Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review.

STUDY DESIGN: A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE: To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS: A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS: Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION: This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE: 3.

Assessment of Outcomes of Spine Surgery in Indian Athletes Involved in High-End Contact Sports.

STUDY DESIGN: This study was a retrospective analysis. PURPOSE: This study aimed to analyze the functional outcome following spinal surgery in elite athletes using return-to-play criteria. OVERVIEW OF LITERATURE: Spinal ailments are relatively common in athletes and are bound to increase due to the ever-growing popularity of contact sports. An elite athlete is highly motivated to make a rapid recovery and return to full participation in sports. Although the criteria for diagnosis and surgical treatment of various spinal disorders in athletes have been well defined in the literature, there is no clear definition about the factors determining the return to play in athletes. METHODS: This study was a retrospective analysis of the data of 10 elite athletes who underwent spinal surgery for symptomatic degenerative disorder of the spine. Eight patients underwent lumbar spine surgery (two patients of microdiscectomy and six patients of fusion), and the remaining two patients underwent cervical spine surgery (one each anterior cervical discectomy and fusion and anterior cervical disc replacement). Outcome measures were investigated using return-to-training and return-to-sports criteria, as indicated by the length of time between surgery and return to competitive sports as parameters. RESULTS: Of the 10 patients, eight were males and two were females. The average age of the patients at the time of surgery was 32.4 years (range, 25-41 years). All patients returned to active participation of their sports. The average time for return to training was 7.3 weeks (range, 3-12 weeks). The average time for return to sports was 45.6 weeks (range, 36-72 weeks), and the average follow-up period was 59 months (range, 27-120 months). CONCLUSIONS: Spine surgery in an elite athlete involved in contact sports is safe and effective. Currently, there is a lack of standardized guidelines for return to sports after spine injuries. An athlete needs to be symptom-free, with full range of motion and full strength before returning to sports.

Does Three-Dimensional Printed Patient-Specific Templates Add Benefit in Revision Surgeries for Complex Pediatric Kyphoscoliosis Deformity with Sublaminar Wires in Situ? A Clinical Study.

STUDY DESIGN: Case-control study. PURPOSE: To evaluate the accuracy of three-dimensional (3D) printed patient-specific templates (PSTs) for placement of pedicle screws (PAs) in patients undergoing revision surgeries for complex kyphoscoliosis deformity with sublaminar wires in situ. OVERVIEW OF LITERATURE: Revision kyphoscoliosis correction surgery in pediatric patients is a challenging task for the treating surgeon. In patients with sublaminar wires in situ, the native anatomical landmarks are obscured, thus making the freehand screw placement technique a highly specialized task. Hence, the concept of using PSTs for insertion of PAs in such surgeries is always intriguing and attractive. METHODS: Five consecutive patients undergoing revision deformity correction with sublaminar wires in situ were included in this study. Patients were divided in two groups based on the technique of PA insertion. A total of 91 PAs were inserted using either a freehand technique (group A) or 3D printed templates (group B) (34 vs. 57). The placement of PAs was classified according to a postoperative computed tomography scan using Neo's classification. Perforation beyond class 2 (>2 mm) was termed as a misplaced screw. The average time required for the insertion of screws was also noted. RESULTS: Mean age, surgical time, and blood loss were recorded. The change in mean Cobb's angle in both groups was also recorded. The difference in rates of misplaced screws was noted in group A and group B (36.21% vs. 2.56%); however, the mean number of misplaced PAs per patient in group A and group B was statistically insignificant (6.5±3.54 vs. 4.67±1.53, p =0.4641). The mean time required to insert a single PA was also statistically insignificant (120±28.28 vs. 90±30 seconds, p =0.3456). CONCLUSIONS: Although 3D printed PSTs help to avoid the misplacement of PAs in revision deformity correction surgeries with sublaminar wires in situ, the mean number of misplaced screws per patient using this technique was found to be statistically insignificant when compared with the freehand technique in this study.

Coronavirus Disease 2019 Transmission: Blood Viremia and Aerosol Generation from Spinal Surgery. Is There an Increased Risk to the Surgical Team?

As a respiratory pathogen, the novel coronavirus is commonly associated with aerosol-generating procedures. However, it is currently unclear whether spinal surgical procedures pose an additional risk of viral transmission to the surgical team. We reviewed the available evidence to ascertain the presence of coronavirus disease 2019 (COVID-19) blood viremia and the virus' blood transmissibility, as well as evidence of blood-aerosol generation and operating room contamination from spinal surgical procedures. There is established evidence of COVID-19 blood viremia, a viral pathogenic cycle via angiotensin-converting enzyme 2 (ACE-2) receptors and similar blood transmission risk data from the SARS (severe acute respiratory syndrome)/MERS (Middle East respiratory syndrome) era. Spinal surgical practices demonstrate significant blood-aerosol generation from the operative wound due to the use of common surgical instruments, such as electrocautery, as well as high-speed and high-impact devices. Based on the evidence, there is an established additional risk of viral transmission faced by surgical teams from blood-aerosols generated from the operative wound of COVID-19- infected patients via the inhalation of virus-laden aerosols and the subsequent initiation of the viral pathogenic cycle through binding with pulmonary ACE-2 receptors. Recognizing this additional risk amidst the ongoing pandemic serves as a caution to front-line surgical personnel to strictly adhere to personal protective equipment usage in operating rooms, to modify surgical techniques to reduce the hazard of surgical aerosol generation and COVID-19 viral exposure, and to consider it as an integral aspect of planning and adapting to the "new normal" operating practices.

Procalcitonin -Vital Tool to Differentiate Septic Progression of Spondylodiscitis from Drug Hypersensitivity: A Case Report and Brief Review of Literature.

INTRODUCTION: Drug hypersensitivity is an important differential diagnosis in patients of infective spondylodiscitis, who develop systemic symptoms such as fever, rash, and arthralgia while on treatment with antibiotics. As these symptoms may also be present in sepsis progression, differentiation between two is very difficult. Procalcitonin (PCT) is one of the important and specific biomarkers of early sepsis. CASE REPORT: We present a case of a 33-year-old male with deep post-operative spinal infection complicated by drug hypersensitivity and worsening of systemic parameters. Serum PCT levels helped us to make correct diagnosis and prevent unnecessary surgical debridement. CONCLUSION: PCT, as a biomarker, can help distinguish the septic progression of spondylodiscitis from drug hypersensitivity and prove vital in clinical decision-making in these difficult scenarios.

Analysis of the Functional and Radiological Outcomes of Lumbar Decompression without Fusion in Patients with Degenerative Lumbar Scoliosis.

STUDY DESIGN: Retrospective study. PURPOSE: This study aimed to analyze the functional and radiological outcomes of lumbar decompression in patients with degenerative lumbar scoliosis (DLS). OVERVIEW OF LITERATURE: Patients with DLS have symptoms related to lumbar canal stenosis (LCS) and those due to compensated spinal imbalance. Whether the deformity is the cause of pain or is an adaptive change for the ongoing LCS remains debatable. The extensive surgery for deformity correction along with spinal fusion is reported to have high perioperative morbidity and complication rate. METHODS: This retrospective analysis involved 51 patients who underwent lumbar decompression for LCS associated with DLS from October 2006 to October 2016. The magnitude of the curve was determined using Cobb's angle and lumbar lordosis (D12-S1) on the preoperative and final follow-up, respectively. The Visual Analog Scale (VAS) and modified Oswestry Disability Index (mODI) scores at the preoperative and final follow-up indicated the functional outcome. Statistical analyses were performed using Student t -test. RESULTS: All 51 patients were included in the statistical analyses. The mean patient age at presentation was 63.88±7.21 years. The average follow-up duration was 48±18.10 months. The average change in the Cobb's angle at the final follow-up was statistically insignificant (1°±1.5°, p=0.924; 20.8°±5.1° vs. 21.9°±5.72°). The mean change in lumbar lordosis at the final follow-up was statistically insignificant (3.29°±1.56°, p=0.328; 30.2°±7.9° vs. 27.5°±7.1°). There was statistically insignificant worsening in the back VAS scores at the final follow-up (4.9±1.9 vs. 6.0±1.2, p=0.07). There was statistically significant improvement in the leg pain component of the VAS score at the final follow-up (5.8±1.05 vs. 2.6±1.2, p<0.001). There was statistically significant improvement in the mODI scores at the final follow-up (p<0.001). CONCLUSIONS: Lumbar decompression in DLS is associated with good functional outcome, especially when the symptoms are related to LCS. Curve progression following lumbar decompression is very less at mid-term and is similar to that in the natural course of the disease.

Management of Catastrophic Proximal Junctional Failure Following Spinal Deformity Correction in an Adult with Osteogenesis Imperfecta: Case Report and Technical Note.

BACKGROUND: Proximal junctional failure (PJF) is a major and sometimes devastating problem following adult spinal deformity (ASD) correction surgery. Common consensus still lags on guidelines for preventing and managing these complications. Surgical treatment of scoliosis in the presence of osteogenesis imperfecta (OI) in the pediatric population is well described. The complication rates are unusually higher in this special subset of patients owing to poor quality of bone. There is a paucity of literature focusing on surgical techniques, strategies, and problems involved in the management of ASD associated with OI. CASE DESCRIPTION: We report a 59-year-old female with type 1 OI and adult scoliosis who underwent T10-to-pelvis fusion for ASD according to the principles of adult deformity correction. At a 1-year follow-up, she presented with asymptomatic proximal junctional kyphosis of 45° and 2 weeks later had PJF along with spinal cord injury after a fall. On computed tomography scan, kyphosis was increased to 60° at T9-T10. She underwent decompression and revision deformity correction using quadruple rods, with extension of instrumentation to T2 with soft landing using rib bands. At a 4-year follow-up, she had a good functional outcome after revision surgery. CONCLUSIONS: This is the first report of successful management of PJF following ASD correction in the presence of OI using this technique. Suboptimal hold of implants due to poor bone quality must be at the focus of any surgical planning for these patients. All possible strategies to prevent PJF must be considered when planning the deformity correction in adults with OI.

A Technical Note on Making Patient-Specific Pedicle Screw Templates for Revision Pediatric Kyphoscoliosis Surgery with Sublaminar Wires In Situ.

INTRODUCTION: Revision deformity correction surgery of a pediatric spine, especially with sublaminar Soacing between wires in situ, is a daunting task for patient as well as treating physician. Obscured native anatomy in the presence of sublaminar wires poses a staunch intraoperative challenge for a surgeon for safe placement of pedicle screws so as to avoid neurological and vascular injury. In revision surgeries with previous implants, it' is challenging, especially due to metal artifacts in imaging, bone loss due to previous surgery. In this note, we describe the technique of making making three-dimensional (3D)-printed patient-specific templates for safe placement of pedicle screws in pediatric patients undergoing revision kyphoscoliosis surgery with sublaminar wires in situ. CASE REPORT: A 12-year-old female presented to the clinic with a history of early-onset scoliosis, for which she underwent deformity correction surgery with spinal rectangle loop and sublaminar wires 4 years ago. At presentation, she had decompensated with increase in deformity and failed implant. She underwent revision deformity correction surgery with pedicle screws. 3D-printed patient-specific pedicle screw templates were useful in this patient for appropriate pedicle screw placement, as patient had obscured native anatomy due to fusion mass and in situ sublaminar wires. CONCLUSION: 3D-printed patient-specific pedicle screw templates are very useful in revision pediatric deformity correction surgeries, especially when the obscured native bony anatomy makes free-hand insertion of pedicle screw unsafe.

Osteoid Osteoma of Cervical Spine: A Case Report and Review of Literature.

INTRODUCTION: Osteoid osteoma of cervical spine is a rare clinical entity and accounts for 4% of cases of overall spinal osteoid osteoma. It has predilection for neural arch and complete resection is difficult task due to proximity to important neurovascular structures. Incomplete resection leads to recurrence in about 4.5% of patients. Computed tomography (CT)-based navigation may aid in resection of tumor without compromising stability, but whenever it inevitable fusion is mandatory. CASE REPORT: We report two cases of osteoid osteoma of cervical spine managed with surgical excision. Case1 had recurrence of tumor at the left C6 pedicle after minimally invasive intervention that was later managed by surgical excision with the help of CT-guided navigation. Case 2 had osteoid osteoma of the right C4 lateral mass that was treated with surgical excision and fusion. CONCLUSION: Osteoid osteoma is a rare pathology in cervical spine. Surgical excision of cervical osteoid osteoma is a daunting task due to the proximity to neurovascular structures. Recurrence though less often is the result of inadequate excision.

Autostabilization of neglected high-grade fracture-dislocation in the cervical spine.

Neglected cervical spine trauma is rare with very few case series reported in literature. There are no clear guidelines for its treatment. If operative treatment is sought, the role of skull traction, type of approach (anterior only, posterior only, or combined), sequence of surgery, type of instrumentation, etc., have to be considered. Hence, the treatment is challenging. Autostabilization has been described in the natural history of degenerative lumbar spondylolisthesis. As a result, many patients are treated nonoperatively, obviating need of surgery. We report two cases of neglected/untreated fracture-dislocation at subaxial cervical spine. They presented with exertional neck pain. Computed tomography scan showed bony fusion at involved level. The patient was treated nonsurgically with favorable outcome at long-term follow-up. Our cases depict autostabilization in a case of neglected traumatic cervical spine injury, which is never been reported. Such patients do well with nonsurgical treatment, thus obviating need for extensive deformity correction.