Background: Recurrent disc herniation is a common condition that often results in months of disabling symptoms and additional costs. Objective: The objective of this study was to investigate the incidence of recurrent disc herniation in patients treated surgically. Materials and Methods: Clinical trials and prospective studies involving patients treated with different techniques, such as open, percutaneous, or microendoscopic discectomy, were included. The incidence of recurrence as well as the level and the time until the recurrent disc herniation was collected. Results: Thirteen studies were included. Recurrence of disc herniation ranged from 0% to 14% of patients. Most recurrences occurred at the same level of herniation and on the same side. The time to recurrence of disc herniation ranged from 1 to 5 years. Conclusion: This study answers the question of how much, when, and where in lumbar recurrent disc herniation.

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Background: Inherent complications associated with surgery and limited success of percutaneous minimally invasive procedures make researches wanting for an ideal treatment for cervical disc herniation. Objective: We prospectively study the role of ozone disc nucleolysis in cervical intervertebral disc herniation. Patients and Methods: From January 2008 to December 2020, we prospectively study 246 consecutive patients of cervical disc herniation treated by a single session of intradiscal injection of ozone–oxygen mixture (ozone disc nucleolysis). There were 55% of females and 45% of males. Age ranged from 28 to 68 years with a mean of 47. The outcome was measured on visual analog scale (VAS) scale and neck disability index (NDI) along with Mcnab method. Results: The mean baseline VAS score was 7.87 which became 3.09 at 1 month, 1.42 at 3 months, 1.40 at 6 months, and 1.35 at 1 year. The mean NDI was 36.27 at baseline which improved to 9.24 at 1 month, 6.25 at 3 months, 6.20 at 6 months, and 6.22 at 1 year. This was found to be significant with P < 0.05. Modified McNab criterion showed excellent recovery in 138 (56.10%), good recovery in 50 (20.32%), and fair recovery in 22 (8.94%), resulting in a successful rate of 85.36%. Mediocre recovery was seen in the remaining 36 patients amounting to a 14.64% failure rate. Conclusion: This study showed that ozone disc nucleolysis significantly reduces the pain related to cervical disc herniation along with a significant reduction in disability.

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Aspergillus spinal epidural abscess (ASEA) is a rare entity that may mimic Pott's paraplegia as it commonly affects immunocompromised patients. We present one institutional case of ASEA with concomitant review of the literature. A 58-year-old female presented with intermittent low back pain for 10 years recently aggravated and with concurrent spastic paraparesis, fever, and weight loss. Emergent magnetic resonance imaging (MRI) showed T11–T12 epidural abscess with discitis and osteomyelitis. After empirical treatment with antibiotics, computed tomography-guided, percutaneous biopsy with drainage was performed, showing granulomatous tubercular-like collection. Antitubercular therapy was initiated, but after 1 month, the patient's condition deteriorated. Repeat MRI showed growth of the spinal epidural abscess with significant cord compression and vertebral osteomyelitis. T11–T12 laminectomy and tissue removal were performed with a posterior midline approach. Tissue histopathology showed necrotic debris colonies of Aspergillus spp. Antifungal therapy was started, and the patient rapidly improved. ASEA may mimic Pott's disease at imaging, leading to immediate start of antitubercular treatment without prior biopsy, leading to severe worsening of patients' clinical status. Cases of ASEA should be considered at pretreatment planning, opting for biopsy confirmation before treatment initiation so to prevent the occurrence of fatal infection-related complications.

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Background: Basilar invagination (BI) is a common malformation of the craniocervical region where the odontoid process protrudes into the foramen magnum. Surgery in this region is difficult because of the complex anatomy of the craniocervical junction. Serious life-threatening complications have been observed with previously described approaches. Therefore, we conceived a novel surgical approach that can be implemented by neurosurgeons with different skill levels to facilitate better outcomes. Methods: We describe a new surgical technique for the treatment of BI that we used in two patients in whom cervical myelopathy and direct ventral compression of the cervicomedullary junction were confirmed through clinical and radiological findings. We present the technique of posterior odontoidectomy in a step-by-step, didactic, and practical manner with surgical tips and tricks. Results: The resection was completed without intraoperative or postoperative complications in both cases. The patients experienced substantial neurological improvements, and full recovery was observed during the 9-month and 12-month follow-up visits after discharge. Compared with the transoral approach, our technique provides a larger decompression area. Conclusions: We describe a novel method for the treatment of BI that was applied in two patients and suggest that the posterior approach might be a safe and effective method for ventral decompression of the craniocervical junction. Posterior odontoidectomy followed by craniocervical fixation helped achieve complete cervicomedullary decompression.

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Background: Os odontoideum (OO) is a craniovertebral junction malformation of unknown origin. In most times, this lesion is highly unstable demanding surgical management. We present our series of OO surgical management and we discuss clinical, radiological, and management aspects of this pathology via our experience and literature opinions. Methods: This is a retrospective study of patients operated on at our department between May 2014 and May 2021 for OO. All patients were explored with plane X-rays and computed tomography (CT). In some cases, magnetic resonance imaging (MRI) was necessary. Posterior C1–C2 or C1-C3 fixation with polyaxial screws and rod fixation was used. In postoperative, the patient is asked to put Philadelphia collar for 3 months. Hospitalization periods vary between 3 and 7 days. After discharge, all our patients are followed up regularly in consultation. Control radiographs of the occipito cervical region were performed. After 3 months postoperatively, the CT scan is performed on all our patients to assess the quality of fusion. Patient's follow-up ranges from 4 months to 6 years. Results: Fifteen patients were included in this study; nine males (60%) and six females (40%); with mean age of 32.5 years old. Ten patients (67%) presented motor weakness, three patients (20%) with neck pain, one patient (6.5%) with torticollis, and one patient (6.5%) presented vertigo. No notable cervical trauma was present in six patients (40%) and in nine patients (60%), a remote history of traumatism was noted. All cases of our series presented mobile OO. Normal thickness of the C2 pedicle was noted in nine patients (60%). In two patients (13%), there was hypoplasia of one pedicle and in four patients (27%) both pedicles. MRI showed direct signs of spinal cord aggression: simple compression, myelomalacia, strangulation, or hypotrophy. C1 lateral mass screw fixation was performed in all patients; and according to C2 morphology: nine patients underwent C1-C2 pedicular fixation, in one patient, bilateral crossing C2 laminar screws technique, in three patients, we skipped C2 to perform a C1-C3 articular fixation, and in two patients, C1-C2-C3 fixations were performed. All patients improved clinically. In one patient, we noted an infection resulting in bad wound healing this infection was successfully treated with no complications. In the patient with bilateral crossing C2 laminar screws technique, CT control objectified 4 mm exceeding of one screw; the patient was reoperated and the screw was slightly pulled back. No other complications were noted. Conclusion: Congenital origin of OO is always evoked. C1-C2 fixation according to Goel and Harms technique with grafting proved its safety, providing high fixation quality with the acceptable biodynamic outcome. Once treated, the prognostic of OO is in general good, and improvement is observed in most patients with few complications.

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Objective: The C1-C2 fixation technique revolutionized the management of complex craniovertebral junction (CVJ) anomalies. Presently used polyaxial screw and rod systems have inadvertent technical difficulties in rod fitting and reduction of atlantoaxial dislocations (AAD) requiring forceful joint handling. The purpose of this study is to analyze the use of a specially designed “reduction screw” in C1 lateral mass in C1-C2 fixation for treating AAD with or without basilar invagination (BI). Study Design: This is a retrospective cohort study in which long lateral mass reduction screws were used for C1-C2 fixation. Materials and Methods: Eighteen patients diagnosed with congenital AAD with or without BI treated with C1-C2 fixations using C1 reduction lateral mass were included in the study. The outcome was measured clinically by the modified Japanese Orthopedic Association score and radiologically by conventional craniometric indices. Results: Among all cases included in the study, 72% (13/18) are males and 18% (5/18) are females with average age at presentation of 33.5 years. Among 18 cases of AAD, 84% (15/18) of patients have BI, 22% (4/18) have Chiari Type 1 malformation, and one patient has Klipple–Feil syndrome. Symptomatic improvement is noted in all patients following surgery. Adequate reduction of AAD with normalization of radiological indices was also achieved in all 18 (100%) patients. Conclusion: C1 lateral mass reduction screw in C1-C2 fixation helps in reduction of AAD and BI (Type A) even in difficult cases of CVJ anomalies with intraoperative technical ease, reduced operative time, no need for special instruments or complex maneuvers, and avoiding potential neurological injury.

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Context: Despite increasing utilization of fusion to treat degenerative pathology, few studies have evaluated outcomes with pelvic fixation (PF). This is the first large-scale database study to compare multilevel fusion with and without PF for degenerative lumbar disease. Aim: The aim of this study was to compare the 30-day outcomes of multilevel lumbar fusion with and without PF. Settings and Design: This was a retrospective cohort study. Subjects and Methods: Lumbar fusion patients were identified using the National Surgical Quality Improvement Program database. Regression was utilized to analyze readmission, reoperation, morbidity, and specific complications and to evaluate for predictors thereof. Statistical Analysis Used: Student's t-test was used for continuous variables and Chi-squared or Fisher's exact test was used for categorical variables. Variables significant in the univariate analyses (P < 0.05) and PF were then evaluated for significance as independent predictors and control variables in a series of multivariate logistic regression analyses of primary outcomes. Results: We identified 38,413 patients. PF predicted 30-day readmission and morbidity. PF was associated with greater reoperation in univariate analysis, but not in multivariate analyses. PF predicted deep wound infections, organ-space infections, pulmonary complications, urinary tract infection, transfusion, deep venous thrombosis, and sepsis. PF was also associated with a longer hospital stay. Age, obesity, steroids, and American Society of Anesthesiologists (ASA) class ≥ 3 predicted readmission. Obesity, steroids, bleeding disorder, preoperative transfusion, ASA class ≥3, and levels fused predicted reoperation. Age, African American race, decreased hematocrit, obesity, hypertension, dyspnea, steroids, bleeding disorder, ASA class ≥3, levels fused, and interbody levels fused predicted morbidity. Male gender and inclusion of anterior lumbar interbody fusion (ALIF) were protective of reoperation. Hispanic ethnicity, ALIF, and computer-assisted surgery (CAS) were protective of morbidity. Conclusions: Adjunctive PF was associated with a 1.5-times and 2.7-times increased odds of readmission and morbidity, respectively. ASA class and specific comorbidities predicted poorer outcomes, while ALIF and CAS were protective. These findings can guide surgical solutions given specific patient factors.

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Study Design: Retrospective cohort study. Objective: The objective of this study is to determine the effect of focal lordosis and global alignment and proportion (GAP) scores on patient reported outcome measures (PROMs) after posterior lumbar fusion for patients with 1- or 2-level lumbar degenerative spondylolisthesis (DS). Summary of Background Data: In patients with DS, improvements in spinopelvic parameters are believed to improve clinical outcomes. However, the effect of changing focal lordosis in patients with 1-or 2-level degenerative lumbar spondylolisthesis is unclear. Materials and Methods: Postoperative spinopelvic parameters and perioperative focal lordosis changes were measured for 162 patients at a single academic center from January 2013 to December 2017. Patients were divided into three groups: >2° (lordotic group), between 2° and −2° (neutral group), and −2°° (kyphotic group). Patients were then reclassified based on GAP scores. Recovery ratios (RR) and the number of patients achieving the minimal clinically important difference (MCID) were calculated for PROMs. Standard descriptive statistics were reported for patient demographics and outcomes data. Multiple linear regression analysis controlled for confounders. Alpha was set at P < 0.05. Results: There was no significant association between change in focal lordosis and surgical complications including adjacent segment disease (P = 0.282), instrumentation failure (P = 0.196), pseudarthrosis (P = 0.623), or revision surgery (P = 0.424). In addition, the only PROM affected by change in focal lordosis was Mental Component Scores (ΔMCS-12) (lordotic = 2.5, neutral = 8.54, and kyphotic = 5.96, P = 0.017) and RR for MCS-12 (lordotic = 0.02, neutral = 0.14, kyphotic 0.10, P = 0.008). Linear regression analysis demonstrated focal lordosis was a predictor of decreased improvement in MCS-12 (β = −6.45 [−11.03- −1.83], P = 0.007). GAP scores suggested patients who were correctly proportioned had worse MCID compared to moderately disproportioned and severely disproportioned patients (P = 0.024). Conclusions: The change in focal lordosis not a significant predictor of change in PROMs for disability, pain, or physical function. Proportioned patients based on the GAP score had worse MCID for Oswestry Disability Index. Level of Evidence: III

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Study Design: This was retrospective cohort study. Purpose: The current investigation uses a large, multi-institutional dataset to compare short-term morbidity and mortality rates between current smokers and nonsmokers undergoing thoracolumbar fusion surgery. Overview of Literature: The few studies that have addressed perioperative complications following thoracolumbar fusion surgeries are each derived from small cohorts from single institutions. Materials and Methods: A retrospective study was conducted on thoracolumbar fusion patients in the American College of Surgeons National Surgical Quality Improvement Program database (2006–2016). The primary outcome compared the rates of overall morbidity, severe postoperative morbidity, infections, pneumonia, deep venous thrombosis (DVT), pulmonary embolism (PE), transfusions, and mortality in smokers and nonsmokers. Results: A total of 57,677 patients were identified. 45,952 (78.8%) were nonsmokers and 12,352 (21.2%) smoked within 1 year of surgery. Smokers had fewer severe complications (1.6% vs. 2.0%, P = 0.014) and decreased discharge to skilled nursing facilities (6.3% vs. 11.5%, P < 0.001) compared to nonsmokers. They had lower incidences of transfusions (odds ratio [OR] = 0.9, confidence interval [CI] = 0.8–1.0, P = 0.009) and DVT (OR = 0.7, CI = 0.5–0.9, P = 0.039) as well as shorter length of stay (LOS) (OR = 0.9, CI = 0.9–0.99, P < 0.001). They had a higher incidence of postoperative pneumonia (OR = 1.4, CI = 1.1–1.8, P = 0.002). There was no difference in the remaining primary outcomes between smoking and nonsmoking cohorts. Conclusions: There is a positive correlation between smoking and postoperative pneumonia after thoracolumbar fusion. The incidence of blood transfusions, DVT, and LOS was decreased in smokers. Early postoperative mortality, severe complications, discharge to subacute rehabilitation facilities, extubation failure, PE, SSI, and return to OR were not associated with smoking.

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Introduction: The standard treatment for a fixed coronal malalignment of the craniovertebral junction is an anterior and/or posterior column osteotomy (PCO) plus instrumentation. However, the procedure is very challenging, carrying an inherently high risk of complications even in experienced hands. This case series demonstrates the usefulness of an alternative treatment that adds a unilateral spacer distraction (USD) to the subaxial cervical facet joint to promote coronal realignment and fusion. Materials and Methods: A single-center retrospective study of the patients with fixed coronal malalignment of the craniovertebral junction caused by different etiologies treated with USD in the concavity side with PCO in the convexity side of the subaxial cervical spine. Demographic characteristics and radiological parameters were collected with special emphasis on clinical and radiological measurements of coronal alignment of the cervical spine. Results: From 2012 to 2019, four patients were treated with USD of the subaxial cervical spine complementing an asymmetrical PCO at the same level. The causes of coronal imbalance were congenital, tuberculosis, posttraumatic, and ankylosing spondylitis. The level of USD was C2–C3 in three patients and C3–C4 in one patient. A substantial coronal realignment was achieved in all four. One patient had an iatrogenic vertebral artery injury during the dissection and facet distraction and developed Wallenberg's syndrome with partial recovery. Conclusions: USD of the concave side with unilateral PCO of the convexity side in the subaxial cervical spine is a promising alternative treatment for fixed coronal malalignment of the craniovertebral junction from different causes.

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Objective: Type II odontoid fractures need surgical stabilization for disabling neck pain and instability. Anterior odontoid screw fixation is a well-known technique. However, certain patients require posterior fixation. We present our surgical results and experiences with nine cases managed by the Goel-Harms technique. Materials and Methods: This is a retrospective review of nine patients operated on between January 2019 and December 2021 for Type II odontoid fractures with posterior fixation technique. Their clinical profile was collected from case files. The radiological data were retrieved from radiology archives. The indications for surgery were instability and refractory neck pain. The surgical decision for posterior fixation was guided by fracture morphology. Results: The mean age of presentation was 37.22 ± 9.85 years. Seven patients had Type II, and two had Type IIa odontoid fracture. All patients presented with unbearable neck pain. One patient had a quadriparesis. The fracture line was anterior-inferior sloping in six, posterior-inferior sloping in two, and transverse in one case. The anterior-posterior displacement of fracture ranged from 0 to 7 mm (mean 2.44 ± 2.18 mm). Partial transverse ligament tear without the Atlanto Axial Dislocation was present in three patients. The C1-C2 joint distraction was required in five cases. C1-C2 joint spacer was required in two cases. Following surgery, neck pain was relieved in all cases. Complete fracture alignment was achieved in eight patients. There were no postoperative complications. At the mean follow-up of 16.22 ± 9.61 months, there was no implant failure. Conclusions: Posterior C1-C2 fixation by the Goel-Harms technique is an excellent alternative to anterior fixation in selected cases.

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Giant cell tumor (GCT) is an intermediate malignant bone tumor which mostly involves long extremity bones, less commonly involving the spine with sacral predominance. Cervical spine involvement is rare. According to literature, the selective approach for the treatment of GCT is en bloc resection with spinal reconstruction. For unusual sites, such as cervical region, which is a mobile spinal segment and critically proximate to the cervical spinal cord, great vessels, and vital organs, it is almost impossible to perform the selective approach for treatment. Alternative approaches in such situations are under investigations. We present a case of C2 vertebral body GCT, who was treated with polymethylmethacrylate intravertebral injection and was followed by adjuvant therapy with denosumab. A 16-year-old boy without any past medical history presented with progressive suboccipital and axial neck pain since 3 months earlier, which had not responded to conservative treatments. There was no neurologic deficit, and pain was significantly controlled. In the 1-year follow-up, no complication and tumor recurrence was seen. Vertebroplasty with bone cement for lytic spinal GCT lesions, followed by adjuvant therapy with denosumab, not only is a less invasive treatment but also has good results in spinal stability, patient recovery, and 12-month recurrence.

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Background: The atlantoaxial complex contributes to significant neck movements, especially the axial rotation. Its instability is currently treated with various C1-C2 fusion techniques. This however, considerably hampers the neck movements and affects the quality of life; a C1-C2 motion preserving arthroplasty could potentially overcome this drawback. Objectives: We evaluate the range of motion (ROM) of lateral C1-C2 artificial joints in cadaveric models. Materials and Methods: This is an in vitro cadaveric biomechanical study. After C1-C2 arthroplasty through a posterior approach, the C1-C2 ROM was tested in 4 fresh-frozen human cadaveric specimens, before and after destabilization. Results: The mean axial rotation demonstrated after the placement of C1-C2 joint implants was 15.46 degrees on the right and 16.03 degrees on the left side; the prosthesis provided stability, with 46% of the baseline C1-C2 axial rotation on either side. The ROM achieved in the other axes was less compared with that of intact specimens. To initiate rotation, a higher moment of 1.5 Nm was required in the presence of joint implants compared to 0.5 NM in unimplanted specimens. Conclusions: In our preliminary ROM evaluation, the C1-C2 arthroplasty appears to be stable and provides about half of the range of atlantoaxial rotation. It has the potential for joint motion preservation in the treatment of atlantoaxial instability resulting from lateral C1-C2 joint pathologies.

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Spinal cervical extradural and intra-extradural hemangioblastomas are exceptional, with only nine reported cases. This study reviews the diagnostic and surgical problems of this rare entity. Two female patients, aged 80 years and 25 years, respectively, one with Von Hippel–Lindau disease (VHLD), experienced brachial pain and weakness. On magnetic resonance imaging, a dumbbell intra-extraspinal hemangioblastoma was evidenced. The surgical resection through posterior laminectomy resulted in clinical remission of brachial pain and weakness. The magnetic resonance aspect of a dumbbell lesion suggests a neurogenic tumor; the correct preoperative diagnosis is possible in individuals with VHLD. The surgical problems include high tumor vascularity, vertebral artery control, and nerve root preservation. However, the surgical excision results in clinical remission.

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Treatment of atlantoaxial pathology is often associated with significant morbidity and mortality. While surgical techniques for fixation are well established, approaches that minimize blood loss and muscle dissection are advantageous for expediting recovering and minimizing surgical risk. We present a 34-year-old female who presented with a Type III odontoid fracture requiring surgical fixation. She underwent a C1-2 fusion employing a novel minimally invasive modification of the Goel-Harms atlantoaxial fusion using percutaneous screws and intra-articular cage.

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Purpose: The purpose is to investigate if a correlation existed between the frequency of cervical degenerative disc disease occurrence and cranial incidence (CI) angle. Materials and Methods: A retrospective analysis of case series. Sagittal parameters of the case series were compared with the sagittal parameters of the same number of consecutive patients with neck pain only but no cervical degenerative disc disease (CDDD). Moreover, CI angle values were noted to be significantly different among groups on variable-based examination. Furthermore, the cervical lordosis (CL) values of men were observed to be significantly different. Therefore, the significant intergroup differences related to the CI angle and CL values support the study hypothesis. Results: No intergroup differences were noted regarding gender and age distribution (p = 0.565; p = 0,498). A significant intergroup difference was observed regarding CS values and the mean vector of CI angle and CL values for men and women (p = 0.002). CI angle values were noted to be significantly different among groups upon variable-based examination (p < 0.001). The CL values of men were observed to be significantly different, but not the CL values of women (p = 0.850). Therefore, the significant intergroup differences related to the CI angle and CL values support the study hypothesis. Conclusions: A reverse correlation between CI angle and CDDD development is demonstrated. This correlation is valid between CL and CDDD development. Therefore, cervical sagittal profile and the CI angle and CL measurements should be performed to follow-up patients with cervical pain.

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Translaminar screws in the cervical spine have been mostly employed at C2 level when conventional trajectories are challenging. However, reports in the literature of translaminar screw of C1 are remarkably anecdotal. We aimed to report a case using C1 translaminar in addition to C1 lateral mass screws for the reinforcement of subaxial cervical spine reconstruction. We present a 22-year-old female patient, who developed persistent cervical pain, and computed tomography scan demonstrated lytic lesions of the vertebral bodies and lateral masses from C3 to C6. Magnetic resonance imaging showed spinal cord compression without myelopathy. Surgical biopsy was inconclusive, and an oncological vertebral instability led to surgical stabilization. Laminectomy and bilateral facetectomy of levels involved was achieved, instrumentation from C1 to T3 and reconstruction with posterolateral fibula bilaterally, and without occipital fixation. A third satellite rod was placed using C1-2–7 translaminar screws. Translaminar screw of C1 is a feasible alternative for increasing the strength of the construct.

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