Doing more with less: surgical results of pediatric posterior fossa tumors from a single center in Latin America.

OBJECTIVE: We aim to report the epidemiology, surgical outcomes, and survival rates of pediatric patients with posterior fossa tumors in a large single-center case series. METHODS: A retrospective analysis was conducted on pediatric patients who underwent surgical treatment for posterior fossa tumors between January 2011 and January 2019. RESULTS: A total of 135 pediatric patients, with an average age of 7.5 years at diagnosis and a mean follow-up of 35.7 months, were included in the study. Most tumors were located within the midline, with ventriculomegaly observed in 71.4% of the patients. Pilocytic astrocytomas encompassed the majority of tumors (34.1%), followed by medulloblastomas (27.4%) and ependymomas (11.8%). Gross total resection (GTR) was achieved in 71.8% of the patients, with a recurrence rate of 20%. Surgical complications were observed in 25.9% of the patients. GTR significantly impacted 5-year overall survival (OS) and 4-year progression-free survival (PFS) in patients with posterior fossa tumors. Patients who underwent GTR had a 5-year OS of 89.7%, compared to 72.7% for near-total resection and 70.8% for subtotal resection. The 4-year PFS for patients who underwent GTR was 82.5%, whereas it was 63.6% for patients who underwent near-total resection and 54.2% for patients who underwent subtotal resection. CONCLUSION: Surgical resection remains the main treatment for pediatric posterior fossa tumors, and higher resection rates are linked to better survival outcomes. Despite limited resources for molecular diagnosis, our institution has demonstrated that a specialized neurooncological center with a high surgical volume can still achieve favorable survival outcomes for these patients.

Predictive Algorithm for Surgery Recommendation in Thoracolumbar Burst Fractures Without Neurological Deficits.

STUDY DESIGN: Predictive algorithm via decision tree. OBJECTIVES: Artificial intelligence (AI) remain an emerging field and have not previously been used to guide therapeutic decision making in thoracolumbar burst fractures. Building such models may reduce the variability in treatment recommendations. The goal of this study was to build a mathematical prediction rule based upon radiographic variables to guide treatment decisions. METHODS: Twenty-two surgeons from the AO Knowledge Forum Trauma reviewed 183 cases from the Spine TL A3/A4 prospective study (classification, degree of certainty of posterior ligamentous complex (PLC) injury, use of M1 modifier, degree of comminution, treatment recommendation). Reviewers' regions were classified as Europe, North/South America and Asia. Classification and regression trees were used to create models that would predict the treatment recommendation based upon radiographic variables. We applied the decision tree model which accounts for the possibility of non-normal distributions of data. Cross-validation technique as used to validate the multivariable analyses. RESULTS: The accuracy of the model was excellent at 82.4%. Variables included in the algorithm were certainty of PLC injury (%), degree of comminution (%), the use of M1 modifier and geographical regions. The algorithm showed that if a patient has a certainty of PLC injury over 57.5%, then there is a 97.0% chance of receiving surgery. If certainty of PLC injury was low and comminution was above 37.5%, a patient had 74.2% chance of receiving surgery in Europe and Asia vs 22.7% chance in North/South America. Throughout the algorithm, the use of the M1 modifier increased the probability of receiving surgery by 21.4% on average. CONCLUSION: This study presents a predictive analytic algorithm to guide decision-making in the treatment of thoracolumbar burst fractures without neurological deficits. PLC injury assessment over 57.5% was highly predictive of receiving surgery (97.0%). A high degree of comminution resulted in a higher chance of receiving surgery in Europe or Asia vs North/South America. Future studies could include clinical and other variables to enhance predictive ability or use machine learning for outcomes prediction in thoracolumbar burst fractures.

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

STUDY DESIGN: A prospective study. OBJECTIVE: to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. METHODS: A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. RESULTS: ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). CONCLUSION: The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

Anatomy of the posterior Fossa: a comprehensive description for pediatric brain tumors.

Posterior fossa tumors are the most common pediatric brain tumors, and present unique challenges in terms of their location and surgical management. The posterior fossa comprehends complex anatomy and represents the smallest and deepest of the three cranial base fossae. An in-depth understanding of posterior fossa anatomy is crucial when it comes to the surgical resection of pediatric brain tumors. Mastering the knowledge of posterior fossa anatomy helps the neurosurgeon in achieving a maximal and safe volumetric resection, that impacts in both overall and progression free survival. With the advancements in microsurgery, the telovelar approach has emerged as the workhorse technique for the resection of posterior fossa tumors in pediatric patients. This approach involves meticulously dissecting of the natural clefts present in the cerebellomedullary fissure, making a comprehensive understanding of the underlying anatomy key for its success.

Posterior fossa tumors in children: current insights.

While in adults most intracranial tumors develop around the cerebral hemispheres, 45 to 60% of pediatric lesions are found in the posterior fossa, although this anatomical region represents only 10% of the intracranial volume. The latest edition of the WHO classification for CNS tumors presented some fundamental paradigm shifts that particularly affected the classification of pediatric tumors, also influencing those that affect posterior fossa. Molecular biomarkers play an important role in the diagnosis, prognosis, and treatment of childhood posterior fossa tumors and can be used to predict patient outcomes and response to treatment and monitor its effectiveness. Although genetic studies have identified several posterior fossa tumor types, differing in terms of their location, cell of origin, genetic mechanisms, and clinical behavior, recent management strategies still depend on uniform approaches, mainly based on the extent of resection. However, significant progress has been made in guiding therapy decisions with biological or molecular stratification criteria and utilizing molecularly targeted treatments that address specific tumor biological characteristics. The primary focus of this review is on the latest advances in the diagnosis and treatment of common subtypes of posterior fossa tumors in children, as well as potential therapeutic approaches in the future.   Conclusion: Molecular biomarkers play a central role, not only in the diagnosis and prognosis of posterior fossa tumors in children but also in customizing treatment plans. They anticipate patient outcomes, measure treatment responses, and assess therapeutic effectiveness. Advances in neuroimaging and treatment have significantly enhanced outcomes for children with these tumors. What is Known: • Central nervous system tumors are the most common solid neoplasms in children and adolescents, with approximately 45 to 60% of them located in the posterior fossa. • Multimodal approaches that include neurosurgery, radiation therapy, and chemotherapy are typically used to manage childhood posterior fossa tumors What is New: • Notable progress has been achieved in the diagnosis, categorization and management of posterior fossa tumors in children, leading to improvement in survival and quality of life.

Surgical outcome of spinal schwannoma and neurofibroma.

OBJECTIVE: The aim of this study was to evaluate the outcome and surgical complications in patients with spinal schwannoma or neurofibroma surgically treated at the Hospital das Clínicas of the State University of Campinas. METHODS: This was a retrospective cohort study, using medical records of patients operated between 2011 and 2021. The sample distribution was verified using the Kolmogorov-Smirnov test. The dynamics between qualitative variables were assessed using Fisher's exact test. We used means analysis to assess patient improvement based on Frankel scores. RESULTS: A total of 16 patients were evaluated, of whom 56.25% (9) were men and 43.75% (7) were women. There were 13 (81.25%) patients with schwannomas and 3 (18.75%) with neurofibromas. Patients with deficits had neurological improvement, such as walking or with at least Frankel D or E after surgery. Laminectomy, performed in 8 patients (50%), and laminoplasty, used in 9 patients (56.25%), were the main techniques. CONCLUSION: The surgical approach was proved to be an effective and safe alternative to the treatment of these tumors, with neurological improvement and minor surgical complications.

Surgical outcome of spinal schwannoma and neurofibroma

SUMMARY OBJECTIVE: The aim of this study was to evaluate the outcome and surgical complications in patients with spinal schwannoma or neurofibroma surgically treated at the Hospital das Clínicas of the State University of Campinas. METHODS: This was a retrospective cohort study, using medical records of patients operated between 2011 and 2021. The sample distribution was verified using the Kolmogorov-Smirnov test. The dynamics between qualitative variables were assessed using Fisher's exact test. We used means analysis to assess patient improvement based on Frankel scores. RESULTS: A total of 16 patients were evaluated, of whom 56.25% (9) were men and 43.75% (7) were women. There were 13 (81.25%) patients with schwannomas and 3 (18.75%) with neurofibromas. Patients with deficits had neurological improvement, such as walking or with at least Frankel D or E after surgery. Laminectomy, performed in 8 patients (50%), and laminoplasty, used in 9 patients (56.25%), were the main techniques. CONCLUSION: The surgical approach was proved to be an effective and safe alternative to the treatment of these tumors, with neurological improvement and minor surgical complications.

Temporopolar Amygdalohippocampectomy for Mesial Temporal Lobe Epilepsy: A Two-Dimensional Anatomical Operative Video.

Mesial temporal lobe epilepsy is the most frequent type of focal epilepsy in young adults and the most commonly reported in surgical series worldwide.1,2 When seizures become refractory to drug therapy, they are unlikely to remit spontaneously, and for the 30% of patients with epilepsy that is refractory to antiepileptic drugs, resection of the mesial temporal lobe structures provides seizure control rates of 70%-80%.3,4 The transsylvian route for amygdalohippocampectomy has been used at our institution for many years, evolving from the first description of Yasargil through the inferior circular sulcus of insula to the most recent one through the amygdala trying to preserve the temporal stem.5,6 Despite good outcomes according to the Engel classification, analysis of late postoperative magnetic resonance imaging scans of our patients showed a high incidence of temporal pole atrophy and potential gliosis.7,8 Therefore, we decided to keep the transsylvian route, but we removed a portion of the temporal pole anterior to the limen insula, resulting in a temporopolar amygdalohippocampectomy.4,9 Temporopolar amygdalohippocampectomy demonstrated good temporal stem preservation, good visual outcomes, and good memory results.4 We also advocate that the transsylvian route has the potential to provide a superior view and resection of the piriform cortex, that is associated with seizure outcome after surgery.10 We present a case of a 42-year-old woman who had refractory seizures secondary to mesial temporal lobe epilepsy and underwent temporopolar amygdalohippocampectomy with a good outcome, remaining seizure-free (Engel IA) (Video 1). The patient provided consent for surgery and video publication.

Growing skull fracture in a child with Ehlers-Danlos syndrome: case report and literature review.

INTRODUCTION: Growing skull fracture (GSF) is a rare complication of head trauma in the pediatric population, commonly observed in children younger than 3 years. DISCUSSION: In this report, the authors describe a case of a 3-year-old male child, with clinical features of Ehlers-Danlos syndrome (EDS), who developed a GSF in frontal bone after a crib fall, treated with duraplasty and cranioplasty with autologous craft. Here, pertinent literature was reviewed with an emphasis on surgical techniques, and correlation with the mentioned syndrome. CONCLUSION: This is the first case of GSF in association with EDS in the literature. The relevance of the case described concerns the rarity of the condition itself, the atypical presentation, and the intraoperative findings, which showed the important fragility of the dura mater, probably due to EDS. Therefore, this syndrome, besides having influenced the pathogenesis, was also a challenging factor in the surgical treatment.

How Knowledgeable Are Spine Surgeons Regarding EMG-NCS for Cervical Spine Conditions? An International Aospine Survey.

STUDY DESIGN: Cross-sectional, international survey. OBJECTIVES: To evaluate the knowledge of spine surgeons regarding the use of electromyography (EMG) and nerve conduction studies (NCS) for degenerative cervical spine conditions (DCC). METHODS: All members of AO Spine International were emailed an anonymous survey to evaluate their clinical knowledge about the use of EMG and nerve conduction studies for DCC. Descriptive statistics were used to analyze the results, as well as to compare the answers among different groups of surgeons and assess demographic characteristics. RESULTS: A total of 402 participants answered the survey, 91.79% were men from the 5 continents. There were 221 orthopedic surgeons (55.39%) and 171 neurosurgeons (42.86%), more than a half of them with a complete spinal fellowship (56.44%). The most common reasons that surgeons obtain the test is to differentiate a radiculopathy from a peripheral nerve compression (88.06%). As a group, the responding surgeons' knowledge regarding EMG-NCS was poor. Only 53.46% of surgeons correctly answered that EMG-NCS is unable to differentiate a C5 from a C6 radiculopathy. Only 23.47% of the surgeons knew that EMG-NCS are not able to diagnose a pre vs a post-fixed brachial plexus. Only 25% of the surgeons correctly answered a question regarding the test's ability to diagnose other neurological diseases. CONCLUSIONS: We found that our respondents' knowledge regarding EMG-NCS for DCC was poor. Identifying the weak points of knowledge about EMG-NCS may help to educate surgeons on the indications for the test and the proper way to interpret the results.

Effect of surgical experience and spine subspecialty on the reliability of the AO Spine Upper Cervical Injury Classification System.

OBJECTIVE: The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5-10 years, 10-20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). METHODS: A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson's chi-square or Fisher's exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS: The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5-10 years: 0.69 vs 10-20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5-10 years: 0.62 vs 10-20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5-10 years: 0.61 vs 10-20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). CONCLUSIONS: The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.

Peritoneal metastasis of a brainstem anaplastic ganglioglioma in a 2-year-old boy: case report and literature review.

Anaplastic gangliogliomas (AGG) are rare tumors of the central nervous system (CNS) that commonly affect children and young adults, with an unusual infratentorial presentation, which is related to hydrocephalus and a worse prognosis. We report a case of a brainstem AGG in a 2-year-old boy who underwent a ventriculoperitoneal shunting (VPS) and later presented peritoneal metastasis. We also reviewed the related literature. Even though rare, disease dissemination through VPS should be sought in patients with CNS tumors and VPS who develop new abdominal symptoms. The early diagnosis and intervention may minimize morbidity and improve quality of life of such patients.

Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients / Impacto das características angioarquiteturais das malformações arteriovenosas cerebrais na apresentaçáo clínica: análise de 183 pacientes

ABSTRACT Background: The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. Objective: The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. Methods: A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). Results: A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). Conclusions: Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.

RESUMO Antecedentes: A correlação entre a angioarquitetura e a apresentação clínica da Malformação Arteriovenosa do cérebro (MAVc) permanece um assunto de debate. Objetivos: Correlacionar as características angioarquiteturais das MAVc com a apresentação clínica. Métodos: Estudou-se pacientes consecutivos atendidos no Hospital Beneficência Portuguesa-SP, entre 2006 a 2016. Após análise geral, criaram-se cinco grupos de acordo com a apresentação clínica: 1- Hemorragia; 2 - Epilepsia; 3 - Cefaléia; 4 - Déficit Neurológico Progressivo (DNP) e 5 - Incidental. Características epidemiológicas (clínica e topografia) e angioarquiteturais (Classificação de Spetzler-Martin Modificada - SMM; Fluxo intranidal; Aneurismas arteriais, intranidais e venosos; Ectasia venosa; Congestão venosa; "Roubo" arterial; Vascularização dural; Drenagem Venosa Profunda) foram analisadas. Resultados: 183 pacientes foram incluídos e analisados globalmente. Após essa etapa, foram divididos nos grupos: 1 - 56 casos (30,6%); 2 - 49 casos (26,7%); 3 - 41 casos (22,4%); 4 - 28 casos (15,3%) e 5 - 9 casos (4,9%). Principais achados foram referentes a apresentação hemorrágica, na qual observamos correlação estatística positiva com o sexo feminino (P<0,02), lesões classificadas como SMM 3B (P<0,0015) e baixo fluxo (P<0,04). Relacionado à epilepsia, encontramos significância estatística que possibilitou a correlação com pacientes com idade inferior a 36 anos (P<0,001), sexo masculino (P<0,018), lesões superficiais (P<0,002), presença de ectasia venosa (P<0,003) e "roubo" arterial (P<0,01). Pacientes com DNP se apresentam com idade superior aos demais (P<0,01). Conclusões: Após análise multivariada, foi possível separar as MAV em grupos de acordo com as características angioarquiteturais, comprovando que algumas dessas características estão fortemente relacionadas a determinada manifestação.

Quality Assessment for Reporting Complications and Adverse Events in Spinal Surgery: A Proposed 5-Item Checklist.

BACKGROUND: Reporting complications and/or adverse events after spinal surgical procedures enables the estimation of their prevalence and of their impact on patient outcomes. However, the documentation of complications is relatively infrequent and highly heterogeneous. The purpose of this study was to evaluate the quality of complication and adverse event reporting in spinal surgery literature. METHODS: A systematic review of the literature from 5 international, peer-reviewed, indexed spinal journals was performed. Included studies were published between January and December 2020 and reported the surgical results of spinal procedures. Data on the level of evidence and study design were collected and analyzed as well as whether the studies were single-center or multicenter studies. The quality of complication reports was evaluated through a 5-item checklist, with 5 questions divided into 3 parts: definition, evaluation, and report. RESULTS: Complications associated with spinal surgical procedures were reported in 292 studies. According to the level of evidence, significantly higher reporting quality was seen in level I and II studies compared with level III and IV studies (P = 0.003). Regarding the 5-item checklist, 49% (143/292) of studies fulfilled the definition section, 16.4% (48/292) fulfilled the evaluation section, and 92% (270/292) fulfilled the report section. CONCLUSIONS: Overall quality assessment when reporting complications in surgical spinal studies showed that only 13% (38/292) of publications that reported complications as part of the outcomes exhibited all items of the 5-item checklist. Additionally, significantly better reports were observed in level I studies compared with level II-IV studies.

Traumatic Atlanto-Occipital Dislocation-A Comprehensive Analysis of All Case Series Found in the Spinal Trauma Literature.

BACKGROUND: Traumatic atlanto-occipital dislocation (TAOD) is one of the most devastating traumatic injuries, generally associated with immediate death after high-energy trauma. The aim of this study was to perform a systematic literature review of all cases series of TAOD and present the current state of this entity. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only case series with at least 5 cases were included in the analysis. We focused on survival rates, diagnostic methods, delays in diagnosis, outcomes, and cases successfully treated nonoperatively. RESULTS: A total of 17 articles were included (16 retrospective and 1 prospective study) with 341 patients. Six studies included pediatric patients only. The mean Glasgow Coma Scale at admission was ≤8 in all studies. Many different diagnostic criteria were used, but none of them had high accuracy. The overall mortality rate was 34.8%, but the studies' designs were heterogeneous (some included only survivors). A high rate of concomitant traumatic brain injury was documented in some studies. We found it interesting that some patients were treated with cervical immobilization (37/341; 10.8%), which was generally used in less unstable injuries; however, the majority of patients were managed with an occipito-cervical fusion (193/341; 56.5%). CONCLUSIONS: TAOD is a devastating traumatic injury, with a high mortality rate. An MRI may be recommended when there are subtle findings of TAOD and a normal computed tomography scan, such as subarachnoid hemorrhage in the posterior fossa, upper cervical injuries, or consistent neurological findings. Further studies are necessary to identify patients with mild MRI findings and TAOD that may be managed nonoperatively.

Traumatic Atlantoaxial Rotatory Subluxation in Adult: Case Report

Traumatic atlantoaxial rotatory subluxation (AARS) is generally found in pediatric patients, rarely found in adults, being a life-threatening condition especially when early diagnosis is not possible, which can lead to severe late neurological deficits.We describe a 38-year-old patient, victim of physical aggression caused by strangulation attempt who developed AARS, an uncommontraumatic cause. During the hospital care, the early diagnosis allowed us to institute a conservative treatment, which made the case uncommon, since most of the time surgical treatment is imperative. With the patient awake and under analgesia, a closed reduction was performed that promoted immediate pain relief, followed by a prescription of wearing a Philadelphia-type collar for 8 weeks. During the follow-up, cervical spine radiographies demonstrated no subluxation after removing the cervical collar. The patient was asymptomatic after 6months of treatment. This case supports the importance of nonoperative management of AARS in selected cases.

Revision Surgeries at the Index Level After Cervical Disc Arthroplasty - A Systematic Review.

OBJECTIVE: To perform a systematic literature review on revision surgeries at the index level after cervical disc arthroplasty (CDA) failure. METHODS: A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Prospective studies on patients who required a secondary surgery after CDA failure were included for analysis. The minimum follow-up for these studies was 5 years. RESULTS: Out of 864 studies in the original search group, a total of 20 studies were included. From a total of 4,087 patients, 161 patients required a reoperation at the index level. A total of 170 surgeries were performed, as some patients required multiple surgeries. The most common secondary procedures were anterior cervical discectomy and fusion (ACDF) (68%, N = 61) and posterior cervical fusion (15.5%, N = 14), followed by other reoperation (13.3%, N = 12). The associated outcomes for those who required a revision surgery were rarely mentioned in the included literature. CONCLUSION: The long-term revision rate at the index level of failed CDA surgery was 3.9%, with a minimum 5-year follow-up. ACDF was the most commonly performed procedure to salvage a failed CDA. Some patients who required a new surgery after CDA failure may require a more extensive salvage procedure and even subsequent surgeries.

Circumferential Operations of the Cervical Spine.

Generally, a combined anterior and posterior cervical approach is associated with significant morbidity since it requires an extended operative time, greater intraoperative blood loss, and both anterior- and posterior-related surgical complications. However, there are some instances where a circumferential cervical fusion can be advantageous. Our objective is to discuss the indications for circumferential cervical spine procedures. A narrative review of the literature was performed. We include the indications for circumferential cervical approaches of the senior author (KDR). Indications for circumferential approaches include: (1) high-risk patients for pseudoarthrosis, (2) cervical deformity (e.g. , degenerative, posttraumatic, cervicothoracic kyphosis), (3) cervical spine metastases (especially those with multilevel involvement), (4) cervical spine infection, (5) unstable cervical trauma, (6) movement disorders and cerebral palsy, (7) Multiply operated patient (especially postlaminectomy kyphosis and patients with massive ossification of the posterior longitudinal ligament), and when (8) early fusion is desirable. Circumferential procedures may be useful in many different cervical spine conditions requiring surgery. Despite its advantages, particularly with reducing the risk for pseudarthrosis, the benefits of a combined approach must be weighed against the risks associated with a dual approach. With appropriate preoperative planning, intraoperative decision-making, and surgical techniques, excellent clinical outcomes can be achieved.

Reporting Complications in Spinal Surgery-a Systematic Literature Review.

BACKGROUND: Many efforts are expended to improve health care quality in the surgical treatment of spinal conditions. However, the prevalence of reporting complications in spinal surgeries is highly heterogeneous, which is partially due to the lack of a universal and comprehensive system. METHODS: A systematic review of the literature was performed in 5 international and indexed spine journals from January to December 2020. All clinical studies that had surgical procedures in any spinal region were classified according to level of evidence, study design, category of spinal condition, and primary outcome. The prevalence and quality of complication reporting were evaluated through a checklist. RESULTS: Of 455 articles screened, complications were reported in 64.2% (292 articles). A significant higher prevalence of reports was observed in randomized compared with nonrandomized studies (P < 0.05). In 89 articles, at least 1 classification was used to report complications, with 12 different classification systems employed in the total sample. Timing to record complications was as follows: 47 (16.1%) articles reported complications at 30 days, 31 (10.6%) reported complications at 90 days, and 88 (30.1%) reported complications during all follow-ups. In 126 (43.1%) articles, complications were not mentioned. CONCLUSIONS: Almost one-third of spine surgical studies did not report complications in their results despite reporting clinical outcomes. The evidence quality of the study was directly related with the reporting of complications. A high heterogeneity regarding complication reporting was seen in the literature.