Background : Traumatic cranio-cervical junction injuries in infants is a rare problem. Because of the unique and crowded anatomy of the occipitocervical junction, the creation of a fusion construct that is both safe and biomechanically sound is challenging, especially in infants. We present a technical report of a 9 month old infant with displaced odontoid synchondrosis fracture with combined occipital-cervical and atlantoaxial dissociation, who underwent surgical stabilization.
Case Description: A 9-month-old male unrestrained infant involved in a high-speed motor vehicle accident presented with weakness of both upper limbs. Imaging revealed a displaced odontoid synchondrosis fracture with combined occipito-cervical and atlantoaxial dissociation and cord signal changes along the entire cervical spinal cord. In view of the unstable nature of the injury surgery in the form of occiput to C2 arthrodesis using dual distal radius locking plates and autologous calvarial full thickness bone graft. There were no intraoperative complications and a Minerva Jacket was applied prior to extubation. CT scan obtained at 12 weeks after surgery demonstrated evidence of bony fusion. The Minerva jacket was well tolerated and the child made a complete neurological recovery.
Conclusion: Combined injuries to the occipito-cervical and atlantoaxial joint in an infant are rare and can be fatal. A thorough assessment of multiple imaging modalities helps to make an early and accurate diagnosis. In this report we would like to highlight a rare injury in an infant which was stabilized with distal radius plates, full thickness autologous calvarial grafts and a Minerva jacket.

Introduction: As the evolution has progressed from Neanderthals to homo sapiens, there have been structural and anatomical changes with early literature suggesting a decrease in the lumbar vertebra from seven in number to five due to thoracization leading to more erect posture. Our aim of the study was to find out the incidence of the L6 transitional vertebra in the Eastern Indian population and whether it has any role in the degenerative diseases of the lumbar spine by measuring various spinopelvic parameters. Methods: 121 Patients with complaints of the low back with or without radiculopathy for more than 1 year were included in the study from February 2020 to February 2021. Spinopelvic parameters like Pelvic incidence, Slip angle, Lumbosacral angle, Sacral slope, Pelvic tilt were assessed. Results: We observed Symptomatic patients with transitional L6 vertebra were 41 (33.8%) in number, out of which 22 (53.7%) were females and 19 (46.3%) were males. An increase in the prevalence of disc degeneration and a protrusion or extrusion was noted in the disc above the transitional (L6) vertebra. There was an increase in the pelvic incidence, sacral slope, slip angle, and lumbosacral angle noted in the transitional vertebra group. Conclusion: Patients with symptomatic transitional L6 vertebra constitute around 33.8 % of the degenerative diseases. Careful evaluation of spinopelvic parameters should be considered particularly in patients with 6 lumbar vertebrae. Advanced facet joint degeneration, spondylolysis, and spondylolisthesis were usually encountered at the transitional vertebra level.

Septic arthritis of the facet joint is a rare but severe infection of the spine that, if not promptly diagnosed and treated, can lead to significant morbidity or even death due to local or systemic spread. A 56 year old woman, with a clinical history of repetitive urinary tract infections, presented with right-sided back pain, later associated with fever and urinary symptoms. An initial diagnosis of pyelonephritis was made. Due to persistence of lumbar pain despite antibiotics and analgesics, a MRI of the lumbar spine was requested. The MRI showed fluid collection in the right lumbar L4/L5 facet joint associated with an epidural abscess. The patient was treated with an endoscopic debridement and abscess drainage via a transforaminal approach and intravenous and oral antibiotics. Cultures came positive for Staphylococcus Aureus. The patient's health rapidly improved with resolution of her fever and relief of her back pain. Septic arthritis of the facet joint was believed to be a rare diagnosis but, most likely due to advancements in imaging technology, it´s incidence is increasing. Despite these improvements, septic arthritis of the facet joint is still a diagnostic challenge due to an unusual clinical presentation or confounding symptoms. A delayed diagnosis can lead to significant morbidity or even death. Most cases are treated with parenteral antibiotics and with or without surgical debridement, depending on clinical symptoms or severity. Endoscopic spinal surgery may be an effective alternative to the traditional open debridement and decompression for the treatment of septic arthritis of the facet joint.

Background: Amyloidosis is a protein conformational disorder with some distinctive features of accumulation of protein fibrils in different body tissues causing wide range of signs and symptoms. These fibrils usually derived from different precursors that till now about thirty different precursor proteins are identified. Although the most common tissue for their accumulation is the cardiac, amyloidosis may appear in many other tissues but mainly asymptomatic. One of these extracardiac tissues is the ligamentum flavum (LF).Aim of study: The presented study aimed to assess the role of accumulation of amyloid fibrils precursors within Ligamentum flavum and whether it has a direct relationship to lumbar disc degeneration and ligamentum flavum hypertrophy with subsequent spinal canal stenosis. Patient and methods: Patients with lumbar spinal canal stenosis(16) or lumbar disc degeneration(12), who were scheduled for surgery, were included in the study. Tissue biopsy was taken from the ligamentum flavum at the affected level and was stained with special immuno-histochemical stain to detect amyloidosis. The diameter of the lumbar canal and the ligamentum flavum thickness were measured by radiologist at the affected level. Results: the degenerative spinal stenosis group showed 40% positive results(P < 0.005) while the disc degenerative group didn't show any positive result for the stain (P= 0.77). relation between ligamentum flavum thickness and positive stain was statistically significant (P= 0.001) in the spinal stenosis group. Conclusion: There is relation between accumulation of amyloid precursors and ligamentum flavum hypertrophy in lumbar spine canal stenosis in middle age patients; further studies needed.

Introduction: Spinal pseudomeningoceles are a common complication of large iatrogenic tears in the dural-arachnoid layer. We hereby report a case of an unusual giant dorsolumbar pseudomeningocele arising after a traumatic dural tiny tear. Observation: We report a case of a 32-year-old patient, a victim of a road traffic accident which caused severe polytrauma including a C2 Magerl type fracture of T11, with a partial neurological deficit (Frankel B). The patient underwent an emergency T11-T12 laminectomy, posterior fixation of T10-T11-T12-L1 and a posterolateral bone graft. We discovered two millimetric dural breaches opposite T11 which were not related to the laminectomy and which were respected. At two years follow up, the removal of the material was performed with intraoperative discovery of a small right posterolateral pseudomeningocele at T11 level which was respected. One year later, the patient presented with a right paravertebral painful mass measuring 20 centimeters. There were no associated neurological symptoms. The magnetic resonance imaging revealed a dorsolumbar paraspinal giant pseudomeningocele extending from T10 to L1 with no compression of the spinal cord. The patient underwent excision of the pseudomeningocele and repair of the dural sac defect. The right foraminal breach was closed with biological fibrin glue. Seen two years later the patient had no complaints and the magnetic resonance imaging was normal. Conclusion: Several procedures have been described in literature in the management of dural sac tears and pseudomeningoceles. This observation may encourage spinal surgeons to repair small dural tears to avoid potential cerebrospinal fluid leak and its complications.

Cauda equina syndrome (CES) years post-decompression surgery caused by a high pressure pseudo-meningocele is exceptionally rare; we find only one previously reported somewhat similar case. A 44-year-old male was referred from Urology with episodic saddle anaesthesia and urinary incontinence of spontaneous onset plus dynamic right leg L3 to L5 radiculopathy. Spinal decompression surgery five years earlier had achieved a good result, but no records were available. There was absence of several lumbar spinous processes to palpation, no neurological deficit at rest and no obvious fluctuance deep to the scar; anal tone was maintained. MRI scan revealed a large, encapsulated pseudo-meningocele compressing the cauda equina from L2/3 to L5/S1. At re-exploration the pseudo-meningocele capsule was opened and the underlying dura sac was seen to expand and pulsate. A small caudal tear in the dura was feeding CSF into the pseudo-meningocele inflating it episodically. It sealed with fine sutures, patching and dura-seal. Significant amounts of CSF were lost to suction. In recovery worrying complete dermatome and myotome loss was complained of bilaterally from L3 to S4; completely recovered by 12 hours post-surgery. At recent review leg and urinary symptoms had resolved. This cause of re-stenosis is exceptionally rare. We speculate a valve mechanism operated to inflate the pseudo-meningocele to high pressure and create CES intermittently. Whatever the cause of CES, surgical management – adequate removal of compressing elements without destabilising the spine – is the same; identified CSF leaks must be sealed and patches and sealants are helpful adjuncts to simple suture.

In view of the ongoing pandemic, telemedicine has been increasingly adopted worldwide. The current study was planned to evaluate the effectiveness of telemedicine for patients with spine ailments; and to assess the satisfaction rates and concerns of spine surgeons and patients regarding telemedicine consultations in Indian scenario. Telemedicine appointments for spine patients were conducted through “Zoom-Healthcare” online platform between April and November 2020 in a tertiary-care spine center. Questionnaires (including 9 and 5 questions, respectively) were filled by patients and doctors after their consultations. The questionnaire included questions on overall satisfaction, time consumption, ease of setting-up appointment, ease of communication, influence on decision making and patient preference. Overall, 70.1%, 23.6% and 6.3% of patients replied that they were “very satisfied”, “satisfied” and dissatisfied” with their telemedicine appointments. Among post-operative follow-up patients, 69%, 30.2% and 0.8% expressed that they were “very satisfied”, “satisfied” and dissatisfied”, respectively with telemedicine. At the end of the session, 88.5% of patients opined that they would still prefer a telemedicine appointment for the completed consultation; and 93.4% were happy to use telemedicine for future visits. Three major concerns for doctors included difficulty in procuring good-quality MRI(17%), problems with connectivity(14.6%) and difficulty in eliciting certain physical findings. Telemedicine is an effective alternative to in-person visits for the assessment of patients with spine ailments. A majority of the post-operative follow-up patients were satisfied with their remote consultations. In specific situations, these remote visits may need to be complemented by in-person visits for thorough evaluation.

Introduction: The management of neglected (presenting beyond 3-weeks since injury) post-traumatic facet dislocations of the sub-axial cervical spine(AO type F4 injury) is challenging, due to the difficulty in achieving reduction of the subluxated or dislocated facets.We describe an effective surgical strategy for the management of neglected AO-F4 injuries and have analysed its efficacy, safety and outcomes. Methods:This is a retrospective review of twenty-four patients with a mean age of 42.6+/-14.5(range,36-53) years, with neglected facet dislocations of the sub-axial cervical spine.Following a trial of closed reduction, open reduction was carried out as a three-stage procedure(anterior-posterior-anterior approach) under a single anaesthesia.Outcomes were assessed with respect to VAS(Visual Analogue Scale) and NDI(Neck Disability Index) scores, satisfactory reduction and maintenance of alignment on radiographs,with evidence of fusion on radiographs at follow-up. Results: Patients presented at a mean of 7.1+/- 6.7(range, 3-36) weeks since injury.The mean follow-up was 27.5+/-2.4(range, 25-42) months.There was no neurodeterioration in any patient.Radiographs showed satisfactory reduction in 22/24(91.7%) patients.Radiological evidence of fusion was seen at a mean of 9.2 +/- 1.4 months.Spinal alignment was well maintained in all cases at final follow-up.No revision surgeries were needed.VAS and NDI scores showed significant improvement at final follow-up, p<0.05. Conclusion: The single stage, anterior-posterior-anterior approach is an effective and safe surgical strategy in the management of neglected AO-F4 injuries of the sub-axial cervical spine, as evidenced by a 91.7% success rate in achieving reduction, and satisfactory spinal alignment and fusion with good clinical and functional outcomes, at a mean follow up of 27.5+/-2.4 months.

Objectives: To study the role of Epidural Steroid Injection (ESI) in patients with herniated lumbar disc and Lumbar Canal Stenosis (LCS).
Material and Methods: We present a prospective study on efficacy of ESI in 1000 consecutive patients (645 patients with herniated discs and 355 patients with LCS).Patients were evaluated using functional outcome measures (numerical rating scale) immediately, 7 days and 3 months after the injection.
Results: Mean NRS back pain score of herniated disc group reduced from pre-ESI score of 5 (range 4-8) to 4 (range 2-7) immediately after injection, 2 (range 1-7) after 7 days and 2 (range 1-7) after 3 months (p value of <0.001). Mean NRS back pain score of LCS group reduced from pre-ESI score of 5 (range 4-8) to 4 (range 2-7) immediately after injection, 2 (range 1-7) after 7 days and 3 (range 1-7) after 3 months (p value of <0.001). Mean NRS leg pain score of herniated disc group reduced from pre-ESI score of 5 (range 4-9) to 3 (range 3-7) immediately after injection, 1 (range 1-6) after 7 days and 2 (range 1-7) after 3 months (p value of <0.001). Mean NRS leg pain score of LCS group reduced from pre-ESI score of 5 (range 4-9) to 4 (range 3-7) immediately after injection, 3 (range 1-7) after 7 days and 2 (range 1-6) after 3 months (p value of <0.001).
Conclusion :ESI causes statistically significant improvement in back and leg pains in patients with herniated disc and LSC.

Introduction: Pain in the hip joint area is a common reason for seeking medical help. In most cases, this pain originates in the region of the greater trochanter, which can affect other areas. The relationship between greater trochanteric pain syndrome GTPS and lower back pain is widely described in literature. Methods: 112 patients were selected from the retrospective group (group I) and 267 consecutively admitted patients were selected prospectively (group II). After a clinically confirmed diagnosis, group II patients underwent a glucocorticosteroid injection. Results: The conducted study confirmed GTPS in 112 patients from group I (9.5%) and in 43 patients (16.1%) from group II. In 89 group I patients (79.5%), an acute increase in hip joint pain (7.8 points VAS) was observed in the early postoperative period. In group II, glucocorticosteroid injections, led to a pronounced decrease in pain syndrome in 39 (90%) patients; symptoms of radiculopathy or spinal canal stenosis persisted. In the postoperative period, 17 group II patients (6.4%) demonstrated an increase in pain in the region of the greater trochanter (6.7 VAS); among them, 11 patients had signs of insignificant discomfort in the region of the greater trochanter without ultrasound changes, and 6 patients had no clinical or ultrasound signs. Conclusion: A thorough clinical examination of clinical symptoms in patients with complaints of back pain with signs of pain or discomfort along the lateral surfaces of the thighs can lead to a timely diagnosis of GTPS and improvement of the results of surgical treatment.

Cervical radiculopathy is a relatively common condition of the cervical spine. Classical presentation is unilateral pain and sensitive deficit following a dermatomal distribution, as well as motor weakness in specific muscle groups. Different combinations of these symptoms may occur, and absence of one does not exclude cervical radiculopathy. Major causes are cervical spine degeneration, more common in the elderly, and disk herniation, more prevalent in middle aged individuals. In this article we present a very atypical presentation of cervical radiculopathy in an elderly patient, a 90-year-old female with sudden upper limb motor loss. She attended to the hospital only the following day, and entered the emergency room via stroke protocol. Glasgow coma scale was 15. Neurologic exam reported motor strength grade 0 in finger and wrist extension, but no sensitive deficits. No arm pain was present. Head CT scan was normal. Cervical Spine CT scan showed massive disk herniation at C5-C6 level compressing C6 nerve root at foraminal level. The patient was hospitalized and an MRI was performed, excluding other sources of compression. After three weeks with no clinical improvement, surgical treatment was chosen. Anterior cervical discectomy and foraminotomy with one-level fusion was performed. Despite surgical intervention and physical therapy, only mild regression of neurological deficits were observed during follow-up.

Background: Anterior dislodgement of the transforaminal lumbar interbody fusion (TLIF) cage is a potentially life-threatening complication because of the risk of major vessel injury. The authors report a case of anterior cage migration with common iliac vein injury. Case Presentation: A 65-year-old woman referred to our institution with axial back pain that has failed nonoperative management. MRI revealed an L5-S1 isthmic spondylolisthesis. During the TLIF surgery, an unanticipated anterior migration of the cage occurred without massive bleeding. Despite several attempts, extraction was not possible. A computer tomography performed during the post-operative period revealed an antero-lateral cage migration located close to the left common iliac vein. Seven days later, an anterior retroperitoneal approach was performed, and the cage was found intersecting the left common iliac vein. The cage was removed, and a vessel repair was performed by a vascular surgeon. The patient underwent a third operation to complete the interbody fusion with a new cage placement. After 32 months of follow-up the patient remains well, free of pain and with no neurologic deficits. Discussion: This case shows us a possible and major complication of a TLIF procedure. To treat similar cases, we highlight the need of an earlier intervention to prevent adhesion of the cage to the soft tissues. At the removal procedure, the surgeon should be well prepared for the risk of vessel injury, including requesting the attendance of a vascular surgeon.

Introduction: The purpose of study is to evaluate the feasibility, efficacy and safety of OLIF combined with anterior screw fixation in the same approach for lumbar degenerative scoliosis.
Materials and Methods: Eight cases of lumbar degenerative scoliosis (coronal Cobb angle >10∘) underwent OLIF (using cage and allograft bone) combined with anterior screw fixation for L2-5 through the mini approach in a right lateral position without real-time monitoring by electromyography in this study. We assessed statistical differences between preoperative and postoperative (24-month) coronal and sagittal parameters.
Results: The duration of operation was 217.5±22.7 minutes. There was a mean blood loss of 110 mL (50–600 mL). The incision length was 4.6±0.4 cm. The mean stay at the hospital was 6 days (5–8 days). The average follow-up duration was 13.5 (12-18) months. At 2-year follow-up, all patients achieved statistically significant improvement in coronal Cobb angle, apical vertebra translation (AVT), coronal vertical axis (CVA), sagittal vertebral axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and PI-LL mismatch. For the clinical evaluation, VAS for back pain and ODI improved significantly after surgery. Fusion grades based on the Bridwell grading system at 2-year follow-up were grade I in 17 segments (70.8%), grade II in 7 segments (29.2%). No patients had nerve damage and no failure of instruments was observed.
Conclusion: OLIF combined with anterior screw fixation is a good choice of minimally invasive surgery for lumbar degenerative scoliosis.

Meralgia paresthetica is a well-known syndrome caused by the entrapment of the lateral femoral cutaneous nerve at the anterior superior iliac spine, that is characterized by numbness, paresthesias, and pain in the anterolateral thigh. Several other pathologies have been shown to mimic meralgia paresthetica. A 41 year old male patient presented with complaints of persistent pain and paresthesia on the anterolateral side of his left thigh. Electromyography showed absence of sensory response of the lateral femoral cutaneous nerve. Lumbar MRI detected a left facet cyst at the L2/L3 level. The cyst was excised by an endoscopic transforaminal approach. Symptoms substantially improved after surgery, with no postoperative complications. The patient´s pain completely disappeared but a residual paresthesia persisted. The
lateral femoral cutaneous nerve has its origin at the L2 and L3 levels. Although meralgia paresthetica is classically caused by the entrapment of the lateral femoral cutaneous nerve at the anterior superior iliac spine, nerve root compression at the L2/L3 level can mimic meralgia paresthetica. This case emphasizes the importance of a complete radiological investigation of the lumbar spine, including MRI, to exclude radicular compression at the level of L2 or L3 as the cause of meralgia-like symptoms.

Introduction: There is a scarcity of literature in assessing the Sarcopenia of lumbar paraspinal muscle and its association with age in the Indian population. Our aim was to determine the age and sex-dependent lumbar paraspinal muscle morphology.

Methods: The objectives of this study were to calculate the mean of morphological variables such as Total Cross Sectional Area(TCSA), Relative Cross-Sectional Area(RCSA), Functional Cross Sectional Area(FCSA), Percentage of Fat Infiltration(FI%) and their asymmetry between right and left side in multifidus , erector spinae and psoas major muscle in different sex and age groups using MRI and a novel software ImageJ.

Results: Total number of samples included in the study was 210, (98 females and 112 males), with a mean age of 38.8±15.04 years. Psoas muscle Total Cross-Sectional Area, Functional Cross-Sectional Area, and Fat Infiltration Percentage showed a statistically significant correlation (p=0.020,p=0.008, and p=0.016 respectively) with BMI. Erector spinae had the larger TCSA followed by Psoas and the Multifidus had the least TCSA in all age groups. TCSA of Erector spinae had an increasing trend in the early decades and had a decreasing trend in the late decades of life. The Multifidus muscle degenerated significantly at a higher rate than the erector spinae muscle. Psoas degenerated at a lower rate on comparing to other paraspinal muscles.

Conclusion: Digital analysis of MRI images with ImageJ software serves as an ideal tool to investigate morphological features of paraspinal muscle. The normative value of paraspinal muscle morphology documented will be useful to investigate other spinal pathologies.

Introduction: Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. Two decision rules: The National Emergency X-Radiography Utilization Study (NEXUS) and The Canadian Cervical-Spine Rule (CCR) have been developed independently to permit more selective ordering of cervical-spine radiography (CSR) and decrease patients’ exposure to ionizing radiation and economic losses. Methods: We conducted a retrospective study aiming to evaluate the application of the NEXUS and CCR recommendations and to analyze the quality of cervical spine radiography in our emergency department. Results: 213 patients with cervical blunt trauma were analyzed retrospectively. The CCR and the Nexus rules were respected in 88.7% and 91.5% of cases respectively. No lesions were found in 93.8% of patients. A lesion was present in 1.2% and suspected in 5% of patients. The quality of cervical spine radiography was adequate in only 43.2% of cases. The poor quality of CSR was due either to the lack of C7 vertebrae visualization in 61.9% or other lower vertebrae in 32.4% of cases. Other causes included the absence of C1-C2 vertebrae visualization in 8.4%, artifact in 3.3% and the absence of lateral view in 0.9% of cases. Conclusion: NEXUS and CCR are widely used in our emergency department and seems to be reliable guidelines to evaluate patients with possible clinically significant cervical spine injury. The high rate of inadequate CSR reinforces the debate about its utility in emergency condition.

Spino-pelvic dissociation is a rare traumatic entity, usually resulting from high energy trauma. In this work, a case of U-type sacral fracture is presented, with complete dissociation of the lumbar spine and the pelvic ring.
43-year-old male patient, admitted to the emergency department after a motor vehicle accident. Regarding orthopaedic injuries he presented: fracture of the vertebral body of L4 and L5, U-type sacral fracture, diastasis of the pubic symphysis and Lisfranc injury in the righ foot. He was neurologically intact. After initial ressuscitation and damage control surgery, he was admitted to intensive care unit and underwent definitive surgical treatment 11 days later. Pelvic ring was stabilized with anterior fixation with 2 plates and screws, using the modified Stoppa approach, and posterior lumbopelvic percutaneous instrumentation L2-L3-L4-L5-Iliac. Lisfranc fracture was treated with open reduction and internal fixation with screws. No neurologic deficits were developed after surgery. After 1 year of follow-up, the fractures were consolidated, in X-rays and CT scan, and the patient was able to walk without support.
U-Type sacral fractures are rare injuries, they ussually result from an axial load trauma, and represent spino-pelvic dissociation that must be diagnose and surgically stabilized to allow for early rehabilitation and prevention of prolonged decubitus complications. Percutaneus stabilization in neurological intact patients and in cases in which fracture pattern allow for percutaneus techniques is a viable option.

Spondylodiscitis is a rare entity. Diagnosis might be difficult in early stages. Treatment has 5 essential goals: eradication of the agent, preservation of the neurological function, restoration of the spinal stability, decompression of the spinal canal, and promotion of bone fusion. Antibiotic therapy remains the gold standard. Surgical treatment is indicated in cases of failure of medical treatment, spinal instability, paravertebral/epidural abscess, or with any de novo neurological deficit. Prognosis is good if treatment is initiated promptly.
The authors report 4 clinical cases. The first of a 53-year-old man, with L3-L4 spondylodiscitis with an epidural abscess. Surgical decompression and percutaneous posterior fixation L2-L5 were performed.
The second case of a 52-year-old-woman, with an history of low back pain with two months of evolution, and neurological impairment of the right lower leg with spondylodiscitis of L1-L2 with an epidural abscess associated. Surgical decompression and posterior percutaneous instrumentation of D11-D12-L3-L4 were performed.
The third one, a 74-year-old-man, with low back pain for one month with L2-L3 spondylodiscitis, associated with a paravertebral abscess and central stenosis. Surgical decompression and posterior percutaneous fixation of D12-L1, L4-L5 were performed.
The fourth case of a 62-year-old-man, diabetes and hepatitis C with D12-L1 spondylodiscitis, with extensive destruction of the vertebral bodies, and the patient underwent an open biopsy and posterior percutaneous fixation of D10-D11-L2.
At the follow-up appointments all presented without complains, no sign of implant material failure, and vertebral body fusion was achieved.
Conclusion: Percutaneous fixation permits a much faster recovery, and less residual pain.

Antibiotic loading of bone cement for local antibiotic delivery is the gold standard for orthopedic infection treatment, and a variety of treatment strategies across many centers has developed. However, limited data exists linking specific antibiotic type, cement medium, and delivery method to patient outcomes in spinal infection treatment. This retrospective review was performed to determine the safety and efficacy of various antibiotic/Stimulan formulations for spine infections, as well as provide algorithmic approaches for different infection types. One hundred nineteen patients who underwent incision and debridement surgeries with antibiotic loaded Stimulan bead placement for spine infection from 2016 – 2020 were included. The treatment protocols included aggressive debridement, instrumented stabilization when instability was present, local placement of antibiotic beads, and chronic, systemic antimicrobial therapy. Tobramycin/Vancomycin loaded beads were the most common type used. Sixteen patients experienced infection recurrence. Six patients died due to sepsis. Six patients developed post-operative hypercalcemia, and 16 patients developed post-operative acute kidney injury (AKI). There was a significant association between amount of Stimulan used and hypercalcemia. All cases of post-operative hypercalcemia and AKI resolved without bead removal. Acute liver injury (ALI) and AKI were significantly associated with treatment failure. In conclusion, the use of antibiotic Stimulan beads in an algorithmic treatment approach achieves successful infection eradication with little evidence of antibiotic toxicity. Stimulan amount should be limited as much as possible to avoid transient hypercalcemia, and patients with AKI and ALI should possibly be treated more aggressively to avoid treatment failure.

Introduction: Endoscopic spine surgery aims to minimize soft tissue injury during the procedures. In general, the duration of the procedure is used to draw the learning curve but other variables can be used. Methods: We have studied our own learning curve in endoscopic interlaminar spine surgery assessing duration of surgery, blood loss, complications, Oswestry Disability Index (ODI), and pain. From 2010 to 2020 we performed 45 endoscopic lumbar spine procedures, three of which had to be converted to open surgery in two disc herniations and in a lumbar stenosis case (cases 3, 4 and 45). Results: In the remaining series of 42, the patients’ average age was 44.5 (SD 11.92) with an average duration of the procedures of 155 minutes (SD 33). 24 procedures were at L5S1 level, 16 L4L5, one L3L4, and another one L2L3. In this series we had 11 intraoperative complications (4 bleeding in the spinal canal and 7 dural tears). Bleeding in four patients was more than 500cc at the end of the procedure (cases 29, 30, 43 and 44). 39 patients considered the final result as good or very good, and 3 patients as bad or very bad. Discussion: The total duration of the procedure does not decrease along our series, although there is a tendency to be longer when there is a long period of time between procedures. The number of intraoperative complications is reduced after 30 procedures, with the graph of accumulated cases being less steep.