Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis.

INTRODUCTION: Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. METHOD: A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). RESULTS: 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. CONCLUSION: Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

The global impact of the COVID-19 pandemic on pediatric spinal care: A multi-centric study.

Background: The COVID-19 pandemic has affected healthcare worldwide since December 2019. We aimed to identify the effect of the COVID-19 pandemic on outpatient clinic and surgical volumes and peri-operative complications for pediatric spinal deformities patients. Methods: In this multi-center retrospective study, outpatient visits (in-person and virtual care) and pediatric spine surgeries volumes in four high-volume pediatric spine centers were compared between March and December 2019 and the same period in 2020. Peri-operative complications were collected and compared in the same periods. Descriptive statistics were calculated, and comparative analyses were performed. Results: During the 2020 study period, the outpatient visit (in-person and virtual care) volume decreased during local lockdown periods by 71% for new patients (p < 0.001) and 53% for returning patients (p = 0.03). Overall, for 2020, there was a 20% reduction in new patients (p = 0.001) and 21% decrease in returning patients (p < 0.001). During the pandemic, there was also 20% less overall surgical volume of adolescent idiopathic scoliosis (AIS) patients undergoing primary posterior spinal fusion, with a 70% reduction during lockdown times (p < 0.001). Complication rate and profile were similar between periods. Conclusion: There was a significant decrease in outpatient pediatric spine outpatient visits, particularly new patients, which may increase the proportion of pediatric patients with spinal deformities that present late, meeting surgical indication. This, in combination with the reduction in surgical volume of AIS over the first year of the pandemic, could result in an extended waitlist for surgeries during years to come. Complication rate was similar for both periods, suggesting it is safe to continue elective pediatric spine surgery even in a time of a pandemic. Level of evidence: level IV.

Magnetically Controlled Growing Rods Graduation: Lessons From a Single-center Series of 48 Patients.

BACKGROUND: Magnetically controlled growing rod (MCGR) treatment for early-onset scoliosis (EOS) has become a widely utilized method of deformity control, but long-term follow-up reports are sparse. We evaluated the outcomes of a large group of consecutive pediatric patients diagnosed with EOS who were treated by MCGR to the endpoint of definitive spinal fusion in a single center. We hypothesized that lessons learned from treating a large volume of MCGR patients would lower the complication rate in comparison to what was previously reported by other studies. METHODS: The records of 48 EOS patients with varied etiologies who were treated by MCGR between 2012 and 2022 and reached the end of treatment were analyzed retrospectively for baseline and final radiographic measurements and surgery-related complications. RESULTS: The mean percent of improvement in the major coronal deformity was 51.7±25.0% and the mean T1 to T12 total growth was 52.9±21.9 mm. The total complication rate was 22.9% of which 12.5% required a single unplanned surgery, 6.3% required multiple unplanned surgeries, and 4% did not require any unplanned surgery. CONCLUSION: MCGR treatment provides adequate control of EOS, enabling satisfactory growth of the thoracic spine. The complication rate in a single large volume center is moderate. LEVEL OF EVIDENCE: IV.

Metastatic Plasmacytoid Urothelial Carcinoma Masquerading as a Primary Signet Ring Cell Carcinoma of the Duodenum.

Plasmacytoid urothelial carcinoma can histologically mimic gastrointestinal signet ring cell carcinoma, a potential diagnostic pitfall resulting in improper clinical management. We present a rare case of a malignant duodenal ulcer due to metastasis from plasmacytoid urothelial carcinoma. Only by histological and retrospective immunohistochemical comparison with the primary bladder tumor was this revealed as a metastasis from a plasmacytoid urothelial carcinoma. This case report highlights the importance of clinical correlation and comparison with any previous pathology specimens, the limitations of immunohistochemical staining, and the utilization of both old and new immunohistochemical tools when differentiating signet ring cell carcinomas of primary sites versus potential metastases.

Risk factors associated with in-hospital adverse events: a multicenter observational cohort study of 1853 pediatric patients with traumatic spinal cord injury.

OBJECTIVE: In this study, the authors aimed to quantify the frequency of in-hospital major adverse events (AEs) in a multicenter cohort of pediatric patients with spinal cord injury (SCI) managed at North American trauma centers. They also sought to identify patient and injury factors associated with the occurrence of major and immobility-related AEs. METHODS: Data derived from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) were used to identify a cohort of pediatric patients (age < 19 years) with traumatic SCI. The authors identified individuals with major and immobility-related AEs following injury. They used mixed-effects multivariable logistic regression to identify clinical variables associated with AEs after injury. This analytical approach allowed them to account for similarities in care delivery between patients managed in the same trauma settings during the study period while also adjusting for patient-level confounders. The adjusted impact of AEs on in-hospital mortality and length of stay (LOS) were also assessed through further multivariable regression analysis. Additional subgroup analyses were performed to reduce bias associated with competing risks and explore the age-specific risk factor associations with AEs. RESULTS: A total of 1853 pediatric patients who sustained either cervical or thoracic SCI were managed at ACS TQIP trauma centers between 2017 and 2020. The most frequently encountered AE types were pressure ulcer, unplanned intubation, cardiac arrest requiring cardiopulmonary resuscitation, and ventilator-associated pneumonia. The crude rate of major in-hospital and immobility-related AEs significantly differed between subgroups, with higher proportions of AEs in complete injuries compared with incomplete injuries. The adjusted risk for major AE following injury was significantly elevated for cervical complete SCI, patients with severe concomitant abdominal injuries, and for those presenting with depressed Glasgow Coma Scale scores less than 13. These same risk factors were associated with major AEs in children older than 8 years but were not significant for younger children (age ≤ 8 years). Complication occurrence was not associated with difference in risk-adjusted mortality (OR 0.72, 95% CI 0.45-1.14), but did increase LOS by 2.2 days (95% CI 1.4-2.7 days). CONCLUSIONS: The authors outlined the prevalence of in-hospital AEs in a large multicenter cohort of North American pediatric SCI patients. Important risk factors predisposing this population to AEs include cervical complete injuries, simultaneous abdominal trauma, and Glasgow Coma Scale scores < 13 at presentation. Postinjury complications impacted health resource utilization by increased LOS but did not affect postinjury mortality. These findings have important implications for pediatric SCI providers and future care quality benchmarking.

Utility of intraoperative neurophysiological monitoring in detecting motor and sensory nerve injuries in pediatric high-grade spondylolisthesis.

BACKGROUND CONTEXT: Intraoperative neuromonitoring (IONM) during surgical correction of spinal deformity has been shown to reduce iatrogenic injury in pediatric and adult populations. Although motor-evoked potentials (MEP), somatosensory-evoked potentials (SSEP), and electromyography (EMG) have been shown to be highly sensitive and specific in detecting spinal cord and nerve root injuries, their utility in detecting motor and sensory nerve root injury in pediatric high-grade spondylolisthesis (HGS) remains unknown. PURPOSE: We aim to assess the diagnostic accuracy and therapeutic impact of unimodal and multimodal IONM in the surgical management of HGS. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Pediatric patients undergoing posterior spinal fusion (PSF) for treatment of HGS. OUTCOME MEASURES: Data on patient demographics, spinopelvic and spondylolisthesis parameters, and the presence of pre-and postoperative neurological deficits were collected. METHODS: Intraoperative MEP, SSEP, and EMG alerts were recorded. Alert criteria were defined as a change in amplitude of more than 50% for MEP and/or SSEP, with or without change in latency, and more than 10 seconds of sustained EMG activity. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each modality and the combination of MEP and SSEP. The 95% confidence intervals (CIs) were calculated using the exact (Clopper-Pearson) method. RESULTS: Fifty-four pediatric patients with HGS undergoing PSF between 2003 and 2021 in a single tertiary center were included. Seventy-two percent (39/54) of patients were female; the average age of patients was 13.7±2.3 years. The sensitivity of MEP in detecting new postoperative neurologic deficit was 92.3% (95% CI [64.0-99.8]), SSEP 77.8% (95% CI [40.0-97.2]), EMG 69.2% (95% CI [38.6-90.9]), and combination MEP and SSEP 100% (95% CI [73.5-100]). The specificity of MEP was 80.0% (95% CI [64.4-91.0]), SSEP 95.1% (95% CI [83.5-99.4]), EMG 65.9% (95% CI [49.4-79.9]), and combination MEP and SSEP 82.9% (95% CI [67.9-92.9]). The accuracy of SSEP was 92.0% (95% CI [80.8%-97.8%]), and the combination of MEP and SSEP was 86.8% (95% CI [74.7%-94.5%]). Twelve (22.2%) patients had a new motor or sensory deficit diagnosed immediately postoperatively. Nine patients made a full recovery, and 3 had some neurologic deficit on final follow-up. CONCLUSION: Unimodal IONM using SSEP and MEP alone were accurate in diagnosing sensory and motor nerve root injuries, respectively. The diagnostic accuracy in predicting motor and sensory nerve injuries in pediatric HGS improved further with the use of multimodal IONM (combining MEP and SEP). We recommend the utilization of multimodal IONM in all HGS PSF surgeries.

An Unusual Case of Mucinous Adenocarcinoma of the Lung Presenting as Septic Emboli.

This is a case of a 92-year-old female with multiple hospitalizations for dyspnea on exertion and hypoxemia. Her symptoms were initially thought to be secondary to pneumonia, and on subsequent admission, culture-negative endocarditis. A computed tomography (CT) of the chest was remarkable for numerous bilateral lung nodules of varying size, some of which had a cavitary appearance raising concern for septic emboli. While a transthoracic echo was unremarkable, a transesophageal echo found a small 3 mm echodensity at the tip of the right coronary leaflet of the aortic valve and a possible mobile echodensity on the tricuspid valve leaflet. These findings further supported a clinical diagnosis of endocarditis with septic emboli in the lungs. Initial bronchoscopy yielded an unremarkable biopsy and a bronchial alveolar lavage with the growth of Actinomyces odontolyticus. During a subsequent hospitalization, a repeat bronchoscopy with transbronchial biopsy revealed a final diagnosis of invasive pulmonary mucinous adenocarcinoma. This case highlights a unique presentation of mucinous adenocarcinoma of the lung initially masquerading as septic emboli, resulting in a delay in the final diagnosis.

Colonic Lymphangiomatosis.

Lymphangiomas are benign malformations of the lymphatic vessels which can be primary or secondary in etiology. Colonic involvement is rare, and the diagnosis is mostly incidental. Sometimes, the initial endoscopic appearance can be misleading. We present a case of colonic lymphangiomatosis presenting with free air under the diaphragm requiring surgical removal of the involved portion of the colon. The diagnosis was confirmed by the pathology of the resected specimen and its correlation with prior clinical information. The patient recovered well with an uneventful postoperative course and follow-up. This case demonstrates a rare complication of colonic lymphangiomatosis prompting definitive treatment by surgical resection.

Utilization of individual components of enhanced recovery after surgery (ERAS) protocol improves post-operative outcomes in adolescent idiopathic scoliosis: a blueprint for progressive adoption of ERAS.

PURPOSE: Enhanced recovery after surgery [ERAS] is an approach for standardization of perioperative care aimed at improving patient outcomes. The primary aim of this study was to determine if length of stay (LOS) differed by protocol type (ERAS vs. non-ERAS [N-ERAS]) in patients undergoing surgery for adolescent idiopathic scoliosis (AIS). METHODS: A retrospective cohort study was conducted. Patient characteristics were collected and compared between groups. Differences in LOS were assessed using regression adjusting for age, sex, BMI, pre-surgical Cobb angle, levels fused and year of surgery. RESULTS: Fifty nine ERAS patients were compared to 81 N-ERAS patients. Patients were comparable in their baseline characteristics. Median LOS was 3 days (IQR = 3-4) for the ERAS group, compared to 5 days (IQR = 4-5) for the N-ERAS group (p < 0.001). The ERAS group had a significantly lower adjusted rate of stay (RR = 0.75; 95% CI = 0.62-0.92). The ERAS group had significantly lower average pain on post-operative days 0 (least-squares-mean [LSM] 2.66 vs. 4.41, p < 0.001), POD1 (LSM 3.12 vs. 4.48, p < 0.001) and POD5 (LSM 2.84 vs. 4.42, p = 0.035). The ERAS group had lower opioid consumption (p < 0.001). LOS was predicted by the number of protocol elements received; those receiving two (RR = 1.54 95% CI = 1.05-2.24), one (RR = 1.49; 95% CI = 1.09-2.03) or none (RR = 1.60, 95% CI = 1.21-2.13) had significantly longer rates of stay than those receiving all four. CONCLUSION: Adoption of modified ERAS-based protocol for patients undergoing PSF for AIS led to significant reduction in LOS, average pain scores, and opioid consumption.

A comparison of three- and two-rod constructs in the correction of severe pediatric scoliosis.

Purpose: Managing severe scoliosis is challenging and risky with a significant complication rate regardless of treatment strategy. In this retrospective comparative study, we report our results using a three-rod compared to two-rod construct in the surgical treatment of severe spine deformities to investigate which technique is safer, and which provides superior radiological outcomes. Methods: Forty-six consecutive patients undergoing posterior spine fusion for scoliosis between 2006 and 2017 were identified in our institutional records. Inclusion criteria were minimum coronal deformity of 90°, age < 18 years at the time of surgery and a minimum 2 years of follow-up. Radiographic and clinical parameters, as well as post-operative complications were compared between the two groups. Results: There were 21 patients in the three-rod group and 25 in the two-rod group. The mean preoperative major coronal deformity was 100°± 9 and 102°± 10 in the three-rod and two-rod, respectively (p = 0.6). The average major curve correction was 51% and 59% in three-rod and two-rod groups, respectively (p = 0.03). The post-operative thoracic kyphosis was 30°± 11 and 21°± 12 in the three-rod and the two-rod groups, respectively (p = 0.01). The surgical time was 476 ± 52 and 387 ± 84 min in three-rod and two-rod, respectively (p < 0.01). One patient in the two-rod cohort showed permanent post-operative sensory deficit. There were three unplanned returns to operating theater in the two-rod group. Conclusions: Coronal correction was better with two-rod, whereas sagittal balance was superior with three-rod. Both techniques achieved balanced spine treating severe scoliosis. The two-rod technique was associated with a higher likelihood of requiring revision surgery. Level of evidence: level 3.

How useful is pre-referral pediatric spine imaging?

PURPOSE: Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. The objectives were to determine (1) the adequacy of index images to inform treatment decisions at the initial consultation and (2) the utility of index radiology reports for appropriate triage decisions. METHODS: A retrospective chart review was conducted including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1 and April 30, 2021. A score out of five was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity. Index images were considered inadequate if repeat imaging was necessary. Index radiology reports, associated imaging, and new imaging, if obtained at the initial consultation, were compared. RESULTS: Of the 94 patients reviewed, 79% (n = 74) required repeat imaging at the initial consultation, of which 74% (n = 55) were due to insufficient quality and/or limited field of view. Of index images available for review at the initial consult (n = 80), 41.2% scored five out of five, and 32.5% scored two or below. Comparing index radiology reports to initial visit evaluation with ≤ 60 days between imaging (n = 49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients. The Risser stage was reported in 14% of index radiology reports. CONCLUSION: Although pre-referral pediatric spine radiographs serve a diagnostic purpose, most are inadequate for comprehensive idiopathic scoliosis evaluation. LEVEL OF EVIDENCE: III.

Management of perinatal cervical spine injury using custom-fabricated external orthoses: design considerations, narrative literature review, and experience from the Hospital for Sick Children. Illustrative cases.

BACKGROUND: Cervical spine injuries in neonates are rare and no guidelines are available to inform management. The most common etiology of neonatal cervical injury is birth-related trauma. Management strategies that are routine in older children and adults are not feasible due to the unique anatomy of neonates. OBSERVATIONS: Here, the authors present 3 cases of neonatal cervical spinal injury due to confirmed or suspected birth trauma, 2 of whom presented immediately after birth, while the other was diagnosed at 7 weeks of age. One child presented with neurological deficits due to spinal cord injury, while another had an underlying predisposition to bony injury, infantile malignant osteopetrosis. The children were treated with a custom-designed and manufactured full-body external orthoses with good clinical and radiographic outcomes. A narrative literature review further supplements this case series and highlights risk factors and the spectrum of birth-related spinal injuries reported to date. LESSONS: The current report highlights the importance of recognizing the rare occurrence of cervical spinal injury in newborns and provides pragmatic recommendations for management of these injuries. Custom orthoses provide an alternate option for neonates who cannot be fitted in halo vests and who would outgrow traditional casts.

Surgical management of high-grade paediatric spondylolisthesis: meta-analysis and systematic review.

PURPOSE: There is currently no consensus on the management of high-grade spondylolisthesis (HGS) in paediatric populations. The objective of this analysis is to compare the outcomes of reduction followed by fusion (RFF) or in situ fusion (ISF) in paediatric patients. METHODS: Using major databases, a systematic literature search was performed. Primary studies comparing ISF with RFF in paediatric and adolescent patients were identified. Study data including patient-reported outcomes, complications, and spinopelvic parameters were collected and analysed. RESULTS: Seven studies were included, comprising 97 ISF and 131 RFF. Average patient age was 14.4 ± 2.1 years and follow up was 8.2 ± 5.1 years. Patients undergoing RFF compared to patients undergoing ISF alone were less likely to develop pseudarthrosis (RR 0.51, 95% CI, [0.26, 0.99], p = 0.05). On average, RFF led to 11.97º more reduction in slip angle and 34.8% more reduction in sagittal translation (p < 0.00001) compared to ISF. There was no significant difference between patient satisfaction and pain at follow up. Neurologic complications and reoperation rates were not significantly different. CONCLUSIONS: Both RFF and ISF are effective techniques for managing HGS. Performing a reduction followed by fusion reduces the likelihood of pseudarthrosis in paediatric patients. The difference between risk of neurologic complications, need for reoperation, patient satisfaction, and pain outcomes did not reach statistical significance. Correlation with patient-reported outcomes still needs to be further explored. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

Increased proximal vertebral rotation is associated with shoulder imbalance after posterior spinal fusion for severe adolescent idiopathic scoliosis.

PURPOSE: Residual shoulder imbalance is associated with suboptimal outcomes following the surgical correction of adolescent idiopathic scoliosis (AIS) including poor patient satisfaction. In this retrospective study, we evaluate the radiographic parameters and the relationship between the global and local indices of spinal alignment with shoulder balance pre- and postoperatively utilizing EOS imaging and 3D reconstruction. METHODS: A retrospective radiographic analysis was performed on patients with AIS, treated with posterior spinal fusion. Postoperative radiographs were obtained immediately following surgery, at 6 months and final follow-up over 2 years postoperatively. 3D Radiographic measurements included in the coronal plane radiographic shoulder height difference (RSHD), proximal thoracic Cobb angle (PT) and main thoracic Cobb (MT), in the sagittal plane T4-T12 kyphosis, T12-L5 lordosis, in the axial plane proximal thoracic (PT AVR) and main thoracic apical vertebral rotation (MT AVR). RESULTS: Sixty-six patients were included (63 females) with an average main thoracic curvature of 76 degrees. RSHD averaged 14 mm ± 14 preoperatively, -15 mm ± 12 postoperatively, -8.5 mm ± 11 at 6 months, and -8.3 mm ± 8.7 at final follow-up, respectively. Statistical analysis revealed a significant correlation between RSHD and proximal thoracic Cobb angle, between RSHD and proximal thoracic apical vertebral rotation (PTAVR) (r > 0.20, p < 0.05). CONCLUSION: The significant correlation presented in this study suggests that PT Cobb angle and PT AVR are involved in postoperative shoulder imbalance. THE LEVEL OF EVIDENCE: Level 4.

A comparison of the reliability and vulnerability of 3D sterEOS and 2D EOS when measuring the sagittal spinal alignment of patients with adolescent idiopathic scoliosis.

PURPOSE: An essential component of making the diagnosis of adolescent idiopathic scoliosis (AIS) is standing anteroposterior and lateral radiographs. Two-dimensional (2D) radiographs inevitably fail to reflect every plane of the three-dimensional (3D) deformity in scoliosis. We have tested the hypothesis that there is no difference in the assessment of the sagittal plane deformity when measured with either 2D or 3D EOS radiography. METHODS: A retrospective radiographic analysis was performed on patients diagnosed with AIS, with subdivided into three groups according to the coronal angular deformity (mild group: 45°-69°, moderate group: 70°-89°, and severe group: 90° +). The sagittal parameters were compared between manual measurement with 2D sterEOS and those made using computer-aided 3D reconstruction. RESULTS: Fifty-two patients were included in each group. The inter-study reliability when measuring the thoracic Kyphosis (TK) and lumbar lordosis (LL) between the two study modalities was excellent in mild group (ICC: 0.90, 95% CI 0.82 ~ 0.94 and ICC: 0.84, 95% CI 0.74 ~ 0.91), excellent in TK and fair in LL in moderate group (ICC: 0.76, 95% CI 0.61 ~ 0.85 and ICC: 0.70, 95% CI 0.53 ~ 0.81), and fair in TK and LL in severe group, respectively (ICC: 0.74, 95% CI 0.57 ~ 0.84 and ICC: 0.65, 95% CI 0.46 ~ 0.84). A Bland-Altman plot showed proportional bias in TK measurements in each group and LL in moderate group, which means the measured value is underestimated in 2D method when the angle is small. CONCLUSION: 3D sterEOS is less vulnerable to the influence of coronal plane than 2D EOS in evaluating the sagittal spinal parameters of patients with a coronal deformity exceeding 70°.