Surgical Outcomes of Adults with Spinal Caries from 1992 to 2019: A Single-Center Study-Risk Factors for the Progression of Kyphosis after Anterior Spinal Fixation Reveal Cases Needing Additional Posterior Instrumentation.

Background: This study aims to investigate the postoperative improvement of paralysis, fusion rate and risk factors for kyphosis progression in adults affected with spinal caries. Methods: Overall, 134 patients with spinal caries from the thoracic to lumbar spine from 1992 to 2021 were included in this study. Data concerning the affected level (thoracic, thoracolumbar, lumbar, and lumbosacral), bone fusion rate, and progression of the postoperative local kyphosis angle were collected. The risk factors for the progression of local kyphosis angle after anterior spinal fixation (ASF) were determined using linear regression analysis. Results: Preoperatively, the degree of spinal cord paralysis was D and E on Frankel classification. Improvement of paralysis was good with surgery, especially from C, D. The overall bone fusion rate was 83.2%. The only factor influencing the progression of local kyphosis angle after ASF was the level of the affected vertebra. Progression of kyphosis angle after ASF was very advanced in the thoracolumbar transition area. Conclusions: Surgical improvement in paraplegia and the fusion rate of ASF with only grafted bone was good. However, in patients affected in the thoracolumbar spine region, posterior instrumentation is desirable because of local kyphosis progression risk after surgery.

Surgical outcomes of anterior column reconstruction for spinal fractures caused by minor trauma-preoperative examination of the number of intervertebral bone bridges is key to obtaining good bone fusion.

BACKGROUND: To achieve good bone fusion in anterior column reconstruction for vertebral fractures, not only bone mineral density (BMD) and bone metabolism markers but also lever arms due to bone bridging between vertebral bodies should be evaluated. However, until now, no lever arm index has been devised. Therefore, we believe that the maximum number of vertebral bodies that are bony and cross-linked with the contiguous adjacent vertebrae (maxVB) can be used as a measure for lever arms. The purpose of this study is to investigate the surgical outcomes of anterior column reconstruction for spinal fractures and to determine the effect of bone bridging between vertebral bodies on the rate of bone fusion using the maxVB as an indicator of the length of the lever arm. METHODS: The clinical data of 81 patients who underwent anterior column reconstruction for spinal fracture between 2014 and 2022 were evaluated. The bone fusion rate, back pain score, between the maxVB = 0 and the maxVB ≥ 2 patients were adjusted for confounding factors (age, smoking history, diabetes mellitus history, BMD, osteoporosis drugs, surgical technique, number of fixed vertebrae, materials used for the anterior props, etc.) and analysed with multivariate or multiple regression analyses. The bone healing rate and incidence of postoperative back pain were compared among the three groups (maxVB = 0, 2≦maxVB≦8, maxVB ≧ 9) and divided by the maxVB after adjusting for confounding factors. RESULTS: Patients with a maxVB ≥ 2 had a significantly higher bone fusion rate (p < 0.01) and postoperative back pain score (p < 0.01) than those with a maxVB = 0. Among the three groups, the bone fusion rate and back pain score were significantly higher in the 2≦maxVB≦8 group (p = 0.01, p < 0.01). CONCLUSIONS: Examination of the maxVB as an indicator of the use of a lever arm is beneficial for anterior column reconstruction for vertebral fractures. Patients with no intervertebral bone bridging or a high number of bone bridges are in more need of measures to promote bone fusion than patients with a moderate number of bone bridges are.

Long-term outcomes of the nano-hydroxyapatite/polyamide-66 cage versus the titanium mesh cage for anterior reconstruction of thoracic and lumbar corpectomy: a retrospective study with at least 7 years of follow-up.

BACKGROUND: The nano-hydroxyapatite/polyamide-66 (n-HA/PA66) cage is a biomimetic cage with a lower elastic modulus than the titanium mesh cage (TMC). This study aimed to compare the long-term outcomes of the n-HA/PA66 cage and TMC in the anterior reconstruction of thoracic and lumbar fractures. METHODS: We retrospectively studied 113 patients with acute traumatic thoracic or lumbar burst fractures, comprising 60 patients treated with the TMC and 53 treated with the n-HA/PA66 cage for anterior reconstruction following single-level corpectomy. The radiographic data (cage subsidence, fusion status, segmental sagittal alignment) and clinical data (visual analogue scale (VAS) for pain and Oswestry Disability Index (ODI) for function) were evaluated preoperatively, postoperatively, and at final follow-up after a minimum 7-year period. RESULTS: The n-HA/PA66 and TMC groups had similar final fusion rates (96.2% vs. 95.0%). The cage subsidence at final follow-up was 2.3 ± 1.6 mm with subsidence of more than 3 mm occurring in 24.5% in the n-HA/PA66 group, which was significantly lower than the respective values of 3.9 ± 2.5 mm and 58.3% in the TMC group. The n-HA/PA66 group also had better correction of the bisegmental kyphotic angle than the TMC group (7.1° ± 7.5° vs 1.9° ± 8.6°, p < 0.01), with lower loss of correction (2.9° ± 2.5° vs 5.2° ± 4.1°, p < 0.01). The mean ODI steadily decreased after surgery in both groups. At final follow-up, the ODI and VAS were similar in the TMC and n-HA/PA66 groups. CONCLUSIONS: The n-HA/PA66 cage is associated with excellent radiographic fusion, better maintenance of the height of the fused segment, and better correction of kyphosis than the TMC during 7 years of follow-up after one-level anterior corpectomy. With the added benefit of radiolucency, the n-HA/PA66 cage may be superior to the TMC in anterior reconstruction of thoracic or lumbar fractures.

Incidence and predictive factors of shoulder imbalance after selective anterior spinal fusion surgery in Lenke type 5C adolescent idiopathic scoliosis.

Background: No study has assessed the incidence or predictors of postoperative shoulder imbalance (PSI) in patients with Lenke type 5C adolescent idiopathic scoliosis (AIS) who underwent selective anterior spinal fusion (ASF). This study evaluated the incidence and predictors of shoulder imbalance after selective ASF for Lenke type 5C AIS. Methods: In total, 62 patients with Lenke type 5C AIS (4 men and 58 women, mean age at surgery of 15.5 ± 1.5 years) were included and divided into the following two groups according to the radiographic shoulder height (RSH) at the final follow-up: PSI and non-PSI groups. All patients in this study underwent a whole-spine radiological evaluation. Various spinal coronal and sagittal profiles on radiographs were compared between the 2 groups. The clinical outcomes were assessed using the Scoliosis Research Society (SRS)-22 questionnaires. Results: The mean final follow-up duration was 8.6 ± 2.7 years. PSI was observed in 10 patients (16.1%) immediately after surgery; however, in the long-term follow-up period, PSI improved in 3 patients spontaneously, whereas the remaining 7 patients had residual PSI. The preoperative RSH and correction rates of the major curve immediately after surgery or at the final follow-up were significantly larger in the PSI group than in the non-PSI group (p=.001, p=.023, and p=.019, respectively). Receiver operating characteristic curve analysis indicated that the cutoff values for preoperative RSH and the correction rates immediately after surgery and at the final follow-up were 11.79 mm (p=.002; area under the curve [AUC], 0.948), 71.0% (p=.026; AUC, 0.822), and 65.4% (p=.021; AUC, 0.835), respectively. No statistically significant difference was observed in the preoperative and final follow-up SRS-22 scores in any domain between the PSI and non-PSI groups. Conclusions: Paying attention to the preoperative RSH and avoiding excessive correction of the major curve can prevent the occurrence of shoulder imbalance after selective ASF for Lenke type 5C AIS.

Influence of Lateral Translation of Lowest Instrumented Vertebra on L4 Tilt and Coronal Balance for Thoracolumbar and Lumbar Curves in Adolescent Idiopathic Scoliosis.

This study aimed to evaluate the lowest instrumented vertebra translation (LIV-T) in the surgical treatment of thoracolumbar/lumbar adolescent idiopathic scoliosis and to analyze the radiographic parameters in relation to LIV-T and L4 tilt and global coronal balance. A total of 62 patients underwent posterior spinal fusion (PSF, n = 32) or anterior spinal fusion (ASF, n = 30) and were followed up for a minimum of 2 years. The mean preoperative LIV-T was significantly larger in the ASF group than the PSF (p < 0.01), while the final LIV-T was equivalent. LIV-T at the final follow-up was significantly correlated with L4 tilt and the global coronal balance (r = 0.69, p < 0.01, r = 0.38, p < 0.01, respectively). Receiver-operating characteristic analysis for good outcomes, with L4 tilt <8° and coronal balance <15 mm at the final follow-up, calculated the cutoff value of the final LIV-T as 12 mm. The cutoff value of preoperative LIV-T that would result in the LIV-T of ≤12 mm at the final follow-up was 32 mm in PSF, although no significant cutoff value was calculated in ASF. ASF can centralize the LIV better than PSF with a shorter segment fusion, and could be useful in obtaining a good curve correction and global balance without fixation to L4 in cases with large preoperative LIV-T.

Destructive Spondyloarthropathy due to Congenital Insensitivity to Pain with Anhidrosis: A Case Report of Long-Term Follow-Up.

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare autosomal-recessive hereditary neuropathy causing congenital loss of pain sensation, thermoception, and perspiration. CIPA sometimes causes destructive spondyloarthropathy, the so-called Charcot spine, because of insensitivity to pain stimuli. Herein, we report a case of CIPA with severe spinal destruction treated by multiple spinal reconstructive surgeries and over 15 years of follow-up. A 15-year-old male patient who had been diagnosed with CIPA at the age of 17 months presented to his previous spine clinic with gait disturbance due to muscle weakness in his lower extremities. Imaging studies revealed that collapsed L3 and L4 vertebral bodies involved the spinal canal, and it was treated by L3-L4 instrumented posterior fusion. Fourteen years after surgery, the patient became unable to walk again due to spinal canal stenosis at the proximal fusion segment. An L2-L3 posterior interbody fusion alleviated his gait ability for 2 years; however, he became unable to stand again because of the collapsed fusion segment that caused severe lumbar kyphosis. Subsequently, a two-staged posterior and anterior fusion surgery from the lower thoracic spine to the pelvis was performed, and spinal fusion and neurological recovery were achieved 3 years after surgery. A kyphotic deformity in patients with CIPA-associated Charcot spine could be favorably treated by a long spinal fusion in combination with a reconstruction of an anterior spinal column. This case report provides a significant lesson for a treatment of CIPA-associated Charcot spine.

Anterior versus posterior approach in Lenke type 1 adolescent idiopathic scoliosis: a comparison of long-term follow-up outcomes.

Background: After surgical treatment of adolescent idiopathic scoliosis (AIS), doctors should not only focus on the short-term surgical effect, but also pay special attention to whether the patients can live normally in the long-term. This work compared the long-term effects of thoracoscopy-assisted anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in AIS. Methods: Twenty-two patients underwent thoracoscopy-assisted ASF, and twenty-three patients underwent PSF from 2004 to 2009 were involved , including 14 males and 31 females with an average age of 14.8±2.6 years, and all patients suffered from only Lenke type 1 AIS. The mean follow-up time was 102 months, the radiographic parameters and operation time, hospitalization time, fusion segments and estimated blood loss were evaluated. Comparisons between groups were made such as Cobb's angle, thoracic kyphosis, the instrumented levels, curve correction, preoperative parameters, SF-36/SRS-22 questionnaire scores, and pulmonary function. Results: There was no significant difference in age, gender, Risser sign and follow-up period between two groups. The instrumentation level had an average of 6 in the thoracoscopy-assisted ASF group and 9.7 in the PSF group (P<0.001). The average correction rate of the main curve was 67.4% in ASF group versus 79.2% in PSF group (P>0.05). The postoperative thoracic kyphosis was 16.2°±3.9° in ASF group and 25.6°±4.4° in PSF group (P=0.023). Patients had momentous advancement in self-image, vitality and mental health in the SRS-22 and SF-36 questionnaires. Compared to preoperatively, the pulmonary function of both groups was satisfactorily improved at the final follow-up. Conclusions: Since there was no statistically significant difference in the general conditions of the two groups selected for this study, so we finally concluded that thoracoscopy-assisted ASF had a satisfactory correction rate, famous long-term radiography outcomes and desirable pulmonary function results. However, compared to PSF, it has a longer operation time, a more complicated surgical procedure and a weaker three-dimensional correction effect, and PSF has affirmative long-term outcomes, fewer complications, and satisfactory sagittal balance, all of which make PSF the standard operation to treat AIS.

Complications following surgical treatment of adolescent idiopathic scoliosis: a 10-year prospective follow-up study.

BACKGROUND: Accurate reporting of long-term complications of surgical treatment of adolescent idiopathic scoliosis (AIS) is critical, but incomplete. This study aimed to report on the rate of complications following surgical treatment of AIS among patients with at least 10 years of follow-up. METHODS: This was a retrospective review of prospectively collected data from a multicenter registry of patients who underwent surgical treatment for AIS with minimum 10-year follow-up. Previously published complications were defined as major if they resulted in reoperation, prolonged hospital stay/readmission, neurological deficits, or were considered life-threatening. Rates and causes of reoperations were also reviewed. RESULTS: Two hundred and eighty-two patients were identified with mean age at surgery of 14.6 ± 2.1 years. Mean follow-up was 10.6 (range 9.5-14) years. Eighty-seven patients had anterior spinal fusion (ASF); 195 had posterior spinal fusion (PSF). The overall major complication rate was 9.9% (n = 28) in 27 patients. Among PSF patients, the complication rate was 9.7% (n = 19) in 18 patients. The complications were surgical site infection (37%), adding-on (26%), pulmonary (16%), neurologic (11%), instrumentation (5%), and gastrointestinal (5%). In ASF patients, the complication rate was 10.3% (n = 9) among nine patients. The complications were pulmonary (44%), pseudoarthrosis (22%), neurologic (11%), adding-on (11%), and gastrointestinal (11%). The reoperation rate was 6.0% (n = 17) among 17 patients. Although most of the complications presented within the first 2 years (60.7%), surgical site infection and adding-on were also seen late into the 10-year period. CONCLUSION: This is the largest prospective study with at least a 10-year follow-up of complications following spinal fusion for AIS, the overall major complication rate was 9.9% with a reoperation rate of 6.0%. Complications presented throughout the 10-year period, making long-term follow-up very important for surveillance. LEVEL OF EVIDENCE: Therapeutic II.

Differences in the Prevalence of Clinical Adjacent Segment Pathology among Continents after Anterior Cervical Fusion: Meta-Analysis of Randomized Controlled Trials.

Development of adjacent segment pathology leading to secondary operation is a matter of concern after anterior cervical discectomy and fusion (ACDF). Some studies have reported anatomic difference between races, but no epidemiological data on prevalence of clinical adjacent segment pathology (cASP) among races or continents has been published. The purpose of this study was to compare the prevalence of cASP that underwent surgery after monosegmental ACDF among continents by meta-analysis. MEDLINE, EMBASE, and Cochrane Library with manual searching in key journals, reference lists, and the National Technical Information Service were searched from inception to December 2018. Twenty studies with a total of 2009 patients were included in the meta-analysis. We extracted the publication details, sample size, and prevalence of cASP that underwent surgery. A total of 15 papers from North America, three from Europe, and two from Asia met the inclusion criteria. A total number of 2009 patients underwent monosegmental ACDF, and 113 patients (5.62%) among them had cASP that underwent surgery. The rate of cASP that underwent surgery was 4.99% in the North America, 3.65% in the Europe, 6.34% in the Asia, and there were no statistically significant differences (p = 0.63). The current study using the method of meta-analysis revealed that there were no significant differences in the rate of cASP that underwent surgery after ACDF among the continents.

Clinical Efficacies of the Minimal Retroperitoneal Approach for Infectious Spondylodiscitis: A Clinical Case Series.

INTRODUCTION: An anterior surgical approach for severe infectious spondylodiscitis in the lumbar region is optimal but not always atraumatic. The aim of this study was to evaluate the efficacy and safety of a minimal anterior-lateral retroperitoneal approach, also known as a surgical approach for oblique lumbar interbody fusion, for cases with severe infectious spondylodiscitis with osseous defects. METHODS: Twenty-four consecutive patients who underwent anterior debridement and spinal fusion with an autologous strut bone graft for infectious spondylodiscitis with osseous defects were reviewed retrospectively. Eleven patients underwent the minimal retroperitoneal approach (Group M), and 13 underwent the conventional open approach (Group C). Peri- and postoperative clinical outcomes, that is, estimated blood loss (EBL), operative time (OT), creatine kinase (CK) level, visual analog scale (VAS), and rates of bone union and additional posterior instrumentation, were evaluated, and the differences between both groups were assessed statistically. RESULTS: Mean EBL, serum CK on the 1st postoperative day, and VAS on the 14th postoperative day were 202.1 mL, 390.9 IU/L, and 9.5 mm in Group M and 648.3 mL, 925.5 IU/L, and 22.3 mm in Group C, respectively, with statistically significant differences between the groups. There were no statistically significant intergroup differences in OT and rates of bone union and additional posterior instrumentation. CONCLUSIONS: Anterior debridement and spinal fusion using the minimal retroperitoneal approach is a useful and safe surgical technique. Although a preponderance of the minimal approach regarding early bone union is not validated, this technique has the advantages of conventional open surgery, but reduces blood loss, muscle injury, and pain postoperatively.

The Incidence of Adding-On or Distal Junctional Kyphosis in Adolescent Idiopathic Scoliosis Treated by Anterior Spinal Fusion to L3 Was Significantly Higher Than by Posterior Spinal Fusion to L3.

OBJECTIVE: To compare and identify risk factors for distal adding-on (AO) or distal junctional kyphosis (DJK) in adolescent idiopathic scoliosis (AIS) treated by anterior- (ASF) and posterior spinal fusion (PSF) to L3. METHODS: AIS patients undergoing ASF versus PSF to L3 from 2000-2010 were analyzed. Distal AO and DJK were deemed poor radiographic results. New stable (SV) and neutral vertebra (NV) scores were defined for this study. The total stability (TS) score was the sum of the SV and NV scores. RESULTS: Twenty of 42 (ASF group: 47.6%) and 8 of 72 patients (PSF group: 11.1%) showed poor radiographic outcome. Fused vertebrae, correction rate of main curve, coronal reduction rate of L3 were significantly higher in PSF group. Multiple logistic regression results indicated that preoperative SV-3 at L3 in standing and side benders (odds ratio [OR], 2.7 and 3.7, respectively), TS score -5, -6 at L3 (OR, 4.9), rigid disc at L3-4 (OR, 3.7), lowest instrumented vertebra (LIV) rotation > 15° (OR, 3.3), LIV deviation > 2 cm from center sacral vertical line (OR, 3.1) and ASF (OR, 13.4; p < 0.001) were independent predictive factors. There was significant improvement of the Scoliosis Research Society (SRS)-22 average scores only in PSF group. Furthermore, the ultimate scores of PSF group were significantly superior to ASF group. CONCLUSION: The prevalence of AO or DJK at ultimate follow-up for AIS with LIV at L3 was significantly higher in ASF group. Ultimate SRS-22 scores were significantly better in PSF group.

Use of lordotic cages in L5-S1 Anterior Lumbar Interbody Fusion (ALIF) procedures

Anterior Lumbar Interbody Fusion (ALIF) has gained popularity in the last few years, thanks to its numerous advantages. Recently the use of lordotic cages has been described, allowing theoretically a better lordosis restoration of the lumbar disc space. We described the results obtained with the use of lordotic cages in 27 patients who underwent ALIF procedure for L5-S1 disc degenerative disease, in terms of segmental lordosis and global lumbar lordosis changes.

Comparison of Adjacent Segment Degeneration, Cervical Alignment, and Clinical Outcomes After One- and Multilevel Anterior Cervical Discectomy and Fusion.

OBJECTIVE: This study aimed to assess the influence of a fused segment on cervical range of motion (ROM) and adjacent segmental kinematics and determine whether increasing number of fusion levels causes accelerated adjacent segment degeneration (ASD) after anterior cervical discectomy and fusion (ACDF). METHODS: A total of 165 patients treated with ACDF were recruited for assessment, and they were divided into 3 groups based on the number of fusion levels. Radiological measurements and clinical outcomes included visual analogue scale (VAS) and Neck Disability Index (NDI) assessed preoperatively and at ≥2 years of follow-up. RESULTS: ASD occurred in 41 of 165 patients who underwent ACDF (1-level, 12 of 78 [15.38%]; 2-level, 14 of 49 [28.57%]; 3-level, 15 of 38 [39.47%]; p=0.015) at final follow-up (mean, 31.9 months). Significant differences were found in reduction of global ROM based on the number of fusion levels (p<0.001). The upper adjacent segment ROM increased over time (p=0.004); however, lower segment ROM did not. Three-level ACDF did not obtain greater amounts of lordosis than did 1- or 2-level ACDF (p=0.003). Postoperative neck VAS scores and NDI were significantly higher for 3-level ACDF than for 1- or 2-level ACDF (p=0.033 and p=0.001). CONCLUSION: ASD occurred predominantly in multilevel cervical fusion, more frequently in the upper segment of the prior fusion and as the number of fusion levels increased. Patients who underwent multilevel fusion had greater reduction of global ROM and increased compensatory motion at the upper adjacent segment. Three-level ACDF did not appear to restore cervical lordosis significantly compared with 1- or 2-level arthrodesis.

Progressive decline in pulmonary function 5 years post-operatively in patients who underwent anterior instrumentation for surgical correction of adolescent idiopathic scoliosis.

PURPOSE: To evaluate changes in pulmonary function tests (PFT) at 5 years post-operatively in patients with adolescent idiopathic scoliosis (AIS) and to determine whether these changes are progressive or static after 2 years. METHODS: AIS surgical patients with pre-operative and 5 year post-operative forced expiratory volume (FEV) and forced vital capacity (FVC) were included. The percentage of patients with pulmonary impairment at 5 years was calculated. Repeated measures ANOVA was used to evaluate changes between pre-operative PFT and 5 years post-operative PFT and to determine whether the changes differed between curve types and approach. A sub-analysis of patients with 2 year data was performed to determine whether PFT changes were static or progressive. RESULTS: Two hundred and sixty-two patients had undergone pre-operative and 5 year post-operative PFTs. At 5 years, 42% were normal, 41% had mild impairment, and 17% had moderate-severe impairment. Overall, there was a decline in % predicted FVC (p < 0.05); FEV remained stable. There was no difference based on major curve type (p > 0.05). Anterior instrumentation cases declined significantly between pre-operative PFT and 5 years post-operative PFT (FEV: - 10% open, - 6% thoracoscopic; FVC: - 13% open, - 8% thoracoscopic) (p ≤ 0.02). The posterior cases remained stable (2% FEV, p = 0.7; - 0.6% FVC, p = 0.06). A subgroup of 90 patients with 2 year post-operative PFTs demonstrated that changes were progressive between 2 and 5 years post-operatively. The average change in FVC from 2 to 5 years was significantly different between the anterior open (- 9%) and posterior-only (0.7%) groups (p = 0.015). CONCLUSION: In patients who underwent anterior instrumentation, PFTs declined from the pre-operative to the 5 years post-operative time point. There was a progressive decline of 4-10% beyond 2 years post-operatively. Patients who underwent posterior instrumentation remained stable. These slides can be retrieved under Electronic Supplementary Material.

Factors associated with surgical approach and outcomes in cerebral palsy scoliosis.

BACKGROUND: Neuromuscular scoliosis is often treated with posterior spinal fusion, with or without anterior release, and either a same-day or staged, 2-day procedure. METHODS: We retrospectively reviewed 222 patients from a prospectively collected, multi-center database of patients with cerebral palsy scoliosis with 2-year follow-up. Baseline characteristics, perioperative, radiographic, and HRQoL measures were compared in six sub-analyses: (1) staged versus same-day surgeries, (2) posterior-only fusion (PSF) versus anterior-posterior spinal fusion (APSF), (3) same-day versus staged PSF, (4) staged versus same-day APSF, (5) same-day PSF versus same-day APSF, (6) staged PSF versus staged APSF. RESULTS: Staged patients had larger curves and more pelvic obliquity, longer anesthesia and surgical times, longer hospital and ICU stays (p < 0.001), and more days intubated (p = 0.021). The staged PSF group had larger curves (p = 0.006), longer anesthesia (p = 0.020) and surgeries (p = 0.007), hospital (p = 0.009) and ICU stays (p = 0.028) compared to same-day PSF. The staged APSF group had longer hospital (p < 0.001) and ICU stays (p = 0.004) and anesthesia and surgeries (p < 0.001). Same-day APSF was associated with larger curves (p < 0.002), longer anesthesia (p = 0.012) and surgeries (p = 0.042), greater residual curves (p = 0.035), and greater absolute correction (p = 0.007) compared to same-day PSF. The staged APSF group had longer anesthesia times (p < 0.001) compared to the staged PSF group. No sub-analysis revealed significant differences in baseline characteristics, complications, or HRQoL. CONCLUSION: Staged and circumferential approaches tend to be used for greater deformity, but were not associated with superior deformity correction, and were associated with longer operative time, hospital stays, ICU stays, and days intubated. However, for the most severe deformity, other patient factors may play more important roles in treatment decisions given that patients treated with a staged PSF or an APSF, whether staged or not, were similar at baseline. LEVEL OF EVIDENCE: III. These slides can be retrieved under Electronic Supplementary Material.

Postoperative translation of the upper instrumented vertebra in thoracic adolescent idiopathic scoliosis.

OBJECTIVEThe aim of this retrospective study was to analyze the influence of upper instrumented vertebra (UIV) translation from the C7 plumb line (C7PL) on the long-term postoperative results of patients with main thoracic (MT) adolescent idiopathic scoliosis (AIS).METHODSTwenty-five patients had been treated surgically for AIS with a Lenke type 1 curve and had been followed up for a mean period of 18.2 years. Radiographic parameters, pulmonary function measurements, and clinical outcomes were compared between the patients (n = 15) with UIV translation < 20 mm and those (n = 10) with UIV translation ≥ 20 mm at the final follow-up. Correlations between UIV translation and radiographic or pulmonary function parameters were analyzed.RESULTSPatients with ≥ 20 mm UIV translation at the final follow-up had a significantly larger preoperative UIV translation than that in the patients with < 20 mm UIV translation at follow-up. The former group also had a significantly lower correction rate of the MT curve, higher chest cage ratio, and lower radiographic shoulder height (p = 0.01, 0.005, and 0.025, respectively) at the final follow-up. The Scoliosis Research Society (SRS)-30 Questionnaire scores were equivalent between the two groups. Correlation analysis showed that the following parameters were significantly associated with UIV translation: MT curve correction rate (r = -0.481, p = 0.015), chest cage ratio (r = 0.673, p < 0.001), and percent-predicted forced expiratory volume in 1 second (r = -0.455, p = 0.033).CONCLUSIONSThe UIV translation should be considered an important factor that influences postoperative results. In MT AIS patients whose preoperative upper end vertebra (UEV) is distant from the C7PL, the UIV should be selected above the UEV to prevent large UIV translation at the postoperative follow-up.

Anterior Spinal Fusion and Posterior Spinal Fusion Both Effectively Treat Lenke Type 5 Curves in Adolescent Idiopathic Scoliosis: A Multicenter Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Retrospective comparison of radiographic and clinical outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in surgical treatment of Lenke 5 curves. SUMMARY OF BACKGROUND DATA: ASF and PSF are used for treatment of Lenke 5 curves in patients with adolescent idiopathic scoliosis (AIS). Currently, no consensus exists for optimal surgical treatment of Lenke 5 curves. METHODS: Patients with Lenke 5 curves treated with either ASF or PSF were prospectively enrolled in a multicenter database and then retrospectively reviewed. Demographic data, perioperative measures, radiographic data, and SRS-22R scores were collected and compared for statistical significance. RESULTS: A total of 149 patients were included in the study; 51 underwent PSF and 98 underwent ASF. There was no difference in demographics between groups. The PSF group was fused one level longer than the ASF group (5.9 levels PSF, 4.6 levels ASF, p < .0001). The PSF group had shorter operative times (223 minutes PSF, 297 minutes ASF; p < .0001) and a higher proportion of patients who received a postoperative blood transfusion (45% vs. 5%, p < .0001). PSF patients had longer hospital stays (6.1d PSF vs. 5d ASF, p = .031). The ASF group had larger preoperative major curve (48.2° ASF, 44.2° PSF; p < .01). Coronal balance, thoracolumbar/lumbar Cobb angle, shoulder height, trunk shift, and overall sagittal balance were not different between groups at two-year follow-up. Curve correction at two-year follow-up was similar between groups (66% ASF vs. 62% PSF). There were no significant differences in clinical outcomes or complication rates between groups. CONCLUSION: There is no difference in radiographic or clinical outcomes in patients treated with ASF or PSF for Lenke 5 curves. ASF may save a fusion level, but has longer operative time than PSF. Ultimately, the risks and benefits of each approach merit consideration by surgeon and patient. LEVEL OF EVIDENCE: Level II.

Is vertebral rotation correction maintained after thoracoscopic anterior scoliosis surgery? A low-dose computed tomography study.

BACKGROUND: Axial vertebral rotation is a key characteristic of adolescent idiopathic scoliosis (AIS), and its reduction is one of the goals of corrective surgery. Recurrence of deformity after surgical correction may relate to rotation changes that occur in the anterior vertebral column after surgery, but whether any change occurs within the fused segment or in adjacent unfused levels following thoracoscopic anterior spinal fusion (TASF) is unknown. An analysis of measurements from an existing postoperative CT dataset was performed to investigate the occurrence of inter- and intra-vertebral rotation changes after TASF within and adjacent to the fused spinal segment and look for any relationships with the Cobb angle and rib hump in the two years after surgery. METHODS: 39 Lenke Type 1 main thoracic patients underwent TASF for progressive AIS and low dose computed tomography scanning of the instrumented levels of the spine at 6 and 24 months after surgery. Vertebral rotation was measured at the superior and inferior endplates on true axial images for all vertebral levels in the fused segment plus one adjacent level cranially and caudally. Intra-observer variability for rotation measurements was assessed using 95% limits of agreement to detect significant changes in inter/intra-vertebral rotation. RESULTS: Significant local changes in inter- and intra-vertebral rotation were found to have occurred between 6 and 24 months after anterior surgical fusion within the fused spinal segment, albeit with no consistent pattern of location or direction within the instrumented fusion construct. No significant en-bloc movement of the entire fused spinal segment relative to the adjacent un-instrumented cranial and caudal intervertebral levels was found. No clear correlation was found between any vertebral rotation changes and Cobb angle or rib hump measures. CONCLUSIONS: Localised inter- and intra-vertebral rotation occurs between 6 and 24 months after TASF, both within the instrumented spinal segments and in the adjacent un-instrumented levels of the adolescent spine. The lack of measurable en-bloc movement of the fused segment relative to the adjacent un-instrumented levels suggests that overall stability of the instrumented construct is achieved, however the vertebrae within the fusion mass continue to adapt and remodel, resulting in ongoing local anatomical and biomechanical changes in the adolescent spine.

A malignant solitary fibrous tumour arising from the first lumbar vertebra and mimicking an osteosarcoma: a case report.

BACKGROUND: A solitary fibrous tumour (SFT) is an unusual neoplasm typically found in soft tissues. Although SFTs can arise in the bones, they very rarely arise in the vertebral arch. Here, we describe a case of a SFT that arose in the vertebral arch of the first lumbar (L1) spinal vertebrae and mimicked osteosarcoma. CASE PRESENTATION: A 49-year-old woman presented with a 2-month history of lower back pain and a lumbar region mass. Magnetic resonance imaging demonstrated a heterogeneously enhanced mass in the L1 vertebral arch. The patient received neoadjuvant chemotherapy, followed by a surgical procedure comprising an anterior spinal fusion and en bloc resection. Histologically, our initial diagnosis was osteosarcoma. The postoperative course was uneventful, and the patient received adjuvant chemotherapy. However, the tumour metastasised to the lung 5 years after the first surgery, and a second surgery was performed for lung tumour resection. The histology of the metastatic lung tumour appeared similar to that of the malignant SFT, and the specimen from the first surgery was re-examined. Immunohistochemically, the tumour was positive for STAT6. Reverse transcription-polymerase chain reaction revealed a NAB2-STAT6 fusion gene, thus confirming our final diagnosis of malignant SFT. The patient died of disease progression 8 years after the first surgery; however, there was no evidence of local recurrence. CONCLUSIONS: Malignant SFT in the vertebral arch is extremely rare and very difficult to distinguish histologically an osteoid from lace-like collagen. STAT6 immunostaining is useful for distinguishing malignant SFTs from other neoplasms. Although it is difficult to completely resect a SFT arising from the spine, we demonstrated the feasibility of an en bloc resection of spinal tumours arising from posterior elements, without local recurrence.

A rare postoperative complication of anterior lower thoracic instrumentation: diaphragmatic laceration with hemothorax.

PURPOSE: To highlight the importance of preventing visceral injury due to prominent anterior implants at the spinal column. METHODS: A 52-year-old man with cord compression was treated with a T9/10 discectomy and instrumented fusion via a right thoracotomy and trans-pleural approach. Postoperatively, he had improved lower limb numbness. However, after a bout of coughing, there was sudden increase in chest drain output, hemodynamic instability and massive fluid collection in the right chest cavity. RESULTS: Emergency re-exploration of the thoracotomy was performed and a 6 cm laceration of the right postero-medial diaphragm was identified as the bleeding source and was found to be in close proximity with the locking nut of the anterior implants. The laceration was repaired and a soft synthetic patch was used to cover the implants. Postoperatively, the hemothorax resolved and the patient recovered from the neurological deficit. CONCLUSIONS: Prevention of diaphragmatic injury can be performed using lower profile and less sharp-edged implants. Implant coverage with a soft synthetic material is necessary if unable to perform direct repair of the parietal pleura over the implants.