The Three-Step Approach for Lumbar Disk Herniation with Anatomical Insights Tailored for the Next Generation of Young Spine Surgeons.

Background/Objectives: Lumbar disc herniation, a complex challenge in spinal health, significantly impacts individuals across diverse age groups. This article delves into the intricacies of this condition, emphasising the pivotal role of anatomical considerations in its understanding and management. Additionally, lumbar discectomy might be considered an "easy" surgery; nevertheless, it carries significant risks. The aim of the study was to present a groundbreaking "three-step approach" with some anatomical insight derived from our comprehensive clinical experiences, designed to systematise the surgical approach and optimise the outcomes, especially for young spine surgeons. We highlighted the purpose of the study and introduced our research question(s) and the context surrounding them. Methods: This retrospective study involved patients treated for lumbar disc herniation at a single institution. The patient demographics, surgical details, and postoperative assessments were meticulously recorded. All surgeries were performed by a consistent surgical team. Results: A total of 847 patients of the 998 patients initially included completed the follow-up period. A three-step approach was performed for every patient. The recurrence rate was 1.89%. Furthermore, the incidence of lumbar instability and the need for reoperation were carefully examined, presenting a holistic view of the outcomes. Conclusions: The three-step approach emerged as a robust and effective strategy for addressing lumbar disc herniation. This structured approach ensures a safe and educational experience for young spinal surgeons.

The Role of Psychosomatic Traits in Tailored Workup for Anterior Cervical Discectomy and Fusion-A Case Series.

STUDY DESIGN: Prospective study. OBJECTIVE: To evaluate the influence of preoperatively assessed psychosomatic traits on postoperative pain, disability, and quality of life outcomes. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and fusion (ACDF) is a widely employed surgical procedure for treating cervical spondylosis. Despite its effectiveness, various studies have reported non-success rates in terms of alleviating disability and pain. Psychological factors have become increasingly recognized as critical determinants of surgical outcomes in various medical disciplines. The full extent of their impact within the context of ACDF remains insufficiently explored. This case series aims to assess the influence of preoperative psychological profiling on long-term pain, disability and quality of life outcomes. METHODS: We conducted a prospective cohort study of prospectively collected data from 76 consecutive patients who underwent ACDF with PEEK inter-fixed cages from July 2019 to November 2021. The preoperative psychological traits were assessed using the Symptom Checklist 90 (SCL-90) questionnaire. The Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Neck Disability index (NDI), EuroQol-5D (EQ-5D), and Short Form-36 (SF-36) were collected preoperatively, one month postoperatively, and at least one year after the surgical procedure. RESULTS: The correlation analyses revealed associations between psychosomatic traits and multiple preoperative and postoperative outcome measures. The univariate analyses and linear regression analyses demonstrated the influence of the Global Severity Index (GSI) over the final follow-up scores for the ODI, VAS, NDI, EQ-5D, and SF-36. The GSI consistently exhibited a stronger correlation with the final follow-up pain, disability, and quality of life outcomes with respect to the correspondent preoperative values. CONCLUSION: This study highlights the importance of psychosomatic traits as predictive factors for ACDF outcomes and emphasizes their relevance in preoperative assessment for informing patients about realistic expectations. The findings underscore the need to consider psychological profiles in the preoperative workup, opening avenues for research into medications and psychological therapies. Recognizing the influence of psychosocial elements informs treatment strategies, fostering tailored surgical approaches and patient care.

Safety and Efficacy of Zero-Profile Polyetheretherketone (PEEK) Cages Filled with Biphasic Calcium Phosphate (BCP) in Anterior Cervical Discectomy and Fusion (ACDF): A Case Series.

Background: In the evolving landscape of anterior cervical discectomy and fusion (ACDF), the integration of biomechanical advancements and proper fusion-enhancing materials is crucial for optimizing patient outcomes. This case series evaluates the efficacy and clinical implications of employing zero-profile polyetheretherketone (PEEK) cages filled with biphasic calcium phosphate (BCP) in ACDF procedures, focusing on fusion and subsidence rates alongside patient disability, residual pain, and quality of life. Methods: This case series comprises 76 consecutive patients, with a median follow-up of 581 days. The Bridwell classification system was used for assessing fusion rates while subsidence occurrence was recorded, correlating these radiographic outcomes with clinical implications. Results: The results demonstrated a satisfactory fusion rate (76.4% for grades I and II). The subsidence rate was low (6.74% of segments). Significant clinical improvements were observed in pain, disability, and quality-of-life metrics, aligning with the minimum clinically important difference thresholds; however, subgroup analyses demonstrated that subsidence or pseudoarthrosis group improvement of PROMs was not statistically significant with respect to baseline. ANOVA analyses documented that subsidence has a significant weight over final follow-up pain and disability outcomes. No dysphagia cases were reported. Conclusions: These findings underscore the efficacy of zero-profile PEEK cages filled with BCP in ACDF, highlighting their potential to improve patient outcomes while minimizing complications. Pseudoarthrosis and subsidence have major implications over long-term PROMs. The study reinforces the importance of selecting appropriate surgical materials to enhance the success of ACDF procedures.

Combination of Tractography, Intraoperative Computed Tomography and 5-Aminolevulinic Acid Fluorescence in Stereotactic Brain Biopsies: A Case Series.

Stereotactic needle biopsy (SNB) may be performed to collect tissue samples from lesions not amenable to open surgery. Integration of tractography, intraoperative imaging and fluorescence has been applied to reduce risk of complications and confirm the adequacy of bioptic specimens. Clinical and radiological data from patients who underwent stereotactic needle biopsy with the use of intraoperative CT, tractography and 5-aminolevulinic acid (5-ALA) fluorescence in a single Hospital were retrospectively reviewed to evaluate the accuracy and safety of the procedure. Seven patients were included in the study, and all the collected specimens showed red fluorescence. In six of them, the final histopathological diagnosis was grade 4 glioblastoma IDH-wt and in the other case it was Diffuse large B-Cell Lymphoma. The integration of tractography, intraoperative CT and 5-ALA as an intraoperative marker of diagnostic samples may be suggested in biopsies of suspect gliomas and lymphomas. The cost-effectiveness of the procedure should be evaluated in future studies.

Navigated, percutaneous, three-step technique for lumbar and sacral screw placement: a novel, minimally invasive, and maximally safe strategy.

BACKGROUND: Minimally invasive spine surgery is a field of active and intense research. Image-guided percutaneous pedicle screw (PPS) placement is a valid alternative to the standard free-hand technique, thanks to technological advancements that provide potential improvement in accuracy and safety. Herein, we describe the clinical results of a surgical technique exploiting integration of neuronavigation and intraoperative neurophysiological monitoring (IONM) for minimally invasive PPS. MATERIALS AND METHODS: An intraoperative-computed tomography (CT)-based neuronavigation system was combined with IONM in a three-step technique for PPS. Clinical and radiological data were collected to evaluate the safety and efficacy of the procedure. The accuracy of PPS placement was classified according to the Gertzbein-Robbins scale. RESULTS: A total of 230 screws were placed in 49 patients. Only two screws were misplaced (0.8%); nevertheless, no clinical sign of radiculopathy was experienced by these patients. The majority of the screws (221, 96.1%) were classified as grade A according to Gertzbein-Robbins scale, seven screws were classified as grade B, one screw was classified as grade D, and one last screw was classified as grade E. CONCLUSIONS: The proposed three-step, navigated, percutaneous procedure offers a safe and accurate alternative to traditional techniques for lumbar and sacral pedicle screw placement. Level of Evidence Level 3. Trial registration Not applicable.

The role of psychopathological symptoms in lumbar stenosis: A prediction model of disability after lumbar decompression and fusion.

Introduction: Pre-operative psychological factors may influence outcome after spine surgery. The identification of patients at risk of persisting disability may be useful for patient selection and possibly to improve treatment outcome. Methods: Patients with neurogenic claudication associated with degenerative lumbar spinal stenosis (DLSS) performed a psychological assessment before lumbar decompression and fusion (LDF) surgery. The following tests were administrated: Visual Analogic Scale; Symptom Checklist-90 (SCL-90-R), Short Form-36 and Oswestry Disability Index (ODI). The primary outcome was ODI score lower than 20. A cross correlation matrix (CCM) was carried out with significant variables after univariate analysis and a linear logistic regression model was calculated considering the most significant variable. Results: 125 patient (61 men and 64 women) were included in the study. Seven parameters of the SCL-90-R scale showed statistical significance at the univariate analysis: obsessivity (p < 0.001), Current Symptom Index (p = 0.001), Global Severity Index (p < 0.001), depression (p < 0.001), positive Symptom Total (p = 0.002), somatization (p = 0.001) and anxiety (p = 0.036). Obsessivity was correlated with other significant parameters, except GSI (Pearson's correlation coefficient = 0.11).The ROC curve for the logistic model considering obsessivity as risk factor, has an area under the curve of 0.75. Conclusion: Pre-operative psychopathological symptoms can predict persistence of disability after LDF for DLSS. Future studies will evaluate the possibility of modifying post operative outcome through targeted treatment for psychological features emerged during pre-operative assessment.

Intraoperative CT-guided navigation versus fluoroscopy for percutaneous pedicle screw placement in 192 patients: a comparative analysis.

BACKGROUND: Percutaneous pedicle screw (PPS) placement is a key step in several minimally invasive spinal surgery (MISS) procedures. Traditional technique for PPS makes use of C-arm fluoroscopy assistance (FA). More recently, newer intraoperative imaging techniques have been developed for PPS, including CT-guided navigation (CTNav). The aim of this study was to compare FA and CTNav techniques for PPS with regard to accuracy, complications, and radiation dosage. MATERIALS AND METHODS: A total of 192 patients with degenerative lumbar spondylolisthesis and canal stenosis who underwent MISS posterior fusion ± interbody fusion through transforaminal approach (TLIF) were retrospectively reviewed. Pedicle screws were placed percutaneously using either standard C-arm fluoroscopy guidance (FA group) or CT navigation (CTNav group). Intraoperative effective dose (ED, mSv) was measured. Screw placement accuracy was assessed postoperatively on a CT scan using Gertzbein and Robbins classification (grades A-E). Oswestry disability index (ODI) and visual analog scale (VAS) scores were compared in both groups before and after surgery. RESULTS: A total of 101 and 91 procedures were performed with FA (FA group) and CTNav approach (CTNav group), respectively. Median age was 61 years in both groups, and the most commonly treated level was L4-L5. Median ED received from patients was 1.504 mSv (0.494-4.406) in FA technique and 21.130 mSv (10.840-30.390) in CTNav approach (p < 0.001). Percentage of grade A and B screws was significantly higher for the CTNav group (96.4% versus 92%, p < 0.001), whereas there were 16 grade E screws in the FA group and 0 grade E screws in the CTNav group (p < 0.001). A total of seven and five complications were reported in the FA and CTNav group, respectively (p = 0.771). CONCLUSIONS: CTNav technique increases accuracy of pedicle screw placement compared with FA technique without affecting operative time. Nevertheless, no significant difference was noted in terms of reoperation rate due to screw malpositioning between CTNav and FA techniques. Radiation exposure of patients was significantly higher with CTNav technique. LEVEL OF EVIDENCE: Level 3.

Intraoperative Integration of Multimodal Imaging to Improve Neuronavigation: A Technical Note.

BACKGROUND: Brain shift may cause significant error in neuronavigation, leading the surgeon to possible mistakes. Intraoperative magnetic resonance imaging (MRI) is the most reliable technique in brain tumor surgery. Unfortunately, it is highly expensive and time consuming and, at the moment, it is available only in few neurosurgical centers. METHODS: In this case series the surgical workflow for brain tumor surgery is described where neuronavigation of preoperative MRI, intraoperative computed tomography (CT) scan, and ultrasound (US) as well as rigid and elastic image fusion between preoperative MRI and intraoperative US and CT, respectively, was applied to 4 brain tumor patients in order to compensate for surgically induced brain shift by using a commercially available software (Elements Image Fusion 4.0 with Virtual iMRI Cranial; Brainlab AG, München, Germany). RESULTS: Four illustrative cases demonstrated successful integration of different components of the described intraoperative surgical workflow. The data indicate that intraoperative navigation update is feasible by applying intraoperative 3-dimensional US and CT scanning as well as rigid and elastic image fusion applied depending on the degree of observed brain shift. CONCLUSIONS: Integration of multiple intraoperative imaging techniques combined with rigid and elastic image fusion of preoperative MRI may reduce the risk of incorrect neuronavigation during brain tumor resection. Further studies are needed to confirm the present findings in a larger population.

Single-Level Anterior Cervical Discectomy and Interbody Fusion: A Comparison between Porous Tantalum and Polyetheretherketone Cages.

Background: Anterior cervical discectomy and interbody fusion (ACDF) may be performed with different kinds of stand-alone cages. Tantalum and polyetheretherketone (PEEK) are two of the most commonly used materials in this procedure. Few comparisons between different stand-alone implants for ACDF have been reported in the literature. Methods: We performed a comparison between patients who underwent ACDF with either a porous tantalum or a PEEK stand-alone cage, in two spine surgery units for single-level disc herniation. Clinical outcome [Neck Disability Index (NDI), Visual Analog Scale (VAS) for pain, Short Form-36 (SF-36)] and radiological outcome (lordosis, fusion and subsidence) were measured before surgery and at least one year after surgery in both groups. Results: Thirty-eight patients underwent ACDF with a porous tantalum cage, and thirty-one with a PEEK cage. The improvement of NDI and SF-36 was significantly superior in the PEEK group (p = 0.002 and p = 0.049 respectively). Moreover, the variation of the Cobb angle for the cervical spine was significantly higher in the PEEK group (p < 0.001). Conclusions: In a retrospective analysis of two groups of patients with at least one year of follow-up, a stand-alone PEEK cage showed superior clinical results, with improved cervical lordosis, compared to a stand-alone porous tantalum cage. Further studies are needed to confirm these data.