Posterior Spine Research Articles

88. New onset central diabetes insipidus in pediatric scoliosis fusions utilizing tranexamic acid

<h3>BACKGROUND CONTEXT</h3> Central diabetes insipidus (CDI) is a polyuric disease characterized by renal excretion of large volumes of dilute urine, plasma volume contraction, hypernatremia and serum hyperosmolality. CDI occurs frequently after pituitary surgery and traumatic brain injury, and has been rarely reported after significant spinal cord trauma. CDI occurring in pediatric surgery during spinal fusion has only been sporadically reported and, to date, we found only one reported case of CDI with a documented suppressed vasopressin level that developed during spine fusion for idiopathic scoliosis in a pediatric patient. CDI presenting during anesthesia has been related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine and opioids. Our scoliosis surgery protocol uses total intravenous anesthesia (TIVA) with infusions of remifentanil, propofol, ketamine and tranexamic acid (TXA) (loading dose 10 mg/kg, maintenance at 1 mg/kg/hour, later increased to 5 mg/kg/hour). Since increasing the TXA dosing, we have documented 9 cases of intraoperative CDI marked by sudden development of polyuria. We did not have any documented cases of CDI prior to TXA use or at the lower dose of 1mg/kg/hour. <h3>PURPOSE</h3> To document the incidence of CDI in pediatric patients undergoing posterior scoliosis utilizing TXA. <h3>STUDY DESIGN/SETTING</h3> Retrospective chart review. <h3>PATIENT SAMPLE</h3> The study included 599 posterior scoliosis surgery cases performed by three different surgeons between March 2012 and November 2017 at a tertiary pediatric hospital. <h3>OUTCOME MEASURES</h3> Cessation of polyuria and correction of sodium elevation. There were no cases of CDI postoperatively. <h3>METHODS</h3> Retrospective chart review. <h3>RESULTS</h3> Of 599 posterior spine fusions, 9 cases were diagnosed with introperative CDI. Five of nine of there curves were idiopathic and females predominanted. Mean urine output prior to TXA infusion was 1.1 ml/kg/hour and increased to 4.2 ml/kg/hour within 1-3.5 hours of the start of TXA infusion. Concomitantly, mean plasma sodium increased from 137 ± 3.2 mEq/L to 142 ± 3.5 mEq/L. All responded to vasopressin infusion with TXA continuation orcessation of TXA alone. No cases of postoperative CDI were seen. Group 1 (TXA at 1 mg/kg/hr) had 0/363 cases. Group 2 (TXA at 2-5mg/kg/hr) had 9/236 cases. A Fisher's exact test for comparing the Group 1 rate (0%) vs Group 2 rate (3.8%) had a significant p-value of <0.001. <h3>CONCLUSIONS</h3> This is the first reported series of intraoperative CDI development in pediatric deformity correction surgery utilizing TXA infusion. The evidence suggests a dose-dependent association between TXA and CDI. Surgeons and anesthesiologists need to be aware that TXA in pediatric scoliosis surgery can lead to intraoperative CDI. Rapid treatment with vasopressin or cessation of infusion can prevent potential sequelae. <h3>FDA DEVICE/DRUG STATUS</h3> Tranexamic Acid (Approved for this indication)

201. Intraoperative placement of analgesic calcium sulfate beads improves functional outcomes in thoracolumbar spine surgery

201. Intraoperative placement of analgesic calcium sulfate beads improves functional outcomes in thoracolumbar spine surgery

A Multi-surgeon Robotic-guided Thoracolumbar Fusion Experience: Accuracy, Radiation, Complications, Readmissions, and Revisions of 3,874 Screws across Three Robotic Generations

Objective: Robotic guidance provides indirect visualization of key anatomic landmarks to facilitate minimally invasive surgery (MIS) and is emerging as a reliable and accurate technique for posterior spine instrumentation. We sought to describe eight years of experience with robotic guidance at a high-volume, multi-surgeon center. We hypothesize that robotic guidance will lead to (1) low rates of complication, readmissions, and revision surgery, (2) reduced fluoroscopic radiation exposure, (3) and accurate thoracolumbar instrumentation.Methods: A retrospective review of complications, revision surgery, and readmission rates in patients undergoing thoracolumbar fusion surgery utilizing three robotic generations. Secondary analysis was conducted comparing the three robotic generations for complications, revision surgery, accuracy, and readmission rates along with intraoperative fluoroscopic duration. Results: A total of 628 patients (3,874 robotic-guided screws) ages 12–81 years-old (43.9% male) were included in the study. At one year, the cumulative complication incidence was 15.5% with a 10.3% incidence of surgical complications (3.7% wound, 1.2% robot-related, and 5.4% non-robot-related complications). At one year, the revision surgery incidence was 9.4%. There was no statistical difference between complications, readmission, or revision surgery after initial admission among the three robotic generations. The average intraoperative fluoroscopic duration was 53.8 seconds (11.9 seconds per screw and 17.6 seconds per instrumented level).Conclusion: Robotic guidance in thoracolumbar instrumented fusions was associated with low complication, revision surgery, and readmission rates. Our results suggest robotic guidance can provide accurate guidance with minimal adverse events in thoracolumbar instrumentation.

Posterior Instrumented Spinal Surgery Outcomes in the Elderly: A Comparison of the 5-Item and 11-Item Modified Frailty Indices.

Retrospective Cohort. To validate the most concise risk stratification system to date, the 5-item modified frailty index (mFI-5), and compare its effectiveness with the established 11-item modified frailty index (mFI-11) in the elderly population undergoing posterior instrumented spine surgery. A single centre retrospective review of posterior instrumented spine surgeries in patients aged 65years and older was conducted. The primary outcome was rate of post-operative major complications (Clavien-Dindo Classification ≥ 4). Secondary outcome measures included rate of all complications, 6-month mortality and surgical site infection. Multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated and compared by DeLong's test. The indices were correlated with Spearman's rho. 272 cases were identified. The risk of major complications was independently associated with both the mFI-5 (OR 1.89, 95% CI 1.01-3.55, P = .047) and mFI-11 (OR 3.73, 95% CI 1.90-7.30, P = .000). Both the mFI-5 and mFI-11 were statistically significant predictors of risk of all complications (P = .007 and P = .003), surgical site infection (P = .011 and P = .003) and 6-month mortality (P = .031 and P = .000). Adjusted ROC curves determined statistically similar c-statistics for major complications (.68 vs .68, P = .64), all complications (.66 vs .64, P = .10), surgical site infection (.75 vs .75, P = .76) and 6-month mortality (.83 vs .81, P = .21). The 2 indices correlated very well with a Spearman's rho of .944. The mFI-5 and mFI-11 are equally effective predictors of postoperative morbidity and mortality in this population. The brevity of the mFI-5 is advantageous in facilitating its daily clinical use.

Feasibility of Conducting Long-term Health and Behaviors Follow-up in Adolescents: Longitudinal Observational Study.

BackgroundMachine learning uses algorithms that improve automatically through experience. This statistical learning approach is a natural extension of traditional statistical methods and can offer potential advantages for certain problems. The feasibility of using machine learning techniques in health care is predicated on access to a sufficient volume of data in a problem space.ObjectiveThis study aimed to assess the feasibility of data collection from an adolescent population before and after a posterior spine fusion operation.MethodsBoth physical and psychosocial data were collected. Adolescents scheduled for a posterior spine fusion operation were approached when they were scheduled for the surgery. The study collected repeated measures of patient data, including at least 2 weeks prior to the operation and 6 months after the patients were discharged from the hospital. Patients were provided with a Fitbit Charge 4 (consumer-grade health tracker) and instructed to wear it as often as possible. A third-party web-based portal was used to collect and store the Fitbit data, and patients were trained on how to download and sync their personal device data on step counts, sleep time, and heart rate onto the web-based portal. Demographic and physiologic data recorded in the electronic medical record were retrieved from the hospital data warehouse. We evaluated changes in the patients’ psychological profile over time using several validated questionnaires (ie, Pain Catastrophizing Scale, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Pediatric Quality of Life Inventory). Questionnaires were administered to patients using Qualtrics software. Patients received the questionnaire prior to and during the hospitalization and again at 3 and 6 months postsurgery. We administered paper-based questionnaires for the self-report of daily pain scores and the use of analgesic medications.ResultsThere were several challenges to data collection from the study population. Only 38% (32/84) of the patients we approached met eligibility criteria, and 50% (16/32) of the enrolled patients dropped out during the follow-up period—on average 17.6 weeks into the study. Of those who completed the study, 69% (9/13) reliably wore the Fitbit and downloaded data into the web-based portal. These patients also had a high response rate to the psychosocial surveys. However, none of the patients who finished the study completed the paper-based pain diary. There were no difficulties accessing the demographic and clinical data stored in the hospital data warehouse.ConclusionsThis study identifies several challenges to long-term medical follow-up in adolescents, including willingness to participate in these types of studies and compliance with the various data collection approaches. Several of these challenges—insufficient incentives and personal contact between researchers and patients—should be addressed in future studies.

Axial Neck-Shoulder Pain After Posterior Correction and Fusion for Adolescent Idiopathic Scoliosis With Structural Thoracic Curve: Does Cranial Fusion Level Affect Neck Symptoms?

A retrospective cohort study using prospectively collected data. To investigate the incidence and impact of fusion to the upper thoracic spine on neck-shoulder symptoms after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Axial neck-shoulder pain is established as a sequela of posterior cervical spine surgery and is mainly caused by the dissection of extensor muscles in the cervical and upper thoracic spine. Sixty-three female patients with AIS who underwent PSF using segmental pedicle screw constructs for structural main thoracic curve with a minimum 2-year follow-up were included. Axial neck-shoulder pain was assessed using the visual analog scale and cervical spine function domain score of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire. The patients were divided into 2 groups, a higher group (underwent fusion up to T3 or above, n=27) and a lower group (underwent fusion up to T4 or below, n=36), and radiologic and clinical outcomes were compared. The incidence of axial neck-shoulder pain (visual analog scale ≥30) preoperatively and at the 2-year follow-up was 29 and 40%, respectively. The pain and mental health domains of the Scoliosis Research Society-22 and cervical spine function domain of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire were correlated with the severity of axial neck pain. In the comparison of clinical outcomes between the 2 groups, the pain domain score of the Scoliosis Research Society-22 in the lower group was significantly better than that in the higher group at the 2-year follow-up ( P <0.05). Other parameters showed no significant differences preoperatively or at the 2-year follow-up. Female patients with AIS had a relatively high incidence of axial neck-shoulder pain after PSF, which affected their health-related quality of life. Both groups showed similar clinical outcomes, and the cranial fusion level did not affect axial neck-shoulder pain and cervical spine function. Level 3.

Morphological Variations of the Posterior Superior Iliac Spine in Chinese Population: Potential Effects on the Reliability of Palpation.

Objectives The posterior superior iliac spine (PSIS) is an important anatomical landmark often involved in spinal manipulation and surgical bone harvest. Hence, knowledge of variations in the PSIS may be predictive and valuable in clinical settings. Taking the complex morphology into account, the study is aimed at proposing a classification of PSIS in the Chinese population. Methods An anatomical study was undertaken on 288 human ilia. First, the morphological features of variations in the PSIS were noted following visual inspection. Then, 12 variable anatomical parameters were measured in order to determine the differences based on morphology, side, and sex. Results Overall, four types of PSIS were found among 288 bones, including type I “V-shape” (106, 36.8%), type II “U-shape” (121, 42.0%), type III “W-shape” (36, 12.5%), and type IV “ossification-shape” (25, 8.7%). There were no significant sex or bilateral differences in the morphological distribution of the PSIS (p > 0.05). Furthermore, the measurements showed that type I was the narrowest and type III the broadest (p < 0.05). Moreover, female specimens had an overall larger distance and width of surrounding landmarks (p < 0.05), and a significant difference was found in the width of the PSIS between the left and right sides (p < 0.05). Conclusion The PSIS samples displayed multiple morphological variations and could be classified into four types. In addition, sex-based or bilateral differences existed in the size and relative positions. It is thus likely that differences in the morphology and asymmetry of the PSIS provide references for palpation, bone harvest, and other clinical settings.

Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty.

This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty. A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap. Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6 ± 2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5 ± 2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications. Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.

The impact of misplaced percutaneous iliac dynamic reference frame pins used during navigated spine surgery: incidence and outcomes.

Image guidance requires placement of a dynamic reference frame (DRF), often either onto local spinous process or by freehand intraosseous DRF placement into the ilium via the posterior superior iliac spine (PSIS). There is a paucity of studies in the literature that describe the complications of intraosseous DRF placement. The aim of this study was to describe the radiographic location, prevalence and nature of complications, and long-term clinical outcomes of attempted DRF placement into the PSIS. All lumbosacral spine surgical procedures performed between August 2019 and February 2021 at a single institution were queried, and operations in which a DRF was targeted to the PSIS were included. Patient demographic characteristics, indications for surgery, surgical outcomes, and complications were extracted. Intraoperative CT scans were reviewed by 2 independent researchers to determine the accuracy of DRF placement into the PSIS and to assess for DRF malposition. Of 497 lumbar spine operations performed between August 2019 and February 2021 by 4 surgeons, 85 utilized intraoperative navigation with a PSIS pin. Thirteen operations were excluded due to an inability to visualize the entirety of the pin on intraoperative CT. Of 72 DRFs evaluated, 77.8% had been correctly placed in the PSIS. Of the 22.2% of DRFs not placed into the PSIS, 11 entered the sacrum, 6 crossed the sacroiliac joint, and 2 were deep enough to enter the pelvis. Pain at the pin site was present in 4 patients, of whom 3 had resolution of pain at the last follow-up evaluation. There were no significant complications due to DRF placement: no sacral fractures, significant navigation errors, retroperitoneal hematomas, or neurological deficits. Over a mean ± SD follow-up period of 9 ± 5.2 months, there were no incidences of pin site infection. Interrater reliability between the reviewers was 95.8%. This was the first study to examine radiological and clinical outcomes after DRF placement in the PSIS. In this study, a majority of pins were correctly placed within the PSIS, although 22.2% of pins were malpositioned. There were no serious complications, and a majority of those patients with persistent pin site pain had resolution at last follow-up.

X-Ray Cephalometric Analysis of the Effects of Angle Class II and III Malocclusion on the Upper Airway Width and Hyoid Position between Parents and Children of Uygur Nationality.

Objective The objective of this paper is to analyze the effect of angle class II and III malocclusion on the sagittal diameter of the upper airway between parents and children of Uygur nationality and to compare the degree of influence. Methods 29 Uygur adolescents with malocclusion and their fathers (mothers) were selected as our subjects via X-ray cephalometric radiograph to analyze the difference between the upper airway sagittal dimension and normal occlusion and compare the influence of malocclusion on the upper airway between parents and children. Results Compared with normal group, the vertical distance from the hyoid point to orbital-ear plane (H-FH) and vertical distance from hyoid point to the mandibular plane (H-MP) in angle class II malocclusion elevated signally, while the vertical distance from hyoid point to anterior cervical plane (H-VL), PNS-UPW, H-FH, and H-MP decreased significantly; compared with normal group: the distance between the posterior nasal spine and the upper pharynx wall (PNS-UPW), H-FH, and H-MP in angle class III malocclusion visually reduced, while PAS, and horizontal distance from the hyoid point and center point of sella turcica to orbital-ear foot (H-S), increased markedly. The impact of class II malocclusion on parents' U-MPM was greater than their children. Conclusion The oropharyngeal space of upper airway becomes smaller and hyoid shifts downwards due to class II malocclusion. Class III malocclusion results in decreased nasopharyngeal gap with hyoid to shift upward. The influence of class II malocclusion on the upper pharyngeal tract of parents was greater than their children.

Severe dysphagia after a posterior cervical spine fusion at the C1–C3 level and its improvement after correction surgery for malalignment: a case report

BackgroundThe development of dysphagia and trismus following posterior C1–C3 fusion is rare compared to occipitocervical fusion, and there are very few reports in the literature.Case presentationA 75-year-old Thai man who had an extradural tumor at the C1/C2 level developed severe dysphagia and trismus immediately after tumor resection and C1–C3 fusion. During the surgery for malalignment correction, the C1–C2 screws were re-aligned into an increased lordotic position. The symptoms resolved immediately post-surgery.ConclusionsShort upper cervical fusion can produce trismus and dysphagia in a relatively flexed position. Preoperative planning should be individualized based on the patient’s resting neutral alignment to prevent complications.

Computed tomographic evaluation of three types of screw trajectories for posterior cervical spine fixation: Cervical pedicle screw, lateral mass screw, and paravertebral foramen screw.

Computed tomography (CT) attenuation values of cervical spine were evaluated in vivo using a clinically relevant group. To compare CT attenuation values between cervical pedicle screw (CPS), lateral mass screw (LMS), and paravertebral foramen screw (PVFS) trajectories. CPS and LMS are commonly used for posterior fixation of the cervical spine. The PVFS method has been reported as a new method. CT attenuation values along the screw trajectory are reportedly associated with screw stability. We identified 45 patients who had undergone whole-body CT for trauma with no injury to the cervical spine. Regions of interest (ROIs) were designated along the trajectories that would be used for CPS, LMS, and PVFS through vertebral pedicles and lateral masses of the C3-C6 vertebrae. CT attenuation values of each ROI were measured and compared between each screw trajectories at each cervical vertebral level. Participants were divided into Group I (age, 20-39 years; n = 12), Group II (age, 40-59 years; n = 17), and Group III (age, 60-79 years; n = 16). CT attenuation values of ROIs were compared between each age group. PVFS trajectories showed higher CT attenuation values than LMS trajectories at every vertebral level and also higher values than CPS trajectories at C5 and C6 levels. CT attenuation values at C3 were lower than those at C4 in the LMS trajectory and lower than those at C5 and C6 in the PVFS trajectory. CT attenuation values were lower in the elder group (>60 years old) than in the other 2 groups for all screw trajectories. CT attenuation values suggested that the PVFS technique may be useful for posterior fixation of the cervical spine in elder patients who require more secure fixation.

Immediate Effects of Cervical Spine Manipulation Compared With Muscle Energy Technique on Neck Muscle Activity and Range of Motion in Asymptomatic Participants: A Randomized Study

ObjectiveThe purpose of this study was to investigate the immediate effects of cervical spine manipulation (SM) compared with muscle energy technique (MET) on neck muscle activity and range of motion in asymptomatic people. MethodsA randomized parallel-group study was conducted at a chiropractic teaching clinic in Durban, South Africa. Fifty asymptomatic participants between 18 and 35 years of age were randomly assigned into group 1 or group 2. Group 1 received cervical SM, and group 2 received MET. Participants were blinded to group allocation only. Baseline and post-test measurements consisted of resting upper trapezius and posterior cervical muscle activity and cervical spine range of motion (ROM) in lateral flexion and extension. ResultsA significant difference was found in cervical ROM within groups (P < .001), with no significant difference observed between the 2 groups. The right posterior cervical muscles showed a significant difference in group 1 only (P = .012). No significant muscle activity changes occurred in group 2. Resting muscle activity measures showed no statistically significant changes between groups. ConclusionA single application of SM and MET to the cervical spine immediately increased cervical ROM. Neither cervical SM nor MET changed resting posterior cervical and upper trapezius muscle activity.

Cost analysis comparison between anterior and posterior cervical spine approaches.

Background: The costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution.Methods: We performed propensity score matching on financial data from 276 patients undergoing 1–3 level anterior versus posterior cervical fusions for degenerative disease (2015–2019).Results: We found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = −392.3) and length of stay (LOS; β = −1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01).Conclusion: Anterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.

Management of postoperative cervical pseudomeningocele with percutaneous aspiration and epidural blood patch.

While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine. A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed. In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery. Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?

The rigid external distraction (RED) device is reported to have the ability to three-dimensionally reposition the maxilla. The purpose of this study is to assess the ability of RED to intentionally alter the maxillary pitch. Retrospective cohort study. Institutional practice. A retrospective chart review was completed over the past 12 years and a total of 50 patients met the inclusion criteria. Cephalometric changes and alteration in palatal plane angle. Cephalometric analysis of standardized landmarks was completed on calibrated, standardized lateral cephalograms. Pre-distraction and post-consolidation variables were compared via a two-tailed paired t-test. The mean age at surgery of 12.2 ± 3.2 years. Through distraction osteogenesis (DO), the maxilla was moved anteriorly with a mean distraction distance of 8.4 ± 4.8 mm. The mean change in the angles sella-nasion-A-point angle (SNA), sella-nasion-B-point angle (SNB), and A-point-nasion-B-point angle (ANB) were 10.2 ± 4.8, 0.9 ± 2.7, and 9.3 ± 4.1, respectively. The mean change in the palatal plane angle was −4.4 ± 3.7. The mean change in the vertical position of the anterior nasal spine (ANS) and posterior nasal spine (PNS) in relation to the Frankfort horizontal (FH) were −2.0 ± 4.1 mm and 1.7 ± 3.8 mm, respectively. This study documents short-term findings of RED in a large cleft lip and palate (CLP) population. Despite positioning of distraction eyelets superior to the theoretical center of resistance, a counterclockwise (CCW) rotation of the palatal plane occurred. This suggests that adjunctive methods of vector control should be considered if clockwise (CW) rotation of the palatal plane is intended with the RED device.

Navigated, Percutaneous Posterior Cervical Minimally Invasive Surgery Fixation: Technique and Nuances.

Cervical pedicle screw fixation provides a biomechanically superior fixation in comparison to traditional lateral mass screws. The traditional open technique has limited adoption due to technical challenges and significantly increased wound morbidity. Navigated, percutaneous pedicle screw fixation circumvents the traditional technical challenges and minimizes wound morbidity. We present here a technique description and case report of navigated, percutaneous posterior cervical minimally invasive fixation. Small lateral skin incisions are made on the neck using intraoperative computed tomography-guided navigation. Navigated cervical pedicle screws were placed using the proficient minimally invasive system (Spine Wave, Shelton, CT). Minimally invasive cervical fixation options have been limited traditionally. Navigated, percutaneous cervical minimally invasive surgery (MIS) fixation provides an effective, safe option for cervical fixation. This technique is described and illustrated in a case example of a patient who suffered a burst fracture and underwent treatment. Navigated, percutaneous posterior cervical MIS fixation provides biomechanically superior fixation while avoiding the morbidity of traditional, open approaches to the posterior cervical spine. Percutaneous cervical pedicle screw techniques will be pivotal in the continued advancement of posterior cervical decompression and fusion techniques. Navigated, percutaneous cervical minimally invasive fixation is an achievable form of cervical fixation with acceptable complication rates and radiographic outcomes.

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.

A COMPARATIVE STUDY OF SACROILIAC JOINT RADIOFREQUENCY DENERVATION WITH INTRA ARTICULAR SACROILIAC STEROID INJECTION IN PATIENTS WITH SACROILIAC JOINT DYSFUNCTION.

Introduction:To compare and evaluate the efcacy of sacroilliac joint radiofrequency denervation with intra articular sacroiliiac steroid injection in patients of sacroiliiac joint dysfunction as evidence by relief of pain, decrease in analgesic requirement and complications. After clearance from institutional review committee weMethod: included 60 patients in study. Patients were divided in two groups. Group I undergone intraarticular injection and another, radiofrequency denervation of sacroiliac joint.Patient with low back pain with or without leg pain&gt; 3months,ASA 1&amp;2,age group 20-60 years, low back pain below L5 dermatome,tenderness over posterior superior iliac spine, positive faber, Yheomen,Ganeslens and local anaesthetic diagnostic test were included while patient with history of lumbar radicular pain of discogenicorigin,RA, Ankylosing spondylitis, Spondylolisthesis, Vertebral compression or fractures were excluded Results: During pretreatment mean VAS score between two groups, there was no signicant difference (p=0.142).After management ;3 month - no signicant difference between two groups. However, there was signicant difference between two groups at 6months (p=0.022),12 months (p=0.06) and 18 months (p=0.012). Radiofrequncy denervation of sacroiliac joint is best inConclusion: terms of long term pain relief, better functional improvement and minimum side effects

Efficacy and Safety of Subfascial Epidural Drainage Protocol After Intraoperative Durotomy in Posterior Thoracic and Lumbar Spine Surgery: Reoperation Prevention and Outcomes Among Drained and Undrained Cohorts.

Persistent cerebrospinal fluid (CSF) egress after durotomy in posterior thoracic or lumbar spine surgery may cause devastating complications. Persistent CSF leaks may require reoperation, which confers additional cost and morbidity. To evaluate the efficacy of our subfascial epidural drainage protocol in the setting of durotomy to prevent reoperation. A retrospective cohort study of drained and undrained cohorts was completed to identify factors associated with reoperation for persistent CSF leak-related symptoms. The efficacy and safety of this 7-day subfascial epidural drainage protocol was assessed by comparing reoperation incidence, perioperative complications, rehabilitation necessity, and readmissions. In total, 156 patients underwent subfascial epidural drainage, and 14 were not drained. Subfascial drainage for up to 7 days was associated with a significantly lower incidence of reoperation than no drainage (3.3% vs 14%, respectively; P = .03). Perioperative complication incidence was similar between cohorts (12.8% vs 21.4%, respectively; P = .37), and length of stay was unchanged regardless of drainage (median 7 days). Subfascial drainage conferred a nearly 2-fold relative risk reduction in inpatient rehabilitation requirement (RR 0.55) and 3-fold relative risk reduction in 30-day (RR 0.31) and 90-day readmission (RR 0.36). Factors associated with reoperation among drained patients included drainage longer than 7 days, tobacco use, age younger than 50 years, and longer segment operations. Revision spine surgery was associated with reoperation among undrained patients. When followed after durotomy, our subfascial epidural drainage protocol results in fewer reoperations than in an undrained cohort without prohibitive cost and no added morbidity.