Search

Background Lower back pain is the fifth most common reason for visiting a physician in the United States. Degenerative disc disease, degenerative spondylolisthesis, arthritis, and facet arthrosis are leading causes for lumbar spinal stenosis. The previous gold standard involved open laminectomy combined with medial facetectomy and foraminotomy. The advent of minimally invasive surgery (MIS) and endoscopic technologies has led to less invasive and targeted interventions. In this study, the authors aim to show a five-year experience using a three-blade retractor for lumbar decompression and microdiscectomy. Methods A database review of a single spine surgeon over the last 5 years with a total of 306 patients undergoing single-level lumbar decompression with and without microdiscectomy. Results The average age was 47 ± 12 years and the average BMI was 29.7 ± 5.7 kg/m2 with a total of 52% male patients. Operative levels included L3-4, L4-L5, and L5-S1, with 65% of procedures at the L5-S1 level and follow-up was for two years. Overall mean VAS back scores decreased from 7.9 ± 1.6 to 2.5 ± 1.1 at two-year follow-up, p = 0.001. Preoperative ODI scores improved from 32.1 ± 5.1 to 17.9 ± 4.3 at two-year follow-up, p = 0.002. The mean EBL and surgeon time was 21 ± 15 ml and 35 ± 17 min, respectively. Conclusion This less exposure surgery technique can be performed to allow lumbar decompression, with or without microdiscectomy. This is an anatomy preserving technique with improved outcomes.

Introduction Anterior cervical discectomy and fusion (ACDF) is the gold standard for the treatment of cervical spondylosis. However, new techniques, technologies, and improved implants have aided surgeons in reducing operative time with enhanced patient outcomes. Impregnated hydroxyapatite polyetheretherketone (HA PEEK) cages (Arena-C HA®, LESspine Inc. Malden, MA) are one such option that has aimed to increase the fusion rate. The authors herein aimed to assess the use of HA PEEK interbody cages by looking at outcomes, complications, and radiographic fusion. Methods The medical records of 41 consecutive patients undergoing single-level ACDF with impregnated HA PEEK cages (group 1) were compared to the control group of 47 patients who had single-level ACDF without impregnated HA PEEK cages (group 2). Outcomes assessed included Visual Analog Scale (VAS) neck, Neck Disability Index (NDI) scores, radiographic fusion, and complication rates. Results Of the 41 patients in group 1 (HA PEEK), 48% were female population with a mean age of 58.5+/- 1.7 years and BMI 29.7+/-1.2 kg/m2. Of the 47 patients in group 2 (non-HA PEEK), 53% were female with a mean age of 54.3+/- 1.2 years and BMI 27.8+/-0.8 kg/m2. Using t-test, there was a statistically significant intergroup difference in two-year VAS neck and NDI scores, p=0.007, and p=0.001, respectively. Radiographic fusion occurred as early as three months in the HA PEEK group. Conclusions This study has demonstrated the equivalence of impregnated HA PEEK cages in single-level ACDF. Significant improvements were seen in VAS and NDI scores in the HA PEEK group. There was no incidence of heterotopic bone formation or reaction to HA PEEK cages. Additionally, a trend toward fusion was seen in HA PEEK patients as early as three to five months compared to seven to eight months for the ACDF group. We conclude that HA PEEK cages can be safely placed with excellent outcomes. However, further studies are required to look at added benefits.

Purpose The sacroiliac joint (SIJ) is estimated to be a source of pain in 15%-30% of patients presenting for the evaluation of low back pain. The SIJ may develop symptoms in an estimated 43% of patients who have had previous lumbar fusion surgeries. With increased awareness of SIJ as a pain source and for those patients who have intractable pain and who fail nonoperative treatment, surgery to stabilize the SIJ is becoming more common. Thus multiple different technologies and techniques need to be evaluated. The purpose of this study is to report on the clinical and radiographic follow-up of percutaneous lateral-oblique sacroiliac joint fusion with a threaded compression screw performed in an outpatient ambulatory surgery center (ASC). Methods Three consecutive patients were chosen for this technique, and after completion, were followed for at least 24 months as part of a pilot study to see how they responded to the treatment. The medical charts of these patients were reviewed along with follow-up radiographs and computed tomography (CT) scans to assess for radiographic fusion designated as bridging bone across the SIJ with no signs of implant loosening such as haloes around the screws, change in position, or screw breakage. The SacroFuse (Sacrix LLC, Boston, MA) SIJ screws were 12 mm x 60 mm at S1 and 12 mm x 50 mm at S2 with threads for compressive fixation and cannulated for percutaneous placement over a guidewire. We evaluated patients' demographics, the pain visual analog scale (VAS) score, and the Oswestry Disability Index (ODI) preoperatively and postoperatively. Results Our first patient was a 51-year-old male body mass index (BMI) 33.3 kg/m2 with a previous lumbar fusion. He underwent a two-staged SIJ fusion. The first surgery was done as an open direct lateral surgery, and the second stage was performed three months later using a direct percutaneous lateral-oblique technique for three months. The second and third patients, respectively, were 22-year-old female status prior L5-S1 anterior lumbar interbody fusion (ALIF) plus right posterior unilateral pedicle screws. She had a BMI of 38.3 kg/m2. The third patient was a 41-year-old male with a BMI of 29.5 kg/m2 who underwent lateral-oblique bilateral percutaneous SIJ fixation. The latest CT imaging of each patient demonstrated increased bone density adjacent and within implants with intra-articular osseous bridging. There were no implant failures or complications. Conclusion This pilot study demonstrated the feasibility and effectiveness of a new percutaneous lateral-oblique SIJ fusion technique with a threaded compression screw done safely in an ASC. Patients demonstrated early pain relief and long-term fusion of their SIJ. We introduced the Sacrix line as a key fluoroscopic landmark for the success of this percutaneous technique.

This is a level III retrospective study.The authors aim to review the outcomes and complications of ball and socket total disk replacements (TDRs).TDR is a motion-preserving technique that closely reproduces physiologic kinematics of the cervical spine. However, heterotopic ossification and spontaneous fusion after implantation of the total cervical disk have been reported in several studies to decrease the range of motion postulated by in vitro and in vivo biomechanical studies.The medical records of 117 consecutive patients undergoing cervical TDR over a 5-year period with Mobi-C, Prodisc-C, Prestige LP, and Secure-C implants were followed. Outcomes assessed included Visual Analogue Scale neck and arm and Neck Disability Index scores. The radiographic assessment looked at heterotopic ossification leading to fusion and complication rates.Of the 117 patients that underwent TDR, 56% were male with the group's mean age being 46.2±10.3 years and body mass index of 18.9±13.6 kg/m. The longest follow-up was 5 years with Prodisc-C group, with overall fusion noted in 16% of patients. One patient was also noted to have fusion which was not seen radiographically but noted intraoperatively for adjacent segment disease. There has been no demonstrable radiographic fusion seen in the Prestige LP group, however, the follow-up has only been 12-24 months for this group.In this study, we have demonstrated radiographic fusion anterior to the ball and socket TDR as well as the uncovertebral joint. We postulate that with the use of a mobile core disk there is an increased potential for fusion leading to a nonfunctional disk replacement.

Background The authors aim to demonstrate the feasibility, outcomes and fusion rate of a standalone PEEK cage in the outpatient setting. Methods 48 consecutive patients undergoing standalone ACDF (S-ACDF) (Group 1) were compared to control group of 49 patients who had ACDF with ACP (Group 2). Results Analysis of follow-up at the one year period postoperative outcomes between groups 1 and 2 demonstrated no intergroup statistical significant difference in VAS neck, arm and NDI scores p = 0.414, 0.06 and p = 0.328 respectively. Conclusion We conclude that S-ACDF can be safely done in an ambulatory surgery center with satisfactory clinical and patient-reported outcomes.

Background Lumbar spinal stenosis is treated with decompression directly such as laminectomies and indirectly with an interspinous device through distraction and extension block. Interspinous devices (IPD) have also been used as an adjunct to spinal fusion. However, the design for IPD to treat spinal stenosis does not fixate the spine while the design for spinal fusion is designed to fixate the spine. There is a paucity of data on a single device that has been used for both fusion and stenosis. Authors aim to demonstrate the long-term outcomes of interspinous fixation at L4-5 for degenerative spinal stenosis. Methods We evaluated patients with spinal stenosis and degenerative disc disease who were treated with open decompression and distraction of the spinous processes at L4-L5 using an interspinous device. All patients complained of lower back pain and neurogenic claudication. This is a retrospective review of prospectively collected data (level 3) under an IRB approved study cohort. The charts of patient undergoing lumbar decompression with Interspinous Distraction, Fixation using InSpan device (INSPAN LLC) in an outpatient setting were reviewed with over a 5-year follow-up period. Results 122 surgical cases of lumbar decompression with interspinous fixation, spanning between the timeframe of September 2011 to October 2016. A total of 56 patients had instrumentation at L4-L5. Total female population was 46%. The median age of the patients included in the population was 50.9±10.7 years with a median BMI of 24.8±11.4 kg/m2. Two-year VAS and ODI showed significant improvement from 8.1±1.2 to 1.5±1.1 and 42.9±14.3 to 14.8±5.1. All surgeries were completed in less than one hour. There was a total of 1 revision case with removal of INSPAN and open hemilaminectomy decompression. Conclusions Long term results demonstrated improved outcomes in patients who underwent Interspinous distraction decompression in an ambulatory surgery center using the INSPAN IPD at L4-L5 for Degenerative Spinal Stenosis. There was one revision converted to hemilaminectomy. There were no complications or blood transfusions.

BACKGROUND: Authors aim to report on the outcomes of combining selective anterior cervical decompression and fusion (ACDF) with laminectomy in patients with cervical spondylotic radiculomyelopathy (CSR). METHODS: 10 patients with ACDF and posterior laminectomy reviewed. RESULTS: 60% female population, mean age 61 ± 3 years, mean BMI 24.7 ± 3.4 kg/m(2). VAS and NDI showed significant improvement, p

Background Authors aim to evaluate the correct placement of TDR using the instant center of rotation (ICR) as a guide. Methods Placement of disc would be divided into three groups using a standard of 1 mm from the ICR: Posterior to ICR, In line with ICR and Anterior to ICR. Results 49 patients, mean age was 39.96 ± 1.45 years. 42 intraop fluoroscopy images compared to 41 post op radiographic images demonstrated TDR in line with ICR. Conclusion Total discs replacements can be placed intraoperatively using proper technique with verification confirmed using the ICR postoperatively. Keywords Total disc replacement; instant center of rotation; ideal placement; fluoroscopy; adjacent segment disease; less exposure surgery.

Level III.To retrospectively review the eligibility of surgical patients meeting predetermined outpatient surgery criteria in a single-surgeon private practice.There is a burgeoning awareness among patients, surgeons, and insurers of the cost benefits and safety of outpatient spine surgeries. At the end of 2014, Centers for MedicareMedicaid Services have released its final 2015 payment rules and codes for spinal decompression and fusion. This move confirms the safety of procedures being performed in the ambulatory surgery centers (ASCs).We conducted a database review between 2008 and 2014 and identified 1625 orthopedic procedures. All nonsurgical spine procedures were excluded from the study. Eligibility for outpatient spine surgery was based on criteria generated from a combination of published standard of care for major operations and the chief surgeon's experience. A matched cohort based on type of surgery in each facility of all spine surgery patients was created, group 1 (hospital patients) and group 2 (ASC patients).A total of 708 patients underwent spinal surgery during this time period with a 53% female population. A total of 557 of 708 (79%) patients were eligible for outpatient spine surgery. There were 210 surgical procedures in group 1 (inpatient) comprised of 72 decompression and 138 fusion procedures. In group 2 (outpatient), there were 347 procedures made up of 150 patients undergoing decompression and 197 undergoing fusion or disc replacement. To confirm that hospital procedures are eligible to be performed in the ASC, the χ test was performed. We found that ASC-eligible hospital patients can indeed be done in an ASC (P=0.037).Outpatient spine surgery is feasible in 79% of patients in this single-surgeon private practice. On the basis of these results, a majority of spine procedures can be performed in an outpatient setting following our eligibility criteria.

Study design Level III. Objective To report on the outcomes of midline cortical bone trajectory (CBT) pedicle screw surgical technique for posterior lumbar fixation in the outpatient surgery center (OSC) compared with traditional pedicle screws in the hospital. Summary of background data Traditional pedicle screws have been the gold standard for posterior lumbar fusion. Advances in spine surgery, including less invasive procedures have propelled the design of instruments and implants to achieve greater posterior spinal fixation, with decreased tissue destruction and higher safety margins. Biomechanical studies have validated the superior pullout strength of cortical screws versus the traditional pedicle screws and represent an opportunity to perform safe lumbar fusions in OSCs with same day discharge. Materials and methods The medical records of 60 patients with prospectively collected data were reviewed. Two matched cohort groups consisting of 30 patients each, CBT pedicle screws performed in OSC patients (group 1) was compared with traditional pedicle screws performed in hospital patients (group 2). Outcomes were assessed with self-reported Visual Analog Scale (VAS) scores, Oswestry Disability Index scores, and radiologic fusion rate. Results Totally, 33 males and 27 females, age range (28-75), average 58±3 years. Average body mass index was 29±1.15 kg/m. A total of 65% of surgeries were at L5-S1 level. Significant improvement noted in VAS back pain scores in the OSC group from 7.8±0.5 to 2.5±0.7, P=0.001. Comparing intergroup VAS back pain scores and Oswestry Disability Index scores, OSC group demonstrated significant improvement, P=0.004 and 0.027, respectively. Fusion rate at 2 years was similar, P=0.855 between groups. Conclusions We successfully transitioned our lumbar fusions from hospitals to OSCs using a midline CBT pedicle screw technique. Although traditional pedicle screw placement is effective and may be viable in an OSC, we see more advantages to use midline cortical screws over traditional pedicle screws.

Background In anterior cervical diskectomy and fusion (ACDF), misaligned plates are concerning because of the risk of screw-and-plate failure; however, these plates also hypothetically have the potential for asymmetric micromotion on the facet and uncovertebral joint. The aim of this study was to determine whether misaligned plate placement during ACDF had clinical benefits compared with straight plate placement. Methods Postoperative AP radiographs of 128 consecutive patients who underwent ACDF with anterior cervical plate (ACP) fixation were reviewed, and plate alignment was assessed. Patients were separated into control group 1 (straight plates) or group 2 (misaligned plates). Results The mean age of patients was 51.5 ± 0.9 years, and women represented 51% of the total population. There was no significant difference between groups with regard to the preoperative visual analog scale (VAS) and Neck Disability Index (NDI) scores (P = 0.744 and P = 0.943, respectively). At 6 weeks postoperatively, the VAS scores for group 1 decreased from 7.6 ± 0.2 to 4.0 ± 0.2 compared with the scores in group 2, which decreased from 7.7 ± 0.2 to 2.1 ± 0.1, which demonstrated statistical significance (P = 0.019). At 2-year follow-up, no significant difference was demonstrated between the groups' VAS and NDI scores (P = 0.670 and P = 0.266). Conclusion Misaligned plates have increased torsional strength and are associated with better clinical outcomes compared with those of straight plates in the early postoperative period. After fusion, no significant difference in clinical outcomes between the groups was noted, which may reduce the concerns regarding misaligned plates. Level of evidence Retrospective comparative study.

Radiation dose continues to be a concern especially in the field of spine surgery, where anterior and posterior instrumentation is frequently utilized to treat multiple pathologies. The authors aim to demonstrate the feasibility of decreasing the radiation dose in standalone anterior cervical discectomy and fusion (ACDF).Standalone ACDF (S-ACDF) with 48 consecutive patients (Group 1) with a comparison control group with ACDF with an anterior cervical plate (ACP) of 49 patients (Group 2). Fluoroscopy was performed for positioning, identification of level, placement of the implant, each screw, final AP and lateral images for the first 20 patients in Group 1. Screw placement could then be performed confidently based on cosine rule of cosine (Ѳ) = adj/hyp.Forty-eight patients in Group 1 (S-ACDF) and 49 patients in Group 2 (ACDF-ACP). Statistical significance not demonstrated for age, BMI or gender, P=0.691, 0.947 and 0.286 respectively. Mean radiation dose in group 1 of 17.9±6.6 mAs and 0.8±0.3 mSv was significantly less compared to group 2 which was 29.8±5.4 and 1.3±0.2 mSv, P0.001. The average radiation dose for single-level fusion in Group 1 was 12.5±3.5 mAs and 0.5±0.1 mSv this is compared to Group 2 of 27.8±3.9 mAs and 1.2±0.2 mSv, P=0.001. The average radiation dose for two level fusion in Group 1 was 22.2±5.1 mAs and 0.9±0.2 mSv this is compared to Group 2 of 33.9±6.0 and 1.4±0.3 mSv, P=0.001.In the outpatient setting, S-ACDF has shown a statistically significant intergroup difference in overall radiation dose, as well as single and two-level fusions, (P0.001). We conclude that S-ACDF can decrease overall radiation exposure to patients.

Introduction Authors aim to demonstrate the surgical technique and outcomes of using a platysma sparing approach to anterior cervical spine surgery. Methods Medical records of 496 prospective patients, group 1 (259 patients) with an outpatient platysma muscle-sparing approach. Group 2 (237 patients) with inpatient standard muscle-splitting approach. Results Intergroup comparison showed statistical significant improvement in VAS neck and NDI scores p = 0.009 and p = 0.012 and surgical operative time and estimated blood loss, p = 0.003 and p = 0.006 respectively. Conclusion This anatomy sparing technique demonstrates a safe, effective and reproducible approach to cervical spine surgery which is a goal of less exposure surgery philosophy.

Study design Comparative analysis. Objective To evaluate the safety and outcomes of moving lateral lumbar interbody fusion (LLIF) surgeries to an outpatient setting. Summary of background data LLIF has been popularized as a less invasive lumbar fusion surgery as an alternative approach to anterior lumbar interbody fusions, posterior lateral interbody fusion, and transforaminal lateral interbody fusion (TLIF). Lumbar fusions have been traditionally performed in a hospital setting because of the potential blood loss, length of surgery, and need for longer recovery. There is a movement to transition spine surgeries to outpatient settings with many benefits afforded by less invasive techniques and technologies. Methods The medical records of 70 consecutive patients with prospectively collected data were retrospectively reviewed. Two cohort groups, inpatients (40 patients) and outpatients (30 patients), were created. Patient demographics, risk factors, and body mass index (BMI) were evaluated to determine inclusion criteria for study. Result A total of 34 males and 36 females, age range (31-71) average 59.3 ± 2.3 years. Average BMI was 29.6 ± 1.1 kg/m. The most common level operated on being L3-L4 in both groups (63%). Mean preoperative inpatient Oswestry Disability Index (ODI) increased from 48.5 ± 3.0 to 55.5 ± 3.2 compared with outpatient preoperative ODI means reduced from 45.2 ± 5.1 to 39.1 ± 4.6. There was no statistically significant change in VAS scores between groups. There was however significant improvement in outpatient preoperative VAS scores from 7.3 ± 0.5 to 4.1 ± 0.5, P = 0.045. Conclusion The outcomes of the present study have shown that patients who had LLIF performed in the outpatient setting had statistically significant improvement in ODI scores compared with the inpatient setting (P = 0.013). Fusion was achieved in all patients and there was no evidence of implant failure or subsidence. Complications were transient in both settings. We conclude that outpatient LLIF improves patients' outcomes with similar safety profile as the hospital setting. Level of evidence 3.

Background The supine straight-leg raise (SLR) test has the potential to be exploited by malingering patients. The sitting SLR is believed to be less recognizable, therefore decreasing the chance of fabrication. The authors aim to compare the supine and sitting SLR test in patients with radiculopathy. Methods A total of 107 patients with radiculopathy were included in this study. Two groups were created: patients with workman9s compensation (Group 1) and a control group of patients without litigation claims (Group 2). Results Mean age was 47.3 ± 1.3 years with a 51% female population. Correlation analysis demonstrated association between mean angles in both positions, r = 0.248 with significance P = .01. There was equivalence in the mean angles in sitting position of 37 ± 3° compared to 35 ± 2° in supine position (P = .549). There was no significant difference in the mean angle at which the test became positive in the litigation group in the sitting or supine position compared to the nonlitigation group, P = .616 and P = .49 respectively. Conclusion This study demonstrated that the SLR test is equivalent in the sitting and supine position. Therefore, patients with a positive test should have similar angles in both positions, decreasing the chance of falsifying the examination. Level of Evidence Prospective analysis. Clinical Relevance Clinical practice.

Background: The technique of transpsoas lateral interbody fusion has been adopted to avoid direct anterior interbody fusion, but lateral fusions have been limited to disc spaces above L5 and are associated with neurologic injuries especially to the lumbar plexus when approaching L4–5. The authors aim to demonstrate a psoas splitting technique to decrease risk of complications associated with the standard transpsoas technique. Methods: Medical records of 84 patients with prospectively collected data reviewed. Two groups created 44 patients with standard lateral transpsoas approach (group 1) and 40 patients with psoas splitting approach (group 2). The psoas splitting approach utilizes two blades placed anteriorly and posteriorly to split the psoas fibers anteriorly while keeping the posterior blade docked in place where it enters the psoas muscle. The cephalocaudal blades sit above the psoas muscle measuring 30–40 mm shorter than the posterior docking blade. Results: Thirty-nine males and 45 females, age range 31–71 years, average 58±2 years. Average body mass index (BMI) was 28.4±1.1 kg/m 2 . Mean preoperative standard approach Oswestry disability index (ODI) increased from 48.4±3.0 to 55.2±4.0 compared to psoas splitting approach preoperative ODI means reduced from 45.1±5.0 to 34.9±6.0 (P=0.010). Group 1 mean preoperative visual analogue scale (VAS) score improved from 7.8±0.3 to 3.8±0.6 compared to group 2 mean preoperative VAS score which improved from 7.2±0.4 to 2.7±0.5 (P=0.048). Major complication rate of 20.5% was noted in standard transpsoas approach patients, including inability to walk and dermatome numbness. Conclusions: The outcomes of this study have shown that patients who had lateral lumbar interbody fusion (LLIF) with the psoas splitting approach had statistically significant improvement in ODI scores compared to the standard approach. Fusion was achieved in all patients and there was no evidence of implant failure or subsidence. In the psoas splitting group the major complication rate was only 5%.

Background Authors aim to determine patients’ preference for surgical incision and factors affecting the decision for surgery to the anterior neck. Methods A questionnaire was presented prior to evaluation and if preceded to surgery followup given. Results 243 patients completed questionnaire, with 60% female population and younger than 50 years. 151 patients preferred a transverse midline incision with a statistically significant increase in outcomes and cosmesis importance and a decrease in the importance of board certification. Conclusion Findings of questionnaire demonstrate that patients’ prefer a transverse midline anterior neck incision, with surgical outcomes being the overall factor affecting decision making.

The effects of nonsteroidal anti-inflammatory drugs (NSAIDs) have been implicated as a risk factor for nonunion after spinal fusion in both animal and human models1-6, but there remains debate about the real risk of NSAIDs with spinal fusion because prospective, randomized trials are still insufficient for robust meta-analysis7. Diclofenac sodium has a dose-dependent inhibitory effect on spinal fusion, especially in the immediate postoperative period, that is independent of smoking history, age, sex, and levels of vertebrae that have been fused2. Perioperative corticosteroids and their anti-inflammatory properties may improve the outcomes (e.g., length of hospital stay and time to return to full-time work) of microscopic disc surgical procedures, and may reduce pain and improve the functional outcome of these procedures8. Postoperative use of high-dose intravenous (IV) corticosteroids (at least 30 mg/kg of body weight of methylprednisolone or equivalent corticosteroid preparations per kg of body weight) have potent anti-inflammatory effects and may be useful in cases of acute spinal cord injury9-12, despite major dose-related side effects and relatively modest improvements in neurological function. Conversely, prolonged systemic administration of corticosteroids may induce osteoporosis and delayed fracture-healing13-15, and may suppress natural corticosteroid (adrenocorticotropic hormone) secretion. The effects of corticosteroids on spinal fusion and bone remodeling are not yet well documented in the literature16. We present two patients who underwent cervical spinal fusion; one experienced a severe neurological deficit and the other had acute respiratory failure requiring prolonged intubation. Both of these patients were believed to have experienced the potential benefits of high-dose steroids, but this treatment plan also raised concerns about the effects steroids may have had on the success …

Background: The purpose of this study is to present clinical outcome data from a 2-year post-market study of a viscoelastic one-piece cervical total disc replacement (TDR) in Europe. Methods: Thirty-nine patients were implanted at five surgical sites in an European post-market clinical study. Clinical outcomes included improvement of neck disability index (NDI) and visual analog scale scores for neck and arm pain from baseline to 2-year follow-up, neurological examinations, patients view on the success of surgery, complications, and subsequent surgical interventions. Results: Thirty patients had the Freedom ® Cervical Disc (FCD) implanted at a single level, and nine patients were implanted at two adjacent levels. The population had a similar distribution of male [20] and female [19] subjects, with a mean age of 45 years. All self-administered outcome measures showed significant clinically important improvements from baseline to the 2-year follow-up. Mean preoperative NDI score improved from 48% to 20%, 13%, 8%, 6% and 4% at 6 weeks, 3, 6, 12, and 24 months, respectively. Average preoperative visual analog scale (VAS) scores of the neck, right and left arm pain intensity and frequency showed significant improvement. All neurological outcome measurements showed immediate improvement from preoperative values and continued improvement throughout 2 years follow-up. From pre-op to 24 months, neurological deficits declined in the population from 21% to 6% for reflex function, 62% to 17% for sensory function, and 38% to 3% for motor function. No patients experienced a deterioration in any measured outcomes compared with the preoperative situation. Patient satisfaction increased over 2 years post-op, with 83% of patients responding that they would “definitely” choose to have the same treatment for their neck/arm condition and another 11% responding that they would “probably” choose to have the same treatment. Conclusions: The FCD performs as expected in patients with single-level and two-level degenerative disc disease.

Background context The transforaminal lumbar interbody fusion (TLIF) technique supplements posterior instrumented lumbar spine fusion and has been tested with different types of screw fixation for stabilization. Transforaminal lumbar interbody fusion is usually placed through a unilateral foraminal approach after unilateral facetectomy, although extraforaminal entry allows the facet to be spared. Purpose To characterize the biomechanics of L4–L5 lumbar motion segments instrumented with bilateral transfacet pedicle screw (TFPS) fixation versus bilateral pedicle screw-rod (PSR) fixation in the setting of intact facets and native disc or after discectomy and extraforaminal placement of a TLIF technology graft. Study design Human cadaveric lumbar spine segments were biomechanically tested in vitro to provide a nonpaired comparison of four configurations of posterior and interbody instrumentation. Methods Fourteen human cadaveric spine specimens (T12–S1) underwent standard pure moment flexibility tests with intact L4–L5 disc and facets. Seven were studied with intact discs, after TFPS fixation, and then with TLIF and TFPS fixation. The others were studied with intact discs, after PSR fixation, and then combined with extraforaminally placed TLIF. Loads were applied about anatomic axes to induce flexion-extension, lateral bending, and axial rotation. Three-dimensional specimen motion in response to applied loads during flexibility tests was determined. A nonpaired comparison of the four configurations of posterior and interbody instrumentation was made. Results Transfacet pedicle screw and PSR, with or without TLIF, significantly reduced range of motion during all directions of loading. Transfacet pedicle screw provided greater stability than PSR in all directions of motion except lateral bending. In flexion, TFPS was more stable than PSR (p=.042). A TLIF device provided less stability than the intact disc in constructs with TFPS and PSR. Conclusions These results suggest that fixation at L4–L5 with TFPS is a promising alternative to PSR, with or without TLIF. A TLIF device was less stable than the native disc with both methods of instrumentation presumably because of a fulcrum effect from a relatively small footplate. Additional interbody support may be considered for improved biomechanics with TLIF.

STUDY DESIGN Case report. OBJECTIVE To describe the technique used to place bilateral lumbar transfacet pedicle screws. SUMMARY OF BACKGROUND DATA Transfacet pedicle screw fixation is a growing alternative and biomechanically comparable with traditional pedicle screw fixation. There is no clear description of technique steps for placing transfacet pedicle screws available in the literature, despite recognizing that screw placement is not intuitive even with fluoroscopy, and is dissimilar to placing traditional pedicle screws or translaminar facet screws. METHODS We present 2 illustrative cases where bilateral transfacet pedicle screws were placed for posterior instrumentation after a step-by-step technique that can be used in a mini-open or percutaenous procedure. RESULTS Postoperatively, both patients had adequately placed transfacet pedicle screws bilaterally on x-ray imaging with 1 patient demonstrating fusion and intact fixation at 11 months follow-up. CONCLUSIONS Transfacet pedicle screws were successfully placed in 2 patients in a stepwise technique described to achieve lumbar fusion.

STUDY DESIGN Retrospective study. OBJECTIVE To report surgical and patient-reported outcomes after outpatient lumbar fusions in an ambulatory setting. SUMMARY OF BACKGROUND DATA There is growing interest in the potential benefits of outpatient spine surgery such as reduced costs, consistent operative team, and decreased postoperative complications during in-hospital recovery. However, there are limited studies on outcomes after outpatient lumbar fusions, to guide patient selection, treatment techniques and postoperative expectations. METHODS Medical records of 16 consecutive patients, who underwent outpatient direct open, single-level, posterior lumbar interbody fusions, were examined by a single surgeon. Outcome measures included visual analogue scale (VAS) scores for lower back and Oswestry Disability Indices (ODIs). Mean body mass indices (BMIs), estimated blood loss, surgical times and complications, and fusion rates were evaluated. RESULTS Males represented 56% of patients. Mean age was 42.81 ± 3.05 years (mean ± standard error) and mean body mass index was 28.95 ± 1.04. History of smoking and narcotics use were statistically noncontributory. Mean final follow-up was 15 (range, 5.52-34.2 mo) months. Mean postoperative scores were determined by the final follow-up VAS and ODI. L5-S1 was the most common level of the 16 levels operated on (69%). Preoperative and postoperative VAS and ODI scores for lower back were obtained for 15 patients (93.75%). Mean lower back VAS score of 8.4 ± 0.37 preoperatively reduced to 4.96 ± 0.73 postoperatively, (P = 0.001). Mean ODI improved from 52.71 ± 0.04 preoperatively, to 37.43 ± 0.06 postoperatively, (P = 0.04). One patient experienced postoperative worsened back pain with clinical and radiological signs of possible aseptic discitis. Estimated blood loss was 161 ± 32 mL and average operating time was 124.85 ± 7.10 minutes. The overall fusion rate was 87.5%. CONCLUSION Direct open posterior lumbar interbody fusions were done safely with statistically significant reduction in average pain and ODI scores. Surgical times were approximately 2 hours with minimal blood loss, allowing patients to be comfortably discharged the same day without a drain.

Background context C2 pedicle screws provide stable fixation for posterior cervical fusion. Placing C2 pedicle screws is fraught with risks, and a misplaced screw can result in cortical breach of the pedicle, resulting in injury to the vertebral artery or spinal cord. Purpose We sought to identify a reproducible starting point and trajectory for C2 pedicle screw placement using three-dimensional (3D) computed tomography (CT) imaging. Our aims included identifying correct cephalad and mediolateral angles used for determining the most accurate trajectory through the C2 pedicle. Study design A radiographic analysis of the anatomy of the C2 pedicle using CT. Patient sample A random sample of 34 cervical spine CT scans in patients without medical or surgical pathology of the cervical spine. Outcome measures Normal anatomic measurements made in the axial and sagittal planes of the CT scans. Angles and measures in millimeters were recorded. Methods The C2 pedicles were evaluated using CT scanning with a 3D imaging application. The ideal trajectory through each pedicle was plotted. The mediolateral and cephalad angles were measured using the midline sagittal plane and the inferior vertebral body border as references. Other measurements made were the distances through the pedicle and vertebral bodies, and the surface distances along the laminae between the isthmus and the starting point of the chosen trajectories. Other measurements involving the height of the laminae were also made. The mean values, standard deviations, and intraobserver variations are presented. Results CT scans from 34 patients were reviewed. The sex of the patient did not predict angle measurements (p=.2038), so combined male and female patient measures are presented. The mean mediolateral angle measured was 29.2°, and the mean cephalad angle was 23.0°. The mean distance along the lamina surface between the isthmus and the starting point was 8.1 mm. The mean distance from the superior border of the lamina to the starting point was 5.7 mm. There were no statistically significant differences between the dataset collected in duplicate by the same observer (p=.74); as such, we present one data analysis on combined data from the two datasets collected. Conclusion It is possible to determine an ideal trajectory through the C2 pedicle. These measurements may facilitate C2 pedicle screw fixation decreasing the risk of injury to the vertebral artery, spinal cord, or nerve roots. Delineating the individual anatomy in each case with imaging before surgery is recommended.

Introduction Outpatient surgery has a great opportunity to demonstrate the role of using mobile video conference (VC) postoperatively. Our patients use technology to help decision making in finding physicians. The authors aim to assess patient's perception on the use of mobile apps for VC with the surgeon and/or staff. Methods Consenting patients completed a questionnaire of 10 questions preoperatively and postoperatively to assess the difference in opinion. Results Overall, 120 patients completed the questionnaire preoperatively with 58% female population, 71% younger than 65 years, and 67% having a GED/higher education. Fifty-two patients had surgery with 54% female population, and 60% were younger than 65 years. All patients had mobile apps for VC with 55% using WhatsApp, 40% using Facetime, and 5% other. In person, being with a trained educator at the office was the preferred method for learning about surgical procedures. Overall, four patients contacted the surgeon directly preoperatively. After surgery, 8 of 52 patients (15%) used VC to the surgeon directly, and 37 patients used the VC with the team. Conclusion With advances in new technology, the use of mobile video conferencing adds a new forum for communication with patients. In the outpatient surgical setting, this forum would improve patient-physician relations.

STUDY DESIGN: A cross-sectional study. OBJECTIVE: To assess using postoperative magnetic resonance imaging whether the posterior longitudinal ligament (PLL) caused residual cord compression after anterior cervical decompression and fusion (ACDF) in a series of patients in whom the PLL was retained. SUMMARY OF BACKGROUND DATA: There is a lack of data evaluating the postoperative compressive effects of the PLL in patients undergoing ACDF providing guidance as to whether to remove or retain the PLL during discectomy to facilitate adequate decompression. METHODS: Postoperative gadolinium enhanced magnetic resonance images were reviewed in a series of 33 patients who underwent ACDF for cervical radiculomyelopathy and who had persistent or recurrent postoperative symptoms. Patients with ossification of the posterior longitudinal ligament or with a herniated disc behind the PLL were excluded from this study. RESULTS: There were no cases of discernible compression by the retained PLL identified on the magnetic resonance image (P < 0.001) as assessed by 2 independent reviewers. Four patients underwent subsequent revision surgery unrelated to the PLL. CONCLUSION: We were unable to demonstrate magnetic resonance imaging evidence to suggest that the retained PLL caused compression after ACDF in this patient cohort. Therefore we suggest that removing the PLL should be considered for reasons other than concern about residual compression.

STUDY DESIGN A single-center, retrospective study. OBJECTIVE The aim of this study was to determine the safety and outcomes of total disc replacement (TDR) as an outpatient procedure in the ambulatory surgery center (ASC). SUMMARY OF BACKGROUND DATA Anterior cervical discectomy and fusion (ACDF) has been demonstrated to be safe in the outpatient setting, as the awareness of same-day surgery procedures is on the rise due to better outcome and shorter recovery time. There is a need for motion preservation in a subset of patients TDR provides a solution. Transitioning spine surgery to the outpatient setting including cervical TDR is the next logical step. METHODS The medical records of 55 consecutive patients undergoing single level TDR (Group 1) were compared with our control group of 55 patients who had single-level ACDF (Group 2). Outcomes assessed included Visual Analogue Scale (VAS) neck, arm, neck disability index (NDI) scores, and complication rate. RESULTS Fifty-five patients in Group 1 (TDR, 60%) were male with the group's mean age being 42.6 ± 1.4 years and body mass index (BMI) 24.8 ± 1.2 kg/m. Fifty-five patients in Group 2 (ACDF), 57%, were male with the group's mean age being 53 ± 1.0 years and mean BMI 27.9 ± 0.8 kg/m. There was no statistically significant intergroup difference in 2-year VAS neck, arm and NDI scores. Dysphagia was the most common postoperative compliant in both groups (six patients), with no intergroup significance, P = 0.4. CONCLUSION In the ambulatory setting, TDR has shown statistical significant intragroup improvement in VAS neck, arm pain scores, and NDI scores (P

Multilevel anterior cervical fusion often necessitates a large extensile incision for exposure and substantial retraction of the esophagus for placing long plates, potentially predisposing patients to complications such as dysphagia, dysphonia, and neurovascular injury. To the authors' knowledge, the use of 2 incisions as an option has not been published, and so it is not intuitive to young surgeons or widely practiced. In this report, the authors discuss the advantages and raise awareness of using 2 incisions for multilevel anterior cervical fusion, and they document a safe skin bridge length. They also describe the advantages of using 2 incisions for performing multilevel anterior cervical fusion either at contiguous or noncontiguous levels as in adjacent-segment disease. By using the 2-incision technique, the authors made the surgery technically easier and diminished the amount of esophageal retraction otherwise needed through 1 long transverse or longitudinal incision. A skin bridge of 3 cm was safe.

Background context Of the injuries involving the lumbar spine, pedicle fractures are among the least common; those involving bilateral pedicles are rare. Purpose The aims of the study were to provide the first documentation of bilateral pedicle fractures at two consecutive levels after a gunshot, to review the mechanism of injury, and to evaluate a nonfusion treatment option for pedicle fractures. Study design This is a technical note and case report. Outcome measure The outcome measures were lumbar range of motion, return of motor and sensory functions, and return to normal activities. Methods A 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. He underwent repair of the dural tear and lag screw fixation of the pedicle fractures without fusion. Results The patient had full range of motion of his lumbar spine, full strength in his lower extremities, and bladder control. Conclusions This is the first report of bilateral multilevel lumbar pedicle fractures after a single penetrating gunshot wound. The case documents this injury pattern after a gunshot, reviews the mechanism of injury, and presents the successful application of a nonfusion treatment option.

Study design Retrospective radiographic review. Objective To determine the utility of the mandibular angle as a landmark for identification of cervical spinal level. Summary of background data Improper localization of the skin incision during anterior cervical spine surgery may lead to increased technical difficulty of the surgery. Although the use of traditional palpable anterior neck landmarks (hyoid bone, cricoid cartilage, thyroid cartilage, and carotid tubercle) help identify appropriate spinal levels, their reliability has not been validated in actual surgeries. We hypothesize that the angle of the mandible (AM) is a consistently palpable landmark, and that the mandible can be used to accurately template the distance to subaxial cervical levels using preoperative radiographs. Methods As a pilot study, we prospectively evaluated 30 consecutive patients who underwent anterior cervical diskectomy and fusion to assess the interobserver accuracy of palpating the mandibular angle, hyoid, carotid tubercle, and thyroid and cricoid cartilages. In a second set of 26 consecutive patients undergoing anterior cervical diskectomy and fusion, we then retrospectively reviewed standing preoperative lateral plain radiographs of the cervical spine, in addition to supine lateral cervical spine radiographs taken at the time of surgery, to assess: (1) the position of the AM relative to the corresponding cervical spinal level, and (2) whether or not the position of the AM relative to the subaxial cervical levels is different on preoperative standing films and intraoperative supine films. In these same 26 patients, we also measured the vertical distance between the AM and the location of each subaxial intervertebral disc space. These measurements were repeated for the hyoid bone as a control for each patient. Results The interobserver accuracy was 100% between observers for identifying the AM, hyoid bone, thyroid cartilage, and cricothyroid membrane, and 93% for carotid tubercle. The frequency with which anterior neck landmarks were palpable by the surgeon and assisting senior residents was as follows: AM (100%), hyoid bone (83%), thyroid cartilage and cricothyroid membrane (93%), and carotid tubercle (Surgeon: 63%, Resident: 57%, P = 0.79). There was 100% correlation between the position of the mandibular angle in the preoperative standing lateral radiograph and the intraoperative supine lateral radiograph, compared with 65% with the hyoid bone. The distances between the AM or hyoid to each disc space did not vary significantly between preoperative and intraoperative radiographs (P > 0.05). Conclusion The mandibular angle was shown to be the most consistently palpable landmark. Further, the distance from the mandible, measured on preoperative plain lateral cervical spine radiographs, is an accurate template to determine cervical spine levels during anterior cervical spine surgery.

Study design Prognostic Study, Level II (Retrospective review of prospectively collected data). Objective To identify an association between preoperative narcotic use and clinical outcome after cervical arthrodesis. Summary of background data Little data exists regarding the influence that chronic preoperative narcotic use has on clinical outcomes after surgery. Cervical arthrodesis is a common procedure that has a predictably high success rate for relief of radicular pain. In addition, the patient population presenting for this procedure has a high propensity for preoperative narcotic use. Methods Charts and prospectively collected questionnaires concerning the use of pain medication from 91 consecutive patients who underwent cervical arthrodesis for relief of radicular pain by a single surgeon at a single institution were reviewed. Group I consisted of 47 patients who took narcotic pain medication for their radicular pain on a daily basis for greater than 6 months before surgery. Group II consisted of 44 patients who were not on narcotics chronically before surgery. Postoperative narcotic use and patient outcome based on the modified Robinson criteria were assessed. Patients were observed for a minimum of 2 years. Results Of the group I patients, 16 (34%) continued to require chronic narcotic pain medication up to 2 years after surgery whereas only 3 (7%) of the group II patients required narcotic pain medication past 3 months (P = 0.002). Of the group I patients, 24 (51%) had a good or excellent result after surgery and 15 (32%) had a poor result whereas 38 (86%) of the group II patients had a good or excellent result and no patient had a poor result (P Conclusion Chronic narcotic use before cervical arthrodesis was found to be associated with continued narcotic use after surgery and worse functional outcomes following surgery. While further studies will be necessary to ascertain if this relationship is generalizable to other orthopaedic procedures and to analyze for potential confounding variables, surgeons may want to counsel their patients about the potential for inferior clinical outcomes if narcotics are used before surgery.

Study design Retrospective chart review of documented adverse events in 637 consecutive patients after computed tomogram myelography and follow-up interview of the most recent 100 of these patients. Objectives This study assessed documented prevalence of adverse events after diagnostic myelography in cervical spondylotic patients and compared with perceived adverse events and satisfaction in a subset of the same cohort of patients. Summary of background data There are some data that suggest complimentary benefits of myelography to magnetic resonance imaging. However, given the invasive nature of myelography, there are little data documenting the adverse events and patient experience with myelography to guide informed consent and physician choice of this study. Methods We analyzed the records of 637 consecutive patients (364 males and 273 females) after myelography. Five hundred forty-four patients (group 1) had a cervical approach and 93 (group 2) had a lumbar approach. The last 100 consecutive patients (85 in group 1 and 15 in group 2) were asked questions that addressed patient perceived adverse reactions, pain levels, and satisfaction. Results There was a 4.4% (28/637) prevalence of documented abnormal reactions. Group 1 had a 4.9% (25/506) prevalence of adverse reactions compared with 3.4% (3/89) in group 2. Overall 6.6% (42/637) had to have their myelographic procedures converted. Group 1 had 7% (38/544) converted to the lumbar approach group 2 had 4.3% (4/93) converted to the cervical approach. Thirty percent of the 100 patients interviewed felt they had an unexpected reaction (28 group 1 and 2 group 2). When interviewed, 14% of patients had maximum pain scores of 10 during the procedure and 8% (all group 1) felt worse pain after the procedure was completed. Six group 1 and 2 group 2 patients would not have the procedure again even when recommended by the surgeon. There was no statistically significant difference between complication rates, conversion rates, or patient perceived unexpected reactions between the 2 groups (beta=0.90). Conclusions This paper demonstrated the discrepancy between documented adverse events with computed tomogram myelography and patient reported tolerance as recorded by telephone follow-up. The cervical approach had a greater degree of patient perceived discomfort and a trend toward higher documented and patient reported adverse events and rate of approach conversion to a lumbar approach (P>0.5). When choosing myelography to evaluate patients with cervical spondylosis, the surgeon should consider the low patient tolerance and frequent adverse reactions that often go undocumented.

Prospective case controlled.To determine the outcome after microdiscectomy in patients with disc herniation, concordant sciatica, and low-back pain with Modic I and II degenerative changes compared with similar patients without Modic changes.The decision to perform a microdiscectomy versus a fusion or total disc replacement in a patient with a disc herniation and sciatica may be confounded by the presence of low-back pain, degenerative disc disease, and marrow and endplate (Modic) changes.Thirty consecutive patients underwent a microdiscectomy by a single surgeon. Group 1 consisted of 15 patients, 6 men and 9 women, with a mean age of 36.7 years (range, 21 to 48 y), with Modic I and II changes. Group 2 contained 15 patients, 9 men and 6 women, with a mean age of 34.1 years (range, 20 to 68 y), without Modic changes. The average duration of low-back pain before surgery was 25.6 months (range 4 to 120 mo) in group 1 and 17.5 months (range 5 to 120 mo) in group 2. The visual analog scale (VAS) was used to grade low-back pain and the Oswestry score was used to grade overall disability.There was no significant difference in preoperative sciatica, low-back pain, VAS or Oswestry scores for group 1 versus group 2 patients. Postoperatively, all patents had improved sciatica and resolution of any nerve tension sign. Eighty-six percent of patients in group 1 versus 93% of patients in group 2 had improvements in postoperative VAS score for low-back pain at 6 months. Average improvement within each group was 67% and 75%, respectively. VAS scores for low-back pain at 6 months improved from 6.9 to 2.3 (P=0.0005) in group 1 and 6.3 to 1.6 (P=0.0002) in group 2. Group 1 and 2 had 89% and 100% of patients show improvement in postoperative Oswestry score at 6 months with an average improvement of 58% and 84%, respectively. Oswestry scores at 6 months improved from 68.7% to 28.8% (P=0.0007) in group 1 and 61.2% to 9.9% (P=0.00003) in group 2.There was a trend toward greater improvement in Oswestry scores in patients without Modic changes (P=0.09). Both groups reported statistically significant improvement in sciatica, low-back pain, and disability after microdiscectomy. Microdiscectomy was therefore an effective treatment for disc herniation and concordant sciatica despite low-back pain and Modic I and II degenerative changes.Therapeutic II.

The conventional method of inserting pedicle screws (ie, plain radiography, standard 2D fluoroscopy, direct palpation) was found to be less accurate with cortical violation ranging from 10 to 50%. Small and variable anatomy of the cervical and thoracic spine poses a particular challenge, and it can lead to a devastating neurovascular complication. With recent advances in imaging technologies, such as computed tomography-based image guidance and isocentric C-arm fluoroscopy, surgeons are now able to visualize hidden pedicles and reduce screw misplacement. Using these various navigation systems, the rate of pedicle screw perforation can be decreased to less than 10% and potentially eliminate clinically significant complications and revision surgeries.

There is a need to improve postoperative analgesia to support the trend to shorter hospitalization after minimally invasive spine surgeries. Ketorolac Tromethamine has proven efficacy in decreasing postoperative pain but there is concern with postoperative epidural bleeding after spine procedures. We prospectively assessed the incidence of bleeding complications after microdiscectomy in patients treated with a single 30 mg intraoperative dose of Ketorolac subsequent to wound closure. Group 1 consisted of 44 patients, 24 women and 20 men with mean age of 35.7 years (20 to 68 y) treated with Ketorolac. Group 2 consisted of 45 patients, 28 men and 17 women with mean age 46.8 years (32 to 74 y), who underwent discectomy without Ketorolac. Postoperative bleeding complications were monitored along with pain levels and time to discharge. We detected no significant postoperative changes in coagulation parameters or bleeding from the surgical site in either group. Both group 1 and 2 had averaged preoperative visual analog scale scores for leg pain of 8. Group 1 had an average postoperative visual analog scale score of 2.6 compared with 4 for group 2 two hours after surgery. Single dose intravenous Ketorolac provided beneficial analgesia without significant increase in risk of bleeding after microdiscectomy, enabling us to consistently perform microdiscectomy as an ambulatory procedure. Meticulous hemostasis should be accomplished before closure. Prolonged postoperative use is a promising alternative to narcotics.

Background The use of pedicle screws is the gold standard for supplemental posterior fixation in lateral interbody fusion. Information about the performance of transfacet pedicle screws compared to standard pedicle screws and rods in the upper lumbar spine with or without a lateral interbody fusion device in place is limited. Methods Fifteen fresh frozen human cadaveric lumbar spine segments (T12-L4) were studied using standard pure moment flexibility tests. Specimens were divided into two groups to receive either bilateral transfacet pedicle screws (n = 8) or bilateral pedicle screws (n = 14). Stability of each motion segment (L1–L2 and L2–L3) was evaluated intact, with posterior instrumentation with an intact disc, with posterior instrumentation and a lateral interbody fusion device in place, and following cyclic loading with the interbody device and posterior instrumentation still in place. Both raw values of motion (range of motion, lax zone and stiff zone) and normalized mobility (ratios to intact) were analyzed for each case. Findings In terms of immediate stability, transfacet pedicle screws performed equivalent to similarly sized pedicle screws, both with intact disc and with lateral interbody fusion device in all directions of loading. Stability following cyclic loading decreased significantly during lateral bending and axial rotation. Interpretation Posterior fixation with transfacet pedicle screws provides equivalent immediate stability to similarly sized pedicle screws. However, in the presence of a lateral interbody fusion device, pedicle screws seem to resist loosening more and may be a better option for fusion in the upper lumbar spine.

Study Background: Wrong level surgery remains one of the detrimental technical mistakes that can occur during a surgeon’s career. There is a higher frequency of wrong site surgery in the lumbar spine compared to the cervical spine. The authors aim to present a localization technique designed to aid in the prevention of wrong level surgery with the use of preoperative and intraoperative localization. Methods: We prospectively followed 240 patients who underwent less exposure surgery for the lumbar spine. We identified the correct operative level using a combination of a 22-guage spinal needle placed under fluoroscopy in the lamina of the vertebra of the target intervertebral disc space prior to incision and then placing a hooked dilator between the spinous processes of the intervertebral space to provide actual confirmation within the operative space. Results: Data showed that all 240 patients had surgery performed on the correct level using the described technique and the placement of the percutaneous needle assisted in minimizing the incision size to less than 5 cm for a single level fusion in all cases. Conclusion: The described technique allows for localization prior to incision, smaller incision size, consistent and accurate localization when performing lumbar spinal surgery.

Study background: Fibula strut grafts alone during anterior cervical corpectomies have some inherent vulnerability. In contrast PEEK (Polyetheretherketone) cages are more stable but need separate graft material for interbody fusion. The opportunity therefore exists to combine the positive attributes of a fibula strut graft and a PEEK interbody cage for corpectomy. The authors aim to illustrate the use of stacking multiple PEEK cages around a fibula strut graft for cervical corpectomy. Methods: We present two illustrative cases of the technique of stacking three PEEK cages around a fibula strut graft (group 1). Cases were compared to cohort of 15 patients (group 2) with 3 level anterior cervical discectomy and fusion (ACDF). Results: Average age and BMI for group 1 was 52 years and 36.9 kg/m2 compared to group 2 average age 59 years and BMI 25 kg/m2, p=0.53 and 0.21 respectively. Mean preop VAS neck score in group 1 of 8.5 compared to group 2 of 6.5, p=0.08. Preop NDI in group 1 of 52 compared to group 2 of 43.4, p=0.355. There was no statistical difference in post op outcomes at 6, 12 and 24 months, p>0.05. There was no evidence of construct failure, subsidence, or focal kyphosis in either group which was demonstrated on CT radiograph. Conclusion: We have illustrated technique of combining the strength of a fibula strut graft for achieving fusion and PEEK cages for stability and favourable modulus of elasticity of that the vertebrae. The assessment of outcome scores demonstrated similar efficacy of treatment. There were no reported major complications in either group. Further application of this approach is the next steps to establish this technique’s efficacy.

Giant cell tumors are hypervascular tumors that represent approximately 5% of all primary bone neoplasms. Vertebral tumors often require surgery to maintain spinal stability or to relieve spinal cord and nerve root compression. However, surgical resection of hypervascular tumors like giant cell tumors can be hazardous because of the risk of excessive intraoperative hemorrhage. Preoperative embolization can be useful to decrease perioperative blood loss in primary and metastatic vertebral tumors, and preoperative embolization for vertebral tumor surgery is relatively safe. We report a patient who had the unusual but serious complications of paralysis and paresthesia at the T12 vertebra and below as a result of preoperative embolization. At 6 months followup, the patient was disease-free but without neurologic function from T12 and below. Therefore, it is imperative physicians be aware of the possible preoperative embolization complication of cord infarction and the safety measures proposed in this article to avoid this complication.

Sacral fractures most commonly occur after pelvic ring injuries but occasionally in isolation. Although the true incidence of sacral fractures is unknown, an estimated 30% are identified late. Sequelae of inappropriately treated or untreated sacral fractures include persistent pain, decreased mobility, and neurologic compromise. Because these fractures often result from high-energy trauma, concomitant injuries should be suspected. A thorough physical examination, including a detailed neurologic assessment and radiographic evaluation, is necessary to determine treatment. Computed tomography of the pelvis/sacrum can provide significant information about fracture pattern. Surgical intervention, often as a combination of neural decompression and stabilization, is indicated in patients with neurologic deficits, significant soft-tissue compromise, and lumbosacral instability. Patient satisfaction with surgical intervention has not been definitively documented, although neurologic improvement with timely intervention has been noted.

Study Design. Case report. Objective. To report on thoracic spinal cord compression caused by a mass in a 66-year-old female with new onset of myelopathic symptoms and a history of multiple hereditary exostoses. Summary of Background Data. To our knowledge, there have been no previous reports of spinal cord compression in a patient with multiple hereditary exostoses caused by breast adenocarcinoma metastatic to osteochondromas of the spine. Methods. Chart, pathologic, and radiographic documentation of the preoperative and postoperative clinical course of the patient was used. Results. The patient had resolution of her neurologic symptoms following wide surgical excision, decompression, and stabilization from T2 to T10. The patient’s mass was found to be breast adenocarcinoma metastatic to osteochondromas of the spine. Conclusions. When faced with a patient with a history of multiple hereditary exostoses with new onset of myelopathic symptoms and a mass compressing the spinal cord, the clinician’s differential should be broad and always initially include a metastatic lesion, osteochondroma, or chondrosarcoma.

Background context It is known that positioning patients on the Jackson and Andrews operative tables causes changes in lumbar lordosis and pelvic rotation. However, it is unknown if the relationship between the iliac crest and underlying lumbar levels, in particular the L4–L5 interspace, changes from standing to prone on these tables. Purpose To assess the changes in the relationship between the iliac crests and lumbar spinal levels from standing to prone on two different operative positions using the Jackson and Andrews frames. Study design/setting Comparative analysis of iliac crest position relative to spinal levels in the preoperative standing position and while positioned on the Jackson and Andrews frames. Patient sample 48 randomly selected patients who underwent spinal surgery on either the Jackson or Andrews frame. Outcome measures Imaging. Method Comparative measurements were made of the preoperative and intraoperative plain lateral lumbar radiographs. The location of the superior border of the iliac crest relative to the L4 lumbar spine level was compared between radiographs. Results Preoperatively, the iliac crest aligned with L4/L4–L5 spinal level in 79.2% of the 48 patients compared with 85.5% of intraoperative cases (p=.59). Intraoperative iliac crest level aligned with the L4/L4–L5 level in 80.8% and 90.9% of the patients on the Andrews and Jackson tables respectively (p=.43). Thirty-four patients (70.8%) demonstrated no change in iliac crest alignment between intraoperative and preoperative radiographs. There was a trend for the iliac crest to shift cephalad with operative positioning. Conclusion Approximately 30% of patients demonstrated changes in the relationship between the iliac crest and lumbar levels between standing and positioning prone. The intraoperative position of the iliac crest aligned more accurately with the L4/L4–L5 spine level on the Jackson and Andrews frame compared with preoperative standing radiographs respectively. Further biomechanical studies should investigate the implication for lumbopelvic fixation.

In an era of increasing use of spinal hardware whether for fusion or to preserve segmental motion, radiologic determination of spinal instability plays a prominent role in the treatment algorithm for practically all disorders affecting the spine. Although the presence of spinal instability does not always equate to symptoms directly related to the instability, spinal imaging in combination with clinical history and physical examination can provide valuable insights into the preoperative evaluation of patients, the selection of treatment options, and the subsequent postoperative follow-up. For instance, patients with confirmed instability are currently contraindicated for total disc replacements because of concerns with the long-term survival of the discs, while the presence of instability at the segment above a fusion or disc prosthesis is indicative of adjacent level disease. This article reviews the radiology of spinal instability in patients with degenerative disc disease. Instability secondary to other common causes such as trauma, congenital anomalies, deformity, inflammatory disorders, and prior surgery are outside the scope of this review.

UNLABELLED: After knee trauma, radiographs showing patella alta supercede other signs that suggest patellar tendon rupture. However, without patella alta the diagnosis may be missed. A standard lateral radiograph with the knee flexed showed the infrapatellar fat pad as a dark band with a smooth contour. Our pilot study identified a disruption of the fat pad contour as a radiographic sign of tendon rupture. Two blinded reviewers independently analyzed randomly selected lateral radiographs of the knees of 14 patients with knee injuries. Seven patients had confirmed ruptures diagnosed at surgery, and the other patients had different diagnoses. There were 12 men and two women with an average age of 49 years (range, 20-81 years). One observer detected five of the seven disrupted tendons and six of the seven intact tendons. The other observer detected six of the seven disrupted tendons and all seven intact tendons. Disruption in the contour of the infrapatellar fat pad on routine lateral view radiographs was a reasonably reliable sign of patellar tendon rupture. Diagnostic accuracy should increase when used with the patient's history, physical examination, and other radiographic signs. Absence of this sign should not supersede other suggestive signs of patella tendon rupture. LEVEL OF EVIDENCE: Diagnostic study, Level II (development of diagnostic criteria on consecutive patients--with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

A 40-yr-old woman received a series of three interlaminar epidural steroid injections for the treatment of axial neck pain secondary to degenerative disc disease. Immediately after her third injection, she experienced symptoms of a dural puncture-induced headache. This headache persisted on a daily basis for 3 mos, despite two epidural blood patches using an interlaminar approach, which was finally completely abated with a transforaminal blood patch. The headache was immediately relieved and remained alleviated through the follow-up interval of 1 yr. In this patient, a fluoroscopically guided transforaminal epidural blood patch proved to be more effective than the classic blind interlaminar approach in the treatment of post-dural puncture headache.

The Pre-Lister era of surgery in the mid 19th century was complicated by infection in over 90% of cases, the result of which often led to significant widespread morbidity and mortality known as “hospitalism.” Ironically, the “laudable pus” was often welcomed as a natural sign of the healing process before it inevitably signified the development of gangrene, tetanus, erysipelas, septicemia, and other dreaded lethal consequences. 1 The principles of antiseptic and aseptic surgery,setforthbyListerinhismanuscriptdated1867,“On the Antiseptic Principle in the Practice of Surgery,” were based on preliminary work from Pasteur who described a microbial source for disease. Some of the techniques that are attributed to Lister’s principles of antiseptic surgery include carbolic acid sprays, soaking of suture materials, and hand washing; use of these principles alone reduced infection rates to approximately 10%. 2

Although olecranon osteotomy provides excellent exposure of the distal humerus, enthusiasm for this approach has been limited by reports suggesting numerous complications. It has been suggested that specific techniques for creating and repairing an olecranon osteotomy may help limit complications. This paper describes a technique for olecranon osteotomy using an apex, distal, chevron-shaped osteotomy, Kirschner wires directed out the anterior ulnar cortex distal to the coronoid process and bent 180degrees and impacted into the olecranon proximally, and two 22- gauge, figure-of-eight, stainless steel tension wires. A single surgeon used this technique for exposure of a fracture (16 patients) or nonunion (29 patients) of the distal humerus in 45 consecutive patients. One patient returned to activity too soon, had loosening of the wire fixation, and required a second operation for plate fixation of the ulna. The remaining 44 osteotomies (98%) healed with good alignment within 6 months. There were no broken or migrated wires prior to healing. Twelve patients (27%) had removal of the wires used to repair the olecranon: in 6 patients, this was for symptoms related to the wires (13%); 1 for septic olecranon bursitis, and 5 at the time of another procedure (elbow capsular release in 4 patients and submuscular ulnar nerve transposition in 1). Olecranon osteotomy can be used for exposure of the distal humerus with a low rate of complications when specific techniques are used.