Anterior Approach Research Articles

Hip & Pelvis

The October 2024 Hip & Pelvis Roundup360 looks at: Does the primary surgical approach matter when choosing the approach for revision total hip arthroplasty?; Time to achieve the minimal clinically important difference in primary total hip arthroplasty: comparison of anterior and posterior surgical approaches; To scope or not to scope: arthroscopy as an adjunct to PAO does not provide better clinical outcomes at one year than PAO alone; Re-exploring horizons in hip resurfacing: two-year results of a ceramic-on-ceramic hip resurfacing; Association between tranexamic acid and decreased periprosthetic joint infection risk in patients undergoing total hip and knee arthroplasty; Octogenarians fare well: in revision for infection age is not a bar.

Pulmonary artery mass with PIK3CA mutation after orthotopic heart transplantation

BackgroundPatients can develop de novo malignancies following orthotopic heart transplantation. However, vascular tumors are not commonly described in this population.Case presentationWe present a 69-year-old female with a history of orthotopic heart transplantation for chemotherapy-induced cardiomyopathy who developed an incidental pulmonary artery mass six years after her transplantation. Given concerns for malignancy, the patient underwent an operative excisional biopsy through a left anterior mini-thoracotomy with femoral artery and vein cannulation for cardiopulmonary bypass. The mass was determined to be a non-malignant vascular overgrowth with PIK3CA mutation.ConclusionWe present the case of an unusual pulmonary artery mass with PIK3CA mutation found in a post heart transplant patient. We were able to spare her the morbidity of a redo-sternotomy by excising the mass via a minimally invasive left anterior thoracotomy approach.

S1514 Anterior versus Posterior Approach in Peroral Endoscopic Myotomy (POEM) in Patients with Achalasia

S1514 Anterior versus Posterior Approach in Peroral Endoscopic Myotomy (POEM) in Patients with Achalasia

Percutaneous core needle biopsy for paraaortic retroperitoneal lesions: impact of size and location on diagnostic accuracy of CT-guided biopsy and feasibility of ultrasound guidance

AimTo evaluate the safety and efficacy of computed tomography (CT)-guided core needle biopsy (CNB) for paraaortic retroperitoneal lesions, identify factors affecting false-negative results, and explore the feasibility of alternative CT-guided and ultrasound-guided approaches for challenging anatomical regions. Materials and methodsThis single-institution retrospective study included 317 consecutive patients who underwent CNB for paraaortic retroperitoneal lesions. A total of 345 biopsies were performed using 18-gauge cutting needles under CT or ultrasound guidance. Diagnostic accuracy was calculated based on biopsy and follow-up results, and univariate analysis was performed to identify predictors of false-negative CT-guided biopsies. ResultsOf the 332 CT-guided biopsies, 203 targeted lateral aortic lesions. The standard posterior paravertebral approach was commonly used; complex cases requiring alternative CT or ultrasound-guided approaches involved pre-aortocaval or inter-aortocaval lesions. In CT-guided biopsies, 5 of the 30 lesions in these regions were accessed via trans-caval, trans-pedicle, or trans-disc approaches. All 13 ultrasound-guided biopsies were performed with anterior access except for 2 cases. Malignant lymphoma and nodal metastasis were the most common pathologic findings. Overall sensitivity, specificity, and accuracy were 96.7%, 100%, and 97%, respectively. Neither lesion size nor location predicted false-negative CT-guided biopsies, with similar accuracy for lesions ≤15 mm (98.4%) and >15 mm (96.9%). Major bleeding occurred in two CT-guided biopsies (0.6%). ConclusionCT-guided CNB demonstrated high diagnostic accuracy across all lesion locations, particularly with the standard posterior paravertebral approach. For more challenging pre-aortocaval or inter-aortocaval lesions, alternative CT-guided posterior or ultrasound-guided anterior approaches may help overcome anatomical constrains and expand percutaneous options.

Differences in Time to Return to Work Between Patients Undergoing Staged Versus Simultaneous Bilateral Total Hip Arthroplasty

Patients who undergo total hip arthroplasty (THA) oftentimes have severe osteoarthritis (OA) in both hips and may consider staged or simultaneous bilateral THA (bTHA). The goal of this study was to compare the total workdays missed following staged and simultaneous bTHA performed via either postero-lateral or direct anterior approach. Patients who were (1) employed, (2) underwent a staged (within 12 months) or simultaneous bTHA at our institution between February 1, 2016 and December 31, 2021, (3) completed a return to work questionnaire, and (4) had the same surgical approach for both THAs were included. The primary outcome of interest was the total days of work missed. We identified 78 employed patients who had undergone staged bTHA (62 postero-lateral approach [PA], 16 direct anterior approach [DAA]) and 76 patients (44 PA, 32 DAA) who underwent simultaneous bTHA, and had completed the return to work questionnaire. Simultaneous bTHA patients missed an average of 25.6 days of work (standard deviation [SD]: 14.3 days) compared to staged bTHA patients, who missed an average of 36.9 days of work (SD: 23.4) when combining days missed from both operations (P < 0.001). In multivariate mixed regression analysis adjusted for sex, age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, type of work, and surgical approach, the staged bTHA group missed a mean of 8.2 more days of work (SD: 3.3) compared to the simultaneous bTHA group (95% confidence interval: 1.8-14.7, P = 0.013). Employed patients who underwent simultaneous bTHA missed an average of 8.2 fewer days of work compared to those who were treated with staged bTHA. These findings may help surgeons counsel their employed patients who have bilateral hip OA and are considering surgical treatment.

Cervical ossification of the posterior longitudinal ligament revealed by cervical trauma: A case report with literature review

Background: Ossification of the posterior longitudinal ligament (OPLL) refers to bone formation within the posterior longitudinal ligament of the spinal column. This disease of the cervical spine results in a reduced volume of the spinal canal and can cause spinal cord damage. The onset of cervical OPLL is insidious. OPLL may increase the risk of spinal cord injury with various neurological deficits after minor trauma. An acute event can reveal a previously unknown or paucysymptomatic cervical OLLP. The aim: To present a case of unknown cervical OLLP revealed by cervical trauma after a traffic road accident. Case report: A 47-year-old female presented intractable cervicobrachial neuralgia in the posttraumatic aftermath of a traffic road accident. Computed Tomography (CT) and Magnetic resonance imaging (MRI) demonstrated an isolated OPLL from C5 to C6, causing significant nerve compression operated via anterior approach with discectomy and intervertebral cervical cage. Conclusion: Acute cervical trauma must be considered a mode of revelation of previously unknown or paucisymptomatic cervical OLLP and must be considered in the emergency room.

In Situ Assembly of Dual Mobility Liners in Isolated Cup Revision in Hip Arthroplasty: A Technical Note

Objective: Isolated cup revisions to a dual mobility system through the minimally invasive direct anterior approach represent a major challenge in revision hip arthroplasty. Materials and Methods: We present 2 cases of isolated cup revision to a dual mobility system due to aseptic loosening, in which the dual mobility liners were assembled in situ. In the first case, a well-fixed cemented monobloc stem did not require revision; in the second, the collared prosthetic head could not be removed from the well-fixed stem. Results: In situ assembly of the polyethylene liner to the prosthetic head was performed using the standard press, designed for back-table assembly. Conclusion: In situ assembly of dual mobility liners is technically simple using standard instruments and can be performed through a direct anterior approach.

Comparison of Biomechanical, Clinical Indicators, and Quality of Life in People Undergoing Hip Replacement Surgery with Anterior and Posterior Approaches

Background: There are ongoing debates among surgeons regarding the most effective surgical method for hip replacement, with varying preferences for the anterior and posterior approaches. Both methods have demonstrated excellent long-term outcomes, with clinical differences primarily observed in the early postoperative period. Objectives: This study aimed to compare the anterior and posterior methods of hip replacement after six months of surgery in terms of biomechanical and clinical indicators, as well as quality of life. Methods: In this cross-sectional observational study, 42 patients who underwent hip replacement surgery using either the anterior (n = 22) or posterior method (n = 20) at least six months (and a maximum of 12 months) post-surgery, along with 20 healthy individuals, were evaluated. Biomechanical indices of the center of pressure (COP) were measured using a force plate during two-leg standing with eyes open and closed. Functional balance, independence, self-perception of performance, satisfaction, and quality of life were assessed using the timed up and go test (TUG), Barthel Index, Canadian Occupational Performance Measure (COPM), and the SF-36, respectively. Results: No significant differences were found between the anterior and posterior groups in terms of COP, clinical variables, and quality of life (P &gt; 0.05). However, when compared to the control group, the anterior replacement group exhibited significantly higher COP displacement in the medial-lateral direction (P = 0.03) and COP velocity in the anterior-posterior direction (P = 0.02) during two-leg standing with eyes open. No significant differences in COP variables were observed in the posterior replacement group compared to the control group (P &gt; 0.05). Conclusions: The findings indicate no significant differences between the anterior and posterior approaches to hip replacement in terms of biomechanical and clinical indicators, as well as quality of life after six months. Therefore, the choice of surgical method can be based on the patient's condition and the surgeon’s expertise in the respective approach.

Risk factors of postoperative trigeminal neuropathy in surgical treatment of trigeminal schwannomas.

Trigeminal schwannomas are rare benign tumors originating from the Schwann cells of the trigeminal nerve. Despite the common occurrence of trigeminal neuropathy in trigeminal schwannomas, a detailed analysis has not yet been performed because of the rarity of this disease. This study aimed to analyze trigeminal neuropathy in trigeminal schwannoma resection and identify the risk factors for postoperative worsening of trigeminal neuropathy. A retrospective analysis of 86 surgical cases was performed at our institution between 1975 and 2018. Obtained parameters included age, sex, diagnosis, reoperation, tumor size, tumor location, presence or absence of cysts, surgical approach, degree of tumor removal, and pre/postoperative trigeminal neuropathy. Uni- and multivariate analyses were performed to identify the risk factors for worsening postoperative sensory disturbances. Of 83 patients, 58.1% had preoperative trigeminal neuropathy. Postoperative sensory disturbance occurred in 27.9%, with worsening in two cases and de novo symptoms in 22 cases. Regarding risk factors for worsening postoperative sensory disturbances, older age, smaller tumor size, middle and posterior (MP) type, gross total removal (GTR), and anterior transpetrosal approach were identified in the univariate analysis, while MP type and GTR were identified in the multivariate analysis. This study analyzed trigeminal neuropathy in trigeminal schwannomas in detail and identified tumor location and removal rate as risk factors for worsening postoperative sensory disturbances. Treatment strategies to reduce the risk of trigeminal neuropathy should be considered.

Robot-Assisted Pancreaticoduodenectomy Using the Anterior Superior Mesenteric Artery-First Approach for Pancreatic Cancer.

The superior mesenteric artery (SMA)-first approach for pancreatic cancer (PC) is common surgical technique in pancreaticoduodenectomy. To date, few studies have reported SMA-first approach in robot-assisted pancreaticoduodenectomy (RPD). Herein, we present the anterior SMA-first approach for PC during RPD. A 75-year-old man with resectable PC underwent RPD after neoadjuvant chemotherapy. As pancreatic head tumor contacted with the superior mesenteric vein (SMV), the anterior SMA approach was applied. After the mesenteric Kocher maneuver, the jejunum was divided and the left side of the SMA was dissected. Subsequently, the anterior plane of the SMA was dissected. Following the division of branches from the mesenteric vessels, the SMA was taped, and the circumferential dissection around the SMA was performed to detach the pancreatic neck from the SMA completely. Finally, the dissection between the SMV and the tumor was performed under vascular control to remove the specimen. The anterior SMA-first approach can be optional in patients with PC undergoing RPD. This unique approach allows for the circumferential dissection around the SMA during RPD.

Are the Umbilicus and Iliac Crests Truly at the Level of L4 to L5? A Computed Tomography-Based Study of Surface Anatomy of the Anterior Lumbar Spine.

This study aimed to determine whether the iliac crests are truly at the level of L4 to L5, accounting for patient demographic and anthropometric characteristics. We measured the umbilicus and iliac crests relative to the lumbar spine using computed tomography of patients without spinal pathology, accounting for the influences of patient height, weight, body mass index (BMI), sex, race, and ethnicity. A total of 834 patients (391 men and 443 women) were reviewed. The location of the umbilicus relative to the lumbar spine demonstrated a unimodal distribution pattern clustered at L4, while the iliac crests were most frequently located from L4 to L5. Iliac crests were located above the L4 to L5 disc space 26.5% of the time. Iliac crests were located at the L4 to L5 disc space 29.8% of the time. No correlations were observed between the umbilicus and iliac crests with patient height, weight, or BMI. There was no difference in the location of the umbilicus with respect to patient sex, race, and ethnicity. The locations of the iliac crests were cephalad in women compared with men and in Hispanics compared with African American, Caucasian, and Asian patients. The iliac crests were located above the level of the L4 to L5 disc space approximately 26% of the time. The umbilicus is most frequently at the level of the L4 vertebral body. Patient height, weight, and BMI do not influence the location of the umbilicus or the iliac crests relative to the lumbar spine. Patient sex and ethnicity influence the location of the iliac crests but not the umbilicus relative to the lumbar spine. Modern neurosurgical techniques require clearance of the iliac crests during anterior and anterolateral approaches. Understanding the level of the iliac crests is crucial in planning for transpsoas fusion approaches.

Assessment of radiological and functional outcomes of complex acetabulum fracture managed with combined anterior and posterior approach in a single anaesthetic setting: a retrospective study

Background: Appropriate selection of surgical approach for associated fractures of the acetabulum that involves both columns is still elusive. Therefore, present study aimed to assess the quality of life of complex acetabulum fracture managed with combined anterior and posterior approach (dual approach) as well as the association of postoperative reduction and patient reported outcomes. Material and methods: This retrospective study was performed on 42 associated acetabular fracture patients with involvement of both columns, who were treated with a dual approach including combined anterior modified ilio-inguinal approach in combination with posterior Kocher-Langenbeck (K-L) approach in a single anaesthetic session having minimum two years follow-up. Postoperative reduction and radiological outcomes were assessed using Matta criteria. Functional outcome was assessed by a score system developed by Merle d’Aubigné-Postel. Patient-reported outcomes were assessed using the 36-Item Short Form Survey (SF-36). Results: The mean age of participants was 47.9 ± 11.95 years and mean follow-up period was 2.8 ± 0.49 years. Anatomical reduction was achieved in 32 (76.19%) cases in postoperative period. 8 (19.04%) cases had congruent and 2 (4.76%) had incongruent reduction. Radiological and functional outcome was excellent/good n = 35 (83.33%) cases. Patient-reported outcome on domains physical function and role physical showed a significant improvement between 6 to 24 months period ( p &lt; 0.001). Conclusions: The dual approach for complex acetabulum fracture with mid-term follow-up showed good to excellent radiological and functional outcomes. A significant improvement in patient-reported outcomes on Physical function and Role physical domains of SF-36 was also seen over the follow-up period.

Distal Basilar Artery Aneurysm Clipping by an Anterior Temporal Transcavernous Approach: 2-Dimensional Operative Video

Distal Basilar Artery Aneurysm Clipping by an Anterior Temporal Transcavernous Approach: 2-Dimensional Operative Video

“Heterotopic ossification after total hip arthroplasty through direct anterior approach without a dedicated orthopaedic table or direct lateral approach: a quasi-randomized single-center study”

Abstract Introduction Heterotopic ossifications (HO) are common after total hip arthroplasty (THA). The invasiveness of surgical approaches plays a relevant role in HO development. The aims of this study were to assess the development of HO 6 months after THA through direct lateral approach (DLA) or direct anterior approach (DAA) without a dedicated orthopaedic table and to assess the clinical impact of HO. Methods This is a single-center IRB-approved, quasi-randomized prospective cohort, observational imaging study. Fifty patients underwent primary THA through DLA and 50 through DAA. Age, sex, BMI and side of the affected hip were collected. At the 6 post-operative month the Harris Hip Score (HHS) and the presence of HO (scored through the Brooker classification system) were assessed. Results There was no significant difference in the demographic data between groups. Operative time was significantly higher in the DAA group (72 ± 10 min vs. 58 ± 8 min: p &lt; 0.03). At 6 post-operative months the incidence of HO was 14% in the DAA group and 32% in the DLA group (p = 0.02). Severe HO (Brooker 3–4) were significantly more common in the DLA group (p = 0.04). There was no significant difference in the HHS of patients with HO between the DAA and DLA groups. There was no association between poorer clinical outcomes and the severity of HO. Conclusion The DAA without a dedicated orthopaedic table is associated with a significant lower incidence of HO than the DLA 6 months after elective THA. Except for the surgical approach, no other factors correlated with the occurrence of HO. Even though a lower HHS was found with severe HO, the correlation between severity of HO and clinical outcomes did not reach statistical significance.

Odontoid fractures in the pediatric population: a systematic review and management algorithm.

The management of odontoid fractures in adult patients has been widely described. However, there is sparse literature about this injury in the pediatric population. This study aimed to review published literature regarding the management and outcomes of pediatric odontoid fractures to develop a stepwise treatment algorithm. A literature review was conducted using PRISMA guidelines on PubMed to identify studies between 1960 and 2023 that reported on the management and outcomes of odontoid fracture in pediatric patients. Studies were included if they were published in English and if their sample included at least four patients aged 0-18, minimum follow-up of 6 weeks, and outcomes for each patient clearly differentiated. In total, 15 studies including 125 pediatric patients with odontoid fractures were included. Treatment options varied from non-operative management with immobilization in rigid collars, halo vests, cervicothoracic orthosis, or soft collars to surgical management with fixation and/or arthrodesis. There were 73 patients initially treated nonoperatively, 47 initially treated surgically, 2 who healed with observation alone, and 3 who died acutely of concomitant injuries. The nonunion rate for nonoperative management was 5.5%. Surgery was successful, demonstrating bony union at final follow-up, in 94.6% of cases treated via a posterior approach and 85.7% of cases treated with an anterior approach. Odontoid fractures must be considered in pediatric patients with cervical spine trauma. This is the largest literature review of pediatric odontoid fractures. Various management strategies exist and can be considered. The proposed algorithm offers an evidence-based framework for the management of pediatric odontoid fractures.

Comparison of anterior vs. posterior surgery for cervical myelopathy due to OPLL: a systematic review and meta-analysis

Study Design: Systematic review and meta-analysis. Objective: To compare the effectiveness and safety between the anterior and posterior approach, and identify the more effective surgical approach for treating ossification of the posterior longitudinal ligament (OPLL) in the cervical spine. Method: This meta-analysis searched three electronic databases (PubMed, Embase, Cochrane library), including 17 randomized and non-randomized controlled studies published since 2000 to 2023 that compared the effectiveness and safety of anterior and posterior surgical approaches for the treatment of ossification of the posterior longitudinal ligament. Japanese Orthopaedic Association (JOA) scores, functional recovery rates, excellent and good outcomes of the surgical approaches, Visual Analogue Scale(VAS), C2-C7 angle cobb and complication were analyzed. RevMan 5.3 was utilized for data analysis. Results: This study suggested that there were no statistically differences between the anterior group and posterior group in terms of preoperative JOA score (WMD=0.23, 95%CI, [−0.22, 0.67], P=0.32), preoperative VAS (WMD=0.03, 95%CI,[−0.24, 0.30]) ,postoperative VAS(WMD=−0.16 ,95%CI,[−0.47, 0.15] P=0.97) function recovery rate of patients with canal narrowing ratio&lt;50-60% (WMD=−1.54, 95%CI, [−4.46, 1.38], P=0.30). The anterior group showed higher postoperative JOA score(WMD=0.99 ,95%CI, [036,1.63] P&lt;0.05) , post C2-C7 angle cobb(WMD=2.62, 95%CI,[0.36, 4.87], P=0.02) as well as function recovery rate(regardless of canal narrowing ratio) (WMD=16.05, 95%CI,[14.08, 18.03], P&lt;0.05) , especially a significant higher function recovery rate of patients with canal narrowing ratio&gt;50-60%(WMD=19.32, 95%CI,[17.25, 21.40], P&lt;0.05). There was a significant difference between anterior group and posterior group in complication. (OR=0.12, 95%CI, [0.01, 0.24], P&lt;0.05). Conclusion: Based on the study’s finding, The study suggested that when the conservative treatment for OPLL is unsatisfied, surgical approach of entering through the anterior approach is a better choose. Nevertheless, it is still necessary to consider the specific situation of the patient. One of the next research direction is how to reduce the complications of anterior surgery.

The DySLOH Study: Comparative Evaluation of the Results between the ProFlor and Lichtenstein Techniques for Open Inguinal Hernia Repair-A Randomized Controlled Trial.

Background: The Lichtenstein open anterior approach with static flat meshes, the most popular inguinal hernia repair technique, has raised concerns regarding mesh fixation, defect patency, and poor quality biological response. To address these issues, the 3D dynamic ProFlor scaffold promoting a fixation-free hernia defect obliteration has been developed as an alternative. Methods: The results of open inguinal hernia repair with the ProFlor approach compared with those of the Lichtenstein repair were evaluated. Results: In a time frame of 24 months, two cohorts of patients were enrolled, 95 in the ProFlor group and 93 in the Lichtenstein group. ProFlor demonstrated superior outcomes compared to the Lichtenstein technique, with shorter procedure times, decreased intraoperative complications, and lower rates of postoperative complications. Additionally, ProFlor provided enhanced postoperative pain relief, a faster return to daily activities, and no long-term discomfort. No chronic pain was reported in the ProFlor group and 11.8% reported chronic pain in the Lichtenstein group. Conclusions: The results highlight the need to reevaluate the conventional Lichtenstein approach and align it with recent scientific progress. Further consideration of the evolving understanding of inguinal pathophysiology and groin protrusion genesis is crucial for advancing surgical techniques.

Innovations in the treatment of cervical spine myelopathy – a comprehensive review

Introduction and aim of the study Myelopathy of the cervical spine is a set of symptoms resulting from compression of the spinal cord. There are many causes that may lead to this disorder, including degenerative changes, ligament ossification and tumors. Middle-aged and older patients usually suffer from it, and its diagnosis is expected to increase as the population gets older. Due to non-specific and initially mild symptoms, cervical myelopathy is usually diagnosed in later stages, often when the patient's fitness and independence are significantly impaired. The aim of the study is to present the current state of knowledge about myelopathy of the cervical spine, methods of its effective diagnosis, and to present available therapeutic options, because early diagnosis and optimal treatment enable patients to maintain their ability to work and improve their overall quality of life. Materials and methods The literature included in the PubMed, BioMed Central and Polish Medical Platform databases is searched by means of the words such as cervical myelopathy, decompression, spinal cord, corpectomy, discectomy. Quoted sources in selected works were also used. Conclusion Surgical treatment is the most effective method to improve the clinical condition of people suffering from cervical myelopathy. Both anterior and posterior approach surgeries are characterized by similar effectiveness, and the choice of a specific method depends on the patient's general condition, the degree of cervical lordosis, and the number of affected spinal segments. Due to the correct diagnosis of the disease and applying treatment, it is possible to slow down the progression of the disease and improve the quality of life of patients.

High Lumbar Spinal Fusion Rates Using Cellular Bone Allograft Irrespective of Surgical Approach.

Mounting evidence demonstrates a promising safety and efficacy profile for spinal fusion procedures using cellular bone allograft (CBA). However, limited data exists on fusion outcomes stratified by surgical approach. The current study investigates the effectiveness of CBA in lumbar spinal fusion by surgical approach (ie, anterior, lateral, and posterior approaches). Patients undergoing lumbar spinal fusion with CBA (Trinity Elite) were enrolled into a prospective, multi-center, open-label clinical study (NCT02969616). Fusion status was assessed by an independent review of dynamic radiographs and computed tomography images. Clinical outcome measures included quality of life (QoL; EQ5D), disability (Oswestry Disability Index [ODI]), and pain (visual analog scale [VAS]) for back pain and leg pain). Patient data extending to 24 months were analyzed in a post-hoc analysis. A total of 252 patients underwent interbody fusion (159 women; 93 men). Patients had a mean age of 58.3 years (SD 12.5), height of 168.3 cm (SD 10.2), and weight of 87.3 kg (SD 20.0) with a body mass index of 30.8 kg/m2 (SD 6.5). At 12 months, the overall fusion success rate for bridging bone was 98.5%; fusion success was 98.1%, 100.0%, and 97.9% for anterior, lateral, and posterior approaches, respectively. At 24 months, the overall fusion success rate for bridging bone was 98.9%; fusion success was 97.9%, 100.0%, and 98.8% for anterior, lateral, and posterior approaches, respectively. The surgical approach did not significantly impact fusion success. A significant (P < 0.0001) improvement in QoL, pain, and disability scores was also observed. Significant differences in the ODI, VAS, and EQ5D were observed between the treatment groups (P < 0.05). CBA represents an attractive alternative to autograft alone, reporting a high rate of successful fusion and clinical outcomes across various surgical approaches. The use of CBA for spinal fusion procedures, regardless of surgical approach, provides high rates of fusion with a favorable safety profile and improved patient outcomes. NCT02969616.

"White Cord Syndrome" as clinical manifestation of the spinal cord reperfusion syndrome: a systematic review of risk factors, treatments, and outcome.

Paralysis subsequent to spinal cord decompression in the cervical or thoracic region is infrequent, with White Cord Syndrome (WCS) being among its several causes. Due to WCS's infrequency, there exists a paucity of high-level evidence concerning its manifestations. Our primary objective is to systematically collate all documented WCS cases, discern prevalent risk and prognostic factors, appraise available treatment modalities, and evaluate patient outcomes. A systematic review was conducted following PRISMA guidelines. The search included PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria required studies to be written in English, be case reports, and contain data on clinical features, management, and treatment outcomes. Exclusion criteria excluded meta-analyses, reviews, editorials, letters, books, studies with insufficient clinical data, and studies not in English or with unavailable full texts. Grey literature was not actively pursued due to identification challenges, potentially introducing selection bias. Two authors independently evaluated papers based on criteria. Disagreements were resolved with a third author. Additionally, the included articles' references were screened for additional relevant articles. We found a total of 580 articles through our electronic search. After removing duplicates, 399 articles were screened. Out of the remaining 51 studies, 27 were included in the final quantitative analysis. The average age was 54 (3-79 years) with a male-to-female ratio of 2:1, 33% had OPLL, and Common medical histories were hypertension (30%), diabetes mellitus (20%), and previous ACDF surgery (8%). Of all Surgeries, 70% were done with a posterior approach and 30% with the anterior approach. 48% of cases used Intraoperative NeuroMonitoring(IONM), and Loss of Motor Evoked Potentials (MEP) occurred in 37% of cases. Patients received high-dose intravenous steroids. In 26% of cases, additional posterior cervical decompression was performed, and efforts were made to maintain mean arterial pressure above 85 mmHg in 37% of cases. Other medications were administered in 30% of cases. Over an average 26-week follow-up, 37% of patients had good recovery, 40% had partial recovery, and 23% showed no recovery. The average final Nurick grade was 3.2. WCS is a rare cause of postoperative neurological deficit following spinal cord decompression surgery. Risk factors for WCS include advanced age, extensive surgery, posterior approach for decompression, and the presence of OPLL. Treatment includes high-dose steroids, posterior cervical decompression, maintaining MAP over 85mmHg, rehabilitation, and sometimes neurotrophic drugs. Most patients can walk with or without assistance during follow-up, but around a quarter never regain neurological function. The only preoperative factor impacting outcomes is the preoperative neurological status (Nurick Grade).