Is young adult idiopathic scoliosis a distinct clinical entity from adolescent idiopathic scoliosis? a Systematic Review and Meta-analysis comparing pre-operative characteristics and operative outcomes.

PURPOSE: This study aims to conduct a systematic review of the literature comparing pre-operative, intraoperative, and post-operative characteristics between adolescent idiopathic scoliosis (AIS) and young adult idiopathic scoliosis (YAdIS) patients. METHODS: Following PRISMA guidelines, we conducted a search of the PubMed/Medline, EMBASE, and Cochrane Central databases to identify full-text articles in the English-language literature. Our inclusion criteria were studies that compared preoperative, intraoperative, and postoperative characteristics between AIS and YAdIS patients. We performed a meta-analysis reporting mean difference (MD) for continuous variables and Odds ratios (ORs) to assess differences in postoperative complications. RESULTS: Seven studies consisting of 1562 patients were included in the meta-analysis. The AIS group exhibited less intraoperative bleeding and shorter surgical procedures, with a mean difference between groups of 122.3 ml (95% CI 46.2-198.4, p = 0.002) and 28.7 min (95% CI 6.5-50.8, p = 0.01), respectively. Although the preoperative Cobb angle did not differ between groups (p = 0.65), patients with AIS achieved superior postoperative deformity correction, with a mean difference of 7.3% between groups, MD - 7.3 (95% CI - 9.7, - 4.8, p < 0.00001), and lower postoperative Cobb angles of the major curve, MD 4.2 (95% CI 3.1, 5.3, p < 0.00001). YAdIS patients were fused, on average, 0.2 more vertebral levels than AIS patients, MD 0.2 (95% CI 0.01, 0.5, p = 0.04). AIS patients experienced a significantly shorter length of stay after the surgical procedure, with an MD of 0.8 days (95% CI 0.1, 1.6, p = 0.02). No significant difference was found between groups in terms of complications (p = 0.19). CONCLUSIONS: YAdIS should be regarded as a distinct surgical entity, characterized by increased bleeding, longer surgical duration, greater deformity correction challenges, and the need for fusion of additional vertebral levels compared to AIS. Surgeons should be mindful of these differences and discuss them with patients and their families, especially in cases where the correction of the AIS deformity is delayed and there is a high risk of progression after skeletal maturity. Further research is needed to explore alternative surgical techniques and enhance outcomes for YAdIS patients.

Establishing case volume benchmarks for ACGME-accredited orthopedic surgery of the spine fellowship training.

BACKGROUND CONTEXT: There has been increasing scrutiny on the standardization of surgical training in the US. PURPOSE: This study provides case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic spine surgery fellowship training. STUDY DESIGN/SETTING: This was a retrospective cross-sectional study of fellows at ACGME-accredited orthopedic spine surgery fellowships (2017-2022). PATIENT SAMPLE: N/A. OUTCOME MEASURES: Reported case volume during fellowship training. METHODS: Case volume percentiles were calculated across ACGME-defined case categories and temporal changes assessed via linear regression. Variability between the highest and lowest deciles by case volume was calculated as fold-differences (90th percentile/10th percentile). Sensitivity analyses were performed to identify potential targets for case minimum requirements. RESULTS: A total of 163 spine surgery fellows were included in this study. Total mean reported spine surgery case volume increased from 313.2±122 in 2017 to 382.0±164 in 2022 (p=.19). Most cases were classified as adult (range, 97.2%-98.0%) over pediatric cases (range, 2.0%-2.8%). An average of 322.0 cases were reported and most were classified as laminectomy (32%), posterior arthrodesis (29%), and anterior arthrodesis (20%). Overall variability in total case volume was 2.4 and the greatest variability existed for posterior instrumentation (38.1), application of cage (34.6), anterior instrumentation (20.8), and fractures and dislocations (17.3). If case minimum requirements for total reported cases was assumed at 200 cases, then all spine fellows included in this study would achieve this requirement. However, if case minimum requirements were assumed at 250 total cases, then approximately thirty percent of fellows (n=49) would not achieve this requirement for graduation. CONCLUSIONS: Increasingly, national societies and accrediting bodies for surgical education recognize the need for standardized training. This study provides benchmarks to inform potential case minimum requirements and help reduce variability during spine fellowship training. Future studies are needed to establish case minimum requirements for spine surgery fellowship training across comprehensive and granular case categories that cover the full gamut of orthopedic spine surgery.

Applications of SPECT/CT in the Evaluation of Spinal Pathology: A Review.

BACKGROUND: Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS: A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS: SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS: SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE: SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology.

A Novel Untethering and Duraplasty Technique for Postsurgical Tethered Spinal Cord.

Progressive post-traumatic postsurgical myelopathy (PPPM) is a known entity that can occur months to years after the initial insult. Symptomatic patients can become myelopathic and have rapid and progressive neurological decline. Surgical correction of PPPM usually involves intradural exploration and lysis of adhesions that carries the risk of further injury to the spinal cord. In this manuscript, we provide a report of a patient presenting more than 50 years after the initial resection of an intramedullary tumor. Additionally, we present and describe a novel surgical technique for managing this difficult problem and restoring normal CSF dynamics.

Metastatic mesenchymal chondrosarcoma of the spine managed with nonsurgical treatment: A case report and review of the literature.

In this report, we present a rare case of a 17-year-old male patient with metastatic mesenchymal chondrosarcoma (MCS) managed with nonsurgical treatment who subsequently demonstrated a favorable response to concurrent chemotherapy and radiation therapy, followed with pazopanib target therapy. Further study regarding nonoperative care for metastatic MCS of spine is warranted.

Lifetime incremental cost-utility ratios for minimally invasive surgery for degenerative lumbar spondylolisthesis relative to failed medical management compared with total hip and knee arthroplasty for osteoarthritis.

Background: The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis. Methods: A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost-utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form-6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed. Results: Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses. Conclusion: Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures.

Contexte: L'objectif de cette étude était de comparer le rapport coût­efficacité de la chirurgie minimalement effractive (CME) chez les patients atteints de spondylolisthésis lombaire dégénératif (SLD) en lien avec un échec de la prise en charge médicale à celui de l'arthroplastie de la hanche et du genou pour des cohortes assorties de patients atteints d'arthrose. Méthodes: Une cohorte de patients atteints de SLD soumis à une CME avec décompression seule ou décompression avec arthrodèse entre 2008 et 2014 a été assortie à des cohortes de patients soumis à une arthroplastie totale pour arthrose de la hanche et du genou. Les rapports coût­utilité différentiels (RCUD) ont été calculés du point de vue du ministère de la Santé de l'Ontario à l'aide des données d'utilité du questionnaire Short Form­6 Dimension recueillies de manière prospective. Les coûts et les années de vie ajustées en fonction de la qualité (AVAQ) ont été actualisés à un taux de 3 % et des analyses de sensibilité ont été effectuées. Résultats: Soixante-six patients répondaient aux critères d'inclusion pour la cohorte SLD (n = 35, décompression seule), avec un suivi d'une durée minimale de 1 an (moyenne 1,7 an). L'âge moyen des gens de la cohorte SLD était de 64,76 ans, et 45 patients (68,2 %) étaient de sexe féminin. Pour chaque cohorte, les scores d'utilité se sont améliorés entre les valeurs de départ et les valeurs de suivi et l'ampleur du gain n'a pas différé entre les groupes. Les RCUD pour la vie entière entre les soins chirurgicaux et non chirurgicaux ont été 7946 $CA/QALY, 7104 $CA/QALY et 5098 $CA/QALY pour les cohortes SLD, arthrose du genou et de la hanche, respectivement. L'analyse de sous-groupes a généré un RCUD accru pour les patients atteints de SLD qui ont subi la décompression avec arthrodèse (9870 $CA/QALY) comparativement à la décompression seule (5045 $CA/QALY). Le classement des RCUD par groupe n'a pas changé en fonction des analyses de sensibilité déterministes ou probabilistes. Conclusion: Les RCUD pour la vie entière associés à la CME dans les cas de SLD sont similaires à ceux de l'arthroplastie totale. Les recherches futures devraient adopter une perspective sociétale et refléter davantage les bienfaits économiques de la CME.

Image Guidance-Assisted Decompression and Removal of Heterotopic Ossification Following the Use of Recombinant Human Bone Morphogenetic Protein-2 in Transforaminal Lumbar Interbody Fusion.

Heterotopic ossification (HO) following the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in the setting of transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) is a troublesome and well-described postoperative complication. There is currently no consensus regarding the treatment of this offending pathology. In this report, we present a retrospective single-surgeon review of 14 patients who underwent image-guided decompression of HO. We describe a new technique where navigation demonstrates a safe and thorough decompression compared to that with fluoroscopy or anatomical landmarks alone. To evaluate successful decompression, we reviewed patient self-reported clinical outcomes. Seven patients demonstrated positive results, while three had mixed outcomes and four showed poor outcomes. While more studies are needed to determine the overall efficacy of intraoperative navigation-assisted decompression, findings from this small cohort of patients suggest that it is a useful technique in the setting of the removal of heterotopic bone.

Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

INTRODUCTION: Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery. METHODS: Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use. RESULTS: Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53-2.36; p = 0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15-5.75; p = 0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49-3.17; p = 0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses. CONCLUSION: Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP.

Use of a Fascia Lata Autograft to Reconstruct a Large Triceps Tendon Defect After En-Bloc Resection of a Soft-Tissue Sarcoma: A Case Report.

CASE: In this report, we present the case of a patient undergoing en-bloc resection of a large triceps soft-tissue sarcoma, requiring reconstruction of the triceps tendon including its distal insertion. We describe a surgical technique using fascia lata (FL) autograft to reconstruct the patient's extensor mechanism with long-term follow-up and functional results. CONCLUSIONS: FL autograft is a viable option for reconstruction of large tendinous defects. It is simple and straightforward to harvest, inexpensive when compared with alternatives, with many potential applications.

Slip progression in degenerative lumbar spondylolisthesis following minimally invasive decompression surgery is not associated with increased functional disability.

PURPOSE: The aim of this study is to determine whether there is a relationship between radiographic slip progression and symptomatic worsening after decompression without fusion for low-grade degenerative lumbar spondylolisthesis (DLS). METHODS: A retrospective review of 1-2-level minimally invasive surgical decompression for grade I-II DLS was performed. Included subjects had a minimum of 1-year follow-up with prospectively collected baseline and follow-up Oswestry Disability Index (ODI) scores. RESULTS: Fifty-six patients (33 females, 58.9%), having a mean age 65.6 years (SD 10.0), met inclusion criteria. Spondylolisthesis slip percentage increased in 55.4% (31/56) of patients. Slip percentage increased significantly (p = 0.002) from baseline (mean 17.2; SD 8.0) to follow-up (mean 20.1; SD 9.6). A logistic regression model identified that females were more likely to have progressive slips compared to males (odd ratio 6.09, 95% CI 1.77-21.01; p = 0.004). ODI scores and spondylolisthesis slip percentage did not correlate at baseline (r = 0.0170; p = 0.90) nor follow-up (r = 0.094; p = 0.49). There was no correlation between the change in ODI scores and change in slip percentage from baseline to final follow-up (r = 0.0474; p = 0.73). Of the 31 patients with slip progression, there was no difference in mean ODI score changes (p = 0.91) for those with 1-5% progression (13/31 [41.9%]; - 18.0 [SD 19.7]) compared to those with > 5% slip progression (18/31 [58.1%]; - 18.7 [SD 16.4]). CONCLUSIONS: Despite a small degree of slip progression in the majority of patients, there was no correlation with symptom worsening, as measured by the ODI. These slides can be retrieved under Electronic Supplementary Material.

Vertebral Osteotomies in Ankylosing Spondylitis-Comparison of Outcomes Following Closing Wedge Osteotomy versus Opening Wedge Osteotomy: A Systematic Review.

Study Design Systematic review. Study Rationale To seek out and assess the best quality evidence available comparing opening wedge osteotomy (OWO) and closing wedge osteotomy (CWO) in patients with ankylosing spondylitis to determine whether their results differ with regard to several different subjective and objective outcome measures. Objective The aim of this study is to determine whether there is a difference in subjective and objective outcomes when comparing CWO and OWO in patients with ankylosing spondylitis suffering from clinically significant thoracolumbar kyphosis with respect to quality-of-life assessments, complication risks, and the amount of correction of the spine achieved at follow-up. Methods A systematic review was undertaken of articles published up to July 2012. Electronic databases and reference lists of key articles were searched to identify studies comparing effectiveness and safety outcomes between adult patients with ankylosing spondylitis who received closing wedge versus opening wedge osteotomies. Studies that included pediatric patients, polysegmental osteotomies, or revision procedures were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus. Results From a total of 67 possible citations, 4 retrospective cohorts (class of evidence III) met our inclusion criteria and form the basis for this report. No differences in Oswestry Disability Index, visual analog scale for pain, Scoliosis Research Society (SRS)-24 score, SRS-22 score, and patient satisfaction were reported between the closing and opening wedge groups across two studies. Regarding radiological outcomes following closing versus opening osteotomies, mean change in sagittal vertical axis ranged from 8.9 to 10.8 cm and 8.0 to 10.9 cm, respectively, across three studies; mean change in lumbar lordosis ranged from 36 to 47 degrees and 19 to 41 degrees across four studies; and mean change in global kyphosis ranged from 38 to 40 degrees and 28 to 35 degrees across two studies. Across all studies, overall complication risks ranged from 0 to 16.7% following CWO and from 0 to 23.6% following OWO. Conclusion No statistically significant differences were seen in patient-reported or radiographic outcomes between CWO and OWO in any study. The risks of dural tear, neurological injury, and reoperation were similar between groups. Blood loss was greater in the closing wedge compared with the opening wedge group, while the risk of paralytic ileus was less. The overall strength of evidence for the conclusions is low.