To Örebro University

BACKGROUND: Simulation-based training is a key component of modern neurosurgical education, providing a repeatable environment for procedural practice. External ventricular drain (EVD) placement is a common emergency procedure performed in the early stages of neurosurgical training. This study presents the design, fabrication, and evaluation of a modular phantom targeting a specific brain subregion, intended to replicate the mechanical and procedural aspects of EVD insertion with improved material efficiency and reusability compared to existing full-brain approaches.

METHODS: A human cranium model was generated from medical imaging data and 3D-printed in two configurations. Both housed a replaceable polyvinyl alcohol (PVA) hydrogel brain sample containing a ventricular cavity. Mechanical tests compared three hydrogel variants for stability and haptic fidelity during controlled catheter advancement. A user study with seven experienced neurosurgeons provided a preliminary qualitative assessment of realism, ergonomics, and simulation fidelity through questionnaires and semi-structured interviews.

RESULTS: Modified hydrogel designs with enlarged or reinforced ventricles demonstrated greater mechanical stability and higher insertion resistance (∼0.6 N) compared to the standard configuration (∼0.4 N), with force-displacement profiles suggesting more consistent haptic feedback during ventricular entry. Surgeons rated cranial realism highly (visual M = 4.43, tactile M = 4.00), though brain visual realism scored lower (M = 2.71), likely reflecting the absence of meninges and cortical surface detail.

CONCLUSIONS: The proposed phantom represents an early-stage platform for EVD simulation, offering reproducibility, low cost, and modularity supporting repeated use and anatomical customization. Further validation with larger and more diverse cohorts is needed to substantiate its educational value.

OBJECTIVE: Adjacent segment disease (ASD) is a recognized long-term complication after anterior cervical discectomy and fusion (ACDF). Cervical disc arthroplasty (CDA) was introduced as a motion-preserving alternative, thought to reduce stress at adjacent levels and lower ASD risk. This study aimed to compare the risk of ASD requiring reoperation after ACDF and CDA and identify factors associated with ASD.

METHODS: This retrospective cohort study used prospectively collected data from the Swedish Spine Registry (Swespine) and included adult patients undergoing anterior cervical surgery for degenerative cervical disease between 2006 and 2026. ASD was defined as a secondary operation at an adjacent level ≥12 months after the index procedure. Cumulative incidence was estimated using Kaplan-Meier analysis, and associations with ASD were evaluated using multivariable Cox proportional hazards regression. Radiological or conservatively treated ASD were not assessed.

RESULTS: A total of 9,338 patients were included (ACDF, n=9,005; CDA, n=333). During 45,666 person-years follow-up, 509 ASD events occurred (incidence rate 11.1 per 1,000 person-years). Cumulative incidence was 4.9% at 5 years and 10.4% at 10 years. CDA was associated with lower ASD hazard than ACDF (hazard ratio [HR], 0.61) though this association was not significant after propensity score matching (HR, 0.88). Multilevel procedures (HR, 0.61), increasing age (HR, 0.96 per year), and radiculopathy were associated with lower risk, while myelopathy or stenosis was associated with higher risk (HR, 1.22).

CONCLUSION: The long-term risk of ASD requiring reoperation was lower than previously reported. After adjustment, CDA was associated with lower ASD risk compared to ACDF, although the absolute difference was small, and the clinical significance remains uncertain.

PURPOSE: Realistic off-patient training plays a crucial role in surgical education, particularly in complex and high-risk fields such as cervical spine surgery. To investigate effects of cadaver-based surgical education, this study investigates the educational value of a cadaver-based course in cervical spine surgery.

METHODS: 24 participants completed a three-day cadaver-based training course covering anterior and posterior cervical spine approaches in March 2024 in Sweden. The course focused on anatomical dissection with supervised instrumentation. Participants completed pre-, post-course and 6-month follow-up questionnaires assessing prior experience, post-course satisfaction, and longitudinal changes in surgical confidence and clinical impact. Educational impact was analyzed based on Kirkpatrick's model for evaluating training programs.

RESULTS: All respondents (n = 23/23, 100%) reported that the course met their expectations. At six-month follow-up, a considerable proportion of participants indicated increased surgical independence across all practiced procedures. The highest rates of perceived improvement (Kirkpatrick level 1 - reaction) in independent surgical performance were observed for anterior cervical discectomy and fusion (ACDF) procedures (n = 15/19, 78.9%) and laminectomies (n = 13/19, 68.4%). Cadaveric hands-on training (n = 13/19, 68.4%) and expert guidance (n = 3/19, 15.8%) were indicated as the most valued aspects of the course.

CONCLUSION: This study highlights the perceived impact (Kirkpatrick level 1 - reaction) of a three-day hands-on course in cervical spine surgery, demonstrating its effectiveness in improving surgical confidence and self-perceived autonomy among participants, contributing to an increased number of independently performed procedures. Overall, cadaver-based training on anatomical specimens represents a valuable addition to surgical education in the operating room for cervical spine surgery.

Coccydynia is a painful condition of the coccyx that is frequently misdiagnosed and managed inconsistently. This review summarizes and grades the current evidence on diagnostic strategies and treatment options. We systematically searched the literature and included 42 studies covering conservative, interventional, and surgical management. Based on these data, we propose a current best framework for diagnostic evaluation and therapeutic management. Initial assessment should include detailed history and focused examination with palpation for localized coccygeal tenderness and symptom provocation. Standard anteroposterior and lateral radiographs are recommended mainly to exclude serious pathology, while dynamic sitting-standing radiographs can be considered when mechanical pain is suspected and symptoms persist. Cross-sectional imaging with magnetic resonance imaging or computed tomography (CT) should be reserved for trauma, red-flag features, suspected neoplasm or infection, or inconclusive basic imaging. First-line treatment should consist of education, ergonomic advice, offloading strategies, nonsteroidal anti-inflammatory drugs or other simple analgesics, and physiotherapy, with extracorporeal shock wave therapy having the strongest support. In patients with persistent pain, image-guided diagnostic and therapeutic injections and radiofrequency procedures can provide substantial relief and help select candidates for more invasive treatment. Coccygectomy should be reserved for patients with chronic, function-limiting pain who have failed conservative and interventional care and show concordant findings on assessment, imaging, and diagnostic blocks, while modified incision strategies and minimally invasive techniques may be considered in selected cases.

PURPOSE: The decision to cross the cervicothoracic junction (CTJ) during multilevel posterior cervical fusion remains controversial. While constructs extending into the thoracic spine may enhance stability, they may also increase surgical complexity. The clinical relevance of these differences, particularly regarding patient-reported outcomes (PROMs), is still unclear. We hence aimed to determine whether extending fusion across the CTJ impacts PROMs and perioperative complication rates in a nationwide cohort.

METHODS: This retrospective cohort study used prospectively collected data from the Swedish Spine Registry (Swespine). Adult patients who underwent multilevel posterior cervical fusion were divided into two groups: those ending at C7 and those extending beyond the CTJ. Baseline characteristics, surgical details, complication rates, and PROMs at 1- and 5-years were compared.

RESULTS: Baseline characteristics were similar between groups (p ≥ 0.5). Perioperative complication and reoperation rates did not differ significantly between groups (p ≥ 0.5). Similarly, at both one- and five-years of follow-up, PROMs, including pain scores, disability indices, and satisfaction, were comparable (p ≥ 0.5). However, a significant difference was observed in terms of fine motor recovery, with patients whose constructs crossed the CTJ demonstrating a greater degree of improvement (p = 0.009).

CONCLUSIONS: Crossing the CTJ in multilevel posterior cervical fusion does not significantly affect complication rates, reoperations, or most PROMs at one and five years. Surgical decisions should prioritize anatomical and clinical factors, rather than expected differences in PROMs.

BACKGROUND AND OBJECTIVES: Patient-reported outcome measures (PROMs) are today's gold standard outcomes in surgery for degenerative cervical spine disorders. Long-term outcome research may be limited by missing data at later follow-up time-points. Previous studies on lumbar disorders suggest that no significant changes to PROMS occur after 1-year postsurgery. However, no previous study has examined the evolution of PROMS after surgery for degenerative cervical spine disease. We hence aimed to study the evolution of PROMs at 1, 2, and 5 years of postoperative follow-up in patients with cervical spondylosis treated for degenerative radiculopathy or myelopathy.

METHODS: A total of 6467 patients (4785 radiculopathy and 1682 myelopathy) undergoing surgery for cervical spondylosis between 2006 and 2018 in Sweden were included. Prerequisites for inclusion were PROMs at 1 and 2 or 5 years. The evolution of PROMs over time, the correlation between 1-year PROMs and 2- or 5-year PROMs and the predictive capability of 1-year PROMs were assessed.

RESULTS: No significant changes in PROMs beyond 1-year postoperatively could be observed among both degenerative radiculopathy and myelopathy cohorts (P ≥ .05). Significant (P < .0001) moderately strong to strong correlations were found between 1-year and 2- or 5-year PROMs (Pearson's R ranging from 0.56 to 0.85). On univariable analysis, 1-year PROMs were found to be strong predictors of long-term outcomes (P < .0001).

CONCLUSIONS: After surgery for cervical spondylosis with either degenerative radiculopathy or myelopathy, PROMs remained stable beyond 1 year, with minimal changes occurring thereafter. 1-year PROMs correlated with and served as a good proxy for predicting 2- and 5-year PROMs. This suggests that on a population level, 1-year PROMs are sufficient to assess longer term outcomes.

BACKGROUND: Several surgical approaches exist for extraforaminal (far lateral) lumbar disc herniations, including paraspinal Wiltse-type, interlaminar, lateral intertransverse, and combined medial-lateral techniques.

METHOD: We present microsurgical extraforaminal sequestrectomy through a midline intertransverse approach, chosen for familiar anatomy, minimal facet joint resection, and avoidance of a muscle-splitting trajectory. Unilateral subperiosteal dissection exposes the isthmus, facet margin, and transverse processes with the intertransverse ligament; the facet margin is removed with a straight osteotome, the ligament resected, the intertransverse artery coagulated, and the nerve root and disc space exposed for sequestrectomy.

CONCLUSION: This approach provides effective sequestrectomy while preserving spinal stability using familiar midline anatomy.

Background: Cervical spondylosis is a common degenerative condition of the cervical spine that often requires surgical intervention. Obesity is a modifiable risk factor that may influence surgical outcomes, including those in cervical spine procedures. This study aims to examine the relationship between obesity and patient-reported outcomes, including pain, function, and return to work, following anterior surgery for cervical spondylosis.

Methods: We conducted a retrospective longitudinal cohort study using data from the Swedish National Spine Register (Swespine) on patients who underwent anterior cervical surgery for cervical spondylosis between 2006 and 2021. We compared preoperative and postoperative pain, function, and quality of life, between obese and non-obese patients.

Results: A total of 7,933 patients were included in the analysis. Baseline characteristics differed between obese and non-obese groups, with obese patients reporting lower preoperative baseline health-related quality of life and higher disability scores (p < 0.05). Nonetheless, at 1-year follow-up, both groups showed similar improvements in neck pain, arm pain, disability (NDI), and quality of life (EQ-5D index and EQ VAS). However, obese patients were less likely to experience complete arm pain relief and had slightly poorer recovery in fine motor skills. Additionally, obese patients had lower rates of return to work (33% vs. 28%, p = 0.003). On subgroup analysis, patients with severe or morbid obesity were found to have significantly higher risks of overall complications following surgery when compared to non-obese patients (3.4% vs. 1.4%; p = 0.009).

Conclusion: Although obese patients were worse at baseline, they showed similar improvements in pain, function, and quality of life compared to non-obese patients following anterior cervical surgery. Our findings suggest that obesity should not preclude surgical intervention, as obese patients have the potential for significant postoperative recovery, although attention when treating severely or morbidly obese patients is warranted.

INTRODUCTION: Despite procedural standardization, external ventricular drain-related infections (EVD-RI) remain frequent, with reported incidences of 5-30%. The underlying risk factors, however, remain insufficiently understood and have been debated for decades. RESEARCH QUESTION: To address this, patient-related and periprocedural risk factors for EVD-RI in adults undergoing EVD placement were analyzed.

MATERIALS AND METHODS: This single-center cohort included adults receiving EVD implantation between 2014 and 2022. Suspected EVD-RI was defined according to Infectious Diseases Society of America (IDSA). Confirmed EVD-RI required a positive CSF culture and/or broad-range eubacterial PCR. The primary outcome was suspected EVD-RI. Patient-related factors were assessed for their role as independent predictors or confounders using a multivariable Cox proportional hazards model with purposeful variable selection.

RESULTS: A total of 387 patients with 421 EVDs were included. Suspected EVD-RI occurred in 104 (26.9%) patients and confirmed EVD-RI in 63 (16.3%) patients. EVD exchange (HR: 3.13, 95% CI: 2.02-4.85, p < 0.001), aneurysmal subarachnoid hemorrhage (aSAH) (HR: 2.56, 95% CI: 1.40-4.68, p = 0.002), and non-aneurysmal SAH (HR: 2.11, 95% CI: 0.90-4.96, p = 0.09) were associated with a significantly higher risk, whereas postoperative systemic antibiotics given for other suspected infections (HR: 0.33, 95% CI: 0.21-0.51, p < 0.001) and additional implantation of neuromonitoring (HR: 0.54, 95% CI: 0.30-0.97, p = 0.04) were associated with a significantly lower risk for EVD-RI.

DISCUSSION AND CONCLUSION: EVD-RI risk is driven primarily by periprocedural rather than patient-related factors. Avoiding EVD exchanges, preventing leaks/obstruction, minimizing drainage duration, and early definitive diversion may reduce infections.

PURPOSE: Patient involvement and shared decision-making (SDM) are central to patient-centered care and have been linked to improved patient satisfaction and outcomes. However, their implementation in spinal surgery remains limited, and the effect of patient involvement on postoperative outcomes is not well described.

METHODS: This observational cohort study used data from the Swedish Spine Registry (Swespine) to examine the association between perceived patient involvement in decision-making and postoperative outcomes among adults undergoing cervical spinal surgery between 2006 and 2020. Propensity score-matching was performed at a ratio of 2:1 to minimize baseline differences between groups. Uni- and multivariable analyses were conducted to identify factors associated with patient's perception of involvement in decision-making.

RESULTS: A total of 3,249 patients were included, with 81% (n = 2,640) reporting perceived involvement in decision-making and 19% (n = 609) not. Following matching, patients who were involved in decision-making had significantly greater improvements at one year follow-up regarding neck and arm pain (p < 0.001), disability (p < 0.001), health-related quality of life (p < 0.001), and subjective satisfaction (p < 0.001). Patients with poorer preoperative health status are more likely to feel involved in decision making, while those undergoing minor procedures feel significantly less involved. Positive predictors of perceived patient involvement included number of operated levels (OR 1.13, p = 0.041), unemployment (OR 1.89, p < 0.001), walking less than 100 m at a normal pace (OR 1.45, p = 0.044), and higher preoperative NDI (OR 1.01, p = 0.039). Negative predictors included higher preoperative EQ-5D index (OR 0.64, p = 0.022) and higher preoperative myelopathy score (OR 0.96, p = 0.042).

CONCLUSION: Patients with a higher degree of perceived involvement report better postoperative patient-reported outcomes following cervical spinal surgery. Patients undergoing larger surgeries and with poorer preoperative health status were more likely to perceive involvement than those undergoing minor procedures. Identifying and supporting patients that are susceptible to feel less involved in treatment-related decisions through individualized information or counseling may help optimize outcomes and satisfaction.