Self-image in spinal deformity: a state-of-the-art review.

PURPOSE: To review the current literature surrounding the assessment of self-image in pediatric and adult spinal deformity. METHODS: The literature were reviewed for studies examining patient-reported outcome measurements (PROM) and self-image in pediatric and adult spinal deformity. PROM performance metrics were collected and described. The relationships between self-image PROM and patient outcomes, including satisfaction, were described. RESULTS: Several self-image PROM exist, including the Scoliosis Research Society-22r (SRS-22r) self-image domain, the Body Image Disturbance Questionnaire (BIDQ), and the Spinal Appearance Questionnaire (SAQ). The most commonly used is the self-image domain of the SRS-22r. It is validated in adult and pediatric spinal deformity and is correlated with patient desire for surgery and satisfaction after surgery. This domain is limited by floor and ceiling effects. CONCLUSION: Self-image assessment is critical to both pediatric and adult spinal deformity surgeries. The SRS-22r self-image domain is the most frequently reported PROM for this health domain. While valid in both surgical cohorts, this PROM is affected by floor and ceiling effects which limits the ability to discriminate between health states. Given the overall importance of this domain to patients with spinal deformity further efforts are needed to improve discrimination without gross increases in PROM question burden, which may limit broad acceptance and use.

A tryptophan-derived uremic metabolite-Ahr-Pdk4 axis governs skeletal muscle mitochondrial energetics in chronic kidney disease.

Chronic kidney disease (CKD) causes an accumulation of uremic metabolites that negatively impact skeletal muscle function. Tryptophan-derived uremic metabolites are agonists of the aryl hydrocarbon receptor (AHR) which has been shown to be activated in the blood of CKD patients. This study investigated the role of the AHR in skeletal muscle pathology of CKD. Compared to control participants with normal kidney function, AHR-dependent gene expression (CYP1A1 and CYP1B1) was significantly upregulated in skeletal muscle of patients with CKD (P=0.032) and the magnitude of AHR activation was inversely correlated with mitochondrial respiration (P<0.001). In mice with CKD, muscle mitochondrial oxidative phosphorylation (OXPHOS) was significantly impaired and strongly correlated with both the serum level of tryptophan-derived uremic metabolites and AHR activation. Muscle-specific deletion of the AHR significantly improved mitochondrial OXPHOS in male mice with the greatest uremic toxicity (CKD+probenecid) and abolished the relationship between uremic metabolites and OXPHOS. The uremic metabolite-AHR-mitochondrial axis in skeletal muscle was further confirmed using muscle-specific AHR knockdown in C57BL6J that harbour a high-affinity AHR allele, as well as ectopic viral expression of constitutively active mutant AHR in mice with normal renal function. Notably, OXPHOS changes in AHRmKO mice were only present when mitochondria were fueled by carbohydrates. Further analyses revealed that AHR activation in mice led to significant increases in Pdk4 expression (P<0.05) and phosphorylation of pyruvate dehydrogenase enzyme (P<0.05). These findings establish a uremic metabolite-AHR-Pdk4 axis in skeletal muscle that governs mitochondrial deficits in carbohydrate oxidation during CKD.

Preoperative Robotics Planning Facilitates Complex Construct Design in Robot-Assisted Minimally Invasive Adult Spinal Deformity Surgery-A Preliminary Experience.

(1) Background: The correction of adult spinal deformity (ASD) can require long, complex constructs with multiple rods which traverse important biomechanical levels to achieve multi-pelvic fixation. Minimally invasive (MIS) placement of these constructs has historically been difficult. Advanced technologies such as spinal robotics platforms can facilitate the design and placement of these constructs and further enable these surgical approaches in MIS deformity surgery. (2) Methods: A retrospective study was performed on a series of ASD patients undergoing MIS deformity correction with ≥eight fusion levels to the lower thoracic spine with preoperative robotic construct planning and robot-assisted pedicle screw placement. (3) Results: There were 12 patients (10 female, mean age 68.6 years) with a diagnosis of either degenerative scoliosis (8 patients) or sagittal imbalance (4 patients). All underwent preoperative robotic planning to assist in MIS robot-assisted percutaneous or transfascial placement of pedicle and iliac screws with multiple-rod constructs. Mean operative values per patient were 9.9 levels instrumented (range 8-11), 3.9 interbody cages (range 2-6), 3.3 iliac fixation points (range 2-4), 3.3 rods (range 2-4), 18.7 screws (range 13-24), estimated blood loss 254 cc (range 150-350 cc), and operative time 347 min (range 242-442 min). All patients showed improvement in radiographic sagittal, and, if applicable, coronal parameters. Mean length of stay was 5.8 days with no ICU admissions. Ten patients ambulated on POD 1 or 2. Of 224 screws placed minimally invasively, four breaches were identified on intraoperative CT and repositioned (three lateral, one medial) for a robot-assisted screw accuracy of 98.2%. (4) Conclusions: Minimally invasive long-segment fixation for adult spinal deformity surgery has historically been considered laborious and technically intensive. Preoperative robotics planning facilitates the design and placement of even complex multi-rod multi-pelvic fixation for MIS deformity surgery.

Scoliosis Research Society-22r and Ceiling Effects: Limited Capabilities for Precision-Medicine with Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective registry analysis. OBJECTIVE: To examine predictions of individual Scoliosis Research Society-22r (SRS-22r) questions one year after surgery for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: A precision-medicine approach to AIS surgery will inform patients of the likelihood of achieving particular results from surgery, specifically individual responses to the SRS-22r questionnaire. METHODS: A multi-center AIS registry was queried for surgical AIS patients treated between 2002-2020. Preoperative data collected included standard demographic data, deformity descriptive data, and SRS-22r scores. Postoperative 1yr SRS-22r scores were modeled using ordinal logistic regression. . The highest probability was the most likely response. Model performance was examined by c-statistics, where c>.8 was considered excellent. Ceiling effects were measured by the proportion of patients reporting "5" to each question. RESULTS: 3251 patients contributed data to the study; mean age 14.4 (±2.2) yrs, female 2631 (81%), major thoracic coronal curve 53°, mean lumbar 41°. C-statistic values ranged from .6 (poor) to .8 (excellent) evidence of varied predictive capabilities. Q17 ("days off work/school", c = .84, ceiling achieved 75%) and Q15 ("financial difficulties", c = .86, ceiling achieved 82%) had the greatest predictive capabilities while Q11 ("pain medication", c=.73, ceiling achieved 67%), Q10 ("appearance", c=.72, ceiling achieved 35%), and Q19 ("attractive", c=.69, ceiling achieved 37%) performed poorly. CONCLUSION: Prediction of individual SRS-22r item responses perhaps most germane to AIS treatment was poor. Prediction of less relevant outcomes, where ceiling effects are present, was greater as the models chose "5" for all responses. These ceiling effects may limit discrimination and hamper efforts at personalized outcome predictions. LEVEL OF EVIDENCE: 3.

A systematic review of pseudarthrosis and reoperation rates in minimally invasive adult spinal deformity correction.

Background/objective: The recent development of minimally invasive surgical techniques (MIS) has made possible the correction of adult spinal deformity (ASD) with less blood loss and shorter hospital stays. However, minimally invasive placement of pedicle screws at the proximal level of the construct can increase pseudarthrosis risk, leading to implant failure, kyphosis, and reoperations. We aggregate existing literature to describe pseudarthrosis rates at the proximal thoracic or thoracolumbar junction in MIS and subsequent reoperation rates. Methods: After a three-tied search strategy in PubMed, we identified 9 articles for study inclusion, describing outcomes from MIS correction of ASD, pseudarthrosis as complication, and surgery on 4+ levels. Baseline patient characteristics and combined rates of pseudarthrosis and reoperation were calculated. Results: A total of 482 patients were studied with an average [range] age of 65.5 [60.4,72], 6.3 [4.4,11] levels fused per patient, follow-up time of 28.3 [12,39] months, and 64.8% females. Pseudarthrosis was reported in 28 of 482 pooled patients (5.8%) of which 15 of 374 pooled patients (4.0%) ultimately underwent a reoperation for pseudarthrosis. Post-operative characteristics included an estimated blood loss (EBL) of 527.1 [241,1466] mL, operating time of 297.9 [183,475] minutes, and length of stay of 7.7 [5,10] days. Among the papers comparing MIS to open surgery, all reported a significantly lower EBL in patients treated with MIS. Conclusion: This analysis demonstrate a measurable pseudarthrosis risk when using MIS to treat ASD, overwhelming requiring reoperation. The benefits of MIS must be considered against the drawbacks of pseudarthrosis when determining ASD management.

De novo cerebral pseudoaneurysm formation: a rare delayed complication of stereotactic electroencephalography in children.

OBJECTIVE: To describe the rare complication of cerebral pseudoaneurysm formation following stereotactic electroencephalography (sEEG) lead implantation in children. METHODS: A retrospective chart review of all pediatric patients undergoing sEEG procedures between 2015 and 2020 was performed. Cases of pseudoaneurysm were identified and reviewed. RESULTS: Cerebral pseudoaneurysms were identified in two of 58 total cases and 610 implanted electrodes. One lesion was detected 1 year after sEEG explantation and required craniotomy and clipping. The other was detected 3 months post-explantation and underwent coil embolization. Neither patient had any neurologic deficits associated with the pseudoaneurysm before or after treatment. CONCLUSIONS: Pseudoaneurysm formation post-sEEG explantation is rare and likely underreported. Routine, post-explantation/treatment imaging is warranted to detect this rare but potentially lethal complication.

Patient-specific rods in adult spinal deformity: a systematic review.

PURPOSE: The purpose of this review was to evaluate the effectiveness of patient-specific rods for adult spinal deformity. METHODS: A systematic review of the literature was performed through an electronic search of the PubMed, Scopus, and Web of Science databases. Human studies between 2012 and 2023 were included. Sample size, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), operation time, blood loss, follow-up duration, and complications were recorded for each study when available. RESULTS: Seven studies with a total of 304 adult spinal deformity patients of various etiologies were included. All studies reported SVA, and PT; two studies did not report PI-LL. Four studies reported planned radiographic outcomes. Two found a significant association between preoperative plan and postoperative outcome in all three outcomes. One found a significant association for PI-LL alone. The fourth found no significant associations. SVA improved in six of seven studies, PI-LL improved in all five, and three of seven studies found improved postoperative PT. Significance of these results varied greatly by study. CONCLUSION: Preliminary evidence suggests potential benefits of PSRs in achieving optimal spino-pelvic parameters in ASD surgery. Nevertheless, conclusions regarding the superiority of PSRs over traditional rods must be judiciously drawn, given the heterogeneity of patients and study methodologies, potential confounding variables, and the absence of robust randomized controlled trials. Future investigations should concentrate on enhancing preoperative planning, standardizing surgical methodologies, isolating specific patient subgroups, and head-to-head comparisons with traditional rods to fully elucidate the impact of PSRs in ASD surgery.

Navigated Radiofrequency Ablation Peripheral Rhizotomy for Lumbosacral Hypertonia in a Nonambulatory Patient With Spinal Fusion: Indications, Surgical Techniques, and Lessons Learned.

BACKGROUND AND OBJECTIVES: Radiofrequency ablation (RFA) is a destructive therapy which causes target tissue destruction by application of a thermal dose. Neurosurgical applications of RFA are well-described for myriad chronic pain and movement disorder diagnoses. In fact, RFA pallidotomy and thalamotomy are the initial procedures from which the field of neurosurgical management for movement disorders emerged. RFA rhizotomy for post-traumatic spasms was popular in the 1970s and 1980s, although it was largely abandoned after the invention and Food and Drug Administration approval of intrathecal baclofen therapy. RFA has not been described as a primary treatment of hypertonia in nonambulatory children. METHODS: We report a case of computer-navigated, nonselective RFA peripheral rhizotomy for a nonambulatory child with a history of severe scoliosis and spinal fusion, where an open rhizotomy was technically impractical. RESULTS: Navigation to and ablation of the bilateral L1-L5 peripheral nerves with this approach was successful, and the patient experienced bilateral lower extremity tone improvement. CONCLUSION: We use this case to highlight considerations in indications, our applied operative technique, and lessons learned from this novel application of RFA peripheral rhizotomy in children.

Rett Syndrome-Associated Scoliosis: Analysis of National Trends and Treatment Patterns of a Rare Indication for Posterior Instrumented Fusion.

STUDY DESIGN: Retrospective database cohort study. OBJECTIVE: To evaluate U.S. treatment trends and inpatient outcomes for children undergoing posterior spinal fusion (PSF) for Rett syndrome (RTT)-associated scoliosis (RAS). SUMMARY OF BACKGROUND DATA: RTT is a rare, sporadic neurodevelopmental disorder presenting in childhood with developmental regression, ataxia, and seizures. RAS occurs in 50% to 80% of cases of RTT, but little is known about the case volume and perioperative experience for children undergoing PSF. MATERIALS AND METHODS: Using the International Classification of Diseases Ninth and 10th revision codes in the national Kids' Inpatient Database, we identified children with RTT who underwent PSF from 2000 to 2019. Annual case volumes were analyzed. Clinical characteristics and outcomes were compared with those of a cohort of patients with neuromuscular scoliosis (NMS). RESULTS: Among 220 patients with RAS, 216 (98.2%) were females (mean age at surgery: 12.3±3.3 yr). Surgical case incidence steadily increased over 19 years, with more RAS admissions in the South (31.4%). Overall, patients with RAS demonstrated a higher mean Elixhauser Comorbidity Index score (2 vs . 1, P < 0.001) and had more perioperative complications (41.4% vs . 18%, P < 0.001) than patients with NMS. RTT diagnosis independently predicted higher odds of any complications (odds ratio: 1.98, P < 0.001) and increased length of stay (odds ratio: 1.18, P = 0.009) for admissions for PSF. CONCLUSIONS: Surgical treatment for RAS is rare but increased over a 19-year period. Cases appear to be clustering by region, with the highest proportion in the South. The higher Elixhauser Comorbidity Index in RAS patients predicted higher costs, longer hospital stays, more complications (particularly respiratory), and more nonroutine discharge disposition than in other patients with NMS. RTT was independently associated with higher odds of complications and longer length of stay. Because RAS cases appear to be increasing in number, future studies should emphasize methods to reduce morbidity and investigate deformity-specific metrics to help better understand this population.

Single position robot-assisted pedicle screw placement with S2-alar-iliac fixation in lateral decubitus: cadaveric feasibility study and early clinical experience.

OBJECTIVES: Single position lateral fusion with robotic assistance eliminates the need for surgical staging while harnessing the precision of robotic adjuncts. We expand on this technique by demonstrating the technical feasibility of placing bilateral pedicle screws with S2-alar-iliac (S2AI) fixation while in the lateral position. METHODS: A cadaveric study was performed using 12 human specimens. A retrospective clinical series was also performed for patients who had undergone robot-assisted placement of S2AI screws in lateral decubitus between June 2020 and June 2022. Case demographics, implant placement time, implant size, screw accuracy, and complications were recorded. Early postoperative radiographic outcomes were reported. RESULTS: In the cadaveric series, a total of 126 screws were placed with robotic assistance in 12 cadavers of which 24 screws were S2AI. There were four breaches from pedicle screws and none with S2AI screws for an overall accuracy rate of 96.8%. In the clinical series, four patients (all male, mean age 65.8 years) underwent single position lateral surgery with S2AI distal fixation. Mean BMI was 33.6 and mean follow-up was 20.5 months. Mean radiographic improvements were lumbar lordosis 12.3 ± 4.7°, sagittal vertical axis 1.5 ± 2.1 cm, pelvic tilt 8.5 ± 10.0°, and pelvic incidence-lumbar lordosis mismatch 12.3 ± 4.7°. A total of 42 screws were placed of which eight screws were S2AI. There were two breaches from pedicle screws and none from S2AI screws for an overall accuracy rate of 95.2%. No repositioning or salvage techniques were required for the S2AI screws. CONCLUSIONS: We demonstrate here the technical feasibility of single position robot-assisted placement of S2-alar-iliac screws in the lateral decubitus position for single position surgery.

SRS-22r Self-Image After Surgery for Adolescent Idiopathic Scoliosis at 10-year Follow-up.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To examine SRS-Self Image scores at up to 10 years after surgery for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Self-image is complex with implications for surgical and patient-reported outcomes after AIS surgery. Surgically modifiable factors that impact self-image are inconsistently reported in the literature with few longer-term reports. We examined the rate and durability of self-image improvement. MATERIALS AND METHODS: An AIS registry was queried for patients with up to 10 years of follow-up after AIS surgery. A mixed effects model estimated change in SRS-22 Self Image from baseline to 6 weeks, 1 year, 2 years, 5 years, and 10 years. All enrolled patients contributed data to the mixed effects models. A sub-analysis of patients with 1-year and 10-year follow-up evaluated worsening/static/improved SRS-22 Self Image scores examined stability of scores over that timeline. Baseline demographic data and 1-year deformity magnitude data were compared between groups using parametric and nonparametric tests as appropriate. RESULTS: Data from 4608 patients contributed data to the longitudinal model; 162 had 1-year and 10-year data. Mean SRS-Self Image improvement at 10-year follow-up was 1.0 (95% CI: 0.9-1.1) point. No significant changes in Self-Image domain scores were estimated from 1-year to 10-year (all P >0.05) postoperative. Forty (25%) patients had SRS-Self Image worsening from 1 year to 10 years, 36 (22%) improved, and 86 (53%) were unchanged. Patients who worsened over 10 years had lower SRS-Self Image at baseline than those unchanged at enrollment (3.3 vs. 3.7, P =0.007). Neither radiographic parameters nor SRS-Mental Health were different at baseline for the enrolled patients. CONCLUSION: Ten years after surgery, 75% of patients reported similar or better SRS-Self Image scores than one year after surgery. Nearly 25% of patients reported worsening self-image at 10 years. Patients who worsened had lower baseline SRS-Self Image scores, without radiographic or mental health differences at baseline or follow-up.

Radiographic alignment outcomes after the single-position prone transpsoas approach: a multi-institutional retrospective review of 363 cases.

OBJECTIVE: The aim of this paper was to evaluate the changes in radiographic spinopelvic parameters in a large cohort of patients undergoing the prone transpsoas approach to the lumbar spine. METHODS: A multicenter retrospective observational cohort study was performed for all patients who underwent lateral lumber interbody fusion via the single-position prone transpsoas (PTP) approach. Spinopelvic parameters from preoperative and first upright postoperative radiographs were collected, including lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT). Functional indices (visual analog scale score), and patient-reported outcomes (Oswestry Disability Index) were also recorded from pre- and postoperative appointments. RESULTS: Of the 363 patients who successfully underwent the procedure, LL after fusion was 50.0° compared with 45.6° preoperatively (p < 0.001). The pelvic incidence-lumbar lordosis mismatch (PI-LL) was 10.5° preoperatively versus 2.9° postoperatively (p < 0.001). PT did not significantly change (0.2° ± 10.7°, p > 0.05). CONCLUSIONS: The PTP approach allows significant gain in lordotic augmentation, which was associated with good functional results at follow-up.

Prone-lateral access to the lumbar spine: single-level corpectomy with approach discussion.

The lateral lumbar interbody fusion has evolved as newly envisioned access corridors become feasible with technological advances. Prone lateral access has evolved as a single-access approach to combine the benefits of minimally invasive surgery with direct and indirect decompression of the neural elements with synergistic anterior and posterior column correction. In this video, the authors discuss the pearls, pitfalls, and adjuvant technologies they use in a high-volume prone lateral center via case demonstration of a prone lateral corpectomy. The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2216.

360 TOTUM ALIF for a Symptomatic Fractional Curve.

As patient-specific implants become a tool in the spine surgeon's arsenal, understanding how to effectively implement multiple systems in a single surgery requires careful planning. In Video 1, we describe our workflow for a total custom anterior lumbar interbody fusion, featuring patient-specific interbodies and rods. We discuss the required cross talk necessary to ensure maximum desired correction, as well as the logic for pursuing custom devices in this index case. Appropriate consent from the patient was obtained before the procedure.

Complementary Tools in Cerebral Bypass Surgery.

Cerebral revascularization surgery has been advanced by the refinement of several adjunctive tools. These tools include perioperative blood thinners, intraoperative spasmolytic agents, electrophysiological monitoring, and methods for assessing bypass patency or marking arteriotomies. Despite the array of options, the proper usage and comparative advantages of different complements in cerebral bypass have not been well-cataloged elsewhere. In this literature review, we describe the appropriate usage, benefits, and limitations of various bypass adjuncts. Understanding these adjuncts can help surgeons ensure that they receive reliable intraoperative information about bypass function and minimize the risk of serious complications. Overall, this review provides a succinct reference for neurosurgeons on various cerebrovascular bypass adjuncts.

Minimally Invasive L5-S1 Oblique Lumbar Interbody Fusion With Simultaneous Robotic Single Position Posterior Fixation: 2-Dimensional Operative Video.

The unique anatomy at L5-S1 presents different challenges and considerations to be made when compared to other areas in the lumbar spine. In this way, the oblique lumbar interbody fusion (OLIF) is more closely related to a supine anterior lumbar interbody fusion (ALIF) except that the former is performed in a lateral position down a smaller minimally invasive retroperitoneal corridor. This lateral positioning at L5-S1, however, provides an opportunity for single-position surgery simultaneously with posterior fixation, which is not afforded by other approaches. We present here a case of a 57-yr-old male with a prior right-sided L5-S1 microdiscectomy who presents with worsening lumbar radiculopathy and foot drop. He subsequently underwent a minimally invasive L5-S1 OLIF with posterior instrumentation placed bilaterally while remaining in a single lateral position (Mazor X Stealth Edition, Medtronic, Dublin, Ireland). Both the anterior OLIF surgeon and posterior instrumentation surgeon were able to work simultaneously. There is currently a need for further high-quality operative videos showing the L5-S1 OLIF technique, and to our knowledge, this is the first video demonstrating a 2-surgeon near-simultaneous workflow approach using a spinal robotics platform at this level. There is no identifying information in this video. A patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

Precedent for the Present: Neurosurgery During the 1918 Wartime Influenza Pandemic.

In the early twentieth century, early neurosurgical pioneers marked their claims in the specialty during the combined threats of the Spanish influenza and World War I. Their stories, intimately connected, demonstrate personal and professional losses in the backdrop of overarching perseverance to achieve that which allowed neurosurgery to evolve into modernity. Today, as global order adapts to the severe acute respiratory syndrome coronavirus (SARS-COVID-19) pandemic, their stories provide an opportunity for reflection as we carve our way forward as a specialty.