INTRODUCTION:Odontoid fractures (OFs) are one of the most common fractures of the upper cervical spine, estimated to represent 9-15% of all cervical fractures. Although their relative frequency, its optimal management is still debated. When surgery is required, anterior odontoid screw fixation (AOSF) offers several advantages, such as preservation of neck rotation, reduced surgical risk, and shorter hospital stay. However, only well-selected patients are eligible for this procedure, and an accurate interpretation of imaging as well as an optimal surgical timing should be taken into account to identify who may be the "best candidates". METHODS:The aim of this narrative review is to report the current advances in the treatment of OFs by AOSF. We will focus on surgical details, including minimally invasive surgery, as well as on pre- and postoperative critical aspects. RESULTS:With regard to preoperative imaging, type II b OFs (with fracture line oriented from anterior superior to posterior inferior) typically present favourable configuration to be treated by AOSF. Furthermore, a fracture gap >2 mm, an angulation >11° and a displacement >2 mm as well as timing duration from injury to surgery >7 days are predictors of non-union after AOSF. With regard to surgical technique, compared to traditional open technique, MIS procedures are more and more reported. This approach can be performed percutaneously under fluoroscopy or navigation guidance. Finally, the use of a single, bicortical lag screw is strongly suggested to compress the fractured bone surfaces, to reduce the fracture gap and to obtain the best mechanical stability. CONCLUSION:Our review suggests that AOSF is an effective option in the treatment of type II OFs. However, a meticulous assessment of preoperative images is mandatory, and particular attention has to be paid to fracture configuration, gap, angulation, displacement and ligament integrity. With regard to elderly population, the possibility of wearing rigid collar should be considered, and recent literature reports encouraging results even without any treatment. If a surgical intervention is required, the timing from injury to the operation represents a crucial parameter, making early decisions an important element in the management of type II OFs. Compared to the traditional open approach, minimally invasive AOSF is reliable, promotes faster recovery and in select cases can be performed even under sedation.

Percutaneous endoscopic spine surgery and tubular minimally invasive surgery (MIS) each offer distinct advantages but also important limitations. We describe a proof-of-concept study of a hybrid technique—tubular endoscopic spine surgery (TESS)—combining a tubular retractor with a 30° endoscope and continuous irrigation, aiming to integrate the advantages of both approaches. TESS was first evaluated in a cadaveric L4–L5 model and subsequently applied in a single clinical case of L4–L5 lumbar stenosis with right L5 radiculopathy. The technique uses a standard tubular retractor to establish a single paramedian muscle-splitting corridor. A 30° endoscope is introduced through the tube with continuous irrigation, while standard microsurgical instruments are used through the working channel. The tubular retractor provided a stable, reproducible single-incision transmuscular corridor to the interlaminar space. The addition of the endoscope with irrigation ensured a consistently clear operative field, while maintaining the ergonomics and simplicity of a single working channel. Instrument handling and exchange were straightforward, and no specific technical difficulties were encountered. In the clinical case, adequate decompression was achieved with complete symptom resolution at 6 and 12 months. TESS is a feasible hybrid technique that combines the familiar ergonomics of tubular MIS surgery with the dynamic visualization of endoscopic systems using irrigation. Further studies are needed to evaluate its clinical value before widespread clinical adoption.

Background/Objectives: Degenerative cervical myelopathy (DCM) is the leading cause of non-traumatic spinal cord dysfunction in adults. Both anterior and posterior surgical approaches are widely used for its treatment, yet their comparative impact on clinical outcomes and complication profiles remains clinically relevant. This study aimed to describe early and one-year postoperative outcomes between anterior and posterior surgical strategies in a consecutive single-center cohort. Methods: We conducted a retrospective single-center study of 102 consecutive adult patients surgically treated for DCM between 2013 and 2024, with complete datasets and a minimum one-year follow-up. Surgical approaches were classified as anterior, posterior, or combined. Clinical outcomes were assessed using the modified Japanese Orthopaedic Association scale (mJOA), Neck Disability Index (NDI), and Numeric Rating Scale for arm pain (NRS-arm) preoperatively, at 4-6 weeks and at one year. Complications were systematically recorded and stratified by approach. Nonparametric tests were used for all comparisons (significance threshold p < 0.05). Results: Anterior procedures were performed in 82 patients (80.4%), posterior in 18 (17.6%), and combined in 2 (2.0%). No significant between-group differences were observed in neurological, functional, or pain outcomes at either time point (ΔmJOA p = 0.268; ΔNDI p = 0.632; ΔNRS p = 0.562 at one year). Complications occurred in 13 patients (12.7%), with approach-specific profiles: anterior surgery was associated with hematoma, dysphagia, and dysphonia, posterior surgery with CSF leak, wound infection, and kyphosis. No C5 palsy was recorded. Conclusions: Both anterior and posterior surgical approaches were followed by neurological and functional improvement at one year. Given the descriptive nature of the study and the baseline differences between groups, these findings should not be read as a formal comparison of effectiveness, but they reinforce the importance of individualized, pathology-driven surgical planning in DCM.

Systematic review. X-linked hypophosphatemia (XLH) is a rare genetic disorder characterized by impaired phosphate homeostasis due to renal phosphate wasting. It leads to osteomalacia and skeletal abnormalities and represents the most common inherited cause of vitamin D-resistant rickets. In some patients, heterotopic ossification of the ligamentum flavum and paravertebral ligaments may result in spinal cord compression and myelopathy. Due to its rarity, large case series evaluating patient characteristics and surgical outcomes are lacking. We conducted a PRISMA-P based systematic review on spine surgery and X-linked hypophosphatemia from 1960 to 2022. Twenty-five studies were included, comprising 32 clinical cases. An illustrative case is also presented. Thirty-two patients (16 females and 16 males) with spinal cord compression due to XLH were included in this systematic review. Thirty out of 32 patients underwent surgery (one death and one refusal of surgery). The mean age of onset of symptoms was 41 years. 83

Introduction:thoracolumbar fractures often require fixation. Minimally invasive surgery (MIS), including Wiltse and percutaneous techniques, aims to reduce morbidity compared to open surgery. Research question:to evaluate multidimensional outcomes in high-energy thoracolumbar fractures treated via MIS versus open surgery. Methods:a single-centre retrospective cohort study including 82 neurologically intact adults (43.2 ± 18.5 y) who underwent open or MIS posterior fixation. Patients were divided into the Open (n = 23), versus MIS Wiltse (n = 30) and Percutaneous (n = 29) cohorts. The primary outcome was length of stay. Secondary outcomes included intraoperative blood loss, radiographic correction, second-stage surgery, concomitant kyphoplasty, pain and return-to-work status. Results:Length of stay was reduced for Wiltse (11.2 ± 4.5 d, p < 0.001) and Percutaneous (16.5 ± 7.8 d; p<0.05) versus Open patients (21.6 ± 10 d). Return-to-work delay was shorter in Wiltse (34 ± 12 d; p < 0.01) versus Open patients (72 ± 48 d). Intraoperative estimated blood loss was significantly reduced in Wiltse (929.5 ± 453.9 ml; p < 0.003) and Percutaneous (653 ± 429 ml; p < 0.0001) compared to Open surgery (1584 ± 1027 ml). This was mirrored in peri-operative ΔHb (37 g/L Open, 25 g/L Wiltse, p < 0.05; 17 g/L Percutaneous, p < 0.001). Pain recovery was faster in MIS. Second-stage corpectomy was performed in 47.8% (Open), 3.3% (Wiltse) and 33.2% (Percutaneous). Kyphoplasty was more frequent in Wiltse (66.6%) than Percutaneous (31%). Radiographic correction was maintained in all cohorts. Conclusions:MIS approaches were associated with comparable fracture stabilisation to open surgery, with shorter hospital stay and lower estimated blood loss.

Background: The atlanto-axial segment is highly mobile and, therefore, prone to instability in the setting of inflammatory disease, infection, tumor or trauma. While minimally invasive surgical (MIS) techniques have gained acceptance in the thoracolumbar spine due to their advantages over traditional approaches, their use at the atlanto-axial segment is controversial due to the surgical risk associated with its complex anatomy. To evaluate the current evidence on MIS atlanto-axial fixation, we carried out a systematic review of the literature and compared the reported results with those of open procedures. Methods: This systematic review follows PRISMA-DTA 2020 guidelines. A comprehensive search was conducted in November 2023 across PubMed/Medline, Google Scholar and clinicaltrials.gov using specific keywords related to minimally invasive atlanto-axial fixation. Data regarding study characteristics, patient demographics, surgical techniques, and outcomes were extracted from included studies. Results: This systematic review included 13 articles reporting on the results of surgery in 305 patients, in whom a total of 683 screws were inserted through a posterior MIS approach. N = 162 screws were inserted using the Harms–Goel technique, while N = 521 were placed using the Magerl technique. N = 40 screws were inserted using navigation guidance, while N = 643 were introduced with fluoroscopy assistance. Eight screws were misplaced. A Vertebral Artery (VA) injury was reported in three patients. With a mean value of 26.2 ± 15.3 months, the rate of fusion ranged between 80% and 100%. Conclusions: This study highlights the potential of MIS for posterior atlanto-axial fixation, which was achieved using Magerl transarticular screws in a large majority of cases. Despite technical challenges, MIS approaches appear to achieve satisfactory clinical and radiological outcomes with complication rates similar to those of open techniques. Future studies may help refine the indications for MIS and identify those cases better suited for open approaches.

Introduction:Recurrent lumbar disc herniation (RLDH) is defined as the reappearance, following initial discectomy, of disc material and pain after a period of at least six symptom-free months. Redo surgery is usually considered following unsuccessful conservative management or in the presence of neurological deficits. Research question:Given the lack of consensus on the ideal surgical strategy for RLDH, we conducted this study to evaluate when lumbar fusion (LF) should be considered in the treatment of RLDH. Material and methods:A literature search was conducted on PubMed, Google Scholar and clinicaltrials.gov focusing on the treatment of recurrent disc herniation using microdiscectomy alone or through fusion. The quality of the studies was evaluated using the Newcastle-Ottawa Quality Assessment Scale and Cochrane Risk of Bias Tool 2.0. The weighted mean difference was calculated for both binary and continuous outcomes. Results:This resulted in a list of 900 references, from which 11 studies were identified as meeting the inclusion criteria for the study. There were four prospective studies and seven retrospective studies. A comparison of LF and redo discectomy (RD) revealed no significant differences in clinical outcome scores. LF resulted in significantly higher intraoperative blood loss, longer hospitalizations and longer surgeries. No further differences were identified. Discussion and conclusions:Both LF and RD represent safe and effective treatment options in first RLDH. The choice of surgical strategy should integrate the eventual co-existence of clinical and radiological features of segmental instability, as well subjective aspects, such as surgeons' training and patient preference.

Background/Objectives: Sacral chordomas are rare, locally invasive tumors that pose significant surgical and oncological challenges due to their anatomical complexity, proximity to critical structures, and resistance to conventional therapies. Methods: A literature search focused on contemporary multidisciplinary management of sacral chordoma was conducted. An illustrative case of such a multidisciplinary approach is presented. Results: Achieving optimal outcomes necessitates a multidisciplinary approach that balances en-bloc resection with negative margins and preservation of biomechanical stability and neurological function. Negative resection margins are a key determinant of long-term survival and reduced recurrence, particularly for tumors involving the upper sacrum (S1–S2). While postoperative radiation therapy provides adjunctive benefits, precision in surgical planning and execution remains paramount. Emerging technologies, such as augmented reality and 3D-printed anatomical models, are enhancing surgical precision, while the role of multidisciplinary surgical teams in improving outcomes requires further study. Conclusions: This review highlights the complexities of sacral chordoma management, focusing on surgical strategies, functional trade-offs, and future directions to optimize oncological and functional outcomes.

BACKGROUND:Traumatic spinal cord injury is a devastating condition resulting in significant functional impairment. It is known that spinal manipulation therapy, often used as complementary treatment for presumed muscular neck pain, may rarely precipitate spinal cord compression and injury in patients with undiagnosed cervical canal stenosis. OBSERVATIONS:The authors report the case of a 68-year-old woman who presented to the emergency department with right scapular-paravertebral pain and right upper limb paresthesia, initially attributed to muscular causes without imaging. Spinal manipulation therapy was administered in the emergency department, causing sudden bilateral lower limb sensory loss and right lower limb motor deficit. No imaging or neurosurgical consultation was undertaken until she returned the next day with progressive weakness, hypoesthesia, and burning dysesthesia. Subsequently, MRI revealed a large acute C6-7 disc extrusion with underlying chronic multilevel stenosis, requiring anterior fusion and posterior decompression. Postoperatively, she partially improved, but a partial motor deficit, lower limb hypoesthesia, and neuropathic pain persisted. LESSONS:This case highlights the importance of thorough clinical and radiological assessment prior to administering spinal manipulation in the cervical spine, particularly in patients with signs of sensory or motor dysfunction. Torticollis and muscular contractions in the limbs may be presenting signs of cervical stenosis and degenerative cervical myelopathy, thus requiring further neurological investigation before patients are considered for spinal manipulation therapy. https://thejns.org/doi/10.3171/CASE25304.

Introduction: Degenerative cervical myelopathy (DCM) is a progressive spinal cord disorder driven by static compression and dynamic instability. Cervical sagittal alignment has recently emerged as a potential factor influencing both pathogenesis and surgical outcomes. Research question: This review synthesizes current evidence on alignment parameters and their clinical relevance in DCM management, with the primary aim of guiding surgical decision-making. Material and methods: A narrative literature review was performed, analyzing radiological parameters of cervical alignment, their normative thresholds, and associations with functional outcomes. Both cranio-cervical and subaxial metrics were examined, alongside emerging global alignment concepts. Results: Key parameters include C2–C7 sagittal vertical axis (SVA), cervical lordosis (CL), T1 slope (T1S), and the T1S–CL mismatch. Malalignment is generally defined as SVA >40 mm, CL < 15°, or T1S–CL > 20°. Increased SVA and cervical kyphosis correlate with reduced mJOA scores and poorer surgical results. Alignment also informs surgical strategy: anterior approaches are favored in kyphosis or ventral compression, while posterior techniques are preferred in lordotic or neutral spines. Novel measures such as the C2–T1 Pelvic Angle (CTPA) seek to contextualize cervical alignment within global sagittal balance. Evidence further suggests reciprocal cervical adaptations following thoracolumbar correction. Discussion and conclusion: Cervical sagittal alignment is clinically relevant in DCM pathophysiology and surgical decision-making. While correlations between alignment parameters and outcomes are established, robust evidence defining corrective thresholds remains limited. Prospective studies are required to validate these measures and refine realignment strategies in DCM.

Study Design.Heterogeneous data collection through a mix of prospective, retrospective, and ambispective methods. Objective.To evaluate the effect of biological sex on patient-reported outcomes after spinal fusion surgery for lumbar degenerative disease. Summary of Background Data.Current literature suggests sex differences regarding clinical outcome after spine surgery may exist. Substantial methodological heterogeneity and limited comparability of studies warrants further investigation of sex-related differences in treatment outcomes. Materials and Methods.We analyzed patients who underwent spinal fusion with or without pedicle screw insertion for lumbar degenerative disease included within a multinational study, comprising patients from 11 centers in seven countries. Absolute values and change scores (change from preoperative baseline to postoperative follow-up) for 12-month functional impairment [Oswestry disability index (ODI)] and back and leg pain severity [numeric rating scale (NRS)] were compared between male and female patients. Minimum clinically important difference (MCID) was defined as >30% improvement. Results.Six-hundred sixty (59%) of 1115 included patients were female. Female patients presented with significantly baseline ODI (51.5 +/- 17.2 vs. 47.8 +/- 17.9, P<0.001), back pain (6.96 +/- 2.32 vs. 6.60 +/- 2.30, P=0.010) and leg pain (6.49 +/- 2.76 vs. 6.01 +/- 2.76, P=0.005). At 12 months, female patients still reported significantly higher ODI (22.76 +/- 16.97 vs. 20.50 +/- 16.10, P=0.025), but not higher back (3.13 +/- 2.38 vs. 3.00 +/- 2.40, P=0.355) or leg pain (2.62 +/- 2.55 vs. 2.34 +/- 2.43, P=0.060). Change scores at 12 months did not differ significantly among male and female patients in ODI (triangle 1.31, 95% CI: -3.88 to 1.25, P=0.315), back (triangle 0.22, 95% CI: -0.57 to 0.12, P=0.197), and leg pain (triangle 0.16, 95% CI: -0.56 to 0.24, P=0.439). MCID at 12 months was achieved in 330 (77.5%) male patients and 481 (76.3%) female patients (P=0.729) for ODI. Conclusion.Both sexes experienced a similar benefit from surgery in terms of relative improvement in scores for functional impairment and pain. Although female patients reported a higher degree of functional impairment and pain preoperatively, at 12 months only their average scores for functional impairment remained higher than those for their male counterparts, while absolute pain scores were similar for female and male patients.

Study DesignSystematic review.ObjectivesThe pre-symptomatic state of Degenerative Cervical Myelopathy (DCM), wherein degenerative changes and spinal cord compression are seen without clinical findings, is poorly understood and inconsistently categorised. Clear identification may elucidate the temporality of DCM development. Therefore, a systematic assessment was undertaken of current terminology for pre-DCM states, with the objective of standardising definitions and informing an AO Spine expert position statement.MethodsMedline and Embase were searched for all studies on asymptomatic spinal compression or clinical findings preceding DCM, returning 3585 studies. After screening, 96 studies were included in the final analysis. The terminology used for pre-DCM states and their definitions were extracted, along with their frequencies or speciality/country of author in the literature.ResultsMultiple terms were used to represent pre-DCM stages, including "asymptomatic" (86 studies), "non-myelopathic" (26 studies), "without myelopathy" (15 studies), "pre-symptomatic" (9 studies) and "sub-clinical" (7 studies). "asymptomatic" was associated with the greatest inconsistency. Some defined this as patients with radiological signs of spinal degeneration with/without spinal cord compression but no clinical signs of myelopathy, whereas others used the term synonymously with healthy controls. This inconsistency is particularly challenging in clinical studies in which DCM patients are compared to those with pre-DCM states and/or healthy volunteers.ConclusionThere is substantial inconsistency in the terms used to describe pre-DCM states. There is no clear relationship between the terms used and the country or speciality of the main author. Standardised definitions for these disease states should be agreed and used in future studies.

OBJECTIVE:Variations exist among surgeons in the treatment of recurrent lumbar disc herniation (LDH), generating major issues in decision-making models. The authors aimed to identify international nuances in surgical treatment patterns, highlight the differences in responses in each country group and different treatment trends across countries, and identify factors that influence surgical decisions. METHODS:An online survey with preformulated answers was submitted to 292 orthopedic surgeons and 223 neurosurgeons from 16 countries regarding 3 clinical vignettes (recurrence without low back pain, recurrence with severe low back pain, and recurrence with 2-level disc disease). The variability for each country was calculated according to the index of qualitative variation (IQV; ranging from 0 [no variability] to 1 [maximum variability]). To integrate the surgeons' perspectives, 2 Likert-type queries were submitted concerning the specific criteria for fusion and overall decision-making for each clinical case. RESULTS:Except for the case of first recurrence with pure radiculopathy without instability or inflammatory disc disease, where the variability was low (mean IQV 0.24, redo discectomy 86.2%), the other cases showed high variability (mean IQV range 0.63-0.71), with frequent proposals for surgery with implants. For countries with low variability, a high rate of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures (55.3%) and low rates of anterior/combined procedures (5.9%) and posterolateral fusion (4.9%) were observed. For countries with high variability, a lower rate of PLIF/TLIF procedures was observed (33.1%), with alternate proposals for anterior/combined procedures (20.8%) and posterolateral fusion without interbody fusion (12.8%). Orthopedic surgeons performed significantly more procedures with implants compared with neurosurgeons (p < 0.01). Age, practice type, and the annual number of surgery cases did not play a significant role in the choice of procedures. The most important criteria for fusion were lumbar pain symptoms associated with radiculopathy (77.9% strongly agreed) and the existence of inflammatory disc disease (73.0%). Furthermore, 62.1% of the respondents strongly agreed with performing fusion for all second recurrences. For the final decision, surgeons agreed with following the literature (81.9%), selecting low-morbidity procedures (78.6%), and using a familiar technique (78.6%). Patient preference was an important and/or very important decision factor for 64.1% of respondents. CONCLUSIONS:Significant differences existed between spine surgeons in the surgical treatment of recurrent LDH. Intra- and intergroup variations were observed, reflecting the lack of consensus in the literature and the challenge of adapting differences in habits and training to the few existing guidelines.

Introduction The management of de novo non-specific spinal infections (spondylodiscitis - SD) remains inconsistent due to varying clinical practices and a lack of high-level evidence, particularly regarding the indications for surgery. Research Question This study aims to develop consensus recommendations for the diagnosis and management of SD, addressing diagnostic modalities, surgical indications, and treatment strategies. Material and Methods A Delphi process was conducted with 26 experts from the European Association of Neurosurgical Societies (EANS). Sixtytwo statements were developed on diagnostic workup, management decisions, surgical techniques, non-surgical treatment, and follow-up and submitted to the panel of experts. Results Consensus was reached on 38 of 62 statements. MRI was confirmed as the gold standard for diagnosis. Regarding surgical indications, the panel agreed that any new neurological deficit, even subtle, warrants surgical consideration. Motor deficits with a motor score (MRC) below 4 and bladder or bowel dysfunction were unanimously considered clear indications for surgery. For spinal deformity and instability, thresholds such as kyphosis >20°, scoliosis >10°, and vertebral body collapse >50% were established to guide surgical decision-making. Minimally invasive surgery (MIS) was endorsed whenever feasible, and a 12 week antibiotic treatment regimen was favored in cases of complicated infections. Discussion and Conclusion This EANS consensus provides updated recommendations for SD management, incorporating recent evidence on improved outcomes with surgical therapy. While these guidelines offer a more structured approach to clinical decision-making, further research is required to optimize surgical timing and validate the long-term impact of these treatment strategies.

Introduction:Controversy exists regarding the optimal management of type II odontoid fractures in the geriatric population. The objective of this study was to determine the current treatment patterns of spine surgeons for geriatric patients (≥70 years) with type II odontoid fractures. Research question:How much do treatment practices for type II odontoid fractures in the geriatric population differ amongst spine surgeons? Methods:The European Association of Neurosurgical Societies (EANS) Spine Section distributed a 39-items web-based survey among spine surgeons between July 2024 and February 2025. Results:A total of 154 responses were collected from 119 neurosurgeons (77.8 %) and 34 orthopedic surgeons (22.2 %). Participants were predominantly from Europe (92.7 %), and 63.2 % have been in practice >10 years. Fracture displacement, comorbidities and age were the most influential factors for decision-making. For non-displaced fractures, 78.8 % of respondents recommended conservative treatment for patients aged 70-80 years, and 83.7 % for those aged 80-90 years. For displaced fractures, 70.9 % preferred surgery for patients aged 70-80 years, whereas this preference decreased to 47.9 % for those aged 80-90 years. Posterior C1-2 fixation was the most common technique for 67.3 % of respondents, and 48.3 % prescribe a collar postoperatively. 51.3 % routinely order CT imaging postoperatively to assess for bony fusion. For conservative treatment, 59.3 % prescribe an external orthosis for 3 months. Discussion and conclusion:Our survey found both variability and consistency in treatment practices of geriatric type II odontoid fractures, reflecting the ongoing debate and lack of consensus in clinical decision-making.

Chronic seroma and pseudomeningocele formation following spinal instrumentation, particularly in the setting of prior infection and multiple revision surgeries, remains rare but pose a significant therapeutic challenge due to high recurrence rate. In this context, we present a complex case of pseudomeningocele that evolved into a persistent seroma with cutaneous fistula after multi-level lumbar fusion with a comprehensive review of sclerotherapy protocols. A 75-year-old patient with prior L3-S1 fusion surgery presented with rod fracture and underwent surgical revision. Postoperatively, a collection with purulent discharge and altered consciousness raised suspicion of a dural breach, later confirmed by Beta-Trace protein testing. Despite multiple revisions and placement of a pedicled SGAP flap, persistent pseudomeningocele developed, evolving in a chronic seroma after CSF leak resolution. The course was further complicated with chronic Staphylococcus Epidermidis infection. Revision surgery with flap mobilization and capsulectomy failed to resolve the seroma. Due to limited surgical options, a multi-instillation doxycycline sclerotherapy protocol via radiologically guided drain was initiated. The sclerotherapy protocol resulted in progressive decrease in drain output, ultimately allowing for drain removal after 34 days. Follow-up ultrasound 7 days and 3 months after drain removal showed no significant fluid collection. No recurrence of fistula or seroma was observed during follow-up. This case highlights the challenges of managing postoperative wound complications in spinal surgery, particularly in the context of prior infection, hardware exposure, and suspected cerebrospinal fluid leak. A pedicled SGAP flap provided durable coverage, and doxycycline sclerotherapy proved an effective salvage treatment for persistent seroma after unsuccessful surgical revision.

Background: Perineural Tarlov cysts are extrathecal cerebrospinal fluid-filled cavities in the perineural recesses around dorsal spinal nerve roots. They are mostly asymptomatic but may occasionally cause back pain, radiculopathy, neurological deficits, and idiopathic intracranial hypotension. Case Description: A 40-year-old female presented with a partial left foot drop attributed to a symptomatic L5 Tarlov cyst with an extension anterior to the sacrum. Following a computed tomography (CT)-guided percutaneous trans-sacral fibrin glue intracystic injection, the cyst was markedly reduced in size, and the patient’s symptoms resolved. Conclusion: Rarely, patients may present with symptomatic lumbar Tarlov cysts located anterior to the sacrum. Here, we present a patient whose left-sided foot drop resolved following the percutaneous trans-sacral CT-guided L5 intracyst injection of fibrin glue.

Osteoporotic vertebral compression fractures (OVCFs) present a significant health concern, affecting a substantial portion of the older adult population worldwide. This narrative review explores the prevalence, diagnostic challenges and management strategies for OVCFs. Despite the increasing incidence and impact on morbidity and mortality, existing clinical guidelines lack consistency and clear diagnostic and therapeutic recommendations. The review addresses key questions faced by physicians dealing with older adult patients experiencing acute back pain, offering insights into triage, radiological assessments and classification systems. We propose a comprehensive algorithm for clearing OVCF, considering clinical presentation, radiological findings and morphological aspects. Emphasis is placed on the importance of medically treating osteoporosis alongside OVCF management. The review encompasses relevant literature from 1993 to 2023, provides a detailed discussion on triage issues and incorporates a clinically oriented classification system developed by the German Society for Orthopaedics and Trauma. The Material and Methods section outlines the extensive literature search carried out in PUBMED, encompassing clinical and experimental studies, systematic reviews and meta-analyses. The articles retained focused mainly on answering critical questions regarding radiological assessments, imaging modalities and the presence of a specific classification system for OVCFs. The review emphasises that the evaluation and management of OVCFs necessitates a multidisciplinary approach involving spine specialists and bone disease experts. It also addresses the role of conservative versus surgical treatments, with a focus on percutaneous vertebral augmentation. The conclusion summarises the algorithm derived for use in emergency departments and general practice, aiming to streamline OVCF management, reduce unnecessary examinations and ensure optimal patient care. The algorithm recommends primary diagnosis using computed tomography, with magnetic resonance imaging reserved for specific cases. The review advocates a holistic approach, integrating medical and surgical interventions to address the complex challenges posed by OVCFs in ageing populations.