Iyer, Harshvardhan

Management of unstable upper lumbar fractures with corpectomy and posterior fixation is technically demanding, and conventional workflows may require intraoperative repositioning, increasing operative complexity. Lateral mini-open upper lumbar corpectomy (LMULC) paired with robotic-assisted (RA) posterior percutaneous pedicle screw fixation (PPPSF) can be performed in a single position to facilitate ventral spinal decompression and stabilization in the anatomically constrained upper lumbar spine. In this study, we describe the operative technique and report four illustrative cases of unstable L1 or L2 fractures treated with single-position LMULC, RA-PPPSF, and short-segment fusion. Clinical, radiological, intraoperative variables and postoperative outcomes were evaluated. The mean age was 52.3 ± 17.7 years. The median operation time was 314 min (range 268–361 min); the median estimated blood loss (EBL) was 225 mL (range 100–400 mL). The median preoperative kyphosis was 10.15° (range 8.4–14.6°), the median postoperative kyphosis measured 6.65° (range 1.7–10.8°) and the median correction achieved was 3.5° (range −2.4–12.9°). The median visual analog scale (VAS) pain score reduced from 7 (range 7–9) preoperatively to 4.5 (range 2–6) postoperatively at discharge. At a median follow-up of 12 months (range 6–15 months), all patients had uncomplicated recoveries, demonstrated solid fusion on imaging, and reported favorable MacNab outcomes. Single-position LMULC with RA-PPPSF was technically feasible in this preliminary illustrative series and resulted in favorable clinical and radiographic outcomes. However, further studies in larger cohorts are warranted to help confirm these findings and better define the potential advantages and limitations of this technique.

Background/Objectives: Postoperative opioid exposure after lumbar fusion remains a key clinical concern. Understanding which perioperative factors are associated with lower postoperative opioid use may help optimize recovery after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). This study aimed to determine if patients undergoing MIS-TLIF under spinal anesthesia (SA) showed lower postoperative opioid use compared to those undergoing MIS-TLIF under general anesthesia (GA). Methods: We retrospectively studied all adult patients (>18 years) undergoing 1- and contiguous 2-level MIS-TLIFs performed by a single surgeon. Patients undergoing the procedure under GA were compared to those undergoing the procedure under SA. Postoperative oral opioid use, up to 3 months post discharge, was collected. A 1:1 propensity score matching (PSM) protocol was implemented. Each outcome variable was initially assessed using univariate regression. Predictor variables with a p-value < 0.2 were included in the multivariate regression model. This was a retrospective, non-randomized study, and residual confounding cannot be excluded despite PSM. Results: The matched groups (n = 50 in each group) did not differ significantly depending on demographics or levels fused. Before regression, mean number of postoperative opioid prescriptions (p = 0.03), mean total operating room (OR) time in minutes (p < 0.01), and median length of stay (LOS) in days (p = 0.03) were significantly different. Multivariate regression showed that the GA group received 216.5 more total morphine milligram equivalents than the SA group (95% CI = 0.7–432.2, p = 0.049). The days of opioid use were higher in the GA group by 3.8 days (95% CI = 0.5 to 7.1, p = 0.025). On multivariate regression, LOS in hours was greater in the GA group by 14.1 h (p = 0.042). Conclusions: SA is an effective anesthetic modality for spinal surgery with the advantages of reduced postoperative opioid use, reduced OR time, and shorter LOS compared to GA.

OBJECTIVE The implementation of robotics and spinal anesthesia (SA) in spine surgery is rapidly expanding, offering significant benefits for an increasingly complex and aging patient population with degenerative spinal disease. Here, the authors present the largest cohort to date evaluating the combined use of these two techniques in minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). METHODS The authors retrospectively analyzed surgical outcomes of a series of patients who underwent robot-assisted (RA)–MIS TLIF under SA and general anesthesia (GA) at their institution from 2018 to 2024. Primary outcomes included operative times and postoperative pain intensity. Secondary outcomes included estimated blood loss, intraoperative complications, postoperative functional status, length of stay (LOS), and discharge status. To address potential confounders, a 1:1 propensity score–matching and regression analysis was implemented. Statistical analyses were conducted using Python. RESULTS A total of 209 patients underwent RA-MIS TLIF, with 31 (14.83%) receiving SA and 178 (85.17%) GA. After propensity score matching, the SA cohort demonstrated significantly shorter median total operating room (OR) time, total procedure time, time from entering the OR to skin incision, and time from closure to leaving the OR (all p < 0.01). Additionally, postoperative pain scores were significantly lower (p < 0.01), and LOS was significantly shorter (p < 0.01) in the SA cohort. Regression analysis, adjusting for potential confounders, further supported these findings. CONCLUSIONS RA-MIS TLIF fusion under SA is a safe and effective approach that significantly reduces operative time, postoperative pain, and hospital LOS in patients undergoing surgery for degenerative lumbar spine disease.

Background/Objectives: Chordoma, a rare slow-growing malignant bone tumor, remains therapeutically challenging due to its invasive nature. We examined institutional outcomes comparing imatinib and brachyury-directed vaccines. Methods: We used data from three sites of our quaternary care academic institution to analyze demographics, time to progression, overall survival, and adverse events in chordoma patients treated with imatinib or enrolled in a brachyury vaccine trial. Results: We included a total of 52 patients (8 in the brachyury vaccine cohort and 44 in the imatinib cohort) in the analysis. As expected, sacrococcygeal location was the most predominant in both cohorts: 62.5% in the brachyury cohort and 45.5% in the imatinib cohort. No demographic differences were present between the cohorts. ECOG was similar in both groups (p = 0.796). The primary outcome, time to progression (TTP), was shorter in the brachyury compared to the imatinib cohort (5.6 vs. 13 months, p = 0.0589), almost reaching statistical significance. Overall survival (OS) was comparable, 211 vs. 212 months for the brachyury and imatinib cohorts, respectively (p = 0.277). Although the brachyury vaccine cohort presented a higher incidence of adverse events than the imatinib cohort (75% vs. 31.8%, p = 0.021), the severity was milder. Conclusions: Imatinib showed longer disease control than the brachyury vaccine, though overall survival was similar. Future studies and deeper molecular insights are essential to develop better therapies and improve patient quality of life.

Study Design Systematic Review. Objective To assess the current literature regarding the accuracy of different imaging modalities and criteria used to assess lumbar fusion, and their correlation with surgical direct observation as the current Gold Standard. Methods Following PRISMA guidelines, we conducted a comprehensive search of PubMed, Embase, Google Scholar, and Cochrane Library, studies were included if they focused on patients with a prior history of lumbar interbody fusion and at least 1 year of radiographic follow-up. The review assessed the sensitivity, specificity, and accuracy of different imaging techniques, and their correlation with surgical findings. Results Thirteen studies (1989-2019) were reviewed, including 715 patients, common imaging modalities included plain radiographs (53.8%), Computed Tomography (CT) (69.2%), and dynamic radiographs (30.7%). CT appeared as the most utilized modality post-2006. There was substantial variability in diagnostic accuracy, with CT showing high variability in sensitivity and specificity. Descriptive criteria for fusion were widely used, but interobserver agreement was generally low. Conclusion The review highlights a lack of standardized criteria for assessing lumbar fusion. Despite advancements in imaging techniques, the variability in diagnostic parameters suggests a need for consensus and multicentric studies to stablish reliable, universal criteria for evaluating fusion success.

BACKGROUND AND OBJECTIVES: Awake minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) generates minimal surrounding tissue damage and has been shown to be a safe, time-effective, and cost-reductive technique in single-level procedures. The purpose of this study was to advocate for the utilization of multilevel MIS-TLIF even in challenging cases as it has demonstrated positive outcomes. METHODS: Chart review was conducted for consecutive patients undergoing awake multilevel MIS-TLIF from 2020 to 2023. Various demographic, preoperative, and postoperative variables were collected and descriptively analyzed. RESULTS: Sixteen patients underwent multilevel awake MIS-TLIF at our institution during the specified period. Among them, 87.5% underwent a two-level procedure and 12.5% a three-level procedure. The median age ± IQR was 69.5 ± 11 years, with a slight male predominance (56.25%). Common comorbidities included hypertension (56.25%), obesity (37.5%), sleep apnea (25%), and type 2 diabetes (18.75%). The American Society of Anesthesiologists risk was 2 in 43.75% of patients and 3 in 56.25%. All patients presented pain, and 12.5% showed motor deficit. Intraoperative data showed a median of 196 minutes in the operating room where 156 ± 27.75 minutes corresponded to actual procedure time. The median estimated blood loss was 50 ± 70 cc. In the immediate postoperative period, 1 patient had nausea and emesis, and 1 reported fatigue. The median pain score during this period was 4.6 ± 2.03. Pain control medications were required for various patients, with methocarbamol (50%), hydromorphone (37.5%), and oxycodone (25%) being the most commonly prescribed in the postanesthesia care unit. No patient had new neurological deficits after the surgical intervention. The median length of stay was 2 days ±1.25. All patients were discharged with no complications. CONCLUSION: Multilevel awake MIS-TLIF emerges as a safe and effective technique for complex cases, enhancing patient quality of life with minimal blood loss and postoperative pain.