Efficacy and safety of tranexamic acid use in elderly patients undergoing anterior cervical discectomy and fusion: a retrospective study.

OBJECTIVE: To evaluate the safety and efficacy of intravenous tranexamic acid (TXA) administration in anterior cervical discectomy fusion (ACDF) for the treatment of cervical spondylosis in the elderly. METHODS: Data from elderly patients who underwent ACDF between January 2020 and January 2023 were retrospectively reviewed. Patients who received 1 g intravenous TXA administration before skin incision (TXA group) were compared with patients who did not receive TXA (controls). Total and hidden blood loss were calculated, and the following outcomes were recorded: haemoglobin and haematocrit drop, operation time, drainage duration, drain volume, length of hospitalization, coagulation changes, and incidence of complications. RESULTS: A total of 114 patients were included (TXA group, n = 53 and controls, n = 61). Total blood loss, hidden blood loss, and postoperative drainage volume, haemoglobin and haematocrit drop were significantly lower in the TXA group than the control group. There were no significant differences in operation time, intraoperative blood loss, drainage duration, length of hospitalization, or coagulation function between the two groups. The incidence of complications did not differ significantly between the two groups during 3 months of follow-up. CONCLUSIONS: Intravenous TXA is effective in reducing perioperative blood loss in elderly patients undergoing ACDF without changing the coagulation function or increasing the risk of complications.

[Rehabilitation of patients after spinal surgery: effectiveness of nonthermal techniques of peloidotherapy]. / Reabilitatsiya patsientov posle operatsii na pozvonochnike: effektivnost' neteplovykh metodik peloidoterapii.

The problem of patients' rehabilitation after spinal surgery remains relevant. The use of therapeutic physical factors, both preformed and natural, including pelotherapy, is very important. The application of the latter requires to develop new techniques in this pathology, one of which is low temperature exposure. OBJECTIVE: To study the possibility and to assess the effectiveness of resource-saving nonthermal pelotherapy techniques in patients' rehabilitation, who underwent surgeries for intervertebral discs' herniation. MATERIAL AND METHODS: The number of patients equal 88, including 39 males and 49 females, after lumbar microdiscectomy, was examined in this study. The patients were divided into 3 groups. Control group (28 patients) received a basic rehabilitation complex (therapeutic gymnastics, massage, low-frequency magnetotherapy); the 1st study group (30 patients) - basic complex and procedures of thin layer applications with peat muds preparation (Tomed-applikat) at 20-24 °C; the 2nd study group (30 patients) - basic complex and procedures of fluctuoresis of 2% solution of peat mud Tomed-aqua preparation. RESULTS: There was a significant reduction of pain syndrome, recovery of sensitivity and motor activity, decrease of Oswestry index, characterizing the degree of vital activity disturbance, in patients of the study group compared to the control group after treatment. CONCLUSION: The inclusion of nonthermal resource-saving techniques of pelotherapy in rehabilitation complex of patients who underwent spinal surgery is effective and pathogenetically justified.

Unilateral biportal endoscopic discectomy via translaminar approach for highly upward-migrated lumbar disc herniation: a technical note and preliminary treatment outcomes.

STUDY DESIGN: A technical note and retrospective case series. OBJECTIVE: Highly upward-migrated lumbar disc herniation (LDH) is challenging due to its problematic access and incomplete removal. The most used interlaminar approach may cause extensive bony destruction. We developed a novel translaminar approach using the unilateral portal endoscopic (UBE) technique, emphasizing effective neural decompression, and preserving the facet joint's integrity. METHODS: This retrospective study included six patients receiving UBE translaminar discectomy for highly upward-migrated LDHs from May 2019 to June 2021. The migrated disc was removed through a small keyhole on the lamina of the cranial vertebra. The treatment results were evaluated by operation time, hospital stays, complications, visual analog scale (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, and modified MacNab criteria. RESULTS: The mean pre-operative VAS for back pain (5.0 ± 4.9), VAS for leg pain (9.2 ± 1.0), JOA score (10.7 ± 6.6), and ODI (75.7 ± 25.3) were significantly improved to 0.3 ± 0.5, 1.2 ± 1.5, 27.3 ± 1.8, 5.0 ± 11.3 respectively at the final follow-up. Five patients had excellent, and one patient had good outcomes according to the Modified MacNab criteria. The hospital stay was 2.7 ± 0.5 days. No complication was recorded. The MRI follow-up showed complete disc removal, except for one patient with an asymptomatic residual disc. CONCLUSIONS: UBE translaminar discectomy is a safe and effective minimally invasive procedure for highly upward-migrated LDH with satisfactory treatment outcomes and nearly 100% facet joint preservation.

The Impact of Endplate Coverage on Heterotopic Ossification Following Cervical Disc Replacement: A Systematic Review and Meta Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Describe the impact of endplate coverage on HO in cervical disc replacement (CDR). SUMMARY OF BACKGROUND DATA: CDR is a motion-sparing alternative to anterior cervical discectomy and fusion. However, the high prevalence of heterotopic ossification threatens to diminish range of motion and limit this benefit associated with CDR. MATERIALS AND METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. EMBASE and PubMed databases were queried. Results were deduplicated and screened. Relevant studies were included. All metrics that were reported in ≥3 studies were aggregated for analysis. SPSS was used to perform the meta-analysis. RESULTS: A total of 10 studies were included in the systematic review. Endplate coverage was assessed using a wide variety of measurements, including anteroposterior implant depth (ID), endplate depth (ED), exposed endplate depth (EED), implant depth to endplate depth ratio (ID:ED), EED to ED ratio (EED:ED), implant width (IW) to endplate width (EW) ratio (IW:EW), and the implant area (IA) to endplate area (EA) ratio (IA:EA). No evidence has linked ID (three studies) to HO. Mixed evidence has linked ID:ED (3/5) and IW:ED (1/2) to HO. All available evidence has linked ED (2), EED (4), EED:ED (2), and IA:EA (1) to HO. In our meta-analysis, ID was not found to be a significant risk factor for HO. However, EED and ID:ED were found to be significant risk factors for HO formation. CONCLUSIONS: Exposed endplate, especially as assessed by EED and ID:ED, is a significant risk factor for HO. Surgeons should focus on preoperative planning and intraoperative implant selection to maximize endplate coverage. While optimizing technique and implant selection is crucial, improved implant design may also be necessary to ensure that appropriate implant-endplate footprint matching is possible across the anatomic spectrum.

Comparison of fusion, arthroplasty and hybrid surgery outcomes in patients with two-level cervical disc disease.

OBJECTIVES: The study aims to explore the management of two-level cervical disc disease and to compare outcomes of anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), and hybrid surgery (HS). PATIENTS AND METHODS: Between December 2011 and December 2021, a total of 120 patients (76 males, 44 females; mean age: 44.8±8.1 years; range, 18 to 68 years) who were diagnosed as two-level cervical disc disease and underwent anterior cervical surgery were retrospectively analyzed. The patients were randomly divided into three groups as ACDF, CDA, and HS each consisting of 40 patients. The Neck Disability Index (NDI), Visual Analog Scale (VAS), clinical and radiological findings, and range of motion (ROM) data were evaluated. RESULTS: All of the groups showed a significant improvement according to clinical and radiological outcomes (p=0.01). The mean follow-up was 27.5±6.1 months for ACDF, 20.0±4.7 months for CDA, and 21.1±5.0 months for HS, showing consistency in monitoring post-surgery outcomes. The mean postoperative NDI scores were 13.4±5.6, 14.8±5.2 and 15.0±5.5 in the ACDF, CDA and HS groups, respectively (p=0.056). The mean postoperative ROM values were 20.82±5.66, 32.45±11.21 and 27.18±10.89, respectively (p=0.045). CONCLUSION: All three surgical techniques, ACDF, CDA, and HS, are safe and successful in the treatment of two-level cervical disc disease. However, HS and CDA may be more preferable over ACDF attributed to their motion-preserving benefits and effectively combining fusion and motion preservation techniques, with comparable clinical and radiological outcomes.

Effects of Surgical Timing on the Prognosis of Far Lateral Disk Herniation.

AIM: To evaluate the effects of surgical timing on the prognosis in far lateral disk herniations. MATERIAL AND METHODS: We retrospectively evaluated 171 patients diagnosed with far lateral disk herniation who underwent surgery between 2015 and 2021. Patients were divided into three groups: Those operated within the first 3 weeks, within 3-6 weeks, and after 6 weeks. Patients with progressive neurologic deficits and severe pain refractory to the analgesic treatment underwent surgery. RESULTS: The mean age was 57±3 (28-85) years. The patients consisted of 96 females and 75 males. Sixty-eight patients underwent surgery at the L4-L5, 45 at the L3-L4, 37 at the L5-S1, and 21 at L2-3 levels. All patients had low back and radicular leg pain. Lasegue test was positive in 67% of patients. Femoral nerve stretch test was positive in 68%. Motor deficits, patellar reflex loss, and sensory deficits were present in 76%, 80%, and 91% respectively. When the postoperative recovery rates of patients who underwent surgery in all three time periods were compared according to visual analog scale, Oswestry disability index, and MacNab criteria, notably, statistically significant improvements in recovery were observed among patients who underwent surgery in the preoperative short time period when compared to those in the other time periods. CONCLUSION: We believe that early surgery is important to prevent the progression of pain from acute to chronic neuropathic pain to promptly eliminate factors that activate the process and to provide faster and clearer symptom treatment.

Is There a Risk of Stroke During Anterior Cervical Discectomy? A Randomized Controlled Trial.

AIM: To examine the effects of different retractor techniques for anterior cervical discectomy on cerebral oxygen saturation. MATERIAL AND METHODS: In this study, a prospective comparative design was employed to examine the effects of different retractor techniques on a cohort of 48 adult patients with ASA I-II classification who underwent anterior cervical discectomy under general anesthesia. The study was conducted under assessor-blinded conditions, and the patients were divided equally into two groups: the self-retaining retractor group and the hand-held retractor group. In addition to standard anaesthesia monitoring, the utilization of cerebral oximetry monitoring was implemented for all patients. A total of 7 measurements were obtained at various stages, including preoperative, during anaesthesia induction, surgical positioning, surgical retraction, release of retractors, after correction of extension position, and prior to extubation. The main objective of this study was to evaluate the impact of neck position and surgical retraction on brain perfusion, as measured by regional cerebral oximetry. RESULTS: Sociodemographic data, duration of operation, hemodynamic parameters, bilateral regional cerebral oxygen saturation (rScO2), and Mini Mental State Examination (MMSE) scores did not differ significantly between the two groups. In both groups, the bilateral rScO2 decreased significantly with positioning and the left rScO2 decreased significantly following the installation of retractors. Only the left rScO2 increased significantly upon the release of both retractors. Following the correction of the neck position, bilateral rScO2 increased significantly in both groups (p < 0.001). CONCLUSION: The rScO2 of the left carotid artery was shown to significantly decrease due to the indirect impact of the retractors. After extending the head and neck, bilateral rScO2 values decreased significantly in both groups. However, despite this decline, there was no significant decrease in brain perfusion that would result in ischemia. The absence of a statistically significant distinction between the groups implies that it is unlikely to have an impact on brain perfusion.

[Surgical treatment of recurrent herniated discs of the lumbar spine depending on risk factors]. / Vybor taktiki khirurgicheskogo lecheniya retsidivov gryzh diskov poyasnichnogo otdela pozvonochnika na osnovanii analiza faktorov riska ikh razvitiya.

According to the literature, recurrent disc herniation of the lumbar spine occurs in 5-10% of cases. Objective. To develop an algorithm for surgical treatment of recurrent lumbar spine disc herniation based on analysis of risk factors of relapse and assessment of intra- and postoperative period. MATERIAL AND METHODS: The study included 61 patients with recurrent intervertebral disc herniation. Thirty patients underwent repeated microdiscectomy without transpedicular fixation, 31 patients - resection of recurrent disc herniation with transpedicular fixation (PLIF technique). The control group included 63 patients without recurrent disc herniation. Mean follow-up period was 3.5 years. RESULTS: Discectomy with transpedicular fixation is characterized by larger extent, prolonged surgery time and rehabilitation period. However, there is lower risk of recurrent disc herniation and CSF leakage. Repeated microdisectomy without transpedicular fixation is characterized by smaller extent and shorter surgery time, as well as faster recovery period. Nevertheless, we have higher risk of recurrent disc herniation and CSF leakage. We developed a method for assessing the probability of recurrent intervertebral disc herniation. This algorithm allows us to predict the probability of recurrent disc herniation in a particular patient with 86.7% accuracy. CONCLUSION: We proposed an algorithm for choosing surgical treatment of recurrent disc herniation. Microdiscectomy without fixation is advisable for the risk of recurrent disc herniation <30%, discectomy with transpedicular fixation - for risk of disc herniation >30%.

Biportal Endoscopic Spine Surgery for Lumbar Laminectomy and Diskectomy: Postoperative Outcomes and Surgical Learning Curve, a Single US Surgeon's Experience.

INTRODUCTION: Biportal endoscopic spine surgery (BESS) has gained traction for lumbar laminectomy and diskectomy. To justify the transition to BESS, outcomes and the surgical learning curve should be known. This study evaluates rates of complications with BESS and how these rates change with increased surgeon experience. METHODS: A single surgeon's consecutive patients who underwent BESS were evaluated. Patients older than 18 years who underwent BESS for lumbar laminectomy and diskectomy were included. Patients with previous spine surgery, multiple levels, or BESS for fusion were excluded. Demographics, length of surgery, intraoperative complications, postoperative complications, and revision surgery were recorded. The learning phase group and mastery phase group were based on a cumulative summation analysis based on surgical time. RESULTS: A total of 63 patients, with 31 and 32 patients in the learning and mastery group, respectively, were included. Surgical time decreased from 87 to 52 minutes in the mastery phase. Conversion to open decreased from 3 to 0 cases (P = 0.1803), intraoperative complications decreased from 3 to 0 (P = 0.1803), postoperative complications decreased from 7 to 2 (P = 0.017), and rates of revision surgery decreased from 4 to 1 (P = 0.4233). CONCLUSION: This study suggests a learning curve of 31 cases for adequate performance of BESS for lumbar laminectomy and diskectomy.

Outcomes of non-contiguous two-level anterior cervical discectomy and fusion in patients with degenerative cervical myelopathy: a retrospective study.

BACKGROUND: Non-contiguous two-level Anterior Cervical Discectomy and Fusion (ACDF) may be a viable option for patients with degenerative cervical myelopathy and imaging-evident spine and radicular compression at two non-contiguous cervical levels. The risk of hastening degeneration and triggering Adjacent Segment Disease at the spine levels located between the fused levels is a putative adverse event, which was assessed in a few studies. The aim of this study is to investigate the clinical outcomes of patients undergoing non-contiguous two levels ACDF and to assess biomechanical modifications at non-fused segments. METHOD: We retrospectively reviewed all patients with noncontiguous two-level spine and radicular compression, who underwent simultaneous noncontiguous two-level ACDF at our center. We analyzed clinical and radiological outcomes and investigated the rate of adjacent segment disease. Radiographic parameters were calculated on pre- and postoperative images. RESULTS: Thirty-two patients underwent simultaneous noncontiguous two-level ACDF for cervical myelo-radiculopathy between 2015 and 2021 and were followed up for a mean period of 43.3 months. For all patients, the mJOA score significantly improved from 14.57 ± 2.3 to 16.5 ± 2.1 (p<0.01) and the NDI score significantly decreased from 21.45 ± 4.3 to 12.8 ± 2.3 (p<0.01) postoperatively. Cervical lordosis increased after surgery (from 9.65° ±9.47 to 15.12° ± 6.09); intermediate disc height decreased (5.68 mm ± 0.57 to 5.27 mm ±0.98); the ROMs of intermediate (from 12.45 ± 2.33 to 14.77 ± 1.98), cranial (from 14.63 ± 1.59 to 15.71 ± 1.02), and caudal (from 11.58 ± 2.32 to 13.33 ± 2.67) segments slightly increased. During follow-up assessment, in one patient the myelopathy worsened due to spine compression at the intermediate level. CONCLUSIONS: Simultaneous and non-contiguous two-level ACDF is a safe and effective procedure. The occurrence of postoperative adjacent and intermediate segment disease is rare.

Functional outcomes in unstable complete subaxial cervical spinal injuries with respiratory paralysis and/or hemodynamic instability.

INTRODUCTION: Subaxial cervical spine injuries (SCSI) can lead to disastrous consequences such as quadriplegia, with/without respiratory paralysis (RP) and hemodynamic instability (HDI). Till date, there is no literature available for reporting outcomes of SCSI patients specifically pertaining to those presenting with RP/HDI and ours is the first study to document the same. METHODS: Retrospective 6-year study from a tertiary trauma centre database including patients >/= 18 years of operated SCSI. Only patients with ASIA A grade with admission RP/HDI and unstable injuries (fractures, subluxations) were included. Patients with ASIA grade B and above, patients with non-osseous injuries (such as disc herniation, central cord syndrome etc.) were excluded. RESULTS: 24 cases were analysed. C5 and C6 levels were the commonest. Vertebral listhesis/subluxation was the predominant radiological finding. The mean age was 47.4 years (22-79 years) and all, except one were males. Fall from height and road traffic accident (RTA) were the most common mechanisms of injury. The most common surgery was anterior discectomy and fusion followed by corpectomy. The overall mortality rate was 22/24 (92)%. Cord edema and hemorrhage had significant association with survival. None of the grade A survivors with HDI/RP showed improvement. The mean FU duration was 18.5 months (range, 16.5-20.5 months). CONCLUSIONS: Subaxial ASIA A cervical spine injuries with pre-operative RP/HDI is an indicator for non-improvement. This is the first study documenting outcome in such patients. The mortality rate in these patients is very high and is an extremely poor prognostic factor for recovery. Hence, surgery in such patients need to be decided judiciously, especially in developing countries that has a significant financial impact on the family members.

Clinical outcomes of fenestration discectomy and iLESSYS-Delta interlaminar endoscopic system for treatment of LDH: a single-center retrospective cohort study.

To compare the clinical efficacy of interlaminar endoscopic surgical system delta (iLESSYS-Delta) discectomy with that of classical fenestration discectomy for treating lumbar disc herniation. Patients who underwent iLESSYS-Delta or fenestration discectomy were enrolled in this study. Baseline information and clinical indicators were collected. The baseline data were matched using propensity score matching. Fifty-two patients were in each group. In the iLESSYS-Delta cohort, the volume of intraoperative bleeding was 18.17 ± 4.20 ml, the length of postoperative hospital stay was 4.16 ± 2.29 days, and the length of postoperative off-bed activity was 1.58 ± 0.88 days. In contrast, in the fenestration group, the volume of intraoperative bleeding was 32.50 ± 17.13 ml, the length of postoperative hospital stay was 6.66 ± 2.44 days, and the length of postoperative off-bed activity was 3.18 ± 1.28 days. The difference between the two groups was statistically significant (P < 0.05). The operation time was 88.90 ± 19.14 min in the iLESSYS-Delta group and 67.63 ± 19.32 min in the fenestration group, and the difference between the two groups was statistically significant (P < 0.05). Regarding the pain visual analogue scale scores at 24, 48, and 72 h after surgery, patients in the iLESSYS-Delta group had less pain than did those in the fenestration group (P < 0.05). The Oswestry disability indices of postoperative patients in both groups significantly improved at 3 months after surgery and at the last follow-up (P < 0.05); however, there was no statistically significant difference in the postoperative ODI scores between the two surgery groups (P > 0.05). The two groups showed no significant differences in clinical effects, postoperative recurrence rates, or perioperative complications. iLESSYS-Delta can cause less intraoperative bleeding and faster recovery than fenestration discectomy.

Is Posterior Cervical Foraminotomy Better Than Fusion for Warfighters?: A Biomechanical Study.

INTRODUCTION: Cervical spondylosis in the warfighter is a common musculoskeletal problem and can be career-ending especially if it requires fusion. Head-mounted equipment and increased biomechanical forces on the cervical spine have resulted in accelerated cervical spine degeneration. Current surgical gold standard is anterior cervical discectomy and fusion (ACDF). Posterior cervical foraminotomy (PCF) is a nonfusion surgical alternative, and this can be effective in alleviating radiculopathy from foraminal stenosis caused by disc-osteophyte complex. Biomechanical studies have not been done to analyze motion associated with military aircrew personnel following PCF. The aim of this study was to compare the biomechanical responses of the effects of ACDF and PCF with different grades of facet resection under simulated military aircrew conditions using range of motion, disc pressure, and facet loads at the index and adjacent levels. MATERIALS AND METHODS: A validated 3D finite element model of the human cervical spinal column was used to simulate various graded PCF and ACDF. All surgical simulations were performed at the most commonly operated level (C5-C6) in warfighters. Pure moment loading under flexion, extension, and lateral bending, and in vivo follower force of 75 N were applied to the intact spine. Hybrid loading protocol was used to achieve 134 degrees of combined flexion-extension and 83 degrees of lateral bending in intact and surgical models to reflect military loading conditions. Segmental motions, disc pressure, and facet load were obtained and normalized with respect to the intact model to quantify the biomechanical effect. RESULTS: Anterior cervical discectomy and fusion decreased range of motion at the index and increased motion at the adjacent levels, while all graded PCF responses had an opposite trend: increased motion at the index and decreased motion at adjacent levels. The magnitude of changes depended on the level of resection, spinal level, and loading mode. Disc pressure increased at the index level and decreased at the adjacent levels after PCF. These changes were exaggerated with increasing extent of facet resection. Facet load increased at the index level after PCF especially with extension and right (contralateral) lateral bending. Complete facetectomy led to facet load increases greater than ACDF at the adjacent levels in both flexion and extension. CONCLUSIONS: Posterior cervical foraminotomy is a motion-preserving implant-free surgical alternative to ACDF for warfighters with cervical radiculopathy after failure of conservative management. The treating surgeon must pay close attention to the extent of facet resection to avoid potential spinal instability and future disc and facet degeneration after PCF. Posterior cervical foraminotomy can be more advantageous than ACDF in terms of adjacent segment degeneration, motion preservation, reoperation rate, surgical cost, and retention of warfighters.

Postoperative Opioid Medication Consumption Following Single-Level Lumbar Microdiscectomy Before and After Implementation of a Multimodal Opioid-Sparing Pathway.

In response to the national opioid crisis, there have been increasing efforts to decrease opioid usage in favor of nonopioid alternatives. We compared post-discharge opioid and nonopioid pain medication prescriptions in lumbar microdiscectomy (MLD) patients before and after implementation of an opioid-sparing pathway for outpatient spine surgery. Patients were grouped into pre-implementation (pre) and post-implementation (post) cohorts based on date of surgery relative to pathway implementation on September 1, 2018. Primary outcomes were the average daily morphine milligram equivalent (MME) of opioids and percentages of nonopioids prescribed at 2-week, 6-week, and 3-month follow-up. Two hundred consecutive MLD patients (100 pre, 100 post) were evaluated. Pre-implementation, average daily MME significantly decreased from 19.59 at 2 weeks, to 1.73 at 6 weeks, to 0.11 at 3 months postoperatively (p < 0.001); post-implementation, average daily MME was 14.12, 1.31, and 0.27, respectively (p < 0.001). Average daily MME at 2-week follow-up decreased by 5.48 (p < 0.001) following implementation, while the rate of nonopioid prescriptions increased from 59% to 79% (p = 0.002) overall, specifically for acetaminophen (8% vs. 47%, p < 0.001) and nonsteroidal anti-inflammatory drugs (36% vs. 61%, p < 0.001). There were no significant differences at 6-week and 3-month follow-up. Opioid usage decreased while nonopioid pain medication usage increased from discharge to 2 weeks postoperatively. Beyond 2 weeks, opioid usage decreased significantly but were comparable between pre-implementation and post-implementation.

Rapid qualitative analysis of recruitment obstacles in the FORVAD (Posterior Cervical Foraminotomy surgery versus Anterior Cervical Discectomy surgery in the treatment of cervical brachialgia) randomised, controlled trial.

BACKGROUND: The number of surgical trials is increasing but such trials can be complex to deliver and pose specific challenges. A multi-centre, Phase III, RCT comparing Posterior Cervical Foraminotomy versus Anterior Cervical Discectomy and Fusion in the Treatment of Cervical Brachialgia (FORVAD Trial) was unable to recruit to target. A rapid qualitative study was conducted during trial closedown to understand the experiences of healthcare professionals who participated in the FORVAD Trial, with the aim of informing future research in this area. METHODS: Semi-structured interviews were conducted with 18 healthcare professionals who had participated in the FORVAD Trial. Interviews explored participants' experiences of the FORVAD trial. A rapid qualitative analysis was conducted, informed by Normalisation Process Theory. RESULTS: Four main themes were generated in the data analysis: (1) individual vs. community equipoise; (2) trial set-up and delivery; (3) identifying and approaching patients; and (4) timing of randomisation. The objectives of the FORVAD trial made sense to participants and they supported the idea that there was clinical or collective equipoise regarding the two FORVAD interventions; however, many surgeons had treatment preferences and lacked individual equipoise. The site which had most recruitment success had adopted a more structured process for identification and recruitment of patients, whereas other sites that adopted more "ad hoc" screening strategies struggled to identify patients. Randomisation on the day of surgery caused both medico-legal and practical concerns at some sites. CONCLUSIONS: Organisation and implementation of a surgical trial in neurosurgery is complex and presents many challenges. Sites often reported low recruitment and discussed the logistical issues of conducting a complex surgical RCT. Future trials in neurosurgery may need to offer more flexibility and time during set-up to maximise opportunities for larger recruitment numbers. Rapid qualitative analysis informed by Normalisation Process Theory was able to quickly identify key issues with trial implementation so rapid qualitative analysis may be a useful approach for teams conducting qualitative research in trials. TRIAL REGISTRATION: ISRCTN, ISRCTN reference: 10,133,661. Registered 23rd November 2018.

[Curative effect analysis of anterior cervical discectomy and fusion in patients with cervical spondylosis of vertebral artery type].

OBJECTIVE: To investigate the clinical effect of anterior cervical discectomy and fusion (ACDF) in the treatment of cervical spondylosis of vertebral artery type(CSA). METHODS: The clinical data of 42 patients with CSA from January 2020 to January 2022 were retrospectively analyzed. There were 25 males and 17 females, aged from 30 to 74 years old with an average of (53.9±11.0) years old. There were 18 cases with single-segment lesions, 17 cases with two-segment lesions, and 7 cases with three-segment lesions. The American Academy of Otolaryngology-Head and Neck Surgery's Hearing and Balance Committee score (CHE), the Neck Disability Index (NDI) and the cervical curvature Cobb angle were recorded before surgery and after surgery at 6 months. RESULTS: All 42 ACDF patients were followed up for 6 to 30 months with an average of (14.0±5.2) months. The operative time ranged from 95 to 220 min with an average of (160.38±36.77) min, the intraoperative blood loss ranged from 30 to 85 ml with an average of (53.60±18.98) ml. Tow patients had mild postoperative dysphagia, which improved with symptomatic treatment such as nebulized inhalation. CHE score decreased from (4.05±0.96) preoperatively to (2.40±0.70) at 6 months postoperatively (t=12.97, P<0.05). The number of improved vertigo at 6 months postoperatively was 38, with an improvement rate of 90.5%. NDI score was reduced from (34.43±8.04) preoperatively to (20.76±3.91) at 6 months postoperatively (t=11.83, P<0.05). The cervical curvature Cobb angle improved from (8.04±6.70)° preoperatively to (12.42±5.23)° at 6 months postoperatively (t=-15.96, P<0.05). CONCLUSION: The ACDF procedure has outstanding clinical efficacy in treating CSA. The operation can rapidly relieve patients' episodic vertigo symptoms by relieving bony compression and reconstructing cervical curvature. However, it is necessary to strictly grasp the indications for surgery and clarify the causes of vertigo in patients, and ACDF surgery is recommended for CSA patients for whom conservative treatment is ineffective.

Posterior Cervical Foraminotomy Compared with Anterior Cervical Discectomy with Fusion for Cervical Radiculopathy: Two-Year Results of the FACET Randomized Noninferiority Study.

BACKGROUND: Posterior cervical foraminotomy (posterior surgery) is a valid alternative to anterior discectomy with fusion (anterior surgery) as a surgical treatment of cervical radiculopathy, but the quality of evidence has been limited. The purpose of this study was to compare the clinical outcome of these treatments after 2 years of follow-up. We hypothesized that posterior surgery would be noninferior to anterior surgery. METHODS: This multicenter, randomized, noninferiority trial assessed patients with single-level cervical radiculopathy in 9 Dutch hospitals with a follow-up duration of 2 years. The primary outcomes measured reduction of cervical radicular pain and were the success ratio based on the Odom criteria, and arm pain and decrease in arm pain, evaluated with the visual analog scale, with a 10% noninferiority margin, which represents the maximum acceptable difference between the new treatment (posterior surgery) and the standard treatment (anterior surgery), beyond which the new treatment would be considered clinically unacceptable. The secondary outcomes were neck pain, Neck Disability Index, Work Ability Index, quality of life, complications (including reoperations), and treatment satisfaction. Generalized linear mixed effects modeling was used for analyses. The study was registered at the Overview of Medical Research in the Netherlands (OMON), formerly the Netherlands Trial Register (NTR5536). RESULTS: From January 2016 to May 2020, 265 patients were randomized (132 to the posterior surgery group and 133 to the anterior surgery group). Among these, 25 did not have the allocated intervention; 11 of these 25 patients had symptom improvement, and the rest of the patients did not have the intervention due to various reasons. At the 2-year follow-up, of 243 patients, primary outcome data were available for 236 patients (97%). Predicted proportions of a successful outcome were 0.81 after posterior surgery and 0.74 after anterior surgery (difference in rate, -0.06 [1-sided 95% confidence interval (CI), -0.02]), indicating the noninferiority of posterior surgery. The between-group difference in arm pain was -2.7 (1-sided 95% CI, 7.4) and the between-group difference in the decrease in arm pain was 1.5 (1-sided 95% CI, 8.2), both confirming the noninferiority of posterior surgery. The secondary outcomes demonstrated small between-group differences. Serious surgery-related adverse events occurred in 9 patients (8%) who underwent posterior surgery, including 9 reoperations, and 11 patients (9%) who underwent anterior surgery, including 7 reoperations (difference in reoperation rate, -0.02 [2-sided 95% CI, -0.09 to 0.05]). CONCLUSIONS: This trial demonstrated that, after a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction in patients with cervical radiculopathy. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Biological performance of a bioabsorbable magnesium-magnesium phosphate cement interbody fusion cage in a porcine lumbar interbody fusion model: a feasibility study.

PURPOSE: The aim of the study was to evaluate the feasibility of a bioabsorbable cage consisting of magnesium and magnesium phosphate cement (MPC) in a porcine lumbar interbody fusion model. METHODS: Twelve male Ba-Ma mini pigs underwent lumbar discectomy and fusion with an Mg-MPC cage or a PEEK cage at the L3/L4 and L4/L5 level. Computed tomography (CT) scans were made to evaluate the distractive property by comparing average disc space height (DSH) before and at 6, 12, and 24 weeks after the operation. After the lumbar spines were harvested at 6 or 24 weeks after the operation, micro-CT examination was conducted to analyze the fusion rate, and stiffness of motion segments was investigated through mechanical tests. A histological study was performed to evaluate the tissue type, inflammation, and osteolysis in the intervertebral space. RESULTS: CT scans showed no significant difference between the two groups in average DSH at each time point. Micro-CT scans revealed an equal fusion rate in both groups (0% at 6 weeks, 83.3% at 24 weeks). Both groups showed time-dependent increases in stability, the Mg-MPC cages achieved an inferior stiffness at 6 weeks and a comparable stiffness at 24 weeks. Histologic evaluation showed the presence of newly formed bone in both groups. However, empty spaces were observed at the interface or around the Mg-MPC cages. CONCLUSION: Compared with the PEEK cages, the Mg-MPC cages achieved comparable distraction, fusion rate, and spinal stability at 24 weeks after the operation. However, due to inferior stiffness at the early stage and fast degradation, further modification of material composition and design are necessary.

A microdiscectomy surgical video annotation framework for supervised machine learning applications.

PURPOSE: Lumbar discectomy is among the most common spine procedures in the US, with 300,000 procedures performed each year. Like other surgical procedures, this procedure is not excluded from potential complications. This paper presents a video annotation methodology for microdiscectomy including the development of a surgical workflow. In future work, this methodology could be combined with computer vision and machine learning models to predict potential adverse events. These systems would monitor the intraoperative activities and possibly anticipate the outcomes. METHODS: A necessary step in supervised machine learning methods is video annotation, which involves labeling objects frame-by-frame to make them recognizable for machine learning applications. Microdiscectomy video recordings of spine surgeries were collected from a multi-center research collaborative. These videos were anonymized and stored in a cloud-based platform. Videos were uploaded to an online annotation platform. An annotation framework was developed based on literature review and surgical observations to ensure proper understanding of the instruments, anatomy, and steps. RESULTS: An annotated video of microdiscectomy was produced by a single surgeon. Multiple iterations allowed for the creation of an annotated video complete with labeled surgical tools, anatomy, and phases. In addition, a workflow was developed for the training of novice annotators, which provides information about the annotation software to assist in the production of standardized annotations. CONCLUSIONS: A standardized workflow for managing surgical video data is essential for surgical video annotation and machine learning applications. We developed a standard workflow for annotating surgical videos for microdiscectomy that may facilitate the quantitative analysis of videos using supervised machine learning applications. Future work will demonstrate the clinical relevance and impact of this workflow by developing process modeling and outcome predictors.

Comparison of Percutaneous Endoscopic Transforaminal Discectomy, Chemonucleolysis, Microdiscectomy, and Microendoscopic Discectomy for Symptomatic Lumbar Disc Herniation: One-year Follow-up Clinical Results and Disc Degeneration.

This study compared the 1-year clinical outcomes and disc degeneration rates after transforaminal full-endoscopic lumbar discectomy (TF-FED), condoliase injection, open discectomy (OD), and microendoscopic discectomy (MED) for lumbar disc herniation (LDH). In total, 279 patients with LDH were divided into four treatment groups: TF-FED, OD, MED, and condoliase injection. Outcomes were evaluated on the basis of the complication rate, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), visual analog scale (VAS) scores, and the modified MacNab criteria. Surgical and hospital costs were assessed. Disc degeneration and endplate bone marrow edema were evaluated using magnetic resonance images. The mean postoperative JOABPEQ, VAS, or modified MacNab scores among the four groups had no significant differences. Additionally, the nerve injury or reoperation rate among the TF-FED, OD, and MED groups had no significant difference. However, the reoperation rate with condoliase injection was high because of residual disc herniation. Surgical and hospital costs were lower with condoliase injection and higher with OD and MED than those with TF-FED. With TF-FED and condoliase injection, the Pfirrmann grade progressed, and the disc height was significantly smaller than that with OD and MED. Endplate bone marrow edema was more common with condoliase injection and TF-FED. All groups had good outcomes. TF-FED and condoliase injection may reduce the burden of surgery because they can be performed under local anesthesia with little blood loss and low medical costs but tend to be associated with disc degeneration and endplate bone marrow edema. A randomized controlled study with a larger sample is needed.