Chondrosarcomas are cartilage-matrix-forming tumors that make up 20-27% of primary malignant bone tumors and are the third most common primary bone malignancy after multiple myelomas and osteosarcomas. Radiographic assessment of this condition includes plain radiography, computed tomography, and magnetic resonance imaging for tumor characterization and delineation of intraosseous and extraosseous involvement. Most chondrosarcomas are refractory to chemotherapy and radiation therapy; therefore, wide en bloc surgical excision offers the best chance for cure. Chondrosarcomas frequently affect the pelvis and upper and lower extremities. In rare instances, the chest wall can be involved, with chondrosarcomas occurring in the ribs, sternum, anterior costosternal junction, and posterior costotransverse junction. In this article, we present a patient with thoracic chondrosarcoma centered at the left T7 costotransverse joint with effacement of the left T7-T8 neuroforamen. We also detail our operative technique of wide en bloc chondrosarcoma excision and review current literature on this topic.

Study Design Retrospective analysis. Clinical Question Is there a difference between the screw-rod construct (SRC) procedure without wiring and the SRC procedure with wiring with respect to fusion, implant failure, reoperation, donor-site morbidity, and complication rates? Patients and Methods We performed a retrospective analysis of 26 patients who underwent C1-2 fixation between 2004 and 2012 (SRC with wiring and structural bone graft, 13 patients; SRC with autograft but without wiring, 13 patients). Fusion was assessed using dynamic X-rays in all patients and computed tomographic scans in selected cases. Pseudoarthrosis was confirmed during reoperation. Results The mean follow-up time was 2 years and 5 months for the SRC without wiring group and 2 years and 1 month for the SRC with wiring group. Patients with less than 1-year follow-up time were excluded. The fusion rate, implant failure rate, and reoperation rates for the SRC without wiring group were 92, 8, and 8%, respectively. The fusion, implant failure, and reoperation rates for the SRC with wiring group were 100, 0, and 0%, respectively. There were no donor-site morbidities or complications in either group (both 0%). There were no differences in parameters we examined between the two groups (p > 0.05 for each rate, Fisher exact test). Conclusions The results suggest that supplementing the SRC procedure with wiring may increase fusion rate, but this difference is not statistically significant. Although the sample size was small, there was not a significant discrepancy in outcomes between the two groups at an average follow-up of 2 years. [Table: see text].

Direct ventral access to the cervicothoracic spine (C7-T4) poses a technical challenge in spine surgery, given the vital neurovascular structures residing anterior to the cervicothoracic junction (CTJ). The transsternal approach is a feasible surgical option that allows for direct anterior exposure of the lower cervical and upper thoracic vertebrae. Here, the authors report a case of an elderly gentleman with upper thoracic (T1-2) vertebral osteomyelitis and epidural abscess who underwent a transsternal full median sternotomy for ventral decompression and fusion of C7-T2. We also detail our operative procedure and review relevant literature on different transsternal approaches to the CTJ.

OBJECTIVE:The oblique lumbar interbody fusion (OLIF) can be done with either fluoroscopy or navigation. However, it is unclear how navigation affects the overall flow of the procedure. We wished to report on the accuracy of this technique using navigation and on how navigation affects surgical time and complications. METHODS:A retrospective review was undertaken to evaluate patients who underwent OLIF using spinal navigation at University of California San Francisco. Data collected were demographic variables, perioperative variables, and radiographic images. Postoperative lateral radiographs were analyzed for accuracy of cage placement. The disc space was divided into 4 quadrants from anterior to posterior, zone 1 being anterior, and zone 4 being posterior. The accuracy of cage placement was assessed by placement. RESULTS:There were 214 patients who met the inclusion criteria. A total of 350 levels were instrumented from L1 to L5 using navigation. The mean follow-up time was 17.42 months. The mean surgical time was 211 minutes, and the average surgical time per level was 129.01 minutes. After radiographic analysis, 94.86% of cages were placed within quartiles 1 to 3. One patient (0.47%) underwent revision surgery because of suboptimal cage placement. For approach-related complications, transient neurological symptoms were 10.28%, there was no vascular injury. CONCLUSION:The use of navigation to perform OLIF from L1 to L5 resulted in a cage placement accuracy rate of 94.86% in 214 patients.

Study Design Retrospective analysis. Clinical Question Is there a difference between the screw-rod construct (SRC) procedure without wiring and the SRC procedure with wiring with respect to fusion, implant failure, reoperation, donor-site morbidity, and co

Spinal cord herniation (SCH) is a rare cause of myelopathy. When reported, SCH has most commonly been described as occurring spontaneously in the thoracic spine, and being idiopathic in nature (anterior thoracic spinal cord herniation, ATSCH) [1-3]. Several theories have been proposed to explain its occurrence, including congenital, inflammatory, and traumatic etiologies alike [1-4]. Even more rarely, SCH has been described to occur in the cervical spine in association with brachial plexus avulsion injuries (BPAI-SCH). In our accompanying article, "Late Cervical Spinal Cord Herniation Resulting from Post-Traumatic Brachial Plexus Avulsion Injury," two cases of BPAI-SCH are presented and discussed in the context of the reviewed literature [5]. Here, pertinent accompanying follow-up data was collected and is presented for the cases, including postoperative radiographic outcome imaging. Furthermore, a table is presented comparing and contrasting ATSCH to BPAI-SCH. Although the two phenomena have been previously grouped together, this table highlights ATSCH and BPAI-SCH as distinct entities; more specifically, BPAI-SCH is a separate, long-term complicating feature of BPAI. This supplementary data helps treating physicians by increasing awareness and knowledge of BPAI-SCH as a distinct entity from ATSCH and cause of delayed neurological deterioration.

It can be difficult to avoid violating the pleura during the retropleural approach to the thoracolumbar spine. In this video, the authors resect a short segment of rib to allow more room for pleural dissection during a minimally invasive (MIS) lateral retropleural approach. After a lateral MIS skin incision, the rib is dissected and removed, clearly identifying the retropleural space. The curvature of the rib can then be followed, decreasing the risk of pleural violation. The pleura can then be mobilized ventrally until the spine is accessed. Managing the diaphragm is also illustrated by separating the fibers without a traditional cut through the muscle. The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID21138.

OBJECTIVE:Recurrent tethered cord syndrome (TCS), believed to result from tension on the distal portion of the spinal cord, causes a constellation of neurological symptoms. Detethering surgery has been the traditional treatment for TCS. However, in cases of recurrent TCS, there is a risk of new neurological deficits developing, and subsequent retethering is difficult to prevent. Spinal column shortening has been proposed as an alternative technique to reduce the tension on the spinal cord without incurring the morbidity of revision surgery on the spinal cord. The authors compared the perioperative outcomes and morbidity of patients who were treated with one or the other procedure. METHODS:The medical records of 16 adult patients with recurrent TCS who were treated between 2005 and 2018 were reviewed. Eight patients underwent spinal column shortening, and 8 patients underwent revision detethering surgery. Patient demographics, clinical outcomes, and perioperative factors were analyzed. The authors include a video to illustrate their technique of spinal column shortening. RESULTS:Within the spinal column shortening group, no patients experienced any complications, and all 8 patients either improved or stabilized with regard to lower-extremity and bowel and bladder function. Within the revision detethering group, 2 patients had worsening of lower-extremity strength, 3 patients had worsening of bowel and bladder function, and 1 patient had improvement in bladder function. Also, 3 patients had wound-related complications. The median estimated blood loss was 731 ml in the shortening group and 163 ml in the revision detethering group. The median operative time was 358 minutes in the shortening group and 226 minutes in the revision detethering group. CONCLUSIONS:Clinical outcomes were comparable between the groups, but none of the spinal column shortening patients experienced worsening, whereas 3 of the revision detethering patients did and also had wound-related complications. Although the operative times and blood loss were higher in the spinal column shortening group, this procedure may be an alternative to revision detethering in extremely scarred or complex wound revision cases.

Introduction

The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery.

Methods

Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009).

Results

Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization.

Conclusions

Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.

Introduction

Although matching lumbar lordosis (LL) with pelvic incidence (PI) is an important surgical goal for adult spinal deformity (ASD), there is concern that overcorrection may lead to proximal junctional kyphosis (PJK). We introduce the upper instrumented vertebra-femoral angle (UIVFA) as a measure of appropriate postoperative position in the setting of lower thoracic to pelvis surgical correction for patients with sagittal imbalance. We hypothesize that a more posterior UIV position in relation to the center of the femoral head is associated with an increased risk of PJK given compensatory hyperkyphosis above the UIV.

Methods

In this retrospective cohort study, adult patients undergoing lower thoracic (T9-T12) to pelvis correction of ASD with a minimum of 2-year follow-up were included. UIVFA was measured as the angle subtended by a line from the UIV centroid to the femoral head center to the vertical axis. Patients who developed PJK and those who did not were compared with preoperative and postoperative UIVFA as well as change between postoperative and preoperative UIVFA (deltaUIVFA).

Results

Of 119 patients included with an average 3.6-year follow-up, 51 (42.9%) had PJK and 24 (20.2%) had PJF. Patients with PJK had significantly higher postoperative UIVFA (12.6 ± 4.8° vs. 9.4 ± 6.6°, p = 0.04), deltaUIVFA (6.1 ± 7.6° vs. 2.1 ± 5.6°, p < 0.01), postoperative pelvic tilt (27.3 ± 9.2 vs. 23.3 ± 11, p = 0.04), postoperative lumbar lordosis (47.7 ± 13.9° vs. 42.4 ± 13.1, p = 0.04) and postoperative thoracic kyphosis (44.9 ± 13.2 vs. 31.6 ± 18.8) than patients without PJK. With multivariate logistic regression, postoperative UIVFA and deltaUIVFA were found to be independent risk factors for PJK (p < 0.05). DeltaUIVFA was found to be an independent risk factor for PJF (p < 0.05). A receiver operating characteristic (ROC) curve for UIVFA as a predictor for PJK was established with an area under the curve of 0.67 (95% CI 0.59-0.76). Per the Youden index, the optimal UIVFA cut-off value is 11.5 degrees.

Conclusion

The more posterior the UIV is from the femoral head center after lower thoracic to pelvis surgical correction for ASD, the more patients are at risk for PJK. The greater the magnitude of posterior translation of the UIV from the femoral head center from preop to postop, the greater the likelihood for PJF.