Pub Date : 2024-07-01Epub Date: 2024-03-21DOI: 10.1007/s43390-024-00842-x
Michael J Heffernan, Claudia Leonardi, Lindsay M Andras, Bailli Fontenot, Luke Drake, Joshua M Pahys, John T Smith, Peter F Sturm, George H Thompson, Michael P Glotzbecker, Tyler A Tetreault, Benjamin D Roye, Ying Li
Purpose: This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV.
Methods: A multicenter pediatric spine database was queried for patients ages 2-10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated.
Results: Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 - T12 length was associated with more caudal LIV selection (p = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection (p = < 0.0001). Implant type was not associated with LIV selection (p = 0.32) including MCGR actuator length (p = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below (p < 0.0001).
Conclusions: Most EOS patients have an LIV of L3 or below and display TV-LIV and LSTV-LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS.
Level of evidence: III.
目的:本研究的目的是评估患者和植入物特征对EOS患儿LIV选择的影响,并评估触及椎体(TV)、最后大体触及椎体(LSTV)、稳定椎体(SV)、矢状稳定椎体(SSV)和LIV之间的关系:方法: 我们查询了一个多中心儿科脊柱数据库,该数据库收录了2-10岁接受生长友好型器械治疗且至少随访2年的患者。评估了LIV与术前脊柱高度、曲线幅度和植入物类型之间的关系。此外,还评估了 TV、LSTV、SV、SSV 和 LIV 之间的关系:共有 281 名患者符合纳入标准。大多数腰椎LIV患者的LIV位于L3或以下:L1(9.2%)、L2(20.2%)、L3(40.9%)、L4(29.5%)。较小的 T1 - T12 长度与更多的尾椎 LIV 选择相关(p = 0.001)。更大的曲线幅度同样与更多的尾侧 LIV 选择有关(p = 结论:大多数 EOS 患者都有尾侧 LIV 选择:大多数 EOS 患者的 LIV 值为 L3 或以下,并表现出 TV-LIV 和 LSTV-LIV 不一致。这些发现表明,在治疗结束时,EOS 患者很少有选择性胸椎融合的可能。有必要开展进一步的工作,以评估在 EOS 中选择更具选择性的 LIV 方法的潜力:证据等级:III。
{"title":"Lowest instrumented vertebrae in early onset scoliosis: is there a role for a more selective approach?","authors":"Michael J Heffernan, Claudia Leonardi, Lindsay M Andras, Bailli Fontenot, Luke Drake, Joshua M Pahys, John T Smith, Peter F Sturm, George H Thompson, Michael P Glotzbecker, Tyler A Tetreault, Benjamin D Roye, Ying Li","doi":"10.1007/s43390-024-00842-x","DOIUrl":"10.1007/s43390-024-00842-x","url":null,"abstract":"<p><strong>Purpose: </strong>This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV.</p><p><strong>Methods: </strong>A multicenter pediatric spine database was queried for patients ages 2-10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated.</p><p><strong>Results: </strong>Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 - T12 length was associated with more caudal LIV selection (p = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection (p = < 0.0001). Implant type was not associated with LIV selection (p = 0.32) including MCGR actuator length (p = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below (p < 0.0001).</p><p><strong>Conclusions: </strong>Most EOS patients have an LIV of L3 or below and display TV-LIV and LSTV-LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS.</p><p><strong>Level of evidence: </strong>III.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11217120/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140185518","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: Waist line asymmetry is a major cosmetic concern in patients with adolescent idiopathic scoliosis (AIS). The primary surgical goal in patients with AIS is to correct spinal deformities and prevent further progression while maintaining global alignment. Additionally, an important objective of surgical treatment is to address physical appearance by reducing asymmetry. This study aimed to evaluate changes in waistline asymmetry using digital photographs in adolescents with thoracolumbar/lumbar (TL/L) scoliosis who underwent corrective surgery.
Methods: We retrospectively analyzed the data of patients with Lenke types 5C and 6C AIS who underwent posterior fusion surgery with at least 2 years of follow-up. Waist line asymmetry was assessed using digital photography. The waist angle ratio (WAR), waist height angle (WHA), and waistline depth ratio (WLDR) were measured pre- and postoperatively. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were also evaluated.
Results: Forty-two patients (40 females and 2 males; 34 with type 5C and 8 with type 6C) were included in the study. The WAR, WHA, and WLDR significantly improved after surgery (0.873 → 0.977, - 2.0° → 1.4°, and 0.321 → 0.899, respectively). Every waistline parameter moderately correlated with the apical vertebral translation of the TL/L curve (WAR: r = - 0.398, WHA: r = - 0.442, and WLDR: r = - 0.692), whereas no correlations were observed with the TL/L curve magnitude. No correlations were observed between the photographic parameters and SRS-22r scores.
Conclusion: Lateral displacement of the apical vertebra on the TL/L curve correlated with waistline asymmetry. Preoperative waistline asymmetry improved with scoliosis correction.
{"title":"Evaluation of the changes in waistline asymmetry using digital photography in adolescents with idiopathic thoracolumbar/lumbar scoliosis after corrective surgery.","authors":"Tomohiro Banno, Yu Yamato, Tomohiko Hasegawa, Go Yoshida, Hideyuki Arima, Shin Oe, Koichiro Ide, Tomohiro Yamada, Kenta Kurosu, Yukihiro Matsuyama","doi":"10.1007/s43390-024-00850-x","DOIUrl":"10.1007/s43390-024-00850-x","url":null,"abstract":"<p><strong>Purpose: </strong>Waist line asymmetry is a major cosmetic concern in patients with adolescent idiopathic scoliosis (AIS). The primary surgical goal in patients with AIS is to correct spinal deformities and prevent further progression while maintaining global alignment. Additionally, an important objective of surgical treatment is to address physical appearance by reducing asymmetry. This study aimed to evaluate changes in waistline asymmetry using digital photographs in adolescents with thoracolumbar/lumbar (TL/L) scoliosis who underwent corrective surgery.</p><p><strong>Methods: </strong>We retrospectively analyzed the data of patients with Lenke types 5C and 6C AIS who underwent posterior fusion surgery with at least 2 years of follow-up. Waist line asymmetry was assessed using digital photography. The waist angle ratio (WAR), waist height angle (WHA), and waistline depth ratio (WLDR) were measured pre- and postoperatively. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were also evaluated.</p><p><strong>Results: </strong>Forty-two patients (40 females and 2 males; 34 with type 5C and 8 with type 6C) were included in the study. The WAR, WHA, and WLDR significantly improved after surgery (0.873 → 0.977, - 2.0° → 1.4°, and 0.321 → 0.899, respectively). Every waistline parameter moderately correlated with the apical vertebral translation of the TL/L curve (WAR: r = - 0.398, WHA: r = - 0.442, and WLDR: r = - 0.692), whereas no correlations were observed with the TL/L curve magnitude. No correlations were observed between the photographic parameters and SRS-22r scores.</p><p><strong>Conclusion: </strong>Lateral displacement of the apical vertebra on the TL/L curve correlated with waistline asymmetry. Preoperative waistline asymmetry improved with scoliosis correction.</p><p><strong>Level of evidence: </strong>Level 4.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140288911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-08DOI: 10.1007/s43390-024-00837-8
Yashas Reddy, Adam Jamnik, David Thornberg, Anne-Marie Datcu, Emily Lachmann, Megan Johnson, Brandon Ramo, Amy L McIntosh
Background: Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA's endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads.
Methods: Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90 days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention.
Results: 282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p = 0.0147), non-verbal status (p = 0.0048), and longer fusions (p = 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p = 0.9).
Conclusion: The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).
{"title":"The effect of antibiotic-impregnated calcium sulfate beads and Medical Optimization Clinic attendance on the acute surgical site infection rate in high-risk pediatric neuromuscular and syndromic scoliosis patients.","authors":"Yashas Reddy, Adam Jamnik, David Thornberg, Anne-Marie Datcu, Emily Lachmann, Megan Johnson, Brandon Ramo, Amy L McIntosh","doi":"10.1007/s43390-024-00837-8","DOIUrl":"10.1007/s43390-024-00837-8","url":null,"abstract":"<p><strong>Background: </strong>Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA's endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads.</p><p><strong>Methods: </strong>Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90 days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention.</p><p><strong>Results: </strong>282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p = 0.0147), non-verbal status (p = 0.0048), and longer fusions (p = 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p = 0.9).</p><p><strong>Conclusion: </strong>The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140060490","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-31DOI: 10.1007/s43390-024-00854-7
Roger F Widmann, Jenna L Wisch, Olivia C Tracey, Colson P Zucker, Tyler Feddema, Florian Miller, Gabriel S Linden, Mark Erickson, Jessica H Heyer
Purpose: This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions.
Methods: We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded.
Results: Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room.
Conclusion: Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.
目的:本研究评估了两家不同机构的三位外科医生在小儿脊柱后路融合术(PSF)中使用机器人辅助椎弓根螺钉置入术的术中和短期并发症:我们回顾性研究了334例小儿患者,这些患者在3年(2020-2022年)内接受了两家机构的机器人辅助导航脊柱后路融合术。共评估了 570 例机器人置入螺钉的患者。数据收集的重点是术中和术后早期并发症,至少随访30天。接受翻修手术的患者不包括在内:术中并发症包括1例硬膜外切开术、6例神经监测警报与螺钉置入无关的患者,以及62例螺钉(1.2%)有记录的椎弓根破损,所有这些患者在手术时都进行了翻修。从四分位数来看,椎弓根破损率从第一四分位数到第四四分位数呈统计学下降趋势(1.8% vs. 0.56%,p 结论:机器人辅助椎弓根螺钉置入术是一种有效的治疗方法:机器人辅助椎弓根螺钉置入术是由两个中心的三位外科医生对小儿脊柱畸形进行的安全可靠的手术,具有可接受的安全性和较低的意外返回手术室发生率。
{"title":"Analysis of 5,070 consecutive pedicle screws placed utilizing robotically assisted surgical navigation in 334 patients by experienced pediatric spine deformity surgeons: surgical safety and early perioperative complications in pediatric posterior spinal fusion.","authors":"Roger F Widmann, Jenna L Wisch, Olivia C Tracey, Colson P Zucker, Tyler Feddema, Florian Miller, Gabriel S Linden, Mark Erickson, Jessica H Heyer","doi":"10.1007/s43390-024-00854-7","DOIUrl":"10.1007/s43390-024-00854-7","url":null,"abstract":"<p><strong>Purpose: </strong>This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions.</p><p><strong>Methods: </strong>We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded.</p><p><strong>Results: </strong>Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room.</p><p><strong>Conclusion: </strong>Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140332034","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-20DOI: 10.1007/s43390-024-00841-y
Asem Mahmoud Sayed Abdel Rasol, Ahmed Mohamed El Badrawi, Ali Ibrahim Abdel Latif, Fady Michael Fahmy, Hany El Zahlawy, Mohammed Ali Hussien
Background: One method for treating adolescent idiopathic scoliosis (AIS), which is characterized by abnormal spinal alignment in the coronal, sagittal, and rotational planes, is surgical correction. The two surgical techniques most typically used to correct spine alignment are simple rod derotation (SRD) and direct vertebral derotation (DVR).
Aim: The study's goal was to assess the effectiveness of two treatment methods for adolescent idiopathic scoliosis: simple rod derotation and direct vertebral rotation.
Subjects and methods: A randomized controlled research involving 36 adolescents with idiopathic scoliosis was done. Patients were randomly split into one of two groups: 18 patients in group A had DVR treatment, while 18 patients in group B received SRD with a 2-year follow-up.
Results: Apical Vertebral Rotation measured from CT scans in DVR group was 24.4° ± 8.38° preoperatively and it decreased significantly postoperatively to 14.4° ± 4.61° with (42.22%) correction rate, while in SRD group, it was 25.03° ± 7.99° preoperatively and it also decreased significantly postoperatively to a mean value of 21.41° ± 7.01° with (14.65%) correction rate. There were statistically significant differences between both groups post-operative (P < 0.001).
Conclusion: The apical vertebral rotation was greatly enhanced in both procedures, with direct vertebral rotation being better. Both Simple rod derotation and direct vertebral rotation reduce the rib hump, although the improvement is much greater with direct vertebral rotation.
{"title":"Direct vertebral rotation versus simple rod derotation techniques in correction of adolescent idiopathic scoliosis.","authors":"Asem Mahmoud Sayed Abdel Rasol, Ahmed Mohamed El Badrawi, Ali Ibrahim Abdel Latif, Fady Michael Fahmy, Hany El Zahlawy, Mohammed Ali Hussien","doi":"10.1007/s43390-024-00841-y","DOIUrl":"10.1007/s43390-024-00841-y","url":null,"abstract":"<p><strong>Background: </strong>One method for treating adolescent idiopathic scoliosis (AIS), which is characterized by abnormal spinal alignment in the coronal, sagittal, and rotational planes, is surgical correction. The two surgical techniques most typically used to correct spine alignment are simple rod derotation (SRD) and direct vertebral derotation (DVR).</p><p><strong>Aim: </strong>The study's goal was to assess the effectiveness of two treatment methods for adolescent idiopathic scoliosis: simple rod derotation and direct vertebral rotation.</p><p><strong>Subjects and methods: </strong>A randomized controlled research involving 36 adolescents with idiopathic scoliosis was done. Patients were randomly split into one of two groups: 18 patients in group A had DVR treatment, while 18 patients in group B received SRD with a 2-year follow-up.</p><p><strong>Results: </strong>Apical Vertebral Rotation measured from CT scans in DVR group was 24.4° ± 8.38° preoperatively and it decreased significantly postoperatively to 14.4° ± 4.61° with (42.22%) correction rate, while in SRD group, it was 25.03° ± 7.99° preoperatively and it also decreased significantly postoperatively to a mean value of 21.41° ± 7.01° with (14.65%) correction rate. There were statistically significant differences between both groups post-operative (P < 0.001).</p><p><strong>Conclusion: </strong>The apical vertebral rotation was greatly enhanced in both procedures, with direct vertebral rotation being better. Both Simple rod derotation and direct vertebral rotation reduce the rib hump, although the improvement is much greater with direct vertebral rotation.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140176351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-27DOI: 10.1007/s43390-024-00851-w
Mason A Fawcett, Richard M Schwend
Purpose: Proximal junctional failure is a complication that can occur following posterior spine surgery with instrumentation. The ability to surgically revise this complication is important for the spine surgeon, yet there is little literature on the topic, especially for pediatric patients.
Methods: The technique we describe involves proximal extension of the existing instrumentation using paired levels of sublaminar bands that allows for a smooth transition of forces at the junction of instrumented and non-instrumented regions of the spine.
Results: The results of this technique have been promising with a case series demonstrating improved radiographic and clinical outcomes for eight children at a minimum of 1 year follow-up.
Conclusion: This a reliable, effective, and safe technique for salvage of PJF in children that uses posterior osteotomies and proximal extension of the instrumentation using sublaminar bands, resulting in gradual load sharing correction to restore sagittal balance.
{"title":"Surgical technique: proximal extension of instrumentation using sublaminar bands for salvage of postoperative proximal junctional failure in pediatric patients.","authors":"Mason A Fawcett, Richard M Schwend","doi":"10.1007/s43390-024-00851-w","DOIUrl":"10.1007/s43390-024-00851-w","url":null,"abstract":"<p><strong>Purpose: </strong>Proximal junctional failure is a complication that can occur following posterior spine surgery with instrumentation. The ability to surgically revise this complication is important for the spine surgeon, yet there is little literature on the topic, especially for pediatric patients.</p><p><strong>Methods: </strong>The technique we describe involves proximal extension of the existing instrumentation using paired levels of sublaminar bands that allows for a smooth transition of forces at the junction of instrumented and non-instrumented regions of the spine.</p><p><strong>Results: </strong>The results of this technique have been promising with a case series demonstrating improved radiographic and clinical outcomes for eight children at a minimum of 1 year follow-up.</p><p><strong>Conclusion: </strong>This a reliable, effective, and safe technique for salvage of PJF in children that uses posterior osteotomies and proximal extension of the instrumentation using sublaminar bands, resulting in gradual load sharing correction to restore sagittal balance.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140306875","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-28DOI: 10.1007/s43390-024-00849-4
Alberto Ruffilli, Matteo Traversari, Marco Manzetti, Giovanni Viroli, Elena Artioli, Simone Ottavio Zielli, Antonio Mazzotti, Cesare Faldini
Purpose: Surgical treatment of adolescent idiopathic scoliosis (AIS) requires a careful choice of fusion levels. The usual recommendation for the selection of the lowest instrumented vertebra (LIV) for double major or thoracolumbar/lumbar (TL/L) curves falls on L3 or L4. The aim of the present study is to assess if the spinal fusion with LIV selection of L3 or L4 in AIS patients has a clinical or radiological impact in terms of degenerative disc disease (DDD) in distal unfused segments at long-term follow-up.
Methods: A systematic search of electronic databases from eligible articles was conducted. Only studies regarding long-term follow-up of AIS patients treated with spinal fusion were included. Clinical and radiographic outcomes were extracted and summarized. Meta-analysis on long-term follow-up MRI studies was performed. p value < 0.05 was considered significant.
Results: Fourteen studies were included, for a total of 1264 patients. Clinical assessment of included patients showed a slight tendency to have worse clinical outcomes if spinal fusion is extended to L4 rather than L3. Despite that, meta-analysis could not be performed on clinical parameters because of heterogeneity of evaluated PROMs in included studies. Magnetic resonance imaging (MRI) evaluation at long-term follow-up showed no significant difference in terms of disc degeneration rate at overall meta-analysis (p = 0.916) between patients fused to L3 and L4.
Conclusion: The LIV selection of L3 rather than L4, according to current literature, does not prevent disc degeneration in distal unfused segments over the long term. Long-term studies of patients treated with contemporary spinal instrumentation are needed.
{"title":"Comparable rates of lumbar disc degeneration at long-term following adolescent idiopathic scoliosis spinal fusion extended to L3 or L4: systematic review and meta-analysis.","authors":"Alberto Ruffilli, Matteo Traversari, Marco Manzetti, Giovanni Viroli, Elena Artioli, Simone Ottavio Zielli, Antonio Mazzotti, Cesare Faldini","doi":"10.1007/s43390-024-00849-4","DOIUrl":"10.1007/s43390-024-00849-4","url":null,"abstract":"<p><strong>Purpose: </strong>Surgical treatment of adolescent idiopathic scoliosis (AIS) requires a careful choice of fusion levels. The usual recommendation for the selection of the lowest instrumented vertebra (LIV) for double major or thoracolumbar/lumbar (TL/L) curves falls on L3 or L4. The aim of the present study is to assess if the spinal fusion with LIV selection of L3 or L4 in AIS patients has a clinical or radiological impact in terms of degenerative disc disease (DDD) in distal unfused segments at long-term follow-up.</p><p><strong>Methods: </strong>A systematic search of electronic databases from eligible articles was conducted. Only studies regarding long-term follow-up of AIS patients treated with spinal fusion were included. Clinical and radiographic outcomes were extracted and summarized. Meta-analysis on long-term follow-up MRI studies was performed. p value < 0.05 was considered significant.</p><p><strong>Results: </strong>Fourteen studies were included, for a total of 1264 patients. Clinical assessment of included patients showed a slight tendency to have worse clinical outcomes if spinal fusion is extended to L4 rather than L3. Despite that, meta-analysis could not be performed on clinical parameters because of heterogeneity of evaluated PROMs in included studies. Magnetic resonance imaging (MRI) evaluation at long-term follow-up showed no significant difference in terms of disc degeneration rate at overall meta-analysis (p = 0.916) between patients fused to L3 and L4.</p><p><strong>Conclusion: </strong>The LIV selection of L3 rather than L4, according to current literature, does not prevent disc degeneration in distal unfused segments over the long term. Long-term studies of patients treated with contemporary spinal instrumentation are needed.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11217089/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140319149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-26DOI: 10.1007/s43390-024-00848-5
Brett R Lullo, Patrick J Cahill, John M Flynn, Jason B Anari
Purpose: Surgical treatment of early-onset scoliosis (EOS) is associated with high rates of complications, often requiring unplanned return to the operating room (UPROR). The aim of this study was to create and validate a machine learning model to predict which EOS patients will go on to require an UPROR during their treatment course.
Methods: A retrospective review was performed of all surgical EOS patients with at least 2 years follow-up. Patients were stratified based on whether they had experienced an UPROR. Ten machine learning algorithms were trained using tenfold cross-validation on an independent training set of patients. Model performance was evaluated on a separate testing set via their area under the receiver operating characteristic curve (AUC). Relative feature importance was calculated for the top-performing model.
Results: 257 patients were included in the study. 146 patients experienced at least one UPROR (57%). Five factors were identified as significant and included in model training: age at initial surgery, EOS etiology, initial construct type, and weight and height at initial surgery. The Gaussian naïve Bayes model demonstrated the best performance on the testing set (AUC: 0.79). Significant protective factors against experiencing an UPROR were weight at initial surgery, idiopathic etiology, initial definitive fusion construct, and height at initial surgery.
Conclusions: The Gaussian naïve Bayes machine learning algorithm demonstrated the best performance for predicting UPROR in EOS patients. Heavier, taller, idiopathic patients with initial definitive fusion constructs experienced UPROR less frequently. This model can be used to better quantify risk, optimize patient factors, and choose surgical constructs.
Level of evidence: Prognostic: III.
目的:早发脊柱侧凸(EOS)的手术治疗与高并发症发生率有关,通常需要意外返回手术室(UPROR)。本研究的目的是创建并验证一个机器学习模型,以预测哪些 EOS 患者在治疗过程中需要进行 UPROR:方法:对所有随访至少两年的手术 EOS 患者进行回顾性研究。根据患者是否经历过 UPROR 对其进行了分层。在独立的患者训练集上使用十倍交叉验证训练了十种机器学习算法。在独立的测试集上,通过接收者操作特征曲线下面积(AUC)对模型性能进行评估。结果:257 名患者被纳入研究。146 名患者至少经历了一次 UPROR(57%)。有五个因素被确定为重要因素并纳入模型训练:初次手术时的年龄、EOS病因、初次构建类型以及初次手术时的体重和身高。高斯天真贝叶斯模型在测试集中表现最佳(AUC:0.79)。初次手术时的体重、特发性病因、初次确定的融合结构以及初次手术时的身高是避免发生UPROR的重要保护因素:高斯天真贝叶斯机器学习算法在预测EOS患者的UPROR方面表现最佳。体重较重、身高较高、有初次明确融合结构的特发性患者发生 UPROR 的频率较低。该模型可用于更好地量化风险、优化患者因素和选择手术结构:预后:III。
{"title":"Predicting early return to the operating room in early-onset scoliosis patients using machine learning techniques.","authors":"Brett R Lullo, Patrick J Cahill, John M Flynn, Jason B Anari","doi":"10.1007/s43390-024-00848-5","DOIUrl":"10.1007/s43390-024-00848-5","url":null,"abstract":"<p><strong>Purpose: </strong>Surgical treatment of early-onset scoliosis (EOS) is associated with high rates of complications, often requiring unplanned return to the operating room (UPROR). The aim of this study was to create and validate a machine learning model to predict which EOS patients will go on to require an UPROR during their treatment course.</p><p><strong>Methods: </strong>A retrospective review was performed of all surgical EOS patients with at least 2 years follow-up. Patients were stratified based on whether they had experienced an UPROR. Ten machine learning algorithms were trained using tenfold cross-validation on an independent training set of patients. Model performance was evaluated on a separate testing set via their area under the receiver operating characteristic curve (AUC). Relative feature importance was calculated for the top-performing model.</p><p><strong>Results: </strong>257 patients were included in the study. 146 patients experienced at least one UPROR (57%). Five factors were identified as significant and included in model training: age at initial surgery, EOS etiology, initial construct type, and weight and height at initial surgery. The Gaussian naïve Bayes model demonstrated the best performance on the testing set (AUC: 0.79). Significant protective factors against experiencing an UPROR were weight at initial surgery, idiopathic etiology, initial definitive fusion construct, and height at initial surgery.</p><p><strong>Conclusions: </strong>The Gaussian naïve Bayes machine learning algorithm demonstrated the best performance for predicting UPROR in EOS patients. Heavier, taller, idiopathic patients with initial definitive fusion constructs experienced UPROR less frequently. This model can be used to better quantify risk, optimize patient factors, and choose surgical constructs.</p><p><strong>Level of evidence: </strong>Prognostic: III.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140294395","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-16DOI: 10.1007/s43390-024-00839-6
McKenna C Noe, Daniel Hagaman, Brittany Sipp, Fahad Qureshi, Jonathan R Warren, Ellie Kaji, Ashley Sherman, Richard M Schwend
Background: Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis.
Methods: This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into "short" (< 6 h) or "long" (≥ 6 h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors.
Results: After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100 cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225 cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5 days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003).
Conclusions: Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6 h may have safety and efficacy advantages over longer times.
{"title":"The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis.","authors":"McKenna C Noe, Daniel Hagaman, Brittany Sipp, Fahad Qureshi, Jonathan R Warren, Ellie Kaji, Ashley Sherman, Richard M Schwend","doi":"10.1007/s43390-024-00839-6","DOIUrl":"10.1007/s43390-024-00839-6","url":null,"abstract":"<p><strong>Background: </strong>Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis.</p><p><strong>Methods: </strong>This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into \"short\" (< 6 h) or \"long\" (≥ 6 h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors.</p><p><strong>Results: </strong>After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100 cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225 cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5 days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003).</p><p><strong>Conclusions: </strong>Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6 h may have safety and efficacy advantages over longer times.</p><p><strong>Level of evidence: </strong>III.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140140651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2024-03-31DOI: 10.1007/s43390-024-00855-6
Yoji Ogura, A Noelle Larson, Laurel Blakemore, Firoz Miyanji, Lindsay M Andras, Stefan Parent, Ron El-Hawary, Michelle Cameron Welborn
Purpose: Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT.
Methods: Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD.
Results: Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0.
Conclusion: CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.
目的:术后冠状失代偿(CD)仍然是治疗青少年特发性脊柱侧凸(AIS)的难题。选择性脊柱融合术后的冠状失代偿已被研究过。然而,目前有关椎体拴系(VBT)术后冠状面失代偿(CD)的信息还很少。因此,本研究旨在更好地了解 VBT 后 CD 的发生率和风险因素:方法:对前瞻性多中心数据库进行回顾性分析。纳入标准:接受胸椎 VBT 的患者,至少随访 2 年,LIV 为 L1 或以上,骨骼不成熟(Risser ≤ 1),可获得术前和最终随访的 AP 和侧位直立放射线照片。测量的放射学参数包括主要和次要 Cobb 角、曲线类型、LIV 倾斜/平移、L4 倾斜和冠状面平衡。CD的定义是C7PL和CSVL之间的距离大于2厘米。多重逻辑回归模型用于确定CD的重要预测因素:在 136 名接受 VBT 的患者中,94 名患者(86 名女性和 6 名男性)符合纳入标准。手术时的平均年龄为 12.1 岁(9-16 岁),平均随访时间为 3.4 年(2-5 年)。手术后,患者的主要和次要曲线、AVR、冠状面平衡、LIV平移、LIV倾斜、L4倾斜均有明显改善。最终随访时,11%的患者出现了脊柱侧弯。与1A-L(4%)、2(0%)和3(0%)相比,Lenke 1A-R(24%)和1C(26%)的CD发生率更高。LIV 选择与 CD 无关。多变量逻辑回归分析显示,1A-R 和 1C 曲线是 CD 的预测因子,几率为 17.0:结论:11%的胸部 VBT 患者发生了 CD。Lenke 1A-R 和 1C 曲线类型是 VBT 患者 CD 的预测因子。术前没有其他与 CD 相关的预测因素。
{"title":"Coronal decompensation following thoracic vertebral body tethering in idiopathic scoliosis.","authors":"Yoji Ogura, A Noelle Larson, Laurel Blakemore, Firoz Miyanji, Lindsay M Andras, Stefan Parent, Ron El-Hawary, Michelle Cameron Welborn","doi":"10.1007/s43390-024-00855-6","DOIUrl":"10.1007/s43390-024-00855-6","url":null,"abstract":"<p><strong>Purpose: </strong>Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT.</p><p><strong>Methods: </strong>Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD.</p><p><strong>Results: </strong>Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0.</p><p><strong>Conclusion: </strong>CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.</p>","PeriodicalId":21796,"journal":{"name":"Spine deformity","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140332035","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}