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.

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report.

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

Establishing case volume benchmarks for ACGME-accredited orthopedic surgery of the spine fellowship training.

BACKGROUND CONTEXT: There has been increasing scrutiny on the standardization of surgical training in the US. PURPOSE: This study provides case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic spine surgery fellowship training. STUDY DESIGN/SETTING: This was a retrospective cross-sectional study of fellows at ACGME-accredited orthopedic spine surgery fellowships (2017-2022). PATIENT SAMPLE: N/A. OUTCOME MEASURES: Reported case volume during fellowship training. METHODS: Case volume percentiles were calculated across ACGME-defined case categories and temporal changes assessed via linear regression. Variability between the highest and lowest deciles by case volume was calculated as fold-differences (90th percentile/10th percentile). Sensitivity analyses were performed to identify potential targets for case minimum requirements. RESULTS: A total of 163 spine surgery fellows were included in this study. Total mean reported spine surgery case volume increased from 313.2±122 in 2017 to 382.0±164 in 2022 (p=.19). Most cases were classified as adult (range, 97.2%-98.0%) over pediatric cases (range, 2.0%-2.8%). An average of 322.0 cases were reported and most were classified as laminectomy (32%), posterior arthrodesis (29%), and anterior arthrodesis (20%). Overall variability in total case volume was 2.4 and the greatest variability existed for posterior instrumentation (38.1), application of cage (34.6), anterior instrumentation (20.8), and fractures and dislocations (17.3). If case minimum requirements for total reported cases was assumed at 200 cases, then all spine fellows included in this study would achieve this requirement. However, if case minimum requirements were assumed at 250 total cases, then approximately thirty percent of fellows (n=49) would not achieve this requirement for graduation. CONCLUSIONS: Increasingly, national societies and accrediting bodies for surgical education recognize the need for standardized training. This study provides benchmarks to inform potential case minimum requirements and help reduce variability during spine fellowship training. Future studies are needed to establish case minimum requirements for spine surgery fellowship training across comprehensive and granular case categories that cover the full gamut of orthopedic spine surgery.

Comparison of Different Osteobiologics in Terms of Imaging Modalities and Time Frames for Fusion Assessment in Anterior Cervical Discectomy and Fusion: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: The study's primary objective was to determine how osteobiologic choice affects fusion rates in patients undergoing anterior cervical discectomy and fusion (ACDF). The study's secondary objectives were to 1) determine the optimal timing of fusion assessment following ACDF and 2) determine if osteobiologic type affects the timing and optimal modality of fusion assessment. METHODS: A systematic search of PubMed/MEDLINE was conducted for literature published from 2000 through October 2020 comparing anterior fusion in the cervical spine with various osteobiologics. Both comparative studies and case series of ≥10 patients were included. RESULTS: A total of 74 studies met the inclusion criteria. Seventeen studies evaluated the efficacy of autograft on fusion outcomes, and 23 studies assessed the efficacy of allograft on fusion outcomes. 3 studies evaluated the efficacy of demineralized bone matrix, and seven assessed the efficacy of rhBMP-2 on fusion outcomes. Other limited studies evaluated the efficacy of ceramics and bioactive glasses on fusion outcomes, and 4 assessed the efficacy of stem cell products. Most studies utilized dynamic radiographs for the assessment of fusion. Overall, there was a general lack of supportive data to determine the optimal timing of fusion assessment meaningfully or if osteobiologic type influenced fusion timing. CONCLUSIONS: Achieving fusion following ACDF appears to remain an intricate interplay between host biology and various surgical factors, including the selection of osteobiologics. While alternative osteobiologics to autograft exist and may produce acceptable fusion rates, limitations in study methodology prevent any definitive conclusions from existing literature.

Applications of SPECT/CT in the Evaluation of Spinal Pathology: A Review.

BACKGROUND: Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS: A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS: SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS: SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE: SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology.

A Novel Untethering and Duraplasty Technique for Postsurgical Tethered Spinal Cord.

Progressive post-traumatic postsurgical myelopathy (PPPM) is a known entity that can occur months to years after the initial insult. Symptomatic patients can become myelopathic and have rapid and progressive neurological decline. Surgical correction of PPPM usually involves intradural exploration and lysis of adhesions that carries the risk of further injury to the spinal cord. In this manuscript, we provide a report of a patient presenting more than 50 years after the initial resection of an intramedullary tumor. Additionally, we present and describe a novel surgical technique for managing this difficult problem and restoring normal CSF dynamics.

Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the incidence of medical complications in the pediatric population aged 10-20 years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes. METHOD: Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression. RESULTS: 251/311pts had min 2 year f/u. 142F/109 M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68 days. Mean OR time was 459 min, blood loss averaged 1465 ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be an independent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2 year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group. CONCLUSION: Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.

Metastatic mesenchymal chondrosarcoma of the spine managed with nonsurgical treatment: A case report and review of the literature.

In this report, we present a rare case of a 17-year-old male patient with metastatic mesenchymal chondrosarcoma (MCS) managed with nonsurgical treatment who subsequently demonstrated a favorable response to concurrent chemotherapy and radiation therapy, followed with pazopanib target therapy. Further study regarding nonoperative care for metastatic MCS of spine is warranted.

Do Multidisciplinary Spine Conferences Alter Management or Impact Outcome?

BACKGROUND: Multidisciplinary spine conferences (MSCs) are a strategy for discussing diagnostic and treatment aspects of patient care. Although they are becoming more common in hospitals, literature investigating how they impact patient care and outcomes is scarce. The aim of this study is to examine the impact of MSCs on surgical management and outcomes in elective spine surgical care. METHODS: A systematic review of the literature was conducted to evaluate the impact of MSCs on patient management and outcomes. PubMed and Cochrane databases were searched using combinations and variations of search terms "Spine Conferences," "Multidisciplinary," and "Spine Team." RESULTS: The literature search yielded 435 articles, of which 120 were selected for full-text review. Four articles (N = 529 patients) were included. Surgical plans were discussed in 211 patients. The decision was altered to conservative treatment in 70 patients (33.17%) and a different surgical strategy in 34 patients (16.11%). The differences were significant in 2 studies (P < 0.05). A 51% reduction in 30-day complications rates was observed when MSC was implemented in patients with adult complex scoliosis. Other spinal disorders showed a 30-day complication rate between 0% and 14% after MSC. CONCLUSIONS: To our knowledge, this is the first systematic review of outcomes of MSCs in elective spine surgery and it confirms that MSCs impact management plan and outcomes. Consistent MSCs that include surgeons and nonsurgeons have the potential to enhance communication between specialists, standardize treatments, improve patient care, and encourage teamwork. More analysis is warranted to determine if patient outcomes are improved with these measures.

Is the routine use of systemic antibiotics after spine surgery warranted? A systematic review and meta-analysis.

PURPOSE: To determine whether the published literature supports the current practice of utilizing antibiotics postoperatively in spine surgery. METHODS: A systematic review from PubMed and Cochrane Central Register of Controlled trials databases was performed. Search terms used: "Antibiotic Prophylaxis"[Mesh], antibiotic*, antibacterial*, "Spine"[Mesh], "Surgical Procedures, Operative"[Mesh]. Only comparative, clinical studies were included. Those studies with surgical site infection (SSI) criteria that were not similar to the CDC definition were excluded. A meta-analysis for overall SSI was performed. A subgroup analysis was also performed to analyze the outcomes specifically on instrumented groups of patients. A random-effects model was used to calculate risk ratios (RR). Forest plots were used to display RR and 95% confidence intervals (CI). RESULTS: Thirteen studies were included (four Randomized-Controlled Trials, three prospective cohorts, and six retrospective). Three different perioperative strategies were used in the selected studies: Group 1: preoperative antibiotic administration (PreopAbx) versus PreopAbx and any type of postoperative antibiotic administration (Pre + postopAbx) (n = 6 studies; 7849 patients); Group 2: Pre + postopAbx ≤ 24 h versus Pre + postopAbx > 24 h (n = 6; 1982); and Group 3: Pre + postopAbx ≤ 48 h versus. Pre + postopAbx ≤ 72 h (n = 1; 502). The meta-analysis performed on Groups 1 and 2 did not show significant effects (RR = 1.27, 95% CI = 0.77, 2.09, and RR = 0.97, 95% CI = 0.64, 1.46, respectively). CONCLUSION: A meta-analysis and comprehensive review of the literature show that the routine use of postoperative antibiotics in spine surgery may not be effective in preventing surgical site infections.

Is L5/S1 interbody fusion necessary in long-segment surgery for adult degenerative scoliosis? A systematic review and meta-analysis.

OBJECTIVE: There is no consensus regarding the best surgical strategy at the lumbosacral junction (LSJ) in long constructs for adult spinal deformity (ASD). The use of interbody fusion (IF) has been advocated to increase fusion rates, with additional pelvic fixation (PF) typically recommended. The actual benefit of IF even when extending to the pelvis, however, has not been vigorously analyzed. The goal of this work was to better understand the role of IF, specifically with respect to arthrodesis, when extending long constructs to the ilium. METHODS: A systematic review of the PubMed and Cochrane databases was performed to identify the relevant studies in English, addressing the management of LSJ in long constructs (defined as ≥ 5 levels) in ASD. The search terms used were as follows: "Lumbosacral Junction," "Long Constructs," "Long Fusion to the Sacrum," "Sacropelvic Fixation," "Interbody Fusion," and "Iliac Screw." The authors excluded technical notes, case reports, literature reviews, and cadaveric studies; pediatric populations; pathologies different from ASD; studies not using conventional techniques; and studies focused only on alignment of different levels. RESULTS: The PRISMA protocol was used. The authors found 12 retrospective clinical studies with a total of 1216 patients who were sorted into 3 different categories: group 1, using PF or not (n = 6); group 2, using PF with or without IF (n = 5); and group 3, from 1 study comparing anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion. Five studies in group 1 and 4 in group 2 had pseudarthrosis rate as primary outcome and were selected for a quantitative analysis. Forest plots were used to display the risk ratio, and funnel plots were used to look at the risk of publication bias. The summary risk ratios were 0.36 (0.23-0.57, p < 0.001) and 1.03 (0.54-1.96, p = 0.94) for the PF and IF, respectively; there is a protective effect of overall pseudarthrosis for using PF in long constructs for ASD surgeries, but not for using IF. CONCLUSIONS: The long-held contention that L5/S1 IF is always advantageous in long-construct deformity surgery is not supported by the current literature. Based on the findings from this systematic review and meta-analysis, PF with or without additional L5/S1 interbody grafting demonstrates similar overall construct pseudarthrosis rates. The added risk and costs associated with IF, therefore, should be more closely considered on a case-by-case basis.

10-Year Trends in the Surgical Management of Patients with Spinal Metastases: A Scoping Review.

BACKGROUND: Spinal metastases are present in approximately 20% of patients with cancer, giving a risk for neurologic dysfunction and instability. In already frail patients, surgeons strive to improve quality of life. Our goal was to review a 10-year trend in the surgical management of spinal metastases. METHODS: A scoping review was performed systematically using PubMed to assess trends in surgical treatment for spinal metastases. The search terms used were: metastas∗, "neoplasm metastasis"[Mesh], "Spine"[Mesh], spine, spinal, "vertebral column," "vertebral body," laser, robot, radiofrequency, screws, fixation, "separation surgery," corpectomy, vertebrectomy, spondylectomy, vertebroplasty, kyphoplasty, surgery, "open surgery," "mini open surgery," "minimally invasive surgery," endoscopy, thoracoscopy, corpectom∗, vertebrectom∗, spondylectom∗, "en bloc," and MIS. The variables of interest were neurologic improvement, tumor recurrence, reoperation, and overall survival. RESULTS: A total of 2132 articles were found within the primary query. Fifty-six studies were selected for final review. The results were organized into main surgical practices: decompression, mechanical stabilization, and pain management. For separation surgery, clinical outcomes were overall 1-year survival, 40.7%-78.4%; recurrence rate, 4.3%-22%; reoperation, 5%; and complications, 5.4%-14%. For corpectomy, clinical outcomes were overall 1-year survival, 30%-92%; reoperation, 1.1%-50%; and recurrence rate, of 1.1%-28%. Complications and reoperations with spinal instrumentation were 0%-13.6% and 0%-15%, respectively. Cement augmentation achieved pain reduction rates of 56%-100%, neurologic improvement/stability 84%-100%, and complication rates 6%-56%. Laser achieved local tumor control rate of 71%-82% at 1 year follow-up, reoperation rate of 15%-31%, and complication rate of 5%-26%. CONCLUSIONS: Minimally invasive techniques for decompression and stabilization seem to be the preferred method to surgically treat metastatic spine disease, with good outcomes. More research with high level of evidence is required to support the long-term outcomes of these approaches.

Fusion Extension Leads to Spontaneous Resolution of Symptomatic Disc Herniations Associated With Proximal Junctional Kyphosis: A Report of 3 Cases.

CASES: A retrospective chart and radiographic review was performed of 3 patients presenting with neurological deficits secondary to soft thoracic disc herniation associated with proximal junctional kyphosis. The patients were treated with proximal extension of the construct, correction of the focal sagittal malalignment, and posterior decompressive laminectomy without excision of the herniated disc. All 3 patients made complete neurological recovery and subsequent magnetic resonance imaging showed resolution of the herniated discs. CONCLUSIONS: Laminectomy in conjunction with proximal extension of the construct without formal thoracic discectomy was associated with complete neurological recovery and spontaneous resolution of soft thoracic disc herniations associated with junctional failures.

Lifetime incremental cost-utility ratios for minimally invasive surgery for degenerative lumbar spondylolisthesis relative to failed medical management compared with total hip and knee arthroplasty for osteoarthritis.

Background: The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis. Methods: A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost-utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form-6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed. Results: Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses. Conclusion: Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures.

Contexte: L'objectif de cette étude était de comparer le rapport coût­efficacité de la chirurgie minimalement effractive (CME) chez les patients atteints de spondylolisthésis lombaire dégénératif (SLD) en lien avec un échec de la prise en charge médicale à celui de l'arthroplastie de la hanche et du genou pour des cohortes assorties de patients atteints d'arthrose. Méthodes: Une cohorte de patients atteints de SLD soumis à une CME avec décompression seule ou décompression avec arthrodèse entre 2008 et 2014 a été assortie à des cohortes de patients soumis à une arthroplastie totale pour arthrose de la hanche et du genou. Les rapports coût­utilité différentiels (RCUD) ont été calculés du point de vue du ministère de la Santé de l'Ontario à l'aide des données d'utilité du questionnaire Short Form­6 Dimension recueillies de manière prospective. Les coûts et les années de vie ajustées en fonction de la qualité (AVAQ) ont été actualisés à un taux de 3 % et des analyses de sensibilité ont été effectuées. Résultats: Soixante-six patients répondaient aux critères d'inclusion pour la cohorte SLD (n = 35, décompression seule), avec un suivi d'une durée minimale de 1 an (moyenne 1,7 an). L'âge moyen des gens de la cohorte SLD était de 64,76 ans, et 45 patients (68,2 %) étaient de sexe féminin. Pour chaque cohorte, les scores d'utilité se sont améliorés entre les valeurs de départ et les valeurs de suivi et l'ampleur du gain n'a pas différé entre les groupes. Les RCUD pour la vie entière entre les soins chirurgicaux et non chirurgicaux ont été 7946 $CA/QALY, 7104 $CA/QALY et 5098 $CA/QALY pour les cohortes SLD, arthrose du genou et de la hanche, respectivement. L'analyse de sous-groupes a généré un RCUD accru pour les patients atteints de SLD qui ont subi la décompression avec arthrodèse (9870 $CA/QALY) comparativement à la décompression seule (5045 $CA/QALY). Le classement des RCUD par groupe n'a pas changé en fonction des analyses de sensibilité déterministes ou probabilistes. Conclusion: Les RCUD pour la vie entière associés à la CME dans les cas de SLD sont similaires à ceux de l'arthroplastie totale. Les recherches futures devraient adopter une perspective sociétale et refléter davantage les bienfaits économiques de la CME.

Correction to: Pathologic Clavicle Fracture Secondary to Cutibacterium acnes Abscess: Case Report and Review of Literature.

[This corrects the article DOI: 10.1007/s43465-020-00042-5.].

The prevalence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients undergoing circumferential minimally invasive surgical (cMIS) correction for adult spinal deformity: long-term 2- to 13-year follow-up.

OBJECTIVES: This aim of this study is to evaluate the prevalence of PJK and PJF in patients who underwent circumferential minimally invasive surgery (cMIS) for ASD. METHODS: A prospective database of patients who underwent cMIS correction of ASD from November 2006 to July 2018 was queried. PJK was defined as angle > 10° and at least 10° greater than the baseline when measuring UIV to UIV + 2. PJF was defined as any type of symptomatic PJK which required surgery. Pre-op, latest and delta SVA and PI-LL mismatch were compared between patients with PJK and without. Only patients instrumented at 4 or more levels with full length 36″ films and a minimum 2-year follow-up were included. RESULTS: A total of 184 patients met inclusion criteria for this study. Mean follow-up time was 85.2 months (24-158.9 months, SD 39.1). Mean age was 66 years (22-85 years). The mean number of operated levels was 6.9 levels (4-16 levels, SD 2.8). A total of 21 patients (10.8%) met PJK criteria. Only 10 (4.9%) were symptomatic (PJF) and underwent revision surgery. The other 11 patients remained asymptomatic. Comparing PJK to non-PJK patients, there was no statistically significant difference in the post-op SVA, delta SVA, post-op PI/LL and delta PI/LL between the two groups. CONCLUSION: Our study would suggest that in the appropriately selected and well-optimized patient, CMIS deformity correction is associated with a low prevalence of PJK and PJF.

Frailty adversely affects outcomes of patients undergoing spine surgery: a systematic review.

BACKGROUND: With an aging population, there are an increasing number of elderly patients undergoing spine surgery. Recent literature in other surgical specialties suggest frailty to be an important predictor of outcomes. PURPOSE: The aim of this review was to examine the association between frailty and outcomes after spine surgery. STUDY DESIGN: A systematic review was performed. PATIENT SAMPLE: Electronic databases from 1946 to 2020 were searched to identify articles on frailty and spine surgery. OUTCOME MEASURES: The primary outcome was adverse events. Secondary outcomes included other measures of morbidity, mortality, and patient outcomes. METHODS: Sample size, mean age, age limitation, data source, study design, primary pathology, surgical procedure performed, follow-up period, assessment of frailty used, surgical outcomes, and impact of frailty on outcomes were extracted from eligible studies. Quality and bias were assessed using the PRISMA 27-point item checklist and the QUADAS-2 tool. RESULTS: Thirty-two studies were selected for review, with a total of 127,813 patients. There were eight different frailty indices/measures. Regardless of how frailty was measured, frailty was associated with an increased risk of adverse events, mortality, extended length of stay, readmission, and nonhome discharge. CONCLUSION: There is strong evidence that frailty is associated with an increased risk of morbidity and mortality in patients who received spine surgery. However, it remains inconclusive whether frailty impacts patient outcomes and quality of life after surgery.

Image Guidance-Assisted Decompression and Removal of Heterotopic Ossification Following the Use of Recombinant Human Bone Morphogenetic Protein-2 in Transforaminal Lumbar Interbody Fusion.

Heterotopic ossification (HO) following the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in the setting of transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) is a troublesome and well-described postoperative complication. There is currently no consensus regarding the treatment of this offending pathology. In this report, we present a retrospective single-surgeon review of 14 patients who underwent image-guided decompression of HO. We describe a new technique where navigation demonstrates a safe and thorough decompression compared to that with fluoroscopy or anatomical landmarks alone. To evaluate successful decompression, we reviewed patient self-reported clinical outcomes. Seven patients demonstrated positive results, while three had mixed outcomes and four showed poor outcomes. While more studies are needed to determine the overall efficacy of intraoperative navigation-assisted decompression, findings from this small cohort of patients suggest that it is a useful technique in the setting of the removal of heterotopic bone.

Late-Onset Radial Nerve Palsy in the Setting of Humeral Shaft Hypertrophic Nonunion: A Case Report.

CASE: A 67-year-old woman presented 9 months after a closed midshaft humerus fracture with a new onset radial nerve palsy. Radiographs demonstrated a hypertrophic nonunion. Upon exploration, the radial nerve was in continuity and entrapped in fracture callus. It was extricated from the callus, and an open reduction and plate fixation was performed. Full radial nerve function returned by 3 months. CONCLUSION: We recommend that delayed onset radial nerve palsies be treated on a semiurgent basis with radial nerve exploration and decompression followed by internal fixation to achieve primary bone healing and minimize fracture callus formation.