Is the routine use of systemic antibiotics after spine surgery warranted? A systematic review and meta-analysis.

PURPOSE: To determine whether the published literature supports the current practice of utilizing antibiotics postoperatively in spine surgery. METHODS: A systematic review from PubMed and Cochrane Central Register of Controlled trials databases was performed. Search terms used: "Antibiotic Prophylaxis"[Mesh], antibiotic*, antibacterial*, "Spine"[Mesh], "Surgical Procedures, Operative"[Mesh]. Only comparative, clinical studies were included. Those studies with surgical site infection (SSI) criteria that were not similar to the CDC definition were excluded. A meta-analysis for overall SSI was performed. A subgroup analysis was also performed to analyze the outcomes specifically on instrumented groups of patients. A random-effects model was used to calculate risk ratios (RR). Forest plots were used to display RR and 95% confidence intervals (CI). RESULTS: Thirteen studies were included (four Randomized-Controlled Trials, three prospective cohorts, and six retrospective). Three different perioperative strategies were used in the selected studies: Group 1: preoperative antibiotic administration (PreopAbx) versus PreopAbx and any type of postoperative antibiotic administration (Pre + postopAbx) (n = 6 studies; 7849 patients); Group 2: Pre + postopAbx ≤ 24 h versus Pre + postopAbx > 24 h (n = 6; 1982); and Group 3: Pre + postopAbx ≤ 48 h versus. Pre + postopAbx ≤ 72 h (n = 1; 502). The meta-analysis performed on Groups 1 and 2 did not show significant effects (RR = 1.27, 95% CI = 0.77, 2.09, and RR = 0.97, 95% CI = 0.64, 1.46, respectively). CONCLUSION: A meta-analysis and comprehensive review of the literature show that the routine use of postoperative antibiotics in spine surgery may not be effective in preventing surgical site infections.

Myofascial Flap Closure Decreases Complications in Complex Surgery of the Craniocervical Junction in Ehlers-Danlos Patients.

INTRODUCTION: Patients with Ehlers-Danlos syndrome (EDS) are at elevated risk for soft tissue complications when undergoing decompression with or without fusion of the craniocervical junction. We have previously shown that muscle flap closure can decrease reoperative rates. This study investigated whether myofascial flap closure improved clinical outcomes after simple or complex surgery of the craniocervical junction in EDS patients specifically. METHODS: We performed a retrospective chart review of EDS patients who had undergone surgery for Chiari malformation at the Weill Cornell Medical Center between 2013 and 2020. Postoperative complications were recorded, including infection, wound dehiscence, seroma, hematoma, hardware removal, cerebrospinal fluid (CSF) leak, reoperation, and pseudomeningocele. Patients were stratified by type of closure and type of surgery. Fisher exact test was used for statistical comparison. RESULTS: Between 2013 and 2020, 62 EDS patients who had surgery of the cervicocranial junction were reviewed. Of these, 31 patients had complex surgery with myofascial flap closure and 22 had simple surgery with traditional closure. The mean age at the time of surgery was 21.3 years. There were no significant differences in wound complications or reoperation rates between the simple surgery and complex surgery groups. In addition, there were no significant differences in complications between complex surgery with flap closure and simple surgery with traditional closure. Our CSF cutaneous fistula rate was 0%, considerably lower than rates reported in the literature, and, in one case, a patient developed a postoperative pseudomeningocele secondary to a dural leak, but the myofascial flap closure prevented its progression. CONCLUSIONS: Patients with EDS undergoing surgery of the cervicocranial junction may benefit from myofascial flap closure. Flap closure reduced complications after complex surgery of the craniocervical junction to the level of simple surgery. Our CSF leak rate was exceptionally low and only one patient experienced pseudomeningocele. Myofascial flaps are safe to perform in the EDS cohort and prevented CSF cutaneous fistula formation.

Myofascial Flap Closure in Treatment for Patients With Craniocervical Instability and Ehlers-Danlos Syndrome.

INTRODUCTION: The benefits of decompression and fusion for patients with craniocervical instability are well described. However, complications such as wound breakdown and need for unplanned reoperation frequently occur. Recent studies have shown advantages of myofascial flap closure for various spinal procedures. This study investigated whether closure with myofascial flaps after surgery for craniocervical instability decreases complications with further subgroup analysis of patients with Ehlers-Danlos syndrome (EDS). METHODS: A retrospective review of patients presenting to Weill Cornell Medical Center from 2010 to 2017 for craniocervical surgery was performed. All patients who underwent craniocervical surgery, regardless of plastic surgical involvement, were included in the study. Data including patient demographics, comorbidities, EDS diagnosis, surgical history, complications, and follow-up information were collected and analyzed. RESULTS: Data from 57 patients were analyzed. Eighteen patients (31.6%) had craniocervical surgery without myofascial flap closure, whereas 39 (68.4%) had surgery with flap closure. In the nonflap group, 9 patients required unplanned reoperation (50%). In the flap group, there were 5 patients requiring unplanned reoperation (15%). For reoperation, the Fisher exact test 2-tailed P value is 0.0096. Of those 57 patients, 24 had EDS: 5 (20.8%) had no flap closure, whereas 19 (79.2%) had flap closure. In the no-flap group, 3 patients required unplanned reoperation (60%). In the flap group, 5 patients required unplanned reoperation (21%). For reoperation, the Fisher exact test 2-tailed P value is 0.1265. CONCLUSIONS: Patients undergoing surgery for craniocervical instability may benefit from myofascial flap closure even if they have EDS. Mobilizing well-vascularized tissue can decrease rates of reoperation.

Instrumented arthrodesis for non-traumatic craniocervical instability in very young children.

PURPOSE: Occipitocervical instrumentation is infrequently required for stabilization of the axial and subaxial cervical spine in very young children. However, when it is necessary, unique surgical considerations arise in children when compared with similar procedures in adults. METHODS: The authors reviewed literature describing fusion of the occipitocervical junction (OCJ) in toddlers and share their experience with eight cases of young children (age less than or equal to 4 years) receiving occiput to axial or subaxial spine instrumentation and fixation. Diagnoses and indications included severe or secondary Chiari malformation, skeletal dysplastic syndromes, Klippel-Feil syndrome, Pierre Robin syndrome, Gordon syndrome, hemivertebra and atlantal occipitalization, basilar impression, and iatrogenic causes. RESULTS: All patients underwent occipital bone to cervical spine instrumentation and fixation at different levels. Constructs extended from the occiput to C2 and T1 utilizing various permutations of titanium rods, autologous rib autografts, Mersilene sutures, and combinations of autografts with bone matrix materials. All patients were placed in rigid cervical bracing or halo fixation postoperatively. No postoperative neurological deficits or intraoperative vascular injuries occurred. CONCLUSION: Instrumented arthrodesis can be a treatment option in very young children to address the non-traumatic craniocervical instability while reducing the need for prolonged external halo vest immobilization. Factors affecting fusion are addressed with respect to preoperative, intraoperative, and postoperative decision-making that may be unique to the toddler population.

A comprehensive review of the diagnosis and management of congenital scoliosis.

PURPOSE: To provide the reader with a comprehensive but concise understanding of congenital scoliosis METHODS: We have undertaken to summarize available literature on the pathophysiology, epidemiology, and management of congenital scoliosis. RESULTS: Congenital scoliosis represents 10% of pediatric spine deformity and is a developmental error in segmentation, formation, or a combination of both leading to curvature of the spine. Treatment options are complicated by balancing growth potential with curve severity. Often associated abnormalities of cardiac, genitourinary, or intraspinal systems are concurrent and should be evaluated as part of the diagnostic work-up. Management balances the risk of progression, growth potential, lung development/function, and associated risks. Surgical treatment options involve growth-permitting systems or fusions. CONCLUSION: Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.

Evaluation and management of adolescent idiopathic scoliosis: a review.

Adolescent idiopathic scoliosis (AIS) is a 3D spinal deformity affecting children between the ages of 11 and 18, without an identifiable etiology. The authors here reviewed the available literature to provide spine surgeons with a summary and update on current management options. Smaller thoracic and thoracolumbar curves can be managed conservatively with observation or bracing, but corrective surgery may be indicated for rapidly growing or larger curves. The authors summarize the atypical features to look for in patients who may warrant further investigation with MRI during diagnosis and review the fundamental principles of the surgical management of AIS. Patients with AIS can be managed very well with a combination of conservative and surgical options. Outcomes for these children are excellent with sustained longer-term results.

Residual neurological function after sacral root resection during en-bloc sacrectomy: a systematic review.

PURPOSE: Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss of important function depending on the resection level and nerve roots sacrificed. The current literature regarding residual function after sacral resection comes from several small case series. The goal of this review is to appraise residual motor function and gait, sensitivity, bladder, bowel, and sexual function after sacrectomies, with consideration to the specific roots sacrificed. METHODS: An exhaustive literature search was conducted. All manuscripts published before May 2015 regarding residual function after sacrectomy were considered; if a clear correlation between root level and functioning was not present, the paper was excluded. The review identified 15 retrospective case series, totaling 244 patients; 42 patients underwent sacrectomies sparing L4/L4, L4/L5 and L5/L5; 45 sparing both L5 and one or both S1 roots; 8 sparing both S1 and one S2; 48 sparing both S2; 11 sparing both S2 and one S3, 54 sparing both S3, 9 sparing both S3 and one or both S4, and 27 underwent unilateral variable resection. RESULTS: Patients who underwent a sacrectomy maintained functionally normal ambulation in 56.2 % of cases when both S2 roots were spared, 94.1 % when both S3 were spared, and in 100 % of more distal resections. Normal bladder and bowel function were not present when both S2 were cut. When one S2 root was spared, normal bladder function was present in 25 % of cases; when both S2 were spared, 39.9 %; when one S3 was spared, 72.7 %; and when both S3 were spared, 83.3 %. Abnormal bowel function was present in 12.5 % of cases when both S1 and one S2 were spared; in 50.0 % of cases when both S2 were spared; and in 70 % of cases when one S3 was spared; if both S3 were spared, bowel function was normal in 94 % of cases. When even one S4 root was spared, normal bladder and bowel function were present in 100 % of cases. Unilateral sacral nerve root resection preserved normal bladder function in 75 % of cases and normal bowel function in 82.6 % of cases. Motor function depended on S1 root involvement. CONCLUSION: Total sacrectomy is associated with compromising important motor, bladder, bowel, sensitivity, and sexual function. Residual motor function is dependent on sparing L5 and S1 nerve roots. Bladder and bowel function is consistently compromised in higher sacrectomies; nevertheless, the probability of maintaining sufficient function increases progressively with the roots spared, especially when S3 nerve roots are spared. Unilateral resection is usually associated with more normal function. To the best of our knowledge, this is the first comprehensive literature review to analyze published reports of residual sacral nerve root function after sacrectomy.

The Tokuhashi score: effectiveness and pitfalls.

PURPOSE: Accurate survival estimation is prerequisite to determine the most appropriate treatment for patients with metastatic spine disease. Several authors have proposed classification systems analyzing clinical and radiological parameters, such as, performance status, metastasis localization, and primary tumor histotype, but the modified Tokuhashi score (mTS) is the most widely used. Although it is regarded as one of the most complete and accurate systems, it does not take the effectiveness of new therapeutic strategies into consideration, contributing to a progressive loss of accuracy. The purpose of this review is to verify the ability of the mTS to accurately estimate metastatic spine patient survival, nearly 10 years after it was introduced. METHODS: A literature review was conducted to evaluate mTS accuracy to predict metastatic spine patient survival. RESULTS: Ten studies were selected, representing 1686 patients. The total predictive accuracy of the mTS was 63.00%; for patients expected to survive less than 6 months (group I), it was 64.10%; 6-12 months (group II), 55.32%; and more than 12 months (group III), 77.21%. A progressive decrease in accuracy over time was statistically significant in groups I and II. CONCLUSIONS: The mTS is suggestive of actual survival for patients with a good prognosis. It is less accurate for patients with an estimated survival of less than 12 months. The decreasing trend in mTS accuracy over time will likely further reduce mTS utility. An important opportunity exists to develop new instruments to assist spine surgeons and oncologists to choose appropriate surgical or non-surgical treatment modalities for patients with metastatic spine disease.

The surgical neurovascular anatomy relating to partial and complete sacral and sacroiliac resections: a cadaveric, anatomic study.

PURPOSE: Pelvic and sacral surgeries are considered technically difficult due to the complex multidimensional anatomy and the presence of significant neurovascular structures. Knowledge of the key neurovascular anatomy is essential for safe and effective execution of partial and complete sacral resections. The goal of this anatomic, cadaveric study is to describe the pertinent neurovascular anatomy during these procedures. METHODS: Three embalmed human cadaveric specimens were used. Sacrectomies and sacroiliac joint resections were simulated and the structures at risk were identified. Both anterior and posterior approaches were evaluated. RESULTS: During sacroiliac joint resection, L5 nerve roots are at high risk for iatrogenic injury; the vasculatures at greatest risk are the common iliac vessels and internal iliac vessels with L5-S1 and S1-S2 high sacrectomies. Minor bleeding risk is associated with S2-S3 osteotomy because of the potential to damage superior gluteal vessels. S3-S4 osteotomy presents a low risk of bleeding. Adjacent nerve roots proximal to the resection level are at high risk during higher sacrectomies. CONCLUSIONS: Several sacrectomy techniques are available and selection often depends on the specific case and surgeon preference; nevertheless, anatomic knowledge is extremely important. Considering the highly variable anatomic relations of the vascular bundles, a preoperative evaluation with CT or MRI with vascular reconstruction may be helpful to decrease bleeding risk by preemptively binding the internal iliac vessels in cases where higher tumors are present. To decrease the risk of damaging nerve roots, it is recommended to perform the resection as close to the involved foramina as possible.

The surgical vascular anatomy of the minimally invasive lateral lumbar interbody approach: a cadaveric and radiographic analysis.

PURPOSE: The minimally invasive (MI) lateral lumbar interbody fusion (LLIF) approach has become increasingly popular for the treatment of degenerative lumbar spine disease. The neural anatomy of the lumbar plexus has been studied; however, the pertinent surgical vascular anatomy has not been examined in detail. The goal of this study is to examine the vascular structures that are relevant in relation to the MI-LLIF approach. METHODS: Anatomic dissection of the lumbar spines and associated vasculature was performed in three embalmed, adult cadavers. Right and left surgeon perspective views during LLIF were for a total of six approaches. During the dissection, all vascular elements were noted and photographed, and anatomical relationships to the vertebral bodies and disc spaces were analyzed. In addition, several axial and sagittal MRI images of the lumbar spine were analyzed to complement the cadaveric analysis. RESULTS: The aorta descends along the left anterior aspect of lumbar vertebra with an average distance of 2.1 cm (range 1.9-2.3 cm) to the center of each intervertebral disc. The vena cava descends along the right anterior aspect of lumbar vertebrates with average distance of 1.4 cm (range 1.3-1.6 cm) to the center of the intervertebral disc. Each vertebral body has two lumbar arteries (direct branches from the aorta); one exits to the left and one to the right side of the vertebral body. The lumbar arteries pass underneath the sympathetic trunk, run in the superior margin of the vertebral body and extend all the way across it, with average length of 3.8 cm (range 2.5-5 cm). The mean distance between the arteries and the inferior plate of the superior disc space is 4.2 mm (range 2-5 mm) and mean distance of 3.1 cm (range 2.8-3.8 cm) between two arteries in adjacent vertebrae. One of the cadavers had an expected normal anatomical variation where the left arteries at L3-L4 anastomosed dorsally of the vertebral bodies at the middle of the intervertebral disc. CONCLUSIONS: Understanding the vascular anatomy of the lateral and anterior lumbar spine is paramount for successfully and safely executing the LLIF procedure. It is imperative to identify anatomical variations in lumbar arteries and veins with careful assessment of the preoperative imaging.

Brain tumors enhance plasmatic coagulation: the role of hemeoxygenase-1.

BACKGROUND: Patients with brain tumors suffer significant thrombotic morbidity and mortality. In addition to increased thrombin generation via tumor release of tissue factor-bearing microparticles and hyperfibrinogenemia, brain tumors and surrounding normal brain likely generate endogenous carbon monoxide (CO) via the hemeoxygenase-1 (HO-1) system. CO has been shown to enhance plasmatic coagulation via formation of carboxyhemefibrinogen (COHF). Thus, our goals in this study were to determine whether patients with brain tumors had increased HO-1 upregulation/CO production, plasmatic hypercoagulability, and formation of COHF. METHODS: Patients with brain tumors (N = 20) undergoing craniotomy had blood collected for determination of carboxyhemoglobin as a marker of HO-1 activity, plasmatic hypercoagulability (defined as clot strength > 95% confidence interval value of normal subject plasma), and COHF formation (determined with a thrombelastograph-based assay). Plasma obtained from commercially available normal subjects (N = 30) was used for comparison with brain tumor patient samples. RESULTS: Brain tumor patients had carboxyhemoglobin concentrations of 1.5% ± 0.5% (mean ± SD), indicative of HO-1 upregulation. Compared with normal subject plasma, brain tumor patient plasma had significantly (P < 0.0001) greater clot formation velocity (5.2 ± 1.5 vs 9.5 ± 2.3 dynes/cm/s, respectively) and significantly (P = 0.00016) stronger final clot strength (166 ± 28 vs 230 ± 78 dynes/cm, respectively). Ten of the brain tumor patients had plasma clot strength that exceeded the 95% confidence interval value observed in normal subjects, and 12 of the brain tumor patients had COHF formation. Five of the brain tumor patients in the hypercoagulable subgroup had COHF formation. Last, 5 of the hypercoagulable patients had primary brain tumors, whereas the other 5 patients had metastatic tumors or an inflammatory mass lesion. CONCLUSIONS: A subset of patients with brain tumors has increased endogenous CO production, plasmatic hypercoagulability, and COHF formation. Future investigation of the role played by HO-1 derived CO in the pathogenesis of brain tumor-associated thrombophilia is warranted.

The role of minimally invasive lateral lumbar interbody fusion in sagittal balance correction and spinal deformity.

PURPOSE: The recent proliferation of minimally invasive lateral lumbar interbody fusion (LLIF) techniques has drawn attention to potential for these techniques to control or correct sagittal misalignment in adult spinal deformity. We systemically reviewed published studies related to LLIF use in adult spinal deformity treatment with emphasis on radiographic assessment of sagittal balance. METHODS: A literature review was conducted to examine studies focusing on sagittal balance restoration in adult degenerative scoliosis with the LLIF approach. RESULTS: Fourteen publications, 12 retrospective and 2 prospective, reported data regarding lumbar lordosis correction (1,266 levels in 476 patients) but only two measured global sagittal alignment. CONCLUSION: LLIF appears to be especially effective when the lumbar lordosis and sagittal balance correction goals are less than 10° and 5 cm, respectively. However, the review demonstrated a lack of consistent reporting on sagittal balance restoration with the MIS LLIF techniques.

Optimal trajectory for the occipital condyle screw.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To understand what may constitute an optimal trajectory for an occipital condyle (OC) screw. SUMMARY OF BACKGROUND DATA: OC screws are an alternative to standard occipital plates as a cephalad fixation point in occipitocervical fusion. An optimal trajectory for placement of OC screws has not been described. METHODS: We conducted a computed tomography-based study of 340 human occipital condyls. All computed tomographies were negative for traumatic, degenerative, and neoplastic pathology. On the basis of the current literature, linear measurements of distances were made based on a constant entry point. Medial angulations of 10, 20, and 25 degrees relative to the sagittal midline were used. In addition, 10-, 5-degree cranial, 10- and 30-degree caudal angulations were studied to evaluate the incidence of hypoglossal canal and atlantooccipital joint compromise. RESULTS: Average distances were 17.1±2.8, 20.4±2.8, and 22.2±2.9 for 10, 20, and 25 degrees of medial angulation, respectively. Right-sided and left-sided measurements for each category were not significantly different. However, the difference in the measured distances between 10 versus 20 degrees, 10 versus 25 degrees, and 20 versus 25 degrees was all significantly different (P<0.01). Hypoglossal canal compromise incidence was 0% and 7.1% for 5- and 10-degree cranial angulation, respectively. Atlantooccipital joint compromise incidence was 21.8% and 99.1% for 10- and 30-degree caudal angulation, respectively. CONCLUSIONS: The condylar entry point should be medial to the condylar fossa, midcondylar, and ≥2 mm caudal to the skull base. An optimal trajectory for the OC screw should have a medial angulation of ≥20 degrees relative to the sagittal midline, trying to stay parallel to the skull base. Minor adjustments in angulation can be made, but any adjustment approaching 10 degrees cranial or caudal leads to an increased risk of hypoglossal canal cranially or atlantooccipital joint compromise caudally.

Surgical anatomy of the diaphragm in the anterolateral approach to the spine: a cadaveric study.

STUDY DESIGN: Laboratory cadaveric study. OBJECTIVE: To delineate the pertinent surgical anatomy of the diaphragm during access to the anterolateral thoracolumbar junction. SUMMARY OF BACKGROUND DATA: The general anatomy of the thoracic diaphragm is well described. The specific surgical anatomy as it pertains to the lateral and thoracoabdominal approaches to the thoracolumbar junction is not well described. METHODS: Dissections were performed on adult fresh cadaveric specimens. Special attention was paid to the diaphragmatic attachments to the lower rib cage and to the spinal thoracolumbar junction. RESULTS: The pertinent diaphragmatic attachments to the rib cage are at the 11th and 12th ribs. Whether the diaphragm is incised or mobilized ventrally, the pertinent spinal attachments are the lateral and medial arcuate ligaments. Identifying and sectioning these structures allows for direct access to the thoracolumbar junction, particularly the L1 vertebral body. CONCLUSIONS: An understanding of the diaphragmatic-costal and diaphragmatic-spinal attachments is key for the safe and effective implementation of diaphragm mobilization during the lateral and thoracoabdominal approaches to the spine.

Radiographic assessment of thoracolumbar fractures based on axial zones.

STUDY DESIGN: Retrospective study of computed tomography imaging of patients with thoracolumbar (TL) fractures. OBJECTIVE: To propose an axial model of spinal fractures based on the osteoligamentous continuity of the TL spinal segments in the axial plane and to determine the correlation between the 3-column theory and the proposed axial zone model. SUMMARY OF BACKGROUND DATA: Predicting spinal instability of TL fractures is based on several radiologic and clinical parameters. Efforts to refine fracture classification schemes to better predict instability continue. METHODS: Computed tomography scans of 229 consecutive patients who presented with TL fractures between March 2005 and April 2007 were reviewed. TL fractures were classified according to both the Denis 3-column theory and the proposed axial zone model. The incidence of column and axial zone injuries was determined. On the basis of these results, a treatment algorithm was developed. RESULTS: Zone disruption in surgical fractures was distributed as follows: 24 (96%) involved zone A, 25 (100%) involved zone B, 17 (68%) involved zone C, and 15 (60%) involved zone D. All surgical fractures involved 2 or more zones. Zone B was involved in all surgical fractures. The likelihood of surgical intervention increased as the number of zones increased, especially if the injury was a 2-column or 3-column injury. CONCLUSIONS: The current 3-column theory of spinal stability does not account for the axial component of an injury. Application of our proposed "axial zone model" may enhance the ability to predict stability, depending not only on the number of columns, but also on the number of zones involved in the injuries. Further clinical and biomechanical studies are warranted to validate this model.

Subfascial drains are safe and effective in preventing postoperative cerebrospinal fluid leaks after intradural spine tumor surgery.

Background: Delayed cerebrospinal fluid (CSF) leaks are a known complication following intradural spinal tumor surgery. The placement of subfascial drains in these patients undergoing requisite intradural surgery is controversial. Here, we demonstrated that placing a subfascial drain on partial suction for 48 h, with early ambulation, proved to be safe and effective in preventing early/delayed recurrent CSF fistulas. Methods: Medical records of 17 patients undergoing surgery for intradural spinal tumors over a 30-month were reviewed. All patients underwent intradural tumor resection followed by primary dural closure, placement of Gelfoam in a non-compressive fashion, application of fibrin sealant, and utilization of a subfascial drain placed on partial suction for 48 h postoperatively. Patients are mobilized the morning following surgery. We tracked the incidence of postoperative recurrent CSF leaks, over drainage, infection, wound dehiscence, pseudo meningocele formation, and the reoperation rate. Results: For the 17 patients, our programmed average utilization of subfascial drains was 48 h. Moreover, the average drain output was 165 mL. Over the 1-year follow-up period, no patient developed a recurrent early/ delayed CSF leak, there were no wound complications, nor need for revision surgery. Conclusion: Utilizing subfascial drains on partial suction following the resection of intradural spinal tumors with primary dural closure proved to be safe and effective.

Applications of SPECT/CT in the Evaluation of Spinal Pathology: A Review.

BACKGROUND: Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS: A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS: SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS: SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE: SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology.

C2 versus C3 or C4 as the upper instrumented vertebra for long-segment cervical fusions: a systematic review and meta-analysis.

OBJECTIVE: Selecting C2 versus C3 or C4 (i.e., C3/C4) as the rostral anchoring level in long-segment cervical fusions is a common clinical conundrum. The data regarding proximal failure in long constructs of the cervical spine is scarce. The objective of this study was to systematically review the published literature and perform a meta-analysis of the incidence for proximal adjacent-segment disease (ASD) in the context of long cervical fusions and cervicothoracic fusions ending in C2 versus those ending in the subaxial spine (C3 or C4). METHODS: Using the PRISMA guidelines, the authors performed a search of the PubMed/MEDLINE, Embase/Ovid, and Cochrane Central databases to identify all full-text articles in the English-language literature with the following inclusion criteria: 1) studies including patients with the upper instrumented vertebra (UIV) at C2 versus C3/C4; 2) patients undergoing ≥ 3-level posterior cervical fusion; and 3) indication for surgery of degenerative disc disease, cervical spondylotic myelopathy, or cervical deformity. Studies that were not published in the English language, case reports, review articles, letters to the editor, and meeting abstracts were excluded. A meta-analysis was conducted using a fixed-effects model when I2 values were below 70%. Conversely, when I2 values were equal to or greater than 70%, a random-effects model was used. A funnel plot was used to assess the presence of publication bias. RESULTS: Seven studies consisting of 1215 patients were included in the meta-analysis. There were 403 (32.8%) patients in the C2 UIV group and 812 (67.2%) patients in the C3/C4 UIV group. When the 7 studies were analyzed, the overall rate of reoperation was comparable between the C2 (9.2%) and C3/C4 (9.4%) UIV groups (p = 0.93) but the rate of surgical ASD due to proximal pathology was 1.2% and 3%, respectively (OR 0.36, 95% CI 0.15-0.86; p = 0.02). When comparing between groups, no statistical difference was found regarding the rate of reoperation due to distal pathology or surgical infection. CONCLUSIONS: Long-segment cervical or cervicothoracic constructs that anchor into C2 may have similar complication rates but lower revision rates for proximal ASD than constructs that anchor into the subaxial spine.

Is young adult idiopathic scoliosis a distinct clinical entity from adolescent idiopathic scoliosis? a Systematic Review and Meta-analysis comparing pre-operative characteristics and operative outcomes.

PURPOSE: This study aims to conduct a systematic review of the literature comparing pre-operative, intraoperative, and post-operative characteristics between adolescent idiopathic scoliosis (AIS) and young adult idiopathic scoliosis (YAdIS) patients. METHODS: Following PRISMA guidelines, we conducted a search of the PubMed/Medline, EMBASE, and Cochrane Central databases to identify full-text articles in the English-language literature. Our inclusion criteria were studies that compared preoperative, intraoperative, and postoperative characteristics between AIS and YAdIS patients. We performed a meta-analysis reporting mean difference (MD) for continuous variables and Odds ratios (ORs) to assess differences in postoperative complications. RESULTS: Seven studies consisting of 1562 patients were included in the meta-analysis. The AIS group exhibited less intraoperative bleeding and shorter surgical procedures, with a mean difference between groups of 122.3 ml (95% CI 46.2-198.4, p = 0.002) and 28.7 min (95% CI 6.5-50.8, p = 0.01), respectively. Although the preoperative Cobb angle did not differ between groups (p = 0.65), patients with AIS achieved superior postoperative deformity correction, with a mean difference of 7.3% between groups, MD - 7.3 (95% CI - 9.7, - 4.8, p < 0.00001), and lower postoperative Cobb angles of the major curve, MD 4.2 (95% CI 3.1, 5.3, p < 0.00001). YAdIS patients were fused, on average, 0.2 more vertebral levels than AIS patients, MD 0.2 (95% CI 0.01, 0.5, p = 0.04). AIS patients experienced a significantly shorter length of stay after the surgical procedure, with an MD of 0.8 days (95% CI 0.1, 1.6, p = 0.02). No significant difference was found between groups in terms of complications (p = 0.19). CONCLUSIONS: YAdIS should be regarded as a distinct surgical entity, characterized by increased bleeding, longer surgical duration, greater deformity correction challenges, and the need for fusion of additional vertebral levels compared to AIS. Surgeons should be mindful of these differences and discuss them with patients and their families, especially in cases where the correction of the AIS deformity is delayed and there is a high risk of progression after skeletal maturity. Further research is needed to explore alternative surgical techniques and enhance outcomes for YAdIS patients.

Neuronavigation in minimally invasive spine surgery.

OBJECT: Parallel advancements in image guidance technology and minimal access techniques continue to push the frontiers of minimally invasive spine surgery (MISS). While traditional intraoperative imaging remains widely used, newer platforms, such as 3D-fluoroscopy, cone-beam CT, and intraoperative CT/MRI, have enabled safer, more accurate instrumentation placement with less radiation exposure to the surgeon. The goal of this work is to provide a review of the current uses of advanced image guidance in MISS. METHODS: The authors searched PubMed for relevant articles concerning MISS, with particular attention to the use of image-guidance platforms. Pertinent studies published in English were further compiled and characterized into relevant analyses of MISS of the cervical, thoracic, and lumbosacral regions. RESULTS: Fifty-two studies were included for review. These describe the use of the iso-C system for 3D navigation during C1-2 transarticular screw placement, the use of endoscopic techniques in the cervical spine, and the role of navigation guidance at the occipital-cervical junction. The authors discuss the evolving literature concerning neuronavigation during pedicle screw placement in the thoracic and lumbar spine in the setting of infection, trauma, and deformity surgery and review the use of image guidance in transsacral approaches. CONCLUSIONS: Refinements in image-guidance technologies and minimal access techniques have converged on spinal pathology, affording patients the ability to undergo safe, accurate operations without the associated morbidities of conventional approaches. While percutaneous transpedicular screw placement is among the most common procedures to benefit from navigation, other areas of spine surgery can benefit from advances in neuronavigation and further growth in the field of image-guided MISS is anticipated.