Telemedical Support Using Smartphones for Spine Surgery in Low- and Middle-Income Countries

Objective: Low- and middle-income countries (LMICs) face many challenges compared to industrialized nations, most notably in regard to the health care system. Patients often have to travel long distances to receive medical care with few reliable transportation mechanisms. In time-critical emergencies, this is a significant disadvantage. One specialty that is particularly affected by this is spine surgery. Within this field, traumatic injuries and acutely compressive pathologies are often time-critical. Increasing global networking capabilities through internet access offers the possibility for telemedical support in remote regions. Recently, high-performance cameras and processors became available in commercially available smartphones. Due to their wide availability and ease of use, this could provide a unique opportunity to offer telemedical support in LMICs. Methods: We conducted a feasibility study with a neurosurgical institution in east Africa. To ensure telemedical support, a commercially available smartphone was selected as the experimental hardware. Preoperatively, resolution, contrast, brightness, and color reproduction were assessed under theoretical conditions using a test chart. Intraoperatively, the image quality was assessed under different conditions. In the first step, the instrumentation table was displayed, and the mentor surgeon marked an instrument that the mentee surgeon should recognize correctly. In the next evaluation step, the surgical field was shown on film and the mentor surgeon marked an anatomical structure, and in the last evaluation step, the screen of the X-ray machine was captured, and the mentor surgeon again marked an anatomical structure. Subjective image quality was rated by two independent reviewers using the similar modified Likert scale as before on a scale of 1-5, with 1 indicating inadequate quality and 5 indicating excellent quality. Results: The image quality during the video calls was rated as sufficient overall. When evaluating the test charts, a quality of 97% ± 5 on average was found for the chart with the white background and a quality of 84% ± 5 on average for the chart with the black background. The color reproduction, the contrast, and the reproduction of brightness were rated excellent. Intraoperatively, the visualization of the instrument table was also rated excellent. Visualization of the operative site was rated 1.5 ± 0.5 on average and it was not possible to recognize relevant anatomical structures with the required confidence for surgical procedures. Image quality of the X-ray screen was rated 1.5 ± 0.9 on average. Conclusion: Current generation smartphones have high imaging performance, high computing power, and excellent connectivity. However, relevant anatomical structures during spine surgery procedures and on the X-ray screen in the operating room could not be identified with reliability to provide adequate surgical support. Nevertheless, our study showed the potential in smartphones supporting surgical procedures in LMICs, which could be helpful in other surgical fields.

Feasibility of High-Fidelity Simulator Models for Minimally Invasive Spine Surgery in a Resource-Limited Setting: Experience From East Africa

BACKGROUND

Spine surgery is a rapidly evolving specialty with a continuous need to learn new skills. In resource-limited settings such as Africa, the need for training is greater. The use of simulation-based training is important in different stages of skill acquisition, especially for high-stake procedures such as spine surgery. Among the available methods of simulation, the use of synthetic models has gained popularity among trainers.

METHOD

Twenty participants of a neurosurgery training course, most of whom (65%) were neurosurgery residents and fellows, were recruited. They had hands-on training sessions using a high-fidelity lumbar degenerative spine simulation model and hands-on theater experience. After this, they completed a survey to compare their experience and assess the effectiveness of the lumbar spine model in stimulating real patient and surgery experiences.

RESULTS

The participants were from four African countries, and the majority were neurosurgery residents. There were varying levels of experience among the participants in minimally invasive spine surgery, with the majority either having no experience or having only observed the procedure. All the participants said that the high-fidelity lumbar spine model effectively simulated real minimally invasive spine setup and real bone haptics and was effective in learning new techniques. Most of the participants agreed that the model effectively simulated real dura and nerve roots (95%), real muscle (90%), real bleeding from bones and muscles (95%), and real cerbrospinal fluid in the subarachnoid space. Among them, 95% agreed that the model is effective in lumbar minimally invasive spine training in resource-limited settings.

CONCLUSION

With the development of new and better surgical techniques, the use of high-fidelity models provides a good opportunity for learning and training, especially in resource-poor settings where there is a paucity of training facilities and personnel.

Variation in Cervical Pedicle Morphology: Important Considerations for Posterior Cervical Procedures

BACKGROUND

Safe posterior cervical spine surgery requires in-depth understanding of the surgical anatomy and common variations. The cervical pedicle attachment site to the vertebral body (VB) affects the location of exiting nerve roots and warrants preoperative evaluation. The relative site of attachment of the cervical pedicle has not been previously described.

OBJECTIVE

To describe the site of the pedicle attachment to the VB in the subaxial cervical spine.

METHODS

Cervical spine computed tomography scans without any structural, degenerative, or traumatic pathology as read by a board-certified neuroradiologist during 2021 were reviewed. Multiplanar reconstructions were created and cross-registered. The pedicle's attachment to the VB was measured relative to the VB height using a novel calculation system.

RESULTS

Fifty computed tomography scans met inclusion criteria yielding 600 total pedicles between C3-T1 (100 per level). The average patient age was 26 ± 5.3 years, and 21/50 (42%) were female. 468/600 (78%) pedicles attached in the cranial third of the VB, 132/600 (22%) attached in the middle third, and 0 attached to the caudal third. The highest prevalence of variant anatomy occurred at C3 (36/100 C3 pedicles; 36%).

CONCLUSION

In the subaxial cervical spine, pedicles frequently attach to the top third of the VB, but significant variation is observed. The rate of variation is highest at C3 and decreases linearly with caudal progression down the subaxial cervical spine to T1. This is the first report investigating this morphological phenomenon.

Treatment of Odontoid Fractures in Elderly Patients Using C1/C2 Instrumented Fusion Supplemented With Bilateral Atlantoaxial Joint Spacers: A Case Series

BACKGROUND

Spinal fractures are among the most common traumatic injuries in elderly patients, with the odontoid process being frequently affected. As this patient group usually has high rates of comorbidity and chronic diseases, a nonoperative approach may offer a reasonable solution for a favorable fracture pattern.

OBJECTIVE

We modified the procedure by implanting a bilateral atlantoaxial joint spacer (model DTRAX) into the joint space and review our experience utilizing this technique for the treatment of patients with a fracture of the odontoid process.

METHODS

A retrospective evaluation was performed on patients treated surgically for unstable traumatic fractures of the odontoid process. The stabilization was performed using a dorsal rod and screw instrumentation of the lateral mass of the atlas and the pars interarticularis of the axis. The procedure was further modified by implanting a bilateral atlantoaxial joint spacer (DTRAX) into the joint space bilaterally after the removal of the articular cartilage. Patients older than 70 years with a traumatic fracture of the odontoid process were included. Pain was assessed pre- and postoperatively using the visual analog scale (VAS). To verify fusion during follow-up, either x-ray imaging of the cervical spine or magnetic resonance imaging or computed tomography were performed.

RESULTS

A total of 5 patients were included in our study. Four patients had an American Society of Anesthesiology score of 3 and 1 had a score of 4. The average duration of surgery was 187 ± 38.1 minutes. The average blood loss during the procedure was 340 ± 270 mL. The average radiological follow-up period was 21.2 ± 17.5 months. Preoperatively, the average VAS pain score was 2.3 ± 3.3. Postoperatively, the mean VAS decreased to 0.6 ± 0.9. The average follow-up period for pain was 27.2 ± 19 months. No patient showed neurological deficits before or after surgery. Follow-up demonstrated solid fusion in all cases.

CONCLUSION

The fusion of the atlantoaxial joint with bilateral atlantoaxial joint spacers represents a suitable and feasible option for achieving high fusion rates in elderly patients with odontoid fractures.

CLINICAL RELEVANCE

A significant percentage of patients who are treated non-operatively will experience nonunion, which may cause instability of the atlantoaxial joint. Posterior fixation with screws and rods is a treatment option, but it leaves the cartilaginous joint surface in place, which can be an impediment to the fusion process. In other cases, degenerative collapse of the C1/C2 joint can cause compression of the C2 nerve root.

LEVEL OF EVIDENCE: 4

Clinical Significance of Redundant Nerve Roots in Patients with Lumbar Stenosis Undergoing Minimally Invasive Tubular Decompression

OBJECTIVE

Symptomatic lumbar spinal stenosis (LSS) is a common indication for surgery in the elderly. Preoperative radiographic evaluation of patients with LSS often reveals redundant nerve roots (RNRs). The clinical significance of RNRs is uncertain. RNRs have not been studied in the setting of minimally invasive surgery. This study investigates the relationship between RNRs and clinical outcomes after minimally invasive tubular decompression.

METHODS

Chart review was performed for patients with degenerative LSS who underwent minimally invasive decompression. Preoperative magnetic resonance imaging parameters were assessed, and patient-reported outcomes were analyzed.

RESULTS

Fifty-four patients underwent surgery performed at an average of 1.8 ± 0.8 spinal levels. Thirty-one patients (57%) had RNRs. Patients with RNRs were older (median = 72 years vs. 66 years, P = 0.050), had longer median symptom duration (32 months vs. 15 months, P < 0.01), and had more levels operated on (2.1 vs. 1.4; P < 0.01). The median follow-up after surgery was 2 months (range = 1.3-12 months). Preoperative and postoperative patient-reported outcomes were similar based on RNR presence. Patients without RNRs had larger lumbar cross-sectional areas (CSAs) (median = 121 mm² vs. 95 mm², P = 0.014) and the index-level CSA (52 mm² vs. 34 mm², P = 0.007). The CSA was not correlated with RNR morphology or location.

CONCLUSIONS

Preoperative RNRs are associated with increased age, symptom duration, and lumbar stenosis severity. Patients improved after minimally invasive decompression regardless of RNR presence. RNR presence had no effect on short-term clinical outcomes. Further study is required to assess their long-term significance.

Safety and Feasibility of DTRAX Cervical Cages in the Atlantoaxial Joint for C1/2 Stabilization

BACKGROUND

Pathological changes in the atlantoaxial joint often lead to instability, pain, and neurological deterioration. One treatment option is the surgical stabilization of the atlantoaxial joint. In other areas of the spine, fusion rates have been improved by the introduction of an interbody cage. Our aim was to use cervical interbody spacers, originally designed to augment fusion across subaxial posterior cervical facets, to optimize the conditions for atlantoaxial fusion.

OBJECTIVE

To evaluate the safety and efficacy of implanting cervical cages in the atlantoaxial joint for C1/2 stabilization.

METHODS

Our retrospective study evaluated patients who had undergone C1/2 cervical fusions by the Harms/Goel technique. This technique was modified by implanting a titanium cervical interbody spacer into the joint space. Mean overall pain, as measured by a 0 to 10 visual analog scale (VAS) and neurological outcomes were measured preoperatively and postoperatively. In addition, radiological outcomes were collected using follow-up imaging.

RESULTS

Nine patients were included in this case series. The mean preoperative VAS for overall pain was 5.0 ± 4.0, which changed to a mean VAS of 2.0 ± 3.0 after an average follow-up period of 41.4 ± 20.4 (P = .043). All patients showed a bony fusion in our case series. None of the radiological imaging during follow-up showed screw loosening, hardware breakage, implant migration, or nonunion.

CONCLUSION

The implantation of cervical titanium cages into the atlantoaxial joint in combination with posterior fixation appears to be a safe and effective method for achieving C1/2 fusion.

Outcome of non-instrumented lumbar spinal surgery in obese patients: a systematic review

INTRODUCTION

Lumbar spinal decompression procedures are well known in their techniques and outcomes. However, outcomes of lumbar spinal surgery in patients with obesity are relatively unknown. The aim of this review is to assess the effect of obesity on post-operative outcomes of lumbar non-instrumented decompressive spinal surgery.

METHODS AND MATERIALS

A literature search through PubMed, Embase, Web of Science and Cochrane was performed. Articles were included if they reported outcomes of obese patients after non-instrumented lumbar decompression surgery, if these outcomes were described using patient-reported outcome measures and if there was at least two months of follow-up. Risk of bias was assessed using an adjusted version of the Cowley score.

RESULTS

From the 222 unique articles, 14 articles, comprising 13,653 patients, met the inclusion criteria. Eight out of 14 studies had a low risk of bias, while the remaining six had an intermediate risk of bias. Thirteen studies evaluated leg and back pain, and the vast majority demonstrated less decrease in pain in the obese group. Six studies evaluated disability and all but one showed less improvement in obese patients. Five studies evaluated functionality and wellbeing and all but one showed less satisfactory outcome in obese patients.

CONCLUSIONS

Literature does not reveal a difference in clinical outcome nor in complications in patients undergoing non-instrumented lumbar surgery with a BMI lower than 30 or equal to or higher than 30. This may be used by physicians to inform patients prior to lumbar decompression surgery.