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July-September 2022
Volume 13 | Issue 3
Page Nos. 221-363

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EDITORIAL  

External syringomyelia − is it an evidence of focal spinal instability? p. 221
Atul Goel
DOI:10.4103/jcvjs.jcvjs_109_22  
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REVIEW ARTICLES Top

Atlantoaxial instability secondary to Bartonella henselae osteomyelitis managed surgically by atlantoaxial instrumentation: A case report and systematic review p. 224
Mansour Mathkour, Julie Chu, Tyler Scullen, Naser Ibrahim, Cassidy Werner, Christopher J Carr, Brendan Huang, Hussam Abou-Al-Shaar, Robert F Dallapiazza, Christopher M Maulucci, Manish Singh
DOI:10.4103/jcvjs.jcvjs_206_20  
Cat scratch disease (CSD), caused by Bartonella henselae, may atypically present with vertebral osteomyelitis. Antibiotic regimens are tailored to presentation, which is markedly variable and not well defined for any atypical disease. In cases of spinal instability, the use of antibiotics alone may not be sufficient. Atlantoaxial instability caused by osteomyelitis is a rare complication of CSD. In this report, we describe the rare case of vertebral osteomyelitis complicated by atlantoaxial instability, requiring both antibiotics and atlantoaxial fusion. We discuss our case, surgical technique, rationale, and outcome. In addition, we conducted a systematic review of the literature of vertebral osteomyelitis in pediatric secondary to B. henselae. A 2-year-old child presented with a 2-month history of irritability, fever, and rigid neck pain along with a recent history of feline exposure. Physical examination revealed cervical tenderness and decreased range of motion. Computed tomography (CT) showed osteolysis of the right C1 lateral mass and pars articularis; T1-weighted magnetic resonance imaging with contrast showed enhancement around the right C1 lateral mass. The titer for B. henselae was high. A diagnosis of cat scratch osteomyelitis with cervical instability was made, for which the patient underwent surgery with atlantoaxial fusion. Postoperative imaging demonstrated resolution of the contrast-enhanced lesion. At 6-year follow-up, the patient showed no signs of residual complications from surgical intervention with a solid fusion. Our review revealed 44 cases of pediatric CSD vertebral osteomyelitis. Conservative management with antibiotic employed in 86% while antibiotics with surgical intervention in 14% of the cases. Surgical intervention was most often in the form of incision for drainage and decompression without fusion. Average follow-up 10 months with 86% achieved complete resolution. Cervical instability caused by osteolysis is a rare complication of CSD. This can subsequently lead to vertebral instability, requiring definitive surgical intervention.
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Diagnosis and management of isolated C1 fractures: A systematic review p. 233
Kyle Samuel Chan, Nathan A Shlobin, Nader S Dahdaleh
DOI:10.4103/jcvjs.jcvjs_61_22  
Objective: Atlas fractures are a common craniocervical injury, often resulting from trauma. However, diagnosis and management of atlas fractures continues to be the subject of controversy. We aimed to characterize the factors related to diagnosis of atlas fractures, delineate important considerations in selecting the optimal management for a patient with an atlas fracture, and compare outcomes of surgical and conservative management. Methods: We performed a systematic review using PubMed, Embase, and Scopus to identify articles that analyzed diagnosis and management of isolated atlas fractures published between 2013 and 2020. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. Results: Of 305 resultant articles, 13 were included. C1:C2 ratio and lateral mass displacement (LMD) were used to predict transverse atlantal ligament (TAL) injury. Surgery promoted high fusion rates overall. Stable atlas fractures achieved high fusion rates with conservative management, while spinal fusion promoted greater fusion rates than halo vest immobilization management for unstable fractures. Visual Analog Scale scores, range of motion, and/or LMD improved after surgery. LMD increased for unilateral sagittal split fractures with TAL injury after conservative treatment. Conclusion: Stable atlas fractures can be sufficiently treated conservatively. Unstable atlas fractures can be managed both conservatively and surgically, while surgery is associated with favorable outcomes for unstable isolated atlas fractures. Future studies are necessary to further guide risk stratification and treatment approaches in management of the patients with isolated atlas fractures.
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The current status and surgical outcome of the minimally invasive techniques for lumbar interbody fusion in India: A systematic review and meta-analysis p. 245
Ashutosh Kumar, Jayesh Sardhara, Prabhaker Mishra, Vishwas Kapoor, Anant Mehrotra, Vandan Raiyani, Mayank Singh, Nishant Goyal, Arvind G Kulkarni, Umesh Srikantha, Kamlesh Singh Bhaisora, Kuntal Kanti Das, Arun K Srivastava, Sanjay Behari
DOI:10.4103/jcvjs.jcvjs_4_22  
Objective: The global shift of trends to minimally invasive spine (MIS) surgery for lumbar degenerative diseases has become prominent in India for few decades. We aimed to assess the current status of MIS techniques for lumbar interbody fusion and their surgical outcomes in the Indian population. Materials and Methods: A systematic review (following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines) was performed using PubMed and Google Scholar till November 2020. The primary (visual analog scale [VAS] and oswestry disability index [ODI] scores; intraoperative blood loss; duration of surgery; duration of hospital stay, and fusion rate) and secondary (wound-associated complications and dural tear/cerebrospinal fluid (CSF) leak) outcomes were analyzed using Review Manager 5.4 software. Results: A total of 15 studies comprising a total of 1318 patients were included for analysis. The pooled mean of follow-up duration was 26.64 ± 8.43 months (range 5.7–36.5 months). Degenerative spondylolisthesis of Myerding grade I/II was the most common indication, followed by lytic listhesis, herniated prolapsed disc, and lumbar canal stenosis. The calculated pooled standard mean difference (SMD) suggested a significant decrease in postoperative ODI scores (SMD = 5.53, 95% confidence interval [CI] = 3.77–7.29; P < 0.01) and VAS scores (SMD = 6.50, 95% CI = 4.6–8.4; P < 0.01). The pooled mean blood loss, duration of postoperative hospital stay, duration of surgery, and fusion rate were 127.75 ± 52.79 mL, 4.78 ± 3.88 days, 178.59 ± 38.69 min, and 97.53% ± 2.69%, respectively. A total of 334 adverse events were recorded in 1318 patients, giving a complication rate of 25.34%. Conclusions: Minimally invasive transforaminal lumbar interbody fusion (TLIF) is the most common minimally invasive technique employed for lumbar interbody fusion in India, while oblique lumbar interbody fusion is in the initial stages. The surgical and outcome-related factors improved significantly after MIS LIF in the Indian population.
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Os odontoideum: A comprehensive review p. 256
Sia Cho, Nathan A Shlobin, Nader S Dahdaleh
DOI:10.4103/jcvjs.jcvjs_71_22  
Os odontoideum (OO) is a rare craniocervical anomaly that is characterized by a round ossicle separated from the C2 vertebral body. With a controversial etiology and unknown prevalence in the population, OO may be asymptomatic or present in patients with myelopathic and neurological symptoms. In this literature review, we aimed to investigate epidemiology, embryology, pathophysiology, clinical presentation, and the role of diagnostic radiography in OO. By providing an overview of different management strategies, surgical complications, and postoperative considerations for OO, our findings may guide neurosurgeons in providing proper diagnosis and treatment for OO patients. A literature review was conducted using the PubMed, EMBASE, and Scopus databases. A search using the query “os odontoideum” yielded 4319 results, of which 112 articles were chosen and analyzed for insights on factors such as etiology, clinical presentation, and management of OO. The presentation of OO varies widely from asymptomatic cases to severe neurological deficits. Asymptomatic patients can be managed either conservatively or surgically, while symptomatic patients should undergo operative stabilization. Although multiple studies show different techniques for surgical management involving posterior fusion, the diversity of such cases illustrates how treatment must be tailored to the individual patient to prevent complications. Conflicting studies and the paucity of current literature on OO highlight poor comprehension of the condition. Further understanding of the natural history of OO is critical to form evidence-based guidelines for the management of OO patients. More large-center studies are thus needed to promote accurate management of OO patients with optimal outcomes.
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Sporadic hemangioblastoma of cauda equina: A case report and brief literature review p. 265
Salvatore D' Oria, David Giraldi, Daniel Andres Alvarado Flores, Domenico Murrone, Vincenzo D' Angelo, Bipin Chaurasia
DOI:10.4103/jcvjs.jcvjs_87_22  
Background: Hemangioblastomas (HBs) are rare lesions accounting for 1%–5% of all spinal cord tumors, and are mostly associated with Von Hippel-Lindau (VHL) syndrome. Localization in the cauda equina is uncommon. Aim: In this manuscript, we aimed to describe a rare case of sporadic intradural extramedullary HB of the cauda equina and present a literature review. Mathods: A systematic research was performed on PubMed, MEDLINE, and Google Scholar, using the keywords “spinal HB” and “cauda equina tumors.” The previous literature is integrated by the description of the present case. A 49-year-old female presented in August 2020 to our institution with a magnetic resonance imaging (MRI) which showed an intradural mass at L1/2 level and angiography that showing a nidus of serpiginous vessels inside the lesion. Symptoms were right sciatica and paresthesia in right L5 radicular dermatome for more than 3 months. Neurological examination revealed claudicatio spinalis and hypoesthesia on right L5 dermatome and weakness of right anterior tibialis muscle. Microsurgical en bloc resection of lesion was performed with adjuvant neurophysiological intraoperative monitoring. The histological examination provided the diagnosis of HB. Results: After surgery, symptoms and neurological impairment gradually improved. Postoperative MRI showed no residual tumor. Conclusions: Although intradural extramedullary HB of the cauda equina without VHL syndrome is a rare pathological entity, this diagnosis must be taken in consideration when a mass affects cauda equina. Preoperative embolization is an option to minimize intraoperative bleeding. Radiosurgery seems to prevent recurrences when the tumor is not completely excised. A complete surgical removal of the lesion is usually possible and it leads to a low likelihood of recurrence.
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ORIGINAL ARTICLES Top

Cervical deformity patients with baseline hyperlordosis or hyperkyphosis differ in surgical treatment and radiographic outcomes p. 271
Peter Gust Passias, Haddy Alas, Nicholas Kummer, Peter Tretiakov, Bassel G Diebo, Renaud Lafage, Christopher P Ames, Breton Line, Eric O Klineberg, Douglas C Burton, Juan S Uribe, Han Jo Kim, Alan H Daniels, Shay Bess, Themistocles Protopsaltis, Gregory M Mundis, Christopher I Shaffrey, Frank J Schwab, Justin S Smith, Virginie Lafage, International Spine Study Group
DOI:10.4103/jcvjs.jcvjs_66_21  
Background: Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), although patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD corrective surgery with regard to HK and hyperlordosis (HL). Objective: The objective of the study is to evaluate patterns in treatment for CD patients with baseline (BL) HK and HL and understand how extreme curvature of the spine may influence surgical outcomes. Materials and Methods: Operative CD patients with BL and 1-year (1Y) radiographic data were included in the study. Patients were stratified based on BL C2–C7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (−6.96 ± 21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (<−28.43°) depending on directionality. Patients within 1SD were considered control group. Results: 102 surgical CD patients (61 years, 65% F, 30 kg/m2) with BL and 1Y radiographic data were included. 20 patients met definitions for HK and 21 patients met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with posterior approach. Operative time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-SVA (10.8 vs. 7.0 vs. −47.8 mm, P = 0.001). HL patients had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had 3x revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL patients had higher cSVA and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK patients had higher McGregor's slope (MGS) (16.1° vs. 3.3°, P = 0.002) and C0–C2 Cobb (43.3° vs. 26.9°, P < 0.001), however, postoperative differences in MGS and C0–C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary CT (38.1%), UT (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1-year postoperative, perhaps due to undercorrection compared to kyphotic etiologies.
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Total disc replacement alters the biomechanics of cervical spine based on sagittal cervical alignment: A finite element study p. 278
Muzammil Mumtaz, Justin Mendoza, Sudharshan Tripathi, Amey Kelkar, Norihiro Nishida, Ashish Sahai, Vijay K Goel
DOI:10.4103/jcvjs.jcvjs_21_22  
Introduction: The correlation between cervical alignment and clinical outcome of total disc replacement (TDR) surgery is arguable. We believe that this conflict exists because the parameters that influence the biomechanics of the cervical spine are not well understood, specifically the effect of TDR on different cervical alignments. Methods: A validated osseo-ligamentous model from C2-C7 was used in this study. The C2-C7 Cobb angle of the base model was modified to represent: lordotic (−10°), straight (0°), and kyphotic (+10°) cervical alignment. The TDR surgery was simulated at the C5-C6 segment. The range of motion (ROM), intradiscal pressure, annular stresses, and facet loads were computed for all the models. Results: The ROM results demonstrated kyphotic alignment after TDR surgery to be the most mobile when compared to intact base model (41% higher in flexion–extension, 51% higher in lateral bending, and 27% higher in axial rotation) followed by straight and lordotic alignment, respectively. The annular stresses for the kyphotic alignment when compared to intact base model were higher at the index level (33% higher in flexion–extension and 48% higher in lateral bending) compared to other alignments. The lordotic model demonstrated higher facet contact forces at the index level (75% higher in extension than kyphotic alignment, 51% higher in lateral bending than kyphotic alignment, and 78% higher in axial rotation than kyphotic alignment) when compared among the three alignment models. Conclusion: Preoperative cervical alignment should be an integral part of surgical planning for TDR surgery as different cervical alignments may significantly alter the postsurgical outcomes.
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A comparative study between preoperative and postoperative conventional autonomic functions in congenital craniovertebral junction anomalies p. 288
Hardik L Siroya, Dhananjaya Ishwar Bhat, Bhagavatula Indira Devi, Dhaval P Shukla
DOI:10.4103/jcvjs.jcvjs_57_22  
Background: Autonomic nervous system (ANS) is invariably affected by craniovertebral junction (CVJ) anomalies. The usual presentation is sudden after trivial trauma. When symptomatic, most of this autonomic dysfunction is clearly elicited clinically with bedside tests. Nonetheless, ANS functionality in relatively less symptomatic or asymptomatic patients is not known as no studies exist. Methodology: We performed a longitudinal prospective study of 40 less symptomatic patients who underwent surgery with conventional autonomic function tests (AFT) in pre- and post-operative periods. Correlation of its association with such anomalies is studied. Results: All 40 had both pre- and post-operative clinical follow-up, pre-operative AFT, whereas only 22 patients had follow-up AFT. The mean age for the group was 32 years and male: female ratio was 2.3:1. Mean Nurick's grade was 1.8, whereas Barthel's index was 83.75%. Clinical improvement was seen in almost 98% at follow-up. Orthostatic test showed a significant association with Nurick's grade. Barthel's index was significantly associated with degree of compression. The mean follow-up was 17.4 months. Most conventional AFTs were significantly decreased in the preoperative period (P ≤ 0.01). Both parasympathetic and sympathetic tone improved on follow-up with better improvement later. Overall clinical involvement of ANS was seen in 22.5% whereas subclinical involvement in the form of AFT impairment was seen in 100%. Conclusion: There is a definite involvement of subclinical ANS in all patients of CVJ anomalies irrespective of their symptomatology. Knowing the extent of involvement in the preoperative period can help prognosticate, prioritize regarding surgery as well as correlate with the extent of improvement.
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How does spinopelvic alignment influence short-term clinical outcomes after lumbar fusion in patients with single-level degenerative spondylolisthesis? p. 300
Stephen DiMaria, Brian A Karamian, Mark J Lambrechts, Arun P Kanhere, John J Mangan, Winston W Yen, Arlene Maheu, Mahir A Qureshi, Jose A Canseco, David I Kaye, Barrett I Woods, Mark F Kurd, Kris E Radcliff, Alan S Hilibrand, Christopher K Kepler, Alexander R Vaccaro, Gregory D Schroeder
DOI:10.4103/jcvjs.jcvjs_58_22  
Context: Studies on adult spinal deformity have shown spinopelvic malalignment results in worse outcomes. However, it is unclear if this relationship exists in patients with single-level degenerative spondylolisthesis (DS) receiving short-segment fusions. Aims: To determine if spinopelvic alignment affects patient-reported outcome measures (PROMs) after posterior lumbar decompression and fusion (PLDF) with or without a transforaminal lumbar interbody fusion in patients with L4-5 DS. Settings and Design: A retrospective cohort analysis was conducted on patients who underwent PLDF for L4-5 DS at a single tertiary referral academic medical center. Materials and Methods: Patients were divided into groups based on preoperative cutoff values of 20° for pelvic tilt (PT) and 11° for pelvic incidence-lumbar lordosis mismatch (PI-LL) with subsequent reclassification based on correction to <20° PT or 11° PI-LL. Radiographic outcomes and PROMs were compared between the groups. Statistical Analysis Used: Multiple linear regression analyses were performed to determine whether radiographic cutoff values served as the independent predictors of change in PROMs. Statistical significance was set at P < 0.05. Results: A total of 188 patients with completed PROMs were included for the analysis. Preoperative PT >20° was associated with significantly greater reduction in PI-LL (−2.41° vs. 1.21°, P = 0.004) and increase in sacral slope (SS) (1.06° vs. −1.86°, P = 0.005) compared to patients with preoperative PT <20°. On univariate analysis, no significant differences were observed between any groups with regard to PROMs. Preoperative sagittal alignment measures and postoperative correction were not found to be independent predictors of improvement in clinical outcomes. Conclusion: A preoperative PT >20° is associated with improved PI-LL reduction and an increase in SS. However, no differences in clinical outcomes were found 1 year postoperatively for patients with preoperative PT >20° and PI-LL ≥11° compared to patients below this threshold.
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Magnetic resonance imaging anatomy of the craniovertebral ligaments: A radiological study with confirmatory dissection p. 309
Peter Grant Osmotherly, Gary J Cowin, Darren A Rivett
DOI:10.4103/jcvjs.jcvjs_62_22  
Background: Descriptions of the radiological appearance of the craniovertebral ligaments often lack detail. This study aimed to provide an accurate description of the morphology and radiological appearance of the alar and cruciform ligaments with confirmation of findings by fine dissection. Materials and Methods: Six embalmed human cadaveric specimens were reduced to an osseoligamentous arrangement spanning the C2/3 disc to the occiput. Specimens were imaged on a 4.6T Bruker magnetic resonance (MR) system using a 3D RARE multiple SE sequence with acquisition time 18 h 24 min. Acquired images were viewed in three planes, and detailed descriptions and morphometric measurement of the ligaments were obtained. Specimens were then examined and described using fine dissection. Direct comparison of the descriptions of each method was undertaken. Results: From imaging, detailed features of all alar ligaments could be identified in all specimens. Consistency in shape, orientation, and attachments is described. Attachment to the medial aspect of the atlantooccipital joints was evident in all specimens. Five of six alar ligament pairs contained fibers that traversed the dens without attachment. Ascending cruciform ligaments could be clearly identified in four of six specimens. No descending cruciform ligaments could be clearly delineated. Detailed features of the transverse ligaments could be identified and described in all planes. Dissection findings were mostly consistent with descriptions obtained from MR images. Conclusion: 4.6T MR images provide accurate detail of the structure, dimensions, and attachments of the craniovertebral ligaments. The morphology of the craniovertebral ligaments assessed radiologically was consistent with findings on gross dissection.
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Polymorphisms in paired box 1 gene were associated with susceptibility of adolescent idiopathic scoliosis: A case–control study p. 318
Antônio Eulálio Pedrosa, Gustavo Borges Laurindo de Azevedo, Jessica Vilarinho Cardoso, João Antonio Matheus Guimarães, Helton Luiz Aparecido Defino, Jamila Alessandra Perini
DOI:10.4103/jcvjs.jcvjs_54_22  
Background: Association of genetic polymorphisms in paired box 1 (PAX-1) gene can influence the development of adolescent idiopathic scoliosis (AIS). PAX-1 is mainly expressed in the region of the vertebral bodies and intervertebral discs, being important for the proper formation of spinal structures. Objectives: The objective of this study was to evaluate the association of polymorphisms in PAX-1 gene with the susceptibility of AIS. Settings and Design: This was an analytical observational case–control study. Materials and Methods: Samples of 59 AIS indicated for surgical treatment, and 119 controls, without spinal disease were genotyped for PAX-1 rs6137473 and rs169311 polymorphisms. Statistical Analysis: The association of the polymorphisms with AIS was evaluated by a multivariable logistic regression model, using odds ratios (OR) and 95% confidence intervals (CI). Results: According to Lenke's classification, 89.8% had Type I and 10.2% II curves. The mean value of the Cobb angle of the proximal thoracic curve was 30.8°, 58.7° thoracic, and 30.4° for the lumbar and on the bending films 14.6°, 40.7°, and 11°, respectively. Among the AIS group, there was a predominance of females (8.8:1). The PAX-1 rs169311 and rs6137473 polymorphisms were positively associated with developing the AIS (OR = 1.98; 95% CI = 1.2–3.3 and OR = 3.16; 95% CI = 1.4–7.3, respectively). The rs6137473 polymorphism was associated with the lumbar modifier B and C compared to A (OR = 2.52; 95% CI = 1.1–5.8). Conclusions: PAX-1 polymorphisms were associated with an increased risk of developing the AIS and with curve severity and can be used as a biomarker to map the risk of developing surgical-grade AIS, guiding the treatment of patients.
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An evaluation of patients with abdominal pain after lateral lumbar interbody fusion p. 325
Tristan B Fried, Khoa Tran, Mark J Lambrechts, Nicholas D D'Antonio, Brian A Karamian, Justin Chu, Jose A Canseco, Alan S Hilibrand, Christopher K Kepler, Alexander R Vaccaro, Gregory D Schroeder
DOI:10.4103/jcvjs.jcvjs_82_22  
Context: Abdominal pain after surgery can occur for numerous reasons. Postoperative radiographs may be indicated to evaluate for ileus or other reasons for the pain. Whether outcomes are significantly different based on whether patients get radiographs following lateral lumbar interbody fusion (LLIF) are unclear. Aims: To investigate the postoperative outcomes of patients experiencing abdominal pain after LLIF. Settings and Design: This retrospective cohort study included patients at a tertiary academic medical center and surrounding affiliated hospitals. Materials and Methods: Patients >18 years of age who underwent elective LLIF at a single institution were retrospectively identified. Patients were stratified into two groups depending on whether they received a postoperative abdominal radiograph or computed tomography (CT) scan for postoperative abdominal pain. Statistical Analysis: Patient demographics, surgical characteristics, and surgical outcomes were compared between groups utilizing independent t-tests or Mann–Whitney U-tests for continuous variables or Pearson's Chi-square tests for categorical variables. Results: A total of 153 patients (18 with abdominal scans, 135 without) were included. Patients who received a postoperative abdominal radiograph or CT scan were more likely to undergo exploratory laparotomy (11.1% vs. 0.00%, P = 0.013). Ultimately, patients with abdominal scans had a longer hospital length of stay (6.67 vs. 3.79 days, P = 0.002) and were discharged home less frequently (71.4% vs. 83.7%, P = 0.002). Conclusions: Patients who received abdominal imaging after LLIF were more likely to undergo exploratory laparotomy, experience longer hospital length of stay, and were discharged home less frequently. Intra-abdominal air on postoperative imaging without corresponding physical exam findings consistent with bowel injury is not an appropriate indication for surgical intervention.
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What is a better value for your time? Anterior cervical discectomy and fusion versus cervical disc arthroplasty p. 331
Austen David Katz, Junho Song, Daniel Bowles, Terence Ng, Eric Neufeld, Sayyida Hasan, Dean Perfetti, Nipun Sodhi, David Essig, Jeff Silber, Sohrab Virk
DOI:10.4103/jcvjs.jcvjs_69_22  
Introduction: Compared to anterior cervical discectomy and fusion (ACDF), the motion preservation of cervical disc arthroplasty (CDA) provides an attractive alternative with similar short-term results. However, there is a paucity of the economics of performing CDA over ACDF. Study Design: This was retrospective study. Objective: The objective of this study is to evaluate relative-value-units (RVUs), operative time, and RVUs-per-minute between single-level ACDF and CDA. Secondary outcomes included 30-day readmission, reoperation, and morbidity. Methods: Adults who underwent ACDF or CDA in 2011–2019 National Surgical Quality Improvement Program database datasets. Multivariate quantile regression was utilized. Results: There were 26,595 patients (2024 CDA). ACDF patients were older, more likely to be female, discharged to inpatient rehabilitation, and have a history of obesity, smoking, diabetes, steroid use, and the American Society of Anesthesiologists-class ≥≥3. ACDF had greater median RVUs-per-case (41.2 vs. 24.1) and RVUs-per-minute (0.36 vs. 0.27), despite greater operative-time (109 min vs. 92 min) (P < 0.001). ACDF predicted a 16.9 unit increase in median RVUs per case (P < 0.001, confidence interval [CI]95: 16.3–17.5), an 8.81 min increase in median operative time per case (P < 0.001, CI95: 5.69–11.9), and 0.119 unit increase in median RVUs-per-minute (P < 0.001, CI95: 0.108–0.130). ACDF was associated with greater unadjusted rates of readmission (3.2% vs. 1.4%) morbidity (2.3% vs. 1.1%) (P < 0.001), but similar rates of reoperation (1.3% vs. 0.8%, P = 0.080). After adjusting for significant patient-related and procedural factors, readmission (odds ratio [OR] = 0.695, P = 0.130, CI95: 0.434–1.113) and morbidity (OR = 1.102, P = 0.688, CI95: 0.685–1.773) was similar between ACDF and CDA. Conclusions: Median RVUs-per-minute increased by 0.119 points for ACDF over CDA, or $257.7/h for each additional-hour of surgery. Adjusted 30-day outcomes were similar between procedures. Reimbursement for CDA does not appear to be in line with ACDF and may be a barrier to widespread usage.
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Correlation between the cervical sagittal alignment and spine - pelvic sagittal alignment in asymptomatic adults p. 339
Juan Esteban Muñoz Montoya, Andrés Felipe Vargas Rosales, Diana Paola Duarte Mora, Johan David Serrato Perdomo, Gabriel Vargas Rosales, Gerardo Ardila Duarte, Erik Edgardo Muñoz Rodríguez
DOI:10.4103/jcvjs.jcvjs_73_22  
Background: Although there are studies that adequately document the linear correlation between pelvic incidence (PI), sacral slope, lumbar lordosis, and thoracic kyphosis, few have analyzed the pelvic-spine correlation including the cervical spine. Methods: This is a cross-sectional study, wherein the cervical spine was evaluated using radiography and computed tomography (CT) scans, the lumbosacral spine and the pelvis was evaluated using radiography, in adult patients without spinal pathology. Using the Surgimap tool, cervical and spinopelvic parameters were calculated by several investigators. To evaluate the correlation between cervical and spinopelvic parameters, Spearman's coefficient was calculated. To evaluate the concordance correlation of the measured parameters of cervical sagittal alignment on tomography and conventional radiography, Lin's coefficient was calculated and Bland–Altman plots were performed. Results: A total of 51 healthy adults were included in a follow-up from January 2019 to December 2020. Cervical sagittal alignment and sagittal spinopelvic alignment were assessed using radiography, and a correlation was observed between T1 slope (T1S) and lumbar mismatch (coefficient of 0.28, P = 0.047). Then, cervical sagittal alignment was evaluated using CT and sagittal spinopelvic alignment using radiography, and no correlation was observed between PI and thoracic inlet angle or cervical mismatch with lumbar mismatch. Conclusion: In asymptomatic patients, in whom cervical sagittal alignment and spinal-pelvic alignment were evaluated, only a positive correlation was found between lumbar mismatch and T1S, which lacks clinical significance. No concordance was identified between lumbar mismatch and cervical mismatch. Therefore, it is inferred that there is an independence between the sagittal spine-pelvic alignment with respect to the sagittal cervical alignment.
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Unilateral atlanto-occipital injury: A case series and detailed radiographic description p. 344
Jacob Richard Lepard, Logan A Reed, Steven M Theiss, Sakthi Rajan Rajaram
DOI:10.4103/jcvjs.jcvjs_79_22  
Context: Atlanto-occipital dissociation is a highly lethal ligamentous injury at the craniocervical junction (CCJ). Previous studies have described rare cases of milder forms of atlanto-occipital injury (AOI) which might be managed nonoperatively, but there is a paucity of literature on this subject. Aims: We retrospectively reviewed our institutional experience to characterize the injury patterns, treatments, and clinical courses of patients with unilateral AOI. Methods: We included patients with radiographic evidence of unilateral occipitocervical joint capsular disruption, distraction, or edema ± injury of the apical ligament, tectorial membrane, anterior atlanto-occipital membrane, posterior atlanto-occipital membrane, alar ligaments, or cruciate ligament. The long-term outcomes were gathered from medical records, and six patients were available for Neck Disability Index via phone call at the time of the study. Results: Eight patients were included in the study. The mean age was 45.1 years ± 26.5. Causes of trauma included motor vehicle collision for five patients (5/8, 62.5%), falls for two (2/8, 25), and assault for one (1/8, 12.5%). All patients had a widened condyle-C1 interval >2 mm. Three patients underwent occipitocervical fusion, one patient underwent atlantoaxial fusion, and another received subaxial fusions for other injuries. Three patients underwent no surgical intervention. All patients were seen at least once as an outpatient following hospital discharge. There were no delayed neurologic injuries or deaths. Conclusions: We propose that ligamentous injury at the CCJ functions more as a spectrum rather than dichotomous diagnosis, of which a subset can likely be safely managed nonoperatively.
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Comparison of clinical and radiological results of dynamic and rigid instrumentation in degenerative lumbar spinal stenosis p. 350
Eyup Varol, Mustafa Umut Etli, Furkan Avci, Cumhur Kaan Yaltirik, Ali Fatih Ramazanoglu, Mehmet Resid Onen, Sait Naderi
DOI:10.4103/jcvjs.jcvjs_63_22  
Objective: Lumbar spinal stenosis is defined as a clinical syndrome characterized by neurogenic claudication or radicular pain due to the narrowing of the spinal canal or neural foramen and the compression of its neural elements. Surgical treatment is applied to decompress the neural structures. In some cases, transpedicular instrumentation and fusion may also be applied. In this study, we aimed to investigate and compare the preoperative and postoperative, clinical and radiological aspects of patients with lumbar spinal stenosis who underwent lumbar instrumentation using a polyetheretherketone (PEEK) rod or a titanium rod. Materials and Methods: In this study, the files of 293 patients who underwent posterior lumbar transpedicular stabilization between January 2015 and February 2018 in the Neurosurgery Clinic of Ümraniye Training and Research Hospital were reviewed retrospectively. Patients who did not meet the study criteria were excluded, and 127 patients who met the criteria and underwent posterior lumbar transpedicular stabilization due to lumbar spinal stenosis and/or lumbar degenerative disc disease were retrospectively reviewed. The patients were divided into two groups, dynamic and rigid, according to the rod types used. The two groups were compared using various postoperative clinical and radiological parameters. Results: The demographic data, surgical data, Visual Analog Scale-Oswestry Disability Index (VAS-ODI) data, and radiological data of both groups were carefully examined. There were 63 patients in the rigid group and 64 patients in the dynamic group. The age range in both groups was from 30 to 78 years, with a mean age of 56.44 years; 99 of the cases were female and 28 were male. The analysis of the participants' demographic data showed no significant differences between the two groups. Compared with the preoperative data, the postoperative evaluations revealed a significant decrease in VAS and ODI, but no significant difference was observed between the two groups. There was no difference between the two groups in terms of duration of surgery, follow-up time, operating distances, hospitalization duration, pseudoarthrosis, or fusion. Regarding the total and segmental range of motion, the affection was less in the dynamic group, which allowed for more movement. While there was no difference in disc height index between the two preoperative groups, it was observed that it was better maintained in the rigid group in the postoperative long term. Regarding foraminal height (FH), there was no difference between the two groups in the preoperative and early postoperative periods, but in the long term, FH was better maintained in the dynamic group. The long-term follow-ups revealed that adjacent segment disease (ASD) had developed in 19 patients in the rigid group, whereas ASD developed in only nine patients in the dynamic group. Based on these results, the probability of developing significant ASD in the rigid group was higher. Conclusion: Previous experience with PEEK rod systems has demonstrated physiological spine movement, increased fusion rates, minimal complications, reduction in adjacent segment degeneration, and biomechanical compatibility. Although further long-term studies are needed and the cost of PEEK systems is likely to be a barrier, the results of the present study support the use of PEEK rods and other dynamic systems in spinal surgery.
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Comparative outcome analysis of lateral mass fixation and trans-facet fixation with posterior decompression in the management of cervical spondylotic myelopathy: An institutional experience p. 357
Deepak Kumar Singh, Vijay Kumar, Kuldeep Yadav, Kaif Mohammad, Prevesh Kumar Sharma
DOI:10.4103/jcvjs.jcvjs_51_22  
Aims and Objectives: Posterior subaxial cervical fusion with lateral mass screw and rod instrumentation is a well-established fixation technique. Subaxial transarticular facet fixation is a lesser known fusion technique that has been shown to be biomechanically equivalent to lateral mass screws. The aim of this study was to evaluate the outcome of cervical decompressive laminectomy with lateral mass fixation compared with decompressive laminectomy with trans-facet fixation. Materials and Methods: The study was conducted with 20 patients operated for cervical decompressive laminectomy with lateral mass fixation compared with 20 patients operated with trans-facet fixation. The modified Japanese orthopedic association score (mJOA) scale, Nurick's functional grading and neurological recovery rate (NRR) was used as the functional outcome measurement. The clinical follow-up period was 6 months. Results: In Group I, the mean preoperative and postoperative mJOA scores in Group I and II were 8.2 ± 2.1 and 12.7 ± 2.8 and 9.3 ± 1.9 and 13.5 ± 1.88, respectively, were statistically significant (P < 0.05). Postoperative NRR at the end of the follow-up period was satisfactory (excellent and good) 55% in Group I and 60% in Group II. Fusion was documented in all 40 patients. No patients experienced neural or vascular injury as a result of screw position. Conclusions: Both trans-facet and lateral mass fixation techniques are simple, safe, and effective procedures in achieving relief and improvement in patients with multilevel cervical spondylotic myelopathy. Trans-facetal fixation can provide a reasonable alternative to lateral mass fixation.
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