Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures.

BACKGROUND: This study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs). METHODS: In this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence. RESULTS: Blood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6-9), 9 (range: 5-23), and 7 (range: 1-21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage. CONCLUSIONS: The HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

Cervical syringomyelia associated with cervical disc disease.

Background and purpose:

Syringomyelia is a neurological condition in which a longitudinal fluid-filled cavity is formed within the spinal cord. It usually occurs in the cervical region and is associated with Chiari malformation, infections, trauma, and tumors of the spinal cord. However, syringomyelia associated with cervical disc disease (SCD) is very rare and only a few cases have been reported so far. This case report presents the clinical and radiological findings of 13 cases of SCD to describe the properties of SCD and explore the nature of the relationship between syringomyelia and cervical disc disease.

SCD was diagnosed in 13 using MRI findings, including coexistence of syringomyelia and cervical disc disease, presence of narrowed cervical subarachnoid space secondary to the cervical disc herniation or cervical local kyphosis associated with cervical disc degeneration or herniation, and the cervical disc herniation or segmental kyphosis and syrinx should be located within the same levels. The MRI findings were used to grade the syrinx and determine whether the cervical disc herniation or local kyphosis was located at the proximal or distal end of the syrinx.

All patients had single-level disc herniation or kyphosis, the most common level being C5–6 (n = 6), followed by C6–7 (n = 4) and C4–5 (n = 3). Eight patients had a distal type (disc disease located in the proximal end of the syrinx) SCD while five had the proximal variety (cervical disc disease located in the distal end of the syrinx). The average length of the syrinx was two vertebral segments. Surgery was performed in five cases and some degree of syrinx resolution was observed in all of them.
Discussion – The main cause of syringomyelia is obstruction of cerebrospinal fluid (CSF) pathways; total obstruction could cause distal syrinx, whereas partial obstruction could cause proximal or distal syrinxes. Restoration of CSF pathways may result in some degree of resolution of syringomyelia. A causal association may exist between cervical disc disease and cervical syringomyelia but needs further exploration.

SCD is a mild form of syringomyelia with symptoms primarily arising due to disc herniation or local kyphosis. The surgical treatment of the cervical disc disease is sufficient and results in a syringomyelia resolution of some degree.

The role of pineal gland volume in the development of scoliosis.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is believed to be caused by genetic, neurological, osseous growth anomalies, histological variables including muscle fiber percentage and core structure changes, metabolic and hormonal dysfunction, vestibular dysfunction, and platelet microarchitecture. The objective of this study was to contribute to the determination of the cause of AIS by analyzing the changes in pineal gland volume in AIS cases. METHODS: Study (AIS) and control group were each comprised of 26 patients who met the inclusion requirements. Scoliosis radiograph and MRI of the pineal glands were used for radiological examinations. The distribution of age, gender, Risser grading for skeletal radiological development, and sexual maturation according to Tanner categorization were uniform and statistically insignificant between groups. RESULTS: When the pineal gland volumes of the cases were evaluated according to age, the AIS group was found to have significantly reduced pineal gland volumes in all age groups. The pineal gland volume was found to be 38.1% lower in the AIS group compared to the control group (p˂0.001). In the AIS group, patients aged 13 years had the lowest pineal gland volume (77.2 ± 13.86 mm3), while patients aged 15 years had the highest volume (97.9 ± 16.47 mm3). CONCLUSION: Changes in pineal gland volume support the role of the pineal gland in the etiopathogenesis of AIS.

Evaluation of cerebellum volume and trunk oscillation velocity in cases with adolescent idiopathic scoliosis: a preliminary report.

PURPOSE: It has been suggested that the cause of the balance disorder seen in adolescent idiopathic scoliosis (AIS) originates from the central nervous system. However, the extent of the balance problem and the dysfunction of which part of the central nervous system has not been investigated in detail. This study aimed to correlate the values obtained by balance analysis and cerebellum volume measurement in female individuals with AIS with healthy individuals. METHODS: Cerebellum volume was calculated via the cloud-based software " https://volbrain.upv.es " using brain magnetic resonance images of 27 healthy and 26 individuals with AIS. The duration of stay in the test positions, the movement strategy used during this time and the amount of postural sway were analyzed by using a computer-assisted force platform and compared statistically. RESULTS: Significant differences were found between the AIS and control groups in cerebellum total volume, vermis cerebelli volume (cm3), and trunk oscillation velocity (mm/s) parameters (p < 0.05). Cerebellum and vermis cerebelli volumes were found to be lower and trunk oscillation velocity was found to be greater in patients with AIS. CONCLUSION: Balance problems in patients with AIS are correlated with decreased cerebellum volume and increased trunk oscillation velocity.

Impact of mental health components on the development of back pain in young adults with adolescent idiopathic scoliosis.

BACKGROUND: Back pain occurs commonly in adults and is multifactorial in nature. This study aimed to assess the prevalence and intensity of back pain during young adulthood in subjects with adolescent idiopathic scoliosis (AIS), as well as factors that may be associated with its prognosis. METHODS: Subjects with AIS aged 20-39 treated conservatively were included in this study. Patient-reported outcome measures in adulthood involved episodes of back pain, and scales of self-image, depression, anxiety, and stress. Additionally, pain, self-image, and mental health scores were retrieved at the first clinic consultation. Occurrence of back pain was defined as a numeric pain rating scale ≥ 6. RESULTS: 101 participants were enrolled. The prevalence of back pain in the lifetime, past 12 months, past 6 months, past 1 month, past 7 days, and past 24 h were 37%, 35%, 31%, 27%, 23%, and 20%, respectively. Male, self-image, and depression were significant associated factors for the development of back pain at all time points. Furthermore, the analyses of the initial presentation of participants have shown that participants with back pain in adulthood were characterised by poor self-image and mental health during their adolescence. CONCLUSION: The present study addressed the natural history of back pain in young adults with conservatively treated AIS. Psychological makeup has been shown to constitute the development of back pain and is strongly hinted as an early sign of having back pain in adulthood among subjects with AIS.

Kyphectomy in myelomeningocele revisited: risk factors for failure.

PURPOSE: Lumbar kyphosis occurs in approximately 8-20% of patients with myelomeningocele (MMC). The purpose of this article is to analyze the risks and benefits of vertebrectomy and spinal stabilization in MMC children with severe lumbar kyphosis and to establish treatment guidelines. METHODS: This is an IRB-approved retrospective analysis of 59 patients with MMC who underwent kyphectomy and posterior instrumentation in three centers. Average age at surgery was 7.9 years (2 weeks-17 years). Sitting trunk position, skin status, kyphosis angle, and thoracic lordosis were analyzed preoperatively, postoperatively, and at an average follow-up of 8.2 years (range 2.5-16). The correction was maintained by applying a short posterior instrumentation in 6 patients, and extending to the pelvis in 53 cases. Pelvic fixation was achieved using the Warner and Fackler technique in 24 patients, the Dunn-McCarthy in 8, Luque-Galveston in 8, sacral screws in 2, and ilio-sacral screws in 11. RESULTS: Sitting position improved postoperatively in 47 of the 53 patients who underwent pelvic fixation and only in one patient with short instrumentation. All 6 patients with long instrumentation and poor postoperative sitting balance were in the Dunn-McCarthy fixation group. Skin sores at the apex of the deformity disappeared postoperatively in all patients but recurred in two patients with short instrumentations. Kyphosis angle improved from 109° (45°-170°) preoperatively to 10° (0°-45°) postoperatively and 21° (0°-55°) at last follow-up. The best results were seen in cases where a cross-k-wire fixation of the kyphectomy site was used, augmented with a long thoraco-pelvic instrumentation consisting of Luque sublaminar wires in the thoracic region and a Warner-Fackler type of pelvic fixation. Good results were also found with the bipolar technique and ilio-sacral screw fixation. Six over 24 patients with the Warner and Fackler technique showed gradual dislodgment or hardware failure, with subsequent nonunion of the kyphectomy site in four. Infection, with or without wound dehiscence and/or hardware exposure, occurred in 17 cases, necessitating hardware removal in 9 patients. CONCLUSION: Lumbar kyphosis in MMC children is best managed by resection of enough vertebrae from the apex to produce a flat lumbar spine, with perfect bone-to-bone contact and long thoraco-pelvic instrumentation using the Warner and Fackler technique through the S1 foramina or the bipolar technique with ilio-sacral screw fixation. Additional local fixation of the osteotomy site using cross-wires with or without cerclage increases the stability of the construct. The majority of complications occurred in patients with short instrumentations or where residual kyphosis persisted postoperatively regardless of the type of pelvic fixation or hardware density. The Dunn-McCarthy technique for pelvic fixation following kyphectomy in MMC was less successful in producing stable pelvic fixation and should not be considered in this patient category.

Intermittent pedicle screw application provides better kyphosis restoration in adolescent idiopathic scoliosis for Lenke type 1 and type 2 curves.

PURPOSE: There is still no consensus on the optimum pedicle screw density required for the desired thoracic kyphosis restoration in adolescent idiopathic surgery (AIS). The aim of this study to evaluate the effect of pedicle screw density on thoracic kyphosis restoration in AIS surgery. METHODS: The data of 106 patients from two centers that operated for Lenke type 1 and 2 AIS were retrospectively reviewed. Two groups were constituted according to the pedicle screw density: intermittent pedicle screw constructs (IPSC) (n = 52 patients) and consecutive pedicle screw construct (CPSC) (n = 54 patients) groups. The preoperative and at least 24-month follow-up radiographs and SRS-22 scores were evaluated. The Cobb angle of the main and concomitant curves in the coronal plane and the sagittal plane were measured and compared. RESULTS: The mean follow-up period for the IPSC and CPSC groups was 72.3 ± 37.2 and 62.9 ± 28.8 months, respectively. In the SRS-22 questionnaire, there was no significant difference between the two groups in terms of self-image/appearance domain scores (p = 0.466), but better results were obtained in the IPSC group in terms of treatment satisfaction domain scores (p = 0.010) and better thoracic kyphosis restoration was achieved in IPSC group radiologically for Lenke type 1 curves with - 81.4 ± 81.4% in the IPSC group and 6.8 ± 83.8% in the CPSC group (p < 0.001). CONCLUSION: It was considered that better thoracic kyphosis restoration could be achieved with the less lordotic effect of IPSC in Lenke type 1 curves. Although the current situation had a significant impact on radiological outcomes, its effect on SRS-22 scores was limited.

Effectiveness and prognostic factors of different minimally invasive surgeries for vertebral compression fractures.

BACKGROUND: The aging of China's population has led to an increase in the incidence rate of osteoporosis, which indirectly increases the risk of OVCF in osteoporosis patients. Low back pain is the main symptom of OVCF, and severe patients can further develop kyphosis. Although the conservative treatment of OVCF can effectively control the patient's condition, long-term bed rest will increase the risk of OVCF complications. Minimally invasive surgery is a common solution for OVCF. METHODS: 100 OVCF patients admitted to our hospital from January 2021 to January 2022 are selected for analysis and randomly divided into PVP group and PKP group, 50 cases in each group. The PVP group and the PKP group undergo PVP and PKP operations respectively. The differences in efficacy indicators and adverse reactions are compared, and the multivariate Logistic regression method is used to analyze the influencing factors of postoperative secondary fractures in patients with vertebral compression fractures. RESULTS: Compared with the PVP group, the total effective rate of PKP group is significantly increased, and the VAS, ODI score, kyphotic Cobb Angle, lateral distribution rate of bone cement and bone cement leakage rate are significantly decreased (P < 0.05). Age ≥ 80 years old, female, glucocorticoid use, lateral distribution of bone cement and bone cement leakage are significantly higher in the proportion of secondary fractures and are independent risk factors for postoperative secondary fractures in patients with OVCF. CONCLUSION: PKP surgery has a higher efficacy in the treatment of OVCF patients, which can reduce the incidence of pain, adverse reactions and promote the recovery of kyphotic Cobb Angle. PKP surgery has a higher value in the treatment of OVCF. In addition, the influencing factors of secondary fracture after minimally invasive surgery in OVCF patients include age, gender, glucocorticoid use, bone cement distribution pattern, bone cement leakage, etc.

Effect of C7-T1 Extensional Posterior Transpedicle Osteotomy on Mobility and Quality of Life in Patients with Ankylosing Spondylitis Complicated with Lumbar Kyphosis and Related Factors.

Objective: To analyze the effect of C7-T1 extensional posterior transpedicular vertebral osteotomy (PSO) on mobility and quality of life in patients with ankylosing spondylitis (AS) and lumbar kyphosis. Methods: This study was conducted from February 2019 to February 2021 and a total of 38 patients with AS combined with kyphosis from Tianjin Union Medical Center, Tianjin, China, were selected for the study. After performing all preoperative examinations, all patients were treated with C7-T1 extensional posterior PSO osteotomy. The patients' operation and follow-up, pain degree as a Visual analogue scale (VAS) score and sagittal balance index changes before and after surgery, spinal function measured as; Bath Ankylosing Spondylitis Functional Index (BASFI) score and quality of life by Scoliosis Research Society-22 (SRS-22) score, were observed before and after surgery. Pearson correlation coefficient was used to analyze the correlation between patients' quality of life and BASFI score. Results: After surgery, the pain of the patients' back was significantly relieved, the patients' appearance and trunk balance function were significantly improved, and the symptoms related to nerve function were not significantly aggravated. No complications such as infection, internal fixation failure or spinal decompensation occurred in all patients. VAS score, kyphosis Cobb Angle and Sagittal Vertical Axis (SVA) of all patients showed P < .05 before and 1 year after surgery. BASFI score 1 year after surgery decreased significantly than that before surgery (P < .05). 1 year after surgery, body function, pain symptoms, self-image and psychological state of the patients were significantly improved, and the SRS-22 total score of the patients 1 year after surgery increased significantly than before surgery (P < 0.05). BASFI score was negatively correlated with SRS-22 score by Pearson correlation coefficient analysis (P < .05). Conclusion: C7-T1 extensional posterior PSO osteotomy has a good effect in the treatment of AS patients with lumbar kyphosis. The sagittal balance was well-restored with improvement in patients' quality of life after surgery, which makes C7-T1 osteotomy worthy of clinical application to treat patients suffering from AS combined with lumbar kyphosis.

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.

Clinical and radiographic characteristics of increased signal intensity of the spinal cord at the vertebral body level in patients with cervical myelopathy.

BACKGROUND: Increased signal intensity (ISI) is usually recognized at the disc level of the responsible lesion in the patients with cervical myelopathy. However, it is occasionally seen at the vertebral body level, below the level of compression. We aimed to investigate the clinical significance and the radiographic characteristics of ISI at the vertebral body level. METHODS: This retrospective study included 135 patients with cervical spondylotic myelopathy who underwent surgery and with local ISI. We measured the local and C2-7 angle at flexion, neutral, and extension. We also evaluated the local range of motion (ROM) and C2-7 ROM. The patients were classified into group D (ISI at disc level) and group B (ISI at vertebral body level). RESULTS: The prevalence was 80.7% (109/135) and 19.3% (26/135) for groups D and B, respectively. Local angle at flexion and neutral were more kyphotic in group B than in group D. The local ROM was larger in group B than in group D. Moreover, C2-7 angle at flexion, neutral and extension were more kyphotic in group B than in group D. Two years later, local angle at flexion, neutral, and extension were also kyphotic in group B than group D; however, local and C2-7 ROM was not significantly different between the two groups. There was no significant difference of clinical outcomes 2 years postoperatively between both groups. CONCLUSIONS: Group B was associated with the kyphotic alignment and local greater ROM, compared to group D. As the spinal cord is withdrawn in flexion, the ISI lesion at vertebral body might be displaced towards the disc level, which impacted by the anterior components of the vertebrae. ISI at the vertebral body level might be related to cord compression or stretching at flexion position. This should be different from the conventionally held pincer-mechanism concept.

Trabecular bone score and its association with Cobb angle kyphosis in older men: a cross-sectional study for the Osteoporotic Fractures in Men (MrOS) Study.

Hyperkyphosis (HK), or accentuated forward spinal curvature, commonly affects older people, although its causes are not completely understood. We tested whether a measure of bone quality, trabecular bone score (TBS), is associated with HK in 1997 older men, and determined that men with degraded TBS were more likely to have HK. INTRODUCTION: While vertebral fractures and low bone mineral density (BMD) contribute to kyphosis progression, it is unknown whether the trabecular bone score (TBS) may provide additional information on bone quality that could influence the degree of kyphosis. We hypothesized that degraded TBS would be associated with hyperkyphosis (HK) defined as a Cobb angle > 50°. METHODS: Using data from 1997 participants of the Osteoporotic Fractures in Men (MrOS) Study who had baseline TBS and Cobb angle kyphosis measured, we investigated whether men with degraded TBS were more likely to be hyperkyphotic, even after adjustment for BMD and prevalent vertebral fractures. RESULTS: Men were an average age of 74 ± 6 (mean ± SD) years with a mean kyphosis angle of 38.6 ± 11.5°, 295 (15%) were classified as hyperkyphotic, and 416 (21%) had degraded TBS. Compared with men with TBS > 1.2, men with degraded TBS were more likely to have HK (OR: 1.47, 95% CI: 1.06-2.06, p = 0.02) after adjusting for age, clinic, race, BMI, hip BMD, and prevalent vertebral fracture. If spine instead of hip BMD was included in the model, the odds ratio decreased to 1.35 (95% CI: 0.97-1.89, p = 0.08). CONCLUSIONS: Older men with degraded TBS are more likely to have HK not explained by underlying vertebral fractures.

Medical complications in children with achondroplasia.

AIM: To determine the rates of medical investigations, complications, interventions, and outcomes in children with achondroplasia. METHOD: Children and adolescents with achondroplasia born between 2000 and 2019, aged between 0 and 18 years of age, and seen at The Children's Hospital at Westmead skeletal dysplasia clinic were included. Data were collected retrospectively from clinical records. Standard descriptive statistics were used for analysis. RESULTS: The study included 108 participants, 58 males and 50 females. Ninety-nine participants (91.7%) entered the study at birth. The other nine (8.3%) participants entered the study after birth (mean age = 2 years 4 months, SD = 1 year 8 months). The median age of exit from the study was 8 years 8 months (IQR = 8 years 9 months) with a median follow-up of 8 years 8 months (IQR = 8 years 9 months). Fifty-two (48%) participants presented with craniocervical stenosis, 15 (13.9%) with hydrocephalus, 66 (61.1%) with hearing impairment, 44 (40.7%) with sleep-disordered breathing, 46 (42.6%) with lower-limb malalignment, 24 (22.2%) with thoracolumbar kyphosis, 10 (9.3%) with symptomatic spinal stenosis, 12 (11.1%) with obesity, and 16 (14.8%) who had at least one admission for respiratory illness. Two children died during the study period. INTERPRETATION: We report contemporary rates of medical complications in an Australian population of children with achondroplasia. Recommendations for surveillance in clinical practice are discussed. This information will help guide clinicians with their expectant management of achondroplasia and provide prognostic information to the families of children with achondroplasia.

Spinal Curvatures, Deformities, and the Level of Disability in People with Bilateral Spastic Cerebral Palsy Living in South Africa; A 6-Year Follow-Up Study During Adulthood.

OBJECTIVE: Determine if spinal curvatures, deformities, as well as level of disability (due to back pain) changes with aging in adults with bilateral spastic cerebral palsy after receiving orthopedic interval surgery approach treatment in childhood. DESIGN: Consecutive case-series SETTING: Urban South Africa PARTICIPANTS: Twenty-seven ambulatory adults with cerebral palsy MAIN OUTCOME MEASURES: Spinal curvatures (scoliosis, thoracic kyphosis and lumbar lordosis) and deformities (spondylolysis and spondylolisthesis) were determined with X-rays, while the level of disability was assessed with the Oswestry Disability Index. RESULTS: The prevalence of spinal abnormalities were: 30% scoliosis (mild: <30°), 0% thoracic hyperkyphosis, 15% lumbar hyperlordosis, 0%; spondylolysis, and 0% spondylolisthesis. No changes in scoliosis and lumbar lordosis angles were observed, while the change in thoracic kyphosis angle was smaller than the minimal clinically important difference and moved closer toward the norm-values for typically developing adults. Level of disability remained similar with 63% reporting minimal disability, 26% moderate disability and 11% severe disability. No associations with spinal curvatures were found. CONCLUSIONS: No clinically meaningful changes in spinal curvatures, deformities and level of disability due to pain were seen during the 6 years follow-up period in adults with cerebral palsy who have been treated with interval surgery approach in childhood.

The Reliability of Computer-Assisted Three-Dimensional Surgical Simulation of Posterior Osteotomies in Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis Patients.

Objectives: The study was aimed at investigating the reliability of computer-assisted three-dimensional surgical simulation (CA3DSS) of posterior osteotomies in thoracolumbar kyphosis secondary to ankylosing spondylitis (TLKAS) patients. Methods: Eligible TLKAS patients who underwent posterior correction surgery with posterior osteotomies were consecutively included. Simulated posterior osteotomies were performed in Mimics and 3-Matic Medical software. Coronal and sagittal angle and alignment parameters were measured in preoperative full-length X-ray, preoperative original 3D spine (Pre-OS), simulated 3D spine (SS), and postoperative original 3D spine (Post-OS). Reliability was tested by both intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Results: A total of 30 TLKAS patients were included. Excellent consistency of radiological parameters was shown between preoperative X-ray and Pre-OS model. In SS and Post-OS models, excellent reliabilities were shown in global kyphosis (ICC 0.832, 95% CI 0.677-0.916), thoracic kyphosis (ICC 0.773, 95% CI 0.577-0.885), and lumbar lordosis (ICC 0.896, 95% CI 0.794-0.949) and good reliabilities were exhibited in the main curve (ICC 0.680, 95% CI 0.428-0.834) and sagittal vertical axis (ICC 0.619, 95% CI 0.338-0.798). ICCs of correction angle achieved by pedicle subtraction osteotomy (PSO) was 0.754 (95% CI 0.487-0.892), and that of posterior column osteotomies (PCO) was 0.703 (95% CI 0.511-0.829). Bland-Altman analysis also showed good agreement for both Cobb angle and distance measurements in Pre-OS and SS models, and good reliabilities were shown in PCO and PSO in real spine and SS models. Conclusions: CA3DSS can provide an accurate measurement, and it is a reliable and effective method to conduct proper simulation for correction surgery with posterior osteotomies in TLKAS patients. This trial is registered with Chinese Clinical Trial Registry ChiCTR2100053808.

C2 translaminar screw fixation in pediatric occipitocervical fusion.

PURPOSE: Rigid occipitocervical (O-C) instrumentation can reduce the anterior pathology and has a high fusion rate in children with craniovertebral instability. Typically, axis (C2) screw fixation utilizes C1-C2 transarticular screws or C2 pars screws. However, anatomic variation may preclude these screw types due to the size of fixation elements or by placing the vertebral artery at risk for injury. Pediatric C2 translaminar screw fixation has low risk of vertebral artery injury and may be used when the anatomy is otherwise unsuitable for C1-C2 transarticular screws or C2 pars screws. METHODS: We retrospectively reviewed a neurosurgical database at UCSF Benioff Children's Hospital Oakland for patients who had undergone a cervical spinal fusion that utilized translaminar screws for occipitocervical instrumentation between 2002 and 2020. We then reviewed the operative records to determine the parameters of C2 screw fixations performed. Demographic and all other relevant clinical data were then recorded. RESULTS: Twenty-five patients ranging from 2 to 18 years of age underwent O-C fusion, with a total of 43 translaminar screws at C2 placed. Twenty-three patients were fused (92%) after initial surgery with a mean follow-up of 43 months. Two patients, both with Down syndrome, had a nonunion. Another 2 patients had a superficial wound dehiscence that required wound revision. One patient died of unknown cause 7 months after surgery. One patient developed an adjacent-level kyphosis. CONCLUSION: When performing occipitocervical instrumentation in the pediatric population, C2 translaminar screw fixation is an effective option to other methods of C2 screw fixation dependent on anatomic feasibility.

Treatment of spinal deformity with diastematomyelia type I: one-stage, two-stage surgery and new technique (vertebral column resection through wide bony septum).

STUDY DESIGN: Case series, literature review, and technical note. OBJECTIVES: To compare two different approaches to treat the spinal deformity with split cord malformation type I (SCM I). To present a new method of one-stage surgical treatment of congenital spinal deformity with wide bony septum (SCM I). METHODS: Analysis of the literature on the different types of combined surgical treatment of spinal deformities with SCM I was performed. We have provided our own data on 27 patients treated for congenital spinal deformity and SCM I, one of which underwent Schwab IV type osteotomy at the apex of the deformity through the bony septum and pedicles. Inclusion criteria were presence of spinal deformity in combination with SCM 1, performed surgery to correct spinal deformity, and follow-up period of at least 2 years. RESULTS: The result of the literature review was controversial and requires additional research. The average age of patients was 8.8 ± 6.6 years old. One-stage treatment of SCM I and spinal deformity was performed in 10 patients (group I) and two-stage in 14 patients (group II). Three patients with severe myelodysplasia, SCM I, and congenital kyphoscoliosis underwent correction of spinal deformity without SCM I removing (group III). The group I had the longest surgery duration (mean 289 ± 75 min) and largest blood loss (mean 560 ± 386 ml), a high percentage of deformity correction (mean 69.6%), and the highest rate of complications (60%). The most optimal was the two-stage treatment with the mean surgery duration 191 ± 137 min, mean blood loss 339 ± 436 ml, mean correction rate 63%, and frequency of complications 21%. The average follow-up time was 6.0 ± 2.6 years. CONCLUSIONS: One stage surgery associated with a large surgical invasion and a large number of complications. It can be used in some cases, for example when the wide bony septum (SCM I) is localized at the apex of the congenital scoliosis or kyphosis. In all other cases, it is worth adhering to a two-stage treatment. Many new works demonstrate the relative safety and effectiveness of deformity correction without removing the SCM. In our opinion, indications for treatment of spinal deformity without SCM I removing can be the need to perform a shortening ostetomy outside the SCM zone. The remaining cases require a thorough assessment and a balanced decision.

Delayed aortic injury after thoracic corrective osteotomy: a case report.

PURPOSE: To present a case of delayed aortic perforation due to a nondisplaced fracture of the 9th rib after vertebral osteotomy for degenerative kyphoscoliosis in patients with osteoporosis. METHODS: A 78-year-old female patient with osteoporosis had undergone T9-iliac correction surgery for degenerative kyphoscoliosis. After 2 years, the patient underwent T10 pedicle subtraction osteotomy for a T10 vertebral fracture and progression of kyphosis. Postoperatively, the patient had been doing well for 3 weeks; however, just before the day of discharge, she died following a cardiopulmonary arrest. An autopsy was performed with the consent of her family. RESULTS: Autopsy revealed a large amount of blood and a clot in the left thoracic cavity. Aortic perforation was found just in front of a nondisplaced fracture of the left 9th rib. CONCLUSION: This report describes a new critical complication after spinal correction surgery. Even without pedicle screw malposition, aortic injuries can happen to patients with osteoporosis after corrective osteotomy for degenerative kyphoscoliosis due to positional change of aorta and fragility of the ribs. The spine surgeon should be aware of this type of complication, and rib fractures around the aorta after vertebral osteotomy should not be neglected even when there is no displacement.

Radiographic outcomes and complications after L4 or L5 pedicle subtraction osteotomy for fixed sagittal malalignment in 102 adult spinal deformity patients with a minimum 2-year follow-up.

PURPOSE: The objective of this retrospective study was to provide the radiographic outcomes and complications for pedicle subtraction osteotomy (PSO) performed at the low lumbar spine, i.e., L4 or L5 for ASD patients with fixed sagittal malalignment. METHODS: ASD patients who underwent L4 or L5 PSO with a minimum 2-year follow-up were included. Preoperative and postoperative radiographs, and complications were collected. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), thoracic kyphosis (TK), sagittal vertical axis (SVA), spinal lordosis (SL) ratio and global tilt (GT) on standing long-cassette radiographs. RESULTS: A total of 102 patients from 2 spinal centers were analyzed. 66 patients underwent PSO at L4 and 36 patients at L5. From preoperatively to the final follow-up, significant improvements occurred in LL (from - 31° to - 52°), SVA (from 13 to 5 cm), and GT (from 44° to 27°) (all, p < 0.05). 12 patients had transient neurological deficits, and 8 patients had persistent neurological deficit. 23 patients underwent revision for PJK (2), pseudarthrosis (10), neurological deficit (2), epidural hematoma (1), or deep surgical site infection (8). No PJK was observed in any of the patients with L5 PSO. CONCLUSIONS: PSO at the level of L4 or L5 remains a challenging technique but with an acceptable rate of complications and revisions. It enables correction of fixed sagittal malalignment in ASD patients with a globally satisfactory outcome. In comparison with L4 PSO, L5 PSO patients did not show PJK as a mechanical complication. Distal lumbar PSO at the level of L5 may represent one of the factors that may help preventing the proximal junctional kyphosis complication.

Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery?

PURPOSE: Surgical site infection (SSI) is a major complication after adolescent idiopathic scoliosis (AIS) surgery, with an incidence ranging from 0.5 to 7%. Intraoperative wound decontamination with povidone-iodine (PVP-I) irrigation and/or vancomycin powder in adult spinal surgery has gained attention in the literature with controversial results. The aim of this study was to investigate the impact of using intrawound PVP-I irrigation and local vancomycin powder (LVP) on the incidence of early SSI in AIS surgery. METHODS: All AIS patients who underwent posterior spinal fusion between October 2016 and December 2019 were retrospectively reviewed. The incidence of early SSI was reported and compared between 2 groups defined by the treating spinal surgeons' preferences: group 1-intrawound irrigation with 2L of PVP-I and application of 3 g LVP before closure and control group 2-patients that did not receive either of these measures. RESULTS: Nine early cases of SSI (2.9%) were reported among the 307 AIS posterior spinal fusion patients. Incidence of SSI in group 1 (2/178 = 1.1%) was significantly lower than in group 2 (7/129 = 5.4%; p = 0.04). There were no adverse reactions to the use of PVP-I and LVP in our study. At latest follow-up, rate of surgical revision for mechanical failure with pseudarthrosis was significantly lower in group 1 (2/178 = 1.1%) than in group 2 (9/129 = 7.0%; p = 0.01). CONCLUSION: Intraoperative use of intrawound PVP-I irrigation and vancomycin powder is associated with a significant reduction of early SSI after AIS spine surgery. LEVEL OF EVIDENCE IV: Retrospective study.