Journal of Neurosurgery: Spine
Volume 34: Issue null (Apr 2021): Pages 541-689

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Authors: Marjorie C. Wang and Mohammed Y. T. AlGhamdi
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Authors: Anouk Borg, Ciaran Scott Hill, Besnik Nurboja, Giles Critchley, and David Choi

In Brief

The primary objective of this randomized controlled trial was to establish whether the X-Stop interspinous distractor device is more or less cost-effective than laminectomy for the treatment of lumbar spinal stenosis. The authors found that laminectomy was more cost-effective, patients had higher quality-of-life scores, and the procedure was cheaper than insertion of the interspinous device. The complication rate and operative time were higher for laminectomy. However, the X-Stop may have a role in patients who are unable to have a laminectomy.

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Authors: Rachid Bech-Azeddine, Søren Fruensgaard, Mikkel Andersen, and Leah Y. Carreon
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Authors: Jin-Sung Park, Se-Jun Park, Chong-Suh Lee, Tae-hoon Yum, and Bo-Taek Kim

In Brief

The authors aimed to determine which radiological parameters related to the aging spine are associated with curve progression in early degenerative lumbar scoliosis (DLS), in particular which factors predict curve progression. In early DLS patients observed for a mean of 13.7 years, asymmetrical disc degeneration in the lower disc space of the apical vertebra, leading to lower apical vertebral disc wedging angles, was the most important factor in predicting curve progression. Therefore, patients with this finding need to be closely monitored.

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Authors: Dong Hyun Lee, Dong-Geun Lee, Jin Sub Hwang, Jae-Won Jang, Dae Hyeon Maeng, and Choon Keun Park

In Brief

This study aimed to evaluate the clinical and radiological effects of indirect decompression after anterior lumbar interbody fusion for central spinal canal stenosis. The authors believe that their study makes a significant contribution to the literature because it reports on the effects of indirect decompression of central canal stenosis performed using anterior lumbar interbody fusion, which has been less studied, and this is also the first quantitative analysis of indirect decompression after anterior lumbar interbody fusion for central spinal canal stenosis.

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Authors: Shizumasa Murata, Akihito Minamide, Masanari Takami, Hiroshi Iwasaki, Sae Okada, Kento Nonaka, Hiroshi Taneichi, Andrew J. Schoenfeld, Andrew K. Simpson, and Hiroshi Yamada

In Brief

The objective of this study was to elucidate the efficacy of the cyst-dyeing method in microendoscopic spinal decompression surgery for lumbar spinal stenosis caused by facet cysts. The adjunctive cyst-dyeing method effectively delineated cyst and dural boundaries, facilitating safer and more effective cyst separation and neural decompression, even with microendoscopic surgery. Microendoscopic surgery combined with the authors' novel facet cyst-dyeing method is a safe and effective minimally invasive technique for facet-joint cysts.

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Authors: Daniel Lubelski, James Feghali, Amy S. Nowacki, Vincent J. Alentado, Ryan Planchard, Kalil G. Abdullah, Daniel M. Sciubba, Michael P. Steinmetz, Edward C. Benzel, and Thomas E. Mroz

In Brief

Analyzing approximately 3000 degenerative lumbar spine surgeries at Cleveland Clinic, the investigators found that 7% are seen in the ED and 12% are readmitted at 30 days; 3% undergo reoperation within 3 months. Fifty-six percent of patients achieve clinically significant improvement in EuroQOL-5D quality-of-life scores. Prediction nomograms and a web-based calculator were developed to preoperatively identify the likelihood of those outcomes. Concordance indices for the models ranged from 0.63 to 0.84 and can be accessed here: https://riskcalc.org/PatientsEligibleForLumbarSpineSurgery/.

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Authors: Hiroshi Moridaira, Satoshi Inami, Daisaku Takeuchi, Haruki Ueda, Hiromichi Aoki, Takuya Imura, and Hiroshi Taneichi

In Brief

Researchers evaluated radiographic and clinical outcomes after shorter fusion for subtypes of adult spinal deformity and examined factors associated with successful short fusion. If the pelvic incidence is < 47°, the use of short fusion can produce adequate lumbar lordosis for the pelvic incidence, improving both postoperative global spinal alignment and quality of life. The researchers proposed an algorithm to decide when to consider the shorter constructs.

Open access
Authors: Daisuke Sakai, Jordy Schol, Akihiko Hiyama, Hiroyuki Katoh, Masahiro Tanaka, Masato Sato, and Masahiko Watanabe

In Brief

The authors compared an adapted simultaneous translation on two rods (ST2R) technique to the standard rod rotation technique for spinal corrections in patients with hypokyphotic adolescent idiopathic scoliosis (AIS). This study revealed that ST2R was more effective in Cobb angle support and corrections of thoracic kyphosis and apex location, with patient decreases in pain and increased treatment satisfaction. This work reveals an improved method using ST2R for AIS corrections and provides a clear and detailed technical description of the technique to enhance adaptation by other surgeons.

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Authors: Chang-Hyun Lee, Young II Won, Young San Ko, Seung Heon Yang, Chi Heon Kim, Sung Bae Park, and Chun Kee Chung

In Brief

This study aimed to compare various surgical methods for Scheuermann kyphosis. In the past, the anterior-posterior approach was the gold standard. Recently, the posterior-only approach with osteotomies accomplished comparable correction of the deformity and few complications. With the technical advancement of deformity correction, the posterior-only surgery needs to be reevaluated as a gold standard for Scheuermann kyphosis.

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Authors: Anthony L. Mikula, Jeremy L. Fogelson, Soliman Oushy, Zachariah W. Pinter, Pierce A. Peters, Kingsley Abode-Iyamah, Arjun S. Sebastian, Brett Freedman, Bradford L. Currier, David W. Polly, and Benjamin D. Elder

In Brief

The authors compared standing and supine radiographs for 73 patients and found that those with bilateral sacroiliac (SI) joint vacuum signs, as identified on CT, had a change in pelvic incidence between the supine and standing positions. This suggests there may be increasing motion across the SI joint with significant joint degeneration.

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Authors: Christopher Wilson, Mariana Hoyos, Andrew Huh, Blake Priddy, Stephen Avila, Stephen Mendenhall, Miracle C. Anokwute, George J. Eckert, and David W. Stockwell

In Brief

The authors assessed the safety of fibrous union in type II odontoid fractures, which occurred commonly with nonoperative management. The use of braced upright cervical radiographs to aid decision-making in type II odontoid fracture management was validated. Operative and nonoperative management outcomes were compared. A management algorithm for these common fractures is provided with supporting safety and efficacy profiles from the authors' high-volume center.

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Authors: Parmenion P. Tsitsopoulos, Ulrika Holmström, Kaj Blennow, Henrik Zetterberg, and Niklas Marklund

In Brief

The authors tested the hypothesis that preoperative cerebrospinal fluid (CSF) biomarkers are altered in patients with cervical spondylotic myelopathy and correlate with neurological status and outcome. Biomarkers of glial and axonal damage in CSF biomarkers were increased, while amyloid breakdown products were decreased. Correlations between preoperative neurological picture and outcome were noted. CSF biomarkers can reflect the ongoing pathophysiology of spinal cord compression and damage and may provide prognostic information on surgical outcome.

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Authors: Alberto Campione, Gianluca Agresta, Davide Locatelli, and Fabio Pozzi
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Authors: Takumi Kajitani, Toshiki Endo, Naoya Iwabuchi, Tomoo Inoue, Yoshiharu Takahashi, Takatsugu Abe, Kuniyasu Niizuma, and Teiji Tominaga

In Brief

Multilineage-differentiating stress-enduring (Muse) cells are pluripotent stem cells that can migrate after transplantation to an injured site and exert repair effects, showing promise for the treatment of spinal cord injury (SCI). The authors applied Muse cells in a rat model of SCI using a human-derived preclinical product, CL2020. Intravenous administration of CL2020 successfully led to significant functional recovery from SCI, an important finding indicating that intravenous Muse cell administration via CL2020 could be a feasible SCI treatment option in future clinical studies in human patients.

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Authors: Hiroki Ushirozako, Tomohiko Hasegawa, Yu Yamato, Go Yoshida, Tatsuya Yasuda, Tomohiro Banno, Hideyuki Arima, Shin Oe, Yuki Mihara, Tomohiro Yamada, Koichiro Ide, Yuh Watanabe, Keichi Nakai, Takaaki Imada, and Yukihiro Matsuyama

In Brief

The authors used a propensity score–matched analysis for the adjustment of patient baseline and surgical data, including nutritional status, to clarify whether intrawound vancomycin powder decreases surgical site infection (SSI) rates after posterior spinal surgery. Intrawound vancomycin powder reduced the risk of SSI after posterior spinal surgery by half without systemic adverse events, an important finding indicating that the use of intrawound vancomycin powder is a safe and effective procedure for SSI prevention.

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Authors: Timothy J. Yee, Yamaan S. Saadeh, Michael J. Strong, Ayobami L. Ward, Clay M. Elswick, Sudharsan Srinivasan, Paul Park, Mark E. Oppenlander, Daniel E. Spratt, William C. Jackson, and Nicholas J. Szerlip

In Brief

It is not definitively known whether fusion following decompression and instrumentation for spinal metastatic disease is necessary for a good outcome or even feasible. In this large and comprehensive study, rates of both fusion and hardware failure were found to be low due to a high competing risk of death. These data give further impetus to the study of nonfusion methods in this population, which can reduce both procedural morbidity and healthcare costs.

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Authors: Gonzague Guillaumet, Nozar Aghakhani, Silvia Morar, Razvan Copaciu, Fabrice Parker, and Steven Knafo

In Brief

In this study the authors compared the clinical outcome and rate of reintervention between arachnolysis and shunting for syringomyelia secondary to spinal arachnoiditis. The authors showed that arachnolysis led to better outcome and fewer reinterventions than shunting, but that this result was largely driven by the extension of the arachnoiditis. Therefore, arachnolysis should be proposed as a treatment to patients with focal (< 3 spinal segments) arachnoiditis, while surgery should be avoided whenever possible for extensive cases.

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Authors: Robert Young, Ethan Cottrill, Zach Pennington, Jeff Ehresman, A. Karim Ahmed, Timothy Kim, Bowen Jiang, Daniel Lubelski, Alex M. Zhu, Katherine S. Wright, Donna Gavin, Alyson Russo, Marie N. Hanna, Ali Bydon, Timothy F. Witham, Corinna Zygourakis, and Nicholas Theodore

In Brief

The authors have designed and implemented an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective procedures at a tertiary care facility and evaluated the ERASS protocol's efficacy (e.g., opiate use on postoperative day 1 and length of stay) by comparing patients enrolled in the ERASS group (n = 97) to a historic cohort (n = 146). Implementation of ERASS reduced postoperative opiate consumption and hospitalization, supporting its efficacy in reducing care costs and improving patient outcomes in spine surgery.

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Authors: Asham Khan, John Pollina, and Jeffrey P. Mullin
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Author: Presented Virtually, April 8–10, 2021
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In Brief

This study sought to investigate functional outcomes of patients with degenerative cervical myelopathy who were managed nonoperatively and the utility of quantitative clinical measures and anatomical MRI to detect deterioration. The results suggest that degenerative cervical myelopathy has a poor natural history, with more than 50% deteriorating in short- to midterm follow-up. Clinical assessments to detect deterioration should include the modified Japanese Orthopaedic Association score, grip strength, dexterity, balance, and gait analysis. Anatomical MRI and modified Japanese Orthopaedic Association score (as a stand-alone clinical measure) are insufficient to identify neurological deterioration in the majority of cases.

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In Brief

Researchers retrospectively evaluated the effectiveness of posterior spinal fixation with penetrating endplate screws (PESs) in patients with diffuse idiopathic skeletal hyperostosis (DISH)-related thoracolumbar fractures. Patients treated with the PES technique had less blood loss, shorter range of fixation, and less screw loosening than those with the conventional pedicle screw technique. This simple and highly fixable PES technique may be an ideal spinal fixation procedure for DISH-related fractures.

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In Brief

The authors sought to identify the drivers of length of stay (LOS) in the hospital following elective lumbar laminectomy and to understand their relationships with patient outcomes and costs. Even after adjusting for underlying health risks, the authors found that discharge to specialty care facilities and late-week surgery are significant predictors of prolonged LOS and result in greater costs of care. Efforts to optimize surgical scheduling and care coordination may help lower costs and improve patient experience without changing neurosurgical care.

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In Brief

The authors investigated the effects of cervical reconstruction on global sagittal alignment, including lower extremities and HRQOL. Patients with cervical kyphosis showed compensatory changes in the upper cervical spine and thoracolumbar spine instead of in the lower extremities, which resolved reciprocally in a different manner in the head- and trunk-balanced subtypes. Reciprocal change occurs differently according to the subtype of cervical kyphosis.

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In Brief

This study aims to classify intradural spinal arteriovenous shunts (ID-SAVSs) into 5 types of lesions, based on the precise anatomical disposition, angioarchitectonics, and spinal histogenetic segmentations. Each type of lesion is associated with specific genetic nonhereditary and hereditary syndromes, specific angioarchitectonics, and a specific distribution in spinal histogenetic segmentation. The current classification will facilitate a better understanding of the pathophysiology and etiology of ID-SAVSs and better therapeutic management.

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In Brief

Researchers aimed to identify patient-related factors and radiographic parameters associated with an increased risk for inferior health-related quality-of-life scores in nonoperative (N-Op) patients with adult spinal deformity. When controlling for baseline deformity in N-Op versus operative (Op) patients, subsequent deterioration in frailty, BMI, and radiographic progression over the 2-year follow-up were found to drive suboptimal patient-reported outcome measures in N-Op cohorts as measured by validated Oswestry Disability Index and Scoliosis Research Society clinical instruments. These findings may be incorporated into clinical decision-making to aid surgeons in providing treatment options that achieve the best possible patient outcomes.

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In Brief

The authors reviewed a large institutional series of patients undergoing 4- and 5-level anterior cervical discectomy and fusion procedures. They found that 57% of patients experienced transient dysphagia, with rates decreasing to 6% and 2.8% at 1 and 2 years, respectively. Short-term dysphagia was more likely in patients with a larger increase in lordosis postoperatively. This study provides information to help counsel patients regarding their risk of swallowing difficulty after this procedure.

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In Brief

This study described a novel sequential correction technique and compared the results with the traditional correction technique. The results revealed that this technique could significantly and practically reduce the difficulty of rod installation with a better correction rate of the deformity and fewer complications. The technique could serve as a safe and effective method for better postoperative radiographic and clinical outcomes for the surgical treatment of severe thoracic idiopathic scoliosis.

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In Brief

In this study, the authors aimed to evaluate the clinical outcomes of different distal fixation anchors in lumbosacral spinal deformities associated with sacral agenesis. They found that S2AI screws can achieve a more satisfactory correction with fewer implant-related complications than occurred with S1 and iliac screws. These findings provide surgeons with a better understanding of spinopelvic fixation and may guide surgical decision-making for patients with lumbosacral scoliosis associated with sacral agenesis.

Open access

In Brief

Within a randomized clinical trial, standard titanium alloy and stiffer cobalt-chromium rods were compared on their ability to support adolescent idiopathic scoliosis (AIS) surgical deformity correction. This study found that both titanium alloy and cobalt-chromium supported clinically significant spine deformity corrections and pain, self-image, and disability scores at similar rates. This work reveals that both materials are equally effective in correcting AIS, suggesting that rod selection should primarily involve considerations regarding material costs, MRI compatibility, and rod profile longevity.

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In Brief

The authors engaged in an ongoing effort to reach consensus on a core set of outcome measures and harmonize the measure definitions across patient registries that collect large amounts of data on degenerative lumbar spondylolisthesis treatment pathways and patient outcomes. This process will make it easier to connect data across registries to answer research questions, support clinical decision-making, and ultimately improve patient outcomes.

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In Brief

The authors used the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey to assess the key drivers of patient satisfaction with their surgeon after lumbar spine surgery. Top-box responses on those questions pertaining to physician communication were found to be associated with the greatest likelihood of overall satisfaction. This confirms the importance of effective communication in the patient-provider interaction and points to potential prospects for quality improvement efforts in the spine care setting.

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In Brief

The authors sought to provide information on primary adult tethered cord syndrome (TCS). The pathologies found in 24 patients analyzed were diastematomyelia, TCS with conus lipoma, and TCS with taut filum terminale. Despite previous neurosurgical or orthopedic evaluations, no patients had missed cases of neurocutaneous stigmata or scoliosis. The triad of nondermatomal back or perineal pain, bladder dysfunction, and preexisting neurological deficits raises suspicion of a TCS diagnosis. In patients with symptom duration less than 3 years, objective postoperative improvement was documented.

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In Brief

This study analyzed cervical deformity conversion following corrective surgery for adult spinal deformity across radiographic parameters, proximal junctional kyphosis rates, revision rates, and clinical factors. Conversion from baseline cervical alignment to postoperative cervical deformity occurred the most within the immediate postoperative period (<6 weeks), although late conversion up to 3 years was also observed. Predictors of cervical deformity conversion included higher baseline pelvic incidence–lumbar lordosis mismatch and lower thoracic kyphosis and lumbar lordosis. Higher cervical lordosis, C2–T3 angle, body mass index, and Charlson Comorbidity Index were specific positive predictors of late (1- to 3-year) cervical deformity conversion.

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In Brief

This study evaluates the treatment of coronal deformity in patients treated with circumferential minimally invasive surgical fusion in which lateral and anterior lumbar interbody fusion with percutaneous pedicle screw fixation were used. This study is the first to examine coronal malalignment in this context. Circumferential minimally invasive surgical fusion is successful at correcting coronal malalignment in most patients; however, patients whose preoperative truncal shift is toward the convexity of their major curve (type C) remain the most difficult to treat.

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In Brief

Minimally invasive surgery (MIS) for spinal deformity uses interbody techniques for correction, indirect decompression, and arthrodesis. Selection criteria for choosing a particular interbody approach are lacking. The authors created the minimally invasive interbody selection algorithm (MIISA) to provide a framework for rational decision-making in MIS for deformity. Understanding the limitations and differences in segmental lordosis for each level by approach can assist surgeons in optimizing care.

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In Brief

In patients undergoing surgery for cervical ossification of the posterior longitudinal ligament, the authors compared neurological recoveries based on patient presentation with mild, moderate, or severe preoperative myelopathy. Important determinants of unfavorable outcome were patient-related factors such as age or diabetes in patients with mild preoperative myelopathy and high signal intensity change in the spinal cord, male sex, and age older than 60 years in patients with moderate to severe myelopathy. The authors recommend anterior decompression with fusion for patients with moderate to severe preoperative myelopathy.

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In Brief

The authors used augmented reality neuronavigation via a head-mounted display with an integrated optical tracking camera to perform an en bloc spondylectomy of an L1 chordoma. Augmented reality projection of neuronavigation data overlaid onto the surgical field resulted in simultaneous visualization for guidance and positioning of an ultrasonic osteoplastic blade. The technique enabled minimized tissue dissection by providing precise navigational data for avoiding a tumor capsule breach while still performing the narrowest cuts possible.

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In Brief

The authors sought to investigate the safety and efficiency of growing rods in early-onset scoliosis (EOS) patients with untreated intraspinal anomalies (IAs). Through comparing the clinical and radiological outcomes between EOS patients with and those without untreated IAs, no significant difference in surgical outcomes was observed between the two groups. These results indicate that repeated lengthening procedures may be safe and effective for EOS patients with untreated IAs.

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In Brief

The objective of this work was to simplify the complex field of predictive models for the practicing neurosurgeon. The authors graded each model based on characteristics of the original study, in addition to its performance in subsequent validation studies. They found this to stratify existing models in a useful manner. The hope is that in addition to simplifying these models, the utility of prediction model score can push future model development to incorporate the most generalizable and statistically robust methodologies.

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In Brief

In this study the authors determined the concurrent validity, discriminant ability, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) in adult spinal deformity, and they calculated minimal clinically important differences for PROMIS scores. With this information, clinicians will be better equipped to interpret changes in PROMIS scores after surgery for adult spinal deformity.

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In Brief

Pseudarthrosis including rod fracture is a common complication in adult spinal deformity surgery. In this study, researchers analyzed the methods for reducing rod fracture in deformity correction of adult spinal deformity. Greater preoperative sagittal spinopelvic malalignment including preoperative pelvic incidence minus lumbar lordosis mismatch was the crucial risk factor in patients 65 years or older. Application of the cobalt chrome rod, accessory rod technique, or lateral lumbar interbody fusion was found to be effective for reducing the risk of rod fracture.

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In Brief

Patients with cervical deformity (CD) have severe disability and poor health status. Little is known about how patients with fixed CD compare with those with flexible CD. In this study, the authors set out to determine whether patients with rigid CD have worse baseline alignment and require more aggressive surgical corrections than flexible CD patients and found that their outcomes are similar.

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In Brief

Patients with cervical deformity (CD) have severe disability and poor health status. Little is known about how patients with fixed CD compare with those with flexible CD. In this study, the authors set out to determine whether patients with rigid CD have worse baseline alignment and require more aggressive surgical corrections than flexible CD patients and found that their outcomes are similar.

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In Brief

In this study, the authors investigated the impact of different types of accessory rod connectors on stability and instrumentation strain in a long-segment deformity construct using human cadavers. The risk of instrumentation failure and fracture is high in long-segment deformity, and while we know that accessory rods are beneficial, we do not understand the ideal nature of the connector, nor the ideal orientation; an improved understanding would yield decreased failure and fracture rates.

Open access

In Brief

Researchers investigated the safety and neurological recovery results in patients with complete (i.e., no function below the level of injury) thoracic spinal cord injury who were implanted with a novel bioresorbable scaffold (Neuro-Spinal Scaffold) during open spine surgery. The results from this first-in-human study are important because they demonstrate that the potential benefits of the Neuro-Spinal Scaffold outweigh the risks in this patient population and support further clinical investigation in a randomized controlled trial.

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In Brief

The authors tested the hypothesis that preoperative cerebrospinal fluid (CSF) biomarkers are altered in patients with cervical spondylotic myelopathy and correlate with neurological status and outcome. Biomarkers of glial and axonal damage in CSF biomarkers were increased, while amyloid breakdown products were decreased. Correlations between preoperative neurological picture and outcome were noted. CSF biomarkers can reflect the ongoing pathophysiology of spinal cord compression and damage and may provide prognostic information on surgical outcome.

Restricted access

In Brief

The authors compared standing and supine radiographs for 73 patients and found that those with bilateral sacroiliac (SI) joint vacuum signs, as identified on CT, had a change in pelvic incidence between the supine and standing positions. This suggests there may be increasing motion across the SI joint with significant joint degeneration.

Restricted access

In Brief

The objective of this study was to elucidate the efficacy of the cyst-dyeing method in microendoscopic spinal decompression surgery for lumbar spinal stenosis caused by facet cysts. The adjunctive cyst-dyeing method effectively delineated cyst and dural boundaries, facilitating safer and more effective cyst separation and neural decompression, even with microendoscopic surgery. Microendoscopic surgery combined with the authors' novel facet cyst-dyeing method is a safe and effective minimally invasive technique for facet-joint cysts.

Restricted access

In Brief

The authors aimed to determine which radiological parameters related to the aging spine are associated with curve progression in early degenerative lumbar scoliosis (DLS), in particular which factors predict curve progression. In early DLS patients observed for a mean of 13.7 years, asymmetrical disc degeneration in the lower disc space of the apical vertebra, leading to lower apical vertebral disc wedging angles, was the most important factor in predicting curve progression. Therefore, patients with this finding need to be closely monitored.

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In Brief

Thoracic ossification of the posterior longitudinal ligament (OPLL) remains one of the most challenging disorders for spine surgeons. No ideal surgical procedures have been developed for patients with thoracic myelopathy caused by OPLL. In this study, the authors' technique of modified decompression through a posterior approach clearly resulted in better surgical results, with the recovery rate of the Japanese Orthopaedic Association score > 70%. Patients who are nonambulatory due to thoracic OPLL could become able to walk again after this procedure.

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In Brief

The objective of this study was to estimate the incidence rate of spine-specific skeletal related events (SREs) in patients with non–small cell lung cancer and to quantify the impact of SREs on overall mortality. The presence of SREs was found to be associated with an increased incidence rate of mortality. The observed findings may be used to help patients and providers make treatment decisions based on the presence (or lack thereof) of SREs.

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In Brief

The authors studied the epidemiology of spinal cord astrocytoma (SCA) between 1995 and 2016, utilizing the Central Brain Tumor Registry of the United States database to provide a comprehensive epidemiological description of SCAs. The most important finding/contribution of this work to the literature is the description of age-adjusted incidence trends between 1995 and 2016, along with SCA incidence stratified by histology and patient demographics. Due to the rarity of SCA, it has since evaded complete epidemiological description. This study represents the most comprehensive epidemiological descriptions of SCAs to date.