Predictive factors for critical care dependency after posterior spinal fusion for adolescent idiopathic scoliosis.

Aims: Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF). Methods: We retrospectively reviewed all AIS patients who had undergone PSF between January 2018 and January 2020 in a specialist tertiary spinal referral centre. All patients were assessed preoperatively in an anaesthetic clinic. Postoperative care was defined as ward-based (WB) or critical care (CC), based on the preoperative FEV1, FVC, major curve Cobb angle, and the planned number of instrumented levels. Results: Overall, 105 patients were enrolled. Their mean age was 15.5 years (11 to 25) with a mean weight of 55 kg (35 to 103). The mean Cobb angle was 68° (38° to 122°). Of these, 38 patients were preoperatively scored to receive postoperative CC. However, only 19% of the cohort (20/105) actually needed CC-level support. Based on these figures, and an average paediatric intensive care unit stay of one day before stepdown to ward-based care, the potential cost-saving on the first postoperative night for this cohort was over £20,000. There was no statistically significant difference between the Total Pathway Score (TPS), the numerical representation of the four factors being assessed, and the actual level of care received (p = 0.052) or the American Society of Anesthesiologists grade (p = 0.187). Binary logistic regression analysis of the TPS variables showed that the preoperative Cobb angle was the only variable which significantly predicted the need for critical care. Conclusion: Most patients undergoing posterior fusion surgery for AIS do not need critical care. Of the readily available preoperative measures, the Cobb angle is the only predictor of the need for higher levels of care, and has a threshold value of 74.5°.

Hip reduction surgery versus scoliosis correction in non-ambulant neuromuscular patients: which surgery is the first step?

PURPOSE: Children and young adults with neuromuscular disorders have a high incidence of both spine and hip deformities. The aim of this study was to evaluate the outcome of either primary scoliosis or hip surgery in children and young adults with neuromuscular disorders. METHODS: A retrospective study was conducted on all children and young adults with neuromuscular-related synchronous hip subluxation/dislocation and scoliosis undergoing hip or scoliosis surgery in our institution between 2012 and 2021 with a minimum follow-up of 24 months. Demographic and operative data were collected; radiological parameters were measured preoperatively and postoperatively at final follow-up. RESULTS: Forty neuromuscular patients with synchronous hip displacement and scoliosis were included. Twenty patients with an average age of10.2 years had hip correction surgery performed primarily, with a mean follow-up of 54.9 (24-96) months. The other 20 patients with an average age of 12.4 years had scoliosis correction first, with a mean follow-up of 40 (24-60) months. In the "Hip first" group, pelvic obliquity, hip MP and Cobb angle were 16.8°, 71%, and 49°, respectively. At final follow-up, the mean pelvic obliquity and Cobb angles significantly progressed to 27.2° (p = 0.003) and 82.2° (p = 0.001), respectively. Eighteen patients (90%) required scoliosis correction after the hip surgery. In the "Scoliosis first" group, the mean pelvic obliquity, hip MP and Cobb angle were 21.2°, 49% and 65.5°, respectively. At final follow-up, both pelvic obliquity and Cobb angle significantly improved to 8.44° (p = 0.002) and 23.4° (p = 0.001), respectively. In 11/20 (55%) patients, the hip MP had significantly increased following the spinal surgery to 62% (p = 0.001), but only 5/20 (25%) patients underwent hip surgery after scoliosis correction. CONCLUSION: In neuromuscular patients presenting with synchronous hip displacement and scoliosis deformity, corrective scoliosis surgery is associated with a significant correction of pelvic obliquity and lower rates of secondary hip surgery. On the other hand, primary hip surgery does not reduce the risk of pelvic obliquity and scoliosis deformity progression.

Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial.

Aims: Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS). Methods: UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion: The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.

Pin Fracture in Magnetically Controlled Growing Rods: Influence of the Year of Manufacture.

BACKGROUND: Magnetically controlled growing rods (MCGRs) have a known issue with fracture of the internal locking pin resulting in early revisions. The manufacturer reported that rods manufactured before March 26, 2015, had a 5% risk of locking pin fracture. Locking pins made after this date are thicker in diameter and of a tougher alloy; their rate of pin fracture is not known. The aim of this study was to better understand the impact of the design changes on the performance of MCGRs. METHODS: This study involves 46 patients with 76 removed MCGRs. Forty-six rods were manufactured before March 26, 2015, and 30 rods after that date. Clinical and implant data were collected for all MCGRs. Retrieval analysis comprised plain radiographs evaluations, force and elongation testing, and disassembly. RESULTS: The 2 patient groups were statistically comparable. We found that 14 of 27 patients implanted with rods manufactured before March 26, 2015 (group I) had a fracture of their locking pins. Three of the 17 patients with rods manufactured after this date (group II) were also found to have a fractured pin. CONCLUSIONS: Retrieved rods collected at our center and made after March 26, 2015, had far fewer locking pin fractures than those made before this date; this may be due to the change in pin design.

Non-iatrogenic spontaneous acute spinal subdural haematoma after transforaminal lumbar interbody fusion.

PURPOSE: Reporting a rare case of a non-iatrogenic spontaneously resolved spinal subdural haematoma (SSDH) following revision of transforaminal lumbar interbody fusion (TLIF) and its possible explanation. METHODS: Case report of a 40-year-old man with a history of persistent lower back and left lower extremity radicular pain, secondary to recurrent disc prolapse, lumbar spondylosis with foraminal stenosis. He underwent an L5/S1 transforaminal interbody fusion via a right sided approach (through previous lumbar microdiscectomy incision). On post-operative day two, the patient developed headache and photophobia that were discovered to be secondary to an acute thoracolumbar subdural haematoma with no objective neurological deficit. RESULTS: After close observation of his neurological status and conservative management of the subdural haematoma, the patient fully recovered from his symptoms and remained problem-free at 2-year follow-up. CONCLUSIONS: Although the occurrence of acute spinal subdural haematoma after spinal surgery is a rare complication following spinal surgery, its appropriate management relies on early recognition if significant morbidity is to be avoided.

Blood titanium levels in patients with large and sliding titanium implants.

BACKGROUND: Titanium, which is known to be a highly biologically inert element, is one of the most commonly used metals in orthopaedic implants. While cobalt and chromium blood metal ion testing is routinely used in the clinical monitoring of patients with metal-on-metal hip implants, much less is known about the levels of titanium in patients with other implant types. The aim of this study was to better understand the normal ranges of blood titanium levels in patients implanted with large and sliding titanium constructs by comparison with reference levels from conventional titanium hips. METHODS: This study examined data collected from 136 patients. Over a period of 24 months, whole blood samples were collected from 41 patients implanted with large titanium implants: long (range 15 to 30 cm) spine rods with a sliding mechanism ("spine rods", n = 18), long bone tumour implants ("tumour implants", n = 13) and 3D-printed customised massive acetabular defect implants ("massive acetabular implants", n = 10). This data was compared with standard, uncemented primary titanium hip implants ("standard hips", 15 cm long) (n = 95). Clinical, imaging and blood titanium levels data were collected for all patients and compared statistically between the different groups. RESULTS: The median (range) of blood titanium levels of the standard hip, spine rods, femoral tumour implants and massive acetabular implants were 1.2 ppb (0.6-4.9), 9.7 ppb (4.0-25.4), 2.6 ppb (0.4-104.4) and 5.7 ppb (1.6-31.5) respectively. Spine rods and massive acetabular implants had significantly greater blood titanium levels compared to the standard hips group (p < 0.001). CONCLUSION: This study showed that titanium orthopaedic implants that are large and/or have a sliding mechanism have higher blood titanium levels compared to well-functioning, conventionally sized titanium hips. Reassuringly, the increased levels did not appear to induce adverse metal reactions. This study provides useful baseline data for future studies aimed at assessing blood titanium levels as a biomarker for implant function.

Understanding the implant performance of magnetically controlled growing spine rods: a review article.

PURPOSE: Early-Onset Scoliosis (EOS) (defined as a curvature of the spine ≥ 10° with onset before 10 years of age) if not properly treated, can lead to increased morbidity and mortality. Traditionally Growing Rods (TGRs), implants fixated to the spine and extended every 6-8 months by surgery, are considered the gold standard, but Magnetically Controlled Growing Rods (MCGRs) avoid multiple surgeries. While the potential benefit of outpatient distraction procedure with MCGR is huge, concerns still remain about its risks, up to the release of a Medical Device Alert (MDA) by the Medicines and Healthcare Regulatory Agency (MHRA) advising not to implant MCGRs until further notice. The aim of this literature review is to (1) give an overview on the use of MCGRs and (2) identify what is currently understood about the surgical, implant and patient factors associated with the use of MCGRs. METHODS: Systematic literature review. RESULTS: Surgical factors such as use of single rod configuration or incorrect rod contouring might affect early failure of MCGRs. Patient's older age and higher BMI are correlated with rod slippage. Wear debris and distraction mechanism failure may result from implant design and iteration. CONCLUSION: Despite the complications reported, this technology still offers one of the best solutions to spine surgeons dealing with severe EOS. Lowering the complication rate by identifying risk factors for failure is possible and further studies in this direction are required. Once the risk factors are well described, some of these can be addressed enabling a safer use of MCGRs.

Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review.

STUDY DESIGN: A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE: To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS: A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS: Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION: This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE: 3.

Coronavirus Disease 2019 Transmission: Blood Viremia and Aerosol Generation from Spinal Surgery. Is There an Increased Risk to the Surgical Team?

As a respiratory pathogen, the novel coronavirus is commonly associated with aerosol-generating procedures. However, it is currently unclear whether spinal surgical procedures pose an additional risk of viral transmission to the surgical team. We reviewed the available evidence to ascertain the presence of coronavirus disease 2019 (COVID-19) blood viremia and the virus' blood transmissibility, as well as evidence of blood-aerosol generation and operating room contamination from spinal surgical procedures. There is established evidence of COVID-19 blood viremia, a viral pathogenic cycle via angiotensin-converting enzyme 2 (ACE-2) receptors and similar blood transmission risk data from the SARS (severe acute respiratory syndrome)/MERS (Middle East respiratory syndrome) era. Spinal surgical practices demonstrate significant blood-aerosol generation from the operative wound due to the use of common surgical instruments, such as electrocautery, as well as high-speed and high-impact devices. Based on the evidence, there is an established additional risk of viral transmission faced by surgical teams from blood-aerosols generated from the operative wound of COVID-19- infected patients via the inhalation of virus-laden aerosols and the subsequent initiation of the viral pathogenic cycle through binding with pulmonary ACE-2 receptors. Recognizing this additional risk amidst the ongoing pandemic serves as a caution to front-line surgical personnel to strictly adhere to personal protective equipment usage in operating rooms, to modify surgical techniques to reduce the hazard of surgical aerosol generation and COVID-19 viral exposure, and to consider it as an integral aspect of planning and adapting to the "new normal" operating practices.

Management of patients with magnetically controlled growth rods amidst the global COVID-19 pandemic.

INTRODUCTION: At the time of writing, we are all coping with the global COVID-19 pandemic. Amongst other things, this has had a significant impact on postponing virtually all routine clinic visits and elective surgeries. Concurrently, the Magnetic Expansion Control (MAGEC) rod has been issued with a number of field safety notices and UK regulator medical device alerts. METHODS: This document serves to provide an overview of the current situation regarding the use of MAGEC rods, primarily in the UK, and the impact that the pandemic has had on the management of patients with these rods. RESULTS AND CONCLUSION: The care of each patient must of course be determined on an individual basis; however, the experience of the authors is that a short delay in scheduled distractions and clinic visits will not adversely impact patient treatment. The authors caution against a gap in distractions of longer than 6 months and emphasise the importance of continued remote patient monitoring to identify those who may need to be seen more urgently.

Management of Catastrophic Proximal Junctional Failure Following Spinal Deformity Correction in an Adult with Osteogenesis Imperfecta: Case Report and Technical Note.

BACKGROUND: Proximal junctional failure (PJF) is a major and sometimes devastating problem following adult spinal deformity (ASD) correction surgery. Common consensus still lags on guidelines for preventing and managing these complications. Surgical treatment of scoliosis in the presence of osteogenesis imperfecta (OI) in the pediatric population is well described. The complication rates are unusually higher in this special subset of patients owing to poor quality of bone. There is a paucity of literature focusing on surgical techniques, strategies, and problems involved in the management of ASD associated with OI. CASE DESCRIPTION: We report a 59-year-old female with type 1 OI and adult scoliosis who underwent T10-to-pelvis fusion for ASD according to the principles of adult deformity correction. At a 1-year follow-up, she presented with asymptomatic proximal junctional kyphosis of 45° and 2 weeks later had PJF along with spinal cord injury after a fall. On computed tomography scan, kyphosis was increased to 60° at T9-T10. She underwent decompression and revision deformity correction using quadruple rods, with extension of instrumentation to T2 with soft landing using rib bands. At a 4-year follow-up, she had a good functional outcome after revision surgery. CONCLUSIONS: This is the first report of successful management of PJF following ASD correction in the presence of OI using this technique. Suboptimal hold of implants due to poor bone quality must be at the focus of any surgical planning for these patients. All possible strategies to prevent PJF must be considered when planning the deformity correction in adults with OI.

Subarachnoidal pleural fistula after resection of intradural thoracic disc herniation and multimodal treatment with noninvasive positive pressure ventilation (NPPV).

Subarachnoid pleural fistula (SPF) is a type of cerebrospinal fluid (CSF) fistula that can arise as a complication following transthoracic resection of intervertebral disc herniation in the thoracic spine. It is an abnormal communication between the subarachnoid and pleural space. Negative intrapleural pressure promotes CSF leak due to a suction effect into the pleural cavity, with little chance of spontaneous closure. Due to the risk of severe complications with CSF leak into the thoracic cavity, early diagnosis and treatment are mandatory. However, management can be challenging. We report a case of a 72-year-old woman who underwent anterior thoracic surgery to treat thoracic myelopathy caused by an ossified intradural disc herniation. The postoperative period was complicated by a subarachnoidal pleural fistula. We describe our successful treatment of this using noninvasive positive pressure ventilation and lumbar CSF drainage and review other methods reported in the literature.

Does transcranial stimulation for motor evoked potentials (TcMEP) worsen seizures in epileptic patients following spinal deformity surgery?

PURPOSE: To investigate the effect of Transcranial Motor Evoked Potentials (TcMEP) in increasing the severity or frequency of post-operative seizures in patients undergoing deformity corrective spine surgery with a known history of seizures pre-operatively. METHODS: The information on all patients with history of epilepsy/seizures who underwent spinal TcMEP cord monitoring for deformity correction surgery was retrospectively collected through a review of the hospital notes. The benefits of TcMEP in the early detection of potential cord ischemia were deemed by the operating surgeon to outweigh the increased risks of seizures, tongue biting, etc. Data on age, gender, pre-operative diagnosis, curve type, intra-operative monitoring alerts, duration of hospital stay, and post-operative in-hospital seizures were collected. Additionally, the patients were contacted following discharge and data on any change in the frequency of the seizures or an alteration in seizure-related medication post-operatively was also collected. RESULTS: The records of 449 consecutively monitored patients were reviewed and 12 (2.7 %) patients with a history of seizures pre-operatively were identified. The mean age was 23 (9-59) years, 7 females, 11 scoliosis corrections (4 neuromuscular, 1 degenerative, 6 idiopathic adolescent), and one sagittal balance correction surgery. Intra-operatively, all patients had TcMEP monitoring, were catheterised, and had no neuromonitoring alerts or record of tongue biting or laceration. Post-operatively, the mean hospital stay was 12 (4-25) days with no recorded seizures. At a mean of 23 (12-49) months post-discharge, none of the patients reported a worsening of seizures (pattern or frequency) or required an alteration in the seizure-related medications. CONCLUSION: TcMEP does not appear to trigger intra-operative or post-operative seizures and is not associated with deterioration in the seizure control of patients suffering seizures pre-operatively.

Open reduction and posterior instrumentation of type 3 high transverse sacral fracture-dislocation: technical note.

The authors describe an open reduction and fixation through a posterior approach of Roy-Camille Type 3 transverse sacral fractures. This technique involves posterior staged reduction of the fracture applying distraction forces to restore the height, followed by posterior translation to restore sagittal alignment. Tips and pearls of this procedure, described for the first time in the literature, are also discussed in this report.

Rhizolysis: an unusual postoperative complication.

Percutaneous retrogasserian glycerol rhizolysis, introduced in 1981, has become established in the management of trigeminal neuralgia secondary to multiple sclerosis and pontine infarction. More recently, this technique was established as safe and reliable in managing pain originating from the zygapophyseal joints, with successful relief of pain in 67% of patients treated for lower back pain. In this article, we report a case of complete paralysis of lumbar paravertebral muscle function caused by severe multifidus degeneration after 3-level lumbar rhizolysis. This paralysis resulted in kyphosis and loss of sagittal balance.

High-grade spondylolisthesis: gradual reduction using Magerl's external fixator followed by circumferential fusion technique and long-term results.

PURPOSE: To report the results of a cohort of patients treated with this technique high lighting radiological and functional outcomes, discussing also benefits arising from a gradual reduction procedure compared with other techniques. METHODS: We evaluated nine patients who have undergone high-grade listhesis reduction and circumferential fusion at our institution from 1988 to 2006. Average length of follow-up was 11 years (5-19). Functional outcomes and radiological measurements were recorded and reported. RESULTS: Slip magnitude was reduced by an average of 2.9 grades (Meyerding classification). Slip angle improved by an average of 66% (p = 0.0001), lumbosacral angle by 47% (p = 0.0002), sacral rotation by 51% (p = 0.0068) and sacral inclination by 47% (p = 0.0055). At the latest follow-up 88.9% had achieved solid fusion. Post-operative 10-point Visual Analogue Score (VAS) for back pain had improved by 70% (p < 0.001) and that for leg pain by 76% (p < 0.001) compared with pre-operative score. Average postoperative Oswestry Disability Index for all patients was 8% (range 0-16%) and that for Low Back Outcome Scores was 56.6 (range 44-70). All components of Short Form 36 Health Survey were greater than 80%. Overall patients' expectations were met in 100%. CONCLUSIONS: This is an effective and safe technique which addresses the lumbosacral kyphosis and cosmetic deformity without the neurological complications which accompany other reduction and fusion techniques for high-grade spondylolisthesis.

A lipoma within the Achilles tendon sheath.

We report a case demonstrating a rare finding associated with a relatively common injury. Lipomata are rarely found within tendon sheaths; but in the case of our patient, at the time of operative repair for a ruptured Achilles tendon, we found a fatty growth within the tendon sheath. The diagnosis of a lipoma was confirmed by histology. Although uncommon, it remains important to be aware of the existence of neoplastic growths within tendon sheaths and to establish the exact nature of these growths by histological analysis.