Spine deformity最新文献

Enhanced Recovery After Surgery (ERAS) protocols represent a multidisciplinary, evidence-based approach to optimize perioperative care and expedite recovery for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS). Historically, postoperative care for AIS emphasized prolonged immobility and variable practices driven largely by surgeon preference. In recent years, ERAS pathways have been developed to standardize care through preoperative education and optimization, multimodal intraoperative analgesia and blood conservation, and early postoperative mobilization with expedited transition to oral pain regimens. This review identified 24 studies describing ERAS implementation for AIS. Across the included studies, ERAS protocols consistently reduced hospital length of stay by 25-55% (mean reduction of 1.44 days), facilitated earlier mobilization, and decreased opioid consumption without compromising pain control, complication rates, or readmissions. While some studies demonstrated cost savings, others showed increased costs, with intraoperative surgeon-dependent factors such as implant density and bone graft utilization emerging as dominant cost drivers. Quality improvement strategies, including Lean process mapping and plan-do-study-act (PDSA) cycles, were commonly used to support implementation, and studies demonstrated persistent, sustainable benefits over multiple years with moderate-to-good adherence. ERAS pathways have become an integral strategy for improving perioperative care in AIS surgery, offering reliable reductions in length of stay, opioid use, and time to mobilization, though further work is needed to standardize protocols and clarify their impact on healthcare costs.

Introduction: Unplanned hospital readmissions remain one of the largest causes for increased episode of care and adverse events. These readmissions are especially significant in posterior spinal fusion (PSF) for idiopathic adolescent scoliosis (AIS). Therefore, this study aimed to 1) determine the overall 90-day PSF readmission rate; 2) report the timing of readmission post-discharge; and 3) identify the most frequent causes of 90-day readmissions (i.e., medical- or orthopedic-related).

Methods: A cohort of 657 consecutive patients undergoing PSF for AIS between January 1, 2010 and February 28, 2021 were selected. Readmissions were examined manually for determination of primary cause and verification. Two-tailed t tests and chi-squared/Fisher tests were utilized with logistic regressions for individual variables.

Results: The 90-day readmission rate was 6.24% or 41 patients with most of the readmissions being in the first 6 weeks with 3.5% medical and 2.74% orthopedic readmissions. Wound infections (44%), normal physiological events (27%), and postoperative pain (17%) were the three top orthopedic readmission causes while gastrointestinal (45%), pulmonary (13%), and neurologic (13%) causes were the top three medical reasons. There was no difference between the rates of ICU admission (p = 0.573) or length of readmission stay (p = 0.201). However, orthopedic readmissions were significantly more likely to be treated operatively (p < 0.001) and more likely to receive transfusions (p = 0.030). Regression analysis found that decreased length of stay (p = 0.031) and less levels fused (p = 0.039) were associated with decreased risks for readmission while age (p = 0.126), BMI (p = 0.312), race (p = 0.13), preoperative Cobb's Angle (p = 0.197), OR Time (p = 0.156), autograft use (p = 0.092, and sex (p = 0.271) had no effect.

Conclusion: Most readmissions after PSF for scoliosis occur in the first 6 weeks postoperative with wound infections and gastrointestinal issues being the leading factors for orthopedic and medical readmission respectively. Length of stay and number of levels fused were associated with risks for unplanned hospital readmissions within 90 days.

Purpose: To demonstrate the utility of routine preoperative magnetic resonance imaging (MRI) in detecting neural axis abnormalities in presumed adolescent idiopathic scoliosis (AIS) patients.

Methods: A retrospective analysis of pediatric patients who underwent posterior spinal instrumentation and fusion (PSIF) for presumed AIS at a single institution over 14 years. Patients with syndromic, congenital, or neuromuscular scoliosis were excluded. MRI findings, history and exam findings, and neurosurgery consultation/intervention were documented.

Results: Among 233 patients with presumed AIS who underwent routine preoperative MRI, 24 (10.3%) had positive findings, including Arnold-Chiari malformations, syringomyelia, and tethered cords. Five patients (2.1%) required neurosurgical intervention before PSIF; only one exhibited an atypical curve pattern before MRI. The remaining cases did not alter surgical plans but required consultation with neurosurgery.

Conclusion: Routine MRI in presumed AIS patients identified neural axis abnormalities in a subset of patients who otherwise lacked neurological indicators. These findings support the consideration of preoperative MRI in AIS management to optimize surgical planning and patient safety.

Purpose: Surgical correction of adolescent idiopathic scoliosis (AIS) involves correction of coronal plane deformity to establish coronal and sagittal balance. Posterior column osteotomies (PCOs) are frequently employed but have been associated with complications. We hypothesize that utilization of a novel geometry rod construct will achieve comparable coronal and sagittal correction in AIS surgery regardless of whether PCOs are performed.

Methods: A single-arm, prospective, multi-center study was completed to evaluate the primary curve and thoracic kyphosis (TK) correction in Lenke 1 and 2 AIS subjects as a function of rod stiffness. Baseline, initial postoperative, and 2-year postoperative radiographs were used. Results from pooled literature were used for comparison.

Results: Fifty-five patients were included; 22 had PCOs (PCO group) and 33 did not (NPCO group). There were no differences between cohorts in terms of baseline demographics or radiographic features. Between the NPCO and PCO cohorts, no differences were seen in preoperative primary Cobb (58.0 vs 61.6, p = 0.1427), Flexibility (%) (41.4 vs 36.8, p = 0.2453), ultimate post-op primary curve size (17.0 vs 17.1, p = 0.9501) or degree of correction (pre-post, %) (70.6 vs 72.2, p = 0.4806). Those with PCOs had increased blood loss (NPCO: %EBV: 13.5, 543.0 cc, PCO: %EBV: 17.8, 717.6 cc, p = 0.0260), transfusion volume (NPCO: 171.7 mL, PCO: 429.9 mL, p = 0.0009), and surgical time (NPCO: 266.2 min, PCO: 297.1 min, p = 0.0434). Compared to previously published literature (LIT), our cohort had slightly higher average preoperative TK (Study = 21.5°, LIT: 19.8°, z = 0.1041) and postoperative TK (Study All = 23.4°, LIT = 21.7°, z = 0.0399 and Study PCO 24.7°, z = 0.0237).

Conclusions: In our cohort, curves treated using a novel rod with increased rigidity, comparable corrections were achieved regardless of whether PCO was performed. We noted a higher intraoperative EBL and longer operative times when PCOs were utilized.

Level of evidence: II.

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.

Background: Accurate assessment of spinopelvic alignment is essential for managing adult spinal deformities. This study validates the Brainlab Elements Spine Planning software for automated measurement of spinopelvic parameters, comparing it with manual methods.

Methods: Spinopelvic parameters were measured manually and with the software in 21 patients with degenerative spinal disease, including instrumented and non-instrumented spines. Accuracy, intraobserver, and interobserver reliability were evaluated using Bland-Altman plots and intraclass correlation coefficients (ICCs). Measurement times were also compared.

Results: The software showed high reliability (ICC = 1), while manual measurements ranged from fair to excellent reliability (ICC 0.44-0.99). Bland-Altman plots indicated strong agreement between automated and manual measurements, though variability was noted for certain parameters. Automated measurements were significantly faster, averaging 62 s versus 227 s in manual measurements (p < 0.001), though 76.2% of cases had at least one parameter that could not be measured automatically, most frequently the sagittal vertical axis (SVA) and several coronal parameters.

Conclusion: The Brainlab Elements software provides accurate, reproducible, and time-efficient spinopelvic measurements for parameters it successfully captures. However, frequent failures in assessing SVA and coronal plane parameters automatically suggest that further refinement of the software is necessary.

Purpose: In this study, we examine the characteristics of Gram-negative and Gram-positive infections following scoliosis corrective surgery, as well as the potential risk factors contributing to infection.

Methods: We queried the Scoliosis Research Society (SRS) database from 2013 to 2023 to identify patients with degenerative scoliosis who developed postoperative infections. To account for comorbidities and minimize bias, 1:1 propensity score matching with replacement was performed. The total cohort sample was 706 (353 in each group), with 64% being female and a mean age of 67.9 years. The outcomes analyzed included infection duration, presence of neurological deficits, and mortality.

Results: Gram-negative infections had higher rates of return to the operating room (95.2% vs 74.5%, p < 0.001), and re-insertion of instruments (10.5% vs 4.5%, p = 0.004). However, Gram-positive bacteria were associated with higher rates of antibiotic-related complications (4.3% vs 1.1%, p = 0.02).

Conclusion: Gram-positive infections were associated with prolonged infection courses and higher mortality, while Gram-negative infections more often resulted in a return to surgery and neurological deficits. These findings suggest that Gram staining may provide an early and clinically meaningful distinction in risk stratification for patients with postoperative wound infections following scoliosis surgery.