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Many surgical options exist for multilevel lumbar interbody fusion, including anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF). While current technique of repositioning patients between supine ALIF and lateral decubitus LLIF offers many benefits, intraoperative repositioning can be cumbersome. We present a novel approach that accomplishes both multilevel LLIF and L5-S1 ALIF in a lateral decubitus position. This case series retrospectively enrolled 12 consecutive patients who underwent L5-S1 ALIF in the lateral decubitus position and anterior-to-psoas LLIF at more cranial levels as part of a multilevel lumbar interbody fusion surgery between September 2020 and December 2021. All surgeries were performed by a single spine-focused neurosurgeon at an urban academic hospital. Radiographic imaging analysis demonstrated significant changes in coronal Cobb angle (−5.43° ± 3.81°; P = 0.0029), global lumbar lordosis (6.77° ± 12.04°; P = 0.0049), segmental lumbar lordosis (8.91° ± 10.21°; P = 0.0005), spinopelvic mismatch (−7.93° ± 7.91°; P = 0.0010), average disc height (5.30 ± 1.64 mm; P = 0.0005), and L5-S1 disc height (6.68 ± 2.10 mm; P = 0.0005). Two patients developed postoperative complications including wound dehiscence and grade I graft subsidence at L4-L5. This case series demonstrated that a combined lateral decubitus L5-S1 ALIF and LLIF at more cranial levels is a safe, efficient approach to multilevel lumbar interbody fusions. This technique significantly restored spinopelvic alignments with a low complication rate and no patient repositioning. Efficacy of this minimally invasive deformity correction technique should be further investigated through a multicenter trial. [ABSTRACT FROM AUTHOR]

With advances and refinements in endoscopic lumbar spine surgery showing effective and satisfactory results, the need for simple yet effective anesthetic techniques for minimally invasive endoscopic spine surgery has increased. The aim of this study was to compare feasibility and postoperative outcomes of fluoroscopy-guided epidural anesthesia with general anesthesia in patients undergoing endoscopic lumbar decompression surgery (≤3 levels). Patients who underwent 1–3 levels of endoscopic lumbar decompression surgery under either fluoroscopy-guided epidural or general anesthesia between January 2019 and October 2020 were retrospectively reviewed. Postoperative pain intensity and use of rescue analgesics for up to 48 hours were compared between the epidural and general anesthesia groups. Intraoperative anesthetic data and postoperative recovery profiles were also analyzed. Postoperative pain scores were significantly lower in the epidural anesthesia group compared with the general anesthesia group at 10 minutes after recovery room admission (2.1 ± 1.8 vs. 5.7 ± 1.9, P < 0.001), 24 hours postoperatively (3.3 ± 1.0 vs. 5.4 ± 1.8, P < 0.001), and 48 hours postoperatively (3.2 ± 0.6 vs. 4.4 ± 1.4, P < 0.001). The proportion of patients requiring rescue analgesics in the recovery room was significantly lower in the epidural anesthesia group (1.9% vs. 20.5%, P = 0.027). The median 15-item Quality of Recovery score on postoperative day 1 was significantly higher in the epidural anesthesia group (118.0 [113.5–123.0] vs. 82.0 [73.5–111.5], P < 0.001). Occurrence of nausea, vomiting, and voiding difficulty up to 48 hours postoperatively did not differ between groups. Compared with general anesthesia, epidural anesthesia provided better analgesia and recovery characteristics during the early postoperative period in endoscopic lumbar decompression surgery. [ABSTRACT FROM AUTHOR]

Anterior cervical discectomy and fusion (ACDF) is the most common procedure for the treatment of degenerative cervical conditions. The objective of this study is to determine time-dependent trends in patient outcomes following ACDF for degenerative disease from 2006 to 2016. We used the National Surgical Quality Improvement Program (NSQIP) database to retrospectively review all patients who underwent elective ACDF between 2006 and 2016. A descriptive statistical analysis followed by time trend analysis was performed on demographics, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission rates. Secondary outcomes were medical and surgical complications reported within 30 days of operation. A total of 36,854 patients underwent elective ACDF from the 2006 to 2016 NSQIP database. Mean age increased from 48.19 years [standard error: 1.49] in 2006 to 54.08 years [standard error: 0.12] in 2016 (P < 0.001). There was a significantly greater number of outpatient procedures from 2012 to 2016 (P < 0.001). The proportion of patients with American Society of Anesthesiologists classes 3/4 significantly increased over time (P < 0.001, P < 0.001, P = 0.005, respectively). Readmission risk, first documented in NSQIP in 2011, increased over time from 2011 to 2016 (P < 0.001). Unplanned reoperations have remained consistent at about 1.4%. Postoperative complications varied over time with no discernable patterns or trends. Since the establishment of the NSQIP database, there have been no considerable improvements in reoperation or postoperative complication rates based on available data, however, there have been increased rates of readmission. Changes in data collection and an aging patient population with greater burden of comorbidities could confound these trends. [ABSTRACT FROM AUTHOR]

Preoperative laboratory tests are varied in their administration among physicians, and previous studies have published conflicting reports on their utility. Anterior cervical discectomy and fusion (ACDF) is a commonly performed spine surgery, and patients often undergo preoperative testing. We sought to assess the relationship between preoperative laboratory values and risk for adverse postoperative outcomes after ACDF. The American College of Surgeons–National Surgical Quality Improvement Program was queried from 2012 to 2017 to identify patients undergoing elective ACDF. Multivariable logistic regression was performed to assess the association between abnormal laboratory test values and adverse 30-day outcomes. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom. A total of 47,111 patients were included. On multivariable analysis, high creatinine (P = 0.030), anemia (P < 0.001), hyponatremia (P = 0.034), and leukocytosis (P < 0.001) were found to be significantly associated with any 30-day complications. Anemia (P < 0.001), hypernatremia (P = 0.028), hyponatremia (P = 0.016), and leukocytosis (P < 0.001) were found to be significantly associated with serious 30-day complications. High creatinine (P = 0.027), anemia (P < 0.001), hyponatremia (P = 0.047), and leukocytosis (P = 0.004) were found to be significantly associated with 30-day unplanned readmissions. High blood urea nitrogen (P = 0.007), high creatinine (P = 0.028), anemia (P < 0.001), low platelet count (P < 0.001), hyponatremia (P < 0.001), and leukocytosis (P < 0.001) were found to be significantly associated with nonhome discharge. Predictor importance analysis revealed that abnormal preoperative laboratory values were important determinants in predicting these 30-day outcomes. Our analyses indicate that abnormal preoperative laboratory values are associated with increased risk for adverse outcomes after elective ACDF and can be used in predictive analyses of outcomes. [ABSTRACT FROM AUTHOR]

Postoperative C5 palsy affects 8% of patients undergoing posterior cervical decompression. It is associated with a period functional disability that may exceed 12 months and increase direct care costs > $2000. All patients undergoing posterior cervical decompression at a single tertiary-care facility for degenerative conditions were evaluated for preoperative imaging, clinical presentation, surgical operation, and postoperative course. We sought to identify those variables predictive of postoperative C5 palsy. Of 221 included patients (mean age, 63 years; 54% male), 12.2% experienced C5 palsy. On univariate analysis, C5 palsy was associated with foraminal diameter (P = 0.0005), spinal cord cross-sectional area (P = 0.11), number of levels undergoing laminectomy (P = 0.14), and clinical presentation of dropping objects (P = 0.07), hand clumsiness (P = 0.13), or paresthesias in the upper extremities (P = 0.08). Foraminal diameter (odds ratio, 0.31 per mm increase; 95% confidence interval, 0.16–0.60; P < 0.001) and patient report of gait disturbance (odds ratio, 0.53; 95% confidence interval, 0.33–0.85; P = 0.008) were the only significant predictors on multivariate analysis. A foraminal diameter <2 mm had 2-fold greater odds of postoperative C5 palsy. A receiver operating curve for the multivariate logistic model had an associated C -statistic of 0.7818. The absolute error of this model was 9.3% on internal validation. Foraminal stenosis most strongly predicted postoperative C5 palsy. A proof-of-concept model incorporating foramen size, as well as clinical complaints of paresthesias, hand clumsiness, and gait abnormality, successfully predicts the occurrence of postoperative palsy with an overall accuracy of 78%. [ABSTRACT FROM AUTHOR]

Atlantoaxial instability, a common finding in patients with Down syndrome (DS), is attributed to laxity of ligamentous structures. Cervical spondylosis identified in these patients has a pathogenesis of ligament laxity and early degeneration compared with the normal population. No cases have been reported showing affection of thoracic or lower levels. Two adults with DS presented with progressive spastic paraparesis with hypertrophy of ligamentum flavum at the lower thoracic level, causing canal stenosis and myelopathy. Degenerative changes were seen in the entire spine. Both patients improved with canal decompression. Degenerative changes of the spine occur earlier in DS, probably due to increased movements across the vertebrae owing to laxity in the ligaments. Routine workup of patients with DS presenting in their adult lives should keep in mind the affection of lower spinal levels. Early identification of thoracic myelopathy and lumbar canal stenosis gives a chance of cure. [ABSTRACT FROM AUTHOR]

Background Vascularized bone grafts (VBGs) are described as having superior osteogenicity, osteoconductivity, and osteoinductivity compared with other graft types and have been used in high-risk patients to augment arthrodesis. Pedicled VBGs are rotated on an intact vascular pedicle and therefore maintain all the benefits of VBGs but avoid many of the challenges and additional morbidity of free-tissue transfer. This study describes a novel surgical technique for rotating vascularized spinous process into the posterolateral space for augmenting arthrodesis in patients undergoing posterolateral fusion (PLF). Methods A technique is described for rotating the spinous process into the posterolateral space on an intact vascular pedicle of paraspinal muscle. Early clinical and radiographic outcomes are reported for 4 patients who have undergone this procedure. Results Four patients were treated with a single or 2-level PLF combined with posterior, anterior, or lateral interbody fusion and vascularized spinous process graft. Three-month postoperative computed tomography scans demonstrated a dislodged graft in 1 patient and successful arthrodesis in 3 patients. Additional operative time taken for graft harvest and implantation ranged from 22 minutes for the first patient to 6 minutes for the fourth patient. Conclusions Rotation of vascularized spinous process graft for augmentation of posterolateral arthrodesis in the lumbar spine is a potentially safe, effective surgical technique that results in successful arthrodesis in as little as 3 months but requires further study. This technique is expected to add little additional time or morbidity to the traditional lumbar PLF because it requires no separate incision or additional bone removal. [ABSTRACT FROM AUTHOR]

Objective Lumbar fusion is a widely used procedure for degenerative spine diseases but frequently is accompanied with substantial surgical blood loss. We aimed to investigate the risk factors for significant intraoperative blood loss and the influence of excessive bleeding on postoperative complications in patients undergoing fusion for degenerative lumbar spines. Methods For this retrospective study, we enrolled 199 patients who had undergone lumbar fusion surgery for degeneration. The definition of significant blood loss at operation was 500 mL or more in blood volume. The patients were subdivided into 2 groups on the basis of whether significant blood loss was present (n = 107) or not (n = 92). Results The incidence of significant blood loss during lumbar fusion was 53.8%. In the multivariate logistic regression model, the independent risk factors for significant blood loss included body mass index ( P = 0.027), extreme spinal canal narrowing ( P = 0.023), spine fusion segments >1 level ( P = 0.008), and transforaminal lumbar interbody fusion ( P = 0.006). Significant blood loss in lumbar fusion was associated with a greater incidence of postoperative complications ( P = 0.002). The length of hospital stay for patents with excessive bleeding was prolonged significantly ( P = 0.045). Conclusions Because substantial bleeding in lumbar fusion is associated with a greater incidence of morbidities and prolonged length of hospital stay, attention to the risk factors for significant blood loss is important in the preoperative assessment and postoperative guidance for the level of care. [ABSTRACT FROM AUTHOR]

Background A major drawback to use of cortical bone trajectory pedicle screws (CBTPSs) with traditional posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion grafts is that traditional graft insertion trajectories require wider posterior exposure. This wider exposure, beyond the limits otherwise required for CBTPS placement, negates a primary benefit of CBTPS fixation. The aim of this study was to define an alternative surgical technique for interbody graft placement that, when used in conjunction with CBTPS fixation, permits both minimal soft tissue dissection and optimal graft placement. Methods A team of neurosurgeons specializing in treatment of spinal pathologies developed a surgical technique for insertion of bilateral PLIF grafts that complements the principles of CBTPS fixation. This technique is illustrated in a patient undergoing lumbosacral decompression, CBTPS fixation, and 3-column arthrodesis. Results The described technique uses a divergent trajectory of bilateral PLIF grafts rather than the traditional parallel or convergent trajectories. Conclusions By aiming medially to laterally with the interbody graft, one recapitulates many advantages of CBTPSs, including avoidance of wide tissue dissection, greater intergraft volume available for bone grafting, and greater graft coverage of the hypophyseal ring. The prospective collection of outcome data for patients who undergo lumbosacral fusion using the divergent PLIF technique is ongoing. [ABSTRACT FROM AUTHOR]