Factors Related to Proximal Junctional Kyphosis and Device Failure in Patients with Early-Onset Scoliosis Treated with a Traditional Dual Growing Rod: A Single Institution Study.

STUDY DESIGN: Observational study. PURPOSE: Investigation of factors related to proximal junctional kyphosis (PJK) and device failure in patients with early-onset scoliosis. OVERVIEW OF LITERATURE: The use of growth-friendly devices, such as traditional dual growing rod (TDGR) for the treatment of earlyonset scoliosis (EOS), may be associated with important complications, including PJK and device failure. METHODS: Thirty-five patients with EOS and treated with TDGR from 2014 to 2021 with a minimum follow-up of 2 years were retrospectively evaluated. Potential risk factors, including demographic factors, disease etiology, radiological measurements, and surgical characteristics, were assessed. RESULTS: PJK was observed in 19 patients (54.3%), and seven patients (20%) had device failure. PJK was significantly associated with global final kyphosis change (p=0.012). No significant correlation was found between the rod angle contour, type of implant, connector design, and the risk of PJK or device failure. CONCLUSIONS: Treatment of EOS with TDGR is associated with high rates of complications, particularly PJK and device failure. The device type may not correlate with the risk of PJK and device failure. The progression of thoracic kyphosis during multiple distractions is an important risk factor for PJK.

The role of environmental and seasonal factors in spine deep surgical site infection: the air pollution, a factor that may be underestimated.

BACKGROUND: Different strategies have been described in order to reduce spine deep surgical site infection (SSI); however, non-intervenable items such as environmental factors remain as one of the main concerns for spine surgeons. METHODS: A retrospective cohort study was designed in order to evaluate the effect of environmental factors such as temperature, humidity and particularly the air pollution index (PM 2.5) on spine surgical site infection. The files of 3609 patients who underwent spinal surgery from April 2019 to March 2022 were reviewed, and 121 patients with spine SSI were detected. RESULTS: There was no significant relationship between mean temperature and humidity of each month with infection and type of bacteria. However, there was a significant relation between warmer season periods and infection. The rate of infection among patients was 3.25% ranged from 2.5% to 4% in colder and warmer seasons accordingly. It was determined that air pollution had a significant relationship with the infection and the type of bacteria. (p value < 0.05, R-Squared = 0.249). CONCLUSIONS: Our study revealed a 60% increase in spine SSI during warmer seasons. There was a significant correlation between air pollution and the rate of infection. These may suggest the necessity to reduce the number of elective spine surgeries during warmer seasons and when the level of air pollutant is high.

Perioperative complications of symptomatic congenital kyphosis: a retrospective cohort study.

BACKGROUND: Despite the recent improvements in the surgical treatment of congenital kyphosis, this surgery may be associated with high rate of complications "particularly when patients are symptomatic preoperatively". MATERIALS AND METHODS: Medical profiles of 40 patients with symptomatic congenital kyphosis were retrospectively reviewed. Perioperative complications were recorded and divided in two groups including catastrophic complications (neurologic deficit, pulmonary thromboembolic events, and death) and major complications (infection, deep vein thrombosis, device failure, and dural injury). RESULTS: Catastrophic surgical complications occurred in nine (22.5%) patients including seven neurological deficits and two death. A significant association was observed between the incidence of major complications and type III of congenital kyphosis (P = 0.021). Major complications occurred in 14 (30%) patients. CONCLUSION: Surgical treatment significantly improve symptomatic congenital kyphosis deformity; however, surgery of symptomatic patient may be associated with higher rate of complications and even death.

Descriptive Epidemiology and Survival Rate of Osteosarcoma: The First National Population-Based Study in the Middle East (2008-2014).

Objectives: The epidemiology of osteosarcoma (OS), the most common primary bone sarcoma, was not evaluated in the Middle East. Therefore, this study aimed to examine the incidence, demographic characteristics, epidemiology, and survival rate of patients with different subtypes of OS, based on data derived from the Iran National Cancer Registry (INCR) to evaluate the influence of ethnicity and race. Methods: All OS patients registered in the INCR between March 20, 2008, and March 20, 2014, were enrolled in this study, and information such as age, gender, cancer location, OS subtype, and survival time were evaluated statistically. Results: The Age-Standardized Incidence Rate (ASIR) for OS was 3.02 per million person-years, with a mean age of 25.6 years and a male-female ratio of 1.54:1. Not Otherwise Specified (NOS) OS, chondroblastic OS, and central OS had the highest frequencies among the subtypes of OS. The overall one-, three-, and five-year survival rates were 87%, 61%, and 49%, respectively, with a mean duration of 6.16 years. Conclusion: The ASIR of OS in our country was similar to that in the US and higher than that in China. The peak frequency was between 15-19 years old. The male-female ratio in our patients was higher than the OS gender ratio in most series. Although it was not statistically significant, older age at the time of diagnosis, axial location, and male gender were the poorest prognosis factors.

Congenital lumbosacral junction kyphosis in an adult patient: A case report.

Rare lumbosacral junction kyphosis due to S1-S2 hemivertebra in a 40-year-old woman was managed surgically, improving neurological disturbances, and low back pain. Early intervention is vital for congenital anomalies.

Selective Thoracolumbar/Lumbar Fusion in Adolescent Idiopathic Scoliosis: A Comprehensive Review of the Literature.

In Adolescent Idiopathic Scoliosis (AIS), correction surgery can correct the maximum movement and balance of the spine. Under certain conditions for two simultaneous curvatures, the procedure, in which correcting one of the curvatures can result in the automatic correction of another curvature, is called selective fusion, attracting spine surgeons' interest because of more movement in the spine. However, the majority of surgeons have not used this technique due to the lack of sufficient information. The current study aimed to totally investigate selective thoracolumbar/lumbar fusion and to provide accurate information on outcomes and complications of surgery for spinal surgeons. This technique can also help spinal surgeons have a better selection of patients' surgical procedures.

Comparison of coagulation profile and thromboembolic events among patients undergoing spinal surgery before and after COVID-19 pandemic.

BACKGROUND: Impairment of coagulation parameters and increased rate of thromboembolism are known complications of COVID-19 infection. In this study the coagulation profile and rate of thromboembolic events between two groups of patients who underwent spinal surgery before and after the COVID-19 pandemic was compared. PATIENTS AND METHOD: Clinically and laboratory negative for COVID-19 elective patients before (n: 211) and during COVID- 19 pandemic (n: 294) with spinal surgeries were included in this retrospective study. Surgical characteristics, Physiologic parameters, coagulation parameters and thromboembolic events were compared between the two study groups. RESULTS: Preoperative coagulation parameters, including PT, PTT, and INR were significantly increased during the COVID-19 pandemic (P < 0.001. P = 0.001, and P < 0.001, respectively), while the platelet count was significantly reduced (P = 0.04). The same differences were observed between the two study groups after the spinal surgery. In addition, respiratory rate and postoperative bleeding of the first postoperative 24 h was significantly more in patients who were operated on during COVID-19 outbreak (P = 0.03 and P = 0.002, respectively). The rate of thromboembolic events was 3.1% during the COVID-19 pandemic (seven PE, one DVT, and one MI) and 0% before that. This difference was statistically significant (P = 0.043). CONCLUSION: The rate of thromboembolic events seems to be increased during the COVID-19 pandemic. These findings urge more stringent monitoring of the patients' coagulation parameters during the COVID-19 outbreak.

The effect of cage type on local and total cervical lordosis restoration and global spine alignment in single-level anterior cervical discectomy and fusion based on EOS® imaging: A comparison between standalone conventional interbody polyether ether ketone cage and integrated cage and plate (Perfect-C®).

Background: There is a small level of evidence regarding the alterations in global spine alignment following the restoration of cervical lordosis using anterior cervical discectomy and fusion (ACDF). Different cage types are available to restore cervical lordosis through ACDF. In this study, we evaluate the impact of two types of these cages on local and global spine alignments. Patients and Methods: Thirty-two patients with a mean age of 46 ± 10 who underwent ACDF for cervical disc herniation were included in this retrospective study. Patients were divided according to their cage type into two groups, 17 patients with standalone conventional polyether ether ketone cages and 15 patients with integrated cage and plate (ICP) (Perfect-C®). Cervical alignment and global spine alignment were evaluated on the pre- and post-operative EOS® images. Results: Three months after the ACDF, total cervical lordosis correction was higher in patients with ICP (P = 0.001), while the local cervical lordosis correction was not significantly different between conventional cages and prefect-C cages (P = 0.067). Lumbar lordosis and pelvic tilt change were significantly higher among patients with Perfect-c cages (P = 0.043). Conclusion: In patients undergoing ACDF, alignment of the global spine changes along with the restoration of the cervical spine. Cage type affects this association, mainly through the compensatory alteration of pelvic tilt.

Incidence of primary bone sarcomas in Iranian population (2008-2015): A national population-based study.

Background: Epidemiological characteristics of bone sarcomas are variant in different populations, however, there is no previous study on primary bone sarcomas among Iranian population. This study aimed to evaluate the incidence, age, sex distribution, histologic type, and location of malignant bone sarcomas, based on the Iran National Cancer Registry (INCR). Methods: This was a national population-based study using INCR data from March 20, 2008, to March 20, 2015, on patients who were diagnosed with primary bone sarcomas of the appendicular (C-code:40) and axial skeleton (C-code 41), excluding skull and face bones. Primary bone sarcomas were classified according to the International Classification of Diseases for Oncology (ICD-O-3: C40-C41). Results: A total of 4112 patients (59.5% males and 40.5% females) with a mean age of 36 years were included in the study. 60.38% of patients were between 10 to 44 years old. The overall age-standardized incidence rates (ASIR) was 8.23 (males=9.67 and females=6.80) per million person-years. Osteosarcoma chondrosarcoma and Ewing sarcoma were the three main histology subtypes with the ASIR of 2.36, 1.26, and 1.08 per million person-years. Long bones of the lower limb were the most affected area, with the ASIR of 3.18 (95% CI: 3.02-3.33) per million. We found an increasing trend in the incidence of bone sarcomas in Iran from 8.59 in 2007 to 11.37 per million person-year in 2015. Conclusion: This study provided the epidemiological features of bone sarcomas, including the histological type of sarcoma, tumors' location, and patients' age and gender in the Iranian population for the first time.

Iatrogenic long thoracic nerve injury and scapular winging in posterior spinal fusion surgery: A case report.

This is an extremely rare case of scapular winging following posterior spinal fusion for correction of adolescent idiopathic scoliosis in an 18-year-old boy due to iatrogenic injury to a long thoracic nerve. Scapular winging manifested 5 days after the operation and spontaneously improved after 7 months.

Soft Tissue Sarcoma of Extremities: Descriptive Epidemiological Analysis According to National Population-based Study.

Background: Soft-Tissue Sarcoma (STS) is a heterogeneous group of neoplasms of mesenchymal origin, occurring in connective tissues. According to previously conducted studies, STS accounts for approximately 1% and 7-%15% of adult and pediatric malignancies, respectively. Almost 50%-60% of sarcomas arise from extremities and usually present as a large painless or rarely painful soft-tissue mass. The present study aimed to describe the epidemiology of soft-tissue sarcomas, especially in the Iranian population. Methods: This epidemiological study of limb soft-tissue sarcoma was conducted based on Iran National Cancer Registry data (INCR) between 2009 and 2014. Patients with soft-tissue sarcoma confirmed by histopathological studies were included, and data were classified based on the International Classification of Diseases for Oncology (first revision-third edition [ICD-O-3]) and analyzed. Descriptive analysis was performed to extract age-standardized and age-specific incidence rates. Results: A total of 2, 593 patients (1,476 males and 1,117 females) were enrolled and assessed in the present study. The age-standardized incidence rate(ASIR) of total soft tissue sarcomas was 6.34 per million person-years. In addition, the highest and lowest ASIR scores stratified by age were observed in patients aged above 65 and under 0 with the value of 19.61 (95% CI:17.91-21.30) and 1.91 (95% CI 1.69, 2.13) per million, respectively. Limb soft tissue sarcomas stratified by gender were dominant in males, and it was statistically significant (P<0.05). The most common extremity soft tissue sarcomas subtypes were mesenchymal tumor (12.26%), spindle cell sarcoma (12.18%), and malignant fibrous histiocytoma (11.45%). Conclusion: As evidenced by the results of the present study, the ASIR of soft tissue sarcoma dramatically increased with age, and the peak ASIR occurred in the age range of above 65 years. The incidence rate of soft tissue sarcomas analyzed by disease site was higher in hip and lower limb than upper limb and pelvis region, and it was detected consistently in all age groups and both genders.

Mobile Spine Osseous Sarcoma: Descriptive Epidemiological Analysis Based on a National Population-Based Study.

BACKGROUND: Primary osseous sarcomas of the mobile spine are rare bony tumors. Ewing sarcoma, chondrosarcoma, chordoma and osteosarcoma constitute the majority of primary bone sarcomas of the spine; however, other rare sarcoma tumors may also affect the spine. In order to perform an epidemiological study of theses tumors, national registries may help to evaluate data for populations with similar characteristics. METHODS: A population-based study was designed based on data from the Iran National Cancer Registry (INCR). All morphology codes (M-Code) of primary osseous sarcomas of the mobile spine (C-code 41.2) were derived and analyzed. RESULTS: Among 186 patients with primary osseous sarcomas of the mobile spine, 67.2% were men and 32.8% were women. The median (IQR) age was 37.0 (20.0-59.0) years and the age-standardized incidence rate (ASIR) was 0.37 per million. The majority of cases of Ewing sarcoma (29.5%) were observed in the age group 20-25 years. Among male patients with chondrosarcoma, the median age was 39.0 (30.0-50.0), while females showed a median age of 56.0 (50.0-59.0). The median age of patients with chordoma was 54.0 (47.0-63.0) years. The crude incidence rate of mobile spine osteosarcoma was 0.04 per million. CONCLUSION: Ewing sarcoma was the most frequent primary osseous sarcoma of the mobile spine. A male predilection was observed among all major sarcomas of the mobile spine. Ewing sarcoma in Iran affects the mobile spine in slightly older ages compared to other studies. Myxoid chondrosarcoma is the most frequent subtype of the mobile spine chondrosarcoma. Chordoma affects male in older ages compared to females. In contrast with other studies which showed a bimodal distribution of osteosarcoma of the spine including young adult and older age groups, 86% of cases in Iran were in the age group of 10-40 years.

Management of a Lumbar Burst Fracture Occurring After a Sneeze in a Patient Affected by Systemic Mastocytosis: A Case Report.

CASE: We present a 36-year-old man with L1 burst fracture after a sneeze. He was in follow-up for indolent systemic mastocytosis (ISM), and osteoporosis was treated with bisphosphonate. Owing to neurologic impairment, posterior decompressive laminectomy and thoraco-lumbar fusion with cemented screws were performed. CONCLUSION: Vertebral fractures in young patients affected by ISM required a multidisciplinary approach and a careful preoperative planning to achieve acceptable results. These fractures are so rare that even an experienced spine surgeon may not come across them during his whole career. Nevertheless, diagnostic tool improvement makes its diagnosis more frequent, that is why every spine surgeon should know this disease.

Surgical Treatment for Bisphosphonate-related Atypical Femoral Fracture: A Systematic Review.

BACKGROUND: Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanter and the supracondylar flare of the femur. Long-term bisphosphonates, as the most common preventive and treatment medications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should be treated surgically, and the complications are considerable. METHODS: We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed and retrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independently extracted data from the studies and rated their quality.Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Society for Bone and Mineral Research definition, were included. Animal studies, case reports, studies with high-energy trauma, pathological fracture, or malignancy-related fractures were excluded. RESULTS: In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years, and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was the most common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric, respectively. Moreover, the most common fixation type was intramedullary. Rate of complication was 17.52%, and the most frequent one was non-union, followed by implant failure. The main limitation of this research was that most of the studies did not have a high level of evidence. CONCLUSION: An increase in the rate of atypical femoral fracture with its challenging management makes it an important issue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have more complications post-operatively and are suggested to be operated on by more experienced surgeons. It was also found that extra-medullary fixation increases the risk of complications. Future studies on union time, outcomes of different surgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures.

Pigmented Villonodular Synovitis Arising from Calcaneocuboid Joint in an Army Staff: A Case Report.

Pigmented villonodular synovitis (PVNS) is a locally destructive benign lesion usually affecting the synovial tissue of weight-bearing joints. Herein we reported a 20-year-old male patient who was an army staff with a foot lesion which was painful in army boots. In the beginning, the lesion was considered a ganglion cyst. Further investigations revealed cortical erosion of cuboid bone on the radiograph. Pigmented villonodular synovitis was considered as a probable diagnosis after observation of low signal lesion around the calcaneocuboid joint on both T1 and T2 images of Magnetic Resonance Imaging. The treatment included excision of the lesion and synovectomy of the calcaneocuboid joint. The diagnosis was confirmed with histological studies. At more than one year follow-up, the patient was completely asymptomatic, and there was no evidence of recurrence. This study aimed to raise the awareness of clinicians about the diagnosis of this rare soft tissue neoplasm which might be misdiagnosed as a ganglion or synovial cysts in the hindfoot zone.

Epidemiologic trend of mobile spine and sacrum chordoma: A National population-based study.

INTRODUCTION: Chordoma is a rare sarcoma of the axial skeleton. The incidence of this tumor is different between races. To understand the epidemiologic characteristic and due to rarity of this pathology, large number of cases should be evaluated through national data registries. MATERIALS AND METHODS: All pathologically confirmed cases of chordoma were derived from the Iran National Cancer Registry. Descriptive analysis was performed to extract age-standardized and age-specific incidence rates. Data regarding tumor location and chordoma subtypes were derived and analyzed. RESULTS: One hundred twenty-two cases of chordoma including 80 male and 42 female were identified. One hundred seven cases of nonotherwise specified chordoma, 14 chondroid chordoma, and one dedifferentiated chordoma were detected. The age-standardized incidence rate (ASIR) of chordoma was 0.28. Chordoma of the sacrum composed 67.2% of cases. The mean survival time was 4.5 years. CONCLUSION: Epidemiology characteristic of chordoma in Iran is similar to other studies; however, the total ASIR was lower and the incidence in sacrum is nearly twice respect to the mobile spine. While men affected by sacral chordoma in relatively older age, the female patients had higher mean age in case of mobile spine involvement. The survival rate of chordoma is significantly lower in comparison with other studies.

Fracture Surgery in Known COVID-19 Infected Patients: What Are the Challenges?

BACKGROUND: Surgery in the time of COVID-19 pandemic is a challenging issue while treatment of affected fracture patients is inevitable. The present study summarizes the challenges that an orthopedic surgeon is confronting during the surgical treatment of fracture patients with concomitant COVID-19 infection. METHODS: Demographic and fracture related data of 13 fracture patients with concomitant COVID-19 infection who were treated with surgery was collected from three trauma centers in Tehran and Kermanshah cities from 21, February 2020 to April 3, 2020. RESULTS: All patients were male with mean age of 38.6±19.5 years. Eight patients had high energy fracture and seven patients had multiple fractures and trauma. Wrist and hand were the common sites of fracture following hip and pelvis. The mean interval time period between the diagnosis of COVID-19 infection and surgery was 2.3±1.5 days. Before surgery, all patients except one had been admitted to the corona dedicated wards, while two patients were admitted to the intensive care unit (ICU). One of the ICU admitted patients died. All the 12 alive patients remained in home isolation after discharge. CONCLUSION: Fracture surgery in COVID-19 patients has many challenges such as lack of medical resources, delay of surgery, medial staff fear, and patient isolation. However, a multidisciplinary approach using all potential hospital resources would lead to successful operation and acceptable outcome.

The Survival and Incidence Rate of Ewing Sarcoma; a National Population-based Study in Iran (2008-2015).

BACKGROUND: The effect of race and ethnicity on some kind of malignant bone tumors including Ewing sarcoma has been proven in different studies. In order to evaluate the latter, national cancer registries may help to increase understanding about potential cancer causes, prevention and control strategies, and apply these findings to control health problems among populations with similar characteristics. METHODS: A national population-based cancer registry study based on all patients affected by Ewing Sarcoma was registered in the Iran National Cancer Registry (INCR) between 2008 and 2015 was designed. Demographic data of microscopically confirmed cases of bone Ewing sarcoma were registered. Patients with Ewing sarcoma were divided in groups to describe the primary site of the tumor (including axial or appendicular bones) and analyzed. In order to analyze the survival rate, randomized selection of the patient through the INCR data-base was performed. RESULTS: A total of 678 cases of malignant Ewing sarcoma of the bone were identified through the INCR. The mean age of Ewing sarcoma in Iran was 21.53 years. Nearly half of patients were observed at the age group of 15-24. The total crude incidence rate of Ewing sarcoma was 1.29 in 1 million. The mean 5 year survival rate was 47%. The Mean survival rate for study population was 5.53. CONCLUSION: The crude incidence rate of Ewing sarcoma in Iran is relatively lower with respect to other registries. The majority of patients are in 15-25 years group and shows affection by Ewing sarcoma in an older age. Socioeconomic factors had direct influence on survival rate.

Management of Spine Trauma in COVID-19 Pandemic: A Preliminary Report.

BACKGROUND: COVID-19 was first identified in Iran in February 2020 and since then it spread rapidly through all over the country and soon after that it was reported as a pandemic. The current study presents a preliminary report of spine trauma management during COVID-19 pandemic. METHODS: A cross sectional study was designed to evaluate patients admitted for vertebral fractures with diagnosis of COVID-19 infection on February and March 2020. Analysis was made based on clinical and laboratory data along with the imaging findings from chest HRCT. RESULTS: Seven patients with spine trauma including five males and two females ranging from 14 to 59 years were diagnosed for COVID-19 infection through CT-scan findings. Except one, all other patients were asymptomatic for COVID-19 at the time of admission. In three cases the COVID diagnosis was made the day after arrival and in others after 10, 14 and 35 days. Five patients were treated surgically among whom four were admitted to ICU soon after the surgery. The mean ICU stay for operated patients were eight days and the mean hospital stay was 22.6 days. CONCLUSION: Proper diagnosis of COVID-19 is the keystone to protect both patients and health care providers. During the pandemic all admitted patients should be screened for COVID-19 infection. Unnecessary procedures for spine trauma patients should be avoided in order to reduce complications related to surgery and to preserve ICU beds.