Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery. . Cite this article: Bone Joint J 2014;96-B:641–5

Aims. The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT. Patients and Methods. Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT. Results. In total, 429/12 171 patients (3.5%) had a DT. Multivariable analysis revealed that PEG hydrogel significantly reduced the incidence of dural leak and prolonged bed rest, and that patients treated with sealants (fibrin glue and PEG hydrogel) significantly less frequently suffered from headache. A longer drainage duration significantly increased the incidence of headache, nausea/vomiting, and delayed wound healing. Headache and nausea/vomiting were significantly more prevalent in younger female patients. Postoperative neurological deficit and reoperation for DT significantly depended on the presence of cauda equina/nerve root herniation. A longer operative time was the sole independent risk factor for SSI and was also a risk factor for dural leak, prolonged bed rest, and nausea/vomiting. Conclusion. Sealants, particularly PEG hydrogel, may be useful in reducing symptoms related to cerebrospinal fluid leakage, whereas prolonged drainage may be unnecessary. Younger female patients should be carefully treated when DT occurs. Cite this article: Bone Joint J 2019;101-B:1115–1121

A dural tear is a common but troublesome complication of endoscopic spinal surgery. The limitations of space make repair difficult, and it is often necessary to proceed to an open operation to suture the dura in order to prevent leakage of cerebrospinal fluid. We describe a new patch technique in which a small piece of polyglactin 910 is fixed to the injured dura with fibrin glue. Three pieces are generally required to obtain a watertight closure after lavage with saline. We have applied this technique in seven cases. All recovered well with no adverse effects. MRI showed no sign of leakage of cerebrospinal fluid

Purposes of the study and background

MRI of the lumbar spine is a clinically important examination in low back pain (LBP) when serious underlying pathology or radiculopathy is suspected or when pain does not improve, e.g. to identify herniated discs. The general population has high confidence in this modality. Little documented knowledge exists about how the MRI results should be communicated to the patients in an optimal way. The aim of this study was to explore the patients' perspectives, i.e. worries, thoughts and interpretations of terms used when health care providers convey the MRI results.

Aims. This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases. Methods. We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed. Results. The significant risk factors (p < 0.050) for ULP were OPLL (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.29 to 2.75), foraminotomy (OR 5.38, 95% CI 3.28 to 8.82), old age (per ten years, OR 1.18, 95% CI 1.03 to 1.36), anterior spinal fusion (OR 2.85, 95% CI 1.53 to 5.34), and the number of operated levels (OR 1.25, 95% CI 1.11 to 1.40). OPLL was also a risk factor for neurological deficit except ULP (OR 5.84, 95% CI 2.80 to 12.8), dural tear (OR 1.94, 95% CI 1.11 to 3.39), and dural leakage (OR 3.15, 95% CI 1.48 to 6.68). Among OPLL patients, dural tear and dural leakage were frequently observed in those with a canal-occupying ratio ≥ 50%. Cervical rheumatoid arthritis (RA) was a risk factor for SSI (OR 10.1, 95% CI 2.66 to 38.4). Conclusion. The high risk of ULP, neurological deficit except ULP, dural tear, and dural leak should be acknowledged by clinicians and OPLL patients, especially in those patients with a canal-occupying ratio ≥ 50%. Foraminotomy and RA were dominant risk factors for ULP and SSI, respectively. An awareness of these risks may help surgeons to avoid surgery-related complications in these conditions. Cite this article: Bone Joint J 2021;103-B(1):157–163

Background. Magnetic resonance imaging (MRI) algorithm identifies end stage severely degenerated disc as ‘black’, and a moderately degenerate to non-degenerated disc as ‘white’. MRI is based on signal intensity changes that identifies loss of proteoglycans, water, and general radial bulging but lacks association with microscopic features such as fissure, endplate damage, persistent inflammatory catabolism that facilitates proteoglycan loss leading to ultimate collapse of annulus with neo-innervation and vascularization, as an indicator of pain. Thus, we propose a novel machine learning based imaging tool that combines quantifiable microscopic histopathological features with macroscopic signal intensities changes for hybrid assessment of disc degeneration. Methods. 100-disc tissue were collected from patients undergoing surgeries and cadaveric controls, age range of 35–75 years. MRI Pfirrmann grades were collected in each case, and each disc specimen were processed to identify the 1) region of interest 2) analytical imaging vector 3) data assimilation, grading and scoring pattern 4) identification of machine learning algorithm 5) predictive learning parameters to form an interface between hardware and software operating system. Results. Kernel algorithm defines non-linear data in xy histogram. X,Y values are scored histological spatial variables that signifies loss of proteoglycans, blood vessels ingrowth, and occurrence of tears or fissures in the inner and outer annulus regions mapped with the dampening and graded series of signal intensity changes. Conclusion. To our knowledge this study is the first to propose a machine learning method between microscopic spatial tissue changes and macroscopic signal intensity grades in the intervertebral disc. No conflict of interest declared.  . Sources of Funding. ICMR/5/4-5/3/42/Neuro/2022-NCD-1, Dr TMA PAI SMU/ 131/ REG/ TMA PURK/ 164/2020. A part of the above study was presented as an oral paper at the International Society for the Study of Lumbar Spine (ISSLS) meeting held on 1–5. th. May 2023, Melbourne, Australia

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The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system.

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The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

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The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

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To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Purpose. To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome. Methods. Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A. In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented. Results. Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline. Conclusion. Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term. Ethics - none, Interest –none

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome. Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A. In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented. Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline. Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term

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Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

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With resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic.

Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion. In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD $91 909 vs. $87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001). . In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses. Cite this article: Bone Joint J 2014;96-B:807–16

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To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

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To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability.

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain

Background. Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders. Methods. We included data from 4′940 patients documented in Eurospine's Spine Tango Registry from 2004 to 2015. Medical history and surgical details were documented on the Tango Surgery form, as were surgical and general medical complications arising between admission and discharge. Multiple logistic regression models were built to investigate the relationship between the number of any previous surgeries and the presence of a perioperative complication, controlling for other potential confounders (age, sex, smoking, BMI, comorbidity, number of vertebral levels affected). Results. There were 9.4% surgical complications (most commonly dural tear, neurological sequelae, haematoma, infection) and 6.5 % general complications (most commonly cardiovascular, urinary, pulmonary, liver/GI). In the multivariable models, previous surgery significantly increased the odds of having a surgical complication (OR 1.148, 95%CI 1.051–1.253; p=0.002) and a medical complication (OR 1.185, 95%CI 1.074–1.307; p=0.001) i.e., for each previous surgery, the odds of a complication increased by 15% and 19%, respectively. Conclusion. We demonstrated a significant dose-response effect of previous surgery on the risk of incurring a complication during subsequent spine surgery. The results can be used by the surgeon when assessing the risk/benefit ratio of further surgery, for informing and consenting the patient. No conflicts of interest. No funding obtained

Object. Giant thoracic discs (occupying more than 40% of the spinal canal) are a difficult surgical pathology. They are increasingly being recognized as or particular subset of thoracic disc pathology. It has been recommended that an aggressive surgical approach of open 2 level verteberectomy and instruments should be utilized.21 However Retropleural thoracotomy provides the shortest direct route to the anterior thoracic spine and avoids pleural cavity entry making it an ideal if infrequently used approach to access ventral thoracic and thoracolumbar spine abnormalities. We present a detailed description of our experience utilising this approach, for the treatment of Giant Thoracic discs without the need for vertebrectomy or instrumentation. Methods. A prospective cohort of patients with Giant thoracic discs operated on utilizing the mini open retropleural thoracotomy technique was used, intra-operative and post-operative complications and length of post-op stay. Functional outcome and pain scores, were also prospectively recorded using SF-36, Oswestry Disability Index (ODI), and visual analogue pain scores (VAS). Results. 17 patients underwent a retropleural thoracotomy for Giant thoracic disc between 2001 and 2010. There were 8 male and 9 female patients with a median age of 50 years (range 35 – 70). The surgical level was T8/9 (58%) followed by T10/11 (33%) and finally T11/12 (8%). 1 patient had redo surgery following a failed primary discectomy at another institution. The mean post-operative length of stay was 12.8 days Intra-operative complications included 5 pleural tears during the approach. Chest drain was placed post-op in one patient. The tears were primarily repaired and the approach did not have to be abandoned. 2 patients had an intra-operative CSF leak (1 had intradural disc erosion). Post-operative complications included 1 pleural effusion, 1 patient had pneumonia and a PE, 1 patient died from an unrelated respiratory tract infection of the lung (opposite to the side of the approach) 40 days after surgery. Conclusion. Large calcified thoracic disc herniations can be a very challenging pathology. The retropleural transthoracic approach can be employed safely in this setting with acceptable morbidity for the patient