Journal of Neurosurgery: Spine
Volume 37: Issue 2 (Aug 2022)

Images from Zhou et al. (pp 274–282).

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Srujan Kopparapu, Gordon Mao, Brendan F. Judy, and Nicholas Theodore

In Brief

The objective of this paper was to revisit the often-quoted "rule of Spence." Although innovative at the time, this rule is no longer applicable. This paper helps researchers better understand spinal instability in light of the most current evidence available.

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Liang Yan, Jinpeng Du, Junsong Yang, Baorong He, Dingjun Hao, Bolong Zheng, Xiaobin Yang, Hua Hui, Tuanjiang Liu, Xiaodong Wang, Hua Guo, Jian Chen, Shaofei Wang, Shengzhong Ma, and Shengli Dong
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Daniel Coban, Michael Faloon, Stuart Changoor, Stephen Saela, Nikhil Sahai, Nicole Record, Kumar Sinha, Ki Hwang, and Arash Emami
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Yuichiro Hisada, Tsutomu Endo, Yoshinao Koike, Masahiro Kanayama, Ryota Suzuki, Ryo Fujita, Katsuhisa Yamada, Akira Iwata, Hiroyuki Hasebe, Hideki Sudo, Norimasa Iwasaki, and Masahiko Takahata

In Brief

In this study, the authors aimed to elucidate the difference in the progression pattern of ossification of the posterior longitudinal ligament (OPLL) and its risk factors between cervical and thoracic OPLL using longitudinally acquired whole-spine CT scans. Patients with thoracic OPLL were predisposed to diffuse progression of OPLL over the entire spine, whereas patients with cervical OPLL were likely to have progression in only the cervical spine. Young age and obesity were significant risk factors for OPLL progression, especially in patients with thoracic OPLL.

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Ifije E. Ohiorhenuan, Corey T. Walker, James J. Zhou, Jakub Godzik, Soumya Sagar, S. Harrison Farber, and Juan S. Uribe
Open access
Leonardo Kapural, Jessica Jameson, Curtis Johnson, Daniel Kloster, Aaron Calodney, Peter Kosek, Julie Pilitsis, Markus Bendel, Erika Petersen, Chengyuan Wu, Taissa Cherry, Shivanand P. Lad, Cong Yu, Dawood Sayed, Johnathan Goree, Mark K. Lyons, Andrew Sack, Diana Bruce, Frances Rubenstein, Rose Province-Azalde, David Caraway, and Naresh P. Patel

In Brief

Researchers conducted the first randomized controlled trial reporting the efficacy and durability of high-frequency (10-kHz) spinal cord stimulation (SCS) for nonsurgical refractory back pain (NSRBP) over 12 months compared with conventional medical management (CMM) alone. Patients who received 10-kHz SCS therapy experienced clinically and statistically significant improvements in pain, function, and quality of life. The 10-kHz SCS therapy provided a safe and effective treatment option for patients with back pain that is refractory to CMM and who are not spine surgery candidates.

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Kyle A. McGrath, Jonathan Lee, Nicolas R. Thompson, Joseph Kanasz, and Michael P. Steinmetz

In Brief

This study examined iliolumbar ligament anatomy in patients with Bertolotti syndrome compared to that in controls without a lumbosacral transitional vertebra (LSTV). The authors found significant differences in ligament thickness between the side of the LSTV and the anatomically normal side in patients with unilateral defects. Given the role that the iliolumbar ligament plays in lumbosacral stability, the authors hope that this study provides insight into how Bertolotti syndrome can impact the risk of degenerative disease seen in these patients.

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Katherine G. Holste, Mark M. Zaki, Clare M. Wieland, Yamaan S. Saadeh, and Paul Park

In Brief

Use of a dynamic reference frame (DRF) is necessary for accurate spinal navigation. Iliac pins are typically placed into the posterior superior iliac spine (PSIS) for DRF fixation using a freehand technique. This study showed that appropriate pin placement was achieved in only 77.8% of patients; however, accuracy was not compromised when the pin was not ideally placed into the PSIS. No significant complications were due to suboptimal pin placement.

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Tetsuhiko Mimura, Shota Ikegami, Shugo Kuraishi, Masashi Uehara, Hiroki Oba, Takashi Takizawa, Ryo Munakata, Terue Hatakenaka, Takayuki Kamanaka, Yoshinari Miyaoka, Michihiko Koseki, and Jun Takahashi

In Brief

This study aimed to clarify the extent to which a residual postoperative deformity would be acceptable following adolescent idiopathic scoliosis (AIS) surgery. In patients with Lenke type 1 and 2 AIS, the residual postoperative thoracolumbar/lumbar (TL/L) Cobb angle was significantly associated with self-image and treatment satisfaction. Satisfaction with treatment was more likely when the TL/L Cobb angle was 12.5° or less. This study may be useful for preoperative consultation with patients and surgical planning.

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Khoi D. Than, Vikram A. Mehta, Vivian Le, Jonah R. Moss, Paul Park, Juan S. Uribe, Robert K. Eastlack, Dean Chou, Kai-Ming Fu, Michael Y. Wang, Neel Anand, Peter G. Passias, Christopher I. Shaffrey, David O. Okonkwo, Adam S. Kanter, Pierce Nunley, Gregory M. Mundis Jr., Richard G. Fessler, and Praveen V. Mummaneni
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Jin Yang, Zhiyu Peng, Qingquan Kong, Hao Wu, Yu Wang, Weilong Li, Chuan Guo, and Ye Wu
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Aladine A. Elsamadicy, Andrew B. Koo, Benjamin C. Reeves, Zach Pennington, James Yu, C. Rory Goodwin, Luis Kolb, Maxwell Laurans, Sheng-Fu Larry Lo, John H. Shin, and Daniel M. Sciubba

In Brief

The authors utilized the Hospital Frailty Risk Score, which incorporates more than 100 ICD-10 diagnostic codes, to investigate the association of increasing frailty and healthcare outcomes and healthcare resource utilization after spine surgery for metastatic column spinal tumors. Increasing frailty was associated with increased hospitalizations, nonroutine discharges, and hospital costs. The full clinical significance of how frailty should be incorporated in treatment paradigms in the management of metastatic spine patients is still being investigated.

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Andrew M. Hersh, Jaimin Patel, Zach Pennington, Jose L. Porras, Earl Goldsborough, Albert Antar, Aladine A. Elsamadicy, Daniel Lubelski, Jean-Paul Wolinsky, George Jallo, Ziya L. Gokaslan, Sheng-Fu Larry Lo, and Daniel M. Sciubba

In Brief

The authors present their institutional experience operating on 302 patients with intramedullary spinal cord tumors. Perioperative outcomes were most influenced by operative characteristics rather than tumor pathology, whereas patients with astrocytomas had poorer overall survival than those with ependymomas or hemangioblastomas. As consensus guidelines on the management of intramedullary tumors are lacking, the authors discuss their operative decision-making process as well as the use of intraoperative ultrasound, neuromonitoring, and follow-up assessments.

Open access
Elie Massaad, Christopher P. Bridge, Ali Kiapour, Mitchell S. Fourman, Julia B. Duvall, Ian D. Connolly, Muhamed Hadzipasic, Ganesh M. Shankar, Katherine P. Andriole, Michael Rosenthal, Andrew J. Schoenfeld, Mark H. Bilsky, and John H. Shin

In Brief

The authors used CT imaging to analyze the body composition parameters of patients who underwent surgery for spine metastases. They used machine learning to identify phenotypes of sarcopenia and frailty that were associated with adverse outcomes and compared these with the prospectively validated New England Spinal Metastasis Score. The authors found that low muscle mass and adiposity were associated with a greater risk of complications. Body composition shows promise as a biomarker of frailty and for risk stratification of patients with spinal metastases.

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Hua Zhou, Shanshan Liu, Zhehuang Li, Xiaoguang Liu, Lei Dang, Yan Li, Zihe Li, Panpan Hu, Ben Wang, Feng Wei, and Zhongjun Liu

In Brief

The authors investigated whether 3D artificial vertebral bodies allowing bone ingrowth for anterior reconstruction can quickly provide good stability without the need for bone grafts and with low incidence of prosthesis subsidence after en bloc resection of thoracolumbar spinal tumors. CT HU values measured to evaluate fusion status within the 3D prostheses were significantly higher during longer-term follow-up than the immediate postoperative period, suggesting osseointegration. This is to the authors' knowledge the first report of CT HU values used to detect osseointegration, which may be valuable to detect bone ingrowth of the 3D prosthesis without bone graft.

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Yike Jin, Ann Liu, Jessica R. Overbey, Ravi Medikonda, James Feghali, Sonya Krishnan, Wataru Ishida, Sutipat Pairojboriboon, Ziya L. Gokaslan, Jean-Paul Wolinsky, Nicholas Theodore, Ali Bydon, Daniel M. Sciubba, Timothy F. Witham, and Sheng-Fu L. Lo

In Brief

Researchers analyzed the demographic and clinical factors of all patients who presented to a single institution with primary spinal infections over a 9.5-year period. The presence of epidural abscess, involvement of the cervical and/or thoracic spine, and increasing number of levels involved were all risk factors for eventually requiring surgery. Physicians caring for patients with primary spinal infections can assess for these risk factors when making decisions on the need for surgical intervention.

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Samantha E. Hoffman, Blake M. Hauser, Mark M. Zaki, Saksham Gupta, Melissa Chua, Joshua D. Bernstock, Ayaz M. Khawaja, Timothy R. Smith, and Hasan A. Zaidi
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Matthew A. Tovar, Ehsan Dowlati, David Y. Zhao, Ziam Khan, Kory B. D. Pasko, Faheem A. Sandhu, and Jean-Marc Voyadzis

In Brief

Use of technology-enhanced thoracolumbar instrumentation with robotic and augmented reality assistance continues to grow in the field of spinal surgery. The authors aimed to quantify the magnitude of benefit imparted by these technologies with respect to screw accuracy and other patient-centered perioperative outcomes. Technology-enhanced thoracolumbar instrumentation is advantageous for both patients and surgeons. This observed patient benefit is paramount as more institutions choose to invest fiscal resources in these advanced technologies.

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Tadatsugu Morimoto, Masatsugu Tsukamoto, Tomohito Yoshihara, Takaomi Kobayashi, and Masaaki Mawatari
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In Brief

Patients with spinal column dislocation-translation injuries are at high risk for spinal cord injury. The authors found that 6.1 mm of spinal column translation was an optimal cutoff point to predict complete spinal cord injury, whereas 10.4 mm of translation predicted no postoperative neurologic improvement. More robust data are available for predicting outcomes after cervical spine injuries than those of the thoracic spine.

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OBJECTIVE

Extension fractures in the setting of diffuse idiopathic skeletal hyperostosis (DISH) represent highly unstable injuries. As a result, these fractures are most frequently treated with immediate surgical fixation to limit any potential risk of associated neurological injury. Although this represents the standard of care, patients with significant comorbidities, advanced age, or medical instability may not be surgical candidates. In this paper, the authors evaluated a series of patients with extension DISH fractures who were treated with orthosis alone and evaluated their outcomes.

METHODS

A retrospective review from 2015 to 2022 was conducted at a large level 1 trauma center. Patients with extension-type DISH fractures without neurological deficits were identified. All patients were treated conservatively with orthosis alone. Baseline patient characteristics and adverse outcomes are reported.

RESULTS

Twenty-seven patients were identified as presenting with extension fractures associated with DISH without neurological deficit. Of these, 22 patients had complete follow-up on final chart review. Of these 22 patients, 21 (95.5%) were treated successfully with external orthosis. One patient (4.5%) who was noncompliant with the brace had an acute spinal cord injury 1 month after presentation, requiring immediate surgical fixation and decompression. No other complications, including skin breakdown or pressure ulcers related to bracing, were reported.

CONCLUSIONS

Treatment of extension-type DISH fractures may be a reasonable option for patients who are not candidates for safe surgical intervention; however, a risk of neurological injury secondary to delayed instability remains, particularly if patients are noncompliant with the bracing regimen. This risk should be balanced against the high complication rate and potential mortality associated with surgical intervention in this patient population.

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In Brief

This study evaluated the trends of single-level subaxial anterior cervical discectomy and fusion utilization from 2011 to 2019 to determine whether the 2015 Centers for Medicare & Medicaid Services (CMS) audit of interbody cages and anterior instrumentation coding influenced the reported usage of additional anterior instrumentation. From 2015 to 2019, additional anterior instrumentation documentation significantly decreased by 18.1%. The 2015 CMS audit may account for this, and understanding auditing could help surgeons perceive changes in practice patterns to better evaluate patient outcomes, costs, and value.

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OBJECTIVE

Lumbar synovial cysts (LSCs) represent a relatively rare clinical pathology that may result in radiculopathy or neurogenic claudication. Because of the potential for recurrence of these cysts, some authors advocate for segmental fusion, as opposed to decompression alone, as a way to eliminate the risk for recurrence. The objective of this study was to create a predictive score for synovial cyst recurrence following decompression without fusion.

METHODS

A retrospective chart review was completed of all patients evaluated at a single center over 20 years who were found to have symptomatic LSCs requiring intervention. Only patients undergoing decompression without fusion were included in the analysis. Following this review, baseline characteristics were obtained as well as radiological information. A machine learning method (risk-calibrated supersparse linear integer model) was then used to create a risk stratification score to identify patients at high risk for symptomatic cyst recurrence requiring repeat surgical intervention. Following the creation of this model, a fivefold cross-validation was completed.

RESULTS

In total, 89 patients were identified who had complete radiological information. Of these 89 patients, 11 developed cyst recurrence requiring reoperation. The Lumbar Synovial Cyst Score was then created with an area under the curve of 0.83 and calibration error of 11.0%. Factors predictive of recurrence were found to include facet inclination angle > 45°, canal stenosis > 50%, T2 joint space hyperintensity, and presence of grade I spondylolisthesis. The probability of cyst recurrence ranged from < 5% for a score of 2 or less to > 88% for a score of 7.

CONCLUSIONS

The Lumbar Synovial Cyst Score model is a quick and accurate tool to assist in clinical decision-making in the treatment of LSCs.

Open access

In Brief

The authors describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of every historical sacral and pelvic grading system to date. The novel AO Spine classification is universally applicable and redefines as well as reorders traditional fracture morphologies into a rational hierarchical system. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking neurological status into consideration.

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In Brief

Adult cervical deformity (ACD) can markedly impact health-related quality of life (HRQL). The authors' objective was to prospectively assess minimum 2-year outcomes and complications of ACD surgery based on patients enrolled at 13 centers. Overall, 57% of patients had at least one complication. Patient-reported outcome measures of pain, disability, and health significantly improved from baseline to last follow-up. Despite high complication rates, operative treatment for ACD can significantly improve HRQL at minimum 2-year (mean 3.4-year) follow-up.

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In Brief

The objective of this study was to provide an initial validation of a recent morphological classification of cervical spine deformity pathology. One unique feature of this classification is its broad application in various care settings, based solely on plain radiographs. The overall reliability and accuracy of this cervical deformity morphological classification across various experiences were demonstrated. Understanding the main drivers of these deformities can aid the preoperative workup and initial treatment-planning algorithm.

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In Brief

The authors aimed to investigate the incidence of postoperative persistent coronal imbalance (PCI) in patients with idiopathic scoliosis Lenke types 5C and 6C. Among 108 patients, 10 (9%) had PCI. The PCI (+) group had significantly worse clinical scores than the PCI (−) group. Preoperative apical vertebral translation of the thoracolumbar/lumbar curve and postoperative coronal balance are important parameters for predicting PCI. In selective fusion surgery, PCI tends to occur in older patients due to reduced flexibility and compensatory abilities.

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In Brief

The objective of this study was to evaluate the mitigating effects of sublaminar bands (SBs), placed rostral to the instrumented lumbar spine, against adjacent-segment disease (ASD). The investigation revealed that SBs reduced, but did not eliminate, motion of the segment above the instrumented spine and reduced intradiscal pressure. Potentially, SBs applied around the mobile spine adjacent to the fusion will protect against the development of ASD and reduce the need for future extension of the fusion.

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In Brief

The authors investigated the association between thoracolumbar junctional parameters and the proximal junctional kyphosis (PJK) following adult spinal deformity surgery. The risk of PJK was higher when the changes in thoracolumbar angle (ΔTLA) and postoperative thoracolumbar slope (TLS) were larger than 3.58° and -9.46°, respectively. The present study highlights the thinking that extensive correction of ΔTLA and TLS should be avoided. Contouring the rod to the natural curve of the upper instrumented vertebra region could help lower the odds of PJK.

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In Brief

This study aimed to determine if artificial intelligence (AI) could accurately and independently measure 4 key spinopelvic parameters on radiographs comparable to the manual measurements by experts. AI was found to have a high degree of accuracy when compared to experts. Spinopelvic measurements are part of the surgical routine, but are time-consuming and potentially error prone. Advancements in AI can increase efficiency and reduce errors in the day-to-day workflow.

Open access

In Brief

This study was designed to demonstrate the safety of intraspinal cord injection of an oligodendrocyte progenitor cell line in individuals with subacute cervical spinal cord injury (SCI). The secondary goal was to evaluate efficacy to return neurological function. The results clearly demonstrate safety and, although not a randomized controlled study, also suggested efficacy in returning one level of neurological function in nearly all patients, and two levels on at least one side in one-third of the patients. This study provides valuable information that can be applied in the next steps in evaluating stem cell treatment of subacute SCI.

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Chu et al. present an interesting single-institution series of a unique microsurgical approach to treat symptomatic sacral Tarlov cysts (TCs). 1 Sacral TCs are extradural meningeal cysts with CSF between the endoneurium and perineurium of the nerve root sheath and contain neural tissue (nerve roots and/or dorsal root ganglia). 2 While most are clinically silent without consequence, a variably reported percentage (1%–20%) may be associated with low-back or coccygeal pain, radiculopathy, paresthesia, leg weakness, bladder and bowel dysfunction, dyspareunia or sexual dysfunction, and positional headache. 3 In this series, the authors report notable long-term symptomatic

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In Brief

The objective of this study was to assess the outcomes of minimally invasive lumbar decompression in patients 80 years of age or older and compare them with those of younger patients. It was found that although there was less and slower improvement in patients ≥ 80 years of age, they did improve significantly and had low complication and reoperation rates. Advanced age should not be seen as a barrier to surgery but act as a reminder for careful patient selection and the setting of realistic expectations.

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OBJECTIVE

Tarlov cysts (TCs) are a common cystic entity in the sacral canal, with a reported prevalence between 1.5% and 13.2%; 10%–20% of patients are symptomatic and need appropriate clinical intervention. However, the choice of treatment remains controversial. The goal of this study was to describe a new microsurgical sealing technique for symptomatic sacral TCs (SSTCs) as well as its long-term outcomes.

METHODS

Microsurgical sealing was performed using a short incision, leakage coverage with a piece of autologous fat, and cyst sealing with fibrin glue. Postoperative data were collected at three stages: discharge, 1-year follow-up, and a follow-up of 3 years or more. According to the improvement in neurological deficits and degree of pain relief, outcomes were divided into four levels: excellent, good, unchanged, and deteriorated.

RESULTS

A total of 265 patients with SSTCs were treated with microsurgical sealing from January 2003 to December 2020. The mean follow-up was 44.69 months. The percentages of patients who benefited from the operation (excellent and good) at the three stages were 87.55%, 84.89%, and 80.73%, respectively, while those who received no benefit (unchanged and deteriorated) were 12.45%, 15.11%, and 19.27%, respectively. Of the patients with postoperative MRI, the cysts were reduced in size or disappeared in 209 patients (94.14%). CSF leakage from the wound was observed in 15 patients, and 4 patients experienced an infection at the incision. There were no cases of new-onset nerve injury or aseptic meningitis after the operation.

CONCLUSIONS

SSTC patients undergoing microsurgical sealing had persistently high rates of symptom relief and few postoperative complications. Microsurgical sealing is an effective, simple, and low-risk method for treating SSTCs.

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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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In Brief

In this retrospective, single-center study, 120 patients who underwent laminoplasty for multilevel cervical spondylotic myelopathy (CSM) were analyzed to identify factors that could predict residual anterior spinal cord compression (RASCC). The risk factors for RASCC differed, depending on the location of the most stenotic segment (C3–4 vs C4–7). If there is segmental kyphosis at the most stenotic segment at C4–7, anterior decompression and fusion should be considered. If C3–4 is the most stenotic, the authors also recommend anterior surgery, or one can choose laminoplasty with complete C3 laminectomy and resection of the C2–3 ligamentum flavum.

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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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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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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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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.

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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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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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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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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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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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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.

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OBJECTIVE

Patients with ankylosing spinal disorders (ASDs), including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), have been shown to experience significantly increased rates of postoperative complications. Despite this, very few risk stratification tools have been validated for this population. As such, the purpose of this study was to identify predictors of adverse events and mortality in ASD patients undergoing surgery for 3-column fractures.

METHODS

All adult patients with a documented history of AS or DISH who underwent surgery for a traumatic 3-column fracture between 2000 and 2020 were identified. Perioperative variables, including comorbidities, time to diagnosis, and number of fused segments, were collected. Three instruments, including the Charlson Comorbidity Index (CCI), modified frailty index (mFI), and Injury Severity Score (ISS), were computed for each patient. The primary outcomes of interest included 1-year mortality, as well as postoperative complications.

RESULTS

A total of 108 patients were included, with a mean ± SD age of 73 ± 11 years. Of these, 41 (38%) experienced at least 1 postoperative complication and 22 (20.4%) died within 12 months after surgery. When the authors controlled for potential known confounders, the CCI score was significantly associated with postoperative adverse events (OR 1.20, 95% CI 1.00–1.42, p = 0.045) and trended toward significance for mortality (OR 1.19, 95% CI 0.97–1.45, p = 0.098). In contrast, mFI score and ISS were not significantly predictive of either outcome.

CONCLUSIONS

Complications in spine trauma patients with ASD may be driven by comorbidity burden rather than operative or injury-related factors. The CCI may be a valuable tool for the evaluation of this unique population.

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TO THE EDITOR: I read with interest the article by Sugawara et al. 1 (Sugawara T, Higashiyama N, Tamura S, et al. Novel wrapping surgery for symptomatic sacral perineural cysts. J Neurosurg Spine. 2022;36[2]:185-192). The authors presented seven carefully selected Tarlov cyst patients who underwent partial sacral laminectomy, cyst aspiration, and wrapping with an expanded polytetrafluoroethylene (ePTFE) membrane (Gore-Tex). As reported, all patients had durable relief. This nicely illustrated paper provides a refreshing proof of concept of one mechanism of Tarlov cyst disease and the benefits of surgery. It should be noted that this small

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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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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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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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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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Dr. Ruth Jackson, born in 1902, was the first female spine surgeon on record. Her story of remarkable resilience and sacrifice is even more relevant given the stark gender disparities in orthopedic surgery and neurosurgery that remain today. Dr. Jackson entered the field during the Great Depression and overcame significant barriers at each step along the process. In 1937, she became the first woman to pass the American Board of Orthopedic Surgery examination and join the American Academy of Orthopedic Surgeons as a full member. Her work in the cervical spine led to a notable lecture record and the publication of several articles, as well as a book, The Cervical Syndrome, in which she discussed the anatomy, etiology, and treatment of cervical pathologies. Additionally, Dr. Jackson developed the Jackson CerviPillo, a neck support that is still in use today. She left a legacy that continues to resonate through the work of the Ruth Jackson Orthopedic Society, which supports women at all levels of practice and training. From the story of Dr. Jackson’s life, we can appreciate her single-minded determination that blazed a path for women in spine surgery, as well as consider the progress that remains to be made.

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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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In Brief

The authors used the profiles of multiple diffusion basis spectrum imaging (DBSI) metrics as imaging outcome predictors to accurately predict a patient's response to therapy and long-term prognosis using a support vector machine (SVM). The SVM incorporating clinical and DBSI metrics had the highest performance in predicting patient outcomes. The results suggest that DBSI metrics along with clinical presentation could serve as a surrogate in prognosticating surgical outcomes of patients with cervical spondylotic myelopathy.

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OBJECTIVE

In multilevel posterior cervical instrumented fusion, extension of fusion across the cervicothoracic junction (CTJ) at T1 or T2 has been associated with decreased rates of reoperation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient-reported outcomes (PROs) remains unclear. The primary objective was to determine whether extension of fusion through the CTJ influenced PROs at 3, 12, and 24 months after surgery. The secondary objective was to compare the number of patients who reached the minimal clinically important differences (MCIDs) for the PROs, modified Japanese Orthopaedic Association (mJOA) score, operative time, intraoperative blood loss, length of stay, discharge disposition, adverse events (AEs), reoperation within 24 months of surgery, and patient satisfaction.

METHODS

This was a retrospective observational cohort study of prospectively collected multicenter data of patients with degenerative cervical myelopathy. Patients who underwent posterior instrumented fusion of 4 levels or greater (between C2 and T2) between January 2015 and October 2020 and received 24 months of follow-up were included. PROs (scores on the Neck Disability Index [NDI], EQ-5D, physical component summary and mental component summary of SF-12, and numeric rating scale for arm and neck pain) and mJOA scores were compared using ANCOVA and adjusted for baseline differences. Patient demographic characteristics, comorbidities, and surgical details were abstracted. The proportions of patients who reached the MCIDs for these outcomes were compared with the chi-square test. Operative duration, intraoperative blood loss, AEs, reoperation, discharge disposition, length of stay, and satisfaction was compared by using the chi-square test for categorical variables and the independent-samples t-test for continuous variables.

RESULTS

A total of 198 patients were included in this study (101 patients with fusion not crossing the CTJ and 97 with fusion crossing the CTJ). Patients with a construct extending through the CTJ were more likely to be female and have worse baseline NDI scores (p > 0.05). When adjusted for baseline differences, there were no statistically significant differences between the two groups in terms of the PROs and mJOA scores at 3, 12, and 24 months. Surgical duration was longer (p < 0.001) and intraoperative blood loss was greater in the group with fusion extending to the upper thoracic spine (p = 0.013). There were no significant differences between groups in terms of AEs (p > 0.05). Fusion with a construct crossing the CTJ was associated with reoperation (p = 0.04). Satisfaction with surgery was not significantly different between groups. The proportions of patients who reached the MCIDs for the PROs were not statistically different at any time point.

CONCLUSIONS

There were no statistically significant differences in PROs between patients with a posterior construct extending to the upper thoracic spine and those without such extension for as long as 24 months after surgery. The AE profiles were not significantly different, but longer surgical time and increased blood loss were associated with constructs extending across the CTJ.

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TO THE EDITOR: We read the article by Ronald et al. 1 with great interest and concern (Ronald AA, Sadda V, Rabah NM, et al. Patient complaints in the postoperative period following spine surgery. J Neurosurg Spine. 2022;36[3]:509-516). The authors present a retrospective, observational, matched case-control study designed to better understand postoperative patient complaints following spinal surgeries performed at their institution over a 5-year period. We appreciate and applaud the authors’ efforts to evaluate the complex relationship between diversity, systemic bias, and patient feedback. Despite our respect for the authors’ approach, we believe that there

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TO THE EDITOR: We read with great interest the article by Liu et al. 1 (Liu A, Jin Y, Cottrill E, et al. Clinical accuracy and initial experience with augmented reality–assisted pedicle screw placement: the first 205 screws. J Neurosurg Spine. 2022;36[3]:351-357). The authors performed a retrospective study aimed at reporting on the accuracy of pedicle screw placement using augmented reality (AR) assistance with a head-mounted display (HMD) navigation system. Here, we add our contribution, which may help to better understand the use of AR technology.

To begin, we provide some historical context: the virtual

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