PURPOSE: The purpose of this study was to investigate the association between cannabis use disorder and adverse clinical events following anterior cervical discectomy and fusion (ACDF). METHODS: This propensity-matched retrospective cohort study was performed using a multi-institutional electronic medical record database. Adult patients undergoing single- and multi-level ACDF were included. The primary cohort of interest consisted of patients with a pre-operative diagnosis of cannabis use disorder. Controls were propensity matched with over three-hundred clinical variables. We excluded patients with prior spine surgery, spine neoplasms, trauma, osteomyelitis, and inflammatory conditions. Comparisons were made with Chi-squared and independent t-tests at thirty-days, ninety-days, one-year, and two-years. RESULTS: After propensity matching, there were 1,055 patients in the single-level and 1,003 patients in the multi-level cohorts. At thirty- and ninety-days, patients with cannabis use disorder undergoing single-level ACDF exhibited higher rates of mental health service engagement. However, at thirty-days, patients with cannabis use disorder demonstrated lower rates of opioid utilization in the multi-level cohort. At one- and two-year follow-up, there were similar rates of cervical spine reoperation, pseudoarthrosis, and adjacent segment disease between study cohorts. CONCLUSION: Patients with cannabis use disorder demonstrated higher rates of mental health service engagement following single-level ACDF surgery and reduced rates of opioid consumption following multi-level ACDF surgery. These findings demonstrate increased short-term healthcare utilization among patients with cannabis use disorder following ACDF and underscore the need for prospective studies to clarify the clinical impact of cannabis on surgical outcomes.

The purpose of this study was to characterize the short- and long-term outcomes following anterior cervical discectomy and fusion (ACDF) among patients on testosterone replacement therapy (TRT). A multi-institutional, propensity-matched retrospective cohort study was conducted on an electronic medical record database for patients undergoing single-level ACDF. The cohort of interest was TRT exposure one-year prior to surgery. Exclusion criteria included prior cervical spine surgery, < 18 years old, and a history of spine neoplasms, trauma, inflammatory, or infectious bone conditions. Odds ratios with 95

OBJECTIVE:Infection following cervical artificial disc replacement (ADR) is poorly understood, with no established guidelines for prevention or management. This case series aimed to characterize the clinical presentation, microbiological findings, and outcomes of patients with cervical ADR infections. METHODS:The authors conducted a retrospective review of patients at their institution who developed infection following cervical ADR and underwent revision surgery. Data collected included patient demographics, clinical presentation, infective organism, and implant type. Infections were identified based on clinical symptoms and radiological findings and confirmed with microbiological cultures. Infection management, including antibiotic therapy and revision surgery, was recorded. RESULTS:Forty-two cases involving 30 patients were included. Nine patients required 2 or more revision surgeries. Intractable neck pain and upper extremity pain were the most reported clinical symptoms at 83.3% and 38.1%, respectively. Time from symptom onset to diagnosis ranged from 4 days to 208 weeks (mean 44.2 weeks). The top 3 species most commonly isolated from disc space cultures were Cutibacterium acnes (n = 22, 52.4%), Staphylococcus epidermidis (n = 11, 26.2%), and Propionibacterium acnes (n = 7, 16.7%). Cultures were negative in 5 (11.9%) cases. Notably, 27 of 30 patients (90.0%) eventually underwent conversion to fusion. Furthermore, regarding clinical improvement in symptoms, a majority of patients (21/30 patients, 70.0%) experienced symptom improvement or resolution, while 8 (26.7%) had persistent symptom and 1 patient (3.3%) was lost to follow-up. CONCLUSIONS:Infection following cervical ADR is rare but poses significant clinical challenges, with most patients requiring conversion to fusion. Early identification and appropriate management are critical to optimizing patient outcomes. This study reports the largest cohort of patients with infected cervical ADRs to date and provides valuable insights to inform future guidelines for prevention and management.

BACKGROUND:Robot-assisted spine surgery (RASS) enables precise pedicle screw insertion via pre-planned trajectories, and yet complications remain a notable concern. Prior work suggests that osseous pedicle wall breaches from instrumentation and ensuing complications related to robotic surgery may be from shifting of the reference frame or improper methodology. In this study, we hypothesized that the introduction of standardized institutional guidelines for RASS would reduce complications associated with robotic screw placement. METHODS:This retrospective cohort study included patients who underwent RASS using 2 robotic systems at a single institution. We analyzed the cases of 264 patients in a historical cohort before, and 290 patients after, the implementation of a standardized institutional protocol developed to ensure safety with robotic placement of pedicle screws. The protocol provided surgeons with detailed guidelines for reference-frame placement, intraoperative screw trajectory and alignment checks, depth of drill insertion, verification of screw positioning, neuromonitoring for thoracic instrumentation, and postoperative imaging. Patient demographics, preoperative diagnoses, surgical characteristics, and complications were collected for all patients. RESULTS:There was no difference between the pre-protocol and post-protocol groups with respect to patient demographics. In the pre-protocol cohort, 6 (2.3%) of the patients experienced robot-related complications, including nerve injury, durotomy, and malpositioned screws, with half of these complications attributed to reference-frame errors. Following the implementation of the protocol, no patient (0%) experienced a robot-related complication among 290 cases involving 2,030 screws placed with robotic assistance, representing a significant reduction (p = 0.01). The number of patients with open surgery (versus minimally invasive surgery) did not differ significantly between the pre-protocol (132 patients, 50%) and post-protocol (143 patients, 49.3%) groups. The mean number of instrumented levels per patient post-protocol was 3.3 ± 2.1. Non-robot-related complication rates were similar post-protocol (19.7%) versus pre-protocol (26.1%) (p > 0.05). Notably, post-protocol, there were no instances of a pedicle breach with neurostimulation or on postoperative imaging. CONCLUSIONS:Following the implementation of standardized robotic surgery guidelines, no robot-related screw complications occurred in a post-protocol cohort of 290 patients. This study underscores the importance of protocol standardization, alongside technological advancements, in optimizing patient safety and improving outcomes in RASS. Well-designed institutional protocols may notably reduce robotic surgery complications and can be a valuable model for other institutions. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction The anatomy of the vertebral artery (VA) can be variable around the C1 and C2 vertebrae, which can pose risk during cervical spine instrumentation and pain blocks. A patient with prior cerebellar astrocytoma required a C2 nerve root block for treatment of occipital neuralgia. Precise location of the VA was questioned due to previous posterior C1 arch excision. Case The objective was to describe the utility of CT angiogram (CTA) in describing VA location in planning the C2 nerve root block. Once determined that the VA was not in proximity of the lateral atlantoaxial joint (LAA), then the C2 nerve block was completed uneventfully with resolution of occipital pain. Conclusions The CTA was critical in determining VA location in advance of C2 nerve root block, and can be used with regularity when vascular anatomy is questioned.

BACKGROUND CONTEXT:A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations. PURPOSE:To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set. STUDY DESIGN/SETTING:Cost-utility analysis of the TOPSTM system compared to TLIF. PATIENT SAMPLE:A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up. OUTCOME MEASURES:Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds. METHODS:The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results. RESULTS:The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively. CONCLUSIONS:This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

BACKGROUND:Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS:A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS:SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS:SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE:SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology. LEVEL OF EVIDENCE: 4:

Background:Robotic assistance has become increasingly prevalent in spinal surgery in recent years, emerging as a tool to increase accuracy and precision and lower complication rates and radiation exposure. The 7th and 8th Annual Seattle Science Foundation (SSF) Robotics Courses showcased presentations and demonstrations from some of the field's most experiences leaders on latest topics in robotics and spinal surgery, including cutting-edge preoperative planning technologies, augmented reality (AR) in the operating room, cervical fusion with transpedicular screws, and neuro-oncologic management. We provide a scoping review of the use of robotics technology in spinal surgery featuring highlights from the 7th and 8th Annual SSF Robotics Courses. Methods:A scoping review of the literature was conducted (last search conducted in July 2024). Key search terms included "robotic assistance", "spine surgery", and "robotic technology" on the PubMed database. Additionally, highlights are included from the 7th and 8th Annual SSF Robotics Courses. Results:Applications of navigation robotics span subspecialties of spine surgery including deformity correction, minimally invasive approaches, lateral single position operations, spinal oncology, and cervical fusion. Tips on overcoming traditional obstacles of robotics integration such as streamlining staff workflow and adoption while financing robotic-assisted technology are shared. Future directions of robotics enhanced with AR may further guide surgeon decision-making, assist in more practical fashion intraoperatively, and optimize patient outcomes. Conclusions:While improved precision and accuracy, less radiation, and standardization of procedures represent current advantages of robotic-assistance across spine surgery, robotics in spine surgery will usher more transformative changes to patient care and operative skill in coming years.

Progressive post-traumatic postsurgical myelopathy (PPPM) is a known entity that can occur months to years after the initial insult. Symptomatic patients can become myelopathic and have rapid and progressive neurological decline. Surgical correction of PPPM usually involves intradural exploration and lysis of adhesions that carries the risk of further injury to the spinal cord. In this manuscript, we provide a report of a patient presenting more than 50 years after the initial resection of an intramedullary tumor. Additionally, we present and describe a novel surgical technique for managing this difficult problem and restoring normal CSF dynamics.

Background: Given the increased attention to functional improvement in spine surgery as it relates to activities of daily living and cost, it is critical to fully understand the health care economic impact of enabling technologies. The use of intraoperative neuromonitoring (IOM) during spine surgery has long been controversial. Questions pertaining to utility, medico-legal considerations, and cost-effectiveness continue to be unresolved. The purpose of this study is to determine the cost-effectiveness by assessing quality-of-life due to adverse events averted, decreased postoperative pain, decreased revision rates, and improved patient reported outcomes (PROs). Methods: The study patient population was extracted from a large multicenter database collected by a single, national IOM provider. Over 50,000 patient charts were abstracted and included in this analysis. The analysis was conducted in accordance with the second panel on cost-effectiveness health and medicine. Health-related utility was derived from questionnaire answers and expressed in quality-adjusted life years (QALYs). Both cost and QALY outcomes were discounted at a yearly rate of 3% to reflect their present value. Cost-effectiveness was calculated as the incremental cost-effectiveness ratio (ICER) for IOM. A value under the commonly accepted United States-based willingness-to-pay (WTP) threshold of $100,000 per QALY was considered cost-effective. Scenario (including litigation), probabilistic (PSA), and threshold sensitivity analyses were conducted to determine model discrimination and calibration. Results: The primary time horizon used to estimate cost and health utility was 2-years following index surgery. On average, index surgery for patients with IOM costs are approximately $1,547 greater than non-IOM cases. The base case assumed an inpatient Medicare population however multiple outpatient and payer scenarios were assessed in the sensitivity analysis. From a health system perspective IOM is cost-effective, yielding better utilities but at a higher cost than the non-IOM strategy (ICER $60,734 per QALY). From a societal perspective the IOM strategy was dominant, suggesting that better outcomes were achieved at less cost. Except for an entirely privately insured population, alternative scenarios such as, outpatient and a 50:50 Medicare/privately insured population sample also demonstrated cost-effectiveness. Notably, IOM benefits were unable to overcome the sheer costs associated many litigation scenarios, but the data was severely limited. In the 5,000 iteration PSA, at a WTP of $100,000, 74% of simulations using IOM were cost-effective. Conclusions: The use of IOM in spine surgery is cost-effective in most scenarios examined. In the emerging and rapidly expanding field of value-based medicine, there will be an increased demand for these analyses, ensuring surgeons are empowered to make the best, most sustainable solutions for their patients and the health care system.

INTRODUCTION: Computer assisted neuronavigation (CAN) during spine fusions has increasing being utilized in the United States. The impact of CAN on long-term health care utilization is not well defined. METHODS: MarketScan database were queried using the ICD-9/10 and CPT 4th edition, from 2003 to 2019. We included patients ≥ 18 of age who underwent spine fusions with at least 2 years follow-up. Outcomes were repeat fusions or new fusions, length of stay (LOS), discharge disposition, hospital re-admissions, outpatient services, and medication refills for up to 24 months following the index procedure. RESULTS: Of 183,620 patients who underwent spine fusions during the study years, 5046 (2.75%) were identified to have CAN used for the fusions. Exact matching was successful for 4861/5046 (96%) in the CAN group. CAN had no effect on LOS, home discharge, or complications at index hospitalization and 30-days post discharge. However, CAN was associated with a $7667 difference in median payments ($60501 vs $52834, p < .0001). CAN was associated with lower rates of repeat fusions at 6-months (3% vs. 4%), 12 months (2% vs. 3%) and 24 months (5% vs. 6%) following the index procedure, p < 0.05. Patients who underwent CAN had lower payments at 6 months ($5186 vs $5527, p: 0.0159), 12 months ($10267 vs $11262, p: 0.0207) and 24 months ($21453 vs $24355, p: 0.0021). CONCLUSIONS: CAN is increasing being used for spine fusions primarily for thoraco-lumbar procedures. No difference in complications, discharge disposition and LOS were noted across the cohorts at index hospitalization, with higher index payments with CAN use. CAN was associated with lower rates of repeat fusions and corresponding health care utilization for up-to 24 months following the index procedures compared to non-CAN cohort.

Amyotrophic lateral sclerosis (ALS) involves progressive motor neuron loss, leading to paralysis and death typically within 3–5 years of diagnosis. Dysfunctional astrocytes may contribute to disease and glial cell line-derived neurotrophic factor (GDNF) can be protective. Here we show that human neural progenitor cells transduced with GDNF (CNS10-NPC-GDNF) differentiated to astrocytes protected spinal motor neurons and were safe in animal models. CNS10-NPC-GDNF were transplanted unilaterally into the lumbar spinal cord of 18 ALS participants in a phase 1/2a study (NCT02943850). The primary endpoint of safety at 1 year was met, with no negative effect of the transplant on motor function in the treated leg compared with the untreated leg. Tissue analysis of 13 participants who died of disease progression showed graft survival and GDNF production. Benign neuromas near delivery sites were common incidental findings at post-mortem. This study shows that one administration of engineered neural progenitors can provide new support cells and GDNF delivery to the ALS patient spinal cord for up to 42 months post-transplantation.

Introduction: For decades, researchers and surgeons have sought to determine the optimal biomaterial for spinal fusion implants. Successful fusion is associated with improved quality of life while failures are often associated with costly and complex revisions. One common failure is subsidence. Biomaterials with higher modulus are thought to be related to subsidence risk but this has not been thoroughly investigated. The aim of this systematic review and meta-analysis is to assess silicon nitride and biomaterial modulus as they relate to subsidence risk in spinal fusions. Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Databases searched included PubMed-Medline, Google Scholar, Embase, EBSCO, and Cochrane Library. Study quality was assessed according to the Newcastle-Ottawa Scale. A network meta-analysis was chosen, allowing for direct and indirect comparisons for multiple treatments using a Bayesian hierarchical framework with Markov chain Monte Carlo methods. Outcomes were reported as odds ratios with 95% confidence intervals. Heterogeneity between studies was evaluated using the I2 test. A pairwise meta-analysis was also produced to compare the results of network analysis for consistency. Publication bias was assessed using a funnel plot, Egger test, and Begg test. All analyses were conducted using R (Project for Statistical Computing, ver. 4.0.4). Results: The initial search yielded a total of 821 articles. After removal of duplicates and screening based on inclusion and exclusion criteria, 64 articles were available for review and 13 were selected for meta-analysis. Biomaterial implant types in the final studies included: silicon nitride (Si3N4), polyetheretherketone (PEEK), titanium (Ti), and two composites, nano-hydroxyapatite/polyamide 66 (n-HA/PA66) and a carbon fiber reinforced polymer (CFRP). A total of 1,192 patients were included in this analysis – 419 with titanium implants, 460 with PEEK, 96 with Si3N4, 332 with n-HA/PA66, and 35 with CFRP. Titanium had the highest rate of subsidence compared to other biomaterials. Pairwise analysis was consistent with these results. Both the Egger test (p = 0.28) and Begg test (p = 0.37) were found to be non-significant for publication bias. Conclusions: Spinal fusion implants derived from Si3N4, compared to PEEK and titanium, do not appear to be correlated with increased subsidence risk.

OBJECTIVE:There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS:Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS:Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence-lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5-S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS:Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

Background: Given the increased attention to functional improvement in spine surgery as it relates to motion preservation, activities of daily living, and cost, it is critical to fully understand the healthcare economic impact of new devices being tested in large FDA randomized controlled trials (RCT). The purpose of this analysis was to comprehensively evaluate the cost-effectiveness of the novel Total Posterior Spine (TOPS™) System investigational device compared with the trial control group, standard transforaminal lumbar interbody fusion (TLIF). Objective: To evaluate the cost-effectiveness of TOPS™ compared with TLIF. Methods: The study patient population was extracted from a multicenter RCT with current enrollment at n=121 with complete 1-year follow-up. The primary outcome was cost-effectiveness, expressed as the incremental cost-effectiveness ratio. Secondary outcomes were health-related utility, presented as quality-adjusted life-years (QALYs), and cost, calculated in US dollars. Analysis was conducted following Second Panel on Cost-Effectiveness Health and Medicine recommendations. The base case analysis utilized SF-36 survey data from the RCT. Both cost and QALY outcomes were discounted at a yearly rate of 3% to reflect their present value. A cohort Markov model was constructed to analyze perioperative and postoperative costs and QALYs for both TOPS™ and control groups. Scenario, probabilistic, and threshold sensitivity analyses were conducted to determine model discrimination and calibration. Results: The primary time horizon used to estimate cost and health utility was 2 years after index surgery. From a health system perspective, assuming a 50/50 split between Medicare and private payers, the TOPS™ cohort is cost-effective 2 years postoperatively ($6158/QALY) compared with control. At 6 years and beyond, TOPS™ becomes dominant, irrespective of payer mix and surgical setting. At willingness-to-pay thresholds of $100 000/QALY, 63% of all 5000 input parameter simulations favor TOPS, even with a $4000 upcharge vs TLIF. Discussion: The novel TOPS™ device is cost-effective compared with TLIF and becomes the dominant economic strategy over time. Conclusions: In the emerging, rapidly expanding field of value-based medicine, there will be an increased demand for these analyses, ensuring surgeons are empowered to make the best, most sustainable solutions for their patients and society.

OBJECTIVE:Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen-B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery.METHODS:Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution's modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures.RESULTS:A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention.CONCLUSIONS:AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.

OBJECTIVEThe purpose of this study was to describe the evolution of thoracoscopic spine surgery from basic endoscopic procedures using fluoroscopy and anatomical localization through developmental iterations to the current technology use in which endoscopy and image-guided surgery are merged with intraoperative CT scanning.METHODSThe authors provided detailed explanations of their thoracoscopic spine surgery techniques, beginning with their early-generation endoscopy with fluoroscopic localization, which was followed with point surface matching techniques and early image guidance. The authors supplanted this with the modern era of image guidance, thoracoscopic spine surgery, and seamless integration that has reached its current level of refinement.RESULTSA retrospective review of single-institution thoracoscopic procedures performed by the senior author over the course of 19 years yielded a total of 160 patients, including 73 women and 87 men. The mean patient age was 55 years, and the range included patients 16-94 years of age. There were no patients with worsened neurological function. One hundred sixteen patients underwent surgery for thoracic disc herniation, 18 for underlying neoplasms with spinal cord compression, 14 for osteomyelitis and discitis, 12 for thoracic deformity with neurological changes, and 8 for traumatic etiologies.CONCLUSIONSMore than 19 years of experience has revealed the benefits of integrating thoracoscopic spine surgery with intraoperative CT scanning and image-guided surgery, including direct decompression without manipulation of neural elements, superior 3D spatial orientation, and localization of complex spinal anatomy. With the exponential growth of machine learning, robotics, artificial intelligence, and advances in imaging techniques and endoscopic imaging, there may be further refinements of this technique on the horizon.