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  1. Article: The Evolution of Minimally Invasive Spine Tumor Resection and Stabilization: From K-Wires to Navigated One-Step Screws.

    Shiber, Mai / Kimchi, Gil / Knoller, Nachshon / Harel, Ran

    Journal of clinical medicine

    2023  Volume 12, Issue 2

    Abstract: Minimization of the surgical approaches to spinal extradural metastases resection and stabilization was advocated by the 2012 Oncological Guidelines for Spinal Metastases Management. Minimally invasive approaches to spine oncology surgery (MISS) are ... ...

    Abstract Minimization of the surgical approaches to spinal extradural metastases resection and stabilization was advocated by the 2012 Oncological Guidelines for Spinal Metastases Management. Minimally invasive approaches to spine oncology surgery (MISS) are continually advancing. This paper will describe the evolution of minimally invasive surgical techniques for the resection of metastatic spinal lesions and stabilization in a single institute. A retrospective analysis of patients who underwent minimally invasive extradural spinal metastases resection during the years 2013-2019 by a single surgeon was performed. Medical records, imaging studies, operative reports, rates of screw misplacement, operative time and estimated blood loss were reviewed. Detailed description of the surgical technique is provided. Of 138 patients operated for extradural spinal tumors during the study years, 19 patients were treated in a minimally invasive approach and met the inclusion criteria for this study. The mortality rate was significantly improved over the years with accordance of improve selection criteria to better prognosis patients. The surgical technique has evolved over the study years from fluoroscopy to intraoperative 3D imaging and navigation guidance and from k-wire screw insertion technique to one-step screws. Minimally invasive spinal tumor surgery is an evolving technique. The adoption of assistive devices such as intraoperative 3D imaging and one-step screw insertion systems was safe and efficient. Oncologic patients may particularly benefit from the minimization of surgical decompression and fusion in light of the frailty of this population and the mitigated postoperative outcomes associated with MIS oncological procedures.
    Language English
    Publishing date 2023-01-09
    Publishing country Switzerland
    Document type Journal Article
    ZDB-ID 2662592-1
    ISSN 2077-0383
    ISSN 2077-0383
    DOI 10.3390/jcm12020536
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  2. Article: Short-term post-operative complications in 207 patients with multi-level degenerative cervical myelopathy: the effect of surgical approach.

    Harel, Ran / Nulman, Maya / Kimchi, Gil / Knoller, Nachshon

    Neurologia i neurochirurgia polska

    2022  Volume 56, Issue 5, Page(s) 404–409

    Abstract: Introduction: Degenerative cervical myelopathy (DCM) is a common condition often treated by surgical decompression and fusion. The objective of this paper was to compare short-term post-operative complication rates of patients with multi-level DCM ... ...

    Abstract Introduction: Degenerative cervical myelopathy (DCM) is a common condition often treated by surgical decompression and fusion. The objective of this paper was to compare short-term post-operative complication rates of patients with multi-level DCM treated with decompression and fusion using either an anterior or a posterior cervical approach.
    Material and methods: A retrospective evaluation of patients' charts, imaging studies and operative reports of patients operated for multilevel subaxial DCM from 2011 to 2016 at a single institution was performed. Patients who were operated upon for the treatment of three stenosed spinal levels or above and who underwent anterior cervical discectomy and fusion, or anterior cervical corpectomy and fusion, or posterior cervical laminectomy and fusion, were included. Short-term post-operative complications were compared between the anterior and posterior approaches.
    Results: Overall, 207 patients were included in this study. 156 were operated via an anterior approach and 51 via a posterior approach. The mean number of treated levels was 3.4 and 4.3 for the anterior and posterior approach groups, respectively (p < 0.001). In the posterior approach group, the proportion of stenosed spinal levels within all operated levels was significantly lower than in the anterior approach group (p = 0.025). Early post-operative neurological status change was favourable for both groups. Deep wound infection rate was significantly higher in the posterior approach group (7.8% vs. none; p = 0.001).
    Conclusions: Posterior cervical laminectomy and fusion is significantly associated with an increased rate of deep wound infection and wound revision surgery compared to the anterior approach. We recommend the anterior approach as the valid option in treating multi-level DCM.
    MeSH term(s) Humans ; Cervical Vertebrae/surgery ; Retrospective Studies ; Spinal Fusion/methods ; Treatment Outcome ; Spinal Cord Diseases ; Decompression, Surgical/methods ; Laminectomy/methods ; Postoperative Complications/surgery ; Wound Infection/surgery
    Language English
    Publishing date 2022-07-08
    Publishing country Poland
    Document type Journal Article
    ZDB-ID 415519-1
    ISSN 1897-4260 ; 0028-3843
    ISSN (online) 1897-4260
    ISSN 0028-3843
    DOI 10.5603/PJNNS.a2022.0052
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  3. Article ; Online: C1 lateral mass screw insertion using cannulated, navigated screws: preliminary results of a novel technique.

    Harel, Ran / Kimchi, Gil / Perry, Avital / Knoller, Nachshon

    British journal of neurosurgery

    2022  Volume 37, Issue 6, Page(s) 1624–1627

    Abstract: Purpose: The upper cervical spine region is densely populated by neural and vascular structures impeding the approach for fusion surgery. Technological advancement simplify the approach to C1-C2 fusion, thus reduce risks. The current paper purpose is to ...

    Abstract Purpose: The upper cervical spine region is densely populated by neural and vascular structures impeding the approach for fusion surgery. Technological advancement simplify the approach to C1-C2 fusion, thus reduce risks. The current paper purpose is to describe initial experience with a novel technique modification for C1 lateral screw insertion that incorporates cannulated-navigated screw system with intra-operative 3D imaging.
    Methods: A single-center single surgeon database was reviewed to identify all patients who underwent placement of C1 lateral mass screw insertion using the novel technique modification described below, on 2020. This cohort was retrospectively analyzed and compared with a cohort of patients who were operated on by the same surgeon with non-cannulated, navigated screws with intra-operative 3D imaging (O-arm, Medtronic, USA) between 2011 and 2019. Following navigated starting hole and drilling of the C1 lateral mass, a blunt guide-wire is used to palpate the hole and cannulated screw is advanced to the correct position over the wire. After initial purchase, a navigated screw driver is used for final screw depth position.
    Results: Twelve C1 lateral mass screws were inserted in six patients using this novel cannulated-navigated screw placement technique and compared to 24 patients operated using navigated non-cannulated screws. Minimal Estimated Blood Loss (EBL) was recorded in five of six cases undergoing the novel cannulated navigated placement of C1 lateral mass screws. Comparison to non-cannulated cohort demonstrated an EBL of 83CC vs. 354CC (Not significant). Mean surgery time was 97min and 118min for the cannulated-navigated and navigated only procedures (
    Conclusion: The new method presented allows for faster and possibly safer and more accurate C1 lateral mass screw insertion.
    MeSH term(s) Humans ; Retrospective Studies ; Imaging, Three-Dimensional/methods ; Surgery, Computer-Assisted ; Tomography, X-Ray Computed ; Spinal Fusion/methods ; Bone Screws ; Cervical Vertebrae/diagnostic imaging ; Cervical Vertebrae/surgery
    Language English
    Publishing date 2022-03-28
    Publishing country England
    Document type Journal Article
    ZDB-ID 639029-8
    ISSN 1360-046X ; 0268-8697
    ISSN (online) 1360-046X
    ISSN 0268-8697
    DOI 10.1080/02688697.2022.2054948
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  4. Article ; Online: MRI blind zone: A proposed novel index for spinal implants artifacts.

    Harel, Ran / Kimchi, Gil / Knoller, Nachshon

    Clinical imaging

    2022  Volume 89, Page(s) 78–83

    Abstract: Background: To advocate the formulation of a new index termed MRI Blind Zone, designated to predict the dimensions of the magnetic resonance metallic artifact caused by specific spinal implants. The index may also specify the obscured organs of interest. ...

    Abstract Background: To advocate the formulation of a new index termed MRI Blind Zone, designated to predict the dimensions of the magnetic resonance metallic artifact caused by specific spinal implants. The index may also specify the obscured organs of interest.
    Methods: A retrospective evaluation of post-operative MR images of patients operated for spinal instrumentation with various implants from different materials, in our institution, was performed. The MRI blind zone was described for each product, and the related obscured region of interest was discussed. A proposed 3D model was created as an example for suggested future reporting by the implants' industry.
    Results: Seven implant types are presented. The post-operative MR artifacts were detailed, and the clinical implications were discussed. Material type, processing methods and individual anatomical traits have a dramatic effect on the MRI blind zone and the obscured regions.
    Conclusion: MRI artifact is multifactorial and is influenced in part by the implant's shape, size, material and processing method. Individual products affect post-operative MR artifacts to different extents, and may carry clinical implications when post-operative imaging is required. A standardized index displaying the predicted post-operative artifact is warranted. For the manufacturers to accurately report the data to the surgeons, a parametric standardization should be performed. MRI blind zone index will allow surgeons to compare between different implants efficiently, and improve the informed decision-making process of implant selection.
    MeSH term(s) Artifacts ; Humans ; Magnetic Resonance Imaging/methods ; Metals ; Prostheses and Implants ; Retrospective Studies
    Chemical Substances Metals
    Language English
    Publishing date 2022-06-23
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1028123-x
    ISSN 1873-4499 ; 0899-7071
    ISSN (online) 1873-4499
    ISSN 0899-7071
    DOI 10.1016/j.clinimag.2022.06.007
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  5. Article ; Online: Post-laminectomy Dorsal Cord Migration Resulting in Immediate Neurologic Deterioration during Ventral Meningioma Resection: Proposed Mechanism of Injury and Prevention Technique.

    Harel, Ran / Kimchi, Gil / Perry, Avital / Korn, Akiva / Knoller, Nachshon

    Journal of neurological surgery. Part A, Central European neurosurgery

    2022  Volume 84, Issue 5, Page(s) 498–505

    Abstract: Background:  Ventral thoracic meningiomas may pose a technical challenge owing to a limited surgical corridor and the presence of long-standing ventral cord compression. Unopposed dorsal spinal cord migration may occur following a laminectomy resulting ... ...

    Abstract Background:  Ventral thoracic meningiomas may pose a technical challenge owing to a limited surgical corridor and the presence of long-standing ventral cord compression. Unopposed dorsal spinal cord migration may occur following a laminectomy resulting in immediate neurologic injury. We discuss the possible mechanism underlying such a phenomenon, suggesting alternative approach to prevent neurologic injury.
    Methods:  Two patients operated on for ventral thoracic meningioma and sustained neurologic compromise were retrospectively evaluated. Image editing software was used for 3D modeling to simulate the possible underlying mechanism of injury. Cases where ventral thoracic meningiomas were approached via unilateral hemilaminectomy, performed in 2020, were retrospectively analyzed and compared with the laminectomy approach cohort.
    Results:  Two patients sustained postoperative neurologic function decline following resection of ventral thoracic meningioma via the laminectomy approach. Both exhibited permanent abolishment of transcranial motor evoked potentials (MEPs) following laminectomy. Based on the extrapolated 3D models for these two cases, dorsal cord migration was postulated as the cause for the acute neurologic compromise.
    Conclusion:  Laminectomy for resection of thoracic ventral meningioma may lead in some cases to dorsal cord migration resulting in grave neurologic deterioration. Unilateral approach to these tumors restricts the dorsal migration and may mitigate neurologic outcomes.
    MeSH term(s) Humans ; Meningioma/surgery ; Laminectomy/adverse effects ; Laminectomy/methods ; Retrospective Studies ; Meningeal Neoplasms/surgery ; Magnetic Resonance Imaging
    Language English
    Publishing date 2022-04-22
    Publishing country Germany
    Document type Journal Article
    ZDB-ID 2651663-9
    ISSN 2193-6323 ; 2193-6315
    ISSN (online) 2193-6323
    ISSN 2193-6315
    DOI 10.1055/a-1832-3393
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  6. Article ; Online: One-step insertion of navigated pedicle screws in minimally invasive transforaminal lumbar interbody fusion (MITLIF): preliminary results of a novel technique.

    Harel, Ran / Kimchi, Gil / Knoller, Nachshon

    British journal of neurosurgery

    2020  Volume 35, Issue 6, Page(s) 753–756

    Abstract: Objective: To describe a novel technique modification and evaluate initial results of pedicle screw insertion in minimally invasive transforaminal lumbar interbody fusion (MITLIF), using self-drilling self-tapping one-step screws.: Patients and ... ...

    Abstract Objective: To describe a novel technique modification and evaluate initial results of pedicle screw insertion in minimally invasive transforaminal lumbar interbody fusion (MITLIF), using self-drilling self-tapping one-step screws.
    Patients and methods: All patients who were operated for MITLIF using the one-step technique over the last 6 months period at a single institute, were retrospectively identified. The surgical technique is described and depicted. Outcome evaluation was performed, including screw misplacement, screw insertion time, and post-operative complications.
    Results: We describe a novel technique modification in which self-drilling self-tapping navigated screws incorporate an embedded K-wire that enables a one-step insertion which obviates the need for instrument exchange. The first four patients in whom this technique was implemented were included (mean age was 55). All patients had been previously operated at the fused level. The mean surgical duration was 142 minutes and the calculated mean screw insertion time was 8.2 minutes. The mean estimated blood loss was 66 cc. An intraoperative 3D scan demonstrated no screw pedicle breach. There were no neurological complications or wound healing disturbances. The clinical course was uneventful for all patients.
    Conclusion: To our knowledge, the use of one-step navigation-assisted self-drilling self-tapping pedicle screws with an embedded K-wire has not been previously described. Our initial experience with this novel technique modification was efficient and safe. Navigated surgery allows for newer and safer techniques to be incorporated into the surgeon's toolbox. Further studies should be performed to thoroughly evaluate this technique.
    MeSH term(s) Humans ; Lumbar Vertebrae/surgery ; Middle Aged ; Minimally Invasive Surgical Procedures ; Pedicle Screws ; Retrospective Studies ; Spinal Fusion ; Surgery, Computer-Assisted ; Treatment Outcome
    Language English
    Publishing date 2020-06-10
    Publishing country England
    Document type Journal Article
    ZDB-ID 639029-8
    ISSN 1360-046X ; 0268-8697
    ISSN (online) 1360-046X
    ISSN 0268-8697
    DOI 10.1080/02688697.2020.1777257
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  7. Article ; Online: Post-operative dysphagia following ventral cervical approach: complication or side-effect? Retrospective analysis and review of the literature.

    Kimchi, Gil / Michaeli, Nofar / Nulman, Maya / Knoller, Nachshon / Maimon, Tomer / Harel, Ran

    British journal of neurosurgery

    2022  Volume 37, Issue 1, Page(s) 86–89

    Abstract: Objective: To ameliorate the clinical decision-making process when debating between a ventral or dorsal cervical approach by elucidating whether post-operative dysphagia be regarded as a complication or a transient side effect.: Methods: A literature ...

    Abstract Objective: To ameliorate the clinical decision-making process when debating between a ventral or dorsal cervical approach by elucidating whether post-operative dysphagia be regarded as a complication or a transient side effect.
    Methods: A literature review of studies comparing complication rates following ventral and dorsal cervical approaches was performed. A stratified complication rate excluding dysphagia was calculated and discussed. A retrospective cohort of patients operated for degenerative cervical myelopathy in a single institution comprising 665 patients was utilized to analyze complication rates using a uniform definition for dysphagia.
    Results: Both the ventral and the dorsal approach groups exhibited comparable neurological improvement rates. Since transient dysphagia was not considered a complication, the dorsal approach was associated with higher level of overall complications.
    Conclusions and relevance: Inconsistencies in the definition of dysphagia following ventral cervical surgery impedes the interpretation of trials comparing dorsal and ventral complication rates. A uniform definition for complications and side effects may enhance the validity of medical trials.
    MeSH term(s) Humans ; Retrospective Studies ; Cervical Vertebrae/surgery ; Diskectomy/adverse effects ; Spinal Fusion/adverse effects ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Postoperative Complications/surgery ; Deglutition Disorders/etiology ; Deglutition Disorders/surgery ; Treatment Outcome
    Language English
    Publishing date 2022-08-09
    Publishing country England
    Document type Review ; Journal Article
    ZDB-ID 639029-8
    ISSN 1360-046X ; 0268-8697
    ISSN (online) 1360-046X
    ISSN 0268-8697
    DOI 10.1080/02688697.2022.2107179
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  8. Article ; Online: Prevalence and Characteristics of Cervical Ossified Posterior Longitudinal Ligament in the Jewish Population.

    Kimchi, Gil / Maimon, Tomer / Geva, Liat Lerner / Knoller, Nachshon / Peled, Anton / Yaniv, Gal / Orlev, Alon / Klug, Maximiliano / Harel, Ran

    World neurosurgery

    2023  Volume 179, Page(s) e256–e261

    Abstract: Background: Numerous studies have demonstrated an association between ethnic identity and the prevalence rate of cervical ossified posterior longitudinal ligament (C-OPLL). To date, its prevalence rate in the Jewish population has not been determined. ... ...

    Abstract Background: Numerous studies have demonstrated an association between ethnic identity and the prevalence rate of cervical ossified posterior longitudinal ligament (C-OPLL). To date, its prevalence rate in the Jewish population has not been determined. The aim of this historical prospective study is to evaluate the prevalence and characteristics of C-OPLL in the Jewish population.
    Methods: We performed a retrospective evaluation of imaging studies of all adult patients who underwent both cervical computed tomography and magnetic resonance imaging for all clinical indications within a span of 36 months between January 2017 and July 2020 at a single tertiary referral hospital located in central Israel. Identified C-OPLL carriers were interviewed by telephone. All the patients provided informed consent and then were questioned for current symptoms and demographics, including religion, Jewish ethnic identity, birthplace, parental birthplace and ethnic identity, and family history of spinal disorders.
    Results: Overall, 440 participants were radiographically evaluated. The prevalence of C-OPLL in the Jewish population was 7.5% (33 of 440). The mean age of the C-OPLL carriers was 65.8 years. All the C-OPLL carriers were symptomatic at analysis. The carriers had an increased proportion with a Sephardic Jewish ethnic identity (65.4%), with a significantly high rate of homogeneous parental Jewish identity (92.4%), suggesting a prominent genetic contribution to the development of this condition.
    Conclusions: The prevalence of C-OPLL in the Jewish population in central Israel was 7.5%. This rate is significantly higher than that in other previously studied populations. To the best of our knowledge, this is the first study to identify the Jewish population as experiencing an increased prevalence of C-OPLL.
    MeSH term(s) Adult ; Humans ; Aged ; Longitudinal Ligaments/pathology ; Cervical Vertebrae/diagnostic imaging ; Cervical Vertebrae/pathology ; Ossification of Posterior Longitudinal Ligament/pathology ; Retrospective Studies ; Prospective Studies ; Jews ; Prevalence
    Language English
    Publishing date 2023-08-22
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2534351-8
    ISSN 1878-8769 ; 1878-8750
    ISSN (online) 1878-8769
    ISSN 1878-8750
    DOI 10.1016/j.wneu.2023.08.064
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  9. Article: Intraoperative imaging and navigation for C1-C2 posterior fusion.

    Harel, Ran / Nulman, Maya / Knoller, Nachshon

    Surgical neurology international

    2019  Volume 10, Page(s) 149

    Abstract: Background: Cervical axial spine fusion is challenging as the anatomy is extremely variable, and screw misplacement can lead to severe complications. C1 lateral mass screws and C2 pedicle screws are routinely placed under either fluoroscopic guidance or ...

    Abstract Background: Cervical axial spine fusion is challenging as the anatomy is extremely variable, and screw misplacement can lead to severe complications. C1 lateral mass screws and C2 pedicle screws are routinely placed under either fluoroscopic guidance or imaging-assisted navigation. Here, we compared the two for axial screw placement.
    Methods: We retrospectively evaluated patients' treated from 2011-2016 utilizing the Harm's procedure for C1-C2 screw fixation performed under either fluoroscopic guidance (nine patients) or image-assisted O-arm navigation (five patients). The groups had similar demographic and risk factors. Variables studied included operative time, estimated blood loss (EBL), accuracy of screw placement, screw reposition rates, and reoperation rates.
    Results: The mean EBL was 555CC and 260CC, respectively (not a significant difference) utilizing fluoroscopic versus O-arm navigation. Of interest, the mean surgical duration was 27 min longer in the O-arm versus fluoroscopy group (
    Conclusion: Axial cervical spine instrumentation is challenging. Utilization of Imaging-assisted navigation increases the accuracy and safety of screw placement.
    Language English
    Publishing date 2019-07-26
    Publishing country United States
    Document type Journal Article
    ISSN 2229-5097
    ISSN 2229-5097
    DOI 10.25259/SNI_340_2019
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  10. Article: Post-laminectomy Dorsal Cord Migration Resulting in Immediate Neurologic Deterioration during Ventral Meningioma Resection: Proposed Mechanism of Injury and Prevention Technique

    Harel, Ran / Kimchi, Gil / Perry, Avital / Korn, Akiva / Knoller, Nachshon

    Journal of Neurological Surgery Part A: Central European Neurosurgery

    2022  Volume 84, Issue 05, Page(s) 498–505

    Abstract: Background: Ventral thoracic meningiomas may pose a technical challenge owing to a limited surgical corridor and the presence of long-standing ventral cord compression. Unopposed dorsal spinal cord migration may occur following a laminectomy resulting ... ...

    Abstract Background: Ventral thoracic meningiomas may pose a technical challenge owing to a limited surgical corridor and the presence of long-standing ventral cord compression. Unopposed dorsal spinal cord migration may occur following a laminectomy resulting in immediate neurologic injury. We discuss the possible mechanism underlying such a phenomenon, suggesting alternative approach to prevent neurologic injury.
    Methods: Two patients operated on for ventral thoracic meningioma and sustained neurologic compromise were retrospectively evaluated. Image editing software was used for 3D modeling to simulate the possible underlying mechanism of injury. Cases where ventral thoracic meningiomas were approached via unilateral hemilaminectomy, performed in 2020, were retrospectively analyzed and compared with the laminectomy approach cohort.
    Results: Two patients sustained postoperative neurologic function decline following resection of ventral thoracic meningioma via the laminectomy approach. Both exhibited permanent abolishment of transcranial motor evoked potentials (MEPs) following laminectomy. Based on the extrapolated 3D models for these two cases, dorsal cord migration was postulated as the cause for the acute neurologic compromise.
    Conclusion: Laminectomy for resection of thoracic ventral meningioma may lead in some cases to dorsal cord migration resulting in grave neurologic deterioration. Unilateral approach to these tumors restricts the dorsal migration and may mitigate neurologic outcomes.
    Keywords thoracic meningioma ; dorsal cord migration ; unilateral approach ; Intradural tumors ; Intraoperative neuromonitoring
    Language English
    Publishing date 2022-04-22
    Publisher Georg Thieme Verlag KG
    Publishing place Stuttgart ; New York
    Document type Article
    ZDB-ID 2651663-9
    ISSN 2193-6323 ; 2193-6315
    ISSN (online) 2193-6323
    ISSN 2193-6315
    DOI 10.1055/a-1832-3393
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