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Study Design: Retrospective analysis of consecutive case series. Objective: To introduce a novel method of stabilizing the cranium using bivector traction in posterior cervical fusions. Methods: A retrospective review of 50 consecutive patients undergoing instrumented posterior cervical arthrodesis was performed. All patients had at least 3 levels of subaxial fusion using the bivector traction apparatus. Patients’ demographic data was recorded for the following: pre- and postoperative cervical lordosis, pre- and postoperative cervical sagittal vertical alignment (cSVA), and intraoperative complications from pin placements. Results: A total of 50 patients were studied. There were 31 females and 19 males. The mean age at the time of surgery was 49 years (range 35-79). A mean 5.8 levels were fused. The most common levels fused were C2-T3 in 14 patients followed by C2-T2 in 7 patients. In no case did the surgeon or assistant have to scrub out to adjust the alignment. The mean pre- and postoperative cervical lordosis was −6.0° and −10°, respectively ( P = .04). The mean pre-and postoperative cSVA was 30.5 mm and 32 mm, respectively ( P = .6). There were no complications related to placement of the Gardner-Well tongs. Conclusion: The bivector traction is an easy, safe, and effective method of stabilizing the head and obtaining adequate cervical sagittal alignment.

Background: Surgical drains are commonly used after spine surgery to minimize infection and hematoma formation. The aim of this study was to determine the incidence of post-operative complications after spinal decompression and fusion with and without a subfascial drain. Methods: The medical records of 139 adult (≥18 years old) spinal deformity patients undergoing elective spinal decompression and fusion at a major academic institution were reviewed. We identified 116 (83.5%) who had a post-operative drain and 23 (16.5%) who did not have a postoperative drain (No-Drain: n=23; Drain-Use: n=116). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation. Results: Patient demographics and comorbidities were similar between both cohorts, with the body mass index (BMI) slightly higher in the Drain-Use cohort (No-Drain: 26.1 kg/m 2 vs . Drain-Use: 29.1 kg/m 2 , P=0.02). Operative time and the median number of levels fused were similar between the cohorts. The postoperative complications profile was similar between both cohorts, including deep and superficial SSIs (P=0.52 and P=0.66, respectively), and incidence of hematoma formation (P=0.66). Length of hospital stay (LOS) was significantly higher for the Drain-use cohort compared to the No-Drain cohort (5.0 vs . 2.8 days, P Conclusions: Our study suggests that the use of postoperative subfascial drains in patients undergoing spinal decompression with fusion may not be associated with a reduction in SSIs or hematoma formation.

Background: This study aims to assess 30-day complication and unplanned readmission rates associated with resection of metastatic spinal tumors. Methods: Medical records were reviewed for 135 adults who underwent elective resection of a spinal cord tumor. Patient demographics, comorbidities, and tumor characteristics were collected. Tumor pathology was analyzed and diagnosed by a pathologist. The primary outcomes were intra- and 30-day post-operative complication and readmission rates. Results: Of the 135 spinal tumor resections, 30 (22.2%) cases were metastatic. The most common tumor pathology was bone (13.3%) and the most common locations were thoracic (45.2%), and cervical (32.7%). Most patients had an open surgery (96.7%), with a mean laminectomy/laminoplasty level of 1.9±1.5 and mean operative time of 328.4±658.0 min. There was a 3.3% incidence rate of intraoperative durotomies, with no spinal cord or nerve root injuries. Post-operatively, 44.8% of patients were transferred to the intensive care unit (ICU). The most common post-operative complications were weakness (20.0%), new sensory deficits (16.7%), and hypotension (13.3%). The mean length of stay was 8.8±7.6 days, with the majority of patients discharged home (96.7%). The 30-day readmission rate was 9.7%, with the most common 30-day complications being uncontrolled pain (16.7%), sensory-motor deficits (13.3%), and fever (10.0%). Conclusions: Our study suggests that weakness, sensory deficits, and uncontrolled pain are the most common complications after resection of spinal metastases, with a relatively high associated 30-day readmission rate. Further studies are necessary to corroborate our findings and identify strategies to reduce complication and readmission rates after resection of spinal metastases.

Background: Percutaneous pedicle screw placement is now commonly used to treat spinal instability. It is imperative, especially at thoracic levels, to avoid damage to adjacent neurovascular structures. Although more technically demanding when compared with the lumbar spine, we believe that the percutaneous placement of thoracic pedicle screws can be performed safely without image-navigation. Purpose: The purpose was to evaluate the safety of percutaneous pedicle screw placement in the thoracic and thoracolumbar spine without image-navigation. Study Design / Setting: A retrospective study at a single institution. Patient Sample: Patients over the age of 18 years who presented with degenerative disease, trauma or tumor that required surgical stabilization. Outcome Measures: Our outcomes included postoperative plain film X-rays and computerized tomography (CT). Materials and Methods: We performed a retrospective study of patients who underwent percutaneous pedicle screw placement without image-navigation between T2 and L2. Results: Between 2005 and 2011, a total of 507 pedicle screws were placed in 120 patients. The indications included trauma (17%), tumor (8%), and degenerative conditions (75%). The mean age was 61.3 years (range: 20-81 years). Fifty-seven percent were male, and 43% were female. The mean blood loss was 297 ± 40 ml. All patients underwent postoperative anterior-posterior and lateral films that showed safe placement of pedicle screws. Moreover, 57% of patients underwent postoperative CT imaging. There was 1 (0.4%) medial breach and 13 (5%) lateral breaches of the pedicle screw patients who underwent CT imaging as read by an independent neuroradiologist. None of the breaches resulted in adverse neurological sequelae either immediately after or at most recent follow-up. Conclusion: Thoracic and thoracolumbar percutaneous pedicle screw placement can be performed safely and accurately without image-navigation.

While there are variations in techniques and surgical approaches to spinal fusion, there is not a defined consensus on a recommended surgical approach. The aim of this study is to determine if there was a difference in intra- and post-operative complication rates between different surgical approaches after elective spinal fusion (≥3 levels) for adult spine deformity.The medical records of 443 adult spine deformity patients undergoing elective spinal fusion (≥3) at a major academic institution from 2005 to 2015 were reviewed. We identified 96 (21.7%) anterior only, 225 (50.8%) posterior only, and 122 (27.5%) combined anterior/posterior approaches taken for spinal fusion (anterior: n=96; posterior: n=225). Patient demographics, comorbidities, anatomical location, and complication rates were collected for each patient. The primary outcome investigated in this study was the rate of intra- and post-operative complications.Patient demographics and comorbidities were similar between all groups. The posterior approach had significantly higher EBL (P0.0001) and number of PRBC blood transfusions (P0.002), while the combined approach had a higher operative time (P0.0001). The posterior approach had a significantly higher rate of intraoperative durotomies than anterior and combined (anterior: 0%Our study suggests that posterior approaches to spinal fusion may lead to a higher incidence of complications compared to anterior or combined anterior/posterior approaches.

Study Design: A cadaveric study to determine the accuracy of percutaneous screw placement in the thoracic spine using standard fluoroscopic guidance. Summary of Background Data: While use of percutaneous pedicle screws in the lumbar spine has increased rapidly, its acceptance in the thoracic spine has been slower. As indications for pedicle screw fixation increase in the thoracic spine so will the need to perform accurate and safe placement of percutaneous screws with or without image navigation. To date, no study has determined the accuracy of percutaneous thoracic pedicle screw placement without use of stereotactic imaging guidance. Materials and Methods: Eighty-six thoracic pedicle screw placements were performed in four cadaveric thoracic spines from T1 to T12. At each level, Ferguson anterior-posterior fluoroscopy was used to localize the pedicle and define the entry point. Screw placement was attempted unless the borders of the pedicle could not be delineated solely using intraoperative fluoroscopic guidance. The cadavers were assessed using pre- and postprocedural computed tomography (CT) scans as well as dissected and visually inspected in order to determine the medial breach rate. Results: Ninety pedicles were attempted and 86 screws were placed. CT analysis of screw placement accuracy revealed that only one screw (1.2%) breached the medial aspect of the pedicle by more than 2 mm. A total of four screws (4.7%) were found to have breached medially by visual inspection (three Grade 1 and one Grade 2). One (1.2%) lateral breach was greater than 2 mm and no screw violated the neural foramen. The correlation coefficient of pedicle screw violations and pedicle diameter was found to be 0.96. Conclusions: This cadaveric study shows that percutaneous pedicle screw placement can be performed in the thoracic spine without a significant increase in the pedicle breach rate as compared with standard open techniques. A small percentage (4.4%) of pedicles, especially high in the thoracic spine, may not be safely visualized.

Background. To our knowledge, this is the sixth reported case in the literature of fourth ventricular schwannoma. The etiology and natural history of intraventricular schwannomas is not well understood. A thorough review of potential etiopathogenic mechanisms is provided in this case report.Case Description. A 69-year-old man presented with an incidentally found fourth ventricular tumor during an evaluation for generalized weakness, gait instability, and memory disturbance. Magnetic resonance imaging (MRI) revealed a heterogeneously enhancing lesion in the fourth ventricle. A suboccipital craniotomy was performed to resect the lesion. Histopathological examination confirmed the diagnosis of schwannoma (WHO grade I).Conclusions. Schwannomas should be considered in the differential diagnosis of intraventricular tumors. Although the embryologic origins may be different from nerve sheath-derived schwannomas, the histologic, clinical, and natural history appear identical and thus should be managed similarly.

It has been observed that the efficient transfection of T cells by RNA electroporation requires prior activation of T cells with mitogens or by anti-CD3 antibody stimulation. We hypothesized that this requirement for T cell activation could be leveraged to express marker genes within activated T cells responding to antigen-pulsed dendritic cells and allow for the selective enrichment and modification of antigen-specific T cells. Using electroporation of mRNA encoding green fluorescent protein as a marker gene, we demonstrate that RNA electroporation can efficiently allow for the separation of cytomegalovirus-specific CD8+ and CD4+ T cells from bulk culture responding to cytomegalovirus pp65 antigen-pulsed dendritic cells. Furthermore, we demonstrate that cytomegalovirus-specific T cells can be functionally modified by RNA transfection of the C-X-C chemokine receptor, CXCR2, to migrate efficiently toward a variety of CXCR2-specific chemokines in vitro and in vivo. These studies demonstrate the utility of RNA transfection as a simple method by which to purify and selectively modify the function of antigen-specific T cells for use in adoptive immunotherapy, and importantly provide evidence that transient expression of proteins by RNA transfection is an efficient means of modulating the in vivo function of activated T cells.

For the study of malignant glioma, we have previously characterized a highly tumorigenic murine astrocytoma, SMA-560, which arose spontaneously in an inbred, immunocompetent VM/Dk mouse. Using this cell line as a model of murine glioma, we performed DNA microarray analysis of autologous normal murine astroctyes (NMA) and SMA-560 tumor cells grown in monolayer culture or intracranially in syngeneic immunocompetent or immunocompromised hosts in order to determine whether tumors grown in vitro recreate the complex genetic regulation that occurs in vivo. Our findings support our hypothesis that glioma phenotype in vitro may be quite different in vivo and significantly altered by in situ growth factors and other invading cell populations.