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PURPOSE OF THE STUDY Unplanned revision spinal surgeries constitute a complication in the treatment algorithm for the patient, surgeon and the entire treatment team. Any complication leading to an unplanned revision surgery is therefore undesirable. The percentage of complications referred to in publications on this topic focusing on unplanned revision surgeries only varies from 0.7% to 29.8%, with obvious diversity of causes and significant risk factors. The purpose of the submitted paper is to carry out a prospective evaluation of the most serious complications requiring unplanned revision spinal surgeries in the course of 13 years at a single department performing a broad range of spinal surgeries, namely 1300 procedures annually on average. MATERIAL AND METHODS In the period 2006 – 2018, a total of 16872 patients underwent a surgery at our department. During this period, in 556 patients an unplanned revision spinal surgery was performed. In agreement with literature, the patients were categorised by cause for revision: 1/ impaired wound suprafascial (superficial) healing – superficial infection, 2/ impaired wound subfascial (deep) healing – deep infection, 3/ surgical wound hematoma, 4/ deterioration or occurrence of new neurological symptoms, 5/ cerebrospinal fluid leak (liquorrhoea) and 6/ others. The patients operated on for inflammatory diseases of the spine with subsequent infectious complications, primarily treated at another department, and the patients with open spinal injury were excluded from the study. According to these criteria, a cohort of 521 patients was followed up, namely 236 (45.3%) women and 285 (54.7%) men, aged 1 year to 86 years, with the mean age of 55.0 years (median 60 years). Demographic effects, tobacco smoking and comorbidities were followed up in the cohort, together with the effects of surgery, diagnosis, surgical approach and physician. All parameters were statistically evaluated at a p-value below 0.05, including comparison with the control group. RESULTS Of the total number of 16872 operated patients, a group of 521 (3.09%) patients undergoing a revision surgery for complications was analysed in detail. Impaired wound healing – infection (SSI) was found in 199 (1.18%) patients, of whom superficial infection in 124 cases (0.73%) and deep infection in 75 cases (0.44%). Hematoma in a surgical site was detected in 149 (0.88%) patients. In 63 (0.37%) cases, deterioration of the existing neurological finding or occurrence of a new neurological finding were observed, in 68 (0.40%) cases cerebrospinal fluid leak was reported and in 40 (0.24%) cases other complications were identified. As concerns the surgical assistant, the percentage of complications in a board-certified physician is 2.77 (1.14 – 3.29%), in a medical resident it increases to 3.60 (0.00 – 9.38%) (p<0.05). The prevalence of smokers in the group with complications (N=521) was 34.7%. The control group (N=3650) included 30.1% of smokers (p<0.05). The mean age of patients in the group with complications (N=521) was higher, i.e. 55.0 years, with the median age of 60.0 years, than in the primary cohort (N=16872) with the mean age of 49.8 years and the median age of 52.0 years (p<0.05). The mean BMI in the group with complications was (N=521) 27.3, the median BMI was 26.9. In the control group (N=16872), the mean BMI was 27.11, the median BMI was 26.8. In this case the significance (p>0.05) was not confirmed. The complications prevailed strongly in posterior surgical approach, namely in 483 patients (92.7%). As concerns the surgically treated segment, lumber spine dominates with 320 (61.4%) cases. Corticosteroid therapy was used twice as often in women, namely in 13.1% vs. 6.3%. The group of patients with complications (N=521) showed a much higher average length of hospital stay of 12.8 days compared to the average of 4.6 days (N=16872). DISCUSSION In our cohort, the complication rate was 3.09%, of which infections constituted 1.18%, which is in agreement with similarly focused papers. As regards the patient-related factors, in our study the results reported by literature were confirmed with respect to the age, smoking and comorbidities. Moreover, the posterior surgical procedure, lumber spine surgery and presence of a medical resident are essential (p<0.05). No major age difference was observed between women and men (p>0.05). Obesity is one of the key risk factors, especially in infectious complications. In our cohort, a higher BMI did not increase the risk of complications in general (p>0.05). CONCLUSIONS In correlation with current literature, our cohort confirmed a significantly higher risk of complications leading to revision spinal surgery associated with age, smoking, posterior surgical procedure in thoracic or lumber spine, and presence of a medical resident as a surgical assistant. The average length of hospital stay was demonstrably longer in complicated patients, it almost tripled compared to the whole cohort. Contrary to literature, the effect of obesity on the occurrence of complications was not confirmed. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY Atlantoaxial Rotatory Dislocation (AARD) mostly occurs in children and prevailing majority of cases are successfully managed by non-operative treatment. Surgical intervention is necessary in patients in whom non-operative treatment failed, in case of repeated dislocations and in patients with anatomical defects of the atlantoaxial complex. The purpose of the presented study is the radiological and clinical evaluation of patients with AARD surgically treated at our department. MATERIAL AND METHODS In the period from 2001 to 2017, altogether 15 patients with AARD were surgically treated at our department, namely 6 men and 9 women aged 5-72 years, with the mean age of 27.3 years. 8 patients were younger than 18 years of age. Apart from regular checks, all the patients were examined also at the end of the study, which means at a follow-up of 12-214 months, i.e. 112.1 months postoperatively on average. In the study, the anatomy of the atlantoaxial complex and craniocervical junction, course of the surgical procedure, correction of deformity, bone fusion, clinical condition of the patient and complications were monitored and evaluated. The clinical evaluation was performed using the Visual Analogue Scale (VAS) for neck pain and the Neck Disability Index (NDI). All the parameters were statistically evaluated at the p-level below 0.05. RESULTS In all 15 patients the surgery was preceded by unsuccessful non-operative treatment. The period between the rotation and the surgery was 4 days to 48 months, with the mean value of 11.3 months. All the patients included in the study showed an intact dens axis, the other patients were excluded from the study. In 10 patients their head was rotated to the left, in 5 patients to the right. The anterior atlantodental interval (ADI) was 2-7 mm with the mean value of 3.5 mm. In 13 cases the ADI was less than 5 mm, in 2 cases it was greater. According to the Fielding and Hawkins classification there were 9 cases of type I, 4 cases of type II and two cases of type III. According to the Ishii et al. classification, 2 cases of type I, 12 cases of type II and one case of type III were identified. In 9 patients predisposing factors were found in the history, namely 7 cases of trauma, 2 cases of infection. Mutual rotation of C1-C2 from 7.0° to 60.0° with the mean value of 27.3° was observed preoperatively, while after the correction it was from 1.0° to 7.0° with the mean value of 3.9° (p < 0.05). Lateral inclination was 3.4°-23.6° preoperatively with the mean value of 9.9°, and 0.7°-4.0° after the correction with the mean value of 2.2° (p < 0.05). The postoperative ADI ranged from 1 to 3 mm, with the mean value of 1.9 mm (p < 0.05). The bone fusion of C1-C2 or C1-C2-C3 was achieved in all the relevant cases (N = 13, 100%), in two patients a temporary fixation was used. The mean value of VAS for neck pain was 6.3 preoperatively, 1.0 (p < 0.05) at one year and 1.0 (p < 0.05) again at the final examination. The mean value of NDI was 50.4 % preoperatively, 9.3% (p < 0.05) at one year and 9.5% (p < 0.05) at the final examination. All patients that we operated on stated that they would undergo surgery again. DISCUSSION Compared to the other authors, our group of patients included surprisingly many adult patients (46.7%) with a high percentage of neurological defects (33.3%). In agreement with the literature, the cause of rotation was revealed in 60% of cases. At our department, correction is preferred in all the patients, while especially in paediatric patients in situ fixation causes the developmental deformities of the face and cervical spine. High success rate of bone fusion was confirmed (13/15, 13 = 100%) and also the transient atlantoaxial fixation was successfully used in two patients, both with traumatic etiology. CONCLUSIONS If non-operative treatment fails, surgical correction of AARD is a suitable treatment method which ensures favourable position of the atlantoaxial complex, improves the clinical condition of the patient and prevents the asymmetric development of the face in children. The Goel-Harm's fixation technique and C1-C2 fusion are considered by us the method of choice in older paediatric and adult patients. [ABSTRACT FROM AUTHOR]

Purpose: The most common injuries to the upper cervical spine are fractures of the dens axis. Therefore, the purpose of our study was to answer three questions, namely (1) whether the size of the dens is adequate at all levels to accommodate two screws, (2) what the angle of the posterior tilt of the dens is in a healthy individual and (3) compare the measured variables between the sexes.Methods: The cohort comprised 50 males and 50 females CT examination of the craniocervical junction. We measured the five diameters of the dens and posterior dens angulation angle (PDAA) and screw insertion angle (SIA). The same dimensions were measured in a control group, consisting of 40 non-pathological second cervical vertebrae specimens.Results: On CT scans, the mean PDAA was 162.7 degrees in males and 160.26 degrees in females; the mean SIA was 62.0 degrees in males and 60.2 degrees in females. On specimens, the mean PDAA was 169.47 degrees in males and 166.95 degrees in females; the mean SIA was 65.42 degrees in males and 64.47 degrees in females. All obtained values were higher in males; regardless of their measuring on either CT scans or specimens, differences between males and females were statistically significant (p < 0.05) in a, c, d and e values.Conclusions: The values of our measurements correlate with the dimensions identified previously in other studies. Based on our clinical experience and measurements, we presume that two 3.5-mm screws can be inserted into the dens of all adult patients, except for those with pronounced anatomical anomalies. Posterior dens angulation angle is slightly larger than we expected. The dens is significantly larger in males almost in all measurement. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]