Biportal endoscopic spine surgery offers advantages over open approaches but presents challenges with anatomical orientation. We describe a reproducible technique for fully navigated biportal endoscopic lumbar decompression using a non-invasive surface reference and continuously tracked working instruments, and report operative metrics and safety outcomes in an initial consecutive series. Seven consecutive patients underwent fully navigated biportal endoscopic lumbar decompression between June and November 2025 after institutional review board approval. The Stryker navigation platform was paired with intraoperative computed tomography (Ziehm 3D), a SpineMask Tracker surface reference, and NavLock quick-release adapters permitting continuous tracking of the working cannula, radiofrequency probe, high-speed burr, and 30-degree endoscope. Decompression followed the standardized five-step “Z” sequence, with en bloc “butterfly/two-wings” ligamentum flavum resection where indicated. Three men and four women (mean age 71.0 ± 19.4 years; mean body mass index 30.6 ± 5.7 kg/m²) underwent decompression at nine lumbar levels. Common pathologies included central canal stenosis (86

Spinal cord injury remains a major cause of disability in young adults, and beyond acute decompression and rehabilitation, there are no pharmacological treatments to limit the progression of injury and optimize recovery in this population. Following the thorough investigation of the complement system in triggering and propagating cerebral neuroinflammation, a similar role for complement in spinal neuroinflammation is a focus of ongoing research. In this work, we survey the current literature investigating the role of complement in spinal cord injury including the sources of complement proteins, triggers of complement activation, and role of effector functions in the pathology. We study relevant data demonstrating the different triggers of complement activation after spinal cord injury including direct binding to cellular debris, and or activation via antibody binding to damage-associated molecular patterns. Several effector functions of complement have been implicated in spinal cord injury, and we critically evaluate recent studies on the dual role of complement anaphylatoxins in spinal cord injury while emphasizing the lack of pathophysiological understanding of the role of opsonins in spinal cord injury. Following this pathophysiological review, we systematically review the different translational approaches used in preclinical models of spinal cord injury and discuss the challenges for future translation into human subjects. This review emphasizes the need for future studies to dissect the roles of different complement pathways in the pathology of spinal cord injury, to evaluate the phases of involvement of opsonins and anaphylatoxins, and to study the role of complement in white matter degeneration and regeneration using translational strategies to supplement genetic models.

Anterior cervical spine surgeries are often complicated by difficulty swallowing due to local postoperative swelling, pain, scarring, and tissue dysfunction. These postoperative events lead to systemic steroid and narcotic use. Local, sustained drug delivery may address these problems, but current materials are unsafe for tight surgical spaces due to high biomaterial swelling, especially upon degradation. To address these shortcomings, a low-swelling, amphiphilic hydrogel system termed DexaPatch is developed containing dexamethasone-poly(lactic-co-glycolic acid) (PLGA) microparticles for sustained release upon local implantation in the surgical site. The bulk amphiphilic hydrogel, comprised of 4-arm poly(ethylene glycol) (PEG)-maleimide macromer cross-linked with triblock dithiolated PEG-poly(propylene glycol)-PEG (poloxamer a.k.a. Pluronic), achieves consistent and tunable mechanical and low-swelling properties. Dexamethasone is released in a burst, followed by a sustained release over 40 days, similar to the release from microparticles alone. The DexaPatch system is lyophilized for shelf stability and surgical handling properties, sterilized, and briefly rehydrated in the operating room prior to surgical implantation in a rabbit model of anterior spinal surgery. DexaPatch results in significantly reduced prevertebral edema radiographically and decreased fibrosis in prevertebral muscles compared to sham surgery. This implantable biomaterial platform reduces local postoperative inflammation with potential surgical applications throughout the body.

In the evolving landscape of ependymoma classification, which integrates histological, molecular, and anatomical context, we detail a rare case divergent from the usual histopathological spectrum. We present the case of a 37-year-old man with symptomatic spinal cord compression at the L3-L4 level. Neuroradiological evaluation revealed an intradural, encapsulated mass. Histologically, the tumor displayed atypical features: bizarre pleomorphic giant cells, intranuclear inclusions, mitotic activity, and a profusion of eosinophilic cytoplasm with hyalinized vessels, deviating from the characteristic perivascular pseudorosettes or myxopapillary patterns. Immunohistochemical staining bolstered this divergence, marking the tumor cells positive for glial fibrillary acidic protein and epithelial membrane antigen with a characteristic ring-like pattern, and CD99 but negative for Olig-2. These markers, alongside methylation profiling, facilitated its classification as a myxopapillary ependymoma (MPE), despite the atypical histologic features. This profile underscores the necessity of a multifaceted diagnostic process, especially when histological presentation is uncommon, confirming the critical role of immunohistochemistry and molecular diagnostics in classifying morphologically ambiguous ependymomas and exemplifying the histological diversity within MPEs.

Introduction: This is a retrospective study of consecutive patients undergoing transforaminal lumbar interbody fusion (TLIF) at a single institution. The objective of this study was to compare the long-term results associated with cortical bone trajectory (CBT) and traditional pedicle screw (TPS) via posterolateral approach in TLIF. Methods: Consecutive patients treated from November 2014 to March 2019 were included in the CBT TLIF group, while consecutive patients treated from October 2010 to August 2017 were included in the TPS TLIF group. Inclusion criteria comprised single-level or two-level TLIF for degenerative spondylolisthesis with stenosis and at least one year of clinical and radiographic follow-up. Variables of interest included pertinent preoperative, perioperative, and postoperative data. Non-parametric evaluation was performed using the Wilcoxon test. Fisher's exact test was used to assess group differences for nominal data. Results: Overall, 140 patients met the inclusion criteria; 69 patients had CBT instrumentation (mean followup 526 days) and 71 patients underwent instrumentation placement via TPS (mean follow-up 825 days). Examination of perioperative and postoperative outcomes demonstrate comparable results between the groups with perioperative complications, length of stay, discharge destination, surgical revision rate, and fusion rates all being similar between groups (p = 0.1; p = 0.53; p = 0.091; p = 0.61; p = 0.665, respectively). Conclusions: CBT in the setting of TLIF offer equivalent outcomes to TPS with TLIF at both short-and longterm intervals of care.

We present a surgical video highlighting the resection of an intradural thoracic hemangiopericytoma with intramedullary invasion. A 43-yr-old man was referred to the clinic with progressive bilateral lower extremity numbness which had been present for several years, now accompanied by 6 mo of painless, progressive lower extremity weakness. Neuroimaging demonstrated an intradural contrast-enhancing lesion at T6-7. On preoperative imaging, it was difficult to determine whether the tumor only displaced the spinal cord or there was also spinal cord invasion. The patient was taken for surgery in the form of a T5-7 laminectomy for resection of an intradural tumor which also had an intramedullary component. Final pathology was consistent with hemangiopericytoma. After surgery, he had 3/5 strength in the left leg and 1/5 strength in the right leg, but this improved to 2/5 strength in the right leg at the 6-wk follow-up. Hemangiopericytoma is a rare diagnosis accounting for <1% of central nervous system tumors, but it is even more rare in the spine because there are fewer than 100 reported cases. Given the unique nature of the case, there are limited data on optimal treatment paradigms, but surgical resection should be considered for anyone who has severe spinal cord compression with a neurological deficit, and this is often paired with postoperative radiation therapy. The patient provided written informed consent for the surgical procedure and video recording.

Abstract Purpose Metallic implants have been correlated to local control failure for spinal sarcoma and chordoma patients due to the uncertainty of implant delineation from computed tomography (CT). Such uncertainty can compromise the proton Monte Carlo dose calculation (MCDC) accuracy. A component method is proposed to determine the dimension and volume of the implants from CT images. Methods The proposed component method leverages the knowledge of surgical implants from medical supply vendors to predefine accurate contours for each implant component, including tulips, screw bodies, lockers, and rods. A retrospective patient study was conducted to demonstrate the feasibility of the method. The reference implant materials and samples were collected from patient medical records and vendors, Medtronic and NuVasive. Additional CT images with extensive features, such as extended Hounsfield units and various reconstruction diameters, were used to quantify the uncertainty of implant contours. Results For in vivo patient implant estimation, the reference and the component method differences were 0.35, 0.17, and 0.04 cm3 for tulips, screw bodies, and rods, respectively. The discrepancies by a conventional threshold method were 5.46, 0.76, and 0.05 cm3, respectively. The mischaracterization of implant materials and dimensions can underdose the clinical target volume coverage by 20 cm3 for a patient with eight lumbar implants. The tulip dominates the dosimetry uncertainty as it can be made from titanium or cobalt–chromium alloys by different vendors. Conclusions A component method was developed and demonstrated using phantom and patient studies with implants. The proposed method provides more accurate implant characterization for proton MCDC and can potentially enhance the treatment quality for proton therapy. The current proof‐of‐concept study is limited to the implant characterization for lumbar spine. Future investigations could be extended to cervical spine and dental implants for head‐and‐neck patients where tight margins are required to spare organs at risk.

INTRODUCTION: COVID-19 has accelerated the use of telemedicine in all aspects of health care delivery, including initial surgical evaluation. No existing literature investigates the safety and efficacy of telemedicine to preoperatively evaluate spine surgery candidates. Our objectives were: (1) Compare the change in visual analogue scale (VAS) scores between the telemedicine preoperative visit and in-person preoperative visit groups. (2) Compare the average surgical time, estimated blood loss (EBL), length of hospital stay (LOS), rates of intraoperative complications, rates of readmission, and rates of reoperation between the telemedicine preoperative visit and in-person preoperative visit groups. METHODS: The previously stated metrics were collected for 276 patients, 138 who were exclusively evaluated preoperatively with telemedicine and 138 historical controls who were evaluated preoperatively in person. We used chi(2) and independent samples t tests to determine significance. RESULTS: There were no significant differences in the mean change in VAS scores (-2.7 +/- 3.1 telemedicine vs. -2.2 +/- 3.7 in-person, P = 0.317), mean percentage change in VAS scores (-40.5% +/- 54.3% vs. -39.5% +/- 66.6%, P = 0.811), mean surgical time (2.4 +/- 1.4 hours vs. 2.3 +/- 1.3 ours, P = 0.527), mean EBL (150.4 +/- 173.3 mL vs. 156.7 +/- 255.0 mL, P = 0.811), mean LOS (3.3 +/- 2.4 days vs. 3.3 +/- 2.5 days, P = 0.954), intraoperative complication rates (0.7% vs. 1.4%, P = 0.558), reoperation rates (7.9% vs. 4.3%, P = 0.208), or readmission rates (10.1% vs. 5.1%, P = 0.091) between the telemedicine preoperative visit and in-person preoperative visit groups. CONCLUSIONS: Preoperative evaluation via telemedicine leads to the same short-term surgical outcomes as in-person evaluation with no increased risk of surgical complications.

Background: Oblique Lateral Interbody Fusion (OLIF) is a relatively new approach which allows for access to the intervertebral disk space anterior to the psoas muscles, while remaining posterior to the more anterior vascular structures. Compared to posterior only fusion, OLIF results in reduced muscle dissection and preserved spinal anatomy, all while maximizing fusion surface area and providing indirect decompression. Methods: Thirteen patients treated by OLIF with percutaneous posterior screw placement since 2016 were retrospectively analyzed. Post-operative outcomes evaluated included fusion, adjacent segment degeneration, and pain scores. Spinopelvic parameters were analyzed pre and postoperatively. Results: The average number of vertebral levels treated was 2 (1-3), all between L2 and L5. Fusion was confirmed in all patients with an available CAT scan (7 of 7 patients). Adjacent segment degeneration was seen in 0 of the 13 patients. VAS showed an average improvement of 3.8 (2-8), with 11 out of 13 patients experiencing an improvement in pain. All 11 patients with multilevel fusions showed an improvement in pain. 8 of the 13 patients had mild degenerative scoliosis defined as a cobb angle >10 degrees. All five of these patients showed improvement in postoperative pain scores. Conclusion: OLIF with percutaneous posterior screws can be considered a safe and effective treatment option for lumbar disk degeneration, with complication rates and improvement comparable to those seen with alternative approaches. Further studies are warranted to evaluate outcomes in larger samples with longer follow up data.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:The aim of this study was to analyze how a Current Procedural Terminology (CPT)-based categorization method can predict cost variation in surgical spine procedures. SUMMARY OF BACKGROUND DATA:Neck and back disorders affect a majority of the adult population and account for tens of billions of dollars in health care spending each year. In the era of bundled payments and value-based reimbursement, it is imperative for surgeons to identify sources of cost variability across surgical spine procedures. Historically, this has been accomplished using Medicare Severity Diagnosis Related Group (MS-DRG) codes, but they utilize an overly simplistic categorization of surgical procedures. The specificity and familiarity of the CPT coding structure makes it a better option for categorizing differences in surgical decision making and technique. METHODS:Hospital billing data for patients undergoing a surgical spine procedure requiring an overnight, in-patient stay was retrospectively collected over 4 fiscal years (2012-2016) from a single health care system. Linear regression analysis was performed to assess the correlation between cost variation and: spine-specific MS-DRG codes; a novel CPT-based categorization method; and the combination of MS-DRG codes and CPT-based categorization. RESULTS:There were 5020 surgical procedures were analyzed with respect to 16 different MS-DRG codes and 30 distinct CPT-based surgical categories (CSCs). Linear regression results were: MS-DRG R2 = 0.6545 (P < 0.001); CSC R2 = 0.5709 (P < 0.001); and R2 = 0.744 for the combined MS-DRG and CSC methods (P < 0.05). Median difference between the actual and predicted cost for the combined model was -$261.00, compared with -$727.50 for the CSC model and -$478.70 for the MS-DRG model. CONCLUSION:Addition of the CPT-based categorization method to MS-DRG coding provides an enhanced method to evaluate the association between predicted and actual cost when using linear regression analysis to assess cost variation in spine surgery.Level of Evidence: 3.

Objective To investigate the frequency, time-course and predictors of intracerebral haemorrhage (ICH), recurrent convexity subarachnoid haemorrhage (cSAH), and ischemic stroke after cSAH associated with cerebral amyloid angiopathy (CAA). Methods We performed a systematic review and international individual patient-data pooled analysis in patients with cSAH associated with probable or possible CAA diagnosed on baseline MRI using the modified Boston criteria. We used Cox proportional hazards models with a frailty term to account for between-cohort differences. Results We included 190 patients (mean age 74.5 years; 45.3% female) from 13 centers with 385 patient-years of follow-up (median 1.4 years). The risks of each outcome (per patient-year) were: ICH 13.2% (95% CI 9.9–17.4); recurrent cSAH 11.1% (95% CI 7.9–15.2); combined ICH, cSAH, or both 21.4% (95% CI 16.7–26.9), ischemic stroke 5.1% (95% CI 3.1–8) and death 8.3% (95% CI 5.6–11.8). In multivariable models, there is evidence that patients with probable CAA (compared to possible CAA) had a higher risk of ICH (HR 8.45, 95% CI 1.13–75.5, p = 0.02) and cSAH (HR 3.66, 95% CI 0.84–15.9, p = 0.08) but not ischemic stroke (HR 0.56, 95% CI 0.17–1.82, p = 0.33) or mortality (HR 0.54, 95% CI 0.16–1.78, p = 0.31). Conclusions Patients with cSAH associated with probable or possible CAA have high risk of future ICH and recurrent cSAH. Convexity SAH associated with probable (vs possible) CAA is associated with increased risk of ICH, and cSAH but not ischemic stroke. Our data provide precise risk estimates for key vascular events after cSAH associated with CAA which can inform management decisions.

To the Editor: Novel coronavirus 2019 (COVID-19) has had a drastic impact upon our ability to impart neurosurgical care for our patients, as others have highlighted in a recently published letter in your journal.1 The Centers for Disease Control and Prevention (CDC) has declared the COVID-19 outbreak a pandemic.2 National and international governing bodies have embraced “social distancing” and “shelter-in-place” paradigms to lower the rate of person-to-person transmission of COVID-19, and “flatten the curve” of new diagnoses.3-5 However, despite aggressive attempts to lower viral transmission, epidemiologists expect a long-term disruption of our “normal” pattern of delivering medical care, on the order of months to years.6 Additionally, hospitals have redeployed surgical residents into critical care and emergency medicine practices to increase access to care.7,8 While the 7 yr of residency and fellowship is long; even 3 mo of change to the existing state of neurosurgical care will have far-reaching effects on resident and fellow training. We wish to share our initial experience at Emory University Medical Center, a high-volume, tertiary, urban medical center in providing the sometime competing needs to (1) protect residents and fellows from illness, (2) provide emergent and urgent neurosurgical care, (3) utilize Telemedicine to maintain continuity of care, (4) assist the larger medical community, and (5) continue neurosurgical education in novel ways. PROTECT NEUROSURGICAL RESIDENTS AND FELLOWS FROM ILLNESS We educated our neurosurgical service about the signs and symptoms of COVID-19 as well as learned how to protect ourselves with personal protective equipment (PPE) via institutionally provided online modules. Our neurosurgery department (which includes 5 separate training hospitals) holds weekly online “town-hall meetings” to address the COVID-19 crisis and specific concerns such as PPE supplies and allocation of resident/fellow resources. Since March 23, 2020, we have been streamlining our resident services to reduce exposure to patients potentially infected with COVID-19. For example, our neurosurgical spine service was subdivided into 2 working teams; each team has 2 attending neurosurgeons, 1 resident, and 1 advanced-practice provider (APP). One team self-quarantined from March 23, 2020 until April 6, 2020, wherein they supported the neurosurgical team with outpatient Telemedicine visits and by helping to coordinate and advise upon inpatient care remotely. The inpatient team covers neurosurgical on-call, rounds on patients, and performs emergent surgery when indicated. On April 6, 2020, the teams switched roles. We employed this 14-d cycle due to the early research that has suggested a mean incubation time of the COVID-19 virus to be 6.4 d, ranging in between 2.1 and 11.1 d.9 We have additional residents available to backfill positions if residents/fellows become infected with the virus and need to quarantine. We have also discussed attending coverage of resident duties. PROVIDE EMERGENT AND URGENT NEUROSURGICAL CARE Due to our position in the community as a high-volume, tertiary, neurosurgical center of excellence, we still receive patient transfers that need emergent neurosurgical care.10 We are currently seeing all in-patient consultations at all of our staffed medical centers in person, while outpatient visits are made with Telemedicine visits. Our faculty completed rapid online training for the practice of Telehealth/Telemedicine in accordance with Emory University, industry, and Center for Medicare & Medicaid Services (CMS) guidelines, and they all became certified within a few days. Similar to the University of California, San Francisco team, our senior neurosurgical staff created a document to define emergent (surgery to be performed immediately), urgent (surgery to be performed within 24 h), time-sensitive (neurological deficit or other serious issues are expected to occur if surgery is not performed within 4 wk), and elective neurosurgical procedures.1 This was circulated among our entire neurosurgical team throughout the Emory Healthcare system of hospitals. In an effort to preserve PPE and other human and material hospital resources and to decrease patient exposure to COVID-19, we are performing only urgent and emergent neurosurgical procedures at this time. All cases must be reviewed by the Chair or his designee and institutionally appointed surgical and anesthesia adjudicators. Factors taken into consideration include the following: availability of anesthesia and nursing personnel needed for the case; availability of intensive care unit (ICU)/beds if either needed for case; length of case; risk of prolonged hospitalization/ICU or critical supply (blood, PPE, etc) usage after case; likelihood of patient survival if surgery is successful; potential for adverse clinical outcomes if surgery or intervention is delayed; less than 2 wk; 2 to 4 wk; more than 4 wk. We have also created an algorithm for accepting patient transfers from outside institutions given the limited surgical resources at our hospitals. UTILIZE TELEMEDICINE TO MAINTAIN CONTINUITY OF CARE Resource reallocation and social distancing have forced the cancelation of much of our operating room volume and shuttered our clinics, but that does not mean we are unable to see patients. We have adapted internet-based Telemedicine video technology for outpatient clinic visits. This has forced us to create new workflows in a virtual clinic setting, but has opened our eyes to a tool that had heretofore been underutilized. Highly specialized care is a limited resource and can be difficult for people to access, but Telemedicine will help us reach patients who would otherwise have difficulty reaching us. Patient perceptions of this experience have been overwhelmingly positive. It benefits all residents and fellows about to embark upon the task of building their own practice to experience and interact with this tool as they think about the best ways to reach patients, streamline clinic efficiency, and optimize patient satisfaction. ASSIST THE LARGER MEDICAL COMMUNITY The dissemination of the COVID-19 virus will put strain upon our colleagues in critical care medicine.11 We are beginning to see neurological manifestations from COVID-19 infection, including encephalitis.12 Given our stoppage of elective cases and the need for the creation of additional ICU capacity for COVID-19 patients, we have decided to provide our Neurological Critical Care team with multiple members of our neurosurgical resident and fellow staff. Each resident will rotate a minimum of 1 wk on the Neurological Critical Care team in the month of April, which will allow for the creation of additional ICU beds across our campuses, and allow for neurocritical care APPs and fellows to transfer to medical ICUs to assist in care of COVID-19 patients. Redeploying our residents to the neurocritical care units actually enhances their ongoing education as these activities are part of our specialty and board certification, as opposed to redeployment to an emergency department, labor and delivery, or other services in need of assistance. CONTINUE NEUROSURGICAL EDUCATION FOR RESIDENTS AND FELLOWS The decrease in neurosurgical inpatient consultations and elective surgical procedures has lessened our robust clinical exposure. Nevertheless, we have forged on to continue nonclinical educational activities and didactic education. Our program is the only neurosurgical training program for a large, urban city/city-sprawl, and we staff 5 hospitals with residents/fellows. To facilitate grand rounds and educational didactic lectures, we have a robust infrastructure to communicate remotely, including audio/visual wiring of our grand rounds lecture hall. We have employed Zoom Inc (San Jose, California) technology to live-stream our conferences for over a year. We performed our first remote morbidity and mortality conference through a secure-conference Zoom Inc link on April 2, 2020. Additionally, we have live-streamed Congress of Neurological Surgeons-provided video grand rounds and have engaged in lively discussions afterwards. We have also instituted daily spine conferences (Monday-Friday) via Zoom staffed by both our neurosurgery and orthopedic attending spine surgeons and is open to neurosurgery residents and fellows, orthopedic spine fellows and residents, and any interested medical students. Each daily conference will include a lecture and case reviews and is moderated by a rotating schedule of 2 attending physicians. This platform, or similarly positioned technologies, can also be utilized for direct resident and fellow education via remote journal clubs, research meetings, and complex neurosurgical case conferences. Similarly, many society and industry-organized resident and fellow educational events have been transitioned to the virtual meeting space. CONCLUSION The COVID-19 pandemic will persist to affect the usual delivering of neurosurgical care and resident/fellow education. This crisis has reminded our global community that healthcare and education are limited resources. As residents, fellows, and attendings, our focus is typically caring for neurosurgical patients, but now we must gain an education in disaster planning and supply allocation on a hospital and institutional scale. In the throes of this global pandemic with a limited precedent, it is difficult to envision post-COVID-19 medical care. However, this pandemic, like all those throughout the history of humankind, will end. After COVID-19, we will be still faced with challenges and learning—how will we triage our response to those whom care has been delayed? How will we maximize efficiency and cost-control as we treat this backlog? Perhaps most importantly, how can we contribute to reducing the risk of another similar event in the future? Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

STUDY DESIGN Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution. OBJECTIVE This study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone. SUMMARY OF BACKGROUND DATA One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients. METHODS An 11-part questionnaire was developed to assess the attitudes towards telemedicine for all patients seen within a 7-week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. Chi squared and the Wilcoxon Rank-Sum Test were performed to determine significance. RESULTS Ninety-five percent were "satisfied" or "very satisfied" with their telemedicine visit, with 62% stating it was "the same" or "better" than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to in-person visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirty-seven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137), p = 0.0007. Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone. CONCLUSIONS Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates. LEVEL OF EVIDENCE 3.

BACKGROUND CONTEXT Prolonged surgical procedures have an increased risk of pressure and nerve injuries. Lateral lumbar interbody fusion (LLIF) procedures require patient positioning with tape to secure and minimize movement of the patient. Decreased interface pressures have previously been attributed to increased patient comfort. We assessed the preoperative interface pressures for a LLIF procedure. PURPOSE Lateral peak interface pressures on a flat surgical table is increased with taping during patient positioning. STUDY DESIGN/SETTING Prospective. PATIENT SAMPLE Peak pressures were measured in four phases of patient positioning: lateral (n=93 frames), lateral + axilla pad (n=43 frames), lateral + axilla pad + taping (n=506 frames), and lateral + axilla pad + taping + draping (n=414 frames). Peak pressure measurements were captured over a timeframe of minimal contact to the patient. Four regions were assessed: the shoulder, right thorax, hip and leg. OUTCOME MEASURES Peak pressures (mmHg) for the shoulder, right thorax, hip, and leg regions. METHODS Pressure sensors were placed on a flat surgical table. A patient was positioned laterally according to Association of Surgical Technologists Standards of Practice for Surgical Positioning. An axilla pad was placed to support the right thorax and egg crate foam were used to support the lateral side of the right knee. Peak pressures were measured in four phases of patient positioning: lateral (n=93 frames), lateral + axilla pad (n=43 frames), lateral + axilla pad + taping (n=506 frames), and lateral + axilla pad + taping + draping (n=414 frames). Peak pressure measurements were captured over a timeframe of minimal contact to the patient. Four regions were assessed: the shoulder, right thorax, hip and leg. RESULTS Before taping to secure the patient, peak pressures for the shoulder, right thorax, hip, and leg regions were 33.4±0.5 mmHg, 59.5±0.6 mmHg, 68.4±1.0 mmHg, and 50.8±0.8 mmHg. After taping, peak pressures were significantly increased in all regions except the shoulder and legs. Peak pressures were 35.0±0.4 mmHg, 71.1±0.5 mmHg (p<0.001), 103.6±1.6 mmHg (p<0.001), and 43.8±0.4 mmHg (p<0.001); respectively. Unless additional force is applied (eg, taping, leaning/resting on patient), peak interface pressures are expected to remain static throughout the course of a procedure. CONCLUSIONS Pressure sensors can provide real-time feedback during patient positioning. Securing a patient with tape increases the static pressure applied to a patient in a single position procedure. Optimal techniques to minimize excessive pressure can be identified. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Prolonged surgical procedures have an increased risk of pressure and nerve injuries. Lateral lumbar interbody fusion (LLIF) procedures require patient positioning with tape to secure and minimize movement of the patient. Decreased interface pressures have previously been attributed to increased patient comfort. We assessed the preoperative interface pressures for a LLIF procedure. Lateral peak interface pressures on a flat surgical table is increased with taping during patient positioning. Prospective. Peak pressures were measured in four phases of patient positioning: lateral (n=93 frames), lateral + axilla pad (n=43 frames), lateral + axilla pad + taping (n=506 frames), and lateral + axilla pad + taping + draping (n=414 frames). Peak pressure measurements were captured over a timeframe of minimal contact to the patient. Four regions were assessed: the shoulder, right thorax, hip and leg. Peak pressures (mmHg) for the shoulder, right thorax, hip, and leg regions. Pressure sensors were placed on a flat surgical table. A patient was positioned laterally according to Association of Surgical Technologists Standards of Practice for Surgical Positioning. An axilla pad was placed to support the right thorax and egg crate foam were used to support the lateral side of the right knee. Peak pressures were measured in four phases of patient positioning: lateral (n=93 frames), lateral + axilla pad (n=43 frames), lateral + axilla pad + taping (n=506 frames), and lateral + axilla pad + taping + draping (n=414 frames). Peak pressure measurements were captured over a timeframe of minimal contact to the patient. Four regions were assessed: the shoulder, right thorax, hip and leg. Before taping to secure the patient, peak pressures for the shoulder, right thorax, hip, and leg regions were 33.4±0.5 mmHg, 59.5±0.6 mmHg, 68.4±1.0 mmHg, and 50.8±0.8 mmHg. After taping, peak pressures were significantly increased in all regions except the shoulder and legs. Peak pressures were 35.0±0.4 mmHg, 71.1±0.5 mmHg (p<0.001), 103.6±1.6 mmHg (p<0.001), and 43.8±0.4 mmHg (p<0.001); respectively. Unless additional force is applied (eg, taping, leaning/resting on patient), peak interface pressures are expected to remain static throughout the course of a procedure. Pressure sensors can provide real-time feedback during patient positioning. Securing a patient with tape increases the static pressure applied to a patient in a single position procedure. Optimal techniques to minimize excessive pressure can be identified.

Study Design. Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution. Objective. This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone. Summary of Background Data. One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients. Methods. An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7-week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. chi(2) and the Wilcoxon Rank-Sum Test were performed to determine significance. Results. Ninety-five percent were "satisfied" or "very satisfied" with their telemedicine visit, with 62% stating it was "the same" or "better" than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to in-person visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirty-seven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient-reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P = 0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone. Conclusion. Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates.

Abstract Background One percent to 8% of patients undergoing spinal instrumentation surgeries develop infections. There is no consensus on the medical and surgical management of these infections. Methods We conducted a retrospective chart review based on International Classification of Diseases, Ninth Revision, and Common Procedural Terminology codes relevant to spinal infections with hardware within Emory Healthcare over a 10-year period. Extracted data included patient demographics, clinical presentation, laboratory and microbiologic results, and surgical and medical management including choice and duration of suppressive therapy. Multivariable logistic regression was used to assess the association of length of use of suppressive antibiotics with treatment success and to identify predictors of use of suppressive antibiotics. Results Of 869 records, 124 met inclusion criteria. Fifty patients (40.3%) had an infection that occurred after hardware placement, mostly within 3 months postsurgery, while the remainder had vertebral osteomyelitis that required hardware placement. After initial intravenous antibiotic treatment for ≥4 weeks, 72 patients (64.5%) were given suppressive antibiotics. The overall treatment success rate was 78.2%. In spinal infections involving hardware with gram-negative rods, patients were less likely to receive suppressive antibiotics, less likely to have hardware removed, and less likely to have treatment success compared with patients with infections with Staphylococcus species. Conclusions Management of spinal infections involving hardware should be tailored to the timing of onset of infection and causative organism. Further studies are needed to determine best management practices, particularly for gram-negative rod infections where the role of further suppressive antibiotics and hardware removal may be warranted.

Objective: The use of stand-alone 2-level anterior lumbar interbody fusion (ALIF) for degenerative lumbar disease has been increasing as an alternative to routinely augmenting these constructs with posterior fixation or fusion. Despite the potential benefits of a stand-alone approach (decreased cost and operative time, decreased pain and early mobilization), there is a paucity of information regarding these operations in the literature. This investigation aimed to determine the safety profile, radiographic outcomes including fusion rates, improvement in preoperative pain, and spinopelvic parameter modification, for patients undergoing stand-alone 2-level ALIF. Methods: This retrospective case series involved a chart review of all patients undergoing 2-level stand-alone ALIF at a single tertiary hospital from 2008 to 2018. Data included patient demographics, hospitalization, complications and radiological studies. Visual analog scale (VAS) back and leg scores were measured via patient-administered surveys preoperatively and up to 18 weeks postoperatively. Results: Forty-one patients who underwent L4-S1 stand-alone ALIF were included. Sixteen (39%) of patients had undergone previous posterior lumbar surgery. Length of stay averaged 4.2 days. Complication rates were comparable to 1-level ALIF. Two patients required reoperation. Fusion rates were 100% for L4-5 and 94.4% for L5-S1. There was no significant change in lumbar lordosis (LL) or LL-pelvic incidence (PI), but there was improved segmental lordosis (SL) and disc height at L4-S1 on final follow-up imaging. There was also modest but statistically significant improvement in VAS back and leg scores. Conclusions: Stand-alone 2-level ALIF is an option for a surgeon to perform in the absence of significant instability, even in the setting of prior posterior surgery. These procedures increase SL and disc height, but do not have the same effect on LL or LL-PI.

BACKGROUND AND IMPORTANCE:Traditionally, when a patient presents with a midline chordoma with extension to the mid-S1 body where neither S1 nerve roots can be spared, the recommendation would be to perform a total sacrectomy for en bloc resection. This procedure, however, results in a large bony defect that makes it difficult to achieve fusion across the lumbosacral and sacroiliac junction (SIJ). To help prevent this challenge in the situation described above, we propose performing a high sacrectomy for en bloc resection with placement of an anterior L5-S1 graft instead in specific situations where the tumor extends to the mid-S1 body leaving the superior aspect of S1 unaffected. CLINICAL PRESENTATION:A 56-yr-old female presented to our clinic with back pain, leg pain, urinary incontinence, and perineal numbness. She was found to have a chordoma that extended to the mid-S1 body superiorly. Her S1 nerve roots were involved extraforaminally. We performed the operation described above with no signs of hardware malfunction or tumor recurrence at 5 mo. CONCLUSION:In patients where the sacral tumor that involves the S1 nerve roots but does not involve the superior portion of the S1 body, there continues to be unaffected SIJ to allow for arthrodesis, and an anterior approach is necessary for other indications, we recommend performing a high partial sacrectomy with placement of an anterior L5-S1 graft rather than a total sacrectomy as long as the bony resection offers ability to obtain tumor margins.