In general, the scientific literature recommends extended fusion of the lumbar decompressed level adjacent to a fused level. Tubular decompression of lumbar canal stenosis defies this concept as it minimizes collateral damage. This study explores the concept of tubular hybrid surgery, where tubular decompression is performed adjacent to a fused level. A descriptive study of the technique is presented with a few case examples. The concept of tubular hybrid surgery wherein tubular minimally invasive spinal fusion is performed at one level and microscopic tubular decompression is executed at the adjacent levels is discussed, along with clinical and biomechanical evidence and case examples. The tubular hybrid method represents a significant advancement in minimally invasive spine surgery. Larger long-term, multicentric, prospective studies are necessary to establish the benefits of the procedure.

Purpose: S1 pedicle screw loosening remains a significant challenge in lumbosacral fixation due to the unique anatomical and biomechanical properties of the sacrum. Traditional trajectories often face limitations, including poor screw hold and an elevated risk of complications. This study introduces the Vishal Peshattiwar (VP) trajectory for S1 pedicle screw placement, aiming to optimize screw positioning, improve construct stability, and reduce associated complications. Methods: A prospective analysis was conducted on 117 patients undergoing L5–S1 minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and multilevel MIS-TLIF including the L5–S1 level between June 2019 and August 2022. In total, 234 S1 pedicle screws were placed using the VP trajectory under O-arm-guided 3-dimensional computed tomography navigation. Screw parameters, including length, entry point, and angulation, were analyzed. Finite element analysis (FEA) was performed using Altair OptiStruct software to assess displacement forces and elemental stresses. Results: The average screw length was 45.90 mm in men and 44.88 mm in women. The caudocranial angle ranged from 50° to 65°, and the lateromedial angle from 18° to 25°. FEA demonstrated reduced displacement forces and elemental stresses, indicating improved construct stability. At a 2- to 4-year follow-up, complications were minimal, with 1 case of bilateral screw breakage and 1 dural tear. Conclusion The VP trajectory provides an improved approach for S1 screw placement, offering enhanced biomechanical stability, reduced complications, and better long-term outcomes. Its application is most effective with minimally invasive surgical techniques and navigation assistance.

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.