BACKGROUND:Proximal junctional kyphosis (PJK) is a common complication following long-segment spinal fusion, characterized by abnormal kyphotic angulation at the junctional level adjacent to the upper instrumented vertebra (UIV). Multiple risk factors, including construct rigidity and abrupt stiffness transitions have been implicated. Strategies such as sublaminar hooks and transition rods have been proposed to achieve a "soft landing" and mitigate PJK risk. METHODS:A validated FE model of the T1-pelvis human spine was developed and instrumented with four posterior construct configurations: (1) uniform 6 mm rods; (2) transition rods tapering from 6 mm to 5 mm; (3) transition rods tapering from 6 mm to 4.5 mm; and (4) pedicle screws with a sublaminar hook at T10. Flexion-extension, lateral bending, and axial rotation were simulated. Range of motion (RoM), von Mises stress at the UIV and vertebra directly above the UIV (UIV + 1), and discal stresses were evaluated. FINDINGS:All constructs reduced global RoM (≈54-73%) relative to intact model. Sublaminar hook constructs reduced UIV stress (13 MPa) and annular stress (29.4%) most effectively. Transition rods showed superior performance in lowering rod stress (≈69 MPa) and nucleus stress (≈40.5%). INTERPRETATION:While transition rods are effective in reducing the rod and nucleus pulposus stress, hooks are better in reducing UIV and annular stress. The results emphasize that hooks and transition rods may be preferred in osteoporotic and sagittal imbalance cases, respectively.

Purpose Proximal junctional kyphosis (PJK) is an alignment loss above an instrumented vertebra. We hypothesize that careful pre-operative consideration of major procedures and risk factors associated with development of PJK will minimize the likelihood of vertebral instability, functional and neurological complications, and need for revision surgery. Methods The authors performed a systematic search of published literature in the PubMed, Web of Science, and Cochrane Library databases from January 01, 2012, to December 31, 2023, per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This retrospective analysis included 1304 pediatric and 1101 adult patients from articles published between 2012 and 2023 in PubMed, Web of Science, and Cochrane databases using search terms “proximal junctional kyphosis”, “proximal junctional failure”, and “scoliosis”. Eligible studies included randomized controlled trials and other clinical studies with a minimum of two-year follow-up and a sample size of at least 30 patients. Results Nine surgical procedures and eight risk factors were determined to significantly contribute to the development of PJK. The two procedures with the greatest association with post-operative development of PJK in pediatrics are posterior interbody fusions (45.5%, P < 0.01) and rib-based proximal anchors (24.7%, P = 0.03). The highest-risk adult spine procedures include tetherless procedures (60.7%, P = 0.0002) and lower thoracic junctional tethers (31.5%, P < 0.001). The two greatest risk factors for the development of PJK in pediatrics are increased rod-contouring angle (65%, P < 0.001) and increased spinopelvic malalignment (40%, P = 0.04). Conclusion PJK has significant implications on surgical outcomes, leading to further functional and neurologic side effects and potentially proximal junctional failure. Spine surgeons should consider the risk factors while selecting a procedure to minimize the likelihood of developing PJK in spinal deformity patients.

Postoperative spine surgery wound infection has been reported at up to 10.9%. Intraoperative application of vancomycin and prolonged use of postoperative prophylactic antibiotics have been used by some surgeons to decrease the rate of postoperative surgical site infection (SSI). Given the current global emphasis on rational antibiotic use, any recommendation to extend prophylaxis beyond 24 hours should be weighed against potential risks of resistance and microbiome disruption. To identify the epidemiology of postoperative spine SSI, diagnosis of infection, major risk factors contributing to infection, and current recommendation of using prophylactic systemic and local antibiotics. Literature review: 1992-2025, PubMed research words - postoperative antibiotic; Prolonged; intrawound local vancomycin, spine surgery; postoperative infection. Current recommendations for antibiotic surgical prophylaxis are: 1-2 g of cefazolin and 1-2 g of vancomycin preoperatively, dependent upon the patient’s weight and allergies. Re-dose antibiotics at 4-hour intervals during prolonged surgery. Intraoperative application of vancomycin and prolonged use of postoperative prophylactic antibiotics have been used by some surgeons to decrease the rate of postoperative SSI. There is still no current standard of care, especially in patients with high risks of postoperative wound infection. When deciding on antibiotic surgical prophylaxis, one has to consider multiple factors, including patient and surgical factors. Using local as well as prolonged postoperative systemic antibiotics may be considered in high-risk patients to decrease the rate of SSI. Recommendation to extend postoperative prophylaxis antibiotic beyond 24 hours has to be weighed against the current global emphasis on rational antibiotic use, to decrease potential risks of antibiotic resistance.

ABSTRACT Cervical degenerative disc disease (DDD) occurs when there is deterioration of the intervertebral discs in the cervical spine and can cause extreme pain and disability. Cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) are the two prominent surgical treatment options. There are a few meta‐analyses that examine the cost‐effectiveness of these two methods. This meta‐analysis study seeks to provide a thorough overview of cost‐effectiveness and postoperative complications between CDA and ACDF in the treatment of cervical DDD. Publication search was carried out on PubMed and Embase up until March 2025. Comparison studies that included the two treatment methods of interest and reported a cost analysis with complication metrics were included in this meta‐analysis. Review Manager 5.4. was utilized for statistical analyses, and a p value ≤ 0.05 was considered statistically significant. Thirteen studies were included. Regarding the cost analysis, there was a significant difference in initial cost in favor of ACDF compared to CDA. As for the outcome metrics, there was a significant difference in reoperation as well as DVT/PE rates in favor of CDA. There was a significant difference in mean operative time in favor of ACDF. No other significant differences were found. ACDF appears to be a cost‐effective option, while CDA offers advantages in certain complication metrics. Additional studies investigating the relationship between treatment costs and complications should be completed in order to solidify the superior treatment method for cervical DDD.

Background Cervical disc arthroplasty (CDA) is a surgical treatment indicated for symptomatic pathologies of the cervical spine. Cervical disc designs fall under one of the three categories: semi-constrained, unconstrained, or constrained. This meta-analysis aims to provide an overview of differences in postoperative outcomes and functional scores among the three types of cervical discs. Methods A literature search was conducted on PubMed and Embase through June 2025. Comparison studies that included at least two of the disc categories and reported outcomes of interest were included in this study. Review Manager 5.4. was utilized for statistical analyses, and a P-value ≤ 0.05 was considered statistically significant. Results Fifteen studies were included, with a total of 1341 patients. Comparing semi-constrained to unconstrained, a significant difference in operative time was found in favor of semi-constrained, while the incidence of heterotopic ossification (HO) was found in favor of unconstrained. Comparing semi-constrained to constrained, a significant difference in incidence of HO was found in favor of semi-constrained. Lastly, comparing unconstrained to constrained, significant differences were found in the changes of Visual Analog Score-Neck, Neck Disability Index, 12- Item Short Form Survey Physical Component Score, and Functional Spinal Unit (FSU) total range of motion in favor of unconstrained, while the change of FSU angle was found in favor of constrained. Conclusion Unconstrained cervical discs seem to provide better functional scores compared to constrained discs, with an advantage in the rate of HO compared to semi-constrained discs. There does not seem to be many significant differences between semi-constrained compared to unconstrained and constrained cervical discs in terms of functional scores and complications. Future studies should be carried out to identify the most effective disc design. Level of Evidence 3

Background: Adult spinal deformity (ASD) leads to significant pain, disability, and quality-of-life issues due to sagittal imbalance. Restoring alignment is key to improving outcomes, and anterior column realignment (ACR) techniques are increasingly used for this purpose. This study examines the biomechanical impact of varying hyper-lordotic cage configurations in ACR. Specifically, we evaluated a 30 degrees cage at 1 level (L3-L4), two 15 degrees cages at 2 levels (L3-L5), and three 10 degrees cages at 3 levels (L2-L5), assessing range of motion (ROM), implant stress, and adjacent segment biomechanics. Methods: Finite element (FE) simulations of the thoracolumbar spine (T8-Pelvis) were performed on a validated model of a 55-year-old male. ACR was simulated at one, two, and three levels with 30 degrees, 15 degrees, and 10 degrees lordotic cages, respectively, with posterior pedicle screw and rod fixation. Loads included a 300 N compressive force at the thoracic region, 400 N at lumbar levels, and a 7.5Nm moment to simulate flexion, extension, lateral bending, and axial rotation. Outcomes analyzed included ROM, von Mises stress on rods, and annulus stress at adjacent segments. Results: Increasing ACR levels reduced ROM in instrumented segments: the 2-level ACR reduced flexion by 12.9% and the 3-level by 17.1%. Rod stress decreased in flexion (2-level: ~2.3%, 3-level: ~5%) and extension (2-level: 6.1%, 3-level: 8%). Lateral bending showed reductions (1.1-4.3%), while rotation exhibited a slight increase for multi-level ACR. Conclusions: Multi-level ACR reduces ROM, suggesting enhanced spinal stability with minimal adjacent segment impact. Further studies are recommended to validate and optimize ACR strategies for ASD.

Anterior cervical spine surgery is widely performed to manage degenerative, traumatic, and compressive spinal conditions. Despite its effectiveness, iatrogenic nerve injuries remain a significant concern due to the complex anatomy of the cervical region. This review offers a focused narrative on nerve injuries associated with anterior cervical approaches, including recurrent and superior laryngeal nerve palsy, C5 nerve root palsy, and hypoglossal nerve injury. Less common complications such as Parsonage-Turner syndrome (PTS), C8-T1 radiculopathy, and Horner's syndrome are also addressed. Each injury is discussed in terms of anatomical relevance, incidence, clinical features, diagnosis, and strategies for prevention and management. A structured review of PubMed-indexed literature from the past 25 years was conducted to ensure the inclusion of current evidence. Risk factors such as multilevel surgery, revision procedures, and excessive retraction are highlighted. While many nerve injuries are self-limited, a subset may result in long-term deficits, reinforcing the need for meticulous surgical planning and intraoperative care. By increasing awareness of these complications, this review aims to inform surgical technique and reduce morbidity in anterior cervical spine surgery. This review emphasizes not only the incidence and anatomical relevance of these complications, but also underscores the importance of preventive measures such as careful retraction, intraoperative neuromonitoring, and preoperative planning. By synthesizing data across multiple studies and including rare complications such as Horner's syndrome and PTS, this review provides a practical reference for surgeons aiming to reduce morbidity. Ultimately, the goal is to improve surgical safety and patient quality of life through heightened awareness and refinement of technique.

BACKGROUND CONTEXT Over the past decade, new health care reforms have introduced all-cause hospital readmission as a metric for quality of care. Concurrently, payers have started to implement bundled payment systems, in which hospitals will be accountable for the costs of readmission for any reason, up to 90 days from discharge. Both medical and surgical complications in the 30- and 90-day postoperative period contribute to causes of readmission that may be modifiable by medical optimization prior to discharge after index procedure. PURPOSE The purpose of this study was to answer two questions. Does an increased number of postoperative consults, and therefore, an increase in medical optimization, lead to reduced 30 and 90-day readmission rates in patients undergoing spine procedures? Will an increased length of stay, and therefore, allowing for stabilization of medical comorbidities reduce 30 and 90-day readmission rates in patients undergoing spine procedures? STUDY DESIGN/SETTING This study was a single academic center that included patient cases from two neurosurgeons and two orthopedic spine surgeons. PATIENT SAMPLE N/A OUTCOME MEASURES N/A METHODS Five hundred ninety-three patients who had elective spine surgery over a 17-month period and required hospital admission after the index surgery at an academic medical center were included. The electronic database was reviewed to collect the following data: patient demographics, original surgical diagnosis, medical comorbidities, length of stay, number of consults and which services were consulted, 30- and 90-day readmission, and reasons for readmission. Pearson correlation coefficients, odds ratios and associated risk reduction calculations were performed between the variables of interest. RESULTS The average patient age was 50.8 (range 26-90 years). The average number of diagnoses at discharge was 2.36, and average number of inpatient consults was less than 1 (0.13). The most common consulting service was the hospitalist service (63 consults), followed by cardiology (6). All other services received 2 consultations, including neurology, psychiatry, and urology. There was a significant correlation with the number of consults and readmission rates within 30 days (P=0.017), and similarly significant correlation with the number of consults and number of comorbidities related to 90-day readmission rates (P=0.013 and P=0.038, respectively). There was a 49% and 48% reduction in 30- and 90-day readmission, respectively, based on number of postoperative consults. Additionally, average length of stay (LOS) was 2.7 days and a negative correlation was noted between 30 and 90-day readmission and length of stay (r = -0.07 and -0.10, respectively). CONCLUSIONS Patients who are optimized medically for discharge following spine surgery have a significant reduction in 30- and 90-day readmission rates. Safe discharge is a priority for patient outcomes and minimizes patient morbidity and health care related costs. An attempt to identify patients at risk of readmission may allow for intervention prior to discharge to reduce readmission rates thus patients with longer lengths of stay, necessary for medical optimization, may lead to a lower likelihood of readmission. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

Background: Over the past decade, new health care reforms have introduced all-cause hospital readmission as a metric for quality of care. Concurrently, payers have started to implement bundled payment systems, in which hospitals will be accountable for the costs of readmission for any reason, up to 90 days from discharge. Both medical and surgical complications in the 30and 90-day postoperative period contribute to causes of readmission that may be modifiable by medical optimization prior to discharge after index procedure. We investigated two questions. Does an increased number of postoperative consults, and therefore, an increase in medical optimization, lead to reduced 30and 90-day readmission rates in patients undergoing spine procedures? Will an increased length of stay (LOS), and therefore, allowing for stabilization of medical comorbidities reduce 30and 90-day readmission rates in patients undergoing spine procedures? Methods: Five hundred ninety-three patients who had elective spine surgery over a 17-month period from 1/1/2014 to 5/11/2015 at the University of Toledo Medical Center and required hospital admission after the elective spine surgeries were included. The electronic database was reviewed to collect the following data: patient demographics, original surgical diagnosis, medical comorbidities, LOS, number of consults and which services were consulted, 30and 90-day readmission, and reasons for readmission. Logistic regression models were used to assess the impact of the number of postoperative consults on 30and 90-day readmission. Results: There was a significant correlation with the number of consults and readmission rates within 30and 90-day readmission rates. There was a 49% and 48% reduction in 30-day [P=0.02, odds ratio (OR) 0.51, 95% confidence interval (CI): 0.29-0.89] and 90-day (P=0.01, OR 0.52, 95% CI: 0.31-0.87) readmission, respectively, based on number of postoperative consults. Additionally, the average LOS was 2.7 days for all patients. The median LOS during the initial hospital admission was significantly higher for patients readmitted at both 30 and 90 days compared to patients who did not require readmission (P=0.002 and P=0.03, respectively). Conclusions: Patients who are optimized medically for discharge following spine surgery have a significant reduction in 30and 90-day readmission rates. Safe discharge is a priority for patient outcomes and minimizes patient morbidity and healthcare related costs. An attempt to identify patients at risk of readmission may allow for intervention prior to discharge to reduce readmission rates thus patients with longer lengths of stay, necessary for medical optimization, may lead to a lower likelihood of readmission.

Introduction Lumbar spinal stenosis is a common cause of lower back pain and weakness in elderly patients. The gold standard treatment for this is lumbar laminectomy which involves widespread muscle damage to the multifidus, a complete loss of the posterior tension band which contains the supraspinous and interspinous ligaments. However, in recent years minimally invasive techniques such as bilateral and unilateral laminotomy have become more popular and are showing efficacy in the decompression of spinal stenosis. Due to its minimally invasive approach, the muscle retraction required for laminotomy is less intensive than that required for laminectomy. The overall body of literature on the surgical treatment of spinal stenosis is sparse in its interrogation of the biomechanical outcomes of these techniques and to our knowledge, there are no current publications that incorporate muscle forces. Methods A previously validated thoracolumbar ribcage finite element (FE) model was used for this study. Three different surgeries, traditional laminectomy, unilateral and bilateral midline sparing approaches at L4-L5 segment were simulated by removing the spinous process, supraspinous, and interspinous ligaments. The segmental range of motion (ROM) for all models were acquired and input into a musculoskeletal modelling software to calculate muscle forces. Results Unilateral and bilateral laminotomy showed similar muscle forces for every muscle group in both flexion and extension motion. While comparing the muscle forces in laminotomy to the laminectomy in extension motion displayed an increase in Iliocostalis lumborum (IL) by 12 % and multifidus (MF) by 16% and decrease in transverse abdominus (TA) by 138% and erector spine (ES) by 12%. For flexion, there was an increase in IL by 35%, and MF by 12%. Conclusion Our results highlight that laminectomy, which involves the removal of paraspinal muscles and posterior ligamentous structures to relieve stenosis, can lead to increased instability and necessitate muscle compensation, particularly in adjacent and thoracic spine segments. Conversely, midline sparing approaches such as laminotomies, are associated with decreased muscle compensation across spinal segments and enhanced stability. ### Competing Interest Statement The authors have declared no competing interest.

Background: A few isolated vertical distraction cervical spine injuries and high cervical spinal cord transections cases have been described in the literature. Spinal cord transections leave patients with complete irreversible motor and sensory loss distal to their injury level. They often are associated with a fracture and/ or dislocation at the level of the injury, many of the reported cases due to atlanto-occipital dislocation with high fatality rates. Additionally, floating cervical spine injuries have similarly been described without spinal cord transection. We report the first described high cervical spinal cord transection with a noncontiguous sub-axial vertical distraction injury. Case Description: Here we present a 27-year-old patient with complete spinal cord transection at occiput-C1 and C6-7 vertical distraction injury after a motor vehicle accident. The patient presented in spinal and neurogenic shock. Patient subsequently underwent C4-T2 posterior instrumentation and fusion to stabilize his vertical distraction injury to allow for sitting in a wheelchair. Postoperatively he had adequate fixation and reduction of his fracture. Sequela of his condition required long term acute care and complications including autonomic dysreflexia, multiple pressure ulcers requiring incision and drainage at outside hospitals. Conclusions: Complete high cervical cord transections are devastating injuries leaving patients with limited expected recovery and function; patient care involves multidisciplinary discussion of patients' quality of life to necessitate surgical goals versus nonoperative management. Meticulous preoperative planning is required for successful reduction and adequate fixation intraoperatively. Our paper discusses the case in detail regarding clinical management, surgical technique, patient follow-up, and literature review of vertical distraction injury case reports, spinal cord transections, and floating cervical spine injuries.

Diabetes predisposes to spine degenerative diseases often requiring surgical intervention. However, the statistics on the prevalence of spinal fusion success and clinical indications leading to the revision surgery in diabetes are conflicting. The purpose of the presented retrospective observational study was to determine the link between diabetes and lumbar spinal fusion complications using a database of patients (n = 552, 45% male, age 54 +/- 13.7 years) residing in the same community and receiving care at the same health care facility. Outcome measures included clinical indications and calculated risk ratio (RR) for revision surgery in diabetes. Paravertebral tissue recovered from a non-union site of diabetic and nondiabetic patients was analyzed for microstructure of newly formed bone. Diabetes increased the RR for revision surgery due to non-union complications (2.80; 95% CI, 1.12-7.02) and degenerative processes in adjacent spine segments (2.26; 95% CI, 1.45-3.53). In diabetes, a risk of revision surgery exceeded the RR for primary spinal fusion surgery by 44% (2.36 [95% CI, 1.58-3.52] vs 1.64 [95% CI, 1.16-2.31]), which was already 2-fold higher than diabetes prevalence in the studied community. Micro-CT of bony fragments found in the paravertebral tissue harvested during revision surgery revealed structural differences suggesting that newly formed bone in diabetic patients may be of compromised quality, as compared with that in nondiabetic patients. In conclusion, diabetes significantly increases the risk of unsuccessful lumbar spine fusion outcome requiring revision surgery. Diabetes predisposes to the degeneration of adjacent spine segments and pseudoarthrosis at the fusion sites, and affects the structure of newly formed bone needed to stabilize fusion. Individuals with diabetic disease often have degenerative diseases of the spine, which require spinal fusion surgery to stabilize an alignment of vertebrae. The primary surgery is often followed by repeated surgery if spine stabilization is not successful due to either insufficient new bone formation at the fusion site (non-union complication) or degenerative processes in adjacent spine segments. The purpose of the presented study was to determine the link between diabetes and lumbar spinal fusion complications. This retrospective observational study used a database of nondiabetic and diabetic patients residing in the same community and receiving care at the same health care facility. We found that, when compared with nondiabetic patients, spinal fusion patients with diabetes have a 2.8-times higher risk of unsuccessful surgery due to non-union complications and a 2.3-times higher risk due to the development of degenerative processes in adjacent spine segments. An analysis of newly formed bone retrieved from the fusion site during revision surgery showed structural differences suggesting that the bone formed in diabetic patients may be of compromised quality, which may account for a higher rate of spinal fusion complications. In conclusion, diabetes significantly increases the risk of unsuccessful lumbar spine fusion outcome requiring revision surgery and affects the structure of newly formed bone needed to stabilize fusion. Graphical Abstract

-OBJECTIVE: Spinopelvic parameters are vital compo-nents that must be considered when treating patients with spinal disease. Several finite element (FE) studies have explored spinopelvic parameters such as sacral slope (SS) and the impact on the lumbar spine, although no study has examined the effect on the hip and sacroiliac joint (SIJ) on varying SS angles. Therefore, it is necessary to have a biomechanical understanding of the impact on the spino-pelvic complex.-METHODS: An FE lumbar, pelvis, and femur model was created from computed tomography scans of a 55-year-old female patient with no abnormalities. Three models were created: a normal model (SS = 26 & DEG;), a model with high SS (SS = 30 & DEG;), and a model with low SS (SS = 20 & DEG;). These models underwent loading for flexion, extension, lateral bending, and axial rotation. Range of motion (ROM), intra-discal pressures, hip joint, and SIJ contact stresses were analyzed. -RESULTS: The high SS model (SS = 30 & DEG;) indicated the highest ROM in the L5-S1 (slip angle) level and the highest intradiscal pressures. The highest average hip and SIJ contact stresses were present in this model, although the low SS model (SS = 20 & DEG;) in extension had the largest stresses for the hip and SIJ.-CONCLUSIONS: The results provide evidence that pa-tients with higher SS may be more prone to increased ROM at the slip angle (L5-S1). In addition, patients with higher SS were shown to have higher contact stresses on the hip joint and SIJ, potentially leading to SIJ dysfunction. Clini-cally, correcting lumbar lordosis including SS is important; however, a high SS may have a negative impact on the intervertebral disc, SIJ, and hip joint.

Ankylosing spondylitis is the most common type of seronegative inflammatory spondyloarthropathy often presenting with low back or neck pain, stiffness, kyphosis and fractures that are initially missed on presentation; however, there are other spondyloarthropathies that may present similarly making it a challenge to establish the correct diagnosis. Here, we will highlight the similarities and unique features of the epidemiology, pathophysiology, presentation, radiographic findings, and management of seronegative inflammatory and metabolic spondyloarthropathies as they affect the axial skeleton and mimic ankylosing spondylitis. Seronegative inflammatory spondyloarthropathies such as psoriatic arthritis, reactive arthritis, noninflammatory spondyloarthropathies such as diffuse idiopathic skeletal hyperostosis, and ochronotic arthritis resulting from alkaptonuria can affect the axial skeleton and present with symptoms similar those of ankylosing spondylitis. These similarities can create a challenge for providers as they attempt to identify a patient's condition. However, there are characteristic radiographic findings and laboratory tests that may help in the differential diagnosis. Axial presentations of seronegative inflammatory, non-inflammatory, and metabolic spondyloarthropathies occur more often than previously thought. Identification of their associated symptoms and radiographic findings are imperative to effectively diagnose and properly manage patients with these diseases.

heights (3). Larger cage footprints were made to allow more contact area to improve fusion rates and maintain the relationship between vertebral body endplates (4). Evolution to increase the lordotic morphology of these cages allowed restoration of lordotic curvature to improve segmental lordosis (SL) and sagittal balance. Sembrano et al. discussed radiographic changes when comparing lordotic and non-lordotic cages and found that lordotic cages resulted in a statistically significant increase in SL at the operative level, where non-lordotic cages did not change from preoperative SL levels (2). Anterior and posterior disc height (PDH) was significantly increased in both cohorts and noted that neither had any significant change to lumbar lordosis (LL) on a more regional level. These early results gave surgeons a viable option for interbody implants during lumbar fusions. Interbody cages were initially posterior lumbar interbody fusions (PLIF) or transforaminal lumbar

Cervical spondylotic myelopathy (CSM) is defined as compression of the spinal cord in the neck, resulting in problems with fine motor skills, hand numbness, pain or stiffness of the neck, and difficulty walking due to loss of balance. Brachial plexus (BP) neuropathies arise due to compression to any distal branches arising from C5-T1, whereas cervical radiculopathy involves compression at the nerve root in the neck. Such conditions can present with variable degrees of musculoskeletal pain, weakness, sensory changes, and reflex changes. The pronounced convergence in symptomatic manifestation within these conditions can pose a formidable challenge to clinicians, particularly in primary care. Thus, the primary objective of this paper is to enhance clarity and distinction among these pathological conditions. This objective is pursued through comprehensive delineation of the dermatomal and myotomal distributions characteristic of each condition. Furthermore, a meticulous examination is undertaken to elucidate physical indicators and maneuvers that exhibit a notably high sensitivity in detecting these conditions. Accurate diagnosis and treatment of each nerve pathology is important as long-term spinal cord compression and its roots may result in permanent disability and severely impact one's quality of life. As such, this systematic review serves as a guide that aids clinicians in differentiating the aforementioned conditions based on anatomy, physical exam findings, and imaging studies. Furthermore, this study aims to outline common peripheral nerve neuropathies in the upper extremities and ways to mitigate these pathologies using the least to most invasive treatment modalities.

Background and Objectives: Intracranial hemorrhage following spinal surgery is an infrequent but severe complication. Due to its rarity, the etiology, clinical characteristics, and treatment have not yet been fully elucidated. This literature review analyzed the incidence, clinical manifestations, hemorrhage location, current therapeutic strategies, location of operation, and interval time between surgery and bleeding. The objectives of the article were to provide insights for clinicians to promptly identify and prevent potential cases of intracranial hemorrhage. Methods: The authors queried PubMed and Web of Science databases using predefined keywords and included published literature reporting on intracranial hemorrhage after spinal surgery. Relevant case reports, case series, and reviews describing the mechanism of intracranial hemorrhage after spinal surgery and meeting diagnostic criteria for intracranial hemorrhage related to spinal surgery were included. Clinicodemographc data, presentations symptoms, location, index surgery type, and neurological outcomes after brain hemorrhage. Oxford Centre Level of Evidence guidelines was used to evaluate the quality of included studies. Descriptive statistics were used to synthesize the results. Key Content and Findings: A total of 80 publications of level of evidence IV involving 108 patients with median age at diagnosis was 58.5 years (inter- quartile range: 6-85) were analyzed. The incidence of intracranial hemorrhage was 0.08-0.37% among patients who underwent spinal surgery, and this complication occurred predominantly within 48 hours postoperatively. The initial presentation included headache, reduced level of consciousness, dysarthria, nausea, vomiting, hearing loss, blurred vision, neck rigidity, and delayed recovery from anesthesia. More than half (58.3%) of patients improved, while 23.1% still experienced neurological dysfunctions, and 7.4% died. Conclusions: The present study is limited by the levels of evidence of the included studies. There is heterogeneity among cases with respect to patient demographics and medical history. Angiography is critical in assessing the presence and extent of underlying vascular diseases. Intracranial hemorrages may be caused by intraoperative or postoperative cerebrospinal fluid leakage that will lead to intracranial pressure change and induced by intracranial venous or arterial bleeding. The treatment strategies include conservative medical management and surgical treatment. Individualized treatment should be emphasized.

Background and Objective:To highlight the surgical anatomy, procedural variations, presentation, and management of sympathetic nerve injury after surgery of the lumbar spine.Methods:PubMed and Google Scholar were searched for publications that were completed between 1951 and 2021. Relevant full-text articles published in the English language were selected and critically reviewed.Key Content and Findings:Sympathetic injury is a highly variable postsurgical complication with a greater incidence after an anterior or oblique approach to the lumbar spine compared to posterior and lateral approaches. The direct and extreme lateral approaches reduce the need to disturb sympathetic nerves thus reducing the risk of complications. It can present in multiple manners, including complex regional pain syndrome (CRPS) and retrograde ejaculation. These complications can be transient and resolve spontaneously or be treated with medications, physical therapy, and spinal blocks. The severity of the conditions and extent of recovery can vary drastically, with some patients never fully recovering.Conclusions:To access the lumbar spine, there are operational approaches and techniques that should be used to decrease the risk of intraoperative injury. It is crucial to understand the advantages and risks to different approaches and take the necessary steps to minimize complications. Early identification of dysfunction and adequate management of symptoms are imperative to effectively manage patients with lumbar sympathetic trunk and sympathetic nerve fiber injuries.

Introduction Recent literature has associated pseudarthrosis and pedicle screw loosening with subchronic infection at the pedicle of the vertebra. The positive culture results of a previous retrieval analysis show that such patients have a high frequency of bacterial contamination. The objective of this study is to visually capture the architecture of these undiagnosed infections, which have been described in other studies as biofilms on supposedly “aseptic” screw loosening. Methods Explants from 10 consecutive patients undergoing revision spine surgery for pseudarthrosis were collected and fixed in glutaraldehyde solution. Each of these implants was imaged thoroughly by using scanning electron microscopy and x-ray spectroscopy to evaluate the architecture of the biofilm. Additionally, eight patient swabs from tissues around the implants were sent for cultures to assess bacterial infiltration in tissues beyond the biofilm. The implants were also analyzed using energy dispersive x-ray spectroscopy. The exclusion criteria included clinically diagnosed infection (current or previous) and/or mechanical failure of the implant due to falls/accidents. Results The study was successful in capturing the visual architecture of the biofilm on retrieved implants. A total of 77% of pseudarthrosis cases presented with loose pedicle screws, which were diagnosed by a preoperative computed tomography scan showing radiolucency along the screw track and were confirmed intraoperatively, and 72% of the cases showed biofilm on explants. Conclusions In the absence of the clinical presentation of infection, impregnated bacteria could form a biofilm around an implant, and this biofilm can remain undetected via contemporary diagnostic methods, including swabbing. Implant biofilm is frequently present in “aseptic” pseudarthrosis cases.