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BACKGROUND Incidental durotomy (ID) is a common complication during lumbar spine surgery. A paucity of literature has studied the impact of minimally invasive surgery (MIS) on durotomy rates and strategies for repair as compared to open surgery. OBJECTIVE To examine the impact that MIS techniques have on the durotomy rate, repair techniques, and need for surgical revision following surgery for degenerative lumbar disease as compared to open technique. METHODS A single-center retrospective review of consecutive cases between 2013 and 2016 was performed. All patients underwent lumbar decompression with or without instrumented fusion for degenerative pathology using either open posterior or MIS techniques. ID rate, closure technique, and need for surgical revision related to the durotomy were recorded. RESULTS A total of 1,196 patients were included with an overall ID rate of 6.8%. There was no difference between open or minimally invasive surgical techniques (P = .14). There was a higher durotomy rate with open technique in patients that underwent decompression with fusion (P = .03) as well as in revision cases (P = .02). Primary repair was feasible more frequently in the open group (P = .001), whereas use of dural substitute (P < .001) was more common in the MIS group. Fibrin sealant was used routinely in both groups (P = .34). There were no failed repairs, regardless of technique used. CONCLUSION MIS techniques may reduce durotomies in cases involving instrumentation or revisions. Use of dural substitute onlay and fibrin sealant was effective at preventing reoperation. Both MIS and open techniques result in a low rate of future surgical revision when a durotomy occurs.

STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery. SUMMARY OF BACKGROUND DATA Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial. METHODS We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded. RESULTS Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00). CONCLUSION Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.

It is unclear if minimally invasive techniques reduce the rate of perioperative complications when compared to traditional open approaches to the lumbar spine. Our aim was to evaluate perioperative complications in patients that underwent MIS and conventional open techniques for degenerative lumbar pathology. A retrospective review of a prospectively collected database identified 1435 patients that underwent surgery for degenerative lumbar pathology from January 2013–2016. We evaluated the rates of deep vein thrombosis, pulmonary embolism, urinary tract infection, and pneumonia. Groups were analyzed based on decompression alone as compared with decompression and fusion for both MIS and traditional open techniques. Patients that underwent traditional open lumbar decompression surgery were more likely to develop a DVT (P = .01) than those undergoing MIS decompression. There was no significant difference in rates of PE (P = .99), UTI (P = .24), or pneumonia (P = .56). Patients that underwent traditional open lumbar fusion surgery compared to MIS fusion were also more likely to have a PE (P = .03). There was no significant difference in rates of DVT (P = .22), UTI (P = .43), or pneumonia (P = .24). Minimally invasive spinal surgery was found to reduce the rate of DVT for decompression surgeries and reduce the rate of PE for fusion surgeries.

Background Spine surgery has been transformed by the growth of minimally invasive surgery (MIS) procedures. Previous studies agree that MIS has shorter hospitalization and faster recovery time when compared to conventional open surgery. However, the reoperation and readmission rates between the 2 techniques have yet to be well characterized. Objective To evaluate the rate of subsequent revision between MIS and open techniques for degenerative lumbar pathology. Methods A total of 1435 adult patients who underwent lumbar spine surgery between 2013 and 2016 were included in this retrospective analysis. The rates of need for subsequent reoperation, 30- and 90-d readmission, and discharge to rehabilitation were recorded for both MIS and traditional open techniques. Groups were divided into decompression alone and decompression with fusion. Results The rates of subsequent reoperation following MIS and open surgery were 10.4% and 12.2%, respectively (P = .32), which were maintained when subdivided into decompression and decompression with fusion. MIS and open 30-d readmission rates were 7.9% and 7.2% (P = .67), while 90-d readmission rates were 4.3% and 3.6% (P = .57), respectively. Discharge to rehabilitation was significantly lower for patients under 60 yr of age undergoing MIS (1.64% vs 5.63%, P = .04). Conclusion The use of minimally invasive techniques for the treatment of lumbar spine pathology does not result in increased reoperation or 30- and 90-d readmission rates when compared to open approaches. Patients under the age of 60 yr undergoing MIS procedures were less likely to be discharged to rehab.

Background As chordomas are slow growing and locally invasive with high recurrence rates, initial recommendations include complete surgical resection with or without radiation therapy. A large proportion of recurrences occur years after initial resection necessitating lengthy follow-up. The novel biomarker brachyury and the repurposing of pharmaceutical products have the potential to substantially impact long-term recurrence rates. Case presentation A 43-year-old woman presented with an isolated, cervical extraosseous intradural extramedullary chordoma attached to a nerve root underwent a C3-5 laminectomy, C3-5 lateral mass screw instrumentation, and mass resection. All symptoms resolved by the 12-month postoperative follow-up visit. Conclusions This is the first report of an isolated, cervical extraosseous intradural extramedullary chordoma attached to a nerve root, and this case adds to the previous six Type IV chordomas in the literature. Unfortunately, the very rare form of extraosseous intradural chordoma is poorly understood: the lack of detailed knowledge in how they are differentiated from other forms of chordoma confounds the development of optimal treatment strategies and follow-up guidelines.

Background and purpose The atlantal tubercle is the attachment point of the transverse atlantal ligament, the main stabilizer of the atlantoaxial complex. No system of classification of the tubercle exists in the literature. We aimed to develop a morphologically based classification system of the atlantal tubercle to aid clinicians who deal with craniocervical pathology. Materials and methods A retrospective review of computed tomography (CT) scans of the cervical spine was performed. The morphology of the atlantal tubercle was classified into four variants: rounded (classical), pointed, flattened, and hypoplastic. Age, presence, and morphological type were recorded. Results A total of 200 CT scans were identified and reviewed. The tubercle was present bilaterally in all patients. Patients were equally distributed over various age ranges. The following morphological types were recorded: rounded (227/400; 56.8%), pointed (13/400; 3.3%), flattened (126; 31.5%), and hypoplastic (34/400; 8.5%). The same type was seen bilaterally in 68% (135/200) of patients. Morphological types appear equally on the right and left side of the atlas. Conclusions The first morphologically based classification system of the atlantal tubercle utilizing CT is presented. Morphology type, especially hypoplastic type, may confer an increased risk for subsequent need for posterior fusion.

Background Complications associated with the lateral lumbar transpsoas approach largely comprise various nerve-related syndromes particularly at L4-5. Quadriceps weakness can occur from stretch injury to the femoral nerve during retraction. Objective The purpose of this study is to evaluate the role of retraction time in the development of postoperative neuropathic motor weakness at the L4-5 level. Methods A retrospective review of a prospectively collected database at a single institution was reviewed over a two-year period (March 2014–2016) for a single surgeon. Twenty-six patients undergoing single level LLIF at L4-5 were identified. Pre- and postoperative data collection obtained included motor function grading (0–5/5) with a minimum of 3-month postoperative follow-up. Intraoperative data collection included retraction time (RT) defined as the time the retraction system was affixed to the spine and expanded to the time of closure and removal. Two-Tailed T-Test was used to determine clinical significance. Results 50% of patients had leg weakness after surgery (13/26). All postoperative motor deficits were at least antigravity strength (>3/5) and all deficits resolved. The mean RT for the motor dysfunction cohort was 29 min (14–51) compared to 27.5 min for the cohort without postoperative weakness (19–37) (p = 0.685). Conclusion The results of this study suggest that longer retraction time (within a range of 14–51 min) did not correlate with a greater risk of postoperative neuropathic quadriceps muscle dysfunction for lateral lumbar interbody fusions performed at L4-5. Other factors may contribute to postoperative neurologic dysfunction regardless of RT. Motor deficits resolved quickly after surgery.

OBJECTIVE The effect of obesity on outcomes in minimally invasive surgery (MIS) approaches to posterior lumbar surgery is not well characterized. The authors aimed to determine if there was a difference in operative variables and complication rates in obese patients who underwent MIS versus open approaches in posterior spinal surgery, as well as between obese and nonobese patients undergoing MIS approaches. METHODS A retrospective review of all consecutive patients who underwent posterior lumbar surgery from 2013 to 2016 at a single institution was performed. The primary outcome measure was postoperative complications. Secondary outcome measures included estimated blood loss (EBL), operative time, the need for revision, and hospital length of stay (LOS); readmission and disposition were also reviewed. Obese patients who underwent MIS were compared with those who underwent an open approach. Additionally, obese patients who underwent an MIS approach were compared with nonobese patients. Bivariate and multivariate analyses were carried out between the groups. RESULTS In total, 423 obese patients (57.0% decompression and 43.0% fusion) underwent posterior lumbar MIS. When compared with 229 obese patients (56.8% decompression and 43.2% fusion) who underwent an open approach, patients in both the obese and nonobese groups who underwent MIS experienced significantly decreased EBL, LOS, operative time, and surgical site infections (SSIs). Of the nonobese patients, 538 (58.4% decompression and 41.6% fusion) underwent MIS procedures. When compared with nonobese patients, obese patients who underwent MIS procedures had significantly increased LOS, EBL, operative time, revision rates, complications, and readmissions in the decompression group. In the fusion group, only LOS and disposition were significantly different. CONCLUSIONS Obese patients have poorer outcomes after posterior lumbar MIS when compared with nonobese patients. The use of an MIS technique can be of benefit, as it decreased EBL, operative time, LOS, and SSIs for posterior decompression with or without instrumented fusion in obese patients.

Background Surgical site infection (SSI) in spinal surgery contributes to significant morbidity and healthcare resource utilization. Few studies have directly compared the rate of minimally invasive surgery (MIS) SSI with open surgery. Objective To investigate whether MIS techniques had a lower SSI rate in degenerative lumbar procedures as compared with traditional open techniques. Methods A single-center, retrospective review of a prospectively collected database was queried from January 2013 to 2016 for adult patients who underwent lumbar decompression and/or instrumented fusion for which the surgical indication involved degenerative disease. The SSI rate was determined for all procedures as well as in the open and minimally invasive groups. Risk factors associated with SSI were also reviewed for each patient. Results A total of 1442 lumbar spinal procedures were performed during this time period. Of these, there were 961 MIS and 481 open (67% vs 33%, respectively). The overall SSI rate was 1.5% (21/1442). The surgical site infection rate for MIS was less than open techniques (0.5% vs 3.3%; P = .0003). For decompression only, the infection rate for MIS and open was 0.4% vs 3.9% (P = .04), and for decompression with fusion it was 0.7% vs 2.6%, respectively (P = .68). Conclusion Our study demonstrates a significant 7-fold reduction in SSIs when comparing MIS with open surgery. This significance was also demonstrated with a 10-fold reduction for procedures involving decompression alone. Procedures that require fusion as well as decompression showed a trend towards a decreased infection rate that did not reach clinical significance.

There is a paucity of information regarding outcomes in minimally invasive surgical (MIS) approaches to posterior lumbar surgery in morbidly obese patients. We seek to determine if there are differences in operative variables and early complication rates in morbidly obese patients undergoing MIS posterior lumbar surgery compared to obese and non-obese patients.A single institution retrospective review of patients undergoing MIS posterior lumbar surgery (decompression and/or fusion) between 2013 and 2016 was performed. Morbidly obese patients (BMI ≥ 40) were compared to obese (BMI 30-39.9) and non-obese (BMI 30) cohorts. Postoperative complication rates and perioperative variables including estimated blood loss, operative time, and outcome measures including length of stay (LOS), in-hospital complications, readmission, and disposition were assessed.47 morbidly obese, 135 obese and 224 non-obese patients underwent posterior MIS instrumented fusion. 59 morbidly obese, 182 obese and 314 non-obese patients underwent posterior MIS decompression. The morbidly obese group experienced a greater rate of deep vein thrombosis and had an increased hospital LOS (p 0.05). Morbidly obese patients who underwent MIS decompression experienced increased postoperative complications (p 0.01), and increased LOS (p 0.0001) compared to obese and non-obese patients. There were no differences in revision rates, readmissions, and other complications including surgical site infection. Morbid obesity was an independent predictor of overall complications and increased LOS on multivariate analysis.Morbidly obese patients undergoing posterior MIS fusion had a higher rate of complications and increased LOS. While weight loss should be encouraged, complication rates remains acceptably low in morbidly obese patients and MIS posterior lumbar surgery should still be offered.

A retrospective analysis of two consecutive patients who underwent a novel surgical technique. A report of a novel surgical technique utilizing an electronic conductivity device guidance to aide placement of S2-Alar-Iliac (S2-AI) instrumentation. Electronic conductivity guidance for instrumentation of the thoracolumbar spine is an accepted means of improving intraoperative accuracy. Although commercially available for percutaneous techniques, there is a paucity of literature regarding its use. Percutaneous implantation of S2-AI screws has been previously described as another technique surgeons can avail, primarily employing fluoroscopy as a means of intraoperative feedback. We describe a novel technique that utilizes electronic conductivity as an added feedback measure to increase accuracy of percutaneous S2-AI fixation. Two patients were treated by the senior author (FAS) who underwent surgery employing S2-AI fixation utilizing an electronic conductivity device (Pediguard cannulated probe, Spineguard, Paris, France). The surgical technique, case illustrations, and radiographic outcomes are discussed. Stable and accurate fixation was attained in both patients. There were no peri-operative complications related to hardware placement. To the authors’ knowledge, this is the first reported literature combining S2-AI screws with electronic conductivity for immediate intraoperative feedback. This technique has the opportunity to provide surgeons with increased accuracy for placement of S2-AI screws while improving overall radiation safety. This feedback can be particularly helpful when surgeons are learning new techniques such as placement of S2AI screws.

Lumbar disc disease is a common pathology seen by spine surgeons. Far lateral disc herniations represent a rare cause of lumbar disc compression syndromes. Patients often present with a severe pain, numbness, and sometimes weakness. Various conservative treatment modalities are available. As compared with traditional open techniques, minimally invasive approaches can better treat the pathology while minimizing collateral damage. This chapter reviews the presentation of far lateral disc herniations and emphasizes the surgical nuances to the minimally invasive approach.

Spinal schwannomas most likely occur at the thoracic level and within the intradural extramedullary compartment. They are benign, typically slow-growing, peripheral nerve sheath tumors that produce symptoms by displacing or compressing the nerve roots and spinal cord. There is an association with patients that have neurofibromatosis type 2. Surgical pearls including the utilization of intraoperative ultrasound for localization, D wave monitoring, and microsurgical dissection are demonstrated. Pertinent high-yield radiographic and histological features of schwannomas are reviewed.1-4 We report the case of a 59-yr-old female who presented with progressively worsening gait instability that was associated with lower extremity numbness progressing to weakness. She had myelopathic findings on examination, which included brisk patellar reflexes and persistent clonus with sensory changes to the umbilicus and mild leg weakness. Full body examination revealed no stigmata of neurofibromatosis. Magnetic resonance imaging of the neuroaxis demonstrated a large, intradural extramedullary mass with peripheral enhancement that spanned the T9 to T11 vertebral levels with severe compression of the spinal cord. There were no intracranial, cervical, or lumbar findings. Surgical intervention was planned with the following objectives: decompression of the neural elements, curative resection, and diagnosis. Patient consent for the procedure was obtained. Institutional Review Board approval for solitary case reports are not needed at our institution.

Lumbar spondylolisthesis presents a formidable challenge to the complex biomechanical properties inherent to this region of the spine. Anatomical malalignment of the lumbar spine in the sagittal plane secondary to spondylolisthesis alters both the kinematic and load distribution patterns in the three predominant loading classifications, resulting in a pathomechanical response of the lumbopelvic spine and global sagittal balance. From a biomechanical standpoint, the mechanisms of injury and grade of spondylolisthesis affect the three longitudinal columns of spinal stability, degenerative processes of the three-joint-complex, and efficiency of the lumbosacral spine to optimally transmit load and motions in the axial skeleton.

Synovial cysts of the lumbar spine result from degeneration of the facet capsule, and their prevalence may be as high as 10% in symptomatic patients. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption, minimizes soft-tissue trauma, and limits disruption of the ligamentous and bony structures. Additionally, by approaching contralateral, the cyst/dura interface is better visualized especially at the depths of the lateral recess. Seeing the full extent of this interface from an ipsilateral approach is very difficult without decompressing the cyst, which, in turn, makes dissecting and separating the remaining cyst wall more difficult and increases the risk of durotomies.1,2 We report the case of a 53-yr-old female who presented with persistent left leg pain in an L5 distribution that was associated with some mild lower back pain. She was refractory to conservative management that included physical therapy along with a series of epidural steroid injections. She was noted to have some weakness with dorsiflexion on the left side and as absent a straight leg raise. Given the predominance of her leg over her back symptoms along with the patient's age, a minimally invasive contralateral approach for resection of the synovial cyst was offered as opposed to more traditional decompression and fusion. Institutional Review Board approval and patient consent for solitary case reports are not needed at our institution.

The critical care management of patients with traumatic brain injury (TBI) has undergone major advancements over the last several decades. Improved evidence-based research has allowed us a greater understanding of the pathophysiology and parameters that impact outcomes. Despite this, much uncertainty still remains, and further studies should be performed to identify ways to optimize parameters to achieve the best outcomes for TBI patients.

Injury to the thoracic duct during anterior cervical spine surgery is a rare occurrence. A delayed chyle leak following an elective anterior cervical spinal surgery has not been reported in the literature. We present a report of a 59-year-old female with multiple prior neck surgeries who underwent an anterior cervical corpectomy and fusion (ACCF). The patient developed a delayed thoracic duct injury on postoperative day (POD) one, as no injury was noted intraoperatively. She was managed with conservative care involving a low-fat diet along with octreotide which led to the resolution of her symptoms. We present this case report because of its unique presentation and to assist spine surgeons with initial management. Surgeons should have increased awareness when performing anterior cervical approaches to the lower cervical and upper thoracic levels from the left side.

Sinusitis and otitis are common within the pediatric population. If left untreated, these can extend intracranially and lead to the development of infections in the various intracranial compartments resulting in a high rate of morbidity and mortality. We report the first case of an intrafalcine empyema, absent subdural purulence, in a patient with the likely spread from a sinogenic origin. This case illustrates the novelty of this as a pathological entity as well as the surgical considerations for intrafalcine purulence in the absence of expected subdural collections.

Objective This video was aimed to demonstrate the middle fossa approach for the resection of an intracanalicular vestibular schwannoma. Design Present study is a video case report. Setting The operative video is showing a microsurgical resection. Participant The patient was a 59-year-old man who presented with worsening headache and right-side hearing loss. He was found to have a right intracanalicular vestibular schwannoma. After weighing risks and benefits, he chose surgery to remove his tumor. Since his hearing remained “serviceable,” a middle fossa approach was chosen. Main Outcome Measures Pre- and postoperative patient photographs evaluated the muscles of facial expression as a marker for facial nerve preservation. Results A right middle fossa craniotomy was performed which allowed access to the floor of the middle cranial fossa. The greater superficial petrosal nerve (GSPN) and arcuate eminence were identified. Using these two landmarks, the internal acoustic canal (IAC) was localized. After drilling the petrous bone, the IAC was unroofed. The facial nerve was identified by stimulation and visual inspection and the tumor was separated from it with microsurgical dissection. In the end, the tumor was fully resected. Both the facial and cochlear nerves were preserved. Postoperatively, the patient experienced no facial palsy and his hearing is at baseline. Conclusion With radiosurgery gaining increasing popularity, patients with intracanalicular vestibular schwannomas are frequently treated with it, or are managed with observation. The middle fossa approach is therefore becoming a “lost art,” but as demonstrated in this video, remains an effective technique for tumor removal and nerve preservation.The link to the video can be found at: https://youtu.be/MD6o3DF6jYg.

Introduction: Suboccipital craniotomy is a workhorse neurosurgical operation for approaching the posterior fossa but carries a high risk of pseudomeningocele and cerebrospinal fluid (CSF) leak. We describe our experience with a simple T-shaped fascial opening that preserves the occipital myofascial cuff as compared to traditional methods to reduce this risk. Methods: A single institution, retrospective review of prospectively collected database was performed of patients that underwent a suboccipital craniectomy or craniotomy. Patient data was reviewed for craniotomy or craniectomy, dural graft, and/or sealant use as well as CSF complications. A pseudomeningocele was defined as a subcutaneous collection of cerebrospinal fluid palpable clinically and confirmed on imaging. A CSF leak was defined as a CSF-cutaneous fistula manifested by CSF leaking through the wound. All patients underwent regular postoperative visits of two weeks, one month, and three months. Results: Our retrospective review identified 33 patients matching the inclusion criteria. Overall, our cohort had a 21% (7/33) rate of clinical and radiographic pseudomeningocele formation with 9% (3/33) requiring surgical revision or a separate procedure. The rate of clinical and radiographic pseudomeningocele formation in the myofascial cuff preservation technique was less than standard techniques (12% and 31%, respectively). Revision or further surgical procedures were also reduced in the myofascial cuff preservation technique vs. the standard technique (6% vs 13%). Conclusions: Preservation of the myofascial cuff during posterior fossa surgery is a simple and adoptable technique that reduces the rate of pseudomeningocele formation and CSF leak as compared with standard techniques.

Preoperative embolization of meningiomas can be safely performed using a variety of embolic agents. Most commonly, the vascular supply from branches of the external carotid artery is the target of embolization. In our report, we detail the treatment of a patient with a parafalcine meningioma that received its supply via branches of the anterior cerebral artery. One of the feeder vessels appeared to contain a dysplastic aneurysmal dilatation of the vessel. Due to patient circumstances, embolization was performed using standard microcatheterization techniques to minimize intraoperative blood loss. We report a rare instance of endovascular treatment of a pial vessel to treat an intracranial meningioma using Onyx.