Minimally invasive surgery (MIS) of the posterior cervical spine with robotic assistance has recently emerged to treat degenerative disc disease. Robotic arms and 3D neuronavigation with preoperatively planned placement are used to achieve real-time intraoperative guidance, reducing screw malposition through increased accuracy and stability. This results in decreased blood loss, postoperative pain, and quicker recovery time compared to other techniques. We aim to demonstrate a novel technical approach to posterior cervical spine fusion using robotic assistance and discuss its advantages. In a patient with right hand weakness and a right paracentral disc herniation of the cervicothoracic spine, we performed a MIS percutaneous and robotically assisted posterior spinal fusion at C7-T2, with complete C7-T1 and T1-2 right-sided facetectomies and also a T1-T2 discectomy. Preoperative software planning and a robotic platform attachment configuration was used. There was immediate postoperative improvement in upper extremity strength and the patient was discharged without complications. Postoperative imaging confirmed accurate hardware placement, and follow-up at both 3- and 4-month confirmed improved upper extremity strength with sensation intact throughout. MIS robotic posterior cervicothoracic fusion can effectively be used to improve patient outcomes. Further implementation of robotic assistance during cervical fusion in larger studies is needed to further evaluate its effectiveness.

Single position lateral fusion reduces the need for a secondary surgery and robotic guidance allows for potentially higher accuracy of screw placement. We expand the role of robotics with a simultaneous workflow where 2 surgeons can work in single position surgery and discuss the technical feasibility of placement of S2-alar-iliac (S2AI) screws in the lateral position. A 70-year-old male presented with chronic back pain and bilateral leg pain with the left side worse than the right. He subsequently underwent an L3-S1 oblique lumbar interbody fusion (OLIF) with a minimally invasive L3-ilium robotic posterior spinal fixation simultaneously in single lateral position with S2AI screws. The software planning requisite of robotics allowed for a preoperative plan where lumbar cortical screws were used to line up with bilateral S2AI screws. Intraoperatively, the OLIF was performed anterior to the patient which allowed for a second surgeon to perform the posterior stage of screw placement simultaneously in overlapping fashion during OLIF exposure. Once all screws were placed, the OLIF discectomy and cage placement were completed. As the OLIF incision is closed, rodding proceeds posteriorly with subsequent closure simultaneously as well. Operative time from skin incision to skin closure was 3 hours and 47 minutes. We present here a novel technical report on the recommended workflow of simultaneous robotic single position surgery OLIF and demonstrate the feasibility of placement of sacroiliac fixation in the lateral decubitus position. We believe this technique to be minimally invasive, effective, with the benefit of shortening valuable operating room case time.

Cervical angina is an often-overlooked etiology of noncardiac chest pain that may mimic true angina pectoris but is due to cervical spine disease. Diagnosis can be difficult, and treatment ranges from conservative therapy to surgical management. However, of patient's refractory to conservative therapy, approximately ninety percent experience postoperative relief of angina symptoms. Here, we present a case report on cervical angina and performed a systematic review of the literature. A 34-year-old male with prior surgery for thoracic outlet syndrome presented with persistent anterior neck and chest pain as well as posterior left scapular and upper lateral arm pain. The pain was refractory to 12 months of conservative therapy. Cardiac workup was negative and cervical spine imaging revealed a C6-7 herniation with neuroforaminal stenosis. A systematic literature search was conducted in PubMed, Web of Science, and Cochrane databases from database inception to April 2020. Studies reporting cervical level, average symptom duration, location of pain, and postoperative pain improvement were included. The patient's atypical symptoms were completely resolved after C6-7 anterior cervical discectomy and arthroplasty. To our knowledge, this is the first study which reports on the use of arthroplasty in the treatment of cervical angina. The systematic review included 11 articles from 1989-2020 consisting of 1,186 total patients and 109 patients (age range, 36-84 years; 60.7% male) meeting inclusion criteria. Symptom duration range was 2 days to 90 months, with the most common location of pain being localized to the anterior chest wall (66.7% of patients). All patients (100%) had postoperative resolution of their pain symptoms. The most common herniation level was C6-7 (87.3% of patients). We conclude that a broad and multidisciplinary approach is necessary for the diagnosis and management of noncardiac chest pain. When cervical disease is identified as the underlying cause for the angina-like pain, conservative therapy should be sought. Refractory cases should be treated surgically depending on the cervical pathology.

Background

Surgical treatment of scoliosis includes long and invasive multi-level instrumentation and correction which may result in high rates of postoperative complications, especially in elderly patients with osteopenia or multiple comorbidities. Minimally invasive surgical options may benefit these patients.

Case description

A 73-year-old female patient with a history of degenerative lumbar scoliosis, L4-5 pseudarthrosis, and resulting L5-S1 adjacent segment following prior unsuccessful lateral L4-5 interbody fusion presented to the clinic with severe lower back pain and lower extremity radiculopathy. The decision was made to proceed with surgical correction via a robotic-guided prone transpsoas (PTP) approach, which is a novel approach similar to lateral lumbar interbody fusion (LLIF) with the patient in a prone decubitus position. Excellent spinal alignment was achieved with no complications. On two-month follow-up, imaging revealed pedicle screws at the L3, L4, L5 levels and at the sacrum without change and continued interbody cages position with no signs or symptoms of infection.

Discussion

Minimally invasive procedures have demonstrated benefit in spine surgery especially for at risk populations. The LLIF procedure has been well established for use in a wide range of spinal pathologies given its noted benefits in increasing spinal column stability through posterior fixation and indirect decompression. However, only marginal improvements in segmental lordosis are expected and there are reports of neurological complications. The PTP procedure has emerged as an alternative to LLIF for the treatment of spinopelvic pathologies. This approach enables greater improvements to spinal lordosis through single-position surgery while simultaneously reducing intraoperative repositioning and providing the known benefits of lateral interbody surgery.

Conclusion

Our experience suggests that the PTP approach is safe and effective because it does not require patient repositioning, easily interfaces with robotic guidance, and achieves increased lordosis gains via the prone positional effect compared to LLIF and comparable approaches.

Although early therapeutic research on psychedelics dates back to the 1940s, this field of investigation was met with many cultural and legal challenges in the 1970s. Over the past two decades, clinical trials using psychedelics have resumed. Therefore, the goal of this study was to (1) better characterize the recent uptrend in psychedelics in clinical trials and (2) identify areas where potentially new clinical trials could be initiated to help in the treatment of widely prevalent medical disorders. A systematic search was conducted on the clinicaltrials.gov database for all registered clinical trials examining the use of psychedelic drugs and was both qualitatively and quantitatively assessed. Analysis of recent studies registered in clinicaltrials.gov was performed using Pearson's correlation coefficient testing. Statistical analysis and visualization were performed using R software. In totality, 105 clinical trials met this study's inclusion criteria. The recent uptrend in registered clinical trials studying psychedelics (p = 0.002) was similar to the uptrend in total registered clinical trials in the registry (p < 0.001). All trials took place from 2007 to 2020, with 77.1% of studies starting in 2017 or later. A majority of clinical trials were in phase 1 (53.3%) or phase 2 (25.7%). Common disorders treated include substance addiction, post-traumatic stress disorder, and major depressive disorder. Potential research gaps include studying psychedelics as a potential option for symptomatic treatment during opioid tapering. There appears to be a recent uptrend in registered clinical trials studying psychedelics, which is similar to the recent increase in overall trials registered. Potentially, more studies could be performed to evaluate the potential of psychedelics for symptomatic treatment during opioid tapering and depression refractory to selective serotonin reuptake inhibitors.

Objective

To study the impact of demographic factors on management of traumatic injury to the lumbar spine and postoperative complication rates.

Methods

Data was obtained from the National Inpatient Sample (NIS) between 2010-2014. International Classification of Diseases, 9th revision, Clinical Modification codes identified patients diagnosed with lumbar fractures or dislocations due to trauma. A series of multivariate regression models determined whether demographic variables predicted rates of complication and revision surgery.

Results

A total of 38,249 patients were identified. Female patients were less likely to receive surgery and to receive a fusion when undergoing surgery, had higher complication rates, and more likely to undergo revision surgery. Medicare and Medicaid patients were less likely to receive surgical management for lumbar spine trauma and less likely to receive a fusion when operated on. Additionally, we found significant differences in surgical management and postoperative complication rates based on race, insurance type, hospital teaching status, and geography.

Conclusion

Substantial differences in the surgical management of traumatic injury to the lumbar spine, including postoperative complications, among individuals of demographic factors such as age, sex, race, primary insurance, hospital teaching status, and geographic region suggest the need for further studies to understand how patient demographics influence management and complications for traumatic injury to the lumbar spine.