Early and ultra-early surgical decompression for acute spinal cord injury: bracing for the winds of change.

PURPOSE: Until recently, there has been no consensus on the optimal operative window for decompressive surgery in acute spinal cord injury (aSCI). However, recent evidence is now supporting a role for early intervention in improving outcomes in this type of patients. The purpose of this letter is to discuss the implications for clinical practice within the European community. METHODS: Critical appraisal and interpretation of these results for clinical implementation. RESULTS: Leveraging on the evidence that early (< 24 h), and possibly ultra-early (< 8 h), decompressive spinal surgery in aSCI affords better neurological outcomes, the next challenge for our community will be to ensure that spinal surgery services can accommodate this caseload. Here, we discuss the challenges that will be faced by spinal surgeons and draw parallels between the scaling of these services and the implementation of mechanical thrombectomy for acute ischaemic stroke. We outline key lessons that have been learnt from the rapid scaling of mechanical thrombectomy services and highlight the provisions in infrastructure, education, and staffing that will be required. CONCLUSION: This is a call for hospital systems to swiftly restructure spinal services in order to meet the need for early, and possibly ultra-early, spinal decompression in aSCI cases in the near future.

The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management.

PURPOSE OF REVIEW: Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5-10,000 (Chiu et al. Mayo Clin Proc. 89(1):34-42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476-85, 4). RECENT FINDINGS: The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30-50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149-58, 147, Murdoch et al. N Engl J Med. 286(15):804-8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308-1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS. Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the "systemic features score" (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.

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.

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.

The Value of a Modified Wiltse Approach for Deformity Correction in Neuromuscular Scoliosis.

BACKGROUND: Wiltse approaches have been shown to reduce operative blood loss and enhance recovery in lumbar spinal surgery; however, their efficacy in neuromuscular scoliosis (NMS) deformity correction has never been assessed. Thus, the purpose of this study was to compare the outcomes of deformity correction requiring pelvic fixation in NMS performed through a Wiltse approach in contrast to a standard midline approach. METHODS: This is a retrospective review of 24 consecutive children with NMS undergoing deformity correction by a single surgeon in our institution. Patient demographic data, operative time, blood loss, curve correction, length of stay, and complications were recorded. RESULTS: In 16 children, the procedure was performed through a Wiltse approach and in 8 through a midline approach. There was no significant difference in age, sex, preoperative Cobb angle, or number of levels fused. Patients who underwent a Wiltse approach had significantly less blood loss yet similar curve correction. The hospital length of stay and complication rate were not significantly different between the groups. CONCLUSIONS: A modified Wiltse approach can be safely used for NMS deformity correction. This approach achieves similar curve corrections to a traditional midline approach with less blood loss and no need for iliac screw connectors. LEVEL OF EVIDENCE: 3.

Smartphone application technique for localising magnetically controlled growth rod actuators: the Oxford Magnetic Counter App Technique (TOMCAT).

PURPOSE: The purpose of this study is to report a novel smartphone app technique to localise a magnetically controlled growing rod (MCGR) actuator, along with determining this novel technique accuracy compared to current tactile localisation techniques through an experimental study. METHODS: Five spinal surgery fellows recorded attempts localising the MCGR magnetic actuator using a novel smartphone app technique, MAGEC Wand and magnetic disc. Three attempts per technique were performed and repeated in both the average and overweight patient models. RESULTS: In total, 90 separate localisation attempts were recorded. The smartphone app produced less localisation error than both the MAGEC Wand and magnetic disc. Mean difference was - 0.71 cm (95% CI - 1.24 to - 0.18 cm p = 0.06) and - 0.58 cm (95% CI - 1.11 to - 0.04 cm p = 0.031), respectively. Mean localisation error for the smartphone app, MAGEC Wand and magnetic disc, was 0.9 cm, 1.61 cm, 1.47 cm, respectively, for both average and overweight models combined. CONCLUSIONS: This novel smartphone app localisation technique is accurate. Current MAGEC Wand and magnetic disc techniques produced more localisation error than the reported tolerance of the external remote control lengthening unit in this experiment.

A critical thoracic kyphosis is required to prevent sagittal plane deterioration in selective thoracic fusions in Lenke I and II AIS.

PURPOSE: Thoracic hypokyphosis following AIS correction may be associated with reduced lumbar lordosis with potential adverse effects on the global sagittal balance. In the present study, we were interested in how the amount of thoracic kyphosis influences the sagittal profile and balance in selective thoracic (STF) and thoracolumbar fusions. METHODS: Out of 154 patients, 86 patients had correction of AIS Lenke I or II with a side-loading pedicle screw system and completed a 2-year follow-up. Patient factors such as age, Risser grade, lowest and upper instrumented vertebra, and lumbar modifier were recorded. Coronal Cobb and sagittal parameters were measured using Surgimap. Statistical analysis according to distributions and multiple linear and logistic regressions was performed using STATA for Mac v13. RESULTS: In STF, logistic regression against post-operative change in SVA versus thoracic kyphosis allowed calculation of a critical thoracic kyphosis of 23° (ROC AUC 0.65, spec 0.70, sens 0.63), below which deterioration of the sagittal vertical axis is more likely (PPV 71.4%). Patients with hypokyphosis exhibited an increase in the SVA (pre-operative 7.2 ± 37.1 mm vs. 23.1 ± 27.6 mm at 2 years, p = 0.0164), whereas it was maintained from pre-operative to 2 years post-operative if thoracic kyphosis is above 23° (pre-operative 2.5 ± 28.9 mm vs. 5.4 ± 26.9 mm at 2 years, p = 0.579). CONCLUSION: A critical thoracic kyphosis of 23° and more should be aimed for in hypokyphotic patients to potentially avoid post-operative sagittal plane deterioration with mechanical and likely also clinical consequences. These slides can be retrieved under Electronic Supplementary Material.

Preservation of Spine Motion in the Surgical Treatment of Adolescent Idiopathic Scoliosis Using an Innovative Apical Fusion Technique: A 2-Year Follow-Up Pilot Study.

BACKGROUND: This trial reports the 2-year and immediate postremoval clinical outcomes of a novel posterior apical short-segment (PASS) correction technique allowing for correction and stabilization of adolescent idiopathic scoliosis (AIS) with limited fusion. METHODS: Twenty-one consecutive female AIS patients were treated at 4 institutions with this novel technique. Arthrodesis was limited to the short apical curve after correction with translational and derotational forces applied to upper and lower instrumented levels. Instrumentation spanned fused and unfused segments with motion and flexibility of unfused segments maintained. The long concave rods were removed at maturity. Radiographic data collected included preoperative and postoperative data for up to 2 years as well as after long rod removal. RESULTS: All 21 patients are beyond 2 years postsurgery. Average age at surgery was 14.2 years (11-17 years). A mean of 10.5 ± 1 levels per patient were stabilized and 5.0 ± 0.5 levels (48%) were fused. Cobb angle improved from 56.1° ± 8.0° to 20.8° ± 7.8° (62.2% improvement) at 1 year and 20.9° ± 8.4°, (62.0% improvement) at 2 years postsurgery. In levels instrumented but not fused, motion was 26° ± 6° preoperatively compared to 10° ± 4° at 1 year postsurgery, demonstrating 38% maintenance of mobility in nonfused segments. There was no report of implant-related complications. CONCLUSIONS: PASS correction technique corrected the deformity profile in AIS patients with a lower implant density while sparing 52% of the instrumented levels from fusion through the 2-year follow-up.

Systematic review of the complications associated with magnetically controlled growing rods for the treatment of early onset scoliosis.

PURPOSE: To analyse the complication profile of magnetically controlled growing rods (MCGRs) in early onset scoliosis (EOS). METHODS: This is a systematic review using PUBMED, Medline, Embase, Google Scholar and the Cochrane Library (keywords: MAGEC, Magnetically controlled growing rods and EOS) of all studies written in English with a minimum of five patients and a 1-year follow-up. We evaluated coronal correction, growth progression (T1-S1, T1-T12) and complications. RESULTS: Fifteen studies (336 patients) were included (42.5% male, mean age 7.9 years, average follow-up 29.7 months). Coronal improvement was achieved in all studies (pre-operative 64.8°, latest follow-up 34.9° p = 0.000), as was growth progression (p = 0.001). Mean complication rate was 44.5%, excluding the 50.8% medical complication rate. The unplanned revision rate was 33%. The most common complications were anchor pull-out (11.8%), implant failure (11.7%) and rod breakage (10.6%). There was no significant difference between primary (39.8%) and conversion (33.3%) procedures (p = 0.462). There was a non-statistically significant increased complication rate with single rods (40 vs. 27% p = 0.588). CONCLUSIONS: MCGRs improve coronal deformity and maintain spinal growth, but carry a 44.5% complication and 33% unplanned revision rate. Conversion procedures do not increase this risk. Single rods should be avoided. These slides can be retrieved under Electronic Supplementary material.

Targeted Distraction: Spinal Growth in Children With Early-Onset Scoliosis Treated With a Tail-gating Technique for Magnetically Controlled Growing Rods.

STUDY DESIGN: Prospective cohort study OBJECTIVE.: To understand the efficacy of a tail-gating technique (TGT) to mirror the normal spinal growth of children with early-onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR). SUMMARY OF BACKGROUND DATA: MCGR allow outpatient distraction and guided spinal growth without the need for repeat surgery. Two techniques (maximal and targeted) are currently employed to determine the distraction amount, however the efficacy of each is unknown. This study specifically assesses the ability of targeted distraction to achieve physiological growth. METHODS: We performed a retrospective review of European children treated with MCGR using a TGT and analyzed the post-operative clinical and radiographic outcomes, including the sitting height, standing height, coronal Cobb angle, T1-T12 and T1-S1 height. Furthermore, we compared the post-operative sitting/standing height ratio every 6 months to those reported for normal age- and sex-matched European children. RESULTS: Thirty-five children were included with a mean follow-up of 3.4 years (1.8-5.8 years). All clinical and radiographic parameters significantly (P < 0.05) improved immediately post-operatively and were maintained until final follow-up. The TGT mirrored the normative sitting/standing height ratios for expected spinal growth (Pearson correlation 0.95 for males and 0.90 for females). The mean difference between the reference values for the sitting/standing height ratio and our results was 0.0124 (P < 0.001) for males and 0.0068 (P = 0.010) for females. CONCLUSION: MCGR can reliably improve the coronal deformity in children with EOS while maintaining spinal growth. A TGT to determine the distraction amount at follow-up accurately mirrors the normal growth pattern of age-, sex-, and ethnicity-matched children. However, patients treated with this technique have a statistically significant, but clinically insignificant, shorter than physiologically normal spinal height. LEVEL OF EVIDENCE: 3.

Unplanned Reoperations in Magnetically Controlled Growing Rod Surgery for Early Onset Scoliosis With a Minimum of Two-Year Follow-Up.

STUDY DESIGN: A retrospective review of prospectively collected clinical and radiologic data of patients with magnetically controlled growing rods (MCGRs) from a multi-centered study with a minimum of 2-year follow-up. OBJECTIVE: The aim of this study was to describe the incidence and causes of unplanned reoperations and to report the outcomes of patients treated with MCGR for early-onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA: Published clinical studies have demonstrated that MCGR is safe and effective for curvature control of EOS, and can avoid repeated surgeries for distractions. However, there have been no reports on the unplanned reoperations and complications of MCGR for EOS with a large series of patients. METHODS: Between 2009 and 2012, 30 patients with EOS underwent MCGR implantation in six institutions. A retrospective review of prospectively collected clinical and radiologic data with a minimum of 2-year follow-up was conducted. Demographic data, radiologic measurements, unplanned reoperations, and other complications were noted. Risk factors for unplanned reoperations were analyzed. RESULTS: Patients underwent MCGR implantation at the mean age of 7.2 years. The mean follow-up period was 37 months. Fourteen patients (46.7%) underwent an unplanned reoperation within the follow-up period, with a mean time to reoperation of 23 months after initial surgery (range, 5-48 months). Causes of unplanned reoperation were failure of rod distractions, proximal foundation failure, rod breakage, and infection. More frequent distractions (between 1 week and 2 months) were associated with a higher rate of reoperation than distraction frequencies between 3 and 6 months (71% vs. 25%). CONCLUSION: This is the largest series with the longest follow-up to date that examines the need for additional unplanned surgery after the initial procedure. It highlights that MCGR surgery can be associated with unplanned reoperations, and more frequent distractions may be a risk factor. Long-term comparative studies with traditional growing rod are required to evaluate the effectiveness of this implant. LEVEL OF EVIDENCE: 4.

Paper #31: The Oxford 5 year observational study on 35 patients with Magnetically Controlled Growing Rods (MCGR).

MCGR controls scoliosis progression and allows growth. Functional activity also improves generally. Primary infection rates are low. The overall unplanned return to theatre rates are still high but the psychosocial benefits are obvious.

Paper #25: Quantifying the 'Law of Diminishing Returns' in Magnetically Controlled Growing Rods.

The 'law of diminishing returns' can also be observed following serial distraction in MCGR. In comparison to previously published data for CGRS, there is a gradual linear decline as opposed to a rapid initial decline in lengthening. In the older, heavier child a reduced distraction ratio in the concave rod of the MCGR device is noted over time.

Analysis of Segmental Mobility Following a Novel Posterior Apical Short-Segment Correction for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A prospective, nonrandomized, multicenter study. OBJECTIVES: The purpose of this study was to evaluate the amount of motion present at instrumented but unfused segments and at motion segments adjacent to the instrumentation following application of a new posterior apical short-segment correction technique for correcting adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: High-density pedicle screw instrumentation and posterior arthrodesis of all instrumented levels is the most common surgical treatment for AIS stabilization. The consequence of long fusion is an abnormal load on adjacent levels with an increased risk of future adjacent segment degeneration. METHODS: This new system applied translational and derotational forces over a short apical segment. The short apical region was prepared for fusion while maintaining motion of unfused vertebral segments. Radiographic data were collected pre-operatively, at surgery, and at 3, 6, and 12 months after surgery. RESULTS: Twenty-one female patients, mean age of 14.2 years (10.6-16.9 years) with Lenke 1A/1B curves, were enrolled. The range of motion in the unfused instrumented segment was significantly higher than the apical fused segment (11 vs. 0.9, P < 0.001). The range of motion of unfused vertebral levels distal to the construct at one year did not differ significantly from their respective pre-op values. When the analysis was extended to understand the impact of lower instrumented vertebra (LIV) on motion of unfused segments distal to the construct, it appeared that (1) the change in motion from pre-op to 12 months post-op as a function of LIV is not statistically significant; and (2) The motion of the unfused distal vertebral segments at 12 months does not statistically increase with a lower LIV. CONCLUSION: Through one year, this novel technique achieved and maintained similar AIS correction to current posterior fusion techniques while maintaining the mobility of unfused motion segments with less implant density. LEVEL OF EVIDENCE: 4.

Preliminary comparison of primary and conversion surgery with magnetically controlled growing rods in children with early onset scoliosis.

PURPOSE: Non-invasive distraction of magnetically controlled growing rods (MCGR) avoids repeated surgical lengthening in patients with early onset scoliosis, but it is not known how effective this technique is in previously operated children. METHODS: In a retrospective, multicentre study, the data were obtained for 27 primary (P) patients [mean age 7.0 (2.4-10.7) years at surgery] and 23 conversion (C) patients [mean age 7.7 (3.6-11.0) years at conversion from standard growing rods] with 1-year follow-up. RESULTS: The mean major curve was 63.9° in the P group and 46.5° in the C group at baseline (preoperatively, p = 0.0009) and 39.5° and 39.6°, respectively, at 1-year follow-up (p = 0.99). The mean percentage change of spinal growth from baseline to 1-year follow-up was 18.3 % in the P group and 6.5 % in the C group (p = 0.007). Comparing the spinal growth from postoperative to 1-year follow-up no statistical difference was observed between the study groups (1.8 % P vs -2.2 % C, p = 0.09). CONCLUSIONS: Scoliosis can be equally controlled after conversion from traditional growing rods into MCGR, but spinal growth from baseline is less in the conversion patients as compared with the primary group. LEVEL OF EVIDENCE: III.

Magnetic controlled growth rods versus conventional growing rod systems in the treatment of early onset scoliosis: a cost comparison.

PURPOSE: To evaluate the cost differences between a conventional growth rod system (CGRS) and magnetic controlled growth rods (MCGR) in treating early onset scoliosis (EOS) over a projected 5 year period. We hypothesise that the high initial outlay for MCGR would be recouped from fewer admissions and surgical procedures over the lifetime of the implant. METHODS: The costs of all aspects of treatment for 14 patients undergoing conversion from CGRS to MGRS were collected over a 3 year period. The costs of all aspects of each treatment including clinic visits, hospital stay, theatre and complications were calculated and projected over the lifetime of each device. RESULTS: The initial outlay for insertion for MCGR was £12,913 more than the CGRS. There were significant cost savings for each lengthening which projected over the 5 year lifetime amounted to a cost saving of over £8,000 per patient. CONCLUSIONS: Magnetic controlled growth rods reduce the need for multiple invasive procedures in the management of EOS. The implant has a significant projected cost saving in comparison to CGRS.

Sagittal plane deformity: an overview of interpretation and management.

The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment.

When is the appropriate time for surgical intervention of the herniated lumbar disc in the adolescent?

Symptomatic lumbar disc herniation in the adolescent is uncommon. The appropriate treatment in this particular age group is not clear. We conducted a retrospective review of the medical, surgical, and radiological records of six adolescents with symptomatic lumbar disc herniation who underwent microdiscectomy after failed conservative therapy. The mean follow-up was 13 months. All patients improved quickly and returned to their normal activity levels. We suggest that severe pain resulting from a herniated lumbar disc, even without any neurological deficit, is an indication for microdiscectomy in adolescents so that these patients return to full-time education and normal activities as soon as possible.