Evidence-based Indications for Vertebral Body Tethering in Spine Deformity.

Posterior spinal fusion has long been established as an effective treatment for the surgical management of spine deformity. However, interest in nonfusion options continues to grow. Vertebral body tethering is a nonfusion alternative that allows for the preservation of growth and flexibility of the spine. The purpose of this investigation is to provide a practical and relevant review of the literature on the current evidence-based indications for vertebral body tethering. Early results and short-term outcomes show promise for the first generation of this technology. At this time, patients should expect less predictable deformity correction and higher revision rates. Long-term studies are necessary to establish the durability of early results. In addition, further studies should aim to refine preoperative evaluation and patient selection as well as defining the benefits of motion preservation and its long-term effects on spine health to ensure optimal patient outcomes.

The use of deep learning in medical imaging to improve spine care: A scoping review of current literature and clinical applications.

Background: Artificial intelligence is a revolutionary technology that promises to assist clinicians in improving patient care. In radiology, deep learning (DL) is widely used in clinical decision aids due to its ability to analyze complex patterns and images. It allows for rapid, enhanced data, and imaging analysis, from diagnosis to outcome prediction. The purpose of this study was to evaluate the current literature and clinical utilization of DL in spine imaging. Methods: This study is a scoping review and utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to review the scientific literature from 2012 to 2021. A search in PubMed, Web of Science, Embased, and IEEE Xplore databases with syntax specific for DL and medical imaging in spine care applications was conducted to collect all original publications on the subject. Specific data was extracted from the available literature, including algorithm application, algorithms tested, database type and size, algorithm training method, and outcome of interest. Results: A total of 365 studies (total sample of 232,394 patients) were included and grouped into 4 general applications: diagnostic tools, clinical decision support tools, automated clinical/instrumentation assessment, and clinical outcome prediction. Notable disparities exist in the selected algorithms and the training across multiple disparate databases. The most frequently used algorithms were U-Net and ResNet. A DL model was developed and validated in 92% of included studies, while a pre-existing DL model was investigated in 8%. Of all developed models, only 15% of them have been externally validated. Conclusions: Based on this scoping review, DL in spine imaging is used in a broad range of clinical applications, particularly for diagnosing spinal conditions. There is a wide variety of DL algorithms, database characteristics, and training methods. Future studies should focus on external validation of existing models before bringing them into clinical use.

Teriparatide Treatment Increases Hounsfield Units in the Thoracic Spine, Lumbar Spine, Sacrum, and Ilium Out of Proportion to the Cervical Spine.

STUDY DESIGN: This was a retrospective chart review. OBJECTIVE: The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). SUMMARY OF BACKGROUND DATA: HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA. MATERIALS AND METHODS: A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available. RESULTS: One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA. CONCLUSIONS: Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA.

Back Pain and Outcomes of Pregnancy After Instrumented Spinal Fusion for Adolescent Idiopathic Scoliosis.

OBJECTIVE: We hypothesized that women undergoing scoliosis surgery who became pregnant would go to full term, have uncomplicated pregnancies, and similar patient-reported outcome measures than non-pregnant patients and healthy controls. METHODS: Two hundred five women with adolescent idiopathic scoliosis (AIS) undergoing scoliosis surgery between 1998 and 2015 at several institutions in 1 country and 173 healthy women, without AIS, parous and nulliparous, were selected at random. RESULTS: One hundred eight women with scoliosis surgery and no pregnancy (SNP), 97 women with scoliosis surgery and pregnancy (SP), 91 healthy controls and no pregnancy, and 82 healthy controls and pregnancy (HP) were reviewed. Mean follow-up was 5 years in the SNP, 6 years in the SP, 5 years in the healthy controls and no pregnancy, and 5 years in the HP. The average time from surgery to childbirth was 5 years. Back pain (BP) during pregnancy was observed in 48% of the SP and 34% of the HP. BP after childbirth was present in 43% of the SP and 42% of the HP. Patients fused to L3 or L4 experienced more frequent low BP during pregnancy (40%) than those fused above L3 (P < 0.05). Cesarean section (CS) was performed for 64% and 33% in SP and HP, respectively (P < 0.05). As the lowest instrumented vertebra moved caudal to L4, the frequency of CS increased (P < 0.05; R = 0.8). The majority of CS in SP were performed in patients fused to L4 (55%) versus patients fused above and to L3 (45%) (P < 0.05). The most common analgesia for CS was spinal block (75% in SP and 86% in HP). Patients fused to L4 required general anesthesia significantly more often (7%) versus those fused above L4 (4%, P < 0.05). The health-related quality of life after spinal fusion showed general satisfaction and were similar for SNP and SP (mean 3.84 and 3.91, respectively). No sexual dysfunction was reported. CONCLUSIONS: Women with a history of spinal fusion for AIS fused to L3 or L4 reported a higher incidence of low BP, and CSs are more frequently required. This risk increased to 55% when spinal fusion to L4 was performed. The quality of life and sexual function were at the same level in women after scoliosis surgery than in healthy controls.

When patients are harmed, but are not wronged: ethics, law, and history.

Iatrogenic injury-injury caused unintentionally by medical treatment-breaks the oldest and most famous rule of medical ethics: primum non nocere, or above all, do no harm. Medical malpractice law, however, focuses on whether an injury was caused by negligence, not on whether an injury was iatrogenic. Iatrogenic injury inflicted without negligence is a common pattern in medical malpractice lawsuits; it is likely the pattern of Jacobs v Cross (Minnesota, 1872), in which Dr W. W. Mayo testified as an expert witness. As a matter of law, the doctor defendants should win all those lawsuits, for iatrogenic injury inflicted without negligence is not a legal wrong in the United States and has not been considered a legal wrong for hundreds of years. However, the medical ethics applicable to doctors' duties to report incompetence in colleagues, including those who inflict excessive iatrogenic injury, have developed dramatically over time. In 1872, the ethical codes in the United States exhorted doctors not to criticize another doctor, even if incompetent. Today, doctors in the United States are ethically required to report an incompetent colleague.

Avascular necrosis most common indication for hip arthroplasty in patients with slipped capital femoral epiphysis.

BACKGROUND: Recently, much attention has been focused on the prevention of arthritis after slipped capital femoral epiphysis (SCFE). Little, however, is published on which subset of SCFE patients eventually require hip replacement, how soon arthroplasty is required, and the long-term outcomes after arthroplasty. METHODS: A hip registry database at a tertiary referral center was searched for all primary hip arthroplasties in patients with a confirmed childhood diagnosis of SCFE. RESULTS: From 1954-2007, 38 hips in 33 patients underwent arthroplasty, including total hip arthroplasty (28), hip resurfacing (8), and hemiarthroplasty (2) for the diagnosis of SCFE. During this time period, over 33,000 primary total hip arthroplasties were carried out at our center. Underlying diagnoses included avascular necrosis or chondrolysis in 25 hips and degenerative changes and/or impingement in 13 hips. The slip severity in 20 cases was severe, 4 moderate, 7 mild, and 7 hips had unknown slip severity. Half of the slips (7/14) in the degenerative group were mild or moderate. Fourteen (70%) of the 20 severe slips and 10 (71%) of the 14 acute or acute-on-chronic slips presented for arthroplasty with the diagnosis of avascular necrosis. Avascular necrosis was associated with a severe slip (P=0.03) and an acute or acute-on-chronic presentation (P=0.008). With the exception of 2 mild slips treated nonoperatively, all slips underwent either pin fixation (27) or primary osteotomy (9). Mean time from slip to arthroplasty was 7.4 years in patients with AVN or chondrolysis, compared with 23.6 years in patients with degenerative change (P<0.0002). Mean age at arthroplasty was 20 years in the AVN or chondrolysis group compared with 38 years in the degenerative group (P<0.0001). Sixteen hips required revision arthroplasty at a mean of 11.6 years postoperatively, most commonly for component loosening and/or polyethylene wear. Kaplan Meier 5-year survival free from revision for all causes was 87% overall and 95% in the total hip arthroplasty subset. CONCLUSIONS: The majority of hip arthroplasties in patients with slipped capital femoral epiphysis were carried out for the indication of avascular necrosis rather than degenerative changes related to femoroacetabular impingement. We found a moderately high revision rate in SCFE patients undergoing total hip arthroplasty or other joint replacement. LEVEL OF EVIDENCE: IV, case series.

Iatrogenic thoracic outlet syndrome secondary to vertical expandable prosthetic titanium rib expansion thoracoplasty: pathogenesis and strategies for prevention/treatment.

BACKGROUND: An innovative treatment for thoracic insufficiency syndrome involves a vertical expansion of the chest wall through a horizontal chest wall osteotomy maintained by a distraction device (vertical expandable prosthetic titanium rib or VEPTR). Upper-extremity neurovascular dysfunction has been reported after expansion. The purposes of this study are to identify potential etiologies for compression of the brachial plexus after expansion thoracoplasty and to suggest strategies to reduce the incidence of this complication. METHODS: A simulated VEPTR procedure was performed on 8 fresh cadaveric specimens. Manometric measurements were taken in the 3 anatomic regions of the thoracic outlet after thoracotomy and rib distraction were performed. Confirmation of the location of compression was performed by placing barium-impregnated putty along the course of the brachial plexus and evaluating the effect of expansion using video fluoroscopy. A midclavicular osteotomy was then performed and video fluoroscopy repeated. RESULTS: A 20% increase in pressure was seen in the costoclavicular region of the thoracic outlet after expansion. Constriction of the midclavicular region of the thoracic outlet between the first rib and clavicle was confirmed using the putty model. Midclavicular osteotomy alleviated this region of compression. CONCLUSIONS: Expansion thoracoplasty with the VEPTR procedure causes increased pressure in the costoclavicular region of the thoracic outlet. A midclavicular osteotomy may be one method to alleviate thoracic outlet narrowing after VEPTR procedure, although the short- and long-term effects of this is procedure is not known. CLINICAL RELEVANCE: Our model supports an iatrogenic thoracic outlet syndrome caused by expansion thoracoplasty. Based on our data as well as a review of the literature, we recommend intraoperative neurologic monitoring of the ipsilateral upper extremity during the VEPTR procedure.

Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis.

Treatment of scaphoid nonunions remains a challenging problem, especially in the setting of proximal pole avascular necrosis or humpback deformity. Conventional bone grafting techniques have demonstrated unpredictable results in the setting of collapse deformities, whereas pedicled dorsal distal radius vascularized bone grafts have recently been reported to have nearly a 50% failure rate when used in scaphoid nonunions with proximal pole nonunion. Free vascularized medial femoral condyle bone grafting is one option for the treatment of scaphoid nonunions with proximal pole avascular necrosis associated with a humpback deformity. The indications, contraindications, and technique of free vascularized medial femoral condyle bone grafting are presented for the treatment of scaphoid nonunions associated with proximal pole avascular necrosis and humpback deformities.

Locking plate technology and its applications in upper extremity fracture care.

Locking plate technology has been a major advance in fracture care. These plates afford a stronger construct and have been useful in cases where the bone is osteoporotic and unicortical fixation or distal periarticular fracture fixation is necessary. Disadvantages include fixed angle screw fixation and inability to compress at the fracture site; however, the use of a combination of compression and locking screws allows for both fracture compression with cortical screws and stronger fixation with locking screws. Future studies will refine the indications and overall efficacy in the use of this technology.