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Menopause leads to fluctuations in androgenic hormones which directly affect bone metabolism. Bone resorption, mineralization, and remodeling at fusion sites are essential in order to obtain a solid and biomechanically stable fusion mass. Bone metabolic imbalance seen in the postmenopausal state may predispose to fusion related complications. The aim of this study was to investigate fusion outcomes in lumbar spinal fusion surgery in women based on menopausal status. A retrospective analysis of all female patients who underwent posterior lumbar decompression and fusion at a single institution from 2013 to 2017 was performed. A total of 112 patients were identified and stratified into premenopausal (n = 25) and postmenopausal (n = 87) groups. Clinical and radiographic data was assessed at 1 year follow up. Postmenopausal patients had a higher rates of pseudarthrosis (11.63% vs 0%, p = 0.08), PJK (15.1% vs 4%, p = 0.14), and revision surgery (3.5% vs 0%, p = 0.35). The number of levels fused was associated with increased risk of pseudarthrosis (OR 1.4, p = 0.02); however, there was no association between age, hormonal use, prior tobacco use, or T-score. Age was associated with increased risk of developing PJK (OR = 1.11, p = 0.01); however, PJK was not associated with menopause, hormonal use, prior tobacco use, or T-score. Revision surgery was not associated with age, hormonal use, prior tobacco use, or T-score. This study suggests that postmenopausal women may be prone to have higher rates of pseudarthrosis, PJK and revision surgery, although our results were not statistically significant. Larger studies with longer follow up will help elucidate the true effects of menopause in spine surgery., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Surgical site infection (SSI) remains a complication of spine deformity surgery. Although fusion/instrumentation failure in the setting of SSI has been reported, few studies have investigated the relationship between these entities. We examine the relationship between early SSI and fusion/instrumentation failure after instrumented fusion in patients with thoracolumbar scoliosis., Methods: A retrospective review of a prospectively maintained case series for patients undergoing spine surgery between January 1, 2006, and October 3, 2017. Inclusion criteria included age ≥18 years and surgery performed for correction of thoracolumbar scoliosis. Data collected included various demographic, clinical, and operative variables., Results: 532 patients met inclusion criteria, with 20 (4%) experiencing SSI. Diabetes mellitus was the only demographic risk factor for increased SSI (P = 0.026). Number of fused levels, blood volume loss, and operative time were similar between groups. Fusion/instrumentation failure occurred in 68 (13%) patients, 10 of whom (15%) had SSI, whereas of the 464 patients with no fusion/instrumentation failure, only 10 (2%) had SSI (P < 0.001). Of the 20 patients with SSI, 10 (50%) had fusion/instrumentation failure, whereas in the 512 patients with no infection, only 58 (11%) had fusion/instrumentation failure (P < 0.001). Patients with infection also experienced significantly shorter time to fusion/instrumentation failure (P = 0.025), higher need for revision surgery (P < 0.001), and shorter time to revision surgery (P = 0.012)., Conclusions: Early SSI significantly increases the risk of fusion/instrumentation failure in patients with thoracolumbar scoliotic deformity, and it significantly shortens the time to failure. Patients with early SSI have a significantly higher likelihood of requiring revision surgery and after a significantly shorter time interval., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Posterior cervical decompression and fusion (PCDF) can result in substantial blood loss, leading to blood transfusions and associated complications, such as infections, hypotension and organ damage. The antifibrinolytic tranexamic acid (TXA), an inhibitor of the activation of plasminogen, has been shown to be beneficial in multiple surgical procedures without any apparent increase in postoperative complications. However, there are only few studies reporting TXA utilization in cervical spine surgery and there is currently no literature detailing the short-term safety of its use in this setting. The purpose of our study is to determine the safety profile of TXA in posterior cervical decompression and fusion. From January 2015 to April 2018, 47 patients were identified to have undergone PCDF, 19 with the utilization of a TXA protocol at our institution. The incidence of adverse events was evaluated in the perioperative period and at 1 month follow-up. Of 39 patients, Nineteen (49%) received TXA as per our instructional protocol and 20 (51%) did not. Post-operative blood was significantly reduced (453 ml vs 701 ml; p = 0.03) in the group that received TXA. There was also a significant reduction in duration of surgery associated with TXA use (269 min vs 328 min; p = 0.05). There were no complications on the first 30 days after surgical intervention on the TXA group. TXA use during PCDF is a safe, effective method to reduce postoperative blood loss. Considering the limited number of patients in this study, these results should be validated on a larger group of patients., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Surgical treatment of high-grade spondylolisthesis and spondyloptosis is recommended in symptomatic patients, yet there exists much debate regarding the optimal surgical approach and the need for reduction. Similar to the Bohlman technique in that fixation is achieved across two vertebral endplates, we discuss a novel technique with the advantage of using bilateral threaded pedicle screws of large diameter and length instead of a single fibula allograft. Patients underwent posterior instrumented fusion without spondylolisthesis reduction using a novel technique placing pedicle screws with a transvertebral trajectory through the two end plates involved in the spondylolisthesis. Following screw placement, patients underwent decompression ± discectomy. Screws were connected to adjacent pedicle screws either in the upper adjacent vertebrae (i.e. L5) or the more rostral adjacent vertebrae (i.e. L4) if spinal alignment or instability necessitate including additional levels of fixation. Three patients were reviewed with ages of 67, 62, 58 years, operative times of 377-790 min, estimated blood loss 400-1050 cc, and follow-up times of 478-1082 days. There were no CSF leaks, intragenic neurologic deficits post-operatively, implant failures, revisions, or other systemic events. Two patients achieve radiographic fusion assessed by CT. At the time of final follow up, all patients were satisfied and essentially pain free. This one-stage technique offers the ability to manage local malalignment with a technique that inherently minimizes risk. The minimal complications and favorable outcomes make this technique an effective, efficient and safe procedure. Additional studies will focus on long term outcomes and should include larger patient samples., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background Context: Prior reports have compared posterior column osteotomies with pedicle subtraction osteotomies in terms of utility for correcting fixed sagittal imbalance in adolescent patients with deformity. No prior reports have described the use of multilevel Smith-Petersen Osteotomies (SPOs) alone for surgical correction in the adult spinal deformity (ASD) population., Purpose: The study aimed to determine the utility of multilevel SPOs in the management of global sagittal imbalance in ASD patients., Study Design/setting: This is a retrospective observational study at a single academic center., Patient Sample: The sample included 85 ASD patients., Outcome Measures: This is a radiographic outcomes cohort study., Methods: The radiographs of 85 ASD patients were retrospectively evaluated before and after long-segment (>5 spinal levels) fusion and multilevel SPO (≥3 levels) for sagittal imbalance correction. The number of osteotomies, correction in regional lumbar lordosis (LL), and correction per osteotomy was evaluated. Independent predictors of correction per SPO were evaluated with a hierarchical linear regression analysis., Results: Eighty-five patients (mean age: 67.5±11 years) were identified with ASD (372 SPOs). The mean preoperative sagittal vertical axis (SVA) and T1 pelvic angle (TPA) were 8.16±6.75 cm and 25°±13.23°, respectively. The mean postoperative central sacral vertical line (CSVL) and SVA were 0.67±0.70 cm and 1.29±5.41 cm, respectively. The mean improvement in SVA was 6.29 cm achieved with a correction of approximately 5.05° per SPO. The mean LL restoration was 20.3°±13.9°, and 33(39%) patients achieved a final pelvic incidence minus lumbar lordosis (PI-LL) ≤10°. Fifty-four (64%) achieved a postoperative PI-LL ≤15°, 75 (88%) with a PI-LL ≤20°, and 85 (100%) achieved a PI-LL ≤25°. Correction per SPO was similar regardless of prior fusion (4.87° vs. 5.72° for revisions, p=.192). In a subgroup analysis of SVA greater than 10 cm, there was no significant difference in the final LL, thoracic kyphosis, PI-LL, SVA, CSVL, and TPA, as compared with SVA <10 cm. The LL was the only independent predictor of osteotomy correction per level (LL: β coefficient=-0.108, confidence interval: -0.141 to 0.071, p<.0001)., Conclusions: Multilevel SPOs are feasible for restoration of LL as well as sagittal and coronal alignment in the ASD population with or without prior instrumented fusion., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background Context: Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common problems after long-segment (>5 levels) thoracolumbar instrumented fusions in the treatment of adult spinal deformity (ASD). No specific surgical strategy has definitively been shown to lower the risk of PJK as the result of a multifactorial etiology., Purpose: The study aimed to assess the incidence of PJK and PJF in patients treated with prophylactic polymethylmethacrylate (PMMA) cement augmentation at the uppermost instrumented vertebrae (UIV) and rostral adjacent vertebrae (UIV+1)., Study Design/setting: This is a retrospective cohort-matched surgical case series at an academic institutional setting., Patient Sample: Eighty-five adult patients over a 16-year enrollment period were identified with long-segment (>5 levels) posterior thoracolumbar instrumented fusions for ASD., Outcome Measures: Primary outcomes measures were PJK magnitude and PJF formation. Secondary outcomes measures were spinopelvic parameters, as well as global and regional sagittal alignment., Methods: The impact of adjunctive PMMA use in long-segment (≥5 levels) fusion for ASD was assessed in adult patients aged 18 and older. Patients were included with at least one of the following: lumbar scoliosis >20°, pelvic tilt >25°, sagittal vertical axis >5 cm, central sacral vertical line >2 cm, and thoracic kyphosis >60°. The frequency of PJF and the magnitude of PJK were measured radiographically preoperatively, postoperatively, and at maximum follow-up in controls (Group A) and PMMA at the UIV and UIV+1 (Group B)., Results: Eighty-five patients (64±11.1 years) with ASD were identified: 47 control patients (58±10.6) and 38 patients (71±6.8) treated with PMMA at the UIV and UIV+1. The mean follow-up was 27.9 and 24.2 months in Groups A and B, respectively (p=.10). Preoperative radiographic parameters were not significantly different, except the pelvic tilt which was greater in Group A (26.6° vs. 31.4°, p=.03). Postoperatively, the lumbopelvic mismatch was greater in Group B (14.6° vs. 7.9°, p=.037), whereas the magnitude of PJK was greater in controls (9.36° vs. 5.65°, p=.023). The incidence of PJK was 36% (n=17) and 23.7% (n=9) in Groups A and B, respectively (p=.020). The odds ratio of PJK with vertebroplasty was 0.548 (95% confidence interval=0.211 to 1.424). Proximal junctional kyphosis was observed in 6 (12.8%) controls only (p=.031). The UIV+1 angle, a measure of PJK, was significantly greater in controls (10.0° vs. 6.8°, p=.02). No difference in blood loss was observed. No complications were attributed to PMMA use., Conclusions: The use of prophylactic vertebral cement augmentation at the UIV and rostral adjacent vertebral segment at the time of deformity correction appears to be preventative in the development of proximal junctional kyphosis and failure., (Copyright © 2017. Published by Elsevier Inc.)

The purpose of this study is to evaluate whether the vacuum phenomenon (VP) resolves after posterolateral lumbar fusion, and whether persistence of VP is indicative of failed fusion. We retrospectively reviewed patients with degenerative lumbar spinal stenosis with instability with a positive VP on preoperative computed tomography (CT) who underwent posterolateral lumbar spinal fusion. Lumbar CT and radiographs were evaluated for the presence of VP and fusion at each level. Thirty-six positive VP levels were identified on the preoperative lumbar CT at the levels in the fusion in 18 patients. The mean age at surgery was 67.6 ± 9.4 years and mean follow-up was 1.6 ± 0.86 years. Fusion was seen at 32 levels (88.9%). Of the 15 levels where VP persisted, evidence of fusion was seen in 13 levels and pseudarthrosis was seen at 2. Of the 21 levels where VP disappeared, fusion was seen at 19 levels and pseudarthrosis was seen at 2 .There was no significant difference between the 2 groups (P > .05). We did not find an association between persistence of VP and pseudarthrosis. Persistence of VP after spinal fusion may not be an indicator of pseudarthrosis, and should not be misinterpreted as an indication for additional surgery.

Background: Perioperative blood loss is a frequent concern in spine surgery and often necessitates the use of allogeneic transfusion. Minimally invasive technique (MIS) is an option that minimizes surgical trauma and therefore intra-operative bleeding. The purpose of this study is to evaluate the blood loss, surgical complications, and duration of inpatient hospitalization in patients undergoing open posterolateral lumbar fusion (PLF), open posterior lumbar interbody fusion (PLIF) with PLF, or MIS transforaminal lumbar interbody fusion (MIS TLIF)., Methods: Operative reports and perioperative data of patients undergoing single-level, primary open PLF (n=41), open PLIF/PLF (n=42), and MIS TLIF (n=71) were retrospectively evaluated. Patient demographics, operative blood loss, use of transfusion products, complications, and length of stay were tabulated. Patient data was controlled for age, BMI, and gender for statistical analysis., Results: Patients undergoing open PLF and open PLIF/PLF respectively experienced a significantly higher blood loss (p<0.001), higher volume of blood transfusion (p<0.001), higher volume of cell saver transfusion (p<0.001), and more surgical complications (dural injury, wound infections, screw malposition) (p=0.02) than those undergoing MIS TLIF. There was no statistically significant difference in duration of hospital stay (p=0.11)., Conclusions: MIS TLIF provides interbody fusion with less intraoperative blood loss and subsequently a lower transfusion rate compared to open techniques, but this did not influence length of hospital stay. MIS TLIF is at least as safe as open techniques with respect to dural tear, wound infection, and screw placement., Level of Evidence: Level III, Therapeutic.

Object: The goal of this study was to compare the rates of solid arthrodesis and complications following multilevel, instrumented anterior cervical fusion in patients treated with and without bone morphogenetic protein (BMP)., Methods: The authors conducted a retrospective cohort study of patients who underwent multilevel (2+ level) anterior cervical fusions performed for degenerative disc disease with or without the concurrent use of BMP-2 from 1997 to 2012. The dosage throughout the study ranged from 2.1 to 0.26 mg/level (mean 1.0 mg/level). All patients were evaluated postoperatively by means of radiographs and CT scans to determine fusion status., Results: The overall fusion rate for the patients treated without BMP (n = 23) was 82.6% compared with a 100% fusion rate in the group treated with BMP (n = 22) (p = 0.04). The pseudarthrosis rates increased with number of fusion levels in patients who did not receive BMP, whereas all patients in the group treated with BMP had solid arthrodesis. Furthermore, there were 2 instrumentation failures in the non-BMP group. There was a direct correlation between the incidence of complications and the dosage of BMP used per level, with no complications reported at doses equal to or less than 1.1 mg/level., Conclusions: The overall rate of bony arthrodesis was increased following the use of BMP in multilevel anterior cervical fusion. Traditional methods without BMP had a high rate of pseudarthrosis. The complications associated with the use of BMP appeared to be dose related and of low incidence when BMP is used in doses equal to or less than 1.1 mg/level.

Background Context: Several relatively new screw techniques have been described that rigidly capture the posterior elements of C2. The previously described procedures of axis fixation are technically demanding and place the vertebral artery at some risk. A novel and less technically demanding technique of obtaining C-2 translaminar screws has been recently described. Although the risk of vertebral artery injury has been essentially eliminated, the authors recognize that neurologic injury from breakthrough of the inner cortex of the lamina by the drill or screw is still a possibility., Purpose: Describe and illustrate a modified C2 translaminar technique and review the results of patients who have undergone the surgery. The current modification of the C2 translaminar screw technique was designed to reduce the risk of inadvertent screw placement within the spinal canal., Study Design/setting: A techniques paper combined with a retrospective clinical review of patients undergoing the surgery., Patient Sample: Patients undergoing posterior instrumented fusion surgery of the cervical spine, which incorporates C2 posterior elements using the translaminar technique., Outcome Measures: Radiographic analysis of the fusion construct incorporating the C2 translaminar screws., Methods: We have modified the previously described technique of C-2 translaminar screw placement with the addition of "exit" cortical windows to assure bicortical, intralaminar screw placement., Results: The results of the first six patients with an average follow-up of 12 months demonstrated this method to be safe and effective in fixating the axis., Conclusions: We have made a simple modification of Wright's elegant technique with the addition of "exit" windows at the facet-laminar junctions. This gives us the assurance that the C2 screw has not entered the spinal canal by directly visualizing the tip of the screw exiting the outer cortices of the lamina before leaving the operating room.

Objective and Importance: Adjacent segment disc disease is a well-described phenomenon that occurs after anterior cervical spinal fusion. One of the advantages of cervical laminoplasty over anterior approaches is that although the treated segments are stiffened, no formal fusion is performed. This is thought to reduce the biomechanical stresses placed on adjacent levels and thus decrease the likelihood of adjacent level degeneration., Clinical Presentation: A 62-year-old man presented with myelopathy attributable to cervical spondylosis and underwent a C3-C7 laminoplasty. Improvements in gait were followed 2 years later by symptomatic disc degeneration and spinal cord compression at T1-T2, which rendered him wheelchair bound., Intervention: The patient was treated with a laminectomy at the level of stenosis accompanied by posterior instrumentation and fusion from C5 to T3. This resulted in clinical improvement, and the patient was returned to his baseline ambulatory status., Conclusion: Adjacent segment disease is an uncommon complication that occurs after laminoplasty. Careful attention to preserving facet joint motion in the cervical spine may minimize the stresses placed on adjacent motion segments.

Objective: The technique of lateral mass screw and rod or plate fixation is a major advancement in the posterior instrumentation of the cervical spine. This technique provides rigid three-dimensional fixation, restores the dorsal tension band, and provides highly effective stabilization in patients with many types of traumatic injuries., Methods: Patient 1 was a 32-year-old man who had been in a motor vehicle accident. He presented with right C5 radiculopathy. X-ray findings included 45% anterolisthesis of C4 on C5, bilateral facet disruption, and right unilateral C4-C5 facet fracture and dislocation. The patient was placed in Gardner-Wells tongs, and the fracture was reduced with 25 pounds of traction. Patient 2 was a 56-year-old woman who had been in a motor vehicle accident that resulted in complete quadriplegia. Her initial imaging studies revealed a C3-C4 right unilateral facet fracture with subluxation. She was placed in traction, and her neurological status was reassessed. The findings of her neurological examination revealed improvement: she was found to have Brown-Séquard syndrome. Patient 3 was a 33-year-old man who was involved in a diving accident that resulted in bilaterally jumped facets at C3-C4. The patient was neurologically intact, and attempts at closed reduction were not successful., Results: Patients 1 and 2 underwent anterior cervical discectomy with iliac crest autograft fusion and plating. They were then placed in the prone position, and a dilator tubular retractor system was used to access the facet joint at the level of interest. The facet joints were then denuded and packed with autograft. Lateral mass screws were then placed by means of the Magerl technique, and a rod was used to connect the top-loading screws. Patient 3 underwent posterior surgery that included only removal of the superior facet, intraoperative reduction, and bilateral lateral mass screw and rod placement., Conclusion: This technical note describes the successful placement of lateral mass screw and rod constructs with the use of a minimally invasive approach by means of a tubular dilator retractor system. This approach preserves the integrity of the muscles and ligaments that maintain the posterior tension band of the cervical spine.

Objective: Autologous iliac crest bone enhances the rate of spinal arthrodesis. However, graft site complications are common, with donor site pain being particularly troublesome. Reconstruction of the hip defect with an absorbable polylactic acid mesh to restore the bony cortical contour has been proposed to reduce hip pain., Methods: Thirty-nine consecutive patients treated by a single senior surgeon (BAG) during a 14-month period were studied. All patients had cervical spondylosis treated through an anterior approach supplemented with an autologous hip graft. Patients with preexisting hip pain were excluded. Pain was rated on a scale of 1 to 10 at 1 week and 3 months after surgery via a questionnaire. Postoperative pain medication regimens were standardized., Results: Thirty patients were available for follow-up, 15 with mesh implantation and 15 without. Hip pain in the mesh-treated group averaged 4.7 and 1.6 at 1 week and 3 months, respectively. Hip pain in the standard-treatment group averaged 6.9 and 2.5 at 1 week and 3 months, respectively. These differences were statistically significant (P = 0.004 at 1 wk and 0.055 at 3 mo). Hospital length of stay was shorter in the mesh-treated group (2.1 versus 3.2 d, respectively), but this difference was not statistically significant. Two patients without mesh treatment complained of the cosmetic defect resulting from absent bone, and three had temporary difficulty with hip eversion or flexion. Two patients in the mesh-treated group developed seromas, which were treated conservatively., Conclusion: Reconstruction of the iliac crest reduces early postoperative pain. Other potential benefits may include shorter hospitalizations and a reduced incidence of hip weakness; however, careful attention to wound closure is necessary to prevent seroma formation.