Anterior spinal fusion (ALIF/OLIF/LLIF) with lumbosacral transitional vertebra: A systematic review and proposed treatment algorithm.

•Key anterior approaches differences in LSTV include vascular (aortic bifurcation/iliocaval confluence), muscular (psoas) and osseus anatomy (inter-crestal tangent/pubic symphysis), when compared to non-LSTV.•There are increased surgical deviations but not significantly greater complications for anterior approaches in LSTV.•Vascular awareness while accessing L45 will be in the presence of a more cephalad ABF and ICC with sacralized L5, and access to the deeper L56 level will be in the presence of a more caudal ABF and ICC in lumbarized S1.

Impact of radiologic variables on item responses of ODI, SRS22 and SF-36. in adult spinal deformity patients: differential item functioning (DIF) analysis results from a multi-center database.

PURPOSE: To determine if responses given to each question of the Scoliosis Research Society-22 (SRS22), Oswestry disability index (ODI) and Short Form-36 (SF-36) questionnaires are influenced by the radiological parameters. METHODS: Patients enrolled in a multi-centre prospectively collected adult spinal deformity database who had complete SRS22, ODI and SF-36 data at baseline and at one-year follow-up were analysed. The presence of a differential item function of each question within each score in relation to radiological parameters was analysed using a mixed Rasch model with the radiological threshold value(s) determined. RESULTS: Of those patients analysed (n = 1745; 1406 female, average age 51.0 ± 19.8 years), 944 were surgically and 801 were non-surgically treated. For the SRS22, questions (Q) 3, 5 and 18 were sensitive to almost all radiological parameters and the overall score was found sensitive to the Cobb angle. For the ODI, Q3, 6, 9 and 10 were not sensitive to any radiologic parameters whereas Q4 and 5 were sensitive to most. In contrast, only 3 of the SF-36 items were sensitive to radiological parameters. CONCLUSIONS: 78% of the SRS-22, 60% of the ODI and 8% of the questions in the SF-36 are sensitive to radiological parameters. Sagittal imbalance is independently associated with a poor overall outcome, but affects mental status and function more than pain and self-image. The assembly of questions responsive to radiological parameters may be useful in establishing a connection between changes in radiologic parameters and HRQL.

The Impact of Corrective Surgery on Health-Related Quality of Life Subclasses in Adult Scoliosis: Will Degree of Correction Prognosticate Degree of Improvement?

PURPOSE: Objectives in scoliosis corrective surgery include restoration of normal sagittal and coronal parameters to achieve patient satisfaction. HRQLs improvements remain limited after corrective surgery. The aim of this study was to evaluate the HRQL subclass variability specific to the sagittal and coronal correction in adult scoliosis surgery. METHODS: This multi-centre prospective analysis of consecutive adult spinal deformity (ASD) patients, from five European centres, only included multilevel instrumentation for scoliosis. d-(delta) values for each parameter represented pre to post-operative changes. Parameters included demographics, baseline, 1- and 2-year. HRQL outcomes (Oswestry disability index (ODI), Scoliosis Research Society (SRS)-22 and Short Form (SF36)), sagittal correction including relative spinopelvic alignment (dRSA) and coronal correction including major Cobb (dCobb) angles. RESULTS: A total of 353 patients reached 1-year and 2-year follow up. All HRQL total scores significantly improved postoperatively, including ODI, SRS-22 and SF36. HRQL subclasses which displayed persistent improvements correlated to dRSA included sex-life, self-image, fatigue, vitality, social functioning. The only HRQL subclass improvement that correlated with dCobb was self-image. CONCLUSION: Adult scoliosis surgery improves overall HRQL, having a minimal effect on each variable. Importantly, greater coronal deformity correction affects only greater self-image scores, whereas with greater sagittal correction there are many greater HRQL sub-class impacts. Correction and restoration of coronal balance is one of the surgical goals in adult scoliosis but the degree to which Cobb angle is corrected, apart from self-image, does not correlate with gains in sub-classes of HRQL. These results need to be taken into account when planning surgery.

Impact of COVID-19 on the pain and disability of patients with adult spinal deformity.

PURPOSE: To evaluate the pain and functional effect of the COVID-19 pandemic on patients with ASD reflected by their response to SRS-22, ODI, and SF-36 questionnaires. METHODS: Patients who had stable pain and functional outcome scores over the preceding 2 years were enrolled in a local prospectively collected adult spinal deformity (ASD) database. A reanalysis of their SRS22, ODI and SF-36 data 14 days into confinement were compared to their last pre-confinement scores. RESULTS: 89 patients were included in this study (average age 60.7 years, 91% female) with an average time from last FU until confinement of 9.6 months. The ODI total score worsened by 5 points post-confinement with no difference seen in personal care, walking and social life. In contrast, the SRS-22 score showed small improvements in function/activity and satisfaction, but no significant differences for the other domains. Similarly, the SF-36 showed small improvements in physical function, physical and emotional role, vitality and PCS. CONCLUSION: The global COVID-19 pandemic and ensuing confinement had variable overall effects on ASD patients, without the expected marked worsening. In addition, this study illustrates that the SRS-22 questionnaire is less influenced by environmental and psychological factors than the ODI supporting its objectivity and accuracy in the evaluation of the QoL of ASD patients.

Validation of a Simplified SRS-Schwab Classification Using a Sagittal Modifier.

STUDY DESIGN: Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE: To Validate Schwab's classification accuracy for surgical indication, and to evaluate a simplified sagittal modifier. SUMMARY OF BACKGROUND DATA: The SRS-Schwab Radiologic Classification based on clinical impact parameters, offers 27 different sagittal classification possibilities regarding sagittal vertical alignment (SVA), pelvic tilt (PT), and pelvic incidence-lumbar lordosis (PI-LL). The high number of classification possibilities makes it complex to use. METHODS: Inclusion criteria were ASD patients, presenting at least 1 criteria: Cobb ≥ 20°, SVA ≥ 5 cm, thoracic kyphosis ≥ 60°, or PT ≥ 25°. A total of 1,004 patients (410 nonoperative and 594 operative) were classified regarding SVA, PT, and PI-LL (0, +, ++), and 27 possibilities were identified. Categories were formed by adding the number of + signs, considering PT, SVA, and PI-LL. Three specific categories were identified: Aligned: 0 +; Moderate deformity: 1 to 3+; and Severe deformity: 4 to 6+. A χ-square test was performed for surgical indication (operated or not) and an analysis of variance was performed to evaluate the relationship between categories and Oswestry Disability Index (ODI). Probability <.05 was considered significant. RESULTS: Significant differences for HRQoL scores and surgical indication were found in the 27 sagittal parameter possibilities. For nonoperative patients, 230 (56.1%) were classified as aligned, 145 (35.4%) as moderate, and 35 (8.5%) as severe. For operative patients, there were 200 (33.7%), 215 (36.2%), and 179 (30.1%) in each respective subgroup. For HRQoL scores and surgical indication, no significant differences were found within each category, but significant differences were found when comparing the subgroups. CONCLUSIONS: Despite the correlation between SRS-Schwab classification and surgical indication, it is complex to use, with a total of 27 possibilities regarding sagittal modifiers. This simplification into three categories offers more readability, without losing any significant information, and could replace Schwab sagittal modifiers. In association with other parameters, they could be used for decision-making. LEVEL OF EVIDENCE: Level II.

Cervical spine fracture through a cervical disc replacement.

INTRODUCTION: We report a rare case of cervical spine trauma through a cervical disc replacement and adjacent multilevel disc fusions. Cervical disc replacement (CDR) is a viable option for the surgical treatment of degenerative disc disease however long term follow up data regarding this operative technique is poor specifically relating to traumatic complications. We know of no previous reports of bilateral cervical pedicle fractures occurring adjacent to CDR and anterior cervical spine instrumentation. PRESENTATION OF CASE: A 46 year-old with a history of C6C7 CDR and C4-6 anterior cervical decompression and fusion was an unrestrained driver involved in a road traffic accident and suffered bilateral C7 pedicle fractures and a right C6C7 facet joint fracture-subluxation without neurological deficit. Reduction and fixation via a posterior approach achieved a satisfactory alignment and the patient made an uneventful recovery. DISCUSSION: A significant force coupled with cervical fixation resulted in a bilateral pedicle fracture of the cervical spine with preserved neurological function. CONCLUSION: The protective role of the CDR has not been previously demonstrated but may have played a role in this case. The authors believe the challenges encountered in the treatment of this patient provide valuable lessons in the management of complex cervical spine trauma in the setting of previous instrumentation.

Delayed post-operative tension pneumocephalus and pneumorrhachis.

INTRODUCTION: The incidence of pneumocephalus and pneumorrhachis after spinal surgery is unknown, with a paucity of literature on this complication. MATERIALS AND METHODS: We present the first published case of delayed onset tension pneumocephalus and pneumorrhachis associated with spinal surgery. RESULTS: This complication occurred from a cerebro-spinal fluid (CSF) leak after posterior instrumentation removal and was successfully treated with emergent wound debridement and the formation of a CSF fistula. CONCLUSIONS: This case illustrates that delayed post-operative tension pneumocephalus and pneumorrhachis can occur after spinal surgery in a patient with a CSF leak. It also illustrates that pneumocephalus and pneumorrhachis can be easily diagnosed with cross-sectional CT imaging. Furthermore, in a patient with rapid deterioration emergent surgical debridement may be necessary. Lastly, if the dural tear cannot be identified intra-operatively, the formalization of a CSF fistula should be considered.

Erratum to: Delayed post-operative tension pneumocephalus and pneumorrhachis.

Unfortunately, two author names were missed out in author group of the original publication.

Trends in fractures and fatalities of farmyard injuries in Ireland: a 10 year analysis.

The farming and agricultural sector remains one of Ireland's primary industries. Fatality rates remain higher than the European average. The aim of this study was to analyze the national trend in hospital in-patient admissions for farmyard related fractures and related fatalities in Ireland from 2005 to 2014. Relevant socioeconomic trends were used for comparison. There were 2,064 farm-related fractures and 187 fatalities recorded over the same period. Despite a decrease in incidence of farmyard fractures over 2005-2014, fatality rates have increased indicating the alarming continued occupational hazards and severity of sustained injuries.

Simultaneous bilateral total hip arthroplasties in nonagenarians.

Total hip arthroplasty (THA) is an effective and durable treatment option for hip osteoarthritis (OA). As life expectancy continues to increase, so too will the demand for joint arthroplasty in the 10th decade of life, frequently in cases involving osteoarthritis of both hips. Simultaneous bilateral total hip arthroplasty (SBTHA) is a valuable therapeutic option in appropriately selected patients with bilateral degenerative hip disease, although its use in the very elderly is poorly reported on in the literature. A case of bilateral hip OA successfully treated with SBTHA in a nonagenarian is presented and the literature is reviewed.

An investigation of the inelastic behaviour of trabecular bone during the press-fit implantation of a tibial component in total knee arthroplasty.

The stress distribution and plastic deformation of peri-prosthetic trabecular bone during press-fit tibial component implantation in total knee arthroplasty is investigated using experimental and finite element techniques. It is revealed that the computed stress distribution, implantation force and plastic deformation in the trabecular bone is highly dependent on the plasticity formulation implemented. By incorporating pressure dependent yielding using a crushable foam plasticity formulation to simulate the trabecular bone during implantation, highly localised stress concentrations and plastic deformation are computed at the bone-implant interface. If the pressure dependent yield is neglected using a traditional von Mises plasticity formulation, a significantly different stress distribution and implantation force is computed in the peri-prosthetic trabecular bone. The results of the study highlight the importance of: (i) simulating the insertion process of press-fit stem implantation; (ii) implementing a pressure dependent plasticity formulation, such as the crushable foam plasticity formulation, for the trabecular bone; (iii) incorporating friction at the implant-bone interface during stem insertion. Simulation of the press-fit implantation process with an appropriate pressure dependent plasticity formulation should be implemented in the design and assessment of arthroplasty prostheses.

Cementing techniques for the tibial component in primary total knee replacement.

The optimum cementing technique for the tibial component in cemented primary total knee replacement (TKR) remains controversial. The technique of cementing, the volume of cement and the penetration are largely dependent on the operator, and hence large variations can occur. Clinical, experimental and computational studies have been performed, with conflicting results. Early implant migration is an indication of loosening. Aseptic loosening is the most common cause of failure in primary TKR and is the product of several factors. Sufficient penetration of cement has been shown to increase implant stability. This review discusses the relevant literature regarding all aspects of the cementing of the tibial component at primary TKR.

Optimal patient positioning for ligamentotaxis during balloon kyphoplasty of the thoracolumbar and lumbar spine.

Percutaneous balloon kyphoplasty aims to restore vertebral height, correct angular deformity and stabilize the spine in the setting of vertebral compression fractures. The patient is positioned prone with supports under the iliac crests and upper thorax to allow gravity to extend the spine. In the treatment of lumbar fractures, we evaluated patient positioning with the contribution of hip extension to increase anterior ligamentotaxis, thus facilitating restoration of vertebral height. Our positioning technique created a mean anterior height increase from 72% to 78% of the average height of the cranial and caudal vertebrae (p=0.037). Balloon inflation did not significantly further increase anterior or posterior vertebral height, or Cobb angle.