Navigation-Assisted One-Staged Posterior Spinal Fusion Using Pedicle Screw Instrumentation in Adolescent Idiopathic Scoliosis-A Case Series.

Background and Objectives: Adolescent idiopathic scoliosis (AIS) is a prevalent three-dimensional spinal disorder, with a multifactorial pathogenesis, including genetics and environmental aspects. Treatment options include non-surgical and surgical treatment. Surgical interventions demonstrate positive outcomes in terms of deformity correction, pain relief, and improvements of the cardiac and pulmonary function. Surgical complications, including excessive blood loss and neurologic deficits, are reported in 2.27-12% of cases. Navigation-assisted techniques, such as the O-arm system, have been a recent focus with enhanced precision. This study aims to evaluate the results and complications of one-stage posterior instrumentation fusion in AIS patients assisted by O-arm navigation. Materials and Methods: This retrospective study assesses 55 patients with AIS (12-28 years) who underwent one-stage posterior instrumentation correction supported by O-arm navigation from June 2016 to August 2023. We examined radiological surgical outcomes (initial correction rate, loss of correction rate, last follow-up correction rate) and complications as major outcomes. The characteristics of the patients, intraoperative blood loss, operation time, number of fusion levels, and screw density were documented. Results: Of 73 patients, 55 met the inclusion criteria. The average age was 16.67 years, with a predominance of females (78.2%). The surgical outcomes demonstrated substantial initial correction (58.88%) and sustained positive radiological impact at the last follow-up (56.56%). Perioperative complications, including major and minor, occurred in 18.18% of the cases. Two patients experienced a major complication. Blood loss (509.46 mL) and operation time (402.13 min) were comparable to the literature ranges. Trend analysis indicated improvements in operation time and blood loss over the study period. Conclusions: O-arm navigation-assisted one-stage posterior instrumentation proves reliable for AIS corrective surgery, achieving significant and sustained positive radiological outcomes, lower correction loss, reduced intraoperative blood loss, and absence of implant-related complications. Despite the challenges, our study demonstrates the efficacy and maturation of this surgical approach.

Complete Intradural Interbody Cage Migration in Lumbar Spine Surgery: A Case Report and Literature Review.

Background: Spinal fusion is a common surgery, in which vertebrae are fused to restore spinal stability and eliminate pain during movement. The use of an interbody cage facilitates spinal fusion. However, complete cage migration into the dura matter rarely occurs and can be challenging to manage. Case Presentation: A 44-year-old man presented at our spine center with a history of incomplete paraplegia and cauda equina syndrome that had lasted for 2 years and 4 months. This condition developed after he underwent six lumbar spine surgeries to address lower back pain and right-sided sciatica. A structural allograft kidney-shaped cage was found completely within the dura at the level of the L3 vertebra. Durotomy, cage retrieval, and pedicle screw fixation from the L2 to L4 vertebrae were performed. Numbness in both lower limbs markedly decreased within several days of the operation. After four months following the progressive physical therapy, the patient could partially control both urination and defecation. Five months postoperatively, he could stand with slight assistance. Conclusions: Complete intradural cage migration is a rare and serious complication. To the best of our knowledge, this is the first reported case with such a condition in the literature. Even if treatment is delayed, surgical intervention may salvage the remaining neurologic function and may even lead to partial recovery.

Computed Tomography-Guided Endoscopic Surgery in Lumbar Disc Herniation With High-grade Migration: A Retrospective, Comparative Study.

BACKGROUND: Symptomatic herniated intervertebral discs are debilitating. However, surgical management poses a significant challenge for endoscopic spine surgeons, especially in high-grade migrated lesions. OBJECTIVES: This study aimed to  assess the surgical and clinical outcomes after applying a computed tomography navigated percutaneous endoscopic lumbar discectomy. STUDY DESIGN: The data of patients with high-grade lumbar disc migration who underwent percutaneous endoscopic lumbar discectomy at our spine center were retrospectively collected and analyzed from November 2017 to May 2019. The patients were divided into 2 groups based on different workflows, with group O who underwent percutaneous endoscopic lumbar discectomy with computed-tomography navigation (O-arm), and group C who underwent conventional fluoroscopic guidance (C-arm). SETTING: Twenty-one (n = 21) patients were enrolled with data fully documented. There were 9 patients in group O (n = 9) and 12 patients in group C (n = 12). METHODS: An intraoperative 3-dimensional image was obtained using the O-arm device (O-arm®, Medtronic, Inc., Louisville, CO, United States) after patient positioning in group O, and enable multiplanar visualization during exploring the entry point, trajectory, orientation, and finally discectomy. In group C, conventional imaging scanner intensifier (C-arm) was used during the procedure. RESULTS: The operative time (99.4 ± 40.7 vs 86.9 ± 47.9 minutes, P = .129), blood loss (11.1 ± 15.7 vs 6.7 ± 8.2 mL, P = .602), and hospital stay (2.9 ± 0.3 vs 2.8 ± 0.6 days, P = .552) were similar between the 2 groups. However, group O showed more reduction in the pain and faster functional recovery immediately after the surgery (Visual Analog Score [VAS]: -9 vs -6.7, P =.277; Oswestry Disability Index [ODI]: -53.2% vs -29.1%, P = 0.006) and during the one-year follow-up (VAS: -8.1 vs -7.3, P =.604; ODI: -56.7% vs -40.1%, P = .053) compared with group C. LIMITATIONS: The retrospective nature of the study design, the small population size, and the shorter period of follow-up required further study. CONCLUSIONS: Computed tomography-navigated percutaneous endoscopic surgery is safe and effective for lumbar disc herniation with high-grade migration, and enhance early functional recovery even compared with conventional fluoroscopic guidance.

Percutaneous Endoscopic Surgery Alone to Treat Severe Infectious Spondylodiscitis in the Thoracolumbar Spine: A Reparative Mechanism of Spontaneous Spinal Arthrodesis.

BACKGROUND: Infective spondylodiscitis has been treated solely with antibiotics based on the pathogen identified. Surgical intervention was used in cases of unidentified pathogens, failed antibiotic treatment, neurological deficit, or instability. The standard surgical procedure was debridement and interbody fusion with a bone graft through the anterior approach, followed by posterior instrumentation. Recently, percutaneous endoscopic surgery has been proven to be safe and effective for treating infectious spondylodiscitis. The results of endoscopy surgery treatment alone for infectious spondylodiscitis with severe bony destruction were analyzed in this study. OBJECTIVE: To describe the clinical and radiological outcomes in patients with infectious spondylodiscitis and severe bony destruction, who were treated with minimally invasive endoscopic surgery alone. STUDY DESIGN: Retrospective observational study (Institutional Review Board: CMUH 105-REC2-101). SETTING: An inpatient surgery center. METHODS: The study included 24 patients with infectious spondylodiscitis and severe bony destruction treated with endoscopy surgery. The patients were treated according to the endoscopic surgical protocol and were followed up for at least 5 years. A retrospective chart review was conducted to evaluate the locations, symptoms and signs, comorbidity, pain scale, and functional outcome. Laboratory data, such as erythrocyte sedimentation rate and C-reactive protein level, and clinical outcomes, including the pain scale, visual analogue scale, and functional score of Oswestry disability index, were recorded. All patients underwent a preoperative magnetic resonance imaging (MRI) scan and were carefully reviewed and classified based on the severity, including endplate erosion, bone edema (low T1, high T2), loss of vertebral height, paravertebral inflammation, paravertebral abscess, and epidural abscess. All patients underwent a plain film follow-up at 3, 6, 9, 12, and 18 months after surgery and computed tomography at 12 months postoperatively. RESULTS: The comorbidities of patients were categorized according to the Charlson Comorbidity Index. The results revealed 10 lesions on the thoracic or upper lumbar spine (between T10 and L3) and 14 on the lower lumbar spine (between L3 and S1). Bone destruction as a result of severe infection and loss of disc height was observed in most cases. During the final follow-up, no significant changes were observed in the sagittal alignment, and a kyphotic angle change of less than 10° was observed in 20 cases. Syndesmophyte formation along the anterior longitudinal ligament (ALL), paravertebral syndesmophyte formation, intervertebral bony fusion, and bony ankylosis of the facet joints in the form of osteophyte formation and fusion were noted. No posterior instrumentation surgery was performed for instability in our case series. LIMITATIONS: This was a retrospective observational clinical case series with small sample size. CONCLUSIONS: A trend of spontaneous spinal arthrodesis, including syndesmophyte formation along the ALL, paravertebral ligaments, direct intervertebral bone growth, and bony ankylosis of the facet joint were observed after a minimally invasive endoscopy treatment for infectious spondylodiscitis. The stability of the 3 columns resulted in segmental stability, which prevented the progression of the kyphotic deformity. Percutaneous endoscopic surgery is safe and effective for treating infectious spondylodiscitis even in patients with severe bony destruction.

Adjacent segment disease following Dynesys stabilization for lumbar disorders: A case series of mid- and long-term follow-ups.

BACKGROUND: Radiologic adjacent segment degeneration (ASDeg) can occur after spinal surgery. Adjacent segment disease (ASDis) is defined as the development of new clinical symptoms corresponding to radiographic changes adjacent to the level of previous spinal surgery. Greater pre-existing ASDeg is generally considered to result in more severe ASDis; nonetheless, whether the ASDeg status before index surgery influences the postoperative risk of revision surgery due to ASDis warrants investigation. AIM: To identify possible risk factors for ASDis and verify the concept that greater preexisting ASDeg leads to more severe ASDis. METHODS: Data from 212 patients who underwent posterior decompression with Dynesys stabilization from January 2006 to June 2016 were retrospectively analyzed. Patients who underwent surgery for ASDis were categorized as group A (n = 13), whereas those who did not were classified as group B (n = 199). Survival analysis and Cox proportional hazards models were used to compare the modified Pfirrmann grade, University of California-Los Angeles grade, body mass index, number of Dynesys-instrumented levels, and age. RESULTS: The mean time of reoperation was 7.22 (1.65-11.84) years in group A, and the mean follow-up period was 6.09 (0.10-12.76) years in group B. No significant difference in reoperation risk was observed: Modified Pfirrmann grade 3 vs 4 (P = 0.53) or 4 vs 5 (P = 0.46) for the upper adjacent disc, University of California-Los Angeles grade 2 vs 3 for the upper adjacent segment (P = 0.66), age of < 60 vs > 60 years (P = 0.9), body mass index < 25 vs > 25 kg/m2 (P = 0.3), and sex (P = 0.8). CONCLUSION: Greater preexisting upper ASDeg was not associated with a higher rate of reoperation for ASDis after Dynesys surgery. Being overweight tended to increase reoperation risk after Dynesys surgery for ASDis.

Seizure After Percutaneous Endoscopic Surgery-Incidence, Risk Factors, Prevention, and Management.

BACKGROUND: Percutaneous endoscopic surgery is a popular surgery to treat lumbar spinal disorders. However, seizure after percutaneous endoscopic surgery is an unpredictable complication. The only prodromal sign for seizure currently known is neck pain. We reviewed the incidence of, and risk factors for, seizure during percutaneous endoscopic surgery and present the cases of 3 patients with seizure and our management. CASE DESCRIPTION: From October 2006 to March 2019, 3 of 816 patients (0.34%) with thoracic lumbar disorders who had undergone percutaneous endoscopic surgery experienced a seizure episode. The cases of those 3 patients were carefully reviewed. Studies of the risk factors for seizure after spinal procedures reported before June 13, 2019 were identified through a PubMed search. We found that infusion fluid containing cefazolin, the infusion rate, a prolonged operative time, the occurrence of a dural tear, and sevoflurane anesthesia might be associated with seizure, both described in the reported data and found in our experience. Three patients who experienced a seizure episode had had general anesthesia with sevoflurane, and the surgical approach used was interlaminar for a herniated disc in L5-S1. We noted a "red flag sign," namely an uncontrollable hypertension episode combined with a decreasing pulse rate, in all 3 patients who had experienced a seizure, which was not observed in the other patients. All 3 patients had received antihypertensive medication (labetalol) ≥3 times without response. CONCLUSION: Seizure after percutaneous endoscopic surgery is rare, but lethal. Although its cause remains unknown, all risk factors for seizure should be checked and corrected immediately when a red flag sign, uncontrolled hypertension, appears.