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Paraspinal hematomas are common complications following spine surgery. In general, these hematomas are asymptomatic and resolve without issue. Unfortunately, there is a paucity of literature that describes the recurrence of these hematomas in a chronic setting. This case report describes a patient with a chronic recurrent calcified paraspinal hematoma that first developed over 4 years and then reoccurred 11 years later at the same site. The case features a 53-year-old female presented with severe lumbar back pain and right lower extremity radiculopathy in which she underwent a lumbar decompression posterior spinal fusion from L3 to L5 in 2008. Postoperatively, she developed a lumbar paraspinal hematoma which was treated with aspiration followed by conservative management. Four years later, the patient had a large paraspinal mass removed from a similar location in an outside medical facility. The procedure required the assistance of plastic surgery for flap closure and a pathologic review of the mass revealed a calcified hematoma. Ten years later, the patient sought treatment from her index surgeon for a recurrence of the lumbar mass with new onset radicular symptoms. Magnetic resonance imaging of the lumbar spine confirmed the presence of a large paraspinal mass. The patient proceeded with the removal of hardware, revision of laminectomy, revision of posterior instrumentation from L2 to L5, and removal of the lumbar mass. The pathology report classified the mass as a chronic calcified hematoma. The patient remains symptom-free for 1 year following the revision procedure. This case demonstrates an extremely rare presentation, ill-described in the existing literature, of a recurrent symptomatic calcified lumbar paraspinal hematoma requiring repeat operative intervention., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2025.)

Study Design: An in vitro biomechanical study., Objective: The aim of this study was to determine the effect of an optional sleeve on height restoration and compare it with the fracture reduction achieved by a commercially available inflatable bone tamp under simulated physiological load (110 N)., Summary of Background Data: Loss of reduction after bone tamp deflation before cement injection still remains a concern. The optional sleeve surrounds the bone tamp to help maintain height during the kyphoplasty procedure while filling the created cavity with bone cement on the contralateral side., Methods: Eighteen osteoporotic vertebral bodies (VBs) (T11-L4) were alternately assigned to 1 of the 2 treatment groups: group A: KYPHON (Kyphon Inc.) and group B: AFFIRM with sleeve (Globus Medical Inc.). The VBs were compressed axially at a rate of 5 mm/min until compressed to 40% of the initial anterior height. The fractured VBs then underwent kyphoplasty with cement augmentation while still maintaining load (110 N). The augmented VBs were then recompressed and anterior VB height (mm) and wedge angle (degrees) were measured initially after mechanically creating an anterior wedge fracture, and after repairing the compression fracture. The effect of kyphoplasty on vertebral height, kyphotic angle, cement volumes, and inflation pressures were compared between the treatment groups. Failure load (N) data were compared between intact and repaired VBs., Results: Average percentage of lost VB height restored in group A was 30%, compared with 56% for group B. The mean changes in wedge angle were similar to those of vertebral height measurements. No significant difference in mean inflation pressures (group A: 175±37 psi; group B: 160±36 psi) were found between the 2 groups. Average percentage increase in failure load was 241% and 212% in groups A and B, respectively., Conclusions: Some height restoration was observed using the commercially available bone tamp in fractured VBs under simulated physiological load. The use of an outer sleeve significantly enhanced height restoration compared with the inflatable bone tamp alone.

Study Design: An in vitro biomechanical study., Objective: To determine the fracture reduction achieved by a novel inflatable bone tamp under simulated physiological load., Summary of Background Data: Previous biomechanical studies have showed that kyphoplasty allows near-total restoration of lost vertebral height in unloaded conditions and partial height restoration under simulated physiological loads. Clinically, loss of reduction has been observed after bone tamp deflation, before cement injection. The present study evaluated fracture reduction achieved by an inflatable bone tamp during kyphoplasty while maintaining physiological load. Comparison to commercially available inflatable bone tamp was also performed., Materials and Methods: Eighteen osteoporotic vertebral bodies (T11-L4) were alternately assigned to one of the 2 treatment groups: group A-AFFIRM (Algea Thearpies, a division of Globus Medical Inc., Audubon, PA); and group B-KYPHON (Kyphon Inc., Sunnyvale, CA). The vertebral bodies were compressed axially on an MTS Bionix 858 machine at a rate of 5 mm/min until compressed to 40% of the initial anterior height. Load versus displacement was recorded. The fractured VBs then underwent kyphoplasty with cement augmentation. The augmented vertebral bodies were then recompressed and anterior vertebral body height (mm) and wedge angle (degrees) was measured initially, after mechanically creating an anterior wedge fracture, and after repairing the compression fracture. Each vertebral body was subjected to 111 N load to simulate in vivo physiological loading during inflation and cement augmentation. The vertebral height, wedge angle, cement volume, and inflation pressures were compared between the treatment groups using an unpaired t test (P<0.05). Failure loads were compared between intact and repaired VBs using a paired t test (P<0.05)., Results: Average lost height restored in group A was 29%, and 30% in group B compared to the compressed state. Similar trends were observed in the mean changes of vertebral body wedge angle in both the groups. No significant difference in mean inflation pressures (group A 182±33 psi; group B 175±37 psi) were found between the 2 groups. Average percentage increase in failure load was 218% and 241% for groups A and B, respectively. Mean injected cement volume was 6.65±0.65 and 6.73±0.41 mL for groups A and B, respectively., Conclusions: Some height restoration was observed using the 2 bone tamps in fractured vertebral bodies under simulated physiological load. The fracture reduction achieved by the 2 inflatable bone tamps was equivalent. No significant difference between mean inflation pressures and failure load was demonstrated between the 2 groups.

Study Design: Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5-S1 is detailed. A case report is also presented., Objective: To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure., Summary of Background Data: Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach., Methods: The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot-assisted approach is presented., Results: The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques., Conclusion: The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine., Level of Evidence: 4.

Background Context: Anterior lumbar interbody fusion (ALIF) procedures have a known incidence of subsidence. The individual risk of subsidence for specific lumbar levels in ALIF procedures has not been determined., Purpose: To evaluate the incidence of subsidence with two ALIF constructs. A paired Bagby and Kuslich (BAK) standard cage construct is compared with a paired BAK Proximity construct (Sulzer Spine-Tech, Minneapolis, MN). Study purpose is to evaluate lumbar intervertebral disc subsidence including the subsidence incidence for each disc level and with single- and two-level constructs. Also evaluated is the site of maximal subsidence within each end plate, risk with increased reaming depth, fusion incidence and clinical outcome., Study Design: A consecutive series of 70 fused levels fused with paired standard BAK cages is compared with a subsequent series of 70 fused levels using paired Proximity BAK cages., Patient Sample: The study population is derived from a consecutive series of ALIF procedures completed by a single surgeon. In 1998 the construct was changed from dual-standard to dual-Proximity cages. In the year 2000 there were 52 patients with a 2-year follow-up. These were matched to the previous 52 patients with dual-standard construct., Outcome Measures: Clinical outcome was determined using pre- and postoperative Oswestry questionnaires. Postoperative questionnaires were completed at the yearly follow-up. Radiographic outcome was determined by fusion status and evaluation of subsidence. Also evaluated was reaming depth and cage size for each fused level., Methods: A total of 52 patients with ALIF procedures using paired BAK standard cages (the SS group) were studied with a group of 52 patients using paired BAK Proximity cages (the PP group). The study population was derived from an ongoing prospective study of consecutive ALIF fusion procedures completed by a single surgeon. Disc height measurements were used to determine subsidence. Reaming depth, fusion status and the site of maximal subsidence were all recorded. Clinical outcome was determined with a pre- and postoperative Oswestry functional questionnaire., Results: Subsidence greater than 2 mm was noted in 5 of the 70 SS fused levels and in 9 of the 70 fused PP levels. Subsidence was always at the L4-L5 level in the SS subsided levels. Subsidence was in two-level fusions in all but one of the SS constructs. Subsidence was at the L4-L5 level in eight of the nine subsided PP levels. Subsidence was associated with increased reaming depth and the use of larger cage sizes. Subsidence was usually in the posterior and superior end plate. The clinical outcome was not affected by subsidence. Subsidence incidence was not associated with the age, sex or weight of the patient., Conclusions: There is a statistically significant increased incidence of subsidence at the L4-L5 level as opposed to other fused lumbar levels in ALIF fusions with BAK cage constructs. There is an increased incidence of subsidence with the PP constructs. Subsidence also is associated with increased reaming depth and with larger cage sizes. The lowest risk for subsidence was with single-level dual-standard cage constructs.

Ninety of 110 consecutive patients with rheumatoid deformities of the cervical spine surgically treated had associated neurologic deficits. Fifty-five patients had atlantoaxial subluxation. In this group, there were 16 Ranawat Class I patients (normal), 21 Class II (weakness, hyperreflexia, dysesthesia), 13 Class IIIA (paresis and long-tract findings but can ambulate), and five Class IIIB (quadriparesis and inability to ambulate). After C1-C2 stabilization, 94.8% improved at least one class. Twenty-two patients had AAS-SMO (atlanto-axial subluxation and superior migration of the odontoid) only one before surgery was Class I, five Class II, eight Class IIIA, and eight Class IIIB. Seventy-six percent improved at least one class after surgery. Nineteen had isolated subaxial subluxation (SAS). Three were Class I, two Class II, nine Class IIIA, and five were Class IIIB. After surgery, 94% improved at least one class, and all were ambulating. Fourteen had combined AAS-SMO-SAS deformities. There were no Class I patients, only four Class II, four Class IIIA, and six Class IIIB. After surgery, 71% improved. The four deaths that occurred in the immediate postoperative period were Class IIIB. Fifteen patients had worsening or recurrence of their symptoms. Thirteen of these were related to the later development of subaxial subluxation. Neurologic symptoms and recovery were related to severity of the deformity. Those with SMO had greater neurologic deficits and worse results. In general, neurologic recovery is encouraging even in the IIIB patient. Earlier surgery should be done, however, particularly before SMO develops, if possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifteen patients with symptomatic metastatic melanoma were retrospectively reviewed. All patients had severe back pain, and seven presented with neurologic findings. The interval between spinal involvement and death was 5.9 months (range 3 weeks to 24 months). The average survival after onset of neurologic signs was 3.5 months (range 3 weeks to 7 months). In the seven patients with neurologic involvement, the average survival for the four who had surgery was 5.25 months (range 3-7 months) from the onset of symptoms and 1.2 months (range 2 weeks to 3 months) for those who did not have surgery. This dismal prognosis must be considered along with the magnitude and morbidity of any spinal procedure, the adverse impact on quality of life from neurologic compromise, and the relative failure of medical therapy for melanoma.

In a retrospective study, 110 patients with rheumatoid arthritis who had cervical spine fusion were evaluated for recurrence of cervical spine instability and resultant need for further surgery. Recurrence of cervical instability was correlated with initial radiographic abnormality, primary surgical procedure and interval between the 2 surgeries. There were 55 patients who had atlantoaxial subluxation (AAS) and required C1-C2 fusion as primary surgery. Three of these patients (5.5%) developed subaxial subluxation (SAS) and had a second procedure after a mean interval of 9 years. Twenty-two patients had AAS with superior migration of the odontoid (AAS-SMO) and had initial surgery of occiput-C3 fusion. Eight of these patients (36%) developed SAS and had a second surgery after a mean interval of 2.6 years. Of the 19 patients with primary radiographic deformity of SAS, one required further surgery for subluxation of an adjacent superior vertebra after a period of 6 years. Fourteen patients had combined deformity of AAS-SMO-SAS, and one required further surgery for SAS after an interval of 22 months. Recurrence of cervical instability following a previous fusion occurred in 15% of these 110 patients. It was seen in 5.5% of patients with initial deformity of AAS vs 36% of patients with AAS-SMO. No patients with C1-C2 fusion for AAS progressed to develop superior migration of the odontoid. We conclude that early C1-C2 fusion for AAS before development of SMO decreases the risk of further progression of cervical spine instability. The pattern of progression of cervical spine involvement, as discussed in the literature, is reviewed.

Eighty-three segmental fusions were performed on 42 patients who underwent anterior cervical discectomy and fusion with freeze-dried fibular allograft for cervical spondylosis. Fusions were carried out over one to four levels. The mean follow-up period was 22.1 months (range, 9-47 months). The patients had both clinical and radiographic follow-up. Eighty-eight percent of the patients were found to have excellent or good clinical results. Radiographic follow-up revealed that 92% of the grafts obtained complete or partial union by 6 months after surgery. Forty patients were shown to be radiographically stable on lateral flexion and extension films by 8 weeks after surgery. The use of freeze-dried fibular allograft is a safe and efficacious procedure.

A retrospective study of 79 patients with rheumatoid arthritis was undertaken to determine the incidence of subaxial subluxation after upper cervical fusions. Fifty-five patients had isolated axial subluxation and underwent atlantoaxial fusion. Twenty-four underwent occipitocervical fusion for atlantoaxial subluxation and superior migration of the odontoid. The two groups were comparable in age, duration of disease, and time to follow-up (atlantoaxial fusion, 65.4 months; occipitocervical fusion, 72.6 months). Fusion rates were comparable: 80% atlantoaxial fusion and 90.1% occipitocervical fusion. Of the occipitocervical fusion patients, 36% developed subaxial subluxation requiring surgery at an average of 2.6 years after fusion. Of the atlantoaxial fusion patients, 5.5% developed subaxial subluxation requiring surgery after an average of 9 years after fusion. No patient with atlantoaxial fusion developed superior migration of the odontoid. Subaxial subluxation requiring surgery developed early in patients after occipitocervical fusion. This was not true of atlantoaxial fusion. Early atlantoaxial fusion seemed to prevent the development of superior migration of the odontoid. When occipitocervical fusion is necessary and early subaxial subluxation is present, longer fusions or occipitocervicothoracic fusion should be strongly considered.