The Arrival of Robotics in Spine Surgery: A Review of the Literature

Systematic review. The authors aim to review comparative outcome measures between robotic and free-hand spine surgical procedures including: accuracy of spinal instrumentation, radiation exposure, operative time, hospital stay, and complication rates. Misplacement of pedicle screws in conventional open as well as minimally invasive surgical procedures has prompted the need for innovation and allowed the emergence of robotics in spine surgery. Before incorporation of robotic surgery in routine practice, demonstration of improved instrumentation accuracy, operative efficiency, and patient safety are required. A systematic search of the PubMed, OVID-MEDLINE, and Cochrane databases was performed for articles relevant to robotic assistance of pedicle screw placement. Inclusion criteria were constituted by English written randomized control trials, prospective and retrospective cohort studies involving robotic instrumentation in the spine. Following abstract, title, and full-text review, 32 articles were selected for study inclusion. Intrapedicular accuracy in screw placement and subsequent complications were at least comparable if not superior in the robotic surgery cohort. There is evidence supporting that total operative time is prolonged in robot-assisted surgery compared to conventional free-hand. Radiation exposure appeared to be variable between studies; radiation time did decrease in the robot arm as the total number of robotic cases ascended, suggesting a learning curve effect. Multilevel procedures appeared to tend toward earlier discharge in patients undergoing robotic spine surgery. The implementation of robotic technology for pedicle screw placement yields an acceptable level of accuracy on a highly consistent basis. Surgeons should remain vigilant about confirmation of robotic-assisted screw trajectory, as drilling pathways have been shown to be altered by soft tissue pressures, forceful surgical application, and bony surface skiving. However, the effective consequence of robot-assistance on radiation exposure, length of stay, and operative time remains unclear and requires meticulous examination in future studies. 4

Surgical Management Update in Metastatic Disease of the Spine

Approximately 12%-20% of patients with metastatic disease will initially present with symptomatic spinal metastasis. Treatment goals include pain control, spinal stability, recovery of neurologic function, local tumor control through debulking or tumor excision, and improved quality of life. Treatment options depend on several factors: spinal stability, patient health and comorbidities, clinical presentation, prognosis, life expectancy, and tumor histology. The following chapter reviews classification of metastatic spinal diseases and the various options, techniques, and reported outcomes for surgical management. (C) 2021 Elsevier Inc. All rights reserved

Dysphagia following lumbar spine surgery in the setting of undiagnosed DISH of the cervical spine: a case report

Dysphagia is an often multifactorial pathology affecting many elderly patients. In addition to global neuromuscular change with normal aging, one component of its etiology may be direct compression of the pharynx or esophagus from overgrown bone from the anterior cervical spine. Diffuse idiopathic skeletal hyperostosis (DISH) is one condition that may contribute to this phenomenon. Of relatively high incidence (2.5% to 33.3%) in elderly populations, DISH has been described in the cervical spine though more frequently affects other spinal regions. The clinical case of an elderly man who developed significant dysphagia after undergoing lumbar spine surgery for spinal stenosis caused by DISH is presented. Awareness of the involvement in his cervical spine before surgery would likely have enabled a more prompt diagnosis of the etiology of dysphagia and allowed for peri-operative optimization of swallowing function to reduce morbidity. We recommend routine preoperative imaging of the cervical spine in all patients with a diagnosis of DISH to stratify risk for development of postoperative dysphagia

Primary Osteosarcoma of the Bone with Rhabdoid Features: A Rare, Previously Undescribed Primary Malignant Tumor of Bone

Primary osteosarcoma of the bone with rhabdoid features is a rare malignant tumor of bone, not previously described in the literature. Here we report a 69-year-old female who originally presented with a right femur pathologic fracture. Radiographs of the injury showed an aggressive-appearing lesion of the distal femur. Initial biopsy was done, which was not diagnostic; additional advanced imaging studies were performed, which failed to show any other site within the body with detectable disease process. Accordingly, the patient underwent radical resection of the distal femur and reconstruction with endoprosthesis. Histopathology obtained from the operative specimen showed osteosarcoma with rhabdoid features. Two months after surgery, the patient is symptom-free and doing well; she is currently pending adjuvant chemotherapy. Although rhabdoid features have been described in extraskeletal osteosarcoma, this appears to be the first mention of osteosarcoma of bone with rhabdoid features in the literature

What is the Rate of Lumbar Adjacent Segment Disease after Percutaneous versus Open Fusion?

Objective: Adjacent segment disease (ASD) requiring treatment or re-operation is a common problem after surgery on the lumbar spine. The hypothesis of this retrospective study was that ASD occurs less often following lumbar spine fusion in patients who undergo percutaneous minimally invasive (MIS) instrumentation than in those in whom open instrumentation is used. Methods: A case-control study was performed on consecutive patients who had undergone staged single or two level anterior lumbar interbody fusion for degenerative conditions followed by open or MIS instrumentation from 2002 to 2005 in our institution. ASD was defined as that necessitating additional procedures for new symptoms related to an adjacent lumbar dermatome. Results: One hundred and seventeen patients met the inclusion criteria. Of these, 53 had been followed up by chart or medical record review for longer than one year. There were 23 patients in the MIS group and 30 in the open group. Of the 30 patients in the open group, 9 had developed ASD (30%). Of the 23 patients in the MIS group, 7 had developed ASD (30%). This difference is not statistically significant (P = 1.00). Conclusion: Contrary to our hypothesis, there was no significant difference in incidence of ASD in patients who had underwent open versus percutaneous instrumentation following anterior lumbar interbody fusion

Why you should wear your seatbelt on an airplane: Burst fracture of the atlas (jefferson fracture) due to in-flight turbulence

The Jefferson fracture is a burst-type fracture to the atlas first described in 1919, characterized by anterior and posterior fractures of the weak C1 ring caused by a sudden axial load to the vertex of the skull. Here we report a Jefferson fracture caused by head trauma due to mid-flight turbulence in an unrestrained 56-year-old male airline passenger. Imaging revealed a comminuted burst fracture of the atlas with an avulsion fracture of the transverse atlantal ligament. The patient was treated conservatively in a Miami-J collar with close clinical and radiographic follow-up. Lateral flexion-extension radiographs demonstrated fracture stability, and clinically the patient lacked pain or neurologic symptoms at 12 weeks from injury. To our knowledge this is the first report of a Jefferson fracture caused by axial compression attributable to in-flight turbulence. Traditionally associated with automobile crashes and diving headfirst into shallow pools, the axial load results in a compressive force to the atlas and subsequent lateral separation of the two halves of the C1 vertebral ring. The purpose of this case study is to alert providers, aircraft personnel, and passengers of the inherent risk of air travel and the importance of wearing a seatbelt at all times, describe the signs and symptoms of this often-overlooked fracture, and provide general treatment guidelines based on radiographic assessments of fracture stability

The Safety Profile of Percutaneous Minimally Invasive Sacroiliac Joint Fusion

Study Design: Literature review. Objectives: Systematic review of the existing literature to determine the safety of minimally invasive (MI) sacroiliac (SI) joint fusion through the determination of the rate of procedural and device-related intraoperative and postoperative complications. Methods: All original studies with reported complication rates were included for analysis. Complications were defined as procedural if secondary to the MI surgery and device related if caused by placement of the implant. Complication rates are reported using descriptive statistics. Random-effects meta-analysis was performed for preoperative and postoperative Visual Analog Score (VAS) pain ratings and Oswestry Disability Index (ODI) scores. Results: Fourteen studies of 720 patients (499 females/221 males) with a mean follow-up of 22 months were included. Ninety-nine patients (13.75%) underwent bilateral SI joint arthrodesis resulting in a total of 819 SI joints fused. There were 91 reported procedural-related complications (11.11%) with the most common adverse event being surgical wound infection/drainage (n = 17). Twenty-five adverse events were attributed to be secondary to placement of the implant (3.05%) with nerve root impingement (n = 13) being the most common. The revision rate was 2.56%. MI SI joint fusion reduced VAS scores from 82.42 (95% confidence interval [CI] 79.34-85.51) to 29.03 (95% CI 25.05-33.01) and ODI scores from 57.44 (95% CI 54.73-60.14) to 29.42 (95% CI 20.62-38.21). Conclusions: MI SI joint fusion is a relatively safe procedure but is not without certain risks. Further work must be done to optimize the procedure's complication profile. Possible areas of improvement include preoperative patient optimization, operative technique, and use of intraoperative real-time imaging

The 100 Classic Papers in Spinal Deformity Surgery

Bibliometric review of the literature. To identify and analyze the top 100 cited articles in spinal deformity surgery. The field of spinal deformity surgery is an ever-growing and complex field that owes its development to the work and visions of many dedicated individuals. The authors searched the Thomson Reuters Web of Knowledge for citations of all articles relevant to scoliosis and spinal deformity surgery. The number of citations, authorship, year, journal, and country and institution of publication were recorded for each article. The most cited article was the 2001 work by Lenke et al. describing a new 2-dimensional classification system of adolescent idiopathic scoliosis used to determine the appropriate vertebral levels to be included in an arthrodesis. The second most cited was Harrington's 1962 article describing the first instrumented method for the treatment of scoliosis. The third most cited article was the 1983 study by King et al. recommending specific vertebral levels for inclusion into spinal arthrodesis. Most articles originated in the United States (62), and most were published in Spine (32). Most were published in the 1990s (28), and the 3 most common topics, in descending order, were adolescent idiopathic scoliosis (28), spinal instrumentation (18), and surgical complications (5). Author Suk had 5 articles in the top 100 list, whereas authors Kim, Liljenqvist, Lonstein, and Weinstein had 3 each. Washington University in St. Louis had 7 articles in the top 100 list. This report's identification of the 100 classic articles in spinal deformity surgery allows insight into the development and trends of this challenging subspecialty of spine surgery. Furthermore, this article identifies individuals who have contributed the most to the advancement of spinal deformity surgery and the body of knowledge used to guide evidence-based clinical decision making in spinal deformity surgery today