Posterior Decompression Research Articles

Revision Chiari surgery in adults: surgical evaluation algorithm and outcomes in a continuity-of-care practice.

Patients with a prior surgical history for Chiari malformation (CM) as a child or an adult who presents with a recurrence or persistence of symptoms pose a challenging clinical scenario. The authors analyzed preoperative presentations, surgical histories, and outcomes of adult CM revision cases to create an algorithm for the assessment of revision surgery in adult CM patients and contrast this with the care of pediatric CM patients within the context of an integrated continuity-of-care CM practice seeing pediatric and adult patients. The authors retrospectively reviewed the records of patients with CM0, -1, and -1.5 who were 21 years of age or older, had a prior history of CM surgery as either children or adults, and underwent revision surgery as adults at the authors' institution from December 2009 to February 2020. The cohort was divided into three groups depending on the type of revision surgery performed: posterior fossa decompression with or without duraplasty (PFD/D group), occipitocervical fusion without ventral decompression (OCF group), and ventral decompression in the form of endoscopic endonasal odontoidectomy (VD group). A total of 50 adult revision cases were divided into 30 PFD/D cases, 13 OCF cases, and 7 VD cases. Forty cases had previously undergone one CM surgery, and 10 had undergone two. Preoperatively, the PFD/D group had significantly fewer cases of diagnosed craniocervical instability (CCI), Ehlers-Danlos syndrome, and dysautonomia than the OCF and VD groups. A retroflexed odontoid was significantly more common in the VD group than in the PFD/D and OCF groups. Postoperatively, rates of improvement were 60.0% with PFD/D, 84.6% with OCF, and 85.7% with VD, but differences in these rates were not statistically significant. In this challenging group of CM patients, possible etiologies warranting additional surgery included residual dorsal compression, persistent syrinx, CCI, and ventral brainstem compression from a significant retroflexed odontoid. Outcomes after revision were often favorable, but careful evaluation, patient selection, and communication with patients are needed in deciding to reoperate. The suggested algorithm can aid decision-making.

Early effects of unilateral biportal endoscopic posterior total laminectomy decompression in the treatment of cervical stenosis

To investigate the early efficacy and safety of unilateral biportal endoscopic posterior total laminectomy decompression in the treatment of cervical stenosis (CS). The clinical data of 28 patients with CS treated by unilateral biportal endoscopic posterior total laminectomy decompression from January 2021 to October 2022 in the Henan NO.3 Provincial People's Hospital were retrospectively analyzed. Of the patients, 16 were male and 12 were female, the mean age was (55.6±9.6) years. The CS occurred at C3-4 level in 1 cases, at C4-5 level in 3 cases, at C5-6 level in 16 cases and at C6-7 level in 8 cases. Each case was compared at the moment of pre-operation and final follow-up by the Japanese Orthopedic Association (JOA) score. The postoperative complications were recorded. The JOA improvement rate was computed at the final follow-up. As a result, all patients underwent successful surgery and were followed up for (11.6±4.7) months. The operation time was (43.0±5.3) min. Intraoperative blood loss (7.9±2.8) ml; Postoperative drainage volume (8.1±2.3) ml. The JOA score increased from 7.9±1.2 before surgery to 13.5±1.3 six months after surgery, and it was 13.7±1.2 at the last follow-up, the differences between postoperative and preoperative were both statistically significant (both P<0.001). No complications occurred, such as cerebrospinal fluid leakage, nerve injury and intraspinal hematoma. At the last follow-up, cervical spine X-ray or CT evaluation showed no instability in the operative segment. The overall curative effect was evaluated according to JOA score at the last follow-up: 16 cases got excellent outcome, 7 cases got good and 2 cases got medium outcome, with an excellent and good rate of 89.3% (25/28). This study shows that unilateral biportal endoscopic posterior total laminectomy decompression in the treatment of single-level cervical stenosis can achieve satisfactory efficacy, has no impact on spinal stability, and has a high safety.

Mercedes Benz pattern craniosynostosis associated with Chiari malformation type 1: A case report of a rare condition

Introduction: Craniosynostosis results from the premature fusion of cranial sutures and is classified as complex when it affects multiple sutures. The abnormal and rare fusion of the sagittal and bilateral lambdoid sutures is known as the Mercedes-Benz (CMB) pattern responsible for up to 0.7% of craniosynostoses. It's characterized by flattening of the occipital bone and sub-lambdoid depression. Additionally, the Arnold-Chiari malformation, one of the anomalies associated, occurs due to the junction of deformities in the posterior fossa and rhombencephalon. Type 1 (CM1) is the most incident and less severe, represented by the pointed shape of the cerebellar tonsils. Objective: The objective of this article is to report a rare case presentation of Mercedes Benz pattern Craniosynostosis associated with Arnold Chiari malformation Case presentation: Male patient, 11 months old, diagnosed with CMB associated with CM1, presenting with anterior turribrachycephaly and occipital brachycephaly. The diagnosis was made after the 10th month of life, with typical findings on computed tomography and cerebellar tonsil herniation (CTH) on magnetic resonance imaging (MRI). No signs of neurodevelopmental delay were observed, and there is no history of cranial malformations in the family. At 11 months, the patient underwent neurosurgery involving cranial parietal remodeling to correct craniosynostosis, along with posterior fossa decompression to address CM1. Conclusion: Neurosurgical techniques like parietal remodeling and posterior decompression, despite their complexity, play a central role in addressing CMB. It's crucial to discuss this rare condition to ensure early diagnosis and treatment, facilitating an efficient approach and preventing potential later consequences.

Impact of Preoperative Intervertebral Disc Degeneration on Patient-Reported Outcome Measures After Lumbar Fusion

The Pfirrmann scoring system classifies lumbosacral disc degeneration based on MRI signal intensity. The relationship between pre-existing disc degeneration and PROMs after one-level lumbar fusion is not well documented. The purpose of this study was to investigate the relationship between the severity of preoperative intervertebral disc degeneration and pre- and postoperative patient-reported outcome measures (PROMs) in patients undergoing one-level lumbar fusion. All adult patients underwent posterior lumbar decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF) between 2014-2022 were included. Patient demographics, and comorbidities were extracted from medical records. Lumbar intervertebral discs on sagittal MRI T2-weighted images were assessed by two independent graders utilizing Pfirrmann criteria. Grades I-III were categorized as low-grade disc degeneration, while IV-V were considered high-grade. Multivariable linear regression assessed the impact of disc degeneration on PROMS. A total of 150 patients were included, of which, 69 (46%) had low grade disc degeneration, while 81 (54%) had high grade degeneration. Patients with high-grade degeneration had increased preoperative VAS-Leg scores (6.10 vs. 4.54, p=0.005) and displayed greater one-year postoperative improvements in VAS-Back scores (-2.11 vs -0.66, p=0.002). Multivariable regression demonstrated Pfirrmann scores as independent predictors for both preoperative VAS-Leg scores (p=0.004) and postoperative VAS-Back improvement (p=0.005). In patients undergoing one-level lumbar fusion, higher Pfirmann scores were associated with increased preoperative leg pain and greater one-year postoperative improvement in back pain. Further studies into the relationship of pre-operative disc degeneration and their impact on postoperative outcomes may help guide clinical decision making and patient expectations.

Perioperative complications and cost of posterior decompression with fusion in thoracic spine for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum -a comparative study using a national inpatient database

BackgroundAlthough posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF.MethodsPatients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching.ResultsIn a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001).ConclusionThis research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.

Vocal Cord Paralysis in Pediatric Chiari Malformation: A Systematic Review and Meta-analysis.

Arnold-Chiari Malformation is one possible cause of congenital vocal cord paralysis (VCP). The natural history of VCP in children with Chiari malformation has previously been limited to small case studies. This systematic review seeks to better characterize the prognostic factors that may predict symptom severity and resolution of congenital VCP in children with Arnold-Chiari malformation. We hypothesized that the onset of stridor or VCP at a younger age would be associated with a poorer prognosis and earlier intervention with posterior fossa decompression would be associated with better outcomes. PubMed, Web of Science, Cochrane Library, and bibliographic review. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Database search yielded 866 articles. Study abstracts were reviewed by 2 independent examiners. One hundred and seventy-six studies underwent full-text review. The following were extracted: age at onset of stridor or VCP, Chiari malformation type, laryngoscopy findings, type and timing of neurosurgical intervention, and tracheostomy history. Statistical analyses utilized χ2 tests. Younger age at symptom onset showed statistically significant associations with decreased likelihood for symptom resolution and tracheostomy decannulation. The shorter time interval from symptom onset to neurosurgical intervention was not significantly associated with better outcomes. This meta-analysis suggests poorer prognosis in those with earlier-onset symptoms, reinforcing prior case series findings. Additional prospective studies are needed to elucidate the natural history and utility of early intervention in children with vocal cord paralysis secondary to Chiari malformation.

Prevalence, Implications, and Risk Factors of Traumatic Dural Tears in Thoracic and Lumbar Fractures: A Retrospective Study.

Introduction Spine fracture in association with traumatic dural tear is a serious injury. A traumatic dural tear is difficult to determine based on initial clinical presentation and radiological imaging even with magnetic resonance imaging (MRI). However, during decompression surgery, cerebrospinal fluid leaks surrounding the injured segments are usually confirmed by directly visualizing them. For preoperative planning and intraoperatively limiting further damage to the dural and neurological structures, early detection of traumatic dural tears before surgery is important. This study aims to determine the prevalence, implication, risk factors, and complications of traumatic dural tears in patients who have undergone surgical treatment for thoracic and lumbar fractures. We believe our retrospective study would identify more accurate risk factors for traumatic dural tears and aid us with preoperative planning and operative precaution. Methods This study retrospectively included all patients who had thoracic and lumbar fractures and had posterior instrumentation and decompression surgery at three hospitals in the Northern region of Malaysia from January 2018 to December 2020. Fractures associated with pathological spine including metastatic, severe osteoporosis, ankylosing spondylitis, metabolic bone disease, those with missing data, and iatrogenic dural tears were excluded from this study. Preoperative and postoperative neurological assessments based on theAmerican Spinal Injury Association (ASIA) impairment scale, blood loss volume, duration of the surgery, and post-surgery complications were gathered from medical records. Interpedicular distance, ratio of central canal diameter, laminar fracture gap, and pedicle fractures were identified and measured. The obtained data was analyzed using Pearson's chi-square and Fisher's exact test for categorical variables, and independent t-test/Mann-Whitney test for numerical variables. Result This study comprised a total of 93 patients who had fractures in their thoracic and lumbar regions. The mean age of the patients was 38 years. The number of patients with traumatic dural tears was 20 (21.5%). There was an association between the presence of dural tears and preoperative neurological deficits (P<0.001). Wider mean interpedicular distance (P=0.004), increased central canal diameter ratio (P<0.001), and displaced laminar fracture (P<0.001) were significantly higher in patients with traumatic dural tears. Multiple logistic regression analysis showed both incomplete (P=0.002) and complete (P=0.037) preoperative neurological deficit, increase of central diameter ratio of encroachment (P=0.011), and presence of >2mm laminar fracture gap (P=0.015) had a significant association with a traumatic dural tear. This study found that patients with traumatic dural tears had longer surgical times and statistically larger mean blood loss volumes when compared to patients without dural tears (P<0.001). There is no significant association between the complications following the surgery and the presence of a dural tear (P>0.05). Conclusion This study shows that the presence of preoperative neurological deficits, wider interpedicular distance, severe canal encroachment, and wide separation of laminar fracture may indicate the likelihood of traumatic dural tear in spine fracture. These factors will enable surgeons to enhance their operational planning and make early preparations for the management of dural tears.

Pediatric Lumbosacral Spondylolisthesis: Overcoming the Disability!

Congenital spondylolisthesis is characterized by dysplasia of the facet joint or congenital defect in the pars. Our study highlights the clinical and radiological profile, various treatment options, and outcomes in patients with pediatric congenital lumbar and lumbosacral spondylolisthesis. A retrospective analysis and follow-up of 22 patients were conducted presented with radiological diagnosis of congenital lumbar/lumbosacral spondylolisthesis (2018-2021). Twenty patients (91%) had L5-S1 listhesis and two patients (9%) had L4-L5 listhesis. Six (27.3%) patients had low-grade listhesis (grades 1-2), 16 (72.7%) had high-grade listhesis (grades 3-5). Seventeen (77.3%) had S1, three (13.6%) had L5, and two (9%) had both L4-L5 radiculopathy. All patients had neurogenic claudication. One had an associated spina bifida occulta. Six (27.3%) patients underwent two-level fixation, and 16 (72.7%) underwent three-level fixation. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS TLIF) was done in two patients. Revision of at least one screw was done in three patients. After one year of follow-up, all the patients had 75-100% relief in radicular pain and neurogenic claudication. The Oswestry Disability Index (ODI) score in preop for all patients was 41-60% and postoperatively they showed an improvement in ODI score (0-20). The postoperative low back pain score on the Numeric Rating Scale was 0-1 for all patients. Congenital lumbar spondylolisthesis usually presents with high-grade listhesis. Management of such cases is a surgical challenge but posterior decompression resulted in relief of pain in all patients. However, in situ fixation without reduction is also effective in selective cases where attempts to reduce the listhesis result in a decline in intraoperative neuromonitoring parameters.

Short-Term Outcomes of Posterior Fossa Decompression with or without Duraplasty for Chiari Malformation Type 1: Insights from a Tertiary Care Hospital

Objectives: To assess and compare short-term outcomes of patients who underwent posterior fossa decompression with and without duraplasty for Chiari Malformation Type 1 (CM1).Methodology: This retrospective cohort study was conducted at Khyber Teaching Hospital's Peshawar, Pakistan, in December 2023 after securing permission from the Institutional Review Board (IRB) with reference. We included patients who underwent posterior fossa decompression for Chiari Malformation Type 1 (CM1) over a one-year period from March 2022 to March 2023 at Khyber Teaching Hospital. Retrospective data of specified duration concerning CM1 Patient’s demographics, preoperative symptoms, surgical details including the use of duraplasty, and postoperative outcomes were extracted from electronic health records at Khyber Teaching Hospital, Peshawar. Data was analyzed by SPSS27. Descriptive statistics were employed to summarize demographic characteristics and baseline clinical data and frequencies were reported.Comparative analyses between posterior fossa decompression surgery with duraplasty and that without duraplasty groups were performed using t-tests for continuous variables and chi-square tests for categorical variables. Results: 52 patients were included in our study out of which 28 underwent posterior fossa decompression with duraplasty and 24 without duraplasty. 8 patients (15.4%) experienced postoperative complications. Cerebrospinal fluid leaks were observed in 3 cases (5.8%), all of which occurred in the PFD with duraplasty group. The mean length of hospital stay for patients undergoing PFD with duraplasty was 6.2 days (SD ± 1.4), while for those undergoing PFD without duraplasty, it was 5.4 days (SD ± 0.9).Conclusion: Posterior fossa decompression with duraplasty carries the risk of CSF leak so the preferred procedure for Chiari Malformation Type 1 is posterior fossa decompression without duroplasty. Those patients requiring posterior fossa decompression with duroplasty should be highly individualized.

The postoperative clinical effects of utilizing 3D printed (Ti6Al4V) interbody fusion cages in posterior lumbar fusion: A retrospective cohort study.

The research focused on the postoperative effect of using interbody fusion cage in lumbar posterior lamina decompression and interbody fusion with pedicle screw by comparing the postoperative effect of using 3D printing (Ti6Al4V) and PEEK material interbody fusion cage. Ninety-one patients with lumbar degenerative diseases from the Department of Spine Surgery of Tianjin Hospital were included in the study cohort. They were divided into 3D group (n = 39) and PEEK group (n = 52) according to the use of interbody fusion cage. The imaging data of the patients were collected and the postoperative data of the 2 groups were compared to evaluate patients' health status and the recovery of lumbar structure and function after operation. Combined with the degree of fusion, the clinical effect of 3D printing titanium alloy interbody fusion cage was comprehensively judged. At the last follow-up, the JOA score, ODI index, VAS, prolo function score, and SF-36 scale of the 2 groups showed that the clinical symptoms were better than those before operation (P < .05). The height of intervertebral disc, the area of intervertebral foramen and the physiological curvature of lumbar vertebrae increased in varying degrees after operation (P < .05). At the last follow-up, the vertebral cage fusion rates were as high as 89.13% and 90.91% in the 3D and PEEK groups, with collapse rates of 6.5% and 4.5%, respectively. There were 10 cases of cage displacement in 3D group and 7 cases of cage displacement in PEEK group. There was no significant difference between the 2 groups (P > .05). In conclusion, 3D printed (Ti6Al4V) interbody fusion cage can obtain good clinical effect in the surgical treatment of lumbar degenerative diseases. Posterior lumbar lamina decompression, bilateral pedicle screw fixation combined with 3D printed cage interbody fusion is excellent in rebuilding the stability of lumbar vertebrae. 3D printed interbody fusion cage can be an ideal substitute material for intervertebral bone grafting. The stable fusion time of interbody fusion cage after lumbar fusion is mostly from 3 months to half a year after operation.

Predictors of poor functional outcomes in adults with type I Chiari Malformation: Clinical and surgical factors assessed with the Chicago Chiari Outcome Scale over long-term follow-up

ObjectiveThis study aimed to identify clinical and surgical features associated with poor long-term postoperative outcomes in patients diagnosed with Type I Chiari Malformation (CMI) treated with posterior fossa decompression with duroplasty (PFDD), with or without tonsillar coagulation. MethodsThis retrospective, single-center study included 107 adult patients with CMI surgically treated between 2010 and 2021. The surgical technique involved a midline suboccipital craniectomy, C1 laminectomy, durotomy, arachnoid dissection, duroplasty, and tonsillar coagulation until 2014, after which tonsillar coagulation was discontinued. Postoperative outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) at a median follow-up of 35 months. Clinical, surgical, and neuroimaging data were analyzed using the Wilcoxon signed-rank test, Cox regression analysis, and Kaplan-Meier survival curves to identify predictors of poor functional outcomes. ResultsOf the 107 patients (mean age 43.9 years, SD 13), 81 (75.5 %) showed functional improvement, 25 (23.4 %) remained unchanged, and 1 (0.9 %) experienced worsened outcomes. Cephalalgia, bilateral motor weakness, and bilateral paresthesia were the most frequent initial symptoms. Tonsillar coagulation was performed in 31 cases (28.9 %) but was clinically associated with higher rates of unfavorable outcomes. The Wilcoxon signed-rank test indicated that long-term follow-up CCOS was significantly higher than postoperative CCOS (Z = −7.678, p < 0.000). Multivariate Cox analysis identified preoperative bilateral motor weakness (HR 6.1, 95 % CI 1.9–18.9; p = 0.002), hydrocephalus (HR 3.01, 95 % CI 1.3–6.9; p = 0.008), and unilateral motor weakness (HR 2.99, 95 % CI 1.1–8.2; p = 0.033) as significant predictors of poor outcomes on a long-term follow-up. ConclusionThis study highlights the high rate of functional improvement in CMI patients following PFDD. Preoperative motor weakness and hydrocephalus were significant predictors of poor long-term outcomes. Tonsillar coagulation did not demonstrate a clear clinical benefit and may be associated with worse outcomes. Our findings suggest that careful preoperative assessment and selection of surgical techniques are crucial for optimizing patient outcomes.

Neuromonitoring Signal Changes in Degenerative Cervical Myelopathy: An Analysis of Risk Factors for Signal Drops During Posterior Cervical Decompression

To analyze intraoperative neuromonitoring data of patients with degenerative cervical myelopathy undergoing cervical laminectomy and assess the incidence of signal drops and their risk factors. This retrospective observational study included patients with degenerative cervical myelopathy who underwent cervical laminectomy with intraoperative neuromonitoring between July 2018 and March 2023. We analyzed the signal changes for any correlation with the type of pathology (ossified posterior longitudinal ligament vs. cervical spondylotic myelopathy [CSM]) and clinical (severity of myelopathy, duration of symptoms) and radiological (length of cord signal changes and K-line) parameters. Of 100 degenerative cervical myelopathy cases, 55 were diagnosed as OPLL and 45 as CSM. Signal drops were recorded in 26 patients-14 persistent drops and 12 transient drops. True positive drops were seen in 4 patients (2 OPLL and 2 CSM), 3 of whom had sustained bimodal drops (both somatosensory evoked potentials and motor evoked potentials). Signal drops were significantly more frequent with OPLL compared with CSM (P < 0.01). Ten of 14 persistent signal drops and 9 of 12 transient drops were seen in patients in OPLL. Continuous OPLL, negative K-line, hill type OPLL, severity of myelopathy, and longer duration of symptoms were risk factors for signal drops. Patients with cervical OPLL have a higher incidence of false positive and transient signal drops after decompression compared with patients with CSM. Longer duration of symptoms, high-grade myelopathy, continuous OPLL, hill type OPLL, and negative K-line were risk factors for signal drops.

Microbubble Contrast-Enhanced Transcutaneous Ultrasound Enables Real-Time Spinal Cord Perfusion Monitoring Following Posterior Cervical Decompression

Ultrasound imaging is inexpensive, portable, and widely available. The development of a real-time transcutaneous spinal cord perfusion monitoring system would allow more precise targeting of mean arterial pressure goals following acute spinal cord injury (SCI). There has been no prior demonstration of successful real-time cord perfusion monitoring in humans. Four adult patients who had undergone posterior cervical decompression and instrumentation at a single center were enrolled into this prospective feasibility study. All participants had undergone cervical laminectomies spanning ≥2 contiguous levels ≥2months prior to inclusion with no history of SCI. The first 2 underwent transcutaneous ultrasound without contrast and the second 2 underwent contrast-enhanced ultrasound (CEUS) with intravenously injected microbubble contrast. Using noncontrast ultrasound with or without Doppler (n= 2), the dura, spinal cord, and vertebral bodies were apparent however ultrasonography was insufficient to discern intramedullary perfusion or clear white-gray matter differentiation. With application of microbubble contrast (n= 2), it was possible to quantify differential spinal cord perfusion within and between cross-sectional regions of the cord. Further, it was possible to quantify spinal cord hemodynamic perfusion using CEUS by measuring peak signal intensity and the time to peak signal intensity after microbubble contrast injection. Time-intensity curves were generated and area under the curves were calculated as a marker of tissue perfusion. CEUS is a viable platform for monitoring real-time cord perfusion in patients who have undergone prior cervical laminectomies. Further development has the potential to change clinical management acute SCI by tailoring treatments to measured tissue perfusion parameters.

Current insights and surgical interventions in craniovertebral junction instability

Abstract Background: The Craniovertebral Junction (CVJ) is prone to various pathologies, including instability and congenital anomalies. Understanding these conditions and their management strategies is critical for effective treatment. Materials and Methods: A systematic search was conducted in Science Direct and PubMed databases following PRISMA guidelines. Inclusion criteria encompassed studies addressing craniovertebral instability and associated pathologies. Six systematic investigations were assessed for methodological quality. Data extraction involved 702 patients with CVJ issues, among which 129 had related conditions, while 279 displayed normal CVJ. Surgical interventions encompassed various techniques such as C1-C2 fixation, posterior decompression, and screw placements. Results: Among 702 patients studied, atlantoaxial subluxation, basilar invagination, and odontoid fractures were observed in 129 cases. Surgical treatments showed favorable outcomes, with fusion achieved within a year post-surgery for both C1-C2 fixation techniques and posterior decompression strategies. Studies highlighted successful outcomes in cases of cervical myelopathy, especially with early occipitocervical fusion. Conclusion: Managing atlantoaxial instability remains a debated topic, with varying success rates observed in different surgical interventions. Recommendations emphasize the importance of stabilization techniques and imaging modalities for effective preoperative planning and postoperative care. However, limitations in the available data underscore the need for further research to refine treatment strategies for better patient outcomes in this complex area of spinal pathology. Keywords: Craniovertebral junction, atlantoaxial instability, Basilar invagination, fusion, CVJ pathologies

Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion

BACKGROUND CONTEXTProlonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated. PURPOSEThe purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery. STUDY DESIGNRetrospective cohort study. PATIENT SAMPLEAdult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF. OUTCOME MEASURESDemographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day. METHODSA 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 – 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use. RESULTSA total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs 0.65, p=.023) and take more morphine milligram equivalents (MME) per day (0.60 vs 0.04, p=.014) within 1 year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs 10.4%, p=.040) and take more MMEs per day (0.70 vs 0.05, p=.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs 52.1%, p<.001) and took more MMEs per day (3.73 vs 1.71, p<.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate: −1.63 p=.022). CONCLUSIONCervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients’ postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

Surgical Management of Chiari Malformation Type I in the Pediatric Population: A Single-Center Experience.

Background: Chiari malformation type 1 (CM-1) involves the cerebellar tonsils' descent below the foramen magnum. In Chiari malformation type 1.5 (CM-1.5), both the cerebellar tonsils and the brainstem are herniated. Common symptoms include headaches and cervical pain, often associated with conditions like syringomyelia and hydrocephalus. Surgical treatment is not performed in asymptomatic patients, while the presence of syringomyelia represents an indication for surgery. Methods: This study retrospectively examined pediatric patients with CM-1 and CM-1.5 at Giannina Gaslini Hospital from 2006 to 2020, analyzing demographics, radiological findings, surgical interventions, and outcomes. Results: Out of 211 patients who underwent surgery, 83.9% were diagnosed with CM-1 and 16.1% with CM-1.5. Headaches were prevalent (69%) and cerebellar signs were noted in 29% of patients. Syringomyelia and hydrocephalus were present in 28.4% and 8% of cases, respectively. Intraoperative ultrasonography guided interventions, with 59.8% requiring bony and ligamentous decompression, and 27.1% undergoing duraplasty. Conclusions: The surgical treatment of CM-1/CM-1.5 involves posterior cranial fossa decompression. Choosing between bony decompression alone and its combination with duraplasty has always been controversial in the pediatric population. If we consider as surgical endpoint the restoration of cerebrospinal fluid (CSF) flux, intraoperative ultrasound may be a real-time helpful tool in orienting the surgical strategy, yet refinement with quantitative measures is needed.

Predicting the presence of 4th ventricular outlet obstruction in Chiari I Malformation

IntroductionA subset of children with Chiari 1 malformation (CM-1) have a 4th ventricle arachnoid veil—a thin membrane covering the outlet of the 4th ventricle. Studies suggest that failure to disrupt this veil during posterior fossa decompression can reduce the likelihood of syringomyelia resolution. However, there is no reliable method for predicting the presence of the veil without direct surgical exploration. This study aims to evaluate the association between pre-operative symptoms, radiographic measurements, and the arachnoid veil.MethodsA retrospective review of an institutional database of children evaluated for CM-I was conducted. For patients treated with surgery, operative notes were reviewed to determine if an arachnoid veil was present. Logistic regression was used to test for relationship of clinical variables and radiographic measurements with the presence of an arachnoid veil.ResultsOut of 997 children with CM-1, 226 surgical patients were included in the analysis after excluding those with inadequate documentation. An arachnoid veil was found in 23 patients (10.2%). Larger syrinx, spinal canal, and thecal sac diameters were significantly associated with the presence of a veil, with odds ratios of 1.23 (95% CI 1.2–1.48; p = 0.03), 1.27 (95% CI 1.02–1.59; p = 0.03), and 1.35 (95% CI 1.03–1.77; p = 0.03), respectively. No significant associations were found with any signs or symptoms.ConclusionsArachnoid veil was present in 10% of cases. Radiographic measurements indicating larger syrinx size were the only variables found to be significantly associated with an arachnoid veil. Exploration of the 4th ventricular outlet is recommended for CM-I decompression in the setting of expansile syringomyelia.

Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study.

Retrospective multicenter study. To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. We included 203 patients with cervical OPLL who were followed for a minimum of 1year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons. BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups. Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.

Does Paraspinal Muscle Mass Predict Lumbar Lordosis before and after Decompression for Degenerative Spinal Stenosis?

Retrospective Cohort Study. The purpose of this study was to determine if muscle mass and quality of the lumbar paraspinal muscles was associated with improvements in lumbar lordosis and other sagittal parameters after isolated posterior lumbar decompression surgery for lumbar spinal stenosis. Over time, either due to degenerative changes or other spinal conditions, individuals may develop sagittal imbalance. In patients with lumbar spinal stenosis, sagittal imbalance can further exacerbate symptoms of pain and radiculopathy. Sarcopenia of paraspinal muscles has been implicated in previous spine research as a variable with influence on surgical outcomes. Sagittal parameters were measured on preoperative and postoperative lateral lumbar radiographs and included lumbar lordosis (LL), sacral slope (SS), and pelvic tilt (PT). Preoperative MRI images were evaluated at the base of the L4 vertebral body to assess muscles mass of the psoas muscle and paravertebral muscles (PVM) and Goutallier grade of the PVM. Patients were divided into 3 muscle size groups based on PVM normalized for body size (PVM/BMI): Group A (smallest), Group B, and Group C (largest). Patients in Group C had greater LL preoperatively (51.5° vs. 47.9° vs. 43.2, P=0.005) and postoperatively (52.2° vs. 48.9° vs. 45.7°, P=0.043). There was no significant difference in the ∆LL values between groups (P>0.05). Patients in Group C had larger SS preoperatively (35.2° vs. 32.1° vs. 30.0°, P=0.010) and postoperatively (36.1° vs. 33.0° vs. 31.7°, P=0.030). Regression analysis showed that PVM/BMI was a significant predictor of LL preoperatively (P=0.039) and postoperatively (P=0.031), as well as SS preoperatively (P=0.001) and postoperatively (P<0.001). Muscle mass of the paravertebral muscles significantly impacts lumbar lordosis and sacral slope in patients with lumbar spinal stenosis before and after posterior lumbar decompression. These findings highlight a need to address risk factors for poor muscle quality in patients with sagittal imbalance.

Stopping at C2 Versus C3/4 in Elective Posterior Cervical Decompression and Fusion: A 5-Year Follow-up Study.

This is a retrospective cohort study. In patients undergoing elective posterior cervical laminectomy and fusion (PCLF) with a minimum of 5-year follow-up, we sought to compare reoperation rates between patients with an upper instrumented vertebra (UIV) of C2 versus C3/4. The long-term outcomes of choosing between C2 versus C3/4 as the UIV in PCLF remain unclear. A single-institution, retrospective cohort study from a prospective registry was conducted of patients undergoing elective, degenerative PCLF from December 2010 to June 2018. The primary exposure was UIV of C2 versus C3/4. The primary outcome was reoperation. Multivariable logistic regression controlled for age, smoking, diabetes, and fusion to the thoracic spine. Of the 68 patients who underwent PCLF with 5-year follow-up, 27(39.7%) had a UIV of C2, and 41(60.3%) had a UIV of either C3/4. Groups had similar duration of symptoms (P=0.743), comorbidities (P>0.999), and rates of instrumentation to the thoracic spine (70.4% vs. 53.7%, P=0.210). The C2 group had significantly longer operative time (231.8±65.9 vs. 181.6±44.1mins, P<0.001) and more fused segments (5.9±1.8 vs. 4.2±0.9, P<0.001). Reoperation rate was lower in the C2 group compared with C3/4 (7.4% vs. 19.5%), though this did not reach statistical significance (P=0.294). Multivariable logistic regression showed increased odds of reoperation for the C3/4 group compared with the C2 group (OR=3.29, 95%CI=0.59-18.11, P=0.170), though statistical significance was not reached. Similarly, the C2 group had a lower rate of instrumentation failure (7.4% vs. 12.2%, P=0.694) and adjacent segment disease/disk herniation (0% vs. 7.3%, P=0.271), though neither trend attained statistical significance. Patients with a UIV of C2 had less than half the number of reoperations and less adjacent segment disease, though neither trend was statistically significant. Despite a lack of statistical significance, whether a clinically meaningful difference exists between UIV of C2 versus C3/4 should be validated in larger samples with long-term follow-up. Level-3.