Abdominal aortic calcification is an independent predictor of perioperative blood loss in posterior spinal fusion surgery.

OBJECTIVE: Abdominal aortic calcification (AAC), often found incidentally on lateral lumbar radiographs, is increasingly recognized for its association with adverse outcomes in spine surgery. As a marker of advanced atherosclerosis affecting cardiovascular dynamics, this study evaluates AAC's impact on perioperative blood loss in posterior spinal fusion (PSF). METHODS: Patients undergoing PSF from March 2016 to July 2023 were included. Estimated blood loss (EBL) and total blood volume (TBV) were calculated. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. Predictors of the EBL-to-TBV ratio (%EBL/TBV) were examined via univariable and multivariable regression analyses, which adjusted for parameters such as hypertension and aspirin use. RESULTS: A total of 199 patients (47.2% female) were analyzed. AAC was present in 106 patients (53.3%). AAC independently predicted %EBL/TBV, accounting for an increase in blood loss of 4.46% of TBV (95% CI 1.17-7.74, p = 0.008). CONCLUSIONS: This is the first study to identify AAC as an independent predictor of perioperative blood loss in PSF. In addition to its link to degenerative spinal conditions and adverse postoperative outcomes, the relationship between AAC and increased blood loss warrants attention in patients undergoing PSF.

Usefulness of the spectral shaping dual-source computed tomography imaging technique in posterior corrective fusion for adolescent idiopathic scoliosis.

PURPOSE: Since childhood exposure to radiation has been demonstrated to increase cancer risk with increase in radiation dose, reduced radiation exposure during computed tomography (CT) evaluation is desired for adolescent idiopathic scoliosis (AIS). Therefore, this retrospective study aimed to investigate the radiation dose of dual-source CT using a spectral shaping technique and the accuracy of the thoracic pedicle screw (TPS) placement for posterior spinal fusion (PSF) in patients with AIS. METHODS: Fifty-nine female patients with thoracic AIS who underwent PSF using CT-guided TPSs were included and divided into two groups comprised of 23 patients who underwent dual-source CT (DSCT) with a tin filter (DSCT group) and 36 who underwent conventional multislice CT (MSCT group). We assessed the CT radiation dose using the CT dose index (CTDIvol), effective dose (ED), and accuracy of TPS insertion according to the established Neo's classification. RESULTS: The DSCT and MSCT groups differed significantly (p < 0.001) in the mean CTDIvol (0.76 vs. 3.31 mGy, respectively) and ED (0.77 vs. 3.47 mSv, respectively). Although the correction rate of the main thoracic curve in the DSCT group was lower (65.7% vs. 71.2%) (p = 0.0126), the TPS accuracy (Grades 0-1) was similar in both groups (381 screws [88.8%] vs. 600 screws [88.4%], respectively) (p = 0.8133). No patient required replacement of malpositioned screws. CONCLUSION: Spectral shaping DSCT with a tube-based tin filter allowed a 75% radiation dose reduction while achieving TPS insertion accuracy similar to procedures based on conventional CT without spectral shaping.

Optimising operating theatre (OT) efficiency while maintaining the standardised patient care in adolescent idiopathic scoliosis (AIS) surgery with the dedicated spine team approach: a specialised spine unit experience.

PURPOSE: To report the efficiency of OT utilisation and perioperative outcomes with a dedicated spine team approach in AIS patients who underwent posterior spinal fusion (PSF) surgeries in a consecutive case operation list. METHODS: Three AIS patients operated in a day (8:00 AM-8:00 PM) by a dedicated spine team were recruited between 2021 and 2022. The dedicated team comprised of three senior spine consultants who operated using a dual attending surgeon strategy, an anaesthetic consultant, dedicated surgical scrub nurses, anaesthesiology nurses, radiographers, and neuromonitoring technicians. Patients were categorised according to the sequence of operation list of the day (Case 1, Case 2, and Case 3). OT efficiency was represented by OT time in five stages (preoperative time, operative time, postoperative time, total OT time, and turnover time). OT time and perioperative outcomes were compared. RESULTS: 102 cases were analysed. On average, Case 1 began at 8:38 AM whereas Case 3 ended by 5:54 PM. OT efficiency was consistent throughout the day of operation with comparable OT time in all five stages between groups (p > 0.05). The mean turnover time was 15.1 ± 13.5 min and the mean operative time was 123.0 ± 28.1 min. Intraoperative arterial blood gas (ABG) parameters were maintained in an optimal range. The complication rate was 2.0% (N = 2/102). CONCLUSION: Consistent OT efficiency was demonstrated with a dedicated spine team approach. Despite performing three AIS cases in a consecutive case operation list, patients' safety was not compromised as perioperative outcomes between groups were comparable.

A comparative cohort study of surgical approaches for adult spinal deformity at a minimum 2-year follow-up.

STUDY DESIGN: This study was a retrospective multi-center comparative cohort study. MATERIALS AND METHODS: A retrospective institutional database of operative adult spinal deformity patients was utilized. All fusions > 5 vertebral levels and including the sacrum/pelvis were eligible for inclusion. Revisions, 3 column osteotomies, and patients with < 2-year clinical follow-up were excluded. Patients were separated into 3 groups based on surgical approach: 1) posterior spinal fusion without interbody (PSF), 2) PSF with interbody (PSF-IB), and 3) anteroposterior (AP) fusion (anterior lumbar interbody fusion or lateral lumbar interbody fusion with posterior screw fixation). Intraoperative, radiographic, and clinical outcomes, as well as complications, were compared between groups with ANOVA and χ2 tests. RESULTS: One-hundred and thirty-eight patients were included for study (PSF, n = 37; PSF-IB, n = 44; AP, n = 57). Intraoperatively, estimated blood loss was similar between groups (p = 0.171). However, the AP group had longer operative times (547.5 min) compared to PSF (385.1) and PSF-IB (370.7) (p < 0.001). Additionally, fusion length was shorter in PSF-IB (11.4) compared to AP (13.6) and PSF (12.9) (p = 0.004). There were no differences between the groups in terms of change in alignment from preoperative to 2 years postoperative. There were no differences in clinical outcomes. While postoperative complications were largely similar between groups, operative complications were higher in the AP group (31.6%) compared to the PSF (5.4%) and PSF-IB (9.1) groups (p < 0.001). CONCLUSION: While there were differences in intraoperative outcomes (operative time and fusion length), there were no differences in postoperative clinical or radiographic outcomes. AP fusion was associated with a higher rate of operative complications.

Neck and shoulder pain in thoracic adolescent idiopathic scoliosis 10 years after posterior spinal fusion.

PURPOSE: We aimed to determine the clinical significance of neck and shoulder pain (NSP) 10 years after posterior spinal fusion (PSF) for thoracic adolescent idiopathic scoliosis (AIS) and the relationship between radiographic parameters and NSP. METHODS: Of 72 patients who underwent PSF for thoracic AIS (Lenke 1 or 2) between 2000 and 2013, we included 52 (46 females; Lenke type 1 in 34 patients and type 2 in 18; mean age, 25.6 years) who underwent NSP evaluation using visual analog scale (VAS, 10 cm) 10 years postoperatively (follow-up rate, 72.2%). Correlation analyses were performed using Spearman's rank correlation coefficient (r). RESULTS: The VAS for NSP was 2.6 cm in median and 3.4 cm in mean at 10 years. The VAS had significant negative correlations with several SRS-22 domain scores (rs = - 0.348 for pain, - 0.347 for function, - 0.308 for mental health, and - 0.372 for total) (p < 0.05). In addition, the VAS score was significantly correlated with cervical lordosis (CL) (rs = 0.296), lumbar lordosis (rs = - 0.299), and sacral slope (rs = 0.362) (p < 0.05). Furthermore, at the 10-year follow-up, CL was significantly negatively correlated with T1 slope (rs = - 0.763) and thoracic kyphosis (TK) (- 0.554 for T1-12 and - 0.344 for T5-12) (p < 0.02). CONCLUSION: NSP was associated with deterioration in SRS-22 scores, indicating that NSP is a clinically significant long-term issue in PSF for thoracic AIS. Restoring or maintaining the TK and T1 slopes, which are controllable factors during PSF, may improve cervical lordosis and alleviate NSP at 10-year follow-up.

Analysis of duration of different stages of surgery in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients: comparison between severe versus non-severe AIS.

PURPOSE: Prolonged surgical duration in severe adolescent idiopathic scoliosis (AIS) patients is associated with increased blood loss and perioperative complications. The aim of this study was to compare the duration of each stage of posterior spinal fusion (PSF) in severe AIS (Cobb angle ≥ 90°) with non-severe AIS patients. This analysis will identify the most time-consuming stage of PSF and help surgeons formulate strategies to shorten operative time. METHODS: Retrospective study whereby 90 AIS patients (Lenke type 2, 3, 4, and 6) who underwent PSF from 2019 to 2023 were recruited. Twenty-five severe AIS patients were categorized in Gp1 and 65 non-severe AIS patients in Gp2. Propensity score matching (PSM) with one-to-one with nearest neighbor matching (match tolerance 0.05) was performed. Outcomes measured via operation duration of each stage of surgery, blood loss, number of screws, fusion levels and screw density. RESULTS: Twenty-five patients from each group were matched. Total operative time was significantly higher in Gp1 (168.2 ± 30.8 vs. 133.3 ± 24.0 min, p < 0.001). The lengthiest stage was screw insertion which took 58.5 ± 13.4 min in Gp1 and 44.7 ± 13.7 min in Gp2 (p = 0.001). Screw insertion contributed 39.5% of the overall increased surgical duration in Gp1. Intraoperative blood loss (1022.2 ± 412.5 vs. 714.2 ± 206.7 mL, p = 0.002), number of screws (17.1 ± 1.5 vs. 15.5 ± 1.1, p < 0.001) and fusion level (13.1 ± 0.9 vs. 12.5 ± 1.0, p = 0.026) were significantly higher in Gp1. CONCLUSION: Screw insertion was the most time-consuming stage of PSF and was significantly longer in severe AIS. Adjunct technologies such as CT-guided navigation and robotic-assisted navigation should be considered to reduce screw insertion time in severe AIS.

Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

BACKGROUND: Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. AIM: To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. METHODS: Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. RESULTS: Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). CONCLUSIONS: Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

Delayed presentation of Wilkie's syndrome after scoliotic curve correction surgery: a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare but serious complication following scoliosis correction surgery. It occurs as a result of mechanical compression of third part of duodenum between the SMA and aorta. This condition occurs most commonly in significantly underweight patients with deformities, and usually during the first week following spinal deformity corrective surgeries. The angle between the abdominal aorta and the SMA gets reduced following spinal lengthening during deformity correction surgery causing compression of third part of duodenum resulting in development of SMA syndrome. CASE PRESENTATION: We present a case of 17-year-old male with congenital scoliosis with a 70-degree scoliotic curve who underwent spinal deformity correction surgery with posterior instrumented fusion. Post-operative course was uneventful and the patient was discharged after suture removal on post-operative day 15. The patient presented after 21-days of symptom onset on post-operative-day 51, with a 3 week history of post-prandial vomiting, abdominal pain and distension which resulted in rapid weight loss of 11 kg. A CT-angiogram showed obstruction at third part of duodenum. After reviewing clinical and radiological profile of the patient, a diagnosis of SMA syndrome was made. Conservative management was tried, but due to rapid deterioration of patient condition and symptoms of complete intestinal obstruction, the patient was treated surgically by gastro-jejunostomy and side-to-side jejuno-jejunostomy, which improved his condition. CONCLUSION: SMA syndrome can occur much later than previously reported cases and with potentially life-threatening symptoms following scoliosis correction. Having a high index of suspicion, early recognition of condition and institution of appropriate treatment are essential to prevent occurrence of severe complications including risk of intestinal perforation and mortality. This case highlights management of delayed onset of SMA syndrome, with presentation further delayed after symptom onset, as is common in developing parts of the world, due to limited availability and accessibility of resources, and low socio-economic status of large segments of the population.

Comparative surgical outcomes of navigated vs non-navigated posterior spinal fusions in ankylosing spondylitis patients.

INTRODUCTION: Ankylosing Spondylitis (AS) patients with acute spinal fractures represent a challenge for practicing spine surgeons due to difficult operative anatomy and susceptibility to complications. RESEARCH QUESTION: Does intraoperative CT-navigation improve outcomes in patients with ankylosing spondylitis undergoing surgery? METHODS: A retrospective review was carried out at our centre from 05/2016-06/2021 to identify AS patients presenting with a traumatic spinal fracture, managed surgically with posterior spinal fusion (PSF). Cohorts were categorised and compared for outcomes based on those who underwent PSF with intraoperative CT-navigation versus those surgically managed with traditional intraoperative fluoroscopy. RESULTS: 37 AS patients were identified. 29/37 (78.4%) underwent PSF. Intraoperative navigation was used in 14 (48.3%) cases. Mean age of the entire cohort was 67.6 years. No difference existed between the navigated and non-navigated groups for mean levels fused (5.35 vs 5.07; p â€‹= â€‹0.31), length of operation (217.9mins vs 175.3mins; p â€‹= â€‹0.07), overall length-of-stay (12 days vs 21.9 days; p â€‹= â€‹0.16), patients requiring HDU (3/14 vs 5/15; p â€‹= â€‹0.09) or ICU (5/14 vs 9/15; p â€‹= â€‹0.10), postoperative neurological improvement (1/14 vs 1/15; p â€‹= â€‹0.48) or deterioration (1/14 vs 0/15; p â€‹= â€‹0.15), intraoperative complications (2/14 vs 3/15; p â€‹= â€‹0.34), postoperative complications 4/14 vs 4/15; p â€‹= â€‹0.46), revision surgeries (3/14 vs 1/15; p â€‹= â€‹0.16) and 30-day mortality (0/14 vs 0/15). CONCLUSION: This is the first study that compares surgical outcomes of navigated vs non-navigated PSFs for AS patients with an acute spinal fracture. Although limited by its retrospective design and sample size, this study highlights the non-inferiority of intraoperative navigation as a surgical aid in a challenging cohort.

Effectiveness of gelatin matrix with human thrombin for reducing blood loss in palliative decompressive surgery with posterior spinal fusion for metastatic spinal tumors.

BACKGROUND: This study aimed to investigate the effect of gelatin matrix with human thrombin (GMHT) on blood loss and survival time in patients with metastatic spinal tumors treated with palliative decompression surgery with posterior spinal fusion. METHODS: We retrospectively reviewed 67 consecutive patients with metastatic spinal tumors who underwent palliative decompression surgery with posterior spinal fusion. We compared patients in whom GMHT was not used during surgery with those in whom GMHT was used. The following baseline characteristics were evaluated: age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, Karnofsky Performance Status score, Charlson comorbidities index score, the percentage of patients who received perioperative chemotherapy, main tumor level, Frankel category, revised Tokuhashi score, spinal instability neoplastic score (SINS), number of fusion segments, operation time, intraoperative blood loss, drainage blood loss, red blood cell transfusion, hemoglobin level, total protein (TP), albumin values, total blood loss (TBL), hidden blood loss, postoperative bed rest and postoperative survival time. Perioperative complications were assessed. RESULTS: Age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, CCI score, main level of tumors, SINS score, preoperative Tokuhashi score and number of fusion segments did not differ significantly between the two groups. Operation time, intraoperative blood loss, postoperative drainage blood loss, and TBL were significantly decreased in the group with GMHT than in the group without GMHT. The total number of perioperative complications was significantly lesser in the group with GMHT than in the group without GMHT. The median postoperative survival time was significantly longer in the GMHT group than in the group without GMHT. CONCLUSION: GMHT should be considered a valid option for the treatment of patients with metastatic spinal tumors with a short life expectancy.

Is posterior vertebral arthrodesis at the end of the electromagnetic rod lengthening program necessary for all patients? Comparative analysis of sixty six patients who underwent definitive spinal arthrodesis and twenty four patients with in situ lengthening rods.

PURPOSE: Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did. METHODS: This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022. RESULTS: A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%). CONCLUSION: Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.

Effect of gabapentin on length of stay, opioid use, and pain scores in posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective review across a multi-hospital system.

BACKGROUND: Gabapentin has been adopted in Enhanced Recovery After Surgery protocols as a means to reduce opioid consumption while maintaining adequate post-operative analgesia. The purpose of our study was to review and compare changes in length of stay, opioid use, and patient reported pain scores after the addition of gabapentin into five, distinct pain protocols for posterior spinal fusion in adolescent idiopathic scoliosis. METHODS: A retrospective review was completed using a database of electronic medical data from a single pediatric orthopedic healthcare system that was queried for patients with adolescent idiopathic scoliosis who underwent first-time posterior spinal fusion. Perioperative data including demographics, hospital length of stay, surgical details, opioid use, patient reported pain scores, and non-opioid analgesic use were collected. RESULTS: From December 2012 to February 2019, 682 hospitalizations for posterior spinal fusion in adolescent idiopathic scoliosis were identified with complete inpatient data; 49% were administered gabapentin. For the gabapentin cohort, the system saw no statistically significant effect on length of stay or pain averaged over POD#0-3. Opioid use was statistically lower averaged over POD#0-3. Individual sites saw variation on length of stay and opioid use compared to the system. CONCLUSION: In conclusion, system-wide data showed gabapentin containing protocols reduced opioid use while maintaining clinically equivalent analgesia. However, variations of individual site results make it difficult to conclude the degree to which gabapentin were responsible for this effect.

Respiratory variation in the internal jugular vein does not predict fluid responsiveness in the prone position during adolescent idiopathic scoliosis surgery: a prospective cohort study.

BACKGROUND: Respiratory variation in the internal jugular vein (IJVV) has not shown promising results in predicting volume responsiveness in ventilated patients with low tidal volume (Vt) in prone position. We aimed to determine whether the baseline respiratory variation in the IJVV value measured by ultrasound might predict fluid responsiveness in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with low Vt. METHODS: According to the fluid responsiveness results, the included patients were divided into two groups: those who responded to volume expansion, denoted the responder group, and those who did not respond, denoted the non-responder group. The primary outcome was determination of the value of baseline IJVV in predicting fluid responsiveness (≥15% increases in stroke volume index (SVI) after 7 ml·kg-1 colloid administration) in patients with AIS undergoing PSF during low Vt ventilation. Secondary outcomes were estimation of the diagnostic performance of pulse pressure variation (PPV), stroke volume variation (SVV), and the combination of IJVV and PPV in predicting fluid responsiveness in this surgical setting. The ability of each parameter to predict fluid responsiveness was assessed using a receiver operating characteristic curve. RESULTS: Fifty-six patients were included, 36 (64.29%) of whom were deemed fluid responsive. No significant difference in baseline IJVV was found between responders and non-responders (25.89% vs. 23.66%, p = 0.73), and no correlation was detected between baseline IJVV and the increase in SVI after volume expansion (r = 0.14, p = 0.40). A baseline IJVV greater than 32.00%, SVV greater than 14.30%, PPV greater than 11.00%, and a combination of IJVV and PPV greater than 64.00% had utility in identifying fluid responsiveness, with a sensitivity of 33.33%, 77.78%, 55.56%, and 55.56%, respectively, and a specificity of 80.00%, 50.00%, 65.00%, and 65.00%, respectively. The area under the receiver operating characteristic curve for the baseline values of IJVV, SVV, PPV, and the combination of IJVV and PPV was 0.52 (95% CI, 0.38-0.65, p=0.83), 0.54 (95% CI, 0.40-0.67, p=0.67), 0.58 (95% CI, 0.45-0.71, p=0.31), and 0.57 (95% CI, 0.43-0.71, p=0.37), respectively. CONCLUSIONS: Ultrasonic-derived IJVV lacked accuracy in predicting fluid responsiveness in patients with AIS undergoing PSF during low Vt ventilation. In addition, the baseline values of PPV, SVV, and the combination of IJVV and PPV did not predict fluid responsiveness in this surgical setting. TRAIL REGISTRATION: This trial was registered at www.chictr.org (ChiCTR2200064947) on 24/10/2022. All data were collected through chart review.

Operative differences for posterior spinal fusion after vertebral body tethering: Are we fusing more levels in the end?

PURPOSE: Little is known about the perioperative characteristics associated with a posterior spinal fusion (PSF) in adolescent idiopathic scoliosis patients previously treated with vertebral body tethering (VBT). We aimed to determine if operative time, estimated blood loss, postoperative length of stay, instrumentation type, and implant density differed in patients that received a PSF (i.e., PSF-Only) or a PSF following a failed VBT (i.e., PSF-VBT). METHODS: We retrospectively assessed matched cohort data (PSF-VBT = 22; PSF-Only = 22) from two multi-center registries. We obtained: (1) operative time, (2) estimated blood loss, (3) postoperative length of stay, (4) instrumentation type, and (5) implant density. Theoretical fusion levels prior to the index procedure were obtained for PSF-VBT and compared to the actual levels fused. RESULTS: We observed no difference in operative time, estimated blood loss, or postoperative length of stay. Instrumentation type was all-screw in PSF-Only and varied in PSF-VBT with nearly 25% of patients exhibiting a hybrid construct. There was no added benefit to removing anterior instrumentation prior to fusion; however, implant density was higher in PSF-Only (1.9 ± 0.2) than when compared to PSF-VBT (1.7 ± 0.3). An additional two levels were fused in 50% of PSF-VBT patients, most of which were added to the distal end of the construct. CONCLUSIONS: We found that operative time, estimated blood loss, and postoperative length of stay were similar in both cohorts; however, the length of the fusion construct in PSF-VBT is likely to be two levels longer when a failed VBT is converted to a PSF.

Scoliosis in osteogenesis imperfecta: results of posterior spinal fusion in 39 patients.

PURPOSE: To evaluate the outcomes of scoliosis corrective surgery in Osteogenesis Imperfecta (OI) patients with primarily pedicles screw fixation in terms of correcting and maintaining the correction of the spinal deformity, and to assess for several peri-operative parameters and complications associated with this surgical treatment. METHODS: Retrospective case series of 39 consecutive patients with OI treated surgically for scoliosis. The surgeries were performed between 2002 and 2020 by three different surgeons. All patients' medical peri-operative and post-operative charts were evaluated. Radiological assessment was performed by evaluation of the pre-operative, immediate post-operative and last follow-up plain radiographs. RESULTS: There were 20 females and 19 males included in this review with a mean age of 14 years (range, 6-20 years) at the time of surgery. The median follow-up time was 7.9 years. The mean pre-operative cobb angle (CA) of the major curve was 76.5 degrees (SD ± 18.9), decreasing to 42.6 (SD ± 17.4) in the long-term post-operative follow-up (P < 0.001). A total of 21 adverse events in 16 patients were noted. Only 4 patients required subsequent invasive surgical treatment or prolonged hospital stay. All other patients were treated conservatively with no lasting complication. CONCLUSION: Scoliosis surgical correction in OI patients seems to yield acceptable results, with maintained coronal plane surgical correction in the long-term follow-up. Even though a high peri-operative complications rate is observed in this series, there were no long-term sequelae or lasting complications. LEVEL OF EVIDENCE: Level IV, Case series.

Patient and surgical predictors of 3D correction in posterior spinal fusion: a systematic review.

BACKGROUND: Restoration of three-dimensional (3D) alignment is critical in correcting patients with adolescent idiopathic scoliosis using posterior spinal fusion (PSF). However, current studies mostly rely on 2D radiographs, resulting in inaccurate assessment of surgical correction and underlying predictive factors. While 3D reconstruction of biplanar radiographs is a reliable and accurate tool for quantifying spinal deformity, no study has reviewed the current literature on its use in evaluating surgical prognosis. PURPOSE: To summarize the current evidence on patient and surgical factors affecting sagittal alignment and curve correction after PSF based on 3D parameters derived from reconstruction of biplanar radiographs. METHODS: A comprehensive search was conducted by three independent investigators on Medline, PubMed, Web of Science, and Cochrane Library to obtain all published information on predictors of postoperative alignment and correction after PSF. Search items included "adolescent idiopathic scoliosis," "stereoradiography," "three-dimensional," "surgical," and "correction." The inclusion and exclusion criteria were carefully defined to include clinical studies. Risk of bias was assessed with the Quality in Prognostic Studies tool, and level of evidence for each predictor was rated with the Grading of Recommendations, Assessment, Development, and Evaluations approach. 989 publications were identified, with 444 unique articles subjected to full-text screening. Ultimately, 41 articles were included. RESULTS: Strong predictors of better curve correction included preoperative normokyphosis (TK > 15°), a corresponding rod contour, intraoperative vertebral rotation and translation, and upper and lower instrumented vertebrae selected based on sagittal and axial inflection points. For example, for Lenke 1 patients with junctional vertebrae above L1, fusion to NV-1 (1 level above the neutral vertebra) achieved optimal curve correction while preserving motion segments. Pre-op coronal Cobb angle and axial rotation, distal junctional kyphosis, pelvic incidence, sacral slope, and type of instrument were identified as predictors with moderate evidence. For Lenke 1C patients, > 50% LIV rotation was found to increase spontaneous lumbar curve correction. Pre-op thoracolumbar apical translation and lumbar lordosis, Ponte osteotomies, and rod material were found to be predictors with low evidence. CONCLUSIONS: Rod contouring and UIV/LIV selection should be based on preoperative 3D TK in order to achieve normal postoperative alignment. Specifically, Lenke 1 patients with high-lying rotations should be fused distally at NV-1, while hypokyphotic patients with large lumbar curves and truncal shift should be fused at NV to improve lumbar alignment. Lenke 1C curves should be corrected using > 50% LIV rotation counterclockwise to the lumbar rotation. Further investigation should compare surgical correction between pedicle-screw and hybrid constructs using matched cohorts. DJK and overbending rods are potential predictors of postoperative alignment.

Clinical and radiological results of final fusion in patients who underwent lengthening with magnetically controlled growing rods. About 66 patients with a mean follow-up of 5 years.

PURPOSE: The aim of this study was to evaluate the effects of definitive arthrodesis on frontal and sagittal spine balance in EOS patients treated with MCGR, as well as the complications associated with this procedure and the outcome at last follow-up. METHODS: This was a multicentre study in 10 French centres. All patients who underwent posterior spinal arthrodesis after completion of MCGR treatment, regardless of age, etiology of scoliosis between 2011 and 2022, were included. RESULTS: A total of 66 patients who had a final fusion after the lengthening programme were included in the study. The mean follow-up time was 5.5 ± 1.7 years (range: 2.1-9). The mean follow-up time after arthrodesis was 24 ± 18 months (range: 3-68) and the mean age at arthrodesis was 13.5 ± 1.5 years (range: 9.5-17). The main and secondary curves were significantly (p < 0.005 and p = 0.03) improved by arthrodesis (16.4° and 9° respectively) and stabilised at the last follow-up. The T1-T12 and T1-S1 distances increased by 8.4 mm and 14 mm with spinal fusion, with no significant difference (p = 0.096 and p = 0.068). There was no significant improvement in the rest of the parameters with arthrodesis, nor was there any significant deterioration at last follow-up. After final fusion, there were a total of 24 complications in 18 patients (27.3%) that routinely led to repeat surgery. CONCLUSION: Final fusion after MCGR provides satisfactory additional correction of the main and secondary curves and a moderate increase in the T1-T12 distance but has no impact on sagittal balance and other radiological parameters. The post-operative complication rate is particularly high in patients at risk of complications. LEVEL OF EVIDENCE: Level 4.

Clinical and radiographic evolution of graduate patients treated with magnetically controlled growing rods: results of a French multicentre study of 90 patients.

PURPOSE: The purpose of this study was to investigate patients with early-onset scoliosis (EOS) who completed their electromagnetic lengthening rod program to assess the demographics of this population and to analyze the evolution of clinical and radiological parameters and the occurrence of complications. METHODS: This was a multicenter study with 10 French centers. We collected all patients with EOS who had undergone electromagnetic lengthening between 2011 and 2022. They had to have reached the end of the procedure (graduate). RESULTS: A total of 90 graduate patients were included. The mean follow-up time over the entire period was 66 months (25.3-109). Of these, only 66 patients (73.3%) underwent definitive spinal arthrodesis at the end of the lengthening phase, whereas 24 patients (26.7%) kept their hardware in situ with a mean follow-up time from the last lengthening of 25 months (3-68). Patients had an average of 2.6 surgeries (1-5) over the entire follow-up. Patients had an average of 7.9 lengthenings for a mean total lengthening of 26.9 mm (4-75). Analysis of the radiological parameters showed a percentage reduction in the main curve of 12 to 40%, depending on the etiology, with an average reduction of 73-44°, and an average thoracic height of 210 mm (171-214) for an average improvement of 31 mm (23-43). There was no significant difference in the sagittal parameters. During the lengthening phase, there were a total of 56 complications in 43 patients (43.9%; n = 56/98), of which 39 in 28 patients (28.6%) resulted in unplanned surgery. In the graduate patients, there were a total of 26 complications in 20 patients (22.2%), all of which resulted in unscheduled surgery. CONCLUSION: MCGR, allow to decrease the number of surgeries, to progressively improve the scoliotic deformity and to reach a satisfactory thoracic height at the price of an important complication rate linked in particular to the complexity of the management of patients with an EOS.

Spontaneous induced bone fusion in minimally invasive fusionless bipolar fixation in neuromuscular scoliosis: a computed tomography analysis.

PURPOSE: Posterior spinal fusion (PSF) at skeletal maturity is still the gold standard in children with neuromuscular scoliosis (NMS) who underwent fusionless surgery. The aim of this computed tomography (CT) study was to quantify the spontaneous bone fusion at the end of a lengthening program by minimally invasive fusionless bipolar fixation (MIFBF), that could avoid PSF. METHODS: NMS operated on with MIFBF from T1 to the pelvis and at final lengthening program were included. CT was performed at least five years postoperatively. The autofusion was classified as completely or not fused at the facets joint (on both coronal and sagittal plane, right and left side, from T1 to L5), and around the rods (axial plane, right and left side, from T5 to L5). Vertebral body heights were assessed. RESULTS: Ten patients were included (10.7y ± 2 at initial surgery). Mean Cobb angle was 82 ± 20 preoperatively and 37 ± 13 at last follow-up. CT were performed on average 6.7y ± 1.7 after initial surgery. Mean preoperative and last follow-up thoracic vertebrae height were respectively 13.5 mm ± 1.7 and 17.4 mm ± 1.7 (p < 0.001). 93% facets joints were fused (out of 320 analyzed joints), corresponding to 15/16 vertebral levels. Ossification around the rods was observed in 6.5±2.4 levels out of 13 in the convex side, and 4.2 ± 2.2 in the concave side (p = 0.04). CONCLUSIONS: This first computed quantitative study showed MIFBF in NMS preserved spinal growth, while it induced 93% of facet joints fusion. This could be is an additional argument when questionning the real need for PSF at skeletal maturity.

Estimated cumulative radiation exposure in patients treated for adolescent idiopathic scoliosis.

PURPOSE: Adolescent idiopoathic scoliosis (AIS) is a progressive spinal deformity, most often observed in female patients of pubescent age. The deformity's severity, its progression through time, its treatment and subsequent follow-up are assessed with routine radiological evaluation of the patient's full spine. This study aimed to determine the cumulative radiation exposure in average patients with AIS treated by brace or surgery throughout their treatment. METHODS: The average number of imaging procedures and corresponding radiation doses were retrospectively obtained from the medical charts of AIS patients treated conservatively and/or surgically at our institution. The median radiation exposure of all imaging modalities was stated in effective dose (mSv). The estimated cumulative effective radiation dose of the each treatment group was determined by multiplication of the average number of imaging conducted, and the median effective radiation dose per imaging modality. RESULTS: In total, 73 AIS patients were included (28 brace, 45 surgically). Patients treated with a brace were subjected to an average of 9.03 full spine radiographs, resulting in an estimated effective cumulative dose of 0.505 mSv over a median treatment period of 3.23 years. Patients treated surgically received an average of 14.29 full spine radiographs over a median treatment period of 2.76 years. The estimated effective cumulative dose amounted from 0.951 to 1.841 mSv, depending on the surgical technique. CONCLUSION: The cumulative effective radiation doses rendered to AIS patients as part of their treatment and follow-up were relatively low. However, every exposure to ionising radiation for medical imaging purposes should be minimised.