Spine deformity最新文献

Purpose: Body mass index (BMI), is a nutritional index based on standing height and weight. Children with early onset scoliosis (EOS) have shorter height due to their spine curvature. In these patients' pulmonary function tests, which are also based off height, arm span is standardly used as a surrogate for height to allow for normative comparisons. Arm span has not been used for nutritional assessments in children with EOS.

Methods: We used both arm span and measured height to calculate BMI, and BMI as a percent of predicted published norms (BMI%ile) to assess the error produced using height in this population of children. We used a Wilcoxon signed-rank test to compare standard height BMI (BMI) vs arm span BMI (asBMI) and BMI%iles, Spearman correlation to assess the influence of age or coronal curve angle on any differences, and an adjusted linear model for the coronal curve's impact on BMI.

Results: BMI and BMI%ile consistently over-estimated nutritional status compared to asBMI with substitution of arm span for height. 15.6% of patients had a BMI%ile of < 1% using height compared to 44.4% using arm span. The difference between BMI and asBMI correlated with the coronal curve magnitude but not with age. The adjusted linear model showed that for each degree of Cobb angle, the difference between BMI and asBMI increased by 0.0294 kg/m² (p = 0.0062).

Conclusion: Arm span BMI reveals lower, more accurate nutritional status in children with EOS than standard height BMI.

Level of evidence: IV.

Purpose: Scoliosis in neuromuscular scoliosis (NMS) is a spinal deformity often treated with posterior spinal fusions (PSF). There is a relatively high risk to develop surgical site infection (SSI) after PSF in NMS compared to adolescent idiopathic scoliosis (AIS) patients. The purpose of this retrospective cohort study was to determine perioperative risk factors for NMS patients undergoing PSF.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried for patients who underwent PSF for NMS and/or cerebral palsy from 2015 to 2020. Statistical analysis of patient characteristics was completed utilizing likelihood ratio chi-squared test for categorical factors and median test or Wilcoxon rank sum test for quantitative factors. Logistic regression was used for odds ratios for quantitative factors.

Results: 4145 patients underwent PSF for NMS, and 102 developed an SSI (2.5%). Identified risk factors include American Society of Anesthesiologists (ASA) ≥ 3 (p = 0.030, odds ratio 2.4), preoperative corticosteroids (p = 0.049, odds ratio 2.4), preoperative ostomy (p = 0.026, odds ratio 1.6), prolonged anesthetic time (p = 0.045, odds ratio 1.09 per 60 min), prolonged operative time (p = 0.043, odds ratio 1.1 per 60 min), and postoperative development of urinary tract infection (UTI) (p < 0.001, odds ratio 4.5). Patients with SSI had higher body mass index (p = 0.047, odds ratio 1.3 per 5 kg/m²).

Conclusion: The prevalence of deep SSI was 2.5% in this cohort, and risk factors include ASA ≥ 3, preoperative ostomy, prolonged anesthetic or operative time, and postoperative UTI. Large multicenter database studies can help identify and stratify risk factors for SSI in this high-risk patient population.

Level of evidence: 3:

Purpose: Pelvic fixation in pediatric neuromuscular patients with scoliosis is performed when significant pelvic obliquity is present. Instrumentation to the pelvis can be technically demanding and challenging, often associated with a high complication rate, prolonged operative time, increased radiation exposure, and increased intraoperative bleeding. The high complexity of the pelvic instrumentation technique, particularly in severe cases, led us to develop computed tomography (CT)-based 3D in a series of 53 consecutive neuromuscular patients. This analysis aimed to improve the understanding of pelvic asymmetry and preoperatively simulate pelvic instrumentation.

Methods: A CT-based 3D analysis of all pelvises was performed using Mimics software (version 21), segmenting them for analysis in all three planes. We proceeded with the simulation of pelvic instrumentation with iliac screws, obtaining the angle values and corresponding orientations in the three planes for each screw. A total of 53 CT scans were analyzed, corresponding to 36 patients with myelodysplasia and 17 with neuromuscular disorders.

Results: Pelvic asymmetry was observed in 88.6% (47 CT scans) of the patients. This asymmetry indicated that the weight-bearing hemipelvis underwent anatomical changes compared to the contralateral hemipelvis, including opening or closing of the pelvis relative to the sacroiliac joint, pivoting of the hemipelvis in a cephalocaudal or caudocephalic direction, and shortening of the innominate line.

Conclusion: The shape of the weight-bearing hemipelvis is closely related to pelvic asymmetry. A distinct pattern was identified, characterized by cephalic or caudal pivoting, greater prominence of the iliac crest, increased distance from the sciatic spine to the coccyx, and shortening of the innominate line. This finding is relevant for surgical planning and pelvic fixation.

Level of evidence: IV.

Purpose: While multiple studies have evaluated the role of intraoperative red blood cell salvage (IOCS) in instrumented posterior spinal fusion as a method to reduce allogenic blood transfusion and its associated risks and cost, few studies have quantified the blood available for return to the patient when using IOCS. Given this paucity of data, the purpose of this study was to evaluate the relationship between estimated blood loss and cell saver volume returned.

Methods: Patients aged 18 years or older who underwent elective spinal fusion for correction of deformity requiring six or more levels of fusion were included. Demographic data, surgical details, EBL as measured by cell saver, and cell saver blood volume returned were recorded.

Results: 138 consecutive patients were included in the study. Average EBL as measured by cell saver across 138 cases was 734 cc. Based on patients' height, weight, and sex, the average percentage of estimated circulating blood volume lost during surgery was 15.9%. Average EBL per level was 84.2 cc.; mean percentage of total blood volume lost per level was 1.8%. Average blood volume returned was 256 cc., resulting in an average 34.9% of blood loss returned to the patient via IOCS.

Conclusions: On average, 34.9% of blood lost was subsequently transfused. While literature on this topic is very limited, this finding was similar to smaller cohorts that have examined IOCS autologous transfusion volumes. A better understanding of the available fraction of blood for return may allow providers to predict the need for allogenic blood transfusion or more clearly evaluate cost effectiveness of IOCS.

Purpose: To compare the perioperative outcome differences between male and female AIS patients who underwent posterior spinal fusion (PSF) surgeries.

Methods: This was a retrospective study of 570 patients (84 male, 486 female). Patients were divided into male and female groups. A propensity score matching analysis was performed with match tolerance of 0.005. Preoperative data collected were age, height, weight, body mass index (BMI), Lenke curve classification, preoperative Cobb angle, and preoperative flexibility. Intraoperative data collected were operation duration, intraoperative blood loss, amount of salvaged blood, number of patients required transfusion, number of screws and fusion level. Postoperative data collected were postoperative hemoglobin, postoperative Cobb angle, correction rate, length of postoperative hospital stay and perioperative complications.

Results: Before matching, age, height, weight, and fusion level showed significant difference between genders (p < 0.05). After matching, there was no difference in the perioperative outcome parameters. When matched patients excluding height and weight, males had significantly longer wound, higher intraoperative blood loss and more blood salvaged from cell saver. When matched patients excluding fusion levels, males had significantly higher intraoperative blood loss. When matched patients excluding age, we found no significant differences.

Conclusion: Male AIS patients who underwent PSF surgeries were older, taller, heavier and had longer fusion levels but there was no difference in perioperative outcomes between matched male and female patients.

Background: Spinal deformity can develop in childhood and adulthood. There is often a loss of follow-up for these patients during the transition to adulthood. The aim of this study was to describe the management of those patients. Hypothesis transitional care enhances patient's adherence to long-term follow-up.

Methods: A consultation was organized between two orthopedic surgery departments, one pediatric and the other adult, to ensure a transitional follow-up. All patients followed up in the pediatric department for spinal deformity between 2019 and 2021 were included (Ped group). Patients referred to the adult department were analyzed (Ped_Ad group). Data collected included type of deformity, age at first and last consultation, overall follow-up time, and number lost to follow-up (LTFU).

Results: Overall, 383 patients were included: 11% were referred to an adult center (Ped_Ad), and 89% remained in pediatrics (Ped). Age at first and last consultation was significantly higher in the Ped_Ad group. Mean follow-up time was 4 years in both groups. In the Ped group, 18% of patients had undergone surgery, versus 61% in the Ped_Ad group. The rate of LTFU was twice higher in the Ped group (25%) than in the Ped_Ad group (12%), but the difference was not significant (p = 0.07). Among LTFU, patients aged between 14 and 16 years were the most represented (53%), and they were most often unoperated patients in the Ped group.

Conclusion: When adult follow-up was organized, adherence to follow-up was better. This would enable patients to be managed earlier, in the event of worsening of an unoperated deformity.

Level of evidence: IV.

Study design: Retrospective, chart review.

Purpose: Improvements in operative time, blood loss, and length of stay (LOS) when using a dual surgeon approach for the treatment of scoliosis have been suggested in the literature; however, the external validity of these findings has been debated. In this study, we examined the impact of transitioning from a single surgeon to a dual surgeon approach in the treatment of adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS) across non-contemporary periods at a single institution.

Methods: Through a retrospective chart review we identified 208 adolescent patients who underwent spinal fusion for the treatment of AIS or NMS between November 2015 and January 2022. The 73 cases meeting inclusion criteria were analyzed for operative time, blood loss, pre-and post-operative Cobb angles, and hospital length of stay.

Results: The dual surgeon AIS group was found to have a shorter hospital (3.6 vs. 5.2 days, p < 0.001) and ICU length of stay (0.3 vs. 3.7 days, p < 0.001), greater Cobb angle correction (35.6 vs. 23.3 degrees, p < 0.001), and lower transfusion requirement compared to the single surgeon AIS group (0.1 vs. 0.7 units, p = 0.003). Total operative time and estimated blood loss (EBL) were not significantly different. The dual surgeon NMS group only showed shorter ICU length of stay (2.9 vs. 9.1 days, p = 0.043).

Conclusions: Utilizing a dual surgeon approach for AIS patients could improve hospital and ICU length of stay, blood transfusion requirements, and Cobb angle correction without an increase in operative time.

Level of evidence: Level III, retrospective, comparative study.

Background: Pain catastrophizing has been linked to poorer patient-reported pain outcomes for orthopedic surgery, but its effect on perioperative pain and narcotic use is poorly understood. Our purpose was to determine if pain catastrophizing has a negative effect on perceptions of perioperative pain and narcotic use in patients undergoing posterior spinal fusion (PSF) for idiopathic scoliosis (IS).

Methods: A retrospective, IRB-approved review of prospectively collected data of IS patients undergoing PSF. Patients were considered PCs when they scored above the 75th percentile in the PCS (total score ≥ 30). Inpatient narcotic consumption was calculated as morphine equivalent per Kg (mEq/Kg).

Results: Five hundred seventeen patients (411F, 106M) underwent PSF for IS. Forty-five (8.7%) patients were pain catastrophizers (PCs). PC patients had significantly lower pain, appearance, and mental scores. PCs scored slightly higher on VAS pain scores (2.20 vs 1.92, p = 0.015) in the first 24 h only. There were no differences in opioid use between PC vs. non-PC cohorts for inpatient (2.01 vs 2.14 mEq/Kg, p = 0.4), discharge (5.6 vs 5.87 mEq/Kg, p = 0.3), or total narcotics (7.61 v 8.01 mEq/Kg, p = 0.2). Fifty-five patients out of five hundred seventeen requested narcotic refills with no difference in refill rates between cohorts (p = 0.7076).

Conclusion: We found that pain catastrophizers had lower pre-operative SRS-30 scores across all domains except satisfaction. We found no association between pain catastrophizing and increased opioid use in either the inpatient stay or post-discharge. While pain catastrophizing has been associated with lower pre- and post-operative pain scores, it does not appear to predispose to higher narcotic utilization perioperatively.

Level of evidence: II: retrospective comparative study.

Purpose: Pedicle screw-based constructs are the standard of surgical management in AIS. Several manufacturers have developed navigation systems utilising intraoperative 3D imaging to improve screw placement accuracy. However, concerns remain regarding intraoperative radiation exposure utilising these systems compared to traditional techniques. The aim of this study was to evaluate our experience of 3D intraoperative imaging compared to techniques utilising 2D fluoroscopy for pedicle screw placement in cases of posterior spinal fusion (PSF) for AIS.

Methods: This was a single-centre, retrospective analysis of cases undergoing PSF for AIS using 3D navigation or freehand screw insertion techniques. The two groups were matched for curve type, curve magnitude, implant density and fused levels. We compared the correction achieved, intraoperative radiation exposure, operating time and rates of intraoperative screw repositioning.

Results: A total of 52 cases were identified (26 navigated and 26 freehand). No significant differences were observed in baseline characteristics between the two groups. There were no significant differences observed in correction achieved between groups; however, mean radiation exposure in the navigated cases was approximately 11 times higher. Operative time was significantly longer in the navigated group but there was a significant reduction in requirement for intraoperative screw repositioning using navigation at 0.2% versus the freehand group at 1.5%.

Conclusions: Our early experience of intraoperative 3D imaging for navigated implant insertion for AIS has shown equivalence to freehand techniques in achieved correction, with fewer changes in intraoperative screw positioning at the expense of significantly increased overall radiation exposure and procedure duration.

Level of evidence: II.