Use of the Scan-and-Plan Workflow in Next-Generation Robot-Assisted Pedicle Screw Insertion: Retrospective Cohort Study and Literature Review.

OBJECTIVE: To report our experience using the scan-and-plan workflow and review current literature on surgical efficiency, safety, and accuracy of next-generation robot-assisted (RA) spine surgery. METHODS: The records of patients who underwent RA pedicle screw fixation were reviewed. The accuracy of pedicle screw placement was determined based on the Ravi classification system. To evaluate workflow efficiency, 3 demographically matched cohorts were created to analyze differences in time per screw placement (defined as operating room [OR] time divided by number of screws placed). Group A had <4 screws placed, Group B had 4 screws placed, and Group C had >4 screws placed. Intraoperative errors and postoperative complications were collected to elucidate safety. RESULTS: Eighty-four RA cases (306 pedicle screws) were included for analysis. The mean number of screws placed was 2.1 ± 0.3 in Group A and 6.4 ± 1.2 in Group C; 4 screws were placed in Group B patients. The accuracy rate (Ravi grade I) was 98.4%. Screw placement time was significantly longer in Group A (101 ± 37.7 minutes) than Group B (50.5 ± 25.4 minutes) or C (43.6 ± 14.7 minutes). There were no intraoperative complications, robot failures, or in-hospital complications requiring a return to the OR. CONCLUSIONS: The scan-and-plan workflow allowed for a high degree of accuracy. It was a safe method that provided a smooth and efficient OR workflow without registration errors or robotic failures. After the placement of 4 pedicle screws, the per-screw time remained constant. Further studies regarding efficiency and utility in multilevel procedures are necessary.

Evaluation of Benefit and Cost Utility of Immediate Postanesthesia Care Unit Radiographs to Predict Airway Compromise After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure that may be complicated by airway compromise postoperatively. This life-threatening complication may necessitate reintubation and reoperation. We evaluated the cost utility of conventional postoperative x-ray. SUMMARY OF BACKGROUND DATA: Studies have demonstrated minimal benefit in obtaining an x-ray on postoperative day 1, but there is some utility of postanesthesia care unit (PACU) x-rays for predicting the likelihood of reoperation. METHODS: We retrospectively reviewed the records of consecutive patients who underwent ACDF between September 2013 and February 2017. Patients were dichotomized into those who received PACU x-rays and those who did not (control group). Primary outcomes were reoperation, reintubation, mortality, and health care costs. RESULTS: Eight-hundred and fifteen patients were included in our analysis: 558 had PACU x-rays; 257 did not. In those who received PACU x-rays, mean age was 53.7 ±â€Š11.3 years, mean levels operated on were 2.0 ±â€Š0.79, and mean body mass index (BMI) was 30.3 ±â€Š6.9. In those who did not, mean age was 51.8 ±â€Š10.9 years, mean levels operated on were 1.48 ±â€Š0.65, and mean BMI was 29.9 ±â€Š6.3. Complications in the PACU x-ray group were reintubation-0.4%, reoperation-0.7%, and death-0.3% (due to prevertebral swelling causing airway compromise). Complications in the control group were reintubation-0.4%, reoperation-0.8%, and death-0. There were no differences between groups with respect to reoperation (P = 0.92), reintubation (P = 0.94), or mortality (P = 0.49). The mean per-patient cost was significantly higher (P = 0.009) in those who received PACU x-rays, $1031.76 ±â€Š948.67, versus those in the control group, $700.26 ±â€Š634.48. Mean length of stay was significantly longer in those who had PACU x-rays (P = 0.01). CONCLUSION: Although there were no differences in reoperation, reintubation, or mortality, there was a significantly higher cost for care and hospitalization in those who received PACU x-rays. Further studies are warranted to validate the results of the presented study.Level of Evidence: 3.

Navigation-Guided Subaxial Cervical Pedicle Screws in Revision Spine Surgery: 2-Dimensional Operative Video.

Traditionally, lateral mass screws (LMSs) have been the mainstay of posterior fixation in the subaxial spine. Although LMSs provide adequate fixation, cervical pedicle screws (CPSs) facilitate high fusion rates (90.5%) and provide for greater bone purchase, better reduction, lower rates of screw loosening or pull out, 2 times greater biomechanical advantage, superior stabilization, decreased development of pseudarthrosis, and decreased revision surgeries compared to LMSs.1-4 In addition, CPSs can be a powerful bail-out option after lateral mass construct failure. Navigation-guided CPS placement has been reported to have an accuracy of 90.3%.5 Navigation has the added advantage of mitigating screw malposition for the placement of CPS because of the smaller pedicle sizes and variability in cervical anatomy.1,3,6 The potential risks of subaxial CPS placement include the risks of vertebral artery injury, spinal cord injury, and injury to adjacent neurovasculature.2 The overall radiographic breach rate with intraoperative imaging is reported to range from 2.9% of 22.9%, with the majority of breaches occurring in the lateral direction.7,8 Despite radiographic breaches, the occurrence of nerve root injury (0.31% per screw), vertebral artery injury (0.15% per screw), and spinal cord injury (0% per screw) is rare.3,7 Here, we demonstrate navigation-assisted C1-C2 posterior fusion, with combined C1 LMSs and C2 pedicle screws with subaxial pedicle screw revision of prior failed instrumentation.3 The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary.

Technologic Evolution of Navigation and Robotics in Spine Surgery: A Historical Perspective.

Spine surgery is continuously evolving. The synergy between medical imaging and advances in computation has allowed for stereotactic neuronavigation and its integration with robotic technology to assist in spine surgery. The discovery of x-rays in 1895, the development of image intensifiers in 1940, and then advancements in computational science and integration have allowed for the development of computed tomography. In combination with the advancements of stereotaxy in the late 1980s, and manipulation of volumetric and special data for 3-dimensional reconstruction in 1998, computed tomography has revolutionized neuronavigational systems. Integrating all these technologies, robotics in spine surgery was introduced in 2004. Since then, it has become a safe modality that can reproducibly place accurate pedicle screws. Robotics may have the added benefits of improving the surgical workflow and optimizing surgeon ergonomics. Growing at a rapid rate, the second-generation spinal robotics have overcome preliminary limitations and errors. However, comparatively, robotics in spine surgery remains in its infancy. By leveraging technologic advancements in medical imaging, computation, and stereotactic navigation, robotics in spine surgery will continue to mature and expand in utility.

Assessment of Rod Material Types in Spine Surgery Outcomes: A Systematic Review.

BACKGROUND: Lumbar spine fusion surgery is traditionally performed with rigid fixation. Because the rigidity is often supraphysiologic, semirigid rods were developed. To the best of our knowledge, a comprehensive evaluation of rod material type on surgical outcomes has yet to be conducted. METHODS: A systematic review based on PRISMA guidelines was conducted across 3 electronic databases. After examination for inclusion and exclusion criteria, data were extracted from the studies. RESULTS: Seventeen studies, including 1399 patients, were included in this review. The mean rigid rod fusion rate is 92.2% and 95.5% for semirigid rods (P = 0.129). The mean improvement in back pain was 60.6% in rigid rods and 71.6% in semirigid rods. The improvement in leg pain was 81.9% and 77.2%, respectively. There were no differences in visual analog scale back pain score (P = 0.098), visual analog scale leg pain score (P = 0.136), or in functional improvement between rigid and semirigid rods (P = 0.143). There was no difference (P = 0.209) in the reoperation rate between rigid rods (13.1%) and semirigid rods (6.5%). There was a comparable incidence of adjacent segment disease (3%), screw fracture (1.7%), and wound infection (1.9%) between rod material types. CONCLUSIONS: There is a moderate level of evidence supporting that surgical intervention results in high fusion rates regardless of rod material type. Surgical intervention improves back pain, leg pain, and function, with neither material type showing clear superiority. There are comparable rates of reoperation, development of adjacent segment disease, development of mechanical complications, and incidence of infection in both rigid and semirigid rods. Further studies regarding rod material type are warranted.

Utilization, Utility, and Variability in Usage of Adjunctive Hyperbaric Oxygen Therapy in Spinal Management: A Review of the Literature.

The objective of this review was to understand the clinical utilization, utility, and variability in the usage of adjunctive hyperbaric oxygen therapy (HBOT). Surgical site infection is associated with high morbidity and mortality, increased health care expenditure, and decreased quality of life. With the increasing prevalence of adult spinal deformity and spinal fusion surgery, it is imperative to understand the potential benefits of adjunctive treatments. HBOT is a safe and common procedure indicated to treat various medical conditions. We conducted a literature search across 3 databases for English articles published between December 1, 2019 and December 1, 2000. Thirteen studies were included. HBOT may lessen the duration of antimicrobial therapy and mitigate instrument removal and revision surgery. The current usage indications for HBOT are supported by level III evidence for chronic osteomyelitis and level IV evidence for osteoradionecrosis. However, the same level of evidence exists to support the beneficial use of adjunctive HBOT for noncomplicated spinal infections within 2 months after surgery. When cultured, the most common organisms were Staphylococcus aureus and other low-virulence organisms. The most common treatment protocol consists of 90-minute sessions of 100% Fio2 at 2-3 atmosphere absolute with a mean of 35.3 ± 11.6 sessions for 5.2 ± 1.4 weeks. Adjunctive HBOT should be considered in select high-risk patients. Further improvements in diagnosis and categorization of spinal infections are necessary and will indelibly aid the decision making for the initiation of HBOT.

Comparing Cortical Bone Trajectories for Pedicle Screw Insertion using Robotic Guidance and Three-Dimensional Computed Tomography Navigation.

BACKGROUND: Cortical bone trajectories (CBTs) for pedicle screw insertion can be used to stabilize the spine. Surgeons often rely on fluoroscopy or computed tomography (CT)-navigation technologies to guide screw placement. Robotic technology has potential to increase accuracy. We report our initial experience with robotic guidance for pedicle screw insertion utilizing CBTs in patients with degenerative disc disease. METHODS: A retrospective chart review was conducted using data for consecutive patients who underwent spinal stabilization using a posterior approach for CBTs. The newest robotic platform (Mazor X) was used in these cases. Accuracy was determined by applying the Ravi Scale: grade I (no breach or deviation), II (breach <2 mm), III (breach 2-4 mm), or IV (breach >4 mm). The results were compared with those for a historical cohort of patients who underwent CT navigation-guided pedicle screw insertion using CBTs. RESULTS: Twenty-two patients underwent robot-assisted pedicle screw placement using CBTs. A total of 92 screws were inserted across 24 spinal levels with grade I accuracy and without complications in the robotic group. Eighteen patients underwent CT-navigation for CBT pedicle screw insertion. A total of 74 screws were inserted across 19 levels, 69 of which were grade I accuracy and 5 were grade II accuracy. When comparing operative time (P = 0.97), fluoroscopy time (P = 0.8), and radiation dose (P = 0.4), no significant differences were observed between cohorts. CONCLUSIONS: Robotic technology and CT-navigation technology for CBT pedicle screw insertion were safe and accurate.

Use of a neck-bridging device for endovascular coiling of a wide-necked middle cerebral artery aneurysm.

Endovascular treatment of wide-necked bifurcation intracranial aneurysms is technically challenging, often requiring adjunctive devices such as stents or balloons to maintain coil mass within the aneurysm sac. Comaneci is a radiopaque embolization-assist device that can be temporarily deployed in the parent artery across the aneurysm neck without arresting blood flow for remodeling of coil mass. It is removed once coiling without luminal coil protrusion is achieved. In this video, we demonstrate use of the device for coiling of a wide-necked right middle cerebral artery (MCA) aneurysm in a 54-year-old woman. This patient presented with an unruptured MCA bifurcation aneurysm that showed growth on serial imaging. She wanted to avoid dual antiplatelet therapy, precluding the use of stent-assisted coiling. After detailed discussion with the patient, we proceeded with Comaneci-assisted coiling. Satisfactory aneurysm coiling was achieved without periprocedural complication. In the video, we further discuss potential indications and advantages of the device.

Robot-Assisted Cortical Bone Trajectory Insertion of Pedicle Screws: 2-Dimensional Operative Video.

Robot-assisted pedicle screw insertion has been slowly gaining popularity in the spine surgery community. In previous studies, robotics has been shown to increase accuracy and reduce complication rates compared to other navigation technologies, although those studies have been conducted using traditional trajectories for pedicle screw insertion. We present a surgical video in which a robotics system (Mazor X; Mazor Robotics Ltd, Caesarea, Israel) was used to create cortical bone trajectories for the insertion of the screws. The patient in this case is a 52-yr-old woman with severe L4-5 disc herniation requiring a transforaminal interbody fusion with the insertion of pedicle screws. The robotic system's scan-and-plan technique was utilized, in which an intraoperative computed tomography (CT) scan generates a real-time operative plan. Other techniques for inserting pedicle screws using cortical bone trajectories include CT navigation and fluoroscopic guidance. These techniques allow the surgeon to manually direct the screw under precise guidance in multiple planes, although the surgeon is still using all 6 degrees of freedom the human hand provides. With robotic guidance, a pilot hole is drilled, which eliminates 4 of 6 degrees of freedom, which can potentially reduce the risk of misplaced screws. To our knowledge, this is the first video demonstrating pedicle screw insertion through cortical bone trajectories using robotic guidance. Future studies are warranted to compare cortical bone trajectory insertion using different navigation techniques to determine the long-term efficacy of each technique. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary.

Incidence of nonaccidental head trauma in infants: a call to revisit prevention strategies.

OBJECTIVE: Traumatic brain injury is a major sequela of nonaccidental trauma (NAT) that disproportionately affects young children and can have lasting sequelae. Considering the potentially devastating effects, many hospitals develop parent education programs to prevent NAT. Despite these efforts, NAT is still common in Western New York. The authors studied the incidence of NAT following the implementation of the Western New York Shaken Baby Syndrome Education Program in 1998. METHODS: The authors performed a retrospective chart review of children admitted to our pediatric hospital between 1999 and 2016 with ICD-9-CM and ICD-10-CM codes for types of child abuse and intracranial hemorrhage. Data were also provided by the Safe Babies New York program, which tracks NAT in Western New York. Children with a diagnosis of abuse at 0-24 months old were included in the study. Children who suffered a genuine accidental trauma or those with insufficient corroborating evidence to support the NAT diagnosis were excluded. RESULTS: A total of 107 children were included in the study. There was a statistically significant rise in both the incidence of NAT (p = 0.0086) and the incidence rate of NAT (p = 0.0235) during the study period. There was no significant difference in trendlines for annual NAT incidence between sexes (y-intercept p = 0.5270, slope p = 0.5263). When stratified by age and sex, each age group had a distinct and statistically significant incidence of NAT (y-intercept p = 0.0069, slope p = 0.0374). CONCLUSIONS: Despite educational interventions targeted at preventing NAT, there is a significant rise in the trend of newly reported cases of NAT, indicating a great need for better injury prevention programming.

Fusarium species intramedullary spinal cord fungus ball: case report.

The Fusarium species are one of the most common opportunistic fungal infections occurring in immunocompromised patients and are associated with high morbidity and mortality. Common sites of infection include blood, skin, nasal passages, lungs, bone, and other visceral organs. There is a paucity of literature on Fusarium infections in the brain, and the true nature and extent of central nervous system involvement is not well described. To the authors' knowledge, there have been no reported cases of Fusarium infection of the spine. The authors report the case of a man with acute myeloblastic leukemia and resultant pancytopenia who presented with fungal sinusitis, upper- and lower-extremity weakness, and cardiopulmonary arrest. Imaging studies revealed a spinal cervical intramedullary ring-enhancing lesion. Because of the progressive nature of his symptoms, neurosurgical intervention involving a C2-3 laminectomy and drainage of the lesion was performed. Intraoperative cultures and histopathology results were positive for Fusarium species and, along with intraoperative findings, were consistent with a fungus ball. The patient was placed on a regimen of intravenous and intrathecal antifungal therapy. Unfortunately, his clinical condition declined postoperatively, and he ultimately died of disseminated infection.

Cervical Kyphotic Deformity Worsening After Extensor Cervical Muscle Paralysis from Botulinum Toxin Injection.

BACKGROUND: Botulinum toxin (Botox) has long been used therapeutically to treat a variety of diseases, including migraine headaches, cervical spine dystonia, and chronic cervical spine pain, among many others. Although quite useful, Botox has been reported to cause adverse events, some of which may lead to devastating morbidity. CASE DESCRIPTION: An elderly woman presented with severe neck pain after a motor vehicle collision. She underwent Botox administration to the neck extensor muscles, after which she developed severe cervical kyphotic deformity, a complication previously reported only in patients with a history of cervical fusion. In addition, the patient had a pre-existing cervical spine degenerative disc disease with listhesis resulting in cervical kyphotic deformity and loss of cervical lordosis. CONCLUSIONS: This case illustrates a potential danger of using Botox in the neck of an elderly patient who may have pre-existing cervical spine instability, underlying cervical musculature weakness, and pre-existing cervical kyphosis. It demonstrates the need to evaluate patients who are predisposed to developing cervical kyphotic deformities before offering them Botox treatment.

Successful Kissing Balloon Expandable Stent Graft Treatment for a Right Common Carotid Pseudoaneurysm Caused by Tracheotomy.

BACKGROUND: A rare complication following tracheotomy is common carotid artery (CCA) pseudoaneurysm. Treatment modalities for CCA pseudoaneurysm include surgical repair and single-artery balloon-covered stent graft technique. We describe successful treatment of tracheotomy-related CCA pseudoaneurysm with the "kissing balloon" expandable stent graft technique. CASE DESCRIPTION: We successfully implemented the kissing balloon expandable stent graft technique for treatment of a large, narrow-necked, bilobed CCA pseudoaneurysm that arose owing to a tracheotomy complication. The pseudoaneurysm was detected while performing a diagnostic angiogram of the aortic arch and surrounding vessels. The stent was deployed while the 2 balloons were introduced in a kissing manner such that they faced one another to avoid occlusion of either branch of the innominate artery coming into contact; 1 balloon was inflated at the origin of the right subclavian artery, and the other was inflated at the right innominate artery simultaneously. The pseudoaneurysm was successfully contained; normal blood flow was restored in the CCA. The balloons were deflated and withdrawn. The patient remained neurologically intact after the procedure. CONCLUSIONS: The kissing balloon technique is a safe and effective alternative to surgical repair, as it prevents morbidities associated with the surgical procedure. Also, this technique decreases the risk of major side-branch occlusion associated with the single-artery balloon-covered stent graft technique.

Case Report of a Primary Pituitary Abscess and Systematic Literature Review of Pituitary Abscess with a Focus on Patient Outcomes.

BACKGROUND: Pituitary abscess is a rare but potentially life-threatening condition with an incidence of 0.2%-1.1% of operative pituitary lesions. Diagnosis can be challenging, because this disorder shares many similarities with other pituitary lesions in terms of signs and symptoms and radiographic findings. Most pituitary abscesses are categorized as secondary, arising from preexisting pituitary lesions or in conjunction with transsphenoidal surgery, sepsis, meningitis, or sinusitis. There have been only a few reports of primary pituitary abscess, which occurs without any of the aforementioned risk factors. CASE DESCRIPTION: We present a case of primary pituitary abscess in a 38-year-old woman with headaches, blurry vision, polyuria, and polydipsia who was found to have hypopituitarism. Brain magnetic resonance imaging showed a sellar/suprasellar mass, which was endoscopically resected via a transsphenoidal approach. Egress of yellow-greenish creamy fluid was noted on dural incision. The patient was treated with a 6-week course of antibiotic therapy postoperatively and had resolution of symptoms. CONCLUSIONS: A PubMed search was performed; all cases of pituitary abscess reported in the literature were screened, and 200 cases including our case were analyzed with a focus on outcomes. The most common presentations were headache, visual disturbance, and endocrine abnormalities. Approximately 66.1% of patients achieved partial or complete recovery of pituitary function; 75.7% with vision deficits recovered visual function. Treatment via a craniotomy had a recurrence rate of 17.2% compared with 9.7% via a transsphenoidal approach. To our knowledge, this is the first systematic review on the topic and the largest series reported.