What’s New in Spine Surgery

Although the COVID-19 pandemic has undoubtedly disrupted the scientific enterprise, spine surgeons remained committed to improving the science of our discipline. We present a review of high-quality, peer-reviewed articles over the past year, revealing advances in our understanding of cervical myelopathy and trauma, deformity, spinal cord injury, and other degenerative spinal conditions. These articles were chosen for their originality, insightfulness, methodology, and potential impact on the field of spine surgery. COVID-19 and Spine Surgery The coronavirus has resulted in a global pandemic, with 120 million infected people around the world and over 2.6 million lives lost by March 2021. This disease results in pulmonary compromise and the need for inpatient hospitalizations in a subset of patients. An estimated 3% to 32% of patients required intensive care support and artificial ventilation. Hospitals in the United States and across the world responded swiftly and in similar ways. Travel bans were rapidly initiated to limit the spread of the virus and to preserve the physician workforce, non-urgent surgical procedures were cancelled in order to increase hospital capacity for patients infected with the virus, and in-person clinics were cancelled and were replaced by telemedicine visits to slow down the rate of community spread. The economic impact on health care was staggering. In the initial weeks of the pandemic, 60,000 health-care jobs were lost1, and almost all interventional spine procedures were postponed or cancelled. Over 60% of spine surgeons reported reductions in their salary or benefits, and 17% reported that they, or other spine surgery providers, were involuntarily reassigned to cover non-neurosurgical services during the COVID-19 pandemic. Sixty-nine percent received no financial compensation for these work efforts, and 31% of respondents were compensated at a rate equal to or lower than their established salary rate. Cervical Pathologies Cervical Spondylosis and Cervical Spondylotic Myelopathy Degenerative cervical myelopathy remains the most common cause of spinal cord dysfunction. In a Level-I multicenter study, Fehlings et al. investigated whether riluzole enhances outcomes in patients undergoing a decompression and fusion procedure for degenerative cervical myelopathy. This was a multicenter, double-blinded, placebo-controlled, randomized, phase-3 trial of patients undergoing a surgical procedure across 16 university-affiliated hospitals in the United States and Canada. Patients were randomized to either riluzole or placebo. The primary end point was a change in modified Japanese Orthopaedic Association (mJOA) scores at 6 months after the surgical procedure. Secondary outcomes were changes from baseline in functional status (Nurick grade), disability (Neck Disability Index), American Spinal Injury Association (ASIA) score, grip strength, Numeric Rating Scale scores, and quality of life (Short Form-36 [SF-36] and EuroQol-5 Dimensions [EQ-5D]). Of the 408 patients who were screened, 300 were eligible and 290 were randomly assigned to the intervention group (n = 141) or the placebo group (n = 149), and 108 patients were excluded. The mean patient age was 58 years. Baseline characteristics were balanced between both groups. At 6 months after the surgical procedure, both patient groups showed improvement in mJOA scores; however, there were no between-group differences in the extent of improvement. Similarly, the extent of improvement from baseline in all secondary outcomes was not significantly different between both groups. At 1 year after the surgical procedure, the riluzole group demonstrated a greater reduction in neck pain, although pain was not a prespecified primary end point. Riluzole does not provide an additional benefit with respect to functional outcome scores in patients undergoing decompression and fusion for cervical myelopathy2. In a Level-I study investigating the effectiveness of local intraoperative corticosteroids at decreasing dysphagia after multilevel anterior discectomy and fusion surgical procedures3, Kim et al. demonstrated a significant decrease in the severity of postoperative dysphagia with local intraoperative corticosteroids. This was a prospective, double-blinded, randomized controlled trial of patients undergoing multilevel anterior cervical discectomy and fusion (ACDF). Patients were randomized to receive the treatment (local corticosteroids) or placebo. Additionally, patients received 10 mL of intravenous dexamethasone, regardless of group allocation (institutional protocol). The primary outcome was change in swallowing assessed with the Eating Assessment Tool-10 (EAT-10) and the Swallowing Quality of Life (SWAL-QOL) Questionnaire. There were 128 patients who were eligible and were randomized, and 109 patients (56 in the treatment group and 53 in the control group) were used in the analysis. At baseline, both groups were balanced; however, the treatment group had a lower frequency of drain placement and shorter operative time. The EAT-10 scores were significantly lower in the corticosteroid group on postoperative day 2, and this difference was durable through 1 month after the surgical procedure. The findings of this study suggest that the local administration of corticosteroids after multilevel ACDF is associated with decreased severity of postoperative dysphagia3. Cervical Trauma In a Level-II study4, Buchanan et al. investigated whether the addition of magnetic resonance imaging (MRI) adds value for patients presenting with acute traumatic cervical spinal cord injury. This was a vignette-based study of patients presenting with acute spinal cord injury to a level-1 trauma center between 2010 and 2019. Patients included in the study presented to the emergency department with signs of quadriplegia, and underwent computed tomography (CT), MRI, and subsequently a surgical procedure within 48 hours of arrival. The clinical vignettes were presented to the surgeons in 2 phases. In phase I, the clinical vignettes were presented with only the corresponding CT scans, and in phase II, the vignettes were presented with both CT and MRI scans. A minimum washout period of 2 weeks was included between phases I and II to prevent recall bias. Twenty-nine patient vignettes were utilized for this study (a total of 174 surgical plans). The researchers found that surgical timing was changed in 55% of cases, approach was changed in 44% of cases, and targeted vertebral levels were changed in 63% of cases. Combined, 93% of surgical plans changed after the MRI. Collision sports have inherent risk of injuries, such as cervical spinal injuries. Up to 10% of injuries in the National Football League (NFL) are head, neck, and spine injuries. Return to play after cervical injuries is controversial, given the paucity of data on this topic. Using a modified Delphi methodology, Schroeder et al.5 attempted to establish return-to-play recommendations. They conducted a 3-round survey with fellowship-trained spinal surgeons and physicians from the NFL. The first-round survey was sent to all Cervical Spine Research Society (CSRS) members and consisted of 14 clinical scenarios and 38 questions related to cervical spine injuries in football. The results for this survey informed the development of 13 consensus statements, which were subsequently sent to CSRS members (second round). The feedback from the second survey was used to develop return-to-play recommendations for professional athletes who sustained cervical spine injuries. The researchers reported strong consensus among respondents that athletes with cervical spine injuries who undergo 1 or 2-level ACDF without increased T2 signal intensity may return to play. There was low consensus for returning to play for athletes who undergo a 3-level ACDF. For asymptomatic athletes without radiographic evidence of spinal cord injury (increased T2 signal intensity) and spinal canal diameter of >10 mm, there was strong consensus for returning to play. There was no consensus on retuning to play for cases with pseudarthrosis after ACDF. For athletes with a history of cervical spine injury, there was strong consensus for screening MRI scans before sports participation5. Cervical Deformity Adult cervical deformity is a common cause of disability in elderly patients. A surgical procedure for deformity correction is technically challenging and is associated with high complication rates and prolonged recovery. Kim et al.6 investigated the incidence, patient-level risk factors, and recovery rate of neurological complications in patients undergoing a corrective surgical procedure for adult cervical deformity. There were 106 patients enrolled in this multicenter study. The mean age was 60.8 years and the mean duration of follow-up was 18.2 months. Neurological complications occurred in 18.9% of patients, of which 68.1% were major complications. The majority (91%) of complications resolved within 6 months, with only 2% of patients with delayed neurological recovery. In a Level-III study, Lau et al. reported outcomes and complications profiles after a Smith-Petersen osteotomy compared with a 3-column osteotomy for the correction of adult cervical deformity. This was a retrospective, single-institution study of patients with adult, non-oncologic cervical deformity. Ninety-five patients with a diagnosis of cervical or cervicothoracic deformity were included. The mean patient age was 63.2 years, and 60% of patients were female. With regard to the mean preoperative values, the cervical sagittal vertical axis was 6.2 cm, the lordosis was 6.8°, the T1 slope was 40.9°, and the coronal Cobb angle was 6.7°. Forty-six patients underwent Smith-Petersen osteotomy and 49 patients underwent 3-column osteotomy. Three-column osteotomies were most commonly performed at T3 (26.5%), followed by T2 (20.4%). Overall, compared with baseline, there was a significant improvement in all cervical radiographic parameters. The combined complication rate (major and minor) was 37.9%. Neurological complications occurred in 16.8% of patients, surgical complications were seen in 17.9%, and medical complications were seen in 23.2% of patients. When comparing complication profiles, the overall complication rate was 32.6% in the Smith-Petersen osteotomy group and 42.9% in the 3-column osteotomy group. This difference was not significant. Complication rates were highest when osteotomies were performed at C7 (37.5%) and T1 (37.5%)7. Lumbar Stenosis, Spondylolisthesis, and Clinical Outcomes Endoscopic spinal surgery has grown in popularity over the past decade. Compared with traditional minimally invasive or open approaches, the use of endoscopy is associated with minimal tissue disruption and pain. To date, the preponderance of these studies focused on endoscopic discectomy, with few studies investigating the effectiveness of this approach for lumbar laminectomy. Salim et al. investigated the effectiveness of a unilateral endoscopic approach for bilateral decompression in patients with lumbar stenosis. The primary outcomes were changes in the visual analog scale, Oswestry Disability Index, MacNab criteria, Medical Research Council (MRC) grading for leg strength, and ASIA score for sensation. Sixty patients (97 levels decompressed) with degenerative spinal stenosis were enrolled in the study. The mean age was 61 years and 38% of patients were male. The mean follow-up period was 30 months. Postoperatively, there was a significant improvement in back and leg pain and disability across all outcome measures assessed. Using the MacNab criteria, 88.4% showed excellent to good outcomes. A unilateral percutaneous endoscopic approach to perform bilateral decompression for patients with lumbar stenosis is both safe and effective8. Lumbar epidural steroid injections are commonly used for nonoperative management of lumbar radiculopathy. In patients who undergo failed conservative management and require a surgical procedure, it is unclear whether preoperative epidural steroid injections may increase risk of postoperative infection. In a retrospective study of 15,011 patients who underwent elective lumbar spine surgical procedures for radiculopathy and/or spinal stenosis at a single institution, Kreitz et al.9 investigated the temporal relationship between preoperative epidural steroid injection, patient demographic characteristics, and comorbidities on postoperative infection. Of the 15,011 patients enrolled, 5,108 underwent fusion procedures and 9,903 underwent decompression only. Patients were categorized as having no preoperative epidural steroid injection or a preoperative epidural steroid injection <30 days, 30 to 90 days, and >90 days prior to the surgical procedure. The primary outcome measure was postoperative surgical site infection requiring reoperation within 90 days of the surgical procedure. In the 9,903 patients who underwent decompression, 2,957 had a preoperative epidural steroid injection. Among the patients who underwent decompression, there was no increased rate of infection in the patients who had a preoperative epidural steroid injection compared with those patients who did not. Additionally, among patients who underwent decompression, there was no increased rate of infection in patients who had an epidural steroid injection within 30 days of a surgical procedure (508 patients) compared with those who had the injection at 30 to 90 days before the surgical procedure (1,252 patients) and those who had the injection >90 days before the surgical procedure (1,197 patients). Among the 5,108 patients who underwent fusion, 1,383 had a preoperative epidural steroid injection. In patients who underwent fusion, there was a significantly higher rate (p = 0.025) of postoperative infection for patients who had a preoperative epidural steroid injection (2.68%) compared with those who did not (1.69%). Additionally, among patients who underwent fusion, there was a significantly higher rate of infection among patients who had an epidural steroid injection within 30 days of the surgical procedure (5.74%; p = 0.005) and those who had the injection >90 days prior to the surgical procedure (2.9%; p = 0.022) compared with patients who had no preoperative epidural steroid injection. For patients who underwent fusion and had an epidural steroid injection between 30 and 90 days before the surgical procedure, there was no increased risk of postoperative infection. Regression analysis of the entire cohort demonstrated that lumbar fusion, body mass index, and Charlson Comorbidity Index were independent predictors of postoperative infection, and age, sex, and exposure to postoperative epidural steroid injection at any time point were not significantly predictive of infection. Exposure to preoperative epidural steroid injection had a marginal but insignificant impact on postoperative infection among all patients undergoing a lumbar surgical procedure9. Deformity Adult Spinal Deformity In a Level-III study, Yao et al. investigated the association between Hounsfield units (HU) at the planned upper instrumented vertebra (UIV) and proximal junctional kyphosis (PJK) in patients with adult spinal deformity. This was a single-institutional study of 63 patients undergoing a corrective surgical procedure for adult spinal deformity. The primary outcome was the incidence of PJK. Local vertebra HU at the planned UIV and UIV+1 was measured using preoperative CT scans. HU were obtained using thin slices (thickness, 1.25 mm). Patients were divided into 1 of 3 groups: (1) no PJK, (2) non-osseous PJK, and (3) osseous PJK. Non-osseous PJK (type 1) was defined as PJK caused by disc and ligamentous lesions, and osseous PJK (type 2) was defined as PJK caused by bone failure. Of the 108 patients reviewed, 63 met the inclusion criteria. The mean age was 58 years, and the mean duration of follow-up was 13 months. Seventy-five percent of patients were female, and 43% of cases were revision cases. The incidence of PJK was 24% at 6 weeks, 32% at 6 months, and 37% at 1 year. There were 16 patients in the non-osseous PJK group and 7 patients in the osseous PJK group. Post hoc analysis demonstrated significantly lower mean HU in the osseous PJK group than in the non-osseous PJK group. Patients with ≤120 HU had a risk of osseous PJK that was 5.74 times higher compared with those with >120 HU10. In an era of bundled payments in health care, understanding discharge disposition and costs after adult spinal deformity surgery is important. Theologis et al. investigated the costs and functional utility of post-discharge rehabilitation after corrective surgical procedures for adult spinal deformity. This was a single-center study of 937 operations for spinal deformity. The primary outcomes were rates of discharge to inpatient rehabilitation facility, costs and duration of stay, and change in the Functional Independence Measure. Of the 937 operations, 391 (41.7%) were followed by discharge to an inpatient rehabilitation facility. The mean patient age was 70.5 years, and the mean length of the in-hospital stay was 8.2 days. The mean duration of stay in the acute inpatient rehabilitation facility was 11.7 days and the mean cost of stay in the acute inpatient rehabilitation facility was $38,808. The Functional Independence Measure significantly improved over the duration of stay at the inpatient rehabilitation facility. The pre-admission Functional Independence Measure score was 66 and improved to 94 at discharge. Assuming a discharge disposition to rehabilitation rate of 41%, the total costs of inpatient rehabilitation are estimated to be $1,674,872 for every 100 patients undergoing a surgical procedure for adult spinal deformity. Future cost utility analysis may be needed to assess the added value of an inpatient rehabilitation stay11. Sex-based differences in health care, such as variance in the perception of pain and functional improvement after a surgical procedure between men and women, have been extensively studied. However, to date, there has been a paucity of data assessing the impact on sex on functional outcomes and complication rates after corrective surgical procedures for adult spinal deformity. In a Level-III, single-center study, Montgomery et al. investigated the relationship between sex and clinical outcomes. In the study, 156 patients with symptomatic adult spinal deformity were enrolled; 66.7% (104 patients) were female and the rest of the patients were male. At the time of the surgical procedure, the female patients were younger and had a higher prevalence of smoking. The female cohort had higher rates of baseline affective disorders, such as depression, as well as more severe baseline pain (assessed by the visual analog scale) and worse functional disability (assessed by the Patient-Reported Outcomes Measurement Information System [PROMIS] and Oswestry Disability Index scores). Postoperatively, the extent of functional improvement was greater in women than men, with no difference in postoperative complication rates. This study suggested that both sexes respond equally well to corrective surgery for adult spinal deformity12. Adolescent Idiopathic Scoliosis The relationship between pulmonary function and spinal deformity has generated substantial interest. Progressive spinal deformity can lead to pulmonary insufficiency and respiratory failure. In a Level-IV study, Deng et al. investigated the relationship between thoracic morphology and pulmonary function in patients with adolescent idiopathic scoliosis. This was a single-center study of 108 patients. The following data were collected on all patients: costophrenic angle distance, distance between T1 and the mean diaphragm height (T1-diaphragm), T1-T12 height, and apical vertebral deviation ratio. Pulmonary function data included forced vital capacity, forced expiratory volume in 1 second (FEV1), vital capacity, total lung capacity, and their predicted values. The mean patient age was 15.6 years. The main thoracic Cobb angle was 78°. The mean costophrenic angle distance was 21.14 cm, and the mean apical vertebral deviation ratio was 0.21. The mean forced vital capacity was 2.31 L, which was 76.76% of the predicted value. There was a strong positive correlation between the costophrenic angle distance and forced vital capacity, FEV1, vital capacity, and total lung capacity, indicating that the costophrenic angle distance had a strong correlation with pulmonary volume. The authors observed that when the apical vertebral deviation ratio was <0.2, 93.1% of patients showed normal or mild lung function impairment. In contrast, when the apical vertebral deviation ratio was >0.2, 46% of patients demonstrated moderate to severe impairment. This study demonstrated that, in patients with adolescent idiopathic scoliosis, an apical vertebral deviation ratio of >0.2 is associated with moderate to severe impairment. Additionally, the costophrenic angle distance can be used to assess pulmonary function outcome13. Infantile, Congenital, and Early-Onset Scoliosis In patients with infantile idiopathic scoliosis, serial body casting arrests the progression of the deformity. Historically, serial body casting has been performed under general anesthesia; however, several reports have demonstrated the neurotoxic effects of general anesthetics in young children. LaValva et al.14 investigated the outcomes of serial body cast placement with and without the use of general anesthesia in children with progressive infantile scoliosis. There were 121 patients enrolled in this multicenter study. Ninety-two patients underwent casting under general anesthesia, and 29 patients did not. At baseline, patients in the awake cohort (those who did not have general anesthesia) were older, had more severe curves, and had lower body mass index. The rate of success of casting was higher in the awake cohort, with similar rates of conversion to a surgical procedure in both patient cohorts. Awake casting may be a suitable and safe alternative to casting under general anesthesia in patients with symptomatic infantile scoliosis14. Early-onset scoliosis (EOS) is a heterogenous disease entity. There is a paucity of disease-specific data on health-related quality of life in this patient population. Ramo et al. investigated the influence of the classification of EOS etiology designation, radiographic parameters, and medical comorbidities on the Early Onset Scoliosis Questionnaire (EOSQ). In a multicenter prospective study, 610 patients with EOS were enrolled: 119 patients had congenital EOS, 201 had idiopathic EOS, 156 had neuromuscular EOS, and 134 had syndromic EOS. Scores were lower in many EOSQ domains (general health, transfer, fatigue, daily living, emotion) in patients with neuromuscular and syndromic etiologies. The total and subdomain scores were similar between patients with congenital EOS and those with idiopathic EOS. The severity of the deformity (assessed by coronal Cobb and kyphosis angles) was inversely associated with the EOSQ15. A hemivertebra is the most common cause of congenital scoliosis. The patient age and the number of hemivertebrae significantly affect the progression of the deformity. If improperly treated, the spinal deformity could become severe, compromising cardiac and pulmonary function; hence, timely surgical management is important. To date, there has been a paucity of long-term outcome data on patients undergoing surgical hemivertebra resection. In their study, Yang et al. reported on their single-institution experience and long-term outcomes after posterior hemivertebra resection in children <10 years of age. Sixty-seven patients were enrolled in the study; of these patients, 21 were <10 years of age with a minimum follow-up of 5 years. The mean age at the time of surgical procedure was 4.7 years. Ten patients had thoracolumbar resected hemivertebrae, 4 patients had thoracic resected hemivertebrae, and 7 patients had lumbar resected hemivertebrae. The preoperative main curve Cobb angle was 32.7°, which improved to 10.3° postoperatively and to 15.4° at the last follow-up. Compared with preoperative values, the correction rate was 68.5% postoperatively and 52.9% at the last follow-up, reflecting a loss of correction of approximately 15.6% during the follow-up period. The postoperative coronal balance improved from 10.4 to 2.2 mm. The preoperative sagittal vertical axis was 6.7 mm and increased to 7.8 mm at the last follow-up. No patient had permanent neurological deficits, but 2 patients experienced deformity progression16. Conclusions Combined, these studies reflect meaningful advancements in our understanding and management of spinal cord dysfunction, degenerative spinal pathologies, and deformity. Improvements in augmented reality, biomechanics, neurotherapeutics, registry science, and artificial intelligence create exciting opportunities to improve the science of our discipline. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system. In addition to articles cited already in this update, 5 other articles relevant to spine surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Edström E, Burström G, Persson O, Charalampidis A, Nachabe R, Gerdhem P, Elmi-Terander A. Does augmented reality navigation increase pedicle screw density compared to free-hand technique in deformity surgery? Single surgeon case series of 44 patients. Spine (Phila Pa 1976). 2020 Sep 1;45(17):E1085-90. Compared with conventional, non-navigated pedicle screw placement, surgical navigation using intraoperative, 3-dimensional imaging has been shown to increase implant density and to improve screw placement accuracy, thereby decreasing implant-related complications as well. In this Level-III study, Edström et al. investigated whether the use of augmented reality navigation systems to place pedicle screws in deformity surgical procedures alters total implant density and the pedicle screw-to-hook ratio. A total of 44 patients were enrolled in this retrospective study (15 in the augmented reality navigation group and 29 in the control [free-hand technique] group). Implant density, defined as the combined number of screws and hooks per level fused, was compared between the groups. Overall, the implant density was 88.5% in the augmented reality navigation group and 84.4% in the free-hand technique group. Compared with the free-hand technique group, the pedicle screw density was higher in the augmented reality navigation group, and the hook density was lower. At the UIV and UIV+1, the pedicle screw density was significantly higher in the augmented reality navigation group. There was no significant difference in the total procedure time between the groups. Augmented reality and navigation have been fully integrated into routine clinical practice. The use of these technologies has improved the accuracy of implant placement, but do lead to increased implant density. Gum JL, Shasti M, Yeramaneni S, Carreon LY, Hostin RA, Kelly MP, Lafage V, Smith JS, Passias PG, Kebaish K, Shaffrey CI, Burton DL, Ames CP, Schwab FJ, Protopsaltis T, Bess RS; ISSG. Improvement in SRS-22R self-image correlate most with patient satisfaction after 3-column osteotomy. Spine (Phila Pa 1976). 2020 Dec 17. [Epub ahead of print]. In this Level-III study, Gum et al. investigated the relationship between patient satisfaction, patient-reported outcomes, and radiographic parameters in adult patients with spinal deformity undergoing a 3-column osteotomy. This was a multicenter, retrospective study utilizing the International Spine Study Group (ISSG) database. There were 135 patients with follow-up of 2 years enrolled in the study. Sixty-nine percent of the patients were female, with a mean age of 61 years and a mean body mass index of 29.7 kg/m2. The majority (73%) were primary surgical procedures. There was significant improvement in all patient-reported outcome measures and radiographic parameters, except for the coronal vertical axis. The majority of patients were satisfied with their outcomes. Patient satisfaction was positively strongly correlated with the Self-Image domain in the Scoliosis Research Society 22-item (SRS-22R) questionnaire. This is an interesting study. Historically, for older patients, pain and desire for improved function were the drivers of the need for surgical corrections. This article suggested that self-image appears to be a driver for a surgical procedure in this patient population. Khalid SI, Maasarani S, Nunna RS, Shanker RM, Cherney AA, Smith JS, Reme AI, Adogwa O. Association between social determinants of health and postoperative outcomes in patients undergoing single-level lumbar fusions: a matched analysis. Spine (Phila Pa 1976). 2021 May 1. Across several specialties, social determinants of health have been shown to affect disease outcomes and treatment success. Khalid et al. investigated the influence of social determinants of health on postoperative complication and hospital readmission rates after lumbar spine surgical procedures. The 5 categories of social determinants of health include economic, education, health-care, environmental, and social. In this study, 16,560 patients undergoing single-level lumbar fusion were enrolled. Fifty percent of patients had a social determinant of health disparity and the other 50% did not. Both groups were balanced at baseline for clinical and demographic variables. The postoperative complication rate was higher in the group with a social determinant of health disparity. In a multivariate regression model, the presence of a social determinant of health disparity was associated with 70% increased odds of developing a postoperative complication. Over the past 2 decades, a large, compelling body of evidence has demonstrated a powerful role for social factors, apart from medical care, in shaping health outcomes across a wide range of diseases and populations. This evidence does not deny that medical care influences health; rather, it indicates that medical care is not the only influence on health and suggests that the effects of medical care may be more limited than commonly thought. Maziad AM, Adogwa O, Duah HO, Yankey KP, Owusu DN, Sackeyfio A, Owiredu MA, Wilps T, Ofori-Amankwah G, Coleman F, Akoto H, Wulff I, Boachie-Adjei O; FOCOS Spine Research Group. Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa. Spine Deform. 2021 Jan 5. [Epub ahead of print]. Tuberculosis remains a challenge for several countries in the developing world. Skeletal tuberculosis may be present in up to 10% of patients infected with tuberculosis. A subset of patients develops post-tuberculosis kyphotic deformity, which can lead to restrictive cardiopulmonary disease and potentially late-onset neurological deficits many years after the resolution of the initial infection. Posterior approaches such as costotransversectomy pedicle subtraction osteotomy and posterior vertebral column resection have been demonstrated to be safe and effective techniques to correct the spinal deformity and decompress the neural elements, while avoiding an anterior transthoracic osteotomy. Maziad et al. presented their radiographic and clinical outcomes after 57 patients with severe post-tuberculosis kyphosis underwent correction with posterior vertebral column resection technique with or without preoperative halo gravity traction at a single institution in West Africa. The mean patient age was 19 years. Thirty-six patients were male, and 21 patients were female. Preoperative halo gravity traction was used in 40% of patients at a mean duration of 86 days. Compared with the non-traction group, the baseline kyphosis was higher in patients who underwent preoperative traction at 125° compared with 65°. The mean post-halo gravity traction regional kyphosis was corrected to 101°. Postoperatively, 7% of patients had wound infection, 5% had implant failure, 3.5% had junctional failure, 3.5% had sacral ulcers, 1.7% had neurological failure, and 1.7% had a wound problem. The majority of patients demonstrated significant improvements in all radiographic parameters as well as SRS total and domain scores. This is the first study to address this question in a West African population. The authors reported excellent deformity correction and outcomes, despite performing these complex surgical procedures in a resource-limited climate. Sriphirom P, Siramanakul C, Chaipanha P, Saepoo C. Clinical outcomes of interlaminar percutaneous endoscopic decompression for degenerative lumbar spondylolisthesis with spinal stenosis. Brain Sci. 2021 Jan 10;11(1):83. Degenerative lumbar spondylolisthesis is a common cause of low back pain and radicular symptoms. Although the majority of patients can be managed without a surgical procedure, a subset of patients requires a surgical procedure. In cases of dynamic spondylolisthesis, decompression with fusion is the optimal surgical approach; however, there remains an ongoing debate on whether decompression alone is sufficient in patients with non-dynamic spondylolisthesis. Sriphirom et al. investigated the clinical outcomes associated with interlaminar percutaneous endoscopic decompression in patients with stable degenerative spondylolisthesis. Twenty-eight patients were enrolled in this single-center, Level-III study. The mean follow-up duration was 25 months. At the last follow-up, patient-reported outcome measures including the visual analog scale and the Oswestry Disability Index were significantly improved from baseline. No patients developed postoperative spinal instability. The use of endoscopic techniques continues to miniaturize approaches to spinal disorders. These technologies have been primarily deployed for discectomies; however, this study demonstrated that endoscopic techniques can be safely utilized for the treatment of other common degenerative spinal disorders.