External Validation of Predictive Models for Failed Medical Management of Spinal Epidural Abscess.

OBJECTIVE: There is limited consensus regarding management of spinal epidural abscesses (SEA), particularly in patients without neurologic deficits. Several models have been created to predict failure of medical management in patients with SEA. We evaluate the external validity of five predictive models in an independent cohort of patients with SEA. METHODS: 176 patients with SEA between 2010 and 2019 at our institution were identified, and variables relevant to each predictive model were collected. Published prediction models were used to assign probability of medical management failure to each patient. Predicted probabilities of medical failure and actual patient outcomes were used to create Receiver Operating Characteristic (ROC) curves, with the area under the ROC curve (AUROC) used to quantify a model's discriminative ability. Calibration curves were plotted using predicted probabilities and actual outcomes. The Spiegelhalter Z-test was used to determine adequate model calibration. RESULTS: One model (Kim et al.) demonstrated good discriminative ability and adequate model calibration in our cohort (ROC = 0.831, p-value = 0.83). Parameters included in the model were age >65, diabetes, MRSA infection, and neurologic impairment. Four additional models did not perform well for discrimination or calibration metrics (Patel et al., ROC=0.580, p=<0.0001; Shah et al., ROC=0.653, p=<0.0001; Baum et al., ROC=0.498, p=<0.0001; Page et al., ROC=0.534, p=<0.0001). CONCLUSION: Only one published predictive model demonstrated acceptable discrimination and calibration in our cohort, suggesting limited generalizability of the evaluated models. Multi-institutional data may facilitate the development of widely applicable models to predict medical management failure in patients with SEA.

Resection of an incidentally discovered spinal arachnoid web: illustrative case.

BACKGROUND: Spinal arachnoid webs (SAWs) are rare pathologies of the spinal meninges often associated with syringomyelia and the radiographic "scalpel sign." Patients can experience pain, numbness, gait disturbances, or no symptoms at all. They are typically diagnosed via magnetic resonance imaging and treated with laminectomy and excision. OBSERVATIONS: A 61-year-old male presented after a mechanical fall and had an incidentally discovered SAW on imaging. He was initially asymptomatic and was therefore conservatively managed. Several years later, however, the patient experienced new-onset back pain, paresthesia, and balance problems, with interval imaging demonstrating worsening of the edema surrounding his SAW. The patient subsequently underwent resection of the SAW, which led to significant resolution of his symptoms. LESSONS: An SAW can be asymptomatic or can manifest with a wide variety of symptoms. When this condition is incidentally discovered in asymptomatic patients, neurosurgeons should guide these patients to follow-up urgently if they develop any neurological symptoms. At that time, further imaging can be performed to determine if surgical treatment is indicated. Although SAW is rare, clinicians should be aware of the signs and symptoms, because prompt surgical intervention can significantly improve neurological symptoms.

Concomitant Traumatic Brain Injury Delays Surgery in Patients With Traumatic Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: Growing evidence supports prompt surgical decompression for patients with traumatic spinal cord injury (tSCI). Rates of concomitant tSCI and traumatic brain injury (TBI) range from 10% to 30%. Concomitant TBI may delay tSCI diagnosis and surgical intervention. Little is known about real-world management of this common injury constellation that carries significant clinical consequences. This study aimed to quantify the impact of concomitant TBI on surgical timing in a national cohort of patients with tSCI. METHODS: Patient data were obtained from the National Trauma Data Bank (2007-2016). Patients admitted for tSCI and who received surgical intervention were included. Delayed surgical intervention was defined as surgery after 24 hours of admission. Multivariable hierarchical regression models were constructed to measure the risk-adjusted association between concomitant TBI and delayed surgical intervention. Secondary outcome included favorable discharge status. RESULTS: We identified 14 964 patients with surgically managed tSCI across 377 North American trauma centers, of whom 2444 (16.3%) had concomitant TBI and 4610 (30.8%) had central cord syndrome (CCS). The median time to surgery was 20.0 hours for patients without concomitant TBI and 24.8 hours for patients with concomitant TBI. Hierarchical regression modeling revealed that concomitant TBI was independently associated with delayed surgery in patients with tSCI (odds ratio [OR], 1.3; 95% CI, 1.1-1.6). Although CCS was associated with delayed surgery (OR, 1.5; 95% CI, 1.4-1.7), we did not observe a significant interaction between concomitant TBI and CCS. In the subset of patients with concomitant tSCI and TBI, patients with severe TBI were significantly more likely to experience a surgical delay than patients with mild TBI (OR, 1.4; 95% CI, 1.0-1.9). CONCLUSION: Concomitant TBI delays surgical management for patients with tSCI. This effect is largest for patients with tSCI with severe TBI. These findings should serve to increase awareness of concomitant TBI and tSCI and the likelihood that this may delay time-sensitive surgery.

Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression.

Purpose: Although surgical decompression is the gold standard for metastatic epidural spinal cord compression (MESCC) from solid tumors, not all patients are candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with stereotactic body radiation therapy (SBRT) to high-grade MESCC. Methods and Materials: Patients with Bilsky grade 2 to 3 MESCC from solid tumor metastases treated with SBRT at a single institution from 2009 to 2020 were retrospectively reviewed. Patients who received upfront surgery before SBRT were included only if postsurgical Bilsky grade remained ≥2. Neurologic examinations, magnetic resonance imaging, pain assessments, and analgesic usage were assessed every 3 to 4 months post-SBRT. Cumulative incidence of local recurrence was calculated with death as a competing risk, and overall survival was estimated by Kaplan-Meier. Results: One hundred forty-three patients were included. The cumulative incidence of local recurrence was 5.1%, 7.5%, and 14.1% at 6, 12, and 24 months, respectively. At first post-SBRT imaging, 16.2% of patients with initial Bilsky grade 2 improved to grade 1, and 53.8% of patients were stable. Five of 13 patients (38.4%) with initial Bilsky grade 3 improved to grade 1 to 2. Pain response at 3 and 6 months post-SBRT was complete in 45.4% and 55.7%, partial in 26.9% and 13.1%, stable in 24.1% and 27.9%, and worse in 3.7% and 3.3% of patients, respectively. At 3 and 6 months after SBRT, 17.8% and 25.0% of patients had improved ambulatory status and 79.7% and 72.4% had stable status. Conclusions: We report the largest series to date of patients with high-grade MESCC treated with SBRT. The excellent local control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.

Assessing the Accuracy of Spinal Instrumentation Using Augmented Reality (AR): A Systematic Review of the Literature and Meta-Analysis.

Technological advancements, particularly in the realm of augmented reality (AR), may facilitate more accurate and precise pedicle screw placement. AR integrates virtual data into the operator's real-world view, allowing for the visualization of patient-specific anatomy and navigated trajectories. We aimed to conduct a meta-analysis of the accuracy of pedicle screw placement using AR-based systems. A systematic review of the literature and meta-analysis was performed using the PubMed/MEDLINE database, including studies reporting the accuracy of pedicle screw placement using AR. In total, 8 studies with 163 patients and 1259 screws were included in the analysis. XVision (XVS) was the most commonly used AR system (595 screws) followed by the Allura AR surgical navigation system (ARSN) (462 screws). The overall accuracy was calculated as 97.2% (95% CI 96.2-98.1% p < 0.001). Subgroup analysis revealed that there was no statistically significant difference in the accuracy rates achieved by XVS and Allura ARSN (p = 0.092). AR enables reliable, accurate placement of spinal instrumentation. Future research efforts should focus on comparative studies, cost effectiveness, operative time, and radiation exposure.

Synovial Cyst in the Setting of an Interspinous Fusion Device.

Synovial cysts of the spine are degenerative cystic lesions that can lead to severe symptoms secondary to compression of the spinal cord, individual nerve roots, and/or the cauda equina. Some believe the etiology of this entity is related to increased motion across the facet joint and instability. We report a case of a lumbar synovial cyst located at the same level as a previously inserted spinous process fusion device. This case illustrates that, unlike a transpedicular instrumented fusion where the risk of synovial cyst formation is zero, a spinal process fusion can still lead to synovial cyst formation likely due to persistent micromotion across that segment.

Contemporary Trends in Minimally Invasive Sacroiliac Joint Fusion Utilization in the Medicare Population by Specialty.

BACKGROUND AND OBJECTIVES: Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare. METHODS: We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare. RESULTS: A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures. CONCLUSION: Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs.

Safety and clinical efficacy of immune checkpoint inhibition and stereotactic body radiotherapy in patients with spine metastasis.

OBJECTIVE: Immunotherapy, particularly immune checkpoint inhibitors (ICIs), has revolutionized the treatment of patients with many tumor histologies. Simultaneously, stereotactic body radiotherapy (SBRT) provides excellent local control (LC) and plays an important role in the management of spine metastasis. Promising preclinical work suggests the potential therapeutic benefit of combining SBRT with ICI therapy, but the safety profile of combined therapy is unclear. This study aimed to evaluate the toxicity profile associated with ICI in patients receiving SBRT and, secondarily, whether ICI administration sequence with respect to SBRT affects LC or overall survival (OS) outcomes. METHODS: The authors retrospectively reviewed patients with spine metastasis treated with SBRT at an academic center. Patients who received ICI at any point during their disease course were compared to those with the same primary tumor types who did not receive ICI by using Cox proportional hazards analyses. Primary outcomes were long-term sequelae, including radiation-induced spinal cord myelopathy, esophageal stricture, and bowel obstruction. Secondarily, models were created to evaluate OS and LC in the cohort. RESULTS: Two hundred forty patients who received SBRT to 299 spine metastases were included in this study. The most common primary tumor types were non-small cell lung cancer (n = 59 [24.6%]) and renal cell carcinoma (n = 55 [22.9%]). One hundred eight patients received at least 1 dose of ICI, with the most common regimen being single-agent anti-PD-1 (n = 80 [74.1%]), followed by combination CTLA-4/PD-1 inhibitors (n = 19 [17.6%]). Three patients experienced long-term radiation-induced sequelae: 2 had esophageal stricture and 1 had bowel obstruction. No patients developed radiation-induced myelopathy. There was no association between receipt of ICI and development of any of these adverse events (p > 0.9). Similarly, ICI was not significantly associated with either LC (p = 0.3) or OS (p = 0.6). In the entire cohort, patients who received ICI prior to beginning SBRT had worse median survival, but ICI sequence with respect to SBRT was not significantly prognostic of either LC (p > 0.3) or OS (p > 0.07); instead, baseline performance status was most predictive of OS (HR 1.38, 95% CI 1.07-1.78, p = 0.012). CONCLUSIONS: Treatment regimens that combine ICIs before, concurrent with, and after SBRT for spine metastases are safe, with minimal risk for increased rates of long-term toxicity.

Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons.

STUDY DESIGN: International survey. OBJECTIVES: C5 palsy (C5P) is a neurological complication affecting 5-10% of patients after cervical decompression surgery. Most cases improve with conservative treatment; however, nearly 20% of patients may be left with residual deficits. Guidelines are lacking on C5P management and timing of surgical intervention. Therefore, we sought to survey peripheral nerve surgeons on their management of C5P. METHODS: An online survey was distributed centered around a patient with C5P after posterior cervical decompression and fusion. Questions included surgeon demographics, diagnostic modalities, and timing and choice of operation. Responses were summarized and the chi-squared and Kruskal-Wallis H tests were used to examine differences across specialties. RESULTS: A total of 154 surgeons responded to the survey, of which 59 (38%) indicated that they manage C5P cases. Average time prior to operating was 4.5 ± 2.2 months for complete injuries and 6.6 ± 3.2 months for partial injuries, with neurosurgeons significantly more likely to wait longer periods for complete (P = .01) and partial injuries (P = .03). Foraminotomies were selected by 19% of surgeons, while 92% selected nerve transfers. Transfer of the ulnar nerve to the musculocutaneous nerve was the most common choice (81%), followed by transfer of the radial nerve to the axillary nerve (58%). CONCLUSION: Consensus exists among peripheral nerve surgeons on the use of nerve transfers for surgical treatment in cases with severe motor weakness failing to improve. Most surgeons advocate for early intervention in complete injuries. Disagreement concerns the type of nerve transfer employed, timing of surgery, and efficacy of foraminotomy.

Antiresorptive Medications Prior to Stereotactic Body Radiotherapy for Spinal Metastasis are Associated with Reduced Incidence of Vertebral Body Compression Fracture.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: Antiresorptive drugs are often given to minimize fracture risk for bone metastases, but data regarding optimal time or ability to reduce stereotactic body radiotherapy (SBRT)-induced fracture risk is limited. This study examines the association between antiresorptive use surrounding spinal SBRT and vertebral compression fracture (VCF) incidence to provide information regarding effectiveness and optimal timing of use. METHODS: Patients treated with SBRT for spinal metastases at a single institution between 2009-2020 were included. Kaplan-Meier analysis was used to compare cumulative incidence of VCF for those taking antiresorptive drugs pre-SBRT, post-SBRT only, and none at all. Cox proportional hazards and Fine-Gray competing risk models were used to identify additional factors associated with VCF. RESULTS: Of the 234 patients (410 vertebrae) analyzed, 49 (20.9%) were taking bisphosphonates alone, 42 (17.9%) were taking denosumab alone, and 25 (10.7%) were taking both. Kaplan-Meier analysis revealed a statistically significant lower VCF incidence for patients initiating antiresorptive drugs before SBRT compared to those taking none at all (4% vs 12% at 1 year post-SBRT, P = .045; and 4% vs 23% at 2 years, P = .008). On multivariate analysis, denosumab duration (HR: .87, P = .378) or dose (HR: 1.00, P = .644) as well as bisphosphonate duration (HR: .98, P= .739) or dose (HR: .99, P= .741) did not have statistical significance on VCF incidence. CONCLUSION: Initiating antiresorptive agents before SBRT may reduce the risk of treatment-induced VCF. Antiresorptive drugs are underutilized in patients with spine metastases and may represent a useful intervention to minimize toxicity and improve long-term outcomes.

Anterior cervical discectomy and fusion versus posterior decompression in patients with degenerative cervical myelopathy: a systematic review and meta-analysis.

OBJECTIVE: The optimal surgical approach for patients with multilevel degenerative cervical myelopathy (DCM) remains unknown. This systematic review and meta-analysis sought to compare anterior cervical discectomy and fusion (ACDF) versus posterior decompression (PD) in patients with DCM spanning ≥ 2 levels without ossification of the posterior longitudinal ligament. METHODS: MEDLINE and PubMed were searched from inception to February 22, 2022. The primary outcomes were Neck Disability Index (NDI), SF-36 Physical Component Summary (PCS), modified Japanese Orthopaedic Association (mJOA) scale, visual analog scale (VAS), and EQ-5D scores. Secondary outcomes were operative bleeding, operative duration, hospital length of stay (LOS), postoperative morbidity (including hematoma, surgical site infection [SSI], CSF leakage, dysphagia, dysphonia, C5 palsy, and fusion failure), mortality, readmission, reoperation, and Cobb angle. RESULTS: Nineteen studies comprising 8340 patients were included, of whom 4118 (49.4%) and 4222 (50.6%) underwent ACDF and PD, respectively. The mean number of involved spinal levels was comparable between the groups (3.1 vs 3.5, p = 0.15). The mean differences (MDs) of the primary outcomes were the mean of each index in the ACDF group minus that of the PD group. At the 1-year follow-up, the MDs of the NDI (-1.67 [95% CI -3.51 to 0.18], p = 0.08), SF-36 PCS (2.48 [95% CI -0.59 to 5.55], p = 0.11), and VAS (-0.32 [95% CI -0.97 to 0.34], p = 0.35) scores were similar between the groups. While the MDs of the mJOA (0.71 [95% CI 0.27 to 1.16], p = 0.002) and EQ-5D (0.04 [95% CI 0.01 to 0.08], p = 0.02) scores were greater in the ACDF group, the differences were not clinically significant given the minimal clinically important differences (MCIDs) of 2 and 0.05 points, respectively. In the ACDF group, the MDs for operative bleeding (-102.77 ml [95% CI -169.23 to -36.30 ml], p = 0.002) and LOS (-1.42 days [95% CI -2.01 to -0.82 days], p < 0.00001) were lower, the dysphagia OR (11.10 [95% CI 5.43-22.67], p < 0.0001) was higher, and the ORs for SSI (0.43 [95% CI 0.24-0.78], p = 0.006) and C5 palsy (0.32 [95% CI 0.15-0.70], p = 0.004) were lower. The other outcomes were similar between the groups. Overall evidence according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was moderate. CONCLUSIONS: ACDF and PD are similar regarding functional outcomes. ACDF is beneficial in terms of less bleeding, shorter LOS, and lower odds of SSI and C5 palsy, while the procedure carries higher odds of dysphagia. The authors recommend individualized treatment decision-making.

In-Human Report of S2 Alar-Iliac Screw Placement Using Augmented Reality Assistance.

BACKGROUND: S2 alar-iliac (S2AI) screws provide spinopelvic fixation with the advantages of minimized dissection, easier rod contouring, and decreased symptomatic screw-head prominence. However, placement of S2AI screws may be challenging because of the anatomy of the lumbosacral junction. Augmented reality is a nascent technology that may enhance placement of S2AI screws. OBJECTIVE: To report the first in-human placement of augmented reality (AR)-assisted S2 alar-iliac screws and evaluate the accuracy of screw placement. METHODS: A retrospective review was performed of patients who underwent AR-assisted S2AI screw placement. All surgeries were performed by 2 neurosurgeons using an AR head-mounted display (Xvision, Augmedics). Screw accuracy was analyzed in a blinded fashion by an independent neuroradiologist using the cortical breach grading scale. RESULTS: Twelve patients underwent AR-assisted S2AI screw placement for a total of 23 screws. Indications for surgery included deformity, degenerative disease, and tumor. Twenty-two screws (95.6%) were accurate-defined as grade 0 or grade 1. Twenty-one screws (91.3%) were classified as grade 0, 1 screw (4.3%) was grade 1, and 1 screw (4.3%) was grade 3. All breaches were asymptomatic. CONCLUSION: AR-assisted S2AI screw placement had an overall accuracy rate of 95.6% (grade 0 and grade 1 screws) in a cohort of 12 patients and 23 screws. This compares favorably with freehand and robotic placement. 1,2 AR enables spine surgeons to both better visualize anatomy and accurately place spinal instrumentation. Future studies are warranted to research the learning curve and cost analysis of AR-assisted spine surgery.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review.

BACKGROUND: Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE: To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS: A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS: After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS: Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Predictors of Blunt Cerebrovascular Injury, Stroke, and Mortality in Patients with Cervical Spine Trauma.

BACKGROUND: Blunt cerebrovascular injury (BCVI), defined as blunt traumatic injury to the carotid or vertebral arteries, is associated with significant risk of stroke and mortality. Cervical spine trauma is a recognized risk factor for BCVI. OBJECTIVE: The objective of this study was to identify significant predictors of BCVI and its sequelae in patients with known cervical spine injury. METHODS: Patients from 2007 to 2018 with blunt cervical spine injury diagnoses were identified in the National Trauma Data Bank. Multivariable logistic regression models were used to identify patient baseline and injury characteristics associated with BCVI, stroke, and mortality. RESULTS: We identified 229,254 patients with cervical spine injury due to blunt trauma. The overall rate of BCVI was 1.6%. Factors associated with BCVI in patients with cervical spine injury included lower Glasgow Coma Scale, motor vehicle crash, higher Injury Severity Score, concomitant traumatic brain or spinal cord injury, and current smoking status. BCVI was a strong predictor of stroke (odds ratio, 8.2; 95% confidence interval, 5.7-12.0) and was associated with mortality (odds ratio, 1.7; 95% confidence interval, 1.3-2.2). Stroke occurred in 3.3% of patients with BCVI versus 0.02% for patients without BCVI. CONCLUSIONS: While BCVI is rare following cervical spine injury due to blunt trauma, it is a significant predictor of stroke and mortality. The risk factors associated with BCVI, stroke, and mortality identified here should be used in the development of more effective predictive tools to improve care.

Safety and Accuracy of Freehand Pedicle Screw Placement and the Role of Intraoperative O-Arm: A Single-Institution Experience.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to investigate the accuracy of pedicle screw placement by freehand technique and to compare revision surgery rates among three different imaging verification pathways. SUMMARY OF BACKGROUND DATA: Studies comparing different imaging modalities in freehand screw placement surgery are limited. MATERIALS AND METHODS: A single-institution retrospective chart review identified adult patients who underwent freehand pedicle screw placement in the thoracic, lumbar or sacral levels. Patients were stratified into three cohorts based on the intraoperative imaging modality used to assess the accuracy of screw position: intraoperative X-rays (cohort 1); intraoperative O-arm (cohort 2); or intraoperative computed tomography (CT)-scan (cohort 3). Postoperative CT scans were performed on all patients in cohorts 1 and 2. Postoperative CT scan was not required in cohort 3. Screw accuracy was assessed using the Gertzbein-Robbins grading system. RESULTS: A total of 9179 pedicle screws were placed in the thoracic or lumbosacral spine in 1311 patients. 210 (2.3%) screws were identified as Gertzbein-Robbins grades C-E on intraoperative/postoperative CT scan, 137 thoracic screws, and 73 lumbar screws ( P <0.001). Four hundred and nine patients underwent placement of 2754 screws followed by intraoperative X-ray (cohort 1); 793 patients underwent placement of 5587 screws followed by intraoperative O-arm (cohort 2); and 109 patients underwent placement of 838 screws followed by intraoperative CT scan (cohort 3). Postoperative CT scans identified 65 (2.4%) and 127 (2.3%) malpositioned screws in cohorts 1 and 2, respectively. Eleven screws (0.12%) were significantly malpositioned and required a second operation for screw revision. Nine patients (0.69%) required revision operations: eight of these patients were from cohort 1 and one patient was from cohort 2. CONCLUSION: When compared to intraoperative X-ray, intraoperative O-arm verification decreased the revision surgery rate for malpositioned screws from 0.37% to 0.02%. In addition, our analysis suggests that the use of intraoperative O-arm can obviate the need for postoperative CT scans.

Management of traumatic sacral spondyloptosis: illustrative case.

BACKGROUND: Grade V spondylolisthesis, or spondyloptosis, is a complication of high-energy trauma that is most commonly reported at the lumbosacral junction. Sacral intersegmental spondyloptosis is extremely rare. The authors present a case of spondyloptosis of S1 on S2 with a comminuted fracture of S2 and complex fractures of the L4 and L5 transverse processes, resulting in severe stenosis of the lumbosacral nerve roots. OBSERVATIONS: The patient was a 70-year-old woman with a history of a fall 3 weeks prior and progressive L5 and S1 radiculopathy. Instrumentation and fusion were undertaken, extending from L3 to the pelvis because degenerative stenosis at L3-4 and L4-5 was also found. Reduction was achieved, leading to diminished pain and partial resolution of weakness. LESSONS: Traumatic sacral spondyloptosis adds a degree of difficulty to reduction, fixation, and fusion. The technique presented herein achieved sagittal realignment via a distraction maneuver of S1-2 in which rods were attached to bilateral dual S2 alar-iliac screws with reduction screws placed at S1, ultimately pulling L5 and S1 up to the rod for fixation.

Etiologies and Outcomes of Spinal Epidural Lipomatosis: Systematic Review of the Literature and Meta-Analysis of Reported Cases.

STUDY DESIGN: This was a systematic review of the literature. OBJECTIVE: The aim was to examine the contemporary demographics, etiological factors, treatment options and outcomes of spinal epidural lipomatosis (SEL) in adults. SUMMARY OF BACKGROUND DATA: SEL is primarily seen in obese patients as well as those on steroid therapy. Much regarding the etiology and treatment outcomes of SEL is unknown. METHODS: We reviewed Ovid MEDLINE, PubMed, SCOPUS, and Google Scholars databases from 1990 through August 2020 to identify cases of SEL. Data collected included patient characteristics, disease associations, level of pathology, treatment, and clinical outcomes. RESULTS: Ninety articles (145 individual cases) were included in the analysis. The median age was 54 years and 79% were males. Obesity-associated SEL constituted the largest proportion (52%) of our cohort. 22% of SEL cases were related to steroid use, while 26% cases were considered to be idiopathic. Lumbosacral SEL was the most frequently reported level of disease (68.9%), followed by the thoracic level (26.2%). The mean age of cases who underwent surgical intervention was 55 years, as compared with 48 years in those who received conservative management ( P =0.03). 95% of patients reported some degree of symptomatic improvement regardless of the treatment modality. Logistic regression suggested a possible superior outcome associated with those undergoing surgical treatment. CONCLUSION: In contrast to historical comparisons, contemporary articles support that obesity has become the major contributing factor for SEL. Logistic regression of the existing cases suggests that there may be a role for surgical intervention in select patients.

Adoption of awake spine surgery - trends from a national registry over 14 years.

BACKGROUND CONTEXT: Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied. PURPOSE: To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States. STUDY DESIGN/SETTING: A retrospective observational study. PATIENT SAMPLE: Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019. OUTCOME MEASURES: The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019. METHODS: Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006. RESULTS: We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m2; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively). CONCLUSIONS: Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery.

Surgeon specialty effect on early outcomes of elective posterior spinal fusion for adolescent idiopathic scoliosis: a propensity-matched analysis of 965 patients.

BACKGROUND AND OBJECTIVE: Comparative effectiveness research plays a vital role in health care delivery. Specialty training is one of these variables; surgeons who are trained in different specialties may have different outcomes performing the same procedure. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: This is a retrospective, 1:4 propensity score-matched cohort study. 5520 AIS patients were reviewed from ACS-NSQIP pediatric database. Propensity score matching was utilized. RESULTS: Patients operated on by orthopedic surgeons were more likely to have shorter operation time (263 min vs 285 min), shorter total hospital stay (95 h vs 118 h), lower rate of return to operating room within the same admission (1.2% vs 3.8%), lower discharge rates after postoperative day 4 (23.8% vs 30.9%), and lower unplanned readmission rate (1.6% vs 4.1%), (p < 0.05). On the other hand, patients operated on by neurosurgeons had lower perioperative blood transfusion rate (62.1% vs 69.8%), (p < 0.05). Other outcome measures and mortality rates were not significantly different between the two cohorts. CONCLUSIONS: This retrospective study found significant differences in early perioperative outcomes of patients undergoing PSF for AIS by neurosurgeons and orthopedic surgeons. Further studies are recommended to corroborate this finding which may trigger changes in the educational curriculum for neurosurgery residents.