The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment.

PURPOSE: In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters. METHODS: A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18-80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student's t tests, Kruskal-Wallis, Wilcoxon rank-sum, linear regression, and Pearson's correlation were used with significance at p < 0.05. RESULTS: 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3 mm ± 6.5 mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1 mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005). CONCLUSION: Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.

Clinical Outcomes of a Minimally Invasive Percutaneous Brostrom Technique without Arthroscopic Assistance.

BACKGROUND/OBJECTIVES: Surgical management of chronic lateral ankle instability has traditionally been performed using an open technique. Arthroscopic-assisted and all-arthroscopic techniques have gained popularity as they have achieved strong clinical outcomes. However, they rely on the surgeon's arthroscopic skills and familiarity with arthroscopic anatomy. Recently, a minimally invasive percutaneous technique without arthroscopic assistance has been developed that incorporates the benefits of arthroscopy, such as minimal soft tissue disruption, without the additional requirements of performing an arthroscopic technique. The aim of the current study is to describe the minimally invasive percutaneous technique for chronic lateral ankle instability and report on its clinical outcomes. METHODS: Fifty-four consecutive patients without intra-articular ankle pathology underwent lateral ligament repair for chronic ankle instability with a percutaneous technique at a single institution by a fellowship-trained foot and ankle surgeon. Foot Function Index (FFI) score was recorded pre-operatively and post-operatively at final follow-up. All patients had a minimum follow-up of 12 months. Post-operative complications and patient satisfaction were also recorded. RESULTS: A significant improvement (p < 0.001) in FFI compared to pre-operative values (from 55, SD 4.1, to 10, SD 1.9) was observed. A single patient required a return to the operating room for open revision with allograft reconstruction following a fall 2.5 months post-operatively. There were no other complications including infection or nerve injury. The overall rate of satisfaction after surgery was 98.1%, with one patient dissatisfied due to excessive ankle stiffness. CONCLUSIONS: The described minimally invasive percutaneous Brostrom procedure is safe and effective for the treatment of chronic lateral ankle instability without intra-articular ankle pathology.

Improvement in axial rotation with bracing reduces the risk of curve progression in patients with adolescent idiopathic scoliosis.

PURPOSE: New evidence highlights the significance of 3D in-brace correction for Adolescent Idiopathic Scoliosis (AIS) patients. This study explores how axial parameters relate to treatment failure in braced AIS patients. METHODS: AIS patients (Sanders 1-5) undergoing Rigo-Chêneau bracing at a single institution were included. Axial vertebral rotation (AVR) was determined by utilizing pre-brace and in-brace 3D reconstructions from EOS® radiographs. The primary outcome was treatment failure: surgery or coronal curve progression > 5°. Minimum follow-up was two years. RESULTS: 75 patients (81% female) were included. Mean age at bracing initiation was 12.8 ± 1.3 years and patients had a pre-brace major curve of 31.0° ± 6.5°. 25 patients (76% female) experienced curve progression > 5°, and 18/25 required surgical intervention. The treatment failure group had larger in-brace AVR than the success group (5.8° ± 4.1° vs. 9.9° ± 7.6°, p = 0.003), but also larger initial coronal curve measures. In-brace AVR did not appear to be associated with treatment failure after adjusting for the pre-brace major curve (Hazard Ratio (HR):0.99, 95% Confidence Interval (CI):0.94-1.05, p = 0.833). Adjusting for pre-brace major curve, patients with AVR improvement with bracing had an 85% risk reduction in treatment failure versus those without (HR:0.15, 95% CI:0.02-1.13, p = 0.066). At the final follow-up, 42/50 (84%) patients without progression had Sanders ≥ 7. CONCLUSIONS: While in-brace rotation was not an independent predictor of curve progression (due to its correlation with curve magnitude), improved AVR with bracing was a significant predictor of curve progression. This study is the first step toward investigating the interplay between 3D parameters, skeletal maturity, compliance, and brace efficacy, allowing a future prospective multicenter study. LEVEL OF EVIDENCE: Retrospective study; Level III.

Strategies to Avoid Distal Junctional Pathology.

Distal junctional pathology remains an unsolved issue in spine surgery. Distal junctional pathology can occur on a spectrum from asymptomatic radiographic finding to catastrophic distal construct failure. It is significant to address as postoperative sagittal balance has been shown to be correlated with patient-reported outcomes. Current literature and clinical experience suggest there are techniques that can be implemented regardless of setting to avoid distal junctional pathology. Much of the avoidant strategy relies on understanding the deformity pathology, selection of the lowest instrumented vertebra (LIV), health of the segments caudal to the LIV, and methods of fixation.

Clinical Outcomes Following Percutaneous Ankle Fusion With Bone Graft Substitute.

Background: Percutaneous ankle fusion is an emerging technique with minimal published outcome data. The goal of the present study is to retrospectively review clinical and radiographic outcomes following percutaneous ankle fusion and provide technique tips to perform percutaneous ankle fusion. Methods: Patients >18 years of age, treated by a single surgeon, from February 2018 to June 2021, who underwent primary isolated percutaneous ankle fusion supplemented with platelet-derived growth factor B (rhPDGF-BB) and beta-tricalcium phosphate, with at least 1-year follow-up were included. Surgical technique consisted of percutaneous ankle preparation followed by fixation with 3 headless compression screws. Pre- and postoperative visual analog scale (VAS) and Foot Function Index (FFI) were compared using paired t tests. Fusion was assessed radiographically by the surgeon on postoperative radiographs and computed tomography (CT) at 3 months postoperatively. Results: Twenty-seven consecutive adult patients were included in the study. Mean follow-up was 21 months. Mean age was 59.8 years. Mean preoperative and postoperative VAS scores were 7.4 and 0.2, respectively (P < .01). Mean preoperative FFI pain domain, disability domain, activity restriction domain, and total score were 20.9, 16.7, 18.5, and 56.4, respectively. Mean postoperative FFI pain domain, disability domain, activity restriction domain, and total score were 4.3, 4.7, 6.7, and 15.8, respectively (P < .01). Fusion was achieved in 26 of 27 patients (96.3%) at 3 months. Four patients (14.8%) had complications. Conclusion: We found in this cohort with surgery performed by a surgeon highly experienced in minimally invasive surgery that percutaneous ankle fusion augmented with a bone graft supplement achieved a high rate of fusion (96.3%) and a significant improvement in pain and function postoperatively while associated with minimal complications. Level of Evidence: Level IV, case series.

Intraoperative Anaphylaxis to the Bovine Flowable Gelatin Matrix: A Report of 2 Cases.

CASE: We present 2 cases of life-threatening intraoperative anaphylaxis to the bovine flowable gelatin matrix during pediatric spinal deformity surgery for kyphoscoliosis. Both patients had no known bovine or gelatin allergies. Anaphylaxis occurred shortly after pressurized injection into the first cannulated pedicle tract and was successfully treated with epinephrine, diphenhydramine, and methylprednisolone infusion. The allergic reaction was confirmed with tryptase levels and serum-specific immunoglobulin E for beef, pork, bovine collagen, and porcine collagen. CONCLUSION: In patients with beef, pork, or gelatin intolerance, a significant atopic history or childhood vaccine reaction, preoperative allergy consultation, and testing should be performed to prevent this life-threatening complication.

Distal adding-on in adolescent idiopathic scoliosis results in diminished health-related quality of life at 10 years following posterior spinal fusion.

PURPOSE: The purpose of this study was to investigate associations between the various definitions of adding-on identified in the literature and HRQoL at 10 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) to identify a clinically relevant definition. METHODS: In this retrospective cohort study, patients with Lenke type 1 or 2 AIS with 10-year follow-up after PSF were identified in a multicenter registry. Adding-on was identified independently using 5 published definitions and expert spine surgeons' visual confirmation. Worsening of HRQoL was defined as a preoperative to 10-year postoperative decrease in SRS-22 domain score ≥ the minimal clinically important difference (MCID). RESULTS: One hundred fifty patients were included, and 118 had HRQoL data available for the main analysis. Worsening pain was noted in 49 (41.5%) patients, appearance in 1 (0.8%), and activity in 70 (59.3%) from preoperative to postoperative. 4 of the 5 definitions of adding-on demonstrated no evidence of association with worsening HRQoL. By Cho's definition (either 1. ≥ 5° increase in Cobb angle AND increase in number of vertebrae in curve distally, or 2. ≥ 5° increase in angulation of 1st disc below LIV), adding-on (27 patients, 22.9%) was associated with an increased risk of worsening pain (59.3% vs. 36.3%, p = 0.033) and activity (77.8% vs. 53.8%, p = 0.026). There was no evidence of association with changes in appearance. Risk of worsening pain and activity was increased by 1.75 and 1.51 times (p = 0.023 and p = 0.002), respectively. CONCLUSION: Cho's definition of adding-on was associated with worsening HRQoL at 10 years following PSF for Lenke type 1 and 2 AIS. Consistent use of this definition will allow us to compare studies and obtain meaningful information in this population. LEVEL OF EVIDENCE: Level II.

The deformity angular ratio: can three-dimensional computed tomography improve prediction of intraoperative neuromonitoring events?

PURPOSE: Assess whether a novel deformity angular ratio (DAR) calculated using preoperative three-dimensional computed tomography (3D CT) is more accurate than total DAR (T-DAR) radiographic measurements at predicting intraoperative neuromonitoring (IONM) events during vertebral column resection (VCR). METHODS: Consecutive, unique patients undergoing thoracic VCR by a single surgeon from 2015 to 2021 were identified. The T-DAR was calculated by dividing the total radiographic Cobb angle by the number of vertebral segments the angle subtends. 3D CT DAR was calculated for each patient from a preoperative CT scan by finding the maximum angle subtended by three contiguous vertebral segments. All patients were assessed for IONM events. A binary threshold of 25 was used for T-DAR and 3D CT DAR measurements for predictive analysis. p < 0.05 indicated significance. RESULTS: In total, 68 patients were identified. Mean age was 28 years. Mean levels fused was 15. Twenty-one patients (31%) had IONM events. In patients, with and without an IONM event, mean T-DAR was 26.6 ± 9.8 and 21.5 ± 8.8 (p = 0.04), respectively. 3D CT DAR mean values were 26.4 ± 10.8 and 18.4 ± 5.6, respectively (p < 0.001). 3D CT DAR accurately classified 81% of patients with a positive predictive value (PPV) of 75%. In comparison, T-DAR accurately classified 60% of patients with a PPV of 39%. CONCLUSION: 3D CT substantially improves preoperative IONM event prediction when compared to traditional radiographic measurements. A 3D CT DAR of 25 or greater was correlated with an increased rate of IONM events. 3D CT reconstructions are a useful adjunct for planning prior to a VCR.

Development and Validation of a Health-Related Quality-of-Life Measure in Older Children and Adolescents with Early-Onset Scoliosis: Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF).

BACKGROUND: The 24-question Early-Onset Scoliosis Questionnaire (EOSQ-24) is a proxy measure assessing health-related quality of life (HRQoL) among patients with early-onset scoliosis (EOS). There exists an increasing need to assess HRQoL through a child's own perspective, particularly for older children and adolescents with EOS. The purpose of this study was to develop and validate a self-reported questionnaire, the Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF), to assess HRQoL in older children and adolescents with EOS. METHODS: A literature review, an expert focus group, and patient interviews were used to generate a preliminary survey of appropriate domains and question items. This survey was provided to English-speaking patients with EOS who were 8 to 18 years of age and capable of answering survey questions. Content validity was assessed for clarity and relevance of questions. Confirmatory factors analysis was performed to reduce the number of items and determine domains that fit items. Reliability was evaluated by measuring the internal consistency of items and test-retest reliability. Construct validity was evaluated by convergent, discriminant, and known-group validity. RESULTS: The literature review, expert focus group, and patient interviews identified 59 questions in 14 domains. Psychometric analysis reduced these to 30 questions across 12 domains: General Health, Pain/Discomfort, Pulmonary Function, Transfer, Physical Function/Daily Living, Participation, Fatigue/Energy Level, Sleep, Appearance, Relationships, Emotion, and Satisfaction. The final questionnaire was found to have good content and construct validity and adequate reliability. CONCLUSIONS: The EOSQ-SELF is a valid and reliable instrument for measuring self-reported HRQoL among older children and adolescents with EOS (ages 8 to 18 years). This will serve as an important research outcome measure and enhance clinical care by providing a better understanding of HRQoL for these patients. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Resection of congenital hemivertebra in pediatric scoliosis: the experience of a two-specialty surgical team.

OBJECTIVE: Institutions investigating value and quality emphasize utilization of two attending surgeons with different areas of technical expertise to treat complex surgical cases and to minimize complications. Here, the authors chronicle the 12-year experience of using a two-attending surgeon, two-specialty model to perform hemivertebra resection in the pediatric population. METHODS: Retrospective cohort data from 2008 to 2019 were obtained from the NewYork-Presbyterian Morgan Stanley Children's Hospital operative database. This database included all consecutive pediatric patients < 21 years old who underwent hemivertebra resection performed with the two-attending surgeon (neurosurgeon and orthopedic surgeon) model. Demographic information was extracted. Intraoperative complications, including durotomy and direct neurological injury, were queried from the clinical records. Intraoperative neuromonitoring data were evaluated. Postoperative complications were queried, and length of follow-up was determined from the clinical records. RESULTS: From 2008 to 2019, 22 patients with a median (range) age of 9.1 (2.0-19.3) years underwent hemivertebra resection with the two-attending surgeon, two-specialty model. The median (range) number of levels fused was 2 (0-16). The mean (range) operative time was 5 hours and 14 minutes (2 hours and 59 minutes to 8 hours and 30 minutes), and the median (range) estimated blood loss was 325 (80-2700) ml. Navigation was used in 14% (n = 3) of patients. Neither Gardner-Wells tongs nor halo traction was used in any operation. Neuromonitoring signals significantly decreased or were lost in 14% (n = 3) of patients. At a mean ± SD (range) follow-up of 4.6 ± 3.4 (1.0-11.6) years, 31% (n = 7) of patients had a postoperative complication, including 2 instances of proximal junctional kyphosis, 2 instances of distal junctional kyphosis, 2 wound complications, 1 instance of pseudoarthrosis with hardware failure, and 1 instance of screw pullout. The return to the operating room (OR) rate was 27% (n = 6), which included patients with the abovementioned wound complications, distal junctional kyphosis, pseudoarthrosis, and screw pullout, as well as a patient who required spinal fusion after loss of motor evoked potentials during index surgery. CONCLUSIONS: Twenty-two patients underwent hemivertebra resection with a two-attending surgeon, two-specialty model over a 12-year period at a specialized children's hospital, with a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and a 27% rate of unplanned return to the OR.