Evaluating robotic pedicle screw placement against conventional modalities: a systematic review and network meta-analysis.

OBJECTIVE: Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods. METHODS: A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome. RESULTS: Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement. CONCLUSIONS: The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.

Noniatrogenic spinal cord ischemia: A patient level meta-analysis of 125 case reports and series.

Background: Guidelines are needed to manage spinal cord infarctions. Here, we evaluated the incidence of noniatrogenic spinal ischemia, focusing on the spinal levels involved, and the relative efficacy of different management strategies. Methods: We performed a meta-analysis of 147 patients who sustained noniatrogenic spinal cord ischemia within the past 10 years. The most common causes of injury were idiopathic (i.e., 47% medical/surgery-related) followed by systemic/chronic conditions (23.6%) and aortic vascular pathology (20%). Postdiagnostic treatment options included rehabilitation in 53.7% of patients, while steroids (35.37%), antiplatelets aggregates (30.61%), and anticoagulation (18.37%) were also used. Results: Traumatic causes of spinal cord ischemia were associated with worse outcomes, while those without a clear diagnosis despite extensive work-up had better results. At discharge, patients managed with cerebrospinal fluid (CSF) drainage had significant improvement (P = 0.04), while other therapies were not effective. Notably, ischemia mostly occurring between the T4 and T7 levels and was associated with the worst outcomes. In this thoracic "watershed" region, thoracic cord ischemia was most likely attributed to an increased susceptibility toto cord under-perfusion in this region (P < 0.05). Conclusion: This meta-analysis revealed a variety of etiologies for noniatrogenic typically T4-T7 spinal cord ischemia. Several different treatment strategies may be utilized in this patient population, including CSF drainage, blood pressure elevation, corticosteroids, antiplatelets/anticoagulants/thrombolytics, mannitol, naloxone, surgical revascularization, hyperbaric oxygen, and systemic hypothermia.

Short-Segment Pedicle Fixation of Traumatic Low Lumbar Fractures (L3-L5): Report of 36 Cases.

STUDY DESIGN: Prospective review. OBJECTIVE: The aim was to assess the efficacy and safety of short-segment pedicle fixation of low lumbar fractures (L3-L5). BACKGROUND: Low lumbar fractures are relatively uncommon, and limited data exists regarding the management of these injuries. No previous studies have specifically examined the surgical management of L3-L5 fractures exclusively with pedicle fixation. MATERIALS AND METHODS: We reviewed prospectively collected data of 36 patients who underwent short-segment pedicle fixation for low lumbar fractures at our institution between 1993 and 2018. RESULTS: There was no worsening of neurological status following surgery, and three patients regained motor or sphincter function. Thirty-one (86.1%) patients went on to successful fusion. Three (8%) patients required reoperation. Four (11%) patients had surgical complications. CONCLUSIONS: This large series provides information regarding the safety and efficacy of surgical management of low lumbar fractures with pedicle fixation. Following surgery, there was no neurological worsening and some patients regained neurological function. Low complication rates, low reoperation rates, and low pain levels at final follow-up provide evidence that the surgical management of low lumbar fractures utilizing short-segment pedicle fixation is safe and efficacious.

The evolving neurosurgical perspective on Enhanced Recovery After Surgery (ERAS): a systematic review.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs may be implemented to minimize the body's stress response to surgery and enable a safe and timely discharge. Successful implementation involves a multifaceted approach from surgeons, anesthesiologists, nurses, nutritionists, and nonclinical staff. EVIDENCE ACQUISITION: National databases (MEDLINE (PubMed), Cochrane Central, and Google Scholar databases) were searched to identify studies on the clinical implementation of ERAS protocols in neurosurgery. A systematic review was chosen to select studies and pooled data analysis was performed. EVIDENCE SYNTHESIS: Thirty-five studies reported the use of enhanced recovery after surgery (ERAS), with 13 studies on cranial surgery and 22 on spinal surgery. Overall, 27 studies reported length of stay, 10 studies reported differences in opioid use, 21 studies reported either complications, readmission rate, or long term (>30 day) follow-up, 14 studies reported patient feedback, and 10 studies reported cost reduction of ERAS implementation. Findings supported significant reduction in length of stay, opioid use, and costs associated with ERAS regimens. Complications, readmission rates, and follow-up pain scores remained similar in ERAS and control groups. CONCLUSIONS: Our review finds that ERAS regimen implementation can serve an important role in facilitating clinical quality improvement and cost-effective care in all applications related to neurosurgical care and recovery. While application of ERAS in neurological surgery may have an important role in facilitating patient beneficial and cost-effective care, the findings of this review confirm that several challenges remain in select settings and prevent widespread implementation.

BIIB093 (intravenous glibenclamide) for the prevention of severe cerebral edema.

BACKGROUND: Vasogenic edema in the setting of acute ischemic stroke can be attributed to the opening of transient receptor potential 4 channels, which are expressed in the setting of injury and regulated by sulfonylurea receptor 1 (SUR1) proteins. Glibenclamide, also known as glyburide, RP-1127, Cirara, and BIIB093, is a second-generation sulfonylurea that binds SUR1 at potassium channels and may significantly reduce cerebral edema following stroke, as evidenced by recent clinical trials. This review provides a comprehensive analysis of clinical considerations of glibenclamide use and current patient outcomes when administered in the setting of acute ischemic stroke to reduce severe edema. METHODS: National databases (MEDLINE, EMBASE, Cochrane, and Google scholar databases) were searched to identify studies that reported on the clinical outcomes of glibenclamide administered immediately following acute ischemic stroke. RESULTS: The pharmacological mechanism of glibenclamide was reviewed in depth as well as the known indications and contraindications to receiving treatment. Eight studies were identified as having meaningful clinical outcome data, finding statistically significant differences in glibenclamide treatment groups ranging from matrix metalloproteinase-9 serum levels, midline shift, modified Rankin Scores, National Institute of Health Stroke Score, and mortality endpoints. CONCLUSION: Studies analyzing the GAMES-Pilot and GAMES-PR trials suggest that glibenclamide has a moderate, however, measurable effect on intermediate biomarkers and clinical endpoints. Meaningful conclusions are limited by the small sample size of patients studied.

Iatrogenic spinal cord ischemia: A patient level meta-analysis of 74 case reports and series.

BACKGROUND: We seek to characterize the features of iatrogenic spinal ischemia, determine which spinal levels are affected, and evaluate the efficacy of management strategies. METHODS: We performed a meta-analysis of case reports and series of spinal ischemia in the past 10 years. 343 full-length case reports and case series were screened against predefined inclusion/exclusion criteria. 89 patients were included for our final meta-analysis using PRISMA guidelines. RESULTS: Mean age of patients was 59.62 years (range: 9 months-88 years). 66% of all cases were male. Endovascular surgery (32.6%) and aortic surgery (36.0%) were most common causes of iatrogenic injury, followed by non-aortic surgery (32.6%), and non-surgical procedures (22.47%). A- and B-level ASIA Impairment was found in 66% of all patients. Rehabilitation was the most common management (49.44% of cases), followed by blood pressure management (40.45%). Non-aortic surgeries had the poorest overall outcomes (OR = 0.28, p = 0.016), whereas aortic and endovascular surgeries saw significant improvement in outcomes measured at discharge (OR = 2.6, OR = 2.3, respectively, p < 0.05). Therapeutic surgical infarctions were found to be associated with improved outcomes (OR = 5.33, p = 0.032). Ischemic injury to T4-T7, and T10 were associated with significantly poorer outcomes. Autonomic impairment was associated with a likelihood of infarction at T10 (OR = 4.54, p = 0.0183). CONCLUSIONS: In this paper, we compare outcomes following iatrogenic spinal ischemia. We demonstrate the need for more comprehensive randomized controlled trials to test effective treatment strategies.

Weight-Bearing Magnetic Resonance Imaging as a Diagnostic Tool That Generates Biomechanical Changes in Spine Anatomy.

Weight-bearing magnetic resonance imaging (MRI) is a unique modality in diagnostic imaging that allows for the assessment of spinal pathology in ways considered previously inaccessible or insufficient with the conventional MRI technique. Due to limitations in positioning within the MRI machine itself, difficulties would be posed in determining the underlying cause of a patient's pain or neurological symptoms, as the traditional supine position utilized can, in many cases, alleviate the severity of presented symptoms. Weight-bearing MRI addresses this concern by allowing a clinician to position a patient (to a certain degree) into flexion, extension, rotation, or side-bending with an axial load that can mimic physiologic conditions in order to replicate the conditions the patient experiences in order to give clinicians a clearer understanding of the anatomical relationship of the spine and surrounding tissues that may lead to a particular presentation of symptoms. These findings can then guide treatment approaches that are better tailored to a patient's needs in order to initiate treatment earlier and shorten the duration of treatment necessary for patient benefit. The goal of this review is to describe and differentiate weight-bearing MRI from conventional MRI as well as examine the advantages and disadvantages of either imaging modality. This will include assessing cost-effectiveness and improvements in clinical outcomes. Further, the advancements of weight-bearing MRI will be discussed, including potentially unique clinical applications in development.

Enhanced Spinal Therapy: Extracorporeal Shock Wave Therapy for the Spine.

Extracorporeal shock wave therapy (ESWT) is a non-invasive therapeutic method used for pain management and muscle strength improvement through the use of shock waves. In vitro studies have demonstrated that shockwave therapy induces fluctuation in redox reaction regulation and increases in Mitogen-Activated Protein Kinase (MAPK) signal transduction pathways, stimulating increased gene expression in the nucleus. ESWT has also been shown to upregulate angiogenesis and growth factors through activation of endothelial nitric oxide synthase (eNOS) and vascular endothelial growth factor (VEGF). The use of ESWT in the treatment of various musculoskeletal disorders was widely adopted throughout Europe, South America, and Asia before being introduced in the United States in 2000. Within the past 20 years, the clinical application of ESWT in the treatment of musculoskeletal and bone disorders has grown. This paper provides a comprehensive narrative review of applications and outcomes of ESWT in clinical spinal pathology and assesses reported efficacy as it relates to the pathology. A review of the literature yielded studies describing the use of ESWT in degenerative osteoporotic neuro-spinal pathology, heterotopic ossification due to spinal cord injury, cervical spondylosis, scoliosis, sacroiliitis, and coccydynia. The efficacy of ESWT as an adjunct treatment in patients with spinal cord pathologies varied with the specific pathology, however, all pathologies discussed in this review provided evidence of potential benefits with minimal adverse effects. While the use of ESWT for pain management has widely been established, further literature should aim to identify the long-term benefits of ESWT.