To evaluate the learning curve for exoscope and three-dimensional (3D) 4K hybrid visualization in terms of operating time, advantages, disadvantages, and surgical complications in tubular-access minimally invasive spine surgery (MISS) and to assess surgeon satisfaction with image quality, ergonomics, and ability to perform target site treatment. Overview of Literature: Working through tubular retractors poses a challenge. The extreme angulations during microsurgical decompression, especially contralateral decompression, require surgeons to work non-ergonomically. An exoscope allows surgeons to work ergonomically and independently of the microscope oculars as visualizations are now provided by large 3D 4K monitors. However, the value and efficacy of solely depending on an exoscope and 3D 4K monitors during microsurgical work are still unknown. Methods: Seventy-four patients (99 levels) underwent trans-tubular MISS between March 2018 and January 2019. Five patients were excluded: one had pyogenic discitis, two had revisions, and two were trans-tubular transoral. In total, we analyzed 69 for operating time, blood loss, and complications. The learning curve graph was plotted using the surgical time for each procedure. Surgeons were asked to rate their satisfaction with image quality, ability to maintain ergonomic posture, and efficient target site treatment. Results: For tubular microdiscectomy, the operating time plateaued after six cases, and for tubular decompression and minimally invasive transforaminal lumbar interbody fusion, the operating time plateaued after nine cases. Mean operating time was significantly reduced after the plateau. Complications included four cases of dural tear. All patients improved symptomatically, and there were no postoperative neurological deficits. Conclusions: Use of the exoscope has a short learning curve. Surgeons benefit from improved ergonomic posture during surgery, and resident teaching appears to be good. The only drawback is the need to rearrange the operating table setup. Complications were comparable to those when using the surgical microscope. An exoscope with hybrid digital visualization provides excellent visualization, depth perception, clarity, and precision target site treatment.

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Objective To assess the efficacy of an exercise program towards reducing back pain in pregnant women. Methods In this prospective control study, 145 low risk pregnant women who scored more than 20 for functional limitation assessment were recruited. The severity of back pain was assessed using the visual analoque scale (VAS) and the functional limitation was assessed using the Oswestry disability questionnaire (ODQ). All participants were informed of back care measures and provided with Paracetamol as an adjunct analgesia. The intervention group will have a session with a trained physiotherapist. Subsequently, all participants will be required to fill in a similar questionnaire regarding pain intensity and functional limitation assessment after 6 weeks post-intervention. Results There was a significant reduction in the VAS score and improvement in functional ODQ score in the intervention group. The median usage of Paracetamol as an analgesia to control back pain in the control group was 500 mg higher than the intervention group. There was a weak association of age, parity, duration of back pain, and body mass index with functional ODQ score at 6 week following intervention. Conclusion The back pain exercise reducing program was effective in reducing back pain intensity and analgesia usage with a significant improvement in functional ability.

Transoral approach to the cervico-medullary junction is a well-established procedure. However oropharyngeal complications in the form of soft tissue morbidity postoperatively do occur. We report a case of a teenage boy with traumatic quadriparesis secondary to compression of the cervico-medullary junction by an os odontoideum. Decompression was done via transoral approach through a tubular retractor system, hence obviating the need for the splitting or separate retraction of the soft palate and minimised the damage and violation of surrounding soft tissues. His neurological status improved and he was able to ambulate with support on fourth post-operative day with no soft tissue morbidity in the oral cavity. To our knowledge this is the first case reported using this technique. We conclude that adoption of this method would improve the traditional transoral approach and reduce the oropharyngeal complications.

IntroductionManaging patients who present with symptoms of cervical myelopathy secondary to cervical ossification of the posterior longitudinal ligament (OPLL) is challenging. Various factors such as the number of levels involved with OPLL, types of OPLL, canal occupying ratio, K-line characteristics, and C2-C7 lordosis angle were found to guide decision-making and surgical approaches in managing this condition. However, no clear treatment algorithm has been published. This study aims to investigate the outcome of the management of cervical OPLL using a treatment algorithm used in a tertiary university hospital. MethodsThis is a retrospective cross-sectional study. Patients with cervical myelopathy secondary to cervical OPLL who were treated surgically in our center from 2014 to 2020 were included in this study. Demographic data and preoperative parameters that determined the treatment given according to our treatment algorithm were analyzed. ResultA total of 24 patients fit the inclusion and exclusion criteria of the study. The mean recovery rate for all groups is 61.8 21.9% and the mean postoperative neck disability index (NDI) is 17.83 16.67%. There was a statistically significant difference between preoperative and postoperative Japanese Orthopaedic Association (JOA) scores for both anterior and posterior surgery subgroups. ConclusionWe believe that the treatment algorithm used in our center could benefit other surgeons as a guide in managing patients who suffer from cervical myelopathy secondary to cervical OPLL. Further study including newer techniques would increase the surgeon's arsenal in providing the best outcome in managing this condition.

The porous property of tantalum metal coupled with its high frictional surface and biocompatibility has made it an ideal biomaterial to facilitate bony fusion. This biomaterial is not unfamiliar to surgeons as it has been utilized with good clinical outcomes in arthroplasty. The usage of tantalum cages in spine surgery has gained traction. Complications resulting from the use of tantalum cage in lumbar fusion surgery were rarely reported. Here the authors would present a case of revision spinal surgery where the tantalum cage underwent migration from the previous posterior lumbar interbody fusion surgery. We further discuss ways to prevent such complications, precautions, tips, and tricks that could help other surgeons while dealing with this complication.

Patients with myelomeningocele associated with severe kyphoscoliosis usually presented with rigid and angulated gibbus at their back. The condition causes this group of patients to face difficulties in their daily activities, especially in sitting and lying in supine positions. They are also prone to have a pressure sore over the gibbus and encounter the risk of infection. Here the authors would present a case of a four-year-old girl with underlying myelomeningocele who was diagnosed with worsening kyphoscoliosis along her growth. Her whole spine x-ray radiograph revealed a kyphosis angle of 80° between the T11 and L4 levels. The patient underwent a deformity corrective surgery with total kyphectomy in a combination of anterior and posterior spinal instrumentation. In the present case, we were able to obtain sufficient correction of the spinal kyphotic deformity in that patient in a single-stage surgery with satisfactory surgical outcomes at a four years follow-up.

Since the late 1990s, navigation systems have been widely used in a variety of orthopaedic surgical procedures, with the majority of these procedures being complex arthroplasty surgeries and the correction of spinal abnormalities. Navigation systems are, however, infrequently used in trauma cases, especially in unstable pelvic ring fractures. The conventional method of percutaneous sacroiliac screw fixation typically used fluoroscopic image intensifiers to fix unstable pelvic ring fractures. We will examine how navigation systems can be used in trauma situations, particularly those involving unstable posterior pelvic ring fractures and focus on the advantages and disadvantages that we experienced during management.