Patient-specific rods in adult spinal deformity: a systematic review.

PURPOSE: The purpose of this review was to evaluate the effectiveness of patient-specific rods for adult spinal deformity. METHODS: A systematic review of the literature was performed through an electronic search of the PubMed, Scopus, and Web of Science databases. Human studies between 2012 and 2023 were included. Sample size, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), operation time, blood loss, follow-up duration, and complications were recorded for each study when available. RESULTS: Seven studies with a total of 304 adult spinal deformity patients of various etiologies were included. All studies reported SVA, and PT; two studies did not report PI-LL. Four studies reported planned radiographic outcomes. Two found a significant association between preoperative plan and postoperative outcome in all three outcomes. One found a significant association for PI-LL alone. The fourth found no significant associations. SVA improved in six of seven studies, PI-LL improved in all five, and three of seven studies found improved postoperative PT. Significance of these results varied greatly by study. CONCLUSION: Preliminary evidence suggests potential benefits of PSRs in achieving optimal spino-pelvic parameters in ASD surgery. Nevertheless, conclusions regarding the superiority of PSRs over traditional rods must be judiciously drawn, given the heterogeneity of patients and study methodologies, potential confounding variables, and the absence of robust randomized controlled trials. Future investigations should concentrate on enhancing preoperative planning, standardizing surgical methodologies, isolating specific patient subgroups, and head-to-head comparisons with traditional rods to fully elucidate the impact of PSRs in ASD surgery.

Analysis of Personalized Interbody Implants in the Surgical Treatment of Adult Spinal Deformity.

STUDY DESIGN: Multicenter cohort. OBJECTIVES: A report from the International Spine Study Group (ISSG) noted that surgeons failed to achieve alignment goals in nearly two-thirds of 266 complex adult deformity surgery (CADS) cases. We assess whether personalized interbody spacers are associated with improved rates of achieving goal alignment following adult spinal deformity (ASD) surgery. METHODS: ASD patients were included if their surgery utilized 3D-printed personalized interbody spacer(s) and they met ISSG CADS inclusion criteria. Planned alignment was personalized by the surgeon during interbody planning. Planned vs achieved alignment was assessed and compared with the ISSG CADS series that used stock interbodies. RESULTS: For 65 patients with personalized interbodies, 62% were women, mean age was 70.3 years (SD = 8.3), mean instrumented levels was 9.9 (SD = 4.1), and the mean number of personalized interbodies per patient was 2.2 (SD = .8). Segmental alignment was achieved close to plan for levels with personalized interbodies, with mean difference between goal and achieved as follows: intervertebral lordosis = .9° (SD = 5.2°), intervertebral coronal angle = .1° (SD = 4.7°), and posterior disc height = -0.1 mm (SD = 2.3 mm). Achieved pelvic incidence-to-lumbar lordosis mismatch (PI-LL) correlated significantly with goal PI-LL (r = .668, P < .001). Compared with the ISSG CADS cohort, utilization of personalized interbodies resulted in significant improvement in achieving PI-LL <5° of plan (P = .046) and showed a significant reduction in cases with PI-LL >15° of plan (P = .012). CONCLUSIONS: This study supports use of personalized interbodies as a means of better achieving goal segmental sagittal and coronal alignment and significantly improving achievement of goal PI-LL compared with stock devices.

Integrating navigation assistance for redirecting freehanded spinal instrumentation: experience and technique.

Retrospective review of all spinal fusions > 3 levels involving the thoracolumbar and/or sacroiliac at a single institution, by a single surgeon between 3/12/2020 and 8/13/2021 were reviewed. All screws that were secondarily navigated after identified as misdirected on intraoperative CT scan were included. Neuromonitoring reports were culled for mA threshold to triggered EMG response for all redirected screws. Intraoperative, post-de novo screw placement images (fluoroscopy scout and intraoperative CT) and post-redirection intraoperative scoliosis films and post-operative scoliosis films were independently reviewed by a senior neuroradiologist. Fifty redirected screws in the thoracic, lumbar, sacral, and ilium were identified as misdirected and redirected via navigation. The new trajectory of all screws was confirmed satisfactory by independent review between a senior neuroradiologist and neurosurgeon. Four screws could not be verified by post-operative imaging (4/50, 8%). All triggered EMG stimulated > 15 mA. No screws required return to the operating room for revision. No patients experienced a post-operative deficit. Redirection of misdirected thoracolumbar and sacroiliac screws can be performed using intraoperative CT and navigation as a means to detect and directly visualize appropriate placement.

External Validation of the Global Alignment and Proportion Score as Prognostic Tool for Corrective Surgery in Adult Spinal Deformity: A Systematic Review and Meta-Analysis.

BACKGROUND: Since its proposal, the Global Alignment and Proportion (GAP) score has been the topic of several external validation studies, which have yielded conflicting results. Given the lack of consensus regarding this prognostic tool, the authors aim to assess the accuracy of GAP scores for predicting mechanical complications following adult spinal deformity correction surgery. METHODS: A systematic search was performed using PubMed, Embase, and Cochrane Library for the purpose of identifying all studies evaluating the GAP score as a predictive tool for mechanical complications. GAP scores were pooled using a random-effects model to compare patients reporting mechanical complications after surgery versus those reporting no complications. Where receiver operator curves were provided, the area under the curve (AUC) was pooled. RESULTS: A total of 15 studies featuring 2092 patients were selected for inclusion. Qualitative analysis using Newcastle-Ottawa criteria revealed moderate quality among all included studies (5.99/9). With respect to sex, the cohort was predominantly female (82%). The pooled mean age among all patients in the cohort was 58.55 years, with a mean follow-up of 33.86 months after surgery. Upon pooled analysis, we found that mechanical complications were associated with higher mean GAP scores, albeit minimal (mean difference = 0.571 [ 95% confidence interval: 0.163-0.979]; P = 0.006, n = 864). Additionally, age (P = 0.136, n = 202), fusion levels (P = 0.207, n = 358), and body mass index (P = 0.616, n = 350) were unassociated with mechanical complications. Pooled AUC revealed poor discrimination overall (AUC = 0.69; n = 1206). CONCLUSIONS: GAP scores may have a minimal-to-moderate predictive capability for mechanical complications associated with adult spinal deformity correction.

A New Objective Radiographic Criteria for Diagnosis of Adult Idiopathic Scoliosis: Apical Pedicle Diameter Asymmetry.

OBJECTIVE: We sought to test the hypothesis that a difference of ≥1 mm in pedicle diameter between the convex and concave pedicles at the apex of a lumbar curve is a sensitive and/or specific criteria for adult idiopathic scoliosis (AdIS). METHODS: Thirty-nine operative patients with adult deformity and lumbar major curves were identified. A chart review was performed. Radiographic measurements included lumbar Cobb, curve apex, and Cobb levels involved. Apical pedicle diameter at the concavity and convexity of the curve apex were measured. RESULTS: Among these 39 patients, the average Cobb angle was 48.3 degrees. Curve apex averaged at L1/2 (range L1-L3). The curves spanned 4.7 levels (range 3-7). Twenty-five curves had the apex to the left, while 14 had the apex to the right. The average pedicle diameter at the apex was 6.1 mm. Fourteen patients had apical pedicle diameter asymmetry (APDA) >1 mm. Most (7 of 8, or 87.5%) of the patients with a history of adult idiopathic scoliosis had APDA >1 mm. A minority (7 of 31, 22.5%) of patients without known history of adult idiopathic scoliosis had APDA >1 mm (P < 0.01). CONCLUSIONS: Apical pedicle diameter asymmetry is among the sensitive diagnostic criteria for AdIS and may be useful for differentiating lumbar major AdIS from degenerative lumbar scoliosis. The sensitivity of APDA >1 mm is 87.5%, with specificity of 77.4%. We propose a new, sensitive radiographic criterion for adult idiopathic scoliosis. A difference of ≥1 mm in pedicle diameter between the convex and concave pedicles at that apex of a lumbar curve has a sensitivity of 87.5% and specificity of 77.4% for patient-reported history of adolescent scoliosis. It can be a useful tool as exclusion criteria for studies on AdIS.

Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series.

OBJECTIVE: Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established. METHODS: A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March 2020. RESULTS: Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n = 9, 25%), followed by fracture (n = 8, 22.2%), deformity (n = 7, 19.4%), pseudarthrosis (n = 6, 16.7%), and symptomatic lumbar disc herniation (n = 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients. CONCLUSIONS: This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.

360 TOTUM ALIF for a Symptomatic Fractional Curve.

As patient-specific implants become a tool in the spine surgeon's arsenal, understanding how to effectively implement multiple systems in a single surgery requires careful planning. In Video 1, we describe our workflow for a total custom anterior lumbar interbody fusion, featuring patient-specific interbodies and rods. We discuss the required cross talk necessary to ensure maximum desired correction, as well as the logic for pursuing custom devices in this index case. Appropriate consent from the patient was obtained before the procedure.

Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results.

OBJECTIVE: The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results. METHODS: Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to measure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fashion without any fluoroscopic, radiographic, navigational or robotic assistance. RESULTS: Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°-36.3°), lateral vertebral body purchase was 13.4 mm (range, 0-28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9-31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0 ± 4.9 vs. 15.5 ± 4.5, p < 0.001). Three of 73 screws were repositioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, respectively, at an average of 17.5 months postoperative. CONCLUSION: Freehand juxtapedicular screw placement is a safe technique for type D pedicles in adult idiopathic scoliosis patients.

Minimally invasive multiple-rod constructs with robotics planning in adult spinal deformity surgery: a case series.

PURPOSE: Multiple-rod constructs (MRCs) are often used in deformity correction for increased stability and rigidity. There are currently no reports showing minimally invasive placement of MRCs in adult deformity surgery and its technical feasibility through preoperative software planning. METHODS: Data were collected retrospectively from medical records of six consecutive patients who underwent minimally invasive MRCs with robotics planning by a single surgeon at an academic center between March-August 2020. RESULTS: A total of six patients (4 females, mean age 69.7 years) underwent minimally invasive long-segment (6 +) posterior fixation with multiple rods (3 +) using the Mazor X Stealth Edition robotics platform. Average follow-up was 14.3 months. All patients underwent oblique lumbar interbody fusion (OLIF) as a first stage, followed by second stage posterior fixation in the same day. The mean number of levels posteriorly instrumented was 8.8. One patient underwent 3 rod fixation (1 iliac, 2 S2AI) and 5 patients underwent quad rod fixation (2 iliac, 2 S2AI). The mean time to secure all rods was 8 min 36 s. Mean improvement in spinopelvic parameters was -4.9 cm sagittal vertical axis, 18.0° lumbar lordosis, and -10.7° pelvic tilt with an average pelvic incidence of 62.5°. Estimated blood loss (EBL) was 100-250 cc with no blood transfusions, and all but one patient ambulated on postoperative day 1 or 2. CONCLUSION: Spinal robotics brings us into a new era of minimally invasive construct design. To our knowledge, this is the first description of the technical feasibility of MRCs in minimally invasive adult spinal deformity surgery.

Minimally Invasive L5-S1 Oblique Lumbar Interbody Fusion With Simultaneous Robotic Single Position Posterior Fixation: 2-Dimensional Operative Video.

The unique anatomy at L5-S1 presents different challenges and considerations to be made when compared to other areas in the lumbar spine. In this way, the oblique lumbar interbody fusion (OLIF) is more closely related to a supine anterior lumbar interbody fusion (ALIF) except that the former is performed in a lateral position down a smaller minimally invasive retroperitoneal corridor. This lateral positioning at L5-S1, however, provides an opportunity for single-position surgery simultaneously with posterior fixation, which is not afforded by other approaches. We present here a case of a 57-yr-old male with a prior right-sided L5-S1 microdiscectomy who presents with worsening lumbar radiculopathy and foot drop. He subsequently underwent a minimally invasive L5-S1 OLIF with posterior instrumentation placed bilaterally while remaining in a single lateral position (Mazor X Stealth Edition, Medtronic, Dublin, Ireland). Both the anterior OLIF surgeon and posterior instrumentation surgeon were able to work simultaneously. There is currently a need for further high-quality operative videos showing the L5-S1 OLIF technique, and to our knowledge, this is the first video demonstrating a 2-surgeon near-simultaneous workflow approach using a spinal robotics platform at this level. There is no identifying information in this video. A patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

Simultaneous Robotic Single-Position Surgery With Oblique Lumbar Interbody Fusion With Software Planning: 2-Dimensional Operative Video.

The use of robotic guidance for spinal instrumentation is promising for its ability to offer the advantages of precision, accuracy, and reproducibility. This has become even more important in the era of lateral interbody surgery because spinal robotics opens up the possibility of a straightforward workflow for single-position surgery in the lateral position. We present here a case of a 72-yr-old woman who presented with an L4-5 spondylolisthesis with axial back pain and radiculopathy. She subsequently underwent an L4-5 oblique lumbar interbody fusion with L4-5 bilateral posterior instrumentation in a single lateral position (Mazor X Stealth Edition, Medtronic Sofamor Danek, Medtronic Inc, Dublin, Ireland). Due to the oblique lateral approach and posterior robotic assistance, both surgeons were able to work simultaneously for increased efficiency. To our knowledge, this is the first video demonstrating a two-surgeon simultaneous robotic single-position surgery with oblique lumbar interbody fusion using a spinal robotic platform. There is no identifying information in this video. Patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

A new modular radiographic classification of adult idiopathic scoliosis as an extension of the Lenke classification of adolescent idiopathic scoliosis.

PURPOSE: To propose and test the reliability of a radiographic classification system for adult idiopathic scoliosis. METHODS: A three-component radiographic classification for adult idiopathic scoliosis consisting of curve type, a lumbosacral modifier, and a global alignment modifier is presented. Twelve spine surgeons graded 30 pre-marked cases twice, approximately 1 week apart. Case order was randomized between sessions. RESULTS: The interrater reliability (Fleiss' kappa coefficient) for curve type was 0.660 and 0.798, for the lumbosacral modifier 0.944 and 0.965, and for the global alignment modifier 0.922 and 0.916, for round 1 and 2 respectively. Mean intrarater reliability was 0.807. CONCLUSIONS: This new radiographic classification of adult idiopathic scoliosis maintains the curve types from the Lenke classification and introduces the lumbosacral and global alignment modifiers. The reliability of the lumbosacral modifier and global alignment modifier shows near perfect agreement, and sets the foundation for further studies to validate the reliability, utility, and applicability of this classification system.

Predictors of Patient Satisfaction in Spine Surgery: A Systematic Review.

BACKGROUND: Recently, there has been increased interest in patient satisfaction measures such as Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. In this systematic review, the spine surgery literature is analyzed to evaluate factors predictive of patient satisfaction as measured by these surveys. METHODS: A thorough literature search was performed in PubMed/MEDLINE, Google Scholar, and Cochrane databases. All English-language articles from database inception to July 2020 were screened for study inclusion according to PRISMA guidelines. RESULTS: Twenty-four of the 1899 published studies were included for qualitative analysis. There has been a statistically significant increase in the number of publications across years (P = 0.04). Overall, the studies evaluated the relationship between patient satisfaction and patient demographics (71%), preoperative and intraoperative clinical factors (21%), and postoperative factors (33%). Top positive predictors of patient satisfaction were patient and nursing/medical staff relationship (n = 4; 17%), physician-patient relationship (n = 4; 17%), managerial oversight of received care (n = 3; 13%), same sex/ethnicity between patient and physician (n = 2; 8%), and older age (n = 2; 8%). Top negative predictors of patient satisfaction were high Charlson Comorbidity Index/high disability/worse overall health functioning (n = 7; 29%), increased length of hospital stay (n = 4; 17%), high rating for pain/complications/readmissions (n = 4; 17%), and psychosocial factors (n = 3; 13%). CONCLUSIONS: There is heterogeneity in terms of different factors, both clinical and nonclinically related, that affect patient satisfaction ratings. More research is warranted to investigate the role of hospital consumer surveys in the spine surgical patient population.

Evaluating the Clinical Utility and Cost of Imaging Strategies in Adults with Newly Diagnosed Primary Intradural Spinal Tumors.

OBJECTIVE: In patients with new primary intradural spinal tumors, the best screening strategy for additional central nervous system (CNS) lesions is unclear. The goal of this study was to document the rate of additional CNS tumors in these patients. METHODS: Adults with primary intradural spinal tumors were retrospectively reviewed. Imaging strategy at diagnosis was classified as focused spine (cervical, thoracic, or lumbar), total spine, or complete neuraxis (brain and total spine). Tumor pathology, genetic syndromes, and presence of additional CNS lesions at diagnosis or follow-up were collected. RESULTS: The study comprised 319 patients with mean age of 51 years and mean follow-up of 41 months. In 151 patients with focused spine imaging, 3 (2.0%) were found to have new lesions with 2 (1.4%) requiring treatment. In 35 patients with total spine imaging, there were no additional lesions. In 133 patients with complete neuraxis imaging, 4 (3.0%) were found to have new lesions with 2 (1.5%) requiring treatment. There was no difference in the identification of new lesions (P = 0.542) or new lesions requiring treatment (P = 0.772) across imaging strategies. Among patients without genetic syndromes, rates of new lesions requiring treatment were 1.4% for focused spine, 0% for total spine, and 2.2% for complete neuraxis (P = 0.683). There were no cases of delayed identification causing risk to life or neurological function. Complete neuraxis imaging carried an increased charge of $4420 per patient. CONCLUSIONS: Among patients without an underlying genetic syndrome, the likelihood of identifying additional CNS lesions requiring treatment is low. In appropriate cases, focused spine imaging may be a more cost-effective strategy.

Does the Global Alignment and Proportion score overestimate mechanical complications after adult spinal deformity correction?

OBJECTIVE: The goal of this study was to validate the Global Alignment and Proportion (GAP) score in a cohort of patients undergoing adult spinal deformity (ASD) surgery. The GAP score is a novel measure that uses sagittal parameters relative to each patient's lumbosacral anatomy to predict mechanical complications after ASD surgery. External validation is required. METHODS: Adult ASD patients undergoing > 4 levels of posterior fusion with a minimum 2-year follow-up were included. Six-week postoperative standing radiographs were used to calculate the GAP score, classified into a spinopelvic state as proportioned (P), moderately disproportioned (MD), or severely disproportioned (SD). A chi-square analysis, receiver operating characteristic curve, and Cochran-Armitage analysis were performed to assess the relationship between the GAP score and mechanical complications. RESULTS: Sixty-seven patients with a mean age of 52.5 years (range 18-75 years) and a mean follow-up of 2.04 years were included. Patients with < 2 years of follow-up were included only if they had an early mechanical complication. Twenty of 67 patients (29.8%) had a mechanical complication. The spinopelvic state breakdown was as follows: P group, 21/67 (31.3%); MD group, 23/67 (34.3%); and SD group, 23/67 (34.3%). Mechanical complication rates were not significantly different among all groups: P group, 19.0%; MD group, 30.3%; and SD group, 39.1% (χ2 = 1.70, p = 0.19). The rates of mechanical complications between the MD and SD groups (30.4% and 39.1%) were less than those observed in the original GAP study (MD group 36.4%-57.1% and SD group 72.7%-100%). Within the P group, the rates in this study were higher than in the original study (19.0% vs 4.0%, respectively). CONCLUSIONS: The authors found no statistically significant difference in the rate of mechanical complications between the P, MD, and SD groups. The current validation study revealed poor generalizability toward the authors' patient population.

The effect of anterior lumbar interbody fusion staging order on perioperative complications in circumferential lumbar fusions performed within the same hospital admission.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions. METHODS: The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed. RESULTS: A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different. CONCLUSIONS: In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.

Occipitocervical Fixation: General Considerations and Surgical Technique.

STUDY DESIGN: Narrative literature review. OBJECTIVE: To review and present details on the occipitocervical fixation (OCF) technique as well as considerations for planning the procedure. METHODS: We present the surgical technique of OCF in a step-by-step didactic and practical manner with surgical tips and tricks, including C1 and C2 screw fixation techniques. Additionally, we discuss complications, the extension of fusion, types of OCF, and how to avoid common side effects associated with OCF. RESULTS: The complex and mobile anatomy of the craniocervical junction, when requiring fixation and fusion, warrants rigid instrumentation that can be achieve using a modern screw-plate-rod construct. Indications for OCF are craniocervical instability, and atlantoaxial instability when selective atlantoaxial fusion is not feasible. OCF generally involves occiput-C2 fusion. C1 fixation is generally unnecessary, since it increases the surgical time and is associated with the risk of vascular complications. Selective occiput-C2 fusion is recommended when there is no need for including the cervical subaxial region (eg, when stenosis or fractures coexist in the subaxial spine), and good fixation is achieved at C2. Most instrumentation systems now have occipital plates that are not pre-integrated to rods, making fixation much simpler. Surgical steps, from position to wound closure, are presented in detail, with pearls for practice and discussion of cervical alignment. CONCLUSIONS: OCF is a challenging procedure, with potential risk of severe adverse effects. Understanding the surgical indications, as well as the nuances of the surgical technique, is required to improve patient outcomes and avoid complications.

Quad S2-Alar-Iliac Screw Fixation via Navigated Spinal Robotics With Software Planning: 2-Dimensional Operative Video.

The use of robotic guidance for spinal instrumentation has become promising for its ability to offer the advantages of precision, accuracy, and reproducibility. However, utilization and adoption of robotic platforms for spine surgery remain limited especially in comparison to other surgical fields. We present here a case of a 71-yr-old man with a prior T4-pelvis long-segment fusion who presented with distal sacro-iliac instrumentation loosening with pseudarthrosis. He subsequently underwent construct revision with quad (bilateral dual) S2-alar-iliac screw fixation with navigated spinal robotic assistance (Mazor X Stealth Edition, Medtronic Sofamor Danek, Medtronic Inc, Dublin, Ireland). To our knowledge, this is the first video demonstrating the preoperative software planning and intraoperative workflow for placing quad S2-alar-iliac screws with navigated spinal robotic guidance using the Mazor X Stealth Edition. There is no identifying information in this video. Patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.