Spine deformity最新文献

Purpose: Despite the introduction of "standardized counting" methods, errors in counting spinal levels and subsequent wrong-level surgery (WLS) remain critically important patient safety concerns. Previous work by our group has documented inconsistency in the identification of T12 despite the use of these systems including the Spinal Deformity Study Group (SDSG) conventions. To assist with consistent and repeatable identification of proposed preoperative surgical levels, the current study investigates a new strategy: utilization of a "landmark vertebra". It was hypothesized that individuals using a "landmark vertebra" strategy will achieve high concordance with target level identification between distinct time points as compared to conventional methods defining T12.

Methods: Survey participants analyzed 99 pre-op radiographs, identifying and naming a "landmark vertebra" with concise descriptions like "last bilaterally ribbed vertebra." They then noted the proposed lowest instrumented vertebra's (LIV) distance relative to landmark (i.e., one below landmark). After a waiting period, participants used their written descriptions of the landmark and distance to LIV to reidentify these vertebrae. Cohen's Kappa (k) was used to measure intra-rater agreeability. The landmark strategy was compared to our previous work evaluating consistency in defining T12 based on the SDSG system.

Results: All raters showed perfect to near-perfect agreement when re-identifying the landmark and target vertebrae (k = 0.819-1.00; Table 1A). Raters at all training levels had higher agreeability in naming the landmark vertebra and target when compared to raters at similar training levels defining T12 (k = 0.34-0.91; Table 1B). This high agreement across training demonstrates the strategy's versatility and generalizability.

Conclusion: Utilization of a landmark strategy proved to be highly effective in reducing intra-rater variability, with perfect to near-perfect agreement among all raters and consistently higher agreeability when compared to defining T12.

Level of evidence: Level II-prospective survey.

Purpose: To determine, at 2 year follow-up, 3D spine growth for idiopathic early onset scoliosis (iEOS) patients treated with magnetically controlled growing rods (MCGR).

Methods: From an international EOS registry, patients with iEOS treated with MCGR were identified. Scoliosis, kyphosis, traditional coronal height, and 3D true spine length (3D-TSL) were measured pre-index surgery, post-index, and at 2 year follow-up.

Results: 135 participants, mean age 8.1 years (2.7-15.6) were included. Scoliosis improved from 71° pre-index to 41° post-index (p < 0.001) and remained constant at 2 years (43°, p = 0.58). Kyphosis improved from 49° to 36° (p < 0.001); then increased by 2 years to 42° (p = 0.002). Traditional T1-S1 height, which reflects both spine growth and changes in deformity, increased from pre-index to post-index (274 mm vs. 310 mm; p < 0.001), and again at 2 years (332 mm, p < 0.001). As 3D-TSL reflects growth of the spine, independent of changes in deformity, as expected it did not change perioperatively (335 mm vs. 339 mm, p = 0.83), but significantly changed by 2 years (367 mm; p < 0.001). Participants < 5 years at surgery increased 22 mm (8.2%), 5-10 years increased 26 mm (7.8%), and > 10 increased 41 mm (11.0%). For instrumented levels, mean vertebral growth was 1.3 mm/level for < 5 years, 1.4 mm/level for 5-10 years, and 2.2 mm/level for > 10 years.

Conclusions: As kyphosis increased over time, these out of the coronal plane changes justify the use of 3D-TSL for this cohort of patients. For idiopathic EOS patients treated with MCGR, 3D spine length increased by 28 mm during the 2 year post-operative period.

Purpose: Previous reports have identified factors associated with open chest surgery for congenital heart disease (CHD) and scoliosis. However, these reports included conditions such as Down syndrome and Marfan syndrome, which involve both cardiac disease and scoliosis. The relationships between these factors and open chest surgery remain unclear. This study aimed to identify factors contributing to severe scoliosis in CHD patients who have undergone open chest surgery.

Methods: Seventy-four post-CHD surgery patients with severe scoliosis (Scoliosis group) and 30 post-CHD surgery patients without scoliosis (NS group), excluding those with any syndrome or intellectual disability, were retrospectively analyzed. Patient background characteristics and radiographic parameters were compared between the NS and Scoliosis groups. Furthermore, the patients in the Scoliosis group were classified into three categories, namely, mild scoliosis, moderate scoliosis, and severe scoliosis, and the results were compared among the four groups.

Results: Eighteen patients in the NS group and 63 in the Scoliosis group met the inclusion criteria. Compared with the NS group, the Scoliosis group included significantly more girls and patients who had younger ages at first CHD surgery and multiple open chest surgeries. Severe scoliosis progression was observed in patients who underwent multiple surgeries for severe CHD with cardiomegaly.

Conclusions: Progression to severe scoliosis was noted in patients with younger ages at first CHD surgery and those who underwent multiple surgeries for severe CHD. Assessing spinal deformities should be a key aspect of postoperative care for CHD, particularly in patients with severe CHD who are undergoing multiple chest surgeries.

Level of evidence: III.

Purpose: Investigate zones where implant density should not be reduced in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) Lenke type 1A curves.

Methods: 126 consecutive patients (118 female and 8 male; mean age: 15.1 ± 2.2 years) with Lenke type 1A AIS who underwent PSF using pedicle screw constructs were included. Correction loss which was calculated using immediately postoperative and 2-year postoperative Cobb angle. Implant density was assessed by dividing the instrumented levels into four zones each on the concave and convex sides. The risk factors for significant correction loss were examined using logistic regression analysis. For convex apical zone, correction loss was compared among the three groups of low (0-59%), medium (60-99%), and high (100%) implant density.

Results: Multivariate analysis revealed the apical zone of the convex side (Odds ratio [OR] 1.27; 95% confidence interval [CI] 1.01-1.59; P = 0.04) and the peri-apical zone of the convex side (OR 1.33; 95% CI 1.11-1.59; P = 0.002) as independent predictors of significant correction loss. In the convex apical zone, the median (interquartile range) correction loss of the low implant density, medium implant density, and high implant-density groups was 4.8° (1.5°), 5.3° (0.8°), and 2.2° (0.3°), respectively. The median difference was 2.6° (P = 0.048) between the low implant density and high implant-density group and 3.1° (P < 0.001) between the medium implant density and high implant-density group.

Conclusion: In PSF for AIS Lenke 1A, low implant density in the convex apical zones were significant factors affecting correction loss at 2 years postoperatively. However, the difference in correction loss between groups may not be large enough to consider clinically meaningful. Prospective studies of longer term outcomes are needed to determine whether these results are clinically important.

Study design: Retrospective analysis.

Objective: This study sought to report the long-term outcomes of patients that underwent minimally invasive surgery (MIS) correction for Adolescent Idiopathic Scoliosis (AIS) in terms of radiographic, clinical, and patient-reported outcomes. Furthermore, we examined the learning curve of MIS technique over the course of 13 years. Both MIS and open techniques are used to surgically address AIS. MIS techniques are purported to preserve the midline spinal musculature and to decrease estimated blood loss (EBL) and hospital length of stay (LOS).

Methods: Data were collected at a single tertiary care center of all consecutive AIS patients undergoing deformity surgery from January 2008 to October 2021. Demographic, clinical, and radiographic data were collected at various intervals. Descriptive and inferential analyses were conducted.

Results: 70 AIS patients were included in the study. Mean patient age was 16.2 years of which 95.7% were female, with a mean BMI of 21.7. The majority of the patients were Lenke type 1A (60%) followed by Lenke 1B (18.6%) with mean preop Cobb angle as 52.2°. The mean follow-up was approximately 6 years with 35.7% of our cohort meeting the long-term follow-up landmark (> 5 years, 2-11). The mean number of spinal levels treated was 9.3 with mean ASA score of 1.7. Overall, mean EBL was 151 cc with mean OR of 308 min. The mean LOS was 3.94 days with postop Day 1 as the initiation of ambulation. Overall, the percent correction at the last visit was significantly greater than preop (Cobb: 77.6%, p < 0.05). Mean loss of correction on follow-ups was less than 5º. The overall revision rate was 2.9%. At 2 years postop, 98.6% (69/70) of the patients achieved fusion with 100% (24/24) at 5 years, and 96% (24/25) beyond the 5-year mark. Surgeon's technical proficiency in performing MIS for the treatment of AIS corrections was achieved after 23 cases.

Conclusions: Based on our cohort's 2-11 year follow-up data, we conclude that MIS provides an effective treatment option for AIS reconstruction. Our study indicates that MIS can achieve adequate deformity correction and positive long-term clinical outcomes as indicated by Cobb angle, VAS, ODI, and SRS-22r scores during follow-ups. If the individual goals of AIS surgery can be achieved, consideration should be given to less-invasive techniques.

Level of evidence: IV.

Purpose: Proximal junctional kyphosis is an infrequent complication in AIS; however, equipoise remains on the effects of ending a fusion proximally at the C7-T1 junction on the future development of PJK. The purpose of this study was to determine the rate of PJK in patients with AIS who had a UIV of T1 vs those with a UIV of T2 at 5 years of follow-up.

Methods: A query was performed of a prospective, multi-center AIS database of patients who received a PSF with at least 5 years of follow-up. Patients with a T1 UIV (n = 29) were compared to those with a T2 UIV (n = 58). PJK was defined as a proximal junctional angle (PJA) > 10 degrees.

Results: There was no difference between the T1 and T2 UIV cohorts in preoperative T2-T12 kyphosis or pelvic incidence; however preoperatively, T1 UIV patients had a significantly decreased PJA at - 3° ± 4.5° as compared to T2 UIV patients 1.6° ± 6.5° (p = 0.0014). No patients with a T1 UIV experienced PJK at 5-years of follow-up, while 16% of patients with a T2 UIV experienced PJK (p = 0.025). No patients in the T2 UIV cohort required revision surgeries for their PJK. There was no difference found in total SRS22 scores, however at 5 years of follow-up, T2 UIV patients had better Pain domain scores (4.4 ± 0.6) vs T1 UIV patients (4.0 ± 0.6; p = 0.004).

Conclusion: While T1 is an uncommon UIV in AIS, at 5 years of follow-up, a T1 UIV did not result in PJK, nor did it result in a clinically significant change in patient-reported outcome scores.

Purpose: This study evaluates the relationship between existing radiographic measurements of shoulder asymmetry with novel surface topographic (ST) measurements, hypothesizing that these relationships will be weak.

Methods: Data were gathered from a prospectively collected registry of patients who underwent ST scanning at a single tertiary care institution. Inclusion criteria were diagnosis of juvenile or adolescent idiopathic scoliosis, age 11-21, same-day ST and EOS radiographic evaluation. Twelve radiographic variables that evaluate shoulder height were measured, as well as curve magnitudes and vertebral axial rotation. ST data were collected using the 3dMDbody scanning system. Three ST measurements of shoulder symmetry were evaluated: ST-based AC angle (the angle between a line made between the surface of the AC joints and a line parallel to the ground), Shoulder Normal Asymmetry angle (the angle between the mirrored normals to the planes defined by the jugular notch, vertebral prominence, and AC joint), and Shoulder Volume Asymmetry Index (difference in volumes between the right and left shoulder). Univariate, followed by a stepwise multivariate linear regression was performed to evaluate the correlations of the radiographic measurements to the ST-based measurements. Correlation categories: weak (x < 0.4), moderate (0.4 ≤ x < 0.6), strong (0.6 ≤ x < 0.8), and very strong (x ≥ 0.8).

Results: 141 patients with idiopathic scoliosis were evaluated (65.2% female, mean age 15.1 years, mean BMI 20.5 kg/m², with mean maximum curve 44.7 degrees). ST-based AC angle had moderate-to-strong correlations with several radiographic measurements, while ST-based Shoulder Normal Asymmetry angle and Shoulder Volume Asymmetry Index had weak or no correlation with individual radiographic measures. Multivariate models created using a combination of radiographic variables demonstrated a strongly positive correlation between radiographic variables and ST-based AC angle (R = 0.678) and moderately positive correlations with ST-based Shoulder Normal Asymmetry Angle (R = 0.488), and ST-based Shoulder Volume Asymmetry Index (R = 0.514).

Conclusion: Radiographic measurements may be acceptable stand-ins for two-dimensional ST measurements such as AC angle, but not for more complex shoulder measurements based on three dimensions. This study demonstrates the inadequacy with which radiographic assessments evaluate shoulder height asymmetry and highlights the use of ST measurements.

Purpose: Anterior vertebral body tethering (VBT) is a non-fusion surgical option for skeletally immature patients with idiopathic scoliosis. Prior studies demonstrated compensatory correction of the thoracic curve after lumbar posterior spinal fusion (PSF); however, no studies have examined thoracic curve correction after lumbar VBT.

Methods: Patients with Lenke 5 + 6 lumbar scoliosis who underwent VBT and at least 2 years' follow-up were compared to matched lumbar PSF patients. Groups were compared for major lumbar (L) and compensatory thoracic (T) curve correction, coronal/sagittal balance, and complications.

Results: 24 AVBT and 24 PSF patients were matched 1:1 for skeletal maturity and curve flexibility. There were no significant differences between VBT and PSF for average pre-operative or 2 year post-operative major L or compensatory T curves. Average final L curve correction was 50% VBT and 60% PSF (p = 0.08); average T curve correction was 17% VBT and 20% PSF (p = 0.18). Compared to pre-operative flexibility radiographs, the final post-op thoracic curves were 6° (VBT) and 5° (PSF) larger. PSF had better coronal balance by average of 17 mm (p < 0.0001). There were seven (24%) reoperations in the VBT group: two overcorrections relaxed, two T adding-on (extended to T by PSF-1, VBT-1), one broken tether converted to PSF. There was one (4%) reoperation in the PSF group (10-year post-op extension).

Conclusion: Compensatory thoracic correction was achieved to a similar degree for lumbar VBT and PSF patients. There was little change in thoracic curve magnitude over time, and, on average, the correction did not reach the pre-operative flexibility curve measurement. There was better coronal balance by PSF, and a higher rate of re-operation in VBT patients.

Level of evidence: III.

Purpose: This study aimed to investigate the relationship of preoperative hemoglobin levels as an independent prognostic factor for hospital and intensive care unit (ICU) length of stay (LOS) in patients undergoing surgery for adult spinal deformity (ASD), with the intent of determining whether there exists a correlation and enhancing patient preoperative optimization protocols.

Methods: The authors reviewed consecutive patients who underwent elective thoracolumbosacral posterior spinal fusion (PSF) involving six or more vertebrae for ASD from January 1, 2013, to December 13, 2021, with a minimum follow-up period of two years. This study primarily investigated the association of preoperative hemoglobin levels with hospital and ICU LOS. To analyze the data, both unadjusted and adjusted generalized linear models (GLM), incorporating cubic splines for non-linear variables, were applied.

Results: A total of 598 patients were included. GLMs for hospital and ICU LOS demonstrated nonlinear relationships with preoperative hemoglobin levels. Specifically, hospital LOS decreased with increasing preoperative hemoglobin until a significance threshold of 13.5 g/dl. Similarly, ICU LOS significantly decreased with increasing preoperative hemoglobin until 13.0 g/dl. Lower preoperative hemoglobin was associated with more perioperative transfusions, less likely discharge to home, and greater risk of reoperation.

Conclusions: Preoperative anemia is an independent non-linear risk factor that significantly affects LOS, disposition, and outcomes after surgery for ASD. These findings advocate for a systemic preoperative approach and highlight the need for future research to improve postoperative outcomes and reduce hospital resource utilization.

Level of evidence: IV.

Study design: Review article.

Objective: To review the literature on the effect of specialized pediatric spine teams on clinical outcomes.

Results: Thirty-eight studies were identified in the review. There were 11 studies discussing the efficacy of the dual-surgeon strategy, 5 studies discussing the benefits of adult dedicated spine teams, 3 studies discussing the benefits of dedicated pediatric spine teams, 8 studies discussing the healthcare professional composition of multidisciplinary spine teams, and 20 studies discussing various clinical markers evaluating the efficacy of new team- or protocol-based interventions.

Conclusion: Pediatric spinal deformity surgery is a highly invasive procedure with room for intervention to minimize surgical complications and enhance patient outcomes. The use of standardized spine teams, comprising surgeons and various healthcare professionals from diverse disciplines, has proven to be an effective strategy for improving both quality and efficiency of care. Furthermore, implementing uniform protocols among these teams has led to reductions in surgical duration, hospitalization periods, and risks such as infections at the surgical site and excessive bleeding. Further studies are necessary to evaluate additional benefits that specialized pediatric spine teams can offer in terms of clinical outcomes.