Posterior Approach Research Articles

Comparative study of the prevalence of organ injury in placenta accreta spectrum disorder between posterior colpotomy and conventional peripartum hysterectomies at a single referral center in southern Thailand.

To compare the prevalence of adjacent organ injury in placenta accreta spectrum disorder (PAS) between the posterior colpotomy approach and conventional peripartum hysterectomy. This retrospective study analyzed the data of pregnant women diagnosed with PAS who underwent peripartum hysterectomy at Songklanagarind Hospital between January 2006 and December 2021. The patients were divided into two groups: posterior colpotomy and conventional approaches. The characteristics and surgical and obstetric outcomes were compared. Univariate and multivariate logistic regression was used to identify factors and risk of organ injury. Among 174 patients, 64 underwent conventional peripartum hysterectomy, and 110 underwent the posterior colpotomy approach. The overall incidence of adjacent organ injury was 17.82%. Organ injury prevalence was lower in the posterior colpotomy group (10%) than in the conventional group (31.25%), with no difference in operative time. Multivariate analysis showed that posterior colpotomy reduced adjacent organ injury (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.06-0.54, P = 0.002). Placenta percreta was associated with increased injury risk (OR 6.83, 95% CI 2.53-18.44, P < 0.002). Subgroup analysis showed that the posterior approach reduced bladder injury in placenta increta (OR 0.14, 95% CI 0.04-0.57, P = 0.003) and percreta (OR 0.19, 95% CI 0.05-0.77, P = 0.017). Compared with conventional peripartum hysterectomy, the posterior colpotomy approach in patients with PAS reduced the risk of adjacent organ injury, particularly for placenta increta and percreta. This technique should be considered in PAS cases, but further investigations with a prospective study design are needed.

Incidence, Risk Factors, and Functional Outcomes of Symptomatic Postoperative Spinal Epidural Hematoma: Case-Control Study.

Symptomatic postoperative spinal epidural hematomas (PEDHs) are rare complications with significant implications on patients' functional outcomes. Strategies for PEDH prevention are poorly understood. This study sought to evaluate preoperative and intraoperative variables predicting the risk of PEDH, and patients' functional outcomes after PEDH evacuation. This is a single institution study of all PEDH cases requiring a reoperation and matched controls over six year period. The incidence of PEDH was calculated by region and operative technique. The preoperative and intraoperative parameters of 40 cases and 40 matched controls were compared. 5,941 spine surgeries and 40 symptomatic PEDH cases requiring reoperation were identified (0.67% overall incidence). The highest incidence of PEDH was observed after minimally invasive lumbar laminectomimes. Higher preoperative diastolic blood pressure was a risk factor for PEDH. Of the 17 PEDH cases that had a drain placed at the time of index surgery, 8 patients (47%) still had the drain in place at the time of diagnosis of PEDH. Among the posterior index approaches, 18 cases (51.43%), one cervicothoracic and seventeen lumbar, did not develop paresis at the time of PEDH diagnosis. 17 cases (48.57%), nine cervicothoracic and eight lumbar, developed paresis. Ten of the patients with paresis had complete resolution of motor weakness, while seven never achieved complete resolution. While the incidence of PEDH was below one percent, nearly half of the patients developed motor weakness as a presenting symptom and a third of the patients never had resolution of the weakness.

Early Postoperative Outcomes of the Direct Superior Approach versus the Posterior Approach in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background/Objectives: The direct superior approach (DSA) is a tissue-sparing alternative to the traditional posterior approach (PA) in total hip arthroplasty (THA), potentially offering improved recovery and fewer complications. This study compares perioperative parameters, radiological and functional outcomes, and complications between the DSA and the PA in primary THA. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. Databases searched included MEDLINE/PubMed, Cochrane Library, Embase, and Scopus. Studies comparing the DSA and the PA in primary THA were included based on predefined criteria. Data extraction and quality assessment were performed independently by two authors. Statistical analyses included calculating standardized mean differences (SMD), odds ratios (OR), and 95% confidence intervals (CI). Heterogeneity was assessed using the χ2 test, I2 statistics, and sensitivity analyses. Results: Out of 126 identified articles, 10 studies were included, which encompassed 28,063 patients (DSA: 1464; PA: 26,599). Significant advantages of the DSA over the PA were observed in blood loss (SMD −0.26, p &lt; 0.01), transfusion rate (OR 0.59, p = 0.03), length of stay (SMD −0.59, p &lt; 0.01), discharge to home rates (OR 2.32, p &lt; 0.01), and incision length (SMD −2.75, p &lt; 0.01). No significant differences were found in radiological outcomes or most functional scores, although the DSA showed higher Harris Hip Scores at 1 month (SMD 0.77, p &lt; 0.01). Conclusions: The DSA offers significant perioperative advantages over the PA, including reduced blood loss, transfusion rates, LOS, incision length, and improved early functional recovery with higher discharge to home rates. Comparable complication rates and radiological outcomes support the DSA’s safety and efficacy for quicker recovery in THA.

Stress Maneuver for Basilar Invagination Reduction: A Technical Report

BackgroundBasilar invagination (BI) is a prolapse of the odontoid process cranially and posteriorly towards the foramen magnum. Several surgical treatment options are available for this condition. Herein, we describe a stress maneuver technique for BI reduction using a single-stage posterior approach. MethodsWe described the case of a 56-year-old male diagnosed with type A BI and brainstem compression, who was treated with posterior fossa decompression and occipitocervical fusion. The BI was reduced intraoperatively using a stress maneuver, and cranial traction or atlantoaxial joint distraction was not necessary. ResultsPostoperative imaging revealed a reduction of the odontoid process and adequate brainstem decompression. The patient showed progressive improvement of his symptoms. ConclusionIn selected cases, stress maneuvers for BI reduction can be a less morbid, easier, and replicable option within the already existing technical arsenal.

STATE OF HAEMODYNAMICS AND OXYGEN BUDGET IN THE PERIOPERATIVE PERIOD IN PATIENTS WITH OSTEOARTHRITIS AND CONCOMITANT CARDIAC PATHOLOGY DURING TOTAL HIP ARTHROPLASTY SURGERY DEPENDING ON THE TYPE OF SURGICAL ACCESS

Summary. Aim. To compare the hemodynamic status and oxygen budget in patients with osteoarthritis and comorbid cardiac pathology during total hip arthroplasty, based on the type of surgical approach used. Materials and Methods. The study analyzed the treatment outcomes of 90 patients with stage 3-4 osteoarthritis of the hip who underwent total cemented hip arthroplasty. All patients were divided into two groups according to the surgical approach (traditional posterior or modified posterior). The study was conducted at the following stages: before surgery, immediately after surgery, 24 hours post-surgery, and one week after surgery. The following parameters were recorded: hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and central venous pressure) and oxygen budget parameters (hemoglobin (Hb), lactate, hematocrit (Ht), oxygen saturation of hemoglobin in arterial and venous blood (SaO2 and SvO2), partial pressure of oxygen in arterial and venous blood (paO2 and pvO2)). Based on these data, the following indices were calculated: left ventricular ejection fraction (LVEF), cardiac index (CI); oxygen content in arterial and venous blood (CaO2 and CvO2), arteriovenous oxygen content difference (C(a-v)O2), oxygen transport (TO2), oxygen consumption (VO2); systemic perfusion pressure (SPP), blood flow power (BFP), oxygen reserve (OR), and circulatory reserve (CR). Results. The use of the modified posterior approach positively influenced hemodynamic parameters. After the surgery and on the 7th day post-surgery, SPP was significantly lower with the modified posterior approach. The CI was also significantly affected by the modified posterior approach. Throughout the study, except for the first stage, CI was significantly higher when using the modified posterior approach. LVEF increased significantly with both approaches, but on the 7th day post-surgery, it was significantly higher in the second group. BFP did not statistically differ between the two groups throughout the study, but its energy efficiency was lower, primarily due to the arteriovenous oxygen content difference (C(a-v)O2). C(a-v)O2 was the same before surgery for both approaches. At subsequent stages of the study, the differences between the groups increased, and on the 7th day, they were the most significant, with C(a-v)O2 being lower after using the modified posterior approach. The energy efficiency of blood flow was assessed by calculating OR and CR. Both indicators were significantly higher during the study, except at the preoperative stage, when using the modified posterior approach. Conclusions. Our study clearly demonstrates the benefits of implementing the modified posterior approach in total hip arthroplasty for patients with osteoarthritis and comorbid cardiac pathology. This approach improves hemodynamic and oxygen budget parameters compared to the traditional approach, which can significantly impact treatment outcomes for patients with cardiac comorbidity and reduce the number of postoperative complications.

A clinical study on the effect of axillary approach in the treatment of Ideberg type II scapular glenoid fractures

BackgroundDue to its deep position and complex surrounding anatomy, the scapular glenoid fracture was relatively difficult to deal with especially in cases of severe fracture displacement. Improper treatment may lead to failure of internal fixation and poor fracture reduction, severely affecting the function of the shoulder joint. Inferior scapular glenoid fracture was Ideberg type II fracture, and posterior approach was commonly used to deal with inferior scapular glenoid fracture. However, there are shortcomings of above surgical approach for inferior scapular glenoid fracture, such as insufficient exposure of the operative field, significant trauma, and limited screw fixation direction. This study adopts the axillary approach for surgery, which has certain advantages.MethodsThe clinical data of 13 patients with Ideberg type II scapular glenoid fractures treated from December 2018 to January 2024 were retrospectively analyzed. There were 8 males and 5 females, with an age range of 19 to 58 years and an average age of 38 years. The causes of injury were falls from heights in 7 cases and car accidents in 6 cases. There were 5 cases on the left side and 8 cases on the right side. The time from injury to surgery was 2 to 11 days, with an average of 5.5 days. All cases underwent open reduction and internal fixation through the axillary approach. Postoperative X-ray and CT three-dimensional reconstruction were performed on the next day to evaluate the fracture reduction and the position of internal fixation. During the follow-up period, follow-up examinations were performed every two months in the first half of the year and every three months in the second half. CT scans were performed during the examinations to assess the glenohumeral joint congruence, fracture healing, and position of internal fixation. The shoulder joint function was evaluated at 6 months postoperatively according to the Constant-Murley value score.ResultsThe patients all achieved primary wound healing after surgery, without any complications such as infection or nerve injury. Re-examination on the second day after operation, all fractures obtained excellent reduction, and the internal fixation was in excellent position, and no screw was found to enter the joint cavity. All patients in this group were followed up for 6 to 25 months, with an average follow-up time of 11.7 months. All fractures were bony unioned, and the healing time ranged from 4 to 6 months, with an average healing time of 4.8 months. At 6-month follow-up, according to the Constant-Murley score, 11 cases were excellent and 2 case was good.ConclusionOpen reduction and internal fixation through the axillary approach is an feasible and safe surgical method for the treatment in scapular Ideberg type II glenoid fractures with less stripping of soft tissue, minimal surgical trauma, and the incision is concealed and beautiful. It can provide a strong internal fixation for fractures, so patients can perform functional exercise early after operation, and the clinical results is satisfactory.

Analysis of Failed Posterior Fossa Decompression and an Effective Revision Surgery in Patients with Basilar Invagination and Atlantoaxial Dislocation.

The objective of this study was to analyze failed posterior fossa decompression (PFD) in patients with basilar invagination and atlantoaxial dislocation (BI-AAD). Revision surgery in these patients is challenging and has been rarely reported. In addition, the anatomical variations of the vertebral artery increase the risk of revision surgery. Here, we introduce the implementation of a new type of one-stage posterior revision surgery, whose difficulties and effects are summarized. A total of 21 patients with BI-AAD who underwent PFD were retrospectively analyzed in our center from November 2017 to April 2021. The revision surgery in all patients was performed through the posterior approach. The Japanese Orthopaedic Association (JOA) score and the Short Term 12 (SF-12) score were employed to evaluate the clinical symptoms and health status. The distance from the tip of the odontoid to Chamberlain's line (DCL), the atlantodental interval (ADI), the clivus-canal angle (CCA), the diameter of the subarachnoid space (DSS), and the craniovertebral junction triangular area (CTA) were assessed radiographically. The pre- and postoperative results were compared by paired t test. The data of 21 consecutive patients were reviewed, with an average follow-up period of 28 ± 14 months. Postoperative imaging showed effectively reduced compression of BI-AAD. No implant failure or neurovascular injury occurred. Eleven patients had vertebral artery abnormalities, but none had vertebral artery injury. All patients had evidence of bone fusion on the CT scan images within a 12-month follow-up period. The JOA and SF-12 scores were significantly improved 1 year postoperatively (p < 0.001). Posterior surgery using the technique of interarticular distraction, fusion with cage grafting, and fixation is a safe and effective revision surgery to treat patients with basilar invagination and atlantoaxial dislocation who failed PFD, which will result in good outcome.

Analysis on the related factors of misplacement of freehand pedicle screws via posterior approach in degenerative scoliosis

BackgroundTo study the risk factors associated with misplacement of freehand pedicle screws through a posterior approach for degenerative scoliosis.MethodsA total of 204 patients who underwent posterior pedicle screw-rod system surgery for degenerative scoliosis in our hospital from December 2020 to December 2023 were retrospectively analyzed. Patient demographics, radiographic accuracy, and surgery-related information were recorded.ResultsA total of 204 patients were included. A total of 2496 screws were placed. 2373 (95.07%) were in good position. Misplacement screws were 123 (4.93%). None of the patients had postoperative spinal nerve symptoms due to screw malposition. The misplacement rate of thoracic (T10-T12) pedicle screws was 11.11% (60/540). Misplacement of pedicle screws in the lumbar spine (L1-L5) was 3.22% (63/1956). Age, gender, surgeon, and operation time had no significant effect on misplacement of pedicle screws (P>0.05). Body mass index, Hu value, number of screw segments, Cobb angle, vertebral rotation, and spinal canal morphology had some correlation with pedicle screw misplacement. Among them, BMI, Hu value, number of screw segments, Cobb angle, and vertebral rotation grade were independent risk factors for PS misplacement (P<0.05). The height of the posterior superior iliac spine had a significant effect on pedicle screw misplacement in the lower lumbar spine (L4/5) (P<0.05).ConclusionBMI, Hu value, number of screw levels, Cobb angle, and vertebral rotation grade were independent risk factors for pedicle screw misplacement in patients with degenerative scoliosis. Posterior superior iliac spine height has a large impact on PS placement in the lower lumbar spine. Patients with degenerative scoliosis should be preoperatively planned for the size and direction of the placed screws by X-ray and CT three-dimensional, to reduce the misplacement rate of pedicle screws.

The Long-Term Clinical and Radiographic Outcomes of Cerclage Cable Fixation for Displaced Acetabular Fractures Using a Posterior Approach: A Retrospective Cohort Study.

Background and Objectives: Cerclage cable fixation with 2 mm multiple-braided cables for displaced acetabular fractures has shown good midterm functional and radiographic outcomes. We retrospectively evaluated the clinical and radiographic outcomes of cerclage cable fixations over ten years. Materials and Methods: We extracted data for patients who underwent cerclage cable fixation for acetabular fractures at a single institution from 2007 to 2012. We adopted this procedure for acetabulum fractures with posterior column fractures. Postoperative reduction quality, complications, reoperations, and Japanese Orthopedic Association (JOA) hip objective functional scores were analyzed. Postoperative reduction quality was classified using plain radiography and computed tomography. Results: We evaluated nine patients with a mean follow-up period of 14.1 ± 2.6 years (range: 10.8-18.1 years). The mean age was 47.1 ± 15.5 years old (range: 28-74 years); the mean injury severity score was 13.6 ± 4.7 (range: 9-22). The most frequent type of fracture was a both-column fracture. Anatomical reduction quality was achieved in five cases. Four patients had hip osteoarthritis at the last follow-up; among them, one patient had worsening hip arthritis > 5 years after surgery, and one patient developed osteoarthritis > 10 years after surgery. Their postoperative reduction quality was worse than their anatomical reduction quality, and both engaged in physical labor. None of the patients underwent revision total hip arthroplasty. The mean JOA hip score was 90.9 ± 7.9 (range: 74-100); seven patients scored >90 at the last follow-up. Conclusions: Cerclage cable fixation showed satisfactory postoperative reductions and favorable long-term clinical outcomes. Long-term follow-up might be necessary for patients whose postoperative reduction is not anatomical to detect late occurrence of hip osteoarthritis, even if osteoarthritis is not evident during short-term follow-up periods.

Comparison of patient outcomes of anterior and posterior lumbar interbody fusions: A retrospective national database analysis

BackgroundLumbar interbody fusions are used to treat degenerative lumbar disease unresponsive to conservative treatment. This procedure may be divided into anterior lumbar interbody fusion (ALIF), and posterior lumbar interbody fusion (PLIF/TLIF). Despite their widespread use, comparative research on their outcomes remains limited. MethodsThe PearlDiver Database was utilized to identify patients undergoing single and multi-level ALIF and PLIF/TLIF between 2010 and 2022. We examined demographic data, comorbidities, and reoperation rates at 90 days, 1 year, and 2 years. Complications were assessed using multivariable regression to adjust for confounders. ResultsThe study included multi-level anterior interbody fusions (N = 569, mean age 59.8, 59 % female), multi-level posterior interbody fusions (N = 43,651, mean age 57.9, 60 % female), single-level anterior interbody fusions (N = 3,547, mean age 55.3, 61 % female) and single-level posterior interbody fusions (N = 25,792, mean age 56.9, 62 % female). Multi-level posterior interbody fusion patients had a lower prevalence of HTN (OR .77, P < .05), ischemic heart disease (OR .73, P < .05), CDK (OR .77, P < .05), postoperatively more DVTs (OR 1.44, P < .05), a lower incidence of respiratory failure (OR .57, P < .05), and a higher 90-day, 1-year, and 2-year all-cause reoperation rate (7.3 %) compared to multi-level anterior interbody fusion patients (3.7 %). Single-level posterior interbody fusion patients had more HTN (OR 1.1, P < .05), less ischemic heart disease (OR .89, P < .05), obesity (OR .92, P < .05), and postoperatively a higher incidence of DVT (OR 1.34, P < .05) but lower 90-day, 1-year, and 2-year all-cause reoperation rates. ConclusionsThis study confirms that posterior interbody fusions are more common than anterior procedures, though the latter is increasing. Reoperation rates are higher for multi-level posterior and single-level anterior fusions. Both anterior and posterior approaches show similar complication profiles, though specific risks, such as postoperative DVT, vary. These findings emphasize the need for ongoing research and consideration of individual patient factors when choosing an interbody fusion technique.

An interventional prospective cohort study of efficacy of unilateral vs bilateral percutaneous posterior approach neurolytic celiac plexus blocks

Background: The neurolytic celiac plexus block (NCPB) has been a valuable intervention for managing upper abdominal cancer pain. However, the optimal approach for performing a NCPB remains a topic of debate. We conducted this study to establish the efficacy of unilateral vs bilateral percutaneous posterior approach NCPB. Methodology: This prospective, interventional study includes a cohort of individuals through chronic abdominal pain related to malignancies who were scheduled to undergo NCPB. Patients were divided into two groups, one group received the unilateral percutaneous posterior approach NCPB, and the other group received the bilateral NCPB by percutaneous posterior. Pain scores and adverse events at multiple time points post-procedure were recorded. Statistical analysis was conducted to compare pain score and adverse events between the two groups and evaluate the impact of the chosen approach on pain management. Results: Bilateral percutaneous posterior approach provides slightly better pain relief compared to the unilateral approach in the early post-procedure period which is not statistically significant. Complication rates appear to be comparable between the two approaches, with no major safety concerns identified. Conclusion: While the bilateral approach initially offers more effective pain relief, the long-term benefits and safety profiles of both methods are comparable. Clinical decision-making should consider these findings and prioritize individualized patient care. Abbreviations: CPB - Celiac Plexus Block; NCPB - neurolytic celiac plexus block; PACU - post-anesthesia care unit; VAS - visual analogue scale Keywords: Neurolytic celiac plexus block, Pancreatic cancer pain, upper abdominal malignancy Citation: Abbas MQ, Abbas SM, Farooq MF, Siddique M, Malik S. An interventional prospective cohort study of efficacy of unilateral vs bilateral percutaneous posterior approach neurolytic celiac plexus blocks. Anaesth. pain intensive care 2024;28(5): 798−803; DOI: 10.35975/apic.v28i5.2559 Received: March 24, 2024; Reviewed: August 05, 2024; Accepted: August 08, 2024

MNGA-06 MANAGEMENT OF FORAMEN MAGNUM TUMORS, EXPERIENCE OF THE SERVICE OF THE ARRAZI HOSPITAL OF THE CHU MOHAMMED VI OF MARRAKECH

Abstract Tumors of the foramen magnum (FM) are intra or extradural expansive processes located in a region, very complex anatomically, limited, according to George and Al. Meningiomas and neuromas are the main tumors encountered intradurally, while extradural ones are mainly represented by chordomas and bone tumors. The objective of this work was to study the radio-clinical and anatomopathological characteristics, the place of surgery in the therapeutic management, as well as the prognostic factors of this pathological entity through a series of 10 cases collected at the service of Neurosurgery of the Mohamed VI of Marrakech, with literature review. The FM, unusual seat of expansive processes, gives passage to several vital anatomical structures which make the gravity and the particularity of this pathological entity. The preposterous clinical symptomatology, where no sign is pathognomonic, can simulate several other neurological disorders. MRI is the most useful and least invasive examination for the diagnosis and management of foramen magnum tumors. The optimal therapeutic option is total excision of the tumour. However, given the location, nature and tumor volume as well as the involvement of the vertebral artery, the surgical procedure may be limited to subtotal excision. Several surgical approaches have been described to increase efficiency and minimize operative morbidity. A midline posterior approach combined with microsurgical techniques yields good results. Postoperative complications can be dramatic and should be anticipated. The histological spectrum essentially includes meningiomas and neuromas. The prognosis largely depends on the early diagnosis and treatment, the preoperative neurological state, the location and extent of tumor excision, as well as the quality of care provided postoperatively.

A Systematic Review and Meta-Analysis of Supercapsular Percutaneously Assisted Total Hip Arthroplasty Versus Standard Posterior Approach for Femoral Neck Fracture in Elderly Patients.

This meta-analysis aimed to evaluate the efficacy and safety of the supercapsular percutaneously assisted total hip arthroplasty (SuperPATH) and the standard posterior approach in hip arthroplasty in treating femoral neck fractures in elderly patients. A systematic search was conducted for studies from 2012 to December 2022. Meta-analysis was conducted using Review Manager 5.3 on surgical time, intraoperative blood loss, Harris hip scores, and visual analog scale scores. A total of 26 studies involving 2,236 patients with femoral neck fractures were included. The SuperPATH group performed better than traditional posterior approach group in reducing intraoperative blood loss (in ml), shortening incision length (in cm), length of hospitalization period (in days) and improving Harris Hip score (HHS). The operation time took longer than the traditional posterior approach, with statistically significant differences. The VAS scores at 1 week and 3 months after surgery in the SuperPATH group were lower than those of the traditional posterior approach, with statistically significant differences. There was no statistical significance between the two groups in VAS scores 2 weeks and 1 month after surgery. The SuperPATH group resulted in better effects in reducing intraoperative blood loss (in ml), shortening incision length (in cm), length of hospitalization period (in days), and improving Harris hip score (HHS), which is conducive to the rapid postoperative recovery of patients.

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.

Superior approach to the glenoid for treating acromion fractures combined with ideberg type III scapular glenoid fractures: a technical note.

Scapular glenoid fractures, categorized based on the Ideberg classification, are commonly addressed surgically through approaches like the anterior deltoid-pectoral approach, posterior Judet approach, modified Judet approach, or posterior axillary approach. However, these methods present limitations in exposing the superior part of the glenoid. Therefore, we propose an approach for patients with concomitant acromion fractures, involving the anterior lateral flipping of the fractured acromion, allowing direct superior visualization of the superior and posterior superior parts of the glenoid. Retrospective analysis was conducted on the data of five patients with shoulder fractures combined with scapular Ideberg III fractures between June 2018 and May 2023. All patients were treated using the shoulder approach above the scapular spine. There were four males and one female, aged 23-54 years with an average age of 36.6 years. One case involved the left shoulder, and four cases involved the right shoulder. X-rays and CT were taken before and after surgery to assess the location of the fractures and the healing status. Clinical evaluation included the assessment of efficacy using the Constant-Murley scoring criteria and analysis of surgical complications. All five patients were followed up for a duration of 14-36 months. All fractures healed completely, with an average healing time of 4.3 months (range: 3-6 months). There were no complications such as suprascapular nerve injury, nonunion, wound infection, or shoulder joint instability observed postoperatively. At the final follow-up, the Constant-Murley shoulder joint function score ranged from 84 to 98 points, with an average of 91.4 points. Three patients achieved an excellent rating in shoulder joint function score, while two patients achieved a good rating. The shoulder approach above the scapular spine exhibits advantages such as easy exposure and reduction, minimal intraoperative trauma, and clear visualization.

Managing Cerebrospinal Fluid Leak After Lumbar Spinal Fusion: When Conservative Treatment is Not the Answer?

IntroductionCSF leaks are a known complication of lumbar fusion surgery. There is a scarcity of literature describing the management of this complication. The aim of this study was to identify patients who are at risk of requiring further intervention for managing CSF leaks. MethodsThe Nationwide Inpatient Sample (NIS) database was used to identify patients who had lumbar fusion in the United States from 2002 to 2014. Inpatient outcomes including the incidence and risk factors for requiring an intervention were calculated. Secondary outcomes including average length of stay (LOS), mean cost, and mortality rates were calculated. All statistical analyses were conducted based on multivariate regression models using the SPSS software. ResultsA total of 11,636 patients with post-operative CSF leak after elective lumbar fusion were identified in the NIS database from 2002 to 2014. Of these patients, 79.9% (9,294/11,636) required an advanced intervention including epidural blood patch, simple repair, or operative management. There was an increase of 13% per year in the use of an intervention in managing CSF leaks. After controlling for several confounding factors, independent risk factors for requiring an intervention included: older age (OR: 1.01; 95% CI: 1.005-1.013; p<0.0001), lateral approach (OR: 1.52; 95% CI: 1.26-1.81; p<0.0001) and posterior approach (OR: 1.60; 95% CI: 1.34-1.91; p<0.0001) compared to anterior approach.Nonsurgical treatment was associated with increased length of stay (5.93±4.61 vs. 5.25±3.63;p<0.0001) with similar hospitalization costs (119,537.2±89,045.6 vs. 120,277.9±87,894.1; p=0.72) and mortality (0.3% vs. 0.3%; p>0.05). ConclusionSpine surgeons should be aware of certain patient and procedure-specific characteristics that increase the risk of requiring an intervention for CSF leak management after lumbar fusion to improve patient outcomes.

Does Femoral Stem Design Influence Periprosthetic Fracture Incidence and Morphology in Total Hip Arthroplasty?

BackgroundAs the incidence of total hip arthroplasty (THA) increases, the number of periprosthetic femur fractures (PFF) will also rise. The surgical approach and stem design have been shown to influence the rate of PFF. This study evaluated PFF in cementless THA done through the posterior approach and described how stem design influences intraoperative and early postoperative fracture incidence and morphology. MethodsA retrospective review of 3,183 primary THAs for osteoarthritis from 2013 to 2021 was performed. Demographics, comorbidities, femoral stem designs, intraoperative and early postoperative PFFs (< 90 days), and aseptic femoral revisions were recorded. Stems were classified as single-wedge taper (Type 1), double-wedge taper (Type 2), or ream and broach (Type 3). There were 1,192 Type 1, 240 Type 2, and 1,726 Type 3 femoral stems. The PFF and aseptic femoral revisions were compared with univariable and multivariable analyses. Cox regression and Kaplan-Meier analyses evaluated survival to femoral revision. ResultsIn this population, 25 patients (0.8%) had an intraoperative or early postoperative PFF. Patients who had PFFs were older (68 versus 63; P = 0.03) and more likely to be women (76 versus 24%; P = 0.02). Type 2 stems had a significantly higher incidence of all-cause PFFs when compared to Type 1 (3.6 versus 0.7%; P < 0.01) and Type 3 (3.6 versus 0.4%; P < 0.01) stems. Type 2 stems also had a higher incidence of Vancouver B2 PFFs when compared to Type 3 stems (0.8 versus 0.05%; P = 0.04). Stem design was not associated with PFF or all-cause femoral revision. There were no differences in survival to femoral revision. ConclusionDouble-wedge taper stems may be associated with increased intraoperative and early postoperative PFFs, including those requiring femoral stem revision. However, there was no statistically significant difference in late PFF, aseptic loosening, or femoral revision.

Regional differences in reimbursement rates from Medicare, Medicaid, and FAIR Health across common procedures for neurological surgeons.

FAIR Health-a nonprofit, state-funded database-was created as an independent repository of healthcare claims paid data to address allegations of price fixing. Many insurers have forced physicians to negotiate payments based on Medicare rates, rather than utilizing FAIR Health. The authors' objective was to provide an overview of regional differences in reimbursement rates per several sample neurosurgical Current Procedural Terminology (CPT) codes and to compare Medicare, Medicaid, and usual, customary, and reasonable rates via FAIR Health rate estimates. The authors compared FAIR Health rates for three common neurosurgical CPT codes: 61510 (removal of bone from skull for removal of upper brain tumor), 22630 (fusion of lower spine bones with removal of disc, posterior approach, single interspace), and 62223 (creation of a brain fluid drainage shunt, ventriculoperitoneal, ventriculopleural, or other terminus), with Medicare and Medicaid reimbursement to evaluate differences in five different regions in the US. Medicare and Medicaid reimbursement rates were consistently and significantly lower than FAIR Health in-network rates across all three CPT codes evaluated (p < 0.001 for all). Significant regional differences exist per census data in median age, median income, employment rates, and degree of health coverage (p < 0.001, p = 0.002, p = 0.002, and p = 0.001, respectively). Reimbursement estimates were found to have regional variation: Medicare/Medicaid rates were significantly lower than FAIR Health in-network rates for all codes across regions with a region-based interaction for reimbursement for code 62223 (p = 0.020). Medicare and Medicaid rates did not significantly vary across regions. Inherent differences exist between cities and states, including median income, employment rates, and health coverage. Despite geographic cost practice indices for Medicare and state-specific production of Medicaid, Medicaid/Medicare reimbursement rates did not vary across regions but were consistently and significantly lower than FAIR Health estimates throughout the US. Locale-specific variation in FAIR Health may further indicate a better accounting of regional differences in cost of practice.

Hip &amp; Pelvis

The October 2024 Hip &amp; 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.

Functional outcomes of total hip replacement by a posterior surgical approach

Functional outcomes of total hip replacement by a posterior surgical approach