To identify the incidence and clinical outcomes of spinopelvic fixation loosening following surgical correction of adult spinal deformity (ASD). A single-institution retrospective cohort of 152 consecutive patients meeting inclusion criteria who underwent long-segment fusion with pelvic fixation for correction of ASD was reviewed. Pelvic screws were assessed on follow-up post-operative standing radiographs for evidence of loosening. Surgical revision of spinal instrumentation served as the primary outcome. PROMIS Pain Interference and Physical Function T-Scores were assessed as secondary outcomes among the subset of cases (n = 92) with available scores. Pelvic screw loosening was appreciated in 25 cases (16.4

Background:The prevalence of cervical spondylotic myelopathy (CSM) is increasing annually and represents a large burden of disability. Anterior cervical discectomy and fusion (ACDF), posterior cervical decompression (PCD), and PCD and fusion (PCDF) are commonly used surgical approaches to address this pathology. This single-institution retrospective cohort of ACDFs, PCDFs, and PCDs compares readmission rates and the incidence/indication for reoperation at 90-day, 1-year, and 2-year follow-up. Methods:Patients undergoing ACDF, PCD, or PCDF between 2013 and 2019 were identified using CPT codes. Charts were reviewed for demographics, surgical characteristics, and reoperations. Statistical analysis included t-tests for continuous variables and χ2 testing for categorical variables. Results:A total of 366 patients undergoing 175 ACDFs, 86 PCDFs, and 105 PCDs were included. Initial analysis of complications by surgical approach showed that the rate of reoperation was significantly higher in the PCDF group at 30-day and 1-year (P<0.001, P=0.003) with no difference at 2-year. Overall readmission rate over 1 year was 30.6%, and there was no significant difference between groups. Subsequent analyses demonstrated that patients undergoing PCDF or PCD had significantly higher Charleston Comorbidity Indices (CCI) than ACDF patients (P<0.001). Upon controlling for CCI in regression analyses, neither reoperation nor readmission rates varied significantly by surgical approach. Conclusions:In our cohort, we observe advantages and limitations for each surgical approach. On examination of patient factors, patients undergoing PCDF and PCD tended to have a higher burden of comorbidities compared to those treated via an anterior approach. Upon controlling for comorbidity index, the observed difference in reoperation rates was no longer apparent. Thus, patient comorbidities, rather than surgical approach, may be the major driver for postoperative complications for treatment of CSM.

BACKGROUND CONTEXT Occupational radiation exposure, particularly from intraoperative fluoroscopy, has raised concerns about long-term cancer risk for spine surgeons. Prior studies suggest that cumulative exposure over a career may elevate stochastic risk. However, few investigations have converted routine dosimeter readings into standardized, organ-specific effective doses or estimated lifetime cancer risk under contemporary protective practices. This study quantified surgeon exposure during spine surgery and contextualized associated stochastic risk. PURPOSE This study aimed to develop a quantitative framework that translates routine dosimeter measurements into organ-specific effective doses and estimates lifetime attributable cancer risk for spine surgeons under contemporary fluoroscopy protocols. STUDY DESIGN/SETTING N/A PATIENT SAMPLE N/A OUTCOME MEASURES N/A METHODS Radiation exposure was prospectively measured for a single spine-focused neurosurgeon during 65 consecutive surgeries over nine months. Dosimeters were placed over and under the lead apron, on surgical loupes (lens dose), and on the dominant hand (extremity dose). Whole-body effective dose was calculated using standard vendor and National Council on Radiation Protection and Measurements (NCRP) 2-badge methods, and organ-specific equivalent doses were derived from International Commission on Radiological Protection (ICRP) tissue weighting factors. Lifetime attributable cancer risk (LAR) was estimated using BEIR VII nominal cancer risk coefficients (5% per Sv). RESULTS Cumulative over- and under-apron doses were 176 mrem and 8 mrem, confirming effective shielding. Combined badge effective dose was 0.190 mSv (vendor) and 0.084 mSv (NCRP), well below occupational limits. Lens and hand doses were 1.525 mSv and 3.29 mSv, respectively. Organ-specific effective doses ranged from 0.00084 to 0.01008 mSv, with the highest exposure in lung, colon, and stomach tissues. Using BEIR VII coefficients to scale organ-specific doses, total LAR was 0.00042%, roughly one excess cancer per 240,000 surgeons. CONCLUSIONS While cumulative lifetime exposure could increase risk, modern fluoroscopy protocols and standard protective measures keep spine surgeon exposure extremely low. Importantly, by calculating organ-specific effective doses, this study demonstrates how radiation exposure varies across different tissues. This approach translates routine dosimeter readings into biologically meaningful metrics, offering a practical tool for occupational safety. It further provides reassurance regarding contemporary protective measures and a framework for future guidelines and epidemiologic studies aimed at minimizing risk. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

OBJECTIVE Surgical correction of adult spinal deformity (ASD) is associated with a high rate of hardware complication that can be challenging to predict. Hardware integrity and alignment after surgery are typically followed with standing radiography, where pedicle screw loosening may be incidentally identified but the clinical significance of which is often unclear. This study aimed to identify the incidence and implications of pedicle screw loosening at the upper instrumented vertebra (UIV) after surgical correction of ASD. METHODS A single-institution retrospective analysis was performed on a cohort of 217 patients who underwent long- segment fusion with pelvic fixation for correction of ASD between September 2013 and November 2021. Cases with a minimum 1-year follow-up were included. UIV pedicle screws were graded on radiographs for evidence of loosening with a 0- to 3-point scale: 0, no loosening; 1, lucency within screw threads; 2, lucency around screw threads; and 3, screw dislodgment/backout. Need for hardware revision surgery was assessed as the primary outcome. Patient-reported outcome measures (PROMIS and Oswestry Disability Index scores) were assessed as secondary outcomes among the patients with available scores. RESULTS Low-grade UIV screw loosening (grade 1) was identified in 37 patients (17.1%), and high-grade UIV loosening (grade 2 or 3) was identified in 23 patients (10.6%). Low-grade UIV loosening was not associated with eventual need for hardware revision (OR 0.52, 95% CI 0.17-1.61, p = 0.258); however, high-grade loosening was associated with increased odds of hardware revision (OR 5.17, 95% CI 1.74-15.36, p = 0.003), including specifically surgery for correction of proximal junctional kyphosis (OR 5.73, 95% CI 1.27-25.95, p = 0.024). Among patients with PROMIS T-scores, those requiring hardware revision reported worse Pain Interference (65.0 +/- 5.1 vs 59.6 +/- 7.7, p = 0.001) and Physical Function (33.3 +/- 5.6 vs 37.4 +/- 7.4; p = 0.011). Patients with high-grade UIV loosening reported higher Oswestry Disability Index scores than those without high-grade loosening (grade 0 or 1), although this failed to reach statistical significance (44.0 +/- 8.5 vs 33.7 +/- 18.5, p = 0.101). CONCLUSIONS Grade 1 UIV pedicle screw loosening may represent a benign incidental finding, whereas high-grade loosening is associated with significantly increased odds of hardware revision surgery. High-grade loosening may also be associated with worse patient-reported disability. The authors' findings suggest that while low-grade UIV loosening may often be managed expectantly, identification of high-grade UIV pedicle screw loosening on follow-up imaging warrants increased attention and continued surveillance.

Background/Objectives: Utilization of polyetheretherketone (PEEK) cages for spinal fusion has surged in the U.S., yet comprehensive comparisons evaluating its postoperative effectiveness with alternative materials remain limited. This systematic review investigates the efficacy of PEEK cages against traditional fusion materials across various surgery types, elucidating PEEK’s impact on fusion rates, postoperative outcomes, and long-term success. Methods: A systematic search of PubMed, CINAHL, Scopus, Embase, and Web of Science was conducted through 14 October 2024. Included studies were randomized controlled trials (RCTs) comparing PEEK cages with titanium, silicon nitride, and metal-coated PEEK cages for anterior cervical discectomy and fusion (ACDF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF). Article quality was assessed using GRADE criteria. Results: From 288 initially screened articles, 25 RCTs involving 2046 patients (mean follow-up 23.1 ± 18.2 months) met inclusion criteria and were determined as moderate (n = 21) or high (n = 4) quality. Fusion rates by cage material for PEEK (n = 1041), Ti-PEEK (n = 291), and titanium (n = 53) were 85.63 ± 18.00%, 80.05 ± 19.9%, and 92.75 ± 11.31%, respectively. In ACDF, titanium cages achieved higher fusion rates than PEEK (100% vs. 94%). In PLIF and TLIF, coated PEEK outperformed uncoated PEEK (75% vs. 71% and 94% vs. 84%, respectively). Uncoated PEEK achieved fusion rates of 94.04 ± 5.04% for ACDF, 71.21 ± 21.93% for PLIF, and 83.50 ± 24.66% for TLIF, with titanium outperforming PEEK in early fusion outcomes. Coated PEEK demonstrated potential improvements in fusion rates over uncoated PEEK in PLIFs and TLIFs. Conclusions: Selection of cage material for spinal fusions should be tailored to surgical requirements and patient needs. While titanium and PEEK are effective, their performance varies across contexts. New materials and surface modifications may enhance these outcomes further, warranting future research in long-term studies and development of novel materials. These findings can help surgeons choose cage materials according to procedure type, patient characteristics, and imaging needs.

Gas-containing intraspinal synovial cysts are rare, and few surgical reports are available. This case highlights the importance of considering synovial cysts on the differential for presentations of radiculopathy and demonstrates successful surgical management in a rare case. A 63-year-old man with progressive low back pain and neurogenic claudication was found to have a gas-filled synovial cyst at L4-L5 causing severe central canal stenosis. Imaging revealed an 8 × 8 mm synovial cyst compressing the thecal sac and right L4 nerve root. He underwent L4 decompressive laminectomy with cyst resection. Postoperatively, the patient reported resolution of leg pain and improvement in mobility.

BackgroundAdult spinal deformity (ASD) is a prevalent condition often treated with circumferential spinal fusion (CF), which can be performed as staged or same-day procedures. However, evidence guiding the choice between these approaches is lacking. ObjectiveThis study aims to compare patient outcomes following staged and same-day CF for ASD. MethodsFollowing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted in PubMed, MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus. Eligibility criteria included studies comparing outcomes following staged and same-day CF in adults with ASD. Searches were exported to Covidence, and records were deduplicated automatically. Title and abstract screening, full-text review, and data extraction were performed by two independent reviewers, with all conflicts being resolved by a third reviewer. A meta-analysis was conducted for outcomes reported in 3 or more studies. ResultsSeven studies with 741 patients undergoing CF for ASD were included in the review (staged: n=331, 44.7% and same-day: n=410, 55.3%). Four studies that had comparable outcomes were merged for the quantitative meta-analysis and split based on observed measures. The meta-analysis revealed significantly shorter hospital length of stay (mean difference 3.98, 95% CI 2.23-5.72 days; P<.001) for same-day CF. Three studies compared the operative time between staged and same-day CF, with all reporting a lower mean operative time for same-day CF (mean between 291-479, SD 129 minutes) compared to staged CF (mean between 426-541, SD 124 minutes); however, inconsistent reporting of mean and SD made quantitative analyses unattainable. Of the 4 studies that compared estimated blood loss (EBL) in the relevant groups, 3 presented a lower EBL (mean between 412-1127, SD 954 mL) in same-day surgery compared to staged surgery (mean between 642, SD 550 to 1351, SD 869 mL). Both studies that reported intra- and postoperative adverse events showed more intraoperative adverse events in staged CF (10.9% and 13.6%, respectively) compared to same-day CF (9.1% and 3.6%, respectively). Four studies measuring any perioperative adverse events showed a higher incidence of adverse events in staged CF than all studies combined. However, quantitative analysis of EBL, intraoperative adverse events, and perioperative adverse events found no statistically significant difference. Postoperative adverse events, reoperation, infection rates, and readmission rates showed inconsistent findings between studies. Data quality assessment revealed a moderate degree of bias for all included studies. ConclusionsSame-day CF may offer shorter operating time and hospital stay compared to staged CF for ASD. However, there was marked heterogeneity in perioperative outcomes reporting, and continuous variables were inconsistently presented. This underscored the need for standardized reporting of clinical variables and patient-reported outcomes and higher evidence of randomized controlled trials to elucidate the clinical superiority of either approach. Trial RegistrationPROSPERO CRD42022339764; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339764 International Registered Report Identifier (IRRID)RR2-10.2196/42331

Adult spinal deformity (ASD) is a prevalent condition often treated with circumferential spinal fusion (CF), which can be performed as Staged or Same-Day procedures. However, evidence guiding the choice between these approaches is lacking. This systematic review and meta-analysis aimed to evaluate patient outcomes following Staged and Same-Day CF for ASD. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search was conducted in major databases. Eligible studies comparing Staged and Same-Day CF in adults with ASD were included. Data were extracted, and meta-analysis was performed for peri-operative outcomes and adverse events. Following exclusion criteria, seven studies were included for review. A total of 741 patients undergoing CF for ASD were included in the review (Staged: 331; Same-Day: 410). Four studies that had comparable outcomes were merged for the quantitative meta-analysis and split based on observed measures. Meta-analysis revealed significantly shorter operative time and hospital length of stay for Same-Day CF. Estimated blood loss and peri-operative adverse events trended towards significance favoring Same-Day CF. However, intra-operative and post-operative adverse event, reoperation, and readmission rates showed inconsistent findings between studies. Data quality assessment revealed a moderate degree of bias for all included studies. Same-Day CF may offer advantages in terms of shorter operative time and hospital stay compared to Staged CF for ASD. However, there was marked heterogeneity in peri-operative outcomes reporting, and continuous variables were inconsistently presented. This underscored the need for standardized reporting of clinical variables and patient reported outcomes and higher evidence randomized controlled trials to elucidate the clinical superiority of either approach. In accordance with PRISMA-P guidelines, the protocol of the systematic review was registered on the International Prospective Register of Ongoing Systematic Reviews (PROSPERO) (CRD42022339764) and disseminated through the Journal of Medical Internet Research (JMIR) Research Protocols (International Registered Report Identifier (IRRID): PRR1-10.2196/4233) RR2-10.2196/42331

BACKGROUND CONTEXT:Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE:To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING:A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE:Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES:Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS:Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS:A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS:Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.

Acellularized nerve allografts (ANAs) have been developed as substitutes for nerve autograft to promote nerve regeneration after surgical repair. In this video, the authors demonstrate operative techniques for using ANAs to repair potentially functional nerve fascicles during tumor resection. A 67-year-old female with schwannomatosis requested resection of a painful enlarging mass of the left ulnar nerve proximal to the elbow. During surgery, neuromonitoring suggested that fascicles entering the tumor could be functional. Therefore, nerve allograft was used to repair the transected fascicles. The patient recovered with full strength and sensation in the ulnar distribution, with resolution of her preoperative symptoms. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22101