Bilateral sacroiliac joint fusion in long constructs using self-harvesting porous S2-alar iliac screws with an integrated tulip: technical considerations and early clinical and radiographic experience.

OBJECTIVE: The incidence of sacroiliac joint (SIJ) dysfunction after lumbosacral fusion is high. Upfront bilateral SIJ fusion using novel fenestrated self-harvesting porous S2-alar iliac (S2AI) screws could reduce the incidence of SIJ dysfunction and need for subsequent SIJ fusion. In this study, the authors report their early clinical and radiographic results of SIJ fusion using this novel screw. METHODS: The authors began using self-harvesting porous screws in July 2022. This is a retrospective review of consecutive patients at a single institution who underwent long thoracolumbar surgery with extension to the pelvis using this porous screw. Radiographic parameters of regional and global alignment were collected preoperatively and at the time of last follow-up. The incidence of intraoperative complications and need for revision were collected. The incidences of mechanical complications, including screw breakage, implant loosening/pullout, and screw cap dislocation at the time of last follow-up were also collected. RESULTS: Ten patients with a mean age of 67 years were included, 6 of whom were male. Seven patients had a thoracolumbar construct with extension to the pelvis. Three patients had upper instrumented vertebrae at the proximal lumbar spine. Intraoperative breach was not encountered in any of the patients (0%). Postoperatively, 1 patient (10%) had screw breakage at the neck of the tulip of the modified iliac screw discovered at routine follow-up without clinical sequalae. CONCLUSIONS: Use of self-harvesting porous S2AI screws incorporated into long thoracolumbar constructs was safe and feasible, demanding unique technical considerations. Long-term clinical and radiographic follow-up with a large patient cohort is necessary to determine their durability and efficacy to achieve SIJ arthrodesis and prevent SIJ dysfunction.

Evolution of polyetheretherketone (PEEK) and titanium interbody devices for spinal procedures: a comprehensive review of the literature.

INTRODUCTION: Interbody fusion is commonly utilized for arthrodesis and stability among patients undergoing spine surgery. Over the last few decades, interbody device materials, such as titanium and polyetheretherketone (PEEK), have been replacing traditional autografts and allografts for interbody fusion. As such, with the exponential growth of bioengineering, a large variety cage surface technologies exist. Different combinations of cage component materials and surface modifications have been created to optimize interbody constructs for surgical use. This review aims to provide a comprehensive overview of common surface technologies, their performance in the clinical setting, and recent modifications and material combinations. MATERIALS AND METHODS: We performed a comprehensive review of the literature on titanium and PEEK as medical devices between 1964 and 2021. We searched five major databases, resulting in 4974 records. Articles were screened for inclusion manually by two independent reviewers, resulting in 237 articles included for review. CONCLUSION: Interbody devices have rapidly evolved over the last few decades. Biomaterial and biomechanical modifications have allowed for continued design optimization. While titanium has a high osseointegrative capacity, it also has a high elastic modulus and is radio-opaque. PEEK, on the other hand, has a lower elastic modulus and is radiolucent, though PEEK has poor osseointegrative capacity. Surface modifications, material development advancements, and hybrid material devices have been utilized in search of an optimal spinal implant which maximizes the advantages and minimizes the disadvantages of each interbody material.

3D printing applications in spine surgery: an evidence-based assessment toward personalized patient care.

PURPOSE: Spine surgery entails a wide spectrum of complicated pathologies. Over the years, numerous assistive tools have been introduced to the modern neurosurgeon's armamentarium including neuronavigation and visualization technologies. In this review, we aimed to summarize the available data on 3D printing applications in spine surgery as well as an assessment of the future implications of 3D printing. METHODS: We performed a comprehensive review of the literature on 3D printing applications in spine surgery. RESULTS: Over the past decade, 3D printing and additive manufacturing applications, which allow for increased precision and customizability, have gained significant traction, particularly spine surgery. 3D printing applications in spine surgery were initially limited to preoperative visualization, as 3D printing had been primarily used to produce preoperative models of patient-specific deformities or spinal tumors. More recently, 3D printing has been used intraoperatively in the form of 3D customizable implants and personalized screw guides. CONCLUSIONS: Despite promising preliminary results, the applications of 3D printing are so recent that the available data regarding these new technologies in spine surgery remains scarce, especially data related to long-term outcomes.

Patient perception of scoliosis correction surgery on Instagram.

OBJECTIVE: Patient feedback surveys provide important insight into patient outcomes, satisfaction, and perioperative needs. Recent critiques have questioned provider-initiated surveys and their capacity to accurately gauge patient perspectives due to intrinsic biases created by question framing. In this study, the authors sought to evaluate provider-independent, patient-controlled social media Instagram posts in order to better understand the patient experience following scoliosis correction surgery. METHODS: Twitter and Instagram were queried for posts with two tagged indicators, #scoliosissurgery or @scoliosissurgery, resulting in no relevant Twitter posts and 25,000 Instagram posts. Of the initial search, 24,500 Instagram posts that did not directly involve the patient's own experience were eliminated. Posts were analyzed and coded for the following criteria: the gender of the patient, preoperative or postoperative timing discussed in the post, and classified themes related to the patient's experiences with scoliosis correction surgery. RESULTS: Females made 87.6% of the Instagram posts about their experience following scoliosis correction surgery. The initial postoperative stage of surgery was mentioned in 7.6% of Instagram posts. The most common theme on Instagram involved offering or seeking online support from other patients, which constituted 85.2% of all posts. Other common themes included concern about the surgical scar (31.8%), discussing the results of treatment (28.8%), and relief regarding results (21.2%). CONCLUSIONS: Social media provided a platform to analyze unprompted feedback from patients. Patients were most concerned with their scoliosis correction surgery in the period of time 2 weeks or more after surgery. Themes that were most commonly found on Instagram posts were offering or seeking online support from other patients and concern about the surgical scar. Patient-controlled social media platforms, like Instagram, may provide a useful mechanism for healthcare providers to understand the patient experience following scoliosis correction surgery. Such platforms may help in evaluating postoperative satisfaction and improving postoperative quality of care.

Risk associated with perioperative red blood cell transfusion in cranial surgery.

We assessed the impact of intra- and postoperative RBC transfusion on postoperative morbidity and mortality in cranial surgery. A total of 8924 adult patients who underwent cranial surgery were identified in the 2006-2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing a biopsy, radiosurgery, or outpatient surgery were excluded. Propensity scores were calculated according to demographic variables, comorbidities, and preoperative laboratory values. Patients who had received RBC transfusion were matched to those who did not, by propensity score, preoperative hematocrit level, and by length of surgery, as an indirect measure of potential intraoperative blood loss. Logistic regression was used to predict adverse postoperative outcomes. A total of 625 (7%) patients were transfused with one or more units of packed RBCs. Upon matching, preoperative hematocrit, length of surgery, and emergency status were no longer different between transfused and non-transfused patients. RBC transfusion was associated with prolonged length of hospitalization (OR 1.6, 95% CI 1.2-2.2), postoperative complications (OR 2.8, 95% CI 2.0-3.8), 30-day return to operation room (OR 2.0, 95% CI 1.3-3.2), and 30-day mortality (OR 4.3, 95% CI 2.4-7.6). RBC transfusion is associated with substantive postoperative morbidity and mortality in patients undergoing both elective and emergency cranial surgery. These results suggest judicious use of transfusion in cranial surgery, consideration of alternative means of blood conservation, or pre-operative restorative strategies in patients undergoing elective surgery, when possible.

The 100 most cited articles in metastatic spine disease.

OBJECTIVE Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field. METHODS A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency. RESULTS The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations). CONCLUSIONS The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.

Surgical Management of Hip-Spine Syndrome: A Systematic Review of the Literature.

BACKGROUND: Hip-spine syndrome (HSS) was first described in 1983 to describe the symptomatology resulting from concomitant lumbar degenerative stenosis and hip osteoarthritis. Numerous studies have sought to understand the underlying pathology and appropriate management of this syndrome. The purpose of this article is to review the literature for the specific imaging characteristics and the optimal surgical treatment of HSS. METHODS: A systematic review was conducted via an electronic database search through PubMed to identify all publications related to HSS. All publications that contained data on patients who underwent surgical treatment for HSS and reported patient-reported outcome measures or radiographic data were included. Exclusion criteria consisted of publications in a language other than English, review articles, and technique articles. RESULTS: Fifteen articles that focused on the surgical management of HSS were identified. Of these 15 articles, 8 reported radiographic outcomes, with most reporting no significant change in spinopelvic parameters before and after surgery. Thirteen articles reported clinical outcomes, with 8 of those 13 articles identifying patient-reported outcome measures to be significantly improved following surgery. CONCLUSIONS: The data on the surgical management of HSS remains sparse. While there is some evidence that total hip arthroplasty in patients who previously underwent spinal fusion may have higher complication rates, there remains debate regarding which surgical problem to address first, the hip or the spine.

Incidence of radiographic and clinically significant pneumothorax or hemothorax after thoracic discectomy via mini-open lateral retropleural approach without prophylactic chest tube placement.

OBJECTIVE: The mini-open lateral retropleural (MO-LRP) approach is an effective option for surgically treating thoracic disc herniations, but the approach raises concerns for pneumothorax (PTX). However, chest tube placement causes insertion site tenderness, necessitates consultation services, increases radiation exposure (requires multiple radiographs), delays the progression of care, and increases narcotic requirements. This study examined the incidence of radiographic and clinically significant PTX and hemothorax (HTX) after the MO-LRP approach, without the placement of a prophylactic chest tube, for thoracic disc herniation. METHODS: This study was a single-institution retrospective evaluation of consecutive cases from 2017 to 2022. Electronic medical records were reviewed, including postoperative chest radiographs, radiology and operative reports, and postoperative notes. The presence of PTX or HTX was determined on chest radiographs obtained in all patients immediately after surgery, with interval radiographs if either was present. The size was categorized as large (≥ 3 cm) or small (< 3 cm) based on guidelines of the American College of Chest Physicians. PTX or HTX was considered clinically significant if it required intervention. RESULTS: Thirty patients underwent thoracic discectomy via the MO-LRP approach. All patients were included. Twenty patients were men (67%), and 10 (33%) were women. The patients ranged in age from 25 to 74 years. The most commonly treated level was T11-12 (n = 11, 37%). Intraoperative violation of parietal pleura occurred in 5 patients (17%). No patient had prophylactic chest tube placement. Fifteen patients (50%) had PTX on postoperative chest radiographs; 2 patients had large PTXs, and 13 had small PTXs. Both patients with large PTXs had expansion on repeat radiographs and were treated with chest tube insertion. Of the 13 patients with a small PTX, 1 required 100% oxygen using a nonrebreather mask; the remainder were asymptomatic. One patient, who had no abnormal findings on the immediate postoperative chest radiograph, developed an incidental HTX on postoperative day 6 and was treated with chest tube insertion. Thus, 3 patients (10%) required a chest tube: 2 for expanding PTX and 1 for delayed HTX. CONCLUSIONS: Most patients who undergo thoracic discectomy via the MO-LRP approach do not develop clinically significant PTX or HTX. PTX and HTX in this patient population should be treated with a chest tube only when there are postoperative clinical and radiographic indications.

Reciprocal Changes in Sagittal Spinal Alignment After L5-S1 Anterior Lumbar Interbody Fusion.

OBJECTIVE: Degenerative diseases of the lumbar spine decrease lumbar lordosis (LL). Anterior lumbar interbody fusion (ALIF) at the L5-S1 disc space improves segmental lordosis, LL, and sagittal balance. This study investigated reciprocal changes in spinopelvic alignment after L5-S1 ALIF. METHODS: A retrospective chart review identified patients who underwent L5-S1 ALIF with or without posterior fixation at a single institution (November 1, 2016 to October 1, 2021). Changes in pelvic tilt, sacral slope, proximal LL (L1-L4), distal LL (L4-S1), total LL (L1-S1), segmental lordosis, pelvic incidence-LL mismatch, thoracic kyphosis, cervical lordosis, and sagittal vertical axis were measured on preoperative and postoperative radiographs. RESULTS: Forty-eight patients were identified. Immediate postoperative radiographs were obtained at a mean (SD) of 17 (20) days after surgery; delayed radiographs were obtained 184 (82) days after surgery. After surgery, patients had significantly decreased pelvic tilt (15.71° [7.25°] vs. 17.52° [7.67°], P = 0.003) and proximal LL (11.86° [10.67°] vs. 16.03° [10.45°], P < 0.001) and increased sacral slope (39.49° [9.27°] vs. 36.31° [10.39°], P < 0.001), LL (55.35° [13.15°] vs. 51.63° [13.38°], P = 0.001), and distal LL (43.17° [9.33°] vs. 35.80° [8.02°], P < 0.001). Segmental lordosis increased significantly at L5-S1 and decreased significantly at L2-3, L3-4, and L4-5. Lordosis distribution index increased from 72.55 (19.53) to 81.38 (22.83) (P < 0.001). CONCLUSIONS: L5-S1 ALIF was associated with increased L5-S1 segmental lordosis accompanied by pelvic anteversion and a reciprocal decrease in proximal LL. These changes may represent a reversal of compensatory mechanisms, suggesting an overall relaxation of spinopelvic alignment after L5-S1 ALIF.

Associating T1-Weighted and T2-Weighted Magnetic Resonance Imaging Radiomic Signatures With Preoperative Symptom Severity in Patients With Cervical Spondylotic Myelopathy.

BACKGROUND: Preoperative symptom severity in cervical spondylotic myelopathy (CSM) can be variable. Radiomic signatures could provide an imaging biomarker for symptom severity in CSM. This study utilizes radiomic signatures of T1-weighted and T2-weighted magnetic resonance imaging images to correlate with preoperative symptom severity based on modified Japanese Orthopaedic Association (mJOA) scores for patients with CSM. METHODS: Sixty-two patients with CSM were identified. Preoperative T1-weighted and T2-weighted magnetic resonance imaging images for each patient were segmented from C2-C7. A total of 205 texture features were extracted from each volume of interest. After feature normalization, each second-order feature was further subdivided to yield a total of 400 features from each volume of interest for analysis. Supervised machine learning was used to build radiomic models. RESULTS: The patient cohort had a median mJOA preoperative score of 13; of which, 30 patients had a score of >13 (low severity) and 32 patients had a score of ≤13 (high severity). Radiomic analysis of T2-weighted imaging resulted in 4 radiomic signatures that correlated with preoperative mJOA with a sensitivity, specificity, and accuracy of 78%, 89%, and 83%, respectively (P < 0.004). The area under the curve value for the ROC curves were 0.69, 0.70, and 0.77 for models generated by independent T1 texture features, T1 and T2 texture features in combination, and independent T2 texture features, respectively. CONCLUSIONS: Radiomic models correlate with preoperative mJOA scores using T2 texture features in patients with CSM. This may serve as a surrogate, objective imaging biomarker to measure the preoperative functional status of patients.

Short-term outcomes of craniotomy for malignant brain tumors in the elderly.

BACKGROUND: Disparity in resection rates for malignant brain tumors in elderly patients is partially attributed to a belief that advanced age is associated with an increased risk of postoperative morbidity and mortality. The objective of this study was to investigate the effect of advanced age (≥75 years) on 30-day outcomes in patients with primary and metastatic brain tumors who underwent craniotomy for definitive resection of a malignant brain tumor. METHODS: The authors conducted prospective analyses of the American College of Surgeons' National Surgical Quality-Improvement Project (NSQIP) database from 2006 to 2010 of 970 patients aged ≥40 years who underwent craniotomy for definitive resection of neoplasm. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by age. By using propensity scores, 134 patients (aged ≥75 years) were matched to 134 patients ages 40 to 74 years. Logistic regression was used to predict adverse postoperative outcomes. RESULTS: The median length of hospital stay was 5 days; the rate of minor and major complications were 5.9% and 13.1%, respectively; 5.7% of patients returned to the operating room; and 4.3% of patients died within 30 days. Advanced age did not increase the odds for poorer short-term outcomes. CONCLUSIONS: Advanced age did not increase the risk of poor outcomes after surgical resection of primary or metastatic intracranial tumors when analyses were controlled for other risk factors. These results suggest that age should not be used, in isolation, as an a priori factor to discourage pursuing craniotomy.

Top-ten most-cited articles on anterior column release in the context of minimally invasive lumbar interbody fusion.

Introduction: Lateral anterior column release (ACR) is a minimally invasive option for the correction of sagittal plane deformity. To assemble a homogeneous picture of published research on ACR, an advanced bibliometric analysis was conducted to compile the top-ten most-cited articles on the topic of ACR. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles discussing the role of lateral ACR. The articles were then ranked based on the total number of citations to identify the ten most-cited articles published. A subjective appraisal of the findings of these articles was conducted to provide a ranked literature review and to examine trends in the study of ACR between 2012 and 2019. Results: The earliest published article on ACR was in 2012 by Deukmedjian et al. Three articles were in vitro biomechanical assessments of ACR, and seven articles were on outcome analyses, which were either case series or case controlled. The most-cited article was a biomechanical study authored by Uribe et al. The article with the highest rate of citations/year was authored by Manwaring et al. Uribe and the European Spine Journal were the most frequently cited author and journal, respectively. Conclusions: The lateral ACR approach has enjoyed significant scholarly attention since its advent. Higher-level analyses with robust control groups, larger sample sizes, and long-term follow-up are necessary to improve our understanding of this approach.

Surgical treatment of young adults with idiopathic scoliosis.

OBJECTIVE: In this study, the authors report on their experience with the surgical treatment of young adults with idiopathic scoliosis (YAdISs) who did not have surgical treatment in adolescence but did require intervention after skeletal maturity. METHODS: The medical records of YAdISs between 18 and 40 years of age who had been surgically treated at two institutions between 2009 and 2018 were retrospectively evaluated. Pre- and postoperative clinical and radiographic information was gathered and compared at 2 years after treatment. RESULTS: Twenty-eight patients (9 male, 19 female) with a median age of 25 years (range 18-40 years) met the study inclusion criteria. Five patients (18%) had postoperative complications, including 2 deep venous thromboses, 1 ileus, and 2 reoperations, one for implant failure and the other for pseudarthrosis. The mean maximum coronal curve angle improved from 43° ± 12° to 17° ± 8° (p < 0.001), but there were no significant differences in sagittal vertical axis, lumbar lordosis, pelvic tilt, or thoracic kyphosis (p > 0.05). There was no relationship between the amount of correction obtained and patient age (p = 0.46). Significant improvements in the Oswestry Disability Index (31 vs 24, p = 0.02), visual analog scale score for both back pain (6.0 vs 4.0, p = 0.01) and leg pain (2.6 vs 1.1, p = 0.02), and self-image score (Δ1.1, p < 0.001) were seen. CONCLUSIONS: YAdISs can present with pain, deformity progression, and/or appearance dissatisfaction because of their scoliosis despite successful nonoperative management during adolescence. Once the scoliosis becomes symptomatic, surgical correction can result in significant clinical and radiographic improvements at the 2-year follow-up with a relatively low complication rate compared to that for other types of adult spinal deformity.

Long-Term Durability of Stand-Alone Lateral Lumbar Interbody Fusion.

BACKGROUND: The long-term durability of stand-alone lateral lumbar interbody fusion (LLIF) remains unknown. OBJECTIVE: To evaluate whether early patient-reported outcome measures after stand-alone LLIF are sustained on long-term follow-up. METHODS: One hundred and twenty-six patients who underwent stand-alone LLIF between 2009 and 2017 were included in this study. Patient-reported outcome measures included the Oswestry Disability Index (ODI), EuroQOL-5D (EQ-5D), and visual analog score (VAS) scores. Durable outcomes were defined as scores showing a significant improvement between preoperative and 6-week scores without demonstrating any significant decline at future time points. A repeated measures analysis was conducted using generalized estimating equations (model) to assess the outcome across different postoperative time points, including 6 weeks, 1 year, 2 years, and 5 years. RESULTS: ODI scores showed durable improvement at 5-year follow-up, with scores improving from 46.9 to 38.5 ( P = .001). Improvements in EQ-5D showed similar durability up to 5 years, improving from 0.48 to 0.65 ( P = .03). VAS scores also demonstrated significant improvements postoperatively that were durable at 2-year follow-up, improving from 7.0 to 4.6 ( P < .0001). CONCLUSION: Patients undergoing stand-alone LLIF were found to have significant improvements in ODI and EQ-5D at 6-week follow-up that remained durable up to 5 years postoperatively. VAS scores were found to be significantly improved at 6 weeks and up to 2 years postoperatively but failed to reach significance at 5 years. These findings demonstrate that patients undergoing stand-alone LLIF show significant improvement in overall disability after surgery that remains durable at long-term follow-up.

Durability of stand-alone anterolateral interbody fusion in staged minimally invasive circumferential scoliosis surgery with delayed posterior instrumentation due to medical necessity.

PURPOSE: Circumferential minimally invasive scoliosis surgeries are often staged, wherein anterior and/or lateral lumbar interbody fusion is followed by percutaneous posterior fixation days later. This study examines the impact on outcomes when posterior augmentation was delayed due to unexpected medical issues following the first stage, anterolateral procedure. METHODS: A retrospective review was conducted of all patients undergoing minimally invasive circumferential deformity corrections from 2006 to 2019. Patients in whom planned posterior fixation was postponed due to medical necessity or safety concerns were identified. Perioperative surgical metrics and radiographic parameters were collected. RESULTS: Three of the six patients initially scheduled for circumferential fusion never underwent posterior augmentation due to symptomatic improvement (2.3, 5, and 10.7 years of follow-up). The other three underwent posterior fixation once medically optimized after an average interval of 4.7 months (range 3.2-7.8 months) due to persistent symptoms. It was also observed that the average coronal malalignment in the postoperative period was 5.1 cm in the group requiring further fixation and only 1.6 cm in the group which did not. CONCLUSION: In select cases, the indirect decompression and stability conferred by minimally invasive anterolateral arthrodesis alone may afford adequate pain relief to delay or even avoid posterior fixation in patients with adult spinal deformity.

The 'candy cane' technique for construct augmentation and correction of severe angular chin-on-chest kyphoscoliosis.

PURPOSE: To manage severe angular chin-on-chest deformity. METHODS: A single midline incision and periosteal dissection were utilized to expose from C2 to T6. Bilateral C2 pars screws, C3 to C7 lateral mass screws, and T1 to T6 pedicle screws were placed. Following the placement of screws, multiple two column posterior osteotomies and interlaminar decompressions from C6 to T3 were performed to amplify both the sagittal and coronal corrections. Titanium rods were utilized in light of the patient's known osteopenia and nickel allergy. As such, the construct was augmented via the use of a third accessory rod. This third titanium rod was placed into a supplementary translaminar screw with three connectors to the right-sided main rod. Once the lordotic configuration of the contralateral main rod was secured, an additional corrective maneuver of gentle distraction across this third rod was employed to assist with coronal correction. RESULTS: In this patient with osteopenia, a known nickel allergy, and significant cervical imbalance, the Candy Cane construct allowed for a durable correction of the severe sagittal and coronal plane deformity. The chin-brow angle was corrected by 44°. The coronal Cobb angle improved by 10°. On long-term follow-up, the patient reported continued satisfaction with the operation and was able to perform his activities of daily living. CONCLUSION: A one-stage, posterior approach along with construct augmentation, with a third rod hooked into a supplementary C2 translaminar screw, can be employed for the correction of chin-on-chest kyphoscoliosis.

Direct Iliac Screw vs Sacral-2-Alar-Iliac Screws Technique for Sacropelvic Fixation: Technical Nuances and a Review of the Literature.

Sacropelvic (SP) fixation is the immobilization of the sacroiliac joint to attain lumbosacral fusion and prevent distal spinal junctional failure. SP fixation is indicated in numerous spinal conditions (eg, scoliosis, multilevel spondylolisthesis, spinal/sacral trauma, tumors, or infections). Many SP fixation techniques have been described in the literature. Currently, the most used surgical techniques for SP fixation are direct iliac screws and sacral-2-alar-iliac screws. There is currently no consensus in the literature on which technique carries more favorable clinical outcomes. In this review, we aim to assess the available data on each technique and discuss their respective advantages and disadvantages. We will also present our experience with a modification of direct iliac screws using a subcrestal approach and outline the future prospects of SP fixation.

Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study.

BACKGROUND AND OBJECTIVES: Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs. METHODS: A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction). RESULTS: Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up. CONCLUSION: This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.

Clinical Validation of a Novel Musculoskeletal Modeling Framework to Predict Postoperative Sagittal Alignment.

STUDY DESIGN: A retrospective radiographic and biomechanical analysis of 108 thoracolumbar fusion patients from two clinical centers. OBJECTIVE: This study aimed to determine the validity of a computational framework for predicting postoperative patient posture based on preoperative imaging and surgical data in a large clinical sample. SUMMARY OF BACKGROUND DATA: Short-term and long-term studies on thoracolumbar fusion patients have discussed that a preoperative predictive model would benefit surgical planning and improve patient outcomes. Clinical studies have shown that postoperative alignment changes at the pelvis and intact spine levels may negatively affect postural balance and quality of life. However, it remains challenging to predict such changes preoperatively because of confounding surgical and patient factors. MATERIALS AND METHODS: Patient-specific musculoskeletal models incorporated weight, height, body mass index, age, pathology-associated muscle strength, preoperative sagittal alignment, and surgical treatment details. The sagittal alignment parameters predicted by the simulations were compared with those observed radiographically at a minimum of three months after surgery. RESULTS: Pearson correlation coefficients ranged from r=0.86 to 0.95, and mean errors ranged from 4.1° to 5.6°. The predictive accuracies for postoperative spinopelvic malalignment (pelvic incidence minus lumbar lordosis>10°) and sagittal imbalance parameters (TPA>14°, T9PA>7.4°, or LPA>7.2°) were between 81% and 94%. Patients treated with long fusion (greater than five segments) had relatively lower prediction errors for lumbar lordosis and spinopelvic mismatch than those in the local and short groups. CONCLUSIONS: The overall model performance with long constructs was superior to those of the local (one to two segments) and short (three to four segments) fusion cases. The clinical framework is a promising tool in development to enhance clinical judgment and to help design treatment strategies for predictable surgical outcomes. LEVEL OF EVIDENCE: 3.

Minimally Invasive Surgery Strategies to Prevent Proximal Junctional Kyphosis.

Proximal junctional kyphosis (PJK) is a common complication following long-segment thoracolumbar fusions for patients with adult spinal deformities. PJK is described as a progressive kyphosis at the upper instrumented vertebra or 1 or 2 segments adjacent to the instrumented vertebra. This condition can lead to proximal junction failure, which results in vertebral body fractures, screw pullouts, and neurological deficits. Revision surgery is necessary to address symptomatic PJK. Research efforts have been dedicated to elucidating risk factors and prevention strategies. It has been postulated that minimally invasive surgery (MIS) techniques may help prevent PJK because these techniques aim to preserve the soft tissue integrity at the top of the construct and maintain posterior element support. In this article, the authors define PJK, describe MIS strategies to prevent PJK, and compare PJK rates after MIS with PJK rates after open approaches for long-segment thoracolumbar fusion.