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The oblique lateral interbody fusion (OLIF) procedure is an important component of the surgeon's armamentarium for the treatment of degenerative spinal conditions. OLIF with posterior spinal fixation frequently is performed and requires additional time because the patient is flipped to a prone position and redraped. We report a series of cases in which robotic-assistance was used for a 2-surgeon workflow in which OLIF and single lateral position posterior spinal fixation were performed at the same time, termed simultaneous robotic single position surgery (SR-SPS). Data were collected retrospectively from medical records of 13 consecutive patients who underwent SR-SPS by a single surgeon at an academic center between June and December 2020. Instrumentation accuracy, total operating room time, estimated blood loss, length of stay, and complications were assessed. A total of 13 patients whose mean age was 64.1 years (range 46–84 years) underwent SR-SPS over a 6-month period. Average follow-up was 10.3 months. All patients were treated for degenerative spine disease. The average operative duration was 111.2 ± 25.2 minutes. A total of 60 pedicle screws were placed bilaterally in the lateral position with an accuracy rate of 95.0%. Complications included 1 postoperative seroma, and 1 patient required reoperation 3 months postoperatively due to a fall. We report the first case series describing SR-SPS. Our study shows that this method can reduce operative time while ensuring accurate and timely screw placement with minimal complications. [ABSTRACT FROM AUTHOR]

In this retrospective review study, the authors systematically reviewed the literature to elucidate the efficacy and complications associated with decompression and interspinous devices (ISDs) used in surgeries for lumbar spinal stenosis (LSS). LSS is a debilitating condition that affects the lumbar spinal cord and spinal nerve roots. However, a comprehensive report on the relative efficacy and complication rate of ISDs as they compare to traditional decompression procedures is currently lacking. The PubMed database was queried to identify clinical studies that exclusively investigated decompression, those that exclusively investigated ISDs, and those that compared decompression with ISDs. Only prospective cohort studies, case series, and randomized controlled trials that evaluated outcomes using the Visual Analog Scale (VAS), Oswestry Disability Index, or Japanese Orthopedic Association scores were included. A random-effects model was established to assess the difference between preoperative and the 1--2-year postoperative VAS scores between ISD surgery and lumbar decompression. This study included 40 papers that matched our criteria. Twenty-five decompressionexclusive clinical trials with 3,386 patients and a mean age of 68.7 years (range, 31--88 years) reported a 2.2% incidence rate of dural tears and a 2.6% incidence rate of postoperative infections. Eight ISD-exclusive clinical trials with 1,496 patients and a mean age of 65.1 (range, 19--89 years) reported a 5.3% incidence rate of postoperative leg pain and a 3.7% incidence rate of spinous process fractures. Seven studies that compared ISDs and decompression in 624 patients found a reoperation rate of 8.3% in ISD patients vs. 3.9% in decompression patients; they also reported dural tears in 0.32% of ISD patients vs. 5.2% in decompression patients. A metaanalysis of the randomized controlled trials found that the differences in preoperative and postoperative VAS scores between the two groups were not significant. Both decompression and ISD interventions are unique surgical interventions with different therapeutic efficacies and complications. The collected studies do not consistently demonstrate superiority of either procedure over the other but understanding the differences between the two techniques can help tailor treatment regimens for patients with LSS. [ABSTRACT FROM AUTHOR]

Summary of Background Data: Although pseudoangina is most commonly caused by cervical disc herniation, several cases have been described where thoracic herniation produced symptoms of pseudoangina. If thoracic herniation can produce angina-like pain, then it is important to consider whether pathology of the thoracolumbar spine, in general, can trigger false pain syndromes distinct from pseudoangina., Objective: We seek to provide the most comprehensive study regarding the diagnosis and treatment of spinal conditions causing false pain syndromes., Study Design: Systematic review of the current literature using PRISMA 2020 recommendations., Methods: We queried the literature and systematically selected relevant studies according to PRISMA guidelines., Results: Across 22 selected studies, the sample size was 30 patients, and a total of 26 met the criteria for statistical analysis. Seven (26.9%) of these patients presented with a chief complaint of pseudoangina resulting from thoracic disc herniation. 73.1% (19/26) of patients exhibited pain mimicking visceral origin. Overall, 13/19 (68.4%) patients exhibited thoracic spine disease only and 4/19 (21.1%) patients were affected at lumbar levels only, while 2 (10.5%) patients exhibited thoracolumbar herniation. Presentations included abdominal pain (11/19) mimicking appendicitis or pancreatitis, flank pain mimicking renal colic (8/19), and 2 cases of scrotal pain/orchalgia. Symptom durations ranged from acute (<24 h) to 7 years. Treatments were reported for 18/19 patients and all treated patients reported alleviated pain. Seven out of 18 patients were managed conservatively while 11/18 were treated surgically. Misdiagnosis resulted in unnecessary surgery (pancreaticojejunostomy) or other invasive procedures., Conclusions: In spinal disorders manifesting with atypical pain syndromes, delay in proper diagnosis and unnecessary treatments can, unfortunately, cause prolonged patient suffering and increased cost of health care. As a result, some have proposed that spinal screening should be incorporated into clinical examinations involving false pain syndromes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Yolk sac tumor (YST), or endodermal sinus tumor, is classically associated with pediatric populations. Metastasis to the spine rarely occurs, usually involving the lower thoracic or lumbar vertebrae. The objective of this report is to present a rare case of YST metastasis to the lower cervical and upper thoracic vertebrae in an adult male. A case-based review of the literature on metastatic YSTs was also performed as an update to the relevant literature., Case Description: A 28-year-old male with a history of YST presented to our institution with urinary retention, increasing weakness in the upper extremities, and acute onset lower extremity weakness. Computed tomography (CT) and magnetic resonance imaging (MRI) scans confirmed evidence of metastasis from a known YST with symptomatic cord compression. The patient was treated with surgical excision via decompressive laminectomies with instrumentation as described, and histopathologic analysis of the specimen confirmed YST metastasis. His disease recurred one year after index surgery. He succumbed to his disease despite repeated debulking., Conclusions: Metastasis of YST is rare, but metastasis to lower cervical and upper thoracic vertebrae is possible. YSTs are usually treated via primary surgical resection. Systemic chemotherapy and radiation may prevent recurrence. However, individualized treatment is imperative for improved patient outcomes., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-28/coif). M.H.P. reports grants from Medtronic and consulting fees from Medtronic, Globus, Thompson Surgical, and NovApproach. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Purpose: Minimally invasive single position lateral ALIF at L5-S1 with simultaneous robot-assisted posterior fixation has technical and anatomic considerations that need further description., Methods: This is a retrospective case series of single position lateral ALIF at L5-S1 with robotic assisted fixation. End points included radiographic parameters, lordosis distribution index (LDI), complications, pedicle screw accuracy, and inpatient metrics., Results: There were 17 patients with mean age of 60.5 years. Eight patients underwent interbody fusion at L5-S1, five patients at L4-S1, two patients at L3-S1, and one patient at L2-S1 in single lateral position. Operative times for 1-level and 2-level cases were 193 min and 278 min, respectively. Mean EBL was 71 cc. Mean improvements in L5-S1 segmental lordosis were 11.7 ± 4.0°, L1-S1 lordosis of 4.8 ± 6.4°, sagittal vertical axis of - 0.1 ± 1.7 cm°, pelvic tilt of - 3.1 ± 5.9°, and pelvic incidence lumbar-lordosis mismatch of - 4.6 ± 6.4°. Six patients corrected into a normal LDI (50-80%) and no patients became imbalanced over a mean follow-up period of 14.4 months. Of 100 screws placed in lateral position with robotic assistance, there were three total breaches (two lateral grade 3, one medial grade 2) for a screw accuracy of 97.0%. There were no neurologic, vascular, bowel, or ureteral injuries, and no implant failure or reoperation., Conclusion: Single position lateral ALIF at L5-S1 with simultaneous robotic placement of pedicle screws by a second surgeon is a safe and effective technique that improves global alignment and lordosis distribution index., (© 2023. The Author(s).)

Purpose: The purpose of this review was to evaluate the effectiveness of patient-specific rods for adult spinal deformity., Methods: A systematic review of the literature was performed through an electronic search of the PubMed, Scopus, and Web of Science databases. Human studies between 2012 and 2023 were included. Sample size, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), operation time, blood loss, follow-up duration, and complications were recorded for each study when available., Results: Seven studies with a total of 304 adult spinal deformity patients of various etiologies were included. All studies reported SVA, and PT; two studies did not report PI-LL. Four studies reported planned radiographic outcomes. Two found a significant association between preoperative plan and postoperative outcome in all three outcomes. One found a significant association for PI-LL alone. The fourth found no significant associations. SVA improved in six of seven studies, PI-LL improved in all five, and three of seven studies found improved postoperative PT. Significance of these results varied greatly by study., Conclusion: Preliminary evidence suggests potential benefits of PSRs in achieving optimal spino-pelvic parameters in ASD surgery. Nevertheless, conclusions regarding the superiority of PSRs over traditional rods must be judiciously drawn, given the heterogeneity of patients and study methodologies, potential confounding variables, and the absence of robust randomized controlled trials. Future investigations should concentrate on enhancing preoperative planning, standardizing surgical methodologies, isolating specific patient subgroups, and head-to-head comparisons with traditional rods to fully elucidate the impact of PSRs in ASD surgery., (© 2024. The Author(s).)

Background/objective: The recent development of minimally invasive surgical techniques (MIS) has made possible the correction of adult spinal deformity (ASD) with less blood loss and shorter hospital stays. However, minimally invasive placement of pedicle screws at the proximal level of the construct can increase pseudarthrosis risk, leading to implant failure, kyphosis, and reoperations. We aggregate existing literature to describe pseudarthrosis rates at the proximal thoracic or thoracolumbar junction in MIS and subsequent reoperation rates., Methods: After a three-tied search strategy in PubMed, we identified 9 articles for study inclusion, describing outcomes from MIS correction of ASD, pseudarthrosis as complication, and surgery on 4+ levels. Baseline patient characteristics and combined rates of pseudarthrosis and reoperation were calculated., Results: A total of 482 patients were studied with an average [range] age of 65.5 [60.4,72], 6.3 [4.4,11] levels fused per patient, follow-up time of 28.3 [12,39] months, and 64.8% females. Pseudarthrosis was reported in 28 of 482 pooled patients (5.8%) of which 15 of 374 pooled patients (4.0%) ultimately underwent a reoperation for pseudarthrosis. Post-operative characteristics included an estimated blood loss (EBL) of 527.1 [241,1466] mL, operating time of 297.9 [183,475] minutes, and length of stay of 7.7 [5,10] days. Among the papers comparing MIS to open surgery, all reported a significantly lower EBL in patients treated with MIS., Conclusion: This analysis demonstrate a measurable pseudarthrosis risk when using MIS to treat ASD, overwhelming requiring reoperation. The benefits of MIS must be considered against the drawbacks of pseudarthrosis when determining ASD management., Competing Interests: 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., (© 2024 The Authors.)

Background: Robotic assistance has been shown to increase instrumentation placement accuracy in open and minimally invasive spinal fusion. These gains have been achieved without increases in operative times, blood loss, or hospitalization duration. However, most work has been done in the degenerative population and little is known of the utility of robotic assistance when applied to spinal trauma. This is largely due to the uncertainty stemming from the disruption of normal anatomy by the traumatic injury. Since the robot depends upon registration for instrumentation guidance according to the fiducials it uses, trauma can introduce unique challenges. The present study sought to evaluate the safety and efficacy of robotic assistance in a consecutive cohort of spine trauma patients., Methods: All patients with Thoracolumbar Injury Classification and Severity Scale (TLICS) >4 who underwent robot-assisted spinal fusion using the Globus ExcelsiusGPS at a single tertiary care center for trauma between 2020 and 2022 were identified. Demographic, clinical, and surgical data were collected and analyzed; the primary endpoints were operative time, fluoroscopy time, estimated blood loss, postoperative complications, admission time, and 90-day readmission rate. The paired t-test was used to compare differences between mean values when looking at the number of surgical levels., Results: Forty-two patients undergoing robot-assisted spinal surgery were included (mean age 61.3±17.1 year; 47% female. Patients were stratified by the number of operative levels, 2 (n = 10), 3-4 (n = 11), 5 to 6 (n = 13), or >6 (n = 8). There appeared to be a positive correlation between number of levels instrumented and odds of postoperative complications, admission duration, fluoroscopy time, and estimated blood loss. There were no instances of screw malposition or breach., Conclusions: This initial experience suggests robotic assistance can be safely employed in the spine trauma population. Additional experiences in larger patient populations are necessary to delineate those traumatic pathologies most amenable to robotic assistance., Competing Interests: 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., (© 2023 The Author(s).)

Purpose: To examine the role of demographics on surgical management and inpatient complications in patients with spinal deformity between 2010 and 2014 via retrospective analysis., Methods: Data were obtained from the National Inpatient Sample (NIS). International Classification of Diseases 9th revision codes were used to identify patients with a primary diagnosis of adult spinal deformity (ASD). Multivariable Poisson regression analyses were used to determine whether any individual demographic variables were predictive of surgical management, surgical complexity, postoperative complications and revision operations., Results: 17,433 patients were identified for analysis. Surgical intervention was performed for 94.5% of patients with a primary diagnosis of ASD. Patients at urban teaching hospitals were the most likely to receive surgery (OR= 2.13; 95% CI 1.51-2.95; p < 0.001) relative to rural patients. Female patients were the majority undergoing surgery and were more likely to receive a complication or require a revision when controlling for surgical complexity. Medicare patients were the least likely to undergo surgery and the most likely to receive complex fusion when undergoing an operation. Medicare patients were the least likely to experience complications (OR=0.89; 95% CI 0.80-0.98; p = 0.022) after adjusting for surgical complexity. With regards to race and ethnicity, Hispanics had a decreased likelihood of receiving a revision surgery., Conclusion: There were substantial differences in rates of surgical management, postoperative complications, and revisions among individuals of different demographics including sex, insurance status, ethnicity and hospital teaching status. Further research evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient outcomes., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Accurate spinal screw placement in spinal instrumentation is of utmost importance to avoid injury to surrounding neurovascular structures. This study was performed to investigate differences in accuracy, operating room time, length of stay, and operative blood loss across studies involving all types of spinal fixation., Methods: PubMed, EMBASE, and Scopus were systematically queried to identify articles that fit the inclusion and exclusion criteria. Meta-analysis was performed using R software, and odds ratios and 95% CIs were calculated., Results: Sixty-nine articles were included in qualitative synthesis, and 35 studies in the meta-analysis, for a total of 8,174 robotically placed screws in 1,492 patients compared to 9,791 conventionally placed screws in 1,638 patients. A total of 9 screw trajectories were studied in the literature, although only 4 had enough evidence to be included in the meta-analysis. Robotic screw placement was more accurate than conventional screw placement (OR 2.24; 95% CI, 1.71-2.94). Robotic placement was not associated with significantly different postoperative length of stay (SMD -0.32; 95% CI, -1.20, 0.51), operative blood loss (SMD -0.25; 95% CI, -0.79, 0.19), or operative duration (SMD 0.08; 95% CI -1.00, 1.39). A total of 8 robotic platforms were found in the literature with accuracy rates above 93%., Conclusion: Robotic spinal fixation is associated with increased screw placement accuracy and similar operative blood loss, length of stay, and operative duration. These findings support the safety and cost-effectiveness of robotic spinal surgery across the spectrum of robotic systems and screw types., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Multiple-rod constructs (MRCs) are often used in deformity correction for increased stability and rigidity. There are currently no reports showing minimally invasive placement of MRCs in adult deformity surgery and its technical feasibility through preoperative software planning., Methods: Data were collected retrospectively from medical records of six consecutive patients who underwent minimally invasive MRCs with robotics planning by a single surgeon at an academic center between March-August 2020., Results: A total of six patients (4 females, mean age 69.7 years) underwent minimally invasive long-segment (6 +) posterior fixation with multiple rods (3 +) using the Mazor X Stealth Edition robotics platform. Average follow-up was 14.3 months. All patients underwent oblique lumbar interbody fusion (OLIF) as a first stage, followed by second stage posterior fixation in the same day. The mean number of levels posteriorly instrumented was 8.8. One patient underwent 3 rod fixation (1 iliac, 2 S2AI) and 5 patients underwent quad rod fixation (2 iliac, 2 S2AI). The mean time to secure all rods was 8 min 36 s. Mean improvement in spinopelvic parameters was -4.9 cm sagittal vertical axis, 18.0° lumbar lordosis, and -10.7° pelvic tilt with an average pelvic incidence of 62.5°. Estimated blood loss (EBL) was 100-250 cc with no blood transfusions, and all but one patient ambulated on postoperative day 1 or 2., Conclusion: Spinal robotics brings us into a new era of minimally invasive construct design. To our knowledge, this is the first description of the technical feasibility of MRCs in minimally invasive adult spinal deformity surgery., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To study the impact of demographic factors on management of traumatic injury to the lumbar spine and postoperative complication rates., Methods: Data was obtained from the National Inpatient Sample (NIS) between 2010-2014. International Classification of Diseases, 9th revision, Clinical Modification codes identified patients diagnosed with lumbar fractures or dislocations due to trauma. A series of multivariate regression models determined whether demographic variables predicted rates of complication and revision surgery., Results: A total of 38,249 patients were identified. Female patients were less likely to receive surgery and to receive a fusion when undergoing surgery, had higher complication rates, and more likely to undergo revision surgery. Medicare and Medicaid patients were less likely to receive surgical management for lumbar spine trauma and less likely to receive a fusion when operated on. Additionally, we found significant differences in surgical management and postoperative complication rates based on race, insurance type, hospital teaching status, and geography., Conclusion: Substantial differences in the surgical management of traumatic injury to the lumbar spine, including postoperative complications, among individuals of demographic factors such as age, sex, race, primary insurance, hospital teaching status, and geographic region suggest the need for further studies to understand how patient demographics influence management and complications for traumatic injury to the lumbar spine.

Objective: Robotics is a major area for research and development in spine surgery. The high accuracy of robot-assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems., Methods: An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days., Results: In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases., Conclusions: The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery.

Single position lateral fusion reduces the need for a secondary surgery and robotic guidance allows for potentially higher accuracy of screw placement. We expand the role of robotics with a simultaneous workflow where 2 surgeons can work in single position surgery and discuss the technical feasibility of placement of S2-alar-iliac (S2AI) screws in the lateral position. A 70-year-old male presented with chronic back pain and bilateral leg pain with the left side worse than the right. He subsequently underwent an L3-S1 oblique lumbar interbody fusion (OLIF) with a minimally invasive L3-ilium robotic posterior spinal fixation simultaneously in single lateral position with S2AI screws. The software planning requisite of robotics allowed for a preoperative plan where lumbar cortical screws were used to line up with bilateral S2AI screws. Intraoperatively, the OLIF was performed anterior to the patient which allowed for a second surgeon to perform the posterior stage of screw placement simultaneously in overlapping fashion during OLIF exposure. Once all screws were placed, the OLIF discectomy and cage placement were completed. As the OLIF incision is closed, rodding proceeds posteriorly with subsequent closure simultaneously as well. Operative time from skin incision to skin closure was 3 hours and 47 minutes. We present here a novel technical report on the recommended workflow of simultaneous robotic single position surgery OLIF and demonstrate the feasibility of placement of sacroiliac fixation in the lateral decubitus position. We believe this technique to be minimally invasive, effective, with the benefit of shortening valuable operating room case time.

Background: Giant pseudomeningoceles are an uncommon complication of spine surgery. Surgical management and extirpation can be difficult, and guidelines remain unclear., Methods: Here, we present a 56-year-old female patient with a history of grade III L5-S1 spondylolisthesis who was treated with 2 prior spine surgeries. The patient was treated with bone grafting for pseudarthrosis and instrumentation from L4 to ilium. After unsuccessful intraoperative and postoperative cerebrospinal fluid drainage and dural repair, the patient presented to the emergency room with debilitating positional headaches., Results: The patient underwent dural repair with bovine pericardial patch inlay sutured with 7-0 prolene, blood patch, and a dural sealant. Plastic surgery performed a layered closure, using acellular dermal matrix over the dural closure. The bilateral paraspinal flaps were advanced medially to cover the entirety of the acellular dermal matrix, and the fasciocutaneous flaps were then advanced to the midline for a watertight closure. At 3-month follow-up, the patient was headache free and had returned to her activities of daily living., Conclusions: We conclude that early consultation with plastic surgery can be greatly beneficial to effectively extirpate dead space and resolve giant sacral pseudomeningoceles, especially if there is concern of persistent cerebrospinal fluid leakage due to relatively immobile avascular soft tissue as a result of prior revision surgery., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2020 ISASS.)

Objective: The objective of this study was to describe and evaluate a new surgical procedure for the correction of coronal imbalance (CI) in adult spinal deformity patients, called the "kickstand rod" technique., Methods: The authors analyzed the records of 24 consecutive patients with pediatric and adult spinal deformity and CI treated between July 2015 and October 2017 with a long-segment fusion and a kickstand rod. For the kickstand rod technique, an iliac screw was placed on the ipsilateral side of the trunk shift and connected proximally through a side-by-side domino link to the thoracolumbar junction; this rod was distracted to promote coronal plane balancing. Distraction occurred with the rod on the contralateral side locked in order to preserve sagittal correction. Radiographic and clinical analyses were conducted to evaluate the outcomes and possible complications of the kickstand rod technique., Results: The mean age of the patients was 55 years (range 14-73 years). Eighteen of the 24 patients were female. CI preoperatively was a mean of 63 mm, and the mean measurement at the final follow-up (mean duration 1.4 years) was 47 mm. There were no neurological, vascular, or implant-related complications in any of the patients. One patient developed wound dehiscence that was successfully treated without implant removal, and one developed proximal junctional kyphosis requiring extension of the construct proximally. One patient also returned to the operating room for excision of a spinous process. There were no complaints about screw prominence, kickstand construct failure, or significant worsening of CI after surgery., Conclusions: The kickstand rod technique is safe and effective for the correction of CI in spinal deformity patients. This technique was found to provide marked coronal correction and additional strength to the overall construct without significant adverse consequences.

Background: Treatment of spondylolisthesis can be difficult with regard to patients with high sacral slopes that may prohibit placement of interbody grafts for fusions across that segment. Here, we describe placement of a reverse Bohlman technique from an anterior approach to obtain fusion across a low-grade spondylolisthesis with a high sacral slope to obtain anterior fusion., Methods: A chart review was conducted on this single patient regarding his clinical course and outcome., Results: A 54-year-old male presented with low-back pain associated with bilateral leg pain dating back several years. Plain films demonstrated a Grade II isthmic spondylolisthesis at L5-S1 with spinopelvic measurements of 73° sacral slope, 82° lumbar lordosis, 12° pelvic tilt, and 94° pelvic incidence. Magnetic resonance imaging showed bilateral L5 pars defects with diffuse degenerative disease from L4 through S1 and significant ligamentous and facet hypertrophy. He underwent an L4-5 anterior lumbar interbody fusion and an L5-S1 reverse Bohlman placement of a transvertebral transsacral titanium mesh cage. This was supplemented with a posterior decompression and instrumentation from L4-ilium. He had resolution of his radiculopathy and has maintained a good clinical outcome at 3 years follow up., Conclusions: We present here a patient with low-grade spondylolisthesis and a steep sacral slope who underwent a successful reverse Bohlman approach with long-term follow up. This report highlights the potential utility of this method as a viable alternative for patients with low-grade spondylolisthesis., Level of Evidence: IV., Clinical Relevance: Technical description of surgical technique., Competing Interests: Disclosures and DOI: The authors have no commercial relationships or financial interests to disclose., (©International Society for the Advancement of Spine Surgery 2019.)

Background: Endonasal transsphenoidal surgery (ETSS) remains the preferred treatment for recurrent or residual nonfunctional pituitary adenomas (NFPAs). However, surgical complications and outcomes with repeat ETSS are unclear., Objective: To compare outcomes from primary and repeat ETSS in patients with NFPAs., Methods: Retrospective review of ETSS for NFPAs at USC University Hospital and LAC + USC Medical Center between 2000 and 2015. Patients with ≥3-mo follow-up data were included. Patients were categorized as primary or repeat ETSS. Patient and tumor characteristics were compared preoperatively, and postoperative outcomes were analyzed., Results: Two hundred sixty-eight patients (89%) met the inclusion criteria (primary ETSS = 211 and repeat ETSS = 57) with a mean follow-up time of 38 mo (range 3-235 mo). Both groups had similar demographics, endocrine function, and tumor characteristics. Surgical complication rates were similar and no mortalities were observed. Repeat ETSS patients had a higher rate of new postoperative panhypopituitarism (primary ETSS: 0.5% vs repeat ETSS: 7.1%, P = .011), lower rates of gross total resection (GTR; primary ETSS: 59.2% vs repeat ETSS: 26.3%, P = .001), and greater rates of postoperative radiosurgery (36.8% vs 24.2%, P = .009). At 2-yr follow-up, progression-free survival on MRI was similar in both groups (primary ETSS: 97.9% vs repeat ETSS: 95.4%, log-rank test P = .807)., Conclusion: At experienced tertiary pituitary centers, repeat ETSS for NFPAs was associated with a similar incidence of surgical complications as primary ETSS. However, repeat ETSS carried a higher rate for worsening endocrine dysfunction and a lower rate of GTR.

The past several years have demonstrated an increased recognition of operative videos as an important adjunct for resident education. Currently lacking, however, are effective methods to record video for the purposes of illustrating the techniques of minimally invasive (MIS) and complex spine surgery. We describe here our experiences developing and using a shoulder-mounted camera system for recording surgical video. Our requirements for an effective camera system included wireless portability to allow for movement around the operating room, camera mount location for comfort and loupes/headlight usage, battery life for long operative days, and sterile control of on/off recording. With this in mind, we created a shoulder-mounted camera system utilizing a GoPro™ HERO3+, its Smart Remote (GoPro, Inc., San Mateo, California), a high-capacity external battery pack, and a commercially available shoulder-mount harness. This shoulder-mounted system was more comfortable to wear for long periods of time in comparison to existing head-mounted and loupe-mounted systems. Without requiring any wired connections, the surgeon was free to move around the room as needed. Over the past several years, we have recorded numerous MIS and complex spine surgeries for the purposes of surgical video creation for resident education. Surgical videos serve as a platform to distribute important operative nuances in rich multimedia. Effective and practical camera system setups are needed to encourage the continued creation of videos to illustrate the surgical maneuvers in minimally invasive and complex spinal surgery. We describe here a novel portable shoulder-mounted camera system setup specifically designed to be worn and used for long periods of time in the operating room.