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Background: Retro-odontoid pseudotumor (ROPT) is a non-neoplastic pathology of the craniovertebral junction that is usually associated with atlantoaxial instability. The mass compresses the spinal cord, causing cervical myelopathy and potentially resulting in severe disability. Posterior atlantoaxial fixation without laminectomy is a suitable surgical option when the symptoms are mild and the static compression is moderate. In the setting of patients with severe symptoms and large ROPTs, posterior decompression becomes necessary. However, achieving solid posterior atlantoaxial fusion is difficult without a bony surface, namely the C1 posterior arch. Here, we describe a novel technique of C1 laminoplasty to achieve C1 decompression, and posterior atlantoaxial fusion with a modified Goel technique. Methods: An 83-year-old man was referred to our orthopedic department with quadriplegia due to atlantoaxial instability. His daily life had been affected by severe neck pain, clumsiness of bilateral hands, and gait disturbance for more than 2 years. Preoperative cervical radiograms revealed atlantoaxial instability, and magnetic resonance imaging showed a large pseudotumor compressing to the spinal cord. Results: The patient underwent C1 laminoplasty to decompress the spinal cord and retain the posterior arch as a bony surface for grafting and posterior atlantoaxial fusion. The procedure was well tolerated. The patient’s quadriparesis was improved and his Japanese Orthopedic Association score improved from 9/17 to 15/17 and his visual analog scale score for neck pain improved from 75 mm to 28 mm at the 1-year follow-up. Conclusion: C1 laminoplasty and posterior atlantoaxial fusion appears useful when C1 decompression and atlantoaxial fusion become necessary.

Background: Adult spinal deformity (ASD) is caused by spinal malalignment and results in severe low back pain, neurological dysfunction, and severe deformity. Surgical treatment, such as long spinal fusion offers improved patient-reported outcomes compared to conservative treatment. However, surgical complication of proximal screw pullout represents a difficult problem in minimally invasive ASD surgery. We describe a novel technique to prevent screw pullout in ASD. Case presentation: A 71-year-old woman was referred to our hospital with severe low back pain and gait difficulty. Her daily life had been affected by severe lower back pain for more than 6 months. Standing radiograms indicated severe kyphoscoliosis. Two-stage minimally invasive corrective T10-to-pelvis fixation was performed. The first surgery was an L1–S1 image-guided oblique lumbar interbody fusion, with an operation time of 3 h 57 min and an estimated blood loss of 240 mL. After 1 week, the second percutaneous pedicle screw (PPS) fixation was performed and proximal screws were inserted under a transdiscal approach (T11) and with a lower angulation trajectory (T10) to enhance pullout strength. For this second surgery, operation time was 3 h 33 min, and estimated blood loss was 320 mL. No postoperative complications or neurological compromise was reported. In terms of clinical outcomes, Oswestry Disability Index improved from 56% to 24%, and visual analog scale score for lower back pain improved from 62 mm to 24 mm at the 1-year follow-up. Conclusions: Minimally invasive circumferential surgery with triangular fixation is effective for preventing proximal screw back-out and surgical invasiveness. With this new technique, surgeons and operating room staff can avoid the risk of adverse events due to intraoperative radiation exposure.

Background: Indirect decompression for lumbar canal stenosis as a technique of minimally invasive surgery (MIS), is receiving considerable attention. Conventional MIS indirect decompression at L5-S1 is performed using intraoperative fluoroscopy. In this work, we describe a novel C-arm free simultaneous MIS indirect decompression technique for L5-S1 pathology. Methods: A 72-year-old woman with symptomatic L5 isthmic spondylolisthesis was referred to our hospital. The patient’s daily life had been affected by severe low back pain for 5 years and left leg pain for 2 years. The surgery was performed without C-arm fluoroscopy. The percutaneous pedicle screws and intervertebral cages were inserted only under navigation guidance in a single lateral position. Results: The patient was successfully treated with surgery. Her low back pain and left leg pain improved dramatically. Her clinical outcomes, the Oswestry disability index (ODI) improved from 48% to 14% and the low back pain visual analog scale (VAS) score improved from 78 mm to 23 mm at 1 year of final follow-up. Conclusions: C-arm-free simultaneous MIS indirect decompression for L5-S1 is a useful technique, which may reduce surgical time and blood loss. With this new technique, surgeons and operation room staff can avoid the risk of an adverse event of intraoperative radiation.

Background: Navigation surgery is becoming very popular for anterior cervical surgery. However, one difficult problem for anterior cervical surgery is setting the reference frame (RF), due to the lack of reliable structures. If the RF is attached to the head holder or operation table instead of the patient, the accuracy of navigation is not good. Materials and methods: This retrospective study included six patients who underwent anterior cervical surgeries with O-arm navigation. The RF was attached to the Caspar retractor using a special adaptor. Patients comprised three men and three women with a mean age of 62.8 years. Anterior cervical discectomy and fusion was performed in three cases, and anterior cervical corpectomy and fusion in three cases. We evaluated the accuracy of navigation, surgical time, intraoperative blood loss, complications, bony fusion, and clinical results. Results: Mean accuracy of anterior navigation was 1.1 ± 0.7 mm (range, 0–2 mm). Mean surgical time and blood loss were 166 ± 39 min (range, 121–359 min) and 280 ± 189 ml (range, 50–600 ml), respectively. Complications comprised one case of postoperative C5 palsy that recovered within 6 months. Mean Japanese Orthopedic Association (JOA) recovery rate was 52.4% (range, 20–100%). Adequate decompression and solid fusion were obtained in all cases. Conclusions: Intraoperative O-arm navigation-guided anterior cervical decompression and fusion is an effective technique for achieving precise decompression. This new navigation technique provides excellent results for severe cervical ossification of the posterior longitudinal ligament (OPLL) with minimum risk of adverse events from intraoperative radiation. We advocate the use of this novel technique in cases of cervical canal stenosis due to large disc osteophyte complex and OPLL, and also in cases of distorted cervical anatomy due to deformity, tumor, or revision surgery.

Study design: Retrospective comparative study. Objective: Comparative study of C-arm free O-arm navigated minimally invasive cervical pedicle screw (MICEPS) fixation with conventional cervical pedicle screw fixation. Methods: Twenty-five patients with different cervical spine pathologies were operated with MICEPS with O-arm navigation (group M; 18 patients) and conventional pedicle screw (group C; 7 patients) from June 2017 to January 2020. Operative time, blood loss were recorded. Preoperative and postoperative radiograms, CT scans and MRI were evaluated. Postoperatively screw position accuracy and angulation was determined on CT. Breach rate was evaluated on CT scan and classified according to Neo grading. Complications if any were noted. Results: The average blood loss in group M and group C was 129 ml and 329 ml, respectively. The average operative time in group M and group C was 77.4 min and 82.3 min, respectively. A total of 148 screws were inserted. In group M, no patient showed grade 2 and 3 breach while in group C, grade 0 and 1 breach was found in 85.7% screws and grade 2 in 14.3% screws. Mean screw medial angulation was 45.2 degrees in group M and 33.4 degrees in group C. There was one dural tear and two C5 palsies in each group. Conclusion: With C -arm free O-arm navigated MICEPS fixation operative time and blood loss are less though not statistically significant. It has less pedicle breach rate, less incidence of neurovascular complications than conventional technique. There is no radiation exposure to operating surgeon and staff.

Background: Percutaneous pedicle screw (PPS) fixation as a minimally invasive surgery (MIS) is becoming the standard method for stabilizing thoracolumbar burst fractures. However, with the conventional PPS percutaneous reduction is difficult, and a great amount of usage of fluoroscopy is necessary. We describe a novel technique of C-arm free PPS with new reduction device for thoracolumbar fractures. Methods: A 22-year-old man presented to our hospital with severe low back pain and impending paraplegia secondary to T12 burst fracture. We performed short-segment fixation and reduction for this patent. The special PPS which have reduction mechanism were inserted under O-arm navigation guidance. The trauma reduction system was applied and the fracture was reduced without fluoroscopy. Results: Postoperative computed tomography (CT) showed the adequate screws position and complete reduction of the vertebral body. On one-year follow-up, the patient was asymptomatic, with the fracture healed and no implant loosening. Conclusions: C-arm free PPS and reduction is a useful MIS technique for thoracolumbar burst fractures.

Background: Surgical management of spondyloptosis (grade 5 spondylolisthesis) is challenging and controversial, from in situ fusion to complete reduction. In situ fusion is less technically demanding and offers the advantage of a low risk of neurological complications, but the pseudoarthrosis rate is high and sagittal alignment cannot be normalized. We present a relatively rare case of a patient with L5 spondyloptosis who needed revision surgery due to psuedoarthrosis and rod breakage. Case description: A 12-year-old girl with L5 spondyloptosis was referred to our hospital. She had a 3-year history of low back pain (visual analogue scale: VAS 8/10), bilateral L5 dermatomal pain (VAS 6/10) and paresthesia. The patient was successfully treated with surgery, partial reduction was performed and sagittal and coronal alignments were normalized. But at 1.5 year follow up, patient presented with low back pain, rod breakage and psuedoarthrosis, so revision surgery was done with fibula grafting, dual sacro-alar-iliac screws and additional rod. At the 3-year follow-up, VAS for low back pain had improved from 8/10 to 2/10 and leg pain had disappeared. Postoperative radiograms at final follow-up revealed no loss of reduction or loosening of implants. Conclusions: Sagittal reduction is more important than horizontal reduction for patients with spondyloptosis showing sagittal malalignment (SDSG type 5 or 6). Cantilever and table-bending techniques are useful to obtain good sagittal alignment for patients showing spondyloptosis. It is important to have circumferential fusion if reduction is aimed.

Background: Anterior cervical corpectomy and fusion (ACCF) with floating technique is one of the best surgical interventions for severe ossification of the posterior longitudinal ligament (OPLL). However, insufficient decompression and a thinned ossification mass often lead to poor clinical outcome. This report describes a novel floating technique with intraoperative O-arm navigation to facilitate surgical treatment of the OPLL, which has not previously been described as a therapeutic option. Case description: An 82-year-old woman with myelopathy of the OPLL was referred to our hospital. Activities of daily living had been restricted by severe left arm pain, myelopathy hand, and gait disturbance for 3 years. ACCF was performed under the guidance of O-arm navigation and C-arm-free minimally invasive cervical pedicle screw fixation (MICEPS). The patient was successfully treated surgically and manual muscle test results and sensory function of the left arm had recovered fully by final follow-up at 1 year. Japanese Orthopedic Association score of the patient had improved from 10/17 to 16/17. Conclusions: Intraoperative O-arm navigation-guided ACCF with C-arm-free MICEPS is an effective technique for achieving precise decompression and strong, minimally invasive fixation. This new anterior navigation technique provides an excellent result for severe OPLL without the risk of adverse events from intraoperative radiation.

Background: Pedicle screw fixation is the standard method for stabilizing fractures in an ankylosed spine, as seen in diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing spondylitis. However, with the conventional screw insertion technique, screw loosening, backout and loss of fixation are often encountered in osteoporotic bone. To enhance screw pull-out strength, we describe a new technique of percutaneous transdiscal pedicle screw (TPS) insertion in this technical note. Methods: A 74-year-old man with DISH presented with severe back pain and impending paraplegia secondary to osteoporotic T11 vertebral fracture. We performed short-segment PTS fixation under computer navigation guidance. Screws were inserted in a 25° cephalad direction to engage the superior endplate of the instrumented vertebrae. Increased insertional torque was appreciated by the surgeon when the screw engaged the superior endplate, but was not felt while crossing the pedicle. Results: Computed tomography (CT) immediately postoperatively showed the screws in the intended position engaging the superior end plate. On 1-year follow-up, the patient was asymptomatic, with the fracture healed and no implant loosening. Conclusions: The PTS insertion technique may be a useful option for spine fixation in DISH to overcome the problems of osteoporotic bone by enhancing screw pull-out strength.