Hip reduction surgery versus scoliosis correction in non-ambulant neuromuscular patients: which surgery is the first step?

PURPOSE: Children and young adults with neuromuscular disorders have a high incidence of both spine and hip deformities. The aim of this study was to evaluate the outcome of either primary scoliosis or hip surgery in children and young adults with neuromuscular disorders. METHODS: A retrospective study was conducted on all children and young adults with neuromuscular-related synchronous hip subluxation/dislocation and scoliosis undergoing hip or scoliosis surgery in our institution between 2012 and 2021 with a minimum follow-up of 24 months. Demographic and operative data were collected; radiological parameters were measured preoperatively and postoperatively at final follow-up. RESULTS: Forty neuromuscular patients with synchronous hip displacement and scoliosis were included. Twenty patients with an average age of10.2 years had hip correction surgery performed primarily, with a mean follow-up of 54.9 (24-96) months. The other 20 patients with an average age of 12.4 years had scoliosis correction first, with a mean follow-up of 40 (24-60) months. In the "Hip first" group, pelvic obliquity, hip MP and Cobb angle were 16.8°, 71%, and 49°, respectively. At final follow-up, the mean pelvic obliquity and Cobb angles significantly progressed to 27.2° (p = 0.003) and 82.2° (p = 0.001), respectively. Eighteen patients (90%) required scoliosis correction after the hip surgery. In the "Scoliosis first" group, the mean pelvic obliquity, hip MP and Cobb angle were 21.2°, 49% and 65.5°, respectively. At final follow-up, both pelvic obliquity and Cobb angle significantly improved to 8.44° (p = 0.002) and 23.4° (p = 0.001), respectively. In 11/20 (55%) patients, the hip MP had significantly increased following the spinal surgery to 62% (p = 0.001), but only 5/20 (25%) patients underwent hip surgery after scoliosis correction. CONCLUSION: In neuromuscular patients presenting with synchronous hip displacement and scoliosis deformity, corrective scoliosis surgery is associated with a significant correction of pelvic obliquity and lower rates of secondary hip surgery. On the other hand, primary hip surgery does not reduce the risk of pelvic obliquity and scoliosis deformity progression.

Restoration of the sagittal profile according to the Roussouly classification reduces mechanical complications and revision surgery in older patients undergoing surgery for adult spinal deformity (ASD).

PURPOSE: The mechanical complications related to ASD remain a concern due to their morbidity and associated revision surgery. Restoration of each patient's Roussouly profile may reduce these. Our aim was to examine if the restoration of the Roussouly profile reduced these complications and revision rates in older patients operated for degenerative ASD. METHODS: Retrospective analysis of a single-centre, 2-year minimum follow-up patient database. All patients undergoing corrective surgery (≥ 4 levels) for ASD were included with analysis of demographic data, operative records, restoration of Roussouly sagittal profile, mechanical complications and revision rates. Univariate and multivariate analysis was conducted. RESULTS: Fifty-two patients were included (mean age was 72.3 years, average follow-up 56.3 months). Twenty-six patients had a "restored" profile (50%) and 26 an "unrestored" profile (50%). The incidence of mechanical complications was 7 (27%) and 23 (88%) for the restored and unrestored groups, respectively (p < 0.001). Revision rates were 4 (15.4%) and 18 (69.2%), respectively (p < 0.000), in the restored and unrestored profiles. Univariate analysis determined that profile restoration and BMI were associated with mechanical complications and revision surgery, whilst only the profile restoration status maintained its statistical power in multivariate analysis (p = 0.002 and p = 0.002, respectively). Age was not a significant factor in univariate analysis. The relative risk for mechanical failure and revision surgery was 5.6 times (CI 1.929-16.39) and 3.08 times (CI 1.642-5.734) greater if the profile was not restored. CONCLUSIONS: Achieving each patient's ideal Roussouly profile is associated with a reduced incidence of mechanical complications and revision rates in the older population after surgery for degenerative ASD.

Reconstruction of irreparable rotator cuff tears with an acellular dermal matrix in elderly patients without joint arthritis.

Background: Reverse shoulder arthroplasty is the mainstay of treatment for symptomatic irreparable rotator cuff tears in elderly patients without arthritis. However, this treatment incurs significant costs and is a major surgical undertaking. This study explores an alternative that involves the reconstruction of irreparable rotator cuff tears using an acellular dermal matrix in elderly patients without established joint arthritis. Methods: We prospectively evaluated the reconstruction of massive irreparable rotator cuff tears in 21 patients aged 68 years and over without radiographic glenohumeral joint osteoarthritis in whom conservative management had failed. A human dermal acellular matrix graft was used as a bridging graft for reconstruction. Pain scores, Oxford Shoulder Scores and ranges of movement were all assessed preoperatively and postoperatively. The mean follow-up period was 5.8 years (range 2.6 to 8.9 years). Results: Statistically significant (p < 0.05) improvements were observed in Oxford Shoulder Scores (mean preoperative score, 21; mean postoperative score, 46), pain scores (mean preoperative score, 6; mean postoperative score, 0) and ranges of movement. Patients also reported a high satisfaction rate with the procedure. Discussion: Human tissue matrix allografts could serve as a suitable option for the treatment of elderly patients with massive irreparable rotator cuff tears without arthritis.

Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review.

STUDY DESIGN: A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE: To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS: A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS: Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION: This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE: 3.

Ability of Spine Specialists to Identify Psychosocial Risk Factors as Obstacles to Recovery in Patients with Low Back Pain-Related Disorders.

STUDY DESIGN: Prospective study. PURPOSE: Yellow flags are psychosocial associated with a greater likelihood of progression to persistent pain and disability. These are referred to as obstacles to recovery. Despite their recognized importance, it is unknown how effective clinicians are in detecting them. The primary objective of this study was thus to determine the effectiveness of spine specialist clinicians in detecting the presence of yellow flags in patients presenting to an orthopedic outpatient clinic with low back-related disorders. OVERVIEW OF LITERATURE: Psychosocial factors have been previously studied as important predictors of prognosis in patients with low back pain. However, the ability of spinal specialist to identify them remains unknown. METHODS: A prospective, single-center, consecutive cohort study was conducted over a period of 30 months. All new patients with low back-related disorders regardless of pathology completed a Yellow Flag Questionnaire that was adapted from the psychosocial flags framework. Clinicians assessing these patients completed a standardized form to determine which and how many yellow flags they had identified during the consultation. RESULTS: A total of 130 patients were included in the analysis, and the clinicians reported an average of 5 flags (range, 0-9). Fear of movement or injury was the most frequently reported yellow flag, reported by 87.7% (n=114) of patients. Clinician sensitivity in detecting yellow flags was poor, correctly identifying only 2 flags, on average, of the 5 reported by patients, with an overall sensitivity of only 39%. CONCLUSIONS: The ability of spine specialists to identify yellow flags is poor and can be improved by asking patients to complete a simple screening questionnaire.

Coronavirus Disease 2019 Transmission: Blood Viremia and Aerosol Generation from Spinal Surgery. Is There an Increased Risk to the Surgical Team?

As a respiratory pathogen, the novel coronavirus is commonly associated with aerosol-generating procedures. However, it is currently unclear whether spinal surgical procedures pose an additional risk of viral transmission to the surgical team. We reviewed the available evidence to ascertain the presence of coronavirus disease 2019 (COVID-19) blood viremia and the virus' blood transmissibility, as well as evidence of blood-aerosol generation and operating room contamination from spinal surgical procedures. There is established evidence of COVID-19 blood viremia, a viral pathogenic cycle via angiotensin-converting enzyme 2 (ACE-2) receptors and similar blood transmission risk data from the SARS (severe acute respiratory syndrome)/MERS (Middle East respiratory syndrome) era. Spinal surgical practices demonstrate significant blood-aerosol generation from the operative wound due to the use of common surgical instruments, such as electrocautery, as well as high-speed and high-impact devices. Based on the evidence, there is an established additional risk of viral transmission faced by surgical teams from blood-aerosols generated from the operative wound of COVID-19- infected patients via the inhalation of virus-laden aerosols and the subsequent initiation of the viral pathogenic cycle through binding with pulmonary ACE-2 receptors. Recognizing this additional risk amidst the ongoing pandemic serves as a caution to front-line surgical personnel to strictly adhere to personal protective equipment usage in operating rooms, to modify surgical techniques to reduce the hazard of surgical aerosol generation and COVID-19 viral exposure, and to consider it as an integral aspect of planning and adapting to the "new normal" operating practices.

Dural tears in primary decompressive lumbar surgery. Is primary repair necessary for a good outcome?

STUDY DESIGN: Case control series with prospective data collection. OBJECTIVE: To establish whether incidental durotomy treated without primary suture repair adversely affects the outcome following lumbar surgery in the longer term. METHOD: Outcome scores from a prospective database were used for an audit of dural tears in primary lumbar decompressive surgery. Outcome data collected includes the Short Form 36 General Health Questionnaire (SF36), the Oswestry Disability Index (ODI) and Visual Analogue Scores for leg pain (VAL) and back pain (VAB). RESULTS: Out of 200 consecutive procedures, a dural tear occurred in 19 (9.5%) patients. Of 19 patients with a dural tear, data was incomplete in 4 patients, and 1 further patient who had their dural tear sutured was excluded, leaving 14 patients to be studied. There were seven males and seven females, with an average age of 50.8 years (31-69). These 14 patients (group 1) were compared to a matched group (age, sex, surgical diagnosis and duration of follow-up) of 14 patients (group 2) with no tear. Both groups had similar pre-operative scores. At 6-month follow-up, both groups had significant improvements in all outcomes measures except for the general health domain of the SF-36. At final follow-up, patients with dural tears appeared to have better improvements in outcome measures amongst the VAB, VAL and ODI with similar scores in the SF-36 domains. CONCLUSION: Our study demonstrates that incidental durotomy in primary lumbar decompressive surgery can be successfully managed without primary suture repair with no adverse effect on surgical outcome in the longer term.

Dose response and structural injury in the disability of spinal injury.

INTRODUCTION: In traumatic injury there is a clear relationship between the dose of energy involved, structural tissue damage and resultant disability after recovery. This relationship is often absent in cases of non-specific chronic low back pain that is perceived by patients as attributed to a workplace injury. There are many studies assessing risk factors for non-specific low back pain. However, studies addressing causality of back pain are deficient. PURPOSE: To establish whether there exists a causal relationship between structural injury, low back pain and spinal disability. METHODS: Retrospective analysis of prospectively gathered validated spinal outcome measures [Oswestry disability index (ODI), low back outcome score (LBO), modified somatic perception (MSP), modified Zung depression index (MZD)] between patients with healed high energy thoracolumbar spinal fractures and patients with self-perceived work-related low back pain. Causality was established according to two of Bradford Hill's criteria of medical causality, temporal and dose-response relationships. RESULTS: Twenty-three patients with spinal fractures (group 1) of average age 44 years were compared to 19 patients with self-reported back pain in the workplace pursuing claims for compensation (group 2) of average age 48 years. Both groups were comparable in terms of age and sex. The average ODI in group 1 was 28 % (SD 19) compared to 42 % (SD 19) in group 2 (P < 0.05). Similarly, LBOS was 39.7 versus 24.3 (P < 0.05), MSP 4.3 versus 9.3 (P < 0.05) and MZD 20.2 versus 34.8 (P < 0.05) in groups 1 and 2, respectively. CONCLUSION: Despite high-energy trauma and significant structural damage to the spine, patients with the high energy injuries had better spinal outcome scores in all measures. There is no 'dose-response' relationship between structural injury, low back pain and spinal disability. This is the reverse of what would be anticipated if structural injury was the cause of disability in workplace reported onset of low back pain.

Dual pathology as a result of spinal stenosis and vitamin B12 deficiency.

Vitamin B12 deficiency can confound the clinical assessment of patients presenting with features of spinal disorders. Speciality practice within spinal surgery may lead the clinician to a focus upon spinal explanations for symptoms and that belief may be reinforced by supporting imaging. In the presence of mainly sensory symptoms consideration and exclusion of non surgical causes needs to occur. This study aimed at identifying the prevalence of vitamin B12 deficiency; the presence of dual pathology on imaging performed; the implementation of replacement therapy and their subsequent clinical response as perceived by patients. This was performed through a retrospective review of patients presenting to specialist spine out-patient clinics over a 4-year period via access to pathology reports followed by a telephone survey. 457 patients were investigated of which 8.5% were vitamin B12 deficient. 70% of patients had repeat levels and 31% continued to be deficient. 26% of these patients were not placed on any supplemental therapy. 72% of patients on treatment had self perceived improved outcomes as compared with 55% not on treatment. 73% of patients underwent MRI/CT imaging. 59% of which had evidence of spinal stenosis. In older patients with sensory symptoms, the coexistence of B12 deficiency should be considered. Detection of deficiency with consequent treatment results in better global outcomes than no treatment. Unless the correct blood test is done, the pathology will remain undetected, and patients may continue with their primary symptoms despite high-risk spinal surgical procedures.