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Background Navigated transcranial magnetic stimulation (nTMS) is an established, noninvasive tool to preoperatively map the motor cortex. Despite encouraging reports from few academic centers with vast nTMS experience, its value for motor-eloquent brain surgery still requires further exploration. Objective To further elucidate the role of preoperative nTMS in motor-eloquent brain surgery. Methods Patients who underwent surgery for a motor-eloquent supratentorial glioma or metastasis guided by preoperative nTMS were retrospectively reviewed. The nTMS group (n = 105) was pair-matched to controls (non-nTMS group, n = 105). Gross total resection (GTR) and motor outcome were evaluated. Subgroup analyses including survival analysis for WHO III/IV glioma were performed. Results GTR was significantly more frequently achieved in the entire nTMS group compared to the non-nTMS group (P = .02). Motor outcome did not differ (P = .344). Bootstrap analysis confirmed these findings. In the metastases subgroup, GTR rates and motor outcomes were equal. In the WHO III/IV glioma subgroup, however, GTR was achieved more frequently in the nTMS group (72.3%) compared to non-nTMS group (53.2%) (P = .049), whereas motor outcomes did not differ (P = .521). In multivariable Cox-regression analysis, prolonged survival in WHO III/IV glioma was significantly associated with achievement of GTR and younger patient age but not nTMS mapping. Conclusion Preoperative nTMS improves GTR rates without jeopardizing neurological function. In WHO III/IV glioma surgery, nTMS increases GTR rates that might translate into a beneficial overall survival. The value of nTMS in the setting of a potential survival benefit remains to be determined.

In this study the authors compare the radiographic findings of patients undergoing 1-3 level ACDF a rigid CFRP plate and a translational titanium plate system with a focus on radiographic alignment.A retrospective review 70 consecutive patients undergoing a 1 to 3 level ACDF for cervical spondylosis was conducted. 2 groups depending on the cervical plating system were created including 38 patients in group 1 (dynamic plate) and 32 in group 2 (rigid CFRP plate). Plain neutral radiographs preoperatively, immediately after surgery and at most recent follow-up were used to assess parameters on sagittal alignment, fusion height, adjacent segment ossification (ASO), fusion rate and implant failure.There were no significant differences between groups preoperatively. Both groups had a more than 12 months follow-up (ACDF allows for correction and maintenance of cervical alignment. Rigid rigid plate appears more effective at maintaining segmental lordotic correction. The fusion rate and implant failure was not different for both groups.

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work–life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur–investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Detailed surgical management, magnetic resonance imaging (MRI), and computer tomography (CT) images of a broken annular closure device (ACD) have not been reported yet. In this case, a 28-year-old male presented with a new onset of radiculopathy three years after lumbar discectomy and placement of an ACD. The CT-myelography and MRI revealed a recurrent disc herniation (RDH) and dislocation of a broken ACD. ACD removal was performed and confirmed breakage due to RDH with scarring around the RDH and displaced ACD. Implant-associated complications and management should be reported in detail in order to enhance knowledge on device-related complications.

Background Atlantoaxial fixation is technically challenging in younger children. The C1-C2 screw-rod fixation technique is established for adults but limited data about the clinical and radiographical outcome for the treatment of children with 5 years of age or younger is available. Methods All files of children who were consecutively treated for spinal disorders were reviewed. Inclusion criteria for further evaluation were: 0 to 5 years of age at initial procedure; detailed surgical report of a posterior C1-C2 fusion with mass lateral and pedicle screw-rod fixation as described by Harms; a minimum clinical and radiographical follow-up of 24 months. The postoperative and last follow-up computed tomography scan and radiographs were used to assess the positioning and stability of the C1-C2 screw-rod construct. Results Eleven patients (3 boys) with a mean age of 46 months (range: 8 to 66 mo) fulfilled inclusion criteria and were evaluated retrospectively. The mean clinical and radiographical follow-up was 79 months (range: 24 mo to 170 mo). The diagnosis was atlantoaxial rotatory dislocation (4 cases), C1-C2 instability with subluxation (3 cases), atlantoaxial dislocation and os odontoideum (1 case), type II odontoid fracture (1 case), traumatic odontoid epiphysiolysis (1 case), and traumatic rupture of the transverse ligament with C1 subluxation (1 case). Intraoperatively and postoperatively no new neurovascular or vascular complication occurred. C1 lateral mass screws were placed correctly in all cases. Twenty-two C2 pedicle screws were placed correctly (85.7%), and 3 screws showed penetration of the pedicle wall (14.3%). No implant revision, implant failure, and pseudarthrosis were noted. Loss of correction was noted in 1 patient with unilateral C1-C2 fixation and a repeated dorsal fusion procedures were performed. A repeat procedure for implant removal and segmental release was performed in 3 patients to increase the axial rotation of the head. Conclusions The C1-C2 screw-rod fixation is a safe technique that achieves solid fixation of the atlantoaxial complex in young children with various disorders. The technique preserves the joint and allows for segmental release via implant removal.

Loss of consciousness (LOC) at presentation with aneurysmal subarachnoid hemorrhage (aSAH) has been associated with early brain injury and poor functional outcome. The impact of LOC on the clinical course after aSAH deserves further exploration. A retrospective analysis of 149 aSAH patients who were prospectively enrolled in the Cerebral Aneurysm Renin Angiotensin Study (CARAS) between 2012 and 2015 was performed. The impact of LOC was analyzed with emphasis on patients presenting in excellent or good neurological condition (Hunt and Hess 1 and 2). A total of 50/149 aSAH patients (33.6%) experienced LOC at presentation. Loss of consciousness was associated with severity of neurological condition upon admission (Hunt and Hess, World Federation of Neurosurgical Societies (WFNS), Glasgow Coma Scale (GCS) grade), hemorrhage burden on initial head CT (Fisher CT grade), acute hydrocephalus, cardiac instability, and nosocomial infection. Of Hunt and Hess grade 1 and 2 patients, 21/84 (25.0%) suffered LOC at presentation. Cardiac instability and nosocomial infection were significantly more frequent in these patients. In multivariable analysis, LOC was the predominant predictor of cardiac instability and nosocomial infection. Loss of consciousness at presentation with aSAH is associated with an increased rate of complications, even in good-grade patients. The presence of LOC may identify good-grade patients at risk for complications such as cardiac instability and nosocomial infection.

Background: Endoscopic techniques are well accepted as surgical technique for decompression of lumbar lateral recess stenosis (LRS). It is uncertain if there is a difference in clinical outcome for decompression alone (DA) or decompression with partial discectomy (DPD) for the treatment of LRS. Methods: All files of patients who underwent an endoscopic procedure for lumbar LRS were identified from a prospectively collected database. Preoperative magnetic resonance imaging and endoscopic video were analyzed with special focus on the technique of nerve root decompression. Clinical outcome was assessed via a personal examination, a standardized questionnaire including the numeric rating scale (NRS) for leg and back pain, the Oswestry disability index (ODI), and the modified MacNab criteria to assess functional outcome and clinical success. Results: Sixty-six patients were identified of which 57 attended for evaluation (86.4%). DA was performed in 15 (26.3%) patients and DPD in 42 patients (73.7%). The mean follow-up was 45.0 months (range: 16–82 months). Fifty-two patients reported to be free of leg pain (91.1%), 42 patients had no noticeable back pain (73.7%), 49 patients had full muscle strength (85.9%), and 48 patients had no sensory disturbance (84.2%). The mean NRS for leg pain was 1, the mean NRS for back pain was 2, mean ODI was 16% (range: 0%–60%). Clinical success was noted in 49 patients (85.9%) and it was significantly higher for patients following DPD (P = .024). The overall repeat procedure rate was 12% with reoperation rate at the index segment in 10.5% of cases. There were no significant differences with respect to leg and back pain, ODI, and reoperation between both groups. Conclusion: Microendoscopic DPD of LRS achieves a 92% clinical success rate which is significantly higher compared to 67% clinical success achieved by DA. There was no significant difference for the rate of reoperation, leg and back pain, and ODI. Level of Evidence: 4.

Background Pyogenic spondylodiscitis (PSD) is a complex disorder that often required postoperative imaging. Carbon-fiber–reinforced polyether ether ketone (CFRP) is radiolucent and offers an optimal assessability of anatomic structures. Methods A retrospective file review of patients who were operated on for PSD using CFRP implants was performed to assess the clinical outcome, implant-associated complications, and revision surgery. A minimum follow-up of 3 months was required for evaluation of clinical and radiographic data, which included computed tomography and magnetic resonance imaging (MRI) assessment, to determine implant stability and assessability of soft tissue and nerve structures using a grading system. Results Eighty-one consecutive patients with a mean of 69.5 years were identified. Debridement and stabilization were performed in 8 cervical, 17 thoracic, and 57 lumbar procedures; 72 interbody fusion procedures using cages were performed. Intraoperatively, no implant-associated complication was noted. The mean follow-up was 7 months, at which 52 patients attended. Improved mobility and reduced pain levels were reported by 87%, and MRI assessability was graded ideal. Residual sign of infection was seen in 5 cases, which influenced antibiotic therapy. Asymptomatic radiolucent zones were identified in 13 patients (16%) and screw loosening in 2 (2.4%). In 1 patient, the pedicle screw tip broke and remained within the vertebral body. A repeated procedure because of progressive vertebral body destruction, implant loosening, or subsidence was performed in 5 patients (6.1%). Conclusions The surgical treatment of PSD using CFRP is safe. The repeat procedure rate as a result of implant loosening is 6.1%. Minimal artifacts offer ideal assessability of soft tissue structures on an MRI.

Background Context A potential correlation between surgery for symptomatic adjacent segment degeneration (sASD) and the development of degenerative disease of the lumbar spine or osteoarthritis of the musculoskeletal joints remains to be determined. Purpose To assess the rate of sASD following anterior cervical discectomy and fusion (ACDF), the rate of lumbar discectomy (LD), and rate of surgery performed for osteoarthritis at the joints of the musculoskeletal in a long term follow-up. Study design/Setting Cohort study Outcome Measures Repeat procedure for sASD, microsurgical lumbar discectomy (MSD) and/or the musculoskeletal joints (shoulder, knee, hip). Patient sample Retrospectively, a total of 833 consecutive patients who underwent ACDF for degenerative disorders ≥20 years ago were identified. Charts were reviewed for preoperative neurological status, smoking status, physical labour and repeat procedures. Missing data lead to exclusion from follow-up assessment. Methods At final follow-up the need for pain medication, Neck disability index (NDI), and Odoms criteria were evaluated. An MRI was performed to assess the grade of degeneration of the cervical spine via the segmental degeneration index (SDI). Patients without (group 1) and with (group 2) repeat procedure for sASD were compared. Results Collectively, 313 patients met inclusion criteria and 136 patients were evaluated. The mean follow-up was 26 years. Clinical success rate according to Odoms was 85.3%, mean NDI was 14.4%, the rate of regular intake of pain medication was 14.7%, the rate of repeated procedure for sASD was 10.3%. MSD was performed in 23.5%, surgery for osteoarthritis of the shoulder, the hip, and the knee were performed in 11.8%, 6.9%, and 27.7%, respectively. The rate of MSD (p=0.018) was significantly higher in group 2 compared to group 1. Gender, smoking status, surgery of the musculoskeletal joints, and the grade of degeneration of the cranial and caudal adjacent segments were similar between group 1 and group 2. Conclusion The overall clinical success following ACDF was 85.3%. The rate of repeat procedure for sASD was 10.3% within 26 years. Patients with sASD had a significantly higher rate of MSD and poorer clinical outcome compared to patients without sASD.

BACKGROUND Congenital scoliosis due to hemivertebra of the cervicodorsal spine is a rare disorder. It might be accompanied by impaired cosmetic appearances such as head tilt and trunk shift. Little is known about the effect of correction of the major curve on head tilt and trunk shift in children. The purpose of this study was to assess radiographic changes of head tilt and trunk shift following posterior hemivertebra resection (PHVR). METHODS Retrospectively, all children who underwent PHVR at the cervicodorsal spine (C6-Th6) with pedicle screw fixation with a minimum radiographic follow-up of 1 year were identified for further assessment. A total of 5 radiographic parameters were assessed on preoperative, postoperative, and final follow-up radiographs. (1) Head tilt was defined as the angle between the horizontal line and the line through both molars of the maxillary, (2) trunk shift as the angle between the line of the center of C7 to the sacrum and the central sacral vertical line, (3) Cobb angle was used to assess the major curve, (4) cranial, and (5) caudal compensatory curvature. RESULTS Seven boys and 10 girls with a mean age of 9.0 years at surgery were evaluated. The mean radiographic follow-up was 89.5 months (range: 12 to 166 mo). The mean head tilt reoriented from 6.9 to 1.9 degrees (P

Background The authors describe the application of a new exoscope that offers 3-dimensional (3D) visualization in cranial and spinal neurosurgery in detail. Methods Five cranial and 11 spinal procedures were performed with a 3D exoscope. Instrument handling, repositioning of the exoscope, handling of the image control unit, the adjustment of magnification and focal length, the depth perception, the image quality, the illumination, and the comfort level of the posture during the procedure were assessed via a questionnaire. Results The following procedures were performed: Microvascular decompression (n = 1), craniotomy and tumor resection (n = 4), anterior cervical discectomy and fusion with cervical plating (n = 2), cervical laminectomy and lateral mass fixation (n = 1), shear cervical lateral mass osteosynthesis (n = 1), lumbar canal decompression (n = 1), transforaminal lumbar interbody fusion (n = 2), thoracic intraspinal extradural tumor resection (n = 1), and lumbar discectomy (n = 3). Instrument handling, the intraoperative repositioning and handling of the VITOM-3D, and the comfort level of the intraoperative posture was rated excellent in 100% of procedures. The image quality was rated equal to the operating microscope in 68.75% of procedures. None of the procedures had to be stopped because of technical problems. No surgical complications were noted that could be related to the use of the exoscope. Conclusions The 3D-exoscopic system is safe and effective tool to perform spinal procedures and less demanding cranial procedures. The image quality and 3D visualization were comparable with the operating microscope. The technique harbors the unique advantage of excellent comfort for the involved surgical team during the procedure.

Extreme long-term clinical outcome studies following anterior cervical discectomy and fusion (ACDF) with an autologous iliac crest with and without Caspar plating (ACDF + CP) for the treatment of radiculopathy caused by cervical disc herniation (CDH) are extremely rare. Hospital records of patients who underwent ACDF or ACDF + CP for the treatment of CDH at least 17 years ago were reviewed. Information about diagnosis, surgery, pre- and postoperative clinical process, and repeated procedure was analyzed. At final follow-up, patients were reviewed with a standardized questionnaire including the current neurological status, Neck Disability Index (NDI), Odom's criteria, a modified EQ-5D, and limitations in quality of life. One hundred twenty-two patients with a mean follow-up of 25 years were evaluated. ACDF was performed in 80 and ACDF + CP in 42 patients, respectively. At final follow-up, 81.1% of patients were free of radicular pain and had no repeated procedure. According to Odom's criteria, 86.1% of good to excellent functional recovery was noted. The mean NDI and EQ-5D was 14% and 5 points, respectively. There was no significant difference in the assessed clinical outcome parameters between patients treated with ACDF and ACDF + CP. The rate for repeated procedure due to degenerative cervical disorders was 10.7 and 7.4% due to symptomatic adjacent segment disease with 25 years. ACDF and ACDF + CP achieved a high rate radicular pain relief (89.3%) and clinical success (86.1%) for the treatment of CDH within a 25 years follow-up. No statistical difference concerning clinical outcome and rate of repeated procedure was detected.

BACKGROUND Anterior cervical decompression and fusion (ACDF) is a widely accepted surgical technique for the treatment of degenerative disc disease. ACDF is associated with adjacent segment degeneration (ASD). OBJECTIVE To assess whether physiological aging of the spine would overcome ASD by comparing adjacent to adjoining segments more than 18 yr after ACDF. METHODS Magnetic resonance imaging of 59 (36 male, 23 female) patients who underwent ACDF was performed to assess degeneration. The mean follow-up was 27 yr (18-45 yr). Besides measuring the disc height, a 5-step grading system (segmental degeneration index [SDI]) including disc signal intensity, anterior and posterior disc protrusion, narrowing of the disc space, and foraminal stenosis was used to assess the grade of adjacent and adjoining segments. RESULTS The SDI of cranial and caudal adjacent segments was significantly higher compared to adjoining segments (P < .001). The disc height of cranial and caudal adjacent segments was significantly lower compared to adjoining segments (P < .001, P < .01). The SDI of adjacent segments in patients with repeat cervical procedure was significantly higher than in patients without repeat procedure (P = .02, P = .01). The disc height of the cranial adjacent segments in patients with repeat procedure was significantly lower than in patients without repeat procedure (P = .01). CONCLUSION The physiological aging of the cervical spine does not overcome ASD. The disc height and the SDI in adjacent segment are significantly worse compared to adjoining segments. Patients who underwent repeat procedure had even worse findings of disc height and SDI.

Olfactory performance has rarely been assessed in the perioperative phase of elective aneurysm surgery. Here, we assessed the risk for olfactory deterioration following surgical treatment of unruptured cerebral aneurysm via the supraorbital keyhole craniotomy. A retrospective review of patients with electively treated cerebral aneurysms who underwent perioperative assessment of olfactory function using a sniffin' sticks odor identification test between January 2015 and January 2016 was performed. A subgroup of patients without history of subarachnoid hemorrhage, without prior aneurysm treatment, and confirmed olfactory function underwent supraorbital keyhole craniotomy for aneurysm clipping. Microscopic and endoscopic videos were reviewed for this subgroup. Sixty-four patients who underwent elective aneurysm treatment either via surgical clipping or endovascular aneurysm obliteration were identified. Prior to treatment, 4/64 (6.3%) demonstrated bilateral anosmia. Collectively, 14 patients (21.9%) met subgroup criteria of supraorbital keyhole craniotomy for aneurysm clipping. Here, olfactory performance significantly decreased postoperatively on the side of craniotomy (ipsilateral, P = 0.007), whereas contralateral and bilateral olfactory function remained unaltered (P = 0.301 and P = 0.582, respectively). Consequently, 4/14 patients (28.6%) demonstrated ipsilateral anosmia 3 months after surgery. One patient (1/14, 7.1%) also experienced contralateral anosmia resulting in bilateral anosmia. Intraoperative visualization of the olfactory tract and surgical maneuvers do not facilitate prediction of olfactory outcome. The supraorbital keyhole craniotomy harbors a specific risk for unilateral olfactory deterioration. Lack of perioperative olfactory assessment likely results in underestimation of the risk for olfactory decline. Despite uneventful surgery, prediction of postoperative olfactory function and dysfunction remain challenging. Clin. Anat. 33:316-323, 2020. © 2019 Wiley Periodicals, Inc.

OBJECTIVEThere is currently no consensus on whether adjacent-segment degeneration (ASD), loss of disc height (DH), and loss of sagittal segmental angle (SSA) are due to anterior cervical discectomy and fusion (ACDF). The purpose of the present study was to assess the grade of segmental degeneration after ACDF and to analyze if there is a difference with respect to clinical outcome, diagnosis, and number of operated levels.METHODSA total of 102 patients who underwent ACDF with a minimum follow-up of 18 years were retrospectively identified. At final follow-up, the clinical outcome according to Odom’s criteria, the Neck Disability Index (NDI), and reoperation for symptomatic ASD (sASD) was assessed. MRI was performed, and DH, SSA, and the segmental degeneration index (SDI, a 5-step grading system that includes disc signal intensity, anterior and posterior disc protrusion, narrowing of the disc space, and foraminal stenosis) were assessed for evaluation of the 2 adjacent and 4 adjoining segments to the ACDF. MRI findings were compared with respect to clinical outcome (NDI: 0%–20% vs > 20%; Odom’s criteria: success vs no success), reoperation for sASD, initial diagnosis (cervical disc herniation [CDH] vs cervical spondylotic myelopathy [CSM] and spondylosis), and the number of operated levels (1 vs 2–4 levels).RESULTSThe mean follow-up was 25 years (range 18–45 years), and the diagnosis was CDH in 74.5% of patients and CSM/spondylosis in 25.5%. At follow-up, the mean NDI was 12.4% (range 0%–36%), the clinical success rate was 87.3%, and the reoperation rate for sASD was 15.7%. For SDI, no significant differences were seen with respect to NDI, Odom’s criteria, and sASD. Patients diagnosed with CDH had significantly more degeneration at the adjacent segments (cranial, p = 0.015; caudal, p = 0.017). Patients with a 2- to 4-level procedure had less degeneration at the caudal adjacent (p = 0.011) and proximal adjoining (p = 0.019) segments. Aside from a significantly lower DH at the proximal cranial adjoining segment in cases of CSM/spondylosis and without clinical success, no further differences were noted. The degree of SSA was not significantly different with respect to clinical outcome.CONCLUSIONSNo significant differences were seen in the SDI grade and SSA with respect to clinical outcome. The SDI is higher after single-level ACDF and with the diagnosis of CDH. The DH was negligibly different with respect to clinical outcome, diagnosis, and number of operated levels.

Objective: Infection of the cervical spine is a rare disease but is associated with significant risk of neurological deterioration, morbidity, and a poor response to nonsurgical management. The ideal treatment for cervical spondylodiscitis (CSD) remains unclear. Methods: Hospital records of patients[for full text, please go to the a.m. URL], 70. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Skandinavischen Gesellschaft für Neurochirurgie

Objective: Among spinal surgeons the safety of endoscopic spinal techniques has been criticized due a prolonged learning curve and divergent surgical technique from traditional microsurgery. In this manuscript the authors assesses the learning curve of four experienced microsurgical neurosurgeons in[for full text, please go to the a.m. URL], 70. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Skandinavischen Gesellschaft für Neurochirurgie

Purpose: To assess whether the instrument handling and image quality of endoscopic spinal decompression procedures is adequate and effects the treatment of degenerative spinal disorders. Material and Methods: Forty-six patients underwent endoscopic procedures for radicular pain or sensorimotor deficit due to a degenerative disorder using a 15mm tubular retractor. Endoscopic video recordings were reviewed with focus on instrument handling and intraoperative complication. At final follow-up the clinical outcome was assessed via a standardized questionnaire including the Oswestry Disability Index (ODI) Neck Disability Index (NDI), Odoms criteria and a personal examination focusing on pain, and sensorimotor deficits. Results: Forty out of 46 patients attended a final follow-up (86.9%). The mean follow-up time was 51.8 month (range 15-84 month). At final follow-up, of patients who were operate at the lumbar spine 93.9% and at the cervical spine 85.7% were free of radicular pain, no weakness was documented in 84.9% of cases after lumbar and 85.7% after cervical spine procedure, and according to Odoms criteria clinical success was noted in 84.5% and 100%, respectively. The mean ODI was 9.0% and mean NDI was 11.7%. The dural tear rate was 4.3%, all dural tear were closed endoscopically. The recurrent disc herniation rate was 6.1%. Conclusions: Endoscopic decompression using a 15m tubular retractor offers a good view onto the surgical field and a high clinical success rate. The decompression of degenerative pathologies in bimanual technique is not limited by a 15mm tubular retractor.

Background Long-term clinical results after anterior cervical discectomy and fusion (ACDF) with an autologous iliac crest are rare. The purpose of this study was to assess this, with special focus on pain, functional outcome, and repeat surgery for adjacent segment disease (ASD). Methods Hospital records of 212 patients who were affected by degenerative cervical disc disease and treated by the Smith-Robinson technique were reviewed. Information about diagnosis, surgery, pre- and postoperative clinical process, and complications was analyzed. Patients were reviewed with a standardized questionnaire including the current neurologic status, Neck Disability Index, EQ-5D, Patient Satisfaction Index, Odom criteria, and limitations in quality of life. Results Ninety-five patients with a mean follow-up of 28 years were evaluated. ACDF was performed at 1 level in 67 and 2 levels in 28 patients. Ninety-two patients reported pain before surgery and 68 patients remained pain free and did not require second surgery. At follow-up, the mean Neck Disability Index was 14%, and mean EQ-5D score was 5. Postoperatively, 96.8% of patients were satisfied and 84.2% of patients reported good to excellent functional recovery. One patient had a hairline fracture at the iliac crest donor site. Fourteen patients underwent second surgery because of degenerative changes, including 11 at the symptomatic ASD. Conclusions ACDF yields significant decrease in pain, a significant increase in function, and a high degree of patient satisfaction. Overall prevalence for ASD was 12.0% after 25 years. Patients with reoperation had similar clinical outcome regarding pain, compared with patients without reoperation.

Background Anterior cervical discectomy and fusion with plate stabilization (ACDF+PS) is an accepted surgical procedure. We sought to evaluate the long-term clinical results of ACDF+PS with a special focus on pain, functional outcome, and adjacent segment disease. Methods Retrospectively, 139 patients who underwent ACDF+PS were reviewed with a standardized questionnaire including the current neurologic status, Neck Disability Index, EuroQuol-5 Dimension, Patient Satisfaction Index, Hospital Anxiety and Depression Scale, the Odom criteria, complications at the iliac crest donor side, and limitations in quality of life. Results Mean follow-up time was 22 years (range: 17–34 years). Sixty five (46.8%) patients were evaluated by completed questionnaires, and 74 (53.2%) did not participate. Forty-six patients attended a physical examination. ACDF+PS were performed at 1 level in 28 patients, at 2 levels in 29 patients, and at 3 levels in 8 patients. Fifty (83.3%) of the patients with preoperative pain remained free of pain and did not require another procedure as the result of degenerative cervical disease. The mean NDI was 14%; according to the Odom criteria 86.2% of patients reported good-to-excellent functional recovery. A total of 100% of patients were satisfied or very satisfied with their outcome and would decide to undergo ACDF+PS again. Two developed adjacent segment disease and needed a second procedure. Conclusions ACDF+PS resulted in a significant increase in function, pain relief, and to a high degree of patient satisfaction. The rate for symptomatic adjacent segment disease was 4.5% after 20 years' follow-up.

Objective 3D exoscopic visualization in neurosurgical procedures is of interest for several reasons. The VITOM-3D exoscopic system is cheaper compared to the operating microscope (OM) and offers each person involved in the procedure the same image of the operative field. Little is known of limitations of this visualization technique. Patients and methods : Prospectively, a consecutive series 34 procedures were assessed with focus on the following aspects: intraoperative limitation and the cause for a switch to the OM or endoscopy. A standardized questionnaire was answered by each individual involved in the procedure to assess the image quality, illumination, and magnification of the operative field. Intraoperative video recording and pre- and postoperative MRI and CT-scan were analyzed to assess the dimensions of the surgical approach. Results Sixteen cranial and 18 spinal procedures (10 intra-axial, 6 extra-axial, 6 cervical, and 12 lumbar) were performed by seven neurosurgical attendings, twelve residents and twelve scrub nurses who all completed a standardized questionnaire after each procedure. Handling and identification of anatomical structures was rated equal or superior to the OM in 62 % and over 80 % of cases, respectively. The illumination and magnification of the operative field on the surface was rate in equal od superior in all cases and on the depth it was rated inferior to the OM over 60 % of cases. In one spinal and five cranial procedures a switch to the OM or endoscope were performed for the following reasons: poor illumination (4 cases), tissue identification (1 case), need for fluorescence imaging (1 case). Conclusion 3D exoscopic visualization using the VITOM-3D is best suited for spinal procedures and for extra-axial cranial procedures. In case of small approach dimensions, the illumination and magnification of the depth of the operative field is rated inferior to the OM which resulted in difficulty of tissue identification and a switch to the OM.

In the 1940s, the posterior cervical foraminotomy (PCF) was first described. At that time, this technique represented a big step ahead for the treatment of cervical radiculopathy. Rightly, a multitude of studies demonstrated that open microsurgical posterior foraminotomy is an effective treatment for cervical radiculopathy. Open posterior approaches have still the disadvantage of detaching the extensor cervical muscles from the laminae and the spinous processes, which can lead to severe collateral tissue and muscle damage, followed by postoperative complications, such as axial neck pain, shoulder pain, loss of lordosis, or even spinal instability. Minimally invasive techniques have been developed to reduce the approach related trauma. Initially, these techniques have been performed using endoscopic visualization and applied to the lumbar spine with great success. With this in mind, spine surgeons have extended the spectrum of indication and applied endoscopic techniques to treat degenerative cervical spine disorders. Indications for PCF are single-level or multilevel unilateral lateral disc herniation, osseous foraminal stenosis secondary to isolated facet hypertrophy, and persistent radicular symptoms following an anterior cervical spine procedure. Depending on the underlying pathology, clinical success rates from 75% to 96% for the treatment of cervical radiculopathy have been reported. Mainly, there are 2 different endoscopic techniques to perform PCF. The so-called full-endoscopic techniques are performed under continuous irrigation in single-handed technique. The endoscopic tubular assisted technique is performed in bimanual fashion with microsurgical instruments. The purpose of this video is to describe the endoscopic tubular assisted technique in detail. Patient consent was obtained prior to preparation of the video.

Objective A plate is commonly applied after anterior cervical discectomy and fusion (ACDF); particularly in cases of multilevel fusion. Recent comparative studies have focused on constrained versus semiconstrained plates, however little data is available to assess differences between semiconstrained plates. Patients and Methods A retrospective review of 60 consecutive adult patients undergoing a 1, 2 or 3 level ACDF with a lordotic allograft for treatment of symptomatic cervical spondylosis was conducted at a single center. The cohort was separated into two groups depending on the cervical plating system used. Patients in the first group had a semiconstrained translational plate and those in the second group had a semiconstrained rotational plate. Plain neutral radiographs were assessed preoperatively, immediately after surgery and at most recent follow-up. The measured radiographic parameters focused on sagittal alignment, adjacent segment pathology, fusion rate and implant failure. Results There were 30 patients in each group. There were no significant differences in demographic characteristics or distribution of levels fused between groups. All patients had at least 6 months of follow-up and mean follow-up was 14.8 ± 6.2 months in the translational plate group and 13.1 ± 4.8 months in the rotational plate group (p = 0.227). Significant improvement in sagittal segmental alignment was noted in both groups following surgery. The translational plate group improved from 1.0 ± 7.5 degrees to 4.8 ± 7.6 degrees (p = 0.03) and the rotational group improved from 2.7 ± 9.1 degrees to 8.4 ± 7.8 degrees (p = 0.001). This significant sagittal correction was maintained through follow-up for those in the rotational plate group; 5.5 ± 9.1 degrees (p = 0.002). However, a partial loss of segmental lordosis was observed in the translational plate group leading to a failure to maintain significance of the lordotic correction; 1.7 ± 8.3 degrees (p = 0.280) over the follow-up period. Segmental fusion rates were not significantly different between groups. However, there was a higher rate of screw breakage within the rotational plate group (4 instances versus 0 instances in the translational plate group). Conclusion This comparative cohort series suggests that performing an ACDF with a lordotic allograft using either semiconstrained translational or rotational plate system allows for correction and maintenance of cervical alignment, however the rotational plate appears more effective at maintaining segmental lordotic correction. Further prospective controlled study will be needed to determine if this may come at the expense of greater rates of instrumentation failure in the rotational plate group.

Objective: Lumbar disc herniation (LDH) is a common cause of radicular pain and sensorimotor deficit. Long-term follow-up studies are rare and the reported rate of clinical success and reoperation is not well understood. To assess the long-term clinical outcome, the cause and rate of reoperation following[for full text, please go to the a.m. URL], 69. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Mexikanischen und Kolumbianischen Gesellschaft für Neurochirurgie

Anterior cervical discectomy and fusion (ACDF) without and with cervical plating (ACDF+CP) are accepted surgical techniques for the treatment of degenerative cervical disc disorders. The effect of CP on the development of adjacent segment degeneration (ASD) remains unclear.To assess whether CP accelerates the degeneration of the adjacent and adjoining segments.This is an imaging cohort study.Retrospectively, a total of 84 patients who underwent ACDF or ACDF+CP were identified. At final follow-up, an MRI was performed and evaluated in this study.An MRI of 84 patients who underwent ACDF (46 patients) and ACDF+PS (38 patients) was performed. The mean follow-up was 24 years (17-45 years). None of the patients had a repeat procedure in the cervical spine. The grade of degeneration of the segments adjacent and adjoining to the fusion was assessed via a five-step grading system (segmental degeneration index, or SDI) that includes disc signal intensity, anterior and posterior disc protrusion, narrowing of the disc space, and foraminal stenosis. Furthermore, the disc height (DH) and sagittal segmental angle (SSA) of fused segments were measured.A significantly (p.001) greater SDI was identified at the caudal adjacent segment following ACDF compared to ACDF+CP. No other significant differences were identified in patients following ACDF and ACDF+CP. Between 50% and 96% of all segments showed severe degenerative changes according to SDI. There was no significant difference in DH between the patients following ACDF and ACDF+CP. The SSA in patients who underwent ACDF+CP was significantly greater than in the ACDF patients (p=.002).In this cohort of patients, cervical plating had no significant impact on segmental degeneration and decrease of DH in the adjacent and adjoining segments. ACDF+CP seem to preserve the lordotic alignment more with respect to the SSA than ACDF.

Objective The incidental dural tear is a common complication in lumbar spine surgery. It has been reported that the incidence of dural tears is much greater in endoscopic procedures. Primary closure via suturing remains challenging in endoscopic procedures. The objective of this study was to conduct a literature review on the surgical technique for dural closure and repair in endoscopic spine surgery. Methods A systematic literature search was performed using the database PubMed. In total, 12 studies reported specifically about the surgical treatment for dural tear in percutaneous and tubular assisted endoscopic technique. The dural tear rate, the technique of dural closure, postoperative time of bed rest, postoperative symptoms related to cerebrospinal fluid fistula, and revision surgery were assessed. Results The overall rate of dural tears in endoscopic spinal surgery was 2.7%, with a range from 0% to 8.6%. The incidence of a dural tear was much greater in cases with lumbar stenosis (3.7%) than in lumbar disc herniation (2.1%). The greatest rate was accompanied by resecting synovial cysts. In addition, the risk of dural tear is greater in bilateral decompression procedures via a unilateral approach. There is no consensus about the ideal technique for dural closure in endoscopic procedures. Furthermore, there is a debate whether dural tear requires surgical treatment or not. Conclusions An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in lumbar endoscopic spine surgery.

Lumbar disc herniation (LDH) is a common degenerative disease, and up to 10% of LDH migrates into the so-called "hidden zone." The traditional interlaminar approach carries the risk of subsequent instability due to osseous destruction by reaching the hidden zone and exposing the nerve root. In the 1990s, the first reports were published on the open microsurgical "translaminar approach" (TLA) for the resection of migrated LDH with the intention to minimize osseous destruction. However, the open technique still had the disadvantage of soft-tissue and muscle dissection. Endoscopic tubular procedures were developed to reduce approach-related muscle trauma. Endoscopic tubular surgery combines the bimanual microsurgical technique with continuous endoscopic visualization of the surgical field. The high-definition endoscopic visualization allows for excellent illumination and identification of tissue and anatomical structures. The rate of clinical success for the treatment of migrated LDH via endoscopic TLA has been reported to be up to 95%. However, endoscopic TLA has not been analyzed extensively, and reports with a detailed description are rare. The purpose of the present video is to demonstrate endoscopic tubular TLA and resection of a migrated LDH. This is the case of a 62-year-old man with right-sided leg pain and quadriceps paresis due to LDH that migrated behind the L3 vertebral body. Special focus is given to the planning of the skin incision and the trajectory toward the disc herniation. Furthermore, the dissection and extraction of large disc herniation are explained in detail.

Background Lumbar synovial cysts (LSCs) are an uncommon cause of radiculopathy and back pain. Open surgical treatment is associated with extensive bone resection and muscle trauma. The endoscopic tubular–assisted LSC resection has not been described in detail. Here the authors assessed the effectiveness of this technique for LSC resection. Methods Eleven patients (4 female and 7 male patients) were operated on via an ipsilateral approach for resection of LSC using an endoscopic tubular retractor system. Preoperative magnetic resonance imaging was evaluated for signs of degeneration and instability. At follow-up a standardized questionnaire including the Oswestry Disability Index and functional outcome according to MacNab criteria was conducted. Additionally, a personal examination with particular reference to back and leg pain was performed. Results The mean follow-up was 10.5 months. Preoperatively, spondylolisthesis grade 1 was noted in 4 patients (36.4%). Ten patients had bilateral facet joint effusion (90.9%). At follow-up 10 patients reported being free of leg pain (90.9%), eight patients reported no back pain (72.7%), ten patients had full motor strength (90.9%), and 9 patients had no sensory deficit (81.8%). Nine patients reported an excellent or a good clinical outcome (81.8%). The mean Oswestry Disability Index was 4.7%. None of the patients developed new mechanical low back pain or required subsequent fusion procedure. Conclusion The endoscopic tubular–assisted procedure is a safe way to treat LSC. It offers complete resection of LSC and achieves good clinical outcome by preserving muscle and ligamentous and bony structures, which prevents delayed instability.

The purpose of this study was to assess long-term follow-up data after anterior cervical decompression and fusion (ACDF) with and without Caspar plating (ACDF + PS) for the treatment of cervical spondylotic myelopathy (CSM) with special focus on functional outcome, pain, and repeat surgery for adjacent segment disease (ASD). Hospital records of 45 patients who were affected by CSM and underwent ACDF or ACDF + PS at least 17 years ago were reviewed. Information about diagnosis, surgical report, pre- and postoperative clinical process, and complications was analyzed. Clinical outcome was assessed using a standardized questionnaire including the Neck Disability Index (NDI), modified JOA-score, Odom’s criteria, limitations in quality of life, and questions about the current neurological status and pain. Twenty-three patients with a mean follow-up of 26 years were evaluated. ACDF was performed in nine and ACDF + PS in 14 patients, respectively. At follow-up 78.3% of patients were free of pain, 91.3% had no motor deficit, 73.9% had no sensory deficit, and 60.7% had no gait disturbance. The current mean NDI is 14% (range 2–44%), the mean modified JOA-score was 17.2 (range 15–18). According to Odom’s criteria 78.3% of patients had clinical success. In four patients repeat surgery was indicated due to pseudarthrosis or symptomatic ASD (17.4%). ACDF and ACDF + PS yield significant decrease in neck pain, a significant increase in sensorimotor function and a high rate of clinical success. Patients with preoperative gait disturbance completely recovered in about 60% of cases. Overall prevalence for ASD was 17.4% after 25 years.

The first evidence of spinal surgery was found in Egyptian mummies 2900 BC [1]. In the antiquity, about 2500 years later, Hippocrates who is considered “The father of spine surgery” collected a valuable heritage of knowledge and methodology about the human body. He was the first who described sciatica and low-back pain. He also proposed a traction procedure and invented devices based on his fundamental principle [2]. Concerning the cervical spine, Aulus Celsus was the first who noted death following injury of the cervical spinal cord [3]. Paulus of Aegina performed the first operative repair of injured spinal cord by removing bony fragments which irritated the spinal cord and caused consecutive paralysis in the seventh century [3]. It took spinal surgery about 1900 years until an endoscope was applied. In 1983, the first report of an examination technique for intervertebral disc space after nucleotomy via endoscopy/arthroscopy was described by Frost and Hausmann [4]. Since then new surgical technology and techniques for minimally invasive approaches have revolutionized the work of surgeons of all subspecialties. Procedures such as laparoscopic cholecystectomy and orthopedic arthroscopy have proven to decrease surgically related morbidity, shorten postoperative hospital time and improve clinical outcomes [5–7]. In spinal surgery, morbidity is associated with iatrogenic muscle and soft tissue injury due to approach and exposure of the surgical field. Particularly in lumbar spine surgery, the standard open approach leads to iatrogenic injury of the paraspinal muscles which might result in decreased muscle strength and muscle atrophy after extensive muscle retraction [8, 9]. Biomechanical studies have investigated the function of the posterior column and its importance in maintaining lumbar spinal stability [10, 11]. Serial tube dilators and retractors were designed to split the back muscle gently and thus made to minimize retraction and disruption of the paraspinal muscular integrity. Further, other studies demonstrated that the postoperative recovery of CK and CRP levels occurred within 1 week and that the intensity of low back pain was mild [12, 13]. Mayer et al. studied the postoperative muscle architecture on CT scan and its relevance for failed-back syndrome [8]. They found that the integrity of paraspinal muscles might be of utmost importance for the postoperative result. A tubular retraction system provides direct and focal access to the diseased anatomy via a less invasive approach [14, 15]. Surgery can be done by using either an endoscope or using a microscope for visualization. The microendoscopic technique for interlaminar fenestration is considered safe and effective treatment of degenerative lumbar spine diseases and makes this to be seen as an option along with the traditional technique for every spine surgeon [16].

Background Posterior cervical foraminotomy is a valuable treatment option for cervical radiculopathy. Here the authors present their technique and results in the treatment of a series of patients suffering from osseous foraminal stenosis. Methods Forty-three patients suffering from cervical osseous foraminal stenosis were operated on via a posterior approach with the EasyGO endoscopic system. Decompression was performed in 1 segment in 31 patients, in 2 segments in 11 patients, and in 3 segments in 1 patient. Bilateral decompression was performed in 4 cases. Twenty-four (55.8%) patients had been subjected to previous spine surgery. All procedures were video recorded and afterwards retrospectively analyzed. In addition, particular reference was given to previous cervical spine surgery, postoperative outcome, reoperation rate, and complications. Results The endoscopic system was easy to handle intraoperatively in all procedures. No emergency stopping was required. Forty-one patients reported improved and/or even no remaining pain postoperatively (95%). Thirty-five patients (81.4%) regained full motor strength. Clinical success rate with respect to Odom's criteria reached 39 patients (90.7%). One reoperation was needed due to postoperative hematoma (2.3%). One patient suffered from transient worsening of his preoperative paresis (2.3%). Neither dural tear nor nerve root injury was observed. Reoperation rate due to degenerative changes was 18.6% (8 of 43 patients). Conclusions This retrospective analysis shows that posterior endoscopic decompression is a successful option in the treatment of osseous cervical foraminal stenosis.