A Novel Surgical Indication for Scheuermann's Kyphosis.

Scheuermann kyphosis can be treated surgically to restore proper sagittal alignment. Thoracic curves >70° are typically indicated for surgical intervention. However, patients who have reached their natural limit of compensatory lumbar hyperlordosis are at risk of accelerated degeneration. This can be determined by comparing lumbar lordosis on standing neutral radiographs and supine extension radiographs. Minimal additional lordosis in extension compared with neutral, abutment of the spinous processes, or greater lumbar lordosis standing than with attempted extension suggest the patient is maximally compensated. We present a case of an adolescent boy with Scheuermann kyphosis who had reached the limit of his hyperlordosis compensation reserve. He subsequently underwent a T4 to L2 posterior spinal fusion with T7 to T11 Ponte Smith-Petersen grade two osteotomies. He tolerated the procedure well with no intraoperative complications or neuromonitoring changes. The patient has continued to do well and progressed to normal activity at 5-month follow-up.

Spine surgeon versus AI algorithm full-length radiographic measurements: a validation study of complex adult spinal deformity patients.

INTRODUCTION: Spinal measurements play an integral role in surgical planning for a variety of spine procedures. Full-length imaging eliminates distortions that can occur with stitched images. However, these images take radiologists significantly longer to read than conventional radiographs. Artificial intelligence (AI) image analysis software that can make such measurements quickly and reliably would be advantageous to surgeons, radiologists, and the entire health system. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this study. Preoperative full-length standing anterior-posterior and lateral radiographs of patients that were previously measured by fellowship-trained spine surgeons at our institution were obtained. The measurements included lumbar lordosis (LL), greatest coronal Cobb angle (GCC), pelvic incidence (PI), coronal balance (CB), and T1-pelvic angle (T1PA). Inter-rater intra-class correlation (ICC) values were calculated based on an overlapping sample of 10 patients measured by surgeons. Full-length standing radiographs of an additional 100 patients were provided for AI software training. The AI algorithm then measured the radiographs and ICC values were calculated. RESULTS: ICC values for inter-rater reliability between surgeons were excellent and calculated to 0.97 for LL (95% CI 0.88-0.99), 0.78 (0.33-0.94) for GCC, 0.86 (0.55-0.96) for PI, 0.99 for CB (0.93-0.99), and 0.95 for T1PA (0.82-0.99). The algorithm computed the five selected parameters with ICC values between 0.70 and 0.94, indicating excellent reliability. Exemplary for the comparison of AI and surgeons, the ICC for LL was 0.88 (95% CI 0.83-0.92) and 0.93 for CB (0.90-0.95). GCC, PI, and T1PA could be determined with ICC values of 0.81 (0.69-0.87), 0.70 (0.60-0.78), and 0.94 (0.91-0.96) respectively. CONCLUSIONS: The AI algorithm presented here demonstrates excellent reliability for most of the parameters and good reliability for PI, with ICC values corresponding to measurements conducted by experienced surgeons. In future, it may facilitate the analysis of large data sets and aid physicians in diagnostics, pre-operative planning, and post-operative quality control.

Academic career progression in AANS/CNS Spine Section award recipients.

OBJECTIVE: The American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Spine Section awards highlight outstanding abstracts submitted to the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves by trainees interested in spine surgery, although the academic trajectory of awardees has not been studied. The aim of this study was to assess the academic career progression of prior recipients of the Journalistic and Academic Neurosurgical Excellence (JANE), Mayfield, and Kuntz research awards. METHODS: Prior JANE, Mayfield, and Kuntz award recipients were identified using awardee records accrued between 1984 and February 2022. Awardee sex, country of residence, specialty, subspecialty focus, and current academic appointment status (if applicable) were searched online. Awardee h-indices and number of peer-reviewed publications were assessed via Google Scholar profiles (or Scopus if unavailable) and PubMed, respectively. Receipt of federal research funding as principal investigator (PI) was determined using the websites of the National Institutes of Health, the National Science Foundation, and the Department of Defense Congressionally Directed Medical Research Programs. The abstract-to-publication rate was assessed. RESULTS: A total of 7 JANE awards, 57 Mayfield awards, and 149 Kuntz awards were identified. Of the JANE awardees, all recipients were male. Of the 4 unique JANE awardees who completed training, 2 (50.0%) held academic appointments at the time of the study. All of the JANE abstracts were published in peer-reviewed journals. The mean h-index of all JANE awardees was 28 and the mean number of publications was 126. None of the awardees have received federal research funding. Of the Mayfield awards, 98.2% were awarded to males. Of the 43 unique Mayfield awardees who completed training, 20 (46.5%) held faculty appointments at academic medical centers. All of the Mayfield abstracts since 2011 were published in peer-reviewed journals. The mean h-index of all Mayfield awardees was 26 and the mean number of publications was 82. Five Mayfield awardees received National Institutes of Health funding as PI, and 7 awardees received Department of Defense funding as PI. Of the Kuntz awards, 95.3% were awarded to males. Most awards were given to current residents and fellows (46.3%). Of the 55 unique Kuntz awardees who completed training, 31 (56.4%) held faculty appointments at academic medical centers. The abstract-to-publication rate of the total Kuntz abstracts was 70.5%. The mean h-index of all Kuntz awardees was 15 and the mean number of publications was 58. Five Kuntz awardees (3.4%) received federal research funding as PI. CONCLUSIONS: Many recipients of the JANE, Mayfield, and Kuntz Joint Spine Section awards have successfully translated award abstracts into peer-reviewed publications. Furthermore, approximately one-third of the awardees are active in academic neurosurgery, with some having secured federal research funding.

Does A Hinged Operating Table Facilitate Sagittal Correction in Transforaminal Lumbar Interbody Fusion With Smith-Peterson Osteotomy? A Radiographic Analysis.

BACKGROUND: Osteotomies allow the restoration of appropriate sagittal alignment; however, closure of osteotomies can be challenging. Typical closure involves compressing pedicle screw heads across the rods, potentially causing screw loosening and failure. Motorized hinged operating tables are often used to assist with controlled closure of osteotomies without manual compression, but there is no published research quantifying the amount of correction provided solely by changes in the table angle. QUESTION/PURPOSE: What is the incremental amount of correction achieved by change in the table angle versus instrumented manipulation during osteotomy closure in transforaminal lumbar interbody fusion (TLIF) with Smith-Petersen osteotomy? METHODS: Sixty-one patients undergoing Smith-Peterson osteotomy and bilateral TLIF using a motorized hinged table from October 2019 to March 2022 were prospectively enrolled. Two patients did not undergo surgery, two did not have table extension, and seven did not have data collected intraoperatively because of disruptions in research protocols owing to the coronavirus-19 pandemic. Fifty patients (24 male, 26 female) who underwent a total of 73 osteotomies were included in the final analysis. The mean ± standard deviation age was 61 ±11 years, and the mean BMI was 31 ± 6 kg/m2. Patients were positioned prone on the table and flexed to 10° for decompression, Smith-Petersen osteotomy, and TLIF. The table was then extended in 5° increments, and radiographs were taken until 10° of extension was achieved or the osteotomy was fully closed. Changes in segmental lordosis across the operative site for each 5° increment were measured to the nearest degree by two reviewers. Intraclass correlation coefficients for segmental lordosis measurements at each table angle change were calculated as 0.97 to 0.98, with all p values < 0.001, indicating excellent agreement. RESULTS: Table change from 10° to 5° yielded a mean segmental lordosis change of 1.9° ± 1.5° (73 osteotomies), 5° to 0° yielded a change of 1.3° ± 0.9° (73 osteotomies), 0° to -5° yielded a change of 1.3° ± 1.0° (69 osteotomies), and -5° to -10° yielded a change of 1.1° ± 1.3° (61 osteotomies). Rod placement and compression yielded a mean 1.8° ± 2.0° of additional segmental lordosis. CONCLUSION: Using a motorized hinged table facilitated an average of 5.6° of total segmental lordosis correction during controlled Smith-Peterson osteotomy closure without the need for cantilevering forces across spinal instrumentation. Surgeons can use this technique to reduce the compression forces needed to close osteotomies, which could eliminate a potential source of complications.Level of Evidence Level II, therapeutic study.

Management of High-Grade Dysplastic Spondylolisthesis.

The Meyerding classification grades the degree of slippage in the sagittal plane on lateral standing neutral imaging: 0% to 25% Grade I, 25% to 50% Grade II, 50% to 75% Grade III, 75% to 100% Grade IV, and greater than 100% Grade V (Spondyloptosis). Grades I and II are considered low-grade and Grades III-V are considered high-grade. There are several etiologies of spondylolisthesis. A classification system of the most common causes: Type I - Dysplastic, Type II - Isthmic (including subtypes: A - Lytic, B - Elongation, and C - Acute fracture), Type III - Degenerative, Type IV - Traumatic, Type V - Pathologic, and Type VI - Iatrogenic. Dysplastic spondylolisthesis is a type of spondylolisthesis that occurs at L5-S1 when dysplastic lumbosacral anatomy is present, and is associated with high-grade slip and spina bifida occulta.

Chance Fracture Pattern Presenting in Proximal Junctional Failure.

INTRODUCTION: We present a case series of proximal junctional failure due to a Chance-type fracture. METHODS: This is a retrospective review of patients who developed proximal junctional kyphosis because of Chance-type proximal junctional failure after spinal fusion for adult spinal deformity. RESULTS: Fifteen patients were identified (4M:11F). The average age was 61.4 years (range, 39 to 77). The mean time to fracture identification was 25.4 days (range, 3 to 65). The average number of levels instrumented was 6.7 (range, 2 to 17). No patients had antecedent trauma before fracture onset. In 67% of cases with a lumbar upper instrumented vertebra (UIV), there was overcorrection of lumbar lordosis (LL) and/or lower LL. The five cases with a lower thoracic UIV had undergone notable correction of preoperative thoracolumbar junction kyphosis. 14 of 15 patients were treated with extension of fusion. Pedicle screws at the fracture level were salvaged by changing to an anatomic trajectory. CONCLUSION: Continued pain at 6 to 12 weeks with radiographs showing an increased proximal junctional angle and cephalocaudal pedicle widening at the UIV should raise suspicion for this unique fracture pattern. A CT scan is recommended. Low bone density, LL and/or lower LL overcorrection, and selection of lower thoracic UIV in the setting of notable thoracolumbar junction correction may contribute to fracture risk.

Sacroiliac joint fusion navigation: how accurate is pin placement?

OBJECTIVE: Sacroiliac joint (SIJ) fusion utilizing intraoperative navigation requires a standard reference frame, which is often placed using a percutaneous pin. Proper placement ensures the correct positioning of SIJ fusion implants. There is currently no grading scheme for evaluation of pin placement into the pelvis. The purpose of this study was to evaluate the occurrence of ideal percutaneous pin placement into the posterior ilium during navigated SIJ fusion. METHODS: After IRB approval was obtained, electronic medical records and intraoperative computed tomography images of patients who underwent navigated SIJ fusion by the senior author between October 2013 and January 2020 were reviewed. A pin placement grading scheme and the definition of "ideal" placement were developed by the authors and deemed acceptable by fellow attending surgeons. Six attending surgeons completed two rounds of pin placement grading, and statistical analysis was conducted. RESULTS: Of 90 eligible patients, 73.3% had ideal pin placement, 17.8% medial/lateral breach, and 8.9% complete miss. Male patients were 3.7 times more likely to have ideal placement than females (p < 0.05). There was no relationship between BMI, SIJ fusion laterality, or pin placement laterality and ideal placement. Interobserver reliability was 0.72 and 0.70 in the first and second rounds, respectively, and defined as "substantial agreement." Intraobserver reliability ranged from 0.74 (substantial agreement) to 0.92 (almost perfect agreement). CONCLUSIONS: Nonideal pin placement occurred in 26.7% of cases, but a true "miss" into the sacrum was rare. Ideal pin placement was more likely in males and was not associated with BMI, SIJ fusion laterality, or pin placement laterality. The grading scheme developed has high intraobserver and interobserver reliability, indicating that it is reproducible and can be used for future studies. When placing percutaneous pins, surgeons must be aware of factors that can decrease placement accuracy, regardless of location.

Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors.

OBJECTIVE: There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS: Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS: Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence-lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5-S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS: Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

Odontoid Fracture as Proximal Junctional Failure in Patients With Multilevel Spine Fusions.

STUDY DESIGN: Retrospective study. OBJECTIVE: Proximal junctional failure (PJF) commonly occurs as a recognized potential outcome of fusion surgery. Here we describe a unique series of patients with multilevel spine fusion including the cervical spine, who developed PJF as an odontoid fracture. METHODS: We performed a single site retrospective review of patients with prior fusion that included a cervical component, who presented with an odontoid fracture between 2012 and 2019. Radiographic measurements included C2-C7 SVA, C2-C7 lordosis, T1 slope, Occiput-C2 angle, proximal junctional kyphosis, and cervical mismatch. Associated fractures, medical comorbidities, and treatments were determined via chart review after IRB approval. RESULTS: Nine patients met inclusion criteria. 5 reported trauma with subsequent onset of pain. All patients sustained a Type II odontoid fracture. 5 with associated C1/Jefferson fractures. In all patients, pre-injury Occiput-C2 angle was outside normative range; C2-C7 SVA was greater than 4 cm in 6 patients; T1-slope minus cervical lordosis was greater than 18.5 degrees in 6 patients. 7 patients were treated operatively with extension of fusion to C1 and 2 patients declined operative treatment. CONCLUSION: In this series of 9 patients with multilevel fusion with type II odontoid fractures, all patients demonstrated abnormal pre-fracture sagittal alignment parameters and a greater than normal association of C1 fractures was noted. Further study is needed to establish the role of poor sagittal alignment with compensatory occiput-C2 angulation as a predisposing factor for odontoid fracture as a proximal junctional failure mechanism.

Multiple Points of Pelvic Fixation: Stacked S2-Alar-Iliac Screws (S2AI) or Concurrent S2AI and Open Sacroiliac Joint Fusion with Triangular Titanium Rod.

Sacropelvic fixation is a continually evolving technique in the treatment of adult spinal deformity. The 2 most widely utilized techniques are iliac screw fixation and S2-alar-iliac (S2AI) screw fixation1-3. The use of these techniques at the base of long fusion constructs, with the goal of providing a solid base to maintain surgical correction, has improved fusion rates and decreased rates of revision4. Description: The procedure is performed with the patient under general anesthesia in the prone position and with use of 3D computer navigation based on intraoperative cone-beam computed tomography (CT) imaging. A standard open posterior approach with a midline incision and subperiosteal exposure of the proximal spine and sacrum is performed. Standard S2AI screw placement is performed. The S2AI starting point is on the dorsal sacrum 2 to 3 mm above the S2 foramen, aiming as caudal as possible in the teardrop. A navigated awl is utilized to establish the screw trajectory, passing through the sacrum, across the sacroiliac (SI) joint, and into the ilium. The track is serially tapped with use of navigated taps, 6.5 mm followed by 9.5 mm, under power. The screw is then placed under power with use of a navigated screwdriver.Proper placement of the caudal implant is vital as it allows for ample room for subsequent instrumentation. The additional point of pelvic fixation can be an S2AI screw or a triangular titanium rod (TTR). This additional implant is placed cephalad to the trajectory of the S2AI screw. A starting point 2 to 3 mm proximal to the S2AI screw tulip head on the sacral ala provides enough clearance and also helps to keep the implant low enough in the teardrop that it is likely to stay within bone. More proximal starting points should be avoided as they will result in a cephalad breach.For procedures with an additional point of pelvic fixation, the cephalad S2AI screw can be placed using the previously described method. For placement of the TTR, the starting point is marked with a burr. A navigated drill guide is utilized to first pass a drill bit to create a pilot hole, followed by a guide pin proximal to the S2AI screw in the teardrop. Drilling the tip of the guide pin into the distal, lateral iliac cortex prevents pin backout during the subsequent steps. A cannulated drill is then passed over the guide pin, traveling from the sacral ala and breaching the SI joint into the pelvis. A navigated broach is then utilized to create a track for the implant. The flat side of the triangular broach is turned toward the S2AI screw in order to help the implant sit as close as possible to the screw and to allow the implant to be as low as possible in the teardrop. The navigation system is utilized to choose the maximum possible implant length. The TTR is then passed over the guide pin and impacted to the appropriate depth. Multiplanar post-placement fluoroscopic images and an additional intraoperative CT scan of the pelvis are obtained to verify instrumentation position. Alternatives: The use of spinopelvic fixation in long constructs is widely accepted, and various techniques have been described in the past1. Alternatives to stacked S2AI screws or S2AI with TTR for SI joint fusion include traditional iliac screw fixation with offset connectors, modified iliac fixation, sacral fixation alone, and single S2AI screw fixation. Rationale: The lumbosacral junction is the foundation of long spinal constructs and is known to be a point of high mechanical strain5-7. Although pelvic instrumentation has been utilized to increase construct stiffness and fusion rates, pelvic fixation failure is frequently reported8,9. At our institution, we identified a 5% acute pelvic fixation failure rate over an 18-month period10. In a subsequent multicenter retrospective series, a similar 5% acute pelvic fixation failure rate was also reported11. In response to these findings, our institution changed its pelvic fixation strategies to incorporate multiple points of pelvic fixation. From our experience, utilization of multiple pelvic fixation points has decreased acute failure. In addition to preventing instrumentation failure, S2AI screws are lower-profile, which decreases the complication of implant prominence associated with traditional iliac screws. S2AI screw heads are also more in line with the pedicle screw heads, which decreases the need for excessive rod bending and connectors.The use of the techniques has been described in case reports and imaging studies12-14, but until now has not been visually represented. Here, we provide technical and visual presentation of the placement of stacked S2AI screws or open SI joint fusion with a TTR above an S2AI screw. Expected Outcomes: Pelvic fixation provides increased construct stiffness compared with sacral fixation alone15-17 and has shown better rates of fusion4. However, failure rates of up to 35%8,9 have been reported, and our own institution identified a 5% acute pelvic fixation failure rate10. In response to this, the multiple pelvic fixation strategy (stacked S2AI screws or S2AI and TTR for SI joint fusion) has been more widely utilized. In our experience utilizing multiple points of pelvic fixation, we have noticed a decreased rate of pelvic fixation failure and are in the process of reporting these findings18,19. Important Tips: The initial trajectory of the caudal S2AI screw needs to be as low as possible within the teardrop, just proximal to the sciatic notch.The starting point for the cephalad implant should be 2 to 3 mm proximal to the S2AI screw tulip head. This placement provides enough clearance and helps to contain the implant in bone.More proximal starting points may result in cephalad breach of the TTR.The use of a reverse-threaded Kirschner wire helps to prevent pin backout while drilling and broaching for TTR placement.If malpositioning of the TTR is found on imaging, removal and redirection is technically feasible. Acronyms and Abbreviations: S2AI = S2-alar-iliacTTR = triangular titanium rodCT = computed tomographyAP = anteroposteriorOR = operating roomSI = sacroiliacDRMAS = dual rod multi-axial screwK-wire = Kirschner wireDVT = deep vein thrombosisPE = pulmonary embolism.

Bilateral open sacroiliac joint fusion during adult spinal deformity surgery using triangular titanium implants: technique description and presentation of 21 cases.

OBJECTIVE: Pelvic fixation enhances long constructs during deformity surgery. Subsequent loosening of iliac screws and pain at the pelvis occur in as many as 29% of patients. Concomitant sacroiliac (SI) fusion may prevent potential pain and failure. The objective of this study was to describe a novel surgical technique and a single institution's experience using bilateral SI fusion during adult deformity surgery with S2-alar-iliac (S2AI) screws and triangular titanium rods (TTRs) placed with navigation. METHODS: The authors reviewed open SI joint fusions with TTR performed between August 2019 and March 2020. All patients underwent lumbosacral fusion through a midline approach and bilateral S2AI pelvic fixation in the caudal teardrop, followed by TTR placement just proximal and cephalad to the S2AI screws using intraoperative CT imaging guidance. RESULTS: Twenty-one patients were identified who received 42 TTRs, ranging in size from 7.0 × 65 mm to 7.0 × 90 mm. Three TTRs (7%) were malpositioned intraoperatively, and each was successfully repositioned during index surgery without negative sequelae. All breaches occurred in a medial and cephalad direction into the pelvis. Incremental operative time for adding TTR averaged 8 minutes and 33 seconds per implant. CONCLUSIONS: Image-guided open SI joint fusion with TTR during lumbosacral fusion is technically feasible. The bony corridor for implant placement is narrower cephalad, and implants tend to deviate medially into the pelvis. Detection of malpositioned implant is aided with intraoperative CT, but this can be salvaged. A prospective randomized clinical trial is underway that will better inform the impact of this technique on patient outcomes.

Acute failure of S2-alar-iliac screw pelvic fixation in adult spinal deformity: novel failure mechanism, case series, and review of the literature.

OBJECTIVE: Pelvic fixation with S2-alar-iliac (S2AI) screws is an established technique in adult deformity surgery. The authors' objective was to report the incidence and risk factors for an underreported acute failure mechanism of S2AI screws. METHODS: The authors retrospectively reviewed a consecutive series of ambulatory adults with fusions extending 3 or more levels, and which included S2AI screws. Acute failure of S2AI screws was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS: Failure occurred in 6 of 125 patients (5%) and consisted of either slippage of the rods or displacement of the set screws from the S2AI tulip head, with resultant kyphotic fracture. All failures occurred within 6 weeks postoperatively. Revision with a minimum of 4 rods connecting to 4 pelvic fixation points was successful. Two of 3 (66%) patients whose revision had less fixation sustained a second failure. Patients who experienced failure were younger (56.5 years vs 65 years, p = 0.03). The magnitude of surgical correction was higher in the failure cohort (number of levels fused, change in lumbar lordosis, change in T1-pelvic angle, and change in coronal C7 vertical axis, each p < 0.05). In the multivariate analysis, younger patient age and change in lumbar lordosis were independently associated with increased failure risk (p < 0.05 for each). There was a trend toward the presence of a transitional S1-2 disc being a risk factor (OR 8.8, 95% CI 0.93-82.6). Failure incidence was the same across implant manufacturers (p = 0.3). CONCLUSIONS: All failures involved large-magnitude correction and resulted from stresses that exceeded the failure loads of the set plugs in the S2AI tulip, with resultant rod displacement and kyphotic fractures. Patients with large corrections may benefit from 4 total S2AI screws at the time of the index surgery, particularly if a transitional segment is present. Salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

The effect of simulation training on resident proficiency in thoracolumbar pedicle screw placement using computer-assisted navigation.

OBJECTIVE: Residency work-hour restrictions necessitate efficient, reproducible training. Simulation training for spinal instrumentation placement shows significant benefit to learners' subjective and objective proficiency. Cadaveric laboratories are most effective but have high cost and low availability. The authors' goal was to create a low-cost, efficient, reproducible spinal instrumentation placement simulation curriculum for neurosurgery and orthopedic surgery residents using synthetic models and 3D computer-assisted navigation, assessing subjective and objective proficiency with placement of thoracolumbar pedicle screws. METHODS: Fifteen neurosurgery and orthopedic surgery residents participated in a standardized curriculum with lecture followed by two separate sessions of thoracolumbar pedicle screw placement in a synthetic spine model utilizing 3D computer-assisted navigation. Data were collected on premodule experience, time and accuracy of screw placement, and both subjective and objective ratings of proficiency. RESULTS: Fifteen of 15 residents demonstrated improvement in subjective (Physician Performance Diagnostic Inventory Scale [PPDIS]) and 14 in objective (Objective Structured Assessment of Technical Skills [OSATS]) measures of proficiency in navigated screw placement with utilization of this curriculum (p < 0.001 for both), regardless of the number of cases of previous experience using thoracolumbar spinal instrumentation. Fourteen of 15 residents demonstrated decreased time per screw placement from session 1 to session 2 (p = 0.006). There was no significant difference in pedicle screw accuracy between session 1 and session 2. CONCLUSIONS: A standardized curriculum using synthetic simulation training for navigated thoracolumbar pedicle screw placement results in significantly improved resident subjective and objective proficiency. Development of a nationwide competency curriculum using simulation training for spinal instrumentation placement should be considered for safe, efficient resident training.

The Deformity TLIF: Bilateral Facetectomy and Osteotomy Closure with a Hinged Table.

Background: Increasing emphasis has been placed on segmental lordosis correction, even in short segment constructs. However, the majority of reports on TLIF indicate that lordosis correction is modest at best. TLIF with bilateral facetecomy has been described with better lordosis correction, but is usually performed with the spine in extension throughout the case. This report presents a new technique for lordosis correction during TLIF with the use of bilateral facetectomy and osteotomy closure using a mechanically hinged operative table. Methods: A 78-year-old male presented with claudicatory back and leg pain due to foraminal stenosis and spondylolisthesis at L4-5 and L5-S1, and was operated on with bilateral facetectomies and TLIF while positioned on a motorized-hinged table, which started in flexion for the decompression and was brought into extension at the end of the case for osteotomy closure. Results: Segmental lordosis from L4-S1 increased from 15° pre-operatively to 42° postoperatively. Conclusions: A comparison of pre- and post-operative lateral radiographs showed 27° segmental lordosis correction, and intra-operative fluoroscopy showed correlation between extension of the table and segmental lordosis correction. Bilateral facetectomy and TLIF allows for segmental lordosis correction. Use of the hinged table allowed for ideal positioning during the decompression and controlled osteotomy closure with close correlation between table position and segmental alignment.Level of Evidence: V.

Cost-Effectiveness for Surgical Treatment of Degenerative Spondylolisthesis.

Surgery for degenerative lumbar spondylolisthesis is significantly more cost-effective than nonsurgical management in patients who have failed to improve with a 6-week trial of nonsurgical management. Decompression plus fusion becomes more cost-effective compared with decompression alone at 2 years following surgery. Further study is needed to evaluate the most cost-effective fusion approach and augmentation strategy.

Controlled Pedicle Subtraction Osteotomy Site Closure Using Flexible Hinge-Powered Operating Table.

BACKGROUND AND IMPORTANCE: Pedicle subtraction osteotomy (PSO) is a 3-column osteotomy used to correct rigid, large magnitude sagittal spinal deformity. PSO is an inherently destabilizing procedure intraoperatively, with high risk of neurological deficits from vertebral body subluxation or translation during osteotomy closure. Traditionally, PSO closure has been performed utilizing compression or cantilevering forces across adjacent level instrumentation. Such forces can loosen the instrumentation or cause abrupt subluxation or translation due to the magnitude of force required for PSO closure, resulting in neurological injury. Here, we report using a flexible hinge-powered operating table for controlled closure of PSO in 1º increments via remote-control power of the table, without compression or cantilevering force required across implants. CLINICAL PRESENTATION: The patient is a 68-yr-old man with a history of prior L2-S1 anterior-posterior fusion, healed sacral fracture, and left sacroiliac joint fusion presenting to our institution with severe back pain while standing. X-rays demonstrated significant sagittal malalignment with pelvic incidence (PI) of 79º and lumbar lordosis (LL) of 37º, while computed tomography scan confirms complete bone healing around prior interbody fusion sites, resulting in rigid sagittal deformity. Due to rigid PI-LL mismatch of 42º, we planned for L2-pelvis revision fusion with L4 PSO. CONCLUSION: Here we demonstrate the utility of a flexible hinge-powered operating table for closure of PSO site. This technique eliminates force application to adjacent implants, minimizing vertebral body subluxation, or translation. We believe this allows for safer, more controllable osteotomy closure that minimizes risk of neurological injury.

Thoracic spinal cord impingement by an arachnoid web at the level of a hemivertebra: case report.

Congenital scoliosis due to a hemivertebra requires surgical stabilization prior to skeletal maturity if rapidly progressive curve growth occurs. Here the authors present the unique case of a man who, at the age of 12 years, had undergone Harrington rod placement for stabilization of progressive congenital scoliosis due to a T-11 hemivertebra and then, at the age of 53 years, presented with acutely progressive myelopathy due to spinal cord compression from an arachnoid web at T-11 despite a solid fusion mass at the prior surgical site. The patient underwent a posterior midline approach for resection of the T-11 pedicle at the level of the hemivertebra, intradural spinal cord detethering with resection of the arachnoid web at T-11, and T2-L2 instrumented fusion with deformity correction, leading to subsequent resolution of his acute myelopathic symptoms. In conclusion, arachnoid web formation superimposed on preexisting tension on the thoracic spinal cord from congenital scoliosis due to a T-11 hemivertebra caused acute myelopathy in an adult with a previously solid fusion mass from childhood. The resolution of acute myelopathy and halting of further progression occurred with pedicle resection, arachnoid web fenestration, and spinal deformity correction.

Tranexamic Acid Reduced the Percent of Total Blood Volume Lost During Adolescent Idiopathic Scoliosis Surgery.

BACKGROUND: Multilevel posterior spine fusion is associated with significant intraoperative blood loss. Tranexamic acid is an antifibrinolytic agent that reduces intraoperative blood loss. The goal of this study was to compare the percent of total blood volume lost during posterior spinal fusion (PSF) with or without tranexamic acid in patients with adolescent idiopathic scoliosis (AIS). METHODS: Thirty-six AIS patients underwent PSF in 2011-2014; the last half (n=18) received intraoperative tranexamic acid. We retrieved relevant demographic, hematologic, intraoperative and outcomes information from medical records. The primary outcome was the percent of total blood volume lost, calculated from estimates of intraoperative blood loss (numerator) and estimated total blood volume per patient (denominator, via Nadler's equations). Unadjusted outcomes were compared using standard statistical tests. RESULTS: Tranexamic acid and no-tranexamic acid groups were similar (all p>0.05) in mean age (16.1 vs. 15.2 years), sex (89% vs. 83% female), body mass index (22.2 vs. 20.2 kg/m2), preoperative hemoglobin (13.9 vs. 13.9 g/dl), mean spinal levels fused (10.5 vs. 9.6), osteotomies (1.6 vs. 0.9) and operative duration (6.1 hours, both). The percent of total blood volume lost (TBVL) was significantly lower in the tranexamic acid-treated vs. no-tranexamic acid group (median 8.23% vs. 14.30%, p = 0.032); percent TBVL per level fused was significantly lower with tranexamic acid than without it (1.1% vs. 1.8%, p=0.048). Estimated blood loss (milliliters) was similar across groups. CONCLUSIONS: Tranexamic acid significantly reduced the percentage of total blood volume lost versus no tranexamic acid in AIS patients who underwent PSF using a standardized blood loss measure.Level of Evidence: 3. Institutional Review Board status: This medical record chart review (minimal risk) study was approved by the University of Minnesota Institutional Review Board.

Placement of Thoracic Pedicle Screws.

Thoracic pedicle screws have become the spinal anchor of choice because of the superior biomechanics of this technique. It is widely used for the treatment of scoliosis, spinal deformity (such as kyphosis), trauma, tumors, infection, and other pathologies. The technique demands precision as malposition can result in spinal cord or visceral injury with potential catastrophic consequences (death or paralysis). There have been many published articles looking at the anatomy and the anatomic variation in various populations according to race, age, deformity, etc. Lenke and others have developed start point guidelines that seem to have reasonable validity. There are two basic screw trajectories:The straightforward technique.The anatomic trajectory. The straightforward technique parallels the superior end plate of the instrumented vertebra. It has the best insertional torque. The anatomic trajectory bisects the sagittal axis of the pedicle, typically 15° cranial to caudal, and has the largest available bone channel. The accuracy of placement is a debated topic. There are several meta-analyses and systematic reviews that address this question. However, there are a variety of definitions of acceptable compared with optimal placement. The current gold standard for judging screw placement is the use of computed tomography; however, it carries a substantial radiation burden to the patient, which must be considered. There are a myriad of described techniques, including freehand (anatomically based), fluoroscopy-guided, and three-dimensional (3-D) image-guided methods. All have their advantages and disadvantages. Surgeons must find the technique that is safe and reliable in their hands. The procedure is performed with the following steps:Preoperative planning is done by initially looking at plain radiographs and by assessing bending radiographs and preoperative computed tomography scans, if available.The patient is placed on a Jackson table, which is radiolucent and allows easy access for C-arm or O-arm technology.Locate the start point around the thoracic level (T12, T8, etc.); a review of the Lenke start point map is helpful.Create the dorsal cortical hole, which is best done with a small pilot hole; we recommend the use of a 3-mm high-speed burr (Midas Rex; Medtronic).Create a track within the pedicle by probing with either a navigated probe or a Lenke-style freehand probe.Confirm the accuracy of the screw tract placement, which can be done by palpation although it is not 100% reliable.Place the screw after tapping 1 mm less than the nominal screw diameter.Confirm the accuracy of screw placement with fluoroscopy or plain radiographs; 3-D intraoperative imaging is the most reliable technique, but it also exposes the patient to the most radiation.Confirm the neurological status of the patient by monitoring the motor evoked potential signals after screw placement.Close the wound after the screws have been checked with intraoperative 2-D or 3-D imaging to ensure that they have not cut or plowed out. The results of thoracic pedicle screw placement are specific to the spinal condition treated. For adolescent idiopathic scoliosis, no brace is needed and walking can be progressed as tolerated. With good thoracic screw placement, rehabilitation typically is accelerated because a stable spinal construct is achieved. Most patients are able to walk without any sort of external mobilization or special adjunctive protection.