The Positive Side Effect of Anterior Cervical Decompression and Fusion on Axial Neck Pain.

STUDY DESIGN: Observational Cohort Study. OBJECTIVES: This study aims to comprehensively assess the outcomes of anterior cervical spine surgery in patients who have undergone surgical intervention for radiculopathy or myelopathy, with a specific focus on the surgery's impact on axial neck pain. METHODS: Data from an institutional spine surgery registry were analyzed for patients who underwent anterior cervical spine surgery between January 2016 and March 2022. Patient demographics, clinical variables, and outcome measures, including the Neck Disability Index (NDI), numeric rating scales for neck and arm pain (NRS-Neck and NRS-Arm), and 36-Item Short Form Health Survey (SF-36) scores, were collected. Statistical analysis included paired t-tests, chi-squared tests, and multivariate linear regression. RESULTS: Of 257 patients, 156 met the inclusion criteria. Patients showed significant improvement in NDI, NRS-Neck, NRS-Arm, SF-36 (Physical and Mental components), and all changes exceeded the minimum clinically important difference. Multivariate regression revealed that lower preoperative physical and mental component scores and higher preoperative NRS-Neck predicted worse NDI scores at follow-up. CONCLUSIONS: This study underscores that anterior cervical fusion not only effectively alleviates arm pain and disability but also has a positive impact on axial neck pain, which may not be the primary target of surgery. Our findings emphasize the potential benefits of surgical intervention when neck pain coexists with neurologic compression. This contribution adds to the growing body of evidence emphasizing the importance of precise diagnosis and patient selection. Future research, ideally focusing on patients with isolated neck pain, should further explore alternative surgical approaches to enhance treatment options.

Diagnostic Approach and Differences between Spinal Infections and Tumors.

STUDY DESIGN: A systematic review of the literature about differential diagnosis between spine infection and bone tumors of the spine. BACKGROUND AND PURPOSE: The differential diagnosis between spine infection and bone tumors of the spine can be misled by the prevalence of one of the conditions over the other in different areas of the world. A review of the existing literature on suggestive or even pathognomonic imaging aspects of both can be very useful for correctly orientating the diagnosis and deciding the most appropriate area for biopsy. The purpose of our study is to identify which imaging technique is the most reliable to suggest the diagnosis between spine infection and spine bone tumor. METHODS: A primary search on Medline through PubMed distribution was made. We identified five main groups: tuberculous, atypical spinal tuberculosis, pyogenic spondylitis, and neoplastic (primitive and metastatic). For each group, we evaluated the commonest localization, characteristics at CT, CT perfusion, MRI, MRI with Gadolinium, MRI diffusion (DWI) and, in the end, the main features for each group. RESULTS: A total of 602 studies were identified through the database search and a screening by titles and abstracts was performed. After applying inclusion and exclusion criteria, 34 articles were excluded and a total of 22 full-text articles were assessed for eligibility. For each article, the role of CT-scan, CT-perfusion, MRI, MRI with Gadolinium and MRI diffusion (DWI) in distinguishing the most reliable features to suggest the diagnosis of spine infection versus bone tumor/metastasis was collected. CONCLUSION: Definitive differential diagnosis between infection and tumor requires biopsy and culture. The sensitivity and specificity of percutaneous biopsy are 72% and 94%, respectively. Imaging studies can be added to address the diagnosis, but a multidisciplinary discussion with radiologists and nuclear medicine specialists is mandatory.

Quality Control for Spine Registries: Development and Application of a New Protocol.

Registries are gaining importance both in clinical practice and for research purposes. However, quality control is paramount to ensure that data are consistent and reliable. Quality control protocols have been proposed for arthroplasty registries, but these are not directly applicable to the spine setting. This study aims to develop a new quality control protocol for spine registries. Based on the available protocols for arthroplasty registries, a new protocol for spine registries was developed. The items included in the protocol were completeness (yearly enrollment rate and rate of assessment completion), consistency, and internal validity (coherence between registry data and medical records for blood loss, body mass index, and treated levels). All aspects were then applied to the spine registry of the Institution to verify its quality for each of the 5 years in which the registry has been used (2016-2020). Regarding completeness, the yearly enrollment rate ranged from 78 to 86%; the completion of preoperative assessment from 79% to 100%. The yearly consistency rate varied from 83% to 86%. Considering internal validity, the interclass correlation coefficient ranged from 0.1 to 0.8 for blood loss and from 0.3 to 0.9 for body mass index. The coherency for treated levels ranged from 25% to 82%. Overall, all 3 items showed an improvement over time. All 3 analyzed domains showed good to excellent results. The overall quality of the registered data improved over time.

The Diagnostic Process of Spinal Post-traumatic Deformity: An Expert Survey of 7 Cases, Consensus on Clinical Relevance Does Exist.

STUDY DESIGN: Survey of cases. OBJECTIVE: To evaluate the opinion of experts in the diagnostic process of clinically relevant Spinal Post-traumatic Deformity (SPTD). SUMMARY OF BACKGROUND DATA: SPTD is a potential complication of spine trauma that can cause decreased function and quality of life impairment. The question of when SPTD becomes clinically relevant is yet to be resolved. METHODS: The survey of 7 cases was sent to 31 experts. The case presentation was medical history, diagnostic assessment, evaluation of diagnostic assessment, diagnosis, and treatment options. Means, ranges, percentages of participants, and descriptive statistics were calculated. RESULTS: Seventeen spinal surgeons reviewed the presented cases. The items' fracture type and complaints were rated by the participants as more important, but no agreement existed on the items of medical history. In patients with possible SPTD in the cervical spine (C) area, participants requested a conventional radiograph (CR) (76%-83%), a flexion/extension CR (61%-71%), a computed tomography (CT)-scan (76%-89%), and a magnetic resonance (MR)-scan (89%-94%). In thoracolumbar spine (ThL) cases, full spine CR (89%-100%), CT scan (72%-94%), and MR scan (65%-94%) were requested most often. There was a consensus on 5 out of 7 cases with clinically relevant SPTD (82%-100%). When consensus existed on the diagnosis of SPTD, there was a consensus on the case being compensated or decompensated and being symptomatic or asymptomatic. CONCLUSIONS: There was strong agreement in 5 out of 7 cases on the presence of the diagnosis of clinically relevant SPTD. Among spine experts, there is a strong consensus to use CT scan and MR scan, a cervical CR for C-cases, and a full spine CR for ThL-cases. The lack of agreement on items of the medical history suggests that a Delphi study can help us reach a consensus on the essential items of clinically relevant SPTD. LEVEL OF EVIDENCE: Level V.

The burden of preoperative fear-avoidance beliefs in workers after thoracic and lumbar spine surgery: a 2-year follow-up study.

ABSTRACT: Spinal disorders are the main reasons for sick leave and early retirement among the working population in industrialized countries. When "red flags" are present, spine surgery is the treatment of choice. However, the role of psychosocial factors such as fear-avoidance beliefs in spine surgery outcomes is still debated. The study aims to investigate whether patients presenting high or low levels of fear-avoidance thoughts before the spine surgery reported different surgical results and return-to-work rates over 2 years. From an institutional spine surgery registry, workers surgically treated with a preoperative score in the Oswestry Disability Index (ODI) higher than 20/100 and provided ODI questionnaires, return-to-work status at 3-, 6-, 12-, and 24-month follow-ups were analyzed. A total of 1769 patients were stratified according to the work subscale of the Fear-Avoidance Beliefs Questionnaire (FABQ-W) in high fear (FABQ-W ≥ 34/42) or low fear (FABQ-W < 34/42). Multivariate regression was used to search for preoperative factors, which might interact with FABQ-W. The higher-fear group showed a different recovery pattern, with higher levels of disability according to the ODI (total score, absolute change, frequency of clinically relevant change, and disability categories) and lower return-to-work ratios over the 24-month follow-up. High fear, high disability, greater age, female gender, smoking, and worse physical status at baseline were associated with worse ODI outcomes 2 years after the surgery. In summary, fear-avoidance beliefs significantly influence the speed and the entity of surgical outcomes in the working population. However, the contribution of FABQ-W in predicting long-term disability levels was limited.

Long spine fusions to the sacrum-pelvis are associated with greater post-operative proximal junctional kyphosis angle in sitting position.

STUDY DESIGN: A single-centre retrospective study. BACKGROUND AND PURPOSE: Although adult patients spend most of their time in sitting positions, the assessment of spinopelvic parameters in adult deformity surgery is commonly performed in standing X-rays. Our study compares the standing and sitting sagittal alignment parameters in subjects who underwent thoracolumbar fusion. METHODS: Patients who underwent corrective surgery for adult scoliosis with at least five instrumented vertebra were stratified according to the upper instrumented vertebra (UIV) and pelvic fixation. Group A:UIV proximal to T6 with pelvis fixation. B:UIV lower than T6 and pelvic fixation. Group C: thoracolumbar fusion without pelvic fixation. Post-operative spinopelvic sagittal parameters were measured in both standing and sitting X-rays. RESULTS: A total of 51 patients were enrolled in the study (11:Males and 40:Females). The mean age was 52.3 ± 21.7y/o. The comparison of post-operative standing and sitting X-ray within the group A and B showed that a significant change was observed in terms of JA-Junctional Angle-(Group A 6.3 ± 4.3 vs. 8.1 ± 3.3, p value = 0.03) (Group B 8.5 ± 6.4 vs. 10.9 ± 6.4, p value = 0.02). Group C showed statistically significant difference in terms of PT (15.6 ± 11.2 vs. 19.3 ± 9.2, p value = 0.04), AVA-Acetabular Version Angle-(41.1 ± 5.9 vs. 48.3 ± 6.6, p value < 0.01) and LL (- 51.3 ± 16.0 vs. - 42.6 ± 10.7, p value < 0.01). CONCLUSION: In our series, the post-operative sagittal alignment showed peculiar behaviours and adaptations in sitting position, depending on the length and the site of the instrumented area. If the pelvis is included, the JA tends to significantly increase in sitting position. These findings can improve the knowledge of pathologies as proximal junctional kyphosis or specific cases of anterior hip impingement. LEVEL OF EVIDENCE: IV.

Rapidly destructive osteoarthritis of the spine: lessons learned from the first reported case.

BACKGROUND: Rapidly Destructive Osteoarthritis (RDOA) has been described for the hip and shoulder joints and is characterized by a quickly developing bone edema followed by extensive remodeling and joint destruction. Confronted with a similarly evolving case of endplate edema and destruction of the disk space, we offer the first described case of spinal RDOA and illustrate the challenges it presented, along with the strategies we put in place to overcome them. CASE PRESENTATION: We present a case of spinal RDOA that, also due to the delay in the diagnoses, underwent multiple revisions for implant failure with consequent coronal and sagittal imbalance. A 37-years-old, otherwise healthy female presented with atraumatic low back pain: after initial conservative treatment, subsequent imaging showed rapidly progressive endplate erosion and a scoliotic deformity. After surgical treatment, the patient underwent numerous revisions for pseudoarthrosis, coronal and sagittal imbalance and junctional failure despite initially showing a correct alignement after each surgery. As a mechanic overload from insufficient correction of the alignement of the spine was ruled out, we believe that the multiple complications were caused by an impairment in the bone structure and thus, reviewing old imaging, diagnosed the patient with spinal RDOA. In case of spinal RDOA, particular care should be placed in the choice of extent and type of instrumentation in order to prevent re-intervention. CONCLUSION: Spinal RDOA is characterized by a quickly developing edema of the vertebral endplates followed by a destruction of the disk space within months from the first diagnosis. The disease progresses in the involved segment and to the adjacent disks despite surgical therapy. The surgical planning should take the impaired bone structure account and the use of large interbody cages or 4-rod constructs should be considered to obtain a stable construct.

Need of vascular surgeon and comparison of value for anterior lumbar interbody fusion (ALIF) in lateral decubitus: Delphi consensus.

BACKGROUND AND PURPOSE: Anterior lumbar approaches are recommended for clinical conditions that require interbody stability, spinal deformity corrections or a large fusion area. Anterior lumbar interbody fusion in lateral decubitus position (LatALIF) has gained progressive interest in the last years. The study aims to describe the current habit, the perception of safety and the perceptions of need of vascular surgeons according to experienced spine surgeons by comparing LatALIF to the standard L5-S1 supine ALIF (SupALIF). METHODS: A two-round Delphi method study was conducted to assess the consensus, within expert spine surgeons, regarding the perception of safety, the preoperative planning, the complications management and the need for vascular surgeons by performing anterior approaches (SupALIF vs LatALIF). RESULTS: A total of 14 experts voluntary were involved in the survey. From 82 sentences voted in the first round, a consensus was reached for 38 items. This included the feasibility of safe LatALIF without systematic involvement of vascular surgeon for routine cases (while for revision cases the involvement of the vascular surgeon is an appropriate option) and the appropriateness of standard MRI to evaluate the accessibility of the vascular window. Thirteen sentences reached the final consensus in the second round, whereas no consensus was reached for the remaining 20 statements. CONCLUSIONS: The Delphi study collected the consensus on several points, such as the consolidated required experience on anterior approaches, the accurate study of vascular anatomy with MRI, the management of complications and the significant reduction of the surgical times of the LatALIF if compared to SupALIF in combined procedures. Furthermore, the study group agrees that LatALIF can be performed without the need for a vascular surgeon in routine cases.

Post-operative L5 radiculopathy after L5-S1 hyperlordotic anterior lumbar interbody fusion (HL-ALIF) is related to a greater increase of lordosis and smaller post-operative posterior disc height: results from a cohort study.

STUDY DESIGN: A single-centre retrospective study. BACKGROUND AND PURPOSE: This study aims to investigate the rate of L5 radiculopathy, to identify imaging features associated with the complication and to evaluate the clinical outcomes in adult spine deformity patients undergoing L5-S1 ALIF with hyperlordotic cages. METHODS: Design: retrospective cohort study. A single-centre prospective database was queried to analyse patients undergoing hyperlordotic (HL) ALIF with posterior fusion to correct spinal deformity. Clinical status was evaluated by back and leg pain numeric rate scale and Oswestry Disability Index pre-operatively and at 3-, 6- and 12-month follow-up. Spinopelvic parameters, such as pelvic incidence, pelvic tilt, lumbar lordosis and L5-S1 lordosis, posterior disc height (PDH) and anterior disc height, were assessed pre-operatively and post-operatively on standardized full-spine standing EOS images. The sagittal foraminal area was measured pre- and post-operatively on a CT scan. RESULTS: Thirty-nine patients with a mean age of 63.2 ± 8.6 years underwent HL-ALIF from January 2016 to December 2019. Seven of them developed post-operative root pain (5) or weakness (2) (Group A), while thirty-two did not (Group B). Root impairment was associated with greater segmental correction magnitude, 26° ± 11.1 in Group A versus 15.1° ± 9.9 in Group B (p < 0.05), and to smaller post-operative PDH, 5.9 mm ± 2.7 in Group A versus 8.3 mm ± 2.6 (p < 0.05). CONCLUSIONS: Post-operative root problems were observed in 17.9% of patients undergoing HL-ALIF for adult spine deformity. L5 radiculopathy was associated with larger sagittal angular corrections and smaller post-operative posterior disc height. One patient (2.6%) needed L5 root decompression. At 12 months of follow-up, results were equivalent between groups. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Setting for single position surgery: survey from expert spinal surgeons.

PURPOSE: To describe a comprehensive setting of the different alternatives for performing a single position fusion surgery based on the opinion of leading surgeons in the field. METHODS: Between April and May of 2021, a specifically designed two round survey was distributed by mail to a group of leaders in the field of Single Position Surgery (SPS). The questionnaire included a variety of domains which were focused on highlighting tips and recommendations regarding improving the efficiency of the performance of SPS. This includes operation room setting, positioning, use of technology, approach, retractors specific details, intraoperative neuromonitoring and tips for inserting percutaneous pedicle screws in the lateral position. It asked questions focused on Lateral Single Position Surgery (LSPS), Lateral ALIF (LA) and Prone Lateral Surgery (PLS). Strong agreement was defined as an agreement of more than 80% of surgeons for each specific question. The number of surgeries performed in SPS by each surgeon was used as an indirect element to aid in exhibiting the expertise of the surgeons being surveyed. RESULTS: Twenty-four surgeons completed both rounds of the questionnaire. Moderate or strong agreement was found for more than 50% of the items. A definition for Single Position Surgery and a step-by-step recommendation workflow was built to create a better understanding of surgeons who are starting the learning curve in this technique. CONCLUSION: A recommendation of the setting for performing single position fusion surgery procedure (LSPS, LA and PLS) was developed based on a survey of leaders in the field.

The sitting vs standing spine.

Background: Planning of surgical procedures for spinal fusion is performed on standing radiographs, neglecting the fact that patients are mostly in the sitting position during daily life. The awareness about the differences in the standing and sitting configuration of the spine has increased during the last years. The purpose was to provide an overview of studies related to seated imaging for spinal fusion surgery, identify knowledge gaps and evaluate future research questions. Methods: A literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews (PRISMASc) was performed to identify reports related to seated imaging for spinal deformity surgery. A summary of the finding is presented for healthy individuals as well as patients with a spinal disorder and/or surgery. Results: The systematic search identified 30 original studies reporting on 1) the pre- and postoperative use of seated imaging of the spine (n=12), 2) seated imaging of the spine for non - surgical evaluation (n=7) and 3) seated imaging of the spine among healthy individuals (12). The summarized evidence illuminates that sitting leads to a straightening of the spine decreasing thoracic kyphosis (TK), lumbar lordosis (LL), the sacral slope (SS). Further, the postural change between standing and sitting is more significant on the lower segments of the spine. Also, the adjacent segment compensates the needed postural change of the lumbar spine while sitting with hyperkyphosis. Conclusions: The spine has a different configuration in standing and sitting. This systematic review summarizes the current knowledge about such differences and reveals that there is minimal evidence about their consideration for surgical planning of spinal fusion surgery. Further, it identifies gaps in knowledge and areas of further research.

The Influence of Baseline Clinical Status and Surgical Strategy on Early Good to Excellent Result in Spinal Lumbar Arthrodesis: A Machine Learning Approach.

The study aims to create a preoperative model from baseline demographic and health-related quality of life scores (HRQOL) to predict a good to excellent early clinical outcome using a machine learning (ML) approach. A single spine surgery center retrospective review of prospectively collected data from January 2016 to December 2020 from the institutional registry (SpineREG) was performed. The inclusion criteria were age ≥ 18 years, both sexes, lumbar arthrodesis procedure, a complete follow up assessment (Oswestry Disability Index-ODI, SF-36 and COMI back) and the capability to read and understand the Italian language. A delta of improvement of the ODI higher than 12.7/100 was considered a "good early outcome". A combined target model of ODI (Δ ≥ 12.7/100), SF-36 PCS (Δ ≥ 6/100) and COMI back (Δ ≥ 2.2/10) was considered an "excellent early outcome". The performance of the ML models was evaluated in terms of sensitivity, i.e., True Positive Rate (TPR), specificity, i.e., True Negative Rate (TNR), accuracy and area under the receiver operating characteristic curve (AUC ROC). A total of 1243 patients were included in this study. The model for predicting ODI at 6 months' follow up showed a good balance between sensitivity (74.3%) and specificity (79.4%), while providing a good accuracy (75.8%) with ROC AUC = 0.842. The combined target model showed a sensitivity of 74.2% and specificity of 71.8%, with an accuracy of 72.8%, and an ROC AUC = 0.808. The results of our study suggest that a machine learning approach showed high performance in predicting early good to excellent clinical results.

Peri-Surgical Inflammatory Profile Associated with Mini-Invasive or Standard Open Lumbar Interbody Fusion Approaches.

BACKGROUND: Different surgical approaches are available for lumbar interbody fusion (LIF) to treat disc degeneration. However, a quantification of their invasiveness is lacking, and the definition of minimally invasive surgery (MIS) has not been biochemically detailed. We aimed at characterizing the inflammatory, hematological, and clinical peri-surgical responses to different LIF techniques. METHODS: 68 healthy subjects affected by single-level discopathy (L3 to S1) were addressed to MIS, anterior (ALIF, n = 21) or lateral (LLIF, n = 23), and conventional approaches, transforaminal (TLIF, n = 24), based on the preoperative clinical assessment. Venous blood samples were taken 24 h before the surgery and 24 and 72 h after surgery to assess a wide panel of inflammatory and hematological markers. RESULTS: martial (serum iron and transferrin) and pro-angiogenic profiles (MMP-2, TWEAK) were improved in ALIF and LLIF compared to TLIF, while the acute phase response (C-reactive protein, sCD163) was enhanced in LLIF. CONCLUSIONS: MIS procedures (ALIF and LLIF) associated with a reduced incidence of post-operative anemic status, faster recovery, and enhanced pro-angiogenic stimuli compared with TLIF. LLIF associated with an earlier activation of innate immune mechanisms than ALIF and TLIF. The trend of the inflammation markers confirms that the theoretically defined mini-invasive procedures behave as such.

The aging spine: the effect of vertebral fragility fracture on sagittal alignment.

Our study investigates the relationship, in the aging population, between vertebral fractures, spinal alignment, and quality of life. Kyphotic fractures were related to more significant disability and impaired spinopelvic alignment. The spinal malalignment was strongly associated with fractures in the thoracolumbar junction vertebrae and the absence of powerful compensatory mechanisms as thoracic hypokyphosis and lower lumbar hyperlordosis. INTRODUCTION: In adult spine deformity (ASD), the sagittal imbalance is defined by the deformity in the sagittal plane that causes the need for greater use of muscle strength to maintain an upright static posture or walking. Fragility vertebral fractures (VF) and ASD are frequent causes of spinal morbidity in the elderly. The prevalence of both ASD and VF increases with aging. Although these two clinical conditions insist on the same population, little is known about the interactions between sagittal imbalance and vertebral fracture (VF) deformity. The aim of our work is to examine the associations between vertebral fractures, sagittal alignment, and their impact on the quality of life scores in elderly patients. METHODS: A retrospective cohort study of 110 patients of both sexes, from a spine surgery waiting list, with at least one VF with ≥ 5° of kyphosis and a full-standing X-ray. INDEPENDENT VARIABLES: the presence of VF with kyphotic deformity ≥ 10°, fracture level, degree of kyphosis (deformity) of the fracture, number of fractures, spinopelvic angular parameters, demographic parameters, and scales of evaluation of the health-related quality of life. RESULTS: A total of 110 patients with mean age 73.8 ± 5.2, of which 70 women (63%) were included in the study. Subjects with at least one VF ≥ 10° presented greater disability and an overall worse sagittal spinal alignment (no VF10° vs VF10°: TPA 21.30 ± 11.5 vs 26.51 ± 12.6, p = 0.041) and more disability (no VF10° vs VF10°: ODI 41.91 ± 16.9 vs 54.67 ± 15.8, p < 0.001) than patients with less degree of vertebral deformity. Significant compensatory mechanisms involved the thoracic area and the lower lumbar region. CONCLUSION: Kyphotic VFs were associated with severe alterations of sagittal spine alignment and perceived disability. Subjects with sagittal imbalance have a greater degree of deformity in the thoracolumbar junction area. Thoracic hypokyphosis and lower lumbar hyperlordosis are effective compensatory mechanisms in case of lumbar or thoracic fracture, respectively.

Correlation between age, coronal and sagittal parameters and spine flexibility in patients with adolescent idiopathic scoliosis.

PURPOSE: To investigate the correlation between spine flexibility and age, skeletal maturity, coronal and sagittal parameters for adolescent idiopathic scoliosis (AIS). METHODS: All AIS patients evaluated for surgery were included. Following parameters were obtained: age, gender, skeletal maturity (Risser and Sanders), Cobb angle at high thoracic (HT), mean thoracic (MT) and thoracolumbar/lumbar (TL/L) level, flexibility of HT, MT and TL/L curves, coronal and sagittal parameters. A multivariate diagnostic through the Pearson Product-Moment Correlation Coefficient ([Formula: see text]) was performed. RESULTS: Data from 200 patients were obtained (30 males, age 15 ± 1.9 years). No significant correlation was found between curve flexibility and age or gender. A negative correlation was observed between flexibility of MT curves and magnitude of HT ([Formula: see text] = - 0.4) and MT curves ([Formula: see text] = - 0.4). A weak correlation among curve flexibility at different levels was observed: the flexibility of HT curves correlated with the flexibility of MT and TL/L curves, and the flexibility of MT curves correlated with flexibility TL/L curves. A negative correlation between flexibility of MT curves and AVT-T (thoracic apical vertebral translation) ([Formula: see text] = - 0.2) was evidenced. No correlations between flexibility and sagittal parameters were observed. CONCLUSIONS: No strong correlation were observed between curve flexibility and age or skeletal maturity. A negative correlation between curve magnitude and flexibility at thoracic level was demonstrated. Furthermore, a weak positive correlation between flexibility of PT, MT and TL/L curves was observed.

Anterior Lumbar Interbody Fusion (ALIF) L5-S1 with overpowering of posterior lumbosacral instrumentation and fusion mass: a reliable solution in revision spine surgery.

BACKGROUND AND PURPOSE: In cases of spine surgical revisions of patients affected by sagittal malalignment, the restoration of the ideal lumbar lordosis (LL) is mandatory. ALIF procedures represent a powerful and effective approach to improve the LL in case of hypolordosis. This study evaluates the feasibility of ALIF to overpower posterior lumbar instrumentation and fusion mass in revision spine surgery and secondarily to estimate complications, clinical and radiological outcomes. METHODS: This is a single-center retrospective analysis of prospectively collected data on the use of ALIF overpowering in cases of lumbosacral instrumentation and/or fusion. Demographic, comorbidity, corrective strategy adopted, surgical data, clinical and radiological results, and intraoperative and postoperative complications were recorded. RESULTS: Twelve patients (3 male; 9 female) underwent overpowering ALIF L5-S1 were included in the study with a mean FU of 34.0 ± 13.4 months. In 10 cases, a posterior titanium instrumentation and fusion mass were present; in 2 patients, only a fusion mass was present. Indicators of pain and disability improved in all patients (p < 0.01). Sagittal realignment with the restoration of ideal spinopelvic parameters was obtained in all cases. One peritoneal lesion requiring intraoperative suture without sequelae, two cases of postoperative radiculopathy, and one posterior wound infection requiring surgical debridement and antibiotic therapy were reported. CONCLUSIONS: Anterior implant of lordotic and hyperlordotic cages with increasing segmental lordosis is possible in the presence of posterior instrumentation and/or solid fusion mass. The biomechanical strength of this corrective technique can overcome posterior instrumentation and bone fusion resistance, therefore allowing a single-staged surgery for sagittal realignment.

The use of electronic PROMs provides same outcomes as paper version in a spine surgery registry. Results from a prospective cohort study.

BACKGROUND AND PURPOSE: Patient-Reported Measured Outcomes (PROMs) are essential to gain a full understanding of a patient's condition, and in spine surgery, these questionnaires are of help when tailoring a surgical strategy. Electronic registries allow for a systematic collection and storage of PROMs, making them readily available for clinical and research purposes. This study aimed to investigate the reliability between the electronic and paper form of ODI (Oswestry Disability Index), SF-36 (Short Form Health Survey 36) and COMI-back (Core Outcome Measures Index for the back) questionnaires. METHODS: A prospective analysis was performed of ODI, SF-36 and COMI-back questionnaires collected in paper and electronic format in two patients' groups: Pre-Operatively (PO) or at follow-up (FU). All patients, in both groups, completed the three questionnaires in paper and electronic form. The correlation between both methods was assessed with the Intraclass Correlation Coefficients (ICC). RESULTS: The data from 100 non-consecutive, volunteer patients with a mean age of 55.6 ± 15.0 years were analysed. For all of the three PROMs, the reliability between paper and electronic questionnaires results was excellent (ICC: ODI = 0.96; COMI = 0.98; SF36-MCS = 0.98; SF36-PCS = 0.98. For all p < 0.001). CONCLUSIONS: This study proved an excellent reliability between the electronic and paper versions of ODI, SF-36 and COMI-back questionnaires collected using a spine registry. This validation paves the way for stronger widespread use of electronic PROMs. They offer numerous advantages in terms of accessibility, storage, and data analysis compared to paper questionnaires.

Major complications in extreme lateral interbody fusion access: multicentric study by Italian S.O.L.A.S. group.

PURPOSE: The eXtreme Lateral Interbody Fusion (XLIF) approach has gained increasing importance in the last decade. This multicentric retrospective cohort study aims to assess the incidence of major complications in XLIF procedures performed by experienced surgeons and any relationship between the years of experience in XLIF procedures and the surgeon's rate of severe complications. METHODS: Nine Italian members of the Society of Lateral Access Surgery (SOLAS) have taken part in this study. Each surgeon has declared how many major complications have been observed during his surgical experience and how they were managed. A major complication was defined as an injury that required reoperation, or as a complication, whose sequelae caused functional limitations to the patient after one year postoperatively. Each surgeon was finally asked about his years of experience in spine surgery and XLIF approach. Pearson correlation test was used to evaluate the association between the surgeon's years of experience in XLIF and the rate of major complications; a p-value of last than 0.05 was considered significant. RESULTS: We observed 14 major complications in 1813 XLIF procedures, performed in 1526 patients. The major complications rate was 0.7722%. Ten complications out of fourteen needed a second surgery. Neither cardiac nor respiratory nor renal complications were observed. No significant correlation was found between the surgeon's years of experience in the XLIF procedure and the number of major complications observed. CONCLUSION: XLIF revealed a safe and reliable surgical procedure, with a very low rate of major complications, when performed by an expert spine surgeon.