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OBJECTIVERecent studies have demonstrated the efficacy of subfascial intrawound application of vancomycin powder in spine surgery in reducing the rate of surgical site infections (SSIs). However, to date no study has evaluated the efficacy and safety of suprafascial application of vancomycin powder in spine surgery. The purpose of this study was to quantify the rate of SSIs after open instrumented posterior spinal fusion with and without application of suprafascial vancomycin powder and to evaluate the rate of vancomycin powder–related local adverse effects.METHODSThe authors conducted a single-center retrospective case-control study of adult patients undergoing open instrumented posterior fusion of the cervical, thoracic, or lumbar spine performed by a single surgeon from January 2010 through December 2016. In March 2013, routine application of 1 g of suprafascial vancomycin powder was started for all cases in addition to standard systemic antibiotic prophylaxis. Baseline demographics and operative data as well as the SSI rates were compared between the study groups. The incidence of vancomycin powder–related adverse effects was analyzed.RESULTSA total of 515 patients (268 in the untreated group and 247 in the treated group) were included in the study. The mean age was significantly higher in the treated group than in the untreated group (58.4 vs 54.4 years, p < 0.01). Operative variables were similar between the study groups. Patients receiving vancomycin powder had a significantly lower infection rate (5.6% in the untreated group vs 0% in the treated group, p < 0.001). No vancomycin powder–related adverse effects were identified in the treated group.CONCLUSIONSRoutine application of suprafascial intrawound vancomycin powder in addition to systemic antibiotic prophylaxis is an easy-to-use, safe, and effective strategy for preventing SSIs after instrumented posterior spinal fusion. Suprafascial application of vancomycin powder could be a valuable alternative to previously reported subfascial distribution, minimizing the risk of local adverse drug reactions.

A spinal intradural extramedullary venous angioma is extremely rare and has not been previously reported. In this paper, the authors report on this entity with morphological and immunohistochemical evidence, and discuss the surgical strategy for its treatment. A 54-year-old woman presented to Nagoya University Hospital complaining of left-sided pain in the hip, thigh, and inguinal and perianal regions, with progressive worsening during the previous 2 weeks. Lumbar spine MRI showed an intradural extramedullary cyst at the level of T12–L1, which extended from the conus medullaris to the cauda equina. The cyst wall was not enhanced on T1-weighted MRI with Gd. Intraoperatively, a midline dural opening allowed the authors to easily visualize a dark-reddish cyst behind the spinal nerve rootlets in the cauda equina adjacent to the conus medullaris. The cyst was believed to originate from one of the spinal nerve rootlets in the cauda equina and a cluster of veins was identified on the cyst wall. The cyst was resected with the affected nerve rootlet. The surgery left no detectable neurological deficit. Based on the morphological and immunohistochemical evidence, the lesion was diagnosed as a venous angioma. No tumor recurrence was confirmed based on MRI at the time of the 2-year follow up. This is the first report of an intradural extramedullary cystic venous angioma that was successfully resected.

✓ Although atlantoaxial transarticular screw fixation is technically demanding and there is a significant risk of vertebral artery (VA) injury, transarticular screw insertion in the middle and lower cervical spine is simple and can be performed safely with the aid of lateral fluoroscopic guidance. The authors describe the surgical techniques and outcome of transarticular screw fixation in the middle and lower cervical spine. Transarticular screw insertion into C2–3 or caudal cervical joints was performed from the articular pillar, directing the screw anterocaudally to penetrate the facet joint and the anterior cortex of the articular pillar, parallel to the sagittal plane. Because the VA and the nerve roots are anterior to the articular pillar at these levels, the screw can be placed safely with the assistance of lateral fluoroscopic guidance. Twenty-five patients ranging in age from 15 to 84 years underwent transarticular screw fixation, with a total of 81 screws. The transarticular screw was used as an anchor screw in combination with posterior cervical instrumentation in 19 patients and for facet screw fixation itself in six patients. Screw placement was successful and uncomplicated in all cases. The follow-up period ranged from 3 months to 5 years. No instance of screw backout or loosening was identified radiographically; fusion was achieved in all patients. Biomechanical strength is maintained by penetrating four cortical layers. When performed appropriately, this method is safe and reliable and deserves more widespread use.