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In laminectomy, the laminas above the spinal nerves need to be removed by milling. This process is very dangerous because of the special lesion, and surgeons usually control the milling process by sensing the surgical status. However, in robot-assisted laminectomy, safety monitoring will be difficult because the surgeon is not directly involved. Based on the human tactile perception mechanism, this paper proposes a surgical status perception method using the acceleration sensor and force sensor installed on the robot. The Sinc-convolutional layer is introduced to process high-frequency vibration signals, and the obtained features are processed together with the averaged force signals using a 1D convolutional network. The proposed method classifies the surgical status into 5 categories, and outputs the burr clogging probability. Experiments on animal bones show the effectiveness of the proposed model. In addition, it has also been proved that the fusion of the two tactile signals can significantly improve the status recognition accuracy under changing milling parameters.

Objective To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. Material and methods We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients’ positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as > 50% attenuation in amplitude or > 10% increase in latency of SEP, or abolishment or 50–80% attenuation of MEP. Results Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n = 6) or partial (n = 4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. Conclusion Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

OBJECTIVE Roussouly lumbopelvic sagittal profiles are associated with distinct pathologies or distinct natural histories and prognoses. The associations between developmental lumbar spinal stenosis (DLSS) and native lumbopelvic sagittal profiles are unknown. Moreover, the relative effects of multilevel decompression on lumbar sagittal alignment, geometrical parameters of the pelvis, and compensatory mechanisms for each of the Roussouly subtypes are unknown. This study aimed to explore the association between DLSS and native lumbar lordosis (LL) subtypes. It also attempts to understand the natural history of postlaminectomy lumbopelvic sagittal changes and compensatory mechanisms for each of the Roussouly subtypes and to define the critical lumbar segment or specific lordosis arc that is recruited after relief of the stenosis effect. METHODS A total of 418 patients with multilevel DLSS were grouped into various Roussouly subtypes, and lumbopelvic sagittal parameters were prospectively compared at follow-up intervals of preoperative to < 2 years, 2 to < 5 years, and 5 to ≥ 10 years after laminectomy. The variables analyzed included LL, upper lordosis arc from L1 to L4, lower lordosis arc from L4 to S1, and segmental lordosis from L1 to S1. Pelvic parameters included pelvic incidence, sacral slope, pelvic tilt, and pelvic incidence minus LL values. RESULTS Of the 329 patients who were followed up throughout this study, 33.7% had Roussouly type 1 native lordosis, whereas the incidence rates of types 2, 3, and 4 were 33.4%, 21.9%, and 10.9%, respectively. LL was not reduced in any of the Roussouly subtypes after multilevel decompressions. Instead, LL increased by 4.5° (SD 11.9°—from 27.3° [SD 11.5°] to 31.8° [SD 9.8°]) in Roussouly type 1 and by 3.1° (SD 11.6°—from 41.3° [SD 9.5°] to 44.4° [SD = 9.7°]) in Roussouly type 2. The other Roussouly types showed no significant changes. Pelvic tilt decreased significantly—by 2.8°, whereas sacral slope increased significantly—by 2.9° in Roussouly type 1 and by 1.7° in Roussouly type 2. The critical lumbar segment that recruits LL differs between Roussouly subtypes. Increments and changes were sustained until the final follow-up. CONCLUSIONS The study findings are important in predicting patient prognosis, LL evolution, and the need for prophylactic or corrective deformity surgery. Multilevel involvement in DLSS and the high prevalence of Roussouly types 1 and 2 suggest that spinal canal dimensions are closely linked to the developmental evolution of LL.

Background The K-line in the neck-flexed position (FK-line) on radiography reflects dynamic factors and cervical alignment. Although the FK-line has been reported to affect the neurological recovery after muscle-preserving selective laminectomy for cervical spondylotic myelopathy (CSM), its influence on surgical outcomes after expansive open-door laminoplasty (ELAP) has not been investigated. Methods We reviewed the surgical outcomes in 81 patients with multilevel CSM who underwent C4–C6 ELAP combined with C3 and C7 partial laminectomy using a laminoplasty plate and were followed up for at least 2 years. We defined the K-line (−) as some portion of a bony spur or the vertebral body crossing the FK-line, whereas the FK-line (+) was defined as that never crossing the FK-line. Patients were divided into the FK-line (+) (n = 61) and FK-line (−) groups (n = 20), and the surgical outcomes were compared between the groups. A multivariate analysis was performed to identify the factors that influenced the neurological outcomes. Results The FK-line (−) group had a smaller C2–C7 angle, smaller C7 slope, greater postoperative increase in the C2–C7 sagittal vertical axis, greater kyphosis in cervical flexion and less lordosis in cervical extension, and higher incidence of postoperative residual spinal cord compression. The preoperative-to-postoperative changes in the Japanese Orthopedic Association (JOA) score and JOA score recovery rate (RR) were lower in the FK-line (−) group. The multiple linear regression analysis revealed that the K-line (−) (β = −0.327, P = 0.011) and high signal intensity (SI) changes on T2-weighted imaging (WI) combined with the low SI changes on T1-WI in the spinal cord (β = −0.320, P = 0.013) negatively affected the JOA score RR. Conclusions The FK-line can be used for patients with CSM as a simple indicator of neurological outcomes after ELAP.

Objective The purpose of this study was to assess the ability of intraspinal microstimulation, triggered by action potentials (spikes) recorded in motor cortex, to alter synaptic efficacy in descending motor pathways in an anesthetized rat model of spinal cord injury. Approach Experiments were carried out in adult, male, Sprague Dawley rats with a moderate contusion injury at T8. Four weeks after SCI, and under ketamine/xylazine anesthesia, fine wire electromyographic (EMG) electrodes were implanted into four muscles of the right hindlimb. After exposure of the left motor cortex hindlimb area and laminectomy of the T13-L1 vertebrae, intracortical microstimulation (ICMS) and intraspinal microstimulation (ISMS) were used to determine the location of evoked hip movements in cortex and spinal cord, respectively. For activity-dependent stimulation sessions, a single shank, 16-channel, recording microelectrode was used to detect neuronal spikes in motor cortex that triggered ISMS in the spinal cord grey matter. Spinal cord injured rats were randomly assigned to one of four experimental groups differing by: a) cortical spike-ISMS stimulus delay (10 or 25 ms) and b) number of ISMS pulses (1 or 3). Activity-dependent stimulation sessions were conducted in three consecutive 1-hour conditioning bouts for a total of 3 hours. At the end of each conditioning bout, changes in synaptic efficacy were assessed using ICMS to examine the number of spikes evoked in spinal cord neurons during five minute test bouts. Evoked spikes were recorded, sorted, and displayed in post-stimulus spike histograms in 1-ms bins. Post-stimulus spike histograms and EMG recordings were characterized using stimulus triggered averaging techniques. Main results The results showed that activity-dependent stimulation resulted in an increase in cortically-evoked spikes in spinal cord neurons at specific combinations of spike-ISMS delays and numbers of pulses. Efficacy in descending motor pathways was increased throughout all dorsoventral depths of the hindlimb spinal cord, including the ventral horn, in the vicinity of motor neurons. Changes were evident in some conditions as early as 1 hour after conditioning. EMG responses were never evoked with ICMS pre-or post-conditioning. Significance These results show that after a spinal cord contusion injury, activity-dependent stimulation, consisting of cortical spike-driven ISMS, can increase synaptic efficacy in spared pathways between motor cortex and spinal cord. This suggests that activity-dependent stimulation may serve as an effective therapeutic approach for enhancing descending motor control after spinal cord injury.

Cervical myelopathy is a clinical syndrome caused by compression of the spinal cord between the levels of the C1 and T1 vertebrae. Its clinical presentation can mimic many other degenerative and neurological pathologies, making diagnosis challenging. Diagnosis is confirmed with appropriate imaging studies carefully correlated with history and physical examination. Treatment options are focused on decompression of the spinal canal from an anterior, posterior, or combined anterior and posterior surgical approach depending on the location of compression and patient factors. Outcomes are favorable if treatment is performed prior to severe symptom onset.

OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. METHODS A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran’s Q test, and I2 test performed with R statistical programming software. RESULTS A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference −218.44 mL; 95% CI −379.34 to −57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. CONCLUSIONS TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.

The present study aimed to understand the characteristics of adjacent segment stenosis post-surgery by examining the status of adjacent segment stenosis in patients with long-term follow-up after muscle-preserving selective laminectomy (SL).We examined 43 patients who underwent muscle-preserving SL at a single academic institution and were followed up for10 years. The C2-C7 angle, C2-C7 sagittal vertical axis, range of motion, and C7 slope were measured using an X-ray lateral view. The anterior-posterior diameter of the spinal cord (AP of SC) and anterior-posterior diameter of the dural tube (AP of dura) at adjacent segment were measured using magnetic resonance imaging T2-weighted sagittal section. Residual space for the spinal cord at the adjacent segment (SAC) was calculated as the difference between AP of SC and AP of dura.Four cases had cephalad adjacent segment stenosis at the last follow-up (upper stenosis (US) group), 9 cases had caudal adjacent segment stenosis ( lower stenosis (LS) group), and 30 cases had no stenosis (none (N) group). AP of SC, AP of dura, and SAC at the upper adjacent segment were significantly lower in the US group. AP of dura and SAC at the lower adjacent segment were significantly lower in the LS group. Multivariate logistic regression analysis revealed that the small AP of dura in the upper adjacent segment and small SAC in the lower adjacent segment were risk factors for developing a new stenosis.Decompression should be considered beforehand in adjacent segments with small AP of SC and small AP of dura when performing cervical decompression.

Approximately one in five adults in the United States experiences chronic pain. Over the last 50 years, spinal cord stimulation has become increasingly recognized as a minimally invasive, efficacious treatment modality for the management of chronic pain. The authors report a case study of a 46-year-old female in the first documented spinal cord stimulation simultaneously targeting intractable neuropathic and visceral pain caused by post-laminectomy syndrome and chronic pancreatitis, respectively. This case study demonstrates near-total relief of the patient's neuropathic low back/leg pain and visceral epigastric pain, showing evidence of potential clinical usefulness for spinal cord stimulation as a treatment option in patients who present with a combination of visceral and somatic pain symptoms.Lay abstract Approximately one in five adults in the United States experiences chronic pain. Over the last 50 years, a treatment for chronic pain referred to as spinal cord stimulation has become a promising alternative to back surgery and may minimize the need for strong opioid pain medications. The authors report a case study of a 46-year-old female patient who suffered from chronic pain following back surgery as well as persistent pain from chronic pancreatitis. This case study demonstrates the use of spinal cord stimulation to provide near-total relief of the patient's low back/leg pain and pain from visceral inflammatory symptoms.

Objective Spinal Subdural Haematoma (SSH) is a rare and infrequently reported complication of hemilaminectomy, laminectomy and other spinal decompression surgeries. In this review, we aim to analyse the available literature for reported cases of SSH to better identify risk factors and presenting symptoms, as well as highlighting the importance in prompt investigation and management of SSH to prevent long-term morbidity and chronic neurological deficit. Method A review of the medical literature was undertaken using search terms hemilaminectomy OR laminectomy AND spinal subdural haematoma. All identified reports were screened for language, adult population and human studies. Report abstracts were screened for relevance to question, with SSH occurring postoperatively following hemilaminectomy or laminectomy included. Four reports were included in the review. Conclusion SSH is a rare, emergency condition with neurological deficit that can present as recurrent back pain and acute cauda equina post-operatively following hemilaminectomy and laminectomy procedures. Vigilance, early investigation and surgical evacuation is important in preventing short- and long-term morbidity. Further collation of data and analysis is required to better identify patients at high risk for developing SSH postoperatively.

Introduction Indocyanine green (ICG) is commonly used to visualize cerebral vasculature, particularly in the management of cerebral aneurysms. There have also been attempts to use ICG for visualization of tumors. Injection of ICG followed by immediate fluorescence microscopy is limited by the short time window for imaging and administration and restricted depth of imaging. Second Window Indocyanine Green (SWIG) addresses these issues by allowing for longer contrast times and the imaging of deeper regions of brain tissue. Biopsy of spinal cord lesions is often difficult for a variety of reasons, including the delicate nature of the tissue and differentiating normal from lesional tissue visually, especially in lesions with heterogeneous enhancement. Methods In this case report, we describe the use of second window ICG to facilitate the visualization of a spinal cord lesion and subsequent biopsy of the lesion. Results This patient is a 24-year-old female who had recurrence of a suprasellar germinoma. An MRI of the rest of the neuraxis was performed to assess for the presence of drop metastases. The spinal cord from C2-5 was expanded with areas of patchy enhancement; however, this lesion was asymptomatic. The patient's oncologist requested a biopsy of this lesion to help direct subsequent care of her recurrent germinoma. The day before surgery, the patient had an intravenous injection of ICG dye. She then underwent a C3-5 laminectomy for biopsy of her cervical intramedullary lesion. After opening of the dura, no visible abnormality of the spinal cord could be identified. A Stryker endoscope showed an area of ICG uptake in the cord at approximately the C3-4 level. A midline myelotomy was centered over the ICG demarcated area and several samples were taken for pathology. Final biopsy results determined the lesion to be spinal cord parenchyma with perivascular and intraparenchymal lymphocytes – not consistent with spinal cord tumor or germinoma. Conclusion Second Window ICG is effective in visualizing otherwise visually unremarkable spinal cord lesions. This technology can facilitate biopsy of these lesions and possibly their surgical resection.

OBJECTIVE Chronic adhesive spinal arachnoiditis (SA) is a complex disease process that results in spinal cord tethering, CSF flow blockage, intradural adhesions, spinal cord edema, and sometimes syringomyelia. When it is focal or restricted to fewer than 3 spinal segments, the disease responds well to open surgical approaches. More extensive arachnoiditis extending beyond 4 spinal segments has a much worse prognosis because of less adequate removal of adhesions and a higher propensity for postoperative scarring and retethering. Flexible neuroendoscopy can extend the longitudinal range of the surgical field with a minimalist approach. The authors present a cohort of patients with severe cervical and thoracic arachnoiditis and myelopathy who underwent flexible endoscopy to address arachnoiditis at spinal segments not exposed by open surgical intervention. These observations will inform subsequent efforts to improve the treatment of extensive arachnoiditis. METHODS Over a period of 3 years (2017–2020), 10 patients with progressive myelopathy were evaluated and treated for extensive SA. Seven patients had syringomyelia, 1 had spinal cord edema, and 2 had spinal cord distortion. Surgical intervention included 2- to 5-level thoracic laminectomy, microscopic lysis of adhesions, and then lysis of adhesions at adjacent spinal levels performed using a rigid or flexible endoscope. The mean follow-up was 5 months (range 2–15 months). Neurological function was examined using standard measures. MRI was used to assess syrinx resolution. RESULTS The mean length of syringes was 19.2 ± 10 cm, with a mean maximum diameter of 7.0 ± 2.9 mm. Patients underwent laminectomies averaging 3.7 ± 0.9 (range 2–5) levels in length followed by endoscopy, which expanded exposure by an average of another 2.4 extra segments (6.1 ± 4.0 levels total). Endoscopic dissection of extensive arachnoiditis in the dorsal subarachnoid space proceeded through a complex network of opaque arachnoidal bands and membranes bridging from the dorsal dura mater to the spinal cord. In less severely problematic areas, the arachnoid membrane was transparent and attached to the spinal cord through multifocal arachnoid adhesions bridging the subarachnoid space. The endoscope did not compress or injure the spinal cord. CONCLUSIONS Intrathecal endoscopy allowed visual assessment and safe removal of intradural adhesions beyond the laminectomy margins. Further development of this technique should improve its effectiveness in opening the subarachnoid space and untethering the spinal cord in cases of extensive chronic adhesive SA.

Introduction: Due to the narrow portal of entry, microendoscopic laminectomy (MEL) is associated with a risk of postoperative spinal epidural hematoma (POSEH). This risk might be higher when performing multiple-level (m-) MEL. The purpose of this study is to clarify the incidence rate of POSEH following single-level (s-) and m-MEL by each interlaminar level and identify the risk factors for POSEH following m-MEL. Methods: A total of 379 patients underwent MEL of the lumbar spine (s-MEL, n=141; m-MEL, n=238). We determined the incidence of POSEH following s-MEL and m-MEL by each interlaminar level. For m-MEL, we clarified the correlation between POSEH and possible risk factors, such as operative findings, the sequence of operated interlaminar levels, and the preoperative cross-sectional dural area (CSA) on magnetic resonance imaging. Results: The incidence rate at L2/3 was significantly higher than that at L3/4 and L4/5. Patients who underwent L2/3 decompression at the end of the procedure showed a higher incidence of POSEH at the L2/3 level. Preoperative spinal stenosis was associated with POSEH at the L2/3 level, and CSA of 56 mm2 was a predictive factor for POSEH. Logistic regression analysis revealed that both were significant risk factors. Conclusions: In patients undergoing m-MEL, the incidence of POSEH is highest at the L2/3 level, and treatment of the L2/3 level at the end of the procedure and the presence of spinal stenosis are risk factors for POSEH.

Introduction: Kyphotic deformity is common after spinal tumor resection surgery. An adequate field of view is needed to resect the spinal cord tumor, and, in some cases, the facet joint must be removed during laminectomy, and fixation may be performed simultaneously. In this study, we investigated the incidence of postoperative deformity after spinal tumor resection and the factors associated with postoperative deformity. Methods: We retrospectively analyzed patients who underwent thoracic spinal cord tumor resection at a single institution between 2010 and 2017 and were followed up for at least 24 months after surgery. Fifty percent or more of the facet joint was removed during the laminectomy, and fixation was performed simultaneously. Patients were divided into two groups, with and without kyphotic deformity. Patient demographic characteristics (age at surgery and gender), whether they underwent primary surgery or reoperation, tumor level, pathological type, and surgical method were compared. Multiple linear regression analysis was performed to identify independent predictors of kyphotic deformity. Results: Thirty-one patients were found to be eligible. Thirteen patients had intramedullary spinal cord tumors. Laminectomy was performed in 52% (N=16), laminoplasty in 6% (N=2), and laminectomy and/or laminoplasty combined with fusion in 42% (N=13) of the patients. During a mean follow-up period of 66.8 months, 12 (39%) patients had postoperative kyphosis deformities, of which one patient (3%, a 12-year-old girl who underwent combined postoperative radiation therapy) underwent kyphosis correction surgery three years after surgery. The number of laminectomies was independently associated with kyphotic deformity. Conclusions: Although kyphotic deformity after spinal tumor surgery was observed in about 39% of the patients, corrective surgery was rarely required due to the progression of the deformity. The high number of laminectomies is a risk factor for postoperative kyphosis, and prophylactic fixation may be considered in cases of multiple laminectomies.

Background The open-door laminoplasty has been used to treat cervical spondylotic myelopathy. This technique has been applied to the surgical treatment of thoracic and lumbar spinal canal tumors instead of simple laminectomy or hemilaminectomy. However, previously reported laminoplasty methods did not keep posterior supporting elements intact such as the laminae and the spinous processes with supraspinous and interspinous ligaments, and almost all of them needed instruments for the fixation of reconstructed laminae. The purpose of this paper is to introduce our open-door laminoplasty method, which keep all posterior supporting elements intact and reconstruct the laminae without instrument. Methods Eight patients (mean age 61 years) underwent en bloc open-door laminoplasty in the thoracic and lumbar spine for resection of intradural spinal tumors. Two grooves are made bilaterally on the laminae just medial side of the facet joints. One-half of each spinous process of the adjacent vertebrae above and below the laminoplasty is cracked diagonally to create a green stick fracture and bent to the hinged side for sufficient elevation of the laminar flap. After tumor resection, the laminar flap is restored to its original site, resulting in the complete preservation of the posterior supporting elements. Results Operative exposure was good and permitted complete resection. No complications such as postoperative spinal canal stenosis or kyphosis were observed. Computed tomography(CT) indicated that bony fusion occurred in all cases. Conclusion The supraspinous and interspinous ligaments above and below laminoplasty were kept intact during surgery in our method. Therefore, the continuity of posterior supporting elements (laminae and spinous processes connected by supraspinous and interspinous ligaments) were completely preserved.

Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.

BACKGROUND CONTEXT Early postoperative MR images are frequently necessary after spine surgery. The appearance of commonly used adjunct hemostatic agents and dural sealants in MR images has not been systematically evaluated. PURPOSE The purpose of this experimental study was to systematically analyze and describe the characteristics of the most commonly applied hemostatic agents and dural sealants in spine surgery on early postoperative MR images. STUDY DESIGN Cadaver Study METHODS Four commonly applied dural sealants (Duraseal, Bioglue, Tachosil, Tisseel) and five commonly used hemostatic agents (Surgiflo, Bonewax, , Spongostan, Gelfoam, Avitene) were investigated. The experimental setting involved a human cadaver where a standard left-sided laminotomy was performed on nine levels of the thoracolumbar spine, and the materials were separately applied and mixed with fresh blood or water for hemostatic and dural sealants, respectively. The cadaver model was scanned at a 3 Tesla MRI and the imaging findings for all materials were compared to the surrounding tissue and systematically reported. RESULTS All investigated dural sealants and hemostatic agents were distinguishable from the surrounding tissue on MR images with different appearances on the MR sequences. A detailed atlas for the identification of the materials in postoperative spine MRI was established. CONCLUSION Commonly used hemostatic agents and dural sealants can be successfully identified on early postoperative spine MRI. CLINICAL SIGNIFICANCE Knowledge about MRI appearances of commonly used adjunct surgical materials helps in interpretation of postoperative imaging and supports clinical decision making.

Background Arachnoid web (AW) is a rare but probably underestimated cause of spinal cord injury that is complex to diagnose due to subtle MRI findings and similarities to other better-known diseases such as arachnoid cyst (AC) or transdural spinal cord herniation (TSCH). Increased recognition of AW is mandatory since delay in diagnosis can lead to potentially serious neurological sequelae. Case presentations We report two additional cases of AW for didactic purposes, with special emphasis on the distinctive MRI and intraoperative findings. Both patients presented with progressively worsening neurological symptoms, including proprioceptive ataxia, motor weakness, numbness and neuropathic pain. The diagnosis of AW was suspected on the basis of specific MRI criteria, especially the so-called “scalpel sign”. Formal confirmation of the diagnosis was obtained in two patients that were managed surgically. Postoperative follow-up demonstrated significant functional recovery. Discussion There is a need for better recognition of AW by the medical community. Careful analysis of MRI semiology is crucial for the distinction between AW, AC and TSCH. Prompt and accurate diagnosis is mandatory to conserve functional prognosis, since appropriate surgical treatment with AW resection is curative, halting or even resolving the neurological symptoms.

Laminectomy with instrumented fusion (LF) has demonstrated better prevention of ossification of posterior longitudinal ligament (OPLL) growth compared to laminoplasty (LP). There remains uncertainty, however, as to which surgical approach is more beneficial with respect to clinical outcomes and complications. We retrospectively reviewed 273 cervical OPLL patients of more than 3 levels, from the two institutions’ databases, who underwent LF or LP between January 1998 and January 2016. Each 273 patient (85 with LF, 188 with LP) was assessed for postoperative neurologic and radiologic outcomes, complications and reoperations. The mean length of follow-up was 40.11 months. There were baseline differences between cohorts. Overall, postoperative JOA recovery rate at last follow up was significantly better in the LP group with similar improvement in visual analog neck score. Postoperative C2-7 Cobb angle was decreased compared to baseline for both LF and LP cohorts, but there was no significant difference between groups. Complications occurred in 19 (22.35%) LF patients, and 11 (5.85%) LP patients, with higher incidence of C5 palsy and instrumentation failure in the LF group. Four LF patients (4.71%) and five LP patients (2.66%) underwent reoperation during the follow up period.

Optimal restoration of the L5-S1 disc angle (DA) is an important surgical goal in spinal reconstructive surgery. Anterior approach is beneficial for L5-S1 DA reconstruction and fusion. However, factors associated with a greater DA restoration in oblique lateral interbody fusion (OLIF) at L5-S1 have not been studied.This study aimed to identify factors that aid in achieving a greater DA in OLIF at L5-S1.A retrospective analysis.This study involved 61 consecutive patients who underwent OLIF at L5-S1 for lumbar degenerative disease and were followed for more than 1 year. Patients with incomplete data or posterior column osteotomy at L5-S1 were excluded.The L5-S1 DA was measured preoperatively, postoperatively, and at the last follow-up on standing lateral lumbar radiographs. The associations between demographics and/or surgical and/or radiological factors and the L5-S1 DA at the last follow-up were analyzed using multiple regression analysis.Demographics and surgical factors were reviewed from the medical records with respect to age, sex, body mass index, bone mineral density, diagnosis, surgery level, cage parameters (cage lordotic angle and height), laminectomy performed and/or not performed, estimated blood loss, operative time, configuration of the left common iliac vein. Radiological factors were measured with respect to sagittal parameters, the L5-S1 disc parameters, and the postoperative cage parameters.The mean preoperative DA at L5-S1 was 5.4±5.0°, which increased to 18.9±5.6° postoperatively (p.001) and was maintained as 16.5±5.9° at the last follow-up (p.001). The preoperative DA, end plate lesions, anterior spur, facet joint osteoarthritis, or cage position at L5-S1 did not affect the DA at the last follow-up (all p.05). Multiple regression analysis showed four independent variables, including increased age, increased cage lordotic angle, laminectomy performed, and absence of cage subsidence as the factors associated with the greater DA at L5-S1.OLIF at L5-S1 showed favorable DA restoration regardless of the preoperative conditions. To achieve a greater DA, surgeons should try to distract the anterior disc space for insertion of a larger lordotic cage. Laminectomy during posterior fixation is recommended for achieving additional DA restoration.

OBJECTIVE Although evaluating tissue elasticity has various clinical applications, spinal cord elasticity (SCE) in humans has never been well documented. In this study, the authors aimed to evaluate the impact of compression on human SCE in vivo. METHODS The authors prospectively assessed SCE using intraoperative shear wave elastography (SWE). All consecutive patients undergoing spinal cord (SC) decompression (laminectomy or corpectomy) between June 2018 and June 2019 were included. After intraoperative exposure of the patient’s dura mater, at least three SWE measurements of the SC and its coverings were performed. Intraoperative neurological monitoring in the form of motor and somatosensory evoked potentials was utilized. Cases were divided into two groups based on the state of SC compression following bone removal (laminectomy or corpectomy): patients with adequate decompression (the decompressed SC group [DCG]) following bone removal and patients with remining compression, e.g., compressing tumor or instability (the compressed SC group [COG]). RESULTS A total of 25 patients were included (8 females and 17 males) with a mean age of 48.28 ± 21.47 years. Most cases were degenerative diseases (10 cases) followed by tumors (6 cases), and the compression was observed at cervical (n = 14), thoracic (n = 9), and conus medullaris (n = 2) levels. The COG (6 cases) expressed significantly higher elasticity values, i.e., greater stiffness (median 93.84, IQR 75.27–121.75 kPa) than the decompressed SC in DCG (median 9.35, IQR 6.95–11.22 kPa, p < 0.001). Similarly, the compressed dura mater in the COG was significantly stiffer (mean ± SD 121.83 ± 70.63 kPa) than that in the DCG (29.78 ± 18.31 kPa, p = 0.042). Following SC decompression in COG, SCE values were significantly reduced (p = 0.006; adjusted for multiple comparisons). Intraoperative monitoring demonstrated no worsening from the baseline. CONCLUSIONS The current study is to the authors’ knowledge the first to quantitatively demonstrate increased stiffness (i.e., elasticity value) of the human SC and dura mater in response to external compression in vivo. It appears that SCE is a dynamic phenomenon and is reduced following decompression. Moreover, the evaluation of human SCE using the SWE technique is feasible and safe. Information from future studies aiming to further define SCE could be valuable in the early and accurate diagnosis of the compressed SC.

OBJECTIVES Different anesthesia techniques are used for surgical implantation of paddle lead electrodes for neurostimulation through a laminectomy. We wanted to evaluate the use of dexmedetomidine as sedative for this procedure in a series of patients. Second, we wanted to verify whether the stimulation pattern and position of the electrode had to be changed during the procedure guided by the patient's feedback. MATERIAL AND METHODS Twenty-five consecutive patients received surgical implantation of a spinal cord stimulation electrode under conscious sedation using dexmedetomidine and local anesthesia. We evaluated the effects of the administered drug, the patient comfort, and the adequacy of the stimulation pattern. RESULTS Twenty-four patients completed the procedure with only dexmedetomidine and local anesthetic. Infusion was started on average 55 minutes (sd 29) prior to incision. The mean dose of lidocaine was 430 mg (sd 95). There were no significant hemodynamic changes. Median time to reach Modified Aldrete's score postoperative was 67 minutes (sd 38). In 46% of the patients, the position of the electrode was changed guided by the feedback of the patient. More than half of the patients remember most details of the procedure. Only four patients mentioned substantial discomfort and only three would definitely not want to undergo this procedure again. CONCLUSIONS Implantation of spinal cord stimulation electrodes through a surgical laminectomy using dexmedetomidine is a safe and feasible procedure with adequate comfort for patient and surgeon. This way of working increases the optimal position of the electrode resulting in the most convenient stimulation pattern and avoiding revisions.

Objective To determine if there is a difference in either the cervical alignment or the clinical outcomes in cervical ossification of the posterior longitudinal ligament (OPLL) patients who underwent laminectomy with instrumented fusion (LIF) ending at C6, C7, or proximal thoracic spine for the treatment of multilevel OPLL, and to find out the appropriate distal fusion level. Methods This was a single‐center retrospective study. In total, 36 patients with cervical OPLL who underwent three or more level LIF in our institution between January 2015 and January 2017 were enrolled. They were divided into three groups according to their distal ends: C6 (nine females and 11 males, 60.45 ± 9.68 years old), C7 (four females and six males, 61.60 ± 10.29 years old), and T‐group (two females and four males, 64.33 ± 8.12 years old). Radiographic (compression level, classification of OPLL, occupying rate, C2‐7 cobb angle, C2‐7 sagittal vertical axis, and fusion level) and clinical outcomes (NDI score, operative time, and blood loss) were compared. Predictors of postoperative sagittal imbalance were also identified according to if the postoperative C2‐7 SVA was greater than 40 mm. The sensitivity and specificity of preoperative parameters predicting postoperative cervical stability were evaluated via the receiver operating characteristic (ROC) curve. Results All patients were followed up at least 1 year. The blood loss in T group was significantly more than C6 or C7 group. The length of fusion level became significantly longer when the caudal level extended to the thoracic spine. The age, preoperative SVA, and NDI score at follow‐up were significantly greater in the imbalance group. At the final follow‐up, the cervical lordosis tended to be straight and the C2‐7 SVA tended to be greater when the caudal level of fusion was extended to upper thoracic segment. Further ROC curve analysis suggested that patients’ age had a sensitivity of 75.00%, specificity of 79.17% for cervical stability, and the AUC was 0.844 (P 67 years) with great preoperative SVA (>30 mm), terminating at C6 was recommended to limit the invasion of cervical extensor muscles, provided the decompression was adequate., At the final follow‐up, the cervical lordosis tended to be straight and the C2‐7 SVA tended to be greater when the caudal level of fusion was extended to upper thoracic segment. However, for elderly patients (>67 years) with great preoperative SVA (>30 mm), terminating at C6 was recommended to limit the invasion of cervical extensor muscles.

Objective We examined the role of intrawound vancomycin powder as prophylaxis against postoperative surgical site infection (SSI) after spinal cord stimulator (SCS) implantation. Methods We performed a retrospective analysis of 153 consecutive patients who had undergone permanent SCS implantation surgery via open laminectomy between 2014 and 2020. We queried the patients' medical records for patient age, sex, relevant medical history, and whether intrawound vancomycin had been administered. We compared the rates of SSI (primary outcome) and seroma (secondary outcome) within 3 months after surgery between the vancomycin and no-vancomycin groups. Finally, we conducted multivariable logistic regression analyses to identify independent predictors of postoperative SSI or seroma. Results Of the 153 patients, 59% were women, and the average age was 65.4 years. Overall, 3 patients (2%) had developed an SSI: 2 (methicillin-resistant Staphylococcus aureus, Klebsiella) in the vancomycin group and 1 (methicillin-sensitive Staphylococcus aureus) in the no-vancomycin group. This difference in SSI rate between the 2 groups was insignificant (P = 0.73). Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P = 0.04). Multivariate logistic regression failed to identify any perioperative characteristics as independent predictors of postoperative SSI or seroma. Conclusions Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation. We failed to draw any definitive conclusions regarding its efficacy, despite referencing the largest single case series of SCS implantation to date.

To evaluate the comparative effectiveness and safety of open-door laminoplasty (OLP), French-door laminoplasty (FLP), laminectomy and fusion (LF), and laminectomy alone (LA) in treating multilevel degenerative cervical myelopathy (MDCM). Embase, PubMed, and Cochrane library were searched from their inception date to 7 January 2021. Randomized controlled trials and cohort studies comparing OLP, FLP, LF, and LA were identified to perform a network meta-analysis (NMA). A total of 30 studies with 2671 patients were included. Our NMA results showed no significant difference between LF and OLP, but both are superior to LA and FLP in the comparison of JOA (Japanese Orthopaedic Association) score improvement. LF showed a most unsatisfactory outcome in postoperative range of motion (ROM) compared with LA or OLP or with FLP. For the complication outcome, no significant differences were found. The surface under the cumulative ranking curves (SUCRA) for JOA improvement was as follows: LF, OPL, LA, and FLP. For ROM reduction it was LA, OPL, FPL, and LF. For complications it was LF, LA, OLP, and FLP. Considering all the evaluated criteria, none of the procedures showed the best outcome with least complications and optimal efficacy. However, OLP can be most recommended because of its second-ranking spectra in both of JOA improvement and ROM reduction, also with an acceptable incidence of complications, with the third least.

Cervical kyphosis is rare in the pediatric population. It may be syndromic or acquired secondary to laminectomy, neoplasia, or trauma. Regardless, this should be avoided to prevent progressive spinal deformity and neurological deficit. Long-term follow-up is needed to evaluate fusion status, spine growth, potential instability, and neurological function. A retrospective review of 27 children (6 months to 16 years) with cervical kyphotic deformity was performed and limited to the MRI era until 2008, to provide a long-term follow-up after which complex instrumentation was available. There were 27 patients, 19 syndromic (average age 5.36 years), and 8 non-syndromic (average age 14 years). Syndromes encountered were spondyloepiphyseal dysplasia (SED) 4, spondylometaphyseal dysplasia 1, unnamed collagen abnormality syndrome 1, osteogenesis imperfecta (OI) 2, Aarskog syndrome 1, Weaver syndrome 1, Larsen syndrome 1, multiple cervical level disconnection syndrome 1, Klippel-Feil 3, congenital absence of C2 pars 4. Non-syndromic cases; 2 with neurofibromatosis (NF1) and prevertebral tumors, fibromatosis 1, spontaneous kyphosis 1, and postlaminectomy 4. Factors considered were age, pathology, flexibility on cervical spine dynamic films, reduction with traction and spinal cord compression. Patients with flexible kyphosis underwent dorsal fixation. Children with non-flexible ventral compression/kyphosis had crown halo traction. Irreducible kyphosis had ventral decompression and fusion as well as dorsal fusion. Eleven of 19 syndromic children with flexible and reducible kyphosis underwent dorsal fixation alone. Four of 8 non-syndromic (2 NF1) needed ventral and dorsal approaches. The preoperative deformity (global and local Cobb angles) as well as neurological status improved. Growth during follow-up was not impaired, and we did not encounter instability or junctional kyphosis. The only complications were seen in syndromic patients. One patient with SED showed delayed cantilever bending of the ventral fusion mass requiring reoperation, and 1 other OI child had left C5 and C6 nerve root weakness after anterior C4 and C5 decompression which resolved over 1 year. One child with SED developed cervicothoracic junction scoliosis 18 years later after thoracic scoliosis surgery. Syndromic pathology presented early with neurological dysfunction and 24% had rigid kyphosis. An attempt at traction/reduction was successful as in Tables 1 and 2. The majority exhibited long-term improvement in kyphosis and function. A treatment algorithm and literature review is presented.

STUDY DESIGN Basic science study. OBJECTIVE The aim of this study was to examine whether epidural fat tissue (EFT) transplantation can prevent epidural adhesion after laminectomy more efficiently than subcutaneous fat tissue (SFT) transplantation. SUMMARY OF BACKGROUND DATA Epidural adhesion is almost inevitable after laminectomy. Although many materials have been used to prevent adhesion, none has been widely accepted. As EFT is an ectopic fat tissue located on the dura mater and there is no adhesion between EFT and the dura mater, we focused on the efficacy of EFT for adhesion prevention. METHODS We examined the differences in histology and gene expression between EFT and SFT of mice. We performed laminectomy at the 10th thoracic level and immediately transplanted EFT or SFT to the dura mater in mice. At six weeks after transplantation, we performed histological and gene expression analyses and evaluated the adhesion tenacity. In addition, we examined the characteristic differences between human EFT and SFT. RESULTS The adipocytes of EFT were significantly smaller than those of SFT in mice and humans. The gene expression of inflammatory cytokine and fibrosis-related factors was significantly higher in SFT than in EFT. At six weeks after transplantation, the percentage of the remaining fat area over the dura mater was significantly greater in the EFT group than in SFT group, and the adhesion tenacity score was significantly lower in the EFT group than that in the SFT group. An RNA sequencing analysis revealed 1921 differentially expressed genes (DEGs) between human EFT and SFT, and a Gene Ontology term associated with the inflammatory response was most highly enriched in SFT. CONCLUSIONS EFT has different molecular and histological profiles from SFT and EFT grafting is more effective for epidural adhesion prevention than conventional SFT transplantation after laminectomy in a mouse model.Level of Evidence: N/A.

STUDY DESIGN Retrospective cohort study. OBJECTIVE a) Compare operative variables, complications, and patient-reported outcomes (PROs) in patients with an upper instrumented vertebrae (UIV) of C2 vs. C3/4, and b) assess outcomes based on C2 screw type. SUMMARY OF BACKGROUND DATA When performing elective posterior cervical laminectomy and fusion (PCLF), spine surgeons must choose the upper instrumented vertebrae (UIV) at the subaxial cervical spine (C3/4) versus C2. Differences in long-term complications and PROs remain unknown. METHODS A single-institution, retrospective cohort study from a prospective registry was conducted. All patients undergoing elective, degenerative PCLF from 12/2010-06/2018 were included. Patients were divided into a UIV of C2 vs. C3/4. Groups were 2:1 propensity matched for fusion extending to the thoracic spine. Demographics, operative, perioperative, complications, and 1-year PRO data were collected. RESULTS 117 patients underwent elective PCLF and were successfully propensity matched (39 C2 vs. 78 C3/4). Groups were similar in fusion extending to the thoracic spine (p = 0.588). Expectedly, the C2 group had more levels fused (5.63 ± 1.89) compared to the C3/4 group (4.50 ± 0.91) (p = 0.001). The C2 group had significantly longer operative time (p

Objective : It is challenging to make solid fusion by posterior screw fixation and laminectomy with posterolateral fusion (PLF) in thoracic and thoracolumbar (TL) diseases. In this study, we report our experience and follow-up results with a new surgical technique entitled posterior thoracic cage interbody fusion (PTCIF) for thoracic and TL spine in comparison with conventional PLF.Methods : After institutional review board approval, a total of 57 patients who underwent PTCIF (n=30) and conventional PLF (n=27) for decompression and fusion in thoracic and TL spine between 2004 and 2019 were analyzed. Clinical outcomes and radiological parameters, including bone fusion, regional Cobb angle, and proximal junctional Cobb angle, were evaluated.Results : In PTCIF and conventional PLF, the mean age was 61.2 and 58.2 years (p=0.46), and the numbers of levels fused were 2.8 and 3.1 (p=0.46), respectively. Every patient showed functional improvement except one case of PTCIF. Postoperative hematoma as a perioperative complication occurred in one and three cases, respectively. The mean difference in the regional Cobb angle immediately after surgery compared with that of the last follow-up was 1.4° in PTCIF and 7.6° in conventional PLF (p=0.003), respectively. The mean durations of postoperative follow-up were 35.6 months in PTCIF and 37.3 months in conventional PLF (p=0.86).Conclusion : PTCIF is an effective fusion method in decompression and fixation surgery with good clinical outcomes for various spinal diseases in the thoracic and TL spine. It provides more stable bone fusion than conventional PLF by anterior column support.

Objective Vertebral hemangiomas are benign but highly vascular lesions and are one of the most common lesions of the vertebral column. Anterior soft-tissue compression of spinal cord due to vertebral body hemangioma is challenging to manage. Our objective was to assess long-term clinical and radiologic effects of direct transpedicular absolute alcohol embolization, laminectomy, and short-segment instrumented fusion on resolution of extraosseous epidural soft tissue and improvement in myelopathy in cases of vertebral hemangioma causing anterior soft-tissue compression. Materials and Methods This was a retrospective analysis that included patients with single-level vertebral hemangioma with anterior intraspinal soft-tissue growth causing spinal cord compression and clinical features of myelopathy between June 2007 and June 2019 at authors' institute. Transpedicular vertebral body injection of absolute alcohol, laminectomy, and pedicle screw rod instrumentation was performed in all patients. Clinicoradiologic outcomes of surgery were noted. We proposed a grading system for the extent of anterior extraosseous epidural soft-tissue compression. Results In total, 14 patients were included in study. Their mean age was 28.4 ± 14.4 years. Mean follow-up duration was 67.5 ± 36.2 months. All patients had preoperative radiologic grade 4 compression. Postoperative radiologic grading improved to grade 1 in 4 (28.6%), grade 2 in 8 (57.1%), and grade 3 in 2 (14.3%). All the patients improved neurologically after surgery. Eleven patients improved to American Spinal Injury Association (ASIA) grade E, 2 improved to ASIA D, and 1 improved to ASIA C at the last follow-up visit. Conclusions Vertebral hemangiomas with anterior extraosseous epidural extension causing spinal canal compromise and myelopathy can be managed with direct transpedicular ethanol embolization, laminectomy, and short-segment instrumented fusion with resolution of the extraosseous soft tissue and improvement in myelopathy. The procedure is relatively simple, cost effective, and has a good outcome.

Background Composite hemangioendothelioma is an extraordinarily rare form of vascular neoplasm which develops predominantly in the skins and soft tissues of the adults. Neuroendocrine marker expression in composite hemangioendothelioma is considered as specifically relevant to the more aggressive behavior. Case presentation The patient was a 71-year-old man complaining continuous back pain. Computed tomography (CT) showed that 10 cm of contrast-enhanced soft tissue mass was occurring on the right posterior chest wall and developing adjacent to the spinal canal. Via the laminectomy, the tumor end was identified and separated from the dura mater. Then, via the posterolateral thoracotomy, the en bloc resection was achieved by separating the tumor from the diaphragm and vertebras. Histologic examination showed a complex combination of epithelioid and retiform hemangioendothelioma areas which were positive for anti-synaptophysin staining. At 12-month follow-up, there were no signs of tumor recurrence on CT, and the patient had no symptom. Conclusions We achieved the complete resection of a huge thoracic neuroendocrine composite hemangioendothelioma developing adjacent to the spinal canal. The combination of the posterior lumbar laminectomy and the following posterior thoracotomy is a viable approach to radically resect a thoracic neuroendocrine composite hemangioendothelioma involving chest wall.

Unlike tandem stenosis of the cervical and lumbar spine, tandem cervical and thoracic stenosis (TCTS) of the spine is less common, and the approach and order of intervention are controversial. We aim to review the literature to evaluate the incidence and interventions for patients with cervical and thoracic stenosis. We provide illustrative cases to demonstrate that thoracic myelopathy in the setting of asymptomatic cervical stenosis can be treated safely. A systematic review of the literature through electronic databases of PubMed, EMBASE, Web of Science, and Cochrane Library was performed to present the current literature that evaluates TCTS as it relates to incidence and surgical interventions. We also present two cases of patients undergoing operative intervention for thoracic myelopathy in the setting of concurrent cervical stenosis. A total of 26 English original studies and case reports were identified. Nine studies evaluated the incidence of TCTS. 20 studies with a total of 168 patients with TCTS presented information on surgical intervention options. There is an overall aggregate incidence of 11.6% (530/4751) based on incidence studies. 165 patients underwent thoracic intervention. Of these patients, 63 patients underwent cervical intervention first, 29 underwent thoracic intervention first, and 73 underwent simultaneous, single-stage intervention. In patients presenting with myelopathy, both cervical and thoracic spine should be evaluated for TCTS. Order of operative intervention is tailored to clinical and radiographic information. In cases of thoracic myelopathy with asymptomatic cervical stenosis, thoracic intervention can be pursued with precautions to prevent further cervical cord injury.

Effective postoperative pain management after lumbar disc surgery reduces complications and improves postoperative care. The purpose of this prospective, randomized, double-blind, placebo-controlled clinical study is to evaluate the effects of IV paracetamol and ibuprofen on postoperative pain, morphine consumption and side effects of morphine in patients who underwent lumbar disc surgery.Seventy-five patients aged 18-85 years scheduled for lumbar disk surgery with a single level laminectomy included in this study. All patients received morphine with an IV patient-controlled analgesia device during the first postoperative 24hour. The patients were divided randomly and double-blinded into three groups (control, paracetamol and ibuprofen). The demographic characteristics and procedure data, VAS score, cumulative morphine consumption, opioid-related side effects were recorded.There was no significant difference regarding to demographic characteristics, comorbidities, and durations of anesthesia and surgery. There was a significant difference between all groups regarding to total morphine consumption (P0.001). IV ibuprofen significantly reduced the total morphine consumption in comparison with control and paracetamol (P0.001). Repeated measures ANOVA showed in all periods of the study that VAS score was significantly lower in ibuprofen (P0.001), but not in paracetamol (P=0.394) in comparison with control. There was no difference between groups regarding postoperative heart rate, mean arterial pressure, nausea-vomiting, pruritus and urinary retention.This study showed that pain scores and morphine consumption, but not the side effects of patient-controlled analgesia during 24hours after the lumbar disk surgery, were significantly reduced by IV ibuprofen as a supplemental analgesic when compared with controls and paracetamols.

STUDY DESIGN This was a systematic review and meta-analysis study. OBJECTIVE The purpose of this study is to evaluate the available evidence on the preservation of posterior midline structures in decompression surgery for lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA The gold-standard treatment for LSS refractory to conservative management is facet-preserving laminectomy. The question remains whether the midline structures should be preserved in decompression surgery for LSS. MATERIALS AND METHODS We performed a systematic review of the Medline, PubMed, Embase, and Cochrane databases in search of published reports comparing midline structure preservation (MSP) and conventional laminectomy (CL) for LSS. The population was divided into 2 groups: (1) MSP group (intervention) and (2) CL group (control). The various outcome parameters including blood loss, operation time, hospital stay, back and leg pain, functional scores including Oswestry Disability Index (ODI) score, Japanese Orthopedic Association score, and 36-Item Short Form Survey (SF-36) scores, satisfaction, and instability rates were analyzed. Data were extracted and aggregated for meta-analysis. RESULTS Of the published reports, 16 met our inclusion criteria with an aggregated 540 in the intervention and 538 in the control groups, respectively. The aggregated data demonstrated patients undergoing MSP had significantly decreased back pain Visual Analog Scale compared with CL, regardless of time after surgery (P=0.007). The MSP group also showed a significantly lower Oswestry Disability Index score and SF-36 Mental Component Summary score (P=0.005 and 0.03, respectively) and longer 6-month walking distance (P

STUDY DESIGN Retrospective cohort comparison study. OBJECTIVE The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF. MATERIALS AND METHODS Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups. RESULTS In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%). CONCLUSIONS The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures. LEVEL OF EVIDENCE Level III.