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Vasospasm, so commonly described after aneurysmal rupture, is very rare after surgery for brain tumors. Its occurrence after transsphenoidal surgery is extremely uncommon with only three cases reported as per the authors' review of the literature. The authors report a case of pituitary macroadenoma in a 34-year-old female who underwent transsphenoidal tumor decompression and developed angiographically documented vasospasm during the course of her illness. The rarity of the occurrence of vasospasm after transsphenoidal surgery makes its management very challenging, frequently leading to a delay in diagnosis and a poor outcome. The key to successful management is a high index of suspicion and early proactive management. [ABSTRACT FROM AUTHOR]

The authors describe an extremely unusual case of a giant hemicranial subdural empyema occurring nine years after insertion of a venticuloperitoneal shunt. Though the empyema was evacuated, the child suffered significant morbidity and remained hemiparetic. The present case highlights the delayed morbidity following a ventriculoperitoneal shunt insertion and the need of prolonged and regular follow up in children who have undergone this procedure. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Systematic review. OBJECTIVE.: To systematically review the literature related to distal adjacent segment pathology (ASP) after long thoracolumbar fusions for deformity including frequency, risk factors, frequency differences between adolescents and adults, surgical approach for revision, and revision complications. SUMMARY OF BACKGROUND DATA.: Spinal deformity surgery complications include ASP. Although ASP at the rostral end of instrumented fusions has been well described, substantially less has been documented about distal ASP. METHODS.: A systematic search was conducted in Medline and the Cochrane Collaboration Library for articles published between January 1, 1983, and March 15, 2012. We included all articles that described distal ASP after long thoracolumbar fusion for deformity. Radiographical ASP (RASP) was defined as evidence of ASP based on imaging, and clinical ASP (CASP) was defined as symptomatic ASP. RESULTS.: Seven retrospective cohort studies met inclusion criteria. Distal CASP developed in 17.7% at 2- 6-year follow-up and 19.8% at 9-year follow-up, whereas reoperation due to CASP was reported in 15.6% at 2 to 6 years and 14.4% at 9 years. Distal RASP was more frequent (44.7%-65.5%). Preoperative sagittal imbalance was associated with increased risk of distal ASP. There was increased risk of CASP in patients with higher postoperative fractional curve and increased risk of RASP in younger patients and those with preoperative disc degeneration, longer fusions, circumferential procedures, and postoperative L5-S1 disc space narrowing. No studies meeting inclusion criteria compared distal ASP in adults and adolescents or defined the best approach or complications for distal ASP revision. CONCLUSION.: Low-quality evidence suggests a cumulative rate of 18% to 20% for CASP and 45% to 65% for RASP after long thoracolumbar fusion for spinal deformity during 9-year follow-up. Low-quality evidence suggests an association between preoperative sagittal imbalance and distal ASP, with greater risk of distal ASP in patients with sagittal imbalance. Low-quality evidence suggests increased risk of CASP in patients with higher postoperative fractional curve and increased risk of RASP in younger patients and those with preoperative disc degeneration, longer fusions, circumferential procedures, and postoperative L5-S1 disc space narrowing. CONSENSUS STATEMENT: [ABSTRACT FROM AUTHOR]

Background: Patients with thoracic metastatic epidural spinal cord compression (MESCC) often undergo extensive surgical decompression to avoid functional decline. Though limited in scope, scales including the revised cardiac risk index (RCRI) are used to stratify surgical risk to predict perioperative morbidity. This study uses the 5-item modified frailty index (mFI-5) to predict outcomes following transpedicular decompression/fusion for high-grade MESCC., Methods: A retrospective chart review was conducted on patients who underwent transpedicular decompression and fusion for MESCC (baseline demographics, spinal instability neoplastic score, preoperative and postoperative Bilsky scores, primary cancer type, and RCRI). Primary outcomes included length of stay (LOS), intraoperative estimated blood loss, readmission/reoperation within 90 days of index surgery, 90-day mortality, and posthospitalization disposition., Results: One hundred twenty-seven patients were included in our study. Ninety percent of patients' lesions were Bilsky 2 or greater. Increasing frailty, measured by mFI-5, was a significant predictor of increased LOS (P < 0.01) and 90-day mortality (P < 0.05). Multivariate analysis adjusting for sex, body mass index , and age still showed statistical significance (P < 0.05). MFI-5 was not a significant predictor of readmission/reoperation within 90 days or estimated blood loss. Age - not mFI-5 or RCRI - was a significant predictor for posthospitalization nonhome disposition (P = 0.001)., Conclusions: The mFI-5 can serve as a useful predictor of outcomes after transpedicular decompression and fusion for thoracic MESCC as it can account for the patient's frailty. Our study demonstrated the mFI-5 as a predictor of LOS and 90-day mortality. These results provide a background to both understanding and integrating frailty into decision-making in MESCC., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy., Methods: A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition., Results: A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02)., Conclusions: Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Thoracic disc herniations (TDH) are uncommon compared to cervical and lumbar disc herniations. Surgical treatment of TDH can be challenging due to the anatomical constraints and the high risk of morbidity due to proximity to the thoracic spinal cord. Moreover, the selection of appropriate surgical approach depends on various factors such as the size and location of disc herniation within the spinal canal, spinal level, presence or absence of calcification, degree of spinal cord compression, and familiarity with various approaches by the treating surgeon. While there is agreement that posterolateral approaches can be used to treat posterolateral and central soft disc herniation, there is a lack of consensus on the best surgical approach for central calcified and giant calcified TDH where an anterior approach is perceived as the best option. There is increasing evidence that support the safety and efficacy of posterolateral approaches even for central calcified and giant calcified TDH. This review highlights the evolution of surgical management for TDH based on the past and current literature and the author's experience at his institution., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Postoperative C5 palsy (C5P) is a known complication in cervical spine surgery. However, its exact pathophysiology is unclear. The authors aimed to provide a review of the current understanding of C5P by performing a comprehensive, systematic review of the existing literature and conducting a critical appraisal of existing evidence to determine the risk factors of C5P., Methods: A systematic search of PubMed/MEDLINE (January 1, 2019, to July 2, 2021), EMBASE (inception to July 2, 2021), and Cochrane (inception to July 2, 2021) databases was conducted. Preestablished criteria were used to evaluate studies for inclusion. Studies that adjusted for one or more of the following factors were considered: preoperative foraminal diameter (FD) at C4/5, posterior spinal cord shift at C4/5, preoperative anterior-posterior diameter (APD) at C4/5, preoperative spinal cord rotation, and change in C2-7 Cobb angle. Studies were rated as good, fair, or poor based on the Quality in Prognosis Studies (QUIPS) tool. Random effects meta-analyses were done using methods outlined by Cochrane methodologists for pooling of prognostic studies. Overall quality (strength) of evidence was based on Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods for prognostic studies. The protocol for this review was published on the PROSPERO (CRD264358) website., Results: Of 303 potentially relevant citations of studies, 12 met the inclusion criteria set a priori. These works provide moderate-quality evidence that preoperative FD substantially increases the odds of C5P in patients undergoing posterior cervical surgery. Pooled estimates across 7 studies in which various surgical approaches were used indicate that the odds of C5P approximately triple for each millimeter decrease in preoperative FD (OR 3.05, 95% CI 2.07-4.49). Preoperative APD increases the odds of C5P, but the confidence is low. Across 3 studies, each using different surgical approaches, each millimeter decrease in preoperative APD was associated with a more than 2-fold increased odds of C5P (pooled OR 2.51, 95% CI 1.69-3.73). Confidence that there is an association with postoperative C5P and posterior spinal cord shift, change in sagittal Cobb angle, and preoperative spinal cord rotation is very low., Conclusions: The exact pathophysiological process resulting in postoperative C5P remains an enigma but there is a clear association with foraminal stenosis, especially when performing posterior procedures. C5P is also related to decreased APD but the association is less clear. The overall quality (strength) of evidence provided by the current literature is low to very low for most factors. Systematic review registration no.: CRD264358 (https://www.crd.york.ac.uk/prospero/).

Competing Interests: None

Competing Interests: None

Purpose: To report the safety and efficacy of posterolateral approach for thoracic disc herniation (TDH) via a consecutive clinical case series of 30 central thoracic disc herniations that were all operated through a posterolateral approach., Methods: A retrospective review was conducted of all patients with symptomatic TDH who underwent surgical intervention from 2016 to 2021. A total of 23 patients comprising 30 central TDH were included in the study. Age, gender, location of the lesion, preoperative and post-operative Frankel and Nurick scores, surgical approach and instrumented vertebrae, and length of stay were recorded., Findings: 23 patients with an average age of 62 were included in the study. 30 of the 32 symptomatic TDH were centrally located. 8/32 TDH were calcified while 24/32 TDH were non-calcified. Unilateral and bilateral transpedicular approach was used in the treatment of 12/32 and 10/32 disc herniations respectively. A transfacet-pedicle sparing approach was used in 10/32 disc herniations. 19/23 (82.6%) of the patients had improvement in Nurick score while 12/23 (52.2%) patients had improvement in their Frankel scores. The average length of stay was 4.5 days. No major complications were encountered. All patients underwent a short-segment instrumented construct with no need for revision surgery for thoracic disc herniation, worsening myelopathy, or instrumentation failure., Conclusions: 83% of the patients who underwent a transfacet or transpedicular decompression for the treatment of symptomatic TDH had improvement in their myelopathy with no neurological deterioration in any of the patients. Given the familiarity and low morbidity associated with a transfacet or transpedicular approach, posterolateral-based approaches remains an excellent alternative for surgical management of majority of the patients with thoracic disc herniations., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Lumbar synovial cysts (LSC) are one of the manifestations of spinal degenerative cascade. Spinal stenosis or presence of instability in these patients can lead to various symptoms and surgery is indicated following failure of non-operative management for symptomatic synovial cysts. Surgery when performed consists of either decompression with resection of cyst with our without fusion. The efficacy and complications of minimally invasive techniques using tubular retractors (microscopic or endoscopic) in comparison to traditional open techniques remain to be studied., Methods: A comprehensive search of different databases was performed to retrieve studies describing the use of minimal invasive techniques using tubular retractors (both microscopic and endoscopic) in patients with LSC. Meta-analysis with subgroup analysis and metaregression was done., Results: Twenty articles were selected for the systematic review and meta-analysis with total of 388 patients. Eighty-six percent of patients (95% Confidence Interval (CI): 80-90%) had favorable outcome as per Macnab's criteria (excellent and good outcome) with the pooled standard mean difference between preoperative and postoperative Oswestry Disability Index (ODI) being -4.44 (95% CI -8.78 to -0.10, p-value=0.0474, I 2 82%). The pooled percentage change in visual analogue scale (VAS) after surgery was 76.5% (95% CI 66.9-84%, I 2 82%). The pooled proportion of incidental durotomies, cyst recurrence and patients requiring operation being 8% (95% CI 5-11%, I 2 0%), 4% (95% CI 2-7%, I 2 0%,) and 5% (95% CI 3-9%) respectively. Studies were homogeneous with an I 2 value of 0%. Subgroup analysis revealed no significant difference in the outcome rates or complication rates between the microscopic and endoscopic subgroups., Conclusion: Minimally invasive techniques for the resection of LSC is a safe and effective alternative to traditional surgical approaches with no difference between the microscopic and endoscopic approaches., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Competing Interests: None

Background: A scarcity of data has been reported on tandem thoracic lumbar stenosis, which might be related to either the rarity or underdiagnosis of the condition. We have presented a systematic review of the clinical presentation, diagnosis, and treatment patterns for patients with symptomatic tandem thoracic and lumbar stenosis., Methods: A PubMed/MEDLINE search was performed to find reports of patients with symptomatic tandem thoracic and lumbar stenosis., Results: The review identified 10 studies with a total of 48 patients with tandem thoracic and lumbar stenosis. Most patients (n = 41; 85%) had had tandem stenosis diagnosed at the initial investigation, with 71% of the reports citing ossification of the ligamentum flavum as a contributing etiology. A few patients (n = 7; 15%) had had thoracic lesions diagnosed after neurologic deterioration that had occurred after lumbar surgery for previously suspected isolated lumbar stenosis. Surgical management varied from isolated thoracic decompression, staged decompression, and simultaneous decompression. Most patients (n = 41; 87%) showed improved neurologic status after surgery., Conclusion: Ossification of the ligamentum flavum might play a key role in the pathogenesis of the condition. Most patients with tandem thoracic and lumbar stenosis will show improvement after surgical decompression. Although the limited evidence available has raised concerns regarding neurologic deterioration after initial lumbar decompression in patients with coexisting thoracic stenosis, the data are insufficient to definitively determine an optimal surgical strategy. Further research is needed to identify the optimal diagnostic and management criteria for patients with symptomatic tandem thoracic and lumbar stenosis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: T1 slope has emerged as an important radiographic parameter in the evaluation and surgical management of adult cervical spinal deformity. Given the high rates of nonvisualization of T1 slope on upright cervical radiographs, however, this study examined the evaluation of C7 slope as a potential surrogate marker., Methods: This is a retrospective review in adult patients with and without cervical deformity to examine the correlation of C7 and T1 slopes on routine upright cervical radiographs. In secondary analysis, correlations of C7 and T1 slopes were made amongst various demographic variables, different surgical groups, and various measures of cervical alignment. Cervical deformity was defined as sagittal vertical axis >40 mm, coronal Cobb angle >10°, and sagittal Cobb >10° in kyphosis., Results: C7 slope was visualized in 93% of patients as opposed to T1 slope in 68% of patients, leading to a final study population of 129 patients. Mean values of C7 and T1 slopes were 26.5° and 28.1°, respectively. Significant correlation was found in patients with and without cervical deformity (r = 0.9, P < 0.01). This correlation remained significant amongst demographics, surgical groups, and measures of cervical alignment., Conclusions: Results demonstrated that C7 and T1 were in direct correlation in a variety of different cohorts regardless of deformity status or prior fusion. This study indicates that C7 slope may be reliably used a surrogate marker especially when visualization of T1 slope is not possible., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion., Objective: To identify the 100 most-cited articles on spine trauma., Methods: The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles., Results: The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list., Conclusions: We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work., Competing Interests: None

Competing Interests: There are no conflicts of interest.

Objective: Chordomas of the spine and sacrum are a rare but debilitating cancer and require complex multidisciplinary care. Studies of other such rare cancers have demonstrated an association of high-volume and/or multidisciplinary centers with improved outcomes and survival. Such an association has been proposed for chordomas, but evidence to support this claim is lacking. The authors performed a study to investigate if treatment facility type is associated with patterns of care and survival for patients with spinal and sacral chordomas by assessing records from a US-based cancer database., Methods: In this observational retrospective cohort study, the authors identified 1266 patients from the National Cancer Database with vertebral column or sacral chordomas diagnosed between 2004 and 2015. The primary study outcome was overall survival, and secondary outcomes included odds of receiving treatment and time to treatment, defined as radiation therapy, surgery, and/or any treatment, including surgery, radiation therapy, chemotherapy, or participation in clinical trials. The results were adjusted for age, sex, race/ethnicity, level of education, income, and Charlson/Deyo score., Results: Of the 1266 patients identified, the mean age at diagnosis was 59.70 years (SD 16.2 years), and the patients were predominantly male (n = 791 [62.50%]). Patients treated at community cancer programs demonstrated an increased risk of death (HR 1.98, 95% CI 1.13-3.47, p = 0.018) when compared to patients treated at academic/research programs (ARPs). The median survival was longest for those treated at ARPs (131.45 months) compared to community cancer programs (79.34 months, 95% CI 48.99-123.17) and comprehensive community cancer programs (CCCPs) (109.34 months, 95% CI 84.76-131.45); 5-year survival rates were 76.08%, 52.71%, and 61.57%, respectively. Patients treated at community cancer programs and CCCPs were less likely to receive any treatment compared to those treated at ARPs (OR 6.05, 95% CI 2.62-13.95, p < 0.0001; OR 3.74, 95% CI 2.23-6.28, p < 0.0001, respectively). Patients treated at CCCPs and community cancer programs were less likely to receive surgery than those treated at ARPs (OR 2.69, 95% CI 1.82-3.97, p = 0.010; OR = 2.64, 95% CI 1.22-5.71, p = 0.014, respectively). Patients were more likely to receive any treatment (OR 0.59, 95% CI 0.40-0.87, p = 0.007) and surgery (OR 0.58, 95% CI 0.38-0.88, p < 0.0001) within 30 days at a CCCP compared to an ARP. There were no differences in odds of receiving radiation therapy or time to radiation by facility type., Conclusions: Clinical care at an ARP is associated with increased odds of receiving treatment that is associated with improved overall survival for patients with spinal and sacral chordomas, suggesting that ARPs provide the most comprehensive specialized care for patients with this rare and devastating oncological disease.

Objective: Cervical spondylotic myelopathy (CSM) is a progressive degenerative pathology that frequently affects older individuals and causes spinal cord compression with symptoms of neck pain, radiculopathy, and weakness. Anterior decompression and fusion is the primary intervention to prevent neurological deterioration; however, in severe cases, circumferential decompression and fusion is necessary. Published data regarding perioperative morbidity associated with these complex operations are scarce. In this study, the authors sought to add to this important body of literature by documenting a large single-surgeon experience of single-session circumferential cervical decompression and fusion., Methods: A retrospective analysis was performed to identify intended single-stage anterior-posterior or posterior-anterior-posterior cervical spine decompression and fusion surgeries performed by the primary surgeon (V.C.T.) at Rush University Medical Center between 2009 and 2016. Cases in which true anterior-posterior cervical decompression and fusion was not performed (i.e., those involving anterior-only, posterior-only, or delayed circumferential fusion) were excluded from analysis. Data including standard patient demographic information, comorbidities, previous surgeries, and intraoperative course, along with postoperative outcomes and complications, were collected and analyzed. Perioperative morbidity was recorded during the 90 days following surgery., Results: Seventy-two patients (29 male and 43 female, mean age 57.6 years) were included in the study. Fourteen patients (19.4%) were active smokers, and 56.9% had hypertension, the most common comorbidity. The most common clinical presentation was neck pain in 57 patients (79.2%). Twenty-three patients (31.9%) had myelopathy, and 32 patients (44.4%) had undergone prior cervical spine surgery. Average blood loss was 613 ml. Injury to the vertebral artery was encountered in 1 patient (1.4%). Recurrent laryngeal nerve palsy was observed in 2 patients (2.8%). Two patients (2.8%) had transient unilateral hand grip weakness. There were no permanent neurological deficits. Dysphagia was encountered in 45 patients (62.5%) postoperatively, with 23 (32%) requiring nasogastric parenteral nutrition and 9 (12.5%) patients ultimately undergoing percutaneous endoscopic gastrostomy (PEG) placement. Nine of the 72 patients required a tracheostomy. The incidence of pneumonia was 6.9% (5 patients) overall, and 2 of these patients were in the tracheostomy group. Superficial wound infections occurred in 4 patients (5.6%). Perioperative death occurred in 1 patient. Reoperation was necessary in 10 patients (13.9%). Major perioperative complications (permanent neurological deficit, vascular injury, tracheostomy, PEG tube, stroke, or death) occurred in 30.6% of patients. The risk of minor perioperative complications (temporary deficit, dysphagia, deep vein thrombosis, pulmonary embolism, urinary tract infection, pneumonia, or wound infection) was 80.6%., Conclusions: Single-session anterior-posterior cervical decompression and fusion is an inherently morbid operation required in select patients with cervical spondylotic myelopathy. In this large single-surgeon series, there was a major perioperative complication risk of 30.6% and minor perioperative complication risk of 80.6%. This overall elevated risk for postoperative complications must be carefully considered and discussed with the patient preoperatively. In some situations, shared decision making may lead to the conclusion that a procedure of lesser magnitude may be more appropriate.

Objective: To report baseline demographics and examine for differences in survival for patients with World Health Organization (WHO) grade II and III spinal meningioma., Methods: The National Cancer Database was queried for patients diagnosed with WHO grade II or grade III spinal meningioma between 2004 and 2015. Cases with histopathological confirmation were included. Descriptive statistics were calculated and stratified by tumor type. Facility type, 30-day readmission, and 90-day mortality were also examined. Crude and adjusted Cox proportional hazards regression models were used to evaluate for differences in survival., Results: A total of 287 patients with WHO grade II or grade III spinal meningioma (white, n = 237; black, n = 32; Asian and Pacific Islander, n = 11; unknown race, n = 7) were identified. The mean patient age was 56.4 years, and the majority were female (70%; n = 201). Almost one-half of the patients were treated in an academic/research program (45.3%; n = 130,). Those with WHO grade III lesions received the earliest treatment, at a mean of 10.8 days following diagnosis. The proportion of patients with unplanned 30-day readmission following surgery was 4.2% (n = 12). Two patients died within 90 days of surgery. Multivariable analysis demonstrated no differences in survival for patients with WHO grade II or grade III lesions (hazard ratio, 2.01; 95% confidence interval, 0.89-4.52; P = 0.09)., Conclusions: No difference in overall survival was identified between patients with WHO grade II or III spinal meningioma, although a trend was seen toward worse survival for patients with WHO grade III lesions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Vascular anomalies involving the V3 segment of the vertebral artery are common and may complicate posterior atlantoaxial instrumentation. We report a patient with a fenestrated vertebral artery that underwent successful C1-2 instrumentation and fusion. Various vertebral artery anomalies are discussed with a review of pertinent literature.

Competing Interests: There are no conflicts of interest.

Cervical spine degenerative pathologies remain one of the most common spinal conditions treated by spine surgeons worldwide. Surgery is recommended in all patients with symptomatic cervical spinal stenosis with either moderate to severe myelopathy, degeneration, or refractory radiculopathy. As the number of levels increases the potential for complications associated with anterior surgery can be significant, especially dysphagia and pseudarthrosis. The objective of this study was to analyze the fusion rate following three- or more level anterior cervical discectomy and fusion (ACDF). A retrospective review was performed analyzing patients who underwent three or more level ACDF. Fusion was evaluated using post-operative dynamic upright radiographs Relevant post-operative complications especially dysphagia requiring dietary modifications or placement of feeding tube was also noted. A total of 72 patients were included in the study. Of the 232 levels fused, pseudarthrosis occurred at 47 (14%) levels. Overall 45.8% of patients (33/72) had a pseudarthrosis. The incidence of pseudarthrosis was higher in patients with 4 level ACDF as compared to those with 3 level ACDF [56% (9/16) versus 42% (24/56)]. At last follow up, the number of patients that were symptomatic from their pseudarthrosis and required posterior spinal instrumentation was 8/72 (11.1%). Fusion rates in a large cohort of patients with three- and four-level ACDF performed utilizing allograft and segmental instrumentation is reported. The study demonstrates that 3-4 level, stand-alone anterior cervical arthrodeses result in at least one level of pseudarthrosis in almost half of patients, especially at the caudal level of the construct., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Ossification of the ligamentum flavum (OLF) is a well-recognized but rare cause of thoracic myelopathy. Its subtle and variable clinical presentation often makes the diagnosis challenging. The treatment of symptomatic OLF requires surgical intervention, with the most common surgical procedure being a posterior decompression with or without instrumentation. Recurrence of ossification and stenosis after surgery is rare and usually occurs at the same intervertebral level. Multiple recurrences of ossification and stenosis are exceptionally rare. The authors report the case of OLF in a 60-year-old man who experienced recurrence of ossification and stenosis twice after posterior decompression surgeries alone. The patient was ultimately treated with revision decompression and instrumented fusion. The authors also present a pertinent review of the literature.

Competing Interests: There are no conflicts of interest