Growth hormone treatment and the risk of adolescent scoliosis: A large matched cohort study.

AIM: We aimed to evaluate the risk of developing adolescent scoliosis among recipients of recombinant human growth hormone (rhGH). METHODS: This registry-based cohort study included 1314 individuals who initiated rhGH treatment since 2013, treated during 10-18 years of age for at least 6 months. This group was matched to a comparison group of 6570 individuals not treated with rhGH. Demographic and clinical information was extracted from the electronic database. The results are presented using hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: During a median follow-up of 4.2 years, 59 (4.5%) rhGH recipients and 141 individuals (2.1%) from the comparison group were diagnosed with adolescent scoliosis. The age at diagnosis did not differ between the groups (14.7 versus 14.3 years, p = 0.095). Patients treated with rhGH were more likely diagnosed with scoliosis (HR 2.12, 95% CI 1.55-2.88, p < 0.001). Among males, the risk was about three times greater in the treated versus the comparison group (HR 3.15, 95% CI 2.12-4.68, p < 0.001), while in females the risk was not increased (HR 1.12, 95% CI 0.72-2.04, p = 0.469). CONCLUSIONS: Recombinant human growth hormone treatment was associated with an increased risk to be diagnosed with adolescent scoliosis in males. Scoliosis development should be monitored appropriately in rhGH recipients.

Do drains help reduce the risk of complications after thoracoplasties in posterior spinal fusions for adolescent idiopathic scoliosis?

PURPOSE: In adolescent idiopathic scoliosis (AIS), the rib prominence is a major cosmetic concern which can be improved using thoracoplasties. We sought to determine if the use of deep drains helps minimize the development of pleural effusions after thoracoplasties. METHODS: Retrospective study of 45 patients with AIS undergoing posterior spinal fusion (PSF) and thoracoplasties. RESULTS: Thirty six out of 45 patients (80.0%) required placement of a deep surgical drain, and 16 out of 45 (35.6%) developed pleural effusions after PSF with concomitant thoracoplasty. Of the 16 patients who developed pleural effusion, 12 of 36 (33.3%) required a placement of a deep drain (p > 0.05). Of the total 45 patients in this cohort, 3 patients (6.7%) required chest tubes, and 4 patients (8.9%) developed surgical site infections (SSIs). We found that deep drains were associated with a lower incidence of SSI (2.8% vs 33.3%; p = 0.021). Patients who had a pleural effusion had longer ICU stays (p = 0.037) and longer requirements of nasal oxygen (p = 0.025). DISCUSSION: The presence of a pleural effusion in patients with AIS undergoing PSF with thoracoplasty was associated with longer oxygen requirements and length of hospital ICU admission. Thirty six percent of patients with thoracoplasties developed pleural effusions, but deep subfascial drains did not significantly decrease the incidence of pleural effusions.

Early surgery for thoracolumbar extension-type fractures in geriatric patients with ankylosing disorders reduces patient complications and mortality.

BACKGROUND CONTEXT: The management of trauma patients with ankylosing spinal disorders has become an issue of increasing interest. Geriatric patients frequently sustain unstable extension type vertebral fractures with ankylosed spines. In this population, studies have shown that early surgery for other injuries such as hip fractures may reduce patient complications and mortality. These studies have changed patient care protocols in many medical centers worldwide. PURPOSE: We aim to assess the relationship between the timing of surgery for unstable vertebral fractures in ankylosed spines in the geriatric population and patient outcomes. STUDY DESIGN/SETTING: Retrospective clinical study conducted in a tertiary hospital. PATIENT SAMPLE: Patients included were those diagnosed with isolated thoracolumbar extension type fractures and a spinal ankylosing disorder over 65 years old following minor trauma and with no additional injuries or neurological deficit. OUTCOME MEASURES: Primary outcome measures included postoperative medical complications and mortality at 1 and 6 months. Secondary outcome measures included rehospitalization rates, length of stay, and surgical site infections. METHODS: We searched our department's database for all that met our inclusion criteria who underwent surgery. The difference in patient outcomes that underwent early surgery defined as less than 72 hours from diagnosis as opposed to those that underwent later surgery was assessed. RESULTS: A total of 82 patients underwent surgery following a diagnosis of an extension type thoracolumbar fracture at our institution between 2015 and 2021. Of these, 50 met inclusion criteria. Nineteen patients underwent surgery less than 72 hours from diagnosis and 31 more than 72 hours from diagnosis. No difference was found in age, functional status, and Elixhauser comorbidity scores between the groups. A statistically significant difference in perioperative patient complications between the early and the late groups (p=.005) was found. Mortality at six-months was significantly different between the groups as well (p=.035). There was no statistically significant difference between the groups when comparing surgical site infections, length of hospital stay, rehospitalization within a month, and perioperative mortality. CONCLUSIONS: Time to surgery affects complication rates and six-month mortality in geriatric patients with spinal ankylosing disorders presenting with an isolated unstable hyperextension type thoracolumbar fracture. Early surgery of less than 72 hours from presentation in this patient population is recommended.

Scoliosis in RETT Syndrome: A National Referral Centre Experience.

STUDY DESIGN: This was a retrospective case series. OBJECTIVE: The objective of this study was to discuss the treatment challenges in scoliosis patients with Rett syndrome (RTT) in a national referral centre for RTT. We describe structural characteristics of curves, age of onset, genetic mutation, ambulation status, and treatment through RTT progression. Based on this unique experience, we aimed to suggest guidelines for scoliosis treatment in RTT patients. SUMMARY OF BACKGROUND DATA: RTT is a neurodevelopmental disorder associated with a mutation in the methyl-CpG binding protein 2 (MECP2) gene, primarily in females with significant features of growth failure, gastrointestinal and pulmonary dysfunction, ataxia, seizures, and intellectual disability. Scoliosis is the most common orthopedic manifestation of RTT and is present in 64%-75% of patients. No clear guidelines for scoliosis treatment in RTT are available, and typically patients are treated according to guidelines of another neuromuscular scoliosis. METHODS: Clinical and radiographic data were gathered, including MECP2 mutation type, scoliosis characteristics, preoperative treatment, surgical treatment, functional status, and postoperative follow-up. RESULTS: Our cohort included 102 patients with RTT. They were 36 who presented with scoliosis; 18 were treated surgically. C-curve was found in 17 patients and S-type in 19. Scoliosis treatment onset was 8.76 years in the C-type group and 13.88 years in the S-type group. The average curve at the time of surgery was 52.42 degrees. The average time until surgery was 2.44 years. Seventeen patients underwent posterior spinal fusion, and 1 patient underwent posterior spinal fusion+anterior spinal fusion with an average correction of 40 degrees. The most common mutation was R255X nucleotide (30% of cases). The most severe curves had mutations R168X and R270X nucleotides. CONCLUSIONS: We advise early monitoring for patients with RTT and scoliosis due to early and rapid progression. Common mutations found were R255X, R168X, R270X, and T158M. We recommend surgical treatment in every curve above 45 degrees, independently of age.

Limitations of Plain Film Radiography in Identification of Hyperextension Fractures in Patients With Ankylosing Spinal Disorders.

STUDY DESIGN: Efficacy study. OBJECTIVES: To elucidate the limitations of radiography in patients with spinal ankylosing disorders (SAD) with an emphasis on thoracolumbar injuries, which have been less focused upon. METHODS: We searched our hospital's emergency room database for patients who underwent a total spine computed tomography (CT) following a diagnosis of SAD on radiographs following a minor fall. A high-quality presentation containing 50 randomly situated anteroposterior + lateral radiographs was created. Of these, 24 contained a hyperextension type fracture diagnosed by CT. Twelve physicians-4 spine surgeons, 4 senior orthopedic residents and 4 junior orthopedic residents were requested to identify the pathologic radiographs and note the fracture level. RESULTS: Fracture diagnosis stood at 65% for the best reader. When examining the different subgroups, the mean rate of diagnosis for spine surgeons was 55% and for orthopedic residents 32%. Mean diagnosis of thoracic fractures was 26%, of lumbar fractures was 55%, and for the entire thoracolumbar spine was 40%. The interobserver agreement (kappa coefficient) was found to be 0.37 for the entire group and 0.39 for spine surgeons. This finding was statistically significant. CONCLUSIONS: The simple radiograph is an inefficient modality for diagnosis of hyperextension type thoracolumbar fractures in patients with SAD. The poor interobserver agreement rate further amplifies this finding. Advanced imaging is recommended in these patients.

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.

Reassuring the medical students' disease--health related anxiety among medical students.

BACKGROUND: Studying a specific illness could lead medical students to an incorrect interpretation of certain physical symptoms, so that symptoms which were previously considered normal are now regarded as a true sign of an illness. AIM: To examine the appraisal of self-health state, the existing fear of morbidity and the level of health-related anxiety among medical students throughout medical school. METHODS: Anonymous questionnaires were distributed to first through sixth year medical students at the Tel-Aviv University Medical School. The questionnaires were distributed to all the students who were present on the study days. RESULTS: We observed a significant rise in the emotional-distress process with entering the clinical years followed by a significant decrease later on. Similar pattern was seen in health anxiety and in preoccupation with and fear of illness and death. While the perceptual-cognitive process increased gradually, there was no change in interference with life scores. CONCLUSION: "Medical student's disease" should be regarded as a phenomenon depending on the years of learning. By breaking it down into its components, one can better characterize it and predict its onset. By defining it as a normal process, one can assist in guiding medical students to reduce their level of anxiety and distress.

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.

Outcomes of multilevel vertebrectomy for spondylodiscitis.

BACKGROUND CONTEXT: The incidence of pyogenic vertebral osteomyelitis (PVO) continues to increase in the United States, highlighting the need to recognize unique challenges presented by these cases and develop effective methods of surgical management. To date, no prior research has focused on the outcomes of PVO requiring two or more contiguous corpectomies. PURPOSE: To describe our experience in the operative management of PVO in 56 consecutive patients who underwent multilevel corpectomies (≥2 vertebral bodies) via a combined approach. STUDY DESIGN/SETTING: Single institution retrospective cohort review between January 2002 and December 2015. All patients had been treated at an academic tertiary referral center by one of two fellowship-trained orthopedic spine surgeons. PATIENT SAMPLE: Patient records were cross-referenced with International Classification of Diseases osteomyelitis codes and paravertebral abscess code. Inclusion criteria for the study were patients within the cohort who had adequate medical records for review, a minimum patient age of 18 years, active vertebral osteomyelitis as an indication for surgical intervention, a minimum of 1-year radiographic follow-up, and surgical intervention that included at least two complete vertebral corpectomies. Subsequently, 56 patients met the inclusion criteria and were reviewed for this retrospective analysis. OUTCOME MEASURES: Outcomes of interest were readmission and reoperation rates related to treatment of PVO, 30-day and 1-year mortality rates, radiographic outcomes, perioperative complications, infection control, and length of stay. METHODS: After obtaining approval from the Institutional Review Board, retrospective review was performed on records of all adults with PVO refractory to standard nonoperative treatment who underwent complete corpectomy of two or more contiguous vertebrae at a single institution between January 2002 and December 2015. This study was not funded, and no potential conflict of interest-associated biases were present. RESULTS: Fifty-six patients were identified (63% men; mean age 56.8 years; mean radiographic follow-up 2.8 years). Median length of stay was 13 days with nearly half readmitted (47%) after a median of 222.5 days after surgery. Twelve (22%) posterior revisions were required after a median 54 days for infection, painful or failed hardware, proximal junction kyphosis, adjacent level disease, or extension of the fusion. Thirty-day and 1-year mortality rates were 7.14% and 19.6%, respectively, with an infectious etiology as the most common cause of death. CONCLUSIONS: Multilevel vertebral corpectomy for treatment of refractory vertebral osteomyelitis is associated with relatively high rates of complications and mortality compared with historical controls for 1 or 2 level procedures. We found clinical resolution and absence of complications requiring return to the operating room in 75% of patients when complete extirpation of the involved vertebrae is achieved. Our findings suggest multilevel anterior corpectomies with posterior stabilization may be a reasonable surgical option when approaching patients with complicated spondylodiscitis.

Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical approaches.

OBJECTIVE: To compare the reduction quality, surgery time, and early postoperative complications between the 2 following surgical approaches: the ilioinguinal and the anterior intrapelvic (AIP or modified Rives-Stoppa). DESIGN: Retrospective study. PATIENTS: Comparison of 122 patients operated in our center between 1996 and 2003 with the ilioinguinal approach and 103 cases operated between 2004 and 2011 with the AIP approach. SETTING: Level 1 trauma center, acetabular fracture surgery referral center. OUTCOME MEASUREMENT: The patients' demographics, fracture type, fracture reduction quality, surgery time, and postoperative complications were compared. RESULTS: Anatomic reduction was achieved in 84 patients (68.9%) treated by the ilioinguinal approach and in 85 patients (82.5%) treated by the AIP approach (P = 0.018). In both the columns, acetabular fracture type anatomic reduction was achieved in 54.2% of the ilioinguinal group and 79.4% of the AIP group (P = 0.018). In the ilioinguinal group, surgery time decreased as the number of surgeries increased (P = 0.021), whereas a similar trend was not found in the AIP group. Fracture type distribution and complication rates were similar for both the groups. CONCLUSIONS: The AIP approach is a safe alternative that offers better exposure and possibly improved reduction quality of acetabular fractures compared with the ilioinguinal approach. We believe that the major advantage of the AIP approach is that it enables reduction of the posterior column and the quadrilateral plate from the contralateral side and enables application of a buttress plate below the pelvic brim. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.