Invasive Spinal Procedures Research Articles

Minimally Invasive Spine Surgery for Lumbar Decompression or Disc Herniation

ABSTRACTMany people experience low back pain caused by degenerative disease of the lumbar spine; this includes spinal stenosis, spondylolisthesis, disc degeneration, and disc herniation. Conservative management of degenerative disease, which includes physical therapy, lifestyle modifications, and medications, is the initial approach. If this approach fails, a surgical procedure may be the next step. Previously, open lumbar surgery would have been the planned procedure; today, minimally invasive spine surgery gives patients another choice. Perioperative nurses should understand how minimally invasive spine surgery differs from the open procedure, the steps involved during a minimally invasive procedure, the benefits of this type of procedure, and nursing considerations for patients undergoing minimally invasive spinal procedures.

A Clinical Review on Spinal Epidural Abscess: Epidemiology, Pathophysiology, Diagnosis, and Management for Emergency Medicine and Hospitalist Physicians.

Description Spinal epidural abscess (SEA), a critical surgical emergency, demands prompt recognition and intervention to prevent severe complications and fatalities. The incidence of SEA is notably increasing, particularly among individuals with diabetes, intravenous drug use, or a history of invasive spinal procedures. Although SEA can manifest through various clinical symptoms, the presence of its classic triad-back pain, fever, and neurological deficits-is noteworthy despite its occurrence in only 10% to 13% of cases. Identifying this triad is vital due to its high specificity for SEA, which is essential to guiding swift diagnostic and therapeutic actions in a condition where early intervention is critical. Magnetic resonance imaging is pivotal in diagnosing SEA, offering unmatched sensitivity and specificity compared to other imaging techniques. Immediate empirical antibiotic therapy and timely neurosurgical consultation, when required, form the foundation of SEA treatment. The prognosis significantly depends on the patient's initial neurological status, underlying health conditions, and the timeliness of their presentation, diagnosis, and treatment initiation. Given the complexity of SEA and the high risk of diagnostic delays, managing this condition involves substantial medicolegal considerations. Enhanced comprehension of SEA is imperative for improving patient outcomes and reducing health care resource burdens. Prompt and accurate diagnosis and appropriate interventions are essential for effectively managing this urgent condition.

Advanced Visualization in Minimally Invasive Spine Surgery: The Ergonomics, Economics, and Evolution of Camera-Based Tubes and Retractors.

Tubular spine surgery has emerged as a hallmark of minimally invasive spine (MIS) procedures. In recent years, thanks to technological advances, tubular dilators and retractors have been integrated with digital cameras to allow for ergonomic, high-definition visualization of the surgical field. To detail the evolution, ergonomics, economics, and outcomes of camera-based tubular spine surgery, spanning the origins of MIS tubular techniques to the current use of operative microscopes and tube-mounted digital cameras (TMDCs). This is a narrative review of studies examining the evolution of tubular spine surgery as well as its most recent advances, with a particular emphasis on advances in visualization of the surgical field. Despite early resistance to tubular techniques due to a steep learning curve, minimally invasive tubular approaches are being increasingly adopted by the mainstream spine surgical community, which has resulted in an expansion of both indications and procedural modalities. This can largely be attributed to the increased quality of visualization, as evidenced by improvements in microscopes as well as emerging technologies like exoscopes and TMDCs. Tubular MIS procedures have also achieved superior efficacy compared with open surgical approaches for the treatment of several spinal pathologies while allowing for improved ergonomics, which may have lasting consequences on surgeon longevity. Advances in visualization technologies have allowed tubular surgery to become an effective, ergonomic, and muscle-sparing alternative to open spine surgery. Further research is necessary to quantify the true costs and outcomes associated with nascent TMDC technology. This work elucidates developments in visualization for tubular spine surgery.

A Biomechanics-Aware Robot-Assisted Steerable Drilling Framework for Minimally Invasive Spinal Fixation Procedures.

In this paper, we propose a novel biomechanics-aware robot-assisted steerable drilling framework with the goal of addressing common complications of spinal fixation procedures occurring due to the rigidity of drilling instruments and implants. This framework is composed of two main unique modules to design a robotic system including (i) a Patient-Specific Biomechanics-aware Trajectory Selection Module used to analyze the stress and strain distribution along an implanted pedicle screw in a generic drilling trajectory (linear and/or curved) and obtain an optimal trajectory; and (ii) a complementary semi-autonomous robotic drilling module that consists of a novel Concentric Tube Steerable Drilling Robot (CT-SDR) integrated with a seven degree-of-freedom robotic manipulator. This semi-autonomous robot-assisted steerable drilling system follows a multi-step drilling procedure to accurately and reliably execute the optimal hybrid drilling trajectory (HDT) obtained by the Trajectory Selection Module. Performance of the proposed framework has been thoroughly analyzed on simulated bone materials by drilling various trajectories obtained from the finite element-based Selection Module using Quantitative Computed Tomography (QCT) scans of a real patient's vertebra.

The Safety and Effectiveness of Orthobiologic Injections for Discogenic Chronic Low Back Pain: A Multicenter Prospective, Crossover, Randomized Controlled Trial with 12 Months Follow-up

BACKGROUND: Chronic low back pain is one of the most common causes of disability, affecting more than 600 million people worldwide with major social and economic costs. Current treatment options include conservative, surgical, and minimally invasive interventional treatment approaches. Novel therapeutic treatment options continue to develop, targeting the biological cascades involved in the degenerative processes to prevent invasive spinal surgical procedures. Both intradiscal platelet-rich plasma (PRP) and bone marrow concentrate (BMC) applications have been introduced as promising regenerative treatment procedures. OBJECTIVES: The primary objective of this study is to assess the safety and effectiveness of an orthobiologic intradiscal injection, PRP or BMC, when compared to control patients. The secondary objectives are to measure: patient satisfaction and incidence of hospitalization, emergency room visit and spine surgery at predetermined follow-up intervals. STUDY DESIGN: A multicenter, prospective, crossover, randomized, controlled trial. SETTING: Comprehensive Spine and Sports Center and participating centers. METHODS: Forty patients were randomized into saline trigger point injection, intradiscal PRP, or BMC. Follow-up was 1, 3, 6, and 12 months posttreatment. Placebo patients were randomized to PRP and BMC injection if < 50% decrease in numeric rating scale (NRS) scores in 3 months, while PRP and BMC patients to the other active group if < 50% decrease in NRS scores in 6 months. RESULTS: Both PRP and BMC demonstrated statistically significant improvement in pain and function. All the placebo patients reported < 50% pain relief and crossed to the active arm. None of the patients had any adverse effects, hospitalization, or surgery up to 12 months posttreatment. LIMITATIONS: The limitations of our study were the small number of patients and open-label nature of the study. CONCLUSION: This is the only human lumbar disc study that evaluates both PRP and BMC in the same study and compares it to placebo. PRP and BMC were found to be superior to placebo in improving pain and function; however, larger randomized clinical trials are needed to answer further questions on the comparative effectiveness of various biologics as well as to identify outcome differences specific to disc pathology. KEY WORDS: Low back pain, disc, mesenchymal stem cells, platelet-rich plasma, biologics, back pain, degenerative disc disease, intradiscal biologics, lumbar spine, low back, regenerative treatment spine, radiculopathy

Enhancing Minimally Invasive Spinal Procedures Through Computer Vision and Augmented Reality Techniques

Enhancing Minimally Invasive Spinal Procedures Through Computer Vision and Augmented Reality Techniques

Predicting major complications and discharge disposition after adult spinal deformity surgery

Background ContextSeveral spine-specific comorbidity indices are available to help risk-stratify patients before they undergo invasive spine procedures. Studies of patients with adult spinal deformity (ASD) typically use the Charlson Comorbidity Index (CCI), which is not specific to spine patients. PurposeTo compare the CCI with the Seattle Spine Score (SSS), the Adult Spinal Deformity-Comorbidity Score (ASD-CS), and the Modified 5-Item Frailty Index (mFI-5) and identify which tool more accurately predicted major perioperative complications and discharge disposition after ASD surgery. Study Design/SettingRetrospective review. Patient SamplePatients with ASD who underwent spinal arthrodesis of at least four levels at a single institution. Outcome MeasuresSelf-reported measures include SSS, ASD-CS, and mFI-5. Functional measures include the CCI. MethodsWe retrospectively reviewed records of 164 patients with ASD who underwent spinal arthrodesis of ≥ four levels from January 2008 to February 2018 at our U.S. academic tertiary care center and who had available Oswestry Disability Index values. To assess the predictive ability of the comorbidity indices, we created five multivariable logistic regression models, with the presence of major complications and discharge disposition (home or inpatient rehabilitation) as the primary outcome variables. The base model used validated demographic and surgical factors that were predictors of complications and outcomes in those with ASD and within the broader spinal literature. The other four models used the base model along with one of the four indices. The predictive ability of each model was compared using goodness-of-fit testing, with higher pseudo-R2 values and lower Akaike information criteria (AIC) values indicating better model fit. ResultsThirty-one patients (19%) experienced major perioperative complications, and 68 (42%) were discharged to inpatient rehabilitation facilities (vs home). The model using the SSS had the highest pseudo-R2 value and lowest AIC value for both major complications and discharge disposition. The mFI-5 had a similar predictive ability. The models using the CCI and ASD-CS were weaker predictors. ConclusionsCompared with the CCI and the ASD-CS, the SSS and the mFI-5 were strong predictors of major complications and discharge disposition after ASD surgery. These results suggest that the SSS and the mFI-5 are preferable to the CCI for clinical risk stratification and outcomes research in patients undergoing ASD surgery.

Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored.

Patients with postoperative spinal epidural hematomas (pSEH) typically require emergency treatment to avoid paralysis; these hematomas should not be ignored. pSEH patients need to undergo immediate MR studies to document the location/extent of their hematomas, and emergent surgical decompression with/ without fusion if warranted. The frequencies of symptomatic pSEH ranged in various series from 0.1%-4.46%. Major predisposing factors included; perioperative/postoperative coagulation abnormalities/disorders, multilevel spine surgeries, previous spine surgery, and intraoperative cerebrospinal fluid (CSF) leaks. For surgery at all spinal levels, one study observed pSEH developed within an average of 2.7 postoperative hours. Another series found 100% of cervical/thoracic, and 50% of lumbar pSEH were symptomatic within 24 postoperative hrs., while a third series noted a 24-48 postoperative window for pSEH to develop. Early recognition of postoperative symptoms/signs of pSEH, warrant immediate MR examinations to diagnose the local/extent of hemorrhages. Subsequent emergent spinal decompressions/fusions are critical to limit/avert permanent postoperative neurological deficits. Additionally, patients undergoing open or minimally invasive spinal procedures where pSEH are suspected, warrant immediate postoperative MR studies. Patients undergoing spinal surgery at any level typically become symptomatic from pSEH within 2.7 to 24 postoperative hours. Early recognition of new neurological deficits, immediate MR studies, and emergent surgery (i.e., if indicated) should limit/minimize postoperative neurological sequelae. Thus, pSEH should be treated, not ignored.

Trends in usage of navigation and robotic assistance in elective spine surgeries: a study of 105,212 cases from 2007 to 2015.

Identify trends of navigation and robotic-assisted elective spine surgeries. Elective spine surgery patients between 2007 and 2015 in the Nationwide Inpatient Sample (NIS) were isolated by ICD-9 codes for Navigation [Nav] or Robotic [Rob]-Assisted surgery. Basic demographics and surgical variables were identified via chi-squared and t tests. Each system was analyzed from 2007 to 2015 for trends in usage. Included 3,759,751 patients: 100,488 Nav; 4724 Rob. Nav were younger (56.7 vs 62.7years), had lower comorbidity index (1.8 vs 6.2, all p < 0.05), more decompressions (79.5 vs 42.6%) and more fusions (60.3 vs 52.6%) than Rob. From 2007 to 2015, incidence of complication increased for Nav (from 5.8 to 21.7%) and Rob (from 3.3 to 18.4%) as well as 2-3 level fusions (from 50.4 to 52.5%) and (from 1.3 to 3.2%); respectively. Invasiveness increased for both (Rob: from 1.7 to 2.2; Nav: from 3.7 to 4.6). Posterior approaches (from 27.4 to 41.3%), osteotomies (from 4 to 7%), and fusions (from 40.9 to 54.2%) increased in Rob. Anterior approach for Rob decreased from 14.9 to 14.4%. Nav increased posterior (from 51.5% to 63.9%) and anterior approaches (from 16.4 to 19.2%) with an increase in osteotomies (from 2.1 to 2.7%) and decreased decompressions (from 73.6 to 63.2%). From 2007 to 2015, robotic and navigation systems have been performed on increasingly invasive spine procedures. Robotic systems have shifted from anterior to posterior approaches, whereas navigation computer-assisted procedures have decreased in rates of usage for decompression procedures.

Thoracic costotransversectomy characteristics and 90-day complications vary based on underlying diagnosis.

Thoracic costotransversectomies are among the most invasive spinal procedures performed and are associated with unanticipated medical and surgical complications. Few studies have specifically assessed medical and surgical complications after a thoracic corpectomy via a costotransversectomy approach (TCT) or compared complications between different diagnoses. The purpose of this study was to describe the differences in operative characteristics and rates of 90-day surgical and medical complications in patients undergoing TCTs based on underlying diagnosis. A retrospective chart review of 123 consecutive patients who underwent TCTs at a single academic referral center over a 10-year period was conducted. Surgical indication, corpectomy levels, intraoperative dural tears, pleural injuries, neurological injuries, 90-day mortality, 90-day reoperations, and hospital-based medical complications were evaluated. One hundred twenty-three patients underwent a TCT, including 35 for infection, 42 for malignancy, 23 for trauma, and 23 for deformity. Fifty-nine patients (48.0%) had at least one medical or 90-day operative complication, with 22 patients (17.9%) having two or more complications. Patients with a diagnosis of infection were more likely to undergo two-level corpectomies (80% vs 26.1%, p < 0.0005). Patients with a diagnosis of malignancy had significantly higher 90-day mortality (19.0% vs 4.9%, p = 0.022) and were more likely to undergo three-level corpectomies (9.5% vs 3.7%, p = 0.002) and upper thoracic (T1-4) corpectomies (37.9% vs 12.4%, p = 0.001), and sustain a pleural injury (14.3% vs 2.5%, p = 0.019). Ninety-day reoperation rates (p = 0.970), postoperative ventilator days (p = 0.224), intensive care unit stays (p = 0.350), hospital lengths of stay (p = 0.094), neurological injuries (p = 0.338), and dural tears (p = 0.794) did not significantly vary between the different groups. Nearly half of the patients undergoing a TCT will experience an unanticipated short-term complication related to the procedure. Short-term complications may vary with the underlying patient diagnosis.

Incidence and treatment trends of infectious spondylodiscitis in South Korea: A nationwide population-based study.

The incidence of infectious spondylodiscitis (IS) has increased in recent years due to an increase in the numbers of older patients with chronic diseases, as well as patients with immunocompromise, steroid use, drug abuse, invasive spinal procedures, and spinal surgeries. However, research focusing on IS in the general population is lacking. This study investigated the incidence and treatment trends of IS in South Korea using data obtained from the Health Insurance Review and Assessment Service. A total of 169,244 patients (mean age: 58.0 years) diagnosed from 2010 to 2019 were included in the study. A total of 10,991 cases were reported in 2010 and 18,533 cases in 2019. Hence, there was a 1.5-fold increase in incidence rate per 100,000 people from 22.90 in 2010 to 35.79 in 2019 (P < 0.05). The incidence rate of pyogenic spondylodiscitis per 100,000 people increased from 15.35 in 2010 to 33.75 in 2019, and that of tuberculous spondylodiscitis decreased from 7.55 in 2010 to 2.04 in 2019 (P < 0.05, respectively). Elderly individuals ≥ 60 years of age accounted for 47.6% (80,578 patients) of all cases of IS. The proportion of patients who received conservative treatment increased from 82.4% in 2010 to 85.8% in 2019, while that of patients receiving surgical treatment decreased from 17.6% to 14.2% (P < 0.05, respectively). Among surgical treatments, the proportions of corpectomy and anterior fusion declined, while proportion of incision and drainage increased (P < 0.05, respectively). The total healthcare costs increased 2.9-fold from $29,821,391.65 in 2010 to $86,815,775.81 in 2019 with a significant increase in the ratio to gross domestic product. Hence, this population-based cohort study demonstrated that the incidence rate of IS has increased in South Korea. The conservative treatment has increased, while the surgical treatment has decreased. The socioeconomic burden of IS has increased rapidly.

Posterior Vertebral Pedicular Tethering for the Treatment of Idiopathic Adolescent Scoliosis.

Over the last decade, there has been a new wave of interest in non-fusion techniques for the treatment of adolescent idiopathic scoliosis. These are not new techniques, as they were first published and presented in the late 1950s, using compression of the convexity or distraction of the concavity of the main curvature. More recently, anterior vertebral body tethering has raised great interest, as although it is a major procedure through the child's chest, it seems appropriate for the thoracic curves. The main objective of this article is to describe Posterior Vertebral Pedicular Tethering (PVPT) as a "new" technique performed as a less invasive spinal procedure for the treatment of certain thoracolumbar and lumbar scoliosis in growing adolescents. It is an alternative growth modulation technique appropriate for thoracolumbar and lumbar curvatures where we observe reduction of the three plane deformity of idiopathic scoliosis in adolescents.

Anterior Endoscopic Cervical Discectomy: Surgical Technique and Literature Review.

The conventional surgical technique for radiculopathy with cervical disc herniation (CDH) is anterior cervical discectomy and fusion, with a good clinical outcome and fusion rate. However, significant perioperative morbidity related to extensive surgical exposure has been reported. Therefore, anterior endoscopic cervical discectomy (AECD) using a working channel endoscope has been developed to reduce surgical complications and tissue damage. The objective of this study was to describe a cutting-edge technique for AECD of soft CDH. The primary indication is cervical radiculopathy with or without axial neck pain due to soft CDH. The surgical procedure consists of 2 parts: (1) a safe anterior percutaneous approach under fluoroscopic control and (2) selective endoscopic discectomy and foraminal decompression using specialized mechanical tools under endoscopic visualization. The clinical outcomes are comparable to those of conventional surgery and show the benefits of minimally invasive spine procedure. Perioperative data revealed typical minimalism, including reduced muscle damage, blood loss, operative time, and recovery time. With technical advancements in surgical instruments and optics, AECD will become more practical and safer. AECD is effective in selected CDH cases with cervical radiculopathy. However, high-quality clinical studies are needed to verify the effectiveness of this endoscopic cervical spinal procedure.

Minimally invasive microsurgical decompression of the lumbar spine using a novel robotised digital microscope: A preliminary experience.

The operative microscope (OM) represents, to date, the standard for neurosurgical procedures. However, new technologies have been proposed during the latest years to overcome its limitations, from high-quality exoscopes to complex robotised visualisation systems. We report our preliminary experience with a novel digital robotised microscope, the BHS RoboticScope (RS), for minimally invasive spinal surgery. We employed the RS in five consecutive patients who underwent bilateral lumbar spine decompression through a monolateral approach. Patient outcomes, device technical characteristics and the surgeon's personal perspectives have been evaluated. No complications occurred. All procedures were concluded without switching to the microscope. Image quality, lightning, depth perception and freedom of movement were judged satisfactory as compared to the standard microscope. The easy maneuverability and the high quality of pictures provided by the RS device improve the surgeon's comfort in deep fields, representing an effective option for minimally invasive spinal procedures.

Reduction in Radiation Exposure in Minimally Invasive Pedicle Screw Placement Using a Tubular Retractor: A Pilot Study

Percutaneous pedicle screw (PPS) placement is a minimally invasive spinal procedure that has been rapidly adopted over the last decade. However, PPS placement has elicited fear of increased radiation exposure from some surgeons, medical staff, and patients. This is because PPS placement is performed using a K-wire, and the operator must perform K-wire insertion into the pedicle under fluoroscopy. In order to prevent erroneous insertion, there are many occasions when direct insertion is required during radiation exposure, and the amount of radiation exposure to hands and fingers in particular increases. Although these problems are being addressed by navigation systems, these systems are still expensive and not widely available. Attempts have been made to address this situation using instrumentation commonly used in spinal surgery. First, it was considered to visualize anatomical bone markers using a tubular retractor and a microscope. In addition, the use of a self-drilling pin was adopted to locate the pedicle in a narrower field of view. Based on these considerations, a minimally invasive and highly accurate pedicle screw placement technique was developed while avoiding direct radiation exposure. This study evaluated radiation exposure and accuracy of pedicle screw placement using this new procedure in one-level, minimally invasive, transforaminal lumbar interbody fusion (MIS-TLIF). Data were collected retrospectively to review pedicle screw placement in single-level MIS TLIFs using a tubular retractor under a microscope. The total fluoroscopy time, radiation dose, and screw placement accuracy were reviewed. Extension of operating time was also evaluated. Twenty-four patients underwent single-level MIS TLIFs, with placement of 96 pedicle screws. There were 15 females and 9 males, with an average age of 64.8 years and a mean body mass index of 25.5 kg/m2. The mean operating time was 201.8 min. The mean fluoroscopic time was 26.8 s. The mean radiation dose of the area dose product was 0.0706 mGy∗m2. The mean radiation dose of air kerma was 6.0 mGy. The mean radiation dose of the entrance skin dose was 11.31 mGy. Postoperative computed tomography scans demonstrated 93 pedicle screws confined to the pedicle (97%) and three pedicle screw breaches (3.2%; two lateral, one medial). A patient with screw deviation of the medial pedicle wall developed right-foot numbness necessitating reoperation. There were no complications after reoperation. The average added time with this combined procedure was 39 min (range 16-69 min) per patient. This novel pedicle screw insertion technique compares favorably with other reports in terms of radiation exposure reduction and accuracy and is also useful from the viewpoint of avoiding direct radiation exposure to hands and fingers. It is economical because it uses existing spinal surgical instrumentation.

Multicenter Prospective Study of Lateral Lumbar Interbody Fusions Using Bioactive Porous Titanium Spacers without Bone Grafts.

Prospective multicenter clinical study. To evaluate the efficacy of bioactive surface treatment for porous titanium spacers without bone graft for lateral lumbar interbody fusion (LLIF) through clinical and radiological examinations. LLIF is a minimally invasive spinal fusion procedure. To achieve bony union, a substantial volume of grafted bone is typically packed into the cage; however, this is related to donor site morbidities-one of the disadvantages of LLIF. For this prospective multicenter study, 40 patients were followed up through radiologic and clinical examinations for at least 1 year postoperatively. All surgical procedures were either single- or double-level LLIF using bioactive porous titanium spacers without bone grafts. Four patients were excluded from the study owing to aggravation from other comorbidities. Another 36 patients, including 26 and 10 with single- and double-level LLIFs, respectively, participated in the follow-up. The mean age at the time of surgery was 63.7 years. The mean operating time was 50.5 minutes per level. The mean estimated intraoperative blood loss was 11.6 mL per level. Clinical scores improved in all cases and were maintained throughout the follow-up period. The intervertebral bony union rates were 67.4% and 84.8% at 6 and 12 months, respectively. Endplate cyst signs were observed in 13.0% and 8.7% of patients at 6 and 12 months, respectively. Fused segmental angles were maintained throughout the follow-up period, indicating no cage subsidence. Single- and double-level LLIFs using bioactive porous titanium spacers without bone grafts were found to be minimally invasive, resulting in clinical and imaging results comparable with conventional procedures. Therefore, this type of implant may be an option for minimally invasive spinal fusion surgery.

Letter: Global Neurosurgery: The Pakistani Perspective.

Letter: Global Neurosurgery: The Pakistani Perspective.

Omission of tranexamic acid does not increase the amount of perioperative blood transfusions in patients undergoing one-level spinal fusion surgery: a retrospective propensity score-matched noninferiority study

IntroductionApplication of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions.MethodsWe conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins (delta).ResultsAfter propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA–TXA) of intraoperative transfusion was − 4.7% (CI 90% − 13.62 to 4.32%), and omitting TXA was noninferior (delta = pm 10%). The mean intergroup difference in transfused volume (no TXA–TXA) was − 23.26 ml intraoperatively (CI 90% − 69.34 to 22.83 ml) and − 46.51 ml overall (CI 90% − 181.12 to 88.1 ml), respectively, suggesting equivalence of TXA omission (delta = pm 300 ml). The hemoglobin decline between both groups was also equivalent (with delta = pm 1 g/dl) both on the first postoperative day (Delta Delta Hb = 0.02 g/dl, CI 90% − 0.53 to 0.56 g/dl) and at discharge (Delta Delta Hb = − 0.29 g/dl, CI 90% − 0.89 to 0.31 g/dl).ConclusionWe demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.

Spine Surgery: A Narrative Review About Recent Updates and Future Directions

Background: Advances in case selection, operative methods, and postsurgical care have facilitated spine surgeons to manage complex spine cases with short operative times, decreased hospital stay and improved outcomes. Methods: This is an overview of recent updates and future directions in the field of spine surgery. All the articles were obtained through a literature review on PubMed. Results: Minimally invasive spine procedures like Endoscopic spine surgeries, Oblique Lumbar Interbody Fusion, use of retractor systems, etc. are emerging in rapidly in modern world. Fusion surgeries are associated with adjacent level disease hence, motion preservation surgeries that mimic the natural biomechanics of the spine are being explored as alternatives. In view of risks to vital structures, nerve injury due to mal-positioning, etc.; robotic spine surgery has paved a way to allow surgeons real-time procedural manipulation along with instrument control, real-scale magnification. Many high-impact discoveries in cancer research, stereotactic radiotherapy, newer combinations of chemotherapy, and tumor-specific antibodies have increased our understanding of spine oncology. Past two decades have seen many advancements in treatment of spine deformities right from initial radiographic assessment, surgical planning to postoperative care. Conclusion: All in all, all stakeholders in innovation including the industry, scientists and surgeons must work in an open and honest collaboration to benefit the future patients and continue the evolution in Spine Surgery. Keywords: Spine surgery, Recent updates, Minimally invasive surgery, Artificial disc replacement, Artificial intelligence.

Comparison of Radiation Exposure of AIRO Intraoperative CT with C-Arm Fluoroscopy during Posterior Lumbar Interbody Fusion

Navigation systems used during minimally invasive spine procedures have evolved from uniplanar, two-dimensional C-arm fluoroscopy to multiplanar, 3D intraoperative computed tomography (iCT). In this study, the radiation exposure to the patient and operating room staff in posterior intervertebral lumbar fusion procedures is compared between iCT and C-arm fluoroscopy. The effective dose of the surgeon, operating nurse, and anesthesiologist was measured during surgery with personal dosimeters, and the effective dose of the patient was measured with GafchromicTM films. The time efficiency of the procedure was evaluated by recording the duration of pedicle screw fixation and the duration of the total surgery time. A total of 75 patients participated in the study; 30 patients had surgery guided by iCT and 45 by C-arm fluoroscopy. The radiation dose of the surgeon, the operating nurse, and the anesthesiologist was thirteen fold lower with surgeries assisted by iCT compared to C-arm fluoroscopy. In contrast, the effective dose of the patient significantly increased with iCT. Using iCT, radiation exposure of the operating room staff can be significantly reduced. iCT increases the effective dose of the patient and prolongs the operative time.