinde and Mark Bernstein

procedure (for example, aspirator inadvertently bruised brain)  contamination e.g., instrument required re-sterilization  equipment failure or missing e.g., instrument required re-sterilization  delay e.g., long wait for a spine-localizing radiograph  nursing e.g., nurse failed to properly set up piece of equipment  anesthesia e.g., anesthetist prematurely extubated patient requiring urgent re-intubation  management/judgment e.g., patient arrived in operating room w/ an abnormal blood result missed by the team  communication

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Brian F. Saway, Mohammed Alshareef, Orgest Lajthia, Coby Cunningham, Chelsea Shope, Jaime L. Martinez, and Stephen P. Kalhorn

radiculopathy from non-steroidal anti-inflammatory drug-induced dorsal epidural haematoma . BMJ Case Rep . 2019 ; 12 ( 3 ): e229015 . 24 Anaizi AN , Kalhorn C , McCullough M , Voyadzis JM , Sandhu FA . Thoracic spine localization using preoperative placement of fiducial markers and subsequent CT. A technical report . J Neurol Surg A Cent Eur Neurosurg . 2015 ; 76 ( 1 ): 66 – 71 . 25 Santos JLM , Kalhorn SP . Anatomy of the posterolateral spinal epidural ligaments . Surg Neurol Int . 2021 ; 12 : 33 . 26 Lowe SR , Alshareef MA , Kellogg