Adeno-associated viral vector 9 (AAV9) has recently been shown to penetrate the blood--brain barrier via intravascular administration, making it a good candidate for diffuse gene delivery. However, the potential side effects of systemic delivery are unknown. Intrathecal viral vector administration may be more invasive than intravenous injections, but it requires far less vector and it can be performed on an outpatient basis, making it an ideal route of delivery for clinical translation. A total of 12 domestic farm pigs (o20 kg) underwent a single-level lumbar laminectomy with intrathecal catheter placement for AAV9 delivery. Animals were perfused and the tissue was harvested 30 days after treatment. Gene expression was assessed by anti-green fluorescent protein immunohistochemistry. Although a single lumbar injection resulted in gene expression limited to the lumbar segment of the spinal cord, three consecutive boluses via a temporary catheter resulted in diffuse transduction of motor neurons (MNs) throughout the cervical, thoracic and lumbar spinal cords. We now present the first successful robust transduction of MNs in the spinal cord of a large animal via intrathecal gene delivery using a self-complementary AAV9. These promising results can be translated to many MN diseases requiring diffuse gene delivery.

OBJECTIVE Esophageal perforation is a rare but well-known complication of anterior cervical spine surgery. The authors performed a systematic review of the literature to evaluate symptomatology, direct causes, repair methods, and associated complications of esophageal injury. METHODS A PubMed search that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included relevant clinical studies and case reports (articles written in the English language that included humans as subjects) that reported patients who underwent anterior spinal surgery and sustained some form of esophageal perforation. Available data on clinical presentation, the surgical procedure performed, outcome measures, and other individual variables were abstracted from 1980 through 2015. RESULTS The PubMed search yielded 65 articles with 153 patients (mean age 44.7 years; range 14–85 years) who underwent anterior spinal surgery and sustained esophageal perforation, either during surgery or in a delayed fashion. The most common indications for initial anterior cervical spine surgery in these cases were vertebral fracture/dislocation (n = 77), spondylotic myelopathy (n = 15), and nucleus pulposus herniation (n = 10). The most commonly involved spinal levels were C5–6 (n = 51) and C6–7 (n = 39). The most common presenting symptoms included dysphagia (n =63), fever (n = 24), neck swelling (n = 23), and wound leakage (n = 18). The etiology of esophageal perforation included hardware failure (n = 31), hardware erosion (n = 23), and intraoperative injury (n = 14). The imaging modalities used to identify the esophageal perforations included modified contrast dye swallow studies, CT, endoscopy, plain radiography, and MRI. Esophageal repair was most commonly achieved using a modified muscle flap, as well as with primary closure. Outcomes measured in the literature were often defined by the time to oral intake following esophageal repair. Complications included pneumonia (n = 6), mediastinitis (n = 4), osteomyelitis (n = 3), sepsis (n = 3), acute respiratory distress syndrome (n = 2), and recurrent laryngeal nerve damage (n = 1). The mortality rate of esophageal perforation in the analysis was 3.92% (6 of 153 reported patients). CONCLUSIONS Esophageal perforation after anterior cervical spine surgery is a rare complication. This systematic review demonstrates that these perforations can be stratified into 3 categories based on the timing of symptomatic onset: intraoperative, early postoperative (within 30 days of anterior spinal surgery), and delayed. The most common source of esophageal injury is hardware erosion or migration, each of which may vary in their time to symptomatic manifestation.

In environments in which opioids are increasingly abused for recreation, children are becoming more at risk for both accidental and nonaccidental intoxication. In toxic doses, opioids can cause potentially lethal acute leukoencephalopathy, which has a predilection for the cerebellum in young children. The authors present the case of a 2-year-old girl who suffered an accidental opioid overdose, presenting with altered mental status requiring cardiorespiratory support. She required emergency posterior fossa decompression, partial cerebellectomy, and CSF drainage due to cerebellar edema compressing the fourth ventricle. To the authors’ knowledge, this is the first report of surgical decompression used to treat cerebellar edema associated with opioid overdose in a child.

BACKGROUND: The coronavirus identified in 2019 (COVID-19) pandemic effectively ended all major spine educational conferences in the first half of 2020. In response, the authors formed a "virtual" case-based conference series directed at delivering spine education to health care providers around the world. We herein share the technical logistics, early participant feedback, and future direction of this initiative.-METHODS: The Virtual Global Spine Conference (VGSC) was created in April 2020 by a multiinstitutional team of spinal neurosurgeons and a neuroradiologist. Biweekly virtual meetings were established wherein invited national and international spine care providers would deliver casebased presentations on spine and spine surgeryLrelated conditions via teleconferencing. Promotion was coordinated through social media platforms such as Twitter.-RESULTS: VGSC recruited more than 1000 surgeons, trainees, and other specialists, with 50e100 new registrants per week thereafter. An early survey to the participants, with 168 responders, indicated that 92% viewed the content as highly valuable to their practice and 94% would continue participating post COVID-19. Participants from the United States (29%), Middle East (16%), and Europe (12%) comprised the majority of the audience. Approximately 52% were neurosurgeons, 18% orthopedic surgeons, and 6% neuroradiologists. A majority of participants were physicians (55%) and residents/fellows (21%).-CONCLUSIONS: The early success of the VGSC reflects a strong interest in spine education despite the COVID-19 pandemic and social distancing guidelines. There is widespread opinion, backed by our own survey results, that many clinicians and trainees want to see "virtual" education continue post COVID-19.