Thoracic Spine Surgery Research Articles

Accuracy and Safety of Freehand Placement of Upper Thoracic Pedicle Screws Supported Solely by Anteroposterior, i.e., Frontal, X-Ray Fluoroscopy (C-Arm): Technical Note Including 23 Patients

IntroductionThe biomechanical resistance and the surgical morbidity of spinal posterior pedicle screw fixation relies on the intraosseous position of the implants. Upper thoracic pedicle screws are particularly demanding given their convergence and thin character. We present our experience as military surgeons of free hand placement of upper thoracic pedicle screws supported by antero-posterior, i.e. frontal X-ray fluoroscopy solely. Materials and methodsMonocentric retrospective analysis at Sainte-Anne Military Teaching Hospital between 2017 and 2024 of patients operated on using upper thoracic pedicle screws (levels T1 to T5) using antero-posterior fluoroscopy solely. Results23 patients were included (mean age 59, male/female 3.6), 16 traumas and 7 neoplastic lesions), with 15 cervicothoracic junction fixation and 8 upper thoracic spine surgeries. 124 screws were inserted (T1 to T5). 85% (106/124) were graded 0 (Gertzbein-Robbins scale) whereas 14.5% (18/124) displayed some degree of misplacement (grade 1 to 3): all the T1 screws (22/22) were accurately placed compared to 83% (20/24) of T2 screws, 88% (30/34) of T3 screws, 85% (17/20) of T4 screws, and finally 71% (17/24) of T5 screws, without any clinical consequences. There were 3 surgical revisions (1 asymptomatic misplaced screw, 2 mechanical failures in trauma). Last, 92.7% (n=51/55) of the screws inserted during working hours were accurately placed compared to 79.7% (n=55/69) during after-hours surgeries (p=0.039) ConclusionClinically speaking, placement of upper thoracic pedicle screws using antero-posterior fluoroscopy solely appears safe. The surgical technique is simple enough to be used in strained resources settings such as a mobile field surgical team.

Delayed chylous fluid leakage at the surgical site following thoracic corpectomy via a lateral extracavitary approach: illustrative case.

Chylous fluid leakage following spinal surgery is a rare and potentially difficult-to-manage complication that can lead to wound complications, pain, or nutritional deficiencies. Although the thoracic duct is localized near the thoracic spine, reports of thoracic duct injuries secondary to posterior thoracic spine surgery are rare. The authors present the case of a 57-year-old male with a known history of metastatic renal cell carcinoma to the thoracic spine who had undergone a thoracolumbar fusion with thoracic corpectomy and presented with concern for a chyle leak almost a year after his surgery. The patient had a complicated oncological history and underwent decompression and fusion to treat his significant thoracic metastatic disease. A year later, he presented with back pain and a significant fluid collection at the surgical site, which was drained and found to be consistent with chyle. The patient was treated conservatively, and imaging of the thoracic duct a few months later demonstrated no direct injury, likely indicating either transient injury or potential obstruction of the thoracic duct from metastatic disease. This case demonstrates a rare, potential complication when treating extensive thoracic metastatic disease as well as the workup and potential treatments when facing thoracic duct injury. https://thejns.org/doi/10.3171/CASE24280.

Analysis of risk factors for postoperative delirium in elderly patients undergoing spinal surgery

To investigate the risk factors of postoperative delirium in elderly patients undergoing spine surgery. The basic case data of 566 patients who underwent spine surgery under general anesthesia from January 2021 to January 2023 were retrospectively analyzed. There were 296 males and 270 females with an average age of (71.58 ± 4.21) years old. There were 195 cases of cervical spine surgery, 26 cases of thoracic spine surgery and 345 cases of lumbar spine surgery.According to the occurrence of postoperative delirium, the patients were divided into postoperative delirium group(41 patients) and non-delirium group (525 patients). Univariate analysis was used to analyze the possible influencing factors such as gender, age, weight, smoking history, drinking history, surgical site, preoperative anxiety, intraoperative hypotension times, blood loss and so on, and binary Logistic regression was used to analyze the univariate factors with P<0.05. A total of 41 patients developed postoperative delirium. Univariate analysis showed that age (P=0.000), duration of surgery (P=0.039), preoperative anxiety (P=0.001), blood loss (P=0.000), history of opioid use (P=0.003), history of stroke (P=0.005), C-reactive protein (P=0.000), sodium ion(P=0.000) were significantly different between delirium group and non-delirium group. These factors were included in the binary Logistic regression analysis, and the results showed that age [OR=0.729, 95%CI(0.569, 0.932), P=0.012], opioid use [OR=21.500, 95%CI(1.334, 346.508), P=0.031], blood loss [OR=0.932, 95%CI(0.875, 0.993), P=0.029], C-reactive protein [OR=0.657, 95%CI(0.485, 0.890), P=0.007], preoperative anxiety [OR=23.143, 95%CI(1.859, 288.090), P=0.015], and sodium [OR=1.228, 95%CI(1.032, 1.461), P=0.020] were independent risk factors for the development of delirium after spinal surgery in elderly patients. Age, opioid use, blood loss, preoperative anxiety, elevated c-reactive protein, and hyponatremia are independent risk factors for the development of postoperative delirium in elderly patients undergoing spinal surgery.

Assessing the Accuracy and Safety Thresholds of Patient-Specific Screw Guide Template System in Cervical and Thoracic Spine Surgeries Using DAST Measurements.

To analyze the reliability of the newly developed patient-specific Screw Guide Template (SGT) system as an intraoperative navigation device for spinal screw insertion. We attempted to place 428 screws for 51 patients. The accuracy of the screw track was assessed by deviation of the screw axis from the preplanned trajectory on postoperative CT. The safety of the screw insertion was evaluated by the bone breach of the screw. The bone diameter available for screw trajectory (DAST) was measured, and the relations to the bone breach were analyzed. In the inserted screws, 98.4% were defined as accurate, and 94.6% were contained in the target bone. In the cervical spine, the screw deviation between breaching (0.57 mm) and contained screws (0.43 mm) did not significantly differ, whereas DAST for breaching screws (3.62 mm) was significantly smaller than contained screws (5.33 mm) (p<0.001). Cervical screws with ≥4.0 mm DAST showed a significantly lower incidence of bone breach (0.4%) than ≤3.9 mm DAST (28.3%) (p<0.001). In the thoracic spine, screw deviation and DAST had significant differences between breaching (1.54 mm, 4.41 mm) and contained (0.75 mm, 6.07 mm) (p<0.001). The incidence of the breach was significantly lower in thoracic screws with ≥5.0 mm (1.9%) than ≤4.9 (21.9%) DAST (p<0.001). This study demonstrated that our SGT system could support precise screw insertion for 98.4% accuracy and 94.6% safety. DAST was recommended to be ≥4.0 and ≥5.0 mm in the cervical and thoracic spines for safe screw insertion.

Differences in the Demographics and Clinical Characteristics between the Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum in Patients Who Underwent Thoracic Spinal Surgery for Compressive Myelopathy.

Ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) are related diseases associated with the ossification of spinal ligaments that can occasionally lead to thoracic myelopathy. We retrospectively analyzed the clinical data of 34 consecutive patients who underwent thoracic spinal surgeries for OPLL and/or OLF at our hospital between July 2010 and June 2022, and statistically compared data between patients with thoracic OPLL (TOPLL; n = 12) and those with thoracic OLF (TOLF; n = 22). The mean age of the TOPLL group was significantly lower than that of the TOLF group (53.7 vs. 68.4 years). The TOPLL group exhibited a greater female predominance than the TOLF group (58.3% vs. 18.2%). The median body mass index of the TOPLL group was significantly higher than that of the TOLF group (33.0 vs. 26.0 kg/m2). Patients with TOPLL significantly required instrumented fusion and repetitive surgical intervention more than those with TOLF (83.3% vs. 9.1%; 50.0% vs. 0.0%). Although neurological deterioration just after the intervention was more common in patients with TOPLL (41.7% vs. 4.6%), no difference was observed in thoracic Japanese Orthopaedic Association score and recovery rate in the chronic phase between TOPLL and TOLF. The TOPLL group had a younger onset, female dominance, and a greater degree of obesity when compared with the TOLF group. The surgery for TOPLL is challenging, considering that it requires long-range decompression and fusion, subsequent operations, careful management, and long-term follow-up, when compared to TOLF, which necessitates only simple decompression.

Postoperative Thoracic Cord Compression Induced by a Dural Sealant System (DuraSeal®): A Case Report and Literature Review

Cerebrospinal fluid (CSF) leakage is a rare complication that can occur due to dural defects during spinal surgery, hindering the improvement of the surgical site and increasing the possibility of infection. DuraSeal® is a dural sealing adhesive that prevents CSF leakage and is used as an adjunct to enable the watertight repair of dural defects when the dura is damaged during spinal surgery. In the present case, DuraSeal® was applied to repair a dural defect in the surgical area after thoracic spine surgery, and no neurological problems occurred immediately after surgery. However, a day later, the patient’s paraparesis worsened; therefore, reoperation was performed and the symptoms improved.

Differences in microorganisms causing infection after cranial and spinal surgeries.

The primary aim of this retrospective study was to assess differences in the pathogens causing surgical site infections (SSIs) following craniectomies/craniotomies and open spinal surgery. The secondary aim was to assess differences in rates of SSI among these operative procedures. ANOVA tests with Bonferroni correction and incidence risk ratios (RRs) were used to identify differences in pathogens by surgical site and procedure using retrospective, de-identified records of 19,993 postneurosurgical patients treated between 2007 and 2020. The overall infection rates for craniotomy/craniectomy, laminectomy, and fusion were 2.1%, 1.1%, and 1.5%, respectively, and overall infection rates for cervical, thoracic, and lumbar spine surgery were 0.3%, 1.6%, and 1.9%, respectively. Craniotomy/craniectomy was more likely to result in an SSI than spine surgery (RR 1.8, 95% CI 1.4-2.2, p < 0.0001). Cutibacterium acnes (RR 24.2, 95% CI 7.3-80.0, p < 0.0001); coagulase-negative staphylococci (CoNS) (methicillin-susceptible CoNS: RR 2.9, 95% CI 1.6-5.4, p = 0.0006; methicillin-resistant CoNS: RR 5.6, 95% CI 1.4-22.3, p = 0.02); Klebsiella aerogenes (RR 6.5, 95% CI 1.7-25.1, p = 0.0003); Serratia marcescens (RR 2.4, 95% CI 1.1-7.1, p = 0.01); Enterobacter cloacae (RR 3.1, 95% CI 1.2-8.1, p = 0.02); and Candida albicans (RR 3.9, 95% CI 1.2-12.3, p = 0.02) were more commonly associated with craniotomy/craniectomy cases than fusion or laminectomy SSIs. Pseudomonas aeruginosa was more commonly associated with fusion SSIs than craniotomy SSIs (RR 4.4, 95% CI 1.3-14.8, p = 0.02), whereas Escherichia coli was nonsignificantly associated with fusion SSIs compared to craniotomy SSIs (RR 4.1, 95% CI 0.9-18.1, p = 0.06). Infections with E. coli and P. aeruginosa occurred primarily in the lumbar spine (p = 0.0003 and p = 0.0001, respectively). SSIs due to typical gastrointestinal or genitourinary gram-negative bacteria occur most commonly following lumbar surgery, particularly fusion, and are likely to be due to contamination of the surgical bed with microbial flora in the perianal area and genitourinary tract. Cutibacterium acnes in the skin flora of the head and neck increases risk of infection due to this microbe following surgical interventions in these body sites. The types of gram-negative bacteria associated with craniotomy/craniectomy SSIs suggest potential environmental sources of these pathogens. Based on the authors' findings, neurosurgeons should consider using a two-step skin preparation with benzoyl peroxide, in addition to a standard antiseptic such as alcoholic chlorhexidine for cranial, cervical, and upper thoracic surgeries. Additionally, broader gram-negative bacterial coverage, such as use of a third-generation cephalosporin, should be considered for lumbar/lumbosacral fusion surgical antibiotic prophylaxis.

A Case of an Iatrogenic Pseudomeningocele after Thoracic Spinal Cord Tumor Surgery with a Long-Term Follow-Up.

A Case of an Iatrogenic Pseudomeningocele after Thoracic Spinal Cord Tumor Surgery with a Long-Term Follow-Up.

ПРЕИМУЩЕСТВА СТРАТЕГИИ МАЛОИНВАЗИВНОЙ ТОРАКОЭНДОСКОПИЧЕСКОЙ ХИРУРГИИ ПРИ ОПЕРАТИВНЫХ ВМЕШАТЕЛЬСТВАХ НА ГРУДНОМ ОТДЕЛЕ ПОЗВОНОЧНИКА

The technology of video-assisted minimally invasive interventions on the thoracic spine is a promising direction in surgical endoscopy. Thoracic endoscopic spine surgery is effective for the diagnosis and treatment of various pathologies (tumors, inflammation, deformities, degenerative-dystrophic lesions, injuries). The advantages of thoracic endoscopic interventions are – trauma/injury reduction, reduced blood loss, full visualization of the operation area, the ability to control the allocation of surgical instruments, early activation and rehabilitation of patients as a result of minimally invasive technology, reduced hospital stay and treatment costs. Video-assisted minimally invasive interventions on the thoracic spine are a promising area of surgical endoscopy. The use of thoracoscopic technology allows us to move to a qualitatively new level of surgical interventions from anterior surgical approaches for various pathologies of the thoracic spine (tumors, deformities, degenerative-dystrophic lesions, injuries, inflammatory processes).

Skin closure using skin staples may have higher risk for surgical site infection compared to running subcuticular skin closure with absorbable suture in posterior thoracic and lumbar spine surgeries

Skin closure using skin staples may have higher risk for surgical site infection compared to running subcuticular skin closure with absorbable suture in posterior thoracic and lumbar spine surgeries

Risk Factor Analysis of Surgery-related Complications in Primary Thoracic Spine Surgery for Degenerative Diseases and Characteristics of the Patients Also Undergoing Surgery on the Cervical and/or Lumbar Spine.

A retrospective cohort study using prospectively collected data. This study primarily aimed to investigate the risk factors for surgery-related complications in primary thoracic spine surgery for degenerative diseases using a surgeon-maintained database. The secondary purpose was to elucidate the characteristics of surgically treated thoracic myelopathy that also required cervical and/or lumbar spine surgery in the study period. Few studies reported surgical complications and the feature of tandem spinal stenosis in thoracic myelopathy in detail because of their rarity. This study included 840 thoracic myelopathy patients undergoing primary surgery for degenerative diseases from 2012 to 2021, investigating the effects of diseases, surgical procedures, and patient demographics on postoperative neurological deterioration, dural tear, dural leakage, surgical-site infection, and postoperative hematoma. In thoracic myelopathy patients who were surgically treated and also undergoing cervical and/or lumbar surgery, we investigated the proportion, the effects of diseases, and the order and intervals between surgeries. Multivariate logistic regression revealed that significant risk factors ( P <0.05) for postoperative neurological deterioration were intervertebral disk herniation [odds ratio (OR): 4.59, 95% confidence interval (CI): 1.32-16.0) and degenerative spondylolisthesis (OR: 11.1, 95% CI: 2.15-57.5). Ossification of the ligamentum flavum (OR: 4.12, 95% CI: 1.92-8.86), anterior spinal fusion (OR: 41.2, 95% CI: 4.70-361), and circumferential decompression via a posterior approach (OR: 30.5, 95% CI: 2.27-410) were risk factors for dural tear. In thoracic myelopathy patients surgically treated, 37.0% also underwent degenerative cervical and/or lumbar surgery. Pathologies involving anterior decompression and instability increased the risk of postoperative neurological deterioration. The risk of dural tear was increased when dura mater adhesions were likely to be directly operated upon. It should be recognized that a relatively high proportion (37.0%) of surgically treated thoracic myelopathy patients also underwent cervical and/or lumbar surgery.

Tetraparesis following thoracic spine surgery in a patient with Klippel–Feil syndrome and ABCB4 mutation: a case report

BackgroundKlippel–Feil syndrome is a rare condition described in 1912 by Maurice Klippel and André Feil. It is defined as a congenital cervical fusion of at least two vertebrae, associated with a classical triad of clinical signs: short neck, low posterior hairline, and limited range of movement. However, Klippel–Feil syndrome manifests with a vast spectrum of phenotypes, ranging from no symptoms to complete triad, with or without other associated malformations. Most commonly, CCF results from sporadic mutations, even though autosomal recessive, autosomal dominant, or even X-linked inheritance can be detected. The ATP-binding cassette subfamily B member 4 is only expressed in the liver and is involved in biliary phospholipid secretion. The clinical spectrum includes various hepatobiliary pathologies, including low phospholipid-associated cholelithiasis, and has never been associated with musculoskeletal anomalies.Case presentationA 55-year-old male Caucasian patient presenting with low phospholipid-associated cholelithiasis syndrome with ATP-binding cassette subfamily B member 4 mutation and liver cirrhosis was referred to our clinic for a liver transplant. A period of 6 months before, the patient underwent a T7–T9 posterior fixation for a T8 osteoporotic fracture. Postoperatively, he was tetraparetic, whereas he was neurologically intact before the operation. At admission to our hospital, he was still tetraparetic and presented with clinical signs of cervical myelopathy. Moreover, he suffered a limitation of cervical range of motion in all directions, short neck, and low posterior hairline. Imaging showed multiple cervical and thoracic vertebral bodies fusion, as well as cervical spine stenosis. Based on the available data, we diagnosed a type 3 Klippel–Feil syndrome according to Samartzis’ classification.ConclusionsThe heterogeneity of KFS and the various potential hereditary links that are known indicate that it is important to highlight all potential cases related to known genetic defects. At present, no association between ATP-binding cassette subfamily B member 4 mutation and congenital cervical fusions has been reported. The other important clinical focus of this case is the appearance of spontaneous tetraparesis after thoracic spine surgery. This mechanism remains unclear, but considering different spinal anatomy it might have been due to difficult intubation and patient’s positioning during his previous operation.

Validity of evoked potential as biomarker for predicting early neural function changes after thoracic spinal decompression surgery in patients with neurological deficits.

To evaluate the validity of intraoperative evoked potential (EP) including motor evoked potential (MEP) and somatosensory evoked potentials (SEP) as a biomarker for predicting neural function changes after thoracic spinal decompression (TSD) surgery. A consecutive series of 336 TSD surgeries were reviewed between 2010 and 2021 from four spine center. All patients with TSD were divided into 3 groups according to different intraoperative EP results: group 1, EP alerts; group 2, no obvious EP deterioration; group 3, EP improvement compared with baselines. The lower limb Japanese Orthopedic Association (JOA) scores (as well as early and long-term JOA recovery rate) were utilized to quantitatively assess pre- and postoperative neural function change. Among the 3 subgroups according to the different EP changes, the early JOA recovery rate (RR%) in the EP improvement group was significantly better than the other two groups (51.3 ± 58.6* vs. 27.5 ± 31.2 and 33.3 ± 43.1; p < 0.01) after 3-month follow-up. The mean MEP and SEP amplitude were from 116 ± 57µV to 347 ± 71µV (p < 0.01) and from 1.86 ± 0.24µV to 2.65 ± 0.29µV (p < 0.01) between spinal cord pre-decompression and post-decompression. Moreover, multivariate logistic regression analysis revealed that risk factors of EP improvement were duration of symptom (p < 0.001, OR 10.9) and Preop. neurologic deficit degree (p = 0.013, OR 7.46). The intraoperative EP can predict postoperative neural function changes as a biomarker during TSD. Patient with EP improvement probably has better prognosis for early neural function recovery. The duration of symptom and preoperative neurologic deficit degree may be related to intraoperative EP improvement.

Overview and Prevention of Complications During Biportal Endoscopic Thoracic Spine Surgery

Objective: Although the unilateral biportal endoscopy (UBE) technique has remarkable advantages, thoracic laminectomy by UBE is technically difficult and can potentially lead to serious complications. By reviewing previous articles on thoracic laminectomy by UBE, we aimed to identify the complications of thoracic laminectomy by UBE and to establish specific surgical strategies to avoid complications.Methods: A literature search was performed using the National Center for Biotechnology Information database using the PubMed/MEDLINE search engine. There are 3 published clinical studies in which at least one of these approaches has been performed.Results: In previous articles, several cases of perioperative complications were observed, including spinal cord injury, hyperalgesia, cerebrospinal fluid leakage, headache or neck pain, insufficient decompression, epidural hematoma, subdural hematoma, excessive facet resection, and delayed spinous process fracture.Conclusion: UBE technique has remarkable advantages, but endoscopic thoracic surgery is technically challenging and has the potential to cause serious complications. For avoidable complications, surgeons should be familiar with prevention methods and pitfalls to minimize complications.

Variability of somatosensory evoked potential and motor evoked potential change criteria in thoracic spinal decompression surgery based on preoperative motor status

Background contextCombined somatosensory- and motor-evoked potential (SSEP and MEP) changes for predicting prognosis in thoracic spinal surgery have been variably reported. PurposeWe aimed to explore the validity of combined SSEP and MEP for predicting postoperative motor deficits (PMDs) in thoracic spinal decompression surgery (TSDS) and identify a relatively optimal neurophysiological predictor of PMDs in patients based on preoperative motor status. Study settingRetrospective study. Patient sampleA total of 475 patients were analyzed. Outcome MeasuresA reduction in muscle strength by more than or equal to one manual muscle testing (MMT) grade postoperatively compared with the preoperative MMT grade was identified as PMDs. Postoperative motor deficits were detected by comparing the preoperative and postoperative physical examination findings in short- and long-term follow-up visits. MethodsAll patients were divided into two subgroups according to preoperative motor status. The following data were collected: (1) demographic data; (2) IONM (intraoperative neuromonitoring) data; and (3) postoperative motor outcomes. Binary logistic regression analysis was performed to assess the efficacy of IONM change to predict PMDs. A receiver operating characteristic curve (ROC) was used to establish optimal IONM warning criteria. ResultsNinety-eight patients had severe preoperative motor deficits (Group S), and 377 patients did not (Group N). MEP and SSEP change was effective for predicting PMDs in the short term (p<.01) and long term (p<.01) for TSDS patients. In Group N, the cutoff values for predicting PMDs in the short term were a decrease of 65% in SSEP amplitude and 89.5% in MEP amplitude of the baseline value. Furthermore, the cutoff values for predicting PMDs in the short term were durations of change of 24.5 minutes for SSEP and 32.5 minutes for MEP. In Group S, however, the cutoff values for predicting PMDs in the short term were a decrease of 36.5% in SSEP amplitude and 59.5% in MEP amplitude of the baseline value. Moreover, the critical values for predicting short-term PMDs were durations of change of 16.5 minutes for SSEP and 17.5 minutes for MEP. ConclusionsThe optimal IONM changes for prediction vary depending on preoperative motor status. Combined SSEP and MEP are excellent for predicting PMDs in TSDS.

Postoperative Recovery of Gait Function at Early Phase Is Delayed in Patients with Spinal Tumors with Impairment of the Joint Position Sense in the Big Toe: A Retrospective Cohort Study.

We investigated the effect of preoperative joint position sense in the big toe on the postoperative recovery of gait function after spinal tumor surgery. Seventy-three patients with spinal tumors who underwent surgery at our hospital between 2014 and 2019 and could be followed for at least 6 months after surgery were included. The patients were divided into the cervical spinal (41 cases) and thoracic spinal (32 cases) groups according to the localization of the tumor. These groups were further classified into an Impaired group (cervical spinal, 34 cases; thoracic spinal, 19 cases) and an Intact group (cervical spinal, 7 cases; thoracic spinal, 13 cases) according to the presence or absence of preoperative joint position sense in the big toe. The amount of change in ambulatory function from the preoperative period to 3 and 6 months postoperatively was compared between the Impaired and Intact groups within each tumor localization category. Impaired preoperative joint position sense in the big toe in patients undergoing thoracic spinal tumor surgery delayed the recovery of gait function in the early postoperative period. In patients with thoracic spinal tumor surgery, the absence of preoperative joint position sense in the big toe delayed the recovery of postoperative gait function.

Impact of Preoperative Motor Status for the Positive Predictive Value of Transcranial Motor-Evoked Potentials Alerts in Thoracic Spine Surgery: A Prospective Multicenter Study by the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research.

Prospective multicenter study. To investigate the validity of transcranial motor-evoked potentials (Tc-MEP) in thoracic spine surgery and evaluate the impact of specific factors associated with positive predictive value (PPV). One thousand hundred and fifty-six cases of thoracic spine surgeries were examined by comparing patient backgrounds, disease type, preoperative motor status, and Tc-MEP alert timing. Tc-MEP alerts were defined as an amplitude decrease of more than 70% from the baseline waveform. Factors were compared according to preoperative motor status and the result of Tc-MEP alerts. Factors that showed significant differences were identified by univariate and multivariate analysis. Overall sensitivity was 91.9% and specificity was 88.4%. The PPV was significantly higher in the preoperative motor deficits group than in the preoperative no-motor deficits group for both high-risk (60.3% vs 38.3%) and non-high-risk surgery groups (35.1% vs 12.8%). In multivariate logistic analysis, the significant factors associated with true positive were surgical maneuvers related to ossification of the posterior longitudinal ligament (odds ratio = 11.88; 95% CI: 3.17-44.55), resection of intradural intramedullary spinal cord tumor (odds ratio = 8.83; 95% CI: 2.89-27), preoperative motor deficit (odds ratio = 3.46; 95% CI: 1.64-7.3) and resection of intradural extramedullary spinal cord tumor (odds ratio = 3.0; 95% CI: 1.16-7.8). The significant factor associated with false positive was non-attributable alerts (odds ratio = .28; 95% CI: .09-.85). Surgeons are strongly encouraged to use Tc-MEP in patients with preoperative motor deficits, regardless of whether they are undergoing high-risk spine surgery or not. Knowledge of PPV characteristics will greatly assist in effective Tc-MEP enforcement and minimize neurological complications with appropriate interventions.

Complications of Endoscopic Thoracic Spine Surgery: Overview and Complication Avoidance

In endoscopic thoracic spine surgery, adaptations of thoracic surgical techniques such as full endoscopic uniportal and biportal surgical techniques have been developed. Full endoscopic uniportal surgery for thoracic disc herniation or thoracic ossified ligamentum flavum (OLF) has been performed via transforaminal and interlaminar approaches. In the case of thoracic OLF or thoracic spinal stenosis, the uniportal interlaminar approach is appropriate. The uniportal interlaminar approach has been used to treat thoracic OLF and has shown good surgical results. Thoracic OLF removal via a biportal endoscopic technique has been developed recently and is described in a few studies. Although endoscopic thoracic spine surgery has significant advantages, complications often occur with this approach. We reviewed the literature to date on the complications associated with endoscopic spine surgery in thoracic pathology. This review emphasizes how to avoid and manage complications. Based on the results of several previous studies, endoscopic thoracic spine surgery could be associated with fewer potential complications than conventional surgery. Endoscopic spine surgery has remarkable advantages; however, endoscopic thoracic surgery is technically challenging and is potentially associated with serious complications. To minimize the risk of avoidable complications, surgeons should be familiar with prevention methods and pitfalls.

Paraspinal interfascial plane block for thoracic spine surgery in a paediatric patient - A case study.

Paraspinal interfascial plane block for thoracic spine surgery in a paediatric patient - A case study.

Radiation doses and accuracy of navigated pedicle screw placement in cervical and thoracic spine surgery: a comparison of sliding gantry CT and mobile cone-beam CT in a homogeneous cohort.

Multiple solutions for navigation-guided pedicle screw placement are currently available. Intraoperative imaging techniques are invaluable for spinal surgery, but often there is little attention paid to patient radiation exposure. This study aimed to compare the applied radiation doses of sliding gantry CT (SGCT)- and mobile cone-beam CT (CBCT)-based pedicle screw placement for spinal instrumentation. The authors retrospectively analyzed 183 and 54 patients who underwent SGCT- or standard CBCT-based pedicle screw placement, respectively, for spinal instrumentation at their department between June 2019 and January 2020. SGCT uses an automated radiation dose adjustment. Baseline characteristics, including the number of screws per patient and the number of instrumented levels, did not significantly differ between the two groups. Although the accuracy of screw placement according to Gertzbein-Robbins classification did not differ between the two groups, more screws had to be revised intraoperatively in the CBCT group (SGCT 2.7% vs CBCT 6.0%, p = 0.0036). Mean (± SD) radiation doses for the first (SGCT 484.0 ± 201.1 vs CBCT 687.4 ± 188.5 mGy*cm, p < 0.0001), second (SGCT 515.8 ± 216.3 vs CBCT 658.3 ± 220.1 mGy*cm, p < 0.0001), third (SGCT 531.3 ± 237.5 vs CBCT 641.6 ± 177.3 mGy*cm, p = 0.0140), and total (SGCT 1216.9 ± 699.3 vs CBCT 2000.3 ± 921.0 mGy*cm, p < 0.0001) scans were significantly lower for SGCT. This was also true for radiation doses per scanned level (SGCT 461.9 ± 429.3 vs CBCT 1004.1 ± 905.1 mGy*cm, p < 0.0001) and radiation doses per screw (SGCT 172.6 ± 110.1 vs CBCT 349.6 ± 273.4 mGy*cm, p < 0.0001). The applied radiation doses were significantly lower using SGCT for navigated pedicle screw placement in spinal instrumentation. A modern CT scanner on a sliding gantry leads to lower radiation doses, especially through automated 3D radiation dose adjustment.