Establishing a Benchmark for Iatrogenic Hemodilution and Blood Transfusion in Long-Segment Spine Fusion Surgery.

STUDY DESIGN: Single-center retrospective cohort study. OBJECTIVE: To identify risk factors for transfusion during long-segment thoracolumbar fusion surgery and benchmark cutoffs that could be used by the operative team to guide the use of transfusion. SUMMARY OF BACKGROUND DATA: Perioperative transfusion for patients undergoing long-segment thoracolumbar fusion surgery is common. To date, no standardized intra- and perioperative management of transfusion administration has been defined. METHODS: Patients who underwent thoracolumbar fusion surgeries of 8 or more levels between 2015 and 2020 were identified. Patient demographics, surgical details, anesthesia and critical care records, and laboratory data were compared between patients who received intraoperative and postoperative blood transfusions and those who did not. Univariate and multivariate propensity-matched analyses were performed to identify independent predictors for blood transfusion, and ordinal analysis was performed to identify possible benchmark cutoffs. RESULTS: Among 233 patients identified who underwent long-segment fusions, 133 (57.1%) received a blood transfusion. Multivariate propensity-matched logistic regression showed that intravenous (IV) fluid volume was an independent predictor for transfusion (transfusion group 8051 mL vs. non-transfusion group 5070 mL, P<0.01). Patients who received ≥4 L total IV fluids were more likely to undergo transfusion than those who received <4 L (93.2% vs. 50.7%, P<0.01). Those receiving total IV fluids at a rate ≥60 mL/Kg (OR 10.45; 95% CI: 2.62-41.72, P<0.01) or intraoperative IV fluids at a rate ≥9 mL/Kg/hr (OR 4.46; 95% CI: 1.39-14.32, P<0.01) were more likely to require transfusions. CONCLUSIONS: IV fluid administration is an independent predictor for blood transfusion after long-segment fusion surgery. Limiting IV fluid administration may prevent iatrogenic hemodilution and decrease transfusion rates. These data can be used to create perioperative protocols with the goal of decreasing transfusion rates when not indicated and allowing earlier administration when indicated.

Frequency and predictors of complication clustering within 30 days of spinal fusion surgery: a study of children with neuromuscular scoliosis.

PURPOSE: There is limited information on the clustering or co-occurrence of complications after spinal fusion surgery for neuromuscular disease in children. We aimed to identify the frequency and predictive factors of co-occurring perioperative complications in these children. METHODS: In this retrospective database cohort study, we identified children (ages 10-18 years) with neuromuscular scoliosis who underwent elective spinal fusion in 2012-2020 from the National Surgical Quality Improvement Program-Pediatric database. The rates of co-occurring complications within 30 days were calculated, and associated factors were identified by logistic regression analysis. Correlation between a number of complications and outcomes was assessed. RESULTS: Approximately 11% (709/6677 children with neuromuscular scoliosis undergoing spinal fusion had co-occurring complications: 7% experienced two complications and 4% experienced ≥ 3. The most common complication was bleeding/transfusion (80%), which most frequently co-occurred with pneumonia (24%) and reintubation (18%). Surgical time ≥ 400 min (odds ratio (OR) 1.49 [95% confidence interval (CI) 1.25-1.75]), fusion ≥ 13 levels (1.42 [1.13-1.79]), and pelvic fixation (OR 1.21 [1.01, 1.44]) were identified as procedural factors that independently predicted concurrent complications. Clinical risk factors for co-occurring complications included an American Society of Anesthesiologist physical status classification ≥ 3 (1.73 [1.27-2.37]), structural pulmonary/airway abnormalities (1.24 [1.01-1.52]), impaired cognitive status (1.80 [1.41-2.30]), seizure disorder (1.36 [1.12-1.67]), hematologic disorder (1.40 [1.03-1.91], preoperative nutritional support (1.34 [1.08-1.72]), and congenital malformations (1.20 [1.01-1.44]). Preoperative tracheostomy was protective against concurrent complications (0.62 [0.43-0.89]). Significant correlations were found between number of complications and length of stay, non-home discharge, readmissions, and death. CONCLUSION: Longer surgical time (≥ 400 min), fusion ≥ 13 levels and pelvic fixation are surgical risk factors independently associated with co-occurring complications, which were associated with poorer patient outcomes. Recognizing identified nonmodifiable risk factors might also be important for preoperative planning and risk stratification of children with neuromuscular scoliosis requiring spinal fusion. LEVEL OF EVIDENCE: Level IV evidence.

A radiological analysis of pelvic fixation trajectories: patient series.

BACKGROUND: Three well-defined methods for pelvic fixation are used for biomechanical support in spine fusion constructs: iliac, recessed iliac, and S2-alar-iliac (S2AI) screws. The authors compared the maximum screw sizes that could be placed with these techniques by using image-guidance software and high-resolution computed tomography scans from 20 randomly selected patients. Six trajectories were plotted per side, beginning at recognized starting points (standard or recessed posterior superior iliac spine [PSIS] or S2AI screw) and ending at the anterior inferior iliac spine (AIIS) or supra-acetabular notch (SAN). OBSERVATIONS: The mean maximum screw length and width ranged from 80.0 ± 32.2 mm to 140.8 ± 22.6 mm and from 8.25 ± 1.2 mm to 13.0 ± 2.7 mm, respectively, depending on the trajectory. Statistically significant differences in length were found between the standard and recessed PSIS trajectories to the AIIS (p < 0.001) and between the standard PSIS-to-AIIS trajectory and the S2AI-to-AIIS (p = 0.007) or S2AI-to-SAN (p < 0.001) trajectories. The most successful trajectory was the PSIS to SAN (95%, 38/40). LESSONS: The traditional iliac screw trajectory enabled the longest and widest screw trajectories and highest rate of successful screw placement with the fewest theoretical breaches more reliably than recessed and S2AI trajectories. These findings may help surgeons plan for maximum screw purchase for pelvic fixation.

Epidemiology of Gunshot-Related Spinal Injuries and Related Risk Factors for In-Hospital Mortality in the United States from 2015-2019: A National Trauma Data Bank Analysis.

Firearm injuries in the U.S. pose a significant public health burden, but data on gunshot wounds (GSWs) specifically involving the spine are scarce. We examined epidemiological trends in GSWs to the spine and associated spinal cord injury (SCI) and mortality rates. This was a cross-sectional study of data from level I-III trauma centers in the U.S. participating in the American College of Surgeons National Trauma Data Bank (ACS NTDB) in 2015-2019. We identified adult and pediatric patients presenting with GSW and evaluated those with Abbreviated Injury Scale codes indicating spinal involvement and SCI. We assessed in-hospital mortality and GSW-related SCI. A total of 5,021,316 patients were enrolled in the ACS NTDB. Of the 107,233 patients (2.1% of total) presenting with GSW, 9023 (8.4%) patients had spine involvement. Overall rates of GSW and spinal GSW were similar across years. The most common cause of spinal GSW injury was assault (86.7%). The cervical spine was involved in 24.2% of patients, thoracic spine in 42.8%, and lumbar spine in 39.7%. Cervical SCI was present in 8.7% of all spinal GSW (35.7% of cervical GSW), thoracic SCI in 17.4% (40.6% of thoracic GSW), and lumbar SCI in 8.1% (20.3% of lumbar GSW). The mean patient age was 29.0 ± 12.2 years, 88.5% were male, 62.4% were black, 23.7% were white, and 13.9% were another race. Blood alcohol content was ≥0.08 in 12.1%, and illicit drugs were positive in 24.4%. In-hospital mortality was high in patients with spinal GSWs (8.1%), and mortality was significantly higher with cervical involvement (18.1%), cervical SCI (30.7%), or thoracic incomplete SCI (13.6%) on univariate analysis. On multi-variate analysis of age (excluding patients <16 years of age), sex, Injury Severity Score (ISS), complete SCI, and spinal area of involvement, only greater patient age (age 40-65 years: adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.09-2.11, p = 0.014; age >65 years: aOR 3.90, 95% CI 2.10-7.27, p < 0.001) and higher ISS (ISS 9-15: aOR 6.65, 95% CI 2.38-18.54, p < 0.001; ISS 16-24: aOR 18.13, 95% CI 6.65-49.44, p < 0.001; ISS >24: aOR 68.44, 95% CI 25.39-184.46, p < 0.001) were independently associated with in-hospital mortality risk after spinal GSW. These results demonstrate that spinal GSW is not uncommon and that older patients with more severe systemic injuries have higher in-hospital mortality risk.

Mid-term and Long-term Outcomes After Total Cervical Disk Arthroplasty Compared With Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

STUDY DESIGN: A meta-analysis of randomized controlled trials (RCTs). OBJECTIVE: The aim of this study was to compare mid-term to long-term outcomes of cervical disk arthroplasty (CDA) with those of anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical degenerative disk disease. SUMMARY OF BACKGROUND DATA: After ACDF to treat symptomatic cervical degenerative disk disease, the loss of motion at the index level due to fusion may accelerate adjacent-level disk degeneration. CDA was developed to preserve motion and reduce the risk of adjacent segment degeneration. Early-term to mid-term clinical outcomes from RCTs suggest noninferiority of CDA compared with ACDF, but it remains unclear whether CDA yields better mid-term to long-term outcomes than ACDF. MATERIALS AND METHODS: Two independent reviewers searched PubMed, Embase, and the Cochrane Library for RCTs with at least 60 months of follow-up. The risk ratio or standardized mean difference (and 95% CIs) were calculated for dichotomous or continuous variables, respectively. RESULTS: Eighteen reports of 14 RCTs published in 2014-2023 were included. The pooled analysis demonstrated that the CDA group had a significantly greater improvement in neurological success and Neck Disability Index than the ACDF group. The ACDF group exhibited a significantly better improvement in the Short Form-36 Health Survey Physical Component Summary than the CDA group. Radiographic adjacent segment degeneration was significantly lower in the CDA group at 60- and 84-month follow-ups; at 120-month follow-up, there was no significant difference between the 2 groups. Although the overall rate of secondary surgical procedures was significantly lower in the CDA group, we did not observe any significant difference at 60-month follow-up between the CDA and ACDF group and appreciated statistically significant lower rates of radiographic adjacent segment degeneration, and symptomatic adjacent-level disease requiring surgery at 84-month and 108- to 120-month follow-up. The rate of adverse events and the neck and arm pain scores in the CDA group were not significantly different from those of the ACDF group. CONCLUSIONS: In this meta-analysis of 14 RCTs with 5- to 10-year follow-up data, CDA resulted in significantly better neurological success and Neck Disability Index scores and lower rates of radiographic adjacent segment degeneration, secondary surgical procedures, and symptomatic adjacent-level disease requiring surgery than ACDF. ACDF resulted in improved Short Form-36 Health Survey Physical Component Summary scores. However, the CDA and ACDF groups did not exhibit significant differences in overall changes in neck and arm pain scores or rates of adverse events.

Closed cervical traction techniques: moving into the 21st century.

Closed cervical traction for reducing dislocating cervical injuries, deformity correction, or discectomy distraction has been implemented in its modern form since the 1930s. Cervical traction state of the art has not changed significantly since the 1960s, with most reductions performed by using Gardner-Wells tongs or halo traction; however, there are many limitations of traditional weight-pulley traction, including limited reduction efficacy and patient safety shortcomings. In this paper, the authors review the history of cervical traction in the 20th century and the limitations of current traction techniques and describe a novel traction device developed at the University of Utah with robotic actuator load or position control and real-time force-sensing capabilities. Preliminary biomechanical testing results using the novel device in an extension spring loading model, with intact cadavers, and in iatrogenic facet injury cadaveric models demonstrated preliminary safety and efficacy of the device. The authors believe this and future research efforts aimed toward improving the efficacy and safety of cervical traction will help advance the field into the 21st century.

Motorized Robotic Closed Cervical Traction: Biomechanical Proof of Concept.

STUDY DESIGN: Biomechanical study. OBJECTIVE: To demonstrate that robotic cervical traction can apply closed cervical traction as effectively as manual weight-and-pulley traction in extension spring and cadaveric models. SUMMARY OF BACKGROUND DATA: Closed cervical traction is used to reduce subaxial cervical spine dislocation injuries and to distract the intervertebral space during cervical spine surgery. Weight-and-pulley cervical traction relies on cumbersome and imprecise technology without any safeguard to prevent over-traction or weights being pulled/released inadvertently. METHODS: A prototype robotic traction device was designed and manufactured by the authors with real-time tensile force measurement, ±1-lbs (5 N) force application accuracy, locking/non-backdriveable linear actuators with actuator position sensing, 200-lbs (900 N) maximum force capability, up to 20° of flexion/extension manipulation, <25-lbs (111 N) device weight, and compatibility with Gardner-Wells tongs or Mayfield head clamp. The device was tested using an extension spring model and an intact fresh cadaver specimen to assess applied and desired force over time and radiographic changes in the cervical spine as traction force increased. The cadaver was tested in manual traction initially and then robotic traction in 10-lbs (50 N) increments up to 80-lbs (355 N) to compare methods. RESULTS: The prototype device met or exceeded all requirements. In extension spring testing, the device reached the prescribed forces of both 25-lbs (111 N) and 80-lbs (355 N) accurately and maintained the desired weight. In cadaveric testing, radiographic outcomes were equivalent between the prototype and manual weight-and-pulley traction at 80-lbs (355 N; disk space measurements within ±10% for all levels), and the device reached the desired weight within±1-lbs (5 N) of accuracy at each weight interval. CONCLUSION: This preliminary work demonstrates that motorized robotic cervical traction can safely and effectively apply controlled traction forces.

High Failure Rates in Prisoners Undergoing Spine Fusion Surgery.

OBJECTIVE: The medical literature on prisoner health care is limited, despite data showing that prisoners experience high rates of physical and mental health challenges. We compared clinical outcomes for prisoners undergoing spine fusion with comparable nonincarcerated patients and determined what factors were implicated in differences in outcomes. METHODS: Prisoners who underwent spinal fusion in 2011-2021 were retrospectively compared with an age-, sex-, and procedure-matched 3:1 control group of nonincarcerated spinal fusion patients. Fusion failure was confirmed by lack of bridging bone between vertebrae on CT or radiographic images >1 year postoperatively or evidence of instrumentation failure with resultant >2 mm of translation on flexion/extension radiographs. RESULTS: Twenty-seven identified prisoners were compared with 81 nonincarcerated controls. Ten prisoners and 6 controls experienced nonunion (37% vs. 7%, P < 0.01). Rates of risk factors for nonunion, such as smoking history, elevated body mass index, chronic steroid use, diabetes mellitus, previous spine surgery, and levels fused, were not significantly different between prisoners and controls. Among prisoners, those with nonunion were younger (45 vs. 53 years, P = 0.03), had greater body mass index (34 vs. 29, P = 0.02), and were more likely to undergo reoperation (30% vs. 0%, P = 0.02). Multivariate analysis revealed that prisoners carry a 9.62 increased odds of nonunion compared with controls. CONCLUSIONS: This is one of few studies investigating health care outcomes in prisoners. We found they had a significantly higher rate of nonunion than matched control patients from the general population treated at the same hospital, suggesting additional measures may be necessary postoperatively to support fusion in prisoners.

Identification of an Operative Time Threshold for Substantially Increased Postoperative Complications Among Elderly Spine Surgery Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To identify whether thresholds exist beyond which operative duration or age increases risks for complications among patients ≥65 years undergoing elective spine surgery. METHODS: Elective inpatient spine procedures unrelated to infection/trauma/tumor diagnoses in patients <65 years recorded in the 2006-2019 American College of Surgeons National Surgical Quality Improvement database were identified. Univariate analyses was used to compare 30 day complication rates among 5 operative duration and age-stratified groups. To quantify the risk of prolonged operative duration on complications, multivariate analyses were performed controlling for confounders. A generalized linear model was used to assess the individual and combined effect strength of age and operative duration on complication rates. RESULTS: Among 87,705 patients stratified by operative duration, 30 day complication rates rose nonlinearly as operative duration increased, with a sharp rise after 4.0-4.9 hours (28.3% at 4.0-4.9 hours, 51.7% at ≥5 hours, P < .001). Multivariate analysis found operative duration was independently associated with increased risk of overall complications (odds ratio 1.10→1.69, P < .001) and medical complications (odds ratio 1.19→1.98, P < .001). Although complication rates rose by age (all P < .001), age was not independently predictive of overall complications within any operative duration group on multivariate analysis. Operative duration had a greater effect (η2P = .067) than age (η2P = .003) on overall complication rates. CONCLUSIONS: Increased operative duration was strongly associated with 30 day complication rates, particularly beyond a threshold of 5 hours. Furthermore, operative duration had a notably larger effect on overall complication rates than age.

Using Frailty Measures to Predict Functional Outcomes and Mortality After Type II Odontoid Fracture in Elderly Patients: A Retrospective Cohort Study.

STUDY DESIGN: Single-center retrospective cohort study. OBJECTIVES: Type II odontoid fractures occur disproportionately among elderly populations and cause significant morbidity and mortality. It is a matter of debate whether these injuries are best managed surgically or conservatively. Our goal was to identify how treatment modalities and patient characteristics correlated with functional outcome and mortality. METHODS: We identified adult patients (>60 years) with traumatic type II odontoid fractures. We used multivariate regression controlling for patient demographics, Glasgow Coma Scale (GCS) score, Charlson Comorbidity Index (CCI), modified Rankin Scale (mRS) score, modified Frailty Index (mFI-5 and mFI-11), fracture displacement, and conservative vs operative treatment. RESULTS: Of the 59 patients (mean age 77.9 years), 24 underwent surgical intervention and 35 underwent conservative management. Operatively managed patients were younger (73.4 vs 80.6 years, P < .001) and had higher degree of fracture displacement (3.5 vs 1.0 mm, P = .002) than conservatively managed patients but no other differences in baseline characteristics. Twenty-four patients (40.7%) died within the study period (median time to death: 376 days). There were no differences between treatment groups in functional outcomes (mRS or Frankel Grade) or mortality (33.3% in operative group vs 45.7%, P = .34). There was a statistically significant correlation between higher presentation mRS score and subsequent mortality on multivariate analysis (OR = 2.06, 95% CI 1.04-4.10, P = .039), whereas surgical intervention, age, GCS score, CCI, mFI-5, mFI-11, sex, and fracture displacement were not significantly correlated. CONCLUSIONS: Mortality after type II odontoid fractures in elderly patients is common. mRS score at presentation may help predict mortality more accurately than other patient factors.

O-Arm Accuracy and Radiation Exposure in Adult Deformity Surgery.

OBJECTIVE: In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation. METHODS: In this retrospective single-center cohort study, all patients aged >18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related perioperative and postoperative complications or revision surgery within 3 years. RESULTS: Of 1477 pedicle screws placed in 91 patients (mean 16.41 ± 5.6 screws/patient), 1208 pedicle screws (81.8%) could be evaluated by 3-dimensional imaging after placement. Heary Grade I placement was achieved in 1150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54 ± 14.29 mSv and effective dose/spin was 8.25 ± 2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded. CONCLUSIONS: With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.

Postoperative ileus risk after posterior thoracolumbar fusion performed with total intravenous anesthesia versus inhaled anesthesia.

OBJECTIVE: There has been an increase in the use of total intravenous anesthesia (TIVA) for intraoperative neuromonitoring during thoracolumbar posterior spinal fusion (PSF). Although prior studies have identified risk factors for postoperative ileus (PI) after PSF, to the authors' knowledge, PI rates in patients receiving inhaled anesthetic versus TIVA have not been evaluated. In this study the authors analyzed whether TIVA is associated with greater risk of PI in PSF patients. METHODS: In this retrospective single-institution cohort study, all patients undergoing PSF at the authors' tertiary academic institution from May 2014 to December 2020 were included. Patients undergoing anterior/lateral approaches or who had concurrent abdominal procedures unrelated to ileus in the same admission were excluded. PI was defined using radiographic and/or clinical diagnoses (postoperative radiographs, abdominal CT, and/or ICD-9 or -10 codes) and was confirmed via chart review. The use of TIVA or inhaled anesthetic was captured from the anesthesia record; patients were excluded if they were missing anesthesia technique data. Postoperative occurrence of PI was compared between patients who had TIVA or inhaled anesthetics while controlling for collected demographic, clinical, and surgical variables. RESULTS: Of the 2819 patients meeting inclusion criteria, 283 (10.0%) had PI (mean ± SD age 59.3 ± 15.8 years; 155 [54.8%] male). The mean patient length of stay was 7.7 ± 5.0 days, which was significantly longer than that of patients without PI (4.9 ± 3.9 days, p < 0.001). Patients with PI had more levels fused (46% of PI patients with ≥ 5 levels fused vs 25% of non-PI patients, p < 0.001) and longer operations (6.0 ± 2.2 vs 5.4 ± 1.9 hours, p < 0.001). TIVA patients were more likely than inhalation-only patients to experience PI, but this finding did not reach significance on univariate analysis (11.0% PI rate vs 8.9%, p = 0.06). After propensity matching 125 non-PI patients and 50 PI patients by age, sex, operative time, and number of levels fused, there was a significant difference in intraoperative opiate dosing between TIVA and inhalational patients (275.7 ± 187.5 intravenous morphine milligram equivalents vs 120.9 ± 155.5, p < 0.001). On multivariate analysis of PI outcome, TIVA was an independently significant predictor (OR 1.45, p = 0.02), as was anesthesia time (OR per hour increase: 1.09, p = 0.03) and ≥ 8 levels fused (OR 1.86, p = 0.01). CONCLUSIONS: In a large cohort of PSF patients, TIVA was associated with a higher rate of PI compared with inhaled anesthetic. This effect is likely due to higher intraoperative opiate use in these patients.

Neurosurgery at Pearl Harbor: Ralph Cloward's legacy.

Ralph B. Cloward (1908-2000) was the sole neurosurgeon present during the Japanese attack on Pearl Harbor on December 7, 1941. Cloward operated on 42 patients in a span of 4 days during the attacks and was awarded a commendation signed by President Franklin D. Roosevelt in 1945 for his wartime efforts. During the attacks, he primarily treated depressed skull fractures and penetrating shrapnel wounds, but he also treated peripheral nerve and spine injuries in the aftermath. His techniques included innovative advancements such as tantalum cranioplasty plates, electromagnets for intracranial metallic fragment removal, and the application of sulfonamide antibiotic powder within cranial wounds, which had been introduced by military medics for gangrene prevention in 1939 and described for penetrating cranial wounds in 1940. Despite the severity of injuries encountered, only 2 soldiers died in the course of Cloward's interventions. As the sole neurosurgeon in the Pacific Theater until 1944, he remained in Honolulu through World War II's duration and gained immense operative experience through his wartime service. Here, the authors review the history of Cloward's remarkable efforts, techniques, injury patterns treated, and legacy.

Case Series and Systematic Review of Electronic Scooter Crashes and Severe Traumatic Brain Injury.

OBJECTIVE: Electric scooters (e-scooters) are an increasingly popular form of transportation, but their use has also resulted in increased incidence of traumatic brain injury (TBI). Previous reports have predominantly described mild TBI with limited attention to other injury patterns. Our objective was to evaluate the impact of e-scooter use on rates of severe TBI. METHODS: We performed a multicenter retrospective case review of patients who presented with severe TBI (Glasgow Coma Scale score 3-8) related to e-scooter use and undertook a systematic literature review to identify other reports of severe TBI related to e-scooter use. RESULTS: Of the 19 patients (mean age, 38 ± 16 years; 73.7% male) included in the case series, 13 (68.4%) experienced a fall and 6 (31.6%) were involved in a collision. Various cerebral injury patterns, associated craniofacial fractures, and cervical spine injuries were also seen. Twelve patients (63.2%) underwent intracranial pressure monitor placement and 6 (31.6%) underwent a decompressive hemicraniectomy. Most patients (n = 12; 63.2%) were discharged to acute rehabilitation, with a median modified Rankin Scale score of 2 at 4.9 ± 7.7 months follow-up (52.6% had a good outcome of modified Rankin Scale score ≤2), but 4 patients died of primary injuries. The systematic review identified 18 studies with 77,069 patients between 2019 and 2021, with 37 patients who required intensive care and 6 patients who had neurosurgical intervention. CONCLUSIONS: Severe TBI after e-scooter use is associated with high morbidity and is likely underdiagnosed in the literature. Awareness and public policies may be helpful to reduce the impact of injury.

L4 Corpectomy: Surgical Approaches and Mitigating the Risk of Femoral Nerve Injuries.

OBJECTIVE: Because of the challenging anatomic location, corpectomies are performed less often at the fourth lumbar vertebral body than at other levels. Our objective was to review the literature of L4 corpectomy and anterior column reconstruction. METHODS: A literature search in the Medline/PubMed database was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify all relevant cases and cases series describing corpectomies of the L4 vertebral body using "lumbar" AND "corpectomy" as search terms. We present an illustrative case to describe the technique. RESULTS: We identified 18 articles with 30 patients who met the search criteria. Including our case illustration, the most common approach used was the lateral retroperitoneal approach (n = 17, 54.8%), of which 8 (26.7%) were performed via a transpsoas approach. Seven (23%) patients underwent corpectomy through a posterior approach, 4 (12.9%) through an anterior retroperitoneal approach, and 3 (10%) through combined anterior and lateral retroperitoneal. The overall complications rate was 19.3% including 1 case each of femoral nerve injury and iatrogenic lumbar nerve root injury. CONCLUSIONS: Corpectomies of the L4 vertebral body are challenging. None of the various approaches described clearly demonstrates any superiority in mitigating the risk of neural complications. Decision making about which surgical approach to use should be based on patient-specific characteristics.

Laminectomy at T4 and T5 for Resection of Symptomatic Cavernous Malformation.

Although rare, intramedullary spinal cavernous malformations have a 1.4%-6.8% annual hemorrhage risk and can cause significant morbidity.1 Prior hemorrhage and size >1 cm are risk factors for future hemorrhage that, in addition to notable or progressive symptoms, may justify early surgical intervention.1,2 In this video, we present key steps in surgical management of a large, symptomatic thoracic cavernous malformation. A 56-year-old woman presented with worsening lower extremity weakness, imbalance, and difficulty ambulating. Strength was 3/5 in her right lower extremity and 4/5 in her left lower extremity. She had an incomplete T4 sensory level and hyperreflexia. Magnetic resonance imaging demonstrated a heterogeneous "popcorn"-appearing expansile intradural intramedullary 2.2- × 1.2-cm lesion at T4-5, consistent with a cavernous malformation. Angiography was deferred given the characteristic magnetic resonance imaging appearance. Given her progressive symptoms (including weakness), lesion size, and good health, resection was recommended. Using neurological monitoring, a T4-5 laminectomy, midline myelotomy, and piecemeal microsurgical resection of the lesion was performed, clearly identifying the cavernoma-spinal cord interface and avoiding spinal cord retraction. Histopathology confirmed a cavernoma. Postoperatively, the patient had improved left lower extremity strength and stable right lower extremity strength but worsened dorsiflexion (1/5), which improved with rehabilitation. At 1-year follow-up, she had full strength in her left lower extremity and 4/5 in her right lower extremity, with mild paresthesias below T10. Consistent with prior series demonstrating low complication rates and good long-term neurological outcomes,2 microsurgical resection of selected symptomatic intramedullary spinal cavernous malformations can halt neurological decline and potentially improve neurological function.

Preoperative Magnetic Resonance Imaging Abnormalities Predict Symptomatic Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion.

Introduction Anterior cervical discectomy and fusions (ACDFs) are generally limited to the levels causing neurological symptoms, but whether adjacent asymptomatic levels should be included if they demonstrate severe radiographic degeneration is a matter of controversy. We evaluated whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation for symptomatic adjacent-segment degeneration (ASD) after the initial ACDF. Methods We reviewed patients treated with ACDF in 2000-2010 who had MRIs preoperatively and again ≥3 years after the index surgery to evaluate new neurological symptoms. Patients were stratified by ASD severity score, calculated based on MRI features. The associations between preoperative ASD severity score and reoperation for ASD were evaluated with logistic and Cox regressions after adjusting for covariates. Results Of 1038 patients who underwent ACDF, 96 (9%) had MRI evaluation ≥3 years postoperatively (mean follow-up 78 months). Of the 195 adjacent segments evaluated, 14 (7%) were included in subsequent fusion procedures. The 10-year surgery-free survival estimate was 82.7% (73.4-93.2%). After adjusting for covariates, ASD severity scores were predictive of reoperation only for patients with the highest score (hazard ratio [HR] 4.5 [1.0-19.8]) and those with foraminal stenosis (HR 4.2 [.4-12.7]). However, the prevalence of reoperation for ASD in these groups was only 16% and 15%, respectively. Conclusion The prevalence of reoperation for ASD was low for patients who presented with new symptoms ≥3 years after the index ACDF. Our findings do not support including asymptomatic levels in an anterior fusion construct, even if severe MRI abnormalities are present preoperatively.

Clinical Effectiveness of S2-Alar Iliac Screws in Spinopelvic Fixation in Pediatric Neuromuscular Scoliosis: Systematic Literature Review.

STUDY DESIGN: Systematic literature review. OBJECTIVES: To comprehensively review the S2-alar iliac (S2-AI) screw technique for pelvic fixation in pediatric neuromuscular scoliosis. METHODS: Articles identified from the PubMed and EMBASE databases were reviewed for relevance and applicability, and the studies were summarized. RESULTS: Eight articles met the inclusion criteria. A total of 277 pediatric patients underwent spinopelvic fixation using S2-AI fixation for neuromuscular scoliosis; the mean follow-up was 3 years (range = 0.75-6 years). Six articles had level III evidence (5 retrospective cohort studies, 1 observational study), and 2 articles had level IV evidence (case series). Wound complications occurred in 34 (12.2%) patients. Instrumentation complications occurred in 36 patients (13.0%), including lucency around the screw (6.5%), screw fracture (3.6%), disengaging of the set/screw or rod from the tulip head (2.8%), and screw displacement (0.7%). Three patients (1.1%) required reoperation for instrumentation failures. The overall reoperation rate-including 3 hardware replacements and 3 cases of L5-S1 pseudarthrosis-was 2.1%. The mean Cobb angle correction was 51.4°, and the mean pelvic obliquity correction was 14.8°; deformity correction was maintained at 3- and 5-year follow-ups. There were 10 (3.6%) cases of implant prominence/implant-related pain, 1 case of sacroiliac joint pain (resolved with longer screw placement), and no major neurological or vascular complications secondary to S2-AI screw placement. CONCLUSIONS: This review suggests that the use of S2-AI screws in pediatric neuromuscular scoliosis is efficacious with a reasonable safety profile and provides a useful technique for pelvic fixation in children with scoliosis.

Minimally invasive oblique interbody fusion for correction of iatrogenic lumbar deformity.

Spinal instability may arise as a consequence of decompressive lumbar surgery. An oblique lumbar interbody fusion combined with pedicle screw fixation can provide indirect decompression on neural elements, stabilization of mobile spondylolisthesis, and restoration of segmental lordosis. Minimally invasive techniques may facilitate a shorter hospitalization and faster recovery than a traditional open revision operation. The authors describe the use of an anterior interbody fusion via an oblique retroperitoneal approach and posterior pedicle screw fixation to treat a 67-year-old woman who developed L3-4 and L4-5 unstable spondylolisthesis after a lumbar laminectomy. The video can be found here: https://youtu.be/KWwGMIoDrmU.