Three-column osteotomy in long constructs has lower rates of proximal junctional kyphosis and better restoration of lumbar lordosis than anterior column realignment.

PURPOSE: Three-column osteotomies (TCOs) and minimally invasive techniques such as anterior column realignment (ACR) are powerful tools used to restore lumbar lordosis and sagittal alignment. We aimed to appraise the differences in construct and global spinal stability between TCOs and ACRs in long constructs. METHODS: We identified consecutive patients who underwent a long construct lumbar or thoracolumbar fusion between January 2016 and November 2021. "Long construct" was any construct where the uppermost instrumented vertebra (UIV) was L2 or higher and the lowermost instrumented vertebra (LIV) was in the sacrum or ileum. RESULTS: We identified 69 patients; 14 (20.3%) developed PJK throughout follow-up (mean 838 days). Female patients were less likely to suffer PJK (p = 0.009). TCO was more associated with open (versus minimally invasive) screw/rod placement, greater number of levels, higher UIV, greater rate of instrumentation to the ilium, and posterior (versus anterior) L5-S1 interbody placement versus the ACR cohort (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.005, respectively). Patients who developed PJK were more likely to have undergone ACR (12 (32.4%) versus 2 (6.3%, p = 0.007)). The TCO cohort had better improvement of lumbar lordosis despite similar preoperative measurements (ACR: 16.8 ± 3.78°, TCO: 23.0 ± 5.02°, p = 0.046). Pelvic incidence-lumbar lordosis mismatch had greater improvement after TCO (ACR: 14.8 ± 4.02°, TCO: 21.5 ± 5.10°, p = 0.042). By multivariate analysis, ACR increased odds of PJK by 6.1-times (95% confidence interval: 1.20-31.2, p = 0.29). CONCLUSION: In patients with long constructs who undergo ACR or TCO, we experienced a 20% rate of PJK. TCO decreased PJK 6.1-times compared to ACR. TCO demonstrated greater improvement of some spinopelvic parameters.

The Safety and Efficacy of Stand-Alone Lateral Lumbar Interbody Fusion for Adjacent Segment Disease in a Cohort of 44 Patients.

BACKGROUND: A mainstay of treatment for symptomatic adjacent segment disease (ASD) has consisted of revision with posterior decompression and fusion. This carries significant morbidity and can be technically difficult. An alternative is stand-alone lateral lumbar interbody fusion (LLIF), which may avoid complications associated with revision surgery. We describe the largest cohort of patients treated with LLIF for ASD to our knowledge. METHODS: We conducted a retrospective cohort study on all patients who underwent transpsoas LLIF for ASD at a single academic center between 2012 and 2019. Postoperative improvement was measured using the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). RESULTS: Forty-four patients who underwent LLIF for ASD were identified. Median age was 65 years. Median time from index surgery to ASD development was 78 months. Median levels fused via LLIF was 1. Our median follow-up was 358 days. At follow-up, the median VAS back pain score was 0 (mean, 0.884), median VAS leg pain score was 1 (mean, 0.953), and median ODI was 8. The median improvement for VAS back pain was 8, for VAS leg pain was 6, and for ODI was 40. No patients suffered new neurologic symptoms postoperatively. Of the 17 patients who initially presented with non-pain neurologic symptoms, 8 (47.1%) experienced complete resolution of symptoms, and 5 (29.4%) experienced only some improvement. CONCLUSIONS: To our knowledge, this is the largest cohort study of patients to date evaluating stand-alone LLIF for ASD. Our patient outcomes show it is safe and effective with low risk of morbidity.

Expandable Titanium Cages in the Emergent Treatment of Severe Spinal Deformity Secondary to Osteomyelitis: A Series of Three Complex Cases.

The literature lacks robust evidence on the benefits versus risks of instrumenting and fusing the spinal column in the setting of active osteomyelitis. We report three patients with vertebral osteomyelitis and subsequent severe and complex kyphotic deformities. Patients 1 and 2 had previous instrumentation that required revision because of hardware failure in the thoracic and thoracolumbar regions, respectively. Patient 3 developed a severe cervical kyphotic deformity at 2 months after being diagnosed and treated with antibiotics for osteomyelitis, necessitating emergent instrumentation and fusion. All the three patients are doing very well so far. Spinal instrumentation and fusion for correction of kyphotic deformity is sometimes necessary in the context of active osteomyelitis and should be done emergently and without hesitation when spinal cord injury from spinal instability is of concern.

Nonaneurysmal Subarachnoid Hemorrhage in Scuba Diving.

BACKGROUND: Decompression illness often presents with a wide variety of vague neurologic symptoms. Animal models have suggested that intracranial hemorrhages may result from nitrogen bubble ischemic insults. However, there is a paucity of cases and no known case reported to date of non-aneurysmal subarachnoid hemorrhage after rapid ascension from diving. CASE DESCRIPTION: A 60-year-old man presented with headache, nausea, emesis, and confusion 2 days after ascending rapidly from scuba diving. Given the severity and his symptoms unremitting despite oxygen at home, a computed tomography scan of the head was obtained revealing a prepontine and right sylvian fissure subarachnoid hemorrhage with ventriculomegaly. No underlying vascular abnormality was discovered. The patient was discharged from the hospital posthemorrhage day 7, neurologically intact. CONCLUSIONS: In patients presenting with persistent headache, nausea, emesis and/or other neurologic symptoms after diving, health care providers should consider intracranial hemorrhage in their work up.

Use of a Yasargil mirror as an adjunct to indocyanine green angiography to evaluate the patency of elusive posterior communicating arteries during aneurysm clipping: case report.

BACKGROUND AND IMPORTANCE: Indocyanine green angiography (ICGA) has become a useful intraoperative tool during aneurysm surgery to determine parent, branching, and perforator vessel patency. Although extremely useful, ICGA is limited to the evaluation of vessels that are in direct view in the surgical field. CLINICAL PRESENTATION: We present 2 cases of patients who underwent a craniotomy for clipping of unruptured posterior communicating artery aneurysms. A Yasargil movable mirror was used as an adjuvant to ICGA to visualize the ventromedial posterior communicating vessels after clip placement to determine vessel patency. CONCLUSION: Although ICGA can be very useful during aneurysm surgery, it is limited to vessels directly visualized in the surgical field. A Yasargil movable mirror can be used during ICGA to visualize elusive vessels, in these cases on the ventromedial surface of the internal carotid artery.