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Background Context: Concurrent degeneration of the lumbar spine, hip, and knee can cause significant disability and lower quality of life. Osteoarthritis in the lower extremities can lead to movement limitations, possibly requiring total knee arthroplasty (TKA) or total hip arthroplasty (THA). These procedures often impact spinal posture, causing alterations in spinopelvic alignment and lumbar spine degeneration. It is unclear if patients with a history of prior total joint arthroplasty (TJA) have different spinopelvic alignment compared to patients without., Purpose: To assess the relationship between a history of previous THA or TKA, as well as combined THA and TKA, and the spinopelvic alignment in patients undergoing elective lumbar surgery for degenerative conditions., Study Design: A retrospective analysis was conducted on patients who underwent lumbar surgery for degenerative conditions. The patients were stratified based on a history of TKA, THA, or both TKA and THA., Patient Sample: A total of 632 patients (63% female) with an average age of 64±11 years and an average BMI of 30±6 kg/m 2 were included., Outcome Measures: Patients were stratified based on a history of THA, TKA, or combined THA and TKA. Spinopelvic parameters (lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI)) were assessed. The relationship between spinopelvic alignment and prior TKA, THA or TKA and THA was analyzed., Methods: The data was tested for normal distribution using the Shapiro-Wilk test. We analyzed the relationship between the spinopelvic parameters and the different arthroplasty groups. Differences in scores between groups were examined using ANOVA. Tukey's Honestly Significant Difference test was used for pairwise comparison for significant ANOVA test results. Multivariable linear regression was applied, adjusted for age, sex and BMI., Results: A total of 632 patients (63% female) were included in the study. Of these patients, 74 (12%) had a history of isolated TKA, 40 (6%) had prior isolated THA, and 15 (2%) had TKA and THA prior to lumbar surgery. Patients with prior arthroplasty were predominantly female (59%) and significantly older (68±7 years vs 63±12 years, p<.001) with a significantly higher BMI (31±6 kg/m 2 vs 29±6 kg/m 2 , p<.001). The LL was significantly lower (45.0°±13 vs 50.9°±14 p=.011) in the arthroplasty group compared to the nonarthroplasty group. A history of isolated TKA was significantly associated with lower LL (Est=-3.8, 95% CI -7.3 to -0.3, p=.031) and SS (Est=-2.6, 95% CI -5.0 to -0.2, p=.012) compared to patients without TJA. Prior combined THA and TKA was found to be significantly associated with a higher PT compared to the nonarthroplasty group (Est=5.1, 95% CI 0.4-9.8, p=.034)., Conclusions: The spinopelvic alignment differs between patients with and without prior TJA who undergo elective lumbar surgery. The study shows that a history of TKA is significantly associated with a lower LL and SS. The combination of THA and TKA was associated with a significantly higher PT. These findings highlight the complex relationship between the hip, spine, and knee. Moreover, the results could aid in enhancing preoperative planning of lumbar surgery in patients with known TJA., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024. Published by Elsevier Inc.)

Background: Robotic-assisted spine surgery has been reported to improve the accuracy and safety of pedicle screw placement and to reduce blood loss, hospital length of stay, and early postoperative pain 1 . Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a procedure that is well suited to be improved by recent innovations in robotic-assisted spine surgery. Heretofore, the capability of robotic navigation and software in spine surgery has been limited to assistance with pedicle screw insertion. Surgical decompression and decortication of osseous anatomy in preparation for biological fusion had historically been outside the scope of robotic-assisted spine surgery. In 2009, early attempts to perform surgical decompressions in a porcine model utilizing the da Vinci Surgical Robot for laminotomy and laminectomy were limited by the available technology 2 . Recent advances in software and instrumentation allow registration, surgical planning, and robotic-assisted surgery on the posterior elements of the spine. A human cadaveric study assessed the accuracy of robotic-assisted bone laminectomy, revealing precision in the cutting plane 3 . Robotic-assisted facet decortication, decompression, interbody cage implantation, and pedicle screw fixation add automation and accuracy to MI-TLIF., Description: A surgical robotic system comprises an operating room table-mounted surgical arm with 6 degrees of freedom that is physically connected to the patient's osseous anatomy with either a percutaneous Steinmann pin to the pelvis or a spinous process clamp. The Mazor X Stealth Edition Spine Robotic System (Version 5.1; Medtronic) is utilized, and a preoperative plan is created with use of software for screw placement, facet decortication, and decompression. The workstation is equipped with interface software designed to streamline the surgical process according to preoperative planning, intraoperative image acquisition, registration, and real-time control over robotic motion. The combination of these parameters enables the precise execution of preplanned facet joint decortication, osseous decompression, and screw trajectories. Consequently, this technique grants the surgeon guidance for the drilling and insertion of screws, as well as guidance for robotic resection of bone with a bone-removal drill., Alternatives: The exploration of robotically guided facet joint decortication and decompression in MI-TLIF presents an innovative alternative to the existing surgical approaches, which involve manual bone removal and can be less precise. Other robotic systems commonly utilized in spine surgery include the ROSA (Zimmer Biomet), the ExcelsiusGPS (Globus Medical), and the Cirq (Brainlab) 4 ., Rationale: The present video article provides a comprehensive guide for executing robotic-assisted MI-TLIF, including robotic facet decortication and osseous decompression. The introduction of advanced robotic technology capable of both decompressing bone and providing implant guidance represents a considerable advancement in robotic-assisted spine surgery. Software planning for robotic-assisted decortication of fused surfaces, surgical decompression, interbody cage placement, and pedicle screw placement allows for a less invasive and more precise MI-TLIF., Expected Outcomes: Anticipated outcomes include reduction in low back and leg pain, improved functional status, and successful spinal fusion. Radiographic outcomes are expected to show restored foraminal height and solid bony fusion. Further, enhanced surgical precision, reduced approach-related morbidity by expanded robotic capabilities in spinal fusion surgery, and a shift from manual bone removal to precise mechanized techniques can be expected. The introduction of robotic-assisted facet joint decortication and decompression represents a notable milestone in spine surgery, enhancing patient care and technological advancement., Important Tips: Although robotic systems were initially predominantly employed for thoracic or lumbar pedicle screw insertion, recent advancements in robotic technology and software have allowed registration of the posterior elements. This advancement has expanded the utility of robotic systems to the initiation of spinal decompression and the decortication of facet joint surfaces, enhancing fusion procedures.Maintaining anatomical precision and preventing the need for re-registration are critical considerations in this surgical procedure. It is recommended to follow a consistent surgical workflow: facet decortication, decompression, modular screw placement, discectomy, insertion of an interbody cage, placement of reduction tabs, rod insertion, and set screw locking.The incorporation of robotic assistance in MI-TLIF is not exempt from a set of challenges. These encompass issues that pertain to dependability of the setup process, occurrences of registration failures, logistical complexities, time constraints, and the unique learning curve associated with the novel capability of robotic decompression of bone and facet joints., Acronyms and Abbreviations: MI-TLIF= minimally invasive transforaminal lumbar interbody fusionOR = operating roomPSIS= posterior superior iliac spineCT = computed tomographyAP = anteroposterior., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A476)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

For years, anterior cervical diskectomy and fusion has been considered the benchmark for patients with cervical radiculopathy/myelopathy. However, concerns regarding adjacent segment pathology have promoted the popularity of cervical disk arthroplasty (CDA) with its motion-preserving properties. To replicate the natural cervical disk's six degrees of freedom and compressibility in cervical spine implants, designers need to carefully consider the level of constraint for stability and material selection. Recent CDA designs have incorporated strategies to facilitate unrestricted or semirestricted motion, deploying various articulating components and materials with distinct wear and compressibility properties. To optimize outcomes, patient selection considering additional degeneration of the cervical spine is critical. Clinical long-term studies have been reported in industry-funded FDA investigational device exemption and nonindustry-funded data for one-level and two-level CDA. There are limited data available on three-level and four-level CDA. Adverse events such as heterotopic ossification, osteolysis, migration, subsidence, and failure have been described, where analysis from explanted devices yields insight into in vivo wear and impingement performance. CDA has shown short-term cost advantages, such as decreased procedural expenses. Nonetheless, long-term analysis is necessary to assess possible economic tradeoffs. Advancements in designs may lead to improved implant longevity while evidence-based decision making will guide and responsibly manage the rapid advancement in CDA technology., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Despite growing numbers of scientific publications on the optimal antibiotic treatment for diabetic foot infections, the data on the adult population with non-diabetic (postsurgical) foot infections is limited. Therefore, one of the largest single-center databases at the Balgrist University Hospital in Zurich, Switzerland, was established between January 2014 and August 2022. Using a case-control study design, we retrospectively investigated failures of combined surgical and antibiotic therapy for surgical site foot infections (SSIs). Overall, 17.4% of the episodes experienced therapeutic failures, particularly in patients with infected ankle prostheses. However, age, biological sex, pathogens, the duration of post-debridement antibiotic treatment, the number of surgical debridements, or the use of negative-pressure wound care altered the failure risk. In the multivariate logistic regression analyses, the duration of postsurgical antibiotic use was completely indifferent (as a continuous variable with an odds ratio of 1.0 and a 95% confidence interval ranging from 0.96 to 1.03) when stratified into inter-tertiary groups. Our findings suggest that shorter courses of systemic antibiotics may be appropriate in non-diabetic adults, supporting better antibiotic stewardship. Ongoing randomized controlled trials are under way to investigate which patients might safely receive shorter antibiotic treatments for surgical site infections following elective foot and ankle procedures.

Study Design: Retrospective cohort study., Objectives: To identify imaging predictors on pre- and perioperative imaging that are associated with a future revision surgery for adjacent segment disease (ASD) following lumbar fusion., Methods: Patients undergoing open posterior lumbar fusion between 2014-2022 were followed-up for >2-year. The initial MRI was evaluated for disc degeneration by Pfirrmann (grade 1-5); Modic changes (0-3); as well as fatty infiltration and functional cross-sectional area (fCSA) of the multifidus, erector spinae, and psoas. Spinopelvic alignment was measured pre- and postoperatively., Results: Of 216 patients, 14.8% (n = 32) required revision surgery for ASD in the further course. There were no significant differences in Modic changes or Pfirrmann grades between the ASD group and controls. Fatty infiltration was significantly higher in the ASD group for both the erector spinae (40.5% vs 36.9%, P = 0.043) and multifidus muscles (61.0% vs 53.9%, P = 0.003). Additionally, the multifidus fCSA was smaller in patients who developed ASD (5.7 cm 2 vs 6.7 cm 2 ). Pre- and postoperative spinopelvic parameters were not significantly different between groups, and no other MRI measurements showed a significant difference. In a multivariable logistic regression model adjusting for age and sex, multifidus fatty infiltration emerged as the only significant predictor of ASD revision surgery ( P = 0.004). Patients with more than 58% multifidus fatty infiltration had over double the risk of developing ASD (OR 2.7, 95% CI: 1.1-6.5, P = 0.032)., Conclusions: Multifidus fatty infiltration is the key imaging predictor for the development of ASD requiring surgical revision. Disc degeneration and spinopelvic alignment appear to have less impact., Competing Interests: Declaration of Conflicting InterestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AAS reports royalties from Ortho Development, Corp. DePuy Spine Products/Medical Device Business Services, Clariance, Inc.; private investments for Vestia Ventures MiRUS Investment, LLC, ISPH II, LLC, ISPH 3, LLC, and Centinel Spine (Vbros Venture Partners V); consulting fees from DePuy Spine Products/Medical Device Business Services, Clariance, Inc., Kuros Biosciences AG; speaking and/or teaching arrangements for DePuy Spine Products/Medical Device Business Services; membership of scientific advisory board of DePuy Spine Products/Medical Device Business Services, Kuros Biosciences AG, Clariance, Inc., and research support from Spinal Kinetics, Inc./Orthofix, Inc., outside the submitted work. FPC reports royalties from Accelus; ownership interest for 4WEB Medical/4WEB, Inc.; Healthpoint Capital Partners, LP; ISPH II, LLC; ISPH 3 Holdings, LLC; Ivy Health care Capital Partners, LLC; Medical Device Partners II, LLC; Medical Device Partners III, LLC; Orthobond Corporation; Spine Biopharma, LLC; Tissue Differentiation Intelligence, LLC; Tissue Connect Systems, Inc.; VBVP VI, LLC; VBVP X, LLC; Woven Orthopedics Technologies; consulting fees from Spine Biopharma, LLC, and Accelus; membership of scientific advisory board/other office of Healthpoint Capital Partners, Medical Device Partners II, LLC, Orthobond Corporation, Spine Biopharma, LLC, and Woven Orthopedic Technologies; and research support from 4WEB Medical/4WEB, Inc., Camber Spine, Choice Spine, DePuy Synthes, Centinel Spine, and Royal Biologics outside the submitted work. FPG reports royalties from Lanx, Inc. And Ortho Development Corp.; ownership interest in Centinel Spine, BICMD; consulting fees from Lanx, Inc, Ortho Development Corp, and Sea Spine;and stock ownership in Centinel Spine, Healthpoint Capital Partners, LP; membership of scientific advisory board/other office of Healthpoint Capital Partners, outside the submitted work. APH reports research support from Kuros Biosciences AG and Expanding Innovations, Inc.; private investments in Tissue Connect Systems, Inc.; and fellowship support from NuVasive, Inc., Globus Medical North America, Inc., and Alphatec Spine, Inc., outside the submitted work.

Background Context: Preoperative imaging for lumbar spine surgery often includes magnetic resonance imaging (MRI) for soft tissues and computer tomography (CT) for bony detail. While CT scans expose patients to ionizing radiation, whereas MRI scans do not. Emerging MRI techniques allow CT-like 3-dimensional (3D) visualization of bony structures, potentially removing the need for ionizing radiation from CT scans., Purpose: This study aims to explore the accuracy of robot-assisted lumbar pedicle screw placement based on preoperative CT-like 3D MRI as the data source for robotic registration., Study Design: Human cadaveric study., Methods: CT-like 3D MRI scans of the lumbar spine were acquired in ten human cadavers. A robotic navigation platform was used to plan and navigate pedicle screw placement based on the CT-like 3D MRI. Postoperative CT scans assessed the accuracy of screw positioning compared to preoperative planning based on the Gertzbein-Robbins scale (GRS) and by direct measurement (mm)., Results: A total of 100 lumbar pedicle screws were robotically placed in ten cadavers (L1 through L5 bilaterally) based on CT-like 3D MRI. On postoperative CT evaluation, 99.0% of the positioned screws achieved an acceptable grade on the GRS (Grade A: n=89 or Grade B: n=10), with 89.0% classified as Grade A and 10.0% as Grade B. Meaning that 89.0% of screws were fully contained within the pedicle (GRS A), and 10% had a minor cortical breach <2 mm (GRS B). The median deviation from the planned trajectory was 0.2 mm (axial IQR: 0.1 to 0.5 mm; sagittal: IQR: 0.1 to 0.4 mm), in both axial and sagittal planes., Conclusion: This study showed that image registration of CT-like 3D MRI for robotic-assisted spine surgery is technically feasible and that accurate pedicle screw placement can be achieved without preoperative CT. Each CT-like 3D MRI was successfully registered for robotic navigation., Clinical Significance: The results suggest that CT-like 3D MRI has the potential to be a radiation-free alternative for preoperative planning and navigation in lumbar spine instrumentation procedures., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DBS reports relationships with AMAG Pharmaceuticals, Inc., General Electric Healthcare, Private Health Management, RemedyLogic, Siemens Healthcare, USA. DRL reports relationships with Choice Spine, Depuy Synthes, HS2, LLC, ISPH II, LLC, Medtronic Sofamor Danek USA, Inc., Nuvasive, Inc., Remedy Logic, Stryker, Vestia Ventures, MiRus Investment LLC, Viseon, Inc., Woven Orthopedic Technologies. The other authors declared no potential conflicts of interest.

Study Design: Retrospective database review., Objective: The aim of this study was to analyze revisions of CDAs reported to the MAUDE database., Summary of Background Data: Cervical disk arthroplasty (CDA) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion (ACDF) for degenerative cervical disease, demonstrating comparable outcomes. Despite the availability of variable CDA designs, there is limited data on the specific complications of individual CDAs. The Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database has been used to systematically report complications associated with CDAs. However, data on specific reasons for CDA revision remains scarce. The purpose of this study is to compare common complications associated with revision for different CDAs., Methods: The MAUDE database was queried from January 2005 to September 2023, including all nine FDA-approved CDAs. The full-text reports of each complication were categorized based on whether revision surgery was performed, the complications and the type of CDA collected and compared., Results: A total of 678 revisions for nine CDAs were reported: Mobi-C (239), M6 (167), Prodisc-C (88), Prestige (60), PCM (44), Bryan (35), Secure (23), Simplify (21), and Discover (1). The top three complications associated with revision were migration (23.5%), neck pain (15.5%), and heterotopic ossification (6.6%). The most common complications per device were migration for Mobi-C (26.4%), Prodisc-C (21.3%), Prestige (24.6%), PCM (84.1%), Bryan (48.6%), Secure (30.4%), and Discover (100%). For M6, the most common complications associated with revision surgery were osteolysis (18.6%) and neck pain (18.6%), while neck pain (23.8%) was the most common for the Simplify., Conclusions: The MAUDE database highlights complications related to CDA revision in which the primary complications consistently include implant migration, neck pain, and heterotopic ossification, varying in their rerelvance depending on the CDA., Level of Evidence: Level II., Competing Interests: C.A. is a consultant on the advisory board for Camber Spine Tech; a consultant for Centinel Spine Inc.; is in the advisory board, and has an ownership interest in Orthobond Corporation and Surgalign. D.R.L. is a consultant and on the advisory board for Choice Spine; is a consultant for Depuy Synthes; has ownership interest from Woven Orthopedic Technologies, Vestia Ventures MiRus Investment LLC, HS2 LLC, and ISPH II LLC; has research support from Medtronic Sofamor Danek USA Inc.; has royalties from Nuvasive Inc.; is on the advisory board and has ownership interest from Remedy Logic; is a consultant and has royalties from Stryker; is a consultant and has ownership interest from Viseon Inc. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to compare the outcome of intralesional gross-total resection (GTR) followed by high-energy particle therapy with en bloc and intralesional resections., Methods: A retrospective study of patients diagnosed with primary osteogenic sarcoma (OGS) of the spine between 2009 and 2020 was conducted. Demographic information, including age, affected site, tumor volume, and Weinstein-Boriani-Biagini stage, was collected. Additionally, information on metastases at diagnosis, length of stay, operating time, complications, planned surgical treatment, and radiotherapy was also collected. Outcome measures, including local recurrence (LR) and disease-specific survival (DSS), were compared using Kaplan-Meier curves., Results: In total, 20 patients with a median age of 38 (IQR 23-60) years were included. The median follow-up was 15.7 (IQR 6.3-36.9) months. Eight patients underwent en bloc resection with a 38% (3 patients) LR rate and a median DSS of 26.4 months. Four patients received adjuvant high-energy particle therapy after planned GTR. Their median follow-up was 36 months; none of these patients experienced LR. Both the 1-year and 3-year DSSs were 100%. Another 8 patients underwent intralesional resection. Six of the 8 patients (75%) died of their disease, with a median survival of 7.3 (IQR 4.7-14) months., Conclusions: GTR combined with adjuvant high-energy particle therapy appears to be a safe and effective alternative approach for patients with OGS of the spine when en bloc resection is not feasible. The results demonstrated a 3-year DSS of 100% and no major surgical complications.

Aims: To report the development of the technique for minimally invasive lumbar decompression using robotic-assisted navigation., Methods: Robotic planning software was used to map out bone removal for a laminar decompression after registration of CT scan images of one cadaveric specimen. A specialized acorn-shaped bone removal robotic drill was used to complete a robotic lumbar laminectomy. Post-procedure advanced imaging was obtained to compare actual bony decompression to the surgical plan. After confirming accuracy of the technique, a minimally invasive robotic-assisted laminectomy was performed on one 72-year-old female patient with lumbar spinal stenosis. Postoperative advanced imaging was obtained to confirm the decompression., Results: A workflow for robotic-assisted lumbar laminectomy was successfully developed in a human cadaveric specimen, as excellent decompression was confirmed by postoperative CT imaging. Subsequently, the workflow was applied clinically in a patient with severe spinal stenosis. Excellent decompression was achieved intraoperatively and preservation of the dorsal midline structures was confirmed on postoperative MRI. The patient experienced improvement in symptoms postoperatively and was discharged within 24 hours., Conclusion: Minimally invasive robotic-assisted lumbar decompression utilizing a specialized robotic bone removal instrument was shown to be accurate and effective both in vitro and in vivo. The robotic bone removal technique has the potential for less invasive removal of laminar bone for spinal decompression, all the while preserving the spinous process and the posterior ligamentous complex. Spinal robotic surgery has previously been limited to the insertion of screws and, more recently, cages; however, recent innovations have expanded robotic capabilities to decompression of neurological structures., Competing Interests: D. R. Lebl discloses being a consultant and on the advisory board for Choice Spine; being a consultant for Depuy Synthes; having an ownership interest in HS2, ISPH, and Vestia Ventures MiRus Investment; being a consultant and having ownership interest in Viseon; being a consultant and having royalties from Stryker; receiving royalties from Nuvasive; and getting research support form Medtronic Sofamor Danek USA, all of which is unrelated to this manuscript. D. B. Sneag declares research support from GE Healthcare, Siemens Healthcare, Medtronic, and AMAG Pharmaceuticals, which are unrelated to this work. J. L. Chazen reports being a consultant for Lexeo Therapeutics, which is also unrelated., (© 2024 Lebl et al.)

Instrumentation of the upper cervical spine, such as cervical pedicle, lateral mass, pars, or translaminar screws, is considered high risk due to the specific challenges of this anatomic region, including the proximity of vertebral and carotid arteries and nerve roots, as well as its delicate bony architecture. In recent years, advanced three-dimensional (3D) imaging techniques, such as intraoperative computed tomography (iCT; AIRO CT), have emerged, enabling computer-assisted navigation (CAN). This integration of real-time imaging into navigation enhances screw accuracy and diminishes perioperative risks, extending to the postsurgical confirmation of screw placement. Although CAN utilization has become more prominent in lumbar and thoracic surgeries, its integration into cervical spine procedures has been constrained thus far. This can be ascribed to the variable screw trajectories necessary for cervical spine procedures, coupled with potential anatomical variations such as a high-riding vertebral artery, increasing the degree of challenge during surgery. To date, no study has comprehensively described in detail the technique of upper cervical instrumentation employing automatic image registration, navigation, and iCT validation of the positioned screws. In this manuscript, a detailed description of CAN in high cervical instrumentation is given, including C1 lateral mass screws with the notching technique, C2 and C3 pars screws, and translaminar screws guided by preoperative magnetic resonance imaging (MRI) data and iCT for assessment of screw position. For this purpose, three different patients suffering from distinct cervical pathologies, such as nonunion of a C2 fracture and atlantoaxial arthropathy with or without ankylosis, are presented, with a specific surgical approach tailored to the anatomical variations of each patient., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-26/coif). D.R.L. reports research support from Medtronic; royalties from NuVasive, Inc. and Stryker; consulting fee from Depuy Synthes and Vizeon, Inc.; private investments from HS2, LLC, Woven Orthopedic Technologies, Vestia Ventures MiRus Investiment LLC, ISPH, and LLC; and he is the member of scientific advisory board of Remedy Logic. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Study Design: This was a single-center prospective clinical and radiographic analysis of pedicle screw instrumentation with Robotic-assisted navigation (RAN) and augmented reality (AR)., Objective: This study aimed to compare the accuracy of lumbosacral pedicle screw placement with RAN versus AR., Summary of Background Data: RAN and AR have demonstrated superior accuracy in lumbar pedicle screw placement compared to conventional free-hand techniques. RAN and AR techniques both tout specific advantages over their counterparts, but to date, no study has directly compared the two technologies regarding pedicle screw accuracy., Patients and Methods: Patients who underwent RAN or head-mounted AR navigated lumbosacral (L1-S1) pedicle screw placement for degenerative conditions were included. Screw accuracy was assessed by two independent reviewers on intraoperative 3D fluoroscopic scans using the Gertzbein and Robbins scale. A generalized linear mixed model was applied to evaluate the relationship between the screw placement technique and accuracy., Results: 212 patients undergoing lumbosacral instrumentation with a total of 1,211 pedicle screws placed using RAN (n=108; screws= 827) or AR (n=104; screws= 384). Overall, Grade A was achieved in 92.6% of screws. No significant difference was found between RAN and AR screw placement regarding the incidence of accurate (Grade-A and -B screws; RAN n=824; 99.6% and AR n=379, 98.7%) versus inaccurate screws (Grade-C and -D screws; RAN n=3, 0.4% and AR n=5, 1.3%). When comparing "optimal" Grade-A screws (RAN n= 787, 95.2%, AR n=345, 89.8%) versus all other screws (B, C, and D), significantly higher accuracy was achieved using RAN (P=0.001)., Conclusion: RAN and AR both achieved high accuracy in lumbosacral pedicle screw placement, proving reliable for this procedure. However, RAN resulted in significantly more Grade-A screw placements than AR., Competing Interests: Conflict of interest disclosure: FCSA, MJK, FA, MDB, JZ, and FA do not have a conflict of interest in this study. FPC received research support and/or has an ownership interest in 4WEB Medical/4WEB, Inc., Camber Spine, Centinel Spine, Choice Spine, DePuy Synthes, and Royal Biologics. Has ownership interests in 4WEB Medical/4WEB, Inc., Healthpoint Capital Partners, LP, ISPH II, LLC, where FPC is also in the advisory board, ISPH 3 Holdings, LLC, Ivy Healthcare Capital Partners, LLC, Medical Device Partners II, LLC, Medical Device Partners III, LLC, where FPC is also in the Board of directors, Orthobond Corporation, where FPC is on the board of directors, Spine Biopharma, LLC, Tissue Differentiation Intelligence, LLC, Tissue Connect Systems, Inc., VBVP VI, LLC, VBVP X, LLC, and Woven Orthopedic Technologies, where FPC is also in the Board of directors. FPC has consulting and royalty agreements with Accelus and Spine Biopharma, LLC, with royalties specifically for the “Toro” titanium, bi-planar expandable, lumbar spine interbody implant designed for insertion via lateral approach from Accelus. FCP is in the board of Director positions with Medical Device Partners II, LLC, Orthobond Corporation, Spine Biopharma, LLC, with ownership interest, and Woven Orthopedic Technologies. FCP is on the Advisory Board and has ownership interest with Healthpoint Capital Partners, LP. AS has Ownership Interest from Centinel Spine (Vbros Venture Partners V), HSS ASC Development Network, LLC, HS2, LLC, ISPH 3 Holdings, LLC, ISPH II, LLC, VBros Venture Partners X, and Vestia Ventures MiRus Investment, LLC. AS is a Consultant and on the Scientific Advisory Board for Clariance, Inc. AS is on the Advisory Board and a Consultant for Depuy Synthes Products, Inc. (a Johnson & Johnson Company). AS is a Consultant and on the Strategic Advisory Board for Kuros Biosciences. AS is a Consultant and has Royalties from Ortho Development Corp. MF is Consultant for Arthrex and Medacta, and President of the Board and shareholder of Moving Spine DRL is a Consultant and on the Advisory Board for Choice Spine. DRL is a consultant for Depuy Synthes. DRL has Ownership Interest from Woven Orthopedic Technologies, Vestia Ventures MiRus Investment LLC HS2, LLC and ISPH II, LLC. DRL has Research Support from Medtronic Sofamor Danek USA, Inc. DRL has Royalties from Nuvasive, Inc. DRL is on the Advisory Board and has Ownership Interest from Remedy Logic. DRL is a Consultant and has Royalties from Stryker. DRL is a Consultant and has Ownership Interest from Viseon, Inc., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background/Objective: Surgical treatment of aneurysmal bone cysts (ABCs) can be challenging, especially in the spine. Non-surgical treatments such as with denosumab have shown promising results in different osteolytic pathologies. This retrospective observational study aimed to evaluate the long-term clinical and radiologic response of patients with ABCs of the mobile spine treated with denosumab and propose an updated treatment algorithm. Methods: Six patients with relapsed and symptomatic ABCs of the mobile spine were treated with denosumab (120 mg subcutaneously on days 1, 8, 15, 29, and every 4 weeks thereafter) between 2012 and 2023. Disease assessments were conducted using CT and MRI at 3, 6, 9, and 12 months post-treatment. Clinical data, including pain levels, symptoms, and adverse events, were documented from patients' charts. Results: Patients underwent an initial phase of treatment with denosumab, receiving a mean of 22 administrations (range 13-42) over a median follow-up period of 41 months (range 15-98 months). Clinical improvement was observed in all patients after 4 weeks of treatment, and all patients demonstrated a radiological response after 12-24 weeks on denosumab. Three patients were progression-free after discontinuing denosumab following 13, 15, and 42 administrations, respectively. At the last follow-up, after 38, 43, and 98 months, these patients remained stable without relapse of the disease. Three patients had a relapse of disease after denosumab; two of them underwent denosumab re-challenge, while one patient received one mesenchymal stem cells (MSCs) injection. All patients showed clinical and radiological improvement and were resulted to be disease-free at the last follow-up. Conclusions: This study demonstrates the long-term efficacy and safety of denosumab in treating ABCs of the mobile spine, as well as the potential of re-challenge in managing recurrence. A treatment algorithm is proposed, positioning denosumab as a viable therapeutic option after other local treatments. Careful patient selection, monitoring, and further research are necessary to optimize denosumab use for ABCs.

Background: Anterior cervical discectomy and fusion (ACDF) is known to elicit adverse biomechanical effects on immediately adjacent segments; however, its impact on the kinematics of the remaining nonadjacent cervical levels has not been understood. This study aimed to explore the biomechanical impact of ACDF on kinematics beyond the immediate fusion site. We hypothesized that compensatory motion following single-level ACDF is not predictably distributed to adjacent segments due to compensation from noncontiguous levels., Methods: Six fresh-frozen cervical spines (C2-T1) underwent fluoroscopic screening and sagittal and coronal reformats from computed tomography scans and were utilized to grade segmental degeneration. Each specimen was tested to 30° of flexion and extension intact and following single-level ACDF at the C5-C6 level. The motions of each vertebral body were tracked using 3-dimensional (3D) motion capture into an inverse kinematics model, facilitating correlations between the 3D reconstruction from computed tomography images and the 3D motion capture data. This model was used to calculate each level's flexion/extension range of motion (ROM)., Results: Single-level fusion at the C5-C6 level across all specimens resulted in a significant motion reduction of -6.8° ( P = 0.002). No significant change in ROM occurred in the immediate adjacent segments C4-C5 ( P = 0.07) or C6-C7 ( P = 0.15). Hypermobility was observed in 2 specimens (33%) exclusively in adjacent segments. In contrast, the other 4 spines (66%) displayed hypermobility at noncontiguous segments. Hypermobility occurred in 42% (5/12) of the adjacent segments, 28% (5/18) of the noncontiguous segments, and 50% (3/6) of the cervicothoracic segments., Conclusion: Single-level ACDF impacts ROM beyond adjacent segments, extending to noncontiguous levels. Compensatory motion, not limited to adjacent levels, may be influenced by degenerative changes in noncontiguous segments. Surprisingly, hypermobility may not occur in adjacent segments after ACDF., Clinical Relevance: Overall, the multifaceted biomechanical effects of ACDF underscore the need for a comprehensive understanding of cervical spine dynamics beyond immediate adjacency, and it needs to be taken into consideration when planning single-level ACDF., Competing Interests: Declaration of Conflicting Interests : The authors report no conflicts of interest in this work., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2024 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Background: Anterior cervical discectomy and fusion (ACDF) for the surgical treatment of cervical degenerative disease often includes an intervertebral cage, which restores disc height and lordosis while promoting fusion . Cage materials include titanium (TTN) or polyetheretherketone (PEEK). Controversy in material selection stems from higher fusion rates with TNN, despite a higher subsidence rate, while PEEK cages demonstrate superior preservation of interspace height. Combining the advantages of both materials, TTN-coated PEEK (TCPEEK) cages were developed, featuring a PEEK core with similar stiffness to the bone, enveloped with a TTN coat, improving osteointegration. However, the potential superiority of TCPEEK over TTN cages has not been investigated. This study aimed to compare clinical and radiographic outcomes following single- or double-level ACDF using either TTN or TCPEEK cages., Methods: This retrospective single-center study included patients undergoing single- or double-level ACDF between 2017 and 2019. Clinical outcomes included the Neck Disability Index and revision surgery incidence. Radiographic parameters included cervical and segmental lordosis, C2 to C7 sagittal vertical axis, fusion, subsidence, and adjacent segment degeneration at a minimum 12-month follow-up., Results: A total of 45 patients (16 TTN; 29 TCPEEK) and 58 cervical levels (21 TTN; 37 TCPEEK) were included. Both cages significantly improved Neck Disability Index scores (TTN -10.0; TCPEEK -14.1) without significant differences. Two single-level TCPEEK patients required revision surgery due to non-union. In the radiological assessments, no significant difference was found for subsidence rates (TTN 52.4%; TCPEEK 56.8%), adjacent segment degeneration, cervical and segmental lordosis, and changes in C2 to C7 sagittal vertical axis. Though not statistically significant, fusion rates trended slightly higher with TTN (90.5%) vs TCPEEK cages (86.5%)., Conclusion: TTN and TCPEEK cages achieve satisfactory clinical and radiological outcomes in single- or double-level ACDF. This finding suggests that the choice between them can be based on other factors, such as surgeon preference or availability, rather than specific material properties., Clinical Relevance: This study found that the selection of ACDF cage material did not affect clinical outcomes., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2024 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Background: Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication., Observations: Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints., Lessons: Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.

Chronic low back pain is a major source of pain and disability globally involving multifactorial causes. Historically, intervertebral disc degeneration and disruption have been associated as primary back pain triggers of the anterior column, termed "discogenic pain." Recently, the vertebral endplates have been identified as another possible pain trigger of the anterior column. This "endplate-driven" model, defined "vertebrogenic pain," is often interconnected with disc degeneration. Diagnosis of vertebrogenic and discogenic pain relies on imaging techniques that isolate pain generators and exclude comorbid conditions. Traditional methods, like radiographs and discography, are augmented by more sensitive methods, including SPECT, CT, and MRI. Morphologic MRI is pivotal in revealing indicators of vertebrogenic (eg, Modic endplate changes) and discogenic pain (eg, disc degeneration and annular fissures). More advanced methods, like ultra-short-echo time imaging, and quantitative MRI further amplify MRI's accuracy in the detection of painful endplate and disc pathology. This review explores the pathophysiology of vertebrogenic and discogenic pain as well as the impact of different imaging modalities in the diagnosis of low back pain. We hope this information can help identify patients who may benefit from personalized clinical treatment and image-guided therapies., Competing Interests: Disclosure The authors have no conflicts to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Study Design: Human Cadaveric Study., Objective: This study aims to explore the feasibility of using preoperative magnetic resonance imaging (MRI), zero-time-echo (ZTE) and spoiled gradient echo (SPGR), as source data for robotic-assisted spine surgery and assess the accuracy of pedicle screws., Methods: Zero-time-echo and SPGR MRI scans were conducted on a human cadaver. These images were manually post-processed, producing a computed tomography (CT)-like contrast. The Mazor X robot was used for lumbar pedicle screw-place navigating of MRI. The cadaver underwent a postoperative CT scan to determine the actual position of the navigated screws., Results: Ten lumbar pedicle screws were robotically navigated of MRI (4 ZTE; 6 SPGR). All MR-navigated screws were graded A on the Gertzbein-Robbins scale. Comparing preoperative robotic planning to postoperative CT scan trajectories: The screws showed a median deviation of overall 0.25 mm (0.0; 1.3), in the axial plane 0.27 mm (0.0; 1.3), and in the sagittal plane 0.24 mm (0.0; 0.7)., Conclusion: This study demonstrates the first successful registration of MRI sequences, ZTE and SPGR, in robotic spine surgery here used for intraoperative navigation of lumbar pedicle screws achieving sufficient accuracy, showcasing potential progress toward radiation-free spine surgery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of this study was to determine tissue-specific blood perfusion impairment of the cervical cord above the compression site in patients with degenerative cervical myelopathy (DCM) using intravoxel incoherent motion (IVIM) imaging. A quantitative MRI protocol, including structural and IVIM imaging, was conducted in healthy controls and patients. In patients, T2-weighted scans were acquired to quantify intramedullary signal changes, the maximal canal compromise, and the maximal cord compression. T2*-weighted MRI and IVIM were applied in all participants in the cervical cord (covering C1-C3 levels) to determine white matter (WM) and grey matter (GM) cross-sectional areas (as a marker of atrophy), and tissue-specific perfusion indices, respectively. IVIM imaging resulted in microvascular volume fraction ([Formula: see text]), blood velocity ([Formula: see text]), and blood flow ([Formula: see text]) indices. DCM patients additionally underwent a standard neurological clinical assessment. Regression analysis assessed associations between perfusion parameters, clinical outcome measures, and remote spinal cord atrophy. Twenty-nine DCM patients and 30 healthy controls were enrolled in the study. At the level of stenosis, 11 patients showed focal radiological evidence of cervical myelopathy. Above the stenosis level, cord atrophy was observed in the WM (- 9.3%; p = 0.005) and GM (- 6.3%; p = 0.008) in patients compared to healthy controls. Blood velocity (BV) and blood flow (BF) indices were decreased in the ventral horns of the GM (BV: - 20.1%, p = 0.0009; BF: - 28.2%, p = 0.0008), in the ventral funiculi (BV: - 18.2%, p = 0.01; BF: - 21.5%, p = 0.04) and lateral funiculi (BV: - 8.5%, p = 0.03; BF: - 16.5%, p = 0.03) of the WM, across C1-C3 levels. A decrease in microvascular volume fraction was associated with GM atrophy (R = 0.46, p = 0.02). This study demonstrates tissue-specific cervical perfusion impairment rostral to the compression site in DCM patients. IVIM indices are sensitive to remote perfusion changes in the cervical cord in DCM and may serve as neuroimaging biomarkers of hemodynamic impairment in future studies. The association between perfusion impairment and cervical cord atrophy indicates that changes in hemodynamics caused by compression may contribute to the neurodegenerative processes in DCM., (© 2023. The Author(s).)

Background: Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting., Methods: A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome., Results: Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome ( P = .021, P = .028, and P = .033)., Conclusion: Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle. Level of Evidence: Level III, systematic review and meta-analysis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background Context: Early postoperative MR images are frequently necessary after spine surgery. The appearance of commonly used adjunct hemostatic agents and dural sealants in MR images has not been systematically evaluated., Purpose: The purpose of this experimental study was to systematically analyze and describe the characteristics of the most commonly applied hemostatic agents and dural sealants in spine surgery on early postoperative MR images., Study Design: Cadaver Study METHODS: Four commonly applied dural sealants (Duraseal, Bioglue, Tachosil, Tisseel) and five commonly used hemostatic agents (Surgiflo, Bonewax, , Spongostan, Gelfoam, Avitene) were investigated. The experimental setting involved a human cadaver where a standard left-sided laminotomy was performed on nine levels of the thoracolumbar spine, and the materials were separately applied and mixed with fresh blood or water for hemostatic and dural sealants, respectively. The cadaver model was scanned at a 3 Tesla MRI and the imaging findings for all materials were compared to the surrounding tissue and systematically reported., Results: All investigated dural sealants and hemostatic agents were distinguishable from the surrounding tissue on MR images with different appearances on the MR sequences. A detailed atlas for the identification of the materials in postoperative spine MRI was established., Conclusion: Commonly used hemostatic agents and dural sealants can be successfully identified on early postoperative spine MRI., Clinical Significance: Knowledge about MRI appearances of commonly used adjunct surgical materials helps in interpretation of postoperative imaging and supports clinical decision making., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)