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Study design: Retrospective review of a prospectively collected single-center adolescent idiopathic scoliosis (AIS) database.

Objective: To evaluate the outcomes of single-sided thoracic anterior vertebral body tethering (VBT) versus bilateral thoracic/thoracolumbar VBT for the treatment of Lenke 1C type curves, as well as the outcomes of Lenke 1A/B curves compared to 1C curves.

Background: Lenke 1C curves can be successfully treated with selective thoracic fusion alone. However, there are few data to support whether this classification scheme holds true for VBT in Lenke 1C curves.

Materials and methods: A total of 242 consecutive AIS patients with Lenke 1 curves and a minimum two-year follow-up were grouped based on preoperative lumbar modifier A/B (n=163) or C (n=79). The total C group (CTot) was further subdivided into single-sided thoracic VBT (CSing, n=49) and bilateral thoracic and thoracolumbar VBT (CBil, n=30).

Results: The preoperative lumbar Cobb angle was larger for CBil (47°) than for CSing (36°, P=0.04), but similar at two years postoperative (CBil, 19°; CSing, 19°). Patients with preoperative open triradiate cartilage (TRC) had significantly increased revision rates, primarily for overcorrection, in all groups (A/B, 38%; CSing, 29%; CBil, 89%; P=0.01), compared to preoperative closed TRC (A/B, 10%; CSing, 17%; CBil, 19%). A similar percentage of patients in both groups required subsequent fusion (A/B, 5% vs. CTot, 10%; P=0.1).

Conclusion: The mean lumbar Cobb angle (19°) and percentage of patients with a lumbar Cobb angle > 35° (10%) were similar for CSing and CBil groups at the latest follow-up. Thus, performing a bilateral VBT did not significantly improve the postoperative lumbar curve magnitude compared with thoracic-only VBT (CSing) in our cohort. There was a non-significant difference in revision rates for A/B vs. C groups (18% vs. 28%), and CSing vs. CBil (20% vs. 40%). Revision rates were threefold higher in all patients with preoperative open TRC.

Study design: Systematic review and meta-analysis.

Objective: To investigate evidence on the prevalence and timeline of RTW after lumbar microdiskectomy.

Summary of background data: While lumbar microdiskectomy is a widely used and well-studied procedure, there is lack of evidence on the postoperative prevalence and schedule of return to work after this type of surgery.

Methods: Search at Medline, Embase, Cinahl, Scopus and Web of Science. Assessment of risk of systematic bias using Quality in Prognosis Studies (QUIPS). Random effects meta-analysis and meta-regression. Adults undergoing lumbar microdiskectomy due to degenerative disc herniation, excluding spinal stenosis, percutaneous diskectomy, artificial disk, arthroplasty, laminectomy, fusion or symptoms of cauda equina.

Results: Of identified 2,285 records, 31 were included in meta-analysis. Most of the studies had low risk of systematic bias. Pooling 21 studies, the mean prevalence of postoperative return to work was 78% (95% CI 71% to 83%). Pooling 13 studies the mean time of return to work was 4.79 (95% CI 3.88 to 5.70) weeks. The meta-regression of prevalence of return to work by the duration of follow-up resulted in significant but small coefficient of 0.02 (95% CI 0.01 to 0.03, P=0.006). There was considerable heterogeneity for all three models.

Conclusion: The results of this review suggest that approximately 70%-80% of patients who undergo a microsurgical procedure for disc herniation return to work within the first month and a half. It also seems that returning to work after this period is quite unlikely. The duration of preoperative symptoms did not affect significantly the prevalence of RTW. Information about these trends should be taken into account both in the planning phase of the procedure and in setting goals for postoperative rehabilitation.

Study design: Prospective cohort study.

Objective: This study aimed to investigate the durability of postural stability after ASD correction surgery and its' association with clinical outcomes.

Summary of background data: The prevalence of symptomatic adult spinal deformity (ASD) necessitates surgical intervention, aiming to correct global spinal balance and spinopelvic parameters. Short-term studies have shown improvements in postural control following surgery, but the long-term impact remains unclear.

Methods: This single-center prospective cohort study included adult patients undergoing long-segment fusion surgery between November 2019 and July 2021. Preoperative and postoperative balance assessments, radiographic analyses, and patient-reported outcome measures (PROMs) were conducted. Statistical analyses evaluated changes in postural stability and clinical outcomes.

Results: Fifteen ASD patients were analyzed. Significant improvements were observed in the early postoperative period in coronal center of pressure (COP) sway (P=0.048) and amplitude (P=0.027), total COP sway (P=0.042), coronal center of gravity (COG) amplitude (P=0.013), total COG sway (P=0.044), and head sway in the coronal plane (P=0.025). These improvements were maintained at the final postoperative visit for all measurements except coronal COG amplitude (early vs. last postoperative visit, P=0.040). Radiographic parameters, including pelvic incidence - lumbar lordosis mismatch (P=0.041) and sagittal vertical axis (P=0.032), also significantly improved postoperatively. PROMs revealed significant enhancements in VAS back pain (P=0.045), RAND SF-36 pain (P=0.016), RAND SF-36 physical functioning (P=0.008), and PROMIS pain interference (P=0.032) scores at the last follow-up.

Conclusion: These results demonstrate that the postural stability improvements seen after ASD correction are durable and correlate with enhanced clinical outcomes, such as reduced back pain and improved physical functioning. These findings underscore the clinical importance of achieving sagittal alignment in ASD patients. Further research with larger cohorts and extended follow-up periods is warranted to confirm these associations and establish postural stability assessment as a vital parameter in evaluating patients' quality of life postoperatively.

Level of evidence: Level 3.

Study design: Retrospective observational cohort.

Objectives: This study explores the impact of Intraoperative hypotension (IOH) on postoperative complications for major thoracolumbar spine fusion procedures.

Summary of background data: IOH with mean arterial pressure (MAP) <65 mm Hg is associated with postoperative acute kidney injury (AKI) in general surgery. In spinal deformity surgery, IOH is a contributing factor to MEP changes and spinal cord dysfunction with deformity correction.

Methods: A total of 539 thoracolumbar fusion cases, more than six surgical levels and >3 hours duration, were identified. Anesthetic/surgical data included OR time, fluid volume, blood loss, blood product replacement and use of vasopressors. Arterial-line based MAP data was collected at 1-minute intervals. Cummulative duration of MAP <65 mm Hg was recorded. IOH within the first hour of surgery vs. the entire case was determined. Post-op course and complications including SSI, GI complications, pulmonary complications, MI, DVT, PE, AKI, and encephalopathy were noted. Cumulative complications were grouped as none, one to two complications, or more than three complications.

Results: There was a significant association between occurrence of complications and duration of IOH within the first hour of surgery (8.2 vs . 5.6 min, P <0.001) and across the entire procedure (28.1 vs . 19.3 min, P =0.008). This association persisted for individual major complications including SSI, acute respiratory failure, PE, ileus requiring NGT, and postoperative cognitive dysfunction. Comparison of patients with zero versus one to two versus three or more complications demonstrated that patients with three or more complications had a longer duration of IOH in the first hour of the surgery and that patients who had no complications received less vasopressor than patients who had one to two or three or more complications.

Conclusion: This study identifies duration of IOH during the first hour of surgery as a previously unrecognized modifiable risk associated with major complications for multilevel lumbar fusion surgery.

Level of evidence: III.

Study design: Multicentric retrospective study of prospectively collected data.

Objective: On the basis of normative data from a cohort of asymptomatic volunteers, this study sought to determine the rate of abnormal values of proximal junctional angles (PJA) in adult spinal deformity (ASD) surgery patients, and compare it with PJK rate.

Summary of background data: Proximal junctional kyphosis (PJK) definition does not take the vertebral level into account.

Patients and methods: This study included 721 healthy volunteers and 824 ASD surgery patients with two-year postoperative follow-up. Normative values for each disc and vertebral body between T1 and T12 were analyzed, then normative values for PJA at each thoracic level were defined in the volunteer cohort as the mean±2SD. PJA abnormal values at the upper instrumented vertebra (UIV) were compared with Glattes' and Lovecchio's definitions for PJK in the ASD population at two years.

Results: Mean age was 37.7±16.3 in the volunteer cohort, with 50.5% of females. Mean thoracic kyphosis (TK) was -50.9±10.8°. Corridors of normality included PJA greater than 20° between T3 and T12. Mean age was 60.5±14.0 years in the ASD cohort, with 77.2% of females. Mean baseline TK was -37.4±19.9°, with a significant increase after surgery (-15.6±15.3°, P <0.001). There was 46.2% of PJK according to Glattes' versus 8.7% according to Lovecchio's and 22.9% of kyphotic PJA compared with normative values ( P <0.001).

Conclusion: This study provides normative values for segmental and regional alignment of thoracic spine, used to describe abnormal values of PJA for each level. Using level-adjusted PJA values allows a more precise assessment of abnormal proximal angles and question the definition for PJK.

Level of evidence: Level II.

Study design: Genome-wide association study (GWAS) meta-analysis with downstream analyses.

Objective: To explore the genetic architecture of chronic low back pain (cLBP) and identify underlying biological mechanisms that contribute to its development.

Summary of background data: Chronic low back pain is prevalent and debilitating, with many cases having no identifiable biological cause. Current treatment options provide only limited relief, highlighting the need for a deeper understanding of the genetic and molecular factors involved in cLBP pathogenesis. Identifying these factors may lead to more effective, targeted therapies.

Methods: We conducted a GWAS meta-analysis involving 325,078 participants from the UK Biobank and the HUNT population studies. This was followed by downstream analyses, including gene prioritization, tissue enrichment analysis, and functional gene set analysis. Genetic loci were examined for their association with cLBP, and gene sets were assessed for functional relevance.

Results: Eighteen genetic loci associated with cLBP were identified corresponding to as many prioritized genes, including eight novel genes not previously linked to the condition. Tissue enrichment analysis highlighted significant involvement of hippocampal brain tissue, suggesting central memory processes may contribute to cLBP. Functional gene set analysis identified 37 gene sets, many related to transcription factors involved in bone and cartilage maintenance. Literature on the prioritized genes suggested a potential role for neurological, cartilaginous, and inflammatory mechanisms, including genes implicated in the innervation of intervertebral discs, inflammatory cell death, and central sensitization. Comparison with previous GWASs indicated potential differences between individuals who seek medical care and those who do not.

Conclusion: This study enhances our understanding of the genetic basis of cLBP, revealing distinct biological mechanisms and suggesting the existence of patient subgroups with differing treatment needs. These insights may pave the way for more tailored and effective treatment approaches in the future.

Level of evidence: Level 3 (observational study).

Study design: Retrospective cohort.

Objective: To compare the clinical outcomes of trial versus standard clinical practice (SCP) patients following cervical disc arthroplasty (CDA).

Background: CDA is hypothesized to reduce the shear strain and related complications resulting from fusion procedures. CDA has gained significant traction in recent decades. The typical non-trial patient undergoing CDA does not undergo the same level of preoperative scrutiny as those treated in formal clinical trials. Concerns exist about diverging clinical outcomes between these groups.

Methods: This investigation retrospectively reviews prospectively collected data on one and two-level CDA patients from C3-T1. Patients were recruited into randomized, controlled trials or SCP practice beginning in 2002 or 2018, respectively. One-year minimum follow-up was required. Hybrid constructs and prior cervical spine surgical history have been excluded. Clinical assessments included reoperation history and the patient-reported outcome measures of Visual Analog Scale (VAS) neck, VAS arm, and Neck Disability Index (NDI). Data was collected at the preoperative, postoperative, one-year, two-year, three-year, five-year, and ten-year time points.

Results: One hundred and sixty-eight patients underwent CDA at 193 cervical levels, including 104 trial patients and 64 SCP patients. Mean follow-up for the entire cohort was 6.1 years (0.9 - 20.4 years). Eight unique disc designs were utilized. Trial patients had a greater proportion of females and longer follow-up duration (P<0.05). Trial patients had significantly worse preoperative clinical scores with greater improvements at each follow-up time point. SCP patients had significantly higher index-level reoperation rates at five years.

Conclusion: Trial patients have lower rates of reoperation and improved clinical performance which could be in part due to more stringent selection criteria. This study is limited by long-term SCP response rates. Additional studies with larger cohorts are needed to improve our understanding of disc implant performance.

Study design: Meta-Analysis.

Objective: The purpose of this systematic review and meta-analysis was to pool the available data comparing MIS to open surgery for thoracolumbar fractures and provide a more comprehensive assessment on this topic.

Background: There remains a debate over whether minimally invasive surgery (MIS) or open fixation provides superior outcomes for patients with thoracolumbar fractures. While several randomized controlled trials and prospective studies have compared these two approaches, the published studies are limited by sample size.

Methods: Following PRISMA guidelines, a systematic review of the PubMed, Cochrane, and Google Scholar (pages 1-20) databases was performed on October 1, 2024. The extracted data consisted of complications, surgery-related parameters, early and late post-operative back pain, and post-operative regional kyphosis.

Results: Five RCTs and five prospective studies were included in the meta-analysis, including 584 patients, with 299 in the MIS group and 285 in the open group. MIS patients were shown to have less EBL (MD=-155.86; 95% CI: -217.97- -93.76, P<0.001), a shorter LOS (MD=-3.34; 95% CI: -4.62- -2.06, P<0.001), lower pain scores during the early post-operative period (MD=-1.14; 95% CI: -1.56- -0.71, P<0.001), and less regional kyphosis (MD=-5.17; 95% CI: -7.17- -3.16, P<0.001), even when stratifying by study type. Additionally, fluoroscopy time was longer in the MIS group (MD=0.60; 95% CI: 0.21-0.98, P=0.003), although this difference was not seen when looking at RCTs only.

Conclusion: Among patients with thoracolumbar fractures, treatment with MIS was associated with decreased EBL, shorter LOS, earlier pain reduction, and less regional kyphosis compared to treatment with open fixation. Additionally, higher radiation-exposure was seen among patients treated with MIS. While MIS offers several potential benefits, both MIS and open fixation remain safe and reliable options for the treatment of thoracolumbar fractures.

Study design: Retrospective registry analysis.

Objective: To examine predictions of individual Scoliosis Research Society-22r (SRS-22r) questions one year after surgery for adolescent idiopathic scoliosis (AIS).

Summary of background data: A precision-medicine approach to AIS surgery will inform patients of the likelihood of achieving particular results from surgery, specifically individual responses to the SRS-22r questionnaire.

Methods: A multicenter AIS registry was queried for surgical AIS patients treated between 2002 and 2020. Preoperative data collected included standard demographic data, deformity descriptive data, and SRS-22r scores. Postoperative one-year SRS-22r scores were modeled using ordinal logistic regression. The highest probability was the most likely response. Model performance was examined by c-statistics, where c >0.8 was considered excellent. Ceiling effects were measured by the proportion of patients reporting "5" to each question.

Results: A total of 3251 patients contributed data to the study; mean age 14.4 (±2.2) years, female 2631 (81%), major thoracic coronal curve 53°, mean lumbar 41°. C-statistic values ranged from 0.6 (poor) to 0.8 (excellent), evidence of varied predictive capabilities. Q17 ("days off work/school," c = 0.84, ceiling achieved 75%) and Q15 ("financial difficulties," c = 0.86, ceiling achieved 82%) had the greatest predictive capabilities while Q11 ("pain medication," c=0.73, ceiling achieved 67%), Q10 ("appearance," c=0.72, ceiling achieved 35%), and Q19 ("attractive," c=0.69, ceiling achieved 37%) performed poorly.

Conclusions: Prediction of individual SRS-22r item responses, perhaps most germane to AIS treatment, was poor. The prediction of less relevant outcomes, where ceiling effects are present, was greater as the models chose "5" for all responses. These ceiling effects may limit discrimination and hamper efforts at personalized outcome predictions.

Level of evidence: Level 3.