Frailty is not an independent risk factor for worse clinical outcomes in lumbar spinal surgery: a prospective cohort study.

PURPOSE: Recently, many studies revealed that frailty affects unfavorably on postoperative outcomes in lumbar spinal diseases. This study aimed to investigate the relationship between frailty and clinical outcomes while identifying risk factors associated with worse clinical outcomes following lumbar spinal surgery. METHODS: From March 2019 to February 2021, we prospectively enrolled eligible patients with degenerative lumbar spinal diseases requiring surgery. Frailty was assessed preoperatively. To identify the impact of frailty on lumbar spinal diseases, clinical outcomes, which were measured with patient-reported outcomes (PROs) and postoperative complications, were compared according to the frailty. PROs were assessed preoperatively and one year postoperatively. In addition, risk factors for preoperative and postoperative worse clinical outcomes were investigated. RESULTS: PROs were constantly lower in the frail group than in the non-frail group before and after surgery, and the change of PROs between before and after surgery and postoperative complications were not different between the groups. In addition, frailty was a persistent risk factor for postoperative worse clinical outcome before and after surgery in lumbar spinal surgery. CONCLUSION: Frailty persistently affects the clinical outcome negatively before and after surgery in lumbar spinal surgery. However, as the change of the clinical outcome is not different between the frail group and the non-frail group, it is difficult to interpret whether the frail patients are vulnerable to the surgery. In conclusion, frailty is not an independent risk factor for worse clinical outcome in lumbar spinal surgery.

Effectiveness of intraoperative table modification for achieving lumbar lordosis in multilevel lumbar fusion surgery: a propensity score-matched study.

BACKGROUND: In multilevel posterior lumbar interbody fusion (PLIF) with posterior screw fixation, obtaining sufficient lumbar lordosis (LL) is difficult, especially in patients with osteoporosis. We performed intraoperative table modification (TM) using gravitational dropping of the patient's lumbar spine, to improve restoration of LL. METHODS: We retrospectively reviewed the medical records of patients who underwent three- or four-level PLIF between 2005 and 2019. One hundred eleven patients were enrolled, with 96 patients receiving non-TM-PLIF and 15 patients receiving TM-PLIF. Radiological parameters, including segmental lordosis (SL), LL, sacral slope (SS), pelvic incidence, and pelvic tilt, were measured. Clinical outcomes were measured using a visual analogue scale (VAS) for the back and leg preoperatively and at the last follow-up. Additionally, the correlation between the bone mineral density (BMD) and the radiological parameters was calculated for TM-PLIF. We performed propensity score matching between the groups to control the baseline difference. RESULTS: We found a statistically better correction between immediate and last follow-up postoperative SL (p = 0.04), as well as between preoperative and last follow-up SL (p < 0.01) in the TM-PLIF group compared to that in the non-TM-PLIF group. VAS for the back and leg were not significantly different between the two groups. Additionally, the efficacy of lordosis correction in the TM-PLIF group showed a statistically significant negative correlation between BMD and the SS change both before and after the surgery (rho = -0.60, p = 0.02). CONCLUSION: Whilst further study is required to conclusively establish its efficacy, TM-PLIF (table modification using gravitational dropping) shows potential advantages for restoring and maintaining LL in multilevel lumbar fusion, particularly in cases with low BMD.

The risk factors of intracerebral hemorrhage in deep brain stimulation: does target matter?

BACKGROUND: Although deep brain stimulation (DBS) is a relatively safe and effective surgery compared with ablative surgeries, intracerebral hemorrhage (ICH) is a serious complication during DBS that could result in a fatal prognosis. We retrospectively investigated whether ICH incidence differed between patients who underwent DBS in the subthalamic nucleus (STN) and in the globus pallidus interna (GPi), together with previously identified risk factors for ICH. METHODS: We retrospectively reviewed the medical records of 275 patients (527 DBS targets) who received DBS for Parkinson's disease or dystonia from April 2001 to December 2020. In cases that developed intra- or postoperative ICH, patients were classified as asymptomatic, symptomatic with temporary neurological deficit or symptomatic with permanent neurological deficit, according to patient clinical status. RESULTS: ICH occurred in 12 procedures (2.3%) among the 527 DBS procedures (275 patients) evaluated. In multivariable logistic regression analysis, the risk factor for all cases of ICH was systolic blood pressure (BP) during surgery (cut-off value 129.4 mmHg) (OR = 1.05, 95% CI = 1.01-1.09, P = 0.023). In addition, for ICH with permanent neurological deficit, STN target site (P = 0.024) and systolic BP during surgery (cut-off value: 148.3 mmHg) (P = 0.004) were identified as risk factors in univariable analyses. CONCLUSION: Even though the risk factor for all ICH in DBS was BP during surgery, when focused on ICH evoking permanent neurological deficit, the target location as well as systolic BP during surgery proved to be related.

Three-Dimensional Laparoscopic Anatomical Segment 8 Liver Resection with Glissonian Approach.

BACKGROUND: Anatomical liver resection has been reported to have oncologic benefit over nonanatomical resection in surgery for hepatocellular carcinoma (HCC). Basic concept of anatomical resection is preventing tumor spread through the portal or venous flow. Few cases have been reported for laparoscopic anatomical segment 8 resection because of its technical difficulties. This video shows operative techniques for laparoscopic anatomical resection of segment 8, exposing middle and right hepatic vein and inferior vena cava using three-dimensional video. METHODS: A 61-year-old male was diagnosed to be a hepatitis B virus carrier 6 years ago. A 6.6-cm-sized HCC lesion was detected at segment 8 by computed tomography scan. We have used a high-definition, three-dimensional laparoscope with a deflectable tip (Olympus Medical Systems Corp., Japan), a trocar inserted in the right seventh intercostal space to obtain the optimal field of view on the superior-posterior portion of the liver. Using the Glissonian pedicle approach, we isolated and clamped the branch to the segment 8 to confirm the anatomical border of the segment 8. Segmentectomy was completed exposing the middle and right hepatic vein and inferior vena cava. RESULTS: Operation took 420 min. Estimated blood loss was 600 mL, and no red blood cell was transfused. Final pathology was an HCC with 0.3-cm safety margin. The patient discharged on the sixth day after operation with normal liver function test results. There was no operation-related complication from the operation day to the first outpatient visit day. CONCLUSIONS: Laparoscopic anatomical resection of segment 8 is feasible.

Cauda equina lymphoma mimicking non-neoplastic hypertrophic neuropathy of the cauda equina: A case report.

Spinal cauda equina lymphoma (CEL) is very rare, with only about 14 cases reported in the English medical literature. Magnetic resonance image findings and the gross appearance of CEL at surgery are similar to those of non-neoplastic hypertrophic neuropathy of the cauda equina (HNCE); however, their prognosis and treatment are very different. We report a case of CEL and discuss the differences from non-neoplastic HNCE.

Total laparoscopic living donor right hepatectomy.

BACKGROUND: Right lobe living donor liver transplantation (LDLT) is the predominant form of adult-to-adult LDLT. Accordingly, cosmetic and functional demand by young donors is increasing. We developed the world first total laparoscopic donor right hepatectomy (LDRH) in adult living donors. METHODS: Total LDRH was performed in two young donors without vascular clamping. Modified extended right graft (right liver including all the middle hepatic vein branches) was retrieved from suprapubic transverse incision. FINDINGS: After full mobilization of right liver, hilar dissection was done. First, right portal vein was isolated under retracting common bile duct laterally. Right hepatic artery was cautiously dissected and isolated without injuring. An exact transection line was drawn during transient clamping of the hepatic artery and portal vein on the right side of the liver using bulldog clamp. Dissection was meticulously performed along the right side of the middle hepatic vein until the origin of middle hepatic vein until exposure of the hilar plate. Anterior section vein branches (V5 and V8) were finely dissected and were reconstructed using an artificial vascular graft. A modified extended right graft with preservation of the middle hepatic vein branches was extracted through the suprapubic incision. There was no complication in both donors and recipients. Postoperative hospital stay of donors was 10 and 8 days, respectively. After follow-up of more than 1 year, all donors and recipients live well with normal liver function. CONCLUSION: Total LDRH was feasible in selected adult donors. If this procedure will be more standardized, then total LDRH will be new option for adult LDLT, which meets demand by donors and diminish guilty feeling by recipients.

Role of gadoxetic acid-enhanced magnetic resonance imaging in the preoperative evaluation of small hepatic lesions in patients with colorectal cancer.

BACKGROUND: The initial abdominal computed tomography (CT) scans of patients with colorectal cancer (CRC) sometimes reveal equivocal hepatic lesions. In this study, we evaluated the outcomes of equivocal hepatic lesions found by abdominal CT and the diagnostic accuracy of subsequent liver magnetic resonance imaging (MRI). METHODS: We evaluated data of patients who underwent CRC resection between January 1, 2009 and December 31, 2009. Equivocal hepatic lesions of <1 cm in size on preoperative staging CT scans were included in this study. Gadoxetic acid-enhanced liver MRI was subsequently performed in all patients. Hepatic lesions that grew during the follow-up period (≥ 3 years) were considered potential metastases. RESULTS: Overall, 121 equivocal hepatic lesions were detected on preoperative staging CT in 65 out of 494 patients (13.2 %) who underwent colorectal surgery. Based on subsequent MRI, 11 lesions were classified as definitive metastatic lesions and 100 were classified as definitive benign lesions, including simple cysts or hemangiomas. Findings in the other 10 lesions were still inconclusive even after examining CT and MRI. Of the 11 lesions that were classified as metastatic by MRI and were resected, 10 were pathologically confirmed as metastases and one lesion was a pathologically benign nodule. All 100 benign lesions were stable on follow-up imaging and were classified as benign. Of the 10 equivocal lesions, 6 increased in size during the follow up, suggesting they were early metastases, while 4 were stable. The sensitivity and specificity for detecting liver metastases by gadoxetic acid-enhanced MRI of small equivocal hepatic lesions found by CT were 100 % (16/16) and 95.2 % (100/105), respectively, if MRI was equivocal or indicated definite metastasis. The negative predictive value was 100 % (100/100). CONCLUSION: Gadoxetic acid-enhanced MRI is a useful diagnostic tool for assessing equivocal hepatic lesions on preoperative CT of CRC patients that allows increased diagnostic accuracy and detection of additional colorectal liver metastasis lesions.

Intraoperative direct puncture and embolization (IOPE) using a glue material for spinal cord arteriovenous fistula: a case report.

INTRODUCTION: Spinal arteriovenous fistula (AVF) is treated by embolization or surgery. However, transarterial embolization or surgery is difficult in rare cases when the fistula site is very complicated to access especially as in fistular nidus supplied by posterior and anterior spinal artery. We present the case which was treated with intraoperative direct puncture and embolization (IOPE) using glue material, since the usual transarterial or transvenous neurointerventional approach was difficult to embolize the AVF. METHODS: A 36-year-old woman presented with progressive leg weakness and pain after a 20-year history of lower back pain. She had pelvic and spinal AVF combined with arteriovenous malformation (AVM). Despite prior treatment of the pelvic lesion with radiotherapy and coil embolization, the spinal lesion persisted and caused repeated subarachnoid hemorrhages. A spinal angiogram revealed a tortuous and long feeder of the AVF which had growing venous sac, as well as AVM. Two embolization trials failed because of the long tortuosity and associated anterior spinal artery. Four months later, drastic leg weakness and pain occurred, and IOPE was performed using a glue material. RESULTS: The subsequent recovery of the patient was rapid. One month later, the use of a strong opioid could be discontinued, and the patient could walk with aid. A follow-up spinal angiogram revealed that the venous sac of the AVF had disappeared. CONCLUSION: In spinal AVF which is not feasible to access by usual intervention approach and to dissect surgically, IOPE with glue material can be considered for the treatment.

Surgery on the C3-4 Level and the Presence of Ligamentum Flavum Hypertrophy Increases the Risk of 30-Day Reoperation Rate After Anterior Cervical Discectomy and Fusion.

BACKGROUND AND OBJECTIVES: Cervical myelopathy caused by C3-4 level degeneration often exhibits different characteristics after anterior cervical discectomy and fusion (ACDF) than other cervical levels. This study compared the outcomes of C3-4 ACDF with surgeries at other levels and identified risk factors of 30-day reoperation after ACDF. METHODS: We retrospectively analyzed patients who underwent ACDF for degenerative cervical disease from 2018 to 2023. The patients were divided into 2 groups based on the level of surgery: C3-4 and non-C3-4 groups. Radiological outcomes, including cervical alignment and range of motion (ROM), were analyzed. Clinical outcomes were assessed with patient-reported outcomes and the rates of 30-day reoperation and complications after ACDF. Patient-reported outcomes included visual analog scale for neck pain, visual analog scale for arm pain, and modified Japanese Orthopedic Association scores. Risk factors of 30-day reoperation were assessed. RESULTS: Of 259 patients, 74 (28.6%) and 185 (71.4%) were in the C3-4 and non-C3-4 groups, respectively. The C3-4 group exhibited lower C2-7 ROM (P = .019), higher C3-4 ROM (P = .015), and greater C3-4 %ROM (P = .014). The C3-4 group demonstrated lower preoperative and 1-month postoperative modified Japanese Orthopedic Association scores (P < .001; P < .001, respectively). The rate of 30-day reoperation was significantly higher in the C3-4 group (9.5%) compared with the non-C3-4 group (2.2%) (P = .014). In addition, C3-4 surgical level (odds ratio = 4.99, P = .034) and ligament flavum hypertrophy (odds ratio = 5.84, P = .018) were identified as independent risk factors of 30-day reoperation after ACDF. CONCLUSION: Surgery on C3-4 level showed a higher risk of 30-day reoperation than other levels. It is likely due to C3-4 surgical level, and ligament flavum hypertrophy contributes to cord compression, particularly in the unstable early postoperative period.

Is it necessary to use a cervical brace after single- or double-level ACDF?

Although anterior cervical discectomy and fusion (ACDF) is one of the most frequently performed spinal surgeries, there is no consensus regarding the necessity of prescribing a cervical brace after surgery. This study aimed to investigate any difference in radiological and clinical outcomes when wearing or not wearing cervical braces after single- or double-level ACDF. We examined 2 cohorts of patients who underwent single- or double-level ACDF surgery with and without a cervical brace: patients who underwent ACDF between March 2018 and December 2019 received a cervical brace, while patients who underwent ACDF between January 2020 and May 2021 did not. Each patient was evaluated radiologically and functionally using plain X-ray, modified Japanese Orthopedic Association score, and visual analog scale for neck and arm until 12 months after surgery. Fusion rate, subsidence, and postoperative complications were also evaluated. Eighty-three patients were included in the analysis: 38 were braced and 45 were not. The demographic characteristics and baseline outcome measures of both groups were similar. There was no statistically significant difference in any of the clinical measures at baseline. The modified Japanese Orthopedic Association score and visual analog scale for neck and arm were similar in both groups at all time intervals and showed statistically significant improvement when compared with preoperative scores. In addition, fusion rate, subsidence, and postoperative complications were similar in both groups. Our results suggest that the use of cervical braces does not improve the clinical outcomes of individuals undergoing single- or double-level ACDF.

Is It Meaningful and Necessary to Avoid the Seventh Cervical Vertebra in Long Level Cervical Fusion?

AIM: To compare the clinical and radiological results of patients who underwent multilevel posterior cervical fusion (PCF) with different end levels (C6 or C7). MATERIAL AND METHODS: We collected radiographs and clinical results of all subjects who underwent 3 level or more PCF for degenerative disease from May 2012 to December 2020. Based on the location of the end of fusion during surgery, patients were divided into C6 (group 1) and C7 patients (group 2). The clinical and radiological results of both groups were compared over two years. RESULTS: A total of 52 patients met the inclusion criteria of this study (21 in group 1 and 31 in group 2). The clinical results demonstrated a statistically significant difference with respect to a lower neck visual analog scale score in group 1 than in group 2 at the last follow-up (p=0.03). With regard to the radiological results, the C2-C7 sagittal vertical axis showed significantly greater values in group 2 than in group 1 at the final follow-up (p=0.02). For thoracic kyphosis (TK), group 2 had lower TK values than group 1 (p=0.03), and the T9 spinopelvic inclination was significantly greater in group 2 than in group 1 (p=0.01). CONCLUSION: In this study, aggravation of cervical kyphosis and neck pain was observed when C7 was included in multilevel PCF surgery. The inclusion of C7 also affected the thoracolumbar parameters and global spine alignment.

Are There Advantages in Cervical Intrafacetal Fusion With Minimal Posterolateral Fusion (PLF) Compared to Conventional PLF in Posterior Cervical Fusion?

OBJECTIVE: We propose that cervical intrafacetal fusion (cIFF) using bone chip insertion into the facetal joint space additional to minimal PLF is a supplementary fusion method to conventional posterolateral fusion (PLF). METHODS: Patients who underwent posterior cervical fixation accompanied by cIFF with minimal PLF or conventional PLF for cervical myelopathy from 2012 to 2023 were investigated retrospectively. Radiological parameters including Cobb angle and C2-7 sagittal vertical axis (SVA) were compared between the 2 groups. In cIFF with minimal PLF group, cIFF location and PLF location were carefully divided, and the fusion rates of each location were analyzed by computed tomography scan. RESULTS: Among enrolled 46 patients, 31 patients were in cIFF group, 15 in PLF group. The postoperative change of Cobb angle in 1-year follow-up in cIFF with minimal PLF group and conventional PLF group were 0.1° ± 4.0° and -9.7° ± 8.4° respectively which was statistically lower in cIFF with minimal PLF group (p = 0.022). Regarding the fusion rate in cIFF with minimal PLF group in postoperative 6 months, the rates was achieved in 267 facets (98.1%) in cIFF location, and 244 facets (89.7%) in PLF location (p < 0.001). CONCLUSION: Postoperative sagittal alignment was more preserved in cIFF with minimal PLF group compared with conventional PLF group. Additionally, in cIFF with minimal PLF group, the bone fusion rate of cIFF location was higher than PLF location. Considering the concerns of bone chip migration onto the spinal cord and relatively low fusion rate in PLF method, applying cIFF method using minimized PLF might be a beneficial alternative for posterior cervical decompression and fixation.

Unilateral Pediculectomy and Reduction with Short-Segment Pedicle Screw Fixation for Thoracolumbar Burst Fracture: A Case Series.

BACKGROUND: This study aimed to evaluate the efficacy of unilateral pediculectomy and reduction with short-segment pedicle screw fixation for thoracolumbar burst fracture. METHODS: We retrospectively reviewed patients who underwent a unilateral pediculectomy and reduction with short-segment fixation and interbody fusion for thoracolumbar burst fracture. The unilateral pediculectomy created sufficient space to approach the ventral side of the spinal cord for removing bone fragments and insertion of an interbody cage to correct kyphosis. Lumbar lordosis (LL), pelvic incidence (PI) minus LL, and segmental Cobb angle were measured at 3 time points: preoperatively, postoperatively, and final follow-up. Furthermore, sagittal vertical axis (SVA) was measured to assess global sagittal balance at the final follow-up. RESULTS: A total of 10 patients, with a mean age of 39.8 ± 21.0, underwent the surgical procedure. All patients had a thoracolumbar injury classification and severity score > 5. The mean follow-up period was 15.8 ± 13.9 months. The mean postoperative LL (46.0 ± 5.8) was significantly higher (P = 0.008) than the preoperative measurement (32.8 ± 8.2). The mean postoperative PI minus LL (2.2 ± 8.4) was not significantly lower (P = 0.051) than preoperative measurement (15.4 ± 12.6). The mean postoperative segmental Cobb angle (11.4 ± 8.4) was significantly higher (P < 0.001) than the preoperative measurement (-11.6 ± 10.9). At the final follow-up, the mean sagittal vertical axiswas 10.0 ± 28.8 mm. CONCLUSIONS: Unilateral pediculectomy and reduction with short-segment fixation and interbody fusion served as an efficient surgical method for thoracolumbar burst fracture.

Quantitative Analysis of the Effect of Stereotactic Radiosurgery for Postoperative Residual Cervical Dumbbell Tumors: A Multicenter Retrospective Cohort Study.

OBJECTIVE: Stereotactic radiosurgery (SRS) has been performed for spinal tumors. However, the quantitative effect of SRS on postoperative residual cervical dumbbell tumors remains unknown. This study aimed to quantitatively evaluate the efficacy of SRS for treating postoperative residual cervical dumbbell tumors. METHODS: We retrospectively reviewed cases of postoperative residual cervical dumbbell tumors from 1995 to 2020 in 2 tertiary institutions. Residual tumors underwent SRS (SRS group) or were observed with clinical and magnetic resonance imaging (MRI) follow-up (observation group). Tumor regrowth rates were compared between the SRS and observation groups. Additionally, risk factors for tumor regrowth were analyzed. RESULTS: A total of 28 cervical dumbbell tumors were incompletely resected. Eight patients were in the SRS group, and 20 in the observation group. The mean regrowth rate was not significantly lower (p = 0.784) in the SRS group (0.18 ± 0.29 mm/mo) than in the observation group (0.33 ± 0.40 mm/mo). In the multivariable Cox regression analysis, SRS was not a significant variable (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.18-1.79; p = 0.336). CONCLUSION: SRS did not significantly decrease the tumor regrowth rate in our study. We believe that achieving maximal resection during the initial operation is more important than postoperative adjuvant SRS.

GSK-3ß and ß-Catenin Signaling Pathway is Involved in Myofibroblast Transition of Ligamentum Flavum in Lumbar Spinal Stenosis Patients.

STUDY DESIGN: Histologic analysis of the ligamentum flavum (LF) in the lumbar spine. OBJECTIVE: The objective of this study is to investigate the levels of glycogen synthase kinase-3ß (GSK-3ß) and ß-catenin in the LF tissue of patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: The hypertrophy of the LF is the primary cause of the progression of LSS. Recently, Wnt signaling has been proposed as one of the molecular processes contributing to LF hypertrophy. GSK-3ß and ß-catenin are recognized to play a crucial part in the control of this signaling pathway. MATERIALS AND METHODS: From May 2020 to July 2022, LF from 51 LSS patients (LSS group) and 18 lumbar disc herniation patients (control group) were prospectively collected during surgery. Histologic analysis was investigated to confirm the progression of LF fibrosis. The levels of α-smooth muscle actin, phosphorylation of GSK-3ß (p-GSK-3ß; inactive form), and ß-catenin were analyzed in LF with Western blot analysis to reveal the GSK-3ß/ß-catenin signaling pathway. Continuous variables are expressed as mean±SD and compared using the student t test. Categorical variables are compared using the χ 2 test or Fisher exact test, as appropriate. To determine the association between p-GSK-3ß and LF thickness, the Pearson correlation coefficient was calculated based on the results of Western blot analysis. RESULTS: The LSS group was older and had thicker LF than the controls. The LSS group showed increased collagen fiber and cellularity than the controls. The levels of α-smooth muscle actin, p-GSK-3ß, and ß-catenin in the LF of the LSS group were significantly higher than that of the control group. There was a strong positive correlation between p-GSK-3ß (Ser9) level and LF thickness in LSS patients ( r =0.69, P =0.01). CONCLUSION: This research proposes a molecular mechanism for the pathogenesis of LF hypertrophy in LSS. Specifically, GSK-3ß/ß-catenin signaling appears to be related to LF hypertrophy in LSS and a positive correlation exists between p-GSK-3ß level and LF thickness. LEVEL OF EVIDENCE: Level 3.

Antibiotics Prophylaxis for Endoscopic Endonasal Approach for Skull Base Tumor Surgery: A Meta-Analysis.

BACKGROUND: The regimen of prophylactic antibiotic for endoscopic endonasal skull base surgery (EE-SBS) varies considerably depending on surgeons and their institutes. The purpose of the present meta-analysis is to assess the effect of antibiotic regimens on EE-SBS surgery for anterior skull base tumor. METHODS: The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched through October 15, 2022. RESULTS: The 20 included studies were all retrospective. The studies included a total of 10,735 patients who underwent EE-SBS for skull base tumor. The proportion of patients with postoperative intracranial infection across all 20 studies was 0.9% (95% confidence interval [CI] 0.5%-1.3%). The proportion of postoperative intracranial infection in the multiple antibiotics group did not show statistically significant difference to that of the single antibiotic agent group (proportion: 0.6%, 95% CI 0%-1.4% vs. proportion: 1%, 95% CI 0.6%-1.5%, respectively, P = 0.39). The ultra-short duration maintenance group showed lower incidence of postoperative intracranial infection, although it did not reach statistical significance (ultra-short group: 0.7%, 95% CI 0.5%-0.9%; short duration: 1.8%, 95% CI 0.5%-3%; and long duration: 1%, 95% CI 0.2%-1.9%, P = 0.22) The combination of the multiple antibiotics group did not show meaningful low incidence of postoperative intracranial infection (antibiotics combination group: 0.6%, 95% CI 0%-1.4%; cefazolin single group: 0.8%, 95% CI 0%-1.6%; and single antibiotics other than cefazolin: 1.2%, 95% CI 0.7%-1.7%, P = 0.22). CONCLUSIONS: Multiple antibiotics did not show superiority compared with single antibiotic agent. Also, long maintenance duration of antibiotics did not reduce the incidence of postoperative intracranial infection.

Comparison of the Efficacy of an Anchored Cage with Unidirectional and Bidirectional Screw Fixation in Single-Level Cervical Discectomy and Fusion Surgery.

AIM: To compare, and to analyze the clinical and radiological signs between bidirectional and unidirectional screw fixation in single level cervical discectomy and fusion surgery. MATERIAL AND METHODS: We retrospectively reviewed the data collected from 90 patients and divided them into the upper or lower spine fixation group (unidirectional) and the normal upper and lower spine fixation group (bidirectional). The patients' demographic data and preoperative and postoperative (24 months) clinical outcomes were collected. Pre- and postoperative (immediately and at 3, 6, 12, and 24 months) changes in the segmental angle in the operating field (SA), cervical lordosis, C2-7 sagittal vertical axis, and active disc height (aDH) were evaluated. We also compared the rate of fusion and muscle size change between the groups. RESULTS: The operation time in the bidirectional screw fixation group was significantly longer than that in the unidirectional screw fixation group ( > 6 min; p=0.03). There was no significant difference between the two groups in radiographic parameters before and immediately after surgery. From 3 months postoperatively, the unidirectional group had significantly higher SA and aDH than the bidirectional group (p=0.03). The fusion rate was higher in the bidirectional screw fixation group than in the unidirectional group, but this was not statistically significant (97% vs. 88%, p=0.07). CONCLUSION: The results of this study suggest that unidirectional screw fixation surgery can be useful as it has been associated with simple surgery, short surgery time, and maintenance of the lordotic curvature of SA and disc height.

Comparison of the Efficacy of Romosozumab and Teriparatide for the Management of Osteoporotic Vertebral Compression Fractures.

OBJECTIVE: Romosozumab is increasingly employed to manage osteoporosis. However, no studies have analyzed its effects on recent osteoporotic vertebral compression fractures (OVCFs). Therefore, this study aimed to evaluate the efficacy of romosozumab compared with teriparatide in managing OVCFs. METHODS: The electronic medical records of postmenopausal patients with recent OVCFs who were administered romosozumab or teriparatide for one year from March 2018 to August 2022 were retrospectively reviewed. We compared the 2 groups for demographics, radiological outcomes (compression ratio, Cobb angle, and bone mineral density [BMD]), and clinical outcomes (Numerical Rating Scale [NRS] for back pain). RESULTS: Fifty-five patients with OVCFs, 32 patients treated with romosozumab and 23 with teriparatide, were included in this study. The change of BMD (g/cm2) values was significantly higher (p = 0.016) in the romosozumab (0.04 ± 0.06) than in the teriparatide group (0.00 ± 0.08) in the femur total. Furthermore, in subgroup analysis, the change of BMD (g/cm2) values in the lumbar spine was significantly higher (p = 0.016) in the romosozumab (0.12 ± 0.06) than in the teriparatide group (0.07 ± 0.06) in the lumbar spine. The decrease in NRS was significantly higher (p = 0.013) in the romosozumab (6.6 ± 2.0) than in the teriparatide group (5.5 ± 2.1). However, there was no significant difference in radiologic outcomes between the 2 groups. CONCLUSION: Our findings suggest that romosozumab may be more effective than teriparatide in treating OVCFs in postmenopausal females, particularly in improving BMD and reducing back pain as measured by NRS.

Management of Cerebrospinal Fluid Leakage by Pump-Regulated Volumetric Continuous Lumbar Drainage Following Anterior Cervical Decompression and Fusion for Ossification of the Posterior Longitudinal Ligament.

OBJECTIVE: Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage. METHODS: We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage. RESULTS: Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed. CONCLUSION: The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.

Sacropelvic Fixation for Adult Deformity Surgery Comparing Iliac Screw and Sacral 2 Alar-Iliac Screw Fixation: Systematic Review and Updated Meta-Analysis.

OBJECTIVE: Two commonly used techniques for spinopelvic fixation in adult deformity surgery are iliac screw (IS) and sacral 2 alar-iliac screw (S2AI) fixations. In this article, we systematically meta-analyzed the complications of sacropelvic fixation for adult deformity surgery comparing IS and S2AI. METHODS: The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched until March 29, 2023. The proportion of postoperative complications, including implant failure, revision, screw prominence, and wound complications after sacropelvic fixation, were pooled with a random-effects model. Subgroup analyses for the method of sacropelvic fixation were conducted. RESULTS: Ten studies with a total of 1,931 patients (IS, 925 patients; S2AI, 1,006 patients) were included. The pooled proportion of implant failure was not statistically different between the IS and S2AI groups (21.9% and 18.9%, respectively) (p = 0.59). However, revision was higher in the IS group (21.0%) than that in the S2AI group (8.5%) (p = 0.02). Additionally, screw prominence was higher in the IS group (9.6%) than that in the S2AI group (0.0%) (p < 0.01), and wound complication was also higher in the IS group (31.7%) than that in the S2AI group (3.9%) (p < 0.01). CONCLUSION: IS and S2AI fixations showed that both techniques had similar outcomes in terms of implant failure. However, S2AI was revealed to have better outcomes than IS in terms of revision, screw prominence, and wound complications.