Rate of complications in scoliosis surgery - a systematic review of the Pub Med literature

Is young adult idiopathic scoliosis a distinct clinical entity from adolescent idiopathic scoliosis? a Systematic Review and Meta-analysis comparing pre-operative characteristics and operative outcomes

PURPOSE

This study aims to conduct a systematic review of the literature comparing pre-operative, intraoperative, and post-operative characteristics between adolescent idiopathic scoliosis (AIS) and young adult idiopathic scoliosis (YAdIS) patients.

METHODS

Following PRISMA guidelines, we conducted a search of the PubMed/Medline, EMBASE, and Cochrane Central databases to identify full-text articles in the English-language literature. Our inclusion criteria were studies that compared preoperative, intraoperative, and postoperative characteristics between AIS and YAdIS patients. We performed a meta-analysis reporting mean difference (MD) for continuous variables and Odds ratios (ORs) to assess differences in postoperative complications.

RESULTS

Seven studies consisting of 1562 patients were included in the meta-analysis. The AIS group exhibited less intraoperative bleeding and shorter surgical procedures, with a mean difference between groups of 122.3 ml (95% CI 46.2-198.4, p = 0.002) and 28.7 min (95% CI 6.5-50.8, p = 0.01), respectively. Although the preoperative Cobb angle did not differ between groups (p = 0.65), patients with AIS achieved superior postoperative deformity correction, with a mean difference of 7.3% between groups, MD - 7.3 (95% CI - 9.7, - 4.8, p < 0.00001), and lower postoperative Cobb angles of the major curve, MD 4.2 (95% CI 3.1, 5.3, p < 0.00001). YAdIS patients were fused, on average, 0.2 more vertebral levels than AIS patients, MD 0.2 (95% CI 0.01, 0.5, p = 0.04). AIS patients experienced a significantly shorter length of stay after the surgical procedure, with an MD of 0.8 days (95% CI 0.1, 1.6, p = 0.02). No significant difference was found between groups in terms of complications (p = 0.19).

CONCLUSIONS

YAdIS should be regarded as a distinct surgical entity, characterized by increased bleeding, longer surgical duration, greater deformity correction challenges, and the need for fusion of additional vertebral levels compared to AIS. Surgeons should be mindful of these differences and discuss them with patients and their families, especially in cases where the correction of the AIS deformity is delayed and there is a high risk of progression after skeletal maturity. Further research is needed to explore alternative surgical techniques and enhance outcomes for YAdIS patients.

Risk predictive score and cord morphology classification for intraoperative neuromonitoring alerts in kyphosis surgery

BACKGROUND

Intraoperative neuromonitoring (IONM) alert is one of the worrying events of kyphosis corrective surgery, which can result in a postoperative neurological deficit. To our knowledge, there is no risk prediction score to predict such events in patients undergoing kyphosis surgery.

PURPOSE

To develop a new preoperative MRI-based cord morphology classification (CMC) and risk prediction score for predicting IONM alerts in patients with kyphotic deformity.

STUDY DESIGN

Retrospective analysis of prospectively collected data.

PATIENT SAMPLE

About 114 patients undergoing surgical correction for kyphotic deformity.

OUTCOME MEASURES

Intraoperative neuromonitoring alerts and postoperative neurological status using AIS grading.

METHODS

Kyphotic deformity patients undergoing posterior spinal fusion were retrospectively reviewed. Based on the morphology of the spinal cord and surrounding CSF in MRI, there are 5 types of cord. Type 1 (normal cord): circular cord with surrounding visible CSF between the cord and the apex, Type 2 (flattened cord): cord with <50% distortion at the apex with obliteration of the anterior CSF; Type 3 (deformed cord): cord with >50% distortion at the apex with complete obliteration of the surrounding CSF; Type 4 (stretched cord): the cord is stretched and atrophied over the apex of the curve. Type 5 (translated cord): horizontal translation of the cord at the apex with buckling collapse of the vertebral column. Preoperative radiographs were used to measure the preoperative sagittal cobbs angle, sagittal deformity angular ratio (S-DAR), sagittal vertical axis (SVA), apex of the curve, and type of kyphosis. Clinical data like the duration of symptoms, clinical signs of myelopathy, neurological status (AIS grade), grade of myelopathy using the mJOA score, and type of osteotomy were documented. Multivariate logistic regression was used to determine the risk factors for IONM alerts and the risk prediction score was developed which was validated with new cohort of 30 patients.

RESULTS

A total of 114 patients met the inclusion criteria. IONM alerts were documented in 33 patients (28.9%), with full recovery of the signal in 25 patients and a postoperative deficit in 8 patients. Rate of IONM alerts was significantly higher in Type 5 (66%), followed by Type 4 (50%), Type 3 (21.1%), Type 2 (11.1%), and Type 1 (11.1%) (p-value<.001). Based on multiple logistic regression, 7 factors, namely preoperative neurological status, mJOA score≤6, presence of signs of myelopathy, apex of the curve above T5, preoperative sagittal cobbs, S-DAR, and MRI-based CMC, were identified as risk predictors. The value for the risk factors varies from 0 to 4, and the maximum total risk score was 13. The cut-off value of 6 had good sensitivity (84.9%) and specificity (77.8%) indicating a high risk for IONM alerts. The AUC of the predictive model was 0.92, indicating excellent discriminative ability.

CONCLUSION

We developed and validated a risk predictive score that identifies patients at risk of IONM alerts during kyphosis surgery. Identification of such high-risk patients (risk score≥6) helps in proper evaluation and preoperative counselling and helps in providing a proper evidence-based reference for treatment strategies.

Biomechanical analysis of spinal cord injury during scoliosis correction surgery

Introduction: Surgical correction is a common treatment for severe scoliosis. Due to the significant spinal deformation that occurs with this condition, spinal cord injuries during corrective surgery can occur, sometimes leading to paralysis. Methods: Such events are associated with biomechanical changes in the spinal cord during surgery, however, their underlying mechanisms are not well understood. Six patient-specific cases of scoliosis either with or without spinal complications were examined. Finite element analyses (FEA) were performed to assess the dynamic changes and stress distribution of spinal cords after surgical correction. The FEA method is a numerical technique that simplifies problem solving by replacing complex problem solving with simplified numerical computations. Results: In four patients with poor prognosis, there was a concentration of stress in the spinal cord. The predicted spinal cord injury areas in this study were consistent with the clinical manifestations of the patients. In two patients with good prognosis, the stress distribution in the spinal cord models was uniform, and they showed no abnormal clinical manifestations postoperatively. Discussion: This study identified a potential biomechanical mechanism of spinal cord injury caused by surgical correction of scoliosis. Numerical prediction of postoperative spinal cord stress distribution might improve surgical planning and avoid complications.

The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis

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.

LEVEL OF EVIDENCE

III.

Adolescent idiopathic scoliosis in adulthood

Adolescent idiopathic scoliosis (AIS) is an abnormal coronal curvature of the spine that most commonly presents in adolescence. While it may be asymptomatic, AIS can cause pain, cosmetic deformity, and physical and psychological disability with curve progression. As adolescents with AIS enter adulthood, condition outcomes vary with some experiencing curve stabilization and others noting further curve progression, chronic pain, osteoporosis/fractures, declines in pulmonary and functional capacity, among others. Regular monitoring and individualized management by healthcare professionals are crucial to address the diverse challenges and provide appropriate support for a fulfilling adult life with AIS. This review examines the prevalence, risk factors, presenting symptoms, diagnosis, management, and complications of AIS in the adult population, informing targeted interventions by clinicians caring for adult patients with AIS.

The impact of spinal fusion of adolescent idiopathic scoliosis in Salah (Islamic Prayer) movement: a retrospective case-control study

BACKGROUND

Corrective spine surgery is widely accepted for treating severe adolescent idiopathic scoliosis (AIS). Postoperative spinal range of motion (ROM) could be affected after such surgery. In certain populations, such as Muslims, this ROM change can impact daily life, as it may affect the five-times-a-day prayer (Salah). This study aims to assess the influence of spinal fusion (SF) in Adolescent Idiopathic Scoliosis (AIS) during the daily Islamic prayer (Salah).

METHODS

SF-AIS patients were videoed while performing Salah prayer. The kinematic documentation was assessed and compared to Salah movements of a control group of age-matched Muslim AIS patients, who had not had surgery. The prayer quality changes were subjectively classified into improved, no change/remained, and worsened, according to the Global Perceived Effect (GPE). Functional outcome and pain were assessed by the Scoliosis Research Society Questionnaire Version 30 (SRS-30).

RESULTS

Thirty-nine women and five men (mean age±SD: 14.8±2.3 years) met the inclusion criteria, and unoperated AIS patients were used as control (twenty-two women, mean age±SD: 15.32±1.43 years). The prostrations ROM of the SF-AIS group differed significantly from the control group (p<0.05). The GPE of the prayer movement showed improvement in 36.4%, no change in 59.1%, and worsening in 4.5% of the SF-AIS patients. The worsened group had a significantly lower bowing ROM and higher prostrations ROM compared to all groups of prayer quality changes (p<0.05). SRS-30 scores showed good outcomes (function 4.0±0.2, pain 4.2±0.5), along with the overall bowing ROM and prostrations ROM (84.2±12.0° and 53.4±9.6°, respectively). Moreover, a significant moderate positive correlation between the bowing ROM and pain (r=0.417, p=0.007) was also found.

CONCLUSION

Spinal fusion positively affects AIS Islamic patients in maintaining their daily Salah movement, ROM and prayer quality. Prayer quality assessment should be given extra attention as an adjuvant of the SRS-30 questionnaire to evaluate Muslim patients.

Pre-contoured patient-specific rods result in superior immediate sagittal plane alignment than surgeon contoured rods in adolescent idiopathic scoliosis

Background

Adolescent idiopathic scoliosis (AIS) surgery typically involves posterior spinal fusion (PSF) using rods contoured by the surgeon, which may be time-consuming and may not reliably restore optimal sagittal alignment. However, pre-contoured patient-specific rods may more optimally restore sagittal spinal alignment. This study evaluates the radiographic outcomes of AIS patients who underwent PSF utilizing surgeon contoured vs. pre-contoured rods.

Methods

This is a retrospective cohort study of AIS patients who underwent PSF with either surgeon contoured or pre-contoured rods. Demographics, Lenke classification, fused levels, osteotomies, estimated blood loss (EBL), and surgical time were also obtained via chart review. Coronal curve magnitude, T5-T12 thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL mismatch, and T1 pelvic angle (TPA) were obtained pre-operatively, postoperatively and at last follow up. Outcome measures included rate of achievement of postoperative radiographic alignment goals (TK between 20 and 40 degrees, PI-LL mismatch within 10 degrees, and TPA <14 degrees). Predicted post-operative sagittal alignment was also compared with observed measurements. Student's and paired t-tests were performed to determine significant mean differences for continuous variables, and chi-square for categorical variables.

Results

No differences were found in demographics, Lenke classification, preop radiographic measurements, fused levels, osteotomies, EBL, and surgical time in the surgeon contoured cohort (n=36; average follow up 11.3 months) and pre-contoured cohort (n=22; average follow up 9.7 months). At last follow up, 95.5% of patients with pre-contoured rods vs. 61.1% of patients with surgeon contoured rods (P=0.004) met TK goal. During assessment of first standing postoperative X-ray, 72.7% of patients with pre-contoured rods vs. 33.3% of patients with surgeon contoured rods met PI-LL mismatch goal (P=0.004). Other radiographic measurements were similar. Artificial intelligence (AI) predicted and observed differences for the pre-contoured group were 3.7 for TK (P=0.005), -7.6 for PI-LL mismatch (P=0.002), and -2.6 for TPA (P=0.11).

Conclusions

AI and pre-contoured rods help achieve global sagittal balance with high accuracy and improved kyphosis restoration and PI-LL mismatch than surgeon contoured rods in AIS patients.

Paraspinous Muscle Flaps in Complex Pediatric Spine Surgeries: A 12-Year Single Institution Experience

PURPOSE

The benefits of paraspinous flaps in adult complex spine surgery patients are established in the literature; however, their use in pediatric patients has not been well described. This study compares clinical outcomes with and without paraspinous muscle flap closure in pediatric patients who have undergone spine surgery.

METHODS

We conducted a retrospective review of all pediatric spine surgeries at the University of California, San Francisco from 2011 to 2022. Patients were divided into 2 cohorts based on whether the plastic surgery service closed or did not close the wound with paraspinous muscle flaps. We matched patients by age, American Society of Anesthesiology classification, prior spinal surgical history, and diagnosis. Surgical outcomes were compared between the 2 cohorts.

RESULTS

We identified 226 pediatric patients who underwent at least one spinal surgery, 14 of whom received paraspinous flap closure by plastic surgery. They were matched in a 1:4 ratio with controls (n = 56) that did not have plastic surgery closure. The most common indication for plastic surgery involvement was perceived complexity of disease by the spine surgeon with concern for inadequate healthy tissue coverage (78.6%), followed by infection (21.4%). Postoperative complications were similar between the two groups. The plastic surgery cohort had a higher rate of patients who were underweight (57.1% vs 14.3%, P < 0.01) and had positive preoperative wound cultures (28.6% vs 8.9%, P = 0.05), as well as a higher rate of postoperative antibiotic usage (78.6 vs 17.9%, P < 0.01). There was no difference in recorded postoperative outcomes.

CONCLUSIONS

Spine surgeons requested paraspinous flap closure for patients with more complex disease, preoperative infections, history of chemotherapy, or if they were underweight. Patients with paraspinous flap coverage did not have increased postoperative complications despite their elevated risk profile. Our findings suggest that paraspinous muscle flaps should be considered in high-risk pediatric patients who undergo spine surgery.

Scoliocorrector Fatma-UI for correction of adolescent idiopathic scoliosis: Development, effectivity, safety and functional outcome

BACKGROUND

Adolescent idiopathic scoliosis remains a major problem due to its high incidence, high risk, and high cost. One of the aims of the management in scoliosis is to correct the deformity. Many techniques are available to correct scoliosis deformity; however, they are all far from ideal to achieve three-dimensional correction in scoliosis.

AIM

To develop a set of tools named Scoliocorrector Fatma-UI (SCFUI) to aid three-dimensional correction and to evaluate the efficacy, safety, and functional outcome.

METHODS

This study consists of two stages. In the first stage, we developed the SCFUI and tested it in finite element and biomechanical tests. The second stage was a single-blinded randomized clinical trial to evaluate the SCFUI compared to direct vertebral rotation (DVR). Forty-four subjects with adolescent idiopathic scoliosis were randomly allocated into the DVR group (n = 23) and SCFUI group (n = 21). Radiological, neurological, and functional outcome was compared between the groups.

RESULTS

Finite element revealed the maximum stress of the SCFUI components to be between 31.2 - 252 MPa. Biomechanical analysis revealed the modulus elasticity of SCFUI was 9561324 ± 633277 MPa. Both groups showed improvement in Cobb angle and sagittal profile, however the rotation angle was lower in the SCFUI group (11.59 ± 7.46 vs 18.23 ± 6.39, P = 0.001). Neurological and functional outcome were comparable in both groups.

CONCLUSION

We concluded that SCFUI developed in this study resulted in similar coronal and sagittal but better rotational correction compared to DVR. The safety and functional outcomes were also similar to DVR.

Neuromonitoring Changes in Spinal Deformity Surgery

Spinal cord injury is one of the most feared complications in spinal deformity surgery. The surgeon must be vigilant of direct and indirect sources of injury at all points during surgery. The incidence of complications has greatly decreased with the ability to monitor the motor and sensory pathways. Changes in signaling of these pathways provide context for what the insult is, and how to correct it before it becomes irreversible. There are well-established protocols that provide an algorithmic response to changes that can help all in the room determine the source of injury, and the appropriate reaction.

Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial

Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS).

Methods

UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination.

Discussion

The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.

Assessment of the Efficacy of Low-Density Pedicle Screw Construction Correction of Adolescent Idiopathic Scoliosis: A Prospective Single-Center Study

Background Adolescent idiopathic scoliosis (AIS) poses physical and psychological challenges for affected individuals, necessitating effective and less invasive treatment approaches. This study aimed to evaluate the efficacy of low-density posterior pedicle screw fixation in AIS correction, exploring its impact on deformity parameters, patient quality of life, and potential complications. Methodology A prospective study involving 20 AIS patients, employing low-density pedicle screw fixation, was conducted. Clinical, radiological, and Scoliosis Research Society (SRS-22) outcomes were assessed. Data analysis was conducted using SPSS version 26 software (IBM Corp., Armonk, NY, USA). Results Significant reductions in major and minor curve Cobb angles were observed (mean major curve reduction: 79.14%, p < 0.001; mean minor curve reduction: 68.91%, p < 0.001), indicating substantial deformity correction. As measured by the SRS-22 questionnaire, quality of life showed noteworthy improvements (mean pain score increase: 0.54, p < 0.05; mean self-image score increase: 1.22, p < 0.01), reflecting enhanced patient satisfaction and well-being. Complications were documented in four (20%) cases, including infection, adding-on phenomenon, proximal junctional kyphosis, and thoracic hypokyphosis. Conclusions Our study highlights the efficacy of low-density pedicle screw constructs in AIS correction. Significant deformity reductions and improved quality of life underscore the success of the approach. However, long-term studies with larger cohorts are crucial for confirming durability.

Prophylactic Spinal Cord Untethering in Children with Spinal Dysraphism Undergoing Thoracolumbar Fusion for Scoliosis

BACKGROUND

It remains unclear whether spinal cord untethering is necessary to reduce the chances of neurologic decline in children with myelomeningocele and complex closed spinal dysraphism who undergo thoracolumbar fusion for scoliosis. We sought to determine the neurologic and functional outcomes of children with spinal dysraphism undergoing spinal fusion for scoliosis with and without prophylactic spinal cord untethering.

METHODS

Retrospective, single-center review of patients with spinal dysraphism treated with thoracolumbar fusion over the last 10 years (2009-2019) with or without prophylactic spinal cord untethering.

RESULTS

Seventeen patients with myelomeningocele and complex closed spinal dysraphism underwent spinal fusion for scoliosis. Mean age at time of surgery was 13.9 years. Prophylactic spinal cord untethering was performed in 8 of 17 (47%) patients. The change in Cobb angle after surgery was similar between the 2 groups (19.4° untethered vs. 19.9° no untethering). The ambulatory status was similar between the groups, with 37% of the untethered cohort and 44% of the non-untethered cohort being community or household ambulators. There were no changes in intraoperative motor or sensory evoked potentials in any patient during fusion surgery. No patient had a change in motor level or ambulatory status after scoliosis surgery.

CONCLUSIONS

Our data suggest that prophylactic spinal cord untethering in children with spinal dysraphism undergoing thoracolumbar fusion for scoliosis may not be necessary in patients with moderate curvatures. Our conclusions are limited by the small sample size. A larger review of registry data may yield more powerful conclusions on the necessity of prophylactic spinal cord untethering in this patient population.

Feasibility, Safety and Reliability of Surgeon-Directed Transcranial Motor Evoked Potentials Monitoring in Scoliosis Surgery

(1) Background: Neuromonitoring is essential in corrective surgery for scoliosis. Our aim was to assess the feasibility, safety and reliability of "surgeon-directed" intraoperative monitoring transcranial motor evoked potentials (MEP) of patients. (2) Methods: A retrospective single-center study of a cohort of 190 scoliosis surgeries, monitored by NIM ECLIPSE (Medtronic), between 2017 and 2021. Girls (144) and boys (46) (mean age of 15 years) were included. There were 149 idiopathic and 41 secondary scoliosis. The monitoring consisted of stimulating the primary motor cortex to record the MEP with muscular recording on the thenar, vastus lateralis, tibialis anterior and adductor hallucis muscles. (3) Results: The monitoring data was usable in 180 cases (94.7%), with 178 true negatives, no false negatives and one false positive. There was one true positive case. The predictive negative value was 100%. The monitoring data was unusable in 10 cases (i.e., three idiopathic and seven secondary scoliosis). (4) Conclusions: Simplified transcranial MEP monitoring known as "surgeon-directed module" is usable, safety and reliable in surgery for moderate scoliosis. It is feasible in 95% of cases with a negative predictive value of 100%.

Anterior vertebral body tethering for adolescent idiopathic scoliosis associated with less early post-operative pain and shorter recovery compared with fusion

PURPOSE

While posterior spinal instrumentation and fusion (PSIF) for severe adolescent idiopathic scoliosis (AIS) is the gold standard, anterior vertebral body tethering (AVBT) is becoming an alternative for select cases. Several studies have compared technical outcomes for these two procedures, but no studies have compared post-operative pain and recovery.

METHODS

In this prospective cohort, we evaluated patients who underwent AVBT or PSIF for AIS for a period of 6 weeks after operation. Pre-operative curve data were obtained from the medical record. Post-operative pain and recovery were evaluated with pain scores, pain confidence scores, PROMIS scores for pain behavior, interference, and mobility, and functional milestones of opiate use, independence in activities of daily living (ADLs), and sleeping.

RESULTS

The cohort included 9 patients who underwent AVBT and 22 who underwent PSIF, with a mean age of 13.7 years, 90% girls, and 77.4% white. The AVBT patients were younger (p = 0.03) and had fewer instrumented levels (p = 0.03). Results were significant for decreased pain scores at 2 and 6 weeks after operation (p = 0.004, and 0.030), decreased PROMIS pain behavior at all time points (p = 0.024, 0.049, and 0.001), decreased pain interference at 2 and 6 weeks post-operative (p = 0.012 and 0.009), increased PROMIS mobility scores at all time points (p = 0.036, 0.038, and 0.018), and faster time to functional milestones of weaning opiates, independence in ADLs, and sleep (p = 0.024, 0.049, and 0.001).

CONCLUSION

In this prospective cohort study, the early recovery period following AVBT for AIS is characterized by less pain, increased mobility, and faster recovery of functional milestones, compared with PSIF.

LEVEL OF EVIDENCE

IV.

Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review

INTRODUCTION

The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery.

METHODS

Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009).

RESULTS

Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization.

CONCLUSIONS

Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.

Factors Affecting Transcranial Motor-Evoked Potential Measurements Using Single-Train Stimulation with an Increased Number of Pulses during Adolescent Scoliosis Surgery: A Prospective Observational Study

Measurement of transcranial motor-evoked potentials (TcMEPs) during scoliosis surgery helps detect postoperative new neurological defects. However, TcMEP interpretation is difficult owing to the influence of intraoperative physiological, pharmacological, and time-related factors as well as stimulation conditions. In this study, we aimed to investigate the effect of the abovementioned factors on TcMEP amplitude using single-train stimulation with an increased number of pulses (STS-INP) during adolescent scoliosis surgery; moreover, we evaluated the complications of TcMEP measurement. We included 50 patients and 706 TcMEP measurements. A total of 1412 TcMEP waveforms were analyzed, each on the bilateral abductor pollicis brevis, tibialis anterior, and abductor hallucis muscles. We estimated the mean difference (95% confidence interval (CI)) and predicted mean difference (95% CI) evaluated using the interquartile range of each factor, based on a mixed-effect model with random intercepts for TcMEP amplitude. The predicted mean differences in TcMEP amplitude were clinically small compared with the actual TcMEP amplitude, suggesting that each factor had a limited effect on TcMEP amplitude. No intraoperative bite injuries or seizures were observed. Using STS-INP during adolescent scoliosis surgery may enable accurate measurement of TcMEP amplitude with neither complications nor the influence of various intraoperative factors.

Risk factors of early complications after thoracic and lumbar spinal deformity surgery: a systematic review and meta-analysis

PURPOSE

To determine risk factors increasing susceptibility to early complications (intraoperative and postoperative within 6 weeks) associated with surgery to correct thoracic and lumbar spinal deformity.

METHODS

We systematically searched the PubMed and EMBASE databases for studies published between January 1990 and September 2021. Observational studies evaluating predictors of early complications of thoracic and lumbar spinal deformity surgery were included. Pooled odds ratio (OR) or standardized mean difference (SMD) with 95% confidence intervals (CI) was calculated via the random effects model.

RESULTS

Fifty-two studies representing 102,432 patients met the inclusion criteria. Statistically significant patient-related risk factors for early complications included neurological comorbidity (OR = 3.45, 95% CI 1.83-6.50), non-ambulatory status (OR = 3.37, 95% CI 1.96-5.77), kidney disease (OR = 2.80, 95% CI 1.80-4.36), American Society of Anesthesiologists score > 2 (OR = 2.23, 95% CI 1.76-2.84), previous spine surgery (OR = 1.98, 95% CI 1.41-2.77), pulmonary comorbidity (OR = 1.94, 95% CI 1.21-3.09), osteoporosis (OR = 1.60, 95% CI 1.17-2.20), cardiovascular diseases (OR = 1.46, 95% CI 1.20-1.78), hypertension (OR = 1.37, 95% CI 1.23-1.52), diabetes mellitus (OR = 1.84, 95% CI 1.30-2.60), preoperative Cobb angle (SMD = 0.43, 95% CI 0.29, 0.57), number of comorbidities (SMD = 0.41, 95% CI 0.12, 0.70), and preoperative lumbar lordotic angle (SMD = - 0.20, 95% CI - 0.35, - 0.06). Statistically significant procedure-related factors were fusion extending to the sacrum or pelvis (OR = 2.53, 95% CI 1.53-4.16), use of osteotomy (OR = 1.60, 95% CI 1.12-2.29), longer operation duration (SMD = 0.72, 95% CI 0.05, 1.40), estimated blood loss (SMD = 0.46, 95% CI 0.07, 0.85), and number of levels fused (SMD = 0.37, 95% CI 0.03, 0.70).

CONCLUSION

These data may contribute to development of a systematic approach aimed at improving quality-of-life and reducing complications in high-risk patients.

Paediatric Spinal Deformity Surgery: Complications and Their Management

Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.

A practical method for real-time detection of pedicle wall breaching during funneling

BACKGROUND

A reliable, real-time method for the detection of pedicle wall breaching during funnelling in spine deformity surgery could be accessible to any surgeon assisted with neuromonitoring.

METHODS

Fifty-six consecutive patients (1066 pedicles), who were submitted to spinal deformity surgery from December 2013 to July 2015 were included in the study group. A control group of 13 consecutive patients (226 pedicles) with spinal deformity surgery were operated on from January to December 2013 and were excluded from finder stimulation. In the study cohort, continuous stimulation during funnelling was delivered via a finder and subsequently a compound muscle action potential (CMAP) threshold was determined. Following funnelling, manual inspection of the pedicular internal walls was performed. The CMAP thresholds were compared with the results of palpation to determine the sensitivity and specificity of the technique for detecting pedicular breaching. To cover common ranges of damage, the medial and lateral breaches were compared and the concave-apical breaches compared to the non-apical or convex-apical breaches. In addition, a pedicle screw test was estimated for all patients.

RESULTS

ROC analysis showed 9 mA cut-off to have a sensitivity of 88.0% and a specificity of 89.5% for predicting pedicular breaching, with an area under the curve of 0.92 (95% confidence interval 0.90-0.94; P < 0.001). Using 9 mA threshold as an alert criterion, funnelling at the concave-apical pedicles showed significantly more true and false positive alerts and fewer true negative alerts when compared with the non-apical and convex-apical pedicles (P < 0.001). Medial breaches had significantly lower stimulation thresholds than lateral breaches (P < 0.001). Thresholds of screw-testing were significantly higher for study than for control-patients (P = 0.002).

CONCLUSIONS

Finder stimulation has a considerably higher sensitivity and specificity for prediction of pedicular breaching, most prominent for medial breaches. Screw-testing displayed significantly better results in patients undergoing the finder stimulation technique, as compared with the control group. The main advantages of our method are its high safety level and low cost, which may be critical in less affluent countries.

LEVEL OF EVIDENCE

III.

Hidden blood loss in adolescent idiopathic scoliosis surgery

INTRODUCTION

Posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS) have higher blood loss than other pediatric orthopedic surgeries. There is a paucity of literature estimating the hidden blood loss (HBL) in patients with AIS undergoing PSF. The purpose of this study was to compare intraoperative and postoperative estimated blood loss (EBL) in patients undergoing PSF for AIS to determine HBL.

HYPOTHESIS

With contemporary blood loss prevention strategies, HBL will be higher than intraoperative EBL.

MATERIAL AND METHODS

Over a 3-year period, 67 patients with preoperative and postoperative hemoglobin (Hgb) measurements undergoing PSF for AIS were evaluated. Intraoperative EBL was estimated using a volumetric method and recorded by a perfusionist managing a cell saver machine. Total perioperative EBL was estimated using the validated formula: EBL=weight (kg)×age sex factor×(preoperative Hgb - postoperative Hgb)/preoperative Hgb. HBL was calculated as the total perioperative EBL minus the intraoperative EBL.

RESULTS

Calculated total EBL was higher than intraoperative EBL (771±256mL vs. 110±115mL, p<0.001). Mean HBL after wound closure was 660±400mL. Patients 14 years or greater (p=0.03), with a BMI≥25kg/m²(p=0.02) and with surgical times over 3.5hours (p=0.05) had increased HBL. Multivariate analysis determined BMI≥25kg/m² (OR 9.91; CI, 1.01-104.26; p=0.05) was associated with increased HBL. Allogenic blood transfusion was rare (4%) and associated with increased HBL (897±112mL vs. 540±402mL, p=0.05).

DISCUSSION

For patients undergoing PSF for AIS there is more HBL after wound closure than intraoperative blood loss. This HBL is higher in older patients who undergo longer operations and have a BMI≥25kg/m².

LEVEL OF EVIDENCE

IV; retrospective cohort study.

Intraoperative neuromonitoring in non-idiopathic pediatric scoliosis operated with minimally fusionless procedure: A series of 290 patients

BACKGROUND

One of the worst complications of surgery for spinal deformity is postoperative neurological deficit. Multimodal intraoperative neuromonitoring (IONM) can be used to detect impending neurological injuries. This study aimed to analyze IONM in non-idiopathic scoliosis using a minimally invasive fusionless surgical technique.

METHODS

This retrospective, single-center study was performed from 2014 to 2018. Patients with non-idiopathic scoliosis who underwent a minimally invasive fusionless procedure and had at least 2 years of follow-up were included. IONM was performed using a neurophysiological monitoring work station with somatosensory evoked potentials (SSEP) and neurogenic mixed evoked potentials (NMEP).

RESULTS

A total of 290 patients were enrolled. The mean age at surgery was 12.9±3 years. The main etiology was central nervous system (CNS) disorders (n=139, 48%). Overall, 35 alerts (11%) in the SSEP and 10 (7%) in the NMEP occurred. There were two neurological deficits with total recovery after 6 months. There were no false negatives in either SSEP or NMEP, although there was one false positive in SSEP and two false positives for NMEP in the group without signal recovery. There was no significant relationship between the incidence of SSEP or NMEP loss and age, body mass index (BMI), number of rods used, upper instrumented vertebrae (p=0.36), lower instrumented vertebrae, or type of surgery. A preoperative greater Cobb angle was associated with a significantly higher risk of NMEP loss (p=0.02). In CNS patients, a higher BMI was associated with a statistically significant risk of NMEP loss (p=0.004). The use of a traction table was associated with a higher risk of signal loss (p=0.0005).

CONCLUSION

A preoperative higher Cobb angle and degree of correction were associated with a significant risk of NMEP loss. In CNS scoliosis, a higher BMI was associated with a significant risk of NMEP loss. The use of a traction table was associated with a higher risk of signal loss.

Nonoperative management of adolescent idiopathic scoliosis (AIS) using braces

This review presents the state of the art according to the current evidence on nonoperative treatment for adolescent idiopathic scoliosis, focusing on bracing. The definition of braces for the treatment of adolescent idiopathic scoliosis and a short history are provided. The analysis includes biomechanics, types, existing classifications, indications for treatment, time of brace wear and weaning, adherence, three-dimensional modeling, use of ultrasound imaging for bracing, management of treatment, issue of immediate in-brace correction, and documentation of the outcomes usually assessed for brace treatment, including the quality-of-life issues. According to the current evidence, there are two randomized control trials in favor of bracing. There are insufficient data on the superiority of one brace over another, although it is possible to classify and grade braces for efficacy from nonrigid to rigid and very rigid. Nevertheless, there is consensus on patients' management on the need for teamwork focusing on adherence to treatment, acceptability, and family and patient involvement.

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA

BACKGROUND

Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery.

METHODS

We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded.

RESULTS

Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03).

CONCLUSIONS

Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively.

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

Quality of Life Evaluation Using SRS-30 Score for Operated Children and Adolescent Idiopathic Scoliosis

Background and objective: Adolescent idiopathic scoliosis (A.I.S.) is a disorder with a significant impact on health and self-image. This spinal deformity can affect between 2% and 4% of the adolescent population and may alter one’s quality of life. This study aims to assess the patient outcome, satisfaction, and quality of life following surgical treatment using the SRS-30 questionnaire. Materials and Methods: A number of 49 children and adolescent patients diagnosed with idiopathic scoliosis that had surgery were included in this study. They thoroughly completed the SRS-30 questionnaire before and after the surgery, based on which data analysis was carried on. Correlations between the test results and imagistic data (pre- and postoperative Cobb angle, correction rate of Cobb angle, number of instrumented spinal segments, and number of pedicle screws/laminar hooks used in the surgery) were performed. Results: Our results showed that 87.76% of the patients were girls, and the mean age at surgery was 14.83 years. Postoperatively, the Cobb angle improved significantly (p < 0.0001). The questionnaire domain “Satisfaction with management” improved dramatically after surgery, averaging 13.65 points (91% out of the maximum score). The average postoperative test score was 125.1 points. Statistically significant correlations were found between the correction rate and SRS-30 score improvement (p < 0.001), in total as well as per each domain of the survey, respectively. Comparing the questionnaire domains, “Self-image” was positively correlated with “Satisfaction with management” (p < 0.0001). Conclusions: Better correction rate led to higher values of SRS-30 score. Additionally, the younger the age at surgery is, the higher the score. The number of instrumented spinal segments does not alter the quality of life. Overall, the most crucial factor influencing patient satisfaction after surgical treatment is self-image.

Wound-Related Complication in Growth-Friendly Spinal Surgeries for Early-Onset Scoliosis-Literature Review

Background: The treatment for early-onset scoliosis (EOS) is one of the most challenging for pediatric orthopedics. Surgical treatment is often necessary, and wound problems and surgical site infections (SSIs) are common, with potentially severe complications in these patients. The aim of the study was to review current literature according to this complication. Methods: PubMed, Cochrane Library, and Embase were systematically searched for relevant articles by two independent reviewers in January 2022. Every step of the review was done according to PRISMA guidelines. Results: A total of 3579 articles were found. Twenty four articles were included in this systematic review after applying our inclusion and exclusion criteria. EOS surgery has a varying but high rate of wound-related problems (on average, 15.5%). Conclusion: The literature concerning the definitions, collection, and interpretation of data regarding EOS wound-related complications is often difficult to interpret. This causes problems in the comparison and analysis. Additionally, this observation indicates that data on the incidence of SSI may be underestimated. Awareness of the high rate of SSI of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

Effectiveness of Acupuncture for Scoliosis: A Systematic Review

Scoliosis is a 3-dimensional change of the spine, presenting 10° above Cobb angle. Various acupuncture methods are being increasingly performed to correct scoliosis. However, no systematic review has been published. Therefore, we report on the effectiveness of acupuncture on mild scoliosis in this systematic review. We searched various databases for acupuncture treatment for scoliosis published before June 2021. The primary outcome was Cobb angle, and the secondary outcomes were patient-centered scores. Six studies were identified. RCTs that compared combination therapy with acupuncture, and other treatment methods and showed significant improvement in the Cobb angle, and effective rate, but, with low quality evidence. Acupuncture monotherapy resulted in significant improvement in the Cobb angle and had high heterogeneity compared with other treatment methods, but no significant improvement in the effective rate was observed, and the quality of evidence was low. Regardless of the type of scoliosis, acupuncture monotherapy or combination therapy with acupuncture showed significant improvement in the Cobb angle, and the quality of evidence was moderate. No serious adverse events were observed in the 6 studies reviewed. Acupuncture is considered safe, and it is more effective when performed with other conventional treatments.

Surgeon-Directed Neuromonitoring in Adolescent Spinal Deformity Surgery Safely Assesses Neurological Function

Background

Spinal deformity correction is associated with the risk of intra-operative neurological injury. Surgeon-directed monitoring (SDM) of transcranial motor-evoked potentials (TcMEP) is an option to monitor intra-operative spinal cord function. We report a retrospective analysis of a prospective database to assess the safety of this technique in spinal deformity correction in adolescent patients.

Methods

Surgeon-directed neuro-monitoring was utilised in 142 consecutive deformity correction surgeries (2012-2017). Surgeons were responsible for electrode placement, intra-operative stimulation, and interpretation of TcMEP data. If waveform disappearance occurred in the lower limb (LL), the surgeon would re-stimulate after excluding technical or anaesthetic factors. Failure to return normal waveforms led to maneuver reversal and reducing distractive force and ensuring subsequent return to baseline. Wake up test and ankle clonus followed by staging surgery was considered if the LL waveforms failed to return indicating potential motor injury.

Results

Of 142 patients, three cases (2.11%) had a complete visual loss of LL signals that did not resolve with anaesthetic stabilisation, leading to reversed surgical manoeuvre and staged surgery. No cases with permanent neurological dysfunction were recorded. This outcome supports surgeon-directed monitoring as a safe monitoring option, as an alternative to neurophysiologist-led monitoring. It also provides evidence in support of the waveform disappearance criteria as a safe TcMEP warning criterion with a 100% negative predictive value.

Conclusions

Where there is a lack of availability of trained neurophysiologists, surgeon-directed neuro-monitoring is a safe and reliable method of preventing intra-operative neurological injury amongst adolescent patients undergoing deformity correction.

One-Way Self-Expanding Rod in Neuromuscular Scoliosis: Preliminary Results of a Prospective Series of 21 Patients

Fusionless techniques for the treatment of neuromuscular early-onset scoliosis (EOS) are increasingly used to preserve spinal and thoracic growth and to postpone posterior spinal fusion (PSF). These techniques have greatly improved thanks to magnetically controlled growing rods, which allow the avoidance of repeated surgery. However, the surgery-related complication rate remains high. The objective of the current study was to report the preliminary outcomes of 21 patients with neuromuscular EOS who were treated with a 1-way self-expanding rod (OWSER). This device was designed to avoid repeated surgery and preserve spinal and thoracic growth thanks to its free rod sliding.

Surgical versus Nonsurgical Treatment for Adult Spinal Deformity: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically evaluate the efficacy and safety of surgical and nonsurgical methods for the treatment of adult spinal deformity (ASD).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant controlled studies of surgical and nonsurgical approaches for the treatment of ASD; all studies reported from database creation to October 2021 were eligible for inclusion. Stata 11.0 software was used for the meta-analysis. Publication bias was assessed using a Begg test. Heterogeneity was assessed using the I² test, and fixed-effects or random-effects models were used, as appropriate. Meta-regression was used to determine the cause of heterogeneity. Subgroup analyses were performed to assess the effects of age on the outcomes.

RESULTS

Eleven articles comprising 1880 participants met the inclusion criteria. Meta-analysis showed that surgical treatment was associated with a better improvement in function than was nonsurgical treatment (Scoliosis Research Society 22 questionnaire score change value: weighted mean difference = 0.696; 95% confidence interval [CI], 0.686-0.705; P < 0.0001; Oswestry Dysfunction Index change value: WMD = 11.222; 95% CI, 10.801-11.642; P < 0.0001). Surgical treatment was more effective in relieving pain and correcting the deformity (numeric rating scale pain score: WMD = 3.341; 95% CI, 2.832-3.85; P < 0.0001; Cobb angle change value: WMD = 15.036°; 95% CI, 13.325-16.747; P < 0.0001). The complication rate in the surgical group was 17.6%-80.3%.

CONCLUSIONS

Surgical treatment is better than nonsurgical methods for improving the function of patients with ASD and achieving good pain improvement and deformity correction. Elderly patients with ASD can also obtain good symptomatic improvement through surgery.

Is there an indication for surgery in patients with spinal deformities? - A critical appraisal

Background

High-quality evidence exists to support physiotherapy and brace treatment for scoliosis and other spinal deformities. However, according to previous systematic reviews, it seems that no evidence exists for surgery. Nevertheless, the number of research articles focussing on spinal surgery highly exceeds the number of articles focussing on conservative treatment.

Objective

The purpose of this study is to conduct an updated search for systematic reviews providing high-quality evidence for spinal surgery in patients with spinal deformities.

Method

A narrative review including PubMed and the Cochrane database was conducted on April 12, 2020, with the following search terms: (1) spinal deformities, surgery, systematic review and outcome; (2) kyphosis, surgery, systematic review and outcome; (3) Scheuermann's disease, surgery, systematic review and outcome, and (4) scoliosis, surgery, systematic review and outcome.

Results

No reviews containing prospective controlled or randomised controlled studies were found providing evidence for surgery.

Conclusions

A general indication for spine surgery just based on the Cobb angle is not given. In view of the long-term unknown variables and the possible long-term complications of such treatment, a surgical indication for patients with spinal deformities must be reviewed on an individual basis and considered carefully. A current systematic review appears necessary in order to be able to draw final conclusions on the indication for surgery in patients with spinal deformities.

Clinical implications

In view of the increasing number of surgeons with an affiliation to industry, the indication for surgery needs to be given by independent conservative specialists for spinal deformities in order to provide an objective recommendation.

Performing Multiple Posterior Spinal Fusions in 1 Day: A Comparison of Perioperative Outcomes Between Morning and Afternoon Cases

BACKGROUND

High-volume centers for idiopathic scoliosis (IS) have difficulty in scheduling posterior spinal fusions (PSFs) due to operating room availability, particularly during school vacation. A solution is for 1 surgeon to perform 2 PSF cases back-to-back. This study aims to compare morning and afternoon PSF cases performed by the same surgeon for perioperative outcomes.

METHODS

A retrospective review of PSF cases for IS that occurred on the same day as another PSF by the same surgeon between January 2013 and December 2019 was conducted. Perioperative outcomes included surgical time, estimated blood loss, length of stay, and inpatient opioid consumption normalized by the patient's weight. Postoperative outcomes included complications, revision rate, curve correction, and patient-reported outcomes using the Scoliosis Research Society-30.

RESULTS

A total of 95 patients (87% female), mean age 15.6 years, were analyzed, with 48 morning cases and 47 afternoon cases. The median follow-up was 1.9 years (range: 0.3 to 6.1 y). Tests for equivalency determined equivalence in median anesthesia and mean surgical duration (P=0.05). The groups had similar initial curve correction (P=0.43) and rate of complications at 90 days postoperative (2 in each group for a total of 4 complications). No significant differences were seen between Scoliosis Research Society-30 scores at 6 months or in those who have reached 2 years postoperative.

CONCLUSIONS

Little literature exists on the safety of a surgeon performing 2 PSF cases in 1 day, particularly in regard to pain outcomes, 30- and 90-day complication rates, and quality of life measures. This study indicates that few differences in safety, pain, and quality of life outcomes may appear between morning and afternoon PSF cases.

LEVEL OF EVIDENCE

Level II.

Risk of early complication following anterior vertebral body tethering for idiopathic scoliosis

PURPOSE

The purpose of this study was to determine peri-operative morbidity associated with anterior vertebral body tethering (aVBT) for idiopathic scoliosis.

METHOD

Of 175 patients treated with aVBT, 120 patients had 2 year follow up and were included in this study. Prospectively collected clinical and radiographic data was analyzed retrospectively.

RESULTS

Pre-operatively, the mean patient age was 12.6 year (8.2-15.7 year), Risser 0-3, with main thoracic scoliosis 51.2° (40-70°). Immediately post-operative, scoliosis improved to 26.9° (6-53°; p < 0.05), at 1-year post-operative was 23.0° (- 11 to 50°; p < 0.01 vs immediate post-op) and at 2-year post-operative was 27.5° (- 5 to 52; p = 0.64 vs immediate post-op). Pre-operative T5-T12 kyphosis was 16.0° (- 23 to 52°), post-operative was 16.9° (- 7 to 44°), at 1-year was 17.5° (- 14 to 61°) and at 2-year was 17.0° (- 10 to 50°; p = 0.72 vs pre-op). All patients underwent thoracoscopic approach, EBL 200 ml (20-900 ml), surgical time 215.3 min (111-472 min), anesthesia time 303.5 min (207-480 min), ICU stay of 0.2 day (0-2 days), and post-operative hospital stay 4.5 days (2-9 days). During the in-hospital peri-operative period, there were no unplanned return to the operating room (UPROR) and there was a 0.8% rate of complication: one pneumothorax requiring reinsertion of chest tube. By 90 days post-operative, there was no UPROR and a 5% rate of complication. Five additional patients developed complications after discharge: one CSF leak treated with blood patch injection in the clinic and resolved, two pleural effusions requiring chest tubes, one superficial wound infection and one pneumonia treated with outpatient antibiotics. By 1-year post-op, there was a 1.7% rate of UPROR and 8.3% rate of complication. Four additional patients developed complications beyond 90 days: two upper limb paresthesia required outpatient medical management, one CSF leak which initially treated blood patch injection in the clinic initially which then required UPROR, and one compensatory lumbar curve add on that was treated with extension of the tether. By 2-years post-op, there was a 6.7% rate of UPROR and 15.8% rate of complication. 9 additional complications developed after 1 year. One curve progression, one keloid scar, one right leg weakness, 4 cable failures and 2 curve overcorrections.

CONCLUSION

This large, multicenter series of aVBT demonstrated a 15.8% complication rate and a 6.7% UPROR rate at 2 year post-operatively. This early study during the learning curve of aVBT found higher rates of CSF leaks and overall complications than would be expected for PSFI at 1 year post-operatively and a higher rate of overall complications and of UPROR than would be expected for PSFI at 2 year post-operatively. As is common with new procedures, the complication rate may fall with further experience.

Complications in growth-friendly spinal surgeries for early-onset scoliosis: Literature review

BACKGROUND

The treatments for early-onset scoliosis (EOS), defined as curvature of the spine with onset before 10 years of age, continue to pose a great challenge for pediatric orthopedics. The treatment goals for EOS include minimizing spinal deformity while maximizing thoracic volume and pulmonary function. Different surgical techniques have different advantages and drawbacks; however, the two major concerns in the management of EOS are repeated surgeries and complications.

AIM

To review the current literature to assess the safety of EOS surgical treatment in terms of the rate of complications and unplanned surgeries.

METHODS

In January 2021 two independent reviewers systematically searched three electronic medical databases (PubMed, the Cochrane Library, and Embase) for relevant articles. Every step of the review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Due to the heterogeneity of articles and topics after data analysis, a descriptive (synthetic) analysis was performed.

RESULTS

A total of 2136 articles were found. Forty articles were included in this systematic review, after applying our inclusion and exclusion criteria. EOS surgery has a varying but high rate of complications. The most frequent complications were categorized as implant (54%), general (17%), wound (15%) and alignment (12%). The rate of complications might have been even higher than reported, as some authors do not report all types of complications. About 54% of patients required unplanned surgeries due to complications, which comprised 15% of all surgeries.

CONCLUSION

The literature concerning the definitions, collection, and interpretation of data regarding EOS surgery complications is often difficult to interpret. This creates problems in the comparison, analysis, and improvement of spine surgery practice. Additionally, this observation indicates that data on the incidence of complications can be underestimated, and should be interpreted with caution. Awareness of the high rate of complications of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

Early and late hospital readmissions in adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective review of a prospectively collected multicenter database.

OBJECTIVES

To identify risk factors for early and late readmission of surgically treated patients with adolescent idiopathic scoliosis (AIS). Specific risk factors associated with readmission in patients with AIS remain poorly understood.

METHODS

Patients with AIS who were operatively treated from 19 centers specializing in the treatment of pediatric spinal deformity were studied. Data from a minimum 2 years of clinical follow-up and any readmission were available for analysis. Characteristics of patients with no readmission, early readmission (< 90 days), and late readmission (> 90 days) were evaluated. Both univariate and multivariate analyses of risk factors for readmission were performed.

RESULTS

2049 patients were included in our cohort, with 1.6% requiring early readmission and 3.3% late readmission. In the multivariate analysis, greater preoperative coronal imbalance was associated with early readmission. Longer operative time was associated with late readmission. Finally, greater preoperative pain (SRS-22 pain scale) was associated with both early and late readmission. GI complications accounted for a higher proportion of early readmissions than previously reported in the literature.

CONCLUSIONS

Preoperative counseling of patients with higher levels of pain and coronal imbalance and the implementation of a thorough postoperative bowel regimen may help optimize patient outcomes.

LEVEL OF EVIDENCE

3.

Outcomes of Surgical Treatment for One Hundred Thirty-Eight Patients With Severe Sagittal Deformity at a Minimum 2-Year Follow-up: A Case Series

BACKGROUND

Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. It is well established that patients benefit from such treatment; however, the surgical outcomes for patients with severe sagittal deformity have not been reported.

OBJECTIVE

To report the outcomes of patients undergoing surgical correction for severe sagittal deformity.

METHODS

Retrospective review of a prospective, multicenter ASD database. Inclusion criteria: operative patients age ≥18, sagittal vertical axis (SVA) ≥15 cm, mismatch between pelvic incidence and lumbar lordosis (PI-LL) ≥30°, and/or lumbar kyphosis ≥5° with minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores including minimal clinically important difference (MCID)/substantial clinical benefit (SCB), sagittal and coronal radiographic values, demographic, frailty, surgical, and complication data were collected. Comparisons between 2 yr postoperative and baseline HRQOL/radiographic data were made. P < .05 was significant.

RESULTS

A total of 138 patients were included from 502 operative patients (54.3% Female, Average (Avg) age 63.3 ± 11.5 yr). Avg operating room (OR) time 386.2 ± 136.5 min, estimated blood loss (EBL) 1829.8 ± 1474.6 cc. A total of 71(51.4%) had prior fusion. A total of 89.9% were posterior fusion only. Mean posterior levels fused 11.5 ± 4.1. A total of 44.9% had a 3-column osteotomy. All 2 yr postoperative radiographic parameters were significantly improved compared to baseline (P < .001 for all). All 2yr HRQOL measures were significantly improved compared to baseline (P < .004 for all). A total of 46.6% to 73.8% of patients met either MCID/SCB for all HRQOL. A total of 74.6% of patients had at least 1 complication, 11.6% had 4 or more complications, 33.3% had minimum 1 major complication, and 42(30.4%) had a postop revision.

CONCLUSION

Patients with severe sagittal malalignment benefit from surgical correction at 2 yr postoperative both radiographically and clinically despite having a high complication rate.

Perioperative outcome and complications following single-staged Posterior Spinal Fusion (PSF) using pedicle screw instrumentation in Adolescent Idiopathic Scoliosis (AIS): a review of 1057 cases from a single centre

Background

There has been a growing interest in using all pedicle screw construct in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) surgery in recent years. However, studies focusing on perioperative outcome and complications utilizing only pedicle screw system in AIS population are lacking. This study aims to evaluate perioperative outcomes and to determine the prevalence of major and minor complications following single-staged PSF for AIS.

Methods

In this retrospective study of prospectively collected data, 1057 AIS patients operated between 2012 and 2019 were included. Main outcome measures were operative time, intraoperative blood loss, allogeneic blood transfusion rate, length of hospital stay after surgery, complication rate, and mean drop of haemoglobin (Hb) level. We documented the number of fusion levels, screw density, and postoperative radiographic parameters.

Results

There were 917 females and 140 males. Majority were Lenke 1 curve type (46.9%). Mean age was 15.6 ± 3.7 years, with mean BMI of 18.6 ± 3.2 kg/m². Mean operative time was 146.8 ± 49.4 min. Average intraoperative blood loss was 952.9 ± 530.4 ml with allogeneic blood transfusion rate of 5%. Mean screw density was 1.27 ± 0.21 screws per fusion level. Average hospital stay after surgery was 3.5 ± 0.9 days. Twenty-four complications were documented: twelve superficial infections (1.14%), five transient neurological deficits (0.47%), two deep infections (0.19%), two superior mesenteric artery syndrome, and one case each (0.09%) for massive intraoperative blood loss, intraoperative seizure, and lung atelectasis.

Conclusion

AIS patients treated with single-staged PSF using pedicle screw construct had a 0.95% rate of major complications and 1.32% rate of minor complications. Rate of neurologic complication was 0.47% while non-neurologic postoperative complications was 1.80% with infection being the leading complication at 1.32%.

Finite element assessment of a disc-replacement implant for treating scoliotic deformity

BACKGROUND

Bracing and spinal fusion surgery have long been the primary methods for idiopathic scoliosis correction; however, there exist multiple limitations with both techniques. Growth modulation techniques have recently been attempted, but are typically performed across multiple vertebral elements. The aim of this study was to quantify the corrective abilities of a dual-angled, wedge shaped, rigid disc implant designed to correct spinal deformity.

METHODS

The 3D spinal geometry of four patients was reconstructed using calibrated radiographs, from which personal finite element models were created. Coronal and sagittal Cobb angles and axial stress distribution were calculated pre- and post- simulation of device implantation at the apical vertebral element.

FINDINGS

Insertion of a rigid wedged implant resulted in up to 90.1% coronal correction with kyphotic normalization, and reduced axial stress differential within adjacent vertebrae by up to 83.3%. This correction in axial stress differential was seen to propagate to subjacent vertebrae in both rostral and caudal directions. Insertion of two implants yielded greater correction with respect to all three measures.

INTERPRETATION

Local Cobb angle correction, increased kyphotic angle, and a decrease in axial stress differential with adjacent and subjacent vertebral levels demonstrate a potential for deformity correction from within the disc space. The decrease in axial stress differential demonstrates a capacity for growth modulation and reversal of the Heuter-Volkmann principle. Based on qualitative views of spinal shape following device implantation, the wedged implant proved more efficacious in correcting single thoracic curves than double major curves.

Cost-Utility Analysis of Anterior Vertebral Body Tethering versus Spinal Fusion in Idiopathic Scoliosis from a US Integrated Healthcare Delivery System Perspective

Purpose

Anterior vertebral body tethering (VBT) is a non-fusion, minimally invasive, growth-modulating procedure with some early positive clinical outcomes reported in pediatric patients with idiopathic scoliosis (IS). VBT offers potential health-related quality of life (HRQoL) benefits over spinal fusion in allowing patients to retain a greater range of motion after surgery. We conducted an early cost-utility analysis (CUA) to compare VBT with fusion as a first-choice surgical treatment for skeletally immature patients (age >10 years) with moderate to severe IS, who have failed nonoperative management, from a US integrated healthcare delivery system perspective.

Patients and Methods

The CUA uses a Markov state transition model, capturing a 15-year period following index surgery. Transition probabilities, including revision risk and subsequent fusion, were based on published surgical outcomes and an ongoing VBT observational study (NCT02897453). Patients were assigned utilities derived from published patient-reported outcomes (PROs; SRS-22r mapped to EQ-5D) following fusion and the above VBT study. Index and revision procedure costs were included. Probabilistic (PSA) and deterministic sensitivity analyses (DSA) were performed.

Results

VBT was associated with higher costs but also higher quality-adjusted life years (QALYs) than fusion (incremental costs: $45,546; QALYs gained: 0.54). The subsequent incremental cost-effectiveness ratio for VBT vs fusion was $84,391/QALY gained. Mean PSA results were similar to the base case, indicating that results were generally robust to uncertainty. The DSA indicated that results were most sensitive to variations in utility values.

Conclusion

This is the first CUA comparing VBT with fusion in pediatric patients with IS and suggests that VBT may be a cost-effective alternative to fusion in the US, given recommended willingness-to-pay thresholds ($100,000–$150,000). The results rely on HRQoL benefits for VBT compared with fusion. For improved model accuracy, further analyses with longer-term PROs for VBT, and comparative effectiveness studies, would be needed.

Surgeon-directed transcranial motor evoked potential spinal cord monitoring in spinal deformity surgery

AIMS

Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy.

METHODS

We carried out a retrospective review of a single surgeon's prospectively maintained database of cases in which TcMEP monitoring had been used between 2010 and 2017. The upper limbs were used as the control. A true alert was recorded when there was a 50% or more loss of amplitude from the lower limbs with maintained upper limb signals. Patients with true alerts were identified and their case history analyzed.

RESULTS

Of the 299 cases reviewed, 279 (93.3%) had acceptable traces throughout and awoke with normal clinical neurological function. No patient with normal traces had a postoperative clinical neurological deficit. True alerts occurred in 20 cases (6.7%). The diagnoses of the alert group included nine cases of adolescent idiopathic scoliosis (AIS) (45%) and six of congenital scoliosis (30%). The incidence of deterioration based on diagnosis was 9/153 (6%) for AIS, 6/30 (20%) for congenital scoliosis, and 2/16 (12.5%) for spinal tuberculosis. Deterioration was much more common in congenital scoliosis than in AIS (p = 0.020). Overall, 65% of alerts occurred during rod instrumentation: 15% occurred during decompression of the internal apex in vertebral column resection surgery. Four alert cases (20%) awoke with clinically detectable neurological compromise.

CONCLUSION

Surgeon-directed TcMEP monitoring has a 100% negative predictive value and allows early identification of physiological cord distress, thereby enabling immediate intervention. In resource constrained environments, surgeon-directed TcMEP is a viable and effective method of intraoperative spinal cord monitoring. Level of evidence: III Cite this article: Bone Joint J 2021;103-B(3):547-552.

Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems.

METHODS

Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette.

RESULTS

Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management.

CONCLUSION

Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.

The importance of curve severity, type and instrumentation strategy in the surgical correction of adolescent idiopathic scoliosis: an in silico clinical trial on 64 cases

Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine which is frequently corrected with the implantation of instrumentation with generally good or excellent clinical results; mechanical post-operative complications such as implant loosening and breakage are however relatively frequent. The rate of complications is associated with a lack of consensus about the surgical decision-making process; choices about the instrumentation length, the anchoring implants and the degree of correction are indeed mostly based on personal views and previous experience of the surgeon. In this work, we performed an in silico clinical trial on a large number of subjects in order to clarify which factors have the highest importance in determining the risk of complications by quantitatively analysing the mechanical stresses and loads in the instrumentation after the correction maneuvers. The results of the simulations highlighted the fundamental role of the curve severity, also in its three-dimensional aspect, and of the instrumentation strategy, whereas the length of the fixation had a lower importance.

Comparison of a dual-surgeon versus single-surgeon approach for scoliosis surgery: a systematic review and meta-analysis

PURPOSE

Corrective surgery for scoliosis is a complex and challenging prospect for experienced spine surgeons due to the prolonged duration of surgery and the significant level of technical skill and expertise required. Traditionally, shorter operative time and lower blood loss have correlated well with improved outcomes and as such, efforts have been made to affect these metrics including the use of two attending surgeons for major cases in preference to one. This systematic review and meta-analysis assessed the available literature to further clarify the potential benefit that adopting a dual-surgeon approach offers over single-surgeon operations.

METHODS

A systematic review and meta-analysis assessed the effect of dual-surgeon operating compared to single-surgeon with respect to a number of indicators including blood loss, operative duration and length of hospital stay. In addition, we evaluated whether blood transfusion or complication rates differed between the two groups.

RESULT

Seven studies met our inclusion criteria. Mean difference indicated shorter duration of surgery (- 90.5 min, 95% CI [- 103.3, - 77.6]) and a lower blood loss (- 379.1, 95% CI [- 572.2, - 230.9]) in the dual-surgeon group compared to the single-surgeon group. Six studies reported mean length of stay and also favoured the dual-surgeon group.

CONCLUSION

This review observed that there are no randomised control trials evaluating dual-surgeon versus single-surgeon operating for scoliosis. We provide aggregated data and analysis of available literature, suggesting that outcomes in complex scoliosis surgery may be improved by adopting a dual-surgeon approach.

LEVEL OF EVIDENCE

III.

A 16-Year-Old Male with Thoracic Compression following Posterior Spinal Instrumentation and Fusion for Marfan-Associated Syndromic Scoliosis

Introduction

Marfan syndrome is an autosomal dominant disorder caused by a mutation in the FBN1 gene which affects connective tissue. The features of Marfan syndrome include many musculoskeletal abnormalities which require orthopaedic surgical intervention. Given the expansive phenotypic variations and comorbidities associated with Marfan syndrome, knowledge of perioperative risk factors and potential complications is essential.

Case

In this case report, the authors describe a patient with Marfan syndrome who underwent spinal instrumentation and fusion from T3 to L4 for correction of syndromic scoliosis. The patient had a complicated perioperative course requiring significant fluid resuscitation and vasoactive medications to support blood pressure. He required intensive care unit level care for continued hemodynamic instability despite resuscitation in the postoperative period. Common causes of postoperative hypotension such as hypovolemic shock, sepsis, ongoing hemorrhage, and prolonged effects of anesthesia were diagnostically ruled out. Ultimately, the patient's refractory hypotension was determined to be from mechanical compression, both from prolonged intraoperative prone positioning exacerbated by pectus excavatum and from the surgically corrected spine decreasing the diameter of his thoracic cavity (as referenced by his postoperative Haller index).

Conclusion

Mechanical compression of thoracic contents as a result of a worsening chest wall deformity can be a complication of spinal deformity correction.

Passive stiffness characteristics and neutral zone quality of the scoliotic lumbar torso in the principle anatomical planes of motion

BACKGROUND

The 1-10% prevalence rate of adult scoliosis frequently requires expensive therapy and surgical treatments and demands further research into the disease, especially with an aging population. Most studies examining the mechanics of scoliosis have focused on in vitro testing or computer simulations. This study quantitatively defined the passive stiffness properties of the in vivo scoliotic spine in three principle anatomical motions and identified differences relative to healthy controls.

METHODS

Adult scoliosis (n = 14) and control (n = 17) participants with no history of spondylolisthesis, spinal fracture, or spinal surgery participated in three different tests (torso lateral side bending, torso axial rotation, and torso flexion/extension) that isolated mobility to the in vivo lumbar spine. The spinal stiffnesses and spinal neutral zone width were calculated. These parameters were statistically compared between factor of population and within factor of direction.

FINDINGS

Torque-rotational displacement data were fit using a double sigmoid function, resulting an in excellent overall fit (Avg. R² = 0.95). There was a significant interaction effect between populations when comparing axial twist neutral zone width vs. lateral bend neutral zone width and axial twist stiffness vs. lateral bend stiffness. The axial twist neutral zone width magnitude was significantly larger in scoliosis patients.

INTERPRETATION

The present study is the first investigation to quantify the whole trunk neutral zone of the scoliotic lumbar spine. Future research is needed to determine if lumbar spine mechanical characteristics can help explain progression of scoliosis and complement scoliosis classification systems.

Is detethering necessary before deformity correction in congenital scoliosis associated with tethered cord syndrome: a meta-analysis of current evidence

PURPOSE

To compare the clinical and radiological outcomes in patients with congenital scoliosis (CS) and tethered cord syndrome (TCS) undergoing deformity correction with (NI group) versus without (NNI group) prior neurosurgical intervention aimed at detethering the cord.

METHODS

A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until March 2020. Inclusion criteria was studied describing performance of deformity correction and fusion surgery for congenital scoliosis with tethered cord syndrome with or without prior detethering procedure. Studies describing growth sparing procedures or congenital scoliosis associated with non-tethering pathologies such as syrinx were excluded. Case reports and series with less than 10 subjects were also excluded. NIH quality assessment tool was used for assessing quality of individual study.

RESULTS

Sixteen studies were included for analysis of which eight were found to be retrospective case series (level IV evidence) and retrospective case-control studies (level III evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, operative duration, blood loss or complication rate between the NI and NNI groups. However, subgroup analysis performed after inclusion of only level III evidence studies revealed significantly lesser operative duration and blood loss with comparable correction and complication rate in NNI group.

CONCLUSION

Deformity correction and fusion surgery may be performed safely and effectively in CS with TCS patients without the need of a prior detethering procedure.

From genetics to epigenetics to unravel the etiology of adolescent idiopathic scoliosis

Scoliosis is defined as the three-dimensional (3D) structural deformity of the spine with a radiological lateral Cobb angle (a measure of spinal curvature) of ≥10° that can be caused by congenital, developmental or degenerative problems. However, those cases whose etiology is still unknown, and affect healthy children and adolescents during growth, are the commonest form of spinal deformity, known as adolescent idiopathic scoliosis (AIS). In AIS management, early diagnosis and the accurate prediction of curve progression are most important because they can decrease negative long-term effects of AIS treatment, such as unnecessary bracing, frequent exposure to radiation, as well as saving the high costs of AIS treatment. Despite efforts made to identify a method or technique capable of predicting AIS progression, this challenge still remains unresolved. Genetics and epigenetics, and the application of machine learning and artificial intelligence technologies, open up new avenues to not only clarify AIS etiology, but to also identify potential biomarkers that can substantially improve the clinical management of these patients. This review presents the most relevant biomarkers to help explain the etiopathogenesis of AIS and provide new potential biomarkers to be validated in large clinical trials so they can be finally implemented into clinical settings.

Unusual cause of hemoptysis: A case report

Hemoptysis is defined as bleeding from the lower respiratory tract. It can be life-threatening and requires urgent investigation and intervention. Common causes of hemoptysis include bronchiectasis, tuberculosis, aspergilomas and malignancy. We present an unusual case of hemoptysis in a young woman with a history of surgery for scoliosis 18 years earlier. A 30-years-old woman was admitted to our institution for recurring hemoptysis since one year. She had a history of scoliosis and had undergone antero-lateral Th7 through Th12 spinal fusion surgery 18 years earlier. The hemoptysis was slight and resolved spontaneously or after empirical antibiotic therapy, and was attributed to bronchitis. Computed tomography revealed spinal rod penetration into the lung resulting in injury, while the caudal edge of the rod migrated into the liver and the joining screws had entered the mediastinum. Hemoptysis was due to penetration of the rod into the lung. The patient underwent extensive surgery, which was successful. The case highlights the need for thorough evaluation of patients with hemoptysis. Every incident of hemoptysis, even if minor, should be promptly investigated, because it can be life-threatening.

Outcomes of Nonsurgical Treatments for Symptomatic Adult Degenerative Scoliosis: A Systematic Review

OBJECTIVE

To evaluate the effectiveness of nonsurgical treatments in symptomatic adult degenerative scoliosis (ADS).

DESIGN

A systematic literature review.

METHODS

PubMed, Web of Science, and The Cochrane Library were searched to identify research published since 1988. Randomized controlled trials (RCTs) and observational cohort studies were eligible if they featured symptomatic ADS patients aged ≥50 who received nonsurgical treatment. Minimum follow-up was six weeks, and outcomes of interest were pain, disability, quality of life, and Cobb angle. Evidence quality per intervention was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Six studies were included. Of these, four focused specifically on injections, bracing, or yoga; two involved multiple treatments. One RCT provided evidence for greater effectiveness of transforaminal epidural steroid injection over anesthetic alone in reducing radiating pain and disability. Two single-group retrospective cohort studies lent support for bracing to slow curve progression. One retrospective single-group cohort study suggested an association between yoga and reduced curve progression. Evidence for injections to reduce ADS symptoms was rated as low quality; evidence for bracing and yoga was rated as very low quality. No specific evidence was identified regarding other treatments, including physical therapy and analgesics.

CONCLUSIONS

Literature describing the effectiveness of nonoperative treatments in symptomatic ADS is scarce. The quantity and quality of the evidence regarding injections, bracing, and yoga are insufficient to advise for or against the use of these methods to improve outcomes in symptomatic ADS. For these and other nonoperative treatment forms, further research is needed.