White Cord Syndrome Following Cervical Surgery in a Patient With Klippel-Feil Syndrome: A Case Report.

White cord syndrome is a rare entity, as there are very few cases described in the current literature. Postoperative MRI examination reveals cord intrinsic changes, including edema and ischemia. It is also described as a reperfusion injury of the spinal cord. This report depicts a rare case of "white cord syndrome" with tetraplegia after posterior laminectomy and fusion of the cervical spine in a patient with Klippel-Feil syndrome. A 33-year-old male patient with Klippel-Feil syndrome presented to our department with cervical myelopathy, claudication, deteriorating neurological status, imbalance, and lower limb spasticity. Due to kyphotic malformation of the cervical spine, a two-stage surgical intervention was scheduled. The patient first underwent anterior spinal fusion of C4-C6 with corpectomy of C5, where many anatomical and visceral differentiations were signed, so the surgical team was enhanced by a vascular surgeon. The postoperative period was uneventful and the patient was discharged after a week of hospitalization without any neurological deterioration. A second surgical intervention was scheduled after two months where laminectomy of C5-C7 and posterior fusion of C5-T1 were carried out. However, due to intraoperative spinal instability and various anatomical spinal variations, a third surgery, which would be occipitocervical fusion, was decided as the final surgical solution. During the third surgical operation, after the laminectomy of C1 to C5 and the placement of the occipital plate, the screws, and the two rods in situ, complete nullification of the intraoperative neurophysiologic control was signed. The internal fixation was removed immediately, the wake-up test revealed tetraplegia below C5, and the patient was transferred to the ICU. Immediate MRI revealed no spinal cord hematoma; however, spinal cord edema was present. The patient underwent a tracheostomy and remained quadriplegic with a sensory level of T8 and motor level of C5 and was discharged to a rehabilitation center. The possibility of white cord syndrome should be explained by surgeons before any cervical decompression surgery, as well as a thorough neurological examination should be performed postoperatively. The early recognition and prompt management of white cord syndrome is recommended.

Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences.

Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.

A C-Arm-Free Minimally Invasive Technique for Spinal Surgery: Cervical and Thoracic Spine.

Background and Objectives: C-arm-free MIS techniques can offer significantly reduced rates of postoperative complications such as inadequate decompression, blood loss, and instrumentation misplacement. Another advantageous long-term aspect is the notably diminished exposure to radiation, which is known to cause malignant changes. This study emphasizes that, in some cases of spinal conditions that require a procedural intervention, C-arm-free MIS techniques hold stronger indications than open surgeries guided by image intensifiers. Materials and Methods: This study includes a retrospective analysis and review of various cervical and thoracic spinal procedures, performed in our hospital, applying C-arm-free techniques. The course of this study explains the basic steps of the procedures and demonstrates postoperative and intraoperative results. For anterior cervical surgery, we performed OPLL resection, while for posterior cervical surgery, we performed posterior fossa decompression for Chiari malformation, minimally invasive cervical pedicle screw fixation (MICEPS), and modified Goel technique with C1 lateral mass screw for atlantoaxial subluxation. Regarding the thoracic spine, we performed anterior correction for Lenke type 5 scoliosis and transdiscal screw fixation for diffuse idiopathic skeletal hyperostosis fractures. Results: C-arm-free techniques are safe procedures that provide precise and high-quality postoperative results by offering sufficient spine alignment and adequate decompression depending on the case. Navigation can offer significant assistance in the absence of normal anatomical landmarks, yet the surgeon should always appraise the quality of the information received from the software. Conclusions: Navigated C-arm-free techniques are safe and precise procedures implemented in the treatment of surgically demanding conditions. They can significantly increase accuracy while decreasing operative time. They represent the advancement in the field of spine surgery and are hailed as the future of the same.

Surgical Site Infection Following the Correction of Adolescent Idiopathic Scoliosis With ApiFix: A Retrospective Study Analyzing Its Incidence and Recurrence.

Background and objective ApiFix (OrthoPediatrics, Warsaw, IN) is an internal brace used for the correction of adolescent idiopathic scoliosis (AIS) classified as Lenke 1 or 5 with a Cobb angle of 35-60 degrees that decreases to ≤30 degrees on lateral side-bending radiographs. Since the indications are very specific, it is not a common procedure. Our study aimed to evaluate the incidence of surgical site infection (SSI) and its recurrence following treatment with ApiFix. Materials and methods A retrospective study of 44 cases of AIS treated at our center from 2016 to 2022 with ApifiX was conducted. Two patients who presented with SSI were initially treated with irrigation and debridement (I&D) following antibiotic therapy.  Results A total of 44 patients with a mean age of 15.1 years were evaluated. Two of our patients presented with early-onset infection while one of them presented after the end of treatment with a skin ulcer due to septic screw loosening. The removal of the ApiFix implant revealed a pedicle abscess during the screw removal. Conclusions In this study of 44 patients, we observed two cases of infection and one case of reinfection. Given the limited muscle detachment and short operating time needed for Apifix, statistics suggest that the risk of SSI is always present. Further randomized trials are needed to gather more evidence on this subject.