Civilian Ballistic Injuries to the Atlantoaxial Spine: A Single Institution Case Series.

STUDY DESIGN: Retrospective case series. OBJECTIVE: Describe the injury characteristics of ballistic fractures involving the atlantoaxial spine. SUMMARY OF BACKGROUND DATA: Civilian gunshot wounds to the spine are an increasingly common injury in the United States. Civilian studies have focused on ballistic injuries to the entire spine as opposed to a region-specific fashion. Only a single 10-patient case series investigating ballistic fractures to the upper cervical spine (C1 and C2) exists, leaving a large gap in the understanding of this injury complex. METHODS: A retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. RESULTS: Thirty-six patients were identified, with 86% being male with an average patient age of 30.0 ± 10.36 years (mean ± SD). Fracture morphology was characterized using proportional analysis. Initial neurological exams were either ASIA A or ASIA E, without any incomplete injuries noted. Patients who sustained a transcanal injury did not show any neurological improvement. The initial in-hospital mortality rate was 5.6%, with a 1-year mortality rate of 8.3%. There is a high incidence of associated vascular injury (66%) and mandible fracture (33%). CONCLUSIONS: Ballistic penetrating trauma to the atlantoaxial spine often results in complex injury patterns necessitating multidisciplinary care with high rates of morbidity and mortality. If neurological deficits are present initially, they are often complete. Two thirds of patients sustained an associated vascular injury, which should be screened for with CT angiography.

A predictive model of motor deficit in civilian ballistic lumbosacral spine injuries.

BACKGROUND CONTEXT: Civilian gunshot wounds to the spine are an increasingly common injury in the USA. A majority of the available research is focused on a military population suffering high energy missile injury. Minimal research has focused on civilian ballistic injuries to the lumbosacral spine as the available studies focus on the entire spine due to limited numbers. PURPOSE: Characterize ballistic injuries to the lumbosacral spine and develop a model to predict the presence of neurological deficit based upon a patients presenting fracture morphology. STUDY DESIGN: Retrospective chart review. PATIENT SAMPLE: One hundred forty-eight consecutive patients that were presented to an urban level 1 trauma center with ballistic injures to the spine involving the levels L1-S2. OUTCOMES MEASURES: Neurological status at presentation and final follow up using the American Spinal Injury Association (ASIA) Impairment Scale. METHODS: IRB approval was obtained, and retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation and final follow-up, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Chi-square testing was done to identify fracture characteristics associated with neurologic injury. A multiple logistical regression was performed using fracture characteristics highly associated with neurological deficit to develop a model to predict neurologic deficit. The model was then validated with a receiver operator curve. RESULTS: Of the 148 patients, 14 patients underwent spinal surgery with the most common indication being decompression and foreign body removal. There was a high incidence of intra-abdominal injury (73.6%). Fractures were characterized by level, affected vertebral component, and spinal canal involvement. Neurological injury was classified using the ASIA scale at presentation and final follow up. Odds-ratios of vertebral fracture characteristics showed neurologic deficit was highly associated with pedicle fractures (OR=9.07 [4.14-21.54] - 95% CI), lamina fractures (OR=6.42 [3.16-13.62] - 95% CI), facet fractures (OR=5.95 [2.90-12.79] - 95% CI), intra-canal bone (OR=12.79 [5.98-29.05] - 95% CI), and an intra-canal trajectory (OR=1078 [4.48-28.98]) - 95% CI. Multiple logistic regression was performed to construct a predictive model of neurologic deficit which showed that intra-canal trajectory, pedicle fracture and facet fracture are associated with neurologic deficit. An ROC curve was made with an area of 0.849 ([0.7853 to 0.9128 - 95% CI], p<.0001) demonstrating a good model fit. CONCLUSIONS: Ballistic injuries to the lumbosacral spine involve complex injury patterns in an often polytraumatized patient. Fractures involving the pedicle, lamina, and facet are highly associated with neurologic injury, as is a trans-canal trajectory. A patients fracture morphology can be used to predict if a neurologic deficit is present.

Bubble rupture & viability of red blood cells under resonant acoustic standing waves.

Objective: The presentation of a novel prospective treatment for scenarios where bubble presence in the bloodstream poses a clinical risk. The method relies on generating resonant acoustic standing waves within a limb to non-invasively accelerate the dissolution of bubbles present in the bloodstream via bubble rupture. Additionally, a preliminary assessment of the effects of the resonant acoustic waves and bubble rupture events on red blood cell viability is provided. Methods: Two semicircular piezoelectric (PZT) transducers electrically connected to each other were assembled around a small-girth segment of a rear thigh removed from a swine specimen. When driven at the frequency of electric resonance, this swine thigh and PZT transducer arrangement generates resonant acoustic standing waves within the swine thigh. Consequently, mechanical resonance of the system was non-invasively established by monitoring the electric response of the PZT to the applied frequency. The resonant acoustic field generated was used for the detection and rupture of bubbles that travel through a simulated blood vessel installed across the swine thigh. Two sets of experiments were carried out using this methodology, one with the artificial blood vessel filled with saline solution and one with defibrinated sheep blood. For the latter case, a preliminary hematologic assessment was done with red blood cell counts. Conclusion: Resonant acoustic standing waves effectively rupture bubbles of 300µm to 900µm within a simplified swine thigh model. The average dissolved gas content was 44% due to resonant acoustic waves at powers above 20W. No significant effect on red blood cell counts was observed.

The neurosurgical marriage: evaluating the interplay of work life and home life from the perspective of partners of neurosurgical residents.

OBJECTIVE: Burnout and work-life balance have been noted to be problems for residents across all fields of medicine, including neurosurgery. No studies to date have evaluated how these factors may contribute to issues outside of the hospital, specifically residents' home lives. This study aimed to evaluate the interplay between home life and work life of neurosurgical residents, specifically from the point of view of residents' significant others. METHODS: Online surveys were distributed to the significant others of neurosurgical residents at 12 US neurosurgery residencies. Residents' partners were asked about relationship dynamics, their views on neurosurgery residency (work-life balance and burnout), and their views of neurosurgery as a career. RESULTS: The majority of residents' significant others (84%) reported being satisfied with their relationship. Significant others who reported dissatisfaction with their relationship were more likely to report frustration with work-life balance and more likely to report their resident partner as having higher levels of burnout. CONCLUSIONS: From the perspective of neurosurgery residents' significant others, higher perceived levels of burnout and lower satisfaction with work-life balance are correlated with lower levels of relationship satisfaction. These findings speak to the complex interplay of work life and home life and can be used to inform future interventions into improving the quality of life for both the resident and the significant other.

Gunshot Wounds to the Lumbosacral Spine: Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Indications for surgical decompression of gunshot wounds to the lumbosacral spine are controversial and based on limited data. METHODS: A systematic review of literature was conducted to identify studies that directly compare neurologic outcomes following operative and non-operative management of gunshot wounds to the lumbosacral spine. Studies were evaluated for degree of neurologic improvement, complications, and antibiotic usage. An odds ratio and 95% confidence interval were calculated for dichotomous outcomes which were then pooled by random-effects model meta-analysis. RESULTS: Five studies were included that met inclusion criteria. The total rate of neurologic improvement was 72.3% following surgical intervention and 61.7% following non-operative intervention. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the rate of neurologic improvement between surgical and non-operative intervention (OR 1.07; 95% CI 0.45, 2.53; P = 0.88). In civilian only studies, a random-effects model meta-analysis failed to show a statistically significant difference in the rate of neurologic improvement between surgical and non-operative intervention (OR 0.75; 95% CI 0.21, 2.72; P = 0.66). Meta-analysis further failed to show a statistically significant difference in the rate of neurologic improvement between patients with either complete (OR 4.13; 95% CI 0.55, 30.80; P = 0.17) or incomplete (OR 0.38; 95% CI 0.10, 1.52; P = 0.17) neurologic injuries who underwent surgical and non-operative intervention. There were no significant differences in the number of infections and other complications between patients who underwent surgical and non-operative intervention. CONCLUSIONS: There were no statistically significant differences in the rate of neurologic improvement between those who underwent surgical or non-operative intervention. Further research is necessary to determine if surgical intervention for gunshot wounds to the lumbosacral spine, including in the case of retained bullet within the spinal canal, is efficacious.

Pseudosubarachnoid hemorrhage: A systematic review of causes, diagnostic modalities, and outcomes in patients who present with pseudosubarachnoid hemorrhage.

BACKGROUND: Patients with computed tomography (CT) findings consistent with subarachnoid hemorrhage without evidence of hemorrhage following autopsy or cerebrospinal fluid testing are termed to have pseudosubarachnoid hemorrhage (pSAH). METHODS: A systematic review of literature was conducted based on the preferred reporting items for systematic reviews and meta-analysis statement. Studies were evaluated for associated cause of pSAH, imaging modality used in assessment, method of confirmatory testing, and clinical outcome. RESULTS: Fifty studies were included in qualitative analysis including 197 cases of pSAH. Systematic review revealed 23 studies including 110 patients with pSAH attributed to hypoxic-ischemic brain injury following cardiac arrest. Three studies were included in meta-analysis that quantitatively analyzed differences in CT densities in patients with pSAH and true subarachnoid hemorrhage (true SAH). A random effects model meta-analysis showed a statistically significant decrease in densities in the Sylvian fissure in patients with pSAH compared to true SAH and a statistically significant decrease in densities in adjacent parenchyma in patients with pSAH compared to true SAH. Systematic review further revealed 32 patients with pSAH associated with spontaneous intracranial hypotension, 11 patients with pSAH related to infectious etiologies, 15 patients with pSAH associated with subdural hemorrhage, 20 cases of pSAH related to hyperhemoglobinemia, 2 cases related to valproate toxicity, and individual cases related to hyponatremia, diabetic ketoacidosis, sudden infant death syndrome, cerebellar infarction, and dialysis disequilibrium syndrome. CONCLUSION: This study is the first systematic review of causes, diagnostic modalities, and outcomes in patients who present with pSAH. A diagnosis of pSAH may be considered following assessment of CT densities following cardiac arrest.

Pseudo-subarachnoid hemorrhage and gadolinium encephalopathy following lumbar epidural steroid injection.

Patients with imaging findings concerning for subarachnoid hemorrhage, however, with no evidence of hemorrhage following autopsy or cerebrospinal fluid testing are diagnosed with having pseudo-subarachnoid hemorrhage. A 73-year-old female presented to the emergency department with altered mental status one day after undergoing a lumbar epidural steroid injection at an outside hospital; a noncontrast computed tomography scan of the head revealed evidence of diffuse hyperdensity within the subarachnoid space concerning for subarachnoid hemorrhage. The patient underwent magnetic resonance imaging which demonstrated diffuse opacification of the cerebrospinal fluid spaces with gadolinium and the diagnoses of pseudo-subarachnoid hemorrhage and gadolinium encephalopathy were made. The combination of the neurologic symptoms related to gadolinium encephalopathy and the radiographic findings of pseudo-subarachnoid hemorrhage can create a clinical presentation nearly identical to ruptured aneurysmal subarachnoid hemorrhage. Patient history, magnetic resonance imaging findings, and temporal changes in computed tomography provide vital tools in establishing a diagnosis of pseudo-subarachnoid hemorrhage, especially after an iatrogenic intrathecal contrast administration.

Steroid Use Associated With Increased Odds of 30-Day Mortality in Surgical Patients With Metastatic Spinal Tumors in the Setting of Disseminated Disease.

BACKGROUND: Steroid administration is part of a standard treatment regimen in metastatic spinal cord compression, though the appropriate dose, duration, efficacy, and risks remain controversial. OBJECTIVE: To analyze the risk of preoperative steroid use on 30-d mortality in surgical metastatic spinal tumors with dissemination disease using a large multicenter national database. METHODS: Adult patients who underwent surgical treatment for metastatic spine tumors between 2005 and 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Demographic, preoperative risk factors, operative information, and postoperative events were extracted. Multivariate logistical regression modeling was used to investigate the association with preoperative steroid use with the outcome of interest, 30-d mortality. Other independent risk factors associated with 30-d mortality were also identified. RESULTS: Five hundred fifty-two patients underwent surgical treatment of spinal metastases with disseminated cancer present at time of surgery. Independent risk factors of 30-d mortality included prolonged steroid use (odds ratio [OR] 2.48, 95% confidence interval [CI]: 1.22-5.04, P = .012), dependent functional status (OR 2.91, 95% CI: 1.68-5.04, P < .001), history of bleeding disorder (OR 2.80, 95% CI: 1.16-6.74, P = .021), history of smoking (OR 2.26, 95% CI: 1.11-4.61, P = .024), preoperative transfusions (OR 2.91, 95% CI: 1.02-8.29, P = .049), and preoperative infection/sepsis (OR 2.67, 95% CI: 1.18-6.08, P = .02). Our model demonstrates very strong predictive capabilities, with an area under the receiver operating characteristic curve of 0.7447. CONCLUSION: Steroid use is associated with a significant increased risk of 30-d mortality in surgical metastatic spine tumor patients with disseminated disease. These findings warrant further investigation in controlled experimental environments.

Opioid Dependence and Prolonged Length of Stay in Lumbar Fusion: A Retrospective Study Utilizing the National Inpatient Sample 2003-2014.

STUDY DESIGN: Retrospective cohort utilizing the National Inpatient Sample (NIS) 2003 to 2014. OBJECTIVE: To investigate the association of opioid dependence with prolonged length of stay (LOS), costs, and surgical complications in elective one-to-two level lumbar fusion. SUMMARY OF BACKGROUND DATA: Opioids are the most commonly prescribed drug class to treat back pain. Few studies have examined the impact of opioid dependence on spinal fusion outcomes. The data available show inconsistent conclusions regarding the association between opioid dependence and LOS. METHODS: Data from 1,826,868 adult elective one-to-two level lumbar fusion discharges in the NIS from 2003 to 2014 were included. Discharges were categorized into an opioid-dependent or unaffected cohort based on the presence or absence of an International Classification of Disease, Ninth Revision-Clinical Modification (ICD-9-CM) code for opioid dependence. Incidence of opioid dependence was compared between 2003 and 2014 via adjusted Wald tests. Patient and surgical characteristics, costs, and complications were compared between cohorts via chi-square tests or adjusted Wald tests for categorical and continuous variables, respectively. Patient and surgical factors were tested for association with prolonged LOS via univariable logistic regressions, and significant (P ≤ 0.01) factors were included in a multivariable logistic regression. RESULTS: Seven thousand nine hundred sixty-four (0.44%) discharges included a diagnosis of opioid dependence. The incidence of opioid dependence increased from 2003 to 2014. Opioid dependence was associated with an adjusted 2.11 times higher odds of prolonged LOS. Opioid-dependent discharges accrued higher costs and had higher frequencies of infection, device-related complications, hematoma- or seroma-related complications, acute posthemorrhagic anemia, and pulmonary insufficiency. CONCLUSION: This nationally-representative study suggests that opioid dependence is associated with prolonged LOS in lumbar fusion, as well as higher costs and higher frequencies of surgical complications. Further investigations are needed to determine the optimal method to treat opioid-dependent patients who require lumbar fusion. LEVEL OF EVIDENCE: 3.

Thromboprophylaxis in Spinal Surgery.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Determine the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in spinal surgery patients receiving no thromboprophylaxis, mechanoprophylaxis, and chemoprophylaxis. SUMMARY OF BACKGROUND DATA: The incidence of thromboembolic complications after spinal surgery is not well established. Although a variety of effective mechanical and chemical thromboprophylaxis interventions exist, their role in spinal surgery remains unclear. Spine surgeons are faced with the difficult decision of balancing the risk of death from a thromboembolic complication against the risk of permanent neurological damage from an epidural hematoma (EDH). METHODS: The Medline database was queried using combinations of the terms related to the aforementioned subject matter. Articles meeting our predetermined inclusion criteria were reviewed and relevant data extracted. Meta-analyses were created using a random-effects model for incidence of DVT and PE by type of thromboprophylaxis, method of screening, and study type. RESULTS: Twenty-eight articles were included in the final analyses. The higher mean incidence of DVT and PE in the mechanoprophylaxis group (DVT: 1%, PE: 0.81%) compared to the chemoprophylaxis group (DVT: 0.85%, PE: 0.58%) was not observed to be statistically significant. Six percent of PEs was fatal; the rate of EDHs was 0.3%. The incidence of DVT was higher in prospective studies (1.4%) compared to retrospective studies (0.61%); the incidence of DVT was not affected by whether the study screened only symptomatic patients. CONCLUSION: Although the incidence of DVT and PE was relatively low regardless of prophylaxis type, the true incidence is difficult to determine given the heterogeneous nature of the small number of studies available in the literature. Our findings suggest there may be a role for chemoprophylaxis given the relatively high rate of fatal PE. Future studies are needed to determine which patient population would benefit most from chemoprophylaxis. LEVEL OF EVIDENCE: 2.

Trend of Spine Surgeries in the Outpatient Hospital Setting Versus Ambulatory Surgical Center.

STUDY DESIGN: Retrospective database review. OBJECTIVE: The aim of the present study was to examine how often spine surgery is being performed in an outpatient hospital setting versus a more "true" ambulatory setting, specifically ambulatory surgery centers (ASCs) in which admission and discharge are required on the same calendar day. SUMMARY OF BACKGROUND DATA: Recent studies have assessed the safety, satisfactory clinical outcomes, and increasing utilization of both cervical and lumbar spinal surgeries performed in the outpatient setting. No studies have delineated between true ambulatory settings and outpatient hospitals when assessing the rates of these procedures. METHODS: A retrospective review of the Truven Health Marketscan Research Databases was conducted for patients undergoing spine operations between 2003 and 2014. The frequency of each Common Procedural Terminology code was identified per year, and then categorized into each of "inpatient hospital," "outpatient hospital," or "ASC" in states that clearly define ASCs as facilities in which patients are discharged on the same calendar day of the operation, and do not stay overnight. RESULTS: During the period between 2003 and 2014, the procedures that had the most dramatic increase as an outpatient hospital procedure included lumbar decompression laminotomy first level (18.7%-68.5%) and posterior cervical decompression laminectomy without facetectomy discectomy first level (0%-46.7%). ASC procedures had more modest increases during this time period with the most significant increases in lumbar decompression laminotomy first level (0.7%-10.6%) and posterior cervical decompression laminotomy first level (0%-23.4%). CONCLUSION: "True" ambulatory surgeries are not increasing at the same rate as outpatient procedures with 23-hour observation capacity. Although prior studies have demonstrated the safety of outpatient spine surgery, one possible reason for this trend may be that surgeons feel that this safety may not be comparable to that of other outpatient procedures. LEVEL OF EVIDENCE: 3.

Giant cell tumors of the spine: has denosumab changed the treatment paradigm?

OBJECT Giant cell tumors (GCTs) of the spine are rare and complex to treat. They have a propensity for local recurrence and the potential to metastasize. Treatment is currently surgical and presents unique challenges due to the proximity of neural structures and the need for reconstruction. Denosumab has been shown in clinical trials to be an effective treatment for GCT, but has not yet been studied specifically in GCT of the spine or as a surgical adjunct. To the authors' knowledge this is the first such reported series. METHODS A multicenter, prospective series of 5 patients with GCT of the spine treated with denosumab were included. Patient demographic data, oncological history, neurological status, tumor staging, treatment details and adverse events, surgical procedure, complications, radiological and histological responses, and patient outcome were analyzed. RESULTS All patients were women, with a mean age of 38 years, and presented with pain; 2 patients had additional neurological signs and symptoms. The mean duration of symptoms was 62 weeks. No patient had a prior tumor or metastatic disease at presentation. All patients had Enneking Stage III tumors and were treated with monthly cycles of 120 mg of denosumab, with initial additional loading doses on Days 8 and 15. Patients were given daily supplements of calcium (500 mg) and vitamin D (400 IU). There were no denosumab-related adverse events. All patients had a radiological response to denosumab. One patient failed to have a histological response to denosumab, with > 90% of tumor cells found to be viable on histological investigation. CONCLUSIONS This study reports the early experience of using denosumab in the treatment of spinal GCT. The results demonstrate a clinically beneficial radiological response and an impressive histological response in most but not all patients. Further experience with denosumab and longer patient follow-up is required. Denosumab has the potential to change the treatment paradigm for spinal GCT.

Incidence of eclampsia with HELLP syndrome and associated mortality in Latin America.

OBJECTIVE: To describe the maternal outcome among women with eclampsia with and without HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). METHODS: A cross-sectional study of women with eclampsia was undertaken in 14 maternity units in Latin America between January 1 and December 31, 2012. Outcomes were compared between women with and without concomitant HELLP syndrome. Logistic regression analysis was performed to identify independent risk factors of maternal mortality. RESULTS: There were 196 eclampsia cases among 115 038 deliveries; 142 (72.4%) women had eclampsia alone and 54 (27.6%) women had concomitant HELLP syndrome. Severe systolic hypertension (≥160 mm Hg), severe diastolic hypertension (≥110 mm Hg), and hypertensive encephalopathy were significantly more common among women with HELLP than among those with eclampsia alone (P=0.01 for all). There were 8 (4.1%) maternal deaths, all in the group with HELLP syndrome, and 18 (9.1%) perinatal deaths. In a multivariate regression model, maternal mortality was significantly associated with low platelet count and severe systolic hypertension (P<0.05). CONCLUSION: Eclampsia with HELLP syndrome is a dangerous complication associated with pregnancy. Low platelet count secondary to HELLP syndrome and severe systolic hypertension were independently associated with maternal mortality from eclampsia.

Sustained long-term complete regression of a giant cell tumor of the spine after treatment with denosumab.

BACKGROUND CONTEXT: Although giant cell tumors (GCTs) are histologically benign, they may become locally aggressive bone tumors. As these lesions tend to respond poorly to radio- and chemotherapy, currently the standard surgical paradigm for the treatment of spinal GCTs involves en bloc surgical resection. Denosumab is a newly developed monoclonal antibody designed to inhibit the receptor activator of nuclear factor kappa-B ligand (RANKL) which has already been demonstrated to induce marked radiographic responses on GCTs of the appendicular skeleton. Nevertheless, the role of denosumab in the treatment algorithm of GCTs of the spine has not yet been defined. PURPOSE: To describe the first case of sustained long-term complete clinical and radiographic regression of a GCT of the spine after treatment with the new RANKL antibody denosumab. STUDY DESIGN: Case report and literature review. METHODS: The authors describe the case of 22-year-old female patient, harboring a GCT involving the C2 vertebral body and odontoid process, who was treated in monotherapy with denosumab, resulting in complete long-term clinical and radiographic tumor remission. RESULTS: There were no major side effects associated with the long-term pharmacological treatment with denosumab. From the clinical standpoint, the patient demonstrated complete remission of the disease while under treatment. The 16-month radiographic follow-up demonstrated complete disappearance of the osteolytic process and intense new cortical bone formation with restoration of the bone integrity of the C2 vertebral body. CONCLUSIONS: This is the first report of sustained long-term complete clinical and radiographic regression of a GCT of the spine after treatment with the new RANKL antibody denosumab. Although future long-term follow-up studies are still necessary to establish important key points regarding the best therapeutic protocol with such a new drug (such as the optimal time frame to keep the patient under treatment), denosumab promises to bring major changes to the current therapeutic paradigm for GCTs of the spine, which, up to now, has strongly relied on en bloc surgical resection.

Complications of the mini-open anterolateral approach to the thoracolumbar spine.

The mini-open anterolateral approach to the thoracolumbar spine is gaining popularity as a minimally-invasive alternative to traditional open thoracolumbar approaches. Published studies reporting and discussing the complications associated with this minimally invasive approach, however, are limited. We performed a retrospective review of patients undergoing the mini-open lateral approach to the thoracolumbar spine for corpectomy/fusion. Intraoperative and postoperative complications are reported and analyzed. Eighty consecutive patients underwent the mini-open lateral approach with corpectomy and fusion for trauma (71%), tumor (26%) and infection (3%). Total complication rate was 12.5% (dural tear 2.5%, intercostal neuralgia 2.5%, deep vein thrombosis 2.5%, pleural effusion 1.3%, wound infection 1.3%, hardware failure 1.3%, hemothorax 1.3%). Two patients needed a re-operation to address the complication (hardware failure, hemothorax). There were no postoperative neurological complications. The mini-open anterolateral approach to the thoracolumbar spine is an appealing alternative to the traditional open approaches. This technique, however, is technically demanding and requires proficiency in the use of minimally invasive spinal surgery instruments and retractors.