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Study Design: Case-control whole-genome sequencing analysis of a highly select, young cohort with symptomatic lumbar disk herniation (LDH) compared with the standard variation in a large reference population.Objective: To assess genetic influences predisposing pediatric and young adult patients to symptomatic LDH.Summary Of Background Data: LDH has traditionally been attributed to natural weakening or mechanical insult, but recent literature supports a potential genetic influence.Methods: Young patients with symptomatic, clinically confirmed LDH who underwent surgical treatment were included. Patients were younger than the average age of presentation, limiting the influence of environmental risks. DNA collected from these patients was compared with a reference genome (1000 Genomes Project). A genome-wide association study using whole-genome sequencing was used to characterize genetic mutations potentially associated with LDH.Results: Among the 61 candidate genes flagged, 20 had missense mutations in 2 or more LDH cases. Missense mutations in collagen-encoding genes were observed in 12 of 15 patients (80%). A potential association with clinical presentation was indicated by odds ratios of key single-nucleotide polymorphism (SNP) variants in genes that encode collagen. Relative to the reference population, the LDH cohort demonstrated two statistically significant SNP variants in the gene encoding for aggrecan, a protein that facilitates load-bearing properties in the cartilaginous end plate. Aggrecan genes SNPs rs3817428 and rs11638262 were significantly associated with decreased odds of symptomatic LDH: odds ratio 0.05 (0.02-0.11) and 0.04 (0-0.26), respectively (P < 1 × 10 for both).Conclusion: These results suggest that collagen-encoding variants may be a genetic risk factor for LDH. They also shed new light on the role of variants that impact aggrecan, which sustains the cartilaginous end plate. Genetic predisposition to LDH may therefore be related to a multimodal combination of mutations that affect the nucleus pulposus, annulus fibrosus, and the cartilaginous end plates.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Increased utilization of prescription opioids for pain management has led to a nationwide public health crisis with alarming rates of addiction and opioid-related deaths. In the surgical setting, opioid prescriptions have been implicated as a contributing factor to the opioid epidemic. The authors developed an innovative model to address aspects of pain management and opioid utilization during preoperative evaluation, acute surgical hospitalization, and postoperative follow-up for chronic opioid users. This program involves multidisciplinary teams that include acute and chronic pain specialists, psychiatrists, integrative medicine specialists, and physical medicine and rehabilitation services. It also features a novel infrastructure for triage and pain management education and treatment. Individualized patient plans are devised that can include preoperative opioid weaning, regional anesthesia that minimizes opioid use, and multimodal techniques for surgical pain treatment. Multidisciplinary programs such as this have the potential to both improve perioperative pain control and prevent escalation of opioid use among chronic opioid users. [ABSTRACT FROM AUTHOR]

Tethered cord syndrome (TCS) occurs as a constellation of neurologic signs and symptoms resulting from longitudinal traction on the spinal cord between fixed points. This condition involves a tug-of-war between ascent and inhibition of ascent of intrathecal nervous tissue within the vertebral canal during growth. Causes include thickened filum terminale, myelomeningocele, split cord malformation, and previous intradural surgery. Patients report low back, lower extremity, and perineal pain; lower extremity sensory and motor deficits; urinary and bowel incontinence; and sexual dysfunction. When not treated early or adequately, TCS can lead to neurologic devastation. [ABSTRACT FROM AUTHOR]

The article discusses the history of robotics in spine surgery. It discusses about the first robotic assisted system for spinal surgery, SpineAssist from Mazor Robotics Ltd., Casesarea, Israel that received Food and Drug Administration clearance in 2004 and presented an average error of less than 2mm in 98.3% of pedicle screws inserted. SpineAssist had a greater proportion of non-misplaced screws in comparison to freehand surgery.

Objectives: Cone beam computed tomography (CBCT) imaging is becoming an indispensable intraoperative tool; however, the current field of view prevents visualization of long anatomical sites, limiting clinical utility. Here, we demonstrate the longitudinal extension of the intraoperative CBCT field of view using a multi-turn reverse helical scan and assess potential clinical utility in interventional procedures., Materials and Methods: A fixed-room robotic CBCT imaging system, with additional real-time control, was used to implement a multi-turn reverse helical scan. The scan consists of C-arm rotation, through a series of clockwise and anticlockwise rotations, combined with simultaneous programmed table translation. The motion properties and geometric accuracy of the multi-turn reverse helical imaging trajectory were examined using a simple geometric phantom. To assess potential clinical utility, a pedicle screw posterior fixation procedure in the thoracic spine from T1 to T12 was performed on an ovine cadaver. The multi-turn reverse helical scan was used to provide postoperative assessment of the screw insertion via cortical breach grading and mean screw angle error measurements (axial and sagittal) from 2 observers. For all screw angle measurements, the intraclass correlation coefficient was calculated to determine observer reliability., Results: The multi-turn reverse helical scans took 100 seconds to complete and increased the longitudinal coverage by 370% from 17 cm to 80 cm. Geometric accuracy was examined by comparing the measured to actual dimensions (0.2 ± 0.1 mm) and angles (0.2 ± 0.1 degrees) of a simple geometric phantom, indicating that the multi-turn reverse helical scan provided submillimeter and degree accuracy with no distortion. During the pedicle screw procedure in an ovine cadaver, the multi-turn reverse helical scan identified 4 cortical breaches, confirmed via the postoperative CT scan. Directly comparing the screw insertion angles (n = 22) measured in the postoperative multi-turn reverse helical and CT scans revealed an average difference of 3.3 ± 2.6 degrees in axial angle and 1.9 ± 1.5 degrees in the sagittal angle from 2 expert observers. The intraclass correlation coefficient was above 0.900 for all measurements (axial and sagittal) across all scan types (conventional CT, multi-turn reverse helical, and conventional CBCT), indicating excellent reliability between observers., Conclusions: Extended longitudinal field-of-view intraoperative 3-dimensional imaging with a multi-turn reverse helical scan is feasible on a clinical robotic CBCT imaging system, enabling long anatomical sites to be visualized in a single image, including in the presence of metal hardware., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: In vitro assessment of rib cage biomechanics in the region of true ribs with the ribs intact then sequentially resected in 5 steps., Objective: To determine the contribution of the rib cage to thoracic spine stability and kinematics., Summary of Background Data: Previous in vitro studies of rib cage biomechanics have used animal spines or human cadaveric spines with ribs left unsecured, limiting the ability of the ribs to contribute to stability., Methods: Eight upper thoracic specimens that included 4 ribs and sternum were tested in special fixtures that disallowed relative movement of the distal ribs and their vertebrae. While applying 7.5 Nm pure moments in 3 planes, angular motion at the middle motion segment was studied in intact specimens and then (1) after splitting the sternum, (2) after removing the sternum, (3) after removing 50% of ribs, (4) after removing 75% of ribs, and (5) after disarticulating and completely removing ribs., Results: During flexion/extension, the sternum and anterior rib cage most contributed to stability. During lateral bending, the posterior rib cage most contributed to stability. During axial rotation, stability was directly related to the proportion of ribs remaining intact. On average, intact ribs accounted for 78% of thoracic stability. An intact rib cage shifted the axis of rotation unpredictably, but its position remained consistent after partial resection of the ribs. During lateral bending, coupled axial rotation was mild and unaffected by ribs., Conclusion: Because of testing methodology, the rib cage accounted for a greater percentage of thoracic stability than previously estimated. Different rib cage structures resisted motion in different loading planes.

Study Design: In vitro human cadaveric study simultaneously quantifying sagittal plane flexibility and spinal canal stenosis., Objective: To compare biomechanical stability and the change in cross-sectional area during flexion and extension after laminectomy and open-door laminoplasty., Summary of Background Data: Spinal canal stenosis has been quantified in vitro but has not been quantified in studies of laminectomy or laminoplasty., Methods: Cadaveric specimens were loaded in physiologic-range flexion and extension using nonconstraining pure moments while recording segmental angles optoelectronically. Custom flexible tubing was placed within the spinal canal, and water was continuously pumped through the tubing while measuring upstream pressure. Spinal canal cross-sectional area correlated to water pressure, allowing continuous monitoring of the smallest cross-sectional area of the canal. Specimens were tested (1) normal, (2) after modeling stenosis by inserting hemispherical wooden beads in the spinal canal at 3 levels, (3) after open-door laminoplasty at 5 levels, and (4) after expanding laminoplasty to laminectomy., Results: Range of motion (ROM) in the normal, stenotic, and laminoplasty conditions did not differ significantly. However, laminectomy increased ROM significantly more than other conditions. ROM after laminectomy was 13% greater than after laminoplasty. After modeling stenosis, the cross-sectional area decreased to 52% +/- 12% of normal. Laminoplasty restored the cross-sectional area to 70% +/- 12% of normal whereas laminectomy restored cross-sectional area to 101% +/- 4% of normal. Among all conditions, areas differed significantly except normal versus laminectomy., Conclusion: Laminoplasty leaves the spine in a significantly more stable condition than laminectomy. However, laminoplasty failed to relieve stenosis completely. In this study, stenosis was modeled as about 50% occlusion of the spinal canal. The degree of stenosis should be considered in clinical decisions of whether laminectomy or laminoplasty is more appropriate.

Study Design: Fifty-two study participants underwent cervical spine surgery using intraoperative Iso-C imaging with or without spinal navigation., Objectives: To evaluate prospectively the feasibility, advantages, limitations, and applications of Iso-C in cervical spine surgery., Summary of Background Data: Existing stereotactic spinal navigational systems images must be acquired before surgery and typically require cumbersome point-to-point registration. Intraoperative computed tomography (CT) and magnetic resonance imaging (MRI) provide real-time information but can restrict access to the patient, preclude the use of traditional operating room tables, and are time-consuming. The Iso-C allows quick, CT-quality, real-time data acquisition without restricting access to the patient. The data acquired can be automatically transferred to navigational systems with the immediate ability to navigate for anterior or posterior cervical spine procedures., Methods: High-resolution isotropic three-dimensional data sets were acquired using the Iso-C intraoperative fluoroscopy in 52 cervical spine cases. In 30 cases, the data were imported automatically to the StealthStation Treon to support neuronavigation. In 22 cases, a postprocedural intraoperative CT was obtained with the Iso-C primarily to assess the extent of osseous decompression and/or the accuracy of implants or instrumentation. In most cases, a postoperative high-resolution CT image was obtained and compared with the Iso-C data., Results: Successful automated registration suitable for navigation was attained for all anterior and posterior cervical spinal cases. The postprocedural intraoperative Iso-C data were 100% concordant with those of postoperative high-resolution CT as determined by a blinded neuroradiologist., Conclusions: Iso-C intraoperative fluoroscopy is an accurate and rapid way to perform CT-quality image-guided navigation in cervical spinal surgery. In most cases, it obviates the need for postoperative imaging.