The effect of Providence night-time bracing on the sagittal profile in adolescent idiopathic scoliosis.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is characterized by coronal scoliosis and often a sagittal hypokyphosis. The effect of bracing on the sagittal profile is not well understood. The aim of this study is to assess the effect of night-time bracing on the sagittal profile in patients with AIS. METHODS: We retrospectively included AIS patients with a main curve of 25-45° treated with a night-time brace in our institution between 2005 and 2018. Patients with estimated growth potential based on either Risser stage, hand X-rays, or menarchal status were included. Coronal and sagittal radiographic parameters were recorded at both brace- initiation and -termination. Patients were followed until surgery or one year after brace termination. Results were compared to a published cohort of full-time braced patients. RESULTS: One hundred forty-six patients were included. Maximum thoracic kyphosis (TK) increased 2.5° (± 9.7) (p = 0.003), corresponding to a 3.5-fold relative risk increase post bracing in TK compared to a full-time brace cohort. Twenty-seven percent (n = 36) of the patients were hypokyphotic (T4/T12 < 20°) at brace initiation compared with 19% (n = 26) at brace termination (p = 0.134). All other sagittal parameters remained the same at follow-up. We found no association between progression in the coronal plane and change in sagittal parameters. CONCLUSION: This is the first study to indicate that night-time bracing of AIS does not induce hypokyphosis. We found a small increase in TK, with a substantially lower risk of developing flat back deformity compared to full-time bracing. The coronal curve progression was not coupled to a change in TK.

The influence of night-time bracing on curve progression is not affected by curve magnitude in adolescent idiopathic scoliosis: a study of 299 patients.

BACKGROUND AND PURPOSE: The efficacy of bracing larger curves in adolescent idiopathic scoliosis (AIS) patients is uncertain. We aimed to assess the influence of night-time bracing in AIS patients with main curves exceeding 40° Cobb angle at brace initiation. METHODS: We reviewed AIS patients treated with nighttime braces between 2005 and 2018. Patients with curves ≥ 25° and estimated growth potential were included. Patients were monitored with radiographs from brace initiation until brace weaning at skeletal maturity. Patients were grouped based on curve magnitude at initial evaluation: a control group (25-39°) and a large-curves group (≥ 40°). Progression was defined as > 5° increase. RESULTS: We included 299 patients (control group, n = 125; large-curves group, n = 174). In the control group, 65 (52%) patients progressed compared with 101 (58%) in the large-curves group (P = 0.3). The lower-end vertebra (LEV) shifted distally post-bracing in 41 (23%) patients in the largecurves group. Patients with progressive large curves were younger (age 13.2 [SD 1.5] vs. 13.9 [SD 1.1], P = 0.009) and more premenarchal (n = 36 [42%] vs. n = 6 [9%], P < 0.001) compared with non-progressive large curves. CONCLUSION: Progression risk in patients with curves exceeding 40° treated with night-time bracing is similar to smaller curves. The LEV moved distally in almost one-fourth of the larger curves, possibly affecting fusion levels in cases of surgery.

Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing?

PURPOSE: Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing. METHODS: AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs. RESULTS: One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67). CONCLUSION: Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.

The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols are often specific to a specific type of surgery without assessing the overall effect on the ward. Previous studies have demonstrated reduced length of stay (LOS) with ERAS protocols in patients with adolescent idiopathic scoliosis (AIS), although the patients are often healthy and with few or no comorbidities. In 2018, we used ERAS principles for patients undergoing AIS surgery with a subsequent 40% reduced LOS. The current study aims to assess the potential collateral effect of LOS in patients surgically treated for neuromuscular scoliosis admitted to the same ward and treated by the same staff but without a standardized ERAS protocol. METHODS: All patients undergoing neuromuscular surgery 2 years before and after ERAS introduction (AIS patients) with a gross motor function classification score of 4 to 5 were included. LOS, intensive care stay, and postoperative complications were recorded. After discharge, all complications leading to readmission and mortality were noted with a minimum of 2 years of follow-up using a nationwide registry. RESULTS: Forty-six patients were included; 20 pre-ERAS and 26 post-ERAS. Cross groups, there were no differences in diagnosis, preoperative curve size, pulmonary or cardiac comorbidities, weight, sex, or age. Postoperative care in the intensive care unit was unchanged between the two groups (1.2 vs 1.1; P = 0.298). When comparing LOS, we found a 41% reduction in the post-ERAS group (11 vs 6.5; P < 0.001) whereas the 90-day readmission rates were without any significant difference (45% vs 34% P = 0.22) We found no difference in the 2-year mortality in either group. CONCLUSION: The employment of ERAS principles in a relatively uncomplicated patient group had a positive, collateral effect on more complex patients treated in the same ward. We believe that training involving the caregiving staff is equally important as pharmacological protocols.

Morbidity and mortality following degenerative spine surgery in a prospective cohort of 1687 consecutive surgical procedures.

STUDY DESIGN: Prospective, observational cohort study. OBJECTIVE: To determine the true incidence of adverse events (AEs) in European adults undergoing surgery for degenerative spine diseases. The majority of surgeries performed for degenerative spinal diseases are elective, and the need for adequate estimation of risk-benefit of the intended surgery is imperative. A cumbersome obstacle for adequate estimation of surgery-related risks is that the true incidence of complications or adverse events (AEs) remains unclear. METHODS: All adult patients (≥ 18 years) undergoing spine surgery at a single center from February 1, 2016, to January 31, 2017, were prospectively and consecutively included. Morbidity and mortality were determined using the Spine AdVerse Events Severity (SAVES) system. Additionally, the correlation between the AEs and length of stay (LOS) and mortality was assessed. RESULTS: A total of 1687 procedures were performed in the study period, and all were included for analysis. Of these, 1399 (83%) were lumbar procedures and 288 (17%) were cervical. The overall incidence of AEs was 47.4%, with a minor AE incidence of 43.2% and a major of 14.5%. Female sex (OR 1.5 [95% CI 1.2-1.9), p < 0.001) and age > 65 years (OR 1.5 [95% CI 1.1-1.7], p = 0.012) were significantly associated with increased odds of having an AE. CONCLUSION: Based on prospectively registered AEs in this single-center study, we validated the use of the SAVES system in a European population undergoing spine surgery due to degenerative spine disease. We found a higher incidence of AEs than previously reported in retrospective studies. The major AEs registered occurred significantly more often perioperatively and in patients > 65 years.

Scheuermann's Kyphosis: a 39-year follow-up from diagnosis in non-operated patients.

PURPOSE: To investigate the impact of Scheuermann's Kyphosis (SK) on health -related quality of life (HRQOL) in adult patients and compare it to the general population. Moreover, to assess whether location of the kyphosis affects pelvic parameters, HRQOL, and pulmonary function. METHODS: Of a cohort of 251 patients seen for a pediatric spinal deformity in the years 1972-1982 in our outpatient clinic, 55 had radiologically verified SK. Thirty-eight participated in the study and responded to HRQOL questionnaires, 34 had radiographs taken and 31 had pulmonary function testing. The patients were divided into two groups according to location of the SK apex: thoracic (Th) above Th10 and thoracolumbar (TL) from Th10 and below. Spinopelvic parameters were measured for all radiographs. The HRQOL scores for all SK patients were compared with normative data from a Scandinavian population. Pulmonary function measurements were compared between the Th and TL SK groups. RESULTS: Mean follow-up was 39 ± 1.6 years, and mean age at follow-up was 53 ± 2.4 years. We found lower score in the TL group for SRS-22r function domain (p = 0.027) compared with the Th group, but no significant difference in the remaining domains and SRS-22r subscore (p > 0.18). The patients had significantly lower mean scores compared to normative values on SRS-22r domains pain (p = 0.049) and self-image (p = 0.006), but no statistically significant difference on SRS-22r subscore (p = 0.064). There was no difference in pelvic parameters between the two SK groups. We did not find a difference in pulmonary function on percent predicted FEV1 (FEV1%) (p = 0.91) and percent predicted FEV1/FVC (FEV1/FVC%) (p = 0.82) between the two SK groups. CONCLUSION: We found a lower HRQOL in adult patients with SK 39 years after diagnosis regarding SRS-22r domains pain and self-image, and a tendency toward lower overall HRQOL compared with a background population. The location of the SK apex did not seem to have an overall impact on HRQOL. There was no difference in pelvic parameters in the two groups and no difference in pulmonary function. These slides can be retrieved under Electronic Supplementary Material.

Correction to: Evaluation of a new sagittal classification system in adolescent idiopathic scoliosis.

Unfortunately, the names of the members of the Texas Children's Hospital Spine Study Group have not been mentioned in the published article.

Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study.

PURPOSE: To evaluate the incidence of mechanical complications in patients with adult spine deformity (ASD) treated by restoring the normal shape according to the Roussouly classification. METHODS: This is a retrospective multicentric study with a minimum follow-up of 2 years. Patients operated on with fusion for ASD (minimum performed fusion: L2 to sacrum) were included. Patients with a history of previous spinal fusion of more than three levels were excluded. Spinal and pelvic parameters were measured on the preoperative and the immediate postoperative follow-up. All mechanical complications were recorded. RESULTS: A total of 290 patients met the criteria of inclusion with a minimum follow-up of 2 years. Mechanical complications occurred in 30.4% of the cohort. The most common complication was PJK with an incidence of 18% while nonunion or instrumentation failure (rod breakage, implant failure) occurred in 12.4%. 66% of the patients were restored to the normal shape according to the Roussouly classification based on their PI and had a mechanical complication rate of 22.5%, whereas the remaining 34% of patients had a complication rate of 46.8% (p < 0.001). The relative risk for developing a mechanical complication if the algorithm was not met was 3 (CI 1.5-4.3; p < 0.001) CONCLUSION: In the recent literature, there are no clear guidelines for ASD correction. Restoring the sagittal spinal contour to the normal shapes of Roussouly according to the PI could serve as a guideline for ASD treatment. Ignoring this algorithm has a threefold risk of increased mechanical complications. We recommend this algorithm for treatment of ASD. LEVEL OF EVIDENCE: IV cross-sectional observational study. These slides can be retrieved under Electronic Supplementary Material.

Evaluation of a new sagittal classification system in adolescent idiopathic scoliosis.

PURPOSE: The purpose of the present study was to validate a new spinal sagittal classification. METHODS: We retrospectively included 105 consecutive AIS patients who underwent posterior spinal fusion. Preoperative long-standing EOS radiographs were available on all patients. Patients were classified according to the four suggested sagittal patterns: type 1, 2a, 2b or 3. Several predetermined sagittal parameters were compared between the groups. RESULTS: The mean preoperative Cobb angle was 64° ± 12°, and 73% of the patients were female. Of 105 patients, 51 were type 1, 14 were type 2a, one was type 2b and 39 were type 3. The distribution of the four sagittal patterns was significantly different compared with the original publication (p < 0.05). However, the two study populations were comparable in terms of Lenke and Roussouly types (p = 0.49 and 0.47, respectively). In our study population, the sagittal groups differed significantly in terms of thoracic kyphosis, length of thoracic and lumbar curves, lumbar lordosis, thoracic slope, C7 slope, pelvic incidence and sacral slope (p < 0.05). CONCLUSION: The distribution of the four sagittal patterns varies between AIS cohorts. Type 2b was rare, which limits the clinical applicability. Contrary to the original publication, we found that the spinopelvic parameters lumbar lordosis, pelvic incidence and sacral slope were significantly different between the Abelin-Genevois types. Hence, the corrective surgical strategy may need to incorporate these spinopelvic parameters to achieve a balanced spine requiring a minimum of energy expenditure. These slides can be retrieved under Electronic Supplementary Material.

Distraction-to-stall Versus Targeted Distraction in Magnetically Controlled Growing Rods.

BACKGROUND: Consensus is lacking regarding the lengthening procedures in magnetically controlled growing rods (MCGR), and no studies have compared the outcome between different distraction principles. The purpose of the present study was to compare distraction-to-stall with targeted distraction and identify variables associated with achieved distraction. METHODS: We performed a 2-center retrospective study of all children treated with MCGR from November 2013 to January 2019, having a minimum of 1-year follow-up and undergoing a minimum of 3 distractions. Exclusion criteria were single-rod constructs and conversion cases. In group 1 (21 patients), we used a distraction-to-stall (maximum force) principle where each rod was lengthened until the internal magnetic driver stopped (clunking). In group 2 (18 patients), we used a targeted distraction principle, where the desired distraction was entered the remote control before distraction. In both groups we aimed for maximal distraction and curve correction at index surgery. Achieved distraction was measured on calibrated radiographs and compared between the 2 groups using a linear mixed effects model. Univariate and multivariate analyses were performed to identify variables associated with achieved distraction within the first year. RESULTS: Mean age at surgery was 9.5±2.0 years. Etiology of the deformity was congenital/structural (n=7), neuromuscular (n=9), syndromic (n=3), or idiopathic (n=20). Demographics and preoperative characteristics including spinal height (T1T12 and T1S1) did not differ significantly between the groups (P≥0.13). Time interval between distractions were mean 18 days (95% confidence interval: 10-25) shorter in group 1. Implant-related complications occurred in 10/39 patients, 5 in each group. We found no difference in achieved distraction between the groups in the linear mixed effects model. In the multivariate analysis, preoperative major curve angle was the only independent variable associated with achieved distraction. CONCLUSIONS: In 2 comparable and consecutive cohorts of patients treated with MCGR, we found no difference in achieved distraction between a distraction-to-stall and a targeted distraction principle. Preoperative major curve angle was the only independent predictor of achieved distraction. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Effectiveness of surgery for sciatica with disc herniation is not substantially affected by differences in surgical incidences among three countries: results from the Danish, Swedish and Norwegian spine registries.

PURPOSE: Yearly incidence of surgery for symptomatic lumbar disc herniation varies and is 29/100,000 in Sweden, 46/100,000 in Denmark and 58/100,000 in Norway. This variation was used to study whether differences in surgical incidence were associated with differences in preoperative patient characteristics as well as patient-reported outcomes. METHODS: Data from the national spine registers in Sweden, Denmark and Norway during 2011-2013 were pooled, and 9965 individuals, aged 18-65 years, of which 6468 had one-year follow-up data, were included in the study. Both absolute and case-mix-adjusted comparisons of the primary outcome Oswestry Disability Index (ODI) and the secondary outcomes EQ-5D-3L, and Numerical Rating Scale (NRS) for leg and back pain were performed. Case-mix adjustment was done for baseline age, sex, BMI, smoking, co-morbidity, duration of leg pain and preoperative value of the dependent variable. RESULTS: Mean improvement in the outcome variables exceeded previously described minimal clinical important change in all countries. Mean (95% CI) final scores of ODI were 18 (17-18), 19 (18-20) and 15 (15-16) in Sweden, Denmark and Norway, respectively. Corresponding results of EQ-5D-3L were 0.74 (0.73-0.75), 0.73 (0.72-0.75) and 0.75 (0.74-0.76). Results of NRS leg and back pain behaved similarly. Case-mix adjustment did not alter the findings substantially. CONCLUSION: We found no clear association between incidence of surgery for lumbar disc herniation and preoperative patient characteristics as well as outcome, and the differences between the countries were lower than the minimal clinical important difference in all outcomes. These slides can be retrieved under Electronic Supplementary Material.

Classification of normal sagittal spine alignment: refounding the Roussouly classification.

PURPOSE: Although the Roussouly classification of common variants in spinal sagittal alignment is well accepted, no studies have implemented it in an asymptomatic adult population. In addition, no study investigated the radiographic features of asymptomatic patients with an anteverted pelvis. The aim of this prospective radiographic study of 296 asymptomatic adults without spinal pathology was to investigate how the Roussouly classification could include the anteverted pelvis concept. METHODS: Pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), and the lumbar parameters lumbar lordosis (Global LL), lordosis tilt angle (LTA), total number of lordotic vertebra (LL verteb), and C7 plumbline/sacrofemoral distance ratio (C7PL ratio) were evaluated in 296 healthy volunteers (126 males, 170 females; mean age, 27 years; range 18-48 years). Comparison between the five types of the Roussouly classification used Student, ANOVA, and Tukey tests for quantitative variables and χ 2, Fischer, and Holm tests for qualitative variables. RESULTS: Mean PI and PT were, respectively, (39°, 10°) for type 1, (41°, 10°) for type 2, (53°, 13°) for type 3, and (62°, 12°) for type 4 (p < 0.0001 and p < 0.01). A sizable portion (16%) of the population (type 3 AP) showed low-grade PI (mean, 48° ± 6°) despite having SS > 35°. PT was low or negative (mean 4° ± 3°). C7PL ratio was >1 (in front of the hip axis) in 13% of all cases, and between 0 and 1 (between sacrum and hip axis) in 49%. CONCLUSION: Although asymptomatic adults stood with stable global balance, the sagittal spinal alignment of healthy subjects, newly divided in 5 sagittal types, varied significantly. Type 3 AP appears as a new and unusual sagittal shape with low-grade PI, very low or negative PT, and hyperlordosis. Whereas most asymptomatic adults stood with C7PL behind the hip axis, a sizeable portion had C7 in front of the hip axis. This could be a new controversial aspect of ideal spinal balance.

Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases.

BACKGROUND: The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program. STUDY DESIGN AND METHODS: Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography. RESULTS: In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99). CONCLUSION: A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.

Range of motion after thoracolumbar corpectomy: evaluation of analogous constructs with a novel low-profile anterior dual-rod system and a traditional dual-rod system.

STUDY DESIGN: An in vitro biomechanical study. OBJECTIVES: To compare the biomechanical stability of traditional and low-profile thorocolumbar anterior instrumentation after a corpectomy with cross-connectors. Dual-rod anterior thoracolumbar lateral plates (ATLP) have been used clinically to stabilize the thorocolumbar spine. METHODS: The stability of a low-profile dual-rod system (LP DRS) and a traditional dual-rod system (DRS) was compared using a calf spine model. Two groups of seven specimens were tested intact and then in the following order: (1) ATLP with two cross-connectors and spacer; (2) ATLP with one cross-connector and spacer; (3) ATLP with spacer. Data were normalized to intact (100 %) and statistical analysis was used to determine between-group significances. RESULTS: Both constructs reduced motion compared to intact in flexion-extension and lateral bending. Axial rotation motion became unstable after the corpectomy and motion was greater than intact, even with two cross-connectors with both systems. Relative to their respective intact groups, LP DRS significantly reduced motion compared to analogous DRS in flexion-extension. The addition of cross-connectors reduced motion in all loading modes. CONCLUSIONS: The LP DRS provides 7.5 mm of reduced height with similar biomechanical performance. The reduced height may be beneficiary by reduced irritation and impingement on adjacent structures.

Improved restoration of thoracic kyphosis using a rod construct with differentiated rigidity in the surgical treatment of adolescent idiopathic scoliosis.

OBJECTIVE The objective of this study was to compare postoperative sagittal alignment among 3 rod constructs with different rigidity profiles. METHODS This was a dual-center retrospective cohort study involving 2 consecutive cohorts in which patients were surgically treated for adolescent idiopathic scoliosis. Lenke Type 5 curves were excluded. Patients were operated on with all-pedicle screw instrumentation using 3 different rod constructs. The first group was operated on using a hybrid construct (HC) consisting of a normal circular rod on the convex side and a beam-like rod (BR) on the concave side. The second group was operated on with a standard construct (SC) using bilateral BRs in the full length of the fusion. The third group was operated on with a modified construct (MC). The modified rods have a beam-like shape in the caudal portion, but in the cranial 2 or 3 fusion levels the rod transitions to a circular shape with a smaller anteroposterior diameter. Radiographs were analyzed preoperatively and at the first postoperative follow-up (range 1-8 weeks). The primary outcome was pre- to postoperative change in thoracic kyphosis (TK), and the secondary outcome was the ability to achieve postoperative TK within the normal range. RESULTS The HC, SC, and MC groups included 23, 70, and 46 patients, respectively. The 3 groups did not differ significantly in preoperative demographic or radiographic parameters. The mean ± standard deviation of the preoperative main curve was 60.7° ± 12.6°, and the mean of curve correction was 62.9% ± 10.4% with no significant difference among groups (p ≥ 0.680). The groups did not differ significantly in coronal balance or proximal or thoracolumbar curve correction (p ≥ 0.189). Mean postoperative TK was 23.1° ± 6.3°, 19.6° ± 7.6°, and 23.4° ± 6.9° in the HC, SC and MC groups, respectively (p = 0.013), and the mean change in TK was -3.5° ± 11.3°, -7.1° ± 11.6°, and 0.1° ± 10.9°, respectively (p = 0.005). The MC group had significantly higher postoperative TK and less loss of TK compared with the SC group (p ≤ 0.018). Postoperative TK ≤ 10° was found in 12 patients (17%) in the SC group, 1 patient (5%) in the HC group, and 1 patient (2%) in the MC group (p = 0.021). There were no differences in proximal alignment, thoracolumbar alignment, or sagittal vertical axis (p ≥ 0.249). Lumbar lordosis was 58.9° ± 11.2° in the HC group versus 52.0° ± 1.3° and 55.0° ± 11.0° and the SC and MC groups, respectively (p = 0.040). CONCLUSIONS In the 3 rod constructs with different rigidity profiles, significantly better restoration of kyphosis was achieved with the use of bilateral modified rods compared with bilateral standard rods. In the MC and HC groups, the rate of severe postoperative hypokyphosis was significantly lower than in the SC group. This is the first study to describe the clinical use of a rod with a reduced proximal diameter and show marked radiographic improvement in sagittal alignment.

A proposed set of metrics for standardized outcome reporting in the management of low back pain.

BACKGROUND AND PURPOSE: Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set. PATIENTS AND METHODS: An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions. RESULTS: Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools. INTERPRETATION: The outcome measures recommended here are structured around specific etiologies of LBP, span a patient's entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.

Postoperative lordosis distribution index, patient reported outcome measures, and revision surgery following transforaminal lumbar interbody fusion.

Objective: Lordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. Methods: This study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results: 126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was -15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). Conclusions: We found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

Carbon Instrumentation in Patients with Metastatic Spinal Cord Compression.

Recently carbon spinal implants have been introduced in the treatment of patients with metastatic spinal cord compression (MSCC). This is expected to decrease the deflection of radiation and improve diagnostic imaging and radiotherapy when compared to titanium implants. The aim of this study was to determine the safety and effectiveness of spinal carbon instrumentation (CI) in patients with MSCC in a large cohort study. A total of 163 patients received instrumentation between 1 January 2017 and 31 December 2021. A total of 80 were stabilized with CI and 83 with TI. The outcome measures were surgical revision, postsurgical survival, peri-operative bleeding, and surgery time. The peri-operative blood loss in the CI-group was significantly lower than that in the TI-group: 450mL vs. 630mL, (p = 0.02). There were no significant differences between the groups in mean survival (CI 9.9) vs. (TI 12.9) months (p = 0.39), or the number of patients needing a revision (CI 6) vs. (TI 10), (p = 0.39). The median duration of surgery was 121 min, (p = 0.99) with no significant difference between the two groups. Surgical treatment with CI for MSCC is safe and an equally sufficient treatment when compared to TI.

Demineralized cortical fibers are associated with a low pseudarthrosis rate in patients undergoing surgery for adult spinal deformity without three-column osteotomy.

Introduction: Following surgical treatment for adult spinal deformity (ASD) there is an increased risk of revision surgery due to mechanical failure or pseudarthrosis. Demineralized cortical fibers (DCF) were introduced at our institution aiming to reduce the risk of pseudarthrosis after ASD surgery. Research question: We wanted to investigate the effect of DCF on postoperative pseudarthrosis compared with allogenic bone graft in ASD surgery without three-column osteotomies (3CO). Materials & Methods: All patients undergoing ASD surgery between January 1, 2010 to June 31, 2020 were included in this interventional study with historical controls. Patients with current or previous 3CO were excluded. Before February 1, 2017, patients undergoing surgery received auto- and allogenic bone graft (non-DCF group) whilst patients after received DCF in addition to autologous bone graft (DCF group). Patients were followed for at least two years. The primary outcome was radiographic or CT-verified postoperative pseudarthrosis requiring revision surgery. Results: We included 50 patients in the DCF group and 85 patients in the non-DCF group for final analysis. Pseudarthrosis requiring revision surgery at two-year follow-up occurred in seven (14%) patients in the DCF group compared with 28 (33%) patients in the non-DCF group (p â€‹= â€‹0.016). The difference was statistically significant, corresponding to a relative risk of 0.43 (95%CI: 0.21-0.94) in favor of the DCF group. Conclusion: We assessed the use of DCF in patients undergoing ASD surgery without 3CO. Our results suggest that the use of DCF was associated with a considerable decreased risk of postoperative pseudarthrosis requiring revision surgery.

Health-related quality of life in patients 40 years after diagnosis of an idiopathic scoliosis.

AIMS: Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL. METHODS: We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves. RESULTS: The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains. CONCLUSION: In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis.Cite this article: Bone Joint J 2023;105-B(2):166-171.