Complicated Spinal Stenosis and Spinal Deformity in Patients with Achondroplasia: Case Series and Review of the Literature.

OBJECTIVE: Due to the low incidence of achondroplasia (Ach), there is a relative lack of research on the treatment and management of spinal complications of Ach. Characteristics and interventions for spinal complications in patients with Ach are in urgent need of investigation. This study aimed to summarize the common spinal complications in patients with Ach and the corresponding treatment strategies. METHODS: This study is a retrospective case series. We retrospectively collected and analyzed Ach cases who presented to our hospital with neurological symptoms due to skeletal anomalies between February 2003 and October 2023. A total of seven patients were included, four males (57.1%) and three females (42.9%) with a mean age of 38.57 years. Patient pain/numbness visual analog scale (VAS), preoperative Oswestry disability index (ODI), development of neurological complaints, and presentation of skeletal abnormalities were collected and followed up routinely at 3, 6, 12 and 24 months postoperatively. The relevant literature was reviewed. RESULTS: Seven patients were included in this series. The mean preoperative VAS was 4, and the mean preoperative ODI was 50.98%. All patients had concomitant spinal stenosis, four with thoracolumbar kyphosis (TLK), and one with scoliosis. Six of the seven patients underwent surgery, and one patient received conservative treatment. In the routine follow-ups, all patients experienced satisfactory relief of symptoms. Only one of the seven patients developed a new rare lesion adjacent to the primary segments. Six months after the first surgery, a follow-up visit revealed thoracic spinal stenosis caused by ossification of the ligamentum flavum, and his symptoms were relieved after thoracic decompression surgery. CONCLUSIONS: Ach seriously affects the skeletal development of patients and can lead to the development of spinal stenosis, spinal deformities, and other complications of the locomotor system. Surgery remains the primary treatment for complications of the musculoskeletal system. Specific surgical approaches and comprehensive, long-term management are critical to the treatment of patients with spinal complications.

Spinal presentations in children with spinal muscular atrophy type 1 following gene therapy treatment with onasemnogene abeparvovec - The SMA REACH UK network experience.

Spinal muscular atrophy (SMA) is a neuromuscular disorder of mainly early onset and variable severity. Prior to the introduction of disease modifying therapies (DMTs), children with SMA type 1 typically died before 2 years of age and management was primarily palliative. Onasemnogene abeparvovec (OA), nusinersen, and risdiplam are novel DMTs which ameliorate the effects of the underlying genetic defect at least partially making SMA a treatable condition. Survival and achievement of previously unmet developmental milestones result in treated SMA type 1 children spending more time upright than expected based on the natural history of the treatment-naïve condition. Consequently, spinal asymmetry and kyphosis, features not typically seen in untreated SMA type 1 children due to early mortality, are increasingly common complications. Precise data regarding their prevalence, severity, and management are currently limited. This study describes the spinal features and management in 75 children with SMA type 1 who received OA between March 2021 and December 2022. Retrospective analysis from SMA REACH UK data showed that 44/75 (59 %) clinically had spinal asymmetry and 37 (49 %) had kyphosis. This study aims to raise awareness of this important feature as part of the changed natural history of SMA type 1 post OA treatment.

Clinical Outcome of Posterior Instrumented Stabilization and Transpedicular Decompression in Patients Presenting with Thoracic or Lumbar Spinal Tuberculosis in a Tertiary Care Center: A Descriptive Cross-sectional Study.

INTRODUCTION: Posterior instrumented stabilization is a commonly done surgery in spinal tuberculosis. This study aims to evaluate the clinical, radiological, and neurological outcomes of posterior instrumented stabilization and transpedicular decompression in thoracic and lumbar spinal tuberculosis. METHODS: A descriptive cross-sectional study was conducted for one and a half years with at least six months of follow-up in a tertiary care center. The study was approved by the Institutional Review Committee (Reference number: 119 (6-11-5) 2/075-076). Total sampling was done and the study included patients over 18 years of age with spinal tuberculosis of the thoracic or lumbar regions. These patients underwent posterior instrumented stabilization and transpedicular decompression at the tertiary care center. The age, site of involvement, Visual Analog Scale score for back pain, neurological status as per Frankel Neurology grading, and local kyphotic angle in X-ray were recorded. The median, interquartile range and percentage were calculated. The data was entered in Microsoft Excel 2016 and analysis was done using Epi Info software version 7.2. RESULTS: Thoracic level was most commonly involved in 14 (46.68%) cases. The median back pain as assessed by the Visual Analogue Scale score improved from 8 to 2 at the 6-month follow-up. There was improvement in the neurological grading of all cases and there was no loss of correction in the local kyphotic angle till the final follow-up. The median age of cases was 48 years (interquartile range: 28-62.50). CONCLUSIONS: Posterior instrumented stabilization and transpedicular decompression in adult patients with thoracic or lumbar spinal tuberculosis achieves improvements in clinical, radiological, and neurological outcomes.

Distal Junctional Failure After Fusion Stopping at L5 in Patients With Adult Spinal Deformity: Incidence, Risk Factors, and Radiographic Criteria.

OBJECTIVE: To identify risk factors and establish radiographic criteria for distal junctional failure (DJF) in patients with adult spinal deformity (ASD), who underwent fusion surgery stopping at L5. METHODS: This retrospective study was undertaken from January 2016 to December 2020. Patients with ASD who underwent fusion surgery (≥5 levels) stopping at L5 were analyzed. DJF was defined as symptomatic adjacent segment pathology at the lumbosacral junction necessitating consideration for revision surgery. Demographic data and radiographic measurements were compared between the DJF and non-DJF groups. Receiver operating characteristic curve analysis was performed to identify the radiographic cutoff value for DJF. RESULTS: Among 76 patients, 16 (21.1%) experienced DJF. DJF was associated with older age, antidepressant/anxiolytic medication, longer level of fusions, and worse preoperative sagittal alignment. Antidepressant/anxiolytic medication (odds ratio, 5.60) and preoperative pelvic incidence (PI)-lumbar lordosis (LL) mismatch>40° (odds ratio, 5.87) were independent risk factors for DJF. Without both factors, the incidence of DJF has been greatly reduced (9.1%). Two radiographic criteria were determined for DJF: last distal junctional angle (DJA)>-5° and Δ last DJA-post DJA>5°. When both criteria were met, the sensitivity and specificity of the DJF were 93.3% and 91.7%, respectively. CONCLUSION: Use of antidepressant/anxiolytic medication and preoperative PI-LL mismatch >40° were independent risk factors for DJF. DJF could be diagnosed using postoperative changes in the DJA. If both criteria were met, DJF could be strongly suggested.

Spinal deformity surgery in Scheuermann's kyphosis versus adolescent idiopathic scoliosis: meta-analysis of complications and clinical outcomes.

BACKGROUND: Surgical management of adolescent idiopathic scoliosis (AIS) and Scheuermann's kyphosis (SK) may be associated with several complications including extended length of stay and unplanned reoperations. Several studies have previously compared postoperative complications and functional outcomes for AIS and SK patients with mixed results. However, a meta-analysis compiling the literature on this topic is lacking. METHODS: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored until April 2024. The extracted data consisted of complications (overall and surgical-site infections [SSI]), readmissions, reoperations, and Scoliosis Research Society-22 (SRS-22) score. Mean differences (MD) with 95% CI were used for continuous data and odds ratio (OR) was utilized for dichotomous data were calculated across studies. RESULTS: Seven retrospective articles were included in the meta-analysis, including 4866 patients, with 399 in the SK group and 4467 in the AIS group. SK patients were found to have statistically significantly higher rates of overall complications (OR = 5.41; 95% CI 3.69-7.93, p < .001), SSI (OR = 11.30; 95% CI 6.14-20.82, p < .001), readmissions (OR = 2.81; 95% CI 1.21-6.53, p = 0.02), and reoperations (OR = 7.40; 95% CI 4.76-11.51, p < .001) than AIS patients. However, they had similar SRS-22 scores postoperatively (MD = -0.06; 95% CI -0.16 to 0.04, p = 0.26) despite the SK group having lower SRS-22 scores preoperatively (MD = -0.30; 95% CI -0.42 to -0.18, p < .001). CONCLUSION: In this meta-analysis of studies comparing spinal deformity surgery outcomes in AIS and SK patients, SK was associated with more complications, readmissions, and reoperations. SK did have equivalent SRS-22 scores postoperatively to AIS patients, highlighting the benefit of surgical treatment despite higher complication rates. This data may help inform healthcare institutions, payors, and quality monitoring organizations who examine outcomes of pediatric and adult spinal deformity surgery.

An effective strategy for treatment of severe kyphosis secondary to ankylosing spondylitis: one-level modified osteotomy combined with shoulders lifting correction method.

BACKGROUND: Severe kyphosis is a common condition in patients with advanced ankylosing spondylitis (AS). Although two-level osteotomy may serve as a potential alternative, it is often associated with increased blood loss and elevated surgical risks. To date, the optimal treatment for the challenging condition remains unclear. This study aims to introduce an effective strategy for the treatment of severe kyphosis secondary to AS, using one-level modified osteotomy combined with shoulders lifting correction method. METHODS: Seventy AS kyphosis who were treated with the strategy from 2012 to 2022, were reviewed retrospectively. All patients were followed up for a minimum duration of 2 years. Spinal and pelvic parameters were measured, including pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumber lordosis (LL), PI and LL mismatch (PI-LL), thoracic kyphosis, global kyphosis (GK), T1 pelvic angle (TPA), sagittal vertical axis (SVA), osteotomized vertebral angle (OVA), and chin-brow vertical angle (CBVA). Parameters of local osteotomized complex were measured and calculated, including the height of osteotomized complex and the length of spinal cord shortening. Clinical outcome was evaluated using Scoliosis Research Society-22 and Oswestry Disability Index scores. RESULTS: Seventy patients with average age of 39.8 years were followed-up for 29.3 months. Average operation time was 373.5 min, and average blood loss was 751.0 ml. Postoperatively, sagittal balance was successfully restored. GK decreased from 90.6° to 35.6°, LL decreased from 8.0° to -35.1°, TPA decreased from 56.8° to 27.8°, and SVA decreased from 24.4 cm to 8.7 cm (P < 0.05). A harmonious and matched spinopelvic alignment was achieved. PT decreased from 37.2° to 26.3°, PI-LL decreased from 54.1° to 10.2°, and SS increased from 9.2° to 19.7°(P < 0.05). Horizontal vision was obtained with postoperative CBVA of 8.8°. Average OVA correction was up to 47.3°, and the spinal cord was shortened by 24.3 mm, with a shortening rate of 36.0%. All patients demonstrated a favorable clinical outcome. No permanent nerve damage, screw loosening, rod breakage and main vascular injury were observed. One case required revision surgery due to screw cap loosening and delayed union. Solid bone fusion was achieved in all other patients. CONCLUSIONS: One-level modified osteotomy combined with shoulders lifting correction method is a safe and effective strategy for the treatment of severe AS kyphosis. This strategy offers a promising alternative for managing severe AS kyphosis, and may be particularly well-suited for individuals with concurrent osteoporosis. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Severe Cervical Myelopathy in a Patient With Intellectual Disability Successfully Managed With Combined Anterior and Posterior Fixation Surgery.

Intellectual disability is a disorder characterized by lower developmental abilities in mental and physical performances. Due to advancements in healthcare management for patients with intellectual disabilities, the survival rate of these individuals has increased. Consequently, middle-aged patients with intellectual disabilities may present symptoms related to degenerative cervical spondylosis. However, there appear to be few reports focusing on this topic. A 52-year-old patient with intellectual disability was accompanied by his elderly parents to our hospital. The patient could not stand independently after experiencing motor weakness in the bilateral upper and lower extremities. Radiologically, cervical kyphosis and severe cervical cord compression were identified. After obtaining informed consent from the patient's parents, cervical anterior and posterior fixation surgery was performed in two sessions to resolve cervical myelopathy. The patient was discharged from the hospital 45 days after the second operation. A year post-surgery, the patient could walk independently. With the long life expectancy of patients with intellectual disability, spinal degenerative diseases resulting in cervical myelopathy can significantly impact patients' quality of life. Adequately examining, diagnosing, and surgically managing the patient can lead to improved status for patients with intellectual disability.

Pediatric spinal arachnoid cysts with compressive myelopathy: single-center experience and update on surgical management.

PURPOSE: This study describes the surgical outcome of pediatric primary spinal arachnoid cysts (SACs) presenting with compressive myelopathy and gives an update on the classification and management of these rare lesions. METHODS: We performed a single-center retrospective analysis of pediatric patients operated for primary spinal arachnoid cysts. The clinical and radiologic profiles and surgical outcomes of these children were analyzed. Subgroup analysis was done in the laminoplasty vs laminectomy groups to see for the development of spinal deformity. RESULTS: There were 10 males and seven females with a mean age of 10.4 years (range:6-14 years). The cysts extended to an average of 5.2 levels (range:2-8). They were extradural in seven (41%) and intradural in 10 (59%). Six intradural and four extradural cysts underwent laminectomy (n = 10) while four intradural and three extradural cysts underwent laminoplasty (n = 7). Although three out of 10 cases in the laminectomy group and none in the laminoplasty group had post-operative spinal deformity, this result was not statistically significant (p = 0.110). There was a moderate negative correlation between post-operative cord occupancy ratio (COR) and post-operative McCormick grade (Pearson correlation coefficient = -0.453, p = 0.068), suggesting that higher CORs are associated with lower McCormick grades. CONCLUSION: Symptomatic pediatric primary spinal arachnoid cysts are safely and effectively managed by marsupialization or microsurgical excision. Considering the growing age group, laminoplasty rather than laminectomy should be the standard surgical procedure to prevent late postoperative spinal deformity. Clinically significant recurrences are rare in the setting of adequate cord expansion and restored subarachnoid CSF flow following surgery.

A New Minimally Invasive Technique for Thoracolumbar/Lumbar Focal Kyphosis Due to Osteoporotic Vertebral Fracture: A Case Report.

Osteoporotic vertebral fractures are common fractures in the elderly population and are often associated with low back pain and disruption in daily living activities. Reconstruction surgeries, such as corpectomy, are among the treatment options for these conditions. However, a corpectomy requires a longer surgical procedure and involves a significant amount of blood loss. We present the case of an 80-year-old woman with severe low back pain due to an L2 fracture and focal kyphosis treated with a novel minimally invasive technique. The patient underwent anterior and posterior surgery in the right decubitus position using a C-arm-free technique. Hyperlordotic cages were inserted in the upper and lower disc space via a lateral approach, while percutaneous pedicle screws were inserted from a posterior approach. These procedures were performed simultaneously under navigation guidance only.

Necessity of posterior osteotomies for mild flexible cervical deformity correction.

OBJECTIVE: Correction of mild flexible cervical deformity (CD) via the posterior approach has been described with and without the use of posterior osteotomies (POs), despite a lack of clarity regarding their necessity or risks. The purpose of this study was to determine whether the use of POs when correcting mild flexible CD leads to improved clinical or radiographic outcomes, as well as defining the relative risks in utilizing them. METHODS: A prospective multicenter registry of operative CD patients was analyzed. Inclusion criteria were cervical kyphosis > 10°, cervical scoliosis > 10°, cervical sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle > 25°. Mild deformity was defined by a cSVA of 3-5 cm and/or kyphosis < 15°. Flexibility was defined by a C2-7 angular change > 5° on preoperative flexion/extension radiographs. Patients who received a posterior column osteotomy (PCO) (Ames grades 1 and 2) were compared with patients who did not undergo a PCO (noPCO) as well as those who underwent a three-column osteotomy (3CO) (Ames grades 3-6). RESULTS: Ninety-five patients (33 PCO, 49 noPCO, 13 3CO) met the inclusion criteria. Both the number of levels fused (9.2 vs 7.7, p = 0.001) and the estimated blood loss (EBL) (1027 vs 486 mL, p = 0.012) were higher in the PCO cohort. Patients in the noPCO group were more likely to have a cervical apex of kyphosis (71.1%, p = 0.046), while those undergoing 3COs were more likely to have a thoracic apex (58.3%, p = 0.005). Preoperative cSVA (PCO vs noPCO: 45.4 vs 37.9 cm, p = 0.084), T1 slope (32.5° vs 29.6°, p = 0.376), C2-7 lordosis (-8.9° vs -9.2°, p = 0.942), and modified Japanese Orthopaedic Association (mJOA) score (13.4 vs 13.5, p = 0.854) were similar; however, both Neck Disability Index (NDI) (55.6 vs 42, p = 0.002) and numeric rating scale (NRS) neck (7.2 vs 5.8, p = 0.028) scores were higher in the PCO group before surgery. When adjusting for the use of an anterior approach, there was no significant difference in 1-year postoperative cSVA (35.7 and 35.6 cm, respectively; p = 0.969), C2-7 lordosis (13.7° and 10.1°, respectively; p = 0.393), and patient-reported outcome measures (NRS, NDI, and mJOA) between the PCO and noPCO groups. Two-year radiographic outcomes were largely similar, except for C2 slope, which was higher in the PCO group (29.1° vs 18°, p = 0.026). The overall complication rates progressively increased with more complex osteotomy use (noPCO 68.8% vs PCO 71.9% vs 3CO 75%) but did not reach significance (p = 0.063). CONCLUSIONS: The use of POs for mild flexible adult CD may not be necessary to achieve desirable radiographic correction. They are associated with greater EBL and fusion burden. Further studies are needed to fully delineate the risks of adverse events for various types of osteotomies.

Lateral lumbar and thoracic interbody fusion (LLIF) for thoracolumbar spine trauma (Trauma LLIF): A single-center, retrospective observational cohort study.

Background: Pain, disability and progressive kyphosis is a common problem after traumatic injury of the thoracolumbar (TL-) junction. Surgical treatment may include long-segment posterior or short-segment anterior-posterior fusion. We aim to report our experience with the application of short-segment posterior instrumented fusion with anterior column support using lateral lumbar or thoracic interbody (LLIF) cages. Methods: In this retrospective, single-center observational cohort study we included consecutive patients treated surgically for traumatic injury of the TL-junction (Th10/11-L2/3) by posterior instrumentation/fusion and LLIF. We measured segmental kyphosis, complications, and outcomes until last follow-up (about 3 years postoperative). Results: We identified 61 patients (mean age 39.0 years [SD 13.3]; 23 females [37.7%]) with A3 fractures without (n=48; 78.7%) or with additional sagittal split component n=11; 18.0%. Additional posterior tension band injury was present in n=26 (42.6%). The affected levels of injury were Th12/L1 in n=25 (41.0%) and Th11/12 in n=22 (36.1%). The segmental kyphotic angle was 14.6° (6.7°) preoperative and remained significantly reduced at all times of follow-up at discharge (5.4°±5.5°; p<.001), at 90 days (7.2°±5.5°; p<.001), after partial hardware removal (7.2°±6.0°; p<.001) and at last follow-up (8.1°±6.3°; p<.001). We noticed a tendency for less progression of kyphosis in the group with 2-staged, compared to single-staged bisegmental surgery (mean difference (MD) 3.1° after partial hardware removal, p=.064). During follow-up, n=11 experienced complications (18%), n=58 (95.1%) had an excellent or good outcome and solid fusion was noticed in n=60 (98.4%). Conclusions: "Trauma LLIF" should be considered as possibility for short-segment anterior-posterior fusion for injuries of the TL- junction. We observed most reproducible and long-lasting kyphosis reduction with a temporary bisegmental, 2-staged procedure resulting in monosegmental fusion (posterior instrumentation/fusion with delayed LLIF and partial hardware removal to release the noninjured caudal motion segment).

Analysis of Risk Factors Associated with Proximal Junctional Kyphosis Following Long Instrumented Fusion from L1 to Sacrum: Age Itself Does Not Independently Increase the Risk.

Background and Objectives: This study is a retrospective analysis aimed at understanding the incidence and risk factors of proximal junctional kyphosis (PJK) following long-instrumented spinal fusion from L1 to the sacrum in patients with mild to moderate sagittal imbalance. Materials and Methods: It recruited consecutive patients undergoing instrumented fusion from L1 to the sacrum for degenerative lumbar disease between June 2006 and November 2019 in a single institution. The patients' preoperative clinical data, muscle status at T12-L1 on magnetic resonance images, and sagittal spinopelvic parameters were analyzed. Univariate analysis was used to compare clinical and radiographic data between PJK and non-PJK patients. Logistic regression analysis was used to investigate the independent risk factors for PJK. Results: A total of 56 patients were included in this study. The mean age at surgery was 67.3 years and mean follow-up period was 37.3 months. In total, 10 were male and 46 were female. PJK developed in 23 (41.1%) out of 56; of these patients, 20 (87.0%) developed PJK within 1 year postoperatively. In the univariate analysis between PJK and non-PJK patients, the PJK group showed more frequent osteoporosis, lower body mass index, smaller cross-sectional area (CSA) and more fat infiltration (FI) in erector spinae muscle at T12-L1 and larger preoperative TLK and PT with statistical significance (p < 0.05). In the logistic regression analysis, severe (>50%) FI in erector spinae muscle (OR = 43.60, CI 4.10-463.06, R2N = 0.730, p = 0.002) and osteoporosis (OR = 20.49, CI 1.58-264.99, R2N = 0.730, p = 0.021) were statistically significant. Conclusions: Preexisting severe (>50%) fat infiltration in the erector spinae muscle and osteoporosis were independent risk factors associated with PJK following instrumented fusion from L1 to the sacrum, but age was not a risk factor.

Comparison of two surgical approaches in treating children with thoracolumbar junction tuberculosis: a multicenter study.

OBJECTIVES: We conducted a multicenter retrospective analysis to compare the clinical outcomes and complications associated with the posterior-anterior and posterior-only approaches in treating Thoracolumbar Junction (TLJ) Tuberculosis (TB) in children aged 3-10 years. METHODS: Herein, 52 TLJ TB patients (age range = 3-10 years; mean age = 6.8 ± 2.2 years; females = 22; males = 30) treated with debridement, fusion, and instrumentation were recruited from two hospitals in China between May 2008 and February 2022, and their clinical data were reviewed retrospectively. Among them, 24 group A patients and 28 group B patients underwent the posterior-anterior and posterior-only approaches, respectively. The two groups were assessed for surgical time, blood loss, hospitalization duration, operative complications, inflammatory indicators, Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, kyphosis angles, and neurologic functions. Results or differences with P < 0.05 were considered statistically significant. RESULTS: The average follow-up period was 37.5 ± 23.3 months. Compared to group A patients, group B patients exhibited significantly lower surgical time, blood loss amount, time it took to stand, and hospitalization duration, as well as fewer complications. Notably, the Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) values of patients in both groups returned to normal one year post-surgery. Furthermore, compared to the preoperative values, patients' VAS and ODI scores, as well as neurological functions and kyphosis angles, were significantly improved postoperatively and at the final follow-up, but with no statistically significant differences between the two groups. Moreover, there was no internal fixation failure or TB recurrence, and all patients exhibited solid bone fusion at the last follow-up. CONCLUSION: For pediatric TLJ TB involving no or at most two segments, both posterior-anterior and posterior-only approaches could effectively remove lesions and decompress the spinal cord, restore spinal stability, correct kyphosis, and prevent deformity deterioration. Nonetheless, the posterior-only approach can more effectively shorten the surgical time, reduce related trauma and complications, and promote rapid recovery, making it a safer and highly preferable minimally invasive approach.

Surgical Treatment Strategies for Ankylosing Spondylitis with "Folded Man" Deformity: A Single-Center Retrospective Case Series Study.

OBJECTIVE: Ankylosing spondylitis (AS) combined with severe kyphotic deformity can cause the trunk to collapse, pressing tightly against the front of the thighs and forming a "folded man" deformity. The purpose of this article is to evaluate the effectiveness and safety of a treatment strategy for correcting the "folded man" deformity. METHODS: A retrospective study was conducted to analyze 12 AS patients with "folded man" deformity treated at our hospital with staged kyphosis correction in the lateral position, followed by total hip arthroplasty, from May 2018 to July 2021. Global kyphosis (GK), thoracic kyphosis, lumbar lordosis, sagittal vertical axis, chin-brow vertical angle, and Scoliosis Research Society-22 Patient Questionnaire scores were compared preoperation and postoperation. Surgical duration, positioning time, blood loss, and complications were also recorded and analyzed. RESULTS: All patients demonstrated a correction of the "folded man" deformity, achieving sagittal balance and horizontal gaze with mild complications. Postoperatively, there were significant improvements in spinal sagittal parameters (GK, thoracic kyphosis, lumbar lordosis, and sagittal vertical axis) and chin-brow vertical angle compared to preoperative values (P < 0.05). The preoperative GK of 139.6 ± 9.1° was corrected to 55.3 ± 5.7° postoperatively, with a mean correction of 84.3°. CONCLUSIONS: The standardized treatment strategy involving staged correction of spinal kyphosis in a lateral position, followed by subsequent total hip arthroplasty, offers a safe and effective solution for managing AS with "folded man" deformity.

The Effect of Radiological Assessment of Volunteers for French Paratrooper Training: A Five-Year Retrospective Study.

INTRODUCTION: A systematic radiological examination is needed for military airborne troops in order to detect subclinical medical contraindications for airborne training. Many potential recruits are excluded because of scoliosis, kyphosis, or spondylolisthesis. This study aimed to determine whether complementary radiological assessment excludes too many recruits and whether medical standards might be lowered without increasing medical risk to appointees. METHODS: This retrospective, epidemiological, cross-sectional single-center study spanned 5 years at the French paratroopers' initial training center. We analyzed all medical files and full-spine X-ray results of all enlisted troops during this period. Secondary evaluation by an orthopedic surgeon enabled 23 enlisted personnel, deemed medically unacceptable because of X-ray findings, to be given waivers for airborne training. A follow-up review of their 23 files was conducted to determine whether static-line parachute jumps were hazardous to those who were initially declared medically unacceptable. RESULTS: Of the 3,993 full-spine X-rays, 67.5% (2,695) were described as having normal alignment and structure; 21.8% (871) had lateral spinal deviation; and 10.7% (427) had scoliosis. Sixty-six recruits (1.6%) were deemed unfit because of findings that did not meet the standard on the fullspine X-ray: 53 enlisted personnel had scoliosis greater than 15°, and 13 had spondylolisthesis (grade II or III). Of the 23 patients granted waivers, 82.3% with scoliosis (14) and all patients with kyphosis had not declared any back pain after 5 years. CONCLUSION: The findings, supported by a literature review of foreign military data, suggest that spondylolisthesis above grade I and low back pain are more significant than scoliosis and kyphosis for establishing airborne standards.

The effect of different tensions/directions of I-shaped taping in combination with corrective exercise on postural kyphosis in adolescents.

BACKGROUND: Choosing appropriate complementary methods, such as exercise, along with taping methods may be effective in treating patients with kyphosis. OBJECTIVE: The present study aimed to examine the effect of different tape tensions/directions combined with corrective exercises on the degree of postural kyphosis in adolescents. METHODS: In this randomized controlled trial, 54 adolescents with postural kyphosis were assigned into three groups: No taping (control), I-shaped taping technique with 10% stretching force (Kinesiotape I), and I-shaped taping using facilitation technique with 40% stretching force (Kinesiotape II). Both groups in Kinesiotaping also received a V-shaped tape (10% stretching force). All participants received a similar comprehensive corrective exercise. Patients received the allocated interventions for 6 weeks and visited every two weeks at the clinic. Measurements were done using a flexible ruler, kyphometer, and photogrammetry. RESULTS: Between-group analyses revealed no significant differences between the study groups following the interventions (p> 0.05). However, the within-group analyses according to flexible ruler, Kyphometer, and Photogrammetry measurements indicated that exercise alone (control) [p= 0.011, p= 0.056, and p= 0.005, respectively], Kinesiotape I - exercise [p= 0.001, p= 0.002, p= 0.013, and respectively], as well as Kinesiotape II - exercise [p< 0.001, p< 0.001, and p< 0.001, respectively] significantly decreased the postural kyphosis degree except exercise alone using Kyphometer measurement. No adverse events were observed during the study. CONCLUSION: The findings of photogrammetry, flexible rulers, and photogrammetry similarly indicated that the corrective exercises with or without tape tension/directions significantly decreased the postural kyphosis degree in adolescents.

Differences in cervical sagittal parameters and muscular function among subjects with different cervical spine alignments: a surface electromyography-based cross-sectional study.

Background: We analyzed cervical sagittal parameters and muscular function in different cervical kyphosis types. Methods: This cross-sectional study enrolled subjects with cervical spine lordosis (cervical curvature < -4°) or degenerative cervical kyphosis (cervical curvature > 4°), including C-, S-, and R-type kyphosis. We recorded patients' general information (gender, age, body mass index), visual analog scale (VAS) scores, and the Neck Disability Index (NDI). Cervical sagittal parameters including C2-C7 Cobb angle (Cobb), T1 slope (T1S), C2-C7 sagittal vertical axis (SVA), spino-cranial angle (SCA), range of motion (ROM), and muscular function (flexion-relaxation ratio (FRR) and co-contraction ratio (CCR) of neck/shoulder muscles on surface electromyography). Differences in cervical sagittal parameters and muscular function in subjects with different cervical spine alignments, and correlations between VAS scores, NDI, cervical sagittal parameters, and muscular function indices were statistically analyzed. Results: The FRR of the splenius capitis (SPL), upper trapezius (UTr), and sternocleidomastoid (SCM) were higher in subjects with cervical lordosis than in subjects with cervical kyphosis. FRRSPL was higher in subjects with C-type kyphosis than in subjects with R- and S-type kyphosis (P < 0.05), and was correlated with VAS scores, Cobb angle, T1S, and SVA. FRRUTr was correlated with NDI, SCA, T1S, and SVA. FRRSCM was correlated with VAS scores and Cobb angle. CCR was correlated with SCA and SVA. Conclusion: Cervical sagittal parameters differed among different cervical kyphosis types. FRRs and CCRs were significantly worse in R-type kyphosis than other kyphosis types. Cervical muscular functions were correlated with cervical sagittal parameters and morphological alignment.

Investigation of the Usefulness of Implants With Locking Mechanisms for Diffuse Idiopathic Skeletal Hyperostosis (DISH)-Induced Thoracic and Lumbar Fractures in Patients Operated in the Prone Position.

Background Diffuse idiopathic skeletal hyperostosis (DISH) is a disease that causes bone growth in the spine and musculoskeletal system, and even minor trauma can cause fractures that often require surgery. DISH-induced fractures show a tendency for bone loss when operated in the prone position, which can lead to poor fusion and implant failure; therefore, surgery in the lateral recumbent position is often recommended. However, inserting a pedicle screw (PS) in the lateral recumbent position is technically difficult. This study examined the effectiveness of the repair and fixation of thoracic and lumbar spine fractures using implants with locking mechanisms in the prone position in patients with DISH. Methods We retrospectively analyzed the data from 11 patients (six males and five females; mean age: 87 years) who underwent surgery for thoracic and lumbar fractures caused by DISH between December 2023 and June 2024. Surgery was performed in the prone position using PSs or transdiscal screws (TSDs) for DISH. Ennovate® implants manufactured by B-BRAUN were used. The fixed range was three above-three below for PSs and two above-two below for TSDs. The evaluation parameters were the height/level of injury, operative time, blood loss, local kyphosis angle, anterior wall height ratio, and complications. The local kyphosis angle was measured as the angle between the upper and lower endplates of the fractured vertebrae. The ratio of the anterior wall height was evaluated. Results The average operative time was 87 min (52-172 min), and the average blood loss was 40ml (10-140 ml). The preoperative and postoperative local kyphosis angle was -8.7° and -2.4°, respectively, and the average local kyphosis angle improvement was 6.3° (0.1-14°). The preoperative and postoperative anterior wall height ratio was 132% and 110%, respectively, and the average anterior wall height ratio improvement was 22% (2-82%). No complications, such as screw deviation, implant loosening, loss of correction, or skin problems, were observed. Conclusion This study demonstrated that DISH-induced thoracic and lumbar spine fractures could be repaired and fixed using implants with locking mechanisms in the prone position. The prone position is familiar to spine surgeons and is considered safe. Additionally, screw migration may occur due to decreased bone density in the vertebral bodies with DISH; in such cases, it would be better to fix the screw without forcing it to be repositioned.

Bone Health Optimization in Adult Spinal Deformity Patients: A Narrative Review.

Osteoporosis and low bone mineral density (BMD) pose significant challenges in adult spinal deformity surgery, increasing the risks of complications such as vertebral compression fractures, hardware failure, proximal junctional kyphosis/failure, and pseudoarthrosis. This narrative review examines the current evidence on bone health optimization strategies for spinal deformity patients. Preoperative screening and medical optimization are crucial, with vitamin D supplementation showing particular benefit. Among the pharmacologic agents, bisphosphonates demonstrate efficacy in improving fusion rates and reducing hardware-related complications, though the effects may be delayed. Teriparatide, a parathyroid hormone analog, shows promise in accelerating fusion and enhancing pedicle screw fixation. Newer anabolic agents like abaloparatide and romosozumab require further study but show potential. Romosozumab, in particular, has demonstrated significant improvements in lumbar spine BMD over a shorter duration compared to other treatments. Surgical techniques like cement augmentation and the use of larger interbody cages can mitigate the risks in osteoporotic patients. Overall, a multifaceted approach incorporating medical optimization, appropriate pharmacologic treatment, and tailored surgical techniques is recommended to improve outcomes in adult spinal deformity patients with compromised bone quality. Future research should focus on optimizing the treatment protocols, assessing the long-term outcomes of newer agents in the spine surgery population, and developing cost-effective strategies to improve access to these promising therapies.

Systematic review and meta-analysis for the proximal junctional kyphosis in adolescent idiopathic scoliosis.

Objective: The risk factors of PJK (proximal junctional kyphosis) related to AIS (adolescent idiopathic scoliosis) are inconsistent due to heterogeneity in study design, diagnostic criteria, and population. Therefore, the meta-analysis was conducted to investigate the factors affecting PJK after posterior spinal fusion for AIS patients. Methods: We implemented a systematic search to obtain potential literature relevant to PJK in AIS surgery. Then, a meta-analysis was performed to assess the incidence of PJK and its risk factors. Results: We retrieved 542 articles, and 24 articles were included. The PJK incidence was 17.67%. The use of hooks at UIV (upper instrumented vertebrae) (p = 0.001) could prevent PJK. Before surgery, the larger TK (thoracic kyphosis) (p < 0.001), GTK (global thoracic kyphosis) (p < 0.001), and LL (lumbar lordosis) (p < 0.001) were presented in the PJK group. Immediately post-operatively, in the PJK group, the following parameters were higher: TK (p = 0.001), GTK (p < 0.001), LL (p = 0.04), PJA (proximal junctional angle) (p < 0.001), and PJA-RCA (rod contouring angle) (p = 0.001). At the final follow-up, the following parameters were higher in the PJK group: TK (p < 0.001), GTK (p < 0.001), LL (P < 0.001), and PJA (P < 0.001). Sub-group analysis detected that before surgery, the following parameters were larger in the PJK group: TK (p < 0.001), LL (p = 0.005), and PJA (p = 0.03) in Lenke type 5 AIS patients. Immediately post-operatively, in the PJK group, the following parameters were higher: TK (p < 0.001), LL (p = 0.005), and PJA (p < 0.001). At the final follow-up, the following parameters were higher in the PJK group: TK (p < 0.001), LL (p < 0.001), and PJA (p < 0.001). Conclusion: The individuals with larger preoperative TK were more susceptible to PJK, and PJA was mainly influenced by the adjacent segments rather than the whole sagittal alignment. Using hooks or claws at UIV should prevent PJK.