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Electrical stimulation is an important adjuvant therapy for spinal surgery, but whether receiving electrical stimulation can improve the fusion rate after spinal surgery is still controversial. The purpose of this study was to analyse and evaluate the effect of electrical stimulation on the fusion rate after spinal surgery. We systematically searched for related articles published in the PubMed, Embase and Cochrane Library databases on or before September 30, 2023. The odds ratio (OR) with 95% confidence interval (CI) and the fusion rates of the experimental group and the control group were calculated by a random-effects meta-analysis model. The analysis showed that receiving electrical stimulation significantly increased the probability of successful spinal fusion (OR 2.66 [95% CI 1.79-3.97]), and the average fusion rate of the electrical stimulation group (86.8%) was significantly greater than that of the control group (73.7%). The fusion rate in the direct current (DC) stimulation group was 2.33 times greater than that in the control group (OR 2.33 [95% CI 1.37-3.96]), and that in the pulsed electromagnetic field (PEMF) group was 2.60 times greater than that in the control group (OR 2.60 [95% CI 1.29-5.27]). Similarly, the fusion rate in the capacitive coupling (CC) electrical stimulation group was 3.44 times greater than that in the control group (OR 3.44 [95% CI 1.75-6.75]), indicating that regardless of the type of electrical stimulation, the fusion rate after spinal surgery improved to a certain extent. Electrical stimulation as an adjuvant therapy seems to improve the fusion rate after spinal surgery to a certain extent, but the specific effectiveness of this therapy needs to be further studied., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Different methods of sagittal alignment assessment compete for predicting adverse events after adult spinal deformity (ASD) surgery. We wanted to study which method provides greater benefit., Methods: Retrospective study of 391 patients operated for ASD, with > 6 instrumented levels, fused to the pelvis, and 2 years of follow-up. Three alignment methods were analyzed 6-week postoperatively: (1) Roussouly mismatch; (2) GAP score/GAP categories; (3) T4-L1-Hip axis. Binary logistic regression generated models that best predict the following adverse events: mechanical complications (MC): in general and isolated (PJK, PJF, rod breakage); reinterventions (in general and after MC); and readmissions. ROC/AUC analysis was also implemented. In a second regression round, we added different variables that were selected on univariate analysis-demographic, surgical, and radiographic-to complete the models., Results: The best predictor parameters in most models were T4-L1PA mismatch and GAP score; we could not prove a predictive ability of the Roussouly mismatch. The T4-L1PA mismatch best predicted general MC, PJK, PJK + PJF, and readmission, while the GAP score best predicted PJF and reinterventions (for MC and for any complication). However, the variance explained by these models was limited (Nagelkerke's R2 = 0.031-0.113), with odds ratios ranging from 1.070 to 1.456. ROC curves plotted an AUC between 0.57 and 0.70. Introducing additional variables (demographic, surgical, and radiographic) improved prediction in all the models (Nagelkerke's R2 = 0.082-0.329) and allowed predicting rod breakage., Conclusion: The T4-L1-Hip axis and GAP score show potential in predicting adverse events, surpassing the Roussouly method. Despite partial efficacy in complication anticipation, recognizing postoperative sagittal alignment as a key modifiable risk factor, the crucial need arises to integrate diverse variables, both modifiable and non-modifiable, for enhanced predictive accuracy., Level of Evidence: Level IV., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background Context: Surgical site infections (SSI) are one of the common complications following spinal fusion surgery. Unfortunately, several studies had shown conflicting results regarding optimal timing of surgical antimicrobial prophylaxis (SAP) administration. Due to limitations in population homogeneity and sample size, these studies have not provided significant statistical correlations or clear practical recommendations., Purpose: The purpose of the study was to investigate the impact of timing of cefuroxime SAP on the risk of SSI in patients undergoing spinal fusion surgery, and to determine the optimal timing of administration., Design: Retrospective nested case-control study., Patient Sample: We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021., Outcome Measure: In the current study, the primary outcome measure was SSI., Methods: This was a retrospective nested case-control study. All consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021 formed a retrospective cohort. For each SSI case, 2 controls free of SSI at the time of the index date of their corresponding case were selected, matched by age, sex, and calendar year. Electronic record and radiographic data were reviewed retrospectively in electronic database. SAP related data included timing of administration, preoperative dose, intraoperative second dose, and postoperative use. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Subsequently, subgroup analyses were conducted to assess the robustness of the statistical associations., Results: According to the preplanned statistical scheme and matching factors, we matched 236 controls for these SSI cases, and the subsequent statistical analysis was performed on these 354 patients. After adjusting for confounding factors, the results indicated that the risk of SSI was 70% higher in the group receiving SAP 31 to 60 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=1.732, 95%CI 1.031-2.910, p=.038). Additionally, the risk of SSI was 150% higher in the group receiving SAP 61 to 120 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=2.532, 95%CI 1.250-5.128, p=.010). In subgroup analysis, this statistical trend persisted for both deformity surgeries and different SSI classifications., Conclusion: Administering cefuroxime SAP within 30 minutes before skin incision significantly reduces the risk of SSI, whether they are deep or superficial, in spinal fusion surgery. This pattern remains consistent among spinal deformity patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: To examine the influence of early mobilization on the risk of surgical site infections (SSI) in patients undergoing spinal fusion surgery., Methods: The retrospective cohort consisted of all consecutive patients who underwent spinal fusion surgery at our institution. For each case of SSI, 2 control patients without SSI at the corresponding index date were selected. Mobilization was predefined as "delayed" if it occurred more than 36 hours postoperatively. To account for potential confounding variables, we performed further adjustments using conditional logistic regression models. Subgroup analyses were conducted to evaluate the robustness of the statistical associations., Results: Following the predefined statistical protocol and matching criteria, we matched 236 control cases to the SSI cases. Upon adjustment for confounding factors, our findings revealed that the risk of SSI was 120% higher in the group beginning mobilization more than 36 hours after surgery compared to the group beginning mobilization within 36 hours postoperatively (odds ratio = 2.206, 95% confidence interval 1.169-4.166, P = .015). In subgroup analyses, this statistical trend remained consistent., Conclusions: Early mobilization within 36 hours following spinal fusion surgery significantly reduces the risk of SSI. This pattern of reduced risk remains consistent among patients with degenerative diseases or spinal deformities., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: For the implantation of pedicle screws, navigation-supported systems are nowadays used more and more to avoid screw misalignment by making the direction of the screw more predictable., Objective: Examination of the precision after instrumentation of the pedicle screw with the hand-guided aiming sleeve. The aim was to verify that the implementation of the pedicle screws is plannable and precise by using 2D X‑ray only., Method: This retrospective study analyzed 27 consecutive trauma patients (17-84 years, 13f/14m) with vertebral body fractures. The position and precision of 108 screws, implanted using the hand-guided aiming sleeve was investigated. To determine the position the actual course of the screws was examined using the postoperative 3D CT data set (GE Optima 540, General Electric Company Boston, MA, USA; slice thickness 1.25 mm). The screws were then compared to the previously defined ideal position of the tip of the screw. In addition to the absolute and relative deviation from the ideal target point, the convergence angle and the parallelism to the cover plate were determined., Results: Of 108 implanted pedicle screws, 90 (83%) were within target. The remaining 18 (17%) represented a clinically irrelevant screw deviation: A lateral deviation was found in 17 pedicle screws (16%) and a medial deviation in 1 (1%). The average deviation from the ideal target point in the vertebral body was 2.3 mm ventrally with a standard deviation of ± 2.3 mm. No screw misalignment or pedicle perforation was found., Conclusion: The transcutaneous implantation of pedicle screws with a hand-guided aiming sleeve in the thoracic and lumbar spine represents a safe and precise procedure. The risk of misalignment needing a revision is lower compared to other methods of navigated screw implantation reported in the literature [1-6]. A CT-based preliminary planning is not necessary. The method is economical, special technical equipment is not required., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

This study aimed to assess the effectiveness and safety of robot-assisted versus fluoroscopy-assisted pedicle screw implantation in scoliosis surgery. The study was registered in the PROSPERO (CRD42023471837). Two independent researchers searched PubMed, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. The outcomes included operation time, pedicle screw implantation time, blood loss, number of fluoroscopic, accuracy of pedicle screw position, hospital stays, postoperative hospital stays, Visual Analog Scale (VAS), Japanese Orthopaedic Association (JOA) score, Scoliosis Research Society-22(SRS-22), cobb angle, cobb angle correction rate, sagittal vertical axis (SVA), and complications. Eight papers involving 473 patients met all the criteria. There was no significant difference between the two groups regarding the reduction in operation time. The effect of reducing the pedicle screw implantation time in the RA group was significant (WMD = -1.28; 95% CI: -1.76 to -0.80; P < 0.00001). The effect of reducing the blood loss in the RA group was significant (WMD=-105.57; 95% CI: -206.84 to -4.31; P = 0.04). The effect of reducing the number of fluoroscopic in the RA group was significant (WMD=-5.93; 95% CI: -8.24 to -3.62; P < ). The pedicle screw position of Grade A was significantly more in the RA group according to both the Gertzbein-Robbins scale and the Rampersaud scale. Compared with the FA group, the difference in the hospital stays in the RA group was not statistically significant, but the effect of reducing the postoperative hospital stays in the RA group was significant (WMD = -2.88; 95% CI: -4.13 to -1.63; P < 0.00001). The difference in the VAS, JOA, SRS-22, Cobb angle and Cobb angle correction rate, SVA, and complications between the two groups was not statistically significant. The robot-assisted technique achieved statistically significant results in terms of pedicle screw placement time, blood loss, number of fluoroscopies, accuracy of pedicle screw position, and postoperative hospital stay., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: The respective effects of direct and indirect decompression in the clinical outcome after anterior cervical disc fusion (ACDF) is still debated. The main purpose of this study was to analyze the effects of indirect decompression on foraminal volumes during ACDF performed in patients suffering from cervico-brachial neuralgias due to degenerative foraminal stenosis, i.e. to determine whether implant height was associated with increased postoperative foraminal height and volume., Methods: A prospective follow-up of patients who underwent ACDF for cervicobrachial neuralgias due to degenerative foraminal stenosis was conducted. Patient had performed a CT-scan pre and post-operatively. Disc height, foraminal heights and foraminal volumes were measured pre and post operatively., Results: 37 cervical disc fusions were successfully performed in 20 patients, with a total of 148 foramina studied. Foraminal height and volume were measured bilaterally on the pre- and post-operative CT scans (148 foramina studied). After univariate analysis, it was found a significant improvement for every radiological parameter, with a significant increase in disc height, foraminal height and foraminal volume being respectively +3,22 mm (p < 0,001), +2,12 mm (p < 0,001) and +54 mm 3 (p < 0,001). Increase in disc height was significantly associated with increase in foraminal height (p < 0,001) and foraminal volume (p < 0,001). At the same time, increase in foraminal height was significantly correlated with foraminal volume (p < 0,001), and seems to be the major component affecting increasing in foraminal volume., Conclusion: Indirect decompression plays an important part in the postoperative foraminal volume increase after ACDF performed for cervicobrachial neuralgias., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: To explore the safety and the mid-term efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and 3D microscope-assisted transforaminal lumbar interbody fusion (MMIS-TLIF) for treating single-segment lumbar spondylolisthesis with lumbar spinal stenosis (DLS-LSS)., Methods: The clinical data of 49 patients who underwent UBE-TLIF or MMIS-TLIF in our hospital were retrospectively analyzed, including 26 patients who underwent the UBE-TLIF and 23 patients who underwent the MMIS-TLIF. The demographic and perioperative outcomes of patients before and after surgery were reviewed. Visual analogue scale (VAS) and Oswestry disability index (ODI) were used to evaluate the clinical outcomes of patients before surgery and at 1, 3, 6, 12 and 24 months after surgery. The lumbar lordosis angle (LL), disc height (DH) and lumbar intervertebral fusion rate were assessed before surgery and at the last follow-up., Results: The VAS and ODI scores of the two groups were improved compared with those before surgery. The ODI of UBE-TLIF group was lower than that of MMIS-TLIF group at 1, 3, 6, and 12 months after surgery, and there were no significant differences between the two groups at other time points (P > 0.05). There were no significant differences in VAS between the two groups at each time point (P > 0.05). However, the UBE-TLIF group had more advantages in blood loss and hospital stay. The complications between the UBE-TLIF group (11.54%) and the MMIS-TLIF group (17.39%) were comparable (P > 0.05). Radiographic outcomes showed that the LL and DH of the two groups were improved compared with those before surgery, and the difference before and after surgery was not significant (P > 0.05). The fusion rate was 96.2% in the UBE-TLIF group and 95.7% in the MMIS-TLIF group. There was no significant difference in the fusion rate between the two groups (P > 0.05)., Conclusions: Both UBE-TLIF and MMIS-TLIF have favorable outcomes for treating single-segment DLS-LSS. Both groups have the advantages of clear surgical vision, high surgical efficiency, and favorable mid-term efficacy. In addition, compared with MMIS-TLIF, UBE-TLIF causes less intraoperative bleeding and faster postoperative recovery., (© 2023. The Author(s).)

Background: Accurate pedicle screw placement in spinal surgery is critical as inaccuracies can lead to morbidity and suboptimal outcomes. Navigation and robotics have reduced malplacement rates, but their adoption is limited by high costs, learning curves, surgical time, and radiation. The authors propose an ultrasound-emitting and self-localising drill guide for precise screw placement that overcomes the limitations of current techniques., Materials and Methods: The preliminary configuration analysis involves systematically varying design parameters and assessing localization performance using lumbar spine MRI based simulations. The authors evaluate localization techniques based on accuracy and optimization capture range., Results: Results suggest that feasible designs can accurately estimate position. A promising design features a 5 mm radius cannula with ten 35mm-long ultrasound strips, 32 elements per strip, and a fanned-out emission profile. A multi-start active-set optimization algorithm with six initial estimates ensures reliable and efficient localization., Conclusions: The simulation suggests that the proposed design can achieve sufficient localization accuracy for pedicle screw navigation. These findings will guide the fabrication of a novel ultrasound-emitting drill guide for further evaluation and physical testing., (© 2023 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons Ltd.)

Purpose: Automatic robotic platforms for robot-aided spinal surgery are mostly employed for drilling the pedicle screw path and do not adapt the tool rotational speed depending on the variation of the bone density. This feature is highly desirable in control strategies for robot-aided pedicle tapping, which may result in a poor quality thread if the surgical tool speed is not adequately tuned depending on the bone density to be threaded. Therefore, the objective of this paper is to propose a novel semi-autonomous control for robot-aided pedicle tapping that is able to (i) identify the bone layer transition, (ii) adapt the tool velocity depending on the detected bone layer density and (iii) stop the tool tip before propulsion of the bone boundaries., Methods: The proposed semi-autonomous control for pedicle tapping consists of: (i) a hybrid position/force control loop that allows the surgeon to move the surgical tool along a pre-planned axis and (ii) a velocity control loop that allows him/her to finely tune the tool rotational speed by modulating the tool-bone interaction force along the same axis. The velocity control loop integrates also a bone layer transition detection algorithm that dynamically limits the tool velocity depending on the bone layer density. The approach was tested on the Kuka LWR4+ provided with an actuated surgical tapper which was used to tap a wood specimen simulating the bone layer density characteristics and bovine bones., Results: A normalized maximum time delay in the bone layer transition detection of 0.25 was achieved by the experiments. A success rate of [Formula: see text] was achieved for all the tested tool velocities. The proposed control achieved a maximum steady-state error of 0.4 rpm., Conclusion: The study demonstrated high capability of the proposed approach to i) promptly detect transition among the specimen layers and ii) adapt the tool velocities depending on the detected layers., (© 2023. CARS.)

Introduction: Early-onset scoliosis is a common deformity in neuromuscular disease. When conservative treatment becomes ineffective, several surgical options can be proposed. The most common technique is posterior spinal fusion (PSF) consisting of performing a multiple segmental instrumentation with pedicular screws on the full spine associated with decortication and bone graft. Minimally invasive fusionless surgery (MIFS) is an alternative to correct and fix definitively the spine without graft. The objective of this study was to compare early surgical inpatient period between PSF and MIFS in neuromuscular scoliosis., Material and Methods: 140 NMS operated by PSF or MIFS between 2012 and 2017 was retrospectively reviewed. The following data were compared between groups: general characteristics (age, sex, etiology), preoperative preparation (halo traction, noninvasive ventilation or tracheostomy), Cobb angle and pelvic obliquity correction, use of drugs (vasopressor and/or inotropes, expansion fluids, transfusion and volumes), postoperative complications, and need of noninvasive ventilation., Results: 75 patients were managed by PSF with a mean age of 14.3 ± 2.3y and 65 by MIFS with a mean age of 11.8 ± 3y. Average pelvic obliquity and major curve correction were similar postoperatively. Intraoperative blood transfusion was significantly more common in PSF group (OR, 14; 95% CI [6.3-33.0]). Vasopressors were used non-significantly more often in the PSF group and expansion fluids similar in the two groups. PSF group had more overall complications (OR, 4.6; 95% CI [2.3-9.8]), more infections (OR, 3.6; 95% CI [1.5-9.3]) and more hemodynamic complications (OR, 4.1; 95% CI [1.4-15.1]). Average intubation duration was 5 days in the PSF and 4 days in MIFS (p = 0.05)., Conclusion: In this series of neuromuscular patients, the complication rate was reduced in MIFS comparatively to PSF, with lower blood transfusion and less infections., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The influence of total en bloc spondylectomy (TES) on spinal stability is substantial, necessitating strong fixation to restore spinal stability. The transverse connector (TC) serves as a posterior spinal instrumentation that connects the left and right sides of the pedicle screw-rod system. Several studies have highlighted the potential of a TC in enhancing the stability of the fixed segments. However, contradictory results have suggested that a TC not only fails to improve the stability of the fixed segments but also might promote stress associated with internal fixation. To date, there is a lack of previous research investigating the biomechanical effects of a TC on TES. This study aimed to investigate the biomechanical effects of a TC on internal fixation during TES of the lumbar (L) spine., Methods: A single-segment (L3 segment) TES was simulated using a comprehensive L spine finite element model. Five models were constructed based on the various positions of the TC, namely the intact model (L1-sacrum), the TES model without a TC, the TES model with a TC at L1-2, the TES model with a TC at L2-4, and the TES model with a TC at L4-5. Mechanical analysis of these distinct models was conducted using the Abaqus software to assess the variations in the biomechanics of the pedicle screw-rod system, titanium cage, and adjacent endplates., Results: The stability of the surgical segments was found to be satisfactory across all models. Compared with the complete model, the internal fixation device exhibited the greatest constraint on overextension (95.2-95.6%), while showing the least limitation on left/right rotation (53.62-55.64%). The application of the TC had minimal effect on the stability of the fixed segments, resulting in a maximum reduction in segment mobility of 0.11° and a variation range of 3.29%. Regardless of the use of a TC, no significant changes in stress were observed for the titanium cage. In the model without the TC, the maximum von Mises stress (VMS) for the pedicle screw-rod system reached 136.9 MPa during anterior flexion. Upon the addition of a TC, the maximum VMS of the pedicle screw-rod system increased to varying degrees. The highest recorded VMS was 459.3 MPa, indicating a stress increase of 335.5%. Following the TC implantation, the stress on the adjacent endplate exhibited a partial reduction, with the maximum stress reduced by 27.6%., Conclusion: The use of a TC in TES does not improve the stability of the fixed segments and instead might result in increased stress concentration within the internal fixation devices. Based on these findings, the routine utilisation of TC in TES is deemed unnecessary., (© 2023. The Author(s).)

Objective: To assess agreement between pedicle screw placement evaluated on postoperative computed tomography (CT) and on intraoperative cone-beam CT (CBCT) and compare procedure characteristics when using first-generation and second-generation robotic C-arm systems in the hybrid operating room., Methods: All patients who received pedicle screws for spinal fusion at our institution between June 2009 and September 2019 and underwent intraoperative CBCT and postoperative CT were included. The CBCT and CT images were reviewed by 2 surgeons to assess the screw placement using the Gertzbein-Robbins and the Heary classifications. Intermethod agreement of screw placement classifications as well as interrater agreement were assessed using Brennan-Prediger and Gwet agreement coefficients. Procedure characteristics using first-generation and second-generation generation robotic C-arm systems were compared., Results: Fifty-seven patients were treated with 315 pedicle screws at thoracic, lumbar, and sacral levels. No screw had to be repositioned. On CBCT, accurate placement was found for 309 screws (98.1%) using the Gertzbein-Robbins classification and 289 (91.7%) using the Heary classification and on CT, these were 307 (97.4%) and 293 (93.0%), respectively. Intermethod between CBCT and CT and interrater agreements between the 2 raters were almost perfect (>0.90) for all assessment. There were no significant differences in mean radiation dose (P = 0.83) and fluoroscopy time (P = 0.82), but length of surgery using the second-generation system was estimated at 107.7 minutes (95% confidence interval, 31.9-183.5 minutes; P = 0.006) shorter., Conclusions: Intraoperative CBCT provides accurate assessment of pedicle screw placement and enables intraoperative repositioning of misplaced screws., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Bone morphogenetic proteins (BMPs) are part of the transforming growth factor-beta superfamily and are involved in bone formation and repair. In spine surgery, recombinant human BMP (rhBMP) is used as an alternative to autografts for spinal fusions. This study aimed to evaluate bibliometric parameters and citations of the literature on BMPs to provide an overview of how the field has evolved., Methods: A comprehensive search of the literature was conducted using Elsevier's Scopus database to capture all the published and indexed studies relevant to BMPs from 1955 to the present. A discrete set of validated bibliometric parameters was extracted and analyzed. All statistical analyses were performed using R 4.1.1., Results: The 100 most cited articles were published between 1994 and 2018 by 472 unique authors in 40 sources (e.g., journals and books). On average, there were 279 citations per publication and 17.69 citations per publication per year. The United States had the publications with the most citations (n = 23,761), followed by Hong Kong (n = 580) and the United Kingdom (n = 490). The three institutions in the United States with the greatest number of publications in the field were Emory University (n = 14), Hughston Clinic (n = 9), Hospital for Special Surgery (n = 6), and University of California (n = 6)., Conclusions: The authors evaluated and characterized the 100 most cited articles about BMP. Most of the publications were clinical in nature and focused on BMP's application in spine surgery. While early scientific efforts focused on basic science research to advance the understanding of BMP's mechanism of action in promoting bone formation, the majority of the more recent publications are clinically focused. It will be beneficial to conduct more controlled clinical trials to compare the outcomes of BMP use with other methods.

Background: We developed a spinal deformity complexity checklist (SDCC) to assess the difficulty in performing a circumferential minimally invasive surgery (MIS) for adult spinal deformity., Methods: A modified Delphi method of panel experts was used to construct an SDCC checklist of radiographic and patient-related characteristics that could affect the complexity of surgery via MIS approaches. Ten surgeons with expertise in MIS deformity surgery were queried to develop and refine the SDCC with 3 radiographic categories (x-ray, magnetic resonance imaging, computed tomography) and 1 patient-related category. Within each category, characteristics affecting MIS complexity were identified by initial roundtable discussion. Second-round discussion determined which characteristics substantially impacted complexity the most., Results: Thirteen characteristics within the x-ray category were determined. Spinopelvic characteristics, endpoints of instrumentation, and prior hardware/fusion were associated with increased complexity. Vertebral body rotation-as reflected by the Nash-Moe grade-added significant complexity. Psoas anatomy and spinal stenosis added the most complexity for the 5 magnetic resonance imaging characteristics. There were 3 characteristics in the CT category with pre-exisiting fusion, being the variable most highly selected. Of the 5 patient-related characteristics, osteoporosis and BMI were found to most affect complexity., Conclusions: The SDCC is a comprehensive list of pertinent radiographic and patient-related characteristics affecting complexity level for MIS deformity surgery. The value of the SDCC is that it allows rapid assessment of key factors when determining whether MIS surgery can be performed effectively and safely. Patients with scores of 4 in any characteristic should be considered challenging to treat with MIS; open surgery may be a better alternative., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: There is scarce information regarding the effectiveness of postoperative braces in decreasing mechanical complications and reinterventions following adult deformity surgery., Methods: Retrospective matched cohort study from a prospective adult deformity multicenter database. We selected operated patients, fused to the pelvis, > 6 instrumented levels, and minimum 2 year follow-up. Three hundred and eighty patients were separated into two groups (Brace-3 months TLSO-vs No Brace) and then matched controlling for age, gender and frailty. We studied demographic, intraoperative, and postoperative spinopelvic parameters. Both groups were compared regarding complications and reinterventions in the first 2 postoperative years, using univariate and multivariate logistic regression analysis., Results: We finally analyzed 359 matched patients, mean age of 65.3 ± 8.9 years, frailty-index (0.43 ± 0.15), and mostly females (84%). 224 patients wore a postoperative brace (B) and 135 didn't (NoB). They showed no difference in intraoperative variables and postoperative spinopelvic alignment. They differed (P < 0.05) in: Pelvic incidence (B:58° ± 13 vs NoB:54.5° ± 13); BMI (B:25.8 ± 4 vs NoB:27.4 ± 5); upper instrumented vertebra (B:81.7% T8-L1 vs NoB:72.6% T8-L1), and the use of multiple rods (B:47.3% vs NoB:18.5%). Univariate analysis showed a higher rate of mechanical complications and reinterventions when not using a brace. As well as higher NRS-back and leg pain at 6 weeks. However, multivariate analysis selected the use of multiple rods as the only independent factor protecting against mechanical complications (OR: 0.38; CI 95% 0.22-0.64) and reinterventions (OR: 0.41; CI 95% 0.216-0.783)., Conclusion: After controlling for potential confounders, our study could not identify the protective effect of postoperative braces preventing mechanical complications and reinterventions in the first two postoperative years., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction/objectives: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC., Methodology: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system., Results: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries., Conclusions: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment., (Copyright © 2022 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background Context: There remains significant variability in the use of postoperative opioids. On one end, it is proven that appropriate pain control is a critical aspect of patient management; on the other end, past few decades have been associated with major increases in opioid-related overdoses and addiction treatment. We hypothesized that several pre- and postoperative risk factors affecting long-term opioid use could be identified., Purpose: Evaluation of factors associated with minimum 5-year postoperative opioid use following adult spinal deformity surgery., Study Design/setting: Prospectively followed study group database., Patient Sample: Adult spinal deformity patients who underwent elective spine surgery between 2009 and 2016 were included., Outcome Measures: Opioid usage or otherwise at minimum 5 years follow-up. Use of nonopioid analgesics, weak and strong opioids METHODS: Retrospective analysis of patients undergoing elective spinal deformity surgery. A total of 37 factors comprising patient characteristics, radiographic measurements, operative details, preoperative and early postoperative opioid use, and mechanical complications and revisions were analyzed. Details on identified factors were provided., Results: A total of 265 patients (215F, 50M) from five sites were included. The mean follow-up duration was 68.4±11.7 (60-102) months. On average, 10.6±3.5 levels were fused. Preoperatively, 64 (24.2%) patients were using opioids. The rate of opioid users increased to 33.6% at 6 weeks and decreased to 21.5% at 6 months. During follow-up, there were patients who discontinued opioids, while others have started and/or restarted using opioids. As a result, 59 (22.3%) patients were still on opioids at the latest follow-up. Multivariate analyses showed that factors independently affecting opioid use at an average of 68 months postoperatively, in order of significance, were opioid use at sixth weeks, preoperative opioid use and opioid use at sixth months with the odds ratios of 2.88, 2.51, and 2.38 respectively. At these time points, factors such as age, number of comorbidities, tobacco use, the time of the last prior spine surgery and postoperative sagittal plane alignment affected opioid usage rates., Conclusions: Opioid usage at 6 weeks was found to be more predictive of long-term opioid use compared to preoperative use. Patients should be well informed to have realistic expectations regarding opioid use when considering adult spinal deformity surgery., Competing Interests: Declarations of Competing Interests One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Degenerative spinal disease (DSD) is one of the most common musculoskeletal conditions and a leading cause of sickness absence. It also contributes significantly to the global burden of disease. The aim of this study was to assess the frequency of reoperation after surgical treatment of DSDs in Poland, and to identify risk factors for reoperation., Material and Methods: A retrospective analysis of hospitalisations for DSD in 2018 that were reported to Poland's National Health Fund (NHF) was performed. Reoperations reported within 365 days of hospital discharge were identified. Demographic factors and multimorbidities were included in the analysis. A logistic regression model was then performed to assess risk factors for reoperations., Results: In 2018, 38,953 surgical hospitalszations for DSD were reported. A total of 3,942 hospitalised patients (10.12%) required reoperation within 365 days. Patients requiring reoperation were predominantly female (female-to-male ratio 1.34:1) and elderly (mean age of reoperated patients 56.66 years, mean age of other patients 53.24). The percentage reoperated upon correlated with multiple diseases (from 8.81% in the group of patients without comorbidities to 15.31% in the group of patients with three or more comorbidities). The risk of reoperation was most increased by comorbid depression, neurological diseases, obesity, and older age. The risk of reoperation was reduced by instrumented spinal surgery, surgery in a neurosurgical unit, and hospitalisations other than same-day surgery., Conclusions: Reoperations within a year after DSD surgical treatment are common. Identifying risk factors for reoperation, including those related to the presence of comorbidities and the phenomenon of multimorbidity, can be an important tool in reducing reoperation rates.

The literature has had some conflicting evidence regarding the effective management of lumbar spondylolisthesis (LS). Herein, we review active and prospective clinical trials to identify the emerging trends for the management of LS. A systematic search was conducted utilizing the NIH Clinical Trials database using the search term "lumbar spondylolisthesis" on February 2, 2022. Currently active and prospective clinical trials for LS were included and analyzed. All statistical analyses were performed on R 4.1.2. We identified 37 clinical trials. Nearly half the trials (n = 18, 48.6%) include novel technologies; 6 (16.2%) are comparing surgical approaches, of which 4 (67%) include decompression alone versus decompression with instrumented fusion; 6 (16.2%) are evaluating perioperative pain management protocols, of which 3 (50%) include bupivacaine or ropivacaine; 3 (8.1%) are evaluating alternative medicines in LS; 2 (5.4%) are observational studies about the natural history of LS; 1 (2.7%) involves surgical infection prophylaxis; and 1 (2.7%) is evaluating AK1320 microspheres. The 18 trials involving novel technologies include 3D-printed titanium cages (n = 3, 16.7%), interbody implants (n = 4, 22.2%), bone graft materials (n = 4, 22.2%), and miscellaneous intraoperative devices (n = 7, 38.9%). The top 3 outcomes measured were Oswestry Disability Index (n = 28, 75.7%), visual analog scale (n = 21, 56.7%), and postoperative radiographs (n = 16, 43.2%). Patient-reported outcome measures (PROMs) were included in 34 (91.9%) trials, while 23 (62.2%) trials included lumbar spine imaging. LS can often require a multifaceted approach. Novel technologies and utilization of PROMs appear to be a significant emerging trend in LS management., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Prolonged surgical site infections after spinal fusion surgery may lead to exposure of the implant due to the formation of extensive tissue defects and endanger the clinical outcome., Objective: This study aims to enlighten the role of the keystone perforator flap method in the reconstruction of lumbar soft tissue defects., Material and Methods: The retrospective study included 11 consecutive patients with a wound dehiscence of over 6 × 6 cm defect area persisting for 2 weeks after spinal fusion. The keystone perforator flap was applied for the reconstruction of tissue defects, whereas the arterial blood supply of the flaps was based on the intramuscular and intermuscular perforating branches of the dorsal branches of the lumbar arteries., Results: The median age of our cohort was 58 years. The median body mass index (BMI) and Charlson comorbidity index (CCI) were 29.9 and 3.4, respectively. In eight cases a lumbosacral was carried out whereas in the remaining series a lumbar fusion was performed. In the course of the subsequent wound revision, on average 4 applications of negative pressure wound therapy (NPWT) were performed. The average defect size was 7.5 cm in width and 16.5 cm in length. The microbiological analysis of the tissue samples obtained intraoperatively after repeated NPWT revealed positive evidence of pathogenic bacteria in all cases. The average duration of inpatient treatment after flap surgery was 15 days, which was significantly shorter than the NPWT management of the open defect wounds (15.5 ± 2.5 vs. 37 ± 16.5, p < 0.05)., Conclusion: The keystone perforator flap offers a stable coverage for soft tissue defects and supports infection control after spinal fusion., (© 2021. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: CSF leaks are a known complication of lumbar fusion surgery. There is a scarcity of literature describing the incidence and risk factors associated with this complication. The aim of this study was to identify patients who are at risk of developing postoperative CSF leak., Methods: The Nationwide Inpatient Sample database was used to identify patients who had lumbar fusion in the US from 2002 to 2014. Inpatient outcomes included the incidence and risk of developing CSF leak based on selected patient-specific characteristics. Secondary outcomes included average length of stay, mean costs, and mortality rates. All statistical analyses were conducted based on multivariate regression models using the SPSS software., Results: A total of 439,220 patients who underwent elective lumbar fusion procedures were identified. Of these patients, 2.6% (11,636 /439,220) were found to have CSF leak. Independent important risk factors for CSF leak development included: older age (OR: 1.025; 95% CI: 1.02-1.03; p < 0.0001), posterior approach (OR: 1.71; 95% CI: 1.59-1.85; p < 0.0001) compared to anterior approach, chronic deficiency anemia (OR: 1.21; 95% CI:1.14-1.30; p < 0.0001), obesity (OR: 1.22; 95% CI: 1.15-1.30; p < 0.0001), and pulmonary circulatory disease (OR: 1.44; 95% CI: 1.18-1.75; p < 0.0001). CSF leak was associated with increased length of stay (5.39 ± 3.86 vs. 3.74 ± 2.55; p < 0.0001), hospitalization costs (120,129.0 ± 88,123.5 vs. 89,226.8 ± 65,350.3; p < 0.0001) and mortality (0.3% vs. 0.1%; p < 0.05)., Conclusion: Spine surgeons should be aware of certain patient and procedure-specific characteristics that increase the risk of developing postoperative CSF leak after lumbar fusion in order to improve patient outcomes., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To evaluate surgical outcomes and fusion rate following spinal fusion surgery in patients with chronic kidney disease and assess the impact of kidney function., Methods: From March 2017 to February 2021, 54 consecutive adult patients with chronic kidney disease who underwent spinal fusion surgery were enrolled. According to the glomerular filtration rate (GFR) categories, 35 and 19 patients were classified into the non-end-stage renal disease (ESRD) group (GFR categories 3a-4; eGFR, 15-59 mL/min/1.73 m 2 ) and ESRD group (GFR category 5; eGFR, <15 mL/min/1.73 m 2 ), respectively., Results: Baseline characteristics did not differ between the groups. The lumbar and thoracolumbar spines were the most operated. The mean number of fused vertebrae (4.9 ± 2.3 vs. 4.1 ± 2.0, P = 0.122), operative time (228.4 ± 129.6 min vs. 160.5 ± 87.5 min, P = 0.113), and surgical bleeding (743.1 ± 630.5 mL vs. 539.5 ± 384.4 mL, P = 0.354) did not differ between the groups. However, occurrence rates of medical complications (25.7% vs. 52.6%, P = 0.048) and 3-month readmission (8.6% vs. 35.3%, P = 0.045) were significantly different between the groups. While the 3-month mortality (10.5% vs. 2.9%, P = 0.28) and pseudarthrosis rates (35.3% vs. 9.1%, P = 0.047) were higher in the ESRD group, the difference was not statistically significant for the former entity., Conclusions: Surgeons should consider the possibility of high morbidity and pseudarthrosis associated with spine surgeries when operating on patients with ESRD., (Copyright © 2022 Elsevier Inc. All rights reserved.)

This study investigated the effect of romosozumab on bone union in a rat posterolateral lumbar fixation model. Posterolateral lumbar fixation was performed on 8-week-old male Sprague Dawley rats (n = 20). For bone grafting, autogenous bone (40 mg) was harvested from the spinous processes of the 10th thoracic vertebra until the 2nd lumbar vertebra and implanted between the intervertebral joints and transverse processes of the 4th and 5th lumbar vertebrae on both sides. Rats were matched by body weight and equally divided into two groups: R group (Evenity®, 25 mg/kg) and control (C) group (saline). Subcutaneous injections were administered twice a week until 8 weeks after surgery. Computed tomography was performed at surgery and week 8 after surgery. The area and percentage of bone trabeculae in the total area of bone fusion were calculated. Statistical analysis was performed using an unpaired t test (p < 0.05). We found that the R group rats had significantly higher mean bone union rate and volume than did the C group rats at all time courses starting week 4 after surgery. The R group had significantly higher increase rates than did the C group at weeks 4 and 6 after surgery. The percentage of bone trabeculae area in the R group was approximately 1.7 times larger than that in the C group. Thus, we demonstrated that romosozumab administration has stimulatory effects on bony outgrowth at bone graft sites. We attribute this to the modeling effect of romosozumab., (© 2022 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Background: Depression and Degenerative Spine Disease (DSD) frequently co-exist. Pooled prevalence estimates of depression before and after lumbar fusion surgery has not been analyzed before. The purpose of this systematic review was to estimate the pre- and post-operative prevalence of depression in patients with DSD undergoing lumbar fusion., Methods: A literature review until April 30th 2022 was performed. All studies on DSD patients undergoing lumbar spine fusion surgery with either a history of formal diagnosis of depression or a recording of depression using a validated tool were included. Patients with other psychiatric conditions or undergoing a different form of spinal surgery were excluded. Risk of bias of the included studies was evaluated using the Newcastle-Ottawa Scale., Results: Fifteen (15) studies with a total of 98.375 patients met the inclusion and exclusion criteria and were included in the analysis. The prevalence estimate of depression in patients before surgery was 15,35 % (95% CI: 10,56-20,86%). In the 7 studies including patients who had undergone lumbar fusion, the pooled prevalence was estimated 11,46% (95% CI: 8,11-15,30%)., Conclusion: An increased prevalence of depression in patients undergoing lumbar spine fusion was noted. Given the correlation between depression and poor surgical outcomes, strategies should be identified to prevent and treat depression in these patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: To determine the effect of surgical instrumentation on pulmonary function after surgery., Methods: A literature review was performed to identify articles reporting on the effect of scoliosis surgery on the pulmonary function in patients with spinal muscular atrophy (SMA). Data for each patient were extracted from included studies, and a meta-analysis was performed using the values of forced vital capacity (FVC) before and after surgery., Results: A total of 127 articles were reviewed, and ten articles were selected for data extraction according to inclusion criteria. The results of the meta-analysis showed no difference in respiratory function pre-operatively and at last follow-up. Four out of ten studies demonstrated similar results and five studies reported a decrease in pulmonary function after surgery. Only one study showed improvement in lung function., Conclusion: At the moment, there is insufficient evidence in the literature to support that spinal surgery can improve respiratory function. According to our meta-analysis study, vital capacity remains either unchanged or the rate of deterioration is decreased after surgery. Nevertheless, these are both considered favorable outcomes taking into account the natural course of the disease with progressive deterioration of pulmonary function over time., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The ischemia/reperfusion mechanism is believed to be responsible for parenchymal damage caused by temporary hypoperfusion and worsened by the subsequent attempt of reperfusion. This represents a true challenge for physicians of several fields, including neurosurgeons. A limited number of papers have shed the light on a rare pathologic condition that affects patients experiencing an unexplained neurologic deficit after spine surgery, the so-called "white cord syndrome." This entity is believed to be caused by an "ischemia/reperfusion" injury on the spinal cord, documented by a postoperative intramedullary hyperintensity on T2-weighted magnetic resonance imaging sequences. To date, the cases of white cord syndrome reported in literature mostly refer to cervical spine surgery. However, the analysis of several reviews focusing on spine surgery outcome suggests postoperative neurologic deficits of new onset could be charged to a mechanism of ischemia/reperfusion, even if the physiopathology of this event is seldom explored or at least discussed. The same neuroradiologic finding can suggest mechanical damage due to inappropriate surgical manipulation. On this purpose, we performed a systematic review of the literature with the aim to identify and analyze all the factors potentially contributing to ischemic/reperfusion damage of the spinal cord that may potentially complicate any spinal surgery, without distinction between cervical or thoracic segments. Finally, we believe that postoperative neurologic deficit after spinal surgery constituting the "white cord syndrome" could be under-reported; both neurosurgeons and patients should be fully aware of this rare but potentially devasting complication burdening cervical and thoracic spine surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The incidence of perioperative stroke following spinal surgery, including ischemic and hemorrhagic stroke, has not been fully investigated in the Chinese population. Whether specific spinal or emergency/elective procedures are associated with perioperative stroke remains controversial. This study aimed to investigate the incidence of perioperative stroke, health economic burden, clinical outcomes, and associated risk factors., Method: A retrospective cohort study using an electronic hospital information system database was conducted from Jan 1, 2015, to Jan 1, 2021, in a tertiary hospital in China. Patients aged ≥18 years who had undergone spinal surgery were included in the study. We recorded patient demographics, comorbidities, and health economics data. Clinical outcomes included perioperative stroke during hospitalization and associated risk factors. The patients' operative data, anesthetic data, and clinical manifestations were recorded., Result: A total of 17,408 patients who had undergone spinal surgery were included in this study. Twelve patients had perioperative stroke, including seven ischemic stroke (58.3%) and five hemorrhagic stroke (41.7%). The incidence of perioperative stroke was 0.07% (12/17,408). In total, 12 stroke patients underwent spinal fusion. Patients with perioperative stroke were associated with longer hospital stay (38.33 days vs. 9.78 days, p < 0.001) and higher hospital expenses (RMB 175,642 vs. RMB 81,114, p < 0.001). On discharge, 50% of perioperative patients had severe outcomes. The average onset time of perioperative stroke was 1.3 days after surgery. Stroke history (OR 146.046, 95% CI: 28.102-759.006, p < 0.001) and hyperlipidemia (OR 4.490, 95% CI: 1.182-17.060, p = 0.027) were associated with perioperative stroke., Conclusion: The incidence of perioperative stroke of spinal surgery in a tertiary hospital in China was 0.07%, with a high proportion of hemorrhagic stroke. Perioperative stroke patients experienced a heavy financial burden and severe outcomes. A previous stroke history and hyperlipidemia were associated with perioperative stroke., (© 2022. The Author(s).)

Background: Various surgical techniques for treating spondylodiscitis have been proposed, but the optimal surgical treatment remains controversial. In this study, we propose a new procedure that is implanting antibiotic-loaded calcium sulfate (CS) beads into the disc after debridement using the Quadrant channel combined with percutaneous fixation through a single-stage posterolateral approach for the treatment of spondylodiscitis. Thus, the purpose of this study is to assess the safety and efficacy of this procedure., Methods: This study collected the data of 32 patients with spine spondylodiscitis and was surgically treated in our department from July 2015 to August 2020. The Demographic data included age, gender, involved segment, and complications were collected. The intra-operative details, results of culture, functional outcome, radiologic outcome, and length of hospital stay, laboratory examination were recorded., Results: The mean age of the 32 patients was 61.1 ± 9.7 years old. The mean operative time was 135.0 ± 30.6 minutes, and the mean blood loss was 243.4 ± 92.1 ml. The positive rate of culture was 72%. The mean Visual analogue scale (VAS) and Oswestry Disability Index (ODI) score significantly improved from 7.5 to 1.6 and from 65% to 10%. Cobb angle was significantly improved and could be maintained at final follow-up. New bone formation was observed in all patients. There were no recurrences of infection in our study., Conclusions: The posterolateral debridement and percutaneous fixation combined with antibiotic-loaded calcium sulfate beads filling are effective in the treatment of spondylodiscitis in terms of infection control, early mobilization, and recovery., (© 2022. The Author(s).)

Purpose: This study aimed to evaluate the clinical efficacy and imaging results of percutaneous endoscopic transforaminal lumbar interbody fusion (PETLIF) through comparing it with minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF)., Materials and Methods: We performed a retrospective analysis on patients with lumbar degenerative disease treated by PETLIF or MISTLIF from September 2017 to January 2019, and the patients were divided into two groups: the PETLIF group and the MISTLIF group. The clinical and imaging parameters of the two groups were evaluated., Results: There was no significant difference between the two groups in operative time and complication rate. The estimated blood loss and the length of hospital stay in the PETLIF group were significantly better than those in the MISTLIF group. Compared with those before operation, the postoperative VAS-L and VAS-B scores were significantly improved after operation in the both groups. In addition, the postoperative VAS-B score of the PETLIF group was significantly lower than that of the MISTLIF group. At the last follow-up, there was no significant difference between the two groups in the VAS-L score, VAS-B score, ODI score, and bony fusion rate., Conclusions: Both PETLIF and MISTLIF could achieve satisfactory clinical outcomes in the treatment of lumbar degenerative disease, but our study suggested that PETLIF had less damage, rapid recovery after operation, and short discharge time., (© 2021. The Author(s).)

Background: There is a paucity of information regarding outcomes in minimally invasive surgical (MIS) approaches to posterior lumbar surgery in morbidly obese patients. We seek to determine if there are differences in operative variables and early complication rates in morbidly obese patients undergoing MIS posterior lumbar surgery compared to obese and non-obese patients., Methods: A single institution retrospective review of patients undergoing MIS posterior lumbar surgery (decompression and/or fusion) between 2013 and 2016 was performed. Morbidly obese patients (BMI ≥ 40) were compared to obese (BMI 30-39.9) and non-obese (BMI < 30) cohorts. Postoperative complication rates and perioperative variables including estimated blood loss, operative time, and outcome measures including length of stay (LOS), in-hospital complications, readmission, and disposition were assessed., Results: 47 morbidly obese, 135 obese and 224 non-obese patients underwent posterior MIS instrumented fusion. 59 morbidly obese, 182 obese and 314 non-obese patients underwent posterior MIS decompression. The morbidly obese group experienced a greater rate of deep vein thrombosis and had an increased hospital LOS (p < 0.05). Morbidly obese patients who underwent MIS decompression experienced increased postoperative complications (p < 0.01), and increased LOS (p < 0.0001) compared to obese and non-obese patients. There were no differences in revision rates, readmissions, and other complications including surgical site infection. Morbid obesity was an independent predictor of overall complications and increased LOS on multivariate analysis., Conclusion: Morbidly obese patients undergoing posterior MIS fusion had a higher rate of complications and increased LOS. While weight loss should be encouraged, complication rates remains acceptably low in morbidly obese patients and MIS posterior lumbar surgery should still be offered., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Instrumentation of the lumbosacral region is one of the more challenging regions due to the complex anatomical structures and biomechanical forces. Screw insertion can be done both navigated and based on X-ray verification. In this study, we demonstrate a fast and reliable open, low exposure X-ray-guided technique of iliac screw placement., Methods: Between October 2016 and August 2019, 48 patients underwent sacropelvic fixation in tear-drop technique. Screw insertion was performed in open technique by using an X-ray converter angulated 25-30° in coronal and sagittal view. The anatomical insertion point was the posterior superior iliac spine. Verification of correct screw placement was done by intraoperative 3D scan., Results: In total, 95 iliac screws were placed in tear-drop technique with a correct placement in 98.1%., Conclusions: The tear-drop technique showed a proper screw position in the intraoperative 3D scan and therefore may be considered an alternative technique to the navigated screw placement.

Objective: To evaluate the effects of early ambulation on elderly patients' postoperative physical functional outcomes, complications, 90-day readmission rate, and the length of postoperative hospital stay., Methods: This is a prospective cohort study conducted between June 2019 and December 2019. The study enrolled 86 elderly patients (39 males) with newly diagnosed lumbar degenerative disease undergoing single-segment decompression and fusion surgerywere enrolled. Of all 86 patients, 39 voluntarily joined the early ambulation group, and 47 joined the regular ambulation group. The early ambulation group included patients ambulated within 4 h postoperatively, whereas the regular ambulation group included patients who were ambulatory at a minimum of 24 h after surgery. Participants' baseline characteristics, surgical information, ambulation ability, degree of pain, functional scores, postoperative complications, 90-day readmission rate, and length of postoperative hospital stay were recorded., Results: Participants' baseline demographic characteristics were balanced between the early ambulation group and the regular ambulation group. The operative time and blood loss were similar between groups. The time before the first-time ambulation was 4 ± 0.5 h in the early ambulation group and 28 ± 4.5 h in the regular ambulation group. Ambulating distance was significantly longer in the early ambulation group compared with the regular ambulation group on the 1st (63 ± 45 vs 23 ± 60 m), the 2nd (224 ± 100 vs 101 ± 130 m), and the 3rd (280 ± 102.5 vs 190 ± 170 m) ambulation days based on generalized estimating equation analyses. Generalized estimating equation analyses also demonstrated that the ambulating time was longer in the early ambulation group compared with the regular ambulation group on the 1st (10 ± 5 vs 10 ± 5 min), the 2nd (19 ± 7 vs 15 ± 5 min), and the 3rd (22 ± 16.5 vs 27 ± 12 min) ambulation days. Patients in the regular ambulation group experienced a higher degree of pain than the early ambulation group patients, with an odds ratio of 1.627 (P = 0.002). Short-term functional independence was superior in the early ambulation group, with a lower Roland-Morris disability questionnaire score (P = 0.008) and Oswestry disability index (P < 0.001). The incidences of postoperative urinary retention (early ambulation group: 7.7%, regular ambulation group: 25.5%, P = 0.030) and ileus (early ambulation group: 0%, regular ambulation group: 12.8%, P = 0.030) were significantly higher in the regular ambulation group. The prevalence of at least one complication rate was significantly lower in the early ambulation group than in the regular ambulation group (early ambulation group, 23.1%; regular ambulation group, 46.8%, P = 0.022). The duration of indwelling of the drainage catheter was shorter in the early ambulation group (early ambulation group, 68 ± 24 h; regular ambulation group, 78 ± 20 h, P = 0.001), and the length of the postoperative hospital stay was also shorter in the early ambulation group (early ambulation group, 4 ± 0 days; regular ambulation group: 5 ± 2 days, P < 0.001). However, there was no statistical difference in the 90-day readmission rate between groups., Conclusion: Early ambulation improved patients' postoperative functional status, decreased the incidence of complications, and shortened postoperative hospital stay in elderly patients undergoing lumbar decompression and fusion surgery., (© 2021 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Objective: Participation in physical activity and sports is known to have positive implications for physical health, and for social and emotional wellbeing of children. Following corrective spinal surgery for scoliosis, the timeline for the return to activities and sports varies from surgeon to surgeon and from location to location, and return to activities can be limited due to pain, fear, and decreased flexibility. It is critical that patients know best-practice guidelines, and it is equally critical that medical professionals know whether their patients are following those guidelines. This paper includes a summary of recommendations published in the literature, and a pilot study to address a gap in the literature on determining how long, post-surgery, adolescents with idiopathic scoliosis waited before returning to various self-care and physical activities, and what factors influenced return to activities. We used a mixed-method approach that involved two phases: a questionnaire (n = 8), and subsequent interviews of some participants (n = 3). Participants were ages 14-17 (M = 15.4) and had had posterior instrumentation and fusion for scoliosis in the past 2 years., Results: Some patients were cautious about return to activities, either because of emotional or medical reasons. However, in many instances, participants returned to physical activities earlier than was recommended, primarily for emotional and social reasons.

Background: We assessed pedicle screw accuracy utilizing a novel navigation-based spine surgery robotic system by comparing planned pathways with placed pathways in a porcine model., Methods: We placed three mini screws per vertebra for accuracy evaluation and used a reference frame for registration in four pigs (46 screws in 23 vertebrae). We planned screw paths and performed screw insertion under robot guidance. Using C-arm and CT images, we evaluated accuracy by comparing the 3D distance of the placed screw head/tip from the planned screw head/tip and 3D angular offset., Results: Mean registration deviation between the preoperative 3D space (C-arm) and postoperative CT scans was 0.475 ± 0.119 mm. The average offset from preoperative plan to final placement was 4.8 ± 2.0 mm from the head (tail), 5.3 ± 2.3 mm from the tip and 3.9 ± 2.4 degrees of angulation., Conclusions: Our spine surgery robot showed good accuracy in executing an intended planned trajectory and screw path. This faster and more accurate robotic system will be applied in future studies, first in cadavers and subsequently in the clinical field., (© 2020 John Wiley & Sons Ltd.)

Background: Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). Methods: A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Results: Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Conclusions: Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.

Purpose: Many patients receive magnetic resonance (MR) and computed tomography (CT) scans post-operatively to review screw placement. Traditionally, CT is diagnostic but as metal artefact reduction sequences are advancing in MR, the necessity for both MR and CT scans is questionable. The objective is to establish the statistical agreeability of MR and CT for evaluation of adequate screw placement in posterior lumbar interbody fusion., Methods: This opportunistic retrospective study of 58 patients investigated 297 images of 296 implanted screws. Post-operative MR and CT images were scrutinised for depiction of lumbar pedicle screw position using a 5-point scale. Kappa value for statistical agreeability tested MR against CT., Results: The 297 images of screws resulted in strong to near-perfect agreement between MR and CT (n = 297 k = 0.8042 p < 0.025). MRI resulted in high sensitivity (88.7%) and positive predictive value (78.3%). MRI demonstrated very high specificity (96.2%) and negative predictive value (98.2%). MR depicted screws (mean 12.6 mm diameter, mean 65.3 mm length) with 50% error in diameter and 30% in length from susceptibility artefact compared to manufacturer dimensions (6.5-7.5 mm diameter, 40-50 mm length). Adequate screw placement was high despite this (85.8%). On MR, the cortex border visibility was 60.7% and the spinal canal visibility was 74.6%., Conclusion: There is strong to near-perfect agreement between MR and CT for evaluating adequate screw position in PLIF surgery. MR alone is useful for analyzing screw placement and should be considered first-line imaging in uncomplicated cases with CT analysis reserved for cases of uncertainty., Level of Evidence: Level III retrospective cohort study.

The risks, benefits and technical aspects of surgery require careful consideration. One element of this is the requirement of postoperative blood transfusion. Patients who undergo elective lumbar decompression are at a low risk of requiring a postoperative transfusion yet undergo multiple preoperative group & save tests. For those who are at a low risk of bleeding, a single group & save sample may be adequate. This review analysed the postoperative blood loss and transfusion rate associated with lumbar decompression surgery without fusion in one institution. A subsequent cost analysis and review of the literature was performed. The aim was to assess whether single group & save sampling, within the context of lumbar decompression, was cost effective and amenable to the patient without impacting patient care. Average blood loss was estimated as a drop in Hb of 12.3g/dl. Six patients (14%) had Hb loss of over 20g/dl. No patients underwent a blood transfusion. Through examination of medical records, we found that 65% of patients (35) were suitable for single group & save sampling, estimating a saving of £2415.95 (53%). Selective group & save testing holds economic potential and safeguards patients from undergoing unnecessary testing. The next step after this review would be a prospective multi-centre study.

Objective: The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006-2016., Methods: We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders., Results: A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients., Conclusion: Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To discuss how the sequence of spinal surgery and hip replacement is determined for patients with both degenerative scoliosis and hip disease., Methods: Twenty-six patients treated for both degenerative scoliosis and hip disease from June 2012 to June 2015 were retrospectively studied. Eleven patients underwent hip replacement followed by lumbar surgery (Group A), and 15 patients underwent lumbar surgery followed by hip replacement (Group B). The average follow-up duration was 1.5 years. Related indicators were assessed preoperatively and postoperatively., Results: The parameters showing significant differences between Groups A and B after surgery were acetabular anteversion, the Oswestry functional disability score, and the Harris hip score. Postoperatively, five patients in Group A had unequal shoulder heights and inclination of the trunk to one side. After lumbar surgery and before total hip arthroplasty in Group B, eight patients could not walk, and the limitation was more severe than that preoperatively., Conclusion: Spinal surgery may be performed first to resolve lumbar nerve symptoms and restore sagittal balance of the spine; hip replacement may then be performed to simplify hip replacement difficulties and resolve the imbalance after spinal surgery. Severely limited range of motion exists after lumbar surgery and before total hip arthroplasty.

Objective: To compare economic and clinical outcomes of barbed sutures versus conventional sutures alone in wound closure for patients undergoing spinal surgery., Method: A retrospective study using the Premier Healthcare Database. The database was searched for patients who underwent elective inpatient spinal surgery (fusion or laminectomy) for a spinal disorder between 1 January 2014 and 30 June 2018 (first=index admission). Using billing records for medical supplies used during the index admission, patients were classified into mutually-exclusive groups: patients with any use of STRATAFIX (Ethicon, US) knotless tissue control devices (barbed sutures group); or patients with use of conventional sutures alone (conventional sutures group). Outcomes included the index admission's length of stay, total and subcategories of hospital costs, non-home discharge, operating room time (ORT, minutes), wound complications and readmissions within ≤90 days. Propensity score matching and generalised estimating equations were used to compare outcomes between the study groups., Results: After matching, 3705 patients were allocated to each group (mean age=61.5 years [standard deviation, SD±12.9]; 54% were females). Compared with the conventional suture group, the barbed suture group had significantly lower mean ORT (239±117 minutes, versus 263±79 minutes conventional sutures, p=0.015). Operating room costs were also siginificantly lower in the barbed suture group ($6673±$3976 versus $7100±$2700 conventional sutures, p=0.020). Differences were statistically insignificant for other outcomes (all p>0.05). Subanalysis of patients undergoing fusions of ≥2 vertebral joints yielded consistent results., Conclusion: In this study, wound closure incorporating barbed sutures was associated with lower ORT and operating room costs, with no significant difference in wound complications or readmissions, when compared with conventional sutures alone.

Objective: To examine the cost-effectiveness of case manager-assisted rehabilitation as an add-on to usual physical rehabilitation after lumbar spinal fusion, given the lack of any clinical benefits found on analysing the clinical data., Design: Economic evaluation alongside a randomized controlled trial with two-year follow-up., Setting: Patients from the outpatient clinics of a university hospital and a general hospital., Subjects: A total of 82 lumbar spinal fusion patients., Interventions: Patients were randomized one-to-one to case manager-assisted rehabilitation programme as an add-on to usual physical rehabilitation or to usual physical rehabilitation., Main Measures: Oswestry Disability Index and EuroQol 5-dimension. Danish preference weights were used to estimate quality-adjusted life years. Costs were estimated from micro costing and national registries. Multiple imputation was used to handle missing data. Costs and effects were presented with means (95% confidence interval (CI)). The incremental net benefit was estimated for a range of hypothetical values of willingness to pay per gain in effects., Results: No impact of case manager-assisted rehabilitation on the Oswestry Disability Index or estimate quality-adjusted life years was observed. Intervention cost was Euros 3984 (3468; 4499), which was outweighed by average reductions in inpatient resource use and sickness leave. A cost reduction of Euros 1716 (-16,651; 20,084) was found in the case manager group. Overall, the probability for the case manager-assisted rehabilitation programme being cost-effective did not exceed a probability of 56%, regardless of willingness to pay. Sensitivity analysis did not change the conclusion., Conclusion: This case manager-assisted rehabilitation programme was unlikely to be cost-effective.

Objective: Congenital heart disease (CHD) is associated with the development of scoliosis. Improvements in cardiac care have extended survival of children with cyanotic CHD which possess a need for correction of scoliosis. There is limited information on spinal care for these patients. We present 3 patients with CHD who underwent surgical correction of scoliosis., Materials and Methods: We reviewed demographic and clinical data on patients with cyanotic CHD., Results: Patient 1 underwent posterior spinal fusion T3-L3 at the age of 16 years. He had a double inlet left ventricle and was treated with completion of a Fontan circulation. Hypotensive anaesthesia was used but he lost 3,000 mL of blood. The operative time was 370 min and most of the blood loss occurred in the second half of the procedure. Patient 2 underwent posterior spinal fusion T5-T12 when aged 14 years. She had transposition of the great vessels corrected over multiple surgeries. Hypotensive anaesthesia was used, she had blood loss of 300 mL, and the surgical time was 282 min. Patient 3 underwent posterior spinal fusion extending from T5-T12 when he was 17 years old. He had a double inlet left ventricle and was treated with completion of a Fontan circulation. Hypotensive anaesthesia was used, he had blood loss of 1,021 mL, and a surgical time of 342 min., Conclusion: Scoliosis surgery in patients with complex cardiac disease may be indicated to treat progressive deformities which produce severe symptoms. A multidisciplinary approach including a spinal surgeon as well as a cardiologist, haematologist, respiratory paediatrician, and spinal anaesthetist can evaluate the general medical condition and weigh the benefits and risks of surgery. Deformity correction can be performed using a meticulous technique and has produced a series of satisfactory outcomes., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

Introduction: Spinal surgery of degenerative painful segments is a valuable treatment option in the management of chronic cervical and low back pain. The surgery consists in stabilizing and fusing painful vertebral segment(s). The objective of the study was to report our experience with 45S5 bioactive glass (BAG) to obtain inter-vertebral fusion in the context of posterior spine surgery., Material and Method: In this retrospective study, 30 patients with a wide range of degenerative and traumatic conditions of the cervical or lumbar spine underwent spinal fusion utilizing a synthetic bone graft substitute of BAG (GlassBone™, Noraker, Lyon-Villeurbanne, France). The pain was evaluated by VAS score, and graft consolidation was assessed on according radiographic images at 1-year post-op., Results: All patients underwent posterior spinal fusion either in the cervical or the thoraco-lumbar spine. Multi-level fusions represented the majority of the cohort (43% of patients with more than seven levels treated). Radiographic imaging demonstrated excellent fusion rates (93%) at final follow-up, equivalent to the outcomes reported in the literature for autogenous bone, with excellent bone bridging and no spinal implant loosening. Only two cases of non-union were encountered. Additionally, 90% of the patients demonstrated recovery at 1 year after surgery with a pain reduction of 60%., Conclusion: The results of this retrospective study suggest that the 45S5 BAG may be an interesting alternative option to autologous graft, in terms of safety and bone fusion efficiency., Level of Evidence: IV Retrospective study.

Objective: The aims of this study were to evaluate the risk factors for muscle injury in patients undergoing posterior lumbar spinal surgery and the clearance of postoperative biochemical changes following lumbar fusion and secondarily to evaluate the timing for monitoring postoperative biochemical serum levels and potential clinical correlation., Methods: The study prospectively enrolled 39 patients with degenerative disease of the lumbar spine. Biochemical markers (creatine phosphokinase [CPK], creatinine, and hemoglobin) were analyzed in 5 predefined stages. All relevant clinical data were collected. Rhabdomyolysis (RML) was defined as a postoperative 5-fold increase of the baseline CPK value., Results: Patients from the lumbar fusion group had the highest postoperative CPK ratio. Overall, the rate of RML was 43.6%. CPK and creatinine activity reached their maximum on the first postoperative day in 69.2% and 87.5% of patients, respectively. Lumbar fusion (P = 0.005), surgical time >270 minutes (P = 0.028), and fall in hemoglobin levels >3 g/dL (P = 0.034) were identified as independent factors associated with higher risk of RML., Conclusions: The risk of RML increases with prolonged and invasive surgery with higher bleeding potential. Knowing the clearance of postoperative biochemical changes permits a standardized strategy with measurements in precise intervals, thereby avoiding unnecessary costs. The clinical significance is still undetermined., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Postoperative ileus (PI) is a common complication following posterior thoraco-lumbar spinal fusion surgery. It usually slows patient's recovery and increases postoperative morbidity. However, the risk factors associated with PI in patients undergoing posterior thoraco-lumbar spinal fusion surgery are still unclear. The purpose of this study is to investigate the potential risk factors for PI in those patients., Patients and Methods: A prospective study was conducted and 426 patients received posterior thoraco-lumbar spinal fusion surgery between March 2017 and February 2018 were included in this study. The associations between different clinical factors and PI were analyzed. A logistic regression analysis was performed to detect independent risk factors for PI. The cut-off value, sensitivity and specificity of these independent factors were calculated by receiver operating characteristic (ROC) curve., Results: In this study, 8.2% (35/426) of these patients were identified with PI. The average length of postoperative hospital stay was 12.54 ± 6.06 days in patients with PI compared with 8.91 ± 3.81 days in patients without PI (P =  0.001). These results indicated that surgical duration, PLIF approach, blood loss and length of postoperative diet restriction were potential risk factors for PI in patients with thoraco-lumbar spinal fusion surgery. The cut-off values of surgical duration, blood loss and length of postoperative diet restriction were 4.375 h, 750 ml and 9.5 h, respectively. Combination of surgical duration, PLIF approach, blood loss and length of postoperative diet restriction has the highest predictive value for PI (AUC = 0.910, P <  0.001)., Conclusion: Based on the study, surgical duration, PLIF approach, blood loss and length of postoperative diet restriction were the independent risk factors for PI in patients with posterior thoraco-lumbar spinal fusion surgery. Combined those factors has the highest risk for developing PI., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The purpose of this meta-analysis is to evaluate the efficacy and safety of tranexamic acid (TXA) for patients with degenerative lumbar disc herniation, stenosis or instability undergoing posterior lumbar fusion (PLF) surgery., Methods: We searched PubMed, Embase, and Cochrane Library until May 1, 2018. Two reviewers selected studies, assessed quality, extracted data, and evaluated the risk of bias independently. Weighted mean difference (WMD) and relative risk (RR) were calculated as the summary statistics for continuous data and dichotomous data, respectively. We chose fixed-effects or random-effects models based on I 2 statistics. RevMan 5.0 and STATA 14.0 software were used for data analysis., Results: Nine studies enrolling 713 patients for the study. The pooled outcomes demonstrated that TXA can decrease total blood loss (TBL) in patients underwent PLF surgery [WMD = -250.68, 95% CI (- 325.06, - 176.29), P<0.001], intraoperative blood loss (IBL) [WMD = -72.57, 95% CI (- 103.94, - 41.20), P<0.001], postoperative blood loss (PBL) [WMD = -127.57, 95% CI (- 149.39, - 105.75), P<0.001], and the loss of hemoglobin (Hb) in postoperative 24 h [WMD = -0.31, 95% CI (- 0.44, - 0.18), P<0.001]. However, there is no significant difference between two groups in transfusion rate [RR =0.34, 95% CI (0.09, 1.28), P = 0.11], and none thrombotic event was happened in the two groups., Conclusion: Our meta-analysis demonstrated that TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability underwent PLF surgery. However, there was no significant difference in blood transfusion rates between the two groups.

Background: Formation of a dural arteriovenous fistula (DAVF) after lumbar spine decompression in the lumbar spine has been reported as a late complication, but is extremely rare in the cervical spine., Case Description: A 57-year-old man who underwent a C5-6, C6-7 anterior fusion 5 years previously for cervical myelopathy at another hospital presented with progressive gait disturbance and thermal hypoalgesia on the right side of the body. Magnetic resonance imaging showed flow voids in the spinal cord dorsally at the C4-7 level, which had not been detected before the initial operation. Digital subtraction angiography showed a fistulous connection at the C7 level between the perimedullary vein and a segmental artery from the right vertebral artery, which was diagnosed as a DAVF. Surgical interruption of the intradural draining vein with multilevel posterior cervical decompression was performed, and his symptoms improved., Conclusions: To the best of our knowledge, this is the first report of a DAVF developing after multilevel anterior cervical discectomy and fusion. All the published cases of secondary DAVF, especially after spinal surgery, are reviewed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Optimal transfusion thresholds have been extensively studied for various surgical procedures; however, no transfusion threshold has been set for patients undergoing complex spine surgery. The aim of this study was to compare postoperative outcomes relative to perioperative hemoglobin (Hb) levels for patients undergoing complex spine surgery for adult spinal deformity and to evaluate impact of blood transfusion timing on clinical outcomes., Methods: Retrospective chart review of patients with adult spinal deformity undergoing spine surgery lasting >6 hours or involving ≥6 levels of fusion was performed. Patients were divided into 2 cohorts based on whole hospitalization Hb nadir <9.0 g/dL versus ≥9.0 g/dL., Results: Among 104 patients, 55 (52.9%) had Hb nadir <9.0 g/dL. Compared with the cohort with higher Hb nadir, patients with Hb nadir <9.0 g/dL were more likely to be female (84.5% vs. 65.3%, P = 0.016), present with lower preoperative Hb (12.6 [1.5] g/dL vs. 13.8 [1.2] g/dL, P < 0.001), experience greater change in Hb after surgery (4.4 [1.5] g/dL vs. 3.7 [1.5] g/dL, P = 0.030), receive a postoperative blood transfusion (69.1% vs. 44.9%, P = 0.013), and have a longer length of stay (9.1 [4.8] days vs. 6.2 [3.2] days, P < 0.001)., Conclusions: In patients with adult spinal deformity undergoing complex spine surgery, earlier targeted blood transfusions during surgery, rather than in the postoperative period, may lead to improved postoperative outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)