Annual and intra-annual climate variability and change of the Volta Delta, Ghana.

Deltas are geographically and socio-ecologically distinct systems, with a unique climate and contextually high vulnerabilities to climate dynamics. Hence, they require specific climate change adaptation and policy responses, informed by delta-scale analysis. However, available climate knowledge on deltas is based mainly on broad-scale analysis that masks information unique to deltas. This applies to the Volta Delta system of Ghana. This study presents annual and intra-annual climate variability and trend analysis carried out across the Volta Delta, using the coefficient of variation (CV), anomaly, Mann-Kendall and Pettit statistics. There were time and space differences in climate change and variability. Statistically significant (P < 0.05) positive trends were observed for the major wet season and the mean annual rainfall for Ada and highly significant (P < 0.01) positive trends for Akatsi. These contrasted with the observations in Adidome, which experienced a statistically highly significant (P < 0.01) decreasing trend in rainfall. There were significant (P< 0.05) increases in annual minimum, maximum, and mean temperatures over time in both coastal and inland delta stations. The annual rate of change of mean temperature ranged from 0.03 to 0.05. Ada, the more coastal location, has experienced a narrow range of temperature change, most probably due to the buffering capacity of the ocean. Point changes were observed in the climate data series in four (4) localities. We recommend that adaption and policy actions should include, the provision of small-scale irrigation, encouraging adoption of drought-resistant crop varieties and crop diversification, and also be made responsive to the existing spatiotemporal climate variability and change within the Volta Delta.

Characterization of complex vertebral transposition (gamma deformity) > 180 degrees: clinical and radiographic outcomes of halo gravity traction and vertebral column resection (VCR).

STUDY DESIGN: Prospective case series OBJECTIVE: Results of surgical treatment of complex vertebral transposition "Gamma Deformity" > 180 degrees with halo gravity traction (HGT) and vertebral column resection (VCR). We recently published a novel classification system for complex spine deformities of which complex vertebral transposition > 180 degrees (Gamma; type 3) was described. Halo gravity traction (HGT) has been shown to mitigate surgical risk in complex spine deformity correction and in some cases obviates the need for three-column osteotomy. However, we are not aware of report of its utilization in treating Gamma deformities with or without vertebral column resection (VCR). METHODS: A consecutive series of 13 patients with Gamma deformity (GD) were prospectively enrolled at a single site in West Africa. Standard radiographs and 3D computerized tomography (CT) were done to assess coronal and sagittal vertebral transposition (CVT and SVT). The HGT with 50% of body weight was applied over several weeks followed by VCR. Demographics, operative data, radiographic parameters, and complications data were collected. RESULTS: 13 pts with GD underwent HGT for an avg of 110 days prior to definitive surgery. Etiologies were Congenital-11 pts and Neurofibromatosis-2 pts. Average age: 17.8 years; Pts were reviewed at 3 months post-op and at minimum 2-year follow-up. Preop myelopathy was present in five patients. Pre-op CVT avg 75% and was corrected in all cases post-op. SVT avg 211 deg and improved with HGT by 36% and corrected to 53 deg (74% correction) post-op. Thoracic kyphosis avg -42 deg and averaged 48 deg post-op. Intra-op spinal cord monitoring (SCM) alerts occurred in 8 pts (61%). Post-operative LEM deficits occurred in 5 pts: 2 fully recovered by 3 months and 2 year follow-up, while the remaining 3 improved but had residual motor deficits at final follow-up. There was one post-operative mortality. CONCLUSION: The management of complex vertebral transposition (Gamma deformity) > 180 degrees with HGT prior to VCR is not only effective in some patients, but also associated with high SCM alerts and neurologic injury rates. Myelopathic patients with thoracic deformities are at higher risk of developing permanent neurologic deficits. Surgeons should be aware of this rare and unusual deformity and consider HGT and VCR bearing in mind the technical challenges and high complication rate.

Erratum to Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery [Spine Deformity 2 (2014) 340-349].

The corresponding author regret that co-author name was incorrectly published as "Elias C. Papadopoulus" in the article. The correct name of the author should be displayed as "Elias C. Papadopoulos".

Investigating the Universality of Preoperative Health-Related Quality of Life (HRQoL) for Surgically Treated Spinal Deformity in Young Adults: A Propensity Score-Matched Comparison Between African and US Populations.

STUDY DESIGN: Retrospective analysis of propensity score-matched (PSM) observational cohorts. OBJECTIVES: To evaluate and compare preoperative health-related quality of life (HRQoL) scores and radiographic measurements of young African and US adults with spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Young ASD patients in the United States are motivated more to correct coronal and sagittal plane deformities than to alleviate pain. Motivations for surgical correction in young ASD patients in Africa have not been previously investigated. METHODS: Retrospective review of two large databases of African and US patients with ASD. African patients who underwent ASD surgery were PSM by age, gender, and pelvic tilt with US patients. Preoperative radiographic parameters and HRQoL scores (ODI, SRS-22r, back/leg pain) were compared between cohorts. Pearson correlations used to evaluate relationships between radiographic parameters and HRQoL scores. RESULTS: Fifty-four US patients (average age 22.9 ± 4.9 years; 0% African American) and 54 African patients (24.6 ± 7.2 years) met inclusion criteria. Compared to the United States, African patients had significantly lower body mass index (21.1 ± 3.3 vs. 24.6 ± 7.2) and more severe scoliosis, coronal malalignment, and sagittal malalignment (p < .05). Africans also had significantly better Oswestry Disability Index (12.8 vs. 17.7), worse Scoliosis Research Society questionnaire (SRS-22r)-Appearance (2.5 vs. 3.2), SRS-Function (3.3 vs. 3.9), and SRS-Total (3.2 vs. 3.5) scores than US patients (p < .05). SRS-Appearance scores correlated with Cobb angles of the upper thoracic (r = -0.321), thoracic (r = -0.277), and thoracolumbar (r = -0.300) curves for US patients. For African patients, global sagittal alignment and C7 inclination correlated with SRS-Appearance (r = -0.347, -0.346, respectively). CONCLUSIONS: Young African ASD patients have significantly more severe deformity, less disability, and worse SRS-22r scores preoperatively than a matched cohort of US patients. Spinal deformity and associated poor self-image appear to be the major drivers of surgical intervention in this cohort. Global malalignment in African patients is most closely correlated with appearance scores and should be surgically addressed accordingly. LEVEL OF EVIDENCE: Level III.

Apex of deformity for three-column osteotomy. Does it matter in the occurrence of complications?

BACKGROUND: Posterior vertebral column resection (PVCR) is a challenging but effective technique for the correction of complex spinal deformity. However, it has a high complication rate and carries a substantial risk for neurologic injury. PURPOSE: The aim was to test whether the apex of the deformity influences the clinical outcomes and complications in patients undergoing PVCR. STUDY DESIGN: A historical cohort was recruited from a single center and evaluated preoperatively, postoperatively, and at final follow-up. PATIENT SAMPLE: Ninety-eight hyperkyphotic patients undergoing PVCR were included. Inclusion criteria consisted of kyphoscoliosis and hyperkyphosis surgically treated with PVCR as a primary or revision procedure. OUTCOME MEASURES: The outcome measures included a number of neurologic complications. METHODS: Receiver operator characteristic (ROC) curve analysis and Youden index (J) were used to estimate the optimum cut-off to predict neurologic complications for each potential risk factor. In three ROC analyses, we included separately body mass index (BMI), kyphosis degree, and age as independent variables and neurologic complications as the dependent variable. Logistic regression was used to estimate the odds ratios (ORs) and construct 95% confidence intervals (CIs). RESULTS: Among the 98 patients, the etiologies were: post infectious (50), congenital (31), and others (17). The averages were: age 14±6.5 years, BMI 20±10 kg/m(2), American Society of Anesthesiologists 3±0.7, forced vital capacity 76±23%, fusion levels 10±3, estimated blood loss 1,319±720 mL, surgical time 375±101 minutes, and preoperative localized kyphosis 104±30°. Thirty-three patients had abnormal preoperative neurologic status. Major complications occurred in 46 patients (neurologic in 25). The apex of kyphosis was proximal thoracic T1-T5 (five patients), thoracic (TH) T6-T9 (17 patients), thoracolumbar T10-L2 (55 patients), and lumbar L3-S1 (nine patients). The level of apex and BMI were independent risk factors for neurologic complications: TH apex (OR: 101.30, 95% CI: 1.420-infinite; p=.037); BMI (OR: 1.92, 95% CI: 1.110-infinite; p=.026). CONCLUSIONS: Posterior vertebral column resection for severe spine deformity is technically demanding and carries a substantial risk. The apex is a variable that influences the occurrence of neurologic complications, and the presence of a TH apex in particular could be a preoperative risk factor for neurologic complications.

Preoperative halo-gravity traction for severe spinal deformities at an SRS-GOP site in West Africa: protocols, complications, and results.

STUDY DESIGN: Retrospective analysis of a prospectively collected single-center database. OBJECTIVE: We describe a modified halo-gravity traction (HGT) protocol for patients with severe spinal deformities in West Africa, and assess the clinical and radiographic outcomes. SUMMARY OF BACKGROUND DATA: Three-column osteotomies are frequently used in the correction of severe spinal deformities; however, these can be associated with high complication rates and significant risk for neurological injury. Preoperative traction is one modality used to obtain a partial correction prior to definitive fusion. Low numbers and variability of traction protocols, however, have limited previous reports of sustained HGT. METHODS: All patients who underwent HGT in Ghana from April 2012 to August 2013 were reviewed. HGT was started at 20% body weight and increased by 10% per week until 50% body weight was reached by 4 weeks or thereafter as tolerated. Demographic variables, operative data, radiographic parameters, and health-related quality of life scores were collected. A deformity reduction index was calculated at each time point by summing the scoliosis and abnormal kyphosis for each patient and reported as a percentage of the preoperative deformity. RESULTS: Twenty-nine patients underwent HGT for an average 107 days prior to definitive posterior spinal fusion (24 patients) or placement of growing rods (5 patients). The major curve improved from an average 131° to 90° (31%) after HGT, and to an average 57° (56%) postoperatively. Pure kyphotic curves were rigid (flexibility 22% after traction), with a correction index of 3.88, which is similar to historical controls. Deformity correction with HGT plateaued at 63 days. Overall Scoliosis Research Society-22 questionnaire scores improved significantly pretraction versus postoperatively, but there was no change after traction versus before traction. There were 11 pin tract infections, with no neurological complications. CONCLUSION: HGT is a safe method to partially correct severe spinal deformities prior to a definitive procedure, and may reduce the need for higher risk 3-column osteotomies. Importantly, kyphosis secondary to infection with spontaneous apical ankylosis is relatively resistant to HGT. LEVEL OF EVIDENCE: 4.

Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: The purpose of this study is to review the postoperative complications in pediatric patients undergoing spine surgery and to establish a preoperative classification that stratifies surgical risk and case difficulty. SUMMARY OF BACKGROUND DATA: Pediatric spinal deformity (PSD) surgery can be challenging technically as well as economically. Often, a multidisciplinary approach to managing these patients is necessary. In an environment where resources are limited, such as in global outreach efforts, a method for stratifying PSD surgical cases can be useful for allocating appropriate resources and assigning appropriate skill sets in order to optimize patient outcomes and to streamline efforts. MATERIALS AND METHODS: A total of 145 consecutive PSD patients who underwent instrumented spinal fusion were reviewed. Radiographic measurements and demographic data were reviewed. A classification was established based on the curve magnitude, etiology, ASA grade, number of levels fused, the preoperative neurologic status, body mass index and type of osteotomies. Multiple regression analysis (MRA) and logistic regression analysis (LRA) were applied to indicate risk factors for complications. RESULTS: The average age was 14.3 years (10-20 years). The etiology was idiopathic scoliosis (n = 71), congenital scoliosis (n = 38), infectious (n = 11), and others. 23 patients had neurologic deficits preoperatively. Twenty-three patients had a posterior vertebral column resection. Patients were classified as Level 1 (n = 5), Level 2 (n = 19), Level 3 (n = 24), Level 4 (n = 58), and Level 5 (n = 39). Intraoperative neuro-monitoring changes were observed in 46 cases. Major complications were seen in 45 cases. A major complication consisted of implant related (n = 13), deep wound infection (n = 8), neurologic deficit (n = 7), death (n = 2), and others (n = 9). MRA demonstrated a significant correlation between classified level and %EBL/TBV, operative time, and complication rate. The risk level predicted the occurrence of general (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.08-2.21; p = .019) and neurologic (OR = 3.34; 95% CI = 1.06-17.70; p = .036) complications. Osteotomy and resection procedures were independent predictors for postoperative neurologic complications (OR = 1.7, 95% CI = 1.11-2.85; p = .015). CONCLUSION: Corrective spine surgery for complex pediatric deformity is challenging and carries a substantial risk. No single parameter appears to independently predict postoperative complications. However, when all risk factors are considered, there is a trend toward increased intraoperative electromonitoring change and postoperative neurologic risk with the higher level score in our classification. The newly established surgical risk stratification based on patient-specific clinical and radiographic factors can guide surgeons in their preoperative planning and surgical management of severe spine deformity in order to achieve optimal outcomes.