Technical Considerations and Potential Complications

Funding Information: Conflict of interest statement: The present publication was funded by Fundação Ciência e Tecnologia , IP national support through CHRC ( UIDP/04923/2020 ). Publisher Copyright: © 2023 The Author(s)Objective: We sought to determine the clinical outcomes, complications, and fusion rates in transiliac endoscopic-assisted L5S1 intraforaminal lumbar interbody fusion (iLIF). Methods: Between September 2020 and September 2021, patients with L5S1 degenerative disk disease were enrolled in a prospective study on transiliac L5S1 iLIF and followed for a minimum of 12 months. Conflict of the preoperative planned approach with the ilium was mandatory. The primary outcome measures were the Oswestry Disability Index, the visual analog scale (VAS) score for low back pain (VAS back) and leg pain (VAS leg), and the modified MacNab criteria. The secondary outcomes were complications and fusion rates. Results: Five consecutive patients were enrolled: 2 males and 3 females with a mean age of 50 ± 12.9. All had 12 months’ follow-up. The mean improvement in the Oswestry Disability Index, VAS back, and VAS leg (44 ± 11.75, 6.6 ± 1.7, and 4.7 ± 4.2, respectively) was more than 3 times the minimum clinically important difference. The modified MacNab criteria were good or excellent in 80% of cases at all endpoints. Three patients had ipsilateral lower limb dysesthesia. One patient had revision surgery for foraminal bone fragment removal. All patients achieved fusion. Conclusions: The transiliac iLIF is a feasible but demanding surgical technique that allows overcoming cases in which the ilium prevents endoscopic transforaminal access to L5S1. Our preliminary results had good clinical outcomes and high fusion rates. The main complication was late-onset dysesthesia of the ipsilateral lower limb, 10 to 14 days after surgery. Special care must be taken to prevent L5 dorsal root ganglion injury.proofepub_ahead_of_prin

A personalised approach to spine surgery

Background: Anterior lumbar interbody fusion (ALIF) remains one of the mainstay surgical approaches in treating painful degenerative disc disease with or without segmental instability in the lower spine. The risk factors and complication profile for ALIF differs significantly from other established fusion techniques. Objectives: The goal of the first part of this thesis is to establish the factors associated with long-term clinical outcome (Chapter 2) and short-term perioperative outcomes (Chapter 3) following ALIF. Chapter 4 focuses on the long-term radiographic evidence for biomaterial alternatives for ALIF implants, namely titanium (Ti)-coated PEEK integrated cages. Methods and Results: From a prospective cohort analysis of 147 patients undergoing ALIF, elderly age (≥64 years old) was associated with an increased rate of subsidence but does not affect clinical outcomes. Obesity was not associated with postoperative complications or follow-up patient-reported outcomes. Failed fusion was significantly higher for smokers, and they were significantly more likely than non-smokers to experience postoperative complications such as pseudoarthrosis. To assess risk factors for perioperative complications and readmissions after ALIF, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analysed. ALIF was associated with prolonged length of stay and higher rate of return to operating theatre compared to posterior lumbar fusion. Obesity and alcohol intake increased the risk of 30-day readmissions. Discharge to non-home destination following ALIF was independently associated with wound complications and venous thromboembolism. Finally, a prospective follow-up study was performed to determine the long-term radiographic outcome following ALIF using Ti-coated PEEK cages with allograft and INFUSE. Effective fusion was achieved at up to 24-month follow-up for various indications including degenerative spine/disc disease, low grade lumbar isthmic spondylolisthesis, spondylotic radiculopathy and discogenic low back pain. Conclusions: Collectively, this thesis highlights the importance of personalising the care of an ALIF surgery patient, through identification and optimization of individual risk factors for short-term and long-term outcomes, as well as through choice of implant biomaterial and design

Current Advances in Spinal Diseases of Elderly Patients

The rapid aging of populations in developed countries since the 2000s has placed increasing attention on the issue of musculoskeletal disorders in elderly patients. Notably, spinal disorders not only restrict the social activities of elderly patients, but they also lead to economic loss for society. “Current Advances in Spinal Diseases of Elderly Patients” is a topical collection of articles about current perspectives on diagnosis and treatment of spinal disorders including current surgical strategies. This Special Issue covers a broad range of issues, ranging from managing refractory states such as severe osteoporosis, spinal deformity, ossification of the spinal ligaments, and multiple arthropathy to managing lifestyle-related spinal diseases during the COVID-19 pandemic in elderly populations. We hope that the readers of this Special Issue find the contents interesting

Minimally invasive tubular retraction and transtubular approaches in neurosurgery

Minimally invasive surgical approaches have revolutionized surgical care and are becoming increasingly common and sought after in neurosurgery. Despite significant advancements in these techniques and associated technologies, the use of spatulas, that remain essentially unchanged since the late 1800s, for brain retraction endures as a mainstay of neurosurgical practice. In the last decade, tubular retractors have been successfully used in the management of deep-seated intraparenchymal and intraventricular lesions but have yet to be used to minimize brain retraction in skull base surgery. In order to determine the full applicability of transtubular techniques in neurosurgery, we compare brain retraction pressures between tubular retractors and brain spatulas in common neurosurgical approaches, assess the feasibility of performing minimally invasive transtubular skull base and general neurosurgical approaches, and introduce a novel technique for closure of transtubular minicraniectomies with maintenance of anatomic integrity. In all approaches assessed, tubular retraction resulted in average brain retraction pressures that were 57% less collectively than those resulting from spatula retraction. Tubular retractors demonstrated more consistent average retraction pressures between approaches and required 50% less mean retraction distance compared to spatula retractors, while cortical tearing was observed microscopically in 39% of cases following spatula retraction. Transtubular supraorbital, anterior transpetrosal, interhemispheric transcallosal, retrosigmoid, and supracerebellar infratentorial approaches are safe and effective surgical corridors to their respective intracranial targets, with ample surgical exposure, freedom, and maneuverability and minimal retraction of brain tissue. The tubular retractor provided sufficient working space for standard bimanual surgical technique without obstruction of the visual field and permitted sufficient surgical freedom while allowing for constant monitoring of retracted tissues. Adequate preoperative planning of the surgical trajectory was critical for facilitating a safe, direct, and practicable surgical corridor. Closure of transtubular minicraniectomies could be accomplished by rapid on-demand 3D printing of patient-specific cranioprostheses which was found to be a novel, feasible, and inexpensive option that was accomplished with minimal technical difficulty. Tubular retraction in neurosurgery provides a safe and effective conduit for the application of percutaneous minimally invasive approaches while inducing substantially reduced brain retraction pressures than conventional spatula retractors. Advances in neuronavigation and surgical robotics will continue to expand the indications for tubular retraction in neurosurgery

Selection of fusion levels in adolescent idiopathic scoliosis (AIS) using the fulcrum bending radiograph prediction: verification based on pedicle screw strategy

E-Poster - Adolescent Idiopathic Scoliosis: no. 297Utilizing the fulcrum bending radiographic technique to assess curve flexibility to aid in the selection of fusion levels, a prospective radiographic study was performed to assess the safety and effectiveness of pedicle screw fixation with alternate level screw strategy (ALSS) for thoracic AIS. This study suggests that ALSS obtains greater deformity correction than hook and hybrid systems, and improves balance without compromising fusion levels.postprin

'Clinical Triad' findings in Klippel-feil patients

E-Poster - Congenital Deformity: no. 530It has been propagated that Klippel-Feil Syndrome (KFS) is associated with the clinical triad findings (CTF) of short neck, low posterior hairline, and limited range of motion. This study noted that CTFs are not consistently noted in KFS patients. KFS patients with extensive congenitally fused cervical segments were more likely to exhibit one of the components of CTF.postprin

The safety and efficacy of a remotely distractible, magnetic controlled growing rod (MCGR) for the treatment of scoliosis in children: a prospective case series with minimum two year follow-up

Concurrent Session 2B - Early Onset Scoliosis: paper no. 26SUMMARY: The growing rod has been the gold standard for the treatment of scoliosis in young children. However, such management requires multiple open surgeries under general anesthesia for rod distraction and is associated with numerous postoperative complications. To avoid such pitfalls, we utilized a magnetically-controlled growing rod (MCGR) implant. Our study found that the MCGR was safe and effective, allowing for distractions on a non-invasive out-patient basis at monthly intervals, eliminating the need for surgeries and their associated complications. Introduction: Traditionally, growing rods are the standard of treatment for young children with severe spinal deformities and significant residual growth potential. However, this requires repeated open distractions under general anesthesia and is associated with numerous post-operative complications. This report addresses the safety and efficacy of the MCGR implant for non-invasive out-patient distractions for scoliosis correction in young children. METHODS: This was a prospective, patient series of the MCGR procedure. From November 2009 to March 2011, five patients (n=3 female; n=2 male) were treated with the MCGR. In this study, we report the first three patients (2 females and 1 male) with minimum 2 years follow-up. All cases were non-invasively distracted using an external magnet on a monthly basis. Pre and post distraction radiographs were carried out to assess the Cobb’s angle, predicted versus achieved rod distraction length and spinal length. Clinical outcome assessment was performed with the pain score (Visual Analogue Scale) and the SRS-30 questionnaire. All procedural or rod related complications were recorded. RESULTS: The main correction of the Cobb’s angle was obtained in the initial surgery and was maintained. The mean monthly increase in T1-T12, T1-S1 and instrumented segment length was 1.6mm, 2.5mm and 1.2mm, respectively. Predicted versus actual length gain per distraction were similar. One case had a superficial wound infection and there was one event of loss of distraction. On last follow-up, no pain was noted and SRS-30 scores remained unchanged to baseline. CONCLUSION: The MCGR is a safe and effective procedure for the surgical treatment of scoliosis in children. The MCGR provides external distractions on an out-patient basis without the need for sedation or anesthesia, and that remote distraction allows more frequent lengthening of the rod that may more closely mimic physiologic growth.postprin

Next generation of growth-sparing techniques: preliminary clinical results of a magnetically controlled growing rod in 14 patients

Session 3A - Early Onset Scoliosis: Paper no. 33SUMMARY: Growth-sparing techniques are commonly used for the treatment of progressive EOS. The standard growing rod (GR) technique requires multiple surgeries for lengthening. The preliminary results of MCGR has shown the comparable outcomes to standard GR without the need for repeated surgery which can be expected to reduce the overall complication rate in GR surgery. INTRODUCTION: The growing rod (GR) technique for management of progressive Early-Onset Scoliosis (EOS) is a viable alternative but with a high complication rate attributed to frequent surgical lengthenings. The safety and efficacy of a non-invasive Magnetically Controlled Growing Rod (MCGR) has been previously reported in a porcine model. We are reporting the preliminary results of this technique in EOS. METHODS: Retrospective review of prospectively collected multi-center data. Only patients who underwent MCGR surgery and at least 3 subsequent spinal distractions were included in this preliminary review. Distractions were performed in clinic without anesthesia or analgesics. T1-T12 and T1-S1 height and the distraction distance inside the actuator were analyzed in addition to conventional clinical and radiographic data. RESULTS: Patients (N=14; 7 F and 7 M) had a mean age of 8y+10m (3y+6m to 12y+7m) and underwent a total of 14 index surgeries (SR: index single rod in 5 and DR: dual rod in 9) and 91 distractions. There were 5 idiopathic, 4 neuromuscular, 2 congenital, 2 syndromic and one NF. Mean follow-up (FU) was 10 months (5.8-18.2). Mean Cobb changed from 57° pre-op to 35° post-op and correction was maintained (35°) at latest FU. T1-T12 increased by 4 mm for SR and 10 mm for DR with mean monthly gain of 0.5 and 1.39, respectively. T1-S1 gain was 4 mm for SR and 17 mm for DR with mean monthly gain of 0.5 mm for SR and 2.35 mm for DR. The mean interval between index surgery and the first distraction was 66 days and thereafter was 43 days. Complications included one superficial infection in (SR), one prominent implant (DR) and minimal loss of initial distraction in three after index MCGR (all SR). Overall, partial loss of distraction was observed following 14 of the 91 distractions (one DR and 13 SR). This loss was regained in subsequent distractions. There was no neurologic deficit or implant failure. CONCLUSION: MCGR appears to be safe and provided adequate distraction similar to the standard GR technique without the need for repeated surgeries. DR patients had better initial curve correction and greater spinal height. No major complications were observed during the short follow-up period. The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an ‘off label’ use).postprin