Journal of Neurosurgery: Spine
Volume 37: Issue 5 (Nov 2022)

Images from Gami et al. (pp 713–721).

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Austin J. Borja
,
Ali S. Farooqi
,
Joshua L. Golubovsky
,
Gregory Glauser
,
Krista Strouz
,
Jan-Karl Burkhardt
,
Scott D. McClintock
, and
Neil R. Malhotra

In Brief

The objective was to assess the capability of individual, risk-related patient characteristics, available preoperatively, to predict discharge disposition after single-level, posterior-only lumbar fusion. Patient mobility and the availability of a postoperative caretaker were individually observed to predict home discharge. These findings may help surgeons to streamline preoperative clinic workflow and inform strategies to support the highest-risk spine surgery patients in a targeted fashion.

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Rajiv K. Sethi
,
Caroline E. Drolet
,
Rebecca P. Pumpian
,
Jesse Shen
,
Kelsey Hanson
,
Sofia Guerra
, and
Philip K. Louie

In Brief

The objective of this study was to evaluate the combination of time-driven activity-based costing (TDABC) and lean methodologies in detecting meaningful variability in time-based care of patients undergoing single-level spine fusion surgery. The authors have demonstrated that variability exists. Thus, detailed value stream maps constructed via a lean methodology process are critical to detect this variability by using TDABC methodology in single-level lumbar fusions. Ultimately, competitive value-based pathways of care require robust analysis of quality and cost together. Clinicians and administrators can apply this combination to allocate appropriate resources, optimize existing processes, and continually improve the treatments offered to patients.

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Hani Malone
,
Gregory M. Mundis Jr.
,
Martin Collier
,
Reilly L. Kidwell
,
Fernando Rios
,
Michael Jelousi
,
Shae Galli
,
Bahar Shahidi
,
Behrooz A. Akbarnia
, and
Robert K. Eastlack

In Brief

As innovations continue to accelerate both progress and expenses in spine surgery, corollary opportunities for cost containment have become increasingly important. In this study, the authors evaluated fusion rates in patients who underwent lateral lumbar interbody fusion (LLIF) with 3D-printed porous titanium implants packed with only inexpensive ceramic β-tricalcium phosphate-hydroxyapatite. Successful fusion was achieved (approximately 99% of patients) without augmentation with costly biologics/bone extenders, suggesting that advancements in implant technology may reduce the cost burden of biologics in patients who undergo LLIF.

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Yung-Hsueh Hu
,
Yu-Cheng Yeh
,
Chi-Chien Niu
,
Ming-Kai Hsieh
,
Tsung-Ting Tsai
,
Wen-Jer Chen
, and
Po-Liang Lai

In Brief

Researchers investigated the role of the MRI-based vertebral bone quality (VBQ) score in predicting cage subsidence after transforaminal lumbar interbody fusion (TLIF). The VBQ score was moderately correlated with dual-energy x-ray absorptiometry (DEXA) scores and was shown to significantly predict cage subsidence with an accuracy of 85.6%. The researchers suggest using the VBQ score in the preoperative survey for evaluating bone quality and the risk of cage subsidence.

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Nima Alan
,
Lena Vodovotz
,
Nallammai Muthiah
,
Hansen Deng
,
Daipayan Guha
,
Nitin Agarwal
,
Alp Ozpinar
,
Harry M. Mushlin
,
Lauren Puccio
,
David K. Hamilton
,
David O. Okonkwo
, and
Adam S. Kanter

In Brief

The authors report their institutional experience with subsidence and reoperation using 3D-printed porous titanium (pTi) interbody cages in lateral lumbar interbody fusion (LLIF). They noted that in 55 consecutive patients with 97 treated levels with a minimum 1-year follow-up, the subsidence rate was 8.0% and the reoperation rate was 1.8%. This study corroborates previous biomechanical and case series from other institutions regarding lower subsidence after LLIF using pTi interbody cages.

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Sally El Sammak
,
William Mualem
,
Giorgos D. Michalopoulos
,
Joshua M. Romero
,
Christopher T. Ha
,
Christine L. Hunt
, and
Mohamad Bydon

In Brief

Conventional spinal cord stimulators (SCSs) have demonstrated efficacy in individuals with FBSS. However, a subgroup of patients may become refractory to the effects of these waveforms over time. The aim of this study was to evaluate the studies in the literature on the use of novel waveform SCSs in individuals refractory to conventional SCSs. Six studies with 137 patients were identified. A significant reduction in back pain was seen after conversion. Novel waveforms may be considered after conventional treatment with SCSs.

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Dennis London
,
Ben Birkenfeld
,
Joel Thomas
,
Marat Avshalumov
,
Alon Y. Mogilner
,
Steven Falowski
, and
Antonios Mammis

In Brief

Researchers studied differences among patients regarding which spinal nerves supply muscles in the legs. They electrically stimulated nerves during placement of electrodes for the treatment of chronic pain and mapped patterns of muscle activation in individual patients. They showed a large degree of variation, which is essential to keep in mind when diagnosing and treating patients.

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Andy Y. Wang
,
Matthew Kanter
,
Michelle Olmos
,
Ellen D. McPhail
,
Mina G. Safain
,
James Kryzanski
,
Knarik Arkun
, and
Ron I. Riesenburger

In Brief

The authors compared the degree of disc degeneration in patients with lumbar stenosis stratified by the presence of amyloid deposition in the ligamentum flavum (LF). Traditionally, inflammatory responses due to disc degeneration are implicated in LF thickening in spinal stenosis. In this study, amyloid was associated with a reduced level of disc degeneration. These findings suggest that amyloid-induced thickening of the LF may involve a novel mechanism of spinal stenosis, separate from those currently described.

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Anthony L. Mikula
,
Nikita Lakomkin
,
Zach Pennington
,
Zachariah W. Pinter
,
Ahmad Nassr
,
Brett Freedman
,
Arjun S. Sebastian
,
Kingsley Abode-Iyamah
,
Mohamad Bydon
,
Christopher P. Ames
,
Jeremy L. Fogelson
, and
Benjamin D. Elder

In Brief

Researchers analyzed risk factors for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients with spinal fusions extending from the pelvis to the upper thoracic spine. They found low bone density at the top of the intended construct, as estimated by Hounsfield units (HU), to be the only independent predictor of PJK and PJF. Low HU in the upper thoracic spine is a novel and modifiable risk factor for PJK and PJF.

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Yoichi Tani
,
Takanori Saito
,
Shinichirou Taniguchi
,
Masayuki Ishihara
,
Masaaki Paku
,
Takashi Adachi
, and
Muneharu Ando

In Brief

This study clarified whether the anterior column realignment (ACR) procedure serves well for indirect neural decompression in patients with adult spinal deformity (ASD) and pelvic incidence/lumbar lordosis mismatch. ACR worked as well as, if not better than, lateral lumbar interbody fusion for achieving indirect decompression. Segmental lordosis enhancement with ACR relied on a lever mechanism with the intact facet joints acting as the fulcrum. The ACR plays an important role in not only lumbar lordosis restoration but also stenotic spinal canal enlargement for ASD surgery.

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Parth Gami
,
Kelly Qiu
,
Sindhu Kannappan
,
Yoel Alperin
,
Gaetano De Biase
,
Ian A. Buchanan
,
Alfredo Quiñones-Hinojosa
, and
Kingsley Abode-Iyamah

In Brief

The authors sought to develop and validate a nonradiographic, semiautomatic device that measures spinal alignment intraoperatively using computer vision and deep learning. The device was found to overcome challenges of intraoperative measurement, including extensive time input, unreliability of manual calculations, and radiation exposure, which limit the frequency of measurements taken during surgery. This study presents a novel method to provide surgeons with quantitative feedback nonradiographically when performing spinal alignment surgery to achieve improved surgical outcomes.

Free access
Nikita Lakomkin
,
Anthony L. Mikula
,
Zachariah W. Pinter
,
Elizabeth Wellings
,
Mohammed Ali Alvi
,
Kristen M. Scheitler
,
Zach Pennington
,
Nathan J. Lee
,
Brett A. Freedman
,
Arjun S. Sebastian
,
Jeremy L. Fogelson
,
Mohamad Bydon
,
Michelle J. Clarke
, and
Benjamin D. Elder
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Carly Weber-Levine
,
Brendan F. Judy
,
Andrew M. Hersh
,
Tolulope Awosika
,
Yohannes Tsehay
,
Timothy Kim
,
Alejandro Chara
, and
Nicholas Theodore

In Brief

The authors systematically reviewed literature on the management of spinal cord perfusion pressure (SCPP) following acute traumatic spinal cord injury (SCI). Studies suggest that SCPP is a better indicator of long-term neurological function than mean arterial pressure (MAP) alone. SCPP can be improved by raising MAP with vasopressors or lowering intraspinal pressure with laminectomy and durotomy when dural compression is present. This review emphasizes monitoring and optimizing SCPP in patients with acute traumatic SCI.

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Kazuya Kitamura
,
Eddie de Dios
,
Gergely Bodon
,
Laszlo Barany
, and
Anna MacDowall

In Brief

The objective of this study was to evaluate surgical outcomes between anterior decompression and fusion and muscle-preserving selective laminectomy in patients with degenerative cervical myelopathy. The authors' key findings were comparable patient-reported outcome measures but a significantly lower complication rate and better cost-effectiveness after muscle-preserving selective laminectomy compared with anterior decompression and fusion. This study supports the option of choosing a less-invasive, muscle- and motion-preserving posterior approach to safely treat patients with degenerative cervical myelopathy.

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Ali Kiapour
,
Ashutosh Khandha
,
Elie Massaad
,
Ian D. Connolly
,
Muhamed Hadzipasic
,
Ganesh M. Shankar
,
Vijay Goel
, and
John H. Shin

In Brief

This study was intended to fill the gap in the literature by investigating the effect of rod diameter on the stability and kinematics of the lateral mass fixation construct. An increase in rod diameter improved the rigidity of the construct but resulted in an increase in the kinematics of the adjacent segments. This study can provide surgeons with data to help guide implant selection during posterior cervical fusion surgery.

Free access
Connor Berlin
,
Alexandria C. Marino
,
Praveen V. Mummaneni
,
Juan Uribe
,
Luis M. Tumialán
,
Jay Turner
,
Michael Y. Wang
,
Paul Park
,
Erica F. Bisson
,
Mark Shaffrey
,
Oren Gottfried
,
Khoi D. Than
,
Kai-Ming Fu
,
Kevin Foley
,
Andrew K. Chan
,
Mohamad Bydon
,
Mohammed Ali Alvi
,
Cheerag Upadhyaya
,
Domagoj Coric
,
Anthony Asher
,
Eric A. Potts
,
John Knightly
,
Scott Meyer
, and
Avery Buchholz

In Brief

Researchers set out to determine if retrospective analysis of prospectively collected patient-reported outcomes (PROs) following surgery for cervical spondylotic myelopathy (CSM) differed when stratified by preoperative myelopathy status. Three months after surgical decompression for CSM appears to be an adequate time to achieve maximum improvement in PROs in most patients. This study adds value by providing new insight and more accurate time resolution into how and when patients can be expected to achieve clinical improvement following surgical decompression for CSM and provides the surgeon and patient with more accurate information for counseling and expected postoperative recovery time course.

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Rong Xie
,
Jinping Liu
,
Minghao Wang
,
Yinhui Dong
,
Praveen V. Mummaneni
, and
Dean Chou

In Brief

Researchers used the University of California, San Francisco, dysphagia score, a 7-point scale that categorizes dysphagia into 7 levels, to evaluate dysphagia after ACDF based on levels fused and cervical sagittal parameters and found that the realistic incidence rates of dysphagia after ACDF were 59.5% immediately postoperatively and 33.6% at the 2-year follow-up, higher than previously published rates. However, most dysphagia was not severe. The number of levels fused and loss of preoperative C2– 7 lordosis were the most important risk factors.

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Ethan S. Srinivasan
,
Melissa M. Erickson
,
Christopher I. Shaffrey
, and
Khoi D. Than
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Langston T. Holly
,
William W. Ashley Jr.
,
Edjah K. Nduom
,
Brenton Pennicooke
,
Caple A. Spence
, and
Babu G. Welch
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TO THE EDITOR: We read with interest the recent article by Schenck and colleagues1 regarding interspinous process devices (IPDs) (Schenck CD, Terpstra SES, Moojen WA, et al. Interspinous process device versus conventional decompression for lumbar spinal stenosis: 5-year results of a randomized controlled trial. J Neurosurg Spine. 2022;36[6]:909-917). IPDs were developed as a less destructive alternative to other bony decompression techniques, such as complete laminectomy and discectomy. The IPD simultaneously increases the interspinous distance and helps decompress the canal and foramen through flexion, leading to less aggressive decompression foraminotomies and laminotomies.

Schenck and colleagues

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In Brief

This study was designed to define the impact of injury severity on the therapeutic effect size of neuroprotective interventions following acute spinal cord injury (SCI) in a preclinical rodent model. Neuroprotective effects on locomotor recovery and extent of tissue sparing were assessed in rats. Surgical spinal cord decompression (durotomy or myelotomy) was neuroprotective in the spinal cord contusion injury model. The neuroprotective therapeutic effect size was only evident in animals with moderate SCIs, not in severe SCI, suggesting the existence of a ceiling effect of neuroprotective interventions.

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Traumatic spinal cord injury (tSCI) is a devastating condition affecting approximately 23–100 per 100,000 patients worldwide. The initial mechanical impact causes direct cellular damage (primary injury) and disruption of the blood–spinal cord barrier, followed by secondary injury defined by ischemic damage and inflammatory response, worsening spinal cord edema and creating an inhibitory environment for neuronal regeneration and remyelination. 1 In addition, the secondary injury can substantially surpass the primary injury, thus worsening symptoms and outcome. Consequently, many therapeutic interventions focus on mitigating secondary injury. Any effective therapy in the acute phase to reduce the injury severity will

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In Brief

The aim of this study was to assess the value of conservative treatment in spinal cord cavernous malformation patients. The authors' results indicate that conservative treatment often implies the experience of recurrent bleeding events, and interestingly, the capacity of neurological rehabilitation decreases with every hemorrhage. These data reinforce the value of surgery and suggest early treatment.

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In Brief

Pedicle screw loosening and pullout are common problems in spinal fusion. This study assessed the biomechanical strength of pedicle screw impaction grafting in a cadaveric model.

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In Brief

The objective of this study was to identify if the Global Alignment and Proportion (GAP) score was predictive of the patient-reported outcomes as measured by PROMIS (pain, physical function) and Scoliosis Research Society-22 spinal deformity questionnaire (function, pain, self-image, satisfaction, subtotal) scores. The authors found that postoperative GAP score predicts long-term health-related quality of life outcomes for adult spinal deformity surgery. The authors recommend decreasing the postoperative GAP score and improving proportioning as a goal when planning sagittal plane correction in adult spinal deformity surgery.

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In Brief

The study objective was to define rates of and risk factors for proximal junctional failure (PJF) based on a longer-term follow-up of operatively treated adult symptomatic lumbar scoliosis (ASLS) patients. The overall PJF rate was 28.8% at a mean 4.3-year follow-up. On multivariate analysis, an increased PJF risk was associated with a greater BMI and preoperative thoracic kyphosis and lower preoperative proximal junctional angle. Collectively, this study provides the highest quality data to date on rates of PJF following primary ASLS surgery.

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In Brief

Approximately 25% of patients experience new-onset neck pain after surgery for cervical spondylotic myelopathy. The authors investigated which patient- or surgery-related factors might be associated with new-onset pain. A higher level of disability at baseline, more affected levels, and symptoms lasting longer than 3 months were associated with the risk of new-onset pain. Most patients with new-onset pain were satisfied with surgery, suggesting that the risk of new-onset neck pain should not hinder indicated operations.

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In Brief

Postoperative ileus (PI) is a common complication after thoracolumbar posterior spinal fusion (PSF), but the effect of total intravenous anesthesia (TIVA) as a PI risk factor has not been assessed. TIVA was independently associated with PI on multivariate analysis, and propensity-matched analysis demonstrated higher intraoperative opiate use in patients having TIVA versus those having inhaled anesthesia. These results highlight the importance of preoperative planning and collaboration with anesthesiology to determine the risks and benefits of using TIVA for PSF.

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In Brief

The authors analyzed the cost-effectiveness of conventional medical management (CMM) versus 10-kHz spinal cord stimulation (SCS) in the treatment of nonsurgical refractory back pain. Treatment with 10-kHz SCS was found to be cost-effective compared with CMM in the 2.1-year time frame. This is the first analysis of cost-effectiveness of SCS in this nonsurgical refractory back pain population, with the added value of prospectively collected healthcare utilization data from a randomized controlled trial.

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The objective of every cervical fusion surgery is not only resolution of the nerve root or cervical spinal cord compression symptoms but also clinical and radiographic arthrodesis. As surgeons, we make every effort to ensure that we have stacked the deck in favor of our patients achieving that milestone. In the pursuit of this goal, spine surgery as a whole has advanced the understanding of the biologics of arthrodesis and surface technology for interbody spacers over the past several decades. However, the journey to reliably achieve arthrodesis has not been without turbulence. The unforeseen consequences of human recombinant

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TO THE EDITOR: We read with great interest the article by Elsamadicy et al. 1 (Elsamadicy AA, Koo AB, Reeves BC, et al. Hospital Frailty Risk Score and healthcare resource utilization after surgery for metastatic spinal column tumors. J Neurosurg Spine. 2022;37[2]:241-251). In the study, the Hospital Frailty Risk Score (HFRS) score was applied to hospital discharge records associated with metastatic spinal column tumor (MST) surgery and used to stratify cases into low (61.7%), intermediate (36.2%), and high (2.0%) frailty. 1 HFRS was associated with discharge outcomes and proposed as a novel clinical risk

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In Brief

In this case series, researchers have reported the clinical courses, imaging findings, management techniques, and outcomes at 1 year postoperative for 6 patients who received mesenchymal stem cell bone grafts infected with Mycobacterium tuberculosis. Severe soft-tissue infections occurred, although no extensive skeletal and pulmonary involvement was observed. The severity of these infections arising from stem cell products that undergo alternative sterilization processes raises concerns for increased risk of infection, which should be weighed against the benefits of these grafts.

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In Brief

The primary objective of the study was to evaluate the occurrence of spine injuries and risk factors for spine injuries in ejection seat evacuation. The second objective was the assessment of risk factors for rejection for military flight recertification after ejection seat evacuations. Lumbar fractures are associated with higher odds of rejection for flight recertification than other injuries. This study underlines the importance of diagnosing and treating spine injuries after ejection seat evacuation.

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OBJECTIVE

The purpose of this study was to determine the incidence, mechanism, and potential protective strategies for pelvic fixation failure (PFF) within 2 years after adult spinal deformity (ASD) surgery.

METHODS

Data for ASD patients (age ≥ 18 years, minimum of six instrumented levels) with pelvic fixation (S2-alar-iliac [S2AI] and/or iliac screws) with a minimum 2-year follow-up were consecutively collected (2015–2019). Patients with prior pelvic fixation were excluded. PFF was defined as any revision to pelvic screws, which may include broken rods across the lumbosacral junction requiring revision to pelvic screws, pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws, a broken or loose pelvic screw, or sacral/iliac fracture. Patient information including demographic data and health history (age, sex, BMI, smoking status, American Society of Anesthesiologists score, osteoporosis), operative (total instrumented levels [TIL], three-column osteotomy [3CO], interbody fusion), screw (iliac, S2AI, length, diameter), rod (diameter, kickstand), rod pattern (number crossing lumbopelvic junction, lowest instrumented vertebra [LIV] of accessory rod[s], lateral connectors, dual-headed screws), and pre- and postradiographic (lumbar lordosis, pelvic incidence, pelvic tilt, major Cobb angle, lumbosacral fractional curve, C7 coronal vertical axis [CVA], T1 pelvic angle, C7 sagittal vertical axis) parameters was collected. All rods across the lumbosacral junction were cobalt-chrome. All iliac and S2AI screws were closed-headed tulips. Both univariate and multivariate analyses were performed to determine risk factors for PFF.

RESULTS

Of 253 patients (mean age 58.9 years, mean TIL 13.6, 3CO 15.8%, L5–S1 interbody 74.7%, mean pelvic screw diameter/length 8.6/87 mm), the 2-year failure rate was 4.3% (n = 11). The mechanisms of failure included broken rods across the lumbosacral junction (n = 4), pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws (n = 3), broken pelvic screw (n = 1), loose pelvic screw (n = 1), sacral/iliac fracture (n = 1), and painful/prominent pelvic screw (n = 1). A higher number of rods crossing the lumbopelvic junction (mean 3.8 no failure vs 2.9 failure, p = 0.009) and accessory rod LIV to S2/ilium (no failure 54.2% vs failure 18.2%, p = 0.003) were protective for failure. Multivariate analysis demonstrated that accessory rod LIV to S2/ilium versus S1 (OR 0.2, p = 0.004) and number of rods crossing the lumbar to pelvis (OR 0.15, p = 0.002) were protective, while worse postoperative CVA (OR 1.5, p = 0.028) was an independent risk factor for failure.

CONCLUSIONS

The 2-year PFF rate was low relative to what is reported in the literature, despite patients undergoing long fusion constructs for ASD. The number of rods crossing the lumbopelvic junction and accessory rod LIV to S2/ilium relative to S1 alone likely increase construct stiffness. Residual postoperative coronal malalignment should be avoided to reduce PFF.

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TO THE EDITOR: I read the article by Elias et al. with interest (Elias E, Bess S, Line BG, et al. Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-year follow-up. J Neurosurg Spine. Published online July 22, 2022. doi:10.3171/2022.6.SPINE22422). 1 The article is a compilation of the experience of leading spine surgery centers from North America and can set the tone for future studies on the subject.

In 2014 we introduced a novel clinical entity that we named central or axial atlantoaxial dislocation (CAAD) on the basis of facetal

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TO THE EDITOR: We were interested in the article of Ma et al. 1 (Ma F, Fan Y, Liao Y, et al. Management of fresh odontoid fractures using posterior C1–2 fixation without fusion: a long-term clinical follow-up study. J Neurosurg Spine. 2022;36[6]:968-978). The authors conducted a retrospective cohort study of odontoid fractures, and their results clearly showed that neck stiffness improved after implant removal following C1–2 temporary fixation and that the range of motion (ROM) was not expected to improve with long-term follow-up. Given that these results significantly impact both clinicians and patients as one

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In Brief

Researchers compared the intermediate outcomes of severe congenital early-onset scoliosis (CEOS) patients treated with posterior vertebrectomy/hemivertebrectomy with short fusion and dual growing rods (hybrid technique [HT]) with those of patients who underwent implantation with traditional dual growing rods (TDGRs). The results proved that HT can provide better correction and apex control than TDGRs, with a lower incidence of mechanical complications. HT is a new treatment method for CEOS patients with severe and rigid deformity at the apex level.

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OBJECTIVE

Prior studies have revealed that a body mass index (BMI) ≥ 30 is associated with worse outcomes following surgical intervention in grade 1 lumbar spondylolisthesis. Using a machine learning approach, this study aimed to leverage the prospective Quality Outcomes Database (QOD) to identify a BMI threshold for patients undergoing surgical intervention for grade 1 lumbar spondylolisthesis and thus reliably identify optimal surgical candidates among obese patients.

METHODS

Patients with grade 1 lumbar spondylolisthesis and preoperative BMI ≥ 30 from the prospectively collected QOD lumbar spondylolisthesis module were included in this study. A 12-month composite outcome was generated by performing principal components analysis and k-means clustering on four validated measures of surgical outcomes in patients with spondylolisthesis. Random forests were generated to determine the most important preoperative patient characteristics in predicting the composite outcome. Recursive partitioning was used to extract a BMI threshold associated with optimal outcomes.

RESULTS

The average BMI was 35.7, with 282 (46.4%) of the 608 patients from the QOD data set having a BMI ≥ 30. Principal components analysis revealed that the first principal component accounted for 99.2% of the variance in the four outcome measures. Two clusters were identified corresponding to patients with suboptimal outcomes (severe back pain, increased disability, impaired quality of life, and low satisfaction) and to those with optimal outcomes. Recursive partitioning established a BMI threshold of 37.5 after pruning via cross-validation.

CONCLUSIONS

In this multicenter study, the authors found that a BMI ≤ 37.5 was associated with improved patient outcomes following surgical intervention. These findings may help augment predictive analytics to deliver precision medicine and improve prehabilitation strategies.

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In Brief

Opiate-prescribing practices for elective spinal surgery have come under increasing scrutiny because of the current public health crisis. The authors sought to examine the relationship between outcome and judicious opioid prescribing. When adjusting for a host of confounders, opiate prescribing of less than 225 morphine milligram equivalents over a 7-day period was associated with better outcome for both lumbar and cervical surgery. The authors hope that this provides a framework to curtail opiate prescriptions for spine surgeons.

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In Brief

Contrary to the results of previous studies, researchers revealed that hypolordosis was not a risk factor for kyphotic changes in cervical alignment after posterior cervical foraminotomy (PCF). Kyphotic changes in cervical curvature after PCF were related to older age and Pfirrmann grade of the operative levels. Without these risk factors, the natural return of cervical curvature would be expected with the disappearance of radicular pain.

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OBJECTIVE

Bladder dysfunction after nerve injury has a variable presentation, and extent of injury determines whether the bladder is spastic or atonic. The authors have proposed a series of 3 nerve transfers for functional innervation of the detrusor muscle and external urethral sphincter, along with sensory innervation to the genital dermatome. These transfers are applicable to only cases with low spinal segment injuries (sacral nerve root function is lost) and largely preserved lumbar function. Transfer of the posterior branch of the obturator nerve to the vesical branch of the pelvic nerve provides a feasible mechanism for patients to initiate detrusor contraction by thigh adduction. External urethra innervation (motor and sensory) may be accomplished by transfer of the vastus medialis nerve to the pudendal nerve. The sensory component of the pudendal nerve to the genitalia may be further enhanced by transfer of the saphenous nerve (sensory) to the pudendal nerve. The main limitations of coapting the nerve donors to their intrapelvic targets are the bifurcation or arborization points of the parent nerve. To ensure that the donor nerves had sufficient length and diameter, the authors sought to measure these parameters.

METHODS

Twenty-six pelvic and anterior thigh regions were dissected in 13 female cadavers. After the graft and donor sites were clearly exposed and the branches identified, the donor nerves were cut at suitable distal sites and then moved into the pelvis for tensionless anastomosis. Diameters were measured with calipers.

RESULTS

The obturator nerve was bifurcated a mean ± SD (range) of 5.5 ± 1.7 (2.0–9.0) cm proximal to the entrance of the obturator foramen. In every cadaver, the authors were able to bring the posterior division of the obturator nerve to the vesical branch of the pelvic nerve (located internal to the ischial spine) in a tensionless manner with an excess obturator nerve length of 2.0 ± 1.2 (0.0–5.0) cm. The distance between the femoral nerve arborization and the anterior superior iliac spine was 9.3 ± 1.8 (6.5–15.0) cm, and the distance from the femoral arborization to the ischial spine was 12.9 ± 1.4 (10.0–16.0) cm. Diameters were similar between donor and recipient nerves.

CONCLUSIONS

The chosen donor nerves were long enough and of sufficient caliber for the proposed nerve transfers and tensionless anastomosis.

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In Brief

The incidence and causes of instrument-related complications after primary definitive fusion for pediatric spine deformity were evaluated. Pedicle screw malposition was the primary cause of overall complications and need for subsequent reoperation. In addition to more precise screw insertion techniques, meticulous confirmation, especially regarding medial breach by pedicle screws, may reduce the overall rates of instrument-related complications and revision surgical procedures.

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In Brief

This study provides, to the authors' knowledge, the highest-quality data to date on rod fracture (RF) rates following adult symptomatic lumbar scoliosis surgery. At a median 5.1-year follow-up, 38.8% of patients had at least one RF. The estimated RF rates at 2, 4, and 8 years were 11%, 24%, and 49%, respectively. Greater blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to accurately estimate the true incidence of RF.

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In Brief

The authors compared wound complication rates in metastatic spine tumor patients with a history of preoperative radiation, postoperative radiation within 6 months of surgery, and no radiation. Analysis showed that patients with preoperative radiation had an increased risk of wound complications 7-9 weeks following surgery compared to that in the other groups, despite similar overall wound complication rates. This study provides insight into the timing of wound complications in patients receiving radiation compared to radiation-naive patients.

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In Brief

In this anatomical study of the artery of Adamkiewicz (AKA) and the supporting thoracolumbar radiculomedullary arteries (RMAs), the authors showed that a significant percentage (32%) of their cadaveric specimens had additional RMAs other than the AKA and, in some cases, an extra radiculomedullary vessel of the same caliber as the AKA. New evidence, including these findings, demonstrates the robust capabilities of the spinal cord collateral circulation to withstand the sacrifice of several levels of radicular arteries, including the AKA. A paradigm shift from a single RMA (i.e., the AKA) belief toward a collateral network concept has emerged.

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The authors performed an anatomical study on the artery of Adamkiewicz (AKA). 1 This named vessel has been of historic anatomical significance for many physicians considering nerve root sacrifice, because the blood supply to the spinal cord accompanies the nerve roots. Historically, preservation of the AKA was considered critical in all spine surgeries, and many surgeons would even obtain preoperative angiograms just to localize the artery. In addition, some surgeons have even avoided a definitive operation, such as an en bloc spondylectomy, because of the presence of this artery. However, mounting evidence and many anecdotal discussions have

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In Brief

Researchers evaluated the efficacy and safety of oblique posterior endplate resection for wider decompression. This trumpet-shaped decompression (TSD) widened the workspace during anterior cervical discectomy and fusion (ACDF), and 26% of the region posterior to the vertebral body could be accessed using this technique. The construct stability was not adversely affected by TSD as demonstrated by the similar fusion and subsidence rates among patients who underwent TSD and those who did not. TSD can be safely applied during ACDF when compressive lesions extend behind the vertebral body and are not limited to the disc space, enabling adequate decompression without disrupting construct stability.

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TO THE READERSHIP: Two errors appear in the article by Prasarn et al. (Prasarn ML, Zhou H, Dubose D, et al. Total motion generated in the unstable thoracolumbar spine during management of the typical trauma patient: a comparison of methods in a cadaver model. J Neurosurg Spine. 2012;16[5]:504-508).

In the legend of Fig. 1B, the HoverMatt Air-Transfer Mattress was used, not the Airpal transfer system as incorrectly stated. The corrected legend appears here with the figure.

Photographs demonstrating the maneuvers and transfers. A: The 6-plus-person lift and slide technique.

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In Brief

Researchers sought to investigate differences in outcomes between dural attachment location subgroups in spinal meningioma patients who underwent a posterior-based resection. Posterior-based approaches for resection of spinal meningiomas are safe and effective, regardless of dural attachment location, with similar surgical, oncologic, and neurologic outcomes. In addition, strong oncologic outcomes were had with Simpson grade II resections of spinal meningiomas.

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In Brief

Researchers investigated the risk factors of mechanical complications after multilevel posterior cervical instrumented fusion surgery based on cervical alignment parameters and patient factors. Low body mineral density, a large number of fused vertebrae, a large preoperative C2-7 sagittal vertical axis, and low C2-7 lordosis were significant risk factors for mechanical complications after posterior cervical fusion surgery.

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In Brief

This investigational device exemption study compared the safety and efficacy of a posterior lumbar motion-preserving device with standard transforaminal interbody fusion (TLIF) in the treatment of stenosis due to degenerative spondylolisthesis. The key finding was that posterior lumbar facet arthroplasty was statistically superior compared with TLIF on the composite measure of success. This study demonstrated that posterior lumbar facet replacement may represent a viable alternative to fusion for the treatment of degenerative lumbar spondylolisthesis.

Open access

In Brief

The authors described the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability in patients undergoing anterior cervical discectomy and fusion, and they identified the predictors of poor outcome. Outcome trajectories were variable, with 15.5%–23.5% of patients experiencing a poor result. Demographic, health, clinical, and surgery-related prognostic factors predicted outcomes. This information informs future research and may assist surgeons with patient selection and in setting realistic expectations with patients.

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In Brief

Researchers describe their technique, results, and complications of minimal invasive surgery by means of tubular nonexpandable retractors in patients with spinal CSF leaks and spontaneous intracranial hypotension. Primary sealing was achieved in 96.6% of patients, with up to 90% of patients reporting improvement after surgery. Permanent neurological deficits occurred in 1.7% of patients. Minimally invasive surgery with tubular retractors for the treatment of spinal CSF leaks is safe and effective and should be performed in specialized centers.

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OBJECTIVE

Spinal robotics for thoracolumbar procedures, predominantly employed for the insertion of pedicle screws, is currently an emerging topic in the literature. The use of robotics in instrumentation of the cervical spine has not been broadly explored. In this review, the authors aimed to coherently synthesize the existing literature of intraoperative robotic use in the cervical spine and explore considerations for future directions and developments in cervical spinal robotics.

METHODS

A literature search in the Web of Science, Scopus, and PubMed databases was performed for the purpose of retrieving all articles reporting on cervical spine surgery with the use of robotics. For the purposes of this study, randomized controlled trials, nonrandomized controlled trials, retrospective case series, and individual case reports were included. The Newcastle-Ottawa Scale was utilized to assess risk of bias of the studies included in the review. To present and synthesize results, data were extracted from the included articles and analyzed using the PyMARE library for effect-size meta-analysis.

RESULTS

On careful review, 6 articles published between 2016 and 2022 met the inclusion/exclusion criteria, including 1 randomized controlled trial, 1 nonrandomized controlled trial, 2 case series, and 2 case reports. These studies featured a total of 110 patients meeting the inclusion criteria (mean age 53.9 years, range 29–77 years; 64.5% males). A total of 482 cervical screws were placed with the use of a surgical robot, which yielded an average screw deviation of 0.95 mm. Cervical pedicle screws were the primary screw type used, at a rate of 78.6%. According to the Gertzbein-Robbins classification, 97.7% of screws in this review achieved a clinically acceptable grade. The average duration of surgery, blood loss, and postoperative length of stay were all decreased in minimally invasive robotic surgery relative to open procedures. Only 1 (0.9%) postoperative complication was reported, which was a surgical site infection, and the mean length of follow-up was 2.7 months. No mortality was reported.

CONCLUSIONS

Robot-assisted cervical screw placement is associated with acceptable rates of clinical grading, operative time, blood loss, and postoperative complications—all of which are equal to or improved relative to the metrics seen in the conventional use of fluoroscopy or computer-assisted navigation for cervical screw placement.

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In Brief

The authors sought to determine if a previously identified mechanism and rate of pelvic fixation failure occurred at other institutions. Failures occurred in 37 (5%) of 779 pelvic fixation cases across 13 academic centers. Failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Large corrections may benefit from anterior structural support at the most caudal motion segment and multiple rods connecting to more than two pelvic fixation points.

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In the US, cervical laminoplasty may be an underutilized procedure. Recently, Ghogawala et al. found laminoplasty to have favorable outcomes compared to anterior and posterior cervical fusion surgery for multilevel cervical spondylotic myelopathy (CSM), although this US-based study was aimed at evaluating anterior versus posterior approaches rather than laminoplasty itself. 1 There are significant global variations in the use of laminoplasty, and in the US, utilization of this procedure has lagged behind other countries, although this may be changing. 2,3 As reported by the Centers for Medicare and Medicaid Services procedural database, 4

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In Brief

The aim of this study was to determine the incidence and independent risk factors of dural ossification in patients with thoracic ossification of the ligamentum flavum. The incidence of dural ossification was 35%. The tuberous type according to the Sato classification and large supine local kyphosis angle (≥ 9°) were independent risk factors. These findings are beneficial to predicting the existence of dural ossification preoperatively and investigating the underlying mechanisms.