Osteoporotic vertebral fractures localized in the lumbar area significantly impact sagittal alignment.

Lumbar fractures and/or multiple fractures at the lumbar or thoracolumbar regions are risk factors for sagittal malalignment in patients older than 70 years old. Although patients with OVF show a huge capacity to compensate after the fractures, lumbar and TL lumbar fractures require closer monitoring. PURPOSE: To assess the impact of osteoporotic vertebral fractures on the sagittal alignment of the elderly and identify risk factors for sagittal malalignment. METHODS: We performed a retrospective study on a cohort of 249 patients older than 70 years old and diagnosed with osteoporosis who suffered chronic vertebral fractures. Demographic and radiological data were collected. Full-spine lateral X-rays were obtained to analyze the sagittal plane. Patients were classified according to the number and location of the fractures. Pearson's correlation coefficient was used to assess the relationships between the type of fractures and sagittal alignment. RESULTS: A total of 673 chronic fractures were detected in 249 patients with a mean number of vertebral fractures per patient of 2.7 ± 1.9. Patients were divided into 9 subgroups according to the location and the number of fractures. Surprisingly, any of the aggregated parameters used to assess sagittal alignment exceeded the threshold defined for malalignment. In the second part of the analysis, 41 patients with sagittal malalignment were identified. In this subpopulation, an overrepresentation of patients with lumbar fractures (34% vs. 11%) and an under-representation of thoracic fractures (9% vs. 34%) were reported. We also observed that patients with 3 or more lumbar or thoracolumbar fractures had an increased risk of sagittal malalignment. CONCLUSIONS: Lumbar fractures and/or multiple fractures at the lumbar or thoracolumbar regions are risk factors for sagittal malalignment in patients older than 70 years old. Although patients show a remarkable capacity to compensate, fractures at the lumbar and thoracolumbar regions need closer monitoring.

A Pharmacogenomics-Based In Silico Investigation of Opioid Prescribing in Post-operative Spine Pain Management and Personalized Therapy.

Considering the variability in individual responses to opioids and the growing concerns about opioid addiction, prescribing opioids for postoperative pain management after spine surgery presents significant challenges. Therefore, this study undertook a novel pharmacogenomics-based in silico investigation of FDA-approved opioid medications. The DrugBank database was employed to identify all FDA-approved opioids. Subsequently, the PharmGKB database was utilized to filter through all variant annotations associated with the relevant genes. In addition, the dpSNP ( https://www.ncbi.nlm.nih.gov/snp/ ), a publicly accessible repository, was used. Additional analyses were conducted using STRING-MODEL (version 12), Cytoscape (version 3.10.1), miRTargetLink.2, and NetworkAnalyst (version 3). The study identified 125 target genes of FDA-approved opioids, encompassing 7019 variant annotations. Of these, 3088 annotations were significant and pertained to 78 genes. During variant annotation assessments (VAA), 672 variants remained after filtration. Further in-depth filtration based on variant functions yielded 302 final filtered variants across 56 genes. The Monoamine GPCRs pathway emerged as the most significant signaling pathway. Protein-protein interaction (PPI) analysis revealed a fully connected network comprising 55 genes. Gene-miRNA Interaction (GMI) analysis of these 55 candidate genes identified miR-16-5p as a pivotal miRNA in this network. Protein-Drug Interaction (PDI) assessment showed that multiple drugs, including Ibuprofen, Nicotine, Tramadol, Haloperidol, Ketamine, L-Glutamic Acid, Caffeine, Citalopram, and Naloxone, had more than one interaction. Furthermore, Protein-Chemical Interaction (PCI) analysis highlighted that ABCB1, BCL2, CYP1A2, KCNH2, PTGS2, and DRD2 were key targets of the proposed chemicals. Notably, 10 chemicals, including carbamylhydrazine, tetrahydropalmatine, Terazosin, beta-methylcholine, rubimaillin, and quinelorane, demonstrated dual interactions with the aforementioned target genes. This comprehensive review offers multiple strong, evidence-based in silico findings regarding opioid prescribing in spine pain management, introducing 55 potential genes. The insights from this report can be applied in exome analysis as a pharmacogenomics (PGx) panel for pain susceptibility, facilitating individualized opioid prescribing through genotyping of related variants. The article also points out that African Americans represent an important group that displays a high catabolism of opioids and suggest the need for a personalized therapeutic approach based on genetic information.

Progression toward Vertebral Collapse of Vertebral Metastases Treated with Percutaneous Vertebroplasty: Rate and Risk Factors.

PURPOSE: To evaluate of the rate of and risks for progression toward collapse in vertebral metastases (VMs) treated with percutaneous vertebroplasty (PV). MATERIALS AND METHODS: A total of 151 PVs were performed in 81 patients with vertebral metastases and were retrospectively analyzed. Follow-up imaging was performed at 12 months to measure vertebral body height and to report vertebral collapse at the level of the treated vertebrae. Vertebral characteristics (spine instability neoplastic score [SINS], number of lysed cortices, and prior radiotherapy) and procedural parameters (Saliou score, cortical contact with cement, and intradiscal cement leakage) were compared between the group of patients with and without collapse of the treated vertebrae. RESULTS: Of the vertebrae treated with PV, 41 of 151 (27%) progressed toward collapse. Vertebral collapse was influenced by a high SINS (odds ratio [OR] = 1.27, P = .004), SINS value > 9 (OR = 2.96, P = .004), intradiscal cement leakage (OR = 2.18, P = .048), pre-existing spinal deformity (OR = 2.65, P = .020), and pre-existing vertebral fracture (OR = 3.93, P = .045). A high Saliou score (OR = 0.82, P = .011), more than 3 cortices in contact with the cement (OR = 0.38, P = .014), and preserved spinal alignment (OR = 0.38, P = .020) were associated with a lower incidence of collapse. CONCLUSIONS: Rate of vertebral collapse despite PV was influenced by vertebra-specific characteristics and by cement injection quality. Vertebrae with a SINS of ≤9 and with homogeneous cement filling had a lower incidence of collapse.

Comparison of two modeling approaches for the identification of predictors of complications in children with cerebral palsy following spine surgery.

BACKGROUND: Children with non-ambulatory cerebral palsy (CP) frequently develop progressive neuromuscular scoliosis and require surgical intervention. Due to their comorbidities, they are at high risk for developing peri- and post-operative complications. The objectives of this study were to compare stepwise and LASSO variable selection techniques for consistency in identifying predictors when modelling these post-operative complications and to identify potential predictors of respiratory complications and infections following spine surgery among children with CP. METHODS: In this retrospective cohort study, a large administrative claims database was queried to identify children who met the following criteria: 1) ≤ 25 years old, 2) diagnosis of CP, 3) underwent surgery during the study period, 4) had ≥ 12-months pre-operative, and 5) ≥ 3-months post-operative continuous health plan enrollment. Outcome measures included the development of a post-operative respiratory complication (e.g., pneumonia, aspiration pneumonia, atelectasis, pleural effusion, pneumothorax, pulmonary edema) or an infection (e.g., surgical site infection, urinary tract infection, meningitis, peritonitis, sepsis, or septicemia) within 3 months of surgery. Codes were used to identify CP, surgical procedures, medical comorbidities and the development of post-operative respiratory complications and infections. Two approaches to variable selection, stepwise and LASSO, were compared to determine which potential predictors of respiratory complications and infection development would be identified using each approach. RESULTS: The sample included 220 children. During the 3-month follow-up, 21.8% (n = 48) developed a respiratory complication and 12.7% (n = 28) developed an infection. The prevalence of 11 variables including age, sex and 9 comorbidities were initially considered to be potential predictors based on the intended outcome of interest. Model discrimination utilizing LASSO for variable selection was slightly improved over the stepwise regression approach. LASSO resulted in retention of additional comorbidities that may have meaningful associations to consider for future studies, including gastrointestinal issues, bladder dysfunction, epilepsy, anemia and coagulation deficiency. CONCLUSIONS: Potential predictors of the development of post-operative complications were identified in this study and while identified predictors were similar using stepwise and LASSO regression approaches, model discrimination was slightly improved with LASSO. Findings will be used to inform future research processes determining which variables to consider for developing risk prediction models.

Directional microwave ablation in spine: experimental assessment of computational modeling.

BACKGROUND: Despite the theoretical advantages of treating metastatic bone disease with microwave ablation (MWA), there are few reports characterizing microwave absorption and bioheat transfer in bone. This report describes a computational modeling-based approach to simulate directional microwave ablation (dMWA) in spine, supported by ex vivo and pilot in vivo experiments in porcine vertebral bodies. MATERIALS AND METHODS: A 3D computational model of microwave ablation within porcine vertebral bodies was developed. Ex vivo porcine vertebra experiments using a dMWA applicator measured temperatures approximately 10.1 mm radially from the applicator in the direction of MW radiation (T1) and approximately 2.4 mm in the contra-lateral direction (T2). Histologic assessment of ablated ex vivo tissue was conducted and experimental results compared to simulations. Pilot in vivo experiments in porcine vertebral bodies assessed ablation zones histologically and with CT and MRI. RESULTS: Experimental T1 and T2 temperatures were within 3-7% and 11-33% of simulated temperature values. Visible ablation zones, as indicated by grayed tissue, were smaller than those typical in other soft tissues. Posthumous MRI images of in vivo ablations showed hyperintensity. In vivo experiments illustrated the technical feasibility of creating directional microwave ablation zones in porcine vertebral body. CONCLUSION: Computational models and experimental studies illustrate the feasibility of controlled dMWA in bone tissue.

The Development And Applications Of Augmented And Virtual Reality Technology In Spine Surgery Training: A Systematic Review.

BACKGROUND: The COVID-19 pandemic has accelerated the growing global interest in the role of augmented and virtual reality in surgical training. While this technology grows at a rapid rate, its efficacy remains unclear. To that end, we offer a systematic review of the literature summarizing the role of virtual and augmented reality on spine surgery training. METHODS: A systematic review of the literature was conducted on May 13th, 2022. PubMed, Web of Science, Medline, and Embase were reviewed for relevant studies. Studies from both orthopedic and neurosurgical spine programs were considered. There were no restrictions placed on the type of study, virtual/augmented reality modality, nor type of procedure. Qualitative data analysis was performed, and all studies were assigned a Medical Education Research Study Quality Instrument (MERSQI) score. RESULTS: The initial review identified 6752 studies, of which 16 were deemed relevant and included in the final review, examining a total of nine unique augmented/virtual reality systems. These studies had a moderate methodological quality with a MERSQI score of 12.1 + 1.8; most studies were conducted at single-center institutions, and unclear response rates. Statistical pooling of the data was limited by the heterogeneity of the study designs. CONCLUSION: This review examined the applications of augmented and virtual reality systems for training residents in various spine procedures. As this technology continues to advance, higher-quality, multi-center, and long-term studies are required to further the adaptation of VR/AR technologies in spine surgery training programs.

Classifying High-Risk Patients for Persistent Opioid Use After Major Spine Surgery: A Machine-Learning Approach.

BACKGROUND: Persistent opioid use is a common occurrence after surgery and prolonged exposure to opioids may result in escalation and dependence. The objective of this study was to develop machine-learning-based predictive models for persistent opioid use after major spine surgery. METHODS: Five classification models were evaluated to predict persistent opioid use: logistic regression, random forest, neural network, balanced random forest, and balanced bagging. Synthetic Minority Oversampling Technique was used to improve class balance. The primary outcome was persistent opioid use, defined as patient reporting to use opioids after 3 months postoperatively. The data were split into a training and test set. Performance metrics were evaluated on the test set and included the F1 score and the area under the receiver operating characteristics curve (AUC). Feature importance was ranked based on SHapley Additive exPlanations (SHAP). RESULTS: After exclusion (patients with missing follow-up data), 2611 patients were included in the analysis, of which 1209 (46.3%) continued to use opioids 3 months after surgery. The balanced random forest classifiers had the highest AUC (0.877, 95% confidence interval [CI], 0.834-0.894) compared to neural networks (0.729, 95% CI, 0.672-0.787), logistic regression (0.709, 95% CI, 0.652-0.767), balanced bagging classifier (0.859, 95% CI, 0.814-0.905), and random forest classifier (0.855, 95% CI, 0.813-0.897). The balanced random forest classifier had the highest F1 (0.758, 95% CI, 0.677-0.839). Furthermore, the specificity, sensitivity, precision, and accuracy were 0.883, 0.700, 0.836, and 0.780, respectively. The features based on SHAP analysis with the highest impact on model performance were age, preoperative opioid use, preoperative pain scores, and body mass index. CONCLUSIONS: The balanced random forest classifier was found to be the most effective model for identifying persistent opioid use after spine surgery.

Magnesium malate-modified calcium phosphate bone cement promotes the repair of vertebral bone defects in minipigs via regulating CGRP.

Active artificial bone substitutes are crucial in bone repair and reconstruction. Calcium phosphate bone cement (CPC) is known for its biocompatibility, degradability, and ability to fill various shaped bone defects. However, its low osteoinductive capacity limits bone regeneration applications. Effectively integrating osteoinductive magnesium ions with CPC remains a challenge. Herein, we developed magnesium malate-modified CPC (MCPC). Incorporating 5% magnesium malate significantly enhances the compressive strength of CPC to (6.18 ± 0.49) MPa, reduces setting time and improves disintegration resistance. In vitro, MCPC steadily releases magnesium ions, promoting the proliferation of MC3T3-E1 cells without causing significant apoptosis, proving its biocompatibility. Molecularly, magnesium malate prompts macrophages to release prostaglandin E2 (PGE2) and synergistically stimulates dorsal root ganglion (DRG) neurons to synthesize and release calcitonin gene-related peptide (CGRP). The CGRP released by DRG neurons enhances the expression of the key osteogenic transcription factor Runt-related transcription factor-2 (RUNX2) in MC3T3-E1 cells, promoting osteogenesis. In vivo experiments using minipig vertebral bone defect model showed MCPC significantly increases the bone volume fraction, bone density, new bone formation, and proportion of mature bone in the defect area compared to CPC. Additionally, MCPC group exhibited significantly higher levels of osteogenesis and angiogenesis markers compared to CPC group, with no inflammation or necrosis observed in the hearts, livers, or kidneys, indicating its good biocompatibility. In conclusion, MCPC participates in the repair of bone defects in the complex post-fracture microenvironment through interactions among macrophages, DRG neurons, and osteoblasts. This demonstrates its significant potential for clinical application in bone defect repair.

Determining the Optimal Dosage of Dexmedetomidine for Smooth Emergence in Older Patients Undergoing Spinal Surgery: A Study of 44 Cases.

BACKGROUND Emergence agitation, or delirium, occurs during early recovery from general anesthesia and involves disorientation, excitation, and uncontrolled physical movements. Dexmedetomidine is an alpha agonist that has sedative, anxiolytic, analgesic, and sympatholytic activities and is used as a continuous infusion to prevent emergence agitation. This study aimed to evaluate patients aged 65 years and older undergoing general anesthesia to determine the 90% effective dose (ED90) of dexmedetomidine continuous intraoperative infusion to prevent emergence agitation. MATERIAL AND METHODS We enrolled 44 patients aged 65 years and older undergoing spinal surgery under general anesthesia. Dexmedetomidine administration commenced 30 minutes before surgery completion, with a predetermined infusion dose (µg/kg/h), without a loading dose. The initial dose was 0.2 µg/kg/h, and subsequent step size was ±0.05 µg/kg/h. We tried to find ED90 of dexmedetomidine using the biased-coin design. Vital signs, extubation quality scores, extubation-related complications, and postoperative outcomes were monitored. RESULTS Dexmedetomidine ED90 for smooth emergence in older patients was 0.34 µg/kg/h. Peri-extubation vital signs remained within 20% of baseline values, without requiring pharmacological intervention. No hypoxia, hypoventilation, or post-extubation agitation occurred. In the recovery room, 1 patient briefly exhibited excitement but quickly calmed. Nine patients initially unresponsive in the recovery room fully awoke and were promptly discharged. CONCLUSIONS For older patients who are vulnerable to adverse effects of anesthetics and opioids, dexmedetomidine enables gentle awakening without adverse vital sign changes, respiratory depression, excessive sedation, or emergence agitation (ED90=0.34 µg/kg/h). Further studies should involve a larger patient cohort, considering diverse medical conditions in older individuals.

Comparison of Outcomes between Single-Level and Double-Level Corpectomy in Thoracolumbar Reconstruction: A Retrospective Study of 16 Patients Using Expandable Cages.

BACKGROUND Reconstruction surgery using titanium vertebral body replacements aids in spinal stability after damage. Functional evaluation includes Nurick and ASIA grading systems. This study compares outcomes of single and double-level corpectomy in patients treated with thoracolumbar reconstruction. MATERIAL AND METHODS Records of 16 patients who underwent vertebral reconstruction with expandable cages after single (n=9) and double (n=8) corpectomy were analyzed retrospectively. Thoracal and lumbar cases were approached posteriorly (n=14). Clinical evaluation was performed by neurological examination, Nurick Scale, American Spinal Injury Association (ASIA) Neurological Scores, and Visual Analog Scale (VAS). Preoperative and postoperative 3-month scores were recorded. Radiological evaluation was performed by calculation of regional angulation and postoperative recovery of vertebral body height. RESULTS Preoperatively, 2 patients had no motor or functional sensory deficits (ASIA grade E) and 6 patients were ASIA grade D. Immediately after surgery, 4 of the ASIA grade D patients improved to ASIA grade E, while 2 patients remained ASIA grade D during follow-up. Four patients were ASIA grade A; their conditions showed no improvement postoperatively. Preoperative and postoperative 3-month Nurick grade was statistically significant (P=0.022). Postoperative Cobb angle improved by a mean of 5.4° (P=0.001). Improvement by at least 1 grade in neurological recovery was observed in 6 (38%) of the cases. Pain scores analyzed using the VAS changed from a mean of 7 to a mean of 2.63 (P<0.001). CONCLUSIONS In our experience, expandable cages are useful in the restoration of different pathologies of the thoracolumbar trunk with low complication and revision rates. With expandable cages it is possible to achieve restoration of the Cobb angle, improvement in Nurick Grade and effective pain palliation.

Preoperative frailty tendency predicts delirium occurrence in older people undergoing spinal surgery.

BACKGROUND: This prospective cohort study focused on the predictive value of frailty or pre-frailty assessed by Edmonton Frailty Scale (EFS) for postoperative delirium in spinal surgery patients. METHODS: The primary outcome measurement was postoperative delirium (POD) evaluated by Confusion Assessment Method at day 1, day 2, and day 3 after the surgery. Secondary outcomes included severity and duration of POD, severe postoperative pain measured by Faces Pain Scale-Revised. Patients scheduled for elective spinal surgery were enrolled and assessed for frailty by EFS before surgery. Demographic data, preoperative, intraoperative, and postoperative information were collected. RESULTS: 231 out of 325 patients were enrolled and analyzed in this study at last. The cohort with 36.8% being frail and 28.5% being vulnerable. Postoperative delirium was detected in 41 in 231 patients. Multivariate logistic regression analysis revealed that vulnerable to frailty (OR = 4.681, 95% CI: 1.199 to 18.271, P = 0.026), after adjusted duration of surgery more than 3 h, using flumazenil at the end of surgery, using butorphanol only in postoperative patient-controlled intravenous analgesia, moderate-to-severe pain at day 1 and 2, is a strong predictor of postoperative delirium. Frailty was associated with longer duration (frailty vs. fit, P = 0.364) and stronger severity of postoperative delirium in the first two days (P < 0.001). High EFS score was independent risk factor of severe postoperative pain (Frailty vs. Fit: OR = 5.007, 95% CI: 1.903 to 13.174, P = 0.001; Vulnerable vs. Fit: OR = 2.525, 95% CI: 1.008 to 6.329, P = 0.048). In stratified tests, Sufentanil regimen in intravenous PCA significantly increase the proportion of POD in vulnerable group (P = 0.030), instead of frailty group (P = 0.872) or fit group (P = 0.928). CONCLUSIONS: Frailty can increase the risk, severity, duration of delirium and severe postoperative pain in the first 3 days after surgery of patients. TRIAL REGISTRATION: The protocol of this study has been approved by the Ethic Committee of Shanghai Changzheng Hospital (Approval file number: 2022SL044) and informed consent was obtained from all the patients. The trial was retrospectively registered at chictr.org.cn (ChiCTR2300073306) on 6th July 2023.

Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists.

Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.

Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review.

Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.

Limited exposure to preserve stability and achieve complete excision of limited dorsal myeloschisis - the "Skip-Hop Laminectomy" technique: a technical note.

OBJECTIVE: The fibroneural stalk of an LDM has variable thickness, complexity, and length, which can span 5 to 6 vertebral segments from its skin attachment to its "merge point" with the dorsal spinal cord. Therefore, complete resection may require extensive multi-level laminotomies. In this technical note, a modification of the procedure is presented that avoids long segment laminectomies while ensuring complete excision of long LDM stalks. RESULTS: An illustrative case of resection of LDM is presented using skip laminectomies. The technique ensures complete removal of the stalk, thus reducing the risk of future intradural dermoid development, while at the same time minimizes the risk for delayed kyphotic deformity. CONCLUSIONS: A technique of "skip-hop" proximal and distal short segment laminectomies in cases of LDM optimizes the objectives of complete stalk resection with preservation of spinal integrity.

"Revolutionising spinal surgery: the impact of STRATAFIX™ symmetric barbed sutures on closure time and costs".

Spinal surgery, crucial for correcting structural abnormalities, involves decompressing nerve structures, realigning or stabilizing vertebral segments, and replacing damaged components to restore spinal integrity. Effective wound closure is vital in these procedures, as it prevents infections, minimizes wound dehiscence, and ensures optimal cosmetic results. Recent advancements, particularly in barbed suture technology like STRATAFIX™ Symmetric, offer promising improvements in surgical outcomes. A study by Steven R. Glener et al. evaluated STRATAFIX™ Symmetric for fascial closure in spinal surgery, comparing it to traditional braided absorbable sutures. Although the difference in closure time was not statistically significant, STRATAFIX™ demonstrated a higher closure rate and required significantly fewer sutures, reducing post-surgical material counts and the risk of accidental needle sticks. No adverse events were observed in either group over a 6-month follow-up period. Despite their benefits in reducing operating room time and costs, barbed sutures remain underutilized in neurosurgery. Studies indicate that barbed sutures can significantly decrease wound closure time, particularly in complex or multilevel spinal surgeries, without compromising clinical outcomes. These findings suggest that adopting barbed suture technology in spinal surgery could enhance surgical efficiency and patient care. Further research with larger sample sizes and multicenter studies is necessary to validate these benefits and refine surgical practices, ultimately improving patient outcomes.

Letter to the editor: Prospective analysis of STRATAFIX™ symmetric PDS plus suture for fascial closure in spinal surgery: a pilot study.

Spine surgery is essential for restoring alignment, stability, and function in patients with cervical spine injuries, especially when instability, pain, deformity, or progressive nerve damage is present. Effective wound closure is vital in these procedures, aiming to promote rapid healing, reduce infection risks, enable early mobilization, and ensure satisfactory cosmetic results. However, there is limited evidence on the optimal wound closure technique for posterior spine surgery, highlighting the need for innovative approaches. A study by Glener et al. evaluated the effectiveness of STRATAFIX™ Symmetric barbed sutures compared to traditional braided absorbable sutures in spinal surgery. In a randomized trial involving 20 patients, the STRATAFIX™ group demonstrated a shorter mean closure time and significantly fewer sutures used, though without a statistically significant reduction in closure time. No significant differences were observed in postoperative complications between the groups during a six-month follow-up. While the findings suggest potential cost savings and efficiency improvements with STRATAFIX™, the study's small sample size and short follow-up period limit its generalizability. Furthermore, AI-based models, such as the Xception deep learning model, show promise in improving suture training accuracy for medical students, which could enhance surgical outcomes and reduce complications. Despite the promising results, further research with larger sample sizes, extended follow-up periods, and multi-center trials is necessary to validate the effectiveness of barbed sutures like STRATAFIX™ in neurosurgery. The integration of AI in surgical training and continued exploration of innovative techniques are essential to advancing the field and optimizing patient care in spinal surgery.

Do we really apply evidence-based-recommendations to spine surgery? Results of an international survey.

OBJECTIVE: This international survey investigated Evidence-Based Medicine (EBM) in spine surgery by measuring its acceptance among spine surgeons. It assessed their understanding of EBM and how they apply it in practice by analyzing responses to various clinical scenarios.. MATERIALS AND METHODS: Following the CHERRIES guidelines, an e-survey was distributed to multiple social media forums for neurosurgeons and orthopedic surgeons on Facebook, LinkedIn, and Telegram and circulated further through email via the authors' network. Three hundred participants from Africa, Asia, Europe, North America, and Oceania completed the survey. RESULTS: Our study revealed that 67.7% (n = 203) of respondents used EBM in their practice, and 97.3% (n = 292) believed training in research methodology and EBM was necessary for the practice of spine surgery. Despite this endorsement of using EBM in spine surgery, we observed varied responses to how EBM is applied in practice based on example scenarios. The responders who had additional training tended to obey EBM guidelines more than those who had no additional training. Most surgeons responded as always or sometimes prescribing methylprednisolone to patients with acute spinal cord injury. Other significant differences were identified between geographical regions, training, practice settings, and other factors. CONCLUSIONS: Most respondents used EBM in practice and believed training in research methodology and EBM is necessary for spine surgery; however, there were significant variations on how to use them per case. Thus, the appropriate application of EBM in clinical settings for spinal surgery must be further studied.

Navigating challenges in spine surgery in Nigeria: the current state and strategies for advancing spine care.

The provision of specialized spine care in Nigeria presents a pressing challenge amid limited resources and geographical disparities. This correspondence offers a comprehensive roadmap for improving spine surgery and care within the country. We examine the current state of spinal health infrastructure, highlighting barriers such as limited access to specialists and facilities, particularly in rural areas, and financial constraints for patients. Innovations in spinal treatment, including the adoption of minimally invasive techniques and advancements in surgical modalities, are discussed alongside persistent challenges such as disparities in access and equipment costs. Training and education of spine surgeons emerge as critical areas requiring attention, with a shortage of qualified professionals exacerbated by inadequate training programs and resource constraints. We advocate for fostering local and international collaborations to address these gaps, emphasizing the role of partnerships in capacity building and knowledge exchange. Additionally, we explore the potential of public-private partnerships and investments to enhance the Nigerian spine healthcare system, calling for strategic initiatives to modernize infrastructure and improve accessibility. Finally, we propose a strategic blueprint encompassing infrastructure enhancement, training programs, research initiatives, policy advocacy, and public awareness campaigns. Through concerted efforts from local stakeholders and international partners, we envision a future where spine care in Nigeria is comprehensive, accessible, and of high quality, leading to improved health outcomes and a higher quality of life for those affected by spinal conditions.

Prospective analysis of STRATAFIX™ symmetric PDS plus suture for fascial closure in spinal surgery: a pilot study.

Wound closure is an integral part of every spinal procedure. Effective and secure wound closure is paramount in the prevention of infection, wound dehiscence and the preservation of cosmesis. Barbed suture technologies such as STRATAFIX™ Symmetric have been studied and are used in a variety of specialties, including obstetrics and orthopedic surgery, but is underutilized in neurosurgery. This study aims to assess the time and rate of closure using STRATAFIX™ Symmetric technology for fascial closure and compare this method to the more traditionally used method of fascial closure using braided absorbable sutures below the epidermis. 20 patients were recruited for the study. 10 patients underwent fascial approximation with braided absorbable sutures and definitive fascial closure with STRATAFIX™ Symmetric. In the control group, fascial closure was completed entirely with interrupted braided absorbable stitches. Patients assigned to STRATAFIX™ Symmetric group had shorter mean time for fascial closure, faster rate of average fascial closure, and lower number of total sutures used. The use of barbed suture technology such as STRATAFIX™ Symmetric may reduce the time to closure in thoracolumbar spine surgery without increasing the risk of adverse events. This pilot study forms the framework for a larger randomized, controlled trial appropriately powered for such an analysis.

Wound closure techniques for spinoplastic surgery: a review of the literature.

PURPOSE: The approach to skin closure in spinal surgery is dependent on surgeon preference and experience. Wound complications, including dehiscence and surgical site infection (SSI), are common following spine surgery. The authors reviewed various wound closure techniques employed in spinal surgery. METHODS: A systematic review was conducted to identify articles comparing wound closure techniques after posterior spinal surgery. Articles that employed experimental or observational cohort study designs and reported rates of SSI, dehiscence, or scarring following spinal surgery were included. RESULTS: Eight studies examining closure techniques of the skin were identified: five retrospective cohort studies and three randomized-controlled trials. No differences in the incidence of SSI were reported based on suture technique, although staples were associated with higher SSI rates in single level spinal fusion, and barbed suture resulted in decreased wound complications. The use of intracutaneous sutures was associated with a higher incidence of wound dehiscence when compared to tension-relieving far-near near-far suture (FNS) and far-near near-far interrupted point (FNP) sutures. However, the latter two also resulted in the highest rates of delayed wound healing (i.e., time to fully heal). Modified Allgöwer-Donati suture (MADS) resulted in smaller scar area when compared to vertical mattress suture. CONCLUSION: Significant differences exist in wound healing when comparing suture techniques in spinal surgery. Surgical staples allow for faster closing time, but are also associated with higher wound complications. Intracutaneous sutures appear to have higher rates of dehiscence compared to vertical mattress suture but display faster wound healing. Future studies are necessary to elucidate contributory factors, including local ischemia and changes in tensile forces. LEVEL OF EVIDENCE: Level IV.