Risk factors for L5 pedicle fractures after single-level posterior spinal fusion.

BACKGROUND CONTEXT: Pedicle fractures are a rare but potentially devastating complication of posterior instrumented spinal fusion (PSF). Preoperative awareness of the possible risk factors may help prevent these fractures by modifying the surgical plan. However, the risk factors have not yet been identified. PURPOSE: To determine the preoperative parameters associated with postoperative L5 pedicle fracture after L4/5 PSF. STUDY DESIGN: Case control study. PATIENT SAMPLE: Patients undergoing L4/5 PSF at a single academic institution between 2014 and 2020. OUTCOME MEASURES: Occurrence of postoperative L5 pedicle fracture. METHODS: Of 253 patients (female:male, 145:108) undergoing L4/5 PSF from 2014 to 2020, patients with postoperative L5 pedicle fractures were identified retrospectively as "cases" (n = 8, all female, age: 70 ± 10.7 years). As a control group all remaining patients with a follow-up of more than 12 months were allocated (n = 184, 104 females, age: 64.27 ± 13.00 years). In all but 16 cases, anterior support with transforaminal or posterior interbody fusion was performed. Demographic and clinical data (body mass index (BMI)), surgical factors, and comorbidities) were compared. Radiological assessment of spinopelvic parameters was performed using pre- and postoperative standing lateral radiographs. RESULTS: The overall incidence of L5 pedicle fractures after L4/5 spinal fusion was 3.16%, with a median time from index surgery to diagnosis of 25 days (range, 6-199 days) (75% within the first 32 days postoperatively). Patients with L5 pedicle fractures had higher pelvic incidence (PI) (71° ± 9° vs. 56° ± 11°; p=.001), sacral slope (SS) (45° ± 7° vs. 35° ± 8°; p=.002), L5 slope (30° ± 11° vs. 15° ± 10°, p=.001), L5 incidence (42° ± 14° vs. 26° ± 11°; p= .003), L1-S1 lumbar lordosis (LL) postop (57° ± 10° vs. 45° ± 11°; p=.006), and L4 -S1 LL postop (33° ± 7° vs. 28° ± 7°; p=.049) compared with the control group. Pelvic tilt and PI- LL mismatch were not significantly different. Female gender was a significant risk factor for L5 pedicle fractures (p=.015). BMI (kg/m2) was statistically equal in patients with or without pedicle fractures (28.37 ± 5.96 vs. 28.53 ± 16.32; p=.857). There was no significant difference between the groups for approximative bone mineral density assessment (Hounsfield units; 113 ± 60 vs. 120 ± 43; p=.396) using the L3 trabecular region of interest (ROI) measurement. The correlation analysis demonstrated that most of the identified risk factors except for the postoperative L4-S1 lordosis show significant positive associations among each other. All eight patients in the fracture group underwent revision surgery, and the instrumented fusion was extended to the sacrum, with the addition of sacral-alar-iliac or iliac screws, in six cases. CONCLUSIONS: L5 pedicle fractures occurred in 3% of the patients after single level L4/5 PSF. Risk factors are female gender, higher PI, SS, L5 slope, L5 incidence, and LL postop but not high BMI. These findings can be used for surgical planning and decision of fusion levels.

Multilayer Mattress Stitches for Complicated Wounds in Spine Surgery.

INTRODUCTION: Local infection and prolonged fluid discharge account for most complications in lumbar spine surgery. This report is a brief description of a useful technique for revision of complicated, draining wounds with surprisingly positive results that otherwise frequently require multiple surgical interventions. TECHNICAL NOTE: We describe the postoperative course of three patients, with prolonged and continuous serosanguineous discharge from the skin incision, who underwent wound revision with multilayered mattress stitches after open decompressive or instrumented spinal surgery. For this purpose, a thick monofilament suture is passed through the skin, subcutaneous fatty tissue, and paravertebral muscle in the fashion of a vertical mattress stitch while the loop above the skin level is augmented using a soft silicone capillary drainage to distribute tension along the wound margin. CONCLUSIONS: None of the patients treated with the multilayered mattress stitches required further surgical intervention. In this small case series, the multilayered mattress stitches augmented with soft silicone tubing were a useful technique for treating complicated lumbar surgical wounds with prolonged serosanguineous discharge.

Augmented Reality Navigated Sacral-Alar-Iliac Screw Insertion.

BACKGROUND: Sacral-alar-iliac (SAI) screws are increasingly used for lumbo-pelvic fixation procedures. Insertion of SAI screws is technically challenging, and surgeons often rely on costly and time-consuming navigation systems. We investigated the accuracy and precision of an augmented reality (AR)-based and commercially available head-mounted device requiring minimal infrastructure. METHODS: A pelvic sawbone model served to drill pilot holes of 80 SAI screw trajectories by 2 surgeons, randomly either freehand (FH) without any kind of navigation or with AR navigation. The number of primary pilot hole perforations, simulated screw perforation, minimal axis/outer cortical wall distance, true sagittal cranio-caudal inclination angle (tSCCIA), true axial medio-lateral angle, and maximal screw length (MSL) were measured and compared to predefined optimal values. RESULTS: In total, 1/40 (2.5%) of AR-navigated screw hole trajectories showed a perforation before passing the inferior gluteal line compared to 24/40 (60%) of FH screw hole trajectories (P < .05). The differences between FH- and AR-guided holes compared to optimal values were significant for tSCCIA with -10.8° ± 11.77° and MSL -65.29 ± 15 mm vs 55.04 ± 6.76 mm (P = .001). CONCLUSIONS: In this study, the additional anatomical information provided by the AR headset and the superimposed operative plan improved the precision of drilling pilot holes for SAI screws in a laboratory setting compared to the conventional FH technique. Further technical development and validation studies are currently being performed to investigate potential clinical benefits of the AR-based navigation approach described here. LEVEL OF EVIDENCE: 4.

No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial.

PURPOSE: Incidental durotomy (ID) is a complication occurring in 4-17% of decompressive spinal surgeries. Persisting CSF leakage can occur even after ID repair and requires revision surgery. Prolonged flat bed rest (BR) to reduce the incidence of persisting CSF leakage is frequently applied but highly debated. A randomized controlled trial comparing prolonged BR versus early ambulation after ID repair is lacking. The aim of this study was to investigate the incidence of revision surgery as a result of persistent cerebro-spinal fluid (CSF) leakage and medical complications after immediate or late post-operative ambulation following ID during decompressive spinal surgery. METHODS: Ninety-four of 1429 consecutive cases undergoing lumbar spine surgery (6.58%) were complicated by an ID. Sixty patients (mean age of 64 ± 13.28 years) were randomized to either early post-operative ambulation (EA, n = 30) or flat BR for 48 h (BR, n = 30). The incidence of CSF leakage resulting in revision surgery, medical complications and duration of hospitalization were compared between groups. RESULTS: Two patients in the BR group and two patients in the EA group underwent revision surgery as a result of persisting CSF leakage. Four patients in the BR group experienced medical complications associated with prolonged immobilization. The duration of hospitalization was 7.25 ± 3.0 days in the BR group versus 6.56 ± 2.64 days in the EA group, p = 0.413. CONCLUSION: The results of this study indicate no benefit of prolonged BR after an adequately repaired ID in lumbar spine surgery. LEVEL OF EVIDENCE: Level 1b (individual randomized controlled trial). These slides can be retrieved under Electronic Supplementary Material.

Classification of perioperative complications in spine surgery.

BACKGROUND CONTEXT: Perioperative complications affect surgical outcomes. Classification systems of perioperative complications are well established and widely applied in many surgical fields other than spine surgery. PURPOSE: The aim of this study was to construct and validate a comprehensive classification system for perioperative complications in spine surgery. STUDY DESIGN: Retrospective case series. METHODS: A comprehensive classification system was constructed to stratify complications in spinal surgery and consequently applied to 934 patients who consecutively underwent spine surgery in a university hospital setting. A complication was defined as any kind of deviation from the normal perioperative course, ranging from a postoperative anemia to death. The comprehensive classifications system stratifies complications according to (1) complexity of index procedure (2) immediate cause of complication (surgical vs. medical) (3) the required treatment, and (4) potentially associated long-term functional deficits resulting from neural injury. Subsequently, the proposed classification system was validated by applying the duration of cumulative hospital stay as the primary outcome. RESULTS: Perioperative complications were recorded in 135 (14.3%) out of 934 cases. There was a significant difference in the hospital stay between complications stratified according to therapeutic consequences, grade A: 5.6±1.6 (range: 3-8) days, grade B: 7.9±3.8 (range: 3-21) days, grade C: 13.1±8.1 (range: 4-59) days, and grade D: 55.2±56.6 (range: 14-198) days, respectively (p≤.001). Also, there was a significant difference in hospital stay between groups of increasing point difference of neurologic deficit, 0 versus -1 and -1 versus -2, respectively. CONCLUSION: A comprehensive classification system for perioperative complications in spine surgery (considering four categories) is presented and validated. The categories therapeutic consequence (A-E) and decrease in neurological function correlate strongly with hospital stay.

Assessing the Impact of Color Normalization in Convolutional Neural Network-Based Nuclei Segmentation Frameworks.

Image analysis tools for cancer, such as automatic nuclei segmentation, are impacted by the inherent variation contained in pathology image data. Convolutional neural networks (CNN), demonstrate success in generalizing to variable data, illustrating great potential as a solution to the problem of data variability. In some CNN-based segmentation works for digital pathology, authors apply color normalization (CN) to reduce color variability of data as a preprocessing step prior to prediction, while others do not. Both approaches achieve reasonable performance and yet, the reasoning for utilizing this step has not been justified. It is therefore important to evaluate the necessity and impact of CN for deep learning frameworks, and its effect on downstream processes. In this paper, we evaluate the effect of popular CN methods on CNN-based nuclei segmentation frameworks.

Paternal Exposure to Carbamazepine Impacts Zebrafish Offspring Reproduction Over Multiple Generations.

Chronic low-concentration chemical exposures may have both direct health outcomes on adults and indirect effects on their offspring. Using zebrafish, we examined the impacts of chronic, low-concentration carbamazepine (CBZ) exposure on a suite of male reproductive endpoints in the parents and four generations of offspring reared in clean water. CBZ is one of the most frequently detected pharmaceutical residues in water, is a histone deacetylase inhibitor in mammals, and is reported to lower androgens in mammals and fish. Exposure of adult zebrafish to 10 µg/L CBZ for 6 weeks decreased reproductive output, courtship and aggressive behaviors, 11-ketotestosterone (11KT), and sperm morphology but did not impact milt volume or sperm swimming speed. Pairwise breeding generated lineages of offspring with both parents exposed and two lineages where only one parent was exposed; the control lineage had unexposed parents. Reproductive output and male reproductive indices were assessed in F1-F4 offspring to determine whether parental CBZ exposure had transgenerational impacts. The offspring of CBZ-exposed males had lower 11KT, reproductive output, altered courtship, aggression, and sperm morphology compared to the lineage from unexposed parents. Our results indicate that parental carbamazepine exposure history impacts the unexposed progeny up to the F4 generations and that paternal, but not maternal, exposure is most important for the reproductive health of male offspring.

Conventional Versus Computer-Assisted Corrective Osteotomy of the Forearm: a Retrospective Analysis of 56 Consecutive Cases.

PURPOSE: Accuracy and feasibility of corrective osteotomies using 3-dimensional planning tools and patient-specific instrumentation has been reported by multiple authors with promising results. However, studies describing clinical outcomes following these procedures are rare. Therefore, the purpose of this study was to compare the results of computer-assisted corrective osteotomies of the diaphyseal and distal radius with a conventional non-computer-assisted technique regarding duration of surgery, consolidation of the osteotomy, and complications. Also, subjective and objective clinical outcome parameters were assessed. METHODS: We retrospectively compared the results of 31 patients who underwent a corrective osteotomy performed conventionally with 25 patients treated with a computer-assisted method (CA) using patient-specific instrumentation. Baseline data were similar among both groups. The duration of surgery, bony consolidation, complications, gain in range of motion, and subjective outcome were recorded. RESULTS: The mean operating time was significantly shorter in the CA group compared with the conventional group. After 12 weeks, significantly more osteotomies were considered healed in the CA group compared with the conventional group. Two patients in the CA group required revision surgery to treat nonunion of the osteotomy. Otherwise clinical results were similar among both groups. CONCLUSIONS: The results demonstrate that the computer-assisted method facilitates shorter operation times while providing similar clinical results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.