Robot-guided versus freehand fluoroscopy-guided minimally invasive transforaminal lumbar interbody fusion: a single-institution, observational, case-control study

OBJECTIVE The use of robotics in spinal surgery has gained popularity because of its promising accuracy and safety. ROSA is a commonly used surgical robot system for spinal surgery. The aim of this study was to compare outcomes between robot-guided and freehand fluoroscopy-guided instrumentation in minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF). METHODS This retrospective consecutive series reviewed 224 patients who underwent MIS-TLIF from March 2019 to April 2020 at a single institution. All patients were diagnosed with degenerative pathologies. Of those, 75 patients underwent robot-guided MIS-TLIF, and 149 patients underwent freehand fluoroscopy-guided MIS-TLIF. The incidences of pedicle breach, intraoperative outcomes, postoperative outcomes, and short-term pain control were compared. RESULTS The patients who underwent robot-guided surgery had a lower incidence of pedicle breach (0.27% vs 1.75%, p = 0.04) and less operative blood loss (313.7 ± 214.1 mL vs 431.6 ± 529.8 mL, p = 0.019). Nonsignificant differences were observed in operative duration (280.7 ± 98.1 minutes vs 251.4 ± 112.0 minutes, p = 0.056), hospital stay (6.6 ± 3.4 days vs 7.3 ± 4.4 days, p = 0.19), complications (intraoperative, 1.3% vs 1.3%, p = 0.45; postoperative surgery-related, 4.0% vs 4.0%, p = 0.99), and short-term pain control (postoperative day 1, 2.1 ± 1.2 vs 1.8 ± 1.2, p = 0.144; postoperative day 30, 1.2 ± 0.5 vs 1.3 ± 0.7, p = 0.610). A shorter operative duration for 4-level spinal surgery was found in the robot-guided surgery group (388.7 ± 107.3 minutes vs 544.0 ± 128.5 minutes, p = 0.047). CONCLUSIONS This retrospective review revealed that patients who underwent robot-guided MIS-TLIF experienced less operative blood loss. They also benefited from a shorter operative duration with higher-level (> 3 levels) spinal surgery. The postoperative outcomes were similar for both robot-guided and freehand fluoroscopy-guided procedures.

Evaluation of the effect of preoperative anxiety on intraoperative hemodynamic stability and drug consumption in patients who underwent BIS-guided total intravenous anesthesia (TIVA) for neurophysiological monitoring in spine surgery

In our study, the aim was to evaluate the effects of preoperative anxiety measured by Spielberger’s State-Trait Anxiety Inventory-State (STAI-S) and State-Trait Inventory-Trait (STAI-T) scores on intraoperative hemodynamic stability, drug consumption and recovery in patients who underwent spinal surgery with neurophysiological monitoring and total intravenous anesthesia with bispectral index (BIS) monitoring, without the use of muscle relaxants. Eighty patients with planned spinal surgery and neurophysiological monitoring were included in this prospective observational study. Anxiety scores were recorded by applying Spielberger’s STAI-T and STAI-S scoring questionnaires to all patients included in the study 1 hour before the operation. Age, gender and American Society of Anesthesiologists (ASA) scores of the patients who were taken to the operating table without premedication were recorded. Before anesthesia induction, standard monitoring including electrocardiography (ECG), noninvasive blood pressure, peripheral oxygen saturation (SpO2), BIS was applied. The correlation between STAI-T and STAI-S scores with demographic characteristics of patients, preoperative, post-induction, 5th minute, 10th minute, 30th minute, 50th minute, 70th minute, 90th minute heart rate (HR), mean arterial pressure (MAP), SpO2, operation time, recovery time, and total amount of propofol and remifentanil used during the operation were evaluated statistically. A significant negative correlation was observed between STAI-S anxiety scoring and age (p < 0.05). A significant positive correlation was found between the total amount of remifentanil and propofol used with the STAI-S score (p < 0.05). Significant positive correlations were observed between the STAI-S score and the HR value preoperatively, and in the 5th, 30th, 50th, 70th, and 90th minutes (p < 0.05). Our study showed that preoperative anxiety increases intraoperative drug consumption and heart rate. It is of great importance to keep the amount of intraoperative medication at optimal levels, to measure preoperative anxiety, and to eliminate it with multimodal treatments, especially for the accurate detection of neurological damage in patients with neurophysiological monitoring.

Enhanced recovery after surgery in pediatric spine surgery: systematic review

Objective. To conduct a systematic review of the literature on the use of enhanced recovery after surgery (ERAS) protocols in spinalsurgery of children and adolescents to determine the existing evidence of the effectiveness of ERAS implementation in clinical practice.Material and Methods. The authors conducted a systematic review of the literature on ERAS in spinal and spinal cord surgery in children and adolescents selected in the databases of medical literature and search resources of PUBMED/MEDLINE, Google Scholar, Cochrane Library and eLibrary according to the PRISMA guidelines and the PICOS inclusion and exclusion criteria.Results. A total of 12 publications containing information on the treatment of 2,145 children, whose average age was 14.0 years (from 7.2 to 16.1), were analyzed. In the reviewed publications, the average number of key elements of the ERAS program was 9 (from 2 to 20), and a total of 23 elements used in spinal surgery in children and adolescents were identified. The most commonly used elements were preoperative education and counseling, prevention of infectious complications and intestinal obstruction, multimodal analgesia, refusal of routine use of drains, nasogastric probes and urinary catheters, standardized anesthesia protocol, early mobilization and enteral loading. The introduction of the ERAS protocol into clinical practice allowed to reduce the complication rate in comparison with the control group by 8.2 %(from 2 to 19 %), the volume of blood loss by 230 ml (from 75 to 427 ml), the operation time by 83 minutes (from 23 to 144 minutes), theduration of hospitalization by 1.5 days (from 0.5 to 3 days) and the total cost of treatment by 2258.5 dollars (from 860 to 5280 dollars).The ERAS program was implemented in pediatric clinics in the USA (75 %), France (8 %) and Canada (17 %).Conclusion. The conducted systematic review of the literature allows us to conclude that the technology of enhanced recovery after surgery is a promising technology that improves surgical outcomes and is applicable in pediatric practice. There is a significant shortage of published studies evaluating the implementation of ERAS in pediatric surgical practice in general, and in spinal surgery in particular, which requires further prospective randomized studies to evaluate ERAS in spinal surgery in children and adolescents.

Research progress on the biological modifications of implant materials in 3D printed intervertebral fusion cages

Anterior spine decompression and reconstruction with bone grafts and fusion is a routine spinal surgery. The intervertebral fusion cage can maintain intervertebral height and provide a bone graft window. Titanium fusion cages are the most widely used metal material in spinal clinical applications. However, there is a certain incidence of complications in clinical follow-ups, such as pseudoarticulation formation and implant displacement due to nonfusion of bone grafts in the cage. With the deepening research on metal materials, the properties of these materials have been developed from being biologically inert to having biological activity and biological functionalization, promoting adhesion, cell differentiation, and bone fusion. In addition, 3D printing, thin-film, active biological material, and 4D bioprinting technology are also being used in the biofunctionalization and intelligent advanced manufacturing processes of implant devices in the spine. This review focuses on the biofunctionalization of implant materials in 3D printed intervertebral fusion cages. The surface modifications of implant materials in metal endoscopy, material biocompatibility, and bioactive functionalizationare summarized. Furthermore, the prospects and challenges of the biofunctionalization of implant materials in spinal surgery are discussed.