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.

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.

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 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.

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.

Departments of Neurosurgery and Orthopaedic Surgery The Emory Spine Center Emory University Atlanta, Georgia

Background:Flexion-distraction injuries (FDI) represent 5% to 15% of traumatic thoracolumbar fractures. Treatment depends on the extent of ligamentous involvement: osseous/Magerl type B2 injuries can be managed conservatively, while ligamentous/Magerl type B1 injuries undergo stabilization with arthrodesis. Minimally invasive surgery without arthrodesis can achieve similar outcomes to open procedures. This has been studied for burst fractures; however, its role in FDI is unclear. Objective:To conduct a systematic review of the literature that examined minimally invasive surgery instrumentation without arthrodesis for traumatic FDI of the thoracolumbar spine. Methods:Four electronic databases were searched, and articles were screened using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines for patients with traumatic FDI of the thoracolumbar spine treated with percutaneous techniques without arthrodesis and had postoperative follow-up. Results:Seven studies with 44 patients met inclusion criteria. There were 19 patients with osseous FDI and 25 with ligamentous FDI. When reported, patients (n = 39) were neurologically intact preoperatively and at follow-up. Osseous FDI patients underwent instrumentation at 2 levels, while ligamentous injuries at approximately 4 levels. Complication rate was 2.3%. All patients had at least 6 mo of follow-up and demonstrated healing on follow-up imaging. Conclusion:Percutaneous instrumentation without arthrodesis represents a low-risk intermediate between conservative management and open instrumented fusion. This “internal bracing” can be used in osseous and ligamentous FDIs. Neurologically intact patients who do not require decompression and those that may not tolerate or fail conservative management may be candidates. The current level of evidence cannot provide official recommendations and future studies are required to investigate long-term safety and efficacy.

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) is one of the most common spinal procedures performed. A direct comparison of the fusion and complication rates between recombinant human bone morphogenetic protein-2 (rhBMP2) and beta-tricalcium phosphate (bTCP) has not been reported.METHODS: A retrospective study of 191 consecutive patients who underwent ACDF with polyetheretherketone plastic fusion spacers during a 2-year period with either rhBMP2 (n = 84, 46%) or bTCP (n = 107, 56%) was performed. Patients underwent 1-(35%), 2-(41%), 3-(20%), and 4-(4%) level operations. The primary outcome measure was mature arthrodesis, with secondary measures including clinical outcomes and complication occurrence. Fusion was graded on plain lateral radiographs, with median length of follow-up of 12 months.RESULTS: Rates of cervical fusion were significantly greater for patients treated with rhBMP2 than bTCP at both 6 months (70% vs. 26%, P = 0.000) and 12 months (99% vs. 85%, P = 0.000). Postoperative dysphagia was reported in 35 patients (18%), with no difference in dysphagia incidence between rhBMP2 and bTCP (20% vs. 17%, P = 0.5); however, dysphagia was more severe in the rhBMP2 group, with greater rates of readmission and steroid use (both P < 0.05). A multivariable sensitivity analyses to control for patient characteristics and number of spinal fusion levels showed no differences in dysphagia rate between rhBMP2 and bTCP.CONCLUSIONS: In our cohort, the rate of mature arthrodesis after ACDF was greater with rhBMP2 compared with bTCP with no increased incidence of postoperative dysphagia; however, dysphagia severity was greater in the rhBMP2 cohort.

The authors report the case of a patient who suffered a Jefferson fracture during a professional football game. The C-1 (atlas) fracture was widely displaced anteriorly, but the transverse ligament was intact. In an effort to enable a return to play and avoid intersegmental (C1-2) fusion, the patient underwent a transoral approach for open reduction and internal fixation of the fracture. The associated posterior ring fracture displacement widened after this procedure, and a subsequent posterior arthrodesis and fixation of the fracture site was performed 6 months later when the fracture failed to heal with rigid collar immobilization. The approach maintained the normal range of motion at the atlantoaxial and atlantooccipital joints, which would have been sacrificed by an atlantoaxial or occipitocervical fusion, as is traditionally performed. Ultimately, the patient decided not to return to the football field, but this approach could avoid the more significant loss of motion associated with atlantoaxial or occipitocervical fusion for unstable Jefferson fractures.

Suzie C. Tindall was one of the trailblazing women to enter the male-dominated specialty of neurosurgery in the 1980s. On October 5, 2016, Dr Tindall passed away after a long fight with multiple myeloma. She was born September 16, 1944 in Norfolk, Virginia and raised in Houston, Texas. Her parents, Warren P. Cunningham, Jr and Ellen Benner Cunningham, named her Marianne but called her Suzie. Her name was legally changed when she was a young adult. Her father, an attorney and later a Texas State Civil District Court judge, dedicated much of his time to teaching in the National College for state trial judges. Her mother was educated as a registered nurse but did not work outside the house and raised 3 children. As a child, Suzie always wanted to be a physician. Never for a day did she desire to be anything but a physician, and few days as an adult were any different. At 16 years of age, Suzie began working in a hospital, first as a nurse aide feeding healthy newborns and then as a janitor and scrub tech in the labor and delivery department, a job she held during summers in college. She was always an excellent student and graduated from Spring Branch High School in 1962, obtained her bachelor's degree in Chemistry at Duke University in 1966, and her MD, with honors, at the University of Texas Medical Branch in Galveston in 1970. The early years of medical school were unduly difficult because of financial insecurity. Her father suggested her to talk to a man he had met through his Rotary Club and he offered financial assistance. It was initially unclear to Suzie whether this was a loan and, if so, what the terms of repayment were. After she finished medical school, this generous man simply asked her to do the same for someone else. Dr Tindall completed a medicine internship at Vanderbilt and returned to Galveston to begin her residency in neurology in 1971. That same year she was married to Dr George Tindall, Professor and Chief of Neurosurgery at the University of Texas Medical Branch in Galveston at the time. While in Galveston she engaged in advanced training in electroencephalography and in 1973 moved with her husband to Emory University in Atlanta, Georgia where she completed her neurology training. Dr Tindall practiced neurology in DeKalb County, Georgia from 1973 through 1978, but became frustrated with the inability to definitively treat so many of the patients for whom she provided care. In 1978, she entered a surgical internship and completed her neurosurgery residency at Emory University Affiliated Hospitals in 1982. She joined the academic faculty of the Emory University School of Medicine and The Emory Clinic with appointments in neurology and neurological surgery. From 1982 through 1988, she served as Chief of the Neurosurgical Service at Grady Memorial Hospital, and from 1982 through 2000 as Chief of the Neurosurgical Service at Emory University Hospital at Crawford Long (currently Emory University Hospital, Midtown.) She worked her way up the academic ladder and retired as Professor Emeritus of Neurological Surgery, Emory University School of Medicine. She was certified by The American Board of Neurology and Psychiatry (1976), and The American Board of Neurological Surgery (1984). Dr Tindall was a member of numerous prestigious neurosurgical organizations, including induction into Alpha Omega Alpha medical school honor society. She served as President of the Georgia Neurosurgical Society (1992), and President of the Southern Neurosurgical Society (1995). She served on numerous committees for her institution and for organized neurosurgery. Her major subspecialty interests included treatment of surgical disorders of the peripheral nerves and treatment of trigeminal neuralgia, but she was a consummate general neurosurgeon who could manage all varieties of neurosurgical disorders with exceptional skill. Her greatest love in academic medicine was medical student and resident training. She possessed the rare combination of a broad knowledge of medical neurology, superb surgical skills, excellent judgment, impeccable honesty, and an unusual humility that made it simple for her to ask for her colleagues’ assistance. Those of us who had the honor of practicing with Suzie witnessed a hard-working, honest, and technically gifted surgeon dedicated to her patients and to teaching the medical students and resident physicians she trained. Suzie Tindall developed a passion for wood working as a teenager after her father accepted some tools as payment for a legal case. She was handy throughout her life and could fix almost anything. Following retirement from medicine, she became a master woodworker, and was active in The Woodworker's Guild of Georgia (President 2005) and the Georgia Association of Woodturners. Her work, randing from canoes to fine furniture to bowls to in-laid art, was spectacular and widely acclaimed. She also enjoyed playing golf as a member of the Druid Hills Golf Club and the Atlanta Women's Golf Association. Suzie Tindall never forgot the generosity that provided her with financial assistance during medical school and during her life she quietly provided financial assistance to many medical students in need. In 2009 Dr Tindall was diagnosed with multiple myeloma and underwent a bone marrow transplant, after which she returned to her very active lifestyle. After a recurrence, she was treated with multiple chemotherapeutic regimens over the ensuing 7 years. She was married to George Taylor Tindall from 1971 to 1992, a union that ended in divorce. She is survived by her partner of more than 20 years, Sue Tucker. She is also survived by her 2 brothers, Tom Alan Cunningham (Jeanne) of Houston, Texas, and Warren P. Cunningham, III, (Kathy) of Argyle, Texas, and 2 nephews. On October 29, a memorial service and celebration of life was held in Atlanta for Suzie Tindall. Those of us present reminisced and shared our favorite stories of this remarkable doctor and woman. She will be missed. Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

OBJECTIVE Esophageal perforation is a rare but well-known complication of anterior cervical spine surgery. The authors performed a systematic review of the literature to evaluate symptomatology, direct causes, repair methods, and associated complications of esophageal injury. METHODS A PubMed search that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included relevant clinical studies and case reports (articles written in the English language that included humans as subjects) that reported patients who underwent anterior spinal surgery and sustained some form of esophageal perforation. Available data on clinical presentation, the surgical procedure performed, outcome measures, and other individual variables were abstracted from 1980 through 2015. RESULTS The PubMed search yielded 65 articles with 153 patients (mean age 44.7 years; range 14-85 years) who underwent anterior spinal surgery and sustained esophageal perforation, either during surgery or in a delayed fashion. The most common indications for initial anterior cervical spine surgery in these cases were vertebral fracture/dislocation (n = 77), spondylotic myelopathy (n = 15), and nucleus pulposus herniation (n = 10). The most commonly involved spinal levels were C5-6 (n = 51) and C6-7 (n = 39). The most common presenting symptoms included dysphagia (n =63), fever (n = 24), neck swelling (n = 23), and wound leakage (n = 18). The etiology of esophageal perforation included hardware failure (n = 31), hardware erosion (n = 23), and intraoperative injury (n = 14). The imaging modalities used to identify the esophageal perforations included modified contrast dye swallow studies, CT, endoscopy, plain radiography, and MRI. Esophageal repair was most commonly achieved using a modified muscle flap, as well as with primary closure. Outcomes measured in the literature were often defined by the time to oral intake following esophageal repair. Complications included pneumonia (n = 6), mediastinitis (n = 4), osteomyelitis (n = 3), sepsis (n = 3), acute respiratory distress syndrome (n = 2), and recurrent laryngeal nerve damage (n = 1). The mortality rate of esophageal perforation in the analysis was 3.92% (6 of 153 reported patients). CONCLUSIONS Esophageal perforation after anterior cervical spine surgery is a rare complication. This systematic review demonstrates that these perforations can be stratified into 3 categories based on the timing of symptomatic onset: intraoperative, early postoperative (within 30 days of anterior spinal surgery), and delayed. The most common source of esophageal injury is hardware erosion or migration, each of which may vary in their time to symptomatic manifestation.

Introduction Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumented fusion. A better understanding of clinical course following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumented fusion. Methods A systematic review of the PubMed database was performed, following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The extracted data was recorded in an excel spreadsheet. To be included, the patients must have undergone fusion of the C1/C2 joint using posterior instrumentation with injury to an arterial vessel directly attributable to the surgical procedure. Results 86 incidences of vascular injury were found in 41 articles with 11200 patients. The average age of included patients was 46.4 +/− 24.1 for the screw rod construct (SRC) group and 36.2 +/− 28.2 for the transarticular screw (TAS) group. Vascular injury in SRC cases resulted in ipsilateral stroke in 15.9% ( n = 7/44) of patients and neurologic deficit in 22.7% ( n = 10/44) of patients with a permanent neurologic deficit occurring in 11.4% ( n = 5/44) of patients. Vascular injury following TAS fixation resulted in ipsilateral stroke in 11.9% of cases ( n = 5/42) and neurologic deficit in 23.8% of cases with the deficit being permanent in 9.5% ( n = 4/42) of cases. Death was the result of injury in 9.1% ( n = 4/44) of SRC cases and 7.1% ( n = 3/42) of TAS cases. Conclusions Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. There has been no large-volume studies aimed at identifying a rate of neurologic complications after iatrogenic injury. Surgeons should be aware of the normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic injury.

BACKGROUND: High-grade L5-S1 spondylolisthesis is challenging to treat, and there is no standard recommended operative technique. The authors performed a systematic review of the literature evaluating the efficacy and safety of modern transsacral instrumentation techniques for high-grade L5-S1 spondylolisthesis.METHODS: A systematic PubMed search adherent to PRISMA guidelines included relevant clinical studies reporting transsacral instrumentation for highgrade L5-S1 spondylolisthesis in adult humans from 1980 onward. Available data regarding clinical and radiographic outcomes for individual patients were abstracted.RESULTS: Nine of 311 studies were eligible for detailed review. They reported on 38 patients (mean 33.1 years; range 18-66 years) treated with transsacral instrumentation. Transsacral cages (6 articles, n = 23), screws (2 articles, n = 12) and rods (1 article, n = 3) were used. Posterior (86.8%) and combined anteroposterior approaches were used, both with (55.2%) and without decompression, partial reduction (23.7%), posterior pedicle screw fixation (94.7%), and adjacent level inter-body fusion (42.1%). Four patients had 6 perioperative complications (15.8%). Mean follow-up time was 30.1 months (range 2-58 months; n = 37). All patients had adequate fusion on follow-up imaging (n = 34) and no progression of slip (n = 32). All patients had improvement in pain (n = 32) and at least average function postoperatively (94.7%; n = 33/35).CONCLUSION: Operative techniques for managing high-grade L5-S1 spondylolisthesis are evolving. In our systematic review, modern transsacral instrumentation resulted in good clinical outcome and fusion rates, and acceptable complication rates. Risks and benefits should be individualized for each patient. Transsacral instrumentation is a viable and effective treatment option for this pathology.

Herniated discs usually occur in the cervical and lumbar spine. The thoracic spine is relatively non-mobile due to the attached rib cage and therefore is less commonly affected by disc herniations. Herniated discs typically occur in younger patients between ages 30 and 50 years and present primarily with appendicular pain (radicular pain of arm, leg) as well as axial pain (mechanical pain of neck, back). Cervical and thoracic discs may present with myelopathy due to spinal cord compression or radiculopathy from nerve root compression. Sometimes, a combination of myelopathic and radiculopathic symptoms is present. The majority of patients with a disc herniation obtain relief with conservative treatment. Herniated discs are the initial manifestations of the continuum of degenerative disc disease that is later manifested by dehydration of disc material, loss of disc space height, associated facet joint arthropathy, and the development of osteophytes.