An inception cohort of 107 patients was reviewed to establish the natural history of asymptomatic urolithiasis. With an over-all mean followup of 31.6 months, 73 patients (68.2%) remained asymptomatic and were censored at the time of the last clinical visit. A symptomatic event developed in 34 patients (31.8%). Spontaneous passage occurred in 16 patients (15.0%), endoureteral removal was done in 6 (5.6%), percutaneous nephrostolithotomy was done in 3 (2.8%) and 9 (8.4%) were referred for therapeutic lithotripsy. Cumulative 5-year probability of a symptomatic event developing was 48.5%. A linear association was identified between the development of a symptomatic event and the number of previous stones as well as the number of asymptomatic stones at identification. A significant burden of illness is associated with an expectant strategy as an approach to asymptomatic urolithiasis. Of the patients who had a symptomatic event 47% had spontaneous stone passage, while 26.5% required urological intervention and 26.5% were referred for therapeutic lithotripsy. Prophylactic extracorporeal shock wave lithotripsy, although often advocated, has associated risks and is not always a benign procedure. A randomized controlled trial is required to evaluate properly the role of prophylactic lithotripsy versus an expectant strategy.

Single level axial lumbar interbody fusion (AxiaLIF) using a transsacral rod through a paracoccygeal approach has been developed with promising early clinical results and biomechanical stability. Recently, the transsacral rod has been extended to perform a two-level fusion at both L4-L5 and L5-S1 levels (AxiaLIF II). No biomechanical studies have been conducted on multilevel fusion using the AxiaLIF technique. In this study, the biomechanics of L4-S1 motion segments instrumented with the AxiaLIF II transsacral rod was evaluated. Six human cadaveric lumbosacral spine segments from L4 to S1 were used (age ranges 46-74 years). Unconstrained and non-destructive pure moments in axial torsion, lateral bending, and flexion extension were applied to each specimen following intact, standalone AxiaLIF II, and AxiaLIF II with two posterior fixation options: facet screws and pedicle screws with rods. Range of motion was calculated from the raw data collected with an optical motion tracking system. The two-level transsacral rod was successfully inserted in all the specimens. At L4-L5 level in axial torsion (AT) and flexion extension (FE), none of the surgical treatments showed statistically significant difference between the procedures (all P > 0.05) although facet screws and pedicle screws had higher stability on average. In lateral bending (LB), the two posterior fixation techniques had significantly higher construct stability (P < 0.05) than the standalone rod. No significant difference was found between facet screws and pedicle screws (P = 0.821). At L5-S1 level in AT and LB, none of the surgical treatments were found to be statistically significant (all P > 0.05). In FE, standalone two-level transsacral rod had significantly higher range of motion (ROM) compared with the posterior fixation techniques (P < 0.05). In conclusion, the standalone rod reduced intact ROM significantly. Supplementary fixations including facet screws and pedicle screws are required to achieve higher construct stability for successful fusion. Further clinical studies are essential to evaluate the practical success of this technique.

Acute colonic pseudo-obstruction (ACPO) as a result of anterior lumbar spinal surgery can result in colonic perforation. ACPO is often treated successfully with conservative measures, reserving surgical intervention for severe cases. The most severe cases can result in colonic perforation with a concomitant high mortality rate. Herein we outline a case of a 72-year-old male with multiple medical comorbidities and history of intermittent constipation who underwent anterior lumbar interbody fusion (ALIF) of L5-S1. The patient's multiple medical comorbidities placed him at risk for ACPO. His postoperative course was complicated by an ileus. The patient initially underwent conservative management that failed, resulting in colonic perforation. He underwent urgent exploratory laparotomy and repair of colonic perforation by the general surgery service. The patient had spontaneous return of bowel function on postoperative day 5, and at 6 months, he was doing well. The main purpose of this case report is to present a unique case of colonic perforation after ALIF. Understanding patient risk factors can help in early identification and treatment of potentially life-threatening complications. Surgeons should discuss the possibility of this complication with the patient during surgical counseling for anterior lumbar surgery.