Spine deformity最新文献

Purpose: To better elucidate the C2-related complications and treatments among ASD patients with C2-ilium fusions.

Methods: A single-center series of patients who underwent a posterior spinal instrumented fusion (PSIF) from C2-ilium were included. Patient demographics, medical history, diagnosis, operative procedures, and complications were analyzed.

Results: 37 C2-ilium patients were included with a mean follow-up of 2.8 years, age of 56 ± 19 years, 57% were female, and 38% had osteoporosis/osteopenia. Most patients had a prior fusion surgery 81% (N = 30), which commonly included upper thoracic to sacrum (N = 15) and cervical-thoracic (N = 5) fusions. The most common surgical indications included PJK/F (N = 12), chin-on-chest deformity (N = 5), and pseudarthrosis (N = 5). The surgical complication rate was 46% (17/37), the revision surgery rate was 38% (14/37), and 3 patients required multiple revision surgeries. Reoperations commonly addressed C2-related fractures (N = 6), wound complications (N = 5), and pseudarthrosis unrelated to C2 (N = 4). For those with C2 issues, surgery included either extension of fusion to Occiput (N = 2) and C1 (N = 4) or revision C2 (N = 2). Four patients with radiographic C2 issues were treated non-operatively in a hard collar after appearing stable on repeat imaging.

Conclusion: This is the largest series of C2-ilium reconstructions with a mean follow-up of 2 years. The most common surgical indication was PJK/F, followed by chin-on-chest deformity and pseudarthrosis. The surgical complication and revision rate was 46% and 38%, respectively. The most common reason for revision surgery was C2-related fractures and screw loosening, with 43% being extended to C1 or the occiput. Long constructs from C2-ilium carry a high complication rate and require frequent follow-up to assess for long-term issues.

Purpose: Longer operative time has been associated with increased postoperative complications in various surgical specialties. This has not been studied in pediatric idiopathic scoliosis surgery. The purpose of this study was to study the relationship between operative time and rates of adverse outcomes in pediatric idiopathic scoliosis surgery.

Methods: This was a retrospective cohort study using the NSQIP pediatric database years 2016-2022. Patients were included in this study if they were under 18 years of age and received posterior spinal fusion for idiopathic scoliosis. Revision surgery and anterior approaches were excluded from the study. The primary outcome was the rate of adverse events. Secondary outcomes were surgical site infection, allogeneic transfusion, and length of stay. Patient and surgical characteristics were described using descriptive statistics. Logistic regression analyses were performed to determine the association between operative time and adverse event, surgical site infection, allogeneic transfusion, and postoperative neurological deficit. Linear regression analysis was performed to determine the association between operative time and length of stay. Adverse event rate, surgical site infection rate, transfusion rate, and mean length of stay were stratified by operative time (< 3 h, 3-5 h, 5-7 h, 7-9 h, > 9 h).

Result: There were 22,888 patients included in this study. Mean age was 14.4 years. Mean operative time was 4.5 h. The rate of adverse event increased with operative time (< 3 h: 0.5%; > 9 h: 3.2%). The rate of surgical site infection increased with operative time (< 3 h: 0.2%; > 9 h: 2.3%). The rate of allogeneic transfusion increased with operative time (< 3 h: 4.9%; > 9 h: 32.9%). The rate of postoperative neurological deficit increased with operative time (< 3 h: 0.2%; > 9 h: 5.0%). The mean length of stay increased with operative time (< 3 h: 3.2; > 9 h: 6.2). In adjusted regression analyses, controlling for number of surgical levels, three-column osteotomies, and pelvic instrumentation, each operative hour was associated with higher odds of adverse event (OR 1.18, p < 0.001), higher odds of surgical site infection (OR 1.14, p = 0.012), higher odds of allogeneic transfusion (OR = 1.41, p < 0.001), higher odds of postoperative neurological deficit (OR = 1.45, p < 0.001), and longer length of stay (B = 0.26, p < 0.001).

Conclusion: Increasing operative time is associated with higher risk of adverse event, surgical site infection, transfusion, and longer length of stay. Surgical strategies that reduce operative time should be utilized to optimize outcomes.

Introduction: Prior to surgical intervention for adolescent idiopathic scoliosis (AIS), patients with mild-to-moderate deformity and skeletal growth remaining can be treated conservatively after referral to specialists. Healthcare access may influence screening opportunities and time-to-referral and, therefore, the potential for conservative treatment. This study aimed to assess whether specific social determinants of health (SDOH) and access to care predispose patients to late presentation.

Methods: AIS patients over a 2-year period at a single institution were retrospectively reviewed, assessing the association between SDOH (race/ethnicity, ADI, COI, insurance, distance to institution, and PCP affiliation) and the odds of presenting with surgical indications (> 50°). Secondary aims assessed associations between SDOH and initial treatment type and referral-to-appointment time. Generalized linear models were used with the odds ratio (OR) or geometric mean ratio (GMR) reported.

Results: 279 patients with mean age 13.5 years and 72% female were included. No SDOH were associated with increased odds of a > 50° curve at presentation. However, patients with an institution-affiliated well-child visit had higher odds of observation vs. surgery compared to patients with a non-affiliated visit (OR 2.28, 95% CI 1.06-4.90, P = 0.035). A 10-mile increase in distance from our institution was associated with a 2.9% increase in time from referral to appointment (GMR per 10 miles 1.03, 95% CI 1.01-1.05, P = 0.009).

Discussion: Several factors related to healthcare access influenced initial treatment and referral delays, such as referrals from non-affiliated PCPs and patients from further away had delayed presentation. These findings emphasize potential barriers to healthcare access, including poor screening and delayed referrals, both which may cause patients to initially present with more severe scoliosis.

Purpose: Non-depolarizing neuromuscular blocking agents (nNMBAs) have been subjectively reported to make spinal exposure more efficient. However, there is concern that neuromonitoring may be compromised, even with reversal, and may mask neuromonitoring alerts or result in an increased risk of postoperative neurological complications. We sought to describe the safety of using nNMBAs to facilitate exposure in pediatric posterior spine fusion surgery (PSF).

Methods: All consecutive adolescent idiopathic scoliosis (AIS) patients who underwent PSF at a single institution between 2014 and 2022 were included. Baseline patient comorbidities, utilization of nNMBAs and reversal agents, neuromonitoring changes, surgical details, postoperative neurological deficits, and surgical complications were recorded. Patients were grouped based on nNMBA utilization (-nNMBA or +nNMBA) and their outcomes were compared using univariable and multivariable techniques. Significance was set at α = 0.05.

Results: Three hundred twenty-seven patients met all selection criteria and were included. Of these, 49 (15%) did not receive any nNMBA (-nNMBA) and 278 (85%) did receive a nNMBA (+nNMBA). Baseline patient characteristics were not different between the two groups. There were no significant differences in the rate of intraoperative neuromonitoring changes (6.1% -nNMBA versus 8.6% +nNMBA, p = 0.78), postoperative neurological deficits (6.1% -nNMBA versus 5.8% +nNMBA, p = 0.25), or postoperative complications (22.4%, -nNMBA; 21.6%, +nNMBA; p = 0.85). Modified Clavien-Dindo-Sink complication grades were not different between groups (p = 0.81).

Conclusion: The study found no difference in the rate or severity of complications, rate of neuromonitoring alerts, or rate postoperative neurological changes between -nNMBA and +nNMBA groups.

Level of evidence: Level III, therapeutic.

Purpose: This study aimed to investigate differences in muscle synergies during gait between individuals with adult spinal deformity (ASD) and healthy controls and to assess whether fear of falling influences this. Muscle synergies represent modular neural strategies by which the central nervous system simplifies motor control through combinations of basic muscle activation patterns. A reduction in synergies may indicate decreased neuromuscular adaptability and has been linked with impaired gait.

Methods: 59 individuals with ASD and 17 age- and sex-matched controls were recruited. Surface electromyography of four bilateral trunk and three bilateral lower-limb muscles was recorded. Muscle synergies were extracted via non-negative matrix factorization at a threshold of 95% variance accounted for. Fear of falling was evaluated using the Falls Efficacy Scale-International. Participants were stratified into deformity subgroups using radiographic criteria (decompensated sagittal, compensated sagittal, and coronal malalignment). Ordinal logistic regression assessed the fear of falling, BMI, pain, and subgroups in relation to synergy count.

Results: ASD participants exhibited fewer synergies (χ² = 14.08, p < 0.001) compared to controls. Regression analysis revealed that BMI and deformity subgroups were significantly associated with synergy count, while fear of falling was not, potentially due to its correlation with BMI. Participants with decompensated sagittal alignment had significantly fewer synergies than both those with coronal malalignment and healthy controls. ASD participants had higher FES-I scores than controls (p < 0.001).

Conclusions: Individuals with ASD demonstrate a simplified neuromuscular control during gait. The deformity subgroups and BMI were associated with synergy count. The elevated fear of falling underscores the need for targeted fall-related interventions in this population.

Introduction: Pediatric spine surgery has traditionally been a subspecialty within pediatric orthopedics. This study aimed to analyze changes over time in the proportion of pediatric spinal deformity cases performed by orthopedic surgery and neurosurgery, and to identify trends in the practice patterns and peri-operative variables of these specialties.

Methods: This was a retrospective cohort study using the National Surgical Quality Improvement Program Pediatric database (NSQIP) years 2016-2022. Inclusion criteria are patients < 18 years of age undergoing posterior spinal instrumented fusion for spinal deformity. Outcomes included: specialty of surgeon (orthopedic surgery, pediatric orthopedic surgery, neurosurgery, pediatric neurosurgery), patient age (< 10 years vs. 10-18 years), perioperative allogeneic transfusion, 30-day reoperation, deep surgical site infection, operative time, and length of stay. Descriptive statistics, Chi-square test, and Students' t test were used for analysis.

Results: There were 37,443 patients meeting inclusion criteria. Orthopedic surgery, pediatric orthopedic surgery, neurosurgery, and pediatric neurosurgery performed 8.0%, 90.4%, 0.2%, and 1.3% of the cases, respectively. From 2016 to 2022, there was an increase in the proportion of cases performed by pediatric neurosurgery from 0.7 to 1.2% and a decrease in the proportion of cases performed by pediatric orthopedic surgery from 93.2 to 87.6%. Pediatric neurosurgery performed the highest proportion of cases in patients < 10 years of age (10.8%, p < 0.001). Pediatric orthopedic surgery performed the lowest proportion of cases in patients that have had previous spinal deformity surgery (4.4%, p  < 0.001). Orthopedic surgery had the highest proportion of idiopathic cases (72.7%), whereas pediatric neurosurgery had the lowest (47.0%). For idiopathic scoliosis, neurosurgery and pediatric neurosurgery had higher rates of allogeneic transfusion (p  < 0.001) and longer lengths of stay (p  < 0.001). There were no differences in rates of 30-day reoperation or deep surgical site infection.

Conclusion: In the NSQIP database, the great majority of posterior spine fusions with instrumentation continue to be performed by pediatric orthopedic surgeons. Differences exist among these specialties in terms of patient demographics and perioperative surgical variables.

Purpose: Early onset scoliosis comprises spinal deformities in children younger than 10, creating challenges in diagnosis, risk assessment, and management. Timely intervention is vital, because untreated deformity can lead to cardiopulmonary compromise. Artificial intelligence and machine learning are reshaping orthopaedic care by improving detection, forecasting progression, and guiding treatment. This scoping review maps current use in this patient population.

Methods: Following PRISMA ScR standards, we systematically searched PubMed, Embase, Web of Science, Cochrane, and Scopus for studies that developed, applied, or validated AI models to diagnose, manage, or predict outcomes in EOS.

Results: After removing duplicates, 352 records were screened, 22 full texts were reviewed, and 11 studies met inclusion criteria. Most investigations (63.6%) employed convolutional neural networks (CNNs) such as Mask R CNN, EfficientNet, and U Net. Ensemble learning with gradient boosting, random forest, and logistic regression (9.1%), Gaussian Naïve Bayes (9.1%), sparse additive machines (9.1%), and unsupervised clustering (9.1%) were also used. Image analysis dominated (72.7%), automating radiographic measurements (Cobb angle, skeletal maturity) and monitoring growing-rod distraction. Predictive models (27.3%) estimated prolonged hospital stay, unplanned reoperation, or postoperative complications. Mean accuracy was 91.2% (range 86.1% to 94.0%). Common limitations were small sample sizes, single-centre data, and limited external validation.

Conclusion: AI shows promise for EOS imaging and risk prediction, yet translation is hindered by methodological heterogeneity and scarce external validation. Future work should adopt standardised reporting, aggregate multicentre datasets, and test models prospectively in large cohorts.

Purpose: Despite evidence for the safety and efficacy of zoledronate infusions in pediatric conditions (e.g., osteogenesis imperfecta), its tolerance, safety, and efficacy in medically complex children with neuromuscular scoliosis have not been established. The aim of this study was to determine adverse events associated with pre-operative zoledronate therapy in this patient population.

Methods: A retrospective review was conducted of patients who had undergone pre-operative zoledronate infusions as part of pre-operative optimization at a single tertiary pediatric referral center. The protocol included three infusions with an initial 0.0125 mg/kg dose, a 0.0375 mg/kg dose at 6 weeks, and a 0.05-mg/kg dose at 6 months. Surgery was scheduled no sooner than 6 weeks after infusion.

Results: 47 patients received at least one pre-operative zoledronate infusion, with 66% receiving three infusions of zoledronate. The most common neuromuscular conditions were cerebral palsy (57%), epileptic encephalopathy (12.8%) and Rett syndrome (10.6%). Six minor adverse events were noted, including 2 episodes of post-infusion hypocalcemia, 2 of self-limited flu-like symptoms, 1 of nephrolithiasis, and 1 of unspecified hypotension which resolved after oral fluids. There were no events requiring hospital admission or emergency department presentation related to zoledronate infusions.

Conclusion: No major events were noted after pre-operative zoledronate infusions. The minor adverse events noted were self-resolving or resolved with minimal intervention. Zoledronate infusion can safely be included as part of a pre-operative optimization pathway in medically complex patients with neuromuscular scoliosis. Further research is required to optimize patient selection, infusion dose and schedule, impact on screw pull-out, and long-term complications.

Level of evidence: Level IV.

Purpose: To compare surgical site infection (SSI), reoperation, and readmission proportions following posterior spinal fusion (PSF) with pelvic instrumentation for pediatric nonidiopathic scoliosis between plastic multilayered closure (PMC) and standard orthopaedic closure (SOC).

Methods: This study retrospectively reviewed patients ≤18 years with nonidiopathic scoliosis undergoing primary PSF with pelvic instrumentation at two institutions from 2018-2023. Exclusions were prior spinal fusion, staged procedures, and scoliosis associated with spina bifida, neoplasia, or congenital spondyloptosis. Outcome measures included SSI per CDC criteria, 90-day reoperation, and 30-day readmission. Patient risk was estimated with the NSQIP Pediatric Surgical Risk Calculator. Firth-penalized logistic regression modeled the association between closure technique and SSI.

Results: Of 195 patients, 121 underwent SOC and 74 PMC. BMI was similar (p = 0.14), but SOC patients had higher mean surgical risk scores for any complication (p = 0.02) and SSI (p = 0.01). PMC had longer procedures, hospital stays, and greater drain use (all p < 0.001). SSI was lower with PMC (3% vs. 12%; absolute difference 9%, p = 0.03), whereas reoperation (5% vs. 13%, p = 0.08) and readmission (7% vs. 15%, p = 0.09) did not differ significantly. In multivariable analysis, PMC was associated with lower SSI odds (OR 0.12, 95% CI: 0.02-0.64, p = 0.01), and higher surgical risk scores were associated with increased SSI odds (OR 1.18, 95% CI: 1.04-1.33, p = 0.01).

Conclusion: PMC was associated with an absolute 9% lower SSI proportion. This association remained significant after adjustment for patient- and procedure-specific factors. Reoperation and readmission proportions were similar, but PMC involved longer surgical time, hospital stay, and greater drain use. Given these trade-offs, PMC may be most appropriate for high-risk patients or those with limited soft-tissue coverage. Prospective studies should refine patient selection and assess its broader impact.

Level of evidence: Level III-Therapeutic.

Introduction: Few studies directly compare the efficacy of magnetic-controlled and traditional growing rods for early onset scoliosis (EOS) treatment from pre-implantation to definitive fusion or final lengthening. We hypothesize that TGR is more efficient than MCGR in achieving more spine length and curve correction but at the cost of more complications. We also hypothesize that patient-reported outcomes and pulmonary function are minimally changed after completion of treatment.

Methods: All patients treated at one institution between 2010 and 2022 who graduated from growth-sparing treatment and had undergone definitive fusion or were being observed with retained implants were evaluated. T1-T12 and T1-S1 lengths and curve magnitude were recorded at 3 time points on coronal films: pre-op, prior to definitive fusion or after final lengthening, and post-definitive fusion or last observation. EOSQ-24 scores, PFTs, and complications were collected.

Results: Fifty-one patients (27 MCGR, 24 TGR) had complete graduation radiographs. Age of insertion was no different (MCGR- age 7 vs. TGR-6.5, p = 0.14) or at removal (MCGR-11.7 vs TGR-11.3, p = 0.48). MCGR patients had smaller initial curves (81 vs 89° p = .02), which remained smaller (32° vs TGR 50°, p < .001) after definitive fusion. T1-12 length was initially shorter for TGR (14.8 vs 16.3 cm, p = .05) but no different at pre-definitive due to more effective TGR length gain (TGR > MCGR 5.8 vs 3.6 cm p = .006). Similarly, TGR gained more T1-S1 length than MCGR (8.9 vs 6.1 cm, p = .01). Overall TGR patients gained greater length but at the cost of more complications per patient than MCGR (2.4 vs 1.5 p = 0.0035) and more UPRORs (p = .04). TGR patients gained greater absolute and % predicted PFT volumes compared to preoperative values which did not occur in the MCGR cohort. EOSQ-24 scores for MCGR improved in several domains.

Conclusion: Deformity correction was primarily achieved at initial implantation surgery for both techniques, though MCGR patients achieved even smaller curves after definitive fusion compared to TGR. TGR lengthened more effectively than MCGR but with more complications and UPRORs. PFTs were improved for TGR patients but not for MCGR, while EOSQ scores in the MCGR cohort were modestly improved.