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Background: Proximal junctional failure (PJF) following multilevel thoracolumbar instrumented to the pelvis for adult spinal deformity (ASD) is relatively uncommon but considerably disabling. While the leading etiology is mechanical, other rarer etiologies can play a role in its development. The purpose of this study was to present a case series of ASD patients who experienced PJF secondary to proximal junctional spondylodiscitis (PJS) after long-segment thoracolumbar posterior instrumented fusions., Methods: Adult patients who underwent posterior instrumented fusions at a single academic center between 2017 and 2020 and subsequently developed PJS were retrospectively reviewed. Patient demographics, operative details, clinical presentation, culture data, and management approach were evaluated., Results: Three patients developed PJS and were included for analysis (mean age 67 years [range, 58-76]; women: 2). Indication for all index operations was symptomatic ASD after failed conservative management. Clinical presentation ranged from mild back pain to severe neurological compromise. Average time to infection and PJF after the index procedure was 11 months (range, 3 months-2 years). All 3 patients were successfully managed with urgent revision surgery including surgical debridement and postoperative antibiotics., Conclusion: PJS is a rare yet potentially devastating complication following long-segment posterior thoracolumbar instrumented fusions for ASD. It is critical that surgeons maintain a high index of suspicion of infection when managing PJF given the potential neurological morbidity of PJS., Clinical Relevance: This report highlights a rare but important cause of PJF following ASD surgery. It is critical that one maintains a high index of suspicion of infection when managing PJF., 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 © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Introduction: The effect of pelvic fixation on postoperative medical complications, blood transfusion, length of hospital stay, and discharge disposition is poorly understood. Determining factors that predispose patients to increased complications after spinopelvic fusion will help surgeons to plan these complex procedures and optimize patients preoperatively., Methods: We conducted a retrospective cohort study using data from the ACS-NSQIP database between 2006 and 2016 of patients who underwent lumbar fusion with and without spinopelvic fixation. Data regarding demographics, complications, hospital stay, and discharge disposition were collected., Results: A total of 57,417 (98.5%) cases of lumbar fusion without spinopelvic fixation (LF) and 887 (1.5%) cases of lumbar fusion with spinopelvic fixation (SPF) were analyzed. The transfusion rate in the SPF group was 59.3% vs 13% in the LF group ( p < 0.001). The mean length of stay (LOS) and discharge to skilled nursing facility (SNF) were significantly different (LOS: SPF 6.5 days vs LF 3.5 days p < 0.001; SNF: SPF 21.3% vs LF 10.4% p < 0.001). After controlling for demographic differences, the overall complication rates were not significantly different between the groups ( p = 0.531). The odds ratio for transfusion in the SPF group was 2.9 ( p < 0.001). The odds ratio for increased LOS and increased care discharge disposition were elevated in the SPF group (LOS OR: 1.3, p < 0.012, Discharge disposition OR: 1.8, p < 0.001)., Conclusions: Patients who underwent SPF had increased complications, transfusion rate, LOS, and discharge to SNF or subacute rehab facilities as compared with patients who underwent LF. SPF remains an effective technique for achieving lumbosacral arthrodesis. Surgeons should consider the implications of the associated complication profile for SPF and the value of preoperative optimization in a select cohort of patients., Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest., (Copyright © 2020 by The Japanese Society for Spine Surgery and Related Research.)

Introduction: This study establishes the construct validity of a low-cost training platform designed for high-repetition training of the skills required for fluent use of the five specific tools described for free-hand pedicle screw placement and breach avoidance., Methods: A total of 19 participants were included and divided into three groups based on spine surgery experience. Participants were asked to place five pedicle screws into the model. The performance was assessed by recording breaches, technical criteria (0 to 44 points), time to completion, and angulation of the screws. Success (no breaches, no protrusions) frequency (success/time) was calculated and analyzed., Results: Participants included three spine surgeons, seven advanced trainees (who had placed >10 pedicle screws), and nine inexperienced trainees. None of the screws placed by the spine surgeons breached the pedicle wall. Eight of 35 screws placed by advanced trainees (22.9%) and 31 of 45 screws placed by inexperienced trainees (68.9%) had a pedicle breach. Spine surgeons had a higher median success frequency compared with inexperienced trainees and advanced trainees (P = 0.015). The time needed to place a screw decreased over time (P < 0.0001). There was a trend toward an association between increased training level and decreased time to place five screws (P = 0.076). Increased training level was associated with greater total points scored (P < 0.0001). More screws placed by inexperienced trainees were further away from the ideal pedicle axis compared with those placed by advanced trainees or spine surgeons., Conclusion: An association exists between training level and performance on the pedicle screw model, which suggests construct validity when evaluating our model's use for teaching surgeon learners. The model is easily assembled and is an alternative spine surgery training tool that overcomes limited availability and considerable costs of other training platforms. It can be used in high repetition to establish tool-skill fluency., Level of Evidence: Level I.

An orthopaedic surgeon's knowledge of anatomical landmarks is crucial, but other modalities supplement this by providing guidance and feedback to a surgeon. Advances in imaging have enabled three-dimensional visualization of the surgical field and patient anatomy, whereas advances in computer technology have allowed for real-time tracking of instruments and implants. Together, these innovations have given rise to intraoperative navigation systems. The authors review these advances in intraoperative navigation across orthopaedic subspecialties, focusing on the most recent evidence on patient outcomes and complications, the associated learning curve, and the effects on operative time, radiation exposure, and cost. In spine surgery, navigated pedicle screw placement may increase accuracy and safety, especially valuable when treating complex deformities. Improved accuracy of pelvic and peri-articular tumor resection and percutaneous fixation of acetabular and femoral neck fractures has also been achieved using navigation. Early applications in arthroscopy have included surface-based registration for tunnel positioning for anterior cruciate ligament reconstruction and osteochondroplasty for femoro-acetabular impingement. Navigated arthroplasty techniques have addressed knee gap balancing and mechanical axis restoration as well as acetabular cup and glenoid baseplate positioning. Among these orthopaedic subspecialties, significant variation is found in the clinical relevance and dedication to research of navigation techniques.