Pre- and intraoperative thoracic spine localization techniques: a systematic review

OBJECTIVE In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

Extended tulip cervical reduction screws to restore alignment in traumatic atlantoaxial dislocation after type 3 odontoid fracture: illustrative case

BACKGROUND Traumatic atlantoaxial rotatory subluxation after type 3 odontoid fracture is an uncommon presentation that may require complex intraoperative reduction maneuvers and presents challenges to successful instrumentation and fusion. OBSERVATIONS The authors report a case of a 39-year-old female patient who sustained a type 3 odontoid fracture. She was neurologically intact and managed in a rigid collar. Four months later, she presented again after a second trauma with acute torticollis and type 2 atlantoaxial subluxation, again neurologically intact. Serial cervical traction was placed with minimal radiographic reduction. Ultimately, she underwent intraoperative reduction, instrumentation, and fusion. Freehand C1 lateral mass reduction screws were placed, then C2 translaminar screws, and finally lateral mass screws at C3 and C4. The C2–4 instrumentation was used as bilateral rod anchors to reduce the C1 lateral mass reduction screws engaged onto the subluxated atlantodental complex. As a final step, cortical allograft spacers were inserted at C1–2 under compression to facilitate long-term stability and fusion. LESSONS This is the first description of a technique using extended tulip cervical reduction screws to correct traction-irreducible atlantoaxial subluxation. This case is a demonstration of using intraoperative tools available for the spine surgeon managing complex cervical injuries requiring intraoperative reduction that is resistant to traction reduction.

Automated detection of cervical ossification of the posterior longitudinal ligament in plain lateral radiographs of the cervical spine using a convolutional neural network

Cervical ossification of the posterior longitudinal ligament (OPLL) is a contributing factor to spinal cord injury or trauma-induced myelopathy in the elderly. To reduce the incidence of these traumas, it is essential to diagnose OPLL at an early stage and to educate patients how to prevent falls. We thus evaluated the ability of our convolutional neural network (CNN) to differentially diagnose cervical spondylosis and cervical OPLL. We enrolled 250 patients with cervical spondylosis, 250 patients with cervical OPLL, and 180 radiographically normal controls. We evaluated the ability of our CNN model to distinguish cervical spondylosis, cervical OPLL, and controls, and the diagnostic accuracy was compared to that of 5 board-certified spine surgeons. The accuracy, average recall, precision, and F1 score of the CNN for classification of lateral cervical spine radiographs were 0.86, 0.86, 0.87, and 0.87, respectively. The accuracy was higher for CNN compared to any expert spine surgeon, and was statistically equal to 4 of the 5 experts and significantly higher than that of 1 expert. We demonstrated that the performance of the CNN was equal or superior to that of spine surgeons.

Power-assisted pedicle screws placement: Is it as safe and as effective as manual technique? Narrative review of the literature and our technique

Pedicle screws are the gold standard in spine surgery, allowing a solid tricolumnar fixation which is unmatched by hooks and wires. The freehand technique is the most widely adopted for pedicle screws placing. While freehand technique has been classically performed with manual tools, there has been a recent trend toward the use of power tools. The aim of this review is to summarize and expose potential risks and advantages of power pedicle screws placing. The literature showed that the use of power tools offers an acceptable safety profile, comparable to manual technique. With an adequate training, the power technique may speed up the screw placing, reduce the fluoroscopy time and the physical stress to the spine surgeon. Regarding differences in pull-out strength between power and manual techniques, the literature is still uncertain and inconsistent, both in clinical and preclinical studies. The choice between the use of power and manual freehand pedicle screws placing is still based on the surgeon’s own preference.

Incorporation of MISS in Routine Spine Practice

Traditional open spine surgery is the gold standard procedure in spine practice. Minimally invasive spine surgery (MISS) since last two decades have tremendously improved in technique and technology improving the clinical and functional outcomes of the surgery and patients. But still MISS has steep learning curve, many challenges and hurdles to inculcate it in the routine spine practice of the surgeon who may be either a novice or even an established in spine practice. The author has tried to identify the hurdles in incorporating MISS in routine spine practice and suggested methods to overcome these hurdles to incorporate MISS in routine clinical practice. Keywords: Minimally Invasive Spine Surgery (MISS); Spine practice; Spine Surgeon.

Spinal Brucellosis: A Case Report and Review of the Literature

Introduction: The most common location of infection of brucellosis is the musculoskeletal system. It is estimated that the spine is involved in 2–54% of brucellosis infections, with the lumbar spine most commonly affected. We report an uncommon case of brucellar spondylodiscitis, in addition to the pathology, common presentation, and management of spinal brucellosis through additional literature review. Case Report: A 65-year-old Hispanic male presented to an orthopedic spine surgeon with signs and symptoms concerning for metastatic disease to the spine. Investigation revealed that the patient had the rare diagnosis of brucellar spondylodiscitis. This only became apparent after detailed questioning of the patient’s history revealed his employment within a Mexican meat slaughterhouse and a regular consumer of unpasteurized Mexican cheeses. Conclusion: Although uncommon, brucellosis spondylodiscitis should remain as a differential diagnosis in any patient who presents with back pain and fever. Detailed history taking and thorough physical examination remain vital in the work-up of brucellar spondylodiscitis. Understanding the pathology, radiographic findings, and necessary work-up are essential to properly treat this infection. Keywords: Spine, Brucella, spinal brucellosis, infection, spondylodiscitis, discitis, abscess.