Authors:James Feghali, Yuxi Chen, Yangyiran Xie, Christopher Chen and Judy Huang
In this study, the authors identified a link between depression and worse clinical outcomes after surgery in adult Chiari malformation type 1 (CM-1) patients. This novel finding emphasizes the importance of optimizing the management of depression preoperatively and ensuring appropriate follow-up for psychiatric illness in the postoperative period to achieve the best possible surgical outcome in CM-1 patients. It also highlights the importance of crosstalk between neurosurgeons and psychiatrists in the treatment of CM-1 patients with severe clinical depression.
Authors:Yue-Qi Du, Yi-Heng Yin, Guang-Yu Qiao and Xin-Guang Yu
The authors introduced a novel "in-out-in" technique for posterior C2 screw fixation, the C2 medial pedicle screw. This technique can provide 3-column rigid fixation with satisfactory stability and can be considered to be an efficient alternative when using a C2 pedicle screw is not possible in patients with anatomical constraints.
Authors:Darryl Lau, Vedat Deviren, Rushikesh S. Joshi and Christopher P. Ames
This study compares the effectiveness and complication profiles of two surgical techniques (Smith-Petersen osteotomy and 3-column osteotomy) to correct severe cervical deformities. This study is important because it will help surgeons decide which technique would be most appropriate for their patients.
Authors:Dong-Ho Lee, Choon Sung Lee, Chang Ju Hwang, Jae Hwan Cho, Jae-Woo Park and Kun-Bo Park
The authors aimed to evaluate the improvement in cervical lordosis and sagittal alignment after vertebral body sliding osteotomy (VBSO). VBSO markedly improves segmental cervical lordosis through multiple cervical anterior discectomies and fusions above and below the VBSO level, and a preserved vertebral body may provide more structural support.
Authors:Toru Doi, Ryuji Sakamoto, Chiaki Horii, Naoki Okamoto, Koji Nakajima, Shima Hirai, Fumihiko Oguchi, So Kato, Yuki Taniguchi, Yoshitaka Matsubayashi, Naoto Hayashi, Sakae Tanaka and Yasushi Oshima
The authors clarified the incidence and risk factors for progression of ossification of the posterior longitudinal ligament (OPLL) in asymptomatic subjects. This is the first observational study of OPLL progression in asymptomatic subjects based on long-term CT follow-up data.
Authors:Ki Young Lee, Jung-Hee Lee, Kyung-Chung Kang, Sung Joon Shin, Won Ju Shin, Sang-Kyu Im and Joon Hong Park
The use of iliac screws, in addition to lumbosacral fusion using a metal cage, improves the outcomes of long fusion surgery in adult spinal deformity patients, and this would serve as a useful guideline for spine surgeons who plan and perform spinal reconstruction surgery.
Authors:Michael M. Safaee, Alexander Tenorio, Joseph A. Osorio, Winward Choy, Dominic Amara, Lillian Lai, Annette M. Molinaro, Yalan Zhang, Serena S. Hu, Bobby Tay, Shane Burch, Sigurd H. Berven, Vedat Deviren, Sanjay S. Dhall, Dean Chou, Praveen V. Mummaneni, Charles M. Eichler, Christopher P. Ames and Aaron J. Clark
The authors present data on perioperative complications in obese patients who underwent anterior fusion lumbar interbody fusion and identify for the first time a body mass index threshold associated with increased risk. It is their hope that this will help modify current guidelines for this particular patient population.
Authors:Jeff Ehresman, Zach Pennington, Aditya V. Karhade, Sakibul Huq, Ravi Medikonda, Andrew Schilling, James Feghali, Andrew Hersh, A. Karim Ahmed, Ethan Cottrill, Daniel Lubelski, Erick M. Westbroek, Joseph H. Schwab and Daniel M. Sciubba
While previous studies have looked at risk factors for incidental durotomy in spine surgery, there has been no simple-to-use calculator where these risk factors can be plugged in by the surgeon. The authors created such a clinical calculator and believe that this tool will enable surgeons to become more aware of the true effects of these risk factors.
Authors:Erica F. Bisson, Praveen V. Mummaneni, Michael S. Virk, John Knightly, Mohammed Ali Alvi, Anshit Goyal, Andrew K. Chan, Jian Guan, Steven Glassman, Kevin Foley, Jonathan R. Slotkin, Eric A. Potts, Mark E. Shaffrey, Christopher I. Shaffrey, Regis W. Haid Jr., Kai-Ming Fu, Michael Y. Wang, Paul Park, Anthony L. Asher and Mohamad Bydon
The current study compares the outcomes between conventional open decompression and minimally invasive decompression for patients with low-grade spondylolisthesis. The authors found comparable outcomes between the two procedure groups, indicating that both procedures may be associated with optimum outcomes.
Authors:Taewook Kang, Si Young Park, Gun Woo Park, Soon Hyuck Lee, Jong Hoon Park and Seung Woo Suh
The authors performed a retrospective review in patients who had undergone biportal endoscopic discectomy by a single surgeon after diagnosis of lumbar disc herniation between January 2016 and June 2018. The key finding in this study was that biportal endoscopic discectomy can be effective for high-grade migrated lumbar disc herniation without prolonged operation time and with satisfactory clinical outcomes.
Authors:Keun-Ho Lee, Ki-Tack Kim, Yong-Chan Kim, Joong-Won Lee and Kee-Yong Ha
This study provided assessment of a large single-center cohort of patients with thoracolumbar kyphosis in ankylosing spondylitis. The authors determined the rate of and the risk factors for surgery-related complications demonstrated on radiography after pedicle subtraction osteotomy. A high incidence of complications related to mechanical failure and surgical technique can develop; therefore, thorough radiographic investigation before surgery is needed to determine whether complete ossification occurs along the anterior and posterior longitudinal ligaments.
Authors:Charlie Bouthors, Ruben Dukan, Christophe Glorion and Lotfi Miladi
The authors analyzed the outcomes of a cohort of NF1 patients with early-onset scoliosis (EOS) treated with growing rods (GRs), a method with very few reported studies. This technique provided satisfactory spinal deformity control in EOS patients with NF1 while allowing substantial spinal growth. Additional findings were that adequately contoured dual GRs with proximal hooks placed in nondystrophic regions should be used to minimize implant-related complications, and surgeons should not attempt to correct kyphosis at GR implantation because it will occur gradually throughout a lengthening program.
The authors conducted a multicenter study of patients with spinal epidural arteriovenous fistulas (edAVFs), a rare type of spinal vascular malformation. This study is the largest case series of patients with spinal edAVFs, and it provides specific treatment strategies for edAVFs.
Authors:Rupesh Kotecha, Martin C. Tom, Mihir Naik, Lilyana Angelov, Edward C. Benzel, Chandana A. Reddy, Richard A. Prayson, Iain Kalfas, Richard Schlenk, Ajit Krishnaney, Michael P. Steinmetz, William Bingaman, John H. Suh and Samuel T. Chao
The authors collected and reviewed patient, tumor, and treatment characteristics for all patients with histologically confirmed spinal myxopapillary ependymoma (MPE) treated consecutively from 1974 to 2015 at a tertiary institution. The results support aggressive initial surgical resection to provide the longest recurrence-free interval and RT at the time of salvage for patients treated with surgery alone in the upfront setting. Surveillance imaging of the entire neuraxis is crucial as distant failure is not uncommon, and radiotherapy at the time of relapse is critical to preventing MPE recurrence.
This study demonstrated that smoking had no adverse effects on the improvements of clinical outcomes in pedicle screw–based Dynesys dynamic stabilization surgery. For smokers, the rates of screw loosening trended lower (without significance), but the chances of secondary surgery for adjacent segment disease were higher than in the nonsmoking patients. However, the optimal surgical strategy to stabilize the lumbar spine of smoking patients requires future investigation.
Authors:Gokhan Gürkan, Murat Sayin, Ceren Kizmazoglu, Mumin Alper Erdogan, Gurkan Yigitturk, Huriye Erbak Yilmaz, Inan Uzunoglu, Ismail Kaya and Nurullah Yuceer
The authors tested a new treatment (to their knowledge first reported here) with combined methylprednisolone and ozone in a rat model of spinal cord injury. The important results of this study suggest that methylprednisolone and ozone in combination may be more beneficial for the treatment of spinal cord injury than methylprednisolone alone.
Authors:Wyatt L. Ramey, Alexander von Glinski, Andrew Jack, Ronen Blecher, Rod J. Oskouian and Jens R. Chapman
The authors describe a novel method in the treatment of severe, active osteomyelitis and discitis of the spine. The use of antibiotic-infused polymethylmethacrylate (aPMMA) strut graft in this setting reduces dead space, administers local antibiotics to the infection bed, and provides structural support. To the authors' knowledge, the use of aPMMA is novel for treating cases of severe, pyogenic osteomyelitis requiring extensive debridement and stabilization, followed at a later date by replacement with permanent hardware.
The authors developed a clinical prediction score to identify patients at risk of developing poor postoperative pain control after spine surgery. Seven variables predictive of inadequate pain control were incorporated into this score. This score accurately predicted the probability of heightened pain after elective spine surgery. The ability of clinicians to risk-stratify patients preoperatively creates an opportunity to develop anticipatory therapies and personalized clinical care pathways to improve pain outcomes after spine surgery.
Expected survival is a key determinant of surgical candidacy in patients with spinal metastases. To date, numerous scoring systems have been put forth without achieving consensus on which is the best clinical tool when evaluating surgical candidates. Here, the authors review previously published scoring systems, highlighting their relative strengths and weaknesses and summarizing previous comparative studies aimed at identifying the scoring system with the greatest prognostic accuracy. They found that the more comprehensive web-based Skeletal Oncology Research Group predictive calculators are likely the best available tools; however, further refinement is necessary, including the incorporation of quality-of-life predictors.
The authors developed a novel standardized resident training module for placement of thoracolumbar pedicle screws in a reproducible synthetic spine model utilizing 3D navigation. Neurosurgery and orthopedic surgery residents used a 3D navigation system to place pedicle screws in the synthetic spine training model. Two sessions were completed at least 10 days apart. The residents had significant improvement between the first and second sessions. This model will enhance efficiency and safety of resident education through improving proficiency with pedicle screw placement.
Here, the authors evaluated the prevalence of postoperative coronal imbalance (CIB) and its related factors in patients with adult lumbar scoliosis. The key findings were that postoperative CIB negatively affects health-related quality of life, and an imbalanced correction between thoracolumbar or lumbar and lumbosacral curves may cause postoperative CIB. This study demonstrated the importance of postoperative coronal balance in adult spinal deformity surgery.
Fluoroscopy is still widely used for percutaneous pedicle screw insertion. The coaxial fluoroscopic view of the pedicle to place the percutaneous pedicle screw is expected to improve the accuracy and decrease the risk of the superior facet joint violation. The authors clarified the accuracy of percutaneous pedicle screw insertion and identified the risk factors for malposition, which to their knowledge have not been shown in previous reports.
This retrospective study analyzed the preoperative and postoperative radiological shoulder and neck parameters following posterior spinal fusion (PSF) in two subtypes of Lenke 1 curves. Lenke 1 (stiff) curves had a significantly higher incidence of left medial (T1 tilt) shoulder and neck imbalance (cervical axis) than Lenke 1 (flexible) curves. Following PSF, +ve T1 tilt was noted in 41% of Lenke 1 (stiff) patients versus 2.0% in Lenke 1 (flexible) patients. Recognizing these two Lenke 1 curve subtypes preoperatively would allow surgeons to tailor their surgical strategy to prevent positive medial shoulder imbalance, particularly in Lenke 1 (stiff) curves.
In patients with multiple traumatic injuries, surgeons are unsure as to the optimal timing for surgical repair of spine fractures in patients without spinal cord injury. While awaiting surgery, patients are at risk for complications due to immobility. The authors set out to define the optimal time to perform surgery to repair spinal fractures that occur following trauma. They showed that surgical repair within 24 hours of injury can reduce major complications by 25%–30%.
The authors compared the patient's radiation exposure during intraoperative thoracolumbar 3D scans using a mobile 3D C-arm with a large 30 × 30–cm and a smaller 20 × 20–cm flat-panel detector. The large C-arm displays an enlarged image area as required for the noninvasive patient tracker mask, but causes a 2.25 times higher radiation exposure to the patient. The application of the patient tracker mask and large 3D scans should be based on an individual decision, especially considering the radiation exposure and the extent of instrumentation.
In this study, the authors report their experience developing and implementing a prospective quality improvement tool, the design of which was informed with perspectives gained through analyses of national clinical registry data. Application of the tool was observed to significantly improve both patient outcomes and experience after elective lumbar fusion surgery. The NeuroPoint Alliance–Institute for Healthcare Improvement collaboration described here represents an important proof of principle supporting expanded application of combined registry and continuous quality improvement methods to promote safety and value of neurosurgical care.
The authors determined the rate of postoperative novel neurological events due to pedicle screw malposition after lateral fluoroscopy–assisted screw insertion during lumbar fusion surgery. Pedicle screw malposition was established intraoperatively or postoperatively to have occurred in 3.25% of the total study population, a rate equal to or lower than the rate for other image-guided screw insertion techniques. In the majority of patients, postoperative neurological events were not attributable to pedicle screw malpositioning, but rather to postoperative neurapraxia of peripheral nerves, neuropathy, or intraoperative traction of nerve roots.
The authors identified that 53.9% of abstracts presented at Spine Summit meetings have been published in scientific journals. The publication rate of the Spine Summit is among the highest compared to other spine meetings. Many of the abstracts initially presented at the meeting are further published in high-impact-factor (IF) journals and had a high citation count. Therefore, the Spine Summit keeps its high standards of scientific papers, which reflects the high quality of the research performed in the spine surgery field in North America.
This study is the first report on the surgical outcome of combined anterior-posterior short-segment spinal fusion placed 1 level above and 1 level below the fracture with the X-Core 2 vertebral body replacement system for vertebral pseudarthrosis after osteoporotic vertebral fracture (OVF). This procedure is relatively minimally invasive, which is important when treating elderly patients, and provides good local reconstruction with a minimized fixation range. This procedure should be considered for the surgical treatment of vertebral pseudarthrosis after OVF.
The authors analyzed outcomes following transthoracic microsurgical anterior decompression for treatment of thoracic ossification of the posterior longitudinal ligament (T-OPLL) and determined the predictive factors for surgical outcomes. Favorable clinical outcomes were achieved with this technique, which has the advantage of not requiring posterior instrumentation. Patient age and preoperative kyphotic angle were independent risk factors for lower recovery rates. This study is to the authors' knowledge the first to demonstrate predictive factors affecting surgical outcomes of the transthoracic microsurgical anterior decompression technique in T-OPLL patients.
The authors compared fracture rates in patients treated with stereotactic body radiation therapy versus external-beam radiation therapy for metastatic spine tumors. This study is important because it provides information that can be used to assess the risk of patients developing potential fractures as a result of treatment.
In a large cohort of patients with adult spinal deformity, the authors assessed the use of asymmetrical pedicle subtraction osteotomy (APSO) in patients with concurrent sagittal-coronal deformity, whose outcomes were compared with those for patients with isolated sagittal deformity treated with standard PSO. With APSO the neurosurgeons were readily able to restore sagittal and coronal balance, and the risks associated with APSO were lower than those for traditional approaches (vertebral body resection) and similar to those for standard PSO.
The authors set out to examine the psychometric properties of a recently developed app-based 6-minute walking test (6WT) to determine objective functional impairment in patients with lumbar degenerative disc disease. They found that 6WT self-measurements are a convenient, reliable, and valid way to determine objective functional impairment. App-based standardized objective outcome measures offer great potential for the digital evaluation and serial monitoring of spine patients.
The authors aimed to determine whether patients reporting higher preoperative pain scores have worse outcomes after lumbar microdiscectomy. They found that although patients who report high pain and have a symptomatic lumbar disc herniation may communicate pain in a more extreme manner, clinicians should counsel such patients that outcomes are positive after microdiscectomy.
The purpose of this retrospective study was to evaluate the risk factors of pseudoarthrosis after posterior lumbar interbody fusion (PLIF) and identify preventive measures. A lower occupancy rate of the autograft and the presence of a translucent zone between the autograft and endplate immediately after the surgery were associated with pseudoarthrosis at 12 months after PLIF. It is important to remove the cartilage endplates and pack adequate autograft during PLIF for osseous union enhancement and to avoid excessive absorption of autograft.
The authors describe a new surgical strategy for lumbosacral foraminal stenosis based on anatomical considerations using 3D image fusion with MRI/CT analysis. Most areas of lumbosacral foraminal stenosis existed outside the center of the pedicle (94%) and were rarely seen in the pars region. Considering this anatomical distribution of lumbosacral foraminal stenosis, the authors recommend that lateral fenestration should be the first priority for foraminal decompression. Lumbar instability associated with surgery does not occur, and spinal fusion is not required, so the authors believe that minimally invasive treatment can be achieved for lumbosacral foraminal stenosis.
This study focuses on the influence of proximal rod contouring on the occurrence of proximal junctional kyphosis (PJK). Under-contouring of the proximal part of the rods is a risk factor for PJK in Scheuermann kyphosis. The authors describe a new radiological parameter, the proximal contouring rod angle (PCRA), which allows one to indirectly measure the proximal rod contour, permitting identification of an insufficient rod contour.
The authors identified drivers for nonhome discharge after lumbar fusion surgery. Independent predictors of nonhome discharge in this study were older age, higher BMI, living in an underserved zip code, not being married, using government insurance, and undergoing multilevel spinal surgery. Early identification of these predictors can be useful for early intervention for discharge planning, which can decrease total costs of surgery, including the higher costs of nonhome discharge.
This study's objective was to evaluate predictors of 30-day readmissions following anterior cervical discectomy and fusion and posterior lumbar fusion procedures by using two national databases and an institutional cohort. Discrepancies regarding predictors of 30-day readmissions were found between the national databases and the authors' institutional cohort. Big data provides large sample sizes, enabling studies particularly when single-institution sample sizes are relatively small. It is important to recognize that large national databases may inaccurately predict important outcomes at an institutional level. Ideally, information taken from national and institutional databases should be used in conjunction with each other rather than independently.
The authors detail 18 cases of C5 nerve palsy from a series of 642 cervical spine surgeries that included C4–5, characterizing patterns of C5 nerve palsy in its appearance and recovery of C5 nerve palsy. Never seen immediately after surgery, C5 palsy occurred in a delayed fashion and was not predicted by intraoperative neuromonitoring. Primarily a motor deficit of the deltoid, it may also affect the biceps and triceps. Recovery typically only started 12 weeks postoperatively. Preoperative T2 cord change/myelomalacia at C4–5 was predictive of its occurrence. Understanding the typical pattern of postoperative C5 palsy may aid surgeons' ability to counsel their patients.
The findings will allow readers to understand the factors involved in the incidence of pseudarthrosis after ACDF with self-locking, stand-alone cervical cages filled with hydroxyapatite graft. Furthermore, the authors present and discuss in detail the three cases in which symptomatic pseudarthrosis developed, which aids in the identification of clinical cases that might not benefit from this approach. In so doing, the authors hope that their research advances the tools needed to make proper decisions for the surgical treatment of cervical degenerative disc disease.
This study aimed to identify the preoperative factors that are predictive of residual upper-extremity (UE) numbness after cervical surgery. Forty-one percent of the patients with cervical spondylotic myelopathy experienced residual UE numbness, and female sex and preoperative severe UE pain were the predictive factors for residual UE numbness. These results can aid surgeons in explaining the changes in numbness after cervical surgery, which can result in higher patient satisfaction.
The authors sought to determine if being obese or having psychiatric disease (anxiety or depression) affects how patients perceive clinical benefit after surgical intervention for grade 1 degenerative spondylolisthesis. Using data from a large, prospective multicenter spine surgery registry, the authors calculated minimum clinically important differences with both anchor-based and distribution-based methods. There were no variations in perceptions of improvement after surgery between patients with and those without obesity and/or psychiatric disease, findings that allow for improved preoperative patient counseling, risk stratification, and expectations management.
The authors demonstrated that in carefully selected patients, treatment of high-grade spinal epidural disease with radiosurgery alone offers results similar to those for surgery followed by radiation. Further investigation via clinical trials is warranted to determine clinical efficacy of this treatment approach.
The authors' objective was to identify predictors of increased 2-year reoperation rate in patients enrolled in Medicare who underwent primary thoracolumbar deformity surgery. Patients with osteoporosis, congestive heart failure, or paraplegia were at statistically increased risk of requiring reoperation within 2 years after primary surgery. The use of intraoperative bone morphogenetic protein decreased the risk of reoperation, whereas at 90 days postoperatively the development of a wound complication or a pulmonary embolism was most strongly correlated with increased likelihood of revision surgery. This research adds value to the field because it focuses on a vulnerable, often understudied cohort: Medicare patients.
To identify ideal candidates for cervical disc replacement (CDR), the authors used a previously reported scoring system for cervical vertebral degeneration to determine quantitatively measurable risk factors for heterotopic ossification (HO), a major complication of CDR. Disc height, anterior osteophytes, and endplate sclerosis were identified as independent risk factors for postoperative HO development that can be measured preoperatively to screen patients who are CDR candidates. Rigorous criteria, including nearly normal disc height and no more than mild anterior osteophytes and endplate sclerosis, should be used for patients considering CDR.
The purpose of the present study was to systematically evaluate the use of a high-definition 3D exoscope as an alternative to the operating microscope in spine surgeries with regard to handling, image quality, illumination, and comfort for the whole surgical staff. The authors demonstrated the safety and efficacy of 3D exoscope–based procedures with the unique advantage of excellent comfort and ergonomics for the surgical team, showing that the 3D exoscope is a practical and economical alternative to the operating microscope. However, the drawback—slightly decreased quality of visualization/illumination and reduced ease of handling/repositioning of the exoscope itself—must be kept in mind, particularly in more complex spine or spinal cord procedures.
The authors evaluated patients with lumbar disc herniation (LDH) and substantial back pain (BP) using the DaneSpine Database. Based on the results from this study, patients with LDH and leg pain (LP) and concomitant substantial BP can be counseled to expect improvement in their BP 12 months after surgery after a discectomy alone, as well as improvement in their LP. The study adds evidence that discectomy alone can reduce BP in patients with LDH and substantial BP.
The authors sought to demonstrate the feasibility of establishing a dual-attending care management platform for adult spinal deformity (ASD) correction at their institution. The dual-attending care management platform had a positive safety and outcome profile in ASD patients, which was in agreement with the literature, as identified by a systematic literature review.
The authors describe a novel combined treatment for neurotrauma, based on blood glutamate scavenging (BGS), followed by exercise. This treatment has decreased axonal degeneration and increased the expression of proteins associated with nerve growth. BGS treatment is based on the naturally occurring enzymatic mechanism in the peripheral blood followed by the exercises, the only available rehabilitative treatment for spinal cord injury (SCI) today. BGS treatment technology can be easily implemented within the 1st hour postinjury by a paramedic, making it the first and fastest treatment for SCI, dealing with the excitotoxic events initiated within minutes to hours from the primary trauma.
Multiple bead-like schwannomas at the cauda equina are rare, and surgical removal of these tumors is challenging. The authors have combined a flexible endoscope and microscope and designed a novel surgical technique to achieve the goal of safe removal of these tumors with minimal injury to the patient.
The authors compared similar cervical spine surgeries performed with patients in either the sitting or prone position to examine any differences in perioperative outcomes. The sitting position confers certain logistical benefits when performing these surgeries, but the perceived risks of the sitting position have often hindered its adoption. The authors show that the sitting position can be safely employed for these types of surgeries with an experienced surgical and anesthesia team when compared to the more widely employed prone position.
The objective of the study was to show the surgical results of growing rod surgery after prior foundation surgery and sublaminar taping. This technique yielded effective correction of scoliotic curves and a lower complication rate than those in previous reports. This technique is significant because it produces a good surgical result in patients with early-onset scoliosis.
The authors used a validated instrument for evaluating health information, the DISCERN tool, to assess the quality of online patient education videos pertaining to lateral lumbar interbody fusion (LLIF). An important finding was that the vast majority of LLIF educational content available online presents information of moderate rather than high overall quality. This study demonstrates a method that can be used to determine the value of current patient education videos as well as to guide efforts to provide LLIF educational content of the highest quality.