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Study Design: Retrospective Cohort Objective: Antiresorptive drugs are often given to minimize fracture risk for bone metastases, but data regarding optimal time or ability to reduce stereotactic body radiotherapy (SBRT)-induced fracture risk is limited. This study examines the association between antiresorptive use surrounding spinal SBRT and vertebral compression fracture (VCF) incidence to provide information regarding effectiveness and optimal timing of use. Methods: Patients treated with SBRT for spinal metastases at a single institution between 2009-2020 were included. Kaplan-Meier analysis was used to compare cumulative incidence of VCF for those taking antiresorptive drugs pre-SBRT, post-SBRT only, and none at all. Cox proportional hazards and Fine-Gray competing risk models were used to identify additional factors associated with VCF. Results: Of the 234 patients (410 vertebrae) analyzed, 49 (20.9%) were taking bisphosphonates alone, 42 (17.9%) were taking denosumab alone, and 25 (10.7%) were taking both. Kaplan-Meier analysis revealed a statistically significant lower VCF incidence for patients initiating antiresorptive drugs before SBRT compared to those taking none at all (4% vs 12% at 1 year post-SBRT, P =.045; and 4% vs 23% at 2 years, P =.008). On multivariate analysis, denosumab duration (HR:.87, P =.378) or dose (HR: 1.00, P =.644) as well as bisphosphonate duration (HR:.98, P =.739) or dose (HR:.99, P =.741) did not have statistical significance on VCF incidence. Conclusion: Initiating antiresorptive agents before SBRT may reduce the risk of treatment-induced VCF. Antiresorptive drugs are underutilized in patients with spine metastases and may represent a useful intervention to minimize toxicity and improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: Cone‐beam CT (CBCT) with non‐circular scanning orbits can improve image quality for 3D intraoperative image guidance. However, geometric calibration of such scans can be challenging. Existing methods typically require a prior image, specialized phantoms, presumed repeatable orbits, or long computation time. Purpose: We propose a novel fully automatic online geometric calibration algorithm that does not require prior knowledge of fiducial configuration. The algorithm is fast, accurate, and can accommodate arbitrary scanning orbits and fiducial configurations. Methods: The algorithm uses an automatic initialization process to eliminate human intervention in fiducial localization and an iterative refinement process to ensure robustness and accuracy. We provide a detailed explanation and implementation of the proposed algorithm. Physical experiments on a lab test bench and a clinical robotic C‐arm scanner were conducted to evaluate spatial resolution performance and robustness under realistic constraints. Results: Qualitative and quantitative results from the physical experiments demonstrate high accuracy, efficiency, and robustness of the proposed method. The spatial resolution performance matched that of our existing benchmark method, which used a 3D‐2D registration‐based geometric calibration algorithm. Conclusions: We have demonstrated an automatic online geometric calibration method that delivers high spatial resolution and robustness performance. This methodology enables arbitrary scan trajectories and should facilitate translation of such acquisition methods in a clinical setting. [ABSTRACT FROM AUTHOR]

This document is a response to a letter discussing a study on the use of antiresorptive medications prior to stereotactic body radiotherapy (SBRT) for spinal metastasis. The authors address questions raised in the letter, including the higher risk of vertebral compression fracture (VCF) in patients receiving antiresorptive therapy after SBRT. While the difference in VCF incidence was not found to be statistically significant, the authors speculate that patients who develop fractures may be more likely to receive antiresorptive agents. The document also clarifies components of the statistical analysis and emphasizes the need for larger datasets and prospective studies to confirm the findings. [Extracted from the article]

Background and Objectives: Spinal chordomas are primary bone tumors where surgery remains the primary treatment. However, their low incidence, lack of evidence, and late disease presentation make them challenging to manage. Here, we report the postoperative outcomes of a large cohort of patients after surgical resection, investigate predictors for overall survival (OS) and local recurrence-free survival (LRFS) times, and trend functional outcomes over multiple time periods., Methods: Retrospective review of all patients followed for spinal chordoma at a quaternary spinal oncology center from 2003 to 2023 was included. Data were collected regarding demographics, preoperative and perioperative management, and follow-up since initial definitive surgery. Primary outcomes were OS and LRFS, whereas secondary outcomes were functional deficits., Results: One hundred one patients had an average follow-up of 6.0 ± 4.2 years. At the time of census, 25/101 (24.8%) had experienced a recurrence and 10/101 (9.9%) had died. After surgery, patients experienced a significant decrease in pain over time, but rates of sensory deficits, weakness, and bowel/bladder dysfunction remained static. Tumors ≥100 cm3 (hazard ratio (HR) = 5.89, 95% CI 1.72-20.18, P = .005) and mobile spine chordomas (HR = 7.73, 95% CI 2.09-28.59, P = .002) are related to worse LRFS, whereas having neoadjuvant radiotherapy is associated with improved LRFS (HR = 0.09, 95% CI 0.01-0.88, P = .038). On the other hand, being age ≥65 years was associated with decreased OS (HR = 16.70, 95% CI 1.54-181.28, P = .021)., Conclusion: Surgeons must often weigh the pros and cons of en bloc resection and sacrificing important but affected native tissues. Our findings can provide a benchmark for counseling patients with spinal chordoma. Tumors ≥100 cm3 appear to have a 5.89-times higher risk of recurrence, mobile spine chordomas have a 7.73 times higher risk, and neoadjuvant radiotherapy confers an 11.1 times lower risk for local recurrence. Patients age ≥65 years at surgery have a 16.70 times higher risk of mortality than those <65 years., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objective: Pedicle screw placement guidance is critical in spinal fusions, and spinal surgery robots aim to improve accuracy and reduce complications. Current literature has yet to compare the relative merits of available robotic systems. In this review, the authors aimed to 1) assess the current state of spinal robotics literature; 2) conduct a meta-analysis of robotic performance based on accuracy, speed, and safety; and 3) offer recommendations for robotic system selection., Methods: Following PRISMA guidelines, the authors conducted a systematic literature review across PubMed, Embase, Cochrane Library, Web of Science, and Scopus as of April 28, 2022, for studies on approved robots for placing lumbar pedicle screws. Three reviewers screened and extracted data relating to the study characteristics, accuracy rate, intraoperative revisions, and reoperations. Secondary performance metrics included operative time, blood loss, and radiation exposure. The authors statistically compared the performance of the robots using a random-effects model to account for variation within and between the studies. Each robot was also compared with performance benchmarks of traditional techniques including freehand, fluoroscopic, and CT-navigated insertion. Finally, we performed a Duval and Tweedie trim-and-fill test to assess for the presence of publication bias., Results: The authors identified 46 studies, describing 4670 patients and 25,054 screws, that evaluated 4 different robotic systems: Mazor X, ROSA, ExcelsiusGPS, and Cirq. The weighted accuracy rates of Gertzbein-Robbins classification grade A or B screws were as follows: ExcelsiusGPS, 98.0%; ROSA, 98.0%; Mazor, 98.2%; and Cirq, 94.2%. No robot was significantly more accurate than the others. However, the accuracy of the ExcelsiusGPS was significantly higher than that of traditional methods, and the accuracies of the Mazor and ROSA were significantly higher than that of fluoroscopy. The intraoperative revision rates were Cirq, 0.55%; ROSA, 0.91%; Mazor, 0.98%; and ExcelsiusGPS, 1.08%. The reoperation rates were Cirq, 0.28%; ExcelsiusGPS, 0.32%; and Mazor, 0.76% (no reoperations were reported for ROSA). Operative times were similar for all robots. Both the ExcelsiusGPS and Mazor were associated with significantly less blood loss than the ROSA. The Cirq had the lowest radiation exposure. Robots tended to be more accurate and generally their use was associated with fewer reoperations and less blood loss than freehand, fluoroscopic, or CT-navigated techniques., Conclusions: Robotic platforms perform comparably based on key metrics, with high accuracy rates and low intraoperative revision and reoperation rates. The spinal robotics publication rate will continue to accelerate, and choosing a robot will depend on the context of the practice.

The extracorporeal telescope (exoscope) presents a novel digital camera system as a versatile alternative to traditional optical microscopy for microsurgery and minimally invasive neurosurgical operations. Recent innovations in exoscope technology offer 4K-definition multiscreen outputs, pneumatic robot arms, 3-dimensional depth perception, and greater illumination, focus, and magnification powers for enhanced intraoperative visualization. The authors present their initial institutional experience using a robotic arm-enabled 4K 3D exoscope in a variety of cranial and spinal neurosurgical operations, namely Chiari decompression, microvascular decompression for trigeminal neuralgia, anterior cervical discectomy, and lumbar decompressions. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23150., Competing Interests: Disclosures Dr. Lubelski reported personal fees from CarboFix, ICOtec, Mindset Medical, and Stryker; and fees to institution (clinical trial) from Dilon Technologies outside the submitted work. Dr. Witham reported being a surgical advisory board member for Augmedics Inc., investment in Augmedics Inc., and being a consultant for Cerapedics and DePuy Synthes Spine outside the submitted work. Dr. Theodore reported royalties from and being a consultant for Globus Medical outside the submitted work. Dr. Huang reported stock ownership in Longeviti outside the submitted work.Dr. Lubelski reported personal fees from CarboFix, ICOtec, Mindset Medical, and Stryker; and fees to institution (clinical trial) from Dilon Technologies outside the submitted work. Dr. Witham reported being a surgical advisory board member for Augmedics Inc., investment in Augmedics Inc., and being a consultant for Cerapedics and DePuy Synthes Spine outside the submitted work. Dr. Theodore reported royalties from and being a consultant for Globus Medical outside the submitted work. Dr. Huang reported stock ownership in Longeviti outside the submitted work., (© 2024, The Authors.)

Background and Objectives: Cervical/lumbar total disk replacements (TDRs) are often performed for degenerative conditions but rarely in athletes. Therefore, we sought to conduct a systematic review of athletes undergoing TDRs of both the scientific literature and lay press, with an emphasis on contact sport athletes., Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed/Embase/Cochrane/Scopus/Web of Science databases were queried for all primary literature reporting TDRs in athletes, including both cervical/lumbar disk replacements (CDRs/LDRs). Sports were dichotomized into contact vs limited/noncontact. Because of the public nature of injuries in elite athletes, the lay press was also queried., Results: A total of 488 scientific studies were screened, of which 10 met inclusion criteria. Cervical: seven studies reported CDRs in 53 athletes, of which 7 were professional, 22 semiprofessional, and 24 recreational. Of the seven professional athletes, there was one contact sport athlete (kickboxer). All 7/7 professional and 21/22 semiprofessional athletes successfully returned-to-play at 8-52 weeks without complication. Lumbar: Three studies discussed LDRs in 51 athletes, of which 17 were professional, 6 semiprofessional, and 28 recreational. Of the 17 professional athletes, eight played contact sports (2 boxing, 2 alpine skiing, 2 soccer, judo, rugby). All 17 professional and 6 semiprofessional athletes successfully returned to play at 9-21 weeks. Lay Press: five professional contact sport athletes underwent CDRs, and all returned to play: 3 hockey, 1 mixed-martial arts, and 1 Australian-rules football., Conclusion: The scientific literature and lay press revealed 14 professional contact sport athletes who underwent TDR-6 CDRs and 8 LDRs-all with successful return to play. From the little data that exist, it seems that TDR may be safe in elite athletes; however, the small number of patients highlights the major paucity of data on the safety of TDR in elite contact sport athletes., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)