Spine deformity最新文献

Purpose: The necessity of routine radiographic imaging after spinal fusion surgery is debated due to variations in surgeons' practices. The aim of this study is to determine the role of immediate postoperative radiographic imaging following posterior spinal fusion for AIS. Our hypothesis is that routine immediate postoperative radiographic imaging in patients with AIS undergoing posterior spinal fusion does not impact the decision to return to the operating room.

Methods: We conducted a retrospective cohort study of AIS patients (ages 11-19) who underwent PSF at a single institution. The proportion of unplanned returns to the operating room (UPROR) cases was estimated with a Clopper-Pearson 95% confidence interval. Risk factors for UPROR were compared using Wilcoxon rank-sum and Fisher's exact tests.

Results: Among 527 patients, only 3 (0.5%) had UPROR, and just 1 (0.2%) returned due to routine postoperative imaging findings. Patients with and without UPROR had similar surgical times (321 vs. 277 min, p = 0.24), blood loss (18% of EBV vs. 14% of EBV, p = 0.29), and intraoperative tranexamic acid use (p = 0.52). No demographic or surgical factors differed between the groups. The estimated excess radiation burden was 36.36 mSv.

Conclusion: The decision to undergo reoperation based on routine immediate postoperative imaging findings is exceedingly rare. In addition, blood loss, surgical time, and use of TXA did not differ between those who did return to the operating room and those who did not. These findings demonstrate that most patients do not benefit from routine immediate postoperative imaging.

Purpose: Early-onset scoliosis (EOS) significantly affects lung development and life expectancy. Magnetically Controlled Growing Rods (MCGR) effectively promote thoracic growth while managing curvature progression. This study aims to assess the impact of definitive spinal fusion on residual deformity and complications in EOS patients treated with MCGRs.

Methods: The study included 27 EOS patients who underwent final fusion surgery between January 2017 and September 2022. The primary outcome was the evaluation of coronal and sagittal radiographic parameters postoperatively and at a minimum of 2 years of follow-up (FUP). Secondary outcomes included major complications (≥ IIIB, according to Clavien-Dindo Classification), surgery duration, blood loss and length of hospital stay (LOS).

Results: Major curve (45.5° and 33.5°, p = 0.003, Brunner-Munzel Test Statistic = - 3.869254) and Thoracic Kyphosis (TK) (19.8° and 13.5°, p = 0.002, Brunner-Munzel Test Statistic = - 2.258845) were statistically impacted by arthrodesis, and maintained at the final follow-up. The surgeries had an average duration of 254.2 ± 39.5 min (range: 195-336 min) and an average blood loss of 574.1 ± 255.1 mL (range: 200-1300 mL). The mean LOS was 8.5 ± 1.8 days (range: 6-13 days). Following the final fusion, 5 patients (18.5%) developed a complication, of which one was classified as major.

Conclusions: This study demonstrated substantial improvements in coronal and sagittal alignment following graduation surgery, with results maintained at the two-year FUP. Further research with larger sample sizes is needed to provide a more comprehensive assessment of radiographic and surgical outcomes and to establish guidelines for implant density in MCGR graduation surgery.

Introduction: Intraoperative neuromonitoring (IONM) reduces postoperative spinal cord dysfunction during pediatric spinal deformity surgery by allowing intraoperative corrective actions. Currently, data on false negative IONM events in this population are limited. The purpose of this study is to describe false negative IONM cases and explore immediate and final outcomes.

Methods: An institutional neuromonitoring database (November 1992-April 2024) was reviewed to identify patients (0-18 years) who underwent spinal deformity surgery and experienced false negative IONM. The modalities included somatosensory evoked potentials (SSEP), descending neurogenic evoked potentials (DNEP), and transcranial motor-evoked potentials (TcMEP).

Results: Out of the 5317 consecutive cases, 16 patients (0.32%) experienced false negative outcomes. Mean age was 14 years (11-16). Five cases (31.3%) had abnormal neurologic status preoperatively, and all 16 patients experienced neurologic decline, postoperatively. Outcomes were stratified by injury level: among spinal cord-level cases with known outcomes (n = 7), 29% achieved complete recovery; 90% of spinal cord-level injuries used SSEP/DNEP and 10% used SSEP/TcMEP. In nerve root-level cases (n = 6), 17% achieved full recovery. Reoperations included three decompressions, two instrumentation removals, and two revisions. At final follow-up, three patients (19%) had complete recovery, five (31%) partial recovery, five (31%) no recovery, and outcomes were unknown in three (19%).

Conclusion: This is the largest series of false negative IONM cases in pediatric spinal deformity surgery to date, with 16 false negative outcomes (0.32%) from 5317 consecutive pediatric spinal deformity cases. In worst case scenario only 19% made a complete recovery. Currently, TcMEP and SSEP monitoring is standard of care and when both are used there was only one false negative case, supporting their use over SSEP/DNEP to mitigate the risk of false negative IONM in spinal cord level surgeries.

Purpose: Our study aims to evaluate the impact of rod diameter and material on sagittal plane correction and reoperation. We hypothesize larger diameter rods would improve the sagittal plane alignment without increasing complications or progression of proximal junctional kyphosis (PJK).

Methods: Data were reviewed from consecutive series of Lenke 1-4 AIS patients enrolled in a multicenter registry between 2010 and 2019 with minimum 2-year follow-up. Patients who underwent PSF with 5 common rod types (5.5 or 6.0 cobalt chrome, 5.5 stainless steel, 5.5 or 6.0 titanium rods) were evaluated. Other rod types/diameters were excluded from this study.

Results: 1348 patients treated by 29 surgeons at 13 centers met inclusion criteria. 42 had 5.5 titanium rods (3%), 651 patients had 5.5 cobalt chrome (48%), 586 had 5.5 stainless steel (43%), 46 had 6.0 titanium (3%), and 23 had 6.0 cobalt chrome (2%). Preoperatively there was no difference in curve magnitude or flexibility. Patients that received stiffer rods were older and taller. At 2 years, the 5.5 stainless steel patients had the greatest major curve correction (62.5%) while 5.5 titanium patients had the lowest correction (54.2%) (whole cohort p < 0.001). At 2-year follow-up there was most improved T2-T12 kyphosis in the 6.0 titanium group (+ 6.5°), and least in the 5.5 titanium group (-3.2°) (p = 0.014). T5-T12 changes were greatest in the 6.0 titanium group (+ 3.9°) and lowest in the 5.5 titanium group (-6.7°) (p < 0.001). PJK increased most in the 5.5 titanium cohort (+ 4.0) and least in the 6.0 cobalt chrome cohort (+ 0.8) (p < 0.001). Complication rates were highest in the 5.5 stainless steel patients (12.6%) while rates of reoperations were highest in the 5.5 cobalt chrome cohort (n = 9, 1.4%).

Conclusion: In this retrospective review of patients undergoing PSF with rods of varying size and materials, there was evidence of better restoration of T5-T12 kyphosis with stiffer/larger rods without increased risk of PJK progression.

Purpose: To evaluate a novel proximal thoracic concave rod (PTCR) technique for improving postoperative shoulder imbalance (SI) in adolescent idiopathic scoliosis (AIS) patients with Lenke types 2 and 4 curves, compared to conventional methods.

Methods: A retrospective study of 30 AIS patients (10 with PTCR, 20 without) from a multicentric European database was conducted. Patients aged ≤ 18 years undergoing surgery for Lenke types 2 or 4 curves with ≥ 2 years of follow-up were included. Radiographic parameters, including Clavicle Angle (CA) and T1 Coronal Tilt (T1CT), were assessed preoperatively, immediately postoperatively, and at 2 years. Demographic, surgical, radiological parameters, and patient-reported outcomes measures (PROMs) were compared between groups.

Results: PTCR significantly improved SI, achieving optimal CA in 80% of cases versus 35% in the non-PTCR group (p = 0.02). CA correction was superior in the PTCR group (-1.66° ± 1.34° vs. 1.06 ± 2.59°, p < 0.001). While T1CT correction showed greater improvement in the PTCR group (-3.62° ± 5.56° vs. -0.31° ± 8.13°) it was not statistically significant (p = 0.258). PTCR did not increase surgical time, blood loss, or complications.

Conclusions: PTCR is a promising approach for managing shoulder imbalance in AIS patients with Lenke types 2 or 4 curves. Larger prospective studies are necessary to validate these findings.

Level of evidence: Level of Evidence: III.

Introduction: Though chest tube removal at the completion of an endoscopic thoracic procedure is well accepted in the pediatric and adult general surgery literature, this practice has never been studied in pediatric patients treated with anterior vertebral tethering (AVT) for AIS. This study retrospectively analyzed pulmonary complications in a large series of AIS patients consecutively treated with chest tube removal at the completion of AVT. The rate of pulmonary complication in this series was then compared with the published rate of pulmonary complication in patients managed with chest tube retention after AVT.

Methods: A retrospective review of all AIS patients treated with AVT over a twelve year period yielded 257 consecutive patients (248 primary/9 revision) with 349 curves. Out of a total of 349 chest tubes placed intraoperatively, as a routine step of the procedure, 323 were removed at procedure completion while 26 were maintained for 2-5 days post-operatively as warranted. Patient charts, radiographs, and CT scans were reviewed to confirm any pulmonary complications.

Results: In 257 AIS patients treated with AVT, 233 had chest tube removal at the completion of AVT with 4 (1.7%) peri-operative and 8 (3.4%) delayed pulmonary complications. Peri-operative complications included one symptomatic pneumothorax noted in the operating room that required chest tube reinsertion; one static pneumothorax that resolved without intervention; and two significant pleural effusions that resolved over time without intervention. Delayed complications included seven pleural effusions that occurred 2-6 weeks post-operatively and one chylothorax that occurred 1 week post-operatively. Several clinically significant pleural effusions (4/7) required thoracentesis or chest tube drainage but subsequently resolved. The chylothorax required chest tube drainage, dietary fat restriction, and treatment with octreotide. In 24 patients, 26 chest tubes were retained for 2-5 days post-op for a persistent air leak with presumed parenchymal injury (14), revision with significant adhesions (6), bleeding disorder (2), or diaphragmatic repair related to renal eventration (1) or congenital diaphragmic hernia (1).

Conclusion: This study demonstrated the relative safety of immediate chest tube removal at the completion of AVT in AIS patients. The rate of pulmonary complication in 233 patients with chest tube removal at the completion of AVT was 5.1% which compared favorably with a published rate of 10-11% after chest tube retention. In 24 patients with an indication for chest tube retention at the completion of AVT, chest tube retention for 2-5 days resulted in no pulmonary complications.

Purpose: Posterior spinal instrumentation and fusion (PSF) is the gold standard for severe adolescent idiopathic scoliosis (AIS), yet instrumentation strategies vary widely, often leading to suboptimal results. Deep learning's potential in AIS planning is underexplored.

Methods: This study trained and validated an artificial neural network multi-task learning model (NNML) using preoperative clinical and radiographic data from 189 AIS patients with Lenke 1A and 2A curves enrolled in the MIMO Clinical Trial (NCT01792609). The model mimics experienced spine surgeons' decision-making for selecting the upper and the lower instrumented vertebrae (UIV, LIV), determining rod curvature, and predicting screw density based on the study's randomized allocation. Models were trained with data from 179 patients, utilizing tenfold cross-validation, and externally validated on 10 patients from a separate hospital and surgeons outside the training set. For UIV and LIV selection, accuracy within the top two predictions was used as a classification performance metric, ensuring that other clinically relevant alternatives were considered.

Results: The NNML, which comprised 83 inputs and multiple hidden layers, led to significant gains over ST-NN and proved more robust during the internal validation (loss 6.2 vs. 9.3; p ≤ 0.01). It showed 82-95% and 80-100% accuracy for UIV and LIV predictions and 70-90% accuracy for predicting the rod curvatures ± 5°. The RMSE for the screw density and rod curvature predictions was 0.2-0.3 and 3.7-5.6°, respectively.

Conclusion: An NNML can better use the features of relevant AIS patients for mixed task prediction pertinent to PSF surgery planning than ST-NN. In addition, NNML was capable of mimicking experienced spine surgeons' decision-making process when designing the instrumentation.

Purpose: This study aimed to investigate the effect of 3D rapid prototyping(3DRP) curve-specific scoliosis model in pedicle screws placement, and contrast it with standard free-hand techniques.

Methods: A retrospective review on scoliosis patients operated on by a single surgeon from 2014 to 2018 identified 48 patients with curve-specific models manufactured by 3DRP and used intra-operatively for guidance of instrumentation. They were age and gender-matched to 48 scoliosis patients in whom pedicle screws were placed following the standard free-hand technique. Screw position was determined on CT by a grading system as Grade 0 (no violation), Grade 1 (< 2 mm perforation), Grade 2 (< 4 mm perforation), or Grade 3 (> 4 mm perforation).

Results: 1485 screws (686 in the 3DRP group vs. 799 in the control group) were analyzed. Patients in the 3DRP group had higher Cobb angles and more challenging deformity. Although the overall percentages of critical perforations (those with risk of complications) were comparable between the two groups, the distribution of screw perforation were different. Screws in the 3DRP group were less likely to be critical both medially and laterally, and more likely to be critical anteriorly. Furthermore, laterally and anteriorly, the difference between them were largely due to a difference in Grade 2 perforation, whereas medially, the difference resulted from a higher percentage of both Grade 2 and Grade 3 perforation.

Conclusion: 3DRP scoliosis model represents an affordable and accessible approach to reduce medial pedicle screw perforation with high risk of complications in the thoracic and lumbar spine.