Antimicrobial susceptibility testing of bone and joint pathogens using isothermal microcalorimetry.

The rise in osteomyelitis and periprosthetic joint infections, in combination with increasing life expectancy and the prevalence of diabetes, underscores the urgent need for rapid and accurate diagnostic tools. Conventional culture-based methods are often time-consuming and prone to false-negatives, leading to prolonged and inappropriate antibiotic treatments. This study aims to improve osteomyelitis diagnostics by decreasing the time to detection and the time to an antibiotic susceptibility result to enable a targeted treatment using isothermal microcalorimetry (IMC). IMC measures heat flow in real-time, providing insights into bacterial metabolism without the need for labeling. Using clinical isolates from bone infections, assessing their response to antibiotics through IMC, we demonstrated that IMC could detect bacteria within 4 h and determine antimicrobial susceptibility profiles within 2-22 h (median 4.85, range 1.28-21.78). This is significantly faster than traditional methods. A decision tree, based on antibiotic susceptibility, accurately categorized pathogens, achieving high accuracy (74-100%), sensitivity (100%), and specificity (65-100%). These findings suggest that IMC could redefine diagnostics of bone and joint infections and potentially infections in general, offering timely and precise treatment guidance, thereby improving patient outcomes and reducing health care burdens. Further optimization and clinical validation are needed to fully integrate IMC into routine diagnostics.

Does the coronal deformity angular ratio affect bracing outcome in adolescent idiopathic scoliosis?

PURPOSE: To examine if coronal deformity angular ratio (C-DAR) serves as a predictor for progression to surgical magnitude in patients with Adolescent Idiopathic Scoliosis (AIS) treated with thoracolumbar sacral orthosis (TLSO). METHODS: Patients with AIS, prescribed a full-time TLSO, Cobb angle 20-40°, Risser 0-2, who wore the brace ≥ 12.9 h and reached skeletal maturity/surgery were included retrospectively. C-DAR was defined as the Cobb angle divided by the number of vertebrae in the curve, yielding a larger value in short curves. The association between C-DAR and the risk of progression to surgical magnitude (> 45°) was assessed. Secondly, we evaluated the association between pre-treatment Cobb angle and in-brace correction on the risk of progression to > 45°. RESULTS: We included 165 patients with a mean Cobb angle of 30 ± 6°. Of these, 46/165 (28%) progressed ≥ 6° and 26/165 (16%) reached surgical magnitude at the end of treatment. C-DAR was a significant predictor for risk of progression to surgical magnitude with an OR of 1.9 (CI 1.2-2.9) per unit increase in C-DAR. A threshold value of 5.15 was established and demonstrated an OR 5.9 (CI 2.1-17.9) for curve progression to a surgical magnitude. Likewise, pre-treatment Cobb angle showed a significant OR 1.3(CI 1.2-1.4) per degree increase in Cobb, whereas in-brace % correction showed OR 0.96 (CI 0.93-0.98). CONCLUSION: C-DAR is an independent predictor for progression to a surgical magnitude in AIS patients treated with bracing. Patients with a higher C-DAR should be counseled to help set realistic expectations regarding the likelihood of curve progression despite compliance with brace wear.

Pulmonary function in patients with idiopathic scoliosis 40 years after diagnosis.

BACKGROUND CONTEXT: Pulmonary function in patients with scoliosis has been a topic of concern, with some reports of markedly decreased ventilatory function leading to disability and increased mortality in patients with severe scoliosis. Only limited data is available concerning pulmonary function in adult patients with scoliosis. PURPOSE: To report the long-term pulmonary function (PF) in patients diagnosed with idiopathic scoliosis (IS) compared with an age-matched population using extended pulmonary function testing (EPFT). STUDY DESIGN/SETTING: Retrospective clinical follow-up. PATIENT SAMPLE: A total of 177 patients seen at our institution from 1972 to 1983 for a pediatric spinal deformity were assessed for inclusion in the study. About 77/129 eligible patients with IS (60%) partook in a clinical examination including radiographs, and EPFT. OUTCOME MEASURES: The EPFT values included forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, vital capacity (VC), total lung capacity (TLC), residual volume (RV), RV/TLC ratio, diffusion capacity of carbon monoxide (DLco), carbon monoxide transfer coefficient (KCO) and alveolar volume (VA). Results were expressed with z-scores derived from height and arm span normative data. Z-scores were calculated as z-score=Measured PF-Predicted PF /Relative standard deviation (RSD). The limits of normal, are defined as the 5th and 95th percentile limits (z-score between -1.645 and 1.645), respectively. METHODS: Patients underwent a clinical examination with full spine standing radiographs and EFPT. The results were compared between patients with thoracic and thoracolumbar/lumbar (TL/L) main curves, and overall compared with a background population. Results were expressed with z-scores derived from height and arm span normative data. RESULTS: Of 77 included patients, 76 (99%) were females with a mean age of 54.6±2.5 years. The mean follow-up time was 40.8±2.8 years. Forty-four patients had thoracic main curves, and 33 had TL/L main curves. We found no pulmonary impairment based on z-scores in the total cohort or between groups, with only patients who were current or previous smokers, having z-scores below the normal limits Patients with main thoracic curves displayed significantly lower PF on mean absolute values and mean z-scores on FEV1, FVC, FEV1/FVC ratio, VC, TLC, and DLco compared with main TL/L curves. Patients with thoracic curves had significantly larger Cobb angles at follow-up; 52±17° compared with 40±22° (p-value <.05) in the TL/L group. We found no linear association between thoracic Cobb angle and degree of pulmonary impairment assessed with DLco, TLC, and FVC. Comparison of pulmonary z-scores based on arm span data, differed significantly on FVC and TLC, with the arm span measurements showing lower mean z-scores (p-value <.05). CONCLUSIONS: Using EPFT, no pulmonary impairment could be demonstrated compared to the age-matched population 40 years after a diagnosis of IS. However, patients with thoracic curves had decreased PF compared to patients with TL/L curves although within the normal range. Thus, when treated as current guidelines suggest, patients with idiopathic scoliosis can expect the same long-term pulmonary function as the general population.

Machine learning identifies clusters of the normal adolescent spine based on sagittal balance.

PURPOSE: This study applied a machine learning semi-supervised clustering approach to radiographs of adolescent sagittal spines from a single pediatric institution to identify patterns of sagittal alignment in the normal adolescent spine. We sought to explore the inherent variability found in adolescent sagittal alignment using machine learning to remove bias and determine whether clusters of sagittal alignment exist. METHODS: Multiple semi-supervised machine learning clustering algorithms were applied to 111 normal adolescent sagittal spines. Sagittal parameters for resultant clusters were determined. RESULTS: Machine learning analysis found that the spines did cluster into distinct groups with an optimal number of clusters ranging from 3 to 5. We performed an analysis on both 3 and 5-cluster groups. The 3-cluster groups analysis found good consistency between methods with 96 of 111, while the analysis of 5-cluster groups found consistency with 105 of 111 spines. When assessing for differences in sagittal parameters between the groups for both analyses, there were differences in T4-12 TK, L1-S1 LL, SS, SVA, PI-LL mismatch, and TPA. However, the only parameter that was statistically different for all groups was SVA. CONCLUSIONS: Based on machine learning, the adolescent sagittal spine alignments do cluster into distinct groups. While there were distinguishing features with TK and LL, the most important parameter distinguishing these groups was SVA. Further studies may help to understand these findings in relation to spinal deformities.

Spinal cord injury in high-risk complex adult spinal deformity surgery: review of incidence and outcomes from the Scoli-RISK-1 study.

STUDY DESIGN: Clinical case series. OBJECTIVE: To describe the cause, treatment and outcome of 6 cases of perioperative spinal cord injury (SCI) in high-risk adult deformity surgery. SETTING: Adult spinal deformity patients were enrolled in the multi-center Scoli-RISK-1 cohort study. METHODS: A total of 272 patients who underwent complex adult deformity surgery were enrolled in the prospective, multi-center Scoli-RISK-1 cohort study. Clinical follow up data were available up to a maximum of 2 years after index surgery. Cases of perioperative SCI were identified and an extensive case review was performed. RESULTS: Six individuals with SCI were identified from the Scoli-RISK-1 database (2.2%). Two cases occurred intraoperatively and four cases occurred postoperatively. The first case was an incomplete SCI due to a direct intraoperative insult and was treated postoperatively with Riluzole. The second SCI case was caused by a compression injury due to overcorrection of the deformity. Three cases of incomplete SCI occurred; one case of postoperative hematoma, one case of proximal junctional kyphosis (PJK) and one case of adjacent segment disc herniation. All cases of post-operative incomplete SCI were managed with revision decompression and resulted in excellent clinical recovery. One case of incomplete SCI resulted from infection and PJK. The patient's treatment was complicated by a delay in revision and the patient suffered persistent neurological deficits up to six weeks following the onset of SCI. CONCLUSION: Despite the low incidence in high-risk adult deformity surgeries, perioperative SCI can result in devastating consequences. Thus, appropriate postoperative care, follow up and timely management of SCI are essential.

Opioid Use Prior to Adult Spine Deformity Correction Surgery is Associated With Worse Pre- and Postoperative Back Pain and Prolonged Opioid Demands.

STUDY DESIGN: Prospective multicenter database post-hoc analysis. OBJECTIVES: Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity. METHODS: Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up. RESULT: Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed. CONCLUSIONS: In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.

Using Electric Stimulation of the Spinal Muscles and Electromyography during Motor Tasks for Evaluation of the Role in Development and Progression of Adolescent Idiopathic Scoliosis.

Introduction: The role of the spinal muscles in scoliogenesis is not fully substantiated. Do they act scoliogenic (inducing scoliosis) or counteract scoliosis in adolescent idiopathic scoliosis (AIS)? In this study, we will examine this by using selectively placed Transcutaneous Electric Stimulation (TES) combined with a cinematic radiographic technique and by performing electromyographic (EMG) evaluations during various motor tasks. Method: This is a cross-sectional study of subjects with small-curve AIS. Using cinematic radiography, they were evaluated dynamically either under electrical stimulation or when performing motor tasks of left and right lateral bending and rotation whilst measuring the muscle activity by EMG. Results: Forty-five patients with AIS were included as subjects. Five subjects volunteered for TES and six subjects performed the motor tasks with EMG. At the initial visual evaluation, and when stimulated with TES, the frontal plane spatial positions of the vertebral bodies showed discrete changes without an apparent pattern. However, analyzing the spatial positions when calibrated, we found that the spinal muscles exert a compressive 'response' with a minor change in the Cobb angle (CA) in small-curve AIS (CA = 10-20°). In larger curves (CA > 20°), TES induced a 'larger deformity' with a relative four-fold change in the CA compared to small-curve AIS with a ratio of 0.6. When evaluating local amplitude (peak) or cumulative (mean) EMG signals, we were unable to find consistent asymmetries. However, one subject had rapid progression and one regressed to a straight spine. When adding the absolute EMG ratios for all four motor tasks, the subject with progression had almost 10-fold less summed EMG ratios, and the subject with regression had more than 3-fold higher summed EMG ratios. Discussion: Based on these findings, we suggest that the spinal muscles in small-curve AIS have a stabilizing function maintaining a straight spine and keeping it in the midline. When deformities are larger (CA > 20°), the spine muscle curve exerts a scoliogenic 'response'. This suggests that the role of the muscles converts from counteracting AIS and stabilizing the spine to being scoliogenic for a CA of more than 20°. Moreover, we interpret higher EMG ratios as heightened asymmetric spinal muscle activity when the spinal muscles try to balance the spine to maintain or correct the deformity. When progression occurs, this is preceded or accompanied by decreased EMG ratios. These findings must be substantiated by larger studies.

The effect of Providence night-time bracing on the sagittal profile in adolescent idiopathic scoliosis.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is characterized by coronal scoliosis and often a sagittal hypokyphosis. The effect of bracing on the sagittal profile is not well understood. The aim of this study is to assess the effect of night-time bracing on the sagittal profile in patients with AIS. METHODS: We retrospectively included AIS patients with a main curve of 25-45° treated with a night-time brace in our institution between 2005 and 2018. Patients with estimated growth potential based on either Risser stage, hand X-rays, or menarchal status were included. Coronal and sagittal radiographic parameters were recorded at both brace- initiation and -termination. Patients were followed until surgery or one year after brace termination. Results were compared to a published cohort of full-time braced patients. RESULTS: One hundred forty-six patients were included. Maximum thoracic kyphosis (TK) increased 2.5° (± 9.7) (p = 0.003), corresponding to a 3.5-fold relative risk increase post bracing in TK compared to a full-time brace cohort. Twenty-seven percent (n = 36) of the patients were hypokyphotic (T4/T12 < 20°) at brace initiation compared with 19% (n = 26) at brace termination (p = 0.134). All other sagittal parameters remained the same at follow-up. We found no association between progression in the coronal plane and change in sagittal parameters. CONCLUSION: This is the first study to indicate that night-time bracing of AIS does not induce hypokyphosis. We found a small increase in TK, with a substantially lower risk of developing flat back deformity compared to full-time bracing. The coronal curve progression was not coupled to a change in TK.

The influence of night-time bracing on curve progression is not affected by curve magnitude in adolescent idiopathic scoliosis: a study of 299 patients.

BACKGROUND AND PURPOSE: The efficacy of bracing larger curves in adolescent idiopathic scoliosis (AIS) patients is uncertain. We aimed to assess the influence of night-time bracing in AIS patients with main curves exceeding 40° Cobb angle at brace initiation. METHODS: We reviewed AIS patients treated with nighttime braces between 2005 and 2018. Patients with curves ≥ 25° and estimated growth potential were included. Patients were monitored with radiographs from brace initiation until brace weaning at skeletal maturity. Patients were grouped based on curve magnitude at initial evaluation: a control group (25-39°) and a large-curves group (≥ 40°). Progression was defined as > 5° increase. RESULTS: We included 299 patients (control group, n = 125; large-curves group, n = 174). In the control group, 65 (52%) patients progressed compared with 101 (58%) in the large-curves group (P = 0.3). The lower-end vertebra (LEV) shifted distally post-bracing in 41 (23%) patients in the largecurves group. Patients with progressive large curves were younger (age 13.2 [SD 1.5] vs. 13.9 [SD 1.1], P = 0.009) and more premenarchal (n = 36 [42%] vs. n = 6 [9%], P < 0.001) compared with non-progressive large curves. CONCLUSION: Progression risk in patients with curves exceeding 40° treated with night-time bracing is similar to smaller curves. The LEV moved distally in almost one-fourth of the larger curves, possibly affecting fusion levels in cases of surgery.

Carbon Instrumentation in Patients with Metastatic Spinal Cord Compression.

Recently carbon spinal implants have been introduced in the treatment of patients with metastatic spinal cord compression (MSCC). This is expected to decrease the deflection of radiation and improve diagnostic imaging and radiotherapy when compared to titanium implants. The aim of this study was to determine the safety and effectiveness of spinal carbon instrumentation (CI) in patients with MSCC in a large cohort study. A total of 163 patients received instrumentation between 1 January 2017 and 31 December 2021. A total of 80 were stabilized with CI and 83 with TI. The outcome measures were surgical revision, postsurgical survival, peri-operative bleeding, and surgery time. The peri-operative blood loss in the CI-group was significantly lower than that in the TI-group: 450mL vs. 630mL, (p = 0.02). There were no significant differences between the groups in mean survival (CI 9.9) vs. (TI 12.9) months (p = 0.39), or the number of patients needing a revision (CI 6) vs. (TI 10), (p = 0.39). The median duration of surgery was 121 min, (p = 0.99) with no significant difference between the two groups. Surgical treatment with CI for MSCC is safe and an equally sufficient treatment when compared to TI.

Postoperative lordosis distribution index, patient reported outcome measures, and revision surgery following transforaminal lumbar interbody fusion.

Objective: Lordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. Methods: This study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results: 126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was -15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). Conclusions: We found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing?

PURPOSE: Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing. METHODS: AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs. RESULTS: One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67). CONCLUSION: Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.

Demineralized cortical fibers are associated with a low pseudarthrosis rate in patients undergoing surgery for adult spinal deformity without three-column osteotomy.

Introduction: Following surgical treatment for adult spinal deformity (ASD) there is an increased risk of revision surgery due to mechanical failure or pseudarthrosis. Demineralized cortical fibers (DCF) were introduced at our institution aiming to reduce the risk of pseudarthrosis after ASD surgery. Research question: We wanted to investigate the effect of DCF on postoperative pseudarthrosis compared with allogenic bone graft in ASD surgery without three-column osteotomies (3CO). Materials & Methods: All patients undergoing ASD surgery between January 1, 2010 to June 31, 2020 were included in this interventional study with historical controls. Patients with current or previous 3CO were excluded. Before February 1, 2017, patients undergoing surgery received auto- and allogenic bone graft (non-DCF group) whilst patients after received DCF in addition to autologous bone graft (DCF group). Patients were followed for at least two years. The primary outcome was radiographic or CT-verified postoperative pseudarthrosis requiring revision surgery. Results: We included 50 patients in the DCF group and 85 patients in the non-DCF group for final analysis. Pseudarthrosis requiring revision surgery at two-year follow-up occurred in seven (14%) patients in the DCF group compared with 28 (33%) patients in the non-DCF group (p â€‹= â€‹0.016). The difference was statistically significant, corresponding to a relative risk of 0.43 (95%CI: 0.21-0.94) in favor of the DCF group. Conclusion: We assessed the use of DCF in patients undergoing ASD surgery without 3CO. Our results suggest that the use of DCF was associated with a considerable decreased risk of postoperative pseudarthrosis requiring revision surgery.

Independent Prognostic Factors Associated With Improved Patient-Reported Outcomes in the Prospective Evaluation of Elderly Deformity Surgery (PEEDS) Study.

STUDY DESIGN: Prospective, multicenter, international, observational study. OBJECTIVE: Identify independent prognostic factors associated with achieving the minimal clinically important difference (MCID) in patient reported outcome measures (PROMs) among adult spinal deformity (ASD) patients ≥60 years of age undergoing primary reconstructive surgery. METHODS: Patients ≥60 years undergoing primary spinal deformity surgery having ≥5 levels fused were recruited for this study. Three approaches were used to assess MCID: (1) absolute change:0.5 point increase in the SRS-22r sub-total score/0.18 point increase in the EQ-5D index; (2) relative change: 15% increase in the SRS-22r sub-total/EQ-5D index; (3) relative change with a cut-off in the outcome at baseline: similar to the relative change with an imposed baseline score of ≤3.2/0.7 for the SRS-22r/EQ-5D, respectively. RESULTS: 171 patients completed the SRS-22r and 170 patients completed the EQ-5D at baseline and at 2 years postoperative. Patients who reached MCID in the SRS-22r self-reported more pain and worse health at baseline in both approaches (1) and (2). Lower baseline PROMs ((1) - OR: .01 [.00-.12]; (2)- OR: .00 [.00-.07]) and number of severe adverse events (AEs) ((1) - OR: .48 [.28-.82]; (2)- OR: .39 [.23-.69]) were the only identified risk factors. Patients who reached MCID in the EQ-5D demonstrated similar characteristics regarding pain and health at baseline as the SRS-22r using approaches (1) and (2). Higher baseline ODI ((1) - OR: 1.05 [1.02-1.07]) and number of severe AEs (OR: .58 [.38-.89]) were identified as predictive variables. Patients who reached MCID in the SRS22r experienced worse health at baseline using approach (3). The number of AEs (OR: .44 [.25-.77]) and baseline PROMs (OR: .01 [.00-.22] were the only identified predictive factors. Patients who reached MCID in the EQ-5D experienced less AEs and a lower number of actions taken due to the occurrence of AEs using approach (3). The number of actions taken due to AEs (OR: .50 [.35-.73]) was found to be the only predictive variable factor. No surgical, clinical, or radiographic variables were identified as risk factors using either of the aforementioned approaches. CONCLUSION: In this large multicenter prospective cohort of elderly patients undergoing primary reconstructive surgery for ASD, baseline health status, AEs, and severity of AEs were predictive of reaching MCID. No clinical, radiological, or surgical parameters were identified as factors that can be prognostic for reaching MCID.

The Influence of Multilevel Spinal Deformity Surgery on the EuroQol 5 Dimensions' (EQ-5D) Questionnaire and Residential Status in the Elderly: A Prospective, Observational, Multicenter Study.

STUDY DESIGN: Multicenter, international prospective study. OBJECTIVE: This study investigated the clinical outcome up to 2 years after multi-level spinal deformity surgery in the elderly by reporting the minimal clinically important difference (MCID) of EuroQol 5-dimensions (EQ-5D), EQ-VAS, and residential status. METHODS: As an ancillary study of 219 patients ≥60 years with spinal deformity undergoing primary instrumented fusion surgery of ≥5 levels, this study focuses on EQ-5D (3-L) as the primary outcome and EQ-VAS and residential status as secondary outcomes. Data on EQ-5D were compared between pre-operatively and postoperatively at 10 weeks, 12 months, and 24 months. An anchor-based approach was used to calculate the MCID. RESULTS: The EQ-5D index and EQ-VAS, respectively, improved significantly at each time point compared to pre-operatively (from .53 (SD .21) and 55.6 (SD 23.0) pre-operatively to .64 (SD .18) and 65.8 (SD 18.7) at 10 weeks, .74 (SD .18) and 72.7 (SD 18.1) at 12 months, and .73 (SD .20) and 70.4 (SD 20.4) at 24 months). 217 (99.1%) patients lived at home pre-operatively, while 186 (88.6%), 184 (98.4%), and 172 (100%) did so at 10 weeks, 12 months, and 24 months, respectively. Our calculated MCID for the EQ-5D index at 1 year was .22 (95% CI .15-.29). CONCLUSIONS: The EQ-5D index significantly increased at each time point over 24 months after ≥5 level spinal deformity surgery in elderly patients. The MCID of the EQ-5D-3 L was .22. Patients living at home pre-operatively can expect to be able to live at home 2 years postoperatively.

Health-related quality of life in patients 40 years after diagnosis of an idiopathic scoliosis.

AIMS: Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL. METHODS: We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves. RESULTS: The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains. CONCLUSION: In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis.Cite this article: Bone Joint J 2023;105-B(2):166-171.

Comparison of baseline characteristics and postoperative complications in neuromuscular, syndromic and congenital scoliosis.

Nonidiopathic scoliosis encompasses a group of diagnoses, including neuromuscular scoliosis, syndromic scoliosis and congenital scoliosis. The objective of this study was to compare the preoperative and postoperative clinical differences in pediatric nonidiopathic scoliosis patients with neuromuscular scoliosis vs. syndromic scoliosis/congenital scoliosis. This is a single-center retrospective review of all pediatric patients undergoing spinal instrumentation for nonidiopathic scoliosis during a 5-year period. Neuromuscular scoliosis patients ( n = 144), syndromic scoliosis patients ( n = 44) and congenital scoliosis patients ( n = 52) were compared. Demographics, patient characteristics and outcomes were compared. Neuromuscular scoliosis patients had lower BMI z-scores and were more likely to have pulmonary disease, technology dependence and seizure disorder. Additionally, neuromuscular scoliosis patients underwent bigger procedures with more levels fused and a higher rate of pelvis fixation. By direct comparison, neuromuscular scoliosis patients tended to have more complications including deep surgical site infections, readmission in 30 days, return to operating room in 90 days and emergency care visits in 90 days. When controlling for the differences in their preexisting conditions and surgical procedure, we found that pelvic fixation was a major confounding factor, whereas the others had no effect. We further subanalyzed cerebral palsy patients and found this group to exhibit no difference in complications compared to other neuromuscular scoliosis subtypes. Neuromuscular scoliosis patients have different characteristics and subsequent postoperative complications than those with syndromic scoliosis and congenital scoliosis. The difference in complication profile is mainly due to differences in surgical procedure and a higher rate of pelvic fixation. This should be considered when planning nonidiopathic scoliosis surgery among multidisciplinary teams.

Accuracy of Rod Contouring to Desired Angles With and Without a Template: Implications for Achieving Desired Spinal Alignment and Outcomes.

STUDY DESIGN: Biomechanical Study. OBJECTIVE: The search for optimal spinal alignment has led to the development of sophisticated formulas and software for preoperative planning. However, preoperative plans are not always appropriately executed since rod contouring during surgery is often subjective and estimated by the surgeon. We aimed to assess whether rods contoured to specific angles with a French rod bender using a template guide will be more accurate than rods contoured without a template. METHODS: Ten experienced spine surgeons were requested to contour two 125 × 5.5 mm Ti64 rods to 40°, 60° and 80° without templates and then 2 more rods using 2D metallic templates with the same angles. Rod angles were then measured for accuracy and compared. RESULTS: Average angles for rods bent without a template to 40°, 60° and 80° were 60.2°, 78.9° and 97.5°, respectively. Without a template, rods were overbent by a mean of 18.9°. When using templates of 40°, 60° and 80°, mean bend angles were 41.5°, 59.1° and 78.7°, respectively, with an average underbend of 0.2°. Differences between the template and non-template groups for each target angle were all significant (p < 0.001). CONCLUSIONS: Without the template, surgeons tend to overbend rods compared to the desired angle, while surgeons improved markedly with a template guide. This tendency to overbend could have significant impact on patient outcomes and risk of proximal junctional failure and warrants further research to better enable surgeons to more accurately execute preoperative alignment plans.

Is preoperative S-albumin associated to postoperative complications and readmission in patients with adult spinal deformity: a prospective analysis of 128 patients using the Spine AdVerse Event Severity (SAVES) system.

PURPOSE: To assess the association between preoperative S-albumin and postoperative outcome following adult spinal deformity (ASD) surgery. METHODS: All patients undergoing ASD surgery from February 1, 2017 and January 31, 2018 at a single quaternary referral center were prospectively included. Adverse events (AE) during admission were assessed using the Spine AdVerse Events Severity (SAVES) system. Based on preoperative S-albumin, patients were categorized as "normal" or "abnormal" and compared regarding postoperative outcome, adverse events (AEs), 30- and 90-day readmission, revision surgery, and mortality. RESULTS: A total of 128 patients aged ≥ 18 years were included, and S-albumin was available in 88%. Of these, 73% (n = 93) were classified as "normal", 16% (n = 20) as "abnormal", and 12% (n = 15) as "missing". The "normal" albumin group had less comorbidity burden [ASA score 2 (2, 3) vs 3 (2, 3), p = 0.011], higher hemoglobin levels (8.4 (± 0.9) mmol/L vs 7.4 (± 1.1) mmol/L, p < 0.001), and higher S-albumin (38.9 (± 2.7) g/L vs 31.9 (± 4.4) g/L, < 0.001). The rate of 90-day readmission was significantly increased in the "abnormal" group (65% vs 36%), corresponding to a relative risk increase of 1.25 (95% CI 1.02-1.52, p = 0.029). Similar increased risks were found in subsequent logistic regression analyses, although results were not significant in multivariable analysis (p = 0.102). Comparing remaining outcome parameters, point estimates revealed increased AEs, 30-day readmission, and revision in the "abnormal" albumin group, although effects did not reach statistical significance. CONCLUSIONS: In a prospective, consecutive, single-center cohort of 128 patients undergoing ASD surgery, we found a significant association between "abnormal" preoperative S-albumin and increased 90-day readmission. Furthermore, although the findings were not statistically significant, we did find that AEs, 30-day readmission, and revision were numerically more frequent in the "abnormal" group, suggesting an expected tendency that should be further investigated. We conclude that nutritional status prior to ASD surgery could be important to consider and suggest validation in larger prospective cohorts. LEVEL OF EVIDENCE: Prognostic II.

Use of demineralized cortical fibers is associated with reduced risk of pseudarthrosis after pedicle subtraction osteotomy for adult spinal deformity.

PURPOSE: To assess the effect of demineralized cortical fibers (DCF) on postoperative pseudarthrosis requiring revision surgery in patients undergoing pedicle subtraction osteotomy (PSO) for adult spinal deformity (ASD). METHODS: The use of DCF was introduced across all procedures in 2017 and subsequent patients undergoing PSO surgery were prospectively and consecutively registered. Following sample-size estimation, a retrospective cohort was also registered undergoing the same procedure immediately prior to the implementation of DCF. The non-DCF group underwent surgery with ABG. Minimum follow-up was 2 years in both groups. The main outcome was postoperative pseudarthrosis, either CT-verified or verified intraoperatively during revision surgery due to rod breakage and assessed using Kaplan-Meier survival analyses. RESULTS: A total of 48 patients were included in the DCF group and 76 in the non-DCF group. The DCF group had more frequently undergone previous spine surgery (60% vs 36%) and had shorter follow-up (32 ± 2 vs 40 ± 7 months). Pseudarthrosis occurred in 7 (15%) patients in the DCF group and 31 (41%) in the non-DCF group, corresponding to a relative risk increase of 2.6 (95%CI 1.3-2.4, P < 0.01). 1-KM survival analyses, taking time to event into account and thus the difference in follow-up, also showed increased pseudarthrosis in the non-DCF group (log-rank P = 0.022). Similarly, multivariate logistic regression adjusted for age, instrumented levels and sacral fusion was also with significantly increased odds of pseudarthrosis in the non-DCF group (OR: 4.3, 95%CI: 1.7-11.3, P < 0.01). CONCLUSION: We found considerable and significant reductions in pseudarthrosis following PSO surgery with DCF compared to non-DCF. LEVEL OF EVIDENCE: III.