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Electroencephalography-Based Monitors

Introduction Through the recording of scalp surface electrical activity, electroencephalography (EEG) is unique as a noninvasive tool to explore the functioning brain. The obtained complex tracings correspond to the summation of the activity of several underlying neural assemblies, and they contain a huge amount of information. The time resolution of this tool is excellent, allowing an almost immediate assessment of brain function, while the space resolution…

Jugular Venous Oximetry

Introduction Jugular venous oxygen saturation monitoring (SjvO 2 ) is one of the multimodal neuromonitoring methods used to indirectly assess global cerebral oxygen balance and guide physiologic management decisions in both intraoperative and intensive care unit (ICU) settings. Normal SjvO 2 values range from 55% to 75%, and SjvO 2 less than 55% reflects cerebral desaturation and has been associated with poor outcomes. Jugular bulb monitoring…

Cerebral Blood Flow Monitoring

Introduction Brain perfusion is peculiar, reflecting the specificity of the brain in the human body. Brain metabolic function depends strictly on oxygen and glucose, yet it is not able to store them, meaning that all the energy must be supplied through blood flow, which must be tightly controlled to avoid hypoperfusion and ultimately ischemia. Despite representing just 2% of the total body weight, the brain receives…

Intracranial Pressure Monitoring

Introduction Increased intracranial pressure (ICP) is an important cause of secondary brain injury, and it is associated with poor outcome. Several conditions are associated with intracranial hypertension (ICH), including extracranial (fever, increased abdominal and intrathoracic pressure, hypercarbia, hypoxia) and intracranial causes (cerebral edema, hematoma, contusion, cerebrospinal fluid (CSF) disturbance). In this setting, ICP monitoring is crucial in the management of neurocritical care patients, as clinical signs…

Evidence-Based Report on Interbody Fusions of the Lumbar Spine

Introduction Lumbar fusion is a commonly performed procedure for various spine conditions, including spondylolisthesis, degenerative disk disease, dynamic instability, or lumbar spondylosis. Despite numerous studies, significant debate remains regarding the most effective surgical technique for lumbar fusion. Specifically, use of an interbody graft in lumbar fusion is an area of controversy. Although an interbody graft potentially provides the benefits of improved fusion rate and restoration of…

Interbody Fusion Strategies in Thoracic and Sacral Overlap Diseases

Introduction The thoracolumbar junction is subject to unique biomechanical forces owing to its existence as a transition zone. The thoracic spine is relatively rigid, largely in part to the costovertebral joints as well as coronally oriented facet joints. In contrast, the lumbar spine is more flexible because there are no rib articulations and more sagittally oriented facet joints. Importantly, this relationship may change with aging, as…

Revision Interbody Fusion

Introduction Revision lumbar surgery is a technically challenging operation that requires careful planning and patient selection. In the case of previous interbody fusion, there are particular considerations the surgeon needs to address when planning a revision operation, such as the approach taken at the index surgery. Compared with posterolateral fusions, interbody fusions may be more challenging, as a more complicated dissection involving the thecal sac and…

Instrumentation for Stability After Lumbar Interbody Fusion

Introduction Posterior fixation (PF) after lumbar interbody fusion (LIF) is a standard practice in spine surgery. As stand-alone LIF devices and techniques continue to advance, there is debate around the necessity of PF. Data and literature substantiating fusion outcomes is lacking for stand-alone devices, and therefore the US Food and Drug Administration (FDA) has yet to approve stand-alone LIF as equivalent to LIF with PF. As…

Spinous Process Plates for Lumbar Fixation

Introduction Lumbar interbody fusion is indicated in the treatment of many degenerative lumbar spinal disorders such as spinal stenosis, spondylolisthesis, trauma, and diskogenic pain of the lumbar spine. Successful outcomes after lumbar interbody fusion are dependent, in large part, on the development of bony fusion. Several operative approaches are commonly used to access the anterior column for interbody fusion, including posterior lumbar interbody fusion (PLIF), transforaminal…

Integrated Screw/Plate Interbody Fusion Devices

Introduction The goals of an interbody fusion device is to restore disk height, create or maintain segmental lordosis, maintain sagittal balance, and restore weight bearing to the anterior column while bony fusion develops. Numerous cage options exist, including cages that require posterior fixation, stand-alone cages without integrated fixation devices, and stand-alone cages integrated with screws and/or anterior plates for fixation. Interbody cages that require posterior fixation…

Biologic Options in Interbody Fusion

Introduction Interbody fusion devices aim to provide anterior column support as bony fusion between adjacent vertebral bodies progresses. Irrespective of the material utilized for structural support, depending on exact surgical technique, supplemental graft material should be placed within and/or around the allograft or cages in order to achieve a solid fusion. Achieving a solid arthrodesis can be directly correlated to long-term clinical outcomes and the durability…

Interbody Implant Options in Interbody Fusion

Introduction Lumbar fusion procedures have become increasingly common for the treatment of various degenerative lumbar spinal conditions. Along with this upsurge is the increased utilization of interbody implants with or without traditional posterolateral instrumentation. The increasing usage of interbody cages is owing to the proposed advantages that interbody fusion offers, including higher fusion rates and improved clinical outcomes. Additionally, interbody grafts significantly decrease the strain of…

Endoscopic Lumbar Interbody Fusion

Introduction Since the early 20th century, spinal fusion has been performed as a therapy for both traumatic and degenerative disorders of the spine. Lumbar interbody fusion (LIF) in particular has proved an effective therapy for a variety of conditions, improving patients’ activity and quality of life. As the field of neurosurgery advanced, new and better surgical approaches were developed to reduce the morbidity and complications associated…

Interlaminar Lumbar Instrumented Fusions (ILIF)

Introduction As the population ages, the incidence of lumbar spinal stenosis and the number of available surgical options for its treatment continue to increase. To date, posterolateral spinal fusion via pedicle screw and rod fixation has been regarded as the mainstay surgical treatment option for stabilization of a degenerative spinal segment. The intended benefits of this treatment include reduced back pain and prevention of continued degeneration…

Pre-psoas (Oblique) Lateral Interbody Fusion at L5-S1

Introduction The pre-psoas oblique lateral approach to the lumbar spine was first described by Mayer et al. in 1997. At that time, the approach was described only for the L2-5 disk spaces and the authors recommended an anterior transabdominal approach to the L5-S1 disk space owing to the anatomic considerations surrounding its access. The aortic bifurcation and iliocaval junction typically occur at or just below the L4…

Pre-psoas (Oblique) Lateral Interbody Fusion

Introduction Lumbar interbody fusion (LIF) is a well-accepted treatment for spinal pathologies. Traditionally, LIF is performed using posterior approaches. These open strategies require broad dissection of the paraspinal musculature and nerve root retraction to access the disk space for interbody fusion. A more refined minimally invasive method, transforaminal lumbar interbody fusion (TLIF), approaches the disk space through a tube via a more posterior oblique trajectory. Access…

Lateral Transpsoas Approach to Interbody Fusion

Introduction The transpsoas lateral lumbar interbody fusion (LLIF) technique was first introduced by Pimenta and Taylor in 2006 as an alternative to traditional anterior lumbar interbody fusion. Over the past decade, LLIF has established itself as an effective means and adjunct when treating an array of spinal pathologies. The technique enables access to the spine laterally via the retroperitoneal corridor by splitting the fibers of the…

Minimally Invasive Midline Lumbar Fusion (MIDLIF)

Introduction Each year in the United States more than 250,000 individuals undergo spinal fusions for degenerative lumbar spine pathology. Minimally invasive techniques for posterior lumbar interbody fusion offer the benefits of a smaller incision, minimization of injury to muscles and tendons, and shorter hospital stays over traditional open techniques. With regard to patient outcomes, a meta-analysis of 770 patients reported minimally invasive techniques for lumbar fusion…

Minimally Invasive Transforaminal Lumbar Interbody Fusion (MITLIF)

Introduction Minimally invasive transforaminal lumbar interbody fusion (MITLIF) allows a surgeon to restore intervertebral disk height, lumbar lordosis, and achieve an indirect decompression of the spinal canal and neural foramen while preserving vital posterior soft tissues. Adequate exposure of anatomic landmarks in open transforaminal lumbar interbody fusion (OTLIF) mandates a longer muscle-splitting incision and use of large self-retaining retractors at high tension that can generate pressures…

Transforaminal Lumbar Interbody Fusion (TLIF)

Introduction Posterior lumbar interbody fusion techniques have been popular since the 1950. Specifically, posterior lumbar interbody fusion (PLIF) was a very popular technique; however, it required removal of both facets in order to achieve adequate graft positioning. To surpass the inherent limitations of the PLIF, Harms and Rollinger, in 1982, described the placement of the interbody bone graft via a transforaminal approach. In the transforaminal lumbar…