BACKGROUND CONTEXT:Pseudarthrosis is a known complication following multilevel anterior cervical discectomy and fusion (ACDF), yet data remain limited on its incidence and risk factors in multilevel procedures in the modern era. PURPOSE:This study aimed to characterize the incidence of pseudarthroses and identify associated risk factors in patients undergoing three- or four-level ACDF procedures without posterior fixation, while also evaluating the potential role of low-dose rhBMP-2 in promoting fusion and supporting anterior-only surgical strategies. STUDY DESIGN:Retrospective single-center observational cohort study. PATIENT SAMPLE:Two hundred and six patients treated by three- or four-level ACDF. OUTCOME MEASURES:Radiological records, including independent review of interspinous motion, Cobb angle, bony bridging, and fusion rate, were collected. Surgical-related information and complications were also recorded. METHODS:A retrospective review of adults who underwent three- or four-level ACDF with anterior plating between 2011 and 2024 was performed at a single academic institution. Patients were excluded if follow-up imaging was <12 months or if they had a prior cervical procedure, corpectomy, or combined anterior-posterior surgery. Demographic, surgical details, and outcome data were collected. Pseudarthrosis was assessed using dynamic flexion-extension radiographs evaluating interspinous motion and change in Cobb angle. When flexion-extension imaging was not available, fusion status was evaluated using static radiographs and/or computed tomography. The primary outcome measure was fusion status at 1 year. Secondary outcome measures were postoperative complications, readmission, and reoperation rates. Continuous variables were reported as median (interquartile range) and compared using the Wilcoxon rank-sum test. Categorical variables were presented as percentages and compared using Pearson's chi-square or Fisher's exact tests when cell counts were low. Multivariable logistic regression was performed to identify independent predictors of outcome variables. RESULTS:A total of 206 patients were included (median age 57 [51-66] years; 59.7% female; 66.0% White). Most underwent three-level fusion (85.9%), and recombinant human bone morphogenetic protein (rhBMP-2) was used in 48.5%. In total, pseudarthroses occurred in 28 patients (13.6%), with 13 (6.3%) patients having symptomatic pseudarthrosis. Pseudarthroses occurred in 13.0% (n=23) of three-level constructs versus 17.2% (n=5) of four-level constructs (p=.56). Pseudarthrosis rates did not vary significantly by implant type. Patients with any smoking history had higher pseudarthrosis rates compared with nonsmokers (23.3% vs. 6.7%, p<.001). Among patients with any smoking history, rhBMP-2 was significantly associated with reduced pseudarthrosis incidence (14.0% vs. 36.1%, p=.017). Among all patients, multivariable logistic regression identified rhBMP-2 use as independently protective of pseudarthrosis (odds ratio=0.15, 95% confidence interval 0.04-0.55, p=.004). However, rhBMP-2 was identified as an independent predictor of increased complication rates (odds ratio=2.70, 95% confidence interval 1.01-7.16, p=.047), with transient dysphagia being the most frequent complication (n=15, 93.8%). CONCLUSIONS:Three- and four-level ACDF without posterior fusion demonstrated much lower nonunion rate compared to historic and recently reported rates, with pseudarthroses occurring in 13.6% of patients and symptomatic pseudarthroses occurring in 6.3% of patients. Among all patients, rhBMP-2 use was associated with 6.7-fold lower odds of pseudarthrosis. Smoking history was strongly associated with nonunion, and rhBMP-2 use appeared to mitigate this risk among smokers. These findings support individualized fusion strategies and selective use of biologic augmentation in high-risk patients.

BACKGROUND CONTEXT Pseudarthrosis is a known complication following anterior cervical discectomy and fusion (ACDF), yet data remain limited on its incidence and risk factors in multilevel procedures in the modern era. PURPOSE To characterize the incidence of pseudarthrosis and identify associated risk factors in patients undergoing 3- or 4-level ACDF procedures without posterior fixation. STUDY DESIGN/SETTING Retrospective single-center observational cohort study. PATIENT SAMPLE A total of 206 patients undergoing 3- or 4-level ACDF. OUTCOME MEASURES Radiographic fusion parameters including interspinous motion, Cobb angle, bony bridging, and fusion status, as well as surgical complications, readmission, and reoperation rates. METHODS A retrospective review of adults who underwent 3- or 4-level ACDF with anterior plating between 2011 and 2024 at a single academic institution was performed. Patients were excluded if follow-up imaging was <12 months or if they had prior cervical procedures, corpectomy, or combined anterior-posterior surgery. Demographic, surgical, and outcome data were collected. Pseudarthrosis was assessed using dynamic flexion-extension radiographs evaluating interspinous motion and Cobb angle changes; when unavailable, static radiographs and/or CT were used. The primary outcome was fusion status at one year. Secondary outcomes included postoperative complications, readmission, and reoperation. Continuous variables were reported as median (interquartile range) and compared using the Wilcoxon rank-sum test. Categorical variables were compared using chi-square or Fisher’s exact tests. Multivariable logistic regression identified independent predictors. RESULTS A total of 206 patients were included (median age 57 [51–66] years; 59.7% female; 66.0% White). Most underwent 3-level fusion (85.9%), and recombinant human bone morphogenetic protein-2 (rhBMP-2) was used in 48.5%. Pseudarthrosis occurred in 28 patients (13.6%), with 13 (6.3%) being symptomatic. Rates were 13.0% in 3-level constructs versus 17.2% in 4-level constructs (p = 0.56). Pseudarthrosis did not vary significantly by implant type. Patients with a smoking history had higher pseudarthrosis rates than nonsmokers (23.3% vs 6.7%, p < 0.001). Among smokers, rhBMP-2 use was associated with reduced pseudarthrosis (14.0% vs 36.1%, p = 0.017). Multivariable analysis identified rhBMP-2 use as independently protective against pseudarthrosis (OR 0.15, 95% CI 0.04–0.55, p = 0.004), but also associated with increased complication rates (OR 2.70, 95% CI 1.01–7.16, p = 0.047), most commonly dysphagia (93.8%). CONCLUSIONS Three- and 4-level ACDF without posterior fusion demonstrated lower nonunion rates than historically reported, with pseudarthrosis occurring in 13.6% of patients and symptomatic cases in 6.3%. Smoking was strongly associated with nonunion, while rhBMP-2 appeared to mitigate this risk in smokers. These findings support individualized surgical strategies and selective use of biologic augmentation in high-risk patients. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

Myotome mapping provides essential anatomical and physiological information in neurosurgical practice. However, current cervical myotome charts are based largely on heterogeneous sources with considerable inconsistency and limited electrophysiological validation. This study aimed to describe a cervical functional myotome map based on amplitude-based triggered electromyography (tEMG) during intraoperative rootlet stimulation in the intradural space in patients undergoing cervical spinal tumor surgery. We retrospectively analyzed 20 patients who underwent cervical spinal tumor resection with intraoperative cervical rootlet stimulation between September 2023 and January 2025. After tumor resection, exposed ventral rootlets were directly stimulated using a bipolar stimulator (0.5 mA) to assess the preserved motor function. tEMG was recorded from trapezius (Tr), deltoid (D), biceps (B), triceps (T), and abductor pollicis brevis (APB). For each rootlet, the maximum tEMG amplitude among repeated stimulations was recorded. Functional mapping was constructed by calculating the mean amplitude per muscle across rootlet levels. A total of 33 cervical rootlets were stimulated. The most frequently stimulated levels were C6 and C8 (each 21.2%), followed by C7, C5, and T1. High-amplitude tEMG responses were recorded in the D from both C4 and C5 rootlets, with C4 eliciting a greater response (1097.0 μV) than C5 (659.4 μV), suggesting that C4 may contribute more significantly to D innervation than traditionally recognized. The C6 rootlet elicited distributed responses across the D, B, T, and, notably, also in the APB. C7 predominantly activated the T and APB, while C8 and T1 produced the highest amplitudes in the APB (1350.6 μV and 2259.7 μV, respectively). Some atypical activation patterns were also observed, such as D activation in response to C8 stimulation. This study presents a quantitative, amplitude-based functional mapping of cervical myotomes using intraoperative rootlet stimulation. Our findings reveal discrepancies from conventional myotome charts. Since all patients in this study had cervical spinal tumors, tumor-related direct or indirect effects on rootlet function may have influenced the amplitude patterns observed. Nevertheless, amplitude-based tEMG mapping may serve as a valuable tool for refining cervical functional myotome charts and improving diagnostic and surgical accuracy in cervical spine disorders.

Objective:Cervical laminoplasty is widely used for multilevel degenerative cervical myelopathy. However, despite its broad clinical application, evidence evaluating its cost-effectiveness in terms of quality-adjusted life years (QALYs) remains limited. In addition, little is known about whether the economic value of laminoplasty differs according to the severity of preoperative myelopathy. This study aimed to evaluate the cost-effectiveness of cervical laminoplasty and to determine whether cost-effectiveness varies across severity groups. Methods:We retrospectively reviewed 116 consecutive patients who underwent cervical laminoplasty for degenerative multilevel cervical stenosis between 2017 and 2022 with a minimum follow-up of 24 months. Patient-reported outcomes (PROs), including the Numeric Rating Scale for neck pain (NRS-neck), Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scores, and Euro Quality of Life-5 Dimension (EQ-5D) index value, were collected at baseline and at 3, 6, 12, and 24 months postoperatively. Two-year QALYs were calculated using the EQ-5D index values. Direct and indirect medical costs were obtained from billing records and converted to 2025 US dollars ($). Missing preoperative mJOA scores were addressed using multiple imputation. Patients were stratified into mild, moderate, and severe myelopathy groups based on imputed mJOA scores. Results:The mean total costs per patient were $5,612.9, and a Cost/QALY gain of $29,604.6. All PROs demonstrated significant improvement at 24 months compared with baseline (P < .05). Total costs did not differ among mild, moderate, and severe myelopathy groups (P = .950). However, QALY gains differed significantly (P < .001), with median values of 0.022, 0.052, and 0.397 for mild, moderate, and severe myelopathy, respectively. Patients with severe disease demonstrated significantly higher utility gains than those with mild or moderate disease (adjusted P < .001), whereas no significant difference was observed between the mild and moderate groups (adjusted P = .521). Conclusion:Cervical laminoplasty was associated with clinical improvement in degenerative cervical myelopathy. Patients with more severe preoperative myelopathy achieved greater QALY gains despite similar costs.

Introduction: This guide reviews vertebral artery (VA) anatomy and anomalies, highlights key considerations for VA injury (VAI) prevention, and provides a step-by-step technique guide for VA exposure in the event of an intraoperative VAI. Surgical Technique: VA exposure begins with packing to obtain hemostatic control. If direct repair is necessary and feasible, dissection is carried out laterally beyond the uncus to expose the transverse process (TP) using a Kerrison rongeur at both the superior and inferior levels. The anterior portion of the TP is removed with a Kerrison to unroof the transverse foramen. Temporary clips can be applied proximal and distal to the injured segment of the VA. Primary repair of the injured VA can be attempted using 7-0 or 8-0 prolene sutures. It is critical to not use hemostatic agents that are flowable, expandable, or contain thrombin as they may pose a risk of embolism and subsequent stroke or neurological injury. Postoperatively, the artery is evaluated with angiography. Conclusion: While iatrogenic VAI is rare, it can lead to severe complications. Here, we present an overview of preoperative and postoperative considerations and a step-by-step technique guide for VA exposure from an anterior approach to the cervical spine.

INTRODUCTION:This guide reviews vertebral artery (VA) anatomy and anomalies, highlights key considerations for VA injury (VAI) prevention, and provides a step-by-step technique guide for VA exposure in the event of an intraoperative VAI. SURGICAL TECHNIQUE:VA exposure begins with packing to obtain hemostatic control. If direct repair is necessary and feasible, dissection is carried out laterally beyond the uncus to expose the transverse process (TP) using a Kerrison rongeur at both the superior and inferior levels. The anterior portion of the TP is removed with a Kerrison to unroof the transverse foramen. Temporary clips can be applied proximal and distal to the injured segment of the VA. Primary repair of the injured VA can be attempted using 7-0 or 8-0 prolene sutures. It is critical to not use hemostatic agents that are flowable, expandable, or contain thrombin as they may pose a risk of embolism and subsequent stroke or neurological injury. Postoperatively, the artery is evaluated with angiography. CONCLUSION:While iatrogenic VAI is rare, it can lead to severe complications. Here, we present an overview of preoperative and postoperative considerations and a step-by-step technique guide for VA exposure from an anterior approach to the cervical spine.

Study Design:Cross-sectional study. Objective: To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia. Summary of Background Data:There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia. Methods: A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants. Results: Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms. Conclusions: Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present.

STUDY DESIGN:A national prospective cervical spine surgery registry was developed to archive radiographic studies, patient-reported outcome measures (PROMs), and surgical implant data to assess long-term safety. OBJECTIVE:To describe the design, development, funding, and implementation of a cervical spine data registry for 1000 patients with myelopathy and radiculopathy. SUMMARY OF BACKGROUND DATA:While surgery for cervical radiculopathy and myelopathy is safe and effective, there is significant practice variation among spine surgeons. While randomized clinical trials (RCTs) can provide high-quality comparative effectiveness data, RCTs lack the ability to evaluate the safety and effectiveness of various surgical procedures and implants among heterogenous real-world patient populations. The CSRS Registry was designed to collect patient demographics, outcomes, radiographic imaging, surgical approach, and implant data for the purpose of conducting high-quality research. METHODS:Patients with cervical myelopathy or radiculopathy were enrolled in the CSRS National Registry. De-identified patient data, validated PROMs, radiographic data, and implant data were collected from multiple clinical sites across the United States. RESULTS:One thousand patients [mean age, 58 y; 456 (46%) women] were enrolled, with 31% follow-up at 1 year. Five hundred ninety-two patients were diagnosed with radiculopathy, 252 with myelopathy, and 156 with radiculopathy and myelopathy. Patients had significant improvements in their PROMs after surgery. At 1 year, the mean NDI score improved from 37.2 to 20.9 ( P <0.001). The mean self-reported P-mJOA score at baseline was 14.2 and improved to 15.2 by 1 year ( P <0.001). Baseline CSDI score was 23.6 and improved with a 1-year decrease to an average score of 13.6 ( P <0.001). There was significant improvement in PROMIS-10 Physical Health score from 41.0 to 45.9 (n=311; P <0.001) at 1-year follow-up. CONCLUSIONS:The CSRS Registry has successfully collected clinical outcomes data that is being leveraged for comparative effectiveness research and evaluations of the long-term safety and effectiveness of spinal implants.

Abstract Background Patients undergo regular clinical follow-up after laminoplasty for cervical myelopathy. However, those whose symptoms significantly improve and remain stable do not need to conform to a regular follow-up schedule. Based on the 1-year postoperative outcomes, we aimed to use a machine-learning (ML) algorithm to predict 2-year postoperative outcomes. Methods We enrolled 80 patients who underwent cervical laminoplasty for cervical myelopathy. The patients’ Japanese Orthopedic Association (JOA) scores (range: 0–17) were analyzed at the 1-, 3-, 6-, and 12-month postoperative timepoints to evaluate their ability to predict the 2-year postoperative outcomes. The patient acceptable symptom state (PASS) was defined as a JOA score ≥ 14.25 at 24 months postoperatively and, based on clinical outcomes recorded up to the 1-year postoperative timepoint, eight ML algorithms were developed to predict PASS status at the 24-month postoperative timepoint. The performance of each of these algorithms was evaluated, and its generalizability was assessed using a prospective internal test set. Results The long short-term memory (LSTM)-based algorithm demonstrated the best performance (area under the receiver operating characteristic curve, 0.90 ± 0.13). Conclusions The LSTM-based algorithm accurately predicted which group was likely to achieve PASS at the 24-month postoperative timepoint. Although this study included a small number of patients with limited available clinical data, the concept of using past outcomes to predict further outcomes presented herein may provide insights for optimizing clinical schedules and efficient medical resource utilization. Trial registration This study was registered as a clinical trial (Clinical Trial No. NCT02487901), and the study protocol was approved by the Seoul National University Hospital Institutional Review Board (IRB No. 1505-037-670).

Objectives Patients with progressive neurologic illness still lack access to quality palliative care services. Barriers to the comprehensive provision of neuropalliative care include gaps in palliative care education. To address this barrier, a novel international model of neuropalliative care education e-learning program was launched in 2022.Methods This is a qualitative study on the self-reported learning outcomes and educational gains of participants of a neuropalliative care e-learning course.Results Thematic analysis shows changes in the participants' perceptions of neuropalliative care and several specific educational gains. After attending the course, participants recognized neuropalliative care as a multiprofessional and interdisciplinary effort requiring more than medical knowledge and disease-specific treatment skills. They gained understanding of the complexity of prognosis in neurological diseases, as well as ethical concepts as the basis to approach difficult decisions. Valuing the needs of patients and caregivers, as well as honest and open communication were recognized as key components of the caring process. In particular, providing emotional support and building relationships to enhance the spiritual component of care were avidly discussed as essential nonmedical treatment options.Significance of results E-learning courses are helping to close the gaps in healthcare professionals' knowledge and skills about neuropalliative care.

BACKGROUND AND OBJECTIVES: In cases where dumbbell-shaped cervical schwannoma encases the vertebral artery (VA), there is a risk of VA injury during surgery. The objective of this study is to propose a strategy for preserving the VA during the surgical excision of tumors adjacent to the VA through the utilization of anatomic layers. METHODS: A retrospective analysis was conducted on 37 patients who underwent surgery for dumbbell-shaped cervical schwannoma with contacting VA from January 2004 to July 2023. The VA encasement group consisted of 12 patients, and the VA nonencasement group included 25 patients. RESULTS: The perineurium acted as a protective barrier from direct VA exposure or injury during surgery. However, in the VA encasement group, 1 patient was unable to preserve the perineurium while removing a tumor adjacent to the VA, resulting in VA injury. The patient had the intact dominant VA on the opposite side, and there were no new neurological deficits or infarctions after the surgery. Gross total resection was achieved in 25 patients (67.6%), while residual tumor was confirmed in 12 patients (32.4%). Four patients (33.3% of 12 patients) underwent reoperation because of the regrowth of the residual tumor within the neural foramen. In the case of the 8 patients (66.7% of 12 patients) whose residual tumor was located outside the neural foramen, no regrowth was observed, and there was no recurrence of the tumor within the remaining perineurium after total resection. CONCLUSION: In conclusion, when resecting a dumbbell-shaped cervical schwannoma contacting VA, subperineurium dissection prevents VA injury because the perineurium acts as a protective barrier.

This study aims to identify healthcare costs indicators predicting secondary surgery for degenerative lumbar spine disease (DLSD), which significantly impacts healthcare budgets. Analyzing data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database of Republic of Korea (ROK), the study included 3881 patients who had surgery for lumbar disc herniation (LDH), lumbar spinal stenosis without spondylolisthesis (LSS without SPL), lumbar spinal stenosis with spondylolisthesis (LSS with SPL), and spondylolysis (SP) from 2006 to 2008. Patients were categorized into two groups: those undergoing secondary surgery (S-group) and those not (NS-group). Surgical and interim costs were compared, with S-group having higher secondary surgery costs ($1829.59 vs $1618.40 in NS-group, P = 0.002) and higher interim costs ($30.03; 1.86% of initial surgery costs vs $16.09; 0.99% of initial surgery costs in NS-group, P < 0.0001). The same trend was observed in LDH, LSS without SPL, and LSS with SPL (P < 0.0001). Monitoring interim costs trends post-initial surgery can effectively identify patients requiring secondary surgery.

Study Design: Cross-sectional study. Objective: To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia. Summary of Background Data: There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia. Methods: A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants. Results: Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms. Conclusions: Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present. Level of Evidence: Level V.

This article explores the transformative impact of telemedicine on spine surgery, tracing its evolution from historic roots to its expansion during the COVID-19 pandemic. The widespread adoption of telemedicine is discussed, highlighting some of its benefits such as increased patient accessibility and satisfaction. Despite its advantages, telemedicine introduces complex legal considerations, specifically concerning licensure, malpractice and data security. The article examines the challenges spine surgeons face when practicing telemedicine across state borders, the nuances of malpractice liability in virtual settings, and the importance of maintaining high standards of care. It also highlights the importance of adhering to HIPAA regulations, ensuring secure data transmission, and navigating reimbursement complexities. This article should serve as a thorough guide for spine surgeons navigating the evolving telemedicine landscape, balancing innovation with patient safety and legal accountability.

Background In recent years, the subspecialty of neuropalliative care has emerged with the goal of improving the quality of life of patients suffering from neurological disease, though gaps remain in neuropalliative care education and training. E-learning has been described as a way to deliver interactive and facilitated lower-cost learning to address global gaps in medical care. We describe here the development of a novel, international, hybrid, and asynchronous curriculum with both self-paced modules and class-based lectures on neuropalliative care topics designed for the neurologist interested in palliative care, the palliative care physician interested in caring for neurological patients, and any other physician or advanced care providers interested in neuropalliative care.Methods The course consisted of 12 modules, one per every four weeks, beginning July 2022. Each module is based on a case and relevant topics. Course content was divided into three streams (Neurology Basics, Palliative Care Basics, and Neuropalliative Care Essentials) of which two were optional and one was mandatory, and consisted of classroom sessions, webinars, and an in-person skills session. Evaluation of learners consisted of multiple choice questions and written assignments for each module. Evaluation of the course was based on semi-structured qualitative interviews conducted with both educator and learner, the latter of which will be published separately. Audio files were transcribed and underwent thematic analysis. For the discussion of the results, Khan's e-learning framework was used.Results Ten of the 12 participating educators were interviewed. Of the educators, three identified as mid-career and seven as senior faculty, ranging from six to 33 years of experience. Nine of ten reported an academic affiliation and all reported association with a teaching hospital. Themes identified from the educators' evaluations were: bridging the global gap, getting everybody on board, defining the educational scope, investing extensive hours of voluntary time and resources, benefiting within and beyond the curriculum, understanding the learner's experience, creating a community of shared learning, adapting future teaching and learning strategies, and envisioning long term sustainability.Conclusions The first year of a novel, international, hybrid, and asynchronous neuropalliative care curriculum has been completed, and its educators have described both successes and avenues for improvement. Further research is planned to assess this curriculum from the learner perspective.

OBJECTIVES:Intraoperative ultrasonography (IOUS) offers the advantage of providing real-time imaging features, yet it is not generally used. This study aims to discuss the benefits of utilizing IOUS in spinal cord surgery and review related literature. MATERIALS AND METHODS:Patients who underwent spinal cord surgery utilizing IOUS at a single institution were retrospectively collected and analyzed to evaluate the benefits derived from the use of IOUS. RESULTS:A total of 43 consecutive patients were analyzed. Schwannoma was the most common tumor (35%), followed by cavernous angioma (23%) and ependymoma (16%). IOUS confirmed tumor extent and location before dura opening in 42 patients (97.7%). It was particularly helpful for myelotomy in deep-seated intramedullary lesions to minimize neural injury in 13 patients (31.0% of 42 patients). IOUS also detected residual or hidden lesions in 3 patients (7.0%) and verified the absence of hematoma post-tumor removal in 23 patients (53.5%). In 3 patients (7.0%), confirming no intradural lesions after removing extradural tumors avoided additional dural incisions. IOUS identified surrounding blood vessels and detected dural defects in one patient (2.3%) respectively. CONCLUSIONS:The IOUS can be a valuable tool for spinal cord surgery in identifying the exact location of the pathologic lesions, confirming the completeness of surgery, and minimizing the risk of neural and vascular injury in a real-time fashion.

BackgroundChin-on-chest deformity is a rare and severely disabling condition characterized by kyphotic deformity in the cervicothoracic spine. To treat this deformity, various osteotomy techniques were described.MethodsA comprehensive literature search of biomedical databases including MEDLINE (via PubMed), Scopus (via Elsevier), Embase (via Elsevier), and Cochrane Library in English from 1/1/1990 to 3/31/2022 was conducted using a combination of text and Medical Subject Headings (MeSH).ResultsThe final analysis included 16 studies. All the studies were assigned a level of evidence of four. Except for two articles, all of the articles were non-comparative studies. A total of 288 patients were included in this review. Of the 288 patients, 107 underwent posterior column extension osteotomy (PCEO), 108 underwent pedicle subtraction osteotomy (PSO), and 33 underwent vertebral column resection osteotomy (VCRO). The most common osteotomy level in fifteen of the studies was C7/T1. The studies included in this review described several techniques for cervical sagittal balance correction. The range of preoperative and postoperative visual analogue scale (VAS) scores was 5.5-8.6 to 1.7-4.91, respectively. The range of preoperative and postoperative neck disability index (NDI) was 34.2-65.4 to 22.1-51.3, respectively. The most common complications were upper extremity paresthesia and hand numbness through the C8 dermatome distribution.ConclusionsCorrective osteotomies provide satisfactory results in patients with chin-on-chest deformity, however, the quality of the included studies limits the evidence.

During the first year of the COVID-19 pandemic, the Republic of Korea (ROK) experienced three epidemic waves in February, August, and November 2020. These waves, combined with the overarching pandemic, significantly influenced trends in spinal surgery. This study aimed to investigate the trends in degenerative lumbar spinal surgery in ROK during the early COVID-19 pandemic, especially in relation to specific epidemic waves. Using the National Health Information Database in ROK, we identified all patients who underwent surgery for degenerative lumbar spinal diseases between January 1, 2019 and December 31, 2020. A joinpoint regression was used to assess temporal trends in spinal surgeries over the first year of the COVID-19 pandemic. The number of surgeries decreased following the first and second epidemic waves (p<0.01 and p = 0.34, respectively), but these were offset by compensatory increases later on (p<0.01 and p = 0.05, respectively). However, the third epidemic wave did not lead to a decrease in surgical volume, and the total number of surgeries remained comparable to the period before the pandemic. When compared to the pre-COVID-19 period, average LOH was reduced by 1 day during the COVID-19 period (p<0.01), while mean hospital costs increased significantly from 3,511 to 4,061 USD (p<0.01). Additionally, the transfer rate and the 30-day readmission rate significantly decreased (both p<0.01), while the reoperation rate remained stable (p = 0.36). Despite the impact of epidemic waves on monthly surgery numbers, a subsequent compensatory increase was observed, indicating that surgical care has adapted to the challenges of the pandemic. This adaptability, along with the stable total number of operations, highlights the potential for healthcare systems to continue elective spine surgery during public health crises with strategic resource allocation and patient triage. Policies should ensure that surgeries for degenerative spinal diseases, particularly those not requiring urgent care but crucial for patient quality of life, are not unnecessarily halted.