Anterior cervical corpectomy and fusion (ACCF) is an effective technique to address multi-level degenerative cervical myelopathy. However, as the number of surgical levels increases, the outcomes worsen with respect to complication rates, range of motion and length of surgery. This study aimed to determine the clinical outcome of ACCF procedures performed using a new distally curved and shielded drilling device. A retrospective study was conducted on 43 ACCF procedures in which the device was used for osteophyte removal. Patient files were reviewed to assess the early clinical results and complications following ACCF. Clinical outcomes were evaluated using patient neck and arm pain scores and SF-36 questionnaires. Hospitalization characteristics were compared with historical controls. All procedures were uneventful and without major complications or neurological deterioration. Single-level ACCF procedures required an average of 71 min and followed by an average hospitalization of 3.3 days. Osteophyte removal, verified by intraoperative imaging, was satisfactory. Average neck pain score was improved by 0.9 points (p = 0.24). Average arm pain score was improved by 1.8 points (p = 0.06). SF-36 scores were improved in all domains. The new curved device enabled safe and efficient removal of osteophytes sparing adjacent vertebral removal in ACCF procedures, thus improving the clinical outcome.

INTRODUCTION: Removal of pathologic tissue during degenerative spinal surgery cases near a bone-nerve interface presents a challenge during spinal decompression, especially in minimally invasive procedures. Robotic systems for spinal surgeries can potentially offer greater accuracy than manual operations. However, today’s robotic systems are designed only for placement of fusion hardware and lack the ability to work in-situ and in proximity to neural structures. METHODS: In the proposed approach, the surgeon utilizes a 6-degrees-of-freedom joystick to control an industrial grade robotic arm connected to curved-at-the-tip high-speed, shielded drilling end-effectors to perform various bone removal tasks. Live visual feedback is displayed from top-view and endoscopic camera views. Force readouts, correlated to the force exerted on the end-effector through tissue contact, provide real time visual feedback. Additional safety restrictions are designed into the system to prevent excessive force. System orientation training was conducted on vertebral models. Initially, three spine surgeons used the system to perform ipsilateral decompression and foraminotomy in four surgeries in a live pig model. Next, six surgeons used the system to perform ipsilateral decompression on two human cadavers. All surgeons completed questionnaires assessing procedure efficacy and system usability. RESULTS: Animal studies: Required decompression was achieved in all cases, with no complications and minimum-to-moderate bleeding. Intuitive usability and acceptable kinematic range of motion of the robotic system was confirmed. Cadaver study: Questionnaire results demonstrated high scores of confidence in the technique (4.7/5), overall satisfaction (4.4/5) and achievement of adequate decompression (3.9/5). All neural structures remained intact. CONCLUSIONS: This preliminary data indicates that the proposed robotic system can facilitate safe and precise decompression through removal of sufficient tissue removal at the bone/nerve interface. Further studies with a medical grade robotic arm are planned.

# Abstract 45. Determining clinically important improvement following surgery for degenerative conditions of the spine: analysis of the Canadian Spine Outcomes and Research Network (CSORN) Registry {#article-title-2} There is significant variability in clinically important improvement (CII)

Background Transforaminal lumbar interbody fusion (TLIF) represents a commonly performed spinal procedure that poses a significant financial burden on patients, hospitals and insurers. Reducing these costs, while maintaining efficacy, may be assisted by a new powered endplate preparation device, designed to shorten procedural time while offering positive impacts on other elements that contribute to the cost of care. Objective The aim of the study was to assess and compare the individual cost elements of TLIF procedures with and without the use of the device, to determine whether application of this technology translated into any material procedural savings. Methods The records of 208 single-level TLIF procedures in a single hospital were reviewed. Surgical time, length of hospital stay, blood loss, infection rate, and other parameters were compared for the cases where the device was used (device group; n = 143) and cases which used standard tools (control group; n = 65). The cost per unit of each element was derived from the literature, online resources, and the hospital's financial department. Results The analysis revealed a shorter surgery duration in the device group (23 min, after controlling for procedure year and patient characteristics; statistically significant at p < 0.001) and lower complication and readmission rates (p = 0.67 and p = 0.21, respectively) associated with the use of the device, leading to a statistically significant cost reduction of approximately 2060 US dollars (US$) (p < 0.01). Conclusion The study suggests that use of the device may lead to a cost reduction and shorter procedure without deteriorating the clinical outcome.

BACKGROUND CONTEXT Spinal procedures often require the removal of bony tissues to prevent nerve compression and reduce pain. In order to reach difficult-access spinal regions such as the foramen, the surgeon is often required to drill (or otherwise remove) through healthy supporting bone structures, therefore increasing the risk of spinal instability. PURPOSE This study describes the authors' experience with a recently developed, FDA-approved, curved-at-the-tip drill-like device, designed to provide efficient bone removal from difficult-access areas. The device is shielded on one side of the tip in order to improve safety and reduce the risk of complications. STUDY DESIGN/SETTING Multi-center retrospective study and surgeon questionnaire analysis. PATIENT SAMPLE Device-use patterns were extracted from 103 lumbar foraminotomies, 53 cervical osteophyte removals and 143 transforaminal lumbar interbody fusion (TLIF) procedures conducted using the device and 66 comparable control TLIF procedures conducted by the same surgeon group used as a control group. OUTCOME MEASURES Device-related dural tear rate, surgeon assessment of the procedure, duration of device use. For the TLIF procedures, OR time and length of stay were also compared with the control group. METHODS The rate of device-related dural tears was calculated from 1,116 safety records of procedures conducted using the device and compared with literature rates of traditional-tools device-related tears. Surgeon assessment was obtained using questionnaires at the end of each procedure. The duration of device-use, length of procedure and other operative and postoperative parameters were extracted from procedure records and reviewed where available. RESULTS The device-related dural tear rate was 0.3% (three tears in 1,116 procedures). This rate is significantly lower than the device-related tear rate of 2.9% associated with the Kerrison rongeur and high-speed drill published in a prior literature review. Surgeon satisfaction rate was 94% and sufficient bone volume reduction was reported in 95% of the procedures. Surgery time reduction was the most common comment in surgeon questionnaires. In some cases, of multi-level complicated fusions, the time reduction was estimated as several hours. Lumbar foraminotomy using the device required, on average, 2 minutes/foramen. In some of the cases, the device enabled the surgeon to avoid a spinal fusion as the improved access eliminated the need for excessive bone removal. Cervical osteophyte removal required, on average, three minutes, and in the majority of the cases enabled the surgeons to avoid additional level discectomy or corpectomy. TLIF procedures required on average 10 minutes less than control procedures with a 0.5 days reduction in length-of-stay. The device was successfully used in both open and minimal invasive settings without a significant difference between settings. CONCLUSIONS The device is safe and effective for performing spinal surgery in multiple indications. Procedure time reduction was noted as the most significant advantage by the surgeons. FDA DEVICE/DRUG STATUS Dreal (Carevature Medical Ltd.) (Approved for this indication)

OBJECTIVEA posterior dynamic deformity correction (PDDC) system was used to correct adolescent idiopathic scoliosis (AIS) without fusion. The preliminary outcomes of bridging only 3–4 discs in patients with variable curve severity have previously been reported. This paper examines a subgroup of patients with the authors’ proposed current indications for this device who were also treated with a longer construct.METHODSInclusion criteria included a single AIS structural curve between 40° and 60°, curve flexibility ≤ 30°, PDDC spanning 5–6 levels, and minimum 2-year follow-up. A retrospective review was conducted and demographic and radiographic data were recorded. A successful outcome was defined as a curve magnitude of ≤ 30° at final follow-up. Any serious adverse events and reoperations were recorded.RESULTSTwenty-two patients who met the inclusion criteria were operated on with the PDDC in 5 medical centers. There were 19 girls and 3 boys, aged 13–17 years, with Risser grades ≥ 2. Thirteen had Lenke type 1 curves and 9 had type 5 curves. The mean preoperative curve was 47° (range 40°–55°). At a minimum of 2 years’ follow-up, the mean major curve measured 25° (46% correction, p < 0.05). In 18 (82%) of 22 patients, the mean final Cobb angle measured ≤ 30° (range 15°–30°). Trunk shift was corrected by 1.5 cm (range 0.4–4.3 cm). The mean minor curve was reduced from 27° to 17° at final follow-up (35% correction, p < 0.05). For Lenke type 1 patterns, the mean 2D thoracic kyphosis was 24° preoperatively versus 27° at final follow-up (p < 0.05), and for Lenke type 5 curves, mean lumbar lordosis was 47° preoperatively versus 42° at final follow-up (p < 0.05). The mean preoperative Scoliosis Research Society-22 questionnaire score improved from 2.74 ± 0.3 at baseline to 4.31 ± 0.4 at 2 years after surgery (p < 0.0001). The mean preoperative self-image score and satisfaction scores improved from preoperative values, while other domain scores did not change significantly. Four patients (18%) underwent revision surgery because of nut loosening (n = 2), pedicle screw backup (n = 1), and ratchet malfunction (n = 1).CONCLUSIONSIn AIS patients with a single flexible major curve up to 60°, the fusionless PDDC device achieved a satisfactory result as 82% had residual curves ≤ 30°. These findings suggest that the PDDC device may serve as an alternative to spinal fusion in select patients.

Background: The appropriate approach for surgical removal of thoracic disc herniations is controversial. The posterior approach historically acquired a bad reputation due to high rates of neurologic deterioration subsequent to spinal cord manipulation. The anterior approach has consequently gained popularity but entails a larger magnitude of surgery if open and is technically demanding if approached thoracoscopically. Approaching the thoracic disc posteriorly following unilateral facetectomy and pediculectomy was suggested in 1978. This study presents a technique for posterior unilateral thoracic discectomy through a hemilaminectomy, unilateral facetectomy, and hemipediculectomy, facilitated by a novel curved dorsally shielded high-speed device. Introducing the device ventral to the dural sac allows removal of calcified and soft disc fragments without relying on forceful manual maneuvers and avoiding manipulation of the spinal cord. Methods: The maximal disc protrusion side is approached through a hemilaminectomy, unilateral facetectomy, and hemipediculectomy removing the superior half of the pedicle and exposing the disc transforaminally, allowing its removal using the device. Pedicle fixation and fusion concluded all procedures (TTIF). Between June 2014 and November 2018, 12 patients (6 men and 6 women) ages 23 to 74 years underwent posterior thoracic discectomy applying the above approach. The affected levels were D3 to D4 (1), D5 to D6 (1), D7 to D8 (1), D9 to D10 (1), D10 to D11 (3), D11 to D12 (4), and D12 to L1 (1). Results: All patients presented with neurologic deterioration and all but 2 with pyramidal signs. All procedures were uneventful, without dural tears. None of the patients deteriorated neurologically. Average back pain visual analog scale scores decreased by 1.2, from 6.6 to 5.4. Average leg pain visual analog scale scores decreased by 2.2, from 6.6 to 4.4. Improvement was noted in Oswestry Disability Index scores and 6 SF-36 metrics. Conclusions: The new curved device and approach allow for a faster, safer thoracic disc herniation removal.

OBJECTIVEThe authors evaluated the long-term clinical outcome of a total posterior arthroplasty system in the surgical treatment of lumbar spinal stenosis with degenerative spondylolisthesis.METHODSBetween June 2006 and July 2007, 10 patients with neurogenic claudication due to spinal stenosis and single-level degenerative spondylolisthesis were enrolled in a nonrandomized prospective clinical study. The patients were evaluated with radiographs and MRI scans, the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the SF-36 health survey preoperatively and at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 7 years, and 11 years postoperatively.RESULTSThe mean VAS score for leg pain dropped from 83.5 before surgery to 13 at 6 weeks and 17 at 11 years after surgery. The mean VAS score for back pain dropped from 56.2 preoperatively to 12.5 at 6 weeks and 14 at 11 years after surgery. The mean ODI score decreased from 49.1 preoperatively to 13.5 at 6 weeks and 16 at 11 years after surgery. MRI at 11 years demonstrated stenosis adjacent to the stabilized segment in one patient. This patient was not symptomatic. The authors did not find evidence of progression of the spondylolisthesis in any of the cases. In one patient, conversion to posterolateral fusion was performed due to an early device malfunction.CONCLUSIONSThe results of this 11-year follow-up study demonstrate that, in patients with spinal stenosis and degenerative spondylolisthesis, decompression and posterior arthroplasty maintain clinical improvement and radiological stability.

BACKGROUND CONTEXT Intraoperative neurophysiological monitoring (IONM) has gained rather wide-spread acceptance as a method to mitigate risk to the lumbar plexus during Lateral Lumbar Interbody Fusion (LLIF) surgery. The most common approach to IONM involves using only electromyography (EMG) monitoring, and the rate of postoperative deficit remains unacceptably high. Other test modalities, such as transcranial electric motor-evoked potentials (tcMEPs) and somatosensory-evoked potentials (SSEPs), may be more suitable for monitoring neural integrity but they have not been widely adopted during LLIF. Recent studies have begun to examine their utility in monitoring LLIF surgery with favorable results. PURPOSE To evaluate the efficacy of different IONM paradigms in the prevention of iatrogenic neurologic sequelae during LLIFand to specifically evaluate the utility of including tcMEPs in an IONM strategy for LLIF surgery. STUDY DESIGN/SETTING Nonrandomized, retrospective analysis of 479 LLIF procedures at a single institution over a 4-year period. During the study epoch, three different IONM strategies were employed for LLIF procedures: (1) Surgeon-directed T-EMG monitoring ("SD-EMG"), (2) neurophysiologist-controlled T-EMG monitoring ("NC-EMG"), and (3) neurophysiologist-controlled T-EMG monitoring supplemented with MEP monitoring ("NC-MEP"). PATIENT SAMPLE The patient population was comprised of 254 males (53.5%) and 221 females (46.5%). Patient age ranged from a minimum of 21 years to a maximum of 89 years, with a mean of 56.6 years. OUTCOME MEASURES Physician-documented physiologic measures included manual muscle test (MMT) grading of hip-flexion, hip-adduction, or knee-extension, as well as hypo- or hyperesthesia of the groin and/or anterolateral thigh on the surgical side. Self-reported measures included numbness or tingling in the groin and/or anterolateral thigh on the surgical side. METHODS Patient progress notes were reviewed from the postoperative period up to 12 months after surgery. The rates of postoperative sensory and/or motor deficit consistent with lumbar plexopathy or peripheral nerve palsy on the surgical side were compared between the three cohorts. RESULTS Using the dependent measure of neurologic deficit, whether motor and/or sensory, patients with NC-MEP monitoring had the lowest rate of immediate postoperative deficit (22.3%), compared to NC-EMG monitoring (37.1%) and SD-EMG monitoring (40.4%). This result extended to sensory deficits consistent with lumbar plexopathy (pure motor deficits being excluded); patients with NC-MEP monitoring had the lowest rate (20.5%) compared to NC-EMG monitoring (34.3%) and SD-EMG monitoring (36.9%). Additionally, evaluation of postoperative motor deficits consistent with peripheral nerve palsy (pure sensory deficits being excluded), the NC-MEP group had the lowest rate (5.7%) of motor deficit compared to the SD-EMG (17.0%) and NC-EMG (17.1%) cohorts. Finally, when assessing only those patients whose last follow-up was greater than or equal to 12 months (n=251), the rate of unresolved motor deficits was significantly lower in the NC-MEP group (0.9%), as compared to NC-EMG (6.9%) and SD-EMG (11.0%). Comparison of the NC-MEP versus NC-EMG and SD-EMG groups, both independently and combined, was statistically significant (>95% confidence level) for all analyses. CONCLUSIONS The results of the present study indicate that preservation of tcMEPs from the adductor longus, quadriceps, and tibialis anterior muscles are of paramount importance for limiting iatrogenic sensory and motor injuries during LLIF surgery. In this regard, the inclusion of tcMEPs serves to compliment EMG and allows for the periodic, functional assessment of at-risk nerves during these procedures. Thus, tcMEPs appear to be the most effective modality for the prevention of both transient and permanent neurologic injury during LLIF surgery. We propose that the standard paradigm for protecting the nervous system during LLIF be adapted to include tcMEPs. Intraoperative neurophysiological monitoring (IONM) has gained rather wide-spread acceptance as a method to mitigate risk to the lumbar plexus during Lateral Lumbar Interbody Fusion (LLIF) surgery. The most common approach to IONM involves using only electromyography (EMG) monitoring, and the rate of postoperative deficit remains unacceptably high. Other test modalities, such as transcranial electric motor-evoked potentials (tcMEPs) and somatosensory-evoked potentials (SSEPs), may be more suitable for monitoring neural integrity but they have not been widely adopted during LLIF. Recent studies have begun to examine their utility in monitoring LLIF surgery with favorable results. To evaluate the efficacy of different IONM paradigms in the prevention of iatrogenic neurologic sequelae during LLIFand to specifically evaluate the utility of including tcMEPs in an IONM strategy for LLIF surgery. Nonrandomized, retrospective analysis of 479 LLIF procedures at a single institution over a 4-year period. During the study epoch, three different IONM strategies were employed for LLIF procedures: (1) Surgeon-directed T-EMG monitoring ("SD-EMG"), (2) neurophysiologist-controlled T-EMG monitoring ("NC-EMG"), and (3) neurophysiologist-controlled T-EMG monitoring supplemented with MEP monitoring ("NC-MEP"). The patient population was comprised of 254 males (53.5%) and 221 females (46.5%). Patient age ranged from a minimum of 21 years to a maximum of 89 years, with a mean of 56.6 years. Physician-documented physiologic measures included manual muscle test (MMT) grading of hip-flexion, hip-adduction, or knee-extension, as well as hypo- or hyperesthesia of the groin and/or anterolateral thigh on the surgical side. Self-reported measures included numbness or tingling in the groin and/or anterolateral thigh on the surgical side. Patient progress notes were reviewed from the postoperative period up to 12 months after surgery. The rates of postoperative sensory and/or motor deficit consistent with lumbar plexopathy or peripheral nerve palsy on the surgical side were compared between the three cohorts. Using the dependent measure of neurologic deficit, whether motor and/or sensory, patients with NC-MEP monitoring had the lowest rate of immediate postoperative deficit (22.3%), compared to NC-EMG monitoring (37.1%) and SD-EMG monitoring (40.4%). This result extended to sensory deficits consistent with lumbar plexopathy (pure motor deficits being excluded); patients with NC-MEP monitoring had the lowest rate (20.5%) compared to NC-EMG monitoring (34.3%) and SD-EMG monitoring (36.9%). Additionally, evaluation of postoperative motor deficits consistent with peripheral nerve palsy (pure sensory deficits being excluded), the NC-MEP group had the lowest rate (5.7%) of motor deficit compared to the SD-EMG (17.0%) and NC-EMG (17.1%) cohorts. Finally, when assessing only those patients whose last follow-up was greater than or equal to 12 months (n=251), the rate of unresolved motor deficits was significantly lower in the NC-MEP group (0.9%), as compared to NC-EMG (6.9%) and SD-EMG (11.0%). Comparison of the NC-MEP versus NC-EMG and SD-EMG groups, both independently and combined, was statistically significant (>95% confidence level) for all analyses. The results of the present study indicate that preservation of tcMEPs from the adductor longus, quadriceps, and tibialis anterior muscles are of paramount importance for limiting iatrogenic sensory and motor injuries during LLIF surgery. In this regard, the inclusion of tcMEPs serves to compliment EMG and allows for the periodic, functional assessment of at-risk nerves during these procedures. Thus, tcMEPs appear to be the most effective modality for the prevention of both transient and permanent neurologic injury during LLIF surgery. We propose that the standard paradigm for protecting the nervous system during LLIF be adapted to include tcMEPs.

Purpose: To evaluate the frequency of loss of neurophysiological potentials during head positioning, the usefulness of head repositioning to restore the potentials, and the effect on neurological outcome. Methods: We retrospectively reviewed consecutive cervical spine surgeries performed at the Israel Spine Center, Assuta Medical Center, during 2006 to 2013. Surgeries performed with neuromonitoring (transcranial-electric motor evoked potentials, somatosensory evoked potentials, electromyographic recordings) were included. Demographic data, medical history, findings at neurological examination and imaging, electrophysiological data recorded during surgery, and neurological outcomes were collected and analyzed. Results: Three hundred eighty-one patients met inclusion criteria. Loss of potentials detected in nine patients during patient positioning and repositioning was undertaken with the aim of restoring electrophysiological signals. In 5/9 patients, repositioning resulted in immediate reappearance of potentials; in 1/5, potentials were affected again during decompression. In 4/9, repositioning did not immediately restore electrophysiological signals; in ¼, potentials reappeared later during the decompression and in ¾, potentials had not recovered till the conclusion of surgery. There were new neurological deficits in 2/9, including one patient with loss of potential that was not restored with repositioning and the one in whom potential was restored but lost again during decompression. Conclusions: Intraoperative neuro monitoring is an efficient tool to alert the surgical team to potential neurological damage. Head reposition often restores the electrophysiological signals with possible prevention of impending sequelae.

The standard surgical management of AIS is spinal fusion. Nonfusion solutions for addressing moderate AIS curves are desirable. ApiFix® is a new posterior dynamic device consisting of an expandable ratcheting rod anchored by two pedicle screws to the concave side of the scoliotic spine. It was designed to address single, moderate Lenke type 1 or 5 curves. Surgery is performed without the addition of spine fusion of the instrumented segments. The surgical procedure is short with negligible blood loss and rapid recovery. Deformity correction is achieved by distraction leading to rod elongation. Curve correction is achieved not only during surgery but also after the surgical procedure by performing scoliosis specific exercises. These exercises activate the ratchet with further rod expansion and curve reduction. The reported cases demonstrate the efficacy of the combined approach of surgery and exercises in controlling moderate AIS. This clinical experience with the ratchet device shows consistent curve improvement and stabilization. It lends support to the concept that surgery with this new posterior dynamic device may be a viable alternative to fusion and or as an internal brace in non-compliant brace users for managing moderate AIS curves.

Purpose To evaluate the feasibility and clinical improvement of a total posterior arthroplasty system in the surgical management of lumbar degenerative spondylolisthesis and or spinal stenosis. Methods During a 1-year period (June 2006 to July 2007), ten patients were enrolled in a non-randomized prospective clinical study. The primary indication was neurogenic claudication due to spinal stenosis with single-level degenerative spondylolisthesis. Patients were evaluated with X-rays and MRI scans, visual analog scale (VAS) for back and leg pain, the Oswestry disability questionnaire, and the SF-36 health survey preoperatively, at 6 weeks, 3 months and 6 months and at 1, 2, 3 and 7 years postoperatively. Results The VAS score for back pain dropped from 56.2 preoperatively to 12.5 at 6 weeks and 19 at 7 years follow-up. The VAS score for worse leg pain dropped from 83.5 before surgery to 13 at 6 weeks and 8.8 at 7 years follow-up. The ODI dropped from 49.1 preoperatively to 13.5 at 6 weeks and 7.8 at 7 years follow-up. MRI examination at 7 years after surgery did not demonstrate stenosis adjacent to the stabilized segment. Spondylolisthesis did not progress in any of the cases. One patient had a symptomatic L3–L4 far lateral disc herniation 5 years after surgery whose symptoms resolved with non-operative treatment. In one patient, conversion to posterolateral fusion was performed due to an early device malfunction. Conclusion In patients with spinal stenosis and degenerative spondylolisthesis, decompression and posterior arthroplasty with the TOPS System can maintain clinical improvement and radiologic stability over time.

Spinal anesthesia and lumbar puncture may lead to intracerebral, subdural or subarachnoid bleeding and there have been previous reports on patients who developed subdural hematoma a few days after surgery on the spine. This is a case report of a patient who developed acute subdural hematoma during surgery performed to remove an intradural spine tumor. This report suggests that the possibility of an intracranial hematoma should be considered in cases of neurological deterioration following spinal surgery.

STUDY DESIGN:Case reports and retrospective review of accidental durotomies in lumbar surgeries during 5 years.OBJECTIVES:To draw attention to a potentially serious complication of incidental durotomy-remote cerebellar hemorrhage.SUMMARY AND BACKGROUND DATA:Accidental durotomy is a frequent complication of spinal surgery. In most cases the outcome of incidental durotomy is favorable. A delayed potentially serious complication of CSF loss during and after lumbar surgery is remote cerebellar hemorrhage (RCH).METHODS:During 2008-2012, 1169 lumbar spine procedures were performed at our spine center. In 210 surgeries incidental or intentional durotomies occurred. All patients with durotomies were managed with suturing of the dural wound followed by deep wound drainage left for 5 days and tight wound closure.RESULTS:Of the 210 patients with CSF loss three patients were identified to suffer from RCH-an incidence of 0.26%. The three patients ages 56, 67 and 75 years developed RCH between 36-192 hours after surgery. All three were managed with supportive treatment and close clinical supervision. A gradual clinical and radiological improvement was noted in all three patients.CONCLUSIONS:Severe headache after spinal surgery and or declining mental status should not be attributed only to low CSF pressure secondary to dural tearing. It can also be the result of remote cerebral or cerebellar hemorrhage. Once the diagnosis of RCH is made, close clinical supervision is mandatory. In most cases non-operative supportive treatment may lead to eventual full clinical recovery.

Background Context Although in situ posterolateral fusion is considered the gold standard for surgical treatment of low-grade adult spondylolisthesis, correction of the sagittal translation by instrumented slip reduction is more controversial in adults; nevertheless it may delay adjacent level disc degeneration. Purpose The present study was undertaken to evaluate the safety and clinical outcome of operative instrumented slip reduction in 12 adults with isthmic spondylolisthesis accompanied by advanced disc degeneration at that level. Study Design This study was a retrospective review of 12 consecutive lumbar or lumbosacral isthmic slip, which underwent operative slip reduction in our institute. Patient Sample All adult patients having operative instrumented slip reduction of isthmic spondylolisthesis from January 2000 to December 2005 were assessed. Outcome Measures Outcome measures included the Oswestry Disability Index (ODI) for low back pain and the visual analog scale (VAS) of back and leg pain. Patient outcome was assessed by work status, participation in sports activities and intake of pain medications. Methods Between January 2000 and December 2005, we performed slip reduction on 12 adults aged 28 to 62 years (average 47) with symptomatic lumbar or lumbosacral isthmic spondylolisthesis. The indications for surgery were long-standing low back and leg pain that had not responded to nonoperative management. Results The vertebral slip ranged between 15% and 90% (average 34%). Radiologic evidence of adult slip progression was available in 5 patients, one had a de novo slip formation and the others had increased sagittal translation on flexion-extension lateral x-rays. All 12 patients underwent posterior decompression, pedicle screw fixation, slip reduction, and posterior lumbar interbody fusion. The slip was anatomically reduced by 100% in 5 patients and between 90% and 95% in 7 (average 95% for the group). X-rays revealed no evidence of instrumentation failure at a mean follow-up of 38 months (range: 18 to 72). Minimal loss of correction (5%) was observed in 2 cases. No neurologic complications were encountered. The mean preoperative ODI of 49 dropped to 12 postoperatively (range: 0 to 20). The mean preoperative VAS for back pain of 7.3 dropped to 1.6 after surgery (range: 0 to 3). The mean preoperative VAS for leg pain of 8 dropped to 1 after surgery (range: 0 to 4). Five patients were followed for more than 3 years: none had evidence of adjacent level disc disease. Conclusions Our results may support performing slip reduction in selected adults with isthmic spondylolisthesis.

OBJECTIVES:To evaluate long-term treatment outcome of patients with infected posterior lumbar interbody fusion (PLIF) managed with surgical debridement and or prolonged antiobiotic treatment without removal of the interbody cages. METHODS:Between 1996 and 1999, 8 out of 111 patients who underwent PLIF were diagnosed with deep wound infection (7.2%). All infected patients were clinically followed for at least 2 years after completion of the antibiotic treatment. Longer follow-up of at least 6 years duration was performed by a telephone interview. RESULTS:Six patients were managed with surgical debridement, wound irrigation, and primary closure of the wound. None of the patients required removal of the instrumentation. In 2 patients, the PLIF cages were repositioned in the face of infection. All 8 patients received 4 to 6 weeks of intravenous antibiotic therapy followed by another 6 to 9 weeks of oral antibiotic administration. At 2-year follow-up, no clinical or laboratory signs of recurrent infection were evident. Four of the 8 patients reported improved clinical status compared with their prefusion status. At 6-year follow-up, 3 patients had minimal disability according to the Oswestry Disability Index and 2 patients had moderate disability with residual leg pain. CONCLUSIONS:In cases of postoperative deep wound infection after PLIF with cages, removal of the interbody implants is not necessary. Treatment is composed of prolonged antibiotic therapy guided by antimicrobial susceptibility of the isolated bacteria and supplemented with extensive surgical debridement if needed.

BACKGROUND:Ipsilateral recurrent disc herniation after lumbar discectomy is a significant problem in the management of lumbar disc disease and may necessitate repeat surgical intervention. A population-based study in Finland found that about 14% of all primary lumbar discectomies required additional surgical interventions. Interspinous devices, which have been shown to unload the posterior anulus, may reduce the occurrence of recurrent herniations. We report our short-term experience with the use of the Wallis device in the management of patients with lumbar disc herniation undergoing primary disc excision. PATIENTS AND METHODS:Thirty-seven consecutive patients (23 males and 14 females, average age 36 y) underwent primary lumbar disc excision followed by fixation of the segment with the Wallis implant during a period of 1 year. Indications for implanting the Wallis device were a voluminous disc herniation and preservation of at least 50% of disc space height. Surgery was performed at level L4-5 in most patients. Average follow-up after surgery was 16 months (range 12 to 24). The last 14 patients were also evaluated by the preoperative and postoperative Oswestry Disability Index (ODI) questionnaire, the SF-36 survey, and by a visual analog scale (VAS) for back and leg pain. RESULTS:The average ODI dropped from 43 to 12.7. The average VAS for back pain dropped from 6.6 to1.4 and the average Vas for leg pain dropped from 8.2 to 1.5. Five patients (4 males and 1 female) with relapsing leg pain were diagnosed by contrast-enhanced magnetic resonance imaging as suffering from recurrent herniation (5/37, 13%). All reherniations occurred at level L4-5 level between 1 and 9 months after the index surgery. Two of the 5 patients subsequently underwent additional discectomy and fusion. SUMMARY:The current Wallis implant is probably incapable of reducing the incidence of recurrent herniations, but it still may be useful in patients with discogenic back pain due to early degenerative disc disease.

STUDY DESIGN:Discs were cultured during discectomy from patients with back pain, sciatica, and radiologic evidence of disc herniation causing nerve root compression.OBJECTIVE:To investigate the claim of culpability of bacteria in causing the local inflammatory process seen in patients with disc herniation and radiculopathy.SUMMARY OF BACKGROUND DATA:Bacteria have been cultured from intervertebral discs of patients with sciatica. An infectious etiology for sciatica could have a dramatic effect on treatment options for this common problem.METHODS:To minimize the risk of contamination, the surgeon performed processing and culturing procedures intraoperatively under stringent sterile conditions. Immediately following disc excision, the specimens were divided into 4 pieces, and cultured in various aerobic and anaerobic culture mediums that were incubated for 2 weeks.RESULTS:The 120 specimens from 30 patients underwent bacterial culture growth: 116 were sterile, an 4 aerobic cultures (2 patients) grew coagulase-negative staphylococci, suggestive of contamination.CONCLUSIONS:These results refute the hypothesis that microbial infection plays a role in the pathogenesis of sciatica. It is possible that bacterial growth from discs reported in previous studies was at least partly related to contamination, which we painstakingly avoided by application of rigorous aseptic techniques.

Adolescent disc herniation and its surgical treatment have been the subjects of many published clinical series. The majority of these series were heterogeneous; the number of adolescent patients (12-17 years) as opposed to young adults (18-20 years) was generally small and the length of follow-up varied greatly. Although the short-term outcome of disc excision in adolescents was mostly favorable, their long-term outcome is unknown.To evaluate the mid- and long-term results of discectomy in patients younger than 17 years of age.Retrospective examination of a series of adolescent patients under the age of 17 years who underwent surgery for lumbar intervertebral disc herniation.The medical records of 26 patients (15 males, 11 females, 12-17 years old [average 14.6]) who were operated for lumbar intervertebral disc herniation in three spine centers between 1984 and 2002 were reviewed. These subjects represented the total number of patients meeting the criteria of adolescents undergoing discectomy for lumbar disc herniation in these institutions during the study period. All patients were located and contacted by an independent observer not involved in the care of these patients. Low back pain associated with leg pain was the main clinical symptom in 20 patients (77%), leg pain in 4 (15%), and back pain in 2 (8%). They all underwent posterior disc excision: 23 (88%) patients had one level discectomy, and 3 (12%) had simultaneous discectomy at two levels. The L4-L5 interspace was involved 19 times, and the L5-S1 interspace 10 times. Slipped vertebral apophysis was diagnosed in 4 patients (15%). Twelve of the 26 patients (46%) had a first-degree relative with a history of lumbar disc herniation.Telephone interviews provided follow-up data for 26 patients. Results were classified as excellent, good, moderate, or poor according to current symptom status, the need for additional surgery, the Oswestry Disability Index, and back and leg pain scores.The average time from surgery to follow-up was 8.9 years (range 3-21 years). At follow-up, the clinical results were excellent in 13 patients (50%), good in 4 (15%), moderate in 8 (31%), and poor in 1 (4%). Four subjects (15%) underwent a subsequent disc excision in the lumbar region, and one of them later underwent fusion.Discectomy provides satisfactory clinical results in young patients with disc herniation. The rate of reintervention (15%) is comparable to that in adults, indicating that discectomy for young patients should be approached similarly to that in adults.