Spine deformity最新文献

Background: Chiari malformation type I(CM-I) is one of the most common neurological malformations observed in patients with adolescent idiopathic scoliosis (AIS). It remains uncertain whether AIS patients without neurological symptoms require CM-I decompression before undergoing spinal corrective surgery to prevent cerebellar tonsil herniation and potential neurological complications. This study aims to assess variations in the position of the cerebellar tonsil after posterior spinal fusion (PSF) in neurologically intact patients with AIS.

Methods: We retrospectively evaluated 40 patients with AIS who underwent posterior spinal fusion (PSF) without neurological symptoms. Sagittal hindbrain MRIs were performed before and after spinal surgery. The cerebellar tonsil's position relative to the foramen magnum was measured using the method described by Aboulezz (J Comput Assist Tomogr 1985). We assessed variations in the cerebellar tonsil position concerning spinal correction and elongation after PSF.

Results: The average preoperative magnitude of the scoliotic curve was 53.15 degrees (SD 10.46 degrees), and that of thoracic kyphosis was 35.42 degrees (SD 12.38 degrees). In the immediate postoperative period, the average magnitudes were 7.45 degrees (SD 7.33 degrees) and 27.87 degrees (SD 9.03 degrees), respectively. The average correction achieved with PSF was 86% in the coronal plane (p < 0.00001). The average length of the spine in the coronal plane was 44.5 cm (SD 5.25 cm) preoperatively and 48.27 cm (SD 4.40 cm) postoperatively (p < 0.00001). The average length of the vertebral column in the sagittal plane was 50.87 cm (SD 4.47 cm) preoperatively and 55.13 cm (SD 3.27 cm) postoperatively (p < 0.00001). No significant difference was observed in the position of the cerebellar tonsil in the measurements taken before and after spinal deformity correction (p = 0.6042). In 10 out of 40 patients, caudal displacement of the cerebellar tonsil was observed after PSF. In 28 patients, no variation in the position of the cerebellar tonsil was observed, and in 2, cephalic displacement was noted.

Conclusion: In AIS patients with a normal position of the cerebellar tonsil undergoing posterior spinal fusion, there is no significant change in their position after surgery. Our analysis did not reveal any correlation between curve correction, spine elongation, and variations in the cerebellar tonsil position.

Significance: The position of the cerebellar tonsil remained largely unchanged after PSF in AIS patients without neurological symptoms. Further studies would be necessary to determine whether surgical decompression is required in asymptomatic patients with CM-I before undergoing surgery to correct spinal deformity.

Introduction: Distraction-based growing rods have been considered as an alternative surgical option for the operative treatment of EOS. TGR has been challenged by MCGR, which is reported to have the advantage of non-invasive lengthening with fewer planned returns to theatre. This study explores the radiographic outcomes, Unplanned Returns to the Operating Room (UPROR) and complication profile of both the procedures at the end of the planned growing rod treatment with either TGR or MCGR.

Methods: We included all the EOS cases from the PSSG database that underwent either TGR or MCGR with spine-based proximal anchors, followed up to the time of graduation. Any crossover or hybrid procedures were excluded. 549 patients (409 TGR and 140 MCGR) were eligible for review. We measured the coronal curve magnitude, Kyphosis, T1-T12, T1-S1 and L1-S1 lengths at 4 time points (before and after the index surgery and before and after the definitive surgery).

Results: The TGR group were slightly younger at the time of the index procedure (7 years for TGR vs. 8.5 years for MCGR, p < 0.001). We noted an improvement in all radiological parameters after the growing rod implantation. The spinal lengths increased through the lengthening period, while the coronal curve magnitude and the kyphosis increased. The kyphosis normalized following the final fusion, the coronal curve magnitude reduced further with a further increase in spinal lengths. The final follow-up from the time of the index implantation to the definitive surgery was 5.1 years (IQR 3.8) in TGR and 3.5 years (IQR 1.65) in the MCGR groups. The total number of complications was fewer in the MCGR group. The overall risk of UPROR was lower in the MCGR group and implant breakage was less in the MCGR group by 4.7 times.

Conclusions: This study confirms the equivalence of both the distraction-based growing rods systems from the radiological stand-point, during the lengthening phase and at the time of the definitive surgery. The TGR was more kyphogenic during the lengthening period. The complications and UPROR were fewer in the MCGR groups.

Purpose: To assess patients' perceptions of their abdominal wall following extensile anterolateral approaches to the thoracolumbar spine for adult spinal deformity (ASD) using validated questionnaires.

Methods: Adults who underwent anterior-posterior thoracolumbar spinal operations to the pelvis for ASD in which the anterior fusion was performed through an extensile anterolateral approach were reviewed. Three questionnaires were administered at least 1 year following surgery and included The Abdominal Core Health Quality Collaborative Survey (AHS-QC), The Patient Scar Assessment Scale (PSAS), and The Anterior Abdominal Incision Questionnaire (AAIQ).

Results: Fifty-one patients (80.4% female, median age 65 years) were included. Average follow-up was 2.8 ± 1.7 years. Average number of anterior fusion levels was 3.5 ± 1.4. Patients achieved high satisfaction rates from surgery (74.5%). AAIQ responses included postoperative pain (33.3%), bulging (41.7%), and limitations in daily activities (18.8%) with only 15.7% experienced moderate-severe pain related to their incisions and only 6.3% seeking treatment for their scars. Post-operatively, 63.2% had a neutral or improved self-image of their torso and trunk, while only 10.2% stating it was much worse. Patients' overall opinion of their scar compared to their normal skin was very positive [average 2.75 ± 2.93 (10 = worst possible scar)]. Favorable scores were also reported for color difference, stiffness, change in thickness, and irregularity in their abdominal scar compared to normal skin.

Conclusions: Following extensile anterolateral approaches to the thoracolumbar spine for ASD, the majority of patients reported mild pain, mild functional limitations, good cosmesis, and high satisfaction rates with their anterior incisions based on validated questionnaires.

Purpose: This study aims to measure the impact of the Scoliosis Research Society's travel fellowship on a spinal surgeon's career.

Methods: A non-incentivized survey was sent to 78 previous SRS junior travel fellows from 1993 to 2021. The questionnaire assessed fellowship influence on academic and administrative positions, professional society memberships, and commercial relationships. The trend of these quantitative measures was created according to a compounded annual growth rate (CAGR) calculation of the reported values. The Scopus database was queried for all fellows' publication counts and h-index before the fellowship, as well as 3 years, 5 years, and currently after the fellowship. A control cohort of matched surgeons who did not participate in travel fellowships was used to compare research productivity measures relative to travel fellows.

Results: This study had a 73% response rate. Over the periods of 3-5 years after the fellowship, and up to the present, the mean publication count increased by 31.0%, 31.6%, and 46.4%, respectively. Over the same interval, the mean h-index increased by 19.5%, 17.3%, and 11.3%, respectively. From the year of their respective fellowship to present day, the fellows observed a mean CAGR of + 3.2% in academic positions, + 6.7% in administrative positions, + 2.3% in society memberships, and + 4.7% in commercial relations. Previous fellows concurred the fellowship changed their clinical practice (42.1% Strongly Agree, 36.8% Agree), expanded their network (71.9% Strong Agree, 24.6% Agree), expanded their research (33.3% Strongly Agree, 54.4% Agree), and improved their surgical technique (33.3% Strongly Agree, 49.1% Agree).

Conclusion: Robust feedback from previous fellows suggests a traveling fellowship has a meaningful impact on a surgeon's research productivity and career achievements.

Purpose: This study compared shoulder balance outcomes in "rule breakers" (RB) vs. "rule followers" (RF) based on commonly utilized upper instrumented vertebrae (UIV) selection guidelines.

Methods: Adolescent idiopathic scoliosis (AIS) patients (Lenke 1-4) who underwent posterior spine fusion (PSF) with minimum 2-year follow-up had radiographic measurement of shoulder balance including first rib angle (FRA), T1 tilt, coracoid process height difference (CPHD), and clavicle angle (CA) at preop, postop, 6-month, 1-year, and 2-year timepoints. Postoperative outcomes were compared between RB and RF groups defined based on the UIV selection guidelines of Rose and Lenke.

Results: Among 88 patients (43 RF, 45 RB), age, gender, preoperative T1 tilt, FRA, CA, and CPHD were not significantly different between groups (p > 0.05). Immediately post-surgery, the RF group had more balanced shoulders (CPHD: 11.6 mm vs. 15.7 mm, p = 0.033; CA: 2.8° vs. 3.6°, p = 0.045; FRA: 3.4° vs. 5.1°, p = 0.009; T1 tilt: 4.7° vs. 6.1°, p = 0.045). At 2 years, no difference was observed between RF vs. RB in CA (2.3 vs. 2.2°, p = 0.857) and CPHD (8.5 vs. 8.1 mm, p = 0.791). FRA and T1 tilt were higher in RB vs. RF (FRA: 4.6 vs. 2.9°, p = 0.002; T1 tilt: 5.6 vs. 3.9, p = 0.008). Shoulder balance (CPHD < 1 cm) was achieved in 73.1% of RB and 69.9% of RF at 2-year follow-up (p = 0.216).

Conclusion: Adherence to commonly accepted UIV selection guidelines did not predict better shoulder balance. The RB group had worse shoulder balance immediately post-surgery, but also improved more over time. These results suggest the need to refine current UIV selection and management.

Level of evidence: III.

Purpose: To determine the accuracy of screw placement using fluoroscopy and anatomic landmarks during vertebral body tethering (VBT) surgery.

Methods: Ten patients with 73 VBT screws were converted to posterior spinal fusion (PSF) after continued curve progression. The positions of each VBT screw were analyzed using intraoperative computed tomography (CT) scans performed for image guidance during VBT. Differences for screws placed using an open versus thoracoscopic approach were noted for the screw position in each vertebra, distance from the spinal canal, unicortical versus bicortical placement, the distance of screw tips from the thoracic aorta, and impingement of screws on adjacent rib heads.

Results: Seventy three (73) screws in ten (10) patients were available for analysis. Only 21% of screws were placed traversing the middle one-third of the vertebral body, without spinal canal penetration, with the distal tip placed unicortically or bicortically as planned, and without touching the thoracic aorta. The rates of non-ideal screw placement were not significantly different for screws placed via thoracoscopic versus open approaches. Five (5) screws (6.8%) penetrated the spinal canal 1-2 mm, but without known clinical sequelae.

Conclusion: The majority of VBT screws available for analysis were placed in non-ideal positions, suggesting that accurate screw placement using intraoperative fluoroscopy and anatomic landmarks can be challenging, but without adverse clinical consequences.

Purpose: The aim of this study is to evaluate and compare techniques and outcomes associated with two different technique of pelvic screw insertion in patients with caudal spine absence.

Methods: A cohort of patients with varying degrees of caudal structural regression, serves as the focal point of this investigation. Pelvic configurations were classified based on established criteria to facilitate comparative analysis. Each patient underwent spinal surgical interventions, with a follow-up period extending beyond 2 years. The primary surgical interventions predominantly involved spinal stabilization coupled with correction of scoliosis and kyphosis through one or two pairs of pelvic screws.

Results: In this study, we investigated a cohort of 22 patients with caudal spine absence, encompassing diverse conditions, such as lumbo-sacral aplasia, hemisacrum, and lumbar absence, with preserved sacrum. Following spinal surgery, notable improvements were observed in scoliosis and pathological lumbar kyphosis, with several patients achieving significant functional milestones such as independent ambulation. There were no significant differences in short-term complications between patients undergoing single versus double pair pelvic screw implantation. Long-term complications, primarily non-fusion, were notably more prevalent in patients undergoing fixation with a single pair of pelvic screws.

Conclusion: Surgical intervention, particularly spinopelvic fixation, demonstrated promising outcomes in terms of improving spinal deformities. The implantation of two pairs of pelvic screws demonstrates greater reliability compared to the insertion of a single pair, diminishing the risk of non-fusion.

Background: Surgical management of adolescent idiopathic scoliosis (AIS) and Scheuermann's kyphosis (SK) may be associated with several complications including extended length of stay and unplanned reoperations. Several studies have previously compared postoperative complications and functional outcomes for AIS and SK patients with mixed results. However, a meta-analysis compiling the literature on this topic is lacking.

Methods: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored until April 2024. The extracted data consisted of complications (overall and surgical-site infections [SSI]), readmissions, reoperations, and Scoliosis Research Society-22 (SRS-22) score. Mean differences (MD) with 95% CI were used for continuous data and odds ratio (OR) was utilized for dichotomous data were calculated across studies.

Results: Seven retrospective articles were included in the meta-analysis, including 4866 patients, with 399 in the SK group and 4467 in the AIS group. SK patients were found to have statistically significantly higher rates of overall complications (OR = 5.41; 95% CI 3.69-7.93, p < .001), SSI (OR = 11.30; 95% CI 6.14-20.82, p < .001), readmissions (OR = 2.81; 95% CI 1.21-6.53, p = 0.02), and reoperations (OR = 7.40; 95% CI 4.76-11.51, p < .001) than AIS patients. However, they had similar SRS-22 scores postoperatively (MD = -0.06; 95% CI -0.16 to 0.04, p = 0.26) despite the SK group having lower SRS-22 scores preoperatively (MD = -0.30; 95% CI -0.42 to -0.18, p < .001).

Conclusion: In this meta-analysis of studies comparing spinal deformity surgery outcomes in AIS and SK patients, SK was associated with more complications, readmissions, and reoperations. SK did have equivalent SRS-22 scores postoperatively to AIS patients, highlighting the benefit of surgical treatment despite higher complication rates. This data may help inform healthcare institutions, payors, and quality monitoring organizations who examine outcomes of pediatric and adult spinal deformity surgery.

Purpose: To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS).

Methods: Multicenter comparative cohort study. Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input-output difference (IOD), and normalized input-output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes.

Results: Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = -0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004).

Conclusion: Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes.

Level of evidence: III.

Background: Goldenhar syndrome is a rare congenital disease that presents with a spectrum of clinical sequelae related to the vertebrae and other organs. The spinal manifestations of the syndrome are associated with scoliosis for which fusion may be considered. The current study aimed to evaluate the risks of adverse events and reoperations following posterior spinal fusion for those with Goldenhar syndrome relative to those with adolescent idiopathic scoliosis (AIS).

Methods: Patients with Goldenhar syndrome and AIS between the ages of 10 and 17 who underwent posterior spinal fusion were abstracted from the 2010 to 2022 PearlDiver Database. The Goldenhar syndrome patients were matched 1:4 to patients with AIS based on age, sex, and Elixhauser Comorbidity Index. All 90 day postoperative adverse events, readmissions, and 5 year reoperations were identified using administrative coding. Incidence of adverse events between the cohorts were compared using multivariate logistic regression.

Results: A total of 11,742 patients with AIS and 72 (0.61%) Goldenhar syndrome undergoing deformity surgery were identified. On matched comparison, patients with Goldenhar syndromes had higher odds ratio (OR) of respiratory failure (OR: 2.99, p = 0.009), severe adverse events (p = 2.29, p = 0.01), and readmissions (p = 2.26, p = 0.02). Over 5 years, they had a significantly higher incidence of reoperation compared to those with AIS (18.1% versus 5.5%, p = 0.005).

Conclusions: In this national sample of patients with Goldenhar syndrome undergoing posterior spinal fusion, patients with Goldenhar had increased odds of respiratory failure, readmissions, and reoperations. Targeted risk mitigation strategies may be appropriately considered for those with Goldenhar syndrome undergoing such surgeries.

Level of evidence: Level III; Case-control study or retrospective cohort study.