Jad El Choueiri

BACKGROUND AND OBJECTIVES: Carotid-cavernous fistulas (CCFs) are uncommon arteriovenous shunts that can present with a wide range of nonspecific ophthalmic and neurological symptoms, often leading to diagnostic delays. While endovascular embolization is the primary treatment modality, data on long-term functional outcomes and the prognostic value of baseline symptom burden remain limited. METHODS: We conducted a retrospective single-center cohort study of consecutive patients with angiographically confirmed CCFs treated with endovascular embolization between 2009 and 2025. Clinical outcomes were assessed at early follow-up (median 1.5 months) and long-term follow-up (>1 year; median 52 months). Logistic regression analyses were used to evaluate the association between symptom burden, angiographic occlusion status, and failure of clinical improvement. RESULTS: A total of 107 patients were included (median age: 64 years, 35% male). Diagnostic delays were common (median duration from symptom onset to treatment: 30 days), frequently due to misdiagnosis as inflammatory, infectious, or vascular orbital conditions. Early follow-up demonstrated complete or partial improvement in 91% of patients, with significant progression from partial to complete improvement at long-term follow-up ( P = .001). Complication and repeat treatment rates were low. Neither symptom duration nor number of presenting symptoms was associated with failure of improvement at early or long-term follow-up ( P ≥ .05). Complete angiographic obliteration at the end of the procedure was associated with improved early outcomes (odds ratio 0.09; 95% CI, 0.02-0.39), while complete occlusion at last radiological follow-up predicted favorable long-term outcomes (odds ratio 0.15; 95% CI, 0.02-0.94). CONCLUSION: Endovascular embolization of CCFs is associated with excellent clinical outcomes and sustained long-term improvement. Symptom burden and diagnostic delays did not predict post-treatment recovery, whereas durable angiographic occlusion was a key determinant of outcome. These findings support intervention even in patients presenting late and emphasize the importance of achieving complete fistula occlusion.

Background: Accurate pedicle screw placement remains essential in spinal instrumentation, and robotic navigation has been introduced to improve safety, reproducibility, and workflow standardization. This study evaluated the accuracy of robot-assisted pedicle screw placement using the Excelsius GPS platform during the first year of implementation at two centers and analyzed the associated learning curve. Methods: Consecutive patients undergoing robot-assisted spinal instrumentation between April 2024 and April 2025 were retrospectively reviewed. Screw accuracy was assessed on intraoperative three-dimensional imaging using the Gertzbein–Robbins Scale (GRS). Grades A and B were considered clinically acceptable, whereas grades C–E were considered clinically non-acceptable. Sacral S1 screws and oncological cases requiring carbon fiber-reinforced PEEK instrumentation were excluded from the primary analysis and evaluated separately when appropriate. Robotic workflow time was defined as the interval between the first intraoperative three-dimensional acquisition used for planning and the second acquisition used for screw verification. Results: The primary standard non-oncological cohort included 102 patients and 455 non-S1 screws. Overall, 411 screws were classified as GRS A, yielding a perfect intrapedicular placement rate of 90.3%. Clinically acceptable accuracy was achieved in 449 of 455 screws, corresponding to a GRS A + B rate of 98.7% (95% CI, 97.2–99.4%). Only six screws were classified as GRS C–E, with no GRS D screws observed. Clinically acceptable accuracy was comparable between centers. In Center 1, all clinically non-acceptable screws occurred within the first nine cases, and GRS A + B accuracy increased from 92.9% in the first trimester to 100% thereafter. Median robotic workflow time was 64.4 min per case and 13.9 min per screw. Conclusions: This two-center early experience supports the accuracy and reproducibility of ExcelsiusGPS-assisted spinal instrumentation. Chronological analysis showed that clinically non-acceptable breaches were concentrated in the early implementation phase; however, this observation should be considered exploratory because of the low event count. The study supports high clinically acceptable accuracy and broadly comparable robotic workflow metrics across centers. Chronological patterns observed during early implementation should be interpreted as exploratory rather than as proof of a formal learning curve.

Background: Augmented reality (AR) has rapidly emerged as an important navigational technology in spine surgery, with growing interest in its potential to reduce dependence on fluoroscopy and mitigate radiation exposure for both patients and operating room staff. Methods: This systematic review examined current evidence on radiation-related outcomes of AR-assisted spine procedures. A PRISMA-guided search of PubMed, Embase, and Scopus identified twelve eligible studies, including randomized trials, prospective and retrospective clinical cohorts, and cadaveric or synthetic-model investigations. Results: Across the included studies, AR was consistently associated with reduced fluoroscopy use, with several studies demonstrating statistically significant reductions in exposure time compared with conventional fluoroscopy. Two clinical studies directly measured occupational radiation and reported substantially lower staff doses when AR-based navigation and optimized shielding strategies were employed. Patient radiation exposure was similarly decreased in most studies, particularly when AR was integrated with low-dose cone-beam CT protocols. Operative time findings were mixed, reflecting early learning curves and variability in AR systems, but accuracy remained high across platforms. Conclusion: Current evidence suggests that AR may reduce intraoperative radiation exposure without compromising workflow or surgical precision, available studies are limited by small sample sizes, heterogenous methodologies, and a paucity of direct staff-dosimetry data. Larger, high-quality multicenter studies are needed to clarify the magnitude of AR’s radiation-sparing benefits and to define its role in modern spine surgery.

BACKGROUND AND OBJECTIVES: Decompressive craniectomy (DC) is used to control intracranial pressure in severe pediatric traumatic brain injury (TBI), although evidence of its benefit in pediatric patients remains conflicted. To address this, this meta-analysis evaluates the outcomes of DC vs medical management (MM) in pediatric severe TBI. METHODS: Following PRISMA guidelines, databases were searched through October 2025 for studies comparing DC and MM in patients younger than 18 years with severe TBI. Randomized control trials and prospective and retrospective studies reporting at least one clinical outcome were included. Random-effects models were applied, with relative risks used for dichotomous outcomes and mean differences for continuous outcomes. RESULTS: Our analysis included 553 DC and 2336 MM patients, with 1 randomized trial and 10 observational studies. Pooled analyses showed no significant difference in good functional outcomes between DC and MM, whether based on the Glasgow Outcome Scale or study-specific definitions or mortality (1.06, 95% CI 0.69-1.64; P = .78). Subgroup analyses of Glasgow Outcome Scale scores at discharge and 30 days corroborated these findings. DC was associated with a significantly longer intensive care unit stay (mean differences, 6.2 days, 95% CI 4.4-8.0; P < .001) and a similar trend toward longer hospital stay (mean differences, 4.0 days, 95% CI −0.6 to 8.7; P = .09), which became significant on sensitivity analysis. Reported complication rates, when reported, were low and comparable across groups. CONCLUSION: In children with severe TBI, DC does not appear to provide clear survival or functional advantages over MM and is significantly associated with longer intensive care unit and hospital stays. However, these findings should be interpreted with caution as the current literature mainly composed of small and heterogeneous retrospective studies. Further large, prospective, multicenter studies are needed to confirm these findings, refine surgical indications, and establish pediatric-specific management guidelines.

Background/Objectives: Degenerative cervical myelopathy (DCM) may result from posture-dependent spinal cord compromise not detectable on neutral imaging. Dynamic MRI can uncover clinically relevant mechanisms underlying otherwise unexplained myelopathy and guide management. This report illustrates a dynamic cervical myelopathy phenotype revealed by flexion–extension imaging and its impact on surgical decision-making. Methods: A 49-year-old man presented with progressive bilateral upper-limb paresthesias, intrinsic hand atrophy, and distal weakness. Neutral cervical MRI, standard radiographs, and flexion–extension MRI were performed to investigate a suspected dynamic etiology, including differentiation from Hirayama disease. Surgical treatment consisted of anterior cervical discectomy and fusion (ACDF), with clinical and radiological follow-up. Results: Neutral MRI showed intramedullary T2 hyperintensity from C4 to C6 without static canal stenosis or frank compression, while radiographs demonstrated segmental kyphosis without instability. Flexion MRI revealed reproducible spinal cord contact with a small cranially located osteophyte at C5–C6, concordant with the myelopathic signal. ACDF at C4–C6 led to clinical improvement. One year later, recurrent symptoms from adjacent-segment pathology (C3–C4 myelopathic signal and C6–C7 foraminal disc herniation) required a second ACDF, resulting in durable neurological stability. Conclusions: This case demonstrates flexion-dependent cord–osteophyte conflict causing cervical myelomalacia in the absence of static stenosis. Dynamic MRI resolved a clinical–radiological mismatch and directly informed surgical planning. Recognition of dynamic myelopathy phenotypes and vigilance for adjacent-segment disease after fusion are essential for optimizing outcomes.

Background/Objectives: Conventional static magnetic resonance imaging may underestimate the severity of cervical cord compression by failing to account for positional changes in the spinal canal. Dynamic MRI (dMRI) captures cervical motion, allowing evaluation of cord compression under physiological loading. This systematic review aimed to synthesize evidence on how dMRI modifies the assessment of spinal canal narrowing and signal change, and how these findings correlate with impairment and postoperative outcomes in degenerative cervical myelopathy. Methods: A systematic literature search was conducted across PubMed, Scopus, and Embase databases according to PRISMA guidelines. Studies evaluating the role of dMRI (flexion–extension MRI) in diagnosing or predicting outcomes of cervical degenerative pathology were included. Data were extracted on imaging protocols, diagnostic findings, quantitative parameters, and clinical outcomes. Results: Nineteen studies met the inclusion criteria. dMRI consistently revealed motion-dependent stenosis and intramedullary signal changes not visible on static imaging. Extension imaging frequently demonstrated disease progression, showing altered spinal cord area, cerebrospinal fluid (CSF) reserve, and additional compression levels. Dynamic sequences enhanced sensitivity for pathological segment detection and improved correlation with clinical severity. Preoperative dMRI findings, particularly extension-related compression and T2 hyperintensity, predicted postoperative neurological recovery and influenced surgical planning in up to one third of cases. Conclusions: Dynamic MRI provides superior diagnostic sensitivity and prognostic information compared with static imaging by revealing motion-induced spinal cord compression and microstructural alterations. It should be considered when clinical findings exceed static MRI severity or when the symptomatic level is uncertain. Standardization of protocols and large prospective studies are needed to define evidence-based clinical indications.