What is the early fate of adjacent segmental lordosis compensation at L3-4 and L5-S1 following a lateral versus transforaminal lumbar Interbody Fusion at L4-5?

INTRODUCTION: Degenerative spondylolisthesis causes translational and angular malalignment, resulting in a loss of segmental lordosis. This leads to compensatory adjustments in adjacent levels to maintain balance. Lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF) are common techniques at L4-5. This study compares compensatory changes at adjacent L3-4 and L5-S1 levels six months post LLIF versus TLIF for grade 1 degenerative spondylolisthesis at L4-5. METHODS: A retrospective study included patients undergoing L4-5 LLIF or TLIF with posterior pedicle screw instrumentation (no posterior osteotomy) for grade 1 spondylolisthesis. Pre-op and 6-month post-op radiographs measured segmental lordosis (L3-L4, L4-L5, L5-S1), lumbar lordosis (LL), and pelvic incidence (PI), along with PI-LL mismatch. Multiple regressions were used for hypothesis testing. RESULTS: 113 patients (61 LLIF, 52 TLIF) were studied. TLIF showed less change in L4-5 lordosis (mean = 1.04°, SD = 4.34) compared to LLIF (mean = 4.99°, SD = 5.53) (p = 0.003). L4-5 angle changes didn't correlate with L3-4 changes, and no disparity between LLIF and TLIF was found (all p > 0.16). In LLIF, greater L4-5 lordosis change predicted reduced compensatory L5-S1 lordosis (p = 0.04), while no significant relationship was observed in TLIF patients (p = 0.12). CONCLUSION: LLIF at L4-5 increases lordosis at the operated level, with compensatory decrease at L5-S1 but not L3-4. This reciprocal loss at adjacent L5-S1 may explain inconsistent improvement in lumbar lordosis (PI-LL) post L4-5 fusion.

Correction of cervical kyphoscoliosis, bisected spinal cord, and vertebral artery to epidural vein fistula in neurofibromatosis type 1.

Neurofibromatosis-1 (NF1) presents complex challenges due to its multisystemic effects, including kyphoscoliosis, dural ectasia, and arteriovenous fistulas (AVF). We present a case of a 31-year-old male with NF1 exhibiting severe cervical kyphoscoliosis, dural ectasia, a bisected cervical cord, and an arteriovenous fistula, highlighting the intricacies of managing such intricate cases. Rapid weakening in the patient's right arm and leg prompted imaging revealing severe cervical kyphotic deformity and a dural fold dividing the spinal cord. Surgical intervention addressed a high-flow arteriovenous fistula involving the right vertebral artery and an epidural vein, necessitating sacrifice of the artery. Posterior fusion and laminectomy were performed, resulting in stable neurological status postoperatively and significant improvement in sensory loss and weakness at three months. This case underscores the importance of a tailored posterior-only approach, involving dural fold release, to allow the spinal cord to relocate to a less tense position, thus demonstrating effective decompression in complex NF1 cases with concurrent kyphotic deformity and vertebral artery AVF.

Transdural retrieval of retropulsed transforaminal lumbar interbody fusion cages.

Transforaminal lumbar interbody fusions (TLIFs) are performed for various lumbar spine pathologies. Posterior migration of an interbody cage is a complication that may result in neurologic injury and require reoperation. Sparse information exists regarding the safety and efficacy of a transdural approach for cage retrieval. We describe a surgical technique, in which centrally retropulsed cages were safely retrieved transdurally. A patient with prior L3-S1 posterior lumbar fusion and L4-S1 TLIFs presented with radiculopathy and weakness in dorsiflexion. Imaging revealed posterior central migration of TLIF cages causing compression of the traversing L5 nerve root. Cages were removed transdurally; the correction was performed with an all-posterior T10-pelvis fusion. Aside from temporary weakness in right-sided dorsiflexion, the patient experienced complete resolution in their radiculopathy and strength returned to its presurgical state by 3 months. The transdural approach for interbody removal can be safely performed and should be a tool in the spine surgeon's armamentarium.

The Limits of Earthquake Early Warning Accuracy and Best Alerting Strategy.

We explore how accurate earthquake early warning (EEW) can be, given our limited ability to forecast expected shaking even if the earthquake source is known. Because of the strong variability of ground motion metrics, such as peak ground acceleration (PGA) and peak ground velocity (PGV), we find that correct alerts (i.e., alerts that accurately estimate the ground motion will be above a predetermined damage threshold) are not expected to be the most common EEW outcome even when the earthquake magnitude and location are accurately determined. Infrequently, ground motion variability results in a user receiving a false alert because the ground motion turned out to be significantly smaller than the system expected. More commonly, users will experience missed alerts when the system does not issue an alert but the user experiences potentially damaging shaking. Despite these inherit limitations, EEW can significantly mitigate earthquake losses for false-alert-tolerant users who choose to receive alerts for expected ground motions much smaller than the level that could cause damage. Although this results in many false alerts (unnecessary alerts for earthquakes that do not produce damaging ground shaking), it minimizes the number of missed alerts and produces overall optimal performance.

The limits of earthquake early warning: Timeliness of ground motion estimates.

The basic physics of earthquakes is such that strong ground motion cannot be expected from an earthquake unless the earthquake itself is very close or has grown to be very large. We use simple seismological relationships to calculate the minimum time that must elapse before such ground motion can be expected at a distance from the earthquake, assuming that the earthquake magnitude is not predictable. Earthquake early warning (EEW) systems are in operation or development for many regions around the world, with the goal of providing enough warning of incoming ground shaking to allow people and automated systems to take protective actions to mitigate losses. However, the question of how much warning time is physically possible for specified levels of ground motion has not been addressed. We consider a zero-latency EEW system to determine possible warning times a user could receive in an ideal case. In this case, the only limitation on warning time is the time required for the earthquake to evolve and the time for strong ground motion to arrive at a user's location. We find that users who wish to be alerted at lower ground motion thresholds will receive more robust warnings with longer average warning times than users who receive warnings for higher ground motion thresholds. EEW systems have the greatest potential benefit for users willing to take action at relatively low ground motion thresholds, whereas users who set relatively high thresholds for taking action are less likely to receive timely and actionable information.