Comparison of Staged vs Same-Day Circumferential Spinal Fusions for Adult Spinal Deformity.

BACKGROUND: Patients often undergo circumferential (anterior and posterior) spinal fusions to maximize adult spinal deformity (ASD) correction and achieve adequate fusion. Currently, such procedures are performed in staged (ST) or same-day (SD) procedures with limited evidence to support either strategy. This study aims to compare perioperative outcomes and costs of ST vs SD circumferential ASD corrective surgeries. METHODS: This is a retrospective review of patients undergoing circumferential ASD surgeries between 2013 and 2018 in a single institution. Patient characteristics, preoperative comorbidities, surgical details, perioperative complications, readmissions, total hospital admission costs, and 90-day postoperative care costs were identified. All variables were tested for differences between ST and SD groups unadjusted and after applying inverse probability weighting (IPW), and the results before and after IPW were compared. RESULTS: The entire cohort included a total of 211 (ST = 50, SD = 161) patients, 100 of whom (ST = 44, SD = 56) underwent more than 4 levels fused posteriorly and anterior lumbar interbody fusion (ALIF). Although patient characteristics and comorbidities were not dissimilar between the ST and SD groups, both the number of levels fused in ALIF and posterior spinal fusion (PSF) were significantly different. Thus, using IPW, we were able to minimize the cohort incongruities in the number of levels fused in ALIF and PSF while maintaining comparable patient characteristics. In both the whole cohort and the long segment fusions, postoperative pulmonary embolism was more common in ST procedures. After adjustment utilizing IPW, both groups were not significantly different in disposition, 30-day readmissions, and reoperations. However, within the whole cohort and the long segment fusion cohort, the ST group continued to show significantly increased rates of pulmonary embolism, longer length of stay, and higher hospital admission costs compared with the SD group. CONCLUSIONS: Adjusted comparisons between ST and SD groups showed staging associated with significantly increased length of stay, risk of pulmonary embolism, and admission costs.

Do Prophylactic Inferior Vena Cava Filters Affect the Rates of Venous Thromboembolism and Pulmonary Embolism in Patients Undergoing Major Spine Surgery?

STUDY DESIGN: Retrospective Analysis. BACKGROUND: Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in major spine surgery. Placement of prophylactic inferior vena cava filters (IVCF) in patients undergoing major spine surgery was previously adopted at our institution. This study reports our experience and compares VTE rates between patients with and without preoperative IVCF placement. METHODS: A Retrospective comparative study was conducted on adult patients who underwent IVCF placement and those who did not prior to their spinal fusion procedure, between 2013 and 2016. Thoracolumbar fusions (anterior and/or posterior) of 7 or more levels, spinal osteotomies, and a minimum of a 3-month follow-up were included. Traumatic, oncologic, and cervical pathology were excluded. Primary outcomes measured included the incidence of overall VTE (DVT/PE), death, IVCF related complications, and IVCF retrieval. RESULTS: 386 patients who underwent major spine surgery, 258 met the eligibility criteria. Of those patients, 105 patients (40.7%) had prophylactic IVCF placement. All patients had postoperative SCDs and chemoprophylaxis. The presence of an IVCF was associated with an increased rate of overall VTE (14.3% vs 6.5%, P ≤ .05) and DVT episodes (8.6% vs 2.6%, P = .04). The rate of PE for the IVCF group and non-IVCF group was 8.6% and 4.6%, respectively, which was not statistically significant (P = .32). The all-cause mortality rate overall of 2.3% was statistically similar between both groups (P = 1.0). The IVCF group had higher rates of hematoma/seroma vs the non-IVCF group (12.4% vs 3.9%, P ≤ .05). 99 IVCFs were retrievable designs, and 85% were successfully retrieved. Overall IVCF-related complication rate was 11%. CONCLUSIONS: No statistical difference in PE or mortality rates existed between the IVCF and the control group. Patients with IVCF placement experienced approximately twice the rate of VTE and three times the rate of DVT compared to those without IVCF. The IVCF-related complication rate was 11%. Based on the results of this study, the authors recommend against the routine use of prophylactic IVCFs in adults undergoing major spine surgery. LEVEL OF EVIDENCE: III.

The Rise and Fall of Bone Morphogenetic Protein 2 Throughout the United States.

STUDY DESIGN: Retrospective Database Study. OBJECTIVE: Investigate utilization of bone morphogenetic protein (BMP-2) between 2004 and 2014. SUMMARY OF BACKGROUND DATA: The utilization, particularly off-label utilization, of BMP-2 has been controversial and debated in the literature. Given the concerns regarding cancer and potential complications, the risk benefit profile of BMP must be weighed with each surgical case. The debate regarding the costs and potential side effects of BMP-2 compared with autologous iliac crest bone harvest has continued. METHODS: The National Inpatient Sample (NIS) database was queried for the use of BMP-2 (ICD-9-CM 84.52) between 2004 and 2014 across 44 states. The NIS database represents a 20% sample of discharges, weighted to provide national estimates. BMP-2 utilization rates in spine surgery fusion procedures were calculated as a fraction of the total number of thoracic, lumbar, and sacral spinal fusion surgeries performed each year. RESULTS: Between 2004 and 2014, BMP-2 was utilized in 927,275 spinal fusion surgeries. In 2004, BMP-2 was utilized in 28.3% of all cases (N=48,613). The relative use of BMP-2 in spine fusion surgeries peaked in 2008 at 47.0% (N=112,180). Since then, it has continued to steadily decline with an endpoint of 23.6% of cases in 2014 (N=60,863). CONCLUSIONS: Throughout the United States, the utilization of BMP-2 in thoracolumbar fusion surgeries increased from 28.3% to 47.0% between 2004 and 2008. However, from 2008 to 2014, the utilization of BMP-2 in thoracolumbar spine fusion surgeries decreased significantly from 47.0% to 23.4%. While this study provides information on the utilization of BMP-2 for the entire United States over an 11-year period, further research is needed to the determine the factors affecting these trends.

Soft Landing technique as a possible prevention strategy for proximal junctional failure following adult spinal deformity surgery.

BACKGROUND: This cross sectional study describes a "Soft Landing" strategy utilizing hooks for minimizing proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). The technique creates a gradual transition from a rigid segmental construct to unilateral hooks at the upper instrumented level and preservation of the soft tissue attachments on the contralateral side of the hooks. Authors devise a novel classification system for better grading of PJK severity. METHODS: Thirty-nine consecutive adult spinal deformity (ASD) patients at a single institution received the "Soft Landing" technique. The proximal junctional angle was measured preoperatively and at last follow-up using standing 36-inch spinal radiographs. Changes in proximal junctional angle and rates of PJK and PJF were measured and used to create a novel classification system for evaluating and categorizing ASD patients postoperatively. RESULTS: The mean age of the cohort was 61.4 years, and 90% of patients were women. Average follow up was 2.2 years. The mean change in proximal junctional angle was 8° (SD 7.4°) with the majority of patients (53%) experiencing less than 10° and only 1 patients with proximal junctional angle over 20°. Four patients (10%) needed additional surgery for proximal extension of the uppermost instrumented vertebra (UIV) secondary to PJF. CONCLUSIONS: Soft Landing technique is a possibly effective treatment strategy to prevent PJK and PJF following ASD that requires further evaluation. The described classification system provides management framework for better grading of PJK. The "Soft Landing" technique warrants further comparison to other techniques currently used to prevent both PJK and failure.

The Expanding Frontier of Outpatient Spine Surgery.

BACKGROUND: In 2014, inpatient spinal fusion surgery had the highest aggregate cost of any inpatient surgery performed in the United States, costing 12 billion dollars. As the national health care system seeks to improve value-based care, there is increased motivation to perform surgery on an outpatient basis. To ensure improved patient outcomes with this transition, patient selection has become increasingly important to identify who would most benefit from outpatient spine fusion, for example. This demands an improved understanding of the demographics of patients who have been receiving outpatient spine fusion on which the spine surgery community can build to improve cost-effective care delivered. METHODS: The Healthcare Cost and Utilization Project, State Ambulatory Surgery Databases, and Agency for Healthcare Research and Quality databases were queried for demographic data regarding all-cause outpatient spine surgery between 2012 and 2014. Outpatient surgery volume was compared with inpatient surgery volume-which was provided by the State Inpatient Databases. RESULTS: A total of 1,164,040 spine fusion procedures were identified between 2012 and 2014, of which 132,900 procedures were performed as outpatient surgery (11.4%). Of all fusion procedures amongst 18- to 44-year-old patients, 18.4% were outpatient. A larger proportion of white patients, rather than black or Hispanic patients, underwent ambulatory procedures (12.14% vs 9.53% vs 7.46%, respectively); 16.54% of spinal fusion procedures for patients with private insurance was performed on an outpatient basis. Based on patient income, 76% of all outpatient fusions were performed on patients who live in "not low" income ZIP codes. CONCLUSIONS: There has been a gradual trend toward performing more outpatient spinal fusion procedures over the studied period. This study has also revealed unique trends in the demographics of patients who have received outpatient spine fusion during this time. LEVEL OF EVIDENCE: 3.

Postoperative Sagittal Spinal Alignment Changes Following Corrective Surgery in Adult Spinal Deformity.

BACKGROUND: There is a paucity of literature covering the spinal alignment changes following adult spinal deformities (ASD) corrective surgeries. In theory, patients' posture and overall alignment may vary with postoperative pain, bracing, and other external variables requiring further radiographic follow-up. The purpose of the study is to investigate changes in sagittal alignment in the first 3 months postoperatively. METHODS: This is a retrospective case series of ASD patients who underwent deformity surgeries from October 2015 to June 2018. Patients < 40 years old, had < 6 levels fused, had acute proximal junctional kyphosis (PJK) or failure, or lacked imaging were excluded. Physiologic measures, spine alignment changes measured in whole-spine radiographs. Lumbar lordosis (LL), thoracic kyphosis (TK), and sagittal vertical axis (SVA) at immediate and 3-month postoperative time points were measured, then compared via 2-sample Student t tests. Furthermore, TK after upper thoracic to pelvis (UT-P) fusions was compared with lower thoracic to pelvis (LT-P) fusions via paired t test. RESULTS: Thirty-six patients (24 females, 67%) with a mean age of 61.5 years (range, 40-75 years) were included. Spinal alignment comparisons showed a significant increase in TK at the 3-month time point (P = 0.006). Additionally, wide variations in SVA (range, 47-144 mm) were noted, yet not statistically significant, likely due to the changes being in both positive and negative directions (P = 0.18). No significant difference was found when TK was compared in the UT-P vs LT-P groups. CONCLUSIONS: Our results suggest that as postoperative pain subsides and the body settles into its new alignment, significant changes occur in spine sagittal parameters in the subacute period following surgery. LEVEL OF EVIDENCE: 4.

Proximal junctional kyphosis following T10-pelvis fusion presenting with neurologic compromise: case presentations and review of the literature.

Purpose: Proximal Junctional Kyphosis (PJK) is a well-documented phenomenon following spinal instrumented fusion. Myelopathy associated with proximal junctional failure (PJF) is poorly described in the literature. Adjacent segment disease, fracture above the upper instrumented vertebrae and subluxation may all cause cord compression, ambulatory dysfunction, and/or lower extremity weakness in the postoperative period.Materials and methods: We review the literature on PJK and PJF, and discusses the postoperative management of three patients who experienced myelopathy associated with PJF following T9/10 to pelvis fusion at a single institution.Results and conclusions: PJF with myelopathy must be diagnosed and surgically corrected early on so as to minimize permanent neurologic injury. Patients requiring significant sagittal deformity correction are at greater risk for PJF, and may benefit from constructs terminating in the upper thoracic spine.

Revision surgery for non-union in adult spinal deformity.

As adult spinal deformity surgery is performed more and more, the spine surgeon is faced with the challenge to treat pseudoarthrosis. The presentation may vary, from asymptomatic patients, who should be observed in most of the cases, to patients with acute episode of broken rods, and or chronic pain with often trunk imbalance. In some instances, patients will present with neurologic symptoms. The evaluation of such patients must start with a good understanding of why the surgery failed first place. Poor host, smoking, lack of anterior column support, poor sagittal balance, lack of fusion, poor construct. Often a combination of all of the above is encountered. The workup for such cases consists of imaging studies (with often a CT myelogram as the excessive metal artifact will render the MRI imaging useless), nutrition labs, DEXA scan, EOS films and internal medicine or cardiology consult for risk stratification as this may represent major surgery. Indication of surgery is mostly based on pain and imbalance and/or poor function. The surgeon planning a revision adult deformity surgery has many tasks to perform: Identify and avoid the reasons that lead to failure of the previous surgeries. Plan the anterior column reconstruction either through posterior or anterior interbody fusion. Restore the global alignment through anterior or posterior osteotomies to achieve sagittal and coronal balance. Obtain a solid fixation with sufficient levels above and below the osteotomies sites with in some cases the use of pelvic screws and four rods (Quad-Rod) techniques. The use of bone graft (either autologous, allograft, bone graft enhancers and inducer) agents. The requirement of decompression either through a virgin spine or a previous laminectomy bed. Despite the extent of these surgeries and the potential for immediate postoperative complications, the outcome is in most cases satisfactory if these goals are achieved. In this review, the authors explore different scenarios for pseudoarthrosis in the adult spine deformity patient and the preferred treatment method to obtain the best outcome for every individual patient. These slides can be retrieved under Electronic Supplementary Material.

Occipital neuralgia: A neurosurgical perspective.

Occipital neuralgia typically arises in the setting of nerve compression by fibrosis, surrounding anatomic structures, or osseous pathology, such as bone spurs or hypertrophic atlanto-epistropic ligament. It generally presents as paroxysmal bouts of sharp pain in the sensory distribution of the first three occipital nerves. Due to the long course of the greater occipital nerve (GON), and its peculiar anatomy, and location in a mobile region of the neck, it is unsurprising that the GON is at high risk for compression. Little is known how to diagnose or treat this neuropathic pain syndrome. The objective of this paper is to isolate the etiology involved, and treat this condition promptly. After all nonoperative efforts are exhausted, surgical transection of the nerve is the treatment of choice in these cases. An isolated C2 neurectomy or ganglionectomy is performed for an optimal pain relief. C1-2 instrumented fusion can be considered if, extensive facet arthropathy with instability is identified. Authors review the spectrum of treatment options for this debilitating condition, and discuss the case example of a patient who required conversion to a C1-C2 instrumented fusion following C2 ganglionectomy due to an underlying extensive degenerative disease and intraoperative findings suggestive of atlantoaxial instability.

Surgical Treatment of Flat Back Syndrome With Anterior Hyperlordotic Cages.

BACKGROUND: Traditional correction for flat back syndrome is performed with a posterior-based surgery or combined approaches in revision cases. OBJECTIVE: To evaluate outcome from anterior surgery with the use of hyperlordotic cages (HLCs) in patients with flat back syndrome. METHODS: All patients operated with or without prior posterior lumbar surgery were studied. Pre- to postoperative sagittal alignment was analyzed. Radiographic parameters were analyzed including T1 pelvic angle (T1PA), sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), sacral slope (SS), pelvic incidence and lumbar lordosis (PI-LL), and T4-12TK. RESULTS: All 50 patients (mean age of 58 yr, 72% female with mean body mass index of 28) demonstrated significant radiographic alignment difference in their spinopelvic and global parameters from pre- to postoperative standing: LL (-37.04° vs -59.55°, P < .001), SS (35.12 vs 41.13, P < .001), PI-LL (23.55 vs 6.46), T4-12 TK (30.59 vs 41.67), PT (28.22 vs 22.13), SVA in mm (80.94 vs 37.39), and T1PA (28.70° vs 18.43°, P < .001). Using linear regression analysis, predicted pre- to postoperative change in standing LL corresponded to a pre- to postoperative changes in standing PI-LL mismatch, T1PA, TK, SS, PT, and SVA (R2 = 0.59, 0.38, 0.25, 0.16, 0.12, and 0.17, respectively). Five degrees of pre- to postoperative change in T1PA translates to -4.15° change in LL. CONCLUSION: Anterior surgery with HLCs followed by posterior instrumentation is an effective technique to treat flat back syndrome. HLCs are effective to maximize LL up to 30°, which is equivalent in magnitude to a pedicle subtraction osteotomy, but associated with less blood loss, quicker recovery, lower complications, and good surgical outcome.

Technical Consideration for TLIF Cage Retrieval and Deformity Correction With Anterior Interbody Fusion in Lumbar Revision Surgeries.

INTRODUCTION: Symptomatic pseudoarthrosis after transforaminal lumbar interbody fusion (TLIF) could result in sagittal malalignment. Revision posterior surgery with TLIF cage removal poses a challenge intraoperatively. The authors have proposed salvage anterior approach for cage removal and have discussed unique experience with the correction in their deformity patients. METHODS: All patients with symptoms of clinical deformity or symptomatic pseudoarthrosis operated from January of 2012 to February of 2018 were included in the study. TLIF cage removal followed by anterior lumbar interbody fusion (ALIF) surgery was performed in all patients. Radiographic sagittal parameters including thoracic kyphosis (TK; T4-T12), sagittal vertical axis (SVA), T1 pelvic angle (TPA), lumbar lordosis (LL), the mismatch between pelvic incidence (PI) and LL (PI-LL), sacral slope (SS), pelvic tilt (PT), and PI were analyzed. RESULTS: 6 patients (mean age of 57 years, 83% female) underwent TLIF retrieval through anterior approach and ALIF with hyperlordotic cages (HLCs), followed by posterior spinal fusion surgery. Described technique entails use of tailored instruments with sequential gentle distraction of end plates with TLIF spreader could facilitate in the cage removal. Mean number of interbody levels fused pre as well as post were 1.5. The radiographic sagittal parameters from preoperative versus postoperative standing were as follows: T4-T12 TK, 16° vs. 37.6°; LL, -25° vs. -47.6°; PT, 36° vs. 26°; PI-LL, 35° vs. 12.4°; SVA, 12° vs. 5.6°; and TPA, 44° vs. 25°, with p<.001. Mean number of instrumented level fused were 8.1. Using linear regression analysis, change from pre-to postoperative standing in LL predicted pre-to postoperative change in SVA and TPA for global correction (R= -0.30 and -0.80, respectively). CONCLUSIONS: Anterior approach is a suitable technique for TLIF cage removal while preserving the end plates for subsequent optimal interbody fusion at the index level in symptomatic pseudoarthrosis patients or those with clinical deformity. ALIF with HLCs with or without Ponte osteotomy can restore segmental and overall sagittal alignment.

Utilization and Economic Impact of Posterolateral Fusion and Posterior/Transforaminal Lumbar Interbody Fusion Surgeries in the United States.

STUDY DESIGN: Retrospective database study. OBJECTIVE: To analyze the economic and age data concerning primary and revision posterolateral fusion (PLF) and posterior/transforaminal lumbar interbody fusion (PLIF/TLIF) throughout the United States to improve value-based care and health care utilization. METHODS: The National Inpatient Sample (NIS) database was queried by the International Classification of Diseases, Ninth Revision, Clinical Modification codes for patients who underwent primary or revision PLF and PLIF/TLIF between 2011 and 2014. Age and economic data included number of procedures, costs, and revision burden. The National Inpatient Sample database represents a 20% sample of discharges from US hospitals weighted to provide national estimates. RESULTS: From 2011 to 2014, the annual number of PLF and PLIF/TLIF procedures decreased 18% and increased 23%, respectively, in the Unites States. During the same period, the number of revision PLF decreased 19%, while revision PLIF/TLIF remained relatively unchanged. The average cost of PLF was lower than the average cost of PLIF/TLIF. The aggregate national cost for PLF was more than $3 billion, while PLIF/TLIF totaled less than $2 billion. Revision burden (ratio of revision surgeries to the sum of both revision and primary surgeries) remained constant at 8.0% for PLF while it declined from 3.2% to 2.9% for PLIF/TLIF. CONCLUSION: This study demonstrated a steady increase in PLIF/TLIF, while PLF alone decreased. The increasing number of PLIF/TLIF procedures may account for the apparent decline of PLF procedures. There was a higher average cost for PLIF/TLIF as compared with PLF. Revision burden remained unchanged for PLF but declined for PLIF/TLIF, implying a decreased need for revision procedures following the initial PLIF/TLIF surgery.

Technical nuances of percutaneous sacroiliac joint fixation: A cadaveric study.

Sacroiliac (SI) joint can produce debilitating lower back pain with radiation to groin, buttocks, and lower extremities. SI joint dysfunction poses a clinical challenge to the spine surgeons. Studies entailing surgical arthrodesis utilizing Titanium implants have been reported with reputedly high level of patient satisfaction. Authors have described technical aspects of surgical technique with use of titanium screw implants. The transarticular technique is used to places SI joint screw implants across the articular portion of SI joint. Cadaveric SI joint instrumentation is performed under fluoroscopic guidance. Moreover, Medline literature search is conducted to study surgical outcome, and patient satisfaction. 4 cadavers are prepped prone for the percutaneous approach. Bilaterally 6 screws are placed using transarticular placement technique under fluoroscopic guidance. The posterior technique utilizes alignment guide to place the screws inline on the inlet view, parallel in the outlet view, and parallel to the dorsal aspect of the sacral body in the lateral view. One C-arm is used in the entire technique. The technical aspects of surgical technique have been described in a stepwise fashion for easy reproducibility in the operating room. Each screw track is checked with tactile feel of a blunt K-wire before final deployment. All bilateral screws were checked on a set of fluoroscopic views. A detail clinical examination, diagnostic joint injection, with the radiological imaging must be considered before surgical consideration. SI Joint fusion utilizing 3 transarticular sacral screws is equally effective and safe procedure to treat chronic lower back pain ensuing from SI joint dysfunction.

Overpowering posterior lumbar instrumentation and fusion with hyperlordotic anterior lumbar interbody cages followed by posterior revision: a preliminary feasibility study.

OBJECTIVE The authors' aim in this study was to evaluate whether sagittal plane correction can be obtained from the front by overpowering previous posterior instrumentation and/or fusion with hyperlordotic anterior lumbar interbody fusion (ALIF) cages in patients undergoing revision surgery for degenerative spinal conditions and/or spinal deformities. METHODS The authors report their experience with the application of hyperlordotic cages at 36 lumbar levels for ALIFs in a series of 20 patients who underwent revision spinal surgery at a single institution. Included patients underwent staged front-back procedures: ALIFs with hyperlordotic cages (12°, 20°, and 30°) followed by removal of posterior instrumentation and reinstrumentation from the back. Patients were divided into the following 2 groups depending on the extent of posterior instrumentation and fusion during the second stage: long constructs (≥ 6 levels with extension into thoracic spine and/or pelvis) and short constructs (< 6 levels). Preoperative and postoperative standing radiographs were evaluated to measure segmental lordosis (SL) along with standard sagittal parameters. Radiographic signs of pseudarthrosis at previously fused levels were also sought in all patients. RESULTS The average patient age was 54 years (range 30-66 years). The mean follow-up was 11.5 months (range 5-26 months). The mean SL achieved with 12°, 20°, and 30° cages was 13.1°, 19°, and 22.4°, respectively. The increase in postoperative SL at the respective surgically treated levels for 12°, 20°, and 30° cages that were used to overpower posterior instrumentation/fusion averaged 6.1° (p < 0.05), 12.5° (p < 0.05), and 17.7° (p < 0.05), respectively. No statistically significant difference was found in SL correction at levels in patients who had pseudarthrosis (n = 18) versus those who did not (n = 18). The mean overall lumbar lordosis increased from 44.3° to 59.8° (p < 0.05). In the long-construct group, the mean improvement in sagittal vertical axis was 85.5 mm (range 19-249.3 mm, p < 0.05). Endplate impaction/collapse was noted in 3 of 36 levels (8.3%). The anterior complication rate was 13.3%. No neurological complications or vascular injuries were observed. CONCLUSIONS ALIF in which hyperlordotic cages are used to overpower posterior spinal instrumentation and fusion can be expected to produce an increase in SL of a magnitude that is roughly half of the in-built cage lordotic angle. This technique may be particularly suited for lordosis correction from the front at lumbar levels that have pseudarthrosis from the previous posterior spinal fusion. Meticulous selection of levels for ALIF is crucial for safely and effectively performing this technique.

Ischiospinal Dysostosis in a Child with Pierre-Robin Syndrome.

Ischiospinal Dysostosis (ISD) is a complex and very rare medical entity. It is associated with kyphoscoliosis, dysplasia or aplasia of the ischial rami, segmental anomalies of the bony vertebrae, and peculiar facial morphologies. In this case report, we present a child with Ischiospinal Dysostosis and Pierre-Robin Syndrome. This case report is unique as we followed the patient for 13 years in which he had multiple spinal procedures to treat his kyphoscoliosis. In this paper, we elucidated the number of case reports with documented follow-up regarding spinal cord injury or other complications of ISD and its management.

Vertebral body fracture after TLIF: a new complication.

BACKGROUND: The transforaminal posterior approach (TLIF) procedure was first described in 1982. Current literature indicates its equality in outcomes for fusion constructs as other anterior-posterior procedures. As a procedure becomes more popular and is more frequently performed the types and number of complications that occur increase. We report on a two case series that underwent TLIF. Both patients had satisfactory postoperative imaging, but presented later with coronal plane vertebral body fractures in the caudal vertebral body of the TLIF construct. We believe the complication may be related to: (a) unrecognized fracture of the endplate during cage impaction; (b) overloading the endplates by maximizing the lordosis achieved by using the reverse jackknife position on a Jackson table; (c) underlying mineral bone disease in patients. As the TLIF procedure increases in popularity, caution should be exercised to avoid the same potential complications. PURPOSE: To describe a potential complication with the TLIF procedure. STUDY DESIGN: Case report. PATIENT SAMPLE: 2. OUTCOME MEASURE: Revision surgery. METHODS: Case series. RESULTS: Caudal vertebral body fracture is a potential complication after TLIF. CONCLUSION: TLIF procedures can result in an unstable vertebral body fracture potentially necessitating revision decompression & stabilization. We recommend extra caution in patients with mineral bone disease, as technical errors can be magnified.

Bilateral vascularized rib grafts to promote spinopelvic fixation in patients with sacral agenesis and spinopelvic dissociation: a new surgical technique.

BACKGROUND CONTEXT: Sacral agenesis is a rare congenital disorder that may have spinopelvic instability due to sacroiliac joint malformation. Surgical indication in patients with sacral agenesis is to improve their sitting balance and protect the visceral organs. Achieving solid arthrodesis across this congenital malformation is challenging and prone to non-union. PURPOSE: The purpose of this study was to describe a novel surgical technique with vascularized ribs for management of sacral agenesis and complex spinopelvic dissociation. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Six patients with sacral agenesis were reviewed and followed for a mean of 8.5 years after spinopelvic fusion augmented with vascularized rib graft spanning the lumbo-pelvic junction. OUTCOME MEASURES: The primary outcome measure was the presence or absence of a stable spinopelvic junction and fusion across the spine-vascular rib grafts-pelvis interface. The secondary outcome measures were maintenance of pelvic obliquity, lumbosacral kyphosis, and overall sagittal balance. METHODS: The surgical procedure consisted of two-stage surgeries performed 6-12 weeks apart. The first stage consisted of spinal instrumentation and correction of the deformity via a posterior approach and impaction of one of the vascularized ribs from the spine to the iliac crest. The second stage consisted of an anterior thoraco-lumbar approach for spinal fusion and the second vascularized rib spanning the spine to the iliac crest. RESULTS: All six patients eventually achieved a solid spinal and spinopelvic fusion. All vascularized ribs increased in diameter over time. A high complication rate consisted mainly of spinal infections and prominent hardware requiring revision surgeries (a total of seven procedures in four patients). Two patients had decreased mobility secondary to spinopelvic surgery at last follow-up. CONCLUSIONS: Spinopelvic fusion can be successfully achieved with this novel surgical technique using vascularized rib grafts. This technique allows for biological long-term maintenance of the sagittal deformity correction. Fusion across the lumbosacral junction in patients with sacral agenesis may place them at risk of losing the ability to mobilize independently. Recent lower profile implants have prevented implant-related complications.

Correction of severe pelvic obliquity using maximum-width segmental sacropelvic screw fixation: an analysis of 20 neuromuscular scoliosis patients.

STUDY DESIGN: The present study was a retrospective analysis. OBJECTIVE: The purpose of the study was to evaluate the safety and efficacy of the maximum-width (M-W) segmental sacropelvic fixation technique, comprising iliac screws and/or iliosacral pedicle screws, to correct severe pelvic obliquity. Classic spinal fixation using the Luque-Galveston procedure for the correction of neuromuscular scoliosis may be inadequate to manage severe pelvic obliquities. METHODS: A series of 20 consecutive patients with severe neuromuscular spinopelvic deformities was reviewed by an independent observer. Coronal and sagittal Cobb angle, frontal pelvic obliquity, and trunk shift were measured preoperatively, immediately postoperatively and at final follow-up. RESULTS: All 20 patients underwent spinal fusion with instrumentation extending to the pelvis. Fourteen cases had primary operations, and six patients had undergone previous spinal fusion above the pelvis, requiring extension to the pelvis. The mean age of the patients at surgery was 13 years, and the mean duration of the follow-up period was 36 months. The mean preoperative Cobb angle was 84° (range 56°-135°), which was corrected to a mean of 41° (range 8°-75°) postoperatively. At the final follow-up, the mean spinal curve remained at 42° (range 10°-75°). The mean preoperative pelvic obliquity was 42° (range 15°-105°), which was corrected by 78 % to 9° (range 0°-49°) postoperatively, with a pelvic obliquity of 10° (range 2°-49°) at final follow-up. Comparing the results of the present study with results in the literature describing the Luque-Galveston or unit rod techniques, despite patients in the present study having a greater mean pelvic obliquity (42° compared with 21° in the literature), a 78 % correction was still achieved, which is similar and, in certain instances, superior to the results of other published case series (78 % compared with 53 %). CONCLUSIONS: Maximum-width (M-W) segmental sacropelvic fixation, comprising iliosacral screws and/or iliac screws, enables a superior correction of severe pelvic obliquity in patients with neuromuscular scoliosis.

Time to development, clinical and radiographic characteristics, and management of proximal junctional kyphosis following adult thoracolumbar instrumented fusion for spinal deformity.

STUDY DESIGN: A retrospective review. OBJECTIVE: To study time to development, clinical and radiographic characteristics, and management of proximal junctional kyphosis (PJK) following thoracolumbar instrumented fusion for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: PJK continues to be a common mode of failure following ASD surgery. Although literature exists on possible risk factors, data on management remain limited. METHODS: A retrospective review of medical records of 289 consecutive ASD patients who underwent posterior segmental instrumentation incorporating at least 5 segments was conducted. PJK was defined as proximal kyphotic angle >10 degrees. RESULTS: PJK occurred in 32 patients (11%) at a mean follow-up of 34 months (range, 1.3-61.9±19 mo). Sixteen (50%) patients were revised (mean, 1.7 revisions; range, 1-3) at a mean follow-up of 9.6 months (range, 0.7-40 mo); primary indications for revision were pain (n=16), myelopathy (n=6), instability (n=4), and instrumentation protrusion (n=2). Comparison of preindex and postindex surgery radiographic parameters demonstrated significant improvement in mean lumbar lordosis (24 vs. 42 degrees, P<0.001), pelvic incidence-lumbar lordosis mismatch (30 vs. 11 degrees, P<0.001), and pelvic tilt (29 vs. 23 degrees, P<0.011). The mean T5-T12 kyphosis worsened (30 vs. 53 degrees, P<0.001) and the mean global sagittal spinal alignment failed to improve (9.6 vs. 8.0 cm, P=0.76). There was no apparent relationship between the absolute PJK angle and revision surgery (P>0.05). CONCLUSIONS: The patients in this series who developed PJK had substantial preoperative positive sagittal malalignment that remained inadequately corrected following surgery, likely resulting from a combination of inadequate surgical correction and a significant compensatory increase in thoracic kyphosis. In the absence of direct relationship between a greater PJK angle and worse clinical outcome, clinical symptoms and neurological status rather than absolute reliance on radiographic parameters should drive the decision to pursue revision surgery.

Spinal osteotomy in the presence of massive lumbar epidural scarring.

The combination of Massive epidural scarring and spinal deformity represents the ultimate challenge for the spinal deformity surgeon. This is observed more and more as the population is aging and the number of spine surgery is increasing. In assessing the patient with spinal deformity and epidural scarring, one should carry out a thorough medical work up including Dexa scan, comorbidities, and in most cases a Myelo-CT scan that will identify the extent of the previous fusion, the fixed or semi-rigid nature of the deformity with complete anterior fusion or only bone bridges, the evaluation of the previous instrumentation (if present) with possible screw misplacement, or halo around the screws, the extent of the previous laminectomy, the spinal stenosis and possible arachnoiditis and or meningocele. Once the requirement of deformity correction has been established with specific attention to the pelvic incidence and amount of lordosis required two basic choices can be made. The first one is to perform the spine realignment outside the massive epidural scarring whether this will be performed through simple posterior osteotomies, TLIF combined with Smith-Petersen osteotomies or Pedicle subtraction osteotomies. One should not forget about all the possibilities of an anterior or lateral approach to the spine that can also judiciously realign the spine at the level or at distance of the massive epidural scarring. These anterior realignments have to be supplemented with posterior fixation and or osteotomies. The other alternative is to perform the spine osteotomy at the level of the massive epidural scarring preferably at the junction of normal dura and epidural scar. Working around the dura that will require to be thinned down before the osteotomy is performed represents another challenge where incidental durotomies are not infrequent. During the closing of the osteotomy the dura may not be as giving as a normal dura and too aggressive closure of the osteotomy may not be possible. Instead a closing/opening osteotomy may be preferable, but will require an additional anterior column support. Attention to anterior column reconstruction and solid posterior instrumentation (iliac screws, four rods) should be given to all these revisions to have a long-lasting result.